Background/Objectives: Atrial fibrillation (AF) is the most common sustained arrhythmia in adults, with a prevalence that increases with age. In older patients, its clinical impact is particularly relevant due to higher mortality and greater comorbidity burden. This study aimed to compare patients aged ≥80 years with younger patients in a large AF cohort. Methods: The REGUEIFA registry is an observational, prospective, multicentre study including consecutive patients with AF managed by cardiologists. Baseline clinical characteristics, comorbidities, complementary test findings, AF type, therapeutic strategies, anticoagulation patterns, and patient-reported outcomes were compared. Results: A total of 1007 patients were included, of whom 18.2% were aged ≥80 years. Older patients showed a higher prevalence of hypertension, renal dysfunction, conduction disorders, chronic obstructive pulmonary disease, and neoplastic disease, along with higher thromboembolic (CHA2DS2-VASc 3.7 ± 1.04 vs. 2.1 ± 1.49; p < 0.001) and haemorrhagic risk (HAS-BLED 1.3 ± 0.8 vs. 0.6 ± 0.7; p < 0.001). Permanent AF was more frequent, whereas rhythm control strategies and antiarrhythmic drug use were less common, and quality of life was poorer. Anticoagulation rates were high in both groups (≈90%), with greater use of vitamin K antagonists (VKAs) in older patients, although anticoagulation control was similar. Patients treated with direct-acting oral anticoagulants reported a lower treatment burden and greater perceived benefit than those receiving VKAs. Conclusions: Patients aged ≥80 years with AF exhibit greater comorbidity, poorer perceived health status, and higher thromboembolic and haemorrhagic risk. Their management is more often oriented towards rate control strategies and VKA use, while rhythm control approaches are more common in younger patients.
Real-world comparisons of venetoclax (VEN)-based versus hypomethylating agent (HMA) monotherapy in unfit, newly diagnosed AML remain limited by short follow-up, low genomic testing, and inadequate statistical power. We conducted the largest comparative analysis to date from the PETHEMA registry, including 2,610 patients (929 VEN-based, 1,681 HMA). Composite complete remission was higher with VEN-based therapy (64.4% vs 20.0%; P < 0.001), and both 30-day (4.8% vs 7.5%; P = 0.011) and 60-day mortality (9.7% vs 15.7%; P < 0.001) were significantly lower. Median overall survival was 11.4 versus 8.2 months (HR, 0.66; 95% CI, 0.60–0.73; P < 0.001), consistent with that of VIALE-A (HR, 0.66) despite a broader cohort (ECOG 3–4, 4.7%; secondary AML, 42.5%; adverse-risk cytogenetics, 36.5%). The benefit was confirmed by propensity score matching (HR, 0.66), era-restricted analysis (HR, 0.71), and multivariable Cox regression. A molecular gradient of benefit emerged — greatest in IDH2 (HR, 0.43), NPM1 (0.46), FLT3 -ITD (0.48), IDH1 (0.55), and favorable-risk cytogenetics (0.25). In TP53 -mutated AML, OS improved significantly (HR, 0.70) but remained dismal (7.0 vs 3.7 months); no benefit was observed in AML arising from antecedent MDS or MPN. These findings confirm and extend VIALE-A, refining patient selection for VEN-based therapy in routine practice.
Pulmonary vein (PV) plus posterior wall (PW) isolation is often performed as an empirical strategy in non-paroxysmal atrial fibrillation (AF) patients. This approach is traditionally guided by anatomical landmarks and assumes that PVs and PW harbor triggers contributing to initiation, as well as drivers maintaining AF. An ultrahigh density mapping (UHD) tool has been recently developed, which automatically assesses ablation targets with consistent morphology and activations from intracardiac electrograms (EGMs). To describe the distribution of left atrial (LA) regions of interest (ROIs) featuring EGMs denoting stable localized reentry and report the acute results of an individualized pulsed field ablation (PFA) strategy where isolation of PVs and PW is optimized to include adjacent ROIs detected by the algorithm. We enrolled 36 non-paroxysmal AF patients undergoing first-time ablation at 3 European centers. LA mapping was performed during AF by using a 64-pole catheter. The target number of EGMs was >25000. PFA was performed via a 5-spline catheter. After PV and PW isolation, ablation was extended to ROIs adjacent to the PVs or PW. We included 25 (69.4%) persistent and 11 (30.6%) long-standing persistent AF patients (67.6+/-9.4 years, 63.9% males, median AF duration: 4.3 [interquartile range (IQR): 2.6-12] months). LA mapping time was 19.3+/-11.1 min (mean EGMs: 31872+/-19249). A median of 3 [3-4] AF sources were detected; 28 (77.8%) and 28 (77.8%) patients had ≥1 ROI harbored at the PV antra (median: 1.5 [1-2]) or PW (median: 1 [1-2]), respectively. Further PFA was delivered to 1.5 [1-2] ROIs adjacent to the PV/PW isolation area in 22 (61.1%) patients. PFA led to AF termination in 26 (72.2%) patients; 58.3% was in sinus rhythm after ablation. AF termination occurred concomitantly to ablation of a ROI in 63.9% of patients. Overall, 79+/-19 PFA applications were delivered; LA dwelling time (mapping plus ablation) was 68+/-30 min. None of the patients experienced any major periprocedural complications. Individualized PV and PW isolation to target sites with stable localized rotational activations detected by the novel AF Mapping EGM-based tool effectively terminated AF in 72.2% of patients. Follow-up data to assess the impact of this ablation strategy in the long-term are warranted.LA Map showing a Ockham point
Background/Objectives: Atrial fibrillation (AF) represents the most common sustained cardiac arrhythmia, and its incidence rises markedly with advancing age. The relative prognostic impact of age compared with AF type remains uncertain. This study assessed the association between age, AF type, and clinical outcomes in a large real-world AF cohort. Methods: This study was based on data from the prospective, observational, multicentre REGUEIFA registry, which includes consecutive patients with AF treated at eight hospitals in northwestern Spain. Patients were stratified by age and AF type. Baseline characteristics, comorbidities, treatments, and risk scores were collected. Patients were followed for at least 2 years, and outcomes included all-cause mortality, heart failure (HF) worsening, stroke, and a composite endpoint. Results: A total of 997 patients were included. Increasing age was associated with a worse clinical profile, with higher comorbidity burden and increased thromboembolic and bleeding risk. During follow-up, adverse events increased stepwise with age, including mortality, HF worsening, and the composite endpoint. AF type was not independently associated with outcomes after multivariable adjustment. Rhythm-control strategy was independently associated with a lower risk of the composite endpoint. Age remained an independent predictor of all outcomes. Risk of the composite endpoint increased across age groups (HR 2.01 for 75–84 years; 2.34 for 85–89 years; 6.50 for ≥90 years vs. <75 years). Each additional year of age was associated with a 9% higher mortality risk (HR 1.09; 95% CI 1.06–1.13). Conclusions: In this prospective real-world cohort of patients with AF, age was the strongest and most consistent predictor of adverse clinical outcomes, whereas AF type lost prognostic significance after adjustment. These findings support age and overall clinical burden as key determinants of prognosis, favouring a patient-centred approach over AF subtype classification.
