Associations of dietary patterns, ultra-processed food and nutrient intake with incident atrial fibrillation.

OBJECTIVE: To examine the associations between specific dietary patterns and incident atrial fibrillation (AF). METHODS: Using data from the UK Biobank, dietary intakes were calculated from 24-hour diet recall questionnaires. Indices representing adherence to dietary patterns (Mediterranean-style, Dietary Approaches to Stop Hypertension (DASH) and plant-based diets) were scored, and ultra-processed food consumption was studied as a percentage of total food mass consumed. Incident AF hospitalisations were assessed in Cox regression models. RESULTS: A total of 121 300 individuals were included, with 4 579 incident AF cases over a median follow-up of 8.8 years. Adherence to Mediterranean-style or DASH diets was associated with a lower incidence of AF in minimally adjusted analyses (HR for highest vs lowest quintile 0.87 (95% CI 0.80-0.96) and HR 0.78 (95% CI 0.71-0.86), respectively). However, associations were no longer significant after accounting for lifestyle factors (HR 0.95 (95% CI 0.87-1.04) and 0.94 (95% CI 0.86-1.04) respectively), with adjustment for body mass index responsible for approximately three-quarters of the effect size attenuation. Plant-based diets were not associated with AF risk in any models. Greatest ultra-processed food consumption was associated with a significant increase in AF risk even in fully adjusted models (HR 1.13 (95% CI 1.02-1.24)), and a 10% increase in absolute intake of ultra-processed food was associated with a 5% increase in AF risk (HR 1.05 (95% CI 1.01-1.08)). CONCLUSION: With the possible exception of reducing ultra-processed food consumption, these findings suggest that attention to other modifiable risk factors, particularly obesity, may be more important than specific dietary patterns for the primary prevention of AF.

Factors affecting electrogram sensing in an insertable cardiac monitor: Insights from surface electrocardiogram mapping analysis.

BACKGROUND: Fidelity of electrogram sensing may reduce false alerts from an insertable cardiac monitor (ICM). OBJECTIVE: The purpose of this study was to assess the effect of vector length, implant angle, and patient factors on electrogram sensing using surface electrocardiogram (ECG) mapping. METHODS: Twelve separate precordial single-lead surface ECGs were acquired from 150 participants at 2 interelectrode distances (75 and 45 mm), at 3 vector angles (vertical, oblique, and horizontal), and in 2 postures (upright and supine). A subset of 50 patients also received a clinically indicated ICM implant in 1:1 ratio (Reveal LINQ [Medtronic, Minneapolis, MN]/BIOMONITOR III [Biotronik, Berlin, Germany]). All ECGs and ICM electrograms were analyzed by blinded investigators using DigitizeIt software (V2.3.3, Braunschweig, Germany). The P-wave visibility threshold was set at > 0.015 mV. Logistic regression was used to identify factors affecting P-wave amplitude. RESULTS: A total of 1800 tracings from 150 participants (44.5% [n = 68] female; median age 59 [35-73] years) were assessed. The median P- and R-wave amplitudes were 45% and 53% larger with vector lengths of 75 and 45 mm, respectively (P < .001 for both). The oblique orientation yielded the best P- and R-wave amplitudes, while posture change did not affect P-wave amplitude. Mixed effects modeling found that visible P-waves occur more frequently with a vector length of 75 mm than with 45 mm (86% vs 75%, respectively; P < .0001). A longer vector length improved both P-wave amplitude and visibility in all body mass index categories. There was a moderate correlation of P- and R-wave amplitudes from the ICM electrograms to those from surface ECG recordings (intraclass correlation coefficient 0.74 and 0.80, respectively). CONCLUSION: Longer vector length and oblique implant angle yielded the best electrogram sensing and are relevant considerations for ICM implantation procedures.

Cardiac resynchronization therapy in an orthotopic heart transplant recipient.

Although cardiac resynchronization therapy (CRT) is an established therapy in selected patients with heart failure with reduced ejection fraction (HFrEF), its role in orthotopic heart transplant (OHT) recipients remains understudied. We describe a case of successful CRT implantation in an OHT recipient for HFrEF and high-grade atrioventricular block. This case highlights the deliberations made given the lack of clinical trial and observational evidence for this therapy in OHT recipients. Learning Objective: This case demonstrates the feasibility of cardiac resynchronization therapy (CRT) in an orthotopic heart transplant (OHT) recipient and adds to the scarcely reported data on the utility of CRT in this population. Given the exclusion of OHT recipients from the major CRT trials, further research is required to refine the indications for CRT implantation in this population.

Trends in myocardial infarction and coronary revascularisation procedures in Australia, 1993-2017.

OBJECTIVE: Prior data have shown rising acute myocardial infarction (MI) trends in Australia; whether these increases have continued in recent years is not known. This study thus sought to characterise contemporary nationwide trends in MI hospitalisations and coronary procedures in Australia and their associated economic burden. METHODS: The primary outcome measure was the incidence and time trends of total MI, ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) hospitalisations from 1993 to 2017. The incidence and time trends of coronary procedures were additionally collected, alongside MI hospitalisation costs. RESULTS: Adjusted for population changes, annual MI incidence increased from 216.2 cases per 100 000 to a peak of 270.4 in 2007 with subsequent decline to 218.7 in 2017. Similarly, NSTEMI incidence increased from 68.0 cases per 100 000 in 1993 to a peak of 192.6 in 2007 with subsequent decline to 162.6 in 2017. STEMI incidence decreased from 148.3 cases per 100 000 in 1993 to 56.2 in 2017. Across the study period, there were annual increases in MI hospitalisations of 0.7% and NSTEMI hospitalisations of 5.6%, and an annual decrease in STEMI hospitalisations of 4.8%. Angiography and percutaneous coronary intervention increased by 3.4% and 3.3% annually, respectively, while coronary artery bypass graft surgery declined by 2.2% annually. MI hospitalisation costs increased by 100% over the study period, despite a decreased average length of stay by 45%. CONCLUSIONS: The rising incidence of MI hospitalisations appear to have stabilised in Australia. Despite this, associated healthcare expenditure remains significant, suggesting a need for continual implementation of public health policies and preventative strategies.

The Burden of Cardiac Implantable Electronic Device Checks in the Peri-MRI Setting: The CHECK-MRI Study.

BACKGROUND: Most modern cardiac implantable electronic device (CIED) systems are now compatible with magnetic resonance imaging (MRI) scans. The requirement for both pre- and post-MRI CIED checks imposes significant workload to the cardiac electrophysiology service. Here, we sought to determine the burden of CIED checks associated with MRI scans. METHODS: We identified all CIED checks performed peri-MRI scans at our institution over a 3-year period between 1 July 2017 to 30 June 2020, comprising three separate financial years (FY). Device check reports, MRI scan reports and clinical summaries were collated. The workload burden was determined by assessing the occasions and duration of service. Analysis was performed to determine cost burden/projections for this service and identify factors contributing to the workload. RESULTS: A total of 739 CIED checks were performed in the peri-MRI scan setting (370 pre- and 369 post-MRI scan), including 5% (n=39) that were performed outside of routine hours (weekday <8 am or >5 pm, and weekends). MRIs were performed for 295 patients (75±13 years old, 64% male) with a CIED (88% permanent pacemaker, and 12% high voltage device), including 49 who had more than one MRI scan. The proportion of total MRI scans for patients with a CIED in-situ increased each FY (from 0.5% of all MRIs in FY1, to 0.9% in FY2, to 1.0% in FY3). The weekly workload increased (R2=0.2, p<0.001), but with week-to-week variability due to ad hoc scheduling (209 days with only one MRI vs 78 days with ≥2 MRIs for CIED patients). The projected annual cost of this service will increase to AUD$161,695 in 10 years for an estimated annual 546 MRI scans for CIED patients. CONCLUSIONS: There is an increasing workload burden and expense associated with CIED checks in the peri-MRI setting. Appropriate budgeting, staff allocation and standardisation of automated CIED pre-programming features among manufacturers are urgently needed.

Cardiorespiratory fitness, obesity and left atrial function in patients with atrial fibrillation.

Background: Low cardiorespiratory fitness (CRF) and obesity are related to the development and maintenance of atrial fibrillation (AF). The aim of this study was to determine the association between CRF, obesity and left atrial (LA) mechanical parameters in patients with AF. Methods: A cohort of 154 consecutive paroxysmal and persistent AF patients (Age: 62 ± 10, 26% female) referred for exercise stress testing and transthoracic echocardiography were included. We included patients in sinus rhythm with preserved left ventricular ejection fraction who were able to complete a maximal exercise test. Left atrial strain in the reservoir (LASr), booster (LASb) and conduit (LASc) phases were assessed using dedicated software. LA stiffness, emptying fraction (LAEF) and LA to LV ratio were calculated using previously described formulas. Results: CRF was positively associated with LAEF (ß = 1.3, 95% CI 0.1-2.3, p = 0.02), reservoir (ß = 1.5, 95% CI 0.9-2.1, p < 0.001), booster (ß = 0.8, 95% CI 0.4-1.2, p < 0.001) and conduit strain (ß = 0.7, 95% CI 0.3-1.1, p = 0.001). We observed an inverse association between CRF and both LA stiffness index (ß = -0.02, 95% CI (-0.03)-(-0.01), p < 0.001) and LA to LV ratio (ß = -0.03, 95% CI (-0.04)-(-0.01), p < 0.001). Obese patients had significantly higher indexed LA volumes compared to overweight and normal BMI patients. The association between obesity and measures of LA function and stiffness did not reach statistical significance. Conclusion: Among AF patients, higher CRF was independently associated with greater LA function and compliance. Obesity was associated with higher LA volumes yet preserved mechanical function.

Impact of device length on electrogram sensing in miniaturized insertable cardiac monitors.

BACKGROUND: Little data exists on electrogram sensing in current generation of miniaturized insertable cardiac monitors (ICMs). OBJECTIVE: To compare the sensing capability of ICM with different vector length: Medtronic Reveal LINQ (~40 mm) vs. Biotronik Biomonitor III (BM-III, ~70 mm). METHODS: De-identified remote monitoring transmissions from n = 40 patients with BM-III were compared with n = 80 gender and body mass index (BMI)-matched patients with Reveal LINQ. Digital measurement of P- and R-wave amplitude from calibrated ICM electrograms was undertaken by 3 investigators independently. Further, we evaluated the impact of BMI and gender on P-wave visibility. RESULTS: Patients in both groups were well matched for gender and BMI (53% male, mean BMI 26.7 kg/m2, both p = NS). Median P- and R-wave amplitude were 97% & 56% larger in the BM-III vs. LINQ [0.065 (IQR 0.039-0.10) vs. 0.033 (IQR 0.022-0.050) mV, p < .0001; & 0.78 (IQR 0.52-1.10) vs. 0.50 (IQR 0.41-0.89) mV, p = .012 respectively). The P/R-wave ratio was 36% greater with the BM-III (p < .001). The 25th percentile of P-wave amplitude for all 120 patients was .026 mV. Logistic regression analysis showed BM-III was more likely than LINQ to have P-wave amplitude ≥.026 mV (OR 7.47, 95%CI 1.965-29.42, p = .003), and increasing BMI was negatively associated with P-wave amplitude ≥.026 mV (OR 0.84, 95%CI 0.75-0.95, p = .004). However, gender was not significantly associated with P-wave amplitude ≥.026 mV (p = .37). CONCLUSION: The longer ICM sensing vector of BM-III yielded larger overall P- and R- wave amplitude than LINQ. Both longer sensing vector and lower BMI were independently associated with greater P-wave visibility.

Anemia and iron deficiency in patients with atrial fibrillation.

Atrial fibrillation (AF) is the most common cardiac tachyarrhythmia and has a rising global prevalence. Given the increasing burden of AF-related symptoms and complications, new approaches to management are required. Anemia and iron deficiency are common conditions in patients with AF. Furthermore, emerging evidence suggests that the presence of anemia may be associated with worse outcome in these patients. The role of anemia and iron deficiency has been extensively explored in other cardiovascular states, such as heart failure and ischemic heart disease. In particular, the role of iron repletion amongst patients with heart failure is now an established treatment modality. However, despite the strong bidirectional inter-relationship between AF and heart failure, the implications of anemia and iron-deficiency in AF have been scarcely studied. This area is of mechanistic and clinical relevance given the potential that treatment of these conditions may improve symptoms and prognosis in the increasing number of individuals with AF. In this review, we summarise the current published literature on anemia and iron deficiency in patients with AF. We discuss AF complications such as stroke, bleeding, and heart failure, in addition to AF-related symptoms such as exercise intolerance, and the potential impact of anemia and iron deficiency on these. Finally, we summarize current research gaps on anemia, iron deficiency, and AF, and underscore potential research directions.

Should We Check It? Assessing Interrogation of Cardiac Implantable Electronic Devices in the Emergency Department-The CHECK-ED Study: Implications for Service Planning and Care Delivery.

BACKGROUND: Requests from the emergency department (ED) for cardiac implantable electronic device (CIED) checks constitute a large workload for cardiac electrophysiology services. We sought to determine the yield of, and clinical characteristics associated with, clinically relevant (remarkable) issues from ED CIED checks. METHODS: Consecutive CIED checks from our ED over a 12-month period were studied. A remarkable issue (RI) was defined as arrhythmia relating to the presentation or device/lead issue requiring reprogramming or intervention. The association between the presenting complaint and an RI was assessed using regression analysis. Multivariable regression model was used to identify pre-specified patient-level characteristics that were predictive of a RI. RESULTS: A RI was found in 28% (n=98) of 354 ED CIED checks for 306 patients (76±16 yrs, 59% male). Most patients had no RI (n=224, 73%). One third of checks occurred after-hours and these had a higher yield of RIs than those during routine clinic hours (35% vs 23%, p=0.018). Presenting with a perceived ICD shock was predictive of a RI (odds ratio [OR] 6.0, 95% CI=1.8-20.0). Syncope/presyncope was five-fold less likely to be predictive of a RI (OR 0.19, 95% CI=0.13-0.28) despite being the most common indication for CIED check (51%, n=180 checks). Only history of AF was predictive of RI while advancing age was predictive of not finding a RI. CONCLUSION: Almost three-quarters of ED CIED checks did not yield any RI. Patient-reported ICD shock and history of AF were predictive of RI, while syncope/presyncope was not. New models of care especially during after-hours, may help to reduce the burden on cardiac electrophysiology services and health care costs.

Alcohol intake and bradyarrhythmia risk: a cohort study of 407 948 individuals.

AIMS: There is a paucity of epidemiological evidence on alcohol and the risk of bradyarrhythmias. We thus characterized associations of total and beverage-specific alcohol consumption with incident bradyarrhythmias using data from the UK Biobank. METHODS AND RESULTS: Alcohol consumption reported at baseline was calculated as UK standard drinks (8 g alcohol)/week. Bradyarrhythmia events were defined as sinus node dysfunction (SND), high-level atrioventricular block (AVB), and permanent pacemaker implantations. Outcomes were assessed through hospitalization and death records, and dose-response associations were characterized using Cox regression models with correction for regression dilution bias. We studied 407 948 middle-aged individuals (52.4% female). Over a median follow-up time of 11.5 years, a total of 8 344 incident bradyarrhythmia events occurred. Increasing total alcohol consumption was not associated with an increased risk of bradyarrhythmias. Beer and cider intake were associated with increased bradyarrhythmia risk up to 12 drinks/week; however, no significant associations were observed with red wine, white wine, or spirit intake. When bradyarrhythmia outcomes were analysed separately, a negative curvilinear was observed for total alcohol consumption and risk of SND, but no clear association with AVB was observed. CONCLUSION: In this predominantly White British cohort, increasing total alcohol consumption was not associated with an increased risk of bradyarrhythmias. Associations appeared to vary according to the type of alcoholic beverage and between different types of bradyarrhythmias. Further epidemiological and experimental studies are required to clarify these findings.

Alcohol consumption and risk of ventricular arrhythmias and sudden cardiac death: An observational study of 408,712 individuals.

BACKGROUND: Although previous studies have demonstrated a U-shaped relationship between alcohol and sudden cardiac death (SCD), there is a paucity of evidence on the role of alcohol specifically on incident ventricular arrhythmias (VAs). OBJECTIVE: The purpose of this study was to characterize associations of total and beverage-specific alcohol consumption with incident VA and SCD using data from the UK Biobank. METHODS: Alcohol consumption reported at baseline was calculated as UK standard drinks (8 g of alcohol) per week. Outcomes were assessed through hospitalization and death records. Alcohol consumption was modeled as restricted cubic splines in multivariate Cox regression models and corrected for regression dilution bias. RESULTS: We studied 408,712 middle-aged individuals (52.1% female) over a median follow-up time of 11.5 years. A total of 1733 incident VA events and 2044 SCDs occurred. For incident VA, no clear association was seen with total alcohol consumption. Although consumption of greater amounts of spirits was associated with increased VA risk, no other significant beverage-specific associations were observed. For SCD, a U-shaped association was seen for total alcohol consumption, such that consumption of <26 drinks per week was associated with lowest risk. Consumption of greater amounts of beer, cider, and spirits was potentially associated with increasing SCD risk, whereas increasing red and white wine intake was associated with reduced risk. CONCLUSION: In this predominantly white cohort, no association of total alcohol consumption was observed with VA, whereas a U-shaped association was present for SCD. Additional studies utilizing accurately defined VA and SCD events are required to provide further insights into these contrasting findings.

Prevalence and risk factors for atrial fibrillation in a semi-rural sub-Saharan African population: The hEart oF ethiopia: Focus on Atrial Fibrillation (TEFF-AF) Study.

Background: There is a scarcity of reported data on the prevalence of atrial fibrillation (AF) in sub-Saharan Africa. Objectives: To undertake AF screening in semi-rural Ethiopia. Methods: The TEFF-AF (The hEart oF Ethiopia: Focus on Atrial Fibrillation) study conducted AF screening using a single-lead electrocardiogram device (KardiaMobile) on willing community participants at the Soddo Christian Hospital, Ethiopia. Participants' clinical parameters and medical history were obtained to characterize their risk factor profile, including calculation of CHARGE-AF (Cohorts for Heart and Aging Research in Genomic Epidemiology Atrial Fibrillation) score. Results: A total of 3000 Ethiopians (median 31 [interquartile range 25-41] years of age; 65% men) were screened. The participants were generally well educated, from the local region and with a low burden of cardiovascular risk factors. A total of 50 participants had a CHARGE-AF score (5-year AF risk) of ≥2%. AF was detected in 13 (0.43%) individuals (median 50 [interquartile range 36-60] years of age; n = 7 men). The prevalence among participants over 40 years of age was 1% (n = 9 of 930). AF prevalence was higher for older age groups, with ≥70 years of age reaching 6.67% (n = 3 of 45). Population prevalence was estimated to be 234 (95% confidence interval 7-460) per 10,000 persons for ≥60 years of age. Four (31%) of the 13 participants with AF had a CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category) score of ≥2, and others likely had rheumatic valvular AF, but only 2 of the 13 participants with AF were on oral anticoagulation therapy. Conclusion: In this semi-rural Ethiopian community of relatively younger participants, AF prevalence was found to be low but increased with increasing age. Mobile single-lead electrocardiogram technology can be used effectively for AF screening in low-resource settings.

Risk Thresholds for Total and Beverage-Specific Alcohol Consumption and Incident Atrial Fibrillation.

OBJECTIVES: This study sought to characterize associations of total and beverage-specific alcohol consumption with incident atrial fibrillation (AF). BACKGROUND: Although binge drinking and moderate to high consumption of alcohol are both established risk factors for AF, comparatively less is known about the effect of low alcohol consumption and whether associations differ by specific alcoholic beverages. METHODS: Using data from the UK Biobank, total and beverage-specific alcohol consumption was calculated as UK standard drinks (8 g alcohol) per week. Past drinkers and those with a history of AF were excluded. Incident AF events were assessed through hospitalization and death records, and dose-response associations were characterized using Cox regression models with correction for regression dilution bias. RESULTS: We studied 403,281 middle-aged individuals (52.4% female). Over a median follow-up time of 11.4 years (IQR: 10.7-12.3 years), a total of 21,312 incident AF events occurred. A J-shaped association of total alcohol consumption was observed, with lowest risk of AF with fewer than 7 drinks/week. Beverage-specific analyses demonstrated harmful associations of beer/cider consumption with any consumption. In contrast, consumption of red wine, white wine, and spirits up to 10, 8, and 3 drinks/week, respectively, was not associated with increased risk. CONCLUSIONS: In this predominantly White population, low levels of alcohol consumption (<7 U.K. standard drinks [56 g alcohol]/week) were associated with lowest AF risk. Low consumption of red and white wine and very low consumption of spirits may not be associated with increased AF risk, whereas any consumption of beer/cider may be associated with harm. These findings may have important implications for the primary prevention of AF that should be explored in future studies.

Left atrial, pulmonary vein, and left atrial appendage anatomy in Indigenous individuals: Implications for atrial fibrillation.

BACKGROUND: Indigenous Australians experience a greater burden of AF. Whether this is in-part due to differences in arrhythmogenic structures that appear to contribute to AF differences amongst other ethnicities is not known. METHODS: We studied forty individuals matched for ethnicity and other AF risk factors. Computed tomography imaging was used to characterise left atrial (LA), pulmonary vein (PV), and left atrial appendage (LAA) anatomy. RESULTS: There were no significant differences in LA diameters or volumes between Indigenous and non-Indigenous Australians. Similarly, we could not detect any consistent differences in PV number, morphology, diameters, or ostial characteristics according to ethnicity. LAA analyses suggested that Indigenous Australians may have a greater proportion of non chickenwing LAA type, and a tendency for eccentric, oval-shaped LAA ostia; however, there were no other differences seen with regards to LAA volume or depth. Indexed values for LA, PV and LAA anatomy corrected for body size were broadly similar. CONCLUSIONS: In a cohort of individuals matched for AF risk factors, we could find no strong evidence of ethnic differences in LA, PV, and LAA characteristics that may explain a predisposition of Indigenous Australians for atrial arrhythmogenesis. These findings, in conjunction with our previous data showing highly prevalent cardiometabolic risk factors in Indigenous Australians with AF, suggest that it is these conditions that are more likely responsible for the AF substrate in these individuals. Continued efforts should therefore be directed towards risk factor management in an attempt to prevent and minimise the effects of AF in Indigenous Australians.

Performance of a Mobile Single-Lead Electrocardiogram Technology for Atrial Fibrillation Screening in a Semirural African Population: Insights From "The Heart of Ethiopia: Focus on Atrial Fibrillation" (TEFF-AF) Study.

BACKGROUND: Atrial fibrillation (AF) screening using mobile single-lead electrocardiogram (ECG) devices has demonstrated variable sensitivity and specificity. However, limited data exists on the use of such devices in low-resource countries. OBJECTIVE: The goal of the research was to evaluate the utility of the KardiaMobile device's (AliveCor Inc) automated algorithm for AF screening in a semirural Ethiopian population. METHODS: Analysis was performed on 30-second single-lead ECG tracings obtained using the KardiaMobile device from 1500 TEFF-AF (The Heart of Ethiopia: Focus on Atrial Fibrillation) study participants. We evaluated the performance of the KardiaMobile automated algorithm against cardiologists' interpretations of 30-second single-lead ECG for AF screening. RESULTS: A total of 1709 single-lead ECG tracings (including repeat tracing on 209 occasions) were analyzed from 1500 Ethiopians (63.53% [953/1500] male, mean age 35 [SD 13] years) who presented for AF screening. Initial successful rhythm decision (normal or possible AF) with one single-lead ECG tracing was lower with the KardiaMobile automated algorithm versus manual verification by cardiologists (1176/1500, 78.40%, vs 1455/1500, 97.00%; P<.001). Repeat single-lead ECG tracings in 209 individuals improved overall rhythm decision, but the KardiaMobile automated algorithm remained inferior (1301/1500, 86.73%, vs 1479/1500, 98.60%; P<.001). The key reasons underlying unsuccessful KardiaMobile automated rhythm determination include poor quality/noisy tracings (214/408, 52.45%), frequent ectopy (22/408, 5.39%), and tachycardia (>100 bpm; 167/408, 40.93%). The sensitivity and specificity of rhythm decision using KardiaMobile automated algorithm were 80.27% (1168/1455) and 82.22% (37/45), respectively. CONCLUSIONS: The performance of the KardiaMobile automated algorithm was suboptimal when used for AF screening. However, the KardiaMobile single-lead ECG device remains an excellent AF screening tool with appropriate clinician input and repeat tracing. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12619001107112; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378057&isReview=true.

Atrial Fibrillation in Remote Indigenous and Non-Indigenous Individuals Hospitalised in Central Australia.

BACKGROUND: The epidemiology of atrial fibrillation (AF) amongst Indigenous populations remains poorly characterised. We studied hospitalisations for AF in Central Australia, the most populous Indigenous region in the country. METHODS: Patients with a diagnosis of AF admitted to Alice Springs Hospital, the only secondary health care facility and provider of cardiac care in remote Central Australia, were identified from 2006 to 2016. Age and gender-specific hospitalised AF prevalence, comorbidities, and CHA2DS2-VASc scores were ascertained. RESULTS: Of 57,056 admitted patients over the study period, 1,210 (2.1%; 46% Indigenous) had a diagnosis of AF. For Indigenous and non-Indigenous individuals <45 years, hospitalised AF prevalence per 10,000 population was 105 (CI 84-131) and 50 (CI 36-68) in males (ratio=2.10), and 98 (CI 77-123) and 12 (CI 6-23) in females (ratio=7.92), respectively. For Indigenous and non-Indigenous individuals ≥65 years, hospitalised AF prevalence per 10,000 was 1,577 (CI 1,194-2,026) and 2,326 (CI 2,047-2,623) in males (ratio=0.68), and 1,713 (CI 1,395-2,069) and 1,897 (1,623-2,195) in females (ratio=0.90). Indigenous individuals had higher rates of cardiometabolic comorbidities, particularly at younger ages. CHA2DS2-VASc scores were greater in Indigenous individuals, particularly those <45 years (2.5±1.5 versus 0.7±1.1, p<0.001). CONCLUSIONS: The prevalence of hospitalised AF amongst Indigenous people in remote Central Australia was significantly higher than in non-Indigenous individuals, particularly in younger age groups and females. Indigenous individuals with hospitalised AF also had a markedly greater prevalence of cardiometabolic comorbidities and elevated stroke risk. These data suggest that AF may be contributing to the gap in morbidity and mortality experienced by Indigenous Australians.

Associations of anemia with stroke, bleeding, and mortality in atrial fibrillation: A systematic review and meta-analysis.

BACKGROUND: Anemia frequently coexists with atrial fibrillation (AF) and has been variably associated with worse outcomes. We performed a systematic review and meta-analysis to comprehensively assess the effect of anemia on mortality, stroke/systemic thromboembolism, and bleeding events in patients with AF. METHODS: MEDLINE and Embase were searched from inception until May 2020. Studies examining associations of anemia with the above outcomes in AF patients were included, and maximally adjusted hazard ratios (HRs) meta-analysed. PROSPERO registration number CRD42020171113. RESULTS: Twenty-eight studies involving 365 484 patients (41% female, mean age 74.7 years) were included. The average study follow-up ranged from 0.2 to 4.0 years, and the prevalence of anemia was 16%. Anemia was associated with a 78% increase in all-cause mortality (HR, 1.78; 95% confidence interval [CI], 1.44-2.20), 60% increase in cardiovascular mortality (HR, 1.60; 95% CI, 1.17-2.19), 134% increase in noncardiovascular mortality (HR, 2.34; 95% CI, 1.58-3.47) 15% increase in stroke/systemic thromboembolism (HR, 1.15; 95% CI, 1.01-1.31), 78% increase in major bleeding (HR, 1.78; 95% CI, 1.54-2.05), and 77% increase in gastrointestinal bleeding (HR, 1.77; 95% CI, 1.23-2.55). Sensitivity analyses including studies that reported odds ratios did not result in any material change. CONCLUSION: Anemia is a frequently observed comorbidity in patients with AF, and is associated with an increased risk of all-cause, cardiovascular and noncardiovascular mortality, stroke/systemic thromboembolism, and major and gastrointestinal bleeding. Future studies are required to explore the causes of anemia in AF, and whether investigation and treatment may be clinically beneficial in affected individuals.

Trends in the use, complications, and costs of permanent pacemakers in Australia: A nationwide study from 2008 to 2017.

OBJECTIVE: To characterize contemporary pacemaker procedure trends. METHODS: Nationwide analysis of pacemaker procedures and costs between 2008 and 2017 in Australia. The main outcome measures were total, age- and gender-specific implant, replacement, and complication rates, and costs. RESULTS: Pacemaker implants increased from 12,153 to 17,862. Implantation rates rose from 55.3 to 72.6 per 100,000, a 2.8% annual increase (incidence rate ratio [IRR] 1.028; 95% CI, 1.02-1.04; p < .001). Pacemaker implants in the 80+ age group were 17.37-times higher than the < 50 group (95% CI 16.24-18.59; p < .001), and in males were 1.48-times higher than in females (95% CI 1.42-1.55; p < .001). However, there were similar increases according to age (p = .10) and gender (p = .68) over the study period. Left ventricular lead rates were stable (IRR 0.995; 95% CI 0.98-1.01; p = .53). Generator replacements decreased from 20.5 to 18.3 per 100,000 (IRR 0.975; 95% CI 0.97-0.98; p < .001). Although procedures for generator-related complications were stable (IRR 0.995; 95% CI 0.98-1.01; p = .54), those for lead-related complications decreased (IRR 0.985; 95% CI 0.98-0.99; p < .001). Rates for all pacemaker procedures were consistently greater in males (p < .001). Although annual costs of all pacemaker procedures increased from $178 million to $329 million, inflation-adjusted costs were more stable, rising from $294 million to $329 million. CONCLUSIONS: Increasing demand for pacemaker implants is driven by the ageing population and rising rates across all ages, while replacement and complication procedure rates appeared more stable. Males have consistently greater pacemaker procedure rates than females. Our findings have significant clinical and public health implications for healthcare resource planning.