Atrial Flutter

AimsTo devise effective preventive measures, a profound understanding of the evolving patterns and trends in atrial fibrillation (AF) and atrial flutter (AFL) burdens is pivotal. Our study was designed to quantify the burden and delineate the risk factors associated with AF and AFL across 204 countries and territories spanning 1990-2021.Methods and resultsData pertaining to AF and AFL were sourced from the Global Burden of Disease Study 2021. The burden of AF/AFL was evaluated using metrics such as incidence, disability-adjusted life years (DALYs), deaths, and their corresponding age-standardized rates (ASRs), stratified by age, sex, socio-demographic index (SDI), and human development index (HDI). The estimated annual percentage change was employed to quantify changes in ASRs. Population attributable fractions were calculated to determine the proportional contributions of major risk factors to age-standardized AF/AFL deaths. This analysis encompassed the period from 1990 to 2021. Globally, in 2021, there were 4.48 million incident cases [95% uncertainty interval (UI): 3.61-5.70], 8.36 million DALYs (95% UI: 6.97-10.13) and 0.34 million deaths (95% UI: 0.29-0.37) attributed to AF/AFL. The AF/AFL burden in 2021, as well as its trends from 1990 to 2021, displayed substantial variations based on gender, SDI quintiles, and geographical regions. High systolic blood pressure emerged as the leading contributor to age-standardized AF/AFL incidence, prevalence, death, and DALY rate globally among all potential risk factors, followed closely by high body mass index.ConclusionOur study underscores the enduring significance of AF/AFL as a prominent public health concern worldwide, marked by profound regional and national variations. Despite the substantial potential for prevention and management of AF/AFL, there is a pressing imperative to adopt more cost-effective strategies and interventions to target modifiable risk factors, particularly in areas where the burden of AF/AFL is high or escalating.

ImportancePostoperative atrial fibrillation (POAF) occurring after cardiac surgery is associated with adverse outcomes. Whether POAF persists beyond discharge is not well defined.ObjectiveTo determine whether continuous cardiac rhythm monitoring enhances detection of POAF among cardiac surgical patients during the first 30 days after hospital discharge compared with usual care.Design, setting, and participantsThis study is an investigator-initiated, open-label, multicenter, randomized clinical trial conducted at 10 Canadian centers. Enrollment spanned from March 2017 to March 2020, with follow-up through September 11, 2020. As a result of the COVID-19 pandemic, enrollment stopped on July 17, 2020, at which point 85% of the proposed sample size was enrolled. Cardiac surgical patients with CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, female sex) score greater than or equal to 4 or greater than or equal to 2 with risk factors for POAF, no history of preoperative AF, and POAF lasting less than 24 hours during hospitalization were enrolled.InterventionsThe intervention group underwent continuous cardiac rhythm monitoring with wearable, patch-based monitors for 30 days after randomization. Monitoring was not mandated in the usual care group within 30 days after randomization.Main outcomes and measuresThe primary outcome was cumulative AF and/or atrial flutter lasting 6 minutes or longer detected by continuous cardiac rhythm monitoring or by a 12-lead electrocardiogram within 30 days of randomization. Prespecified secondary outcomes included cumulative AF lasting 6 hours or longer and 24 hours or longer within 30 days of randomization, death, myocardial infarction, ischemic stroke, non-central nervous system thromboembolism, major bleeding, and oral anticoagulation prescription.ResultsOf the 336 patients randomized (163 patients in the intervention group and 173 patients in the usual care group; mean [SD] age, 67.4 [8.1] years; 73 women [21.7%]; median [interquartile range] CHA2DS2-VASc score, 4.0 [3.0-4.0] points), 307 (91.4%) completed the trial. In the intent-to-treat analysis, the primary end point occurred in 32 patients (19.6%) in the intervention group vs 3 patients (1.7%) in the usual care group (absolute difference, 17.9%; 95% CI, 11.5%-24.3%; P Conclusions and relevanceIn post-cardiac surgical patients at high risk of stroke, no preoperative AF history, and AF lasting less than 24 hours during hospitalization, continuous monitoring revealed a significant increase in the rate of POAF after discharge that would otherwise not be detected by usual care. Studies are needed to examine whether these patients will benefit from oral anticoagulation therapy.Trial registrationClinicalTrials.gov Identifier: NCT02793895.

PurposeMitral annular flutter (MAF) is a common arrhythmia after atrial fibrillation ablation. We sought to compare the efficacy and safety of catheter ablation utilizing either a left atrial anterior wall (LAAW) line or a lateral mitral isthmus (LMI) line.MethodsWe performed a systematic review for all studies that compared LAAW versus LMI lines. Risk ratio (RR) and mean difference (MD) 95% confidence intervals were measured for dichotomous and continuous variables, respectively.ResultsFour studies with a total of 594 patients were included, one of which was a randomized control trial. In the LMI ablation group, 40% of patients required CS ablation. There were no significant differences in bidirectional block (RR 1.26; 95% CI, 0.94-1.69) or ablation time (MD -1.5; 95% CI, -6.11-3.11), but LAAW ablation was associated with longer ablation line length (MD 11.42; 95% CI, 10.69-12.14) and longer LAA activation delay (MD 67.68; 95% CI, 33.47-101.89.14) when compared to LMI. There was no significant difference in pericardial effusions (RR 0.36; 95% CI, 0.39-20.75) between groups and more patients were maintained sinus rhythm (RR 1.19; 95% CI, 1.03-1.37, p = 0.02) who underwent LAAW compared to LMI.ConclusionAblation of mitral annular flutter with a LAAW line compared to a LMI line showed no difference in rates of acute bidirectional block, ablation time, or pericardial effusion. However, LAAW ablation required a longer ablation line length, resulted in greater LAA activation delayed and was associated with more sinus rhythm maintenance, with the added advantage of avoiding ablation in the CS.

AimsThe aim of this study was to systematically quantify the global, regional, and national burden of heart failure (HF) attributable to atrial fibrillation/flutter (AF/AFL) from 1990 to 2021, and project trends to 2040.Methods and resultsUsing Global Burden of Disease (GBD) 2021 data, we analysed AF/AFL-attributed HF prevalence and years lived with disability (YLDs) across 204 countries, stratified by age, sex, and socio-demographic index (SDI). Joinpoint regression identified temporal inflection points; decomposition analysis quantified contributions from population growth, ageing, and epidemiological change; Bayesian age-period-cohort (BAPC) models forecasted burden to 2040. Globally, AF-attributed HF cases increased 3.4-fold, from 162 561 (95% UI: 120 008-213 951) in 1990 to 714 137 (95% UI: 520 543-940 901) in 2021, with age-standardized prevalence rates (ASPRs) rising from 5.36 to 8.85 per 100 000 (EAPC: 1.76%, 95% UI: 1.66-1.85%). YLDs increased more than four-fold, from 14 615 (95% UI: 8848-23 114) to 63 943 (95% UI: 39 058-96 196; EAPC: 1.76%, 95% CI: 1.67-1.85%). High-SDI regions exhibited the highest burden (ASPR: 13.97 (95% UI: 10.31 to 18.36) per 100 000), with epidemiological changes contributing 44% of the absolute increase in high-SDI regions to case growth. Women outnumbered men beyond age 65 (female-to-male ratio: 1.1 at age 65-69, widening to 2.4 at ≥95 years), yet age-standardized rates showed no significant sex difference (female ASPR: 8.91 vs. male ASPR: 8.78 per 100 000). Joinpoint analysis revealed accelerated growth during 1990-2007 (APC: 2.12%, P .05). Projections indicate a near-doubling of global cases to 1 307 469 (95% UI: 661 547-1 953 391) by 2040, corresponding to an ASPR of 8.45 per 100 000 (95% UI: 4.28-12.63).ConclusionAF/AFL is a major and growing driver of global HF burden, projected to affect 1.3 million individuals by 2040, with disproportionate impact in older adults (≥65 years) and high-SDI regions. Integrating standardized AF management-including systematic screening, anticoagulation, and early rhythm control-into HF prevention pathways represents a critical strategy to mitigate projected increases.