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ImportancePulmonary vein isolation (PVI) alone is less effective in patients with persistent atrial fibrillation (AF) compared with paroxysmal AF. The left atrial posterior wall may contribute to maintenance of persistent AF, and posterior wall isolation (PWI) is a common PVI adjunct. However, PWI has not been subjected to randomized comparison.ObjectiveTo compare PVI with PWI vs PVI alone in patients with persistent AF undergoing first-time catheter ablation.Design, Setting, and ParticipantsInvestigator initiated, multicenter, randomized clinical trial involving 11 centers in 3 countries (Australia, Canada, UK). Symptomatic patients with persistent AF were randomized 1:1 to either PVI with PWI or PVI alone. Patients were enrolled July 2018-March 2021, with 1-year follow-up completed March 2022.InterventionsThe PVI with PWI group (n = 170) underwent wide antral pulmonary vein isolation followed by posterior wall isolation involving linear ablation at the roof and floor to achieve electrical isolation. The PVI-alone group (n = 168) underwent wide antral pulmonary vein isolation alone.Main Outcomes and MeasuresPrimary end point was freedom from any documented atrial arrhythmia of more than 30 seconds without antiarrhythmic medication at 12 months, after a single ablation procedure. The 23 secondary outcomes included freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures, freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures, AF burden between study groups at 12 months, procedural outcomes, and complications.ResultsAmong 338 patients randomized (median age, 65.6 [IQR, 13.1] years; 76.9% men), 330 (97.6%) completed the study. After 12 months, 89 patients (52.4%) assigned to PVI with PWI were free from recurrent atrial arrhythmia without antiarrhythmic medication after a single procedure, compared with 90 (53.6%) assigned to PVI alone (between-group difference, –1.2%; hazard ratio [HR], 0.99 [95% CI, 0.73-1.36]; P = .98). Of the secondary end points, 9 showed no significant difference, including freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures (58.2% for PVI with PWI vs 60.1% for PVI alone; HR, 1.10 [95% CI, 0.79-1.55]; P = .57), freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures (68.2% vs 72%; HR, 1.20 [95% CI, 0.80-1.78]; P = .36) or AF burden (0% [IQR, 0%-2.3%] vs 0% [IQR, 0%-2.8%], P = .47). Mean procedural times (142 [SD, 69] vs 121 [SD, 57] minutes, P < .001) and ablation times (34 [SD, 21] vs 28 [SD, 12] minutes, P < .001) were significantly shorter for PVI alone. There were 6 complications for PVI with PWI and 4 for PVI alone.Conclusions and RelevanceIn patients undergoing first-time catheter ablation for persistent AF, the addition of PWI to PVI alone did not significantly improve freedom from atrial arrhythmia at 12 months compared with PVI alone. These findings do not support the empirical inclusion of PWI for ablation of persistent AF.Trial Registrationanzctr.org.au Identifier: ACTRN12616001436460

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Background: Gender disparity remains a prominent medical workforce issue, extending beyond surgical specialties with low proportions of female doctors.Aims: To examine female representation within Australia and New Zealand (NZ) among physician specialties and certain comparator surgical specialties with a focus on cardiology as an outlier of workforce gender equality.Methods: Data of practising medical specialists, new consultants and trainees were sought from the Australian Health Practitioner Regulation Agency, the Medical Council of NZ and the Royal Australasian College of Surgeons (2015)(2016)(2017). The stratified data pertaining to interventional cardiologists were obtained through direct contact with individual hospitals (from 2017 to 2018) and derived from state-based cardiac registries.Results: In Australia and NZ, there were fewer female practising adult medicine physician consultants (n = 8956, 32%, P < 0.001), with gender disparities seen across most physician specialties. Cardiology (15%) was the only physician specialty with <20% representation; gastroenterology (23%), neurology (27%) and respiratory medicine (29%) had <30% female representation at the consultant level. The rates of cardiology (15%) and interventional cardiology (5%) were similar to general surgery (15%) and orthopaedics (4%). Although more than half of physician trainees are female, and most physician specialties are approaching or have equal gender ratios at the trainee level, cardiology (23%) and interventional cardiology (9%) remain significantly underrepresented.Conclusions: Cardiology is the only physician specialty with <20% female consultants, and this disparity is reflected throughout every stage of the cardiology training programme. Increased awareness and proactive strategies are needed to improve gender disparity within this underrepresented medical specialty.

Aims Epidemiological studies report the beneficial effects of habitual coffee consumption on incident arrhythmia, cardiovascular disease (CVD), and mortality. However, the impact of different coffee preparations on cardiovascular outcomes and survival is largely unknown. The aim of this study was to evaluate associations between coffee subtypes on incident outcomes, utilizing the UK Biobank. Methods and results Coffee subtypes were defined as decaffeinated, ground, and instant, then divided into 0, &lt;1, 1, 2–3, 4–5, and &gt;5 cups/day, and compared with non-drinkers. Cardiovascular disease included coronary heart disease, cardiac failure, and ischaemic stroke. Cox regression modelling with hazard ratios (HRs) assessed associations with incident arrhythmia, CVD, and mortality. Outcomes were determined through ICD codes and death records. A total of 449 563 participants (median 58 years, 55.3% females) were followed over 12.5 ± 0.7 years. Ground and instant coffee consumption was associated with a significant reduction in arrhythmia at 1–5 cups/day but not for decaffeinated coffee. The lowest risk was 4–5 cups/day for ground coffee [HR 0.83, confidence interval (CI) 0.76–0.91, P &lt; 0.0001] and 2–3 cups/day for instant coffee (HR 0.88, CI 0.85–0.92, P &lt; 0.0001). All coffee subtypes were associated with a reduction in incident CVD (the lowest risk was 2–3 cups/day for decaffeinated, P = 0.0093; ground, P &lt; 0.0001; and instant coffee, P &lt; 0.0001) vs. non-drinkers. All-cause mortality was significantly reduced for all coffee subtypes, with the greatest risk reduction seen with 2–3 cups/day for decaffeinated (HR 0.86, CI 0.81–0.91, P &lt; 0.0001); ground (HR 0.73, CI 0.69–0.78, P &lt; 0.0001); and instant coffee (HR 0.89, CI 0.86–0.93, P &lt; 0.0001). Conclusion Decaffeinated, ground, and instant coffee, particularly at 2–3 cups/day, were associated with significant reductions in incident CVD and mortality. Ground and instant but not decaffeinated coffee was associated with reduced arrhythmia.

The rates of maternal overweight and obesity, but also excess gestational weight gain, are increasing. Pregnancy complications, including gestational diabetes mellitus, gestational hypertension, pre-eclampsia and delivery of a preterm or growth restricted baby, are higher for both women with overweight and obesity and women who gain excess weight during their pregnancy. Other conditions such as polycystic ovary syndrome are also strongly linked to overweight and obesity and worsened pregnancy complications. All of these conditions place women at increased risk for future cardiometabolic diseases. If overweight and obesity, but also excess gestational weight gain, can be reduced in women of reproductive age, then multiple comorbidities associated with pregnancy complications may also be reduced in the years after childbirth. This narrative review highlights the association between maternal overweight and obesity and gestational weight gain, with gestational diabetes, pre-eclampsia, polycystic ovary syndrome and delivery of a preterm or growth restricted baby. This review also addresses how these adverse conditions are linked to cardiometabolic diseases after birth. We report that while the independent associations between obesity and gestational weight gain are evident across many of the adverse conditions assessed, whether body mass index or gestational weight gain is a stronger driving factor for many of these is currently unclear. Mechanisms linking gestational diabetes mellitus, gestational hypertension, pre-eclampsia, preterm delivery and polycystic ovary syndrome to heightened risk for cardiometabolic diseases are multifactorial but relate to cardiovascular and inflammatory pathways that are also found in overweight and obesity. The need for post-partum cardiovascular risk assessment and follow-up care remains overlooked. Such early detection and intervention for women with pregnancy-related complications will significantly attenuate risk for cardiovascular disease.

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