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Yan X, Xia P, Tong H, Lan C, Wang Q, Zhou Y, Zhu H, Jiang C. Development and Validation of a Dynamic Nomogram for Predicting 3-Month Mortality in Acute Ischemic Stroke Patients with Atrial Fibrillation. Risk Manag Healthc Policy 2024; 17:145-158. [PMID: 38250220 PMCID: PMC10799644 DOI: 10.2147/rmhp.s442353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/11/2024] [Indexed: 01/23/2024] Open
Abstract
Background Acute ischemic stroke (AIS) in patients with atrial fibrillation (AF) carries a substantial risk of mortality, emphasizing the need for effective risk assessment and timely interventions. This study aimed to develop and validate a practical dynamic nomogram for predicting 3-month mortality in AIS patients with AF. Methods AIS patients with AF were enrolled and randomly divided into training and validation cohorts. The nomogram was developed based on independent risk factors identified by multivariate logistic regression analysis. The prediction performance of the nomogram was evaluated using the area under the receiver operating characteristic curve (AUC-ROC), calibration plots, decision curve analysis (DCA), and Kaplan-Meier survival analysis. Results A total of 412 patients with AIS and AF entered final analysis, 288 patients in the training cohort and 124 patients in the validation cohort. The nomogram was developed using age, baseline National Institutes of Health Stroke Scale score, early introduction of novel oral anticoagulants, and pneumonia as independent risk factors. The nomogram exhibited good discrimination both in the training cohort (AUC, 0.851; 95% CI, 0.802-0.899) and the validation cohort (AUC, 0.811; 95% CI, 0.706-0.916). The calibration plots, DCA and Kaplan-Meier survival analysis demonstrated that the nomogram was well calibrated and clinically useful, effectively distinguishing the 3-month survival status of patients with AIS and AF, respectively. The dynamic nomogram can be obtained at the website: https://yanxiaodi.shinyapps.io/3-monthmortality/. Conclusion The dynamic nomogram represents the first predictive model for 3-month mortality and may contribute to managing the mortality risk of patients with AIS and AF.
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Affiliation(s)
- Xiaodi Yan
- Department of Pharmacy, Nanjing Drum Tower Hospital, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
| | - Peng Xia
- Department of Pharmacy, Nanjing Drum Tower Hospital, School of Pharmacy, Nanjing Medical University, Nanjing, Jiangsu, People’s Republic of China
| | - Hanwen Tong
- Department of Emergency Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, People’s Republic of China
| | - Chen Lan
- Department of Pharmacy, Nanjing Drum Tower Hospital, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
| | - Qian Wang
- Department of Pharmacy, Nanjing Drum Tower Hospital, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
| | - Yujie Zhou
- Department of Respiratory Critical Care Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, People’s Republic of China
| | - Huaijun Zhu
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, People’s Republic of China
| | - Chenxiao Jiang
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, People’s Republic of China
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Mentel A, Quinn TJ, Cameron AC, Lees KR, Abdul-Rahim AH. The impact of atrial fibrillation type on the risks of thromboembolic recurrence, mortality and major haemorrhage in patients with previous stroke: A systematic review and meta-analysis of observational studies. Eur Stroke J 2020; 5:155-168. [PMID: 32637649 DOI: 10.1177/2396987319896674] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 12/03/2019] [Indexed: 11/15/2022] Open
Abstract
Introduction There is conflicting evidence on the impact of atrial fibrillation (AF) type, i.e. non-paroxysmal AF or paroxysmal AF, on thromboembolic recurrence. The consensus of risk equivalence is greatly based on historical evidence, focussing on initial stroke risks. We conducted a systematic review and meta-analysis to describe the impact of AF type on the risk of thromboembolic recurrence, mortality and major haemorrhage in patients with previous stroke. Methods We systematically searched four multidisciplinary databases from inception to December 2018. We selected observational studies investigating clinical outcomes in patients with ischaemic stroke and AF, stratified by AF type. We assessed all included studies for risk of bias using the 'Risk of Bias In Non-randomised Studies - of Exposures' tool. The Comprehensive Meta-Analysis Software was used to calculate odds ratios from crude event rates. Results After reviewing 14,127 citations, we selected 108 studies for full-text screening. We extracted data from a total of 26 studies, reporting outcomes on 23,054 patients. Overall, risk of bias was moderate. The annual incidence rates of thromboembolism in patients with non-paroxysmal AF and paroxysmal AF were 7.1% (95% confidence interval: 4.2-11.7) and 5.2% (95% confidence interval: 3.2-8.2), respectively. The odds ratio for thromboembolism in patients with non-paroxysmal AF versus paroxysmal AF was 1.47 (95% confidence interval: 1.08-1.99, p = 0.013). The annual mortality rates in patients with non-paroxysmal AF and paroxysmal AF were 20.0% (95% confidence interval: 13.2-28.0) and 10.1% (95% confidence interval: 5.4-17.3), respectively, and odds ratio was 1.90 (95% confidence interval: 1.43-2.52, p < 0.001). There was no difference in rates of major haemorrhage, odds ratio = 1.01 (95% confidence interval: 0.61-1.69, p = 0.966). Conclusion In patients with prior stroke, non-paroxysmal AF is associated with significantly higher risk of thromboembolic recurrence and mortality than paroxysmal AF. Although current guidelines make no distinction between non-paroxysmal AF and paroxysmal AF for secondary stroke prevention, future guidance and risk stratification tools may need to consider this differential risk (PROSPERO ID: CRD42019118531).
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Affiliation(s)
- Antonia Mentel
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Alan C Cameron
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Kennedy R Lees
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Azmil H Abdul-Rahim
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
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Diekmann S, Hörster L, Evers S, Hiligsmann M, Gelbrich G, Gröschel K, Wachter R, Hamann GF, Kermer P, Liman J, Weber-Krüger M, Wasem J, Neumann A. Economic evaluation of prolonged and enhanced ECG Holter monitoring in acute ischemic stroke patients. Curr Med Res Opin 2019; 35:1859-1866. [PMID: 31315471 DOI: 10.1080/03007995.2019.1646000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: Atrial fibrillation (AF) is a major cause for recurrent stroke, has severe impact on a patient's health and imposes a high economic burden for society. Current guidelines recommend 24 h ECG monitoring (standard-of-care, SoC) to detect AF after stroke to reduce the risk of future events. However, paroxysmal AF (PAF) is difficult to detect within this period as it occurs infrequently and unpredictably. In a randomized controlled trial (Find-AFRANDOMISED), prolonged and enhanced Holter ECG monitoring (EPM) revealed a significantly higher detection rate of AF compared to SoC, although its cost-effectiveness has not yet been investigated. Methods: Based on the data of FIND-AFRANDOMISED, an economic evaluation was conducted. One group received EPM for 10 days after the event, and at 3 and 6 months; the other group received SoC. Healthcare resource use and quality of life (QoL) data were measured at baseline, and after 6 and 12 months. Incremental costs and quality-adjusted life years (QALYs) between both groups were compared. Non-parametric bootstrapping and one-way-sensitivity analyses were performed. Results: A total of 281 patients with healthcare resource use and QoL data for all measurement points were considered in the economic evaluation (complete case analysis, CCA). The CCA yielded nonsignificant 315€ lower mean costs and 0.0013 less QALYs for patients receiving EPM with no statistically significant differences in any cost categories. Sensitivity analyses revealed robust results. Bootstrapping the results indicated moderate probability of cost-effectiveness. Conclusions: EPM yielded reduced not significantly different costs without affecting QoL and may be a useful strategy to detect PAF in acute ischemic stroke patients in time.
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Affiliation(s)
- Sandra Diekmann
- Institute for Health Care Management and Research, University of Duisburg-Essen , Essen , Germany
| | - Laura Hörster
- Institute for Health Care Management and Research, University of Duisburg-Essen , Essen , Germany
| | - Silvia Evers
- Faculty of Health, Medicine and Life Sciences, Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University , Maastricht , The Netherlands
- Centre of Economic Evaluations, Trimbos Institute, Netherlands Institute of Mental Health and Addiction , Utrecht , The Netherlands
| | - Mickaël Hiligsmann
- Faculty of Health, Medicine and Life Sciences, Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University , Maastricht , The Netherlands
| | - Götz Gelbrich
- Institute for Clinical Epidemiology and Biometry, University of Würzburg , Würzburg , Germany
- Clinical Trial Centre, University of Würzburg , Würzburg , Germany
| | - Klaus Gröschel
- Department of Neurology, University Medical Centre of Johannes Gutenberg University Mainz , Mainz , Germany
| | - Rolf Wachter
- Clinic for Cardiology and Pneumology, University of Göttingen , Göttingen , Germany
- DZHK (German Centre for Cardiovascular Research) , partner site Göttingen , Germany
| | - Gerhard F Hamann
- Clinic for Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Günzburg , Günzburg , Germany
| | - Pawel Kermer
- Clinic for Neurology, Hospital Nordwest-Krankenhaus Sanderbusch , Sande , Germany
| | - Jan Liman
- Clinic for Neurology, University of Göttingen , Göttingen , Germany
| | - Mark Weber-Krüger
- Clinic for Cardiology and Pneumology, University of Göttingen , Göttingen , Germany
| | - Jürgen Wasem
- Institute for Health Care Management and Research, University of Duisburg-Essen , Essen , Germany
| | - Anja Neumann
- Institute for Health Care Management and Research, University of Duisburg-Essen , Essen , Germany
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Baturova MA, Lindgren A, Shubik YV, Carlson J, Platonov PG. Interatrial block in prediction of all-cause mortality after first-ever ischemic stroke. BMC Cardiovasc Disord 2019; 19:37. [PMID: 30744701 PMCID: PMC6371419 DOI: 10.1186/s12872-019-1015-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 02/04/2019] [Indexed: 12/25/2022] Open
Abstract
Background Interatrial block (IAB) is an ECG indicator of atrial fibrosis related to atrial remodeling and thrombus formation thus leading to embolic stroke and increasing mortality. We aimed to assess weather IAB predicted all-cause mortality during 10 years after ischemic stroke. Methods The study sample comprised 235 patients (median age 74 (interquartile range 25–75% 65–81) years, 95 female) included in the Lund Stroke Register in 2001–2002, who had sinus rhythm ECGs at stroke admission. IAB was defined as a P-wave duration ≥120 ms without = partial IAB (n = 56) or with = advanced IAB (n = 41) biphasic morphology (±) in the inferior ECG leads. All-cause mortality was assessed via linkage with the Swedish Causes of Death Register. Results During follow-up 126 patients died (54%). Advanced IAB, but not partial, was associated with all-cause mortality in univariate Cox regression analysis (hazard ratio (HR) 1.98, 95% CI 1.27–3.09, p = 0.003). After adjustment for age, gender, severity of stroke measured by NIHSS scale and smoking status in patients without additional comorbidities advanced IAB independently predicted all-cause mortality (HR 7.89, 95% CI 2.01–30.98, p = 0.003), while in patients with comorbidities it did not (HR 1.01 95% CI 0.59–1.72, p = 0.966). Conclusion Advanced IAB predicted all-cause mortality after ischemic stroke, but mostly in patients without additional cardiovascular comorbidities.
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Affiliation(s)
- M A Baturova
- Department of Cardiology, Clinical Sciences, Lund University, SE-221 85, Lund, Sweden. .,Research Park, St Petersburg State University, Peterhof, Botanicheskaya, 17, St Petersburg, Russia.
| | - A Lindgren
- Department of Cardiology, Clinical Sciences, Lund University, SE-221 85, Lund, Sweden.,Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
| | - Y V Shubik
- Cardiology research, clinical and educational center, St. Petersburg State University, Universitetskaya Embankment, 7/9, St. Petersburg, Russia
| | - J Carlson
- Department of Cardiology, Clinical Sciences, Lund University, SE-221 85, Lund, Sweden
| | - P G Platonov
- Department of Cardiology, Clinical Sciences, Lund University, SE-221 85, Lund, Sweden.,Arrythmia Clinic, Skåne University Hospital, SE-221 85, Lund, Sweden
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