Left Atrial Glucose Metabolism Evaluation by 18F-FDG-PET in Persistent Atrial Fibrillation and in Sinus Rhythm.

The role of atrial metabolism alterations for initiation and atrial fibrillation (AF) persistence remains poorly understood. Therefore, we evaluated left atrial glucose metabolism by nicotinic acid derivative stimulated 18-fluorodeoxyglucose positron emission tomography in 36 patients with persistent AF undergoing catheter ablation before and 3 months after return to sinus rhythm and compared values against healthy controls. Under identical hemodynamics and metabolic conditions, and although left ventricular FDG uptake remained unchanged, patients in persistent AF presented significantly higher total left atrial and left atrial appendage uptake, which decreased significantly after return to sinus rhythm, despite improvement of passive and active atrial contractile function. These findings support a role of altered glucose metabolism and metabolic wasting underlying the pathophysiology of persistent AF.

Prediction of Left Atrial Fibrosis and Success of Catheter Ablation by Speckle Tracking Echocardiography in Patients Imaged in Persistent Atrial Fibrillation.

Background: Non-invasive evaluation of left atrial structural and functional remodeling should be considered in all patients with persistent atrial fibrillation (AF) to optimal management. Speckle tracking echocardiography (STE) has been shown to predict AF recurrence after catheter ablation; however in most studies, patients had paroxysmal AF, and STE was performed while patients were in sinus rhythm. Aim: The aim of this study was to evaluate the ability of STE parameters acquired during persistent AF to assess atrial fibrosis measured by low voltage area, and to predict maintenance of sinus rhythm of catheter ablation. Methods: A total of 94 patients (69 men, 65 ± 9 years) with persistent AF prospectively underwent measurement of Global Peak Atrial Longitudinal Strain (GPALS), indexed LA Volume (LAVI), E/e' ratio, and LA stiffness index (the ratio of E/e' to GPALS) by STE prior to catheter ablation, while in AF. Low-voltage area (LVA) was assessed by electro-anatomical mapping and categorized into absent, moderate (>0 to <15%), and high (≥15%) atrial extent. AF recurrence was evaluated after 3 months of blanking. Results: Multivariable regression showed that LAVI, GPALS, and LA stiffness independently predicted LVA extent after correcting for age, glomerular filtration rate, and CHA2DS2-VASc score. Of all the parameters, LA stiffness index had the highest diagnostic accuracy (AUC 0.85), allowing using a cut-off value ≥0.7 to predict moderate or high LVA with 88% sensitivity and 47% specificity, respectively. In multivariable Cox analysis, both GPALS and LA stiffness were able to significantly improve the c statistic to predict AF recurrence (n = 40 over 9 months FU) over CHARGE-AF (p < 0.001 for GPALS and p = 0.01 for LA stiffness) or CHA2DS2-VASc score (p < 0.001 for GPALS and p = 0.02 for LA stiffness). GPALS and LA stiffness also improved the net reclassification index (NRI) over the CHARGE-AF index (NRI 0.67, 95% CI [0.33-1.13] for GPALS and NRI 0.73, 95% CI [0.12-0.91] for LA stiffness, respectively), and over the CHA2DS2-VASc score (NRI 0.43, 95% CI [-0.14 to 0.69] for GPALS and NRI 0.52, 95% CI [0.10-0.84], respectively) for LA stiffness to predict AF recurrence at 9 months. Conclusion: STE parameters acquired during AF allow prediction of LVA extent and AF recurrence in patients with persistent AF undergoing catheter ablation. Therefore, STE could be a valuable approach to select candidates for catheter ablation.

Pulmonary Vein Stenosis After Atrial Fibrillation Ablation: Insights From the ADVICE Trial.

BACKGROUND: Pulmonary vein (PV) stenosis is a complication of atrial fibrillation (AF) ablation. The incidence of PV stenosis after routine post-ablation imaging remains unclear and is limited to single-centre studies. Our objective was to determine the incidence and predictors of PV stenosis following circumferential radiofrequency ablation in the multicentre Adenosine Following Pulmonary Vein Isolation to Target Dormant Conduction Elimination (ADVICE) trial. METHODS: Patients with symptomatic AF underwent circumferential radiofrequency ablation in one of 13 trial centres. Computed tomographic (CTA) or magnetic resonance (MRA) angiography was performed before ablation and 90 days after ablation. Two blinded reviewers measured PV diameters and areas. PVs with stenosis were classified as severe (> 70%), moderate (50%-70%), or mild (< 50%). Predictors of PV stenosis were identified by means of multivariable logistic regression. RESULTS: A total of 197 patients (median age 59.5 years, 29.4% women) were included in this substudy. PV stenosis was identified in 41 patients (20.8%) and 47 (8.2%) of 573 ablated PVs. PV stenosis was classified as mild in 42 PVs (7.3%) and moderate in 5 PVs (0.9%). No PVs had severe stenosis. Both cross-sectional area and diameter yielded similar classifications for severity of PV stenosis. Diabetes was associated with a statistically significant increased risk of PV stenosis (OR 4.91, 95% CI 1.45-16.66). CONCLUSIONS: In the first systematic multicentre evaluation of post-ablation PV stenosis, no patient acquired severe PV stenosis. Although the results are encouraging for the safety of AF ablation, 20.8% of patients had mild or moderate PV stenosis, in which the long-term effects are unknown.

His bundle pacing for newly acquired pacing needs in patients implanted with a subcutaneous implantable cardioverter defibrillator: A feasibility study based on the automated screening score and clinical cases.

INTRODUCTION: Management of subcutaneous implantable cardioverter defibrillator (S-ICD) patients with newly acquired pacing needs remains problematic. His bundle pacing (HBP) allows for cardiac pacing without significant changes in the QRS morphology. We hypothesized that HBP does not alter S-ICD sensing and functions. METHODS: Twenty consecutive patients were implanted with a HB pacemaker. Among them, 17 demonstrated successful His recruitment and were prospectively screened with the automated screening tool (AST). Results of screenings performed immediately after implant and during follow-up, during intrinsic rhythm and while pacing from all available pacing configurations, were compared using the AST score. Positive-screening tests were defined by greater than or equal to 1 positive vector. RESULTS: Among the 17 patients successfully implanted (male: 41%; mean age: 73), 13 presented an indication of ventricular pacing and four of cardiac resynchronization. Absolute AST scores during both HBP (all configurations) and intrinsic rhythm were similar (p: NS). Due to left bundle branch block correction, HBP resulted in higher number of positive vectors (AST ≥ 100). AST scores were higher during HBP when compared with right ventricular pacing (RVP) (primary vector: 272 [16; 648] vs 4.6 [0.8; 16.2]; P = .003; secondary vector: 569 [183; 1186] vs 1.5 [0.7; 8.3]; P < .0001; alternate vector: 44 [2;125] vs 4.8 [0.9; 9.3]; P = .02) and resulted in a much higher number of positive vectors. Up to 90% of the patients had a positive-screening test during HBP. This passing rate was higher when compared RVP (17%; P < .0001). CONCLUSION: HBP restores normal intrinsic conduction and minimally modifies the surface electrocardiograph and subcutaneous electrograms. When ventricular pacing is needed, HBP might represent an ideal pacing option for patients implanted with a S-ICD.

Quality of life assessment in children before and after a successful ablation for supraventricular tachycardia.

BACKGROUND AND OBJECTIVES: Young patients suffering from rhythm disorders have a negative impact in their quality of life. In recent years, ablation has become the first-line therapy for supraventricular arrhythmias in children. In the light of the current expertise and advancement in the field, we decided to evaluate the quality of life in young patients with supraventricular arrhythmias before and after a percutaneous ablation procedure. METHODS: The prospective cohort consisted of patients <18 years with structurally normal hearts and non-pre-excited supraventricular arrhythmias, who had an ablation in our centre from 2013 to 2018. The cohort was evaluated with the PedsQL™ 4.0 Generic Core Scales self-questionnaire prior to and post-ablation. RESULTS: The final cohort included 88 patients consisted of 52 males (59%), with a mean age at ablation of 12.5 ± 3.3 years. Forty-two patients (48%) had a retrograde-only accessory pathway mediating the tachycardia, 38 (43%) had atrio-ventricular nodal re-entrant tachycardia, 7 (8%) had ectopic atrial tachycardia, and 1 (1%) had atrial flutter. The main reason for an ablation was the patient's choice in 53%. There were no severe complications. Comparison between the baseline and post-ablation assessments showed that patients reported significant improvement in the scores for physical health, emotional and social functioning, as well as in the total scores. CONCLUSIONS: The present study demonstrates that the successful treatment of supraventricular arrhythmias by means of an ablation results in a significant improvement in the quality of self-reported life scores in young patients.

Impact of paced left ventricular dyssynchrony on left ventricular reverse remodeling after cardiac resynchronization therapy.

INTRODUCTION: We investigated whether pacing-induced electrical dyssynchrony at the time of cardiac resynchronization therapy (CRT) device implantation was associated with chronic CRT response. METHODS AND RESULTS: We included a total of 69 consecutive heart failure patients who received a CRT device. Left (LVp-RVs) and right (RVp-LVs) pacing-induced interlead delays were measured intraoperatively and used to determine if there was paced left ventricular (LV) dyssynchrony, defined as present when LVp-RVs is larger than RVp-LVs. CRT response was defined as a reduction in LV end-systolic volume ≥15%, 6 months after implantation. Paced left ventricular dyssynchrony (PLVD) was associated with ischemic cardiomyopathy (ICM) (χ2 : 8; P = .005) but not with QRS morphology nor with pacing lead positions. In a univariate analysis, PLVD (odds ratio [OR], 6.53; 95% confidence interval [CI], 2.2-18.9; P = .001), atypical left bundle branch block (LBBB) (OR, 3.3; 95% CI, 1.2-9.4; P = .022), and ICM (OR, 5.2; 95% CI, 1.6-17; P = .006) were associated with nonresponse. In a multivariate analysis, both PLVD (OR, 9.74; 95% CI, 2.8-33.9; P < .0001) and atypical LBBB (OR, 5.6; 95% CI, 1.5-20.3; P = .009) were independently associated with nonresponse. Adding PLVD to a model based on QRS morphology provided a significant and meaningful incremental value to predict LV reverse remodeling after CRT (χ2 to enter: 8; P < .005). Computer simulations corroborate these findings by showing that, while intrinsic electrical dyssynchrony is a prerequisite, the level of pacing-induced dyssynchrony modulates acute CRT response. CONCLUSION: In addition to the intrinsic electrical substrate, PLVD is strongly associated with less LV reverse remodeling, demonstrating that measuring the electrical substrate during pacing has additional value for prediction of CRT response in an already well-selected patient population.

Cost-effectiveness and screening performance of ECG handheld machine in a population screening programme: The Belgian Heart Rhythm Week screening programme.

AIMS: Overall, 40% of patients with atrial fibrillation are asymptomatic. The usefulness and cost-effectiveness of atrial fibrillation screening programmes are debated. We evaluated whether an atrial fibrillation screening programme with a handheld electrocardiogram (ECG) machine in a population-wide cohort has a high screening yield and is cost-effective. METHODS: We used a Markov-model based modelling analysis on 1000 hypothetical individuals who matched the Belgian Heart Rhythm Week screening programme. Subgroup analyses of subjects ≥65 and ≥75 years old were performed. Screening was performed with one-lead ECG handheld machine Omron® HeartScan HCG-801. RESULTS: In both overall population and subgroups, the use of the screening procedure diagnosed a consistently higher number of diagnosed atrial fibrillation than not screening. In the base-case scenario, the screening procedure resulted in 106.6 more atrial fibrillation patient-years, resulting in three fewer strokes, 10 more life years and five more quality-adjusted life years (QALYs). The number needed-to-screen (NNS) to avoid one stroke was 361. In subjects ≥65 years old, we found 80.8 more atrial fibrillation patient-years, resulting in three fewer strokes, four more life-years and five more QALYs. The NNS to avoid one stroke was 354. Similar results were obtained in subjects ≥75 years old, with a NNS to avoid one stroke of 371. In the overall population, the incremental cost-effectiveness ratio for any gained QALY showed that the screening procedure was cost-effective in all groups. CONCLUSIONS: In a population-wide screening cohort, the use of a handheld ECG machine to identify subjects with newly diagnosed atrial fibrillation was cost-effective in the general population, as well as in subjects ≥65 and subjects ≥75 years old.

Systemic thrombolysis and endovascular thrombectomy in severe acute ischemic stroke after dabigatran reversal with idarucizumab.

Patients presenting with an acute ischemic stroke despite dabigatran therapy (last intake <24 h or unknown) should be evaluated for reversal by idarucizumab, making them eligible for safe and effective intravenous thrombolysis. It has been shown to be feasible, well-tolerated, and easy to manage in an emergency room or stroke unit.

Giant right atrial thrombus associated with ICD lead externalized conductors: a case report.

INTRODUCTION: Narrow calibre ICD leads are prone to present insulation defects and conductor externalization. Close follow-up of these leads is recommended but as long as their electrical function is maintained, no prophyllactic replacement or extraction is advised. Although the risk of thrombus formation involving externalized conductors has been described, this risk seems considered as negligible compared with the risk of a prophylactic lead extraction. However, when an intracavitar thrombus is identified, the safest therapeutic approach remains undetermined. CASE PRESENTATION: In the present clinical vignette, we describe the case of a giant thrombus developed along the externalized portion of an electrically functional ICD lead. In this case, the thrombus was successfully treated with a systemic oral anticoagulation. DISCUSSION: This case report supports the concept of a prolonged anticoagulation for both the diagnosis and the long-term treatment of thrombus developed along externalized ICD leads, in particular when the patient prefers to avoid or postpone the risk of a trans-venous lead extraction.

Interest of waiting time for spontaneous early reconnection after cavotricuspid isthmus ablation: A monocentric randomized trial.

INTRODUCTION: The aim of this study was to determine the rate of recurrent atrial flutter (AFl) after isolated cavotricuspid isthmus (CTI) ablation and to evaluate the impact of a waiting period with the search for early resumption of the CTI block on the long-term outcome. METHOD: Three hundred and nineteen consecutive patients referred for typical AFl ablation were randomly assigned to CTI ablation with continuous reevaluation of the CTI block during 30 minutes and early reablation if needed (waiting time [WT] + group, n  =  155) or to CTI ablation with no waiting period after proven bidirectional CTI block (WT - group, n  =  164). All patients were regularly followed-up. RESULT: In the WT+ group, 10 patients (6%) presented a recovery across the CTI (time to recovery: 17 ± 7') and were reablated at the end of the waiting period. After a median follow-up of 21 months, the rate of recurrent AFl was significantly higher in the WT - group as compared to the WT+ group (11.6% [19/164] vs 2.5% [4/155], respectively; P  =  0.007). However, no significant differences in the subsequent rate of AF were observed between the two groups (29% [WT -] vs 32% [WT+], P  =  0.66). During the follow-up, 28 patients from the WT - group underwent a second ablation procedure (16 AFl redo and 12 AF ablation) versus 10 patients form the WT+ group (three AFl redo and seven AF ablation). CONCLUSION: Waiting 30 minutes after CTI ablation to check for early resumption and early reablation allows for decreasing significantly the rate of recurrent atrial flutter.

Cerebrovascular disease, associated risk factors and antithrombotic therapy in a population screening cohort: Insights from the Belgian Heart Rhythm Week programme.

Background Cerebrovascular disease confers a major healthcare burden worldwide and is a major cause of death and disability. Several well-established risk factors, such as atrial fibrillation (AF), are associated with cerebrovascular disease and antithrombotic therapy reduces risk. Design This study was a subgroup analysis from the Belgian Heart Rhythm Week, a nationwide AF awareness programme. Methods We studied subjects screened between 2012 and 2014 with available data on clinical risk factors and antithrombotic treatment. Results Of the 38,034 subjects eligible for this analysis, 1513 (4.0%) reported a positive clinical history for cerebrovascular disease. Logistic regression analysis found that age, hypertension, diabetes mellitus, history of vascular disease, history of heart failure and history of AF (all p < 0.001) were independently associated with cerebrovascular disease. Among subjects with history of cerebrovascular disease and AF, 1.7% were taking oral anticoagulant drugs only, while both oral anticoagulant drugs and aspirin were used in 61.5% of subjects, aspirin in 4.3% of patients and no antithrombotic therapy in 32.5% of subjects. Among those subjects without AF, the corresponding figures were 0.8, 9.5, 2.0 and 87.6%, respectively. Conclusions The prevalence of cerebrovascular disease in this contemporary population screening project was higher than that reported in the general population and was associated with the major known stroke risk factors. Sub-optimal antithrombotic therapy management was evident, with a low use of oral anticoagulant drugs among patients with AF and a low use of aspirin among subjects without AF.

A population screening programme for atrial fibrillation: a report from the Belgian Heart Rhythm Week screening programme.

AIMS: Despite the increased prevalence of atrial fibrillation (AF), data for the implementation of nationwide screening programmes are limited. The aim of this national screening study was to increase nationwide awareness about AF and stroke risk, to determine the prevalence of AF in Belgian general population using an ECG handheld machine and its feasibility to identify new AF cases. METHODS AND RESULTS: We analysed data obtained from 5 years of the 'Belgian Heart Rhythm Week' screening programme. All subjects were screened using a one-lead ECG handheld machine. Among 65 747 subjects screened, AF was recorded in 911, with an overall prevalence of 1.4% [95% confidence interval (CI) 1.2-1.6%]. High thrombo-embolic risk, as assessed by CHA2DS2-VASc score ≥2, was recorded in 69% of AF subjects. In subjects with high thrombo-embolic risk, only 5.4% were treated with oral anticoagulant (OAC) and 5.8% were treated with OAC and antiplatelet drugs. Among recorded AF cases, the use of the ECG handheld machine allowed identification of 603 new AF patients (1.1%, 95% CI 0.9-1.3%). Factors associated with incident AF were chronic heart failure (P < 0.001), age (P < 0.001), diabetes mellitus (P < 0.001), previous stroke (P < 0.001), vascular disease (P < 0.001), and male sex (P < 0.001). CONCLUSION: In this Belgian national screening programme, prevalence of AF was 1.4%. The use of an ECG handheld machine is feasible to identify a significant number of new AF cases, most with a high thrombo-embolic risk. Given the low OAC use recorded, greater efforts in AF detection and treatment are urgently needed to reduce the burden of stroke associated with this common arrhythmia.

Adenosine-guided pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation: an international, multicentre, randomised superiority trial.

BACKGROUND: Catheter ablation is increasingly used to manage atrial fibrillation, but arrhythmia recurrences are common. Adenosine might identify pulmonary veins at risk of reconnection by unmasking dormant conduction, and thereby guide additional ablation to improve arrhythmia-free survival. We assessed whether adenosine-guided pulmonary vein isolation could prevent arrhythmia recurrence in patients undergoing radiofrequency catheter ablation for paroxysmal atrial fibrillation. METHODS: We did this randomised trial at 18 hospitals in Australia, Europe, and North America. We enrolled patients aged older than 18 years who had had at least three symptomatic atrial fibrillation episodes in the past 6 months, and for whom treatment with an antiarrhythmic drug failed. After pulmonary vein isolation, intravenous adenosine was administered. If dormant conduction was present, patients were randomly assigned (1:1) to additional adenosine-guided ablation to abolish dormant conduction or to no further ablation. If no dormant conduction was revealed, randomly selected patients were included in a registry. Patients were masked to treatment allocation and outcomes were assessed by a masked adjudicating committee. Patients were followed up for 1 year. The primary outcome was time to symptomatic atrial tachyarrhythmia after a single procedure in the intention-to-treat population. The trial is registered with ClinicalTrials.gov, number NCT01058980. FINDINGS: Adenosine unmasked dormant pulmonary vein conduction in 284 (53%) of 534 patients. 102 (69·4%) of 147 patients with additional adenosine-guided ablation were free from symptomatic atrial tachyarrhythmia compared with 58 (42·3%) of 137 patients with no further ablation, corresponding to an absolute risk reduction of 27·1% (95% CI 15·9-38·2; p<0·0001) and a hazard ratio of 0·44 (95% CI 0·31-0·64; p<0·0001). Of 115 patients without dormant pulmonary vein conduction, 64 (55·7%) remained free from symptomatic atrial tachyarrhythmia (p=0·0191 vs dormant conduction with no further ablation). Occurrences of serious adverse events were similar in each group. One death (massive stroke) was deemed probably related to ablation in a patient included in the registry. INTERPRETATION: Adenosine testing to identify and target dormant pulmonary vein conduction during catheter ablation of atrial fibrillation is a safe and highly effective strategy to improve arrhythmia-free survival in patients with paroxysmal atrial fibrillation. This approach should be considered for incorporation into routine clinical practice. FUNDING: Canadian Institutes of Health Research, St Jude Medical, Biosense-Webster, and M Lachapelle (Montreal Heart Institute Foundation).

Low contact force and force-time integral predict early recovery and dormant conduction revealed by adenosine after pulmonary vein isolation.

AIM: After pulmonary vein isolation (PVI), dormant conduction (DC) is present in at least one vein in a substantial number of patients. The present study seeks to determine whether there is a relationship between poor contact forces (CF) and the presence of DC after PVI. METHODS AND RESULTS: This prospective, operator-blinded, non-randomized dual-centre trial enrolled 34 consecutive patients with paroxysmal atrial fibrillation who were candidates for PVI. Radiofrequency (RF) energy was delivered by using an irrigated-tip force-sensing ablation catheter (Tacticath, St Jude Medical) at pre-defined target power. The operators were blinded to the CF data at all times. A total of 1476 RF applications were delivered in 743 pre-defined PV segments. For each application, the precise location of the catheter was registered and the following data were extracted from the Tacisys unit: application duration, minimum contact force, maximum contact force, average contact force (CF), and force-time integral (FTI). Sixty minutes after PVI, spontaneous early recovery (ER) of the left atrium (LA) to PV conduction was evaluated. In the absence of ER, the presence of a DC was evaluated by using intravenous adenosine (ATP). In the 34 patients recruited (23 males; mean age: 62 ± 9 years), all PVs were successfully isolated. At the end of the 60 min waiting period, 22 patients demonstrated at least one spontaneous ER or DC under ATP. The mean CF and FTI per PV segment differed significantly among the different veins but the sites of ER and DC were evenly distributed. However, both the minimum, the first and the mean CF and FTI per PV segment were significantly lower in the PV segments presenting either ER or DC as compared with those without ER or DC (mean CF: 4.9 ± 4.8 vs. 12.2 ± 1.65 g and mean FTI: 297 ± 291 vs. 860 ± 81 g s, P < 0.001 for both). Using multivariate analysis, both the mean CF and the FTI per lesion remained significantly associated with the risk of ER or DC. Moreover, a CF < 5 g per PV segment predicted ER+ and DC+ with a sensitivity of 71% and specificity of 82%. In contrast, ER and DC were very unlikely if RF application was performed with a mean CF > 10 g (negative predictive value: 98.7%). CONCLUSION: Both a low CF and a low FTI are associated with the ER of the PVI and DC after PVI.

Evaluation of a new semiautomated external defibrillator technology: a live cases video recording study.

AIM: To determine the effect of a new automated external defibrillator (AED) system connected by General Packet Radio Service (GPRS) to an external call centre in assisting novices in a sudden cardiac arrest situation. METHOD: Prospective, interventional study. Layperson volunteers were first asked to complete a survey about their knowledge and ability to give cardiopulmonary resuscitation (CPR) and use an AED. A simulated cardiac arrest scenario using a CPR manikin was then presented to volunteers. A telephone and semi-AED were available in the same room. The AED was linked to a call centre, which provided real-time information to 'bystanders' and emergency services via GPRS/GPS technology. The scene was videotaped to avoid any interaction with examiners. A standardised check list was used to record correct actions. RESULTS: 85 volunteers completed questionnaires and were recorded. Mean age was 44±16, and 49% were male; 38 (45%) had prior CPR training or felt comfortable intervening in a sudden cardiac arrest victim; 40% felt they could deliver a shock using an AED. During the scenarios, 56 (66%) of the participants used the AED and 53 (62%) successfully delivered an electrical shock. Mean time to defibrillation was 2 min 29 s. Only 24 (28%) participants dialled the correct emergency response number (112); the live-assisted GPRS AED allowed alerted emergency services in 38 other cases. CPR was initiated in 63 (74%) cases, 26 (31%) times without prompting and 37 (44%) times after prompting by the AED. CONCLUSIONS: Although knowledge of the general population appears to be inadequate with regard to AED locations and recognition, live-assisted devices with GPS-location may improve emergency care.

Risk scores and geriatric profile: can they really help us in anticoagulation decision making among older patients suffering from atrial fibrillation?

OBJECTIVES: Anticoagulation for the prevention of cardio-embolism is most frequently indicated but largely underused in frail older patients with atrial fibrillation (AF). This study aimed at identifying characteristics associated with anticoagulation underuse. METHODS: A cross-sectional study of consecutive geriatric patients aged ≥75 years, with AF and clear anticoagulation indication (CHADS2 [Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack] ≥2) upon hospital admission. All patients benefited from a comprehensive geriatric assessment. Their risks of stroke and bleeding were predicted using CHADS2 and HEMORR2HAGES (Hepatic or renal disease, Ethanol abuse, Malignancy, Older (age >75 years), Reduced platelet count or function, Rebleed risk, Hypertension (uncontrolled), Anemia, Genetic factors, Excessive fall risk, and Stroke) scores, respectively. RESULTS: Anticoagulation underuse was observed in 384 (50%) of 773 geriatric patients with AF (median age 85 years; female 57%, cognitive disorder 33%, nursing home 20%). No geriatric characteristic was found to be associated with anticoagulation underuse. Conversely, anticoagulation underuse was markedly increased in the patients treated with aspirin (odds ratio [OR] [95% confidence interval]: 5.3 [3.8; 7.5]). Other independent predictors of anticoagulation underuse were ethanol abuse (OR: 4.0 [1.4; 13.3]) and age ≥90 years (OR: 2.0 [1.2; 3.4]). Anticoagulation underuse was not inferior in patients with a lower bleeding risk and/or a higher stroke risk and underuse was surprisingly not inferior either in the AF patients who had previously had a stroke. CONCLUSION: Half of this geriatric population did not receive any anticoagulation despite a clear indication, regardless of their individual bleeding or stroke risks. Aspirin use is the main characteristic associated with anticoagulation underuse.