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Liu L, Wu Z, Kong W, Qiu B, Wang Z, Sun J. Clinical features between paroxysmal and nonparoxysmal atrial fibrillation: a comparative analysis in eastern China. J Cardiothorac Surg 2024; 19:591. [PMID: 39367417 PMCID: PMC11451112 DOI: 10.1186/s13019-024-03097-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Accepted: 09/15/2024] [Indexed: 10/06/2024] Open
Abstract
BACKGROUND Atrial fibrillation (AF) has emerged as a notable public health issue in China due to the aging population and rapid urbanization. This study aimed to describe the characteristics of patients with AF (paroxysmal and nonparoxysmal) and investigate the association between left ventricular ejection fraction (LVEF) levels and AF subtypes to facilitate early prevention in patients with AF. METHOD Patients with AF who presented at the cardiology department of the First People's Hospital of Yancheng were recruited in this study. In univariate and multivariate logistic regression analyses, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to evaluate the relationships between each dependent variable and nonparoxysmal AF. The restricted cubic splines (RCS) curve was employed to explore the linear relationship between LVEF and nonparoxysmal AF on a continuous scale. Subgroup analysis was applied to examine the stability of the results. RESULTS The study included a total of 2054 patients who were diagnosed with AF. 652 (31.74%) patients had paroxysmal AF, and 1402 (68.26%) had nonparoxysmal AF. Multivariate logistic regression analyses indicated that compared to those with paroxysmal AF, patients with nonparoxysmal AF tended to have a higher prevalence of coronary artery disease, lower levels of LVEF, and an elevated heart rate. Additionally, RCS curves also showed that LVEF was negatively and linearly associated with the nonparoxysmal AF. Furthermore, the association between LVEF and nonparoxysmal AF was stronger among patients with hypertension and obesity (P for interaction < 0.05). CONCLUSIONS Patients with nonparoxysmal AF have a more advanced AF burden and the transition from paroxysmal to nonparoxysmal AF should be recognized in time, especially to treat the corresponding comorbidities (including hypertension and obesity) more consistently.
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Affiliation(s)
- Lipin Liu
- The Yancheng Clinical College of Xuzhou Medical University, Yancheng, 224001, China
- The First people's Hospital of Yancheng, Yancheng, 224001, China
| | - Zhuchao Wu
- Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
| | - Weiming Kong
- The Yancheng Clinical College of Xuzhou Medical University, Yancheng, 224001, China
- The First people's Hospital of Yancheng, Yancheng, 224001, China
| | - Beibei Qiu
- Department of Chronic Communicable Disease, Nanjing Municipal Center for Disease Control and Prevention, Nanjing, 210003, China
| | - Zhihua Wang
- The Yancheng Clinical College of Xuzhou Medical University, Yancheng, 224001, China.
- The First people's Hospital of Yancheng, Yancheng, 224001, China.
| | - Jian Sun
- The Yancheng Clinical College of Xuzhou Medical University, Yancheng, 224001, China.
- The First people's Hospital of Yancheng, Yancheng, 224001, China.
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Gu Z, Guo L, Liu C, Lip GYH, Zhu W. Real-world evidence of early rhythm control in patients with atrial fibrillation: A systematic review and meta-analysis. Int J Cardiol 2024; 412:132327. [PMID: 38964555 DOI: 10.1016/j.ijcard.2024.132327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/22/2024] [Accepted: 07/01/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND The favorable benefits of early rhythm control (ERC) therapy in newly diagnosed patients with atrial fibrillation (AF) have been demonstrated in the EAST-AFNET 4 trial. However, the generalizability and applicability of ERC in real-world clinical settings remain inconclusive. METHODS We conducted a systematic search of the PubMed and Embase databases to identify observational studies published between January 2020 and February 2024 that focused on real-world evidence pertaining to ERC. The effectiveness and safety outcomes in our study were analogous to those evaluated in the EAST-AFNET 4 trial. RESULTS A total of 4 observational studies that fulfilled the inclusion criteria of EAST-AFNET 4 were included, involving 130,970 patients with AF, 30.7% of whom received ERC therapy. In our pooled analysis using the fixed-effects model, compared with rate control, ERC significantly decreased the occurrence risk of the primary composite outcome (hazard ratio [HR] 0.86, 95% confidence interval[CI] 0.82-0.91), cardiovascular death (HR 0.87, 95% CI 0.78-0.98), stroke (HR 0.80, 95% CI 0.73-0.87), and hospitalization with worsening heart failure (HR 0.91, 95% CI 0.84-0.99) or acute coronary syndrome (HR 0.72, 95% CI 0.59-0.87). In terms of safety outcomes, there were no differences in the composite safety outcome (HR 1.00, 95% CI 0.95-1.05) and all-cause death (HR 0.93, 95% CI 0.82-1.06) between the two studied groups. CONCLUSIONS ERC therapy showed favorable effectiveness outcomes compared with rate control, whereas the safety outcomes between the two therapeutic strategies did not differ significantly, supporting the benefits of ERC therapy over rate control in selected real-world patients with AF. REGISTRATION The study protocol was registered to PROSPERO (CRD42023443569).
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Affiliation(s)
- Zhenbang Gu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Linjuan Guo
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Chen Liu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; NHC Key Laboratory of Assisted Circulation and Vascular Diseases (Sun Yat-sen University), Guangzhou, China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China.
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Wengen Zhu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
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Serna MJ, Rivera-Caravaca JM, López-Gálvez R, Soler-Espejo E, Lip GYH, Marín F, Roldán V. Dynamic assessment of CHA 2DS 2-VASc and HAS-BLED scores for predicting ischemic stroke and major bleeding in atrial fibrillation patients. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:835-842. [PMID: 38460882 DOI: 10.1016/j.rec.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 02/20/2024] [Indexed: 03/11/2024]
Abstract
INTRODUCTION AND OBJECTIVES Stroke and bleeding risks in atrial fibrillation (AF) are often assessed at baseline to predict outcomes years later. We investigated whether dynamic changes in CHA2DS2-VASc and HAS-BLED scores over time modify risk prediction. METHODS We included patients with AF who were stable while taking vitamin K antagonists. During a 6-year follow-up, all ischemic strokes/transient ischemic attacks (TIAs) and major bleeding events were recorded. CHA2DS2-VASc and HAS-BLED were recalculated every 2-years and tested for clinical outcomes at 2-year periods. RESULTS We included 1361 patients (mean CHA2DS2-VASc and HAS-BLED 4.0±1.7 and 2.9±1.2). During the follow-up, 156 (11.5%) patients had an ischemic stroke/TIA and 269 (19.8%) had a major bleeding event. Compared with the baseline CHA2DS2-VASc, the CHA2DS2-VASc recalculated at 2 years had higher predictive ability for ischemic stroke/TIA during the period from 2 to 4 years. Integrated discrimination improvement (IDI) and net reclassification improvement (NRI) showed improvements in sensitivity and better reclassification. The CHA2DS2-VASc recalculated at 4 years had better predictive performance than the baseline CHA2DS2-VASc during the period from 4 to 6 years, with an improvement in IDI and an enhancement of the reclassification. The recalculated HAS-BLED at 2-years had higher predictive ability than the baseline score for major bleeding during the period from 2 to 4 years, with significant improvements in sensitivity and reclassification. A slight enhancement in sensitivity was observed with the HAS-BLED score recalculated at 4 years compared with the baseline score. CONCLUSIONS In AF patients, stroke and bleeding risks are dynamic and change over time. The CHA2DS2-VASc and HAS-BLED scores should be regularly reassessed, particularly for accurate stroke risk prediction.
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Affiliation(s)
- María José Serna
- Servicio de Hematología y Oncología Médica, Hospital General Universitario Morales Meseguer, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - José Miguel Rivera-Caravaca
- Facultad de Enfermería, Universidad de Murcia, Murcia, Spain; Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), El Palmar, Murcia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
| | - Raquel López-Gálvez
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), El Palmar, Murcia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Eva Soler-Espejo
- Servicio de Hematología y Oncología Médica, Hospital General Universitario Morales Meseguer, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Denmark
| | - Francisco Marín
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), El Palmar, Murcia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Vanessa Roldán
- Servicio de Hematología y Oncología Médica, Hospital General Universitario Morales Meseguer, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
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Mei DA, Imberti JF, Bonini N, Romiti GF, Corica B, Proietti M, Vitolo M, Lip GYH, Boriani G. Performance of HAS-BLED and DOAC scores to predict major bleeding events in atrial fibrillation patients treated with direct oral anticoagulants: A report from a prospective European observational registry. Eur J Intern Med 2024; 128:63-70. [PMID: 38969571 DOI: 10.1016/j.ejim.2024.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 06/17/2024] [Accepted: 06/25/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND The DOAC score has been recently proposed for bleeding risk stratification of patients with atrial fibrillation treated with direct oral anticoagulants (DOAC). OBJECTIVE To compare the performance of HAS-BLED and DOAC score in predicting major bleeding events in a contemporary cohort of European AF patients treated with DOAC. METHODS We included patients derived from a prospective observational registry of European AF patients. HAS-BLED and DOAC scores were calculated as per the original schemes. Our primary endpoint was major bleeding events. Receiver operating characteristic (ROC) curves were used to compare the predictive ability of the scores. RESULTS A total of 2834 AF patients (median age [IQR] 69 [62-77] years; 39.6 % female) treated with DOAC were included in the analysis. According to the HAS-BLED score, 577 patients (20.4 %) were categorized as very low risk of bleeding, as compared to 1276 (45.0 %) according to DOAC score. A total of 55 major bleeding events occurred with an overall incidence of 1.04 per 100 patient-years. Both scores showed only a modest ability for the prediction of bleeding events (HAS-BLED area under the curve [AUC], 0.65, 95 % confidence interval [CI] 0.55-0.70; DOAC score AUC 0.62, 95 % CI 0.59-0.71, p for difference = 0.332]. At calibration analysis, the DOAC score showed modest calibration, especially for patients at high risk, when compared to HAS-BLED. CONCLUSION In a contemporary cohort of DOAC-treated AF patients, both HAS-BLED and DOAC scores only modestly predicted the occurrence of major bleeding events. Our results do not support the preferential use of DOAC score over HAS-BLED.
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Affiliation(s)
- Davide Antonio Mei
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, Modena, Modena 41121, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Jacopo Francesco Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, Modena, Modena 41121, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Niccolò Bonini
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, Modena, Modena 41121, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Translational and Precision Medicine, Sapienza - University of Rome, Italy
| | - Bernadette Corica
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, Modena, Modena 41121, Italy; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milani, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, Modena, Modena 41121, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, Modena, Modena 41121, Italy.
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Soler-Espejo E, Rivera-Caravaca JM. Navigating the bleeding risk dilemma in patients with atrial fibrillation on therapy with direct-acting oral anticoagulants: Comparing the HAS-BLED vs. DOAC Score. Eur J Intern Med 2024; 128:36-39. [PMID: 39068124 DOI: 10.1016/j.ejim.2024.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Accepted: 07/23/2024] [Indexed: 07/30/2024]
Affiliation(s)
- Eva Soler-Espejo
- Department of Hematology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - José Miguel Rivera-Caravaca
- Faculty of Nursing, University of Murcia, Murcia, Spain; Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain; Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
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Li M, Fauchier L, Lip GYH. Residual Stroke Risk in Patients With Atrial Fibrillation following Transcatheter Aortic Valve Implantation: What Else Can We Do to Mitigate Risk? Am J Cardiol 2024; 228:85-87. [PMID: 39059703 DOI: 10.1016/j.amjcard.2024.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Accepted: 07/22/2024] [Indexed: 07/28/2024]
Affiliation(s)
- Meng Li
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Cardiology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Li M, Chu M, Zhang S, Shen Y, Sun X, Gong J, Yang G, Shi J, Ding X, Gu Z, Li C, Zhang C, Xia Y, Wang Z, Lip GYH, Chen M. Is it high time to leave the chronic disease care of rural older people to village doctors in China: Insights from a population-based atrial fibrillation screening study. Curr Probl Cardiol 2024; 49:102759. [PMID: 39067720 DOI: 10.1016/j.cpcardiol.2024.102759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Accepted: 07/23/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVE No study has systematically investigated the quality of long-term care delivered to the rural older people with chronic diseases, such as atrial fibrillation (AF) in China. This study aims to provide contemporary data on the prevalence and awareness of AF among the older population in rural China and to evaluate healthcare knowledge and delivery by village doctors. DESIGN A cross-sectional study. SETTING Rural villages in Daqiao and Xiaoji towns of Jiangsu Province, China. PARTICIPANTS Rural population aged ≥65 years. OUTCOME MEASURES AF was identified using 12-lead electrocardiography in the first-step (government-led health examination) and single-lead electrocardiography in the second-step (in-house AF screening). Questionnaire surveys were designed for the AF patients and their village doctors. RESULTS Among 31,342 permanent residents, 12,630 (40.3 %) declined, 7,956 (25.3 %) participated in the first-step and 10,756 (34.3 %) in the second-step. The overall AF detection rate was 4.3 % (810/18,712). Of the 810 AF patients (mean age 76.1±5.9 years; 51.4 % female), 51.5 % were illiterate, only 2.6 % could use smartphone applications, and 8.1 % lived with their children. Common risk factors were older age, men, hypertension, diabetes, prior stroke, vascular disease, and congestive heart failure. Among the 402 patients with known AF, 367 were at high risk of stroke and 10.9 % (40/367) were anticoagulated. Only 17.6 % patients with known hypertension had blood pressure level <140/90 mmHg, and 6.0 % with known diabetes had a fasting blood glucose level ≤6.1 mmol/L. Only 7.3 % (9/122) village doctors reported having the knowledge of integrated care AF management. CONCLUSIONS This study identified AF in 4.3 %, but AF management was suboptimal in rural China. The current village doctor-dominant rural healthcare system is far from delivering standardized AF management for older patients in rural China. There is an urgent need to empower the village doctors in optimising the care of AF patients.
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Affiliation(s)
- Mingfang Li
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, China
| | - Ming Chu
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, China
| | - Shimeng Zhang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, China
| | - Youmei Shen
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, China
| | - Xingxing Sun
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, China
| | - Jinlong Gong
- Division of Cardiology, Jiangdu People's Hospital, China
| | - Gang Yang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, China
| | - Jiaojiao Shi
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, China
| | - Xiangwei Ding
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, China
| | - Zhoushan Gu
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, China
| | - Chengzong Li
- Division of Cardiology, The Affiliated Hospital of Xuzhou Medical University, China
| | - Chaoqun Zhang
- Division of Cardiology, The Affiliated Hospital of Xuzhou Medical University, China
| | - Yaodongqin Xia
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, China
| | - Zhirong Wang
- Division of Cardiology, The Affiliated Hospital of Xuzhou Medical University, China
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Minglong Chen
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, China.
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Soler-Espejo E, Rivera-Caravaca JM, Bru-Cánovas JD, Esteve-Pastor MA, Lip GYH, Marín F, Roldán V. Patients with atrial fibrillation and common exclusion criteria from clinical trials are at high risk of clinical events: the Murcia AF Project II (MAFP-II) cohort study. Intern Emerg Med 2024; 19:1941-1948. [PMID: 38965203 PMCID: PMC11467067 DOI: 10.1007/s11739-024-03701-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 06/29/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Some clinical characteristics and comorbidities in atrial fibrillation (AF) patients are exclusion criteria in randomized clinical trials (RCTs) investigating oral anticoagulants (OAC). However, these conditions are present also in everyday clinical practice patients. We compared the risk of adverse clinical outcomes between patients with and without RCT exclusion criteria. METHODS The Murcia AF Project II was an observational cohort study including AF outpatients starting vitamin K antagonists (VKAs) from July 2016 to June 2018. For the selection of the exclusion criteria, the four pivotal RCTs of direct-acting OAC (DOACs) were used as reference. During 2 years, all ischemic strokes/transient ischemic attacks, major adverse cardiovascular events (MACEs), major bleeds, and all-cause deaths were recorded. RESULTS 1050 patients (51.5% female, median age 77 years) were included, of whom 368 (35%) met at least one exclusion criterion for RCTs. During follow-up, the incidence rate ratios for major bleeding, MACE and all-cause mortality were higher among patients with exclusion criteria (all p < 0.001). Patients fulfilling at least one exclusion criterion had increased risks of major bleeding (aHR 1.48; 95% CI 1.22-1.81; p < 0.001), MACE (aHR 1.51, 95% CI 1.10-2.09, p = 0.012), and mortality (aHR 3.22, 95% CI 2.32-4.48, p < 0.001), as well as a lower event-free survival (all log-rank p < 0.001). CONCLUSIONS In this AF cohort taking VKAs, more than one-third had at least one RCT exclusion criteria, which translates into higher risk of major bleeding, MACE, and death. These observations should be considered when translating RCTs results to AF patients for a proper and a more patient-centered management.
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Affiliation(s)
- Eva Soler-Espejo
- Department of Hematology, Hospital Clínico Universitario Virgen de La Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - José Miguel Rivera-Caravaca
- Faculty of Nursing, University of Murcia, Murcia, Spain.
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK.
| | | | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de La Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Gregory Yoke Hong Lip
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de La Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Vanessa Roldán
- Department of Hematology, Hospital Clínico Universitario Virgen de La Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
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9
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Mills MT, Calvert P, Velavan P, Lip GYH, Gupta D. Concurrent percutaneous left atrial appendage occlusion and catheter ablation for atrial fibrillation: State-of-the-art review. Trends Cardiovasc Med 2024; 34:423-433. [PMID: 37981202 DOI: 10.1016/j.tcm.2023.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/08/2023] [Accepted: 11/14/2023] [Indexed: 11/21/2023]
Abstract
Stroke prevention and symptom control are two integral pillars in atrial fibrillation (AF) management. Percutaneous left atrial appendage occlusion (LAAO) is effective at reducing stroke risk in high-risk patients with AF who cannot tolerate oral anticoagulant therapy, whilst catheter ablation is effective at reducing AF burden and improving quality-of-life in patients who remain symptomatic despite medical therapy. If both procedures are indicated in an individual patient, they have traditionally been performed on separate occasions, due to long cumulative procedural times, itself associated with thromboembolic risk. Recently, with the advancement of procedural techniques, the concept of concurrent LAAO and AF catheter ablation has gained traction. This review summarises the evidence for and against concurrent LAAO and AF catheter ablation, discussing procedural considerations, including procedural sequencing and post-procedural antithrombotic therapy, safety and efficacy outcomes, and future directions in the field.
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Affiliation(s)
- Mark T Mills
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK
| | - Peter Calvert
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK
| | - Periaswamy Velavan
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK; Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK.
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Ishiguchi H, Abdul-Rahim AH, Huang B, Lam SHM, Liu Y, Olshansky B, Chao TF, Huisman MV, Lip GYH. Residual Risks of Thrombotic Complications in Anticoagulated Patients with Atrial Fibrillation: A Cluster Analysis Approach from the GLORIA-AF Registry. J Gen Intern Med 2024:10.1007/s11606-024-09045-6. [PMID: 39320586 DOI: 10.1007/s11606-024-09045-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 09/11/2024] [Indexed: 09/26/2024]
Abstract
BACKGROUND Assessment of residual thromboembolic risk in patients with atrial fibrillation (AF) prescribed oral anticoagulants (OACs) remains unexplored. We performed hierarchical cluster analysis to identify phenotypic profiles of these patients and their risks of residual thromboembolic events. METHODS We utilised data from non-valvular AF patients on OACs, as documented in phases II and III of the GLORIA-AF (Global Registry on Long-Term Oral Anti-thrombotic Treatment in Patients With Atrial Fibrillation) registry. We performed a hierarchical cluster analysis to identify distinct phenotypic profiles. We compared the incidence and risks of thromboembolic events (composite of ischaemic stroke, transient ischaemic attack, or systemic embolism) and related outcomes (major bleeding and all-cause death) across the profiles. We determined the optimal number of profiles through visual inspection of the generated dendrograms. RESULTS We included 22,410 patients (mean age 70 ± 8 years; 56% male), from which five phenotypes were identified: profile 1 ("uncontrolled hypertension"), profile 2 ("young with a history of coronary artery disease"), profile 3 ("young and obese"), profile 4 ("frailty"), and profile 5 ("non-paroxysmal AF with tachycardia"). Profile 4 was associated with the highest rates of thromboembolic events (1.66/100 person-years [95% confidence interval, 1.46-1.89]), major bleeding (1.92/100 person-years [1.70-2.16]), and death (6.02/100 person-years [5.62-6.43]). Profile 3 was associated with the lowest risk across all measured outcomes (thromboembolic events, 0.64 events/100 person-years [0.48-0.82]; major bleeding, 0.83 events/100 person-years [0.65-1.04]; and death, 1.44 events/100 person-years [1.21-1.71]). Profile 1 had a moderate thromboembolic event rate (1.04/100 person-years [0.91-1.08]), while profiles 2 and 5 showed lower rates. CONCLUSIONS The phenotypic profiles of patients with AF prescribed OACs identified using hierarchical cluster analysis are associated with distinct residual thromboembolic risks and related outcomes. This approach has the potential to enhance patient risk-stratification and holistic approaches to management.
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Affiliation(s)
- Hironori Ishiguchi
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Azmil H Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Stroke Division, Department Medicine for Older People, Whiston Hospital, Mersey and West Lancashire Teaching Hospitals NHS Trust, Prescot, UK.
| | - Bi Huang
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Steven Ho Man Lam
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Yang Liu
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Brian Olshansky
- Division of Cardiology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Centre for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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11
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Chan YH, Chao TF, Chen SW, Lee HF, Li PR, Yeh YH, Kuo CT, See LC, Lip GYH. SGLT2 Inhibitors vs GLP-1 Receptor Agonists and Clinical Outcomes in Patients With Diabetes With/Without Atrial Fibrillation. J Clin Endocrinol Metab 2024; 109:2617-2629. [PMID: 38466894 DOI: 10.1210/clinem/dgae157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/24/2023] [Accepted: 03/10/2024] [Indexed: 03/13/2024]
Abstract
CONTEXT The coexistence of diabetes mellitus and atrial fibrillation (AF) is associated with substantial risks of adverse cardiovascular events. OBJECTIVE The relevant outcomes associated with the use of a sodium-glucose cotransporter-2 inhibitor (SGLT2i) vs glucagon-like peptide-1 receptor agonists (GLP-1RAs) among patients with type 2 diabetes (T2D) with/without concomitant AF remain unknown. METHODS In this nationwide retrospective cohort study from the Taiwan National Health Insurance Research Database, there were 344 392 and 31 351 patients with T2D without AF, and 11 462 and 816 T2D patients with AF treated with SGLT2is and GLP-1RAs, respectively, from May 1, 2016, to December 31, 2019. Patients were followed from the drug index date until the occurrence of study events, discontinuation of the index drug, or the end of the study period (December 31, 2020), whichever occurred first. We used propensity score-stabilized weight to balance covariates across the 2 medication groups. RESULTS The incidence rate of all study outcomes in patients with concomitant AF was much higher than in those without concomitant AF. For the AF cohort, SGLT2i vs GLP-1RA was associated with a lower risk of hospitalization for heart failure (HF) (2.32 vs 4.74 events per 100 person-years; hazard ratio [HR] 0.48, 95% CI 0.36-0.66), with no benefit seen for the non-AF cohort (P for homogeneity < .01). SGLT2i vs GLP-1RA was associated with a lower risk of composite kidney outcomes both in the AF (0.38 vs 0.79 events per 100 person-years; HR 0.47; 95% CI 0.23-0.96) and the non-AF cohorts (0.09 vs 0.18 events per 100 person-years; HR 0.53; 95% CI 0.43-0.64). There were no significant differences in the risk of major adverse cardiovascular events and all-cause mortality in those who received SGLT2i compared with GLP-1RA for the AF or non-AF cohorts. CONCLUSION Considering the high risk of developing HF and/or high prevalence of concomitant HF in patients with concomitant diabetes and AF, whether SGLT2is should be the preferred treatment to GLP-1RAs for such a high-risk population requires further investigation.
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Affiliation(s)
- Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang-Gung University, Taoyuan City 333, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
| | - Shao-Wei Chen
- College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City 333, Taiwan
| | - Hsin-Fu Lee
- College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
- Division of Cardiology, Department of Medicine, New Taipei City Municipal Tucheng Hospital (Chang Gung Memorial Hospital, Tucheng Branch, Taiwan), New Taipei City 236, Taiwan
| | - Pei-Ru Li
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Yung-Hsin Yeh
- The Cardiovascular Department, Chang Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Chi-Tai Kuo
- The Cardiovascular Department, Chang Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
- Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan City 333, Taiwan
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool L69 3BX, UK
- Department of Clinical Medicine, Aalborg University, Aalborg 9000, Denmark
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12
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Choi SE, Bucci T, Huang JY, Yiu KH, Tsang CT, Lau KK, Hill A, Irving G, Lip GY, Abdul-Rahim AH. Early statin use is associated with improved survival and cardiovascular outcomes in patients with atrial fibrillation and recent ischaemic stroke: A propensity-matched analysis of a global federated health database. Eur Stroke J 2024:23969873241274213. [PMID: 39254367 DOI: 10.1177/23969873241274213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024] Open
Abstract
INTRODUCTION Statins reduce recurrent stroke and cardiovascular events in patients with non-cardioembolic stroke. The benefits of statins in patients with AF and recent IS remain unclear. We aimed to investigate the benefits of statins in patients with AF and recent IS. PATIENTS AND METHODS This retrospective, cohort study was conducted using deidentified electronic medical records within TriNetX platform. Patients with AF and recent IS, who received statins within 28 days of their index stroke were propensity score-matched with those who did not. Patients were followed up for up to 2 years. Primary outcomes were the 2-year risk of recurrent IS, all-cause mortality and the composite outcome of all-cause mortality, recurrent IS, transient ischaemic attack (TIA), and acute myocardial infarction (MI). Secondary outcomes were the 2-year risk of TIA, intracranial haemorrhage (ICH), acute MI, and hospital readmission. Cox regression analyses were used to calculate hazard ratios (HRs) with 95% confidence intervals (95%CI). RESULTS Of 20,902 patients with AF and recent IS, 7500 (35.9%) received statins within 28 days of their stroke and 13,402 (64.1%) did not. 11,182 patients (mean age 73.7 ± 11.5; 5277 (47.2%) female) remained after propensity score matching. Patients who received early statins had significantly lower risk of recurrent IS (HR: 0.45, 95%CI: 0.41-0.48, p < 0.001), mortality (HR: 0.75, 95%CI: 0.66-0.84, p < 0.001), the composite outcome (HR: 0.48, 95%CI: 0.45-0.52, p < 0.001), TIA (HR: 0.37, 95%CI: 0.30-0.44, p < 0.001), ICH (HR: 0.59, 95%CI: 0.47-0.72, p < 0.001 ), acute MI (HR: 0.35, 95%CI: 0.30-0.42, p < 0.001) and hospital readmission (HR: 0.46, 95%CI: 0.42-0.50, <0.001). Beneficial effects of early statins were evident in the elderly, different ethnic groups, statin dose intensity, and AF subtypes, large vessel occlusion and embolic strokes and within the context of statin lipophilicity, optimal LDL-cholesterol levels, various cardiovascular comorbidities, treatment with intravenous thrombolysis or endovascular thrombectomy, and NIHSS 0-5 and NIHSS > 5 subgroups. DISCUSSION AND CONCLUSION Patients with AF and recent IS, who received early statins, had a lower risk of recurrent stroke, death, and other cardiovascular outcomes including ICH, compared to those who did not.
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Affiliation(s)
- Sylvia E Choi
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Tommaso Bucci
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Clinical Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Jia-Yi Huang
- Cardiology Division, Department of Medicine, The University of Hong Kong Shen Zhen Hospital, Shen Zhen, China
- Cardiology Division, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Kai-Hang Yiu
- Cardiology Division, Department of Medicine, The University of Hong Kong Shen Zhen Hospital, Shen Zhen, China
- Cardiology Division, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Christopher Tw Tsang
- Cardiology Division, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Kui Kai Lau
- Division of Neurology, Department of Medicine, The University of Hong Kong, Hong Kong, China
- State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong, China
| | - Andrew Hill
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Stroke Division, Department of Medicine for Older People, Whiston Hospital, Mersey and West Lancashire Teaching Hospitals NHS Trust, Prescot, UK
| | - Greg Irving
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Health Research Institute, Edge Hill University Faculty of Health and Social Care, Ormskirk, UK
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Azmil H Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Stroke Division, Department of Medicine for Older People, Whiston Hospital, Mersey and West Lancashire Teaching Hospitals NHS Trust, Prescot, UK
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13
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Leo DG, Trevisan C, Ravelli A, Lobban TCA, Lane DA. Key needs, quality performance indicators and outcomes for patients with atrial fibrillation and multimorbidity: The AFFIRMO study. PLoS One 2024; 19:e0310106. [PMID: 39255255 DOI: 10.1371/journal.pone.0310106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 08/25/2024] [Indexed: 09/12/2024] Open
Abstract
BACKGROUND Patients with atrial fibrillation (AF) often have concomitant long-term conditions that negatively impact their quality of life and the clinical management they receive. The AFFIRMO study aimed to identify the needs, quality performance indicators (QPIs), and outcomes relevant to patients, caregivers and healthcare professionals (HCPs) to improve the care of patients with AF. METHODS An on-line survey to collect the key needs, QPIs, and outcomes relevant to patients with AF, their caregivers and HCPs, was distributed between May 2022 and January 2023 in five countries (UK, Italy, Denmark, Romania and Spain). Results from the on-line survey were discussed in a three-round Delphi process with international representatives of patients with AF, caregivers, and HCPs to determine the key needs, QPIs and outcomes for the management of patients with AF and multimorbidity. RESULTS 659 patients (47.2% males, mean (SD) age 70.9 (10.2) years), 201 caregivers (26.9% males, mean (SD) age: 58.3 (SD 15.2) years), and 445 HCPs (57.8% males, mean (SD) age 47.4 (10.6) years) participated in the survey. An initial list of 27 needs, 9 QPIs, and 17 outcomes were identified. Eight patients, two caregivers, and 11 HCPs participated in the Delphi process. Nineteen (70%) needs, 8 (89%) QPIs, and 13 (76%) outcomes reached "consensus in", and were included in the final list. CONCLUSIONS The final key needs, QPIs and outcomes obtained from the Delphi process will inform the AFFIRMO clinical trial, which aims to test the iABC app which incorporates an empowerment toolbox for patients and their caregivers, providing information to improve patient engagement and empowerment to help improve the clinical and self-management of patients with AF in the context of multimorbidity.
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Affiliation(s)
- Donato Giuseppe Leo
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, Faculty of Health and Life Sciences, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Caterina Trevisan
- Department of Medicine, University of Padua, Padua, Italy
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
- Aging Research Center, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet-Stockholm University, Stockholm, Sweden
| | - Adele Ravelli
- Department of Medicine, University of Padua, Padua, Italy
| | - Trudie C A Lobban
- Arrhythmia Alliance, Stratford upon Avon, Warwickshire, United Kingdom
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, Faculty of Health and Life Sciences, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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14
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Douketis JD, Spyropoulos AC. Perioperative Management of Patients Taking Direct Oral Anticoagulants: A Review. JAMA 2024; 332:825-834. [PMID: 39133476 DOI: 10.1001/jama.2024.12708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Importance Direct oral anticoagulants (DOACs), comprising apixaban, rivaroxaban, edoxaban, and dabigatran, are commonly used medications to treat patients with atrial fibrillation and venous thromboembolism. Decisions about how to manage DOACs in patients undergoing a surgical or nonsurgical procedure are important to decrease the risks of bleeding and thromboembolism. Observations For elective surgical or nonsurgical procedures, a standardized approach to perioperative DOAC management involves classifying the risk of procedure-related bleeding as minimal (eg, minor dental or skin procedures), low to moderate (eg, cholecystectomy, inguinal hernia repair), or high risk (eg, major cancer or joint replacement procedures). For patients undergoing minimal bleeding risk procedures, DOACs may be continued, or if there is concern about excessive bleeding, DOACs may be discontinued on the day of the procedure. Patients undergoing a low to moderate bleeding risk procedure should typically discontinue DOACs 1 day before the operation and restart DOACs 1 day after. Patients undergoing a high bleeding risk procedure should stop DOACs 2 days prior to the operation and restart DOACs 2 days after. With this perioperative DOAC management strategy, rates of thromboembolism (0.2%-0.4%) and major bleeding (1%-2%) are low and delays or cancellations of surgical and nonsurgical procedures are infrequent. Patients taking DOACs who need emergent (<6 hours after presentation) or urgent surgical procedures (6-24 hours after presentation) experience bleeding rates up to 23% and thromboembolism as high as 11%. Laboratory testing to measure preoperative DOAC levels may be useful to determine whether patients should receive a DOAC reversal agent (eg, prothrombin complex concentrates, idarucizumab, or andexanet-α) prior to an emergent or urgent procedure. Conclusions and Relevance When patients who are taking a DOAC require an elective surgical or nonsurgical procedure, standardized management protocols can be applied that do not require testing DOAC levels or heparin bridging. When patients taking a DOAC require an emergent, urgent, or semiurgent surgical procedure, anticoagulant reversal agents may be appropriate when DOAC levels are elevated or not available.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton, and McMaster University, Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Alex C Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Service, Northwell Health at Lenox Hill Hospital, New York, New York
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Institute of Health System Science at the Feinstein Institutes for Medical Research, Manhasset, New York
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Kang DS, Yang PS, Kim D, Jang E, Yu HT, Kim TH, Sung JH, Pak HN, Lee MH, Lip GY, Joung B. Racial Differences in Bleeding Risk: An Ecological Epidemiological Study Comparing Korea and United Kingdom Subjects. Thromb Haemost 2024; 124:842-851. [PMID: 38359877 PMCID: PMC11349425 DOI: 10.1055/a-2269-1123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 02/13/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND This study aimed to evaluate racial differences in bleeding incidence by conducting an ecological epidemiological study using data from Korea and the United Kingdom. METHODS We included healthy participants from the Korean National Health Insurance Service-Health Screening and the UK Biobank who underwent health examinations between 2006 and 2010 and had no comorbidities or history of medication use. Finally, 112,750 East Asians (50.7% men, mean age 52.6 years) and 210,995 Caucasians (44.7% men, mean age 55.0 years) were analyzed. The primary outcome was composed of intracranial hemorrhage (ICH) and bleeding from the gastrointestinal, respiratory, and genitourinary systems. RESULTS During the follow-up, primary outcome events occurred in 2,110 East Asians and in 6,515 Caucasians. East Asians had a 38% lower 5-year incidence rate compared with Caucasians (3.88 vs. 6.29 per 1,000 person-years; incidence rate ratio [IRR]: 0.62, 95% confidence interval [CI]: 0.59-0.65). East Asians showed a lower incidence of major bleeding (IRR: 0.86, 95% CI: 0.81-0.91), bleeding from the gastrointestinal (IRR: 0.53, 95% CI: 0.49-0.56), and genitourinary systems (IRR: 0.49, 95% CI: 0.44-0.53) compared with Caucasians. The incidence rates of ICH (IRR: 3.20, 95% CI: 2.67-3.84) and bleeding from the respiratory system (IRR: 1.28, 95% CI: 1.11-1.47) were higher in East Asians. Notably, East Asians consuming alcohol ≥3 times/week showed a higher incidence of the primary outcome than Caucasians (IRR: 1.12, 95% CI: 1.01-1.25). CONCLUSION This ecological study revealed significant racial differences in bleeding incidence, influenced by anatomical sites and lifestyle habits, underscoring the need for tailored approaches in bleeding management based on race.
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Affiliation(s)
- Dong-Seon Kang
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Pil-Sung Yang
- Division of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Daehoon Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eunsun Jang
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hee Tae Yu
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Hoon Sung
- Division of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Moon-Hyoung Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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16
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Kim DH, Kwak BC, Yoon BA, Cha JK, Park JS, Kwak MS, Woo KS, Han JY. Association Between Plasma Anti-Factor Xa Concentrations and Large Artery Occlusion in Patients With Acute Ischemic Stroke Taking Direct Oral Anticoagulants for Non-valvular Atrial Fibrillation. Ann Lab Med 2024; 44:459-462. [PMID: 38632944 PMCID: PMC11169765 DOI: 10.3343/alm.2024.0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 02/27/2024] [Accepted: 04/12/2024] [Indexed: 04/19/2024] Open
Affiliation(s)
- Dae-Hyun Kim
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Byung-Cheol Kwak
- Department of Neurology, Pohang Stroke and Spine Hospital, Pohang, Korea
| | - Byeol-A Yoon
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Jong-Sung Park
- Department of Cardiology, Dong-A University College of Medicine, Busan, Korea
| | - Min-Sun Kwak
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Kwang-Sook Woo
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Jin-Yeong Han
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Korea
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17
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Bucci T, Wat D, Sibley S, Wootton D, Green D, Pignatelli P, Lip GYH, Frost F. Low-dose azithromycin prophylaxis in patients with atrial fibrillation and chronic obstructive pulmonary disease. Intern Emerg Med 2024; 19:1615-1623. [PMID: 38819711 PMCID: PMC11405424 DOI: 10.1007/s11739-024-03653-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/16/2024] [Indexed: 06/01/2024]
Abstract
Low-dose azithromycin prophylaxis is associated with improved outcomes in people suffering frequent exacerbations of chronic obstructive pulmonary disease (COPD), but the use of macrolides in patients with cardiovascular disease has been debated. To investigate the risk of adverse events after COPD exacerbations in patients with atrial fibrillation (AF) treated with azithromycin prophylaxis. Retrospective cohort study within the TriNetX Platform, including AF patients with COPD exacerbations. Risks of primary and secondary outcomes were recorded up to 30 days post-COPD exacerbations and compared between azithromycin users and azithromycin non-users. The primary outcomes were the risks for a composite of (1) cardiovascular (all-cause death, heart failure, ventricular arrhythmias, ischemic stroke, myocardial infarction, and cardiac arrest), and (2) hemorrhagic events (intracranial hemorrhage (ICH), and gastro-intestinal bleeding). Cox-regression analyses compared outcomes between groups after propensity score matching (PSM). After PSM, azithromycin users (n = 2434, 71 ± 10 years, 49% females) were associated with a lower 30-day risk of post-exacerbation cardiovascular (HR 0.67, 95% CI 0.61-0.73) and hemorrhagic composite outcome (HR 0.45, 95% CI 0.32-0.64) compared to azithromycin non-users (n = 2434, 72 ± 11 years, 51% females). The beneficial effect was consistent for each secondary outcomes, except ICH. On sensitivity analyses, the reduced risk of adverse events in azithromycin users was irrespective of smoking status, exacerbation severity, and type of oral anticoagulation. Azithromycin prophylaxis is associated with a lower risk of all-cause death, thrombotic and hemorrhagic events in AF patients with COPD. The possible role of azithromycin prophylaxis as part of the integrated care management of AF patients with COPD needs further study.
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Affiliation(s)
- Tommaso Bucci
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Dennis Wat
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Knowsley Community Respiratory Service, Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Sarah Sibley
- Knowsley Community Respiratory Service, Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Dan Wootton
- Respiratory Department, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - David Green
- Knowsley Community Respiratory Service, Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Pasquale Pignatelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Freddy Frost
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Knowsley Community Respiratory Service, Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, UK
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18
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Bellfield RAA, Olier I, Lotto R, Jones I, Dawson EA, Li G, Tuladhar AM, Lip GYH, Ortega-Martorell S. AI-based derivation of atrial fibrillation phenotypes in the general and critical care populations. EBioMedicine 2024; 107:105280. [PMID: 39153412 PMCID: PMC11381622 DOI: 10.1016/j.ebiom.2024.105280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 07/26/2024] [Accepted: 07/30/2024] [Indexed: 08/19/2024] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common heart arrhythmia worldwide and is linked to a higher risk of mortality and morbidity. To predict AF and AF-related complications, clinical risk scores are commonly employed, but their predictive accuracy is generally limited, given the inherent complexity and heterogeneity of patients with AF. By classifying different presentations of AF into coherent and manageable clinical phenotypes, the development of tailored prevention and treatment strategies can be facilitated. In this study, we propose an artificial intelligence (AI)-based methodology to derive meaningful clinical phenotypes of AF in the general and critical care populations. METHODS Our approach employs generative topographic mapping, a probabilistic machine learning method, to identify micro-clusters of patients with similar characteristics. It then identifies macro-cluster regions (clinical phenotypes) in the latent space using Ward's minimum variance method. We applied it to two large cohort databases (UK-Biobank and MIMIC-IV) representing general and critical care populations. FINDINGS The proposed methodology showed its ability to derive meaningful clinical phenotypes of AF. Because of its probabilistic foundations, it can enhance the robustness of patient stratification. It also produced interpretable visualisation of complex high-dimensional data, enhancing understanding of the derived phenotypes and their key characteristics. Using our methodology, we identified and characterised clinical phenotypes of AF across diverse patient populations. INTERPRETATION Our methodology is robust to noise, can uncover hidden patterns and subgroups, and can elucidate more specific patient profiles, contributing to more robust patient stratification, which could facilitate the tailoring of prevention and treatment programs specific to each phenotype. It can also be applied to other datasets to derive clinically meaningful phenotypes of other conditions. FUNDING This study was funded by the DECIPHER project (LJMU QR-PSF) and the EU project TARGET (10113624).
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Affiliation(s)
- Ryan A A Bellfield
- Data Science Research Centre, Liverpool John Moores University, Liverpool L3 3AF, UK; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Ivan Olier
- Data Science Research Centre, Liverpool John Moores University, Liverpool L3 3AF, UK; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Robyn Lotto
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; School of Nursing and Advanced Practice, Liverpool John Moores University, Liverpool L2 2ER, UK
| | - Ian Jones
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; School of Nursing and Advanced Practice, Liverpool John Moores University, Liverpool L2 2ER, UK
| | - Ellen A Dawson
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Research Institute for Sport and Exercise Science, Liverpool John Moores University, Liverpool L3 3AF, UK
| | - Guowei Li
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, Guangzhou 510317, China
| | - Anil M Tuladhar
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behavior, Nijmegen, the Netherlands
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Sandra Ortega-Martorell
- Data Science Research Centre, Liverpool John Moores University, Liverpool L3 3AF, UK; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
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19
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Cho MS, Kang DY, Ahn JM, Yun SC, Oh YS, Lee CH, Choi EK, Lee JH, Kwon CH, Park GM, Choi HO, Park KH, Park KM, Hwang J, Yoo KD, Cho YR, Kim JH, Hwang KW, Jin ES, Kwon O, Kim KH, Park SJ, Park DW, Nam GB. Edoxaban Antithrombotic Therapy for Atrial Fibrillation and Stable Coronary Artery Disease. N Engl J Med 2024. [PMID: 39225258 DOI: 10.1056/nejmoa2407362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
BACKGROUND Despite consistent recommendations from clinical guidelines, data from randomized trials on a long-term antithrombotic treatment strategy for patients with atrial fibrillation and stable coronary artery disease are still lacking. METHODS We conducted a multicenter, open-label, adjudicator-masked, randomized trial comparing edoxaban monotherapy with dual antithrombotic therapy (edoxaban plus a single antiplatelet agent) in patients with atrial fibrillation and stable coronary artery disease (defined as coronary artery disease previously treated with revascularization or managed medically). The risk of stroke was assessed on the basis of the CHA2DS2-VASc score (scores range from 0 to 9, with higher scores indicating a greater risk of stroke). The primary outcome was a composite of death from any cause, myocardial infarction, stroke, systemic embolism, unplanned urgent revascularization, and major bleeding or clinically relevant nonmajor bleeding at 12 months. Secondary outcomes included a composite of major ischemic events and the safety outcome of major bleeding or clinically relevant nonmajor bleeding. RESULTS We assigned 524 patients to the edoxaban monotherapy group and 516 patients to the dual antithrombotic therapy group at 18 sites in South Korea. The mean age of the patients was 72.1 years, 22.9% were women, and the mean CHA2DS2-VASc score was 4.3. At 12 months, a primary-outcome event had occurred in 34 patients (Kaplan-Meier estimate, 6.8%) assigned to edoxaban monotherapy and in 79 patients (16.2%) assigned to dual antithrombotic therapy (hazard ratio, 0.44; 95% confidence interval [CI], 0.30 to 0.65; P<0.001). The cumulative incidence of major ischemic events at 12 months appeared to be similar in the trial groups. Major bleeding or clinically relevant nonmajor bleeding occurred in 23 patients (Kaplan-Meier estimate, 4.7%) in the edoxaban monotherapy group and in 70 patients (14.2%) in the dual antithrombotic therapy group (hazard ratio, 0.34; 95% CI, 0.22 to 0.53). CONCLUSIONS In patients with atrial fibrillation and stable coronary artery disease, edoxaban monotherapy led to a lower risk of a composite of death from any cause, myocardial infarction, stroke, systemic embolism, unplanned urgent revascularization, or major bleeding or clinically relevant nonmajor bleeding at 12 months than dual antithrombotic therapy. (Funded by the CardioVascular Research Foundation and others; EPIC-CAD ClinicalTrials.gov number, NCT03718559.).
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Affiliation(s)
- Min Soo Cho
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Do-Yoon Kang
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Jung-Min Ahn
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Sung-Cheol Yun
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Yong-Seog Oh
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Chang Hoon Lee
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Eue-Keun Choi
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Ji Hyun Lee
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Chang Hee Kwon
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Gyung-Min Park
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Hyung Oh Choi
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Kyoung-Ha Park
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Kyoung-Min Park
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Jongmin Hwang
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Ki-Dong Yoo
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Young-Rak Cho
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Ji Hyun Kim
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Ki Won Hwang
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Eun-Sun Jin
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Osung Kwon
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Ki-Hun Kim
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Seung-Jung Park
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Duk-Woo Park
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
| | - Gi-Byoung Nam
- From the Department of Cardiology (M.S.C., D.-Y.K., J.-M.A., S.-J.P., D.-W.P., G.-B.N.) and the Division of Biostatics (S.-C.Y.), Asan Medical Center, University of Ulsan College of Medicine, the Department of Cardiology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea (Y.-S.O.), the Department of Cardiology, Veterans Health Service Medical Center (C.H.L.), the Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital (E.-K.C.), the Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine (C.H.K.), the Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (K.-M.P.), the Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University Medical College (E.-S.J.), and the Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, Catholic University of Korea (O.K.), Seoul, the Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (J.H.L.), the Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (G.-M.P.), the Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon (H.O.C.), the Department of Cardiology, Hallym University Medical Center, Anyang (K.-H.P.), the Department of Cardiology, Keimyung University Dongsan Hospital, Daegu (J.H.), the Department of Cardiology, St. Vincent's Hospital, College of Medicine, Catholic University of Korea, Suwon (K.-D.Y.), the Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine (Y.-R.C.), and the Department of Cardiology, Haeundae Paik Hospital, Inje University College of Medicine (K.-H.K.), Busan, the Department of Cardiology, Dongguk University Ilsan Hospital, Goyang (J.H.K.), and the Department of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan (K.W.H.) - all in South Korea
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Krittayaphong R, Permsuwan U. Employing Real-World Evidence for the Economic Evaluation of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation in Thailand. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:725-734. [PMID: 38858344 DOI: 10.1007/s40258-024-00891-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/14/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND This study aimed to assess the cost-effectiveness of non-vitamin K antagonist oral anticoagulants (NOACs) in comparison with warfarin using data from real practice based on the perspective of the health care system in Thailand. METHODS A four-state Markov model encompassing well-controlled atrial fibrillation (AF), stroke and systemic embolism, major bleeding and death was utilised to forecast clinical and economic outcomes. Transitional probabilities, direct medical costs and utilities were derived from the real-world data of the 'COOL-AF Thailand' registry, Thailand's largest nationwide registry spanning 27 hospitals. The cohort comprised AF patients. The primary outcomes assessed were total costs, life years, quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio. All costs and outcomes were subject to an annual discount rate of 3.0%. A spectrum of sensitivity analyses was conducted. RESULTS The mean age of the cohort was 68.8 ± 10.7 years. The NOACs group incurred a marginally lower total lifetime cost than the warfarin group (247,857 Thai baht [THB] vs 253,654 THB or 7137 USD vs 7304 USD) and experienced gains of 0.045 life years and 0.043 QALYs over the warfarin group. Given the lower cost and higher benefits associated with NOACs, this implies that NOAC treatment is a dominant strategy compared to warfarin for AF patients. At a ceiling ratio of 160,000 THB (4607 USD) per QALY, NOACs presented a 61.2% probability of being cost effective. CONCLUSIONS Non-vitamin K antagonist oral anticoagulants represent a cost-saving alternative to warfarin in the real clinical practice. However, with a probability of being cost effective below 65%, it suggests some parameter uncertainty regarding their overall cost effectiveness compared to warfarin.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Unchalee Permsuwan
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand.
- Center for Medical and Health Technology Assessment (CM-HTA), Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand.
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21
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Krittayaphong R, Treewaree S, Lip GYH. Components of the Atrial fibrillation Better Care pathway for holistic care of patients with atrial fibrillation: a win ratio analysis from the COOL-AF registry. Europace 2024; 26:euae237. [PMID: 39283957 PMCID: PMC11424996 DOI: 10.1093/europace/euae237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 09/09/2024] [Indexed: 09/27/2024] Open
Abstract
AIMS Compliance with integrated care based on the Atrial fibrillation Better Care (ABC) pathway has been associated with improved clinical outcomes. The primary objective of this study was to compare clinical outcomes of AF patients according to the compliant status of each component of the ABC pathway in a hierarchical win ratio approach. METHODS AND RESULTS We studied AF patients in the COOL-AF registry. Each patient was followed every 6 months until 3 years. A win ratio analysis was performed, as not all clinical outcomes are equivalent. The hierarchical outcomes were (1) all-cause death, (2) intracranial haemorrhage (ICH), (3) ischaemic stroke/systemic embolism, (4) non-ICH major bleedings, and (5) acute myocardial infarction or heart failure. We also assessed win ratio and win proportion variance over the follow-up time, and the variations over time. A total of 3405 patients (mean age 67.8 ± 11.3; 41.8% female) were studied. Win ratio of ABC-compliant (all three components) vs. ABC-not-compliant was 1.57 (1.35-1.83), P < 0.001. When adding time in therapeutic range (TTR) data for compliant criteria for those who were on warfarin, the win ratio increased to 2.28 (1.89-2.75), P < 0.001. The A-compliant group (plus TTR data), B-compliant, and C-compliant had the win ratio of 1.81 (1.51-2.12), 1.82 (1.53-2.16), and 1.39 (1.18-1.62), all P < 0.001, compared to not compliant group. CONCLUSION Management of AF patients according to each component of the ABC pathway is associated with better clinical outcomes compared to those non-compliant to ABC pathway. This finding underscores the importance of a holistic management approach strategy for AF patients.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2, Wanglang Rd, Bangkok 10700, Thailand
| | - Sukrit Treewaree
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2, Wanglang Rd, Bangkok 10700, Thailand
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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22
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Shantsila A, Lip GYH, Lane DA. Relationship between systolic blood pressure and renal function on clinical outcomes in patients with atrial fibrillation: a report from the prospective AF-GEN-UK Registry. J Hypertens 2024:00004872-990000000-00530. [PMID: 39315543 DOI: 10.1097/hjh.0000000000003856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 08/18/2024] [Indexed: 09/25/2024]
Abstract
BACKGROUND Blood pressure (BP) extremes and renal (dys)function contribute to poor outcomes in patients with atrial fibrillation (AF). Using data from the prospective AF-GEN-UK study, we investigated the effect of systolic BP and interaction with renal function for prognostication. METHODS Baseline systolic BP (SBP) values were recorded for 1580 patients (mean [SD] age 71 [11] years, 60% male) and categorized as follows: 120-129 mmHg (n = 289, reference group) <110 mmHg (n = 165), 110-119 mmHg, (n = 254), 130-139 mmHg (n = 321), 140-159 mmHg (n = 385) and ≥160 mmHg (n = 166). Cox regression analysis, adjusted for age, oral anticoagulation (OAC) and CHA2DS2-VASc score established the impact of SBP, renal function and their interaction on 1-year outcomes. SBP groups were compared using ANOVA and chi-square tests. RESULTS OAC use was 84% and similar across SBP groups. Renal dysfunction [estimated baseline glomerular filtration rate (eGFR) < 60 ml/min] was present in 24%, with significantly lower eGFR values in the SBP 110-119 mmHg group. History of heart failure was significantly higher in those with SBP <110 mmHg. SBP <110 mmHg was predictive of all cause-death on univariate [hazard ratio (HR) 2.36, 95% confidence interval (CI) 1.20-4.64] and adjusted (aHR 9.71, 95% CI 1.73-54.5) regression. There was no statistically significant interaction between SBP and eGFR, no associations of SBP with haemorrhagic or thromboembolic events. CONCLUSIONS In people with AF, SBP <110 mmHg was independently predictive of all-cause death, with no significant interaction between SBP and renal (dys)function. This may reflect general poor health and/or excessive antihypertensive therapy, which should be avoided.
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Affiliation(s)
- Alena Shantsila
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deirdre A Lane
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Suzuki S, Yamashita T, Akao M, Atarashi H, Ikeda T, Okumura K, Koretsune Y, Shimizu W, Tsutsui H, Toyoda K, Hirayama A, Yasaka M, Yamaguchi T, Teramukai S, Morishima Y, Fukuzawa M, Takita A, Inoue H. Patient Outcomes in Very Elderly Patients With Non-Valvular Atrial Fibrillation - ANAFIE Registry. Circ Rep 2024; 6:283-293. [PMID: 39132332 PMCID: PMC11309779 DOI: 10.1253/circrep.cr-24-0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 06/10/2024] [Indexed: 08/13/2024] Open
Abstract
Background The All Nippon Atrial Fibrillation In the Elderly Registry provides real-world insights into non-valvular atrial fibrillation (NVAF) in >30,000 elderly Japanese patients (aged ≥75 years), including >2,000 nonagenarians. We aimed to investigate outcomes in these patients by age and oral anticoagulant (OAC) type. Methods and Results This prospective, multicenter, observational, cohort, 2-year follow-up study included elderly patients with NVAF who were able to attend hospital visits. The incidences of stroke/systemic embolic events (SEE), major bleeding, intracranial hemorrhage (ICH), cardiovascular death, all-cause death, and major adverse cardiovascular or neurological events (MACNE) were evaluated by age. Incidence rates increased significantly with age. Stroke/SEE, major bleeding, and ICH incidences plateaued in patients aged ≥90 years. Direct OACs (DOACs) yielded a numerically lower event incidence vs. warfarin in all age groups and endpoints, except for major bleeding in patients aged ≥90 years. DOACs (vs. warfarin) were significantly associated with a lower risk of stroke/SEE, major bleeding, and ICH in the ≥80-<85 years group, and reduced cardiovascular and all-cause death in the ≥75-<80 years group. In the ≥90 years subgroup, major bleeding history was a risk factor for all-cause death. Conclusions Although DOAC vs. warfarin offers potential benefits for stroke prevention, limitations occurred in reducing major bleeding among those aged ≥90 years, indicating a potential benefit of very-low-dose DOAC for this demographic.
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Affiliation(s)
| | | | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center Kyoto Japan
| | | | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine Tokyo Japan
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center Kumamoto Japan
| | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tama Nagayama Hospital Tokyo Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University Fukuoka Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center Osaka Japan
| | | | - Masahiro Yasaka
- Department of Cerebrovascular Medicine, Fukuoka Neurosurgical Hospital Fukuoka Japan
| | - Takenori Yamaguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center Osaka Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine Kyoto Japan
| | | | - Masayuki Fukuzawa
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd. Tokyo Japan
| | - Atsushi Takita
- Data Intelligence Department, Daiichi Sankyo Co., Ltd. Tokyo Japan
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24
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Huang B, Li M, Lip GYH. The burden of atrial fibrillation related to metabolic risks: different countries and territories, yet the same challenges. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:379-380. [PMID: 38719482 DOI: 10.1093/ehjqcco/qcae037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 08/09/2024]
Affiliation(s)
- Bi Huang
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
| | - Meng Li
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, and Liverpool Heart & Chest Hospital, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
- Department of Clinical Medicine, Aalborg University, Selma Lagerløfs Vej 249, 9260 Gistrup, Denmark
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25
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Nielsen PB, Brøndum RF, Nøhr AK, Overvad TF, Lip GYH. Risk of stroke in male and female patients with atrial fibrillation in a nationwide cohort. Nat Commun 2024; 15:6728. [PMID: 39112527 PMCID: PMC11306344 DOI: 10.1038/s41467-024-51193-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 07/30/2024] [Indexed: 08/10/2024] Open
Abstract
Female sex has been suggested as a risk modifier for stroke in patients with atrial fibrillation (AF) with comorbid prevalent stroke risk factors. Management has evolved over time towards a holistic approach that may have diminished any sex difference in AF-related stroke. In a nationwide cohort of AF patients free from oral anticoagulant treatment, we examine the time trends in stroke risk overall and in relation to risk differences between male and female patients. Here we show that among 158,982 patients with AF (median age 78 years (IQR: 71 to 85); 52% female) the 1-year thromboembolic risk was highest between 1997-2000 with a risk of 5.6% and lowest between 2013-2016 with a risk of 3.8%, declining over the last two decades. The excess stroke risk for female vs male patients has also been declining, with risk-score adjusted relative risk estimates suggesting limited sex-difference in recent years.
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Affiliation(s)
- Peter Brønnum Nielsen
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg University Hospital, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Rasmus Froberg Brøndum
- Center for Clinical Data Science, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Anne Krogh Nøhr
- Center for Clinical Data Science, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | | | - Gregory Y H Lip
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg University Hospital, Aalborg, Denmark.
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
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26
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Bai Y, Li R, Hao JF, Chen LW, Liu ST, Zhang XL, Lip GYH, Yang JK, Zou YX, Wang H. Accumulated β-catenin is associated with human atrial fibrosis and atrial fibrillation. J Transl Med 2024; 22:734. [PMID: 39103891 PMCID: PMC11302159 DOI: 10.1186/s12967-024-05558-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 07/29/2024] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is associated with increased risk of stroke and mortality. It has been reported that the process of atrial fibrosis was regulated by β-catenin in rats with AF. However, pathophysiological mechanisms of this process in human with AF remain unclear. This study aims to investigate the possible mechanisms of β-catenin in participating in the atrial fibrosis using human right atrial appendage (hRAA) tissues . METHODS We compared the difference of β-catenin expression in hRAA tissues between the patients with AF and sinus rhythm (SR). The possible function of β-catenin in the development of AF was also explored in mice and primary cells. RESULTS Firstly, the space between the membrane of the gap junctions of cardiomyocytes was wider in the AF group. Secondly, the expression of the gap junction function related proteins, Connexin40 and Connexin43, was decreased, while the expression of β-catenin and its binding partner E-cadherin was increased in hRAA and cardiomyocytes of the AF group. Thirdly, β-catenin colocalized with E-cadherin on the plasma membrane of cardiomyocytes in the SR group, while they were dissociated and accumulated intracellularly in the AF group. Furthermore, the expression of glycogen synthase kinase 3β (GSK-3β) and Adenomatous Polyposis Coli (APC), which participated in the degradation of β-catenin, was decreased in hRAA tissues and cardiomyocytes of the AF group. Finally, the development of atrial fibrosis and AF were proved to be prevented after inhibiting β-catenin expression in the AF model mice. CONCLUSIONS Based on human atrial pathological and molecular analyses, our findings provided evidence that β-catenin was associated with atrial fibrosis and AF progression.
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Affiliation(s)
- Ying Bai
- Cardiovascular Center, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Rui Li
- Department of Pathology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Jun-Feng Hao
- Core Facility for Protein Research, Institute of Biophysics, Chinese Academy of Sciences, Beijing, 100101, China
| | - Lian-Wan Chen
- National Laboratory of Biomacromolecules, CAS Center for Excellence in Biomacromolecules, Institute of Biophysics, Chinese Academy of Sciences, Beijing, 100101, China
| | - Si-Tong Liu
- Cardiovascular Center, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Xi-Lin Zhang
- Cardiovascular Center, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jin-Kui Yang
- Department of Endocrinology, Beijing Key Laboratory of Diabetes Research and Care, Beijing Diabetes Institute, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Yi-Xi Zou
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China.
| | - Hao Wang
- Beijing Key Laboratory of Diabetes Research and Care, Beijing Diabetes Institute, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China.
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27
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Collins B, Lip GYH. Delaying Oral Anticoagulants: A False Economy? PHARMACOECONOMICS 2024:10.1007/s40273-024-01422-7. [PMID: 39093501 DOI: 10.1007/s40273-024-01422-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/22/2024] [Indexed: 08/04/2024]
Affiliation(s)
- Brendan Collins
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Public Health Policy and Systems, University of Liverpool, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, and Liverpool Heart and Chest Hospital, Liverpool, UK.
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Haghjoo M, Askarinejad A, Heidarali M, Bakhshandeh H, Fazelifar A, Emkanjoo Z, Madadi S, Kamali F, Noohi F. Implementation of an atrial fibrillation better care (ABC) pathway management strategy: Findings from the Iranian registry of atrial fibrillation. IJC HEART & VASCULATURE 2024; 53:101461. [PMID: 39100545 PMCID: PMC11294695 DOI: 10.1016/j.ijcha.2024.101461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 06/30/2024] [Accepted: 07/02/2024] [Indexed: 08/06/2024]
Abstract
Introduction The Atrial Fibrillation Better Care (ABC) pathway is such an integrated care approach, recommended in guidelines. The aim of this service evaluation study was to evaluate the impact of implementing the ABC pathway in Iranian population. Methods In this prospective longitudinal cohort study, consecutive patients with a diagnosis of AF were initially evaluated. Patients at baseline were evaluated in hence of adherence to ABC pathway strategy. After study enrolment, first and second follow-up service evaluations were conducted at 6 and 12 months, respectively. Results The use of vitamin K antagonists (VKA) decreased from 25.1 % at enrolment to 13.8 % at follow-up; instead, non-VKA oral anticoagulants (NOAC) utilization increased from 40.0 % to 86.1 %, while antiplatelet treatment decreased from 34.9 % to 0 %. Use of antihypertensive drugs, ARBs, diuretics, and statins increased after implementation of the ABC pathway. Implementation of the ABC pathway approach led to a decrease in the occurrence of stroke/TIA (from 6.3 % to 2.2 %, p = 0.002), systemic thromboembolism (from 1.4 % to 0.0 %, p = 0.04), nose bleeds (from 0.8 % to 0.6 %, p = 0.04), skin bruising (from 1.2 % to 0.0 %, p = 0.002), and heart failure (from 7.7 % to 4.7 %, p = 0.04). The proportion of patients in EHRA Class I-II increased from 93.3 % at enrolment to 98.1 % at follow-up. Conclusion In this first study from a Middle East population, compliance with ABC pathway strategy in the management of AF was associated with optimization of management and general improvements in patient outcomes during follow-up.
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Affiliation(s)
- Majid Haghjoo
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
- Department of Cardiac Electrophysiology, Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Amir Askarinejad
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
- Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Mona Heidarali
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
- Department of Cardiac Electrophysiology, Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Hooman Bakhshandeh
- Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Amirfarjam Fazelifar
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
- Department of Cardiac Electrophysiology, Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Zahra Emkanjoo
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
- Department of Cardiac Electrophysiology, Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Shabnam Madadi
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
- Department of Cardiac Electrophysiology, Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Farzad Kamali
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
- Department of Cardiac Electrophysiology, Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Fereidoun Noohi
- Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
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Calvert P, Chen Y, Gue Y, Gupta D, Azariah JL, George Koshy A, Zachariah G, Lip GYH, Gopalan BC. One-year outcomes of rate versus rhythm control of atrial fibrillation in the Kerala-AF Registry. J Arrhythm 2024; 40:822-829. [PMID: 39139885 PMCID: PMC11317704 DOI: 10.1002/joa3.13059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 04/21/2024] [Accepted: 05/02/2024] [Indexed: 08/15/2024] Open
Abstract
Background There is ongoing debate around rate versus rhythm control strategies for managing atrial fibrillation (AF), however, much of the data comes from Western cohorts. Kerala-AF represents the largest prospective AF cohort study from the Indian subcontinent. Objectives To compare 12-month outcomes between rate and rhythm control strategies. Methods Patients aged ≥18 years with non-transient AF were recruited from 53 hospitals across Kerala. Patients were stratified by rate or rhythm control. The primary outcome was a composite of all-cause mortality, arterial thromboembolism, acute coronary syndrome or hospitalization due to heart failure or arrhythmia at 12 months. Secondary outcomes included bleeding events and individual components of the primary. Predictors of the composite outcome were analysed by logistic regression. Results A total of 2901 patients (mean age 64.6 years, 51% female) were included (2464 rate control, 437 rhythm control). Rates of the primary composite outcome did not differ between groups (29.7% vs 30.0%; p = .955), nor did any component of the primary. Bleeding outcomes were also similar (1.6% vs 1.9%; p = .848). Independent predictors of the primary composite outcome were older age (aOR 1.01; p = .013), BMI <18 (aOR 1.51; p = .025), permanent AF (aOR 0.78; p = .010), HFpEF (aOR 1.40; p = .023), HFrEF (aOR 1.39; p = .004), chronic kidney disease (aOR 1.36; p < .001), and prior thromboembolism (aOR 1.31; p = .014). Conclusion In the Kerala-AF registry, 12-month outcomes did not differ between rate and rhythm control cohorts.
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Affiliation(s)
- Peter Calvert
- Liverpool Centre for Cardiovascular Science at University of LiverpoolLiverpool John Moores University and Liverpool Heart and Chest HospitalLiverpoolUK
| | - Yang Chen
- Liverpool Centre for Cardiovascular Science at University of LiverpoolLiverpool John Moores University and Liverpool Heart and Chest HospitalLiverpoolUK
| | - Ying Gue
- Liverpool Centre for Cardiovascular Science at University of LiverpoolLiverpool John Moores University and Liverpool Heart and Chest HospitalLiverpoolUK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of LiverpoolLiverpool John Moores University and Liverpool Heart and Chest HospitalLiverpoolUK
| | - Jinbert Lordson Azariah
- Department of Clinical ResearchAnanthapuri Hospitals and Research InstituteThiruvananthapuramIndia
- Department of ResearchGlobal Institute of Public HealthTrivandrumIndia
| | | | | | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science at University of LiverpoolLiverpool John Moores University and Liverpool Heart and Chest HospitalLiverpoolUK
- Danish Centre for Health Services Research, Department of Clinical MedicineAalborg UniversityAalborgDenmark
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Teppo K, Lip GYH, Airaksinen KEJ, Halminen O, Haukka J, Putaala J, Mustonen P, Linna M, Hartikainen J, Lehto M. Comparing CHA 2DS 2-VA and CHA 2DS 2-VASc scores for stroke risk stratification in patients with atrial fibrillation: a temporal trends analysis from the retrospective Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) cohort. THE LANCET REGIONAL HEALTH. EUROPE 2024; 43:100967. [PMID: 39171253 PMCID: PMC11337097 DOI: 10.1016/j.lanepe.2024.100967] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 06/01/2024] [Accepted: 06/03/2024] [Indexed: 08/23/2024]
Abstract
Background Contemporary data have shown a decrease in the ischaemic stroke risk associated with female sex in patients with atrial fibrillation (AF). We evaluated temporal trends in the predictive value of a non-sex CHA2DS2-VASc risk score (ie. CHA2DS2-VA). Methods The FinACAF study covers all patients with incident AF between 2007 and 2018 in Finland from all levels of care. The CHA2DS2-VA score was compared with the CHA2DS2-VASc using continuous and category-based net reclassification indices (NRIs), integrated discrimination improvement (IDI), c-statistics and decision curve analyses. Findings We identified 144,879 anticoagulant naïve patients with new-onset AF between 2007 and 2018 (49.9% women; mean age 72.1 years), of whom 3936 (2.7%) experienced ischaemic stroke during one-year follow-up. Based on both continuous and category-based NRIs, the CHA2DS2-VA score was inferior to the CHA2DS2-VASc in the early years (-0.333 (95% CI -0.411 to -0.261) and -0.118 (95% CI -0.137 to -0.099), respectively). However, the differences attenuated over time, and by the end of the study period, the continuous NRI became non-significant (-0.093 (95% CI -0.165 to 0.032)), whereas the category-based NRI reversed in favor of the CHA2DS2-VA (0.070 (95% CI 0.048-0.087)). The IDI was non-significant in early years (0.0009 (95% CI -0.0024 to 0.0037)), but over time became statistically significant in favor of the CHA2DS2-VA score (0.0022 (95% CI 0.0001-0.0044)). The Cox models fitted with the CHA2DS2-VA and the CHA2DS2-VASc scores exhibited comparable discriminative capability in the beginning of the study (p-value 0.63), but over time marginal differences in favor of the CHA2DS2-VA score emerged (p-value 0.0002). Interpretation In 2007-2008 (when females had higher AF-related stroke risks than males), the CHA2DS2-VASc score outperformed the CHA2DS2-VA score, but the initial differences between the scores attenuated over time. By the end of the study period in 2017-2018 (with limited/no sex differences in AF-related stroke), there was marginal superiority for the CHA2DS2-VA score. Funding This work was supported by the Aarne Koskelo Foundation, The Finnish Foundation for Cardiovascular Research, The Finnish State Research funding, and Helsinki and Uusimaa Hospital District research fund.
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Affiliation(s)
- Konsta Teppo
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Gregory Yoke Hong Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Jari Haukka
- Faculty of Medicine, University of Helsinki, Finland
| | - Jukka Putaala
- Neurology Department, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pirjo Mustonen
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Miika Linna
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
- University of Eastern Finland, Kuopio, Finland
- Aalto University, Espoo, Finland
| | - Juha Hartikainen
- Heart Center, Kuopio University Hospital and University of Eastern Finland, Finland
| | - Mika Lehto
- Jorvi Hospital, Department of Internal Medicine, Finland
- HUS Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Harenberg J, Gosselin RC, Cuker A, Becattini C, Pabinger I, Poli S, Weitz J, Ageno W, Bauersachs R, Celap I, Choi P, Douketis J, Douxfils J, Elalamy I, Falanga A, Fareed J, Favaloro EJ, Gerotziafas G, Herkner H, Hetjens S, Heubner L, Klamroth R, Langer F, Lip GYH, Grory BM, Margetić S, Merrelaar A, Pikta M, Renne T, Schulman S, Schwameis M, Strbian D, Tafur A, Vassart J, Violi F, Walenga J, Weiss C. Algorithm for Rapid Exclusion of Clinically Relevant Plasma Levels of Direct Oral Anticoagulants in Patients Using the DOAC Dipstick: An Expert Consensus Paper. Thromb Haemost 2024; 124:770-777. [PMID: 38316416 DOI: 10.1055/a-2261-1811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
BACKGROUND With the widespread use of direct oral anticoagulants (DOACs), there is an urgent need for a rapid assay to exclude clinically relevant plasma levels. Accurate and rapid determination of DOAC levels would guide medical decision-making to (1) determine the potential contribution of the DOAC to spontaneous or trauma-induced hemorrhage; (2) identify appropriate candidates for reversal, or (3) optimize the timing of urgent surgery or intervention. METHODS AND RESULTS The DOAC Dipstick test uses a disposable strip to identify factor Xa- or thrombin inhibitors in a urine sample. Based on the results of a systematic literature search followed by an analysis of a simple pooling of five retrieved clinical studies, the test strip has a high sensitivity and an acceptably high negative predictive value when compared with levels measured with liquid chromatography tandem mass spectrometry or calibrated chromogenic assays to reliably exclude plasma DOAC concentrations ≥30 ng/mL. CONCLUSION Based on these data, a simple algorithm is proposed to enhance medical decision-making in acute care indications useful primarily in hospitals not having readily available quantitative tests and 24/7. This algorithm not only determines DOAC exposure but also differentiates between factor Xa and thrombin inhibitors to better guide clinical management.
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Affiliation(s)
- Job Harenberg
- Ruprecht Karls University of Heidelberg, Heidelberg, Germany
- DOASENSE GmbH, Heidelberg, Germany
| | - Robert C Gosselin
- Davis Health System, Thrombosis and Hemostasis Center, University of California, Sacramento, California, United States
| | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Cecilia Becattini
- Internal and Emergency Medicine -Stroke Unit, University of Perugia, Perugia PG, Italy
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tubingen, Germany
| | - Jeffrey Weitz
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Rupert Bauersachs
- GefasCentrum, CCB - Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
| | - Ivana Celap
- Department of Clinical Chemistry, University Hospital Center Sestre, Zagreb, Croatia
- Faculty of Pharmacy and Biochemistry, University of Zagreb, Croatia
| | - Philip Choi
- Neurosciences, Box Hill Hospital, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Australia
| | - James Douketis
- Department Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Research for Life Sciences, Namur, Belgium
- Qualiblood s.a., Department of Research and Development, Namur, Belgium
| | - Ismail Elalamy
- Service d'Hematologie Biologique Hopital Tenon, Hopitaux Universitaires Est Parisien, Assistance Publique Hopitaux de Paris, Paris, France
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Anna Falanga
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, Bergamo, Italy
- University of Milan Bicocca, Monza, Italy
| | - Jawed Fareed
- Department of Molecular Pharmacology & Neuroscience, Loyola University Medical Center, Maywood, Illinois, United States
| | - Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital, Westmead, NSW, Australia
- Faculty of Science and Health, Charles Sturt University, Wagga Wagga, NSW, Australia
| | - Grigorios Gerotziafas
- INSERM, UMR_S 938, Research Group Cancer, Biology and Therapeutics, Centre de recherche Saint-Antoine (CRSA), Institut Universitaire de Cancerologie, Sorbonne Universite, Paris, France
- Thrombosis Center, Tenon-Saint Antoine, Hopitaux Universitaires de l'Est Parisien, Assistance Publique Hopitaux de Paris (APHP), France
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Svetlana Hetjens
- Department of Statistics, Medical Faculty Mannheim, Ruprecht Karls University of Heidelberg, Mannheim, Germany
| | - Lars Heubner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus," Technische Universitat Dresden, Germany
| | - Robert Klamroth
- Vascular Medicine and Haemostaseology, Vivantes Klinikum im Friedrichschain, Berlin, Germany
| | - Forian Langer
- II. Medizinische Klinik und Poliklinik, Universitatsklinikum Eppendorf, Hamburg, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Brian Mac Grory
- Department of Neurology, Duke University, Durham, North Carolina, United States
| | - Sandra Margetić
- GefasCentrum, CCB - Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
- School of Medicine, Catholic University of Croatia, Zagreb, Croatia
| | - Anne Merrelaar
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Marika Pikta
- Department of Laboratory Medicine, North Estonia Medical Centre, Tallinn, Estonia
- Department of Health Technologies, Tallinn University of Technology, Tallinn, Estonia
| | - Thomas Renne
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Sam Schulman
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
- Thrombosis and Atherosclerosis Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Alfonso Tafur
- Department of Medicine, Vascular Medicine, NorthShore University Health System, Evanston, Illinois, United States
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, United States
| | - Julie Vassart
- Department of Pharmacy, Namur Research for Life Sciences, Namur, Belgium
| | - Francesco Violi
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Jeanine Walenga
- Cardiovascular Research Institute, Loyola University Chicago, Maywood, Illinois, United States
| | - Christel Weiss
- Department of Statistics, Medical Faculty Mannheim, Ruprecht Karls University of Heidelberg, Mannheim, Germany
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Schaefer JK, Barnes GD. Are the Direct Oral Anticoagulants Better for Patients with Low Time in the Therapeutic Range on Vitamin K Antagonist Therapy? Thromb Haemost 2024; 124:791-794. [PMID: 38823378 DOI: 10.1055/s-0044-1787299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2024]
Affiliation(s)
- Jordan K Schaefer
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - Geoffrey D Barnes
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
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Menichelli D, Pignatelli P, Brogi T, Pannunzio A, Violi F, Lip GY, Pastori D. Incidence of All-Cause, Cardiovascular, and Atrial Fibrillation-Related Hospitalizations: Focus on Antiarrhythmic Drugs. JACC. ADVANCES 2024; 3:101117. [PMID: 39105112 PMCID: PMC11299568 DOI: 10.1016/j.jacadv.2024.101117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/24/2024] [Indexed: 08/07/2024]
Abstract
Background Atrial fibrillation (AF) is associated with an increased risk of hospital admission, but few data on reasons for hospitalization and on the role of anti-arrhythmic drugs are available. Objectives The purpose of this study was to investigate the incidence rate and factors associated with all-cause, cardiovascular, and AF-related hospitalizations. Methods Prospective ongoing ATHERO-AF (Atherosclerosis in Atrial Fibrillation) cohort study enrolling AF patients on oral anticoagulants. Primary end points were all-cause, cardiovascular, and AF-related hospitalization, the latter defined as AF recurrences for paroxysmal AF and high-rate symptomatic AF episodes for persistent/permanent AF patients. Results 2,782 patients were included (43.5% female; mean age was 74.6 ± 9.1 years). During a mean follow-up of 31 ± 26.8 months, 1,205 (12.1%/year) all-cause, 533 cardiac (5.7%/year), and 180 (2.0%/year) AF-related hospitalizations occurred. Predictors of AF-related hospitalizations were the use of flecainide/propafenone in both paroxysmal and persistent/permanent AF patients (HR: 1.861; 95% CI: 1.116 to 3.101 and 1.947; 95% CI: 1.069 to 3.548, respectively). Amiodarone (HR: 3.012; 95% CI: 1.835-4.943), verapamil/diltiazem (HR: 2.067; 95% CI: 1.117-3.825), and cancer (HR: 1.802; 95% CI: 1.057-3.070) but not beta-blockers and digoxin were associated with an increased risk of AF-related hospitalizations in persistent/permanent AF patients. Conclusions Elderly AF patients frequently undergo hospitalizations for both cardiovascular and noncardiovascular causes. The use of anti-arrhythmic drugs was associated with an increased risk of AF-related hospitalization suggesting a scarce effect of these drugs in preventing AF episodes. Therefore, their use should be carefully considered and reserved for symptomatic patients with frequent AF recurrences.
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Affiliation(s)
- Danilo Menichelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
- Department of General Surgery and Surgical Specialty Paride Stefanini, Sapienza University of Rome, Rome, Italy
| | - Pasquale Pignatelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Tommaso Brogi
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Arianna Pannunzio
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesco Violi
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Daniele Pastori
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
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Ding WY, Calvert P, Lip GYH, Gupta D. Novel stroke prevention strategies following catheter ablation for atrial fibrillation. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:690-696. [PMID: 38428582 DOI: 10.1016/j.rec.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 02/14/2024] [Indexed: 03/03/2024]
Abstract
Stroke prevention following successful catheter ablation of atrial fibrillation remains a controversial topic. Oral anticoagulation is associated with a significant reduction in stroke risk in the general atrial fibrillation population but may be associated with an increased risk of major bleeding, and the benefit: risk ratio must be considered. Improvement in successful catheter ablation and widespread use of cardiac monitoring devices may allow for novel anticoagulation strategies in a subset of patients with atrial fibrillation, which may optimize stroke prevention while minimizing bleeding risk. In this review, we discuss stroke risk in atrial fibrillation and the effects of successful catheter ablation on thromboembolic risk. We also explore novel strategies for stroke prevention following successful catheter ablation.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Peter Calvert
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Danish Centre for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
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Lip GYH, Noxon V, Kang A, Luo X, Atreja N, Han S, Cheng D, Jiang J, Abramovitz L, Deitelzweig S. Effectiveness and safety in non-valvular atrial fibrillation patients switching from warfarin to direct oral anticoagulants in US healthcare claims. J Thromb Thrombolysis 2024; 57:1092-1102. [PMID: 38698197 PMCID: PMC11315758 DOI: 10.1007/s11239-024-02976-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 05/05/2024]
Abstract
INTRODUCTION There is a paucity of real-world studies examining the risks of stroke/systemic embolism (SE) and major bleeding (MB) among non-valvular atrial fibrillation (NVAF) patients switching from warfarin to a direct oral anticoagulant (DOAC). This retrospective study was conducted to compare the stroke/SE and MB risks between patients switched from warfarin to apixaban, dabigatran, or rivaroxaban in real-world clinical practice. MATERIALS AND METHODS This study used data from four United States commercial claims databases from January 1, 2012 to June 30, 2019. The study population included NVAF patients initially treated with warfarin and switched to apixaban, dabigatran, or rivaroxaban within 90 days of their warfarin prescription ending. Patients were matched 1:1 between the DOACs in each database using propensity scores and then pooled for the final analysis. Cox proportional hazards models were used to calculate the risk of stroke/SE and MB. RESULTS AND CONCLUSIONS The final population consisted of 2,611 apixaban-dabigatran, 12,165 apixaban-rivaroxaban, and 2,672 dabigatran-rivaroxaban pairs. Apixaban vs. dabigatran was associated with a lower risk of stroke/SE (hazard ratio [HR]: 0.61; 95% confidence interval [CI]: 0.39-0.96) and MB (HR: 0.67; 95% CI: 0.50-0.91). Apixaban vs. rivaroxaban was associated with a similar risk of stroke/SE (HR: 0.88; 95% CI: 0.73-1.07) and a lower risk of MB (HR: 0.60; 95% CI: 0.52-0.68). There was no significant difference in either risk between dabigatran and rivaroxaban. These results provide important insights into how the risks of stroke/SE and MB for NVAF patients vary when switching from warfarin to different DOACs.
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Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK.
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
- Faculty of Health and Life Sciences, University of Liverpool, Foundation Building, Brownlow Hill, Liverpool, L69 7TX, UK.
| | | | - Amiee Kang
- Bristol-Myers Squibb Company, New York, NY, USA
| | | | | | - Stella Han
- Bristol-Myers Squibb Company, New York, NY, USA
| | - Dong Cheng
- Bristol-Myers Squibb Company, New York, NY, USA
| | - Jenny Jiang
- Bristol-Myers Squibb Company, New York, NY, USA
| | | | - Steven Deitelzweig
- Department of Hospital Medicine, Ochsner Clinic Foundation, New Orleans, LA, USA
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Liao JN, Chan YH, Kuo L, Tsai CT, Liu CM, Chen TJ, Lip GYH, Chen SA, Chao TF. Association between antithrombotic drug regimen changes and clinical outcomes after stroke in atrial fibrillation. Heart Rhythm 2024:S1547-5271(24)03094-7. [PMID: 39094727 DOI: 10.1016/j.hrthm.2024.07.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 07/22/2024] [Accepted: 07/27/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND The impact of post-stroke antithrombotic regimen in atrial fibrillation is uncertain. OBJECTIVE This study aimed to describe antithrombotic therapy prescribing patterns after ischemic stroke and the impact on outcomes. METHODS A total of 23,165 patients with atrial fibrillation experiencing ischemic stroke were identified. Subsequent post-stroke events included recurrent ischemic stroke, intracranial hemorrhage, major bleeding, mortality, and composite outcomes. RESULTS Of those who were nonanticoagulated before a stroke, 33.5% remained nonanticoagulated and 39.2% were prescribed only antiplatelet agents (APs) after a stroke. Compared with non-vitamin K antagonist oral anticoagulants (NOACs) after stroke, there was a significant increase in ischemic stroke and mortality in nonanticoagulated patients (adjusted hazard ratio [aHR], 2.09 and 3.92) and AP users (aHR, 1.32 and 1.28). Post-stroke warfarin was associated with a significantly increased risk of major bleeding compared with NOACs (aHR, 1.23). Of 769 patients receiving NOACs before stroke and continuing NOACs after stroke, those switching to a different NOAC were associated with significantly higher risk of ischemic stroke (aHR, 2.07) and composite outcomes (aHR, 1.36-1.85) with no difference in intracranial hemorrhage, major bleeding, or mortality compared with those receiving the same NOAC after stroke. Of patients receiving NOACs before stroke, the risks of clinical events were similar between patients taking NOACs alone and those taking NOAC plus AP after stroke. CONCLUSION NOAC alone after stroke was associated with a better clinical outcome compared with nonanticoagulation, AP, or warfarin. Of patients already taking NOACs before stroke, the addition of AP did not confer additional benefits compared with NOACs alone. A change of NOAC types after stroke was associated with a 2-fold higher risk of ischemic stroke and composite outcomes.
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Affiliation(s)
- Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsin Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Ling Kuo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chuan-Tsai Tsai
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chih-Min Liu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan; Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Ferguson C, Shaikh F, Allida SM, Hendriks J, Gallagher C, Bajorek BV, Donkor A, Inglis SC. Clinical service organisation for adults with atrial fibrillation. Cochrane Database Syst Rev 2024; 7:CD013408. [PMID: 39072702 PMCID: PMC11285297 DOI: 10.1002/14651858.cd013408.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) is an increasingly prevalent heart rhythm condition in adults. It is considered a common cardiovascular condition with complex clinical management. The increasing prevalence and complexity in management underpin the need to adapt and innovate in the delivery of care for people living with AF. There is a need to systematically examine the optimal way in which clinical services are organised to deliver evidence-based care for people with AF. Recommended approaches include collaborative, organised multidisciplinary, and virtual (or eHealth/mHealth) models of care. OBJECTIVES To assess the effects of clinical service organisation for AF versus usual care for people with all types of AF. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL to October 2022. We also searched ClinicalTrials.gov and the WHO ICTRP to April 2023. We applied no restrictions on date, publication status, or language. SELECTION CRITERIA We included randomised controlled trials (RCTs), published as full texts and as abstract only, involving adults (≥ 18 years) with a diagnosis of any type of AF. We included RCTs comparing organised clinical service, disease-specific management interventions (including e-health models of care) for people with AF that were multicomponent and multidisciplinary in nature to usual care. DATA COLLECTION AND ANALYSIS Three review authors independently selected studies, assessed risk of bias, and extracted data from the included studies. We calculated risk ratio (RR) for dichotomous data and mean difference (MD) or standardised mean difference (SMD) for continuous data with 95% confidence intervals (CIs) using random-effects analyses. We then calculated the number needed to treat for an additional beneficial outcome (NNTB) using the RR. We performed sensitivity analyses by only including studies with a low risk of selection and attrition bias. We assessed heterogeneity using the I² statistic and the certainty of the evidence according to GRADE. The primary outcomes were all-cause mortality and all-cause hospitalisation. The secondary outcomes were cardiovascular mortality, cardiovascular hospitalisation, AF-related emergency department visits, thromboembolic complications, minor cerebrovascular bleeding events, major cerebrovascular bleeding events, all bleeding events, AF-related quality of life, AF symptom burden, cost of intervention, and length of hospital stay. MAIN RESULTS We included 8 studies (8205 participants) of collaborative, multidisciplinary care, or virtual care for people with AF. The average age of participants ranged from 60 to 73 years. The studies were conducted in China, the Netherlands, and Australia. The included studies involved either a nurse-led multidisciplinary approach (n = 4) or management using mHealth (n = 2) compared to usual care. Only six out of the eight included studies could be included in the meta-analysis (for all-cause mortality and all-cause hospitalisation, cardiovascular mortality, cardiovascular hospitalisation, thromboembolic complications, and major bleeding), as quality of life was not assessed using a validated outcome measure specific for AF. We assessed the overall risk of bias as high, as all studies had at least one domain at unclear or high risk of bias rating for performance bias (blinding) in particular. Organised AF clinical services probably result in a large reduction in all-cause mortality (RR 0.64, 95% CI 0.46 to 0.89; 5 studies, 4664 participants; moderate certainty evidence; 6-year NNTB 37) compared to usual care. However, organised AF clinical services probably make little to no difference to all-cause hospitalisation (RR 0.94, 95% CI 0.88 to 1.02; 2 studies, 1340 participants; moderate certainty evidence; 2-year NNTB 101) and may not reduce cardiovascular mortality (RR 0.64, 95% CI 0.35 to 1.19; 5 studies, 4564 participants; low certainty evidence; 6-year NNTB 86) compared to usual care. Organised AF clinical services reduce cardiovascular hospitalisation (RR 0.83, 95% CI 0.71 to 0.96; 3 studies, 3641 participants; high certainty evidence; 6-year NNTB 28) compared to usual care. Organised AF clinical services may have little to no effect on thromboembolic complications such as stroke (RR 1.14, 95% CI 0.74 to 1.77; 5 studies, 4653 participants; low certainty evidence; 6-year NNTB 588) and major cerebrovascular bleeding events (RR 1.25, 95% CI 0.79 to 1.97; 3 studies, 2964 participants; low certainty evidence; 6-year NNTB 556). None of the studies reported minor cerebrovascular events. AUTHORS' CONCLUSIONS Moderate certainty evidence shows that organisation of clinical services for AF likely results in a large reduction in all-cause mortality, but probably makes little to no difference to all-cause hospitalisation compared to usual care. Organised AF clinical services may not reduce cardiovascular mortality, but do reduce cardiovascular hospitalisation compared to usual care. However, organised AF clinical services may make little to no difference to thromboembolic complications and major cerebrovascular events. None of the studies reported minor cerebrovascular events. Due to the limited number of studies, more research is required to compare different models of care organisation, including utilisation of mHealth. Appropriately powered trials are needed to confirm these findings and robustly examine the effect on inconclusive outcomes. The findings of this review underscore the importance of the co-ordination of care underpinned by collaborative multidisciplinary approaches and augmented by virtual care.
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Affiliation(s)
- Caleb Ferguson
- Centre for Chronic & Complex Care Research, Western Sydney Local Health District, Sydney, Australia
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Fahad Shaikh
- Centre for Chronic & Complex Care Research, Western Sydney Local Health District, Sydney, Australia
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Sabine M Allida
- Centre for Chronic & Complex Care Research, Western Sydney Local Health District, Sydney, Australia
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Jeroen Hendriks
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health and Medical Research Institute and Royal Adelaide Hospital, Adelaide, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health and Medical Research Institute and Royal Adelaide Hospital, Adelaide, Australia
| | - Beata V Bajorek
- Heart and Brain Program, Hunter Medical Research Institute, Newcastle, Australia
- College of Health, Medicine, and Wellbeing, University of Newcastle, Newcastle, Australia
- Department of Pharmacy, Hunter New England Local Health District, Newcastle, Australia
| | - Andrew Donkor
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Sally C Inglis
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia
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Veale EL. Pharmacy-Led Management of Atrial Fibrillation: Improving Treatment Adherence and Patient Outcomes. INTEGRATED PHARMACY RESEARCH AND PRACTICE 2024; 13:101-114. [PMID: 39101005 PMCID: PMC11297543 DOI: 10.2147/iprp.s397844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 07/13/2024] [Indexed: 08/06/2024] Open
Abstract
The world's population is ageing, with the number of those over 60 years expected to represent a fifth of the total population by 2050. Increases in chronic long-term health conditions (LTCs) associated with ageing, and requiring regular but often avoidable medical intervention, are pressurising already overloaded, health and social care systems. Atrial fibrillation (AF) is an LTC, which is most frequently diagnosed in the elderly. An often, asymptomatic condition, AF is associated with a 3- to 5-fold increased risk of severe ischemic stroke. Stroke prevention, with risk-stratified oral anticoagulants (OACs) is the standard recommended care for patients with AF. Stroke avoidance is, however, dependent on persistent adherence to OAC medication, with an adherence rate of >80% considered necessary to achieve optimal health outcomes. Suboptimal adherence to OACs is common, with a third of all AF patients not taking their medication as prescribed. This combined with the short half-life of OACs can result in poor clinical outcomes for patients. Policy makers now consider improving adherence to prescribed medicines for LTCs, a public health priority, to ensure better health outcomes for patients, whilst minimising unnecessary health system costs. Prescribing medicines to treat LTCs, such as AF, is not enough, particularly when the patient may not experience any measurable benefit to the treatment and may instead, experience medication-associated adverse events, including a risk of bleeding. Pharmacists who are experts in medicines management are ideally placed to support medication adherence, to educate, and to improve health outcomes for patients with AF. In this review, I will consider the evidence for poor medication adherence in LTCs and in particular adherence to OACs in patients with AF and highlight the role that pharmacists can play in ensuring optimal adherence and showcase pharmacist-led interventions that effectively address this problem.
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Affiliation(s)
- Emma L Veale
- Medway School of Pharmacy, University of Kent and University of Greenwich, Chatham Maritime, Kent, UK
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Pastori D, Menichelli D, Li YG, Brogi T, Biccirè FG, Pignatelli P, Farcomeni A, Lip GYH. Usefulness of the C 2HEST score to predict new onset atrial fibrillation. A systematic review and meta-analysis on >11 million subjects. Eur J Clin Invest 2024:e14293. [PMID: 39072756 DOI: 10.1111/eci.14293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 07/13/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND The incidence of new-onset atrial fibrillation (NOAF) is increasing in the last decades. NOAF is associated with worse long-term prognosis. The C2HEST score has been recently proposed to stratify the risk of NOAF. Pooled data on the performance of the C2HEST score are lacking. METHODS Systematic review and meta-analysis of observational studies reporting data on NOAF according to the C2HEST score. We searched PubMed, Web of Science and Google scholar databases without time restrictions until June 2023 according to PRISMA guidelines. Meta-analysis of the area under the curve (AUC) with 95% confidence interval (95% CI) and a sensitivity analysis according to setting of care and countries were performed. RESULTS Of 360 studies, 17 were included in the analysis accounting for 11,067,496 subjects/patients with 307,869 NOAF cases. Mean age ranged from 41.3 to 71.2 years. The prevalence of women ranged from 10.6 to 54.75%. The pooled analysis gave an AUC of .70 (95% CI .66-.74). A subgroup analysis on studies from general population/primary care yielded an AUC of 0.69 (95% CI 0.64-0.75). In the subgroup of patients with cardiovascular disease, the AUC was .71 (.69-.79). The C2HEST score performed similarly in Asian (AUC .72, 95% CI .68-.77), and in Western patients (AUC .68, 95% CI .62-.75). The best performance was observed in studies with a mean age <50 years (n = 3,144,704 with 25,538 NOAF, AUC .78, 95% CI .76-.79). CONCLUSION The C2HEST score may be used to predict NOAF in primary and secondary prevention patients, and in patients across different countries. Early detection of NOAF may aid prompt initiation of management and follow-up, potentially leading to a reduction of AF-related complications.
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Affiliation(s)
- Daniele Pastori
- Department of Clinical Internal, Anesthesiological, and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Danilo Menichelli
- Department of Clinical Internal, Anesthesiological, and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
- Department of General and Specialized Surgery "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Yan-Guang Li
- Department of Cardiology, Beijing Anzhen Hospital, Beijing, China
| | - Tommaso Brogi
- Department of Clinical Internal, Anesthesiological, and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Flavio Giuseppe Biccirè
- Department of General and Specialized Surgery "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Pasquale Pignatelli
- Department of Clinical Internal, Anesthesiological, and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Alessio Farcomeni
- Department of Economics and Finance, University of Rome 'Tor Vergata', Rome, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Wang Y, Yang Y, Wang L, Zhang H, Tan JS, Shu Y. Antithrombotic therapy at discharge and prognosis in patients with chronic coronary syndrome and atrial fibrillation who underwent PCI: a real-world study. Thromb J 2024; 22:65. [PMID: 39020396 PMCID: PMC11253490 DOI: 10.1186/s12959-024-00628-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 06/28/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND This study aimed to describe the status of antithrombotic therapy at discharge and prognosis in patients with atrial fibrillation (AF) and chronic coronary syndrome (CCS) who underwent percutaneous coronary intervention (PCI). METHODS This was an observational, prospective study. The primary endpoint was major adverse cardiovascular events (MACE), including all-cause death, myocardial infarction, stroke/transient ischemic attach (TIA), systemic embolism or ischemia-driven revascularization. Bleeding events were collected according to the Thrombolysis in Myocardial Infarction (TIMI) criteria. RESULTS Between 2017 and 2019, a cohort of 516 patients (mean age 66, [SD 9], of whom 18.4% were female) with AF and CCS who underwent PCI were evaluated, with a median followed-up time of 36 months (Interquartile range: 22-45). MACE events occurred in 13.0% of the patients, while the TIMI bleeding events were observed in 17.4%. Utilization of TAT (triple antithrombotic therapy) (P < 0.001) and oral anticoagulation (OAC) therapy (P < 0.001) increased through years. History of heart failure (HF) (Hazard ratio [HR], 1.744; 95% confidence interval [CI], 1.011-3.038) and TAT (HR, 2.708; 95%CI, 1.653-4.436) had independent associations with MACE events. OAC (HR, 10.378; 95%CI, 6.136-17.555) was identified as a risk factor for bleeding events. A higher creatine clearance (HR, 0.986; 95%CI, 0.974-0.997) was associated with a lower incidence of bleeding events. CONCLUSIONS Antithrombotic therapy has been improved among patients with AF and CCS who underwent PCI these years. History of HF and TAT were independently associated with MACE events. Higher creatine clearance was protective factor of bleeding events, while OAC was a risk factor for TIMI bleeding events.
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Affiliation(s)
- Yimeng Wang
- Emergency Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishilu, Xicheng District, Beijing, China
| | - Yanmin Yang
- Emergency Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishilu, Xicheng District, Beijing, China.
| | - Lulu Wang
- Emergency Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishilu, Xicheng District, Beijing, China
| | - Han Zhang
- Emergency Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishilu, Xicheng District, Beijing, China
| | - Jiang-Shan Tan
- Emergency Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishilu, Xicheng District, Beijing, China
| | - Yuyuan Shu
- Emergency Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases of China, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishilu, Xicheng District, Beijing, China
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Krittayaphong R, Winijkul A, Methavigul K, Chichareon P, Lip GYH. Clinical outcomes of patients with atrial fibrillation in relation to multimorbidity status changes over time and the impact of ABC pathway compliance: a nationwide cohort study. J Thromb Thrombolysis 2024:10.1007/s11239-024-03007-9. [PMID: 38981981 DOI: 10.1007/s11239-024-03007-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2024] [Indexed: 07/11/2024]
Abstract
Patients with atrial fibrillation (AF) commonly have associated comorbidities. The primary aim was to determine the effect of increasing numbers of comorbidity on clinical outcomes. The secondary aims were (1) the association of comorbidities with oral anticoagulants (OAC) discontinuation, and quality control, (2) the impact of holistic care based on the ABC pathway on clinical outcomes. The primary outcome was the composite of all-cause death, ischemic stroke/systemic embolism, major bleeding, and heart failure. A total of 3405 patients were enrolled; mean age 67.8 ± 11.3 years, 41.8% female. Compared to low comorbidity group [n = 897 (26.3%)], hazard ratios (HR) and 95% confidence intervals (CI) for the composite outcome in the high [n = 929 (27.3%)] and moderate comorbidity [n = 1579 (46.4%)] groups were 5.40 (4.20-6.94) and 2.54 (1.97-3.27), respectively. ABC pathway adherence was associated with reduction of the composite outcome overall (HR 0.63; 0.54-0.74). High comorbidity adversely impacted on OAC use, OAC discontinuation, and quality of warfarin control. If quality of anticoagulation control was included as part of the ABC pathway adherence, the reduction in composite outcome risk was greater (HR 0.46; 0.36-0.58). During 3-year follow-up, 33.9% changed from low- to the moderate-high comorbidity groups and 22.3% changed from moderate- to the high comorbidity group. In conclusion, comorbidity burden in AF patients is an important determinant of clinical outcomes, and changed over time. OAC use, OAC discontinuation, and quality of OAC control were impacted by comorbidity burden. ABC pathway adherence was associated with a reduced risk of adverse clinical outcomes.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
| | - Arjbordin Winijkul
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Komsing Methavigul
- Department of Cardiology, Central Chest Institute of Thailand, Nonthaburi, Thailand
| | - Ply Chichareon
- Cardiology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Krittayaphong R, Boonyapiphat T, Winijkul A, Lip GYH. Clinical outcomes of obese and nonobese patients with atrial fibrillation according to associated metabolic abnormalities: A report from the COOL-AF registry. J Diabetes 2024; 16:e13519. [PMID: 38095262 PMCID: PMC11212287 DOI: 10.1111/1753-0407.13519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 10/16/2023] [Accepted: 11/26/2023] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND The primary objective was to determine the influence of obesity and associated metabolic status on clinical outcomes of Asian patients with atrial fibrillation (AF). METHODS This study was based on a prospective multicenter of patients with nonvalvular AF. Patients were classified as obese and nonobese and being metabolic unhealthy was defined as having at least one of the three cardiovascular risk factors including dyslipidemia, hypertension, or diabetes mellitus. Outcomes were a primary composite outcome of all-cause death, ischemic stroke/systemic embolism (SSE), acute myocardial infarction (MI), and heart failure (HF), as well as the individual end points. RESULTS There were a total of 3141 enrolled patients (mean age 67.4 ± 11.1 years; 41.0% female), of whom 1566 (49.9%) were obese and 2564 (81.6%) were metabolic unhealthy. During a mean follow-up of 32.2 ± 8.3 months, the incidence rate of the composite outcome, all-cause death, SSE, MI, and HF were 7.21 (6.63-7.82), 3.86 (3.45-4.30), 1.48 (1.23-1.77), 0.47 (0.33-0.64), and 2.84 (2.48-3.23) per 100 person-years, respectively. Metabolic unhealthy nonobese subjects were at higher risk of the composite outcomes than metabolic unhealthy obese subjects with hazard ratio (HR) 1.39, 95% confidence interval (CI) 1.17-1.66, p < .001. Metabolic unhealthy obese subjects tend to have an increased risk of the composite outcomes compared to those metabolic healthy obese (HR 1.36, 95% CI 0.91-2.02, p = .133). Metabolic healthy obese subjects were not associated with increased risk. CONCLUSIONS Metabolic unhealthy obese subjects were associated with an increased risk of adverse outcomes in AF patients, whereas metabolically healthy obesity was not associated with an increased risk.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | | | - Arjbordin Winijkul
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest HospitalLiverpoolUK
- Danish Center for Clinical Health Services Research, Department of Clinical MedicineAalborg UniversityAalborgDenmark
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Huang C, Li L, Liu W, Fang Y, Jiang S, Li Y, Fonarow GC, Sia CH, Yeo LLL, Tan BYQ, Lip GYH, Yang Q, Zhou X. Time to benefit and harm of direct oral anticoagulants in device-detected atrial fibrillation: A pooled analysis of the NOAH-AFNET 6 and ARTESiA trials. Heart Rhythm 2024:S1547-5271(24)02812-1. [PMID: 38925332 DOI: 10.1016/j.hrthm.2024.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 06/07/2024] [Accepted: 06/20/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) reduce stroke risk in patients with device-detected atrial fibrillation (DD-AFib) but increase major bleeding risk. The time to benefit (TTB) and time to harm (TTH) are not well quantified. OBJECTIVE The purpose of this study was to determine TTB and TTH in DOAC-treated patients with DD-AFib. METHODS Studies were identified from PubMed searching until November 2023. The primary efficacy outcome was the time to the first stroke event, and the primary safety outcome was the time to the first major bleeding event. Pooled hazard ratio (HR) and its confidence interval (CI) were calculated through reconstructed patient-level data and study-level data. Weibull model and Markov chain Monte Carlo simulation were applied to determine time to specific absolute risk change thresholds. RESULTS Two trials involving DOACs-NOAH-AFNET 6 (Non-vitamin K antagonist Oral anticoagulants in patients with Atrial High rate episodes) and ARTESiA (Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation)-were identified, which randomized 6548 adults with a mean age of >75 years and a median atrial high-rate episode duration ranging from 1.5 to 2.8 hours. DOACs decreased the risk of stroke (HR 0.67; 95% CI 0.50-0.90) but increased the risk of major bleeding (HR 1.57; 95% CI 1.21-2.04). A TTB of 2.67 years was needed to prevent 1 stroke per 100 DOAC-treated patients, while a TTH of 1.67 years was needed to observe 1 major bleeding. CONCLUSION In elderly patients with low durations of DD-AFib, DOACs result in a delayed and restricted stroke-preventive benefit while posing an early-onset bleeding risk. Our findings offer new insights into the risk-benefit profile and provide clinicians an additional dimension to facilitate shared decision-making discussions with patients.
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Affiliation(s)
- Chuanyi Huang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Linjie Li
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Wennan Liu
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Yiwen Fang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Shichen Jiang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Yongle Li
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Ching-Hui Sia
- Yong Loo-Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre, Singapore
| | - Leonard L L Yeo
- Yong Loo-Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, National University Health System, Singapore
| | - Benjamin Y Q Tan
- Yong Loo-Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, National University Health System, Singapore
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Qing Yang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China.
| | - Xin Zhou
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China.
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Camacho EM, Lip GYH. Estimating the impact of implementing an integrated care management approach with Atrial fibrillation Better Care (ABC) pathway for patients with atrial fibrillation in England from 2020 to 2040. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:326-333. [PMID: 37697684 PMCID: PMC11187718 DOI: 10.1093/ehjqcco/qcad055] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 08/21/2023] [Accepted: 09/27/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Stroke prevention is central to the management of atrial fibrillation (AF), but there remains a residual risk of adverse outcomes in anticoagulated AF patients. Hence, current guidelines have proposed a more holistic or integrated approach to AF management, based on the Atrial fibrillation Better Care (ABC) pathway, as follows: (A) avoid stroke with anticoagulation; (B) better symptom control with patient-centred symptom directed decisions on rate or rhythm control; and (C) cardiovascular and comorbidity management, including lifestyle factors. There has been no formal healthcare cost analysis from the UK National Health Service (NHS) perspective of ABC pathway implementation to optimize the management of AF. Our aim was to estimate the number of patients with AF in the UK each year up to 2040, their morbidity and mortality, and the associated healthcare costs, and secondly, to estimate improvements in morbidity and mortality of implementing an ABC pathway, and the impact on costs. RESULTS In 2020, there were an estimated 1 463 538 AF patients, resulting in £286 million of stroke care and £191 million of care related to bleeds annually. By 2030, it is expected that there will be 2 115 332 AF patients, resulting in £666 million of stroke healthcare and £444 million of healthcare related to bleeds. By 2040, this is expected to rise to 2 856 489 AF patients, with £1096 million of stroke healthcare and £731 million of healthcare related to bleeds for that year. If in 2040 patients are managed on an ABC pathway, this could prevent between 3724 and 18 622 strokes and between 5378 and 26 890 bleeds, and save between 16 131 and 80 653 lives depending on the proportion of patients managed on the pathway. This would equate to cost reductions of between £143.9 million and £719.6 million for the year. CONCLUSION We estimate that there will be a substantial healthcare burden in the UK NHS associated with AF, from strokes, bleeds, and mortality over the next decades. If patients are managed with a holistic or integrated care approach based on the ABC pathway, this could prevent strokes and bleeds that equate to substantial NHS healthcare cost reductions, and save lives.
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Affiliation(s)
- Elizabeth M Camacho
- Institute of Population Health, University of Liverpool, UK
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Lee KY, Lee SR, Choi EK, Choi J, Ahn HJ, Kwon S, Kim B, Han KD, Oh S, Lip GYH. Association between changes in renal function and clinical outcomes in anticoagulated atrial fibrillation patients with marginal renal function. A nationwide observational cohort study. Front Cardiovasc Med 2024; 11:1423336. [PMID: 38903967 PMCID: PMC11188773 DOI: 10.3389/fcvm.2024.1423336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 05/28/2024] [Indexed: 06/22/2024] Open
Abstract
Background Renal function is one of the crucial components for determining the dose and type of oral anticoagulants in atrial fibrillation (AF) patients, and is also closely associated with the risks of stroke and bleeding. This study aimed to assess renal function changes and their impact on clinical outcomes in anticoagulated AF patients with marginal renal function. Methods From a Korean claims database, patients with AF on anticoagulants and a baseline eGFR of 45 to <60 ml/min/1.73 m2 were studied. Patients were grouped by changes in renal function over two years-maintained, improved (eGFR >60 ml/min/1.73 m2), or worsened (eGFR <45 ml/min/1.73 m2)-the study analyzed outcomes including ischemic stroke, major bleeding, end-stage renal disease (ESRD), all-cause death, and a composite of clinical outcomes. Results A total of 5,126 patients were included in the study: 2,170 (42.3%) in the maintained group, 2,276 (44.4%) in the improved group, and 680 (13.1%) in the group with worsened renal function. The worsened group was older and had more prevalent comorbidities than other groups. After multivariable adjustment, the worsened group was associated with significantly higher risks of major bleeding (adjusted hazard ratio, 95% confidence interval; 1.46, 1.03-2.07, p = 0.035), ESRD (1.49, 1.24-1.80, p < 0.001), all-cause death (9.29, 4.92-17.6, p < 0.001), and the composite outcome (1.57, 1.36-1.83, p < 0.001). Conclusions In anticoagulated AF patients with marginal renal function, a substantial proportion of patients experienced renal function decline below eGFR 45 ml/min/1.73 m2 within 2 years. Renal function decline was associated with higher risks of major bleeding, ESRD, all-cause death, and the composite outcome compared to those who maintained their baseline renal function.
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Affiliation(s)
- Kyung-Yeon Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - JungMin Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyo-Jeong Ahn
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Soonil Kwon
- Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Bongseong Kim
- Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Kyung-Do Han
- Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y. H. Lip
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Chest & Heart Hospital, Liverpool, United Kingdom
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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46
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Simoni AH, Bucci T, Romiti GF, Frydenlund J, Johnsen SP, Abdul-Rahim AH, Lip GYH. Social determinants of health and clinical outcomes among patients with atrial fibrillation: evidence from a global federated health research network. QJM 2024; 117:353-359. [PMID: 38060301 PMCID: PMC11150002 DOI: 10.1093/qjmed/hcad275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/23/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Few studies have investigated the role of social determinants of health (SDoH) in patients with atrial fibrillation (AF). AIM To investigate the relationship between SDoH and adverse events in a large multinational AF cohort. DESIGN Retrospective study utilizing a global federated health research network (TriNetX). METHODS Patients with AF were categorized as socially deprived defined according to ICD codes based on three SDoHs: (i) extreme poverty; (ii) unemployment; and/or (iii) problems related with living alone. The outcomes were the 5-year risk of a composite outcomes of all-cause death, hospitalization, ischemic heart disease (IHD), stroke, heart failure (HF) or severe ventricular arrhythmias. Cox regression was used to compute hazard rate ratios (HRs) and 95% confidence intervals (CIs) following 1:1 propensity score matching (PSM). RESULTS The study included 24 631 socially deprived (68.8 ± 16.0 years; females 51.8%) and 2 462 092 non-deprived AF patients (75.5 ± 13.1 years; females 43.8%). Before PSM, socially deprived patients had a higher risk of the composite outcome (HR 1.9, 95% CI 1.87-1.93), all-cause death (HR 1.34, 95% CI 1.28-1.39), hospitalization (HR 2.01, 95% CI 1.98-2.04), IHD (HR 1.67, 95% CI 1.64-1.70), stroke (HR 2.60, 95% CI 2.51-2.64), HF (HR 1.91, 95% CI 1.86-1.96) and severe ventricular arrhythmias (HR 1.83, 95% CI 1.76-1.90) compared to non-deprived AF patients. The PSM-based hazard ratios for the primary composite outcome were 1.54 (95% CI 1.49-1.60) for the unemployed AF patients; 1.39 (95% CI 1.31-1.47) for patients with extreme poverty or with low income; and 1.42 (95% CI 1.37-1.47) for those with problems related with living alone. CONCLUSIONS In patients with AF, social deprivation is associated with an increased risk of death and adverse cardiac events. The presence of possible unmeasured bias associated with the retrospective design requires confirmation in future prospective studies.
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Affiliation(s)
- A H Simoni
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Aalborg, Denmark
| | - T Bucci
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of General and Specialized Surgery, Sapienza University of Rome, Rome, Italy
| | - G F Romiti
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - J Frydenlund
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Aalborg, Denmark
| | - S P Johnsen
- Department of Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Aalborg, Denmark
| | - A H Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Stroke Division, Department of Medicine for Older People, Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | - G Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Aalborg, Denmark
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Antony Sheron V, Gooden TE, Uruthirakumar P, Shribavan K, Guruparan M, Subaschandren K, Lip GYH, Nirantharakumar K, Thomas GN, Surenthirakumaran R, Kumarendran B, Manaseki-Holland S. The pathway to diagnosis and follow-up care for atrial fibrillation in Sri Lanka: a descriptive longitudinal study. NIHR OPEN RESEARCH 2024; 3:63. [PMID: 39139280 PMCID: PMC11320028 DOI: 10.3310/nihropenres.13497.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/30/2024] [Indexed: 08/15/2024]
Abstract
Background Early diagnosis and continuity of care is vital for atrial fibrillation (AF), to reduce stroke ; There is a lack of understanding of when and how AF is being diagnosed and managed the care pathway) in in low- and middle-income countries (LMICs). We aimed to identify the AF care pathway in Northern Province, Sri Lanka and determine how the COVID-19 pandemic impacted the care pathway. Methods This descriptive longitudinal study utilised two quantitative questionnaires to evaluate the AF pathway: The first questionnaire (baseline) was used to identify where AF was being diagnosed and the second questionnaire (3 months following baseline) was used to identify where and how often AF follow-up care was being received. How the COVID-19 pandemic impacted the care pathway was asked in the second questionnaire. We aimed to recruit 236 adults (≥18 years) with AF from Jaffna Teaching Hospital. Data were collected between October 2020 and June 2021 and analysed using descriptive statistics. Results 151 participants were recruited (median age 57 years; 70% female). Most participants were diagnosed in the accident & emergency (38%) or inpatient department (26%), followed by an outpatient department (19%) or private facility (16%). Nearly all (97%) participants received follow-up care during the study period, with an average of 1.3 AF-related healthcare visits per person for a month; most visited an outpatient department (88%). The COVID-19 pandemic negatively impacted 39% of participants' care: healthcare visits were reduced or, delayed or medications were unattainable, and longer intervals between blood tests were experienced; however, 24% of participants were able to receive their medication by ambulance, public health staff or post during lockdowns. Conclusions Primary care was not involved in the diagnosis of AF, indicating that most diagnoses occurr after a medical emergency. The frequency of blood tests was lower than the guideline recommendations of one per month which could in-part be due to the adverse impacts of the pandemic. Strengthening primary and community-based care may enable early diagnosis and improve continuity of care during and beyond future healthcare crises.
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Affiliation(s)
- Vethanayagam Antony Sheron
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Northern Province, 40000, Sri Lanka
| | - Tiffany E. Gooden
- Institute of Applied Health Research, University of Birmingham, Birmingham, England, B15 2TT, UK
| | - Powsiga Uruthirakumar
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Northern Province, 40000, Sri Lanka
| | - Kanesamoorthy Shribavan
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Northern Province, 40000, Sri Lanka
| | - Mahesan Guruparan
- Department of Cardiology, Teaching Hospital Jaffna, University of Jaffna, Jaffna, Northern Province, 40000, Sri Lanka
| | - Kumaran Subaschandren
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Northern Province, 40000, Sri Lanka
| | - Gregory Y. H. Lip
- Institute of Applied Health Research, University of Birmingham, Birmingham, England, B15 2TT, UK
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool, England, L2 2QP, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg Universitet, Aalborg, North Denmark Region, DK - 9100, Denmark
| | | | - G. Neil Thomas
- Institute of Applied Health Research, University of Birmingham, Birmingham, England, B15 2TT, UK
| | - Rajendra Surenthirakumaran
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Northern Province, 40000, Sri Lanka
| | - Balachandran Kumarendran
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Northern Province, 40000, Sri Lanka
- Institute of Applied Health Research, University of Birmingham, Birmingham, England, B15 2TT, UK
| | - Semira Manaseki-Holland
- Institute of Applied Health Research, University of Birmingham, Birmingham, England, B15 2TT, UK
| | - NIHR Global Health Research Group on Atrial Fibrillation Management
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Northern Province, 40000, Sri Lanka
- Institute of Applied Health Research, University of Birmingham, Birmingham, England, B15 2TT, UK
- Department of Cardiology, Teaching Hospital Jaffna, University of Jaffna, Jaffna, Northern Province, 40000, Sri Lanka
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool, England, L2 2QP, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg Universitet, Aalborg, North Denmark Region, DK - 9100, Denmark
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48
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Lee SR, Choi EK, Lee SW, Han KD, Oh S, Lip GYH. Clinical Impact of Early Rhythm Control and Healthy Lifestyles in Patients With Atrial Fibrillation. JACC Clin Electrophysiol 2024; 10:1064-1074. [PMID: 38661604 DOI: 10.1016/j.jacep.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 01/19/2024] [Accepted: 02/14/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND There are limited data regarding the combined effect of early rhythm control (ERC) and healthy lifestyle (HLS) behaviors on the risk of ischemic stroke in patients with atrial fibrillation (AF). OBJECTIVES This study sought to evaluate how the combination of ERC and HLS behaviors affects the risk of ischemic stroke in patients with AF. METHODS Using the Korean National Health Insurance database, we included patients with new-onset AF between 2009 and 2016 (n = 208,662). Patients who received rhythm control therapy within 2 years after AF diagnosis were defined as the ERC group. Patients with ≥2 HLS behaviors were defined as the HLS group. Patients were categorized into 4 groups: group 1, without ERC and without HLS (n = 46,972); group 2, with HLS alone (n = 110,479); group 3, with ERC alone (n = 15,133); and group 4, with both ERC and HLS (n = 36,078). The primary outcome was ischemic stroke. RESULTS Compared to group 1, group 2 and group 3 were associated with a lower risk of stroke (HR: 0.769 [95% CI: 0.728-0.881] and HR: 0.774 [95% CI: 0.703-0.852], respectively). Group 4 showed the lowest risk of stroke (HR: 0.575; 95% CI: 0.536-0.617). After propensity score weighting, the incorporation of additional ERC alongside HLS was associated with a relative risk reduction of 22% for stroke, and additional HLS alongside ERC were associated with a relative risk reduction of 27% for stroke. CONCLUSIONS Each of ERC and HLS might reduce the risk of ischemic stroke in patients with new-onset AF. The presence of both ERC and HLS is associated with an enhanced benefit for stroke prevention in this population.
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Affiliation(s)
- So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Seung-Woo Lee
- Department of Medical Statistics, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Kyung-Do Han
- Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y H Lip
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Chest and Heart Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Zhang X, Wang W, Zeng J, Ye Q, Lai X, Cai X, Diao X, Huang J, Li K. Adherence to the atrial fibrillation better care pathway and its associated factors among rural patients with atrial fibrillation in China: A cross-sectional study. Heart Lung 2024; 66:23-30. [PMID: 38520987 DOI: 10.1016/j.hrtlng.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/13/2024] [Accepted: 03/13/2024] [Indexed: 03/25/2024]
Abstract
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.
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Affiliation(s)
- Xiaomin Zhang
- School of Nursing, Sun Yat-Sen University, No.74 Zhong Shan Second Road, Guangzhou 510080, China
| | - Wenxuan Wang
- School of Nursing, Sun Yat-Sen University, No.74 Zhong Shan Second Road, Guangzhou 510080, China
| | - Jianqing Zeng
- School of Nursing, Sun Yat-Sen University, No.74 Zhong Shan Second Road, Guangzhou 510080, China
| | - Qirao Ye
- Department of Cardiology, People's Hospital of Shangyou County, Ganzhou, China
| | - Xinwei Lai
- Department of Cardiology, People's Hospital of Shangyou County, Ganzhou, China
| | - Xiaomei Cai
- Chronic Disease Management Center, People's Hospital of Shangyou County, Ganzhou, China
| | - Xiulin Diao
- Department of Cardiology, People's Hospital of Shangyou County, Ganzhou, China
| | - Jun Huang
- Department of Geriatrics, Guangdong Provincial Geriatrics Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, No. 106 Zhong Shan Second Road, Guangzhou 510080, China
| | - Kun Li
- School of Nursing, Sun Yat-Sen University, No.74 Zhong Shan Second Road, Guangzhou 510080, China.
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Bucci T, Cardamone C, Triggiani M, Ames PRJ, Lip GYH. Risk of death, thrombotic and hemorrhagic events in anticoagulated patients with atrial fibrillation and systemic autoimmune diseases: an analysis from a global federated dataset. Clin Res Cardiol 2024; 113:942-950. [PMID: 38446151 PMCID: PMC11108877 DOI: 10.1007/s00392-024-02426-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/26/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Growing evidence showing that systemic autoimmune diseases (SADs) are associated with a high risk of atrial fibrillation (AF). However, the impact of SAD on the clinical course of AF patients is largely unknown. METHODS Retrospective cohort study within a federated healthcare network (TriNetX). Using ICD codes, AF patients on anticoagulant therapy were categorized according to the presence of SAD (M32: Systemic Lupus Erythematosus (SLE); M33: Dermato-polymyositis (DMP); M34: Systemic Sclerosis (SSc); M35: Sjogren syndrome). The primary outcomes were the 5-year risks of (1) all-cause death, (2) thrombotic events (ischemic stroke, acute myocardial infarction, deep vein thrombosis, and pulmonary embolism), and (3) bleeding (intracranial (ICH) and gastrointestinal (GI)). Secondary outcomes were each component of the primary outcomes. Cox regression analysis after propensity score matching (PSM) was used to estimate hazard ratio (HR) and 95% confidence interval (95%CI). RESULTS We identified 16,098 AF patients with SAD (68.2 ± 13.4 years; 71.0% female) and 828,772 AF controls (70.7 ± 12.9 years, 41.1% females). After PSM, AF patients with SAD were associated with a higher risk of all-cause death (HR 1.13, 95%CI 1.09-1.71), thrombotic events (HR 1.37, 95%CI 1.32-1.43), and hemorrhagic events (HR 1.41, 95%CI 1.33-1.50) compared to AF controls without SAD. The highest risk of all-cause death and GI bleeding was associated with SSc, while the highest risk of thrombotic events and ICH was associated with SLE. CONCLUSION AF patients with SAD are associated with a high risk of all-cause death, thrombotic, and hemorrhagic events. These patients merit careful follow-up and integrated care management to improve their prognosis.
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Affiliation(s)
- Tommaso Bucci
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of General and Specialized Surgery, Sapienza University of Rome, Rome, Italy
| | - Chiara Cardamone
- Division of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
| | - Massimo Triggiani
- Division of Allergy and Clinical Immunology, University of Salerno, Salerno, Italy
| | - Paul R J Ames
- Immune Response and Vascular Disease Unit, CEDOC, Nova University Lisbon, Rua Camara Pestana, Lisbon, Portugal
- Department of Haematology, Dumfries Royal Infirmary, Cargenbridge, Dumfries, UK
| | - Gregory Y H Lip
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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