Insulin-like growth factor-binding protein 7 and risk of congestive heart failure hospitalization in patients with atrial fibrillation

BACKGROUND

The occurrence of congestive heart failure (CHF) hospitalization among patients with atrial fibrillation (AF) is a poor prognostic marker.

OBJECTIVE

The purpose of this study was to assess whether insulin-like growth factor-binding protein 7 (IGFBP-7), a marker of myocardial damage, identifies AF patients at high risk for this complication.

METHODS

We analyzed 2 prospective multicenter observational cohort studies that included 3691 AF patients. Levels of IGFBP-7 and N-terminal pro-brain natriuretic peptide (NT-proBNP) were measured from frozen plasma samples at baseline. The primary endpoint was hospitalization for CHF. Multivariable adjusted Cox regression analyses were constructed.

RESULTS

Mean patient age was 69 ± 12 years, 1028 (28%) were female, and 879 (24%) had a history of CHF. The incidence per 1000 patient-years across increasing IGFBP-7 quartiles was 7, 10, 32, and 85. The corresponding multivariable adjusted hazard ratios (aHRs) (95% confidence interval [CI]) were 1.0, 1.05 (0.63-1.77), 2.38 (1.50-3.79), and 4.37 (2.72-7.04) (P for trend <.001). In a subgroup of 2812 patients without pre-existing CHF at baseline, the corresponding aHRs were 1.0, 0.90 (0.47-1.72), 1.69 (0.94-3.04), and 3.48 (1.94-6.24) (P for trend <.001). Patients with IGFBP-7 and NT-proBNP levels above the biomarker-specific median had a higher risk of incident CHF hospitalization (aHR 5.20; 3.35-8.09) compared to those with only 1 elevated marker (elevated IGFBP-7 aHR 2.17; 1.30-3.60); elevated NT-proBNP aHR 1.97; 1.17-3.33); or no elevated marker (reference).

CONCLUSION

Higher plasma levels of IGFBP-7 were strongly and independently associated with CHF hospitalization in AF patients. The prognostic information provided by IGFBP-7 was additive to that of NT-proBNP.

Association of psychosocial factors with all-cause hospitalizations in patients with atrial fibrillation

Background

A high burden of cardiovascular comorbidities puts patients with atrial fibrillation (AF) at high risk for hospitalizations, but the role of other factors is less clear.

Hypothesis

To determine the relationship between psychosocial factors and the risk of unplanned hospitalizations in AF patients.

Methods

Prospective observational cohort study of 2378 patients aged 65 or older with previously diagnosed AF across 14 centers in Switzerland. Marital status and education level were defined as social factors, depression and health perception were psychological components. The pre‐defined outcome was unplanned all‐cause hospitalization.

Results

During a median follow‐up of 2.0 years, a total of 1713 hospitalizations occurred in 37% of patients. Compared to patients who were married, adjusted rate ratios (aRR) for all‐cause hospitalizations were 1.28 (95% confidence interval [CI], 0.97‐1.69) for singles, 1.31 (95%CI, 1.06‐1.62) for divorced patients, and 1.02 (95%CI, 0.82‐1.25) for widowed patients. The aRRs for all‐cause hospitalizations across increasing quartiles of health perception were 1.0 (highest health perception), 1.15 (95%CI, 0.84‐1.59), 1.25 (95%CI, 1.03‐1.53), and 1.66 (95%CI, 1.34‐2.07). No different hospitalization rates were observed in patients with a secondary or primary or less education as compared to patients with a college degree (aRR, 1.06; 95%CI, 0.91‐1.23 and 1.05; 95%CI, 0.83‐1.33, respectively). Presence of depression was not associated with higher hospitalization rates (aRR, 0.94; 95%CI, 0.68‐1.29).

Conclusions

The findings suggest that psychosocial factors, including marital status and health perception, are strongly associated with the occurrence of hospitalizations in AF patients. Targeted psychosocial support interventions may help to avoid unnecessary hospitalizations.

Trial registration

ClinicalTrials.gov Identifier NCT02105844.

Association of biomarkers of inflammation with hospitalization for heart failure and death in patients with atrial fibrillation

Background

Hospitalization for heart failure and death are among the most common adverse clinical outcomes in patients with atrial fibrillation (AF). The underlying mechanisms are poorly understood.

Purpose

We hypothesised that inflammation, quantified by plasma levels of C-reactive protein (CRP) and interleukin 6 (IL-6), is independently associated with hospitalization for heart failure and death in a large, contemporary cohort of AF patients.

Methods

Patients with established AF and 65 years of age or older were enrolled in two large, prospective, multicentre cohort studies in Switzerland. Plasma levels of high-sensitivity (hs) CRP and IL-6 were measured from frozen EDTA plasma samples obtained at baseline. Using these two biomarkers, we calculated an inflammation score ranging from 0 to 4 (1 point for each biomarker between the 50th and 75th percentile, 2 points for each biomarker above the 75th percentile). We constructed multivariable Cox proportional hazards models to quantify the associations of hs-CRP, IL-6 and the inflammation score with time to first hospitalization for heart failure and time to all-cause mortality, respectively.

Results

A total of 3,784 patients with AF (median age 72 years, 28% women, 24% with a prior history of heart failure and 84% anticoagulation use at baseline) were followed for a median (interquartile range [IQR]) of 4.0 (2.9–5.1) years. The median (IQR) plasma levels of hs-CRP and IL-6 at baseline were 1.64 (0.81–3.69) mg/L and 3.42 (2.14–5.60) pg/mL, respectively. The incidence rates of hospitalization for heart failure and death were 3.04 and 2.80 per 100 person-years, respectively. After multivariable adjustment, both biomarkers were significantly associated with the risk of hospitalization for heart failure (per increase in 1 standard deviation [SD], adjusted hazard ratio [aHR] 1.22, 95% confidence interval [CI] 1.11–1.34 for log-transformed hs-CRP, and aHR 1.48, 95% CI 1.35–1.62 for log-transformed IL-6) and death (per increase in 1 SD, aHR 1.40, 95% CI 1.27–1.54 for log-transformed hs-CRP, and aHR 1.67, 95% CI 1.53–1.81 for log-transformed IL-6). Incidence rates of hospitalization for heart failure increased from 1.34 to 7.31 per 100 person-years across categories of the inflammation score (Figure 1). A strong relationship persisted after multivariable adjustment. Similar findings were observed for all-cause mortality.

Conclusions

Inflammation is a strong predictor of hospitalization for heart failure and death in patients with AF. Targeting inflammation may be a promising treatment strategy to improve outcomes in these patients at high risk for adverse outcomes.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Swiss National Science Foundation

The Admit-AF risk score: a clinical risk score for predicting hospital admissions in patients with atrial fibrillation

Background

Patients with atrial fibrillation (AF) have a high risk of hospital admissions, but there is no validated prediction tool to identify those at highest risk.

Purpose

To develop and externally validate a risk score for all-cause hospital admissions in patients with AF.

Methods

We used a prospective cohort of 2387 patients with established AF as derivation cohort. Independent risk factors were selected from a broad range of variables using the least absolute shrinkage and selection operator (LASSO) method fit to a Cox regression model. The developed risk score was externally validated in a separate prospective, multicenter cohort of 1300 AF patients.

Results

In the derivation cohort, 891 patients (37.3%) were admitted to the hospital over a median follow-up 2.0 years. In the validation cohort, hospital admissions occurred in 719 patients (55.3%) during a median follow-up 1.9 years. The most important predictors for admission were age (75–79 years: adjusted hazard ratio [aHR], 1.33; 95% confidence interval [95% CI], 1.00–1.77; 80–84 years: aHR, 1.51; 95% CI, 1.12–2.03; ≥85 years: aHR, 1.88; 95% CI, 1.35–2.61), prior pulmonary vein isolation (aHR, 0.74; 95% CI, 0.60–0.90), hypertension (aHR, 1.16; 95% CI, 0.99–1.36), diabetes (aHR, 1.38; 95% CI, 1.17–1.62), coronary heart disease (aHR, 1.18; 95% CI, 1.02–1.37), prior stroke/TIA (aHR, 1.28; 95% CI, 1.10–1.50), heart failure (aHR, 1.21; 95% CI, 1.04–1.41), peripheral artery disease (aHR, 1.31; 95% CI, 1.06–1.63), cancer (aHR, 1.33; 95% CI, 1.13–1.57), renal failure (aHR, 1.18, 95% CI, 1.01–1.38), and previous falls (aHR, 1.44; 95% CI, 1.16–1.78). A risk score with these variables was well calibrated, and achieved a C-index of 0.64 in the derivation and 0.59 in the validation cohort.

Conclusions

Multiple risk factors were associated with hospital admissions in AF patients. This prediction tool selects high-risk patients who may benefit from preventive interventions.

The Admit-AF risk score

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Swiss National Science Foundation (Grant numbers 33CS30_1148474 and 33CS30_177520), the Foundation for Cardiovascular Research Basel and the University of Basel

C-reactive protein for prediction of atrial fibrillation recurrence after catheter ablation

BACKGROUND

Inflammation plays an important role in the initiation and progression of atrial fibrillation (AF), but data about the relationship between subclinical inflammation and recurrence of AF after catheter ablation remains poorly studied. We aimed to assess whether plasma levels of C-reactive protein (CRP) are associated with long-term AF recurrence following catheter ablation.

METHODS

Prior to the intervention, plasma CRP concentrations were measured in patients who underwent first catheter ablation for AF. AF recurrence was evaluated after 12 months and defined as any AF episode longer than 30 s recorded on either 12-lead electrocardiogram, 24-h Holter or 7-day Holter monitoring. Multivariable adjusted Cox models were constructed to examine the association of CRP levels and AF recurrence.

RESULTS

Of the 711 patients (mean age: 61 years, 25% women) included in this study, 247 patients (35%) experienced AF recurrence after ablation. Patients who were in the highest CRP quartile had a higher rate of recurrent AF compared to those who were in the lowest quartile (53.4 vs. 33.1% at 1 year of follow-up; P = 0.004). The adjusted hazard ratios (aHR) of recurrent AF across increasing quartiles of CRP were 1.0 (reference), 1.26 (95% confidence interval [CI], 0.86-1.84), 1.15 (95% CI, 0.78-1.70) and 1.60 (95% CI, 1.10-2.34) (P trend = 0.015). A similar effect was observed when CRP was analyzed as continuous variable (aHR per unit increase, 1.21; 95% CI, 1.05-1.39; P = 0.009). When a predefined CRP cut-off of 3 mg/l was applied, patients with CRP levels of 3 mg/l or above had a higher risk of AF recurrence than those with levels below (aHR, 1.44; 95% CI, 1.06-1.95; P = 0.019).

CONCLUSIONS

Increasing pre-interventional CRP levels are associated with a higher risk of AF recurrence in patients undergoing catheter ablation for AF.

TRAIL REGISTRATION

ClinicalTrials.gov identifier, NCT03718364.

Heart Rate Variability Triangular Index as a Predictor of Cardiovascular Mortality in Patients With Atrial Fibrillation

Background

Impaired heart rate variability (HRV) is associated with increased mortality in sinus rhythm. However, HRV has not been systematically assessed in patients with atrial fibrillation (AF). We hypothesized that parameters of HRV may be predictive of cardiovascular death in patients with AF.

Methods and Results

From the multicenter prospective Swiss‐AF (Swiss Atrial Fibrillation) Cohort Study, we enrolled 1922 patients who were in sinus rhythm or AF. Resting ECG recordings of 5‐minute duration were obtained at baseline. Standard parameters of HRV (HRV triangular index, SD of the normal‐to‐normal intervals, square root of the mean squared differences of successive normal‐to‐normal intervals and mean heart rate) were calculated. During follow‐up, an end point committee adjudicated each cause of death. During a mean follow‐up time of 2.6±1.0 years, 143 (7.4%) patients died; 92 deaths were attributable to cardiovascular reasons. In a Cox regression model including multiple covariates (age, sex, body mass index, smoking status, history of diabetes mellitus, history of hypertension, history of stroke/transient ischemic attack, history of myocardial infarction, antiarrhythmic drugs including β blockers, oral anticoagulation), a decreased HRV index ≤ median (14.29), but not other HRV parameters, was associated with an increase in the risk of cardiovascular death (hazard ratio, 1.7; 95% CI, 1.1–2.6; P=0.01) and all‐cause death (hazard ratio, 1.42; 95% CI, 1.02–1.98; P=0.04).

Conclusions

The HRV index measured in a single 5‐minute ECG recording in a cohort of patients with AF is an independent predictor of cardiovascular mortality. HRV analysis in patients with AF might be a valuable tool for further risk stratification to guide patient management.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02105844.

Evaluation of the proposed anti-N-methyl-d-aspartate receptor encephalitis clinical diagnostic criteria in psychiatric patients

OBJECTIVE

The gold standard for diagnosing anti-NMDAR encephalitis is demonstration of the antibody in CSF. Clinical diagnostic criteria have been proposed for when this is not available in a timely manner which is evaluated, in this study, for a psychiatric population.

METHODS

This study retrospectively assessed the proposed criteria in patients presenting to psychiatric services for the first time with known anti-NMDAR antibody status. Antibody-positive cases were derived from the literature (conception to December 2019) and a state-wide (Queensland, Australia) cohort. Antibody-negative cases were derived from a service-wide (Metro South, Queensland, Australia) cohort of psychiatric cases which underwent antibody testing for routine organic screening. Sensitivity and specificity were calculated at 1 week following admission and the point of discharge.

RESULTS

The proposed criteria were applied to 641 cases (500 antibody-positive and 141 antibody-negative), demonstrating a sensitivity which increased from around 19% after 1 week to 49% by the point of discharge. Specificity was 100% at both time points. The mean average time to become positive using the proposed criteria was 19.5 days compared to 34.9 days for return of antibody testing.

CONCLUSIONS

High specificity of the proposed criteria, seen in this study, suggests that cases which are positive can be considered for expedited commencement of treatment. However, if clinical suspicion is high despite criteria being negative, it is essential to test CSF for anti-NMDAR antibody.

Symptoms and quality of life in patients with coexistent atrial fibrillation and atrial flutter

Aims

Atrial fibrillation (AF) and atrial flutter (AFL) are two of the most common atrial arrhythmias and often coexist. Many patients with AF or AFL are symptomatic, which impacts their quality of life (QoL). The purpose of this study was to determine whether coexistent AFL represents an added burden for AF patients.

Methods

We combined baseline data from two large prospective, observational, multicenter cohort studies (BEAT-AF and Swiss-AF). All 3931 patients included in this analysis had documented AF. We obtained information on comorbidities, medication, and lifestyle factors. All participants had a clinical examination and a resting ECG. Symptom burden and QoL at the baseline examination were compared between patients with and without coexistent AFL using multivariable adjusted regression models.

Results

Overall, 809 (20.6%) patients had a history of AFL. Patients with coexistent AFL more often had history of heart failure (28% vs 23%, p = 0.01), coronary artery disease (30% vs 26%, p = 0.007), failed therapy with antiarrhythmic drugs (44% vs 29%, p < 0.001), and more often underwent AF-related interventions (36% vs 17%, p < 0.001). They were more often symptomatic (70% vs 66%, p = 0.04) and effort intolerant (OR: 1.14; 95% CI: 1.01-1.28; p = 0.04). Documented AFL on the baseline ECG was associated with more symptoms (OR: 2.30; 95% CI: 1.26-4.20; p = 0.007).

Conclusion

Our data indicates that patients with coexistent AF and AFL are more often symptomatic and report poorer quality of life compared to patients suffering from AF only.

Associations of symptoms and quality of life with outcomes in patients with atrial fibrillation

OBJECTIVE

We aimed to investigate changes in atrial fibrillation (AF)-related symptoms and quality of life (QoL) over time, and their impact on prognosis.

METHODS

We prospectively followed 3836 patients with known AF for a mean of 3.7 years. Information on AF-related symptoms and QoL was obtained yearly. The primary end point was a composite of stroke or systemic embolism. Main secondary end points included stroke subtypes, all-cause mortality, cardiovascular death, hospitalisation for congestive heart failure (CHF), myocardial infarction and major bleeding. We assessed associations using multivariable, time-updated Cox proportional hazards models.

RESULTS

Mean age was 72 years, 72% were male. Patients with AF-related symptoms (66%) were younger (70 vs 74 years, p<0.0001), more often had paroxysmal AF (56% vs 37%, p<0.0001) and had lower QoL (71 vs 72 points, p=0.009). The incidence of the primary end point was 1.05 and 1.02 per 100 person-years in patients with and without symptoms, respectively. The multivariable adjusted HR (aHR) (95% CIs) for the primary end point was 1.11 (0.77 to 1.59; p=0.56) for AF-related symptoms. AF-related symptoms were not associated with any of the secondary end points. QoL was not significantly related to the primary end point (aHR per 5-point increase 0.98 (0.94 to 1.03; p=0.37)), but was significantly related to CHF hospitalisations (0.92 (0.90 to 0.94; p<0.0001)), cardiovascular death (0.90 (0.86 to 0.95; p<0.0001)) and all-cause mortality (0.88 (0.86 to 0.90; p<0.0001)).

CONCLUSIONS

AF-related symptoms were not associated with adverse outcomes and should therefore not be the basis for prognostic treatment decisions. QoL was strongly associated with CHF, cardiovascular death and all-cause mortality.

Aldosterone-to-renin ratio and blood pressure in young adults from the general population

BACKGROUND

The effect of the renin angiotensin system on blood pressure (BP) values in young adults from the general population is not well studied. We investigated the relationship between the aldosterone-to-renin ratio (ARR) and various BP indices in this population.

METHODS

We assembled a population-based sample of adults aged 25-41 years. Conventional and 24-hour BP recordings were obtained in all patients. Direct renin concentration and plasma aldosterone concentration were measured. Multivariable regression models were constructed to assess the relationships of ARR with BP and hypertension.

RESULTS

We included 1,353 individuals (mean age 37 years, 56% women). The median (interquartile range) ARR, direct renin concentration, and plasma aldosterone concentration were 13.8 (8.7-22.9), 7.2 ng/L (4.4-11.0) and 94 ng/L (68-134). All BP indices were higher across sex-specific ARR quartiles. Per 1-unit increase in log-transformed ARR, the multivariable-adjusted β-coefficients (95% CI) for conventional, 24-hour, daytime, and nighttime systolic BP were 1.68 (0.87-2.48), P < .0001; 2.40 (1.68-3.12), P < .0001; 2.23 (1.48-2.99), P < .0001; and 2.80 (2.03-3.58), P < .0001, respectively. Per 1-unit increase in log-transformed ARR, the multivariable-adjusted odds ratio (95% CI) for conventional, 24-hour, sustained and masked hypertension was 1.70 (1.17-2.28), P = .0004; 1.29 (1.06-1.56), P = .01; 1.82 (1.33-2.49), P = .002; and 1.14 (0.94-1.38), P = .20, respectively.

CONCLUSIONS

In young adults, ARR was strongly associated with conventional and ambulatory BP. Our data suggest that an aldosterone-driven phenomenon occurs very early in the development of hypertension.

The Admit-AF risk score: A clinical risk score for predicting hospital admissions in patients with atrial fibrillation

Aims

To develop and externally validate a risk score for all-cause hospital admissions in patients with atrial fibrillation.

Methods and results

We used a prospective cohort of 2387 patients with established atrial fibrillation as derivation cohort. Independent risk factors were selected from a broad range of variables using the least absolute shrinkage and selection operator method fit to a Cox model. The risk score was validated in a separate prospective cohort of 1300 atrial fibrillation patients. The incidence of all-cause hospital admission was 19.1 per 100 person-years in the derivation cohort and it was 26.1 per 100 person-years in the validation cohort. The most important predictors for admission were age (75–79 years: adjusted hazard ratio (aHR), 1.34; 95% confidence interval (CI), 1.01–1.78; 80–84 years: aHR, 1.50; 95% CI, 1.11–2.03; ≥85 years: aHR, 1.88; 95% CI, 1.36–2.62), prior pulmonary vein isolation (aHR, 0.72; 95% CI, 0.58–0.88), hypertension (aHR, 1.16; 95% CI, 0.99–1.36), diabetes (aHR, 1.38; 95% CI, 1.17–1.62), coronary heart disease (aHR, 1.17; 95% CI, 1.02–1.36), prior stroke/transient ischaemic attack (aHR, 1.26; 95% CI, 1.18–1.47), heart failure (aHR, 1.19; 95% CI, 1.03–1.39), peripheral artery disease (aHR, 1.35; 95% CI, 1.08–1.67), cancer (aHR, 1.33; 95% CI, 1.12–1.57), renal failure (aHR, 1.17; 95% CI, 0.99–1.37) and previous falls (aHR, 1.40; 95% CI, 1.13–1.74). A risk score with these variables was well calibrated, and achieved a C-index of 0.64 in the derivation and 0.59 in the validation cohort.

Conclusions

Multiple risk factors were associated with hospital admissions in atrial fibrillation patients. This prediction tool selects high-risk patients who may benefit from preventive interventions.

Genetic Susceptibility for Atrial Fibrillation in Patients Undergoing Atrial Fibrillation Ablation

BACKGROUND

Ablation is a widely used therapy for atrial fibrillation (AF); however, arrhythmia recurrence and repeat procedures are common. Studies examining surrogate markers of genetic susceptibility to AF, such as family history and individual AF susceptibility alleles, suggest these may be associated with recurrence outcomes. Accordingly, the aim of this study was to test the association between AF genetic susceptibility and recurrence after ablation using a comprehensive polygenic risk score for AF.

METHODS

Ten centers from the AF Genetics Consortium identified patients who had undergone de novo AF ablation. AF genetic susceptibility was measured using a previously described polygenic risk score (N=929 single-nucleotide polymorphisms) and tested for an association with clinical characteristics and time-to-recurrence with a 3 month blanking period. Recurrence was defined as >30 seconds of AF, atrial flutter, or atrial tachycardia. Multivariable analysis adjusted for age, sex, height, body mass index, persistent AF, hypertension, coronary disease, left atrial size, left ventricular ejection fraction, and year of ablation.

RESULTS

Four thousand two hundred seventy-six patients were eligible for analysis of baseline characteristics and 3259 for recurrence outcomes. The overall arrhythmia recurrence rate between 3 and 12 months was 44% (1443/3259). Patients with higher AF genetic susceptibility were younger (P<0.001) and had fewer clinical risk factors for AF (P=0.001). Persistent AF (hazard ratio [HR], 1.39 [95% CI, 1.22-1.58]; P<0.001), left atrial size (per cm: HR, 1.32 [95% CI, 1.19-1.46]; P<0.001), and left ventricular ejection fraction (per 10%: HR, 0.88 [95% CI, 0.80-0.97]; P=0.008) were associated with increased risk of recurrence. In univariate analysis, higher AF genetic susceptibility trended towards a higher risk of recurrence (HR, 1.08 [95% CI, 0.99-1.18]; P=0.07), which became less significant in multivariable analysis (HR, 1.06 [95% CI, 0.98-1.15]; P=0.13).

CONCLUSIONS

Higher AF genetic susceptibility was associated with younger age and fewer clinical risk factors but not recurrence. Arrhythmia recurrence after AF ablation may represent a genetically different phenotype compared to AF susceptibility.

Frailty to predict unplanned hospitalization, stroke, bleeding, and death in atrial fibrillation

Aims

Atrial fibrillation (AF) and frailty are common, and the prevalence is expected to rise further. We aimed to investigate the prevalence of frailty and the ability of a frailty index (FI) to predict unplanned hospitalizations, stroke, bleeding, and death in patients with AF.

Methods and results

Patients with known AF were enrolled in a prospective cohort study in Switzerland. Information on medical history, lifestyle factors, and clinical measurements were obtained. The primary outcome was unplanned hospitalization; secondary outcomes were all-cause mortality, bleeding, and stroke. The FI was measured using a cumulative deficit approach, constructed according to previously published criteria and divided into three groups (non-frail, pre-frail, and frail). The association between frailty and outcomes was assessed using multivariable-adjusted Cox regression models. Of the 2369 included patients, prevalence of pre-frailty and frailty was 60.7% and 10.6%, respectively. Pre-frailty and frailty were associated with a higher risk of unplanned hospitalizations [adjusted hazard ratio (aHR) 1.82, 95% confidence interval (CI) 1.49–2.22; P &lt; 0.001; and aHR 3.59, 95% CI 2.78–4.63, P &lt; 0.001], all-cause mortality (aHR 5.07, 95% CI 2.43–10.59; P &lt; 0.001; and aHR 16.72, 95% CI 7.75–36.05; P &lt; 0.001), and bleeding (aHR 1.53, 95% CI 1.11–2.13; P = 0.01; and aHR 2.46, 95% CI 1.61–3.77; P &lt; 0.001). Frailty, but not pre-frailty, was associated with a higher risk of stroke (aHR 3.29, 95% CI 1.2–8.39; P = 0.01).

Conclusion

Over two-thirds of patients with AF are pre-frail or frail. These patients have a high risk for unplanned hospitalizations and other adverse events. These findings emphasize the need to carefully evaluate these patients. However, whether screening for pre-frailty and frailty and targeted prevention strategies improve outcomes needs to be shown in future studies.

Clinical trial registration

Clinicaltrials.gov identifier number: NCT02105844.

Health-related quality of life in patients with atrial fibrillation: The role of symptoms, comorbidities, and the type of atrial fibrillation

Aims

This study aimed to analyse health related quality of life (HRQoL) for patients with different atrial fibrillation (AF) types and to identify patient characteristics, symptoms and comorbidities that influence HRQoL.

Methods

We used baseline data from the Swiss Atrial Fibrillation (Swiss-AF) study, a prospective multicentre observational cohort study conducted in 13 clinical centres in Switzerland. Between April 2014 and August 2017, 2415 AF patients were recruited. Patients were included in this analysis if they had baseline HRQoL data as assessed with EQ-5D-based utilities and visual analogue scale (VAS) scores. Patient characteristics and HRQoL were described stratified by AF type. The impact of symptoms, comorbidities and socio-economic factors on HRQoL was analysed using multivariable regression analysis.

Results

Based on 2412 patients with available baseline HRQoL data, the lowest unadjusted mean HRQoL was found in patients with permanent AF regardless of whether measured with utilities (paroxysmal: 0.83, persistent: 0.84, permanent: 0.80, p<0.001) or VAS score (paroxysmal: 73.6, persistent: 72.8, permanent: 69.2, p<0.001). In multivariable analysis of utilities and VAS scores, higher European Heart Rhythm Association (EHRA) score, recurrent falls and several comorbidities showed a strong negative impact on HRQoL while AF type was no longer associated with HRQoL.

Conclusions

Multiple factors turned out to influence HRQoL in AF patients. After controlling for several comorbidities, the EHRA score was one of the strongest predictors independent of AF type. The results may be valuable for better patient assessment and provide a reference point for further QoL and health economic analyses in AF populations.

Incidence and Predictors of Atrial Fibrillation Progression

Background The incidence and predictors of atrial fibrillation (AF) progression are currently not well defined, and clinical AF progression partly overlaps with rhythm control interventions (RCIs). Methods and Results We assessed AF type and intercurrent RCIs during yearly follow-ups in 2869 prospectively followed patients with paroxysmal or persistent AF. Clinical AF progression was defined as progression from paroxysmal to nonparoxysmal or from persistent to permanent AF. An RCI was defined as pulmonary vein isolation, electrical cardioversion, or new treatment with amiodarone. During a median follow-up of 3 years, the incidence of clinical AF progression was 5.2 per 100 patient-years, and 10.9 per 100 patient-years for any RCI. Significant predictors for AF progression were body mass index (hazard ratio [HR], 1.03; 95% CI, 1.01-1.05), heart rate (HR per 5 beats/min increase, 1.05; 95% CI, 1.02-1.08), age (HR per 5-year increase 1.19; 95% CI, 1.13-1.27), systolic blood pressure (HR per 5 mm Hg increase, 1.03; 95% CI, 1.00-1.05), history of hyperthyroidism (HR, 1.71; 95% CI, 1.16-2.52), stroke (HR, 1.50; 95% CI, 1.19-1.88), and heart failure (HR, 1.69; 95% CI, 1.34-2.13). Regular physical activity (HR, 0.80; 95% CI, 0.66-0.98) and previous pulmonary vein isolation (HR, 0.69; 95% CI, 0.53-0.90) showed an inverse association. Significant predictive factors for RCIs were physical activity (HR, 1.42; 95% CI, 1.20-1.68), AF-related symptoms (HR, 1.84; 95% CI, 1.47-2.30), age (HR per 5-year increase, 0.88; 95% CI, 0.85-0.92), and paroxysmal AF (HR, 0.61; 95% CI, 0.51-0.73). Conclusions Cardiovascular risk factors and comorbidities were key predictors of clinical AF progression. A healthy lifestyle may therefore reduce the risk of AF progression.

483Blood pressure and white matter lesions in patients with atrial fibrillation

Background

Hypertension (HTN) is one of the most common cardiovascular risk factors in patients with atrial fibrillation (AF). As a potential risk factor for cerebral white matter lesions (WML), HTN might explain the increased risk of cognitive dysfunction in AF patients.

Methods

In a multicenter cohort study of patients with documented AF in Switzerland, systolic and diastolic blood pressure (SBP, DBP) was measured up to three times in a supine position and the mean was calculated. HTN was defined as controlled, when SBP was <140 and DBP <90 mmHg with treatment, and uncontrolled when SBP was ≥140 or DBP ≥90 mmHg with treatment. All patients underwent brain magnetic resonance imaging. Volumes of WML were assessed and graded using the Fazekas scale. A Fazekas score of ≥2 was defined as moderate or severe WML. Multivariable adjusted regression models were used to assess the association between BP and WML.

Results

Overall, 1738 patients were enrolled in this cross-sectional analysis (mean age 73 years, 73% males). Mean BP was 135/79 mmHg, 69% had a history of HTN. Any WMLs were found in 99% of the patients and 54% had at least moderate WMLs. The prevalence of Fazekas ≥2 was 47%, 50% and 61% among AF patients with SBP <120, 120–140 and ≥140mmHg (p<0.001), respectively. Volumes of WMLs significantly increased across the same SBP categories (2943, 3512 and 4988 mm3, p<0.001). Among patients with normotension, controlled and uncontrolled HTN, moderate or severe WMLs were present in 173 (42.5%), 345 (55%) and 307 (61%), respectively. SBP was associated with Fazekas ≥2 and WML volume after multivariable adjustment (Table). Compared to normotension, both controlled and uncontrolled HTN were significantly associated with higher WML volume (Table).

Association between blood pressure and white matter lesions Blood pressure Fazekas ≥2 OR (95% CI) Volume WML β-coefficient (95% CI) <120 mmHg Ref Ref 120–140 mmHg 1.17 (0.88; 1.55) 0.14 (−0.01; 0.30) ≥140 mmHg 1.49 (1.11; 2.00) 0.28 (0.12; 0.43) Continuous, per SD 1.20 (1.09; 1.36), p<0.001 0.12 (0.06; 0.18), p<0.001 Normotension Ref Ref Treated hypertension 1.26 (0.94; 1.68), p=0.12 0.22 (0.07; 0.38), p=0.005 Treated, uncontrolled hypertension 1.52 (1.13; 2.05), p=0.005 0.38 (0.21; 0.54), p<0.001 Regression analyses were adjusted for age, sex, BMI, smoking status, stroke, diabetes, coronary heart disease, AF type, and antihypertensive treatment. One standard Deviation (SD) of SBP = 18 mmHg. Volume of WML was log-transformed.

Conclusion

Moderate or severe cerebral WMLs are highly prevalent in AF patients and strongly associated with SBP. Our data suggests that optimal treatment of HTN might play an essential role in preventing WMLs.

Acknowledgement/Funding

Swiss National Science Foundation

P1876Atrial fibrillation related symptoms and cardiovascular outcomes

Background

Comprehensive information on the impact of atrial fibrillation (AF)-related symptoms and quality of life (QoL) on adverse outcomes is sparse.

Purpose

We aimed to investigate whether AF-related symptoms and/or QoL are associated with cardiovascular outcomes in a large cohort of AF patients.

Methods

A total of 3902 participants with documented AF from two nationwide prospective cohort studies in Switzerland were included. Information on AF-related symptoms was assessed yearly by standardized questionnaires, QoL was quantified using a visual analog scale (0–100, with higher scores indicating better QoL). The primary endpoint was a composite of stroke and systemic embolism. The secondary endpoint was a composite of cardiovascular death, hospitalization for heart failure and myocardial infarction. We assessed associations using multivariable, time-updated Cox proportional-hazards models including age, sex, study cohort, history of heart failure, hypertension, diabetes, prior stroke, prior myocardial infarction, vascular disease and prior catheter ablation for AF as covariates.

Results

Mean age was 72 years, and 72% were male. The median QoL score was 75 points, and 2572 (66%) participants had AF-related symptoms. Symptomatic individuals were younger (71 vs 75 years) and had more often paroxysmal AF (29 vs 23%) (p for both <0.001). The most frequent symptoms were palpitations (42%), dyspnea (25%) and fatigue (18%). In multivariable, time-updated models, the hazard ratio (HR) was 1.24 (95% confidence intervals (CI) 0.72; 2.11, p=0.43) for the primary endpoint and HR 0.83 (95% CI 0.65; 1.06, p=0.14) for the secondary endpoint in symptomatic vs non-symptomatic individuals. There was a significant, inverse association for a 5-point increase in the QoL score with both the primary (HR 0.94 (95% CI 0.88; 0.99), p=0.04) and secondary (HR 0.91 (95% CI 0.88; 0.93), p<0.0001) endpoints.

Conclusions

AF-related symptoms are not associated with adverse cardiovascular events in AF patients. In contrast, QoL is inversely associated with to adverse cardiovascular outcomes.

P3782Frailty to predict unplanned hospitalizations, stroke, bleeding and death in atrial fibrillation

Aim

We investigated the prevalence of frailty, and the relationships between frailty and the risk of adverse clinical outcomes in patients with atrial fibrillation (AF).

Methods

Patients with known AF were enrolled in a nation-wide observational cohort study in Switzerland. Information on medical history, medication, lifestyle factors and clinical measurements were obtained. The primary outcome was unplanned hospitalizations, secondary outcomes were all-cause mortality, bleeding and stroke. The frailty index (FI) was measured using a cumulative deficit approach according to previously published criteria. Participants were divided into three groups (non-frail, pre-frail and frail) according to their FI at study entry. The association between frailty and clinical outcomes was assessed using multivariable adjusted Cox proportional hazard models.

Results

We included 2369 patients with a mean age of 73±8 years (27.3% female). The prevalence of frailty and pre-frailty was 10.6% and 60.7%, respectively. Frailty was associated with unplanned hospitalization (adjusted hazard ratio [HR] 3.59; 95% confidence interval [95% CI], 2.78–4.63; p<0.001), all-cause mortality (adjusted HR 16.72; 95% CI 7.75–36.05; p<0.001), bleeding (adjusted HR 2.46; 95% CI 1.61–3.77; p<0.001), and stroke (adjusted HR 3.29; 95% CI 1.29–8.39; p=0.01) (Figure). Similarly, pre-frailty was significantly associated with unplanned hospitalization (adjusted HR 1.82; 95% CI 1.49–2.22; p<0.001), all-cause mortality (adjusted HR 5.07; 95% CI 2.43–10.59; p<0.001) and bleeding (adjusted HR 1.53; 95% CI 1.11–2.13; p=0.01), but not with stroke.

Cumulative incidence of adverse events

Conclusion

In our cohort, more than two thirds of AF patients were either pre-frail or frail. These patients have a high risk of unplanned hospitalizations and other adverse outcomes, indicating that frailty is a powerful tool to predict adverse clinical outcomes in AF patients.

Acknowledgement/Funding

Swiss National Science Foundation; Foundation for Cardiovascular Research Basel; University of Basel

P1258Left atrial dimension and risk of cardiovascular outcomes in patients with and without atrial fibrillation: a systematic review and meta-analysis

Background

The prognostic value of left atrial (LA) dimensions measured by transthoracic echocardiogram among patients with versus without atrial fibrillation (AF) is uncertain. We aimed to investigate the association of LA echocardiographic parameters with the risk of cardiovascular events in AF patients compared to non-AF patients.

Methods

MEDLINE and EMBASE were searched from inception to July 2018. Records were retained if they studied the association between LA echocardiographic parameters and cardiovascular outcomes in AF patients, and in populations with no or less than 10% of AF patients. Left atrial dimensions had to be measured by transthoracic echocardiography, and parameters of interest were the following: LA diameter (LAD), LA diameter indexed to body surface (LADI), LA volume (LAV) and LA volume indexed to body surface (LAVI). Data were independently abstracted by 2 reviewers and pooled using inverse variance random-effects meta-analysis. The primary outcome was incident stroke and thromboembolic events. Secondary outcomes were heart failure, all-cause mortality and major adverse cardiac events (MACE).

Results

Twenty-three studies of AF patients (14'939 patients) and 69 studies of non-AF patients (52'654 patients) were included. Summary of the meta-analyses for the associations of LA parameters with cardiovascular outcomes is presented in the Figure. Increasing LAD was significantly associated with the risk of stroke and thromboembolic events in non-AF patients (P=0.03), but not among AF patients (P=0.27), and the association did not differ between population (P for difference=0.05) (Figure, A). Greater LADI was associated with risk of stroke and thromboembolic events in AF patients (P<0.001) and in non-AF patients (P=0.04), but the association did not differ between populations (P for difference=0.49). For MACE, increasing LADI was significantly associated with the outcome in AF patients (P<0.001) and in non-AF patients (P<0.001), but the association was stronger in non-AF populations (P for difference<0.001). Increasing LAVI was associated with high risk of MACE in AF patients (P=0.03) and in non-AF populations (P<0.001). Again, the correlation was stronger among non-AF patients (P for difference<0.001). Other associations did not differ between populations, and meta-analysis of LAV was not conducted by the limited number of studies.

Summary of meta-analysis

Conclusions

Left atrial echocardiographic parameters are powerful predictors of adverse cardiovascular events, mainly among individuals without AF.

Different nutrient intake and prevalence of gastrointestinal comorbidities in women with endometriosis

Even though endometriosis presents one of the most common gynaecological diseases, the pathogenesis is insufficiently studied. Besides immunologic, inflammatory or oxidative processes, recent studies also suggest an influence of nutrition on disease onset and progression. Because data about the actual nutrient intake of endometriosis patients are scarce, we aimed to examine the actual nutrient intake and potential influencing factors in these women. A total of 156 women with endometriosis (EM) and 52 age-matched controls were included in this retrospective case-control study. All women filled in a validated food frequency questionnaire to acquire the nutrient intake of the past 12 months and a disease-related questionnaire for the determination of disease status, clinical symptoms and comorbidities. Patients with endometriosis suffered significantly more from diet-related comorbidities like food intolerances (25.6% versus 7.7%; P = 0.009) and allergies (57% versus 31%; P < 0.001) compared to controls. Also gastrointestinal symptoms, including constipation, flatulence, pyrosis, diarrhea or frequent defecation, were higher in the EM group (77% versus 29%; P < 0.001). The nutrient intake of patients with endometriosis differed significantly compared to controls with a significantly lower ingestion of organic acids (P = 0.006), maltose (P = 0.0.16), glycogen (P = 0.035), tetradecenoic acid (P = 0.041), methionine (P = 0.046), lysine (P = 0.048), threonine (P = 0.046) and histidine (P = 0.049). The total intake of animal proteins was significantly lower in the EM group compared to the controls (P = 0.047). EM patients showed a decreased intake of vitamin C (P = 0.031), vitamin B₁₂ (P = 0.008) and magnesium (P = 0.043) compared to controls. This study confirms a high association of endometriosis and gastrointestinal disorders accompanied by an altered nutrient intake. A dietary intervention by a professional nutritionist may help to reduce disease burden in the affected women.