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Hou Y, Yang H, Xu Y, Wang K, Fu Y, Lu Z. Hearing disorders, genetic predisposition, and risk of new-onset atrial fibrillation: A prospective cohort study in the UK biobank. Int J Cardiol 2024; 401:131829. [PMID: 38320667 DOI: 10.1016/j.ijcard.2024.131829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 01/02/2024] [Accepted: 02/01/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common sustained arrhythmia and is associated with significant morbidity and mortality. Hearing impairment has been linked to several cardiovascular diseases. However, the association between hearing disorders, genetic predisposition, and new-onset AF remains largely unknown. METHODS A total of 476,773 participants (mean age 56.5 years) free of AF at baseline (from 2006 to 2010) were included from the UK Biobank study. The presence of hearing disorders including hearing difficulty and tinnitus was self-reported through the touchscreen questionnaire. AF was defined using ICD-10 code: I48 and was followed till February 1st. 2022. The Cox model was used to calculate hazard ratios (HRs) and 95% confidence intervals (95% CI). RESULTS During a median follow-up of 13.0 years, the AF incidence rate was 2.9 per 1000 person-years. After adjustments for potential confounders, the presence of hearing difficulty (HR, 1.35; 95% CI: 1.32-1.39) and the use of hearing aid (1.45; 1.37-1.53) were significantly associated with risk of new-onset AF. Compared to individuals without tinnitus, the AF risk increased by 17% among those who experienced tinnitus occasionally (1.17; 1.09-1.25), 23% among those who experienced tinnitus frequently (1.23; 1.10-1.39), and 32% among those who experienced tinnitus consistently (1.32; 1.22-1.42). No significant difference was observed across different groups of genetic risk score for AF onset. CONCLUSIONS Our study provides evidence regarding significant associations of hearing difficulty, use of hearing aid, and tinnitus with risk of incident AF. Findings highlight the potential that screening hearing disorders can benefit AF prevention.
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Affiliation(s)
- Yabing Hou
- Department of Medical Information Technology and Management, Yanjing Medical College, Capital Medical University, Beijing, China
| | - Hongxi Yang
- Department of Bioinformatics, School of Basic Medical Sciences, Tianjin Medical University, Tianjin, China
| | - Yanning Xu
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Kan Wang
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Yinghong Fu
- Department of Medical Information Technology and Management, Yanjing Medical College, Capital Medical University, Beijing, China
| | - Zuolin Lu
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands; School of Population Medical and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
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Ijaz N, Jamil Y, Brown CH, Krishnaswami A, Orkaby A, Stimmel MB, Gerstenblith G, Nanna MG, Damluji AA. Role of Cognitive Frailty in Older Adults With Cardiovascular Disease. J Am Heart Assoc 2024; 13:e033594. [PMID: 38353229 PMCID: PMC11010094 DOI: 10.1161/jaha.123.033594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 12/19/2023] [Indexed: 02/21/2024]
Abstract
As the older adult population expands, an increasing number of patients affected by geriatric syndromes are seen by cardiovascular clinicians. One such syndrome that has been associated with poor outcomes is cognitive frailty: the simultaneous presence of cognitive impairment, without evidence of dementia, and physical frailty, which results in decreased cognitive reserve. Driven by common pathophysiologic underpinnings (eg, inflammation and neurohormonal dysregulation), cardiovascular disease, cognitive impairment, and frailty also share the following risk factors: hypertension, diabetes, obesity, sedentary behavior, and tobacco use. Cardiovascular disease has been associated with the onset and progression of cognitive frailty, which may be reversible in early stages, making it essential for clinicians to diagnose the condition in a timely manner and prescribe appropriate interventions. Additional research is required to elucidate the mechanisms underlying the development of cognitive frailty, establish preventive and therapeutic strategies to address the needs of older patients with cardiovascular disease at risk for cognitive frailty, and ultimately facilitate targeted intervention studies.
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Affiliation(s)
- Naila Ijaz
- Thomas Jefferson University HospitalPhiladelphiaPAUSA
| | - Yasser Jamil
- Yale University School of MedicineNew HavenCTUSA
| | | | | | - Ariela Orkaby
- New England GRECC, VA Boston Healthcare SystemBostonMAUSA
- Division of AgingBrigham & Women’s Hospital, Harvard Medical SchoolBostonMAUSA
| | | | | | | | - Abdulla A. Damluji
- Johns Hopkins University School of MedicineBaltimoreMDUSA
- The Inova Center of Outcomes ResearchInova Heart and Vascular InstituteFalls ChurchVAUSA
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Zhang S, Zhang N, Liu L, Zheng W, Ma ZL, Qiao SY, Zhao YL, Wei YH, Wu G, Yu QT, Deng B, Shen L. Global epidemiology of mental disorder in atrial fibrillation between 1998-2021: A systematic review and meta-analysis. World J Psychiatry 2024; 14:179-193. [PMID: 38327890 PMCID: PMC10845231 DOI: 10.5498/wjp.v14.i1.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 11/27/2023] [Accepted: 12/20/2023] [Indexed: 01/19/2024] Open
Abstract
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.
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Affiliation(s)
- Shuai Zhang
- Department of Cardiology, LongHua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
| | - Na Zhang
- Department of Cardiology, LongHua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
| | - Liu Liu
- Department of Dermatology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai 200437, China
| | - Wang Zheng
- Department of Cardiology, LongHua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
| | - Zi-Lin Ma
- Department of Cardiology, LongHua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
| | - Si-Yu Qiao
- Department of Cardiology, LongHua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
| | - Ying-Li Zhao
- Department of Cardiology, LongHua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
| | - Yi-Hong Wei
- Department of Cardiology, LongHua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
| | - Gang Wu
- Department of Cardiology, LongHua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
| | - Qiu-Ting Yu
- Department of Cardiology, LongHua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
| | - Bing Deng
- Department of Cardiology, LongHua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
| | - Lin Shen
- Department of Cardiology, LongHua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China
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Bhatt IS, Ramadugu SK, Goodman S, Bhagavan SG, Ingalls V, Dias R, Torkamani A. Polygenic Risk Score-Based Association Analysis of Speech-in-Noise and Hearing Threshold Measures in Healthy Young Adults with Self-reported Normal Hearing. J Assoc Res Otolaryngol 2023; 24:513-525. [PMID: 37783963 PMCID: PMC10695896 DOI: 10.1007/s10162-023-00911-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 09/08/2023] [Indexed: 10/04/2023] Open
Abstract
PURPOSE Speech-in-noise (SIN) traits exhibit high inter-subject variability, even for healthy young adults reporting normal hearing. Emerging evidence suggests that genetic variability could influence inter-subject variability in SIN traits. Genome-wide association studies (GWAS) have uncovered the polygenic architecture of various adult-onset complex human conditions. Polygenic risk scores (PRS) summarize complex genetic susceptibility to quantify the degree of genetic risk for health conditions. The present study conducted PRS-based association analyses to identify PRS risk factors for SIN and hearing threshold measures in 255 healthy young adults (18-40 years) with self-reported normal hearing. METHODS Self-reported SIN perception abilities were assessed by the Speech, Spatial, and Qualities of Hearing Scale (SSQ12). QuickSIN and audiometry (0.25-16 kHz) were performed on 218 participants. Saliva-derived DNA was used for low-pass whole genome sequencing, and 2620 PRS variables for various traits were calculated using the models derived from the polygenic risk score (PGS) catalog. The regression analysis was conducted to identify predictors for SSQ12, QuickSIN, and better ear puretone averages at conventional (PTA0.5-2), high (PTA4-8), and extended-high (PTA12.5-16) frequency ranges. RESULTS Participants with a higher genetic predisposition to HDL cholesterol reported better SSQ12. Participants with high PRS to dementia revealed significantly elevated PTA4-8, and those with high PRS to atrial fibrillation and flutter revealed significantly elevated PTA12.5-16. CONCLUSION These results indicate that healthy individuals with polygenic risk of certain health conditions could exhibit a subclinical decline in hearing health measures at young ages, decades before clinically meaningful SIN deficits and hearing loss could be observed. PRS could be used to identify high-risk individuals to prevent hearing health conditions by promoting a healthy lifestyle.
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Affiliation(s)
- Ishan Sunilkumar Bhatt
- Department of Communication Sciences & Disorders, University of Iowa, 250 Hawkins Dr, Iowa City, IA, 52242, USA.
| | - Sai Kumar Ramadugu
- Department of Communication Sciences & Disorders, University of Iowa, 250 Hawkins Dr, Iowa City, IA, 52242, USA
| | - Shawn Goodman
- Department of Communication Sciences & Disorders, University of Iowa, 250 Hawkins Dr, Iowa City, IA, 52242, USA
| | - Srividya Grama Bhagavan
- Department of Communication Sciences & Disorders, University of Iowa, 250 Hawkins Dr, Iowa City, IA, 52242, USA
| | - Valerie Ingalls
- Department of Communication Sciences & Disorders, University of Iowa, 250 Hawkins Dr, Iowa City, IA, 52242, USA
| | - Raquel Dias
- Department of Microbiology and Cell Science, University of Florida, Gainesville, FL, 32608, USA
| | - Ali Torkamani
- Department of Integrative Structural and Computational Biology, Scripps Science Institute, La Jolla, CA, 92037, USA
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Wang W, Lessard D, Kiefe CI, Goldberg RJ, Parish D, Helm R, Trymbulak K, Mehawej J, Abu H, Bamgbade BA, Hayward R, Gore J, Gurwitz JH, McManus DD, Saczynski JS. Differential effect of anticoagulation according to cognitive function and frailty in older patients with atrial fibrillation. J Am Geriatr Soc 2023; 71:394-403. [PMID: 36273408 PMCID: PMC10207283 DOI: 10.1111/jgs.18079] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/29/2022] [Accepted: 09/02/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND In older patients with atrial fibrillation (AF), cognitive impairment and frailty are prevalent. It is unknown whether the risk and benefit of anticoagulation differ by cognitive function and frailty. METHODS A total of 1244 individuals with AF with age ≥65 years and a CHADSVASC score ≥2 were recruited from clinics in Massachusetts and Georgia between 2016 and 18 and followed until 2020. At baseline, frailty status and cognitive function were assessed. Hazard ratios of anticoagulation on physician adjudicated outcomes were adjusted by the propensity for receiving anticoagulation and stratified by cognitive function and frailty status. RESULTS The average age was 75.5 (± 7.1) years, 49% were women, and 86% were prescribed oral anticoagulants. At baseline, 528 (42.4%) participants were cognitively impaired and 172 (13.8%) were frail. The adjusted hazard ratios of anticoagulation for the composite of major bleeding or death were 2.23 (95% confidence interval: 1.08-4.61) among cognitively impaired individuals and 0.94 (95% confidence interval: 0.49-1.79) among cognitively intact individuals (P for interaction = 0.08). Adjusted hazard ratios for anticoagulation were 1.84 (95% confidence interval: 0.66-5.13) among frail individuals and 1.39 (95% confidence interval: 0.84-2.40) among not frail individuals (P for interaction = 0.67). CONCLUSION Compared with no anticoagulation, anticoagulation is associated with more major bleeding episodes and death in older patients with AF who are cognitively impaired.
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Affiliation(s)
- Weijia Wang
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Catarina I. Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert J. Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - David Parish
- Department of Medicine, School of Medicine, Mercer University, Macon, GA
| | - Robert Helm
- Department of Medicine, School of Medicine, Boston University, Boston, MA
| | - Katherine Trymbulak
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, North Haven, CT USA
| | - Jordy Mehawej
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Hawa Abu
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Benita A. Bamgbade
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - Robert Hayward
- Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | - Joel Gore
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jerry H. Gurwitz
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
- Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA
| | - David D. McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jane S. Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
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6
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Wang W, Saczynski JS, Lessard D, Goldberg RJ, Parish D, Helm R, Kiefe CI, Trymbulak K, Mehawej J, Abu H, Hayward R, Gore J, Gurwitz JH, McManus DD. Presence of Geriatric Conditions Is Prognostic of Major Bleeding in Older Patients with Atrial Fibrillation: a Cohort Study. J Gen Intern Med 2022; 37:3893-3899. [PMID: 35102482 PMCID: PMC9640487 DOI: 10.1007/s11606-022-07410-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/07/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND In older patients with atrial fibrillation (AF), physical, cognitive, and psychosocial limitations are prevalent. The prognostic value of these conditions for major bleeding is unclear. OBJECTIVE To determine whether geriatric conditions are prospectively associated with major bleeding in older patients with AF on anticoagulation. DESIGN Multicenter cohort study with 2-year follow-up from 2016 to 2020 in Massachusetts and Georgia from cardiology, electrophysiology, and primary care clinics. PARTICIPANTS Diagnosed with AF, age 65 years or older, CHA2DS2-VASc score of 2 or higher, and taking oral anticoagulant (n=1,064). A total of 6507 individuals were screened. MAIN MEASURES A six-component geriatric assessment of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Main outcome was major bleeding adjudicated by a physician panel. KEY RESULTS At baseline, participants were, on average, 75.5 years old and 49% were women. Mean CHA2DS2-VASc score was 4.5 and the mean HAS-BLED score was 3.3. During 2.0 (± 0.4) years of follow-up, 95 (8.9%) participants developed an episode of major bleeding. After adjusting for key covariates and accounting for competing risk from death, cognitive impairment (hazard ratio [HR] 1.62, 95% confidence interval [CI]: 1.02-2.56) and frailty (HR 2.77, 95% CI 1.38-5.58) were significantly associated with the development of major bleeding. CONCLUSIONS In older patients with AF taking anticoagulants, cognitive impairment and frailty were independently associated with major bleeding.
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Affiliation(s)
- Weijia Wang
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA.
| | - Jane S Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, USA
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert J Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - David Parish
- Department of Medicine, School of Medicine, Mercer University, Macon, GA, USA
| | - Robert Helm
- Department of Medicine, School of Medicine, Boston University, Boston, MA, USA
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Katherine Trymbulak
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, North Haven, CT, USA
| | - Jordy Mehawej
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Hawa Abu
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert Hayward
- Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA
| | - Joel Gore
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jerry H Gurwitz
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
- Meyers Health Care Institute, University of Massachusetts Medical School, Worcester, MA, USA
| | - David D McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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The Influence of Frailty Syndrome and Dementia on the Convenience and Satisfaction with Oral Anticoagulation Treatment in Elderly Patients with Atrial Fibrillation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19095355. [PMID: 35564748 PMCID: PMC9101389 DOI: 10.3390/ijerph19095355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 04/22/2022] [Accepted: 04/25/2022] [Indexed: 11/17/2022]
Abstract
Background: The impact of frailty syndrome (FS) and dementia on the convenience and satisfaction with oral anticoagulation (OAC) treatment in atrial fibrillation (AF) patients is not well-known. Aim: Assessment the impact of FS and dementia on the convenience and satisfaction with OAC treatment in 116 elderly (mean age 75.2, SD = 8.2) patients with AF. Methodology: A self-administered questionnaire was used in the study to collect basic socio-demographic and clinical data. Tilburg Frailty Indicator (TFI) questionnaire was used to assess the presence of FS, Mini Mental State Examination (MMSE) to assess cognitive impairment (CI), The Perception of Anticoagulant Treatment Questionnaire Part 2 (PACT-Q2) to assess convenience and satisfaction with OAC treatment, and the Arrhythmia-Specific Questionnaire in Tachycardia and Arrhythmia (ASTA) to assess quality of life (QoL). Results: Multivariable analysis as a significant, negative predictor of the convenience and satisfaction domain showed the occurrence of dementia (β = −0.34; p < 0.001, β = −0.41; p < 0.001, respectively) and prior major bleeding (β = −0.30; p < 0.001, β = −0.33; p < 0.001, respectively). Analysis showed a significant relationship between convenience and satisfaction and the overall result of the ASTA (r = −0.329; p < 0.001, r = −0.372; p < 0.001, respectively). Conclusions: Elements of geriatric syndrome, such as FS and dementia, adversely affect treatment convenience and satisfaction with OAC treatment in AF. It has been shown that better convenience and satisfaction with OAC treatment translates into better QoL. There were no differences between satisfaction and convenience and the type of OAC treatment (vitamin K antagonists (VKA) vs. novel oral anticoagulants (NOAC).
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8
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Mehawej J, Saczynski JS, Kiefe CI, Abu HO, Tisminetzky M, Wang W, Bamgbade BA, Ding E, Lessard D, Otabil EM, Saleeba C, Goldberg RJ, McManus DD. Association between risk of obstructive sleep apnea and cognitive performance, frailty, and quality of life among older adults with atrial fibrillation. J Clin Sleep Med 2022; 18:469-475. [PMID: 34432629 PMCID: PMC8805012 DOI: 10.5664/jcsm.9622] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 02/03/2023]
Abstract
STUDY OBJECTIVES Geriatric impairments and obstructive sleep apnea (OSA) are prevalent among older patients with atrial fibrillation (AF). Little is known about the association between OSA and geriatric impairments, including frailty, cognitive performance, and AF-related quality of life. The objective of this study was to examine the associations of OSA with frailty, cognitive performance, and AF-related quality of life among older adults with AF. METHODS Data from the Systemic Assessment of Geriatrics Elements-AF study were used, which included AF participants 65 years and older and with a CHA2DS2-VASc ≥ 2. The STOP-BANG questionnaire was used to assess the risk of OSA. Multivariable logistic regression models were used to examine the association between risk of OSA and geriatric impairments, adjusting for sociodemographic, geriatric, and clinical characteristics. RESULTS A total of 970 participants (mean age 75 years; 51% male) were studied. Of the 680 participants without a medical history of OSA, 26% (n = 179) of participants had a low risk of OSA, 53% (n = 360) had an intermediate risk, and 21% (n = 141) had a high risk for OSA. Compared to those with low risk of OSA, participants with an intermediate or high risk of OSA were more likely to be frail (adjusted odds ratio = 1.67, 95% confidence interval: 1.08-2.56; adjusted odds ratio = 3.00, 95% confidence interval: 1.69-5.32, respectively) in the fully adjusted models. CONCLUSIONS Our findings identify a group of patients at high risk who would benefit from early screening for OSA. Future longitudinal studies are needed to assess the effect of OSA treatment on frailty, physical functioning, and quality of life among patients with AF. CITATION Mehawej J, Saczynski JS, Kiefe CI, et al. Association between risk of obstructive sleep apnea and cognitive performance, frailty, and quality of life among older adults with atrial fibrillation. J Clin Sleep Med. 2022;18(2):469-475.
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Affiliation(s)
- Jordy Mehawej
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jane S. Saczynski
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, Massachusetts
| | - Catarina I. Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Hawa O. Abu
- Department of Medicine, Saint Vincent Hospital, Worcester, Massachusetts
| | - Mayra Tisminetzky
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
- Division of Geriatrics, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Weijia Wang
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Benita A. Bamgbade
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, Massachusetts
| | - Eric Ding
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Edith Mensah Otabil
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Connor Saleeba
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Robert J. Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David D. McManus
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
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Satisfaction With Oral Anticoagulants Among Patients With Atrial Fibrillation: A Prospective Observational Study. CJC Open 2021; 3:1347-1356. [PMID: 34901803 PMCID: PMC8640622 DOI: 10.1016/j.cjco.2021.06.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/22/2021] [Indexed: 11/21/2022] Open
Abstract
Background Satisfaction with treatment has been identified as an important contributing factor to adherence with oral anticoagulant (OAC) therapy in patients with atrial fibrillation (AF). We aimed to evaluate the satisfaction level of patients with AF regarding OAC use over time, using validated patient-reported outcome instruments, and to identify associated patient characteristics. Methods Participants were recruited from specialized AF clinics in Canada. Eligible AF patients who were prescribed OACs were followed for up to 2 years. Participants were interviewed via telephone every 3-4 months using a structured survey. The Treatment Satisfaction Questionnaire for Medication (TSQM II) and the Anti-Clot Treatment Scale (ACTS) were used to measure satisfaction over time. Results Among the 306 participants, satisfaction scores on the TSQM II and ACTS instruments were high. Unadjusted analyses showed significantly greater satisfaction with the burden of therapy with direct OACs (DOACs) compared to that with warfarin (small-magnitude effect) and greater satisfaction with the convenience of rivaroxaban, compared with that of all other OACs (moderate-magnitude effect). After adjustment for all other variables, vitamin K antagonist therapy was associated with greater global satisfaction than was DOAC treatment. Satisfaction with benefit and burden as measured by the ACTS scale, and global satisfaction on the TSQM II scale, tended to increase over time. Patient factors that were somewhat consistently associated with greater satisfaction were female sex and younger age. Conclusions Patients with AF were highly satisfied with their therapy, with few differences among OAC classes and individual OACs. Individual patients may or may not be more satisfied with DOAC than VKA therapy, and regardless of the OAC prescribed, the may require significant support to maintain therapy adherence.
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10
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Essien UR, Kornej J, Johnson AE, Schulson LB, Benjamin EJ, Magnani JW. Social determinants of atrial fibrillation. Nat Rev Cardiol 2021; 18:763-773. [PMID: 34079095 PMCID: PMC8516747 DOI: 10.1038/s41569-021-00561-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 02/05/2023]
Abstract
Atrial fibrillation affects almost 60 million adults worldwide. Atrial fibrillation is associated with a high risk of cardiovascular morbidity and death as well as with social, psychological and economic burdens on patients and their families. Social determinants - such as race and ethnicity, financial resources, social support, access to health care, rurality and residential environment, local language proficiency and health literacy - have prominent roles in the evaluation, treatment and management of atrial fibrillation. Addressing the social determinants of health provides a crucial opportunity to reduce the substantial clinical and non-clinical complications associated with atrial fibrillation. In this Review, we summarize the contributions of social determinants to the patient experience and outcomes associated with this common condition. We emphasize the relevance of social determinants and their important intersection with atrial fibrillation treatment and outcomes. In closing, we identify gaps in the literature and propose future directions for the investigation of social determinants and atrial fibrillation.
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Affiliation(s)
- Utibe R. Essien
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,
| | - Jelena Kornej
- Sections of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Amber E. Johnson
- Division of Cardiology, Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lucy B. Schulson
- Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Emelia J. Benjamin
- Sections of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Jared W. Magnani
- Division of Cardiology, Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Mehawej J, Saczynski J, Abu HO, Gagnier M, Bamgbade BA, Lessard D, Trymbulak K, Saleeba C, Kiefe CI, Goldberg RJ, McManus DD. Factors Associated With Patient Engagement in Shared Decision-Making for Stroke Prevention Among Older Adults with Atrial Fibrillation. Can Geriatr J 2021; 24:174-183. [PMID: 34484500 PMCID: PMC8390325 DOI: 10.5770/cgj.24.475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To examine the extent of, and factors associated with, patient engagement in shared decision-making (SDM) for stroke prevention among patients with atrial fibrillation (AF). METHODS We used data from the Systematic Assessment of Geriatric Elements-Atrial Fibrillation study which includes older ( ≥65 years) patients with AF and a CHA2DS2-VASc≥2. Participants reported engagement in SDM by answering whether they actively participated in choosing to take an oral anticoagulant (OAC) for their condition. Multiple logistic regression was used to assess associations between sociodemographic, clinical, geriatric, and psychosocial factors and patient engagement in SDM. RESULTS A total of 807 participants (mean age 75 years; 48% female) on an OAC were studied. Of these, 61% engaged in SDM. Older participants (≥80 years) and those cognitively impaired were less likely to engage in SDM, while those very knowledgeable of their AF associated stroke risk were more likely to do so than respective comparison groups. CONCLUSIONS A considerable proportion of older adults with AF did not engage in SDM for stroke prevention with older patients and those cognitively impaired less likely to do so. Clinicians should identify patients who are less likely to engage in SDM, promote patient engagement, and foster better patient-provider communication which may enhance long-term patient outcomes.
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Affiliation(s)
- Jordy Mehawej
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jane Saczynski
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston, MA, USA
| | - Hawa O. Abu
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Marc Gagnier
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Benita A. Bamgbade
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston, MA, USA
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Katherine Trymbulak
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Connor Saleeba
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Catarina I. Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert J. Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - David D. McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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Wang W, Lessard D, Saczynski JS, Goldberg RJ, Mehawej J, Gracia E, McManus DD. Prognostic value of geriatric conditions for death and bleeding in older patients with atrial fibrillation. IJC HEART & VASCULATURE 2021; 33:100739. [PMID: 33728372 PMCID: PMC7935705 DOI: 10.1016/j.ijcha.2021.100739] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 01/20/2021] [Accepted: 02/08/2021] [Indexed: 11/24/2022]
Abstract
Background Geriatric conditions, such as frailty and cognitive impairment, are prevalent in older patients with atrial fibrillation (AF). We examined the prognostic value of geriatric conditions for predicting 1-year mortality and bleeding events in these patients. Methods SAGE (Systematic Assessment of Geriatric Elements)-AF study is a multicenter cohort study which enrolled individuals (mean age 75 years, 48% women, 86% taking oral anticoagulation) 65 years and older with AF and CHA2DS2 -VASc score of 2 or higher from clinics in Massachusetts and Georgia, USA between 2016 and 2018. A six-component geriatric assessment included validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing was performed at baseline. Study endpoints included all-cause mortality and clinically relevant bleeding. Results At 1 year, 1,097 (96.5%) individuals attended the follow up visit, 44 (3.9%) had died, and 56 (5.1%) had clinically relevant bleeding. After adjustment for demographic and clinical factors, social isolation (odds ratio [OR] 1.69, 95% confidence interval [CI]: 1.01–2.84), depression (OR 1.94, 95% CI: 1.28–2.95) and frailty (OR 2.55, 95% CI: 1.55–4.19) were significantly associated with the composite endpoint of death or clinically relevant bleeding. After multivariable adjustment, depression (OR 1.79, 95% CI 1.09–2.93) and frailty (OR 2.83, 95% CI 1.55–5.17) were significantly associated with clinically relevant bleeding. Conclusions Social isolation, depression, and frailty were prognostic of dying or experiencing clinically relevant bleeding during the coming year in older men and women with AF. Assessing geriatric impairments merits consideration in the care of these patients.
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Affiliation(s)
- Weijia Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jane S Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, USA
| | - Robert J Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jordy Mehawej
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Ely Gracia
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - David D McManus
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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Mehawej J, S Saczysnki J, I Kiefe C, Ding E, O Abu H, Lessard D, H Helm R, A Bamgbade B, Saleeba C, Wang W, D McManus D, J Goldberg R. Factors Associated with Moderate Physical Activity Among Older Adults with Atrial Fibrillation. J Atr Fibrillation 2021; 13:2454. [PMID: 34950335 PMCID: PMC8691360 DOI: 10.4022/jafib.2454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/22/2020] [Accepted: 01/15/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Engaging patients with atrial fibrillation (AF) in moderate-intensity physical activity has been encouraged by published guidelines. We examined factors associated with engagement in moderate physical activity among older adults with AF. METHODS This was a retrospective study involving ninety patients with episodes of Afib with RVR duData are from the SAGE (Systematic Assessment of Geriatric Elements)-AF study. Older adults (≥ 65 years) with AF and a CHA2DS2-VASc ≥ 2 were recruited from several clinics in Massachusetts and Georgia between 2015 and 2018. The Minnesota Leisure Time Physical Activity questionnaire was used to assess whether participants engaged in moderate-intensity physical activity (i.e. at least 150 minutes of moderate exercise). Logistic regression was utilized to examine the sociodemographic and clinical characteristics and geriatric elements associated with engaging in moderate-intensity physical activity. RESULTS Participants were on average 76 years old and 48% were women. Approximately one-half (52%) of study participants engaged in moderate-intensity physical activity. Morbid obesity (adjusted OR [aOR]=0.41, 90%CI=0.23-0.73), medical history of renal disease (aOR= aOR=0.68,90%CI= 0.48-0.96), slow gait speed (aOR=0.44, 90%CI=0.32-0.60), cognitive impairment (aOR=0.74, 90%CI=0.56-0.97), and social isolation (aOR=0.58, 90%CI= 0.40-0.84) were independently associated with a lower likelihood, while higher AF related quality of life score (aOR=1.64, 90%CI=1.25-2.16) a greater likelihood, of meeting recommended levels of moderate physical activity. CONCLUSIONS Nearly one-half of older adults with NVAF did not engage in moderate-intensity exercise. Clinicians should identify older patients with NVAF who are less likely to engage in physical activity and develop tailored interventions to promote regular physical activity.
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Affiliation(s)
- Jordy Mehawej
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
| | - Jane S Saczysnki
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston MA
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Eric Ding
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Hawa O Abu
- Department of Medicine, Saint Vincent Hospital, Worcester, MA
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Robert H Helm
- Department of Cardiovascular Medicine, Boston University Medical, Boston, MA
| | - Benita A Bamgbade
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston MA
| | - Connor Saleeba
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
| | - Weijia Wang
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
| | - David D McManus
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
| | - Robert J Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
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Abstract
Effective stroke prevention with oral anticoagulation (OAC) is the cornerstone of the management of patients with atrial fibrillation. The use of OAC reduces the risk of stroke and death. For most patients with atrial fibrillation without moderate or severe mitral valve stenosis or prosthetic mechanical heart valves, treatment options include vitamin K antagonists, such as warfarin, and non-vitamin K antagonist oral anticoagulants (NOACs). Although most guidelines generally recommend NOACs as the first-line OAC, caution is required in some groups of patients with atrial fibrillation at high risk of stroke and bleeding who have been under-represented or not studied in the randomized clinical trials on NOACs for stroke prevention. In addition to OAC, non-pharmacological, percutaneous therapies, including left atrial appendage occlusion, for stroke prevention have emerged, sometimes used in combination with catheter ablation for the treatment of the atrial fibrillation. High-risk groups of patients with atrial fibrillation include patients with end-stage renal failure (including those receiving dialysis), extremely old patients (such as those aged >80 years with multiple risk factors for bleeding), patients with dementia or those living in a long-term care home, patients with previous intracranial bleeding or recent acute bleeding (such as gastrointestinal bleeding), patients with acute ischaemic stroke and patients with an intracardiac thrombus. This Review provides an overview of stroke prevention strategies, including left atrial appendage occlusion, in patients with atrial fibrillation at high risk of stroke and bleeding.
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Self-reported risk of stroke and factors associated with underestimation of stroke risk among older adults with atrial fibrillation: the SAGE-AF study. J Geriatr Cardiol 2020; 17:502-509. [PMID: 32952525 PMCID: PMC7475213 DOI: 10.11909/j.issn.1671-5411.2020.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Though engaging patients with atrial fibrillation (AF) in understanding their stroke risk is encouraged by guidelines, little is known regarding AF patients' perceived stroke risk or its relationship with oral anticoagulation (OAC) use. We aim to identify factors associated with underestimation of stroke risk among older patients with AF and relate this to OAC use. METHODS Data are from the ongoing SAGE (Systematic Assessment of Geriatric Elements)-AF study, which included older patients (> 65 years) with non-valvular AF and a CHA2DS2-VASc score of ≥ 2. Participants reported their perceived risk of having a stroke without OAC. We compared the perceived risk to CHA2DS2-VASc predicted stroke risk and classified participants as "over" or "under" estimators, and identified factors associated with underestimation of risk using multiple logistic regression. RESULTS The average CHA2DS2-VASc score of 915 participants (average age: 75 years, 47% female, 86% white) was 4.3 ± 1.6, 43% of participants had discordant predicted and self-reported stroke risks. Among the 376 participants at highest risk (CHA2DS2-VASc score ≥ 5), 46% of participants underestimated their risk. Older participants (≥ 85 years) were more likely and OAC treated patients less likely to underestimate their risk of developing a future stroke than respective comparison groups. CONCLUSIONS A significant proportion of study participants misperceived their stroke risk, mostly by overestimating. Almost half of participants at high risk of stroke underestimated their risk, with older patients more likely to do so. Patients on OAC were less likely to underestimate their risk, suggesting that successful efforts to educate patients about their stroke risk may influence treatment choices.
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Hearing loss and cognitive decline among older adults with atrial fibrillation: the SAGE-AF study. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2020; 17:177-183. [PMID: 32362915 PMCID: PMC7189266 DOI: 10.11909/j.issn.1671-5411.2020.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objective To examine the association between hearing loss and cognitive function cross-sectionally and prospectively among older adults with atrial fibrillation (AF). Methods Patients with AF ≥ 65-year-old (n = 1244) in the SAGE (Systematic Assessment of Geriatric Elements)-AF study were recruited from five internal medicine or cardiology clinics in Massachusetts and Georgia. Hearing was assessed by a structured questionnaire at baseline. Cognitive function was assessed by Montreal Cognitive Assessment (MoCA) at baseline and one year. Cognitive impairment was defined as score ≤ 23 on the MoCA. The associations between hearing loss and cognitive function were examined by multivariable adjusted logistic regression. Results Participants with hearing loss (n = 451, 36%) were older, more likely to be male, and have depressive symptoms than patients without hearing loss. At baseline, 528 (42%) participants were cognitively impaired. Individuals with hearing loss were significantly more likely to have cognitive impairment at baseline [adjusted odds ratio (OR) = 1.37, 95% confidence interval (CI): 1.05–1.81]. Among the 662 participants who did not have cognitive impairment at baseline and attended the one-year follow-up visit, 106 (16%) developed incident cognitive impairment. Individuals with, versus those without, hearing loss were significantly more likely to develop incident cognitive impairment at one year (adjusted OR = 1.68, 95% CI: 1.07–2.64). Conclusions Hearing loss is a prevalent but under-recognized factor associated with cognitive impairment in patients with AF. Assessment for hearing loss may be indicated among these patients to identify individuals at high-risk for adverse outcomes.
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Riera-Mestre A, Camafort M, María Suriñach J, Muñoz Rodríguez FJ, Padilla F, Francisco-Pascual J, Mateo Arranz J, Martínez Rubio A, Villuendas Sabaté R, Freixa-Pamias R, Suárez Fernández C, Santamaría A. Anticoagulación del paciente anciano pluripatológico con fibrilación auricular no valvular: papel del rivaroxabán. REVISTA ESPAÑOLA DE CARDIOLOGÍA SUPLEMENTOS 2020. [DOI: 10.1016/s1131-3587(20)30011-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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