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Key Points Patients with both atrial fibrillation (AF) and heart failure (HF) present unique diagnostic and management challenges No randomized trial has demonstrated that pharmacological rhythm control confers a reduction in mortality compared with rate control in patients with both AF and HF Studies of highly selected populations of patients with both AF and HF indicate that, in the short term, AF ablation improves symptoms of HF, functional capacity, and left ventricular function Randomized, controlled trials to evaluate hard clinical outcomes of AF ablation in patients with both AF and HF are currently in progress Atrial fibrillation (AF) and heart failure (HF) are evolving epidemics with increasing global prevalence. HF is known to promote AF, but how AF exacerbates or even causes HF is uncertain. In this Review, Ling and colleagues present the current understanding of the epidemiology and pathophysiology of AF–HF, and the roles of pharmacological and interventional therapies in the management of patients with this comorbidity. Atrial fibrillation (AF) and heart failure (HF) are evolving epidemics, together responsible for substantial human suffering and health-care expenditure. Ageing, improved cardiovascular survival, and epidemiological transition form the basis for their increasing global prevalence. Although we now have a clear picture of how HF promotes AF, gaps remain in our knowledge of how AF exacerbates or even causes HF, and how the development of HF affects the outcome of patients with AF. New data regarding HF with preserved ejection fraction and its unique relationship with AF suggest a possible role for AF in its aetiology, possibly as a trigger for ventricular fibrosis. Deciding on optimal treatment strategies for patients with both AF and HF is increasingly difficult, given that results from trials of pharmacological rhythm control are arguably obsolete in the age of catheter ablation. Restoring sinus rhythm by catheter ablation seems successful in the medium term and improves HF symptoms, functional capacity, and left ventricular function. Long-term studies to examine the effect on rates of stroke and death are ongoing. Guidelines continue to evolve to keep pace with this rapidly changing field.

National electronic health records (EHR) are increasingly used for research but identifying disease cases is challenging due to differences in information captured between sources (e.g. primary and secondary care). Our objective was to provide a transparent, reproducible model for integrating these data using atrial fibrillation (AF), a chronic condition diagnosed and managed in multiple ways in different healthcare settings, as a case study. Potentially relevant codes for AF screening, diagnosis, and management were identified in four coding systems: Read (primary care diagnoses and procedures), British National Formulary (BNF; primary care prescriptions), ICD-10 (secondary care diagnoses) and OPCS-4 (secondary care procedures). From these we developed a phenotype algorithm via expert review and analysis of linked EHR data from 1998 to 2010 for a cohort of 2.14 million UK patients aged ≥ 30 years. The cohort was also used to evaluate the phenotype by examining associations between incident AF and known risk factors. The phenotype algorithm incorporated 286 codes: 201 Read, 63 BNF, 18 ICD-10, and four OPCS-4. Incident AF diagnoses were recorded for 72,793 patients, but only 39.6% (N = 28,795) were recorded in primary care and secondary care. An additional 7,468 potential cases were inferred from data on treatment and pre-existing conditions. The proportion of cases identified from each source differed by diagnosis age; inferred diagnoses contributed a greater proportion of younger cases (≤ 60 years), while older patients (≥ 80 years) were mainly diagnosed in SC. Associations of risk factors (hypertension, myocardial infarction, heart failure) with incident AF defined using different EHR sources were comparable in magnitude to those from traditional consented cohorts. A single EHR source is not sufficient to identify all patients, nor will it provide a representative sample. Combining multiple data sources and integrating information on treatment and comorbid conditions can substantially improve case identification.

Type-2 diabetes mellitus (DM) is associated with an increased risk of atrial fibrillation (AF). It is unclear whether DM is a risk factor for arrhythmia recurrence following catheter ablation of AF. We performed a nonrandomised, observational study in 7 high-volume European centres. A total of 2,504 patients who underwent catheter ablation of AF were included, and procedural outcomes were compared among patients with or without DM. Patients with DM (234) accounted for 9.3% of the sample, and were significantly older, had a higher BMI and suffered more frequently from persistent AF. Arrhythmia relapses at 12 months after AF ablation occurred more frequently in the DM group (32.0% vs 25.3%, p = 0.031). After adjusting for type of AF (i.e., paroxysmal vs persistent), during a median follow-up of 17 ± 16 months, atrial arrhythmia free-survival was lower in the diabetics with persistent AF (log-rank p = 0.003), and comparable for paroxysmal AF (log-rank p = 0.554). These results were confirmed in a propensity-matched analysis, and DM was also an independent predictor of AF recurrence on the multivariate analysis (hazard ratio 1.39; 95% confidence interval 95%1.07 to 1.88; p = 0.016). There was no significant difference in the rate of periprocedural complications among DM and non-DM patients (3.8% vs 6.3%, p = 0.128). Efficacy and safety of cryoballoon ablation were comparable to radiofrequency ablation in both DM and no-DM groups. In conclusion, catheter ablation of AF appears to be safe in patients with DM. However, DM is associated with higher rate of atrial arrhythmia relapse, particularly for patients with persistent AF.

We evaluated the effect of adenosine upon mechanisms sustaining persistent AF through analysis of contact electrograms and ECGI mapping. Persistent AF patients undergoing catheter ablation were included. ECGI maps and cycle length (CL) measurements were recorded in the left and right atrial appendages and repeated following boluses of 18 mg of intravenous adenosine. Potential drivers (PDs) were defined as focal or rotational activations completing ≥ 1.5 revolutions. Distribution of PDs was assessed using an 18 segment biatrial model. 46 patients were enrolled. Mean age was 63.4 ± 9.8 years with 33 (72%) being male. There was no significant difference in the number of PDs recorded at baseline compared to adenosine (42.1 ± 15.2 vs 40.4 ± 13.0; p = 0.417), nor in the number of segments harbouring PDs, (13 (11-14) vs 12 (10-14); p = 0.169). There was a significantly higher percentage of PDs that were focal in the adenosine maps (36.2 ± 15.2 vs 32.2 ± 14.4; p < 0.001). There was a significant shortening of CL in the adenosine maps compared to baseline which was more marked in the right atrium than left atrium (176.7 ± 34.7 vs 149.9 ± 27.7 ms; p < 0.001 and 165.6 ± 31.7 vs 148.3 ± 28.4 ms; p = 0.003). Adenosine led to a small but significant shortening of CL which was more marked in the right than left atrium and may relate to shortening of refractory periods rather than an increase in driver burden or distribution. Registered on Clinicaltrials.gov: NCT03394404.

Cardiac resynchronisation therapy (CRT) improves prognosis in patients with heart failure (HF) however the role of ABO blood groups and Rhesus factor are poorly understood. We hypothesise that blood groups may influence clinical and survival outcomes in HF patients undergoing CRT. A total of 499 patients with HF who fulfilled the criteria for CRT implantation were included. Primary outcome of all-cause mortality and/or heart transplant/left ventricular assist device was assessed over a median follow-up of 4.6 years (IQR 2.3–7.5). Online repositories were searched to provide biological context to the identified associations. Patients were divided into blood (O, A, B, and AB) and Rhesus factor (Rh-positive and Rh-negative) groups. Mean patient age was 66.4 ± 12.8 years with a left ventricular ejection fraction of 29 ± 11%. There were no baseline differences in age, gender, and cardioprotective medication. In a Cox proportional hazard multivariate model, only Rh-negative blood group was associated with a significant survival benefit (HR 0.68 [0.47–0.98], p = 0.040). No association was observed for the ABO blood group (HR 0.97 [0.76–1.23], p = 0.778). No significant interaction was observed with prevention, disease aetiology, and presence of defibrillator. Rhesus-related genes were associated with erythrocyte and platelet function, and cholesterol and glycated haemoglobin levels. Four drugs under development targeting RHD were identified (Rozrolimupab, Roledumab, Atorolimumab, and Morolimumab). Rhesus blood type was associated with better survival in HF patients with CRT. Further research into Rhesus-associated pathways and related drugs, namely whether there is a cardiac signal, is required.

Suspect bradyarrhythmia in patients with symptoms of fainting, shortness of breath, chest pain, or lethargy, and a heart rate <60beats/min on examination Request 12-lead electrocardiography (ECG) to detect conduction abnormalities such as atrioventricular block or sinus node disease, and blood tests to exclude thyroid disorder and electrolyte imbalance Referral to a cardiologist is usually needed to evaluate heart function and for management Pacemaker implantation is indicated when symptoms can be attributed to bradycardia or atrioventricular block, or in asymptomatic patients with type 2 second-degree heart block or complete heart block Complex devices such as biventricular pacemakers and implantable cardioverter defibrillators are being considered in patients with a pacing indication and left ventricular impairment to prevent worsening left ventricular function or sudden cardiac death Bradyarrhythmias are heart rhythms with a rate of <60beats/min, commonly due to conduction abnormalities in the heart such as sinus node disease or atrioventricular block. 1 There is increased risk of sudden cardiac death due to slowing or stopping of the heart, and of falls, especially in older people, due to fainting.

The coronavirus disease 2019 (COVID-19) pandemic has had a dramatic impact on the way that medical care is delivered. To minimise hospital attendance by both patients and staff, remote clinics, meetings and investigations have been used. Technologies including hand-held ECG monitoring using smartphones, patch ECG monitoring and sending out conventional Holter monitors have aided remote investigations. Platforms such as Google Meet and Zoom have allowed remote multidisciplinary meetings to be delivered effectively. The use of phone consultations has allowed outpatient care to continue despite the pandemic. The COVID-19 pandemic has resulted in a radical, and probably permanent, change in the way that outpatient care is delivered. Previous experience in remote review and the available technologies for monitoring have allowed the majority of outpatient care to be conducted without obviously compromising quality or safety.

To mitigate the damage of oil spills, a filter modified with a hydrophilic and oleophobic coating is proposed for affordable and efficient oil separation and recovery from water. The sol–gel method was chosen to produce a colloidal suspension of titanium dioxide particles for its ease of production and its versatility in application for many different substrates, including paper and cloth fabric. After immersing the substrates into a titanium-containing solution, three techniques were applied to increase the production of titanium dioxide—microwave-assisted, refrigeration, and ultra-sonication. Contact angle tests were done to investigate the change in the filter’s oleophobicity. The titanium dioxide present on the surface of the filter was amorphous, but all treatment methods showed an improvement in oleophobicity. All treated filters improved oil filtration performance by up to eighty percent. The filters isolated motor oil from a mixture while allowing water to pass through. The coated filters also displayed photocatalytic activity by degrading methylene blue on its surface when exposed to sunlight, demonstrating the filter’s self-cleaning ability. For real-world applications, the filter can be supported by a stainless mesh for enhanced strength and durability. While being dragged through the water, the filter collects the surface oil, allowing water to pass through via gravity.

The LHCb experiment at CERN has undergone a comprehensive upgrade, including a complete re-design of the trigger system into a hybrid-architecture, software-only system that records ten times more events per unit time for physics analysis than its predecessor. This increased efficiency - as well as the growing diversity of signals physicists want to analyse - makes it more challenging to conform to crucial operational targets on bandwidth and storage capacity. To address this, a comprehensive, automated testing framework has been developed that emulates the entire LHCb trigger and offline-processing software stack on simulated and real collision data. Scheduled both nightly and on-demand by software testers during development, these tests measure the onlineand offline-processing’s key operational performance metrics (such as rate and bandwidth), for each of the system’s 4000 distinct physics selection algorithms, and their cumulative totals. The results are automatically delivered via concise summaries - to GitLab merge requests and instant messaging channels - that further link to an extensive dashboard of per-algorithm information. The dashboard and pages therein facilitate test-driven trigger development by 100s of physicists, whilst the concise summaries enable efficient, data-driven decision-making by management and software maintainers. This novel bandwidth-testing framework has been helping LHCb build an operationallyviable trigger and data-processing system whilst maintaining the efficiency to satisfy its physics goals.

IntroductionAtrial fibrillation (AF)-induced cardiomyopathy (AIC) is retrospectively defined after normalisation of left ventricular ejection fraction (LVEF) in sinus rhythm. It is unclear why some patients develop AIC.HypothesisPatients with AIC have a subtle cardiomyopathic process that precedes their AF-mediated LVEF reduction. Detailed assessment of cardiac function after successful catheter ablation will reveal this.ObjectiveTo evaluate the utility of measures to identify cardiomyopathic features that persist after LVEF normalisation in AIC.MethodsPatients with rate-controlled persistent AF and LVEF<50% undergoing catheter ablation (CA) were prospectively evaluated using echocardiography, cardio-pulmonary exercise testing and serum N-terminal pro b-type natriuretic peptide (NT-proBNP) at baseline and 6 months after CA. Participants with AIC, (LVEF recovery (≥50%) and no other cause for cardiac dysfunction) were evaluated using left ventricular (LV) longitudinal strain and left atrial (LA) reservoir strain (LARS). Changes in peak oxygen consumption and the minute ventilation/carbon dioxide production slope were measured as markers of functional capacity and ventilatory inefficiency. A control group of patients with persistent AF with preserved LVEF were also enrolled.Results34/41 (82.9%) participants recovered LVEF in sinus rhythm; defined as AIC. NT-proBNP levels were elevated in 18 (52.9%), and 16 reported ongoing heart failure (HF) symptoms. 10 (29.4%) had no improvement in functional capacity, and seven (20.6%) showed persistent ventilatory inefficiency. 20 (58.8%) had impaired global LV longitudinal strain with a relative apical sparing pattern. Nine (26.5%) had impaired LARS. There was an overlap of these abnormalities. 32 (94.1%) demonstrated at least one, 17 (50.0%) having no cardiovascular risk factors. Patients with preserved LVEF during persistent AF had similar demographics but a lower burden of short R-R intervals (<660 ms) on Holter monitoring.DiscussionAbnormal structural, metabolic and HF biomarkers are seen in patients with AIC in sinus rhythm. These features may represent a precedent subtle cardiomyopathic process predisposing them to left ventricular systolic dysfunction in AF.Trial registration numberNCT04987723.