The impact of the Covid-19 pandemic on postnatal anxiety and posttraumatic stress: Analysis of two population-based national maternity surveys in England

BACKGROUND

Few studies have evaluated postnatal anxiety and posttraumatic stress (PTS) before and during the Covid-19 pandemic using comparable data across time. We used data from two national maternity surveys in England to explore the impact of the pandemic on prevalence and risk factors for postnatal anxiety and PTS.

METHODS

Analysis was conducted using population-based surveys carried out in 2018 (n = 4509) and 2020 (n = 4611). Weighted prevalence estimates for postnatal anxiety and PTS were compared across surveys. Adjusted risk ratios (aRR) were estimated for the association between risk factors and postnatal anxiety and PTS.

FINDINGS

Prevalence of postnatal anxiety increased from 13.7 % in 2018 to 15.1 % in 2020 (+1.4 %(95%CI:-0.4-3.1)). Prevalence of postnatal PTS increased from 9.7 % in 2018 to 11.5 % in 2020 (+1.8 %(95%CI:0.3-3.4)), due to an increase in PTS related to birth trauma from 2.5 % to 4.3 % (+1.8 %(95%CI:0.9-2.6); there was no increase in PTS related to non-birth trauma. Younger age (aRR = 1.31-1.51), being born in the UK (aRR = 1.29-1.59), long-term physical or mental health problem(s) (aRR = 1.27-1.94), and antenatal anxiety (aRR = 1.97-2.22) were associated with increased risk of postnatal anxiety and PTS before and during the pandemic, whereas higher satisfaction with birth (aRR = 0.92-0.94) and social support (aRR = 0.81-0.82) were associated with decreased risk.

INTERPRETATION

Prevalence of postnatal PTS was significantly higher during the pandemic, compared to before the pandemic, due to an increase in PTS related to birth trauma. Prevalence of postnatal anxiety was not significantly higher during the pandemic. Risk factors for postnatal anxiety and PTS were similar before and during the pandemic.

The Nitrous Oxide Project: assessment of advocacy and national directives to deliver mitigation of anaesthetic nitrous oxide

The environmental emissions attributed to anaesthetic nitrous oxide across the NHS are comparable to the carbon dioxide released by 135,000 flights from Frankfurt to New York. Much of these emissions are attributable to cumbersome and inadequately managed piped systems, resulting in excessive loss and waste. Since 2020, multiple hospital sites have been engaging with the Nitrous Oxide Project, a quality improvement method supporting a 'lean systems' approach to the provision of nitrous oxide. This review considers the frameworks supporting medical gas management in UK healthcare systems, and the impact of professional advocacy and medical gas stewardship to drive anaesthetic nitrous oxide mitigation in the NHS. Nitrous oxide mitigation efforts by grassroots and professional advocacy networks are enhanced through national centralised emission monitoring, distribution of data, technical information and provision of quality analysis. Given the climate harms of nitrous oxide, concerted efforts should be made to rationalise its use, and resources should be committed to supporting this at local, regional and national levels.

Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation

BACKGROUND

The prevalence of type 2 diabetes is increasing rapidly, particularly among younger age groups. Estimates suggest that people with diabetes die, on average, 6 years earlier than people without diabetes. We aimed to provide reliable estimates of the associations between age at diagnosis of diabetes and all-cause mortality, cause-specific mortality, and reductions in life expectancy.

METHODS

For this observational study, we conducted a combined analysis of individual-participant data from 19 high-income countries using two large-scale data sources: the Emerging Risk Factors Collaboration (96 cohorts, median baseline years 1961-2007, median latest follow-up years 1980-2013) and the UK Biobank (median baseline year 2006, median latest follow-up year 2020). We calculated age-adjusted and sex-adjusted hazard ratios (HRs) for all-cause mortality according to age at diagnosis of diabetes using data from 1 515 718 participants, in whom deaths were recorded during 23·1 million person-years of follow-up. We estimated cumulative survival by applying age-specific HRs to age-specific death rates from 2015 for the USA and the EU.

FINDINGS

For participants with diabetes, we observed a linear dose-response association between earlier age at diagnosis and higher risk of all-cause mortality compared with participants without diabetes. HRs were 2·69 (95% CI 2·43-2·97) when diagnosed at 30-39 years, 2·26 (2·08-2·45) at 40-49 years, 1·84 (1·72-1·97) at 50-59 years, 1·57 (1·47-1·67) at 60-69 years, and 1·39 (1·29-1·51) at 70 years and older. HRs per decade of earlier diagnosis were similar for men and women. Using death rates from the USA, a 50-year-old individual with diabetes died on average 14 years earlier when diagnosed aged 30 years, 10 years earlier when diagnosed aged 40 years, or 6 years earlier when diagnosed aged 50 years than an individual without diabetes. Using EU death rates, the corresponding estimates were 13, 9, or 5 years earlier.

INTERPRETATION

Every decade of earlier diagnosis of diabetes was associated with about 3-4 years of lower life expectancy, highlighting the need to develop and implement interventions that prevent or delay the onset of diabetes and to intensify the treatment of risk factors among young adults diagnosed with diabetes.

FUNDING

British Heart Foundation, Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

Stroke-heart syndrome: sex-specific incidence, risk factors, and major adverse cardiovascular events in 486,515 patients with incident ischaemic stroke

Background

Newly diagnosed cardiovascular complications post-stroke, termed stroke-heart syndrome, are common and associate with worsened prognosis.

Purpose

To investigate the sex-specific incidence and 5-year major adverse cardiovascular events following stroke-heart syndrome, stratified by pre-existing risk factors (sex, age, obesity, hypertension, type 2 diabetes mellitus, and high LDL cholesterol).

Methods

A retrospective cohort study was conducted using anonymised electronic medical records from 56 participating healthcare organizations. Patients with incident ischaemic stroke aged ≥18 years with 5-years of follow-up were included. Patients diagnosed with new-onset cardiovascular complications (heart failure, severe ventricular arrhythmia, atrial fibrillation, ischaemic heart disease, takotsubo syndrome) within 4-weeks of incident ischaemic stroke (exposure) were 1:1 propensity score-matched (age, sex, ethnicity, comorbidities, cardiovascular care) with ischaemic stroke patients without newly diagnosed cardiovascular complications (control). Cox proportional hazards regression models produced hazard ratios (HR) with 95% confidence intervals (CIs) and Kaplan-Meier curves for 5-year risk of all-cause mortality, recurrent stroke, and acute myocardial infarction (AMI).

Results

Of 486,515 patients with ischaemic stroke, 18% (n=87,786) presented with stroke-heart syndrome (47% (n=41,088) female and 52% (n=45,891) male). Following propensity score matching, composite stroke-heart syndrome associated with significantly higher risk of 5-year mortality (HR 1.66 (95% CI 1.62,1.70), P<0.01), recurrent stroke (1.26 (1.24,1.28), P<0.01), and AMI (2.58 (2.50,2.67), P<0.01). These outcomes were similar for both males and females (Figure 1). The risk of mortality, recurrent stroke and AMI following stroke-heart syndrome was relatively higher for patients aged <75 compared to those >75. The risk of all adverse outcomes were relatively higher for females aged <75 compared to males aged <75. Pre-existing obesity associated with a lower risk of mortality for females and males, but a higher risk of recurrent stroke for females. Pre-existing hypertension associated with a lower risk of all outcomes, except recurrent stroke in males. Pre-existing diabetes associated with higher risks for mortality and AMI for both females and males. High LDL cholesterol associated with lower risk of mortality but a higher risk of recurrent stroke and AMI in males and females (Figure 1).

Conclusions

In this cohort study of patients with incident ischaemic stroke, stroke-heart syndrome occurred in 18% of patients. The overall incidence and subsequent 5-year major adverse cardiovascular events following stroke-heart syndrome were similar for females and males, but with important sex-specific differences when stratified by pre-existing risk factors, including age, obesity, and hypertension.

Funding Acknowledgement

Type of funding sources: None.

Rock glaciers represent hidden water stores in the Himalaya

In the high mountains of Asia, ongoing glacier retreat threatens human and ecological systems through reduced water availability. Rock glaciers are climatically more resistant than glaciers and contain valuable water volume equivalents (WVEQ). Across High Mountain Asia (HMA) the WVEQ of rock glaciers is poorly quantified, and thus their hydrological significance versus glaciers is unknown. Here we present the first systematic assessment of Himalayan rock glaciers, totalling ~25,000 landforms with an areal coverage of ~3747 km². We calculate the WVEQ of Himalayan rock glaciers to be 51.80 ± 10.36 km³. Their comparative importance versus glaciers (rock glacier: glacier WVEQ ratio) is 1:25, which means that they constitute hydrologically valuable long-term water stores. In the context of climate-driven glacier recession, their relative hydrological value will likely increase. These cryospheric stores should be included in future scenario modelling to understand their role in sustainable water management for HMA.

Use of oral anticoagulation for people with atrial fibrillation post-stroke and associations with recurrent stroke and mortality: a systematic review

Introduction

Current guidelines recommend oral anticoagulation (OAC) to reduce recurrent stroke risk for people with atrial fibrillation (AF); however, outcomes for post-stroke AF patients receiving different types of anticoagulants and optimal timing of anticoagulation in this population remains unclear.

Purpose

The objective of this systematic review was to summarise observational study data reporting associations between OAC use and risk of mortality, recurrent stroke, and major bleeding within post-stroke AF populations.

Methods

SCOPUS and OVID Medline databases were searched from inception to 02/11/2020. Studies were limited to publications in the English language post-2012. Observational studies, including case-control and cohort studies were eligible for inclusion. The outcomes examined were all-cause mortality, recurrent stroke and major bleeding. Screening and risk of bias assessment with the Newcastle-Ottawa scale were completed independently by two reviewers. Data extraction was completed by one reviewer and checked by a second. The review was registered on PROSPERO: CRD42020221105.

Results

Searches identified 3803 studies; 29 studies were eligible for inclusion. Variations between studies including time of OAC initiation, types of OACs used, and length of follow-up meant a meta-analysis was not possible. Four of six studies reporting effect measures of pre-admission or post-stroke OAC use found significant associations with reduced all-cause post-stroke mortality compared to no OAC use (Figure 1A). One study reported lower recurrent stroke rates in patients with no preadmission OAC use compared to preadmission OAC use (2.9% vs. 5.3%; adjusted hazard ratio (aHR) 1.50, 95% confidence interval [CI] 1.02–2.21). A separate study found post-stroke OAC use resulted in a non-significant lower stroke recurrence rate compared to no post-stroke OAC use (3.7% vs. 4.3%; p=0.9). Eight studies examined non-vitamin K antagonist OACs (NOACs) compared to warfarin; five demonstrated significant associations between post-stroke NOAC use and improved outcomes such as post-stroke mortality (Figure 1B). Two studies examined post-stroke OAC therapy timing; both suggested OAC initiation within 4 days of the index event was associated with reduced all-cause mortality (4.5% and 0.6% vs. 8.7% and 3.1%) and recurrent stroke rates (9.4% and 0.8% vs. 10.5% and 1.6%). One study reported non-significant increased major bleeding rates for earlier OAC initiation (2.7% vs. 2.2%; aHR 1.39, 95% CI 0.42–4.60). Overall, the results were consistent with previously published randomised controlled trials.

Conclusions

Evidence from observational studies suggest that the overall benefit of NOACs in reducing recurrent stroke and post-stroke mortality outweighs the risk of major bleeding in post-stroke AF patients. There is a need for further studies to evaluate the optimum timing of post-stroke anticoagulation initiation and management differences in patients with AF.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The project is supported by the MRes programme in the Institute of Life Course and Medical Sciences at The University of Liverpool. All-Cause Mortality Forest Plots

Improved Constraints on Primordial Gravitational Waves using Planck, WMAP, and BICEP/Keck Observations through the 2018 Observing Season

We present results from an analysis of all data taken by the BICEP2, Keck Array, and BICEP3 CMB polarization experiments up to and including the 2018 observing season. We add additional Keck Array observations at 220 GHz and BICEP3 observations at 95 GHz to the previous 95/150/220  GHz dataset. The Q/U maps now reach depths of 2.8, 2.8, and 8.8  μK_{CMB} arcmin at 95, 150, and 220 GHz, respectively, over an effective area of ≈600 square degrees at 95 GHz and ≈400 square degrees at 150 and 220 GHz. The 220 GHz maps now achieve a signal-to-noise ratio on polarized dust emission exceeding that of Planck at 353 GHz. We take auto- and cross-spectra between these maps and publicly available WMAP and Planck maps at frequencies from 23 to 353 GHz and evaluate the joint likelihood of the spectra versus a multicomponent model of lensed ΛCDM+r+dust+synchrotron+noise. The foreground model has seven parameters, and no longer requires a prior on the frequency spectral index of the dust emission taken from measurements on other regions of the sky. This model is an adequate description of the data at the current noise levels. The likelihood analysis yields the constraint r_{0.05}<0.036 at 95% confidence. Running maximum likelihood search on simulations we obtain unbiased results and find that σ(r)=0.009. These are the strongest constraints to date on primordial gravitational waves.

Discharging patients; does it need to be done by a doctor?

Funding Acknowledgements

None

Background

Patients undergoing angiography and percutaneous coronary intervention (PCI) were historically reviewed post procedure by a member of the medical team who assesses the patient’s suitability for discharge and completes the discharge letter. Over the past 10 years, the number of patients admitted for these procedures as day cases has increased significantly. In addition, there has been an expansion in nursing roles in the UK with the development of a variety of clinical nurse specialist (CNS) posts which have taken over many of the traditional medical roles.

The majority of patients undergoing elective angiography and PCI are admitted to a day case unit at this tertiary cardiac centre. There is no designated medical cover for the unit and medical staff from the acute cardiac unit are called to review patients and complete their discharge paperwork in addition to their other duties. This frequently results in delayed discharge and patients going home without a discharge summary.

It was therefore proposed that suitably qualified CNSs could be trained to discharge these patients and others undergoing day case cardiology procedures.  From June 2017, the CNS team took over the role of reviewing patients post procedure and completing the discharge letter.

Purpose

The aim of the study was to evaluate if CNSs were able to discharge patients and provide a timely and effective service following elective cardiology procedures and to obtain patient feedback.

Method

Data on the number of patients reviewed by the CNSs from June 2017 to the end of December 2019, were prospectively collected in a dedicated database. A pilot study of patient experience was carried out in January 2020. Patients were given a questionnaire which asked about the explanation they received from the CNS regarding the procedure they had undergone, if their medication was reviewed and discussed with them, and if they received a discharge summary to take home.

Results

1287 patients were reviewed by the CNS team during the above period. 811 (63.0%) patients had undergone angiography and 423 (32.9%) PCI.  Informal feedback from the staff working on the day case unit included that patients were discharged earlier, had improved knowledge about their procedure and that the discharge letter was more detailed when completed by the CNS team.

Eight patients completed the pilot questionnaire. Six were discharged by one of the CNS team, one by a doctor and one patient was not sure who did their discharge. All patients were very satisfied with the process and the information they were given.

Conclusion

Experienced CNSs can deliver high-quality, timely discharge of patients following cardiology procedures.  This process is being used as a template to expand nurse-led discharge to other areas in cardiology. Patient experience will continue to be audited with a larger sample size in 2020.

A massive rock and ice avalanche caused the 2021 disaster at Chamoli, Indian Himalaya

On 7 February 2021, a catastrophic mass flow descended the Ronti Gad, Rishiganga, and Dhauliganga valleys in Chamoli, Uttarakhand, India, causing widespread devastation and severely damaging two hydropower projects. More than 200 people were killed or are missing. Our analysis of satellite imagery, seismic records, numerical model results, and eyewitness videos reveals that ~27 × 10⁶ cubic meters of rock and glacier ice collapsed from the steep north face of Ronti Peak. The rock and ice avalanche rapidly transformed into an extraordinarily large and mobile debris flow that transported boulders greater than 20 meters in diameter and scoured the valley walls up to 220 meters above the valley floor. The intersection of the hazard cascade with downvalley infrastructure resulted in a disaster, which highlights key questions about adequate monitoring and sustainable development in the Himalaya as well as other remote, high-mountain environments.

The quality of e-fit notes issued in secondary care

BACKGROUND

Few data are available on the pattern of use of fit notes issued in secondary care settings.

AIMS

To evaluate the pattern and quality of e-fit notes issued in an NHS Trust.

METHODS

Anonymized data on patients admitted to Guy's and St Thomas' NHS Foundation Trust (London, UK) who had an e-fit note issued from 1 January to 31 August 2017 were analysed using descriptive statistical methods. Thematic analysis was used to group the free-text comments into distinct categories and themes.

RESULTS

A total of 815 fit notes were issued during the study period. A total of 659 (81%) fit notes advised that patients were 'not fit' for work, whilst 156 (19%) advised that they 'may be fit' for work. The specialty with the highest proportion of patients assessed as may be fit was plastic surgery 46/104 (44%), whilst the lowest was ear, nose and throat surgery 0/57 (0%). The majority 151/156 (97%) of fit notes which advised that patients may be fit for work used the tick-box sections on the fit note to recommend work modifications. Of the free-text comments in section 4 of the 'may be fit' e-fit notes issued, 91/114 (80%) were related to the functional ability of patients.

CONCLUSIONS

Our study suggests that doctors in secondary care are more willing to use the 'may be fit' option on the fit note than primary care practitioners. Most fit notes, which advised that a patient may be fit for work, suggested workplace modifications.

Impact on outcomes in Europe: a cluster analysis from the ESC-EHRA EORP AF general long-term registry

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

ESC-EHRA EORP AF General Long-Term Registry Investigators

Introduction

Data derived from recent observational studies in atrial fibrillation (AF) show how the complexity of the clinical phenotype, beyond baseline thromboembolic risk, can increase risk of major adverse outcomes. Importantly, risk factors tend to occur in clusters, rather than occur individually in isolation.

Aims

To describe AF patients’ clinical phenotypes among a large contemporary European AF cohort and to analyse the differential impact of these clinical phenotypes on the occurrence of major adverse outcomes.

Methods

We performed a hierarchical cluster analysis based on Ward’s Method and using Squared Euclidean Distance using 22 clinical covariates. All variables were considered as binary. Examining the distances between cluster coefficients and by visual inspection of the dendrogram produced we identified the optimal number of clusters. Patients with data available for all 22 variables were included. We considered occurrence of cardiovascular events and all-cause death.

Results

Among the original 11096 patients included, 9363 (84.4%) were available for this analysis. The cluster analysis identified three clusters: Cluster 1 (n = 3634; 38.8%) characterized by older patients with prevalent noncardiac comorbidities; Cluster 2 (n = 2774; 29.6%) characterized by younger patients mainly admitted for first detected and paroxysmal AF with low prevalence of concomitant conditions; Cluster 3 (n = 2955; 31.6%) included patients with high prevalence of permanent AF, cardiac risk factors and comorbidities. Thromboembolic and bleeding risks were higher in Cluster 3 and progressively lower in Cluster 1 and Cluster 2 (both p &lt; 0.001). Use of oral anticoagulant was significantly lower for Cluster 2 (83.2% vs. 86.5% and 86.7% in Cluster 1 and Cluster 3, respectively; p &lt; 0.001). Over a mean follow-up of 22.5 (SD5.5) months, Cluster 3 had the highest rate of both cardiovascular events (10.0%) and all-cause death (13.2%), compared with Cluster 1 (6.6% and 9.4%, respectively) and Cluster 2 (3.7% and 3.8%, respectively) (both p &lt; 0.001). Kaplan-Meier curves (Figure) show that Cluster 2 (green line) had the lowest cumulative risk of outcomes; risk was progressively higher in Cluster 1 (orange line) and Cluster 3 (yellow line). A Cox multivariable regression analysis, adjusted for type of AF, symptomatic status, CHA2DS2-VASc score and use of oral anticoagulants, showed that both Cluster 3 and Cluster 1 were associated with a significantly increased risk of cardiovascular events (HR: 1.80, 95%CI: 1.39-2.33 and HR: 1.40, 95%CI: 1.09-1.80, respectively) and all-cause death (HR: 1.80, 95%CI: 1.40-2.30 and HR: 1.66, 95%CI: 1.30-2.11) compared to Cluster 2.

Conclusions

In European AF patients, three main clinical clusters were identified, those with non-cardiac comorbidities, low risk and cardiac comorbidities. Both non-cardiac and cardiac comorbidities clusters were found to be associated with an increased risk of cardiovascular events and all-cause death. Abstract Figure. Kaplan-Meier Curves for Outcomes

Associations of exercise-based cardiac rehabilitation with all-cause mortality among patients with atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

There is limited evidence of long-term impact of exercise-based CR on clinical endpoints for patients with AF. We therefore compared 18-month all-cause mortality, hospitalisation, stroke, and heart failure in patients with AF and an electronic medical record (EMR) of exercise-based CR to matched controls.

Methods and Results

This retrospective cohort study included patient data obtained on 11 December 2020, from a global federated health research network. AF patients undergoing exercise-based CR were propensity score matched to AF patients without exercise-based CR by age, sex, race, medication, and co-morbidities. We ascertained 18-month incidence of all-cause mortality, hospitalisation, stroke, and heart failure.

Of 1,350,886 patients with AF, 10,625 patients had an EMR of exercise-based CR within 6-months of incident AF. The propensity score matched cohort of 21,250 patients with AF demonstrated that exercise-based CR was associated with 64% lower odds of all-cause mortality (odds ratio 0.36, 95% confidence interval (CI) 0.33-0.40), 41% lower odds of hospitalisation (0.59, 95% CI 0.56-0.63), and 17% lower odds of incident stroke (0.83, 95% CI 0.71-0.98) compared to propensity score matched controls. No significant associations were shown for heart failure at 18-months (0.92, 95% CI 0.81-1.02). The beneficial association of exercise-based CR on all-cause mortality was independent of sex, older age, comorbidities, and AF subtype.

CONCLUSIONS

Exercise-based CR among patients with incident AF was associated with lower odds of all-cause mortality, hospitalisation, and stroke at 18-months follow-up. The longitudinal nature of this retrospective follow-up study strongly supports the provision of exercise programmes for patients with incident AF.

Cardiac rehabilitation and all-cause mortality in patients with heart failure: A retrospective cohort study

Funding Acknowledgements

Type of funding sources: None.

Background

Despite the benefits of exercise training in the secondary prevention of cardiovascular disease, there are conflicting findings for the impact of exercise-based cardiac rehabilitation (CR) on mortality for patients with heart failure (HF).

Methods

A retrospective cohort study was conducted which utilised a global federated health research network. Patients with a diagnosis of HF were compared between those with and without an electronic medical record of exercise-based CR within 6-months of a HF diagnosis. Patients with HF undergoing exercise-based CR were propensity score matched to HF patients without exercise-based CR by age, sex, race, co-morbidities, medications, and procedures. We ascertained 2-year incidence of all-cause mortality, hospitalisation, stroke, and atrial fibrillation.

Results

Following propensity score matching, a total of 40,364 patients with HF were identified. Exercise-based CR was associated with 42% lower odds of all-cause mortality (odds ratio 0.58, 95% confidence interval (CI): 0.54-0.62), 26% lower odds of hospitalisation (0.74, 95% CI 0.71-0.77), 37% lower odds of incident stroke (0.63, 95% CI 0.51-0.79), and 53% lower odds of incident atrial fibrillation (0.47, 95% CI 0.4-0.55) compared to matched controls. The beneficial association of exercise-based CR on all-cause mortality was consistent across stratification for sex, older age, included comorbidities, and HF subtype (all P &lt; 0.0001), including patients with HFpEF (0.65, 95% CI 0.60-0.71).

Conclusions

Exercise-based CR was associated with lower odds of all-cause mortality, hospitalisations, incident stroke and incident atrial fibrillation at 2-years follow-up for patients with HF. The beneficial association of CR and lower mortality was consistent for patients with HFrEF and HFpEF.

Impact of physical activity on all-cause mortality in European patients with atrial fibrillation: a report from the ESC-EHRA EORP AF General Long-Term Registry

Background

Physical activity (PA) may have a beneficial contribution for outcomes in patients with atrial fibrillation (AF).

Purpose

We aimed to evaluate the impact of self-reported PA in a large contemporary cohort of European AF patients on the risk of all-cause mortality.

Methods

We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Self-reported PA was categorized, on the basis of reported time spent exercising, as follows: i) No PA; ii) Occasional PA; iii) Regular PA; iv) Intense PA. The primary outcome was all-cause death.

Results

Over 11096, a total of 8699 (78.4%) patients (mean age (SD) 69.1 (11.5); 40.7% female) had available data about PA and follow-up observation and were included in the analysis. Of these, 3703 (42.6%) reported no PA, 2829 (32.5%) occasional PA, 1824 (21.0%) regular PA, with only 343 (3.9%) reporting intense PA. With the 4 increasing PA categories, mean age, proportion of female patients, CHA2DS2-VASc and HAS-BLED scores were progressively lower (all p&lt;0.001). Use of vitamin K antagonist (VKA) declined across the classes of PA (53.1% vs. 52.2% vs. 44.5% vs. 33.9%, p&lt;0.001), while use of non-VKA OACs (NOACs) conversely increased. During a mean (SD) 680.6 (171.5) days of follow-up, there were a total of 848 (9.7%) all-cause death events. Based on Kaplan-Meier analysis, there was a progressively lower cumulative risk for all-cause death according to PA categories [Figure]. A multivariable Cox regression analysis, adjusting for CHA2DS2-VASc score, use of OAC at baseline and type of AF, found a lower risk of all-cause death associated with increasing levels of PA (Hazard ratio [HR]: 0.69, 95% confidence interval [CI]: 0.59–0.81 for occasional PA, HR: 0.45, 95% CI: 0.35–0.58 for regular PA, HR: 0.41, 95% CI: 0.23–0.76 for intense PA, when compared to no PA). In a sensitivity analysis, a regular-intense PA was inversely associated with occurrence of cardiovascular (CV) death, after multivariable adjustments for comorbidities (HR: 0.54, 95% CI: 0.37–0.77).

Conclusions

In a large contemporary cohort of European AF patients, self-reported PA was found to be inversely associated with all-cause death and CV death.

Kaplan-Meier Curves

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Since the start of EORP, several companies have supported the programme with unrestricted grants

The cholesterol paradox in atrial fibrillation: results from the LIPIDOGRAM 2015 study

Background

High blood lipid levels are known risk factors for atherosclerotic cardiovascular events, but associations between lipid levels and atrial fibrillation (AF) are unclear. Some previous studies have suggested an inverse association between lipid levels and AF referred to as the “cholesterol paradox”.

Purpose

To examine the prevalence of AF by differing lipid levels in a large population-based study of almost 14,000 adults in Poland.

Methods

The LIPIDOGRAM 2015 study is a cross-sectional study of adults aged 18 years and older recruited in Poland in 2015/2016 by 438 family physicians. Poisson regression models with robust variance were used to estimate prevalence ratios (PRs) for AF with 95% confidence intervals (CIs) for participants with differing lipid profiles. Lipid measures including low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), total cholesterol (TC) and LDL/HDL ratios were grouped into quartiles with the lowest quartile as the reference group. Models were adjusted for potential confounding factors including age, sex, waist-to-hip ratio, smoking, alcohol intake, regular physical activity, hypertension, antihypertensive medication use and treatment of dyslipidaemia.

Results

13,724 participants were recruited to the study, the median (interquartile range: IQR) age was 58.0 (47.7–65.8) years and 5.2% (n=708) had a diagnosis of AF, with a median (IQR) 3 (1–8) years since diagnosis. After adjusting for potential confounding factors, a statistically significant lower prevalence of AF was estimated for participants in the highest quartile for LDL-C (PR (95% CI): 0.60 (0.48, 0.75) p&lt;0.001), HDL-C (0.58 (0.46, 0.74), p&lt;0.001), TC (0.61 (0.49, 0.75), p&lt;0.001) and LDL/HDL ratio (0.75 (0.61, 0.94), p=0.010). No statistically significant difference in prevalence of AF was observed for participants in the highest quartile for TG levels compared to the lowest quartile for TG levels.

Conclusions

The prevalence of AF was lower for people with higher levels of LDL-C, HDL-C, TC and higher LDL/HDL ratios; some of the difference in prevalence was explained by controlling for confounding factors, but in multivariable models the association remained statistically significant. This research adds to the body of evidence which suggests an inverse relationship between cholesterol levels and AF-the “cholesterol paradox” for AF.

Funding Acknowledgement

Type of funding source: None

Temporal changes in quality of life amongst European atrial fibrillation patients: relationship to all-cause mortality. A report from the ESC-EHRA EORP-AF General Long-Term Registry

Background

Atrial fibrillation (AF) significantly impacts on patients' quality of life (QoL). An impaired QoL has been associated with worse outcomes even in AF patients, but contemporary data in a large-scale pan-European population are limited.

Purpose

We aimed to assess temporal changes in AF patients' QoL across 2 years follow-up observation, and the relationship of QoL changes with all-cause death.

Methods

We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. The EQ-5D-5L questionnaire was used to assess QoL. A Health Utility Score (HUS), indicating the overall health state (1 equals perfect health), was derived. Differences throughout the follow-up (Baseline, 1-Y FU, 2-Y FU) observation were assessed. The study outcome was all-cause mortality.

Results

Out of a total of 11906 patients, 8097 (73.0%) were available for this analysis. Mean (SD) age was 69.1 (11.5) years; 60.8% males; median CHA2DS2-VASc and HASBLED scores were 3 (IQR 2–4) and 1 (1–2), respectively. The mean (SD) HUS at baseline was 0.815 (0.200) and 0.834 (0.196), 0.829 (0.195) at 1-year follow-up and 2-year follow-up, respectively (p&lt;0.0001 for changes over time). Patients with a higher CHA2DS2-VASc score (CHA2DS2-VASc 6–9) reported a significant reduction in the quality of life, compared to the other CHA2DS2-VASc strata, with a mean (SD) HUS decreasing from 0.754 (0.214) at baseline to 0.727 (0.238) at 2-year follow-up (F=6.538, p&lt;0.0001) (Figure). Multivariate analysis demonstrated that age [−0.001 (95% CI [−0.002, −0.121]) and coronary artery disease (CAD) [−0.016 (95% CI [−0.029, −0.004] were independently inversely associated with increasing QoL. Positive changes in HUS over time were inversely associated with an increase in the risk of all-cause death, even after adjusting for chronic kidney disease, liver disease, chronic obstructive pulmonary disease, oral anticoagulants and type of AF (OR:0.24, 95% CI: 0.13–0.45 for increasing HUS difference, as a continuous variable).

Conclusions

In a contemporary European-wide cohort of AF patients, significant temporal changes in QoL were found. Patients at higher stroke risk according to CHA2DS2-VASc score showed a significant reduction in the QoL. Age and CAD were independently associated with changes in QoL. A greater reduction in HUS (i.e. worsening QoL) over time was associated with a higher risk of all-cause death.

Temporal changes in HUS

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Since the start of EORP, several companies have supported the programme with unrestricted grants

Relationship between frailty and all-cause mortality in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational research programme AF general long-term registry

Introduction

Frailty is a major health determinant for cardiovascular disease. Thus far, data on frailty in patients with atrial fibrillation (AF) are limited.

Aims

To evaluate frailty in a large contemporary cohort of European AF patients, the relationship with oral anticoagulant (OAC) prescription and with risk of all-cause death.

Methods

We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. A 38-items frailty index (FI) was derived from baseline characteristics according to the accumulation of deficits model proposed by Rockwood and Mitnitsky. All-cause mortality was the primary study outcome.

Results

Out of the 11096 AF enrolled patients, data for evaluating frailty were available for 6557 (59.1%) patients who have been included in this analysis (mean [SD] age 68.9 [11.5], 37.7% females). Baseline median [IQR] CHA2DS2-VASc and HAS-BLED were 3 [2–4] and 1 [1–2], respectively. At baseline, median [IQR] FI was 0.16 (0.12–0.23), with 1276 (19.5%) patients considered “not-frail” (FI&lt;0.10), 4033 (61.5%) considered “pre-frail” (FI 0.10–0.25) and 1248 (19.0%) considered “frail” (FI≥0.25). Age, female prevalence, CHA2DS2-VASc and HAS-BLED progressively increased across the FI classes (all p&lt;0.001). Use of OAC progressively increased among FI classes; after adjustments FI was not associated with OAC prescription (odds ratio [OR]: 1.09, 95% confidence interval [CI]: 0.98–1.19 for each 0.10 FI increase). Conversely, FI was directly associated with vitamin K antagonist (VKA) use (OR: 1.26, 95% CI: 1.18–1.34 for each 0.10 FI increase) and inversely associated with non-VKA OACs (NOACs) use (OR: 0.82, 95% CI: 0.77–0.88). FI was significantly correlated with CHA2DS2-VASc (Rho= 0.516, p&lt;0.001). Over a median [IQR] follow-up of 731 [704–749] days, there were 569 (8.7%) all-cause death events. Kaplan-Meier curves [Figure] showed an increasing cumulative risk for all-cause death according to FI categories. A Cox multivariable analysis, adjusted for age, sex, type of AF and use of OAC, found that increasing FI as a continuous variable was associated with an increased risk of all-cause death (hazard ratio [HR]: 1.56, 95% CI: 1.40–1.73 for each 0.10 FI increase). An association with all-cause death risk was found across the FI categories (HR: 1.71, 95% CI: 1.23–2.38 and HR: 2.88, 95% CI: 2.02–4.12, respectively for pre-frail and frail patients compared to non-frail ones). FI was also predictive of all-cause death (c-index: 0.660, 95% CI: 0.637–0.682; p&lt;0.001).

Conclusions

In a European contemporary cohort of AF patients the burden of frailty is significant, with almost 1 out of 5 patients found to be “frail”. Frailty influenced significantly the choice of OAC therapy and was associated with (and predictive of) all-cause death at follow-up.

Kaplan-Meier Curves

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Since the start of EORP programme, several companies have supported it with unrestricted grants.

The wider consequences of obesity: estimated social and economic costs from Mendelian Randomization

Background

Obesity is a key public health issue worldwide. Accurate estimates of its full impacts on health, social, and economic outcomes are required, but are difficult to obtain due to bias from confounding and reverse causality (the impact of social and economic factors on obesity).

Methods

Using data from the UK Biobank and ALSPAC, we applied a genetic causal inference approach (Mendelian Randomization, MR) to estimate the impact of body mass index (BMI) on key social and economic outcomes. Because genetic variants are assigned before birth and cannot change, estimates from MR studies are less liable to confounding and reverse causation.

Results

Effects of higher BMI were often larger in MR than conventional (non-genetic) models, suggesting previous studies may have underestimated the impact of BMI. For example, in adolescents, MR models implied a standard deviation increase in BMI led to exam scores around 1/3 of a grade lower in all subjects at age 16, and 8.7% (CI: 1.8% to 16.1%) more school absence. In adults a 5kg/m2 increase in BMI corresponded, among other negative outcomes, to £2,778 less annual household income (CI: £1,864 to £3,693), less chance of owning one's home (-1.6%, CI: -2.4% to -0.8%), and higher chance of being lonely (2.4%, CI: 1.4% to 3.5%). At £21.22 (CI: £14.35 to £28.07) per person per marginal kg/m2 per year, MR estimates for inpatient hospital costs were around 40% higher than conventional estimates.

Conclusions

Findings from causal inference based on genetic variation indicate that high BMI has negative impacts on social and economic outcomes that may be larger than previously estimated. This evidence highlights the potential social and economic value of preventing high BMI across the life course.

Key messages

High BMI has considerable negative impacts not only for health, but for individuals’ education and socioeconomic outcomes, and overall health care costs. Previous attempts to quantify these effects may have underestimated BMI’s full impact.