Yoga Yuniadi

The 2026 Asia Pacific Heart Rhythm Society (APHRS) Guidelines represent the first comprehensive APHRS guidelines dedicated to the management of atrial fibrillation (AF) and comprise four parts covering epidemiology, detection/screening and integrated care; stroke prevention; rate and rhythm control; and lifestyle risk factor and comorbidity management. Part 1 focuses on epidemiology and integrated care management, integrating contemporary global evidence with data and clinical considerations specific to the Asia‐Pacific region. It provides evidence‐based and practical recommendations for clinical epidemiology in the region, as well as introduces the need for holistic or integrated care management.

Background: Electrocardiographic markers, including the r′-wave triangle base duration and beta-angle, have been proposed as adjunctive indicators of Brugada syndrome (BrS). As flecainide challenge testing (FCT) carries potential risks, baseline ECG predictors may refine pre-test risk stratification, although their relationship with oral flecainide challenge positivity remains uncertain. Objective: To evaluate whether baseline r′-wave triangle base duration and beta-angle were associated with FCT positivity. Methods: This retrospective, single-center review included consecutive patients who underwent oral flecainide challenge within a historical institutional diagnostic pathway between September 2023 and September 2025. Baseline right-precordial ECG measurements, including r′-wave triangle base duration and beta-angle, were obtained from archived standard 12-lead tracings. The primary outcome was FCT positivity, defined as the emergence of a diagnostic type 1 Brugada pattern Result: Among 40 included patients, 28 had a positive oral flecainide challenge result and 12 had a negative result. In exploratory analyses, larger baseline β-angle and longer r′-wave triangle base duration were associated with oral flecainide challenge positivity. Mean β-angle was 36.07° ± 15.86° in positive versus 21.83° ± 10.72° in negative challenges (p=0.007); mean r′-wave triangle base duration was 161.6 ± 92.8 ms versus 81.6 ± 38.0 ms, respectively (p<0.001). ROC analysis showed moderate discriminatory performance (AUC 0.756 for β-angle, 0.769 for r′-wave). Sample-derived thresholds of 27.5° and 2.625 mm (105 ms) yielded sensitivity of 71.4% and specificity of 83.3%. A combined model incorporating both parameters showed an AUC of 0.780 (95% CI, 0.635–0.924), with 75.0% sensitivity and 83.3% specificity at the Youden-optimal threshold. Conclusion: Baseline r′-wave triangle base duration and beta-angle were associated with FCT positivity. These findings support further prospective investigation using standardized ECG acquisition and contemporary provocation protocols. Keyword : Brugada Syndrome; Electrocardiography; Flecainide Challenge; Sodium Channel Blocker Test.

Background: Differentiating arrhythmogenic right ventricular cardiomyopathy (ARVC) from idiopathic outflow tract ventricular arrhythmias (OT VA) remains a challenge due to overlapping electrocardiographic (ECG) features. However, their pathophysiology and prognosis differ. Given the limited accessibility of advanced imaging, ECG parameters could facilitate early diagnosis. This review and meta‐analysis evaluate the diagnostic accuracy of ECG parameters in distinguishing ARVC from OT VA. Methods: A systematic database search was conducted from inception to March 2025. Observational studies assessing ECG markers for differentiating ARVC from OT VA in adults were included. Diagnostic accuracy metrics (sensitivity, specificity, diagnostic odds ratio, and area under the receiver operating characteristic curve [AUC]) were synthesized using a bivariate random‐effects model. Risk of bias was assessed using the QUADAS‐2 tool. Results: Ten studies enrolling 723 patients were included. T‐wave inversion in V1–V3 was the most commonly assessed parameter, with a pooled sensitivity of 0.55 and specificity of 0.88 (AUC = 0.798). Epsilon waves demonstrated low sensitivity (0.12) but high specificity (0.98). Among depolarization‐based parameters, QRS duration in V1–V3 (AUC = 0.832) and the ratio of QRS duration in precordial leads (AUC = 0.938) demonstrated strong diagnostic performance. S‐wave upstroke and terminal activation delay also showed high specificity (0.95) but moderate sensitivity. Conclusion: Several ECG parameters, particularly depolarization‐based parameters, exhibit high specificity and moderate sensitivity in differentiating ARVC from OT VA. These findings support the use of ECG as a reliable and accessible diagnostic tool, particularly in settings without advanced imaging. A multi‐marker ECG approach may enhance early recognition of patients with suspected ARVC.

Background: Obesity is a major independent risk factor for atrial fibrillation (AF), contributing to adverse outcomes and complicating rhythm control. While lifestyle modification is recommended, catheter ablation remains central to management. Conventional thermal ablation techniques often yield suboptimal results in obese patients due to anatomical and biophysical challenges. Pulsed field ablation (PFA), a novel non-thermal modality, may overcome these limitations. Methods: A systematic search of PubMed, Scopus, and Embase identified observational cohort studies (2017–2026) evaluating PFA outcomes in obese AF patients or across BMI categories. Four cohort studies met the inclusion criteria. Results: Findings on AF recurrence were heterogeneous. Recurrence rates appeared lower with PFA compared to radiofrequency ablation (RFA), though differences were not statistically significant. In a PFA-only study, freedom from arrhythmia recurrence did not vary across BMI categories. Compared with cryoballoon ablation (CBA), one matched-cohort study demonstrated significantly higher one-year freedom from AF with PFA-PVI, whereas another reported no difference. Left atrial epicardial adipose tissue (LA EAT) emerged as the only independent predictor of recurrence in PFA patients, suggesting electrical field perturbation by fat tissue. Radiation exposure was lower with PFA than CBA, while fluoroscopy time and periprocedural complications were comparable across groups. Conclusions: Current observational evidence suggests that PFA may be a feasible and safe option for AF ablation in overweight and obese patients, with outcomes comparable to conventional ablation techniques. However, comparative efficacy and long-term safety remain uncertain. Obesity-related adipose hypertrophy, systemic inflammation, and atrial remodeling may alter electric field distribution, contributing to variable recurrence outcomes. Larger prospective and randomized trials are warranted to define the long-term role of PFA in this high-risk population.

Background: Ischemic and reperfusion injuries occur during cardiac arrest and after successful resuscitation, potentially triggering apoptosis and autophagy, which can cause irreversible cell damage or death. Beclin-1 and Caspase-3 are proteins that play roles in autophagy and apoptosis pathways. However, it remains unclear whether the insertion of an IABP influences the serum levels of these proteins in patients with cardiac arrest and acute coronary syndrome (ACS). Objective: To investigate the Caspace-3 and Beclin-1 serum levels after Intra-Aortic Balloon Pumps (IABP) in cardiac arrest survivors with ACS. Methods: This is a single-center prospective randomized control trial (RCT) study using an unpaired t-test and a Mann-Whitney U-test to analyze the data (p-value<0.05). Result: This study included sixty subjects: 48 males and 12 females, with a mean age of 60.3 ± 9.85 years. The result showed there’s no significant difference in Beclin-1 and Caspase-3 serum levels before and after the insertion of IABP in both survival and non-survival groups (p=0.676). Caspace-3 serum level was higher in non-survival group. ROC curve analysis showed the caspase-3 level has a predictive value for mortality in cardiac arrest survivors with ACS (p=0.012). Conclusion: IABP insertion in cardiac arrest patients with ACS doesn’t significantly affect Beclin-1 and Caspase-3 levels. Caspase-3 serum levels may predict mortality in these patients, with a sensitivity of 64% and a specificity of 66.7%. Keyword : Beclin-1; Cardiac Arrest Survivor; Caspase-3; Critical Care; IABP.

Background: Atrial fibrillation (AF) is an increasing health concern in Asia, but data from developing countries remain scarce. Although direct oral anticoagulants (DOACs) are now preferred globally, vitamin K antagonists (VKAs) remain the mainstay of stroke prevention in low- and middle-income countries, including Indonesia. This study evaluates the clinical outcomes of Indonesian AF patients with warfarin-based treatment. Methods: The OPTIMA (Optimal target of INR for Indonesian) study is a multicenter, prospective cohort study involving 1,599 AF patients across 25 centers in Indonesia. Clinical characteristics, INR levels, and time in therapeutic range (TTR) were analyzed. The primary endpoints were stroke/systemic embolism (efficacy) and major bleeding (safety). Cox proportional hazards regression and Kaplan–Meier analysis assessed outcomes. Results: The mean CHA ₂ DS ₂ -VASc score was 2.43. Anticoagulation quality was poor under the standard INR target of 2.0–3.0, with a mean time in therapeutic range (TTR) of only 30.1%. Patients with an average INR of 1.6–2.5 experienced lower rates of stroke and major bleeding. The incidence rates per 100 patient-years were 1.32 for stroke, 1.51 for major bleeding, and 3.15 for mortality. Stroke risk was highest in persistent/permanent AF, with younger, working-age individuals disproportionately affected. Conclusions: Warfarin management at the standard INR target of 2.0–3.0 was associated with poor anticoagulation quality. Patients with average INR values of 1.6–2.5 experienced fewer adverse events, although this finding requires confirmation in prospective trials. Socioeconomic burden is substantial, as AF-related stroke disproportionately affects younger, working-age Indonesians.

It is well known that soluble suppression of tumorigenicity 2 (sST2) predicts heart failure outcomes. Little attention has been paid to its use in atrial fibrillation (AF). We investigated whether sST2 is involved in AF formation and recurrence after catheter ablation. A systematic review and meta-analysis study was completed. Until the end of November 2023, the potential articles from Cochrane, OpenMD, PubMed, and ScienceDirect were collected. The assessment of study quality was conducted using the Newcastle-Ottawa scale (NOS). All relevant data from eligible studies were extracted. A random effect model was used for the pooled analysis. A total of 14582 participants from 19 studies were involved in this study. The sST2 level was greater in individuals with AF than those with sinus rhythm (standardised mean difference [SMD] = 0.45; 95% confidence interval [CI] = 0.29 to 0.61; p < 0.01). Elevated sST2 levels were correlated with an increased likelihood of developing AF (hazard ratio [HR] = 1.07; 95% CI = 1.00 to 1.14; p = 0.04). A higher sST2 level was found in individuals with recurrent AF (SMD = 0.78; 95% CI = 0.32 to 1.23; p < 0.01). An elevated level of sST2 was related to a greater recurrent AF risk (HR = 1.17; 95% CI = 1.04 to 1.32; p = 0.01). The circulating biomarker sST2 has an essential role in AF development. Moreover, sT2 is a significant predictor for recurrent AF after a successful catheter ablation procedure.

Background The relationship between premature ventricular contractions (PVC) and right ventricular (RV) function is not widely known. Left ventricular (LV) dysfunction due to PVC is known as PVC-induced cardiomyopathy (PIC) and suppressing the PVC substrate would improve LV function. The effect of PVC ablation on changes in RV function in patients with subtle RV subclinical dysfunction remains unknown. Objective Understanding the alterations in RV function parameters after PVC ablation. Method Basic and speckle-tracking echocardiography has been performed on 42 individuals with symptomatic idiopathic outflow tract PVC before and 1 month after a successful ablation. Result At the baseline of the study, there were 26 patients with RV subclinical dysfunction and 16 patients without RV dysfunction. Patients with RV subclinical dysfunction exhibited significantly higher PVC burden and QRS complex duration than those with normal RV function (p < 0.05). A PVC burden ≥ 21% (OR 9.11, 1.54–53.87, p = 0.015) and a QRS complex duration ≥ 138 ms (OR 5.74, 1.07–30.90, p = 0.042) were independently associated with RV subclinical dysfunction. In both groups, measurements of RV subclinical function before and after ablation, specifically by free wall longitudinal strain (FWLS) and global longitudinal strain (GLS), demonstrated significant changes. These improvements were more pronounced in the group with RV dysfunction (FWLS 9.7 ± 4.0, p < 0.001; GLS 7.5 ± 4.2, p < 0.001). Lower initial FWLS and GLS before ablation emerged as significant parameters in the multivariate analysis for the improvement of RV function post-ablation. Conclusion Patients with RV subclinical dysfunction had higher PVC burden and wider QRS duration. Patients with idiopathic outflow tract PVC with RV subclinical dysfunction may experience improvements in RV function after successful PVC ablation. Graphical Abstract

Objective: Atrial fibrillation (AF) is one of the most common arrhythmic disorders worldwide. This study aims to describe the prevalence of AF in various cities in Indonesia using single‐lead hand held electrocardiography linked to a smartphone‐based application.Methods: This is a cross‐sectional epidemiological study conducted at tertiary hospital of major cities in Indonesia, between January 2018 and July 2019. The AliveCor Kardia™ Mobile system device was used as a screening tool for AF and confirmed its finding with clinical diagnoses made by cardiologists.Results: A total of 9773 subjects were enrolled in this study. The prevalence of AF reported by the device and cardiologist was 3.2% and 3.5%, respectively. AF prevalences are equal in men than women. The majority of subjects (56%) are having low risk for stroke or systemic thromboembolism. Prevalence of risk factors such as heart failure, hypertension, diabetes, and history of stroke among AF patients were 50%, 22.9%, 31.9%, 13.5%, and 5.8%, respectively.Conclusion: The prevalence of AF at referral hospitals visitors based on smartphone diagnosis in Indonesia is 3.2%.