Rhythm control better prevents stroke and mortality than rate control strategies in patients with atrial fibrillation - A nationwide cohort study

Predicting stroke in Asian patients with atrial fibrillation using machine learning: A report from the KERALA-AF registry, with external validation in the APHRS-AF registry

Atrial fibrillation (AF) is a significant risk factor for stroke. Based on the higher stroke associated with AF in the South Asian population, we constructed a one-year stroke prediction model using machine learning (ML) methods in KERALA-AF South Asian cohort. External validation was performed in the prospective APHRS-AF registry. We studied 2101 patients and 83 were to patients with stroke in KERALA-AF registry. The random forest showed the best predictive performance in the internal validation with receiver operator characteristic curve (AUC) and G-mean of 0.821 and 0.427, respectively. In the external validation, the light gradient boosting machine showed the best predictive performance with AUC and G-mean of 0.670 and 0.083, respectively. We report the first demonstration of ML's applicability in an Indian prospective cohort, although the more modest prediction on external validation in a separate multinational Asian registry suggests the need for ethnic-specific ML models.

The effect of treatment strategy on long-term follow-up results in patients with nonvalvular atrial fibrillation in Turkey: AFTER-2 subgroup analysis

BACKGROUND

We performed a subanalysis of the data from the AFTER-2 registry. In our study, we aimed to compare the long-term follow-up results of nonvalvular atrial fibrillation (NVAF) patients in Turkey according to their treatment strategies.

METHODS

All consecutive patients older than 18 years of age who presented to cardiology outpatient clinics, had at least one AF attack and did not have rheumatic mitral valve stenosis or prosthetic heart valve disease were included in our prospective study. The patients were divided into two groups as rhythm control and rate control. Stroke, hospitalization and death rates were compared between the groups.

RESULTS

A total of 2592 patients from 35 centers were included in the study. Of these patients, 628 (24.2%) were in the rhythm control group and 1964 (75.8%) in the rate control group. New-onset ischemic cerebrovascular disease or transient ischemic attack (CVD/TIA) was detected at a lower rate in the rhythm control group (3.2% vs. 6.2% p = 0.004). However, there was no significant difference in one-year and five-year mortality rates (9.6% versus 9.0%, p = 0.682 and 31.8% versus 28.6%, p = 0.116, respectively). Hospitalization were found to be significantly higher in patients with rhythm control group (18% vs. 13%, p = 0.002).

CONCLUSION

It was found that rhythm control strategy is preferred in AF patients in Turkey. We found a lower rate of ischemic CVD/TIA in patients in the rhythm control group. Although no difference was observed in mortality rates, we found a higher rate of hospitalization in the rhythm control group.

Rhythm Control Better Prevents Dementia than Rate Control Strategies in Patients with Atrial Fibrillation-A Nationwide Cohort Study

Background: Atrial fibrillation (AF) increases the risk of dementia. Whether the pharmacological rhythm control of AF can reduce the risk of dementia compared to the rate control strategy remains unclear. We hypothesize that the rhythm control strategy is better than the rate control strategy in preventing dementia. Methods: AF patients aged ≥65 years were identified from the Taiwan National Health Insurance Database. Patients receiving anti-arrhythmic drugs at a cumulative defined daily dose (cDDD) of >30 within the first year of enrollment constituted the rhythm control group. Patients who used rate control medications for a cDDD of >30 constituted the rate control group. A multivariate Cox hazards regression model was used to determine the hazard ratio (HR) for dementia. Results: A total of 3382 AF patients (698 in the rhythm control group; 2684 in the rate control group) were analyzed. During a 4.86 ± 3.38 year follow-up period, 414 dementia events occurred. The rhythm control group had a lower rate of dementia than the rate control group (adjust HR: 0.75, p = 0.031). The rhythm control strategy reduced the risk of dementia particularly in those receiving aspirin (p = 0.03). Conclusions: In patients with AF, pharmacological rhythm control was associated with a lower risk of dementia than rate control over a long-term follow-up period, particularly in patients receiving aspirin treatment.

Exploratory Evaluation of Rhythm Control by Dronedarone in Combination With Low-Dose Rivaroxaban, Warfarin, Antiplatelet, or None of the Antithrombotic Therapy in High-Risk Patients With Non-Permanent Atrial Fibrillation: A Retrospective Cohort Study

The emerging data supports rhythm control to prevent major adverse cardiac events (MACE) in high-risk patients with atrial fibrillation (AF). Limited data demonstrated rivaroxaban 10 mg combining dronedarone seemed feasible. This study aimed at investigating clinical events in a dronedarone-treated cohort. This exploratory, retrospective chart review was conducted in nonpermanent AF patients receiving dronedarone for ≥ 3 months between 2009/1 and 2016/2. In Taiwan, dronedarone's labeled indication was strict to age ≥ 70 or 65 to 70 years with either hypertension, diabetes, prior stroke, or left atrium >50 mm. We divided all into 4 groups using antithrombotic strategies to evaluate the safety, effectiveness, and MACE endpoints. A total of 689 patients (mean CHA₂DS₂-VASc score 3.8 ± 1.4) were analyzed: rivaroxaban 10 mg (n = 93, 13.5%), warfarin (n = 89, 12.9%), antiplatelet (n = 331, 48.0%), and none (n = 176, 25.5%). During the follow-up period (mean 946 ± 493.8 days), the rivaroxaban group did not report any stroke or thromboembolism (ishcmeic stroke rate: antiplatelet [0.6%], none [1.1%]; hemorrahgic stroke rate: warfarin [2.2%]; thromboembolism rate: warfarin [2.2%]). There was no significant difference in safety, effectiveness, and MACE endpoints between groups. Also, >104 weeks of dronedarone use was the independent predictor for MACE after adjusting the strategy and other covariates (hazard ratio 0.14 [95% confidence interval 0.04-0.44], P = .001). Our findings warrant concomitant rivaroxaban 10 mg and dronedarone for further investigation. Regardless of antithrombotic strategies, a more extended persistence of dronedarone was associated with fewer MACE.

Outcomes of incident atrial fibrillation in heart failure with preserved or reduced ejection fraction: A community-based study

INTRODUCTION

The best management strategy for patients with atrial fibrillation (AF) with heart failure (HF) and preserved left ventricular ejection fraction (LVEF) is unknown.

METHODS AND RESULTS

This cohort study was conducted in Olmsted County, Minnesota, with resources of the Rochester Epidemiology Project. Patients with incident AF occurring between 2000 and 2014 with a prior or concurrent HF were included. Patients with LVEF ≥ 50% were designated as HF and preserved ejection fraction (HFpEF) and those with LVEF < 50% were designated as HF and reduced ejection fraction (HFrEF). Rhythm control in the first year after AF diagnosis was defined as prescriptions for an antiarrhythmic drug, catheter ablation, or maze procedure. The primary endpoint was all-cause mortality. The secondary endpoints were cardiovascular death, cardiovascular hospitalization, and stroke or transient ischemic attack. Of 859 patients (age, 77.2 ± 12.1 years; 49.2%, female), 447 had HFpEF-AF, and 412 had HFrEF-AF. There was no difference in all-cause mortality (10-year mortality, 83% vs 79%; p = .54) or secondary endpoints between the HFpEF-AF and HFrEF-AF, respectively. Compared with the rate control strategy, rhythm control in HFpEF-AF patients (n = 40, 15.9%) offered no survival benefits (adjusted HR, 0.70; 95% CI, 0.42-1.16; p = .16), whereas rhythm control in HFrEF-AF patients (n = 52, 22.5%) decrease cardiovascular mortality (HR, 0.38; 95% CI, 0.17-0.86; p = .02).

CONCLUSIONS

Patients with HFpEF-AF and HFrEF-AF had similar poor prognoses. Rhythm control strategy was seldom adopted in community care in patients with HF and AF. A rhythm control strategy may provide survival benefit for patients with HFrEF-AF and the benefit of rhythm control in patients with HFpEF-AF warrants further study.

Pulse rate variability predicts atrial fibrillation and cerebrovascular events in a large, population-based cohort

BACKGROUND

Many patients with atrial fibrillation (AF) present with stroke as their first clinical manifestation and since improved AF screening methods are thus required, we investigated whether pulse rate variability parameters predict future AF and cerebrovascular events.

METHODS

In an observational cohort study of 5000 community-resident adults (58% male; 50-84 years), the beat-to-beat variability of suprasystolic brachial blood pressure waveforms was measured with root mean square of successive differences (RMSSD) and irregularity index (IrrIx). Based on outcome-oriented and previously validated thresholds for detecting AF, RMSSD and IrrIx were dichotomised at 100 ms and 7.7%, respectively. Participants were followed up for 4.6 years (median), accruing 249 AF and 120 cerebrovascular events in the total sample (n = 5000), and 133 AF and 90 cerebrovascular events among those without prior AF diagnosis (n = 4296).

RESULTS

In multivariable-adjusted analyses, an elevated RMSSD (>100 ms) or IrrIx (>7.7%) was strongly associated with a higher risk of AF (hazard ratios (HRs) = 2.00-2.95) and cerebrovascular events (HRs = 1.91-2.28), even among people without prior AF diagnosis: HRs for AF = 1.70-2.05 and cerebrovascular events = 2.00-2.28. These associations were strongest in the highest RMSSD tertile >100 ms or IrrIx tertile >7.7%: HRs for AF = 2.32-4.47 and cerebrovascular events = 2.43-3.69. Among those without prior AF diagnosis, the highest categorical net reclassification improvement for 5-year cerebrovascular risk was 14% (95% confidence interval: 7-21%).

CONCLUSIONS

Elevated RMSSD or IrrIx values indicative of the presence of AF predict future AF and cerebrovascular events; more so with increasing pulse irregularity and even among those without prior AF diagnosis.

Data for rate versus rhythm control strategy on stroke and mortality in patients with atrial fibrillation

The data relates to the cohort of patients with atrial fibrillation (AF) from the National Health Insurance Research Database of Taiwan, "Rhythm Control Better Prevents Stroke and Mortality than Rate Control Strategies in Patients with Atrial Fibrillation - A Nationwide Cohort Study" (Weng et al., in press). The AF patients might receive either rate or rhythm control strategy according to the medication used. The baseline medication in rate and rhythm control groups was included in this dataset. Multivariate Cox hazards regression model was used to evaluate the hazard ratio (HR) for major adverse cardiovascular events (MACE), including ischemic/hemorrhagic stroke and mortality in AF patients receiving rate or rhythm control. The occurrence of MACE was identified from the ICD-9 CM codes. The data also contains the HR for MACE stratified by the CHA2DS2-VASc score, baseline characteristics, and the duration of strategy employed of the AF patients.