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Mulholland RJ, Ciminata G, Quinn TJ, Pollock KG, Lister S, Geue C. Delay and Pay? Healthcare Costs Associated with Late Oral Anti-coagulant Prescribing in People with Atrial Fibrillation. PHARMACOECONOMICS 2024:10.1007/s40273-024-01419-2. [PMID: 39093500 DOI: 10.1007/s40273-024-01419-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/14/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) is associated with increased morbidity and mortality and exerts an increasingly significant burden on global healthcare resources, with its prevalence rising with an ageing population. Despite a substantial thromboembolic risk, particularly in the period immediately following diagnosis, oral anti-coagulation is frequently not initiated or is delayed. The aim of this study was to evaluate healthcare costs in people with AF, comparing those who were commenced on oral anti-coagulation in the immediate period following the index diagnosis date with those in whom initiation was late and those who never started anti-coagulation. METHODS This retrospective cost analysis used linked Scottish health data to identify adults newly diagnosed with AF between January 1st 2012 and April 30th 2019 with a baseline CHA2DS2-VASc score of ≥ 2. This AF population was sub-divided according to timing of the first prescription of oral anti-coagulant (OAC) during a 2-year follow-up period: never started (OAC never initiated), immediate OAC (OAC prescribed within 60 days of incident AF diagnosis), and delayed OAC (OAC prescribed more than 60 days after incident AF diagnosis). A two-part model was developed, adjusted for key covariates, including age, sex, and frailty, to estimate costs for inpatient admissions, outpatient care, prescriptions, and care home admissions, and overall costs. RESULTS Of an overall AF population of 54,385, 26,805 (49.3%) never commenced OAC, 7654 (14.1%) initiated an OAC late, and 19,926 (36.6%) were prescribed anti-coagulation immediately. The mean adjusted cost for the overall AF population was £7807 per person per year (unadjusted: £8491). Delayed OAC initiation was associated with the greatest adjusted estimated mean annual cost (unadjusted: £13,983; adjusted: £9763), compared to those that never started (unadjusted: £10,433; adjusted: £7981) and those that received an immediate OAC prescription (unadjusted: £3976; adjusted: £6621). Increasing frailty, mortality, and female sex were associated with greater healthcare costs. CONCLUSION AF is associated with significant healthcare resource utilisation and costs, particularly in the context of delayed or non-initiation of anti-coagulation. Indeed, there exists substantial opportunity to improve the utilisation and prompt initiation in people newly diagnosed with AF in Scotland. Interventions to mitigate against the growing economic burden of AF should focus on reducing admissions to hospitals and care homes, which are the principal drivers of costs; prescriptions and outpatient appointments account for a relatively small proportion of overall costs for AF.
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Menichelli D, Pignatelli P, Brogi T, Pannunzio A, Violi F, Lip GY, Pastori D. Incidence of All-Cause, Cardiovascular, and Atrial Fibrillation-Related Hospitalizations: Focus on Antiarrhythmic Drugs. JACC. ADVANCES 2024; 3:101117. [PMID: 39105112 PMCID: PMC11299568 DOI: 10.1016/j.jacadv.2024.101117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/24/2024] [Indexed: 08/07/2024]
Abstract
Background Atrial fibrillation (AF) is associated with an increased risk of hospital admission, but few data on reasons for hospitalization and on the role of anti-arrhythmic drugs are available. Objectives The purpose of this study was to investigate the incidence rate and factors associated with all-cause, cardiovascular, and AF-related hospitalizations. Methods Prospective ongoing ATHERO-AF (Atherosclerosis in Atrial Fibrillation) cohort study enrolling AF patients on oral anticoagulants. Primary end points were all-cause, cardiovascular, and AF-related hospitalization, the latter defined as AF recurrences for paroxysmal AF and high-rate symptomatic AF episodes for persistent/permanent AF patients. Results 2,782 patients were included (43.5% female; mean age was 74.6 ± 9.1 years). During a mean follow-up of 31 ± 26.8 months, 1,205 (12.1%/year) all-cause, 533 cardiac (5.7%/year), and 180 (2.0%/year) AF-related hospitalizations occurred. Predictors of AF-related hospitalizations were the use of flecainide/propafenone in both paroxysmal and persistent/permanent AF patients (HR: 1.861; 95% CI: 1.116 to 3.101 and 1.947; 95% CI: 1.069 to 3.548, respectively). Amiodarone (HR: 3.012; 95% CI: 1.835-4.943), verapamil/diltiazem (HR: 2.067; 95% CI: 1.117-3.825), and cancer (HR: 1.802; 95% CI: 1.057-3.070) but not beta-blockers and digoxin were associated with an increased risk of AF-related hospitalizations in persistent/permanent AF patients. Conclusions Elderly AF patients frequently undergo hospitalizations for both cardiovascular and noncardiovascular causes. The use of anti-arrhythmic drugs was associated with an increased risk of AF-related hospitalization suggesting a scarce effect of these drugs in preventing AF episodes. Therefore, their use should be carefully considered and reserved for symptomatic patients with frequent AF recurrences.
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Affiliation(s)
- Danilo Menichelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
- Department of General Surgery and Surgical Specialty Paride Stefanini, Sapienza University of Rome, Rome, Italy
| | - Pasquale Pignatelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Tommaso Brogi
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Arianna Pannunzio
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesco Violi
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - 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
| | - Daniele Pastori
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
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Kany S, Jurgens SJ, Rämö JT, Christophersen IE, Rienstra M, Chung MK, Olesen MS, Ackerman MJ, McNally EM, Semsarian C, Schnabel RB, Wilde AAM, Benjamin EJ, Rehm HL, Kirchhof P, Bezzina CR, Roden DM, Shoemaker MB, Ellinor PT. Genetic testing in early-onset atrial fibrillation. Eur Heart J 2024:ehae298. [PMID: 39028637 DOI: 10.1093/eurheartj/ehae298] [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: 10/26/2023] [Revised: 03/18/2024] [Accepted: 04/30/2024] [Indexed: 07/21/2024] Open
Abstract
Atrial fibrillation (AF) is a globally prevalent cardiac arrhythmia with significant genetic underpinnings, as highlighted by recent large-scale genetic studies. A prominent clinical and genetic overlap exists between AF, heritable ventricular cardiomyopathies, and arrhythmia syndromes, underlining the potential of AF as an early indicator of severe ventricular disease in younger individuals. Indeed, several recent studies have demonstrated meaningful yields of rare pathogenic variants among early-onset AF patients (∼4%-11%), most notably for cardiomyopathy genes in which rare variants are considered clinically actionable. Genetic testing thus presents a promising opportunity to identify monogenetic defects linked to AF and inherited cardiac conditions, such as cardiomyopathy, and may contribute to prognosis and management in early-onset AF patients. A first step towards recognizing this monogenic contribution was taken with the Class IIb recommendation for genetic testing in AF patients aged 45 years or younger by the 2023 American College of Cardiology/American Heart Association guidelines for AF. By identifying pathogenic genetic variants known to underlie inherited cardiomyopathies and arrhythmia syndromes, a personalized care pathway can be developed, encompassing more tailored screening, cascade testing, and potentially genotype-informed prognosis and preventive measures. However, this can only be ensured by frameworks that are developed and supported by all stakeholders. Ambiguity in test results such as variants of uncertain significance remain a major challenge and as many as ∼60% of people with early-onset AF might carry such variants. Patient education (including pretest counselling), training of genetic teams, selection of high-confidence genes, and careful reporting are strategies to mitigate this. Further challenges to implementation include financial barriers, insurability issues, workforce limitations, and the need for standardized definitions in a fast-moving field. Moreover, the prevailing genetic evidence largely rests on European descent populations, underscoring the need for diverse research cohorts and international collaboration. Embracing these challenges and the potential of genetic testing may improve AF care. However, further research-mechanistic, translational, and clinical-is urgently needed.
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Affiliation(s)
- Shinwan Kany
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St, 02412, Cambridge, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital,185 Cambridge St, 02114, Boston, MA, USA
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Sean J Jurgens
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St, 02412, Cambridge, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital,185 Cambridge St, 02114, Boston, MA, USA
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, Netherlands
- Department of Experimental Cardiology, Heart Center, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Joel T Rämö
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St, 02412, Cambridge, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital,185 Cambridge St, 02114, Boston, MA, USA
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science (HiLIFE), University of Helsinki, Helsinki, Finland
| | - Ingrid E Christophersen
- Department of Medical Research, Baerum Hospital, Vestre Viken Hospital Trust, Rud, Norway
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Mina K Chung
- Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic, Lerner Research Institute, Cleveland, OH, USA
- Department of Cardiovascular Medicine, Cleveland Clinic, Heart, Vascular & Thoracic Institute, Cleveland, OH, USA
| | - Morten S Olesen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Michael J Ackerman
- Department of Molecular Pharmacology and Experimental Therapeutics, Windland Smight Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, MN, USA
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth M McNally
- Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, University of Sydney, Sydney, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Arthur A M Wilde
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, Netherlands
- Department of Experimental Cardiology, Heart Center, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Department of Cardiology, Heart Center, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- European Reference Network for RARE, Low Prevalence and Complex Diseases of the Heart: ERN GUARD-Heart
| | - Emelia J Benjamin
- Department of Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Heidi L Rehm
- Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, 25 Shattuck St, 02115, Boston, MA, USA
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Connie R Bezzina
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, Netherlands
- Department of Experimental Cardiology, Heart Center, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Dan M Roden
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - M Benjamin Shoemaker
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Patrick T Ellinor
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St, 02412, Cambridge, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital,185 Cambridge St, 02114, Boston, MA, USA
- Harvard Medical School, 25 Shattuck St, 02115, Boston, MA, USA
- Cardiology Division, Massachusetts General Hospital, 55 Fruit St, 02114, Boston, MA, USA
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Pearsons A, Hanson CL, Hendriks JM, Neubeck L. Understanding for whom, under what conditions, and how an integrated approach to atrial fibrillation service delivery works: a realist review. Eur J Cardiovasc Nurs 2024; 23:323-336. [PMID: 38165026 DOI: 10.1093/eurjcn/zvad093] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 08/30/2023] [Accepted: 09/05/2023] [Indexed: 01/03/2024]
Abstract
AIMS To understand for whom, under what conditions, and how an integrated approach to atrial fibrillation (AF) service delivery works (or does not work). METHODS AND RESULTS A realist review of integrated approaches to AF service delivery for adult populations aged ≥18 years. An expert panel developed an initial programme theory, searched and screened literature from four databases until October 2022, extracted and synthesized data using realist techniques to create context-mechanism-outcome configurations for integrated approaches to AF service, and developed an integrated approach refined programme theory. A total of 5433 documents were screened and 39 included. The refined programme theory included five context-mechanism-outcome configurations for how clinical and system-wide outcomes are affected by the way integrated approaches to AF service delivery are designed and delivered. This review identifies core mechanisms underpinning the already known fundamental components of integrated care. This includes having a central coordinator responsible for service organization to provide continuity of care across primary and secondary care ensuring services are patient centred. Additionally, a fifth pillar, lifestyle and risk factor reduction, should be recognized within an AF care pathway. CONCLUSION It is evident from our provisional theory that numerous factors need to interlink and interact over time to generate a successfully integrated model of care in AF. Stakeholders should embrace this complexity and acknowledge that the learnings from this review are integral to shaping future service delivery in the face of an aging population and increased prevalence of AF.
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Affiliation(s)
- Alice Pearsons
- School of Health and Social Care, Edinburgh Napier University, Sighthill Campus, Sighthill Court, Edinburgh EH11 4BN, UK
| | - Coral L Hanson
- School of Health and Social Care, Edinburgh Napier University, Sighthill Campus, Sighthill Court, Edinburgh EH11 4BN, UK
| | - Jeroen M Hendriks
- College of Nursing and Health Sciences, Caring Futures Institute, Flinders University, Sturt Road, Bedford Park, SA 5001, Australia
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Port Road, Adelaide, SA 5001, Australia
| | - Lis Neubeck
- School of Health and Social Care, Edinburgh Napier University, Sighthill Campus, Sighthill Court, Edinburgh EH11 4BN, UK
- Sydney Nursing School, Charles Perkins Centre, University of Sydney, Johns Hopkins Road, Sydney, NSW 2006, Australia
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5
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Jones ID, Lane DA, Lotto RR, Oxborough D, Neubeck L, Penson PE, Smith EJ, Santos A, McGinn EE, Ajiboye A, Town N, Czanner G, Shaw A, El-Masri H, Lip GYH. Supermarket/hypermarket opportunistic screening for atrial fibrillation (SHOPS-AF) using sensors embedded in the handles of supermarket trolleys: A feasibility study. Am Heart J 2024; 271:164-177. [PMID: 38395294 DOI: 10.1016/j.ahj.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) increases the risk of death, stroke, heart failure, cognitive decline, and healthcare costs but is often asymptomatic and undiagnosed. There is currently no national screening program for AF. The advent of validated hand-held devices allows AF to be detected in non-healthcare settings, enabling screening to be undertaken within the community. METHOD AND RESULTS In this novel observational study, we embedded a MyDiagnostick single lead ECG sensor into the handles of shopping trolleys in four supermarkets in the Northwest of England: 2155 participants were recruited. Of these, 231 participants either activated the sensor or had an irregular pulse, suggesting AF. Some participants agreed to use the sensor but refused to provide their contact details, or consent to pulse assessment. In addition, some data were missing, resulting in 203 participants being included in the final analyses. Fifty-nine participants (mean age 73.6 years, 43% female) were confirmed or suspected of having AF; 20 were known to have AF and 39 were previously undiagnosed. There was no evidence of AF in 115 participants and the remaining 46 recordings were non-diagnostic, mainly due to artefact. Men and older participants were significantly more likely to have newly diagnosed AF. Due to the number of non-diagnostic ECGs (n = 46), we completed three levels of analyses, excluding all non-diagnostic ECGs, assuming all non-diagnostic ECGs were masking AF, and assuming all non-diagnostic ECGs were not AF. Based on the results of the three analyses, the sensor's sensitivity (95% CI) ranged from 0.70 to 0.93; specificity from 0.15 to 0.97; positive predictive values (PPV) and negative predictive values (NPV) ranged from 0.24 to 0.56 and 0.55 to 1.00, respectively. These values should be interpreted with caution, as the ideal reference standard on 1934 participants was imperfect. CONCLUSION The study demonstrates that the public will engage with AF screening undertaken as part of their daily routines using hand-held devices. Sensors can play a key role in identifying asymptomatic patients in this way, but the technology must be further developed to reduce the quantity of non-diagnostic ECGs.
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Affiliation(s)
- Ian D Jones
- School of Nursing and Advanced Practice, Faculty of Health, Liverpool John Moores University, Liverpool, UK; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK.
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK; Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Robyn R Lotto
- School of Nursing and Advanced Practice, Faculty of Health, Liverpool John Moores University, Liverpool, UK; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - David Oxborough
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK; School of Sport and Exercise Science, Liverpool John Moores University, Liverpool, UK
| | - Lis Neubeck
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Peter E Penson
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK; School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
| | - Emma Johnston Smith
- School of Nursing and Advanced Practice, Faculty of Health, Liverpool John Moores University, Liverpool, UK
| | - Aimeris Santos
- School of Nursing and Advanced Practice, Faculty of Health, Liverpool John Moores University, Liverpool, UK; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Emily E McGinn
- School of Nursing and Advanced Practice, Faculty of Health, Liverpool John Moores University, Liverpool, UK; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Aderonke Ajiboye
- School of Nursing and Advanced Practice, Faculty of Health, Liverpool John Moores University, Liverpool, UK; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Nicola Town
- School of Nursing and Advanced Practice, Faculty of Health, Liverpool John Moores University, Liverpool, UK; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Gabriela Czanner
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK; School of Computer Science and Mathematics, Liverpool John Moores University, Liverpool, UK; Faculty of Informatics and Information Technology, Slovak University of Technology, Bratislava, Slovakia
| | - Andy Shaw
- School of Civil Engineering and Built Environment, Liverpool John Moores University, Liverpool, UK
| | - Hala El-Masri
- School of Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - 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 Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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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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7
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Wyss F, Barrios V, Méndez M, Ramos S, Gonzalez Á, Ortiz H, Díaz MR, Castillo G, Quesada D, Franco CE, Ventura J, López EP, Somoza F, Montealegre AA, Meneses D, Pichel D, Valdez O. Central American and Caribbean Consensus Document for the Optimal Management of Oral Anticoagulation in Patients with Non-Valvular Atrial Fibrillation Endorsed by the Central American and Caribbean Society of Arterial Hypertension and Cardiovascular Prevention. J Clin Med 2024; 13:314. [PMID: 38256448 PMCID: PMC10816126 DOI: 10.3390/jcm13020314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/24/2024] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in adults. Prevention of the ischaemic risk with oral anticoagulants (OACs) is widely recommended, and current clinical guidelines recommend direct oral anticoagulants (DOACs) as preference therapy for stroke prevention. However, there are currently no clinical practice guidelines or recommendation documents on the optimal management of OACs in patients with AF that specifically address and adapt to the Central American and Caribbean context. The aim of this Delphi-like study is to respond to doubts that may arise in the management of OACs in patients with non-valvular AF in this geographical area. A consensus project was performed on the basis of a systematic review of the literature, a recommended ADOLOPMENT-like approach, and the application of a two-round Delphi survey. In the first round, 31 recommendations were evaluated and 30 reached consensus, of which, 10 unanimously agreed. The study assessed expert opinions in a wide variety of contextualized recommendations for the optimal management of DOACs in patients with non-valvular atrial fibrillation (NVAF). There is a broad consensus on the clinical practice guideline (CPG) statements used related to anticoagulation indication, patient follow-up, anticoagulation therapy complications, COVID-19 management and prevention, and cardiac interventions.
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Affiliation(s)
- Fernando Wyss
- Cardiovascular Services and Technology of Guatemala, CARDIOSOLUTIONS, Central American and Caribbean Society of Arterial Hypertension and Cardiovascular Prevention, Guatemala City 01010, Guatemala
| | - Vivencio Barrios
- Cardiology Department, University Hospital Ramon y Cajal, School of Medicine, Alcala University, 28034 Madrid, Spain
| | - Máxima Méndez
- Cardiologist-Internal Medicine, Medicine Autonomous University, Santo Domingo 10105, Dominican Republic;
- Cardiometabolic Unity, The Hub Innovation and Investigation of the Iberoamerican University, UNIBE, Santo Domingo 10203, Dominican Republic
- Lipid Master National Lipid Association, Jacksonville, FL 32216, USA
| | - Samuel Ramos
- Cardiology Department, Presidente Estrella Ureña Hospital, Santiago de los Caballeros, Salvador B. Gautier Hospital, Santo Domingo 10514, Dominican Republic;
| | - Ángel Gonzalez
- Cardiology Department, Hospiten Santo Domingo, Autónoma de Santo Domingo University, Santo Domingo 1355, Dominican Republic;
- American and Caribbean Society of Arterial Hypertension and Cardiovascular Prevention, Guatemala City 01010, Guatemala;
| | - Héctor Ortiz
- Cardiology Department, Herrera Llerandi Hospital, Guatemala City 01010, Guatemala;
| | - Marco Rodas Díaz
- Guatemalan Association of Cardiology, Cardiovascular Surgery Unit of Guatemala (UNICAR), Guatemala City 01010, Guatemala;
| | - Gabriela Castillo
- Cardiology Department, Max Peralta Hospital, Costa Rica University Cartago, Cartago 30101, Costa Rica;
| | - Daniel Quesada
- Cardiology Department, Hospital San Vicente de Paul, Universidad de Costa Rica, Heredia 40101, Costa Rica;
| | - Carlos Enrique Franco
- Cardiology Department, Surgical and Oncological Medical Hospital, Instituto Salvadoreño del Seguro Social, Escalon Medical Center, San Salvador 1101, El Salvador;
| | - Jaime Ventura
- Cardiology Department, Instituto Salvadoreño del Seguro Social, San Salvador 1101, El Salvador;
| | - Emilio Peralta López
- Cardiology Department, Instituto Nacional Cardiopulmonar, Tegucigalpa 11101, Honduras;
| | - Francisco Somoza
- Cardiology Department, CEMESA Hospital, San Pedro Sula 21102, Honduras;
| | | | - Daniel Meneses
- Cardiology Department, Del Valle Cardiologic Clinique, Nacional Autónoma of Nicaragua University, Managua 14145, Nicaragua;
| | - Daniel Pichel
- Cardiology Department, Paitilla Hospital, University of Panamá, Paitilla 06001, Panama;
| | - Osiris Valdez
- American and Caribbean Society of Arterial Hypertension and Cardiovascular Prevention, Guatemala City 01010, Guatemala;
- Cardiology Department, Central Romana Hospital, La Romana 22000, Dominican Republic
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8
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Gooden TE, Wang J, Carvalho Goulart A, Varella AC, Tai M, Sheron VA, Wang H, Zhang H, Zhong J, Kumarendran B, Nirantharakumar K, Surenthirakumaran R, Bensenor IM, Guo Y, Lip GYH, Thomas GN, Manaseki-Holland S. Generalisability of and lessons learned from a mixed-methods study conducted in three low- and middle-income countries to identify care pathways for atrial fibrillation. Glob Health Action 2023; 16:2231763. [PMID: 37466418 PMCID: PMC10360996 DOI: 10.1080/16549716.2023.2231763] [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: 05/15/2023] [Accepted: 06/27/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Identifying existing care pathways is the first step for understanding how services can be improved to enable early diagnosis and effective follow-up care for non-communicable diseases (NCDs); however, evidence on how care pathways can and should be identified in low- and middle-income countries (LMICs) is lacking. OBJECTIVE To describe generalisability and lessons learned from recruitment and data collection for the quantitative component of a mixed methods study designed to determine the care pathway for atrial fibrillation (AF) in Brazil, China and Sri Lanka. METHODS Adults (≥18 years) that spoke the local language and with an AF diagnosis were eligible. We excluded anyone with a hearing or cognitive impairment or ineligible address. Eligible participants were identified using electronic records in Brazil and China; in Sri Lanka, researchers attended the outpatient clinics to identify eligible participants. Data were collected using two quantitative questionnaires administered at least 2-months apart. A minimum sample size of 238 was required for each country. RESULTS The required sample size was met in Brazil (n = 267) and China (n = 298), but a large proportion of AF patients could not be contacted (47% and 27%, respectively) or refused to participate (36% and 38%, respectively). In Sri Lanka, recruitment was challenging, resulting in a reduced sample (n = 151). Mean age of participants from Brazil, China and Sri Lanka was 69 (SD = 11.3), 65 (SD = 12.8) and 58 (SD = 11.7), respectively. Females accounted for 49% of the Brazil sample, 62% in China and 70% in Sri Lanka. CONCLUSIONS Generalisability was an issue in Brazil and China, as was selection bias. Recruitment bias was highlighted in Sri Lanka. Additional or alternative recruitment methods may be required to ensure generalisability and reduce bias in future studies aimed at identifying NCD care pathways in LMICs.
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Affiliation(s)
- Tiffany E Gooden
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jingya Wang
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Alessandra Carvalho Goulart
- Faculdade de Medicina, Universidade, Sao Paulo, São Paulo, Brazil
- Center for Clinical and Epidemiologic Research and Division of Internal Medicine, University Hospital, University of São Paulo, São Paulo, Brazil
| | - Ana C Varella
- Faculdade de Medicina, Universidade, Sao Paulo, São Paulo, Brazil
| | - Meihui Tai
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Vethanayagan Antony Sheron
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Sri Lanka
| | - Hao Wang
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Hui Zhang
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Jiaoyue Zhong
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Balachandran Kumarendran
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Sri Lanka
| | | | - Rajendra Surenthirakumaran
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Sri Lanka
| | - Isabela M Bensenor
- Faculdade de Medicina, Universidade, Sao Paulo, São Paulo, Brazil
- Center for Clinical and Epidemiologic Research and Division of Internal Medicine, University Hospital, University of São Paulo, São Paulo, Brazil
| | - Yutao Guo
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | - G Neil Thomas
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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9
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Arbelo E, Protonotarios A, Gimeno JR, Arbustini E, Barriales-Villa R, Basso C, Bezzina CR, Biagini E, Blom NA, de Boer RA, De Winter T, Elliott PM, Flather M, Garcia-Pavia P, Haugaa KH, Ingles J, Jurcut RO, Klaassen S, Limongelli G, Loeys B, Mogensen J, Olivotto I, Pantazis A, Sharma S, Van Tintelen JP, Ware JS, Kaski JP. 2023 ESC Guidelines for the management of cardiomyopathies. Eur Heart J 2023; 44:3503-3626. [PMID: 37622657 DOI: 10.1093/eurheartj/ehad194] [Citation(s) in RCA: 316] [Impact Index Per Article: 316.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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10
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Sanghai S, Henrikson CA. ABCs: A Better Chance to Improve Outcomes in Atrial Fibrillation. JACC. ASIA 2023; 3:592-594. [PMID: 37614547 PMCID: PMC10442875 DOI: 10.1016/j.jacasi.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Affiliation(s)
- Saket Sanghai
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Charles A. Henrikson
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
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11
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Bisson A, M Fawzy A, Romiti GF, Proietti M, Angoulvant D, El-Bouri W, Y H Lip G, Fauchier L. Phenotypes and outcomes in non-anticoagulated patients with atrial fibrillation: An unsupervised cluster analysis. Arch Cardiovasc Dis 2023; 116:342-351. [PMID: 37422421 DOI: 10.1016/j.acvd.2023.06.001] [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: 02/23/2023] [Revised: 06/01/2023] [Accepted: 06/05/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Patients with atrial fibrillation are characterized by great clinical heterogeneity and complexity. The usual classifications may not adequately characterize this population. Data-driven cluster analysis reveals different possible patient classifications. AIMS To identify different clusters of patients with atrial fibrillation who share similar clinical phenotypes, and to evaluate the association between identified clusters and clinical outcomes, using cluster analysis. METHODS An agglomerative hierarchical cluster analysis was performed in non-anticoagulated patients from the Loire Valley Atrial Fibrillation cohort. Associations between clusters and a composite outcome comprising stroke/systemic embolism/death and all-cause death, stroke and major bleeding were evaluated using Cox regression analyses. RESULTS The study included 3434 non-anticoagulated patients with atrial fibrillation (mean age 70.3±17 years; 42.8% female). Three clusters were identified: cluster 1 was composed of younger patients, with a low prevalence of co-morbidities; cluster 2 included old patients with permanent atrial fibrillation, cardiac pathologies and a high burden of cardiovascular co-morbidities; cluster 3 identified old female patients with a high burden of cardiovascular co-morbidities. Compared with cluster 1, clusters 2 and 3 were independently associated with an increased risk of the composite outcome (hazard ratio 2.85, 95% confidence interval 1.32-6.16 and hazard ratio 1.52, 95% confidence interval 1.09-2.11, respectively) and all-cause death (hazard ratio 3.54, 95% confidence interval 1.49-8.43 and hazard ratio 1.88, 95% confidence interval 1.26-2.79, respectively). Cluster 3 was independently associated with an increased risk of major bleeding (hazard ratio 1.72, 95% confidence interval 1.06-2.78). CONCLUSION Cluster analysis identified three statistically driven groups of patients with atrial fibrillation, with distinct phenotype characteristics and associated with different risks for major clinical adverse events.
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Affiliation(s)
- Arnaud Bisson
- Service de cardiologie, centre hospitalier régional universitaire et faculté de médecine de Tours, 37000 Tours, France; Service de cardiologie, centre hospitalier régional universitaire d'Orléans, 45100 Orléans, France; EA4245, transplantation immunité inflammation, université de Tours, 37032 Tours, France; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, L7 8TX Liverpool, United Kingdom.
| | - Ameenathul M Fawzy
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, L7 8TX Liverpool, United Kingdom
| | - Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, L7 8TX Liverpool, United Kingdom; Department of Translational and Precision Medicine, Sapienza - University of Rome, 00185 Rome, Italy
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, L7 8TX Liverpool, United Kingdom; Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; IRCCS Istituti Clinici Scientifici Maugeri, 20138 Milan, Italy
| | - Denis Angoulvant
- Service de cardiologie, centre hospitalier régional universitaire et faculté de médecine de Tours, 37000 Tours, France; EA4245, transplantation immunité inflammation, université de Tours, 37032 Tours, France
| | - Wahbi El-Bouri
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, L7 8TX 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, L7 8TX Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark
| | - Laurent Fauchier
- Service de cardiologie, centre hospitalier régional universitaire et faculté de médecine de Tours, 37000 Tours, France
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12
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Modi AD, Pancholi YN, Modi DM. Comparing monopharmacotherapy of antiarrhythmic and anticoagulant drugs with other drugs for atrial fibrillation: A complete review of clinical trials. MEDICINE IN DRUG DISCOVERY 2023. [DOI: 10.1016/j.medidd.2023.100154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
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13
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van den Dries CJ, van der Meulen MP, Frederix GWJ, Hoes AW, Moons KGM, Geersing GJ. Managing the Increasing Burden of Atrial Fibrillation through Integrated Care in Primary Care: A Cost-Effectiveness Analysis. Int J Integr Care 2023; 23:9. [PMID: 37151778 PMCID: PMC10162350 DOI: 10.5334/ijic.5661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 04/19/2023] [Indexed: 05/09/2023] Open
Abstract
Introduction Integrated care for patients with atrial fibrillation (AF) in primary care reduced mortality compared to usual care. We assessed the cost-effectiveness of this approach. Methods Dutch primary care practices were randomised to provide integrated care for AF patients or usual care. A cost-effectiveness analysis was performed from a societal perspective with a 2-year time horizon to estimate incremental costs and Quality Adjusted Life Years (QALYs). A sensitivity analysis was performed, imputing missing questionnaires for a large group of usual care patients. Results 522 patients from 15 intervention practices were compared to 425 patients from 11 usual care practices. No effect on QALYs was seen, while mean costs indicated a cost reduction between €865 (95% percentile interval (PI) -€5730 to €3641) and €1343 (95% PI -€6534 to €3109) per patient per 2 years. The cost-effectiveness probability ranged between 36% and 54%. In the sensitivity analysis, this increased to 95%-99%. Discussion Results should be interpreted with caution due to missing information for a large proportion of usual care patients. Conclusion The higher costs from extra primary care consultations were likely outweighed by cost reductions for other resources, yet this study doesn't give sufficient clarity on the cost-effectiveness of integrated AF care.
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Affiliation(s)
- Carline J. van den Dries
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Str. 6.131, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | - Miriam P. van der Meulen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Str. 6.131, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | - Geert W. J. Frederix
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Str. 6.131, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | - Arno W. Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Str. 6.131, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | - Karel G. M. Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Str. 6.131, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Str. 6.131, PO Box 85500, 3508 GA Utrecht, the Netherlands
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14
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Medhekar A, Mulukutla S, Adams W, Kristofik A, Byers E, Thoma F, Aronis K, Barrington W, Bazaz R, Bhonsale A, Estes NAM, Kancharla K, Voigt A, Wang NC, Saba S, Jain SK. Impact of a dedicated center for atrial fibrillation on resource utilization and costs. Clin Cardiol 2023; 46:304-309. [PMID: 36660876 PMCID: PMC10018075 DOI: 10.1002/clc.23974] [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: 11/16/2022] [Revised: 12/19/2022] [Accepted: 01/04/2023] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) affects millions of Americans each year and can lead to high levels of resource utilization through emergency department (ED) visits and inpatient stays. HYPOTHESIS We hypothesized that referral of patients to a dedicated Center for AF from the ED would reduce costs of care. METHODS The University of Pittsburgh Center for AF serves as a rapid referral center for patients with AF to avoid unnecessary inpatient admissions and provide specialized care. Patients that presented to the ED with AF and met prespecified criteria were directed to rapid outpatient follow-up instead of inpatient admission. The primary outcome of interest was 30-day total costs. Secondary outcomes included outpatient costs, inpatient costs, 90-day costs, and inpatient stay characteristics. RESULTS We identified 96 patients (median age 65, 38% women) referred to the center for AF for a new diagnosis of AF between October 2017 and December 2019 and matched 96 control patients. After 30 days of follow-up, patients referred to the center for AF had a lower average cost ($619 vs. $1252, p < 0.001) compared to controls, driven by lower costs of ED care tempered by slightly higher outpatient costs. Thirty-day admissions and lengths of stay were also lower. These differences were persistent at 90 days. CONCLUSION Directing patients with AF that present to the ED to follow-up at a dedicated Center for AF significantly reduced overall costs, while reducing subsequent inpatient admissions and total lengths of stay in the hospital.
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Affiliation(s)
- Ankit Medhekar
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - Suresh Mulukutla
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Whitney Adams
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amanda Kristofik
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Erica Byers
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Floyd Thoma
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Konstantinos Aronis
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - William Barrington
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Raveen Bazaz
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Aditya Bhonsale
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nathan Anthony Mark Estes
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Krishna Kancharla
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrew Voigt
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Norman C Wang
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Samir Saba
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sandeep K Jain
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Rivera-Caravaca JM, Roldán V, Martínez-Montesinos L, Vicente V, Lip GYH, Marín F. The Atrial Fibrillation Better Care (ABC) Pathway and Clinical Outcomes in Patients with Atrial Fibrillation: the Prospective Murcia AF Project Phase II Cohort. J Gen Intern Med 2023; 38:315-323. [PMID: 35411538 PMCID: PMC9905403 DOI: 10.1007/s11606-022-07567-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/31/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The Atrial fibrillation Better Care (ABC) pathway was proposed for a more holistic or integrated care approach to atrial fibrillation (AF) management. We investigated whether adherence with the ABC pathway reduced the risk of adverse clinical outcomes in real-world AF patients starting vitamin K antagonist (VKAs) therapy. METHODS Prospective cohort study including AF outpatients starting VKA therapy from July 2016 to June 2018. Patients were considered as adherent if all ABC pathway criteria (A: Avoid stroke; B: Better symptom control; and C: Cardiovascular risk factors/comorbidities management) were fulfilled. The primary endpoints were all-cause mortality, net clinical outcomes (NCOs), major adverse cardiovascular events (MACE), and composite thrombotic/thromboembolic events at 2 years. RESULTS We enrolled 1045 patients (51.6% female; median age 77 [70-83] years). Of these, 63.0% (658) were adherent to the ABC pathway and 37% (387) were considered non-adherent. Compared to non-adherent patients, those who were ABC adherent had lower event rates for all-cause mortality (13.76 vs. 6.56; p<0.001), NCOs (19.65 vs. 11.94; p<0.001), and MACE (11.88 vs. 7.75; p=0.006) during the follow-up. Adjusted Cox regression analyses demonstrated that the ABC pathway adherent care reduced the risks of all-cause mortality (aHR 0.57, 95% CI 0.42-0.78), NCOs (aHR 0.72, 95% CI 0.56-0.92), and cardiovascular mortality (aHR 0.54, 95% CI 0.32-0.90). Event-free survivals for all-cause mortality, NCOs (both log-rank p-values <0.001), and MACE (log-rank p-value = 0.004) were also higher in ABC pathway adherent patients. CONCLUSIONS In this real-world prospective cohort of AF patients starting VKA therapy, adherence to the ABC pathway management at baseline significantly reduced the risk of NCOs, all-cause mortality, and cardiovascular death at 2 years.
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Affiliation(s)
- José Miguel Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain.
| | - Lorena Martínez-Montesinos
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Vicente Vicente
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
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16
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Improved prognosis with integrated care management including early rhythm control and healthy lifestyle modification in patients with concurrent atrial fibrillation and diabetes mellitus: a nationwide cohort study. Cardiovasc Diabetol 2023; 22:18. [PMID: 36717853 PMCID: PMC9887851 DOI: 10.1186/s12933-023-01749-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/21/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Patients with concurrent atrial fibrillation (AF) and diabetes mellitus (DM) [AF-DM] have a high risk of cardiovascular and diabetes-related complications, but are less engaged in a comprehensive treatment approach. We evaluated the association of early rhythm control (ERC), lifestyle modification (LSM), and a combination of ERC and LSM with cardiovascular or diabetes-related complication risk in patients with AF-DM (type 2). METHODS From the National Health Information Database, 47,940 patients diagnosed with AF-DM in 2009-2016 were included. We defined ERC as rhythm control therapy within two years of AF diagnosis and LSM as adherence to ≥ 2 of the healthy behaviors among non-current smoking, non-drinking, and regular exercise. We compared the primary (ischemic stroke) and secondary (macro- and microvascular complications, glycemic emergency, and all-cause death) outcomes in four groups: non-ERC and non-LSM (group 1), LSM only (group 2), ERC only (group 3), and both ERC and LSM (group 4). RESULTS Of total, 10,617 (22%), 26,730 (55.8%), 2,903 (6.1%), and 7,690 (16.0%) were classified into groups 1 to 4, in sequence. The mean duration from AF diagnosis to ERC was 25.6 ± 75.5 days. During 4.0 (interquartile range: 2.5-6.2) years' follow-up, groups 2 and 3 were associated with 23% and 33% lower risks of stroke than group 1, respectively. Group 4 was associated with the lowest risk of stroke: hazard ratio (HR) 0.58, 95% confidence interval (CI) 0.51-0.67, p < 0.001. Regarding secondary outcomes, the lowest risks were also observed in group 4; macro- and microvascular complications, glycemic emergency, and all-cause death had HRs (95% CIs) of 0.63 (0.56-0.70), 0.88 (0.82-0.94), 0.72 (0.62-0.84), and 0.80 (0.73-0.87), respectively, all p < 0.001. CONCLUSIONS For AF-DM patients, ERC and LSM exert a synergistic effect in preventing cardiovascular and diabetes-related complications with the greatest lowered risk of stroke. A comprehensive treatment approach should be pursued in AF-DM patients.
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Romiti GF, Proietti M, Bonini N, Ding WY, Boriani G, Huisman MV, Lip GY. Adherence to the Atrial Fibrillation Better Care (ABC) pathway and the risk of major outcomes in patients with atrial fibrillation: A post-hoc analysis from the prospective GLORIA-AF Registry. EClinicalMedicine 2023; 55:101757. [PMID: 36457650 PMCID: PMC9706520 DOI: 10.1016/j.eclinm.2022.101757] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/28/2022] [Accepted: 11/04/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The 'Atrial fibrillation Better Care' (ABC) pathway has been proposed to streamline a more holistic or integrated care approach to atrial fibrillation (AF) management. We aimed to analyse the impact of adherence to the ABC pathway on the risk of major adverse outcomes in a contemporary prospective global cohort of patients with AF. METHODS Patients enrolled Phase II and III of the GLORIA-AF Registry with complete data on ABC pathway adherence and follow-up were included in this post-hoc analysis between November 2011 and December 2014 for Phase II, and between January 2014 and December 2016 for Phase III. The primary outcome was the composite of all-cause death and major adverse cardiovascular events (MACEs). Multivariable Cox-regression and delay of event (DoE) analyses were used to evaluate the association between adherence to the ABC pathway and the risk of outcomes. FINDINGS We included 24,608 patients in this analysis (mean age: 70.2 (10.3) years, 10,938 (44.4%) females). Adherence to the ABC pathway was associated with a significant risk reduction for the primary outcome, with greatest magnitude observed for full ABC pathway adherence (adjusted Hazard Ratio [aHR] 0.54, 95% Confidence Interval [CI]: 0.44-0.67, p < 0.0001). ABC pathway adherence was also associated with reduced risk of mortality (aHR: 0.89, 95% CI: 0.79-1.00, p = 0.048), thromboembolism (aHR: 0.78, 95% CI: 0.65-0.94, p = 0.0078), and MACE (aHR: 0.82, 95% CI: 0.71-0.95, p = 0.0071). An increasing number of ABC criteria attained was associated with longer event-free survival in the DoE analysis. INTERPRETATION Adherence to the ABC pathway in patients with AF was associated with a reduced risk of major adverse events, including mortality, thromboembolism and MACE. This underlines the importance of using the ABC pathway in the clinical care of patients with AF. FUNDING This study was funded by Boehringer Ingelheim.
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Affiliation(s)
- 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, Rome, Italy
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science, at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Niccolò Bonini
- Liverpool Centre for Cardiovascular Science, at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, 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, at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Corresponding author. Liverpool Centre for Cardiovascular Science, University of Liverpool, William Henry Duncan Building, 6 West Derby St, Liverpool L7 8TX, United Kingdom.
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Romiti GF, Proietti M, Vitolo M, Bonini N, Fawzy AM, Ding WY, Fauchier L, Marin F, Nabauer M, Dan GA, Potpara TS, Boriani G, Lip GYH. Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry. BMC Med 2022; 20:326. [PMID: 36056426 PMCID: PMC9440492 DOI: 10.1186/s12916-022-02526-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/12/2022] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Clinical complexity is increasingly prevalent among patients with atrial fibrillation (AF). The 'Atrial fibrillation Better Care' (ABC) pathway approach has been proposed to streamline a more holistic and integrated approach to AF care; however, there are limited data on its usefulness among clinically complex patients. We aim to determine the impact of ABC pathway in a contemporary cohort of clinically complex AF patients. METHODS From the ESC-EHRA EORP-AF General Long-Term Registry, we analysed clinically complex AF patients, defined as the presence of frailty, multimorbidity and/or polypharmacy. A K-medoids cluster analysis was performed to identify different groups of clinical complexity. The impact of an ABC-adherent approach on major outcomes was analysed through Cox-regression analyses and delay of event (DoE) analyses. RESULTS Among 9966 AF patients included, 8289 (83.1%) were clinically complex. Adherence to the ABC pathway in the clinically complex group reduced the risk of all-cause death (adjusted HR [aHR]: 0.72, 95%CI 0.58-0.91), major adverse cardiovascular events (MACEs; aHR: 0.68, 95%CI 0.52-0.87) and composite outcome (aHR: 0.70, 95%CI: 0.58-0.85). Adherence to the ABC pathway was associated with a significant reduction in the risk of death (aHR: 0.74, 95%CI 0.56-0.98) and composite outcome (aHR: 0.76, 95%CI 0.60-0.96) also in the high-complexity cluster; similar trends were observed for MACEs. In DoE analyses, an ABC-adherent approach resulted in significant gains in event-free survival for all the outcomes investigated in clinically complex patients. Based on absolute risk reduction at 1 year of follow-up, the number needed to treat for ABC pathway adherence was 24 for all-cause death, 31 for MACEs and 20 for the composite outcome. CONCLUSIONS An ABC-adherent approach reduces the risk of major outcomes in clinically complex AF patients. Ensuring adherence to the ABC pathway is essential to improve clinical outcomes among clinically complex AF patients.
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Affiliation(s)
- Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby St, Liverpool, L7 8TX, UK.,Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby St, Liverpool, L7 8TX, UK.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Marco Vitolo
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby St, Liverpool, L7 8TX, UK.,Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Niccolò Bonini
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby St, Liverpool, L7 8TX, UK.,Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Ameenathul Mazaya Fawzy
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby St, Liverpool, L7 8TX, UK
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby St, Liverpool, L7 8TX, UK
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Tours, France
| | - Francisco Marin
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, CIBER-CV, Murcia, Spain
| | - Michael Nabauer
- Department of Cardiology, Ludwig-Maximilians-University, Munich, Germany
| | - Gheorghe Andrei Dan
- University of Medicine, 'Carol Davila', Colentina University Hospital, Bucharest, Romania
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Intensive Arrhythmia Care, Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby St, Liverpool, L7 8TX, UK. .,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Bai J, Lu Y, Wang H, Zhao J. How synergy between mechanistic and statistical models is impacting research in atrial fibrillation. Front Physiol 2022; 13:957604. [PMID: 36111152 PMCID: PMC9468674 DOI: 10.3389/fphys.2022.957604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Atrial fibrillation (AF) with multiple complications, high morbidity and mortality, and low cure rates, has become a global public health problem. Although significant progress has been made in the treatment methods represented by anti-AF drugs and radiofrequency ablation, the therapeutic effect is not as good as expected. The reason is mainly because of our lack of understanding of AF mechanisms. This field has benefited from mechanistic and (or) statistical methodologies. Recent renewed interest in digital twin techniques by synergizing between mechanistic and statistical models has opened new frontiers in AF analysis. In the review, we briefly present findings that gave rise to the AF pathophysiology and current therapeutic modalities. We then summarize the achievements of digital twin technologies in three aspects: understanding AF mechanisms, screening anti-AF drugs and optimizing ablation strategies. Finally, we discuss the challenges that hinder the clinical application of the digital twin heart. With the rapid progress in data reuse and sharing, we expect their application to realize the transition from AF description to response prediction.
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Affiliation(s)
- Jieyun Bai
- Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Information Technology, Jinan University, Guangzhou, China
- College of Information Science and Technology, Jinan University, Guangzhou, China
- *Correspondence: Jieyun Bai, ; Jichao Zhao,
| | - Yaosheng Lu
- Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Information Technology, Jinan University, Guangzhou, China
- College of Information Science and Technology, Jinan University, Guangzhou, China
| | - Huijin Wang
- College of Information Science and Technology, Jinan University, Guangzhou, China
| | - Jichao Zhao
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
- *Correspondence: Jieyun Bai, ; Jichao Zhao,
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20
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Arbelo E, Dagres N. The 2020 ESC atrial fibrillation guidelines for atrial fibrillation catheter ablation, CABANA, and EAST. Europace 2022; 24:ii3-ii7. [PMID: 35661865 DOI: 10.1093/europace/euab332] [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: 12/22/2021] [Accepted: 02/22/2022] [Indexed: 12/14/2022] Open
Abstract
Prior randomised clinical trials (RCTs) have suggested that rhythm control offers no benefit compared to accepting AF and instituting rate control in terms of all-cause mortality, CV mortality and sudden death; as a consequence, the ESC AF guidelines have recommended rhythm control for reducing AF-related symptoms and improving quality of life. The Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4) evaluated whether a more up-to-date rhythm control management strategy provides a benefit in mortality or stroke rates while the Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) trial evaluated whether catheter ablation was better than drug therapy in preventing a composite of death, disabling stroke, serious bleeding or cardiac arrest. This document critically reviews the recommendations of the 2020 ESC guidelines for the management of AF in the light of these two landmark trials, both of which have underlined the safety of contemporary rhythm control treatment. Considering the safety of the different strategies in modern AF treatment, a personalized approach taking into account the specific patient profile and preferences of the individual patient is needed.
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Affiliation(s)
- Elena Arbelo
- Arrhythmia Section, Cardiology Department, Cardiovascular Institute, Hospital Clínic, Universitat de Barcelona, C. Villarroel 170, Esc 3, Planta 6, 08036 Barcelona, Spain.,IDIBAPS, Institut d'Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
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21
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Luo X, Xu W, Ming WK, Jiang X, Yuan Q, Lai H, Huang C, Zhong X. Cost-Effectiveness of Mobile Health-Based Integrated Care for Atrial Fibrillation: Model Development and Data Analysis. J Med Internet Res 2022; 24:e29408. [PMID: 35438646 PMCID: PMC9066334 DOI: 10.2196/29408] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 09/23/2021] [Accepted: 02/24/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Mobile health (mHealth) technology is increasingly used in disease management. Using mHealth tools to integrate and streamline care has improved clinical outcomes of patients with atrial fibrillation (AF). OBJECTIVE The aim of this study was to investigate the potential clinical and health economic outcomes of mHealth-based integrated care for AF from the perspective of a public health care provider in China. METHODS A Markov model was designed to compare outcomes of mHealth-based care and usual care in a hypothetical cohort of patients with AF in China. The time horizon was 30 years with monthly cycles. Model outcomes measured were direct medical cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER). Sensitivity analyses were performed to examine the robustness of the base-case results. RESULTS In the base-case analysis, mHealth-based care gained higher QALYs of 0.0730 with an incurred cost of US $1090. Using US $33,438 per QALY (three times the gross domestic product) as the willingness-to-pay threshold, mHealth-based care was cost-effective, with an ICER of US $14,936 per QALY. In one-way sensitivity analysis, no influential factor with a threshold value was identified. In probabilistic sensitivity analysis, mHealth-based care was accepted as cost-effective in 92.33% of 10,000 iterations. CONCLUSIONS This study assessed the expected cost-effectiveness of applying mHealth-based integrated care for AF according to a model-based health economic evaluation. The exploration suggested the potential cost-effective use of mHealth apps in streamlining and integrating care via the Atrial fibrillation Better Care (ABC) pathway for AF in China. Future economic evaluation alongside randomized clinical trials is highly warranted to verify the suggestion and investigate affecting factors such as geographical variations in patient characteristics, identification of subgroups, and constraints on local implementation.
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Affiliation(s)
- Xueyan Luo
- School of Public Health and Management, Chongqing Medical University, Chongqing, China.,School of Biological and Chemical Engineering, Chongqing University of Education, Chongqing, China.,Research Center for Medicine and Social Development, Chongqing Medical University, Chongqing, China
| | - Wei Xu
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjin, China
| | - Wai-Kit Ming
- Department of Infectious Diseases and Public Health, City University of Hong Kong, Hong Kong, Hong Kong
| | - Xinchan Jiang
- School of Pharmacy, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Quan Yuan
- Chong Qing Pharmaceutical Group Co Ltd, Chongqing, China
| | - Han Lai
- School of Public Health and Management, Chongqing Medical University, Chongqing, China
| | - Chunji Huang
- School of Basic Medical Science, Army Medical University, Chongqing, China
| | - Xiaoni Zhong
- School of Public Health and Management, Chongqing Medical University, Chongqing, China.,Research Center for Medicine and Social Development, Chongqing Medical University, Chongqing, China
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22
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23
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Versaci F, Valenti V, Forte M, Cammisotto V, Nocella C, Bartimoccia S, Schirone L, Schiavon S, Vecchio D, D’Ambrosio L, Spinosa G, D’Amico A, Chimenti I, Violi F, Frati G, Pignatelli P, Sciarretta S, Pastori D, Carnevale R. Aging-Related Decline of Autophagy in Patients with Atrial Fibrillation-A Post Hoc Analysis of the ATHERO-AF Study. Antioxidants (Basel) 2022; 11:antiox11040698. [PMID: 35453383 PMCID: PMC9030744 DOI: 10.3390/antiox11040698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/26/2022] [Accepted: 03/31/2022] [Indexed: 01/02/2023] Open
Abstract
Background: Aging is an independent risk factor for cardiovascular diseases. The autophagy process may play a role in delaying aging and improving cardiovascular function in aging. Data regarding autophagy in atrial fibrillation (AF) patients are lacking. Methods: A post hoc analysis of the prospective ATHERO-AF cohort study, including 150 AF patients and 150 sex- and age-matched control subjects (CS), was performed. For the analysis, the population was divided into three age groups: <50−60, 61−70, and >70 years. Oxidative stress (Nox2 activity and hydrogen peroxide, H2O2), platelet activation (PA) by sP-selectin and CD40L, endothelial dysfunction (nitric oxide, NO), and autophagy parameters (P62 and ATG5 levels) were assessed. Results: Nox2 activity and H2O2 production were higher in the AF patients than in the CS; conversely, antioxidant capacity was decreased in the AF patients compared to the CS, as was NO production. Moreover, sP-selectin and CD40L were higher in the AF patients than in the CS. The autophagy process was also significantly impaired in the AF patients. We found a significant difference in oxidative stress, PA, NO production, and autophagy across the age groups. Autophagy markers correlated with oxidative stress, PA, and endothelial dysfunction in both groups. Conclusions: This study provides evidence that the autophagy process may represent a mechanism for increased cardiovascular risk in the AF population.
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Affiliation(s)
- Francesco Versaci
- Department of Cardiology, Santa Maria Goretti Hospital, 04100 Latina, Italy; (F.V.); (V.V.)
| | - Valentina Valenti
- Department of Cardiology, Santa Maria Goretti Hospital, 04100 Latina, Italy; (F.V.); (V.V.)
| | - Maurizio Forte
- IRCCS Neuromed, 86077 Pozzilli, Italy; (M.F.); (G.F.); (S.S.)
| | - Vittoria Cammisotto
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (V.C.); (C.N.); (P.P.)
| | - Cristina Nocella
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (V.C.); (C.N.); (P.P.)
| | - Simona Bartimoccia
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy; (S.B.); (L.S.); (S.S.); (D.V.); (L.D.); (G.S.); (I.C.)
| | - Leonardo Schirone
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy; (S.B.); (L.S.); (S.S.); (D.V.); (L.D.); (G.S.); (I.C.)
| | - Sonia Schiavon
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy; (S.B.); (L.S.); (S.S.); (D.V.); (L.D.); (G.S.); (I.C.)
| | - Daniele Vecchio
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy; (S.B.); (L.S.); (S.S.); (D.V.); (L.D.); (G.S.); (I.C.)
| | - Luca D’Ambrosio
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy; (S.B.); (L.S.); (S.S.); (D.V.); (L.D.); (G.S.); (I.C.)
| | - Giulia Spinosa
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy; (S.B.); (L.S.); (S.S.); (D.V.); (L.D.); (G.S.); (I.C.)
| | - Alessandra D’Amico
- Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, 00135 Rome, Italy;
| | - Isotta Chimenti
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy; (S.B.); (L.S.); (S.S.); (D.V.); (L.D.); (G.S.); (I.C.)
| | | | - Giacomo Frati
- IRCCS Neuromed, 86077 Pozzilli, Italy; (M.F.); (G.F.); (S.S.)
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy; (S.B.); (L.S.); (S.S.); (D.V.); (L.D.); (G.S.); (I.C.)
| | - Pasquale Pignatelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (V.C.); (C.N.); (P.P.)
- Mediterranea Cardiocentro, 80122 Naples, Italy;
| | - Sebastiano Sciarretta
- IRCCS Neuromed, 86077 Pozzilli, Italy; (M.F.); (G.F.); (S.S.)
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy; (S.B.); (L.S.); (S.S.); (D.V.); (L.D.); (G.S.); (I.C.)
| | - Daniele Pastori
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (V.C.); (C.N.); (P.P.)
- Correspondence: (D.P.); (R.C.); Tel.: +39-0649970941 (D.P.); +39-07731757245 (R.C.); Fax: +39-0649972309 (D.P.); +39-07731757245 (R.C.)
| | - Roberto Carnevale
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy; (S.B.); (L.S.); (S.S.); (D.V.); (L.D.); (G.S.); (I.C.)
- Mediterranea Cardiocentro, 80122 Naples, Italy;
- Correspondence: (D.P.); (R.C.); Tel.: +39-0649970941 (D.P.); +39-07731757245 (R.C.); Fax: +39-0649972309 (D.P.); +39-07731757245 (R.C.)
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24
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Atrial fibrillation detection using convolutional neural networks on 2-dimensional representation of ECG signal. Biomed Signal Process Control 2022. [DOI: 10.1016/j.bspc.2021.103470] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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25
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Farinha JM, Jones ID, Lip GYH. Optimizing adherence and persistence to non-vitamin K antagonist oral anticoagulant therapy in atrial fibrillation. Eur Heart J Suppl 2022; 24:A42-A55. [PMID: 35185408 PMCID: PMC8850710 DOI: 10.1093/eurheartj/suab152] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke, which can be prevented by the use of oral anticoagulation. Although non-vitamin K antagonist oral anticoagulants (NOACs) have become the first choice for stroke prevention in the majority of patients with non-valvular AF, adherence and persistence to these medications remain suboptimal, which may translate into poor health outcomes and increased healthcare costs. Factors influencing adherence and persistence have been suggested to be patient-related, physician-related, and healthcare system-related. In this review, we discuss factors influencing patient adherence and persistence to NOACs and possible problem solving strategies, especially involving an integrated care management, aiming for the improvement in patient outcomes and treatment satisfaction.
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Affiliation(s)
- José Maria Farinha
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Ian D Jones
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- School of Nursing and Allied Health, Liverpool John Moores University, Liverpool, UK
| | - 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 University, Aalborg, Denmark
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26
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Abstract
Rate and rhythm control are still considered equivalent strategies for symptom control using the Atrial Fibrillation Better Care algorithm recommended by the recent atrial fibrillation guideline. In acute situations or critically ill patients, a personalized approach should be used for rapid rhythm or rate control. Even though electrical cardioversion is generally indicated in haemodynamically unstable patients or for rapid effective rhythm control in critically ill patients, this is not always possible due to the high percentage of failure or relapses in such patients. Rate control remains the background therapy for all these patients, and often rapid rate control is mandatory. Short and rapid-onset-acting beta-blockers are the most suitable drugs for acute rate control. Esmolol was the classical example; however, landiolol a newer very selective beta-blocker, recently included in the European atrial fibrillation guideline, has a more favourable pharmacokinetic and pharmacodynamic profile with less haemodynamic interference and is better appropriate for critically ill patients.
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Menichelli D, Carnevale R, Nocella C, Cammisotto V, Castellani V, Bartimoccia S, Frati G, Pignatelli P, Pastori D. Circulating Lipopolysaccharides and Impaired Antioxidant Status in Patients With Atrial Fibrillation. Data From the ATHERO-AF Study. Front Cardiovasc Med 2021; 8:779503. [PMID: 34869693 PMCID: PMC8635698 DOI: 10.3389/fcvm.2021.779503] [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: 09/18/2021] [Accepted: 10/26/2021] [Indexed: 01/06/2023] Open
Abstract
Objectives: Atrial fibrillation (AF) is characterized by an oxidative imbalance, which is associated with an increased risk of cardiovascular events (CVEs). It is unclear whether low grade endotoxemia may contribute to the impaired antioxidant status in AF patients. We investigated the relationship between circulating lipopolysaccharides (LPS) and antioxidant status in AF patients. Patients and Methods:Post-hoc analysis from the ongoing prospective observational cohort ATHERO-AF study including 907 patients. Antioxidant status was evaluated by the activity of glutathione peroxidase 3 (GPx3) and superoxide dismutase (SOD). Patients were divided into two groups to evaluate the risk of CVEs: (1) LPS below median and GPx3 above median (n = 254); (2) LPS above median and GPx3 below median (n = 263). Results: The mean age was 73.5 ± 8.3 years, and 43.1% were women. Median LPS and GPx3 were 50.0 pg/ml [interquartile range (IQR) 15–108] and 20.0 U/ml (IQR 10.0–34.0), respectively. Patients of Groups 2 were older, with a higher prevalence of heart failure. LPS above the median was associated with reduced GPx3 [Odds Ratio for LPS 1.752, 95% Confidence Interval (CI) 1.344–2.285, p < 0.001] and SOD (OR 0.525, 95%CI 0.403–0.683) activity after adjustment for CHA2DS2VASc score. In a mean follow-up of 54.0 ± 36.8 months, 118 CVEs occurred, 42 in Group 1 and 76 in Group 2 (Log-Rank test p = 0.001). At multivariable Cox regression analysis, Group 2 was associated with a higher risk of CVEs [Hazard Ratio (HR) 1.644, 95%CI 1.117–2,421, p = 0.012], along with age ≥ 75 years (HR 2.035, 95%CI 1.394–2.972, p < 0.001), diabetes (HR 1.927, 95%CI 1.280–2.900, p = 0.002), and previous cerebrovascular disease (HR 1.895, 95%CI 1.251–2.870, p = 0.003) and previous cardiovascular disease (HR 1.708, 95%CI 1.149–2.538, p = 0.008). Conclusions: Our study indicates that circulating LPS may contribute to impaired antioxidant status in patients with AF. Patients with coincidentally high LPS and reduced GPx3 activity showed the highest risk of CVEs.
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Affiliation(s)
- Danilo Menichelli
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Roberto Carnevale
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Department of Angio-Cardio-Neurology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Neuromed, Località Camerelle, Pozzilli, Italy
| | - Cristina Nocella
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Department of Angio-Cardio-Neurology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Neuromed, Località Camerelle, Pozzilli, Italy
| | - Vittoria Cammisotto
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Valentina Castellani
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Simona Bartimoccia
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Giacomo Frati
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Department of Angio-Cardio-Neurology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Neuromed, Località Camerelle, Pozzilli, Italy
| | - Pasquale Pignatelli
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy.,Mediterranea Cardiocentro, Naples, Italy
| | - Daniele Pastori
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
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Yao Y, Guo Y, Lip GYH. The Effects of Implementing a Mobile Health-Technology Supported Pathway on Atrial Fibrillation-Related Adverse Events Among Patients With Multimorbidity: The mAFA-II Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2140071. [PMID: 34932104 PMCID: PMC8693229 DOI: 10.1001/jamanetworkopen.2021.40071] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE The Mobile Health Technology for Improved Screening and Optimized Integrated Care in Atrial Fibrillation (mAFA-II) trial is a prospective cluster randomized trial that found a significant reduction in the composite clinical outcome of stroke or thromboembolism, all-cause death, and rehospitalization among patients with atrial fibrillation (AF) who used a mobile health (mHealth) technology that implemented the Atrial Fibrillation Better Care (ABC) pathway (ie, A, anticoagulation/avoid stroke; B, better symptom control; and C, cardiovascular disease and comorbidity management) compared with those receiving usual care. Multimorbidity (defined as ≥2 chronic long-term conditions) is common in older patients with AF, but the impact of integrated or holistic care (based on the ABC pathway) on clinical outcomes in this population is uncertain. OBJECTIVE To evaluate whether implementation of the integrated ABC pathway, supported by mHealth technology, would reduce AF-related adverse events in patients with multimorbidity. DESIGN, SETTING, AND PARTICIPANTS This prespecified ancillary analysis of data from the extended follow-up of the mAFA II trial was conducted between June 2018 and April 2021. Adult patients with AF were included in the analysis if they had at least 2 comorbidities. Participants were enrolled across 40 centers in China. INTERVENTION Integrated care supported by mHealth technology (mAFA intervention) vs usual care. MAIN OUTCOMES AND MEASURES The main outcome was the composite outcome of stroke or thromboembolism, all-cause death, and rehospitalization. Cox proportional hazard modeling was performed for adverse outcomes after adjusting for cluster effect and baseline risk factors. RESULTS Of 1890 patients, 833 (mean [SD] age, 72.0 [12.0] years; 278 [33.4%] women) with multimorbidity were allocated to the intervention group (ABC pathway), with a mean (SD) follow-up of 419 (257) days, and 1057 patients (mean [SD] age, 72.8 [13.0] years; 443 [41.9%] women) with multimorbidity were allocated to usual care, with a mean (SD) follow-up of 457 (154) days. Compared with usual care, the composite outcome of stroke or thromboembolism, all-cause death, and rehospitalization was significantly reduced in the intervention group (hazard ratio [HR], 0.37; 95% CI, 0.26-0.53; P < .001), as were rehospitalizations alone (HR, 0.42; 95% CI, 0.27-0.64; P < .001). For the C criterion of the ABC pathway, rates of acute coronary syndrome, heart failure, and uncontrolled blood pressure during follow-up were lower in the intervention group than the usual care group (27 patients [3.2%] vs 145 patients [13.7%]; HR, 0.29; 95% CI, 0.19-0.45; P < .001). Subgroup analyses by age, prior stroke, and sex demonstrated consistently lower HRs for the primary composite outcome and rehospitalization for patients with AF allocated to the intervention group compared with patients receiving usual care. CONCLUSIONS AND RELEVANCE In this study, mHealth technology-based integrated care that facilitated the implementation of the ABC pathway reduced meaningful clinical adverse events in older patients with AF and multimorbidity vs usual care. TRIAL REGISTRATION WHO International Clinical Trials Registry Platform (ICTRP) Registration number: ChiCTR-OOC-17014138.
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Affiliation(s)
- Yuan Yao
- Institute for Hospital Management Research, Chinese PLA General Hospital, Beijing, China
| | - Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease, Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Gregory Y. H. Lip
- Department of Pulmonary Vessel and Thrombotic Disease, Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Chao T, Joung B, Takahashi Y, Lim TW, Choi E, Chan Y, Guo Y, Sriratanasathavorn C, Oh S, Okumura K, Lip GYH. 2021 Focused update of the 2017 consensus guidelines of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation. J Arrhythm 2021; 37:1389-1426. [PMID: 34887945 PMCID: PMC8637102 DOI: 10.1002/joa3.12652] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 10/22/2021] [Indexed: 12/19/2022] Open
Abstract
The consensus of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation (AF) has been published in 2017 which provided useful clinical guidance for cardiologists, neurologists, geriatricians, and general practitioners in Asia-Pacific region. In these years, many important new data regarding stroke prevention in AF were reported. The Practice Guidelines subcommittee members comprehensively reviewed updated information on stroke prevention in AF, and summarized them in this 2021 focused update of the 2017 consensus guidelines of the APHRS on stroke prevention in AF. We highlighted and focused on several issues, including the importance of AF Better Care (ABC) pathway, the advantages of non-vitamin K antagonist oral anticoagulants (NOACs) for Asians, the considerations of use of NOACs for Asian patients with AF with single 1 stroke risk factor beyond gender, the role of lifestyle factors on stroke risk, the use of oral anticoagulants during the "coronavirus disease 2019" (COVID-19) pandemic, etc. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician's decision remains the most important factor in the management of AF.
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Affiliation(s)
- Tze‐Fan Chao
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- Institute of Clinical Medicine, and Cardiovascular Research CenterNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Boyoung Joung
- Division of CardiologyDepartment of Internal MedicineYonsei University College of MedicineSeoulRepublic of Korea
| | - Yoshihide Takahashi
- The Department of Advanced Arrhythmia ResearchTokyo Medical and Dental UniversityTokyoJapan
| | - Toon Wei Lim
- National University Heart CentreNational University HospitalSingaporeSingapore
| | - Eue‐Keun Choi
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
| | - Yi‐Hsin Chan
- Microscopy Core LaboratoryChang Gung Memorial HospitalLinkouTaoyuanTaiwan
- College of MedicineChang Gung UniversityTaoyuanTaiwan
- Microscopy Core LaboratoryChang Gung Memorial HospitalLinkouTaoyuanTaiwan
| | - Yutao Guo
- Pulmonary Vessel and Thrombotic DiseaseChinese PLA General HospitalBeijingChina
| | | | - Seil Oh
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
| | - Ken Okumura
- Division of CardiologySaiseikai Kumamoto HospitalKumamotoJapan
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool & Liverpool Heart and Chest HospitalLiverpoolUK
- Aalborg Thrombosis Research UnitDepartment of Clinical MedicineAalborg UniversityAalborgDenmark
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30
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Pastori D, Sciacqua A, Marcucci R, Del Ben M, Baratta F, Violi F, Pignatelli P. Non-alcoholic fatty liver disease (NAFLD), metabolic syndrome and cardiovascular events in atrial fibrillation. A prospective multicenter cohort study. Intern Emerg Med 2021; 16:2063-2068. [PMID: 33713286 PMCID: PMC8563662 DOI: 10.1007/s11739-021-02682-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 02/17/2021] [Indexed: 01/21/2023]
Abstract
Whether non-alcoholic fatty liver disease (NAFLD) is associated with an increased risk of cardiovascular events (CVEs) independently from metabolic syndrome (MetS) is still matter of debate. Aim of the study was to investigate the risk of CVEs in a high-risk population of patients with non-valvular atrial fibrillation (AF) according to the presence of MetS and NAFLD. Prospective observational multicenter study including 1,735 patients with non-valvular AF treated with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). NAFLD was defined by a fatty liver index ≥ 60. We categorized patients in 4 groups: 0 = neither MetS or NAFLD (38.6%), 1 = NAFLD alone (12.4%), 2 = MetS alone (19.3%), 3 = both MetS and NAFLD (29.7%). Primary endpoint was a composite of CVEs. Mean age was 75.4 ± 9.4 years, and 41.4% of patients were women. During a mean follow-up of 34.1 ± 22.8 months (4,926.8 patient-years), 155 CVEs were recorded (incidence rate of 3.1%/year): 55 occurred in Group 0 (2.92%/year), 12 in Group 1 (2.17%/year), 45 in Group 2 (4.58%/year) and 43 in Group 3 (2.85%/year). Multivariable Cox regression analysis showed that use of DOACs, and female sex were inversely associated with CVEs, whilst age, heart failure, previous cardiac and cerebrovascular events, and group 2 (Group 2, Hazard Ratio 1.517, 95% Confidence Interval, 1.010-2.280) were directly associated with CVEs. In patients with AF, MetS increases the risk of CVEs. Patients with NAFLD alone have lower cardiovascular risk but may experience higher liver-related complications.
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Affiliation(s)
- Daniele Pastori
- I Clinica Medica, Atherothrombosis Centre, Department of Clinical Internal, Anaesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Angela Sciacqua
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Maria Del Ben
- I Clinica Medica, Atherothrombosis Centre, Department of Clinical Internal, Anaesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Francesco Baratta
- I Clinica Medica, Atherothrombosis Centre, Department of Clinical Internal, Anaesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Francesco Violi
- I Clinica Medica, Atherothrombosis Centre, Department of Clinical Internal, Anaesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
- Mediterranea Cardiocentro, Naples, Italy
| | - Pasquale Pignatelli
- I Clinica Medica, Atherothrombosis Centre, Department of Clinical Internal, Anaesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
- Mediterranea Cardiocentro, Naples, Italy
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31
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Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, Benetos A, Biffi A, Boavida JM, Capodanno D, Cosyns B, Crawford C, Davos CH, Desormais I, Di Angelantonio E, Franco OH, Halvorsen S, Hobbs FDR, Hollander M, Jankowska EA, Michal M, Sacco S, Sattar N, Tokgozoglu L, Tonstad S, Tsioufis KP, van Dis I, van Gelder IC, Wanner C, Williams B. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur J Prev Cardiol 2021; 29:5-115. [PMID: 34558602 DOI: 10.1093/eurjpc/zwab154] [Citation(s) in RCA: 211] [Impact Index Per Article: 70.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | | | | | | | | | | | - Alessandro Biffi
- European Federation of Sports Medicine Association (EFSMA).,International Federation of Sport Medicine (FIMS)
| | | | | | | | | | | | | | | | | | | | - F D Richard Hobbs
- World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) - Europe
| | | | | | | | | | | | | | | | | | | | | | - Christoph Wanner
- European Renal Association - European Dialysis and Transplant Association (ERA-EDTA)
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32
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Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, Benetos A, Biffi A, Boavida JM, Capodanno D, Cosyns B, Crawford C, Davos CH, Desormais I, Di Angelantonio E, Franco OH, Halvorsen S, Hobbs FDR, Hollander M, Jankowska EA, Michal M, Sacco S, Sattar N, Tokgozoglu L, Tonstad S, Tsioufis KP, van Dis I, van Gelder IC, Wanner C, Williams B. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2021; 42:3227-3337. [PMID: 34458905 DOI: 10.1093/eurheartj/ehab484] [Citation(s) in RCA: 2295] [Impact Index Per Article: 765.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | - Alessandro Biffi
- European Federation of Sports Medicine Association (EFSMA)
- International Federation of Sport Medicine (FIMS)
| | | | | | | | | | | | | | | | | | | | - F D Richard Hobbs
- World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) - Europe
| | | | | | | | | | | | | | | | | | | | | | - Christoph Wanner
- European Renal Association - European Dialysis and Transplant Association (ERA-EDTA)
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33
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Liu Z, Ma L, Zhang H, Mu G, Xie Q, Zhou S, Wang Z, Wang Z, Hu K, Gong Y, Jiang J, Xiang Q, Cui Y. Comparison of non-vitamin K antagonist oral anticoagulants on bleeding and thrombosis. J Clin Pharm Ther 2021; 46:1729-1742. [PMID: 34462932 DOI: 10.1111/jcpt.13514] [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: 04/25/2021] [Revised: 08/06/2021] [Accepted: 08/17/2021] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Limited data are available for the comparison between different non-vitamin K antagonist oral anticoagulants (NOACs) on clinical outcomes. We aimed to provide evidence of different NOACs for patients with non-valvular atrial fibrillation (NVAF). METHODS Electronic databases were searched from inception through 22 March 2020 to identify eligible studies in which clinical outcomes (stroke, systemic embolism [SE], bleeding or death events) were directly compared between different NOACs. RESULTS 29 real-world studies enrolled more than 700,000 patients were included. Compared with dabigatran, apixaban had higher risk of death (OR 1.07), major bleeding (1.43), GI bleeding (1.64), ischaemic stroke and stroke/SE events (1.10); rivaroxaban had higher risk of death (1.28), major bleeding (1.24), GI bleeding (1.14) and ischaemic stroke (1.08). Compared with rivaroxaban, apixaban had lower risk of death (0.8), major bleeding (0.56) and ischaemic stroke events (0.71). Compared with edoxaban, rivaroxaban had higher risk of major bleeding (2.83), GI bleeding (5.18) and ischaemic stroke (2.28). WHAT IS NEW AND CONCLUSION In view of the global burden of disease and the routine use of NOACs worldwide, the findings have immediate and important implications. Our data suggested that apixaban might be the priority choice in prevention of bleeding and stroke and dabigatran could be the priority choice in prevention of death events. TRIAL REGISTRATION This systematic review and meta-analysis were conducted and reported according to the Preferred Reporting Items for Systematic Reviews (PRISMA), Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines and was registered with PROSPERO (CRD42019140553).
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Affiliation(s)
- Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Lingyue Ma
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Hanxu Zhang
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Guangyan Mu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Shuang Zhou
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zining Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhe Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Kun Hu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Yanjun Gong
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Jie Jiang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
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34
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Pokorney SD, Piccini JP. Treatment of atrial fibrillation: is it as easy as A-B-C? Europace 2021; 23:161-162. [PMID: 33517439 DOI: 10.1093/europace/euaa361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Sean D Pokorney
- Electrophysiology Section, Division of Cardiology, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Jonathan P Piccini
- Electrophysiology Section, Division of Cardiology, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
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35
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Ivany E, Lane DA, Dan GA, Doehner W, Farkowski MM, Iliodromitis K, Lenarczyk R, Potpara TS. Antithrombotic therapy for stroke prevention in patients with atrial fibrillation who survive an intracerebral haemorrhage: results of an EHRA survey. Europace 2021; 23:806-814. [PMID: 34020460 DOI: 10.1093/europace/euaa423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/30/2020] [Indexed: 11/13/2022] Open
Abstract
The aim of this survey is to provide a snapshot of current practice regarding antithrombotic therapy (ATT) in patients with atrial fibrillation (AF) comorbid with intracerebral haemorrhage (ICH). An online survey was distributed to members of the European Heart Rhythm Association. A total of 163 clinicians responded, mostly cardiologists or electrophysiologists (87.7%), predominantly working in University hospitals (61.3%). Most respondents (47.2%) had seen one to five patients with AF comorbid with ICH in the last 12 months. Among patients sustaining an ICH on oral anticoagulation (OAC), 84.3% respondents would consider some form of ATT post-ICH, with 73.2% preferring to switch from a vitamin-K antagonist (VKA) to a non-VKA oral anticoagulant (NOAC) and 37.2% preferring to switch from one NOAC to another. Most (36.6%) would restart OAC >30 days post-ICH. Among patients considered unable to take OAC, left atrial appendage occlusion procedure was the therapy of choice in 73.3% respondents. When deciding on ATT, respondents considered patient's CHA2DS2-VASc score, ICH type, demographics, risk factors, and patient adherence. The main reason for not restarting or commencing ATT was concern about recurrent ICH (80.8%). National or international clinical guidelines would be advantageous to support decision-making (84.3%). Other helpful resources reported were multidisciplinary team involvement (46.9%) and patient education (82%). In summary, most survey respondents would prescribe OAC therapy for patients with AF who have sustained an ICH on OAC and would restart OAC >30 days post-ICH. The risk of recurrent ICH was the main reason for not prescribing any ATT post-ICH.
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Affiliation(s)
- Elena Ivany
- Liverpool Centre for Cardiovascular Science, University of Liverpool, 6 West Derby Street, Liverpool L7 8TX, UK
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, 6 West Derby Street, Liverpool L7 8TX, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gheorghe-Andrei Dan
- 'Internal Medicine, Carol Davila' University of Medicine, Colentina University Hospital, Bucharest, Romania
| | - Wolfram Doehner
- Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany.,Department of Cardiology (Virchow Klinikum), Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Michal M Farkowski
- II Department of Heart Arrhythmia, National Institute of Cardiology, Warsaw, Poland
| | | | - Radoslaw Lenarczyk
- Department of Cardiology, Congenital Heart Defects and Electrotherapy, Medical University of Silesia, Silesian Center of Heart Disease, Zabrze, Poland
| | - Tatjana S Potpara
- Serbia School of Medicine, University of Belgrade, Belgrade, Serbia.,Department for Intensive Care in Cardiac Arrhythmias, Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
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36
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Heijman J, Sutanto H, Crijns HJGM, Nattel S, Trayanova NA. Computational models of atrial fibrillation: achievements, challenges, and perspectives for improving clinical care. Cardiovasc Res 2021; 117:1682-1699. [PMID: 33890620 PMCID: PMC8208751 DOI: 10.1093/cvr/cvab138] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Indexed: 12/11/2022] Open
Abstract
Despite significant advances in its detection, understanding and management, atrial fibrillation (AF) remains a highly prevalent cardiac arrhythmia with a major impact on morbidity and mortality of millions of patients. AF results from complex, dynamic interactions between risk factors and comorbidities that induce diverse atrial remodelling processes. Atrial remodelling increases AF vulnerability and persistence, while promoting disease progression. The variability in presentation and wide range of mechanisms involved in initiation, maintenance and progression of AF, as well as its associated adverse outcomes, make the early identification of causal factors modifiable with therapeutic interventions challenging, likely contributing to suboptimal efficacy of current AF management. Computational modelling facilitates the multilevel integration of multiple datasets and offers new opportunities for mechanistic understanding, risk prediction and personalized therapy. Mathematical simulations of cardiac electrophysiology have been around for 60 years and are being increasingly used to improve our understanding of AF mechanisms and guide AF therapy. This narrative review focuses on the emerging and future applications of computational modelling in AF management. We summarize clinical challenges that may benefit from computational modelling, provide an overview of the different in silico approaches that are available together with their notable achievements, and discuss the major limitations that hinder the routine clinical application of these approaches. Finally, future perspectives are addressed. With the rapid progress in electronic technologies including computing, clinical applications of computational modelling are advancing rapidly. We expect that their application will progressively increase in prominence, especially if their added value can be demonstrated in clinical trials.
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Affiliation(s)
- Jordi Heijman
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Faculty of Health, Medicine, and Life Sciences, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
| | - Henry Sutanto
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Faculty of Health, Medicine, and Life Sciences, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Faculty of Health, Medicine, and Life Sciences, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
| | - Stanley Nattel
- Department of Medicine, Montreal Heart Institute and Université de Montréal, Montreal, Canada
- Department of Pharmacology and Therapeutics, McGill University, Montreal, Canada
- Institute of Pharmacology, West German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen, Duisburg, Germany
- IHU Liryc and Fondation Bordeaux Université, Bordeaux, France
| | - Natalia A Trayanova
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, and Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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37
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Kim IC. Atrial Fibrillation and Heart Failure with Preserved Ejection Fraction: Two Chronic Troublemakers. Heart Fail Clin 2021; 17:377-386. [PMID: 34051970 DOI: 10.1016/j.hfc.2021.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this article, the definition; mechanisms; diagnostic strategies, including scoring systems; treatments; prognosis; and future perspectives in heart failure with preserved ejection fraction with atrial fibrillation, which are common comorbid conditions, are reviewed thoroughly.
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Affiliation(s)
- In-Cheol Kim
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, 1035, Dalgubeol-daero, Dalseo-gu, Daegu 42601, Republic of Korea.
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38
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Gue YX, Lip GYH. Hypertension and atrial fibrillation: Closing a virtuous circle. PLoS Med 2021; 18:e1003598. [PMID: 34061832 PMCID: PMC8168876 DOI: 10.1371/journal.pmed.1003598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Ying Gue and Gregory Lip discuss the accompanying study by Ana-Catarina Pinho-Gomes and co-workers on blood pressure lowering treatment in patients with atrial fibrillation.
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Affiliation(s)
- Ying X. Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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39
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Romiti GF, Pastori D, Rivera-Caravaca JM, Ding WY, Gue YX, Menichelli D, Gumprecht J, Kozieł M, Yang PS, Guo Y, Lip GYH, Proietti M. Adherence to the 'Atrial Fibrillation Better Care' Pathway in Patients with Atrial Fibrillation: Impact on Clinical Outcomes-A Systematic Review and Meta-Analysis of 285,000 Patients. Thromb Haemost 2021; 122:406-414. [PMID: 34020488 DOI: 10.1055/a-1515-9630] [Citation(s) in RCA: 220] [Impact Index Per Article: 73.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The 'Atrial fibrillation Better Care' (ABC) pathway has been recently proposed as a holistic approach for the comprehensive management of patients with atrial fibrillation (AF). We performed a systematic review of current evidence for the use of the ABC pathway on clinical outcomes. METHODS AND RESULTS We performed a systematic review and meta-analysis according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed and EMBASE were searched for studies reporting the prevalence of ABC-pathway-adherent management in AF patients, and its impact on clinical outcomes (all-cause death, cardiovascular death, stroke, and major bleeding). Meta-analysis of odds ratio (OR) was performed with random-effects models; subgroup analysis and meta-regression were performed to account for heterogeneity. Among the eight studies included, we found a pooled prevalence of ABC-adherent management of 21% (95% confidence interval, CI: 13-34%), with a high grade of heterogeneity, explained by the increasing adherence to each ABC criterion. Patients treated according to the ABC pathway showed a lower risk of all-cause death (OR: 0.42; 95% CI: 0.31-0.56), cardiovascular death (OR: 0.37; 95% CI: 0.23-0.58), stroke (OR: 0.55; 95% CI: 0.37-0.82) and major bleeding (OR: 0.69; 95% CI: 0.51-0.94), with moderate heterogeneity. Prevalence of comorbidities was moderators of heterogeneity for all-cause and cardiovascular death, while longer follow-up was associated with increased effectiveness for all outcomes. CONCLUSION Adherence to the ABC pathway was suboptimal, being adopted in one in every five patients. Adherence to the ABC pathway was associated with a reduction in the risk of major adverse outcomes.
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Affiliation(s)
- Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Daniele Pastori
- Emergency Medicine Unit, Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - José Miguel Rivera-Caravaca
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), University of Murcia, CIBERCV, Murcia, Spain
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Ying Xuan Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Danilo Menichelli
- Emergency Medicine Unit, Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Jakub Gumprecht
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,1st Department of Cardiology and Angiology, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Monika Kozieł
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,1st Department of Cardiology and Angiology, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Pil-Sung Yang
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Yutao Guo
- Department of Cardiology, Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
| | - 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
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Ritchie LA, Lip GYH, Lane DA. Optimization of atrial fibrillation care: management strategies and quality measures. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 7:121-133. [PMID: 32761177 DOI: 10.1093/ehjqcco/qcaa063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 07/22/2020] [Accepted: 07/29/2020] [Indexed: 12/14/2022]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and a leading cause of mortality and morbidity. Optimal management of AF is paramount to improve quality of life and reduce the impact on health and social care services. Owing to its strong associations with other cardiovascular and non-cardiovascular comorbidities, a holistic management approach to AF care is advocated but this is yet to be clearly defined by international clinical guidelines. This ambiguity has prompted us to review the available clinical evidence on different management strategies to optimize AF care in the context of performance and quality measures, which can be used to objectively assess standards of care.
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Affiliation(s)
- Leona A Ritchie
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, William Henry Duncan Building, 6 West Derby Street, Liverpool L7 8TX, 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 Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, William Henry Duncan Building, 6 West Derby Street, Liverpool L7 8TX, 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
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, William Henry Duncan Building, 6 West Derby Street, Liverpool L7 8TX, 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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Domek M, Gumprecht J, Li YG, Proietti M, Rashed W, Al Qudaimi A, Gumprecht J, Zubaid M, Lip GYH. Compliance of atrial fibrillation treatment with the ABC pathway in patients with concomitant diabetes mellitus in the Middle East based on the Gulf SAFE registry. Eur J Clin Invest 2021; 51:e13385. [PMID: 32810282 DOI: 10.1111/eci.13385] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 07/19/2020] [Accepted: 08/09/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Atrial fibrillation (AF) and diabetes mellitus (DM) constitute a heavy burden on healthcare expenditure due to their negative impact on clinical outcomes in the Middle East. The Atrial fibrillation Better Care (ABC) pathway provides a simple strategy of integrated approach of AF management: A-Avoid stroke; B-Better symptom control; C-Cardiovascular comorbidity risk management. AIMS Evaluation of the AF treatment compliance to ABC pathway in DM patients in the Middle East. Assessment of the impact of ABC pathway adherence on all-cause mortality and the composite outcome of stroke/systemic embolism, all-cause death and cardiovascular hospitalisations. METHODS From 2043 patients in the Gulf SAFE registry, 603 patients (mean age 63; 48% male) with DM were included in an analysis of ABC pathway compliance: A-appropriate use of anticoagulation according to CHA2 DS2 -VASc score; B-AF symptoms management according to the European Heart Rhythm Association (EHRA) scale; C-Optimised cardiovascular comorbidities management. RESULTS 86 (14.3%) patients were treated in compliance with the ABC pathway. During 1-year follow-up, 207 composite outcome events and 87 deaths occurred. Mortality was significantly lower in the ABC group vs non-ABC (5.8% vs 15.9%, P = .0014, respectively). On multivariate analysis, ABC compliance was associated with a lower risk of all-cause death and the composite outcome after 6 months (OR 0.18; 95% CI: 0.42-0.75 and OR 0.54; 95% Cl: 0.30-1.00, respectively) and at 1 year (OR 0.30; 95% Cl: 0.11-0.76 and OR 0.57; 95% Cl: 0.33-0.97, respectively) vs the non-ABC group. CONCLUSIONS Compliance with the ABC pathway care was independently associated with the reduced risk of all-cause death and the composite outcome in DM patients with AF, highlighting the importance of an integrated approach to AF management.
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Affiliation(s)
- Magdalena Domek
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Internal Diseases, Diabetology and Nephrology, Medical University of Silesia, Zabrze, Poland
| | - Jakub Gumprecht
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Yan-Guang Li
- Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, Fondazione IRCCS Ca'Granda, Ospendale Maggiore Policlinico, Milan, Italy
| | - Wafa Rashed
- Department of Medicine, Mubarak Al-Kabeer Hospital, Kuwait.,Division of Cardiology, Mubarak Al-Kabeer Hospital, Kuwait, Kuwait
| | | | - Janusz Gumprecht
- Department of Internal Diseases, Diabetology and Nephrology, Medical University of Silesia, Zabrze, Poland
| | - Mohammad Zubaid
- Department of Medicine, Mubarak Al-Kabeer Hospital, Kuwait.,Division of Cardiology, Mubarak Al-Kabeer Hospital, Kuwait, Kuwait.,Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait, Kuwait
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Pastori D, Menichelli D, Violi F, Pignatelli P, Lip GYH. The Atrial fibrillation Better Care (ABC) pathway and cardiac complications in atrial fibrillation: a potential sex-based difference. The ATHERO-AF study. Eur J Intern Med 2021; 85:80-85. [PMID: 33358066 DOI: 10.1016/j.ejim.2020.12.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 12/12/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND An integrated care approach is recommended to optimize management of patients with atrial fibrillation (AF). The impact of the Atrial fibrillation Better Care (ABC) pathway on major adverse cardiac events (MACE), which are the main causes of death in AF, has not been explored. MATERIAL AND METHODS We investigated the association between ABC compliance and MACE incidence in 1157 (2690 patient-years) nonvalvular AF patients from the ATHERO-AF study. A subgroup analysis by sex and high cardiovascular risk patients as defined by a 2MACE score ≥3 was performed. RESULTS Overall, 428 (37%) patients composed the ABC-compliant group. During a median follow up of 23 (IQR 12-37) months, 64 MACE occurred (2.38%/year). Kaplan Meier curve analysis showed a higher rate of MACE in ABC non-compliant group compared to the ABC-compliant (log-rank test p=0.006). The risk of MACE increased by the number of non-fulfilled ABC criteria. On multivariable Cox proportional hazard regression analysis, the ABC non-compliance was associated with an increased risk of MACE (Hazard ratio (HR) 2.244, 95% Confidence Interval (95%CI) 1.129-4.462). Men were more likely to have suboptimal anticoagulation control (group A), while uncontrolled symptoms were more frequent in women. The association between non-ABC and MACE was more evident in men than women (HR 3.647, 95%CI 1.294-10.277) and in patients with 2MACE score ≥3 (HR 1.728, 95%CI 1.209-2.472). CONCLUSION An integrated care ABC approach is associated with a reduced risk of MACE in the AF population, especially in men and in patients at high risk of MACE.
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Affiliation(s)
- Daniele Pastori
- Department of Clinical Internal, Anesthesiologic, and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, United Kingdom.
| | - Danilo Menichelli
- Department of Clinical Internal, Anesthesiologic, and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesco Violi
- Department of Clinical Internal, Anesthesiologic, and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Pasquale Pignatelli
- Department of Clinical Internal, Anesthesiologic, and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 5224] [Impact Index Per Article: 1741.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Burdett P, Lip GYH. Atrial Fibrillation in the United Kingdom: Predicting Costs of an Emerging Epidemic Recognising and Forecasting the Cost Drivers of Atrial Fibrillation-related costs. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 8:187-194. [PMID: 33346822 DOI: 10.1093/ehjqcco/qcaa093] [Citation(s) in RCA: 118] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/03/2020] [Accepted: 12/09/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common sustained heart arrhythmia and a major preventable cause of stroke, heart failure and dementia. AF already accounts for a significant amount of National Health Service (NHS) funding, and over the coming years is highly likely to impose a growing cost on NHS budgets and the wider UK health care system. We therefore need greater understanding of the main cost drivers (e.g. hospitalisations) of this increasingly prevalent arrhythmia. Such data would help with NHS resource planning over the next decades. METHODS Based on prior published data, we initially calculated the cost of AF for 1995, and then again for 2000 which was calculated from a combination of contemporary and extrapolated data from that time. These data have been used as the basis for forecasting AF costs in the UK and as a share of total NHS expenditure. AF direct costs were split between cost driver categories; General Practioner (GP) consultations, GP referred OPD (Out Patient Department) visits, prescriptions and monitoring visits, primary admissions and post-discharge OPD visits. Forecast assumptions used: (i) NHS expenditure from 2020 onwards assumed to increase at annual rate of 3%/year; and (ii) the UK inflation rate to increase by 2% annually. Sensitivity modelling of 3%, 4% and 6% projected annual increase in AF prevalence amongst the population was applied. RESULTS The estimated direct and proportion of NHS expenditure of AF in 2020 for each of the assumed increases of 3%, 4% and 6% would be £1,435m (0.91%), £1,741m (1.11%) and £2,548m (1.62%) respectively. For 2030, the modelling would mean that the direct costs of AF and proportion of NHS expenditure would be £2,351m (1.11%), £3,141m (1.48%), £5,562m (2.63%), respectively. For 2040, the modelling shows that the direct costs of AF and proportion of NHS expenditure would be £3,851m (1.35%), £5,668m (1.99%), £12,143m (4.27%), respectively.By far the largest contributor to the total direct AF costs in 2020 was for Primary Admissions (nearly 60%), with a further 7% with post-discharge Outpatient Clinic visits. Taken together the total for these two categories in 2020 would cost the NHS between £949m and £1,685m, depending on the projected increase in annual rate of AF prevalence.The full cost of AF related hospitalisations may be underestimated, due to the other admissions associated with a secondary coding of AF, which in 2020 are forecast to cost between £2,269m and £4,030m, depending on the annual population increase of AF prevalence. There will be an increasing number of patients discharged to a nursing home after a hospital admission associated with a principal AF diagnosis, with cost estimates for this in 2000 being £111m, and predicted to rise to between £346m and £614m by 2020. CONCLUSIONS Focussing on 2020, AF is predicted to directly cost the NHS a total of a minimum of £1,435m and a maximum of £2,548m (depending on AF prevalence); hence, between 0.9-1.6% of NHS expenditure, mostly from primary admissions. The total direct costs of AF would increase to 1.35-4.27% of NHS expenditure, over the next 2 decades. If hospitalisations can be avoided or reduced, we would substantially reduce the healthcare costs of AF to the NHS.
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Affiliation(s)
- Paul Burdett
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; and Liverpool Health Partners
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; and Liverpool Health Partners
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Guo Y, Lane DA, Wang L, Zhang H, Wang H, Zhang W, Wen J, Xing Y, Wu F, Xia Y, Liu T, Wu F, Liang Z, Liu F, Zhao Y, Li R, Li X, Zhang L, Guo J, Burnside G, Chen Y, Lip GYH. Mobile Health Technology to Improve Care for Patients With Atrial Fibrillation. J Am Coll Cardiol 2020; 75:1523-1534. [PMID: 32241367 DOI: 10.1016/j.jacc.2020.01.052] [Citation(s) in RCA: 193] [Impact Index Per Article: 48.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/14/2020] [Accepted: 01/21/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Current management of patients with atrial fibrillation (AF) is limited by low detection of AF, non-adherence to guidelines, and lack of consideration of patients' preferences, thus highlighting the need for a more holistic and integrated approach to AF management. OBJECTIVE The objective of this study was to determine whether a mobile health (mHealth) technology-supported AF integrated management strategy would reduce AF-related adverse events, compared with usual care. METHODS This is a cluster randomized trial of patients with AF older than 18 years of age who were enrolled in 40 cities in China. Recruitment began on June 1, 2018 and follow-up ended on August 16, 2019. Patients with AF were randomized to receive usual care, or integrated care based on a mobile AF Application (mAFA) incorporating the ABC (Atrial Fibrillation Better Care) Pathway: A, Avoid stroke; B, Better symptom management; and C, Cardiovascular and other comorbidity risk reduction. The primary composite outcome was a composite of stroke/thromboembolism, all-cause death, and rehospitalization. Rehospitalization alone was a secondary outcome. Cardiovascular events were assessed using Cox proportional hazard modeling after adjusting for baseline risk. RESULTS There were 1,646 patients allocated to mAFA intervention (mean age, 67.0 years; 38.0% female) with mean follow-up of 262 days, whereas 1,678 patients were allocated to usual care (mean age, 70.0 years; 38.0% female) with mean follow-up of 291 days. Rates of the composite outcome of 'ischemic stroke/systemic thromboembolism, death, and rehospitalization' were lower with the mAFA intervention compared with usual care (1.9% vs. 6.0%; hazard ratio [HR]: 0.39; 95% confidence interval [CI]: 0.22 to 0.67; p < 0.001). Rates of rehospitalization were lower with the mAFA intervention (1.2% vs. 4.5%; HR: 0.32; 95% CI: 0.17 to 0.60; p < 0.001). Subgroup analyses by sex, age, AF type, risk score, and comorbidities demonstrated consistently lower HRs for the composite outcome for patients receiving the mAFA intervention compared with usual care (all p < 0.05). CONCLUSIONS An integrated care approach to holistic AF care, supported by mHealth technology, reduces the risks of rehospitalization and clinical adverse events. (Mobile Health [mHealth] technology integrating atrial fibrillation screening and ABC management approach trial; ChiCTR-OOC-17014138).
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Affiliation(s)
- Yutao Guo
- Medical School of Chinese PLA, Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom, and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Limin Wang
- The National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Hui Zhang
- Medical School of Chinese PLA, Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Hao Wang
- Medical School of Chinese PLA, Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Wei Zhang
- Department of Gerontology and Geriatric Medicine, Seventh Clinical Center, Chinese PLA General Hospital, Beijing, China
| | - Jing Wen
- Department of Geriatric Cardiology, Haidian Hospital, Beijing, China
| | - Yunli Xing
- Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Fang Wu
- Department of Gerontology and Geriatric Medicine, Ruijin Hospital Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yunlong Xia
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Fan Wu
- Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin Geriatrics Institute, Tianjin, China
| | - Zhaoguang Liang
- Department of Cardiology, First Affiliated Hospital of Haerbing Medical University, Haerbing, China
| | - Fan Liu
- Department of Cardiology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yujie Zhao
- Department of Cardiology, Henan Cardiovascular Hospital Affiliated to Southern Medical University, Henan, China
| | - Rong Li
- Department of Cardiology, First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xin Li
- Department of Cardiology, Benq Medical Center, Nanjing Medical University, Nanjing, China
| | - Lili Zhang
- Department of Cardiology, Longhua People's Hospital, Shenzhen, China
| | - Jun Guo
- Medical School of Chinese PLA, Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Girvan Burnside
- Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
| | - Yundai Chen
- Medical School of Chinese PLA, Department of Cardiology, Chinese PLA General Hospital, Beijing, China.
| | - Gregory Y H Lip
- Medical School of Chinese PLA, Department of Cardiology, Chinese PLA General Hospital, Beijing, China; Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom, and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Jiang J, Gu X, Cheng CD, Li HX, Sun XL, Duan RY, Zhu Y, Sun L, Chen FK, Bao ZY, Zhang Y, Shen JH. The Hospital-Community-Family-Based Telemedicine (HCFT-AF) Program for Integrative Management of Patients With Atrial Fibrillation: Pilot Feasibility Study. JMIR Mhealth Uhealth 2020; 8:e22137. [PMID: 33084588 PMCID: PMC7641782 DOI: 10.2196/22137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 07/22/2020] [Accepted: 07/26/2020] [Indexed: 12/30/2022] Open
Abstract
Background The potential effectiveness of integrated management in further improving the prognosis of patients with atrial fibrillation has been demonstrated; however, the best strategy for implementation remains to be discovered. Objective The aim of this study was to ascertain the feasibility of implementing integrated atrial fibrillation care via the Hospital-Community-Family–Based Telemedicine (HCFT-AF) program. Methods In this single-arm, pre-post design pilot study, a multidisciplinary teamwork, supported by efficient infrastructures, provided patients with integrated atrial fibrillation care following the Atrial fibrillation Better Care (ABC) pathway. Eligible patients were continuously recruited and followed up for at least 4 months. The patients’ drug adherence, and atrial fibrillation–relevant lifestyles and behaviors were assessed at baseline and at 4 months. The acceptability, feasibility, and usability of the HCFT-AF technology devices and engagement with the HCFT-AF program were assessed at 4 months. Results A total of 73 patients (mean age, 68.42 years; 52% male) were enrolled in November 2019 with a median follow up of 132 days (IQR 125–138 days). The patients’ drug adherence significantly improved after the 4-month intervention (P<.001). The vast majority (94%, 64/68) of indicated patients received anticoagulant therapy at 4 months, and none of them received antiplatelet therapy unless there was an additional indication. The atrial fibrillation–relevant lifestyles and behaviors ameliorated to varying degrees at the end of the study. In general, the majority of patients provided good feedback on the HCFT-AF intervention. More than three-quarters (76%, 54/71) of patients used the software or website more than once a week and accomplished clinic visits as scheduled. Conclusions The atrial fibrillation–integrated care model described in this study is associated with improved drug adherence, standardized therapy rate, and lifestyles of patients, which highlights the possibility to better deliver integrated atrial fibrillation management. Trial Registration Clinicaltrials.gov NCT04127799; https://clinicaltrials.gov/ct2/show/NCT04127799
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Affiliation(s)
| | - Xiang Gu
- Medical College of Yangzhou University, Yangzhou, Jiangsu, China.,Department of Cardiology, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Chen-Di Cheng
- Second Affiliated Hospital, Xiang-Ya Medical College of Central South University, Changsha, China
| | - Hong-Xiao Li
- Medical College of Yangzhou University, Yangzhou, Jiangsu, China.,Department of Cardiology, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Xiao-Lin Sun
- Medical College of Yangzhou University, Yangzhou, Jiangsu, China.,Department of Cardiology, Northern Jiangsu People's Hospital, Yangzhou, China
| | | | - Ye Zhu
- Medical College of Yangzhou University, Yangzhou, Jiangsu, China.,Department of Cardiology, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Lei Sun
- Medical College of Yangzhou University, Yangzhou, Jiangsu, China.,Department of Cardiology, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Fu-Kun Chen
- Medical College of Yangzhou University, Yangzhou, Jiangsu, China.,Department of Cardiology, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Zheng-Yu Bao
- Medical College of Yangzhou University, Yangzhou, Jiangsu, China.,Department of Cardiology, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Yi Zhang
- Medical College of Yangzhou University, Yangzhou, Jiangsu, China.,Department of Cardiology, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Jian-Hua Shen
- Medical College of Yangzhou University, Yangzhou, Jiangsu, China.,Department of Cardiology, Northern Jiangsu People's Hospital, Yangzhou, China
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Antithrombotic management of patients with atrial fibrillation-Dutch anticoagulant initiatives anno 2020. Neth Heart J 2020; 28:19-24. [PMID: 32780327 PMCID: PMC7418291 DOI: 10.1007/s12471-020-01446-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In recent years, as more and more experience has been gained with prescribing direct oral anticoagulants (DOACs), new research initiatives have emerged in the Netherlands to improve the safety and appropriateness of DOAC treatment for stroke prevention in patients with atrial fibrillation (AF). These initiatives address several contemporary unresolved issues, such as inappropriate dosing, non-adherence and the long-term management of DOAC treatment. Dutch initiatives have also contributed to the development and improvement of risk prediction models. Although fewer bleeding complications (notably intracranial bleeding) are in general seen with DOACs in comparison with vitamin K antagonists, to successfully identify patients with high bleeding risk and to tailor anticoagulant treatment accordingly to mitigate this increased bleeding risk, is one of the research aims of recent and future years. This review highlights contributions from the Netherlands that aim to address these unresolved issues regarding the anticoagulant management in AF in daily practice, and provides a narrative overview of contemporary stroke and bleeding risk assessment strategies.
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Nielsen JC, Lin YJ, de Oliveira Figueiredo MJ, Sepehri Shamloo A, Alfie A, Boveda S, Dagres N, Di Toro D, Eckhardt LL, Ellenbogen K, Hardy C, Ikeda T, Jaswal A, Kaufman E, Krahn A, Kusano K, Kutyifa V, Lim HS, Lip GYH, Nava-Townsend S, Pak HN, Rodríguez Diez G, Sauer W, Saxena A, Svendsen JH, Vanegas D, Vaseghi M, Wilde A, Bunch TJ, Buxton AE, Calvimontes G, Chao TF, Eckardt L, Estner H, Gillis AM, Isa R, Kautzner J, Maury P, Moss JD, Nam GB, Olshansky B, Pava Molano LF, Pimentel M, Prabhu M, Tzou WS, Sommer P, Swampillai J, Vidal A, Deneke T, Hindricks G, Leclercq C. European Heart Rhythm Association (EHRA)/Heart Rhythm Society (HRS)/Asia Pacific Heart Rhythm Society (APHRS)/Latin American Heart Rhythm Society (LAHRS) expert consensus on risk assessment in cardiac arrhythmias: use the right tool for the right outcome, in the right population. Europace 2020; 22:1147-1148. [PMID: 32538434 PMCID: PMC7400488 DOI: 10.1093/europace/euaa065] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | - Alireza Sepehri Shamloo
- Department of Electrophysiology, Leipzig Heart Center at University of Leipzig, Leipzig, Germany
| | - Alberto Alfie
- Division of Electrophysiology, Instituto Cardiovascular Adventista, Clinica Bazterrica, Buenos Aires, Argentina
| | - Serge Boveda
- Department of Cardiology, Clinique Pasteur, Toulouse, France
| | - Nikolaos Dagres
- Department of Electrophysiology, Leipzig Heart Center at University of Leipzig, Leipzig, Germany
| | - Dario Di Toro
- Department of Cardiology, Division of Electrophysiology, Argerich Hospital and CEMIC, Buenos Aires, Argentina
| | - Lee L Eckhardt
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Kenneth Ellenbogen
- Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, USA
| | - Carina Hardy
- Arrhythmia Unit, Heart Institute, University of São, Paulo Medical School, Instituto do Coração -InCor- Faculdade de Medicina de São Paulo-São Paulo, Brazil
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Faculty of Medicine, Toho University, Japan
| | - Aparna Jaswal
- Department of Cardiac Electrophysiology, Fortis Escorts Heart Institute, Okhla Road, New Delhi, India
| | - Elizabeth Kaufman
- The Heart and Vascular Research Center, Metrohealth Campus of Case Western Reserve University, Cleveland, OH, USA
| | - Andrew Krahn
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Kengo Kusano
- Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Valentina Kutyifa
- University of Rochester, Medical Center, Rochester, USA
- Semmelweis University, Heart and Vascular Center, Budapest, Hungary
| | - Han S Lim
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Santiago Nava-Townsend
- Department of Electrocardiology, National Institute of Cardiology “Ignacio Chavez,” Mexico City, Mexico
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Republic of Korea
| | - Gerardo Rodríguez Diez
- Department of Electrophysiology and Hemodynamic, Arrhytmias Unity, CMN 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - William Sauer
- Cardiovascular Division, Brigham and Women s Hospital and Harvard Medical School, Boston, USA
| | - Anil Saxena
- Department of Cardiac Electrophysiology, Fortis Escorts Heart Institute, Okhla Road, New Delhi, India
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Diego Vanegas
- Hospital Militar Central, Fundarritmia, Bogotá, Colombia
| | - Marmar Vaseghi
- Los Angeles UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine, at UCLA, USA
| | - Arthur Wilde
- Amsterdam UMC, University of Amsterdam, Heart Center; Department of Clinical and Experimental Cardiology, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - T Jared Bunch
- Department of Medicine, Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, USA
| | | | - Alfred E Buxton
- Department of Medicine, The Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Lars Eckardt
- Department for Cardiology, Electrophysiology, University Hospital Münster, Münster, Germany
| | - Heidi Estner
- Department of Medicine, I, University Hospital Munich, Ludwig-Maximilians University, Munich, Germany
| | - Anne M Gillis
- University of Calgary - Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada
| | - Rodrigo Isa
- Clínica RedSalud Vitacura and Hospital el Carmen de Maipú, Santiago, Chile
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | | | - Joshua D Moss
- Department of Cardiac Electrophysiology, University of California San Francisco, San Francisco, USA
| | - Gi-Byung Nam
- Division of Cardiology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
| | - Brian Olshansky
- University of Iowa Carver College of Medicine, Iowa City, USA
| | | | - Mauricio Pimentel
- Cardiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Mukund Prabhu
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Wendy S Tzou
- Department of Cardiology/Cardiac Electrophysiology, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Philipp Sommer
- Clinic for Electrophysiology, Herz- und Diabeteszentrum, Clinic for Electrophysiology, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | | | - Alejandro Vidal
- Division of Cardiology, McGill University Health Center, Montreal, Canada
| | - Thomas Deneke
- Clinic for Cardiology II (Interventional Electrophysiology), Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Leipzig Heart Center at University of Leipzig, Leipzig, Germany
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Pastori D, Menichelli D, Lip GYH, Sciacqua A, Violi F, Pignatelli P. Family History of Atrial Fibrillation and Risk of Cardiovascular Events: A Multicenter Prospective Cohort Study. Circ Arrhythm Electrophysiol 2020; 13:e008477. [PMID: 32718257 DOI: 10.1161/circep.120.008477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND To investigate the association between family history of atrial fibrillation (AF) with cardiovascular events (CVEs), major adverse cardiac events (MACE), and cardiovascular mortality. METHODS Multicenter prospective observational cohort study including 1722 nonvalvular AF patients from February 2008 to August 2019 in Italy. Family history of AF was defined as the presence of AF in a first-degree relative: mother, father, sibling, or children. Primary outcome was a composite of CVEs including fatal/nonfatal ischemic stroke and myocardial infarction, and cardiovascular death. Second, we analyzed the association with major adverse cardiac event. RESULTS Mean age was 74.6±9.4 years; 44% of women. Family history of AF was detected in 368 (21.4%) patients, and 3.5% had ≥2 relatives affected by AF. Age of AF onset progressively decreased from patients without family history of AF, compared with those with single and multiple first-degree affected relatives (P<0.001). During a mean follow-up of 23.7 months (4606 patients/y) 145 CVEs (3.15%/y), 98 major adverse cardiac event (2.13%/y), and 57 cardiovascular deaths (0.97%/y) occurred. After adjustment for cardiovascular risk factors, family history of AF was associated with a higher risk of CVEs (hazard ratio, 1.524 [95% CI, 1.021-2.274], P=0.039), major adverse cardiac event (hazard ratio, 1.917 [95% CI, 1.207-3.045], P=0.006), and cardiovascular mortality (hazard ratio, 2.008 [95% CI, 1.047-3.851], P=0.036). Subgroup analysis showed that this association was modified by age, sex, and prior ischemic heart disease. CONCLUSIONS In a cohort of elderly patients with a high atherosclerotic burden, family history of AF is evident in >20% of patients and was associated with an increased risk for CVEs and mortality. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01882114.
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Affiliation(s)
- Daniele Pastori
- I Clinica Medica, Atherothrombosis Center, Department of Clinical, Internal Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Italy (D.P., D.M., F.V., P.P.).,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, United Kingdom (D.P., G.Y.H.L.)
| | - Danilo Menichelli
- I Clinica Medica, Atherothrombosis Center, Department of Clinical, Internal Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Italy (D.P., D.M., F.V., P.P.)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, United Kingdom (D.P., G.Y.H.L.)
| | - Angela Sciacqua
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Italy (A.S.)
| | - Francesco Violi
- I Clinica Medica, Atherothrombosis Center, Department of Clinical, Internal Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Italy (D.P., D.M., F.V., P.P.)
| | - Pasquale Pignatelli
- I Clinica Medica, Atherothrombosis Center, Department of Clinical, Internal Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Italy (D.P., D.M., F.V., P.P.)
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