Yuan Hung

Background: Atrial fibrillation (AF) is often underdiagnosed and undertreated by noncardiologists. This study evaluated whether artificial intelligence–enabled ECG (AI‐ECG) alerts could improve AF diagnosis and non–vitamin K antagonist oral anticoagulant prescriptions by noncardiologists. Methods: In this open‐label, cluster randomized controlled trial (NCT05127460) at 2 hospitals in Taiwan, noncardiologists were randomized to an intervention group (AI‐ECG alerts) or control group (usual care). Alerts were sent to physicians when AI‐ECG identified AF in emergency or hospitalized patients at risk of stroke (CHA₂DS₂‐VASc ≥1 for men, ≥2 for women), excluding those with prior AF or oral anticoagulant use. Primary end points included a non–vitamin K antagonist oral anticoagulant prescription within 90 days after discharge, new AF diagnosis, echocardiogram arrangements, and cardiologist visits. Secondary end points were ischemic stroke, cardiovascular death, and all‐cause death. Results: A total of 8857 and 8960 patients were treated by 120 and 113 noncardiologists in the intervention and control groups, respectively; 275 and 245 patients had AI‐detected AF. The non–vitamin K antagonist oral anticoagulant prescription rate was significantly higher in the intervention group (23.3% versus 12.0%; hazard ratio [HR], 1.85 [95% CI, 1.11–3.07]). The intervention group also had a higher rate of AF diagnosis (HR, 1.40 [95% CI, 1.03–1.90]). No significant differences were observed in echocardiogram arrangements, cardiologist visits, or the rates of ischemic stroke, cardiovascular death, and all‐cause death. Conclusions: An AI‐ECG alert for AF identification promoted non–vitamin K antagonist oral anticoagulant prescriptions among noncardiologists, thus reducing the disparity in AF care quality between cardiologists and noncardiologists. Registration: URL: https://clinicaltrials.gov/ ; Unique identifier: NCT05127460.

The health crisis due to coronavirus disease 2019 (COVID-19) has shocked the world, with more than 1 million infections and casualties. COVID-19 can present from mild illness to multi-organ involvement, but especially acute respiratory distress syndrome. Cardiac injury and arrhythmias, including atrial fibrillation (AF), are not uncommon in COVID-19. COVID-19 is highly contagious, and therapy against the virus remains premature and largely unknown, which makes the management of AF patients during the pandemic particularly challenging. We describe a possible pathophysiological link between COVID-19 and AF, and therapeutic considerations for AF patients during this pandemic.

Background: Taiwan is located in a subtropical area where there are approximately 50 kinds of land snakes and six principal kinds of venous snakes. Snakebite envenomation is not an uncommon issue in Taiwan. We design a study to obtain an understanding of the characteristics of snakebites and snakebite patients in a medical center in northern Taiwan. Materials and Methods: This was a retrospective medical records study of an 8-year period. We used the key word “snake” to search the emergency department (ED) diagnosis of all patients and then used antivenom management codes to select patients for inclusion. The species of snake involved, time and site of the bite, geographic data of the patients and patient outcomes were recorded. Results: In total, there were 125 snakebite patients (male 70%, female 30%). The snakes involved were Protobothrops mucrosquamatus (50%), followed by Trimeresurus stejnegeri (7%). The feet and ankles were the most frequently bitten areas (42.4%). The peak months were July and October. The average ED stasis time was 2 hours and 45 minutes, and 65.6% of snakebite patients received antivenom. In patients bitten by P. mucrosquamatus, there was a high surgical rate, 23.8% higher than those reported in other studies. No mortalities or side effects of antivenom were reported in these patients. Conclusion: We propose a clinical flow chart for physicians who are treating patients bitten by P. mucrosquamatus. Snakebites, especially those inflicted by P. mucrosquamatus, induce severe soft tissue swelling, which can mimic compartment syndrome. Antivenom for P. mucrosquamatus is the first and only choice of treatment. The amount of antivenom needs to match the clinical symptoms. Patients bitten by P. mucrosquamatus may need longer observation times than patients bitten by other species of snakes, in addition to toxicologist consultations, sonographic examinations, and measurement of the objective compartment pressure before surgery.

There are few reports describing ventricular arrhythmias (VAs) from the crux and the corresponding endocardial site, i.e., the basal inferior segment of the interventricular septum (IVS). We aimed to investigate a distinct clinical group of VAs arising from the endocardium at this area in patients with structural heart diseases (SHD).

Introduction: Cigarette smoking contributes to the development of atrial fibrosis via nicotine. The impact of smoking on ablation results in persistent atrial fibrillation (AF) is unknown. We aimed to investigate the triggers and long‐term outcome between smokers and nonsmokers in the patients with persistent AF after catheter ablation.Methods: This study included 201 (177 males, 53 ± 10 years old) patients who received index catheter ablation, including pulmonary vein isolation (PVI) and complex fractionated atrial electrograms (CFAEs) ablation for persistent AF, retrospectively. Electrophysiological characteristics at the index procedure and long‐term outcome were investigated to determine the differences between smokers and nonsmokers.Results: Baseline characteristics were similar between two groups. Pulmonary vein (PV) triggers were found in all patients in the two groups. There was a higher incidence of nonpulmonary vein (NPV) triggers in smokers than in nonsmokers (61% vs. 31%, P < 0.05). There were no differences of the long‐term ablation outcomes between smokers and nonsmokers in Kaplan–Meier analysis. Smokers with PV plus right atrial NPV (RA‐NPV) triggers had a higher incidence of recurrence (log‐rank P < 0.05) than those without RA‐NPV triggers, but not in nonsmokers, after a mean follow‐up of 31 ± 25 months.Conclusions: Smoking increases the incidence of NPV triggers in patients with persistent AF. Smokers who have RA‐NPV triggers during index procedure do have a worse outcome after catheter ablation, indicating the harmful effects of nicotine to right atrium.

Objective Traumatic intracranial haemorrhage (ICH) leads to systemic inflammatory response and arrhythmia. Atrial fibrillation (AF), the most common arrhythmia, is associated with systemic inflammation. However, limited evidence is available regarding the association between traumatic ICH and AF. Methods This study used the National Health Insurance Research Database, a nationwide population-based cohort, in Taiwan and total 130 171 individuals with traumatic ICH from 2000 to 2011 were identified. Furthermore, individuals without traumatic ICH were selected as a comparison cohort by the propensity score method. Individuals with prior history of AF were excluded from this study. The endpoint of interest was the occurrence of AF and the follow-up was terminated by the occurrence of AF, loss of follow-up or the passing of 31 December 2011. Results During the follow-up period, the incidence of AF was higher in patients with traumatic ICH than in those without traumatic ICH (4.24 vs 4.12 per 1000 person-years). After adjustment for age, sex and all AF-associated comorbidities, the individuals with traumatic ICH had a 1.25-fold increased risk of AF (HR=1.25, 95% CI=1.18 to 1.32; pConclusion In this large-scale cohort study, the future risks of AF are higher in patients with traumatic ICH compared with the comparison cohort. Carefully monitoring the occurrence of AF and proper anticoagulation therapy might be important in patients with traumatic ICH.