Mental health conditions and use of rhythm control therapies in patients with atrial fibrillation: a nationwide cohort study.

OBJECTIVES: Mental health conditions (MHCs) have been associated with undertreatment of unrelated medical conditions, but whether patients with MHCs face disparities in receiving rhythm control therapies for atrial fibrillation (AF) is currently unknown. We assessed the hypothesis that MHCs are associated with a lower use of antiarrhythmic therapies (AATs). DESIGN: A nationwide retrospective registry-based cohort study. SETTING: The Finnish AntiCoagulation in Atrial Fibrillation cohort included records on all patients with AF in Finland during 2007-2018 identified from nationwide registries covering all levels of care as well as drug purchases. MHCs of interest were diagnosed depression, bipolar disorder, anxiety disorder, schizophrenia and any MHC. PARTICIPANTS: We identified 239 222 patients (mean age 72.6±13.2 years; 49.8% women) with incident AF, in whom the prevalence of any MHC was 19.9%. OUTCOMES: Primary outcome was use of any AAT, including cardioversion, catheter ablation, and fulfilled antiarrhythmic drug (AAD) prescription. RESULTS: Lower overall use of any AAT emerged in patients with any MHC than in those without MHC (16.9% vs 22.9%, p<0.001). Any MHC, depression, bipolar disorder, anxiety disorder and schizophrenia were all associated with lower incidence of any AAT with adjusted subdistribution HRs of 0.790 (95% CI 0.771 to 0.809), 0.817 (0.796 to 0.838), 0.811 (0.789 to 0.835), 0.807 (0.785 to 0.830) and 0.795 (0.773 to 0.818), respectively. Adjusted rates of AAD, cardioversion and catheter ablation use were lower in all MHC groups compared with patients without MHC. The findings in patients with any MHC were confirmed in propensity score matching analysis. CONCLUSIONS: Among patients with AF, a clear disparity exists in AAT use between those with and without MHCs. TRIAL REGISTRATION NUMBER: ClinicalTrials Identifier: NCT04645537; ENCePP Identifier: EUPAS29845.

Thromboembolisms related to post-operative electrical cardioversions for atrial fibrillation in patients with surgical aortic valve replacement.

Aims: Post-operative atrial fibrillation (POAF) is a frequent complication after open-heart surgery, and cardioversions (CV) are commonly performed to restore sinus rhythm. However, little data exists on thrombo-embolic risk related to early post-operative CV and on the recurrence of POAF after CV. CAREAVR study sought to assess the rate of strokes, transient ischaemic attacks (TIA), and mortality shortly after POAF-triggered CV in patients who underwent isolated surgical aortic valve replacement (SAVR) with a bioprosthesis. Methods and results: Altogether 721 patients underwent isolated SAVR with a bioprosthesis at four Finnish university hospitals. During post-operative hospitalization, after patients with prior chronic AF were excluded, 309/634 (48.7%) of patients had at least one episode of POAF [median time (interquartile range) 3 (3) days], and an electrical CV was performed in 113/309 (36.6%) of them. The length of hospital stay was not affected by CV. At 30 days follow-up, the rate of stroke, TIA or mortality was higher in those AF patients who underwent CV vs. those who did not (9.7% vs. 3.6%, P = 0.04, respectively; adjusted hazard ratio 2.63, 95% confidence interval 1.00-6.92, P = 0.05). Similar proportion of patients in both groups were in AF rhythm at discharge (32.7% vs. 35.7%, P = 0.18); and at 3 months (25.0% vs. 23.6%, P = 0.40), respectively. Conclusion: In this real-world population of patients undergoing isolated SAVR, the rate of POAF was nearly 50%. One-third of these patients underwent an electrical CV, and they exhibited over two-fold risk for thromboembolisms and mortality. Cardioversion did not affect the short-term prevalence of AF.

Cardioversion Of Atrial Fibrillation And Oral Anticoagulation.

The risk of thromboembolic events is a major concern in cardioversion of atrial fibrillation. The vast majority of these events occur in the first week following cardioversion. Processes promoting thrombus formation occur early and thrombus may appear in the left atrium within 48 hours of atrial fibrillation. The risk of thromboembolic events also increases with the presence of stroke risk factors. Thus, the current guidelines recommend that also patients with acute atrial fibrillation should undergo cardioversion under cover of unfractionated or low-molecular weight heparin followed by oral anticoagulation for at least 4 weeks in patients at moderate-to-high risk for stroke. Delay of cardioversion < 12 hours from the symptom onset seems to cause a marked increase in the risk of stroke. Thus, short term anticoagulation should be considered also for patients with a low CHA2DS2VASc score if the delay to cardioversion is 12-48 hours.

Bare-metal vs. drug-eluting stents in patients with atrial fibrillation undergoing percutaneous coronary intervention.

BACKGROUND: We explored 12-month clinical outcomes of 929 patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) with bare-metal stents (BMS) vs. drug-eluting stents (DES) from the prospective multicenter AFCAS (Atrial Fibrillation undergoing Coronary Artery Stenting) registry. METHODS AND RESULTS: Endpoints included the first occurrence of major adverse cardiac and cerebrovascular events (MACCE), defined as a composite of all-cause death, myocardial infarction (MI), target vessel revascularization, definite/probable stent thrombosis (ST), transient ischemic attack or stroke. Bleeding events were defined according to the Bleeding Academic Research Consortium criteria. Altogether, 673 (72.4%) patients received BMS and 220 (23.7%) at least one DES. Patients treated with DES more often had diabetes and prior ischemic events, and a longer stent length (P<0.05 for all), whereas patients treated with BMS more often had heart failure and were more likely to present with acute ST-elevation MI (P<0.05 for both). At 12-month follow-up, rates and risks of MACCE and total bleeding events were comparable between the groups (22.0% with BMS vs. 19.5% with DES, P=0.51, hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.63-1.25 for DES) and (19.5% vs. 15.0%, respectively, P=0.16, HR 0.75, 95% CI 0.51-1.09 for DES). Definite/probable ST was more frequent in the BMS group (1.9% vs. 0%, respectively, P=0.046). CONCLUSIONS: In real-world patients with AF undergoing PCI, DES use was associated with outcomes comparable to those with BMS without excess bleeding complications. More ST was seen in BMS-treated patients.

Cardioversion in Acute Atrial Fibrillation Without Anticoagulation.

A major concern in cardioversion of newly detected atrial fibrillation is the risk of thromboembolic events. The vast majority of these events occur in the first week following cardioversion. Transesophageal echocardiography has demonstrated that thrombus and dense spontaneous echo contrast may occur in the left atrium and left atrial appendage in patients with acute atrial fibrillation (<48 hours) scheduled for cardioversion. Moreover, atrial function may become impaired immediately following successful cardioversion. The risk of thromboembolic events increases with the presence of stroke risk factors, such as heart failure, hypertension, diabetes, prior stroke, female sex and age above 65-75 years. Thus, the current guidelines of the ESC and ACC/AHA/Heart Rhythm Society recommend that patients with acute atrial fibrillation should undergo cardioversion under cover of unfractionated or low-molecular weight heparin followed by oral anticoagulation for at least 4 weeks in patients in patients at moderate-to-high risk for stroke. In line with the guidelines, new evidence from a large patient population suggests that after successful cardioversion of acute atrial fibrillation, patients have a low overall risk of thromboembolic events without any anticoagulation when they have no risk factors for thromboembolism. In contrast, the risk is in the range of 10% in patients with multiple classic risk factors for thromboembolism.