Emergent readmission and long-term mortality risk after incident atrial fibrillation hospitalisation

OBJECTIVE

To assess the frequency and predictors of unplanned readmissions after hospitalisation for incident atrial fibrillation (AF) and the association of readmissions with mortality over 2 years.

METHODS

We performed a retrospective cohort study using Western Australian morbidity and mortality data to identify all patients, aged 25-94 years, who survived incident (first-ever) hospitalisation for AF (principal diagnosis), between 2001 and 2015. Ordinal logistic models determined the covariates independently associated with unplanned readmission(s), and Cox proportional hazards models with time-varying exposures determined the hazard ratios (HR) of one or more readmissions for mortality over 2 years after incident AF.

RESULTS

Of 22 956 patients, 57.7% male, mean age 67.9 (SD 13.8) years, 44.0% experienced 22 053 unplanned readmissions within 2 years, 50.6% being cardiovascular-related. All-cause death occurred in 8.0% of the cohort, and the multivariable-adjusted mortality HR of 1 (vs 0) readmission was 2.9 (95% CI 2.6 to 3.3), increasing to 5.6 (95% CI 5.0 to 6.5) for 3+ readmissions. First emergent readmission for AF, stroke, heart failure or myocardial infarction was independently associated with an increased hazard for mortality. Coexistent cardiovascular and other comorbidities were independently associated with increased readmission and mortality risk, whereas AF ablation was associated with reduced risk.

CONCLUSION

This study highlights the large burden of unplanned all-cause and cardiovascular-specific readmissions within 2 years after being hospitalised for incident AF and their associated adverse impact on mortality. Concomitant comorbidities are independently associated with unplanned hospitalisations and mortality, which supports integrated multidisciplinary management of comorbidities, along with AF-targeted treatments, to improve long-term outcomes in patients with AF.

Unplanned 30-day readmission, comorbidity, and impact on mortality after incident atrial fibrillation hospitalization in Western Australia, 2001–2015

Background

The healthcare burden of atrial fibrillation (AF) is dominated by hospitalizations, but data on 30-day unplanned readmissions after AF hospitalization and impact on mortality are limited.

Objective

To assess causes and trends of 30-day unplanned readmission in incident (first-ever) hospitalized AF patients, and the risk of readmission for subsequent all-cause mortality.

Methods

Patients aged 25–94 years, with an incident AF hospitalization (principal diagnosis) between 2001 and 2015, and surviving 30 days post discharge, were identified from linked Western Australian hospitalization and mortality data. Unplanned 30-day readmissions were categorized by principal diagnosis. Multivariable logistic and Cox regression analyses determined the independent predictors of readmission and the hazard ratio (HR) with 95% confidence intervals (CI) of readmission for subsequent 1-year mortality.

Results

Of 22,814 patients, 57.7% male, mean age 67.8 ± 13.8 (standard deviation) years, 9.5% experienced 1 or more 30-day unplanned readmissions, with standardized rates increasing 2.0% annually (95% CI, 1.0%–3.1%). Among all readmissions, 64.8% were cardiovascular-related, with AF (31.7%), coronary events (12.2%), and heart failure (8.5%) being the most frequent. In 30-day survivors, 4.3% died within 1 year. Patients with any cardiovascular or noncardiovascular readmission (vs none) had a multivariable-adjusted mortality HR of 2.12 (95% CI, 1.82–2.45). Coexistent comorbidities were independently associated with 30-day unplanned readmission and 1-year mortality.

Conclusion

Following incident AF hospitalization, 30-day unplanned readmissions were common, mostly cardiovascular-related, but any readmission, regardless of cause, was associated with a 2-fold higher adjusted mortality risk. Our findings also support the importance of comorbidity optimization within an integrated care pathway to reduce adverse outcomes in AF patients.

Association of Left Atrial Metrics with Atrial Fibrillation Rehospitalization and Adverse Cardiovascular Outcomes in Patients with Nonvalvular Atrial Fibrillation following Index Hospitalization

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice, with significant clinical and economic burdens, largely driven by adverse cardiovascular outcomes and AF-related hospitalization. Left atrial (LA) parameters have been shown to have prognostic value in cardiovascular disease states. We sought to evaluate the prognostic value of measures of LA size and function, as measured through LA volume index and LA emptying fraction (LAEF), respectively, for AF rehospitalization and long-term adverse outcomes in patients with nonvalvular AF following index hospitalization.

METHODS

In this retrospective study, 594 consecutive patients (mean age, 67.8 ± 13.6 years, 53% men) admitted to a tertiary referral center with nonvalvular AF were assessed. Patients who underwent transthoracic echocardiography during their index admission and had complete follow-up data were included and followed for a mean period of 33.18 ± 21.27 months for the primary outcome of AF rehospitalization. The secondary outcome was a composite of all-cause death and major adverse cardiovascular events.

RESULTS

The primary outcome occurred in 250 (42%) patients, and the secondary outcome occurred in 219 (37%) patients. On multivariable regression analysis, LAEF had an independent association with AF rehospitalization (hazard ratio [HR] = 0.967; 95% CI, 0.953-0.982; P < .01), and time-dependent receiver operating characteristic curves demonstrated LAEF to have strong diagnostic accuracy in predicting early and intermediate AF rehospitalization. Both LA volume index (HR = 1.014; 95% CI, 1.003-1.026; P = .01) and LAEF (HR = 0.982; 95% CI, 0.970-0.993; P < .01) were associated with all-cause death and major adverse cardiovascular events.

CONCLUSIONS

Adverse LA remodeling, as reflected through LA enlargement and reduced LA mechanical function, is associated with AF rehospitalization and long-term adverse cardiovascular outcomes in hospitalized patients with nonvalvular AF.

Cardiovascular- and Bleeding-Related Hospitalization Rates With Edoxaban Versus Warfarin in Patients With Atrial Fibrillation Based on Results of the ENGAGE AF–TIMI 48 Trial

Background

The ENGAGE AF–TIMI 48 trial (Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation–Thrombolysis in Myocardial Infarction 48) demonstrated noninferiority of once-daily 60 mg (30 mg dose-reduced) edoxaban compared with warfarin for prevention of stroke/systemic embolism in patients with atrial fibrillation. No previous analysis has explored the impact of treatment with edoxaban versus warfarin on rates of hospitalizations.

Methods

Detailed healthcare resource utilization data from ENGAGE AF–TIMI 48 for the 14 024 randomized patients who received at least one dose of study drug were used to compare the rates of bleeding- and cardiovascular-related hospitalizations for edoxaban versus warfarin. Hospitalization rates were calculated for each treatment group, and relative rates were estimated using Poisson regression. The influence of patient characteristics on the impact of edoxaban versus warfarin was evaluated through the inclusion of interaction terms.

Results

The overall rate of cardiovascular- or bleeding-related hospitalization was significantly lower for edoxaban than warfarin (relative rate [RR], 0.91 [95% CI, 0.85–0.97], P =0.003). Rates of hospitalizations for cardiovascular reasons (RR, 0.91 [95% CI, 0.85–0.97], P =0.004), stroke (RR, 0.80 [95% CI, 0.72–0.88], P <0.0001), and for each stroke subtype (ischemic: RR, 0.89 [95% CI, 0.81–0.99], P =0.03; hemorrhagic: RR, 0.60 [95% CI, 0.54–0.68], P <0.0001) were also lower for edoxaban. Notably, significantly greater reductions with edoxaban versus warfarin were seen for ischemic stroke–related hospitalizations in vitamin K antagonist naive patients and patients with CHADS 2 scores 4 to 6, previous stroke or transient ischemic attack, age ≥75, and no previous coronary artery disease. For nonstroke bleeding–related hospitalizations, greater reductions with edoxaban were seen in vitamin K antagonist naive patients, patients with CHADS 2 scores 4 to 6, and patients with moderate renal dysfunction.

Conclusions

Edoxaban 60 mg (30 mg dose-reduced) was associated with a significantly lower overall rate of cardiovascular- or bleeding-related hospitalization and significant reductions in the subcategories of cardiovascular-related, stroke-related, bleed-related, and nonstroke cardiovascular–related hospitalizations, when compared with warfarin. These results suggest the potential for cost offsets with edoxaban, with even greater reductions in higher-risk patients.

Registration:

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT00781391

Baroreflex activation therapy reduces frequency and duration of hypertension-related hospitalizations in patients with resistant hypertension

Purpose

Baroreflex activation therapy (BAT) has been shown to lower blood pressure in patients with resistant hypertension. The purpose of this study was to analyze whether this translates into a reduction of more relevant clinical endpoints.

Methods

Patients with resistant hypertension were treated with the second-generation BAT system. Records on hospitalization (dates of admission and discharge, main diagnosis) were obtained from medical insurance companies.

Results

Records on hospitalization were available for a period of 1 year before BAT in two patients and 2 years in 22 patients. The total number of hospitalizations per patient was 3.3 ± 3.5/year before BAT and 2.2 ± 2.7/year after BAT (p = 0.03). Hospitalizations related to hypertension were significantly decreased from 1.5 ± 1.6/year before BAT to 0.5 ± 0.9/year after BAT (p < 0.01). The cumulative duration of hypertension-related hospital stays was significantly reduced from 8.0 ± 8.7 days/year before BAT to 1.8 ± 4.8 days/year after BAT (p < 0.01). Office cuff blood pressure was 183 ± 27 mmHg over 102 ± 17 mmHg under 6.6 ± 2.0 antihypertensive drugs before BAT and 157 ± 32 mmHg over 91 ± 20 mmHg (both p < 0.01) under 5.9 ± 1.9 antihypertensive drugs (p = 0.09 for number of drugs) at latest follow-up. Daytime ambulatory blood pressure was 164 ± 21 mmHg over 91 ± 14 mmHg before BAT and 153 ± 21 mmHg (p = 0.03) over 89 ± 15 mmHg (p = 0.56) at latest follow-up. Heart rate was 75 ± 16 bpm before BAT and 72 ± 12 bpm at latest follow-up (p = 0.35).

Conclusions

Rate and duration of hypertension-related hospitalizations in patients with severe resistant hypertension were lowered after BAT. Whether the response is mediated through improvements in blood pressure control requires further studies.

Electronic supplementary material

The online version of this article (10.1007/s10286-020-00670-9) contains supplementary material, which is available to authorized users.

Reasons for hospitalization and risk of mortality in patients with atrial fibrillation treated with dabigatran or warfarin in the Randomized Evaluation of Long-term Anticoagulation Therapy (RE-LY) trial

AIMS

Hospitalizations are common among patients with atrial fibrillation. This article aimed to analyse the causes and consequences of hospitalizations occurring during the Randomized Evaluation of Long-term Anticoagulation Therapy (RE-LY) trial.

METHODS AND RESULTS

The RE-LY database was used to evaluate predictors of hospitalization using multivariate regression modelling. The relationship between hospitalization and subsequent major adverse cardiac events was evaluated in a time dependent Cox proportional-hazard modelling. Of the 18 113 patients in RE-LY, 7200 (39.8%) were hospitalized at least once during a mean follow-up of 2 years. First hospitalization rates were 2312 (39.5%) for dabigatran etexilate (DE) 110, 2430 (41.6%) for DE 150, and 42.6% (N = 2458) for warfarin. Hospitalization was associated with post-discharge death [absolute event rate 9.1% vs. 2.2%; adjusted hazard ratio (HR) 3.6, 95% confidence interval (CI) 3.2-4.0, P < 0.0001], vascular death (adjusted HR 2.9, 95% CI 2.5-3.3, P < 0.0001), and sudden cardiac death (adjusted HR 2.3; 95% CI 1.8-2.9, P < 0.0001). Cardiovascular hospitalization was also associated with an increased risk of post-discharge death (adjusted HR 2.8, 95% CI 2.5-3.2, P < 0.0001), vascular death (adjusted HR 2.8, 95% CI 2.4-3.2, P < 0.0001), and sudden cardiac death (adjusted HR 2.1, 95% CI 1.6-2.7, P < 0.0001) compared with patients not hospitalized for any cardiovascular reason.

CONCLUSION

Hospitalizations are associated an increased risk of with death and cardiovascular death in patients with atrial fibrillation.

Non-valvular atrial fibrillation patients with none or one additional risk factor of the CHA2DS2-VASc score

Oral anticoagulation (OAC) to prevent stroke has to be balanced against the potential harm of serious bleeding, especially intracranial haemorrhage (ICH). We determined the net clinical benefit (NCB) balancing effectiveness and safety of no antithrombotic therapy, aspirin and warfarin in AF patients with none or one stroke risk factor. Using Danish registries, we determined NCB using various definitions intrinsic to our cohort (Danish weights at 1 and 5 year follow-up), with risk weights which were derived from the hazard ratio (HR) of death following an event, relative to HR of death after ischaemic stroke. When aspirin was compared to no treatment, NCB was neutral or negative for both risk strata. For warfarin vs no treatment, NCB using Danish weights was neutral where no risk factors were present and using five years follow-up. For one stroke risk factor, NCB was positive for warfarin vs no treatment, for one year and five year follow-up. For warfarin vs aspirin use in patients with no risk factors, NCB was positive with one year follow-up, but neutral with five year follow-up. With one risk factor, NCB was generally positive for warfarin vs aspirin. In conclusion, we show a positive overall advantage (i.e. positive NCB) of effective stroke prevention with OAC, compared to no therapy or aspirin with one additional stroke risk factor, using Danish weights. ‘Low risk’ AF patients with no additional stroke risk factors (i.e. CHA2DS2-VASc 0 in males, 1 in females) do not derive any advantage (neutral or negative NCB) with aspirin, nor with warfarin therapy in the long run.

Note: The review process for this manuscript was fully handled by Christian Weber, Editor in Chief.

Time in Therapeutic Range and Percentage of International Normalized Ratio in the Therapeutic Range as a Measure of Quality of Anticoagulation Control in Patients With Atrial Fibrillation

BACKGROUND

Time in therapeutic range (TTR), albeit the standard measure of quality of anticoagulation control for warfarin, is underused in everyday clinical practice because of its tedious calculation. In contrast, the percentage of international normalized ratio measurements in range (PINRR) is a convenient alternative. Our objective was to investigate the correlation between PINRR and TTR and whether PINRR has clinical utility for prediction of ischemic stroke and intracranial hemorrhage in a "real-world" atrial fibrillation (AF) cohort.

METHODS

This is an observational study based on a hospital-based AF registry.

RESULTS

Among 1428 Chinese patients with AF who were taking warfarin (76.2 ± 8.7 years; mean CHA₂DS₂-VASc, 4.2 ± 1.6 and HAS-BLED, 2.3 ± 0.9), mean and median TTR values were 38.2% ± 24.4% and 38.8% (interquartile range, 17.9% and 56.2%), respectively. Patients with TTR ≥ 65% (14.8%) had a lower annual risk of ischemic stroke (3.04% per year) than did those with TTR < 65% (5.35% per year). Mean and median PINRR were 34.3% ± 17.1% and 34.2% (interquartile range, 22.7% and 46.0%), respectively. TTR significantly correlated with PINRR in a linear fashion (r = 0.81; P < 0.0001). A cutoff of PINRR ≤ 56.1% was a good discriminator of TTR < 65%, with a high sensitivity (98.3%) and positive predictive value (91.9%). The annual ischemic stroke risk in patients with PINRR > 56.1% was 2.56% per year, lower than those with TTR ≥ 65% (3.04% per year). Patients with PINRR > 56.1% had an annual incidence of intracranial hemorrhage comparable to those with TTR ≥ 65% (0.49% per year vs 0.68% per year).

CONCLUSIONS

Among patients with AF who are taking warfarin, the PINRR is a user-friendly alternative to TTR, having a high sensitivity and positive predictive value in predicting TTR. As with TTR, PINRR is associated with clinical adverse events, ie, ischemic stroke and intracranial hemorrhage.

Comparisons of hospitalization rates among younger atrial fibrillation patients receiving different antiarrhythmic drugs

BACKGROUND

Antiarrhythmic drugs (AADs) are used to reduce the frequency, severity, and duration of atrial fibrillation (AF) events, which should reduce hospitalizations; however, little is known about the associations between different AADs and hospitalization—particularly among younger AF patients without structural heart disease.

METHODS AND RESULTS

Using MarketScan® claims data, we identified AF patients without coronary artery disease or heart failure who received their first AAD prescription (amiodarone, sotalol, dronedarone, or Class Ic) within 14 days post-first AF encounter. The primary outcome was time from first AAD prescription to AF hospitalization, and secondary outcomes included time to cardiovascular and all-cause hospitalizations. We used inverse probability-weighted estimators to adjust for differences in treatment allocation in the Cox proportional hazards model for each outcome. Among 8562 AF patients with a median age of 56 years (interquartile range 49, 61), risk of AF hospitalization was greater with dronedarone than Class Ic (hazard ratio [HR] 1.59; 95% confidence interval 1.13-2.24), amiodarone (HR 2.63; 1.77-3.89), and sotalol (HR 1.72; 1.17-2.54), but lower with amiodarone versus Class Ic (HR 0.68; 0.57-0.80) and sotalol (HR 0.63; 0.53-0.75). Risk of cardiovascular hospitalization was lower with amiodarone than Class Ic (HR 0.80; 0.70-0.92), but not non-AF cardiovascular hospitalization (HR 1.26; 1.01-1.57). There was no difference in all-cause hospitalization between amiodarone, Class Ic, and sotalol.

CONCLUSIONS

Differences in hospitalization rates were found between AADs in younger AF patients without structural heart disease. Amiodarone had the lowest risk of AF hospitalization and dronedarone had the greatest risk. Additional research is needed to better understand associations between AADs and hospitalization risk.

How does Chronic Atrial Fibrillation Influence Mortality in the Modern Treatment Era?

Atrial fibrillation (AF) continues to impose a significant burden upon healthcare resources. A sustained increase in the ageing population and better survival from conditions such as ischaemic heart disease have ensured that both the incidence and prevalence of AF continue to increase significantly. AF can lead to complications such as embolism and heart failure and these acting in concert with its associated co-morbidities portend increased mortality risk. Whilst some studies suggest that the mortality risk from AF is due to the "bad company it keeps" i.e. the associated co-morbidities rather than AF itself; undoubtedly some of the mortality is also due to the side-effects of various therapeutic strategies (anti-arrhythmic drugs, bleeding side-effects due to anti-coagulants or invasive procedures). Despite several treatment advances including newer anti-arrhythmic drugs and developments in catheter ablation, anti-coagulation remains the only effective means to reduce the mortality due to AF. Warfarin has been used as the oral anticoagulant in the treatment of AF for many years but suffers from disadvantages such as unpredictable INR levels, bleeding risks and need for haematological monitoring. This has therefore spurred a renewed interest in research and clinical studies directed towards developing safer and more efficacious anti-coagulants. We shall review in this article the epidemiological features of AF-related mortality from several studies as well as the cardiovascular and non-cardiac mortality mechanisms. We shall also elucidate why a rhythm control strategy has appeared to be counter-productive and attempt to predict the likely future impact of novel anti-coagulants upon mortality reduction in AF.

Prognosis and treatment of atrial fibrillation patients by European cardiologists: one year follow-up of the EURObservational Research Programme-Atrial Fibrillation General Registry Pilot Phase (EORP-AF Pilot registry)

BACKGROUND

The EURObservational Research Programme-Atrial Fibrillation General Registry Pilot Phase (EORP-AF Pilot) provides systematic collection of contemporary data regarding the management and treatment of 3119 subjects with AF from 9 member European Society of Cardiology (ESC) countries. In this analysis, we report the development of symptoms, use of antithrombotic therapy and rate vs. rhythm strategies, as well as determinants of mortality and/or stroke/transient ischaemic attack (TIA)/peripheral embolism during 1-year follow-up in this contemporary European registry of AF patients.

METHODS

The registry population comprised consecutive in- and out-patients with AF presenting to cardiologists in participating ESC countries. Consecutive patients with AF documented by ECG were enrolled. Follow-up was performed by the local investigator, initially at 1 year, as part of a long-term cohort study.

RESULTS

At the follow-up, patients were frequently asymptomatic (76.8%), but symptoms are nevertheless common among paroxysmal and persistent AF patients, especially palpitations, fatigue, and shortness of breath. Oral anticoagulant (OAC) use remains high, ∼78% overall at follow-up, and of those on vitamin K antagonist (VKA), 84% remained on VKA during the follow-up, while of those on non-VKA oral anticoagulant (NOAC) at baseline, 86% remained on NOAC, and 11.8% had changed to a VKA and 1.1% to antiplatelet therapy. Digitalis was commonly used in paroxysmal AF patients. Of rhythm control interventions, electrical cardioversion was performed in 9.7%, pharmacological cardioversion in 5.1%, and catheter ablation in 4.4%. Despite good adherence to anticoagulation, 1-year mortality was high (5.7%), with most deaths were cardiovascular (70%). Hospital readmissions were common, especially for atrial tachyarrhythmias and heart failure. On multivariate analysis, independent baseline predictors for mortality and/or stroke/TIA/peripheral embolism were age, AF as primary presentation, previous TIA, chronic kidney disease, chronic heart failure, malignancy, and minor bleeding. Independent predictors of mortality were age, chronic kidney disease, AF as primary presentation, prior TIA, chronic obstructive pulmonary disease, malignancy, minor bleeding, and diuretic use. Statin use was predictive of lower mortality.

CONCLUSION

In this 1-year follow-up analysis of the EORP-AF pilot general registry, we provide data on the first contemporary registry focused on management practices among European cardiologists, conducted since the publication of the new ESC guidelines. Overall OAC use remains high, although persistence with therapy may be problematic. Nonetheless, continued OAC use was more common than in prior reports. Despite the high prescription of OAC, 1-year mortality and morbidity remain high in AF patients, particularly from heart failure and hospitalizations.

Comparative effectiveness of antiarrhythmic drugs on cardiovascular hospitalization and mortality in atrial fibrillation

AIM

To assess, through a systematic review, evidence for the effects of antiarrhythmic drugs (AADs) on cardiovascular (CV) hospitalization and mortality.

MATERIALS & METHODS

English language articles were identified using MEDLINE, EMBASE and the Cochrane Clinical Trial Registry and were screened for study applicability and methodological quality.

RESULTS

Out of 3526 identified studies, 38 were selected for analysis (19 evaluated individual AADs, 13 compared rate- versus rhythm-control strategies, and 6 evaluated multiple AADs but did not report outcomes for individual agents). None of the studies examining individual AADs employed the CV hospitalization end point used in ATHENA (the reference trial). There were no head-to-head comparisons of individual AADs on CV hospitalization. Most high-quality studies used multidrug rate- versus rhythm-control strategies.

CONCLUSION

Assessment of the comparative effectiveness of individual AADs on CV hospitalization and mortality end points is not possible with the current evidence.

Burden, timing, and relationship of cardiovascular hospitalization to mortality among Medicare beneficiaries with newly diagnosed atrial fibrillation

BACKGROUND

Limited data exist on the burden and relationship of cardiovascular (CV) hospitalization to mortality after newly diagnosed with atrial fibrillation (AF).

METHODS

Using a 20% sample of nationwide Medicare Part A and B claims data, we performed a retrospective cohort study of Medicare beneficiaries with newly diagnosed AF (2004-2008). Cox proportional hazards time-varying exposures were used to determine the risk of death among patients with CV hospitalization after AF diagnosis.

RESULTS

Of 228,295 patients (mean age 79.6 ± 7.4 years, 56% female), 57% had a CV hospitalization after diagnosis of AF (41% in the first year). The most common primary CV hospitalization diagnoses were AF/supraventricular arrhythmias (21%), heart failure (19%), myocardial infarction (11%), and stroke/transient ischemic attack (7.7%). Incidence rates per 1,000 person-years among patients with and without CV hospitalization were 114 and 87, respectively, for all-cause mortality. After adjustment for covariates and time to CV hospitalization, the hazard of mortality among newly diagnosed AF patients with CV hospitalization, compared with those without CV hospitalization, was higher (hazard ratio 1.22, 95% CI 1.20-1.24).

CONCLUSIONS

Cardiovascular hospitalization is common in the first year after AF diagnosis. Atrial fibrillation, heart failure, myocardial infarction, and stroke/transient ischemic attack account for half of primary hospitalization diagnosis. Cardiovascular hospitalization is independently associated with mortality, irrespective of time from diagnosis to first hospitalization, and represents a critical inflection point in survival trajectory. These findings highlight the importance of CV hospitalization as a marker of disease progression and poor outcomes. Efforts to clarify the determinants of hospitalization could inform interventions to reduce admissions and improve survival.

Hospital readmissions in US atrial fibrillation patients: occurrence and costs

The aim of the study was to examine the temporal readmission pattern, proportion of readmissions attributed to cardiovascular (CV) causes, and the duration and costs associated with readmission in hospitalized patients with atrial fibrillation/flutter (AF/AFL). This retrospective cohort study used medical claims data from the PharMetrics Patient-Centric database (IMS Health, Watertown, MA) between January 2007 and March 2008. The patients hospitalized with a primary diagnosis of AF/AFL and with ≥12 months' continuous medical and prescription coverage before and after the initial AF/AFL hospitalization were identified from this database. The main outcome measures were rehospitalization patterns [all-cause, all CV-related (including AF/AFL), and AF/AFL-related only], which were assessed over the 12-month post-index period, and costs of initial and subsequent AF/AFL-related hospitalizations that were compared. The study included 8035 patients with AF/AFL (mean age 66.1 years; 57.6% males). Rehospitalization was common (37.9% of patients), with the most frequent causes being CV (34.1%) and, specifically, AF/AFL-related (26.8%). The highest proportion of rehospitalizations occurred within 30 days of the initial hospitalization (25%). Readmissions with a primary diagnosis of AF/AFL (n = 1238) were significantly longer (4.0 vs. 3.6 days; P = 0.0229) and more costly (US$8966 vs. US$7080; P < 0.0001) than the index hospitalization. Hospitalized AF/AFL patients experience high rates of CV- and AF/AFL-related readmissions, particularly within the first 30 days. Subsequent AF/AFL-related readmissions incur higher costs than the initial AF/AFL hospitalization. Treatments resulting in reduced readmissions would improve patient outcomes, quality of life and the cost burden associated with AF/AFL.

Cardiovascular and non-cardiovascular hospital admissions associated with atrial fibrillation: a Danish nationwide, retrospective cohort study

OBJECTIVE

To examine the excess risk of hospitalisation in patients with incident atrial fibrillation (AF).

DESIGN

A nationwide, retrospective cohort study.

SETTING

Denmark.

PARTICIPANTS

Data on all admissions in Denmark from 1997 to 2009 were collected from nationwide registries. After exclusion of subjects previously admitted for AF, data on 4 602 264 subjects and 10 779 945 hospital admissions contributed to the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Age-stratified and sex-stratified admission rates were calculated for cardiovascular and non-cardiovascular admissions. Temporal patterns of readmission, relative risk and duration of frequent types of admission were calculated.

RESULTS

Of 10 779 945 hospital admissions, 729 088(6.8%) were associated with AF. Admissions for cardiovascular reasons after 1, 3 and 6 months occurred for 6.0, 14.3 and 28.4% of AF patients versus 0.2, 0.6 and 1.8 of non-AF patients. Admissions for non-cardiovascular reasons after 1, 3 and 6 months comprised 6.8, 16.1 and 33.3% of AF patients and 1.2, 3.2 and 9.7% of non-AF patients. When stratified for age, AF was associated with similar cardiovascular admission rates across all age groups, while non-cardiovascular admission rates were higher in older patients. Within each age group and for both cardiovascular and non-cardiovascular admissions, AF was associated with higher rates of admission. When adjusted for age, sex and time period, patients with AF had a relative risk of 8.6 (95% CI 8.5 to 8.6) for admissions for cardiovascular reasons and 4.0 (95% CI 4.0 to 4.0) for admission for non-cardiovascular reasons.

CONCLUSIONS

This study confirms that the burden of AF is considerable and driven by both cardiovascular and non-cardiovascular admissions. These findings underscore the importance of using clinical and pharmacological means to reduce the hospital burden of AF in Western healthcare systems.

Benefit-risk assessment of current antiarrhythmic drug therapy of atrial fibrillation

Over the last decade, several rhythm-versus rate-control trails in patients with atrial fibrillation (AF) have failed to demonstrate benefit of the rhythm control strategy with respect to mortality and morbidity. This had let to the guideline recommendation that antiarrhythmic drug therapy should be considered predominantly for symptomatic improvement of patients. Recent trails and meta-analyses have demonstrated that amiodarone is the most antiarrhythmic drug currently available. However, its use has been associated with many adverse effects. Currently, dronedarone is the only available antiarrhythmic drug which has shown a reduction in cardiovascular hospitalizations in medium-risk AF patients. However, the drug was associated with increased mortality in patients with recently decompensated heart failure. Hence, antiarrhythmic drug therapy has to be evaluated in patients with AF on an individual patients basis.

Incremental cost burden to US healthcare payers of atrial fibrillation/atrial flutter patients with additional risk factors

INTRODUCTION

Atrial fibrillation (AF) and atrial flutter (AFL) patients often have cardiovascular (CV) comorbidities, and have an increased risk of hospitalization and death. Little is known about the real-world cost burden of AF/AFL patients with additional risk factors (ARF). We evaluated the medical resource use and cost burden of AF/AFL patients with ≥1 ARF (other than heart failure [HF]), in comparison with non-AF/AFL controls.

METHODS

This retrospective cohort study included patients from the MarketScan Medicare database who had ≥1 inpatient or ≥2 outpatient AF/AFL claims. Patients were (1) ≥75 years of age or (2) 70-74 years of age with ≥1 ARF (hypertension, diabetes, systemic embolism, or stroke/transient ischemic attack), but without HF. The AF/AFL patients were matched on age, gender, region, and enrollment status with non-AF/AFL patients. Hospital resource use and costs over the 12-month post-index period were compared across cohorts. The impacts of comorbidity were seen by subcategorizing hospitalization as all-cause, CV-related, and AF/AFL-related.

RESULTS

AF/AFL patients with ≥1 ARF had a higher prevalence of comorbidity than non-AF/AFL patients (n=58,555/cohort). Hospitalizations (all-causality) were more than three times more frequent and of longer duration in AF/AFL patients with ≥1 ARF than in non-AF/AFL controls (mean [SD]: 0.72 [0.87] vs. 0.21 [0.51] hospitalizations per patient per year and 3.85 [9.30] and 1.03 [4.53] days, respectively; both P<0.0001). Overall mean (SD) costs over the 12-month post-index period were higher in AF/AFL patients with ≥1 ARF versus the non-AF/AFL control patients for inpatient ($9613 [25,407] vs. $2625 [11,597]; P<0.0001; incremental cost $6988), outpatient ($9447 [15,062] vs. $4906 [11,715]; P<0.0001; incremental cost $4541), and prescription drug costs ($3430 [3637] vs. $2618 [3374]; P<0.0001; incremental cost $812).

CONCLUSION

AF/AFL patients with ≥1 ARF had significantly greater levels of comorbidity, hospitalizations, prescription, and outpatient claims than non-AF/AFL patients. The incremental costs of AF/AFL patients with ≥1 ARF are largely due to higher CV-related inpatient costs.

Impact of dronedarone on hospitalization burden in patients with atrial fibrillation: results from the ATHENA study

AIMS

Cardiovascular (CV) hospitalization is a predictor of CV mortality and has a negative impact on patients' quality of life. The primary endpoint of A placebo-controlled, double-blind, parallel-arm Trial to assess the efficacy of dronedarone 400 mg bid for the prevention of cardiovascular Hospitalization or death from any cause in patiENTs with Atrial fibrillation/atrial flutter (ATHENA), a composite of first CV hospitalization or death from any cause, was significantly reduced by dronedarone. This post hoc analysis evaluated the secondary endpoint of CV hospitalization and the clinical benefit of dronedarone on the number and duration of CV hospitalizations in patients with atrial fibrillation (AF).

METHODS AND RESULTS

ATHENA was a double-blind, parallel group study in 4628 patients with a history of paroxysmal/persistent AF and additional risk factors, treated with placebo or dronedarone. Dronedarone treatment significantly reduced the risk of first CV hospitalization (P < 0.0001 vs. placebo), while the risk of first non-CV hospitalization was similar in both groups (P = 0.77). About half of the CV hospitalizations were AF-related, with a median duration of hospital stay of four nights. The risk of any hospitalization for AF [hazard ratio (95% confidence interval) 0.626 (0.546-0.719)] and duration of hospital stay were significantly reduced by dronedarone (P < 0.0001 vs. placebo). Dronedarone treatment reduced total hospitalizations for acute coronary syndrome (P = 0.0105) and the time between the first AF/atrial flutter recurrence and CV hospitalization/death (P = 0.0048). Hospitalization burden was significantly reduced across all levels of care (P < 0.05). Cumulative incidence data indicated that the effects of dronedarone persisted for at least 24 months.

CONCLUSION

Dronedarone reduced the risk for CV hospitalization and the total hospitalization burden in this patient group. The trial is registered under ClinicalTrials.gov #NCT 00174785.