Latest news with #atrialFibrillation
Medscape
5 days ago
- General
- Medscape
Genetic Tests in AF Patients May Flag Heart Failure Risk
Genetic testing in patients with atrial fibrillation (AF) may identify those at higher risk of developing incident cardiomyopathy or heart failure, new research from the Netherlands suggested. In a study that included two longitudinal cohorts (the All of Us Research program and the UK Biobank), the prevalence of inherited rare gene variants associated with cardiomyopathy was twice as high in patients with AF and up to five times as high in patients with early-onset AF, defined as that occurring in people younger than 45 years. The analysis, of 44,182 patients with AF, also found those with gene variants associated with cardiomyopathy were at a higher risk for incident cardiomyopathy or heart failure after a diagnosis of AF — about 50%-70% higher compared with noncarriers — independent of clinical and polygenic risk. The findings appeared in JAMA Cardiology . 'If you see a young person in the clinic with AF, first of all, it's not a good sign,' Sean J. Jurgens, MD, MSc, PhD, assistant professor in the Department of Experimental Cardiology at Amsterdam UMC, and a co-author of the study, told JAMA in an interview about the research. 'The risk of heart failure and cardiomyopathies are relatively high and substantially elevated in any person with AF at a younger age. It's not a benign disease where you only have to treat the ischemic stroke risk.' People carrying rare pathogenic variants 'are the patients you really need to look after because these will be the ones who will go on to develop heart failure more likely,' he said. Jurgens acknowledged barriers remain with widespread genetic testing, citing cost, insurance coverage, a lack of cardiovascular genetic expertise, and the lack of genetic counselors. Genetic testing is also more widely available in a smaller country like the Netherlands. In the United States, especially outside of urban centers, accessibility is particularly limited. 'This is a very difficult problem, is why it is so important to do the right stratification,' Jurgens said. 'We can't offer it to everyone. One thing that's good to see is that the prices, at least on the technological side are dropping.' Jurgens said the new research may help reduce the cost of genetic testing, as it narrowed the panel of pathogenic variants from more than 100 to 26, with a high degree of confidence. Notable Strengths In an editorial accompanying the journal article, Olivia G. Anderson, MS, CGC, with the Division of Cardiovascular Medicine at the University of Pennsylvania Perelman School of Medicine in Philadelphia, and her colleagues called the new study 'methodologically rigorous.' The work 'affirms the observation that AF can be an early phenotypic manifestation' of genetic cardiomyopathy, they wrote. Anderson and her co-authors praised the study for generating concordant results from a sensitivity analysis using a 12-month blanking period, which reduced the likelihood patients were diagnosed with AF and cardiomyopathy at the same time. They also said the Dutch team's study makes a strong case for genetic testing in patients with AF, particularly for those younger than 45 years. 'Their findings also highlight the increasing need for genetic counselors embedded in cardiology practices and an expanded availability of specialized cardiovascular genetics clinics,' they wrote. This work was supported in part by the Amsterdam UMC YTF, Dutch Heart Foundation, and the AFIP Foundation; the Deutsche Forschungsgemeinschaft; the CIRCULAR NOW Consortium and the Dutch Heart Foundation, focused on genomic risk prediction in cardiomyopathies; the American Heart Association, the European Union, and the Fondation Leducq. Jurgens and the authors of the editorial reported no relevant financial relationships.
Medscape
5 days ago
- Business
- Medscape
Same-Day Discharge Criteria Outlined for AF Ablation
SAN DIEGO — Same-day discharge after ablation of atrial fibrillation (AF) is an appropriate strategy for saving costs if performed with strict selection criteria and protocols, according to a recently issued joint statement from the American College of Cardiology and the Heart Rhythm Society. Same-day discharge has long been indicated for catheter ablations to abort routine atrial flutter, atrioventricular nodal reentrant tachycardia, and focal atrial tachycardias, according to the authors of the new joint statement. Although they maintained patients selected for elective catheter ablation of AF require heightened scrutiny, they endorsed same-day AF ablation when used selectively. The statement evaluates 'evidence supporting shorter hospitalization stay with same-day discharge for intracardiac ablations agonistic to site of care,' reported Amit J. Shankar, MD , an electrophysiologist with Canton-Potsdam Hospital in Potsdam, New York, who served as a representative for the Heart Rhythm Society in developing the statement. Whether in a hospital setting or an outpatient facility, the statement describes same-day discharge ablation as an opportunity to improve patient access, improve efficiency, and reduce healthcare costs. The adoption of same-day discharge after AF ablation was accelerated during the COVID-19 pandemic, said Samuel O. Jones, MD, a cardiologist affiliated with The Chattanooga Heart Institute in Chattanooga, Tennessee, and a fellow of the American College of Cardiology. 'Improved workflows, technological innovations, and procedure advancements have also contributed to the high rates at which these are performed,' added Jones, who helped write the statement. The statement was released on April 24 to coincide with the first day of the Heart Rhythm Society (HRS) 2025 annual scientific meeting. It was simultaneously published in Heart Rhythm and the Journal of the American College of Cardiology . The scientific statement's recommendation is intended for elective rather than urgent or emergency ablations. Support for the statement was drawn from multiple case-controlled studies, meta-analyses, and outcome databases. In one example, a 12-study meta-analysis with data from more than 18,000 elective ablations showed no significant differences in major complications from the procedure among the 40.5% of patients discharged the same day relative to those who were discharged after at least one night in the hospital. In another study, drawn from a real-world prospective registry, outcomes were compared for potential candidates for same-day ablation on the basis of prespecified criteria and those who were not eligible for the procedure. These criteria included no bleeding history, a left ventricular ejection fraction greater than 40%, no pulmonary disease, and no surgical procedures within the previous 60 days. Of the 2332 patients included in the analysis, 1982 (85%) were deemed candidates for same-day ablation. Although freedom for atrial arrhythmias was comparable ( P = .0212) for the two groups, patients discharged the same day had a lower rate of complications (0.8% vs 2.9%; P < .001). The rate of readmission was similar (0.8% vs 09%; P = .924), according to the researchers. Contraindications for Same-Day Ablation In the document, relative contraindications for same-day ablation include decompensated heart failure, significant pulmonary disease, significant risk of bleeding, and any major unstable comorbidities such as diabetes, hypertension, or renal disease. The document recommends limiting same-day procedures to patients who can have readily available social support and can return to a hospital quickly in the event of a post-procedural complication. Acknowledging that most large hospitals offering ablation for AF already have formal selection criteria and protocols in place for same-day discharge, the authors called for free-standing sites to establish their own if they have not done so. In these settings, the authors emphasized the need to rigorously follow prespecified and 'ironclad' selection criteria and protocols. From this standpoint, Shankar said same-day procedures should always be performed on the basis of shared decision-making with the patient. While the economic benefits of same-day procedures might be shared by the facility and the patient, the latter should understand the inherent differences in the settings and participate actively in any decision of where the ablation is performed. Jones said while a substantial body of evidence supports same-day AF ablation as a safe and effective procedure that can free up necessary resources in the healthcare facility, the potential advantages are relevant only to appropriately selected patients. The new statement also suggests transfer agreements with inpatient facilities should be arranged in advance and that patients should be informed such a transfer is a possibility outside of a hospital setting. However, the document makes clear same-day ablations in alternative sites of care are reasonable when the precautions are observed. In any setting that AF ablation is performed, the writing committee encouraged tracking outcomes to ensure that high-quality care is achieved and sustained. Shankar and Jones reported no potential conflicts of interest.
Medscape
12-05-2025
- Health
- Medscape
Atrial Fibrillation: Should We Screen All to Reduce Stroke?
Is it time for universal screening for atrial fibrillation (AF), the most commonly treated type of arrhythmia that sets people up for strokes? The question is important. While estimates of prevalence vary, a recent study found AF affects about 4% of the adult population or about 10 million in the United States. More than 795,000 people in the United States have a stroke each year, and AF is blamed for 1 in 7. For now, however, US organizations that issue guidelines and many leading cardiologists agree: It's not yet warranted and may result in anticoagulation overtreatment, along with what they call the 'nontrivial' risk for bleeding from that treatment. However, it's definitely a stay tuned situation, as researchers continue to investigate whether widespread screening can reduce the number of strokes in the broad population, others look at the role of 'smart' technology, and still others focus on subsets of the population that might benefit most from routine screening. One widely anticipated study is the Heartline Study, a collaboration between Johnson & Johnson and Apple, with researchers analyzing the impact of an app-based heart health program done with the Apple watch on the early detection of irregular heart rhythms consistent with AF and how detection might reduce stroke risk. The trial has concluded, with results expected soon. Current Guidelines Meanwhile, two leading US organizations that issued recent guidelines do not favor universal screening for AF. In 2022, the United States Preventive Services Task Force (USPSTF) guideline concluded that for asymptomatic adults aged 50 years or older, 'the current evidence is insufficient to assess the balance of benefits and harms of screening for atrial fibrillation.' The guideline updated the 2018 guideline, which assessed the evidence for detecting AF using ECG. The updated guideline also looked at other screening tests, still concluding the evidence was inadequate. Besides ECG use, AF may be detected using ambulatory blood pressure monitors, pulse oximeters or wearables, as well as pulse palpitation and heart auscultation. In joint guidelines released in November 2023, the American Heart Association and American College of Cardiology concluded that for risk stratification models and screening programs to be useful, 'they would need to improve outcomes and be cost-effective,' noting that evidence is not established to prove those at a high risk for AF by a validated risk score benefit from screening and intervention to improve stroke rates, embolism rates, and survival. Cardiologist: Currently Little Interest in Universal Screening 'To be honest with you, I don't think many in cardiology are interested in doing universal screening,' said Peter Zimetbaum, MD, associate chief and clinical director of Cardiology at Beth Israel Deaconess Medical Center and Smith professor of medicine at Harvard Medical School, Boston. After the USPSTF guidelines were issued in 2018, Annals of Internal Medicine published an invited point-counterpoint, with Zimetbaum presenting the viewpoint against routine screening. Peter Zimetbaum, MD He wrote: 'Atrial fibrillation is often asymptomatic and paroxysmal, and studies of episodic vs continuous monitoring have demonstrated that the more thoroughly one looks, the more AF will be found.' The potential downside, he noted, is the unintended consequence of initiating lifelong anticoagulation treatment in patients who may not need it, including the potential risk for bleeding and negative impact on quality of life, which 'should not be minimized,' he said. He does recommend screening in some, such as patients with a history of embolic stroke of uncertain source. Taking the pro side in favor of screening, Steven Lubitz, MD, then at Massachusetts General Hospital, Boston, reasoned that AF may be asymptomatic and that subclinical AF is a known risk factor for stroke. He noted the various methods that can be used, including pulse monitoring and electrocardiology. Physicians are already screening for AF with pulse palpation and cardiac auscultation, Lubitz pointed out. The question is whether adding ECG is more effective than the standard of care. Keeping an Open Mind The question of routine screening is understandably an area of research interest, Zimetbaum said, as a significant percentage of patients present for the first time with AF when they have had a stroke, and ongoing advances in technology have made it easier to identify AF. The widespread adoption of wearable technologies such as smartwatches is also picking up AF in patients, he said. Even so, he said, 'the reason why the organizations have come out not in favor of widespread screening is there is not enough evidence to demonstrate we can reduce strokes by identifying AF in the broadscale population.' Many patients will come in to see him, Zimetbaum said, after they have AF picked up on their pacemaker, wanting to talk about the merits of anticoagulation treatment. 'I also get a lot of patients referred to me because they have a wearable of some sort that has alerted them that they have atrial fibrillation.' Of the wearables, he said 'they are reasonably accurate but not very accurate.' Since 2019, when he wrote the counterpoint, 'my opinion has not changed.' However, he is keeping an open mind. He said he expects wearables to improve and sees improving the accurate identification of AF as a goal worthy of more study. Research Focus: Episode Duration, Risk Factors Since the 2022 guidelines were issued, 'we do not have explosive new data to conclude this debate,' said Rod Passman, MD, MSCE, professor of medicine and preventive medicine at Northwestern University Feinberg School of Medicine in Chicago and director of the university's Center for Arrhythmia Research. Rod Passman, MD, MSCE However, 'the ARTESIA trial published in 2024 found a reduction in stroke risk when treating patients with anticoagulation who had short episodes of AF detected on their pacemaker or ICD [implantable cardioverter-defibrillators] who also had other stroke risk factors.' But whether the same can be said for those with AF detected by other screening methods is not yet known, Passman said. 'There is no consensus on how much AF is too much,' Passman told Medscape Medical News . 'Most would agree that one or more episodes over 24 hours may benefit from anticoagulation if multiple other stroke risk factors are present; there is less consensus of opinion on episodes shorter than that.' In a previous study, Passman and his colleagues found that a combination of AF duration and underlying risk factors increases stroke risk. 'AF episodes in someone with no or one risk factor may not increase stroke risk, but the more risk factors you have, the shorter the AF episodes associated with stroke.' In his view, 'When we discuss screening, therefore, it is important to recognize that we should be screening those with an elevated risk of having the disease plus other risk factors that would dictate treatment should the disease be present.' The Promise of Wearables 'Patients come to me every week because their watch told them they have AF,' Passman said. 'So using these technologies as a screening tool makes intuitive sense but has not yet been sufficiently proven to reduce hard endpoints such as stroke, in my opinion.' Zachary Goldberger, MD, MS, a cardiologist and professor of medicine at the University of Wisconsin-Madison School of Medicine and Public Health, told Medscape Medical News : 'I think photoplethysmography can be a very powerful screening tool, but there are clear challenges. One is the amount of data we are going to receive, and already are receiving, and how much of that is interpretable and actionable.' His hope: 'We really need to find a better means of identifying who we should target these wearables toward.' He added: 'It can't be ignored that this technology is not always affordable.'
