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Kondo T, Abdul-Rahim AH, Talebi A, Abraham WT, Desai AS, Dickstein K, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Packer M, Petrie M, Ponikowski P, Rouleau JL, Sabatine MS, Swedberg K, Zile MR, Solomon SD, Jhund PS, McMurray JJV. Predicting stroke in heart failure and reduced ejection fraction without atrial fibrillation. Eur Heart J 2022; 43:4469-4479. [PMID: 36017729 PMCID: PMC9637422 DOI: 10.1093/eurheartj/ehac487] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/18/2022] [Accepted: 08/25/2022] [Indexed: 12/14/2022] Open
Abstract
AIMS Patients with heart failure with reduced ejection fraction (HFrEF) are at significant risk of stroke. Anticoagulation reduces this risk in patients with and without atrial fibrillation (AF), but the risk-to-benefit balance in the latter group, overall, is not favourable. Identification of patients with HFrEF, without AF, at the highest risk of stroke may allow targeted and safer use of prophylactic anticoagulant therapy. METHODS AND RESULTS In a pooled patient-level cohort of the PARADIGM-HF, ATMOSPHERE, and DAPA-HF trials, a previously derived simple risk model for stroke, consisting of three variables (history of prior stroke, insulin-treated diabetes, and plasma N-terminal pro-B-type natriuretic peptide level), was validated. Of the 20 159 patients included, 12 751 patients did not have AF at baseline. Among patients without AF, 346 (2.7%) experienced a stroke over a median follow up of 2.0 years (rate 11.7 per 1000 patient-years). The risk for stroke increased with increasing risk score: fourth quintile hazard ratio (HR) 2.35 [95% confidence interval (CI) 1.60-3.45]; fifth quintile HR 3.73 (95% CI 2.58-5.38), with the first quintile as reference. For patients in the top quintile, the rate of stroke was 21.2 per 1000 patient-years, similar to participants with AF not receiving anticoagulation (20.1 per 1000 patient-years). Model discrimination was good with a C-index of 0.84 (0.75-0.91). CONCLUSION It is possible to identify a subset of HFrEF patients without AF with a stroke-risk equivalent to that of patients with AF who are not anticoagulated. In these patients, the risk-to-benefit balance might justify the use of prophylactic anticoagulation, but this hypothesis needs to be tested prospectively.
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Affiliation(s)
- Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Azmil H Abdul-Rahim
- Institute of Neuroscience and Psychology, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Atefeh Talebi
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, OH, USA
| | - Akshay S Desai
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Kenneth Dickstein
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| | - Lars Køber
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Mikhail N Kosiborod
- Department of Cardiovascular Disease, Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, USA
| | - Felipe A Martinez
- Universidad Nacional de Córdoba, International Society of Cardiovascular Pharmacotherapy, Córdoba, Argentina
| | - Milton Packer
- Cardiovascular Science, Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Mark Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Piotr Ponikowski
- Department of Heart Disease, Wroclaw Medical University, Wroclaw, Poland
| | - Jean L Rouleau
- Department of Medicine, Montréal Heart Institute, Université de Montréal, Montréal, Quebec, Canada
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael R Zile
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
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Ekestubbe S, Fu M, Giang KW, Lindgren M, Rosengren A, Schioler L, Schaufelberger M. Increasing home-time after a first diagnosis of heart failure in Sweden, 20 years trends. ESC Heart Fail 2022; 9:555-563. [PMID: 34837891 PMCID: PMC8788024 DOI: 10.1002/ehf2.13714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 10/22/2021] [Accepted: 10/31/2021] [Indexed: 11/11/2022] Open
Abstract
AIMS This study was performed to compare trends in home-time for patients with heart failure (HF) between those of working age and those of retirement age in Sweden from 1992 to 2012. METHODS AND RESULTS The National Inpatient Register (IPR) was used to identify all patients aged 18 to 84 years with a first hospitalization for HF in Sweden from 1992 to 2012. Information on date of death, comorbidities, and sociodemographic factors were collected from the Swedish National Register on Cause of Death, the IPR, and the longitudinal integration database for health insurance and labour market studies, respectively. The patients were divided into two groups according to their age: working age (<65 years) and retirement age (≥65 years). Follow-up was 4 years. In total, following exclusions, 388 775 patients aged 18 to 84 years who were alive 1 day after discharge from a first hospitalization for HF were included in the study. The working age group comprised 62 428 (16%) patients with a median age of 58 (interquartile range, 53-62) years and 31.2% women, and the retirement age group comprised 326 347 (84%) patients with a median age of 77 (interquartile range, 73-81) years and 47.4% women. Patients of working age had more home-time than patients of retirement age (83.8% vs. 68.2%, respectively), mainly because of their lower 4 year mortality rate (14.2% vs. 29.7%, respectively). Home-time increased over the study period for both age groups, but the increase levelled off for older women after 2007, most likely because of less reduction in mortality in older women than in the other groups. CONCLUSIONS This nationwide study showed increasing home-time over the study period except for women of retirement age and older for whom the increase stalled after 2007, mainly because of a lower mortality reduction in this group. Efforts to improve patient-related outcome measures specifically targeted to this group may be warranted.
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Affiliation(s)
- Sofia Ekestubbe
- Region Västra GötalandSahlgrenska University Hospital/ÖstraGothenburgSweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Michael Fu
- Region Västra GötalandSahlgrenska University Hospital/ÖstraGothenburgSweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Kok Wai Giang
- Region Västra GötalandSahlgrenska University Hospital/ÖstraGothenburgSweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Martin Lindgren
- Region Västra GötalandSahlgrenska University Hospital/ÖstraGothenburgSweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Annika Rosengren
- Region Västra GötalandSahlgrenska University Hospital/ÖstraGothenburgSweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Linus Schioler
- Section of Occupational and Environmental Medicine, Department of Public Health and Community Medicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Maria Schaufelberger
- Region Västra GötalandSahlgrenska University Hospital/ÖstraGothenburgSweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
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Werhahn SM, Becker C, Mende M, Haarmann H, Nolte K, Laufs U, Zeynalova S, Löffler M, Dagres N, Husser D, Dörr M, Gross S, Felix SB, Petersmann A, Herrmann-Lingen C, Binder L, Scherer M, Hasenfuß G, Pieske B, Edelmann F, Wachter R. NT-proBNP as a marker for atrial fibrillation and heart failure in four observational outpatient trials. ESC Heart Fail 2021; 9:100-109. [PMID: 34850596 PMCID: PMC8788004 DOI: 10.1002/ehf2.13703] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 10/10/2021] [Accepted: 10/29/2021] [Indexed: 01/04/2023] Open
Abstract
Aims Heart failure (HF) and atrial fibrillation (AF) frequently coexist and are both associated with increased levels of N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP). It is known that AF impairs the diagnostic accuracy of NT‐proBNP for HF. The aim of the present study was to compare the diagnostic and predictive accuracy of NT‐proBNP for HF and AF in stable outpatients with cardiovascular risk factors. Methods and results Data were obtained from the DIAST‐CHF trial, a prospective cohort study that recruited individuals with cardiovascular risk factors and followed them up for 12 years. Data were validated in three independent population‐based cohorts using the same inclusion/exclusion criteria: LIFE‐Adult (n = 2869), SHIP (n = 2013), and SHIP‐TREND (n = 2408). Serum levels of NT‐proBNP were taken once at baseline. The DIAST‐CHF study enrolled 1727 study participants (47.7% female, mean age 66.9 ± 8.1 years). At baseline, patients without AF or HF (n = 1375) had a median NT‐proBNP of 94 pg/mL (interquartile range 51;181). In patients with AF (n = 93), NT‐proBNP amounted to 667 (215;1130) pg/mL. It was significantly higher than in the first group (P < 0.001) and compared with those with only HF [n = 201; 158 (66;363) pg/mL; P < 0.001]. The highest levels of NT‐proBNP [868 (213;1397) pg/mL] were measured in patients with concomitant HF and AF (n = 58; P < 0.001 vs. control and vs. HF, P = 1.0 vs. AF). In patients with AF, NT‐proBNP levels did not differ between those with HF and preserved ejection fraction (EF) > 50% [n = 38; 603 (175;1070) pg/mL] and those without HF (P = 1.0). Receiver‐operating characteristic curves of NT‐proBNP showed a similar area under the curve (AUC) for the detection of AF at baseline (0.84, 95% CI [0.79–0.88]) and for HF with EF < 50% (0.78 [0.72–0.85]; P = 0.18). The AUC for HF with EF > 50% was significantly lower (0.61 [0.56–0.65]) than for AF (P = 0.001). During follow‐up, AF was newly diagnosed in 157 (9.1%) and HF in 141 (9.6%) study participants. NT‐proBNP was a better predictor of incident AF during the first 2 years (AUC: 0.79 [0.75–0.83]) than of newly diagnosed HF (0.59 [0.55–0.63]; P < 0.001). Data were validated in three independent population‐based cohorts (LIFE‐Adult, n = 2869; SHIP, n = 2013; and SHIP‐TREND, n = 2408). Conclusions In stable outpatients, NT‐proBNP is a better marker for prevalent and incident AF than for HF. In AF patients, the diagnostic value of NT‐proBNP for HF with EF > 50% is very limited.
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Affiliation(s)
- Stefanie M Werhahn
- Clinic for Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Christian Becker
- Clinic for Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Meinhard Mende
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University Hospital Leipzig, Leipzig, Germany
| | - Helge Haarmann
- Clinic for Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Kathleen Nolte
- Clinic for Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Ulrich Laufs
- Department of Cardiology, University Hospital, Leipzig University, Leipzig, Germany
| | - Samira Zeynalova
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University Hospital Leipzig, Leipzig, Germany.,LIFE Research Center for Civilization Diseases, Leipzig, Germany
| | - Markus Löffler
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University Hospital Leipzig, Leipzig, Germany.,LIFE Research Center for Civilization Diseases, Leipzig, Germany
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center, Leipzig, Germany
| | - Daniela Husser
- Department of Electrophysiology, Heart Center, Leipzig, Germany
| | - Marcus Dörr
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Greifswald, Greifswald, Germany
| | - Stefan Gross
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Greifswald, Greifswald, Germany
| | - Stephan B Felix
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Greifswald, Greifswald, Germany
| | - Astrid Petersmann
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Christoph Herrmann-Lingen
- German Centre for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany.,Department of Psychosomatic Medicine and Psychotherapy, University of Oldenburg Medical Centre, Oldenburg, Germany
| | - Lutz Binder
- German Centre for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany.,Institute for Clinical Chemistry/UMG-Laboratories, University Medical Center Göttingen, Göttingen, Germany
| | - Martin Scherer
- Department of Primary Medical Care, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Gerd Hasenfuß
- Clinic for Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Burkert Pieske
- Department of Cardiology, Charité University Medicine, Campus Virchow Klinikum, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany.,German Heart Center, Berlin, Germany
| | - Frank Edelmann
- Clinic for Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany.,Department of Cardiology, Charité University Medicine, Campus Virchow Klinikum, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Rolf Wachter
- Clinic for Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany.,Department of Cardiology, University Hospital, Leipzig University, Leipzig, Germany
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