Background:Patients with atrial fibrillation (AF) face significant bleeding risks, particularly those receiving oral anticoagulation; however, existing risk scores such as HAS-BLED and ORBIT demonstrate limited predictive accuracy. Pulse pressure (PP), calculated as the difference between systolic blood pressure (SBP) and diastolic blood pressure, is a noninvasive marker of arterial stiffness that has been associated with cardiovascular outcomes. However, PP has not been evaluated as a predictor of bleeding in this population. Objective:This study evaluated whether elevated PP independently predicts major bleeding events, overall and by subtype, in patients with AF after adjusting for established clinical risk factors. Methods:We conducted a retrospective cohort study using electronic health records from REACHnet, a PCORnet-affiliated clinical data network in Louisiana. A total of 4935 adults (mean age 63.7, SD 11.0 y; n=1606, 32.5% female) with AF between 2010 and 2019 were included via consecutive sampling of all eligible patients. PP was derived from outpatient blood pressure measurements closest to AF diagnosis and analyzed in tertiles (low: <46, middle: 46-62, high: >62 mm Hg) and continuously per 10 mm Hg. The primary outcome was time to the first bleeding event, a composite of gastrointestinal bleeding, intracranial hemorrhage, and other clinically significant bleeding, identified using ICD-9/ICD-10 codes. Kaplan-Meier survival curves with log-rank testing were used for univariable analysis. Multivariable Cox proportional hazards regression was adjusted for age, sex, race, comorbidities, medications, and the ORBIT score. A sensitivity analysis applied multivariable logistic regression additionally incorporating SBP. Statistical significance was set at P<.05. Results:Over a 5-year follow-up, 677 out of 4935 (13.7%) patients experienced a bleeding event (intracranial hemorrhage: n=60, 1.2%; gastrointestinal bleeding: n=195, 4.0%; and other bleeding: n=149, 3.0%). Gastrointestinal bleeding differed significantly across PP tertiles (P=.007). Kaplan-Meier analysis confirmed lower gastrointestinal bleeding-free survival in the highest tertile (log-rank P=.004). No significant differences were observed for intracranial (P=.08), other (P=.58), or composite bleeding (P=.22). In multivariable Cox regression, each 1 mm Hg increase in PP was independently associated with a 1.4% higher gastrointestinal bleeding risk (hazard ratio 1.014, 95% CI 1.001-1.028; P=.04), approximately 15% per 10 mm Hg. This remained significant after adjusting for SBP and ORBIT score (odds ratio 1.013/mm Hg, 95% CI 1.001-1.025; P=.03), while SBP was not independently significant (P=.13). Conclusions:PP independently predicts gastrointestinal bleeding risk in patients with AF beyond established clinical risk factors and validated bleeding risk scores. Unlike prior investigations that examined SBP or diastolic blood pressure components in isolation, this is the first study to identify PP as a predictor of gastrointestinal bleeding in this population. As a readily available, low-cost hemodynamic parameter derived from routine clinical measurements, PP could enhance existing risk stratification tools and inform more personalized bleeding risk management strategies in patients with AF.

BACKGROUND:Female sex is a part of the stroke risk stratification in atrial fibrillation (AF), although emerging evidence suggests it may function as a risk modifier rather than an independent risk factor. OBJECTIVES:This study aimed to determine whether female sex is a risk factor or risk modifier for stroke in patients with AF. METHODS:Using TriNetX, nonvalvular AF patients were identified and stratified by sex and age (<65, 65-74, and ≥75 years). Female and male patients were propensity matched for comorbidities and anticoagulation. Analyses were conducted comparing male and female patients with no CHA2DS2-VA risk factors beyond age and with one additional CHA2DS2-VA risk factor. The risks of stroke and arterial embolism were compared over a 1-year follow-up period. RESULTS:In patients without additional CHA2DS2-VA risk factors or anticoagulation (n = 252,528), female sex was associated with increased stroke risk only among patients aged ≥75 years (HR: 1.244; 95% CI: 1.087-1.423; P = 0.001). Similarly, in patients with one additional CHA2DS2-VA risk factor (n = 607,612), stroke risk was increased among female patients ≥75 years (HR: 1.065; 95% CI: 1.014-1.118; P = 0.012). CONCLUSIONS:Female sex acts as a modest risk modifier for thromboembolic stroke. Increased risk is primarily observed in patients with greater comorbidity burden or advanced age (≥75 years).

BACKGROUND:Concomitant pulmonary vein isolation (PVI) and left atrial appendage occlusion (LAAO) is increasingly performed in patients with atrial fibrillation (AF) at elevated thromboembolic risk. Radiofrequency ablation (RFA) has been the conventional approach, but pulsed field ablation (PFA) may reduce tissue edema, procedural duration, and peridevice leak (PDL). OBJECTIVE:To compare safety, efficacy, and PDL rates between PFA + LAAO and RFA + LAAO. METHODS:In this single-center, retrospective study, 175 consecutive patients undergoing LAAO with or without concomitant PVI between September 2021 and May 2025 were included: RFA + LAAO (n = 61), PFA + LAAO (n = 39), and LAAO-only (n = 75). Procedural data, device characteristics, and complications were collected. The primary endpoint was PDL at 45-day follow-up transesophageal echocardiography (TEE). Secondary endpoints included procedure duration, vascular and esophageal complications, device-related thrombosis, and arrhythmia recurrence. RESULTS:Baseline characteristics were generally balanced, although RFA + LAAO patients were younger. No large PDL (> 5 mm) was observed. At 45 days, small PDL (≤ 5 mm) was significantly higher in RFA + LAAO (23%) vs. PFA + LAAO (5.1%) and LAAO-only (9.3%; p = 0.015). Mean procedure duration was shorter with PFA + LAAO (67.1 ± 10.4 min) compared with RFA + LAAO (99.6 ± 12.8 min; p < 0.001). Major complications and device-related thrombosis were rare. Minor complications and AF recurrence were comparable across groups. CONCLUSIONS:Concomitant PFA + LAAO is associated with lower PDL incidence and shorter procedural times compared with RFA + LAAO, without compromising safety.

For patients with persistent atrial fibrillation (PersAF), initial treatment strategies often involve rate or rhythm control before offering ablation. This study compared two approaches: (1) catheter ablation without prior medication (referred to as direct-to-catheter ablation, DTCA) and (2) catheter ablation after initial rate control with either diltiazem or metoprolol. This study included two independentanalyses of patients with persistent atrial fibrillation (PersAF) undergoing catheter ablation. Aimed at evaluating the potential impact of pre-ablation rate control medications including beta blockers and calcium channel blockers on post-ablation outcomes. Comparison 1: DTCA without prior beta-blocker use (n = 209) vs. metoprolol use prior to ablation (n = 260). Comparison 2: DTCA without prior calcium channel blocker use (n = 639) vs. diltiazem use prior to ablation (n = 55). Patients were followed for 18 months to evaluate primary outcome: recurrence of atrial fibrillation (AF) and secondary outcomes: Pre-ablation and Post-ablation left atrial percent fibrosis as seen on LGE MRI and Quality of life (QoL), measured with the SF-36 questionnaire. The Wilcoxon tests were conducted to compare the QoL and fibrosis among groups. Time to recurrence among the groups post ablation was assessed via Kaplan-Meier curves. Multivariable Cox models were developed to adjust for other confounders of AF recurrence. In the beta-blocker analysis (n = 469), no significant difference in AF recurrence was observed between patients without prior beta-blocker use (DTCA group) and those treated with metoprolol (Kaplan-Meier, p > 0.05). Similarly, in the calcium channel blocker analysis (n = 694), no difference in recurrence was found between the DTCA group and those with prior diltiazem use (p > 0.05). Multivariable Cox models confirmed that neither metoprolol (p = 0.44) nor diltiazem (p = 0.34) independently predicted AF recurrence. Additionally, no significant differences were found in imaging metrics or QoL between the groups in either comparison (all p > 0.05). Prior treatment with diltiazem or metoprolol before ablation of PersAF did not show additional benefits in reducing patient outcomes such as AF recurrence, fibrosis, or improving QoL.