Risk of myocardial infarction and ischemic stroke in individuals with first-diagnosed paroxysmal vs. non-paroxysmal atrial fibrillation under anticoagulation

Social determinants of health and clinical outcomes among patients with atrial fibrillation: evidence from a global federated health research network

BACKGROUND

Few studies have investigated the role of social determinants of health (SDoH) in patients with atrial fibrillation (AF).

AIM

To investigate the relationship between SDoH and adverse events in a large multinational AF cohort.

DESIGN

Retrospective study utilizing a global federated health research network (TriNetX).

METHODS

Patients with AF were categorized as socially deprived defined according to ICD codes based on three SDoHs: (i) extreme poverty; (ii) unemployment; and/or (iii) problems related with living alone. The outcomes were the 5-year risk of a composite outcomes of all-cause death, hospitalization, ischemic heart disease (IHD), stroke, heart failure (HF) or severe ventricular arrhythmias. Cox regression was used to compute hazard rate ratios (HRs) and 95% confidence intervals (CIs) following 1:1 propensity score matching (PSM).

RESULTS

The study included 24 631 socially deprived (68.8 ± 16.0 years; females 51.8%) and 2 462 092 non-deprived AF patients (75.5 ± 13.1 years; females 43.8%). Before PSM, socially deprived patients had a higher risk of the composite outcome (HR 1.9, 95% CI 1.87-1.93), all-cause death (HR 1.34, 95% CI 1.28-1.39), hospitalization (HR 2.01, 95% CI 1.98-2.04), IHD (HR 1.67, 95% CI 1.64-1.70), stroke (HR 2.60, 95% CI 2.51-2.64), HF (HR 1.91, 95% CI 1.86-1.96) and severe ventricular arrhythmias (HR 1.83, 95% CI 1.76-1.90) compared to non-deprived AF patients. The PSM-based hazard ratios for the primary composite outcome were 1.54 (95% CI 1.49-1.60) for the unemployed AF patients; 1.39 (95% CI 1.31-1.47) for patients with extreme poverty or with low income; and 1.42 (95% CI 1.37-1.47) for those with problems related with living alone.

CONCLUSIONS

In patients with AF, social deprivation is associated with an increased risk of death and adverse cardiac events. The presence of possible unmeasured bias associated with the retrospective design requires confirmation in future prospective studies.

Asymptomatic vs. symptomatic atrial fibrillation: Clinical outcomes in heart failure patients

BACKGROUND

The outcome implications of asymptomatic vs. symptomatic atrial fibrillation (AF) in specific groups of patients according to clinical heart failure (HF) and left ventricular ejection fraction (LVEF) need to be clarified.

METHODS

In a prospective observational study, patients were categorized according to overt HF with LVEF≤40 %, or with LVEF>40 %, or without overt HF with LVEF40 %≤ or > 40 %, as well as according to the presence of asymptomatic or symptomatic AF.

RESULTS

A total of 8096 patients, divided into 8 groups according to HF and LVEF, were included with similar proportions of asymptomatic AF (ranging from 43 to 48 %). After a median follow-up of 730 [699 -748] days, the composite outcome (all-cause death and MACE) was significantly worse for patients with asymptomatic AF associated with HF and reduced LVEF vs. symptomatic AF patients of the same group (p = 0.004). On adjusted Cox regression analysis, asymptomatic AF patients with HF and reduced LVEF were independently associated with a higher risk for the composite outcome (aHR 1.32, 95 % CI 1.04-1.69) and all-cause death (aHR 1.33, 95 % CI 1.02-1.73) compared to symptomatic AF patients with HF and reduced LVEF. Kaplan-Meier curves showed that HF-LVEF≤40 % asymptomatic patients had the highest cumulative incidence of all-cause death and MACE (p < 0.001 for both).

CONCLUSIONS

In a large European cohort of AF patients, the risk of the composite outcome at 2 years was not different between asymptomatic and symptomatic AF in the whole cohort but adverse implications for poor outcomes were found for asymptomatic AF in HF with LVEF≤40 %.

Mid-term changes in cognitive functions in patients with atrial fibrillation: a longitudinal analysis of the Swiss-AF cohort

Background

Longitudinal association studies of atrial fibrillation (AF) and cognitive functions have shown an unclear role of AF-type and often differ in methodological aspects. We therefore aim to investigate longitudinal changes in cognitive functions in association with AF-type (non-paroxysmal vs. paroxysmal) and comorbidities in the Swiss-AF cohort.

Methods

Seven cognitive measures were administered up to five times between 2014 and 2022. Age-education standardized scores were calculated and association between longitudinal change in scores and baseline AF-type investigated using linear mixed-effects models. Associations between AF-type and time to cognitive drop, an observed score of at least one standard deviation below individual's age-education standardized cognitive scores at baseline, were studied using Cox proportional hazard models of each cognitive test, censoring patients at their last measurement. Models were adjusted for baseline covariates.

Results

2,415 AF patients (mean age 73.2 years; 1,080 paroxysmal, 1,335 non-paroxysmal AF) participated in this Swiss multicenter prospective cohort study. Mean cognitive scores increased longitudinally (median follow-up 3.97 years). Non-paroxysmal AF patients showed smaller longitudinal increases in Digit Symbol Substitution Test (DSST), Cognitive Construct Score (CoCo)and Trail Making Test part B (TMT-B) scores vs. paroxysmal AF patients. Diabetes, history of stroke/TIA and depression were associated with worse performance on all cognitive tests. No differences in time to cognitive drop were observed between AF-types in any cognitive test.

Conclusion

This study indicated preserved cognitive functioning in AF patients, best explained by practice effects. Smaller practice effects were found in non-paroxysmal AF patients in the DSST, TMT-B and the CoCo and could indicate a marker of subtle cognitive decline. As diabetes, history of stroke/TIA and depression-but not AF-type-were associated with cognitive drop, more attention should be given to risk factors and underlying mechanisms of AF.