Mohammed Al-Sadawi

Background: Catheter ablation improves outcomes in patients with atrial fibrillation (AF) and heart failure (HF). However, most of the evidence on the importance of ablation timing has been anchored to AF rather than HF onset, leaving the optimal interval between HF diagnosis and ablation incompletely defined. Objectives: To evaluate the association between the timing of catheter ablation following the first diagnosis of HF and subsequent clinical outcomes in patients with established AF. Methods: We performed a retrospective propensity‐score‐matched cohort study using the TriNetX Research Network. Adults (≥18 years) with AF who subsequently developed HF and underwent catheter ablation were included. The primary analysis compared ablation from day 1 through 3 months after HF diagnosis with ablation at least 91 days after HF diagnosis. Propensity‐score matching yielded 2,570 patients in each group. Outcomes were assessed for 2 years after ablation and included all‐cause mortality, electrical cardioversion, emergency department or inpatient encounters, and HF exacerbation. A 1‐year timing threshold and analyses stratified by recorded left ventricular ejection fraction were examined as sensitivity analyses. Results: Mean follow‐up was 549.3±253.2 days after early ablation and 534.1±255.3 days after later ablation. Mortality was similar between groups (11.0% vs 10.0%; hazard ratio [HR] 1.078, 95% confidence interval [CI] 0.910–1.276; p = 0.384), as were emergency department or inpatient encounters (66.2% vs 65.6%; HR 1.006, 95% CI 0.940–1.076; p = 0.865). Early ablation was associated with fewer cardioversions (15.0% vs 18.6%; HR 0.788, 95% CI 0.689–0.901; p < 0.001) and fewer HF exacerbation events (39.5% vs 46.0%; HR 0.824, 95% CI 0.758–0.896; p < 0.001). The 1‐year timing analysis showed a similar pattern for cardioversion and the HF exacerbation. Conclusions: Among patients with AF and HF who ultimately underwent ablation, ablation within 3 months of HF diagnosis was associated with fewer subsequent cardioversions and HF exacerbations than ablation performed from day 91 onward. However, there was no significant difference in mortality between the two cohorts. These findings identify the first months after HF diagnosis as a clinically relevant period for reassessing rhythm‐control strategy and warrant prospective evaluation of ablation timing after HF recognition.

Background: Strategies to estimate risk of cancer therapy‐related cardiac dysfunction (CTRCD) before initiating cardiotoxic cancer treatment are needed. We hypothesized that baseline ECG markers could identify patients at risk for CTRCD. Methods and Results: In this retrospective cohort study, 1278 female patients with stage I–III HER2 (human epidermal growth factor receptor 2)‐positive breast cancer meeting the following inclusion criteria were included: baseline ECG with QRS P P <0.001, likelihood ratio test) with continuous net reclassification improvement of 34.9% and integrated discrimination improvement of 3.4%. Conclusions: Baseline ECG variables are predictive of subsequent CTRCD and provide incremental value to established clinical risk factors for CTRCD risk classification.

Introduction Hypertension (HTN) is a co-morbidity that is commonly associated with heart failure with preserved ejection fraction (HFpEF). However, it remains unclear whether treatment of hypertension in HFpEF patients is associated with improved cardiovascular outcomes. Aim The purpose of this meta-analysis is to evaluate the association of anti-hypertensive medical therapy with cardiovascular outcomes in patients with HFpEF. Methods We performed a database search for studies reporting on the association of anti-hypertensive medications with cardiovascular outcomes and safety endpoints in patients with HFpEF. The databases searched include OVID Medline, Web of Science, and Embase. The primary endpoint was all-cause mortality. Secondary endpoints include cardiovascular (CV) mortality, worsening heart failure (HF), CV hospitalization, composite major adverse cardiovascular events (MACE), hyperkalemia, worsening renal function, and hypotension. Results A total of 12 studies with 14062 HFpEF participants (7010 treated with medical therapy versus 7052 treated with placebo) met inclusion criteria. Use of anti-hypertensive medications was not associated with lower all-cause mortality, CV mortality or CV hospitalization compared to treatment with placebo (OR 1.02, 95% CI 0.77–1.35; p = 0.9, OR 0.88, 95% CI 0.73–1.06; p = 0.19, OR 0.99, 95% CI 0.87–1.12; p = 0.83, OR 0.90, 95% CI 0.79–1.03; p = 0.11). Anti-hypertensive medications were not associated with lower risk of subsequent acute myocardial infarction (AMI) (OR 0.53, 95% CI 0.07–3.73; p = 0.5). Use of anti-hypertensive medications was associated with a statistically significant lower risk of MACE (OR 0.90, 95% CI 0.83–0.98; p = 0.02). Conclusions While treatment with anti-hypertensive medications was not associated with lower risk of all-cause mortality, their use may be associated with reduce risk of adverse cardiovascular outcomes in patients with HFpEF regardless of whether they have HTN. Additional high quality studies are required to clarify this association and determine the effect based on specific classes of medications.

Introduction: Cryptogenic stroke comprises about 25% of all ischemic strokes. Depending on modality and duration of ECG monitoring, subclinical atrial fibrillation (AF) is detectable in 2.7-30% of cryptogenic stroke patients. Hypothesis: Extended ECG monitoring after cryptogenic stroke has not been studied in the African American (AA) population. This retrospective study aims to study the incidence and risk factors of subclinical AF in African Americans. Methods: We retrospectively reviewed 96 patients who received implantable loop recorders (ILR) for detecting subclinical atrial fibrillation after cryptogenic stroke. In the vast majority of patients, the ILR was implanted during index hospitalization. Binary univariate and multivariate analyses were performed to determine predictors for AF detection. Results: AF was detected in 29% of patients (28/96) at 1000 days. All AF that was detected was exquisitely paroxysmal and ranged in duration between 0.05-103 minutes (mean 8.4 minutes with SD= 22.1 minutes). Binary univariate analysis revealed the use of non-dihydropyridine calcium-channel blockers to be associated with decreased odds of AF detection. Multivariate analysis found coronary artery disease diagnosis to be associated with increased odds of AF detection. Fifty percent of the events in the AF group were detected within the first 36 days of loop recorder implantation. Conclusions: AF detection in our population occurs very early after index stroke and at significantly higher rates that reported before. Baseline characteristics have a poor predictive ability for the detection of AF. These findings emphasize the need for pre-discharge ILR implantation to improve AF detection in all patients with cryptogenic stroke.