Frieder Braunschweig

Background: Clinical guidelines recommend integrated, person-centered care with control of modifiable risk factors and coexisting conditions in patients with atrial fibrillation (AF), but many receive insufficient risk factor management. Digital health technologies may provide valuable support in addressing this gap. Objective: Our aim was to evaluate the usability of a co-designed digital platform for supporting person-centered management of modifiable risk factors in individuals with AF. Methods: This mixed methods usability study was conducted at a tertiary university hospital in Sweden between March and April 2025. Eligible participants with AF were recruited to evaluate the co-designed digital platform using the System Usability Scale (SUS) and semistructured interviews analyzed with inductive manifest content analysis. Results: A total of 22 patients were included (mean age 67.7, SD 7.6 y); 32% (7/22) were female, the mean BMI was 27.7 (SD 3.6) kg/m2, 65% (14/22) had paroxysmal AF, 36% (8/22) had persistent AF, and the median AF duration was 26 (IQR 13.3-72.8) months. Relevant comorbidities were hypertension (17/22, 77%), heart failure (8/22, 36%), diabetes mellitus type 2 (3/22, 14%), and ischemic heart disease (4/22, 18%). Usability was rated high, with a median SUS score of 78.8 (IQR 63.8-86.9), indicating above-average user acceptance. Participants’ requirements were summarized into 4 main categories and 10 subcategories. First, they valued a clear layout, simple design, and easy navigation. Second, they appreciated positive content, which is informative, inclusive, and motivating. Third, they requested personalized information on different aspects and provided on different levels. Fourth, they desired individualized medical recommendations that are personalized and flexible but open to individual choice. Conclusions: Participants found the usability acceptable and valued specifically a clear layout, positive content, personalized information, and individualized medical recommendations.

Background and Aims: Randomized trials conducted in the early 2000s established the survival benefit of primary prevention implantable cardioverter-defibrillator (ICD) therapy in patients with reduced left ventricular ejection fraction (LVEF) after myocardial infarction. However, management of myocardial infarction and heart failure has substantially evolved since that time. We investigated whether the estimated association between primary prevention ICD implantation in post-myocardial infarction patients with reduced LVEF and mortality reduction has changed over time. Methods: We analysed individual participant data from 32 214 patients with LVEF ≤35% after myocardial infarction included in the PROFID pooled cohort, comprising 7477 patients carrying a primary prevention ICD (ICD patients) and 24 737 patients without an ICD (non-ICD patients). The primary endpoint was all-cause mortality. Propensity scores were estimated using multivariable logistic regression including age, sex, LVEF, renal function, and diabetes, and overlap weighting was applied to balance treatment groups. Time period-specific analyses were performed across three prespecified time periods defined by inclusion year: 1995–2004, 2005–14, and 2015–20. Weighted cumulative mortality curves were generated for each time period. Temporal changes in the estimated association between ICD implantation and mortality reduction were assessed using a weighted Cox proportional hazards model. Results: A total of 12 097 deaths occurred during a mean follow-up of 43.7 months. The estimated association between ICD implantation and mortality changed significantly across time (P for interaction <.001). In weighted time period-specific analyses, the estimated mortality reduction associated with ICD implantation progressively decreased over more recent periods. The hazard ratio for ICD vs non-ICD patients was 0.54 (95% CI 0.47–0.62; P < .001) in 1995–2004, 0.67 (95% CI 0.62–0.72; P < .001) in 2005–14, and 0.89 (95% CI 0.73–1.07; P = .221) in 2015–20, with negligible separation of the weighted cumulative mortality curves in the most recent time period. Conclusions: In this analysis including a large cohort of post-myocardial infarction patients with reduced LVEF, the estimated mortality reduction associated with primary prevention ICD implantation progressively decreased over time.

BACKGROUND Clinical guidelines recommend integrated, person-centered care with control of modifiable risk factors and coexisting conditions in patients with atrial fibrillation (AF), but many receive insufficient risk factor management. Digital health technologies may provide valuable support in addressing this gap. OBJECTIVE Our aim was to evaluate the usability of a co-designed digital platform for supporting person-centered management of modifiable risk factors in individuals with AF. METHODS This mixed methods usability study was conducted at a tertiary university hospital in Sweden between March and April 2025. Eligible participants with AF were recruited to evaluate the co-designed digital platform using the System Usability Scale (SUS) and semistructured interviews analyzed with inductive manifest content analysis. RESULTS A total of 22 patients were included (mean age 67.7, SD 7.6 y); 32% (7/22) were female, the mean BMI was 27.7 (SD 3.6) kg/m2, 65% (14/22) had paroxysmal AF, 36% (8/22) had persistent AF, and the median AF duration was 26 (IQR 13.3-72.8) months. Relevant comorbidities were hypertension (17/22, 77%), heart failure (8/22, 36%), diabetes mellitus type 2 (3/22, 14%), and ischemic heart disease (4/22, 18%). Usability was rated high, with a median SUS score of 78.8 (IQR 63.8-86.9), indicating above-average user acceptance. Participants’ requirements were summarized into 4 main categories and 10 subcategories. First, they valued a clear layout, simple design, and easy navigation. Second, they appreciated positive content, which is informative, inclusive, and motivating. Third, they requested personalized information on different aspects and provided on different levels. Fourth, they desired individualized medical recommendations that are personalized and flexible but open to individual choice. CONCLUSIONS Participants found the usability acceptable and valued specifically a clear layout, positive content, personalized information, and individualized medical recommendations.

Aims: We compared the effects of ‘ablate and pace’ to pharmacological therapy on mortality and left ventricular ejection fraction (LVEF) in patients with atrial fibrillation (AF), with or without heart failure (HF). Methods and results: Articles were identified by searching PubMed, Central, and Embase until 30 June 2024. Inclusion criteria encompassed observational and randomized controlled trials (RCTs) comparing ‘ablate and pace' with pharmacological therapy and investigating outcomes of mortality and LVEF in patients with AF. An exclusion criterion was lack of a parallel study design. The primary outcomes were all-cause mortality and the mean difference (MD) in LVEF. Endpoints were assessed through meta-analyses computing relative risks (RRs) and MDs. The clinical diagnosis of HF was used to distinguish between patients with and without HF. Initially, 3837 studies were identified, of which 24 (n = 4292 patients) fulfilled the inclusion criteria, including 17 (n = 3261 patients) that focused on HF. Follow-up time varied from 3 to 96 months. Only in HF patients, ‘ablate and pace' reduced mortality significantly with a risk reduction of 36% [RR, 0.64; 95% confidence interval (CI), 0.49–0.85; P < 0.01; n = 10] as compared with pharmacological therapy. Except for two studies, cardiac resynchronization therapy (CRT) was the chosen pace mode. The mortality reduction was independent of study design: RCTs (RR, 0.41; 95% CI, 0.18–0.94; P = 0.04; n = 2) and observational studies (RR, 0.70; 95% CI, 0.55–0.90; P = 0.01; n = 8). ‘Ablate and pace’ and pharmacological therapy were similar for the LVEF outcome (MD, 1.1; 95% CI, −1.6–3.8; P = 0.39; n = 16), which was independent of both HF and study designs (results not shown). Conclusion: ‘Ablate and CRT’ reduced mortality in HF patients as compared with pharmacological therapy, which was supported by statistical associations in observational studies. A single RCT corroborated the finding.

Introduction: Left bundle branch block (LBBB) is common in heart failure with reduced ejection fraction (HFrEF) and causes dyssynchrony, which accelerates cardiac remodelling. The biological mechanisms behind LBBB-associated remodelling remain largely unknown. Therefore, we used an omics approach to test the hypothesis that LBBB is associated with plasma protein dysregulation aiming at defining a proteome that contributes to the specific disease driving phenotype in dyssynchronopathy. Methods: Patients were selected from the BIOlogy Study to TAilored Treatment in Chronic Heart Failure database (n = 4254). Patients with HFrEF and LBBB (HFrEF + LBBB) served as cases (n = 268) and a matched control group (n = 268) with HFrEF without LBBB (HFrEF − LBBB) was selected using propensity score matching. We compared relative plasma concentrations of 364 proteins between the two groups using proximity extension assay. Results: HFrEF + LBBB was associated with up- or downregulation of 41 proteins out of 364 assessed, 11%, compared with HFrEF − LBBB. Fibroblast growth factor 2 (FGF2) decreased, epidermal growth factor receptor (EGFR) increased, and several cytokines and proteins involved in extracellular matrix processing changed expression. Gene ontology pathways enriched among upregulated proteins were mainly involved in immune response and cell signalling and included the mitogen-activated protein kinase (MAPK) pathway. Conclusion: In HFrEF, LBBB was associated with an altered circulating proteome. FGF2 and EGFR were highly dysregulated between the groups and the MAPK signalling pathway was affected, all of which may be pathophysiologically involved in the accelerated cardiac remodelling observed in these patients. These findings constitute a foundation for future studies of relevant LBBB-related biomarkers, treatment targets, and mechanisms behind the cardiac remodelling observed when LBBB is superimposed on HFrEF.

Aims: The number of patients undergoing catheter ablation is continuously growing, and techniques are improving. However, studies reporting contemporary data on catheter ablations from large real-world populations are scarce. This study aims to report characteristics and outcomes of catheter ablation from 2006 to 2020, using a nationwide registry with virtually complete coverage. Methods and results: From the Swedish Catheter Ablation Registry, patients >18 years of age undergoing catheter ablation from 2006 to 2020 were included. Periprocedural data and baseline characteristics were recorded retrospectively. A total of 61 243 procedures were included. There was an overall increase in the number of catheter ablations performed. From 2006, the number of atrial fibrillation (AF) ablations performed increased from 352 procedures in 2006 to 2609 procedures in 2020. Decreased procedural times were seen in catheter ablation of accessory pathway/Wolff–Parkinson–White syndrome, atrial tachycardia (AT), atrioventricular nodal reentry tachycardia, cavotricuspid isthmus (CTI), AF, and atrioventricular junction. Between the time periods 2006–15 and 2016–20, median procedural time in AF ablations decreased from 180 to 140 min (P < 0.001). There was a decreased trend in fluoroscopy time and median dose area product for all ablation procedures (P < 0.001). For AT, CTI, and AF, the cumulative probability of requiring a repeat ablation was significantly lower for procedures performed after January 2016 (P < 0.001). Conclusion: With a yearly increase in the number of ablations performed, there was a reduction in the need for repeat ablations for AF, AT, and CTI, along with reduced procedural times and lower fluoroscopy levels.

Background: Alcohol use is an important cardiovascular risk factor and a major contributor to morbidity and mortality. Successful implementation of alcohol interventions in cardiology depends on patient acceptability. Objective: To understand patient perspectives on the feasibility of implementing alcohol interventions in cardiology services. Methods: Multi-site qualitative study. We conducted semi-structured interviews with a heterogenous-purposive sample of 15 adult cardiology patients with hazardous alcohol use. Participants were recruited from three geographically diverse regions in Sweden (Dalarna, Gävleborg, Stockholm) and were varied in terms of sociodemographic characteristics, cardiovascular diagnosis, risk factor profile, and level of alcohol use. We applied the Capability, Opportunity, Motivation and Behaviour (COM-B) system during coding and conducted a reflexive thematic analysis. Results: We identified 56 feasibility factors: 15 related to capability, 10 to opportunity, and 31 to motivation. Four themes emerged: 1. Alcohol use as relevant to cardiology, where participants recognized cardiovascular risk factors, expressed motivation for change, and identified a need to address alcohol use sensitively; 2. Aligning interventions with expectations and goals, where participants linked acceptability of alcohol interventions to personal goals and social norms; 3. Morbidity and shifting priorities, where participants prioritized quality of life and respect for autonomy; 4. Addressing barriers to alcohol dependence treatments, where participants saw a need to improve access to care. Conclusions: Findings suggest that alcohol interventions are acceptable to cardiology patients with hazardous alcohol use. Implementation strategies that prioritize quality of life, respect autonomy, and align with individual expectations and goals may be among the most acceptable. We also identified an opportunity to improve access to treatments for alcohol dependence within multidisciplinary heart teams or hospital-based addiction care services.

Aims: This study aimed to explore clinicians’ perspectives on the feasibility of implementing alcohol screening and brief interventions (SBI) in cardiology services. Methods and results: We conducted a multi-site, exploratory-sequential mixed methods study. Themes from qualitative interviews were integrated with the Capability, Opportunity, Motivation (COM-B) framework during the design and analysis of a cross-sectional survey of cardiology clinicians across Sweden. We assessed perceived capability, opportunities, motivation, and overall perceived feasibility for SBI, and explored associations using ordinal logistic regression. Among 638 participants (mean age = 43 years, 75% women), median perceived feasibility was 66.7%; motivation for SBI was the highest (68.8%), followed by perceived opportunities (66.6%) and capability (62.5%). Perceived feasibility was higher among doctors [OR = 2.67, 95% confidence interval (CI) = 1.38–5.13] compared to assistant nurses and among outpatient clinicians (OR = 1.75, 95% CI = 1.14–2.70) compared to inpatient staff. Participants with specialist experience in arrhythmia (OR = 1.82, 95% CI = 1.01–3.28) and heart failure (OR = 1.95, 95% CI = 1.14–3.33) perceived SBI as particularly feasible. Integrated analysis indicated that clinicians perceive universal alcohol screening as important and that opportunities for SBI exist in cardiology. Implementation barriers may include low competence with brief interventions and doubts about the reliability of self-reported alcohol use. Conclusion: Findings suggest that the perceived feasibility of SBI varies according to clinicians’ professional backgrounds and the clinical context. Doctors, outpatient staff, and those with specialist experience tended to perceive SBI as feasible and may be important stakeholders for implementation in cardiology. Effective strategies may include task sharing with assistant nurses and adapting training to clinical competencies and professional independence. Registration: OSF (osf.io/x62be)