Background We present a case of short QT syndrome (SQTS) initially manifesting as atrial fibrillation (AF) and degenerating to polymorphic ventricular tachycardia (PMVT), successfully managed with quinidine. Case Summary A 66-year-old man presented with palpitations and was found to be in AF with a QTc interval of 335 ms. He developed PMVT with hemodynamic collapse, requiring 3 successive defibrillation shocks. Refractory to amiodarone and lidocaine, he met Gollob criteria for SQTS. He was successfully managed with oral quinidine, resulting in QTc normalization to 430 ms. A secondary prevention implantable cardioverter-defibrillator was implanted. Genetic testing was unrevealing. He remained arrhythmia-free at 6 months. Discussion With an estimated prevalence of 0.02%, SQTS is frequently underrecognized. This case underscores the specific efficacy of quinidine in normalizing the QT interval and suppressing malignant ventricular arrhythmias in SQTS. Take-Home Message Prompt recognition of a short QTc interval is crucial in patients presenting with PMVT, as diagnosis directs targeted pharmacologic therapy with quinidine.

Importance:In the US, approximately 10.55 million adults have atrial fibrillation (AF). AF is associated with significantly increased risk of stroke, heart failure, myocardial infarction, dementia, chronic kidney disease, and mortality. Observations:Symptoms of AF include palpitations, dyspnea, chest pain, presyncope, exertional intolerance, and fatigue, although approximately 10% to 40% of people with AF are asymptomatic. AF can be detected incidentally during clinical encounters, with wearable devices, or through interrogation of cardiac implanted electronic devices. In patients presenting with ischemic stroke without diagnosed AF, an implantable loop recorder (ie, subcutaneous telemetry device) can evaluate patients for intermittent AF. The 2023 American College of Cardiology (ACC)/American Heart Association (AHA)/American College of Clinical Pharmacy (ACCP)/Heart Rhythm Society (HRS) Guideline writing group proposed 4 stages of AF evolution: stage 1, at risk, defined as patients with AF-associated risk factors (eg, obesity, hypertension); stage 2, pre-AF, signs of atrial pathology on electrocardiogram or imaging without AF; stage 3, the presence of paroxysmal (recurrent AF episodes lasting ≤7 days) or persistent (continuous AF episode lasting >7 days) AF subtypes; and stage 4, permanent AF. Lifestyle and risk factor modification, including weight loss and exercise, to prevent AF onset, recurrence, and complications are recommended for all stages. In patients with estimated risk of stroke and thromboembolic events of 2% or greater per year, anticoagulation with a vitamin K antagonist or direct oral anticoagulant reduces stroke risk by 60% to 80% compared with placebo. In most patients, a direct oral anticoagulant, such as apixaban, rivaroxaban, or edoxaban, is recommended over warfarin because of lower bleeding risks. Compared with anticoagulation, aspirin is associated with poorer efficacy and is not recommended for stroke prevention. Early rhythm control with antiarrhythmic drugs or catheter ablation to restore and maintain sinus rhythm is recommended by the 2023 ACC/AHA/ACCP/HRS Guideline for some patients with AF. Catheter ablation is first-line therapy in patients with symptomatic paroxysmal AF to improve symptoms and slow progression to persistent AF. Catheter ablation is also recommended for patients with AF who have heart failure with reduced ejection fraction (HFrEF) to improve quality of life, left ventricular systolic function, and cardiovascular outcomes, such as rates of mortality and heart failure hospitalization. Conclusions and Relevance:AF is associated with increased rates of stroke, heart failure, and mortality. Lifestyle and risk factor modification are recommended to prevent AF onset, recurrence, and complications, and oral anticoagulants are recommended for those with an estimated risk of stroke or thromboembolic events of 2% or greater per year. Early rhythm control using antiarrhythmic drugs or catheter ablation is recommended in select patients with AF experiencing symptomatic paroxysmal AF or HFrEF.

ImportanceIn the US, approximately 10.55 million adults have atrial fibrillation (AF). AF is associated with significantly increased risk of stroke, heart failure, myocardial infarction, dementia, chronic kidney disease, and mortality.ObservationsSymptoms of AF include palpitations, dyspnea, chest pain, presyncope, exertional intolerance, and fatigue, although approximately 10% to 40% of people with AF are asymptomatic. AF can be detected incidentally during clinical encounters, with wearable devices, or through interrogation of cardiac implanted electronic devices. In patients presenting with ischemic stroke without diagnosed AF, an implantable loop recorder (ie, subcutaneous telemetry device) can evaluate patients for intermittent AF. The 2023 American College of Cardiology (ACC)/American Heart Association (AHA)/American College of Clinical Pharmacy (ACCP)/Heart Rhythm Society (HRS) Guideline writing group proposed 4 stages of AF evolution: stage 1, at risk, defined as patients with AF-associated risk factors (eg, obesity, hypertension); stage 2, pre-AF, signs of atrial pathology on electrocardiogram or imaging without AF; stage 3, the presence of paroxysmal (recurrent AF episodes lasting ≤7 days) or persistent (continuous AF episode lasting >7 days) AF subtypes; and stage 4, permanent AF. Lifestyle and risk factor modification, including weight loss and exercise, to prevent AF onset, recurrence, and complications are recommended for all stages. In patients with estimated risk of stroke and thromboembolic events of 2% or greater per year, anticoagulation with a vitamin K antagonist or direct oral anticoagulant reduces stroke risk by 60% to 80% compared with placebo. In most patients, a direct oral anticoagulant, such as apixaban, rivaroxaban, or edoxaban, is recommended over warfarin because of lower bleeding risks. Compared with anticoagulation, aspirin is associated with poorer efficacy and is not recommended for stroke prevention. Early rhythm control with antiarrhythmic drugs or catheter ablation to restore and maintain sinus rhythm is recommended by the 2023 ACC/AHA/ACCP/HRS Guideline for some patients with AF. Catheter ablation is first-line therapy in patients with symptomatic paroxysmal AF to improve symptoms and slow progression to persistent AF. Catheter ablation is also recommended for patients with AF who have heart failure with reduced ejection fraction (HFrEF) to improve quality of life, left ventricular systolic function, and cardiovascular outcomes, such as rates of mortality and heart failure hospitalization.Conclusions and RelevanceAF is associated with increased rates of stroke, heart failure, and mortality. Lifestyle and risk factor modification are recommended to prevent AF onset, recurrence, and complications, and oral anticoagulants are recommended for those with an estimated risk of stroke or thromboembolic events of 2% or greater per year. Early rhythm control using antiarrhythmic drugs or catheter ablation is recommended in select patients with AF experiencing symptomatic paroxysmal AF or HFrEF.

BACKGROUND:Cognitive impairment is strongly associated with atrial fibrillation (AF). Rate and rhythm control are the two treatment strategies for AF and the effect of treatment strategy on risk of cognitive decline and frailty is not well established. We sought to determine how treatment strategy affects geriatric-centered outcomes. METHODS:The Systematic Assessment of Geriatric Elements-AF (SAGE-AF) was a prospective, observational, cohort study. Older adults with AF were prospectively enrolled between 2016 and 2018 and followed longitudinally for 2 years. In a non-randomized fashion, participants were grouped by rate or rhythm control treatment strategy based on clinical treatment at enrollment. Baseline characteristics were compared. Longitudinal binary mixed models were used to compare treatment strategy with respect to change in cognitive function and frailty status. Cognitive function and frailty status were assessed with the Montreal Cognitive Assessment Battery and Fried frailty phenotype tools. RESULTS:972 participants (mean age = 75, SD = 6.8; 49% female, 87% non-Hispanic white) completed baseline examination and 2-year follow-up. 408 (42%) were treated with rate control and 564 (58%) with rhythm control. The patient characteristics of the two groups were different at baseline. Participants in the rate control group were older, more likely to have persistent AF, prior stroke, be treated with warfarin and have baseline cognitive impairment. After adjusting for baseline differences, participants treated with rate control were 1.5 times more likely to be cognitively impaired over 2 years (adjusted OR: 1.47, 95% CI:1.12, 1.98) and had a greater decline in cognitive function (adjusted estimate: -0.59 (0.23), p < 0.01) in comparison to rhythm control. Frailty did not vary between the treatment strategies. CONCLUSIONS:Among those who had 2-year follow-up in non-randomized observational cohort, the decision to rate control AF in older adults was associated with increased odds of decline in cognitive function but not frailty.

Background: Sex differences in cardiac arrhythmias are well-established and partly attributed to sex hormones. Aim: We aimed to explore the prevalence of arrhythmias in transgender and nonbinary ( TGNB ) adults. Methods: This cross-sectional study utilized patient electronic medical records from a single community healthcare center specializing in TGNB care. Adults aged ≥18 years with ≥2 medical visits between January 1, 2010, and December 31, 2021, were categorized into self-reported gender groups as TGNB (transgender man[TGM], transgender woman[TGW], nonbinary-assigned male at birth, nonbinary-assigned female at birth) and cisgender (cisgender man[CisM] or cisgender woman[CisW]). We categorized arrhythmias as atrial, ventricular, or other. Descriptive statistics characterized the prevalence of arrhythmias by gender group. Age- and race-adjusted Firth-type logistic regression models compared TGNB patients to CisM and CisW. The prevalence of arrhythmias was also descriptively explored in nonbinary people and in TGNB people with a gender-affirming hormone therapy (GAHT) prescription. Results: Among 49,862 adults, 7121 (14%) identified as TGNB persons. Participants were young (median age 28 years-old) and prevalence of arrhythmias was low (0.7-1.4% in nonbinary persons, 1.4-1.5% in transgender persons). Adjusting for age and race, TGM and TGW had a similar risk of arrhythmias compared to CisM (TGW: OR=0.89 (0.63-1.24), p=0.52; TGM: OR=1.17 (0.82-1.62), p=0.37), but statistically significantly higher odds of arrhythmias compared to CisW (TGW: OR=1.65 (1.13-2.34), p=0.01; TGM: OR=2.15 (1.48-3.04), p<0.01). Prevalence of arrhythmias appeared similar among TGNB adults who used GAHT and those who did not (1.5% vs 1.9% in TGM, 1.2% vs 2.1% in TGW). Conclusion: Further research examining arrhythmias in TGNB patients and across gender minority subgroups is warranted, including longitudinal studies evaluating the potential impact of GAHT.

BACKGROUND:The insertion of a PIVC is the most commonly performed invasive procedure in healthcare. Despite its frequency in placement in hospitalized patients, PIVCs are generally perceived as being safe; however, the prevalence of failure ranges from 35%-50%. Additionally, complications are common and often deemed 'acceptable' by clinicians. Healthcare provider and clinician foundational knowledge and competency is lacking nationally. Considering the mere volume of PIVCs placed, the failure and complication rates, the human impact is significant. METHODS:The Association for Vascular Access (AVA) has led a collaborative effort with representatives from the Infusion Nurses Society (INS), the American Association of Critical Care Nurses (AACN), ECRI, and content experts representing nursing vascular access, infusion therapy, infection prevention, critical care, pediatrics, healthcare leadership, a physician, and a patient representative. Our aim is to provide concise guidance that will enhance and standardize practices related to PIVC. By consolidating current standards of practice into a comprehensive document, our framework seeks to advance the quality of care and improve patient safety. RESULTS:This document has undergone meticulous scrutiny to ensure its quality, including incorporation of current standards, methodology for consensus from the expert panel, and input received from public comments. CONCLUSIONS:We anticipate that this work will have a significant impact on healthcare professionals, policymakers, and, most importantly, patients' experiences by the promotion of consistent, high-quality treatment, safety, and comfort for patients receiving a PIVC.

Most prior studies on the prognostic significance of newly-diagnosed atrial fibrillation (AF) in COVID-19 did not differentiate newly-diagnosed AF from pre-existing AF. To determine the association between newly-diagnosed AF and in-hospital and 30-day mortality among regular users of Veterans Health Administration using data linked to Medicare. We identified Veterans aged ≥ 65 years who were hospitalized for ≥ 24 h with COVID-19 from 06/01/2020 to 1/31/2022 and had ≥ 2 primary care visits within 24 months prior to the index hospitalization. We performed multivariable logistic regression analyses to estimate adjusted risks, risk differences (RD), and odds ratios (OR) for the association between newly-diagnosed AF and the mortality outcomes adjusting for patient demographics, baseline comorbidities, and presence of acute organ dysfunction on admission. Of 23,299 patients in the study cohort, 5.3% had newly-diagnosed AF, and 29.2% had pre-existing AF. In newly-diagnosed AF adjusted in-hospital and 30-day mortality were 16.5% and 22.7%, respectively. Newly-diagnosed AF was associated with increased mortality compared to pre-existing AF (in-hospital: OR 2.02, 95% confidence interval [CI] 1.72–2.37; RD 7.58%, 95% CI 5.54–9.62) (30-day: OR 1.86; 95% CI 1.60–2.16; RD 9.04%, 95% CI 6.61–11.5) or no AF (in-hospital: OR 2.24, 95% CI 1.93–2.60; RD 8.40%, 95% CI 6.44–10.4) (30-day: 2.07, 95% CI 1.80–2.37; RD 10.2%, 95% CI 7.89–12.6). There was a smaller association between pre-existing AF and the mortality outcomes. Newly-diagnosed AF is an important prognostic marker for patients hospitalized with COVID-19. Whether prevention or treatment of AF improves clinical outcomes in these patients remains unknown.

This case report documents the management of a 66-year old man with atrial fibrillation with recent placement of a WATCHMAN® Flex atrial appendage occlusion device. The patient presented with renal failure, abdominal pain, and difficulty walking 2 months after placement. The WATCHMAN® Flex device was found to have embolized to his abdominal aorta at the level of the renal arteries with associated thrombus. Extensive workup revealed reduced left ventricular cardiac function and decreased renal function, both of which were felt to be potentially reversible with device removal. The patient then underwent retrieval of the device and all associated thrombus via an open retroperitoneal approach. This case demonstrates a potential consequence of implanting devices such as an atrial appendage occlusion device and describes a technique for removal.

The Apple watch (AW) irregular rhythm notification (IRN) feature uses photoplethysmography to identify prolonged episodes of irregular rhythm suggestive of atrial fibrillation (AF). IRN is FDA cleared for those with no previous history of AF, however, these devices are increasingly being used for AF management.

AIMS Limited data exist to describe the prognostic impact of atrial fibrillation (AF) and oral anticoagulation on patients with alcoholic cardiomyopathy (ACM) compared with dilated cardiomyopathy (DCM) and were investigated in this study. METHODS Using Danish nationwide registries, a cohort analysis was conducted to assess the prognostic differences for patients with a first diagnosis of ACM versus DCM with and without AF 1994-2018 (followed until end 2019). Our study also assessed differences in mortality following initiation of anticoagulation in both populations. RESULTS Totally, 1237 patients with ACM (33% with AF) and 17,211 individuals with DCM (33% with AF) were included. Those with ACM were more often men (89 versus 71%) and younger than patients with DCM (mean age 56 versus 64 years). Cumulative 5-year mortality was greater among patients with ACM, compared with DCM, regardless of AF (ACM with AF 49% [95% CI: 44-54%], ACM without AF 48% [45-53%], DCM with AF 41% [39-42%], DCM without AF 30% [29-31%], P < 0.0001). The prognosis associated with AF was statistically significantly different in people with ACM and DCM (adjusted hazards ratio 0.85 [95% CI: 0.74-0.98] versus 1.04 [1.00-1.09] in ACM and DCM, P < 0.0001). The mortality associated with oral anticoagulation was similar in ACM and DCM (hazards ratio 0.81 [0.61-1.07] versus 0.87 [0.80-0.94], P = 0.49). CONCLUSIONS Patients with ACM had a worse prognosis when compared with patients with DCM, but this did not appear to be driven by AF. Patients with ACM were observed to have similar associated risk benefits of oral anticoagulation as DCM.

Purpose Few studies have examined the relationship between poor atrial fibrillation-related quality of life (AFQoL) and a battery of geriatric factors. The objective of this study is to describe factors associated with poor AFQoL in older adults with atrial fibrillation (AF) with a focus on sociodemographic and clinical factors and a battery of geriatric factors. Methods Cross-sectional analysis of a prospective cohort study of participants aged 65+ with high stroke risk and AF. AFQoL was measured using the validated Atrial Fibrillation Effect on Quality of Life (score 0-100) and categorized as poor (<80) or good (80-100). Chi-square and t-tests evaluated differences in factors across poor AFQoL and significant characteristics (P < 0.05) were entered into a logistic regression model to identify variables related to poor AFQoL. Results Of 1244 participants (mean age 75.5), 42% reported poor AFQoL. Falls in t he past 6 months, pre/frail and frailty, depression, anxiety, social isolation, vision impairment, oral anticoagulant therapy, rhythm control, chronic obstructive pulmonary disease and polypharmacy were associated with higher odds of poor AFQoL. Marriage and college education were associated with a lower odds of poor AFQoL. Conclusions More than 4 out of 10 older adults with AF reported poor AFQoL. Geriatric factors associated with higher odds of reporting poor AFQoL include recent falls, frailty, depression, anxiety, social isolation and vision impairment. Findings from this study may help clinicians screen for patients with poor AFQoL who could benefit from tailored management to ensure the delivery of patient-centered care and improved well being among older adults with AF.

In older patients with atrial fibrillation (AF), physical, cognitive, and psychosocial limitations are prevalent. The prognostic value of these conditions for major bleeding is unclear. To determine whether geriatric conditions are prospectively associated with major bleeding in older patients with AF on anticoagulation. Multicenter cohort study with 2-year follow-up from 2016 to 2020 in Massachusetts and Georgia from cardiology, electrophysiology, and primary care clinics. Diagnosed with AF, age 65 years or older, CHA2DS2-VASc score of 2 or higher, and taking oral anticoagulant (n=1,064). A total of 6507 individuals were screened. A six-component geriatric assessment of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Main outcome was major bleeding adjudicated by a physician panel. At baseline, participants were, on average, 75.5 years old and 49% were women. Mean CHA2DS2-VASc score was 4.5 and the mean HAS-BLED score was 3.3. During 2.0 (± 0.4) years of follow-up, 95 (8.9%) participants developed an episode of major bleeding. After adjusting for key covariates and accounting for competing risk from death, cognitive impairment (hazard ratio [HR] 1.62, 95% confidence interval [CI]: 1.02–2.56) and frailty (HR 2.77, 95% CI 1.38–5.58) were significantly associated with the development of major bleeding. In older patients with AF taking anticoagulants, cognitive impairment and frailty were independently associated with major bleeding.

BACKGROUND:As patient prices for many medications have risen steeply in the United States, patients may engage in cost-reducing behaviors (CRBs) such as asking for generic medications or purchasing medication from the Internet. OBJECTIVE:The objective of this study is to describe patterns of CRB, cost-related medication nonadherence, and spending less on basic needs to afford medications among older adults with atrial fibrillation (AF) and examine participant characteristics associated with CRB. METHODS:Data were from a prospective cohort study of older adults at least 65 years with AF and a high stroke risk (CHA2DS2VASc ≥ 2). CRB, cost-related medication nonadherence, and spending less on basic needs to afford medications were evaluated using validated measures. Chi-square and t tests were used to evaluate differences in characteristics across CRB, and statistically significant characteristics (P < 0.05) were entered into a multivariable logistic regression to examine factors associated with CRB. RESULTS:Among participants (N = 1224; mean age 76 years; 49% female), 69% reported engaging in CRB, 4% reported cost-related medication nonadherence, and 6% reported spending less on basic needs. Participants who were cognitively impaired (adjusted odds ratio 0.69 [95% CI 0.52-0.91]) and those who did not identify as non-Hispanic white (0.66 [0.46-0.95]) were less likely to engage in CRB. Participants who were married (1.88 [1.30-2.72]), had a household income of $20,000-$49,999 (1.52 [1.02-2.27]), had Medicare insurance (1.38 [1.04-1.83]), and had 4-6 comorbidities (1.43 [1.01-2.01]) had significantly higher odds of engaging in CRB. CONCLUSION:Although CRBs were common among older adults with AF, few reported cost-related medication nonadherence and spending less on basic needs. Patients with cognitive impairment may benefit from pharmacist intervention to provide support in CRB and patient assistance programs.

Implantable loop recorder (ILR) is recommended to detect subclinical atrial fibrillation (AF) after cryptogenic stroke; however, the clinical outcomes of this practice is unclear. We conducted a systematic review and meta-analysis of randomized controlled trials to evaluate 12-month AF detection, change in oral anticoagulation (OAC), and recurrent stroke in ILR versus usual care after ischemic stroke. We searched Medline, Embase, Web of Science, Cochrane Library for randomized controlled trials comparing ILR with usual care after any ischemic stroke. Primary outcomes were cumulative AF detection and recurrent stroke (ischemic or hemorrhagic) or transient ischemic attack over 12 months. Secondary outcome was OAC initiation. Meta-analysis was performed with Mantel-Haenszel pooled odds ratios (ORs) and random effects models. Of 200 identified articles, 3 trials were included (1,233 participants). Cryptogenic stroke and underlying AF included cryptogenic stroke only, stroke of known cause and underlying-AF included small or large vessel stroke only, and post embolic rhythm detection with implantable vs external monitoring included all ischemic strokes. The 12-month AF detection was 13% in the ILR group and 2.4% in controls. ILR was more likely to detect AF compared with usual care (OR 5.8, 95% confidence interval 3.2 to 10.2). Stroke or transient ischemic attack occurred in 7% with ILR and 9% with usual care (OR 0.8, 95% confidence interval 0.5 to 1.2). In patients with detected AF, 97% and 100% were started on OAC in cryptogenic stroke and underlying AF and post embolic rhythm detection with implantable vs external monitoring, respectively, compared with 68% in stroke of known cause and underlying-AF. In conclusion, ILR was superior to usual care in AF detection, but the relative low incidence of AF and the nondifferential risk of stroke between the ILR and usual care arms may suggest that most patients do not benefit from ILR implantation. Further studies are warranted to understand if patient selection can be improved to increase the diagnostic yield of ILR.

Background: New-onset atrial fibrillation (AF) during sepsis carries a high risk of death. Its prognostic value in COVID-19 has not been established. Methods: We used national data from the US Veterans Health Administration services to identify patients hospitalized with COVID-19 during 3/1/20-4/1/2021 and ≥ 65 yrs at admission. To maximize diagnostic specificity of new AF, we restricted our analyses to patients with ≥ 4 primary care visits within the prior 24 months. AF status was classified as new-onset, pre-existing and no AF. Primary outcomes were in-hospital and 30-day mortality. Secondary outcomes were initiation of mechanical ventilation, admission to intensive care unit (ICU), and ICU death. We adjusted logistic regression models for demographics and baseline comorbidities. Results: Of 11,791 COVID-19 hospitalized patients (mean age 77 yrs, 99% men, 69% White, 27% Black), 659 (5.6%) developed new-onset AF, 3,202 (27%) had pre-existing AF and 7,930 (67%) had no AF. Prevalence of baseline comorbidities was lower in new-onset AF than in pre-existing AF. Patients with new-onset AF had longer hospital stay and were more likely to receive COVID-19

The Apple Watch (AW) Irregular Rhythm Notification (IRN) feature uses photoplethysmography to identify prolonged episodes of irregular rhythm suggestive of atrial fibrillation (AF). IRN is FDA cleared for those with no previous history of AF, however, these devices are increasingly being used for AF management.