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Background: Impairments in psychosocial status and cognition relate to poor clinical outcomes in patients with atrial fibrillation (AF). However, how often these conditions co-occur and associations between burden of psychosocial and cognitive impairment and quality of life (QoL) have not been systematically examined in patients with AF. Methods: A total of 218 patients with symptomatic AF were enrolled in a prospective study of AF and psychosocial factors between May 2013 and October 2014 at the University of Massachusetts Medical Center. Cognitive function, depression, and anxiety were assessed at baseline and AF-specific QoL was assessed 6 months after enrollment using validated instruments. Demographic and clinical information were obtained from a structured interview and medical record review. Results: The mean age of the study participants was 63.5 ± 10.2 years, 35% were male, and 81% had paroxysmal AF. Prevalences of impairment in 1, 2, and 3 psychosocial/cognitive domains (eg, depression, anxiety, or cognition) were 75 (34.4%), 51 (23.4%), and 16 (7.3%), respectively. Patients with co-occurring psychosocial/cognitive impairments (eg, >1 domain) were older, more likely to smoke, had less education, and were more likely to have heart failure (all P < 0.05). Compared with participants with no psychosocial/cognitive impairments, AF-specific QoL at 6 months was significantly poorer among participants with baseline impairment in 2 (B = −13.6, 95% CI: −21.7 to −5.4) or 3 (B = −15.1, 95% CI: −28.0 to −2.2) psychosocial/cognitive domains. Conclusion: Depression, anxiety, and impaired cognition were common in our cohort of patients with symptomatic AF and often co-occurred. Higher burden of psychosocial/cognitive impairment was associated with poorer AF-specific QoL.

Introduction Although catheter ablation (CA) for atrial fibrillation (AF) is commonly used to improve symptoms, AF recurrence is common and new tools are needed to better inform patient selection for CA. Left Atrial Function Index (LAFI), an echocardiographic measure of atrial mechanical function, has shown promise as a non-invasive predictor of AF. We hypothesized that LAFI would relate to AF recurrence after CA. Methods and Results All AF patients undergoing index CA were enrolled in a prospective institutional AF Treatment Registry between 2011 and 2014. LAFI was measured post-hoc from pre-ablation clinical echocardiographic images in 168 participants. Participants were mostly male (33% female), middle-aged (60±10 years), obese and had paroxysmal AF (64%). Mean LAFI was 25.9±17.6. Over 12 months of follow-up, 78 participants (46%) experienced a late AF recurrence. In logistic regression analyses adjusting for factors known to be associated with AF, lower LAFI remained associated with AF recurrence after CA [OR 0.04 (0.01 – 0.67), p = 0.02]. LAFI discriminated AF recurrence after CA slightly better than CHADS2 (C-statistic 0.60 LAFI, 0.57 CHADS2). For participants with persistent AF, LAFI performed significantly better than CHADS2 score (C statistic = 0.79 LAFI, 0.56 CHADS2, p = 0.02). Conclusion LAFI, an echocardiographic measure of atrial function, is associated with AF recurrence after CA and has improved ability to discriminate AF recurrence as compared to the CHADS-2 score, especially among persistent AF patients. Since LAFI can be calculated using standard two-dimensional echocardiographic images, it may be a helpful tool for predicting AF recurrence. This article is protected by copyright. All rights reserved

Atrial fibrillation (AF) is a common complication of acute myocardial infarction (AMI) and contributes to high rates of in-hospital adverse events. However, there are few contemporary studies examining rates of AF in the contemporary era of AMI or the impact of new-onset AF on key in-hospital and post-discharge outcomes. We examined trends in AF among 6,384 residents of Worcester, Massachusetts who were hospitalized with confirmed AMI during 7 biennial periods between 1999 and 2011. Multivariate logistic regression analysis was used to examine associations between occurrence of AF and various in-hospital and post-discharge complications. The overall incidence of AF complicating AMI was 10.8%. Rates of new-onset AF increased from 1999 to 2003 (9.8% to 13.2%), and declined thereafter. In multivariable adjusted models, patients developing new-onset AF following AMI were at higher risk for inhospital stroke [Odds Ratio (OR) 2.5, 95% Confidence Interval (CI) 1.6–4.1], heart failure [OR 2.0, 95% CI 1.7 to 2.4], cardiogenic shock [OR 3.7, 95% CI 2.8–4.9] and death [OR 2.3, 95% CI 1.9 to 3.0] than patients without AF. Development of AF during hospitalization for AMI was associated with higher rates of readmission within 30-days after discharge [21.7% vs. 16.0%], but no significant difference was noted in early post-discharge 30-day all-cause mortality rates [8.3% vs. 5.1%]. In conclusion, new-onset AF following AMI is strongly related to in-hospital complications of AMI as well as higher short-term readmission rates.

INTRODUCTION Predicting which patients will be free from atrial fibrillation (AF) after pulmonary vein isolation (PVI) remains challenging. Clinical risk prediction scores show modest ability to identify patients at risk for AF recurrence after PVI. B-type natriuretic peptide (BNP) is associated with risk for incident and recurrent AF but is not currently included in existing AF risk scores. We sought to evaluate the incremental benefit of adding preoperative BNP to existing risk scores for predicting AF recurrence during the 6 months after PVI. METHODS One hundred sixty-one patients with paroxysmal or persistent AF underwent an index PVI procedure between 2010 and 2013; 77 patients (48%) had late AF recurrence after PVI (>3 months post-PVI) over the 6-month follow-up period. RESULTS A BNP greater than or equal to 100 pg/dL (P=0.01) and AF recurrence within 3 months after PVI (P

Automated Arrhythmia Discrimination Using a SmartphoneBackground Atrial fibrillation (AF) is a common and dangerous rhythm abnormality. Smartphones are increasingly used for mobile health applications by older patients at risk for AF and may be useful for AF screening. Objectives To test whether an enhanced smartphone app for AF detection can discriminate between sinus rhythm (SR), AF, premature atrial contractions (PACs), and premature ventricular contractions (PVCs). Methods We analyzed two hundred and nineteen 2-minute pulse recordings from 121 participants with AF (n = 98), PACs (n = 15), or PVCs (n = 15) using an iPhone 4S. We obtained pulsatile time series recordings in 91 participants after successful cardioversion to sinus rhythm from preexisting AF. The PULSE-SMART app conducted pulse analysis using 3 methods (Root Mean Square of Successive RR Differences; Shannon Entropy; Poincare plot). We examined the sensitivity, specificity, and predictive accuracy of the app for AF, PAC, and PVC discrimination from sinus rhythm using the 12-lead EKG or 3-lead telemetry as the gold standard. We also administered a brief usability questionnaire to a subgroup (n = 65) of app users. Results The smartphone-based app demonstrated excellent sensitivity (0.970), specificity (0.935), and accuracy (0.951) for real-time identification of an irregular pulse during AF. The app also showed good accuracy for PAC (0.955) and PVC discrimination (0.960). The vast majority of surveyed app users (83%) reported that it was “useful” and “not complex” to use. Conclusion A smartphone app can accurately discriminate pulse recordings during AF from sinus rhythm, PACs, and PVCs.

Introduction: Genetic and transcriptomic factors play important roles as mediators of new-onset and recurrent atrial fibrillation (AF). MicroRNAs (miRNAs) regulate expression of gene networks involved in key aspects of atrial remodeling. Associations between circulating miRNAs and AF recurrence are unknown. We tested the hypothesis that cardiac miRNAs associated with electrical and structural remodeling predict recurrent AF rhythm in post-ablation patients. Methods: We quantified plasma expression of 86 cardiac miRNAs using RT-qPCR in 83 consenting participants undergoing ablation for AF. MiRNA expression was re-measured 1-month post-ablation in a subset of 43 of 83 study participants. Then all 83 patients were followed over a 12-month period for AF recurrence and plasma miRNA expression was compared between baseline and 1-month post-ablation and between those with and without an AF recurrence. Results: The mean age of study participants was 59 years, 34% were female, and 63% had paroxysmal AF. Plasma levels of miRNAs 125a-5p and 10b were 3-fold lower after ablation compared to pre-ablation (p

Although catheter ablation (CA) for atrial fibrillation (AF) is commonly used to improve symptoms, AF recurrence is common and new tools are needed to better inform patient selection for CA. Left atrial function index (LAFI), an echocardiographic measure of atrial mechanical function, has shown promise as a noninvasive predictor of AF. We hypothesized that LAFI would relate to AF recurrence after CA.All AF patients undergoing index CA were enrolled in a prospective institutional AF Treatment Registry between 2011 and 2014. LAFI was measured post hoc from pre-ablation clinical echocardiographic images in 168 participants. Participants were mostly male (33% female), middle-aged (60 ± 10 years), obese and had paroxysmal AF (64%). Mean LAFI was 25.9 ± 17.6. Over 12 months of follow-up, 78 participants (46%) experienced a late AF recurrence. In logistic regression analyses adjusting for factors known to be associated with AF, lower LAFI remained associated with AF recurrence after CA [OR 0.04 (0.01-0.67), P = 0.02]. LAFI discriminated AF recurrence after CA slightly better than CHADS2 (C-statistic 0.60 LAFI, 0.57 CHADS2). For participants with persistent AF, LAFI performed significantly better than CHADS2 score (C statistic = 0.79 LAFI, 0.56 CHADS2, P = 0.02).LAFI, an echocardiographic measure of atrial function, is associated with AF recurrence after CA and has improved ability to discriminate AF recurrence as compared to the CHADS-2 score, especially among persistent AF patients. Since LAFI can be calculated using standard 2D echocardiographic images, it may be a helpful tool for predicting AF recurrence.

Introduction: Atrial fibrillation (AF) is a common condition that adversely impacts quality of life, reduces survival and requires significant healthcare resource utilization. Catheter-based ablation is an effective tool commonly used in the management of symptomatic AF patients, but it remains technically and logistically complex. Data describing the impact of team-based process improvement initiatives on laboratory resource utilization and outcomes of AF ablation are limited. To address this knowledge gap, we examined the impact of a real-time review of quality indicators and systems-based process improvement (PI) initiative on outcomes and resource utilization over 5 years. Methods: We developed an AF Treatment Program to conduct real-time review of ablation outcomes and lab resource utilization to facilitate PI and promote accountability. Key stakeholders and operational deficiencies were identified, and process changes, when needed, were implemented. Real-time feedback on performance was given and monthly results posted. In this analysis we examine the impact of our AF PI initiative on case start times, case duration, procedural adverse outcomes and ablation success rates. Results: Over the study period, concurrent with PI efforts, the rate of adverse outcomes decreased from 16.7% to 1.9% (p=0.03), average case start time improved by 85% (p=0.04), and the mean case duration decreased by 70 minutes (p=0.11). Maintenance of sinus rhythm at 1 year for the pre-intervention group was 78% versus 83% during the most recent study year (p=0.04). Conclusions: A continuous quality improvement AF program was associated with significant declines in adverse event rates and increased laboratory efficiencies, without adversely affecting long-term ablation outcomes. Although the non-randomized nature of our study precludes assumptions of causality, we hypothesize that real-time review and feedback was a major driver of performance improvement.

Objective: The purpose of this investigation was to characterize clinical variables and angiographic distribution of coronary atherosclerosis to classify patients with de novo left main (LM) disease in a real-world population presenting for coronary angiography. Background: Limited quantitative and angiographic published data exist that provide detailed quantitative information to classify potential target population for elective LM percutaneous coronary intervention (PCI) and guide development of dedicated LM PCI platforms. Methods: Medical history and clinical presentation were prospectively collected on 177 consecutive patients with LM stenosis ≥50% by coronary angiography. Blinded quantitative coronary angiography (QCA) was performed on all LM stenoses to classify LM-A (ostial), LM-B (nonostial, non-bifurcation), and LM-C (bifurcation involvement). QCA was performed on the left anterior descending (LAD), left circumflex (LCx), and right coronary arteries (RCA) and branches (≥2.5 mm) to identify lesions with ≥60% stenosis or occlusion. Results: No differences in baseline clinical history or presentation discriminated the distribution patterns of LM stenosis. QCA revealed 66% of LM stenoses were LM-C. Mean LM reference vessel diameter was 4.65 mm and average lesion length was 11.12 mm. Around 88.7% of patients had at least one lesion ≥60% in a major epicardial artery and 32.2% of patients had RCA chronic total occlusion. Right-to-left coronary collateralization was only identified in patients with obstructive stenosis in the LAD or LCx in addition to the LM stenosis. Conclusion: Dedicated LM stent platforms may need to be developed to accommodate larger vessel size and bifurcation distributions. A majority of patients with LM stenosis will require adjunctive epicardial vessel PCI to achieve complete anatomic revascularization.

INTRODUCTION Limited data are available on contemporary percutaneous coronary intervention (PCI) practice patterns and outcomes in elderly patients. The objective of this study was to evaluate "real-world" PCI in elderly and nonelderly patients during the first year of availability of drug-eluting stents (DES) in the United States market (May 1, 2003-April 30, 2004). METHODS One thousand one hundred sixty-six consecutive patients (272 elderly [age > or =75 years] and 894 nonelderly [age

AIMS: Pre-procedural identification of patients with atrial fibrillation (AF) who will remain free from AF after pulmonary vein isolation (PVI) remains challenging. Clinical risk scores, including CHADS2, CHA2DS2-VASc, R2CHADS2, and HATCH scores show modest discriminative ability with respect to AF recurrence. B-type natriuretic peptide (BNP) is associated with risk for AF and AF recurrence but is not currently included in existing AF risk scores. We sought to evaluate the incremental benefit of adding pre-operative BNP to existing risk scores in predicting AF recurrence within 6-months after PVI. METHODS AND RESULTS: One hundred and fifty one patients (105 men, age 60 ± 10 years) with paroxysmal or persistent AF underwent an index PVI procedure between 2010-2014. Seventy-seven patients had an AF recurrence (51%) over the 6-month follow-up period. BNP level of >100 units was significantly associated with 6-month AF recurrence in univariate models (p CONCLUSIONS: Addition of BNP to existing AF risk scores enhanced their predictive value and discriminative ability in predicting AF recurrence after PVI. Further research is needed including large and diverse cohorts of patients undergoing ablation and monitored for AF recurrence over extended periods to further validate the performance of this composite score.

Background: Atrial fibrillation (AF) affects approximately 4 million Americans, and two out of three AF patients are affected by troublesome symptoms. Symptomatic AF often leads to hospitalization, diminishes quality of life, and imposes considerable stress on affected individuals. Depression and anxiety are exceedingly common in AF, affecting up to one-half of these patients. Nevertheless, few investigations have examined the association between severity and type of AF-related symptoms with depression or anxiety. Methods: A cohort of 113 ambulatory patients treated for symptomatic AF in the University of Massachusetts Medical Center’s AF Treatment Program were assessed for depression using the Patient Health Questionnaire (PHQ), anxiety by the Generalized Anxiety Score (GAD), and health-related quality of life using the Atrial Fibrillation Effect on Quality of Life (AFEQT) as part of an ongoing study of AF treatment and psychosocial factors. We used logistic regression models to examine the association between severity of AF symptoms in four symptom classes (palpitations, dizziness, pauses in heart activity, and irregularity) and severity of depression or anxiety. Results: Participants were 34% female with a mean age of 64 years. Seventy-six percent had paroxysmal AF, and the average AFEQT score was 67 ± 23 (range 0-100, 100 = no disability). Twenty-five percent (n=28) reported moderate or severe anxiety and 40% (n=46) had moderate or severe depression. In multivariable analyses adjusting for age, sex, race, AF type, history of heart failure and coronary artery disease, participants with severe palpitations (23%) and dizziness (25%) were 3 to 5 times more likely to report moderate or severe symptoms of depression and anxiety ( Table , p for all Table , p for all Conclusion: Participants with AF commonly had symptoms, and the severity of symptoms was positively associated with depression and anxiety. In light of the known association between AF, depression and anxiety, rhythm control strategies such as catheter ablation for AF might improve quality of life as well as symptoms of depression or anxiety.

Background: Patients with atrial fibrillation (AF) commonly experience symptoms such as palpitations, shortness of breath and chest discomfort. The severity of AF-related symptoms is associated with psychosocial factors such as anxiety and depression. Limited data suggests that catheter ablation, a treatment option in symptomatic patients with AF, reduces depression and anxiety but its effect on cognitive function remains unclear. Methods: Participants were 38 AF patients (mean age = 63 years ±8; 68% male, 66% paroxysmal AF) undergoing an index catheter ablation for AF at the University of Massachusetts Medical Center and interviewed pre-ablation and post ablation (1-week, 1 month and 3 months) as part of an ongoing study of AF treatment and psychosocial factors. A total of 150 ablation patients will be included in the final sample. Cognitive function was assessed using the Montreal Cognitive Assessment Battery (impairment = score Results: Patients reported high levels of depressive symptoms and anxiety and many (>50%) were cognitively impaired prior to ablation. Cognitive function increased following ablation, with improvements observed as early as one week after catheter ablation and continued to improve at 3-months post procedure (Table). Symptoms of depression and anxiety declined immediately following ablation and continued to decline through 3-months post procedure but changes were not statistically significant and may have been limited by power. Conclusions: Catheter-based ablation was associated with improved symptoms of depression and anxiety as well as cognitive function among patients with symptomatic AF. Knowledge of the patient-centered, as well as clinical, benefits of the various treatments for AF will guide patients, their families and their physicians make informed treatment choices.

Background— The effects of lifestyle changes and evolving treatment practices on coronary disease incidence rates, demographic and clinical profile, and the short-term outcomes of patients hospitalized with acute myocardial infarction have not been well characterized. The purpose of this study was to examine multidecade-long trends (1975–2005) in the incidence rates, demographic and clinical characteristics, treatment practices, and hospital outcomes of patients hospitalized with an initial acute myocardial infarction from a population-based perspective. Methods and Results— Residents of the Worcester, Mass, metropolitan area (median age, 37 years; 89% white) hospitalized with an initial acute myocardial infarction (n=8898) at all greater-Worcester medical centers during 15 annual periods between 1975 and 2005 comprised the sample of interest. The incidence rates of initial acute myocardial infarction were lower in 2005 (209 of 100 000 population) than in 1975 (277 of 100 000), although these trends varied inconsistently over time. Patients hospitalized during the most recent study years were significantly older (mean age, 64 years in 1975; 71 years in 2005), more likely to be women (38% in 1975; 48% in 2005), and have a greater prevalence of comorbidities. Hospitalized patients were increasingly more likely to receive effective cardiac medications and coronary interventional procedures for the period under investigation. Hospital survival rates improved significantly over time (81% survived in 1975; 91% survived in 2005), although varying trends were observed in the occurrence of clinically important complications. Conclusions— The results of this community-wide investigation provide insight into the changing magnitude, characteristics, management practices, and outcomes of patients hospitalized with a first myocardial infarction.