Refining Stroke Prediction in Atrial Fibrillation Patients by Addition of African-American Ethnicity to CHA2DS2-VASc Score

The Impact of Health Care Algorithms on Racial and Ethnic Disparities : A Systematic Review

BACKGROUND

There is increasing concern for the potential impact of health care algorithms on racial and ethnic disparities.

PURPOSE

To examine the evidence on how health care algorithms and associated mitigation strategies affect racial and ethnic disparities.

DATA SOURCES

Several databases were searched for relevant studies published from 1 January 2011 to 30 September 2023.

STUDY SELECTION

Using predefined criteria and dual review, studies were screened and selected to determine: 1) the effect of algorithms on racial and ethnic disparities in health and health care outcomes and 2) the effect of strategies or approaches to mitigate racial and ethnic bias in the development, validation, dissemination, and implementation of algorithms.

DATA EXTRACTION

Outcomes of interest (that is, access to health care, quality of care, and health outcomes) were extracted with risk-of-bias assessment using the ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tool and adapted CARE-CPM (Critical Appraisal for Racial and Ethnic Equity in Clinical Prediction Models) equity extension.

DATA SYNTHESIS

Sixty-three studies (51 modeling, 4 retrospective, 2 prospective, 5 prepost studies, and 1 randomized controlled trial) were included. Heterogenous evidence on algorithms was found to: a) reduce disparities (for example, the revised kidney allocation system), b) perpetuate or exacerbate disparities (for example, severity-of-illness scores applied to critical care resource allocation), and/or c) have no statistically significant effect on select outcomes (for example, the HEART Pathway [history, electrocardiogram, age, risk factors, and troponin]). To mitigate disparities, 7 strategies were identified: removing an input variable, replacing a variable, adding race, adding a non-race-based variable, changing the racial and ethnic composition of the population used in model development, creating separate thresholds for subpopulations, and modifying algorithmic analytic techniques.

LIMITATION

Results are mostly based on modeling studies and may be highly context-specific.

CONCLUSION

Algorithms can mitigate, perpetuate, and exacerbate racial and ethnic disparities, regardless of the explicit use of race and ethnicity, but evidence is heterogeneous. Intentionality and implementation of the algorithm can impact the effect on disparities, and there may be tradeoffs in outcomes.

PRIMARY FUNDING SOURCE

Agency for Healthcare Quality and Research.

Anticoagulation for Atrial Fibrillation: A Review of Current Literature and Views

Atrial fibrillation is a common supraventricular tachyarrhythmia with uncoordinated atrial activation and ineffective atrial contraction. This leads to an increased risk of atrial thrombi, most commonly in the left atrial appendage, and increased risks of embolic strokes and/or peripheral thromboembolism. It is associated with significant morbidity and mortality. To meet the concerns of thrombi and stroke, anticoagulation has been the mainstay for prevention and treatment thereof. Historically, anticoagulation involved the use of aspirin or vitamin K antagonists, mainly warfarin. Since early 2010s, direct oral anticoagulants (DOACs) including dabigatran, rivaroxaban, apixaban, and edoxaban have been introduced and approved for anticoagulation of atrial fibrillation. DOACs demonstrated a dramatic reduction in the rate of intracranial hemorrhage as compared to warfarin, and offer the advantages of absolution of monitoring therefore avoid the risk of hemorrhages in the context of narrow therapeutic window and under-treatment characteristic of warfarin, particularly in high-risk patients. One major concern and disadvantage for DOACs was lack of reversal agents, which have largely been ameliorated by the approval of Idarucizumab for dabigatran and Andexanet alfa for both apixaban and rivaroxaban, with Ciraparantag as a universal reversal agent for all DOACs undergoing Fast-Track Review from FDA. In this article, we will be providing a broad review of anticoagulation for atrial fibrillation with a focus on risk stratification schemes and anticoagulation agents (warfarin, aspirin, DOACs) including special clinical considerations.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

The relationship between right atrial wall inflammation and poor prognosis of atrial fibrillation based on 18F-FDG positron emission tomography/computed tomography

Background

Atrial fibrillation (AF) has been identified to increase stroke risk, even after oral anticoagulants (OACs), and the recurrence rate is high after radiofrequency catheter ablation (RFCA). Inflammation is an essential factor in the occurrence and persistence of AF. 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) is an established molecular imaging modality to detect local inflammation. We aimed to investigate the relationship between atrial inflammatory activity and poor prognosis of AF based on 18F-FDG PET/CT.

Methods

A total of 204 AF patients including 75 with paroxysmal AF (ParAF) and 129 with persistent AF (PerAF) who underwent PET/CT before treatment were enrolled in this prospective cohort study. Clinical data, electrocardiograph (ECG), echocardiography, and cardiac 18F-FDG uptake were collected. Follow-up information was obtained from patient clinical case notes or telephone reviews, with the starting point being the time of PET/CT scan. The follow-up deadline was either the date of AF recurrence after RFCA, new-onset stroke, or May 2023. Cox proportional hazards regression models were used to identify predictors of poor prognosis and hazard ratios (HRs) with 95% confidence intervals (CIs) was calculated.

Results

Median follow-up time was 29 months [interquartile range (IQR), 22-36 months]. Poor prognosis occurred in 52 patients (25.5%), including 34 new-onset stroke patients and 18 recrudescence after RFCA. The poor prognosis group had higher congestive heart failure, hypertension, age ≥75 years (doubled), diabetes mellitus, prior stroke or transient ischemic attack (TIA) or thromboembolism (doubled), vascular disease, age 65-74 years, sex category (female) (CHA2DS2-VASc) score [3.0 (IQR, 1.0-3.75) vs. 2.0 (IQR, 1.0-3.0), P=0.01], right atrial (RA) wall maximum standardized uptake value (SUVmax) (4.13±1.82 vs. 3.74±1.58, P=0.04), higher percentage of PerAF [39 (75.0%) vs. 90 (59.2%), P=0.04], left atrial (LA) enlargement [45 (86.5%) vs. 104 (68.4%), P=0.01], and RA wall positive FDG uptake [40 (76.9%) vs. 79 (52.0%), P=0.002] compared with the non-poor prognosis group. Univariate and multivariate Cox proportional hazard regression analysis concluded that only CHA2DS2-VASc score (HR, 1.29; 95% CI: 1.06-1.57; P=0.01) and RA wall positive FDG uptake (HR, 2.68; 95% CI: 1.10-6.50; P=0.03) were significantly associated with poor prognosis.

Conclusions

RA wall FDG positive uptake based on PET/CT is tightly related to AF recurrence after RFCA or new-onset stroke after antiarrhythmic and anticoagulation treatment.

Addressing racial differences in the management of atrial fibrillation: Focus on black patients

Atrial fibrillation (AF) is the most common sustained arrhythmia, affecting between 3 and 6 million people in the United States. It is associated with a reduced quality of life and increased risk of stroke, cognitive decline, heart failure and death. Black patients have a lower prevalence of AF than White patients but are more likely to suffer worse outcomes with the disease. It is important that stakeholders understand the disproportionate burden of disease and management gaps that exists among Black patients living with AF. Appropriate treatments, including aggressive risk factor control, early referral to cardiovascular specialists and improving healthcare access may bridge some of the gaps in management and improve outcomes.

Mechanisms and Prediction of Ischemic Stroke in Atrial Fibrillation Patients

Atrial fibrillation (AF) is the most common arrhythmia in adults worldwide and represents an important burden for patients, physicians, and healthcare systems. AF is associated with substantial mortality and morbidity, due to the disease itself and its specific complications, such as the increased risk of stroke and thromboembolic events associated with AF. The temporal relation between AF episodes and stroke is nonetheless incompletely understood. The factors associated with an increased thromboembolic risk remain unclear, as well as the stroke risk stratification. Therefore, in this review, we intend to expose the mechanisms and physiopathology leading to intracardiac thrombus formation and stroke in AF patients, together with the evidence supporting the causal hypothesis. We also expose the risk factors associated with increased risk of stroke, the current different risk stratification tools as well as future prospects for improving this risk stratification.

Racial and Ethnic Disparities in Stroke Prevention for Atrial Fibrillation

Racial and ethnic disparities in health care are well documented, although often underappreciated. In the setting of atrial fibrillation, stroke risk and severity may be higher in underrepresented ethnic populations. Additionally, the risk of bleeding is not uniform, and pharmacogenetics play an important role in anticoagulant therapy. In this narrative review, we discuss the complex issues surrounding stroke prevention in underrepresented ethnic groups with atrial fibrillation.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

American Indians and atrial fibrillation

The American Indian population is known to experience high rates of cardiovascular disease and have a heightened vulnerability to severe outcomes driven by an overall poor health status and lower access to quality health care. Our group has previously published an analysis demonstrating that American Indians have the highest risk of atrial fibrillation (AF), as well as of AF-related stroke, when compared with other races and ethnicities. Despite this, AF in this population has not been extensively studied and additional publications are scarce. Our review article provides an up-to-date summary of the relevant literature addressing the relationship between race, ethnicity, and AF by focusing on American Indians.

Prescribing of anticoagulation for atrial fibrillation in primary care

Atrial fibrillation (AF) is common in primary care patients. Many patients who could benefit from anticoagulation do not receive it. The objective of this study was to describe anticoagulation prescribing by primary care physicians. We conducted an observational study in the Cleveland Clinic Health System among patients with AF and ≥ 1 primary care appointment between 2015 and 2018 and their physicians. We estimated differences in the odds of an eligible patient receiving anticoagulation versus not and a DOAC versus warfarin using two mixed effects logistic regression models, adjusted for patient sociodemographic factors, history of falls or dementia, and CHA2DS2-VASc and HAS-BLED scores. We categorized physicians into prescribing tertiles, based on their adjusted prescribing rate, which we included as predictors in the models. Among 5253 patients, 47% received anticoagulation. Of those, 56% received a DOAC. CHA2DS2-VASc and HAS-BLED scores were not associated with anticoagulation prescription. Black race was negatively associated with receiving anticoagulation overall (aOR:0.71; 95%CI:0.56-0.89) and with prescription for a DOAC (aOR:0.65; 95%CI:0.45-0.93). Among 195 physicians, the anticoagulation prescribing rate ranged from 27% to 57% and DOAC rates ranged from 34% to 69%. Physician prescribing tertile was associated with odds of a patient receiving anticoagulation overall (aOR:1.51; 95%CI: 1.13-2.01 for the highest versus lowest tertile), but not DOAC prescriptions. When prescribing anticoagulation, physicians appear not to consider risk of stroke or bleeding but patient race is an important determinant. Seeing a physician with a high anticoagulation prescribing rate was strongly associated with a patient receiving it, suggesting a lack of individualization.

Impact of social determinants of health on anticoagulant use among patients with atrial fibrillation: Systemic review and meta-analysis

BACKGROUND

A growing body of literature now exists examining associations between social determinants of health (SDOH) and adverse outcomes in patients with atrial fibrillation; however, little is available on anticoagulant prescriptions and the impact of SDOH.

PURPOSE

Evaluate the impact of SDOH on anticoagulant prescriptions in patients with atrial fibrillation.

DATA SOURCES

Medline and Embase databases up to January 2021.

STUDY SELECTION

Noninterventional studies were included if they reported associations between at least 1 of 14 SDOH domains and anticoagulant prescription in patients with atrial fibrillation. Two investigators independently screened and collected data.

DATA EXTRACTION

Two investigators independently screened and collected data.

DATA SYNTHESIS

Meta-analyses using random-effect models evaluated associations between SDOH and receiving an anticoagulant prescription. We included 13 studies, 11 of which were included in meta-analyses that reported on the impact of 9 of the 14 SDOH included in the search. Pooled estimates indicate a 0.85 (95% confidence interval [CI]: 0.75, 0.97) lower odds of receiving anticoagulant prescriptions among Black compared to non-Black patients (reported in 6 studies); 0.42 (95% CI: 0.32, 0.55) lower odds of receiving anticoagulant prescriptions among patients with mental illness compared to those without mental illness (2 studies); and a 0.64 (95% CI: 0.42, 0.96) lower likelihood of receiving oral anticoagulant prescription among employed patients compared to unemployed patients (2 studies).

LIMITATIONS

SDOH lack consistent definitions and measures within the electronic health record.

CONCLUSION

The literature reports on only half of the SDOH domains we searched for, indicating that many SDOH are not routinely assessed. Second, social needs impact the decision to prescribe anticoagulants, confirming the need to screen for and address social needs in the clinical setting to support clinicians in providing guideline concordant care to their patients.

REGISTRATION

This systematic review and meta-analysis was registered with PROSPERO.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

The burden of undertreatment and non-treatment among patients with non-valvular atrial fibrillation and elevated stroke risk: a systematic review

OBJECTIVE

Global treatment guidelines recommend treatment with oral anticoagulants (OACs) for patients with non-valvular atrial fibrillation (NVAF) and an elevated stroke risk. However, not all patients with NVAF and an elevated stroke risk receive guideline-recommended therapy. A literature review and synthesis of observational studies were undertaken to identify the body of evidence on untreated and undertreated NVAF and the association with clinical and economic outcomes.

METHODS

An extensive search (1/2010-4/2020) of MEDLINE, the Cochrane Library, conference proceedings, and health technology assessments (HTAs) was conducted. Studies must have evaluated rates of nontreatment or undertreatment in NVAF. Nontreatment was defined as absence of OACs (but with possible antiplatelet treatment), while undertreatment was defined as treatment with only antiplatelet agents.

RESULTS

Sixteen studies met our inclusion criteria. Rates of nontreatment for patients with elevated stroke risk ranged from 2.0-51.1%, while rates of undertreatment ranged from 10.0-45.1%. The clinical benefits of anticoagulation were reported in the evaluated studies with reductions in stroke and mortality outcomes observed among patients treated with anticoagulants compared to untreated or undertreated patients. Adverse events associated with all bleeding types (i.e. hemorrhagic stroke, major bleeding or gastrointestinal hemorrhaging) were found to be higher for warfarin patients compared to untreated patients in real-world practice. Healthcare resource utilization was found to be lower among patients highly-adherent to warfarin compared to untreated patients.

CONCLUSIONS

Rates of nontreatment and undertreatment among NVAF patients remain high and are associated with preventable cardiovascular events and death. Strategies to increase rates of treatment may improve clinical outcomes.

Anticoagulation Control in Different Ethnic Groups Receiving Vitamin K Antagonist for Stroke Prevention in Atrial Fibrillation

Vitamin K antagonist such as warfarin reduces the risk of stroke in atrial fibrillation (AF) patients. Since warfarin has a narrow therapeutic index, its administration needs to be regularly monitored to avoid any adverse clinical outcomes such as stroke and bleeding. The quality of anticoagulation control with warfarin therapy can be measured by using time in therapeutic range (TTR). This review focuses on the prevalence of AF, quality of anticoagulation control (TTR) and adverse clinical outcome in AF patients within different ethnic groups receiving warfarin therapy for stroke prevention. A literature search was conducted in Embase and PubMed using keywords of “prevalence,” “atrial fibrillation,” “stroke prevention,” “oral anticoagulants,” “warfarin,” “ethnicities,” “race” “time in therapeutic range,” “adverse clinical outcome,” “stroke, bleeding.” Articles published by 1st February 2020 were included. Forty-one studies were included in the final review consisting of AF prevalence (n = 14 studies), time in therapeutic range (n = 18 studies), adverse clinical outcome (n = 9 studies) within different ethnic groups. Findings indicate that higher prevalence of AF but better anticoagulation control among the Whites as compared to other ethnicities. Of note, non-whites had higher risk of strokes and bleeding outcomes while on warfarin therapy. Addressing disparities in prevention and healthcare resource allocation could potentially improve AF-related outcomes in minorities.

Social determinants of atrial fibrillation

Atrial fibrillation affects almost 60 million adults worldwide. Atrial fibrillation is associated with a high risk of cardiovascular morbidity and death as well as with social, psychological and economic burdens on patients and their families. Social determinants - such as race and ethnicity, financial resources, social support, access to health care, rurality and residential environment, local language proficiency and health literacy - have prominent roles in the evaluation, treatment and management of atrial fibrillation. Addressing the social determinants of health provides a crucial opportunity to reduce the substantial clinical and non-clinical complications associated with atrial fibrillation. In this Review, we summarize the contributions of social determinants to the patient experience and outcomes associated with this common condition. We emphasize the relevance of social determinants and their important intersection with atrial fibrillation treatment and outcomes. In closing, we identify gaps in the literature and propose future directions for the investigation of social determinants and atrial fibrillation.

Stroke Prevention in Atrial Fibrillation

Atrial fibrillation (AF) is the commonest sustained cardiac rhythm disorder associated with an increased risk of stroke and systemic embolic events. The prevention of stroke using oral anticoagulants has been a pivotal component of AF management. The purpose of this review is to summarize recent advances in the treatment and prevention of stroke in AF over the last 5 years. We performed a comprehensive structured literature search using MEDLINE for publications from 11^th March 2015 through to 31^st December 2020. We focused mainly on primarily published research articles and systematic reviews including updates in different international guidelines. We found that improved awareness and detection of AF and use of clinical risk stratification are central to the identification of patients at risk of stroke who would benefit from oral anticoagulation. The recommendation of non-vitamin K antagonist oral anticoagulants over warfarin in both efficacy and safety perspective is represented in all international guidelines. Beyond stroke prevention, there is a move to more holistic or integrated care management of AF, which has been shown to improve outcomes. We conclude that stroke prevention remains a dominant part of the management of patients with AF. Not all stroke risk factors carry equal weight, and many require additional scrutiny (e.g. severity of CAD, type of diabetes, duration of hypertension). The utilization of clinical risk scores to help decision-making should take into account that these scores are mere simplification tools to aid decision-making and the additional clinical benefit with more complex risk scores and addition of biomarkers is limited. Also, stroke and bleeding risks are dynamic and require regular review. Instead of arbitrarily categorizing patients into (artificial) low, moderate, and high stroke risk strata, anticoagulation should be offered to all patients with AF unless they are low risk with no risk factors for stroke. Stroke prevention is also part of the proactive, integrated care approach to holistic management of patients with AF, which can be simplified in the ABC (Atrial fibrillation Better Care) pathway: 'A' Avoid stroke/Anticoagulation; 'B' Better symptom management emphasising patient-centred symptom directed decisions on rate or rhythm control strategies; and 'C' refers to Cardiovascular risk and comorbidity optimization, including lifestyle changes and attention to patient values and preferences, as well as the psychological morbidity associated with AF.

Racial and Sex Disparities in Anticoagulation After Electrical Cardioversion for Atrial Fibrillation and Flutter

Background Anticoagulation is indicated for 4 weeks after cardioversion in patients with atrial fibrillation/flutter. We sought to examine whether there is evidence of sex or racial disparity in anticoagulant prescription following cardioversion, and whether postcardioversion anticoagulation affects outcomes. Methods and Results We identified a representative sample of Medicare patients who underwent elective electric cardioversion in an outpatient setting from 2015 to 2017. We identified patients who had an anticoagulant prescription for 3 months after the cardioversion date. Multivariable logistic regression was used to assess factors associated with a prescription of an anticoagulant after cardioversion. Cox regression analysis was used to test association of anticoagulation with a composite end point of 90-day mortality, ischemic stroke, or arterial embolism. The final study cohort included 7860 patients. Overall, 5510 patients (70.1%) received any anticoagulation following cardioversion, while 2350 (29.9%) did not. Patients who did not receive anticoagulation were younger, with a lower burden of most comorbidities. Patients were less likely to receive anticoagulation if they had dementia or atrial flutter, while patients with valvular heart disease, obesity, heart failure, peripheral vascular or coronary disease, or hypertension were more likely to receive anticoagulation. Female sex (adjusted odds ratio, 0.84; 95% CI, 0.75-0.92; P<0.001), Black and Hispanic race (adjusted odds ratio, 0.50; 95% CI, 0.38-0.65; and odds ratio, 0.56; 95% CI, 0.41-0.75, respectively; P<0.001) were independently associated with lower probability of anticoagulant prescription. Postcardioversion anticoagulation was associated with lower risk of the composite end point (adjusted hazard ratio, 0.38; 95% CI, 0.27-0.52; P<0.001). Conclusions Racial and sex disparities exist in anticoagulant prescription after outpatient elective cardioversion for atrial fibrillation.

Successful modeling of long term outcomes in end-stage renal disease patients undergoing percutaneous coronary intervention with drug-eluting stents

OBJECTIVES

The objective of this study is to identify and model risk factors for major adverse cardiac events (MACE) and all-cause mortality among patients with ESRD treated with PCI using DES.

BACKGROUND

Patients with end-stage renal disease (ESRD) have poor long-term outcomes after percutaneous coronary intervention (PCI) compared with non-ESRD patients. However, there is a paucity of literature regarding risk factors associated with outcomes of ESRD patients after PCI with drug-eluding stents (DES).

METHODS

This retrospective cohort study includes all patients with ESRD who underwent first-time PCI with DES at a single, high-volume hospital between 1/1/2005 and 12/31/2015, with follow-up through 9/1/2019. Primary outcomes were MACE (cardiac death, myocardial infarction, or unplanned revascularization) and all-cause mortality.

RESULTS

Five-year MACE was 83.0% and five-year morality was 77.9% in patients with ESRD (n = 285). Among ESRD patients, factors independently associated with MACE were C-reactive peptide level, SYNTAX score, peripheral vascular occlusive disease, hemoglobin, and treatment of a restenotic lesion (c-index = 0.66). Factors independently associated with mortality in ESRD patients were age, SYNTAX score, non-use of statins at baseline, insulin-dependent diabetes, chronic obstructive pulmonary disease (COPD), peripheral vascular occlusive disease, and platelet count (c-index = 0.65).

CONCLUSIONS

Despite relatively poor 1-and 5-year outcomes among ESRD patients after PCI, risk of MACE and mortality among this cohort can be successfully modelled, which meaningfully informs clinicians regarding management of ESRD patients with coronary artery disease (CAD). Further investigations are necessary to determine whether or not outcomes might be improved through risk profile modification.

Evaluation of the Risk of Stroke Without Anticoagulation Therapy in Men and Women With Atrial Fibrillation Aged 66 to 74 Years Without Other CHA2DS2-VASc Factors

Importance

There are limited clinical trial data and discrepant recommendations regarding use of anticoagulation therapy in patients with atrial fibrillation (AF) aged 65 to 74 years without other stroke risk factors.

Objectives

To evaluate the risk of stroke without anticoagulation therapy in men and women with AF aged 66 to 74 years without other CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, stroke, vascular disease, age 65-74 years, female sex) risk factors and examine the association of stroke incidence with patient age.

Design, Setting, and Participants

A population-based retrospective cohort study was conducted using linked administrative databases. The population included 16 351 individuals aged 66 to 74 years who were newly diagnosed with AF in Ontario, Canada, between April 1, 2007, and March 31, 2017. Exclusion criteria included long-term care residence, prior anticoagulation therapy, valvular disease, heart failure, hypertension, diabetes, stroke, and vascular disease. The cumulative incidence function was used to estimate the 1-year incidence of stroke in patients who did not receive anticoagulation therapy. Fine-Gray regression was used to study the association of patient characteristics with stroke incidence and derive estimates of stroke risk at each age. Death was treated as a competing risk and patients were censored if they initiated anticoagulation therapy. Inverse probability of censoring weights was used to account for patient censoring. Data analysis was performed from May 26, 2019, to December 9, 2020.

Exposures

Atrial fibrillation and age.

Main Outcomes and Measures

Hospitalizations for stroke.

Results

Of the 16 351 individuals with AF (median [interquartile range] age, 70 [68-72] years), 8352 (51.1%) were men; 6314 individuals (38.6%) started anticoagulation therapy during follow-up. The overall 1-year stroke incidence among patients who did not receive anticoagulation therapy was 1.1% (95% CI, 1.0%-1.3%) and the incidence of death without stroke was 8.1% (95% CI, 7.7%-8.5%). The incidence of stroke was not significantly associated with sex. The estimated 1-year stroke risk increased with patient age from 66 years (0.7%; 95% CI, 0.5%-0.9%) to 74 years (1.7%; 95% CI, 1.3%-2.1%).

Conclusions and Relevance

The risk of stroke more than doubled in this study as men and women with AF but no other CHA2DS2-VASc risk factors aged from 66 to 74 years. These data suggest that anticoagulation therapy is more likely to benefit older individuals within this group of patients, whereas younger individuals are less likely to gain net clinical benefit from anticoagulation therapy.

A Review of Biomarkers for Ischemic Stroke Evaluation in Patients With Non-valvular Atrial Fibrillation

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia worldwide and results in a significantly increased ischemic stroke (IS) risk. IS risk stratification tools are widely being applied to guide anticoagulation treatment decisions and duration in patients with non-valvular AF (NVAF). The CHA₂DS₂-VASc score is largely validated and currently recommended by renowned guidelines. However, this score is heavily dependent on age, sex, and comorbidities, and exhibits only moderate predictive power. Finding effective and validated clinical biomarkers to assist in personalized IS risk evaluation has become one of the promising directions in the prevention and treatment of NVAF. A number of studies in recent years have explored differentially expressed biomarkers in NVAF patients with and without IS, and the potential role of various biomarkers for prediction or early diagnosis of IS in patients with NVAF. In this review, we describe the clinical application and utility of AF characteristics, cardiac imaging and electrocardiogram markers, arterial stiffness and atherosclerosis-related markers, circulating biomarkers, and novel genetic markers in IS diagnosis and management of patients with NVAF. We conclude that at present, there is no consensus understanding of a desirable biomarker for IS risk stratification in NVAF, and enrolling these biomarkers into extant models also remains challenging. Further prospective cohorts and trials are needed to integrate various clinical risk factors and biomarkers to optimize IS prediction in patients with NVAF. However, we believe that the growing insight into molecular mechanisms and in-depth understanding of existing and emerging biomarkers may further improve the IS risk identification and guide anticoagulation therapy in patients with NVAF.

Racial and ethnic differences in left atrial appendage occlusion wait time, complications, and periprocedural management

PURPOSE

Non-white patients are underrepresented in left atrial appendage occlusion (LAAO) trials, and racial disparities in LAAO periprocedural management are unknown.

METHODS

We assessed sociodemographics and comorbidities of consecutive patients at our institution undergoing LAAO between 2015 and 2020, then in adjusted analyses, compared procedural wait time, procedural complications, and post-procedure oral anticoagulation (OAC) use in whites versus non-whites.

RESULTS

Among 109 patients undergoing LAAO (45% white), whites had lower CHA₂ DS₂ VASc scores, on average, than non-whites (4.0 vs. 4.8, p = .006). There was no difference in median time from index event (IE) or initial outpatient cardiology encounter to LAAO procedure (whites 10.5 vs. non-whites 13.7 months, p = .9; 1.9 vs. 1.8 months, p = .6, respectively), and there was no difference in procedural complications (whites 4% vs. non-whites 5%, p = .33). After adjusting for CHA₂ DS₂ VASc score, OAC use at discharge tended to be higher in whites (OR 2.4, 95% CI [0.9-6.0], p = .07). When restricting the analysis to those with prior gastrointestinal (GI) bleed, adjusting for CHA₂ DS₂ VASc score and GI bleed severity, whites had a nearly five-fold odds of being discharged on OAC (OR 4.6, 95% CI [1-21.8], p = 0.05). The association between race and discharge OAC was not mediated through income category (total mediation effect 19% 95% CI [-.04-0.11], p = .38).

CONCLUSION

Despite an increased prevalence of comorbidities amongst non-whites, wait time for LAAO and procedural complications were similar in whites versus non-whites. Among those with prior GI bleed, whites were nearly five-fold more likely to be discharged on OAC than non-whites, independent of income.

Racial Disparities in In-Hospital Adverse Events Among Patients With Atrial Fibrillation Implanted With a Watchman Left Atrial Appendage Occlusion Device: A US National Perspective

[Figure: see text].

Incident Strokes Among American Indian Individuals With Atrial Fibrillation

BACKGROUND

American Indian individuals experience a relatively high risk for cardiovascular disease and have exhibited a higher risk of stroke compared with other racial and ethnic minorities. Although this population has the highest incidence of atrial fibrillation (AF) compared with other groups, the relationship between AF and nonhemorrhagic stroke among American Indian individuals compared with other groups has not been thoroughly studied.

METHODS and RESULTS

We used the Healthcare Cost and Utilization Project to evaluate risk of nonhemorrhagic stroke among American Indian individuals, with comparisons to White, Black, Hispanic, and Asian individuals, among all adult California residents receiving care in an emergency department, inpatient hospital unit, or ambulatory surgery setting from 2005 to 2011. Of 16 951 579 patients followed for a median 4.1 years, 105 822 (0.6%) were American Indian. After adjusting for age, sex, income level, insurance payer, hypertension, diabetes mellitus, coronary artery disease, congestive heart failure, cardiac surgery, valvular heart disease, chronic kidney disease, smoking, obstructive sleep apnea, pulmonary disease, and alcohol use, American Indian individuals with AF exhibited the highest risk of nonhemorrhagic stroke when compared with either non‐American Indian individuals with AF (hazard ratio, 1.38; 95% CI, 1.23–1.55; P<0.0001) or to each race and ethnicity with AF. American Indian individuals also experienced the highest overall risk for stroke, with no evidence that AF disproportionately heightened that risk in interaction analyses.

CONCLUSIONS

American Indian individuals experienced the highest risk of nonhemorrhagic stroke, whether in the presence or absence of AF. Our findings likely suggest an opportunity to further study, if not immediately address, guideline‐adherent anticoagulation prescribing patterns among American Indian individuals with AF.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Racial differences in the incidence of atrial fibrillation after cryptogenic stroke

BACKGROUND

The incidence of atrial fibrillation (AF) is lower in nonwhites than in whites despite a higher burden of AF risk factors. However, the incidence of new AF after cryptogenic stroke in minorities is unknown.

OBJECTIVE

The purpose of this study was to determine the incidence of AF after cryptogenic stroke in different racial/ethnic groups.

METHODS

We retrospectively analyzed 416 consecutive patients undergoing insertable cardiac monitor implantation at our hospital from 2014 through 2019. Incidence of AF was identified through the review of device monitoring, including adjudication of AF episodes for accuracy, and compared by race.

RESULTS

The mean follow-up time was 1.5 ± 1.1 years. The predominantly nonwhite cohort included 244 (59%) blacks and 109 (26%) Hispanics, and 45% (n=189) were male. The mean age was 62 ± 12 years; Blacks and Hispanics had more hypertension, diabetes, and chronic kidney disease and higher body mass index than did whites. In blacks and Hispanics, the cumulative incidences of AF at 1, 2, and 3 years were 14.1%, 19.9%, and 24% and 12.9%, 18.3%, and 20.9%, respectively. By comparison, the incidence in whites was significantly higher: 20.8%, 34.3%, and 40.3%. In a Cox proportional hazards model adjusting for common AF risk factors, blacks (hazard ratio 0.49; confidence interval 0.26-0.82; P = .03) and Hispanics (hazard ratio 0.39; confidence interval 0.18-0.83; P = .01) were less likely to have incident AF than whites.

CONCLUSION

In patients with an insertable cardiac monitor after cryptogenic stroke, the incidence of newly detected AF is approximately double in whites compared with both blacks and Hispanics. This has important implications for the investigation and treatment of nonwhites with cryptogenic stroke.

Thromboembolic Risk in Atrial Fibrillation Patients With Left Atrial Scar Post-Extensive Ablation: A Single-Center Experience

OBJECTIVES

This study evaluated the association of the post-ablation scar with stroke risk in patients undergoing atrial fibrillation (AF) ablation.

BACKGROUND

Late gadolinium enhancement-cardiac magnetic resonance studies have reported a direct association between pre-ablation left atrial scar and thromboembolic events in patients with AF.

METHODS

Consecutive patients with AF were classified into 2 groups based on the type of ablation performed at the first procedure. Group 1 involved limited ablation (isolation of pulmonary veins, left atrial posterior wall, and superior vena cava); and group 2 involved extensive ablation (limited ablation + ablation of nonpulmonary vein triggers from all sites except left atrial appendage). During the repeat procedure, post-ablation scar (region with bipolar voltage amplitude <0.5 mV) was identified by using 3-dimensional voltage mapping.

RESULTS

A total of 6,297 patients were included: group 1, n = 1,713; group 2, n = 4,584. Group 2 patients were significantly older and had more nonparoxysmal AF. Nineteen (0.3%) thromboembolic events were reported after the first ablation procedure: 9 (1.02%) in group 1 and 10 (0.61%) in group 2 (p = 0.26). At the time of the event, all 19 patients were experiencing arrhythmia. Median time to stroke was 14 (interquartile range: 9 to 20) months in group 1 and 14.5 (interquartile range: 8 to 18) months in group 2. Post-ablation scar data were derived from 2,414 patients undergoing repeat ablation. Mean scar area was detected as 67.1 ± 4.6% in group 2 and 34.9 ± 8.8% in group 1 at the redo procedure (p < 0.001).

CONCLUSIONS

Differently from the cardiac magnetic resonance-detected pre-ablation scar, scar resulting from extensive ablation was not associated with increased risk of stroke compared with that from the limited ablation.

Antithrombotic management of patients with atrial fibrillation-Dutch anticoagulant initiatives anno 2020

In recent years, as more and more experience has been gained with prescribing direct oral anticoagulants (DOACs), new research initiatives have emerged in the Netherlands to improve the safety and appropriateness of DOAC treatment for stroke prevention in patients with atrial fibrillation (AF). These initiatives address several contemporary unresolved issues, such as inappropriate dosing, non-adherence and the long-term management of DOAC treatment. Dutch initiatives have also contributed to the development and improvement of risk prediction models. Although fewer bleeding complications (notably intracranial bleeding) are in general seen with DOACs in comparison with vitamin K antagonists, to successfully identify patients with high bleeding risk and to tailor anticoagulant treatment accordingly to mitigate this increased bleeding risk, is one of the research aims of recent and future years. This review highlights contributions from the Netherlands that aim to address these unresolved issues regarding the anticoagulant management in AF in daily practice, and provides a narrative overview of contemporary stroke and bleeding risk assessment strategies.

How Will Machine Learning Inform the Clinical Care of Atrial Fibrillation?

Machine learning applications in cardiology have rapidly evolved in the past decade. With the availability of machine learning tools coupled with vast data sources, the management of atrial fibrillation (AF), a common chronic disease with significant associated morbidity and socioeconomic impact, is undergoing a knowledge and practice transformation in the increasingly complex healthcare environment. Among other advances, deep-learning machine learning methods, including convolutional neural networks, have enabled the development of AF screening pathways using the ubiquitous 12-lead ECG to detect asymptomatic paroxysmal AF in at-risk populations (such as those with cryptogenic stroke), the refinement of AF and stroke prediction schemes through comprehensive digital phenotyping using structured and unstructured data abstraction from the electronic health record or wearable monitoring technologies, and the optimization of treatment strategies, ranging from stroke prophylaxis to monitoring of antiarrhythmic drug (AAD) therapy. Although the clinical and population-wide impact of these tools continues to be elucidated, such transformative progress does not come without challenges, such as the concerns about adopting black box technologies, assessing input data quality for training such models, and the risk of perpetuating rather than alleviating health disparities. This review critically appraises the advances of machine learning related to the care of AF thus far, their potential future directions, and its potential limitations and challenges.

Incidence of Atrial Fibrillation in African Americans post Atrial Flutter Ablation

Background

African Americans have a lower incidence of atrial arrhythmias both atrial fibrillation (AF) and atrial flutter (AFL) despite having a greater number of traditional risk factors. The incidence of atrial fibrillation after cavotricuspid isthmus (CTI) ablation in patients with typical AFL is markedly increased approaching 40% in some studies. It is unknown if African Americans specifically have a similar rate of increased AF after CTI ablation for typical AFL.We sought to identify differences in development of AF after CTI ablation for typical AFL with regards to race, between African American and non- African Americans. The hypothesis is that African Americans will have a lower incidence of AF after CTI ablation for typical AFL.

Methods

The electronic medical records of first time, successful CTI ablations performed for typical (AFL) were retrospectively reviewed over a 48 month period. Clinical variables were retrieved from the EMR. AFL was documented on ECG, Holter/ event monitor or device interrogation at clinical follow up visits. Follow up was obtained over a 1 year period. Patients were self-identified as African American, White, Hispanic or Other.

Results

The records of a total of 201 patients - 51 African Americans (25.4%) and 150 non-African Americans (74.6%) - who underwent CTI ablation for typical AFL were examined. Average age was similar (67.8 vs 66.3, p=NS) with a preponderance of men (77.6% vs 23.5%). There was a significantly lower rate of development of AF post CTI ablation for typical AFL in African Americans vs non-African Americans (22.2% vs 46.6%, p=0.002). Additionally, women were more likely to develop AF (53.1% vs 36.2%, p=0.026). African American men were the least likely to develop AF post AFL ablation (p=0.0062).

Conclusions

We observed a significantly lower incidence of AF among African American patients after CTI ablation for typical AFL.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Racial Differences in Atrial Fibrillation Epidemiology, Management, and Outcomes

PURPOSE OF THE REVIEW

Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice and is associated with significant morbidity and healthcare cost. Most of the AF studies have predominantly included white population, with under-representation of minority population. In this review, we analyze the racial differences in epidemiology, disease awareness, risk factors, genetics, treatments, and outcomes of AF.

RECENT FINDINGS

African Americans have a higher prevalence of established AF risk factors but lower incidence and prevalence of AF than non-Hispanic whites. There is also a significant racial and ethnic differences in the prevalence of AF-related symptoms and the detection and awareness of AF. Non-white patients are afforded decreased use of rhythm control treatment strategies and anticoagulation both with warfarin and NOACs for stroke prevention. They are less likely to receive catheter ablation (CA) of AF, compared with non-Hispanic whites. AF in the minority racial and ethnic groups carries increased morbidity and mortality compared with white groups, especially in the black individuals with AF, who have been shown to have a lower QoL compared with their white or Hispanic counterparts. Minorities experience stroke more frequently than the whites which is usually more severe and disabling. There are significant racial differences in AF risk factors, manifestations, management, and outcomes. Recognition of these differences will aid in developing better preventive and treatment strategies for AF to decrease morbidity and mortality. In addition, this knowledge will enhance our understanding regarding the pathophysiology of AF including genetic predisposition.

Ischemic Stroke Risk in Patients With Nonvalvular Atrial Fibrillation: JACC Review Topic of the Week

The last decade has witnessed remarkable advances in pharmacological and nonpharmacological strategies for stroke prevention in patients with atrial fibrillation. However, the currently available clinical stroke risk prediction models do not account for key nonclinical factors (arrhythmia burden, left atrial physiology and anatomy, chemical and electrocardiographic markers) and other competing clinical risks. Hence, their ability to identify patients who will derive the most benefit from pharmacological and mechanical risk prevention strategies remain limited. In this paper, the authors review the current and evolving ischemic stroke risk prediction schemes in patients with nonvalvular atrial fibrillation, highlight the strengths and weaknesses of the models, and discuss the unmet needs in this field.

Stroke Risk in Atrial Fibrillation: Beyond the CHA2DS2-VASc Score

PURPOSE OF REVIEW

Stroke prevention is the cornerstone of atrial fibrillation (AF) management and the anticoagulation decision is currently based on CHA₂DS₂-VASc risk score. We discuss several novel risk factors besides those included in CHA₂DS₂-VASc score and alternative models for stroke prediction.

RECENT FINDINGS

Several clinical markers including obstructive sleep apnea and renal failure, laboratory markers like brain natriuretic peptide, imaging criteria including left atrial appendage morphology, spontaneous echo contrast, and coronary artery calcium score may predict stroke in AF patients. Addition of African American ethnicity to CHA₂DS₂-VASc score also improves stroke prediction in AF. Finally, novel models including TIMI-AF score, ATRIA score, and GARFIELD-AF scores have potential roles in risk stratification for stroke. While CHA₂DS₂-VASc score is the currently recommended risk stratification model for stroke prediction in AF, use of additional clinical, laboratory, imaging markers, ethnicity, and novel stroke prediction models may further assist in decision to anticoagulate the AF patient for stroke prevention.

Discriminative Ability of CHA2DS2-VASc and HAS-BLED Score in Whites and Nonwhites

The CHA₂DS₂-VASc and HAS-BLED scoring systems are used in patients with atrial fibrillation (AF) to estimate risk of stroke and bleeding, respectively. Both were developed in minimally diverse European populations and these scores have not yet been extensively studied in US whites and nonwhites. In a retrospective cohort study, we included patients with AF who received inpatient or outpatient care in a large integrated academic health system from 2011 to 2017. Cox proportional hazards were used to analyze associations between stroke and CHA₂DS₂-VASc score in AF patients not prescribed anticoagulation and between incident bleeding and HAS-BLED score in anticoagulated patients. After exclusions for previous stroke, the cohort included 21,648 patients with a mean age of 66.8 ± 15.8. Anticoagulation was prescribed in 52% of whites and 46% of nonwhites (p < 0.001) with a CHA₂DS₂-VASc score of ≥2. Mean CHA₂DS₂-VASc scores were 2.4 ± 1.6 in whites and 2.2 ± 1.6 in nonwhites and mean HAS-BLED scores was 1.5 ± 1.1 in whites and 1.3 ± 1.0 in nonwhites. After adjusting for baseline differences, the discriminative ability of CHA₂DS₂-VASc and HAS-BLED was similar in whites and nonwhites (p = 0.52, 0.33, respectively). The discriminative ability of HAS-BLED was similar in patients on vitamin K antagonists and direct oral anticoagulants. In conclusion, oral anticoagulation was prescribed less frequently in nonwhites. However, the discriminative ability of CHA₂DS₂-VASc and HAS-BLED were similar in whites and nonwhites.

Stroke risk stratification in atrial fibrillation: a review of common risk factors

Atrial Fibrillation (AF) has become a major global health concern being the most common sustained arrhythmia in clinical practice. Risk factors for AF include congestive heart failure, hypertension, increasing age and diabetes. Many of these factors also increase the risk for thromboembolism and ischemic stroke in AF patients. Great efforts have been made from the latter part of the 20th century towards developing an ideal stroke risk stratification tool in AF with the aim of reducing the incidence of stroke in AF patients and the limiting unnecessary use of thromboprophylaxis. The thromboembolic risks posed by AF with valvular heart disease are an important subgroup that contributes to a significant proportion of stroke in AF patients globally. We review the evolution of stroke risk stratification and summarize the guidelines for stroke prevention in non-valvular AF as well as AF with valvular heart disease, and the most recent recommendations on stroke prevention in AF patients. Abbreviations: AF: Atrial Fibrillation; ACS: Acute Coronary Syndrome; CAD: Coronary Artery Disease; CCF: Congestive Cardiac Failure; DM: Diabetes Mellitus; EHRA: Evaluated Heartvalves, Rheumatic or Artificial; ICH: Intracranial Hemorrhage; NOACs: Novel Oral Anticoagulants; OAC: Oral Anticoagulants; PAD: Peripheral Arterial Disease ; TIA: Transient Ischemic Attack; VHD: Valvular Heart Disease.

CHA2DS2-VASc Score and Stroke Prediction in Atrial Fibrillation in Whites, Blacks, and Hispanics

Background and Purpose- Despite modest predictive ability for ischemic stroke (IS), the CHA₂DS₂-VASc score is widely used for stroke prediction in atrial fibrillation. Among patients with atrial fibrillation, we aimed to (1) compare the IS or transient ischemic attack (TIA) incidence by CHA₂DS₂-VASc in blacks and Hispanics versus whites; (2) compare predictive ability of CHA₂DS₂-VASc score for IS or TIA in blacks and Hispanics versus whites; and (3) determine improvement in predictive ability of CHA₂DS₂-VASc score from addition of race/ethnicity. Methods- Using data from Optum Clinformatics, a large administrative claims database, we analyzed patients with atrial fibrillation enrolled in commercial and Medicare Advantage health plans from 2009 to 2015. We computed IS or TIA incidence rates, improvement in C statistic, continuous and categorical net reclassification improvement, and relative integrated discrimination improvement from addition of race/ethnicity to CHA₂DS₂-VASc. Results- A total of 267 419 patients (mean age, 73.1 [SD, 12.3] years; 46.6% women; 84.2% white, 8.5% black, 7.3% Hispanic) were studied. After a mean follow-up of 22 months, there were 6202 IS or TIA events. IS or TIA incidence rates were higher in blacks than Hispanics or whites (1.65, 1.40, and 1.22 cases per 100 person-years, respectively) and increased with higher CHA₂DS₂-VASc, with no race/ethnicity-based differences (P for interaction=0.17). The CHA₂DS₂-VASc and CHA₂DS₂-VASc+race/ethnicity C statistic (95% CI) were 0.679 (0.670-0.686) and 0.679 (0.671-0.688). The CHA₂DS₂-VASc C statistic in the 3 groups were comparable. With addition of race/ethnicity, the categorical net reclassification improvement, continuous net reclassification improvement, and relative integrated discrimination improvement were -0.045 (95% CI, -0.067 to -0.025), 0.045 (95% CI, 0.025-0.068), and 0.016 (95% CI, 0.014-0.018). Conclusions- The predictive ability of CHA₂DS₂-VASc for IS or TIA in atrial fibrillation is comparable among whites, blacks, and Hispanics; hence, it can be used in the latter 2 groups. Addition of race/ethnicity to the CHA₂DS₂-VASc does not improve its predictive ability.

Race and stroke in an atrial fibrillation inception cohort: Findings from the Penn Atrial Fibrillation Free study

BACKGROUND

Stroke may be the initial manifestation of atrial fibrillation (AF). Limited studies, however, have evaluated racial differences in stroke before the diagnosis of AF.

OBJECTIVE

We assessed racial differences in strokes that occurred before and after AF diagnosis in the Penn Atrial Fibrillation Free study.

METHODS

The Penn Atrial Fibrillation Free study consists of 56,835 patients from the University of Pennsylvania Health System who were free of AF at the index visit. We developed an inception cohort of 3507 patients with incident AF and without any remote history of stroke.

RESULTS

Among the AF inception cohort, there were 538 patients with ischemic strokes and 54 with hemorrhagic strokes. Nearly half (n = 254; 47%) of the ischemic strokes occurred within a 6-month period before the diagnosis of AF. Of these, the majority of strokes occurred either on the day of (n = 158) or within a 7-day period before (n = 30) the diagnosis of incident AF. The remaining 284 (53%) ischemic strokes occurred a median of 3.6 years (interquartile range 1.9-5.4 years) after AF diagnosis. Compared with whites, blacks had an independently higher risk of having an ischemic stroke either before (adjusted odds ratio 1.37; 95% confidence interval 1.03-1.81) or after (adjusted hazard ratio 1.67; 95% confidence interval 1.30-2.14) AF diagnosis.

CONCLUSION

In the population with incident AF, nearly half of the ischemic strokes occurred before the diagnosis of AF. Compared with whites, blacks had a higher risk of developing an ischemic stroke that persisted whether the stroke occurred in the period either before or after AF diagnosis.

Pharmacological and Non-pharmacological Treatments for Stroke Prevention in Patients with Atrial Fibrillation

Atrial fibrillation (AF) is associated with significant risk of stroke and other thromboembolic events, which can be effectively prevented using oral anticoagulation (OAC) with either vitamin K antagonists (VKAs) or non-VKA oral anticoagulants (NOACs) dabigatran, rivaroxaban, apixaban, or edoxaban. Until recently, VKAs were the only available means for OAC treatment. NOACs had similar efficacy and were safer than or as safe as warfarin with respect to reduced rates of hemorrhagic stroke or other intracranial bleeding in the respective pivotal randomized clinical trials (RCTs) of stroke prevention in non-valvular AF patients. Increasing “real-world” evidence on NOACs broadly confirms the results of the RCTs. However, individual patient characteristics including renal function, age, or prior bleeding should be taken into account when choosing the OAC with best risk–benefit profile. In patients ineligible for OACs, surgical or interventional stroke prevention strategies should be considered. In patients undergoing cardiac surgery for other reasons, the left atrial appendage excision, ligation, or amputation may be the best option. Importantly, residual stumps or insufficient ligation may result in even higher stroke risk than without intervention. Percutaneous left atrial appendage occlusion, although requiring minimally invasive access, failed to demonstrate reduced ischemic stroke events compared to warfarin. In this review article, we summarize current treatment options and discuss the strengths and major limitations of the therapies for stroke risk reduction in patients with AF.

Impact of race and gender on clinical outcomes of catheter ablation in patients with atrial fibrillation

BACKGROUND

Radiofrequency catheter ablation (CA) is an effective treatment of drug-refractory atrial fibrillation (AF). However, the efficacy of CA by race and gender has not been well characterized. We sought to determine the impact of ethnicity and gender on clinical outcome following CA in patients with AF.

METHODS

Patients who underwent CA for AF from September 2013 to April 2016 were included in this study. Patients were identified retrospectively and followed prospectively.

RESULTS

A total of 118 patients (15.3% black and 78.8% white, 33% female) comprised the cohort, with mean age at ablation 63.4 ± 10.4 years. Black patients were older at time of the procedure (65.4 vs 63.4 years old) and had more prevalent comorbidities, including hypertension (77.8% vs 63.4%), diabetes (33.3% vs 15.0%), chronic kidney disease (22.2% vs 7.5%), and lower left ventricular ejection fraction (51.8% vs 56.2%). Blacks also had significantly larger left atrial size (P  =  0.03). Late recurrence of AF was similar between blacks and whites (33.3% vs 34.4%, P  =  1) as well as between women and men (28.2% vs 36.7%, P  =  0.41). Early recurrence was predictive of late recurrence in men (P < 0.001) but not in women (P  =  0.48). Enlarged left atrium and early recurrence of AF were significant predictors for late recurrence of AF in the cohort.

CONCLUSIONS

CA for AF is equally effective in black patients despite more prevalent comorbidity and increased left atrial size. Early recurrence of AF after CA was not predictive of late recurrence of AF in women but was in men.

CHA 2 DS 2 -VASc Score (Congestive Heart Failure, Hypertension, Age ≥75 [Doubled], Diabetes Mellitus, Prior Stroke or Transient Ischemic Attack [Doubled], Vascular Disease, Age 65–74, Female) for Stroke in Asian Patients With Atrial Fibrillation

Background and Purpose—

The CHA 2 DS 2 -VASc stroke score (congestive heart failure, hypertension, age ≥75 (doubled), diabetes mellitus, prior stroke or transient ischemic attack (doubled), vascular disease, age 65–74, female) is used in most guidelines for risk stratification in atrial fibrillation (AF), but most data for this score have been derived in Western populations. Ethnic differences in stroke risk may be present. Our objective was to investigate risk factors for stroke in AF and application of the CHA 2 DS 2 -VASc score in an Asian AF population from Korea.

Methods—

A total of 5855 oral anticoagulant–naive nonvalvular AF patients aged ≥20 years were enrolled from Korea National Health Insurance Service Sample cohort from 2002 to 2008 and were followed up until December 2013.

Results—

The incidence rates (per 100 person-years) of ischemic stroke were 3.32 in the total population, being 0.23 in low-risk (CHA 2 DS 2 -VASc score 0 [male] or 1 [female]) and 4.59 in high-risk patients (CHA 2 DS 2 -VASc ≥2). Incidence rates of ischemic stroke or the composite thromboembolism end point showed a clear increase with increasing CHA 2 DS 2 -VASc score. On multivariable analysis, significant associations between CHA 2 DS 2 -VASc risk factors and ischemic stroke were observed; however, the significance of vascular disease or diabetes mellitus was attenuated after multivariate adjustment, and female sex (hazard ratio, 0.73; 95% confidence interval, 0.64–0.84) had a lower risk of ischemic stroke than males. Patients who were categorized as low risk consistently had an event rate <1% per year.

Conclusions—

The performance of CHA 2 DS 2 -VASc score in Asians is comparable with that in Western populations. The score shows good performance in defining the truly-low-risk AF patients for stroke/thromboembolism.

Incorporating Stroke and Bleeding Risk Stratification Tools into Atrial Fibrillation Management Making Sense of the Alphabet Soup

Atrial fibrillation (AF) is a common arrhythmia managed by many physicians in a variety of clinical settings. One of the most important clinical decisions related to effective AF management centers upon the need to perform accurate thromboembolic risk stratification followed by effective management decisions that align with established guidelines. This manuscript will review the present state of the art and provide guidance to physicians to enhance patient outcomes.