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01.
arXiv (CS.AI) 2026-06-11

Noise-Guided Transport for Imitation Learning

arXiv:2509.26294v2 Announce Type: replace-cross Abstract: We consider imitation learning in the low-data regime, where only a limited number of expert demonstrations are available. In this setting, methods that rely on large-scale pretraining or high-capacity architectures can be difficult to apply, and efficiency with respect to demonstration data becomes critical. We introduce Noise-Guided Transport (NGT), a lightweight off-policy method that casts imitation as an optimal transport problem solved via adversarial training. NGT requires no pretraining or specialized architectures, incorporates uncertainty estimation by design, and is easy to implement and tune. Despite its simplicity, NGT achieves strong performance on challenging continuous control tasks, including high-dimensional Humanoid tasks, under ultra-low data regimes with as few as 20 transitions.

02.
arXiv (CS.LG) 2026-06-19

Alzheimer's Disease Diagnosis using a Multimodal Approach with 3D MRI and PET

arXiv:2606.20037v1 Announce Type: new Abstract: Alzheimer's disease (AD) is an irreversible neurodegenerative disorder and a leading cause of death worldwide. Early diagnosis plays an important part especially at the Mild Cognitive Impairment stage, where timely intervention can help slow its progression before it advances to AD. Neuroimaging data, like Magnetic Resonance Imaging (MRI) and Positron Emission Tomography (PET) scans, can help detect brain changes early by providing structural and functional brain changes related to the disease. Yet, many multimodal models still fuse MRI and PET with static concatenation and apply identical computation to all subjects, which limits robustness to patient/site heterogeneity and can waste computation. To address these limitations, we present the first study of combining 3D convolutional feature extractors with three fusion strategies - concatenation, Gated Multimodal Unit (GMU), and gated self-attention - and a sparsely gated Mixture-of-Experts (MoE) classifier that performs input-adaptive routing, activating only the most informative experts per case. Finally, we utilize Grad-CAM to visualize disease-related regions, ensuring model interpretability. Experiments are performed across three binary classification tasks (NC vs. MCI, MCI vs. AD, and NC vs. AD). Results show that GMU achieves accuracies of 80.46 % (NC vs. MCI) and 95.47 % (NC vs. AD), while gated self-attention attains 82.08 % on MCI vs. AD. Ablations show that removing the MoE consistently degrades accuracy across all tasks. These findings underscore the value of input-adaptive, multimodal modeling for AD diagnosis by leveraging the complementary nature of MRI and PET.

03.
arXiv (CS.AI) 2026-06-17

MODE: Modality-Decomposed Expert-Level Mixed-Precision Quantization for MoE Multimodal LLMs

arXiv:2606.17118v1 Announce Type: cross Abstract: Mixture-of-Experts Multimodal Large Language Models (MoE-MLLMs) offer remarkable performance but incur prohibitive GPU memory costs, making compression essential. Among PTQ methods, expert-level mixed-precision quantization has proven effective for MoE-LLMs, yet suffers notable degradation on MoE-MLLMs due to two overlooked biases in expert importance estimation. (1) At the cross-modal level, the numerical dominance of vision tokens causes expert selection frequency to be dominated by vision tokens, masking experts that are critical to the text modality; (2) at the intra-vision level, the large proportion of redundant vision tokens further skew frequency statistics, obscuring experts critical for informative visual content. To bridge gaps, we propose MODE, a modality-decomposed expert-level mixed-precision quantization framework for MoE-MLLMs that decomposes expert selection frequency by modality, filters redundant vision tokens to obtain denoised visual frequency, and further evaluates quantization sensitivity per modality as a complementary signal to frequency-based estimation. These signals are integrated into an Integer Linear Programming formulation to assign per-expert bit-widths under a given budget. Extensive experiments show that MODE is particularly well-suited for MoE-MLLMs, limiting average performance loss to within 2.9% at W3A16, with larger gains at the extreme 2-bit setting.

04.
arXiv (CS.CV) 2026-06-18

Bridging Creative Intent and Visual Quality: Creator-Driven Recurrent Video Generation with Agentic Feedback Loops

Generative AI has made content creation increasingly accessible, but many AI-generated videos lack narrative coherence and creative direction, issues that become more substantial at longer durations. Unlike coding, where AI generation benefits from reliable feedback and techniques such as recurrent self-improvement, video generation requires subjective feedback about plot, scenes, and narrative, which naturally motivates approaches that incorporate human creative direction. We introduce CHIEF, a human-AI co-creation video generation framework that places the creator at the center of human-in-the-loop iterative video refinement, and supports them by providing automatic subjective feedback. The creator incorporates their creative direction by driving each iteration, while their revisions are incorporated by a specialized refiner agent. The feedback loop is generated by persona-conditioned multimodal LLMs that watch generated videos and produce subjective critique from the audience perspectives, providing feedback that self-evaluation alone cannot capture. To test the effectiveness of our proposed framework, we work with high school and college students with no prior filmmaking experience to create videos, from short 1-minute videos to a complete short 10-minute film with a complicated plot.

05.
arXiv (CS.CV) 2026-06-16

Towards Global AI-Driven Cervical Cancer Screening

The global elimination of cervical cancer is a key public health goal set by the World Health Organization (WHO), with screening programs reducing mortality by up to 80%. However, access to experts and biopsy services is limited in low- to middle-income countries (LMICs). Deep learning (DL)-based algorithms offer promising support for screening, but most existing approaches have been developed and validated on private datasets from single countries. We present the first DL-based approach to cervical cancer screening validated on data from multiple countries. Technically, we phrase the problem of detecting and classifying lesions in colposcopy images as a multi-task learning problem, in which we simultaneously perform image-level classification and lesion segmentation. Our model was trained on a private data set of acid stain colposcopy images with manually generated lesion segmentation masks and corresponding histopathological results, employing extensive data augmentation to address image variability. In an in-distribution validation with pathology results serving as ground truth, our algorithm outperformed medical experts (Balanced Accuracy: 0.68 vs 0.64) in CIN1- (Cervical intraepithelial neoplasia grade 1 or lower) versus CIN2+ (grade 2 or higher) classification. External validation on four colposcopy data sets from four countries featuring radical differences in prevalence and patient characteristics yielded superior performance of our method compared to baseline methods. Performance variability across countries was high with AUC values ranging from 0.54 - 0.80. Overall, algorithm performance varied with age, transformation zone (cervical area most prone to lesion development), presence of comorbidities and pathognomonic signs, with comorbidities having by far the largest negative effect. Future work should focus on improving model robustness and generalizability.

07.
arXiv (CS.CV) 2026-06-16

MMDiff: Extending Diffusion Transformers for Multi-Modal Generation

Diffusion transformers have demonstrated remarkable generative capabilities, yet the rich perceptual representations computed across their denoising trajectory are discarded once the content is rendered. We present MMDiff, a framework that transforms a frozen diffusion transformer into a multi-modal generative system that jointly produces images alongside any combination of dense perceptual modalities using lightweight decoder heads. Our central finding is that perceptual information is temporally distributed along the denoising trajectory, and that multi-timestep feature fusion with spatially varying aggregation weights is essential, improving semantic segmentation results by up to 28.7% mIoU over single-timestep extraction. We further adopt concept-driven attention extraction for interpretable spatial guidance, and show that frozen diffusion features are competitive with and complementary to state-of-the-art encoders such as DINOv3. By training only lightweight decoder heads on a frozen backbone, we achieve strong performance in semantic segmentation, salient object detection, and depth estimation, and demonstrate that this framework enables effective synthetic data generation at scale.

08.
Nature (Science) 2026-06-10

‘Hidden hero’ peptides guard crops against sudden cold

作者: 未知作者

A protein signal remains silent under normal conditions but is activated under cold stress to protect developing pollen. This ‘on-demand’ resilience mechanism could enable the development of ‘climate smart’ crops that maintain high yields in good years and food security under climate stress. A peptide signal ensures that, in cold conditions, developing pollen receives nutrients at the right time.

09.
arXiv (CS.CL) 2026-06-19

Leverage Is Not Reach: A Control-Window Law for Single-Neuron Steering in Language Models

Aligned language models gate behaviors such as refusal and language routing through sparse feed forward neurons, yet no theory predicts when a single neuron intervention controls a behavior coherently rather than collapsing the output. We develop a budget normalized control window framework for single neuron steering. A dose along one write direction reduces to one control coordinate: the alignment between the residual stream and the write, driven along a universal saturation curve in units of a coherence budget set by the residual norm divided by the write norm. Coherent control exists when a behavior trigger lies below the collapse ceiling. The same coordinate governs benign mode switches and refusal; the ceiling follows from weights and one generic forward pass, while triggers are measured at rollout. On fifteen held out neurons, the predicted ceiling has mean absolute error 0.14, about 0.07 in bulk layers, and the committed open or closed verdict holds on eleven against a ten of fifteen majority baseline. Closed cases expose three failure modes rather than violations: collapse before trigger, too little depth to propagate, or a normalization that caps how far one neuron can push. The law explains why local gradient attribution anti predicts control: true controllers write off the readout axis and carry a near zero first order gradient. A forward only contrastive screen made precise by the window recovers controllers that attribution misses. On refusal, the hardest case, intervention success is typed, not scalar: coherent bypass and strict actionable reach separate, so a neuron can flip refusal in fluent, on task text with no actionable content, and genuine actionable reach appears only for three of six audited Llama pivots and only at later rollout horizons. Single neuron steering is therefore a budgeted, typed audit of controllability rather than a fixed dose anecdote.

10.
arXiv (math.PR) 2026-06-12

Sub-Riemannian spectral distance

arXiv:2606.12804v1 Announce Type: cross Abstract: We study eigenvalues and eigenfunctions of the ``div-grad type" sub-Laplacian with respect to Popp's volume on a compact equiregular sub-Riemannian manifold $M$. Since Popp's volume is canonically determined by the sub-Riemannian structure of $M$, the spetra of the sub-Laplacian carry geometric meanings. In this paper, we first embed $M$ into the Hilbert space of square-summable sequences using eigenfunctions and then define a spectral distance between two compact equiregular sub-Riemannian manifolds. Our result is a sub-Riemannian analogue of Berard-Besson-Gallot's classical work in the Riemannian case.

11.
arXiv (math.PR) 2026-06-16

A 0-1 Law for Multifractal Spectra via the HGDS Scale Derivative

arXiv:2606.15850v1 Announce Type: new Abstract: We prove that the multifractal spectrum D(h,omega) of a stochastic process is almost surely deterministic under a scale decorrelation condition on the HGDS scale derivative. The key difficulty is that the pointwise Hölder exponent lives in the germ sigma-algebra, where classical 0-1 laws do not reach. We get around this by working with the geometry accumulation integral G_Lambda, which is a genuine Lebesgue integral over scales and concentrates almost surely. The boundary case – log-correlated fields – is sharp: the variance summability condition fails exactly there.

12.
arXiv (CS.LG) 2026-06-15

Temporally Consistent Graph Q-Networks for Intelligent Network Control

arXiv:2606.13848v1 Announce Type: cross Abstract: Mobile networks continue to grow in complexity and next generation networks are expected to support both increasing traffic loads and more diverse services. As network complexity rises, optimizing antenna parameters under dynamic or changing objectives becomes increasingly challenging. We propose a novel multi-agent reinforcement learning (MARL) algorithm for high-level control and orchestration of mobile networks. The Temporally Consistent Graph Q-Network (TC-GQN) algorithm learns a self-predicting representation of the whole network that is task-independent and aggregates information from all base-stations. A graph neural network is trained using a global reward function to assign coordinated local actions based on the learned encoding of the global network state. We evaluate the algorithm in a simulated environment to orchestrate an energy-saving feature across multiple sectors and multiple carriers under different quality of service (QoS) constraints. The proposed algorithm outperforms state-of-the-art graph-based baselines and a competitive rule-based controller by improving hardware sleep time while maintaining QoS. Moreover, the learned representation enables rapid adaptation to changing intents.

13.
bioRxiv (Bioinfo) 2026-06-18

Deciphering shared and divergent tissue architectures from cross-species spatial transcriptomics

作者:

The integration of spatial transcriptomics (ST) data across species is essential for cross-species and translational studies, but remains challenging due to molecular divergence and anatomical differences between organisms. We present STACAME, a graph attention autoencoder-based framework to decipher shared and divergent tissue architectures from cross-species ST data by explicitly modeling both orthologous and species-specific genes. STACAME aligns ST slices in a spatially aware manner, identifies homologous and species-specific domains, and enables a suite of downstream comparative analyses. We demonstrate its utility by integrating ST datasets from diverse tissues, including hippocampus, isocortex, embryo, breast, liver, and cerebellum, across multiple species such as human, macaque, marmoset, mouse, and zebrafish. STACAME supports cross-species spatial domain alignment, the detection of shared and divergent spatially variable genes, development alignment and comparison, and the 3D integration of tissue architecture. This flexible approach facilitates the translation of findings from model organisms to humans, providing a unified computational platform for cross-species spatial transcriptomics.

14.
arXiv (CS.CV) 2026-06-16

3D Classification of Paramagnetic Rim Lesions in Multiple Sclerosis via Asymmetric QSM-FLAIR Modeling

Paramagnetic rim lesions (Rim$^+$) identified on susceptibility-sensitive MRI have recently emerged as a specific biomarker of chronic active inflammation in Multiple Sclerosis (MS) and are associated with long-term disability progression. However, susceptibility imaging and expert interpretation remain limited to specialized centers, visual assessment is time-consuming and variable, and the low prevalence of Rim$^+$ lesions poses severe class imbalance challenges for automated analysis. We propose a 3D multimodal deep learning framework for lesion-level Rim$^+$/Rim$^-$ classification from Quantitative Susceptibility Mapping (QSM) and FLAIR MRI. The architecture explicitly models modality asymmetry by treating QSM as the primary susceptibility-driven signal and conditioning it with FLAIR-derived structural context. To improve robustness under limited data, we employ self-supervised multimodal pretraining followed by supervised fine-tuning with contrastive regularization. The method was evaluated on a clinically acquired cohort of 88 people with MS with expert lesion annotations as reference standard. Results highlight improved performance compared to prior architectures, supporting the effectiveness of asymmetric multimodal modeling for automated chronic active lesion identification.

15.
arXiv (CS.CL) 2026-06-18

Human-AI Coevolution Dynamics: A Formal Theory of Social Intelligence Emergence Through Long-Term Interaction

Current conversational AI systems have made significant progress in language generation, personalization, and long-context interaction. However, most existing methods model social behavior through isolated components such as emotion modeling, memory retrieval, or persona conditioning, lacking a unified framework to explain the emergence of stable social relationships and social intelligence in long-term human-AI interaction.To address this, we propose the Human-AI Coevolution Dynamics Framework (HACD-H), a formal model of human-AI interaction as a self-organizing social cognitive system. HACD-H integrates emotional adaptation, relational organization, social memory, and personality consistency into a unified dynamical framework and introduces principles including multi-timescale social cognition, relational attractors, trust basins, developmental phase transitions, and social cognitive energy dynamics.We construct a conversational dataset with approximately 14,700 interaction turns and develop a theory-driven empirical evaluation framework. Results reveal a hierarchy of temporal persistence in social cognition, stable relational attractors, phase-transition-like developmental patterns, and a structured social cognitive energy landscape. Social intelligence shows a significant negative correlation with social cognitive energy (r = -0.391, p < 0.001), and interaction trajectories exhibit progressive energy reduction over time.These findings suggest that social intelligence emerges from long-term social cognitive coevolution rather than isolated conversational capabilities. HACD-H provides a unified theoretical foundation for modeling adaptive human-AI social interaction and developing socially intelligent AI systems.

16.
arXiv (CS.CV) 2026-06-11

Seeing What Matters: Perceptual Wrapper with Common Randomness for 3D Gaussian Splatting

While 3D Gaussian Splatting (3DGS) achieves impressive real-time rendering, it frequently struggles to synthesize high-frequency textures, a limitation heavily exacerbated in memory-constrained and rate-distortion-optimized (RDO) pipelines. To address this, we propose a versatile 2D perceptual wrapper that enhances the rendered outputs of existing 3DGS representations in a content- and view-dependent manner. Our method leverages a lightweight synthesis network conditioned on pseudo-random Gaussian noise to synthesize perceptually plausible textures. Supervised by Wasserstein Distortion, the network learns to match local feature statistics rather than strictly enforcing pixel-wise reconstruction fidelity, effectively mitigating the blurriness inherent in standard frameworks. We demonstrate the broad applicability of our plug-and-play approach across vanilla, memory-constrained, and RDO 3DGS methods. Comprehensive subjective and objective experiments confirm that our method significantly improves over existing baselines, yielding superior perceptual quality at sharply reduced file or model sizes.

17.
arXiv (CS.AI) 2026-06-11

Towards Data-free and Training-free Compression for Speech Foundation Models Using Parameter Clustering

arXiv:2606.11836v1 Announce Type: cross Abstract: This paper presents a novel data-free and training-free compression approach for speech foundation models using channelwise clustering via k-means. More fine-grained, mixed sparsity pruning by layer-level varying number of parameter clusters is also explored. Experiments conducted on the LibriSpeech dataset suggest that when operating with pruning sparsity of 50% on HuBERT-large, consistent WER reductions of 27.73%/18.61% absolute (34.37%/21.91% relative) over the magnitude-based pruning were obtained on the test-clean and test-other subsets before fine-tuning and 0.19%/0.79% absolute (3.36%/4.62% relative) after fine-tuning with only 3 epochs. Similar WER reductions of 2.86%/5.02% absolute (59.21%/55.29% relative) were observed against magnitudebased pruning on Whisper-large-v3 at 10% sparsity, all with no significant WER increase relative to the uncompressed baseline.

18.
arXiv (CS.LG) 2026-06-18

A Neural Network Framework for Geodesic-Like Curve Computation on Parametric Surfaces

arXiv:2606.18759v1 Announce Type: cross Abstract: The concept of geodesic-like curves was introduced by Chen in 2010 as a method for estimating shortest paths (geodesics) on parametric surfaces, with its convergence established theoretically. However, an efficient numerical computational framework has not yet been developed. In this paper, we propose an elegant and efficient approach for computing geodesic-like curves by leveraging deep learning and Physics-Informed Neural Networks (PINNs). Under the proposed framework, not only can single parametric surfaces be handled efficiently, but a broad class of complex parametric surfaces including multi-surface systems with $C^0$ or higher continuity and surfaces of revolution can also be robustly addressed.

19.
arXiv (CS.AI) 2026-06-18

Equivariant Graph Neural Networks Improve Optical Spectra Prediction for Materials Screening

arXiv:2606.19133v1 Announce Type: cross Abstract: Scalable prediction of optical spectra is a critical component of high-throughput materials screening for optoelectronic applications such as solar cells. Existing surrogate models are trained on spectra computed from lower levels of theory or rely on rotation-invariant scalar features, limiting their geometric expressiveness. We explore the use of equivariant graph neural networks for optical spectra prediction, adapting GotenNet to this task and evaluating it on multiple datasets including a recently published collection of 10,533 structures with spectra computed at the level of the random phase approximation (RPA). The proposed model outperforms the current state of the art, with the largest gains in the 0-8 eV range and on predicting the static real permittivity, both of particular relevance for thin-film optics.

20.
arXiv (CS.CL) 2026-06-11

When Probing Accuracy Saturates, Fragility Resolves: A Complementary Metric for LLM Pre-Training Analysis

Standard linear probing declares a property "encoded" when a classifier on hidden states achieves high accuracy. The protocol works well on a snapshot but breaks across pre-training: probe accuracy saturates within the first few thousand steps, leaving most of training invisible to the instrument. We introduce fragility, a complementary per-layer metric defined as the activation-noise level at which probe accuracy collapses. Fragility is sensitive to both the margin of separability and the redundancy of representation, both of which keep evolving long after accuracy plateaus. Applied to open-checkpoint language models, fragility recovers structure that accuracy alone cannot see. Moralized representations emerge along a lexical $\to$ compositional gradient: lexical moral detection first, compositional moral encoding later. Because probe accuracy on its own tracks how lexically separable a dataset is, we establish the compositional encoding directly, by showing it transfers across construction types that share no contrast tokens. A layer-depth robustness gradient develops monotonically across training while accuracy stays flat. And matched fine-tuning corpora that produce identical probing accuracy leave distinct fragility fingerprints, showing that data curation reshapes probe robustness without changing probe accuracy. In every comparison we test, where probing accuracy returns a flat answer, fragility returns a structured one.

21.
arXiv (CS.LG) 2026-06-16

STAR-NT: Spatiotemporal Acceleration of Real-Time Neural Transparency Rendering

arXiv:2606.16747v1 Announce Type: cross Abstract: Neural order-independent transparency delivers high-quality rendering of overlapping transparent surfaces, but its geometry passes and network input generation remain costly, particularly on mobile and legacy hardware. We present a spatiotemporal acceleration framework that exploits spatial and temporal coherence to reduce this overhead while preserving visual quality. Spatially, we use adaptive quadtree-based screen-space subdivision to scale geometry pass resolution according to local color variance. Temporally, selected frames reuse the previous transparency result through depth-based reprojection instead of full rendering. Together, these optimizations reduce rendering cost and integrate efficiently into existing real-time rendering pipelines.

22.
arXiv (quant-ph) 2026-06-17

Hamiltonian description of nonreciprocal interactions

arXiv:2505.05246v5 Announce Type: replace-cross Abstract: In a vast class of systems, which includes members as diverse as sedimenting particles and bird flocks, interactions do not stem from a potential, and are in general nonreciprocal. Thus, it is not possible to define a conventional energy function, nor to use analytical or numerical tools that rely on it. Here, we overcome these limitations by constructing a Hamiltonian that includes auxiliary degrees of freedom; when subject to a constraint, this Hamiltonian yields the original nonreciprocal dynamics. We show that Glauber dynamics based on the constrained Hamiltonian reproduce both stationary and nonstationary states of the original Langevin dynamics, as we explicitly illustrate for dissipative XY spins with vision-cone interactions. Further, the symplectic structure inherent to our construction enables us to apply the well-developed notions of Hamiltonian engineering, which we demonstrate by varying the amplitude of a periodic drive to tune the spin interactions between those of a square and a chain lattice geometry. Overall, our framework for generic nonreciprocal pairwise interactions paves the way for bringing to bear the full conceptual and methodological power of conventional statistical mechanics and Hamiltonian dynamics to nonreciprocal systems.

23.
arXiv (CS.CV) 2026-06-11

SCAIL-2: Unifying Controlled Character Animation with End-to-end In-Context Conditioning

Controlled character animation requires transferring motion from a driving sequence to a reference character. Prior works heavily rely on intermediate representations, including pose skeletons to represent motion or masked background to represent environment, which inevitably leads to information loss. To address this, we present SCAIL-2, a framework that bypasses those intermediates and achieves end-to-end character animation. By directly concatenating driving videos to the sequence, the model can obtain all the required visual information from the input video. To address the lack of end-to-end data, we unify sub-tasks of character animation with decoupled conditions and then curate a pipeline to synthesize MotionPair-60K, an end-to-end motion transfer dataset containing heterogeneous tasks of character animation. To achieve the unification, we utilize in-context mask conditioning and mode-specific RoPE as soft guidance beyond textual instructions and raw visual information. To address synthetic discrepancy in detailed regions, we propose Bias-Aware DPO to construct preference items to mitigate the errors. Extensive experiments demonstrate that our method substantially outperforms existing state-of-the-art approaches in various character animation tasks. A large subset of synthetic data as well as model weights will be released at our project page: https://teal024.github.io/SCAIL-2/.

24.
arXiv (CS.LG) 2026-06-17

Data augmented bootstrap: Unifying confidence interval construction by approximate invariance

arXiv:2606.09049v2 Announce Type: replace-cross Abstract: We propose the data augmented bootstrap (DAB), a framework for constructing confidence intervals from approximately invariant transformations of the data. As special cases, DAB recovers popular methods that rely on exact group symmetries, such as conformal prediction, wild bootstrap for Maximum Mean Discrepancy U-statistics and the recently proposed SymmPI. Meanwhile, DAB also recovers the classical bootstrap method, which exploits the dataset's approximate invariance under uniform sampling of data indices as the dataset size grows. For all DAB methods, we establish theoretical coverage results that interpolate between finite-sample and asymptotic guarantees according to the strength of the invariance, and without assuming a group structure. The approximate invariance is measured in the Kolmogorov distance and, for statistics that satisfy Gaussian universality, reduces to conditional mean and variance matching. This allows us to incorporate data augmentation (DA), a widely used machine learning heuristic based on approximate invariances, into known statistical methods. We empirically test the performance of incorporating DA into bootstrap, wild bootstrap and conformal prediction for simulated settings as well as for image, language and scientific data.

25.
medRxiv (Medicine) 2026-06-12

The Clinical Characteristics and mortality outcomes of Atrial fibrillation complicating Heart failure with reduced ejection fraction: A prospective study from South Africa

Background: A growing burden of cardiovascular risk factors has raised cardiovascular disease-related mortality in Sub-Saharan Africa (SSA), driving higher prevalence of heart failure with reduced ejection fraction (HFrEF) and its complication with atrial fibrillation (AF). No prospective study has examined AF's clinical impact on HFrEF in SSA. Aim: To determine AF prevalence in HFrEF, describe HFrEF-AF clinical characteristics, and determine AF's impact on mortality. Methods: In this prospective observational study at a tertiary hospital in Johannesburg, 136 HFrEF patients were enrolled and categorised as HFrEF- SR (sinus rhythm) or HFrEF-AF. Baseline clinical characteristics and biochemistry were recorded. Comprehensive echocardiography including left atrial strain by 2D speckle-tracking was performed. Median follow-up was 30.6 months. Results: AF was present in 28 patients (21%). The mean age was 58.7 {+/-} 14.9 years (52.9% male) and differed between groups (p < 0.001). Hypertensive heart disease was the leading cause of HFrEF (36%). Compared with SR, HFrEF-AF patients had poorer health status (KCCQ 27 [16-43] vs 45 [32-60], p < 0.001) and lower left atrial strain (26.2 {+/-} 11.3%, p < 0.001). Guideline-directed medical therapy was suboptimal in the AF group: anticoagulation use was higher than SR (60% vs 9.5%, p < 0.001) but overall inadequate; HFrEF-AF patients received lower median doses of carvedilol (15.6 mg vs 25 mg, p = 0.002) and enalapril (10 mg vs 20 mg, p = 0.004), and fewer received spironolactone (50% vs 75.3%, p = 0.013). Survival was significantly lower in HFrEF-AF (0.41 [0.22-0.61]) versus SR (0.73 [0.61-0.82], p < 0.001). Independent predictors of mortality included prior stroke, lower TAPSE and KCCQ, and higher E/e' and heart rate. Conclusion: AF is common among HFrEF patients in this SSA cohort (though lower than in high-income countries) and associates with worse clinical status, suboptimal therapy, and higher mortality.