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Atrial fibrillation (AF) and heart failure (HF) are frequently associated and can be caused or exacerbated by each other through different mechanisms. AF is particularly common in patients with heart failure with preserved ejection fraction (HFpEF) defined as left ventricular ejection fraction (LVEF) ≥ 50%, with a prevalence ranging around 40–60%. In two recent trials, treatment with SGLT2 inhibitors resulted in a lower risk of worsening heart failure or cardiovascular death than placebo in patients with HFpEF, and SGLT2 inhibitors similarly improved prognosis whether patients had AF or not at enrolment. Analyses for subgroups of interest of patients with HFpEF likely to be at higher risk of AF (particularly those with older age or obesity) similarly indicated a consistent benefit with SGLT2 inhibitors. That subgroup in patients with HFpEF is those with a history of previous HF with LVEF ≤ 40%. The EAST-AFNET 4 trial indicated that early rhythm-control therapy was associated with a lower risk of adverse cardiovascular outcomes than usual care among patients with recent AF and cardiovascular conditions, including those with HF. In patients with AF and HF included in the CABANA trial, catheter ablation produced marked improvements in survival, freedom from AF recurrence, and quality of life compared to drug therapy. When strategies aiming at rhythm control eventually fail in patients with AF and HFpEF, a strategy of rate control with atrioventricular junction ablation and cardiac resynchronisation should be discussed since it may also reduce all-cause mortality. Finally, and in conclusion, considering that patients with AF and HFpEF may have a variety of cardiovascular and non-cardiovascular additional comorbidities, they are among those likely to have the highest clinical benefit being adherent to a holistic and integrated care management of AF following the ABC (Atrial Fibrillation Better Care) pathway.

BackgroundThe cardiotoxic effects of breast cancer (BC) therapies, including drugs and radiotherapy (RT), may increase cardiovascular morbidity, particularly atrial fibrillation (AF). The specific impact of BC laterality on the incidence of cardiovascular events remains unclear. To evaluate laterality-specific cardiovascular risks in women with left-sided versus right-sided BC using a large international cohort.MethodsThis cohort study used global healthcare data from the TriNetX network. Propensity score matching (1:1) was used to select a cohort of women with left-sided or right-sided BC, and follow-up was conducted with a maximum duration of 8 years. Mortality, AF, ventricular tachyarrhythmia, heart failure and implantation of an ICD during follow-up. HRs, cumulative incidences and 95% CIs were calculated for evaluating the treatment effect among the treated patients.ResultsDuring follow-up (median 3.2 years), left-sided BC (compared with right-sided BC) was associated with a similar risk of all-cause death and of all incident cardiovascular events with the notable exception of a significantly higher risk of AF (HR 1.051, 95% CI 1.016 to 1.088, p=0.004). There was no statistical interaction for this higher risk of AF associated with left-sided BC when considering women treated with RT (1.024 (95% CI 0.941 to 1.113), p=0.58) or no RT (HR 1.045 (95% CI 1.006 to 1.084), p=0.02, p for interaction 0.66)ConclusionsIn this large international analysis, left-sided BC was significantly associated with a numerically marginal but statistically significant higher risk of AF than right-sided BC, while there were no differences for BC laterality regarding all-cause death and other cardiovascular events.

BackgroundIn patients with acute myocardial infarction (AMI), history of atrial fibrillation (AF) and new onset AF during the early phase may be associated with a worse prognosis. Whether both conditions are associated with similar outcomes is a matter of debate.MethodsWe collected information for all patients with AMI seen in French hospitals between 2010 and 2019. Among 797,212 patients seen with STEMI or NSTEMI, 75,701 (9.5%) had history of AF, and 34,768 (4.4%) had new AF diagnosed between day 1 and day 30 after AMI.ResultsPatients with new AF were older and had more comorbidities than those with no AF but were younger and had less comorbidities than those with history of AF. During follow-up [mean (SD) 1.8 (2.4) years, median (interquartile range) 0.7 (0.1–3.1) years], 163,845 deaths and 30,672 ischemic strokes were recorded. Using Cox multivariable analysis, compared to patients with no AF, history of AF was associated with a higher risk of death during follow-up (adjusted hazard ratio HR 1.17, 95% CI 1.16–1.19) and this was also the case for patients with new AF (adjusted HR 2.11, 2.07–2.15). Both history of AF and new AF were associated with a higher risk of ischemic stroke compared to patients with no AF: adjusted HR 1.19 (1.15–1.23) for history of AF, adjusted HR 1.78 (1.68–1.88) for new AF. New AF was associated with a higher risk of death and of ischemic stroke than history of AF: adjusted HR 1.74 (1.70–1.79) and 1.32 (1.23–1.42), respectively.ConclusionsIn a large and systematic nationwide analysis, AF first recorded in the first 30 days after AMI was independently associated with higher risks of death and ischemic stroke than those in patients with no AF or previously known AF.Graphic abstract

Background There remain uncertainties regarding diabetes mellitus and the incidence of atrial fibrillation (AF), in relation to type of diabetes, and the interactions with sex and age. We investigated whether diabetes confers higher relative rates of AF in women compared to men, and whether these sex-differences depend on type of diabetes and age. Methods All patients aged ≥ 18 seen in French hospitals in 2013 with at least 5 years of follow-up without a history of AF were identified and categorized by their diabetes status. We calculated overall and age-dependent incidence rates, hazard ratios, and women-to-men ratios for incidence of AF in patients with type 1 and type 2 diabetes (compared to no diabetes). Results In 2,921,407 patients with no history of AF (55% women), 45,389 had prevalent type 1 diabetes and 345,499 had prevalent type 2 diabetes. The incidence rates (IRs) of AF were higher in type 1 or type 2 diabetic patients than in non-diabetics, and increased with advancing age. Among individuals with diabetes, the absolute rate of AF was higher in men than in women. When comparing individuals with and without diabetes, women had a higher adjusted hazard ratio (HR) of AF than men: adjusted HR 1.32 (95% confidence interval 1.27–1.37) in women vs. 1.12(1.08–1.16) in men for type 1 diabetes, adjusted HR 1.17(1.16–1.19) in women vs. 1.10(1.09–1.12) in men for type 2 diabetes. Conclusion Although men have higher absolute rates for incidence of AF, the relative rates of incident AF associated with diabetes are higher in women than in men for both type 1 and type 2 diabetes.

Implantable cardioverter-defibrillators (ICD) are meant to fight life-threatening ventricular arrhythmias and reduce overall mortality. Ironically, life-saving shocks themselves have been shown to be independently associated with an increased mortality. We sought to identify myocardial changes at the protein level immediately after ICD electrical shocks using a proteomic approach. ICD were surgically implanted in 10 individuals of a healthy male sheep model: a control group (N = 5) without any shock delivery and a shock group (N = 5) with the delivery of 5 consecutive shocks at 41 J. Myocardial tissue samples were collected at the right-ventricle apex near to the lead coil and at the right ventricle basal free wall region. Global quantitative proteomics experiments on myocardial tissue samples were performed using mass spectrometry techniques. Proteome was significantly modified after electrical shock and several mechanisms were associated: protein, DNA and membrane damages due to extreme physical conditions induced by ICD-shock but also due to regulated cell death; metabolic remodeling; oxidative stress; calcium dysregulation; inflammation and fibrosis. These proteome modifications were seen in myocardium both \"near\" and \"far\" from electrical shock region. N-term acetylated troponin C was an interesting tissular biomarker, significantly decreased after electrical shock in the \"far\" region (AUC: 0.93). Our data support an acute shock-induced myocardial tissue injury which might be involved in acute paradoxical deleterious effects such as heart failure and ventricular arrhythmias.

Background: The fetal origins hypothesis have associated early life exposures with the development of adverse health outcomes in adulthood. Season of birth has been shown to be associated with overall and cardiovascular mortality. Methods: We performed a retrospective database study to explore the association between season of birth and mortality in patients with atrial fibrillation. Results: A total of 8962 patients with AF were identified in the database with 1253 deaths recorded. AF patients born in spring and summer had a higher mortality rate when compared to those born in autumn and winter (hazard ratio (HR) 1.13, 95% confidence interval (CI) 1.01–1.26, p = 0.03). This effect was consistent in the male subgroup (HR 1.25, 95% CI 1.03–1.51, p = 0.02 for males born in spring; HR 1.24, 95% CI 1.03–1.51, p = 0.03 for males born in summer when compared to winter as the reference) but not in females (HR 1.02, 95% CI 0.79–1.31, p = 0.88 for females born in spring; HR 1.11, 95% CI 0.87–1.42, p = 0.39 for females born in summer when compared to winter as the reference). Results persisted after adjustment for baseline characteristics and clinical risk profile. A similar pattern was observed with cardiovascular mortality. Conclusion: Birth in spring or summer is associated with a higher risk of cardiovascular mortality in male AF patients, but not in females. This could be related to the underlying differences in rates of major adverse clinical events between genders. Further studies should aim at clarifying the mechanisms behind this association, which may help us understand the higher level of risk in female patients with AF.

Correspondence to Professor Laurent Fauchier, Service de Cardiologie, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours 37044, France; lfau@med.univ-tours.fr Because of the effectiveness of many interventions with drugs or devices in the primary prevention of cardiovascular events, there is great interest in developing accurate clinical prediction tools to determine in clinical practice who will benefit most from these interventions. Initially promising, a range of therapies has been found to be rather ineffective in preventing incident AF or AF recurrences, including statins, fish oil, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers and various antiarrhythmic agents.1 However, given the multidimensional nature of AF, the concept of integrated care has been promoted to prevent AF incidence, AF recurrences and to improve patient outcomes, with some evidence of success. Integrated care includes stroke prevention and efforts to reduce cardiovascular risk factors as well as broader approaches that include nurse-led interventions, education and lifestyle changes (such as obesity management, exercise and healthy lifestyle efforts).2 Focusing efforts on increasing awareness among clinicians, patients and the general population helps to improve detection and a comprehensive or holistic approach might improve decision-making and approaches to management for patients at risk of AF. A compromise is probably needed there and the calculation of the new score is uneasy. Since the model has not been calibrated to predict absolute risk of developing AF over a short time frame, and ARIC most likely underestimated the true burden of AF, the authors do not propose a dedicated tool for a quick calculation and practical decision in terms of screening programme for now.

Background Left bundle branch area pacing (LBBAP) has emerged as a promising technique to deliver cardiac resynchronization therapy (CRT). However, safety and efficacy of ventricular arrhythmia sensing via the left bundle in implantable cardioverter-defibrillator (ICD) recipients remain unclear. We sought to evaluate the feasibility of a single LBBAP lead connected to a dual-chamber ICD in patients indicated with a CRT-D implantation. Methods The CROSS-LEFT pilot study prospectively included 10 consecutive patients with a reduced ejection fraction and a complete left bundle branch block, indicated with a prophylactic CRT-D. A DF-1 lead was implanted at the right ventricular (RV) apex, and an LBBAP lead through the interventricular septum. Ventricular fibrillation was induced at implantation in both conventional (RV) and left bundle branch area sensing configurations. The latter was the final sensing configuration, and patients were implanted with a dual-chamber DF-1 ICD connected to the atrial lead (RA port), the LBBAP lead (RV IS-1 port), and the defibrillation lead (RV DF-1 port), the IS-1 pin being capped. Atrioventricular delay was optimized to ensure fusion between LBBAP and native conduction from the right bundle. Patients were followed during 6 months. Results No difference between both configurations was observed regarding R-wave sensing in sinus rhythm ( p  = 0.22), ventricular fibrillation median interval detection ( p  = 1.00), or total induced episode duration ( p  = 0.78). LBBAP resulted in a significant reduction of median QRS width from 164 to 126 ms ( p  = 0.002). Median ventricular sensing significantly improved from 9.7 at implantation to 18.8 mV at 6 months ( p  = 0.01). Median LVEF also significantly improved from 29 to 44% at 6 months ( p  = 0.002). Conclusion Ventricular arrhythmia sensing and defibrillation can be performed via a single LBBAP lead connected to a dual-chamber ICD, and is associated with significant electromechanical reverse remodeling. Clinical trial registration number NCT05102227 Graphical abstract In patients presenting with left bundle branch block and left ventricular systolic dysfunction, a left bundle branch area pacing lead connected to a DF-1 dual-chamber implantable cardioverter-defibrillator provides safe ventricular arrhythmia sensing and efficient electro-mechanical resynchronization.

BackgroundAtrioventricular node ablation (AVNA) with permanent pacing is an effective treatment of symptomatic atrial fibrillation (AF). Left bundle branch area pacing (LBBAP) prevents cardiac dyssynchrony associated with right ventricular pacing and could prevent worsening of heart failure (HF).MethodsIn this retrospective monocentric study, all patients who received AVNA procedure with LBBAP were consecutively included. AVNA procedure data, electrical and echocardiographic parameters at 6 months, and clinical outcomes at 1 year were studied and compared to a matched cohort of patients who received AVNA procedure with conventional pacing between 2010 and 2023.ResultsSeventy-five AVNA procedures associated with LBBAP were studied. AVNA in this context was feasible, with a success rate of 98.7% at first ablation, and safe without any complications. There was no threshold rise at follow-up. At 1 year, 6 (8%) patients were hospitalized for HF and 2 (2.7%) were deceased. Patients had a significant improvement in NYHA class and left ventricular ejection fraction (LVEF) (P ≤ 0.0001). When compared to a matched cohort of patients with AVNA and conventional pacing, AVNA data and pacing complications rates were similar. Patients with LBBAP had a better improvement of LVEF (+5.27 ± 9.62% vs. −0.48 ± 14%, P = 0.01), and a lower 1-year rate of composite outcome of hospitalization for HF or death (HR 0.39, 95% CI: 0.16–0.95, P = 0.037), significant on survival analysis (log-rank P-value = 0.03).ConclusionAVNA with LBBAP in patients with symptomatic AF is feasible, safe, and efficient. Hospitalization for HF or death rate was significantly lower and LVEF improvement was greater.

Background and purpose Epilepsy is associated with higher morbidity and mortality compared to people without epilepsy. We performed a retrospective cross‐sectional and longitudinal cohort study to evaluate cardiovascular comorbidity and incident vascular events in people with epilepsy (PWE). Methods Data were extracted from the French Hospital National Database. PWE (n = 682,349) who were hospitalized between January 2014 and December 2022 were matched on age, sex, and year of hospitalization with 682,349 patients without epilepsy. Follow‐up was conducted from the date of first hospitalization with epilepsy until the date of each outcome or date of last news in the absence of the outcome. Primary outcome was the incidence of all‐cause death, cardiovascular death, myocardial infarction, hospitalization for heart failure, ischaemic stroke (IS), new onset atrial fibrillation, sustained ventricular tachycardia or fibrillation (VT/VF), and cardiac arrest. Results A diagnosis of epilepsy was associated with higher numbers of cardiovascular risk factors and adverse cardiovascular events compared to controls. People with epilepsy had a higher incidence of all‐cause death (incidence rate ratio [IRR] = 2.69, 95% confidence interval [CI] = 2.67–2.72), cardiovascular death (IRR = 2.16, 95% CI = 2.11–2.20), heart failure (IRR = 1.26, 95% CI = 1.25–1.28), IS (IRR = 2.08, 95% CI = 2.04–2.13), VT/VF (IRR = 1.10, 95% CI = 1.04–1.16), and cardiac arrest (IRR = 2.12, 95% CI = 2.04–2.20). When accounting for all‐cause death as a competing risk, subdistribution hazard ratios for ischaemic stroke of 1.59 (95% CI = 1.55–1.63) and for cardiac arrest of 1.73 (95% CI = 1.58–1.89) demonstrated higher risk in PWE. Conclusions The prevalence and incident rates of cardiovascular outcomes were significantly higher in PWE. Targeting cardiovascular health could help reduce excess morbidity and mortality in PWE.