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Background: The DOAC score has been recently proposed for bleeding risk stratification of patients with atrial fibrillation treated with direct oral anticoagulants (DOAC)., Objective: To compare the performance of HAS-BLED and DOAC score in predicting major bleeding events in a contemporary cohort of European AF patients treated with DOAC., Methods: We included patients derived from a prospective observational registry of European AF patients. HAS-BLED and DOAC scores were calculated as per the original schemes. Our primary endpoint was major bleeding events. Receiver operating characteristic (ROC) curves were used to compare the predictive ability of the scores., Results: A total of 2834 AF patients (median age [IQR] 69 [62-77] years; 39.6 % female) treated with DOAC were included in the analysis. According to the HAS-BLED score, 577 patients (20.4 %) were categorized as very low risk of bleeding, as compared to 1276 (45.0 %) according to DOAC score. A total of 55 major bleeding events occurred with an overall incidence of 1.04 per 100 patient-years. Both scores showed only a modest ability for the prediction of bleeding events (HAS-BLED area under the curve [AUC], 0.65, 95 % confidence interval [CI] 0.55-0.70; DOAC score AUC 0.62, 95 % CI 0.59-0.71, p for difference = 0.332]. At calibration analysis, the DOAC score showed modest calibration, especially for patients at high risk, when compared to HAS-BLED., Conclusion: In a contemporary cohort of DOAC-treated AF patients, both HAS-BLED and DOAC scores only modestly predicted the occurrence of major bleeding events. Our results do not support the preferential use of DOAC score over HAS-BLED., Competing Interests: Declaration of competing interest GB: reports small speaker fees from Bayer, Boehringer Ingelheim, Boston, BMS, Daiichi, Sanofi and Janssen outside the submitted work. GYHL: Consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, Daiichi-Sankyo, Anthos. No fees are received personally. He is a National Institute for Health and Care Research (NIHR) Senior Investigator and co-PI of the AFFIRMO project on multimorbidity in AF (grant agreement No 899871), TARGET project on digital twins for personalised management of atrial fibrillation and stroke (grant agreement No 101136244) and ARISTOTELES project on artificial intelligence for management of chronic long term conditions (grant agreement No 101080189), which are all funded by the EU's Horizon Europe Research & Innovation programme. MP: Italian national Principal Investigator of the AFFIRMO project on multimorbidity in atrial fibrillation, which has received funding from the European Union's Horizon 2020 research and innovation program under grant agreement No 899871. GFR: GFR reports consultancy for Boehringer Ingelheim and an educational grant from Anthos, outside the submitted work. No fees are directly received personally. The other authors do not have conflict of interests to report., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

The management of patients with atrial fibrillation (AF) requires intricate clinical decision-making to optimize outcomes. In everyday clinical practice, physicians undergo difficult choices to better manage patients with AF. They need to balance thromboembolic and bleeding risk to focus on patients' symptoms and to manage a variety of multiple comorbidities. In this review, we aimed to explore the multifaceted dimensions of clinical decision-making in AF patients, encompassing the definition and diagnosis of clinical AF, stroke risk stratification, oral anticoagulant therapy selection, consideration of bleeding risk, and the ongoing debate between rhythm and rate control strategies. We will also focus on possible grey zones for the management of AF patients. In navigating this intricate landscape, clinicians must reconcile the dynamic interplay of patient-specific factors, evolving guidelines, and emerging therapies. The review underscores the need for personalized, evidence-based clinical decision-making to tailor interventions for optimal outcomes according to specific AF patient profiles.

Aims: Same-day discharge (SDD) after catheter ablation of atrial fibrillation (AF) may address the growing socio-economic health burden of the increasing demand for interventional AF therapies. This systematic review and meta-analysis analyses the current evidence on clinical outcomes in SDD after AF ablation compared with overnight stay (ONS)., Methods and Results: A systematic search of the PubMed database was performed. Pre-defined endpoints were complications at short-term (24-96 h) and 30-day post-discharge, re-hospitalization, and/or emergency room (ER) visits at 30-day post-discharge, and 30-day mortality. Twenty-four studies (154 716 patients) were included. Random-effects models were applied for meta-analyses of pooled endpoint prevalence in the SDD cohort and for comparison between SDD and ONS cohorts. Pooled estimates for complications after SDD were low both for short-term [2%; 95% confidence interval (CI): 1-5%; I2: 89%) and 30-day follow-up (2%; 95% CI: 1-4%; I2: 91%). There was no significant difference in complications rates between SDD and ONS [short-term: risk ratio (RR): 1.62; 95% CI: 0.52-5.01; I2: 37%; 30 days: RR: 0.65; 95% CI: 0.42-1.00; I2: 95%). Pooled rates of re-hospitalization/ER visits after SDD were 4% (95% CI: 1-10%; I2: 96%) with no statistically significant difference between SDD and ONS (RR: 0.86; 95% CI: 0.58-1.27; I2: 61%). Pooled 30-day mortality was low after SDD (0%; 95% CI: 0-1%; I2: 33%). All studies were subject to a relevant risk of bias, mainly due to study design., Conclusion: In this meta-analysis including a large contemporary cohort, SDD after AF ablation was associated with low prevalence of post-discharge complications, re-hospitalizations/ER visits and mortality, and a similar risk compared with ONS. Due to limited quality of current evidence, further prospective, randomized trials are needed to confirm safety of SDD and define patient- and procedure-related prerequisites for successful and safe SDD strategies., Competing Interests: Conflict of interest: M.M.Z. reports lecture fees/honoraria and travel support by Medtronic, Boston Scientific, Bayer Vital, Pfizer, Abbott, and ZOLL CMS. F.L. is a consultant to and has received financial research support from Medtronic, Abbott, Boston Scientific, Biotronik, and MicroPort. R.C.-A. has received small amounts for educational meetings from Abbott and Boston Scientific. F.B. has received fees from Medtronic and Biotronik for trial committee assignments. Other industry collaborations are handled through the employer with no personal fees paid to FB. H.P. reports honoraria for lectures and scientific advice from Abbott, Boston Scientific, Biosense Webster, and Medtronic. J.L.M reports fees and honoraria for lectures, education and scientific advice from Biotronik, MicroPort, and Zoll. G.B. reports small speaker fees from Bayer, Boehringer Ingelheim, Boston, Daiichi Sankyo, Janssen, and Sanofi outside of the submitted work. The other authors have no conflict of interest to disclose., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: Physiological activation of the heart using algorithms to minimize right ventricular pacing (RVPm) may be an effective strategy to reduce adverse events in patients requiring anti-bradycardia therapies. This systematic review and meta-analysis aimed to evaluate current evidence on clinical outcomes for patients treated with RVPm algorithms compared to dual-chamber pacing (DDD)., Methods and Results: We conducted a systematic search of the PubMed database. The predefined endpoints were the occurrence of persistent/permanent atrial fibrillation (PerAF), cardiovascular (CV) hospitalization, all-cause death, and adverse symptoms. We also aimed to explore the differential effects of algorithms in studies enrolling a high percentage of atrioventricular block (AVB) patients. Eight studies (7229 patients) were included in the analysis. Compared to DDD pacing, patients using RVPm algorithms showed a lower risk of PerAF [odds ratio (OR) 0.74, 95% confidence interval (CI) 0.57-0.97] and CV hospitalization (OR 0.77, 95% CI 0.61-0.97). No significant difference was found for all-cause death (OR 1.01, 95% CI 0.78-1.30) or adverse symptoms (OR 1.03, 95% CI 0.81-1.29). No significant interaction was found between the use of the RVPm strategy and studies enrolling a high percentage of AVB patients. The pooled mean RVP percentage for RVPm algorithms was 7.96% (95% CI 3.13-20.25), as compared with 45.11% (95% CI 26.64-76.38) of DDD pacing., Conclusion: Algorithms for RVPm may be effective in reducing the risk of PerAF and CV hospitalization in patients requiring anti-bradycardia therapies, without an increased risk of adverse symptoms. These results are also consistent for studies enrolling a high percentage of AVB patients., Competing Interests: Conflict of interest: G.B. reports small speaker fees from Bayer, Boehringer Ingelheim, Boston, BMS, Daiichi, Sanofi, and Janssen, outside the submitted work. The other authors do not have conflict of interests to report., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Competing Interests: Conflict of interest: G.B. reported speaker fees of small amount from Bayer, Boston, Boehringer, Daiichi-Sankyo, Janssen, Sanofi, outside the submitted work. The other authors reported no conflict.

Atrial fibrillation (AF) may be asymptomatic and the extensive monitoring capabilities of cardiac implantable electronic devices (CIEDs) revealed asymptomatic atrial tachi-arrhythmias of short duration (minutes-hours) occurring in patients with no prior history of AF and without AF detection at a conventional surface ECG. Both the terms "AHRE" (Atrial High-Rate Episodes) and subclinical AF were used in a series of prior studies, that evidenced the association with an increased risk of stroke. Two randomized controlled studies were planned in order to assess the risk-benefit profile of anticoagulation in patients with AHRE/subclinical AF: the NOAH and ARTESiA trials. The results of these two trials (6548 patients enrolled, overall) show that the risk of stroke/systemic embolism associated with AHRE/subclinical AF is in the range of 1-1.2 % per patient-year, but with an important proportion of severe/fatal strokes occurring in non-anticoagulated patients. The apparent discordance between ARTESiA and NOAH results may be approached by considering the related study-level meta-analysis, which highlights a consistent reduction of ischemic stroke with oral anticoagulants vs. aspirin/placebo (relative risk [RR] 0.68, 95 % CI 0.50-0.92). Oral anticoagulation was found to increase major bleeding (RR 1.62, 95 % CI 1.05-2.5), but no difference was found in fatal bleeding (RR 0.79, 95 % CI 0.37-1.69). Additionally, no difference was found in cardiovascular death or all-cause mortality. Taking into account these results, clinical decision-making for patients with AHRE/subclinical AF at risk of stroke, according to CHA 2 DS 2 -VASc, can now be evidence-based, considering the benefits and related risks of oral anticoagulants, to be shared with appropriately informed patients., Competing Interests: Declaration of competing interest The authors report no conflict of interests related to the present article. G Boriani reported small speaker fees from Bayer, Boehringer Ingelheim, Boston, Daiichi Sankyo, Janssen, and Sanofi outside of the submitted work. G Boriani is the Principal Investigator of the ARISTOTELES project (Applying ARtificial Intelligence to define clinical trajectorieS for personalized predicTiOn and early deTEction of comorbidity and muLtimorbidity pattErnS) that received funding from the European Union within the Horizon 2020 Research and Innovation Program (Grant N. 101080189). M Proietti is the Italian national leader of the AFFIRMO project on multimorbidity in atrial fibrillation, that received funding from the European Union within the Horizon 2020 Research and Innovation Program (Grant N. 899871). The other authors did not report conflicts of interest to disclose outside of the submitted work., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: The outcome implications of asymptomatic vs. symptomatic atrial fibrillation (AF) in specific groups of patients according to clinical heart failure (HF) and left ventricular ejection fraction (LVEF) need to be clarified., Methods: In a prospective observational study, patients were categorized according to overt HF with LVEF≤40 %, or with LVEF>40 %, or without overt HF with LVEF40 %≤ or > 40 %, as well as according to the presence of asymptomatic or symptomatic AF., Results: A total of 8096 patients, divided into 8 groups according to HF and LVEF, were included with similar proportions of asymptomatic AF (ranging from 43 to 48 %). After a median follow-up of 730 [699 -748] days, the composite outcome (all-cause death and MACE) was significantly worse for patients with asymptomatic AF associated with HF and reduced LVEF vs. symptomatic AF patients of the same group (p = 0.004). On adjusted Cox regression analysis, asymptomatic AF patients with HF and reduced LVEF were independently associated with a higher risk for the composite outcome (aHR 1.32, 95 % CI 1.04-1.69) and all-cause death (aHR 1.33, 95 % CI 1.02-1.73) compared to symptomatic AF patients with HF and reduced LVEF. Kaplan-Meier curves showed that HF-LVEF≤40 % asymptomatic patients had the highest cumulative incidence of all-cause death and MACE (p < 0.001 for both)., Conclusions: In a large European cohort of AF patients, the risk of the composite outcome at 2 years was not different between asymptomatic and symptomatic AF in the whole cohort but adverse implications for poor outcomes were found for asymptomatic AF in HF with LVEF≤40 %., Competing Interests: Declaration of Competing Interest The authors reported no conflict of interests related to the present article. GB reported small speaker fees from Bayer, Boehringer Ingelheim, Boston, Daiichi Sankyo, Janssen, and Sanofi. GFR reported consultancy for Boehringer Ingelheim and an educational grant from Anthos, outside the submitted work. (no fees are directly received personally). MP is national leader of the AFFIRMO project on multimorbidity in AF, which has received funding from the European Union's Horizon 2020 research and innovation program under grant agreement No 899871; TP reported to be consultant for Bayer and Pfizer (no fees). GAD reported small speaker fees from Boehringer-Ingelheim, Pfizer, Bayer, Sanofi; GYHL reported to be consultant and speaker for Bayer/Janssen, BMS/Pfizer, Boehringer Ingelheim, and Daiichi-Sankyo (no fees are directly received personally). All the disclosures occurred outside the submitted work. Other authors have no disclosures to declare, (Copyright © 2023 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Aims: Electrophysiological (EP) operations that have traditionally involved long hospital lengths of stay (LOS) are now being undertaken as day case procedures. The coronavirus disease-19 pandemic served as an impetus for many centres to shorten LOS for EP procedures. This survey explores LOS for elective EP procedures in the modern era., Methods and Results: An online survey consisting of 27 multiple-choice questions was completed by 245 respondents from 35 countries. With respect to de novo cardiac implantable electronic device (CIED) implantations, day case procedures were reported for 79.5% of implantable loop recorders, 13.3% of pacemakers (PMs), 10.4% of implantable cardioverter defibrillators (ICDs), and 10.2% of cardiac resynchronization therapy (CRT) devices. With respect to CIED generator replacements, day case procedures were reported for 61.7% of PMs, 49.2% of ICDs, and 48.2% of CRT devices. With regard to ablations, day case procedures were reported for 5.7% of atrial fibrillation (AF) ablations, 10.7% of left-sided ablations, and 17.5% of right-sided ablations. A LOS ≥ 2 days for CIED implantation was reported for 47.7% of PM, 54.5% of ICDs, and 56.9% of CRT devices and for 54.5% of AF ablations, 42.2% of right-sided ablations, and 46.1% of left-sided ablations. Reimbursement (43-56%) and bed availability (20-47%) were reported to have no consistent impact on the organization of elective procedures., Conclusion: There is a wide variation in the LOS for elective EP procedures. The LOS for some procedures appears disproportionate to their complexity. Neither reimbursement nor bed availability consistently influenced LOS., Competing Interests: Conflict of interest: G.B. reported small speaker fees from Bayer, Boehringer Ingelheim, Boston, Daiichi Sankyo, Microport, Janssen, and Sanofi outside of the submitted work. R.C.-A. reported small educational speakers fees from Abbott and Boston Scientific. J.C. reports lecture fees/honoraria, educational grants Boston Scientific, Medtronic, and Biosense Webster outside of the submitted work. M.M.Z. reports lecture fees/honoraria, educational grants, and travel support by Medtronic, Boston Scientific, Bayer Vital, ZOLL CMS, and Pfizer. D.D. received modest lecture honorary fees from Abbott, Astra Zeneca, Biotronik, Boehringer Ingelheim, Boston Scientific, Bristol Myers Squibb, CVRx, Medtronic, Microport, Pfizer, and Zoll. M.M.F. reports speaker/consultation fees from Medtronic, Abbott, and ZOLL. The other authors did not report conflicts of interest to disclose outside of the submitted work., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: To know the prevalence of atrial fibrillation (AF), as well as the incidence of postoperative AF (POAF) in vascular surgery for arterial diseases and its outcome implications., Methods: We performed a systematic review and meta-analysis following the PRISMA statement., Results: After the selection process, we analyzed 44 records (30 for the prevalence of AF history and 14 for the incidence of POAF).The prevalence of history of AF was 11.5% [95% confidence interval (CI) 1-13.3] with high heterogeneity (I2 = 100%). Prevalence was higher in the case of endovascular procedures. History of AF was associated with a worse outcome in terms of in-hospital death [odds ratio (OR) 3.29; 95% CI 2.66-4.06; P < 0.0001; I2 94%] or stroke (OR 1.61; 95% CI 1.39-1.86; P < 0.0001; I2 91%).The pooled incidence of POAF was 3.6% (95% CI 2-6.4) with high heterogeneity (I2 = 100%). POAF risk was associated with older age (mean difference 4.67 years, 95% CI 2.38-6.96; P = 0.00007). The risk of POAF was lower in patients treated with endovascular procedures as compared with an open surgical procedure (OR 0.35; 95% CI 0.13-0.91; P = 0.03; I2 = 61%)., Conclusions: In the setting of vascular surgery for arterial diseases a history of AF is found overall in 11.5% of patients, more frequently in the case of endovascular procedures, and is associated with worse outcomes in terms of short-term mortality and stroke.The incidence of POAF is overall 3.6%, and is lower in patients treated with an endovascular procedure as compared with open surgery procedures. The need for oral anticoagulants for preventing AF-related stroke should be evaluated with randomized clinical trials., (Copyright © 2023 Italian Federation of Cardiology - I.F.C. All rights reserved.)

Aims: The HeartLogic Index combines data from multiple implantable cardioverter defibrillators (ICDs) sensors and has been shown to accurately stratify patients at risk of heart failure (HF) events. We evaluated and compared the performance of this algorithm during sinus rhythm and during long-lasting atrial fibrillation (AF)., Methods and Results: HeartLogic was activated in 568 ICD patients from 26 centres. We found periods of ≥30 consecutive days with an atrial high-rate episode (AHRE) burden <1 h/day and periods with an AHRE burden ≥20 h/day. We then identified patients who met both criteria during the follow-up (AHRE group, n = 53), to allow pairwise comparison of periods. For control purposes, we identified patients with an AHRE burden <1 h throughout their follow-up and implemented 2:1 propensity score matching vs. the AHRE group (matched non-AHRE group, n = 106). In the AHRE group, the rate of alerts was 1.2 [95% confidence interval (CI): 1.0-1.5]/patient-year during periods with an AHRE burden <1 h/day and 2.0 (95% CI: 1.5-2.6)/patient-year during periods with an AHRE-burden ≥20 h/day (P = 0.004). The rate of HF hospitalizations was 0.34 (95% CI: 0.15-0.69)/patient-year during IN-alert periods and 0.06 (95% CI: 0.02-0.14)/patient-year during OUT-of-alert periods (P < 0.001). The IN/OUT-of-alert state incidence rate ratio of HF hospitalizations was 8.59 (95% CI: 1.67-55.31) during periods with an AHRE burden <1 h/day and 2.70 (95% CI: 1.01-28.33) during periods with an AHRE burden ≥20 h/day. In the matched non-AHRE group, the rate of HF hospitalizations was 0.29 (95% CI: 0.12-0.60)/patient-year during IN-alert periods and 0.04 (95% CI: 0.02-0.08)/patient-year during OUT-of-alert periods (P < 0.001). The incidence rate ratio was 7.11 (95% CI: 2.19-22.44)., Conclusion: Patients received more alerts during periods of AF. The ability of the algorithm to identify increased risk of HF events was confirmed during AF, despite a lower IN/OUT-of-alert incidence rate ratio in comparison with non-AF periods and non-AF patients., Clinical Trial Registration: http://clinicaltrials.gov/Identifier: NCT02275637., Competing Interests: Conflict of interest: G.B. reported small speaker fees from Bayer, Boehringer Ingelheim, Boston, Daiichi Sankyo, Janssen, and Sanofi outside of the submitted work. L.S. is a consultant for Boston Scientific, Abbott, and Medtronic and reported small speaker fees from Zoll. M.Z. reported small speaker fees from Abbott, Boston Scientific, and Biotronik. M.C. and S.V. are employees of Boston Scientific, Inc. The other authors did not report other conflicts of interest to disclose., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

There is increasing concern regarding impact of clinical complexity in patients with atrial fibrillation (AF). We explored the impact of different clinical complexity features in AF patients. We analyzed patients from a prospective, observational, multicenter Europe-wide AF registry. Features of clinical complexity among patients with CHA 2 DS 2 -VASc ≥2 were: (1) history of bleeding; (2) frailty; (3) chronic kidney disease (CKD); (4) ≥2 features. A total of 10,169 patients were analyzed. Of these, 141 (1.4%) had history of bleeding, 954 (9.4%) were frail, 1767 (17.4%) had CKD and 1253 (12.3%) had ≥2 features. All features of clinical complexity were less treated with OAC. History of bleeding (HR 1.94, 95% CI 1.32-2.85), frailty (HR 1.38, 95% CI 1.11-1.71), CKD (HR 1.50, 95% 1.28-1.75) and ≥2 features (HR 2.08, 95% CI 1.73-2.51) were associated with outcomes. Presence of features of clinical complexity is associated with lower use of OAC and higher risk of outcomes., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Aim: Atrial fibrillation is a multifaceted disease requiring personalized treatment, in accordance with current ESC guidelines. Despite a wide range of literature, we still have various aspects dividing the opinion of the experts in rate control, rhythm control and thromboembolic prophylaxis. The aim of this survey was to provide a country-wide picture of current practice regarding atrial fibrillation pharmacological management according to a patient's characteristics., Methods: Data were collected using an in-person survey that was administered to members of the Italian Association of Arrhythmology and Cardiac Pacing., Results: We collected data from 106 physicians, working in 72 Italian hospitals from 15 of 21 regions. Our work evidenced a high inhomogeneity in atrial fibrillation management regarding rhythm control, rate control and thromboembolic prophylaxis in both acute and chronic patients. This element was more pronounced in settings in which literature shows a lack of evidence and, consequently, the indications provided by the guidelines are weak or absent., Conclusion: This National survey evidenced a high inhomogeneity in current approaches adopted for atrial fibrillation management by a sample of Italian cardiologist experts in arrhythmia management. Further studies are needed to explore if these divergences are associated with different long-term outcomes., (Copyright © 2023 Italian Federation of Cardiology - I.F.C. All rights reserved.)

Aims: Adherence to guideline-directed oral anticoagulation (OAC) in patients with atrial fibrillation (AF) improves outcomes, but limited data are available from China. We evaluated the adherence to guideline-directed anticoagulation and its impact on clinical outcomes in a high-risk cohort of elderly Chinese patients., Methods and Results: The Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry is a prospective, multicentre study conducted from October 2014 to December 2018. Endpoints of interest were all-cause death, thromboembolic (TE) events and major bleedings in patients with a guideline-directed indication for OACs (CHA2DS2-VASc ≥1 if male or ≥2 if female). The eligible cohort consisted of 5742 patients, of whom 2567 (44.7%) patients were treated with an OAC. Seven independent predictors of OAC undertreatment were identified: age [odds ratio (OR): 1.04; 95% confidence interval (CI): 1.03-1.05; P < 0.001], first diagnosed AF (OR: 1.71; 95%CI: 1.44-2.03; P < 0.001), chronic kidney disease (OR: 1.67; 95%CI: 1.36-2.06; P < 0.001), liver disease (OR: 1.69; 95%CI: 1.19-2.41; P = 0.003), dementia (OR: 1.67; 95%CI: 1.06-2.64; P = 0.026), prior extracranial bleeding (OR: 1.89; 95%CI: 1.35-2.64; P < 0.001), and the use of antiplatelet drug (OR: 6.97; 95%CI: 5.89-8.23; P < 0.001). On multivariate analysis, OAC undertreatment was significantly associated with a higher risk all-cause death (OR: 3.79; 95%CI: 2.61-5.53; P < 0.001) and TE events (OR: 2.28; 95%CI: 1.39-3.72; P = 0.001), and a similar risk of major bleeding as compared with guideline-directed OAC therapy., Conclusion: Only 44.7% of all eligible patients were prescribed OAC in accordance with guideline recommendations. The independent predictors for OAC undertreatment were age, first diagnosed AF, chronic kidney disease, chronic obstructive pulmonary disease, prior extracranial bleeding, and the use of the antiplatelet drugs. Guideline-adherent thromboprophylaxis was safe and may be associated with improved survival and less TE among elderly Chinese patients with AF., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

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., Competing Interests: Declaration of Competing Interest GB: small speaker fee from Bayer, Boston, Boehringer Ingelheim and Daiichi, outside the submitted work. LF: Consultant or speaker for Bayer, BMS/Pfizer, Boehringer Ingelheim, Medtronic, Novartis and XO. FM: Advisor fees Boehringer-Ingelheim, Research Grants Ferrer, Speaker fees Boehringer-Ingelheim, Astra-Zeneca, Pfizer and Bayer; TP: Consultant for Bayer and Pfizer (no fees). GAD: Small speaker fees from Boehringer-Ingelheim, Pfizer, Bayer, Sanofi and Zentiva; DAL has received investigator-initiated educational grants from Bristol-Myers Squibb (BMS), has been a speaker for Bayer, Boehringer Ingeheim, and BMS/Pfizer and has consulted for BMS, and Boehringer Ingelheim. GYHL: Consultant and speaker for Bayer/Janssen, BMS/Pfizer, Boehringer Ingelheim, and Daiichi-Sankyo (No fees are directly received personally). All the disclosures occurred outside the submitted work. Other authors have no disclosures to declare, (Copyright © 2022. Published by Elsevier B.V.)

Aims: To evaluate the quality measures and clinical performance indicators among elderly Chinese patients with atrial fibrillation (AF). The management of patients with AF requires a holistic, multidisciplinary approach. Quality indicators have been proposed to assess the quality of care in 'real-world' clinical practice when managing patients with AF., Methods and Results: The Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry is a prospective, observational, large-scale multicentre registry conducted between October 2014 and December 2018 in China. Data were collected at the enrolment and during the follow-up visits by the local investigators. In the ChiOTEAF registry, 14 primary and 8 secondary indicators from six domains of care were assessed. Six thousand four hundred twenty patients who completed the 1-year follow-up were included in the analysis. Median age was 76 years, and the majority of patients was male (60.8%). Overall, 3246 patients (54.8%) were not treated with oral anticoagulants (OACs) appropriate to their risk of stroke; specifically, among those at highest risk of stroke, OACs were prescribed in only 43.3% patients (1258/2905). Among patients with permanent AF, 32 (3.6%) were prescribed antiarrhythmic drugs, and among those with paroxysmal AF, catheter ablation was performed in 20.7%. Patients were overburdened with multi-morbidities, including hypertension, diabetes mellitus, obesity, and sleep apnoea. During 1-year follow-up, 435 deaths (6.8%) and 89 thromboembolic events (1.4%) occurred. Patient-reported outcomes showed that 55% of patients had indicators of reduced quality of life., Conclusion: Assessment of quality indicators revealed the gaps in AF care among Chinese patients, highlighting the need for a more integrated or holistic approach to AF management., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Clinical practice in atrial fibrillation (AF) patient management is constantly evolving. In the past 3 years, various new AF guidelines or focused updates have been published, given this rapidly evolving field. In 2019, the American College of Cardiology/American Heart Association published a focused update of the 2014 guidelines. In 2020, both the European Society of Cardiology and the Canadian Cardiovascular Society released their new guidelines. Finally, the most recent guidelines were those published in 2021 by the Asian Pacific Heart Rhythm Society, which updates their 2017 version and the 2021 National Institute for Health and Care Excellence (NICE) guidelines. In the present narrative review, we compare these guidelines, emphasizing similarities and differences in the following mainstay elements of patient care: thromboembolic risk assessment, oral anticoagulants (OACs) prescription, bleeding risk evaluation, and integrated patient management. A formal evaluation of baseline thromboembolic and bleeding risks and their reassessment during follow-up is evenly recommended, although some differences in using risk stratification scores. OACs prescription is highly encouraged where appropriate, and prescription algorithms are broadly similar. The importance of an integrated and multidisciplinary approach to patient care is emerging, aiming to address several different aspects of a multifaceted disease., (Copyright © 2022. Published by Elsevier B.V.)

Background: Advancing age is a major risk factor for ischemic stroke in atrial fibrillation. We aimed to evaluate the predictors of all-cause death/any thromboembolism and the impact of oral anticoagulant on clinical outcomes in very elderly (≥85 years) Chinese atrial fibrillation patients., Methods: The ChiOTEAF is a prospective registry proceeded in 44 sites from 20 provinces in China between October 2014 and December 2018. Outcomes of interest were all-cause mortality, any thromboembolism, major bleeding, and new onset/worsening heart failure., Results: The eligible cohort for this analysis included 6416 patients and 1215 (18.9%) patients were aged ≥85 years. Only 320 (26.4%) very elderly patients were treated with oral anticoagulant, of whom 205 (64.1%) received non-vitamin K antagonist oral anticoagulants, while antiplatelet therapy was used among 642 (53.1%) very elderly patients. On multivariate analysis, the use of oral anticoagulant was an independent predictor of a lower risk of the composite outcome (OR: 0.46; 95% CI: 0.32-0.66) and all-cause death (OR: 0.47; 95% CI: 0.32-0.69) among these very elderly atrial fibrillation patients., Conclusions: Advanced age should not be a reason to withhold oral anticoagulant, since the use of oral anticoagulants is safe and improves survival.

Invited Editorial Commenting on: Tufano A, Lancellotti P. "Atrial cardiomyopathy: Pathophysiology and clinical implications". Eur J Intern Med. 2022 Mar 11:S0953-6205(22)00097-8. doi: 10.1016/j.ejim.2022.03.007. Epub ahead of print. PMID: 35288030., (Copyright © 2022 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Background: The 4S-AF scheme and the ABC pathway for integrated care have been proposed to better characterize and treat patients with atrial fibrillation (AF). We aimed to evaluate the assessment of the 4S-AF scheme and ABC pathway in Chinese AF patients., Methods: The ChiOTEAF is a prospective, observational, multicentre registry. Consecutive AF patients from 44 centres across 20 Chinese provinces with available 1-year follow-up data were included., Results: A total of 6419 patients were included, median age 76 years (interquartile range 67-83; 39.1% female). Of these, 3503 (59.8%) patients were not characterized using the 4S-AF scheme and not management according to the ABC pathway (group 1); 1795 (28.0%) were characterized according to the 4S-AF scheme but ABC pathway non-adherent or vice versa (group 2); and 1121 (17.4%) characterized according to the 4S-AF scheme and were ABC pathway adherent (group 3). As compared with group 1, group 2 and group 3 were independently associated with lower odds of the composite endpoint of all-cause death/any thromboembolic event, with the greatest benefit observed in group 3 (OR: 0.19; 95% CI 0.12-0.31) [for group 2: OR: 0.28; 95% CI 0.20-0.37]. Similar results were observed for all-cause death (group 2: OR: 0.18; 95% CI 0.12-0.27; group 3: OR: 0.14; 95% CI 0.07-0.25)., Conclusions: In a contemporary real-word cohort of Chinese AF patients, it is feasible to characterize and manage AF patients using the novel 4S-AF scheme and ABC pathway for integrated care. The use of both these tools is associated with improved clinical outcomes., (© 2022 The Authors. European Journal of Clinical Investigation published by John Wiley & Sons Ltd on behalf of Stichting European Society for Clinical Investigation Journal Foundation.)

Introduction: Mobile health (mHealth) solutions in atrial fibrillation (AF) are becoming widespread, thanks to everyday life devices, such as smartphones. Their use is validated both in monitoring and in screening scenarios. In the published literature, the diagnostic accuracy of mHealth solutions wide differs, and their current clinical use is not well established in principal guidelines., Areas Covered: mHealth solutions have progressively built an AF-detection chain to guide patients from the device's alert signal to the health-care practitioners' (HCPs) attention. This review aims to critically evaluate the latest evidence regarding mHealth devices and the future possible patient's uses in everyday life., Expert Opinion: The patients are the first to be informed of the rhythm anomaly, leading to the urgency of increasing the patients' AF self-management. Furthermore, HCPs need to update themselves about mHealth devices use in clinical practice. Nevertheless, these are promising instruments in specific populations, such as post-stroke patients, to promote an early arrhythmia diagnosis in the post-ablation/cardioversion period, allowing checks on the efficacy of the treatment or intervention.

Objective: To assess the efficacy and safety of catheter ablation (CA) compared with antiarrhythmic drugs (AADs) as first-line treatment for symptomatic paroxysmal atrial fibrillation (AF)., Methods: Systematic review and meta-analysis of randomised controlled trials identified using MEDLINE, Cochrane Library and Embase published between 01/01/2000 and 19/03/2021. The primary efficacy endpoint was the first documented recurrence of atrial arrhythmias following the blanking period. The primary safety endpoint was a composite of all serious adverse events (SAEs)., Results: From 441 records, 6 studies met the inclusion criteria. 609 patients received CA, while 603 received AAD therapy. 212/609 patients in the CA group had a recurrence of atrial arrhythmias as compared with 318/603 in the AADs group resulting in a 36% relative risk reduction (risk ratio: 0.64, 95% CI 0.51 to 0.80, p<0.01). The risk of all SAEs was not statistically different between CA and AAD (0.87, 0.58 to 1.30, p=0.49); 107/609 SAE in the CA group vs 126/603 in the AAD group. Both recurrence of symptomatic atrial arrhythmias (109/505 vs 186/504) and healthcare utilisation (126/397 vs 185/394) were significantly lower in the CA group (0.53, 0.35 to 0.79 and 0.65, 0.48 to 0.89, respectively). There was a 79% reduction in the crossover rate during follow-up among patients randomised to CA compared with AAD (0.21, 0.13 to 0.32, p<0.01)., Conclusions: First-line treatment with CA is superior to AAD therapy in patients with symptomatic paroxysmal AF, as it significantly reduces the recurrence of any atrial arrhythmias and symptomatic atrial arrhythmias, and healthcare resource utilisation with comparable safety profile., Competing Interests: Competing interests: DG: institutional research grants from Boston Scientific, Medtronic and Biosense Webster and personal advisory fees from Boehringer Ingelheim, Boston Scientific and Abbott. GB: small speaker’s fees from Medtronic, Boston, Biotronik, Boehringer and Bayer, outside of the submitted work. GL: Consultant and speaker for BMS/Pfizer, Boehringer Ingelheim and Daiichi-Sankyo. No fees were received personally. JA: grants and personal fees from Medtronic, grants from Baylis, personal fees from Biosense‐Webster. The other authors declare no conflict of interest., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Atrial High Rate Episodes (AHRE) are asymptomatic atrial tachy-arrhythmias detected through continuous monitoring with a cardiac implantable electronic device. The risks of stroke/Thromboembolic (TE) events and incident clinical Atrial Fibrillation (AF) associated with AHRE varies markedly., Objectives: To assess the relationship between AHRE and TE events, and between AHRE and incident clinical AF., Methods: This systematic review and meta-analysis was conducted following the PRISMA recommendations. PubMed, Scopus, and Google Scholar were searched from inception to 18/02/2021 for studies reporting TE events and incident clinical AF in patients with AHRE, as compared with patients without., Results: Ten out of 8081 records fulfilled the inclusion criteria, for a total of 37 266 patients. Seven out of ten studies excluded patients with prior history of clinical AF (4961 patients), embracing the most recent definition of AHRE. The risk ratio (RR) for TE events in AHRE patients was 2.13 (95% CI: 1.53-2.95, I 2 : 0%). The incidence of clinical AF was reported in four studies excluding patients with a history of clinical AF (3574 patients). The RR for incident clinical AF was 3.34 (95%CI: 1.89-5.90, I 2 : 73%)., Conclusions: AHRE are significantly associated with systemic thromboembolism and incident clinical AF. Further studies are needed to improve patients' risk stratification and management., (Copyright © 2021. Published by Elsevier B.V.)

Background: New-onset atrial fibrillation (AF) in non-cardiac postoperative setting is common and is associated with a high risk of in-hospital mortality and morbidity. The long-term risks of stroke, mortality and AF recurrence rate in patients with postoperative AF (POAF) are unclear., Methods: We performed a systematic literature review in electronic databases from inception to March 5th, 2020 of studies reporting the incidence of stroke, mortality and AF recurrence in patients with POAF. We confined our analysis to studies with a cohort of at least 150 patients with POAF and with a median follow-up of 12 months as a minimum. Odds Ratios (OR) were pooled using a random-effects model., Results: Qualitative analysis included 8 studies (7 observational cohort studies and 1 randomized controlled trial) enrolling 3,718,587 patients. Six studies underwent metanalysis comprising 17,684 postoperative patients with POAF and 2,169,248 postoperative patients without POAF. The development of POAF conferred a four-fold increased risk of stroke in the long-term [OR 4.05; 95% confidence interval (CI) 2.91-5.62]. Mortality in the two studies reporting long-term data was higher in patients with POAF compared to those without POAF (OR 3.59; CI 95% 2.84-4.53). Data about recurrence were too heterogeneous to undergo metanalysis., Conclusions: POAF is associated with a greater risk of stroke and mortality over the long-term period. Studies focusing on AF recurrence are needed to address the perception of POAF as a benign transient entity. The increased mortality risk following POAF should encourage systematic detection and prevention of this arrhythmia., (Copyright © 2020. Published by Elsevier B.V.)

Background: The impact of cognitive status on outcomes of patients with atrial fibrillation (AF) is not well defined., Aims: To assess the prevalence of cognitive impairment in AF patients and evaluate its association with: i) all-cause mortality; ii) a composite endpoint of death, stroke/systemic embolism, hemorrhages, acute coronary syndrome, pulmonary embolism, new/worsening heart failure., Methods: In a cohort study, cognitive status was assessed at baseline by the Mini Mental State examination adjusted for age and education (aMMSE). aMMSE <24 was considered indicative of cognitive impairment., Results: The cohort included 437 patients (61.3% male, mean age 73.4 ± 11.7 years). Sixty-three patients (14.4%) had cognitive impairment at baseline aMMSE. Permanent AF (odds ratio [OR] 1.750; 95%CI 1.012-3.025; p = .045), haemoglobin levels (OR 0.827; 95%CI 0.707-0.967; p = .017) and previous treatment with antiplatelet drugs only, without oral anticoagulation, (OR 4.352; 95%CI 1.583-11.963; p = .004) were independently associated with cognitive impairment at baseline. After a median follow-up of 887 days (interquartile range 731-958) 30 patients died (7.1%), and 97 (22.9%) reached the composite endpoint. After adjustment for Elixhauser Comorbidy Measure, aMMSE <24 was significantly associated with all-cause mortality (hazard ratio [HR] 2.473, 95%CI 1.062-5.756, p = .036) and with the composite endpoint (HR 1.852, 95%CI 1.106-3.102, p = .019)., Conclusions: In patients with AF, cognitive impairment (aMMSE <24) is associated with worse outcomes, and the association of adverse outcomes with previous treatment with antiplatelet drugs only, without oral anticoagulation, highlights the potential role of appropriate antithrombotic treatment for improving patient prognosis., Competing Interests: Declaration of Competing Interest RBS reports lecture fees and advisory board fees from BMS/Pfizer outside this work; BF reports prior fees and/or advisory board honoraria from Bayer Pharma AG, Boehringer Ingelheim, Daiichi-Sankyo, Omron, and Pfizer/BMS, and grants to the institution for investigator-initiated studies from BMS and Pfizer outside this work; GB reports speaker's fees from Boehringer Ingelheim, Boston, Biotronik, Medtronic outside this work. The other authors do not report any conflict of interest., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Red blood cell distribution width (RDW) is an inexpensive marker of anisocytosis easily available in the standard complete blood cell count. Besides its traditional use in the differential diagnosis of anemias, RDW values reflect abnormalities in erythropoiesis and red blood cell metabolism related to aging, sex, ethnicity, systemic inflammatory state, and oxidative stress. Thus, higher RDW values are common findings in several acute clinical conditions and chronic diseases. Increasing evidence suggests a prognostic role of higher RDW levels in many cardiovascular diseases. Among them, we aimed to review current literature focusing on the possible relation between RDW and atrial fibrillation (AF). Since aging, inflammation, and atrial substrate remodeling have a well-established role in AF pathogenesis, AF burden, and patient prognosis, we analyzed available data exploring the possible use of RDW in identifying patients at higher risk of AF and as a biomarker of worse outcomes for AF patients., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Atrial fibrillation (AF) represents the most common arrhythmia and is associated with increased morbidity and mortality generating high social costs. Due to its high prevalence, AF is usually managed not only by cardiologists but also by general practitioners or clinicians in emergency departments. The conventional classification of AF includes "recent‑onset AF" defined as an arrhythmia episode shorter than 48 hours. In patients with a definite duration of AF of less than 24 hours and a very low-risk profile (CHA2DS2VASc of 0 in men and 1 in women), the thromboembolic risk seems to be low, and the standard 4‑week anticoagulation therapy is now regarded as optional treatment. Cardioversion (electrical or pharmacological) in recent‑onset AF represents a valid rhythm control strategy. Electrical cardioversion is usually reserved for hemodynamically unstable patients and performed with biphasic waveform shocks. On the other hand, pharmacological cardioversion is preferred in hemodynamically stable patients. Several antiarrhythmic drugs have been studied so far, but some questions still remain unresolved mainly due to lack of randomized clinical trials and prospective studies. The current guidelines do not uniformly agree on which drug to use for pharmacological cardioversion, and drug preference varies widely in clinical practice. The aim of this narrative review is to sum up and critically evaluate novel evidence regarding recent‑onset AF as well as to provide some practical considerations particularly focused on rhythm control with pharmacological cardioversion.

The rapid increase in cardiac implantable electronic device (CIED) implants and their ability to monitor atrial activity significantly contributed to a parallel increase in the occasional detection of atrial tachyarrhythmias, termed as atrial high-rate episodes (AHREs). These episodes of atrial tachyarrhythmia are usually asymptomatic and they are often diagnosed incidentally during the regular follow-up of patients with CIEDs or during the diagnostic work-up for patients affected by cryptogenic stroke. Over the past 20 years, numerous studies attempted to demonstrate the clinical significance and prognostic impact of these episodes, but their clinical management remains unclear. However, AHREs are not only significantly associated with a greater risk of developing clinical atrial fibrillation over time, but are also associated with an increased risk of cerebral and/or systemic thromboembolic events. Therefore, if deemed favorable, the use of oral anticoagulant therapy may be reasonable. The purpose of this review is to perform a state of the art analysis focusing on the clinical management of AHREs, their prognostic impact, the risks and benefits of anticoagulation and the critical issues that have emerged in the last years of studies.

Competing Interests: Declaration of Competing Interest GB has received small speaker's fee from Medtronic, Boston, Boehringer, and Bayer, outside of the submitted work. JFI and MV declare no conflict of interest