Four-year incidence of major adverse cardiovascular events in patients with atherosclerosis and atrial fibrillation

Assessing the Suitability of CHA2DS2-VASc for Predicting Adverse Limb Events and Cardiovascular Outcomes in Peripheral Artery Disease Patients with Percutaneous Transluminal Angioplasty: A Retrospective Cohort Study

Patients with peripheral artery disease (PAD) are at high risk of major adverse limb events (MALEs) and major adverse cardiovascular events (MACEs). CHA2DS2-VASc is a prognostic score for atrial fibrillation stroke risk; however, no study has evaluated its predictive ability for MALEs and MACEs in PAD patients who underwent percutaneous transluminal angioplasty. We conducted a retrospective cohort study on patients from Taiwan with PAD. The patients were stratified into four risk groups based on their modified CHA2DS2-VASc score. Cox proportional hazard models, 10-fold cross-validation, and receiver operating characteristic (ROC) analyses were utilized to evaluate the predictive ability of CHA2DS2-VASc for MALEs, MACEs, and MALEs + MACEs. Kaplan-Meier analysis estimated the survival probability of the risk groups. CHA2DS2-VASc was found to be a significant predictor of MACEs (hazard ratio (HR) 3.52 (95% confidence interval (95% CI) 1.00-12.12; p = 0.048), HR 4.18 (95% CI 1.19-14.36; p = 0.023), and HR 5.08 (95% CI 1.49-17.36; p = 0.009), for moderate-, high-, and very high-risk groups, respectively), while for MALEs and MALEs + MACEs, significance was achieved only for the high-risk group using a univariate model. For the multivariate adjusted model, the score was found to be a significant predictor of MACEs for only the very high-risk group, with an HR of 4.67 (95% CI 1.03-21.09; p = 0.045). The score demonstrated an AUC > 0.8, good discrimination (c-index > 0.8), and good calibration for predicting MACEs. However, it failed to achieve good performance for predicting MALEs and MALEs + MACEs. Based on all of the findings, CHA2DS2-VASc could potentially serve as a risk stratification score for predicting MACEs in patients with PAD, but it failed to qualify as a good predictor for MALEs.

The relationship between atrial fibrillation and coronary artery disease: Understanding common denominators

Atrial fibrillation (AF) and coronary artery disease (CAD) are highly prevalent cardiovascular conditions. The coexistence of both diseases is common as they share similar risk factors and common pathophysiological characteristics. Systemic inflammatory conditions are associated with an increased incidence of both AF and CAD. The presence of both entities increases the incidence of complications and adverse outcomes. Furthermore, their coexistence poses challenges for the management of patients, particularly with respect to anticoagulation and rhythm management. In this review, we aim to better understand the relationship between AF and CAD by detailing basic molecular pathophysiology, assessing therapeutic guidelines, and describing interactions between the two conditions.

Prediabetes: An overlooked risk factor for major adverse cardiac and cerebrovascular events in atrial fibrillation patients

BACKGROUND

Prediabetes is a well-established risk factor for major adverse cardiac and cerebrovascular events (MACCE). However, the relationship between prediabetes and MACCE in atrial fibrillation (AF) patients has not been extensively studied. Therefore, this study aimed to establish a link between prediabetes and MACCE in AF patients.

AIM

To investigate a link between prediabetes and MACCE in AF patients.

METHODS

We used the National Inpatient Sample (2019) and relevant ICD-10 CM codes to identify hospitalizations with AF and categorized them into groups with and without prediabetes, excluding diabetics. The primary outcome was MACCE (all-cause inpatient mortality, cardiac arrest including ventricular fibrillation, and stroke) in AF-related hospitalizations.

RESULTS

Of the 2965875 AF-related hospitalizations for MACCE, 47505 (1.6%) were among patients with prediabetes. The prediabetes cohort was relatively younger (median 75 vs 78 years), and often consisted of males (56.3% vs 51.4%), blacks (9.8% vs 7.9%), Hispanics (7.3% vs 4.3%), and Asians (4.7% vs 1.6%) than the non-prediabetic cohort (P < 0.001). The prediabetes group had significantly higher rates of hypertension, hyperlipidemia, smoking, obesity, drug abuse, prior myocardial infarction, peripheral vascular disease, and hyperthyroidism (all P < 0.05). The prediabetes cohort was often discharged routinely (51.1% vs 41.1%), but more frequently required home health care (23.6% vs 21.0%) and had higher costs. After adjusting for baseline characteristics or comorbidities, the prediabetes cohort with AF admissions showed a higher rate and significantly higher odds of MACCE compared to the non-prediabetic cohort [18.6% vs 14.7%, odds ratio (OR) 1.34, 95% confidence interval 1.26-1.42, P < 0.001]. On subgroup analyses, males had a stronger association (aOR 1.43) compared to females (aOR 1.22), whereas on the race-wise comparison, Hispanics (aOR 1.43) and Asians (aOR 1.36) had a stronger association with MACCE with prediabetes vs whites (aOR 1.33) and blacks (aOR 1.21).

CONCLUSION

This population-based study found a significant association between prediabetes and MACCE in AF patients. Therefore, there is a need for further research to actively screen and manage prediabetes in AF to prevent MACCE.

Validating the predictive ability of the 2MACE score for major adverse cardiovascular events in patients with atrial fibrillation: results from phase II/III of the GLORIA-AF registry

The 2MACE score was specifically developed as a risk-stratification tool in atrial fibrillation (AF) to predict cardiovascular outcomes. We evaluated the predictive ability of the 2MACE score in the GLORIA-AF registry. All eligible patients from phase II/III of the prospective global GLORIA-AF registry were included. Major adverse cardiac events (MACEs) were defined as the composite outcome of stroke, myocardial infarction and cardiovascular death. Cox proportional hazards were used to examine the relationship between the 2MACE score and study outcomes. Predictive capability of the 2MACE score was investigated using receiver-operating characteristic curves. A total of 25,696 patients were included (mean age 71 years, female 44.9%). Over 3 years, 1583 MACEs were recorded. Patients who had MACE were older, with more cardiovascular risk factors and were less likely to be managed using a rhythm-control strategy. The median 2MACE score in the MACE and non-MACE groups were 2 (IQR 1-3) and 1 (IQR 0-2), respectively (p < 0.001). The 2MACE score was positively associated with an increase in the risk of MACE, with a score of ≥ 2 providing the best combination of sensitivity (69.6%) and specificity (51.6%), HR 2.47 (95% CI, 2.21-2.77). The 2MACE score had modest predictive performance for MACE in patients with AF (AUC 0.655 (95% CI, 0.641-0.669)). Our analysis in this prospective global registry demonstrates that the 2MACE score can adequately predict the risk of MACE (defined as myocardial infarction, CV death and stroke) in patients with AF. Clinical trial registration: http://www.clinicaltrials.gov . Unique identifiers: NCT01468701, NCT01671007 and NCT01937377.

Real-world clinical outcomes of oral anticoagulants among Japanese patients with atrial fibrillation and concomitant coronary artery disease

Background

Stroke prevention is complicated in patients with atrial fibrillation (AF) and coronary artery disease (CAD). We compared the risk of major bleeding among Japanese patients with AF and CAD commencing warfarin, dabigatran, or rivaroxaban.

Methods

This study included adults with AF and CAD who were newly prescribed the non-vitamin K antagonist oral anticoagulants (NOACs) dabigatran or rivaroxaban, or warfarin, and registered between 18 April 2011 through 31 December 2020 in the Medical Data Vision hospital-based clinical database. The primary outcome was major bleeding, and the secondary outcome was a composite of stroke, systemic embolism, myocardial infarction, all-cause inpatient mortality, major bleeding, major gastrointestinal bleeding, and intracerebral hemorrhage. Cox proportional hazard models with stabilized inverse probability treatment weighting were used to estimate hazard ratios (HRs) with 95 % CIs via a two-step approach; first between warfarin and each NOAC, then between NOACs if sample size conditions were met.

Results

Dabigatran, rivaroxaban, and warfarin groups included 6712, 20,329, and 12,316 patients, respectively. Major bleeding risk was lower in NOACs versus warfarin (dabigatran: HR 0.50, 95 % CI: 0.40-0.62; rivaroxaban: HR 0.78, 95 % CI: 0.69-0.90); this risk was lower with dabigatran compared with rivaroxaban (HR 0.64, 95 % CI: 0.51─0.79). Net clinical benefit was superior to warfarin in both NOACs (dabigatran: HR 0.78, 95 % CI: 0.71-0.85; rivaroxaban: HR 0.83, 95 % CI: 0.78-0.88).

Conclusions

Among real-world Japanese patients with AF and CAD, NOACs were associated with better clinical outcomes than warfarin. Treatment with dabigatran had a lower risk of major bleeding than rivaroxaban.Clinical trial registration: NCT05051904 (ClinicalTrials.gov).

Vascular protection with rivaroxaban in the comprehensive management of atrial fibrillation

INTRODUCTION

In addition to an increased risk of thromboembolic complications, patients with atrial fibrillation (AF) are at risk for vascular events. Consequently, complete vascular protection is warranted in these patients.

AREAS COVERED

A narrative search was conducted on PubMed (MEDLINE), using the MeSH terms [Rivaroxaban] + [Atrial fibrillation] + [Cardiovascular] + [Vascular] + [Treatment]. Original data from clinical trials, prospective and retrospective studies, useful reviews and experimental studies, were selected.

EXPERT OPINION

The ROCKET-AF trial showed that rivaroxaban is effective in reducing the risk of stroke, with a lower risk of fatal and intracranial bleeding compared to warfarin. Remarkably, experimental data have provided a number of pathogenic mechanisms through which rivaroxaban could provide beneficial vascular properties beyond its antithrombotic activity. Moreover, in the AF population, additional to its ability to reduce the risk of thromboembolic complications, rivaroxaban is associated with a lower risk of myocardial infarction, major adverse cardiac and limb events, and vascular mortality in patients with diabetes, also attenuating renal impairment during follow-up. These findings suggest that rivaroxaban may provide a comprehensive vascular protection in patients with AF.

Heart Failure and Major Adverse Cardiovascular Events in Atrial Fibrillation Patients: A Retrospective Primary Care Cohort Study

BACKGROUND

Atrial fibrillation (AF) is a common cardiac arrhythmia that is associated with an increased risk of major adverse cardiovascular events (MACE). The main goal was to analyze the links and associations between AF and MACE.

METHODS

A multicenter, observational, retrospective, community-based study of a cohort (n = 40,297) of the general population aged 65-95 years between 1 January 2015 and 31 December 2021 without a previous diagnosis of AF or MACE in the Primary Care setting.

RESULTS

2574 people (6.39%) developed a first AF event, resulting in an overall incidence of 8.9/1000 people-years [CI95% 8.6-9.2]. The incidence of MACE among those with AF was 75.1/1000 people-years [CI95% 70.8-79.5], whereas among those without AF, it was 20.6/1000 people-years [CI 95% 20.2-21.1], resulting in a rate ratio of 3.65 [CI 95% 3.43-3.88, p < 0.001]. Besides, the incidence of HF with AF was 40.1 people-years [CI 95% 37.1-43.2], while in the group without AF, it was 8.3 people-years [CI 95% 7.9-8.6, p < 0.001], with a rate ratio of 4.85 [CI 95% 4.45-55.3, p < 0.001]. Before an AF diagnosis, there is already a higher risk of chronic kidney disease, ischemic cardiopathy, and peripheral artery disease. A higher risk of poor nutritional status was detected among those with MACE (49.7% vs. 26.6%, p < 0.001).

CONCLUSIONS

AF diagnosis increases the incidence of heart failure fourfold. Additional information is required to establish the connection between AF, major adverse cardiovascular events, and nutritional status.

Non-embolic outcomes in patients with cardiovascular disease and atrial fibrillation treated with rivaroxaban

Aim: It is not well known how comorbidities may change the prognosis of atrial fibrillation (AF) patients. This study was aimed to analyze the impact of cardiovascular disease on this population. Materials & methods: EMIR was a multicenter, prospective study, including 1433 AF patients taking rivaroxaban for ≥6 months. Data were analyzed according to the presence of vascular disease. Results: Coronary artery disease was detected in 16.4%, peripheral artery disease/aortic plaque in 6.7%, vascular disease in 28.3%. Patients with coronary artery disease had higher rates (per 100 patient-years) of major adverse cardiovascular events (2.98 vs 0.71; p < 0.001) and cardiovascular death (1.79 vs 0.41; p = 0.004). Those with vascular disease had higher rates of thromboembolic events (1.47 vs 0.44; p = 0.007), major adverse cardiovascular events (2.03 vs 0.70; p = 0.004), and cardiovascular death (1.24 vs 0.39; p = 0.025). Patients with peripheral artery disease/aortic plaque had similar rates. Conclusion: AF patients with vascular disease have a higher risk of non-embolic outcomes.

Stroke and Myocardial Infarction in Patients with Abdominal Aortic Aneurysm and New-Onset Atrial Fibrillation

OBJECTIVE

 We investigated the association between new-onset atrial fibrillation (AF) and risk of stroke and myocardial infarction (MI) in patients with abdominal aortic aneurysmal (AAA) disease.

METHODS

 Observational crossover study using Danish nationwide data, including patients with AAA and incident AF between 1997 and 2018. We estimated the 1-year risk of stroke and MI and the within-individual odds ratios (ORs) of ischemic events before and after an AF diagnosis, stratified by year of AF diagnosis (1997-2010 and 2011-2018), and supplemented with analyses on changes in use of antithrombotic therapy.

RESULTS

 A total of 3,035 AAA patients were included: 1,040 diagnosed during 1997 to 2010, and 1,995 during 2011 to 2018 (22.2% females, median age 78 years; median CHA₂DS₂-VASc score 4; interquartile range: 3-5). One-year risk of ischemic events after AF was 5.9% (confidence interval [CI] 95%: 4.6-7.5%) and 4.5% (CI 95%: 3.7-5.5%) for stroke and 5.4% (CI 95%: 4.2-6.9%) and 4.0% (CI 95%: 3.2-4.9%) for MI during 1997 to 2010 and 2011 to 2018, respectively. The OR of ischemic stroke before and after incident AF was 2.8 (CI 95%: 1.6-5.2) during 1997 to 2010; and 2.4 (CI 95%: 1.5 to 3.9) during 2011 to 2018, and 3.5 (CI 95%: 1.7-7.5) and 1.5 (CI 95%: 0.9-2.4) for MI. One-year proportion of prescription claims for oral anticoagulants after AF changed from 66.1% in 1997 to 2010 to 82.6% in 2011 to 2018, while antiplatelet prescription claims changed from 80.8 to 60.9%.

CONCLUSION

 Cardiovascular prognosis has improved in patients with prevalent AAA disease and new-onset AF in concordance with optimization of antithrombotic therapy over time. A diagnosis of AF conferred residual risk of stroke and MI.

Mortality and Major Adverse Cardiovascular Events in Hospitalized Patients With Atrial Fibrillation With COVID-19

COVID-19 results in increased incidence of cardiac arrhythmias, including atrial fibrillation (AF). However, little is known about the combined effect of AF and COVID-19 on patient outcomes. This study aimed to determine if AF, specifically new-onset AF (NOAF), is associated with increased risk of mortality and major adverse cardiovascular events (MACEs) in hospitalized patients with COVID-19. This multicenter retrospective analysis identified 2,732 patients with COVID-19 admitted between March and December 2020. Data points were manually reviewed in the patients' electronic health records. Multivariate logistic regression was used to assess if AF was associated with death or MACE. Patients with AF (6.4%) had an increased risk of mortality (risk ratio 2.249, 95% confidence interval [CI] 1.766 to 2.864, p <0.001) and MACE (risk ratio 1.753, 95% CI 1.473 to 2.085, p <0.001) compared with those with sinus rhythm. Patients with NOAF had an increased risk of mortality compared with those with existing AF (odds ratio 19.30, 95% CI 5.39 to 69.30, p <0.001); the risk of MACE was comparable between NOAF and patients with existing AF (p = 1). AF during hospitalization with COVID-19 is associated with a higher risk of mortality and MACE. NOAF in patients with COVID-19 is associated with a higher risk of mortality but a similar risk of MACE compared with patients with existing AF.

[Modern issues of improving the prognosis in patients with atrial fibrillation after ischemic stroke]

The anticoagulant therapy with a priority of direct oral anticoagulants is an approach to the prevention of recurrent stroke in patients with atrial fibrillation (AF) that has presently proved its efficacy and is stated in international clinical guidelines. An extensive evidence-based database demonstrates advantages of rivaroxaban over other drugs of this class in secondary prevention of stroke in AF. Furthermore, these advantages are combined with the optimal safety profile. The rivaroxaban treatment may provide the most favorable prognosis due to the prevention of recurrent stroke in AF, reducing the rate of kidney disease progression, and slowing vascular atherosclerosis. An important beneficial feature of rivaroxaban is once-a-day intake, which is important in the context of a high incidence of cognitive disorders in this patient category, and may improve their compliance and, thus, help achieving the expected profile of treatment efficacy. Thus, rivaroxaban can be regarded as a drug of choice for secondary prevention of stroke in AF.

Atherosclerosis and Atrial Fibrillation: Double Trouble

PURPOSE OF REVIEW

This review aims to evaluate the major cardiovascular adverse events (MACE) and antithrombotic approaches in concomitant atrial fibrillation (AF) and atherosclerosis.

RECENT FINDINGS

MACE in concomitant AF and atherosclerosis has been evaluated in recent studies. A recent retrospective study of 2670 patients with AF revealed that atherosclerosis burden with AF can be a marker of adverse vascular outcomes with extracranial atherosclerosis as a potent predictor of MACE. Trials to evaluate the antithrombotic approaches in concomitant atherosclerotic disease and AF has been mainly in patients with coronary artery disease (CAD). AFIRE trial demonstrated that in patients with AF and stable CAD rivaroxaban alone is not inferior to rivaroxaban plus aspirin with better safety profile. Atherosclerosis is common in AF and poses additional risk to patients. Antithrombotic management of atherosclerosis in AF is not well investigated and needs further trial to identify the subgroups that benefit from more intensive antithrombotic measures.

Problems of selecting an anticoagulant for secondary stroke prevention in patients with atrial fibrillation

The article describes the urgent problem of ischemic stroke prevention in patients with atrial fibrillation. It is proved that ischemic stroke in combination with AF is the most severe in terms of developing stable motor and speech disorders and disability. The frail older patients, as well as patients with swallowing disorders and reduced medical adherence present a special problem from this point of view. The most famous clinical studies on secondary prevention of cardioembolic stroke are RE-LY, ROCKET-AF, and ARISTOTLE. Based on subanalyses of randomized controlled trials, direct oral anticoagulants demonstrated a favorable efficacy profile in patients with atrial fibrillation and stroke/ transient ischemic attack, but the level of knowledge on each of them remained different. A number of advantages of rivaroxaban for primary and secondary prevention of stroke in patients with atrial fibrillation, including the elderly and patients with cognitive impairments and swallowing disorders, have been demonstrated.

[Atrial fibrillation in old age: risk management and features of the use of direct oral anticoagulants]

Senile patients with atrial fibrillation (AF) are at a higher risk of thromboembolism and hemorrhage than younger patients. Three direct oral anticoagulants (DOAC), apixaban, dabigatran, and rivaroxaban, are registered in the Russian Federation and are extensively used for prevention of stroke in patients with AF. The DOAC treatment of older patients requires considering peculiarities of these patients, clinical situation and properties of individual drugs to achieve the balance of efficiency and safety and a comprehensive protection. According to studies of real clinical practice DOAC may have advantages over warfarin (reduced risk of fractures, diabetes mellitus, and dementia). Compliance with and constancy of the DOAC treatment are important for its efficiency, particularly in senile age. Results of clinical trials and real clinical practice studies have confirmed that rivaroxaban may provide a comprehensive protection for a senile patient with AF due to favorable indexes of efficiency and safety, beneficial effect on the risk of coronary events and impairment оf renal function, whereas once a day dosing of rivaroxaban improves the compliance with this treatment and its constancy.

Atherosclerotic Burden and Vascular Risk in Stroke Patients With Atrial Fibrillation

[Figure: see text].

Concomitant diabetes with atrial fibrillation and anticoagulation management considerations

Atrial fibrillation is a highly prevalent cardiac arrhythmia. It is associated with numerous co mobilities. Approximately 30% of diabetic patients have atrial fibrillation and 15% of atrial fibrillation regulation patients have diabetes mellitus. Diabetes increases the likelihood of the development of atrial fibrillation and contributes to the high risk of thromboembolism seen in patients with both diabetes and atrial fibrillation. Chronic kidney disease is often a consequence of diabetes and presents an additional challenge to the management of patients with both atrial fibrillation and diabetes. All non-vitamin K oral anticoagulants are partially eliminated via the kidney and must be carefully prescribed according to strict dosing schedules to avoid anticoagulation overdose. However, NOACs have the advantage of being associated with less progressive impairment of renal function compared with vitamin K antagonist therapy in both diabetics and non-diabetics. Otherwise, diabetic patients benefit from NOAC therapy as opposed to vitamin K antagonists to a similar extent as patients without diabetes. This review deals with anticoagulation treatment in patients with fibrillation and diabetes mellitus, often complicated by progressive renal impairment.

Effects of Atrial Fibrillation and Chronic Kidney Disease on Major Adverse Cardiovascular Events

Atrial fibrillation (AF) is strongly linked to chronic kidney disease (CKD) and both of these conditions contribute to poor cardiovascular outcomes. We evaluated the impact of renal failure on major adverse cardiovascular events (MACE) in AF, and predictive value of the 2MACE score in this post-hoc analysis of the AMADEUS trial. The primary endpoint was MACE (composite of myocardial infarction, cardiac revascularisation and cardiovascular mortality). Secondary endpoints included the composite of stroke, major bleeding and non-cardiovascular mortality, and each of the specific outcomes separately. Of the 4,554 patients, 1,526 (33.5%) were females and the median age was 71 (IQR 64 to 77) years. There were 3,838 (84.3%) non-CKD and 716 (15.7%) CKD patients. The incidence of cardiovascular and non-cardiovascular mortality were 1.41% and 2.44% per 100 patient-years, respectively. There was no significant difference in crude study endpoints between the groups. Multivariable regression analysis found no association between CKD and MACE (HR 1.03 [95% CI, 0.45 to 2.34]). The c-index of the 2MACE score for MACE was 0.65 (95% CI, 0.59 to 0.71, p <0.001). In the presence of CKD, each additional point of the 2MACE score contributed to a greater risk of MACE (HR 3.17 [95% CI, 1.28 to 7.85] vs 1.48 [95% CI, 1.17 to 1.87] in the non-CKD group). In conclusion, the 2MACE score may be a useful tool for clinical risk stratification of high-risk AF patients with CKD and those at high MACE risk could be targeted for more intensive cardiovascular prevention strategies. The presence of CKD was not found to be independently associated with MACE in AF patients.

Four-year incidence of major adverse cardiovascular events in patients with atherosclerosis and atrial fibrillation

Background

There is a paucity of contemporary data assessing the implications of atrial fibrillation (AF) on major adverse cardiovascular events (MACE) in patients with or at high‐risk for atherosclerotic disease managed in routine practice.

Hypothesis

We sought to evaluate the 4‐year incidence of MACE in patients with or at risk of atherosclerotic disease in the presence of AF.

Methods

Using US MarketScan data, we identified AF patients ≥45 years old with billing codes indicating established coronary artery disease, cerebrovascular disease, or peripheral artery disease or the presence of ≥3 risk factors for atherosclerotic disease from January 1, 2013 to December 31, 2013 with a minimum of 4‐years of available follow‐up. We calculated the 4‐year incidence of MACE (cardiovascular death or hospitalization with a primary billing code for myocardial infarction or ischemic stroke). Patients were further stratified by CHA₂DS₂‐VASc score and oral anticoagulation (OAC) use at baseline.

Results

We identified 625,951 patients with 4‐years of follow‐up, of which 77,752 (12.4%) had comorbid AF. The median (25%, 75% range) CHA₂DS₂‐VASc score was 4 (3, 5) and 64% of patients received an OAC at baseline. The incidence of MACE increased as CHA₂DS₂‐VASc scores increased (P‐interaction<.0001 for all). AF patients receiving an OAC were less likely to experience MACE (8.9% vs 11.6%, P < .0001) including ischemic stroke (5.4% vs 6.7%, P < .0001).

Conclusion

Comorbid AF carries a substantial risk of MACE in patients with or at risk of atherosclerotic disease. MACE risk increases with higher CHA₂DS₂‐VASc scores and is more likely in patients without OAC.