Depression and Uptake of Oral Anticoagulation Therapy in Patients With Atrial Fibrillation: A Danish Nationwide Cohort Study

Global epidemiology of mental disorder in atrial fibrillation between 1998-2021: A systematic review and meta-analysis

BACKGROUND

As the burden of mental disorders among patients with atrial fibrillation (AF) increases, researchers are beginning to pay close attention to the risk and prevalence of these comorbidities. Although studies have independently analyzed the risk of comorbidity with depression and anxiety in patients with AF, no study has systematically focused on the global epidemiology of these two mental disorders.

AIM

To explore the prevalence of depression and anxiety in patients with AF.

METHODS

Five databases were searched from their date of establishment until January 2023. Observational studies reporting the comorbidity of AF with depression and anxiety, were included in this study. Basic information, such as the first author/ publication year, study year, study type, and prevalence of depression and anxiety, were extracted. STATA SE 15.1 was used to analyze the data. Subgroup, meta-regression, and sensitivity analyses were performed to estimate study heterogeneity.

RESULTS

After a thorough search, 26 studies were identified and included in this meta-analysis. The prevalence rates of depression and anxiety in adults with AF were 24.3% and 14.5%, respectively. Among adult males with AF, the prevalence was 11.7% and 8.7%, respectively, whereas in females it was 19.8% and 10.1%, respectively. In older adults with AF, the prevalence rates of depression and anxiety were 40.3% and 33.6%, respectively. The highest regional prevalence of depression and anxiety was observed in European (30.2%) and North American (19.8%) patients with AF.

CONCLUSION

In this study, we found that the prevalence of depression and anxiety among patients with AF varies with sex, region, and evaluation scales, suggesting the need for psychological interventions for patients with AF in clinical practice.

Social and psychological risk factors for decreased adherence among patients with atrial fibrillation

Adherence has a direct impact on reducing the effectiveness of atrial fibrillation therapy and increasing the risk of thromboembolic events. Among the factors involved in the decrease of adherence, the social and psychological characteristics of patients remain insufficiently studied. At the same time, the available publications allow us to conclude that there are markers of the risk of reduced adherence in patients with atrial fibrillation, which include age, cognitive impairment, psychoemotional disorders (including depression and anxiety) and specific behavioral patterns.

Association Between Newly Diagnosed Atrial Fibrillation and Work Disability (from a Nationwide Danish Cohort Study)

It is previously shown that cardiovascular conditions have a negative effect on the ability to work. However, it is unknown if incident atrial fibrillation (AF) influences the ability to work. We examined the association between AF and the risk of work disability and the influence of socioeconomic factors. All Danish residents with a hospital diagnosis of AF and aged ≥30 and ≤63 years in the period January 1, 2000, to September 31, 2014, were included and matched 1:10 with an AF-free gender and age-matched random person from the general population. Permanent social security benefit was used as a marker of work disability. Risk difference (RD) and 95% confidence interval (95% CI) of work disability were calculated over 15 months. The analyses were furthermore stratified in low, medium, and high levels of socioeconomic factors. In total, 28,059 patients with AF and 312,667 matched reference persons were included. The risk of receiving permanent social security benefits within 15 months was 4.5% (4.3% to 4.8%) for the AF cohort and 1.3% (95% CI 1.3% to 1.4%) for the matched reference cohort. Adjusted RD (95% CI) was 2.3% (2.0% to 2.5%). Stratified on income, RDs were higher in low-income groups (adjusted RD 3.7% [95% CI 3.1% to 4.3%]) versus high-income groups (RD 1.3% [1.0% to 1.5%]). In conclusion, the risk of work disability within 15 months after incident AF was more than 3 times as high in patients with AF compared with the general population, especially when comparing individuals in lower socioeconomic strata.

Mental Health Conditions and Nonpersistence of Direct Oral Anticoagulant Use in Patients With Incident Atrial Fibrillation: A Nationwide Cohort Study

Background

Mental health conditions (MHCs) are associated with poor outcomes in patients with atrial fibrillation. However, persistence of oral anticoagulation therapy in patients with atrial fibrillation and MHCs is unknown. We aimed to evaluate the effect of MHCs on the persistence of direct oral anticoagulant (DOAC) use in patients with atrial fibrillation based on a nationwide cohort.

Methods and Results

The nationwide registry‐based FinACAF (Finnish Anticoagulation in Atrial Fibrillation) cohort included 67 503 patients with incident atrial fibrillation and indication for permanent oral anticoagulation (CHA₂DS₂‐VASc score >1 in men and >2 in women) starting DOAC therapy between 2011 and 2018. MHCs of interest were depression, bipolar disorder, anxiety disorder, schizophrenia, and composite of any MHC. The main outcome was nonpersistence of DOAC use, defined as the first 120‐day period without DOAC purchases after drug initiation. The mean age of the patients was 75.3±8.9 years, 53.6% were women, and the prevalence of any MHC was 17.8%. Persistence after 1 year from DOAC initiation was 79.3% in patients without MHCs and 77.2% in patients with any MHC, and after 2 years were 64.4% and 60.6%, respectively (P<0.001). Higher incidence of nonpersistence to DOACs was observed in all MHC categories: adjusted subdistribution hazard ratios, 1.16 (95% CI, 1.11–1.21) for any MHC, 1.32 (95% CI, 1.22–1.42) for depression, 1.44 (95% CI, 1.15–1.80) for bipolar disorder, 1.25 (95% CI, 1.11–1.41) for anxiety disorder, and 1.30 (95% CI, 1.02–1.64) for schizophrenia. However, patients with only anxiety disorder without other MHCs were not at higher risk of nonpersistence.

Conclusions

MHCs are associated with nonpersistence of DOAC use.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04645537.

The effect of mental health conditions on the use of oral anticoagulation therapy in patients with atrial fibrillation: The FinACAF Study

Aims

Little is known about the effects of mental health conditions (MHCs) on the utilization of oral anticoagulation (OAC) therapy in atrial fibrillation (AF) patients. We aimed to assess whether MHCs affect initiation of OAC therapy among AF patients with special focus on non-vitamin K antagonist oral anticoagulants (NOACs).

Methods and results

The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) registry included all 239 222 patients diagnosed with incident AF during 2007–18 in Finland identified from national registries covering primary to tertiary care and drug purchases. Patients with previous depression, bipolar disorder, anxiety disorder, or schizophrenia diagnosis or a fulfilled psychiatric medication prescription within the year preceding the AF diagnosis were classified to have any MHC. The main outcome was OAC initiation, defined as first fulfilled OAC prescription after AF diagnosis. The patients’ mean age was 72.7 years and 49.8% were female. The prevalence of any MHC was 19.9%. A lower proportion of patients with any MHC compared with those without MHCs were initiated on OAC therapy (64.9% vs. 73.3%, P < 0.001). Any MHC was associated with lower incidence of OAC initiation [adjusted subdistribution hazard ratio (aSHR) 0.867; 95% confidence interval (CI) 0.856–0.880], as were depression (aSHR 0.868; 95% CI 0.856–0.880), bipolar disorder (aSHR 0.838; 95% CI 0.824–0.852), anxiety disorder (aSHR 0.840; 95% CI 0.827–0.854), and schizophrenia (aSHR 0.838; 95% CI 0.824–0.851), during the entire follow-up. Any MHC remained associated with impaired incidence of OAC initiation also in the NOAC era during 2015–18 (aSHR 0.821; 95% CI 0.805–0.837).

Conclusion

MHCs are common among AF patients, and they are associated with a lower rate of OAC initiation even during the NOAC era.

The impact of mental health conditions on oral anticoagulation therapy and outcomes in patients with atrial fibrillation: A systematic review and meta-analysis

One third of patients with atrial fibrillation (AF) are estimated to suffer from mental health conditions (MHCs). We conducted a systematic review and meta-analysis to investigate the impact of MHCs on the prevalence and quality of oral anticoagulation (OAC) therapy and outcomes in patients with AF. Medline database was searched for studies published before March 1st 2021 evaluating AF patients with comorbid MHCs reporting on the prevalence of OAC therapy, time in therapeutic range (TTR) in warfarin-receiving patients, adherence to OAC therapy or adverse outcomes (ischemic stroke, hemorrhage or mortality). Studies reporting on outcome events were included in the meta-analysis. The literature search yielded 17 studies including 977,535 patients that fulfilled the inclusion criteria of this review. AF patients with MHCs had a lower prevalence of OAC use and poorer TTR compared with patients without MHCs. Evidence on OAC quality in patients receiving direct oral anticoagulants (DOACs) was minimal and inconclusive. A decrease in depression-associated deficit in OAC prevalence was observed after the introduction of DOACs. Pooled analysis of five studies reporting on outcomes showed that MHCs were an independent risk factor for both stroke (RR 1.25, 95%CI 1.08-1.45, I² 0%) and major bleeding (RR 1.17, 95%CI 1.08-1.27, I² 27%). Data on mortality were lacking and therefore not included in the meta-analysis. Evidence on the impact of specific MHCs on the outcomes were inadequate. In conclusion, MHCs are independent risk factors for stroke and major bleeding in patients with AF. Future studies are needed to confirm the findings of this meta-analysis, to evaluate the prognostic impact of different MHCs and to clarify whether the introduction of DOACs might have improved the outcomes of these patients.

Association Between Bipolar Disorder or Schizophrenia and Oral Anticoagulation Use in Danish Adults With Incident or Prevalent Atrial Fibrillation

IMPORTANCE

Individuals with bipolar disorder or schizophrenia have a higher risk of adverse outcomes from cardiovascular diseases. Oral anticoagulation therapy (OAT) for patients with atrial fibrillation (AF) is needed for stroke prevention, but whether patients with bipolar disorder or schizophrenia face disparities in receiving this therapy is unknown.

OBJECTIVE

To assess whether bipolar disorder or schizophrenia is associated with a lower rate of OAT initiation in patients with incident AF and lower prevalence of OAT in those with prevalent AF.

DESIGN, SETTING, AND PARTICIPANTS

A nationwide cohort study of Danish patients with AF was conducted from January 1, 2005, to December 31, 2016, and data were analyzed from January 1 to June 15, 2020. Data from national registries included information on all redeemed prescriptions and all hospital contacts of all patients with incident or prevalent AF (age, 18-100 years) and increased risk status, defined by a CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, stroke or transient ischemic attack, vascular disease, age 65-74 years, sex category) risk score greater than or equal to 2.

EXPOSURES

Hospital diagnosis of bipolar disorder or schizophrenia.

MAIN OUTCOMES AND MEASURES

Adjusted proportion differences for OAT initiation and OAT prevalence, comparing individuals with and without bipolar disorder or schizophrenia.

RESULTS

Patients included with incident AF (n = 147 810) had a mean (SD) age of 76.9 (10.1) years, 78 577 (53.2%) were women, 1208 (0.8%) had bipolar disorder, and 572 (0.4%) had schizophrenia. Accounting for age, sex, and calendar time, bipolar disorder and schizophrenia were associated with significantly lower frequency of OAT initiation within 90 days after incident AF (bipolar disorder: -12.7%; 95% CI, -15.3% to -10.0%; schizophrenia: -24.5%; 95% CI, -28.3% to -20.7%) and lower OAT prevalence in patients with prevalent AF (bipolar disorder: -11.6%; 95% CI, -13.9% to -9.3% schizophrenia: -21.6%; 95% CI, -24.8% to -18.4%). Adjusting for socioeconomic factors and other comorbid conditions attenuated these associations, particularly for patients with bipolar disorder. However, schizophrenia continued to be associated with a with a lower rate of OAT initiation (-15.5%, 95% CI, -19.3% to -11.7%) and a -12.8% (95% CI, -15.9% to -9.7%) lower OAT prevalence. These associations were also present after the introduction of non-vitamin K antagonists (adjusted proportion difference in 2013-2016: -12.4%; 95% CI, -18.7% to -6.1% for initiation and -10.1%; 95% CI, -13.8% to -6.4% for prevalence).

CONCLUSIONS AND RELEVANCE

In this study, patients with bipolar disorder or schizophrenia were less likely to receive OAT in the setting of AF. For patients with bipolar disorder, this deficit was largely associated with socioeconomic factors and comorbidities, especially toward the end of the study period. For patients with schizophrenia, disparities in this stroke prevention therapy persistently exceeded what could be explained by other patient characteristics.

Atrial fibrillation in older patients and artificial intelligence: a quantitative demonstration of a link with some of the geriatric multidimensional assessment tools-a preliminary report

Atrial fibrillation (AF) associates with disability and frailty. Aim of this study was to evaluate in older AF patients, using artificial intelligence (AI), the relations between geriatric tools and daily standing and resting periods. We enrolled thirty-one > 65 years patients undergoing electrical cardioversion of AF (age: 79 ± 6 years; women: 41.9%; CHA₂DS₂-VASc: 3.7 ± 1.2; MMSE: 27.7 ± 2.7; GDS: 3.0 ± 2.8). The data of the first day following the procedure were analyzed using machine-learning techniques in a specifically designed cloud platform. Standing, activity, time (582 ± 139 min) was directly associated with MMSE and inversely with GDS. Sleep length was 472 ± 230 min. Light sleep, the longer resting phase, was inversely related to GDS. The Chest Effort Index, a measure of obstructive sleep apnea, grew with GDS. In conclusion, AI devices can be routinely used in improving older subjects' evaluation. A correlation exists between standing time, MMSE, and depressive symptoms. GDS associates to length and quality of sleep.