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Lehto M, Luojus A, Halminen O, Haukka J, Putaala J, Linna M, Mustonen P, Kinnunen J, Lehtonen O, Teppo K, Tiili P, Kouki E, Itäinen-Strömberg S, Niemi M, Aro AL, Hartikainen J, Airaksinen KEJ. Time-in-therapeutic-range defined warfarin and direct oral anticoagulants in atrial fibrillation: a Nationwide Cohort Study. Ann Med 2024; 56:2364825. [PMID: 38873855 PMCID: PMC11182072 DOI: 10.1080/07853890.2024.2364825] [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: 03/30/2024] [Accepted: 04/30/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Little is known how individual time-in-therapeutic-range (TTR) impacts the effectiveness and safety of warfarin therapy compared to direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF). OBJECTIVE To compare the effectiveness and safety of standard dose DOACs to warfarin in patients with AF, while categorizing warfarin treated patients into quartiles based on their individual TTR. MATERIALS AND METHODS We conducted a nationwide study including all patients with new-onset AF between 2011 and 2018 in Finland. Hazard ratios (HR) were calculated using Cox regression analysis with the inverse probability of treatment weighted method to assess the risks of ischaemic stroke (IS), intracranial haemorrhage (ICH) and mortality for users of apixaban (n = 12,426), dabigatran (n = 4545), rivaroxaban (n = 12,950) and warfarin (n = 43,548). RESULTS The median TTR for warfarin users was 72%. Compared to the second best TTR quartile (reference), the risk of IS was higher in the two poorest TTR quartiles, and lower in the best TTR quartile and on rivaroxaban [2.35 (95% confidence interval, 1.85-2.85), 1.44 (1.18-1.75), 0.60 (0.47-0.77) and 0.72 (0.56-0.92)]. These differences were non-significant for apixaban and dabigatran. HR of ICH was 6.38 (4.88-8.35) and 1.87 (1.41-2.49) in the two poorest TTR groups, 1.44 (1.02-1.93) on rivaroxaban, and 0.58 (0.40-0.85) in the best TTR group compared to the reference group. Mortality was higher in the two poorest TTR groups and lowest in the best TTR group. CONCLUSIONS The outcome was unsatisfactory in the two lowest TTR quartiles - in half of the patients treated with warfarin. The differences between the high TTR groups and standard dose DOACs were absent or modest.
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Affiliation(s)
- Mika Lehto
- Department of Internal Medicine, Jorvi Hospital, HUS Helsinki University Hospital, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | | | | | | | - Jukka Putaala
- University of Helsinki, Helsinki, Finland
- Department of Neurology, HUS Helsinki University Hospital, Helsinki, Finland
| | - Miika Linna
- Aalto University, Espoo, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Pirjo Mustonen
- Turku University Hospital, Turku, Finland
- University of Turku, Turku, Finland
| | - Janne Kinnunen
- University of Helsinki, Helsinki, Finland
- Department of Neurology, HUS Helsinki University Hospital, Helsinki, Finland
| | | | - Konsta Teppo
- Turku University Hospital, Turku, Finland
- University of Turku, Turku, Finland
| | - Paula Tiili
- University of Helsinki, Helsinki, Finland
- Department of Neurology, HUS Helsinki University Hospital, Helsinki, Finland
| | - Elis Kouki
- University of Helsinki, Helsinki, Finland
| | - Saga Itäinen-Strömberg
- University of Helsinki, Helsinki, Finland
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Mikko Niemi
- Department of Clinical Pharmacology and Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - Aapo L. Aro
- University of Helsinki, Helsinki, Finland
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Juha Hartikainen
- University of Eastern Finland, Kuopio, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | | | - On behalf of the FinACAF Study Group
- Department of Internal Medicine, Jorvi Hospital, HUS Helsinki University Hospital, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
- Aalto University, Espoo, Finland
- Department of Neurology, HUS Helsinki University Hospital, Helsinki, Finland
- University of Eastern Finland, Kuopio, Finland
- Turku University Hospital, Turku, Finland
- University of Turku, Turku, Finland
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
- Department of Clinical Pharmacology and Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
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Kouki E, Salmela B, Aro A, Halminen O, Teppo K, Haukka J, Putaala J, Linna M, Mustonen P, Hartikainen J, Airaksinen JKE, Lehto M. Temporal trends in mortality and causes of death in patients with incident atrial fibrillation: a nationwide register study from 2010 to 2018. BMJ Open 2024; 14:e080836. [PMID: 39277207 PMCID: PMC11407195 DOI: 10.1136/bmjopen-2023-080836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/17/2024] Open
Abstract
OBJECTIVES Atrial fibrillation (AF) is associated with increased mortality. Previous studies have reported conflicting results in temporal trends of mortality after AF diagnosis. We aim to address this disparity by investigating the 1-year mortality and causes of death in Finnish patients diagnosed with AF between 2010 and 2017. DESIGN The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study is a nationwide retrospective register-based cohort study. SETTING The FinACAF study has gathered information on all Finnish AF patients between 2004 and 2018, with information from all national healthcare registers and data from all levels of care (primary, secondary and tertiary care). PARTICIPANTS We included patients with an incident AF diagnosis (International Classification of Diseases, 10th Revision code I48) between 2010 and 2017. To ensure a cohort of only incident AF, we excluded patients who used any oral anticoagulant during the year before cohort entry as well as patients with a recorded use of warfarin between 2004 and 2006. Patients under 20 years of age were excluded, and patients with permanent migration abroad before 1 January 2019 were excluded, N=157 658. PRIMARY OUTCOME MEASURES 1-year all-cause, cardiovascular (CV) and cause-specific mortality following AF diagnosis. RESULTS The study cohort consisted of 157 658 incident AF cases (50.1% male, mean age 72.9 years). Both all-cause and CV mortality declined from cohort entry years 2010-2017 (from 12.9% to 10.6%, mortality rate ratio (MRR) 0.77; 95% CI 0.73 to 0.82 in cohort entry year 2017 with 2010 as reference; and from 7.4% to 5.2%, MRR 0.68; 95% CI 0.63 to 0.74, respectively). Overall mortality and CV mortality were lower in women than in men throughout the study period (MRR 0.66; 95% CI 0.63 to 0.69 and MRR 0.53; 95% CI 0.50 to 0.56, respectively). Deaths attributable to ischaemic heart disease decreased during the study period (from 30.7% to 21.6%, MRR 0.51; 95% CI 0.49 to 0.62 in 2017 vs 2010), whereas dementia and Alzheimer's disease increased as a cause of death over time (6.2% to 9.9%, MRR 1.19; 95% CI 0.96 to 1.48 in 2017 vs 2010). The CHA2DS2-VASc score associated strongly with 1-year survival (p<0.0001). CONCLUSIONS Our study reiterates that mortality after diagnosis of AF has decreased. The CHA2DS2-VASc score highlights the need to treat comorbidities as it strongly associates with patient 1-year survival after initial AF diagnosis.
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Affiliation(s)
- Elis Kouki
- University of Helsinki Faculty of Medicine, Helsinki, Finland
| | - Birgitta Salmela
- Heart Center, Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland
| | - Aapo Aro
- Heart and Lung Center, Helsinki University Central Hospital, Helsinki, Finland
| | | | - Konsta Teppo
- TYKS Turku University Hospital, Turku, Finland
- University of Turku, Turku, Finland
| | | | - Jukka Putaala
- University of Helsinki, Helsinki, Finland
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Mika Linna
- Aalto University, Espoo, Finland
- University of Eastern Finland Faculty of Health Sciences, Kuopio, Finland
| | - Pirjo Mustonen
- TYKS Turku University Hospital, Turku, Finland
- University of Turku, Turku, Finland
| | - Juha Hartikainen
- Kuopio University Hospital, Kuopio, Finland
- University of Eastern Finland, Kuopio, Finland
| | | | - Mika Lehto
- Heart and Lung Center, Helsinki University Central Hospital, Helsinki, Finland
- Department of Internal Medicine, Jorvi Hospital, Espoo, Finland
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Liu Y, Huang M, Sun Y, Dai W. Exploring the effect of lifestyle behaviors and socioeconomic status on atrial fibrillation: the mediating role of 91 inflammatory cytokines. Front Cardiovasc Med 2024; 11:1401384. [PMID: 39328240 PMCID: PMC11424413 DOI: 10.3389/fcvm.2024.1401384] [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: 04/08/2024] [Accepted: 08/26/2024] [Indexed: 09/28/2024] Open
Abstract
Background Atrial fibrillation (AF) is one of the most prevalent cardiac arrhythmias and has a significant economic and social burden. Whether it is associated with lifestyle behaviors and socioeconomic status is currently poorly understood. This study aimed to explore the relationship among these factors and determine the role of inflammatory cytokines. Method We investigated the causal effects of lifestyle behaviors and socioeconomic status on AF using bidirectional two-sample Mendelian randomization (MR). Instrumental variables were obtained from a publicly available genome-wide association study. A two-step MR was conducted to determine the mediating role of 91 inflammatory cytokines. Inverse variance weighted was used as the main method with four supplementary MR methods. To obtain more robust results, several sensitivity analyses were conducted. Result The results indicated that seven of the lifestyle behaviors [smoking initiation, vegetable intake, coffee consumption (cups/day), dozing, lifetime smoking index, napping, and alcohol abuse] were potential risk factors for AF. One socioeconomic status, education attainment (years of education), was causally associated with a decreased risk of AF. Moreover, we found that thymic stromal lymphopoietin, CD40l receptor, C-X-C motif chemokine 6, and C-X-C motif chemokine 11 levels mediated the causal effect, at proportions of 13.6%, 4.1%, 4.3%, and 6.9%, respectively. Conclusion Our findings provide insight into the relationship between lifestyle behaviors, socioeconomic status, and AF. Inflammatory cytokines are potential mediators of this relationship.
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Affiliation(s)
- Yiheng Liu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Mingsheng Huang
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yue Sun
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Weiran Dai
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Teppo K, Airaksinen KEJ, Jaakkola J, Halminen O, Salmela B, Kouki E, Haukka J, Putaala J, Linna M, Aro AL, Mustonen P, Hartikainen J, Lip GYH, Lehto M. Ischaemic stroke in women with atrial fibrillation: temporal trends and clinical implications. Eur Heart J 2024; 45:1819-1827. [PMID: 38606837 PMCID: PMC11129795 DOI: 10.1093/eurheartj/ehae198] [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: 10/30/2023] [Revised: 02/19/2024] [Accepted: 03/18/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND AND AIMS Female sex has been linked with higher risk of ischaemic stroke (IS) in atrial fibrillation (AF), but no prior study has examined temporal trends in the IS risk associated with female sex. METHODS The registry-linkage Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study included all patients with AF in Finland from 2007 to 2018. Ischaemic stroke rates and rate ratios were computed. RESULTS Overall, 229 565 patients with new-onset AF were identified (50.0% women; mean age 72.7 years). The crude IS incidence was higher in women than in men across the entire study period (21.1 vs. 14.9 events per 1000 patient-years, P < .001), and the incidence decreased both in men and women. In 2007-08, female sex was independently associated with a 20%-30% higher IS rate in the adjusted analyses, but this association attenuated and became statistically non-significant by the end of the observation period. Similar trends were observed when time with and without oral anticoagulant (OAC) treatment was analysed, as well as when only time without OAC use was considered. The decrease in IS rate was driven by patients with high IS risk, whereas in patients with low or moderate IS risk, female sex was not associated with a higher IS rate. CONCLUSIONS The association between female sex and IS rate has decreased and become non-significant over the course of the study period from 2007 to 2018, suggesting that female sex could be omitted as a factor when estimating expected IS rates and the need for OAC therapy in patients with AF.
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Affiliation(s)
- Konsta Teppo
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Jussi Jaakkola
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Birgitta Salmela
- Department of Internal Medicine, Heart Center, Päijät-Häme Central Hospital, Lahti, Finland
| | - Elis Kouki
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jari Haukka
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jukka Putaala
- Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Miika Linna
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
- Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland
| | - Aapo L Aro
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pirjo Mustonen
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Juha Hartikainen
- Heart Center, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - 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 Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Aalborg, Denmark
| | - Mika Lehto
- Department of Internal Medicine, Jorvi Hospital, HUS Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Teppo K, Airaksinen KEJ, Jaakkola J, Halminen O, Salmela B, Kalatsova K, Kouki E, Haukka J, Putaala J, Linna M, Aro AL, Mustonen P, Hartikainen J, Lehto M. Temporal trends of gender disparities in oral anticoagulant use in patients with atrial fibrillation. Eur J Clin Invest 2024; 54:e14107. [PMID: 37823410 DOI: 10.1111/eci.14107] [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: 08/31/2023] [Revised: 10/02/2023] [Accepted: 10/05/2023] [Indexed: 10/13/2023]
Abstract
AIMS To investigate sex-specific temporal trends in the initiation of oral anticoagulant (OAC) therapy among patients diagnosed with atrial fibrillation (AF) in Finland between 2007 and 2018. METHODS The registry-linkage Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) Study included all patients with incident AF in Finland from 2007 to 2018. The primary outcome was the initiation of any OAC therapy. RESULTS We identified 229,565 patients with new-onset AF (50.0% women; mean age 72.7 years). The initiation of OAC therapy increased continuously during the observation period. While women were more likely to receive OAC therapy overall, after adjusting for age, stroke risk factors and other confounding factors, female sex was associated with a marginally lower initiation of OACs (unadjusted and adjusted hazard ratios comparing women to men: 1.08 (1.07-1.10) and 0.97 (0.96-0.98), respectively). Importantly, the gender disparities in OAC use attenuated and reached parity by the end of the observation period. Furthermore, when only patients eligible for OAC therapy according to the contemporary guidelines were included in the analyses, the gender inequalities in OAC initiation appeared minimal. Implementation of direct OACs for stroke prevention was slightly slower among women. CONCLUSION This nationwide retrospective cohort study covering all patients with incident AF in Finland from 2007 to 2018 observed that although female sex was initially associated with a lower initiation of OAC therapy, the sex-related disparities resolved over the course of the study period.
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Affiliation(s)
- Konsta Teppo
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Jussi Jaakkola
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Birgitta Salmela
- Heart Center, Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland
| | | | - Elis Kouki
- University of Helsinki, Helsinki, Finland
| | | | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Miika Linna
- Aalto University, Espoo, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Aapo L Aro
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pirjo Mustonen
- Turku University Hospital and University of Turku, Turku, Finland
| | - Juha Hartikainen
- Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Mika Lehto
- Jorvi Hospital, Department of Internal Medicine, HUS Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Putaala J, Teppo K, Halminen O, Haukka J, Tiili P, Jaakkola J, Karlsson E, Linna M, Mustonen P, Kinnunen J, Kiviniemi T, Aro A, Hartikainen J, Airaksinen JK, Lehto M. Ischemic Stroke Temporally Associated With New-Onset Atrial Fibrillation: A Population-Based Registry-Linkage Study. Stroke 2024; 55:122-130. [PMID: 38063017 PMCID: PMC10734779 DOI: 10.1161/strokeaha.123.044448] [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: 07/07/2023] [Revised: 10/30/2023] [Accepted: 11/13/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Limited data exist on the temporal relationship between new-onset atrial fibrillation (AF) and ischemic stroke and its impact on patients' clinical characteristics and mortality. METHODS A population-based registry-linkage database includes all patients with new-onset AF in Finland from 2007 to 2018. Ischemic stroke temporally associated with AF (ISTAF) was defined as an ischemic stroke occurring within ±30 days from the first AF diagnosis. Clinical factors associated with ISTAF were studied with logistic regression and 90-day survival with Cox proportional hazards analysis. RESULTS Among 229 565 patients with new-onset AF (mean age, 72.7 years; 50% female), 204 774 (89.2%) experienced no ischemic stroke, 12 209 (5.3%) had past ischemic stroke >30 days before AF, and 12 582 (5.8%) had ISTAF. The annual proportion of ISTAF among patients with AF decreased from 6.0% to 4.8% from 2007 to 2018. Factors associated positively with ISTAF were higher age, lower education level, and alcohol use disorder, whereas vascular disease, heart failure, chronic kidney disease cancer, and psychiatric disorders were less probable with ISTAF. Compared with patients without ischemic stroke and those with past ischemic stroke, ISTAF was associated with ≈3-fold and 1.5-fold risks of death (adjusted hazard ratios, 2.90 [95% CI, 2.76-3.04] and 1.47 [95% CI, 1.39-1.57], respectively). The 90-day survival probability of patients with ISTAF increased from 0.79 (95% CI, 0.76-0.81) in 2007 to 0.89 (95% CI, 0.87-0.91) in 2018. CONCLUSIONS ISTAF depicts the prominent temporal clustering of ischemic strokes surrounding AF diagnosis. Despite having fewer comorbidities, patients with ISTAF had worse, albeit improving, survival than patients with a history of or no ischemic stroke. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04645537. URL: https://www.encepp.eu; Unique identifier: EUPAS29845.
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Affiliation(s)
- Jukka Putaala
- Department of Neurology (J.P., P.T., J.K.), Helsinki University Hospital and University of Helsinki, Finland
| | - Konsta Teppo
- Heart Center, Turku University Hospital and University of Turku, Finland (K.T., J.J., P.M., T.K., K.E.J.A.)
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland (O.H., M. Linna)
| | - Jari Haukka
- Department of Public Health, University of Helsinki, Finland (J. Haukka)
| | - Paula Tiili
- Department of Neurology (J.P., P.T., J.K.), Helsinki University Hospital and University of Helsinki, Finland
| | - Jussi Jaakkola
- Department of Neurology (J.P., P.T., J.K.), Helsinki University Hospital and University of Helsinki, Finland
| | | | - Miika Linna
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland (O.H., M. Linna)
| | - Pirjo Mustonen
- Heart Center, Turku University Hospital and University of Turku, Finland (K.T., J.J., P.M., T.K., K.E.J.A.)
| | - Janne Kinnunen
- Department of Neurology (J.P., P.T., J.K.), Helsinki University Hospital and University of Helsinki, Finland
| | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital and University of Turku, Finland (K.T., J.J., P.M., T.K., K.E.J.A.)
| | - Aapo Aro
- Heart and Lung Center (A.A.), Helsinki University Hospital and University of Helsinki, Finland
| | - Juha Hartikainen
- Heart Center, Kuopio University Hospital and University of Eastern Finland, Finland (J. Hartikainen)
| | - Juhani K.E. Airaksinen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland (O.H., M. Linna)
| | - Mika Lehto
- University of Helsinki, Finland (E.K., M. Lehto)
- Department of Internal Medicine, Jorvi Hospital and Helsinki University Hospital, Espoo, Finland (M. Lehto)
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Teppo K, Kouki E, Salmela B, Niskanen L, Jaakkola J, Halminen O, Haukka J, Putaala J, Linna M, Mustonen P, Hartikainen J, Juhani Airaksinen KE, Lehto M. Trends and burden of diabetes in patients with atrial fibrillation during 2007-2018: A Finnish nationwide cohort study. Diabetes Res Clin Pract 2023; 203:110875. [PMID: 37582425 DOI: 10.1016/j.diabres.2023.110875] [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: 07/06/2023] [Revised: 08/02/2023] [Accepted: 08/10/2023] [Indexed: 08/17/2023]
Abstract
AIMS We assessed the temporal trends in the prevalence of diabetes and in its associations with outcomes among patients with atrial fibrillation (AF). METHODS The registry-based FinACAF study covered all patients with incident AF in Finland between 2007 and 2018. Ischemic stroke (IS) and mortality rates were computed using Poisson regression model. RESULTS We identified 229565 patients (50.0% female; mean age 72.7 years; mean follow-up 4.0 years) patients with incident AF. The prevalence of diabetes increased steadily from 15.5% in 2007 to 26.3% in 2018. A decrease in IS and mortality rates was observed during the study period both in patients with and without diabetes. Diabetes was associated with IS and mortality (adjusted incidence rate ratios with 95% confidence intervals 1.22 (1.17-1.26) and 1.32 (1.29-1.34), respectively). The impact of diabetes on IS risk remained stable, while its effect on mortality increased slightly during the observation period. CONCLUSIONS The prevalence of diabetes has increased considerably among patients with AF between 2007 and 2018. There have been substantial improvements in the prognosis of AF patients with diabetes. However, diabetes remains a significant risk factor for IS and mortality in this patient population.
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Affiliation(s)
- Konsta Teppo
- Turku University Hospital and University of Turku, Turku, Finland.
| | - Elis Kouki
- University of Helsinki, Helsinki, Finland
| | - Birgitta Salmela
- Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland
| | - Leo Niskanen
- Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland; University of Eastern Finland, Kuopio, Finland
| | - Jussi Jaakkola
- Turku University Hospital and University of Turku, Turku, Finland
| | | | | | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Miika Linna
- Aalto University, Espoo, Finland; University of Eastern Finland, Kuopio, Finland
| | - Pirjo Mustonen
- Turku University Hospital and University of Turku, Turku, Finland
| | | | | | - Mika Lehto
- Jorvi Hospital, Department of Internal Medicine, HUS Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Frost L, Halminen O, Lehto M, Airaksinen KEJ, Andersson T, Wändell P, Holzmann M, Cordsen P, Vinter N, Johnsen SP. Geographical Variation in the Use of Oral Anticoagulation and Clinical Outcomes among Patients with Atrial Fibrillation in Denmark, Sweden, and Finland. TH OPEN 2023; 7:e133-e142. [PMID: 37288117 PMCID: PMC10243918 DOI: 10.1055/a-2080-6171] [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: 10/18/2022] [Accepted: 04/19/2023] [Indexed: 06/09/2023] Open
Abstract
Background Geographical mapping of variations in the treatment and outcomes of a disease is a valuable tool for identifying inequity. We examined international and intranational variations in initiating oral anticoagulation (OAC) therapy and clinical outcomes among patients with atrial fibrillation (AF) in Nordic countries. We also tracked real-world trends in initiating OAC and the clinical outcomes. Methods We conducted a registry-based multinational cohort study of OAC-naive patients with an incident hospital diagnosis of AF in Denmark ( N = 61,345), Sweden ( N = 124,120), and Finland ( N = 59,855) and a CHA 2 DS 2 -VASc score of ≥1 in men and ≥2 in women between 2012 and 2017. Initiation of OAC therapy was defined as dispensing at least one prescription between 90 days before and 90 days after the AF diagnosis. Clinical outcomes included ischemic stroke, intracerebral hemorrhage, intracranial bleeding, other major bleeding, and all-cause mortality. Results The proportion of patients initiating OAC therapy ranged from 67.7% (95% CI: 67.5-68.0) in Sweden to 69.6% (95% CI: 69.2-70.0) in Finland, with intranational variation. The 1-year risk of stroke varied from 1.9% (95% CI: 1.8-2.0) in Sweden and Finland to 2.3% (95% CI: 2.2-2.4) in Denmark, with intranational variation. The initiation of OAC therapy increased with a preference for direct oral anticoagulants over warfarin. The risk of ischemic stroke decreased with no increase in intracranial and intracerebral bleeding. Conclusion We documented inter- and intranational variation in initiating OAC therapy and clinical outcomes across Nordic countries. Adherence to structured care of patients with AF could reduce future variation.
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Affiliation(s)
- Lars Frost
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Mika Lehto
- Department of Internal Medicine, Hospital District of Helsinki and Uusimaa, Lohja Hospital, Lohja, Finland
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Tomas Andersson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Per Wändell
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Martin Holzmann
- Functional Area of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Internal Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Pia Cordsen
- Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | - Nicklas Vinter
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
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