Abstract Objectives To investigate whether polygenic risk score for coronary artery disease (CAD-PRS) can guide the initiation of lipid-lowering treatment as well as deferral beyond the statin eligibility criteria. Methods 311,799 individuals aged 40 to 73 years and free of atherosclerotic cardiovascular disease (ASCVD), diabetes, chronic kidney disease, and lipid-lowering treatment at baseline were included from the UK Biobank. Participants were categorized by statin eligibility using the European and US guidelines on statin use. Results For a median (IQR) follow-up of 11.9 (11.2-12.6) years, 8,196 individuals experienced major coronary events. CAD-PRS added to European-SCORE2 and US-PCE models identified 18% and 12% of individuals with class II indication for statin use whose risk of major coronary events were same or higher than the average risk of those with class I indication and 16% and 12% of individuals with class I indication whose major coronary event risks were same or lower than the average risk of those with class II indication. For ASCVD events, CAD-PRS added to European-SCORE2 and US-PCE models resulted in a net reclassification improvement of 13.6% (95% CI 11.8 to 15.5) and 14.7% (95% CI 13.1 to 16.3) among class I indicated, 10.8% (95% CI 9.6 to 12.0) and 15.3% (95% CI 13.2 to 17.5) among class II indicated, and 0.9% (95% CI 0.6 to 1.3) and 3.6% (95% CI 3.0 to 4.2) among class III indicated individuals. Conclusions CAD-PRS may guide statin initiation as well as deferral among individuals with class I and class II indication for statin use as defined by the European and US guidelines. However, the CAD-PRS had little clinical utility among individuals who were not eligible for statins.
Abstract Funding Acknowledgements Type of funding sources: None. Background Preventive therapy for atrial fibrillation (AF) is lacking, and association between hyperlipidemia and incident atrial fibrillation has been reported. We examined whether measured and genetically predicted low density lipoprotein cholesterol (LDL-C) can detect incident atrial fibrillation (AF) independent of clinical risk for AF. Methods A total of 339,023 individuals aged 39 to 73 without pre-existing ASCVD (coronary artery disease, ischemic stroke or transient ischemic attack, peripheral artery occlusive disease) and AF were included from the UK biobank. Clinical risk for AF was based on tertiles of CHARGE-AF (Cohorts for Heart and Aging Research in Genomic Epidemiology- Atrial Fibrillation) score. We calculated the risk of incident AF per SD increase in measured and genetic LDL, and its association with CHARGE-AF. Results Over a median 11.9 (11.2-12.6) years, the primary outcome occurred in 17,504 patients. Among those with low, moderate, and high CHARGE-AF, each SD increase in measured LDL-C was associated with hazard ratio of 1.09 (95% CI 0.85-1.38, p=0.502), 1.32 (95% CI 1.13-1.54, p<0.001), and 1.23 (95% CI 1.12-1.37, p<0.001). Among these same categories, each SD increase in genetic LDL-C was associated with hazard ratios of 1.10 (95% CI 1.04-1.16, p<0.001), 1.07 (95% CI 1.03-1.11, p<0.001), and 1.05 (95% CI 1.03-1.07, p<0.001). Among those with normal LDL, untreated hyperlipidemia, and treated hyperlipidemia, each SD increase in genetic LDL-C was associated with hazard ratios of 1.11 (95% CI 1.04-1.18, p=0.001), 1.07 (95% CI 1.05-1.09, p<0.001), and 1.02 (0.99-1.05, p=0.25). Conclusion LDL cholesterol polygenic risk score may augment identification of individuals at heightened AF risk, including those with low CHARGE-AF or normal LDL-C. Whether it may also guide antilipidemic initiation or intensification requires further study.
Abstract Funding Acknowledgements Type of funding sources: None. Background and Aims Adverse outcomes associated with atrial fibrillation (AF) in Asians have not been fully elucidated. In a patient-level comparative analysis of UK Biobank and Korean National Health Insurance Service-Health Screening data, we evaluated the race-specific associations of AF with stroke and mortality. Methods This study enrolled 425,805 Asians (mean [SD] age, 56.0 [9.3] years; 55.3% of men) and 372,851 Whites (mean [SD] age, 57.1 [8.0] years; 47.6% of men). The main outcomes were total, ischemic, and hemorrhagic strokes and all-cause death. Results During the follow-up period (mean [SD], 7.3 [1.4] years in Asians; 11.7 [1.5] years in Whites), the incident rates (IR) of AF per 1000 person-years were 2.6 (95% CI, 2.5–2.7) in Asians and 4.4 (95% CI, 4.3–4.5) in Whites. The IR of total, ischemic, and hemorrhagic strokes were greater in Asians with AF than in Whites with AF. The rate difference (IR of the outcome in those with AF minus IR of the outcome in those without AF) for total stroke was 15.2 (95% CI, 13.4–17.0) in Asians and 4.5 (95% CI, 4.0–5.0) in Whites. For ischemic and hemorrhagic strokes, the rate differences were 2.5- to 3.5-fold higher in Asians than in Whites. Asians had a rate difference of 26.3 (95% CI, 24.2–28.4) for all-cause death, whereas Whites had a rate difference of 20.7 (95% CI, 19.7–21.7). Conclusion Despite the higher incidence of AF in Whites, the outcomes of AF-related rates of total, ischemic, and hemorrhagic strokes and all-cause death was greater in Asians than Whites.
Abstract Background Atrial fibrillation (AF) increases the risks of stroke and mortality. AF ablation in patients with heart failure (HF) was associated with a lower risk of death and hospitalisation for worsening HF. Whether AF ablation is beneficial to improve cardiovascular outcomes in patients with concomitant hypertrophic cardiomyopathy (HCM) and AF remains unclear. Objective To investigate whether AF ablation is more effective than conventional medical therapy for improving outcomes in HCM. Methods 2,281 patients with HCM and AF undergoing catheter ablation or medical therapy (antiarrhythmic drugs or rate control drugs) in 2005–2015 were identified from the Korean National Health Insurance Service database. The primary composite outcome of death from cardiovascular causes, ischaemic stroke, hospitalization for worsening HF, or acute myocardial infarction was compared between catheter ablation and medical therapy using propensity score overlap weighting. The time-at-risk was counted from the first medical therapy, and catheter ablation was analysed as a time-varying exposure. Results Of the included (41.1% female; median age: 66 years), 145 (6.1%) underwent catheter ablation for AF during the study period. During a mean follow-up of 3.1 (IQR 1.3–5.8) years, a total of 831 composite outcomes occurred including 292 cardiovascular deaths and 401 strokes. Catheter ablation, compared with medical therapy, was associated with lower risks of the primary composite outcome (weighted incidence rate: 3.84 vs. 6.43 per 100 person-years; weighted HR 0.61, 95% CI 0.38–0.96) and ischaemic stroke (weighted HR 0.43, 95% CI 0.19–0.97). The association between ablation and a lower risk of composite outcome was more pronounced in cases of ablation success whereas no significant difference was observed in cases of ablation failure. Conclusions In patients with AF and HCM, catheter ablation was associated with a lower risk of adverse cardiovascular outcomes than medical therapy.
Abstract Objectives Although Left Bundle Branch Area Pacing (LBBAP) is emerging conduction system pacing modality, it is unclear which parameters are predictive of procedural success and how many screwing attempts are acceptable. This retrospective observational study sought to assess predictors of successful LBBAP, left bundle branch (LBB) capture, and factors associated with the number of screwing attempts. Methods We performed a multicenter retrospective analysis of 120 patients who underwent LBBAP with stylet driven lead. We analyzed factors affecting the number of screwing attempts and procedural success. Procedural, 12-lead ECG, echocardiographic parameters and clinical variables were used in multivariate analyses. Results LBBAP success rate was 95.8% (115/120), and LBB capture success rate was 86.1% (99/115). Few screwing attempts was associated with procedural success (2.1 ± 1.2, 2.7 ± 1.2, and 3.5 ± 1.3 in LBBAP with LBB capture, LBBAP without LBB capture and failed LBBAP group, respectively) (p for trends=0.03). 4 or more screwing attempt was independently associated with higher complication rate compared to fewer screwing attempt (n≤3) (p<0.05). The larger RA size (B = 1.901, 95% confidence interval [CI] 1.07 - 2.73, p <0.001), smaller RV size (B = -0.995, 95% CI -1.88 - -0.31, p = 0.007), and intraventricular conduction delay (IVCD) at pre-implant ECG were independently associated with more screwing attempts. Larger RA size (4th quartile) was associated with larger final sheath size and frequent sheath size change to larger sheath when compared to others. Conclusions More screwing attempts was associated with failed LBBAP procedure and failed LBB capture, and 4 or more screw attempts was associated with higher complication rate. Larger the RA size, smaller the RV size, and IVCD in pre-implant ECG are predictive of more screwing attempt.
Abstract Funding Acknowledgements Type of funding sources: None. Purpose We compared the efficacy, safety, and heart rate variability (HRV) after cryo-balloon (Cryo-PVI), high-power short-duration (HPSD-PVI) or conventional radiofrequency pulmonary vein isolation (conventional-PVI) in patients with atrial fibrillation (AF). Methods In this retrospective analysis of single-center cohort, we included 2,975 patients who underwent AF catheter ablation (74.1% male, median 60 years old, 74.1% paroxysmal AF). We compared the procedural factors, rhythm outcomes, complication rates, and post-procedural heart rate variability (HRV) between the Cryo-PVI (n=493), HPSD-PVI (n=638), and conventional-PVI (n=1,844). Results In spite of significantly shorter procedural time in the Cryo-PVI group (73 min for Cryo-PVI vs 110 min for HPSD-PVI vs 153 min for conventional-PVI, p<0.001), major complication (2.8% for Cryo-PVI vs 2.4% for HPSD-PVI vs 2.5% for conventional-PVI, p=0.875) or freedom from late recurrence (log-rank, p=0.357) did not differ among the three ablation groups. Cryo-PVI showed significantly lower risk for AF recurrence in patients with paroxysmal AF (weighted hazard ratio [WHR] 0.62, 95% confidence interval [CI] 0.41-0.93), but worse rhythm outcome in those with non-paroxysmal AF (WHR 1.47, 95% CI 1.06-2.05, p for interaction=0.002) as compared with conventional-PVI. In the subgroup analysis for HRV (n=1,429), Cryo-PVI group showed significantly higher low-frequency to high-frequency ratio at post-procedure 3 month (p<0.001), 1-year (p<0.001), and 2-year (p=0.023). Conclusion Cryo-PVI showed better rhythm outcome in patients with paroxysmal AF, but worse outcome in those with non-paroxysmal AF with higher long-term post-procedural sympathetic nervous activity as compared with conventional-PVI.
To evaluate the short- and long-term efficacy and safety of abciximab and cilostazol in patients with acute MI and unstable angina undergoing intracoronary stenting.Acute-phase (7 and 30 days), 6-month and long-term composite outcomes involving death, myocardial infarction or urgent target vessel revascularization (TVR) together with other outcomes (composite outcomes involving death, MI and elective TVR with restenosis and stroke) were evaluated retrospectively in a total of 175 patients. Safety outcomes were assessed using data on the incidence of bleeding and thrombocytopenia at Day 7 and Day 30.Of 175 patients, 83 (47.4%) patients received abciximab. At 7 and 30 days, the composite outcome for the group treated with cilostazol alone and that treated with abciximab in combination with cilostazol did not differ significantly. The composite outcomes at 6 months and 1 year were significantly lower in the abciximab plus cilostazol group (relative risk 0.35, 95% Cl 0.13 - 0.90, relative risk 0.28, 95% CI 0.10 -0.78, respectively). The incidence of major bleeding at the access-site and in the gastrointestinal tract and minor bleeding were significantly higher in the group receiving abciximab plus cilostazol group at 7 days (relative risk 3.33, 95% CI 1.66 - 6.65, relative risk 9.98, 95% CI 1.29 - 77.07, relative risk 1.96, 95% CI 1.06 - 3.62, respectively) and at 30 days (relative risk 3.33, 95% CI 1.66 - 6.65, relative risk 5.54, 95% CI 1.25 - 24.56, relative risk 1.96, 95% CI 1.06 - 3.62, respectively).The combination of abciximab and cilostazol showed an improvement in major cardiac incidents at 6 months and 1 year of the treatment when compared to the group receiving cilostazol alone. However, abciximab did not improve the incidence of death but increased the risk of bleeding complications.
Abstract Funding Acknowledgements Type of funding sources: None. Background There is a genetic background in pulmonary vein (PV) development and atrial fibrillation (AF). However, the genetic trait of PV variations and their rhythm outcome after AF catheter ablation (AFCA) is unclear. Objective We explored the genetic and clinical characteristics and long-term rhythm outcomes of AF patients with PV variation or left common trunkus (LCT)-PV. Methods We included 2,897 AF patients (74.0% male, age 59.0 ± 10.7 years, 66.3% paroxysmal AF) with available genome-wide association study results, cardiac computed tomogram data, and protocol-based regular rhythm follow-up from the Yonsei AF ablation cohort database. We defined LCT-PV when the upper and lower PV separate at >10 mm distal to the left PV antrum margin. PV variations included both LCT-PV and accessory PVs. We analyzed the polygenic risk score (PRS) of 12 AF-associated genes (DSP, GJA1, HCN4, KCNQ1, NPPA, PITX2, RYR2, SCN5a, SHOX2, ATP2A2, TBX3, and TBX5) and long-term rhythm outcomes after AFCA. Results We found PV variation in 296 (10.2%) and LCT-PV in 102 (3.5%). PRS of 1,227 single nucleotid polymorphisms (SNPs) was significantly higher in PV variation patients (p=4.93e-08) and LCT-PV patients (p=1.95e-20). The patients with LCT-PV had higher CHA2DS2VASc scores (p=0.024) and lower atrial epicardial adipose tissue volume (p=0.034). During 39.7 ± 34.8 months follow-up period, LCT-PV patients had a significantly higher recurrence rate than their counter part in the paroxysmal AF sub-group (Log-rank p=0.036), but not in overall PV variations. LCT-PV with the highest 10% PRS was independently associated with AF recurrence after AFCA (HR 2.10, 95% CI 1.21-3.63, p=0.008). Conclusions Among the patients who underwent AFCA, PV variation, including LCT-PV, has a significant genetic background. The post-AFCA recurrence rate was significantly higher in patients with LCT-PV and high PRS, especially in paroxysmal AF.
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