Clinical epidemiology of atrial fibrillation and related cerebrovascular events in the United States

Impact of chronic kidney disease on left atrial appendage occlusion: A meta-analysis of procedural outcomes and complications

BACKGROUND

Patients with chronic kidney disease (CKD) experience atrial fibrillation more frequently. The balance of medical management for stroke prevention and bleeding events presents a challenging issue in CKD population. Left atrial appendage occlusion (LAAO) may be an effective solution for stroke prevention in patients who experience frequent bleeding with oral anticoagulants. However, the specific impact of CKD on the procedural success, complications, and outcomes of LAAO implantations remains underexplored.

METHODS

We conducted a search of various databases for articles published before October 31, 2023. This search yielded 7 studies, comparing outcomes between CKD and non-CKD cohorts undergoing LAAO implantation. Our analysis focused on CHA2DS2-VASc scores, average eGFR, use of oral anticoagulants, procedural success rates, procedural complications, and associated outcomes.

RESULTS

The meta-analysis included data from 2576 patients, with 1131 identified as having CKD. The CKD group also had higher CHA2DS2-VASc scores (4.7 ± 1.4 vs 4.0 ± 1.5; P < .001) and HAS-BLED scores (3.8 ± 1.1 vs 3.1 ± 1.0; P < .001) than the non-CKD group. CKD patients showed a nonreduction in procedural success rates and a nonsignificant increase in total complications. The risks of stroke and transient ischemic attack, major bleeding, and cardiovascular mortality were not significantly different between the 2 groups. However, a significantly lower rate of total mortality was observed in the non-CKD group (odds ratio: 0.43; 95% confidence interval, 0.32-0.60).

CONCLUSION

While CKD is associated with a nonsignificant decrease in procedural success and a nonsignificant increase in complication risks, the outcomes of LAAO implantation are comparably favorable between CKD and non-CKD groups. Despite similar procedural outcomes, the CKD group exhibited a higher rate of all-cause mortality.

Comparative effectiveness and safety of apixaban and rivaroxaban in older patients with atrial fibrillation: A population-based cohort study

BACKGROUND

There are no clinical trials with a head-to-head comparison between the 2 most commonly used oral anticoagulants (apixaban and rivaroxaban) in patients with atrial fibrillation (AF). The comparative efficacy and safety between these drugs remain unclear, especially in older patients who are at the highest risk for stroke and bleeding.

OBJECTIVE

The purpose of this study was to compare the risk of major bleeding and thromboembolic events between apixaban and rivaroxaban in older patients with AF.

METHODS

We conducted a population-based retrospective cohort study of all adult patients (66 years or older) with AF in Ontario, Canada, who were treated with apixaban or rivaroxaban between April 1, 2011, and March 31, 2020. The primary safety outcome was major bleeding, and the primary efficacy outcome was thromboembolic events. Secondary outcomes included any bleeding. Rates and hazard ratios (HRs) were adjusted for baseline comorbidities with inverse probability of treatment weighting.

RESULTS

This study included 42,617 patients with AF treated with apixaban and 30,725 patients treated with rivaroxaban. After inverse probability of treatment weighting using the propensity score, patients in the apixaban and rivaroxaban groups were well balanced for baseline values of demographic characteristics, comorbidities, and medications; both groups had a similar mean age of 77.4 years, and 49.9% were female. At 1 year, the apixaban group had a lower risk for both major bleeding with an absolute risk reduction at 1 year of 1.1% (2.1% vs 3.2%; HR 0.65; 95% confidence interval [CI] 0.59-0.71]) and any bleeding (8.1% vs 10.9%; HR 0.73; 95% CI 0.69-0.77), with no difference in the risk for thromboembolic events (2.2% vs 2.2%; HR 1.02; 95% CI 0.92-1.13).

CONCLUSION

In patients with AF, 66 years or older, treatment with apixaban was associated with lower risk for major bleeding, with no difference in the risk for thromboembolic events compared with rivaroxaban.

Relative exposure to psychiatric conditions and medications in pharmacy education

INTRODUCTION

Common psychiatric conditions occur at rates similar to chronic medical conditions. This study aimed to evaluate the exposure to psychiatric disease states as comorbidities in relation to other common chronic conditions within the curriculum at one college of pharmacy.

METHODS

Researchers reviewed course activities for instances of specific conditions as comorbidities. The comorbidities evaluated fell into two categories: psychiatric and non-psychiatric. The primary outcome was the frequency each comorbidity appeared within course content. Secondary outcomes included characterization of instances of comorbidities, including the semester, course topic, and corresponding step of the Pharmacists' Patient Care Process. Prevalence data were analyzed for the health system where students conducted experiential learning.

RESULTS

Overall, hypertension, diabetes, and hyperlipidemia appeared as comorbidities more frequently in the curriculum than depression and anxiety, despite similar prevalence patterns between these conditions. Students received the most exposure to these conditions as comorbidities during team-based learning case activities in therapeutics courses taught during the second professional year.

CONCLUSIONS

This study found that psychiatric conditions were represented as comorbidities less frequently in the curriculum, despite similar prevalence patterns with other common comorbid disease states. With this knowledge, educators may identify potential opportunities for enhancing the curriculum around psychiatric illnesses.

Hybrid Endo-Epicardial Therapies for Advanced Atrial Fibrillation

Atrial fibrillation (AF) is a growing health problem that increases morbidity and mortality, and in most patients progresses to more advanced diseases over time. Recent research has examined the underlying mechanisms, risk factors, and progression of AF, leading to updated AF disease classification schemes. Although endocardial catheter ablation is effective for early-stage paroxysmal AF, it consistently achieves suboptimal outcomes in patients with advanced AF. Identification of the factors that lead to the increased risk of treatment failure in advanced AF has spurred the development and adoption of hybrid ablation therapies and collaborative heart care teams that result in higher long-term arrhythmia-free survival. Patients with non-paroxysmal AF, atrial remodeling, comorbidities, or AF otherwise deemed difficult to treat may find hybrid treatment to be the most effective option. Future research of hybrid therapies in advanced AF patient populations, including those with dual diagnoses, may provide further evidence establishing the safety and efficacy of hybrid endo-epicardial ablation as a first line treatment.

Mortality post in-patient catheter ablation of atrial fibrillation in rural versus urban areas: Insights from national inpatient sample database

BACKGROUND

A growing body of evidence is supportive of early atrial fibrillation (AF) ablation to maintain sinus rhythm. Disparities in health care between rural and urban areas in the United States are well known. Catheter ablation (CA) of AF is a complex procedure and its outcomes among rural versus urban areas has not been studied in the past.

METHODS

The national inpatient sample database 2016-2020 was queried for all hospitalization with the primary diagnosis of AF who underwent AF catheter ablation at the index hospitalization. Then, hospitalizations were stratified into rural versus urban. The primary outcome was in-hospital mortality. Secondary outcomes were total hospitalization costs and likelihood for longer length of stay.

RESULTS

A total of 78,735 patients underwent inpatient CA of AF between January 2016 and December 2020, mean age was 68.5 ± 11 with 44 % being females. 27,180 (35 %) CA were performed in rural areas, while the remaining CA  51,555 (65 %) were done in urban areas. While, there was very low risk of mortality, patients who underwent CA in rural areas had more comorbidities and also was associated with a 79 % increase in post-procedural in-hospital mortality compared with urban areas (aOR 1.79, 0.8 % vs 0.4 %, CI: 1.15-2.78, P < 0.01). CA of AF in rural areas had a longer length of hospital stay (aOR 1.11, 4.21 vs 3.79 days, 95 % CI: 1.02-1.2, P = 0.02), lower overall cost compared with urban areas (49,698 ± 1251 vs. $53,252 ± 1339, P = 0.03). Multivariate regression analysis showed end stage renal disease and congestive heart failure were independent risk factors associated with increase in post CA in-hospital mortality exceeding two-fold.

CONCLUSION

Inpatient CA of AF in rural areas was associated with higher in-hospital mortality, longer length of stay and a lower overall cost when compared with urban areas.

Oral anticoagulation use in non-valvular atrial fibrillation patients in rural setting

Background

The 2019 ACC/AHA/HRS guidelines established direct oral anticoagulants (DOACs) as first line therapy over warfarin for non-valvular atrial fibrillation (AF).

Methods

Ambulatory clinic patients with non-valvular AF or atrial flutter seen between 10/1/2019-7/12/2020 included. High-risk AF defined as males CHA2DS2-VASc score ≥2 and females ≥3. Patients were separated into: warfarin, DOAC, or no oral anticoagulation (OAC). ATRIA bleed score calculated. A provider survey assessing knowledge and barriers to anticoagulation completed via REDCap between 3/5-4/16/2020.

Results

Of 12,014 subjects with AF, 8,032 were high risk (mean age 75.9 ± 9.8 years; 57.5% male). There were 4,619 (57.1%) ≥ 75 years and 63.4% were rural dwelling. There was no significant difference between the number of subjects on anticoagulation before and after the guideline publication (75.6% vs. 75.7%, p = 0.79). Warfarin use decreased 2.3% over 1 year (39.3% to 37.0%), while DOACs increased 2.4% (36.2% to 38.7%, p < 0.001 for both). At 1-year, age, male gender, CHA2DS2-VASc score 4-6, hypertension, stroke and cardiology consult increased prescription of OAC (p<0.05). Vascular disease, high risk ATRIA bleed, renal disease, prior hemorrhage, and left atrial appendage occlusion were associated with decreased OAC use (p < 0.05). Left atrial appendage occlusion device use was low (<1%). In a survey, majority of providers noted bleeding risk (35.1%) and cost (25.0%) to be the biggest barriers to DOAC use.

Conclusions

The new guidelines caused a slight increase in DOACs over time. Significant barriers to DOAC use exist in rural areas; one in four high risk AF patient remains without OAC therapy.

Systemic inflammation indicators and risk of incident arrhythmias in 478,524 individuals: evidence from the UK Biobank cohort

BACKGROUND

The role of systemic inflammation in promoting cardiovascular diseases has attracted attention, but its correlation with various arrhythmias remains to be clarified. We aimed to comprehensively assess the association between various indicators of systemic inflammation and atrial fibrillation/flutter (AF), ventricular arrhythmia (VA), and bradyarrhythmia in the UK Biobank cohort.

METHODS

After excluding ineligible participants, a total of 478,524 eligible individuals (46.75% male, aged 40-69 years) were enrolled in the study to assess the association between systemic inflammatory indicators and each type of arrhythmia.

RESULTS

After covariates were fully adjusted, CRP levels were found to have an essentially linear positive correlation with the risk of various arrhythmias; neutrophil count, monocyte count, and NLR showed a non-linear positive correlation; and lymphocyte count, SII, PLR, and LMR showed a U-shaped association. VA showed the strongest association with systemic inflammation indicators, and it was followed sequentially by AF and bradyarrhythmia.

CONCLUSIONS

Multiple systemic inflammatory indicators showed strong associations with the onset of AF, VA, and bradyarrhythmia, of which the latter two have been rarely studied. Active systemic inflammation management might have favorable effects in reducing the arrhythmia burden and further randomized controlled studies are needed.

Underprescribing vs underfilling to oral anticoagulation: An analysis of linked medical record and claims data for a nationwide sample of patients with atrial fibrillation

BACKGROUND: Oral anticoagulants (OAC) is indicated for stroke prevention in patients with atrial fibrillation (AF) with a moderate or high risk of stroke. Despite the benefits of stroke prevention, only 50%-60% of Americans with nonvalvular AF and a moderate or high risk of stroke receive OAC medication. OBJECTIVE: To understand the extent to which low OAC use by patients with AF is attributed to underprescribing or underfilling once the medication is prescribed. METHODS: This is a retrospective cohort study that used linked claims data and electronic health records from Optum Integrated data. Participants were adults (aged ≥ 18 years) with first AF between January 2013 and June 2017. The outcomes included (1) being prescribed OACs within 180 days of AF diagnosis or not and (2) filling an OAC prescription or not among patients with AF who were prescribed an OAC within 150 days of AF diagnosis. Multivariable logistic regression models were constructed to determine factors associated with underprescribing and underfilling. RESULTS: Of the 6,141 individuals in the study cohort, 51% were not prescribed OACs within 6 months of their AF diagnosis. Of the 2,956 patients who were prescribed, 19% did not fill it at the pharmacy. In the final adjusted model, younger age, location (Northeast and South), a low CHA₂DS₂-VASc score, and a high HAS-BLED score were associated with a lower likelihood of being prescribed OACs. Among patients who were prescribed, Medicare enrollment (odds ratio [OR] [95% CI] = 2.2 [1.3-3.7]) and having a direct oral anticoagulant prescription (1.5 [1.2-1.9]) were associated with a lower likelihood of filling the prescription. CONCLUSIONS: Both underprescribing and underfilling are major drivers of low OAC use among patients with AF, and solutions to increase OAC use must address both prescribing and filling. DISCLOSURES: Research reported in this study was supported by the National Heart, Lung and Blood Institute (K01HL142847 and R01HL157051). Dr Guo is supported by the National Institute of Diabetes and Digestive and Kidney Diseases (R01DK133465), PhMRA Foundation Research Starter Award, and the University of Florida Research Opportunity Seed Fund. Dr Hernandez reports scientific advisory board fees from Pfizer and Bristol Myers Squibb, outside of the submitted work.

Risk Levels and Adverse Clinical Outcomes Among Patients With Nonvalvular Atrial Fibrillation Receiving Oral Anticoagulants

IMPORTANCE

The CHA2DS2-VASc score (calculated as congestive heart failure, hypertension, age 75 years and older, diabetes, stroke or TIA, vascular disease, age 65 to 74 years, and sex category) is the standard for assessing risk of stroke and systemic embolism and includes age and thromboembolic history. To our knowledge, no studies have comprehensively evaluated safety and effectiveness outcomes among patients with nonvalvular atrial fibrillation receiving oral anticoagulants according to independent, categorical risk strata.

OBJECTIVE

To evaluate the incidence of key adverse outcomes among patients with nonvalvular atrial fibrillation receiving oral anticoagulants by CHA2DS2-VASc risk score range, thromboembolic event history, and age group.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was a retrospective claims data analysis using combined data sets from 5 large health claims databases. Eligible participants were adult patients with nonvalvular atrial fibrillation who initiated oral anticoagulants. Data were analyzed between January 2012 and June 2019.

EXPOSURE

Initiation of oral anticoagulants.

MAIN OUTCOMES AND MEASURES

We observed clinical outcomes (including stroke or systemic embolism, major bleeding, and a composite outcome) on treatment through study end, censoring for discontinuation of oral anticoagulants, death, and insurance disenrollment. The population was stratified by CHA2DS2-VASc risk score; history of stroke, systemic embolism, or transient ischemic attack; and age groups. We calculated time to event, incidence rates, and cumulative incidence for outcomes.

RESULTS

We identified 1 141 097 patients with nonvalvular atrial fibrillation; the mean (SD) age was 75.0 (10.5) years, 608 127 patients (53.3%) were men, and over 1 million were placed in the 2 highest risk categories (high risk 1, 327 766 participants; high risk 2, 688 449 participants). Deyo-Charlson Comorbidity Index scores ranged progressively alongside CHA2DS2-VASc risk score strata (mean [SD] scores: low risk, 0.4 [1.0]; high risk 2, 4.1 [2.9]). The crude incidence of stroke and systemic embolism generally progressed alongside risk score strata (low risk, 0.25 events per 100 person-years [95% CI, 0.18-0.34 events]; high risk 2, 3.43 events per 100 person-years [95% CI, 3.06-4.20 events]); patients at the second-highest risk strata with thromboembolic event history had higher stroke incidence vs patients at the highest risk score strata without event history (2.06 events per 100 person-years [95% CI, 2.00-3.12 events] vs 1.18 events per 100 person-years [95% CI, 1.14-1.30 events]). Major bleeding and composite incidence also increased progressively alongside risk score strata (major bleeding: low risk, 0.68 events per 100 person-years [95% CI, 0.56-0.82 events]; high risk 2, 6.29 events per 100 person-years [95% CI, 6.21-6.62 events]; composite incidence: 1.22 events per 100 person-years [95% CI, 1.06-1.41 events]; high risk 2, 10.67 events per 100 person-years [95% CI, 10.26-11.48 events]). The 12-month cumulative incidence proportions for stroke and systemic embolism, major bleeding, and composite outcomes progressed alongside risk score strata (stroke or systemic embolism, 0.30%-1.85%; major bleeding, 0.55%-5.55%; composite, 1.05%-8.23%). Age subgroup analysis followed similar trends.

CONCLUSIONS AND RELEVANCE

The observed incidence of stroke or systemic embolism and major bleeding events generally conformed to an expected increasing incidence by risk score, adding insight into the importance of specific risk score range, thromboembolic event history, and age group strata. These results can help inform clinical decision-making, research, and policy.

Rate versus rhythm control for atrial fibrillation: from AFFIRM to EAST-AFNET 4 - a paradigm shift

The clinical choice between rate or rhythm control therapies has been debated over the years. In 2002, the AFFIRM trial demonstrated that the rhythm-control strategy had no survival advantage over the rate-control strategy. Eighteen years later, EAST-AFNET 4 showed that the rhythm-control approach is better than rate control in reducing adverse cardiovascular outcomes in patients with a recent diagnosis of atrial fibrillation (AF). During the time between AFFIRM and EAST-AFNET 4, rhythm control understanding, specifically ablation, improved, while rate-control strategies remained the same possibly leading to the change in results seen in EAST-AFNET 4. This review seeks to evaluate the rate- and rhythm-control strategies, focusing on the important clinical trials in the past two decades. These trials have shown great advancement in AF management; however, the search for the best approach to controlling AF and minimizing the burden of symptoms is still a work in progress and needs further research.

Pre-existing cardiovascular disease increases risk of atrial arrhythmia and mortality in cancer patients treated with Ibrutinib

Background

Ibrutinib is a Bruton’s tyrosine kinase inhibitor used in the treatment of hematological malignancies. The most common cardiotoxicity associated with ibrutinib is atrial arrhythmia (atrial fibrillation and flutter). It is known that patients with cardiovascular disease (CVD) are at an increased risk for developing atrial arrhythmia. However, the rate of atrial arrhythmia in patients with pre-existing CVD treated with ibrutinib is unknown.

Objective

This study examined whether patients with pre-existing CVD are at a higher risk for developing atrial arrhythmias compared to those without prior CVD.

Methods

A single-institution retrospective chart review of patients with no prior history of atrial arrhythmia treated with ibrutinib from 2012 to 2020 was performed. Patients were grouped into two cohorts: those with CVD (known history of coronary artery disease, heart failure, pulmonary hypertension, at least moderate valvular heart disease, or device implantation) and those without CVD. The primary outcome was incidence of atrial arrhythmia, and the secondary outcomes were all-cause mortality, risk of bleeding, and discontinuation of ibrutinib. The predictors of atrial arrhythmia (namely atrial fibrillation) were assessed using logistic regression. A Cox-Proportional Hazard model was created for mortality.

Results

Patients were followed for a median of 1.1 years. Among 217 patients treated with ibrutinib, the rate of new-onset atrial arrhythmia was nearly threefold higher in the cohort with CVD compared to the cohort without CVD (17% vs 7%, p = 0.02). Patients with CVD also demonstrated increased adjusted all-cause mortality (OR 1.9, 95% CI 1.06-3.41, p = 0.01) and decreased survival probability (43% vs 54%, p = 0.04) compared to those without CVD over the follow-up period. There were no differences in risk of bleeding or discontinuation between the two cohorts.

Conclusions

Pre-existing cardiovascular disease was associated with significantly higher rates of atrial arrhythmia and mortality in patients with hematological malignancies managed with ibrutinib.

Atrial fibrillation in the elderly general population: a 30-year follow-up from 70 to 100 years of age

Objectives. There is limited knowledge of atrial fibrillation (AF) incidence among the very old. Data from longitudinal cohort studies may give us a better insight. The aim of the study was to investigate the incidence rate and prevalence of AF, as well as the impact of AF on mortality, in the general population, from 70 to 100 years of age. Design. This was a population-based prospective cohort study where three representative samples of 70-year-old men and women (n = 2,629) from the Gerontological and Geriatric Populations Studies in Gothenburg (H-70) were included between 1971 and 1982. The participants were examined at age 70 years and were re-examined repeatedly until 100 years of age. AF was diagnosed according to a 12-lead electrocardiogram (ECG) recording at baseline and follow-up examinations, from the Swedish National Patient Register (NPR), or from the Cause of Death Register. Results. The cumulative incidence of AF from 70 to 100 years of age was 65.6% for men and 52.8% for women. Mortality was significantly higher in participants with AF compared with those without, rate ratio (RR) 1.92 (95% CI 1.73-2.14). In a subgroup analysis comprising only participants with AF diagnosed by ECG at screening, the RR for death was 1.29 (95% C.I: 1.03-1.63). Conclusions. Among persons surviving to age 70, the cumulative incidence of AF was over 50% during follow-up. Mortality rate was twice as high in participants with AF compared to participants without AF. Among participants with AF first recorded at a screening examination, the increased risk was only 29%.

Implementation of an emergency department atrial fibrillation and flutter pathway improves rates of appropriate anticoagulation, reduces length of stay and thirty-day revisit rates for congestive heart failure

Objectives

An evidence-based emergency department (ED) atrial fibrillation and flutter (AFF) pathway was developed to improve care. The primary objective was to measure rates of new anticoagulation (AC) on ED discharge for AFF patients who were not AC correctly upon presentation.

Methods

This is a pre-post evaluation from April to December 2013 measuring the impact of our pathway on rates of new AC and other performance measures in patients with uncomplicated AFF solely managed by emergency physicians. A standardized chart review identified demographics, comorbidities, and ED treatments. The primary outcome was the rate of new AC. Secondary outcomes were ED length of stay (LOS), referrals to AFF clinic, ED revisit rates, and 30-day rates of return visits for congestive heart failure (CHF), stroke, major bleeding, and death.

Results

ED AFF patients totalling 301 (129 pre-pathway [PRE]; 172 post-pathway [POST]) were included; baseline demographics were similar between groups. The rates of AC at ED presentation were 18.6% (PRE) and 19.7% (POST). The rates of new AC on ED discharge were 48.6 % PRE (95% confidence interval [CI] 42.1%-55.1%) and 70.2% POST (62.1%-78.3%) (20.6% [p<0.01; 15.1-26.3]). Median ED LOS decreased from 262 to 218 minutes (44 minutes [p<0.03; 36.2-51.8]). Thirty-day rates of ED revisits for CHF decreased from 13.2% to 2.3% (10.9%; p<0.01; 8.1%-13.7%), and rates of other measures were similar.

Conclusions

The evidence-based pathway led to an improvement in the rate of patients with new AC upon discharge, a reduction in ED LOS, and decreased revisit rates for CHF.

Relation of Body Mass Index and Gender to Left Atrial Size and Atrial Fibrillation

Increased body mass index (BMI) and obesity are associated with greater risk of atrial fibrillation (AF). However, whether this correlation is independent and gender specific remains unclear. The objective of this study was to characterize the relation between BMI, left atrial (LA) size, and presence of AF and determine whether this association is gender specific. We prospectively studied 499 patients who underwent a transthoracic echocardiogram at an academic tertiary care medical center. Clinical and echocardiographic data were obtained. The primary outcome of interest was the presence of AF. Of 499 patients studied, 240 (48.1%) were men and 259 (51.9%) were women. Of these, 151 (30.1%) had normal BMI, 181 (36.3%) were overweight, and 167 (33.5%) were obese. Obese patients were younger and had larger LA diameters, LA areas (LAAs), and LA volumes (LAVs). Rates of AF were similar among the BMI classes in the overall population and in men and women separately. In multivariate analysis, BMI and gender were both independently associated with LA diameter, LAA, and LAV. Age (odds ratio 1.02, 95% CI 1.00 to 1.04, p = 0.023) and LA diameter (odds ratio 2.52, 95% CI 1.61 to 3.97, p <0.001) were the only determinants of the presence of AF in the overall population. BMI and gender were not independently associated with AF. In this observational study, our findings demonstrate that higher BMI and male gender were independently associated with greater LA diameter, LAA, and LAV. Older age and greater LA diameter were independently associated with higher rates of AF, whereas BMI and gender were not.

Educational inequalities in mortality of patients with atrial fibrillation in Norway

OBJECTIVES

We explored the educational gradient in mortality in atrial fibrillation (AF) patients.

DESIGN

We prospectively followed patients hospitalized with AF as primary discharge diagnosis in the Cardiovascular Disease in Norway 2008-2012 project. The average length of follow-up was 2.4 years. Mortality by educational level was assessed by Cox proportional hazard models. Population attributable fractions (PAF) were calculated. Analyses stratified by age (≤75 and >75 years of age), and adjusted for age, gender, medical intervention, and Charlson Comorbidity Index.

RESULTS

Of 42,138 AF patients, 16% died by end of 2012. Among younger patients, those with low education (≤10 years) had a HR of 2.3 (95% confidence interval 2.0, 2.6) for all-cause mortality relative to those with any college or university education. Similar results were observed for cardiovascular mortality. Disparities in mortality were greater among younger than older patients. A PAF of 35.9% (95% confidence interval 27.9, 43.1) was observed for an educational level of high school/vocational school or less versus higher education in younger patients.

CONCLUSIONS

Increasing educational level associated with better prognosis suggesting underlying education-related behavioral and medical determinants of mortality. A considerable proportion of mortality within 5 years following hospital discharge could be prevented.

Three-Dimensional Speckle Tracking Imaging for Assessing Left Atrial Function in Hypertensive Patients With Paroxysmal Atrial Fibrillation

Hypertension (HT) is known to be the most prevalent risk factor for paroxysmal atrial fibrillation (PAF), however, its mechanisms have not been fully clarified. Our aim was to investigate the differences in left atrial (LA) function between healthy subjects, and hypertensive patients without PAF (HT-PAF(-)) and with PAF (HT-PAF(+)) using 3-dimensional (3D) speckle tracking imaging (STI). A total of 144 subjects were enrolled: 44 HT-PAF(+) (27 males; mean age 69 ± 10 years), 50 HT-PAF(-) (31 males; mean age 63 ± 11 years), and 50 controls (31 males; mean age 51 ± 14 years). All subjects were in sinus rhythm during the examination. LA volume, LA emptying fraction (LAEF), and LA wall strain were analyzed by 3D area tracking imaging. The maximal value of the global strain curve was defined as the peak global strain. The standard deviation of the time from the R-wave on the electrocardiogram to peak positive values of the segmental strain curves corrected by the R-R' interval in 6 mid LA segments (TP-SD) was calculated to assess LA dyssynchrony. LAEF and peak global strain were lower in HT-PAF(+) than in HT-PAF(-) (P < 0.01) and in the control (P < 0.01). Moreover, TP-SD was higher in HT-PAF(+) than in HT-PAF(-) (P < 0.05) and in the control (P < 0.01). Multivariate analysis revealed LA volume index, peak global strain, and TP-SD were independent determinants of HT-PAF(+). The presence of PAF is associated with diminished LA compliance and advanced mechanical dyssynchrony, as well as LA geometric deformation.

A common data model to assess cardiovascular hospitalization and mortality in atrial fibrillation patients using administrative claims and medical records

Purpose

Atrial fibrillation/flutter (AF) is frequently associated with cardiovascular comorbidities. Observational health care databases are commonly used for research purposes in studies of quality of care, health economics, outcomes research, drug safety, and epidemiology. This retrospective cohort study applied a common data model to administrative claims data (Truven Health Analytics MarketScan^® claims databases [MS-Claims]) and electronic medical records data (Geisinger Health System’s MedMining electronic medical record database [MG-EMR]) to examine the risk of cardiovascular hospitalization and all-cause mortality in relation to clinical risk factors in recent-onset AF and to assess the consistency of analyses for each data source.

Methods

Cohorts of patients with newly diagnosed AF (n=105,262 [MS-Claims] and n=3,919 [MG-EMR]) and demographically similar patients without AF (n=105,262 [MS-Claims] and n=3,872 [MG-EMR]) were followed from the qualifying AF diagnosis until cardiovascular hospitalization, death, database disenrollment, or study completion. A common data model standardized the data in structure, format, content, and nomenclature to allow for systematic assessment and comparison of outcomes from two disparate data sets.

Results

In both databases, AF patients had greater overall baseline comorbidity and higher incidence rates of cardiovascular hospitalization (threefold higher) and all-cause mortality (46% higher) than non-AF patients. For AF patients, incidence rates of cardiovascular hospitalization and all-cause mortality were increased by the concomitant presence of coronary disease, chronic obstructive pulmonary disease, and stroke at baseline. Overall, the pattern of cardiovascular hospitalization in the MS-Claims database was similar to that in the MG-EMR database. Compared with the MS-Claims database, the use of cardiovascular medications and the capture of certain comorbidities among AF patients appeared to be higher in the MG-EMR data set.

Conclusion

Similar standardized analyses across EMR and Claims databases were consistent in the association of AF with acute morbidity and an increased risk of all-cause mortality. Areas of inconsistency were due to differences in underlying population demographics and cardiovascular risks and completeness of certain data fields.

Assessment of atrial synchrony in paroxysmal atrial fibrillation and impact of pulmonary vein isolation for atrial dyssynchrony and global strain by three-dimensional strain echocardiography

BACKGROUND

Atrial fibrillation (AF) is a risk factor for ischemic stroke and congestive heart failure. AF may cause left atrial (LA) dyssynchrony as well as electrical and mechanical remodeling. The aim of this study was to investigate LA dyssynchrony in patients with paroxysmal AF (PAF) and its recovery after pulmonary vein isolation (PVI), using a three-dimensional strain method.

METHODS

Thirty patients with PAF who underwent PVI were enrolled. Three-dimensional echocardiography was performed before and 3 months after PVI. Twenty subjects in whom AF had never been detected served as controls. LA dyssynchrony was quantified by the standard deviation of time to peak strain (TP-SD) from end-diastole by area tracking. Serial changes in TP-SD, LA volume, and global strain in three-dimensional echocardiography were investigated.

RESULTS

In the PAF group, TP-SD was significantly higher (9.19 ± 4.98% vs 4.80 ± 2.30% in controls, P < .02) and global strain significantly lower (48.2 ± 20.2% vs 84.4 ± 32.9% in controls, P = .0003) than in the control group. TP-SD, global strain, and LA volume all improved significantly from before to after PVI (TP-SD, from 9.19 ± 4.98% to 6.31 ± 2.94%, P = .005; global strain, from 48.2 ± 20.2% to 58.1 ± 21.2%, P = .018; LA volume index, 29.5 ± 10.6 to 25.8 ± 7.1 mL/m(2), P = .04). Despite the improvement after PVI, TP-SD was still significantly higher and global strain lower than in controls.

CONCLUSIONS

In patients with PAF, impaired LA function was documented by three-dimensional echocardiography. Despite early LA structural reverse remodeling, LA dyssynchrony was still observed 3 months after PVI. These results may affect medical therapy after successful PVI.

A cluster-randomized controlled trial of a computerized antithrombotic risk assessment tool to optimize stroke prevention in general practice: a study protocol

BACKGROUND

Therapy for stroke prevention in older persons with atrial fibrillation (AF) is underutilized despite evidence to support its effectiveness. To prevent stroke in this high-risk population, antithrombotic treatment is necessary. Given the challenges and inherent risks of antithrombotic therapy, decision-making is particularly complex for clinicians, necessitating comprehensive risk:benefit assessments. Targeted interventions are urgently needed to support clinicians in this context; the Computerized Antithrombotic Risk Assessment Tool (CARAT) offers a unique approach to this clinical problem.

METHODS/DESIGN

This study (a prospective, cluster-randomized controlled clinical trial) will be conducted across selected regions in the state of New South Wales, Australia. Fifty GPs will be randomized to either the 'intervention' or 'control' arm, with each GP recruiting 10 patients (aged ≥65 with AF); target sample size is 500 patients. GPs in the intervention arm will use CARAT during routine patient consultations to: assess risk factors for stroke, bleeding and medication misadventure; quantify the risk/benefit ratio of antithrombotic treatment, identify the recommended therapy, and decide on the treatment course, for an individual patient. CARAT will be applied by the GP at baseline and repeated at 12 months to identify any changes to treatment requirements. At baseline, the participant (patients and GPs) characteristics will be recorded, as well as relevant practice and clinical parameters. Patient follow up will occur at 1, 6, and 12 months via telephone interview to identify changes to therapy, medication side effects, or clinical events.

DISCUSSION

This project tests the utility of a novel decision support tool (CARAT) in improving the use of preventative therapy to reduce the significant burden of stroke. Importantly, it targets the interface of patient care (general practice), addresses the at-risk population, evaluates clinical outcomes, and offers a tool that may be sustainable via integration into prescribing software and primary care services. GP support and guidance in identifying at risk patients for the appropriate selection of therapy is widely acknowledged. This trial will evaluate the impact of CARAT on the prescription of antithrombotic therapy, its longer-term impact on clinical outcomes including stroke and bleeding, and clinicians perceived utility of CARAT in practice.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12613000060741.

The economic burden to medicare of stroke events in atrial fibrillation populations with and without thromboprophylaxis

Some 3 million people in the United States have atrial fibrillation (AF). Without thromboprophylaxis, AF increases overall stroke risk 5-fold. Prevention is paramount as AF-related strokes tend to be severe. Thromboprophylaxis reduces the annual incidence of stroke in AF patients by 22%-62%. However, antithrombotics are prescribed for only about half of appropriate AF patients. The study team estimates the economic implications for Medicare of fewer stroke events resulting from increased thromboprophylaxis among moderate- to high-risk AF patients. The decision model used considers both reduced stroke and increased bleeding risk from thromboprophylaxis for a hypothetical cohort on no thromboprophylaxis (45%), antiplatelets (10%), and anticoagulation (45%). AF prevalence, stroke risk, and stroke risk reduction are adjusted for age, comorbidities, and anticoagulation/antiplatelet status. Health care costs are literature based. At baseline, an estimated 24,677 ischemic strokes, 9127 hemorrhagic strokes, and 9550 bleeding events generate approximately $2.63 billion in annual event-related health care costs to Medicare for every million AF patients eligible for thromboprophylaxis. A 10% increase in anticoagulant use in the untreated population would reduce stroke events by 9%, reduce stroke fatalities by 9%, increase bleed events by 5%, and reduce annual stroke/bleed-related costs to Medicare by about $187 million (7.1%) for every million eligible AF patients. A modest 10% increase in the use of thromboprophylaxis would reduce event-related costs to Medicare by 7.1%, suggesting a compelling economic motivation to improve rates of appropriate thromboprophylaxis. New oral anticoagulants offering better balance between the risks of stroke and major bleeding events may improve these clinical and economic outcomes.

Review of economics and cost-effectiveness analyses of anticoagulant therapy for stroke prevention in atrial fibrillation in the US

OBJECTIVE

To summarize the available evidence on the issues in health economics related to oral anticoagulation for stroke prevention in atrial fibrillation (AF) in the US.

DATA SOURCES

A literature review was performed using PubMed, EMBASE, Cochrane Library, and International Pharmaceutical Abstracts, as well as the websites of professional organizations.

STUDY SELECTION AND DATA EXTRACTION

The search was conducted according to a prespecified protocol, limiting articles to those published in English from 2001 to October 2012 and focused on the economics associated with AF and AF-related stroke in the US. Data from 27 studies were extracted and included in the review.

DATA SYNTHESIS

Strokes in patients with AF are more debilitating and have higher recurrence rates and mortality compared with strokes unrelated to AF. However, data describing the long-term cost of AF-related stroke and stroke subtypes remain limited. The costs of major gastrointestinal (GI) bleeding and intracranial bleeding related to warfarin are significant, whereas the costs of the more frequent minor GI bleeding are relatively low. Overall, the cost-effectiveness of warfarin versus aspirin or no treatment in patients with at least 1 risk factor for stroke is well established. Economic evaluations based on results from randomized controlled clinical trials generally found that new anticoagulants were a cost-effective alternative to warfarin for stroke prevention in AF. However, these cost-effectiveness results are highly sensitive to how well optimal international normalized ratio control is maintained (within target of 2.0-3.0) for warfarin and the time horizon used for analysis. Time in therapeutic range for warfarin in routine clinical practice was lower than in clinical trials, as shown by previous studies.

CONCLUSIONS

This review identified several areas of uncertainty regarding the economic benefit of anticoagulants. The generalizability of cost-effectiveness results of anticoagulant therapy in AF based on clinical trial data must be confirmed by comparative effectiveness research conducted in the real-world setting.

Review of challenges in optimizing oral anticoagulation therapy for stroke prevention in atrial fibrillation

Oral anticoagulant therapy is the mainstay of stroke prevention in patients with atrial fibrillation; it is highly effective at reducing stroke risk, but its use can be limited by increased risk of bleeding. As new oral anticoagulants are available, barriers to optimal use of oral anticoagulation therapy warrant consideration by healthcare professionals and administrators who are seeking to optimize the quality of care for patients with atrial fibrillation. Suboptimal use of oral anticoagulation therapy constitutes an important health problem with significant humanistic and economic consequences. Based on a review of the medical literature published between 2000 and 2011, this article summarizes the literature on the barriers to optimal use of oral anticoagulation therapy, describes the clinical and economic burdens that these barriers add to the burden of atrial fibrillation, and discusses how well the new oral anticoagulants may address some of these issues.

Impact of Metabolic Syndrome on Ablation-Outcome in Patients with Atrial Fibrillation: A Systematic Review

Metabolic syndrome (MS), a pro-inflammatory state with hypertension, diabetes, dyslipidemia and obesity is presumed to be a close associate of atrial fibrillation (AF). However, the exact mechanism by which MS facilitates perpetuation of AF is yet to be fully understood. Moreover, the impact of the components of MS as well as MS as a group, on ablation-outcome in AF is not clearly elucidated until now. This review has compiled the results from major studies that have looked into those risk factors and defined their significance in influencing ablation-outcome in AF. It has also overviewed the impact of life-style changes that might improve the success rate of AF-ablation by effectively addressing the different constituents of MS.

New direct oral anticoagulants--current therapeutic options and treatment recommendations for bleeding complications

To date, clinical studies show that the incidence of spontaneous bleeding with new direct oral anticoagulants (DOAs) is comparable to that of established anticoagulants. However, unlike vitamin K antagonists, there are currently no clinically available antidotes or approved reversal agents for new DOAs. Restoring normal coagulation is important in many cases, such as emergency surgeries, serious bleedings, or anticoagulant overdosing. Attempts have been made to restore normal coagulation after treatment with new DOAs using compounds such as recombinant activated factor VII (rFVIIa), prothrombin complex concentrate (PCC), or FEIBA (factor eight inhibitor bypassing activity). Limited pre-clinical data and even less clinical evidence are available on the usefulness of these methods in restoring normal coagulation for the emergency management of critical bleeding episodes. Evaluating the utility of DOAs is further complicated by the fact that it is unknown how predictive established test systems are of the bleeding risks. Clinical practice requires further evaluation of the emergency management options for the new DOAs to define the agents and the doses that are most useful. Furthermore, patients receiving long-term treatment with a DOA are likely to undergo elective surgery at some point, and there is lack of evidence regarding perioperative treatment regimens under such conditions. This review summarises potential bleeding management options and available data on the new DOAs.

[Potentially inappropriate prescriptions for the elderly: a study of health insurance reimbursements in Southeastern France]

BACKGROUND

This study conducted in the region of Provence-Alpes-Côte d'Azur (PACA) sought to assess the feasibility of constructing and using indicators of potentially inappropriate prescriptions for the elderly from health insurance reimbursement data. We present and discuss different indicators of inappropriate prescriptions for people aged 70 years or older (at-risk prescriptions, dangerous or at-risk coprescriptions, absence of necessary coprescriptions) and reports their prevalence in PACA.

METHODS

The indicators were constructed from the French list of inappropriate prescriptions, national agency guidelines, and the advice of experts in the field. The indicators selected were applied to the databases of the PACA Salaried Workers' Health Insurance Fund for 2008 for all recipients aged 70 years or older and compared according to age, sex, chronic disease status, and, after standardization for age and sex, according to district of residence.

RESULTS

In January 2009, 500,904 recipients aged 70 years or older were identified in the data base of the Salaried Workers' Health Insurance Fund, 60.8% of whom were women and 52.1% of whom had approved coverage for a chronic disease. The potentially inappropriate prescriptions most frequently observed here, in decreasing order, were: prescription of an NSAID without the coprescription of gastric protection (28.1%); long-term benzodiazepine treatment (21.5%); prescription of long half-life benzodiazepine (14.9%), and long-term treatment with NSAIDs (11.6%). Overall, the prevalence of each increased significantly with age and was higher among women and people with chronic diseases. Significant variations were also observed between the different districts of PACA.

CONCLUSION

Our results confirm that a substantial proportion of elderly people receive potentially inappropriate prescriptions. They also suggest that health insurance reimbursement data could be used in some prescription domains for monitoring trends in the potentially inappropriate prescriptions in the populations of various territories, provided that specific limitations are considered.

Metabolic stress, reactive oxygen species, and arrhythmia

Cardiac arrhythmias can cause sudden cardiac death (SCD) and add to the current heart failure (HF) health crisis. Nevertheless, the pathological processes underlying arrhythmias are unclear. Arrhythmic conditions are associated with systemic and cardiac oxidative stress caused by reactive oxygen species (ROS). In excitable cardiac cells, ROS regulate both cellular metabolism and ion homeostasis. Increasing evidence suggests that elevated cellular ROS can cause alterations of the cardiac sodium channel (Na(v)1.5), abnormal Ca(2+) handling, changes of mitochondrial function, and gap junction remodeling, leading to arrhythmogenesis. This review summarizes our knowledge of the mechanisms by which ROS may cause arrhythmias and discusses potential therapeutic strategies to prevent arrhythmias by targeting ROS and its consequences. This article is part of a Special Issue entitled "Local Signaling in Myocytes".

Thirty-day outcomes of emergency department patients undergoing electrical cardioversion for atrial fibrillation or flutter

OBJECTIVES

While the short-term (<7-day) safety and efficiency of electrical cardioversion for emergency department (ED) patients with atrial fibrillation or flutter have been established, the 30-day outcomes with respect to stroke, thromboembolic events, or death have not been investigated.

METHODS

A two-center cohort of consecutive ED patients undergoing cardioversion for atrial fibrillation or flutter between January 1, 2000, and September 30, 2007, was retrospectively investigated. This cohort was probabilistically linked with both a regional ED database and the provincial health registry to determine which patients had a subsequent ED visit or hospital admission, stroke, or thromboembolic event or died within 30 days. In addition, trained reviewers performed a detailed chart abstraction on 150 randomly selected patients, with emphasis on demographics, vital signs, medical treatment, and predefined adverse events. Hemodynamically unstable patients or those whose condition was the result of an underlying acute medical diagnosis were excluded. Data were analyzed by descriptive methods.

RESULTS

During the study period, 1,233 patients made 1,820 visits for atrial fibrillation or flutter to the ED. Of the 400 eligible patients undergoing direct-current cardioversion (DCCV), no patients died, had a stroke, or had a thromboembolic event in the following 30 days (95% confidence interval [CI] = 0.0 to 0.8% for all outcomes). A total of 141 patients were included in the formal chart review, with five patients (3.5%, 95% CI = 0.5% to 6.6%) failing cardioversion, six patients (4.3%, 95% CI = 0.9% to 7.6%) having a minor adverse event that did not change disposition, and five patients (3.5%, 95% CI = 0.5% to 6.6%) admitted to hospital at the index visit.

CONCLUSIONS

Cardioversion of patients with atrial fibrillation or flutter in the ED appears to have a very low rate of long-term complications.

Role of transesophageal echocardiography among patients with atrial fibrillation undergoing electrophysiology testing

External or internal shocks administered to terminate ventricular arrhythmias as a part of electrophysiology or implantable cardioverter-defibrillator testing, can inadvertently cardiovert atrial fibrillation (AF). Moreover, anticoagulation therapy is often withheld in these patients in anticipation of an invasive procedure. The risk of embolic events during these procedures has not been well described. Accordingly, the present study was a prospective evaluation of the incidence of left atrial (LA) thrombus and AF cardioversion among patients undergoing ventricular arrhythmia assessment. Transesophageal echocardiography was routinely performed on 44 consecutive patients in AF with subtherapeutic anticoagulation undergoing electrophysiology or implantable cardioverter-defibrillator testing. Arrhythmia induction was not performed when LA thrombus was present. The incidence and clinical predictors of thrombus, the inadvertent cardioversion of AF, and adverse events related to the procedure were assessed during the subsequent 4 to 6 weeks. Left atrial thrombus was observed in 12 patients (27%). Sinus rhythm was restored in 29 patients (91%), at least transiently, who underwent testing with a shock delivered. No adverse neurologic or hemorrhagic complications were observed. Univariate analysis identified no predictors of LA thrombus or cardioversion to sinus rhythm. In conclusion, LA thrombus and cardioversion to sinus rhythm are common among patients with AF undergoing an evaluation of ventricular arrhythmias. Transesophageal echocardiography performed before the procedure in patients with subtherapeutic anticoagulation is warranted to minimize embolic complications. This strategy appears to be a safe method to guide diagnostic testing in this patient population.

Redox regulation, NF-kappaB, and atrial fibrillation

Atrial fibrillation (AF) is the most common clinically encountered abnormal heart beat. It is associated with an increased risk of stroke and symptoms of heart failure. Current therapies are directed toward controlling the rate of ventricular activation and preventing strokes through anticoagulation. Attempts at suppressing the arrhythmia are often ineffective, in part because the underlying pathogenesis is poorly understood. Recently, structural and electrical remodeling has been shown to occur during AF. These changes involve alterations in gene regulation and help perpetuate the arrhythmia. Some signals for remodeling are have been identified. Moreover, AF is associated with oxidative stress, and this redox imbalance may contribute to the altered gene regulation. One likely mediator of this change in transcriptional regulation is the redox sensitive transcription factor, nuclear factor-kappaB (NF-kappaB). Recently, NF-kappaB has been shown to downregulate transcription of the cardiac sodium channel in response to oxidative stress. NF-kappaB may contribute to the regulation of other ion channels, transcription factors, or splicing factors altered in AF and may represent a therapeutic target in AF management.

Reducing the risk of stroke in type 2 diabetes: pathophysiological and therapeutic perspectives

Reducing the excess cerebrovascular burden in patients with type 2 diabetes remains a major therapeutic challenge, especially with respect to the high risk of recurrent events. Targeting the traditional metabolic risk factors of hypertension, dyslipidemia, and hyperglycemia has failed to remove this excess risk, and agents targeting thrombotic risk (i.e., antiplatelet and anticoagulant drugs) remain poorly studied in the context of stroke in diabetes. This may relate to the accumulation of risk factors in type 2 diabetes as well as to diabetes-specific pathophysiologic factors. Regrettably, there is a lack of prospective evidence to support the efficacy of interventions in the secondary prevention of cerebrovascular events in type 2 diabetes, particularly recurrent stroke events. Overall, there is a need for rigorous evaluations of new therapeutic approaches in both primary and secondary prevention of stroke and management of acute stroke in patients with type 2 diabetes. This systematic review of the published literature summarizes the evidence regarding current therapeutic interventions and their impact on the risk of stroke in people with type 2 diabetes, and highlights potential strategies for improving outcomes.

Does treatment of hypertension decrease the incidence of atrial fibrillation and cardioembolic stroke?

Hypertension is the most common disease affecting humans. Statistical surveys indicate that approximately one billion individuals worldwide suffer from this serious condition. The spotlight of the present review is on the cardiac involvement in patients with hypertension and especially on the possibility that treatment of increased blood pressure may abolish the incidence of cardiac arrhythmia and particularly atrial fibrillation. Modern therapeutic approach based on the electrical and structural remodeling process in the hypertensive heart with a consequent administration of ACE inhibitors and AT1 receptor blockers represent new and more efficient option compared to other antihypertensive drugs, such as calcium channel blockers, beta-blockers and thiazide-type diuretics and might be useful in the prevention of atrial fibrillation and incidence of stroke.

Review: Stroke in type 2 diabetes

Stroke is the second most frequent cause of death worldwide and the most frequent cause of permanent disability. Patients with diabetes are at 1.5 to three times the risk of stroke compared with the general population. Cerebrovascular disease causes 20% of deaths in diabetic patients. Interestingly, there are some striking differences of stroke patterns between diabetic and non-diabetic subjects suffering a stroke. Even more important is the fact that diabetes dramatically increases the risk of stroke in younger subjects as well as women. These data highlight the need for detection and treatment of diabetes particularly in these patient groups. This review summarises several aspects of stroke in type 2 diabetes, focusing on differences from non-diabetic stroke.