1
|
Nielsen PB, Brøndum RF, Nøhr AK, Overvad TF, Lip GYH. Risk of stroke in male and female patients with atrial fibrillation in a nationwide cohort. Nat Commun 2024; 15:6728. [PMID: 39112527 PMCID: PMC11306344 DOI: 10.1038/s41467-024-51193-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 07/30/2024] [Indexed: 08/10/2024] Open
Abstract
Female sex has been suggested as a risk modifier for stroke in patients with atrial fibrillation (AF) with comorbid prevalent stroke risk factors. Management has evolved over time towards a holistic approach that may have diminished any sex difference in AF-related stroke. In a nationwide cohort of AF patients free from oral anticoagulant treatment, we examine the time trends in stroke risk overall and in relation to risk differences between male and female patients. Here we show that among 158,982 patients with AF (median age 78 years (IQR: 71 to 85); 52% female) the 1-year thromboembolic risk was highest between 1997-2000 with a risk of 5.6% and lowest between 2013-2016 with a risk of 3.8%, declining over the last two decades. The excess stroke risk for female vs male patients has also been declining, with risk-score adjusted relative risk estimates suggesting limited sex-difference in recent years.
Collapse
Affiliation(s)
- Peter Brønnum Nielsen
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg University Hospital, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Rasmus Froberg Brøndum
- Center for Clinical Data Science, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Anne Krogh Nøhr
- Center for Clinical Data Science, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | | | - Gregory Y H Lip
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg University Hospital, Aalborg, Denmark.
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
| |
Collapse
|
2
|
Collins B, Lip GYH. Delaying Oral Anticoagulants: A False Economy? PHARMACOECONOMICS 2024:10.1007/s40273-024-01422-7. [PMID: 39093501 DOI: 10.1007/s40273-024-01422-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/22/2024] [Indexed: 08/04/2024]
Affiliation(s)
- Brendan Collins
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Public Health Policy and Systems, University of Liverpool, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, and Liverpool Heart and Chest Hospital, Liverpool, UK.
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| |
Collapse
|
3
|
Chatani R, Kubo S, Tasaka H, Sakata A, Yoshino M, Maruo T, Kadota K. Safety and feasibility of atrial fibrillation ablation after left atrial appendage closure: A single-center experience of the left atrial appendage closure first strategy. J Arrhythm 2024; 40:879-890. [PMID: 39139871 PMCID: PMC11317688 DOI: 10.1002/joa3.13073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/27/2024] [Accepted: 05/09/2024] [Indexed: 08/15/2024] Open
Abstract
Background Patients with atrial fibrillation (AF) who are not suitable for long-term anticoagulant therapy undergo percutaneous left atrial appendage closure (LAAC). The safety and feasibility of left atrial catheter ablation (CA) procedures after LAAC remain unclear. This study aimed to clarify the feasibility and safety of CA after LAAC, including in the early phase within 180 days. Methods Characteristics and clinical outcomes of 46 patients with AF who had undergone both CA and LAAC within 2 years (mean age, 72 years; 29 men) were compared between those who had undergone CA-first (31 patients) and LAAC-first (15 patients). Results The mean CHA₂DS₂-VASc and HAS-BLED scores were 4.8 and 3.3 points, respectively. The LAAC-first strategy was often used in patients with prior major bleeding and LAA thrombosis or sludge. In the LAAC-first group, the mean duration between both procedures was 212 days, and all LAAC-first patients, including seven patients in the early phase, could undergo CA without LAAC device-related complications; moreover, no cardiovascular adverse events were reported after both procedures (mean periods: 420 days). After CA post-LAAC, no device-related adverse events (device-related thrombosis, new peri-device leak appearance, peri-device leak increase, or device dislodgement) were observed, whereas, after LAAC post-CA, 3 new peri-device leak appearance events and 1 peri-device leak increase event were observed, especially patients who underwent LAAC in the early phase post-CA. Conclusion Based on single-center experience, left atrial CA in the presence of an LAAC device implanted including the early phase was safe and feasible.
Collapse
Affiliation(s)
- Ryuki Chatani
- Department of Cardiovascular MedicineKurashiki Central HospitalKurashikiJapan
| | - Shunsuke Kubo
- Department of Cardiovascular MedicineKurashiki Central HospitalKurashikiJapan
| | - Hiroshi Tasaka
- Department of Cardiovascular MedicineKurashiki Central HospitalKurashikiJapan
| | - Atsushi Sakata
- Department of Cardiovascular MedicineKurashiki Central HospitalKurashikiJapan
| | - Mitsuru Yoshino
- Department of Cardiovascular MedicineKurashiki Central HospitalKurashikiJapan
| | - Takeshi Maruo
- Department of Cardiovascular MedicineKurashiki Central HospitalKurashikiJapan
| | - Kazushige Kadota
- Department of Cardiovascular MedicineKurashiki Central HospitalKurashikiJapan
| |
Collapse
|
4
|
Mei DA, Imberti JF, Bonini N, Romiti GF, Corica B, Proietti M, Vitolo M, Lip GYH, Boriani G. Performance of HAS-BLED and DOAC scores to predict major bleeding events in atrial fibrillation patients treated with direct oral anticoagulants: A report from a prospective European observational registry. Eur J Intern Med 2024:S0953-6205(24)00277-2. [PMID: 38969571 DOI: 10.1016/j.ejim.2024.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 06/17/2024] [Accepted: 06/25/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND The DOAC score has been recently proposed for bleeding risk stratification of patients with atrial fibrillation treated with direct oral anticoagulants (DOAC). OBJECTIVE To compare the performance of HAS-BLED and DOAC score in predicting major bleeding events in a contemporary cohort of European AF patients treated with DOAC. METHODS We included patients derived from a prospective observational registry of European AF patients. HAS-BLED and DOAC scores were calculated as per the original schemes. Our primary endpoint was major bleeding events. Receiver operating characteristic (ROC) curves were used to compare the predictive ability of the scores. RESULTS A total of 2834 AF patients (median age [IQR] 69 [62-77] years; 39.6 % female) treated with DOAC were included in the analysis. According to the HAS-BLED score, 577 patients (20.4 %) were categorized as very low risk of bleeding, as compared to 1276 (45.0 %) according to DOAC score. A total of 55 major bleeding events occurred with an overall incidence of 1.04 per 100 patient-years. Both scores showed only a modest ability for the prediction of bleeding events (HAS-BLED area under the curve [AUC], 0.65, 95 % confidence interval [CI] 0.55-0.70; DOAC score AUC 0.62, 95 % CI 0.59-0.71, p for difference = 0.332]. At calibration analysis, the DOAC score showed modest calibration, especially for patients at high risk, when compared to HAS-BLED. CONCLUSION In a contemporary cohort of DOAC-treated AF patients, both HAS-BLED and DOAC scores only modestly predicted the occurrence of major bleeding events. Our results do not support the preferential use of DOAC score over HAS-BLED.
Collapse
Affiliation(s)
- Davide Antonio Mei
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, Modena, Modena 41121, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Jacopo Francesco Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, Modena, Modena 41121, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Niccolò Bonini
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, Modena, Modena 41121, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Translational and Precision Medicine, Sapienza - University of Rome, Italy
| | - Bernadette Corica
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, Modena, Modena 41121, Italy; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milani, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, Modena, Modena 41121, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, Modena, Modena 41121, Italy.
| |
Collapse
|
5
|
Pisanò ECL, Calvi V, Viscusi M, Rapacciuolo A, Lazzari L, Bontempi L, Pelargonio G, Arena G, Caccavo V, Wang CC, Merkely B, Lin LY, Oh IY, Bertaglia E, Saporito D, Menichelli M, Nicosia A, Carretta DM, Coppolino A, Ching CK, del Castillo ÁM, Su X, Del Maestro M, Giacopelli D, Gargaro A, Botto GL. Closed loop stimulation reduces the incidence of atrial high-rate episodes compared with conventional rate-adaptive pacing in patients with sinus node dysfunctions. Europace 2024; 26:euae175. [PMID: 38938169 PMCID: PMC11226787 DOI: 10.1093/europace/euae175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 05/30/2024] [Indexed: 06/29/2024] Open
Abstract
AIMS Subclinical atrial fibrillation (AF) is associated with increased risk of progression to clinical AF, stroke, and cardiovascular death. We hypothesized that in pacemaker patients requiring dual-chamber rate-adaptive (DDDR) pacing, closed loop stimulation (CLS) integrated into the circulatory control system through intra-cardiac impedance monitoring would reduce the occurrence of atrial high-rate episodes (AHREs) compared with conventional DDDR pacing. METHODS AND RESULTS Patients with sinus node dysfunctions (SNDs) and an implanted pacemaker or defibrillator were randomly allocated to dual-chamber CLS (n = 612) or accelerometer-based DDDR pacing (n = 598) and followed for 3 years. The primary endpoint was time to the composite endpoint of the first AHRE lasting ≥6 min, stroke, or transient ischaemic attack (TIA). All AHREs were independently adjudicated using intra-cardiac electrograms. The incidence of the primary endpoint was lower in the CLS arm (50.6%) than in the DDDR arm (55.7%), primarily due to the reduction in AHREs lasting between 6 h and 7 days. Unadjusted site-stratified hazard ratio (HR) for CLS vs. DDDR was 0.84 [95% confidence interval (CI), 0.72-0.99; P = 0.035]. After adjusting for CHA2DS2-VASc score, the HR remained 0.84 (95% CI, 0.71-0.99; P = 0.033). In subgroup analyses of AHRE incidence, the incremental benefit of CLS was greatest in patients without atrioventricular block (HR, 0.77; P = 0.008) and in patients without AF history (HR, 0.73; P = 0.009). The contribution of stroke/TIA to the primary endpoint (1.3%) was low and not statistically different between study arms. CONCLUSION Dual-chamber CLS in patients with SND is associated with a significantly lower AHRE incidence than conventional DDDR pacing.
Collapse
Affiliation(s)
- Ennio C L Pisanò
- Cardiology and Intensive Care Unit, Vito Fazzi Hospital, Lecce, Italy
| | - Valeria Calvi
- Cardiology, G. Rodolico—San Marco University Hospital, Catania, Italy
| | - Miguel Viscusi
- Clinical and Interventional Arrhythmology, Sant’Anna e San Sebastiano Hospital, Caserta, Italy
| | - Antonio Rapacciuolo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Ludovico Lazzari
- Clinical and Interventional Arrhythmology, Santa Maria Hospital, Terni, Italy
| | | | - Gemma Pelargonio
- Arrhythmology, Fondazione Policlinico Gemelli IRCCS Università Cattolica del Sacro Cuore, Roma, Italy
| | - Giuseppe Arena
- Cardiology and Intensive Care Unit, Apuane New Hospital, Massa, Italy
| | - Vincenzo Caccavo
- Cardiology and Intensive Care Unit, Miulli Regional Hospital, Acquaviva delle Fonti, Italy
| | - Chun-Chieh Wang
- Cardiology, Chang Gung Memorial Hospital—Linkou—CGMH, Taipei, Taiwan
| | - Béla Merkely
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Lian-Yu Lin
- Cardiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Il-young Oh
- Cardiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | | | | | | | | | | | - Aldo Coppolino
- Cardiology and Intensive Care Unit, Elecrophysiology, SS Annunziata Hospital, Savigliano, Cuneo, Italy
| | - Chi Keong Ching
- Cardiology/Cardiovascular Surgery, National Heart Center, Singapore
| | | | - Xi Su
- Cardiology, Wuhan Asia Heart Hospital, Wuhan, China
| | | | | | - Alessio Gargaro
- Clinical Research Unit, BIOTRONIK Italia, Cologno Monzese, Milan, Italy
| | - Giovanni L Botto
- ASST Rhodense, Rho & Garbagnate Hospitals, Viale Carlo Forlanini, 95, 20024 Garbagnate Milanese, Milan, Italy
| |
Collapse
|
6
|
Marazzato J, Di Biase L. Left atrial appendage occlusion: are we ready for prime time? Europace 2024; 26:euae187. [PMID: 39082729 PMCID: PMC11289676 DOI: 10.1093/europace/euae187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024] Open
Affiliation(s)
- Jacopo Marazzato
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
- Electrophysiology and Cardiac Pacing Unit, Humanitas Mater Domini, Castellanza, Italy
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| |
Collapse
|
7
|
Sterliński M, Bunting KV, Boriani G, Boveda S, Guasch E, Mont L, Rajappan K, Sommer P, Mehta S, Sun Y, Gale CP, van Deutekom C, Van Gelder IC, Kotecha D. Design and deployment of the STEEER-AF trial to evaluate and improve guideline adherence: a cluster-randomized trial by the European Society of Cardiology and European Heart Rhythm Association. Europace 2024; 26:euae178. [PMID: 38940494 PMCID: PMC11289729 DOI: 10.1093/europace/euae178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 06/19/2024] [Indexed: 06/29/2024] Open
Abstract
AIMS The aim is to describe the rationale, design, delivery, and baseline characteristics of the Stroke prevention and rhythm control Treatment: Evaluation of an Educational programme of the European society of cardiology in a cluster-Randomized trial in patients with Atrial Fibrillation (STEEER-AF) trial. METHODS AND RESULTS STEEER-AF is a pragmatic trial designed to objectively and robustly determine whether guidelines are adhered to in routine practice and evaluate a targeted educational programme for healthcare professionals. Seventy centres were randomized in six countries (France, Germany, Italy, Poland, Spain, and UK; 2022-23). The STEEER-AF centres recruited 1732 patients with a diagnosis of atrial fibrillation (AF), with a mean age of 68.9 years (SD 11.7), CHA2DS2-VASc score of 3.2 (SD 1.8), and 647 (37%) women. Eight hundred and forty-three patients (49%) were in AF at enrolment and 760 (44%) in sinus rhythm. Oral anticoagulant therapy was prescribed in 1543 patients (89%), with the majority receiving direct oral anticoagulants (1378; 89%). Previous cardioversion, antiarrhythmic drug therapy, or ablation was recorded in 836 patients (48.3%). Five hundred fifty-one patients (31.8%) were currently receiving an antiarrhythmic drug, and 446 (25.8%) were scheduled to receive a future cardioversion or ablation. The educational programme engaged 195 healthcare professionals across centres randomized to the intervention group, consisting of bespoke interactive online learning and reinforcement activities, supported by national expert trainers. CONCLUSION The STEEER-AF trial was successfully deployed across six European countries to investigate guideline adherence in real-world practice and evaluate if a structured educational programme for healthcare professionals can improve patient-level care. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov, NCT04396418.
Collapse
Affiliation(s)
| | - Karina V Bunting
- Institute of Cardiovascular Sciences, University of Birmingham, Medical School, Vincent Drive, Birmingham B15 2TT, UK
- Cardiology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Giuseppe Boriani
- Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Serge Boveda
- Heart Rhythm Management Department, Cardiology, Clinique Pasteur, Toulouse, France
| | - Eduard Guasch
- Cardiology Department, Clinic Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Medicine Department, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigación Médica en Red—Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Lluís Mont
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Médica en Red—Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Arrhythmias Section, Cardiovascular Clinical Institute, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Kim Rajappan
- Cardiology Department, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, UK
| | - Philipp Sommer
- Clinic for Electrophysiology, Heart and Diabetes Center NRW, Georgstraße 11, Bad Oeynhausen, Germany
| | - Samir Mehta
- Birmingham Clinical Trials Unit (BCTU), Institute of Applied Health Research, Birmingham, UK
| | - Yongzhong Sun
- Birmingham Clinical Trials Unit (BCTU), Institute of Applied Health Research, Birmingham, UK
| | - Chris P Gale
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Leeds Institute of Data Analytics, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals, Leeds, UK
| | - Colinda van Deutekom
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Dipak Kotecha
- Institute of Cardiovascular Sciences, University of Birmingham, Medical School, Vincent Drive, Birmingham B15 2TT, UK
- Cardiology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, Heritage Building, Mindelsohn Way, Birmingham B15 2TH, UK
- West Midlands NHS Secure Data Environment, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham B15 2GW, UK
| |
Collapse
|
8
|
Cheng S, He J, Han Y, Han S, Li P, Liao H, Guo J. Global burden of atrial fibrillation/atrial flutter and its attributable risk factors from 1990 to 2021. Europace 2024; 26:euae195. [PMID: 38984719 PMCID: PMC11287210 DOI: 10.1093/europace/euae195] [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: 05/29/2024] [Accepted: 07/05/2024] [Indexed: 07/11/2024] Open
Abstract
AIMS To devise effective preventive measures, a profound understanding of the evolving patterns and trends in atrial fibrillation (AF) and atrial flutter (AFL) burdens is pivotal. Our study was designed to quantify the burden and delineate the risk factors associated with AF and AFL across 204 countries and territories spanning 1990-2021. METHODS AND RESULTS Data pertaining to AF and AFL were sourced from the Global Burden of Disease Study 2021. The burden of AF/AFL was evaluated using metrics such as incidence, disability-adjusted life years (DALYs), deaths, and their corresponding age-standardized rates (ASRs), stratified by age, sex, socio-demographic index (SDI), and human development index (HDI). The estimated annual percentage change was employed to quantify changes in ASRs. Population attributable fractions were calculated to determine the proportional contributions of major risk factors to age-standardized AF/AFL deaths. This analysis encompassed the period from 1990 to 2021. Globally, in 2021, there were 4.48 million incident cases [95% uncertainty interval (UI): 3.61-5.70], 8.36 million DALYs (95% UI: 6.97-10.13) and 0.34 million deaths (95% UI: 0.29-0.37) attributed to AF/AFL. The AF/AFL burden in 2021, as well as its trends from 1990 to 2021, displayed substantial variations based on gender, SDI quintiles, and geographical regions. High systolic blood pressure emerged as the leading contributor to age-standardized AF/AFL incidence, prevalence, death, and DALY rate globally among all potential risk factors, followed closely by high body mass index. CONCLUSION Our study underscores the enduring significance of AF/AFL as a prominent public health concern worldwide, marked by profound regional and national variations. Despite the substantial potential for prevention and management of AF/AFL, there is a pressing imperative to adopt more cost-effective strategies and interventions to target modifiable risk factors, particularly in areas where the burden of AF/AFL is high or escalating.
Collapse
Affiliation(s)
- Siyuan Cheng
- Department of Cardiology, The First Affiliated Hospital of Jinan University, No. 613, Huangpu Avenue West, Tianhe District, Guangzhou, Guangdong 510630, China
| | - JinZheng He
- Department of Cardiology, The First Affiliated Hospital of Jinan University, No. 613, Huangpu Avenue West, Tianhe District, Guangzhou, Guangdong 510630, China
| | - Yuchen Han
- Department of Cardiology, The First Affiliated Hospital of Jinan University, No. 613, Huangpu Avenue West, Tianhe District, Guangzhou, Guangdong 510630, China
| | - Shaojie Han
- Department of Cardiology, The First Affiliated Hospital of Jinan University, No. 613, Huangpu Avenue West, Tianhe District, Guangzhou, Guangdong 510630, China
| | - Panpan Li
- Department of Cardiology, The First Affiliated Hospital of Jinan University, No. 613, Huangpu Avenue West, Tianhe District, Guangzhou, Guangdong 510630, China
| | - Huanyan Liao
- Department of Cardiology, The First Affiliated Hospital of Jinan University, No. 613, Huangpu Avenue West, Tianhe District, Guangzhou, Guangdong 510630, China
| | - Jun Guo
- Department of Cardiology, The First Affiliated Hospital of Jinan University, No. 613, Huangpu Avenue West, Tianhe District, Guangzhou, Guangdong 510630, China
| |
Collapse
|
9
|
Merkely B, Hatala R, Merkel E, Szigeti M, Veres B, Fábián A, Osztheimer I, Gellér L, Sasov M, Wranicz JK, Földesi C, Duray G, Solomon SD, Kutyifa V, Kovács A, Kosztin A. Benefits of upgrading right ventricular to biventricular pacing in heart failure patients with atrial fibrillation. Europace 2024; 26:euae179. [PMID: 38979560 PMCID: PMC11264293 DOI: 10.1093/europace/euae179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 06/13/2024] [Indexed: 07/10/2024] Open
Abstract
AIMS Recommendations on cardiac resynchronization therapy (CRT) in patients with atrial fibrillation or flutter (AF) are based on less robust evidence than those in sinus rhythm (SR). We aimed to assess the efficacy of CRT upgrade in the BUDAPEST-CRT Upgrade trial population by their baseline rhythm. METHODS AND RESULTS Heart failure patients with reduced ejection fraction (HFrEF) and previously implanted pacemaker (PM) or implantable cardioverter defibrillator (ICD) and ≥20% right ventricular (RV) pacing burden were randomized to CRT with defibrillator (CRT-D) upgrade (n = 215) or ICD (n = 145). Primary [HF hospitalization (HFH), all-cause mortality, or <15% reduction of left ventricular end-systolic volume] and secondary outcomes were investigated. At enrolment, 131 (36%) patients had AF, who had an increased risk for HFH as compared with those with SR [adjusted hazard ratio (aHR) 2.99; 95% confidence interval (CI) 1.26-7.13; P = 0.013]. The effect of CRT-D upgrade was similar in patients with AF as in those with SR [AF adjusted odds ratio (aOR) 0.06; 95% CI 0.02-0.17; P < 0.001; SR aOR 0.13; 95% CI 0.07-0.27; P < 0.001; interaction P = 0.29] during the mean follow-up time of 12.4 months. Also, it decreased the risk of HFH or all-cause mortality (aHR 0.33; 95% CI 0.16-0.70; P = 0.003; interaction P = 0.17) and improved the echocardiographic response (left ventricular end-diastolic volume difference -49.21 mL; 95% CI -69.10 to -29.32; P < 0.001; interaction P = 0.21). CONCLUSION In HFrEF patients with AF and PM/ICD with high RV pacing burden, CRT-D upgrade decreased the risk of HFH and improved reverse remodelling when compared with ICD, similar to that seen in patients in SR.
Collapse
Affiliation(s)
- Béla Merkely
- Heart and Vascular Center, Semmelweis University, Varosmajor 68, H-1122 Budapest, Hungary
| | - Robert Hatala
- Department of Cardiology and Angiology, National Institute of Cardiovascular Diseases, Slovak Medical University, Bratislava, Slovakia
| | - Eperke Merkel
- Heart and Vascular Center, Semmelweis University, Varosmajor 68, H-1122 Budapest, Hungary
| | - Mátyás Szigeti
- Heart and Vascular Center, Semmelweis University, Varosmajor 68, H-1122 Budapest, Hungary
| | - Boglárka Veres
- Heart and Vascular Center, Semmelweis University, Varosmajor 68, H-1122 Budapest, Hungary
| | - Alexandra Fábián
- Heart and Vascular Center, Semmelweis University, Varosmajor 68, H-1122 Budapest, Hungary
| | - István Osztheimer
- Heart and Vascular Center, Semmelweis University, Varosmajor 68, H-1122 Budapest, Hungary
| | - László Gellér
- Heart and Vascular Center, Semmelweis University, Varosmajor 68, H-1122 Budapest, Hungary
| | - Michal Sasov
- Department of Cardiology and Angiology, National Institute of Cardiovascular Diseases, Slovak Medical University, Bratislava, Slovakia
| | - Jerzy K Wranicz
- Department of Electrocardiology, Medical University of Lodz, Lodz, Poland
| | - Csaba Földesi
- Department of Cardiology, Gottsegen National Cardiovascular Center, Budapest, Hungary
| | - Gábor Duray
- Department of Cardiology, Central Hospital of Northern Pest—Military Hospital, Budapest, Hungary
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Valentina Kutyifa
- Heart and Vascular Center, Semmelweis University, Varosmajor 68, H-1122 Budapest, Hungary
- Clinical Cardiovascular Research Center, University of Rochester, Rochester, NY, USA
| | - Attila Kovács
- Heart and Vascular Center, Semmelweis University, Varosmajor 68, H-1122 Budapest, Hungary
| | - Annamária Kosztin
- Heart and Vascular Center, Semmelweis University, Varosmajor 68, H-1122 Budapest, Hungary
| |
Collapse
|
10
|
Boriani G, Mei DA, Imberti JF. Antiarrhythmic drugs in the era of atrial fibrillation ablation. Europace 2024; 26:euae122. [PMID: 38700094 PMCID: PMC11154134 DOI: 10.1093/europace/euae122] [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: 04/27/2024] [Accepted: 04/29/2024] [Indexed: 05/05/2024] Open
Abstract
Abstract
Collapse
Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41121 Modena, Italy
| | - Davide Antonio Mei
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41121 Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Jacopo Francesco Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41121 Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| |
Collapse
|
11
|
Teppo K, Airaksinen KEJ, Jaakkola J, Halminen O, Salmela B, Kouki E, Haukka J, Putaala J, Linna M, Aro AL, Mustonen P, Hartikainen J, Lip GYH, Lehto M. Ischaemic stroke in women with atrial fibrillation: temporal trends and clinical implications. Eur Heart J 2024; 45:1819-1827. [PMID: 38606837 PMCID: PMC11129795 DOI: 10.1093/eurheartj/ehae198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/19/2024] [Accepted: 03/18/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND AND AIMS Female sex has been linked with higher risk of ischaemic stroke (IS) in atrial fibrillation (AF), but no prior study has examined temporal trends in the IS risk associated with female sex. METHODS The registry-linkage Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study included all patients with AF in Finland from 2007 to 2018. Ischaemic stroke rates and rate ratios were computed. RESULTS Overall, 229 565 patients with new-onset AF were identified (50.0% women; mean age 72.7 years). The crude IS incidence was higher in women than in men across the entire study period (21.1 vs. 14.9 events per 1000 patient-years, P < .001), and the incidence decreased both in men and women. In 2007-08, female sex was independently associated with a 20%-30% higher IS rate in the adjusted analyses, but this association attenuated and became statistically non-significant by the end of the observation period. Similar trends were observed when time with and without oral anticoagulant (OAC) treatment was analysed, as well as when only time without OAC use was considered. The decrease in IS rate was driven by patients with high IS risk, whereas in patients with low or moderate IS risk, female sex was not associated with a higher IS rate. CONCLUSIONS The association between female sex and IS rate has decreased and become non-significant over the course of the study period from 2007 to 2018, suggesting that female sex could be omitted as a factor when estimating expected IS rates and the need for OAC therapy in patients with AF.
Collapse
Affiliation(s)
- Konsta Teppo
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Jussi Jaakkola
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Birgitta Salmela
- Department of Internal Medicine, Heart Center, Päijät-Häme Central Hospital, Lahti, Finland
| | - Elis Kouki
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jari Haukka
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jukka Putaala
- Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Miika Linna
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
- Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland
| | - Aapo L Aro
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pirjo Mustonen
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Juha Hartikainen
- Heart Center, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Aalborg, Denmark
| | - Mika Lehto
- Department of Internal Medicine, Jorvi Hospital, HUS Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| |
Collapse
|
12
|
Okada M, Inoue K, Tanaka N, Tanaka K, Hirao Y, Iwakura K, Egami Y, Masuda M, Watanabe T, Minamiguchi H, Oka T, Hikoso S, Sunaga A, Okada K, Nakatani D, Sotomi Y, Sakata Y. Impact of left atrial appendage flow velocity on thrombus resolution and clinical outcomes in patients with atrial fibrillation and silent left atrial thrombi: insights from the LAT study. Europace 2024; 26:euae120. [PMID: 38691672 PMCID: PMC11106584 DOI: 10.1093/europace/euae120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/14/2024] [Accepted: 04/25/2024] [Indexed: 05/03/2024] Open
Abstract
AIMS Blood stasis is crucial in developing left atrial (LA) thrombi. LA appendage peak flow velocity (LAAFV) is a quantitative parameter for estimating thromboembolic risk. However, its impact on LA thrombus resolution and clinical outcomes remains unclear. METHODS AND RESULTS The LAT study was a multicentre observational study investigating patients with atrial fibrillation (AF) and silent LA thrombi detected by transoesophageal echocardiography (TEE). Among 17 436 TEE procedures for patients with AF, 297 patients (1.7%) had silent LA thrombi. Excluding patients without follow-up examinations, we enrolled 169 whose baseline LAAFV was available. Oral anticoagulation use increased from 85.7% at baseline to 97.0% at the final follow-up (P < 0.001). During 1 year, LA thrombus resolution was confirmed in 130 (76.9%) patients within 76 (34-138) days. Conversely, 26 had residual LA thrombi, 8 had thromboembolisms, and 5 required surgical removal. These patients with failed thrombus resolution had lower baseline LAAFV than those with successful resolution (18.0 [15.8-22.0] vs. 22.2 [17.0-35.0], P = 0.003). Despite limited predictive power (area under the curve, 0.659; P = 0.001), LAAFV ≤ 20.0 cm/s (best cut-off) significantly predicted failed LA thrombus resolution, even after adjusting for potential confounders (odds ratio, 2.72; 95% confidence interval, 1.22-6.09; P = 0.015). The incidence of adverse outcomes including ischaemic stroke/systemic embolism, major bleeding, or all-cause death was significantly higher in patients with reduced LAAFV than in those with preserved LAAFV (28.4% vs. 11.6%, log-rank P = 0.005). CONCLUSION Failed LA thrombus resolution was not rare in patients with AF and silent LA thrombi. Reduced LAAFV was associated with failed LA thrombus resolution and adverse clinical outcomes.
Collapse
Affiliation(s)
- Masato Okada
- Cardiovascular Centre, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Koichi Inoue
- Cardiovascular Centre, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
- Cardiovascular Division, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Nobuaki Tanaka
- Cardiovascular Centre, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Koji Tanaka
- Cardiovascular Centre, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Yuko Hirao
- Cardiovascular Centre, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Katsuomi Iwakura
- Cardiovascular Centre, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Yasuyuki Egami
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
| | - Masaharu Masuda
- Cardiovascular Centre, Kansai Rosai Hospital, Amagasaki, Japan
| | - Tetsuya Watanabe
- Division of Cardiology, Osaka General Medical Centre, Osaka, Japan
| | | | - Takafumi Oka
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shungo Hikoso
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Cardiovascular Medicine, Nara Medical University, Nara, Japan
| | - Akihiro Sunaga
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Katsuki Okada
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Medical Informatics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Daisaku Nakatani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| |
Collapse
|
13
|
Boriani G, Gerra L, Mei DA, Bonini N, Vitolo M, Proietti M, Imberti JF. Detection of subclinical atrial fibrillation with cardiac implanted electronic devices: What decision making on anticoagulation after the NOAH and ARTESiA trials? Eur J Intern Med 2024; 123:37-41. [PMID: 38281819 DOI: 10.1016/j.ejim.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 01/04/2024] [Indexed: 01/30/2024]
Abstract
Atrial fibrillation (AF) may be asymptomatic and the extensive monitoring capabilities of cardiac implantable electronic devices (CIEDs) revealed asymptomatic atrial tachi-arrhythmias of short duration (minutes-hours) occurring in patients with no prior history of AF and without AF detection at a conventional surface ECG. Both the terms "AHRE" (Atrial High-Rate Episodes) and subclinical AF were used in a series of prior studies, that evidenced the association with an increased risk of stroke. Two randomized controlled studies were planned in order to assess the risk-benefit profile of anticoagulation in patients with AHRE/subclinical AF: the NOAH and ARTESiA trials. The results of these two trials (6548 patients enrolled, overall) show that the risk of stroke/systemic embolism associated with AHRE/subclinical AF is in the range of 1-1.2 % per patient-year, but with an important proportion of severe/fatal strokes occurring in non-anticoagulated patients. The apparent discordance between ARTESiA and NOAH results may be approached by considering the related study-level meta-analysis, which highlights a consistent reduction of ischemic stroke with oral anticoagulants vs. aspirin/placebo (relative risk [RR] 0.68, 95 % CI 0.50-0.92). Oral anticoagulation was found to increase major bleeding (RR 1.62, 95 % CI 1.05-2.5), but no difference was found in fatal bleeding (RR 0.79, 95 % CI 0.37-1.69). Additionally, no difference was found in cardiovascular death or all-cause mortality. Taking into account these results, clinical decision-making for patients with AHRE/subclinical AF at risk of stroke, according to CHA2DS2-VASc, can now be evidence-based, considering the benefits and related risks of oral anticoagulants, to be shared with appropriately informed patients.
Collapse
Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.
| | - Luigi Gerra
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Davide A Mei
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Niccolo' Bonini
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Division of Subacute Care IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Jacopo F Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| |
Collapse
|
14
|
Boriani G, Tartaglia E, Imberti JF. A call to action: The need to apply guidelines recommendations with ABC or SOS to improve stroke prevention and cardiovascular outcomes in patients with atrial fibrillation. Eur J Intern Med 2024; 122:42-44. [PMID: 38310009 DOI: 10.1016/j.ejim.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 02/05/2024]
Affiliation(s)
- Giuseppe Boriani
- Department of Biomedical, Cardiology Division, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.
| | - Enrico Tartaglia
- Department of Biomedical, Cardiology Division, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Jacopo F Imberti
- Department of Biomedical, Cardiology Division, Metabolic and Neural Sciences, Italy University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| |
Collapse
|
15
|
Brandes A, Pedersen SS, Hendriks JM. A call for action to include psychosocial management into holistic, integrated care for patients with atrial fibrillation. Europace 2024; 26:euae078. [PMID: 38533841 PMCID: PMC11002641 DOI: 10.1093/europace/euae078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/24/2024] [Indexed: 03/28/2024] Open
Abstract
Contemporary management of atrial fibrillation (AF) has become increasingly complex. Therefore, strong efforts have been made during the past decade to develop models for structured, integrated care for patients with AF. These have also been incorporated in international guidelines for the management of patients with AF. However, implementation of integrated care approaches in daily clinical practice is scarce and far from optimal, and it may require a re-thinking of the structure of the healthcare system. The reasons for the poor implementation are many, from limited time and economic resources to deficits in postgraduate education of healthcare professionals, lack of involvement of patients in how integrated care should be designed, and fragmentation of the healthcare system. Moreover, patients' psychological challenges, which not only impact patients' adherence to treatment but, if untreated, increase their risk of morbidity, mortality, and poor quality of life, are not given sufficient attention. It is time to start a necessary discussion of what integrated care should be, what it should contain, and what is necessary to implement it in daily clinical practice.
Collapse
Affiliation(s)
- Axel Brandes
- Department of Cardiology, Esbjerg Hospital—University Hospital of Southern Denmark, Finsensgade 35, 6700 Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Finsensgade 35, 6700 Esbjerg, Denmark
| | - Susanne S Pedersen
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, Odense University Hospital, OdenseDenmark
| | - Jeroen M Hendriks
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| |
Collapse
|
16
|
Potpara T, Grygier M, Häusler KG, Nielsen-Kudsk JE, Berti S, Genovesi S, Marijon E, Boveda S, Tzikas A, Boriani G, Boersma LVA, Tondo C, De Potter T, Lip GYH, Schnabel RB, Bauersachs R, Senzolo M, Basile C, Bianchi S, Osmancik P, Schmidt B, Landmesser U, Döhner W, Hindricks G, Kovac J, Camm AJ. Practical guide on left atrial appendage closure for the non-implanting physician: an international consensus paper. Europace 2024; 26:euae035. [PMID: 38291925 PMCID: PMC11009149 DOI: 10.1093/europace/euae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/17/2024] [Indexed: 02/01/2024] Open
Abstract
A significant proportion of patients who suffer from atrial fibrillation (AF) and are in need of thromboembolic protection are not treated with oral anticoagulation or discontinue this treatment shortly after its initiation. This undertreatment has not improved sufficiently despite the availability of direct oral anticoagulants which are associated with less major bleeding than vitamin K antagonists. Multiple reasons account for this, including bleeding events or ischaemic strokes whilst on anticoagulation, a serious risk of bleeding events, poor treatment compliance despite best educational attempts, or aversion to drug therapy. An alternative interventional therapy, which is not associated with long-term bleeding and is as effective as vitamin K anticoagulation, was introduced over 20 years ago. Because of significant improvements in procedural safety over the years, left atrial appendage closure, predominantly achieved using a catheter-based, device implantation approach, is increasingly favoured for the prevention of thromboembolic events in patients who cannot achieve effective anticoagulation. This management strategy is well known to the interventional cardiologist/electrophysiologist but is not more widely appreciated within cardiology or internal medicine. This article introduces the devices and briefly explains the implantation technique. The indications and device follow-up are more comprehensively described. Almost all physicians who care for adult patients will have many with AF. This practical guide, written within guideline/guidance boundaries, is aimed at those non-implanting physicians who may need to refer patients for consideration of this new therapy, which is becoming increasingly popular.
Collapse
Affiliation(s)
- Tatjana Potpara
- Medical Faculty, University of Belgrade, Belgrade, Serbia
- University Clinical Centre of Serbia, Belgrade, Serbia
| | - Marek Grygier
- 1st Department of Cardiology, Poznan University School of Medical Sciences, Poznan, Poland
| | - Karl Georg Häusler
- Department of Neurology, Universitätsklinikum Würzburg (UKW), Würzburg, Germany
| | | | - Sergio Berti
- Ospedale del Cuore, Fondazione CNR Regione Toscana G. Monasterio, Pisa, Italy
| | - Simonetta Genovesi
- School of Medicine and Surgery, University of Milano-Bicocca, Nephrology Clinic, Monza, Italy
- Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Eloi Marijon
- Division of Cardiology, European Georges Pompidou Hospital, AP-HP, Paris, France
| | - Serge Boveda
- Cardiology, Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Cardiologie Clinique Pasteur, Brussels University VUB, Brussels, Belgium
| | - Apostolos Tzikas
- Ippokrateio Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Structural and Congenital Heart Disease, European Interbalkan Medical Centre, Thessaloniki, Greece
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Lucas V A Boersma
- Cardiology Department, St. Antonius Hospital Nieuwegein/Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Claudio Tondo
- Centro Cardiologico Monzino, IRCCS, Department of Clinical Electrophysiology & Cardiac Pacing, Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Tom De Potter
- Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Rupert Bauersachs
- Cardioangiology Center Bethanien CCB, Frankfurt, Germany
- Center for Vascular Research, Munich, Germany
| | - Marco Senzolo
- Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Carlo Basile
- Division of Nephrology, Miull General Hospital, Acquaviva delle Fonti, Italy
- EuDial Working Group of the European Renal Association, Acquaviva delle Fonti, Italy
| | - Stefano Bianchi
- Nephrology and Dialysis Unit, ASL Toscana NordOvest, Livorno, Italy
| | - Pavel Osmancik
- Department of Cardiology, University Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus Krankenhaus, Frankfurt, Germany
| | - Ulf Landmesser
- Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum Charité, Charité University Medicine, Berlin
| | - Wolfram Döhner
- Berlin Institute of Health-Center for Regenerative Therapies, Berlin, Germany
- Deutsches Herzzentrum der Charité, Campus Virchow Klinikum, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK)- partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | | | - Jan Kovac
- Leicester NIHR BRU, University of Leicester, Glenfield Hospital, Leicester, UK
| | - A John Camm
- Genetic and Cardiovascular Sciences Institute, Cardiology Academic Group, St. George’s University of London, Cranmer Terrace, London SW190RE, UK
| |
Collapse
|
17
|
Linz D, Andrade JG, Arbelo E, Boriani G, Breithardt G, Camm AJ, Caso V, Nielsen JC, De Melis M, De Potter T, Dichtl W, Diederichsen SZ, Dobrev D, Doll N, Duncker D, Dworatzek E, Eckardt L, Eisert C, Fabritz L, Farkowski M, Filgueiras-Rama D, Goette A, Guasch E, Hack G, Hatem S, Haeusler KG, Healey JS, Heidbuechel H, Hijazi Z, Hofmeister LH, Hove-Madsen L, Huebner T, Kääb S, Kotecha D, Malaczynska-Rajpold K, Merino JL, Metzner A, Mont L, Ng GA, Oeff M, Parwani AS, Puererfellner H, Ravens U, Rienstra M, Sanders P, Scherr D, Schnabel R, Schotten U, Sohns C, Steinbeck G, Steven D, Toennis T, Tzeis S, van Gelder IC, van Leerdam RH, Vernooy K, Wadhwa M, Wakili R, Willems S, Witt H, Zeemering S, Kirchhof P. Longer and better lives for patients with atrial fibrillation: the 9th AFNET/EHRA consensus conference. Europace 2024; 26:euae070. [PMID: 38591838 PMCID: PMC11003300 DOI: 10.1093/europace/euae070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/16/2024] [Indexed: 04/10/2024] Open
Abstract
AIMS Recent trial data demonstrate beneficial effects of active rhythm management in patients with atrial fibrillation (AF) and support the concept that a low arrhythmia burden is associated with a low risk of AF-related complications. The aim of this document is to summarize the key outcomes of the 9th AFNET/EHRA Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA). METHODS AND RESULTS Eighty-three international experts met in Münster for 2 days in September 2023. Key findings are as follows: (i) Active rhythm management should be part of the default initial treatment for all suitable patients with AF. (ii) Patients with device-detected AF have a low burden of AF and a low risk of stroke. Anticoagulation prevents some strokes and also increases major but non-lethal bleeding. (iii) More research is needed to improve stroke risk prediction in patients with AF, especially in those with a low AF burden. Biomolecules, genetics, and imaging can support this. (iv) The presence of AF should trigger systematic workup and comprehensive treatment of concomitant cardiovascular conditions. (v) Machine learning algorithms have been used to improve detection or likely development of AF. Cooperation between clinicians and data scientists is needed to leverage the potential of data science applications for patients with AF. CONCLUSIONS Patients with AF and a low arrhythmia burden have a lower risk of stroke and other cardiovascular events than those with a high arrhythmia burden. Combining active rhythm control, anticoagulation, rate control, and therapy of concomitant cardiovascular conditions can improve the lives of patients with AF.
Collapse
Affiliation(s)
- Dominik Linz
- Department of Cardiology, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jason G Andrade
- Division of Cardiology, Vancouver General Hospital, Vancouver, Canada
- Montreal Heart Institute, Montreal, Canada
| | - Elena Arbelo
- Institut Clínic Cardiovascular, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain
- Institut d’Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart—ERN GUARD-Heart
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Polyclinic of Modena, Modena, Italy
| | - Guenter Breithardt
- Department of Cardiovascular Medicine, University Hospital, Münster, Germany
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George's University of London, London, UK
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | | - Wolfgang Dichtl
- Department of Internal Medicine III, Cardiology and Angiology, Medical University Innsbruck, Innsbruck, Austria
| | | | - Dobromir Dobrev
- Institute of Pharmacology, Faculty of Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Nicolas Doll
- Department of Cardiac Surgery, Schüchtermann-Klinik, Bad Rothenfelde, Germany
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | | | - Lars Eckardt
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Department of Cardiology II—Electrophysiology, University Hospital Münster, Münster, Germany
| | | | - Larissa Fabritz
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- University Center of Cardiovascular Science, UHZ, UKE, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Michal Farkowski
- Department of Cardiology, Ministry of Interior and Administration, National Medical Institute, Warsaw, Poland
| | - David Filgueiras-Rama
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Novel Arrhythmogenic Mechanisms Program, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, C/ Profesor Martín Lagos, Madrid, Spain
| | - Andreas Goette
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Department of Cardiology and Intensive Care Medicine, St Vincenz-Hospital Paderborn, Paderborn, Germany
| | - Eduard Guasch
- Institut d’Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Clinic Barcelona, University of Barcelona, Barcelona, Spain
| | - Guido Hack
- Bristol-Myers Squibb GmbH & Co. KGaA, Munich, Germany
| | | | - Karl Georg Haeusler
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Department of Neurology, Universitätsklinikum Würzburg (UKW), Würzburg, Germany
| | - Jeff S Healey
- Division of Cardiology, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Hein Heidbuechel
- Antwerp University Hospital, Cardiovascular Sciences, University of Antwerp, Antwerp, Belgium
| | - Ziad Hijazi
- Antwerp University Hospital, Cardiovascular Sciences, University of Antwerp, Antwerp, Belgium
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Leif Hove-Madsen
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Biomedical Research Institute Barcelona (IIBB-CSIC), Barcelona, Spain
- IR Sant Pau, Hospital de Sant Pau, Barcelona, Spain
| | | | - Stefan Kääb
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart—ERN GUARD-Heart
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich, Munich Heart Alliance, Munich, Germany
| | - Dipak Kotecha
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Katarzyna Malaczynska-Rajpold
- Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
- Royal Brompton Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - José Luis Merino
- La Paz University Hospital, IdiPaz, Autonomous University of Madrid, Madrid, Spain
| | - Andreas Metzner
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
| | - Lluís Mont
- Institut Clínic Cardiovascular, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain
- Institut d’Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Ghulam Andre Ng
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Michael Oeff
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Cardiology Department, Medizinische Hochschule Brandenburg, Brandenburg/Havel, Germany
| | - Abdul Shokor Parwani
- Department of Cardiology, Deutsches Herzzentrum der Charité (CVK), Berlin, Germany
| | | | - Ursula Ravens
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Institute of Experimental Cardiovascular Medicine, University Clinic Freiburg, Freiburg, Germany
| | - Michiel Rienstra
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Daniel Scherr
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Renate Schnabel
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
| | - Ulrich Schotten
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Departments of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Christian Sohns
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Klinik für Elektrophysiologie—Rhythmologie, Bad Oeynhausen, Germany
| | - Gerhard Steinbeck
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Center for Cardiology at Clinic Starnberg, Starnberg, Germany
| | - Daniel Steven
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Heart Center, Department of Electrophysiology, University Hospital Cologne, Cologne, Germany
| | - Tobias Toennis
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
| | | | - Isabelle C van Gelder
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Manish Wadhwa
- Medical Office, Philips Ambulatory Monitoring and Diagnostics, San Diego, CA, USA
| | - Reza Wakili
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Department of Medicine and Cardiology, Goethe University, Frankfurt, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Germany
| | - Stephan Willems
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Asklepios Hospital St. Georg, Department of Cardiology and Internal Care Medicine, Faculty of Medicine, Semmelweis University Campus, Hamburg, Germany
| | | | - Stef Zeemering
- Departments of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Paulus Kirchhof
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, UK
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
| |
Collapse
|
18
|
Liao JN, Huang YS, Tsai CT, Kuo L, Chen SJ, Tuan TC, Chen TJ, Chen SA, Chao TF. Gender Differences in Patients with Atrial Fibrillation Receiving Oral Anticoagulants. Rev Cardiovasc Med 2024; 25:92. [PMID: 39076938 PMCID: PMC11263856 DOI: 10.31083/j.rcm2503092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 12/31/2023] [Accepted: 01/04/2024] [Indexed: 07/31/2024] Open
Abstract
Background Gender is a well-recognized risk factor in atrial fibrillation (AF)-related ischemic stroke. The association of gender with the use of oral anticoagulants (OACs) and prognosis remains unknown. Methods The National Health Insurance Research Database in Taiwan identified 203,775 patients with AF aged ≥ 20 years from 2012 to 2018, with 55.4% of males. Our main study cohort included 67,426 patients using OACs. The study endpoints include death, ischemic stroke, intracranial hemorrhage, major bleeding, and composite adverse events. Results Significant differences were found in baseline characteristics between sexes. Female patients with AF were older and had higher CHA 2 DS 2 -VASc and HAS-BLED scores. Non-vitamin K antagonist oral anticoagulant (NOAC) use was more prominent in females while the use of warfarin was similar in both sexes. The distribution of baseline characteristics between the warfarin and NOAC groups in both sexes was much alike. Among the whole study cohort, NOAC was associated with a decreased risk of clinical endpoints compared to warfarin, which remained the same in subgroup analyses of both sexes. Additionally, a greater risk reduction of ischemic stroke with NOAC was observed in female patients compared to male patients (adjusted hazard ratio: 0.517 in males, 0.425 in females, interaction p = 0.040). Conclusions This nationwide cohort demonstrated the differences between male and female patients with AF, including baseline characteristics, risk profiles, and medication use. Despite great differences in baseline demographic data, NOAC was associated with better clinical outcomes compared to warfarin in both sexes, and females benefited more than males in preventing ischemic stroke using NOACs.
Collapse
Affiliation(s)
- Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, 11217 Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, 30010 Taipei, Taiwan
- Women’s Heart Section, Cardiovascular Center, Taipei Veterans General Hospital, 11217 Taipei, Taiwan
| | - Yu-Shan Huang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, 11217 Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, 30010 Taipei, Taiwan
| | - Chuan-Tsai Tsai
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, 11217 Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, 30010 Taipei, Taiwan
| | - Ling Kuo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, 11217 Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, 30010 Taipei, Taiwan
| | - Su-Jung Chen
- Institute of Public Health and School of Medicine, National Yang Ming Chiao Tung University, 30010 Taipei, Taiwan
- Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, 11217 Taipei, Taiwan
| | - Ta-Chuan Tuan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, 11217 Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, 30010 Taipei, Taiwan
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital Hsinchu Branch, 31064 Zhudong, Taiwan
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, 11217 Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, 30010 Taipei, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, 40705 Taichung, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, 11217 Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, 30010 Taipei, Taiwan
| |
Collapse
|
19
|
Saljic A, Heijman J. P2X7 receptors: central drivers of the neurocardiac link between atrial fibrillation and depression? Europace 2024; 26:euae023. [PMID: 38261750 PMCID: PMC10873697 DOI: 10.1093/europace/euae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 01/25/2024] Open
Affiliation(s)
- Arnela Saljic
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, BDK-2200 Copenhagen, Denmark
| | - Jordi Heijman
- Gottfried Schatz Research Center, Division of Medical Physics & Biophysics, Medical University of Graz, Neue Stiftingtalstraße 6, 8010 Graz, Austria
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
| |
Collapse
|
20
|
Ahn HJ, Lee SR, Choi J, Lee KY, Kwon S, Choi EK, Oh S, Lip GYH. Association between antithrombotic therapy after stroke in patients with atrial fibrillation and the risk of net clinical outcome: an observational cohort study. Europace 2024; 26:euae033. [PMID: 38290433 PMCID: PMC10872674 DOI: 10.1093/europace/euae033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/24/2024] [Indexed: 02/01/2024] Open
Abstract
AIMS Data on the optimal use of antithrombotic drugs and associated clinical outcomes in patients with atrial fibrillation (AF) and acute ischaemic stroke (IS) are limited. We investigated the prescription patterns of antithrombotics in community practice and long-term clinical prognosis according to early post-stroke antithrombotic therapy in patients with AF and acute IS. METHODS AND RESULTS Patients with AF who were admitted for acute IS at a single tertiary hospital in 2010-2020 were retrospectively reviewed. Clinical profiles including the aetiology of stroke and prescription patterns of antithrombotics were identified. The net clinical outcome (NCO)-the composite of recurrent stroke, any bleeding, hospitalization or emergency department visits for cardiovascular (CV) events, and death-was compared according to the antithrombotic therapy at the first outpatient clinic visit [oral anticoagulation (OAC) alone vs. antiplatelet (APT) alone vs. OAC/APT(s)] following discharge. A total of 918 patients with AF and acute IS (mean age, 72.6 years; male, 59.3%; mean CHA₂DS₂-VASc score 3.3) were analysed. One-third (33.9%, n = 310) of patients were simultaneously diagnosed with AF and IS. The most common aetiology of IS was cardioembolism (71.2%), followed by undetermined aetiology (19.8%) and large artery atherosclerosis (6.0%). OAC, APT(s), and concomitant OAC and APT(s) were prescribed in 33.4%, 11.1%, and 53.4% of patients during admission that changed to 67.0%, 9.1%, and 21.7% at the first outpatient clinic, and were mostly continued up to one year after IS. Non-prescription of OAC was observed in 11.3% of post-stroke patients with AF. During a median follow-up of 2.1 years, the overall incidence rate of NCO per 100 patient-year (PY) was 20.14. APT(s) monotherapy presented the highest cumulative risk of NCO (adjusted hazard ratio 1.47, 95% confidence interval 1.08-2.00, P = 0.015; with reference to OAC monotherapy) mainly driven by the highest rates of recurrent stroke and any bleeding. OAC/APT(s) combination therapy was associated with a 1.62-fold significantly higher risk of recurrent stroke (P = 0.040) and marginally higher risk of any bleeding than OAC monotherapy. CONCLUSION Approximately one-third of acute IS in AF have a distinctive mechanism from cardioembolism. Although APT was frequently prescribed in post-stroke patients with AF, no additive clinical benefit was observed. Adherence to OAC treatment is essential to prevent further CV adverse events in patients with AF and IS.
Collapse
Affiliation(s)
- Hyo-Jeong Ahn
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Chongno-gu, Seoul 03080, Republic of Korea
| | - So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Chongno-gu, Seoul 03080, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul 03080, Republic of Korea
| | - JungMin Choi
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Chongno-gu, Seoul 03080, Republic of Korea
| | - Kyung-Yeon Lee
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Chongno-gu, Seoul 03080, Republic of Korea
| | - Soonil Kwon
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Chongno-gu, Seoul 03080, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Chongno-gu, Seoul 03080, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul 03080, Republic of Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Chongno-gu, Seoul 03080, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul 03080, Republic of Korea
| | - Gregory Y H Lip
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul 03080, Republic of Korea
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Chest & Heart Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| |
Collapse
|
21
|
Potpara T, Blomstrom-Lundqvist C. Anticoagulation in patients with atrial high-rate episodes. Nat Rev Cardiol 2024; 21:5-6. [PMID: 38062192 DOI: 10.1038/s41569-023-00963-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Tatjana Potpara
- Faculty of Medicine, Belgrade University, Belgrade, Serbia.
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia.
| | - Carina Blomstrom-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Medical Science, Uppsala University, Uppsala, Sweden
| |
Collapse
|
22
|
Kongebro EK, Diederichsen SZ, Xing LY, Haugan KJ, Graff C, Højberg S, Olesen MS, Krieger D, Brandes A, Køber L, Svendsen JH. Anticoagulation-Associated Bleeding in Patients Screened for Atrial Fibrillation versus Usual Care-A Post Hoc Analysis from the LOOP Study. TH OPEN 2024; 8:e19-e30. [PMID: 38197016 PMCID: PMC10774012 DOI: 10.1055/a-2202-4296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/14/2023] [Indexed: 01/11/2024] Open
Abstract
Background Atrial fibrillation (AF) prevalence is rising; however, data on the bleeding risks associated with the detection of subclinical AF are needed. Objective Our objective was to determine the bleeding increment associated with implantable loop recorder (ILR) screening for subclinical AF and subsequent anticoagulation initiation compared with usual care. Methods This post hoc study utilized LOOP trial data from 6,004 elderly patients with stroke risks randomized to either ILR ( n = 1,503) or usual care ( n = 4,503). The mean follow-up time was 64.5 months, and none were lost to follow-up. The primary exposure was the initiation of oral anticoagulation, and the main outcome was the risk of major bleeding events following initiation of oral anticoagulants (OACs), determined by time-dependent cox regression. Second, we investigated antithrombotic prescription patterns and major bleeding events after antiplatelet treatment and in subgroups. Results OAC was initiated in 1,019 participants with a mean age (years) of 78.8 (± 4.67) in control versus 77.0 (± 4.84) in ILR, p < 0.0001. Altogether did 202 participants end or pause OAC treatment. Among AF patients (n = 910) had 40 (28%) completely ended OAC and 105 (72%) temporarily paused OAC during follow-up. Major bleeding events totaled 221 (3.7%). Forty-seven major bleeding events followed an OAC initiation in 1,019 participants (4.6%); 26 versus 21 events in the control and ILR groups, respectively. The hazard ratio (HR) for major bleeding after OAC initiation compared with before initiation was 2.08 (1.50-2.90) p < 0.0001 overall, 2.81 (1.82-4.34) p < 0.0001 for control and 1.32 (0.78-2.23) p = 0.31 for the ILR group ( p = 0.07 for interaction). Antiplatelet treatment resulted in an overall adjusted HR of 1.3 (0.96-1.75) p = 0.09. For OAC users aged ≥75 years in the ILR group, the rate of major bleeding was 1.73 (0.92-2.96) compared with 0.84 (0.36-1.66) for an age <75 years, and the rate of the corresponding control subgroup aged ≥75 years was 2.20 (1.23-3.63) compared with 1.64 (0.82-2.93) for an age <75 years. Conclusion The individual risk of major bleeding increased twofold after initiation of oral anticoagulation for all patients in this study. However, the patients screened for subclinical AF did not have a higher bleeding risk after initiation of anticoagulation compared with those in usual care. Trial Registration: The LOOP study is registered at ClinicalTrials.gov, identifier: NCT020364 50.
Collapse
Affiliation(s)
- Emilie Katrine Kongebro
- Department of Cardiology, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - Søren Zöga Diederichsen
- Department of Cardiology, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - Lucas Yixi Xing
- Department of Cardiology, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - Ketil Jørgen Haugan
- Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Denmark
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Søren Højberg
- Department of Cardiology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Morten S. Olesen
- Department of Cardiology, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Derk Krieger
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai Healthcare City, Dubai, United Arab Emirates
- Department of Neurology, Mediclinic Parkview Hospital, Al Barsha South, Dubai, United Arab Emirates
| | - Axel Brandes
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
- Department of Cardiology, University Hospital of Southern Denmark—Esbjerg, Esbjerg, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
23
|
Spartalis M, Kontogiannis C, Spartalis E, Iliopoulos DC, Siasos G. Anticoagulation in Patients with Atrial High-rate Episodes Detected by Cardiac Implantable Electronic Devices. Curr Pharm Des 2024; 30:485-488. [PMID: 38343055 DOI: 10.2174/0113816128291822240131063712] [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: 11/25/2023] [Accepted: 01/22/2024] [Indexed: 05/18/2024]
Abstract
Atrial high-rate episodes (AHRE) are atrial tachyarrhythmias that are identified by the use of continuous rhythm monitoring devices such as pacemakers, defibrillators, or implantable cardiac monitors. Nevertheless, the therapeutic implications of these rhythm disturbances remain uncertain. The presence of AHRE is associated with an increased risk of stroke as compared to patients who do not exhibit AHRE. The utilisation of oral anticoagulation has the ability to mitigate the likelihood of stroke occurrence in patients with AHRE. However, it is important to note that this treatment approach is also linked to a severe bleeding rate of approximately 2% per year. The stroke rate among individuals diagnosed with AHRE appears to be comparatively lower when compared to patients diagnosed with atrial fibrillation. The efficacy and safety of anticoagulation in patients with AHRE have yet to be definitively established. Further research is required to provide a comprehensive understanding of the effectiveness and safety of oral anticoagulation in individuals with AHRE.
Collapse
Affiliation(s)
- Michael Spartalis
- 3rd Department of Cardiology, Sotiria Thoracic Diseases General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Christos Kontogiannis
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleftherios Spartalis
- Laboratory of Experimental Surgery and Surgical Research 'N.S. Christeas', Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios C Iliopoulos
- Laboratory of Experimental Surgery and Surgical Research 'N.S. Christeas', Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Gerasimos Siasos
- 3 rd Department of Cardiology, Sotiria Thoracic Diseases General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
24
|
Auricchio A. Editorial. Europace 2023; 26:euae008. [PMID: 38207128 PMCID: PMC10803038 DOI: 10.1093/europace/euae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Indexed: 01/13/2024] Open
Affiliation(s)
- Angelo Auricchio
- Istituto Cardiocentro Ticino - Ente Ospedaliero Cantonale, Via Tesserete 48, 6900 Lugano, Switzerland
| |
Collapse
|
25
|
Romiti GF, Corica B, Mei DA, Frost F, Bisson A, Boriani G, Bucci T, Olshansky B, Chao TF, Huisman MV, Proietti M, Lip GYH. Impact of chronic obstructive pulmonary disease in patients with atrial fibrillation: an analysis from the GLORIA-AF registry. Europace 2023; 26:euae021. [PMID: 38266129 PMCID: PMC10825625 DOI: 10.1093/europace/euae021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/11/2024] [Indexed: 01/26/2024] Open
Abstract
AIMS Chronic obstructive pulmonary disease (COPD) may influence management and prognosis of atrial fibrillation (AF), but this relationship has been scarcely explored in contemporary global cohorts. We aimed to investigate the association between AF and COPD, in relation to treatment patterns and major outcomes. METHODS AND RESULTS From the prospective, global GLORIA-AF registry, we analysed factors associated with COPD diagnosis, as well as treatment patterns and risk of major outcomes in relation to COPD. The primary outcome was the composite of all-cause death and major adverse cardiovascular events (MACEs). A total of 36 263 patients (mean age 70.1 ± 10.5 years, 45.2% females) were included; 2,261 (6.2%) had COPD. The prevalence of COPD was lower in Asia and higher in North America. Age, female sex, smoking, body mass index, and cardiovascular comorbidities were associated with the presence of COPD. Chronic obstructive pulmonary disease was associated with higher use of oral anticoagulant (OAC) [adjusted odds ratio (aOR) and 95% confidence interval (CI): 1.29 (1.13-1.47)] and higher OAC discontinuation [adjusted hazard ratio (aHR) and 95% CI: 1.12 (1.01-1.25)]. Chronic obstructive pulmonary disease was associated with less use of beta-blocker [aOR (95% CI): 0.79 (0.72-0.87)], amiodarone and propafenone, and higher use of digoxin and verapamil/diltiazem. Patients with COPD had a higher hazard of primary composite outcome [aHR (95% CI): 1.78 (1.58-2.00)]; no interaction was observed regarding beta-blocker use. Chronic obstructive pulmonary disease was also associated with all-cause death [aHR (95% CI): 2.01 (1.77-2.28)], MACEs [aHR (95% CI): 1.41 (1.18-1.68)], and major bleeding [aHR (95% CI): 1.48 (1.16-1.88)]. CONCLUSION In AF patients, COPD was associated with differences in OAC treatment and use of other drugs; Patients with AF and COPD had worse outcomes, including higher mortality, MACE, and major bleeding.
Collapse
Affiliation(s)
- Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Translational and Precision Medicine, Sapienza – University of Rome, Rome, Italy
| | - Bernadette Corica
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Translational and Precision Medicine, Sapienza – University of Rome, Rome, Italy
| | - Davide Antonio Mei
- Department of Translational and Precision Medicine, Sapienza – University of Rome, Rome, Italy
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Frederick Frost
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Arnaud Bisson
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Service de Cardiologie, Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, Tours, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Tommaso Bucci
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of General Surgery and Surgical Specialties ‘Paride Stefanini’, Sapienza – University of Rome, Rome, Italy
| | - Brian Olshansky
- Division of Cardiology, Department of Medicine, University of Iowa, Iowa City, USA
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| |
Collapse
|