Impact of gender on the prognosis of patients with nonvalvular atrial fibrillation

Sex-related differences in presentation, treatment, and outcomes of Asian patients with atrial fibrillation: a report from the prospective APHRS-AF Registry

We aimed to investigate the sex-related differences in the clinical course of patients with Atrial Fibrillation (AF) enrolled in the Asia-Pacific-Heart-Rhythm-Society Registry. Logistic regression was utilized to investigate the relationship between sex and oral anticoagulant, rhythm control strategies and the 1-year chance to maintain sinus rhythm. Cox-regression was utilized to assess the 1-year risk of all-cause, and cardiovascular death, thromboembolic events, acute coronary syndrome, heart failure, and major bleeding. In the whole cohort (4121 patients, 69 ± 12 years,34.3% female), females had different cardiovascular risk factors, clinical manifestations, and disease perceptions than men, with more advanced age (72 ± 11 vs 67 ± 12 years, p < 0.001) and dyslipidemia (36.7% vs 41.7%, p = 0.002). Coronary artery disease was more prevalent in males (21.1% vs 16.1%, p < 0.001) as well as the use of antiplatelet drugs. Females had a higher use of oral anticoagulant (84.9% vs 81.3%, p = 0.004) but this difference was non-significant after adjustment for confounders. On multivariable analyses, females were less often treated with rhythm control strategies (Odds Ratio [OR] 0.44,95% Confidence Interval [CI] 0.38-0.51) and were less likely to maintain sinus rhythm (OR 0.27, 95% CI 0.22-0.34) compared to males. Cox-regressions analysis showed no sex-related differences for the risk of death, cardiovascular, and bleeding. The clinical management of Asian AF patients should consider several sex-related differences.

Gender Differences in Atrial Fibrillation: From the Thromboembolic Risk to the Anticoagulant Treatment Response

Atrial fibrillation (AF) is the most common cardiac arrhythmia associated with an increased thromboembolic risk. The impact of the female sex as an independent risk factor for thromboembolic events in AF is still debated. Background and Objectives: The aim of this review is to evaluate the gender-related differences in cardioembolic risk and response to anticoagulants among AF patients. Materials and Methods: The PubMed database is used to review the reports about gender differences and thromboembolic risk in atrial fibrillation. Results: Non-vitamin K oral anticoagulants (NOACs) represent the gold standard for thromboembolic risk prevention in patients with non-valvular atrial fibrillation (NVAF). Despite a similar rate of stroke and systemic embolism (SE) among men and women in NOACs or vitamin K antagonists (VKAs) treatment, the use of NOACs in AF women is associated with a lower risk of intracranial bleeding, major bleeding, and all-cause mortality than in men. Conclusions: The female sex can be defined as a stroke risk modifier rather than a stroke risk factor since it mainly increases the thromboembolic risk in the presence of other risk factors. Further studies about the efficacy and safety profile of NOACs according to sex are needed to support clinicians in performing the most appropriate and tailored anticoagulant therapy, either in male or female AF patients.

Validation of the CHA2DS2-VA Score (Excluding Female Sex) in Nonvalvular Atrial Fibrillation Patients: A Nationwide Population-Based Study

Sex (i.e., female sex) confers one point for the CHA2DS2-VASc score. For this reason, females with atrial fibrillation (AF) always have a CHA2DS2-VASc score of at least 1. To compare the CHA2DS2-VA (excluding female sex) and CHA2DS2-VASc scores in Korean AF patients using the Korean National Health Insurance Service database, we analyzed the risk of ischemic stroke in nonvalvular AF patients between 2013 and 2017. The predictive values of the CHA2DS2-VA and CHA2DS2-VASc scores for ischemic stroke were evaluated using the C-statistic and net reclassification improvement (NRI). The primary outcome was the occurrence of ischemic stroke. A total of 185,637 patients with AF (49.7% women) were included in this study. The mean ages were 66.5 years for females and 64.9 years for males. The incidence of ischemic stroke in male patients was similar to females (3.63%/year vs. 3.72%/year, p = 0.273, respectively). In addition, no sex difference was apparent for stroke risk in AF patients stratified by risk factor component and age group. In the C-statistic analysis, the predictive ability of the CHA2DS2-VA score for ischemic stroke was similar to the CHA2DS2-VASc score. Additionally, CHA2DS2-VA performed better for predicting ischemic stroke in AF patients with risk scores of ≥2 (AUC 0.701 vs. 0.689, z = 4.596, p < 0.001) or those aged ≥75 years (AUC 0.715 vs. 0.701, z = 4.957, p < 0.001). In Korean AF patients, female sex is not a specific risk factor that contributes to the development of ischemic stroke. The CHA2DS2-VA score, which excludes female sex, may be a more suitable risk score for guiding anticoagulation decisions in Korean AF patients.

Impact of preexisting diabetes mellitus on cardiovascular and all-cause mortality in patients with atrial fibrillation: A meta-analysis

OBJECTIVE

To determine the impact of preexisting diabetes mellitus on cardiovascular and all-cause mortality in patients with atrial fibrillation (AF) by conducting a meta-analysis.

METHODS

PubMed and Embase databases were comprehensively searched for relevant studies publishing until May 19, 2022. Cohort studies or post-hoc analyses of clinical trials that investigated the association of diabetes mellitus with cardiovascular or all-cause mortality in AF patients were included.

RESULTS

A total of 21 studies with 526,136 AF patients were identified. The pooled prevalence of diabetes mellitus in patients with AF was 26%. The summary multivariable-adjusted risk ratio (RR) of all-cause mortality was 1.37 (95% confidence intervals [CIs] 1.23-1.53) for patients with diabetes versus those without diabetes. Moreover, diabetes mellitus was also associated with an increased risk of cardiovascular mortality (RR 1.46; 95% CI 1.34-1.58). Stratified analyses suggested that the impact of diabetes on all-cause and cardiovascular mortality was consistently observed in each named subgroup.

CONCLUSION

The presence of diabetes mellitus in patients with AF is associated with an increased risk of cardiovascular and all-cause mortality, even after adjustment for important confounding factors.

The burden of undertreatment and non-treatment among patients with non-valvular atrial fibrillation and elevated stroke risk: a systematic review

OBJECTIVE

Global treatment guidelines recommend treatment with oral anticoagulants (OACs) for patients with non-valvular atrial fibrillation (NVAF) and an elevated stroke risk. However, not all patients with NVAF and an elevated stroke risk receive guideline-recommended therapy. A literature review and synthesis of observational studies were undertaken to identify the body of evidence on untreated and undertreated NVAF and the association with clinical and economic outcomes.

METHODS

An extensive search (1/2010-4/2020) of MEDLINE, the Cochrane Library, conference proceedings, and health technology assessments (HTAs) was conducted. Studies must have evaluated rates of nontreatment or undertreatment in NVAF. Nontreatment was defined as absence of OACs (but with possible antiplatelet treatment), while undertreatment was defined as treatment with only antiplatelet agents.

RESULTS

Sixteen studies met our inclusion criteria. Rates of nontreatment for patients with elevated stroke risk ranged from 2.0-51.1%, while rates of undertreatment ranged from 10.0-45.1%. The clinical benefits of anticoagulation were reported in the evaluated studies with reductions in stroke and mortality outcomes observed among patients treated with anticoagulants compared to untreated or undertreated patients. Adverse events associated with all bleeding types (i.e. hemorrhagic stroke, major bleeding or gastrointestinal hemorrhaging) were found to be higher for warfarin patients compared to untreated patients in real-world practice. Healthcare resource utilization was found to be lower among patients highly-adherent to warfarin compared to untreated patients.

CONCLUSIONS

Rates of nontreatment and undertreatment among NVAF patients remain high and are associated with preventable cardiovascular events and death. Strategies to increase rates of treatment may improve clinical outcomes.

Does atrial fibrillation ablation worsen preexisting anemia? Another anemia paradox in DOAC era

BACKGROUND

There is a concern about worsening anemia after atrial fibrillation (AF) ablation in anemic patients. We aimed to clarify whether or not patients with anemia who are on an oral anticoagulant therapy are more likely to lose blood after AF ablation.

METHODS

We studied AF patients in 3 cardiovascular centers who skipped a single dose of a direct oral anticoagulant prior to the ablation, and compared the drop in the hemoglobin level 24 hours after the procedure and bleeding complications between the patients with and without preexisting anemia.

RESULTS

We identified 183 (15.7%) patients with anemia at baseline out of 1163 patients. The reduction in the hemoglobin level (-0.39±0.71 vs. -0.93±0.9 g/dL; p<0.001) was smaller in the anemic than non-anemic patients. A fall in the hemoglobin level of ≥2 g/dL, which is a guideline-defined significant hemoglobin drop, was less common in anemic patients (1.6% vs. 11.3%; p<0.001). A female gender [odds ratio (OR) 1.62, confidence interval (CI) 1.07-2.45; p=0.02], persistent or long-standing persistent versus paroxysmal AF (OR 1.67, CI 1.13-2.49; p=0.01), ORBIT score ≥3 (OR 3.5, CI 1.34-8.94; p=0.01), and preexisting anemia (OR 0.02, CI 0.004-0.14; p<0.001) were independently associated with the fall in the hemoglobin level of ≥2 g/dL. No difference was noted in the rate of major bleeding complications (1.6% vs. 1.2%; p=0.72).

CONCLUSIONS

Paradoxically, patients with preexisting anemia may be less likely to lose blood following AF ablation.

Atrial fibrillation and stroke prevention: state of the art-epidemiology and pathophysiology: new risk factors, concepts and controversies

Atrial fibrillation (AF) increases the risk of thromboembolism, and risk assessment for thromboembolism is necessary for the management of AF patients. CHADS2 and CHA2DS2-VASc scores have been adopted in international guidelines for AF management, but the significance of each risk factor included in these risk scores are sometimes controversial, and the performance of these scores is only modest. There are several other risk factors not included in the scores such as renal dysfunction, low body weight, type of AF (paroxysmal or non-paroxysmal) as well as echocardiographic parameters and blood biomarkers, and physicians should assess patients risk in an integrated manner.

Influence of sex on long-term prognosis in patients with atrial fibrillation treated with oral anticoagulants. Results from the prospective, nationwide FANTASIIA study

BACKGROUND

While many risk factors for Atrial Fibrillation (AF) have been identified, there are important differences in their relative impact between sexes. The aim of our study was to investigate the influence of sex as a long-term predictor of adverse events in "real world" AF patients treated with direct oral anticoagulants.

METHODS

The FANTASIIA registry is a prospective, national and multicentric study including outpatients with anticoagulated AF patients. Baseline characteristics and adverse events at 3 years of follow-up were collected and classified by sex. Cox multivariate analysis was performed to investigate the role of sex in major events and composite outcomes.

RESULTS

A total of 1956 patients were included in the study. 43.9% of them were women, with a mean age of 73.8 ± 9.4 years (women were older 76.5 ± 7.9 vs 71.7 ± 10.1, p<0.001). Women had higher rate of cardiovascular risk factors and higher mean of CHA₂DS₂-VASc (4.4 ± 1.4 vs 3.7 ± 1.6, p<0.001) and HAS-BLED (2.1 ± 1.0 vs 1.9 ± 1.1, p<0.001) than men. After 3 years of follow-up, rates of major events were similar in both groups with limit difference for all-cause mortality (4.4%/year in women vs 5.6%/year in men; p = 0.056). However, all the composite events were more frequent in women. We observed in the non-adjusted adverse events lower rate of all-cause mortality (HR 0.62, 95%CI 0.47-0.81; p<0.001), composite 1 outcomes (HR 0.80, 95%CI 0.65-0.98; p = 0.029) and composite 2 (HR 0.77, 95%CI 0.64-0.94; p = 0.010) in women compared with men. In multivariate Cox regression analysis observed that female sex was an independently protector factor for all-cause mortality and for the composite outcomes 1 and 2.

CONCLUSIONS

In this "real world" study of anticoagulated AF patients, women could have a protective role against development of adverse events, mainly on all-cause mortality and combined events.

Sex-related differences in prevalence, treatment and outcomes in patients with atrial fibrillation

To analyze sex-related differences about AF prevalence, use of OAC and outcomes focusing on the older age classes. We used administrative data of the Lombardy Region, describing period prevalence, use of OAC and outcomes from 2002 to 2014 for all patients diagnosed with AF. AF prevalence over the 2002-2014 period was higher in males than in females (2.7% vs. 2.1%, p < 0.001), increasing with age. From 2003 to 2014, not treated AF patients decreased mostly in males (from 40.3 to 33.7% with respect to 43.7-39.8% in females). Age-stratified adjusted logistic regression analysis found that females were more likely treated with OAC when < 65 years in 2003 (OR 1.51, 95% CI 1.35-1.69) and in 2014 (OR 1.32, 95% CI 1.13-1.53); contrariwise, were less likely treated with OAC when age ≥ 75 years, in 2003 (OR 0.92, 95% CI 0.86-0.98) and in 2014 (OR 0.77, 95% CI 0.72-0.81).Adjusted Cox regression analysis confirmed that female AF patients had a higher risk of stroke (HR 1.18, 95% CI 1.14-1.21) and a lower risk of major bleeding (HR 0.83, 95% CI 0.80-0.86), while, had a lower risk for all-cause death (HR 0.82, 95% CI 0.80-0.83). AF prevalence was higher in male than in female patients, while thromboembolic risk was higher in female. Older female patients were under-treated with OAC particularly in recent years. Over long-term follow-up, female had a higher risk of stroke and a lower risk of major bleeding and all-cause death.

Gender Differences in Arrhythmias: Focused on Atrial Fibrillation

There are significant differences in clinical presentation and treatment of atrial fibrillation (AF) between women and men. The primary goal of AF management is to restore sinus rhythm and to prevent various complications, including stroke and heart failure. In many areas of AF, such as prevalence, clinical manifestations, morbidity, risk factors, pathophysiology, treatment strategies, and complications, gender-specific variability is observed and needs to be further addressed by large-scale population researches or randomized clinical trials, which help to promote the customization of AF treatment programs, hence to maximize the success rate of AF therapy in both sexes. This review highlights our current understanding of these gender differences in AF and how these differences affect treatment decisions on AF.

WITHDRAWN: Effectiveness and safety of long-term dabigatran among patients with non-valvular atrial fibrillation in clinical practice: J-Dabigatran Surveillance

The Publisher regrets that this article is an accidental duplication of an article that has already been published in Journal of Cardiology, 73/6 (2018) 507–514, https://doi.org/10.1016/j.jjcc.2018.12.013. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal

Predictive value of CHA2DS2-VASc scores regarding the risk of stroke and all-cause mortality in patients with atrial fibrillation (CONSORT compliant)

BACKGROUND

Patients with atrial fibrillation (AF) have a higher risk of fatal complications (e.g., stroke). This investigation was performed as an observational retrospective cohort study includes 137 patients (age 61 ± 15; 34.3% women) with a primary diagnosis of AF (paroxysmal, persistent, and permanent).

METHODS

We collected information about the drug therapy, comorbidities and survival of AF patients and determined their congestive heart failure, hypertension, age, diabetes mellitus, prior stroke or TIA or thromboembolism, vascular disease, age, sex category (CHA2DS2-VASc) scores. Statistical analysis identified patients with high CHA2DS2-VASc scores and defined the predictive value of individual parameters, or their combination, with regards to the outcomes of stroke and mortality.

RESULTS

CHA2DS2-VASc scores identified 43.8% of the patients as low to intermediate risk (score 0-1) and 56.2% of the patients as high risk (score ≥2). Increasing CHA2DS2-VASc scores were not only accompanied by an increase in the incidence of stroke (Ptrend < .001) but also by an increase in the 3 to 5 years mortality (P = .005). Comparison of anticoagulation and anti-aggregation treatment between the 3 groups of AF did not show any significant statistical difference. Highly significant predictors of death were the CHA2DS2-VASc score (OR 1.71, 95% CI 1.10-2.67, P < .017) as well as other risk factors not included in the CHA2DS2-VASc score such as valvular heart disease (OR 5.04, 95% CI 1.10-23.10, P = .037), hyperlipidemia (OR 4.82, 95% CI 1.03-22.63, P = .046) and chronic renal failure (OR 14.21, 95% CI 2.41-83.91, P = .003). The type of AF type did not affect survival (P = .158) nor the incidence of stroke (P = .466). Patients with paroxysmal AF were linked to significantly lower frequencies of ischemic heart disease (P < .0001), vascular disease (P = .002), diabetes mellitus (P = .047), valvular heart disease (P = .03) and heart failure/left ventricular dysfunction (P = .015).

CONCLUSION

The CHA2DS2-VASc score correctly predicted the patients at high-risk for 3 to 5 years mortality and confirmed its significant predictive value in the patients with AF.

Association of taller stature with lower cardiovascular disease mortality in Asian people: a systematic review

Background

Adult height can serve as a disease marker. While taller stature has been reported to be linked to a decreased risk of cardiovascular disease (CVD), an influence of the height on CVD is not fully understood in specific populations of Asia, which has a lower incidence of CVD and lower stature than Western populations.

Methods

We conducted a systematic review using original articles of prospective cohort studies published in English, via the PubMed database, on the relationship between the height and mortality of CVD, including cerebrovascular disease, in Asian people.

Results

We selected four studies on heart/coronary disease and five studies on cerebrovascular disease. Regarding heart/coronary disease, two studies showed that taller stature was associated with a decreased mortality of heart disease in men or cardiovascular disease in women. The hazard ratios of other studies had not shown a clear significance but a decreased direction of taller stature to the mortality. Regarding cerebrovascular disease, most studies showed that taller stature was associated with a decreased mortality of total cerebrovascular diseases or stroke. In two studies, taller stature showed a decreased mortality of ischemic or hemorrhagic stroke.

Conclusions

Overall, adult height may be inversely predictive to the mortality of CVD, in particular cerebrovascular disease, in Asian people. While this seems to be a similar trend to that of Westerns, further studies are warranted.

Characteristics of Japanese Patients with Nonvalvular Atrial Fibrillation on Anticoagulant Treatment: A Descriptive Analysis of J-dabigatran Surveillance and JAPAF Study

INTRODUCTION

Following approval of dabigatran and other antithrombotics in Japan, few studies have specifically evaluated the clinical characteristics of patients prescribed these antithrombotics for nonvalvular atrial fibrillation (NVAF) in real-world practice.

METHODS

We conducted a descriptive analysis of data from two real-world studies [J-dabigatran surveillance and Japanese study on current Anticoagulation therapies for Patients with nonvalvular Atrial Fibrillation (JAPAF); conducted at sites common to both studies] to determine the characteristics of patients with NVAF initiated on dabigatran etexilate [110 mg twice daily (BID; DE110) or 150 mg BID (DE150)], warfarin, rivaroxaban, or antiplatelets as their first antithrombotic treatment. Inferential statistical analyses were not performed, and no statistical hypothesis was tested.

RESULTS

Data for 1270 and 3011 eligible patients from the J-dabigatran surveillance (DE110, 976; DE150, 273) and JAPAF study (warfarin, 82.5%; rivaroxaban, 10.3%; antiplatelets, 21%), respectively, were extracted. In the J-dabigatran surveillance, 31.8% (full cohort, 28.1%) of patients had been switched from warfarin to dabigatran. Among patients prescribed DE110/DE150, 41.4%/57.5% and 41.5%/18.7% of patients had low-to-intermediate risk for ischemic stroke (CHADS₂ score of 0 or 1) and high risk for bleeding (HAS-BLED score ≥ 3), respectively. Similarly, 33.7%/41.3%/40.2% and 48.7%/42.6%/75.7% of patients taking warfarin/rivaroxaban/antiplatelets had a CHADS₂ score of 0 or 1 and HAS-BLED score ≥ 3, respectively. Dabigatran was favored in patients with creatinine clearance > 50 ml/min.

CONCLUSIONS

In Japan, physicians who attempt stroke prevention in patients with atrial fibrillation choose appropriate anticoagulant treatment, taking into consideration the individual patient backgrounds as well as the features of each antithrombotic agent.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier, NCT01491178 and University Hospital Medical Information Network (UMIN) Clinical Trial Registry Identifier, UMIN000009644.

FUNDING

Nippon Boehringer Ingelheim Co., Ltd. Plain language summary available for this article.

Effectiveness and safety of long-term dabigatran among patients with non-valvular atrial fibrillation in clinical practice: J-dabigatran surveillance

BACKGROUND

The effectiveness and safety of dabigatran etexilate (DE) have not been elucidated thoroughly in clinical practice for Japanese patients with non-valvular atrial fibrillation (NVAF). In particular, those of DE at a reduced dose due to dose reduction recommendations (DRR) remain unknown.

METHODS

NVAF patients who had newly initiated DE treatment for prevention of thromboembolic events between December 2011 and November 2013 were enrolled. They were followed until August 2016. Outcome events included thromboembolism, major bleeding, and all-cause death.

RESULTS

The study group consisted of 6443 patients (mean age, 70.9 years; male, 66.9%; and mean CHADS₂ score, 1.8). During a follow-up period of 610 days (median), stroke, transient ischemic attack (TIA), and systemic embolism (SE) occurred at 1.4%/year for DE 110mg twice daily (BID) (DE220, n=4759) and 0.8% for dabigatran 150mg BID (DE300, n=1571, unadjusted p=0.0317). Major bleeding occurred at 1.3 and 0.6%/year for DE220 and DE300, respectively (unadjusted p=0.0097). All-cause death occurred at 1.5 and 0.5%/year for DE220 and DE300, respectively (unadjusted p=0.0005). When patients were divided into four groups based on DRR and DE doses (DE300 groups meeting and not meeting DRR, and DE220 groups meeting and not meeting DRR), incidence rates of stroke/TIA/SE and major bleeding differed among the four groups (unadjusted p=0.0026 and 0.0194 for trend, respectively); DE220 group meeting DRR had the highest rates (1.7% and 1.4%/year, respectively). However, in multivariate analysis, no differences between doses were observed regarding any outcomes.

CONCLUSIONS

The present results are indicative of the favorable benefit-risk profile of dabigatran in Japanese clinical practice. Dabigatran dose was not independently associated with thromboembolic and bleeding events in Japanese NVAF patients.

Validation of Conventional Thromboembolic Risk Factors in a Korean Atrial Fibrillation Population - Suggestion for a Novel Scoring System, CHA2DS2-VAK

BACKGROUND

There is little evidence that focuses on the ethnic variability of clinical risk factors for thromboembolism (TE) in atrial fibrillation (AF). We aimed to investigate the effect of each traditional risk factor in the Korean AF population. Methods and Results: Medical records of 12,876 consecutive patients (aged >18 years) newly diagnosed and followed up with non-valvular AF from 2000 to 2013 were reviewed. TE events, including ischemic stroke and systemic embolism, were investigated for risk factor validation. Among the total of 12,876 patients, 1,390 (10.8%) had TE events. In univariate/multivariate analysis adjusting for clinical factors and antithrombotic medications, traditional risk factors included in the CHA₂DS₂-VASc scheme showed statistical significance, except for female sex, which was not a predictor of events. Additionally, chronic kidney disease (CKD; hazard ratio 1.62, P<0.001) was shown to be an independent predictor of TE events. Based on the analysis, we developed a novel stratification system, CHA₂DS₂-VAK, omitting the female sex category and adding CKD. The new scoring system showed greater discrimination in event rates between score 0 and 1 patients.

CONCLUSIONS

Female sex was not associated with TE events in a Korean non-valvular AF population. The novel CHA₂DS₂-VAK scoring system, with substitution of CKD for female sex, might be more appropriate for the Korean population.

Female Sex as a Risk Factor for Ischemic Stroke and Systemic Embolism in Chinese Patients With Atrial Fibrillation: A Report From the China-AF Study

Background Previous studies have provided conflicting results as to whether women are at higher risk than men for thromboembolism in the setting of atrial fibrillation ( AF ). We investigated whether women with AF were at higher risk of ischemic stroke in the China-AF (China Atrial Fibrillation Registry) Study. Methods and Results A total of 19 515 patients were prospectively enrolled between August 2011 and December 2016 in the China- AF Study. After exclusion of patients receiving anticoagulation or ablation therapy, 6239 patients (2574 women) with results from at least 6 months of follow-up were used for the analysis. Cox proportional hazards models were performed to evaluate whether female sex was an independent risk factor for thromboembolism after multivariate adjustment. The primary outcome was the time to the first occurrence of ischemic stroke or systemic embolism. After a mean follow-up of 2.81±1.46 years, 152 female patients reached the primary outcome, as compared with 172 male patients. Crude incidence rates of thromboembolism between women and men were of borderline statistical significance (2.08 versus 1.68 per 100 patient-years, P=0.058). After multivariable analysis, female sex was not independently associated with an increased thromboembolism risk (hazard ratio 1.09, 95% confidence interval 0.86-1.39). There was no significant difference in thromboembolism risk by sex stratified by age and presence or absence of risk factors ( P for interaction all >0.1). Conclusions Although crude incidence rates of thromboembolism were higher in Chinese female patients with AF compared with male patients, female sex did not emerge as an independent risk factor for thromboembolism on multivariate analysis. Clinical Trial Registration URL : http://www.chictr.org.cn/ . Unique identifier: Chi CTR - OCH -13003729.

Time in Therapeutic Range and Disease Outcomes in Elderly Japanese Patients With Nonvalvular Atrial Fibrillation

BACKGROUND

The relationship between warfarin treatment quality and prognosis for Japanese patients with nonvalvular atrial fibrillation (NVAF) has not been studied thoroughly. Methods and Results: Data from the J-RHYTHM Registry were used to determine the time in therapeutic range (TTR) of the international normalized ratio (INR) of prothrombin time in elderly patients (≥70 years). Target INR was 1.6-2.6. Of 7,406 patients with NVAF in the database, 3,832 elderly patients (mean [±SD] age 77.0±5.0 years) constituted the study group. Of these patients, 459 did not receive warfarin and 3,373 received warfarin. Patients on warfarin were subdivided into 4 TTR groups: <40%, 40-59.9%, 60-79.9%, and ≥80%. During the 2-year follow-up, the incidence of thromboembolism and all-cause death was lower in patients with higher TTR (Ptrend<0.001); however, the incidence of major hemorrhage was higher in patients with TTR <40%. In multivariate analysis, compared with the no-warfarin group, TTR 60-79.9% and ≥80% were associated with lower thromboembolic risk, with hazard ratios (HR) of 0.34 (95% confidence interval [CI] 0.17-0.67; P=0.002) and 0.35 (95% CI 0.18-0.68; P=0.002), respectively, and lower all-cause death (HR 0.37 [95% CI 0.22-0.65; P<0.001] and 0.43 [95% CI 0.26-0.71; P=0.001], respectively). TTR <40% was associated with major hemorrhage (HR 5.57; 95% CI 2.04-15.25; P=0.001).

CONCLUSIONS

In elderly Japanese patients with NVAF, TTR should be maintained ≥60% to prevent thromboembolism and all-cause death. TTR <40% should be avoided to prevent major hemorrhage.

Sex differences in stroke and major adverse clinical events in patients with atrial fibrillation: A systematic review and meta-analysis of 993,600 patients

BACKGROUND

Atrial fibrillation (AF) is the most commonly diagnosed arrhythmia, which is associated with an increased risk of stroke. Several studies have suggested that female AF patients could have a greater risk for stroke and thromboembolic events (TE).

METHODS

A systematic literature review update and meta-analysis was conducted using Pubmed. The search used the terms "atrial fibrillation", "gender", "sex", "female", "women", "stroke", "thromboembolism". Main aim of the study was to compare and male AF patients for occurrence of stroke and TE. Secondary outcomes were: major bleeding, cardiovascular (CV) death and all-cause death.

RESULTS

Forty-four studies were included in the analysis including 993,603 patients (48.9% women). After pooling the data, there was a higher risk of stroke for women vs. male AF patients (hazard ratio [HR]: 1.24; 95% confidence intervals [CIs]: 1.14-1.36). Overall, TE risk was not different between female and male patients, despite sensitivity analysis left some uncertainties. No sex differences were found for major bleeding, CV death and all-cause death. A significant relationship between increasing age and the difference in stroke risk between female and male AF patients was found (Delta HR: 1.01; 95% CI: 1.00-1.03 for each year of age increase).

CONCLUSIONS

Female patients with AF are at increased risk of stroke compared to men. A significant relationship between increasing age and stroke risk in women compared to men was found, most evident at age > 65 years. Female sex may act as a stroke risk modifier, particularly in elderly and very elderly AF subjects, conferring a significant increase in stroke risk.

Should atrial fibrillation patients with hypertension as an additional risk factor of the CHA2DS2-VASc score receive oral anticoagulation?

Hypertension has been found to be increased a risk of stroke in atrial fibrillation (AF). Both the European and U.S. guidelines advocate the use of the CHA₂DS₂-VASc (congestive heart failure, hypertension, age > 75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65-74 years, sex category) scheme for risk stratification. Although vitamin K antagonists is more effective than acetylsalicylic acid at preventing ischaemic stroke, its benefit is offs by an increased haemorrhage risk. The risk of ischemic stroke in patients with AF and a CHA₂DS₂-VASc score of 1 are considered to be low risk and may be not expected to benefit from anticoagulation therapy. Hypertension carries an increased risk of ischemic stroke, however, it is also a clear risk factor for hemorrhage in AF. Therefore, the optimal antithrombotic management is highlighted in patients with AF with only one risk factor especially hypertension.

Sex-Related Differences in the Clinical Events of Patients With Atrial Fibrillation - The Fushimi AF Registry

BACKGROUND

Female sex is considered a risk factor for thromboembolism in patients with atrial fibrillation (AF), and is included in the risk stratification scheme, CHA₂DS₂-VASc score. The purpose of the present study was to investigate the clinical outcomes of female Japanese AF patients.Methods and Results:The Fushimi AF Registry is a community-based prospective survey of the AF patients in Fushimi-ku, Kyoto. Follow-up data were available for 3,878 patients. Female AF patients (n=1,551, 40.0%) were older (77.0 vs. 71.4 years; P<0.001) than male patients (n=2,327, 60.0%). Female patients were more likely to have heart failure (31.1% vs. 23.7%; P<0.001). Previous stroke incidence (19.2% vs. 21.4%; P=0.083) was comparable between male and female patients. During the median follow-up period of 1,102 days, Cox regression analysis demonstrated that female sex was not independently associated with a risk of stroke or systemic embolism (adjusted hazard ratio [HR] 0.74; 95% confidence interval [CI]: 0.54-1.00, P=0.051). However, female sex showed an association with a lower risk of intracranial hemorrhage (adjusted HR 0.54; 95% CI: 0.30-0.95, P=0.032) and all-cause death (adjusted HR 0.56; 95% CI: 0.46-0.68, P<0.001).

CONCLUSIONS

We demonstrated that female sex is not independently associated with an increased risk of thromboembolism, but is associated with a decreased risk of intracranial hemorrhage and all-cause death in Japanese AF patients enrolled in the Fushimi AF Registry.

Chronic kidney disease is independently associated with acute recurrent cerebral infarct in patients with atrial fibrillation

BACKGROUND AND PURPOSE

The present study aimed to determine the frequency and time of recurrent cerebral infarct (RCI) in patients with acute ischemic stroke (AIS) and atrial fibrillation (AF), and to clarify associated factors.

METHODS

We retrospectively assessed and compared the clinical features of 79 consecutive patients (male, n=56; median age, 75y; median baseline NIHSS, 4) who were hospitalized due to AIS accompanied by AF, and who did or did not develop RCI between January 2012 and March 2015.

RESULTS

Direct oral anticoagulants were administered to 59% of the patients after a median of two days from the onset of the index stroke. Stroke recurred in 10 (13%) of the 79 patients about 5days after admission. The proportion of men was lower (30% vs. 77%, P=0.005) and the patients were older (82vs. 75y, P=0.049) in the group with RCI. Chronic kidney disease was significantly more prevalent in the group with RCI (50% vs. 16%, P=0.025) and independently associated with RCI (OR, 6.59; 95%CI, 1.19-36.63; P=0.031).

CONCLUSIONS

We found that RCI frequently develops about 5days after admission in patients with AIS and AF and that chronic kidney disease is independently associated with RCI.

Safety and efficacy of contemporary catheter ablation for atrial fibrillation patients with a history of cardioembolic stroke in the era of direct oral anticoagulants

BACKGROUND

The safety and efficacy of the contemporary atrial fibrillation (AF) ablation in patients with a recent or previous history of cardioembolic stroke (CS) or transient ischemic attack (TIA) remain to be established.

METHODS

A total of 447 patients who underwent first-ever contact force (CF)-guided AF ablation with circumferential pulmonary vein isolation were included. Of these, 17 had CS or TIA within 6 months before ablation (Group 1), 30 more than 6 months before ablation (Group 2), and the other 400 without CS or TIA (Group 3). Procedural complications and recurrence of AF and atrial tachyarrhythmias were compared among the 3 groups.

RESULTS

The mean age was 71±7, 66±9, and 61±11 years in Groups 1, 2, and 3, respectively (p<0.05, Group 1 versus Group 3). The oral anticoagulants were warfarin (n=108, 24.1%), dabigatran (n=101, 22.6%), rivaroxaban (n=147, 32.9%), apixaban (n=87, 19.5%), and edoxaban (n=4, 0.9%), and did not differ among the 3 groups. Median follow-up period was 14 [IQR 12-22], 13 [12-14], and 12 [10-16] months, respectively. One episode of cardiac tamponade, 2 episodes of arteriovenous fistula, and some minor complications occurred in Group 3, but no complications occurred in Groups 1 and 2 in the periprocedural period. Although one episode of CS occurred 11 days after the procedure in Group 3, there were no periprocedural CS, TIA, or major bleedings in Groups 1 and 2. AF recurrence-free rate after the procedure was 76.5%, 86.7%, and 79.1% in Groups 1, 2, and 3, respectively, and there was no difference in Kaplan-Meier curves among the 3 groups.

CONCLUSION

The safety and efficacy of CF-guided AF ablation in the era of direct oral anticoagulants in patients with a recent or previous history of CS or TIA are similar to those in patients without it.

Higher Risk of Ischemic Events in Secondary Prevention for Patients With Persistent Than Those With Paroxysmal Atrial Fibrillation

Background and Purpose—

The discrimination between paroxysmal and sustained (persistent or permanent) atrial fibrillation (AF) has not been considered in the approach to secondary stroke prevention. We aimed to assess the differences in clinical outcomes between mostly anticoagulated patients with sustained and paroxysmal AF who had previous ischemic stroke or transient ischemic attack.

Methods—

Using data from 1192 nonvalvular AF patients with acute ischemic stroke or transient ischemic attack who were registered in the SAMURAI-NVAF study (Stroke Management With Urgent Risk-Factor Assessment and Improvement-Nonvalvular AF; a prospective, multicenter, observational study), we divided patients into those with paroxysmal AF and those with sustained AF. We compared clinical outcomes between the 2 groups.

Results—

The median follow-up period was 1.8 (interquartile range, 0.93–2.0) years. Of the 1192 patients, 758 (336 women; 77.9±9.9 years old) and 434 (191 women; 77.3±10.0 years old) were assigned to the sustained AF group and paroxysmal AF groups, respectively. After adjusting for sex, age, previous anticoagulation, and initial National Institutes of Health Stroke Scale score, sustained AF was negatively associated with 3-month independence (multivariable-adjusted odds ratio, 0.61; 95% confidence interval, 0.43–0.87; P =0.006). The annual rate of stroke or systemic embolism was 8.3 and 4.6 per 100 person-years, respectively (multivariable-adjusted hazard ratio, 1.95; 95% confidence interval, 1.26–3.14) and that of major bleeding events was 3.4 and 3.1, respectively (hazard ratio, 1.13; 95% confidence interval, 0.63–2.08).

Conclusions—

Among patients with previous ischemic stroke or transient ischemic attack, those with sustained AF had a higher risk of stroke or systemic embolism compared with those with paroxysmal AF.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01581502.

Impact of Blood Pressure Control on Thromboembolism and Major Hemorrhage in Patients With Nonvalvular Atrial Fibrillation: A Subanalysis of the J-RHYTHM Registry

Background

To clarify the influence of hypertension and blood pressure (BP) control on thromboembolism and major hemorrhage in patients with nonvalvular atrial fibrillation, a post hoc analysis of the J‐RHYTHM Registry was performed.

Methods and Results

A consecutive series of outpatients with atrial fibrillation was enrolled from 158 institutions. Of 7937 patients, 7406 with nonvalvular atrial fibrillation (70.8% men, 69.8±10.0 years) were followed for 2 years or until an event occurred. Hypertension was defined as a systolic BP ≥140 mm Hg, a diastolic BP ≥90 mm Hg, a history of hypertension, and/or antihypertensive drug use. Hypertension was an independent risk factor for major hemorrhage (hazard ratio 1.52, 95% CI 1.05–2.21, P=0.027) but not for thromboembolism (hazard ratio 1.05, 95% CI 0.73–1.52, P=0.787). When patients were divided into quartiles according to their systolic BP at the time closest to the event or at the end of follow‐up (Q1, <114; Q2, 114–125; Q3, 126–135; and Q4, ≥136 mm Hg), odds ratios for both events were significantly higher in Q4 than in Q1 (thromboembolism, odds ratio 2.88, 95% CI 1.75–4.74, P<0.001; major hemorrhage, odds ratio 1.61, 95% CI 1.02–2.53, P=0.041) after adjustment for components of CHA₂DS₂‐VASc score, warfarin use, and antiplatelet use. A systolic BP of ≥136 mm Hg was an independent risk factor for thromboembolism and major hemorrhage.

Conclusions

BP control appears to be more important than a history of hypertension and baseline BP values at preventing thromboembolism and major hemorrhage in patients with nonvalvular atrial fibrillation.

Clinical Trial Registration

URL: http://www.umin.ac.jp/ctr. Unique identifier: UMIN000001569.

Regional Differences in Frequency of Warfarin Therapy and Thromboembolism in Japanese Patients With Non-Valvular Atrial Fibrillation - Analysis of the J-RHYTHM Registry

BACKGROUND

The proportion of patients with atrial fibrillation (AF) treated with anticoagulation varies from country to country. In Japan, little is known about regional differences in frequency of warfarin use or prognosis among patients with non-valvular AF (NVAF).

METHODS AND RESULTS

In J-RHYTHM Registry, the number of patients recruited from each of 10 geographic regions of Japan was based on region population density. A total of 7,406 NVAF patients were followed up prospectively for 2 years. At baseline, significant differences in various clinical characteristics including age, sex, type of AF, comorbidity, and CHADS2score, were detected among the regions. The highest mean CHADS2score was recorded in Shikoku. Frequency of warfarin use differed between the regions (P<0.001), with lower frequencies observed in Hokkaido and Shikoku. Baseline prothrombin time international normalized ratio differed slightly but significantly between the regions (P<0.05). On univariate analysis, frequency of thromboembolic events differed among the regions (P<0.001), with the highest rate seen in Shikoku. An inverse correlation was detected between frequency of thromboembolic and of major hemorrhagic events (P=0.062). On multivariate analysis, region emerged as an independent risk for thromboembolism.

CONCLUSIONS

Thromboembolic risk, frequency of warfarin use, and intensity and quality of warfarin treatment differed significantly between geographic regions of Japan. Region was found to be an independent predictor of thromboembolic events. (Circ J 2016; 80: 1548-1555).

Atrial fibrillation in women: epidemiology, pathophysiology, presentation, and prognosis

Atrial fibrillation (AF) is the most common sustained arrhythmia in women and men worldwide. During the past century, a range of risk factors has been associated with AF, severe complications from the arrhythmia have been identified, and its prevalence has been increasing steadily. Whereas evidence has accumulated regarding sex-specific differences in coronary heart disease and stroke, the differences between women and men with AF has received less attention. We review the current literature on sex-specific differences in the epidemiology of AF, including incidence, prevalence, risk factors, and genetics, and in the pathophysiology and the clinical presentation and prognosis of patients with this arrhythmia. We highlight current knowledge gaps and areas that warrant future research, which might advance understanding of variation in the risk factors and complications of AF, and ultimately aid more-tailored management of the arrhythmia.

Gender Differences of Thromboembolic Events in Atrial Fibrillation

Atrial fibrillation (AF) is the most common clinically relevant arrhythmia and increases the risk of thromboembolism and stroke; however, these risks are not the same for women and men. This review examines the evidence and clinical significance of increased thromboembolic risk in women with AF. The balance of results from over 30 recent studies suggests that female gender is an independent stroke risk factor in AF, and the inclusion of female gender in stroke risk stratification models, such as CHA2DS2-VASc, has improved risk assessment. Reasons for the increased thrombogenicity in women remain incompletely elucidated, but biological factors including increased hypertension, renal dysfunction, and hyperthyroidism in female patients with AF; cardiovascular remodeling; increased hypercoagulability, and estrogen hormone replacement therapy in women have been proposed. More importantly, gender differences exist in medical management of patients with AF, and compared with men, women have been found to have greater thromboembolic risk when not on anticoagulants, but may benefit from greater risk reduction when systemically anticoagulated. In conclusion, increased clinician awareness of these gender differences may help to improve the management of patients with AF.

Predictors for Stroke and Death in Non-Anticoagulated Asian Patients with Atrial Fibrillation: The Fushimi AF Registry

Background

Atrial fibrillation (AF) increases the risk of stroke and death. Data on the predictors for stroke and death in ‘real-world’ AF patients are limited, especially from large prospective Asian cohorts.

Methods

The Fushimi AF Registry is a community-based prospective survey designed to enroll all AF patients who visited the participating medical institutions in Fushimi-ku, Kyoto, Japan. Follow-up data were available for 3,304 patients (median follow-up period 741 days). We explored the predictors for ‘death, stroke, and systemic embolism (SE)’ during follow-up in 1,541 patients not receiving oral anticoagulants (OAC) at baseline.

Results

The mean age was 73.1 ± 12.5 years, and 673 (44%) patients were female. The mean CHADS₂ and CHA₂DS₂-VASc scores were 1.76 and 3.08, respectively. Cumulative events were as follows: stroke/SE in 61 (4%) and death in 230 (15%), respectively. On multivariate analysis, advanced age (hazard ratio (HR): 1.68, 95% confidence interval (CI): 1.24–2.29), underweight (body mass index <18.5 kg/m²) (HR: 1.71, 95% CI: 1.25–2.32), previous stroke/SE/transient ischemic attack (HR: 1.70, 95% CI: 1.25–2.30), heart failure (HR: 1.59, 95% CI: 1.17–2.15), chronic kidney disease (HR: 1.53, 95% CI: 1.16–2.02), and anemia (HR: 2.41, 95% CI: 1.78–3.28) were independent predictors for death/stroke/SE. Cumulative numbers of these 6 risk predictors could stratify the incidence of death/stroke/SE in patients without OAC, as well as those with OAC in our registry.

Conclusions

Advanced age, underweight, previous stroke/SE/transient ischemic attack, heart failure, chronic kidney disease, and anemia were independently associated with the risk of death/stroke/SE in non-anticoagulated Japanese AF patients.

Greater Severity of Neurological Defects in Women Admitted With Atrial Fibrillation-Related Stroke

BACKGROUND

The magnitude of the CHA2DS2-VASc score is associated with not only stroke incidence but also long-term outcomes. The association between sex and initial stroke severity in AF-related cardioembolic stroke patients has not been clarified. The present study aimed to elucidate the risk factors for initial stroke severity among patients with cardioembolic stroke enrolled in a multicenter registry.

METHODS AND RESULTS

We selected 12,701 patients (age, 77±10 years; 5,653 women) with AF-related cardioembolic stroke from the Japan Standard Stroke Registry Study between January 2000 and July 2013. Indicators of National Institutes of Health Stroke Scale (NIHSS) scores at admission were identified using a multiple linear regression. Increased NIHSS scores positively correlated with CHA2DS2-VASc score (ρ=0.197; P<0.001). The initial neurological deficits were more severe in women than in men (NIHSS scores, median [interquartile range] 14 [5-22] vs. 8 [3-18]; P<0.001). Multiple regression analysis revealed that higher age (standardized partial regression coefficient [β] 0.162; P<0.001), female sex (β 0.120; P<0.001), diabetes mellitus (β 0.020; P=0.019), dyslipidemia (β -0.076; P<0.001), congestive heart failure (β 0.039; P<0.001), vascular disease (β 0.030; P=0.001), prior stroke/TIA (β 0.085; P<0.001) and prior anticoagulant use (β -0.020; P=0.028) were associated with the NIHSS score at admission.

CONCLUSIONS

Female sex was independently associated with the initial neurological severity among AF-related cardioembolic stroke patients.

Impact of Sex Difference on Severity and Functional Outcome in Patients with Cardioembolic Stroke

INTRODUCTION

Female sex is a risk factor for thromboembolic events in Caucasian, but not in Japanese, patients with nonvalvular atrial fibrillation. However, it remains unclear whether the female sex is also a risk factor for severe stroke and unfavorable functional outcome in patients with cardioembolic (CE) stroke.

METHODS

Three hundred fifty-five consecutive patients with CE stroke within 48 hours after onset and with a modified Rankin Scale (mRS) score of 1 or lower before onset were studied. We compared basic characteristics, stroke severity, and functional outcome between female (n = 157) and male (n = 198) patients.

RESULTS

The mean age was higher in female than in male patients (80 ± 8 versus 75 ± 9 years, P < .00001). The congestive heart failure, hypertension, age [≥ 75 years], diabetes, stroke/transient ischemic attack [TIA] (CHADS2) score before onset was similar between the two groups (median, 3 [2-4] in both groups). Stroke severity on admission, assessed by the National Institutes of Health Stroke Scale (NIHSS), was higher in female than in male patients (13 [5-20] versus 8 [3-16], P = .0009). Functional outcome at discharge, assessed by mRS, was unfavorable in female than in male patients (3 [1-5] versus 2 [1-4], P = .005). An mRS score of 3 or higher at discharge was found more in female than in male patients (59% versus 39%, P = .0001). Multivariate analyses confirmed that female sex was a significant determinant of severe stroke (NIHSS ≥ 8) on admission (odds ratio [OR] to male = 1.97; 95% confidence interval [CI]; 1.24-3.15, P = .004) and for the mRS score of 3 or higher at discharge (OR = 1.83; 95% CI, 1.16-2.89; P = .01). Similar results were obtained by propensity-score matching analysis.

CONCLUSIONS

Female sex is a risk factor for severe stroke on admission and unfavorable functional outcome at discharge in Japanese patients with CE stroke.

Gender differences in stroke prevention in atrial fibrillation in general practice: using the GRASP-AF audit tool

BACKGROUND

Women represent a large proportion of patients with atrial fibrillation (AF) and tend to have higher risk of stroke.

AIMS

This study examines gender differences in the utilisation of oral anticoagulation (OAC) and prognosis (i.e. stroke and death) in AF patients in UK general practice.

DESIGN

Retrospective observational study.

METHODS

The Guidance on Risk Assessment and Stroke Prevention in Atrial Fibrillation (GRASP-AF) tool was employed to identify AF patients from 11 general practices in Darlington, England.

RESULTS

Two thousand two hundred and fifty-nine AF patients (mean±SD age 76 ± 12 years; 46% female) were identified. Based on CHA2 DS2 -VASc score 95% of women and 90% of men were at moderate-high risk of stroke. Women with moderate-high risk of stroke were treated with OAC less frequently than men (47% vs. 52%, p = 0.006). Overall rates of stroke and all-cause mortality were higher among women than men (p = 0.02 and p < 0.001). However, there was no significant gender difference in these outcomes in patients receiving OAC (p = 0.52 for stroke, p = 0.18 for death). Among people not receiving OAC where indicated, female gender was associated with an increased risk of stroke before (p = 0.01), and after (p = 0.04), adjustment for stroke risk factors. Women not receiving OAC had a higher risk of death on univariate regression analysis (p = 0.002), but not after adjustment for stroke risk factors (p = 0.53).

CONCLUSION

Women with AF are at higher risk of stroke than men without OAC. The gender-related differences in risk of stroke disappear if OAC is used. Despite this, women are more likely not to receive OAC.

Non-valvular atrial fibrillation patients with low CHADS2 scores benefit from warfarin therapy according to propensity score matching subanalysis using the J-RHYTHM Registry

INTRODUCTION

Recently, direct-acting oral anticoagulants (DOACs) have been introduced, with increasing use in patients with non-valvular atrial fibrillation (NVAF). However, warfarin continues to be widely used and the benefits and risks of warfarin in NVAF patients warrant closer inspection.

MATERIALS AND METHODS

Thromboembolism, major hemorrhage, and total and cardiovascular mortalities were analyzed in 7,406 NVAF patients in the J-RHYTHM Registry from January to July 2009, prior to DOAC introduction. Propensity score matching analysis was performed to reduce the differences in clinical characteristics between non-anticoagulant (n=1002) and warfarin (n=6404) cohorts to reassess warfarin outcomes over 2years.

RESULTS

The incidence of thromboembolism was significantly greater in the non-anticoagulant cohort (3.0%) than in the warfarin cohort (1.5%, P<0.001) with less frequent major hemorrhage in the non-anticoagulant cohort (0.8%) than in the warfarin cohort (2.1%, P=0.009). Using propensity score matching, new subsets (n=896 each) were obtained, with matching of the clinical characteristics between warfarin and non-anticoagulant subsets. The warfarin subset had lower risk factors compared with the total warfarin cohort. The incidence of thromboembolism was higher in the non-anticoagulant subset (2.9%) than in the warfarin subset (0.7%, P<0.001). However, major hemorrhage was not significantly different between the two subsets.

CONCLUSIONS

Although warfarin was associated with a significantly higher incidence of hemorrhage in the unmatched cohorts, propensity score matching revealed that warfarin reduced thromboembolism without a significant increase in hemorrhage in the matched subsets with lower risks. Propensity score matching reduced selection bias and provided rational comparisons although it had indwelling limitations.

Validation of Risk Scoring System Excluding Female Sex From CHA2DS2-VASc in Japanese Patients With Nonvalvular Atrial Fibrillation – Subanalysis of the J-RHYTHM Registry

BACKGROUND

Because the current Japanese guideline recommends CHADS2 score-based risk stratification in nonvalvular atrial fibrillation (NVAF) patients and does not list female sex as a risk for thromboembolic events, we designed the present study to compare the CHA2DS2-VASc and CHA2DS2-VA scores in the J-RHYTHM Registry.

METHODS AND RESULTS

We prospectively assessed the incidence of thromboembolic events for 2 years in 997 NVAF patients without warfarin treatment (age 68±12 years, 294 females). The predictive value of the CHA2DS2-VASc and CHA2DS2-VA scores for thromboembolic events was evaluated by c-statistic difference and net reclassification improvement (NRI). Thromboembolic events occurred in 7/294 females (1.2%/year) and 23/703 males (1.6%/year) (odds ratio 0.72 for female to male, 95% confidence interval (CI) 0.28-1.62, P=0.44). No sex difference was found in patient groups stratified by CHA2DS2-VASc and CHA2DS2-VA scores. There were significant c-statistic difference (0.029, Z=2.3, P=0.02) and NRI (0.11, 95% CI 0.01-0.20, P=0.02), with the CHA2DS2-VA score being superior to the CHA2DS2-VASc score. In patients with CHA2DS2-VASc scores 0 and 1 (n=374), there were markedly significant c-statistic difference (0.053, Z=6.6, P<0.0001) and NRI (0.11, 95% CI 0.07-0.14, P<0.0001), again supporting superiority of CHA2DS2-VA to CHA2DS2-VASc score.

CONCLUSIONS

In Japanese NVAF patients, the CHA2DS2-VA score, a risk scoring system excluding female sex from CHA2DS2-VASc, may be more useful in risk stratification for thromboembolic events than CHA2DS2-VASc score, especially in identifying truly low-risk patients.

Gender differences in stroke, mortality, and hospitalization among patients with atrial fibrillation: A systematic review

OBJECTIVE

To conduct a systematic review of gender differences in stroke, mortality, and hospitalization for patients with atrial fibrillation and/or flutter (AF/Afl).

METHODS

Full texts, published, peer-reviewed, English language articles from 1999 through July 2014 were examined. Articles with populations of patients with AF/Afl were included if they conducted longitudinal analysis of any of three outcomes: stroke, mortality, and hospitalization, and reported or compared at least one of the outcomes according to gender.

RESULTS

Seventeen articles were included: sixteen on stroke, nine on mortality, and one on hospitalization. In nine articles women had more strokes (RRs 0.89-1.9). Findings about gender differences in mortality (RRs 0.69-2.8) and hospitalizations were equivocal.

CONCLUSIONS

Few articles examine differences in outcomes between men and women with AF/Afl. Given the prevalence of AF/Afl and health care costs it is vital to determine gender differences to evaluate appropriate therapies to decrease stroke, mortality, and hospitalizations.

Bridging the gender gap in atrial fibrillation

Women have a similar lifetime prevalence of non-valvular atrial fibrillation (NVAF) compared with that of men. Given the significant morbidity and potential mortality associated with NVAF, it is crucial to understand gender differences with NVAF. Women can be more symptomatic than men. Despite a higher baseline stroke risk, they are less likely to be on anticoagulation. Women have a greater risk of thromboembolism and a similar rate of bleeding risk compared with men on anticoagulation. Initial experience suggests that novel oral anticoagulants have similar safety and efficacy profile in men and women. Although women can have more adverse reactions from antiarrhythmic therapies, they are often referred later than men for ablation. As a group, a mitigating factor in ablation referral is that women also have a higher incidence of procedural complications from catheter ablation. This review summarizes the available literature highlighting significant gender-based differences and also highlights areas for research to improve NVAF outcomes in women.

Incidence of ischemic stroke in Japanese patients with atrial fibrillation not receiving anticoagulation therapy--pooled analysis of the Shinken Database, J-RHYTHM Registry, and Fushimi AF Registry

BACKGROUND

The incidence rate of ischemic stroke in Japanese non-valvular atrial fibrillation (NVAF) patients without anticoagulation therapy remains unclear.

METHODS AND RESULTS

We performed a pooled analysis of 3,588 patients from the Shinken Database (n=1,099), J-RHYTHM Registry (n=1,002), and Fushimi AF Registry (n=1,487) to determine the incidence rate of ischemic stroke in Japanese NVAF patients without anticoagulation therapy. Average patient age was 68.1 years. During the follow-up period (total, 5,188 person-years; average, 1.4 years), 69 patients suffered from ischemic stroke (13.3 per 1,000 person-years; 95% confidence intervals [CI]: 10.5-16.8). The incidence rates of ischemic stroke were 5.4, 9.3, and 24.7 per 1,000 person-years and 5.3, 5.5, and 18.4 per 1,000 person-years in patients with low (0), intermediate (1), and high (≥ 2) CHADS2 and CHA2DS2-VASc scores, respectively. History of ischemic stroke or transient ischemic attack (hazard ratio [HR], 3.25; 95% CI: 1.86-5.67), age ≥ 75 years (HR, 2.31; 95% CI: 1.18-4.52), and hypertension (HR, 1.69; 95% CI: 1.01-2.86) were independent risk factors for ischemic stroke.

CONCLUSIONS

A low incidence rate of ischemic stroke was observed in Japanese NVAF patients except for those with CHADS2 score ≥ 2. In this pooled analysis, history of ischemic stroke or transient ischemic attack, advanced age, and hypertension were identified as independent risk factors for ischemic stroke.

Thromboembolic events in paroxysmal vs. permanent non-valvular atrial fibrillation. Subanalysis of the J-RHYTHM Registry

BACKGROUND

It is disputed whether the risk of cardiogenic embolism varies with type of atrial fibrillation (AF). Although several studies have found that the risk of cardiogenic embolism was similar among paroxysmal and persistent/permanent AF, a few studies have found that patients with paroxysmal AF had a lower rate of stroke and systemic embolism than those with persistent/permanent AF. In the present study, post-hoc analysis of the J-RHYTHM Registry was done to compare the risk of thromboembolic events among 3 types of non-valvular AF (NVAF). METHODS AND RESULTS:A total of 7,406 NVAF patients were followed up prospectively for 2 years. At baseline, warfarin was used for 78.6%, 90.0%, and 91.8% of patients with paroxysmal, persistent, and permanent AF, respectively. There were 126 thromboembolic events during the follow-up period. The crude event rate was 2-fold higher among the patients with permanent NVAF (2.29%) than among those with paroxysmal (1.16%) or persistent (1.20%) NVAF (P=0.001). After adjusting for warfarin use and CHA2DS2-VASc score components, however, the hazard ratio for thromboembolism did not differ between paroxysmal (reference) and permanent NVAF (1.007; 95% confidence interval: 0.955-1.061).

CONCLUSIONS

The crude rate of thromboembolic events was higher in permanent NVAF than in paroxysmal NVAF, but after adjusting for warfarin use and CHA2DS2-VASc score components, paroxysmal and permanent NVAF patients had similar risk of thromboembolism.