Circulation Journal
Online ISSN : 1347-4820
Print ISSN : 1346-9843
ISSN-L : 1346-9843
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Displaying 1-18 of 18 articles from this issue
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Focus on issue: Arrhythmia / Electrophysiology
Reviews
  • Tomoya Hara, Masataka Sata
    Article type: REVIEW
    2025 Volume 89 Issue 2 Pages 150-152
    Published: January 24, 2025
    Released on J-STAGE: January 24, 2025
    Advance online publication: November 15, 2024
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    Anticoagulant therapy is a drug therapy that inhibits the formation of blood clots. Although anticoagulants are effective in preventing thromboembolism, they also carry the risk of bleeding, so they must be managed carefully, taking both efficacy and safety into account. Evidence regarding the effectiveness and safety of each anticoagulant has already accumulated through many large clinical trials and post-marketing surveillance. However, when making decisions in clinical practice, it is necessary to always take into consideration differences in patient populations between clinical trials and actual clinical practice, as well as differences in historical background. (For example, there are differences in antiplatelet drugs and coronary artery interventions that were mainly used in each era.) In this review we discuss the effectiveness and safety of currently used anticoagulants, focusing on different patient backgrounds and points to keep in mind regarding their proper use, based on the latest reports in Asian populations, especially Japanese people, over the past 1–2 years.

Original Articles
Atrial Fibrillation
  • Dorit Knappe, Julia Vogler, Jessica Weimann, Victor Banas, Julius Ober ...
    Article type: ORIGINAL ARTICLE
    Subject area: Atrial Fibrillation
    2025 Volume 89 Issue 2 Pages 153-161
    Published: January 24, 2025
    Released on J-STAGE: January 24, 2025
    Advance online publication: June 05, 2024
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    Supplementary material

    Background: Achieving early rhythm control and maintaining sinus rhythm are associated with improved outcomes in patients with atrial fibrillation (AF). Pulmonary vein isolation (PVI) is a validated alternative to medical rhythm control. This study determined associations between left atrial strain reservoir (LASR) and AF recurrence after PVI.

    Methods and Results: In all, 132 patients (88 with paroxysmal AF [PAF], 44 with persisting AF [PersAF]) who presented in sinus rhythm for de novo PVI of AF between December 2017 and January 2019 were included in the study. All patients underwent preprocedural echocardiography. After 12 months, all patients underwent 24-h Holter electrocardiogram monitoring to screen for AF recurrence. Kaplan-Meier curve analysis revealed an association between decreasing LASRand increased AF recurrence, with a cut-off at 31.4%. In univariable Cox regression analysis, LASRdemonstrated an association with AF recurrence, with hazard ratios (HR) of 0.83 (95% confidence interval [CI] 073–0.93; P=0.001) per 5% increase in univariable models and 0.83 (95% CI 073–0.95; P=0.005) in multivariable analysis. When clinical variables with age, sex and type of AF (PAF/PersAF) were included in the multivariable analysis, LASRremained relevant in a model with age (HR 0.86; 95% CI 073–1.00; P=0.046).

    Conclusions: In patients undergoing de novo PVI for AF, LASRcould be of use in risk stratification regarding AF recurrence.

  • Hidehira Fukaya, Keiko Ryo-Koriyama
    Article type: EDITORIAL
    2025 Volume 89 Issue 2 Pages 162-163
    Published: January 24, 2025
    Released on J-STAGE: January 24, 2025
    Advance online publication: July 31, 2024
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  • Toyonobu Tsuda, Kenshi Hayashi, Takeshi Kato, Takashi Kusayama, Yoichi ...
    Article type: ORIGINAL ARTICLE
    Subject area: Atrial Fibrillation
    2025 Volume 89 Issue 2 Pages 164-173
    Published: January 24, 2025
    Released on J-STAGE: January 24, 2025
    Advance online publication: August 27, 2024
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    Supplementary material

    Background: Anemia, a common comorbidity in older patients with heart failure (HF) and atrial fibrillation (AF), is associated with an increased risk of adverse events. This study evaluated the prognostic effects of longitudinal changes in anemia status on clinical outcomes in patients with AF.

    Methods and Results: We prospectively evaluated data of 1,388 patients with AF from the Hokuriku-Plus AF Registry (1,010 men; mean [±SD] age 72.3±9.7 years) and recorded the incidence of death, HF, thromboembolism, and major bleeding. Of these patients, the 1,233 for whom hemoglobin levels were available at baseline and at the 1-year follow-up were further evaluated. Patients were categorized into 3 groups based on longitudinal changes in 1-year anemia status: Group 1, AF without anemia; Group 2, AF with improved anemia; and Group 3, AF with sustained or new-onset anemia. Over the 1–5 years of follow up, the incidences of death, HF, thromboembolism, and major bleeding were significantly higher among patients with than without anemia. In addition, the incidence of death or HF was significantly higher in Group 3 than in Groups 1 and 2. Multivariate analysis revealed no anemia or improvement in anemia in 1 year as an independent predictor for a favorable prognosis for cardiovascular death and HF.

    Conclusions: Recovery from anemia may be associated with a favorable clinical course of AF.

  • Nobutoyo Masunaga, Mitsuru Ishii, Kouhei Oka, Keita Okamoto, Yusuke Yo ...
    Article type: ORIGINAL ARTICLE
    Subject area: Atrial Fibrillation
    2025 Volume 89 Issue 2 Pages 174-183
    Published: January 24, 2025
    Released on J-STAGE: January 24, 2025
    Advance online publication: October 31, 2024
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    Supplementary material

    Background: Anticoagulation therapy for atrial fibrillation (AF) has undergone major changes following the introduction of direct oral anticoagulants (DOAC) in 2011. However, the transition of anticoagulation therapy for AF patients with severe renal dysfunction remains to be elucidated.

    Methods and Results: Follow-up data, including creatinine clearance (CrCl), were available for 3,706 patients in the Fushimi AF Registry. We divided patients into 3 groups based on CrCl as follows: (1) CrCl ≥50 mL/min; (2) 50 mL/min>CrCl≥30 mL/min; and (3) CrCl <30 mL/min. In patients with CrCl ≥50 mL/min and 50>CrCl≥30 mL/min, prescription of oral anticoagulants increased year-by-year from 2011 to 2021 with a growing proportion of DOAC; however, the prescription of oral anticoagulants remained almost unchanged in those with CrCl <30 mL/min. In patients with CrCl ≥50 mL/min and 50 mL/min>CrCl≥30 mL/min, the incidence of adverse events, including stroke/systemic embolism and major bleeding, was lower among patients enrolled after 2014 than before 2013. However, these trends were not seen in patients with CrCl <30 mL/min.

    Conclusions: Despite the increased use of DOAC in patients with AF since 2011, anticoagulation therapy for AF patients with severe renal dysfunction has largely remained unchanged, and a reduction in adverse events in those patients has not been observed.

  • Takuma Minami, Takashi Yoshizawa, Kimihiko Murase, Akihiko Komasa, Tak ...
    Article type: ORIGINAL ARTICLE
    Subject area: Atrial Fibrillation
    2025 Volume 89 Issue 2 Pages 184-194
    Published: January 24, 2025
    Released on J-STAGE: January 24, 2025
    Advance online publication: November 12, 2024
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    Supplementary material

    Background: Sleep apnea (SA), subjective sleep duration (SSD), and objective sleep duration (OSD) were reported as risk factors for atrial fibrillation (AF). However, the association between AF and the combination of SA and OSD has not been clarified. Nor has a mismatch between SSD and OSD been investigated.

    Methods and Results: We assessed SA with polysomnography, OSD with actigraphy, and SSD in patients who underwent radiofrequency catheter ablation for persistent AF. We investigated associations among SA, OSD, OSD×3% oxygen desaturation index (3%ODI), and AF recurrence, considering SSD–OSD (i.e., the difference between SSD and OSD) and OSD. Seventy of 94 (74.4%) participants had moderate-to-severe SA (apnea-hypopnea index [AHI] ≥15). Participants were classified into OSD tertiles. Participants in Tertile 3 (mean OSD: 7.3 h) had decreased SSD–OSD (0.0 h) with increased Stage N1 sleep. Over 27.6 months, 10 AF recurrences occurred in 51 participants without treatment for SA. AHI ≥20 and OSD Tertile 3 were associated with AF recurrence (hazard ratios 5.7 [95% confidence interval 1.1–24.7] and 10.3 [95% confidence interval 1.2–88.4], respectively). Participants with AF recurrence had a higher OSD×3%ODI.

    Conclusions: SA and long OSD were predictors of recurrent AF through long exposure to intermittent hypoxia during sleep. SSD–OSD was low in patients with long OSD, possibly because of decreased sleep quality.

  • Hideki Kitahara, Tatsuro Yamazaki, Takashi Hiraga, Sakuramaru Suzuki, ...
    Article type: ORIGINAL ARTICLE
    Subject area: Atrial Fibrillation
    2025 Volume 89 Issue 2 Pages 195-203
    Published: January 24, 2025
    Released on J-STAGE: January 24, 2025
    Advance online publication: December 20, 2024
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    Supplementary material

    Background: Underdoses of direct oral anticoagulants (DOAC) are sometimes prescribed due to bleeding risk concerns in patients with atrial fibrillation (AF). We investigated the prevalence of DOAC underdosing and its impact on clinical outcomes in AF patients undergoing percutaneous coronary intervention (PCI).

    Methods and Results: This multicenter observational cohort study enrolled patients with AF on DOAC undergoing PCI between January 2015 and March 2021 at 15 institutions across Japan. Clinical outcomes within 1 year, including major adverse cardiovascular events (MACE), all-cause mortality, ischemic stroke, and major bleeding events, were evaluated. Of 623 patients enrolled, 167 (26.8%) received underdoses, 224 (36.0%) received appropriate low doses, 210 (33.7%) received appropriate standard doses, and 22 (3.5%) received overdoses. Clinical outcomes were compared between patients with underdoses (n=167) and appropriate doses (n=434). Although the incidence of MACE, all-cause mortality, and major bleeding events did not differ significantly between the 2 groups (log-rank P=0.850, P=0.163, and P=0.711, respectively), ischemic stroke occurred more frequently in the underdose than appropriate-dose group (log-rank P=0.011). After propensity score matching, the same result was observed for the frequency of ischemic stroke (log-rank P=0.026).

    Conclusions: Compared with appropriate doses of DOAC, DOAC underdosing was associated with a higher incidence of ischemic stroke, despite no significant difference in MACE, all-cause mortality, and major bleeding events in AF patients undergoing PCI.

Catheter Ablation
  • Halim Marzak, Justine Hammann, Kensuke Matsushita, Romain Ringele, Sim ...
    Article type: ORIGINAL ARTICLE
    Subject area: Catheter Ablation
    2025 Volume 89 Issue 2 Pages 204-213
    Published: January 24, 2025
    Released on J-STAGE: January 24, 2025
    Advance online publication: September 28, 2024
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    Supplementary material

    Background: Persistent atrial fibrillation (AF) patients with tachycardia-induced cardiomyopathy (TIC) undergoing catheter ablation have similar or even better outcomes than patients without TIC. Data regarding atrial substrate remodeling are scarce in cases of TIC. We assessed regional distribution of left atrial (LA) bipolar voltage, the extent of low-voltage zones (LVZs), and outcomes of voltage-guided ablation in AF patients with and without TIC.

    Methods and Results: In all, 139 patients with persistent AF presenting for a first voltage-guided catheter ablation were enrolled, 61 with TIC and 78 with structurally normal hearts. LA voltage maps were obtained using a 3-dimensional electroanatomical mapping system in sinus rhythm. LVZ was defined as <0.5 mV. Compared with non-TIC patients, TIC patients had a lower indexed LA volume (median [interquartile range] 58.6 [50.6–68.7] vs. 63.4 [60.1–76.1] mL/m2; P<0.01) and higher LA voltage (2.3 [1.5–2.8] vs. 1.7 [1–2.6] mV; P=0.02). LVZs were less frequently found in patients with than without TIC (8 [13.1%] vs. 30 [39%]; P<0.01). There was no significant difference in atrial tachyarrhythmia (AT)-free survival rate over a 36-month follow-up between the 2 groups (log-rank test, P=0.176). No predictor of AT recurrence was identified.

    Conclusions: TIC patients exhibit less LA substrate remodeling with a smaller LA volume, higher bipolar voltage, and fewer LVZs than non-TIC patients. They have a similar favorable outcome after a single procedure.

Devices
  • Ryobun Yasuoka, Masahiro Maruyama, Gaku Nakazawa, Takashi Noda, Takash ...
    Article type: ORIGINAL ARTICLE
    Subject area: Devices
    2025 Volume 89 Issue 2 Pages 214-223
    Published: January 24, 2025
    Released on J-STAGE: January 24, 2025
    Advance online publication: August 22, 2024
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    Supplementary material

    Background: Electrical storms (E-storms), defined as multiple fatal ventricular arrhythmias over a short period, negatively affect the prognosis of patients receiving an implantable cardioverter defibrillator or cardiac resynchronization therapy with a defibrillator (ICD/CRT-D). However, the prognostic impact of recurrent E-storms has not been well elucidated.

    Methods and Results: We analyzed the association between E-storm recurrences and mortality using data from 1,274 participants in the Nippon Storm Study, a prospective observational study conducted at 48 ICD/CRT-D centers in Japan. Differences in E-storm recurrences by patient characteristics were evaluated using the mean cumulative function (MCF), which is the cumulative number of E-storm episodes per patient as a function of time. Patients with multiple E-storms had a 3.39-fold higher mortality risk than those without E-storms (95% confidence interval 1.82–6.28; P<0.01). However, there was no significant difference in mortality risk between patients with a single E-storm and those without E-storms. The MCF curve exhibited a slower ascent in patients who received primary prevention ICD/CRT-D than in those who received secondary prevention ICD/CRT-D. However, when analyzing only patients with E-storms, the MCF curves demonstrated comparable trajectories in both groups.

    Conclusions: E-storm recurrences may have a negative impact on prognosis. Once patients with primary prevention experience an E-storm episode, they face a similar risk of subsequent recurrent E-storms as patients with secondary prevention.

  • Hiroyuki Sato, Takashi Noda, Tomohiro Ito, Nobuhiko Yamamoto, Takahiko ...
    Article type: ORIGINAL ARTICLE
    Subject area: Devices
    2025 Volume 89 Issue 2 Pages 224-233
    Published: January 24, 2025
    Released on J-STAGE: January 24, 2025
    Advance online publication: November 09, 2024
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    Supplementary material

    Background: Although the MADIT-ICD benefit score (MBS) helps select suitable implantable cardioverter defibrillator (ICD) candidates, optimal indicators for cardiac resynchronization therapy (CRT) remain uncertain. Evaluating the applicability of the MBS in Japanese CRT patients is imperative.

    Methods and Results: This multicenter study assessed the cumulative incidence of ventricular tachycardia/fibrillation (VT/VF) and non-arrhythmic mortality (AM) in CRT patients grouped according to potential benefit (lowest, highest, and intermediate). Among 400 primary prevention patients (mean age 65 years, 76% male), VT/VF occurred in 4 (7%), 68 (24%), and 14 (23%) patients in the lowest-, intermediate-, and highest-benefit groups, respectively (P=0.027), over a median follow-up of 34 months. Non-arrhythmic death was observed in 15 (25%), 91 (33%), and 9 (15%) patients in the lowest-, intermediate-, and highest-benefit groups, respectively (P=0.025). Multivariate analysis identified VT/VF score ≥7 (hazard ratio [HR] 2.14; 95% confidence interval [CI] 1.09–4.19; P=0.027) as a significant VT/VF predictor. The presence of left bundle branch block (HR 0.51; 95% CI 0.29–0.92; P=0.025) was associated with a reduced risk of VT/VF events. Non-AM score ≥3 (HR 1.70; 95% CI 1.01–2.88; P=0.047), systolic blood pressure <100 mmHg (HR 1.84; 95% CI 1.25–2.70; P=0.002), and estimated glomerular filtration rate <30 mL/min/1.73 m2(HR 1.98; 95% CI 1.23–3.20; P=0.005) were significant predictors of non-arrhythmic death.

    Conclusions: The MBS can identify suitable candidates for CRT-D among Japanese individuals.

Electrophysiology
  • Gaku Izumi, Satoru Shida, Norio Kobayashi, Hirokuni Yamazawa, Atsuhito ...
    Article type: ORIGINAL ARTICLE
    Subject area: Electrophysiology
    2025 Volume 89 Issue 2 Pages 234-239
    Published: January 24, 2025
    Released on J-STAGE: January 24, 2025
    Advance online publication: July 20, 2024
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    Background: Asymptomatic premature ventricular complex (PVC) in childhood often disappears over time. However, predictive factors for persistent PVC are unknown. We examined predictive factors for persistent PVCs on initial Holter electrocardiogram (ECG) in pediatric patients with asymptomatic PVC.

    Methods and Results: The initial Holter ECG findings of untreated PVC patients (n=216) between 2010 and 2021 were examined. Multivariable analysis was performed to clarify predictive factors for subsequent persistent PVC burden for each index (age, sex, PVC burden, PVC origin, minimum and maximum mean RR intervals [RRmin and RRmax, respectively]) of the 3 heartbeats of baseline sinus rhythm immediately before the PVC. The median age at initial Holter ECG was 11.6 years (range 5.8–18.8 years), the PVC burden was 5.22% (range 0.01–44.21%), RRmin was 660 ms, RRmax was 936 ms, RRrange (=RRmax−RRmin) was 273 ms, and 15 (7%) PVC runs were identified. The median follow-up period was 5.1 years (range 0.8–9.4 years), and the final Holter PVC burden was 3.99% (range 0–36.38%). In multivariate analysis, RRrange was the only independent risk factor for predicting a final Holter PVC burden >10%, with an area under the curve of 0.920 using an RRrange of 600 ms as the cut-off value.

    Conclusions: A wide RRrange at the initial Holter ECG may be a predictive indicator for persistent PVC in childhood.

  • Ryo Tateishi, Masato Shimizu, Makoto Suzuki, Eiko Sakai, Atsuya Shimiz ...
    Article type: ORIGINAL ARTICLE
    Subject area: Electrophysiology
    2025 Volume 89 Issue 2 Pages 240-250
    Published: January 24, 2025
    Released on J-STAGE: January 24, 2025
    Advance online publication: October 01, 2024
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    Supplementary material

    Background: Implantable cardioverter defibrillators (ICDs) reduce mortality associated with ventricular arrhythmia in high-risk patients with cardiovascular disease. Machine learning (ML) approaches are promising tools in arrhythmia research; however, their application in predicting ventricular arrhythmias in patients with ICDs remains unexplored. We aimed to predict and stratify ventricular arrhythmias requiring ICD therapy using 12-lead electrocardiograms (ECGs) in patients with an ICD.

    Methods and Results: This retrospective analysis included 200 adult patients who underwent ICD implantation at a single center. Patient demographics, clinical features, and 12-lead ECG data were collected. Unsupervised learning techniques, including K-means and hierarchical clustering, were used to stratify patients based on 12-lead ECG features. Dimensionality reduction methods were also used to optimize clustering accuracy. The silhouette coefficient was used to determine the optimal method and number of clusters. Of the 200 patients, 59 (29.5%) received appropriate therapy. The mean age of patients was 62.3 years, and 81.0% were male. The mean follow-up period was 2,953 days, with no significant intergroup differences. Hierarchical clustering into 3 clusters proved to be the most accurate (silhouette coefficient=0.585). Kaplan-Meier curves for these 3 clusters revealed significant differences (P=0.026).

    Conclusions: We highlight the potential of ML-based clustering using 12-lead ECGs to help in the risk stratification of ventricular arrhythmia. Future research in a larger multicenter setting may provide further insights and refine ICD indications.

Rapid Communications
  • Masaru Kato, Shunsuke Kawatani, Takuya Tomomori, Akihiro Okamura, Yasu ...
    Article type: RAPID COMMUNICATION
    2025 Volume 89 Issue 2 Pages 251-254
    Published: January 24, 2025
    Released on J-STAGE: January 24, 2025
    Advance online publication: December 06, 2024
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    Background: The Apple Watch (AW) can record single-lead electrocardiograms (ECGs) and has been investigated for arrhythmia detection. In this study we evaluated its accuracy in identifying the origin of premature ventricular contractions (PVCs) vs. standard 12-lead ECGs.

    Methods and Results: A total of 7 patients with PVCs were assessed using both 12-lead and AW ECG recordings. The QRS polarity observed in the AW recordings was consistent with that of the standard ECGs in most cases, demonstrating its utility in estimating three distinct PVC origins.

    Conclusions: The AW holds potential as an auxiliary tool for PVC origin assessment, contributing to arrhythmia management in clinical practice.

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