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Background Theoretically, targeting the same ablation index (AI) using higher power may achieve the same lesion size with a shorter ablation time. We evaluated the acute and long‐term efficacy of higher‐powered ablation guided by ablation index (HPAI) compared with conventional‐powered ablation guided by AI (CPAI) for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). Methods Drug refractory symptomatic AF patients who had been ablated with 40 W on the anterior/roof segments and 30 W on the posterior/inferior/carina segments were enrolled (HPAI group). We compared the HPAI group with the CPAI group who were ablated with 30 W on the anterior/roof segments and 25 W on the posterior/inferior/carina segments. The same AI was targeted (≥450 on the anterior/roof segments and ≥350 on the posterior/inferior/carina segments). We compared ablation time, acute pulmonary vein reconnection (PVR) and 1‐year AF recurrence between the two groups. Results A total of 118 patients were included (86 in the HPAI group and 32 in the CPAI group, paroxysmal AF, 73%). There was no significant difference in the acute PVR rate between the HPAI and the CPAI groups (3.7% vs. 4.2%, P = .580) with a 41% reduction in ablation time for PVI (38.7 ± 8.3 vs. 65.8 ± 13.7 minutes, P, There are limited data regarding the acute and long‐term efficacy and safety of applying higher power than conventional power targeting optimal ablation index (AI) value in our daily pulmonary vein isolation (PVI) procedure in patients with atrial fibrillation. In this study, we found that higher‐than‐conventional radiofrequency power PVI guided by optimal target AI showed comparable acute and long‐term efficacy of PVI with reducing the procedure and ablation times without increasing the risk of complication. This study has shown that higher power strategy could be successfully implemented on the basis of conventional power AI guided PVI.

Background Radiofrequency catheter ablation for atrial fibrillation (AF) without using fluoroscopy has been getting popular. In this study, we reported the transition period experience of the zero‐fluoroscopy procedure by an experienced operator and shared our zero‐fluoroscopy protocol. Method A total of consecutive 30 AF ablation cases attempted to be treated without fluoroscopy were investigated. Ten serial cases were grouped as fluoroscopy‐guided period, and period 1‐3 in chronological order. All zero‐fluoroscopy attempted cases were assisted with an intracardiac echocardiography device with a three‐dimensional electroanatomical system. Results Complete zero‐fluoroscopy procedure was achieved at the 6th case during the transitional period. During the first period, the total procedure time slightly increased in, but afterward, procedure time was continuously decreased, and it became significantly shorter in the third period than the previous fluoroscopy‐guided period. Any additional use of fluoroscopy during the transitional period was mainly for transseptal puncture and diagnostic catheter placement into the coronary sinus. Pulmonary vein isolation was achieved in all patients, and there was one case of hemodynamically insignificant moderate amount pericardial effusion. Conclusion For an experienced operator, complete zero‐fluoroscopy AF ablation might be achieved safely and feasibly within 5‐10 cases. Fluoroscopy equipment backup might be useful during the learning period for beginners in the zero‐fluoroscopy procedure., The complete zero‐fluoroscopy radiofrequency catheter ablation for atrial fibrillation is feasible and safe. The learning period is not too long, and a complete zero‐fluoroscopy procedure was achieved in the 6th case. Pulmonary vein isolation was achieved in all cases, and the total procedure time was shorter than the conventional fluoroscopy‐guided procedure period.

INTRODUCTION: Catheter ablation (CA) for atrial fibrillation (AF) is used as a treatment to restore and maintain sinus rhythm in patients with AF. However, limited data exist regarding the temporal trends of AF ablation in Asia. This study aimed to describe the temporal trends of CA for AF in Korean over 11 years.METHODS: The nationwide claims database in Korea was utilized. Patients underwent CA for AF were identified using combinations of diagnostic codes, claims history, and procedure codes. Comorbidities and complications were also identified, and their temporal trends were evaluated.RESULTS: The numbers of patients underwent CA for AF were observed to gradually increased over 11 years (452 patients in 2007 vs. 3035 patients in 2017). Mean age of the study population increased (55.4 in 2007-2010 vs. 58.9 in 2015-2017); and mean CHA2 DS2 -VASc score also increased (1.9 in 2007-2010 vs. 2.2 in 2015-2017). Risks of complications decreased during the study period but risks of all-cause deaths did not changed significantly. Older age, women, hypertension, cerebrovascular accident, chronic obstructive pulmonary disease, chronic kidney disease, general anesthesia, and small procedure volume were independent predictors of complications but, only diabetes and occurrence of any complication were associated with mortality after CA.CONCLUSION: CA for AF has become an increasingly important treatment option. Although the proportion of high-risk patients increased, risks of complications decreased over time. Performing procedure without complications and prompt managements are essential to improve the outcome of the patients with AF underwent CA.

There is a paucity of information as to whether chromosomal abnormalities, including Down Syndrome, Turner Syndrome, and Klinefelter Syndrome, have an association with atrial fibrillation (AF) and ischemic stroke development. Data from 3660 patients with Down Syndrome, 2408 with Turner Syndrome, and 851 with Klinefelter Syndrome without a history of AF and ischemic stroke were collected from the Korean National Health Insurance Service (2007–2014). These patients were followed-up for new-onset AF and ischemic stroke. Age- and sex-matched control subjects (at a ratio of 1:10) were selected and compared with the patients with chromosomal abnormalities. Down Syndrome patients showed a higher incidence of AF and ischemic stroke than controls. Turner Syndrome and Klinefelter Syndrome patients showed a higher incidence of AF than did the control group, but not of stroke. Multivariate Cox regression analysis revealed that three chromosomal abnormalities were independent risk factors for AF, and Down Syndrome was independently associated with the risk of stroke. In conclusion, Down Syndrome, Turner Syndrome, and Klinefelter Syndrome showed an increased risk of AF. Down Syndrome patients only showed an increased risk of stroke. Therefore, AF surveillance and active stroke prevention would be beneficial in patients with these chromosomal abnormalities.

Background In patients with atrial fibrillation (AF), most biomarkers are still of limited use due to cost-effectiveness and complexity in clinical practice. Hypotheses Biomarkers from routine blood tests improve the current risk stratification in AF patients. Methods This prospective study enrolled 600 patients diagnosed with non-valvular AF, of whom 537 were analyzed. Platelet count; platelet distribution width (PDW); red cell distribution width (RDW); and creatinine, D-dimer, and troponin I levels were measured at enrollment. Results During the mean follow-up period (2.2 ± 0.6 years), 1.9% patients developed ischemic stroke. According to the optimal cutoff of each biomarker, the risk of ischemic stroke was higher in patients with RDW ≥ 13.5%, creatinine ≥ 1.11 mg/dL, or PDW ≥ 13.2% (significant biomarkers; P value: P-for-trend P 2DS2–VASc score (area under the curve 0.790 vs. 0.620, P = 0.043). Conclusion Routine blood tests can provide better risk stratification of AF along with clinical risk factors.

The transition-metal-catalyzed nitrenoid transfer reaction is one of the most attractive methods for installing a new C-N bond into diverse reactive units. While numerous selective aminations are known, understanding complex structural effects of the key intermediates on the observed chemoselectivity is still elusive in most cases. Herein, we report a designing approach to enable selective nitrenoid transfer leading to sp2 spirocyclization and sp3 C-H insertion by cooperative two-point modulation of ligands in the CpXIr(III)(κ2-chelate) catalyst system. Computational analysis led us to interrogate structural motifs that can be attributed to the desired mechanistic dichotomy. Multivariate linear regression analysis on the perturbation on the η5-cyclopentadienyl ancillary (CpX) and LX coligand, wherein we prepared over than 40 new catalysts for screening, allowed for construction of an intuitive yet robust statistical model that predicts a large set of chemoselective outcomes, implying that the catalysts' structural effects play a critical role on the chemoselective nitrenoid transfer. On the basis of this quantitative analysis, a new catalytic platform is now established for the unique lactam formation, leading to the unprecedented chemoselective reactivity (up to >20:1) toward a diverse array of competing sites, such as tertiary, secondary, benzylic, allylic C-H bonds, and aromatic π system.

BackgroudThere is a paucity of information on whether changes in metabolic syndrome (MetS) status affect the risk of new‐onset atrial fibrillation (AF). We aimed to evaluate whether changes in MetS status and components of MetS affect AF risk using data from a nationwide observational cohort.Methods and ResultsA total of 7 565 531 adults without prevalent AF (mean age, 47±14 years) who underwent 2 serial health examinations by the Korean National Health Insurance Cooperation were identified. The patients were categorized into 4 groups according to the change in MetS status in serial evaluations, as follows: patients with persistent MetS (n=1 388 850), healthy patients newly diagnosed with MetS in the second evaluation (n=608 158), patients with MetS who were healthy in the second evaluation (n=798 555), and persistently healthy individuals (n=4 769 968). During a mean 7.9‐year follow‐up, incident AF was diagnosed in 139 305 (1.8%) patients. After multivariable adjustment, the AF risk was higher by 31% in the patients with persistent MetS , 26% in the patients with MetS who were healthy in the second evaluation, and 16% in the healthy patients newly diagnosed with MetS in the second evaluation compared with the persistently healthy individuals. Regardless of the MetS component type, the AF risk correlated with changes in the number of components. The risk of AF was strongly correlated with MetS status changes in the young and middle‐age groups (20–39 years and 40–64 years, respectively) than in the elderly group (≥65 years).ConclusionsDynamic changes in MetS status and persistent MetS were associated with an increased risk of AF in a large‐scale Asian population.

We tested the feasibility of pulmonary vein (PV) and left atrial (LA) posterior wall isolation using non-invasive stereotactic ablative body radiotherapy (SABR) and investigated pathological changes in irradiated lesions in a canine model. Seven male Mongrel dogs received single-fraction 33-Gy SABR. We designed the en-bloc circular target of total PVs and LA posterior wall to avoid the esophagus. The circular box lesion included the LA roof and ridge, low posterior wall, and posterior interatrial septum. At 6 weeks or 4 months post-SABR, electrical isolation of the SABR lesion was confirmed using LA posterior wall pacing, and histopathological review was performed. Electrical isolation of all PVs and the LA posterior wall was achieved in three of five dogs in the 4-month group. There was one target failure and one sudden death at 15 weeks. Although two dogs in the 6-week group failed to achieve electrical lesion isolation, the irradiated atrial myocardium showed diffuse hemorrhage with inflammatory cell infiltration. In successfully isolated 4-month model dogs, we observed transmural necrotic scarring with extensive fibrosis on irradiated atrial tissue. The findings suggest that this novel circular box-design radiotherapy technique using SABR could be applied to humans after further studies are conducted to confirm safety.

INTRODUCTION The left atrium (LA), including the pulmonary vein antrum, is the main target of catheter ablation for atrial fibrillation (AF). However, there is a lack of data on the effect of extensive LA ablation on LA stiffness. This study sought to investigate the impact of extensive LA ablation on LA stiffness and dyspnea after the restoration of sinus rhythm. METHODS In total, 97 patients with AF (80 patients who only underwent pulmonary vein isolation [PVI] and 17 patients who underwent extensive LA ablation) were investigated. Extensive LA ablation was defined as PVI plus at least two sets of LA linear-line ablation. LA stiffness was estimated using the ratio of E/e' to global longitudinal LA strain, as measured by echocardiography. The clinical outcomes we evaluated were AF recurrence and composite dyspnea, which we defined as newly prescribed diuretics or hospitalization for heart failure. RESULTS Patients were 59.3 ± 10.0 years old on average, and 68 (70.1%) were male. There were no significant differences in baseline characteristics or echocardiographic parameters before ablation between the two groups. After ablation, LA stiffness was higher in the extensive ablation group compared with that in the PVI group (0.9 ± 0.6 vs 0.5 ± 0.3, respectively, P = .017). Multivariable linear regression analysis showed that extensive ablation increased LA stiffness (s = 0.363, P

Background Chronic inflammation plays a role in the pathophysiology of atrial fibrillation (AF). However, there is a paucity of information about whether Behcet's disease (BD) is associated with an increased risk of AF. This population-based study aimed to determine the risk of AF in patients with BD. Methods A total of 6636 newly diagnosed BD patients without a history of AF were included from the Korean National Health Insurance Service database between 2010 and 2014. Newly diagnosed non-valvular AF was identified using the claims data. An age- and sex-matched non-BD subjects were extracted at a ratio of 1:5 (n = 31,040). The incidence and risk of AF were compared between groups. Results During a mean follow-up of 3.6 ± 1.5 years, AF was newly diagnosed in 173 patients (51 in the BD group, 122 in the control group). The incidence was 2.3 and 1.1 per 1000 person-years, respectively. After adjustment, the BD group showed a 1.8-fold higher risk of AF compared to the control group. Patients with BD aged ≤40 years had a higher risk of AF, while patients aged ≥65 years showed a similar risk. Men with BD had a 2.5-fold increased risk of AF, whereas women with BD did not. Severe BD had a higher risk for AF compared to non-severe BD and controls. Conclusions BD was associated with an increased risk of AF, particularly in men and young patients. Active surveillance and treatment are needed in BD patients and those with arrhythmic symptoms.

Background This study examined the effects of variability of four metabolic parameters, namely systolic blood pressure (BP), body mass index (BMI), fasting blood glucose (FBG), and total cholesterol level (TC) on the risk of HF. The effects of metabolic parameter variability on the risk of heart failure (HF) remain unclear. Methods We studied individuals aged ≥40 years who had undergone ≥3 health check-ups under the Korean National Health Insurance Corporation during 2009 and 2012, and those who did not have hypertension, diabetes, or dyslipidemia. BP, BMI, FBG, and TC were measured at every visit. We defined the variability of each parameter using the variability independent of the mean (VIM) method. VIMs were categorized into four groups according to quartiles. The metabolic variability (MV) score for each subject was defined as the number of VIMs in the highest quartile. Results Among the 3,820,191 subjects, 17,253 (0.45%) had incident HF during a mean 5.3 ± 1.1 years of follow-up. High variability of each parameter was associated with increased HF risk, which increased according to the MV score. After multivariable adjustment, compared to subjects with MV score = 0, subjects with MV score = 1–4 had an increased risk of HF (adjusted HR [95% CI], 1.15 [1.10–1.19] for MV score = 1, 1.33 [1.28–1.39] for MV score = 2, 1.48 [1.40–1.57] for MV score = 3, 1.74 [1.55–1.96] for MV score = 4 [p-for-trend ≪0.0001]). Conclusions High variability of BP, BMI, FBG, and TC was synergistically associated with a higher incidence of new-onset HF.

Background Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease, associated with a number of cardiovascular diseases. We sought to investigate whether AS increases the risk of atrial fibrillation (AF) in a nationwide population-based study. Methods A total of 14,129 patients newly diagnosed with AS (mean age 41.8 ± 15.3 years, 72% male) were recruited from the Korean National Health Insurance Service database between 2010 and 2014 and followed up for new onset AF. Age- and sex-matched non-AS subjects (1:5, n = 70,645) were selected and compared with the AS patients. Results During a mean follow-up of 3.5 years, AF was newly diagnosed in 486 patients (114 patients of the AS group). The AS patients developed AF more frequently than the non-AS subjects (2.32 vs. 1.51 per 1000 person-years). In multivariate Cox regression analysis, AS was an independent risk factor for AF (Hazard ratio [HR] 1.28, 95% confidence interval [1.03–1.58]). The AS with tumor necrosis factor inhibitor (TNFi) therapy group showed higher risk for AF (HR 1.60 [1.02–2.39]). In younger patients of the AS group (patients Conclusions AS was an independent risk factor for AF, especially in those under 40 years of age and those administered TNFi. It would be reasonable to screen for AF and stroke prevention in these high-risk patients.

Background Atrial fibrillation (AF) and stroke are common in hypertrophic cardiomyopathy (HCM). We aimed to determine the prevalence and incidence of AF and stroke in patients with HCM during a 10-year period. Methods Using the Korean National Health Insurance Services database, we identified patients diagnosed with HCM from the entire Korean population between 2005 and 2015. The annual prevalence and incidence of AF and stroke in HCM patients were estimated. Results The prevalence of AF in HCM patients has gradually increased to 1.6-fold from 13.4% in 2005 to 20.9% in 2015. The incidence of AF ranged from 4.1 to 5.5%, a similar trend was observed for each year in HCM patients. The prevalence of stroke in HCM patients was approximately 10%, while that in HCM patients with AF was about 20%. During 8741 person-years, AF-related stroke occurred in 257 subjects among 2309 HCM patients with new-onset AF. The overall incidence rate of AF-associated stroke was 2.94 per 100 person-years. In subgroup analysis, the incidence rate of AF-associated stroke was 1.49 per 100 person-years in the under 45 year-old group and 1.48 per 100 person-years in the group with CHA2DS2­VASc score of 0 or 1 point in HCM patients. Conclusions The prevalence of AF in HCM patients gradually increased over 10 years. The annual risk of AF-associated stroke in HCM was over 1% even in younger patients and those with CHA2DS2­VASc score of 0 or 1 point, which provide evidence to support the prevention of stroke in HCM patients with AF.

BACKGROUND: The predictors of ischemic stroke in "low-risk" patients with atrial fibrillation (AF) (CHA 2DS 2-VASc score 0 in men or 1 in women) are debated. OBJECTIVE: This study aimed to investigate the factors associated with ischemic stroke in low-risk patients with AF. Imaging characteristics of their ischemic strokes were also evaluated.METHODS: This was a matched case-control study conducted at a single tertiary institution. We identified 44 patients with de novo ischemic stroke and incidentally found AF with a low-risk CHA 2DS 2-VASc score. A 1:5 age- and sex-matched control group was selected for patients with AF and a low-risk CHA 2DS 2-VASc score but without ischemic stroke and oral anticoagulant therapy. Conditional multivariate logistic regression analysis was performed to identify the predictors. RESULTS: There were no significant differences in age, sex, body mass index, comorbidities, left atrial size, and left ventricular ejection fraction. Smokers were more prevalent in the stroke group than in the nonstroke group (24 of 44 [54.5%] vs 22 of 220 [10.0%]; P < .001). Additionally, the mean white blood cell count was significantly higher in the stroke group (P = .019). In conditional univariate logistic regression analysis, smoking and white blood cell count were significant predictors of stroke. In multivariate analysis, smoking was the only significantly associated factors (matched odds ratio 9.10; 95% confidence interval 2.48-33.42). In the stroke group, 14 of 44 patients (31.8%) had multiple vascular territory infarcts.CONCLUSION: Smoking was the predictor associated with ischemic stroke in patients with AF and a low-risk CHA 2DS 2-VASc score.

Described herein is the Ir-catalyzed enantioselective access to chiral spirolactam products via the nitrenoid transfer to aromatic ipso-carbons. The key strategy for precise stereocontrol is to enhance the secondary attractive and repulsive interactions between the chiral catalyst and substrates by the introduction of a traceless O-silyl achiral auxiliary, thus effectively differentiating two prochiral faces of arenol-derived 1,4,2-dioxazol-5-one substrates.

Background and Purpose: Limited data support the benefits of non–vitamin K oral anticoagulants (NOACs) among atrial fibrillation patients with prior gastrointestinal bleeding (GIB). We aimed to evaluate the effectiveness and safety of NOACs compared with those of warfarin among atrial fibrillation patients with prior GIB. Methods: Oral anticoagulant–naive individuals with atrial fibrillation and prior GIB between January 2010 and April 2018 were identified from the Korean claims database. NOAC users were compared with warfarin users by balancing covariates using the inverse probability of treatment weighting method. The primary outcomes were ischemic stroke, major bleeding, and the composite outcome (combined ischemic stroke and major bleeding). Fatal events from each outcome were evaluated as secondary outcomes. Results: A total of 42 048 patients were included (24 781 in the NOAC group and 17 267 in the warfarin group). The mean time from prior GIB to the initiation of oral anticoagulant was 3.1±2.6 years. After inverse probability of treatment weighting, baseline characteristics were balanced between the two groups (mean age, 72 years; men, 56.8%; and mean CHA 2 DS 2 -VASc score, 3.7). Lower risks of ischemic stroke, major bleeding, and the composite outcome were associated with NOAC use than with warfarin use (weighted hazard ratio, 0.608 [95% CI, 0.543–0.680]; hazard ratio, 0.731 [95% CI, 0.642–0.832]; and hazard ratio, 0.661 [95% CI, 0.606–0.721], respectively). For all secondary outcomes, NOACs showed greater risk reductions compared with warfarin. Conclusions: NOACs were associated with lower risks of ischemic stroke and major bleeding than warfarin among atrial fibrillation patients with prior GIB.

Introduction Patients with malignancies are known to have an increased risk of atrial fibrillation (AF). However, there is a paucity of information regarding the cancer type and the risk of AF. We aimed to evaluate the risk of AF according to the type of cancer. Methods We enrolled 816,811 patients who were diagnosed with cancer from the Korean National Health Insurance Service database between 2009 and 2014. Age and sex-matched non-cancer control subjects (1:2, n=1,633,663) were selected and compared with patients with malignancy. Newly diagnosed nonvalvular AF was identified using the claims data. Besides, we performed a sensitivity analysis using lag periods from cancer diagnosis to AF for more than 1 year and more than 5 year. Results During a mean follow up of 4.7 years, AF was newly diagnosed in 25,356 patients with cancer (6.6 per 1000 person-years) whereas 31,801 patients in the control group (3.6 per 1000 person-years). In multivariate Cox regression analysis, cancer was an independent risk factor for incident AF (HR 1.97; 95% CI 1.94–2.00). Hematologic malignancies show higher correlation with incident AF (multiple myeloma, the hazard ratio (HR) 4.57; 95% confidence interval (CI) 4.08–5.12; leukemia, HR 4.15; 95% CI 3.75–4.59). Malignancies of the nervous system, esophagus, lung, and pancreatic cancer show higher risks of AF more than 3 times than control, whereas prostate cancer shows the lowest association with AF risk (HR 1.36; 95% CI 1.29–1.44). In subgroup analysis, the effect of cancer on AF development was more prominent in patients with younger age ( In sensitivity analysis using lag periods, the strength of risks of AF decline with time from cancer diagnosis but remain significant (“>1yr” HR 1.77; 95% CI 1.74–1.81; “>5yrs” HR 1.12; 95% CI 1.07–1.16). However, AF risk was more diverse according to the types of cancers in patients surviving above five years. Multiple myeloma, leukemia, lymphoma, ovarian, liver, and lung cancer show higher risks of AF than control while other types of cancer show no significant association with AF incidence after five years from a cancer diagnosis. Conclusion Although patients with cancer showed a higher risk of AF, but the impact on AF development was diverse among cancer types. Hematologic malignancies showed the highest risk of AF, and the risk was maintained up to 5 year after diagnosis of cancer. Therefore it would be reasonable to screen AF especially in those malignancies with high-risk for AF. Different AF risk in cancer patients Funding Acknowledgement Type of funding source: None

BACKGROUND: The evidence of effectiveness and safety of the non-vitamin K antagonist oral anticoagulants (NOACs) among elderly East Asians is limited.OBJECTIVES: We aimed to describe the effectiveness and safety outcomes associated with NOACs and warfarin among elderly Koreans aged ≥80 years.METHODS: Using the Korean Health Insurance Review and Assessment service database, patients with atrial fibrillation (AF) who were naïve to index oral anticoagulant between 2015 and 2017 were included in this study (20,573 for NOACs and 4086 for warfarin). Two treatment groups were balanced using the inverse probability of treatment weighting (IPTW) method. The clinical outcomes including ischemic stroke, major bleeding including intracranial hemorrhage (ICH) and gastrointestinal bleeding (GIB), and a composite of these outcomes were evaluated.RESULTS: Compared to warfarin, NOACs were associated with lower risks of ischemic stroke (hazard ratio 0.74 [95% confidence interval 0.62-0.89]), and composite outcome (0.78 [0.69-0.90]). NOACs showed nonsignificant trends towards to lower risks of GIB and major bleeding than warfarin. The risk of ICH of NOAC group was comparable with the warfarin group. Among NOACs, apixaban and edoxaban showed better composite outcomes than warfarin. Among the clinical outcomes, only ischemic stroke and the composite outcome had a significant interaction with age subgroups (80-89 years and ≥90 years, P-for-interaction = .097 and .040, respectively).CONCLUSION: NOACs were associated with lower risks of ischemic stroke and the composite outcome (ischemic stroke and major bleeding) compared to warfarin in elderly East Asians. Physicians should be more confident in prescribing NOACs to elderly East Asians with AF.

Introduction Regular exercise is known to decrease the risk of dementia. There is a paucity of information about the impact of the change of exercise habit on cardiovascular outcomes after a new diagnosis of atrial fibrillation (AF). We aimed to investigate whether regular exercise is associated with the risk of developing dementia in patients with AF. Methods Using the Korean National Health Insurance Service database, we enrolled patients with newly diagnosed AF who had undergone health screening between 2010 and 2016. The study population was divided into four groups based on the consistency of regular exercise before and after AF diagnosis: (1) persistent non-exerciser, (2) exercise starter, (3) exercise quitter, and (4) exercise maintainer. We investigated the association between exercise and the risk of dementia. Results A total of 126,555 patients were included (mean age 62.7 years, male 62.0%, and mean CHA2DS2-VASc Score 2.7). During a median follow-up duration of 3.0 years, 5,943 patients were newly diagnosed as dementia (1.57 per 100 person-years). Among patients with incident dementia, 4,410 patients had Alzheimer's dementia and 951 patients had vascular dementia (1.16 and 0.25 per 100 person-years, respectively). Persistent non-exerciser, exercise starter, quitter, and maintainer groups were 65.1%, 12.8%, 12.7%, and 9.4%, respectively. After multivariable adjustment, we found that exercise was associated with a lower risk of developing overall dementia. When compared to persistent non-exerciser, exercise starter and maintainer showed reduced risk of developing dementia (hazard ratio [HR] 0.80, 95% confidence interval [95% CI] 0.73–0.88 and HR 0.63, 95% CI 0.54–0.73, respectively, all p-value 0.05, Figure). Conclusions Regular exercise showed a lower risk of dementia in patients with new-onset AF. Starting exercise even after the diagnosis of AF was beneficial to patients who had little physical activity previously. These findings may support physicians to recommend that AF patients should start exercise or keep their physical activity to reduce the risk of dementia. Funding Acknowledgement Type of funding source: None

Background For the improvement of efficacy in radiofrequency catheter ablation (RFCA) of pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF), fixed target Ablation Index (AI) value has been recommended regardless of individual and regional differences of left atrial wall thickness (LAWT). Objective To evaluate the association between LAWT and residual potential (RP) after first pass encirclement of PVI in AF patients receiving AI-guided PVI. Method A total of 116 patients (29% persistent AF) undergone AF RFCA using AI-guided PVI were included. Using SmartTouch catheter or SmartTouch SF catheter (Biosense Webster Inc., CA, US), point-by-point ablation was delivered at 30–40W on the anterior/roof segments and 25–30W on the posterior/inferior/carina segments. AI targets were 450 on the anterior/roof segments and 350 on the posterior/inferior/carina segments. After first encirclement of PVI was performed, RP was evaluated. LAWT was evaluated by 3-dimensional wall thickness map using computed tomographic images. LAWT values of ablation regions were graded by LAWT in each segment of PV antrum (Figure). Results Among a total of 1564 PV segments, RP was observed in 106 segments (6.8%). Left superior, inferior PV ridges and right superior PV roof segments were the most, second, and third thickest area among 14 PV segments (mean LAWT grade 5.09±1.08, 3.34±1.70, and 2.32±1.11, respectively). Mean LAWT grade was lower in segments with RP than those in without RP (2.74±1.80 vs. 2.07±1.28, p Conclusion Delivering same AI during PVI, thicker LAWT was associated with higher incidence of RP after first pass encirclement of PV in anterior/roof area. Tailored AI should be considered by LAWT to improve acute outcome of PVI. LAWP RP Funding Acknowledgement Type of funding source: None

Background Bodyweight variability is a risk factor for atrial fibrillation (AF), but this has not been studied with a focus on patients with diabetes mellitus (DM). Methods A nationwide population-based cohort of 670,797 patients with type 2 DM from the Korean National Health Insurance Service database without a history of AF and with ≥3 measurements of body weight over a 5-year period were followed up for AF development. Intra-individual bodyweight variability was calculated using variability independent of mean (VIM), and high bodyweight variability was defined as the quintile with the highest variability with the lower four quintiles as reference. Results During a median of 7.0 years of follow-up, 22,019 patients (3.3%) were newly diagnosed with AF. Risk of incident AF was increased in those in the highest quintile of bodyweight variability, after adjustment for baseline body mass index (BMI), age, sex, lifestyle factors, comorbidities, number of oral anti-diabetic medication, insulin use, duration of DM, and fasting glucose (HR 1.16, 95% CI 1.12–1.20). High bodyweight variability was significantly associated with AF development regardless of baseline BMI group and direction of overall weight change. This association was stronger in subjects with lower BMI, those on insulin, and those with a DM duration of greater than 5 years. Conclusions High bodyweight variability was associated with AF development, independently of traditional cardiovascular risk factors and baseline BMI. This association was stronger in underweight patients and in advanced diabetic stage. Funding Acknowledgement Type of funding source: None

Introduction There is a paucity of information about cardiovascular impacts related to the change of exercise habit after a new diagnosis of atrial fibrillation (AF). We aimed to investigate the influence of exercise on the risk of cardiovascular outcomes, such as ischemic stroke, heart failure (HF), and all-cause death, in patients with AF. Methods We included 66,692 patients with newly diagnosed AF (36.4% female, mean age 59.5 years, mean CHA2DS2-VASc 1.9) who underwent two serial health examinations before and after diagnosis of AF from 2010 to 2016, as provided by Korean National Health Insurance Corporation. The individuals self-reported a degree and frequency of exercise by questionnaires and doing vigorous physical activities ≥3 times/week or moderate physical activities ≥5 times/week was defined as a regular exercise group. The study population was divided into four categories according to the status of regular exercise before and after AF diagnosis: persistent non-exerciser (64.0%), new exerciser (13.4%), exercise drop-outs (12.5%), and exercise maintainer (10.1%). The primary outcomes were ischemic stroke, HF, and all-cause death during the follow-up. Results During a median 3.4 years follow-up, ischemic stroke, HF, and all-cause death occurred in 1905, 13112, and 2627 patients, respectively (incidence rates 8.5, 64.8, and 11.5 per 1,000 person-years, respectively). The change in exercise habits did not have a significant association with the risk of ischemic stroke (Figure 1). Regarding HF, those who newly initiated or maintained exercise after AF diagnosis showed a lower risk than those who do not exercise: hazard ratio, HR 0.93; 95% confidence interval, CI [0.88 to 0.98] and 0.90 [0.85 to 0.96] for each group, all p Conclusions Patients who started or continued exercising after a new diagnosis of AF showed a lower risk of HF and mortality, but did not show an association with ischemic stroke. Regular exercise might improve the cardiovascular outcomes in patients with newly diagnosed AF. Figure 1. CV impacts of exercise on AF patients Funding Acknowledgement Type of funding source: None

Objective Parkinson’s disease (PD) is the second most common neurodegenerative disorder associated with various morbidities. Although the relationship between cardiovascular disease and PD has been studied, a paucity of information on PD and atrial fibrillation (AF) association exists. Thus, we aimed to investigate whether patients with PD have an increased risk of AF. Methods This study included 57,585 patients with newly diagnosed PD (≥40‐year‐old, mean age 69.7 years, men 40.2%) and without a history of AF from the Korean National Health Insurance Service (NHIS) database between 2010 and 2015. Furthermore, an equal number of age‐ and sex‐matched subjects without PD were selected for comparison. The primary outcome was new‐onset AF. Results During the mean follow‐up period of 3.4 ± 1.8 years, AF was newly diagnosed in 3,665 patients. A significantly higher incidence rate of AF was noted among patients with PD than among patients without PD (10.75 and 7.86 per 1000 person‐year, respectively). Multivariate Cox‐regression analysis revealed that PD was an independent risk factor for AF (hazard ratio [HR]: 1.27, 95% confidence interval [CI]: 1.18–1.36). Furthermore, subgroup analyses revealed that AF risk was higher in the younger age subgroups, and compared with the non‐PD group, the youngest PD group (age: 40–49 years) had a threefold increased risk of AF (HR: 3.06, 95% CI: 1.20–7.77). Interpretation Patients with PD, especially the younger age subgroups, have an increased risk of AF. Active surveillance and management of AF should be considered to prevent further complications.

BackgroundBodyweight variability is a risk factor for atrial fibrillation (AF). We aimed to examine the relationship between bodyweight variability and the risk of AF in patients with type 2 diabetes mellitus (DM), and whether this relationship was affected by baseline body mass index (BMI), weight change, or advanced diabetic stage.MethodsA nationwide population-based cohort of 670,797 patients with type 2 DM from the Korean National Health Insurance Service database without a history of AF and with ≥ 3 measurements of bodyweight over a 5-year period were followed up for AF development. Intra-individual bodyweight variability was calculated using variability independent of mean, and high bodyweight variability was defined as the quintile with the highest variability with the lower four quintiles as reference.ResultsDuring a median of 7.0 years of follow-up, 22,019 patients (3.3%) newly developed AF. After multivariate adjustment, those in the highest quintile of bodyweight variability showed a higher risk of incident AF (HR 1.16, 95% CI 1.12–1.20) compared to those in the lower 4 quintiles with reference bodyweight variability, irrespective of baseline BMI group and direction of overall weight change. This association was greater in magnitude in subjects with lower BMI, those on insulin, and those with a DM duration of greater than 5 years. In sensitivity analyses, high bodyweight variability was consistently associated with AF development using other indices of variability and adjusting for glycemic variability.ConclusionsHigh variability in bodyweight was associated with AF development, independently of traditional cardiovascular risk factors and baseline BMI. This association was stronger in underweight patients and with advanced diabetic stage. Weight fluctuation may interfere with the beneficial effects of weight loss and should be avoided when possible in weight control regimens for DM patients.

We aimed to describe temporal trends in emergency department (ED) visits of patients with atrial fibrillation (AF) over 12 years. A repeated cross-sectional analysis of ED visits in AF patients using the Korean nationwide claims database between 2006 and 2017 were conducted. We identified AF patients who had &ge, 1 ED visits. The incidence of ED visits among total AF population, cause of ED visit, and clinical outcomes were evaluated. During 12 years, the annual numbers of AF patients who attended ED at least once a year continuously increased (40,425 to 99,763). However, the annual incidence of ED visits of AF patients was stationary at about 30% because the number of total AF patients also increased during the same period. The most common cause of ED visits was cerebral infarction. Although patients had a higher risk profile over time, the 30-day and 90-day mortality after ED visit decreased over time. ED visits due to ischemic stroke, intracranial hemorrhage, and myocardial infarction decreased, whereas ED visits due to AF, gastrointestinal bleeding, and other major bleeding slightly increased among total AF population over 12 years. A substantial proportion of AF patients attended ED every year, and the annual numbers of AF patients who visited the ED significantly increased over 12 years. Optimized management approaches in a holistic and integrated manner should be provided to reduce ED visits of AF patients.

Background Continuous photoplethysmography (PPG) monitoring with a wearable device may aid the early detection of atrial fibrillation (AF). Objective We aimed to evaluate the diagnostic performance of a ring-type wearable device (CardioTracker, CART), which can detect AF using deep learning analysis of PPG signals. Methods Patients with persistent AF who underwent cardioversion were recruited prospectively. We recorded PPG signals at the finger with CART and a conventional pulse oximeter before and after cardioversion over a period of 15 min (each instrument). Cardiologists validated the PPG rhythms with simultaneous single-lead electrocardiography. The PPG data were transmitted to a smartphone wirelessly and analyzed with a deep learning algorithm. We also validated the deep learning algorithm in 20 healthy subjects with sinus rhythm (SR). Results In 100 study participants, CART generated a total of 13,038 30-s PPG samples (5850 for SR and 7188 for AF). Using the deep learning algorithm, the diagnostic accuracy, sensitivity, specificity, positive-predictive value, and negative-predictive value were 96.9%, 99.0%, 94.3%, 95.6%, and 98.7%, respectively. Although the diagnostic accuracy decreased with shorter sample lengths, the accuracy was maintained at 94.7% with 10-s measurements. For SR, the specificity decreased with higher variability of peak-to-peak intervals. However, for AF, CART maintained consistent sensitivity regardless of variability. Pulse rates had a lower impact on sensitivity than on specificity. The performance of CART was comparable to that of the conventional device when using a proper threshold. External validation showed that 94.99% (16,529/17,400) of the PPG samples from the control group were correctly identified with SR. Conclusions A ring-type wearable device with deep learning analysis of PPG signals could accurately diagnose AF without relying on electrocardiography. With this device, continuous monitoring for AF may be promising in high-risk populations. Trial Registration ClinicalTrials.gov NCT04023188; https://clinicaltrials.gov/ct2/show/NCT04023188

Objectives The aim of this study was to evaluate the effect of ticagrelor versus clopidogrel on left ventricular (LV) remodeling after reperfusion of ST-segment elevation myocardial infarction (STEMI) in humans. Background Animal studies have demonstrated that ticagrelor compared with clopidogrel better protects myocardium against reperfusion injury and improves remodeling after myocardial infarction. Methods In this investigator-initiated, randomized, open-label, assessor-blinded trial performed at 10 centers in Korea, patients were enrolled if they had naive STEMI successfully treated with primary percutaneous coronary intervention (PCI) and at least 6-month planned duration of dual-antiplatelet treatment. The coprimary endpoints were LV remodeling index (LVRI) (a relative change of LV end-diastolic volume) measured on 3-dimensional echocardiography and N-terminal pro–B-type natriuretic peptide level at 6 months. Results Among initially enrolled patients with STEMI (n = 336), 139 in each group completed the study. LVRI at 6 months was numerically lower with ticagrelor versus clopidogrel (0.6 ± 18.6% vs. 4.5 ± 16.5%; p = 0.095). Ticagrelor significantly reduced the 6-month level of N-terminal pro–B-type natriuretic peptide (173 ± 141 pg/ml vs. 289 ± 585 pg/ml; p = 0.028). These differences were prominent in patients with pre-PCI TIMI (Thrombolysis In Myocardial Infarction) flow grade 0. By multivariate analysis, ticagrelor versus clopidogrel reduced the risk for positive LV remodeling (LVRI >0%) (odds ratio: 0.56; 95% confidence interval: 0.33 to 0.95; p = 0.030). The LV end-diastolic volume index remained unchanged during ticagrelor treatment (from 54.7 ± 12.2 to 54.2 ± 12.2 ml/m2; p = 0.629), but this value increased over time during clopidogrel treatment (from 54.6 ± 11.3 to 56.4 ± 13.9 ml/m2; p = 0.056) (difference −2.3 ml/m2; 95% confidence interval: −4.8 to 0.2 ml/m2; p = 0.073). Ticagrelor reduced LV end-systolic volume index (from 27.0 ± 8.5 to 24.7 ± 8.4 ml/m2; p Conclusions Ticagrelor was superior to clopidogrel for LV remodeling after reperfusion of STEMI with primary PCI. (High Platelet Inhibition With Ticagrelor to Improve Left Ventricular Remodeling in Patients With ST Segment Elevation Myocardial Infarction [HEALING-AMI]; NCT02224534 )

BACKGROUND: Obesity and weight gain are established risk factors for atrial fibrillation (AF).OBJECTIVE: The purpose of this study was to investigate whether bodyweight variability is also a risk factor for AF development.METHODS: A nationwide population-based cohort of 8,091,401 adults from the Korean National Health Insurance Service database without a history of AF and with ≥3 measurements of bodyweight over a 5-year period were followed up for incident AF. Intraindividual bodyweight variability was calculated using variability independent of mean, and high bodyweight variability was defined as the quartile with the highest variability (Q4) with Q1-Q3 as reference.RESULTS: During median 8.1 years of follow-up, each increase of 1 SD in bodyweight variability was associated with a 5% increased risk of AF development, and the quartile with the highest bodyweight variability showed 14% increased risk of AF development compared to the quartile with the lowest variability (hazard ratio 1.14; 95% confidence interval 1.12-1.15), after adjustment for baseline bodyweight, height, age, sex, lifestyle factors, and comorbidities. High bodyweight variability was significantly associated with AF development in all baseline body mass index (BMI) groups except the very obese (BMI ≥30), and this association was stronger in subjects with lower bodyweight. High bodyweight variability was associated with increased risk of incident AF in all weight change groups, with a stronger association in those who lost weight.CONCLUSION: Bodyweight fluctuation was independently associated with an increased risk of AF development, especially in individuals with low bodyweight, and regardless of weight gain or loss.

Background Despite a sharp increase in the global prevalence of allergy over the past decade, the relation between multiple atopic conditions and atrial fibrillation (AF) has not been fully elucidated. Objective To determine whether there is an association between atopic diseases and AF and to examine the effect of multiple atopic diseases on the incidence of AF. Methods This retrospective population-based study used the database from the 2009 National Health Insurance Services-Health Screening Cohort in Korea. A total of 6,748,564‬ subjects without a previous history of AF were included in the final analysis and observed until 2017. The atopic triad included asthma, allergic rhinitis, and atopic dermatitis. A total of 1,168,196‬ subjects (17.3%) with at least one atopic disease were classified as the atopic group. The primary outcome was new-onset AF. Results During a median 7.2 ± 1.0 years of follow-up, 136,253‬ subjects were given the new diagnosis of AF (30,300 in the atopic group and 105,953 in the nonatopic group). The incidence of AF was 3.63/1000 person-years in the atopic group and 2.64/1000 person-years in the nonatopic group. The risk for AF showed a positive correlation with the number of diseases in the atopic triad (adjusted hazard ratio [aHR], 95% confidence interval [CI]: one disease: aHR = 1.15, CI, 1.14-1.17; two diseases: aHR = 1.34, CI, 1.31-1.38; and three diseases: aHR = 1.35, CI, 1.11-1.66; P for trend Conclusions The atopic triad of asthma, allergic rhinitis, and atopic dermatitis was associated with an increased risk for AF. Moreover, multiple atopic conditions have a higher risk for AF.

Additional file 1. Online only supplement.

Blood pressure variability is a well-known risk factor for cardiovascular disease, but its association with atrial fibrillation (AF) is uncertain. We aimed to evaluate the association between visit-to-visit blood pressure variability and incident AF. This population-based cohort study used database from the Health Screening Cohort, which contained a complete set of medical claims and a biannual health checkup information of the Koran population. A total of 8 063 922 individuals who had at least 3 health checkups with blood pressure measurement between 2004 and 2010 were collected after excluding subjects with preexisting AF. Blood pressure variability was defined as variability independence of the mean and was divided into 4 quartiles. During a mean follow-up of 6.8 years, 140 086 subjects were newly diagnosed with AF. The highest blood pressure variability (fourth quartile) was associated with an increased risk of AF (hazard ratio, 95% CI; systolic blood pressure: 1.06, 1.05–1.08; diastolic blood pressure: 1.07, 1.05–1.08) compared with the lowest (first quartile). Among subjects in the fourth quartile in both systolic and diastolic blood pressure variability, the risk of AF was 7.6% higher than those in the first quartile. Moreover, this result was consistent in both patients with or without prevalent hypertension. In subgroup analysis, the impact of high blood pressure variability on AF development was stronger in high-risk subjects, who were older (≥65 years), with diabetes mellitus or chronic kidney disease. Our findings demonstrated that higher blood pressure variability was associated with a modestly increased risk of AF.

Introduction/Background We introduce fascia closure technique using BERCI© instrument after robot-assisted gynecologic surgery, which is necessary for management and prevention of trocar site hernia. We design a step-by-step explanation of the procedure using a video. Totally 4 trocars were inserted, including 12 mm sized umbilical trocar, bilateral 8 mm sized robot arm trocar, and 5 mm sized extra-trocar for assistant. Methodology This video presents a systemic approach to fascia closure clearly devided into 5 steps after the main operation: (1) Right lateral trocar site fascia was closed first with BERCI© Instrument. Then, Umbilicus, left lateral, assistant port were remained. (2) Vicryl suture was inserted with BERCI© Instrument. (3) Hanging Vicryl suture on the left lateral trocar site, camera was moved from umbilical trocar to left lateral trocar site without trocar. (4) Watching the umbilical trocar site via camera, fascia was closed in the same way with BERCI© Instrument. (5) Finally, removing the camera, Vicryl suture was pulled out and tied on left lateral trocar site. All trocar site fascia was closed. At every step, it is necessary that kelly was inserted in each fascia to check Vicryl suture both sides of fascia. Results The procedure was performed without any complications. The patient had an uneventful postoperative course and was discharged home after routine postoperative care. Since then, she showed no evidence of trocar site hernia and doing well. Conclusion Fascia closure technique using BERCI© Instrument after robot-assisted gynecologic surgery is very safe and certain way because fascia was sutured watching with laparoscopic camera. The patient presented by us is an example showing that BERCI© Instrument can be used in the suture of trocar site. The key point in this procedure is to completely closure of fascia of trocar insertion site compared with conventional technique which is blind closure technique, so certain way to prevent trocar site hernia. Disclosure Nothing to disclose

Introduction/Background The known prognostic factors of uterine leiomyosarcoma (LMS) are initial stage, tumor size, cellular division (mitotic cell count), tumor grade, etc. In LMS, only radically surgical removal offers a chance of long-term survival. Despite complete surgical resection, about 70% develop recurrence within 8 to 16 months after initial diagnosis (even at stage 1 or 2). Even though there are several researches about prognostic factors of recurrent LMS, no definite conclusions that what the prognostic factors for recurrent LMS is. The objective of this research is to evaluate favorable factors of surgical resection for recurrent LMS. Methodology Clinical and pathological data of 38 patients with recurrent LMS who were treated in one center (Seoul National University Hospital) were analyzed retrospectively to identify prognostic factors for their overall survival (OS) and progression-free survival (PFS). Survival curves were generated using the methods of Kaplan and Meier analysis. Results The OS was 3.95 years and the median time of first PFS was 17 months and second PFS was 3.4 months. Mitotic count in tumor tissues and time to first recurrence were correlated with OS, but recurrent pattern was more important in time to second recurrence. Localized first recurrent site, solitary recurrence, second recurrent site which was limited in intra-pelvic were significantly associated with longer time to second recurrence. Conclusion Uterine LMS is a rare disease with extremely poor prognosis. For selected patients who have smaller mitotic count, time to first recurrence, localized and solitary recurrent site, and pelvis-limited second recurrence, secondary cytoreductive surgery can be beneficial and may prolong survival in selected. Disclosure Nothing to disclose.

Background: There are limited data for non-vitamin K antagonist oral anticoagulants (NOACs) impact on outcomes for patients with atrial fibrillation (AF) and valvular heart diseases (VHDs). Methods: We identified patients with AF and associated Evaluated Heartvalves, Rheumatic or Artificial (EHRA) type 2 VHDs, and who had been na&iuml, ve from the oral anticoagulants in the Korean National Health Insurance Service database between 2014 and 2016 (warfarin: n = 2671, NOAC: n = 3058). For analyzing the effect of NOAC on primary prevention, we excluded those with a previous history of ischemic stroke, intracranial hemorrhage (ICH), and gastrointestinal (GI) bleeding events. To balance covariates, we used the propensity score weighting method. Ischemic stroke, ICH, GI bleeding, major bleeding, all-cause death, and their composite outcome and fatal clinical events were evaluated. Results: During a follow-up with a mean duration of 1.4 years, NOACs were associated with lower risks of ischemic stroke (hazard ratio (HR): 0.71, 95% confidence interval (CI): 0.53&ndash, 0.96), GI bleeding (HR: 0.50, 95% CI: 0.35&ndash, 0.72), fatal ICH (HR: 0.28, 95% CI: 0.07&ndash, 0.83), and major bleeding (HR: 0.61, 95% CI: 0.45&ndash, 0.80) compared with warfarin. Overall, NOACs were associated with a lower risk of the composite outcome (HR: 0.68, 95% CI: 0.58&ndash, 0.80). Conclusions: In this nationwide Asian AF population with EHRA type 2 VHDs, NOAC use was associated with lower risks of ischemic stroke, major bleeding, all-cause death, and the composite outcome compared to warfarin use.

Background Patients with atrial fibrillation (AF) often have concomitant valvular heart disease (VHD), especially in Asia. There are limited data on non-vitamin K antagonist oral anticoagulants (NOAC) impact on outcomes for stroke prevention and bleeding for these patients in real world clinical practice. Purpose To investigate the effectiveness and safety of NOACs compared with warfarin in patients with AF and associated Evaluated Heartvalves, Rheumatic or Artificial (EHRA) type 2 VHD. Methods We identified oral anticoagulants naive patients with AF and EHRA type 2 VHD from the Korean National Health Insurance Service database between 2014 and 2016 (n=2,671 taking warfarin; n=3,058 taking NOAC). Six clinical outcomes including ischemic stroke, intracranial hemorrhage (ICH), gastrointestinal bleeding (GI), major bleeding, all-cause death, and their composite outcome and fatal clinical events (any events that led to death within 30-day of its occurrence) were evaluated. Inverse probability of treatment weighting (IPTW) method was used to balance covariates between the two groups. Results After weighted using 5% trimmed IPTW method (n=2371 taking warfarin; n=2792 taking NOAC), the mean age was 71.2 years, male was 57% and CHA2DS2-VASc score was 3.9. During a mean 1.4-year follow-up, weighted incidence rate of ischemic stroke, ICH, GI bleeding, and all-cause death were lower in the NOAC group than in the warfarin group. Compared to warfarin, NOACs were associated with lower risks of ischemic stroke (hazard ratio [HR] 0.71, 95% confidence interval [CI] 0.53–0.96), GI bleeding (HR 0.50, 95% CI 0.35–0.72) and major bleeding (HR 0.61, 95% CI 0.45–0.80). Although NOAC and warfarin groups showed similar incidence rate of ICH, NOAC group was associated with a significantly lower risk of fatal ICH compared to warfarin group (HR 0.28, 95% CI 0.07–0.83). Overall, NOACs were associated with a lower risk of the composite outcome (HR 0.68, 95% CI 0.58–0.80). For an exploratory analysis, patients with EHRA type 1 VHD (n=366 taking warfarin; n=345 taking NOAC) was evaluated. In multivariable Cox regression analysis, NOAC group showed a comparable risk of ischemic stroke, ICH, all-cause death and composite outcome. Clinical outcome in AF patients with VHD Conclusion In this nationwide Asian AF population with EHRA type 2 VHD, NOAC use was associated with lower risks of ischemic stroke, major bleeding, all-cause death, and the composite outcome compared to warfarin.

BACKGROUND Continuous photoplethysmography (PPG) monitoring with a wearable device may aid the early detection of atrial fibrillation (AF). OBJECTIVE We aimed to evaluate the diagnostic performance of a ring-type wearable device (CardioTracker, CART), which can detect AF using deep learning analysis of PPG signals. METHODS Patients with persistent AF who underwent cardioversion were recruited prospectively. We recorded PPG signals at the finger with CART and a conventional pulse oximeter before and after cardioversion over a period of 15 min (each instrument). Cardiologists validated the PPG rhythms with simultaneous single-lead electrocardiography. The PPG data were transmitted to a smartphone wirelessly and analyzed with a deep learning algorithm. We also validated the deep learning algorithm in 20 healthy subjects with sinus rhythm (SR). RESULTS In 100 study participants, CART generated a total of 13,038 30-s PPG samples (5850 for SR and 7188 for AF). Using the deep learning algorithm, the diagnostic accuracy, sensitivity, specificity, positive-predictive value, and negative-predictive value were 96.9%, 99.0%, 94.3%, 95.6%, and 98.7%, respectively. Although the diagnostic accuracy decreased with shorter sample lengths, the accuracy was maintained at 94.7% with 10-s measurements. For SR, the specificity decreased with higher variability of peak-to-peak intervals. However, for AF, CART maintained consistent sensitivity regardless of variability. Pulse rates had a lower impact on sensitivity than on specificity. The performance of CART was comparable to that of the conventional device when using a proper threshold. External validation showed that 94.99% (16,529/17,400) of the PPG samples from the control group were correctly identified with SR. CONCLUSIONS A ring-type wearable device with deep learning analysis of PPG signals could accurately diagnose AF without relying on electrocardiography. With this device, continuous monitoring for AF may be promising in high-risk populations. CLINICALTRIAL ClinicalTrials.gov NCT04023188; https://clinicaltrials.gov/ct2/show/NCT04023188

Although chronic kidney disease is known to increase the risk of atrial fibrillation (AF), the impact of the variability of renal function on the risk of incident AF is unknown. We aimed to evaluate the association between variability of renal function and the risk of developing AF among the general population. We evaluated a total of 3,551,249 adults who had three annual health check-ups provided by the National Health Insurance Service. The variability of renal function was defined as GFR-VIM, which is variability independent of the mean (VIM) of creatinine-based estimated glomerular filtration rate (eGFR). The study population was divided into four groups (Q1-4) based on the quartiles of GFR-VIM, and the risks of incident AF by each group were compared. During a mean of 3.2 ± 0.5 years follow-up, incident AF occurred in 15,008 (0.42%) subjects. The incidence rates of AF increased from Q1 to Q4 (0.98, 1.42, 1.27, and 1.63 per 1,000 person-years, respectively). Adjusting with multiple variables, Q4 showed an increased risk of incident AF compared to Q1 (hazard ratio (HR) 1.125, 95% confidence interval (CI) 1.071–1.181). Variability of serum creatinine or other definitions of variability showed consistent results. On subgroup analyses, Q4 in males or those with a decreasing trend of eGFR had significantly increased risks of incident AF compared to Q1 (HR 1.127, 95% CI 1.082–1.175; and HR 1.115, 95% CI 1.059–1.173, respectively). High variability of eGFR was associated with an increased risk of incident AF, particularly in males or those with decreasing trends of eGFR during follow-up.