Socioeconomic Status as a Predictor of Mortality in Patients Admitted With Atrial Fibrillation

Association between neighborhood household income and inpatient atrial fibrillation outcomes

BACKGROUND

The impact of socioeconomic status on the clinical outcomes of patients admitted to the hospital for atrial fibrillation (AF) is not well described.

OBJECTIVE

The purpose of this study was to determine the association between median neighborhood household income (mNHI) and clinical outcomes among patients admitted to the hospital for AF.

METHODS

We retrospectively analyzed primary AF hospitalizations from the United States National Inpatient Sample between 2016 and 2020. The analyzed sample was divided into quartiles based on the mNHI in the zip code of the patient's residence. The lowest quartile was used as the reference category. Study outcomes included inpatient procedure utilization (ablation, cardioversion, percutaneous left atrial appendage closure), length of stay, cost, mortality, and disposition. Weighted multivariable logistic and linear regression, adjusting for multiple patient and hospital-level characteristics, was performed.

RESULTS

Patients in the highest mNHI quartile had lower comorbidity burden, lower in-hospital mortality (odds ratio [OR] 0.78; 95% confidence interval [CI] 0.7-0.87; P <.001), lower discharges to care facility (OR 0.86; 95% CI 0.83-0.9; P <.001), shorter length of stay (adjusted mean difference -0.26; 95% CI -0.30 to -0.22; P <.001), higher procedure utilization, and higher health care costs ($12,124 vs $10,018) compared to the lowest mNHI quartile patients.

CONCLUSION

We identified significantly higher in-hospital mortality and lower procedural/resource utilization in patients living in lower-income neighborhoods compared to higher-income neighborhoods. Further research is needed to better understand the drivers of these disparities and the strategies to improve health care disparities between socioeconomic groups.

Social determinants of health and clinical outcomes among patients with atrial fibrillation: evidence from a global federated health research network

BACKGROUND

Few studies have investigated the role of social determinants of health (SDoH) in patients with atrial fibrillation (AF).

AIM

To investigate the relationship between SDoH and adverse events in a large multinational AF cohort.

DESIGN

Retrospective study utilizing a global federated health research network (TriNetX).

METHODS

Patients with AF were categorized as socially deprived defined according to ICD codes based on three SDoHs: (i) extreme poverty; (ii) unemployment; and/or (iii) problems related with living alone. The outcomes were the 5-year risk of a composite outcomes of all-cause death, hospitalization, ischemic heart disease (IHD), stroke, heart failure (HF) or severe ventricular arrhythmias. Cox regression was used to compute hazard rate ratios (HRs) and 95% confidence intervals (CIs) following 1:1 propensity score matching (PSM).

RESULTS

The study included 24 631 socially deprived (68.8 ± 16.0 years; females 51.8%) and 2 462 092 non-deprived AF patients (75.5 ± 13.1 years; females 43.8%). Before PSM, socially deprived patients had a higher risk of the composite outcome (HR 1.9, 95% CI 1.87-1.93), all-cause death (HR 1.34, 95% CI 1.28-1.39), hospitalization (HR 2.01, 95% CI 1.98-2.04), IHD (HR 1.67, 95% CI 1.64-1.70), stroke (HR 2.60, 95% CI 2.51-2.64), HF (HR 1.91, 95% CI 1.86-1.96) and severe ventricular arrhythmias (HR 1.83, 95% CI 1.76-1.90) compared to non-deprived AF patients. The PSM-based hazard ratios for the primary composite outcome were 1.54 (95% CI 1.49-1.60) for the unemployed AF patients; 1.39 (95% CI 1.31-1.47) for patients with extreme poverty or with low income; and 1.42 (95% CI 1.37-1.47) for those with problems related with living alone.

CONCLUSIONS

In patients with AF, social deprivation is associated with an increased risk of death and adverse cardiac events. The presence of possible unmeasured bias associated with the retrospective design requires confirmation in future prospective studies.

Reexamining Differences Between Black and White Veterans in Hospital Mortality and Other Outcomes in Veterans Affairs and Other Hospitals

OBJECTIVES

To examine Black-White patient differences in mortality and other hospital outcomes among Veterans treated in Veterans Affairs (VA) and non-VA hospitals.

BACKGROUND

Lower hospital mortality has been documented in older Black patients relative to White patients, yet the mechanisms have not been determined. Comparing other hospital outcomes and multiple hospital systems may help inform the reasons for these differences.

METHODS

Repeated cross-sectional analysis of hospitalization records was conducted for Veterans discharged in VA and non-VA hospitals from January 1, 2013 to December 31, 2017 in 11 states. Hospital outcomes included 30-day mortality, 30-day readmissions, inpatient costs, and length of stay. Hospitalizations were for acute myocardial infarction, coronary artery bypass graft surgery, gastrointestinal bleeding, heart failure, pneumonia, and stroke. Differences in outcomes were estimated between Black and White patients for VA and non-VA hospitals and age groups younger than 65 years or 65 years and older in regression models adjusting for patient and hospital factors.

RESULTS

There were a total of 459,574 study patients. Older Black patients had lower adjusted mortality for acute myocardial infarction, gastrointestinal bleeding, heart failure, and pneumonia. Adjusted probability of readmission was higher and adjusted mean length of stay and costs were greater for older Black patients relative to White patients in non-VA hospitals for several conditions. Fewer differences were observed in younger patients and in VA hospitals.

CONCLUSION

While older Black patients had lower mortality, other outcomes compared poorly with White patients. Differences were not fully explained by observable patient and hospital factors although social determinants may contribute to these differences.

Gender and race-related disparities in the management of ventricular arrhythmias

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.

Lung Cancer Screening Penetration in an Urban Underserved County

PURPOSE

To compare residential geography, sex, socioeconomic status (SES), and race/ethnicity of patients screened at Montefiore's Lung Cancer Screening Program with those of patients diagnosed with lung cancer, assessing whether screening efforts are appropriately focused.

METHODS

This retrospective cohort study involved patients within a multisite urban medical center undergoing lung cancer screening or diagnosed with lung cancer from January 1, 2015 to December 31, 2019. Inclusion criteria were residence within the Bronx, NY and age between 55 and 80 years. Institutional review board approval was obtained. Data were analyzed using the Wilcoxon two-sample t test and χ².

RESULTS

The cohorts comprised 1568 (50.3%) women and 1551 (49.7%) men (mean age 65.6 ± 6.16). The Southeast Bronx had the most diagnosed lung cancers (29.96%) and screenings (31.22%). Sex did not significantly differ (p = 0.053). Cancer and screening cohorts were from impoverished neighborhoods with mean SES of - 3.11 ± 2.78 and - 3.44 ± 2.80 (p < 0.01). The lower tier SES neighborhoods demonstrated more patients in the screening cohort than cancer cohort (p = 0.01). Both cohorts included a majority of Hispanic patients, although race/ethnicity differed significantly (p = 0.01). Lower SES neighborhoods showed no significant difference in race/ethnicity between cancer and screening cohorts (p = 0.262).

CONCLUSION

Though statistically significant differences were found between cohorts, likely due to sample size, few clinically meaningful differences were found, implying our lung cancer screening program was effective in reaching the desired population. Demographics-based programs should be considered in global efforts to screen vulnerable populations.

Association of Neighborhood Disadvantage and Anticoagulation for Patients with Atrial Fibrillation in the Veterans Health Administration: the REACH-AF Study

BACKGROUND

Atrial fibrillation (AF) is a common arrhythmia, the management of which includes anticoagulation for stroke prevention. Although disparities in anticoagulant prescribing have been well documented for individual socioeconomic factors, less is known about the association of neighborhood-level disadvantage and anticoagulation for AF.

OBJECTIVE

To assess the association between neighborhood disadvantage and anticoagulant initiation for patients with incident AF.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A cohort of patients enrolled in the Veterans Health Administration (VA) with incident AF from January 2014 through December 2020 from the Race, Ethnicity, and Anticoagulant CHoice in Atrial Fibrillation (REACH-AF) Study.

MAIN MEASURES

The primary exposure was neighborhood disadvantage quantified using area deprivation index (ADI), classified by quintiles (Q). The outcomes were initiation of any anticoagulant therapy (warfarin or direct oral anticoagulant, DOAC) within 90 days of AF diagnosis and DOAC use among initiators. We used mixed effects logistic regression to assess the association between ADI and anticoagulant therapy, incorporating a fixed effect for treatment site and baseline patient, provider, and facility covariates.

KEY RESULTS

Among 161,089 patients, 105,489 (65.5%) initiated any anticoagulant therapy, and 78,903 (74.8%) used DOACs. Any anticoagulant therapy increased 3.2 percentage points (63.0% to 66.2%; p<.001) from Q1 to Q5, whereas DOAC use decreased 8.2 percentage points (79.4% to 71.2%; p<.0001) across quintiles. The adjusted odd ratios of any anticoagulant therapy were non-significantly different for Q2-Q5 than Q1. The adjusted odds of DOAC use decreased progressively from 0.89 (95% CI, 0.84-0.94) in Q2 to 0.77 (95% CI, 0.73-0.83) in Q5 compared to Q1 (p<.0001).

CONCLUSIONS

Among Veterans with incident AF, we observed similar initiation of any anticoagulant, though neighborhood deprivation was associated with decreased DOAC use among anticoagulant initiators. Future interventions to improve pharmacoequity in anticoagulant prescribing for AF should consider the role of neighborhood-level determinants of health inequities.

The association of disparities in neighborhood median household income and mortality in patients admitted to the hospital with atrial fibrillation

BACKGROUND

Lower neighborhood median household income (nMHI) is associated with increased adverse outcomes in patients with atrial fibrillation (AF). However, its effect on mortality is yet unknown.

METHODS

Data from the regional United States (U.S.) electronic medical records database, Research Action for Health Network (REACHnet), was extracted for adult patients with AF at Tulane Medical Center over 10 years. Annual nMHI & neighborhood high school graduation (HSG) data was collected from the US Census bureau. Only African Americans (AA) and Caucasians (CC) who had socioeconomic data were included. Low nMHI and low HSG were defined as ≤$25,000 & <90% respectively. High nMHI and HSG were defined as >$50,000 & ≥90% respectively. Primary endpoints were all cause and cardiovascular (CV) mortality. Cox-proportional hazard ratios were used to evaluate the endpoints.

RESULTS

We included 4616 patients diagnosed with AF. During a median follow up of 4.6 years, 434 patients died of which 32.7% patients had CV mortality. There was a stepwise decrease in incidence of both all-cause and CV mortality as nMHI increased. Patients with low nMHI had the greatest risk of all-cause mortality (HR 1.9, C.I. 1.2-3.2, P 0.004). The association between low nMHI and all-cause mortality persisted after adjusting for age, sex, race, HSG and stroke risk factors using CHA₂DS₂VASC, delta CHA₂DS₂VASC scores and oral anticoagulant use. CV mortality followed a similar trend as all-cause mortality, however, this association was not significant after adjusting for the above variables. Apart from low nMHI, CHA₂DS₂VASC delta CHA₂DS₂VASC were statistically significant independent predictors of both all-cause and CV mortality.

CONCLUSION

Low nMHI is an independent risk factor for all cause and CV mortality in AF. Higher burden of co-morbidities is the driving force behind this disparity. Future studies should evaluate the role of educational and therapeutic intervention in these populations to reduce mortality.

Impact of Socioeconomic Status on Emergency Department Visits in Patients With Atrial Fibrillation: A Nationwide Population-Based Cohort Study

Background Socioeconomic status (SES) differences could influence management and clinical outcomes in patients with atrial fibrillation (AF), reflecting health inequalities. The authors aimed to investigate emergency department (ED) visits in patients with AF according to SES level. Methods and Results The authors performed a cross-sectional analysis of ED visits in patients with nonvalvular AF using the Korean National Health Insurance Service database in 2016. The patients were divided into health premium quartiles and medical aid groups, with quartile 4 the highest SES and medical aid the lowest SES. Among patients with AF, patients who had ≥1 ED visits in 2016 were identified. The prevalence and cause of ED visits, 30- and 90-day mortality, and rehospitalization risk after ED visits were evaluated. Among the total 371 017 AF patients, 99 306 patients visited the ED in 2016. The medical aid group showed the highest ED visit rate (n=11 833, 38.0%), and patients with the highest quartile of SES (quartile 4 group) showed the lowest ED visit rate (n=38 037, 30.0%). The most common cause of ED visits was cerebral infarction in all groups. The 30- and 90-day mortality rates and rehospitalization risk after ED visits was higher in groups with lower SES. Conclusions Patients with AF and with lower SES had a higher risk of ED visit rate, higher 30- and 90-day mortality rates, and rehospitalization risk after ED visit. Tailored AF management according to different SES levels in patients with AF is needed to improve clinical outcomes.

Association of chronic kidney disease with all-cause mortality in patients hospitalized for atrial fibrillation and impact of clinical and socioeconomic factors on this association

Background

Atrial fibrillation (AF) and chronic kidney disease (CKD) often co-occur, and many of the same clinical factors and indicators of socioeconomic status (SES) are associated with both diseases. The effect of the estimated glomerular filtration rate (eGFR) on all-cause mortality in AF patients and the impact of SES on this relationship are uncertain.

Materials and methods

This retrospective study examined 968 patients who were admitted for AF. Patients were divided into four groups based on eGFR at admission: eGFR-0 (normal eGFR) to eGFR-3 (severely decreased eGFR). The primary outcome was all-cause mortality. Cox regression analysis was used to identify the effect of eGFR on mortality, and subgroup analyses to determine the impact of confounding factors.

Results

A total of 337/968 patients (34.8%) died during follow-up. The average age was 73.70 ± 10.27 years and there were 522 males (53.9%). More than 39% of these patients had CKD (eGFR < 60 mL/min/1.73 m²), 319 patients with moderately decreased eGFR and 67 with severely decreased eGFR. After multivariate adjustment and relative to the eGFR-0 group, the risk for all-cause death was greater in the eGFR-2 group (HR = 2.416, 95% CI = 1.366-4.272, p = 0.002) and the eGFR-3 group (HR = 4.752, 95% CI = 2.443-9.242, p < 0.00001), but not in the eGFR-1 group (p > 0.05). Subgroup analysis showed that moderately to severely decreased eGFR only had a significant effect on all-cause death in patients with low SES.

Conclusion

Moderately to severely decreased eGFR in AF patients was independently associated with increased risk of all-cause mortality, especially in those with lower SES.

The impact of socioeconomic deprivation on the risk of atrial fibrillation in patients with diabetes mellitus: A nationwide population-based study

Objective

To evaluate the relationship between socioeconomic status and the risk of atrial fibrillation (AF) in patients with diabetes mellitus (DM).

Research design and methods

From the National Health Insurance Service (NHIS) database, we identified 2,429,610 diabetic patients who underwent national health check-ups between 2009 and 2012. Tracing back the subjects for 5 years from the date of health check-up, we determined the subjects’ income and whether they received medical aid (MA) during the past 5 years. Subjects were divided into six groups according to the number of years of receiving (MA groups 0 through 5) and into four groups according to socioeconomic status change during the past 5 years. We estimated the risk of AF for each group using the Cox proportional-hazards model.

Results

During a median follow-up of 7.2 ± 1.7 years, 80,257 were newly identified as AF. The MA groups showed a higher risk of AF than the non-MA group with the hazard ratios (HRs) and 95% confidence interval (CI) 1.32 (1.2–1.44), 1.33 (1.22–1.45), 1.23 (1.13–1.34), 1.28 (1.16–1.4), and 1.50 (1.39–1.63) for MA groups 1 through 5, respectively. Dividing subjects according to socioeconomic condition change, those who experienced worsening socioeconomic status (non-MA to MA) showed higher risk compared to the persistent non-MA group (HR 1.54; 95% CI 1.38–1.73).

Conclusion

Low socioeconomic status was associated with the risk of AF in patients with diabetes. More attention should be directed at alleviating health inequalities, targeting individuals with socioeconomic deprivation to provide timely management for AF.

Association of Neighborhood-Level Material Deprivation With Atrial Fibrillation Care in a Single-Payer Health Care System: A Population-Based Cohort Study

BACKGROUND

There are limited data on the association of material deprivation with clinical care and outcomes after atrial fibrillation (AF) diagnosis in jurisdictions with universal health care.

METHODS

This was a population-based cohort study of individuals ≥66 years of age with first diagnosis of AF between April 1, 2007, and March 31, 2019, in the Canadian province of Ontario, which provides public funding and prohibits private payment for medically necessary physician and hospital services. Prescription medications are subsidized for residents >65 years of age. The primary exposure was neighborhood material deprivation, a metric derived from Canadian census data to estimate inability to attain basic material needs. Neighborhoods were categorized by quintile from Q1 (least deprived) to Q5 (most deprived). Cause-specific hazards regression was used to study the association of material deprivation quintile with time to AF-related adverse events (death or hospitalization for stroke, heart failure, or bleeding), clinical services (physician visits, cardiac diagnostics), and interventions (anticoagulation, cardioversion, ablation) while adjusting for individual characteristics and regional cardiologist supply.

RESULTS

Among 347 632 individuals with AF (median age 79 years, 48.9% female), individuals in the most deprived neighborhoods (Q5) had higher prevalence of cardiovascular disease, risk factors, and noncardiovascular comorbidity relative to residents of the least deprived neighborhoods (Q1). After adjustment, Q5 residents had higher hazards of death (hazard ratio [HR], 1.16 [95% CI, 1.13-1.20]) and hospitalization for stroke (HR, 1.16 [95% CI, 1.07-1.27]), heart failure (HR, 1.14 [95% CI, 1.11-1.18]), or bleeding (HR, 1.16 [95% CI, 1.07-1.25]) relative to Q1. There were small differences across quintiles in primary care physician visits (HR, Q5 versus Q1, 0.91 [95% CI, 0.89-0.92]), echocardiography (HR, Q5 versus Q1, 0.97 [95% CI, 0.96-0.99]), and dispensation of anticoagulation (HR, Q5 versus Q1, 0.97 [95% CI, 0.95-0.98]). There were more prominent disparities for Q5 versus Q1 in cardiologist visits (HR, 0.84 [95% CI, 0.82-0.86]), cardioversion (HR, 0.80 [95% CI, 0.76-0.84]), and ablation (HR, 0.45 [95% CI, 0.30-0.67]).

CONCLUSIONS

Despite universal health care and prescription medication coverage, residents of more deprived neighborhoods were less likely to visit cardiologists or receive rhythm control interventions after AF diagnosis, even though they exhibited higher cardiovascular disease burden and higher risk of adverse outcomes.

Income and outcomes of patients with incident atrial fibrillation

BACKGROUND

Socioeconomic disparities can be associated with adverse outcomes in patients with cardiovascular diseases. The impact of personal income on the outcomes of patients with atrial fibrillation (AF) is unclear.

METHODS

Nationwide observational registry-based study on patients with incident AF in Finland during 2007-2018.

RESULTS

203 154 patients (mean age 73.0±13.5; females 49.0%) were diagnosed with incident AF during the study period. Overall, 16 272 (8.0%) patients experienced first-ever ischaemic stroke and 63 420 (31.2%) died (mean follow-up 4.3±3.3 years). After adjusting for confounding factors, low personal income was associated with increased risk of overall mortality in all age strata and the incidence of first-ever stroke in patients aged <65 years and 65-74 years, but not in those ≥75 years. The magnitude of this effect was greatest in patients aged <65 years. After propensity score matching of patients <65 years in the lowest and highest quintiles of maximum personal annual income, at 10 years, those in the highest income quintile (≥€54 000) had significantly lower risk of first-ever stroke (subdistribution HR 0.495, 95% CI 0.391 to 0.628) and overall mortality (HR 0.307, 95% CI 0.269 to 0.351) compared with patients in the lowest income quintile (≤€12 000).

CONCLUSIONS

Personal annual income has a significant impact on the incidence of first-ever ischaemic stroke and overall mortality among patients with incident AF, particularly among patients of working age. Low-income indicate the need for intervention strategies to improve outcomes of AF.

TRIAL REGISTRATION NUMBER

NCT04645537.

American Journal of Preventive Cardiology: Area Deprivation Index and Oral Anticoagulation in New Onset Atrial Fibrillation

Objective

Oral anticoagulation is a standard of care for thromboembolic stroke prevention in individuals with atrial fibrillation (AF). Social determinants of health have had limited investigation in AF and particularly in access to anticoagulation. We examined the relation between area deprivation index (ADI) and anticoagulation in individuals at risk of stroke due to AF.

Methods

We conducted a retrospective analysis of patients with incident, non-valvular AF from 2015-2020 receiving care at a large, regional health center. We extracted demographics, medications, and problem lists and used administrative coding to identify comorbid conditions and relevant covariates, and individual-level residential address to ascertain ADI. We examined the relation between ADI and receipt of prescribed oral anticoagulation (warfarin or direct-acting oral anticoagulant, or DOAC) at 90 days following AF diagnosis in multivariable-adjusted models.

Results

Following exclusions, the dataset included 20,210 individuals (age 74.5±10.9 years; 51% women; 94% white race). In multivariable-adjusted analyses, individuals in the highest quartile of ADI had a 16% lower likelihood of receiving anticoagulation prescription than those in the lowest ADI quartile (Odds Ratio [OR] 0.84; 95% Confidence Interval [CI], 0.75-0.95) at 90 days following AF diagnosis. In those receiving anticoagulation, individuals in the highest ADI quartile had a 24% lower likelihood of receiving a DOAC prescription as opposed to warfarin prescription than those in the lowest quartile (OR 0.76; 95% CI, 0.60-0.96) at 90 days following AF diagnosis.

Conclusions

We demonstrate the association of higher neighborhood deprivation as determined by ADI with decreased likelihood of (1) anticoagulation prescribing for stroke prevention in AF and (2) prescription of a DOAC when any oral anticoagulation is prescribed. Our results suggest neighborhood-based health inequities in the receipt of anticoagulation prescription for stroke prevention in AF in a large, regional health care system.

Social determinants of atrial fibrillation

Atrial fibrillation affects almost 60 million adults worldwide. Atrial fibrillation is associated with a high risk of cardiovascular morbidity and death as well as with social, psychological and economic burdens on patients and their families. Social determinants - such as race and ethnicity, financial resources, social support, access to health care, rurality and residential environment, local language proficiency and health literacy - have prominent roles in the evaluation, treatment and management of atrial fibrillation. Addressing the social determinants of health provides a crucial opportunity to reduce the substantial clinical and non-clinical complications associated with atrial fibrillation. In this Review, we summarize the contributions of social determinants to the patient experience and outcomes associated with this common condition. We emphasize the relevance of social determinants and their important intersection with atrial fibrillation treatment and outcomes. In closing, we identify gaps in the literature and propose future directions for the investigation of social determinants and atrial fibrillation.

Social and environmental risks as contributors to the clinical course of heart failure

Heart failure is a major contributor to healthcare expenditures. Many clinical risk factors for the development and exacerbation of heart failure had been reported, including diabetes, renal dysfunction, and respiratory disease. In addition to these clinical parameters, the effects of social factors, such as occupation or lifestyle, and environmental factors may have a great impact on disease development and progression of heart failure. However, the current understanding of social and environmental factors as contributors to the clinical course of heart failure is insufficient. To present the knowledge of these factors to date, this comprehensive review of the literature sought to identify the major contributors to heart failure within this context. Social factors for the risk of heart failure included occupation and lifestyle, specifically in terms of the effects of specific occupations, occupational exposure to toxicities, work style, and sleep deprivation. Socioeconomic factors focused on income and education level, social status, the neighborhood environment, and marital status. Environmental factors included traffic and noise, air pollution, and other climate factors. In addition, psychological stress and behavior traits were investigated. The development of heart failure may be closely related to these factors; therefore, these data should be summarized for the context to improve their effects on patients with heart failure. The present study reviews the literature to summarize these influences.

Geographical variation and clustering are found in atrial fibrillation beyond socioeconomic differences: a Danish cohort study, 1987-2015

BACKGROUND

The prevalence and incidence rate of atrial fibrillation (AF) increase worldwide and AF is a risk factor for more adverse cardiovascular diseases including stroke. Approximately 44% of AF cases cannot be explained by common individual risk factors and risk might therefore also be related to the environment. By studying geographical variation and clustering in risk of incident AF adjusted for socioeconomic position at an individual level, potential neighbourhood risk factors could be revealed.

METHODS

Initially, yearly AF incidence rates 1987-2015 were estimated overall and stratified by income in a register-based cohort study. To examine geographical variation and clustering in AF, we used both spatial scan statistics and a hierarchical Bayesian Poisson regression analysis of AF incidence rates with random effect of municipalities (n = 98) in Denmark in 2011-2015.

RESULTS

The 1987-2015 cohort included 5,453,639 individuals whereof 369,800 were diagnosed with an incident AF. AF incidence rate increased from 174 to 576 per 100,000 person-years from 1987 to 2015. Inequality in AF incidence rate ratio between highest and lowest income groups increased from 23% in 1987 to 38% in 2015. We found clustering and geographical variation in AF incidence rates, with incidence rates at municipality level being up to 34% higher than the country mean after adjusting for socioeconomic position.

CONCLUSIONS

Geographical variations and clustering in AF incidence rates exist. Compared to previous studies from Alberta, Canada and the United States, we show that geographical variations exist in a country with free access to healthcare and even when accounting for socioeconomic differences at an individual level. An increasing social inequality in AF was seen from 1987 to 2015. Therefore, when planning prevention strategies, attention to individuals with low income should be given. Further studies focusing on identification of neighbourhood risk factors for AF are needed.

Discontinuation of oral anticoagulation and risk of stroke and death after ablation for typical atrial flutter: A nation-wide Danish cohort study

INTRODUCTION

Oral anticoagulation (OAC) is indicated for patients with atrial fibrillation (AF) and atrial flutter (AFL) with a CHA₂DS₂-VASc score ≥ 2 for men and ≥3 for women. This is regardless of successful catheter ablation for their arrhythmia. Studies have mainly focused on AF, and little is known regarding use of OAC in AFL patients following catheter ablation.

PURPOSE

To describe discontinuation of OAC in a national cohort of patients who have undergone first-time cavo-tricuspid isthmus ablation (CTIA) for AFL.

METHODS

We identified patients undergoing first-time CTIA during the period 2010-2016 using the Danish National Ablation Registry. Information on comorbidities and OAC use were gathered using the Danish National Patient Registry and the Danish National Prescription Registry. Patients were followed until March 1st, 2018.

RESULTS

We identified 2409 consecutive patients. Median age was 66 (IQR 58-72) years, and 1952 (81%) were men. During mean follow-up of 4 ± 1.7 years, 723 (30%) patients discontinued OAC. Patients discontinuing OAC were younger, had less comorbidity, and a lower CHA₂DS₂-VASc score. During follow-up, 252 (10%) patients died, and 112 (5%) patients had a stroke. Incidence of both these events increased with increasing age and CHA₂DS₂-VASc score. In adjusted analysis, we observed higher mortality (p < 0.0001) in patients discontinuing OAC, while stroke rate was not significantly higher (p = 0.21).

CONCLUSION

In this national cohort of patients who have undergone first-time CTIA, patients discontinuing OAC treatment were younger and had less comorbidities. Patients remain at elevated risk of death and stroke/TIA, increasing with their age and CHA₂DS₂-VASc score.

Adverse social factors and all-cause mortality among male and female patients receiving care in the Veterans Health Administration

Social factors account more for health outcomes than medical care, yet health services research in this area is limited due to the lack of social factors data contained within electronic health records (EHR) systems. Few investigations have examined how cumulative burdens of co-occurring adverse social factors impact health outcomes. From 293,872 patients in one region of the Veterans Health Administration (VHA), we examined how increasing numbers of adverse social factors extracted from the EHR were associated with mortality across a one-year period for male and female patients. Adverse social factors were identified using four sources in the EHR: responses to universal VHA screens, International Classification of Disease (ICD) diagnostic codes that indicate social factors, receipt of VHA services related to social factors, and templated social work referrals. Seven types of adverse social factors were coded: violence, housing instability, employment or financial problems, legal issues, social or familial problems, lack of access to care or transportation, and nonspecific psychosocial needs. Overall, each increase in an adverse social factor was associated with 27% increased odds of mortality, after accounting for demographics, medical comorbidity, and military service-related disability. Non-specific psychosocial factors were most strongly associated with mortality, followed by social or familial problems. Although women were more likely than men to have multiple adverse social factors, social factors were not associated with mortality among women as they were among men. By incorporating social factors data, health care systems can better understand patient all-cause mortality and identify potential prevention efforts built around social determinants.

Occupational Quartz Exposure in a Population of Male Individuals-Association With Risk of Developing Atrial Fibrillation

OBJECTIVE

Occupational quartz exposure is a health risk, with increased risk of developing lung, autoimmune diseases, and elevated mortality in cardiovascular diseases.

METHODS

The population was obtained from the period 2005 to 2016 and consisted of 5237 cases of patients with atrial fibrillation (AF). Quartz exposure information was obtained through a Swedish job exposure matrix.

RESULTS

The risk of developing AF was increased for the quartz-exposed male population who were within a year of having commenced employment OR 1.54; (95% CI 1.06-2.24); this increased in the age group 20 to 55 (OR 2.05; CI 95% 1.02-4.10).

CONCLUSION

Our main conclusion is that quartz dust exposure may be related to increased risk of AF in high exposed (above 0.05 mg/m mean quartz dust) in men aged 20 to 55 years.

How useful is the smartwatch ECG?

Apple launched a novel feature of the Apple Watch (Apple Inc.) series 4 that enables consumers to record a rhythm strip and assist with self-diagnosis of atrial fibrillation (AF). The watch is paired with an app that provides automatic classification of the rhythm. Ability of the algorithm to identify AF has received Food and Drug Administration clearance. Given increasing use of direct-to-consumer devices, important questions regarding the utilization of such devices and their features in clinical practice arise. It is unclear how the data obtained from these devices can be optimally incorporated in patient care and what it means for patients. Safety and security of using wearables are also of concern. Furthermore, whether data generated from the Electrocardiogram (ECG) feature will be beneficial to public health is to be determined. We discuss possible uses and challenges of Apple's (Apple Inc.) newly launched ECG feature and review an upcoming trial looking at clinical applications and outcomes using this technology. We also review the literature on the Kardia (AliveCor Inc.) mobile and smartwatch ECG technology and briefly discuss Apple Watch irregular heartbeat notifications along with the Apple Heart Study.

Socioeconomic position and risk of atrial fibrillation: a nationwide Danish cohort study

AIM

To examine the association between socioeconomic position and the risk of atrial fibrillation (AF) in different stages of life in a population of Danish citizens.

METHODS

Register-based study. We followed all individuals turning 35, 50, 65 or 80 years from 1 January 1996 to 31 December 2005 until AF, death, emigration or the end of study period (31 December 2015). Exposure was education and income. We used Cox regression for the HRs (95% CI) and the pseudo-observation method for the adjusted risk difference (RD) (%).

RESULTS

A total of 2 173 857 participants were enrolled and 151 340 incident cases of AF occurred over a median of 13.6 years of follow-up. Adjusted HR (95% CI) of incident AF for the youngest age group with the highest education (ref lowest) was 0.62 (0.50 to 0.77) (women) and 0.85 (0.76 to 0.96) (men). The associations attenuated with increasing age, that is, HRs for the oldest age group were 1.04 (0.97 to 1.10) and 0.98 (0.96 to 1.04), respectively. The corresponding adjusted RDs (%) were: -0.28 (-0.43 to -0.14), -0.18 (-0.36 to -0.01), 3.04 (-0.55 to 6.64) and -0.74 (-3.38 to 2.49), respectively. Similar but weaker associations were found for income.

CONCLUSION

Higher level of education and income was associated with a lower risk of being diagnosed with AF in young individuals but the association decreased with increasing age and was almost absent for the oldest age cohort. However, since AF is relatively rare in the youngest the RDs were low.

Socioeconomic differences in outcomes after hospital admission for atrial fibrillation or flutter

Aims

To examine socioeconomic differences in care and outcomes in a 1-year period beginning 30 days after hospital discharge for first-time atrial fibrillation or flutter (AF) hospitalization.

Methods and results

This nationwide register-based follow-up cohort study investigated AF 30-day discharge survivors in Denmark during 2005–2014 and examined associations between patient’s socioeconomic status (SES) and selected outcomes during a 1-year follow-up period beginning 30 days post-discharge after first-time hospitalization for AF. Patient SES was defined in four groups (lowest, second lowest, second highest, and highest) according to each patient’s equivalized income. SES of the included 150 544 patients was: 27.7% lowest (n = 41 648), 28.1% second lowest (n = 42 321), 23.7% second highest (n = 35 656), and 20.5% highest (n = 30 919). Patients of lowest SES were older and more often women. Within 1-year follow-up, patients of lowest SES were less often rehospitalized or seen in outpatient clinics due to AF, or treated with cardioversion or ablation and were slightly more often diagnosed with stroke and heart failure (HF) and significantly more likely to die (16.1% vs. 14.9%, 11.3% and 8.1%). Hazard ratios for all-cause mortality were 0.64 (95% confidence interval 0.61–0.68) for highest vs. lowest SES, adjusted for CHA2DS2-VASc score, chronic obstructive pulmonary disease, rate- and rhythm-controlling drugs, and cohabitation status.

Conclusion

In 30-day survivors of first-time hospitalization due to AF, lowest SES is associated with increased 1-year all-cause and cardiovascular mortality and fewer cardioversions, ablations, readmissions, and outpatient contacts due to AF. Our findings indicate a need for socially differentiated rehabilitation following hospital discharge for first-time AF.

Association of income and health-related quality of life in atrial fibrillation

Objective

Health-related quality of life (HRQoL) is a patient-centred benchmark promoted by clinical guidelines in atrial fibrillation (AF). Income is associated with health outcomes, but how income effects HRQoL in AF has limited investigation.

Methods

We enrolled a convenience cohort with AF receiving care at a regional healthcare system and assessed demographics, medical history, AF treatment, income, education and health literacy. We defined income as a categorical variable (<$20 000; $20 000-$49 999; $50 000-$99 999; >$100 000). We used two complementary HRQoL measures: (1) the atrial fibrillation effect on quality of life (AFEQT), measuring composite and domain scores (daily activity, symptoms, treatment concerns, treatment satisfaction; range 0-100); (2) the 12-item Short Form Survey (SF-12), measuring general HRQoL with physical and mental health domains (range 0-100). We related income to HRQoL and adjusted for relevant covariates.

Results

In 295 individuals with AF (age 71±10, 40% women), we observed significant differences in HRQoL by income. Higher mean composite AFEQT scores were observed for higher income groups: participants with income <$20 000 had the lowest HRQoL (n=35, 68.2±21.4), and those with income >$100 000 had the highest HRQoL (n=64, 81.9±17.0; p=0.04). We also observed a significant difference by income in the AFEQT daily activity domain (p=0.02). Lower income was also associated with lower HRQoL in the mental health composite score of the SF-12 (59.7±21.5, income <$20 000 vs 79.3±16.3, income >$100 000; p<0.01).

Conclusion

We determined that income was associated with HRQoL in a cohort with prevalent AF. Given the marked differences, we consider income as essential for understanding patient-centred outcomes in AF.

Sociodemographic and clinical factors affecting the quality of life of patients with chronic obstructive pulmonary disease

Background

COPD remains a significant challenge for contemporary medicine. It is one of the most common respiratory illnesses and leads to disability as well as deteriorating patient’s quality of life (QOL).

Objective

The objective of this study was to determine the impact of selected sociodemographic and clinical factors on QOL and level of illness acceptance (LIA) of patients with COPD.

Design

This study was a cross-sectional, prospective, observational study.

Patients and methods

The study involved 100 patients (34 women and 66 men) suffering from COPD for at least half a year, treated in the Allergology Clinic at the Department of Internal Medicine, Geriatrics and Allergy, Wroclaw Medical University in Poland. Standardized questionnaires such as Short Form-36 Health Survey, Saint George’s Respiratory Questionnaire, Acceptance of Illness Scale, and COPD Author’s Questionnaire were used to assess QOL and LIA.

Results

Among the most significant results, there were no statistically significant differences between the patients’ sex and their QOL and LIA (P>0.05). It has been observed that with an increase in the age of patients, a statistically significant decrease in LIA is observed, especially after 60 years of age (P=0.001). It was found that the higher level of education of the patients was statistically significant in the higher QOL (P<0.05) and in the greater LIA (P<0.05). Interestingly, there was no statistically significant effect of active smoking and overweight on QOL and LIA (P>0.05).

Conclusion

Sex of COPD patients does not affect their QOL or LIA, nonetheless, the age decreases the level of QOL and LIA. Higher education improves QOL scores; however, factors such as dyspnea, longer duration of illness, comorbidities, oxygen therapy undertaking, and family burden of respiratory disease affect deterioration of QOL.

Lifetime Risk of Atrial Fibrillation by Race and Socioeconomic Status: ARIC Study (Atherosclerosis Risk in Communities)

BACKGROUND

Limited information exists on the lifetime risk of atrial fibrillation (AF) in African Americans and by socioeconomic status.

METHODS

We studied 15 343 participants without AF at baseline from the ARIC (Atherosclerosis Risk in Communities) cohort recruited in 1987 to 1989 from 4 communities in the United States when they were 45 to 64 years of age. Participants have been followed through 2014. Incidence rates of AF were calculated dividing the number of new cases by person-years of follow-up. Lifetime risk of AF was estimated by a modified Kaplan-Meier method considering death as a competing risk. Participants' family income and education were obtained at baseline.

RESULTS

We identified 2760 AF cases during a mean follow-up of 21 years. Lifetime risk of AF was 36% (95% confidence interval, 32%-38%) in white men, 30% (95% confidence interval, 26%-32%) in white women, 21% (95% confidence interval, 13%-24%) in African American men, and 22% (95% confidence interval, 16%-25%) in African American women. Regardless of race and sex, incidence rates of AF decreased from the lowest to the highest categories of income and education. In contrast, lifetime risk of AF increased in individuals with higher income and education in most sex-race groups. Cumulative incidence of AF was lower in those with higher income and education compared with their low socioeconomic status counterparts through earlier life but was reversed after age 80.

CONCLUSIONS

Lifetime risk of AF in the ARIC cohort was ≈1 in 3 among whites and 1 in 5 among African Americans. Socioeconomic status was inversely associated with cumulative incidence of AF before the last decades of life.

Racial and ethnic differences in the prevalence, management, and outcomes in patients with atrial fibrillation: A systematic review

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.