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Atrial fibrillation (AF) is the most prevalent arrhythmia worldwide. The presence of AF is associated with increased risk of systemic thromboembolism, but with the uptake of oral anticoagulant (OAC) and implementation of a holistic and integrated care management, this risk is substantially reduced. The diagnosis of AF requires a 30-s-long electrocardiographic (ECG) trace, irrespective of the presence of symptoms, which may represent the main indication for an ECG tracing. However, almost half patients are asymptomatic at the time of incidental AF diagnosis, with similar risk of stroke of those with clinical AF. This has led to a crucial role of screening for AF, to increase the diagnosis of population at risk of clinical events. The aim of this review is to give a comprehensive overview about the epidemiology of asymptomatic AF, the different screening technologies, the yield of diagnosis in asymptomatic population, and the benefit derived from screening in terms of reduction of clinical adverse events, such as stroke, cardiovascular, and all-cause death. We aim to underline the importance of implementing AF screening programmes and reporting about the debate between scientific societies’ clinical guidelines recommendations and the concerns expressed by the regulatory authorities, which still do not recommend population-wide screening. This review summarizes data on the ongoing trials specifically designed to investigate the benefit of screening in terms of risk of adverse events which will further elucidate the importance of screening in reducing risk of outcomes and influence and inform clinical practice in the next future.

The 4S-AF scheme [Stroke risk, Symptom severity, Severity of atrial fibrillation (AF) burden, Substrate severity] was recently proposed to characterize AF patients. In this post hoc analysis we evaluated the agreement between the therapeutic strategy (rate or rhythm control, respectively), as suggested by the 4S-AF scheme, and the actual strategy followed in a patients cohort. Outcomes of interest were as follows: all-cause death, a composite of all-cause death/any thromboembolism/acute coronary syndrome, and a composite of all-cause death, any thrombotic/ischemic event, and major bleeding (net clinical outcome). We enrolled 615 patients: 60.5% male, median age 74 [interquartile range (IQR) 67-80] years; median CHA2DS2VASc 4 and median HAS-BLED 2. The 4S-AF score would have suggested a rhythm-control strategy in 351 (57.1%) patients while a rate control in 264 (42.9%). The strategy adopted was concordant with the 4S-AF suggestions in 342 (55.6%) cases, and non-concordant in 273 (44.4%). After a median follow-up of 941 days (IQR 365-1282), 113 (18.4%) patients died, 158 (25.7%) had an event of the composite endpoint. On adjusted Cox regression analysis, when 4S-AF score suggested rate control, disagreement with that suggestion was not associated with a worse outcome. When 4S-AF indicated rhythm control, disagreement was associated with a higher risk of all-cause death (HR 7.59; 95% CI 1.65-35.01), and of the composite outcome (HR 2.69; 95% CI 1.19-6.06). The 4S-AF scheme is a useful tool to comprehensively evaluate AF patients and aid the decision-making process. Disagreement with the rhythm control suggestion of the 4S-AF scheme was associated with adverse clinical outcomes.

BackgroundLate reconnections (LR) of pulmonary veins (PVs) after wide antral circumferential ablation (WACA) using point-to-point radiofrequency (RF) ablation are common. Lesion size index (LSI) is a novel marker of lesion quality proposed by Ensite Precision mapping system, expected to improve PV isolation durability. This study aimed to assess the durability of LSI-guided PVI and the risk factors for LR of PVs.MethodsThe prospective study included 33 patients with paroxysmal atrial fibrillation (PAF) who underwent (1) the index LSI-guided WACA procedure (with target LSI of 5.5-6.0 for anterior and 5.0-5.5 for posterior WACA segments) and (2) the 3-month protocol-mandated re-mapping procedure in all patients, irrespective of AF recurrence after the index procedure. Ablation parameters reported by Ensite mapping system were collected retrospectively. The inter-lesion distance (ILD) between all adjacent WACA lesions was calculated off-line. Association between index ablation parameters and the LRs of PVs at 3 months was analyzed.ResultsThe median patient age was 61 (IQR: 53–64) years and 55% of them were males. At index procedure, the first-pass WACA isolation rate was higher for the left PVs than the right PVs (64 vs. 33%, p = 0.014). In addition, a low acute reconnection rates were observed, as follows: in 12.1% of patients, in 6.1% of WACA circles, in 3.8% of WACA segments and in 4.5% of PVs. However, the 3-month remapping study revealed LR of PV in 63.6% of patients, 37.9% of WACA circles, 20.5% of WACA segments and 26.5% of PVs. The LRs were identified mostly along the left anterior WACA segment. Independent risk factors for the LR of WACA were left-sided WACA location (OR 3.216 [95%CI: 1.065–9.716], p = 0.038) and longer ILD (OR 1.256 [95%CI: 1.035–1.523] for each 1-mm increase, p = 0.021). The ILD of > 8.0 mm showed a predictive value for the LR of WACA, with the sensitivity of 84% and specificity of 46%. A single case of cardiac tamponade occurred following the re-mapping invasive procedure. No other complications were encountered.ConclusionAlthough the LSI-guided PVI ensures a consistent PVI during the index procedure, LRs of PVs are still common. Besides the LSI, the PVI durability requires an optimal ILD between adjacent lesions, especially along the anterior lateral ridge.

Funding Acknowledgements Type of funding sources: None. Background Treatment burden (TB) is defined as the patient’s workload of health care and its impact on patient functioning and well-being. High TB can lead to nonadherence, higher risk of adverse outcomes and lower quality of life. We have previously reported a higher TB in patients with atrial fibrillation (AF) vs. those with other chronic conditions. In this analysis, we explored sex-related differences in self-reported TB in AF patients. Methods A single-centre, prospective study included consecutive patients with AF under drug treatment for at least six months before enrolment from April to June 2019. Patients were asked to voluntarily and anonymously answer Treatment Burden Questionnaire (TBQ). All patients signed the written consent for participation. Results Of 331 patients (mean age 65.4 ±10.3 years, mean total AF history 6.41 ±6.62 years), 127 (38.4%) were females. The mean TB was significantly higher in females compared to males (53.7 vs. 42.6 out of 170 points, p Conclusion Our study was first to explore the sex-specific determinants of TB in AF patients. Females had significantly higher TB compared with males. Approximately 2 in 5 females and 1 in 5 males reported TB ≥59 points, previously shown to be an unacceptable burden of treatment for patients. Using a NOAC rather than VKA in females and a rhythm control strategy in males could decrease TB to acceptable values. Table.Multivariable Logistic Regression analysis of the highest TB quartile (TB ≥59)VariableOR95% CIP valueFemalePPI therapy5.3541.97-14.560.001NOAC0.3190.12-0.830.019Diuretic therapy0.3180.13-0.760.010CHA2DS2-VASc score0.7000.49-0.990.045MaleAblation and/or ECV0.3830.18-0.810.012Supraventricular arrhythmias0.2220.05-0.980.047VKA Vitamin K antagonist; ECV: electrical cardioversion; AF: Atrial fibrillation; PPI: Proton pump inhibitor; PCI: Percutaneous coronary intervention; NOAC: Non-vitamin k antagonist oral anticoagulant.Abstract Figure.

COVID-19 is associated with endothelial activation in the setting of a potent inflammatory reaction and a hypercoagulable state. The end result of this thromboinflammatory state is an excess in thrombotic events, in particular venous thromboembolism. Pulmonary embolism (PE) has been of special interest in patients with COVID-19 given its association with respiratory deterioration, increased risk of intensive care unit admission, and prolonged hospital stay. The pathophysiology and clinical characteristics of COVID-19-associated PE may differ from the conventional non–COVID-19-associated PE. In addition to embolic events from deep vein thrombi, in situ pulmonary thrombosis, particularly in smaller vascular beds, may be relevant in patients with COVID-19. Appropriate prevention of thrombotic events in COVID-19 has therefore become of critical interest. Several changes in viral biology, vaccination, and treatment management during the pandemic may have resulted in changes in incidence trends. This review provides an overview of the pathophysiology, epidemiology, clinical characteristics, and risk factors of COVID-19-associated PE. Furthermore, we briefly summarize the results from randomized controlled trials of preventive antithrombotic therapies in COVID-19, focusing on their findings related to PE. We discuss the acute treatment of COVID-19-associated PE, which is substantially similar to the management of conventional non-COVID-19 PE. Ultimately, we comment on the current knowledge gaps in the evidence and the future directions in the treatment and follow-up of COVID-19-associated PE, including long-term management, and its possible association with long-COVID.

BACKGROUND: The prevalence of atrial fibrillation(AF) and diabetes mellitus is rising to epidemic proportions. We aimed to assess the impact of diabetes on the management and outcomes of patients with AF.METHODS: The EORP-AF General Long-Term Registry is a prospective, observational registry from 250 centres across 27 European countries. Outcomes of interest were as follows: i)rhythm control interventions; ii)quality of life; iii)healthcare resource utilisation; and iv)major adverse events.RESULTS: Of 11,028 patients with AF, the median age was 71 (63-77) years and 2537 (23.0%) had diabetes. Median follow-up was 24 months. Diabetes was related to increased use of anticoagulation but less rhythm control interventions. Using multivariable analysis, at 2-year follow-up, patients with diabetes were associated with greater levels of anxiety (p = 0.038) compared to those without diabetes. Overall, diabetes was associated with worse health during follow-up, as indicated by Health Utility Score and Visual Analogue Scale. Healthcare resource utilisation was greater with diabetes in terms of length of hospital stay (8.1 (±8.2) vs. 6.1 (±6.7) days); cardiology and internal medicine/general practitioner visits; and emergency room admissions. Diabetes was an independent risk factor of major adverse cardiovascular event (MACE; HR 1.26 [95% CI, 1.04-1.52]), all-cause mortality (HR 1.28 [95% CI, 1.08-1.52]), and cardiovascular mortality (HR 1.41 [95% CI, 1.09-1.83]).CONCLUSION: In this contemporary AF cohort, diabetes was present in 1 in 4 patients and it served as an independent risk factor for reduced quality of life, greater healthcare resource utilisation and excess MACE, all-cause mortality and cardiovascular mortality. There was increased use of anticoagulation therapy in diabetes but with less rhythm control interventions.

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Importance The arrest and the post-arrest period are an incredibly emotionally traumatic time for family and friends of the affected individual. There is a need to assess prognosis early in the patient pathway to offer objective, realistic and non-emotive information to the next-of-kin regarding the likelihood of survival. Objective To present a systematic review of the clinical risk scores available to assess patients on admission following out-of-hospital cardiac arrest (OHCA) which can predict in-hospital mortality. Evidence review A systematic search of online databases Embase, MEDLINE and Cochrane Central Register of Controlled Trials was conducted up until 20th November 2020. Findings Out of 1,817 initial articles, we identified a total of 28 scoring systems, with 11 of the scores predicting mortality following OHCA included in this review. The majority of the scores included arrest characteristics (initial rhythm and time to return of spontaneous circulation) as prognostic indicators. Out of these, the 3 most clinically-useful scores, namely those which are easy-to-use, comprise of commonly available parameters and measurements, and which have high predictive value are the OHCA, NULL-PLEASE, and rCAST scores, which appear to perform similarly. Of these, the NULL-PLEASE score is the easiest to calculate and has also been externally validated. Conclusions Clinicians should be aware of these risk scores, which can be used to provide objective, nonemotive and reproducible information to the next-of-kin on the likely prognosis following OHCA. However, in isolation, these scores should not form the basis for clinical decision-making.

Aims The risk of developing atrial fibrillation (AF) and its complications continues to increase, despite good progress in preventing AF-related strokes. Methods and results This article summarizes the outcomes of the 7th Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA) held in Lisbon in March 2019. Sixty-five international AF specialists met to present new data and find consensus on pressing issues in AF prevention, management and future research to improve care for patients with AF and prevent AF-related complications. This article is the main outcome of an interactive, iterative discussion between breakout specialist groups and the meeting plenary. AF patients have dynamic risk profiles requiring repeated assessment and risk-based therapy stratification to optimize quality of care. Interrogation of deeply phenotyped datasets with outcomes will lead to a better understanding of the cardiac and systemic effects of AF, interacting with comorbidities and predisposing factors, enabling stratified therapy. New proposals include an algorithm for the acute management of patients with AF and heart failure, a call for a refined, data-driven assessment of stroke risk, suggestions for anticoagulation use in special populations, and a call for rhythm control therapy selection based on risk of AF recurrence. Conclusion The remaining morbidity and mortality in patients with AF needs better characterization. Likely drivers of the remaining AF-related problems are AF burden, potentially treatable by rhythm control therapy, and concomitant conditions, potentially treatable by treating these conditions. Identifying the drivers of AF-related complications holds promise for stratified therapy.

BACKGROUND: Implementation of the Atrial fibrillation Better Care (ABC) pathway is recommended by guidelines on atrial fibrillation (AF), but the impact of adherence to ABC pathway in patients with cancer is unknown.OBJECTIVES: To investigate the adherence to ABC pathway and its impact on adverse outcomes in AF patients with cancer.METHODS: Patients enrolled in the EORP-AF General Long-Term Registry were analyzed according to (i) No Cancer; and (ii) Prior or active cancer and stratified in relation to adherence to the ABC pathway. The composite Net Clinical Outcome (NCO) of all-cause death, major adverse cardiovascular events and major bleeding was the primary endpoint.RESULTS: Among 6550 patients (median age 69 years, females 40.1%), 6005 (91.7%) had no cancer, while 545 (8.3%) had a diagnosis of active or prior cancer at baseline, with the proportions of full adherence to ABC pathway of 30.6% and 25.7%, respectively. Adherence to the ABC pathway was associated with a significantly lower occurrence of the primary outcome vs. non-adherence, both in 'no cancer' and 'cancer' patients [adjusted Hazard Ratio (aHR) 0.78, 95% confidence interval (CI): 0.66-0.92 and aHR 0.59, 95% CI 0.37-0.96, respectively]. Adherence to a higher number of ABC criteria was associated with a lower risk of the primary outcome, being lowest when 3 ABC criteria were fulfilled (no cancer: aHR 0.54, 95%CI: 0.36-0.81; with cancer: aHR 0.32, 95% CI 0.13-0.78).CONCLUSION: In AF patients with cancer enrolled in the EORP-AF General Long-Term Registry, adherence to ABC pathway was sub-optimal. Full adherence to ABC-pathway was associated with a lower risk of adverse events.

This European Heart Rhythm Association (EHRA) Scientific Initiatives Committee, EHRA Young Electrophysiologists, Association of Cardiovascular Nursing and Allied Professionals, and European Society of Cardiology (ESC) Council on Stroke joint survey aimed to assess the interpretation of the CHA2DS2-VASc score components and preferred resources for calculating the score. Of 439 respondents, most were general cardiologists (46.7%) or electrophysiologists (EPs) (42.1%). The overall adherence to the ESC-defined scoring criteria was good. Most variation was observed in the interpretation of the significance of left ventricular ejection fraction and brain natriuretic peptide in the scoring for the ‘C’ component, as well as the ‘one-off high reading of blood pressure’ to score on the ‘H’ component. Greater confidence was expressed in scoring the ‘H’ component (72.3%) compared with the ‘C’ (46.2%) and ‘V’ (45.9%) components. Respondents mainly relied on their recall for the scoring of CHA2DS2-VASc score (64.2%). The three most favoured referencing resources varied among different professionals, with pharmacists and physicians relying mainly on memory or web/mobile app, whereas nurses favoured using a web/mobile app followed by memory or guidelines/protocol. In conclusion, this survey revealed overall good adherence to the correct definition of each component in scoring of the ‘C’, ‘H’, and ‘V’ elements of the CHA2DS2-VASc score, although the variation in their interpretations warrants further clarifications. The preferred referencing resources to calculate the score varied among different healthcare professionals. Guideline education to healthcare professionals and updated and unified online/mobile scoring tools are suggested to improve the accuracy in scoring the CHA2DS2-VASc score.

PURPOSE: Out-of-hospital cardiac arrest (OHCA) carries a very high mortality rate even after successful cardiopulmonary resuscitation. Currently, information given to relatives about prognosis following resuscitation is often emotive and subjective, and varies with clinician experience. We aimed to validate the NULL-PLEASE score to predict survival following OHCA.METHODS: A multicenter cohort study was conducted, with retrospective and prospective validation in consecutive unselected patients presenting with OHCA. The NULL-PLEASE score was calculated by attributing points to the following variables: Nonshockable initial rhythm, Unwitnessed arrest, Long low-flow period, Long no-flow period, pH 7.0 mmol/L, End-stage renal failure, Age ≥85 years, Still resuscitation, and Extracardiac cause. The primary outcome was in-hospital death.RESULTS: We assessed 700 patients admitted with OHCA, of whom 47% survived to discharge. In 300 patients we performed a retrospective validation, followed by prospective validation in 400 patients. The NULL-PLEASE score was lower in patients who survived compared with those who died (0 [interquartile range 0-1] vs 4 [interquartile range 2-4], P < .0005) and strongly predictive of in-hospital death (C-statistic 0.874; 95% confidence interval, 0.848-0.899). Patients with a score ≥3 had a 24-fold increased risk of death (odds ratio 23.6; 95% confidence interval, 14.840-37.5; P < .0005) compared with those with lower scores. A score ≥3 has a 91% positive predictive value for in-hospital death, while a score CONCLUSION: The easy-to-use NULL-PLEASE score predicts in-hospital mortality with high specificity and can help clinicians explain the prognosis to relatives in an easy-to-understand, objective fashion, to realistically prepare them for the future.

The spectrum of inherited arrhythmogenic diseases (IADs) includes disorders without overt structural abnormalities (i.e. primary inherited arrhythmia syndromes) and structural heart diseases (i.e. arrhythmogenic ventricular cardiomyopathy, hypertrophic cardiomyopathy). The aim of this European Heart Rhythm Association (EHRA) survey was to evaluate current clinical practice and adherence to 2015 European Society of Cardiology Guidelines regarding the management of patients with IADs. A 24-item centre-based online questionnaire was presented to the EHRA Research Network Centres and the European Cardiac Arrhythmia Genetics Focus Group members. There were 46 responses from 20 different countries. The survey revealed that 37% of centres did not have any dedicated unit focusing on patients with IADs. Provocative drug challenges were widely used to rule-out Brugada syndrome (BrS) (91% of centres), while they were used in a minority of centres during the diagnostic assessment of long-QT syndrome (11%), early repolarization syndrome (12%), or catecholaminergic polymorphic ventricular tachycardia (18%). While all centres advised family clinical screening with electrocardiograms for all first-degree family members of patients with IADs, genetic testing was advised in family members of probands with positive genetic testing by 33% of centres. Sudden cardiac death risk stratification was straightforward and in line with current guidelines for hypertrophic cardiomyopathy, while it was controversial for other diseases (i.e. BrS). Finally, indications for ventricular mapping and ablation procedures in BrS were variable and not in agreement with current guidelines in up to 54% of centres.

Background Atrial fibrillation (AF) often co‐exists with renal function (RF) impairment. We investigated the characteristics and management of AF patients across creatinine clearance strata and potential changes in the use of nonvitamin K oral anticoagulants (NOAC) according to different equations for estimation of RF. Methods In this post hoc analysis of the BALKAN‐AF survey, patients were classified according to RF (Cockcroft‐Gault formula) as: preserved/mildly depressed RF (P‐RF) ≥50 mL/min, moderately depressed RF (MD‐RF) 30‐49 mL/min, and severely depressed RF (SD‐RF), with severely depressed renal function (SD‐RF) and moderately depressed RF (MD‐RF) were older, more symptomatic, had higher stroke and bleeding risk and more comorbidities than those with preserved/mildly depressed RF (P‐RF). Differences in the management of atrial fibrillation across the RF categories were present, Figure 1. No profound differences were present in terms of nonvitamin K oral anticoagulants (NOAC) dosing or avoidance of prescription with the use of various equations for estimated glomerular filtration rate.

The use of triple antithrombotic therapy (TAT) consisting of an oral anticoagulant (OAC), aspirin, and a P2Y12 inhibitor in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) and / or undergoing percutaneous coronary intervention (PCI) is associated with a high risk of bleeding. Recently, several randomized clinical trials tested the hypothesis as to whether dual antithrombotic therapy (DAT) regimens (consisting of an OAC and a single antiplatelet drug) may be safer in terms of bleeding events as compared with TAT. They also investigated the role of non-vitamin K antagonist oral anticoagulants (NOACs) as a part of DAT and TAT. The purpose of this review is to provide an overview of available evidence regarding the safety and efficacy of DAT compared with TAT regimens, international guidelines recommendations, knowledge gaps, and unmet needs in the management of patients with AF and ACS and / or undergoing PCI.

Supplemental Digital Content is available in the text., Background: Patients with established coronary artery disease or peripheral artery disease often have diabetes mellitus. These patients are at high risk of future vascular events. Methods: In a prespecified analysis of the COMPASS trial (Cardiovascular Outcomes for People Using Anticoagulation Strategies), we compared the effects of rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg daily) versus placebo plus aspirin in patients with diabetes mellitus versus without diabetes mellitus in preventing major vascular events. The primary efficacy end point was the composite of cardiovascular death, myocardial infarction, or stroke. Secondary end points included all-cause mortality and all major vascular events (cardiovascular death, myocardial infarction, stroke, or major adverse limb events, including amputation). The primary safety end point was a modification of the International Society on Thrombosis and Haemostasis criteria for major bleeding. Results: There were 10 341 patients with diabetes mellitus and 17 054 without diabetes mellitus in the overall trial. A consistent and similar relative risk reduction was seen for benefit of rivaroxaban plus aspirin (n=9152) versus placebo plus aspirin (n=9126) in patients both with (n=6922) and without (n=11 356) diabetes mellitus for the primary efficacy end point (hazard ratio, 0.74, P=0.002; and hazard ratio, 0.77, P=0.005, respectively, Pinteraction=0.77) and all-cause mortality (hazard ratio, 0.81, P=0.05; and hazard ratio, 0.84, P=0.09, respectively; Pinteraction=0.82). However, although the absolute risk reductions appeared numerically larger in patients with versus without diabetes mellitus, both subgroups derived similar benefit (2.3% versus 1.4% for the primary efficacy end point at 3 years, Gail-Simon qualitative Pinteraction

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with increased risk of death, stroke, and heart failure. Prevalence and incidence of AF are rising due to better overall medical treatment, longer survival, and increasing incidence of cardiometabolic and lifestyle risk factors. Treatment of AF and AF‑related complications significantly increases healthcare costs. In addition, the use of conventional rhythm control strategies (including, antiarrhythmic drugs and catheter ablation) is associated with limited efficacy for sinus rhythm maintenance and serious adverse effects. Aggressive cardiometabolic risk factor management may prevent incident as well as recurrent AF, improve overall health, and reduce mortality. Therefore, modifiable risk factor management became one of the 3 treatment pillars in AF management along with anticoagulation as well as conventional rate and rhythm control strategies. The second part of this review systematically discusses the association between AF and potentially modifiable risk factors for AF, such as obesity, obstructive sleep apnea, alcohol consumption, and dyslipidemia. We also provide practical guidelines for the risk factor management with respect to primary and secondary prevention of AF.

Background: An incidental lesion of the parasympathetic ganglia during circumferential pulmonary vein isolation (CPVI) may affect heart rate variability (HRV). Aims: We studied the pattern of changes in HRV parameters and the relationship between the 1‑year HRV change following CPVI and the recurrence of atrial fibrillation (AF). Methods: A total of 100 consecutive patients undergoing CPVI for paroxysmal AF were enrolled (mean [SD] age, 56 [11.2] years; 61 men). We measured HRV on the day before and after CPVI, and then at 1 month as well as 3, 6, and 12 months after CPVI using 24‑hour Holter monitoring. Results: During the median follow‑up of 33 months, 38 patients experienced the late recurrence of AF (LRAF). Compared with the pre‑CPVI values, HRV was significantly attenuated on day 1 after CPVI in all patients. However, at 3 to 6 months after CPVI, all HRV parameters remained significantly decreased in LRAF‑free patients but not in those with LRAF. The multivariate Cox analysis showed that early AF recurrence within the blanking period (hazard ratio [HR], 4.87; 95% CI, 2.44–9.69; P < 0.001) and a change in the standard deviation of normal‑to‑normal intervals (SDNN) observed 3 months after ablation (HR, 0.99; 95% CI, 0.98–1; P = 0.01) were associated with LRAF. The cumulative LRAF freedom after CPVI was greater in patients with an SDNN reduction of more than 25 ms reported 3 months after ablation than in those with a reduction of 25 ms or lower (log‑rank P = 0.004). Conclusions: Sustained parasympathetic denervation during 12 months after CPVI was a marker of successful CPVI, whereas a 3‑month post‑CPVI SDNN reduction of 25 ms or lower predicted LRAF.

Patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) are at high risk of stroke, recurrent coronary ischemic events, and cardiovascular mortality. The composition of antithrombotic therapy including an oral anticoagulant and antiplatelet drug(s) should be tailored according to the individual patient’s risk profile, to reduce the bleeding risk and maintain antithrombotic effect. There is no single antithrombotic treatment regimen that would fit to all patients with AF and ACS. However, available data promote the use of full‐dose direct oral anticoagulants (DOACs) (dabigatran 150 mg twice daily or apixaban 5 mg twice daily) or rivaroxaban 15 mg once daily in patients with AF and ACS or percutaneous coronary intervention (PCI). For many patients, a DOAC plus P2Y12 inhibitor early after ACS and/or PCI would be optimal, whereas a longer course of triple therapy should be used in patients at high thrombotic risk.

BACKGROUND: The 4S-AF scheme includes stroke risk, symptoms, severity of burden, and substrate severity domain. AIM: We aimed to assess the adherence to the 4S-AF scheme in patients classified according to stroke risk in post hoc analysis of the BALKAN-AF dataset. METHODS: A 14-week prospective enrolment of consecutive patients with electrocardiographically documented atrial fibrillation (AF) was performed in seven Balkan countries from 2014 to 2015. RESULTS: Low stroke risk (CHA2DS2-VASc score, 0 in males or 1 in females) was present in 162 (6.0%) patients. 2 099 (77.4%) patients had CHA2DS2-VASc score ≥3 in females or ≥2 in males (high stroke risk), and 613 (22.6%) had CHA2DS2-VASc score

Objectives Atrial fibrillation (AF) screening may increase early detection and reduce complications of AF. European, Australian and World Heart Federation guidelines recommend opportunistic screening, despite a current lack of clear evidence supporting a net benefit for systematic screening. Where screening is implemented, the most appropriate approaches are unknown. We explored the views of European stakeholders about opportunities and challenges of implementing four AF screening scenarios. Design Telephone-based semi-structured interviews with results reported using Consolidated criteria for Reporting Qualitative research guidelines. Data were thematically analysed using the framework approach. Setting AF screening stakeholders in 11 European countries. Participants Healthcare professionals and regulators (n=24) potentially involved in AF screening implementation. Intervention Four AF screening scenarios: single time point opportunistic, opportunistic prolonged, systematic single time point/prolonged and patient-led screening. Primary outcome measures Stakeholder views about the challenges and feasibility of implementing the screening scenarios in the respective national/regional healthcare system. Results Three themes developed. (1) Current screening approaches: there are no national AF screening programmes, with most AF detected in symptomatic patients. Patient-led screening exists via personal devices, creating screening inequity. (2) Feasibility of screening: single time point opportunistic screening in primary care using single-lead ECG devices was considered the most feasible. Software algorithms may aid identification of suitable patients and telehealth services have potential to support diagnosis. (3) Implementation requirements: sufficient evidence of benefit is required. National screening processes are required due to different payment mechanisms and health service regulations. Concerns about data security, and inclusivity for those without primary care access or personal devices must be addressed. Conclusions There is an overall awareness of AF screening. Opportunistic screening appears the most feasible across Europe. Challenges are health inequalities, identification of best target groups for screening, streamlined processes, the need for evidence of benefit and a tailored approach adapted to national realities. RS has received funding from the European Research Council under the European Union’s Horizon 2020 research and innovation program (grant agreement no. 648131); the German Center for Cardiovascular Research (DZHK) (81Z1710103); the European Union’s Horizon 2020 research and innovation programme (grant agreement no. 847770, AFFECT-EU) and ERACoSysMed3 (031L0239). We thank the participants and dedicated study staff of the AFFECT-EU studies for their generous contribution of time and efforts.

Europace : the European journal of pacing, arrhythmias and cardiac electrophysiology euac062 (2022). doi:10.1093/europace/euac062, Published by Oxford Univ. Press, Oxford

BACKGROUND: Cardiac troponins (cTn) have been reported to be predictors for adverse outcomes in atrial fibrillation (AF), patients, but their actual use is still unclear.AIM: To assess the factors associated with cTn testing in routine practice and evaluate the association with outcomes.METHODS: Patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry were stratified into 3 groups according to cTn levels as (i) cTn not tested, (ii) cTn in range (≤99th percentile), (iii) cTn elevated (>99th percentile). The composite outcome of any thromboembolism /any acute coronary syndrome/cardiovascular (CV) death, defined as Major Adverse Cardiovascular Events (MACE) and all-cause death were the main endpoints.RESULTS: Among 10 445 AF patients (median age 71 years, 40.3% females) cTn were tested in 2834 (27.1%). cTn was elevated in 904/2834 (31.9%) and in-range in 1930/2834 (68.1%) patients. Female sex, in-hospital enrollment, first-detected AF, CV risk factors, history of coronary artery disease, and atypical AF symptoms were independently associated with cTn testing. Elevated cTn were independently associated with a higher risk for MACE (Model 1, hazard ratio [HR] 1.74, 95% confidence interval [CI] 1.40-2.16, Model 2, HR 1.62, 95% CI 1.28-2.05; Model 3 HR 1.76, 95% CI 1.37-2.26) and all-cause death (Model 1, HR 1.45, 95% CI 1.21-1.74; Model 2, HR 1.36, 95% CI 1.12-1.66; Model 3, HR 1.38, 95% CI 1.12-1.71).CONCLUSIONS: Elevated cTn levels were associated with an increased risk of all-cause mortality and adverse CV events. Clinical factors that might enhance the need to rule out CAD were associated with cTn testing.

Background: Paroxysmal atrial fibrillation (AF) may often progress towards more sustained forms of the arrhythmia, but further research is needed on the factors associated with this clinical course. Methods: We analyzed patients enrolled in a prospective cohort study of AF patients. Patients with paroxysmal AF at baseline or first-detected AF (with successful cardioversion) were included. According to rhythm status at 1 year, patients were stratified into: (i) No AF progression and (ii) AF progression. All-cause death was the primary outcome. Results: A total of 2688 patients were included (median age 67 years, interquartile range 60–75, females 44.7%). At 1-year of follow-up, 2094 (77.9%) patients showed no AF progression, while 594 (22.1%) developed persistent or permanent AF. On multivariable logistic regression analysis, no physical activity (odds ratio [OR] 1.35, 95% CI 1.02–1.78), valvular heart disease (OR 1.63, 95% CI 1.23–2.15), left atrial diameter (OR 1.03, 95% CI 1.01–1.05), or left ventricular ejection fraction (OR 0.98, 95% CI 0.97–1.00) were independently associated with AF progression at 1 year. After the assessment at 1 year, the patients were followed for an extended follow-up of 371 days, and those with AF progression were independently associated with a higher risk for all-cause death (adjusted hazard ratio 1.77, 95% CI 1.09–2.89) compared to no-AF-progression patients. Conclusions: In a contemporary cohort of AF patients, a substantial proportion of patients presenting with paroxysmal or first-detected AF showed progression of the AF pattern within 1 year, and clinical factors related to cardiac remodeling were associated with progression. AF progression was associated with an increased risk of all-cause mortality.

Реални световни регистри на пациенти с предсърдно мъждене (ПМ) предоставиха важни данни за съвременния подход към ПМ и за спазването на препоръките при пациенти от повечето европейски региони. Макар че перспективните рандомизирани клинични изпитвания дават златен доказателствен стандарт, трябва да признаем, че те имат специфични критерии за включване/изключване и многогрупи пациенти могат да останат непредставени. Поради това има нужда от данни от реалния свят, целящи допълване и спазване на препоръките, особено при групи пациенти (напр. много възрастни и немощни, етнически малцинства, с краен стадий на бъбречна недостатъчност, от старчески домове, с когнитиви нарушения и т.н.), които са слабо представени или изключени от клинични проучвания. Изследването BALKAN-AF е най-голямият проспективен, многоцентров (общо 49 центъра), набор от обсервационни данни за AF на Балканите – европейски регион, населяван от около 10% от европейското население, който е недостатъчно представен в много предшестващи клинични изпитвания или регистри. В BALKAN-AF са събирани последователни данни за лица с електрокардиографски документирано невалвуларно ПМ от 7 балкански страни (Албания, Босна и Херцеговина, България, Хърватия, Черна гора, Румъния и Сърбия) от кардиолог или специалист по вътрешни болести при липса на кардиолог. Изследването BALKAN-AF е създадено и проведено от Сръбската асоциация по предсърдно мъждене (от декември 2014 до февруари 2015 г.). Real world registries of patients with atrial fi brillation (AF) have provided important evidence on contemporary AF management and adherence to guidelines in real-world patients across most of regions in Europe. While prospective randomized clinical trials are the ‘gold standard’ of evidence, we recognize that trials have specifi c inclusion/exclusion criteria and many groups of patients can be under-represented. Thus, real world evidence is needed to supplement and augment the evidence, especially for the under-represented patient groups (eg. the very elderly and frail, ethnic minorities, end stage renal failure, those in nursing homes, cognitive impairment, etc) that have been largely under-represented or excluded from clinical trials. The BALKAN-AF survey is the largest prospective, multicenter (a total of 49 centres), observational AF dataset from the Balkans, a European region inhabited by about 10% of the European population that has been under-represented in many prior clinical trials or registries. In BALKAN-AF, data regarding consecutive subjects with electrocardiographically documented non-valvular AF were collected in seven Balkan countries (Albania, Bosnia & Herzegovina, Bulgaria, Croatia, Montenegro, Romania and Serbia) by a cardiologist or an internal medicine specialist where cardiologist was not available. The Serbian Atrial Fibrillation Association created and conducted the BALKAN-AF survey (performed from December 2014 to February 2015).

Background Current classification systems recommended by major international guidelines are based on a single domain of atrial fibrillation (AF): temporal pattern, symptom severity or underlying comorbidity. Lack of integration between these various elements limits our approach to patients with AF and acts as a barrier against the delivery of better holistic care. The 4S-AF classification scheme was recently introduced as a means for the characterisation of patients with AF. It comprises of 4 domains: stroke risk (St), symptoms (Sy), severity of AF burden (Sb) and substrate (Su). We sought to examine the implementation of the 4S-AF scheme in the EORP-AF General Long-Term Registry and effects of individual domains on outcomes in AF. Methods Patients with AF from 250 centres across 27 participating European countries were included. All patients were over 18 years old and had electrocardiographic confirmation of AF within 12 months prior to enrolment. Data on demographics and comorbidities were collected at baseline. Individual domains of the 4S-AF scheme were assessed using the CHA2DS2-VASc score (St), European Heart Rhythm Association classification (Sy), temporal classification of AF (Sb), and cardiovascular risk factors and the degree of left atrial enlargement (Su). Each of these domains were used during multivariable cox regression analysis. Results A total of 6321 patients were included in the present analysis, corresponding to 57.0% of the original cohort of 11096 patients. The median age of patients was 70 (interquartile range [IQR] 62–77) years with 2615 (41.4%) females. Among these patients, 528 (8.4%) had low stroke risk (St=0), 3002 (47.5%) no or mild symptoms (Sy=0), 2558 (40.5%) newly diagnosed or paroxysmal AF (Sb=0), and 322 (5.1%) no cardiovascular risk factors or left atrial enlargement (Su=0). Median follow-up was 24 months. Using multivariable cox regression analysis, independent predictors of all-cause mortality were (St) (adjusted hazard ratio [aHR] 8.21 [95% CI, 2.60–25.9]), (Sb) (aHR 1.21 [95% CI, 1.08–1.35]) and (Su) (aHR 1.27 [95% CI, 1.14–1.41]). For cardiovascular mortality and any thromboembolic event, only (Su) (aHR 1.73 [95% CI, 1.45–2.06]) and (Sy) (aHR 1.29 [95% CI, 1.00–1.66]) were statistically important, respectively. None of the domains were independently linked to ischaemic stroke or major bleeding. Conclusion Overall, we demonstrated that the 4S-AF scheme may be used to provide clinical characterisation of patients with AF using routinely collected data, and each of the domains within the 4S-AF scheme were independently associated with adverse long-term outcomes of all-cause mortality, cardiovascular mortality and/or any thromboembolic event. Funding Acknowledgement Type of funding sources: None.

Background Management of patients with atrial fibrillation (AF) and malignancy is a clinical challenge given the paucity of evidence supporting the appropriate clinical management. Purpose To evaluate the outcomes of patients with active or prior malignancy in a large contemporary cohort of European AF patients. Methods We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. We stratified the population into three categories (i) No Malignancy (NoM) (ii) Prior Malignancy (PriorM) and (iii) Active Malignancy (ActM). The primary outcome for this analysis was all-cause death among the three groups. The association between anticoagulant treatment, all-cause death and haemorrhagic events was also evaluated. Results Among the original 11 096 AF patients enrolled, 10 383 were included in this analysis (median age 71 years (interquartile range [IQR] 63–77, males 59.7%). Of these, 9 597 (92.4%) were NoM patients, 577 (5.6%) PriorM and 209 (2%) ActM. Patients with malignancy (prior or active) had a higher median age, median CHA2DS2-VASc and HAS-BLED scores, compared to patients without malignancy (p After a median follow-up of 730 days [IQR 692–749], 982 (9.5%) patients died. Among all deaths, the proportion of cardiovascular death was different according to the three groups (40.0% in NoM, 26.0% in PrioM and 22.2% in ActM, p=0.002). For all cause-death, Kaplan-Meier analysis showed a progressively higher cumulative risk in the PriorM and ActM groups compared to NoM patients (Figure 1). On multivariable Cox regression analysis, adjusted for CHA2DS2-VASc score, use of AC, type of AF and chronic kidney disease, ActM group was independently associated with a higher risk for all cause death (hazard ratio [HR] 2.90, 95% confidence interval [CI] 2.23–3.76) while PriorM group was not. Among PriorM and NoM patients, multivariable adjusted Cox regression analysis found that the use of any AC was independently associated with a lower risk for all-cause death (HR 0.36, 95% CI 0.19–0.66; HR 0.66, 95% CI 0.54–0.81). No significant association between AC and all-cause death was found for ActM patients. Conclusions In a large contemporary cohort of European AF patients, active malignancy was found to be independently associated with all-cause death. Use of any AC was associated with a lower risk for all-cause death in patients with no malignancies and with prior malignancies, but with no significant association amongst patients with active malignancies. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Since the start of EORP, the following companies have supported the programme: Abbott Vascular Int. (2011–2021), Amgen Cardiovascular (2009–2018), AstraZeneca (2014–2021), Bayer (2009–2018), Boehringer Ingelheim (2009–2019), Boston Scientific (2009–2012), The Bristol Myers Squibb and Pfizer Alliance (2011–2016), The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2011–2017), Edwards (2016–2019), Gedeon Richter Plc. (2014–2017), Menarini Int. Op. (2009–2012), MSD-Merck & Co. (2011–2014), Novartis Pharma AG (2014–2020), ResMed (2014–2016), Sanofi (2009–2011), SERVIER (2010–2021), and Vifor (2019–2022). Figure 1. Kaplan-Meier for all-cause death

Background Current European Society of Cardiology guidelines on atrial fibrillation (AF) propose a structured characterization of AF in order to facilitate the evaluation of patients by physicians at all healthcare levels. The 4S-AF structured scheme includes four domains: stroke risk, symptoms, severity of AF burden and substrate severity. Purpose To evaluate the adherence to the 4S-AF scheme in patients with high risk of stroke (CHA2DS2-VASc score ≥3 in females or ≥2 in males) in the post-hoc analysis of the BALKAN-AF dataset. Methods Prospective enrolment of consecutive patients with electrocardiographically documented AF was conducted in seven Balkan countries. Results Of the 2,712 enrolled patients, 2,712 (100.0%) had data on CHA2DS2-VASc score. 162 (6.0%) had truly low risk of stroke (CHA2DS2-VASc score of 0 in males and 1 in females). 2099 (77.4%) of patients had high risk of stroke and 613 (22.6%) individuals had low or intermediate risk of stroke (CHA2DS2-VASc score Of the 2,712 patients, 2,677 (98.7%) had data on European Heart Rhythm Association (EHRA) symptom score. Among 2,099 patients with high risk of stroke, 703 (33.4%) individuals had EHRA symptom score of 3 or 4. 207 (29.4%) of patients with EHRA symptom score of 3 or 4 and high risk of stroke were offered rhythm control strategy. 620 (55.2%) of patients with first diagnosed AF or paroxysmal AF with high risk of stroke were offered rhythm control strategy. 1927 (91.8%) of patients with high risk of stroke had ≥2 comorbidities. Mean left atrial diameter in patients with high risk of stroke was 46.5±7.8 mm. Conclusions OAC overuse was seen in patients with truly low stroke risk, whist OAC underuse was evident in patients with high risk of stroke. The proportion of highly symptomatic patients (EHRA 3 or 4) with high risk of stroke who were offered rhythm control strategy was low. The proportion of patients with first diagnosed AF or paroxysmal AF with high risk of stroke who received rhythm control was small. The majority of AF patients with high risk of stroke had ≥2 comorbidities. Overall, treatment decision-making was not based on the 4S-AF scheme. Funding Acknowledgement Type of funding sources: None.

Background There is a long-standing and unresolved controversy over the effects of digoxin on mortality. Furthermore, there is scarce evidence comparing the use of digoxin to beta-blocker in the general population with atrial fibrillation (AF). In this study, we aimed to evaluate the effects of digoxin over beta-blocker therapy among patients with AF. Methods Patients from the EORP-AF General Long-Term Registry with AF who were treated with either digoxin or beta-blocker were included. All patients were over 18 years old and had documented evidence of AF within 12 months prior to enrolment. The outcomes of interest were all-cause mortality, cardiovascular (CV) mortality, non-CV mortality and number of patients with unplanned hospitalisation (total and AF-related). These were recorded until the last known follow-up available. Results Of 6377 patients, 549 (8.6%) and 5828 (91.4%) were treated with digoxin and beta-blockers, respectively. Patients in the digoxin group were older (73 vs. 71 years, p Over 24 months follow-up, there were 550 (8.6%) all-cause mortality and 1304 (23.6%) patients with unplanned emergency hospitalisation. Digoxin use was associated with increased all-cause mortality (hazard ratio [HR] 1.90 [95% CI, 1.48–2.44]), both from CV and non-CV causes (CV: HR 2.21 [95% CI, 1.49–3.26]); non-CV: HR 1.70 [95% CI, 1.04–2.79]). There was no statistical difference in terms of unplanned emergency hospitalisation (HR 0.99 [95% CI, 0.80–1.21]) and AF-related hospitalisation (HR 0.78 [95% CI, 0.58–1.06]) between both groups. Using multivariable cox regression analysis, digoxin compared to beta-blocker therapy was independently linked to increased all-cause mortality (HR 1.52 [95% CI, 1.11–2.09]) and CV mortality (HR 1.82 [95% CI, 1.11–2.97]), but was not related to non-CV mortality (HR 1.31 [95% CI, 0.71–2.41]), emergency hospitalisation (HR 0.91 [95% CI, 0.71–1.16]) or AF-related hospitalisation (HR 0.88 [95% CI, 0.62–1.24]), after adjustment for known risk factors. Conclusion We demonstrated that the use of digoxin was independently associated with excess all-cause mortality, driven by CV death, but was non-inferior to beta-blocker in terms of preventing unplanned emergency or AF-related hospitalisation, after accounting for important risk factors. Funding Acknowledgement Type of funding sources: None.

Background Atrial fibrillation (AF) screening has the potential to increase early detection and possibly reduce complications of AF. Guidelines recommend screening, but the most appropriate approaches are unknown. Purpose We aimed to explore the views of stakeholders across Europe about the opportunities and challenges of implementing four different AF screening scenarios. Method This qualitative study included 21 semi-structured interviews with healthcare professionals and regulators potentially involved in AF screening implementation in nine European countries. Data were analysed using thematic analysis. Results Three themes evolved. 1) Current approaches to screening: there are no national AF screening programmes, with most AF detected in symptomatic patients. Patient-led screening exists via personal devices, creating screening inequity by the reach of screening programmes being limited to those who access healthcare services. 2) Feasibility of screening approaches: single time point opportunistic screening in primary care using single lead ECG devices was considered the most feasible approach and AF screening may be possible in previously unexplored settings such as dentists and podiatrists. Software algorithms may aid identification of patients suitable for screening and telehealth services have the potential to support diagnosis. However, there is a need for advocacy to encourage the use of telehealth to aid AF diagnosis, and training for screening familiarisation and troubleshooting. 3) Implementation requirements: sufficient evidence of benefit is required. National rather than pan-European screening processes must be developed due to different payment mechanisms and health service regulations. There is concern that the rapid spread of wearable devices for heart rate monitoring may increase workload due to false positives in low risk populations for AF. Data security and inclusivity for those without access to primary care or personal devices must be addressed. Conclusions There is an overall awareness of AF screening. Opportunistic screening appears to be most feasible across Europe. Challenges that need to be addressed concern health inequalities, identification of best target groups for screening, streamlined processes, the need for evidence of benefit, and a tailored approach adapted to national realities. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): H2020 Screening ScenariosGraphical abstract

INTRODUCTION: The Atrial fibrillation Better Care (ABC) pathway provides a useful way of simplifying decision‑making considerations in a holistic approach to atrial fibrillation management.OBJECTIVES: To evaluate adherence to the ABC pathway and to determine major gaps in adherence in patients in the BALKAN‑AF survey.PATIENTS AND METHODS: In this ancillary analysis, patients from the BALKAN‑AF survey were divided into the following groups: A (avoid stroke) + B (better symptom control) + C (cardiovascular and comorbidity risk management)-adherent and -nonadherent management.RESULTS: Among 2712 enrolled patients, 1013 (43.8%) patients with mean (SD) age of 68.8 (10.2) years and mean CHA2DS2‑VASc score of 3.4 (1.8) had A+B+C-adherent management and 1299 (56.2%) had A+B+C-nonadherent management. Independent predictors of increased A+B+C-adherent management were: capital city (odds ratio [OR], 1.23; 95% CI, 1.03-1.46; P = 0.02), treatment by cardiologist (OR, 1.34; 95% CI, 1.08-1.66; P = 0.01), hypertension (OR, 2.2; 95% CI, 1.74-2.77; P CONCLUSIONS: Physicians' adherence to integrated AF management based on the ABC pathway was suboptimal. Addressing the identified clinical and system‑related factors associated with A+B+C-nonadherent management using targeted approaches is needed to optimize treatment of patients with AF in the Balkan region.

Background/Aim. Atrioventricular nodal (AV) reentry tachycardia (AVNRT) is the most common form of supraventricular tachycardia. Treatment of choice is a catheter-ablation of the slow pathway of the AV node. The aim of the study was to present the outcomes of this procedure after ten years of follow-up. Methods. The catheter- ablation procedure was performed in 92 patients (30 men and 62 women, mean age 52.0 ? 13.3 years, range 19 to 76 years) with confirmed AVNRT during the electrophysiological examination, from 2007 to 2009. Out of these, 64 patients were followed-up for ten years by inviting them to clinical examinations regularly. The occurrence of AV block, arrhythmia and the use of antyarrhythmic drugs were the main outcomes of the ten-year follow-up. Multivariate logistic regression was applied to identify significant predictors of arrhythmia after a follow-up period. Results. The primary success of intervention was achieved in 91 (98.9%) patients. Third-degree AV block was registered in 1 (1.1%) patient after the intervention, which required the implantation of a pacemaker. After ten years of follow-up, AVNRT relapses were not registered. A total of 7 out of 64 (10.9%) patients died during the follow-up period, mostly due to non-cardiac causes. After ten years of follow-up, firstdegree AV block was registered in six (10.5%) patients, whereas other arrhythmias were observed in 17 (29.8%) patients such as atrial fibrillation or flutter, atrial premature beats and sinus tachycardia. The number of antiarrhythmic drugs were reduced from 2.1 ? 1.2 at baseline to 0.5 ? 0.6 during follow-up, mostly beta-blockers, propafenone and amiodarone, and 33 (57.9%) patients were no longer using anti-arrhythmic therapy. Logistic regression identified participant?s age above 55 years at baseline and re-intervention performed after the initial catheter-ablation as significant predictors of arrhythmia after a 10-year follow-up, independent from gender and arterial hypertension at baseline. Conclusion. The catheter-ablation of AVNRT represents a successful and safe procedure, from the perspective of tenyear follow-up.

Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non–vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non–vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.

Aims Arrhythmia recurrences after catheter ablation of atrial fibrillation (AF) still remain an important management issue. Recently, the APPLE score had been introduced to predict rhythm outcomes within 12 months after catheter ablation, while the simple MB-LATER score was developed for the prediction of very late recurrence of AF (VLRAF) occurring after 12 months. The aim of this study was to compare APPLE and MB-LATER scores in predicting VLRAF. Methods and results The study population included arrhythmia-free patients within first 12 months after first radiofrequency catheter ablation from The Heart Center Leipzig AF Ablation Registry. The APPLE [one point for Age >65 years, Persistent AF, imPaired eGFR 120 ms, LA diameter ≥47 mm, AF Type (persistent AF), Early Recurrence Conclusion Prediction of VLRAF is similar for both APPLE and MB-LATER scores. A better score remains still a clinical unmet need.

PURPOSE: Cryoballoon ablation (CBA) is an effective technique for pulmonary vein isolation (PVI). To date, there are no risk models to predict very late recurrence of atrial fibrillation (VLRAF) after CBA. METHODS: Retrospective analysis of a single-center database was performed. Inclusion criteria included PVI using CBA for atrial fibrillation (AF) without additional ablation targets, follow-up > 365 days, and no recurrent AF between 90 and 365 days after procedure. The primary endpoint was recurrent AF > 30 s > 12 months post-CBA. A risk model was created using clinical variables. RESULTS: Of 674 CBA performed from 2011 to 2016, 300 patients (200 male, 62.0 ± 9.9 years) met inclusion criteria. Of these, 159 (53.0%) patients had paroxysmal AF. Patients had an average of 9.5 ± 2.7 cryoballoon freezes, and no patients required additional radiofrequency ablation lesion sets. Over a follow-up of 995 ± 490 days, 77/300 (25.7%) patients exhibited VLRAF. Univariate and multivariate analyses demonstrated that Structural heart disease (1 point), Coronary artery disease (3 points), left Atrial diameter > 43 mm (1 point), Left bundle branch block (3 points), Early return of AF (4 points), and non-paroxysmal AF (3 points) were risk factors for VLRAF. Combining these variables into a risk model, SCALE-CryoAF, (min 0; max 15) predicted VLRAF with an area under the curve of 0.73. CONCLUSION: SCALE-CryoAF is the first risk model to specifically predict first recurrence of AF beyond 1 year, VLRAF, after CBA. Model discrimination demonstrates that SCALE-CryoAF predicts VLRAF after CBA significantly better than other risk models for AF recurrence.