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Chung YW, Cheng JF, Lin YL, Chuang HJ, Chuang CC, Chen CW, Huang WM, Wu CK, Lin LY. A non-invasive nomogram for predicting heart failure with preserved ejection fraction in taiwanese outpatients with unexplained dyspnea and fatigue. J Formos Med Assoc 2024:S0929-6646(24)00108-6. [PMID: 38503670 DOI: 10.1016/j.jfma.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/27/2023] [Accepted: 02/20/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND While Reddy proposed the H2FPEF diagnostic algorithm to aid in diagnosing heart failure with preserved ejection fraction (HFpEF), certain parameters like age and obesity are not suitable for Asian population, especially given the increasing incidence of HFpEF in younger individuals. Therefore, this study aimed to develop an easy-to-use nomogram with non-invasive indices that can be used in outpatient clinics in Taiwan to quickly estimate the probability of HFpEF and help decide whether further invasive cardiopulmonary exercise test (CPET) is needed. METHODS Outpatients with unexplained dyspnea and fatigue were recruited divided into HFpEF (n = 64) and non-HFpEF (n = 34) groups based on invasive CPET and echocardiography. Multivariate logistic regression analyses identified independent noninvasive variables for developing an HFpEF nomogram. The nomogram's performance was assessed and validated using the concordance index (C-index), area under the curve (AUC), calibration curves, and decision curve analysis. RESULTS Multivariate logistic regression analyses identified five independent noninvasive variables for developing an HFpEF nomogram, including dyslipidemia (OR = 5.264, p = 0.010), diabetes (OR = 3.929, p = 0.050), left atrial area (OR = 1.130, p = 0.046), hemoglobin <13 g/dL (OR = 5.372, p = 0.010), and NT-proBNP ≥245 pg/mL (OR = 5.108, p = 0.027). The nomogram showed good discriminatory ability (C-index = 0.842) and calibration performance (p = 0.873) and high net benefit (0.1-0.95). Notably, the HFpEF nomogram showed better diagnostic accuracy than the H2FPEF score model in predicting Taiwanese HFpEF patients (AUC: 0.873 vs. 0.608, p = 0.0006). CONCLUSION The noninvasive HFpEF nomogram provides a preliminary estimation of the probability of HFpEF in Taiwanese outpatients with unexplained dyspnea and fatigue, which may help the decision-making on further invasive CPET.
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Affiliation(s)
- Yi-Wei Chung
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu branch, Hsinchu, Taiwan; Graduate institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jen-Fang Cheng
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; Division of Hospitalist, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Yen-Liang Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu branch, Hsinchu, Taiwan
| | - Hung-Jui Chuang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Chuan Chuang
- Division of Cardiology, Department of internal Medicine and Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Cheng-Wei Chen
- Division of Cardiology, Department of internal Medicine and Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Ming Huang
- Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Cho-Kai Wu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.
| | - Lian-Yu Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan.
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Yoder M, Dils A, Chakrabarti A, Driesenga S, Alaka A, Ghannam M, Bogun F, Liang JJ. Gender and race-related disparities in the management of ventricular arrhythmias. Trends Cardiovasc Med 2023:S1050-1738(23)00086-5. [PMID: 37838298 DOI: 10.1016/j.tcm.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 09/12/2023] [Accepted: 10/08/2023] [Indexed: 10/16/2023]
Abstract
Modern studies have revealed gender and race-related disparities in the management and outcomes of cardiac arrhythmias, but few studies have focused on outcomes for ventricular arrhythmias (VAs) such as ventricular tachycardia (VT) or ventricular fibrillation (VF). The aim of this article is to review relevant studies and identify outcome differences in the management of VA among Black and female patients. We found that female patients typically present younger for VA, are more likely to have recurrent VA after catheter ablation, are less likely to be prescribed antiarrhythmic medication, and are less likely to receive primary prevention ICD placement as compared to male patients. Additionally, female patients appear to derive similar overall mortality benefit from primary prevention ICD placement as compared to male patients, but they may have an increased risk of acute post-procedural complications. We also found that Black patients presenting with VA are less likely to undergo catheter ablation, receive appropriate primary prevention ICD placement, and have significantly higher risk-adjusted 1-year mortality rates after hospital discharge as compared to White patients. Black female patients appear to have the worst outcomes out of any demographic subgroup.
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Jackson II LR, Friedman DJ, Francis DM, Maccioni S, Thomas VC, Coplan P, Khanna R, Wong C, Rahai N, Piccini JP. Race and Ethnic and Sex Differences in Rhythm Control Treatment of Incident Atrial Fibrillation. CLINICOECONOMICS AND OUTCOMES RESEARCH 2023; 15:387-395. [PMID: 37273820 PMCID: PMC10237629 DOI: 10.2147/ceor.s402344] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 05/16/2023] [Indexed: 06/06/2023] Open
Abstract
Background Atrial fibrillation (AF) is associated with considerable morbidity and mortality. Timely management and treatment is critical in alleviating AF disease burden. Variation in treatment by race and ethnic and sex could lead to inequities in health outcomes. Objective To identify racial and ethnic and sex differences in rhythm treatment for patients with incident AF. Methods Using 2010-2019 Optum Clinformatics database, an administrative claims data for commercially insured patients in the United States (US), incident AF patients ≥20 years old who were continuously enrolled 12-months pre- and post-index diagnosis were identified. Rhythm control treatment (ablation, antiarrhythmic drugs [AAD], and cardioversion) for AF were compared by patient race and ethnicity (Asian, Hispanic, Black vs White) and sex (female vs male). Multivariable regression analysis was used to examine the relationship of race and ethnicity and sex with rhythm control AF treatment. Results A total of 77,932 patients were identified with incident AF. Black and Hispanic female patients had the highest CHA2DS2VASc scores (4.3 ± 1.8) and Elixhauser scores (4.1 ± 2.8 and 4.0 ± 6.7), respectively. Black males were less likely to receive AAD treatment (adjusted odds ratio [aOR] 0.87; 95% confidence interval [CI], 0.79-0.96) or ablation (aOR, 0.72; 95% CI, 0.58-0.90). Compared to White males, all groups had lower likelihood of receiving cardioversion with Asian females having the lowest [aOR, 0.48; 95% CI, (0.37-0.63)]. Conclusion Black patients were less likely to receive pharmacologic and procedural rhythm control therapies. Further research is needed to understand the drivers of undertreatment among racial and ethnic groups and females with AF.
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Affiliation(s)
- Larry R Jackson II
- Division of Cardiology, Duke University Medical Center & Duke Clinical Research Institute, Durham, NC, USA
| | - Daniel J Friedman
- Division of Cardiology, Duke University Medical Center & Duke Clinical Research Institute, Durham, NC, USA
| | - Diane M Francis
- Health Economics and Market Access, Johnson & Johnson Medical Devices, Irvine, CA, USA
| | - Sonia Maccioni
- Health Economics and Market Access, Johnson & Johnson Medical Devices, Irvine, CA, USA
| | | | - Paul Coplan
- Medical Device Epidemiology and Real-World Data Sciences, Johnson & Johnson, New Brunswick, NJ, USA
| | - Rahul Khanna
- Medical Device Epidemiology and Real-World Data Sciences, Johnson & Johnson, New Brunswick, NJ, USA
| | - Charlene Wong
- Medical Device Epidemiology and Real-World Data Sciences, Johnson & Johnson, New Brunswick, NJ, USA
| | - Neloufar Rahai
- Medical Device Epidemiology and Real-World Data Sciences, Johnson & Johnson, New Brunswick, NJ, USA
| | - Jonathan P Piccini
- Division of Cardiology, Duke University Medical Center & Duke Clinical Research Institute, Durham, NC, USA
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4
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Jackson LR, Friedman DJ, Francis DM, Maccioni S, Thomas VC, Wood J, Khanna R, Wong C, Rahai N, Piccini JP. Racial/ethnic and sex differences in safety outcomes and atrial fibrillation/atrial flutter-related acute healthcare utilization after catheter ablation of atrial fibrillation. Heart Rhythm O2 2023; 4:291-297. [PMID: 37323995 PMCID: PMC10264254 DOI: 10.1016/j.hroo.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
Background Catheter ablation is recommended for the treatment of symptomatic atrial fibrillation (AF) refractory to medical therapy. Objective The study sought to examine racial/ethnic and sex differences in complications and AF/atrial flutter (AFL)-related acute healthcare utilization following catheter ablation for AF. Methods We performed a retrospective analysis using data from the Centers for Medicare and Medicaid Services Medicare Standard Analytical Files (October 1, 2014, to September 30, 2019) among patients ≥65 years of age with AF who underwent catheter ablation for rhythm control. The risk of any complication within 30 days and AF/AFL-related acute healthcare utilization within 1 year of ablation by race, ethnicity, and sex were assessed using multivariable Cox regression modeling. Results We identified 95,394 patients for analysis of postablation complications and 68,408 patients for analysis of AF/AFL-related acute healthcare utilization. Both cohorts were ∼95% White and 52% male. Female patients had a slightly elevated risk of complications compared with male patients (adjusted hazard ratio [aHR] 1.07, 95% confidence interval [CI] 1.03-1.12). Black (aHR 0.78, 95% CI 0.77-1.00) and Asian (aHR 0.67, 95% CI 0.50-0.89) patients had lower utilization compared with White patients. Specifically, Asian men (aHR 0.58, 95% CI 0.38-0.91) had lower utilization compared with White men. Conclusion Differences in safety and healthcare utilization after catheter ablation for AF were observed by race/ethnicity and sex groups. Underrepresented racial and ethnic groups with AF had a lower risk of AF/AFL-related acute healthcare utilization postablation.
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Affiliation(s)
- Larry R. Jackson
- Department of Internal Medicine, Adult Cardiac Electrophysiology Section, Duke University Medical Center, Durham, North Carolina
| | - Daniel J. Friedman
- Department of Internal Medicine, Adult Cardiac Electrophysiology Section, Duke University Medical Center, Durham, North Carolina
| | - Diane M. Francis
- Health Economics and Market Access, Johnson & Johnson Medical Devices, Irvine, California
| | - Sonia Maccioni
- Health Economics and Market Access, Johnson & Johnson Medical Devices, Irvine, California
| | | | - Jennifer Wood
- Medical Device Epidemiology and Real-World Data Sciences, Johnson & Johnson, New Brunswick, New Jersey
| | - Rahul Khanna
- Medical Device Epidemiology and Real-World Data Sciences, Johnson & Johnson, New Brunswick, New Jersey
| | - Charlene Wong
- Medical Device Epidemiology and Real-World Data Sciences, Johnson & Johnson, New Brunswick, New Jersey
| | - Neloufar Rahai
- Medical Device Epidemiology and Real-World Data Sciences, Johnson & Johnson, New Brunswick, New Jersey
| | - Jonathan P. Piccini
- Department of Internal Medicine, Adult Cardiac Electrophysiology Section, Duke University Medical Center, Durham, North Carolina
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Duke JM, Muhammad LN, Song J, Tanaka Y, Witting C, Khan SS, Passman RS. Racial Disparity in Referral for Catheter Ablation for Atrial Fibrillation at a Single Integrated Health System. J Am Heart Assoc 2022; 11:e025831. [PMID: 36073632 DOI: 10.1161/jaha.122.025831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Guidelines recommend catheter ablation of atrial fibrillation (AFCA) as an option for rhythm control. Studies have shown that Black patients are less likely to undergo AFCA compared with White patients. We investigated whether differences in referral patterns play a role in this observed disparity. Methods and Results Using an integrated repository from the electronic medical record at Northwestern Medicine, we conducted a retrospective cohort study of outpatients with newly diagnosed atrial fibrillation. Baseline characteristics by race and ethnicity were compared. Logistic regression models adjusted for socioeconomic and health factors were constructed to determine the association between race and ethnicity and binary dependent variables including referrals and visits to general cardiology and cardiac electrophysiology (EP) and AFCA. Of 5445 patients analyzed, 4652 were non-Hispanic White (NHW) and 793 were non-Hispanic Black (NHB). In adjusted models, NHB patients initially diagnosed with atrial fibrillation in internal medicine and primary care had a significantly greater odds of referral to general cardiology; among all patients in the cohort, there was no significant difference in the odds of referral to EP between NHB and NHW patients; and there were no differences in the odds of completing a visit in general cardiology or EP. Among patients completing an EP visit, NHB patients were less likely to undergo AFCA (odds ratio, 0.63 [95% CI, 0.40-0.98], P=0.040). Conclusions Similar referral rates to general cardiology and EP were observed between NHB and NHW patients. Despite this, NHB patients were less likely to undergo AFCA.
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Affiliation(s)
- Jessica M Duke
- Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Lutfiyya N Muhammad
- Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Jing Song
- Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Yoshihiro Tanaka
- Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL.,Center for Arrhythmia Research Northwestern University Feinberg School of Medicine Chicago IL
| | - Celeste Witting
- Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Sadiya S Khan
- Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL.,Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL.,Department of Medicine, Division of Cardiology Northwestern University Feinberg School of Medicine Chicago IL
| | - Rod S Passman
- Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL.,Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL.,Center for Arrhythmia Research Northwestern University Feinberg School of Medicine Chicago IL.,Department of Medicine, Division of Cardiology Northwestern University Feinberg School of Medicine Chicago IL
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6
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Thomas KL, Garg J, Velagapudi P, Gopinathannair R, Chung MK, Kusumoto F, Ajijola O, Jackson LR, Turagam MK, Joglar JA, Sogade FO, Fontaine JM, Krahn AD, Russo AM, Albert C, Lakkireddy DR. Racial and ethnic disparities in arrhythmia care: A call for action. Heart Rhythm 2022; 19:1577-1593. [PMID: 35842408 PMCID: PMC10124949 DOI: 10.1016/j.hrthm.2022.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/01/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Kevin L Thomas
- Division of Cardiac Electrophysiology, Duke University School of Medicine, Durham, North Carolina
| | - Jalaj Garg
- Cardiac Arrhythmia Service, Loma Linda University Hospital, Loma Linda, California
| | - Poonam Velagapudi
- Division of Cardiology, University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Mina K Chung
- Cardiac Pacing and Electrophysiology, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Fred Kusumoto
- Heart Rhythm Services, Mayo Clinic, Jacksonville, Florida
| | - Olujimi Ajijola
- Ronald Reagan University of California Los Angeles Cardiac Arrhythmia Center, Los Angeles, California
| | - Larry R Jackson
- Division of Cardiac Electrophysiology, Duke University School of Medicine, Durham, North Carolina
| | - Mohit K Turagam
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jose A Joglar
- Division of Cardiology, Clinical Cardiac Electrophysiology, UT Southwestern Medical Center, Dallas, Texas
| | - Felix O Sogade
- Clinical Cardiac Electrophysiology, Georgia Arrhythmia Consultants, Macon, Georgia
| | - John M Fontaine
- Clinical Cardiac Electrophysiology Service, University of Pittsburgh Medical Center Williamsport, Williamsport, Pennsylvania
| | - Andrew D Krahn
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrea M Russo
- Cooper Medical School of Rowan University, Division of Cardiovascular Disease, Cooper University Hospital, Camden, New Jersey
| | - Christine Albert
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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7
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Deshmukh A, Iglesias M, Khanna R, Beaulieu T. Healthcare utilization and costs associated with a diagnosis of incident atrial fibrillation. Heart Rhythm O2 2022; 3:577-586. [PMID: 36340482 PMCID: PMC9626881 DOI: 10.1016/j.hroo.2022.07.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Atrial fibrillation (AF) is the most common heart rhythm disorder among adults and leads to substantial morbidity and mortality. Objectives The purpose of the study was to provide current estimates on the incremental healthcare utilization and cost burden associated with incident AF diagnosis in the United States. Methods Adults with an incident diagnosis of AF (2017–2020) were identified using the Optum Clinformatics database. Propensity matching was employed to match patients with incident AF to a comparator group of non-AF patients on several demographic and clinical characteristics. Outcomes including 12-month all-cause and cardiovascular (CV)-related healthcare utilization, as well as the medical cost associated with health services use, were assessed. Logistic and general linear models were used to examine study outcomes. Sub-analyses were performed to determine the incremental AF burden by specific sex and racial/ethnic categories. Results A total of 79,621 patients were identified in each cohort (AF and non-AF). As compared to the non-AF cohort, patients with AF had significantly higher all-cause inpatient visits (relative risk [RR] 1.77; 95% confidence interval [CI] 1.76–1.78), CV-related inpatient visits (RR 2.51; 95% CI 2:49–2:53), and CV-related emergency room visits (RR: 2.41; 95% CI 2:35–2:47). The mean total healthcare cost for patients with AF was $27,896 more (per patient per year) than the non-AF cohort ($63,031 vs $35,135, P < .001). Conclusion Medical services utilization and cost were significantly higher among AF patients than non-AF patients. Early treatment is likely to be critical to addressing the considerable disease burden imposed by AF.
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Thomas KL, Al-Khalidi HR, Silverstein AP, Monahan KH, Bahnson TD, Poole JE, Mark DB, Packer DL. Ablation Versus Drug Therapy for Atrial Fibrillation in Racial and Ethnic Minorities. J Am Coll Cardiol 2021; 78:126-138. [PMID: 34238436 DOI: 10.1016/j.jacc.2021.04.092] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/19/2021] [Accepted: 04/26/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Rhythm control strategies for atrial fibrillation (AF), including catheter ablation, are substantially underused in racial/ethnic minorities in North America. OBJECTIVES This study sought to describe outcomes in the CABANA trial as a function of race/ethnicity. METHODS CABANA randomized 2,204 symptomatic participants with AF to ablation or drug therapy including rate and/or rhythm control drugs. Only participants in North America were included in the present analysis, and participants were subgrouped as racial/ethnic minority or nonminority with the use of National Institutes of Health definitions. The primary endpoint was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. RESULTS Of 1,280 participants enrolled in CABANA in North America, 127 (9.9%) were racial and ethnic minorities. Compared with nonminorities, racial and ethnic minorities were younger with median age 65.6 versus 68.5 years, respectively, and had more symptomatic heart failure (37.0% vs 22.0%), hypertension (92.1% vs 76.8%, respectively), and ejection fraction <40% (20.8% vs 7.1%). Racial/ethnic minorities treated with ablation had a 68% relative reduction in the primary endpoint (adjusted hazard ratio [aHR]: 0.32; 95% confidence interval [CI]: 0.13-0.78) and a 72% relative reduction in all-cause mortality (aHR: 0.28; 95% CI: 0.10-0.79). Primary event rates in racial/ethnic minority and nonminority participants were similar in the ablation arm (4-year Kaplan-Meier event rates 12.3% vs 9.9%); however, racial and ethnic minorities randomized to drug therapy had a much higher event rate than nonminority participants (27.4% vs. 9.4%). CONCLUSION Among racial or ethnic minorities enrolled in the North American CABANA cohort, catheter ablation significantly improved major clinical outcomes compared with drug therapy. These benefits, which were not seen in nonminority participants, appear to be due to worse outcomes with drug therapy. (Catheter Ablation vs Anti-arrhythmic Drug Therapy for Atrial Fibrillation Trial [CABANA]; NCT00911508).
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Affiliation(s)
- Kevin L Thomas
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA.
| | | | - Adam P Silverstein
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | | | - Tristram D Bahnson
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Jeanne E Poole
- University of Washington Medical Center, Seattle, Washington, USA
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
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Racial disparities among Asian Americans with atrial fibrillation: An analysis from the NCDR® PINNACLE Registry. Int J Cardiol 2021; 329:209-216. [PMID: 33412180 DOI: 10.1016/j.ijcard.2020.12.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/02/2020] [Accepted: 12/18/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND There is paucity of data on Atrial Fibrillation (AF) management and associated clinical outcomes among Asian Americans. This study sought to investigate baseline risk factor profiles, racial disparities in clinical management and adverse clinical outcomes among White and Asian Americans. METHODS We used National Cardiovascular Data Registry (NCDR®) Practice Innovation and Clinical Excellence (PINNACLE) registry and linked Centers of Medicare and Medicaid Services data to identify Asian and White patients with AF between January 1, 2013-June 30, 2018. We compared rates of baseline risk factors, management strategies (rate versus rhythm control), anticoagulation use and rates of adverse events between racial groups. The two race groups were compared using hierarchical multivariable adjusted regression models to account for site and confounders. RESULTS In total, 1,359,827 patients (18,793 Asians and 1,341,034 Whites) were included in our analysis. Compared to White Americans, Asian Americans were more likely to use a rate control strategy (Odds Ratio [OR]: 1.20, 95% Confidence Interval [CI]: 1.15-1.25) and lower odds of rhythm control strategy (atrial ablations, cardioversions, or use of antiarrhythmic drugs) (OR: 0.83, 95% CI: 0.80-0.87) in adjusted analysis. Use of oral anticoagulants and direct oral anticoagulants were similar. There were no significant race-based differences in likelihood of all-cause mortality, stroke, and bleeding requiring hospitalization. Analyses performed using propensity score matching were consistent with the main results. CONCLUSIONS Asian Americans with AF have a lower likelihood of being managed with rhythm control strategies. Overall use of OAC and AF related adverse events remain similar between the two racial groups.
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Tan ESJ, Goh V, Santema BT, Tay WT, Teng THK, Yap J, Tromp J, Hung CL, Chopra V, Anand I, MacDonald MR, Ling LH, Van Gelder IC, Rienstra M, Voors AA, Richards AM, Lam CSP. Ethnic differences in atrial fibrillation among patients with heart failure in Asia. ESC Heart Fail 2020; 7:1419-1429. [PMID: 32383559 PMCID: PMC7373934 DOI: 10.1002/ehf2.12696] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 03/12/2020] [Indexed: 12/12/2022] Open
Abstract
AIMS We aimed to characterize ethnic differences in prevalence, clinical correlates, and outcomes of atrial fibrillation (AF) in heart failure (HF) with preserved and reduced ejection fraction (HFpEF and HFrEF) across Asia. METHODS AND RESULTS Among 5504 patients with HF prospectively recruited across 11 Asian regions using identical protocols in the Asian Sudden Cardiac Death in Heart Failure study (mean age 61 ± 13 years, 27% women, 83% HFrEF), 1383 (25%) had AF defined as a history of AF and/or AF/flutter on baseline electrocardiogram. Clinical correlates of AF were similar across ethnicities and included older age, prior stroke, higher NT-proBNP, and larger left atria. Diabetes was associated with lower odds of AF in HFrEF [adjusted odds ratio (AOR) 0.79, 95% CI 0.66-0.95] and HFpEF (AOR 0.58, 95% CI 0.39-0.84) regardless of ethnicity. Compared with Chinese ethnicity, Japanese/Koreans had higher odds of AF in HFrEF (AOR 1.76, 95% CI 1.40-2.21), while Indians had lower odds in HFrEF (AOR 0.18, 95% CI 0.13-0.24) and HFpEF (AOR 0.28, 95% CI 0.16-0.49) even after adjusting for clinical covariates. Interaction between ethnicity and region was observed among Indians, with Southeast Asian Indians having higher odds of AF (AOR 3.01, 95% CI 1.60-5.67) compared with South Asian Indians. AF was associated with poorer quality of life and increased risk of 1 year all-cause mortality or HF hospitalisation (adjusted hazard ratio 1.39, 95% CI 1.18-1.63) regardless of ethnicity. CONCLUSIONS Among patients with HF across Asia, clinical correlates and adverse outcomes associated with AF are similar across ethnicities; however, there are striking ethnic variations in the prevalence of AF that are not accounted for by known risk factors.
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Affiliation(s)
- Eugene S J Tan
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Vera Goh
- Department of Internal Medicine, Singapore General Hospital, Bukit Merah, Singapore
| | - Bernadet T Santema
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Wan Ting Tay
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Tiew-Hwa Katherine Teng
- Department of Cardiology, National Heart Centre Singapore, Singapore.,School of Population and Global Health, University of Western Australia, Australia
| | - Jonathan Yap
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Jasper Tromp
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.,Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Chung-Lieh Hung
- Department of Cardiology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Vijay Chopra
- Department of Cardiology, Max Super Speciality Hospital
| | - Inder Anand
- Department of Cardiology, Veterans Affairs Medical Center, Minneapolis, MN, USA
| | | | - Lieng Hsi Ling
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | | | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - A Mark Richards
- Department of Cardiology, National University Heart Centre Singapore, Singapore.,Cardiovascular Research Institute, National University Heart Centre Singapore, Singapore.,Department of Cardiology, University of Otago, Dunedin, New Zealand
| | - Carolyn S P Lam
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.,Department of Cardiology, National Heart Centre Singapore, Singapore.,Department of Cardiovascular Sciences Academic Clinical Program, Duke-National University of Singapore Medical School, Singapore
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11
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Tedla YG, Schwartz SM, Silberman P, Greenland P, Passman RS. Racial Disparity in the Prescription of Anticoagulants and Risk of Stroke and Bleeding in Atrial Fibrillation Patients. J Stroke Cerebrovasc Dis 2020; 29:104718. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.104718] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 01/31/2020] [Indexed: 10/24/2022] Open
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12
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Qureshi WT, Zhang ZM, Chang PP, Rosamond WD, Kitzman DW, Wagenknecht LE, Soliman EZ. Silent Myocardial Infarction and Long-Term Risk of Heart Failure: The ARIC Study. J Am Coll Cardiol 2019; 71:1-8. [PMID: 29301615 DOI: 10.1016/j.jacc.2017.10.071] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 10/18/2017] [Accepted: 10/19/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Although silent myocardial infarction (SMI) accounts for about one-half of the total number of myocardial infarctions (MIs), the risk of heart failure (HF) among patients with SMI is not well established. OBJECTIVES The purpose of this study was to examine the association of SMI and clinically manifested myocardial infarction (CMI) with HF, as compared with patients with no MI. METHODS This analysis included 9,243 participants from the ARIC (Atherosclerosis Risk In Communities) study who were free of cardiovascular disease at baseline (ARIC visit 1: 1987 to 1989). SMI was defined as electrocardiographic evidence of MI without CMI after the baseline until ARIC visit 4 (1996 to 1998). HF events were ascertained starting from ARIC visit 4 until 2010 in individuals free of HF before that visit. RESULTS Between ARIC visits 1 and 4, 305 SMIs and 331 CMIs occurred. After ARIC visit 4 and during a median follow-up of 13.0 years, 976 HF events occurred. The incidence rate of HF was higher in both CMI and SMI participants than in those without MI (incidence rates per 1,000 person-years were 30.4, 16.2, and 7.8, respectively; p < 0.001). In a model adjusted for demographics and HF risk factors, both SMI (hazard ratio [HR]: 1.35; 95% confidence interval [CI]: 1.02 to 1.78) and CMI (HR: 2.85; 95% CI: 2.31 to 3.51) were associated with increased risk of HF compared with no MI. These associations were consistent in subgroups of participants stratified by several HF risk predictors. However, the risk of HF associated with SMI was stronger in those younger than the median age (53 years) (HR: 1.66; 95% CI: 1.00 to 2.75 vs. HR: 1.19; 95% CI: 0.85 to 1.66, respectively; overall interaction p by MI type <0.001). CONCLUSIONS SMI is associated with an increased risk of HF. Future research is needed to examine the cost effectiveness of screening for SMI as part of HF risk assessment, and to identify preventive therapies to improve the risk of HF among patients with SMI.
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Affiliation(s)
- Waqas T Qureshi
- Department of Internal Medicine, Section on Cardiology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Zhu-Ming Zhang
- Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Patricia P Chang
- Division of Cardiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Wayne D Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Dalane W Kitzman
- Department of Internal Medicine, Section on Cardiology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Lynne E Wagenknecht
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Elsayed Z Soliman
- Department of Internal Medicine, Section on Cardiology, Wake Forest School of Medicine, Winston Salem, North Carolina; Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina.
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13
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Tan ESJ, Tay WT, Teng THK, Sim D, Leong KTG, Yeo PSD, Ong HY, Jaufeerally F, Ng TP, Poppe K, Lund M, Devlin G, Troughton RW, Ling LH, Richards AM, Doughty RN, Lam CSP. Ethnic differences in atrial fibrillation in patients with heart failure from Asia-Pacific. Heart 2019; 105:842-847. [PMID: 30661038 DOI: 10.1136/heartjnl-2018-314077] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 11/21/2018] [Accepted: 11/27/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Ethnic differences in the prevalence of atrial fibrillation (AF) in heart failure (HF) remain unclear. We compared the prevalence and clinical correlates of AF among different ethnicities in an Asian-Pacific population with HF. METHODS Patients with validated HF were prospectively studied across Singapore and New Zealand (NZ). RESULTS Among 1746 patients with HF (62% Asian, 26% women, mean age 66 (SD 13) years, mean ejection fraction (EF) 37 (SD 16%), 39% had AF. The prevalence of AF was markedly lower in Singapore-Asians than NZ-Europeans (24% vs 63%; p<0.001), even after adjusting for age, clinical and echocardiographic covariates, regardless of EF group (pinteraction for EF=0.39). Patients with AF were older, had higher body mass index and were more likely to have a history of hypertension, stroke, peripheral vascular disease, renal disease, chronic respiratory disease and increased alcohol intake, but less likely to have diabetes. Clinical correlates were similar for Asians and NZ-Europeans, except diabetes: Asian diabetic patients with HF had less AF compared with Asian patients without diabetes (OR 0.66, 95% CI 0.50 to 0.88), whereas among NZ-Europeans there was no significant association between diabetes and AF (OR 1.22, 95% CI 0.85 to 1.75) (pinteraction for ethnicity=0.01). AF was associated with a higher crude composite outcome of mortality and HF hospitalisations at 2 years (HR 1.19, 95% CI 1.02 to 1.38). CONCLUSION There is a strikingly lower prevalence of AF among Asian compared with NZ-European patients with HF. The underlying mechanisms for the lower prevalence of AF among Asians, particularly in the presence of diabetes, deserve further study. TRIAL REGISTRATION NUMBER ACTRN12610000374066.
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Affiliation(s)
- Eugene S J Tan
- National University Heart Centre, Singapore (NUHCS), Singapore
| | | | | | - David Sim
- National Heart Centre Singapore, Singapore.,Duke-NUS Graduate Medical School, Singapore
| | | | | | - Hean Yee Ong
- Department of Cardiology, Khoo Teck Puat Hospital, Singapore
| | - Fazlur Jaufeerally
- Duke-NUS Graduate Medical School, Singapore.,Department of Internal Medicine, Singapore General Hospital, Singapore
| | - Tze Pin Ng
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Katrina Poppe
- Heart Health Research Group, University of Auckland, Auckland, New Zealand
| | - Mayanna Lund
- Department of Cardiology, Middlemore Hospital, Auckland, New Zealand
| | - Gerard Devlin
- Department of Cardiology, Waikato Hospital, Hamilton, New Zealand
| | | | - Lieng Hsi Ling
- National University Heart Centre, Singapore (NUHCS), Singapore
| | - Arthur Mark Richards
- National University Heart Centre, Singapore (NUHCS), Singapore.,Christchurch Heart Institute, University of Otago, Otago, New Zealand.,Cardiovascular Research Institute, National University Health System, Singapore
| | - Robert N Doughty
- Heart Health Research Group, University of Auckland, Auckland, New Zealand
| | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore.,Duke-NUS Graduate Medical School, Singapore.,University Medical Centre Groningen, Groningen, The Netherlands
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14
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Heart failure and the development of atrial fibrillation in Hispanics, African Americans and non-Hispanic Whites. Int J Cardiol 2018; 271:186-191. [PMID: 29891236 DOI: 10.1016/j.ijcard.2018.05.070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 05/14/2018] [Accepted: 05/21/2018] [Indexed: 11/21/2022]
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15
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Ugowe FE, Jackson LR, Thomas KL. Racial and ethnic differences in the prevalence, management, and outcomes in patients with atrial fibrillation: A systematic review. Heart Rhythm 2018; 15:1337-1345. [PMID: 29803022 DOI: 10.1016/j.hrthm.2018.05.019] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Indexed: 01/26/2023]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia in the United States and is associated with increased morbidity, mortality, and health care expenditures. In this review, our aim was to assess the racial and ethnic differences in the epidemiology, management, and outcomes of patients with AF. A search of relevant studies from January 1, 2007, to December 30, 2017, was conducted in PubMed, EMBASE, and Web of Science and supplemented by manual searches of the bibliographies of retrieved articles. We identified 152 studies of which 64 were subsequently included. We found that underrepresented racial and ethnic groups have a higher prevalence of established risk factors associated with the development of AF but an overall lower incidence and prevalence of AF as compared with non-Hispanic whites. Moreover, racial and ethnic differences exist in detection, awareness, and AF-associated symptoms. Nonwhite populations also experience decreased use of rhythm control modalities and anticoagulation for stroke prevention. Lastly, among those with AF, underrepresented racial and ethnic groups had increased morbidity and mortality relative to white groups. Racial and ethnic differences exist in the prevalence, quality of life, management, and outcomes of individuals with AF; however, the mechanisms for these differences have yet to be fully elucidated. Racial and ethnic differences in AF warrant further analysis to understand the factors contributing to the differences in prevalence and management to ensure the delivery of high quality care that prevents stroke, reduces deaths, and decreases expenses associated with caring for underrepresented populations with AF.
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Affiliation(s)
| | - Larry R Jackson
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Kevin L Thomas
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
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16
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17
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Batul SA, Gopinathannair R. Atrial Fibrillation in Heart Failure: a Therapeutic Challenge of Our Times. Korean Circ J 2017; 47:644-662. [PMID: 28955382 PMCID: PMC5614940 DOI: 10.4070/kcj.2017.0040] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 03/27/2017] [Indexed: 11/11/2022] Open
Abstract
Atrial fibrillation (AF) and heart failure (HF) are growing cardiovascular disease epidemics worldwide. There has been an exponential increase in the prevalence of AF and HF correlating with an increased burden of cardiac risk factors and improved survival rates in patients with structural heart disease. AF is associated with adverse prognostic outcomes in HF and is most evident in mild-to-moderate left ventricular (LV) dysfunction where the loss of "atrial kick" translates into poorer quality of life and increased mortality. In the absence of underlying structural heart disease, arrhythmia can independently contribute to the development of cardiomyopathy. Together, these 2 conditions carry a high risk of thromboembolism due to stasis, inflammation and cellular dysfunction. Stroke prevention with oral anticoagulation (OAC) remains a mainstay of treatment. Pharmacologic rate and rhythm control remain limited by variable efficacy, intolerance and adverse reactions. Catheter ablation for AF has resulted in a paradigm shift with evidence indicating superiority over medical therapy. While its therapeutic success is high for paroxysmal AF, it remains suboptimal in persistent AF. A better mechanistic understanding of AF as well as innovations in ablation technology may improve patient outcomes in the future. Refractory cases may benefit from atrioventricular junction ablation and biventricular pacing. The value of risk factor modification, especially with regard to obesity, sleep apnea, hypertension and diabetes, cannot be emphasized enough. Close interdisciplinary collaboration between HF specialists and electrophysiologists is an essential component of good long-term outcomes in this challenging population.
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Affiliation(s)
- Syeda Atiqa Batul
- Division of Cardiology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY USA
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18
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Cheng X, Zhou X, Song S, Wu M, Baolatejiang R, Lu Y, Li Y, Zhang W, Lv W, Ye Y, Zhou Q, Wang H, Zhang J, Xing Q, Tang B. Ethnicity and anticoagulation management of hospitalized patients with atrial fibrillation in northwest China. Sci Rep 2017; 7:45884. [PMID: 28393880 PMCID: PMC5385550 DOI: 10.1038/srep45884] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 03/02/2017] [Indexed: 02/02/2023] Open
Abstract
The therapeutic management and health challenges caused by atrial fibrillation (AF) differ between different groups. The purpose of this study was to investigate the clinical features of patients hospitalized with AF and to explore the use of anticoagulation treatments in Han and Uygur patients in Xinjiang, northwest China. Data were collected from a retrospective descriptive study involving patients hospitalized at 13 hospitals in Xinjiang, China from Jul 1, 2014 to Jun 31, 2015. Anticoagulation management was measured according to guideline-recommended risk scores. A total of 4,181 patients with AF were included (mean age 69.5 ± 11.7 years, 41.4% females; 71.5% Han, 28.5% Uygur). The prevalence of AF in Uygur individuals may occur earlier than in Han individuals (mean age 64.9 vs 71.3, P < 0.001). Most of the hospitalized patients with AF had a high risk of stroke (CHA2DS2-VASc score ≥2; 80.6% Han vs 73.7% Uygur, P < 0.05); this risk was especially high in elderly patients. In AF patients, the application of anticoagulants according to the guidelines is far from expected, and the underutilization of anticoagulants exists in both ethnic groups.
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Affiliation(s)
- Xinchun Cheng
- Pacing and Electrophysiological Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830011, China.,Cardre health care No. 4 department, The people's hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang, 830054, China
| | - Xianhui Zhou
- Pacing and Electrophysiological Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830011, China
| | - Shifei Song
- The First Department of Cardiology, Hospital of Xinjiang Production &Construction Corps, Urumqi, Xinjiang, 830054, China
| | - Min Wu
- Pacing and Electrophysiological Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830011, China
| | - Roza Baolatejiang
- Pacing and Electrophysiological Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830011, China
| | - Yanmei Lu
- Pacing and Electrophysiological Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830011, China
| | - Yaodong Li
- Pacing and Electrophysiological Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830011, China
| | - Wenhui Zhang
- Pacing and Electrophysiological Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830011, China
| | - Wenkui Lv
- Pacing and Electrophysiological Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830011, China
| | - Yuanzheng Ye
- Pacing and Electrophysiological Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830011, China
| | - Qina Zhou
- Pacing and Electrophysiological Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830011, China
| | - Hongli Wang
- Pacing and Electrophysiological Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830011, China
| | - Jianghua Zhang
- Pacing and Electrophysiological Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830011, China
| | - Qiang Xing
- Pacing and Electrophysiological Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830011, China
| | - Baopeng Tang
- Pacing and Electrophysiological Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830011, China
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