ii108
10.1093/europace/eut196
ORAL ABSTRACT SESSION: ATRIAL FIBRILLATION: CLINICAL ASPECTS 784
785 Atrial fibrillation as a marker of clinical severity in brugada syndrome
Atrial fibrillation ablation patients have long-term stroke rates similar to patients without atrial fibrillation regardless of CHADS2 score T Bunch, HT May, TL Bair, BG Crandall, JS Osborn, JP Weiss, JL Anderson, JB Muhlestein, DL Lappe, and JD Day Intermountain Medical Center, Murray, United States of America Introduction: Atrial fibrillation(AF) is a leading causing of total and fatal ischemic stroke. In AF patients the CHADS2 risk score has reproducibly identified patients had higher risk of stroke. Stroke risk after AF ablation appears to be favorably influenced, however it is largely unknown if the benefit expends to all stroke risk profiles of AF patients. Methods: A total of 4,212 consecutive patients who underwent AF ablation were compared (1:4) to 16,848 age/gender matched controls with AF (no ablation) and 16,848 age/gender matched controls without AF. Patients were enrolled from the large ongoing prospective Intermountain AF Study and were followed for at least 3 years. Results: Of the 37,908 patients, the mean age was 65.0 + 13 years and 4.4% (no AF), 6.3% (AF no ablation), and 4.5% (AF ablation) patients had a prior stroke (p , 0.0001). The profile of CHADS2 scores between comparative groups was similar, 0-1 (69.3% no AF, 62.3% AF, no ablation, 63.6% AF ablation), 2-3 (26.5% no AF, 29.7% AF, no ablation, 28.7% AF ablation), and 4 (4.3% no AF, 8.0% AF, no ablation, 7.7% AF ablation). 1,296 (3.4%) patients had a stroke over the follow-up period. Across nearly all CHADS2 profiles and ages, AF ablation patients had a lower long-term risk of stroke (hazard ratios shown in Figure). Furthermore, AF ablation patients had similar long-term risks of stroke across all CHADS2 profiles and ages compared to patients with no history of AF. Conclusions: AF ablation patients have a significantly lower risk of stroke compared to AF patients that do not undergo ablation independent of baseline stroke risk. These long-term data coupled with risks similar to patients without AF suggest that ablation treatment favorably reduces stroke risk in AF.
N Cabanelas, E Arbelo, P Berne, JM Tolosana, A Berruezo, L Mont, and J Brugada Barcelona Hospital Clinic, Barcelona, Spain Introduction: Sodium channels dysfunction in Brugada Syndrome (BS) predisposes to ventricular arrhythmias. The same mechanism is thought to be also responsible for a higher predisposition to atrial arrhythmias. So, is hypothesized that atrial fibrillation (AF) may be part of clinical manifestations in BS patients, possibly associated with higher level of channel dysfunction. Aims: To evaluate if documented AF episodes before BS diagnosis are associated with poorer prognosis, namely arrhythmic events and conduction cardiac system disease. Methods: 278 patients with BS have been prospectively included. Two groups were established: A, patients with documented AF previous or at the time of BS diagnosis (n=14); and B, patients without documented AF episodes at the time of BS diagnosis (n=264). Syncope and ventricular tachycardia/fibrillation (VT/VF) events incidence during follow-up were evaluated, as well as cardiac conduction system disease incidence. Results: Patients from group A were older (54.4 + 14.3 vs 43.1 + 14.0, p=0.004). Previous syncope and episodes of VT/VF incidences were not significantly different at the time of inclusion (42.9%vs20.8%, p=0.09) and (7.1%vs4.5%, p=ns), respectively. End-point incidence during a followup of 59.3 + 49.4 months is shown in table 1. The multivariate analysis identified the presence of documented AF before BS diagnosis as an independent predictor of future syncope or VF/VT events. Conclusion: Patients with documented AF before or at the time of BS diagnosis had higher incidence of a composed end-point of syncope and VT/VF episodes, as well as cardiac conduction system disease incidence. This facts support the hypothesis that AF can be a marker of higher degree of global sodium channel dysfunction and, consequently, more severe clinical manifestations.
End-points incidence
Total (n=278)
Group A (n=14)
Group B (n=264)
p-value
Non vaso-vagal syncope VF/polymorphic VT Monomorphic VT End-point (syncope þ VT/VF) Death during follow-up AF in follow-up Conduction system disease AV block 1st degree Average maximal PR duration (ms) Average maximal QRS duration (ms)
3.59% 7.2% 1.08% 11.87% 1.14% 4.3% 19.1% 11.2%
14.3% 28.6% 0.0% 35.7% 0.0% 21.4% 42.9% 28.6% 209.4 + 53.7
3.4% 6.0% 1.1% 10.6% 1.14% 3.4%% 17.8% 10.2% 189.8 + 32.7
0.09 0.012 ns 0.016 ns 0.017 0.032 0.051 ns
120.8 + 29.1
110.7 + 17.5
ns
786 Progression of atrial fibrillation after a failed initial ablation procedure in patients with paroxysmal atrial fibrillation: a randomized comparison of antiarrhythmic drug therapy vs re-ablation E Pokushalov1, A Romanov1, M De Melis2, S Artyomenko1, V Baranova1, D Losik1, S Bairamova1, A Karaskov1, S Mittal3, and JS Steinberg3 1 State Research Institute of Circulation Pathology, Novosibirsk, Russian Federation; 2 Medtronic BRC, Maastricht, Netherlands; and 3Columbia University, New York, United States of America Introduction: Antiarrhythmic drugs (AAD) are generally used as first-line therapy to treat patients with atrial fibrillation (AF), but effectiveness remains inconsistent.Catheter ablation has become an alternative therapy for patients with paroxysmal (P)AF, but patients may recur and receive AAD. The aim of this prospective, randomized study was to assess if an early re-ablation is superior to AAD therapy (control) in patients with previous failed pulmonary vein isolation (PVI) PAF, by means of the diagnostic data stored in a subcutaneous AF monitor. Methods: Patients with a history of symptomatic PAF eligible for AAD therapy or re-ablation after a previous failed initial ablation procedure involving only PVI were eligible for this study. Patients were randomized to AAD therapy or re-ablation procedure using a coded envelope system and were followed for 3 year to assess rhythm by means of an implanted cardiac monitor. Results: 154 patients had symptomatic AF recurrences after the blanking period post-ablation and were randomized to AAD therapy ( propafenone, flecainide and/or sotalol; N = 77) and to re-ablation (N = 77). At the end follow-up, 61 (79%) patients in AAD group and 19 (25%) patients in re-ablation group demonstrated AF% progression (increasing AF burden .30% from before randomization; p , 0.01). In AAD group AF% significantly increased compared with patients of re-ablation group: at 36 months AF% was 18.8 + 11.4% vs 5.6 + 9.5%, respectively ( p , 0.01). In addition, 18 (23%) patients in AAD group and 3 (4%) patients in reablation group progressed to persistent AF ( p , 0.01). Moreover, 45 (58%) of the 77 re-ablation group patients became AF/ AT-free on no antiarrhythmic drugs; in contrast, in the AAD group, only 9 (12%) of the 77 patients were AF/AT-free ( p , 0.01). Conclusions: In this prospective randomized controlled clinical trial, redo AF ablation was substantially more effective than AAD in reducing the progression and prevalence of AF after the failure of an initial ablation based on information derived from an implanted monitoring device.
787 Physical activity and risk of atrial fibrillation in men N Drca1, A Wolk2, M Jensen-Urstad1, and S C Larsson2 1 Karolinska Institute, Karolinska University Hospital, Huddinge, Department of Cardiology, Stockholm, Sweden; and 2Karolinska Institute, Institute of Environmental Medicine (IMM), Stockholm, Sweden Purpose: Several studies have reported that long-term regular sport activity elevates the risk for atrial fibrillation (AF). This study examines the influence of physical activity at different ages and of different intensity on the risk of developing AF. Methods: Information about physical activity was obtained from 44,410 AF-free men, aged 45—79 years (mean age 60), who had completed a self-administered questionnaire at baseline in 1997. Participants reported retrospectively their time spent on walking or bicycling for everyday transport (moderate intensity physical activity) and leisure-time exercise (high intensity physical activity) throughout their lifetime (at 15, 30, and 50 years of age, and at baseline). Participants were followed up in the Swedish National Inpatient Register for ascertainment of AF. Cox proportional hazards regression models were used to estimate relative risks (RR) with 95% confidence intervals (CI), adjusted for potential confounders. Results: During a mean follow-up of 9.9 years, 4563 cases of AF were diagnosed. We observed a 17% (95% CI 2%-33%) increased risk of developing AF in men who at age 30 years were engaged in exercise for .5h/week compared with ,1 h/wk. The risk was even higher (RR 1.37, 95% CI, 1.05-1.78) in the group who exercised .5h/week at age 30 and ,1 h/wk at baseline. Walking/bicycling at baseline was inversely associated with risk of AF (RR 0.89, 95% CI, 0.79-0.99 for .1 h/day vs. almost never) and the association was similar after excluding men with previous coronary heart disease at baseline (corresponding RR 0.88, 95% CI, 0.78-0.999). Conclusion: High intensity physical activity at younger age is associated with an increased risk of AF, whereas moderate intensity physical activity at older age is associated with a decreased risk.
Published on behalf of the European Society of Cardiology. All rights reserved. # The Author 2013. For permissions please email:
[email protected]
ii109
788 How well do electrophysiologists estimate the degree of quality of life impairment of their patients with paroxysmal atrial fibrillation? Results from the ANTIPAF Trial K-H Ladwig1, AV Eisenhart-Rothe1, TH Meinertz2, and A Goette3 1 Helmholtz Center Munich, Institute of Epidemiology, Munich, Germany; 2University Heart Center Hamburg, Clinic for General & Interventional Cardiology, Hamburg, Germany; and 3 St. Vincent’s Hospital, Paderborn, Germany Objectives: To assess the degree of congruence between patients’ and physicians’ assessments of the patients’ subjective health status, as an indicator of good communication and shared understanding. Methods: 334 patients with paroxysmal AF without significant concomitant heart diseases and their physicians were asked in a prospective blinded study to rate the patients’ HRQoL. The SF12 was used for self-ratings, the SF-8 for physician-ratings. Using baseline data, Intra-Class Correlations (ICC) and Bland-Altman graphs were used to assess concordance, cross-sectional multivariate regression analyses assessed patient characteristics associated with discordance. Results: On average, physicians rated their patients’ HRQoL higher than patients did (Dmental component score (MCS) =-3.23; p , 0.0001 and Dphysical component score (PCS) =-2.21; p=0.0001). ICCs and Bland-Altman graphs showed unsatisfactory concordance. Physical inactivity (D=4.84) had the greatest bivariate effect on PCS discordance and major depressive disorder (D=7.01) on MCS discordance. In the regression analyses, depression was significantly associated with discord in the MCS (b= -0.94; p , 0.001) and the PCS (b= -0.37; p , 0.002). Sleeping disorder was associated with discord in the MCS (b= -4.13; p , 0.002) and physical activity with discord in the PCS (b= -1.47; p=0.006). Conclusions: In AF-patients, depression, followed by sleeping disorder and physical inactivity were significantly associated with discordance. These findings should be considered by physicians when choosing treatment strategies.
789 Costs of complications for stroke prevention in atrial fibrillation patients, comparing warfarin to left atrial appendage closure L Da Deppo1, S Amorosi2, S Armstrong3, R Peppa4, S Garfield3, and K Stein5 1 Boston Scientific, Milano, Italy; 2Boston Scientific, Natick, United States of America; 3GfK Bridgehead, Wayland, MA, United States of America; 4Boston Scientific, Genova, Italy; and 5Boston Scientific, St, Paul, United States of America Objective: Major practice changes require both clinical and economic rationale, especially where a novel device replaces an established pharmaceutical therapy. Recent studies have reported the clinical benefits of percutaneous left atrial appendage closure (LAAC) for stroke prevention in atrial fibrillation (AF) relative to standard warfarin anticoagulation, but little is published on the cost implications of LAAC. This analysis explores the costs of complications associated with LAAC versus warfarin for stroke prevention in AF. Methods: An Excel-based cost impact model was developed using data from the PROTECT-AF clinical trial which randomized 707 AF patients to either LAAC or warfarin (Holmes 2009). The model captured the costs of complications in stroke prevention in AF, including stroke, systemic embolism, major extracranial bleeding and procedure-related complications. Costs for stroke included acute, direct costs as well as long-term disability costs. The UK, with its established history of using economic methods in healthcare policy decisions, was the basis for this analysis. Cost inputs were taken from 2012 HRG and pharmaceutical data as well as the literature. Results: Over 5 years, the mean cost of complications for LAAC is 60% that of warfarin (£3,865 versus £6,781, [˜$6,190 versus˜$10,861]). Conclusion: The complication cost differential is large and highlights the need for decision makers to consider not only the clinical implications of lifetime strategies for stroke prevention in AF but also the long-term costs of sequalae. LAAC represents an opportunity for substantial savings to health-care systems.
Complications
Ischemic Stroke Hemorrhagic Stroke Major Bleeding Systemic Embolism
Rate Per 100 Patient Years LAAC
Warfarin
Mean Cost Per Patient (Over 5 Years) LAAC Warfarin
1.3 0.1 3.5 0.3
1.6 1.6 4.1 0
£2892 £185 £282 £32
NA NA NA
Mean Cost Per Patient £358 £0 £99 £0 £17 £0
Peri-Procedural Complications
Rate
Ischemic Stroke Pericardial Effusion Device Embolization
0.9 4.8 0.6
£4812 £1393 £576 £0
