1
|
Kodani E, Inoue H, Atarashi H, Okumura K, Yamashita T, Origasa H. Characteristics and outcomes in elderly patients with non-valvular atrial fibrillation and high bleeding risk: subanalysis of the J-RHYTHM Registry. Heart Vessels 2024; 39:330-339. [PMID: 38103100 PMCID: PMC10920444 DOI: 10.1007/s00380-023-02343-9] [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: 08/28/2023] [Accepted: 11/16/2023] [Indexed: 12/17/2023]
Abstract
Recently, a once-daily dose of edoxaban (15-mg) has been approved for stroke prevention in non-valvular atrial fibrillation (NVAF) patients aged ≥ 80 years, in whom standard oral anticoagulants are not recommended because of high bleeding risk (HBR), based on the ELDERCARE-AF trial. However, information regarding the characteristics and clinical outcomes among such patients is limited. Thus, this study aimed to clarify the characteristics and event rates in elderly patients with NVAF and HBR defined by the ELDERCARE-AF criteria. Of the 7406 NVAF outpatients included in the J-RHYTHM Registry, 60 patients with creatinine clearance (CrCl) < 15 mL/min were excluded. The remaining 7346 patients (age, 69.7 ± 9.9 years; men, 70.9%; warfarin use, 78.7%) were divided into three groups: Group 1, aged < 80 years (n = 6165); Group 2, aged ≥ 80 years without HBR (n = 584); and Group 3, aged ≥ 80 years with HBR (at least one of the followings; CrCl, 15-30 mL/min, history of bleeding, body weight ≤ 45 kg, and antiplatelet use) (n = 597, eligible for 15-mg edoxaban). Patients in Group 3 had a higher prevalence of comorbidities, and therefore, both higher thromboembolic and bleeding risk scores than in the other groups. During the 2-year follow-up period, the incidence rates (per 100 person-years) of thromboembolism in Groups 1, 2, and 3 were 0.7, 1.5, and 2.1 (P < 0.001), major hemorrhage, 0.8, 1.2, and 2.0 (P < 0.001), and all-cause death, 0.8, 2.6, and 4.6 (P < 0.001), respectively. Adjusted hazard ratios of Group 3 were 1.64 (95% confidence interval 0.89-3.04, P = 0.116) for thromboembolism, 1.53 (0.85-2.72, P = 0.154) for major hemorrhage, and 1.84 (1.19-2.85, P = 0.006) for all-cause death compared with Group 1. The NVAF Patients aged ≥ 80 years with HBR defined by the ELDERCARE-AF criteria were certainly at a higher adverse event risk, especially for all-cause death. Clinical trial registration: The J-RHYTHM Registry is registered in the University Hospital Medicine Information Network (UMIN) Clinical Trials Registry (unique identifier: UMIN000001569) http://www.umin.ac.jp/ctr/ .
Collapse
Affiliation(s)
- Eitaro Kodani
- Department of Cardiovascular Medicine and Cardiology, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama-shi, Tokyo, 206-8512, Japan.
| | | | | | - Ken Okumura
- Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | | |
Collapse
|
2
|
Yamauchi T, Okumura Y, Nagashima K, Watanabe R, Saito Y, Yokoyama K, Matsumoto N, Miyauchi K, Miyazaki S, Hayashi H, Matsue Y, Nishizaki Y, Nojiri S, Minamino T, Daida H. External Validation of the HELT-E 2S 2 Score in Japanese Patients With Nonvalvular Atrial Fibrillation - A Pooled Analysis of the RAFFINE and SAKURA Registries. Circ J 2023; 87:1777-1787. [PMID: 37558457 DOI: 10.1253/circj.cj-23-0318] [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: 08/11/2023]
Abstract
BACKGROUND The HELT-E2S2score, which assigns 1 point to Hypertension, Elderly aged 75-84 years, Low body mass index <18.5 kg/m2, and Type of atrial fibrillation (AF: persistent/permanent), and 2 points to Extreme Elderly aged ≥85 years and previous Stroke, has been proposed as a new risk stratification for strokes in Japanese AF patients, but has not yet undergone external validation.Methods and Results: We evaluated the prognostic performance of the HELT-E2S2score for stroke risk stratification using 2 large-scale registries in Japanese AF patients (n=7,020). During 23,241 person-years of follow-up (mean follow-up 1,208±450 days), 287 ischemic stroke events occurred. The C-statistic using the HELT-E2S2score was 0.661 (95% confidence interval [CI], 0.629-0.692), which was numerically higher than with the CHADS2score (0.644, 95% CI 0.613-0.675; P=0.15 vs. HELT-E2S2) or CHA2DS2-VASc score (0.650, 95% CI, 0.619-0.680; P=0.37 vs. HELT-E2S2). In the SAKURA AF Registry, the C-statistic of the HELT-E2S2score was consistently higher than the CHADS2and CHA2DS2-VASc scores across all 3 types of facilities comprising university hospitals, general hospitals, and clinics. However, in the RAFFINE Study, its superiority was only observed in general hospitals. CONCLUSIONS The HELT-E2S2score demonstrated potential value for risk stratification, particularly in a super-aged society such as Japan. However, its superiority over the CHADS2or CHA2DS2-VASc scores may vary across different hospital settings.
Collapse
Affiliation(s)
| | - Yasuo Okumura
- Division of Cardiology, Nihon University Itabashi Hospital
| | | | - Ryuta Watanabe
- Division of Cardiology, Nihon University Itabashi Hospital
| | - Yuki Saito
- Division of Cardiology, Nihon University Itabashi Hospital
| | | | | | - Katsumi Miyauchi
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Sakiko Miyazaki
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Hidemori Hayashi
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Yuya Matsue
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Yuji Nishizaki
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
- Medical Technology Innovation Center, Juntendo University
- Division of Medical Education, Juntendo University School of Medicine
| | - Shuko Nojiri
- Medical Technology Innovation Center, Juntendo University
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
- Japan Agency for Medical Research and Development-Core Research for Evolutionary Medical Science and Technology (AMED-CREST), Japan Agency for Medical Research and Development
| | - Hiroyuki Daida
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
- Faculty of Health Science, Juntendo University
| |
Collapse
|
3
|
Xu W, Chen J, Wu S, Huang N, Chen X, Zhang W, Hu W, Su J, Dai H, Gu P, Huang X, Du X, Li R, Zheng Q, Lin X, Zhang Y, Zou L, Liu Y, Zhang M, Liu X, Zhu Z, Zhang J. Safety and efficacy of direct oral anticoagulants in stroke prevention in patients with atrial fibrillation complicated with anemia and/or thrombocytopenia: a retrospective cohort study. Thromb J 2023; 21:118. [PMID: 37986173 PMCID: PMC10662166 DOI: 10.1186/s12959-023-00563-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/13/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND There are limited data about the clinical benefits and harm of direct oral anticoagulants (DOACs) in stroke prevention in patients with atrial fibrillation (AF) complicated with anemia or thrombocytopenia. METHODS This is a multi-center retrospective cohort study involving 5469 AF patients from 15 hospitals in China. Patients were divided into three groups according to hemoglobin and platelet levels: Group 1 (hemoglobin male ≥ 130 g/L; female ≥ 120 g/L and platelet ≥ 100 × 109/L), Group 2 (hemoglobin male < 130 g/L; female < 120 g/L or platelet < 100 × 109/L), and Group 3 (hemoglobin male < 130 g/L; female < 120 g/L and platelet < 100 × 109/L). Patients in each category are further divided into two groups according to their stroke prevention strategies: rivaroxaban or dabigatran. Clinical results include major, minor, total bleeding, thrombosis, and the composite outcome of major bleeding and thrombosis. RESULTS Higher hemoglobin levels were associated with a reduced risk of total bleeding and major bleeding, while platelet counts were not associated with any event. Compared with Group 1, Group 2 had a higher risk of major bleeding (aOR 1.70, 95%CI 1.12-2.57, P = 0.012), and the composite endpoint of major bleeding and thrombosis (aOR 1.70, 95%CI 1.19-2.44, P = 0.004). Compared with Group 1, Group 3 had a higher total bleeding risk (aOR 2.15, 95%CI 1.14-4.05, P = 0.018). Compared with dabigatran, rivaroxaban was associated with higher composite risk in Group 1 (aOR 2.91, 95% CI 1.66-5.16, P < 0.001) and Group 2 (aOR 3.05, 95%CI 1.46-6.39, P = 0.003), but there was no significant difference in Group 3 (aOR 1.78, 95%CI 0.23-13.54, P = 0.577). CONCLUSIONS Higher hemoglobin levels are associated with a reduced risk of total bleeding and major bleeding in patients with AF. Dabigatran was associated with better clinical outcomes than rivaroxaban in patients with anemia or thrombocytopenia but not in those with anemia and thrombocytopenia.
Collapse
Affiliation(s)
- Wenlin Xu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics , Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Jiana Chen
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics , Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Shuyi Wu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics , Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Nianxu Huang
- Department of Pharmacy, Taikang Tongji (Wuhan) Hospital, Wuhan, 430000, China
| | - Xia Chen
- Chendu Qingbaijiang Maternal & Child Health Care Hospital, Chengdu, China
| | - Wang Zhang
- Department of Pharmacy, The First People's Hospital of Changde City, Changde, Hunan, 415000, China
| | - Wei Hu
- Department of Pharmacy, Xinyang Central Hospital, Xinyang Hospital Affiliated to Zhengzhou University, Xinyang, Henan, 464000, China
| | - Jun Su
- Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, 233004, China
| | - Hengfen Dai
- Department of Pharmacy, Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, Fujian, 350009, China
| | - Ping Gu
- Department of Pharmacy, Suining Central Hospital, Suining, Sichuan, 629000, China
| | - Xiaohong Huang
- Department of Pharmacy, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, Fujian, 363000, China
| | - Xiaoming Du
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, 110004, China
| | - Ruijuan Li
- Department of Pharmacy, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030032, China
| | - Qiaowei Zheng
- Department of Pharmacy, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, 710061, China
| | - Xiangsheng Lin
- Department of Pharmacy, Pingtan County General Laboratory Area Hospital, Fuzhou, Fujian, 350400, China
| | - Yanxia Zhang
- Department of Pharmacy, The First Affiliated Hospital of Jiamusi University, Jiamusi, Heilongjiang, 154002, China
| | - Lang Zou
- Department of Pharmacy, Second Affiliated Hospital, Army Medical University, Chongqing, 400037, China
| | - Yuxin Liu
- Department of Pharmacy, Huaihe Hospital of Henan University, Kaifeng, Henan, 475000, China
| | - Min Zhang
- Department of Pharmacy, Affiliated Qingdao Third People's Hospital, Qingdao University, Qingdao, Shandong, 266041, China
| | - Xiumei Liu
- Department of Pharmacy, People's Hospital of He'nan University of Chinese Medicine (People's Hospital of Zhengzhou), Zhengzhou, China
| | - Zhu Zhu
- Department of Pharmacy, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215004, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics , Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China.
| |
Collapse
|
4
|
Shimizu W, Yamashita T, Akao M, Atarashi H, Ikeda T, Koretsune Y, Okumura K, Suzuki S, Tsutsui H, Toyoda K, Hirayama A, Yasaka M, Yamaguchi T, Teramukai S, Kimura T, Morishima Y, Takita A, Inoue H. Renal Function and Clinical Outcomes Among Elderly Patients With Nonvalvular Atrial Fibrillation From ANAFIE. JACC. ASIA 2023; 3:475-487. [PMID: 37396416 PMCID: PMC10308099 DOI: 10.1016/j.jacasi.2023.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 01/24/2023] [Accepted: 01/30/2023] [Indexed: 07/04/2023]
Abstract
Background Advancing age, decreasing renal function, and atrial fibrillation are strongly associated. Real-world evidence of direct oral anticoagulant (DOAC) use among elderly patients ≥75 years of age with nonvalvular atrial fibrillation and renal dysfunction is limited. Objectives This study sought to assess 2-year outcomes and anticoagulant treatment, stratified by renal function. Methods Enrolled patients were divided into 4 subgroups by creatinine clearance (CrCl) to determine the impact of renal dysfunction on clinical outcomes. Results Of 32,275 patients, 26,202 with CrCl data were analyzed (median follow-up 2.00 [IQR: 1.92-2.00] years); 1.3% of patients had CrCl <15 mL/min, 10.7% had CrCl 15 to <30 mL/min, 33.4% had CrCl 30 to <50 mL/min, 35.8% had CrCl ≥50 mL/min, and 18.9% had unknown CrCl. Cumulative incidences of stroke/systemic embolic events, major bleeding, major plus clinically relevant nonmajor bleeding, cardiovascular death, all-cause death, and net clinical outcomes increased with decreasing CrCl. In multivariable Cox regression analysis, lower CrCl emerged as an independent risk factor for these clinical outcomes, except for major bleeding, compared with CrCl ≥50 mL/min. The effectiveness and safety of DOACs over warfarin were similar or better across 3 CrCl subgroups with CrCl 15 mL/min or more. DOAC use was associated with a lower risk of stroke/systemic embolic events, major bleeding, cardiovascular death, all-cause death, and net clinical outcome compared with warfarin in patients with CrCl 30 to <50 mL/min. Conclusions Incidences of major clinical outcomes increased with decreasing renal function in elderly nonvalvular atrial fibrillation patients. DOACs were effective and safe even in patients with renal dysfunction (CrCl 15-<50 mL/min). (Prospective Observational Study in Late-Stage Elderly Patients with Non-Valvular Atrial Fibrillation: All Nippon AF In Elderly Registry [ANAFIE Registry]; UMIN000024006).
Collapse
Affiliation(s)
- Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | | | - 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
| | | | - 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 and Neurology, Cerebrovascular Center, National Hospital Organization Kyushu Medical Center, 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
| | - Tetsuya Kimura
- Primary Medical Science Department, Daiichi Sankyo Co, Ltd, Tokyo, Japan
| | | | - Atsushi Takita
- Data Intelligence Department, Daiichi Sankyo Co, Ltd, Tokyo, Japan
| | | |
Collapse
|
5
|
Characterization of baseline clinical factors associated with incident worsening kidney function in patients with non-valvular atrial fibrillation: the Hokuriku-Plus AF Registry. Heart Vessels 2023; 38:402-411. [PMID: 36251049 DOI: 10.1007/s00380-022-02178-w] [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: 05/10/2022] [Accepted: 09/22/2022] [Indexed: 02/07/2023]
Abstract
Evidence suggests that atrial fibrillation (AF) could increase the risk of worsening kidney function (WKF) which is linked to an increased risk of stroke, bleeding, and death in AF patients. However, limited data exist regarding the factors that could lead to WKF in these patients. Therefore, we sought to identify the potential factors associated with the development of WKF in patients with non-valvular AF (NVAF). We analyzed prospectively recruited 1122 NVAF patients [men 71.9%, median age 73.0 years (interquartile range: 66.0-79.0)] with a baseline estimated glomerular filtration rate (eGFR) ≥ 15 mL/min/1.73 m2 from the Hokuriku-Plus AF Registry. The primary outcome was incident WKF, defined as the %eGFR change from the baseline ≥ 30% during the follow-up period. We evaluated the association between baseline variables and incident WKF using univariate and multivariate Cox proportional hazard models. We also evaluated the non-linear association between the identified factors and incident WKF. During a median follow-up period of 3.0 years (interquartile range: 2.7-3.3), incident WKF was observed in 108 patients (32.6 per 1000 person-years). Compared to the patients without incident WKF, the patients with incident WKF were older and had a higher prevalence of heart failure (HF), diabetes mellitus (DM), and vascular disease at baseline. Those who experienced incident WKF also had higher diastolic blood pressure, lower hemoglobin, lower eGFR, higher B-type natriuretic peptide (BNP) and used warfarin more frequently. Upon multivariate analysis, age ≥ 75 years, HF, DM, and anemia were independently associated with incident WKF. Additionally, age and hemoglobin were linearly associated with the risk of incident WKF, whereas a J- or U-shaped association was observed for HbA1c and BNP. Age ≥ 75 years, HF, DM, and anemia were associated with the development of WKF in Japanese patients with NVAF. In patients with these risk factors, a careful monitoring of the kidney function and appropriate interventions may be important when possible.
Collapse
|
6
|
Sakai S, Hagii J, Shikanai S, Sorimachi Y, Hamaura S, Yamazaki K, Yamada N, Shiroto H, Saito S, Kamada T, Takanashi S, Okumura K, Tomita H. Low Creatinine Clearance Is a Risk Factor for Severe Cardioembolic Stroke in Japanese Female Patients. In Vivo 2023; 37:336-344. [PMID: 36593049 PMCID: PMC9843754 DOI: 10.21873/invivo.13084] [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: 10/18/2022] [Revised: 10/30/2022] [Accepted: 11/01/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND/AIM The relationship between renal function and severity of cardioembolic stroke (CES) stratified by sex remains poorly understood. PATIENTS AND METHODS A total of 640 consecutive CES patients within 48 h after stroke onset and with a modified Rankin Scale (mRS) score of 0 or 1 before onset were studied. The patients were divided into three groups based on their CCr values: low creatinine clearance (CCr) (L-CCr) (n=71, <30 ml/min), middle CCr (M-CCr) (n=227, 30 to <50 ml/min), and high CCr (H-CCr) (n=342, ≥50 ml/min). We compared the severity and functional outcomes of stroke among the three groups according to sex. RESULTS On admission, using the National Institutes of Health Stroke Scale, the L-CCr group had the most severe stroke, followed by the M-CCr and H-CCr groups (p<0.0001). Functional outcomes at discharge, assessed using the mRS, were the worst in the L-CCr group, followed by the M-CCr and H-CCr groups (p<0.0001). Multivariable analyses revealed that L-CCr was a significant determinant of severe stroke on admission and poor functional outcomes at discharge. According to sex, L-CCr was a significant determinant of severe stroke on admission and poor functional outcomes at discharge in female patients, but not in male patients. CONCLUSION Low CCr is a risk factor for severe stroke on admission and unfavorable functional outcomes at discharge in Japanese CES patients, and particularly in female patients.
Collapse
Affiliation(s)
- Shuntaro Sakai
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Joji Hagii
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, Japan
| | - Shun Shikanai
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuya Sorimachi
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shogo Hamaura
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Ken Yamazaki
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Natsumi Yamada
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, Japan
| | | | - Shin Saito
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, Japan
| | | | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Hirofumi Tomita
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan;
- Department of Stroke and Cerebrovascular Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| |
Collapse
|
7
|
Kodani E, Tomita H, Nakai M, Akao M, Suzuki S, Hayashi K, Sawano M, Goya M, Yamashita T, Fukuda K, Ogawa H, Tsuda T, Isobe M, Toyoda K, Miyamoto Y, Miyata H, Okamura T, Sasahara Y, Okumura K. Impact of baseline blood pressure on adverse outcomes in Japanese patients with non-valvular atrial fibrillation: the J-RISK AF. EUROPEAN HEART JOURNAL OPEN 2022; 2:oeac081. [PMID: 36583077 PMCID: PMC9793850 DOI: 10.1093/ehjopen/oeac081] [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: 11/10/2022] [Revised: 11/23/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
Aims This study aimed to investigate the impact of baseline blood pressure (BP) on adverse outcomes in patients with atrial fibrillation (AF), using a pooled analysis performed on data from J-RISK AF, a large-scale cohort of Japanese patients with AF. Methods and results Of the 16 918 patients from five major AF registries including the J-RHYTHM Registry, Fushimi AF Registry, Shinken Database, Keio interhospital Cardiovascular Studies, and Hokuriku-Plus AF Registry, 15 019 non-valvular AF (NVAF) patients with baseline BP values (age, 70.0 ± 11.0 years; men, 69.1%) were analysed. Incidence rates of adverse events were evaluated between patients divided into baseline systolic BP quartiles or at 150 mmHg. During the follow-up period of 730 days, ischaemic stroke, major bleeding, all-cause death, and cardiovascular death occurred in 277, 319, 718, and 275 patients, respectively. Hazard ratios (HRs) for ischaemic stroke and major bleeding were comparable among the quartiles, whereas HRs for all-cause and cardiovascular deaths in the lowest quartile with systolic BP <114 mmHg were significantly higher [HR 1.43, 95% confidence interval (CI) 1.13-1.81; and HR 1.47, 95% CI 1.01-2.12, respectively] than in the third quartile, even after adjusting for known confounding factors. In patients with a systolic BP of ≥150 mmHg, adjusted HR for major bleeding was significantly higher than that of <150 mmHg (HR 1.64, 95% CI 1.12-2.40). Conclusion In Japanese patients with NVAF, a baseline systolic BP <114 mmHg was significantly associated with higher all-cause and cardiovascular mortality. In contrast, a systolic BP ≥150 mmHg was an independent risk factor for major bleeding.
Collapse
Affiliation(s)
- Eitaro Kodani
- Corresponding author. Tel: +81 42 371 2111, Fax: +81 42 372 7379,
| | - Hirofumi Tomita
- Department of Cardiology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki 036-8562, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka 564-8565, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto 612-8555, Japan
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, the Cardiovascular Institute, 3-2-19 Nishi-azabu, Minato-ku, Tokyo 106-0031, Japan
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Science, 13-1 Takara-machi, Kanazawa 920-8640, Japan
| | - Mitsuaki Sawano
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, the Cardiovascular Institute, 3-2-19 Nishi-azabu, Minato-ku, Tokyo 106-0031, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Hisashi Ogawa
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto 612-8555, Japan
| | - Toyonobu Tsuda
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Science, 13-1 Takara-machi, Kanazawa 920-8640, Japan
| | - Mitsuaki Isobe
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan,Sakakibara Heart Institute, 3-16-1 Asahi-cho, Fuchu-shi, Tokyo 183-0003, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka 564-8565, Japan
| | - Yoshihiro Miyamoto
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka 564-8565, Japan,Open Innovation Center, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka 564-8565, Japan
| | - Hiroaki Miyata
- Department of Health Policy and Management School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Tomonori Okamura
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Yusuke Sasahara
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka 564-8565, Japan
| | - Ken Okumura
- Department of Cardiovascular Medicine, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama-shi, Tokyo 206-8512, Japan,Division of Cardiology, Saiseikai Kumamoto Hospital, 5-3-1 Chikami, Minami-ku, Kumamoto-shi, Kumamoto 861-4193, Japan
| | | |
Collapse
|
8
|
Impact of heart rate on adverse events in patients with non-valvular atrial fibrillation: Subanalysis of the J-RHYTHM Registry. IJC HEART & VASCULATURE 2022; 43:101148. [DOI: 10.1016/j.ijcha.2022.101148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/02/2022] [Accepted: 11/10/2022] [Indexed: 11/18/2022]
|
9
|
Nishizawa N, Okawara M, Mori M, Fujino Y, Matsuda S, Fushimi K, Tanaka F. Postoperative cerebral infarction risk is related to lobectomy site in lung cancer: a retrospective cohort study of nationwide data in Japan. BMJ Open Respir Res 2022; 9:9/1/e001327. [PMID: 35868837 PMCID: PMC9316032 DOI: 10.1136/bmjresp-2022-001327] [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: 06/09/2022] [Accepted: 07/16/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To determine the incidence of cerebral infarction after lobectomy at different sites using inpatient data from a diagnosis procedure combination database. DESIGN Retrospective cohort study. SETTING Data were retrieved from the Japanese diagnosis procedure combination inpatient database for patients who underwent lobectomies for lung cancer between April 2018 and March 2020. PARTICIPANTS The analysis included 37 352 patients from 556 institutions who underwent lobectomies for lung cancer. MAIN OUTCOMES AND MEASURES The occurrence of cerebral infarction after lobectomy during hospitalisation was estimated using multilevel logistic regression models adjusted for sex, age, body mass index, smoking history, activity of daily living, surgical approach (thoracotomy or video-assisted), clinical cancer stage, comorbidities and hospital-level factors to describe the association between cerebral infarction and different lobectomy sites. RESULTS Overall cerebral infarction after lobectomy occurred in 99 patients (0.27%): 29 with left upper lobectomy (0.39%), 19 with left lower lobectomy (0.34%), 32 with right upper lobectomy (0.24%), 6 with right middle lobectomy (0.21%) and 13 with right lower lobectomy (0.16%). The multilevel multivariate logistic regression analysis revealed high ORs for the left upper lobectomy and left lower lobectomy groups. In both univariate and multivariate analyses, left upper lobectomy had the highest OR for the occurrence of cerebral infarction compared with lobectomies at other sites. CONCLUSIONS AND RELEVANCE Left upper lobectomy had the highest OR for the occurrence of cerebral infarction after lung cancer lobectomy during hospitalisation. There is an urgent need to investigate the specific mechanisms underlying postoperative cerebral infarction after left upper lobectomy and to establish preventive measures such as altering surgical methods, using radiological examinations for early detection and better use of anticoagulants.
Collapse
Affiliation(s)
- Natsumasa Nishizawa
- Second Department of Surgery, University of Occupational and Environmental Health Japan, Kitakyushu, Fukuoka, Japan
| | - Makoto Okawara
- Department of Environmental Epidemiology, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health Japan, Kitakyushu, Fukuoka, Japan
| | - Masataka Mori
- Second Department of Surgery, University of Occupational and Environmental Health Japan, Kitakyushu, Fukuoka, Japan
| | - Yoshihisa Fujino
- Department of Environmental Epidemiology, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health Japan, Kitakyushu, Fukuoka, Japan
| | - Shinya Matsuda
- Department of Public Health, University of Occupational and Environmental Health Japan, Kitakyushu, Fukuoka, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, Bunkyo-ku, Tokyo, Japan
| | - Fumihiro Tanaka
- Second Department of Surgery, University of Occupational and Environmental Health Japan, Kitakyushu, Fukuoka, Japan
| |
Collapse
|
10
|
Ono K, Iwasaki YK, Akao M, Ikeda T, Ishii K, Inden Y, Kusano K, Kobayashi Y, Koretsune Y, Sasano T, Sumitomo N, Takahashi N, Niwano S, Hagiwara N, Hisatome I, Furukawa T, Honjo H, Maruyama T, Murakawa Y, Yasaka M, Watanabe E, Aiba T, Amino M, Itoh H, Ogawa H, Okumura Y, Aoki-Kamiya C, Kishihara J, Kodani E, Komatsu T, Sakamoto Y, Satomi K, Shiga T, Shinohara T, Suzuki A, Suzuki S, Sekiguchi Y, Nagase S, Hayami N, Harada M, Fujino T, Makiyama T, Maruyama M, Miake J, Muraji S, Murata H, Morita N, Yokoshiki H, Yoshioka K, Yodogawa K, Inoue H, Okumura K, Kimura T, Tsutsui H, Shimizu W. JCS/JHRS 2020 Guideline on Pharmacotherapy of Cardiac Arrhythmias. Circ J 2022; 86:1790-1924. [DOI: 10.1253/circj.cj-20-1212] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | - Yu-ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Masaharu Akao
- Department of Cardiovascular Medicine, National Hospital Organization Kyoto Medical Center
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School of Medicine
| | - Kuniaki Ishii
- Department of Pharmacology, Yamagata University Faculty of Medicine
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yoshinori Kobayashi
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital
| | | | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | | | - Tetsushi Furukawa
- Department of Bio-information Pharmacology, Medical Research Institute, Tokyo Medical and Dental University
| | - Haruo Honjo
- Research Institute of Environmental Medicine, Nagoya University
| | - Toru Maruyama
- Department of Hematology, Oncology and Cardiovascular Medicine, Kyushu University Hospital
| | - Yuji Murakawa
- The 4th Department of Internal Medicine, Teikyo University School of Medicine, Mizonokuchi Hospital
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center
| | - Eiichi Watanabe
- Department of Cardiology, Fujita Health University School of Medicine
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Mari Amino
- Department of Cardiovascular Medicine, Tokai University School of Medicine
| | - Hideki Itoh
- Division of Patient Safety, Hiroshima University Hospital
| | - Hisashi Ogawa
- Department of Cardiology, National Hospital Organisation Kyoto Medical Center
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Chizuko Aoki-Kamiya
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center
| | - Jun Kishihara
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Eitaro Kodani
- Department of Cardiovascular Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Takashi Komatsu
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University School of Medicine
| | | | | | - Tsuyoshi Shiga
- Department of Clinical Pharmacology and Therapeutics, The Jikei University School of Medicine
| | - Tetsuji Shinohara
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Atsushi Suzuki
- Department of Cardiology, Tokyo Women's Medical University
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute
| | - Yukio Sekiguchi
- Department of Cardiology, National Hospital Organization Kasumigaura Medical Center
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Noriyuki Hayami
- Department of Fourth Internal Medicine, Teikyo University Mizonokuchi Hospital
| | | | - Tadashi Fujino
- Department of Cardiovascular Medicine, Toho University, Faculty of Medicine
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Mitsunori Maruyama
- Department of Cardiovascular Medicine, Nippon Medical School Musashi Kosugi Hospital
| | - Junichiro Miake
- Department of Pharmacology, Tottori University Faculty of Medicine
| | - Shota Muraji
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | | | - Norishige Morita
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital
| | - Hisashi Yokoshiki
- Department of Cardiovascular Medicine, Sapporo City General Hospital
| | - Koichiro Yoshioka
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine
| | - Kenji Yodogawa
- Department of Cardiovascular Medicine, Nippon Medical School
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | | |
Collapse
|
11
|
Wang J, Zhang T, Yang YM, Zhu J, Zhang H, Shao XH. Relationship between creatinine clearance and clinical outcomes in Chinese emergency patients with atrial fibrillation. Ann Noninvasive Electrocardiol 2022; 27:e12942. [PMID: 35239203 PMCID: PMC9107078 DOI: 10.1111/anec.12942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/01/2022] [Indexed: 12/02/2022] Open
Abstract
Background Few real‐world data on the relation between creatinine clearance (CrCl) and adverse clinical outcomes in Chinese emergency department (ED) patients with nonvalvular atrial fibrillation (AF). Methods In this prospective, observational, multicenter AF study, enrolled AF patients presenting to an ED at 20 hospitals in China from November 2008 to October 2011, with a follow‐up of 12 month. A total of 863 AF patients with CrCl data were analyzed, and patients were categorized as CrCl ≥ 80, 50 ≤ CrCl < 80, 30 ≤ CrCl < 50, and CrCl < 30(ml/min). Outcomes of analyses were all‐cause death, cardiovascular death, thromboembolism (TE), and major bleeding. Results Among the whole patients, 126(14.6%) patients died during 12‐month follow‐up, 53(40.2%) among CrCl < 30 ml/min group, and 48(16.2%), 22(6.5%), and 3(3.2%) among 30 ≤ CrCl50, 50 ≤ Crl < 80, and CrCl ≥ 80 ml/min groups, respectively (p < 0.001). Cardiovascular death and TE rates also increased with decreasing CrCl. On multivariate analysis, patients with CrCl < 30 ml/min were associated with higher risks of all‐cause death (HR 5.567; 95%CI1.618–19.876; p = .007) and higher cardiovascular death (HR11.939; 95%CI1.439–99.031; p = .022) as compared with CrCl≥80 ml/min category. Nevertheless, for TE and major bleeding risk, CrCl groups showed no significant difference after adjustment for variables in CHA2DS2‐VASc score and status of warfarin prescription in our cohort. Conclusions In Chinese ED nonvalvular AF patients, incidence rates of death increased with reducing CrCl across the whole range of renal function. CrCl < 30 ml/min was associated with all‐cause death, cardiovascular death, but not for TE and major bleeding.
Collapse
Affiliation(s)
- Juan Wang
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Zhang
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan-Min Yang
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Zhu
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Han Zhang
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xing-Hui Shao
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
12
|
Prior direct oral anticoagulant dosage and outcomes in patients with acute ischemic stroke and non-valvular atrial fibrillation: A sub-analysis of PASTA registry study. J Neurol Sci 2022; 434:120163. [DOI: 10.1016/j.jns.2022.120163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/27/2021] [Accepted: 01/18/2022] [Indexed: 11/22/2022]
|
13
|
Atarashi H, Uchiyama S, Inoue H, Kitazono T, Yamashita T, Shimizu W, Ikeda T, Kamouchi M, Kaikita K, Fukuda K, Origasa H, Shimokawa H. Ischemic stroke, hemorrhage, and mortality in patients with non-valvular atrial fibrillation and renal dysfunction treated with rivaroxaban: sub-analysis of the EXPAND study. Heart Vessels 2021; 36:1410-1420. [PMID: 33728513 PMCID: PMC8332581 DOI: 10.1007/s00380-021-01810-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 02/19/2021] [Indexed: 11/30/2022]
Abstract
The EXPAND Study demonstrated the effectiveness and safety of rivaroxaban in patients with non-valvular atrial fibrillation (NVAF) in routine clinical practice in Japan. This sub-analysis was conducted to reveal the effectiveness and safety of rivaroxaban in Japanese NVAF patients according to baseline creatinine clearance (CrCl) levels and rivaroxaban doses in the EXPAND Study. We examined 6806 patients whose baseline CrCl data were available and classified them into 2 groups: normal renal function group with CrCl ≥ 50 mL/min (n = 5326, 78%) and renal dysfunction group with CrCl < 50 mL/min (n = 1480, 22%). In the normal renal function group, 1609 (30%) received 10 mg/day (under-dose), while in the renal dysfunction group, 108 (7%) received 15 mg/day (over-dose). In the normal renal function group, under-dose of rivaroxaban was associated with higher all-cause mortality, while in the renal dysfunction group, over-dose was associated with higher incidence of major bleeding. In contrast, the incidence of stroke or systemic embolism was not different between the 2 groups regardless of the dose of rivaroxaban. In the propensity score matched analysis to adjust the difference in characteristics according to doses of rivaroxaban, the incidences of clinical outcomes were comparable between the 2 dose groups in both renal function groups. These results indicate that the dose of rivaroxaban should be reduced depending on the renal function, considering the balance between risks of bleeding and ischemia.
Collapse
Affiliation(s)
- Hirotsugu Atarashi
- Minamihachioji Hospital, Koyasu-cho 3-18-12, Hachioji, Tokyo, 192-0904, Japan
| | - Shinichiro Uchiyama
- Clinical Research Center for Medicine, International University of Health and Welfare, Akasaka 8-5-35, Minato-ku, Tokyo, 107-0052, Japan
| | - Hiroshi Inoue
- Saiseikai Toyama Hospital, Kusunoki 33-1, Toyama, 931-8533, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Maidashi 3-1-1, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takeshi Yamashita
- Cardiovascular Institute Hospital, Nishiazabu 3-2-19, Minato-Ku, Tokyo, 106-0031, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School, Sendagi 1-1-5, Bunkyo-ku, Tokyo, 113-8602, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Faculty of Medicine, Toho University, Omorinishi 5-21-16, Ota-ku, Tokyo, 143-8540, Japan
| | - Masahiro Kamouchi
- Department of Health Care Administration and Management, Center for Cohort Study, Kyushu University Graduate School of Medical Sciences, Maidashi 3-1-1, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 2-39-1, Kurokami Chuo-ku, Kumamoto, 860-8555, Japan
| | - Koji Fukuda
- Division of Heart Rhythm, International University of Health and Welfare Hospital, Iguchi 537-3, Nasushiobara, Japan
| | - Hideki Origasa
- Division of Biostatistics and Clinical Epidemiology, University of Toyama Graduate School of Medicine, Sugitani 2630, Toyama, 930-0194, Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Seiryomachi 1-1, Aoba-ku, Sendai, 980-8574, Japan. .,International University of Health and Welfare, Kozunomori 4-3, Narita, 286-8686, Japan.
| |
Collapse
|
14
|
Premužić V, Stevanović R, Radić P, Salvetti M, Lovrić-Benčić M, Jelaković A, Miličić D, Capak K, Agabiti-Rosei E, Jelaković B. Chronic kidney disease and cardiovascular mortality in patients with atrial fibrillation: European Society of Hypertension project - ESH A Fib. Medicine (Baltimore) 2021; 100:e23975. [PMID: 33466138 PMCID: PMC7808501 DOI: 10.1097/md.0000000000023975] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/30/2020] [Indexed: 01/05/2023] Open
Abstract
Our aim was to analyze characteristics of atrial fibrillation (AF) patients with chronic kidney disease (CKD) from the Croatian cohort of the ESH A Fib survey and to determine the association of estimated glomerular filtration rate (eGFR) with cardiovascular (CV) mortality after 24 months of follow-up.Consecutive sample of 301 patients with AF were enrolled in the period 2014 to 2018. Hypertension was defined as BP > 140/90 mm Hg and/or antihypertensive drugs treatment, CKD was defined as eGFR (CKD Epi) < 60 ml/min/1.73 m2 which was confirmed after 3 months.CKD was diagnosed in 45.2% of patients (13.3% in CKD stage > 3b). CKD patients were older than non-CKD and had significantly more frequent coronary heart disease, heart failure and valvular disease. CKD patients had significantly higher CHA2DS2-VASc score and more CKD than non-CKD patients had CHA2DS2-VASc > 2. Crude CV mortality rate per 1000 population at the end of the first year of the follow-up was significantly higher in CKD vs non-CKD group who had shorter mean survival time. CV mortality was independently associated with eGFR, male gender, CHA2DS2VASc and R2CHA2DS2VASc scores.Prevalence of CKD, particularly more advanced stages of CKD, is very high in patients with AF. Observed higher CV mortality and shorter mean survival time in CKD patients could be explained with higher CHA2DS2VASc score which is a consequence of clustering of all score components in CKD patients. However, eGFR was independently associated with CV mortality. In our cohort, R2CHA2DS2VASc score was not associated significantly more with CV mortality than CHA2DS2VASc score.
Collapse
Affiliation(s)
- Vedran Premužić
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb
- School of Medicine, Zagreb, Croatia
| | | | - Petra Radić
- University Hospital Center Sisters of Mercy, Zagreb, Croatia
| | | | - Martina Lovrić-Benčić
- Cardiology Clinic, University Hospital Center Zagreb
- School of Medicine, Zagreb, Croatia
| | - Ana Jelaković
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb
| | - Davor Miličić
- Cardiology Clinic, University Hospital Center Zagreb
- School of Medicine, Zagreb, Croatia
| | | | | | - Bojan Jelaković
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb
- School of Medicine, Zagreb, Croatia
| |
Collapse
|
15
|
Kodani E, Inoue H, Atarashi H, Okumura K, Yamashita T, Otsuka T, Origasa H. Impact of Blood Pressure Visit-to-Visit Variability on Adverse Events in Patients With Nonvalvular Atrial Fibrillation: Subanalysis of the J-RHYTHM Registry. J Am Heart Assoc 2020; 10:e018585. [PMID: 33372541 PMCID: PMC7955501 DOI: 10.1161/jaha.120.018585] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background Blood pressure (BP) variability has reportedly been a risk factor for various clinical events. To clarify the influence of BP visit‐to‐visit variability on adverse events in patients with nonvalvular atrial fibrillation, a post hoc analysis of the J‐RHYTHM Registry was performed. Methods and Results Of 7406 outpatients with nonvalvular atrial fibrillation from 158 institutions, 7226 (age, 69.7±9.9 years; men, 70.7%), in whom BP was measured 4 times or more (14.6±5.0 times) during the 2‐year follow‐up period or until occurrence of an event, constituted the study group. SD and coefficient of variation of BP values were calculated as BP variability. Thromboembolism, major hemorrhage, and all‐cause death occurred in 110 (1.5%), 121 (1.7%), and 168 (2.3%) patients, respectively. When patients were divided into quartiles of systolic BP‐SD (<8.20, 8.20–10.49, 10.50–13.19, and ≥13.20 mm Hg), hazard ratios (HRs) for all adverse events were significantly high in the highest quartile compared with the lowest quartile (HR, 2.00, 95% CI, 1.15–3.49, P=0.015 for thromboembolism; HR, 2.60, 95% CI, 1.36–4.97, P=0.004 for major hemorrhage; and HR, 1.85, 95% CI, 1.11–3.07, P=0.018 for all‐cause death) after adjusting for components of the CHA2DS2‐VASc score, warfarin and antiplatelet use, atrial fibrillation type, BP measurement times, and others. These findings were consistent when BP‐coefficient of variation was used instead of BP‐SD. Conclusions Systolic BP visit‐to‐visit variability was significantly associated with all adverse events in patients with nonvalvular atrial fibrillation. Further studies are needed to clarify the causality between BP variability and adverse outcomes in patients with nonvalvular atrial fibrillation. Registration URL: https://www.umin.ac.jp/ctr/; Unique Identifier: UMIN000001569.
Collapse
Affiliation(s)
- Eitaro Kodani
- Department of Internal Medicine and Cardiology Nippon Medical School Tama-Nagayama Hospital Tokyo Japan
| | | | | | | | | | - Toshiaki Otsuka
- Department of Hygiene and Public Health Nippon Medical School Tokyo Japan
| | - Hideki Origasa
- Division of Biostatistics and Clinical Epidemiology University of Toyama Japan
| | | |
Collapse
|
16
|
Kodani E, Akao M. Atrial fibrillation and stroke prevention: state of the art-epidemiology and pathophysiology: new risk factors, concepts and controversies. Eur Heart J Suppl 2020; 22:O1-O13. [PMID: 33380940 PMCID: PMC7753870 DOI: 10.1093/eurheartj/suaa176] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Atrial fibrillation (AF) increases the risk of thromboembolism, and risk assessment for thromboembolism is necessary for the management of AF patients. CHADS2 and CHA2DS2-VASc scores have been adopted in international guidelines for AF management, but the significance of each risk factor included in these risk scores are sometimes controversial, and the performance of these scores is only modest. There are several other risk factors not included in the scores such as renal dysfunction, low body weight, type of AF (paroxysmal or non-paroxysmal) as well as echocardiographic parameters and blood biomarkers, and physicians should assess patients risk in an integrated manner.
Collapse
Affiliation(s)
- Eitaro Kodani
- Department of Cardiovascular Medicine, Nippon Medical School Tama-Nagayama Hospital, 1-7-1, Nagayama, Tama-shi, Tokyo 206-8512, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto 612-8555, Japan
| |
Collapse
|
17
|
Kodani E, Inoue H, Atarashi H, Tomita H, Okumura K, Yamashita T, Origasa H. Predictive ability of creatinine clearance versus estimated glomerular filtration rate for outcomes in patients with non-valvular atrial fibrillation: Subanalysis of the J-RHYTHM Registry. IJC HEART & VASCULATURE 2020; 29:100559. [PMID: 32566722 PMCID: PMC7298529 DOI: 10.1016/j.ijcha.2020.100559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/01/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Renal impairment is a risk factor for various adverse events, especially for death. In general, creatinine clearance (CrCl) is used for dose-adjustments of many drugs including oral anticoagulants, and estimated glomerular filtration rate (eGFR) is adopted for the diagnosis of chronic kidney disease. Predictive ability of CrCl versus eGFR for outcomes in patients with non-valvular atrial fibrillation (NVAF) remains controversial; therefore, this was compared using data from the J-RHYTHM Registry. METHODS Out of 7406 outpatients with NVAF from 158 institutions, 6004 (age, 69.7 ± 9.9 years; men, 71.2%) having data of CrCl (mL/min, by the Cockcroft-Gault formula), eGFR (mL/min/1.73 m2, by the equations of the Japanese Society of Nephrology), and body surface area (BSA) were analyzed. C-statistics (area under the receiver-operating characteristic curve) of CrCl and eGFR for events were compared by DeLong's test. RESULTS Thromboembolism, major hemorrhage, and all-cause death occurred in 107 (1.8%), 117 (1.9%), and 154 (2.6%) patients during the 2-year follow-up period. C-statistics of CrCl for each event were 0.609 (95% confidence interval, 0.559-0.658), 0.599 (0.548-0.657), and 0.746 (0.706-0.786); and those of eGFR were 0.542 (0.487-0.597), 0.573 (0.519-0.626), and 0.677 (0.631-0.723), respectively. C-statistics of CrCl for thromboembolism and all-cause death were significantly higher than those of eGFR (P < 0.001 for both). These results were consistent when BSA-unadjusted eGFR was used instead of eGFR (P = 0.002 for thromboembolism and P < 0.001 for all-cause death). CONCLUSIONS CrCl was superior to eGFR in the prediction of adverse outcomes, i.e., thromboembolism and all-cause death in Japanese patients with NVAF.
Collapse
Affiliation(s)
- Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama-Nagayama Hospital, Tokyo, Japan
| | | | | | - Hirofumi Tomita
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Ken Okumura
- Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Hideki Origasa
- Division of Biostatistics and Clinical Epidemiology, University of Toyama, Toyama, Japan
| | - on behalf of the J-RHYTHM Registry Investigators
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama-Nagayama Hospital, Tokyo, Japan
- Saiseikai Toyama Hospital, Toyama, Japan
- Minamihachioji Hospital, Tokyo, Japan
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Aomori, Japan
- Saiseikai Kumamoto Hospital, Kumamoto, Japan
- The Cardiovascular Institute, Tokyo, Japan
- Division of Biostatistics and Clinical Epidemiology, University of Toyama, Toyama, Japan
| |
Collapse
|
18
|
Akao M, Yamashita T, Suzuki S, Okumura K. Impact of creatinine clearance on clinical outcomes in elderly atrial fibrillation patients receiving apixaban: J-ELD AF Registry subanalysis. Am Heart J 2020; 223:23-33. [PMID: 32135338 DOI: 10.1016/j.ahj.2020.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/06/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Randomized clinical trials demonstrated the efficacy and safety of apixaban in preventing stroke in patients with atrial fibrillation (AF). However, data on patients with low creatinine clearance (CCr), especially CCr 15-29 mL/min, are limited. METHODS The J-ELD AF Registry is a large-scale, multicenter prospective observational study of Japanese nonvalvular AF patients aged ≥75 years taking on-label dose (standard dose of 5 mg bid or reduced dose of 2.5 mg bid) of apixaban. The entire cohort (3,015 patients from 110 institutions) was divided into 3 CCr subgroups: CCr ≥50 mL/min (n = 1,165, 38.6%), CCr 30-49 mL/min (n = 1,395, 46.3%), and CCr 15-29 mL/min (n = 455, 15.1%). RESULTS The event incidence rates (/100 person-years) were 1.76, 1.39, and 1.67 for stroke or systemic embolism (log rank P = .762); 1.39, 1.93, and 3.13 for bleeding requiring hospitalization (log rank P = .159); 1.75, 2.76, and 7.87 for total deaths (log rank P < .001); and 0.46, 0.84, and 2.62 for cardiovascular deaths (log rank P < .001), respectively. After adjusting for confounders by Cox regression analysis, CCr 15-29 was an independent risk for total death and cardiovascular death but not for stroke or systemic embolism, or bleeding requiring hospitalization. CONCLUSIONS The incidence of events in each CCr value group was comparable for stroke or systemic embolism and bleeding requiring hospitalization, and significantly higher for total deaths and cardiovascular deaths only in the CCr 15- to 29-mL/min group, in Japanese nonvalvular AF patients aged ≥75 years.
Collapse
Affiliation(s)
- Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan.
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| |
Collapse
|
19
|
Murakawa Y, Ikeda T, Ogawa S, Kitazono T, Nakagawara J, Minematsu K, Miyamoto S, Hayashi Y, Kidani Y, Okayama Y, Sunaya T, Sato S, Yamanaka S. Impact of body mass index on real-world outcomes of rivaroxaban treatment in Japanese patients with non-valvular atrial fibrillation. Heart Vessels 2020; 35:1125-1134. [PMID: 32253531 PMCID: PMC7332477 DOI: 10.1007/s00380-020-01587-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/13/2020] [Indexed: 01/26/2023]
Abstract
This sub-analysis of the XAPASS, a prospective, single-arm, observational study, aimed to evaluate relationships between body mass index (BMI) and safety (major bleeding and all-cause mortality) and effectiveness [stroke/non-central nervous system (non-CNS) systemic embolism (SE)/myocardial infarction (MI)] outcomes in Japanese patients with non-valvular atrial fibrillation (NVAF) receiving rivaroxaban. Patients were categorized according to BMI (kg/m2) as underweight (< 18.5), normal weight (18.5 to < 25), overweight (25 to < 30), or obese (≥ 30). In total, 9578 patients with NVAF completed the 1-year follow-up and were evaluated; of these, 7618 patients had baseline BMI data. Overall, 542 (5.7%), 4410 (46.0%), 2167 (22.6%), and 499 (5.2%) patients were underweight, normal weight, overweight, and obese, respectively. Multivariable Cox regression analysis demonstrated that none of the BMI categories were independent predictors of major bleeding whereas being underweight was independently associated with increased all-cause mortality [hazard ratio (HR) 3.56, 95% confidence interval (CI) 2.40–5.26, p < 0.001]. The incidence of stroke/non-CNS SE/MI was higher in patients who were underweight than in those of normal weight (HR 2.11, 95% CI 1.20–3.70, p = 0.009). However, in multivariable analyses, being underweight was not identified as an independent predictor of stroke/non-CNS SE/MI (HR 1.64, 95% CI 0.90–2.99, p = 0.104). In conclusion, the high incidence of thromboembolic events and all-cause mortality in patients who were underweight highlights that thorough evaluation of disease status and comorbidities may be required in this population.
Collapse
Affiliation(s)
- Yuji Murakawa
- The 4th Department of Internal Medicine, Teikyo University School of Medicine, Mizonokuchi Hospital, 5-1-1, Futago, Takatsu-ku, Kawasaki, Kanagawa, 213-8507, Japan.
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School of Medicine, Tokyo, Japan
| | - Satoshi Ogawa
- International University of Health and Welfare Mita Hospital, Tokyo, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jyoji Nakagawara
- Osaka Namba Clinic, Osaka, Japan.,National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kazuo Minematsu
- National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.,Iseikai Medical Corporation, Osaka, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yasuhiro Hayashi
- Medical Affairs Thrombosis, Medical Affairs, Bayer Yakuhin, Ltd., Osaka, Japan
| | - Yoko Kidani
- Medical Affairs Thrombosis, Medical Affairs, Bayer Yakuhin, Ltd., Osaka, Japan
| | - Yutaka Okayama
- Pharmacovigilance Monitoring and Medical Governance, Medical Affairs, Bayer Yakuhin, Ltd., Osaka, Japan
| | - Toshiyuki Sunaya
- Research and Development Japan/Data Sciences and Analytics/Statistics and Data Insights, Bayer Yakuhin, Ltd., Osaka, Japan
| | - Shoichiro Sato
- Pharmacovigilance Monitoring and Medical Governance, Medical Affairs, Bayer Yakuhin, Ltd., Osaka, Japan
| | - Satoshi Yamanaka
- Medical Affairs Thrombosis, Medical Affairs, Bayer Yakuhin, Ltd., Osaka, Japan
| |
Collapse
|
20
|
Okumura K, Tomita H, Nakai M, Kodani E, Akao M, Suzuki S, Hayashi K, Sawano M, Goya M, Yamashita T, Fukuda K, Ogawa H, Tsuda T, Isobe M, Toyoda K, Miyamoto Y, Miyata H, Okamura T, Sasahara Y. Risk Factors Associated With Ischemic Stroke in Japanese Patients With Nonvalvular Atrial Fibrillation. JAMA Netw Open 2020; 3:e202881. [PMID: 32293685 PMCID: PMC7160687 DOI: 10.1001/jamanetworkopen.2020.2881] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Despite the development of risk stratification schemes that have been widely used to determine the risk for thromboembolism in patients with nonvalvular atrial fibrillation (NVAF), risk stratification schemes in Asian patients with NVAF remain undetermined. OBJECTIVE To determine risk factors for ischemic stroke in Japanese patients with NVAF. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzed individual patient data from 5 AF registries in Japan: J-RHYTHM (Japanese Rhythm Management Trial for Atrial Fibrillation) Registry, Fushimi AF Registry, Shinken Database, Keio Interhospital Cardiovascular Studies (Keio Study), and Hokuriku-Plus AF Registry. Patients with atrial fibrillation were registered from 158 institutions in the J-RHYTHM Registry, 80 in the Fushimi AF Registry, a single hospital in Shinken Database, 11 in the Keio Study, and 19 in the Hokuriku-Plus AF Registry. Patients with valvular AF or lacking data were excluded. Data were collected and integrated in March 2016, and those from the Keio Study were updated in April 2018. Data were analyzed from April 2018 to February 2020. MAIN OUTCOMES AND MEASURES Significant risk factors for ischemic stroke were determined by adjusted Cox proportional hazards analysis. RESULTS In total, 12 289 patients with NVAF (3758 [31%] female; mean [SD] age 70.2 [11] years) were analyzed with a mean (SD) follow-up period of 649 (181) days (1.8 [0.5] years). During 21 820 person-years of follow-up, 241 cases of ischemic stroke were reported. Risk factors associated with ischemic stroke after adjustment for oral anticoagulant use at enrollment were age (75-84 years: hazard ratio [HR], 1.74; 95% CI, 1.32-2.30; P < .001; and ≥85 years: HR, 2.41; 1.63-3.56; P < .001), hypertension (HR, 1.60; 95% CI, 1.15-2.23; P = .006), previous stroke (HR, 2.75; 95% CI, 2.09-3.62; P < .001), persistent or permanent AF (HR, 1.59; 95% CI, 1.21-2.10; P = .001), and body mass index less than 18.5 (HR, 1.55; 95% CI, 1.05-2.29; P = .03). Neither diabetes nor heart failure were identified as risk factors for ischemic stroke. CONCLUSIONS AND RELEVANCE Previous stroke, advanced age, hypertension, persistent or permanent AF, and low body mass index were independent risk factors associated with ischemic stroke in Japanese patients with NVAF.
Collapse
Affiliation(s)
- Ken Okumura
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Hirofumi Tomita
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Michikazu Nakai
- Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama-Nagayama Hospital, Tokyo, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Mitsuaki Sawano
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Hisashi Ogawa
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Toyonobu Tsuda
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Mitsuaki Isobe
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
- Sakakibara Heart Institute, Tokyo, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshihiro Miyamoto
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroaki Miyata
- Department of Health Policy and Management School of Medicine, Keio University, Tokyo, Japan
| | - Tomonori Okamura
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Yusuke Sasahara
- Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, Suita, Japan
| |
Collapse
|
21
|
Relationship between the Renal Function and Adverse Clinical Events in Patients with Atrial Fibrillation: A Japanese Multicenter Registry Substudy. J Clin Med 2020; 9:jcm9010167. [PMID: 31936260 PMCID: PMC7019418 DOI: 10.3390/jcm9010167] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 12/30/2019] [Accepted: 01/07/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist, but the real-world data after approval of direct oral anticoagulants (DOACs) are still lacking in Japan. We investigated the association of the baseline renal function and adverse clinical events and risk of adverse clinical events with DOACs compared to warfarin for each renal functional level in Japanese AF patients. METHODS The present substudy was based on the SAKURA AF Registry, a Japanese multicenter observational registry (median follow-up period: 39 months). The creatinine clearance (CrCl) values were estimated by the Cockcroft-Gault formula, and divided into normal renal function, and mild and moderate-severe CKD (CrCl ≥ 80, 50-79, <50 mL/min). RESULTS In the SAKURA AF Registry, the baseline CrCl data were available for 3242 patients (52% for DOAC and 48% for warfarin user). The relative risk of adverse clinical events was significantly higher in the patients with a CrCl < 50 mL/min as compared to those with a CrCl ≥ 80 mL/min (adjusted HRs: 2.53 for death, 2.53 for cardiovascular [CV] events, 2.13 for strokes, and 1.83 for major bleeding). Risks of all adverse clinical events were statistically even between DOAC and warfarin users for each renal function level. CONCLUSION Moderate-severe CKD was associated with a higher mortality, CV events, strokes, and major bleeding than normal renal function. The safety and effectiveness of DOACs over warfarin were similar for each renal function level. By a worsening renal function, the incidence of adverse clinical events increased, especially deaths and CV events as compared to strokes and major bleeding.
Collapse
|
22
|
Real-world outcomes of rivaroxaban treatment in patients with nonvalvular atrial fibrillation and worsening renal function. J Cardiol 2019; 74:501-506. [DOI: 10.1016/j.jjcc.2019.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 06/06/2019] [Accepted: 06/10/2019] [Indexed: 12/18/2022]
|
23
|
Kodani E, Inoue H, Atarashi H, Okumura K, Yamashita T, Origasa H. Impact of hemoglobin concentration and platelet count on outcomes of patients with non-valvular atrial fibrillation: A subanalysis of the J-RHYTHM Registry. Int J Cardiol 2019; 302:81-87. [PMID: 31785960 DOI: 10.1016/j.ijcard.2019.11.127] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 11/11/2019] [Accepted: 11/21/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND To clarify the influence of hemoglobin concentration and platelet count on adverse outcomes of Japanese patients with non-valvular atrial fibrillation (NVAF), a post hoc analysis of the J-RHYTHM Registry was performed. METHODS A consecutive series of outpatients with atrial fibrillation were enrolled from 158 institutions and followed up for 2 years or until an event occurred (thromboembolism, major hemorrhage, or all-cause death). Among 7406 patients with NVAF, 6536 with complete blood count data (69.8 ± 9.9 years, 71.0% men) were divided into 4 groups according to the baseline hemoglobin level (<10.0, 10.0-11.9, 12.0-13.9, and ≥14.0 g/dL) or platelet count (<10.0, 10.0-19.9, 20.0-29.9, and ≥30.0 × 104/μL). RESULTS Incidence rates of major hemorrhage (p = 0.004 for trend), all-cause death (p < 0.001 for trend), and composite events (p < 0.001 for trend) increased as hemoglobin levels decreased, and composite events (p = 0.045 for trend) increased as platelet counts decreased. After adjusting for multiple confounders, the incidence of all-cause death and composite events was higher with hemoglobin levels <12.0 g/dL than a hemoglobin level ≥14.0 g/dL. In contrast, platelet count was not associated with any events. This was also true when multivariate analysis was performed using the stepwise forward method. CONCLUSIONS A low hemoglobin level (<12.0 g/dL) was an independent risk factor for all-cause death and composite events in Japanese patients with NVAF. However, platelet count did not impact outcomes. CLINICAL TRIAL REGISTRATION http://www.umin.ac.jp/ctr/ (unique identifier: UMIN000001569).
Collapse
Affiliation(s)
- Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama-Nagayama Hospital, Tokyo, Japan.
| | | | | | - Ken Okumura
- Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Hideki Origasa
- Division of Biostatistics and Clinical Epidemiology, University of Toyama, Toyama, Japan
| | | |
Collapse
|
24
|
Polshakova IL, Povetkin SV. Comparative Analysis of Factors Affecting the Prognosis of Patients with Atrial Fibrillation According to the Results of the REKUR-AF Study. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2019. [DOI: 10.20996/1819-6446-2019-15-5-649-655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Aim. To conduct a comparative analysis of the significance of the influence of various factors and their combinations on the survival of patients with atrial fibrillation (AF) in the REKUR-AF study.Material and methods. The database includes 896 patients with AF over 18 years old who applied to medical organizations in the city of Kursk and seven districts of the Kursk region from September 2015 to August 2016. Achievement by the patients of the “end point” (death from any cause) was assessed using a telephone contact for a period of 9.0±0.55 months from the end of the database formation. Data were obtained on 532 patients, of which 60 patients reached the end point. To study the differences in survival in subgroups of patients with different characteristics, two groups of categorized factors were analyzed – clinical (sex, age, form of AF, etc.) and pharmacological (use of different classes of drugs). The necessary information was obtained from outpatient cards analyzed when patients were included in the study.Results. The survival rate of patients with AF was significantly (p<0.05-0.001) influenced by the following factors and their categories: age (<60 years – 92.5%, 60-65 years – 92.9%, over 75 years – 80.1%); AF form (paroxysmal – 95.1%, persistent – 93.2%, permanent – 84.4%); stable angina (SA) (presence – 86.5%, absence – 90.7%); chronic heart failure functional class (CHF FC) (I-II – 95.9%, III – 91.5%, IV – 69.6%); glomerular filtration rate (GFR) (>50 ml/min – 89.6%, 30-50 ml/min – 85.8%, <30 ml/min – 72.7%); diabetes mellitus (DM) (presence – 81.9%, absence – 90.4%), hospitalization for the year preceding inclusion in the study (presence – 85.5%, absence – 97.3%), the use of oral anticoagulants (OAC) (presence – 96.7%, absence – 87.1%). In subgroups of patients with the above mentioned categories (especially the most severe) of the studied factors, significant (p<0.05-0.01) differences in the proportion of surviving patients depending on the appointment of OAC were revealed: age >75 years – 78.2% and 100%; permanent form of AF – 81.9% and 96.1%, the presence of SA – 85.0% and 94.7%; CHF FC IV – 67.0% and 91.7%; GFR<30 ml/min – 62.5% and 100%; presence of DM – 80.7% and 88.2%.%; the presence of hospitalizations in the last year – 82.9% and 97.2%; >5 points on the CHA2DS2VASc scale – 67.0% and 91.7%, heart rate >90/min – 68.8% and 100% of patients with the absence and presence of the OAC therapy, respectively. Cox regression analy sis revealed clinical predictors contributing to an increase in the risk of death: age over 75 years, permanent form of AF, CHF FC III-IV, the presence of DM, the presence of previous hospitalizations. The absence of the OAC taking was accompanied by an increase in the risk of death by 3.66 times.Conclusion. The results of the REKUR-AF study allowed to establish the most significant factors affecting the survival of patients with AF: age, form of AF, CHF FC, presence of DM, hospitalization in the last year preceding the inclusion of patients in the study, OAK taking. The prescription of OAC is a priority predictor that improves survival in patients with AF.
Collapse
|
25
|
Kodani E, Inoue H, Atarashi H, Okumura K, Yamashita T, Origasa H. Impact of Digitalis Use on Mortality in Japanese Patients With Non-Valvular Atrial Fibrillation - A Subanalysis of the J-RHYTHM Registry. Circ J 2019; 83:1644-1652. [PMID: 31217399 DOI: 10.1253/circj.cj-19-0267] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Because the influence of digitalis use on the death of patients with non-valvular atrial fibrillation (NVAF) remains controversial, a subanalysis of the J-RHYTHM Registry was performed.Methods and Results:A consecutive series of outpatients with AF from 158 institutions was enrolled and followed for 2 years or until the occurrence of an event. Among 7,406 patients with NVAF, 7,018 (age, 69.7±10.0 years; men, 71.1%) with information on antiarrhythmic drug and digitalis use at baseline were divided into 2 groups based on digitalis use. The influence of digitalis on death was investigated using a propensity score-matching model. In 802 patients treated with digitalis, all-cause death was significantly higher than in 6,216 patients with no digitalis use during the 2-year follow-up period (4.4% vs. 2.4%, unadjusted P<0.001). Digitalis use was significantly associated with all-cause death in the crude model (hazard ratio [HR] 1.85, 95% confidence interval [CI] 1.28-2.68, P=0.001). However, after propensity score-matching, the association was not significant (HR 1.31, 95% CI 0.70-2.46, P=0.405). Older age, male sex, heart failure, coronary artery disease, and lower body mass index were significantly associated with all-cause death in NVAF patients treated with digitalis. CONCLUSIONS Digitalis use was not independently associated with all-cause death, and several clinical confounding factors might contribute to increased mortality in NVAF patients treated with digitalis.
Collapse
Affiliation(s)
- Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama-Nagayama Hospital
| | | | - Hirotsugu Atarashi
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama-Nagayama Hospital
| | | | | | - Hideki Origasa
- Division of Biostatistics and Clinical Epidemiology, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences
| | | |
Collapse
|
26
|
Clinical risk factors of stroke and major bleeding in patients with non-valvular atrial fibrillation under rivaroxaban: the EXPAND Study sub-analysis. Heart Vessels 2019; 34:1839-1851. [PMID: 31127325 PMCID: PMC6794239 DOI: 10.1007/s00380-019-01425-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 05/15/2019] [Indexed: 11/24/2022]
Abstract
For Japanese patients with non-valvular atrial fibrillation (NVAF), the risk of stroke and major bleeding events was assessed by using the CHADS2, CHA2DS2-VASc, and HAS-BLED scores. The risk factors for embolism and major bleeding under DOAC may be different from current reports. We analyzed the data set of the EXPAND Study to determine the risk factors for events among Japanese NVAF patients in the era of direct oral anticoagulant. Using the data of EXPAND Study, the validity for predictability of the CHADS2, CHA2DS2-VASc, and HAS-BLED scores was identified using the receiver operating characteristic curve analysis. Multivariate analysis was performed with the Cox proportional hazard model to determine the independent risk factors for stroke/systemic embolism and major bleeding among NVAF patients receiving rivaroxaban. Explanatory variables were selected based on the univariate analysis. A total of 7141 patients (mean age 71.6 ± 9.4 years, women 32.3%, and rivaroxaban 15 mg per day 56.5%) were included. Incidence rates of stroke/systemic embolism and major bleeding were 1.0%/year and 1.2%/year, respectively. The multivariate analysis revealed that only history of stroke was associated with stroke/systemic embolism (hazard ratio 3.4, 95% confidence interval 2.5-4.7, p < 0.0001). By contrast, age (1.7, 1.1–2.6, p = 0.0263), creatinine clearance (CrCl) 30–49 mL/min (1.6, 1.2-2.2, p = 0.0011), liver dysfunction (1.7, 1.1–2.8, p = 0.0320), history/disposition of bleeding (1.8, 1.0–3.0, p = 0.0348), and concomitant use of antiplatelet agents (1.6, 1.2–2.3, p = 0.0030) were associated with major bleeding. This sub-analysis showed that some components of the HAS-BLED score were independently associated with major bleeding in Japanese NVAF patients receiving anticoagulation therapy by rivaroxaban. Additionally, CrCl value of 30–49 mL/min was an independent predictor of major bleeding in patients receiving rivaroxaban.
Collapse
|
27
|
Kuronuma K, Okumura Y, Yokoyama K, Matsumoto N, Tachibana E, Oiwa K, Matsumoto M, Kojima T, Hanada S, Nomoto K, Arima K, Takahashi F, Kotani T, Ikeya Y, Fukushima S, Itou S, Kondo K, Chiku M, Ohno Y, Onikura M, Hirayama A. Different determinants of vascular and nonvascular deaths in patients with atrial fibrillation: A SAKURA AF Registry substudy. J Cardiol 2018; 73:210-217. [PMID: 30591323 DOI: 10.1016/j.jjcc.2018.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 11/29/2018] [Accepted: 12/08/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The incidence and causes of death among patients in Japan treated for atrial fibrillation (AF), a major determinant of strokes and death, with direct oral anticoagulants (DOACs) are unclear. This study's aim was two-fold: to compare the incidence and causes of death between DOAC and warfarin users in Japan and to identify the factors associated with vascular and nonvascular death in the Japanese AF population. METHODS The study was based on the SAKURA AF registry, in which clinical events were tracked in 3267 enrollees from 63 institutions for 2-4 years. Enrollees included warfarin users (n=1577) and users of any of 4 DOACs (n=1690). The incidence, cause, and major determinants of death were analyzed. RESULTS During a median 39.3-month follow-up, 200 patients died, with most succumbing to cardiac death (25%), malignancies (21%), or respiratory infections (20%). There was no significant difference in deaths from any cause between warfarin and DOAC users (108 vs. 92 patients, p=0.34). An age ≥75 years was found to be a major determinant of death, but the relative risk (vs. <75 years) was greater for nonvascular death (hazard ratio: 2.85 and 4.97 for age 75-84 and ≥85 years, respectively) than vascular death (2.14 and 2.98 for 75-84 and ≥85 years, respectively). Heart failure, renal dysfunction, and the type of institution were major determinants of vascular death, and a male sex, weight <50kg, and anemia were major determinants of nonvascular death. CONCLUSIONS The results of our AF registry-based study, in which two thirds of the enrolled patients succumbed to cardiac death, malignancies, or respiratory infections within 2- 4 years and use of DOACs rather than warfarin did not reduce the mortality, indicated that a management of AF that includes prophylaxis for vascular and nonvascular events in addition to strokes is warranted.
Collapse
Affiliation(s)
| | - Yasuo Okumura
- Division of Cardiology, Nihon University Itabashi Hospital, Tokyo, Japan.
| | | | - Naoya Matsumoto
- Department of Cardiology, Nihon University Hospital, Tokyo, Japan
| | | | - Koji Oiwa
- Yokohama Chuo Hospital, Kanagawa, Japan
| | | | | | - Shoji Hanada
- Asakadai Central General Hospital, Saitama, Japan
| | | | - Ken Arima
- Kasukabe Municipal Hospital, Saitama, Japan
| | | | | | | | | | | | | | | | | | | | - Atsushi Hirayama
- Division of Cardiology, Nihon University Itabashi Hospital, Tokyo, Japan
| | | |
Collapse
|
28
|
Proietti R, Gonzini L, Pizzimenti G, Ledda A, Sanna P, AlTurki A, Russo V, Lencioni M. Glomerular filtration rate: A prognostic marker in atrial fibrillation-A subanalysis of the AntiThrombotic Agents Atrial Fibrillation. Clin Cardiol 2018; 41:1570-1577. [PMID: 30144119 DOI: 10.1002/clc.23065] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/26/2018] [Accepted: 08/21/2018] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE An increased cardiovascular mortality and morbidity has been widely reported in patients with atrial fibrillation (AF). In this study, a subanalysis of the AntiThrombotic Agents Atrial Fibrillation (ATA-AF) is performed with the aim to evaluate estimated glomerular filtration rate (eGFR) as an independent prognostic marker of cardiovascular mortality and morbidity in patients with AF. METHODS AND RESULTS The ATA-AF study enrolled 7148 patients with AF, in 360 Italian centers. The eGFR was calculated from data reported in patient notes or hospital database. This post-hoc analysis included 1097 AF patients with eGFR data available and 1-year clinical follow-up. The endpoint was assessed as cardiovascular mortality and/or hospital admission for cardiovascular causes at follow-up. Patients were also divided in two groups according to the eGFR (<60 and ≥60 mL/min/1.73 m2 ). The Kaplan-Meyer curve for the mentioned endpoint showed a higher endpoint incidence in the group of patient with eGFR below 60 mL/min/1.73 m2 (P < 0.001). Using multivariate analysis (Cox regression), a trend toward a higher rate of occurrence of the primary endpoint was observed for eGFR below 60 mL/min/1.73 m2 without reaching the conventional level of statistical significance (hazard ratio [HR] 1.40; 95% confidence interval [CI] 0.99-1.99; P = 0.0572). When eGFR was included in the analysis as continuous variable a significant correlation was observed with the combined endpoint at the Cox regression (HR 0.99, 95% CI 0.98-0.99, P = 0.04). CONCLUSION The result of this post-hoc analysis indicates that an impaired eGFR is independently associated with worse prognosis among patients with AF.
Collapse
Affiliation(s)
- Riccardo Proietti
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua, Padua, Italy
| | | | | | - Antonietta Ledda
- Cardiology Department, Azienda Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Pietro Sanna
- Cardiology Department, San Francesco Hospital, Nuoro, Italy
| | - Ahmed AlTurki
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada.,Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Vincenzo Russo
- Chair of Cardiology, University of Campania "Luigi Vanvitelli", Ospedale Monaldi, Naples, Italy
| | - Mauro Lencioni
- Queen Elizabeth Hospital, Queen Elizabeth Medical Centre, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | | |
Collapse
|
29
|
Inoue H, Kodani E, Atarashi H, Okumura K, Yamashita T, Origasa H. Renal Dysfunction Affects Anticoagulation Control With Warfarin and Outcomes in Japanese Elderly Patients With Non-Valvular Atrial Fibrillation. Circ J 2018; 82:2277-2283. [PMID: 29984788 DOI: 10.1253/circj.cj-18-0242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND It is unclear whether renal dysfunction affects warfarin control in patients with non-valvular atrial fibrillation (NVAF). Methods and Results: Using a dataset from the J-RHYTHM Registry, time in therapeutic range (TTR) of the international normalized ratio (INR) of prothrombin time, and creatinine clearance (CrCl) were determined in elderly patients aged ≥70 years. Target INR values were 1.6-2.6 following Japanese guidelines. Incidences of thromboembolism, major hemorrhage, and all-cause death were determined over 2 years. Of 7,406 NVAF patients enrolled in the registry, 2,782 elderly patients (mean age, 75 years) had data for CrCl measured at baseline and TTR. TTR values were lower in the lower CrCl groups (P<0.001 for trend). CrCl <30 mL/min was independently associated with TTR <65% (odds ratio, 1.49; 95% confidence interval, 1.13-1.95; P=0.004). In the multivariate analysis, TTR <65% was independently associated with thromboembolism (hazard ratio, 2.26; 95% confidence interval, 1.37-3.72; P=0.001), but CrCl was not (CrCl <30 mL/min, 1.68, 0.41-6.85, P=0.473). However, CrCl <30 mL/min and TTR <65% were independently associated with all-cause death (5.32, 1.56-18.18, P=0.008 and 1.60, 1.07-2.38, P=0.022, respectively) and the composite event (thromboembolism, major hemorrhage and all-cause death) (2.03, 1.10-3.76, P=0.024 and 1.58, 1.22-2.04, P=0.001, respectively). CONCLUSIONS Elderly NVAF patients with renal dysfunction had poor warfarin control, which was associated with higher risk of thromboembolism and all-cause death.
Collapse
Affiliation(s)
| | - Eitaro Kodani
- Department of Internal Medicine, Nippon Medical School Tama-Nagayama Hospital
| | - Hirotsugu Atarashi
- Department of Internal Medicine, Nippon Medical School Tama-Nagayama Hospital
| | - Ken Okumura
- Department of Cardiology, Saiseikai Kumamoto Hospital
| | | | - Hideki Origasa
- Division of Biostatistics and Clinical Epidemiology, University of Toyama, Graduate School of Medicine
| | | |
Collapse
|