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Purpose of Review Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. The estimated lifetime risk of developing AF is higher in men; however, due to differences in life expectancy, the overall prevalence is higher among women, particularly in the older age group. Sex differences play an important role in the pathophysiology, presentation, and clinical outcomes of AF. Awareness of these differences minimizes the potential for disparities in AF management. Our review summarizes the current literature on sex differences in AF, including the epidemiology, pathophysiology, risk factors, clinical symptomatology, mechanisms, treatment, and outcomes. We also explore the implications of these differences for clinical practice and future research. Recent Findings Women are more likely to present with atypical symptoms, have a higher stroke risk, and have a worse quality of life with AF when compared to men. Despite this, they are less likely to receive rhythm control strategies and anticoagulants. Summary The sex-based differences in AF pathology and management might be a combination of inherent biological and hormonal differences, and implicit bias of the research entities and treating clinicians. Our review stresses the need for further sex-specific research in the pathophysiology of AF and opens a dialogue on personalized medicine, where management strategies can be tailored to individual patient characteristics, including sex.

The prevalence of CVD in pregnant people is estimated to be around 1 to 4%, and it is imperative that clinicians that care for obstetric patients can promptly and accurately diagnose and manage common cardiovascular conditions as well as understand when to promptly refer to a high-risk obstetrics team for a multidisciplinary approach for managing more complex patients. In pregnant patients with CVD, arrhythmias and heart failure (HF) are the most common complications that arise. The difficulty in the management of these patients arises from variable degrees of severity of both arrhythmia and heart failure presentation. For example, arrhythmia-based complications in pregnancy can range from isolated premature ventricular contractions to life-threatening arrhythmias such as sustained ventricular tachycardia. HF also has variable manifestations in pregnant patients ranging from mild left ventricular impairment to patients with advanced heart failure with acute decompensated HF. In high-risk patients, a collaboration between the general obstetrics, maternal-fetal medicine, and cardiovascular teams (which may include cardio-obstetrics, electrophysiology, adult congenital, or advanced HF)—physicians, nurses and allied professionals—can provide the multidisciplinary approach necessary to properly risk-stratify these women and provide appropriate management to improve outcomes.

•Mechanisms linking Pulsed Field Ablation (PFA) with hemolysis, hemoglobinuria, and acute kidney injury (AKI): PFA uses high-voltage electric fields to ablate myocardial tissue. However, this process can cause red blood cell electroporation, leading to subclinical hemolysis, free hemoglobin release, hemoglobinuria, and in rare cases, hemolysis induced-AKI.•Strategies to minimize hemolysis and improve renal safety in PFA procedures: Effective prevention strategies for PFA related AKI include optimizing catheter-tissue contact to prevent energy dispersion and adequate preprocedural hydration. Moreover, reducing the number of PFA applications, where feasible, (depending on the technology) and using catheter with a lower energy peak might also mitigate hemolysis risks.•Hydration protocols shown to prevent AKI post-PFA in high-risk patients: Preprocedural hydration plays a critical role in preventing AKI after PFA. Studies show that administering at least 2 liters of fluids before and after the procedure significantly reduces serum creatinine elevation. This approach is particularly effective in patients with multiple PFA applications or preexisting renal impairment. Hydration maintains renal perfusion, dilutes free hemoglobin, and prevents tubular obstruction. Incorporating hydration protocols into standard PFA practices enhances renal protection, especially for high-risk patient populations undergoing complex ablations. Pulsed field ablation has emerged as a novel technique for atrial fibrillation ablation, offering myocardial preferential ablation and safety advantages over traditional thermal energy methods. Complications such as hemolysis, hemoglobinuria, and acute kidney injury have been reported, particularly with high-energy delivery and excessive applications. To understand the underlying mechanisms and potential preventative strategies, and identifying at-risk populations, to optimize procedural safety and ensure consistent outcomes. This narrative review explores current data on mechanisms, incidence, clinical biomarkers, and risk factors that contribute to these issues. While transient and subclinical hemolysis is common, large scale registry data demonstrate that clinically significant hemolysis-induced renal complications remain rare, with fewer than 0.05% of patients requiring intervention. As catheter design and technology continue to evolve, further research with long-term data is crucial to continue to better understand and standardize mitigation strategies. This paper provides an evidence-based framework and practical strategies, individual patient assessment, and postprocedural management to address and support safer integration of pulsed field ablation into clinical practice. [Display omitted]

Cardiovascular diseases (CVD) have been the leading causes of morbidity and mortality for over three decades, highlighting the necessity of integrating creative methods with traditional and innovative approaches for patient care, education, and prevention. Historically, artistic representations have played a crucial role in shaping our understanding of the anatomy, physiology, and pathologies of the human heart and cardiovascular system. Creative expressions, including visual arts, are linked to improved overall well-being for individuals of all ages. This review explores the evolution of visual arts in cardiovascular medicine over time, the understanding, diagnosis, and communication of cardiovascular disease and health through major domains of visual arts - education (medical illustrations, interactive anatomic models), symbolism (healing), advocacy (heart disease awareness, cardiac-focused exhibitions, interactive murals or art installations) and innovation (3D modeling, digital art, generative art, advanced medical visualization and imaging). We also reviewed the latest advancements in incorporating visual art into personalized cardiac care, the role of portraits in recognizing underrepresented groups, and future applications of visual representations and concepts through artificial intelligence aimed at enhancing cardiovascular care, medical education, and cardiac research. [Display omitted]

This chapter reviews atrial fibrillation (AF) progression and its associated mechanisms, including comorbidities and AF as contributors to atrial myopathy, and atrial myopathy as a contributing factor to AF progression. In addition, the chapter discusses the concept of comorbidities and atrial myopathy as synergistic contributors to adverse outcomes, the notion of “AF begets AF,” and the consequences of AF burden if left untreated. Clinical trials evaluating outcomes with antiarrhythmic drugs (AADs) compared with placebo have demonstrated efficacy, but also reveal a possible proarrhythmic and mortality risk if AAD selection is not appropriate and patients are not correctly identified based on risk factors and comorbidities. Data from ATHENA, the first and only trial to demonstrate that an AAD (dronedarone) can reduce cardiovascular (CV) hospitalizations in people with AF, are reviewed, along with studies reporting on the use of catheter ablation versus AADs for AF rhythm control. Finally, recent data showing a reduction in major adverse outcomes if rhythm control is initiated early are summarized, including results from the EAST-AFNET 4 trial, as well as confirmatory results from several large “real-world” trials. Chapter 3 is summarized as follows:(1)Based on the pathophysiology of AF, it is logical to use early treatment to try to minimize AF progression and the associated irreversible atrial cardiomyopathy.(2)In the ATHENA trial, rate plus rhythm control (with dronedarone) was associated with better outcomes versus placebo plus rate control.(3)In the EAST-AFNET 4 trial, early rhythm control was associated with a reduced burden of disease and a lower rate of CV adverse events compared with usual care.(4)The benefit of early rhythm control is now supported by multiple trials, and rate control by itself is no longer felt to be an appropriate first-line strategy for most AF patients.

Atrial fibrillation (AF) is a potentially serious health risk, both because of its symptoms and because of its association with an increased risk for heart failure, hospitalization, thromboembolism, and death. Chapter 2 discusses selection of appropriate treatments and when to initiate these therapies. Older trials focused on comparing rate versus rhythm control treatment options for AF. It is now recognized that both rate and rhythm control are important and can be used together. This chapter reviews the historical, pivotal rate versus rhythm control trials that failed to show any overall survival benefit of rhythm over rate control, as well as the trials’ now-recognized limitations with respect to modern therapy. In addition, an in-depth discussion of the more recent trials of antiarrhythmic drugs (AAD) and ablation techniques (which have become available since the original rate versus rhythm trials were performed) is included. These updated trials show that when applied to patient- and disease-specific situations, rhythm control can reduce the risk for mortality and hospitalization. The chapter also reviews the guidelines that have been developed to achieve these goals. Chapter 2 is summarized as follows: (1) Rate control is needed (at rest and during exertion) to reduce rate-related symptoms when rhythm control is ineffective or incomplete and to prevent a tachycardia-induced cardiomyopathy. (2) Previous trials with pharmacological therapy alone comparing rate versus rhythm control using the AADs available at that time failed to show any overall survival benefit of rhythm control over rate control. (3) These earlier trials had many methodological limitations and enrolled participants who did not have access to modern therapies. (4) Newer therapies, including those for stroke prevention, dronedarone (the latest approved AAD), and AF ablation, have improved the safety and efficacy of rhythm control strategies.

This chapter discusses the American College of Cardiology/American Heart Association/ Heart Rhythm Society (AHA/ACC/HRS) and European Society of Cardiology (ESC) guidelines for atrial fibrillation (AF) management with particular focus on antiarrhythmic drug (AAD) selection and the identification of individuals for whom AAD treatment is appropriate. Discussion includes AAD indications, when to start an AAD, choosing among AADs, how to minimize proarrhythmic risk, how to determine efficacy, and the use of adjuvant interventions. The indications for all AADs are based on safety; the current AHA/ACC/HRS and ESC guidelines state that the choice of AAD is based on the presence or absence of structural heart disease (SHD), coronary artery disease, or heart failure (HF), with further recommendations in the ESC guidelines based on HF type (e.g., HF with reduced ejection fraction [HFrEF] versus HF with preserved ejection fraction [HFpEF]). The chapter closes with a discussion of the lack of consistent use of guideline-directed care, with a review of supportive data from the recently reported AIM-AF survey—a multinational survey on AF management that involved both cardiologists and electrophysiologists. In AIM-AF, inappropriate drug selection in terms of suitable candidate selection and drug choice occurred with all types of drugs and in most patient groups. Most notable was the overuse of amiodarone in patients without SHD, and the widespread use of sotalol, including its use in patients with HFrEF. Chapter 5 is summarized as follows:(1)It is important to differentiate between different types of HF (HFrEF versus HFpEF) when choosing AAD therapy.(2)Deviations from guidelines for the use of AADs are common, indicating a need for more education for healthcare providers.(3)Amiodarone is often used over other AADs, despite the known associated extracardiac toxicity risks, and its use is usually discordant with guidelines.(4)Survey responses indicate sustained widespread use of sotalol even though the 2020 ESC guidelines downgraded the recommendation for use of sotalol from Class Ia to Class IIb.

Atrial fibrillation (AF), the most common sustained arrhythmia, represents a significant burden to patients and healthcare systems. Many patients with AF are asymptomatic and often undiagnosed. Improved detection methods and surveillance have resulted in recognition of asymptomatic and subclinical AF, providing earlier diagnosis. The recent EAST-AFNET 4 and Korean studies have demonstrated early rhythm control (ERC) with antiarrhythmic drugs (AADs) or ablation in patients with AF improves outcomes. The EARLY AF and STOP AF First studies have shown that ERC using ablation can slow AF progression. In the following videos, the authors discuss the evolving AF landscape, with an emphasis on the benefits of early diagnosis and treatment. Historic rate versus rhythm control studies and their limitations are reviewed, followed by recent studies that support the use of ERC alongside usual care including rate control. Discussion of ERC treatment includes the selection of appropriate AADs based on safety, when to choose ablation as first-line therapy, and the complementary use of ablation and AADs. The authors summarize the current guidelines for the use of AADs to treat AF, highlighting the importance of concordance with those guidelines. Patient cases are used to relate the contents of the videos to clinical practice and are supplemented with discussion of the importance of shared decision-making involving the patient in treatment decisions. It is anticipated that this digital publication will enable cardiologists and primary care providers to recognize when early treatment of AF will improve patient outcomes, and to empower them to initiate that treatment accordingly.

Chapter 1 begins with data that show the rising prevalence of atrial fibrillation (AF), which is increasing in tandem with the growing number of older adults, increased survival of people who have cardiovascular (CV) disorders, and the expanding use of wearable and insertable/implantable devices capable of detection. Together, these increases will result in healthcare providers seeing more patients with AF who present at earlier stages of the disease. The panel discussion covers information regarding symptoms that are common to patients with AF as well as information about the important adverse outcomes that may occur in patients with AF, including heart failure, hospitalization, thromboembolism, and death. Notably, these events may reflect either the comorbidities commonly underlying AF, AF itself, or a combination of these conditions. The chapter also introduces the four pillars of therapy—“upstream therapy,” rate control, rhythm control, and embolic prevention—with an emphasis on early rhythm control as being optimal. Chapter 1 is summarized as follows:(1)The prevalence of AF is increasing because of the aging population and people with CV comorbidities living longer; this will increase disease burden in the near future.(2)Wearable technology is resulting in earlier detection of AF, creating a larger unmet need.(3)Primary care providers and general cardiologists (non-interventional) will begin to see more patients with AF who will present at earlier stages of the disease.(4)Patients (even without symptoms) should be treated earlier to achieve rate optimization and rhythm control, to delay deterioration in quality of life, and to prevent disease progression, thus reducing the overall burden to the healthcare system.

Associated with longer life expectancy, greater survival of patients with cardiovascular disorders, and increased use of wearable and insertable/implantable devices capable of detection, the frequency of atrial fibrillation (AF) diagnosis is increasing. This chapter describes two representative patient cases that were used to enable a discussion of the evaluation and management of AF in different scenarios. One patient is young and healthy with paroxysmal AF but no major comorbidities (though there is a family history of AF). The other is older with multiple complicating comorbidities. These cases sparked an active discussion among the panelists that demonstrated not only the multitude of considerations when choosing the optimal therapy for each individual, but also the individualistic differences in biases and styles that can exist between experts in the field. The results of these discussions revealed agreement that:(1)Considerations in rhythm control therapy should be based on individual patient needs.(2)Most antiarrhythmic drugs (AADs) have multichannel effects; these may be important determinants of their antiarrhythmic actions and non-cardiac effects.(3)Increasing awareness among healthcare providers (HCPs) of the properties of AADs helps them anticipate potential pro- or antiarrhythmic effects.(4)It is important for HCPs to involve patients (and caregivers) in decisions about their health using shared decision-making approaches.