AIMS:Cavotricuspid isthmus (CTI) ablation is a cornerstone therapy for typical atrial flutter (AFl) and is commonly performed during atrial fibrillation (AF) ablation. In this multicentre randomized trial, we compared a lattice-tip catheter with an irrigated focal-tip catheter for radiofrequency CTI ablation (LINEAR study-ClinicalTrials.gov NCT07078760). METHODS AND RESULTS:Patients were randomized to a lattice-tip, dual-energy catheter (lattice-tip group) or to a standard 3.5-mm irrigated radiofrequency catheter (standard group) in two centres. In the lattice-tip group, only radiofrequency was utilized. The primary endpoint was the achievement and persistence of bidirectional CTI block after a 60-minute waiting period, confirmed by high-density electroanatomical mapping and adenosine testing. Secondary endpoints included the rate of first-pass block, the number of lesions, and the ablation time. Procedural complications were recorded. In total, 102 patients were randomized. The primary endpoint was achieved in significantly more patients in the lattice-tip as compared to the standard group (94.1% vs. 68.6%, P = 0.002). The lattice-tip catheter resulted in a significantly higher rate of first-pass block (90.2% vs. 60.8%, P = 0.001). CTI block required significantly shorter ablation time (41.3 ± 12.1 vs. 245.3 ± 91.3 s, P < 0.001) and a significantly lower number of lesions (8.3 ± 2.4 vs. 13.4 ± 4.5, P < 0.001) in the lattice-tip as compared to the standard group. No procedural complications were documented. CONCLUSION:The lattice tip catheter resulted in higher acute procedural success for radiofrequency CTI ablation compared to the standard irrigated focal-tip catheter. Future studies are needed to assess long-term efficacy and clinical outcomes.

BACKGROUND:Atrial fibrillation (AF) increases cardiovascular risk in patients with chronic kidney disease (CKD). The safety and efficacy of early rhythm control (ERC) in patients with CKD is not fully established. OBJECTIVES:This predefined secondary analysis of the EAST-AFNET 4 trial assessed the effectiveness and safety of ERC in patients with CKD defined by estimated glomerular filtration rate (GFR). METHODS:EAST-AFNET 4 randomized patients with recently diagnosed AF and comorbidities to ERC or usual care (UC). Key outcomes were analyzed by Kidney Disease Improving Global Outcomes defined CKD groups. The primary efficacy outcome combined cardiovascular death, stroke, hospitalization for worsening heart failure, or acute coronary syndrome. The safety outcome combined death, stroke, and serious rhythm control-related adverse events. Recurrent AF was a secondary outcome. RESULTS:Baseline creatinine was available in 2,742 of 2,789 (98.3%) patients. In this study, 23% had CKD (GFR: <60 mL/min/1.73 m2). Patients with CKD were older (CKD: 74 ± 7.4 years; no CKD: 69 ± 8.3 years; P < 0.001), had higher CHA2DS2-VASc scores (CKD: 4 ± 1.4; no CKD: 3.2 ± 1.2; P < 0.001), and more primary outcome events over 5.1 years of follow-up (HR: 0.98 per mL GFR decrease [95% CI: 0.97-0.99 per mL GFR decrease]). ERC reduced the primary outcome with and without CKD (no CKD: ERC: 3.4%/100 patient-years; UC: 4.1%/100 patient-years; HR: 0.84; P < 0.001; CKD: ERC: 5.8%/100 patient-years; UC: 8.5%/100 patient-years; HR: 0.67; P < 0.001; Pinteraction = 0.133). CKD increased safety outcomes without interaction with ERC (Pinteraction = 0.927). Patients with CKD experienced more AF recurrences with UC (Pinteraction = 0.036). CONCLUSION:ERC effectively and safely reduces cardiovascular events in patients with recently diagnosed AF and stroke risk factors with and without CKD. (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST); NCT01288352).

The European Society of Cardiology (ESC) develops and updates clinical practice guidelines (CPGs) based on the latest evidence. However, their implementation remains suboptimal, leading to missed opportunities to improve cardiovascular (CV) outcomes. The success of CPG implementation is influenced by four key factors: (i) patient-related barriers, (ii) health care professionals' engagement, (iii) the clarity and usability of CPGs, and (iv) the health care system and economic context in which care is delivered. To address these challenges, innovative strategies are needed to bridge the gap between CPG recommendations and clinical practice. The ESC has developed several initiatives to improve implementation, including (i) educational programmes, (ii) examinations for cardiologists, (iii) accreditation policies, and (iv) registries. However, persistent gaps indicate that knowledge dissemination alone is insufficient. A more integrated, structured, and equitable approach to quality-of-care improvement is required. Despite the need for evidence-based implementation strategies, only a limited number of high-quality randomized controlled trials have evaluated individual approaches for CV conditions. Strategies such as text messaging, educational interventions, the involvement of non-physician health workers, structured order sheets, and financial incentives have been tested, but their feasibility and effectiveness can vary across health care systems. Future research should explore the potential of artificial intelligence-enhanced technologies to support and scale implementation efforts. This manuscript reviews current evidence on CPG implementation and proposes strategies to enhance the adoption of best practices in CV care.

BACKGROUND AND AIMS:This study aims to provide the most comprehensive assessment to date of interventional cardiology practices across European Society of Cardiology (ESC) national society member countries, with a focus on infrastructure, procedural volumes, temporal trends (2013-22), regional disparities, and adherence to guideline-recommended care. METHODS:The third edition of the ESC-European Association of Percutaneous Cardiovascular Interventions Atlas presents data from 50 ESC national society member countries, collected through a dedicated 2023 survey of national cardiac societies and interventional working groups. Data were subjected to a rigorous multi-step quality control process to ensure consistency and accuracy. Key metrics include interventional resources, such as the number of hospitals with catheterization laboratories, trained personnel, and the proportion of women in the interventional workforce; procedural volumes and types, including percutaneous coronary intervention (PCI), primary PCI, transcatheter aortic valve implantation, transcatheter mitral valve procedures, transcatheter tricuspid valve procedures; and procedural characteristics, including arterial access site, use of intracoronary imaging, physiological lesion assessment, and sex-specific data on patient care delivery. RESULTS:Despite the ongoing expansion of structural heart transcatheter interventions, PCI remains the dominant procedure, accounting for >90% of all percutaneous cardiovascular interventions. Percutaneous coronary intervention volumes showed limited variation across ESC member countries and demonstrated no significant association with gross national income per capita. In contrast, important regional disparities were observed in the use of transcatheter aortic valve implantation, transcatheter mitral valve procedures, and transcatheter tricuspid valve procedures with procedure rates strongly correlated with gross national income (r = .86; r = .63; and r = .64). Workforce data revealed that while women constitute 39% of all cardiologists, they represent only 10% of interventional cardiologists across ESC member countries. Although interventional cardiology has helped reduce female disparity in access compared with cardiac surgery, inequalities persist, e.g. <30% of PCI recipients are women, despite women representing >40% of patients with ischaemic heart disease. Temporal trend analysis showed a narrowing gap in PCI and primary PCI volumes between regions, reflecting improved access across all economic strata. However, growth in structural valve interventions remained disproportionately concentrated in wealthier countries. CONCLUSIONS:The third edition of the ESC-European Association of Percutaneous Cardiovascular Interventions Atlas highlights significant progress in percutaneous cardiovascular interventions across Europe but also underscores persistent disparities. These findings reinforce the need for balanced investment strategies, harmonized training, greater sex equity, and enhanced data infrastructures to support more equitable and evidence-based cardiovascular care.

Abstract Genome-wide association studies have revealed hundreds of genetic variants associated with cardiovascular diseases (CVD). Polygenic risk scores (PRS) can capture this information in a single metric and hold promise for use in CVD risk prediction. Importantly, PRS information can reflect the causally mediated risk to which the individual is exposed throughout life. Although European Society of Cardiology guidelines do not currently advocate their use in routine clinical practice, PRS are commercially available and increasingly sought by clinicians, health systems, and members of the public to inform personalized health care decision-making. This clinical consensus statement provides an overview of the scientific basis of PRS and evidence to date on their role in CVD risk prediction for the purposes of disease prevention. It provides the reader with a summary of the opportunities and challenges for implementation and identifies current gaps in supporting evidence. The document also lays out a potential roadmap by which the scientific and clinical community can navigate any future transition of PRS into routine clinical care. Finally, clinical scenarios are presented where information from PRS may hold most value and discuss organizational frameworks to enable responsible use of PRS testing while more evidence is being generated by clinical studies.

Genome-wide association studies have revealed hundreds of genetic variants associated with cardiovascular diseases (CVD). Polygenic risk scores (PRS) can capture this information in a single metric and hold promise for use in CVD risk prediction. Importantly, PRS information can reflect the causally mediated risk to which the individual is exposed throughout life. Although European Society of Cardiology guidelines do not currently advocate their use in routine clinical practice, PRS are commercially available and increasingly sought by clinicians, health systems, and members of the public to inform personalized health care decision-making. This clinical consensus statement provides an overview of the scientific basis of PRS and evidence to date on their role in CVD risk prediction for the purposes of disease prevention. It provides the reader with a summary of the opportunities and challenges for implementation and identifies current gaps in supporting evidence. The document also lays out a potential roadmap by which the scientific and clinical community can navigate any future transition of PRS into routine clinical care. Finally, clinical scenarios are presented where information from PRS may hold most value and discuss organizational frameworks to enable responsible use of PRS testing while more evidence is being generated by clinical studies.

AIMS:Patients with device-detected atrial fibrillation (DDAF) have a lower stroke risk than those with ECG-diagnosed AF, requiring careful evaluation of oral anticoagulation benefits vs. its inherent bleeding risk. METHODS AND RESULTS:An unmatched win ratio analysis was performed of the NOAH-AFNET 6 trial dataset, using components of the primary efficacy and safety outcomes of the trial. The primary analysis used this hierarchical order: (1) all-cause death, (2) stroke, (3) systemic or pulmonary embolism/myocardial infarction, and (4) major bleeding. Two additional analyses replaced all-cause death with cardiovascular death or included patient-reported outcomes. Win odds were calculated to account for undecided comparisons. Among 2534 patients 77 ± 7 years old, 947 (37%) women, median CHA2DS2-VA score 3 [interquartile range (IQR), 3-4], median follow-up 21 months (IQR, 10-38) 1 605 280 win ratio pairs were analyzed. The win ratio comparing edoxaban to no anticoagulation was 0.87 (95% CI: 0.68-1.10; P = 0.23). Most comparisons resulted in no clear winner (undecided pairs 84.9%). In the remaining comparisons, edoxaban won in 46% of the cases, placebo in 54%. Death and major bleeding were the most common events. The win odds was 0.98 (95% CI: 0.94-1.01; P = 0.23). CONCLUSIONS:This hypothesis-generating win ratio analysis, integrating death, thrombotic events, and major bleeds with and without quality of life, did not find an advantage of anticoagulation with edoxaban over no anticoagulation in patients with DDAF. The most common events were death and major bleeding.

Background:Atrial fibrillation (AF) is currently diagnosed by ECG, creating a binary, lifelong diagnosis. AF burden, estimated as the proportion of time spent in AF, quantifies AF severity dynamically. AF burden can modulate the risk of AF-related outcomes. Whether AF burden modulates cardiovascular outcomes with rhythm-control therapy is unknown. Methods:AF burden on early rhythm-control was estimated using supervised artificial-intelligence-based rhythm classification of patient-operated telemetric short-term ECGs in patients randomised to early rhythm-control in the EAST-AFNET 4 trial (NCT01288352, ISRCTN04708680, conducted between 2011 and 2020). ECGs were transmitted 1-2 times per week and during symptoms. A landmark was set at 12 months and efficacy and safety outcomes occurring during the subsequent 4.1 years of follow-up were compared by estimated AF burden quartiles (Q1-Q4). Findings:In 1178 patients (70 years, 47% women, CHA2DS2-VA 2.8 ± 1.2) transmitting 303,308 ECGs over 5.1 years, (median 1/week, IQR 1; 2) estimated AF burden was 6% [0%; 22%] in the first year of follow-up. Estimated AF burden below the median was associated with low rates of cardiovascular death, stroke, or unplanned hospitalisation for heart failure or acute coronary syndrome (Q1: 2.0 events/100 patient-years; Q2: 2.6 events/100 patient-years). A higher estimated AF burden was associated with higher event rates (Q3: 4.8 events/100 patient-years; Q4: 4.2 events/100 patient-years), comparable to events with usual care (4.5 events/100 patient-years). Sensitivity analyses confirmed these findings. Interpretation:These hypothesis-generating findings suggest that AF burden estimated by weekly short-term patient-operated ECGs modulates AF-related events on rhythm-control therapy. Pending validation and evaluation of residual confounding, estimation of AF burden can refine AF diagnosis. Funding:EAST-AFNET4 was supported by a grant from the German Ministry of Education and Research (01 GI0204) via the German Center for Cardiovascular Research (DZHK), the Atrial Fibrillation NETwork (AFNET), the European Heart Rhythm Association, St. Jude Medical/Abbott, Sanofi, and the German Heart Foundation. These analyses received additional support from the European Union (grant agreement 965286 [MAESTRIA]), British Heart Foundation (AA/18/2/34218), German Center for Cardiovascular Research supported by the German Ministry of Education and Research (DZHK, grant numbers DZHK FKZ 81X2800182, 81Z0710116, and 81Z0710110), German Research Foundation (Ki 509167694) and the Else Kröner-Fresenius Foundation, Dutch Heart Foundation (Grant number 01-002-2022-0118, EmbRACE), and the Leducq Foundation (2024, Immune Targets for Atrial Fibrillation).

BACKGROUND AND AIMS:The optimal antithrombotic therapy in patients with device-detected atrial fibrillation (DDAF) is unknown. Concomitant vascular disease can modify the benefits and risks of anticoagulation. METHODS:These pre-specified analyses of the NOAH-AFNET 6 (n = 2534 patients) and ARTESiA (n = 4012 patients) trials compared anticoagulation with no anticoagulation in patients with DDAF with or without vascular disease, defined as prior stroke/transient ischaemic attack, coronary or peripheral artery disease. Efficacy outcomes were the primary outcomes of both trials, a composite of stroke, systemic arterial embolism (SE), myocardial infarction, pulmonary embolism or cardiovascular death, and stroke or SE. Safety outcomes were major bleeding or major bleeding and death. RESULTS:In patients with vascular disease (NOAH-AFNET 6, 56%; ARTESiA, 46%), stroke, myocardial infarction, systemic or pulmonary embolism, or cardiovascular death occurred at 3.9%/patient-year with and 5.0%/patient-year without anticoagulation (NOAH-AFNET 6), and 3.2%/patient-year with and 4.4%/patient-year without anticoagulation (ARTESiA). Without vascular disease, outcomes were equal with and without anticoagulation (NOAH-AFNET 6, 2.7%/patient-year; ARTESiA, 2.3%/patient-year in both randomized groups). Meta-analysis found consistent results across both trials (I2heterogeneity = 6%) with a trend for interaction with randomized therapy (pinteraction = .08). Stroke/SE behaved similarly. Anticoagulation equally increased major bleeding in vascular disease patients [edoxaban, 2.1%/patient-year; no anticoagulation, 1.3%/patient-year; apixaban, 1.7%/patient-years; no anticoagulation, 1.1%/patient-year; incidence rate ratio 1.55 (1.10-2.20)] and without vascular disease [edoxaban, 2.2%/patient-year; no anticoagulation, 0.6%/patient-year; apixaban, 1.4%/patient-year; no anticoagulation, 1.1%/patient-year; incidence rate ratio 1.93 (0.72-5.20)]. CONCLUSIONS:Patients with DDAF and vascular disease are at higher risk of stroke and cardiovascular events and may derive a greater benefit from anticoagulation than patients with DDAF without vascular disease.

Atrial fibrillation (AF) is the most common cardiac arrhythmia encountered in clinical practice and is associated with significant morbidity and mortality. Even though catheter ablation has emerged as an available and effective treatment for AF, recurrence remains a significant challenge. This review presents the existing evidence on the prognostic role of microRNAs (miRNAs) in the prediction of AF recurrence after catheter ablation. We examined studies investigating the association between miRNA expression and post-ablation AF recurrence. Multiple miRNAs have been highlighted as potential biomarkers, which are involved in pathophysiological processes such as atrial remodeling, fibrosis, and inflammation. Despite some promising results, there has been significant heterogeneity across the studies. In this review, we demonstrate the potential miRNAs that can be routinely used as biomarkers of AF recurrence, and we identify areas that require further research to validate their clinical utility.

Atrial fibrillation (AFib), the most prevalent arrhythmia in clinical practice, presents a growing global health concern, particularly with the aging population, as it is associated with devastating complications and an impaired quality of life. Its pathophysiology is multifactorial, including the pathways of fibrosis, inflammation, and oxidative stress. MicroRNAs (miRNAs), small non-coding RNA molecules, have emerged as substantial contributors in AFib pathophysiology, by affecting those pathways. In this review, we explore the intricate relationship between miRNAs and the aforementioned aspects of AFib, shedding light on the molecular pathways as well as the potential diagnostic applications. Recent evidence also suggests a possible role of miRNA therapeutics in maintenance of sinus rhythm via the antagonism of miR-1 and miR-328, or the pharmacological upregulation of miR-27b and miR-223-3p. Unraveling the crosstalk between specific miRNA profiles and genetic predispositions may pave the way for personalized therapeutic approaches, setting the tone for precision medicine in atrial fibrillation.

Objective Cardiovascular disease (CVD) is the leading cause of death across Europe. We estimated lost earnings (productivity losses) associated with premature mortality due to CVD, and separately for its main sub-categories of coronary heart disease and cerebrovascular disease, across 54 country members of the European Society of Cardiology (ESC). Methods and results We used a standardized approach to estimate working years and earnings lost due to premature death resulting from CVD across the 54 ESC member countries in 2018. Our population-based approach was based on national data on the number of deaths, employment rates, and earnings by age group and sex. We discounted future working years and earnings lost to present values using a 3.5% annual rate. In 2018, there were 4.4 million deaths due to CVD across the 54 countries, with 7.1 million working years lost. This represented productivity losses due to premature death of _62 billion in 2018. Deaths due to coronary heart disease accounted for 47% (_29 billion) of all CVD costs, and cerebrovascular disease accounted for 18% (_11 billion). Approximately 60% (_37 billion) of all productivity losses occurred in the 28 European Union member states, despite accounting for only 42% (1.8 million) of deaths and 21% (1.5 million) of working years lost across the 54 countries. Conclusion Our study provides a snapshot of the economic consequences posed by premature mortality due to CVD across 54 countries in 2018. The considerable variation across countries highlights the potential gains from policies targeting prevention and care of cardiovascular diseases. [GRAPHICS]