The manganese transporter SLC39A8 links alkaline ceramidase 1 to inflammatory bowel disease

The metal ion transporter SLC39A8 is associated with physiological traits and diseases, including blood manganese (Mn) levels and inflammatory bowel diseases (IBD). The mechanisms by which SLC39A8 controls Mn homeostasis and epithelial integrity remain elusive. Here, we generate Slc39a8 intestinal epithelial cell-specific-knockout (Slc39a8-IEC KO) mice, which display markedly decreased Mn levels in blood and most organs. Radiotracer studies reveal impaired intestinal absorption of dietary Mn in Slc39a8-IEC KO mice. SLC39A8 is localized to the apical membrane and mediates 54Mn uptake in intestinal organoid monolayer cultures. Unbiased transcriptomic analysis identifies alkaline ceramidase 1 (ACER1), a key enzyme in sphingolipid metabolism, as a potential therapeutic target for SLC39A8-associated IBDs. Importantly, treatment with an ACER1 inhibitor attenuates colitis in Slc39a8-IEC KO mice by remedying barrier dysfunction. Our results highlight the essential roles of SLC39A8 in intestinal Mn absorption and epithelial integrity and offer a therapeutic target for IBD associated with impaired Mn homeostasis.

Nitrogen and phosphorous acquisition strategies drive coexistence patterns among archaeal lineages in soil

Soil represents the largest reservoir of Archaea on Earth. Present-day archaeal diversity in soils globally is dominated by members of the class Nitrososphaeria. The evolutionary radiation of this class is thought to reflect adaptations to a wide range of temperatures, pH, and other environmental conditions. However, the mechanisms that govern competition and coexistence among Nitrososphaeria lineages in soil remain poorly understood. Here we show that predominant soil Nitrososphaeria lineages compose a patchwork of gene inventory and expression profiles for ammonia, urea, and phosphate utilization. In contrast, carbon fixation, respiration, and ATP synthesis genes are conserved and expressed consistently among predominant phylotypes across 12 major evolutionary lineages commonly found in soil. In situ gene expression profiles closely resemble pure culture reference strains under optimal growth conditions. Together, these results reveal resource-based coexistence patterns among Nitrososphaeria lineages and suggest complementary ecophysiological niches associated with differential nutrient acquisition strategies among globally predominant archaeal lineages in soil.

Trophic Path of Marked Exuviae Within Colonies of Coptotermes gestroi (Blattodea: Rhinotermitidae)

Nitrogen, a limiting growth factor in wood-feeding insects, was hypothesized to play a role in the recently discovered behavior of subterranean termites returning to the nest to molt. Coptotermes gestroi (Wasmann) exuviae is approximately 11% N by dry weight, and therefore a potentially rich source of recyclable nitrogen. Exuviae from a C. gestroi colony were marked with immunoglobulin G (IgG) and were fed to two-year-old C. gestroi colonies. IgG-marked exuviae were detected with an enzyme-linked immunosorbent assay. The IgG marker was later detected in every caste and life stage except first-instar larvae (L1). The proportion of individuals positive for the marker varied by caste, with the queens always being positive for the marker. The queens and second-or-higher-instar workers (W2+) had significantly higher concentrations of the marker than the eggs and L1. The trophic path of exuviae includes individuals that directly fed on marked exuviae (workers and possibly second-instar larvae) and individuals that secondarily received marked exuviae through trophallaxis (queens, kings, and soldiers). This study described the trophic path of consumed exuviae and demonstrated its role in the recycling of nitrogen in a subterranean termite. Molting at the central nest may be an efficient means to transfer nitrogen from shed exuviae to recipients and may be a nitrogen recycling behavior conserved from a termite ancestor.

Association between early rhythm control and the risk of dementia in patients with atrial fibrillation and prior history of stroke: a nationwide population-based study

Background

Patients with atrial fibrillation (AF) who experienced stroke before are at high risk for dementia. Although early rhythm control in patients with AF reduces the risk of stroke, there is a lack of evidence on whether early rhythm control reduces the risk of developing dementia in patients with new-onset AF and a history of prior stroke.

Purpose

To compare the risk of dementia between early rhythm control therapy and usual care in patients with new-onset AF and a history of prior stroke

Methods

Using the Korean nationwide claims database, we identified patients who were newly diagnosed as AF and had a history of prior stroke. Patients with prevalent dementia were excluded. Patients who received rhythm control therapy, including antiarrhythmic drug, direct current cardioversion, or AF catheter ablation, within 1 year after incident AF were defined as the early rhythm control group, otherwise as the usual care group. The inverse probability of treatment weighting method was used to balance baseline characteristics between the two groups. The incidence of all dementia, Alzheimer dementia, and vascular dementia were evaluated during follow-up.

Results

A total of 41,370 patients were included (mean age, 70±11 years; mean CHA2DS2-VASc score 5.3±1.6; 43% female); 10,213 were in the early rhythm control group and 31,157 in the usual care group. All patients received oral anticoagulants. During a median 2.7 years of follow-up, 6414 patients developed incident dementia (incidence rate, 4.9 per 100 person-years). Compared to usual care, early rhythm control was associated with lower risks of all dementia, Alzheimer dementia, and vascular dementia (weighted hazard ratio [95% confidence interval], 0.825 [0.776–0.876], 0.831 [0.774–0.893], and 0.800 [0.702–0.913], respectively, all p<0.001) (Figure 1). The beneficial effect of early rhythm control on the risk of dementia were consistent regardless of the characteristics of prior stroke, for example, recent stroke within 6-month from their enrollment, disabling stroke that required continuous rehabilitation therapy, and severe stroke causing intensive care unit admission.

Conclusion

Early rhythm control within 1 year after AF diagnosis might be beneficial to prevent dementia in patients with incident AF and a history of stroke. To prevent progression of further cognitive dysfunction, early rhythm control should be considered in these patients.

Funding Acknowledgement

Type of funding sources: None.

Comparison of adhesive single-lead ECG device and Holter test for atrial fibrillation monitoring

Background

There is insufficient validation of diagnostic benefits of extended monitoring with an adhesive single-lead ECG device compared to Holter test for routine medical care of AF patients.

Purpose

The study aimed to compare AF detection rates between 72-hour monitoring using an adhesive single-lead ECG device (mobiCARE MC-100, Seers Technology, Republic of Korea) and 24-hour Holter test among AF patients at outpatient clinics.

Methods

A total of 200 AF patients indicated for Holter test at cardiology outpatient clinics enrolled in the study. Study participants equipped both Holter and MC-100 for the first 24 hours (Figure 1). After then, only MC-100 continued ECG monitoring for additional 48 hours. AF detection during the first 24 hours was compared between two devices. The diagnostic benefits of extended monitoring with MC-100 were evaluated.

Results

During the first 24 hours, both monitoring methods detected AF in the same 40/200 (20.0%) patients (20 patients with paroxysmal and persistent AF each). Compared to 24-hour Holter, MC-100 increased AF detection rate by 1.5-fold (58/200; 29.0%) and 1.6-fold (64/200; 32.0%) with 48- and 72-hour monitoring, respectively (Figure 2A). With MC-100, the number of newly discovered patients with paroxysmal AF was 20/44 (45.5%), 18/44 (40.9%), and 6/44 (13.6%) for 24-, 48-, and 72-hour monitoring. Compared to 24-hour Holter, 72-hour monitoring with MC-100 increased the detection rate of paroxysmal AF by 2.2-fold (44/20). If only the episodes lasting over 30 seconds were counted as AF with MC-100, the detection rate of paroxysmal AF was decreased by 9.1% (Figure 2B).

Conclusion

Compared to Holter, AF detection rates could be improved with an adhesive single-lead device, especially for patients with paroxysmal AF. This device is expected to be useful for AF detection among patients whose conventional ECG tests were ineffective in documenting AF episodes.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Korea Medical Device Development Fund grant funded by the Korean government (the Ministry of Science and ICT, the Ministry of Trade, Industry and Energy, the Ministry of Health & Welfare, Republic of Korea, the Ministry of Food and Drug Safety)

The left atrial low-voltage area and persistent atrial fibrillation treated with pulmonary vein isolation alone

Background

There are limited data regarding the association between the burden of the left atrial low-voltage area (LVA) and the outcome of pulmonary vein isolation (PVI) alone in persistent atrial fibrillation (PeAF).

Purpose

The study aimed to investigate the impact of the burden of LVA on the patients with PeAF treated with PVI alone.

Methods

Using a retrospective cohort of PeAF patients who underwent PVI alone, both clinical and the left atrial voltage mapping data were reviewed. LVA was defined as an area of ≤0.5 mV (bipolar) when mapped during sinus rhythm and ≤0.2 mV during AF. The high burden of LVA was defined as a case when the LVA constitutes ≥10% of the total left atrial body area. The patients were categorized into either the high or low burden groups. The recurrence of any atrial tachyarrhythmia was followed up, and multivariable Cox's regression analysis was performed.

Results

A total of 50 and 25 patients were investigated for the low burden (LVA<10%) and high burden (LVA≥10%) groups, respectively. Compared to the low burden group, the high burden group had a significantly less male proportion (56.0% versus 78.0%), a higher CHA2DS2-VASc score (median 3 versus 2), more chronic kidney disease (16.0% versus 2.0%), and a higher burden of LVA (20±11% versus 5±3%). During the median follow-up of 9.5 (6.2–16.2)months, there were 30.0% and 48.0% ofrecurrences for the low and high burden groups, respectively. Compared to the low burden group, the high burden group was associated with higher risks of both early and late recurrences (HR [95% CI] =2.67 [1.15–6.18] and 2.08 [1.03–4.20], respectively) (Figure 1). The best cut-off of LVA to predict 2-year recurrence was 10.1% (Figure 2).

Conclusion

The high burden of LVA was significantly associated with an increased risk of recurrence among PeAF patients treated with PVI alone. Tailored ablation in addition to PVI would be needed to improve outcomes in patients with PeAF having a high burden of LVA.

Funding Acknowledgement

Type of funding sources: None.

A synergistic impact of early rhythm control and lifestyle modification on the risk of stroke in patients with new-onset atrial fibrillation: a Korean nationwide population-based cohort study

Background

Early rhythm control therapy and lifestyle modification have both been associated with a lower risk of stroke in patients with atrial fibrillation (AF). Although guidelines have emphasized integrated care for patients with AF to improve clinical outcomes, the synergistic impact of early rhythm control therapy and lifestyle modification on the risk of stroke is unclear.

Purpose

To evaluate the impact of the combination of early rhythm control therapy and lifestyle modification on the risk of stroke

Methods

Based on data from the Korean National Health Insurance Service database, we included patients with new-onset AF between January 2009 and December 2016. Based on questionnaires from health checks, patients with ≥2 healthy lifestyle behaviors among quitting smoking, abstaining from alcohol, and performing regular exercise were defined as “healthy lifestyle” group. Patients who received rhythm control therapy within 2-year after new-onset AF were defined as the early rhythm control group. With a two-by-two factorial design, patients were categorized into 4 groups as follows: (i) those without early rhythm control and healthy lifestyle (group 1); (ii) those with a healthy lifestyle but without early rhythm control (group 2); (iii) those with early rhythm control but without healthy lifestyle (group 3); and (iv) those with both early rhythm control and healthy lifestyle (group 4). The primary outcome was stroke.

Results

Among a total of 208,662 patients, 46,972, 110,479, 15,133, and 36,078 patients were included in group 1, 2, 3, and 4, respectively. For the early rhythm control group, the mean duration from AF diagnosis to rhythm control therapy was 27±76 days. During a median follow-up of 4.2 years, 9905 patients had an incident stroke (incidence rate, 10.6 per 100 person-years). After multivariable adjustment, compared to group 1, group 2 (healthy lifestyle only) and group 3 (early rhythm control only) were associated with a lower risk of stroke (HR and 95% CI: 0.769, 0.728–0.881, and 0.774, 0.703–0.852, respectively) (Figure 1). Group 4 with early rhythm control and a healthy lifestyle had the lowest risk of stroke among all groups (HR 0.575, 95% CI 0.536–0.617 compared to group 1) (Figure 1). After propensity score (PS) weighting for group 2 and 4, additional early rhythm control based on healthy lifestyle was associated with a lowered risk of stroke by 22% (Figure 2). After PS weighting between groups 3 and 4, additional lifestyle modification based on early rhythm control was associated with a lowered risk of stroke by 27% (Figure 2).

Conclusion

In this large-scale observational cohort study, early rhythm control therapy and healthy lifestyle behavior might reduce the risk of stroke in patients with new-onset AF, consistent with the results from recent randomized clinical trials. Furthermore, implementing both early rhythm control therapy and a healthy lifestyle could synergize stroke prevention in these populations.

Funding Acknowledgement

Type of funding sources: None.

Protective effect of proton pump inhibitor against gastrointestinal bleeding in patients receiving oral anticoagulants: a systematic review and meta-analysis

Background

The concurrent use of proton pump inhibitor (PPI) in oral anticoagulant (OAC) treated patients may be associated with a lower risk of gastrointestinal bleeding (GIB), but evidence is still conflicting according to individual OACs.

Purpose

We conducted a meta-analysis to estimate the risk of GIB in patients with OAC and PPI co-therapy.

Methods

A systematic search of PubMed, EMBASE, and Cochrane was performed for studies reporting GIB risk in OAC and PPI co-therapy. Primary outcomes were total GIB and major GIB events. We calculated pooled estimates of GIB risk by a random-effect meta-analysis and reported as odds ratios (OR) and 95% CI. Stratified analyses according to the origin of GIB, ethnic groups, individual OACs, and the presence of underlying GIB risk factors were performed.

Results

A total of 10 studies (1 randomized controlled study and 9 observational studies) and 1,970,931 patients who received OAC were included. OAC and PPI co-therapy were associated with a lower risk of total GIB, and major GIB; OR (95% CI) was 0.67 (0.62–0.74) for total GIB and 0.68 (0.63–0.75) for major GIB, respectively. Among total GIB, only the risk of upper GIB was lower with OAC and PPI co-therapy (OR 0.67, 95% CI 0.64–0.70). No difference in the lower risk of primary GIB outcomes of PPI co-therapy was observed between Asians and non-Asians (p-for-difference, total GIB=0.695, major GIB=0.748, respectively) and among individual OACs except for edoxaban. The protective effect of PPI on total GIB was more significant in high-risk patients, defined as those with concurrent medication of antiplatelets or non-steroidal anti-inflammatory drugs (OR 0.62, 95% CI 0.52–0.73) and presence of high bleeding risk factors such as previous GIB history, HAS-BLED score ≥3, or underlying gastrointestinal diseases. (OR 0.65, 95% CI 0.61–0.70).

Conclusion

In patients who receive OAC, the use of PPI co-therapy was associated with a lower risk of total GIB and major GIB irrespective of ethnic group and OAC type except for edoxaban. PPI co-therapy can be considered particularly in patients on concomitant NSAID and antiplatelet use or patients with high GIB risk factors.

Funding Acknowledgement

Type of funding sources: None.

Increased risk of atrial fibrillation in patients with uterine fibroids: a nationwide population-based study

Background

Uterine fibroid, the most common benign neoplasm of the uterus, is associated with an elevated risk of cardiovascular disease. The link between incident atrial fibrillation (AF) and the uterine fibroid is unclear because earlier studies focused primarily on the development of atherosclerosis and hypertension. We aimed to investigate the risk of AF in patients with uterine fibroid.

Methods

This is a retrospective cohort study using the Korean National Health Insurance Service database (NHIS). From 2009 to 2012, a total of 2,574,349 women (20 to 40 years old) who underwent general health examinations were included. Diagnosis of uterine fibroids and surgical treatment status was defined by the international classification of diseases, 10th revision codes, and procedural codes from the Korean NHIS. The primary outcome was newly diagnosed AF. The risk of AF according to the uterine fibroids and their surgical treatment status was evaluated using Cox proportional-hazard models.

Results

Of the total population, the mean age was 29.76±4.27 years, and 20,682 (0.8%) were identified to have uterine fibroid. Incident AF was identified in 3,868 patients (61 in the fibroid group, 3,807 in the control group) during a mean follow-up of 7.3±1.1 years. Patients of the uterine fibroid group showed a higher incidence of AF compared to the control group (0.41 and 0.20 per 1000 person-years, respectively, Figure 1). Multivariate Cox-regression analysis presented that uterine fibroid was an independent risk factor of AF: hazard ratio (HR) 1.50, 95% confidence interval (CI) 1.16–1.93, p=0.002. Compared to the control group, uterine fibroid patients who underwent surgical treatment tend to show a lower risk for AF (HR 1.22, 95% CI 0.79–1.90) than patients without surgical treatment (HR 1.69, 95% CI 1.24–2.30), though statistical significance was indeterminate (Figure 2). After propensity score matching, patients of the uterine fibroid group showed higher risk of AF when compared to the control group (HR 1.77, 95% CI 1.32–2.63, p<0.001), which was in line with our main results. The presence of uterine fibroid was consistently associated with higher risk of AF among all subgroups except for the stroke subgroup.

Conclusion

Patients with uterine fibroids are predisposed to an increased risk of AF compared to the control group. Careful monitoring of arrhythmia development would be warranted in patients of uterine fibroid and surgical treatment as it is associated with a modest risk decrement of incident AF.

Funding Acknowledgement

Type of funding sources: None.

Paradoxical association between lipid levels and incident atrial fibrillation according to statin usage

Background

In epidemiology studies, a higher level of total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) is associated with a lower risk of atrial fibrillation (AF). Statin use might exert possible confounding effects in the paradoxical relationship; however, the inverse link between AF and cholesterol level that distinguishes statin users from non-users has not been evaluated.

Objective

We investigated the epidemiological relationships of TC–AF and LDL-C–AF in statin users and non-users, respectively.

Methods

From the Korean National Health Insurance Service database, we included 9,778,014 adults who underwent a health examination in 2009 and had no prior AF history. The levels of TC and LCL-C at the health exam were categorized in quartile (Q) and decile (D) values of the total study population. The study population was grouped into statin users and non-users, and TC–AF and LDL-C–AF relationships were evaluated.

Results

867,336 (8.9%) were on statin use among the total population. Statin users showed higher TC level (208.4±55.6 vs. 194.1±39.5 mg/dL, p<0.001) and LDL-C level (123.0±102.2 vs. 121.3±226.3, p<0.001) compared to non-users. Inverse associations of TC–AF and LCL-C–AF were observed; higher levels of TC and LDL-C were associated with a lower risk of AF. The hazard ratios (HR) and 95% confidence intervals (CI) were 0.797 (0.786–0.809) for the highest quartile of TC (Q4, TC ≥218) and 0.832 (0.82–0.843) for the highest quartile of LDL-C (Q4, LDL-C ≥135) when adjusted by age, sex, lifestyle behaviors, comorbidities, and low-income status. Statin users exhibited higher AF incidence rate than non-statin users, but the association in statin users generally tracked that seen among non-statin users demonstrating similar HR in Q4 of TC [0.812 (0.790–0.835) for statin users and 0.812 (0.798–0.826) for non-statin users] and LDL-C [0.842 (0.819–0.865) for statin users and 0.849 (0.835–0.863) for non-statin users].

Conclusion

The paradoxical relationship between lipid levels (TC and LDL-C) and incident AF remained consistent both in statin users and non-users. Further research is required to investigate an underlying mechanism for the cholesterol paradox of AF which still seems evident despite the pleiotropic effects of statin.

Funding Acknowledgement

Type of funding sources: None.

Fish oil supplements increase atrial fibrillation risk in healthy individuals: a population-based cohort study and Mendelian randomization analysis

Background

There is a paucity of information on the risk of atrial fibrillation (AF) in healthy individuals taking fish oil supplements.

Purpose

We aimed to investigate the epidemiologic and causal relationships between fish oil supplement intake and the long-term risk of AF.

Methods

From the population-based UK Biobank, we selected healthy individuals without a history of AF, other cardiac arrhythmias, or cardiovascular diseases, who were not taking lipid-lowering medications or dietary supplements other than fish oil. The 10-year risk of AF in Fish-Oil-Users vs. Non-Users was evaluated in the total population and propensity-score matched cohort. The causal relationship between n-3 polyunsaturated fatty acids (PUFA) and AF was evaluated using a two-sample summary-level Mendelian randomization analysis with fixed effects robust inverse-variance weighted method, using genetic instruments from previous studies genome-wide association studies for n-3 PUFA levels and AF, respectively.

Results

A total of 338,199 participants (aged 55.2±8.1, 44.3% men) were analysed. Of these, 35.0% (n=118,300) was taking fish oil supplements. The 10-year risk of AF was significantly higher in the Fish-Oil-Users than in the Non-Users (3.83% vs. 2.91%, adjusted hazard ratio [HR] 1.05, 95% CI [1.01–1.10], P=0.023). The result was consistent in the propensity-score matched cohort (propensity-score matched HR 1.06, 95% CI [1.00–1.12], P=0.043). The increased risk of AF by fish oil supplement was prominent in low-risk participants with healthy lifestyles. Among n-3 PUFA, the docosapentaenoic acid (DPA) showed significant causal estimates for the increased risk of AF (odds ratio [OR] 1.15, 95% CI [1.08–1.22], P<0.001), while higher eicosapentaenoic acid (EPA) levels caused a decrease of AF risk (OR 0.85, 95% CI [0.80–0.90], P<0.001).

Conclusion

Fish oil supplement intake significantly increased the long-term risk of AF in a healthy population. The causal effect of fish oil intake on the risk of AF may depend on the specific types of n-3 PUFA.

Funding Acknowledgement

Type of funding sources: None.

Impact of metabolic syndrome on the risk of ischemic stroke in non-anticoagulated atrial fibrillation patients having low CHA2DS2-VASc scores

Background

Metabolic syndrome (MetS) predisposes to a thromboembolic state. However, conflicting results have been reported on whether MetS confers an increased risk of ischemic stroke in atrial fibrillation (AF), especially in patients with low CHA2DS2-VASc score who are not indicated for oral anticoagulant therapy.

Purpose

We investigated the risk of ischemic stroke according to the presence of MetS, the number of MetS components (metabolic burden), and the individual metabolic components in non-anticoagulated AF patients with low CHA2DS2-VASc score.

Methods

A total of 76,015 oral anticoagulant-naïve AF patients with low CHA2DS2-VASc score (0,1 in male and 1 in female) were included from the Korean National Health Insurance Service database. The status of MetS and individual metabolic components were evaluated based on health examination data within two years of AF diagnosis. We estimated the risk of ischemic stroke according to MetS, metabolic burden, and an individual component of MetS using Cox proportional-hazards models.

Results

The mean age was 49.8±11.1 years and 52,388 (68.9%) were male. The average CHA2DS2-VASc score was 0.7±0.5 and MetS was prevalent among 21,570 (28.4%) of the study population. During a mean follow-up of 5.1 years, ischemic stroke was developed in 1,395 (1.84%) patients. MetS was associated with a higher risk of ischemic stroke after adjustment for age, sex, lifestyle behaviors, low income, and cardiovascular comorbidities: adjusted hazard ratio (aHR) 1.19, 95% confidence interval (CI) 1.06–1.33, p=0.002. A positive linear correlation was observed between metabolic burden and ischemic stroke risk. Patients with five MetS components showed the highest aHR of 1.55 (95% CI 1.14–2.11, Figure 1 and Figure 2), whereas those with a single MetS component had a marginal risk of ischemic stroke (aHR 1.18, 95% CI 0.99–1.41). Among individual metabolic components, elevated blood pressure and increased waist circumference was significantly associated with an increased risk of ischemic stroke: aHR (95% CI), 1.45 (1.30–1.62), p<0.001, and 1.15 (1.03–1.30), p=0.016, respectively.

Conclusions

Among AF patients initially with CHA2DS2-VASc score 0 and 1 with no anticoagulation, the presence of MetS is associated with an increased risk of ischemic stroke. Given the linear incremental correlation between metabolic burden and ischemic stroke, special attention to the care of metabolic derangements is required in AF patients who are not indicated for anticoagulation.

Funding Acknowledgement

Type of funding sources: None.

Oral anticoagulation therapy in atrial fibrillation patients with advanced chronic kidney disease: CODE-AF Registry

Background and objectives

Advanced chronic kidney disease (CKD), including end-stage renal disease (ESRD) on dialysis, increases thromboembolic risk among patients with atrial fibrillation (AF). This study examined the comparative safety and efficacy of direct-acting oral anticoagulant (DOAC) compared to warfarin or no OAC among AF patients with advanced CKD or ESRD on dialysis.

Methods

Using data from the COmparison study of Drugs for symptom control and complication prEvention of AF (CODE-AF) registry, 260 non-valvular AF patients with advanced CKD (defined as estimated glomerular filtration rate [eGFR] <3 0ml/min per 1.73 m2) or ESRD on dialysis were enrolled from June 2016 to July 2020. The study population was categorized into DOAC, warfarin, and no OAC group, and differences in major or clinically relevant non-major (CRNM) bleeding, stroke/systemic embolism (SE), myocardial infarction/critical limb ischemia (CLI), and death were assessed.

Results

During a median 24 months of follow-up, major or CRNM bleeding risk was significantly reduced in the DOAC group compared to the warfarin group (hazard ratio [HR] 0.21, 95% confidence interval [CI] 0.05 to 0.95, p=0.042). In addition, the risk of composite adverse clinical outcome (major or CRNM bleeding, stroke/SE, myocardial infarction/CLI, and death) was significantly reduced in the DOAC group compared to the no OAC group (HR 0.32, 95% CI 0.11 to 0.96, p=0.043).

Conclusion

Among AF patients with advanced CKD or ESRD on dialysis, DOAC was associated with a lower risk of major or CRNM bleeding compared to warfarin and a lower risk of composite adverse clinical outcome compared to no OAC.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Korean Healthcare Technology R&D project funded by the Ministry of Health & Welfare (HI15C1200, HC19C0130)

Atrial fibrillation detection in ambulatory patients using a smart ring powered by deep learning analysis of continuous photoplethysmography monitoring

Background

Atrial fibrillation (AF) detection could be effective with photoplethysmography (PPG) signal monitoring by a wearable device.

Purpose

We aimed to validate the performance of AF detection among ambulatory patients who underwent electrical cardioversion for AF using a smart ring capable of continuous PPG monitoring and deep learning analysis.

Methods

In this prospective single-arm study, participants who underwent successful electrical cardioversion for AF were enrolled. The participants equipped a smart ring (CardioTracker, Sky Labs Inc., Seongnam, Republic of Korea) after the electrical cardioversion. The smart ring then continuously monitored PPG over 14 days to detect AF recurrence. The smart ring alarmed AF episodes based on deep learning analysis of PPG. The participants were asked to measure at least three daily ECGs using the smart ring to validate AF recurrence detected by PPG. All ECG snapshots were recorded along with lead I and saved with simultaneous PPG. ECG data were examined by the three cardiologists independently (SK, SRL, and EKC). The monitoring time, analyzable proportions of monitored signals, detection rates of AF episodes, and the diagnostic performance of PPG-based deep learning were evaluated. At the end of the monitoring, a survey on the use of the smart ring was performed.

Results

A total of 35 participants (mean age 58.9 years, male 74.3%) were enrolled. Figure 1 illustrates an example of PPG monitoring and PPG-ECG snapshots by the smart ring. The study participation period was a median of 14 days and the wearing time of the smart ring was a median of 9.2 days (IQR 7.1–11.5 days). Signal artifacts during daily activity decreased the analyzable proportions of monitored PPG by 68.5%. Irregular pulse episodes were detected by the smart ring in 29 (82.9%) participants after a median of 1 day from the cardioversion (Figure 2). A total of 2532 PPG-ECG snapshots were acquired and 1623 (64.1%) were interpretable by both the cardiologists (using ECG) and the deep learning analysis (using PPG). Comparing PPG by simultaneous ECG, the performance of AF detection by the smart ring was 98.7% for sensitivity, 97.8% for specificity, 2.2% for false positives, and 1.3% for false negatives (Figure 2). After using the smart ring, 76.9% of the participants responded that they had no discomfort in using the smart ring in daily activity and another 76.9% responded that it was helpful to monitor their disease.

Conclusion

Despite the signal artifacts during daily activity, AF detection with PPG monitoring by a smart ring could be effective for AF screening among ambulatory patients.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This work was supported by Sky Labs Inc, Seongnam, Republic of Korea, and by the grant No. 0320202040 from the Seoul National University Hospital Research Fund.

Resting heart rate and cardiovascular outcomes in patients with atrial fibrillation: CODE-AF registry

Funding Acknowledgements

Type of funding sources: None.

Background

The prognostic significance of resting heart rate and its therapeutic target in atrial fibrillation (AF) is uncertain.

Purpose

The aim of this study was to investigate the relationships between resting heart rate and cardiovascular outcomes in patients with AF.

Methods

A total of 8,886 patients with AF was included from the COmparison study of Drugs for symptom control and complication prEvention of AF (CODE-AF) registry. Patients were categorized according to baseline heart rate, and cardiovascular outcomes were accessed during a median follow-up of 30 months. The primary outcome was a composite of cardiovascular death, hospitalization due to heart failure, and myocardial infarction/critical limb ischemia.

Results

Compared to heart rate ≥100 beats per minute (bpm), heart rate 80-99 bpm was associated with the lowest risk of primary outcome (adjusted hazard ratio [HR] 0.56, 95% confidence interval [CI] 0.40-0.79, p=0.001). In subgroup of patients with heart failure with preserved ejection fraction (HFpEF), heart rate between 80-99 bpm was associated with reduced risk of primary outcome compared to heart rate ≥100 bpm (HR 0.40, 95% CI 0.16-0.98, p=0.045). However, in patients with heart failure with reduced ejection fraction (HFrEF), there was no association between resting heart rate and cardiovascular outcomes (P for interaction 0.001).

Conclusion

Resting heart rate was associated with cardiovascular outcomes in patients with AF, and those with a resting heart rate between 80-99 bpm had the lowest risk of adverse events. The impact of resting heart rate on adverse events persisted in patients with concomitant HFpEF but was not apparent in those with concomitant HFrEF.

The impact of socioeconomic deprivation on the risk of atrial fibrillation in patients with diabetes mellitus: a nationwide population-based study

Funding Acknowledgements

Type of funding sources: None.

Background

Although the prevalence of atrial fibrillation (AF) is increasing worldwide, little is known about the exact risk factors of AF; and the disease"s association with socioeconomic status (SES) is under debate.

Purpose

This study aimed to examine the association between SES and the risk of AF in Korean patients with diabetes mellitus.

Methods

We studied 2,429,610 diabetic patients (mean age 56.9 years, female 40%) who underwent health check-ups from 2009 to 2012, using the National Health Insurance Service (NHIS) database of Korea. Subjects were categorized into 6 groups according to the number of times (0 through 5) entitled for medical aid (MA) recipient, within the past 5 years from the date of check-up. (Fig. 1)

Division of Medical Care Assistance in the Ministry of Health and Welfare selects the medical aid beneficiaries. The recipients should not have a reliable caregiver, nor their income be more than 40% of the standard median income.

Among the study population, 64,818 were classified as MA group: 10,697 in MA 1, 11,005 in MA 2, 12,431 in MA 3, 10,689 in MA 4, 19,996 in MA 5, respectively. The remaining 2,364,792 were never entitled to MA recipients within 5 years and were assigned to the non-MA group. The incidence rate and hazard ratio of AF were then calculated for each group.

Results

Risk factors for cardiovascular disease were measured at baseline. More current smokers were in MA 5 group (28.7% in MA 5, 26.7% in non-MA, 26.2% in MA 1, 23.8% in MA 2, 23% in MA 3, 23.2% in MA 4, respectively, p < 0.001), while more heavy drinkers were in the non-MA group than among the MA groups (20.7% vs. 6.2–7.9%, p < 0.001).

Hypertension and dyslipidemia were generally higher in MA groups than in the non-MA group (hypertension, 60.8–65.8% in MA groups vs. 54.8% in non-MA group; dyslipidemia, 44.1–54.9% in MA groups vs. 39.6% in non-MA group, all, p < 0.001), and the non-MAs tended to do more physical activities (20.7% vs. 15.4–15.8%, p < 0.001). Obese people with BMI≥30 were more in MA groups, especially in the MA 5, than in the non-MA group (7.5% in non-MA, 9.3%–9.7% in MA 1–4, and 12.2% in MA 5, all, p < 0.001).

80,257 were newly identified as AF in the retrospective 5 years. All the MA groups showed a higher risk of AF than the non-MA group: hazard ratio (95% confidence interval [CI]) for each group, 1.44 (1.32–1.58) in MA 1, 1.58 (1.45–1.73) in MA 2, 1.52 (1.39–1.65) in MA 3, 1.53 (1.40–1.68) in MA 4, and 1.35 (1.24–1.45) in MA 5. Adjusting with multi-variables, the MA 5 showed 54% increased risk of AF compared to the non-MA group (HR, 1.54, [95% CI, 1.42–1.67]). (Fig. 2)

Conclusion

The risk of AF increased more than 50% in patients who needed medical aid 5 years in a row, and the risk also rose greatly in patients with only a short experience of socioeconomic hardship. Based on the findings, we need more attention to individuals with recent socioeconomic deprivation to provide timely management for AF and its complications. Abstract Figure. Fig. 1

Characterizing patients with newly diagnosed atrial fibrillation compared to those with established atrial fibrillation: data from the CODE-AF registry

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Korean Healthcare Technology R&D project funded by the Ministry of Health & Welfare

OnBehalf

CODE-AF investigator

Background/Introduction: The characteristic of atrial fibrillation (AF), such as the risk of complications, may differ depending on the time after diagnosis.

Purpose

This study aimed to compare the baseline characteristics according to the AF diagnosis duration using a large multicenter prospective registry: CODE-AF (COmparison study of Drugs for symptom control and complication prEvention of Atrial Fibrillation).

Methods

A total of 10,021 patients with AF were enrolled between May 2016 to March 2021. We defined patients into two groups: the newly diagnosed (AF duration less than 3 months before enrollment) and the established (AF duration more than 3 months before enrollment) AF groups. We compared the baseline characteristics and the incidence of the composite outcomes (stroke, all-bleeding, heart failure and all-cause death) during follow-up period between the two groups. The survival analysis was performed using Kaplan-Meier curve analysis with validation by log-rank test.

Results

Among the 10,021 patients with AF (age 67.0 ±14.5 years, female 35.7%), patients with newly diagnosed AF were 2181, and those with established AF were 7840. Two groups did not differ between sex, weight, height, and body mass index. The newly diagnosed AF group was younger with higher tobacco and alcohol consumption compared to the established AF group. The established AF group had more comorbidities at the time of enrollment. Also, CHA2DS2-VASc score (2.36 ±1.64 vs. 2.68 ±1.67, p <0.001) and HAS-BLED score (1.55 ±1.02vs. 1.86 ±1.06 p <0.001) were both higher in established AF. The newly diagnosed AF group had a lower proportion of oral anticoagulation prescription (68.6% vs. 73.0%, p <0.001), whereas prescription of non-vitamin K antagonist oral anticoagulants was higher compared to those with established AF (75.7% vs. 68.9%, p <0.001) (Table). There was no significant difference in the event-free survival during the overall follow-up period on the composite outcomes. However, the newly diagnosed AF group showed a significantly higher risk of the composite outcomes within 90 days of enrollment than the established AF group (hazard ratio 2.01, 95% confidence interval 1.48 to 2.72) (Figure).

Conclusion

The newly diagnosed AF group showed different characteristics compared to the established AF group. Also, the composite clinical outcomes, including stroke, bleeding, heart failure, and all-cause death, had occurred more frequently during the early period after diagnosis in the newly diagnosed AF group. For the better clinical outcome of patients with newly diagnosed AF, structured assessment and comprehensive management is needed, especially during the early period after diagnosis. Abstract Figure.

Supraglottic airway device and venoarterial extracorporeal membrane oxygenation support for curative surgery in a patient with huge thyroid mass: A case report

In the case of complete surgical resection of locally aggressive thyroid mass with severely compromised airways, airway management is difficult and can be considerably risky. We report a case of airway management using i-gel™ and cardiopulmonary bypass (CPB) with venoarterial extracorporeal membrane oxygenation (ECMO), which is a safe and feasible method of airway management for providing general anesthesia in a patient with a large thyroid mass.

A neurodegeneration gene, WDR45, links impaired ferritinophagy to iron accumulation

Neurodegeneration with brain iron accumulation (NBIA) is a clinically and genetically heterogeneous group of neurodegenerative diseases characterized by the abnormal accumulation of brain iron and the progressive degeneration of the nervous system. One of the recently identified subtypes of NBIA is β‐propeller protein‐associated neurodegeneration (BPAN). BPAN is caused by de novo mutations in the WDR45/WIPI4 (WD repeat domain 45) gene. WDR45 is one of the four mammalian homologs of yeast Atg18, a regulator of autophagy. WDR45 deficiency in BPAN patients and animal models may result in defects in autophagic flux. However, how WDR45 deficiency leads to brain iron overload remains unclear. To elucidate the role of WDR45, we generated a WDR45‐knockout (KO) SH‐SY5Y neuroblastoma cell line using CRISPR‐Cas9‐mediated genome editing. Using these cells, we demonstrated that the non‐TF (transferrin)‐bound iron pathway dominantly mediated the accumulation of iron. Moreover, the loss of WDR45 led to defects in ferritinophagy, a form of autophagy that degrades the iron storage protein ferritin. We showed that impaired ferritinophagy contributes to iron accumulation in WDR45‐KO cells. Iron accumulation was also detected in the mitochondria, which was accompanied by impaired mitochondrial respiration, elevated reactive oxygen species, and increased cell death. Thus, our study links WDR45 to specific iron acquisition pathways and ferritinophagy.

Net clinical benefit of direct oral anticoagulants in very elderly and high bleeding risk patients with atrial fibrillation who are often excluded from oral anticoagulation therapy: a nationwide popul

Background

In the Edoxaban Low-Dose for Elder Care Atrial Fibrillation Patients (ELDERCARE-AF) trial, low-dose edoxaban (15mg once daily) showed better efficacy for stroke prevention and positive net clinical benefit compared to placebo in very elderly and high bleeding risk patients with atrial fibrillation (AF) who often excluded from oral anticoagulation (OAC) therapy. However, there are limited data to generalize the ELDERCARE-AF results into daily practice.

Purpose

To investigate the optimal OAC strategy for the best net clinical benefit in ELDERCARE-AF-like patients.

Methods

Using the Korean nationwide claims database, we included patients with incident non-valvular AF aged 80 years or older between 2014 and 2017. Among these, patients with one or more of the following criteria were finally included in the analysis: a low creatinine clearance (15 to 30 mL/min), a history of bleeding from a critical area or organ or gastrointestinal bleeding, low body weight (≤45kg), continuous use of nonsteroidal anti-inflammatory drugs, or current use of an antiplatelet drug. The risks of ischemic stroke, major bleeding, all-cause death, and composite clinical outcome (ischemic stroke+major bleeding+all-cause death) as a measure of net clinical outcome were evaluated during follow-up. The inverse probability of treatment weighting (IPTW) method was used to balance covariates between the groups.

Results

A total of 23,858 patients were finally included (no OAC, n=16,575; warfarin, n=2390; and direct oral anticoagulants (DOACs), n=4893, respectively). Among DOAC group, 69% used low-dose including rivaroxaban 15 mg once daily, dabigatran 110 mg twice daily, apixaban 2.5 mg twice daily, and edoxaban 30 mg once daily and 9% used very low dose including rivaroxaban 10 mg once daily and edoxaban 15 mg once daily (Figure). Median follow-up duration was 2 years (interquartile ranges, 1 to 3 years). Baseline characteristics were well-balanced after IPTW. Compared to the no OAC group, the DOAC group was associated with a lower risk of ischemic stroke (hazard ratio [HR], 95% confidence interval [CI]: 0.81, 0.68–0.95) and all-cause death (0.90, 0.85–0.95), and a higher risk of major bleeding (1.43, 1.20–1.69) (Figure). Patients treated with DOAC showed a lower risk of composite clinical outcome compared to those without OAC treatment (0.93, 0.88–0.98). Warfarin treatment did not reduce the risk of ischemic stroke (1.03, 0.85–1.23) and all-cause death (1.05, 0.99–1.12), but increased the risk of major bleeding (1.60, 1.32–1.92) and the composite clinical outcome (1.08, 1.02–1.15) compared to no OAC group.

Conclusion

In very elderly patients with non-valvular AF who had one or more frail components, DOACs which were currently prescribed in usual clinical practice showed better effectiveness and positive net clinical benefit compared to no OAC treatment. Compared to the latter, warfarin did not show benefit and possible harm.

Funding Acknowledgement

Type of funding sources: None.

Dual antithrombotic therapy on early clinical outcomes in patients with atrial fibrillation after percutaneous coronary intervention: a nationwide study in the era of NOAC

Background/Introduction

Recent evidence has confirmed low bleeding risk with double antithrombotic therapy, combining oral anticoagulant (OAC) and single platelet inhibitor, in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). Among the Asian AF population, most of the patients received dual antiplatelet therapy (DAPT) without OACs, even after the introduction of non-vitamin K oral anticoagulants (NOACs).

Purpose

The current nationwide study assessed 3-month ischemic and bleeding risks of DAPT in comparison to triple antithrombotic therapy among the Korean AF population undergoing PCI.

Methods

We analyzed the claims records of 11,039 patients (mean age 70 years, 66.3% male, and mean CHA2DS2-VASc score 3.2) between 2013 to 2018. Patients were categorized into triple therapy group with vitamin K antagonists (VKAs-TT), or NOACs (NOACs-TT), and DAPT group according to the antithrombotic therapy after PCI. 3-month risks of ischemic stroke, non-fatal myocardial infarction, any in-hospital death, and major bleeding were compared between groups after baseline adjustment using inverse probability weighting.

Results

A total of 1,786, 1,997, and 7,256 patients were allocated to the VKAs-TT, NOACs-TT, and DAPT groups. The DAPT group had a higher prevalence of prior MI and coronary revascularization, but had lower thromboembolic and bleeding risks than the triple antithrombotic therapy groups (mean CHA2DS2-VASc score 3.8, 4.1, and 3.5; and mean HAS-BLED score 3.3, 3.4, and 3.1 for VKAs-TT, NOACs-TT, and DAPT groups, respectively). The NOACs-TT group was associated with a lower risk of ischemic stroke (hazard ratio [HR] 0.38, 95% confidence interval [CI] 0.20–0.70) and any in-hospital death (HR 0.70, 95% CI 0.49–0.98) compared with the VKAs-TT group. The DAPT group showed a lower risk of ischemic stroke (HR 0.41, 95% CI 0.27–0.63) and major bleeding (HR 0.55, 95% CI 0.37–0.84) than the VKAs-TT group, especially in patients without prior OAC treatment. The DAPT group showed a comparable ischemic risk against the NOACs-TT group, although the risk of major bleeding was lower in the DAPT group, especially among old age (HR 0.47, 95% CI 0.29–0.78) or OACs-naive patients (HR 0.50, 95% CI 0.29–0.86).

Conclusion

Among the Asian AF population, using short-term DAPT for 3-month after PCI was associated with a lower risk of bleeding without increasing ischemic risk compared to triple antithrombotic therapy with OAC. This may be a therapeutic option in very high bleeding risk patients who have had complex PCI necessitating focus on DAPT in the initial 3 month period.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): This study was supported by grant no 3020200200 from the Seoul National University Hospital Research Fund, by the Korea Medical Device Development Fund grant funded by the Korea government (the Ministry of Science and ICT, the Ministry of Trade, Industry and Energy, the Ministry of Health & Welfare, Republic of Korea, the Ministry of Food and Drug Safety) (Project Number: 202013B14), and by the Korea National Research Foundation funded by the Ministry of Education, Science and Technology (grant 2020R1F1A106740). Figure 1Figure 2

Risk of dementia according to smoking cessation after newly diagnosed atrial fibrillation: a nationwide cohort study

Background

Incident atrial fibrillation (AF) is associated with an increased risk of dementia. There are limited data about the impact of smoking cessation after AF diagnosis on the risk of incident dementia.

Purpose

To evaluate the association between changes in smoking status after newly diagnosed AF and the risk of dementia.

Methods

Among patients with new-onset AF between 2010 and 2016, those who received a national health checkup exam within 2 years before and after the AF diagnosis were included. Patients who had prevalent dementia were excluded. Subjects were categorized into 4 groups according to the status of smoking before and after AF diagnosis: (1) never smoker; (2) ex-smoker; (3) quit-smoker after AF diagnosis; and (4) current smoker. The primary outcome was incident dementia during follow-up.

Results

A total of 126,252 patients were included (mean age 63, SD 12.0; men 62%; mean CHA2DS2-VASc 2.7). During a median 3 years of follow-up, dementia occurred in 5,925 patients (1.11 per 1000 person-years [1000PY]) (Alzheimer's dementia 1.5 per 1000 PY and vascular dementia 0.24 per 1000 PY, respectively). Never smokers, ex-smokers, quit-smokers, and current smokers were 52%, 27%, 7%, and 14% of the total study population, respectively. After multivariable adjustment, quit-smokers showed a higher risk of dementia than never smokers (hazard ratio [HR] 1.16, 95% confidence interval [CI] 1.03–1.32), but the risk was significantly decreased when compared to current smokers (HR 0.83, 95% CI 0.72–0.95). Alzheimer's dementia and vascular dementia showed consistent results as main (Figure).

Conclusion

All types of smoking were associated with a significantly higher risk of dementia in patients with new-onset AF. Smoking cessation after AF diagnosis showed a lower risk of dementia compared to patients smoking persistently. These findings may support the promotion of smoking cessation to lower the risk of dementia in patients with new-onset AF.

Funding Acknowledgement

Type of funding sources: None.

Clustering of healthy lifestyle behaviors is associated with a lower incidence of adverse events in patients with newly diagnosed atrial fibrillation: a nationwide cohort study

Background

Although unhealthy or healthy lifestyle behaviors tend to be clustered, studies on the risk of clinical outcomes depending on how the lifestyle behaviors are managed after atrial fibrillation (AF) diagnosis remain limited.

Purpose

We aimed to evaluate the association between a cluster of healthy lifestyle behaviors and the risk of adverse outcomes in patients with AF.

Methods

Using the Korean National Insurance Service database, patients who were newly diagnosed as nonvalvular AF between 2009 and 2016 and received national health screening examination within 2-year after AF diagnosis were included. A healthy lifestyle behavior score (HLS) was calculated by assigning 1 point each for “non-current” smoking, for non-drinking, and for performing regular exercise from the self-reported questionnaire in health screening examinations. The primary outcome was defined as major adverse cardiovascular events (MACE), including ischemic stroke, myocardial infarction, and hospitalization for heart failure. The secondary outcomes included individual components of the primary composite outcome and all-cause death.

Results

A total of 208,662 patients were included and 7.1%, 22.7%, 58.6%, and 11.6% were HLS 0, 1, 2, and 3 group, respectively. After multivariable adjustment, patients with HLS 1, 2, and 3 were associated with lower risks of MACE compared to those with HLS 0 (adjusted hazard ratio [95% confidence interval]: 0.788 [0.762–0.855], 0.654 [0.604–0.708], and 0.579 [0.527–0.636], respectively) (Figure). Increased number of healthy lifestyle behaviors were associated with lower risks of ischemic stroke, hospitalization for heart failure, and all-cause death. The risk reduction of healthy lifestyle combinations was consistently observed in various subgroups, regardless of CHA2DS2-VASc score and oral anticoagulant use.

Conclusion

Increased number of healthy lifestyle behaviors were significantly associated with lower MACE and all-cause death risks in patients with new-onset AF. These findings support the promotion of a healthy lifestyle to reduce the risk of adverse events in AF patients.

Funding Acknowledgement

Type of funding sources: None.

Risk of atrial fibrillation in young adults aged 20 to 39 years with isolated diastolic, isolated systolic, and systolic-diastolic hypertension: a nationwide population-based study

Background

There is limited evidence regarding the comparative risks of incident atrial fibrillation (AF) associated with stage 1 isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH), and systolic-diastolic hypertension (SDH), especially amongst young adults aged 20–39 years.

Purpose

To evaluate the association between early-stage of hypertension and AF in young adults aged 20–39 years.

Methods

From the Korean nationwide health screening database, 2,958,544 subjects aged 20–39 years who were not prescribed antihypertensive medication at the index examination in 2009 were included. Subjects were categorized into eight groups according to the 2017 American College of Cardiology/American Heart Association blood pressure (BP) guidelines: normal BP, elevated BP, stage 1 IDH, stage 1 ISH, stage 1 SDH, stage 2 IDH, stage 2 ISH, and stage 2 SDH. The primary outcome was new-onset AF during follow-up.

Results

During a median follow-up of 8.3 years, 7,347 subjects had incident AF (incidence rate, 0.3 per 1,000 person-years). Compared to the normal BP group, stage 1 IDH (adjusted hazard ratio [aHR], 1.160; 95% confidence interval [CI], 1.086–1.240) and stage 1 SDH (1.250; 1.165–1.341) were associated with higher risks of incident AF, but not stage 1 ISH. Stage 2 IDH, ISH, and SDH were associated with higher risks of incident AF by 24%, 37%, and 61%, respectively (Figure).

Conclusion

Among young adults, stage 1 IDH and SDH were associated with higher risks of incident AF compared to normal BP. The risk of incident AF with stage 2 IDH was similar to that of stage 1 SDH. Optimal BP control including diastolic BP is crucial for preventing new-onset AF, even amongst young adults.

Funding Acknowledgement

Type of funding sources: None.

Antithrombotic therapy for patients with atrial fibrillation and stable coronary artery disease of 1-year and 3-year after percutaneous coronary intervention: a nationwide population-based study

Background

In a recent trial, rivaroxaban monotherapy was noninferior for efficacy and superior for safety to rivaroxaban plus single antiplatelet therapy, as antithrombotic therapy for patients with atrial fibrillation (AF) and stable coronary artery disease (CAD). However, there are limited data regarding the comparative effectiveness and safety of oral anticoagulant (OAC) monotherapy versus OAC plus single antiplatelet therapy (SAPT) in real-world practice, especially after the introduction of direct oral anticoagulants (DOAC).

Purpose

To compare the effectiveness, safety, and net clinical benefit of OAC monotherapy to OAC plus SAPT in patients with AF and stable CAD of 1-year and 3-year after percutaneous coronary intervention (PCI) in a contemporary real-world observational cohort.

Methods

Using the Korean nationwide claims database, we included AF patients who underwent PCI from January 1, 2009 to February 28, 2019. Considering dynamic changes of antithrombotic therapy according to the period after receiving PCI, the index antithrombotic treatment was independently defined at the different time after receiving PCI and we conducted two cohort: 1-year and 3-year after PCI. In each cohort, the baseline characteristics of OAC monotherapy and OAC plus SAPT groups were balanced using inverse probability of treatment weighting (IPTW) methods. To assess clinical outcomes, ischemic stroke, myocardial infarction, major bleeding, and composite clinical outcomes of each outcome were analyzed.

Results

In cohort with 1-year after PCI, 678 patients with OAC monotherapy and 3159 patients with OAC plus SAPT were included. In cohort with 3-year after PCI, 1038 patients with OAC monotherapy and 2128 patients with OAC plus SAPT were enrolled. The baseline characteristics were well-balanced after IPTW between the two groups in both cohorts. Among total population, about 45% of patients prescribed DOAC as OAC treatment. Among patients with 1-year after PCI, OAC monotherapy and OAC plus SAPT showed comparable results for ischemic stroke, myocardial infarction, major bleeding, and composite clinical outcomes (Figure). In cohort with 3-year after PCI, OAC monotherapy and OAC plus SAPT showed comparable results for ischemic stroke and myocardial infarction, but OAC monotherapy was associated with a lower risk of the composite clinical outcome (hazard ratio [HR] 0.762, 95% confidence interval [CI] 0.607–0.950), mainly driven by reduction of major bleeding risk (HR 0.762, 95% CI 0.607–0.950) compared to OAC plus SAPT (Figure).

Conclusion

OAC monotherapy might be, at least, comparable choice for patients with AF and stable CAD compared to OAC plus SAPT. In patients with stable CAD more than 3-years after index PCI, OAC monotherapy could be better therapeutic choice to achieve less major bleeding and positive net clinical benefit.

Funding Acknowledgement

Type of funding sources: None.