Differences in global, regional, and national time trends in disability-adjusted life years for atrial fibrillation and flutter, 1990-2019: an age-period-cohort analysis from the 2019 global burden of disease study

Background

Atrial fibrillation and flutter, collectively referred to as AF/AFL, pose substantial public health challenges across nations of different economic statuses.

Abjective

This research is intended to assess the discrepancies in global, regional, and national trends in DALYs for atrial fibrillation and flutter throughout 1990 and 2019.

Methods

The GBD 2019 report included statistics on AF/AFL. An age-period-cohort (APC) model was used to calculate the changes in DALYs from ages 30 to 34 years up to 95 + years. The model calculated both net drifts and local drifts in DALYs. In addition, we analysed the relative risks for certain time periods and birth cohorts from 1990 to 2019 in order to assess their impact. In order to measure the changes over time in the age-standardized rate (ASR) of DALYs caused by AF/AFL, we calculated the average annual percentage changes (AAPCs) based on age, gender, socio-demographic index (SDI), and location. This approach enables us to analyse the impact of age, period, and cohort on trends in DALYs, which may uncover disparities in the management of AF/AFL.

Results

The global number of DALYs cases was 8,393,635 [95% uncertainty interval (UI): 6,693,987 to 10,541,461], indicating a 121.6% rise (95% UI: 111.5 to 132.0) compared to 1990. From 1990 to 2019, the worldwide ASR of DALYs decreased by 2.61% (95% UI -6.9 to 1.3). However, the other SDI quintiles, except for high SDI and high-middle SDI, had an increase. During the last three decades, high-income nations in the Asia Pacific region had the most significant reduction in ASR of DALYs, whereas Central Asia experienced the highest rise (with a net drift of -0.9% [95% Confidence Interval (CI): -1.0 to -0.9] and 0.6% [95% CI: 0.5 to 0.7], respectively). Approximately 50% of the burden of AF/AFL has been transferred from areas with high and high-middle SDI to those with lower SDI. There was an inverse relationship between the AAPC and the SDI. In addition, men and older individuals were shown to have a greater burden of AF/AFL DALYs.

Conclusion

The findings of this research demonstrate that the worldwide impact of AF/AFL remains significant and increasing, with the burden differing depending on SDI. The exhaustive and comparable estimates provided by these results may contribute to international efforts to attain equitable AF/AFL control.

The pathway to diagnosis and follow-up care for atrial fibrillation in Sri Lanka: a descriptive longitudinal study

Background

Early diagnosis and continuity of care is vital for atrial fibrillation (AF), to reduce stroke ; There is a lack of understanding of when and how AF is being diagnosed and managed the care pathway) in in low- and middle-income countries (LMICs). We aimed to identify the AF care pathway in Northern Province, Sri Lanka and determine how the COVID-19 pandemic impacted the care pathway.

Methods

This descriptive longitudinal study utilised two quantitative questionnaires to evaluate the AF pathway: The first questionnaire (baseline) was used to identify where AF was being diagnosed and the second questionnaire (3 months following baseline) was used to identify where and how often AF follow-up care was being received. How the COVID-19 pandemic impacted the care pathway was asked in the second questionnaire. We aimed to recruit 236 adults (≥18 years) with AF from Jaffna Teaching Hospital. Data were collected between October 2020 and June 2021 and analysed using descriptive statistics.

Results

151 participants were recruited (median age 57 years; 70% female). Most participants were diagnosed in the accident & emergency (38%) or inpatient department (26%), followed by an outpatient department (19%) or private facility (16%). Nearly all (97%) participants received follow-up care during the study period, with an average of 1.3 AF-related healthcare visits per person for a month; most visited an outpatient department (88%). The COVID-19 pandemic negatively impacted 39% of participants' care: healthcare visits were reduced or, delayed or medications were unattainable, and longer intervals between blood tests were experienced; however, 24% of participants were able to receive their medication by ambulance, public health staff or post during lockdowns.

Conclusions

Primary care was not involved in the diagnosis of AF, indicating that most diagnoses occurr after a medical emergency. The frequency of blood tests was lower than the guideline recommendations of one per month which could in-part be due to the adverse impacts of the pandemic. Strengthening primary and community-based care may enable early diagnosis and improve continuity of care during and beyond future healthcare crises.

Selection of Non-vitamin K Antagonist Oral Anticoagulant for Stroke Prevention in Atrial Fibrillation Based on Patient Profile: Perspectives from Vietnamese Experts. Part 1

In Asia, especially Vietnam, AF is a common arrhythmia and is linked to a higher risk of stroke and systemic embolism. Anticoagulation therapy for stroke prevention in AF patients can result in bleeding complications. To effectively manage AF, adopting appropriate anticoagulation and addressing modifiable risk factors are crucial. Vietnamese clinicians are particularly interested in non-vitamin K antagonist oral anticoagulants (NOACs), a recent development in AF treatment. However, the lack of head-to-head trials comparing NOACs makes selecting a specific NOAC challenging. This review aims to provide a comprehensive overview of the available clinical evidence on NOACs for stroke prevention in AF to assist clinicians in making informed decisions and improving treatment outcomes in patients with AF. The first part of this review will present the current landscape of AF in Vietnam, focusing on AF prevalence and highlighting gaps in clinical practice. Furthermore, this part extensively discusses the anticoagulation strategy for both primary and secondary stroke prevention in AF.

Very Elderly Patients With Atrial Fibrillation Treated With Edoxaban: Impact of Frailty on Outcomes

Background

Age and frailty are associated with underuse of anticoagulation in elderly patients with atrial fibrillation (AF).

Objectives

This study aimed at assessing major clinical outcomes in very elderly patients with AF treated with recommended dose edoxaban and look for a possible relation with frailty measured by a validated score.

Methods

This prospective multicenter cohort study enrolled consecutive very elderly (age ≥80 years) anticoagulation-naïve patients starting recommended doses of edoxaban. Upon entry into the study, patients were categorized into nonfrail, prefrail and frail with the SHARE-FI (Survey of Health, Ageing, and Retirement in Europe-Frailty Index) score. The primary outcome was a composite incidence of stroke/systemic embolism, major bleeding, clinically relevant nonmajor bleeding, and death between frail and fitter patients over 2 years follow-up. Secondary outcomes were frailty-related incidence of the individual components part of the composite outcome.

Results

Of the 180 screened patients, 176 were enrolled in the study. Of these, 58 (32.9%) were frail, 35 (19.8%) prefrail, and 83 (47.2%) nonfrail. The composite outcome occurred in 49 patients (18.9% per patient-year). No difference in the primary endpoint between frail and fitter patients (incidence rate ratio: 1.2; 95% CI: 0.6-2.2) was observed. On multivariable analysis, anemia was significantly related to the primary outcome (HR: 3.6; 95% CI: 1.8-7.3; P < 0.001), while frailty was not (frail vs nonfrail HR: 0.9; 95% CI: 0.5-1.8). No difference across frailty categories of the individual components of composite events was observed, except for death.

Conclusions

Anticoagulation with recommended dose edoxaban is feasible in very elderly patients with AF even if frail. (ESCAPE [Edoxaban and Frailty in Senior Individuals]; NCT03524924).

Clustering of Environmental Parameters and the Risk of Acute Ischaemic Stroke

Acute ischaemic stroke (AIS) risk on days with similar environmental profiles remains unknown. We investigated the association between clusters of days with similar environmental parameters and AIS incidence in Singapore. We grouped calendar days from 2010 to 2015 with similar rainfall, temperature, wind speed, and Pollutant Standards Index (PSI) using k-means clustering. Three distinct clusters were formed 'Cluster 1' containing high wind speed, 'Cluster 2' having high rainfall, and 'Cluster 3' having high temperatures and PSI. We aggregated the number of AIS episodes over the same period with the clusters and analysed their association using a conditional Poisson regression in a time-stratified case-crossover design. Comparing the three clusters, Cluster 3 had the highest AIS occurrence (IRR 1.09; 95% confidence interval (CI) 1.05-1.13), with no significant difference between Clusters 1 and 2. Subgroup analyses in Cluster 3 showed that AIS risk was amplified in the elderly (≥65 years old), non-smokers, and those without a history of ischaemic heart disease/atrial fibrillation/vascular heart disease/peripheral vascular disease. In conclusion, we found that AIS incidence may be higher on days with higher temperatures and PSI. These findings have important public health implications for AIS prevention and health services delivery during at-risk days, such as during the seasonal transboundary haze.

Causes of death of patients with non-valvular atrial fibrillation in Asians

OBJECTIVES

The aim of this study was to determine the causes of death among Asian non-valvular atrial fibrillation (AF) patients who were registered in a nationwide AF registry, and to investigate the differences in the causes of death in AF patients compared between those who were taking and not taking oral anticoagulant (OAC).

METHODS

The COhort of antithrombotic use and Optimal INR Level in patients with non-valvular Atrial Fibrillation in Thailand (COOL-AF) study enrolled non-valvular AF patients from 27 centers in Thailand during 2014-2017 to create the COOL-AF Thailand registry. Cause of death was classified as cardiovascular (CV) death, non-CV death, or undetermined cause of death. All events were evaluated and verified by an independent adjudication committee.

RESULTS

There was a total of 3,405 patients (mean age: 67.8 years, 41.8% female), and the mean follow-up duration was 31.8±8.7 months. Three hundred and eighty patients (11.2%) died during follow-up. CV death, non-CV death, and undetermined cause accounted for 121 (31.8%), 189 (49.7%), and 70 (18.4%) patients, respectively. Of those with a known cause of death, heart failure (10%), intracranial hemorrhage (ICH; 10%), sudden cardiac death (6.8%), and ischemic stroke (5.8%) were the most often observed causes of death. Concerning non-CV death, infection/sepsis (27.7%), cancer (5.5%), respiratory (5.2%), and major bleeding (4.5%) were the most prevalent causes of death. The use and type of OAC were found to be major determinants of ICH and major bleeding incidence.

CONCLUSION

Death due to ischemic stroke was responsible for only 4.7% of all deaths in Asian AF patients. Non-CV death, such as infection/sepsis or malignancy, was more far more prevalent than CV death in Asian AF patients. An improved integrated care approach is needed to reduce the prevalence of non-CV death in Asian AF patients.

Characteristics and health-status outcomes in patients with atrial fibrillation detected via health screening

BACKGROUND

Early detection of atrial fibrillation (AF) is important. Japan has a universal screening system, and regular health screening (HS) is available to support AF detection without a hospital visit. However, health-related outcomes and other characteristics of HS-detected and conventionally diagnosed AF remain unknown.

HYPOTHESIS

That the characteristics and health-related outcomes of patients with HS-detected AF may differ from those of patients whose AF was detected by other procedures.

METHODS

In total, 3318 consecutive newly referred AF cases were enrolled; demographic characteristics and health-related and clinical outcomes were compared between two groups created based on the mode of AF detection (the HS and non-HS groups). Health-related outcomes were assessed using the AF Effect on QualiTy-of-life (AFEQT) questionnaire at baseline and after 1 year of follow-up.

RESULTS

AF was detected by HS in 25.0% of patients; these patients had lower CHADS₂ scores (1.01 vs. 1.50, p < .001), higher prevalence of persistent AF (odds ratio, 95% confidence interval; 2.21, 1.88-2.60) and asymptomatic presentation (3.19, 2.71-3.76), and better baseline QoL scores (83.6 vs. 75.0; p < .001). Catheter ablation was more frequently performed in the HS group at follow-up (44.4% vs. 34.1%; p < .001). At 1-year follow-up, the AFEQT scores of the HS group were significantly better in most subdomains.

CONCLUSIONS

In the Japanese registry, AF was detected via HS in 25% of patients referred to specialty centers for management. Notably, the overall health status of patients with HS-detected AF improved after medical interventions, including catheter ablations.

Effect of Dronedarone in the Treatment of Atrial Fibrillation in the Asian Population: Post Hoc Analysis of the ATHENA Trial

PURPOSE

Limited data are available on the impact of dronedarone treatment in Asian patients with atrial fibrillation (AF) or atrial flutter (AFL). This post hoc analysis evaluated the efficacy and safety of dronedarone compared with placebo in populations from Asian and non-Asian regions randomized in the ATHENA trial (A Placebo-Controlled, Double-blind, Parallel Arm Trial to Assess the Efficacy of Dronedarone 400 mg BID for the Prevention of CV Hospitalization or Death From Any Cause in Patients With AF/AFL).

METHODS

Time to first hospitalization for cardiovascular events or death from any cause (primary outcome) and time to first AF/AFL event recurrence (secondary outcome) were analyzed by Kaplan-Meier curves and Cox proportional hazards regression.

FINDINGS

The risk of experiencing the primary composite outcome was significantly lower in the dronedarone-treated patients in both the Asian (hazard ratio = 0.541; 95% CI, 0.320-0.914]) and non-Asian (hazard ratio = 0.768; 95% CI, 0.696-0.848) populations than in the placebo-treated patients. The median time to the first AF/AFL event recurrence was longer in the dronedarone-treated population than in the placebo-treated populations: 183 vs 92 days (P = 0.165) in the Asian population and 534 vs 196 days (P < 0.001) in the non-Asian population. Treatment-emergent adverse events in Asian (81.2% vs 78.4%) and non-Asian (71.4% vs 68.7%) populations and serious treatment-emergent adverse events in Asian (14.3% vs 15.7%) and non-Asian (20.3% vs 21.5%) patients were comparable in patients taking dronedarone compared with those taking placebo.

IMPLICATION

Efficacy and tolerability of dronedarone were consistent in the Asian population compared with the non-Asian population in the ATHENA trial. These finding may aid Asian health care professionals to select the appropriate first-line treatment for Asian patients with AF/AFL.

XaMINA: A Real-World, Prospective, Observational Study of Treatment-Naïve Patients Treated with Rivaroxaban for Stroke Prevention in Atrial Fibrillation in Asia

INTRODUCTION

The efficacy and safety of rivaroxaban for the prevention of stroke and systemic embolism have been demonstrated in Asian and non-Asian patients with non-valvular atrial fibrillation (NVAF) in multiple studies. However, limited published data exist on its use specifically in treatment-naïve patients from the Asia region. Patients in South Korea and Taiwan can now receive rivaroxaban as first-line therapy, allowing for data generation in this patient group.

METHODS

XaMINA was a prospective, real-world, multicenter, single-arm, observational cohort study of patients with NVAF in South Korea and Taiwan naïve to anticoagulation and initiating rivaroxaban. The primary outcome was major bleeding; secondary outcomes included all-cause mortality, symptomatic thromboembolic events, and treatment persistence.

RESULTS

In total, 1094 patients were included and the follow-up was 1 year. The baseline mean CHADS₂ score was 1.63 ± 0.98, mean CHA₂DS₂-VASc score was 2.92 ± 1.42, and mean HAS-BLED score was 1.00 ± 0.75. The primary outcome occurred in 20 (1.8%) patients [incidence rate 2.1 events per 100 patient-years (95% CI 1.35-3.25)]. Thromboembolic events occurred in 9 (0.8%) patients, of whom 5 (0.5%) had stroke, 3 (0.3%) myocardial infarction, and 1 (0.1%) a transient ischemic attack. There were no cases of non-central nervous system systemic embolism, and 735 (67.2%) patients persisted with rivaroxaban treatment for 1 year.

CONCLUSION

XaMINA demonstrated low incidence rates of major bleeding events and thromboembolic events in patients with NVAF newly initiating rivaroxaban in South Korea and Taiwan, consistent with previous real-world studies reconfirming the results of the ROCKET AF study.

TRIAL REGISTRATION

The trial was registered on ClinicalTrials.gov (identifier NCT03284762) on 15 September 2017.

The Canadian Women's Heart Health Alliance Atlas on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 5: Sex- and Gender-Unique Manifestations of Cardiovascular Disease

This Atlas chapter summarizes sex- and some gender-associated, and unique aspects and manifestations of cardiovascular disease (CVD) in women. CVD is the primary cause of premature death in women in Canada and numerous sex-specific differences related to symptoms and pathophysiology exist. A review of the literature was done to identify sex-specific differences in symptoms, pathophysiology, and unique manifestations of CVD in women. Although women with ischemic heart disease might present with chest pain, the description of symptoms, delay between symptom onset and seeking medical attention, and prodromal symptoms are often different in women, compared with men. Nonatherosclerotic causes of angina and myocardial infarction, such as spontaneous coronary artery dissection are predominantly identified in women. Obstructive and nonobstructive coronary artery disease, aortic aneurysmal disease, and peripheral artery disease have worse outcomes in women compared with men. Sex differences exist in valvular heart disease and cardiomyopathies. Heart failure with preserved ejection fraction is more often diagnosed in women, who experience better survival after a heart failure diagnosis. Stroke might occur across the lifespan in women, who are at higher risk of stroke-related disability and age-specific mortality. Sex- and gender-unique differences exist in symptoms and pathophysiology of CVD in women. These differences must be considered when evaluating CVD manifestations, because they affect management and prognosis of cardiovascular conditions in women.

Anticoagulation Control in Different Ethnic Groups Receiving Vitamin K Antagonist for Stroke Prevention in Atrial Fibrillation

Vitamin K antagonist such as warfarin reduces the risk of stroke in atrial fibrillation (AF) patients. Since warfarin has a narrow therapeutic index, its administration needs to be regularly monitored to avoid any adverse clinical outcomes such as stroke and bleeding. The quality of anticoagulation control with warfarin therapy can be measured by using time in therapeutic range (TTR). This review focuses on the prevalence of AF, quality of anticoagulation control (TTR) and adverse clinical outcome in AF patients within different ethnic groups receiving warfarin therapy for stroke prevention. A literature search was conducted in Embase and PubMed using keywords of “prevalence,” “atrial fibrillation,” “stroke prevention,” “oral anticoagulants,” “warfarin,” “ethnicities,” “race” “time in therapeutic range,” “adverse clinical outcome,” “stroke, bleeding.” Articles published by 1st February 2020 were included. Forty-one studies were included in the final review consisting of AF prevalence (n = 14 studies), time in therapeutic range (n = 18 studies), adverse clinical outcome (n = 9 studies) within different ethnic groups. Findings indicate that higher prevalence of AF but better anticoagulation control among the Whites as compared to other ethnicities. Of note, non-whites had higher risk of strokes and bleeding outcomes while on warfarin therapy. Addressing disparities in prevention and healthcare resource allocation could potentially improve AF-related outcomes in minorities.

A Web-Based Integrated Management Program for Improving Medication Adherence and Quality of Life, and Reducing Readmission in Patients With Atrial Fibrillation: Randomized Controlled Trial

BACKGROUND

Atrial fibrillation (AF) is related to a variety of chronic diseases and life-threatening complications. It is estimated that by 2050, there will be 72 million patients with AF in Asia, of which 2.9 million will have AF-associated stroke. AF has become a major issue for health care systems.

OBJECTIVE

We aimed to evaluate the effects of a web-based integrated management program on improving coping strategies, medication adherence, and health-related quality of life (HRQoL) in patients with AF, and to detect the effect on decreasing readmission events.

METHODS

The parallel-group, single-blind, prospective randomized controlled trial recruited patients with AF from a medical center in northern Taiwan and divided them randomly into intervention and control groups. Patients in the intervention group received the web-based integrated management program, whereas those in the control group received usual care. The measurement tools included the Brief Coping Orientation to Problems Experienced (COPE) scale, Medication Adherence Rating Scale (MARS), the three-level version of the EuroQoL five-dimension self-report questionnaire (EQ-5D-3L), and readmission events 2 years after initiating the intervention. Data were collected at 4 instances (baseline, 1 month, 3 months, and 6 months after initiating the intervention), and analyzed with generalized estimating equations (GEEs).

RESULTS

A total of 231 patients were recruited and allocated into an intervention (n=115) or control (n=116) group. The mean age of participants was 73.08 (SD 11.71) years. Most participants were diagnosed with paroxysmal AF (171/231, 74%), and the most frequent comorbidity was hypertension (162/231, 70.1%). Compared with the control group, the intervention group showed significantly greater improvement in approach coping strategies, medication adherence, and HRQoL at 1, 3, and 6 months (all P<.05). In addition, the intervention group showed significantly fewer readmission events within 2 years (OR 0.406, P=.03), compared with the control group.

CONCLUSIONS

The web-based integrated management program can significantly improve patients' coping strategy and medication adherence. Therefore, it can empower patients to maintain disease stability, which is a major factor in improving their HRQoL and reducing readmission events within 2 years.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04813094; https://clinicaltrials.gov/ct2/show/NCT04813094.

Influence of gender on the clinical outcomes of Asian non-valvular atrial fibrillation patients: insights from the prospective multicentre COOL-AF registry

OBJECTIVE

To determine the effect of gender on clinical outcomes of Asian non-valvular atrial fibrillation patients.

DESIGN

This is a cohort study.

SETTING

27 university and regional hospitals in Thailand.

PARTICIPANTS

Patients with non-valvular atrial fibrillation.

PRIMARY AND SECONDARY OUTCOMES MEASURES

The clinical outcomes were ischaemic stroke/transient ischaemic attack (TIA), major bleeding, intracerebral haemorrhage (ICH), heart failure and death. Follow-up data were recorded every 6 months until 3 years. Differences in clinical outcomes between males and females were determined. Multivariate analysis was performed to assess the effect of gender on clinical outcomes. Survival analysis and log-rank test were performed to determine the time-dependent effect of clinical outcomes, and the difference between males and females. Effect of oral anticoagulant (OAC) on outcomes and net clinical benefit of OAC was assessed. The analysis was performed both for the whole dataset and propensity score matching with multiple imputation.

RESULTS

A total of 3402 patients (mean age: 67.4±11.3 years; 58.2% male) were included. Average follow-up duration 25.7±10.6 months (7192.6 persons-year). Rate of ischaemic stroke/TIA, major bleeding, ICH, heart failure and death were 1.43 (1.17-1.74), 2.11 (1.79-2.48), 0.70 (0.52-0.92), 3.03 (2.64-3.46) and 3.77 (3.33-4.25) per 100 person-years. Females had increased risk for ischaemic stroke/TIA and heart failure and males had increased risk for major bleeding and ICH. Ischaemic stroke/TIA risk in females and major bleeding and ICH risk in males remained even after correction for age, comorbid conditions and anticoagulation treatment. OAC reduced the risk of ischaemic stroke/TIA in males and females, and markedly increased the risk of major bleeding and ICH in males.

CONCLUSIONS

Females had a higher risk of ischaemic stroke/TIA and heart failure, and a lower risk of major bleeding and ICH compared with males. OAC reduced risk of ischaemic stroke/TIA in females, and markedly increased risk of major bleeding and ICH in males.

Cohort profile: patient characteristics and quality-of-life measurements for newly-referred patients with atrial fibrillation-Keio interhospital Cardiovascular Studies-atrial fibrillation (KiCS-AF)

PURPOSE

Besides the high rates of morbidity and mortality, atrial fibrillation (AF) is also associated with impairment of quality-of-life (QOL). However, reports covering non-selected AF population within Asian countries remain scarce. The objective of the Keio interhospital Cardiovascular Studies-atrial fibrillation (KiCS-AF) registry is to clarify the baseline and QOL profiles of the AF patients at the time of initial referral to identify areas for improvement and country-specific gaps.

PARTICIPANTS

The KiCS-AF registry is a multicentre, prospective cohort study designed to specifically recruit AF patients newly referred to the 11 network hospitals within the Kanto area of Japan. The registry completed its enrolment in June 2018. All patients were requested to answer the Atrial Fibrillation Effect on Quality-of-Life (AFEQT) questionnaire both at baseline and 1 year, with planned clinical follow-up for 5 years. The registry also assessed individual treatment strategies including rate and rhythm control, stroke prophylaxis, and their impacts on patient-reported QOL.

FINDINGS TO DATE

As of December 2016, 2464 AF patients were registered; their mean age was 67.1 years (SD, 11.7), majority (69.7%; n=1717) were men and 49.2% presented with paroxysmal AF. The mean CHA₂DS₂-VASc (cardiac failure or dysfunction, hypertension, age ≥75 years, diabetes, stroke including vascular disease, age 65-74 years, and sex category [female]) score was 2.3 (SD, 1.6) and oral anticoagulant therapy was used for 88.6% of patients with CHA₂DS₂-VASc scores ≥2. The median AFEQT-overall summary score was 79.1 (IQR, 66.6-89.1). Roughly 50% had significantly impaired QOL (ie, AFEQT <80) at baseline. Currently, 2307 eligible patients (93.6%) have completed the 1-year follow-up, of which 2072 patients (89.8%) answered the second AFEQT questionnaire.

FUTURE PLANS

The KiCS-AF allowed for extensive investigation of AF-related QOL in a non-selected population with long-term follow-up using a rigorously validated QOL assessment tool. Almost half of patients had impaired QOL at baseline. Further investigations aimed at providing care and improving patient-reported QOL are required.

Guideline-Adherent Treatment for Stroke and Death in Atrial Fibrillation Patients From UK and Japanese AF Registries

BACKGROUND

Guideline-adherent antithrombotic treatment (ATT) reduces the risk of stroke and death in patients with atrial fibrillation (AF). However, the effect of ATT adherence among different ethnicities remains uncertain. We compared the prognosis of AF patients in Japan and the UK according to guideline adherence status.Methods and Results:We compared the clinical characteristics and outcomes of AF patients from the Fushimi AF registry (Japan; n=4,239) and the Darlington AF registry (UK; n=2,259). ATT adherence was assessed against the Japanese Circulation Society Guidelines and UK National Institute for Health and Care Excellence guidelines. The rates of guideline-adherent ATT were 58.6% and 50.8% in the Fushimi and Darlington registries, respectively. There was no significant difference in 1-year stroke rates between Fushimi and Darlington (2.6% vs. 3.0%, P=0.342). On multivariate logistic regression analysis, non-guideline adherent-ATT was significantly associated with an increased risk of stroke (odds ratio [OR]: 1.69, 95% confidence interval [CI]: 1.21-2.34, P=0.002 for undertreatment, OR: 2.13, 95% CI: 1.19-3.80, P=0.010 for overtreatment). No significant interaction for ATT and the 2 populations was found in the incidence of stroke, all-cause death, and the composite outcome.

CONCLUSIONS

Approximately half of the AF patients received optimal ATT according to guideline recommendations, which was associated with a lower risk of stroke. Furthermore, there was no interaction for the 2 populations and the influence of ATT adherence.

Pharmacogenetics of anticoagulants used for stroke prevention in patients with atrial fibrillation

Introduction: The inclusion of pharmacogenetics alongside clinical information in anticoagulant therapy offers the opportunity for a tailored approach to treatment according to individual patient characteristics. Areas covered: Literature was searched using PubMed database, focusing on pharmacogenetics of oral anticoagulants. Original research articles and review articles in English language were included in the literature reviewed. This article includes all information available for the genetic cause of inter-individual variability in anticoagulation response to oral anticoagulant drugs. The pharmacogenetics of VKAs and NOACs are described in detail. Expert opinion: There have been numerous studies focusing on the pharmacogenetics of VKAs, particularly warfarin. Current evidence suggests that known genetic and clinical factors explain a large proportion of the inter-individual variability in response to warfarin. Pharmacogenetic-based algorithms have been validated to determine their clinical utility with equivocal results. To date, only a limited number of mostly small studies on the pharmacogenetics of NOACs exists. The latter have highlighted genetic polymorphisms in specific genes that may affect clinical outcomes. Further evaluations of these polymorphisms are needed before firm conclusions can be drawn about the significance of pharmacogenetics on NOAC therapy.

Short-Term Outcomes in Newly Diagnosed Atrial Fibrillation and Chronic Kidney Disease: How Important Is Ethnicity?

See Article by Goto et al.

Left Atrial or Left Atrial Appendage Thrombus Resolution After Adjustment of Oral Anticoagulant Treatment

BACKGROUND

There are few reports about non-vitamin K antagonist oral anticoagulant (NOAC) treatment for resolution of left atrium (LA) or left atrial appendage (LAA) thrombus. LAA thrombus is an important cause of cardiogenic cerebral thromboembolism, and the detection rate increases due to more and more patients receiving catheter ablation. However, the results from NOAC use for LA or LAA thrombus are still unknown in real-world practice. The aim of this study was to discover the resolution of LA or LAA thrombus after anticoagulant treatment in real-world practice.

METHOD

From January 2013 to December 2016, a total 864 patients underwent transesophageal echocardiography (TEE), and 41 cases of LA or LAA thrombus were detected in our hospital. Among them, a total of 22 patients underwent follow-up TEE to detect the resolution of LA or LAA thrombus.

RESULT

The average age of the study patients was 72.0 ± 11 years old, and 61% were male. The average CHA2DS2-VASc scores were 3.76 ± 2.01 points. A total of 22 patients underwent follow-up TEE, and 19 (86.4%) patients presented LA or LAA thrombus resolution. The average resolution duration was 258.47 ± 218.17 days. One-year all-cause mortality was 4.9%, and the incidence of ischemic stroke was 4.9%. Most physicians favored titration of the dosage of NOAC or warfarin in real-world practice.

CONCLUSION

In real-world practice, most physicians favored titration of the dosage of NOAC or warfarin for LA or LAA thrombus. LA or LAA thrombus could exist if the patient received a reduced dose of NOAC. High frequency of LAA or LA thrombi could resolve, and a low incidence of ischemic stroke occurred after adjustment of oral anticoagulant treatment.

Risk profiles and pattern of antithrombotic use in patients with non-valvular atrial fibrillation in Thailand: a multicenter study

Background

Anticoagulation therapy is a standard treatment for stroke prevention in patients with non-valvular atrial fibrillation (NVAF) that have risk factors for stroke. However, anticoagulant increases the risk of bleeding, especially in Asians. We aimed to investigate the risk profiles and pattern of antithrombotic use in patients with NVAF in Thailand, and to study the reasons for not using warfarin in this patient population.

Methods

A nationwide multicenter registry of patients with NVAF was created that included data from 24 hospitals located across Thailand. Demographic data, atrial fibrillation-related data, comorbid conditions, use of antithrombotic drugs, and reasons for not using warfarin were collected. Data were recorded in a case record form and then transferred into a web-based system.

Results

A total of 3218 patients were included. Average age was 67.3 ± 11.3 years, and 58.2% were male. Average CHADS₂, CHA₂DS₂-VASc, and HAS-BLED score was 1.8 ± 1.3, 3.0 ± 1.7, and 1.5 ± 1.0, respectively. Antiplatelet was used in 26.5% of patients, whereas anticoagulant was used in 75.3%. The main reasons for not using warfarin in those with CHA₂DS₂-VASc ≥2 included already taking antiplatelet (26.6%), patient preference (23.1%), and using non-vitamin K antagonist oral anticoagulants (NOACs) (22.7%). Anticoagulant was used in 32.3% of CHA₂DS₂-VASc 0, 56.8% of CHA₂DS₂-VASc 1, and 81.6% of CHA₂DS₂-VASc ≥2. The use of NOACs increased from 1.9% in 2014 to 25.6% in 2017.

Conclusions

Anticoagulation therapy was prescribed in 75.3% of patients with NVAF. Among those receiving anticoagulant, 90.9% used warfarin and 9.1% used NOACs. The use of NOACs increased over time.

Electronic supplementary material

The online version of this article (10.1186/s12872-018-0911-4) contains supplementary material, which is available to authorized users.

XANAP: A real-world, prospective, observational study of patients treated with rivaroxaban for stroke prevention in atrial fibrillation in Asia

BACKGROUND

ROCKET AF and its East Asian subanalysis demonstrated that rivaroxaban was non-inferior to warfarin for stroke/systemic embolism (SE) prevention in patients with non-valvular atrial fibrillation (NVAF), with a favorable benefit-risk profile. XANAP investigated the safety and effectiveness of rivaroxaban in routine care in Asia-Pacific.

METHODS

XANAP was a prospective, real-world, observational study in patients with NVAF newly starting rivaroxaban. Patients were followed at ~3-month intervals for 1 year, or for ≥30 days after permanent discontinuation. Primary outcomes were major bleeding events, adverse events (AEs), serious AEs and all-cause mortality; secondary outcomes included stroke/SE. Major outcomes were adjudicated centrally.

RESULTS

XANAP enrolled 2273 patients from 10 countries: mean age was 70.5 years and 58.1% were male. 49.8% of patients received rivaroxaban 20 mg once daily (od), 43.8% 15 mg od and 5.9% 10 mg od. Mean treatment duration was 296 days, and 72.8% of patients had received prior anticoagulation therapy. Co-morbidities included heart failure (20.1%), hypertension (73.6%), diabetes mellitus (26.6%), prior stroke/non-central nervous system SE/transient ischemic attack (32.8%) and myocardial infarction (3.8%). Mean CHADS2, CHA2DS2-VASc and HAS-BLED scores were 2.3, 3.7 and 2.1, respectively. The rates (events/100 patient-years [95% confidence interval]) of treatment-emergent major bleeding, stroke and all-cause mortality were 1.5 (1.0-2.1), 1.7 (1.2-2.5) and 2.0 (1.4-2.7), respectively. Persistence was 66.2% at the study end.

CONCLUSIONS

The real-world XANAP study demonstrated low rates of stroke and bleeding in rivaroxaban-treated patients with NVAF from Asia-Pacific. The results were consistent with the real-world XANTUS study and ROCKET AF.

The size of the renal artery orifice contributes to laterality of acute renal infarction

BACKGROUND

Acute renal infarction (ARI) is a rare disease with atrial fibrillation being its main cause. The possible laterality of ARI is controversial. This study aimed to evaluate the association between anatomical features of the renal arteries and ARI.

METHODS

This was a single-center cross-sectional study that evaluated the anatomical and clinical features of renal arteries. The anatomical features of the renal arteries were assessed using computed tomography.

RESULTS

A total of 46 patients (mean age 71.3 ± 14.0 years; men, 59%) were enrolled. ARI involved the left kidney in 63%, right kidney in 28%, and both kidneys in 9% of patients. The right renal artery orifice was often higher than that of the left renal artery (71%). The angle of divergence from the abdominal aorta was similar on both sides. The left renal artery orifice was larger than that of the right (83 ± 24, 72 ± 24 mm²; p = 0.03, respectively). A larger left orifice was present in 72% of all cases. ARI involved the side with the larger orifice in 64% of patients.

CONCLUSION

The size of the renal artery orifice may be a factor that contributes to the laterality of ARI. Assessment of anatomical features is important when considering the laterality of the disease.

Bleeding risk of apixaban, dabigatran, and low-dose rivaroxaban compared with warfarin in Japanese patients with non-valvular atrial fibrillation: a propensity matched analysis of administrative claims data

OBJECTIVES

There is scarce evidence comparing novel oral anticoagulants (NOACs) with warfarin in real-world settings in Japan. This study compared the risk of bleeding events among patients with non-valvular atrial fibrillation (NVAF) initiating treatment with NOACs versus warfarin.

METHODS

A retrospective cohort study was conducted using a de-identified electronic health record based database of health claims and Diagnosis Procedure Combination data from 275 consenting hospitals in Japan. NVAF patients newly initiated on oral anticoagulants were eligible. Based on the first prescription, patients were assigned to 5/2.5 mg BID apixaban, 150/110 mg BID dabigatran, 15/10 mg QD rivaroxaban (approved dose lower in Japan compared to Western countries [20/15 mg QD]) or warfarin groups. One-to-one propensity score matching (PSM) was used to balance patient characteristics between warfarin and each NOAC. Patients were followed up to 1 year post-first prescription.

RESULTS

Among 38,662 eligible patients, a total of 5977, 5090, and 6726 matched pairs were identified for warfarin versus apixaban, warfarin versus dabigatran, and warfarin versus rivaroxaban, respectively after PSM. Compared to warfarin, apixaban (hazard ratio [HR] 0.586; 95% CI 0.421-0.815), dabigatran (HR 0.617; 0.425-0.895) and rivaroxaban (HR 0.693; 0.514-0.933) were associated with a significantly lower risk of major bleeding. The risk of any bleeding was significantly lower for apixaban (HR 0.782; 0.682-0.896), but not for dabigatran (HR 0.988; 0.860-1.135) or rivaroxaban (HR 0.938; 0.832-1.057) when comparing to warfarin.

CONCLUSIONS

Among Japanese patients with NVAF, treatment with apixaban 5/2.5 mg BID was associated with a significantly lower risk of major bleeding and any bleeding when compared to warfarin. Treatment with dabigatran 150/110 mg BID or rivaroxaban 15/10 mg QD was associated with a significantly lower risk of major bleeding, but not any bleeding, than warfarin. The potential benefit of individual NOACs in real-world practice needs to be assessed further.

DOACs - advances and limitations in real world

The group of new oral anticoagulants or NOACs, now termed direct oral anticoagulants or DOACs, with their favourable results from large scale phase III clinical trials, represent a major advancement and expanded armamentarium in antithrombotic therapy. Dabigatran, rivaroxaban, apixaban and edoxaban are now in clinical routine use for prevention and treatment of arterial and venous thrombotic diseases as addressed in their clinical trials. Usage of the DOACs is expected to increase as clinicians gain more experience and reassurance with data from the real world studies which are generally consistent with that from clinical trials. Development of specific antidotes in management of bleeding complications and development of coagulation assays for their plasma levels will further boost the confidence in the DOACs. Nonetheless, there are still limitations associated with the DOACs. Many patients in need of anticoagulant therapy for indications not studied in the clinical trials will not be eligible for treatment with a DOAC. Conditions where more data is required include DOACs use in the paediatric age group, patients with atrial fibrillation and valvular heart disease, thrombosis associated with the anti-phospholipid syndrome and cancer associated thrombosis. The affordability and access to these drugs may pose an issue for many patients under healthcare systems not providing for these medications. With four new anticoagulants coming onboard very quickly, the focus has shifted to the practical approach and management in real life as many clinicians are not yet familiar with the DOACs. Clinicians need to be educated on how to manage this new class for drugs, from choosing the appropriate drug to prevention and managing bleeding complications as a lack of knowledge and understanding in these drugs will lead to inappropriate use and compromise on patient safety.