Development and validation of a prediction model for bothersome stress urinary incontinence after prolapse surgery: a retrospective cohort study

OBJECTIVE

To develop and validate a prediction model for bothersome stress urinary incontinence after prolapse surgery and to compare it with an existing clinical prediction model (CUPIDO model).

DESIGN

Retrospective cohort study.

SETTING

Two tertiary hospitals in South Korea.

POPULATION

A total of 1142 patients who underwent prolapse surgery with or without a concomitant midurethral sling.

METHODS

To construct a prediction model, we performed logistic regression using both exhaustive and stepwise variable selection, validating the model both internally and externally.

MAIN OUTCOME MEASURES

Bothersome stress urinary incontinence defined as the presence of bothersome symptoms of stress urinary incontinence and/or subsequent continence procedure one year after surgery.

RESULTS

Postoperative bothersome stress urinary incontinence occurred in 10% of patients. A model containing six predictors (age, diabetes mellitus, subjective urinary incontinence, prolapse reduction stress test result, type of prolapse surgery, and a concomitant midurethral sling) showed excellent performance for predicting bothersome stress urinary incontinence (area under the curve 0.74, 95% confidence interval 0.62-0.86) and outperformed the CUPIDO model (area under the curve 0.63, 95% confidence interval 0.49-0.76; DeLong's test P = 0.014).

CONCLUSIONS

This prediction model might be a useful tool to guide patient decision making regarding a concomitant continence procedure at the time of prolapse surgery. The predictive value of this model needs to be validated further in cohorts with different characteristics.

TWEETABLE ABSTRACT

The proposed prediction model for bothersome stress urinary incontinence after prolapse surgery outperforms an existing model.

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.

Less dementia in patients with newly diagnosed atrial fibrillation adhering with a clustering of healthy lifestyle behaviours: a nationwide population-based cohort study

Background

Atrial fibrillation (AF) increases the risk of dementia. A new paradigm for AF management should include a new pillar targeting lifestyle modification. There are limited data on the clinical impact of healthy lifestyle behaviours on the risk of dementia in patients with newly diagnosed AF.

Purpose

To evaluate the association between the combination(s) of healthy lifestyle behaviours and the risk of incident dementia in patients with AF

Methods

Using the Korean National Health Insurance database between 2009 and 2016, we identified adult patients who were newly diagnosed as AF without dementia and underwent national health screening examination within 2-year after their AF diagnosis. Patients were categorized into 4 groups according to a healthy lifestyle-behavior score (HLS) 0, 1, 2, and 3 by assigning 1 point each for no current smoking, abstaining alcohol, and performing regular exercise. For the comparison, each group was balanced using the inverse probability of treatment weighting (IPTW). The primary outcome was incident dementia during follow-up.

Results

Among a total of 199,952 patients (mean age 63.2; 60.2% male) were included, the number of patients within the HLS 0, 1, 2, and 3 groups were 8709 (4.4%), 34839 (17.4%), 106796 (53.4%) and 49608 (24.8%), respectively. After IPTW, weighted incidence rates of dementia were 21.8, 16.8, 16.8, and 13.6 per 1000 person-years for HLS 0, 1, 2, and 3 groups, respectively. After multivariable adjustment of subjects edited by IPTW, HLS 1,2, and 3 groups were associated with a lower risk of dementia compared to HLS 0 group: Hazard Ratio [HR] 0.769, 95% confidence interval [CI] 0.704–0.842 for score 1; HR 0.770, 95% CI 0.709–0.836 for score 2; HR 0.622, 95% CI 0.569–0.679 for score 3. The effect of healthy lifestyle was similar for Alzheimer's dementia (HR 0.823, 95% CI 0.739–0.917 for score 1; HR 0.839, 95% CI 0.760–0.927 for score 2; HR 0.660, 95% CI 0.594–0.734 for score 3) and vascular dementia (HR 0.532, 95% CI 0.437–0.648 for score 1; HR 0.503 95% CI 0.422–0.600 for score 2; HR 0.458, 95% CI 0.378–0.554 for score 3). There was consistency in subgroup analyses stratified by age, sex, CHA2DS2-VASc score, oral anticoagulation use and prior stroke history.

Conclusion

A combination of a healthy lifestyle, including quitting smoking, abstaining from alcohol consumption, and performing regular physical activity, was associated with a significantly lower risk of dementia in both Alzheimer's dementia and vascular dementia in patients with new-onset AF. These findings support the promotion of a healthy lifestyle within an integrated care approach to AF patient management, which could reduce the risk of dementia.

Funding Acknowledgement

Type of funding sources: None.

A population-based study for difference in contribution of type 2 diabetes mellitus to cardiovascular outcomes in adult cancer survivors and general population without history of cancer

Background/Introduction

Type 2 diabetes mellitus (T2DM) is a well-established risk factor for cardiovascular disease (CVD). However, evidence is scarce on the difference in burden of T2DM as a cardiovascular risk factor in adult cancer survivors compared to the general population without history of cancer. This evidence gap needs to be addressed as increased risk for CVD in adult cancer survivors compared to the general population has been consistently reported from observational studies.

Purpose

To investigate the association of T2DM with CVD in adult cancer survivors and general population without history of cancer and compare the magnitude of associations for each population using propensity score-matched analyses

Methods

For this population-based cohort study, we used the National Health Insurance Service-National Sample Cohort (NHIS-NSC) established in the Republic of Korea (2002–2015) to identity adult cancer survivors who were aged 18 years or older and survived more than 12 months after the first-ever cancer diagnosis and general population without history of cancer matched for age and sex in a 1:1 ratio. In both cohorts, those with history of CVD prior to the index date were excluded. We used Cox proportional hazards model to compute hazard ratios (HR) and 95% confidence intervals (95% CI) for incident CVD in those with T2DM compared to those without T2DM in both adult cancer survivors and the general population after adjusting for shared confounding factors (income status, cigarette smoking, alcohol consumption, physical inactivity, body mass index, blood pressure, lipid abnormalities, family history of CVD, and aspirin use). Furthermore, we used Q statistic to compare the magnitude of association between T2DM and CVD in this matched cohort.

Results

The overall age and sex matched cohort in the NHIS-NSC comprised of 5,163 adult cancer survivors and the equivalent number of participants categorized as general population without history of cancer. The adjusted HR for CVD among adult cancer survivors with T2DM, as compared to without T2DM was 2.27 (95% CI: 1.25–4.11). Similarly, T2DM was associated with an increased risk of CVD in the general population without cancer (HR=1.88; 95% CI: 1.03–3.42). However, no strong statistical evidence was found for difference in contribution of T2DM to CVD risk between adult cancer survivors and general population without history of cancer (Pheterogeneity = 0.662).

Conclusions

In this population-based cohort study, T2DM was associated with an increased risk for CVD in both adult cancer survivors and those without history of cancer. Difference in magnitude of T2DM-CVD associations between adult cancer survivors and the general population without history of cancer was not substantial from a statistical standpoint. However, adult cancer survivor with T2DM may still need additional clinical attention for CVD prevention compared to those without history of cancer.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Cancer Center (Republic of Korea)

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

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.

Type and severity of migraine determines long-term risk of atrial fibrillation in women: a nationwide population-based study

Background

Migraine, especially when accompanied by aura, increases the risk of ischemic stroke and has also shown a close relationship with the occurrence of atrial fibrillation (AF). Although the risk of stroke and cardiovascular diseases is higher in women with migraine than in men, there is a lack of evidence for gender differences in the risk of AF in migraineurs.

Purpose

We sought to evaluate the gender-specific risk of AF according to the type and severity of migraine.

Methods

The study population included all national health checkup examinees (2009) without a history of AF from the Korean National Health Insurance Service data. The diagnosis and type or severity of migraine were determined using claims data, including diagnostic, procedural, and medication prescription codes. Newly developed non-valvular AF was identified during 10 years of follow-up. Gender-difference in the effect of migraine on AF occurrence was evaluated according to the type and severity of migraine. A multivariate Cox regression model was used to adjust for baseline differences between comparison groups, including age, smoking status, drinking habit, regular physical activity, income level, diabetes mellitus, hypertension, dyslipidemia, body mass index, and glomerular filtration rate as covariates.

Results

Of a total of 4,020,488 subjects (men, n=2,213,147, women, n=1,807,341) enrolled, 4,986 had migraine with aura (mean age 50.6±14.0, men 29.3%) and 105,029 without aura (mean age 51.6±14.3, men 30.9%). The proportion of migraine with aura among migraine patients was 4% in both gender groups. In the total population, migraine or migraine with aura did not significantly increase the risk of AF. The risk of AF did not increase in a mild degree of migraine, irrespective of gender or the presence of aura. Severe migraine without aura modestly increased the risk of AF in both men and women compared to the control group. (Men, incidence rate [IR] 4.51 per 1,000 person-year, adjusted hazard ratio [HR] 1.21, 95% confidence interval [CI] 1.12–1.31; Female, IR 3.00 per 1,000 person-year, adjusted HR 1.16, 95% CI 1.09–1.22) The increase of AF risk was the most prominent in women who had severe migraine with aura (IR 3.39 per 1,000 person-year, adjusted HR 1.48, 95% CI 1.18–1.85). In contrast, no significant association was observed between AF and migraine with aura in men. (IR 2.28, adjusted HR 0.63, 95% CI 0.39–1.01; P for interaction 0.011)

Conclusions

Mild migraine was not associated with an increase in AF risk regardless of gender or the presence of aura. Severe migraine without aura showed a mild increase in AF risk without gender-difference, while severe migraine with aura significantly increased the risk of AF only in women, not in men. Surveillance for incident AF and prompt stroke prevention would be beneficial, particularly for young-aged women suffering from severe migraine with aura.

Funding Acknowledgement

Type of funding sources: None. Figure 1

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.

Impact of cumulative burden of body mass index and waist circumference on risk of atrial fibrillation: an analysis of 3,700,000 participants who underwent 4-year consecutive annual health examination

Background

There is limited evidence for the significance of the combination of waist circumference (WC), as a surrogate marker of central obesity, with body mass index (BMI) for predicting the risk of atrial fibrillation (AF). Furthermore, the additive value of the burden of BMI and WC cumulated over time on AF risk has not been reported.

Purpose

We sought to investigate the effect of cumulative burden of BMI, WC, and their combinations on the risk of AF using health check-up data from the Korean National Health Insurance Service.

Methods

This study included subjects aged >20 years who underwent four times of annual national health check-ups serially during 2009 to 2013, excluding those with a previous history of AF. The 4-year cumulative burden of BMI and WC was represented as burden-score calculated by the summation of BMI score (BMI 18.5–23 kg/m2, score 0; BMI 23–25 kg/m2, score 1; BMI ≥25 kg/m2, score 2) and WC score (WC <90 cm for men or <85 cm for women, score 0; WC ≥90 cm for men or ≥85 cm for women, score 1) at each year of health check-up. Newly developed AF was identified using claims data during a median follow-up of 5.2 years. AF risk was evaluated according to the burden of BMI, WC, and their combinations. A multivariate Cox regression model was used to adjust for baseline differences.

Results

Of 3,726,172 subjects (mean age 44.5±11.1, men 69.5%) enrolled, 27% had BMI burden-score of zero, while 23% had maximal burden-score of 8. For WC, 71% had zero burden-score and 7% had the highest burden-score of 4. Compared to the zero burden-score, maximal burden-score of BMI mildly increased the risk of AF, whereas the risk of AF predominantly increased in the group of maximal burden-score of WC. The different burdens of BMI in the same WC burden group did not significantly affect the risk of AF. Adjusted HR of each BMI burden-score (BMI burden zero as a reference) ranged from 1.01 to 1.12 in the group with WC burden-score zero, 0.84 to 1.06 in WC burden-score 1, 0.84 to 1.19 in WC burden-score 2, 0.59 to 0.83 in WC burden-score 3, and 0.62 to 1.55 in WC burden-score 4 without statistical significance. In contrast, high WC burden-score further increased the risk of AF even in groups with moderate to high burden of BMI (adjusted HR of maximal WC burden versus zero burden 1.97 [1.49–2.59] in the group with BMI burden-score 4; 1.66 [1.23–2.24] in BMI burden-score 5; 1.49 [1.16–1.91] in BMI burden-score 6; 1.43 [1.18–1.73] in BMI burden-score 7; and 1.49 [1.38–1.60] in BMI burden-score 8).

Conclusions

The 4-year cumulative burden of WC was a stronger determinant of future AF risk than BMI burden. Particularly in middle-ranged BMI burden groups that include persistently overweight but not obese population, high burden of WC substantially increased the risk of AF. The strategy of active surveillance for AF and comprehensive management of lifestyle and risk factors should focus on high-risk populations determined by the burden of WC.

Funding Acknowledgement

Type of funding sources: None.

Lower risk of stroke after alcohol abstinence in patients with incident atrial fibrillation: a nationwide population-based cohort study

Background

In a recent study, alcohol abstinence reduced the atrial fibrillation (AF) recurrence in patients with AF. However, the relationship between alcohol consumption and incident stroke in patients with AF per se remains unclear.

Purpose

To evaluate the association between alcohol consumption status (and its changes) after newly diagnosed AF and the risk of ischaemic stroke.

Methods

Using the Korean nationwide claims and health examination database, we included subjects who were newly diagnosed with AF between 2010 and 2016. Patients were categorized into three groups according to the status of alcohol consumption before and after AF diagnosis: non-drinkers; abstainers from alcohol after AF diagnosis; and current drinkers. The primary outcome was incident ischaemic stroke during follow-up.

Results

Among a total of 97,869 newly diagnosed AF patients, 51% were non-drinkers, 13% were abstainers, and 36% were current drinkers. After inverse probability of treatment weighting, baseline characteristics of three groups were well-balanced. Compared to current drinkers, abstainers and non-drinkers were associated with a lower risk of ischaemic stroke (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.77–0.96 for abstainers and HR 0.75, 95% CI 0.70–0.81 for non-drinkers, respectively). Amongst current drinkers, there was a dose-response relationship between the amount of alcohol consumption and the risk of ischaemic stroke.

Conclusion

Current alcohol consumption was associated with an increased risk of ischaemic stroke in patients with newly diagnosed AF, and alcohol abstinence after AF diagnosis could reduce the risk of ischaemic stroke. Lifestyle intervention, including attention to alcohol consumption, should be encouraged as a part of a comprehensive approach to AF management to improve clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.

Association between body mass index and the risk of atrial fibrillation and ischemic stroke according to age: a nationwide population-based cohort study

Background

Atrial fibrillation (AF) and ischemic stroke (IS) are two significant cardiovascular diseases that confer an enormous healthcare burden. A limited study comprehensively evaluated the association between full ranges of body mass index (BMI), including underweight, and AF or IS risks, especially in the different age subgroups.

Purpose

We investigated the association between BMI and AF and IS incidence according to the Korean population's age groups.

Methods

This was a nationwide population-based cohort study using data from the Korea National Health Insurance Service, including 9 194 477 healthy adults who underwent a medical examination in 2009. We stratified the study population into three age subgroups: age 20–39 (young, 33.1%), age 40–64 (middle-aged, 56.3%), and age over 65 years (elderly, 10.6%). In each age group, the individuals were categorized based on BMI (kg/m2) into underweight (<18.5), normal (18.5 to <23), overweight (23 to <25), obese I (25 to <30), and obese II (≥30). The first occurrences of AF and IS were followed up until December 31, 2018. According to BMI in each age group, the risks of AF and IS were analyzed by Cox proportional hazards regression with 95% confidence intervals (CI) by adjusting age, sex, lifestyle behaviors, and comorbidities.

Results

Overall, both underweight and higher BMI were associated with an increased risk of AF and stroke across all age groups. The increased risk of AF for patients with obese II was slightly accentuated compared to patients with normal BMI in the young population than elderly population (hazard ratio [HR] 1.78, 95% CI 1.63–1.94 for age 20–39 years; HR 1.55, 95% CI 1.48–1.61 for age ≥65 years, respectively). For underweight individuals, however, the increased risk of AF became more prominent in the elderly: HR and 95% CI was 1.12 (1.07–1.17) in the age over 65 years old, and 1.05 (0.94–1.16) in the age 20–39. Regarding IS, the young group presented a considerable increment in the magnitude of HRs in both underweight and higher BMI groups. However, the association between the BMI and stroke risk became attenuated in the elderly: HRs and 95% CI in underweight and obese II individuals were 1.10 (0.93–1.30) and 2.223 (1.99–2.49) in the age 20–39 group, whereas 0.97 (0.93–1.01) and 1.03 (0.98–1.08) in the age over 65 years old.

Conclusions

Underweight as well as obesity was associated with increased risks of AF and IS in the general population. In both AF and IS, the gradient of risks according to BMI was apparent at young ages; thus, maintaining normal body weight should be warranted in early life. An interplay of several factors other than BMI may contribute to ischemic stroke in the old ages, requiring integrated risk management in older patients.

Funding Acknowledgement

Type of funding sources: None.

Observation of D_{s}^{±}/D^{0} Enhancement in Au+Au Collisions at sqrt[s_{NN}]=200 GeV

We report on the first measurement of charm-strange meson D_{s}^{±} production at midrapidity in Au+Au collisions at sqrt[s_{NN}]=200  GeV from the STAR experiment. The yield ratio between strange (D_{s}^{±}) and nonstrange (D^{0}) open-charm mesons is presented and compared to model calculations. A significant enhancement, relative to a pythia simulation of p+p collisions, is observed in the D_{s}^{±}/D^{0} yield ratio in Au+Au collisions over a large range of collision centralities. Model calculations incorporating abundant strange-quark production in the quark-gluon plasma and coalescence hadronization qualitatively reproduce the data. The transverse-momentum integrated yield ratio of D_{s}^{±}/D^{0} at midrapidity is consistent with a prediction from a statistical hadronization model with the parameters constrained by the yields of light and strange hadrons measured at the same collision energy. These results suggest that the coalescence of charm quarks with strange quarks in the quark-gluon plasma plays an important role in D_{s}^{±}-meson production in heavy-ion collisions.

Measurement of e^{+}e^{-} Momentum and Angular Distributions from Linearly Polarized Photon Collisions

The Breit-Wheeler process which produces matter and antimatter from photon collisions is experimentally investigated through the observation of 6085 exclusive electron-positron pairs in ultraperipheral Au+Au collisions at sqrt[s_{NN}]=200  GeV. The measurements reveal a large fourth-order angular modulation of cos4Δϕ=(16.8±2.5)% and smooth invariant mass distribution absent of vector mesons (ϕ, ω, and ρ) at the experimental limit of ≤0.2% of the observed yields. The differential cross section as a function of e^{+}e^{-} pair transverse momentum P_{⊥} peaks at low value with sqrt[⟨P_{⊥}^{2}⟩]=38.1±0.9  MeV and displays a significant centrality dependence. These features are consistent with QED calculations for the collision of linearly polarized photons quantized from the extremely strong electromagnetic fields generated by the highly charged Au nuclei at ultrarelativistic speed. The experimental results have implications for vacuum birefringence and for mapping the magnetic field which is important for emergent QCD phenomena.

Hypertension burden and the risk of new-onset atrial fibrillation: a nationwide population-based study

Funding Acknowledgements

Type of funding sources: None.

Background

The association between the cumulative hypertension burden and the development of atrial fibrillation (AF) is unclear.

Purpose

We aimed to investigate the relationship between hypertension burden and the development of incident AF.

Methods and Results: Using the Korean National Health Insurance Service database, we identified 3,726,172 subjects who underwent four consecutive annual health checkups between 2009 and 2013, with no history of AF. During the median follow-up of 5.2 years, AF was newly diagnosed in 22,012 patients (0.59% of the total study population, 1.168 per 1,000 person-years). Using the BP values at each health checkup, we determined the burden of hypertension (systolic blood pressure [SBP] ≥130 mmHg or diastolic blood pressure [DBP] ≥80 mmHg), stratified as 0 to 4 per the hypertension criteria. The subjects were grouped according to hypertension burden scale 1 to 4: 20% (n = 742,806), 19% (n = 704,623), 19% (n = 713,258), 21% (n = 766,204), and 21% (n = 799,281). Compared to normal people, subjects with hypertension burdens of 1, 2, 3, and 4 were associated with an 8%, 18%, 26%, and 27% increased risk of incident AF, respectively. On semi-quantitative analyses with further stratification of stage 1 (SBP 130-139 mmHg or DBP 80-89 mmHg) and stage 2 (SBP ≥140 mmHg or DBP ≥90 mmHg) hypertension, the risk of AF increased with the hypertension burden by up to 71%.

Conclusions

Both a sustained exposure and the degree of increased blood pressure were associated with an increased risk of incident AF. Tailored blood pressure management should be emphasized to reduce the risk of AF. Abstract Figure.

Global Polarization of Ξ and Ω Hyperons in Au+Au Collisions at sqrt[s_{NN}]=200 GeV

Global polarization of Ξ and Ω hyperons has been measured for the first time in Au+Au collisions at sqrt[s_{NN}]=200  GeV. The measurements of the Ξ^{-} and Ξ[over ¯]^{+} hyperon polarization have been performed by two independent methods, via analysis of the angular distribution of the daughter particles in the parity violating weak decay Ξ→Λ+π, as well as by measuring the polarization of the daughter Λ hyperon, polarized via polarization transfer from its parent. The polarization, obtained by combining the results from the two methods and averaged over Ξ^{-} and Ξ[over ¯]^{+}, is measured to be ⟨P_{Ξ}⟩=0.47±0.10(stat)±0.23(syst)% for the collision centrality 20%-80%. The ⟨P_{Ξ}⟩ is found to be slightly larger than the inclusive Λ polarization and in reasonable agreement with a multiphase transport model. The ⟨P_{Ξ}⟩ is found to follow the centrality dependence of the vorticity predicted in the model, increasing toward more peripheral collisions. The global polarization of Ω, ⟨P_{Ω}⟩=1.11±0.87(stat)±1.97(syst)% was obtained by measuring the polarization of daughter Λ in the decay Ω→Λ+K, assuming the polarization transfer factor C_{ΩΛ}=1.

Nonmonotonic Energy Dependence of Net-Proton Number Fluctuations

Nonmonotonic variation with collision energy (sqrt[s_{NN}]) of the moments of the net-baryon number distribution in heavy-ion collisions, related to the correlation length and the susceptibilities of the system, is suggested as a signature for the quantum chromodynamics critical point. We report the first evidence of a nonmonotonic variation in the kurtosis times variance of the net-proton number (proxy for net-baryon number) distribution as a function of sqrt[s_{NN}] with 3.1  σ significance for head-on (central) gold-on-gold (Au+Au) collisions measured solenoidal tracker at Relativistic Heavy Ion Collider. Data in noncentral Au+Au collisions and models of heavy-ion collisions without a critical point show a monotonic variation as a function of sqrt[s_{NN}].