The prognostic significance of non-sustained ventricular tachycardia (NSVT) in Japanese patients receiving implantable cardioverter defibrillators (ICDs) for primary prevention remains unclear. This study aimed to verify the prognostic value of NSVT as recommended in the 2018 Japanese Circulation Society guideline. We analyzed 638 patients with structural heart disease who received an ICD or cardiac resynchronization therapy with defibrillator for primary prevention in the Nippon Storm Study. Analysis 1 (n=429) evaluated the association between NSVT history and predefined endpoints in patients with ischemic heart disease (IHD) or non-ischemic heart disease (non-IHD) and reduced left ventricular ejection fraction. Analysis 2 (n=357) assessed the prognostic impact of NSVT documented by Holter electrocardiography across 2 subgroups: Subgroup 1, IHD and non-IHD; and Subgroup 2, other cardiac diagnoses. Endpoints included appropriate ICD therapy, electrical storm, ventricular fibrillation (VF), shock therapy, and mortality. In Analysis 1, a history of NSVT was not significantly associated with appropriate ICD therapy or other major adverse outcomes. In Analysis 2, Holter-documented NSVT was independently associated only with appropriate ICD therapy (hazard ratio [HR] 1.82; 95% confidence interval 1.04-3.18; P=0.035). This association was significant in Subgroup 2, but not in Subgroup 1. NSVT was modestly associated (HR 1.82) with appropriate ICD therapy but not with VF or mortality, suggesting reconsideration of its clinical role.
Previous clinical studies reported that testosterone replacement therapy unexpectedly increased cardiovascular (CV) events in elderly men, through an unknown underlying mechanism. Because nitric oxide (NO) production is reduced in elderly men, we hypothesized that testosterone exerts harmful CV effects under reduced NO production, and examined this hypothesis using a 2/3 nephrectomized triple neuronal/inducible/endothelial NO synthases (NOS)-knockout (NX-TKO) mouse model that causes death from myocardial infarction (MI). The survival rate was markedly worse in male NX-TKO mice than in male NX-wild-type (NX-WT) mice. Orchiectomy (ORX) significantly aggravated the survival rate in NX-WT mice, but significantly improved it in NX-TKO mice. In the NX-TKO-ORX mice, long-term subcutaneous treatment with testosterone significantly deteriorated the survival rate, the incidence of MI, and CV risk factors. Furthermore, testosterone-induced aortic relaxations were significantly more impaired in the TKO than in the WT mice. RNA sequencing in the hearts of TKO-ORX mice without and with testosterone treatment indicated possible involvements of immunity- and inflammation-mediated mechanisms in the harmful CV effects of testosterone. These results provide the first evidence that testosterone exerts harmful CV effects, including shorter survival, increased incidence of MI, impaired arterial relaxation, and exacerbated cardiovascular risk factors, in the absence of NOS in mice. Our findings may explain in part why testosterone replacement therapy increases CV events in elderly men.
Beyond low-density lipoprotein cholesterol (LDL-C), small dense LDL-C (sdLDL-C) is a residual risk factor for atherosclerotic cardiovascular disease. However, whether sdLDL-C levels can predict the development of chronic kidney disease remains unclear. We investigated the association between the sdLDL-C level calculated using Sampson's equation and the progression of renal impairment in 16,814 Japanese individuals (10,806 men, 6,008 women; mean age: 47 years) who underwent annual health checkups. Participants were divided into 4 groups according to high (H) or low (L) sdLDL-C and LDL-C levels. Over a 10-year follow-up period, 2,533 participants progressed renal impairment, defined as an estimated glomerular filtration rate <60 mL/min/1.73 m2or positive for urine protein. Cox proportional hazards model with a restricted cubic spline after adjustment for confounders showed a gradual increase in the hazard ratio (HR) for renal impairment with high levels of sdLDL-C. Compared with the L-sdLDL-C/L-LDL-C group (reference) the adjusted HRs for renal impairment were significantly higher in the H-sdLDL-C/H-LDL-C and H-sdLDL-C/L-LDL-C groups (1.13 [95% confidence interval 1.03-1.25] and 1.15 [95% confidence interval 1.03-1.29], respectively). The addition of a high sdLDL-C level (≥35.7 mg/dL) to traditional risk factors significantly improved the discriminatory capacity for renal impairment. A high calculated sdLDL-C level was an independent predictor for the progression of renal impairment regardless of LDL-C level in a general Japanese population.
Using the Japan Organ Transplant Network national waitlist, this study investigated confounding factors for waitlist mortality and transplant probability among adult heart transplant candidates, focusing on heart disease and change in status (from registration to observation on June 30, 2024), to provide insights into the use of underlying heart disease or severity in the current revision of the heart transplant allocation criteria. All-cause waitlist mortality and heart transplantation probability were assessed using Gray's test, as well as univariate and multivariate Fine-Gray subdistribution hazard regression models. After excluding heart-lung transplantation candidates, patients with missing data, patients who were never on the waitlist after revision of the Organ Transplant Act, and patients aged <18 and ≥60 years at the time of registration, 1,522 patients were included in the final cohort. Heart transplant candidates with congenital heart disease had a higher risk of mortality, whereas patients waiting for retransplantation had no chance of transplantation and all died. The mortality rate was significantly higher for patients listed as Status 2 (unchanged) at observation than those listed as Status 1 (unchanged). Prioritization of candidates with congenital heart disease should be considered to reduce the risk of mortality while patients are on the transplant waitlist.
The use of information and communication technology (ICT) as a strategy to improve the quality of emergency medical care is gaining attention. A survey was conducted to investigate the extent to which ICT is being used in cardiovascular emergencies. A web-based questionnaire survey targeting cardiovascular surgery, cardiology, and emergency medicine departments at 320 facilities was conducted. The survey questions focused primarily on the presence and effectiveness of image sharing between hospitals and information sharing with emergency technicians using ICT, challenges in the use of ICT, and barriers hindering ICT adoption. The adoption rates of ICT for image sharing in cardiovascular surgery and electrocardiogram transmission in cardiology were 24% and 28%, respectively. ICT implementation was evaluated as being highly useful not only for reducing time to treatment but also for improving collaboration between medical professionals both within and outside the hospital. In emergency medicine, ICT collaboration with emergency technicians was implemented at 38% of hospitals, with image sharing at the emergency scene being prevalent. In cardiovascular surgery, 29% of facilities reported that the number of non-urgent transfers decreased or decreased significantly due to ICT implementation. Although ICT utilization remains at 20-25%, expectations for its widespread adoption are extremely high. Conversely, concerns about the costs and differences in ICT platforms are common, and there is a desire to adopt compatible systems.
The retrograde approach improves the procedural success rate of chronic total occlusion percutaneous coronary interventions (CTO-PCIs). However, it remains unclear whether the primary retrograde approach (PRA) offers benefits in terms of procedural success and burden/resource use in challenging cases. Therefore, we compared efficacy between the primary antegrade approach (PAA) and PRA in complex CTO-PCIs. This single-center retrospective cohort study included all patients undergoing coronary CTO-PCI attempted by experienced high-volume operators between January 2016 and July 2023. The difficulty of the antegrade approach was determined using the Japanese CTO score, and the feasibility of interventional collaterals was determined using the collateral channel score. In 698 patients undergoing CTO-PCI, the overall technical and initial guidewire success rates were 91.4% and 83.8%, respectively. Of 380 patients with a Japanese CTO score ≥3 and a collateral channel score ≥2, PAA and PRA were performed in 161 (42.4%) and 219 (57.6%) patients, respectively. Initial guidewire success was higher with PRA than PAA (88.1% vs. 78.9%; P=0.01), and bail-out success was higher for a retrograde than antegrade approach (91.2% vs. 56%; P=0.0019). PRA was associated with longer guidewire crossing time, longer fluoroscopy time, and greater contrast use. In patients with challenging CTO, poor antegrade conditions, and feasible interventional collaterals, PRA achieved higher initial guidewire success at the expense of higher procedural burden/resource use.
The interventricular septum contributes 30-60% of right ventricular (RV) output. However, few studies have assessed the prognostic value of RV septal strain in pulmonary embolism (PE). We hypothesized that RV septal strain would predict 30-day mortality in patients with intermediate-risk PE. This retrospective cohort study analyzed consecutive patients with intermediate-risk PE admitted to the Penn State Health Milton S. Hershey Medical Center between 2010 and 2018. The primary outcome was 30-day all-cause mortality. RV septal strain was measured within the RV endocardium and was defined as the mean of basal, mid, and apical septal longitudinal strain. Among 251 patients, 31 (12.4%) died within 30 days of PE diagnosis. RV strain analysis was feasible in 230 (91.6%) patients. RV septal strain was significantly lower in those who died and was independently associated with 30-day mortality (P<0.001). Receiver operating characteristic curve analysis indicated 14.4% as the optimal RV septal strain cut-off value (area under the curve 0.816). Kaplan-Meier curves demonstrated that 30-day mortality risk was higher among patients with low (≤14.4%) than high (>14.4%) RV septal strain (hazard ratio 9.29; P<0.001). RV septal strain is a feasible and reproducible parameter with strong prognostic value in patients with intermediate-risk PE. These findings highlight the central role of the interventricular septum in RV function and risk stratification.
Because vascular regeneration of diabetic lower limb ischemia (LLI) and prevention of disease progression is a major problem, we explored the molecular mechanism of E2F transcription factor 5 (E2F5) in regulating autophagy to promote angiogenesis in diabetic HLI. The streptozotocin-induced diabetic mice model, hindlimb ischemia (HLI) model and high glucose (HG)-induced human umbilical vein endothelial cells (HUVECs) were constructed for in vivo and in vitro assays. Autophagy inhibitor, 3-methyladenine, reversed the effects of E2F5 overexpression on microtubule-associated protein 1 light chain 3B (LC3B) expression, cell proliferation, migration and tube formation, supporting the involvement of autophagy in E2F5-mediated HUVEC restoration. In vivo injection of E2F5 overexpressed lentivirus also promoted angiogenesis in diabetic HLI mice, concomitant with autophagy activation. Phosphorylated yes-associated protein (pYAP) expression in HUVECs was upregulated after HG treatment and E2F5 overexpression reversed this change. pYAP colocalized with CD31, and pYAP expression was decreased after E2F5 overexpression. Treatment with Ki16425 increased pYAP expression and affected the influence of E2F5 on the proliferation, migration and tubule formation of HUVECs, and LC3B expression. E2F5 promoted angiogenesis by downregulating pYAP, which is associated with autophagy activation. These findings provide a novel therapeutic strategy for diabetic LLI.
Early detection of subclinical worsening heart failure (HF) is essential to enable timely, proactive treatment that may alter the clinical course and prevent hospitalization. This study demonstrates how early non-invasive telemonitoring of respiratory stability time (RST) can detect subclinical worsening HF. Daily RST was calculated automatically from all-night respiratory signals in 66 patients. Subclinical worsening was detected by declines in RST preceding overt worsening HF in the control group (blinded to RST; n=35) and in the RST group (RST monitored daily by clinicians; n=31). The RST recovery zone sufficient to avert hospitalization was determined by RST responses to treatment escalation for overt worsening HF. Two clinically relevant RST thresholds were identified: RST <20 s, indicating a high-risk zone for subclinical worsening preceding hospitalization; and RST ≥30 s, defining a recovery target zone associated with hospitalization avoidance. The duration of subclinical worsening HF from the onset of RST decline <20 s to overt worsening was 40.0 days in the control group. In contrast, the interval from the onset of overt worsening HF to hospitalization was markedly shorter (control group, 7.5 days; RST group, 8.0 days). Noninvasive RST telemonitoring enables early detection of the prolonged subclinical worsening phase of HF and provides a clinically actionable biological target for proactive intervention aimed at preventing HF-related hospitalization.
Mac-2 binding protein glycosylation isomer (M2BPGi) is a validated biomarker for liver fibrosis in chronic liver disease. We investigated the clinical significance of serum M2BPGi concentrations in patients with Fontan circulation. We prospectively measured serum M2BPGi concentrations in 426 consecutive Fontan patients (mean [±SD] age 23±10 years) and analyzed their associations with patients' pathophysiology, including Fontan-associated liver disease (FALD), as well as all-cause unplanned hospitalization (UPH) and mortality. M2BPGi concentrations were associated with a wide range of Fontan-related pathophysiological features, including characteristic Fontan hemodynamics, total bile acid concentrations, FALD indices such as hepatic fibrosis markers and ultrasonographic image abnormalities, and impaired renal function. Among these variables, older age at Fontan operation, hypoxemia, C-reactive protein, total bile acid levels, and indices of hepatic fibrosis were independently associated with higher M2BPGi concentrations (P<0.05-0.001). During follow-up after the M2BPGi evaluation, 68 patients experienced UPH and 14 patients died. Elevated M2BPGi concentrations were associated with a higher risk of UPH and all-cause mortality (P<0.0001 for both), independent of elevated B-type natriuretic peptide levels. Serum M2BPGi concentrations reflect both FALD pathophysiology and hemodynamic burden, serving as a strong prognostic biomarker. M2BPGi can be a valuable tool for risk stratification in patients with Fontan failure, including those with FALD.
Clinical outcome determinants in cardiac stereotactic body radiotherapy (cardiac-SBRT)/stereotactic arrhythmia radioablation (STAR), a minimally invasive therapy for refractory ventricular tachycardia (VT), remain unclear. We report the final analysis of Japan's first prospective study following a previously published interim report. Between 2019 and 2024, 8 patients with recurrent VT refractory to medical therapy and unsuitable for or refractory to catheter ablation were enrolled. Primary endpoints were safety and VT suppression. Exploratory analyses examined irradiation distribution and autonomic function. Median age was 69 years (75% male), ejection fraction 25%, and median follow-up 2.2 years. Targets were defined using multimodal assessment, with a median planning target volume of 88.9 cc. Treatment-related adverse events included only grade 1 nausea (n=1). Implantable cardioverter-defibrillator shock suppression was 73.6% at 6 months and 76.8% at 1 year. Antitachycardia pacing suppression reached 97.9%, with near-complete suppression in 5 survivors. Analyses remained descriptive and hypothesis-generating. Heart rate variability suggested increased parasympathetic activity, and 123I-metaiodobenzylguanidine imaging indicated reduced washout rate. Three patients died within 2 years but had advanced preexisting heart failure; irradiation more often involved inferior segments. Survival differences were not explained by cohort-level B-type natriuretic peptide levels or systolic function changes. Cardiac-SBRT/STAR achieved sustained arrhythmia suppression. Heart failure severity, irradiation location, and autonomic function, with their interaction, may be associated with clinical outcomes.
The prevalence of patients with heart failure with preserved ejection fraction (HFpEF) who meet the insurance eligibility criteria in Japan for obesity treatment with the glucagon-like peptide-1 receptor agonist (GLP-1RA), and the dual glucose-dependent insulinotropic polypeptide and GLP-1 receptor agonist (GIP/GLP-1RA) remains unclear. This subanalysis of the PARACLETE study included compensated ambulatory patients with HFpEF. Among the 3706 patients, 654 (17.6%) were eligible for GLP-1RA and GIP/GLP-1RA. Eligible patients had more severe symptoms despite higher prescription rates of HF-related medications. Among patients with HFpEF in Japan, 17.6% met the insurance eligibility criteria for obesity treatment with GLP-1RA and GIP/GLP-1RA.
Chronic kidney disease is associated with an increased incidence of stent thrombosis (ST) following drug-eluting stent (DES) implantation, but the clinical outcomes after DES-ST in hemodialysis (HD) patients compared with non-HD patients have not been fully elucidated. From the REAL-ST registry, we evaluated 655 patients with DES-ST, divided into 2 groups: HD group (n=59) and non-HD group (n=596). The primary endpoint was the cumulative 3-year incidence of all-cause death after the index ST event. Late ST was more prevalent in the HD group, whereas early and very late ST were common in the non-HD group. Following the index ST event, the HD group showed significantly higher 3-year incidences of all-cause death (48.2% vs. 22.9%, P=0.0005), cardiac death (33.4% vs.15.8%, P=0.003) and target lesion revascularization (TLR: 36.2% vs. 17.5%, P=0.0002) compared with the non-HD group. The cumulative 3-year incidence of recurrent ST did not differ significantly between groups (7.3% vs. 5.9%, P=0.88). After multivariable adjustment, HD remained significantly associated with an increased risk of all-cause death (adjusted hazard ratio [aHR], 1.95; 95% confidence interval [CI], 1.25-3.04; P=0.003), cardiac death (aHR, 1.75; 95% CI, 1.02-2.99; P=0.04) and TLR (aHR, 2.63; 95% CI, 1.52-4.57; P<0.001). Compared with non-HD patients, HD patients experienced worse clinical outcomes following their index DES-ST event.
We investigated associations between the low-density lipoprotein cholesterol (LDL-C) to high-density lipoprotein cholesterol (HDL-C) ratio (L/H ratio) and cardiovascular events in high-risk type 2 diabetes (T2D) patients with diabetic retinopathy receiving statins. We conducted a post hoc analysis of the EMPATHY study, a randomized controlled trial comparing intensive vs. standard statin therapy in T2D patients with retinopathy and hypercholesterolemia without cardiovascular disease. Baseline and 12-month (12M) L/H ratios were assessed as single and serial measures. Baseline data were available for 5,006 patients (median L/H ratio 2.016), categorized as having either a high (≥2.0) or low (<2.0) L/H ratio. Over a median 36.8-month follow-up, 184 cardiovascular events occurred. The risk of cardiovascular events was higher in the group with a high than low L/H ratio, even after adjusting for age, sex, and LDL-C (hazard ratio 1.89; 95% confidence interval 1.31-2.73; P<0.001); 12M L/H ratio analysis yielded similar results. In serial categories, both low-high (baseline <2.0; 12M ≥2.0) and high-high (baseline ≥2.0; 12M ≥2.0) groups had higher risk than the low-low group (baseline <2.0; 12M <2.0). No significant interactions were observed by age, sex, LDL-C, HDL-C, or statin intensity. An L/H ratio ≥2.0 identifies increased cardiovascular risk in statin-treated T2D patients with diabetic retinopathy and hypercholesterolemia without prior cardiovascular disease. Serial L/H ratio assessment may aid risk stratification in this high-risk population.
Prolonged QRS is an established marker of adverse outcomes in patients with heart failure with reduced ejection fraction (HFrEF). However, the prognostic significance of modest QRS prolongation (120-149 ms; mid-range QRS) remains unclear, especially in patients without cardiac implantable electronic devices (CIEDs). This study assessed the natural prognosis associated with mid-range QRS compared with narrow QRS (<120 ms) in a recent Asian cohort of patients with HFrEF. We analyzed patients with HFrEF from the Epidemiological Multicenter Study for Tailored Treatment in Heart Failure (ELMSTAT-HF; January 2020-October 2023). QRS was measured from 12-lead electrocardiograms. Patients with wide QRS (≥150 ms) or CIEDs were excluded. The primary outcome was a composite of all-cause mortality and heart failure hospitalizations. Multivariable Cox models adjusted for the MAGGIC risk score and log-transformed N-terminal pro B-type natriuretic peptide were used. Among 415 patients, 328 had narrow QRS and 87 had mid-range QRS. Over a median follow-up of 547 days, the primary outcome occurred more frequently in the mid-range QRS group (34.5% vs. 12.5%; P<0.001). Mid-range QRS remained independently associated with adverse outcomes (hazard ratio 3.12; 95% confidence interval 1.91-5.11), consistent across non-left bundle branch block (LBBB) and LBBB subgroups. Mid-range QRS is an independent predictor of adverse outcomes in HFrEF, even in the absence of LBBB.
In patients with pulmonary arterial hypertension, death due to ventricular arrhythmias accounts for 8-26% of total deaths, so in this study we investigated whether mitochondrial Ca2+uptake affects ventricular arrhythmias in right ventricular hypertrophy (RVH). A total of 70 rats were subcutaneously injected with monocrotaline (MCT-rats) or solvent; 8 mice underwent pulmonary artery banding (PAB) surgery. At 4 weeks after MCU injection or PAB surgery, trabeculae were dissected from the RVs. Levels of mitochondrial Ca2+, cytoplasmic Ca2+, and reactive oxygen species (ROS) were measured using fluorescence dyes. Mitochondrial calcium uniporter (MCU) expression was measured by Western blotting. Ca2+waves and arrhythmias were induced by electrical stimulation (24℃). Both MCT-rats and PAB-mice showed RVH. Ru360, an MCU inhibitor, improved arrhythmias in trabeculae from severe RVH, whereas it worsened them in trabeculae from milder RVH in MCT-rats. Depending on the degree of RVH, Ru360 decreased rhod-2 fluorescence in both MCT-rats and PAB-mice, and decreased Ca2+wave velocity, the 2',7'-dichlorofluorescein fluorescence slope, and MitoSox Red fluorescence in the MCT-rats. MCU expression increased with the degree of RVH. Inhibition of mitochondrial Ca2+uptake improved arrhythmias in severe RVH, but worsened them in milder RVH, due to differences in mitochondrial Ca2+uptake, ROS production, and MCU expression.
Nationwide data on in-hospital deaths and complications between leadless pacemakers (LPMs) and transvenous pacemakers (TVPMs) in Japan remain limited. Using a nationwide database, we identified adults who underwent TVPM or LPM implantation between 2017 and 2023. LPM implantation increased from 0.5% to 25% (P for trend <0.001). LPMs were selected more often as patient age increased and those undergoing dialysis or with dementia and atrial fibrillation (P<0.001). After propensity score matching (12,599 per group), composite outcomes (in-hospital deaths and all complications) were comparable between the LPM and TVPM groups (5.41% vs. 5.59%, respectively; P=0.44; odds ratio [OR] 0.95; 95% confidence interval [CI] 0.84-1.07). All-cause in-hospital death did not differ between groups (LPM, 1.09%; TVPM, 1.05%; P=0.55; OR 1.07; 95% CI 0.83-1.38), whereas all-cause death within 7 days after implantation was higher in the LPM group (0.58% vs. 0.33%; P=0.003; OR 1.80; 95% CI 1.21-2.67). All complications was comparable between the LPM and TVPM groups (LPM, 4.78%; TVPM, 4.82%; P=0.59; OR 0.96; 95% CI 0.85-1.09), but cardiac tamponade was more frequent in the LPM group (0.29% vs. 0.06%; P<0.001; OR 5.42; 95% CI 2.38-12.32). Composite outcomes were comparable between the LPM and TVPM groups, but the rates of cardiac tamponade and all-cause death within 7 days after implantation were higher in the LPM group.
Incomplete low-voltage area (LVA) ablation may confound evaluation of its true efficacy in persistent atrial fibrillation (AF). This post hoc subanalysis of the multicenter randomized SUPPRESS-AF trial assessed the impact of complete LVA ablation. Patients with persistent AF and a left atrial (LA) LVA ≥5 cm2after pulmonary vein isolation were randomized to LVA ablation or no additional ablation. The primary endpoint was freedom from AF or atrial tachycardia recurrence, assessed by 24-h Holter and twice-daily electrocardiogram recordings. Outcomes were compared among 3 groups: no LVA ablation; complete LVA ablation; and incomplete LVA ablation. Among 341 patients, 170 underwent LVA ablation, including 37 with incomplete. LVA size was significantly larger in the incomplete than complete ablation group (22.0 vs. 12.2 cm2; P<0.001). Incomplete LVA ablation was not associated with increased arrhythmia recurrence. Arrhythmia-free survival did not differ significantly between the complete and no LVA ablation groups (hazard ratio [HR] 0.80; 95% confidence interval [CI] 0.56-1.13), including after propensity score matching (HR 0.76; 95% CI 0.51-1.15). However, a trend towards greater benefit of complete LVA ablation was observed with increasing LA diameter (Pinteraction=0.099). Leaving LVA ablation incomplete to avoid complications appears reasonable. Although complete LVA ablation showed no overall superiority, LA enlargement may represent a clinically relevant factor for patient stratification.
Artificial intelligence-enhanced electrocardiography (AI-ECG) for detecting atrial fibrillation (AF) using sinus rhythm ECGs has shown promise. However, even when AI-ECG results are positive, ECG confirmation of AF may not always be obtained immediately. Repeat testing may be required, particularly in patients with a dilated left atrium, who may warrant more intensive monitoring. We aimed to investigate whether newly detected AF was frequent in patients with both high risk on AI-ECG evaluation and dilated left atrium. We used a convolutional neural network-based ECG algorithm to predict AF using data (2010-2022) from the Shinken database (n=12,595 patients without a prior AF event). The 3-year incidence of newly detected AF was compared across 3 left atrial diameter (LAD) categories: <35, 35-39, and ≥40 mm (small, middle, and large, respectively). Patients were stratified by the AI-ECG-generated diagnostic probability of AF (AIECG-AF-DP). The incidence of newly detected AF increased according to LAD category among patients with high (≥0.8) vs. low (<0.8) AIECG-AF-DP: 3.2 vs. 0.5%/year for small; 6.1 vs. 0.6%/year for middle, and 11.6 vs. 1.5%/year for large, respectively (all P<0.001). Although the area under the receiver operating characteristic curve was similar across LAD categories of <35, 35-39, and ≥40 mm (0.770, 0.753, and 0.784, respectively), the area under the precision-recall curve differed markedly (0.083, 0.114, and 0.236, respectively). Newly detected AF was particularly frequent in patients with both high AIECG-AF-DP and large LAD, suggesting repeated AF screening may be warranted in this population.