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Anjum M, Ariansen I, Hjellvik V, Selmer R, Kjerpeseth LJ, Skovlund E, Myrstad M, Ellekjær H, Christophersen IE, Tveit A, Berge T. Stroke and bleeding risk in atrial fibrillation with CHA2DS2-VASC risk score of one: the Norwegian AFNOR study. Eur Heart J 2024; 45:57-66. [PMID: 37995254 DOI: 10.1093/eurheartj/ehad659] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 09/14/2023] [Accepted: 09/23/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND AND AIMS The benefit of oral anticoagulant (OAC) therapy in atrial fibrillation (AF) and intermediate stroke risk is debated. In a nationwide Norwegian cohort with a non-sex CHA2DS2-VASc risk score of one, this study aimed to investigate (i) stroke and bleeding risk in AF patients with and without OAC treatment, and (ii) the risk of stroke in non-anticoagulated individuals with and without AF. METHODS A total of 1 118 762 individuals including 34 460 AF patients were followed during 2011-18 until ischaemic stroke, intracranial haemorrhage, increased CHA2DS2-VASc score, or study end. One-year incidence rates (IRs) were calculated as events per 100 person-years (%/py). Cox regression models provided adjusted hazard ratios (aHRs [95% confidence intervals]). RESULTS Among AF patients, the ischaemic stroke IR was 0.51%/py in OAC users and 1.05%/py in non-users (aHR 0.47 [0.37-0.59]). Intracranial haemorrhage IR was 0.28%/py in OAC users and 0.19%/py in non-users (aHR 1.23 [0.88-1.72]). Oral anticoagulant use was associated with an increased risk of major bleeding (aHR 1.37 [1.16-1.63]) but lower risk of the combined outcome of ischaemic stroke, major bleeding, and mortality (aHR 0.57 [0.51-0.63]). Non-anticoagulated individuals with AF had higher risk of ischaemic stroke compared to non-AF individuals with the same risk profile (aHR 2.47 [2.17-2.81]). CONCLUSIONS In AF patients at intermediate risk of stroke, OAC use was associated with overall favourable clinical outcomes. Non-anticoagulated AF patients had higher risk of ischaemic stroke compared to the general population without AF with the same risk profile.
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Affiliation(s)
- Mariam Anjum
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Gjettum, Norway
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - Inger Ariansen
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - Vidar Hjellvik
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - Randi Selmer
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - Lars J Kjerpeseth
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - Eva Skovlund
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Marius Myrstad
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Gjettum, Norway
- Department of Internal Medicine, Bærum Hospital, Vestre Viken Hospital Trust, Gjettum, Norway
| | - Hanne Ellekjær
- Stroke Unit, Department of Internal Medicine, St.Olavs Hospital, Norway
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Norway
| | - Ingrid E Christophersen
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Gjettum, Norway
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - Arnljot Tveit
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Gjettum, Norway
- Department of Cardiology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Trygve Berge
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Gjettum, Norway
- Department of Internal Medicine, Bærum Hospital, Vestre Viken Hospital Trust, Gjettum, Norway
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Hurskainen M, Tynkkynen J, Eskola M, Lehtimäki T, Hernesniemi J. Risk Factors for Ischemic Stroke After Acute Coronary Syndrome. J Am Heart Assoc 2023; 12:e028787. [PMID: 37421266 PMCID: PMC10382101 DOI: 10.1161/jaha.122.028787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/30/2023] [Indexed: 07/10/2023]
Abstract
Background Stroke incidence is elevated after acute coronary syndromes (ACS). The aim of this study was to characterize risk factors related to ischemic stroke (IS) after ACS. Methods and Results We conducted a retrospective registry study based on the data of 8049 consecutive patients treated for ACS between 2007 and 2018 in Tays Heart Hospital with a follow-up until December 31, 2020. Potential risk factors were identified by in-depth review of written hospital records and causes-of-death registry data maintained by Statistics Finland. The association between individual risk factors, early-onset IS (0-30 days after ACS, n=82), and late-onset IS (31 days to 14 years after ACS, n=419) were analyzed using logistic regression and subdistribution hazard analysis. In multivariable analysis, the most substantial risk factors for early- and late-onset IS were previous stroke, atrial fibrillation or flutter, and heart failure status depicted by the Killip classification. Left ventricular ejection fraction and coronary artery disease severity were significant risk factors for early-onset IS; age and peripheral artery disease were significant risk factors for late-onset IS. The risk of early-onset IS with ≥6 CHA2DS2-VASc score points (odds ratio, 6.63 [95% Cl, 3.63-12.09]; P<0.001) was notable compared with patients with 1 to 3 points as well as the risk of late-onset IS with ≥6 points (subdistribution hazard, 6.03 [95% Cl, 3.71-9.81]; P<0.001) in comparison with patients with 1 point. Conclusions Factors related to high thromboembolic risk also predict IS risk after ACS. CHA2DS2-VASc score and its individual components are strong predictors for both early- and late-onset IS.
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Affiliation(s)
- Matilda Hurskainen
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
| | - Juho Tynkkynen
- Department of RadiologyTampere University HospitalTampereFinland
- Centre of Vascular Surgery and Interventional RadiologyTampere University HospitalTampereFinland
| | - Markku Eskola
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
- Tays Heart HospitalTampere University HospitalTampereFinland
| | - Terho Lehtimäki
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
- Department of Clinical ChemistryFimlab LaboratoriesTampereFinland
- Finnish Cardiovascular Research Center TampereTampereFinland
| | - Jussi Hernesniemi
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
- Tays Heart HospitalTampere University HospitalTampereFinland
- Finnish Cardiovascular Research Center TampereTampereFinland
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Martínez-Sellés M, Bruña V, Lacalzada-Almeida J, Díez-Villanueva P, Ruiz-Ortiz M, Alzola E, Arnau MÁ, Tobar J, Hernández JM, Bonet A, Castro V, Rubín JM, García-Martín A, Pérez-David E. Rationale and design of the rigorous atrial analysis in advanced interatrial block (ARABIA) prospective study. J Electrocardiol 2021; 68:135-140. [PMID: 34419649 DOI: 10.1016/j.jelectrocard.2021.08.007] [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: 07/08/2021] [Revised: 08/04/2021] [Accepted: 08/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Advanced interatrial block (IAB) is present in 10% of subjects ≥75 years and is associated with the risk of clinical events. METHODS AND RESULTS Prospective multicenter study that will include subjects ≥75 years without exclusion criteria (indication for anticoagulation, cardiac devices, severe valve disease, systolic dysfunction, moderate or severe cognitive impairment, poor echocardiographic window, non-sinus rhythm or partial IAB, stroke, and life expectancy <2 years). A total of 356 subjects, 178 patients with advanced IAB (exposed) and 178 matched individuals with normal P-wave (non-exposed) will be included. Electrocardiogram and advanced transthoracic echocardiography will be performed. Two substudies will include magnetic resonance imaging: cardiac (86 subjects, 43 exposed, and 43 non-exposed) and brain (86 subjects, 43 exposed, and 43 non-exposed). The follow-up will be 2 years. Our main objective is to determine the association of advanced IAB, P-wave duration, and atrial imaging parameters (I] atrial global longitudinal strain, II] maximal left atrial volume index, III] left atrial ejection fraction, IV] left atrial fibrosis - % total left atrial area V] inter- and intra-atrial asynchrony/dyssynchrony) with clinical events (atrial fibrillation, stroke, cognitive impairment, and mortality). The secondary objective is to assess the association of the P-wave duration with atrial imaging parameters and of both with cerebral microemboli in magnetic resonance imaging. CONCLUSION Our study will provide data regarding the association of advanced IAB, P-wave duration, and atrial imaging parameters with clinical events. We will also assess the association P-wave duration-atrial imaging parameters-cerebral microemboli.
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Affiliation(s)
- Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Universidad Europea. Universidad Complutense, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain.
| | - Vanesa Bruña
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain; Servicio de Cardiología, Hospital Universitario, 12 de Octubre, Madrid, Spain
| | - Juan Lacalzada-Almeida
- Laboratorio de Imagen Cardíaca, Servicio de Cardiología, Hospital Universitario de Canarias, La Laguna, Tenerife, Spain
| | | | - Martin Ruiz-Ortiz
- Servicio de Cardiología, Hospital Universitario Reina Sofia, Córdoba, Spain
| | - Elisabete Alzola
- Servicio de Cardiología, Hospital Universitario de Cruces, Baracaldo, Bilbao, Spain
| | - Miguel Ángel Arnau
- Servicio de Cardiología, Hospital Universitario y Politécnico la Fe, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Javier Tobar
- Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Jesús Manuel Hernández
- Servicio de Cardiología, Hospital Clínico Universitario de Salamanca, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Ana Bonet
- Servicio de Cardiología, Hospital Universitario de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Victor Castro
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Jose Manuel Rubín
- Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Ana García-Martín
- Servicio de Cardiología. Hospital Universitario Ramón y Cajal, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Esther Pérez-David
- Servicio de Cardiología, Hospital Universitario de la Paz, Madrid, Spain
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Bayés-de-Luna A, Martínez-Sellés M, Elosua R, Bayés-Genís A, Mendieta G, Baranchuk A, Breithardt G. Relation of Advanced Interatrial Block to Risk of Atrial Fibrillation and Stroke. Am J Cardiol 2020; 125:1745-1748. [PMID: 32284175 DOI: 10.1016/j.amjcard.2020.02.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/26/2020] [Accepted: 02/27/2020] [Indexed: 12/18/2022]
Abstract
Advanced interatrial block (A-IAB) has been associated to atrial fibrillation (AF) and ischemic stroke, raising the question as to whether such patients, even when still in sinus rhythm without documented AF, could benefit from oral anticoagulation. AF and A-IAB are both markers of stroke. The anatomical substrate in both is fibrotic atrial cardiomyopathy, resulting in atrial electromechanical dyssynchrony, dysfunction, and left atrial remodelling, that favour blood stasis and hypercoagulation. Under these conditions thrombogenic cascade may be triggered, resulting in systemic embolization. Before proposing oral anticoagulation in the management of selected patients with A-IAB, as is currently recommended in patients with AF and high CHA2DS2-Vasc score, a randomized clinical trial will have to demonstrate efficacy and safety of anticoagulation in this setting. In the meantime, an individualized approach may be considered based on the recognition of those patients at a higher risk of stroke. These may be elderly patients with A-IAB and several risk factors and, thus, with a high CHA2DS2-Vasc score and the presence of environmental arrhythmias.
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Martínez-Sellés M, Elosua R, Ibarrola M, de Andrés M, Díez-Villanueva P, Bayés-Genis A, Baranchuk A, Bayés-de-Luna A. Advanced interatrial block and P-wave duration are associated with atrial fibrillation and stroke in older adults with heart disease: the BAYES registry. Europace 2020; 22:1001-1008. [DOI: 10.1093/europace/euaa114] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 04/17/2020] [Indexed: 12/24/2022] Open
Abstract
Abstract
Aims
Advanced interatrial block (IAB), is an unrecognized surrogate of atrial dysfunction and a trigger of atrial dysrhythmias, mainly atrial fibrillation (AF). Our aim was to prospectively assess whether advanced IAB in sinus rhythm is associated with AF and stroke in elderly outpatients with structural heart disease, a group not previously studied.
Methods and results
Prospective observational registry that included outpatients aged ≥70 years with structural heart disease and no previous diagnosis of AF. Patients were divided into three groups: normal P-wave duration (<120 ms), partial IAB (P-wave duration ≥120 ms, positive in the inferior leads), and advanced IAB [P-wave duration ≥120 ms, biphasic (plus/minus) morphology in the inferior leads]. Among 556 individuals, 223 had normal P-wave (40.1%), 196 partial IAB (35.3%), and 137 advanced IAB (24.6%). After a median follow-up of 694 days, 93 patients (16.7%) developed AF, 30 stroke (5.4%), and 34 died (6.1%). Advanced IAB was independently associated with AF –[hazard ratio (HR) 2.9, 95% confidence interval (CI) 1.7–5.1; P < 0.001], stroke [HR 3.8, 95% CI 1.4–10.7; P = 0.010), and AF/stroke (HR 2.6, 95% CI 1.5–4.4; P = 0.001). P-wave duration (ms) was independently associated with AF (HR 1.05, 95% CI 1.03–1.07; P < 0.001), AF/stroke (HR 1.04, 95% CI 1.02–1.06; P < 0.001), and mortality (HR 1.04, 95% CI 1.00–1.08; P = 0.021).
Conclusions
The presence of advanced IAB in sinus rhythm is independently associated with AF and stroke in an elderly population with structural heart disease and no previous diagnosis of AF. P-wave duration was also associated with all-cause mortality.
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Affiliation(s)
- Manuel Martínez-Sellés
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo, 46, 28007 Madrid, Spain
- Facultad de Ciencias Biomédicas Universidad Europea, Facultad de Medicina Universidad Complutense, Madrid, Spain
- CIBER Cardiovascular Diseases, Madrid, Spain
| | - Roberto Elosua
- CIBER Cardiovascular Diseases, Madrid, Spain
- Hospital del Mar Medical Research Institute, Barcelona, Spain
- Medical School, University of Vic-Central University of Catalonia, Vic, Spain
| | | | - Mireia de Andrés
- Department of Cardiology, Hospital Universitario Vall d´Hebron, Barcelona, Spain
| | | | - Antoni Bayés-Genis
- CIBER Cardiovascular Diseases, Madrid, Spain
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Facultad de Medicina, Autonomous University of Barcelona, Barcelona, Spain
| | | | - Antonio Bayés-de-Luna
- Cardiovascular Research Foundation. Cardiovascular ICCC- Program, Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
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Hjelholt TJ, Johnsen SP, Brynningsen PK, Pedersen AB. Association of CHA 2 DS 2 -VASc Score with Stroke, Thromboembolism, and Death in Hip Fracture Patients. J Am Geriatr Soc 2020; 68:1698-1705. [PMID: 32294240 DOI: 10.1111/jgs.16452] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 03/06/2020] [Accepted: 03/13/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Patients undergoing hip fracture surgery have a 10 times increased risk of stroke compared with the general population. We aimed to evaluate the association between the CHA2 DS2 -VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, previous stroke/TIA [transient ischemic attack]/systemic embolism (2 points), vascular disease, age 65-74 years, and female sex) score and the risk of stroke, thromboembolism, and all-cause mortality in patients with hip fracture with or without atrial fibrillation (AF). DESIGN Nationwide prospective cohort study. SETTING Danish hospitals. PARTICIPANTS Subjects were all incident hip fracture patients in Denmark age 65 years and older with surgical repair procedures between 2004 and 2016 (n = 78,096). Participants were identified using the Danish Multidisciplinary Hip Fracture Registry. MEASUREMENTS We calculated incidence rates, cumulative incidences, and hazard ratios (HRs) with 95% confidence intervals (CIs) by CHA2 DS2 -VASc score, stratified on AF history. RESULTS The cumulative incidence of ischemic stroke 1 year after hip fracture increased with ascending CHA2 DS2 -VASc score, and it was 1.9% for patients with a score of 1 and 8.6% for patients with a score above 5 in the AF group. Corresponding incidences in the non-AF group were 1.6% and 7.6%. Compared with a CHA2 DS2 -VASc score of 1, adjusted HRs were 5.53 (95% CI = 1.37-22.24) among AF patients and 4.91 (95% CI = 3.40-7.10) among non-AF patients with a score above 5. A dose-response-like association was observed for all cardiovascular outcomes. All-cause mortality risks and HRs were substantially higher for all CHA2 DS2 -VASc scores above 1 in both the AF group and the non-AF group. CONCLUSION Among patients with hip fracture, a higher CHA2 DS2 -VASc score was associated with increased risk of stroke, thromboembolism, and death. This finding applied both to patients with and without AF. Patients with high CHA2 DS2 -VASc scores had almost similar absolute risks for cardiovascular outcomes, irrespective of AF. J Am Geriatr Soc 68:1698-1705, 2020.
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Affiliation(s)
- Thomas J Hjelholt
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Søren P Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Alma B Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Nayyar R, Sheth D, Chhabra L. Stroke Risk Based on CHA 2DS 2-VASc Score in the Absence of Atrial Fibrillation. Am J Cardiol 2020; 125:658-659. [PMID: 31883677 DOI: 10.1016/j.amjcard.2019.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 11/11/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Raj Nayyar
- Division of Cardiovascular Medicine, Heartland Regional Medical Center, Marion, Illinois
| | - Dwijesh Sheth
- Division of Cardiovascular Medicine, Heartland Regional Medical Center, Marion, Illinois
| | - Lovely Chhabra
- Division of Cardiovascular Medicine, Heartland Regional Medical Center, Marion, Illinois.
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