Atrial fibrillation, venous thromboembolism, ischemic stroke, and all-cause mortality: The Tromsø study

Elevated International Normalized Ratio and Mortality in Hospitalized Patients Treated with Direct Oral Anticoagulants

BACKGROUND

Direct oral anticoagulants (DOACs) are associated with a prolongation of the prothrombin time and an increased international normalized ratio (INR). The clinical significance of these changes is unclear. This study aimed to examine the association between an elevated INR on admission and in-hospital death and long-term survival in patients treated with DOACs.

METHODS

Data were retrospectively retrieved from records of hospitalized patients at the Sheba Medical Center between November 2008 and July 2023. Patients were selected based on DOAC treatment, coagulation profile, and INR test done within 48 hours of hospitalization. The outcomes were in-hospital mortality and mortality in the year following hospitalization.

RESULTS

The study included 11,399 hospitalized patients treated with DOACs. Patients with elevated INR had a 180% higher risk of in-hospital mortality (adjusted odds ratio 2.80; 95% confidence interval, 2.30-3.39) and a 57% increased risk of death during the following year (adjusted hazard ratio 1.57; 95% confidence interval, 1.44-1.71). Similar results were observed in subgroup analyses for each DOAC.

CONCLUSIONS

An elevated INR on admission is associated with a higher risk for in-hospital death and increased risk for mortality during the first year following hospitalization in hospitalized patients treated with DOACs. This highlights that elevated INR levels in patients on DOACs should not be dismissed as laboratory variations due to DOAC treatment, as they may serve as a prognostic marker.

Insomnia and Cardiovascular Health: Exploring the Link Between Sleep Disorders and Cardiac Arrhythmias

Cardiovascular diseases (CVDs), driven by modern lifestyles, have increased, with atrial fibrillation (AF) being a major concern linked to heart failure and stroke. Insomnia affects a large population, especially younger individuals, males, and menopausal women, decreasing the quality of life and potentially causing autonomic disturbances and cardiac arrhythmias. PURPOSE OF REVIEW: This review explores the link between insomnia and cardiac arrhythmias, particularly AF, and its impact on cardiovascular health and emphasizes the need to address insomnia in individuals with cardiac arrhythmias by tailored strategies for sleep management to improve their overall well-being. RECENT FINDINGS: Recent findings emphasize maintaining a regular sleep schedule to lower AF and bradyarrhythmia risks. Better sleep scores correlate with reduced AF and bradyarrhythmia risks, while insomnia increases AF risk, particularly in those under 40 years of age. Studies underscore the potential impact of sleep management in reducing cardiovascular risks and highlight the importance of addressing sleep issues to improve cardiovascular health outcomes. Our review presents compelling evidence connecting insomnia and AF. Improving sleep patterns and addressing sleep issues can reduce AF risk, benefiting cardiovascular health. A comprehensive approach for managing at-risk individuals with cardiac arrhythmias, considering co-existing conditions, can decrease long-term disease burden and expenses. Incorporating sleep assessments and interventions into cardiovascular risk management, especially for those with insomnia, is recommended. Further research is needed to fully comprehend the complex relationship between insomnia and cardiac arrhythmias.

Hypertensive heart disease: risk factors, complications and mechanisms

Hypertensive heart disease constitutes functional and structural dysfunction and pathogenesis occurring primarily in the left ventricle, the left atrium and the coronary arteries due to chronic uncontrolled hypertension. Hypertensive heart disease is underreported and the mechanisms underlying its correlates and complications are not well elaborated. In this review, we summarize the current understanding of hypertensive heart disease, we discuss in detail the mechanisms associated with development and complications of hypertensive heart disease especially left ventricular hypertrophy, atrial fibrillation, heart failure and coronary artery disease. We also briefly highlight the role of dietary salt, immunity and genetic predisposition in hypertensive heart disease pathogenesis.

A recurrent neural network model predicts activated partial thromboplastin time after treatment with heparin: a retrospective study (Preprint)

Background

Anticoagulation therapy with heparin is a frequent treatment in intensive care units and is monitored by activated partial thromboplastin clotting time (aPTT). It has been demonstrated that reaching an established anticoagulation target within 24 hours is associated with favorable outcomes. However, patients respond to heparin differently and reaching the anticoagulation target can be challenging. Machine learning algorithms may potentially support clinicians with improved dosing recommendations.

Objective

This study evaluates a range of machine learning algorithms on their capability of predicting the patients’ response to heparin treatment. In this analysis, we apply, for the first time, a model that considers time series.

Methods

We extracted patient demographics, laboratory values, dialysis and extracorporeal membrane oxygenation treatments, and scores from the hospital information system. We predicted the numerical values of aPTT laboratory values 24 hours after continuous heparin infusion and evaluated 7 different machine learning models. The best-performing model was compared to recently published models on a classification task. We considered all data before and within the first 12 hours of continuous heparin infusion as features and predicted the aPTT value after 24 hours.

Results

The distribution of aPTT in our cohort of 5926 hospital admissions was highly skewed. Most patients showed aPTT values below 75 s, while some outliers showed much higher aPTT values. A recurrent neural network that consumes a time series of features showed the highest performance on the test set.

Conclusions

A recurrent neural network that uses time series of features instead of only static and aggregated features showed the highest performance in predicting aPTT after heparin treatment.

Atrial fibrillation, venous thromboembolism, ischemic stroke, and all-cause mortality: The Tromsø study

Background

Atrial fibrillation (AF) is associated with increased risk of ischemic stroke and all-cause mortality. Patients with AF are also at increased risk of venous thromboembolism (VTE), but information on how AF impacts VTE-related mortality is scarce.

Objectives

To investigate the impact of AF on all-cause mortality in subjects with and without a thromboembolic event (VTE or ischemic stroke).

Methods

We followed 29 833 participants from the Tromsø study (1994-2008) through 2013 and recorded all deaths during follow-up. Incident AF, VTE, and ischemic stroke were registered as time-dependent exposures. We calculated mortality rates (MRs) by exposure during follow-up and obtained hazard ratios (HRs) for death with 95% confidence intervals (CIs).

Results

A total of 2087 AF cases, 756 VTEs, and 1279 ischemic strokes were registered during a median follow-up of 18.7 years, and 4797 people (16.1%) died. The age-adjusted MR for participants without any event was 1.19 per 100 person-years (PY; 95% CI, 1.15-1.23). Compared to these participants, subjects with the joint AF + VTE exposure had a 3.7-fold increased risk of death (HR, 3.67; 95% CI, 2.77-4.66) in age- and sex-adjusted analyses, similar to the risk observed for VTE alone (HR, 3.76; 95% CI, 3.28-4.30). Participants with stroke had a 2.9-fold increased risk of death (HR, 2.85; 95% CI, 2.56-3.18), and the risk was further increased in participants with both AF and stroke (HR, 4.38; 95% CI, 3.85-4.98).

Conclusions

AF was significantly associated with increased risk of death in participants with incident stroke. In contrast, concomitant AF was not associated with excess mortality risk in VTE patients.