Prevalence of atrial fibrillation in different socioeconomic regions of China and its association with stroke: Results from a national stroke screening survey

Adherence to the atrial fibrillation better care pathway and its associated factors among rural patients with atrial fibrillation in China: A cross-sectional study

BACKGROUND

The atrial fibrillation better care (ABC) pathway is an effective strategy for the integrated management of atrial fibrillation (AF). Current data on adherence to the ABC pathway among rural patients with AF in China are limited.

OBJECTIVES

To investigated adherence to the ABC pathway and its associated factors among rural patients with AF in China.

METHODS

In the cross-sectional study, we recruited 870 rural patients with AF from July 2022 to July 2023 in China. AF-related sociodemographic and clinical data was collected.

RESULTS

Among the 870 rural patients with AF, 437 (50.23 %) were male, 714 (82.07 %) were ≥65 years old. The level of adherence to ABC pathway was extremely low (5.75 %), and its associated factors included patients ≥75 years (compared with those <65 years, OR=0.165, 95 %CI: 0.065-0.417, P < 0.001), junior middle school and senior middle school education or above (compared with primary school education or below, OR=3.441, 95 %CI: 1.144-10.351, P = 0.028; OR=11.438, 95 %CI: 3.758-34.814, P < 0.001), average monthly household income per capita 1000-3000 RMB and >3000 RMB (compared with <1000 RMB, OR=3.993, 95 %CI: 1.343-11.877, P = 0.013; OR=4.474, 95 %CI: 1.478-13.541, P = 0.008), persistent AF (compared with paroxysmal AF, OR=0.062, 95 %CI: 0.008-0.466, P = 0.007) and multimorbidity (OR=0.356, 95 %CI: 0.163-0.781, P = 0.010).

CONCLUSIONS

There is an urgent need to develop targeted interventions and national policies to improve the adherence to the ABC pathway of rural AF patients in China.

Edoxaban for stroke prevention in atrial fibrillation and factors associated with dosing: patient characteristics from the prospective observational ETNA-AF-China registry

Real-world data on effectiveness and safety of a single non-vitamin K antagonist oral anticoagulant in the Chinese population with atrial fibrillation (AF) are limited. This study reports characteristics of patients treated with edoxaban and factors associated with dosing patterns from routine care in China. ETNA-AF-China (NCT04747496) is a multicentre, prospective, observational study enrolling edoxaban-treated patients from four economic regions with a targeted 2-year follow-up. Of the 4930 patients with AF (mean age: 70.2 ± 9.5 years; male, 57.1%), the mean creatinine clearance (CrCl), CHA2DS2-VASc, and HAS-BLED scores were 71.2 mL/min, 2.9, and 1.6. Overall, 6.4% of patients were perceived as frail by investigators. Available label dose reduction criteria (N = 4232) revealed that 3278 (77.5%) patients received recommended doses and 954 (22.5%) non-recommended doses. Northeast (53.0%) and West (43.1%) regions had the highest prescriptions of 60 mg and 30 mg recommended doses, respectively. Non-recommended 30 mg doses were more frequently prescribed in patients with antiplatelet use and history of heart failure than recommended 60 mg. Multivariate analysis identified advanced age as the strongest associated factor with non-recommended doses. Frailty had the strongest association with 30 mg except for age, and history of TIA was the most relevant factor associated with 60 mg. In conclusion, patients in the ETNA-AF-China study were predominantly aged 65 years and older, had mild-to-moderate renal impairment and good label adherence. Advanced age was associated with non-recommended doses, with frailty most common for non-recommended 30 mg and a history of TIA for the non-recommended 60 mg dose.

China stroke surveillance report 2021

Since 2015, stroke has become the leading cause of death and disability in China, posing a significant threat to the health of its citizens as a major chronic non-communicable disease. According to the China Stroke High-risk Population Screening and Intervention Program, an estimated 17.8 million [95% confidence interval (CI) 17.6-18.0 million] adults in China had experienced a stroke in 2020, with 3.4 million (95% CI 3.3-3.5 million) experiencing their first-ever stroke and another 2.3 million (95% CI 2.2-2.4 million) dying as a result. Additionally, approximately 12.5% (95% CI 12.4-12.5%) of stroke survivors were left disabled, as defined by a modified Rankin Scale score greater than 1, equating to 2.2 million (95% CI 2.1-2.2 million) stroke-related disabilities in 2020. As the population ages and the prevalence of risk factors like diabetes, hypertension, and hyperlipidemia continues to rise and remains poorly controlled, the burden of stroke in China is also increasing. A large national epidemiological survey initiated by the China Hypertension League in 2017 showed that the prevalence of hypertension was 24.7%; the awareness, treatment, and control rates in hypertensive patients were: 60.1%, 42.5%, and 25.4%, respectively. A nationally representative sample of the Chinese mainland population showed that the weighted prevalence of total diabetes diagnosed by the American Diabetes Association criteria was 12.8%, suggesting there are 120 million adults with diabetes in China, and the awareness, treatment, and control rates in diabetic patients were: 43.3%, 49.0%, and 49.4%, respectively. The "Sixth National Health Service Statistical Survey Report in 2018" showed that the proportion of the obese population in China was 37.4%, an increase of 7.2 points from 2013. Data from 1599 hospitals in the Hospital Quality Monitoring System and Bigdata Observatory Platform for Stroke of China (BOSC) showed that a total of 3,418,432 stroke cases [mean age ± standard error (SE) was (65.700 ± 0.006) years, and 59.1% were male] were admitted during 2020. Of those, over 80% (81.9%) were ischemic stroke (IS), 14.9% were intracerebral hemorrhage (ICH) strokes, and 3.1% were subarachnoid hemorrhage (SAH) strokes. The mean ± SE of hospitalization expenditures was Chinese Yuan (CNY) (16,975.6 ± 16.3), ranging from (13,310.1 ± 12.8) in IS to (81,369.8 ± 260.7) in SAH, and out-of-pocket expenses were (5788.9 ± 8.6), ranging from (4449.0 ± 6.6) in IS to (30,778.2 ± 156.8) in SAH. It was estimated that the medical cost of hospitalization for stroke in 2020 was CNY 58.0 billion, of which the patient pays approximately CNY 19.8 billion. In-hospital death/discharge against medical advice rate was 9.2% (95% CI 9.2-9.2%), ranging from 6.4% (95% CI 6.4-6.5%) for IS to 21.8% for ICH (95% CI 21.8-21.9%). From 2019 to 2020, the information about 188,648 patients with acute IS receiving intravenous thrombolytic therapy (IVT), 49,845 patients receiving mechanical thrombectomy (MT), and 14,087 patients receiving bridging (IVT + MT) were collected through BOSC. The incidence of intracranial hemorrhage during treatment was 3.2% (95% CI 3.2-3.3%), 7.7% (95% CI 7.5-8.0%), and 12.9% (95% CI 12.3-13.4%), respectively. And in-hospital death/discharge against medical advice rate was 8.9% (95% CI 8.8-9.0%), 16.5% (95% CI 16.2-16.9%), and 16.8% (95% CI 16.2-17.4%), respectively. A prospective nationwide hospital-based study was conducted at 231 stroke base hospitals (Level III) from 31 provinces in China through BOSC from January 2019 to December 2020 and 136,282 stroke patients were included and finished 12-month follow-up. Of those, over 86.9% were IS, 10.8% were ICH strokes, and 2.3% were SAH strokes. The disability rate [% (95% CI)] in survivors of stroke at 3-month and 12-month was 14.8% (95% CI 14.6-15.0%) and 14.0% (95% CI 13.8-14.2%), respectively. The mortality rate [% (95% CI)] of stroke at 3-month and 12-month was 4.2% (95% CI 4.1-4.3%) and 8.5% (95% CI 8.4-8.6%), respectively. The recurrence rate [% (95% CI)] of stroke at 3-month and 12-month was 3.6% (95% CI 3.5-3.7%) and 5.6% (95% CI 5.4-5.7%), respectively. The Healthy China 2030 Stroke Action Plan was launched as part of this review, and the above data provide valuable guidelines for future stroke prevention and treatment efforts in China.

Prevalence and trend of atrial fibrillation and its associated risk factors among the population from nationwide health check-up centers in China, 2012-2017

Background

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia, which poses huge disease burdens in China. A study was conducted to systematically analyze the recent prevalence trend of AF and age-related disparities in AF risk among the nationwide healthy check-up population.

Method

We conducted a nationwide cross-sectional study involving 3,049,178 individuals ≥35 years from health check-up centers to explore the prevalence and trend of AF by age, sex, and region from 2012 to 2017. Additionally, we analyzed risk factors associated with AF among the overall population and different age groups via the Boruta algorithm, the LASSO regression, and the Logistic regression.

Result

The age-, sex-. and regional-standardized prevalence of AF kept stable between 0.4%-0.45% among national physical examination individuals from 2012 to 2017. However, the prevalence of AF showed an undesirable upward trend in the 35-44-year age group (annual percentage changes (APC): 15.16 [95%CI: 6.42,24.62]). With increasing age, the risk of AF associated with the overweight or obesity gradually exceeds that associated with diabetes and hypertension. In addition to traditional leading risk factors such as age≥65 and coronary heart disease, elevated uric acid and impaired renal function were tightly correlated with AF in the population.

Conclusion

The significant rise in the prevalence of AF in the 35-44 age group reminds us that in addition to the elderly (the high-risk group), younger people seem to be in more urgent need of attention. Age-related disparities in AF risk also exist. This updated information may provide references for the national prevention and control of AF.

Prevalence and clinical characteristics of atrial fibrillation in hospitalized patients with coronary artery disease and hypertension: a cross-sectional study from 2008 to 2018

BACKGROUND

The clinical characteristics of patients with the comorbidities of hypertension and coronary artery disease (HT-CAD) and atrial fibrillation (AF) are largely unknown. This study aimed to investigate the prevalence of AF in patients with HT-CAD and clinical characteristics of patients with both HT-CAD and AF.

METHODS

This cross-sectional study was conducted in Chinese People's Liberation Army General Hospital in Beijing, China, and included 20,747 inpatients with HT-CAD with or without AF from August 2008 to July 2018. We examined the overall prevalence, clinical characteristics, comorbidity profiles, treatment patterns, and blood pressure (BP) control of patients with both HT-CAD and AF. Multivariate logistic regression was used to investigate the associations of cardiovascular risk factors with AF in patients with HT-CAD.

RESULTS

The overall prevalence of AF in patients with HT-CAD was 4.87% (1011/20,747), and this increased with age; to be specific, the prevalence in women and men increased from 0.78% (2/255) and 1.02% (26/2561) at the age of <50 years to 8.73% (193/2210) and 10.28% (298/2900) at the age of ≥70 years, respectively. HT-CAD patients who had AF had a higher prevalence of cardiovascular-related comorbidities than those without AF. Multivariate logistic regression showed that age, gender (male), body mass index, heart failure, and chronic kidney disease were independently associated with the risk of AF in patients with HT-CAD. For those with both HT-CAD and AF, 73.49% (743/1011) had a CHA 2 DS 2 -VASc score of ≥4, and only about half of them had the BP controlled at <140/90 mmHg, which indicated a high risk of thromboembolism and stroke. The use of oral anticoagulation increased during the study period (10.00% [20/200] in 2008 to 2011 vs. 30.06% [159/529] in 2015 to 2018, P  < 0.01), but remained at a relatively low level.

CONCLUSIONS

AF is highly prevalent among patients with HT-CAD. Patients with both HT-CAD and AF have a higher prevalence of cardiovascular-related comorbidities, lower BP control rate, and lower use of oral anticoagulation.

Trough Concentration Deficiency of Rivaroxaban in Patients With Nonvalvular Atrial Fibrillation Leading to Thromboembolism Events

ABSTRACT

This retrospective study investigated factors influencing the steady-state trough concentrations (C trough ) of rivaroxaban in patients with nonvalvular atrial fibrillation (NVAF). We retrieved data from patients with NAVF who first started rivaroxaban anticoagulation at the Fujian Provincial Hospital from October 2017 to October 2020 through the electronic medical record system. Patients were followed for 1 year after the first dose of rivaroxaban, and the primary efficacy and safety end points were recorded. All follow-up visits were completed by October 2021. A C trough of <12 ng/mL was defined as C trough deficiency. Factors that influenced rivaroxaban C trough deficiency were investigated using multivariate binary logistic regression analysis. Kaplan-Meier survival curve analysis was used to determine differences between C trough deficiency and event-free survival. A total of 167 patients with NVAF were enrolled in the study, including 113 men and 54 women, with an average (± SD) age of 70.40 ± 12.46 years. High albumin levels were an independent protective factor against C trough deficiency (odds ratio, 0.932; P = 0.031). C trough deficiency was associated with the probability of freedom from thrombotic events ( P = 0.004); however, there were no significant differences in the probability of freedom from bleeding events ( P > 0.05). In conclusion, among the variables studied, a low albumin level was the main contributor to C trough deficiency. Rivaroxaban C trough deficiency also increased thrombotic events, but this was not associated with hemorrhagic events in Chinese patients with NVAF.

Distribution of risk factors differs from coronary heart disease and stroke in China: a national population survey

OBJECTIVES

This study aimed to explore the distribution differences of common risk factors between coronary heart disease (CHD) and stroke in China.

SETTING

The China National Stroke Screening Survey is a cluster sampling survey based on a nationwide general community population, adopting multistage stratified sampling method and covering all 31 provinces in China mainland.

PARTICIPANTS

A total number of 725 707 people aged 40 years and above were included in the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The basic demographic information, lifestyle behaviour, physical examination, traditional risk factors, family history of cardiovascular disease (CVD) and CVD events were collected. Risk factors of CHD and stroke were explored and analysed in the whole investigated population to identify the common risk factors. Multivariate logistic regression analysis was used to analyse the distribution difference of risk factors between CHD and stroke.

RESULTS

There were 13 variables associated with CHD and stroke, in which 11 variables revealed differences in the distribution between CHD and stroke. Family history of stroke (OR: 2.30; 95% CI 2.15 to 2.45), men (OR: 1.92; 95% CI 1.80 to 2.05), rural areas (OR: 1.70; 95% CI 1.60 to 1.80), transient ischaemic attack (OR: 1.41; 95% CI 1.30 to 1.54) and hypertension (OR: 1.28; 95% CI 1.19 to 1.38) indicated significantly stronger association with stroke, while family history of CHD (OR: 0.25; 95% CI 0.23 to 0.27), atrial fibrillation (OR: 0.60; 95% CI 0.51 to 0.71), diabetes (OR: 0.76; 95% CI 0.71 to 0.81), dyslipidaemia (OR: 0.76; 95% CI 0.72 to 0.81), smoking (OR: 0.79; 95% CI 0.73 to 0.85) and overweight/obesity (OR: 0.90; 95% CI 0.86 to 0.93) had closer relationship with CHD.

CONCLUSIONS

The distribution of risk factors for CHD and stroke were substantial differences. More specific prevention and control measures should be formulated according to the distribution differences of risk factors related to CVD.

Prevalence of stroke and associated risk factors: a population-based cross-sectional study from the Qinghai-Tibet Plateau of China

BACKGROUND AND OBJECTIVES

The epidemiology of stroke at high altitudes has not been extensively studied, especially at heights of 4000 m and above. Thus, stroke prevention and treatment at high altitudes are challenging. We conducted a cross-sectional study to estimate the prevalence of stroke, the detection rate of individuals at high risk of stroke and the risk factors for stroke in the Qinghai-Tibet Plateau in China, a high altitude plateau that inhabits approximately 15 million people.

DESIGN

A population-based cross-sectional study in the Qinghai-Tibet Plateau.

SETTING

Data were collected from participants through face-to-face screening using a primary screening table. The table relied on the China National Stroke Screening and Prevention Project.

PARTICIPANTS

A total of 10 700 residents aged ≥40 years and living on the Qinghai-Tibet Plateau for more than 6 months participated from January 2019 to December 2021.

MAIN OUTCOME MEASURES

The primary screening table included basic demographic information, medical history information, personal lifestyle habits and physical examination information.

RESULTS

A total of 10 056 people were included in the analysis. The prevalence of stroke was 2.3% (95% CI 2.0% to 2.6%), and the detection rate of individuals at high risk of stroke was 26.2% (95% CI 25.3% to 27.0%). The prevalence of stroke and the detection rate of individuals at high risk of stroke increased with altitude (p<0.01), and the prevalence of stroke at high altitudes was almost 2.2 times that at mid-altitudes (p<0.01). After full adjustments, age, residence, hypertension, family history of stroke and smoking were significantly associated with stroke (p<0.05).

CONCLUSIONS

The prevalence of stroke, the related risk factors and the detection rate of high-risk individuals were clarified. The prevalence rates of hypertension, overweight or obesity and diabetes in the Qinghai-Tibet Plateau were all higher than the Chinese average. Higher-altitude exposure may be an independent risk factor for stroke.

Screening for Atrial Fibrillation by Village Doctors in Rural Areas of China: The Jiangsu Province Rural Community AF Project

China has a large population of elderly in rural areas. Village doctors are acting as health-care gatekeepers for the rural elderly in China and are encouraged to provide more long-term care for patients with chronic diseases such as atrial fibrillation (AF). The data of AF registries from the rural elderly are limited. The present registry aims to provide contemporary data on the current AF-related health status of the rural elderly and the gaps in management of AF by village doctors. This study has two phases. The first phase is a cross-sectional study of AF screening in two rural towns of eastern China. All the residents aged ≥65 years are eligible and will be invited to attend a government-led health examination or an in-house AF screening program. The AF detection rate, the awareness of AF and the usage of oral anticoagulants and smartphones by AF patients, and the ability to diagnose and manage AF by village doctors will be assessed. Participants with AF detected in the first phase are eligible for the second phase. A variety of modes of intensified education will be provided to all AF patients and their family members to enrich their AF-related knowledge. Their village doctors will be offered a lecture-based training program focusing on Atrial fibrillation Better Care (ABC) pathway. Follow-up will be conducted for 1 year. The primary endpoint is the composite of all stroke and all-cause mortality. The first phase of AF screening was conducted between April 2019 and June 2019, and 18,712 participants with the mean age of 73.1±5.8 years were enrolled. The second phase that includes 810 patients with AF, started on 1 May 2019. This study will provide a perspective of primary care system and would indirectly reflect the current status of chronic disease care in rural China.

Epidemiology of atrial fibrillation and risk of CVD mortality among hypertensive population: A prospective cohort study in Northeast China

Background

Determining risk factors of cardiovascular disease (CVD)-related mortality and evaluating their influence are important for effectively reducing corresponding mortality. However, few research findings have estimated the relationship between atrial fibrillation (AF) and CVD-related mortality among hypertension individuals.

Objective

The objective of this study was to investigate the epidemiology of AF in a hypertension population and determine the relationship between AF and CVD-related mortality.

Methods

Using a multistage, stratified, and cluster random sampling method, the prospective cohort study with a median follow-up of 3.51 years enrolled 10,678 hypertensive participants at baseline. The prevalence, awareness, and anticoagulation data of AF in this focal population were carefully assessed. Stepwise logistic regression and Cox regression analysis were respectively performed to evaluate the determinants of AF and the association between AF and CVD-related mortality.

Results

The overall prevalence of AF was 1.3% (95% CI, 1.1%−1.6%) in the hypertensive population, and it was higher in men than in women (1.8% vs. 1.0%, respectively; p=0.001). The awareness of AF was 53.1%, and the rate of oral anticoagulant (OAC) therapy was only 4.2%, although all AF participants should have required according to the European Society of Cardiology guidelines. The determinants of AF included elder, male, and history of coronary heart disease in the hypertensive population. Besides, compared with individuals without AF, the risk of CVD-related mortality significantly increased in the hypertensive population with AF (HR 3.37, 95% CI 2.10–5.40).

Conclusion

Our results indicated a huge burden of AF and underuse of OAC therapy for them in a community-based hypertensive population. Considering that most of the risk factors of AF were unmodifiable in hypertensive individuals, as well as its high risk of mortality, long-term interventions including AF education, timely screening, and widespread use of OACs should be emphasized in the focal populations.

Income and outcomes of patients with incident atrial fibrillation

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION NUMBER

NCT04645537.

Prevalence and risk of atrial fibrillation in China: A national cross-sectional epidemiological study

BACKGROUND

Atrial fibrillation (AF) is the most common persistent cardiac arrhythmia. This study aimed to estimate its prevalence and explore associated factors in adults aged 18 years or older in China.

METHODS

Study data were derived from a national sample from July 2020 to September 2021. Participants were recruited using a multistage stratified sampling method from twenty-two provinces, autonomous regions, and municipalities in China. AF was determined based on a history of diagnosed AF or electrocardiogram results.

FINDINGS

A total of 114,039 respondents were included in the final analysis with a mean age of 55 years (standard deviation 17), 52·1% of whom were women. The crude prevalence of AF was 2·3% (95% confidence interval [CI] 1·7-2·8) and increased with age. The age-standardized AF prevalence was 1·6% (95% CI 1·6-1·7%) overall, and 1·7% (1·6-1·8%), 1·4% (1·3-1·5%), 1·6% (95% CI 1·5-1·7%), and 1·7% (1·6-1·9%) in men, women, urban areas, and rural areas, respectively. The prevalence was higher in the central regions (2·5%, 2·3-2·7%) than in the western regions (1·5%, 1·0-2·0%) and eastern regions (1·1%, 1·0-1·2%) in the overall population, either in the gender or residency subgroups. The associated factors for AF included age (per 10 years; odds ratio 1·41 [95% CI 1·38-1·46]; p < 0·001), men (1·34 [1·24-1·45]; p < 0·001), hypertension (1·22 [1·12-1·33]; p < 0·001), coronary heart disease (1·44 [1·28-1·62]; p < 0·001), chronic heart failure (3·70 [3·22-4·26]; p < 0·001), valvular heart disease (2·13 [1·72-2·63]; p < 0·001), and transient ischaemic attack/stroke (1·22 [1·04-1·43]; p = 0·013).

INTERPRETATION

The prevalence of AF was 1.6% in the Chinese adult population and increased with age, with significant geographic variation. Older age, male sex, and cardiovascular disease were potent factors associated with AF. It is crucial to increase the awareness of AF and disseminate standardized treatment in clinical settings to reduce the disease burden.

FUNDING

This research was supported the Nature Science Foundation of Hubei province (No: 2017CFB204).

Epidemiology, management, and outcomes of atrial fibrillation among 30 million citizens in Shanghai, China from 2015 to 2020: A medical insurance database study

BACKGROUND

Atrial fibrillation(AF) has become a significant public health concern in China, with population aging and urbanization.

METHODS

Data screening was performed for 30,244,930 subjects with medical insurance in the Shanghai Municipal Health Commission database between 2015 and 2020. Patients diagnosed with AF were identified and further assessed for treatment information and clinical outcomes, as well as sex differences and impact of COVID-19 pandemic on AF managment.

FINDINGS

AF prevalence was 0.88% in Shanghai, which increased with age and reached 6.70% at subjects 80 years and over. AF was more prevalent in women compared with men (0.89% vs. 0.88%, p<0.0001), which could be attributed to higher AF burden in women over 80 years. Driven by increased prescription of non-vitamin K antagonist oral anticoagulants, anticoagulant use increased from 19.46% in 2015 to 56.57% in 2020. The number of left atrial appendage closure increased from 0.16% in 2015 to 1.23% in 2020. Rhythm control strategy was increasingly adopted, as the use of antiarrhythmic drugs doubled and ablation increased by 21% in 2020 compared to 2015. Compared with men, women were less prone to receive rhythm control treatments, including antiarrhythmics, ablation and cardioversion, but more likely to adopt rate control drugs. During the 5.5 years follow-up, the incidences of stroke, transient ischemic attack, systemic embolism, bleeding, myocardial infarction, and in-hospital death were 6.09%, 5.74%, 1.44%, 5.11%, 8.41%, and 12.84% in patients with index diagnosis of AF in 2015, respectively.

INTERPRETATION

The burdens of AF and AF-related outcomes in Shanghai are high. Management of AF is markedly improved in recent years, and was not or only slightly impeded by the COVID-19 pandemic. There are sex differences in the prevalence, management, and outcomes of AF.

FUNDING

Shanghai Hospital Development Center, National Natural Science Foundation of China and Shanghai Municipal Science and Technology Commission.

Nomogram to predict hemorrhagic transformation for acute ischemic stroke in Western China: a retrospective analysis

Background and purpose

Hemorrhagic transformation (HT) is the most alarming complication of acute ischemic stroke. We aimed to identify risk factors for HT in Chinese patients and attempted to develop a nomogram to predict individual cases.

Methods

A retrospective study was used to collect the demographic and clinical characteristics of ischemic stroke patients at the Second Affiliated Hospital of Chongqing Medical University (development cohort) and Chongqing Sanbo Changan Hospital (validation cohort) from October 2013 to August 2020. Univariate analysis and multivariate analysis were used to identify the risk factors of patients in the development cohort. The nomogram was generated, and internal validation was performed. We used the area under the receiver-operating characteristic curve (AUC-ROC) to assess the discrimination and used the Hosmer–Lemeshow test to calibrate the model. To further verify the predictability and accuracy of the model, we performed an external validation of the patients in the validation cohort.

Results

A total of 570 patients were used to generate the nomogram. After univariate analysis and multivariate logistic regression, the remaining 7 variables (diabetes mellitus, atrial fibrillation, total cholesterol, fibrous protein, cerebral infarction area, NIHSS score and onset-to-treatment) were independent predictors of HT and used to compose the nomogram. The area under the receiver-operating characteristic curve of the model was 0.889 (95% CI, 0.841–0.938), and the calibration was good (P = 0.487 for the Hosmer–Lemeshow test). The model was validated externally with an AUC-ROC value of 0.832 (95% CI, 0.727–0.938).

Conclusions

The nomogram prediction model in this study has good predictive ability, accuracy and discrimination, which can improve the diagnostic efficiency of HT in patients with acute ischemic stroke.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02678-2.

Prevalence of atrial fibrillation and the risk of cardiovascular mortality among hypertensive elderly population in northeast China

Little is known about the epidemiology and impact of atrial fibrillation (AF) on cardiovascular diseases (CVD) mortality among hypertensive elderly population in northeast China. The community‐based study included 4497 hypertensive elderly residents aged ≥65 years who lived in northeast China from September 2017 to March 2019. Information on CVD deaths was obtained from baseline until July 31, 2021. Cox proportional hazard regression models were performed in the evaluation of CVD mortality. We identified 101 persons with AF. The prevalence of AF was 2.2% among elderly hypertensive population, which increased significantly with age. The prevalence of AF was higher in men than in women. The awareness rate was 51.5%, higher in urban areas than in rural areas (68.8% vs 43.5%, P = .018). Only 4.0% patients received oral anticoagulant (OAC) therapy among AF patients. Moreover, diabetes (26.7%) and dyslipidemia (37.6%) were highly prevalent in AF patients. Furthermore, 212 persons died due to CVD (14.7/1000 person‐years) during a median follow‐up of 3.2 years. AF patients had a 3.42 (95% CI: 2.07‐5.63) times higher risk of CVD mortality than the patients without AF in the fully adjusted model. Therefore, the burden of AF among hypertensive elderly population in northeast China was considerable. Long‐term screening and management strategies for AF and related risk factors are required among hypertensive elderly in northeast China.

Association Between Atrial Fibrillation and the Risk of Cardiovascular Mortality Among Elderly Adults With Ischemic Stroke in Northeast China: A Community-Based Prospective Study

Background

Elderly people are susceptible to atrial fibrillation (AF) and ischemic stroke (IS); however, less information is known about the association between AF and the risk of cardiovascular disease (CVD) mortality in elderly population with IS. We aimed to investigate the features of AF among aged people with IS and to illustrate whether AF accounted for CVD mortality.

Methods

At baseline, 790 patients with IS were enrolled from the general northeast Chinese elderly population (>60 years) between September 2017 to March 2019. The prevalence, awareness, and treatment of AF in each age group were analyzed, as well as major-related cardiovascular risk factors. The population was followed until July 31, 2021, and information on CVD death was obtained.

Results

A total of 25 people had AF, and the prevalence of AF in the elderly population with IS was 3.2%. The AF prevalence grew along with age from 1% (60–64 years) to 4.3% (70–74 years) and 4.2% (≥75 years), which was higher in the urban residents than in the rural residents (5.7 vs. 2.2%, P = 0.014). The awareness and treatment rates of patients with AF were 80 and 8%. After a median follow-up period of 3.3 years, 58 subjects died due to CVD and 5 subjects were accompanied with AF (rate 70.6/1,000 person-years). Elderly IS patients with AF had a 3.65-fold increased risk of CVD death in the fully adjusted model when compared with non-AF participants.

Conclusion

The AF prevalence increased with age among the elderly population with IS. Moreover, elderly patients with IS in northeast China with AF had a higher CVD mortality. Therefore, early screening and prompt management of AF in elderly population with IS in northeast China are required.

Incidence and Complications of Atrial Fibrillation in a Low Socioeconomic and High Disability United States (US) Population: A Combined Statistical and Machine Learning Approach

BACKGROUND

Poor socioeconomic status coupled with individual disability is significantly associated with incident atrial fibrillation (AF) and AF-related adverse outcomes, with the information currently lacking for US cohorts. We examined AF incidence/complications and the dynamic nature of associated risk factors in a large socially disadvantaged US population.

METHODS

A large population representing a combined poor socioeconomic status/disability (Medicaid program) was examined from diverse geographical regions across the US continent. The target population was extracted from administrative databases with patients possessing medical/pharmacy benefits. This retrospective cohort study was conducted from Jan 1, 2016, to Sep 30, 2021, and was limited to 18- to 80-year age group drawn from the Medicaid program. Descriptive and inferential statistics (parametric: logistic regression and neural network) were applied to all computations using a combined statistical and machine learning (ML) approach.

RESULTS

A total of 617413 individuals participated in the study, with mean age of 41.7 years (standard deviation "SD" 15.2) and 65.6% female patients. Seven distinct groups were identified with different combinations of low socioeconomic status and disability constraints. The overall crude AF incidence rate was 0.49 cases/100 person-years (95% confidence limit "CI" 0.40-0.58), with the lowest rate for the younger group (temporary assistance for needy family "TANF") (0.20, 95%CI 0.18-0.21), the highest rates for the older groups (age, blindness, or disability "ABD" duals-1.51, 95% CI 1.31-1.58; long-term services and support "LTSS" duals-1.45, 95% CI 1.31-1.58), and the remaining four other groups in between the lower and upper rates. Based on independent effects after accounting for confounders in main effect modeling, the point estimates of odds ratios for AF status with various clinical outcomes were as follows: stroke (2.69, 95% CI 2.53-2.85); heart failure (6.18, 95% CI 5.86-6.52); myocardial infarction (3.71, 95% CI 3.49-3.94); major bleeding (2.26, 95% CI 2.14-2.38); and cognitive impairment (1.74, 95% CI 1.59-1.91). A logistic regression-based ML model produced excellent discriminant validity for high-risk AF outcomes (c "concordance" index based on training data 0.91, 95%CI 0.891-0.929), together with similar measures for external validity, calibration, and clinical utility. The performance measures for the ML models predicting associated complications with high-risk AF cases were good to excellent.

CONCLUSIONS

A combination of low socioeconomic status and disability contributes to AF incidence and complications, elevating risks to higher levels relative to the general population. ML algorithms can be used to identify AF patients at high risk of clinical events. While further research is definitely in need on this socially important issue, the reported investigation is unique in which it integrates the general case about the subject due to the different ethnic groups around the world under a unified culture stemming from residing in the US.

Associations of mixture of air pollutants with estimated 10-year atherosclerotic cardiovascular disease risk modified by socio-economic status: The Henan Rural Cohort Study

BACKGROUND

Low socio-economic status (SES) and exposure to single-air pollutant relate to increased prevalent atherosclerotic cardiovascular diseases (ASCVD), however, interactive effect between SES and exposure to single- or multiple-air pollutants on high 10-year ASCVD risk remains unclear.

METHODS

A total of 31,162 individuals were derived from the Henan Rural Cohort Study. Concentrations of air pollutants (particulate matter with an aerodynamic diameter ≤ 1.0 μm (PM₁), ≤2.5 μm (PM_2.5) or ≤10 μm (PM₁₀), nitrogen dioxide (NO₂)) were assessed using a spatiotemporal model based on satellites data. Independent and joint associations of SES, single- and multiple- air pollutants with high 10-year ASCVD risk were evaluated using logistic regression models, quantile g-computation and structural equation models. The interactive effects of SES and exposure to single- or multiple air pollutants on high 10-year ASCVD risk were visualized by using Interaction plots.

RESULTS

Exposure to single air pollutant (PM₁, PM_2.5, PM₁₀ or NO₂) related to increased high 10-year ASCVD risk among individuals with low education level or personal average monthly income, compared to the ones with high education level or personal average monthly income. Furthermore, similar results of exposure to mixture of air pollutants with high 10-year ASCVD risk were observed. Positive interactive effects between low SES and exposure to high single air pollutant or the mixture of air pollutants on high 10-year ASCVD risk were observed.

CONCLUSION

Positive association of low SES with high 10-year ASCVD risk was amplified by exposure to high levels of single air pollutant or a mixture of air pollutants, implying that individuals with low SES may more susceptible to air pollution-related adverse health effect.

Cost-Effectiveness of Dronedarone and Amiodarone for the Treatment of Chinese Patients With Atrial Fibrillation

Background: Atrial fibrillation (AF) is one of the most common arrhythmias in clinical practice, which brings great economic burden to patients. This study evaluated the economics of the new antiarrhythmic drug dronedarone and provides suggestions for allocation of health resources.

Methods: Amiodarone was selected as the control group, and the Markov model of AF was established using nine states. The total cost and quality-adjusted life year (QALY) of dronedarone and amiodarone groups were calculated and compared. The incremental cost effectiveness ratio (ICER) value was calculated and compared with the willingness to pay (WTP) and the sensitivity analyses was conducted.

Results: For China's healthcare system, the ICER of the dronedarone group compared with the amiodarone group was RMB 81,741 Yuan/QALY, which is lower than the current recommended WTP (3 times GDP per capita). Sensitivity analyses showed that the model was robust, and the drug price of dronedarone significantly impacted the results.

Conclusions: Compared with amiodarone, dronedarone is more economical in the Chinese healthcare system. However, due to the lack of data on the Chinese population for some parameters, the model needs further improvement and discussion. Real-world studies on the effects of dronedarone on Chinese patients with AF would be beneficial.

Predicting Recurrence for Patients With Ischemic Cerebrovascular Events Based on Process Discovery and Transfer Learning

The recurrence of Ischemic cerebrovascular events (ICE) often results in a high rate of mortality and disability. However, due to the lack of labeled follow-up data in hospitals, prediction methods using traditional machine learning are usually not available or reliable. Therefore, we propose a new framework for predicting the long-term recurrence risk in patients with ICE after discharge from hospitals based on process mining and transfer learning, to point out high-risk patients for intervention. First, process models are discovered from clinical guidelines for analyzing the similarity of ICE population data collected by different medical institutions, and the control flow found are taken as added characteristics of patients. Then we use the in-hospital data (target domain) and the national stroke screening data (source domain), to develop risk prediction models applying instance filter and weight-based transfer learning method. To verify our method, 205 cases from a tertiary hospital and 2954 cases from the screening cohort (2015-2017) are tested. Experimental results show that our framework can improve the performance of three instance-based transfer algorithms. This study provides a comprehensive and efficient approach for applying transfer learning, to alleviate the limitation of insufficient labeled follow-up data in hospitals.

A FEATURE SELECTION-BASED ALGORITHM FOR DETECTION OF ATRIAL FIBRILLATION USING SHORT-TERM ECG

In the presence of premature atrial contraction (PAC), premature ventricular contraction (PVC) or other ectopic beats, RR intervals (RRIs) may be disturbed, which results in other types of heart disease being misdiagnosed as atrial fibrillation (AF). In this study, a low-complexity AF detection method based on short ECG is proposed, which includes RRIs modification and feature selection. The extracted RRIs are used to determine whether the potential RRI interference exists and to modify it. Next, based on the modified RRIs, the features are evaluated and selected by the methods of correlation criterion, Fisher criterion, and minimum redundancy maximum relevance criterion. Finally, filtered features are classified by the artificial neural network (ANN). The algorithm is validated in a test set including 2332 AF, 313 normal (NOR), 239 atrioventricular block (IAVB), 81 left bundle branch block (LBBB), 624 right bundle branch block (RBBB), 426 PAC and 564 PVC. Compared with the previous detection method of AF based on the RRIs, the proposed method achieved an overall sensitivity of 94.04% and an overall specificity of 86.74%. The specificity of the test set containing only AF and NOR is up to 99.04%. Meanwhile, the overall false-positive rate (FPR) of PAC and PVC can be reduced by 9.19%. While ensuring accuracy, this method effectively reduces the probability of misdiagnosis of PVC and PAC as AF. It is an automatic detection method of AF suitable for inter-patient clinical short-term ECG.

Potential Target Genes in the Development of Atrial Fibrillation: A Comprehensive Bioinformatics Analysis

Background

Atrial fibrillation (AF) is the most prevalent arrhythmia worldwide. Although it is not life-threatening, the accompanying rapid and irregular ventricular rate can lead to hemodynamic deterioration and obvious symptoms, especially the risk of cerebrovascular embolism. Our study aimed to identify novel and promising genes that could explain the underlying mechanism of AF development.

Material/Methods

Expression profiles GSE41177, GSE79768, and GSE14975 were acquired from the Gene Expression Omnibus Database. R software was used for identifying differentially expressed genes (DEGs), and Gene Ontology and Kyoto Encyclopedia of Genes and Genomes enrichment analyses were subsequently performed. A protein–protein interaction network was constructed in Cytoscape software. Next, a least absolute shrinkage and selection operator (LASSO) model was constructed and receiver-operating characteristic curve analysis was conducted to assess the specificity and sensitivity of the key genes.

Results

We obtained 204 DEGs from the datasets. The DEGs were mostly involved in immune response and cell communication. The primary pathways of the DEGs were related to the course or maintenance of autoimmune and chronic inflammatory diseases. The top 20 hub genes (high scores in cytoHubba) were selected in the PPI network. Finally, we identified 6 key genes (FCGR3B, CLEC10A, FPR2, IGSF6, S100A9, and S100A12) via the LASSO model.

Conclusions

We present 6 target genes that are potentially involved in the molecular mechanisms of AF development. In addition, these genes are likely to serve as potential therapeutic targets.

Incidence and predictors of hospitalization in patients with atrial fibrillation: results from the Chinese atrial fibrillation registry study

Background

Patients with atrial fibrillation (AF) underwent a high risk of hospitalization, which has not been paid much attention to in practice. Therefore, we aimed to assess the incidence, causes and predictors of hospitalization in AF patients.

Methods

From August 2011 to December 2017, a total number of 20,172 AF patients from the Chinese Atrial Fibrillation Registry (China-AF) Study were prospectively selected for this study. We described the incidence, causes of hospitalization by age groups and sex. The Fine-Gray competing risk model was employed to identify predictors of first all-cause and first cause-specific hospitalization.

Results

After a mean follow-up of 37.3 ± 20.4 months, 7,512 (37.2%) AF patients experienced one or more hospitalizations. The overall incidence of all-cause hospitalization was 24.0 per 100 patient-years. Patients aged < 65 years were predominantly hospitalized for AF (42.1% of the total hospitalizations); while patients aged 65–74 and ≥ 75 years were mainly hospitalized for non-cardiovascular diseases (43.6% and 49.3%, respectively). We found patients complicated with heart failure (HF)[hazard ratio (HR) 1.10, 95% confidence interval (CI) 1.02–1.18], established coronary artery disease (CAD) (HR 1.24, 95%CI 1.17–1.33), ischemic stroke/transient ischemic attack (TIA) (HR 1.22, 95%CI 1.15–1.30), diabetes (HR 1.14, 95%CI 1.08–1.20), chronic obstructive pulmonary disease (COPD) (HR 1.28, 95%CI 1.02–1.62), gastrointestinal disorder (HR 1.37, 95%CI 1.21–1.55), and renal dysfunction (HR 1.24, 95%CI 1.09–1.42) had higher risks of hospitalization.

Conclusions

More than one-third of AF patients included in this study were hospitalized at least once during over 3-year follow-up. The main cause for hospitalization among the elderly patients (≥ 65 years) is non-cardiovascular diseases rather than AF. Multidisciplinary management of comorbidities should be advocated to reduce hospitalization in AF patients older than 65 years old.

Clinical Registryhttp://www.chictr.org.cn/showproj.aspx?proj=5831. Unique identifier: ChiCTR-OCH-13003729. The registration date is October 22, 2013.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-01951-5.

Atrial fibrillation prevalence, awareness and management in a nationwide survey of adults in China

OBJECTIVE

To determine AF prevalence and gaps in atrial fibrillation (AF) awareness and management in China.

METHODS

We conducted a community-based survey of 47 841 adults (age ≥45 years) in seven geographic regions of China between 2014 and 2016. Participants underwent a structured questionnaire, a standard 12-lead ECG, physical examination and blood sampling. AF prevalence, defined by either ECG detection or self-report, was estimated according to sampling weights, non-response and age and sex distribution of the population. We used multivariable logistic regression to estimate associations among sociodemographic, clinical and geographic factors with the AF prevalence, awareness and treatment.

RESULTS

The weighted AF prevalence was 1.8% (95% CI 1.7% to 1.9%), but varied from 0.9% to 2.4% across geographical regions and equates to being present in an estimated 7.9 (95% CI 7.4 to 8.4) million people in China. Among men and women, the AF prevalence increased from 0.8% and 0.6% in the age group 45-54 years to 5.4% and 4.9% in the age group ≥75 years, respectively. Proportions of people who were aware of having AF decreased overall from 65.3% in 45-54 year-olds to 53.9% in ≥75 year-olds and varied between sex (men 58.5%, women 68.8%) and residency status (urban 78.3%, rural 35.3%). Only 6.0% of patients with high-risk AF received anticoagulation therapy.

CONCLUSIONS

AF prevalence is higher than previously reported in China, with low awareness and large treatment gaps. Large-scale efforts are urgently needed to reduce AF adverse consequences.

Epidemiology of Atrial Fibrillation: Geographic/Ecological Risk Factors, Age, Sex, Genetics

Atrial fibrillation is the most common arrhythmia globally. The global prevalence of atrial fibrillation is positively correlated with the sociodemographic index of different regions. Advancing age, male sex, and Caucasian race are risk factors; female sex is correlated with higher atrial fibrillation mortality worldwide likely owing to thromboembolic risk. African American ethnicity is associated with lower atrial fibrillation risk, same as Asian and Hispanic/Latino ethnicities compared with Caucasians. Atrial fibrillation may be heritable, and more than 100 genetic loci have been identified. A polygenic risk score and clinical risk factors are feasible and effective in risk stratification of incident disease.

Atrial fibrillation in low- and middle-income countries: a narrative review

Preventing premature non-communicable disease mortality necessitates a thorough review of one of the most important risk factors for stroke, which is atrial fibrillation (AF). The latter and AF-related stroke are still considered to be problems of high-income countries and are frequently overlooked in low- and middle-income countries (LMICs). In this narrative review, we provide an overview of studies that evaluated at least one of the following determinants of AF burden in LMICs: current epidemiology and trends, stroke prevention, health outcomes, and economic burden. Studies focusing on samples close to the general population (including community- and primary care-based samples) indicate sex-specific prevalence rates up to 7.4% in LMICs. Although AF prevalence is still higher in high-income countries than LMICs, the gap in AF burden between these two groups has been reducing in the past three decades. Oral anticoagulant (OAC) therapy for stroke prevention is underused in LMICs, and there are little data on OAC therapy in relation to stroke risk scores, such as CHA₂DS₂-VASc. Available data also points to higher morbidity and mortality for patient with AF in LMICs than their counterparts in high-income countries. Data on the consequent economic burden in LMICs is scarce, but it is reasonable to consider it will follow the same trend as that observed for health outcomes. Raising the visibility of AF as a public health problem in LMICs is necessary as a first step to providing adequate care for patients with this condition.

Trends of global burden of atrial fibrillation/flutter from Global Burden of Disease Study 2017

OBJECTIVE

This study aimed to estimate the global burden of atrial fibrillation/atrial flutter (AF/AFL).

METHODS

We retrieved data from the Global Health Data Exchange query tool and estimated the age-standardised rates (ASRs) of prevalence, incidence and disability-adjusted life-years (DALYs) of AF/AFL, as well as the population attributable fraction (PAF) of risk factors contributing to DALYs. ASRs and sociodemographic index (SDI) were assessed using Pearson's correlation coefficients.

RESULTS

In 2017, there were 37.6 million (95% uncertainty interval (UI) 32.5 to 42.6 million) individuals with AF/AFL globally. The prevalence rates increased with increased SDI values in most regions for all years. Men had a higher prevalence than women across all regions except for China. From 1990 to 2017, global prevalence rate decreased by 5.08% (95% UI -6.24% to -3.82%), with the largest decrease noted in the region with high SDI values. The global DALYs rate declined by 2.53% (95% UI -4.16 to -0.29). PAF of elevated systolic blood pressure for attributable DALYs accounted for the highest percentage, followed by high body mass index, alcohol use, high-sodium diet, smoking and lead exposure.

CONCLUSIONS

Although the ASRs of prevalence, incidence and DALYs decreased from 1990 to 2017, the absolute number of patients with AF/AFL, annual number of new AF/AFL cases and DALYs lost due to AF/AFL increased. This indicates that the burden of AF/AFL is likely to remain high. Systematic surveillance is needed to better identify and manage AF/AFL so as to prevent its various risk factors and complications.

The epidemiology of atrial fibrillation in Chinese postmenopausal women and its association with age of menopause

OBJECTIVES

To investigate the epidemiology of atrial fibrillation (AF) in postmenopausal women and to evaluate the association between age of menopause and AF.

STUDY DESIGN

A total of 9117 postmenopausal women were selected from a cross-sectional study conducted among the general population of north-east China from September 2017 and March 2019.

MAIN OUTCOME MEASURES

AF was diagnosed according to self-reported medical history of AF and/or current ECG findings. The epidemiology of AF including prevalence, awareness, use of anticoagulants and cardiovascular risk factors in postmenopausal women were carefully assessed. The association between age of menopause and AF was evaluated by stepwise logistic regression.

RESULTS

The prevalence of AF was up to 1.1 % (95 % CI, 0.9 %-1.3 %) in postmenopausal women, but the awareness of it was 61.2 %. The proportion of AF patients requiring treatment with an oral anticoagulant (OAC) was as high as 87.8 % according to CHA₂DS₂-VASc score, while only 5.8 % of them received it. The prevalence of cardiovascular risks factors was high among postmenopausal women with AF, but awareness, treatment and control of these comorbidities were unacceptably low. Compared with the women with premature menopause (< 45 years), participants reporting onset of menopause at 50-54 years had a significantly lower risk of AF (OR 0.49, 95 % CI 0.27-0.91).

CONCLUSIONS

The widespread use of OAC and the control of cardiovascular risk factors in postmenopausal women with AF was of great significance in preventing AF-related stroke. The history of premature menopause provided a reliable opportunity for primary prevention of AF.

China Stroke Statistics 2019: A Report From the National Center for Healthcare Quality Management in Neurological Diseases, China National Clinical Research Center for Neurological Diseases, the Chinese Stroke Association, National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention and Institute for Global Neuroscience and Stroke Collaborations

China faces the greatest challenge from stroke in the world. The death rate for cerebrovascular diseases in China was 149.49 per 100 000, accounting for 1.57 million deaths in 2018. It ranked third among the leading causes of death behind malignant tumours and heart disease. The age-standardised prevalence and incidence of stroke in 2013 were 1114.8 per 100 000 population and 246.8 per 100 000 person-years, respectively. According to the Global Burden of Disease Study 2017, the years of life lost (YLLs) per 100 000 population for stroke increased by 14.6%; YLLs due to stroke rose from third highest among all causes in 1990 to the highest in 2017. The absolute numbers and rates per 100 000 population for all-age disability-adjusted life years (DALYs) for stroke increased substantially between 1990 and 2017, and stroke was the leading cause of all-age DALYs in 2017. The main contributors to cerebrovascular diseases include behavioural risk factors (smoking and alcohol use) and pre-existing conditions (hypertension, diabetes mellitus, dyslipidaemia and atrial fibrillation (AF)). The most prevalent risk factors among stroke survivors were hypertension (63.0%-84.2%) and smoking (31.7%-47.6%). The least prevalent was AF (2.7%-7.4%). The prevalences for major risk factors for stroke are high and most have increased over time. Based on the latest national epidemiological data, 26.6% of adults aged ≥15 years (307.6 million adults) smoked tobacco products. For those aged ≥18 years, age-adjusted prevalence of hypertension was 25.2%; adjusted prevalence of hypercholesterolaemia was 5.8%; and the standardised prevalence of diabetes was 10.9%. For those aged ≥40 years, the standardised prevalence of AF was 2.31%. Data from the Hospital Quality Monitoring System showed that 3 010 204 inpatients with stroke were admitted to 1853 tertiary care hospitals during 2018. Of those, 2 466 785 (81.9%) were ischaemic strokes (ISs); 447 609 (14.9%) were intracerebral haemorrhages (ICHs); and 95 810 (3.2%) were subarachnoid haemorrhages (SAHs). The average age of patients admitted was 66 years old, and nearly 60% were male. A total of 1555 (0.1%), 2774 (0.6%) and 1347 (1.4%) paediatric strokes (age <18 years) were identified among IS, ICH and SAH, respectively. Over one-third (1 063 892 (35.3%)) of the patients were covered by urban resident basic medical insurance, followed by urban employee basic medical insurance (699 513 (23.2%)) and new rural cooperative medical schema (489 361 (16.3%)). The leading risk factor was hypertension (67.4% for IS, 77.2% for ICH and 49.1% for SAH), and the leading comorbidity was pneumonia or pulmonary infection (10.1% for IS, 31.4% for ICH and 25.2% for SAH). In-hospital death/discharge against medical advice rate was 8.3% for stroke inpatients, ranging from 5.8% for IS to 19.5% for ICH. The median and IQR of length of stay was 10.0 (7.0-14.0) days, ranging from 10.0 (7.0-13.0) in IS to 14.0 (8.0-22.0) in SAH. Data from the Chinese Stroke Center Alliance demonstrated that the composite scores of guideline-recommended key performance indicators for patients with IS, ICH and SAH were 0.77±0.21, 0.72±0.28 and 0.59±0.32, respectively.

Catheter ablation of atrial fibrillation after pericardiectomy: multi-center experience in China

Background

To study the effectiveness and safety of atrial fibrillation (AF) catheter ablation after pericardiectomy.

Methods

Data of 24 consecutive AF patients after pericardiectomy underwent catheter ablation from five centers were collected and analyzed retrospectively. All patients were followed up at 1, 3, and 12 months after catheter ablation. Results of a repeated blood test, electrocardiogram, and echocardiography during follow-up were also collected. Adverse events such as recurrence of AF, heart failure, stroke/transient ischemic attack (TIA) and minor, and major bleeding were recorded. All patients underwent brain magnetic resonance imaging (MRI) at the end of 12 months follow-up.

Results

Patients were young (20-73 years old, 48.1±11.0). Fifteen (62.5%) patients were male. CHA2DS2-VASc score (0-3, 0.21±0.41) was low in these 24 patients. Among these patients, 11 (45.8%) were paroxysmal AF, 8 (33.3%) were persistent AF, and 5 (20.8%) were long-lasting persistent AF. Left atrium diameter over 45 mm was detected in 17 (70.8%) patients. All patients underwent catheter ablation successfully. No peri-ablation procedure-related complication happened. Oral anticoagulant therapy was stopped 3 months after the final ablation. Anti-arrhythmia drugs were continued for all patients after ablation. For 12 months follow-up, AF recurred in 10 (41.7%) patients 3-7 months after the first ablation. MRI detected silent cerebral infarction (SCI) in 2 (8.3%) patients. No other adverse events occurred during follow-up.

Conclusions

It is safe for AF patients to undergo catheter ablation after pericardiectomy, but the rate of recurrence of AF is high.

Stroke in China: advances and challenges in epidemiology, prevention, and management

With over 2 million new cases annually, stroke is associated with the highest disability-adjusted life-years lost of any disease in China. The burden is expected to increase further as a result of population ageing, an ongoing high prevalence of risk factors (eg, hypertension), and inadequate management. Despite improved access to overall health services, the availability of specialist stroke care is variable across the country, and especially uneven in rural areas. In-hospital outcomes have improved because of a greater availability of reperfusion therapies and supportive care, but adherence to secondary prevention strategies and long-term care are inadequate. Thrombolysis and stroke units are accepted as standards of care across the world, including in China, but bleeding-risk concerns and organisational challenges hamper widespread adoption of this care in China. Despite little supporting evidence, Chinese herbal products and neuroprotective drugs are widely used, and the increased availability of neuroimaging techniques also results in overdiagnosis and overtreatment of so-called silent stroke. Future efforts should focus on providing more balanced availability of specialised stroke services across the country, enhancing evidence-based practice, and encouraging greater translational research to improve outcome of patients with stroke.

Efficacy and Safety of Non-Vitamin K Anticoagulants for Atrial Fibrillation in Relation to Different Renal Function Levels: A Network Meta-Analysis

Background

We performed a network meta-analysis (NMA) comparing the efficacy (stroke or systemic embolism) and safety (major bleeding) among different non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) and renal impairment, with the aim of recommending the proper drug and the dose based on renal function.

Methods

We searched PubMed, EMBASE, Web of Science, and Cochrane Library with the items “dabigatran, edoxaban, apixaban, rivaroxaban, warfarin, and atrial fibrillation” through August 2019. NMA was analyzed with R (version 3.5.1, R Foundation for Statistical Computing) with the packages gemtc recalling JAGS (version 4.3.0) for the efficacy and safety of each drug with regard to different levels of renal function. NetMetaXL (version 1.6.1) and winBUGS (version 1.4.3) were used to obtain the cumulative ranking curve (SUCRA) of each drug.

Result

In patients with normal renal function, dabigatran150 was ranked as the most effective drug (SUCRA 0.90), followed by dabigatran110 (SUCRA 0.68), apixaban (SUCRA 0.66), and rivaroxaban (SUCRA 0.59). With regard to the safety for preventing major bleeding, there was high probability that edoxaban30 (SUCRA 0.99) ranked first, compared to dabigatran110 (SUCRA 0.78) and edoxaban60 (SUCRA 0.66). For patients with mild renal impairment, with respect to the most effective drug for preventing stroke or systemic embolism, edoxaban60 ranked first (SUCRA 0.98), in comparison with dabigatran150 (SUCRA 0.74) and apixaban (SUCRA 0.64). Possibility of ranking first for the safest drug was edoxaban30 (SUCRA 0.99), followed by dabigatran110 (SUCRA 0.70) and apixaban (SUCRA 0.69). In patients with moderate renal function, dabigatran150 (SUCRA 0.95) ranked as the most effective drug in comparison with apixaban (SUCRA 0.66). Dabigatran110 (SUCRA 0.53), rivaroxaban (SUCRA 0.51), and edoxaban60 (SUCRA 0.50) had the similar probability of ranking third. When referred to the safest drug, probability of ranking first for preventing major bleeding was edoxaban30 (SUCRA 0.98), followed by apixaban (SUCRA 0.85) and edoxaban60 (SUCRA 0.64).

Conclusion

In patients with AF and renal impairment and for patients with normal renal function, dabigatran 110 mg (bid) might have a better effect on the clinical results. And it does not coincide with patients taking dabigatran 110 mg with dose reduction for other factors including aged ≥75 years, renal impairment (CrCL 30–50 mL/min), gastritis, esophagitis, or gastroesophageal reflux, receiving concomitant verapamil, and so on. For patients with mild renal impairment, apixaban 5 mg (bid) would be a better choice for preventing stroke or systemic embolism and major bleeding, while apixaban 5 mg (bid) and edoxaban 60 mg (qd) were recommended for patients with moderate renal impairment. However, considering the fact of no RCTs for the head-to-head comparison, caution should be exercised over selecting each of NOACs for patients.

Using machine learning models to classify stroke risk level based on national screening data

With the character of high incidence, high prevalence and high mortality, stroke has brought a heavy burden to families and society in China. In 2009, the Ministry of Health of China launched the China national stroke screening and intervention program, which screens stroke risk factors and conducts high-risk population interventions for people aged over 40 years old all over China. In this program, stroke risk factors include hypertension, diabetes, dyslipidemia, atrial fibrillation, smoking, lack of exercise, apparently overweight or obese and family history of stroke. People with more than two risk factors or with a history of stroke or transient ischemic attack (TIA) are considered as high-risk. However, it is impossible for this criterion to classify stroke risk level for people with "unknown" values in the fields of risk factors. The missing of stroke risk levels results in reduced efficiency of stroke interventions and inaccuracies in the statistical results at the national level. In this paper, firstly, we construct the training set and test set and process the imbalanced training set based on oversampling and undersampling method. Then, we develop logistic regression model, decision tree model, neural network model and random forest model for stroke risk classification, and evaluate these models based on the recall and precision. The results show that the model based on random forest achieves best performance considering recall and precision. The models constructed in this paper can improve the screening efficiency and avoid unnecessary rescreening and intervention expenditures.

Using machine learning models to improve stroke risk level classification methods of China national stroke screening

Background

With the character of high incidence, high prevalence and high mortality, stroke has brought a heavy burden to families and society in China. In 2009, the Ministry of Health of China launched the China national stroke screening and intervention program, which screens stroke and its risk factors and conducts high-risk population interventions for people aged above 40 years old all over China. In this program, stroke risk factors include hypertension, diabetes, dyslipidemia, smoking, lack of exercise, apparently overweight and family history of stroke. People with more than two risk factors or history of stroke or transient ischemic attack (TIA) are considered as high-risk. However, it is impossible for this criterion to classify stroke risk levels for people with unknown values in fields of risk factors. The missing of stroke risk levels results in reduced efficiency of stroke interventions and inaccuracies in statistical results at the national level. In this paper, we use 2017 national stroke screening data to develop stroke risk classification models based on machine learning algorithms to improve the classification efficiency.

Method

Firstly, we construct training set and test sets and process the imbalance training set based on oversampling and undersampling method. Then, we develop logistic regression model, Naïve Bayesian model, Bayesian network model, decision tree model, neural network model, random forest model, bagged decision tree model, voting model and boosting model with decision trees to classify stroke risk levels.

Result

The recall of the boosting model with decision trees is the highest (99.94%), and the precision of the model based on the random forest is highest (97.33%). Using the random forest model (recall: 98.44%), the recall will be increased by about 2.8% compared with the method currently used, and several thousands more people with high risk of stroke can be identified each year.

Conclusion

Models developed in this paper can improve the current screening method in the way that it can avoid the impact of unknown values, and avoid unnecessary rescreening and intervention expenditures. The national stroke screening program can choose classification models according to the practice need.

Epidemiology of atrial fibrillation in northeast China: a cross-sectional study, 2017–2019

Objective

To evaluate the epidemiology of atrial fibrillation (AF) in northeast China.

Methods

This cross-sectional survey using a multistage, stratified and cluster random sampling method was conducted in Liaoning Province between September 2017 and March 2019. A total of 18 796 participants (28.9% urban, 71.1% rural) aged ≥40 years were included. All participants completed a questionnaire and underwent a physical examination and ECG. AF was diagnosed according to history and ECG findings.

Results

The overall AF prevalence was 1.1%; it increased steeply with age. AF was more prevalent in men than in women (1.5% vs 0.9%, p<0.001); however, the difference between urban and rural areas was not significant (1.3% vs 1.1%, p=0.228). Among the AF population, the overall AF awareness rate was 52.6%, higher in women than in men (61.5% vs 44.1%, p=0.011); however, the difference between areas was not statistically significant (60.0% vs 49.0%, p=0.129). According to the CHA2DS-VASc score, almost all (90.2%, 194/215) of our subjects required oral anticoagulant (OAC) therapy; however, only 4.1% actually received it. Moreover, hypertension (66.5%), dyslipidaemia (32.6%) and diabetes (24.2%) were highly prevalent in patients with AF, but their control rates were unacceptably low (7.0%, 8.6% and 28.8%, respectively).

Conclusions

The burden of AF in northeast China was substantial. Underuse of OAC therapy and uncontrolled comorbidities will likely contribute to the cardiovascular outcomes of patients with AF in the coming decades. Long-term management strategies for AF and related risk factors are required in northeast China.

U-Shaped Relationship Between Left Atrium Size on Echocardiography and 1-Year Recurrence of Atrial Fibrillation After Radiofrequency Catheter Ablation - Prognostic Value Study

BACKGROUND

The larger the left atrium anteroposterior dimension (LAD) and left atrium volume (LAV), the stronger the association with recurrent atrial fibrillation (AF) after radiofrequency catheter ablation (RFCA). Patients with a smaller left atrium (LA) size, however, also have increased AF recurrence.Methods and Results:In 521 patients, routine 48-h Holter electrocardiogram and echocardiography were obtained at each outpatient visit every 3 months for 12 months. On multivariate analysis, AF type, LAD, and LAV calculated using the ellipsoid model/body surface area (LAVe/BSA) were independent predictors of AF recurrence. Patients were divided into 7 groups at 0.4-cm increments of LAD: ≤3 cm, LAD≤3 cm, 3.0<LAD≤3.4 cm, 3.4<LAD≤3.8 cm, 3.8<LAD≤4.2 cm, 4.2<LAD≤4.6 cm, 4.6<LAD≤5.0 cm; and LAD>5.0 cm. Compared with the 3.4-3.8-cm group, the adjusted HR were 3.88 (95% CI: 2.02-7.46, P<0.001), 1.03 (95% CI: 0.50-2.12, P=0.939), 0.96 (95% CI: 0.52-1.77, P=0.901), 1.36 (95% CI: 0.72-2.57, P=0.347), 3.04 (95% CI: 1.67-5.53, P<0.001), and 4.07 (95% CI: 1.93-8.60, P<0.001), respectively. Similarly, we divided LAVe/BSA into 8 groups and also observed a U-shaped curve for AF recurrence.

CONCLUSIONS

Both larger and smaller LAD and LAVe/BSA were associated with a higher risk of AF recurrence 1 year after RFCA. The association of LA size and AF recurrence after RFCA is represented by a U-shaped curve.

Discover high-risk factor combinations using Bayesian network from cohort data of National Stoke Screening in China

BACKGROUND

In recent years, the increasing incidence and prevalence of stroke has brought a heavy economic burden on families and society in China. The Ministry of Health of the Peoples' Republic of China initiated the national stroke screening and intervention program in 2011 for stroke prevention and control. In the screening, only those who have been classified to "potential high-risk" group in preliminary screening need further examination and physician confirmation to determine the risk level of stroke in rescreening. However, at the beginning of the program, the "potential high-risk" classification method in the preliminary screening are determined by experts based on their experience. The primary aim of this study is to study the causality of stroke and risk factors in middle-aged population using the cohort data, and to explore whether the stroke screening and intervention program should include more precise "potential high-risk" evaluation criteria for this age group in preliminary screening.

METHOD

We use the cohort data of screening between 2013 and 2017 in this study. After data cleaning, the cohort consists of 48,007 people aged from 40 to 59 who are free of stroke at baseline. We use Bayesian networks to develop models.

RESULT

The results show that the stroke incidence in middle-aged population with certain two risk factors is higher than some of that with three factors, which is in keeping with our previous study results. We can take the ratio of the stroke incidence with combinations of risk factors and incidence without any of the risk factors as a variable threshold. By adjusting the threshold, we can get precise stroke preliminary screening criteria to achieve a balance between economy and efficiency.

CONCLUSION

We find that the criteria used in preliminary screening are not reasonable enough. There is a need for national stroke screening and intervention program to further include some more important risk factors or combinations of two risk factors as classification criteria in the preliminary screening. The results of the study can directly guide stroke screening program in China to make the screening more accurate and efficient.

Data on prevalence of atrial fibrillation and its association with stroke in low-, middle-, and high-income regions of China

Data presented in this article are supplementary material to our research article entitled " Prevalence of Atrial Fibrillation in Different Socioeconomic Regions of China and Its Association with Stroke: Results from a National Stroke Screening Survey" (Wang et al., 2018) [1]. This data article summarizes previous studies of Atrial Fibrillation (AF) prevalence in China, and estimates the association between AF and stroke in different socioeconomic regions of China through a national survey.