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Special Issue:Atrial fibrillation

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1. The Impact of Home-based Exercise Rehabilitation Compliance on the Recurrence of Atrial Fibrillation after Radiofrequency Ablation
WANG Jie, SUN Guozhen, WANG Qin, BAO Zhipeng, GAO Min, WANG Lin
Chinese General Practice    2025, 28 (12): 1494-1499.   DOI: 10.12114/j.issn.1007-9572.2024.0067
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Background

Although exercise rehabilitation has been proven to be safe and effective for cardiovascular patients, compliance remains suboptimal. The sustained benefits of exercise are closely related to compliance, yet current research has failed to delineate the relationship between exercise compliance and the recurrence of atrial fibrillation (AF) in patients undergoing radiofrequency ablation.

Objective

To investigate the impact of adherence to home-based exercise rehabilitation programs and other relevant factors on the recurrence of atrial fibrillation in patients following radiofrequency ablation.

Methods

Convenience sampling was used to select patients with AF who underwent radiofrequency ablation surgery in the Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University from May to November 2020. Patients routinely underwent a 6-minute walk test, balance and flexibility assessments, and cardiopulmonary exercise testing, and individualized exercise prescriptions were formulated based on the assessment results. General patient data were collected, and exercise rehabilitation compliance was assessed using the Cardiac Rehabilitation Inventory (CRI) to evaluate the cardiac rehabilitation needs and willingness of patients with cardiovascular diseases, and the Patient Activation Measure (PAM13) was used to measure the level of knowledge, skills, behaviors, and confidence in participating in their own health management and health care during the disease diagnosis and treatment process. Compliance data on intensity-time and frequency were followed up at the 1st week, 3rd month, 6th month, 9th month, and 12th month. The generalized estimating equations (GEE) model was used to explore the influencing factors of the recurrence of AF in patients after radiofrequency ablation surgery.

Results

A total of 151 patients aged 29 to 84 years, with an average age of (61.7±11.0) years, and 23 patients experienced a recurrence of AF. The changes in intensity-time compliance and frequency compliance of AF patients after radiofrequency ablation surgery at different follow-up stages were statistically significant (P<0.05). After controlling for time, BMI, smoking, type of AF, activation, process anxiety, and outcome anxiety, the GEE analysis showed that intensity-time compliance≥100% was a protective factor for the recurrence of AF after radiofrequency ablation surgery (P<0.05) .

Conclusion

The compliance with home-based exercise rehabilitation in AF patients after radiofrequency ablation surgery changes over time, and it is recommended that clinical medical staff pay attention to the guidance and supervision of exercise intensity, take targeted measures to reduce process and outcome anxiety, in order to more effectively improve patient outcomes through exercise rehabilitation.

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2. Latent Profile Analysis and Its Influencing Factors of Physical Activity in Patients with Atrial Fibrillation
YOU Zhanhong, SUN Guozhen, LU Jing, TANG Zhijie, WANG Jie, WANG Qin, WANG Lin
Chinese General Practice    2025, 28 (12): 1486-1493.   DOI: 10.12114/j.issn.1007-9572.2024.0236
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Background

Physical activity is the focus of disease management in patients with atrial fibrillation (AF), and different types and intensities of physical activity have different impacts on the health status of patients; however, the current distribution of physical activity types in patients with AF is not clearly characterized.

Objective

To explore differences in the distribution of the daily physical activity energy expenditure in patients with AF and the influencing factors.

Methods

A total of 300 AF patients newly admitted to the Department of Cardiology Medicine at the First Affiliated Hospital with Nanjing Medical University for elective catheter ablation from July to December 2023 were enrolled. General patient information was collected. The International Physical Activity Questionnaire-Long Form (IPAQ-L) was used to assess the level of physical activity, the Fear of Progression Questionnaire-Short Form (FoP-Q-SF) to evaluate fear of disease progression, the Cancer Acceptance Scale-Revised (CAS-R) to assess perceived control, and the Family Apathy Index (FAI) to gauge family care. A latent profile analysis was conducted on energy expenditure from various types of physical activity among AF patients. Starting from a one-class model, the number of classes was incrementally increased to determine the best-fitting model. Multivariate Logistic regression analysis was employed to investigate the impact of various factors on different latent profiles.

Results

Based on IPAQ-L scores, 80 patients (26.7%) had low, 63 (21.0%) had moderate, and 157 (52.3%) had high levels of physical activity. The latent profile analysis of patients' physical activity energy expenditure categorized them into two profiles: low energy expenditure-primarily sedentary (n=198) and high energy expenditure-primarily occupational physical activity (n=102). Univariate analysis revealed statistically significant differences in age, education level, occupation, family monthly income per capita, and scores on the FoP-Q-SF, CAS-R, and FAI between the two profiles (P<0.05). Multivariate Logistic regression analysis indicated that age 40-59 years (OR=0.280, 95%CI=0.087-0.899, P=0.017), bachelor's degree or higher (OR=0.331, 95%CI=0.124-0.883, P=0.027), mental labor (OR=0.315, 95%CI=0.121-0.817, P=0.032), retirement (OR=0.151, 95%CI=0.050-0.452, P<0.001), FoP-Q-SF score (OR=1.086, 95%CI=1.036-1.139, P<0.001), CAS-R score (OR=0.899, 95%CI=0.820-0.985, P=0.022), and FAI score (OR=0.828, 95%CI=0.707-0.969, P=0.018) were influencing factors of the latent profiles of physical activity (PA) energy expenditure (P<0.05) .

Conclusion

There are different latent profiles of physical activity energy expenditure among AF patients, with heterogeneous distribution characteristics across profiles. Patients aged 40-59, with bachelor's degree or higher, engaged in mental labor, retired, possessing strong perceived control, and receiving high family care are more likely to be classified as low energy expenditure-primarily sedentary. Interventions can be tailored based on the characteristics of different physical activity energy expenditure profiles and influencing factors to promote appropriate and scientific physical activity.

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3. Research Progress of Perioperative Symptoms and Management Strategies in Patients Undergoing Catheter Ablation for Atrial Fibrillation
BAO Zhipeng, LI Yunxia, WANG Jie, TANG Zhijie, YOU Zhanhong, HE Ying, SUN Guozhen
Chinese General Practice    2025, 28 (12): 1479-1485.   DOI: 10.12114/j.issn.1007-9572.2024.0337
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The burden of atrial fibrillation (AF) in China is increasing, and catheter ablation has become a first-line treatment. The perioperative symptom clusters of AF patients undergoing catheter ablation are complex and diverse, closely related to patients´ quality of life, disease prognosis, and healthcare resource utilization, and therefore, warrant significant attention. This paper systematically reviews the research related to the perioperative symptom clusters of AF patients undergoing catheter ablation. It introduces the types and current status of these symptom clusters, summarizes the influencing factors of perioperative symptom clusters, organizes the assessment tools for AF symptom clusters, and finally elucidates the management strategies for perioperative symptom clusters in AF patients. The goal is to provide insights for developing innovative comprehensive management models for perioperative symptom clusters in AF patients.

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4. Correlation between Triglyceride Glucose Index and Atrial Fibrillation in Patients with Chronic Heart Failure
BAI Lu, ZHANG Qiang, LIU Fangfang, SUN Caihong, FEI Sijie, XIN Caifeng
Chinese General Practice    2025, 28 (06): 720-728.   DOI: 10.12114/j.issn.1007-9572.2024.0100
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Background

Insulin resistance (IR) is associated with atrial fibrillation (AF) and atrial remodeling, and the correlation of triacylglycerol glucose (TyG) index, a novel, simple, and valuable indicator of IR, with the development of AF in patients with chronic heart failure (CHF) has been poorly studied.

Objective

To investigate the correlation between TyG index and AF in patients with CHF.

Methods

A total of 417 CHF patients hospitalized in the Department of Cardiovascular Medicine of the Second Affiliated Hospital of Zhengzhou University from January 2021 to January 2022 were retrospectively selected for the study, and the CHF patients were divided into two groups according to whether they developed AF: the AF group (138 patients) and the non-AF group (279 patients). The TyG index was categorized into four levels based on quartiles: Q1 (TyG index ≤8.20), Q2 (8.20<TyG index≤8.44), Q3 (8.44<TyG index≤8.84), and Q4 (TyG index>8.84). Patients' baseline data, including TyG index and basic information, laboratory test indexes, and echocardiographic data, were collected through the hospital's electronic medical record system. The LASSO regression algorithm was used for variable screening, and multivariate Logistic regression was used to analyze the correlation between TyG index and the risk of AF occurrence in patients with CHF and to construct a regression model. The predictive value of TyG index for the occurrence of AF in CHF patients was also analyzed using the subject work characteristics curve. Restricted cubic spline plots of the correlation between TyG index and the risk of developing AF in CHF patients were plotted.

Results

Patients in the AF group had higher BMI, New York Heart Association cardiac function class Ⅲ-Ⅳ, proportion of hypertension, serum uric acid (SUA), triacylglycerol, blood urea nitrogen (BUN), fasting blood glucose, N-terminal B-type natriuretic peptide precursor, TyG index, left atrial diameter (LAD), the proportions of β-blockers, calcium antagonists, and diuretics were higher than those in the non-AF group; total cholesterol (TC), endogenous creatinine clearance (Ccr), left ventricular ejection fraction, and the proportion of angiotensin-converting enzyme inhibitors/angiotensin Ⅱ receptor blockers (ACEI/ARB) class of drug use was lower than that of the non-AF group (P<0.05). The results of multivariate Logistic regression analysis showed that the combination of hypertension (OR=1.749, 95%CI=1.048-2.918, P=0.032), elevated BUN (OR=1.269, 95%CI=1.104-1.457, P=0.001), elevated SUA (OR=1.002, 95%CI=1.000-1.005, P=0.047), elevated TyG index (OR=2.360, 95%CI=1.397-3.987, P=0.001), elevated LAD (OR=1.065, 95%CI=1.034-1.097, P<0.001), and use of diuretics (OR=4.019, 95%CI=2.140-7.548, P<0.001) were risk factors for the development of AF in patients with CHF; Ccr (OR=0.985, 95%CI=0.975-0.996, P=0.006), TC (OR=0.587, 95%CI=0.445-0.775, P<0.001), and the proportion of ACEI/ARB class of drug (OR=0.427, 95%CI=0.253-0.718, P= 0.001) were protective factors for the development of AF in patients with CHF. After fully adjusting for confounders, the risk of AF occurrence in CHF patients at the Q2, Q3, and Q4 levels of TyG index was 1.902, 2.060, and 2.841 times higher than that at the Q1 level (P<0.05). Restricted cubic spline analysis showed a linear positive correlation between TyG index and the risk of developing AF (Pnonlinear=0.494). The area under the curve of TyG index and LASSO-Logistic regression model for predicting the development of AF in patients with CHF were 0.661 (95%CI=0.608-0.724, P<0.001), 0.843 (95%CI=0.803-0.882, P<0.001). In addition, the correlation between TyG index and AF was consistent across subgroups.

Conclusion

The TyG index is independently associated with the AF in patients with CHF, with significant clinical value in predicting AF.

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5. Analysis of the Current Status of Atrial Fibrillation Epidemiological Survey in Shihezi Area of Xinjiang Corps
ZHANG Qiang, TANG Min, GUANG Yajie, LIU Dan, ZHAO Xueyan, ZHAO Yuanyuan, ZHANG Lin, NUERBAHETI
Chinese General Practice    2024, 27 (33): 4162-4167.   DOI: 10.12114/j.issn.1007-9572.2024.0050
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Background

Atrial fibrillation (AF) is a common clinical arrhythmia characterized by high prevalence, high disability rate, and high treatment costs, severely affecting patients' quality of life. Currently, there is no large-scale epidemiological survey on the prevalence of AF in the Xinjiang Corps region.

Objective

To further understand the prevalence, associated risk factors, and standardized treatment status of AF in the Shihezi area of the Xinjiang Corps, this study aims to provide reliable data support for the prevention, management, and treatment of AF in this region.

Methods

A cross-sectional age-stratified random sampling survey was conducted from May 2021 to June 2023 among 63 079 permanent residents aged 18 years and above in 18 pastoral and agricultural groups and urban areas of the Shihezi area of the Xinjiang Corps. A questionnaire was used to collect baseline data, epidemiological information, awareness, and treatment status of AF. Patients were divided into an AF group (n=737) and a non-AF group (n=62 342). Multifactorial Logistic regression analysis was used to explore the influencing factors of AF occurrence.

Results

A total of 63 079 residents from the Shihezi area of the Eighth Division of the Xinjiang Corps were included, with an average age of (54.9±15.3) years. A total of 737 AF patients were identified, with a prevalence rate of 1.17%, and an age-adjusted prevalence rate of 1.12%. The awareness rate of AF in the screened population was only 1.62% (1 021/63 079), of which the awareness rate among diagnosed AF patients was 52.78% (389/737). The prevalence rates of AF in the 18-39, 40-49, 50-59, 60-69, 70-79, and ≥80 years age groups were 0.05% (5/9 964), 0.32% (29/9 076), 0.62% (135/21 686), 1.28% (151/11 810), 3.05% (207/6 776), and 5.57% (210/3 767), respectively. The prevalence rates of AF in males and females were 1.60% (441/27 591) and 0.83% (296/35 488), respectively. The prevalence rates of AF among Han, Hui, Uyghur, Kazakh, and other ethnic groups were 1.20% (720/60 014), 0.70% (7/1 007), 0.62% (7/1 130), 1.67% (2/120), and 1.41% (1/171), respectively. The prevalence rates of AF in urban and pastoral and agricultural areas were 0.79% (350/44 504) and 2.08% (387/18 575), respectively. There were statistically significant differences in age, gender, age group distribution, residential area, and education level between the AF and non-AF groups (P<0.05). The prevalence of smoking, alcohol consumption, hypertension, coronary heart disease, type 2 diabetes, hyperlipidemia, chronic heart failure, cerebrovascular diseases, valvular heart disease, chronic pulmonary disease, sleep apnea syndrome, thyroid dysfunction, peripheral vascular disease, and tumors was higher in the AF group than in the non-AF group (P<0.05). Multifactorial Logistic regression analysis showed that age, gender, alcohol consumption, hypertension, valvular heart disease, chronic heart failure, thyroid dysfunction, sleep apnea syndrome, and tumors were influencing factors for the occurrence of AF (P<0.05). There were 85 newly diagnosed cases of AF (11.53%), 257 paroxysmal AF cases (34.87%), 178 persistent AF cases (21.16%), and 217 permanent AF cases (29.44%) ; 360 cases received oral anticoagulant therapy, and 23 cases underwent radiofrequency ablation or one-stop treatment for AF, with a treatment rate of 51.96% in this region. Among AF patients, the rates of standardized treatment, non-standardized treatment, and no treatment were 360 cases (48.85%), 21 cases (2.85%), and 356 cases (48.30%), respectively. The standardized treatment rates for newly diagnosed AF, paroxysmal AF, persistent AF, and permanent AF were 11.11%, 28.89%, 24.72%, and 35.28%, respectively. There was a statistically significant difference in the standardized treatment rates among different types of AF (χ2=18.918, P=0.004) .

Conclusion

The prevalence rate of atrial fibrillation in Shihezi area of Xinjiang Corps is basically the same as that of the whole country, and the risk factors are similar to domestic and foreign studies. However, the awareness rate of atrial fibrillation and the standardized treatment rate of atrial fibrillation in the population are obviously low, and the situation is not optimistic.

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6. Updated Progress and Challenges in the Application of Wearable/Mobile Devices in the Management of Silent Atrial Fibrillation
GAO Chenxi, CHEN Defang, CHEN Qingyong, SHEN Can, LIAO Xiaoyang
Chinese General Practice    2024, 27 (30): 3835-3840.   DOI: 10.12114/j.issn.1007-9572.2023.0755
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Atrial fibrillation (AF) is among the most prevalent types of arrhythmia, leading to severe complications such as heart failure and stroke, thus increasing rates of mortality and disability. Silent AF, which lacks clinical symptoms and has irregular onset, tends to have a low diagnosis rate and often experiences delays in receiving standardized treatments, resulting in negative clinical outcomes. Recent clinical studies highlight the significant benefits of wearable devices in the screening and management of silent AF. In this article, we review the clinical outcomes, cost-effectiveness, challenges and future application prospects of wearable devices in the detection and management of silent AF based on relevant domestic and international literature of recent years to provide more evidence-based support for its further applications.

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7. Treatment Strategies for Atrial Fibrillation with Long Interval: Consensus and Controversy
WANG Xiaorui, ZHENG Ruoyao, SUN Fengzhi, ZHANG Shulong
Chinese General Practice    2024, 27 (27): 3331-3335.   DOI: 10.12114/j.issn.1007-9572.2023.0826
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Atrial fibrillation (AF) is the most common arrhythmia in cardiovascular disease, and it often coexists and interacts with sick sinus syndrome. In the past, pacemaker implantation combined with antiarrhythmic drugs was preferred for symptomatic atrial fibrillation with long interval treatment. However, in recent years, more and more studies have shown that compared with pacemaker implantation, radiofrequency ablation can reduce the hospitalization rate related to tachycardia, effectively control atrial fibrillation, and improve patient prognosis and hospitalization rate of heart failure. However, some patients present intrinsic sinus node dysfunction (SND), and SND may progress and worsen in some patients with atrial fibrillation. Therefore, the first-line treatment strategy for patients with atrial fibrillation with long interval remains controversial. This article reviews the selection of long-term intermittent treatment strategies for atrial fibrillation.

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8. Reasons for Refusal of Exercise Rehabilitation in Patients after Radiofrequency Ablation of Atrial Fibrillation in the Context Digital Medical Care: a Qualitative Research
TANG Zhijie, SUN Guozhen, GAO Min, WANG Jie, BAO Zhipeng, YANG Gang, WANG Lin, WANG Qin
Chinese General Practice    2024, 27 (18): 2218-2224.   DOI: 10.12114/j.issn.1007-9572.2023.0478
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Background

Telerehabilitation based on digital medical care can efficiently improve the health status of patients after radiofrequency ablation of atrial fibrillation. However, the current participation rate in telerehabilitation is low.

Objective

To analyse the reasons for refusal of exercise rehabilitation in patients after radiofrequency ablation of atrial fibrillation in the context digital medical care based on the theory of leisure constraints.

Methods

Patients after radiofrequency ablation of atrial fibrillation in the inpatient department or outpatient clinic of Department of Cardiology, at the First Affiliated Hospital of Nanjing Medical University from July to September 2022 were selected as the study subjects by using the purposive sampling method. The phenomenological approach was adopted to collect data from patients who refused exercise telerehabilitation after radiofrequency ablation through semi-structured interviews, and Colaizzi analysis was used to summarize the reasons.

Results

A total of 14 patients were finally included in this study. Three themes including self-limiting factors, interpersonal limiting factors, and structural limiting factors, and twelve sub-themes were extracted, namely, low level of digital literacy, negative illness perception, psychological distress caused by disease, digital medical trust crisis, deep-rooted personal exercise habits, alienation sense from rehabilitation team, insufficient social network establishment, economic burden related to equipment acquisition, harsh climate, low rehabilitation service capacity in primary care, constraints of available time by role pressure, and poor applicability of wearable devices.

Conclusion

The reasons for refusal to exercise telerehabilitation include lack of literacy and trust in digital medical care, high level of illness perception and psychological distress, poor exercise habits, rehabilitation team and peer alienation, economic burden, harsh climate, lack of capacity and personal time for rehabilitation service capacity in primary care, and inadequate applicability of existing wearable devices.

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9. Analysis of the Effectiveness of Different Atrial Fibrillation Screening Methods in the Community-based Elderly Population
SHI Yushuang, WANG Huihua, LI Yan, LU Ping, SONG Wei, PAN Guijun
Chinese General Practice    2024, 27 (11): 1316-1319.   DOI: 10.12114/j.issn.1007-9572.2023.0723
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Background

Older adults are at high risk for atrial fibrillation (AF). Improving the efficiency of AF screening among the community-based elderly population can help to reduce the risk of AF-related stroke.

Objective

To compare the screening efficiency of different AF screening methods in the elderly population.

Methods

A total of 1 300 cases of older adults were selected from three neighborhood committees of Xiangshan, Huangshan, and Luoshan in Jinyang Community, Pudong New Area, Shanghai from July 2022 to January 2023. AF screening was detected using palpation of radial artery pulse, electronic sphygmomanometer with AF detection function, and single-lead ECG recorder. A positive result of any one of the three methods was considered positive for AF, and finally an electrocardiogram (ECG) was performed and interpreted by a physician in the ECG room. The receiver operating characteristic (ROC) curves of the subjects with different screening methods were plotted, the area under the ROC curve (AUC) was calculated to evaluate the screening value; the association between AF stroke score (CHA2DS2-VASc score) and AF was analyzed using the chi-square test for trend.

Results

AF was detected in 93 of the 1 300 people, including 57 asymptomatic people; 375 people had a positive palpated pulse, 331 people had a positive electronic blood pressure monitor with AF detection function, and 128 people had a positive result of single-lead ECG recorder. The AUCs for the diagnostic value of palpation pulse, electronic sphygmomanometer with AF detection function and single-lead ECG recorder in the elderly was 0.750 (95%CI=0.697-0.803, P<0.01), 0.832 (95%CI=0.790-0.874, P<0.01), 0.939 (95%CI=0.906-0.973, P<0.01) ; the incidence of AF in the elderly gradually increased as the CHA2DS2-VASc score increased (χ2trend=197.46, P<0.01) .

Conclusion

Screening for AF using single-lead ECG recorder is convenient, efficient and accurate, and can be promoted in AF screening among community-based elderly population.

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10. Relationship between Cardiovascular Health Score of Life's Essential 8 and New-onset Atrial Fibrillation: a Large Sample, Long-Term Follow-up Study
ZHANG Yuan, HOU Qiqi, QI Qi, JIANG Yue, WANG Nan, YUE Bocheng, CHEN Shuohua, HAN Quanle, WU Shouling, LI Kangbo
Chinese General Practice    2024, 27 (12): 1431-1437.   DOI: 10.12114/j.issn.1007-9572.2023.0598
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Background

The prevalence of atrial fibrillation (AF) has continued to rise globally in recent years, and AF increases the risk of stroke, heart failure, myocardial infarction, chronic kidney disease, and other diseases. Studies have identified hypertension, diabetes, smoking, obstructive sleep apnea, obesity and sedentary lifestyle as risk factors for AF. And most of these factors are within the scope of the "Life's Essential 8" (LE8) proposed by the American Heart Association.

Objective

To investigate the relationship between cardiovascular health (CVH) score based on the LE8 and AF.

Methods

A study was conducted in which 91 131 employees of Kailuan Group in Tangshan, Hebei Province were selected for physical examination from June 2006 to October 2007, and the LE8 score was evaluated according to the algorithm developed by the American Heart Association, and combined with the actual situation of the Kailuan study to form the Kailuan study version of LE8, including 4 health behaviors (diet, physical activity, tobacco exposure, and sleep) and 4 health factors (BMI, blood lipids, blood glucose, and blood pressure). The study subjects were divided into the three groups of the low CVH group (n=8 407) with a LE8 score less than 50, the medium CVH group (n=73 493) with a LE8 score of 50 or more but less than 80, and the high CVH group (n=9 231) with a LE8 score of 80 or more. The follow-up visit was performed per year with the time of the study subject's first Kailuan physical examination as the starting point, the occurrence of AF as the endpoint event, the end of AF and follow-up (2020-12-31) as the endpoint time. Kaplan Meier survival curve was used to analyze the cumulative incidence of new-onset AF in different groups, and log rank test was used to compare the differences between groups; Cox proportional hazards regression analysis was used to investigate the impact of different LE8 score groups and single factor scores on the risk of new-onset AF.

Results

There were significant differences in age, gender, education level, monthly per capita household income, history of alcohol consumption, and LE8 scores among the three groups of subjects (P<0.001). During follow-up, 1 088 cases of new-onset AF were identified, including 133 cases (1.58%) in the low CVH group, 883 cases (1.20%) in the medium CVH group, and 72 cases (0.78%) in the high CVH group. The median follow-up time was 15.0 (14.7, 15.2) years; there was statistically significant difference in the comparison of cumulative incidence rate of new-onset AF in the three groups (P<0.000 1). Cox proportional hazards regression analysis after adjusting for age, gender, education level, monthly per capita household income, and history of alcohol consumption showed that, compared with the low CVH group, both the medium CVH group (HR=0.697, 95%CI=0.579-0.841, P<0.001) and the high CVH group (HR=0.609, 95%CI=0.454-0.816, P=0.001) reduced the risk of new-onset AF. An increase in LE8 score could reduce the risk of new-onset AF (HR=0.859, 95%CI=0.804-0.918, P<0.001). The individual factors of LE8, including BMI score (HR=0.762, 95%CI=0.717-0.809, P<0.001) and blood pressure score (HR=0.824, 95%CI=0.776-0.876, P<0.001), were negatively correlated with the risk of new-onset AF.

Conclusion

The LE8 score of CVH is negatively correlated with the risk of new-onset AF, and the individual factors of LE8, including BMI score and blood pressure score, are negatively correlated with the risk of new-onset AF.

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11. Influencing Factors of Overanticoagulation at Initial Stage of Warfarin Anticoagulation Therapy in Patients with Atrial Fibrillation
FAN Caixia, LI Jiao, WEI Yanjin, GUO Dequn, LIU Cunfei, LI Zhengrong, QIU Shi
Chinese General Practice    2024, 27 (03): 308-314.   DOI: 10.12114/j.issn.1007-9572.2023.0431
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Background

Atrial fibrillation (AF) is an important risk factor for stroke, cardiovascular disease and all-cause mortality with high prevalence, and appropriate anticoagulant therapy is the core of preventing AF-related stroke. Warfarin is still the main anticoagulant at present, but the therapeutic window of warfarin is narrow, fixed dose of warfarin can easily lead to excessive coagulation or insufficient anticoagulation at the initial stage of treatment. There are few previous clinical studies on overanticoagulation of warfarin.

Objective

To analyze the epidemiological and clinical characteristics of overanticoagulation in patients with AF at the initial stage of warfarin anticoagulation therapy, and explore the influencing factors of overanticoagulation.

Methods

The study was a single-center retrospective cohort study. A total of 552 patients with AF treated with warfarin 2.5 mg/d admitted to Linyi City's Hospital from January 2017 to December 2022 were included as the study subjects. The clinical data of patients were collected, including age, gender, body mass, type of AF (non-valvular/valvular), comorbidities (hypertension, diabetes, hypoproteinemia, transaminase abnormalities, heart failure), combined medication (number of combined drugs, combined antibiotics, combined amiodarone), the laboratory test results before treatment were also collected, including serum albumin (Alb), serum creatinine (Scr), serum alanine aminotransferase (ALT) and serum aspartate aminotransferase (AST) levels, as well as international normalized ratio (INR) before treatment and INR after 7 days of treatment. Patients were divided into the overanticoagulation group (INR>3.0, n=122) and non-overanticoagulation group (INR≤3.0, n=430) according to whether INR>3.0 after 7 days of warfarin therapy. The data of patients between the two groups were compared, univariate and multivariate Logistic regression analysis was used to explore the influencing factors of overanticoagulation in the initial stage of warfarin anticoagulation therapy.

Results

The age, proportion of female, valvular atrial fibrillation, hypoproteinemia, transaminase abnormalities, number of combined drugs, proportion of combined amiodarone and AST of patients in the overanticoagulation group were higher than those in the non-overanticoagulation group, and the body mass, hypertension, diabetes, Alb and ALT were lower than those in the non-overanticoagulation group (P<0.05). Multivariate Logistic regression analysis showed age≥65 years (OR=1.954, 95%CI=1.243-3.073, P=0.004), body mass≤63 kg (OR=2.967, 95%CI=1.841-4.783, P<0.001), number of combined drugs>5 (OR=1.976, 95%CI=1.175-3.323, P=0.010), and Scr≥91 μmol/L (OR=2.087, 95%CI=1.222-3.561, P=0.007) were independent risk factors for overanticoagulation at the initial stage of warfarin anticoagulation in patients with AF, while diabetes (OR=0.424, 95%CI=0.191-0.939, P=0.034) was a protective factor for overanticoagulation at the initial stage of warfarin anticoagulation therapy in patients with AF.

Conclusion

Age≥65 years, body mass≤63 kg, number of combined drugs>5, Scr≥91 μmol/L may be risk factors for overanticoagulation at the initial stage of warfarin anticoagulation therapy in patients with AF, while diabetes may be a protective factor at the initial stage of warfarin anticoagulation therapy in patients with AF. INR should be closely monitored in patients on warfarin anticoagulation with advanced age, low body mass, multiple drug combinations and elevated Scr level.

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12. Development Trajectory and Predictors of Strength-duration Adherence to Home-based Exercise Rehabilitation among Patients with Atrial Fibrillation after Radiofrequency Catheter Ablation: a Longitudinal Study
WANG Jie, SUN Guozhen, BAO Zhipeng, WANG Lin, GAO Min, LIU Shenxinyu, YU Tianxi, WANG Qin, GAO Rongrong
Chinese General Practice    2024, 27 (02): 168-176.   DOI: 10.12114/j.issn.1007-9572.2023.0426
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Background

The prevalence of atrial fibrillation (AF) in China is increasing year by year, and the prognosis and quality of life of patients urgently need attention. Current studies have confirmed that exercise rehabilitation is a beneficial way to improve the prognosis and poor quality of life in patients with AF after radiofrequency catheter ablation (RFCA). Adherence is a key measure of whether the benefits of exercise rehabilitation persist, but its trajectory remains unknown.

Objective

To examine the development trajectory and predictors of strength-duration adherence to home-based exercise rehabilitation among patients with AF after RFCA using five-period follow-up data based on prospective longitudinal observation.

Methods

Convenience sampling method was used to select 246 patients with AF who attended the Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University for RFCA from May to November 2020 for follow-up. The baseline survey was conducted 1 week after enrollment, and the follow-up survey was conducted at 3, 6, 9 and 12 months after enrollment. The general and clinical data of patients were collected. The strength-duration adherence was monitored and recorded using smart devices or fitness log to assess exercise adherence in terms of strength-duration adherence; Self-efficacy for Exercise Scale (SEE), Fear of Activity in Patients with Chronic Heart Failure (Fact-CHF), Perceived Social Support Scale (PSSS), Patient Activation Measure 13 (PAM13) were used for assessing self-efficacy of exercise, fear of activity, social support and motivation level. Mplus tool was used to construct latent class growth model (LCGM), and the optimal fitting model was selected to determine the development trajectory of strength-duration adherence to home-based exercise rehabilitation among patients with AF after RFCA. Logistic regression analysis was used to identify the predictors of trajectory categories.

Results

A total of 202 patients were included in the final analysis with 44 patients lost to follow-up. The number of patients at baseline, 3 months, 6 months, 9 months, and 12 months after exercise were 202, 201, 185, 174 and 159, respectively, and the strength-duration adherence were (0.83±0.55), (1.07±0.54), (0.99±0.57), (0.91±0.55) and (0.89±0.60). The LCGM results showed group heterogeneity in the process of change in strength-duration adherence to exercise rehabilitation in patients, which was divided into 3 latent classes based on their development trajectories, including 69 in slow decline-low level group (34.2%), 14 in rapid increase-high level group (6.9%), and 119 in sustained adherence group (58.9%). Multinomial unordered Logistic regression showed higher levels of intensity-time adherence in the rapid increase-high level group and sustained adherence group using the slow decline-low level group as the reference group (P<0.001). The patients in the rapid increase-high level group and sustained adherence group were older, with higher level of exercise self-efficacy (P<0.05). The level of fear of activity was lower in the rapid increase-high level group, and the level of activation was higher in the sustained adherence group (P<0.05) .

Conclusion

The strength-duration adherence to home-based exercise rehabilitation among patients with AF after RFCA showed a multi-class curve growth trajectory. In the future, intensive interventions can be conducted periodically according to the time-varying characteristics and predictors, to improve and stabilize the adherence to home-based exercise rehabilitation.

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13. Evaluation of Potentially Inappropriate Medication of Direct Oral Anticoagulant in Hospitalized Elderly Patients with Non-valvular Atrial Fibrillation Based on Beers Criteria
LIU Puqing, CHEN Jingwen, SHOU Zhangxuan
Chinese General Practice    2023, 26 (35): 4388-4393.   DOI: 10.12114/j.issn.1007-9572.2023.0376
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Background

Direct oral anticoagulants (DOACs) have gradually replaced the vitamin K antagonist warfarin and become the first line drugs for anticoagulant therapy in patients with non-valvular atrial fibrillation (NVAF), however, the safety and efficacy of DOACs in clinical use require sustained attention.

Objective

To promote rational use of DOACs by investigating and analyzing the potentially inappropriate medication (PIM) of DOACs in elderly patients with atrial fibrillation (AF) hospitalized in Cardiology Department.

Methods

Beers criteria, DOACs drug inserts and anticoagulant treatment guidelines were integrated to develop the PIM evaluation criteria for DOACs therapy, including criterias for the indication of DOACs for AF, PIM evaluation of DOACs dose matched to renal function, DOACs application in patients with different liver function and PIM evaluation of DOACs drug interaction, evaluation references for age related PIM, body weight related PIM and bleeding risk related PIM. A retrospective analysis was performed to collect elderly NVAF patients from Hospital Information System (HIS) who were admitted to the department of cardiology and received DOACs (rivaroxaban tablets, edoxaban tablets and dabigatran etexilate capsules) therapy from January 2022 to December 2022 in the Second Affiliated Hospital of Zhejiang Chinese Medical University. The target population was screened according to the inclusion and exclusion criteria and evaluated individually according to the PIM evaluation criteria.

Results

A total of 89 elderly NVAF patients were enrolled with an average age of (77.9±8.1) years, and the incidence of PIM was 56.18% (50/89). A total of 58 cases of PIM in the three DOACs, including 47 cases (81.03%) in the rivaroxaban, 6 cases (10.35%) in the edoxaban and 5 cases (8.62%) in the dabigatran etexilate. Sorted by PIM categories, the incidence of renal function-related PIM was 75.86% (44 cases), drug interaction related PIM was 15.52% (9 cases), liver function related PIM was 6.90% (4 cases) and weight related PIM was 1.72% (1 case) .

Conclusion

Anticoagulation treatment with DOACs in elderly patients with NVAF is associated with non-negligible PIM, rivaroxaban-treated patients have the highest incidence of PIM, followed by edoxaban-treated patients, which mainly manifests as renal function related PIM, drug interaction related PIM and liver function related PIM. Therefore, the clinicians need to develop individualized anticoagulation regimens integrating patient-specific conditions in the anticoagulation in elderly patients with NVAF, thereby reducing the PIM of DOACs therapy.

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14. Correlation between Glycated Hemoglobin Variability and New-onset Atrial Fibrillation in Type 2 Diabetes Patients Combined with Heart Failure with Preserved Ejection Fraction
FEI Sijie, ZHANG Qiang, LIU Fangfang, BAI Lu, SUN Caihong, XIN Caifeng
Chinese General Practice    2023, 26 (26): 3246-3251.   DOI: 10.12114/j.issn.1007-9572.2023.0183
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Background

Diabetes mellitus has been a major concern as a common risk factor for cardiovascular disease. Glycated hemoglobin (HbA1c) variability is an indicator of long-term blood glucose fluctuation. Therefore, it is of great clinical significance to explore the correlation between HbA1c variability and new-onset atrial fibrillation (AF) in diabetic patients combined with heart failure with preserved ejection fraction (HFpEF) .

Objective

To investigate the correlation between HbA1c variability and new onset AF in type 2 diabetes mellitus (T2DM) patients combined with HFpEF.

Methods

The clinical data of 317 T2DM patients combined with HFpEF diagnosed in the Department of Cardiology, the Second Affiliated Hospital of Zhengzhou University from January 2018 to January 2019 were retrospectively analyzed. The follow-up was performed until February 2022, with a mean follow-up time of 3.4 years. The included patients were divided into the AF group (34 cases) and non-AF group (283 cases) based on the presence of new-onset AF during the follow-up period. The HbA1c variability was expressed as standard deviation of HbA1c measurement (HbA1c-SD) and HbA1c coefficient of variation (HbA1c-CV). Multivariate Cox regression analysis was used to explore the correlation between HbA1c variability and new-onset AF in T2DM patients combined with HFpEF. The survival curves were plotted by the Kaplan-Meier (K-M) method. The receiver operating characteristic (ROC) curve of HbA1c variability predicting new-onset AF in T2DM patients combined with HFpEF was plotted.

Results

The HbA1c-SD and HbA1c-CV of patients in the AF group were higher than those in the non-AF group (P<0.05). The included patients were divided into the low HbA1c variability (HbA1c-SD≤0.34%, HbA1c-CV≤4.74%) and high HbA1c variability (HbA1c-SD>0.34%, HbA1c-CV>4.74%) groups according to the median of HbA1c variability. Log-rank test results showed higher incidence of new-onset AF in patients with high HbA1c variability (PHbA1c-SD<0.001, PHbA1c-CV=0.004). Multivariate Cox regression analysis showed that HbA1c-SDHR=2.22, 95%CI (1.37, 3.61), P=0.001〕 and HbA1c-CVHR=1.65, 95%CI (1.01, 2.67), P=0.001〕 were independent influencing factors for new-onset AF in T2DM patients combined with HFpEF. The AUC of HbA1c-SD for predicting AF in T2DM patients combined with HFpEF was 0.784 〔95%CI (0.713, 0.855), P=0.001〕, with the optimum cutoff value of 0.36%, sensitivity and specificity of 79.4% and 73.1%, respectively. The AUC of HbA1c-CV for predicting AF in patients with T2DM and HFpEF was 0.694 〔95%CI (0.591, 0.797), P<0.001〕, with the optimal cutoff value of 4.97%, sensitivity and specificity of 73.5% and 72.1%, respectively.

Conclusion

High HbA1c variability (HbA1c-SD>0.34%, HbA1c-CV>4.74%) is independently associated with an increased risk of new-onset AF in T2DM patients combined with HFpEF, with significant clinical value in predicting AF.

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15. Correlation between Atrial Fibrillation and the Risk of New-onset Chronic Kidney Disease in Northern Chinese Population
ZHANG Aili, HOU Qiqi, HAN Quanle, ZHANG Boheng, ZHANG Jiawei, CAO Hongxia, ZHANG Chao, CHEN Shuohua, WU Shouling, LI Kangbo
Chinese General Practice    2023, 26 (36): 4521-4526.   DOI: 10.12114/j.issn.1007-9572.2023.0006
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Background

The global population disease burden report shows that atrial fibrillation (AF) and chronic kidney disease (CKD) have emerged as the fast-growing causes of death in the last 20 years. The concept of cardiorenal syndrome suggests that AF may increase the risk of new-onset CKD, however, there are few studies related to the increased risk of new-onset CKD with AF at home and abroad, and the interaction with age remains unclear atpresent.

Objective

To investigate whether AF increases the risk of new-onset CKD in northern Chinese population.

Methods

The population who attended a comprehensive health check-up for the employees of Kailuan Group in Hebei Province from 2006 to 2010 were selected as study subjects. The general information and laboratory test results of the study subjects were collected, and the study subjects were followed up with the final follow-up date of 2020-12-31 and the end point of new-onset CKD. The included patients were divided into AF group (n=368) and non-AF group (n=110 487) according to the presence or absence of AF. The cumulative incidence of new-onset CKD in patients was calculated using the lifetable method. The Kaplan-Meier method was used to plot the survival curves of the cumulative incidence of new-onset CKD in the AF group and the non-AF group. The Log-rank test was used to compare the differences in the cumulative incidence of CKD between the two groups. The multivariate Cox proportional hazard regression model was used to explore the effect of AF on the risk of new-onset CKD.

Results

AF group was higher than non-AF group in age, male proportion, systolic blood pressure level, diastolic blood pressure level, body mass index, the proportions of education level, participation in physical exercise, hypertension, diabetes, taking hypotensive drugs and hypoglycemic drugs, and high-sensitivity C-reactive protein level (P<0.05) . AF group was lower than non-AF group in the proportion of alcohol consumption, total cholesterol, triacylglycerol and low density lipoprotein cholesterinlevels (P<0.05) . There were statistically significant differences in the incidence and cumulative incidence of new-onset CKD between atrial fibrillation group and non-atrial fibrillation group (P<0.05) . Stratifying the study population by age, there were statistically significant differences in the incidence and cumulative incidence of new-onset CKD in the study subjects aged≤65 years (P<0.05) and statistically significant difference in the incidence of new-onset CKD in the study subjects aged>65 years (P<0.05) . The results of the adjusted multivariate Cox proportional hazard regression analysis showed that AF was a risk factor for new-onset CKD in people aged≤65 years〔HR=1.350, 95%CI (1.038, 1.755) , P=0.025〕.

Conclusion

AF is an independent risk factor for new-onset CKD in northern Chinese population, especially for young and middle-aged populationaged≤65 years.

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16. Analyze Mastery of Atrial Fibrillation Related Knowledge and Its Influencing Factors among Grassroots Medical Staffs
DUAN Yuanxia, GU Liuna, ZHANG Lei, ZHOU Liting, ZHU Haiying, YANG Chao, CHEN Haiying, GU Xiaoqing, HUANG Jiaoling, GU Jie
Chinese General Practice    2023, 26 (07): 869-876.   DOI: 10.12114/j.issn.1007-9572.2022.0405
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Background

With the aging of the population, the prevalence of atrial fibrillation is increasing year by year. As the "gatekeepers" of community residents' health, grassroots medical staff with a high level of knowledge about atrial fibrillation is particularly important for standardized management of atrial fibrillation.

Objective

To analyze the mastery of atrial fibrillation-related knowledge among grassroots medical staff in Fengxian District, Shanghai and its influencing factors, thus, providing a theoretical basis for subsequent training work.

Methods

This study is a cross-sectional survey study. From June to July 2021, a systematic sampling method was used to select 1 393 grassroots medical staff as the research objects including general practitioners, nurses, pharmacists, public health physicians and other medical staff (imaging technology/physician, laboratory technician, traditional Chinese medicine doctor and so on) from 21 community health service centers in Fengxian District, Shanghai. This study used a self-developed electronic questionnaire to investigate them. The contents of the questionnaire included general information and knowledge related to atrial fibrillation (basic knowledge about atrial fibrillation, knowledge about anticoagulant therapy and knowledge about rhythm/heart rate control) . This study compared the mastery of atrial fibrillation-related knowledge among grassroots medical staff in different positions, and used univariate Logistic regression, ordinal multiple classification or binary Logistic regression to analyze the influencing factors of grassroots medical staff's mastery of atrial fibrillation-related knowledge.

Results

A total of 1 383 valid questionnaires were recovered, and the valid questionnaire recovery rate was 99.28%. Among 1 383 grassroots medical staff, 506 cases (36.59%) were general practitioners. 54.88% (759/1 383) , 97.69% (1 351/1 383) and 69.63% (963/1 383) failed in the basic knowledge about atrial fibrillation, knowledge about anticoagulation and knowledge about heart rhythm/heart rate control, respectively. There were statistically significant differences in the scores of atrial fibrillation knowledge, anticoagulation knowledge and heart rhythm/heart rate control knowledge among grassroots medical staff in different positions (P<0.05) . Ordinal multiple classification or binary Logistic regression analysis showed that the position as a general practitioner and professional title were the influencing factors of score in the basic knowledge related to atrial fibrillation among grassroots medical staff (P<0.05) . Age and position as a general practitioner were the influencing factors of whether the score in knowledge related to anticoagulation therapy reaches the pass level or above among grassroots medical staff (P<0.05) . The position as a general practitioner, received standardized training and reading the atrial fibrillation guideline within one year were the influencing factors of the score in knowledge related to heart rhythm/heart rate control among grassroots medical staff (P<0.05) .

Conclusion

The mastery of knowledge about atrial fibrillation among grassroots medical staff is generally not ideal, especially the lack of knowledge about anticoagulation therapy. Atrial fibrillation related knowledge training should be especially strengthened for grassroots medical staff who are not general practitioners, have low professional titles, and have not received standardized training.

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17. Hybrid Ablation: a Future Development Trend in the Management of Atrial Fibrillation
ZHANG Ning, HOU Ming, MEI Bo, JIN Weitao, TAN Xiong, YANG Mingchuan, WANG Liang, LIU Yong, LAI Yinglong
Chinese General Practice    2023, 26 (09): 1136-1145.   DOI: 10.12114/j.issn.1007-9572.2022.0760
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As the most common type of arrhythmia, atrial fibrillation has proven to be associated with serious adverse cardiovascular and cerebrovascular events, such as heart failure, stroke and myocardial infarction. The global number of patients with atrial fibrillation has exceeded 33 million, and it is estimated to be more than doubled in the next 40 years. Although years of efforts have been made to the research on pathophysiological mechanism, and the exploration of new treatments and improvement of treatments regarding atrial fibrillation, the management of atrial fibrillation is still a difficult problem in clinical medicine, and there is no consensus on the best treatment and the choice of energy source for ablation in atrial fibrillation with the increasing advances made in surgical and catheter ablative techniques. Catheter ablation often requires multiple operations with unsatisfactory success rate and surgical ablation is often associated with high risk of postoperative adverse events. Hybrid ablation, a new treatment recently developed by the joint efforts of cardiac surgeons and electrophysiologists, integrates the merits of catheter ablation and minimally invasive surgical ablation but overcomes the limitations of the two, has proven to be effective in reducing the risk of postoperative adverse outcomes, and considerably efficacious in treating persistent atrial fibrillation, especially long-term persistent atrial fibrillation. We reviewed the advances in atrial fibrillation ablation, and comparatively analyzed existing studies of hybrid ablation, and summarized the advantages and challenges of this treatment, hoping to provide one more option for clinical treatment of atrial fibrillation.

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18. Effect of Atrial Fibrillation on the Risk of New-onset Myocardial Infarction in Hypertensive Population
YUE Bocheng, HOU Qiqi, HAN Quanle, YANG Bo, WU Zheng, WU Jianmei, CHEN Shuohua, WU Shouling, LI Kangbo
Chinese General Practice    2023, 26 (14): 1739-1744.   DOI: 10.12114/j.issn.1007-9572.2022.0734
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Background

Global population epidemiology research shows that by 2019, there were 1.28 billion hypertensive patients, and about 59.7 million patients with atrial fibrillation (AF) worldwide. Hypertension greatly increases the risk of AF. And in older hypertensive patients, the incidence of AF will be higher than 60%. Moreover, AF increases the risk of ischemic stroke, heart failure, myocardial infarction, chronic kidney disease and dementia. However, there are few studies on whether AF increases the risk of new-onset myocardial infarction, and whether the risk interacts with age is still unclear in large hypertensive populations.

Objective

To examine whether AF increases the risk of new-onset myocardial infarction in hypertensive patients.

Methods

Individuals with hypertension were selected as subjects from the employees of Kailuan Group who underwent the medical check-up in Tangshan Gongren Hospital and Kailuan General Hospital from June 2006 to October 2007. General data and laboratory test results of subjects were collected. And all of them were regularly followed up until 2020-12-31. The endpoint event was new-onset myocardial infarction. The finally enrolled cases (n=42 833) included 270 with AF diagnosed by baseline ECG (AF group) and 42 563 without (non-AF group) . The cumulative incidence of myocardial infarction was calculated by the life table method. The survival curve for the cumulative incidence of new-onset myocardial infarction was plotted by Kaplan-Meier method. The difference of the cumulative incidence of myocardial infarction between AF and non-AF groups was compared by Log-rank test. Multivariate Cox proportional hazards regression model was used to investigate the effect of AF on new-onset myocardial infarction in hypertension.

Results

AF group had greater mean age, and lower mean levels of diastolic blood pressure, total cholesterol, triglyceride, low-density lipoprotein cholesterol than non-AF group (P<0.05) . There were also statistically differences in the incidence of myocardial infarction and cumulative incidence of new-onset myocardial infarction between the two groups (P<0.05) . After age-stratification, it was found that the differences in the incidence of new-onset myocardial infarction and cumulative incidence of myocardial infarction were statistically significant between those aged ≤60 years with AF and without AF (P<0.05) , but were insignificant between those aged > 60 years with and without AF (P>0.05) . Adjusted multivariate Cox proportional hazards regression analysis showed that AF was a risk factor for new-onset myocardial infarction in hypertensive population〔HR=2.89, 95%CI (1.74, 4.82) , P<0.01〕, and also in hypertensive population aged ≤60 years old〔HR=4.72, 95%CI (2.11, 10.56) , P<0.01〕.

Conclusion

AF is a risk factor for new-onset myocardial infarction in hypertensive population, especially in those ≤60 years old. Active control of blood pressure and treatment of AF are important prevention and treatment measures for new-onset myocardial infarction.

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19. Clinical Characteristics and Treatment of Atrial Fibrillation and Heart Failure: a Multicenter Survey
HU Huachao, CHEN Xianya, XIE Siyuan, XIA Zhen, XIAO Hua
Chinese General Practice    2023, 26 (05): 541-549.   DOI: 10.12114/j.issn.1007-9572.2022.0549
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Background

Atrial fibrillation (AF) is a common clinical tachyarrhythmia with high prevalence, and a predisposing factor of stroke. In addition, it has a causal relationship with heart failure (HF) . Treatment options for AF have changed recently owing to the emergence of new drugs. Many investigations are focused on anticoagulant therapies for AF, but relevant multicenter investigations on AF and HF are rare.

Objective

To investigate the clinical characteristics and treatment of patients with AF combined with HF in Chongqing, China.

Methods

A total of 4 011 patients with AF and HF who were discharged from 21 hospitals in Chongqing in 2018 were included. Data were collected through the electronic medical record system of the hospitals, including sex, age, basic comorbid conditions, type of AF, NYHA class, thromboembolism history, bleeding history, Color Doppler echocardiography results, HF type and use of drugs (including antithrombotic drugs, rhythm/ventricular rate-control drugs, ACEIs/ARBs, cardiotonic drugs) . The risk of thromboembolism and bleeding were assessed using admission CHA2DS2-VASc score and HAS-BLED score. Sex, basic comorbid conditions, AF type, NYHA class, admission CHA2DS2-VASc score and HAS-BLED score, left atrial diameter, left ventricular end-diastolic diameter, left ventricular ejection fraction, endpoint events (thromboembolism and bleeding) , HF type, and treatment options were compared across three age groups (<65, 65-75, >75) and across patients by the level of hospitalized hospital (secondary and tertiary) .

Results

In terms of clinical characteristics, the patients had an average age of (74.0±10.6) years, 2 279 (56.8%) were female. The top three prevalent basic comorbid conditions were coronary heart disease (65.1%) , hypertension (51.0%) , and diabetes (17.5%) . 3 346 (83.4%) patients with nonvalvular atrial fibrillation (NVAF) . NYHA class was Ⅲ and Ⅳ in 3 059 patients (76.3%) , thromboembolism events occurred in 531 patients (13.2%) , and bleeding events occurred in 176 patients (4.4%) . In Color Doppler echocardiography results, The average left atrial diameter was (44.12±9.21) mm. The average left ventricular end-diastolic diameter was (48.45±10.06) mm. The average left ventricular ejection fraction was (54.23±11.94) mm. The main type of HF was HF with preserved ejection fraction, accounting for 66.2%. The average CHA2DS2-VASc score was (3.9±1.5) points, and the admission CHA2DS2-VASc score was positively correlated with age (r=0.589, P<0.001) . The average HAS-BLED score was (1.7±1.0) points. 3 641 (90.8%) patients were at high risk of thromboembolism and 723 (18.0%) patients were at high risk of bleeding. In terms of antithrombotic treatment, the overall prevalence of anticoagulation treatment was 47.1%, warfarin was the main anticoagulant (37.8%) , the prevalence of use of the new oral anticoagulant was only 9.3%. The overall prevalence of antiplatelet treatment was 44.6%, most of them were monoclonal antiplatelet agents (13.2%) . The prevalence of anticoagulation treatment decreased with age (χ2trend=136.502, P<0.001) , but that of antiplatelet treatment increased with age (χ2trend=135.730, P<0.001) . The prevalence of anticoagulation treatment, and use of warfarin and new oral anticoagulants in secondary hospitals was significantly lower than that in tertiary hospitals (P<0.001) . A total of 3 162 (78.8%) patients with atrial fibrillation received ventricular rate control. The prevalence of use of beta-blockers, digoxin and ACEIs/ARBs was 61.6%, 17.6%, and 59.7%, respectively.

Conclusion

The majority of patients with AF complicated with HF in Chongqing are elderly, and the proportion of women is relatively high. HFpEF is the main type of atrial fibrillation, and the NYHA classification is mainly classⅢandⅣ. Most were at high risk for thromboembolism, but less than 1/4 were at high risk of bleeding. The prevalence of antithrombotic treatmentin all ages and levels of hospitals was unsatisfactory, and there was a large gap between current treatment and guideline recommendations in improving HF. In view of this, hospitalphysicians should increase their awareness and capability of standardized diagnosis and treatmentregarding AF with HF.

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20. Cost-effectiveness Analysis of Early Screening for Atrial Fibrillation: a Review of Recent Advances
TANG Zhijie, SUN Guozhen, WANG Jie, LIU Shenxinyu, BAO Zhipeng, YANG Gang, WANG Lin
Chinese General Practice    2023, 26 (01): 104-112.   DOI: 10.12114/j.issn.1007-9572.2022.0653
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Atrial fibrillation (AF) is one of common clinical arrhythmias, among which asymptomatic AF is insidious, poorly understood, and prone to adverse outcomes, bringing a serious burden to patients. As disease screening is a measure that should be implemented prior to the prevention of disease-related complications, it is crucial to carry out asymptomatic AF screening and scientific management. Current hot issues in screening for AF include the selection of the most appropriate screening population, the selection of screening devices and modalities, the improvement of screening participation, standard indications of anticoagulation therapy for those diagnosd, and the evaluation of the best economic screening option. We included twenty-five articles related to screening for atrial fibrillation, and systematically reviewed the AF screening section in AF management guidelines published in recent five years and opinions of relevant experts, then gave a summary of the latest advances in AF screening, involving screening strategies, screening devices, screening participation, anticoagulation treatment participation and monitoring duration and monitoring modalities in post-stroke screening, and the association of screening strategies on cost-effectiveness of the screening analyzed using a perspective in health economics, as well as economic impact of patient participation in screening and anticoagulation treatment. All these are beneficial to the guidance for clinical practice. The more internationally recognised guidelines for the screening and management of atrial fibrillation are the European Heart Rhythm Society guidelines and the North American Heart Rhythm Society guidelines. Most studies on the cost-effectiveness of AF screening have used Markov models for lifetime simulation. Health economics analyses include stroke events, bleeding events, quality-adjusted life year (QALY) , and incremental cost-effectiveness ratio (ICER) . Most guidelines recommend routine screening with newer devices, such as portable single-lead ECGs in high-risk groups aged 65-75 years, to facilitate continuous monitoring and improve AF detection rates; for post-stroke screening, national and international guidelines emphasize screening for AF in patients with cryptogenic transient ischemic attacks (TIA) /stroke, with the main focus on Long-range ECG and implantation of an insertable cardiac monitor (ICM) . In summary, although some progress has been made in understanding the cost-effectiveness of AF screening, many differences still need to be fitted, and the health economics of AF screening are poorly understood in China. This will provide an evidence-based basis for improving life expectancy and quality of life and reducing the economic burden of healthcare.

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21. Latest Developments in Wearable Devices for the Screening and Management of Atrial Fibrillation
YU Chao, ZHOU Wei, WANG Tao, ZHU Lingjuan, BAO Huihui, CHENG Xiaoshu
Chinese General Practice    2023, 26 (01): 113-117.   DOI: 10.12114/j.issn.1007-9572.2022.0449
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Atrial fibrillation (AF) is one of the two major bastions that need to be tackled in cardiovascular disease field. The rates of AF screening and standardized management are low, which are mainly due to the limitation of "no onset symptoms of AF at the time of detection and no detection at the time of having onset symptoms of AF" in the traditional screening. Wearable devices are technologies that can facilitate early detection and scientific management of AF, whose applicability, sensitivity and specificity in the screening AF have been gradually verified. We reviewed the latest developments in wearable devices for AF screening and management, including epidemiological characteristics of AF, and current application, applicable limitations and prospect of wearable devices, providing a theoretical basis for the use of wearable devices in the screening and management of AF.

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22. Correlation of Markers of Inflammation and Endothelial Injury with Thrombosis in Left Atrium in Patients with Atria Fibrillation
LI Jinyi, LIANG Guicheng, WANG Shirong, LI Shuhu, KE Honghong
Chinese General Practice    2022, 25 (32): 4018-4022.   DOI: 10.12114/j.issn.1007-9572.2022.0490
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Background

Atrial fibrillation (AF) patients are prone to stroke and peripheral arterial embolism. Studying the pathogenesis of thrombosis formation in AF and providing effective interventions to reduce the risk is an important direction of clinical and basic research on AF.

Objective

To investigate the correlation of markers of inflammation and endothelial injury with thrombosis in the left atrium (LA) in AF patients.

Methods

Twenty-nine patients with valvular heart disease and 10 patients with coronary heart disease who underwent thoracotomy at the First Affiliated Hospital of Guangxi Medical University from July 2017 to December 2019 were selected, and divided into sinus rhythm group (15 cases) and AF group 〔24 cases, including 12 with left atrial appendage thrombus (LAAT), and 12 without LAAT〕 according to heart rhythm. General demographics were collected. Besides that, other data were also collected, including left atrial diameter (LAD) and left ventricular ejection fraction (LVEF), levels of protein kinase B (AKT), nuclear factor-κ B (NF-κ B), high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), IL-8, tumor necrosis factor (TNF-α), endothelin-1 (ET-1), nitric oxide (NO), von Willebrand factor (VWF), intercellular adhesion molecule (ICAM-1) and vascular cell adhesion factor (VCAM-1) in the left atrial blood sample, and calculated thrombus area in patients with AF and LAAT. The relationships of LAD, LVEF, markers of inflammation and endothelial injury with calculated area of thrombus in AF with LAAT patients were analyzed by Pearson correlation.

Results

There were significant differences in LAD and LVEF between sinus rhythm patients and AF patients with or without LAAT (P<0.05). AF patients with and without LAAT had no significant differences in LAD and LVEF (P>0.05). AF patients without LAAT had higher levels of AKT, NF-κB, IL-8, ET-1, ICAM-1 and VCAM-1 and lower NO level in left atrium than patients with sinus rhythm (P<0.05). AF patients with LAAT had higher levels of AKT and hs-CRP, and lower NO level in left atrium than those without (P<0.05). AF patients with and without LAAT had no significant differences in levels of NF-κB, IL-6, IL-8, TNF-α, ET-1, vWF, ICAM-1 and VCAM-1 (P>0.05). The maximum area, minimum area, and average area of the left atrial appendage thrombus in AF patients with LAAT were 4.8 cm2, 1.67 cm2, and (3.48±0.83) cm2, respectively. Pearson correlation analysis showed LAD, LVEF, AKT, NF-κB, hs-CRP, IL-6, IL-8, TNF-α, ET-1, NO, vWF, ICAM-1, and VCAM-1 had no linear correlation with the area of thrombus in AF patients with LAAT (P>0.05) .

Conclusion

Increased levels of markers of inflammation and endothelial injury in left atrium were found in AF patients, which were even more higher when the patients also had LAAT. Detecting the markers of inflammation and endothelial injury in left atrium is helpful to evaluate the thrombus prevalence in AF patients.

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23. Prevalence of Use of Anticoagulation Therapy and Associated Factors in Elderly Patients with Nonvalvular Atrial Fibrillation in Communities
Yuanxia DUAN, Zhigang PAN, Jie GU, Jin SU
Chinese General Practice    2022, 25 (25): 3114-3121.   DOI: 10.12114/j.issn.1007-9572.2022.0195
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Background

Stroke is highly prevalent in patients with atrial fibrillation (AF) , a most common cardiac arrhythmia with high morbidity, and anticoagulation therapy is a key strategy to prevent AF-related stroke. However, there is short of research on the use of anticoagulation therapy in patients with AF in the community.

Objective

To explore the prevalence of use of anticoagulation therapy and influencing factors in elderly patients with nonvalvular atrial fibrillation (NVAF) in Shanghai's communities.

Methods

A cross-sectional survey design was used. Stratified sampling was used to select elderly patients with AF who received the 2018 annual physical examination at four community health centers in Shanghai during July to December 2019, and they were surveyed using a questionnaire (consisting of three parts: demographics, CHA2DS2-VASc score and ORBIT score) compiled by our research team for collecting information on their AF prevalence and associated medication use, awareness of AF, comorbidities, and complication, as well as risk for stroke and bleeding. Based on the results of the survey, we excluded those without previous AF-related medical experience and valvular AF, then analyzed the prevalence of anticoagulation therapy in those with NVAF. Anticoagulation therapy was recommended for patients at high risk for stroke in accordance with the CHA2DS2-VASc score. Univariate and multivariate Logistic regression analyses were used to identify influencing factors of anticoagulation therapy in NVAF patients at high risk of stroke.

Results

Three hundred and two patients with NVAF were finally included, of whom the prevalence of current use of anticoagulant and antiplatelet drugs was 29.5% (89/302) , and 39.7% (120/302) , respectively, and that of non-use of anticoagulant or antiplatelet drugs was 30.8% (93/302) . By the CHA2DS2-VASc score, 279 of the 302 NVAF patients (92.4%) were assessed with high risk of stroke, among whom the prevalence of current use of anticoagulant and antiplatelet drugs was 30.5% (85/279) , 40.1% (112/279) , respectively, and the rest 29.4% (82/279) did not take anticoagulant or antiplatelet drugs. Univariate Logistic regression analysis demonstrated that age, marital status, type of AF, onset of AF symptoms, duration of AF, prescription of anticoagulants at the first visit for AF, knowledge of the harmfulness of AF, prevalence of hyperlipidemia, and risk of bleeding were associated with the use of anticoagulation therapy in NVAF patients at high risk of stroke (P<0.05) . Multivariate Logistic regression analysis showed that age, type of AF, prescription of anticoagulants at the first visit for AF, and knowledge of the harmfulness of AF were associated with the use of anticoagulation therapy in NVAF patients at high risk of stroke (P<0.05) .

Conclusion

The prevalence of the use of anticoagulation therapy in community-living NVAF patients at higher risk of stroke is unsatisfactory, so the use of anticoagulation therapy for this population needs to be further standardized, especially in patients with advanced age and low awareness of the harmfulness of AF.

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24. Does Atrial Fibrillation Increase the Risk of New Onset Myocardial Infarction?
Yujing HAO, Jie YU, Quanle HAN, Ruiying MAO, Jing YU, Lihua SONG, Shouling WU
Chinese General Practice    2022, 25 (17): 2121-2126.   DOI: 10.12114/j.issn.1007-9572.2022.0056
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Background

Atrial fibrillation is the most obvious arrhythmia in medical practice. Atrial fibrillation has been listed as one of the eight fastest-growing causes of death since 1990. Epidemiological investigation shows that the highest incidence of atrial fibrillation is 9% in people over 65 years old and 17% in people over 80 years old; more than 60% of patients with hypertension will develop atrial fibrillation after the age of 60. Atrial fibrillation increases the risk of ischemic stroke, heart failure, chronic kidney disease, cognitive impairment and dementia, but it is unclear whether it increases the risk of new onset myocardial infarction.

Objective

To investigate whether atrial fibrillation increases the risk of new onset myocardial infarction.

Methods

From June 2006 to October 2007, 96 750 employees of Kailuan Group in Tangshan, Hebei Province (Kailuan population) were selected for the study, including 458 patients with atrial fibrillation (atrial fibrillation group) and 96 292 patients without atrial fibrillation (non atrial fibrillation group) . The general information of patients was recorded, including age, gender, personal history (smoking history, drinking history) , past medical history (hypertension, coronary heart disease, diabetes, dyslipidemia) , anthropometric parameters (weight, height, blood pressure, etc.) . Total cholesterol (TC) , triglyceride (TG) , high density lipoprotein cholesterol (HDL-C) , low density lipoprotein cholesterol (LDL-C) and fasting blood glucose (FPG) were collected. The patients were followed up every 2 years, respectively, that was from 2008 to 2009, 2010 to 2011, 2012 to 2013, 2014 to 2015, and 2016 to 2017. The median follow-up was 10 years, and the end point was new onset myocardial infarction. Multivariate Cox regression model was used to analyze the effect of atrial fibrillation on new onset myocardial infarction.

Results

(1) There were significant differences in age, body mass index (BMI) , systolic blood pressure (SBP) , LDL-C, FPG, diabetes, smoking, drinking and new onset myocardial infarction between atrial fibrillation group and non atrial fibrillation group (P<0.05) . (2) Multivariate Cox regression analysis showed that atrial fibrillation increased the risk of new onset myocardial infarction compared with non atrial fibrillation〔RR=1.841, 95%CI (1.118, 2.869) , P<0.05〕. After adjusting for age and gender (male) , atrial fibrillation increased the risk of new onset myocardial infarction compared with non atrial fibrillation〔RR=1.635, 95%CI (1.049, 2.547) , P<0.05〕, after further adjustment for BMI, SBP, LDL-C, FPG, smoking and drinking, atrial fibrillation increased the risk of new onset myocardial infarction compared with non atrial fibrillation〔RR=1.381, 95%CI (1.087, 1.573) , P<0.05〕; drinking was the protective factor of new onset myocardial infarction 〔RR=0.664, 95%CI (0.572, 0.770) , P<0.05〕.

Conclusion

Atrial fibrillation is an independent risk factor of new onset myocardial infarction.

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25.

Effect of Dapagliflozin on the Risk of New-onset Atrial Fibrillation during Hospitalization for Acute Myocardial Infarction in Patients with Type 2 Diabetes

ZHENG Rujie, WANG Yue, JIANG Yaohui, ZHANG Jinying
Chinese General Practice    2022, 25 (05): 542-546.   DOI: 10.12114/j.issn.1007-9572.2021.01.024
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Background

Atrial fibrillation is a common complication of acute myocardial infarction with an incidence varying from 5% to 20%. New-onset atrial fibrillation developing after acute myocardial fibrillation indicates a significantly increased risk of death and stroke. Diabetes mellitus, as a shared risk factor in both acute myocardial infarction and atrial fibrillation, plays an important role in the development of acute myocardial infarction and atrial fibrillation. It has been reported that dapagliflozin, a new hypoglycemic agent, has a positive effect on lowering glucose. However, there are few data regarding its impact on the risk of atrial fibrillation after acute myocardial infarction in patients with diabetes.

Objective

To investigate the effect of dapagliflozin on the risk of new-onset atrial fibrillation after acute myocardial infarction in patients with type 2 diabetes mellitus.

Methods

Total 764 patients with type 2 diabetes mellitus admitted during December 2018 to June 2020 in Cardiovascular Department, the First Affiliated Hospital of Zhengzhou University for acute myocardial infarction were selected. The demographic data, echocardiographic indices and laboratory data were collected, and compared between participants with new-onset atrial fibrillation (n=188) and those without (n=576) . Multivariate Logistic regression analysis was used to assess the impact of dapagliflozin on the risk of new-onset atrial fibrillation after acute myocardial infarction.

Results

Patients with new-onset atrial fibrillationhad older mean age, higher male proportion, and proportion of smokers, higher mean levels of glycosylated hemoglobin, left atrial diameter, NT-proBNP and C-reactive protein, and lower mean levels of systolic blood pressure and high-density lipoprotein, as well as lower prevalence of using insulinand dapagliflozinthan those without (P<0.05) . Multivariate Logistic regression analysis found that dapagliflozin was associated with a 34% reduced risk for new-onset atrial fibrillation after acute myocardial infarction in patients with type 2 diabetes mellitus 〔OR=0.66, 95%CI (0.57, 0.91) , P=0.008〕.

Conclusion

Dapagliflozin may be associated with a lower risk of new-onset atrial fibrillation after acute myocardial infarction in type 2 diabetics.

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26. Dynamic Trajectory of Exercise Rehabilitation Adherence of Patients with Atrial Fibrillation after Radiofrequency Ablation in the Internet+ Home Cardiac Rehabilitation Mode 
WANG Jie,SUN Guozhen,YANG Gang,BAO Zhipeng,LIU Shenxinyu,WANG Lin
Chinese General Practice    2021, 24 (32): 4074-4079.   DOI: 10.12114/j.issn.1007-9572.2021.01.218
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Background Decreased exercise endurance still exists after atrial fibrillation radiofrequency ablation. A number of studies have proved that atrial fibrillation exercise rehabilitation is effective,and adherence is a key determinant of whether the patient continues to benefit from exercise therapy. Therefore,understanding the dynamic changes and influencing factors of patients' exercise adherence after atrial fibrillation radiofrequency ablation is of great significance to establish the mechanism of internalization of external dynamics in patients' home exercise rehabilitation. Objective To analyze the longitudinal follow-up data of home-based exercise rehabilitation in patients with atrial fibrillation after radiofrequency ablation,reveal the dynamic change of exercise adherence and explore its influencing factors,in order to provide theoretical basis for the formulation of targeted intervention strategies. Methods A total of 72 patients with atrial fibrillation after radiofrequency ablation who were selected by convenient sampling method from February 2019 to August 2020 in the First Affiliated Hospital of Nanjing Medical University,were treated with Internet+ home exercise rehabilitation intervention for 12 weeks,and followed up to 24 weeks. The average adherence rates in seven time periods of 0-1 week,2-4 weeks,5-8 weeks,9-12 weeks,13-16 weeks,17-20 weeks and 21-24 weeks were collected. A multi-stage latent growth curve model was constructed for exercise adherence,and robust maximum likelihood estimation(MLR)was used to estimate the mean,the variance and the covariance. Taking gender,education,working status,the existence of comorbidities and frequency adherence as covariates,the latent growth curve model was constructed for intensity-time adherence and the parameters were estimated by MLR method. Results Intensity-time adherence and frequency adherence both showed a second-stage curve increasing trend model,suggesting that there is a turning point in the development of adherence,in the 12th week of exercise. The first-stage of intensity-time adherence(from the beginning to 12th week)showed a curve increasing trend,and the increasing rate slowed down with time(Q1=-0.062,P<0.05);The second stage(from 12 weeks to 24 weeks of exercise)showed a linear downward trend(S2=-0.081,P<0.05),and the differences in the initial level and growth rate of individuals were statistically significant(P<0.05). Frequency adherence showed a quadratic growth trend in the first stage,reaching the peak at the 4th week of exercise,and then decreased slightly;The second stage showed a quadratic downward trend,and the rate of decline accelerated with time(Q2=0.003,P<0.05),and the differences between the individual's initial level and the acceleration of change were statistically significant(P<0.05). Among the time-constant covariates,only the existence of comorbidities had a significant impact on intensity-time adherence at the first week(P<0.05). Between the first week and the 24th week,frequency adherence had a positive impact on intensity-time adherence(P<0.05). Conclusions During the intervention period,the level of intensive-time adherence and frequency adherence are relatively low,both with a curve increasing trend and stabilizing at a higher level,while the adherence decreased gradually during the follow-up period. Patients with comorbidities had poor initial intensity-time adherence,while frequency adherence had a positive impact on intensity-time adherence.
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27. New Value of CHA2DS2-VASc Scoring System:Screening for Atrial Fibrillation and Ischemic Stroke in Community-living Elderly Population 
YANG Hong,LIU Jun,FENG Zhigang,GAO Dayong,SONG Weihua
Chinese General Practice    2021, 24 (18): 2281-2284.   DOI: 10.12114/j.issn.1007-9572.2021.00.501
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Background The elders are a high-risk population for atrial fibrillation(AF).Improving the level of accurately screening for AF among the elderly in the community can help to reduce the risk of AF-related stroke.Objective To examine whether the CHA2DS2-VASc scoring system is feasible for the screening of AF and ischemic stroke in the elderly in the community.Methods The long-term older residents in a community,Beijing's Haidian District,were enrolled from October 2019 to March 2020.Medical history(including basic characteristics,and morbidity of common diseases),and results of normal 12-lead electrocardiogram were collected.Ischemic stroke risk was estimated by using the CHA2DS2-VASc scoring system.Results A total of 328 olders were enrolled,including 40(12.2%) with AF and 60(18.3%) with ischemic stroke detected by the screen,with a mean CHA2DS2-VASc score of(3.2±1.5) points.Participants with AF had higher mean CHA2DS2-VASc score than those without(P<0.05).The mean CHA2DS2-VASc score of those with ischemic stroke was higher than that of those without(P<0.05).The AF prevalence in participants with CHA2DS2-VASc score from 0 to 6 was 0,4.8%(2/42),3.7%(2/54),14.6%(12/82),15.8%(12/76),8.3%(4/48),and 40.0%(8/20),respectively,showing a gradual increase with the CHA2DS2-VASc score(rs=0.248,P<0.001).The ischemic stroke prevalence in participants with CHA2DS2-VASc score from 0 to 6 was 0,4.8%(2/42),11.1%(6/54),12.2%(10/82),18.4%(14/76),45.8%(22/48),and 30.0%(6/20),respectively,demonstrating a gradual increase with the CHA2DS2-VASc score(rs=0.296,P=0.001).Conclusion The CHA2DS2-VASc scoring system could be used to screen for AF and ischemic stroke in community-living elderly population.The olders with a higher CHA2DS2-VASc score may have a higher AF or stroke prevalence.
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28. A Six-year Follow-up Study on the Prognosis in Elderly Patients with Ischemic Stroke Combined with Atrial Fibrillation and Coronary Heart Disease 
DONG Min,XU Lei,HE Qinghua,PEI Zuowei,QU Yimei,YANG Jiefu,WANG Fang
Chinese General Practice    2021, 24 (17): 2148-2156.   DOI: 10.12114/j.issn.1007-9572.2021.00.527
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Background In recent years,patients with atrial fibrillation and coronary heart disease have attracted more and more attention in clinic.Recent clinical studies mainly focused on the prevention and treatment of stroke and thromboembolic events.Objective To evaluate the long-term survival rate of elderly patients with ischemic stroke combined with atrial fibrillation and coronary heart disease,and analyze the risk factors which affected the prognosis.Methods We conducted a retrospective cohort study.A retrospective analysis of 406 patients over 60 years admitted to hospital due to acute ischemic stroke for the first time were enrolled,and 164 patients with atrial fibrillation and coronary heart disease were selected from them as cerebrovascular disease group,164 patients without cerebrovascular disease but with atrial fibrillation and coronary heart disease matched with age,gender and comorbidities were selected from concurrent hospitalized patients in the Department of Cardiology as non-cerebrovascular disease group.The clinical data,including demographic information,types of diseases,types of medications,blood pressure,heart rate,cardiovascular diseases and other diseases of the two groups were collected,laboratory test,echocardiographic parameters,treatment plan.The CHA2DS2-VASc score and CHADS2 score were used to assess the risk of stroke and thromboembolism,and the HAS-BLED score was used to assess the risk of bleeding.The patients were followed up for at least 6 years by telephone,outpatient and inpatient records after discharge,to record the death,readmission and major adverse cardiovascular events(MACE),and to explore the factors that affect his long-term prognosis.Results Compared with non-cerebrovascular disease group,the proportion of hyperlipidemia and chronic gastrointestinal disease in cerebrovascular disease group was lower.LVEDD,CHA2DS2-VASc score,CHADS2 score,and the HAS-BLED score in cerebrovascular disease group were higher(P<0.05).In the 164 patients with cerebrovascular disease group,2 cases were lost to follow-up(1.2%),and 80 cases died(49.4%).They were divided into death group(80 cases) and survival group(82 cases) according to the survival outcome.The death group was older and had lower systolic and diastolic blood pressure than the survival group,and the proportion of hypertension,hyperlipidemia,serum albumin and the use of statins were also lower than the survival group.The resting heart rate and the proportion of old myocardial infarction,the proportion of heart failure,chronic kidney disease,NYHA,D-dimer and NT-proBNP levels in death group were higher than the survival group(P<0.05).The results of multivariate Cox regression analysis showed that for every 10 years of age increase〔HR=1.63,95%CI(1.05,2.51)〕,history of old myocardial infarction〔HR=2.19,95%CI(1.14,4.22)〕 and D-Dimer ≥148 μg/L〔HR=6.99,95%CI(2.10,23.28)〕 were independent risk factors for long-term mortality in elderly patients with ischemic stroke combined with atrial fibrillation and coronary heart disease,while hypertension〔HR=0.28,95%CI(0.11,0.72)〕 and statins use〔HR=0.38,95%CI(0.19,0.78)〕 were the protective factors for long-term death in these patients.Conclusion The long-term mortality of patients with atrial fibrillation and coronary heart disease after the first occurrence of cerebrovascular disease is not related to the coexisting cerebrovascular disease,but related to aging,history of old myocardial infarction and D-dimer level.Maintaining an appropriate blood pressure level and using statins may reduce the long-term mortality patients with atrial fibrillation and coronary heart disease.
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29. Antithrombotic Therapies for Patients with Nonvalvular Atrial Fibrillation:a Single-center Comparative Analysis and Recommendations 
XIE Huanglie,HAN Pengyu,ZHENG Chaoyang,ZHU Wei,TAO Wenxiang,WANG Hengkun
Chinese General Practice    2021, 24 (14): 1758-1763.   DOI: 10.12114/j.issn.1007-9572.2021.00.157
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Background Nonvalvular atrial fibrillation(AF)is a common clinical arrhythmia disease,and AF-related stroke is one of its commonest complications.Available relevant clinical studies mainly focus on antithrombotic therapies or the achievement of antithrombotic goals in coronary heart disease(CHD)patients with AF,but rarely compare the long-term safety and efficacy of different therapies.Objective To compare the efficacy,safety and one-year AF-related endpoint events of different antithrombotic therapies in nonvalvular AF patients,regardless of age and by age group.Methods The included 354 nonvalvular AF inpatients were recruited from Department of Cardiovascular,Guangdong Provincial Hospital of Chinese Medicine from January to October 2018.Information was collected,including gender,age,type of AF(paroxysmal,perpetual,persistent,long-standing persistent),complications(stroke/ transient ischemic attack,heart failure,hypertension,diabetes,CHD,hyperlipidemia),cTnT,CHA2DS2-VASc score,and HAS-BLED score.Also,the incidence of thromboembolic events,hemorrhagic events,all-cause deaths and readmission within one-year follow-up period was obtained.The efficacy and safety were compared between groups treated with non-antithrombotic regimen(42 cases),aspirin(21 cases),clopidogrel(51 cases),dual antiplatelet therapy(25 cases),warfarin(49 cases),dabigatran(89 cases)and rivaroxaban(89 cases).And these regimens' efficacy and safety were further analyzed based on age group﹝<65 age group(60 cases),65-75 age group(92 cases),>75 age group(202 cases)﹞.Results The proportion of men in dual antiplatelet therapy group was higher than that in non-antithrombotic regimen group(P<0.05).The average age of warfarin group was younger than that of clopidogrel group(P<0.05).Paroxysmal AF prevalence in rivaroxaban group was lower than that in dual antiplatelet therapy group(P<0.05).CHD prevalence in non-antithrombotic group was lower than that of clopidogrel group or dual antiplatelet therapy group,and so did that in warfarin group(P<0.05).CHD prevalence in dual antiplatelet therapy group was higher than that of rivaroxaban group or dabigatran group(P<0.05).The average cTnT level of dual antiplatelet therapy group was higher than that of other five groups(P<0.05).Clopidogrel group had higher average HAS-BLED score than dabigatran group(P<0.05).The groups treated with different regimens showed statistically significant differences in the incidence of thromboembolic events within one-year follow-up(χ2=12.404,P=0.054).They also showed statistically obvious differences in the incidence of bleeding events within one-year follow-up(χ2=14.420,P=0.019).But they demonstrated similar incidence of all-cause deaths(χ2=9.925,P=0.128).The readmission rate of patients in three age groups was significantly different(P<0.05).Conclusion Early identification of AF and timely antithrombotic therapy are of great significance in preventing thromboembolism.New oral anticoagulants(NOAC)or warfarin may be the first choice for antithrombotic treatment of nonvalvular AF.NOAC is not inferior to warfarin in preventing thrombosis and bleeding,but the risk of gastrointestinal bleeding should be paid attention to.For elderly AF patients,individualized anticoagulant therapy may be more effective.
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30. Computer-aided Diagnosis Model Assists Paroxysmal Atrial Fibrillation Diagnosis in Primary Care 
YAO Yi,LIAO Xiaoyang,LI Zhichao
Chinese General Practice    2021, 24 (2): 143-147.   DOI: 10.12114/j.issn.1007-9572.2020.00.552
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Atrial fibrillation is a common arrhythmia that can cause many serious complications.Among them,paroxysmal atrial fibrillation is difficult to diagnose due to paroxysmal and asymptomatic characteristics.Big ECG data obtained by long-term ECG can improve the detection rate of paroxysmal atrial fibrillation.However,the interpretation of ECG big data has become a burden and problem for primary medical institutions.To solve the problems,a variety of shallow learning models based on ECG features have been developed,which highly rely on manual feature extraction and have limitations.Deep learning is a data-driven automatic feature learning algorithm,which can make up for the shortcomings of shallow learning.As an emerging method for rapid analysis of ECG big data,the Lorenz scatterplots using two-dimensional graphs is high-quality materials for deep learning.This paper reviews the latest advances in ECG features of atrial fibrillation using computer-aided model for diagnosis,and the application of machine learning in atrial fibrillation diagnosis,providing new insights into the development of a good computer-aided diagnosis model,and a new perspective for the interpretation of ECG big data in primary care.
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31. Refection on the Collaborative and Integrated Management Pathway for Atrial Fibrillation by a Large Tertiary General Hospital and a Community Hospital 
YANG Rong,LIU Changming,LIAO Xiaoyang,WANG Lei
Chinese General Practice    2021, 24 (1): 36-39.   DOI: 10.12114/j.issn.1007-9572.2020.00.481
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Atrial fibrillation(AF) is one of the least manageable cardiovascular diseases in the 21st century. As a result of deepening understanding of AF,continuous promotion of the implementation of hierarchical medical system,and appropriately allocating medical resources to primary care gradually,a tertiary general hospital actively cooperates with a community hospital to carry out a new pattern for integrated management of AF has become an exploratory focus during the medical consortium development. AF,as a high-risk chronic disease,plays an important role in the cardiovascular disease continuum,given that hypertension is its high-risk factor and stroke is one of its complications. Therefore,in addition to managing patients with hypertension,it is necessary for community hospitals to early screen hypertension or stroke or other coexisting conditions in AF patients,and deliver a series of targeted comprehensive management accordingly. We introduced an example of comprehensive management of AF by West China Hospital,Sichuan University and Shuangliu District Xihanggang Community Hospital,a tertiary general hospital in combination with a community hospital. Specifically,by means mainly consist of providing online and offline precise trainings for community general practitioners by physicians from West China Hospital,providing AF-related health education and free consultations for contracted residents,and adopting a bi-directional referral pathway for AF patients,the two hospitals collaboratively managed AF dynamically and comprehensively based on the patient's conditions using integrated general care or/and specialty care in an exploratory way. By presenting a detailed analysis and concise summary of the collaborative experience of these two hospitals,we aimed to offer help for the development of a systematic and standard pattern for collaborative management of AF by a tertiary general hospital and a community hospital,and for the empirical exploration of new ways for the specific implementation of hierarchical medical system.
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32. Investigation of Anticoagulation Strategies in Nonvalvular Atrial Fibrillation Patients Aged 80 and Over 
CHEN Jingwen,PEI Linghua,CHEN Chao,WANG Shen,HUANG Shuwei
Chinese General Practice    2020, 23 (35): 4477-4482.   DOI: 10.12114/j.issn.1007-9572.2020.00.565
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Background The proportion of anticoagulant therapy in elderly patients with nonvalvular atrial fibrillation is generally low.The actual situation of anticoagulation in this population is greatly different from the guideline and there is a lack of clinical evidence in the decision of anticoagulant regimens.Objective The study aimed to investigate anticoagulant regimen use and prognosis in nonvalvular atrial fibrillation patients aged 80 and over.Methods 516 patients (≥80 years)with an initial diagnosis of nonvalvular atrial fibrillation or with a previous diagnosis but without anticoagulant therapy treated in the Second Affiliated Hospital of Zhejiang Chinese Medical University between September 2016 and September 2018 were selected.An analysis was performed on clinical data obtained via reviewing the electronic medical records in the hospital information system and follow-up data,including gender,age,smoking history,comorbidities 〔hypertension,diabetes,coronary artery disease,cardiomyopathy,heart failure,and chronic obstructive pulmonary disease(COPD)〕,types of atrial fibrillation(persistent,paroxysmal or permanent atrial fibrillation),history of ischemic stroke,history of hemorrhage,estimated glomerular filtration rate(eGFR),CHA2DS2-VASc score,HAS-BLED score,post-discharge anticoagulant regimen(warfarin,rivaroxaban,dabigatran or using no anticoagulant therapy),duration of anticoagulant treatment,use of antiplatelet drugs,adverse reactions(bleeding events,ischemic stroke,hemorrhagic stroke,and all-cause mortality).The influencing factors of death,ischemic stroke and bleeding events were analyzed using binary Logistic regression.Results Among the participants,137(26.6%)received anticoagulation therapy,including 21 received oral warfarin(4.1%),67 received oral rivaroxaban(13.0%),and 49 received oral dabigatran(9.5%);379(73.5%)received non-anticoagulant therapy,including 266 received single antiplatelet agents(51.6%),53 received dual antiplatelet agents(10.3%),and 60 received no antiplatelet agent(11.6%).Sex ratio,average age,prevalence of comorbidities(hypertension,diabetes,coronary artery disease,cardiomyopathy,heart failure,and COPD),prevalence of having a history of smoking,ischemic stroke or hemorrhage,and average eGFR,CHA2DS2-VASc score,and HAS-BLED score,and hemorrhage(mild,moderate,severe)showed no significant differences among participants used warfarin,rivaroxaban,dabigatran and those used no anticoagulant therapy(P>0.05),but ischemic stroke prevalence and all-cause mortality were significantly different(P<0.05).There was no significant difference in the duration of anticoagulation treatment between three anticoagulation treatment groups(P>0.05).Binary Logistic regression analysis showed that CHA2DS2-VASc score and anticoagulant regimen were associated with ischemic stroke(P<0.05).Anticoagulant regimen was associated with death(P<0.05).HAS-BLED score was associated with bleeding events(P<0.05).Conclusion  The prevalence of anticoagulant therapy was relatively low in this group of elderly patients with nonvalvular atrial fibrillation.Non-anticoagulant therapy(including oral antiplatelet agents)increased the risk of death and ischemic stroke,while warfarin showed similar safety and effectiveness to new oral anticoagulants without increasing the risk of bleeding and death.
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33. Level and Influencing Factors of Exercise Capacity in Atrial Fibrillation Patients after Radiofrequency Ablation 
BAO Zhipeng,SUN Guozhen,SHANG Shuhua,YANG Gang,WANG Lin
Chinese General Practice    2020, 23 (32): 4080-4084.   DOI: 10.12114/j.issn.1007-9572.2020.00.133
Abstract742)      PDF(pc) (1044KB)(1696)    Save
Background Low exercise capacity level is associated with high risk of death caused by cardiovascular disease.Exercise capacity may be an important factor affecting quality of life and clinical prognosis for patients with atrial fibrillation(AF).Even among those with successful radiofrequency ablation,exercise capacity is still not optimistic in general.At present,there are few studies on its current situation and influencing factors in this group.Objective To investigate the exercise capacity level and its influencing factors among AF patients after radiofrequency ablation.Methods From May 2018 to June 2019,by use of convenience sampling,189 AF patients with radiofrequency ablation were selected from Department of Cardiovascular Medicine,the First Affiliated Hospital with Nanjing Medical University.A self-developed general situation questionnaire was used to survey their general characteristics.Cardiopulmonary exercise test (CPET) was used to evaluate patients' exercise capacity.Multiple linear regression was used to analyze the influencing factors of exercise capacity.Results The mean maximal oxygen uptake (VO2max) in the participants was (19.7±6.1)ml?kg-1?min-1.According to the Weber classification in cardiac rehabilitation,VO2max was classified as level A in 85 cases (45.0%),level B in 45 cases (23.8%),level C in 52 cases (27.5%) and level D in 7 cases (3.7%).The postoperative VO2max differed obviously by sex,age,education level,smoking,drinking,exercise habit,preoperative NYHA class,preoperative EHRA class,and BMI (P<0.05).Multiple linear regression analysis revealed that exercise habit 〔β=3.956,95%CI(2.746,5.269)〕,preoperative EHRA score 〔β=-4.651,95%CI(-5.318,-3.983)〕,and BMI 〔β=-0.224,95%CI(-0.383,-0.066)〕 were associated factors of VO2max in patients with AF after radiofrequency ablation(P<0.05).Conclusion Despite the success of radiofrequency ablation for patients with AF,there is still varying degrees of decline in exercise capacity in the short term.Clinical interventions should be taken according to exercise habit,preoperative EHRA score,and BMI of patients to promote the improvement of exercise capacity and quality of life.
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34. Clinical Characteristics of Patients with Cardiovascular Disease and Chronic Pulmonary Disease Complicated with Atrial Fibrillation 
LIU Xiang,XIANG Li,ZHANG Lan,TONG Guangming
Chinese General Practice    2020, 23 (26): 3274-3279.   DOI: 10.12114/j.issn.1007-9572.2020.00.057
Abstract618)      PDF(pc) (955KB)(624)    Save
Background Atrial fibrillation is an independent risk factor for cerebral infarction.With the introduction of new anticoagulants in recent years,the anticoagulation ratio in patients with cardiovascular disease and atrial fibrillation has gradually increased,and the incidence of cerebral infarction shows the downward trend.However,relatively few reports on the incidence of cerebral infarction and current status of anticoagulant therapy in chronic pulmonary patients with atrial fibrillation are available.Objective To explore the clinical characteristics of patients with cardiovascular disease and chronic pulmonary disease complicated with atrial fibrillation in the same period of admission and the incidence of long-term cerebral infarction among them,and to evaluate the incidence of cerebral infarction and anticoagulation status in patients with chronic pulmonary disease and atrial fibrillation,in order to provide the early intervention and improve the prognosis.Methods 287 Patients with persistent or permanent atrial fibrillation admitted to the Second Affiliated Hospital of Soochow University were selected prospectively and continuously as the study subjects from June 2012 to May 2013.According to the main complications,the subjects were divided into the cardiovascular disease group(combined with cardiovascular diseases,n=162) and the lung disease group(combined with chronic pulmonary diseases,n=125).The general data of patients,blood examination results in the early morning of the day after admission,echocardiographic data and CHA2DS2-VASc scores were recorded.The patients were followed up for a period of five years,and the use of anticoagulants and the incidence of cerebral infarction were recorded.Results The age,proportion of male,resting heart rate,heart failure proportion,right atrial long axis diameter,right atrial short axis diameter,right ventricular diameter(RVD) of basal segment,pulmonary artery pressure,prothrombin time(PT),D-dimer,international normalized ratio(INR),NT-proBNP,CHA2DS2-VASc scores and proportion of CHA2DS2-VASc scores≥4 in the lung disease group were higher than those in the cardiovascular disease group,while the level of thrombin Ⅲ was lower(P<0.05).There was no significant difference in the use of anticoagulants between the two groups(P=0.208).The proportion of clopidogrel,ACEI/ARB and amiodarone in the cardiovascular disease group was higher than that in the lung disease group(P<0.05).During five consecutive years of follow-up,16(9.9%) patients in the cardiovascular disease group and 29(23.2%) patients in the lung disease group suffered from cerebral infarction.The difference between the two groups was statistically significant(χ2=9.477,P=0.002).Multivariate Logistic regression analysis showed that age,CHA2DS2-VASc scores,right atrial short axis diameter and pulmonary artery pressure were the risk factors of cerebral infarction in patients with atrial fibrillation(P<0.05).Conclusion The incidence of long-term cerebral infarction in patients with chronic pulmonary disease and atrial fibrillation is high during the same period of admission,and these patients have high CHA2DS2-VASc scores,right atrial diameter(RAD),RVD and pulmonary artery pressure.For patients with chronic pulmonary disease and atrial fibrillation,anticoagulation indications should be evaluated in time,and corresponding treatment schemes should be strengthened,and the treatment of comorbidities such as heart failure and pneumonia should be emphasized.
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35. Application and challenge of novel oral anticoagulants in patients with nonvalvular atrial fibrillation
LIU Yue,REN Yirong,ZHU Huolan,WANG Fang
Chinese General Practice    2020, 23 (23): 2872-2876.   DOI: 10.12114/j.issn.1007-9572.2020.00.364
Abstract577)      PDF(pc) (1294KB)(802)    Save
 Risk assessment and prevention of stroke is an important part of comprehensive management of atrial fibrillation,the most common cardiac arrhythmia.Anticoagulation therapy is one intervention that can effectively reduce the incidence of atrial fibrillation-related stroke.Novel oral anticoagulants(NOACs)take effect by specifically blocking the key link in the development of clotting cascade,namely,the action of thrombin(coagulation factor Ⅱa) or coagulation factor Ⅹa,to inhibit the final stage of the coagulation pathway.NOACs,with the advantages of using a fixed dose,rapid oral absorption,small food-drug interactions,and using without monitoring routine coagulation indices,have become a hot research theme recently.This paper introduces the advances in clinical research and application of NOACs in atrial fibrillation,it is found that NOACs has the advantages of good efficacy and high safety,so as to guide clinical treatment.
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36. Integrated Care Model for Screening and Multidisciplinary Collaboration of Community Patients with Atrial Fibrillation 
LIU Yanli,MA Li
Chinese General Practice    2020, 23 (7): 774-778.   DOI: 10.12114/j.issn.1007-9572.2020.00.189
Abstract626)      PDF(pc) (1019KB)(1502)    Save
With the aging of the population,atrial fibrillation(AF) has become a major public health problem in China and worldwide.AF is an important risk factor for stroke,cardiovascular disease and embolism,which seriously threatens patient's health and quality of life.Studies abroad have shown that a multidisciplinary,nurse-led,patient-centered integrated care model can help reduce the readmission rate,incidence of cardiovascular events,and all-cause mortality of AF patients,as well as improve their satisfaction and quality of life.At present,there are many problems in the AF management in China,and a standardized integrated care model has not yet been formed.Based on domestic and foreign AF management guidelines and related literature,this paper reviewed the process of integrated care model for AF,including its screening,comprehensive evaluation,management strategy development,health education,regular follow-up and referrals,and specific content of each process.The process of AF screening and integrated care model suitable for the community in China were formulated preliminarily in this paper,which could provide a reference for the establishment of a AF standardized management system in the community.
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37. Risk Factors and Prognostic Impact of New-onset Atrial Fibrillation in Patients with Sepsis 
ZHOU Shuqing,SHEN Tao
Chinese General Practice    2019, 22 (24): 2929-2932.   DOI: 10.12114/j.issn.1007-9572.2019.00.119
Abstract536)      PDF(pc) (1070KB)(614)    Save
Background Atrial fibrillation is one of the most common clinical manifestations in patients with sepsis,which can aggravate the severity of the patient's condition,and even cause adverse prognosis.However,there are few studies on new-onset atrial fibrillation in sepsis.Objective  To identify the risk factors and prognostic impact of new-onset atrial fibrillation in sepsis.Methods A retrospectively study was conducted on 542 cases of sepsis recruited from the ICU,EICU and RICU of  the People's Hospital of Liaoning Province from January 2016 to December 2017,including 82(15.1%)with new-onset atrial fibrillation and 460(84.9%)without.Clinical and prognostic data were collected.And factors associated with new-onset atrial fibrillation were analyzed.Results  Sepsis patients with new-onset atrial fibrillation showed higher rates of having acute renal injury,heart failure,metabolic disorder,coagulation disorders,respiratory failure,mechanical ventilation,continuous renal replacement therapy(CRRT),and catecholamine use,and higher mean APACHE Ⅱ core compared with those without(P<0.05).Multivariate Logistic regression analysis demonstrated that,age〔OR=1.038,95%CI(1.013,1.063)〕,acute kidney injury associated with multiple organ dysfunction syndrome〔OR=2.142,95%CI(1.035,4.432)〕,metabolic disorder〔OR=2.071,95%CI(1.083,3.959)〕,coagulation disorders〔OR=7.621,95%CI(3.236,17.945)〕,use of CRRT〔OR=6.567,95%CI(2.306,18.705)〕 and use of catecholamines〔OR=6.683,95%CI(3.224,13.853)〕 were factors associated with new-onset atrial fibrillation in sepsis(P<0.05).There was no significant difference in 28-day in-hospital mortality between the two groups(P>0.05).The length of ICU stay was longer in new-onset atrial fibrillation group than that of non-new-onset atrial fibrillation group(P<0.05).Conclusion The incidence of new-onset atrial fibrillation in patients with sepsis was high.Old age,acute kidney injury associated with multiple organ dysfunction syndrome,metabolic disorder,coagulation disorders,use of CRRT,and use of catecholamines were independent risk factors for new-onset atrial fibrillation.New-onset atrial fibrillation extended the length of ICU stay,but did not increase the 28-day in-hospital mortality.
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38. Effect of Non-pulmonary Vein Triggers Ablation on Paroxysmal Atrial Fibrillation in Prognosis of Patients with Low Left Ventricular Ejection Fraction 
CAO Zhongnan,DU Xinping,ZHANG Minghui,ZHANG Xiangcan,WU Qinqin
Chinese General Practice    2019, 22 (21): 2564-2570.   DOI: 10.12114/j.issn.1007-9572.2018.00.435
Abstract512)      PDF(pc) (1497KB)(694)    Save
Background Non-pulmonary vein triggers ablation combined with pulmonary vein isolation can effectively reduce postoperative complications,but its efficacy and long-term outcome on atrial fibrillation in patients with low left ventricular ejection fraction(LVEF) were still unclear.Objective To investigate the effects of non-pulmonary vein triggers ablation on prognosis in patients with atrial fibrillation and low LVEF and its influencing factors.Methods A total of 307 patients with paroxysmal atrial fibrillation who underwent primary catheter ablation admitted to Tianjin Fifth Central Hospital from December 2015 to January 2016 were enrolled and divided according to their LVEF:LVEF≤40 % were in groupⅠ(83 cases),LVEF >40.00% in groupⅡ(224 cases);the patients in groupⅠwere further divided intoⅠA subgroup(41 cases,non-pulmonary vein triggers ablation combined with pulmonary vein isolation) andⅠB subgroup(42 cases,pulmonary vein isolation).Pulmonary vein isolation was applied in groupⅡ.The patient's clinical data〔age,gender,duration of disease and treatment history,underlying disease,left atrial diameter(LAD),LVEF,medication history,New York Heart Association (NYHA) cardiac function classification〕were recorded at admission.Surgical parameters(total operating time,fluoroscopy time,ablation time,and proportion of non-pulmonary vein triggers) in each group were recorded during operation.During the follow-up period,the success rate,complications,recurrence of atrial fibrillation after operation of each group were recorded.At the end of follow-up,the LVEF of two subgroups were analyzed and compared with preoperative data.The Kaplan-Meier method was used to draw survival curves of postoperative recurrence of atrial fibrillation and then was compared by Log-rank test.Factors influencing postoperative recurrence of atrial fibrillation in patients with low LVEF were analyzed by multivariate Cox regression analysis.Results The utilization rate of pacemaker/implantable cardioverter defibrill(ICD),left atrial diameter(LAD),angiotensin converting enzyme(ACE) inhibitor/angiotensin receptor blockers(ARBs),and roportion of patients with non-pulmonary vein triggers in groupⅠwas higher than those in groupⅡ(P<0.05).The total operation time,fluoroscopy time and ablation time of patients in subgroupⅠA were significantly longer than those in subgroupⅠB(P<0.05).The success rate of operation in groupⅡwas higher than that in groupⅠ,and success rate of subgroupⅠA was higher than that of subgroupⅠB(P<0.05).There were significant difference in survival curves of recurrence of atrial fibrillation between groupⅠand groupⅡ(P<0.001);there were significant difference in survival curves of recurrence of atrial fibrillation between subgroup ⅠA and Ⅱ subgroup(P=0.029);and there was no significant difference in the incidence of complications between groupⅠand groupⅡ(P=0.875).The LVEF〔(36.54±4.17)%〕at the end of follow-up in subgroupⅠA was higher than that before operation〔(32.17±2.48)%〕(P<0.001);There was no significant difference in LVEF in subgroupⅠB before〔(31.94±3.15)%〕and after operation〔(31.86±2.21)%〕(P>0.05).The results of multivariate Cox regression analysis showed that coronary artery disease,LVEF≤40.00%  and non-pulmonary vein triggers were influencing factors of recurrence of atrial fibrillation(P<0.05).Conclusion There are more non-pulmonary vein triggers in patients with atrial fibrillation and low LVEF and pulmonary vein isolation combined with non-pulmonary vein triggers ablation can improve the success rate of patients with low-paroxysmal atrial fibrillation.The coronary artery disease,LVEF≤40.00%  and non-pulmonary vein triggers were the influencing factors of recurrence of atrial fibrillation.
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39. Network Meta-analysis of the Effectiveness and Safety of Novel Oral Anticoagulants in Patients with Atrial Fibrillation 
HUO Lichao,LI Mengli,SONG Minghui,ZHANG Yanxia,XUE Penglong,QIAO Chengdong
Chinese General Practice    2019, 22 (20): 2455-2464.   DOI: 10.12114/j.issn.1007-9572.2019.00.083
Abstract606)      PDF(pc) (1730KB)(677)    Save
Background Atrial fibrillation (AF) is one of the most common arrhythmias encountered clinically.Thrombosis is a common complication of AF.For a long time,warfarin was a first choice for anticoagulation in patients with AF.But adverse reactions of warfarin have been troubled clinicians and patients.At present,with the new anticoagulants generated,and their efficacies have been verified by large-scale clinical trials,this problem has been solved.But there is still lack of direct comparative studies of such anticoagulants.Objective To evaluate the therapeutic effect of novel oral anticoagulants in patients with AF by network meta-analysis.Methods Databases of PubMed,EMBase,the Cochrane Library,Web of Science,CBM,Wanfang Data,CNKI were searched for randomized controlled trials (RCTs) concerning novel oral anticoagulants in patients with AF from inception to July,2018.Quality assessment and data extraction from the included RCTs were performed.Statistical analyses of the incidence of embolization,intracranial hemorrhage,ischemic stroke,myocardial infarction,and gastrointestinal bleeding,and all-cause mortality were conducted with R 3.4.3 and Stata 14 software.Surface under the cumulative ranking (SUCAR) was used to rank the value of the treatments.Results A total of 28 RCTs were included,involving 261 272 patients.The results of network meta-analysis showed that the incidence of embolic events associated with warfarin was higher than that caused by dabigatran(150 mg),rivaroxaban (20 mg),apixaban (10 mg),and edoxaban (60 mg) (P<0.05).The incidence of intracranial hemorrhage related with warfarin was higher than that caused by dabigatran (110 mg),dabigatran(150 mg),rivaroxaban (20 mg),apixaban (10 mg),edoxaban (30 mg)and edoxaban (60 mg)(P<0.05).Warfarin was associated with a higher incidence of ischemic stroke compared with dabigatran (150 mg) (P<0.05).Other treatments,except for ximelagatran (36 mg) and rivaroxaban (15 mg),were associated with lower all-cause mortality compared with warfarin (P<0.05).Warfarin was associated with a higher incidence of myocardial infarction compared with ximelagatran (36 mg) (P<0.05).But it was associated with a lower incidence of gastrointestinal bleeding compared with rivaroxaban (20 mg) (P<0.05).SUCAR values of all the interventions demonstrated that,dabigatran (150 mg) was associated with lower incidence of embolization and all-cause mortality;edoxaban(30 mg) was related to lower incidence of intracranial hemorrhage and gastrointestinal bleeding;ximelagatran (36 mg) was associated with lower incidence of ischemic stroke and myocardial infarction.Conclusion Available evidence shows that apixaban (10 mg) may be a promising treatment.The overall quality of the included studies is high,and the analysis results have certain guiding significance.However,considering the unsatisfied quality of the included domestic studies,our results need to be verified by more high-quality domestic studies.
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40. Effects of Heart Function on Ischemic Stroke and Mortality Risks in Patients with Nonvalvular Atrial Fibrillation and Coronary Artery Stent Implantation 
WANG Ge,ZHAO Li,ZHANG Boyang,WANG Nannan,LIU Pengfei,LIU Ruchen,HUA Can,YUAN Haifeng,WANG Yubin,LI Tianchang
Chinese General Practice    2019, 22 (10): 1176-1181.   DOI: 10.12114/j.issn.1007-9572.2019.00.094
Abstract460)      PDF(pc) (1098KB)(395)    Save
Background Anticoagulation therapy is often administered to atrial fibrillation(AF) patients whose risk of bleeding with such treatment is outweighed by the benefit of stroke risk reduction.And antiplatelet therapy is often given to those with coronary artery stent implantation (CASI).However,if giving antithrombotic (anticoagulant and antiplatelet) therapies to AF with CASI patients,their risks of bleeding will be increased.Heart failure commonly coexists and interacts with atrial fibrillation,and it is a recognized risk factor for stroke in AF patients.Objective To investigate the effect of heart function on the risk of ischemic stroke and death in patients with nonvalvular AF and CASI.Methods A multicenter study was conducted on 2 471 AF patients with CASI recruited from 11 grade A tertiary hospitals in Beijing from January 2010 to January 2015.After excluding those with valvular AF and those who were lost to follow-up,1 987 patients were finally enrolled.The average follow-up period for them was(3.5±1.5) years.The incidence and mortality of ischemic stroke were compared according to the heart function classification of the New York Heart Association(NYHA).Survival analysis was carried out with ischemic stroke and death as endpoints,and Kaplan-Meier survival curves were drawn.At the same time,the bleeding events were analyzed.Finally,Cox proportional hazards regression model was used to analyze the risk factors of stroke.Results The incidence of ischemic stroke was 4.29%(n=63) in compensated heart failure group(n=1 468),and 6.17%(n=32) in decompensated heart failure group(n=519),with no difference(P=0.085).The mortality rate was 10.35%(n=152) in compensated heart failure group,and 14.84%(n=77) in decompensated heart failure group,showing a significant difference(P=0.006).There were significant differences in survival curves drawn with ischemic stroke and death as endpoints between the two groups (P<0.05).Univariate Cox proportional hazards regression analysis showed that NYHA class was associated with the risk of ischemic stroke (P=0.047).Multivariate Cox proportional hazards regression,which further included traditional risk factors for AF and major echocardiographic indicators,showed that gender,stroke history,NYHA class,left ventricular ejection fraction(LVEF),left atrial diameter,left ventricular end-diastolic diameter were factors associated with ischemic stroke (P<0.05).The rate of anticoagulants use was higher in decompensated heart failure group than that of compensated heart failure group(P=0.001).Patients with different NYHA classes showed significantly different mortality rate (P=0.006),but similar stroke incidence(P=0.086).The incidence of bleeding events was 12.74%(187/1 468) in compensated heart failure group and 11.95%(62/519) in decompensated heart failure group,with no significant difference (P=0.639).Conclusion Nonvalvular AF patients with decompensated heart failure have increased risks of death,and the risk of death grows with the deterioration of cardiac function.
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