Trygve Berge

Background: The increasing prevalence of atrial fibrillation (AF), along with changes in cardiovascular risk factors, AF detection and oral anticoagulant use, may have altered the epidemiology of AF‐related stroke. However, population‐based data on long‐term trends remain limited. Methods: Using mandatory nationwide registry data from the Atrial Fibrillation in Norway (AFNOR) study (2001–2021), we identified incident stroke cases defined as first hospitalization or death due to stroke in individuals aged ≥15 years. Age‐standardized incidence rates were calculated using direct standardization. Sex‐ and age‐adjusted incidence rate ratios (IRR) were estimated using negative binomial regression. Results: Among 227 575 incident strokes, 66 795 (29.4%) were AF‐related, and increased from 22% to 31% during 2001–2021, with 69% of all AF‐related ischemic strokes occurring in non‐anticoagulated individuals. Incidence rate of AF‐related ischemic strokes remained stable overall (67.8 per 100 000 person‐years in 2001 to 68.4 in 2021; IRR=1.01; 95% CI, 1.00–1.03) but increased among individuals aged 15 to 64 years. Non‐AF ischemic strokes declined from 204.4 to 130.8 (IRR=0.98; 95% CI, 0.97–0.99). Incidence of AF‐related intracerebral hemorrhage in individuals aged ≥75 years increased, driven by anticoagulated patients. Incidence of non‐AF intracerebral hemorrhage decreased (IRR=0.98; 95% CI, 0.97–0.99). Conclusions: The favorable decline in ischemic stroke incidence from 2001 to 2021 did not include AF‐related strokes. AF‐related ischemic strokes increased in younger age groups, whereas AF‐related intracerebral hemorrhage increased in the oldest age groups driven by anticoagulated patients. These findings underscore the need for improved strategies for AF detection and stroke prevention, particularly in younger populations, and greater attention towards management of bleeding risk among older, anticoagulated individuals.

Aims: Conventional screening modalities for atrial fibrillation (AF) are often constrained by considerable resource and logistical demands. The randomized controlled NORwegian atrial fibrillation self-SCREENing (NORSCREEN) trial employs a fully digital approach to recruitment and implementation. The aim of this pre-specified analysis was to evaluate the effectiveness of the fully digital recruitment and screening strategy, determine the prevalence of screen-detected AF, and assess initial adherence to therapeutic recommendations. Methods and results: Individuals aged ≥65 years with ≥1 additional risk factor for stroke were digitally recruited from the general Norwegian population and randomized 1:1 to screening or usual care. Exclusion criteria included prior AF, anticoagulation, implantable cardiac electronic devices, or lack of smartphone access. Participants allocated to screening were mailed a patch-based electrocardiogram sensor for site-less continuous monitoring over 7 days. Those with diagnosed AF were advised to contact their general practitioner to initiate appropriate therapy. A total of 551 555 Norwegian residents were digitally invited; of these, 139 596 (25.3%) completed the digital eligibility assessment, 74 956 (53.7%) were eligible, and 50 549 (67.4%) were randomized to screening or usual care. The median age was 75 years (inter-quartile range: 69–78), 23 445 (46.4%) were female, and the mean CHA2DS2-VA risk score was 2.6 ± 0.9. In the screening group, 19 723 (78.1%) completed the study procedures. Previously undiagnosed AF was identified in 382 (1.9%) screened participants, of whom 366 (95.8%) initiated anticoagulation therapy. Conclusion: The NORSCREEN trial demonstrates that fully digital, large-scale, site-less AF screening is feasible and effective in an at-risk population, identifying previously undiagnosed AF in 1.9% of screened individuals and showing high adherence to therapeutic recommendations. Clinical Trial Registration: NCT05914883

Aims: Population-based data on cardiac-related symptoms in individuals without diagnosed cardiac disease remain limited, despite important implications for early detection and management. We aimed to assess the prevalence of self-reported symptoms and the association with quality of life (QoL) among adults aged ≥65 years with ≥1 additional stroke risk factor, but without diagnosed cardiac disease. Methods and results: This is a cross-sectional study of the NORwegian atrial fibrillation self-SCREENing (NORSCREEN) trial population at baseline. NORSCREEN is an ongoing, nationwide, randomized atrial fibrillation screening study in adults aged ≥65 years at increased risk of stroke (CHA2DS2-VA ≥2). All participants completed a baseline questionnaire capturing clinical information, symptoms, and QoL. Of the 50 549 participants enrolled from 2023 to 2025, 39 281 (78%) reported no diagnosed cardiac disease. Among those, 17 069 (43%) reported cardiac-related symptoms compared to 7551 (67%) of 11 268 individuals with known cardiac disease. The most common symptoms were fatigue, exertional dyspnoea, and tachycardia. Female sex [adjusted odds ratio 1.66, (95% CI 1.58–1.75)], physical inactivity [1.43 (1.32–1.55)], current smoking [1.24 (1.12–1.37)], age <75 years [1.14 (1.08–1.20)], living alone [1.13 (1.07–1.20)], and comorbidities including chronic obstructive pulmonary disease [6.51 (5.63–7.54)] and anxiety [3.99 (3.64–4.38)] were associated with cardiac-related symptoms. Symptomatic individuals reported significantly lower RAND-36 QoL scores across all domains compared to those without symptoms. Conclusion: In this cohort of individuals aged ≥65 years at increased risk of stroke, but without diagnosed cardiac disease, nearly half reported cardiac-related symptoms, which were associated with substantially reduced QoL. These findings suggest there might be unmet needs in identifying and managing cardiovascular disease. Registration: Clinical trials: NCT05914883

Background: There is conflicting evidence on the time trends of stroke incidence in younger adults. We aimed to explore time trends in the incidence of stroke, stroke subtypes, and transient ischemic attack in different age groups in Norway the past 2 decades. Methods: In this nationwide registry‐based cohort study, we identified incident stroke cases from hospitalizations with stroke (ischemic stroke, intracerebral hemorrhage and unspecified stroke), transient ischemic attack, or out‐of‐hospital deaths due to stroke. Included individuals were aged ≥15 years with no prior hospitalization for stroke during the past 7 years. Incidence per 100 000 population was age‐standardized and presented by year, sex, and age group. Average annual percentage changes in incidence were estimated using weighted log‐linear regression. Results: From 2001 to 2021, we identified 229 857 incident total stroke cases (49.2% women) among 5 691 495 individuals in the Norwegian adult population. Incidence per 100 000 population decreased over time for all stroke subtypes in both men and women. However, the incidence of ischemic stroke for men aged <35 years increased annually by 1.6% (95% CI, 0.3–2.8). For intracerebral hemorrhage, the incidence was stable in younger men and women and the oldest women. For transient ischemic attack, both sexes experienced a sharp rise in the incidence until 2012, followed by a substantial decrease. Conclusions: Total stroke incidence declined from 2001 to 2021. However, less favorable time trends were observed in younger age groups, with a worrisome increase in ischemic stroke incidence among men aged 15 to 34 years. These trends are concerning and need further investigation.

Background: Rhythm control therapy is recommended for individuals with symptomatic atrial fibrillation (AF) to reduce symptoms and improve quality of life. Electrical cardioversion (ECV) is used to restore sinus rhythm (SR), but AF recurrence is common. Objective: We aimed to investigate if a selection of circulating biomarkers can predict rhythm outcomes in individuals with persistent AF treated with ECV. Design: This was an observational cohort study. Methods: We included 200 individuals aged ⩾ 18 years referred for ECV of AF from November 2017 to March 2022. We obtained blood samples 0 to 6 weeks before ECV. Plasminogen activator inhibitor type 1 (PAI-1) activity, soluble suppression of tumorigenicity 2 (sST2), galectin-3 (GAL-3), interleukin-6 (IL-6), matrix metalloproteinase-9 (MMP-9), tissue inhibitor of metalloproteinase-1 (TIMP-1), growth differentiation factor-15, (GDF-15), transforming growth factor-β-1 (TGF-β1), and fibroblast growth factor-23 (FGF-23) were analyzed by ELISA methods. The participants recorded thumb ECGs twice daily for 28 days after the ECV to detect AF recurrence. Results: A total of 188 individuals were eligible for the analyses. Twenty-four participants converted spontaneously to SR before ECV. Among the cardioverted, 74 maintained SR, whereas 90 experienced AF recurrence before hospital discharge (n = 15) or during the follow-up period of 28 days (n = 75). TIMP-1 was significantly higher in those with AF recurrence than in those who maintained SR, but overlapping distributions suggest limited predictive ability. PAI-1 activity, sST2, GAL-3, IL-6, MMP-9, GDF-15, TGF-β1, and FGF-23 did not differ among the participants who had ECV. Conclusion: TIMP-1 was higher in participants with recurrence of AF after ECV, but its predictive ability was limited. None of the other biomarkers were associated with AF recurrence. We do not recommend using these biomarkers for candidate selection for ECV of persistent AF.

Aims: Stroke risk in atrial fibrillation (AF) patients increases over time, but the optimal reassessment interval remains unclear. This study evaluated changes in the CHA2DS2-VA score in AF patients with low (score 0) or intermediate (score 1) stroke risk and explored appropriate reassessment intervals. Methods and results: Using Norwegian national registries (2011–18), 40 782 individuals with incident AF aged ≥18 years and a low or intermediate CHA2DS2-VA score were identified. Patients were followed from first AF diagnosis until an increase in the CHA2DS2-VA score, and the proportion with increased score was assessed across age groups. The number needed to reassess to detect one new CHA2DS2-VA risk factor was calculated at different time intervals after AF diagnosis. The CHA2DS2-VA score increased in 50% of patients after a median follow-up of 1.7 years. The proportion of patients with an increased CHA2DS2-VA score was 19% at 6 months, 25% at 1 year, and 40% at 3 years after AF diagnosis. At 1 year, the proportion of patients with a new risk factor was lower in those aged 18–44 years (8%) and 45–54 years (14%) compared to those aged >55 years (30%), with the number needed to reassess at 1 year being 12, 7, and 3 patients, respectively. Conclusion: New risk factors emerged in half of AF patients within 1.7 years. Age-specific differences underscore the need for tailored reassessment, suggesting a shorter interval of 6 months for patients ≥55 years and 1 year for those <55 years and routinely at age 65 and 75 years.

Background The 2024 European Society of Cardiology (ESC) Guidelines for hypertension introduced the ‘elevated BP’ (eBP) category (120–139/70–89 mm Hg). Individuals with persistent eBP (130–139/80–89 mm Hg), despite lifestyle intervention, may be recommended pharmacological treatment in case of concomitant elevated cardiovascular (CV) risk. We aimed to assess the impact of these updated recommendations on treatment eligibility at ages 40 and 62–65 and to examine the CV event rates over 30 years of follow-up, focusing on those with eBP (130–139/80–89 mm Hg) eligible for pharmacological treatment. Methods Data from individuals born in 1950 who participated in the Age 40 Programme and the Akershus Cardiac Examination 1950 Study was linked to national health registries. These data include BP measurements at age 40 (1990–1991) and 62–65 (2012–2015), assessment of elevated CV risk based on Systematic Coronary Risk Evaluation 2 (SCORE2) and outcomes of major adverse cardiovascular events (MACEs) tracked through 2022. Results At age 40, 854 (32%) of 2688 individuals had eBP (130–139/80–89 mm Hg), but only 4 had elevated CV risk warranting pharmacological treatment. At age 62–65, 1657 (61%) were on BP-lowering medication or had a BP ≥140/90, while 64 (8%) out of 851 with eBP were eligible for drug treatment. Based on BP values at age 40, only 2 of the 93 MACEs in the eBP (130–139/80–89 mm Hg) category occurred among those eligible for pharmacological treatment. Conclusions A single BP measurement at age 40 identified eBP (130–139/80–89 mm Hg) among one-third of the individuals, yet MACE cases within the eBP category occurred primarily in individuals who were not eligible for medical treatment.

This commentary refers to ‘Stroke and bleeding risk in atrial fibrillation with CHA₂DS₂-VASC risk score of one: the Norwegian AFNOR study’, by M. Anjum et al., https://doi.org/10.1093/eurheartj/ehad659 and the discussion piece ‘A CHA₂DS₂-VASc score of 1 is not the same for every patient with atrial fibrillation’, by J. Neefs et al., https://doi.org/10.1093/eurheartj/ehae511.

Aims: Atrial fibrillation (AF) is a common arrhythmia, and many cases of AF may be undiagnosed. Whether screening for AF and subsequent treatment if AF is detected can improve long-term outcome remains an unsettled question. The primary aim of the NORwegian atrial fibrillation self-SCREENing (NORSCREEN) trial is to assess whether self-screening for AF with continuous electrocardiogram (ECG) for 3–7 days in individuals aged 65 years or older with at least one additional risk factor for stroke, and initiation of guideline-recommended therapy in patients with detected AF, will reduce the occurrence of stroke. Methods and results: This study is a nationwide open, siteless, randomized, controlled trial. Individuals ≥65 years of age are randomly identified from the National Population Register of Norway and are invited to take a digital inclusion/exclusion test. Individuals passing the inclusion/exclusion test are randomized to either the intervention group or the control group. A total of 35 000 participants will be enrolled. In the intervention group, self-screening is performed continuously over 3–7 days at home with a patch ECG device (ECG247) at inclusion and after 12–18 months. If AF is detected, guideline-recommended therapy will be initiated. Patients will be followed up for 5 years through national health registries. The primary outcome is time to a first stroke (ischaemic or haemorrhagic stroke). The first participant in the NORSCREEN trial was enrolled on 1 September 2023. Conclusion: The results from the NORSCREEN trial will provide new insights regarding the efficacy of digital siteless self-screening for AF with respect to stroke prevention in individuals at an increased risk of stroke. Trial registration: Clinical trials: NCT05914883.