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Karakasis P, Patoulias D, Popovic DS, Pamporis K, Theofilis P, Nasoufidou A, Stachteas P, Samaras A, Tzikas A, Giannakoulas G, Stavropoulos G, Kassimis G, Karamitsos T, Fragakis N. Effects of mineralocorticoid receptor antagonists on new-onset or recurrent atrial fibrillation: a Bayesian and frequentist network meta-analysis of randomized trials. Curr Probl Cardiol 2024; 49:102742. [PMID: 39002620 DOI: 10.1016/j.cpcardiol.2024.102742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 07/10/2024] [Indexed: 07/15/2024]
Abstract
Background Clinical and translational research suggests that mineralocorticoid receptor antagonists (MRAs) may prevent atrial fibrosis and electrical remodeling associated with atrial fibrillation (AF). This study aimed to consolidate existing evidence from randomized controlled trials (RCTs) evaluating the effect of MRAs on incident or recurrent AF. Methods Medline, Cochrane Library and Scopus were searched until February 12, 2024. Triple-independent study selection, data extraction and quality assessment were performed. Evidence was pooled using both pairwise and Bayesian and frequentist network meta-analyses. Results Twenty-three RCTs (13,358 participants) were identified. Based on the pairwise random effects meta-analysis, MRAs were associated with a significant reduction in AF events compared to placebo or usual care (risk ratio {RR}= 0.75; 95% confidence interval {CI}= [0.66, 0.87]; P< 0.001; I2= 3%). This protective effect was robust both for new-onset and recurrent AF episodes (subgroup p-value= 0.69), while the baseline HF status was not a significant effect modifier (subgroup p-value= 0.58). MRAs demonstrated a significantly higher reduction in AF events for patients with chronic renal disease compared to placebo (RR= 0.78; 95% CI= [0.62, 0.98]; P= 0.03; I2= 0%). The network meta-analyses revealed that only spironolactone was associated with a significant reduction in AF events (Bayesian RR= 0.76; 95% CI= [0.65, 0.89]; P< 0.001; level of evidence moderate; SUCRA 0.731), while eplerenone and finerenone showed a neutral effect. Conclusion MRAs confer a significant benefit in terms of reducing incident or recurrent AF episodes, irrespective of HF status. In this context, spironolactone may be preferable compared to eplerenone or finerenone.
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Affiliation(s)
- Paschalis Karakasis
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece.
| | - Dimitrios Patoulias
- Outpatient Department of Cardiometabolic Medicine, Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - Djordje S Popovic
- Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Centre of Vojvodina, Medical Faculty, University of Novi Sad, Novi Sad, Serbia
| | - Konstantinos Pamporis
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Panagiotis Theofilis
- First Cardiology Department, General Hospital of Athens "Hippocratio", University of Athens Medical School, Athens, Greece
| | - Athina Nasoufidou
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - Panagiotis Stachteas
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - Athanasios Samaras
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - Apostolos Tzikas
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece; European Interbalkan Medical Center, Department of Cardiology, Thessaloniki, Greece
| | - George Giannakoulas
- First Department of Cardiology, Aristotle University Medical School, Thessaloniki, AHEPA University General Hospital, Greece
| | - George Stavropoulos
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - George Kassimis
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - Theodoros Karamitsos
- First Department of Cardiology, Aristotle University Medical School, Thessaloniki, AHEPA University General Hospital, Greece
| | - Nikolaos Fragakis
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
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Chang YK, Hsu CC, Huang CT, Lien CH, Hsu HY. Differences between atrial fibrillation diagnosed before and after stroke: A large real-world cohort study. PLoS One 2024; 19:e0308507. [PMID: 39141631 PMCID: PMC11324098 DOI: 10.1371/journal.pone.0308507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 07/24/2024] [Indexed: 08/16/2024] Open
Abstract
The clinical characteristics and long-term outcomes of patients with ischemic stroke (IS) and atrial fibrillation detected after stroke (AFDAS) have not been clearly established. Previous studies evaluating patients with AFDAS were limited by the low prescription rates of anticoagulants and short follow-up periods. Consecutive patients hospitalized for IS between 2014 and 2017 were identified from a National Health Insurance Research Database. The included patients were categorized into three groups: (1) known diagnosis of AF (KAF) before the index stroke, (2) AFDAS, and (3) without AF (non-AF). Univariable and multivariable Cox regression analyses were performed to estimate the hazard ratio (HR) for independent variables and recurrent IS, hemorrhagic stroke, or all-cause mortality. We identified 158,909 patients with IS of whom 16,699 (10.5%) had KAF and 7,826 (4.9%) had AFDAS. The patients with AFDAS were younger, more often male, and had lower CHA2DS2-VASc scores (3.8 ± 1.9 versus 4.9 ± 1.8, p < 0.001) than the patients with KAF. Anticoagulant treatment significantly reduced the risks of all outcomes. The standardized mortality rates were 40.4, 28.6, and 18.4 (per 100 person-years) for the patients with KAF, AFDAS, and non-AF, respectively. Compared with AFDAS, KAF was associated with lower risks of recurrent IS [hazard ratio (HR): 0.91, 95% confidence interval (CI): 0.86-0.97, p < 0.01] and hemorrhagic stroke (HR: 0.88, 95% CI: 0.79-0.99, p < 0.01) and a higher risk of all-cause mortality (HR: 1.11, 95% CI: 1.07-1.16, p < 0.001). The risks of recurrent IS and hemorrhagic stroke were higher and of all-cause mortality was lower for patients with AFDAS than with KAF. There is a strong need to refine treatment modalities to reduce the high mortality in patients with KAF and AFDAS.
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Affiliation(s)
- Yu-Kang Chang
- Department of Medical Research, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan
- Department of Life Science, College of Life Science, National Chung Hsing University, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Nursing, Jenteh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan
| | - Chih-Cheng Hsu
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
- National Center for Geriatrics and Welfare Research, National Health Research Institutes, Yunlin, Taiwan
| | - Chi-Ting Huang
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
| | - Chi-Hsun Lien
- Department of Life Science, College of Life Science, National Chung Hsing University, Taichung, Taiwan
- Department of Neurology, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan
| | - Hung-Yi Hsu
- Department of Life Science, College of Life Science, National Chung Hsing University, Taichung, Taiwan
- Department of Neurology, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan
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Wang G, Lian Y, Yang AY, Platt RW, Wang R, Perreault S, Dorais M, Schnitzer ME. Structured learning in time-dependent Cox models. Stat Med 2024; 43:3164-3183. [PMID: 38807296 DOI: 10.1002/sim.10116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 03/14/2024] [Accepted: 05/07/2024] [Indexed: 05/30/2024]
Abstract
Cox models with time-dependent coefficients and covariates are widely used in survival analysis. In high-dimensional settings, sparse regularization techniques are employed for variable selection, but existing methods for time-dependent Cox models lack flexibility in enforcing specific sparsity patterns (ie, covariate structures). We propose a flexible framework for variable selection in time-dependent Cox models, accommodating complex selection rules. Our method can adapt to arbitrary grouping structures, including interaction selection, temporal, spatial, tree, and directed acyclic graph structures. It achieves accurate estimation with low false alarm rates. We develop the sox package, implementing a network flow algorithm for efficiently solving models with complex covariate structures. sox offers a user-friendly interface for specifying grouping structures and delivers fast computation. Through examples, including a case study on identifying predictors of time to all-cause death in atrial fibrillation patients, we demonstrate the practical application of our method with specific selection rules.
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Affiliation(s)
- Guanbo Wang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Yi Lian
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Archer Y Yang
- Department of Mathematics and Statistics, McGill University, Montreal, Quebec, Canada
- Mila Québec AI Institute, Montreal, Quebec, Canada
| | - Robert W Platt
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Rui Wang
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Sylvie Perreault
- Faculté de Pharmacie, Université de Montréal, Montreal, Quebec, Canada
| | - Marc Dorais
- StatSciences Inc., Notre-Dame-de-l'Île-Perrot, Quebec, Canada
| | - Mireille E Schnitzer
- Faculté de Pharmacie, Université de Montréal, Montreal, Quebec, Canada
- Département de Médecine Sociale et Préventive, Université de Montréal, Montreal, Quebec, Canada
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Kotta PA, Nambi V, Misra A, Afshar H, Chelu MG, Nasir K, Abramov D, Minhas AMK. Association between neighborhood household income and inpatient atrial fibrillation outcomes. Heart Rhythm 2024; 21:993-1000. [PMID: 38382688 DOI: 10.1016/j.hrthm.2024.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/22/2024] [Accepted: 02/08/2024] [Indexed: 02/23/2024]
Abstract
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.
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Affiliation(s)
- Prasanti A Kotta
- Baylor College of Medicine, Department of Internal Medicine, Houston, Texas.
| | - Vijay Nambi
- Baylor College of Medicine, Michael E. DeBakey VA Medical Center, Section of Cardiology, Houston, Texas
| | - Arunima Misra
- Baylor College of Medicine, Michael E. DeBakey VA Medical Center, Section of Cardiology, Houston, Texas
| | - Hamid Afshar
- Baylor College of Medicine, Michael E. DeBakey VA Medical Center, Section of Cardiology, Houston, Texas
| | - Mihail G Chelu
- Baylor College of Medicine, Department of Internal Medicine, Houston, Texas; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas; Texas Heart Institute at Baylor St. Luke's Medical Center, Houston, Texas
| | - Khurram Nasir
- Houston Methodist DeBakey Heart & Vascular Center, Section of Cardiology, Houston, Texas
| | - Dmitry Abramov
- Loma Linda, University Health, Department of Cardiology, Loma Linda, California
| | - Abdul Mannan Khan Minhas
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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Huang C, Li L, Liu W, Fang Y, Jiang S, Li Y, Fonarow GC, Sia CH, Yeo LLL, Tan BYQ, Lip GYH, Yang Q, Zhou X. Time to benefit and harm of direct oral anticoagulants in device-detected atrial fibrillation: A pooled analysis of the NOAH-AFNET 6 and ARTESiA trials. Heart Rhythm 2024:S1547-5271(24)02812-1. [PMID: 38925332 DOI: 10.1016/j.hrthm.2024.06.038] [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: 03/04/2024] [Revised: 06/07/2024] [Accepted: 06/20/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) reduce stroke risk in patients with device-detected atrial fibrillation (DD-AFib) but increase major bleeding risk. The time to benefit (TTB) and time to harm (TTH) are not well quantified. OBJECTIVE The purpose of this study was to determine TTB and TTH in DOAC-treated patients with DD-AFib. METHODS Studies were identified from PubMed searching until November 2023. The primary efficacy outcome was the time to the first stroke event, and the primary safety outcome was the time to the first major bleeding event. Pooled hazard ratio (HR) and its confidence interval (CI) were calculated through reconstructed patient-level data and study-level data. Weibull model and Markov chain Monte Carlo simulation were applied to determine time to specific absolute risk change thresholds. RESULTS Two trials involving DOACs-NOAH-AFNET 6 (Non-vitamin K antagonist Oral anticoagulants in patients with Atrial High rate episodes) and ARTESiA (Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation)-were identified, which randomized 6548 adults with a mean age of >75 years and a median atrial high-rate episode duration ranging from 1.5 to 2.8 hours. DOACs decreased the risk of stroke (HR 0.67; 95% CI 0.50-0.90) but increased the risk of major bleeding (HR 1.57; 95% CI 1.21-2.04). A TTB of 2.67 years was needed to prevent 1 stroke per 100 DOAC-treated patients, while a TTH of 1.67 years was needed to observe 1 major bleeding. CONCLUSION In elderly patients with low durations of DD-AFib, DOACs result in a delayed and restricted stroke-preventive benefit while posing an early-onset bleeding risk. Our findings offer new insights into the risk-benefit profile and provide clinicians an additional dimension to facilitate shared decision-making discussions with patients.
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Affiliation(s)
- Chuanyi Huang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Linjie Li
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Wennan Liu
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Yiwen Fang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Shichen Jiang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Yongle Li
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Ching-Hui Sia
- Yong Loo-Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre, Singapore
| | - Leonard L L Yeo
- Yong Loo-Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, National University Health System, Singapore
| | - Benjamin Y Q Tan
- Yong Loo-Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, National University Health System, Singapore
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Qing Yang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China.
| | - Xin Zhou
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China.
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Al-Nusair M, Alrabadi N, Haddad R, Njem S, Aljarrah MI, Hammoudeh A. Residual risk of thromboembolic events despite anticoagulation in Middle Eastern patients with atrial fibrillation. The JoFib study. J Stroke Cerebrovasc Dis 2024; 33:107785. [PMID: 38782168 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107785] [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: 12/23/2023] [Revised: 05/17/2024] [Accepted: 05/20/2024] [Indexed: 05/25/2024] Open
Abstract
OBJECTIVES To investigate residual risk of thromboembolic events despite anticoagulation in patients with atrial fibrillation form the Middle East. MATERIALS AND METHODS Using data from the JoFib registry, we described the characteristics of patients treated with anticoagulants (n = 1654) and calculated the incidence rate for thromboembolic events. We constructed multivariable Cox proportional hazard models and calculated the population-attributable fraction to determine clinical factors predictive of residual thromboembolic events. RESULTS During the one-year follow-up, 57 thromboembolic events occurred (incidence rate 4.1 per 100 person-years). In multivariable time-to-event analysis, prior thromboembolic events (aHR 3.8, 95 %CI 2.2-6.4, p < 0.001) and diabetes (aHR 2.3, 95 %CI 1.3-4.1, p = 0.004) were independently predictive of residual thromboembolism. Percentage of thromboembolic risk attributable to prior thromboembolic events was 30.9 % (95 %CI 13.9-44.6, p = 0.001) and was 37.1 % (95 %CI 8.8-56.6, p = 0.015) for diabetes. Furthermore, the effect of diabetes on thromboembolic events depends on the type of anticoagulant, with diabetes being significantly predictive of thromboembolic events in patients anticoagulated with warfarin (aHR 4.11, 95 %CI 1.81-9.37, p = 0.001), but not non-vitamin K antagonist oral anticoagulants (aHR 1.23, 95 %CI 0.51-2.97, p = 0.643) with a p = 0.045 for interaction. Prior thromboembolism was independently predictive of thromboembolic events in both anticoagulants (aHR 2.67, 95 %CI 1.28-5.58, p = 0.009; aHR 7.33, 95 %CI 3.05-17.65, p < 0.001; respectively; p = 0.084 for interaction). CONCLUSIONS Middle Eastern patients with atrial fibrillation remain at significant risk of thromboembolism and its recurrence despite anticoagulation, and especially in diabetic patients. Therefore, management should focus on controlling diabetes as well as other modifiable risk factors in addition to antithrombotic therapy.
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Affiliation(s)
- Mohammed Al-Nusair
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Nasr Alrabadi
- Department of Pharmacology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan.
| | - Razan Haddad
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Jadara University, Irbid, Jordan
| | - Sumaya Njem
- Department of Pharmacology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Mohammad I Aljarrah
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
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Huang B, Wright DJ, Lip GYH. Subclinical atrial fibrillation patients, who are the best candidates for oral anticoagulant therapy? Eur J Intern Med 2024; 123:49-51. [PMID: 38514288 DOI: 10.1016/j.ejim.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 03/11/2024] [Indexed: 03/23/2024]
Affiliation(s)
- Bi Huang
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - David J Wright
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Cardiology, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Bucci T, Romiti GF, Shantsila A, Teo W, Park H, Shimizu W, Corica B, Proietti M, Tse H, Chao T, Frost F, Lip GYH. Risk of Death and Cardiovascular Events in Asian Patients With Atrial Fibrillation and Chronic Obstructive Pulmonary Disease: A Report From the Prospective APHRS Registry. J Am Heart Assoc 2024; 13:e032785. [PMID: 38533983 PMCID: PMC11179754 DOI: 10.1161/jaha.123.032785] [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: 09/20/2023] [Accepted: 02/27/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is associated with an increased risk of adverse events in patients with atrial fibrillation (AF); however, few data are available on this topic in Asian populations. METHODS AND RESULTS Prospective observational study conducted on patients with AF enrolled in the Asia-Pacific Heart Rhythm Society (APHRS) AF Registry. The diagnosis of COPD was based on data reported in the case report form by the investigators. Cox-regression models were used to assess the 1-year risk of a primary composite outcome of all-cause death, thromboembolic events, acute coronary syndrome, and heart failure. Analysis on single outcomes and cardiovascular death was also performed. Interaction analysis was used to assess the risk of composite outcome and all-cause death in different subgroups. The study included 4094 patients with AF (mean±SD age 68.5±12 years, 34.6% female), of whom 112 (2.7%) had COPD. Patients with COPD showed a higher incidence of the primary composite outcome (25.1% versus 6.3%, P<0.001), all-cause death (14.9% versus 2.6%, P<0.001), cardiovascular death (2.0% versus 0.6%, P<0.001), and heart failure (8.3% versus 6.0%, P<0.001). On multiple Cox-regression analysis, COPD was associated with a higher risk of the primary composite outcome (hazard ratio [HR], 3.17 [95% CI, 2.05-4.90]), all-cause death (HR, 3.59 [95% CI, 2.04-6.30]), and heart failure (HR, 3.32 [95% CI, 1.56-7.03]); no statistically significant differences were found for other outcomes. The association between COPD and mortality was significantly modified by the use of beta blockers (Pint=0.018). CONCLUSIONS In Asian patients with AF, COPD is associated with worse prognosis. In patients with AF and COPD, the use of beta blockers was associated with a lower mortality. REGISTRATION INFORMATION clinicaltrials.gov Identifier: NCT04807049.
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Affiliation(s)
- Tommaso Bucci
- Liverpool Centre of Cardiovascular Science at University of LiverpoolLiverpool John Moores University and Liverpool Heart & Chest HospitalLiverpoolUK
- Department of General and Specialized SurgerySapienza University of RomeRomeItaly
| | - Giulio Francesco Romiti
- Liverpool Centre of Cardiovascular Science at University of LiverpoolLiverpool John Moores University and Liverpool Heart & Chest HospitalLiverpoolUK
- Department of Translational and Precision MedicineSapienza University of RomeRomeItaly
| | - Alena Shantsila
- Liverpool Centre of Cardiovascular Science at University of LiverpoolLiverpool John Moores University and Liverpool Heart & Chest HospitalLiverpoolUK
| | - Wee‐Siong Teo
- Department of CardiologyNational Heart CentreSingaporeSingapore
| | - Hyung‐Wook Park
- Department of Cardiovascular MedicineChonnam National University HospitalGwangjuKorea
| | - Wataru Shimizu
- Department of Cardiovascular MedicineNippon Medical SchoolTokyoJapan
| | - Bernadette Corica
- Liverpool Centre of Cardiovascular Science at University of LiverpoolLiverpool John Moores University and Liverpool Heart & Chest HospitalLiverpoolUK
- Department of Translational and Precision MedicineSapienza University of RomeRomeItaly
| | - Marco Proietti
- Department of Clinical Sciences and Community HealthUniversity of MilanMilanItaly
- Division of Subacute CareIRCCS Istituti Clinici Scientifici MaugeriMilanItaly
| | - Hung‐Fat Tse
- Department of Medicine, School of Clinical Medicine; Queen Mary HospitalThe University of Hong KongHong KongSARChina
| | - Tze‐Fan Chao
- Institute of Clinical Medicine, and Cardiovascular Research CenterNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Division of Cardiology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
| | - Frederick Frost
- Liverpool Centre of Cardiovascular Science at University of LiverpoolLiverpool John Moores University and Liverpool Heart & Chest HospitalLiverpoolUK
| | - Gregory Y. H. Lip
- Liverpool Centre of Cardiovascular Science at University of LiverpoolLiverpool John Moores University and Liverpool Heart & Chest HospitalLiverpoolUK
- Danish Center for Health Services Research, Department of Clinical MedicineAalborg UniversityAalborgDenmark
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Ahn HJ, Choi EK, Rhee TM, Choi J, Lee KY, Kwon S, Lee SR, Oh S, Lip GYH. Accelerometer-derived physical activity and the risk of death, heart failure, and stroke in patients with atrial fibrillation: a prospective study from UK Biobank. Br J Sports Med 2024; 58:427-434. [PMID: 38418213 DOI: 10.1136/bjsports-2023-106862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVE Data on cardiovascular outcomes according to objectively measured physical activity (PA) in patients with atrial fibrillation (AF) are scarce. This study explored the associations between PA derived from wrist-worn accelerometers and the risk of death, incident heart failure (HF), and incident stroke in patients with AF. METHODS From 37 990 patients with AF in UK Biobank, 2324 patients with accelerometer data were included. Weekly moderate-to-vigorous PA (MVPA) duration was computed from accelerometer data. The primary outcome was all-cause mortality. Secondary outcomes were cardiovascular mortality, incident HF, and incident stroke. Restricted cubic splines estimated the dose-response associations between MVPA duration and the outcomes. The adjusted HRs (aHRs) of the outcomes according to adherence to PA standard guidelines (performing MVPA≥150 min/week) were also evaluated. RESULTS The mean age was 66.9±6.2 years and 64.9% were male. During a median follow-up of 6.7 years, there were 181 all-cause deaths, 62 cardiovascular deaths, 225 cases of incident HF, and 91 cases of incident stroke; the overall incidence rate per 1000 patient-years was 11.76, 4.03, 15.16 and 5.99, respectively. There was a linear inverse dose-response relationship between MVPA (≥108 min/week) and all-cause mortality. Performing MVPA for 105-590 min/week was associated with a lower risk of HF than those with no measurable MVPA. The risk of stroke and cardiovascular mortality was not associated with MVPA. Performing guideline-adherent MVPA was related to a 30% lower risk of all-cause mortality (aHR: 0.70 (0.50-0.98), p=0.04) and 33% lower risk of HF (aHR 0.67 (0.49-0.93), p=0.02). CONCLUSION In patients with AF, accelerometer-derived PA data supports lower risks of all-cause mortality and HF according to a greater level of MVPA and adherence to PA guidelines. Regular MVPA should be encouraged in patients with AF as a part of integrated management.
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Affiliation(s)
- Hyo-Jeong Ahn
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Tae-Min Rhee
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Republic of Korea
| | - JungMin Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyung-Yeon Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Soonil Kwon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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10
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McIntyre WF, Benz AP, Becher N, Healey JS, Granger CB, Rivard L, Camm AJ, Goette A, Zapf A, Alings M, Connolly SJ, Kirchhof P, Lopes RD. Direct Oral Anticoagulants for Stroke Prevention in Patients With Device-Detected Atrial Fibrillation: A Study-Level Meta-Analysis of the NOAH-AFNET 6 and ARTESiA Trials. Circulation 2024; 149:981-988. [PMID: 37952187 DOI: 10.1161/circulationaha.123.067512] [Citation(s) in RCA: 60] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Device-detected atrial fibrillation (also known as subclinical atrial fibrillation or atrial high-rate episodes) is a common finding in patients with an implanted cardiac rhythm device and is associated with an increased risk of ischemic stroke. Whether oral anticoagulation is effective and safe in this patient population is unclear. METHODS We performed a systematic review of MEDLINE and Embase for randomized trials comparing oral anticoagulation with antiplatelet or no antithrombotic therapy in adults with device-detected atrial fibrillation recorded by a pacemaker, implantable cardioverter defibrillator, cardiac resynchronization therapy device, or implanted cardiac monitor. We used random-effects models for meta-analysis and rated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework (GRADE). The review was preregistered (PROSPERO CRD42023463212). RESULTS From 785 citations, we identified 2 randomized trials with relevant clinical outcome data: NOAH-AFNET 6 (Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial High Rate Episodes; 2536 participants) evaluated edoxaban, and ARTESiA (Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation; 4012 participants) evaluated apixaban. Meta-analysis demonstrated that oral anticoagulation with these agents reduced ischemic stroke (relative risk [RR], 0.68 [95% CI, 0.50-0.92]; high-quality evidence). The results from the 2 trials were consistent (I2 statistic for heterogeneity=0%). Oral anticoagulation also reduced a composite of cardiovascular death, all-cause stroke, peripheral arterial embolism, myocardial infarction, or pulmonary embolism (RR, 0.85 [95% CI, 0.73-0.99]; I2=0%; moderate-quality evidence). There was no reduction in cardiovascular death (RR, 0.95 [95% CI, 0.76-1.17]; I2=0%; moderate-quality evidence) or all-cause mortality (RR, 1.08 [95% CI, 0.96-1.21]; I2=0%; moderate-quality evidence). Oral anticoagulation increased major bleeding (RR, 1.62 [95% CI, 1.05-2.50]; I²=61%; high-quality evidence). CONCLUSIONS The results of the NOAH-AFNET 6 and ARTESiA trials are consistent with each other. Meta-analysis of these 2 large randomized trials provides high-quality evidence that oral anticoagulation with edoxaban or apixaban reduces the risk of stroke in patients with device-detected atrial fibrillation and increases the risk of major bleeding.
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Affiliation(s)
- William F McIntyre
- McMaster University and Population Health Research Institute, Hamilton, Canada (W.F.M., A.P.B., J.S.H., S.J.C.)
| | - Alexander P Benz
- McMaster University and Population Health Research Institute, Hamilton, Canada (W.F.M., A.P.B., J.S.H., S.J.C.)
| | - Nina Becher
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (N.B., P.K.)
| | - Jeffrey S Healey
- McMaster University and Population Health Research Institute, Hamilton, Canada (W.F.M., A.P.B., J.S.H., S.J.C.)
| | | | | | - A John Camm
- St George's University of London and Imperial College London, United Kingdom (A.J.C.)
| | - Andreas Goette
- Department of Cardiology and Intensive Care Medicine, St Vincenz Hospital Paderborn, Germany (A.G.)
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany (A.Z.)
| | | | - Stuart J Connolly
- McMaster University and Population Health Research Institute, Hamilton, Canada (W.F.M., A.P.B., J.S.H., S.J.C.)
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (N.B., P.K.)
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G., R.D.L.)
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11
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Oraii A, Healey JS, Kowalik K, Pandey AK, Benz AP, Wong JA, Conen D, McIntyre WF. Mineralocorticoid receptor antagonists and atrial fibrillation: a meta-analysis of clinical trials. Eur Heart J 2024; 45:756-774. [PMID: 38195054 DOI: 10.1093/eurheartj/ehad811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/05/2023] [Accepted: 11/28/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND AND AIMS Mineralocorticoid receptor antagonists (MRAs) improve cardiovascular outcomes in a variety of settings. This study aimed to assess whether cardioprotective effects of MRAs are modified by heart failure (HF) and atrial fibrillation (AF) status and to study their impact on AF events. METHODS MEDLINE, Embase, and Cochrane Central databases were searched to 24 March 2023 for randomized controlled trials evaluating the efficacy of MRAs as compared with placebo or usual care in reducing cardiovascular outcomes and AF events in patients with or at risk for cardiovascular diseases. Random-effects models and interaction analyses were used to test for effect modification. RESULTS Meta-analysis of seven trials (20 741 participants, mean age: 65.6 years, 32% women) showed that the efficacy of MRAs, as compared with placebo, in reducing a composite of cardiovascular death or HF hospitalization remains consistent across patients with HF [risk ratio = 0.81; 95% confidence interval (CI): 0.67-0.98] and without HF (risk ratio = 0.84; 95% CI: 0.75-0.93; interaction P = .77). Among patients with HF, MRAs reduced cardiovascular death or HF hospitalization in patients with AF (hazard ratio = 0.95; 95% CI: 0.54-1.66) to a similar extent as in those without AF (hazard ratio = 0.82; 95% CI: 0.63-1.07; interaction P = .65). Pooled data from 20 trials (21 791 participants, mean age: 65.2 years, 31.3% women) showed that MRAs reduce AF events (risk ratio = 0.76; 95% CI: 0.67-0.87) in both patients with and without prior AF. CONCLUSIONS Mineralocorticoid receptor antagonists are similarly effective in preventing cardiovascular events in patients with and without HF and most likely retain their efficacy regardless of AF status. Mineralocorticoid receptor antagonists may also be moderately effective in preventing incident or recurrent AF events.
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Affiliation(s)
- Alireza Oraii
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| | - Krzysztof Kowalik
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Avinash K Pandey
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Alexander P Benz
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
| | - Jorge A Wong
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| | - David Conen
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| | - William F McIntyre
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
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12
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Jung M, Yang PS, Kim D, Sung JH, Jang E, Yu HT, Kim TH, Uhm JS, Pak HN, Lee MH, Joung B. Multimorbidity in atrial fibrillation for clinical implications using the Charlson Comorbidity Index. Int J Cardiol 2024; 398:131605. [PMID: 38000669 DOI: 10.1016/j.ijcard.2023.131605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/05/2023] [Accepted: 11/19/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Predicting survival in atrial fibrillation (AF) patients with comorbidities is challenging. This study aimed to assess multimorbidity in AF patients using the Charlson Comorbidity Index (CCI) and its clinical implications. METHODS We analyzed 451,368 participants from the Korea National Health Insurance Service-Health Screening cohort (2002-2013) without prior AF diagnoses. Patients were categorized into new-onset AF and non-AF groups, with a high CCI defined as ≥4 points. Antithrombotic treatment and outcomes (all-cause death, stroke, major bleeding, and heart failure [HF] hospitalization) were evaluated over 9 years. RESULTS In total, 9.5% of the enrolled patients had high CCI. During follow-up, 12,241 patients developed new-onset AF. Among AF patients, antiplatelet drug use increased significantly in those with high CCI (adjusted odds ratio [OR] 1.05, 95%confidence interval [CI] 1.02-1.08, P < .001). However, anticoagulants were significantly less prescribed in patients with high CCI (OR 0.97, 95%CI 0.95-0.99, P = .012). Incidence of adverse events (all-cause death, stroke, major bleeding, HF hospitalization) progressively increased in this order: low CCI without AF, high CCI without AF, low CCI with AF, and high CCI with AF (all P < .001). Furthermore, high CCI with AF had a significantly higher risk compared to low CCI without AF (all-cause death, adjusted hazard ratio [aHR] 2.52, 95% CI 2.37-2.68, P < .001; stroke, aHR 1.43, 95% CI 1.29-1.58, P < .001; major bleeding, aHR 1.14, 95% CI 1.04-1.26, P = .007; HF hospitalization, aHR 4.75, 95% CI 4.03-5.59, P < .001). CONCLUSIONS High CCI predicted increased antiplatelet use and reduced oral anticoagulant prescription. AF was associated with higher risks of all-cause death, stroke, major bleeding, and HF hospitalization compared to high CCI.
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Affiliation(s)
- Moonki Jung
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Pil-Sung Yang
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Daehoon Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung-Hoon Sung
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Eunsun Jang
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hee Tae Yu
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Sun Uhm
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Moon-Hyoung Lee
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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13
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Wang YT, Chen JH, Liao SF, Chen YJ, Lip GYH, Yeh JS. Cardiac and renal outcomes of direct oral anticoagulants in patients with atrial fibrillation. Eur J Clin Invest 2024; 54:e14086. [PMID: 37635402 DOI: 10.1111/eci.14086] [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: 06/16/2023] [Revised: 08/03/2023] [Accepted: 08/14/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Oral anticoagulation therapy with warfarin or direct oral anticoagulants (DOACs) is the mainstay for stroke prevention in patients with non-valvular atrial fibrillation (AF). The DOACs might have a lower risk of declining renal function than warfarin. This study aimed to compare renal outcomes among rivaroxaban, edoxaban, dabigatran, and warfarin. METHOD This cohort study identified 2203 adults with AF who started anticoagulation therapy between 1 July 2013 and 31 December 2020, in a clinical database at a single centre. Inverse probability of treatment weighting was adopted to balance baseline characteristics among four anticoagulants treatment groups. The primary outcome was a composite of cardiac and renal outcomes, involving a ≥30% decline in estimated glomerular filtration rate (eGFR), renal failure and cardiovascular death. RESULTS After propensity score weighting, dabigatran was associated with significantly lower risks of a ≥30% decline in eGFR (hazard ratio [HR]: .69, 95% confidence interval [CI]: .497-.951, p = .0237), doubling of the serum creatinine level (HR: .49, 95% CI: .259-.927, p = .0282) and the cardiac and renal outcome composite (HR: .67, 95% CI: .485-.913, p = .0115) than warfarin. Rivaroxaban and edoxaban did not show significant protective effects on renal outcomes compared to warfarin. CONCLUSION In this study, patients treated with dabigatran had significantly reduced risks of declining renal function and composite cardiac and renal events than those treated with warfarin. However, rivaroxaban and edoxaban were not associated with lower risks of any renal outcomes than warfarin. More studies are warranted to investigate and compare the impact of renal function between different DOACs in patients with AF.
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Affiliation(s)
- Yu-Ting Wang
- Department of Pharmacy, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Jo-Hsin Chen
- Department of Pharmacy, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Shu-Fen Liao
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
- Department of Medical Research, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yu-Jen Chen
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jong-Shiuan Yeh
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
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14
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Ding WY, Fawzy AM, Romiti GF, Proietti M, Pastori D, Huisman MV, Lip GYH. Validating the predictive ability of the 2MACE score for major adverse cardiovascular events in patients with atrial fibrillation: results from phase II/III of the GLORIA-AF registry. J Thromb Thrombolysis 2024; 57:39-49. [PMID: 37566295 PMCID: PMC10830583 DOI: 10.1007/s11239-023-02866-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2023] [Indexed: 08/12/2023]
Abstract
The 2MACE score was specifically developed as a risk-stratification tool in atrial fibrillation (AF) to predict cardiovascular outcomes. We evaluated the predictive ability of the 2MACE score in the GLORIA-AF registry. All eligible patients from phase II/III of the prospective global GLORIA-AF registry were included. Major adverse cardiac events (MACEs) were defined as the composite outcome of stroke, myocardial infarction and cardiovascular death. Cox proportional hazards were used to examine the relationship between the 2MACE score and study outcomes. Predictive capability of the 2MACE score was investigated using receiver-operating characteristic curves. A total of 25,696 patients were included (mean age 71 years, female 44.9%). Over 3 years, 1583 MACEs were recorded. Patients who had MACE were older, with more cardiovascular risk factors and were less likely to be managed using a rhythm-control strategy. The median 2MACE score in the MACE and non-MACE groups were 2 (IQR 1-3) and 1 (IQR 0-2), respectively (p < 0.001). The 2MACE score was positively associated with an increase in the risk of MACE, with a score of ≥ 2 providing the best combination of sensitivity (69.6%) and specificity (51.6%), HR 2.47 (95% CI, 2.21-2.77). The 2MACE score had modest predictive performance for MACE in patients with AF (AUC 0.655 (95% CI, 0.641-0.669)). Our analysis in this prospective global registry demonstrates that the 2MACE score can adequately predict the risk of MACE (defined as myocardial infarction, CV death and stroke) in patients with AF. Clinical trial registration: http://www.clinicaltrials.gov . Unique identifiers: NCT01468701, NCT01671007 and NCT01937377.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Ameenathul Mazaya Fawzy
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Daniele Pastori
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark.
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15
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Bisson A, Lemrini Y, Romiti GF, Proietti M, Angoulvant D, Bentounes S, El-Bouri W, Lip GYH, Fauchier L. Prediction of early death after atrial fibrillation diagnosis using a machine learning approach: A French nationwide cohort study. Am Heart J 2023; 265:191-202. [PMID: 37595659 DOI: 10.1016/j.ahj.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 08/14/2023] [Indexed: 08/20/2023]
Abstract
AIMS Atrial fibrillation is associated with important mortality but the usual clinical risk factor based scores only modestly predict mortality. This study aimed to develop machine learning models for the prediction of death occurrence within the year following atrial fibrillation diagnosis and compare predictive ability against usual clinical risk scores. METHODS AND RESULTS We used a nationwide cohort of 2,435,541 newly diagnosed atrial fibrillation patients seen in French hospitals from 2011 to 2019. Three machine learning models were trained to predict mortality within the first year using a training set (70% of the cohort). The best model was selected to be evaluated and compared with previously published scores on the validation set (30% of the cohort). Discrimination of the best model was evaluated using the C index. Within the first year following atrial fibrillation diagnosis, 342,005 patients (14.4%) died after a period of 83 (SD 98) days (median 37 [10-129]). The best machine learning model selected was a deep neural network with a C index of 0.785 (95% CI, 0.781-0.789) on the validation set. Compared to clinical risk scores, the selected model was superior to the CHA2DS2-VASc and HAS-BLED risk scores and superior to dedicated scores such as Charlson Comorbidity Index and Hospital Frailty Risk Score to predict death within the year following atrial fibrillation diagnosis (C indexes: 0.597; 0.562; 0.643; 0.626 respectively. P < .0001). CONCLUSION Machine learning algorithms predict early death after atrial fibrillation diagnosis and may help clinicians to better risk stratify atrial fibrillation patients at high risk of mortality.
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Affiliation(s)
- Arnaud Bisson
- Service de Cardiologie, Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, Tours, France; EA4245, Transplantation Immunité Inflammation, Université de Tours, Tours, France; Service de Cardiologie, Centre Hospitalier Régional Universitaire d'Orléans, Orléans, France; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
| | - Yassine Lemrini
- Service de Cardiologie, Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, Tours, France
| | - Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Translational and Precision Medicine, Sapienza - University of Rome, Italy
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Italy; Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milano, Italy
| | - Denis Angoulvant
- Service de Cardiologie, Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, Tours, France; EA4245, Transplantation Immunité Inflammation, Université de Tours, Tours, France
| | - Sidahmed Bentounes
- Service de Cardiologie, Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, Tours, France
| | - Wahbi El-Bouri
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, Tours, France
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Jiang C, Li M, Hu Y, Du X, Li X, He L, Lai Y, Chen T, Li Y, Guo X, Jiang C, Tang R, Sang C, Long D, Xie G, Dong J, Ma C. Identification of atrial fibrillation phenotypes at low risk of stroke in patients with CHA2DS2-VASc ≥2: Insight from the China-AF study. Pacing Clin Electrophysiol 2023; 46:1203-1211. [PMID: 37736697 DOI: 10.1111/pace.14829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 08/07/2023] [Accepted: 09/07/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE Patients with atrial fibrillation (AF) are highly heterogeneous, and current risk stratification scores are only modestly good at predicting an individual's stroke risk. We aim to identify distinct AF clinical phenotypes with cluster analysis to optimize stroke prevention practices. METHODS From the prospective Chinese Atrial Fibrillation Registry cohort study, we included 4337 AF patients with CHA2 DS2 -VASc≥2 for males and 3 for females who were not treated with oral anticoagulation. We randomly split the patients into derivation and validation sets by a ratio of 7:3. In the derivation set, we used outcome-driven patient clustering with metric learning to group patients into clusters with different risk levels of ischemic stroke and systemic embolism, and identify clusters of patients with low risks. Then we tested the results in the validation set, using the clustering rules generated from the derivation set. Finally, the survival decision tree was applied as a sensitivity analysis to confirm the results. RESULTS Up to the follow-up of 1 year, 140 thromboembolic events (ischemic stroke or systemic embolism) occurred. After supervised metric learning from six variables involved in CHA2 DS2 -VASc scheme, we identified a cluster of patients (255/3035, 8.4%) at an annual thromboembolism risk of 0.8% in the derivation set. None of the patients in the low-risk cluster had prior thromboembolism, heart failure, diabetes, or age older than 70 years. After applying the regularities from metric learning on the validation set, we also identified a cluster of patients (137/1302, 10.5%) with an incident thromboembolism rate of 0.7%. Sensitivity analysis based on the survival decision tree approach selected a subgroup of patients with the same phenotypes as the metric-learning algorithm. CONCLUSIONS Cluster analysis identified a distinct clinical phenotype at low risk of stroke among high-risk [CHA2 DS2 -VASc≥2 (3 for females)] patients with AF. The use of the novel analytic approach has the potential to prevent a subset of AF patients from unnecessary anticoagulation and avoid the associated risk of major bleeding.
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Affiliation(s)
- Chao Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Mingxiao Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Yiying Hu
- Ping An Health Technology, Beijing, China
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
- Heart Health Research Center, Beijing, China
| | - Xiang Li
- Ping An Health Technology, Beijing, China
| | - Liu He
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Yiwei Lai
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Tiange Chen
- School of Public Health, Peking University Health Science Center, Beijing, China
| | - Yingxue Li
- Ping An Health Technology, Beijing, China
| | - Xueyuan Guo
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Chenxi Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Ribo Tang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Caihua Sang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Deyong Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | | | - Jianzeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
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17
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Abu-Qaoud MR, Kumar A, Tarun T, Abraham S, Ahmad J, Khadke S, Husami R, Kulbak G, Sahoo S, Januzzi JL, Neilan TG, Baron SJ, Martin D, Nohria A, Reynolds MR, Kosiborod M, Dani SS, Ganatra S. Impact of SGLT2 Inhibitors on AF Recurrence After Catheter Ablation in Patients With Type 2 Diabetes. JACC Clin Electrophysiol 2023; 9:2109-2118. [PMID: 37565953 DOI: 10.1016/j.jacep.2023.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/31/2023] [Accepted: 06/07/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND The effects of sodium-glucose cotransporter 2 inhibitors (SGLT2-Is) on recurrent atrial fibrillation (AF) among patients undergoing catheter ablation is not well described. OBJECTIVES This study sought to assess the impact of SGLT2-Is on the recurrence of AF among patients with type 2 diabetes mellitus (DM) after catheter ablation. METHODS Using the TriNetX research network, we identified, by means of Current Procedural Terminology codes, patients ≥18 years of age with type 2 diabetes mellitus (DM) who had undergone AF ablation from April 1, 2014, to November 30, 2021. Patients were stratified based on the baseline SGLT2-I use. Propensity-score matching resulted in 2,225 patients in each cohort. The primary outcome was a composite of cardioversion, new antiarrhythmic drug (AAD) therapy, or re-do AF ablation after a blanking period after the index ablation. Additional outcomes included heart failure exacerbations, ischemic stroke, all-cause hospitalization, and death during 12 months of follow-up. RESULTS SGLT2-I use in patients with type 2 DM undergoing AF ablation was associated with a significantly lower risk of cardioversion, new AAD therapy, and re-do AF ablation (adjusted OR: 0.68; 95% CI: 0.602-0.776; P < 0.0001). At 12 months, patients on SGLT2-Is had a higher probability of event-free survival (HR: 0.85, 95% CI: 0.77-0.95; log-rank test chi-square = 8.7; P = 0.003). All secondary outcomes were lower in the SGLT2I group; however, the ischemic stroke did not differ between groups. CONCLUSIONS Use of SGLT2-Is in patients with type 2 DM is associated with a lower risk of arrhythmia recurrence after AF ablation and thence a reduced need for cardioversion, AAD therapy, or re-do AF ablation.
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Affiliation(s)
- Moh'd Rasheed Abu-Qaoud
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Ashish Kumar
- Division of Internal Medicine, Cleveland Clinic, Akron, Ohio, USA
| | - Tushar Tarun
- Division of Cardiovascular Medicine, Department of Medicine, University of Arkansas for Medical Sciences, Arkansas, USA
| | - Sonu Abraham
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Javaria Ahmad
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Sumanth Khadke
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Raya Husami
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Guy Kulbak
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Sibasis Sahoo
- U.N. Mehta Institute of Cardiology and Reserch Center, Ahmedabad, Gujarat, India
| | - James L Januzzi
- Division of Cardiovascular Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tomas G Neilan
- Division of Cardiovascular Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Suzanne J Baron
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - David Martin
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Anju Nohria
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew R Reynolds
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City, Missouri, USA
| | - Sourbha S Dani
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Sarju Ganatra
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA.
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18
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Fawzy AM, Bisson A, Bentounes SA, Bodin A, Herbert J, Lip GYH, Fauchier L. Ventricular arrhythmias and cardiac arrest in atrial fibrillation patients with pacemakers and implantable cardioverter-defibrillators. Eur J Intern Med 2023; 115:70-78. [PMID: 37291016 DOI: 10.1016/j.ejim.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/04/2023] [Accepted: 05/08/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) has been linked to ventricular arrhythmias (VAs) and sudden death, but few studies have specifically explored this association. OBJECTIVE We investigated whether AF is associated with an increased risk of ventricular tachycardia (VT), ventricular fibrillation (VF) and cardiac arrests (CA) in patients with cardiac implantable electronic devices (CIEDs). METHODS All patients with pacemakers and implantable cardioverter-defibrillators (ICDs) hospitalised between 2010 and 2020 were identified from the French National database. Patients with a prior history of VT/VF/CA were excluded. RESULTS 701,195 patients were identified initially. After excluding 55,688 patients, 581,781 (90.1%) and 63,726 (9.9%) remained in the pacemaker and ICD groups respectively. 248,046 (42.6%) pacemaker patients had AF and 333,735 (57.4%) had no AF, whereas in the ICD group 20,965 (32.9%) had AF and 42,761 (67.1%) had no AF. The incidence of VT/VF/CA was higher in AF patients compared to non-AF patients both in pacemaker (1.47%/year vs. 0.94%/year) and ICD (5.30%/year vs. 4.21%/year) groups. After multivariable analysis, AF was independently associated with an increased risk of VT/VF/CA in pacemaker (HR 1.236 [95% CI 1.198-1.276]) and ICD (HR 1.167 [95% CI 1.111-1.226]) patients. This risk was still significant in the 1:1 propensity score-matched analysis of the pacemaker (n = 200,977 per subgroup) and ICD cohorts (n = 18,349 per subgroup), HR 1.230 [95% CI 1.187-1.274] and HR 1.134 [95% CI 1.071-1.200] respectively and in the competing risk analysis (pacemaker: HR 1.195 (95% CI 1.154-1.238], ICD: HR 1.094 [95% CI 1.034-1.157]). CONCLUSION CIED patients with AF have a higher risk of VT/VF/CA compared to CIED patients without AF.
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Affiliation(s)
- Ameenathul M Fawzy
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Arnaud Bisson
- Tours Regional University Hospital, Hospital Trousseau, Tours, France; Orleans Regional Hospital, Orleans, France
| | - Sid A Bentounes
- Tours Regional University Hospital, Hospital Trousseau, Tours, France
| | - Alexandre Bodin
- Tours Regional University Hospital, Hospital Trousseau, Tours, France
| | - Julien Herbert
- Tours Regional University Hospital, Hospital Trousseau, Tours, France
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Laurent Fauchier
- Tours Regional University Hospital, Hospital Trousseau, Tours, France.
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19
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Jiao T, Ruzieh M. Letter by Jiao and Ruzieh Regarding Article, "Comparative Effectiveness of Left Atrial Appendage Occlusion Versus Oral Anticoagulation by Sex". Circulation 2023; 148:508-509. [PMID: 37549202 DOI: 10.1161/circulationaha.123.064702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Affiliation(s)
- Tianze Jiao
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy (T.J.)., University of Florida, Gainesville
- Center for Drug Evaluation and Safety (CoDES) (T.J.), University of Florida, Gainesville
| | - Mohammed Ruzieh
- Department of Cardiovascular Medicine, College of Medicine (M.R.), University of Florida, Gainesville
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20
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Bucci T, Proietti M, Shantsila A, Romiti GF, Teo WS, Park HW, Shimizu W, Tse HF, Lip GY, Chao TF. Integrated Care for Atrial Fibrillation Using the ABC Pathway in the Prospective APHRS-AF Registry. JACC. ASIA 2023; 3:580-591. [PMID: 37614548 PMCID: PMC10442886 DOI: 10.1016/j.jacasi.2023.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/27/2023] [Accepted: 04/18/2023] [Indexed: 08/25/2023]
Abstract
Background The Atrial Fibrillation Better Care (ABC) has been proposed as an integrated approach to improve management in patients with atrial fibrillation (AF), based on 3 pillars: "A" Avoid stroke with Anticoagulation; "B" Better symptoms control; "C" Cardiovascular risk-factor and comorbidities management. Objectives This study sought to investigate the association with outcomes of ABC adherence in the prospective multinational Asia-Pacific Heart Rhythm Society (APHRS) Atrial Fibrillation registry. Method Cox-regression analyses adjusted for age, sex, CHA2DS2-VASc score, paroxysmal AF, chronic obstructive pulmonary disease, chronic kidney disease, cancer, dyslipidemia, and dementia were performed to investigate the association with outcomes. Primary outcome was a composite of all-cause death, any thromboembolic events, acute coronary syndrome or percutaneous interventional procedures, and advancing heart failure. Results Of the 4,013 included patients with AF (mean age 68 ± 12 years; 34.4% female); 38.6% were adherent to all 3 main ABC pillars. After 1 year of follow-up, adherence to the ABC pathway was associated with a low incidence of composite outcome (4.0% vs 8.5%, P < 0.001), all-cause and cardiovascular death, and advancing heart failure. On Cox regression analysis, ABC adherence was associated with a lower risk of primary outcome (HR: 0.72; 95% CI: 0.53-0.97), with risk reduction progressively higher with a higher number of ABC criteria attained. No significant interaction in the association was seen according to the different geographic areas (Pint = 0.217). Conclusions In a large contemporary cohort of Asian patients with AF, adherence to ABC pathway was associated with a reduction of the risk for adverse outcomes. (Clinical Survey on the Stroke Prevention in Atrial Fibrillation in Asia (AF-Registry; NCT04807049).
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Affiliation(s)
- Tommaso Bucci
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of General and Specialized Surgery, Sapienza University of Rome, Rome, Italy
| | - Marco Proietti
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Alena Shantsila
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Giulio Francesco Romiti
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Wee-Siong Teo
- Department of Cardiology, National Heart Centre, Singapore
| | - Hyung-Wook Park
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, School of Clinical Medicine, Queen Mary Hospital, the University of Hong Kong, Hong Kong SAR, China
| | - Gregory Y.H. Lip
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Denmark
| | - Tze-Fan Chao
- Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - APHRS-AF Registry Investigators
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of General and Specialized Surgery, Sapienza University of Rome, Rome, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
- Department of Cardiology, National Heart Centre, Singapore
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
- Division of Cardiology, Department of Medicine, School of Clinical Medicine, Queen Mary Hospital, the University of Hong Kong, Hong Kong SAR, China
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Denmark
- Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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21
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Thotamgari SR, Sheth AR, Patel HP, Sandhyavenu H, Patel B, Grewal US, Bhuiyan MAN, Dani SS, Dominic P. Safety of catheter ablation for atrial fibrillation in patients with cancer: a nationwide cohort study. Postgrad Med 2023; 135:562-568. [PMID: 37224412 DOI: 10.1080/00325481.2023.2218188] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/09/2023] [Accepted: 05/23/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common arrhythmia in patients with cancer, especially breast, gastrointestinal, respiratory, urinary tract, and hematological malignancies. Catheter ablation (CA) is a well-established, safe treatment option in healthy patients; however, literature regarding safety of CA for AF in patients with cancer is limited and confined to single centers. OBJECTIVE We aimed to assess the outcomes and peri-procedural safety of CA for AF in patients with certain types of cancer. METHODS The NIS database was queried between 2016 and 2019 to identify primary hospitalizations with AF and CA. Hospitalizations with secondary diagnosis of atrial flutter and other arrhythmias were excluded. Propensity score matching was used to balance the covariates between cancer and non-cancer groups. Logistic regression was used to analyze the association. RESULTS During this period, 47,765 CA procedures were identified, out of which 750 (1.6%) hospitalizations had a diagnosis of cancer. After propensity matching, hospitalizations with cancer diagnosis had higher in-hospital mortality (OR 3.0, 95% CI 1.5-6.2, p = 0.001), lower home discharge rates (OR 0.7, 95% CI 0.6-0.9, p < 0.001) as well as other complications such as major bleeding (OR 1.8, 95% CI 1.3-2.7, p = 0.001) and pulmonary embolism (OR 6.1, 95% CI 2.1-17.8, p < 0.001) but not associated with any major cardiac complications (OR 1.2, 95% CI 0.7-1.8, p = 0.53). CONCLUSION Patients with cancer who underwent CA for AF had significantly higher odds of in-hospital mortality, major bleeding, and pulmonary embolism. Further larger prospective observational studies are needed to validate these findings.
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Affiliation(s)
- Sahith Reddy Thotamgari
- Department of Internal Medicine, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, USA
| | - Aakash R Sheth
- Division of Cardiology, University of Pittsburgh Medical Center, Harrisburg, PA, USA
| | - Harsh P Patel
- Division of Cardiology, Southern Illinois University, Springfield, IL, USA
| | - Harigopal Sandhyavenu
- Department of Internal Medicine, Louis. A. Weiss Memorial Hospital, Chicago, IL, USA
| | - Bhavin Patel
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Udhayvir S Grewal
- Department of Hematology/Oncology, University of Iowa, Iowa City, IA, USA
| | | | - Sourbha S Dani
- Department of Cardiology, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Paari Dominic
- Center of Excellence for Cardiovascular Diseases & Sciences, Louisiana State University Health Sciences Center-Shreveport, LA, USA
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22
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Thorpe J, Perry MD, Contreras O, Hurley E, Parker G, Harvey RP, Hill AP, Vandenberg JI. Development of a robust induced pluripotent stem cell atrial cardiomyocyte differentiation protocol to model atrial arrhythmia. Stem Cell Res Ther 2023; 14:183. [PMID: 37501071 PMCID: PMC10373292 DOI: 10.1186/s13287-023-03405-5] [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: 03/28/2023] [Accepted: 06/27/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Atrial fibrillation is the most common arrhythmia syndrome and causes significant morbidity and mortality. Current therapeutics, however, have limited efficacy. Notably, many therapeutics shown to be efficacious in animal models have not proved effective in humans. Thus, there is a need for a drug screening platform based on human tissue. The aim of this study was to develop a robust protocol for generating atrial cardiomyocytes from human-induced pluripotent stem cells. METHODS A novel protocol for atrial differentiation, with optimized timing of retinoic acid during mesoderm formation, was compared to two previously published methods. Each differentiation method was assessed for successful formation of a contractile syncytium, electrical properties assayed by optical action potential recordings and multi-electrode array electrophysiology, and response to the G-protein-gated potassium channel activator, carbamylcholine. Atrial myocyte monolayers, derived using the new differentiation protocol, were further assessed for cardiomyocyte purity, gene expression, and the ability to form arrhythmic rotors in response to burst pacing. RESULTS Application of retinoic acid at day 1 of mesoderm formation resulted in a robust differentiation of atrial myocytes with contractile syncytium forming in 16/18 differentiations across two cell lines. Atrial-like myocytes produced have shortened action potentials and field potentials, when compared to standard application of retinoic acid at the cardiac mesoderm stage. Day 1 retinoic acid produced atrial cardiomyocytes are also carbamylcholine sensitive, indicative of active Ikach currents, which was distinct from ventricular myocytes and standard retinoic addition in matched differentiations. A current protocol utilizing reduced Activin A and BMP4 can produce atrial cardiomyocytes with equivalent functionality but with reduced robustness of differentiation; only 8/17 differentiations produced a contractile syncytium. The day 1 retinoic acid protocol was successfully applied to 6 iPSC lines (3 male and 3 female) without additional optimization or modification. Atrial myocytes produced could also generate syncytia with rapid conduction velocities, > 40 cm s-1, and form rotor style arrhythmia in response to burst pacing. CONCLUSIONS This method combines an enhanced atrial-like phenotype with robustness of differentiation, which will facilitate further research in human atrial arrhythmia and myopathies, while being economically viable for larger anti-arrhythmic drug screens.
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Affiliation(s)
- Jordan Thorpe
- Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Matthew D Perry
- Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
- Department of Pharmacology, School of Biomedical Sciences, University of New South Wales, Sydney, Australia
| | - Osvaldo Contreras
- Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Emily Hurley
- Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - George Parker
- Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - Richard P Harvey
- Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- School of Biotechnology and Biomolecular Science, University of New South Wales, Sydney, NSW, Australia
| | - Adam P Hill
- Victor Chang Cardiac Research Institute, Sydney, NSW, Australia.
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia.
| | - Jamie I Vandenberg
- Victor Chang Cardiac Research Institute, Sydney, NSW, Australia.
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia.
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23
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Yamashita T, Akao M, Atarashi H, Ikeda T, Koretsune Y, Okumura K, Shimizu W, Suzuki S, Tsutsui H, Toyoda K, Hirayama A, Yasaka M, Yamaguchi T, Teramukai S, Kimura T, Morishima Y, Takita A, Inoue H. Causes of Death in Elderly Patients With Non-Valvular Atrial Fibrillation - Results From the ANAFIE Registry. Circ J 2023; 87:957-963. [PMID: 36653127 DOI: 10.1253/circj.cj-22-0614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Previous studies on mortality in atrial fibrillation (AF) included a limited number of elderly patients receiving direct oral anticoagulants (DOACs). This subanalysis of the ANAFIE Registry evaluated 2-year mortality according to causes of death of elderly non-valvular AF (NVAF) patients in the DOAC era. METHODS AND RESULTS The ANAFIE Registry was a multicenter prospective observational study. Mean patient age was 81.5 years and 57.3% of patients were male. Of the 32,275 patients completing the study, 2,242 died. The most frequent causes of death were cardiovascular (CV) death (32.4%), followed by infection (17.1%) and malignancy (16.1%). Incidence rates of CV-, malignancy-, and infection-related death were 1.20, 0.60, and 0.63 per 100 person-years, respectively. Patients aged ≥85 years showed increased proportions of non-CV and non-malignancy deaths and a decreased proportion of malignancy deaths compared with patients aged <85 years. The incidence of death due to congestive heart failure/cardiogenic shock, infection, and renal disease was higher in patients aged ≥85 than those aged <85 years. Compared with warfarin, DOACs were associated with a significantly lower risk of death by intracranial hemorrhage, ischemic stroke, and renal disease. CONCLUSIONS This subanalysis described the mortality according to causes of death of Japanese elderly NVAF patients in the DOAC era. Our results imply that a more holistic approach to comorbid conditions and stroke prevention are required in these patients.
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Affiliation(s)
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | | | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | | | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Cerebrovascular Center, National Hospital Organization Kyushu Medical Center
| | - Takenori Yamaguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Tetsuya Kimura
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd
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Ukenenye E, Oshiba T, Okoronkwo E, Obomanu E, Asaolu G, Urhi A, Olateju IV, Onyemarim H, Uzzi C, Alugba G, Oladunjoye AF, Oladunjoye O. Quivering hand and heart: Parkinson's disease is not associated with increased in-hospital mortality in atrial fibrillation hospitalizations: A nationwide analysis. Heliyon 2023; 9:e14725. [PMID: 37009247 PMCID: PMC10060677 DOI: 10.1016/j.heliyon.2023.e14725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 03/15/2023] [Accepted: 03/15/2023] [Indexed: 03/29/2023] Open
Abstract
Background Autonomic dysfunction in Parkinson's disease (PD) includes cardiovascular dysregulations which may manifest as an increased risk of atrial fibrillation (AF). However, data on the impact of PD in AF patients is lacking. Our study aimed to investigate the differences in in-hospital mortality of patients admitted for AF with underlying PD versus those without PD. Methods We examined the National Inpatient Sample (NIS) database from 2016 to 2019 for hospitalizations of AF as a principal diagnosis with and without PD as a secondary diagnosis. The primary outcome was inpatient mortality. The secondary endpoints were ventricular tachycardia (VT), ventricular fibrillation (VF), acute heart failure (AHF), cardiogenic shock (CS), cardiac arrest (CA), total hospital charge (THC), and length of stay (LOS). Results Of 1,861,859 A F hospitalizations, 0.01% (19,490) had coexisting PD. Cohorts of PD vs No-PD had a mean age of 78.1 years [CI 77.9-78.4] vs 70.5 years [CI 70.4-70.5]; male (56.3% vs 50.7%), female (43.7% vs 49.3%). The PD category had similar in-hospital mortality with the no-PD category (ORAdj = 1.18 [0.89-1.57] P = 0.240). The PD group had a lesser incidence of AHF (ORAdj = 0.79 [0.72-0.86] P < 0.001) and VT (ORAdj = 0.77 [0.62-0.95] P = 0.015). Conclusion Co-existing PD in patients admitted for AF was not associated with increased in-hospital mortality; however, there were lower odds of AHF and VT. The diminished arrhythmogenic neurohormonal axis may explain these cardiovascular benefits. Notwithstanding, to better understand the outcomes of AF in patients with PD, additional studies are required.
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Affiliation(s)
- Emmanuel Ukenenye
- One Brooklyn Health-Brookdale University Hospital and Medical Center Medical, Brooklyn, NY, United States
- Medical Council of Jamaica, University of the West Indies, 18 West Rd, Kingston, 2762+3VM, Jamaica
- Corresponding author. One Brooklyn Health-Brookdale University Hospital and Medical Center Medical, Brooklyn, NY, United States
| | - Tolulope Oshiba
- Hospitalist/Emergency Medicine Department, University of Texas Health Science Center/UT Physicians/Memorial Hermann Hospital, 6410 Fannin St, Houston, TX 77030, United States
| | - Emeka Okoronkwo
- Neurology Unit of Department of Medicine, Lagos University Teaching Hospital, Ishaga Rd, Idi-Araba, Lagos 102215, Nigeria
| | - Elvis Obomanu
- Department of Project Management, Translational Research in Oncology, 9925 109 St NW Suite 1100, Edmonton, AB T5K 2J8, Alberta, Canada
| | - Gideon Asaolu
- Mandeville Regional Hospital, Mandeville, Manchester, Jamaica
| | - Alexsandra Urhi
- Federal Neuropsychiatric Hospital, New Lagos Rd, Uselu 300103, Benin City, Edo, Nigeria
| | - Iyanu Victoria Olateju
- Department of Internal Medicine, Medstar Union Memorial Hospital, 201 E University Pkwy, Baltimore, MD 21218, United States
| | - Henry Onyemarim
- Asaba Specialist Hospital, GRA Phase 1 320108, Asaba, Delta State, Nigeria
| | - Consolata Uzzi
- Columbus Specialty Hospital, 495 N 13th St, Newark, NJ 07107, United States
| | - Gabriel Alugba
- Delta State University, Abraka - Abbi Rd, 330105, Uruoka, Nigeria
| | - Adeolu Funso Oladunjoye
- Clinical Menninger Department of Psychiatry, Baylor College of Medicine, Houston TX 77030, United States
| | - Olubunmi Oladunjoye
- Section of General Internal Medicine, Baylor College of Medicine, 7200 Cambridge St, Houston, TX 77030, United States
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Pastori D, Menichelli D, Di Rocco A, Farcomeni A, Sciacqua A, Pignatelli P, Fauchier L, Lip GYH. Bleeding and thrombotic events in atrial fibrillation patients with cancer: a systematic review and meta-analysis. Intern Emerg Med 2023; 18:655-665. [PMID: 36480081 DOI: 10.1007/s11739-022-03156-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/16/2022] [Indexed: 12/13/2022]
Abstract
Atrial fibrillation (AF) and cancer are frequently coexisting in elderly patients. Pooled metanalytic data on the impact of cancer on clinical outcomes in AF patients are lacking. We performed a systematic review and meta-regression analysis of clinical studies retrieved from Medline (PubMed) and Cochrane (CENTRAL) databases according to PRISMA guidelines. Bleeding endpoints included any, major, gastrointestinal (GI) bleeding and intracranial haemorrhage (ICH). Cardiovascular (CV) endpoints included myocardial infarction (MI), ischemic stroke/systemic embolism (IS/SE), CV and all-cause death. PROSPERO registration number: CRD42022315678. We included 15 studies with 2,868,010 AF patients, of whom 479,571 (16.7%) had cancer. The pooled hazard ratio (HR) for cancer was 1.43 (95% confidence interval [95%CI] 1.42-1.44) for any bleeding, 1.27 (95% CI 1.26-1.29) for major bleeding, 1.17 (95% CI 1.14-1.19) for GI bleeding, and 1.07 (95% CI 1.04-1.11) for ICH. The risk of major bleeding increased with the proportion of breast cancer. Cancer increased the risk of all-cause death (HR 2.00, 95% CI 1.99-2.02) whereas no association with MI and CV death was found. Patients with AF and cancer were less likely to suffer from IS/SE (HR 0.91, 95% CI 0.89-0.94). Cancer complicates the clinical history of AF patients, mainly increasing the risk of bleeding. Further analyses according to the type and stage of cancer are necessary to better stratify bleeding risk in these patients.
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Affiliation(s)
- Daniele Pastori
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del policlinico 155, 00161, Rome, Italy.
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
| | - Danilo Menichelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del policlinico 155, 00161, Rome, Italy
| | - Arianna Di Rocco
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Alessio Farcomeni
- Department of Economics and Finance, University of Rome "Tor Vergata", Rome, Italy
| | - Angela Sciacqua
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Pasquale Pignatelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del policlinico 155, 00161, Rome, Italy
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau Et EA7505, Faculté de Médecine, Université François Rabelais, Tours, France
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
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26
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Luciani M, Müller D, Vanetta C, Diteepeng T, von Eckardstein A, Aeschbacher S, Rodondi N, Moschovitis G, Reichlin T, Sinnecker T, Wuerfel J, Bonati LH, Saeedi Saravi SS, Chocano-Bedoya P, Coslovsky M, Camici GG, Lüscher TF, Kuehne M, Osswald S, Conen D, Beer JH. Trimethylamine-N-oxide is associated with cardiovascular mortality and vascular brain lesions in patients with atrial fibrillation. Heart 2023; 109:396-404. [PMID: 36593094 DOI: 10.1136/heartjnl-2022-321300] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 11/17/2022] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Trimethylamine-N-oxide (TMAO) is a metabolite derived from the microbial processing of dietary phosphatidylcholine and carnitine and the subsequent hepatic oxidation. Due to its prothrombotic and inflammatory mechanisms, we aimed to assess its role in the prediction of adverse events in a susceptible population, namely patients with atrial fibrillation. METHODS Baseline TMAO plasma levels were measured by liquid chromatography-tandem mass spectrometry in 2379 subjects from the ongoing Swiss Atrial Fibrillation cohort. 1722 underwent brain MRI at baseline. Participants were prospectively followed for 4 years (Q1-Q3: 3.0-5.0) and stratified into baseline TMAO tertiles. Cox proportional hazards and linear and logistic mixed effect models were employed adjusting for risk factors. RESULTS Subjects in the highest TMAO tertile were older (75.4±8.1 vs 70.6±8.5 years, p<0.01), had poorer renal function (median glomerular filtration rate: 49.0 mL/min/1.73 m2 (35.6-62.5) vs 67.3 mL/min/1.73 m2 (57.8-78.9), p<0.01), were more likely to have diabetes (26.9% vs 9.1%, p<0.01) and had a higher prevalence of heart failure (37.9% vs 15.8%, p<0.01) compared with patients in the lowest tertile. Oral anticoagulants were taken by 89.1%, 94.0% and 88.2% of participants, respectively (from high to low tertiles). Cox models, adjusting for baseline covariates, showed increased total mortality (HR 1.65, 95% CI 1.17 to 2.32, p<0.01) as well as cardiovascular mortality (HR 1.86, 95% CI 1.21 to 2.88, p<0.01) in the highest compared with the lowest tertile. When present, subjects in the highest tertile had more voluminous, large, non-cortical and cortical infarcts on MRI (log-transformed volumes; exponentiated estimate 1.89, 95% CI 1.11 to 3.21, p=0.02) and a higher chance of small non-cortical infarcts (OR 1.61, 95% CI 1.16 to 2.22, p<0.01). CONCLUSIONS High levels of TMAO are associated with increased risk of cardiovascular mortality and cerebral infarction in patients with atrial fibrillation. TRIAL REGISTRATION NUMBER NCT02105844.
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Affiliation(s)
- Marco Luciani
- Department of Medicine, Baden Cantonal Hospital, Baden, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Daniel Müller
- Institute of Clinical Chemistry, University Hospital Zurich, Zurich, Switzerland.,Laboratory Medicine, University of Basel, Basel, Switzerland
| | | | - Thamonwan Diteepeng
- Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | | | - Stefanie Aeschbacher
- Cardiovascular Research Institute, University Hospital Basel, Basel, Switzerland.,Cardiology Division, University Hospital Basel, Basel, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,Department of General Internal Medicine, Inselspital University Hospital Bern, Bern, Switzerland
| | - Giorgio Moschovitis
- Division of Cardiology, Ospedale Regionale di Lugano-Civico e Italiano, Lugano, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Tim Sinnecker
- Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland.,Medical Image Analysis Center (MIAC), Basel, Switzerland
| | - Jens Wuerfel
- Medical Image Analysis Center (MIAC), Basel, Switzerland.,Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland.,Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
| | - Seyed Soheil Saeedi Saravi
- Department of Medicine, Baden Cantonal Hospital, Baden, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Patricia Chocano-Bedoya
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,Population Health Laboratory, University of Fribourg, Fribourg, Switzerland
| | - Michael Coslovsky
- Cardiology Division, University Hospital Basel, Basel, Switzerland.,Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Giovanni G Camici
- Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland.,Department of Cardiology, Royal Brompton and Harefield Hospitals Trust, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Michael Kuehne
- Cardiovascular Research Institute, University Hospital Basel, Basel, Switzerland.,Cardiology Division, University of Basel Hospital, Basel, Switzerland
| | - Stefan Osswald
- Cardiovascular Research Institute, University Hospital Basel, Basel, Switzerland.,Cardiology Division, University of Basel Hospital, Basel, Switzerland
| | - David Conen
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jürg Hans Beer
- Department of Medicine, Baden Cantonal Hospital, Baden, Switzerland .,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
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Inciardi RM, Giugliano RP, Park JG, Nordio F, Ruff CT, Chen C, Lanz HJ, Antman EM, Braunwald E, Solomon SD. Risks of Heart Failure, Stroke, and Bleeding in Atrial Fibrillation According to Heart Failure Phenotypes. JACC Clin Electrophysiol 2023; 9:569-580. [PMID: 37100536 DOI: 10.1016/j.jacep.2022.11.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/28/2022] [Accepted: 11/02/2022] [Indexed: 02/24/2023]
Abstract
BACKGROUND The risks of heart failure (HF) events compared with stroke/systemic embolic events (SEE) or major bleeding (MB) in heart failure with reduced ejection fraction (HFrEF) vs heart failure with preserved ejection fraction (HFpEF) in a large atrial fibrillation (AF) population have not been well-studied. OBJECTIVES This study sought to assess HF outcomes, according to HF history and HF phenotypes (HFrEF vs HFpEF), and compare these events with SEE and MB, among patients with AF. METHODS We analyzed patients enrolled in the ENGAGE-AF TIMI 48 (Effective Anticoagulation with Factor Xa Next Generation in AF-Thrombolysis in Myocardial Infarction 48) trial. Cumulative incidence of heart failure hospitalization (HHF) or HF death was assessed and compared with the rates of fatal and nonfatal stroke/SEE and MB over a median follow-up of 2.8 years. RESULTS Overall, 12,124 (57.4%) had a history of HF (37.7% HFrEF, 40.1% HFpEF, 22.1% with unknown ejection fraction). The rate per 100 person-years (py) of HHF or HF death (4.95; 95% CI: 4.70-5.20) was higher than of fatal and nonfatal stroke/SEE (1.77; 95% CI: 1.63-1.92) and MB (2.66; 95% CI: 2.47-2.86) among patients with HF history. HFrEF patients experienced a higher rate of HHF or HF death compared with HFpEF patients (7.15 vs 3.65; P < 0.001), while the rates of fatal and nonfatal stroke/SEE and MB were similar by HF phenotype. Patients with HF history had a higher rate of mortality after a HHF (1.29; 95% CI: 1.17-1.42) than after a stroke/SEE (0.69; 95% CI: 0.60-0.78) or after MB (0.61; 95% CI: 0.53-0.70). Overall, patients with nonparoxysmal AF had a higher rate of HF and stroke/SEE events regardless of HF history. CONCLUSIONS Patients with AF and HF, regardless of ejection fraction, are at a higher risk of HF events with higher subsequent mortality rates than of stroke/SEE or MB. While HFrEF is associated with a higher risk of HF events than HFpEF, the risk of stroke/SEE and MB is similar between HFrEF and HFpEF.
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28
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Fawzy AM, Bisson A, Bodin A, Herbert J, Lip GYH, Fauchier L. Atrial Fibrillation and the Risk of Ventricular Arrhythmias and Cardiac Arrest: A Nationwide Population-Based Study. J Clin Med 2023; 12:jcm12031075. [PMID: 36769721 PMCID: PMC9917986 DOI: 10.3390/jcm12031075] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/18/2023] [Accepted: 01/21/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) has been linked to an increased risk of ventricular arrhythmias (VAs) and sudden death. We investigated this association in hospitalised patients in France. METHODS All hospitalised patients from 2013 were identified from the French National database and included if they had at least 5 years of follow-up data. RESULTS Overall, 3,381,472 patients were identified. After excluding 35,834 with a history of VAs and cardiac arrest, 3,345,638 patients were categorised into two groups: no AF (n = 3,033,412; mean age 57.2 ± 21.4; 54.3% female) and AF (n = 312,226; 78.1 ± 10.6; 44.0% female). Over a median follow-up period of 5.4 years (interquartile range (IQR) 5.0-5.8 years), the incidence (2.23%/year vs. 0.56%/year) and risk (hazard ratio (HR) 3.657 (95% confidence interval (CI) 3.604-3.711)) of VAs and cardiac arrest were significantly higher in AF patients compared to non-AF patients. This was still significant after adjusting for confounders, with a HR of 1.167 (95% CI 1.111-1.226) and in the 1:1 propensity score-matched analysis (n = 289,332 per group), with a HR of 1.339 (95% CI 1.313-1.366). In the mediation analysis, the odds of cardiac arrest were significantly mediated by AF-associated VAs, with an OR of 1.041 (95% CI 1.040-1.042). CONCLUSION In hospitalised French patients, AF was associated with an increased risk of VAs and sudden death.
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Affiliation(s)
- Ameenathul M. Fawzy
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK
| | - Arnaud Bisson
- Service de Cardiologie, Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, 2 Boulevard Tonnellé, 37000 Tours, France
- Cardiology Department, Centre Hospitalier Régional d’Orléans, 45067 Orléans, France
| | - Alexandre Bodin
- Service de Cardiologie, Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, 2 Boulevard Tonnellé, 37000 Tours, France
| | - Julien Herbert
- Service de Cardiologie, Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, 2 Boulevard Tonnellé, 37000 Tours, France
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK
- Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark
- Correspondence: (G.Y.H.L.); (L.F.)
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, 2 Boulevard Tonnellé, 37000 Tours, France
- Correspondence: (G.Y.H.L.); (L.F.)
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Dhore-Patil A, Crawford M, Nedunchezhian S, El Hajjar AH, Mekhael M, O'Keefe E, Daghar L, Noujaim C, Bhatnagar A, Pottle C, Sidhu G, Marrouche N. The association of disparities in neighborhood median household income and mortality in patients admitted to the hospital with atrial fibrillation. Prog Cardiovasc Dis 2023; 76:84-90. [PMID: 36462553 DOI: 10.1016/j.pcad.2022.11.016] [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: 11/26/2022] [Accepted: 11/26/2022] [Indexed: 12/05/2022]
Abstract
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.
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Affiliation(s)
- Aneesh Dhore-Patil
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine; Tulane University Heart and Vascular Institute, New Orleans, LA, USA; Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA
| | - Michael Crawford
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine; Tulane University Heart and Vascular Institute, New Orleans, LA, USA; Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA
| | - Saihaiharan Nedunchezhian
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA; Tulane University School of Medicine, New Orleans, LA, USA
| | - Abdel Hadi El Hajjar
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA; Tulane University School of Medicine, New Orleans, LA, USA
| | - Mario Mekhael
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA; Tulane University School of Medicine, New Orleans, LA, USA
| | - Evan O'Keefe
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine; Tulane University Heart and Vascular Institute, New Orleans, LA, USA; Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA
| | - Lilas Daghar
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA; Department of General Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Charbel Noujaim
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA; Tulane University School of Medicine, New Orleans, LA, USA
| | - Arezu Bhatnagar
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA; Tulane University School of Medicine, New Orleans, LA, USA
| | - Christopher Pottle
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA; Tulane University School of Medicine, New Orleans, LA, USA
| | - Gursukhmandeep Sidhu
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine; Tulane University Heart and Vascular Institute, New Orleans, LA, USA; Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA
| | - Nassir Marrouche
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine; Tulane University Heart and Vascular Institute, New Orleans, LA, USA; Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), New Orleans, LA, USA; Tulane University School of Medicine, New Orleans, LA, USA.
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30
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Krittayaphong R, Boonyapiphat T, Aroonsiriwattana S, Ngamjanyaporn P, Lip GYH. Causes of death of patients with non-valvular atrial fibrillation in Asians. PLoS One 2023; 18:e0282455. [PMID: 36857361 PMCID: PMC9977019 DOI: 10.1371/journal.pone.0282455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/11/2023] [Indexed: 03/02/2023] Open
Abstract
OBJECTIVES The aim of this study was to determine the causes of death among Asian non-valvular atrial fibrillation (AF) patients who were registered in a nationwide AF registry, and to investigate the differences in the causes of death in AF patients compared between those who were taking and not taking oral anticoagulant (OAC). METHODS The COhort of antithrombotic use and Optimal INR Level in patients with non-valvular Atrial Fibrillation in Thailand (COOL-AF) study enrolled non-valvular AF patients from 27 centers in Thailand during 2014-2017 to create the COOL-AF Thailand registry. Cause of death was classified as cardiovascular (CV) death, non-CV death, or undetermined cause of death. All events were evaluated and verified by an independent adjudication committee. RESULTS There was a total of 3,405 patients (mean age: 67.8 years, 41.8% female), and the mean follow-up duration was 31.8±8.7 months. Three hundred and eighty patients (11.2%) died during follow-up. CV death, non-CV death, and undetermined cause accounted for 121 (31.8%), 189 (49.7%), and 70 (18.4%) patients, respectively. Of those with a known cause of death, heart failure (10%), intracranial hemorrhage (ICH; 10%), sudden cardiac death (6.8%), and ischemic stroke (5.8%) were the most often observed causes of death. Concerning non-CV death, infection/sepsis (27.7%), cancer (5.5%), respiratory (5.2%), and major bleeding (4.5%) were the most prevalent causes of death. The use and type of OAC were found to be major determinants of ICH and major bleeding incidence. CONCLUSION Death due to ischemic stroke was responsible for only 4.7% of all deaths in Asian AF patients. Non-CV death, such as infection/sepsis or malignancy, was more far more prevalent than CV death in Asian AF patients. An improved integrated care approach is needed to reduce the prevalence of non-CV death in Asian AF patients.
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Affiliation(s)
- Rungroj Krittayaphong
- Faculty of Medicine Siriraj Hospital, Department of Medicine, Division of Cardiology, Mahidol University, Bangkok, Thailand
- * E-mail:
| | | | | | | | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science at the University of Liverpool, Liverpool John Moores University and the Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Faculty of Medicine, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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31
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Prognostic Impact of Severe Atrial Functional Tricuspid Regurgitation in Atrial Fibrillation Patients. J Clin Med 2022; 11:jcm11237145. [PMID: 36498719 PMCID: PMC9739196 DOI: 10.3390/jcm11237145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/08/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022] Open
Abstract
Background and Aim: Atrial fibrillation (AF) is an epidemic disease with a significant global health impact. Atrial functional tricuspid regurgitation (AF-TR) is a more recently acknowledged complication of AF. The main purpose of this study was to determine the prognostic value of severe AF-TR in patients with AF, and its determinants. Methods: In this retrospective, observational study, we included AF patients admitted consecutively to a tertiary clinical hospital between January 2018 and February 2020, irrespective of cause of hospitalization. Patients with organic TR, significant pulmonary hypertension, left ventricular ejection fraction < 50%, those with implanted cardiac devices and those with in-hospital mortality were excluded. Severe TR was defined according to current guidelines. Median follow-up time was 34 (28−39) months. Primary endpoint was all-cause mortality. Results: We included 246 AF patients, with a mean age of 71.5 ± 9.4 years. 86.2% had AF-TR, while 8.1% had severe AF-TR. Mortality rate was 8.5%. Right atrial diameter (p = 0.005), systolic pulmonary artery pressure (sPAP) (p = 0.015) and NT-proBNP (p = 0.026) were independent predictors for the presence of severe valvular dysfunction. In multivariable survival analysis, severe AF-TR, was an independent predictor of all-cause mortality (HR 5.4, 95% CI 1.1−26.2, p = 0.035). Conclusion: Severe AF-TR was an independent predictor of mortality in AF patients, while mild/moderate AF-TR apparently had no impact on prognosis.
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Karnick C, Modany A, McGraw M, Ludwig J, Marr D, Hammonds T, Good CB, Culley E. Comparison of real-world clinical and economic outcomes in patients receiving oral anticoagulants: A retrospective claims analysis. J Manag Care Spec Pharm 2022; 28:1304-1315. [PMID: 36282935 PMCID: PMC10372967 DOI: 10.18553/jmcp.2022.28.11.1304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND: Direct oral anticoagulants (DOACs) have become widely used for the prevention of stroke in nonvalvular atrial fibrillation (AF) and for the treatment of venous thromboembolism (VTE). Warfarin, the standard of care prior to DOACs, requires monitoring and dose adjustment to ensure patients remain appropriately anticoagulated. DOACs do not require monitoring but are significantly more expensive. We sought to examine real-world effectiveness and costs of DOACs and warfarin in patients with AF and VTE. OBJECTIVE: To examine clinical and economic outcomes. The clinical objectives were to determine the bleeding and thrombotic event rates associated with DOACs vs warfarin. The economic objectives were to determine the cost associated with these events, as well as the all-cause medical and pharmacy costs associated with DOACs vs warfarin. METHODS: This analysis was an observational, propensity-matched comparison of retrospective medical and pharmacy claims data for members enrolled in an integrated health plan between October 1, 2015, and September 30, 2020. Members who were older than 18 years of age with at least 1 30-day supply of warfarin or a DOAC filled within 30 days of a new diagnosis of VTE or nonvalvular AF were eligible for the analysis. Cox hazard ratios were used to compare differences in clinical outcomes, where paired t-tests were used to evaluate economic outcomes. RESULTS: After matching, there were 893 patients in each group. Among matched members, warfarin was associated with increased risk of nonmajor bleeds relative to apixaban (hazard ratio [HR] = 1.526; P = 0.0048) and increased risk of pulmonary embolism relative to both DOACs (apixaban: HR = 1.941 [P = 0.0328]; rivaroxaban: HR = 1.833 [P = 0.0489]). No statistically significant difference was observed in hospitalizations or in length of stay between warfarin and either DOAC. The difference-in-difference (DID) in total costs of care per member per month for apixaban and rivaroxaban relative to warfarin were $801.64 (P = 0.0178) and $534.23 (P = 0.0998) more, respectively. DID in VTE-related cost for apixaban was $177.09 less, relative to warfarin (P = 0.0098). DID in all-cause pharmacy costs for apixaban and rivaroxaban relative to warfarin were $342.47 (P < 0.0001) and $386.42 (P < 0.001) more, respectively. CONCLUSIONS: Warfarin use was associated with a significant decrease in total cost of care despite a significant increase in VTE-related costs vs apixaban. Warfarin was also associated with a significant increase in other nonmajor bleeds relative to apixaban, as well as a significant increase in pulmonary embolism relative to both DOACs. Warfarin was associated with a significant reduction in all-cause pharmacy cost compared with either DOAC. DISCLOSURES: The authors of this study have nothing to disclose.
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Narezkina A, Akhter N, Lu X, Emond B, Panjabi S, Forbes SP, Hilts A, Liu S, Lafeuille MH, Lefebvre P, Huang Q, Choi M. Real-World Persistence and Time to Next Treatment With Ibrutinib in Patients With Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma Including Patients at High Risk for Atrial Fibrillation or Stroke. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e959-e971. [PMID: 35973891 DOI: 10.1016/j.clml.2022.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/24/2022] [Accepted: 07/08/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is a recognized adverse consequence associated with all Bruton's tyrosine kinase inhibitors used to treat chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL); however, real-world time to discontinuation (TTD) and time to next treatment (TTNT) of CLL/SLL patients with a high baseline AF/stroke risk remain unknown. MATERIALS AND METHODS Patients with CLL/SLL from a nationwide electronic health record-derived database (February 12, 2013-January 31, 2021) initiating first-line (1L) or second or later-line (2L+) treatment with ibrutinib or other regimens on or after February 12, 2014 (index date) were analyzed. Kaplan-Meier survival analysis was used to assess TTD and TTNT among all patients, patients with high AF risk (CHARGE-AF risk score ≥10.0%), and patients at high risk of stroke (CHA2DS2-VASc risk score ≥3 [females] or ≥2 [males]). RESULTS In 1L/2L+, 2190/1851 patients received ibrutinib and 4388/4135, were treated with other regimens. Median TTD for ibrutinib was similar regardless of AF/stroke-related risk (1L: all patients, 15.7 months; high AF risk, 11.7 months; high stroke risk, 13.7 months; similar results in 2L+). Median TTNT was significantly longer for ibrutinib vs. other regimens (1L: not reached vs. 45.9 months; 2L+: not reached vs. 23.6 months; both P < .05), including among those with high AF/stroke risk. TTNT was similar between all patients and high-risk cohorts in 1L and 2L+ (all P > .05). CONCLUSION This study highlights that elevated baseline AF/stroke-related risk does not adversely impact TTD and TTNT outcomes associated with ibrutinib use. Additionally, TTNT was significantly longer for patients treated with ibrutinib vs. other regimens.
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Affiliation(s)
- Anna Narezkina
- University of California San Diego Health, San Diego, CA
| | | | - Xiaoxiao Lu
- Janssen Scientific Affairs, LLC, Horsham, PA
| | - Bruno Emond
- Analysis Group, Inc., Montréal, Québec, Canada.
| | | | | | | | | | | | | | - Qing Huang
- Janssen Scientific Affairs, LLC, Horsham, PA
| | - Michael Choi
- University of California San Diego Moores Cancer Center, San Diego, CA
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Mihandoost S, Sörnmo L, Doyen M, Oster J. A comparative study of the performance of methods for f-wave extraction. Physiol Meas 2022; 43. [PMID: 36179708 DOI: 10.1088/1361-6579/ac96ca] [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: 03/01/2022] [Accepted: 09/30/2022] [Indexed: 02/07/2023]
Abstract
Objective.This study proposes a novel technique for atrial fibrillatory waves (f-waves) extraction and investigates the performance of the proposed method comparing with different f-wave extraction methods.Approach.We propose a novel technique combining a periodic component analysis (PiCA) and echo state network (ESN) for f-waves extraction, denoted PiCA-ESN. PiCA-ESN benefits from the advantages of using both source separation and nonlinear adaptive filtering. PiCA-ESN is evaluated by comparing with other state-of-the-art approaches, which include template subtraction technique based on principal component analysis, spatiotemporal cancellation, nonlinear adaptive filtering using an echo state neural network, and a source separation technique based on PiCA. Quality assessment is performed on a recently published reference database including a large number of simulated ECG signals in atrial fibrillation (AF). The performance of the f-wave extraction methods is evaluated in terms of signal quality metrics (SNR, ΔSNR) and robustness of f-wave features.Main results.The proposed method offers the best signal quality performance, with a ΔSNR of approximately 22 dB across all 8 sets of the reference database, as well as the most robust extraction of f-wave features, with 75% of all estimates of dominant atrial frequency well below 1 Hz.
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Affiliation(s)
- Sara Mihandoost
- IADI, U1254, INSERM and Université de Lorraine, Nancy, France.,Department of of Electrical Engineering, Urmia University of Technology, Urmia, Iran
| | - Leif Sörnmo
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | - Matthieu Doyen
- IADI, U1254, INSERM and Université de Lorraine, Nancy, France.,Nancyclotep Molecular and Experimental Imaging Platform, Nancy, France
| | - Julien Oster
- IADI, U1254, INSERM and Université de Lorraine, Nancy, France.,CIC-IT 1433, Université de Lorraine, INSERM, CHRU de Nancy, Nancy, France
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Oraii A, Healey JS, Benz AP, Pandey AK, Wong JA, Fonguh S, Wang J, Conen D, Gerstein HC, Connolly SJ, McIntyre WF. Association of Eligibility for a Sodium-Glucose Cotransporter 2 Inhibitor and Cardiovascular Events in Patients With Atrial Fibrillation. Can J Cardiol 2022; 38:1434-1441. [PMID: 35562018 DOI: 10.1016/j.cjca.2022.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/28/2022] [Accepted: 05/02/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduce heart failure (HF) in a broad range of populations, but they have not been studied specifically in patients with atrial fibrillation (AF). We aimed to examine the association between SGLT2i eligibility and cardiovascular events in patients with AF to evaluate the potential utility of SGLT2is for AF management. METHODS We pooled data from 2 randomized controlled trials (RCTs) of patients with AF (RE-LY and ACTIVE-W). Among patients assigned to anticoagulation arms, those meeting the enrollment criteria from at least 1 of the phase 3 SGLT2i RCTs were classified as "SGLT2i eligible" and the remainder as "SGLT2i ineligible." The primary outcome was the composite of HF hospitalization or cardiovascular death. RESULTS A total of 21,484 patients with AF (mean age: 71.2 ± 8.8, 36.1% women, median CHA2DS2-VASc Score = 3) were included. The proportion of patients with AF eligible for SGLT2i was 41.2%. SGLT2i-eligible patients had higher rates of cardiovascular death or hospitalization for HF (5.8 vs 3.2 per 100 person-years, Plog-rank < 0.001), cardiovascular death (3.9 vs 1.5 per 100 person-years, Plog-rank < 0.001), and hospitalization for HF (2.5 vs 1.9 per 100 person-years, Plog-rank < 0.001). The age- and sex-adjusted model showed that SGLT2i-eligible patients were at a higher risk of cardiovascular death and hospitalization for HF (hazard ratio [HR], 1.97; 95% confidence interval [CI], 1.79-2.17; P < 0.001), cardiovascular death (HR, 2.75; 95% CI, 2.41-3.13; P < 0.001), and hospitalization for HF (HR, 1.41; 95% CI, 1.23-1.62; P < 0.001) than ineligible patients. CONCLUSIONS Most patients with AF do not currently have indications for SGLT2is but still have substantial risk of cardiovascular events. Future randomized trials should evaluate the efficacy of SGLT2is in patients with AF.
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Affiliation(s)
- Alireza Oraii
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Arjun K Pandey
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jorge A Wong
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sylvanus Fonguh
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jia Wang
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - David Conen
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Hertzel C Gerstein
- Population Health Research Institute, Hamilton, Ontario, Canada; Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - William F McIntyre
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
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Wei Y, Zeng Q, Cai L, Wang X, Wang B, Shen C, Li C, Wang C, Shen Y, Yang S, Wu X, Liu Y, Xu J, Lu X, Chen S, Zhou G, Liu S. Contemporary survival and anticoagulation of patients with atrial fibrillation: A community based cohort study in China. Front Cardiovasc Med 2022; 9:911393. [PMID: 35966522 PMCID: PMC9363600 DOI: 10.3389/fcvm.2022.911393] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 07/05/2022] [Indexed: 11/13/2022] Open
Abstract
Backgrounds The understanding of death in patients with atrial fibrillation (AF) in China is limited. This study aimed to assess the contemporary survival of AF patients in China and to explore risk factors for deaths. Methods This was a prospective community-based cohort study including 559 AF patients, who were followed-up from July 2015 to December 2020. Results During 66-month follow-up, there were 200 deaths (56.5% cardiovascular, 40.0% non-cardiovascular, and 3.5% unknown causes) among 559 AF patients with the median age of 76 years. The top three causes of death were heart failure (33.0%), ischemic stroke (17.0%) and cancer (16.5%). Multivariate Cox regression analysis indicated baseline variables positively associated with all-cause death were age (HR: 1.10, 95% CI: 1.08–1.13), AF subtype (HR: 1.37, 95% CI: 1.08–1.73), prior myocardial infarction (HR: 3.40, 95% CI: 1.48–7.78), previous tumor (HR: 2.61, 95% CI: 1.37–4.98), hypoglycemic therapy at baseline (HR: 1.81, 95% CI: 1.13–2.91), but body weight (HR: 0.98, 95% CI: 0.97–1.00) and use of calcium channel blocker (CCB) (HR: 0.62, 95% CI: 0.41–0.95) played a protective role to all-cause death. Of patients who were alive at the end of follow-up, 24.0% were on oral anticoagulants (OAC) alone, 4.5% on dual antithrombotic therapy, 33.1% on antiplatelet agents alone and 38.4% weren't on any antithrombotic medication. Conclusion Ischemic stroke still remains one of the leading causes of death and OAC is seriously underused in AF patients in China. Independent risk factors for death are age, AF subtype, previous tumor, prior myocardial infarction, hypoglycemic therapy, low body weight and no CCB use. Clinical Trial Registration http://www.chictr.org.cn/ (ChiCTR-ICR-15007036).
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Affiliation(s)
- Yong Wei
- Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qingye Zeng
- Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lidong Cai
- Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xingjie Wang
- Shihudang Community Health Care Center, Shanghai, China
| | - Bin Wang
- Dongjing Community Health Care Center, Shanghai, China
| | - Chaoying Shen
- Xiaokunshan Community Health Care Center, Shanghai, China
| | - Chao Li
- Yexie Community Health Care Center, Shanghai, China
| | - Caihong Wang
- Xinbang Community Health Care Center, Shanghai, China
| | - Yahong Shen
- Maogang Community Health Care Center, Shanghai, China
| | - Shunhong Yang
- Chedun Community Health Care Center, Shanghai, China
| | - Xiaoyu Wu
- Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Liu
- Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Juan Xu
- Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaofeng Lu
- Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Songwen Chen
- Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Genqing Zhou
- Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Genqing Zhou
| | - Shaowen Liu
- Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Shaowen Liu
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Clinical Phenotypes of Atrial Fibrillation and Mortality Risk-A Cluster Analysis from the Nationwide Italian START Registry. J Pers Med 2022; 12:jpm12050785. [PMID: 35629207 PMCID: PMC9143727 DOI: 10.3390/jpm12050785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 05/06/2022] [Accepted: 05/10/2022] [Indexed: 01/27/2023] Open
Abstract
Patients with atrial fibrillation (AF) still experience a high mortality rate despite optimal antithrombotic treatment. We aimed to identify clinical phenotypes of patients to stratify mortality risk in AF. Cluster analysis was performed on 5171 AF patients from the nationwide START registry. The risk of all-cause mortality in each cluster was analyzed. We identified four clusters. Cluster 1 was composed of the youngest patients, with low comorbidities; Cluster 2 of patients with low cardiovascular risk factors and high prevalence of cancer; Cluster 3 of men with diabetes and coronary disease and peripheral artery disease; Cluster 4 included the oldest patients, mainly women, with previous cerebrovascular events. During 9857 person-years of observation, 386 deaths (3.92%/year) occurred. Mortality rates increased across clusters: 0.42%/year (cluster 1, reference group), 2.12%/year (cluster 2, adjusted hazard ratio (aHR) 3.306, 95% confidence interval (CI) 1.204−9.077, p = 0.020), 4.41%/year (cluster 3, aHR 6.702, 95%CI 2.433−18.461, p < 0.001), and 8.71%/year (cluster 4, aHR 8.927, 95%CI 3.238−24.605, p < 0.001). We identified four clusters of AF patients with progressive mortality risk. The use of clinical phenotypes may help identify patients at a higher risk of mortality.
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Esteve-Pastor MA, Ruiz-Ortiz M, Muñiz J, Roldán-Rabadán I, Otero D, Cequier Á, Bertomeu-Martínez V, Badimón L, Anguita M, Lip GYH, Marín F. Impact of Integrated Care Management on Clinical Outcomes in Atrial Fibrillation Patients: A Report From the FANTASIIA Registry. Front Cardiovasc Med 2022; 9:856222. [PMID: 35586656 PMCID: PMC9108173 DOI: 10.3389/fcvm.2022.856222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 04/05/2022] [Indexed: 11/28/2022] Open
Abstract
Background An integrated and holistic approach is increasingly advocated in patients with atrial fibrillation (AF), based on the “Atrial fibrillation Better Care (ABC) pathway: A, Avoid stroke with anticoagulation; B, better symptom management; C, cardiovascular and comorbidity risk management.” The aim of this study was to examine the prevalence of adherence to each component of the ABC pathway and to analyze its impact on long-term prognosis in the “real-world” cohort of AF patients from the FANTASIIA registry. Methods This prospective study included consecutive AF outpatients anticoagulated with direct oral anticoagulants (DOAC) or vitamin K antagonists (VKA) from June 2013 to October 2014. From the ABC pathway, adherence to the “A criterion” was defined by a time in the therapeutic range (TTR) ≥ 70% or correct dose with DOAC; “B criterion” adherence was defined by a European Heart Rhythm Association (EHRA) Symptom Scale I-II; and “C criterion” adherence was defined as optimized risk factors and comorbidity management. Baseline features and embolic events, severe bleeding, and all-cause and cardiovascular mortality rates up to 3 years of follow-up were analyzed, and a Cox multivariate analysis was performed to investigate the role of each component of the ABC pathway in predicting major events. Results A total of 1,955 AF patients (age: 74.4 ± 9.4 years; 43.2% female patients) were included in this study: adherence to A criterion was observed in 920 (47.1%) patients; adherence to B criterion was observed in 1,791 (91.6%) patients; and adherence to C criterion was observed in 682 (34.8%) patients. Only 394 (20.2%) of the whole population had good control of AF according to the ABC pathway. After a median follow-up of 1,078 days (IQR: 766–1,113), adherence to A criterion was independently associated with reduced cardiovascular mortality [HR: 0.67, 95%CI (0.45–0.99); p = 0.048] compared with non-adherence. Adherence to the B criterion was independently associated with reduced stroke [HR: 0.28, 95%CI (0.14–0.59); p < 0.001], all-cause mortality [HR: 0.49, 95%CI (0.35–0.69); p < 0.001], cardiovascular mortality [HR: 0.39, 95%CI (0.25–0.62); p < 0.001], and major adverse cardiovascular events (MACE) [HR: 0.41, 95%CI (0.28–0.62); p < 0.001] compared with non-adherence. AF patients with C criterion adherence had a significantly lower risk of myocardial infarction [HR: 0.31, 95%CI (0.15–0.66); p < 0.001]. Fully adherent ABC patients had a significant reduction in MACE [HR: 0.64, 95%CI (0.42–0.99); p = 0.042]. Conclusion In real-world anticoagulated AF patients from FANTASIIA registry, we observed a lack of adherence to integrated care management of AF following the ABC pathway. AF managed according to the ABC pathway was associated with a significant reduction in adverse outcomes during long follow-up, suggesting the benefit of a holistic and integrated approach to AF management.
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Affiliation(s)
- María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, CIBERCV, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Martín Ruiz-Ortiz
- Department of Cardiology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Javier Muñiz
- Grupo de Investigación Cardiovascular, Departamento de Ciencias de la Salud e Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, Universidade da Coruña, A Coruña, Spain
| | | | | | - Ángel Cequier
- Department of Cardiology, Hospital de Bellvitge, CIBERCV, Barcelona, Spain
| | | | - Lina Badimón
- Cardiovascular Research Center (CSIC-ICCC), Hospital de la Santa Creu i Sant Pau, CIBERCV, IIB-Sant Pau, Barcelona, Spain
| | - Manuel Anguita
- Department of Cardiology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, CIBERCV, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
- *Correspondence: Francisco Marín,
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Murtaza M, Baig MMA, Ahmed J, Serbanoiu LI, Busnatu SS. Higher Mortality Associated With New-Onset Atrial Fibrillation in Cancer Patients: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:867002. [PMID: 35498001 PMCID: PMC9047948 DOI: 10.3389/fcvm.2022.867002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/08/2022] [Indexed: 12/30/2022] Open
Abstract
AimThis research was conducted to evaluate the mortality outcome of cancer patients with new-onset atrial fibrillation. We also aimed to assess if there was any confounding relation between the mortality of these patients and surgical intervention.Materials and MethodsA systemic search was conducted from electronic databases (PubMed/Medline, Cochrane Library, and Google Scholar) from inception to 7 February 2022. All statistical analyses were conducted in Review Manager 5.4.1. Studies meeting inclusion criteria were selected. Only those studies that involved cancer patients without pre-existing atrial fibrillation were selected, and mortality rate was compared between the patients who developed atrial fibrillation and those who did not. A random-effect model was used when heterogeneity was seen to pool the studies, and the result was reported in the odds ratio (OR) and the corresponding 95% confidence interval (CI).ResultsEighteen studies were selected for meta-analysis. Statistical analysis showed that the cancer patients who subsequently developed atrial fibrillation had a significantly higher mortality rate as compared to those who did not (OR = 1.90 [1.65, 2.19]; p < 0.00001; I2 = 100%). We also separately analyzed the mortality risk in the surgery group and the non-surgery group. Statistical analysis showed that there was significantly higher mortality rate associated with new-onset atrial fibrillation in cancer patients in the surgery group (OR= 3.68 [2.29, 5.94]; p < 0.00001; I2 = 61%) as well as in the non-surgery group (OR = 1.64 [1.39, 1.93]; p < 0.00001; I2 = 100%).ConclusionCancer patients, who subsequently developed atrial fibrillation, had a higher mortality rate as compared to those cancer patients who did not develop atrial fibrillation. A higher mortality rate was seen in both surgical and non-surgical subgroups. This implies that extra care and specific measures must be taken in the management of cancer patients with new-onset atrial fibrillation.
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Affiliation(s)
- Minha Murtaza
- Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Mirza Mehmood Ali Baig
- Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
- *Correspondence: Mirza Mehmood Ali Baig
| | - Jawad Ahmed
- Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Liviu Ionut Serbanoiu
- Department of Cardiology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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Kotalczyk A, Guo Y, Stefil M, Wang Y, Lip GYH. Effects of the Atrial Fibrillation Better Care Pathway on Outcomes Among Clinically Complex Chinese Patients With Atrial Fibrillation With Multimorbidity and Polypharmacy: A Report From the ChiOTEAF Registry. J Am Heart Assoc 2022; 11:e024319. [PMID: 35377169 PMCID: PMC9075471 DOI: 10.1161/jaha.121.024319] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Patients with atrial fibrillation commonly have complex clinical backgrounds of multimorbidity and polypharmacy. The Atrial Fibrillation Better Care (ABC) pathway has been developed to help deliver integrated and holistic care for patients with atrial fibrillation. In this ancillary analysis, we assessed the adherence to and the effectiveness of the ABC pathway at reducing adverse outcomes in Chinese patients with atrial fibrillation with a complex clinical background of multimorbidity or polypharmacy. Methods and Results The ChiOTEAF (Optimal Thromboprophylaxis in Elderly Chinese Patients With Atrial Fibrillation) registry is a prospective, multicenter, nationwide study conducted from October 2014 to December 2018. The primary outcomes of interest were the composite end point of all-cause death and thromboembolic events, as well as individual end points of all-cause death, thromboembolic events, and major bleeding. Multimorbidity was defined as the presence of ≥2 comorbidities, and polypharmacy was defined as the concomitant use of ≥5 medications. The eligible cohort included 4644 patients with multimorbidity, of whom 2610 (56.2%) had available data to assess the ABC pathway usage (mean age, 74.4±10.2; 42.8% women). Among patients with polypharmacy (n=2262; mean age, 74.6±10.1; 43.3% women), 1328 (58.7%) had available data to assess the use of the ABC pathway. Adherence to the ABC pathway was associated with a lower risk of the primary composite outcome among patients with multimorbidity (odds ratio, 0.48; 95% CI, 0.29-0.79) and in the polypharmacy group (odds ratio, 0.39; 95% CI, 0.19-0.78). Health-related quality of life was lower in the non-ABC-adherent group compared with the ABC-treated patients. Conclusions This nationwide real-world registry shows that adherence to the ABC pathway is associated with improved clinical outcomes and health-related quality of life in clinically complex Chinese patients with atrial fibrillation with multimorbidity or polypharmacy.
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Affiliation(s)
- Agnieszka Kotalczyk
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool United Kingdom.,Department of Cardiology Congenital Heart Diseases and Electrotherapy Medical University of SilesiaSilesian Centre for Heart Diseases Zabrze Poland
| | - Yutao Guo
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool United Kingdom.,Department of Pulmonary Vessel and Thrombotic Disease Sixth Medical CentreChinese PLA General Hospital Beijing China
| | - Maria Stefil
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool United Kingdom.,Liverpool University Hospitals NHS Foundation Trust Liverpool United Kingdom
| | - Yutang Wang
- Department of Cardiology Second Medical Centre Chinese PLA General Hospital Beijing China
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool United Kingdom.,Department of Cardiology Congenital Heart Diseases and Electrotherapy Medical University of SilesiaSilesian Centre for Heart Diseases Zabrze Poland.,Department of Clinical Medicine Aalborg University Aalborg Denmark
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41
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Ono K, Iwasaki YK, Akao M, Ikeda T, Ishii K, Inden Y, Kusano K, Kobayashi Y, Koretsune Y, Sasano T, Sumitomo N, Takahashi N, Niwano S, Hagiwara N, Hisatome I, Furukawa T, Honjo H, Maruyama T, Murakawa Y, Yasaka M, Watanabe E, Aiba T, Amino M, Itoh H, Ogawa H, Okumura Y, Aoki-Kamiya C, Kishihara J, Kodani E, Komatsu T, Sakamoto Y, Satomi K, Shiga T, Shinohara T, Suzuki A, Suzuki S, Sekiguchi Y, Nagase S, Hayami N, Harada M, Fujino T, Makiyama T, Maruyama M, Miake J, Muraji S, Murata H, Morita N, Yokoshiki H, Yoshioka K, Yodogawa K, Inoue H, Okumura K, Kimura T, Tsutsui H, Shimizu W. JCS/JHRS 2020 Guideline on Pharmacotherapy of Cardiac Arrhythmias. Circ J 2022; 86:1790-1924. [DOI: 10.1253/circj.cj-20-1212] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | - Yu-ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Masaharu Akao
- Department of Cardiovascular Medicine, National Hospital Organization Kyoto Medical Center
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School of Medicine
| | - Kuniaki Ishii
- Department of Pharmacology, Yamagata University Faculty of Medicine
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yoshinori Kobayashi
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital
| | | | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | | | - Tetsushi Furukawa
- Department of Bio-information Pharmacology, Medical Research Institute, Tokyo Medical and Dental University
| | - Haruo Honjo
- Research Institute of Environmental Medicine, Nagoya University
| | - Toru Maruyama
- Department of Hematology, Oncology and Cardiovascular Medicine, Kyushu University Hospital
| | - Yuji Murakawa
- The 4th Department of Internal Medicine, Teikyo University School of Medicine, Mizonokuchi Hospital
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center
| | - Eiichi Watanabe
- Department of Cardiology, Fujita Health University School of Medicine
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Mari Amino
- Department of Cardiovascular Medicine, Tokai University School of Medicine
| | - Hideki Itoh
- Division of Patient Safety, Hiroshima University Hospital
| | - Hisashi Ogawa
- Department of Cardiology, National Hospital Organisation Kyoto Medical Center
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Chizuko Aoki-Kamiya
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center
| | - Jun Kishihara
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Eitaro Kodani
- Department of Cardiovascular Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Takashi Komatsu
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University School of Medicine
| | | | | | - Tsuyoshi Shiga
- Department of Clinical Pharmacology and Therapeutics, The Jikei University School of Medicine
| | - Tetsuji Shinohara
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Atsushi Suzuki
- Department of Cardiology, Tokyo Women's Medical University
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute
| | - Yukio Sekiguchi
- Department of Cardiology, National Hospital Organization Kasumigaura Medical Center
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Noriyuki Hayami
- Department of Fourth Internal Medicine, Teikyo University Mizonokuchi Hospital
| | | | - Tadashi Fujino
- Department of Cardiovascular Medicine, Toho University, Faculty of Medicine
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Mitsunori Maruyama
- Department of Cardiovascular Medicine, Nippon Medical School Musashi Kosugi Hospital
| | - Junichiro Miake
- Department of Pharmacology, Tottori University Faculty of Medicine
| | - Shota Muraji
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | | | - Norishige Morita
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital
| | - Hisashi Yokoshiki
- Department of Cardiovascular Medicine, Sapporo City General Hospital
| | - Koichiro Yoshioka
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine
| | - Kenji Yodogawa
- Department of Cardiovascular Medicine, Nippon Medical School
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
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42
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Ifedili I, Mouksian K, Jones D, El Masri I, Heckle M, Jefferies J, Levine YC. Ablation Therapy for Persistent Atrial Fibrillation. Curr Cardiol Rev 2022; 18:e290721195115. [PMID: 34325644 PMCID: PMC9413731 DOI: 10.2174/1573403x17666210729101752] [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: 01/05/2021] [Revised: 06/02/2021] [Accepted: 06/21/2021] [Indexed: 11/22/2022] Open
Abstract
Atrial Fibrillation (AF) is the most common form of electrical disturbance of the heart and contributes to significant patient morbidity and mortality. With a better understanding of the mechanisms of atrial fibrillation and improvements in mapping and ablation technologies, ablation has become a preferred therapy for patients with symptomatic AF. Pulmonary Vein Isolation (PVI) is the cornerstone for AF ablation therapy, but particularly in patients with AF occurring for longer than 7 days (persistent AF), identifying clinically significant nonpulmonary vein targets and achieving durability of ablation lesions remains an important challenge.
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Affiliation(s)
- Ikechukwu Ifedili
- Department of Internal Medicine, Division of Cardiovascular Disease, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - David Jones
- Methodist le Bonheur Cardiovascular Institute, Memphis, TN, USA
| | - Ibrahim El Masri
- Department of Internal Medicine, Division of Cardiovascular Disease, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mark Heckle
- Department of Internal Medicine, Division of Cardiovascular Disease, University of Tennessee Health Science Center, Memphis, TN, USA
| | - John Jefferies
- Department of Internal Medicine, Division of Cardiovascular Disease, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Yehoshua C Levine
- Department of Internal Medicine, Division of Cardiovascular Disease, University of Tennessee Health Science Center, Memphis, TN, USA
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43
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Gue YX, Bisson A, Bodin A, Herbert J, Lip GYH, Fauchier L. Season of Birth and Cardiovascular Mortality in Atrial Fibrillation: A Population-Based Cohort Study. J Cardiovasc Dev Dis 2021; 8:jcdd8120177. [PMID: 34940532 PMCID: PMC8707232 DOI: 10.3390/jcdd8120177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/15/2021] [Accepted: 11/15/2021] [Indexed: 11/30/2022] Open
Abstract
Background: The fetal origins hypothesis have associated early life exposures with the development of adverse health outcomes in adulthood. Season of birth has been shown to be associated with overall and cardiovascular mortality. Methods: We performed a retrospective database study to explore the association between season of birth and mortality in patients with atrial fibrillation. Results: A total of 8962 patients with AF were identified in the database with 1253 deaths recorded. AF patients born in spring and summer had a higher mortality rate when compared to those born in autumn and winter (hazard ratio (HR) 1.13, 95% confidence interval (CI) 1.01–1.26, p = 0.03). This effect was consistent in the male subgroup (HR 1.25, 95% CI 1.03–1.51, p = 0.02 for males born in spring; HR 1.24, 95% CI 1.03–1.51, p = 0.03 for males born in summer when compared to winter as the reference) but not in females (HR 1.02, 95% CI 0.79–1.31, p = 0.88 for females born in spring; HR 1.11, 95% CI 0.87–1.42, p = 0.39 for females born in summer when compared to winter as the reference). Results persisted after adjustment for baseline characteristics and clinical risk profile. A similar pattern was observed with cardiovascular mortality. Conclusion: Birth in spring or summer is associated with a higher risk of cardiovascular mortality in male AF patients, but not in females. This could be related to the underlying differences in rates of major adverse clinical events between genders. Further studies should aim at clarifying the mechanisms behind this association, which may help us understand the higher level of risk in female patients with AF.
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Affiliation(s)
- Ying X. Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK; (Y.X.G.); (G.Y.H.L.)
| | - Arnaud Bisson
- Service de Cardiologie, Centre Hospitalier Universitaire et Faculté de Médecine, Université de Tours, 37044 Tours, France; (A.B.); (A.B.); (J.H.)
| | - Alexandre Bodin
- Service de Cardiologie, Centre Hospitalier Universitaire et Faculté de Médecine, Université de Tours, 37044 Tours, France; (A.B.); (A.B.); (J.H.)
| | - Julien Herbert
- Service de Cardiologie, Centre Hospitalier Universitaire et Faculté de Médecine, Université de Tours, 37044 Tours, France; (A.B.); (A.B.); (J.H.)
- Service d’Information Médicale, d’Épidémiologie et d’Économie de la Santé, Centre Hospitalier Universitaire et Faculté de Médecine, EA7505, Université de Tours, 37044 Tours, France
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK; (Y.X.G.); (G.Y.H.L.)
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire et Faculté de Médecine, Université de Tours, 37044 Tours, France; (A.B.); (A.B.); (J.H.)
- Correspondence: ; Tel.: +33-247474650; Fax: +33-247475919
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44
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Buckley BJR, Harrison SL, Gupta D, Fazio-Eynullayeva E, Underhill P, Lip GYH. Atrial Fibrillation in Patients With Cardiomyopathy: Prevalence and Clinical Outcomes From Real-World Data. J Am Heart Assoc 2021; 10:e021970. [PMID: 34779218 PMCID: PMC9075382 DOI: 10.1161/jaha.121.021970] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Cardiomyopathy is a common cause of atrial fibrillation (AF) and may also present as a complication of AF. However, there is a scarcity of evidence of clinical outcomes for people with cardiomyopathy and concomittant AF. The aim of the present study was therefore to characterize the prevalence of AF in major subtypes of cardiomyopathy and investigate the impact on important clinical outcomes. Methods and Results A retrospective cohort study was conducted using electronic medical records from a global federated health research network, with data primarily from the United States. The TriNetX network was searched on January 17, 2021, including records from 2002 to 2020, which included at least 1 year of follow‐up data. Patients were included based on a diagnosis of hypertrophic, dilated, or restrictive cardiomyopathy and concomitant AF. Patients with cardiomyopathy and AF were propensity‐score matched for age, sex, race, and comorbidities with patients who had a cardiomyopathy only. The outcomes were 1‐year mortality, hospitalization, incident heart failure, and incident stroke. Of 634 885 patients with cardiomyopathy, there were 14 675 (2.3%) patients with hypertrophic, 90 117 (7.0%) with restrictive, and 37 685 (5.9%) with dilated cardiomyopathy with concomitant AF. AF was associated with significantly higher odds of all‐cause mortality (odds ratio [95% CI]) for patients with hypertrophic (1.26 [1.13–1.40]) and dilated (1.36 [1.27–1.46]), but not restrictive (0.98 [0.94–1.02]), cardiomyopathy. Odds of hospitalization, incident heart failure, and incident stroke were significantly higher in all cardiomyopathy subtypes with concomitant AF. Among patients with AF, catheter ablation was associated with significantly lower odds of all‐cause mortality at 12 months across all cardiomyopathy subtypes. Conclusions Findings of the present study suggest AF may be highly prevalent in patients with cardiomyopathy and associated with worsened prognosis. Subsequent research is needed to determine the usefulness of screening and multisdisciplinary treatment of AF in this population.
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Affiliation(s)
- Benjamin J R Buckley
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool UK.,Department of Cardiovascular and Metabolic Medicine Institute of Life Course and Medical Sciences, University of Liverpool Liverpool UK
| | - Stephanie L Harrison
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool UK.,Department of Cardiovascular and Metabolic Medicine Institute of Life Course and Medical Sciences, University of Liverpool Liverpool UK
| | | | | | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool UK.,Department of Cardiovascular and Metabolic Medicine Institute of Life Course and Medical Sciences, University of Liverpool Liverpool UK.,Department of Clinical Medicine Aalborg University Aalborg Denmark
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45
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Wang YF, Jiang C, He L, Du X, Sang CH, Long DY, Tang RB, Dong JZ, Lip GYH, Ma CS. Integrated Care of Atrial Fibrillation Using the ABC (Atrial fibrillation Better Care) Pathway Improves Clinical Outcomes in Chinese Population: An Analysis From the Chinese Atrial Fibrillation Registry. Front Cardiovasc Med 2021; 8:762245. [PMID: 34869677 PMCID: PMC8636991 DOI: 10.3389/fcvm.2021.762245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 10/08/2021] [Indexed: 12/19/2022] Open
Abstract
Background: “Atrial fibrillation Better Care” (ABC) pathway has been proposed to improve the management of patients suffered from atrial fibrillation (AF). This integrated or holistic management approach comprise of three aspects, including “A” Avoid stroke or Anticoagulation; “B” Better symptom control with rate or rhythm control strategies; “C” Cardiovascular risk factor and Concomitant diseases management. We aimed to confirm the beneficial evidence of ABC pathway compliance in a Chinese AF cohort. Method and Results: From the Chinese Atrial Fibrillation registry (CAFR) dataset, a total of 19,187 non-valvular AF patients were enrolled, of which 4.365 (22.8%) were ABC pathway compliant (ABC compliance group). During a median follow-up of 4.1 ± 1.8 years, The incident rate of all-cause death in ABC compliance group and non-ABC compliance group is 2.7 and 1.1 per 100 person-year (p < 0.001), the incident rate of ischemic stroke is 1.3 and 0.8% per 100 person-year (p < 0.001), the incident rate of composite outcome, which consist of all-cause death, ischemic stroke and intracranial hemorrhage, is 3.8 and 1.9 per 100 person-year (p < 0.001). On Cox multivariable analysis, ABC pathway shows an independently association with reduction of all-cause death [hazard ratio (HR) = 0.82; 95% confidence interval (CI) = 0.70–0.95] and the composite outcome (HR 0.86, 95% CI 0.76–0.96). The increasingly components of ABC integrated care compliance is associated with lower risk of all-cause death and composite events. Conclusion: In a large cohort of Chinese AF patients, ABC pathway compliance shows an independently association with reduction of all-cause death and composite outcome of all-cause death, ischemic stroke and intracranial hemorrhage. Better compliance of ABC integrated care contributes to lower HR for adverse events.
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Affiliation(s)
- Yu-Feng Wang
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Chao Jiang
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Liu He
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Xin Du
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China.,Heart Health Research Centre, Beijing, China.,The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Cai-Hua Sang
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - De-Yong Long
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China.,Centre for Cardiovascular Diseases, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Henan, China
| | - Ri-Bo Tang
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Jian-Zeng Dong
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom
| | - Chang-Sheng Ma
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
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46
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Ding WY. Residual Stroke Risk in Atrial Fibrillation. Arrhythm Electrophysiol Rev 2021; 10:147-153. [PMID: 34777818 PMCID: PMC8576486 DOI: 10.15420/aer.2021.34] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 07/22/2021] [Indexed: 12/16/2022] Open
Abstract
AF contributes to increased stroke risk via various mechanisms, including deranged blood constituents, vessel wall abnormalities and abnormal blood flow. This excess risk is frequently managed with anticoagulation therapy, aimed at preventing thromboembolic complications. Yet, a significant proportion of patients with AF remain at high residual stroke risk despite receiving appropriate dose-adjusted anticoagulation. This article explores the residual stroke risk in AF and potential therapeutic options for these patients.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
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47
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Temporal Relationship between Atrial Fibrillation and Heart Failure Development Analysis from a Nationwide Database. J Clin Med 2021; 10:jcm10215101. [PMID: 34768619 PMCID: PMC8585083 DOI: 10.3390/jcm10215101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 10/25/2021] [Accepted: 10/28/2021] [Indexed: 01/04/2023] Open
Abstract
Background Atrial fibrillation (AF) and heart failure (HF) often co-exist and are closely intertwined, each condition worsening the other. The temporal relationships between these two disorders have not yet been fully explored. We aimed to address the outcomes of patients hospitalized with HF and AF based on the chronology of the onset of the two disorders. Methods From the administrative database for the whole French population, we identified 1,349,638 patients diagnosed with both AF and HF between 2010 and 2018; 956,086 of these AF patients developed HF first (prevalent HF), and 393,552 developed HF after AF (incident HF). The outcome analysis (all-cause death, cardiovascular (CV) death, ischemic stroke or hospitalization for HF) was performed with follow-up starting at the time of last event between AF or HF in the whole cohort and in 427,848 propensity score-matched patients. Results During follow-up (mean follow-up 1.6 ± 1.9 year), matched patients with prevalent HF had a higher risk of all-cause death (21.6 vs. 19.3%/year, hazard ratio (HR) 1.10, 95% CI 1.08–1.11), CV death (7.7 vs. 6.5%/year, HR 1.14, 95% CI 1.12–1.16) as well as re-hospitalization for HF (19.4 vs. 13.2%/year, HR 1.44, 95% CI 1.41–1.46) than those with incident HF. The risk for ischemic stroke was lower in prevalent HF than in incident HF (1.2 vs. 2.4%/year, HR 0.50, 95% CI 0.48–0.52). Conclusions We identified two distinct clinical entities: patients in whom HF preceded AF (prevalent HF) had higher mortality and higher risk of re-hospitalization for HF.
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48
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Kuźma Ł, Tomaszuk-Kazberuk A, Kurasz A, Dobrzycki S, Koziński M, Sobkowicz B, Lip GYH. Predicting Mortality in Patients with Atrial Fibrillation and Obstructive Chronic Coronary Syndrome: The Bialystok Coronary Project. J Clin Med 2021; 10:jcm10214949. [PMID: 34768472 PMCID: PMC8584483 DOI: 10.3390/jcm10214949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 10/22/2021] [Accepted: 10/23/2021] [Indexed: 11/25/2022] Open
Abstract
Over the next decades, the prevalence of atrial fibrillation (AF) is estimated to double. Our aim was to investigate the causes of the long-term mortality in relation to the diagnosis of atrial fibrillation (AF) and chronic coronary syndrome (CCS). The analysed population consisted of 7367 consecutive patients referred for elective coronary angiography enrolled in a large single-centre retrospective registry, out of whom 1484 had AF and 2881 were diagnosed with obstructive CCS. During follow-up (median = 2029 days), 1201 patients died. The highest all-cause death was seen in AF(+)/CCS(+) [194/527; 36.8%], followed by AF(+)/CCS(−) [210/957; 21.9%], AF(−)/CCS(+) [(459/2354; 19.5%)] subgroups. AF ([HR]AC = 1.48, 95%CI, 1.09–2.01; HRCV = 1.34, 95%CI, 1.07–1.68) and obstructive CCS (HRAC = 1.90, 95%CI, 1.56–2.31; HRCV = 2.27, 95%CI, 1.94–2.65) together with age, male gender, heart failure, obstructive pulmonary disease, diabetes were predictors of both all-cause and CV mortality. The main findings are as follow among patients referred for elective coronary angiography, both AF and obstructive CCS are strong and independent predictors of the long-term mortality. Mortality of AF without CCS was at least as high as non-AF patients with CCS. CV deaths were more frequent than non-CV deaths in AF patients with CCS compared to those with either AF or CCS alone.
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Affiliation(s)
- Łukasz Kuźma
- Department of Invasive Cardiology, Medical University of Białystok, 15-089 Białystok, Poland; (Ł.K.); (A.K.); (S.D.)
| | - Anna Tomaszuk-Kazberuk
- Department of Cardiology, Medical University of Białystok, 15-089 Białystok, Poland;
- Correspondence: ; Tel.: +48-600-044-992
| | - Anna Kurasz
- Department of Invasive Cardiology, Medical University of Białystok, 15-089 Białystok, Poland; (Ł.K.); (A.K.); (S.D.)
| | - Sławomir Dobrzycki
- Department of Invasive Cardiology, Medical University of Białystok, 15-089 Białystok, Poland; (Ł.K.); (A.K.); (S.D.)
| | - Marek Koziński
- Department of Cardiology and Internal Medicine, Medical University of Gdańsk, 81-519 Gdynia, Poland;
| | - Bożena Sobkowicz
- Department of Cardiology, Medical University of Białystok, 15-089 Białystok, Poland;
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK;
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, 9220 Aalborg, Denmark
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49
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Tang CPS, Lip GYH, McCormack T, Lyon AR, Hillmen P, Iyengar S, Martinez-Calle N, Parry-Jones N, Patten PEM, Schuh A, Walewska R. Management of cardiovascular complications of bruton tyrosine kinase inhibitors. Br J Haematol 2021; 196:70-78. [PMID: 34498258 DOI: 10.1111/bjh.17788] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 08/04/2021] [Accepted: 08/07/2021] [Indexed: 12/01/2022]
Affiliation(s)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | | | | | | | | | | | | | - Anna Schuh
- Oxford University Hospitals NHS Trust, Oxford, UK
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Pandey AK, Okaj I, Kaur H, Belley-Cote EP, Wang J, Oraii A, Benz AP, Johnson LSB, Young J, Wong JA, Verma S, Conen D, Gerstein H, Healey JS, McIntyre WF. Sodium-Glucose Co-Transporter Inhibitors and Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Am Heart Assoc 2021; 10:e022222. [PMID: 34459238 PMCID: PMC8649253 DOI: 10.1161/jaha.121.022222] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Sodium‐glucose co‐transporter (SGLT) inhibitors reduce cardiovascular outcomes including mortality in several populations; however, their effect on atrial fibrillation/flutter (AF) remains unclear. Our objective was to determine whether SGLT inhibitors reduce AF and whether a history of AF modifies the effect of SGLT inhibitors on the composite of heart failure hospitalization or cardiovascular death. Methods and Results We searched MEDLINE, Embase, and CENTRAL to March 2021. Pairs of reviewers identified randomized controlled trials that compared an SGLT inhibitor with placebo or no therapy. We pooled data using RevMan 5.4.1, assessed risk of bias using the Cochrane tool, and determined the overall quality of evidence using Grades of Recommendation, Assessment, Development and Evaluation. Thirty‐one eligible trials reported on AF events (75 279 participants, mean age 62 years, 35.0% women). Moderate quality evidence supported a lower risk of serious AF events with SGLT inhibitors (1.1% versus 1.5%; risk ratio 0.75 [95% CI, 0.66–0.86]; I2=0%). A similar reduction in total AF events was also noted with SGLT inhibitors. Three trials reported on heart failure hospitalization/cardiovascular death stratified by a baseline history of AF (18 832 participants, mean age 66 years, 38.1% women); in patients with a history of AF, SGLT inhibitors resulted in a lower risk in the composite of heart failure hospitalization or cardiovascular death (hazard ratio, 0.70 [95% CI, 0.57–0.85]; I2=0%)—similar to the effect estimate for patients without AF, P value for interaction: 1.00. Conclusions SGLT inhibitors may reduce AF events and likely reduce heart failure hospitalization/cardiovascular death to a similar extent in patients with and without AF.
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Affiliation(s)
- Arjun K Pandey
- Michael G. DeGroote School of Medicine McMaster University Hamilton Ontario Canada
| | - Iva Okaj
- Michael G. DeGroote School of Medicine McMaster University Hamilton Ontario Canada
| | - Hargun Kaur
- Faculty of Health Sciences McMaster University Hamilton Ontario Canada
| | - Emilie P Belley-Cote
- Department of Health Research Methods, Evidence and Impact McMaster University Hamilton Ontario Canada.,Population Health Research Institute Hamilton Ontario Canada.,Division of Cardiology Department of Medicine McMaster University Hamilton Ontario Canada
| | - Jia Wang
- Population Health Research Institute Hamilton Ontario Canada
| | - Alireza Oraii
- Tehran Heart CenterTehran University of Medical Sciences Tehran Iran
| | | | | | - Jack Young
- Faculty of Health Sciences McMaster University Hamilton Ontario Canada
| | - Jorge A Wong
- Population Health Research Institute Hamilton Ontario Canada.,Department of Medicine Faculty of Health Sciences McMaster University Hamilton Ontario Canada
| | - Subodh Verma
- Division of Cardiac Surgery St Michael's Hospital University of Toronto Ontario Canada
| | - David Conen
- Faculty of Health Sciences McMaster University Hamilton Ontario Canada.,Department of Health Research Methods, Evidence and Impact McMaster University Hamilton Ontario Canada.,Population Health Research Institute Hamilton Ontario Canada
| | - Hertzel Gerstein
- Faculty of Health Sciences McMaster University Hamilton Ontario Canada.,Department of Health Research Methods, Evidence and Impact McMaster University Hamilton Ontario Canada.,Population Health Research Institute Hamilton Ontario Canada
| | - Jeff S Healey
- Population Health Research Institute Hamilton Ontario Canada.,Division of Cardiology Department of Medicine McMaster University Hamilton Ontario Canada
| | - William F McIntyre
- Department of Health Research Methods, Evidence and Impact McMaster University Hamilton Ontario Canada.,Population Health Research Institute Hamilton Ontario Canada.,Division of Cardiology Department of Medicine McMaster University Hamilton Ontario Canada
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