Monika Gawałko

Aims: Symptom severity in atrial fibrillation (AF) influences healthcare use, but conventional assessments lack temporal precision. We evaluated the feasibility of smartphone-based symptom severity assessment after AF catheter ablation and explored predictors and variability of symptom severity. Methods and results: In this analysis of the ISOLATION study, 140 patients used a photoplethysmography-supported smartphone application to record heart rhythm, symptoms, and symptom severity three times daily and when symptomatic for 7 days at 3, 6, and 12 months after ablation. Symptom severity was classified using the modified European Heart Rhythm Association scale. A total of 8575 recordings were analysed, of which 11% showed AF. Median adherence was 67%. Symptom severity was higher during AF, in women, and with higher heart rate. Nearly half of AF recordings were asymptomatic. Conclusion: Smartphone-based symptom severity assessment after AF ablation is feasible and reveals substantial individual variability beyond rhythm status alone.

Emerging evidence indicates that the gut microbiome (GM) and its metabolites may play a role in the development of cardiometabolic diseases, including atrial fibrillation (AF). Although the current data are limited, studies suggest that the GM composition in AF mirrors that observed in associated conditions such as heart failure, hypertension, diabetes, and coronary artery disease (characterized by increased genera Lactobacillus, Enterococcus, Streptococcus, and decreased genus Faecalibacterium). Additionally, patients with AF appear to have distinct microbial alterations, including increased abundances of the genera Dialister, Dorea, Haemophilus, Klebsiella, Lachnospira, Parabacteroides, Ruminococcus, and Veillonella and decreased abundances of the genera Butyricicoccus, Hungatella, and Prevotella. Gut-derived metabolites also show associations with AF. Trimethylamine N-oxide and choline have been linked to new-onset and postoperative AF, potentially via autonomic, inflammatory, and fibrotic pathways. In contrast, short-chain fatty acids, which are reduced in AF patients, may offer protective effects. Elevated lipopolysaccharide levels are correlated with AF onset and recurrence through inflammation and structural remodeling. Indoxyl sulfate and bile acids may contribute to arrhythmogenesis via oxidative stress, apoptosis, and disrupted calcium signaling. These mechanisms contribute to AF by disrupting conduction and increasing automaticity. Emerging evidence also links gut microbes to other arrhythmias, but more research is needed to clarify causality and therapeutic potential.

Aims: Identifying risk or probability of heart failure with preserved ejection fraction (HFpEF) in patients with atrial fibrillation (AF) is challenging. This study aimed to assess the prevalence and factors associated with elevated left atrial pressure (LAP) in AF patients undergoing catheter ablation and to evaluate the concordance between elevated LAP and HFpEF risk scores. Methods and results: This study included 336 symptomatic AF patients (median age 65 years, 41% female) undergoing catheter ablation. Elevated LAP was defined as a mean LAP ≥ 15 mmHg. High HFpEF probability was defined by H2FPEF ≥ 6 and/or HFA-PEFF ≥ 5. Elevated LAP was present in 37% (n = 125) of patients, and factors associated with elevated LAP included higher body mass index (BMI; OR 1.21, 95% CI: 1.11–1.31) and lower LA reservoir strain (OR 0.97, 95% CI: 0.94–0.99). General anaesthesia and non-sinus rhythm were linked to higher LAP but not independently; AF type showed no effect. Among 204 eligible patients, 36% had a high HFpEF probability. Over 12 months, AF recurrence (26% vs. 24%, P = 0.775) and repeat ablations (11% vs. 7.2%, P = 0.230) were similar regardless of LAP status, but severe adverse events (death, life-threatening situations, hospitalizations, or persistent disability) were more common in those with elevated LAP (6.7% vs. 1.7%, P = 0.044). Conclusion: Over one-third of catheter ablation patients had elevated LAP. Poor agreement between elevated LAP and HFpEF risk scores suggests that using these risk scores may not be advisable in AF population.

Aims: Autonomic nervous system activation plays an important role in the pathophysiology of atrial fibrillation (AF). It can be determined using heart rate variability (HRV). We aimed to evaluate the feasibility of using photoplethysmography (PPG) recordings for the assessment of the ultra-short-term HRV. Methods and results: TeleCheck-AF is a structured mobile health approach, comprising the on-demand use of a PPG-based smartphone application prior to a scheduled teleconsultation to ensure comprehensive remote AF management. Participants with at least one PPG recording in sinus rhythm were included to assess resting heart rate, root mean square of successive differences (RMSSD), patient compliance and data consistency. In total, 855 patients [39.4% women] with 13 465 recordings were included. Patient compliance was 95.2% (IQR 76.2–114.3%). Median heart rate per patient was 66.5 (IQR 60.0–74.0) b.p.m., median RMSSD per patient was 40 (IQR 33–50) ms and median recording consistency was ±5.2 (IQR 3.8–7.0) b.p.m. and ±14.8 (IQR 9.3–21.1) ms, respectively. RMSSD was lower in men than women, in patients with CHA2D2-VA-Score 0, with a history of AF, and following ablation of AF. Older age and lower body mass index were associated with higher RMSSD. Conclusion: The ultra-short-term HRV can be determined in 1-min PPG recordings with high user compliance and high inter-recording consistency within a structured mobile health AF management approach. The strategy used in this study may also be feasible for the management of other conditions in which the HRV plays a role for diagnostics and therapy.

Reduction of atrial fibrillation (AF) burden is the preferred outcome measure over categorical AF rhythm recurrence after AF ablation. In this sub-analysis of the TeleCheck-AF project, we tested the feasibility of smartphone app-based approximation of time spent with AF and/or symptoms. Patients scheduled for at least one teleconsultation during the 12-month follow-up after AF ablation were instructed to use a smartphone photoplethysmography-based application for simultaneous symptom and rhythm monitoring three times daily for 1 week. Proxies of time spent with AF and/or symptoms (% recordings, load, and % days), temporal aggregation of AF and/or symptoms (density), and symptom–rhythm correlation (SRC) were assessed. In total, 484 patients (60% male, 62 ± 9.9 years) were included. Adherence, motivation, and patient satisfaction were high. %AF recordings, AF load, and %AF days (rs = 0.88–0.95) and %symptom recordings, symptom load, and %symptom days (rs = 0.95–0.98) showed positive correlations. The SRC correlated negatively with time spent with symptoms (rs = −0.65–0.90) and with time spent with AF (rs = −0.31–0.34). In patients with paroxysmal AF before ablation and AF during the monitoring period, 87% (n = 39/44) had a low-density score 90% (‘persistent AF pattern’). Corresponding numbers for patients with persistent AF before ablation were 48% (n = 11/23) and 43% (n = 10/23), respectively. On-demand, app-based simultaneous rhythm and symptom assessment provides objective proxies of time spent with AF and/or symptoms and SRC, which may assist in assessing AF and symptom outcomes after AF ablation.

Atrial fibrillation (AF) is the most prevalent sustained cardiac arrhythmia. Comprehensive modification of established AF risk factors combined with dietary interventions and breaking deleterious habits has been shown to reduce AF burden and recurrence. Numerous AF risk factors, such as diabetes, obesity or hypertension can be partially related to dietary and lifestyle choices. Therefore, dietary interventions may have potential as a therapeutic approach in AF. Based on available data, current guidelines recommend alcohol abstinence or reduction to decrease AF symptoms, burden, and progression, and do not indicate the need for caffeine abstention to prevent AF episodes (unless it is a trigger for AF symptoms). Uncertainty persists regarding harms or benefits of other dietary factors including chocolate, fish, salt, polyunsaturated and monounsaturated fatty acids, vitamins, and micronutrients. This article provides a systematic review of the association between AF and both dietary patterns and components. Additionally, it discusses potentially related mechanisms and introduces different strategies to assess patients’ nutrition patterns, including mobile health solutions and diet indices. Finally, it highlights the gaps in knowledge requiring future investigation.

Background: Heart failure with preserved ejection fraction (HFpEF) frequently coexists with atrial fibrillation (AF). The diagnosis of HFpEF in AF is difficult because some diagnostic criteria for HFpEF may be associated with AF instead of HFpEF per se. Left atrial pressure (LAP) ≥15 mmHg has been used to confirm the diagnosis of HFpEF. Purpose: We aimed to 1) determine LAP measurements in patients with AF undergoing catheter ablation; 2) assess the agreement between LAP measurement HFpEF risk scores and 3) determine the association between LAP measurement and clinical and echocardiographic features. Methods: Consecutive patients with paroxysmal or persistent AF scheduled for catheter ablation were included. Participants were considered to have HFpEF if the mean LAP was ≥15 mm Hg. The LAP was measured only in sedated patients with spontaneous breathing. Participants had high probability of HFpEF if scored >5points in H2FPEF and/or ≥5 points in HFA-PEFF score. Results: Of 107 participants, 29 (27%) had HFpEF according to mean LAP and 32 (30%) had high probability of HFpEF according to HFpEF scores. The highest agreement of HFpEF risk scores relative to elevated LAP was observed for H2FPEF score; among patients with mean LAP ≥15 mm Hg, 38% [n=11/29] of them had also high risk of HFpEF based on H2FPEF score, whereas only 10% [n=3/29] had high risk of HFpEF based on HFA-PEFF score. In multivariable analysis, the independent predictors of HFpEF were left ventricular ejection fraction (LVEF; OR 0.77, 95%CI 0,.64-0.91), intraventricular septum diameter (IVSd; OR 1.75, 95%CI 1.11-2.74), global longitudinal strain (GLS; OR 1.24, 9%CI 1.05-1.48). Conclusions: More than one-fourth of patients scheduled for catheter ablation had HFpEF according to elevated LAP. The highest agreement to elevated LAP was observed for the H2FPEF score. Predictors of HFpEF diagnosis were lower LVEF, higher IVSd and GLS.

Aim: To evaluate changes in healthcare utilisation and comprehensive packages of care activities and procedures (referred in the Netherlands to as ‘diagnose-behandelcombinatie (DBC) care products) during the implementation of the TeleCheck-AF approach (teleconsultation supported by app-based heart rate/rhythm monitoring) in a Dutch atrial fibrillation (AF) clinic. Methods and results: In the Maastricht University Medical Centre+ AF Clinic, data on healthcare utilisation and DBC care products for patients consulted by both a conventional approach in 2019 and the TeleCheck-AF approach in 2020 were analysed. A patient experience survey was performed. Thirty-seven patients (median age 68 years; 40% women) were analysed. With the conventional approach, 35 face-to-face consultations and 0 teleconsultations were conducted. After the implementation of TeleCheck-AF, the number of face-to-face consultations dropped by 80% (p < 0.001) and teleconsultations increased to 45 (p < 0.001). While 42 electrocardiograms (ECGs) and 25 Holter ECGs or echocardiograms were recorded when using the conventional approach, the number of ECGs decreased by 71% (p < 0.001) and Holter ECGs or echocardiograms by 72% (p < 0.001) with the TeleCheck-AF approach. The emergency department patient presentations showed no statistically significant change (p = 0.33). Overall, 57% of medium-weight DBC care products were changed to light-weight ones during implementation of the TeleCheck-AF approach. Patient satisfaction with the TeleCheck-AF approach was high. Conclusion: The implementation of TeleCheck-AF led to a change in healthcare utilisation, a change from medium-weight to light-weight DBC care products and a reduction in patient burden. These results created the basis for a new reimbursement code for the TeleCheck-AF approach in the Netherlands.