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Nakaoku Y, Ogata S, Ren N, Tanaka T, Kurogi R, Nishimura K, Iihara K. Ten-year national trends in in-hospital mortality and functional outcomes after intracerebral hemorrhage by age in Japan: J-ASPECT study. Eur Stroke J 2024; 9:398-408. [PMID: 38288694 DOI: 10.1177/23969873231222736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2024] Open
Abstract
INTRODUCTION National-level data on trends in the prognosis of age-stratified patients with intracerebral hemorrhage (ICH) are lacking. This study aimed to assess time trends in in-hospital mortality and functional outcomes of ICH patients by sex and age, and to explore factors associated with changes in in-hospital mortality trend. PATIENTS AND METHODS Using the largest nationwide, J-ASPECT stroke database in Japan, this serial cross-sectional study included ICH patients aged ⩾18 years who were hospitalized for non-traumatic ICH from April 2010 to March 2020. We examined trends in in-hospital mortality and functional outcomes using the modified Rankin Scale at discharge, as well as differences in in-hospital mortality change between age groups. RESULTS Among 262,399 ICH patients from 934 hospitals, crude in-hospital mortality showed a significant decreasing time trend (from 19.5% to 16.7%), and this trend was consistent across sex and age groups. In addition, differences in in-hospital mortality change over the 10-year study period were significant between male patients aged ⩾75 years and those aged ⩽64 years (-3.9% [95% confidence interval, -5.4 to -2.4] for 75-84 years; -4.1% [-6.3 to -1.9] for ⩾85 years). On the other hand, the proportion of dependent patients (mRS 3-5) at discharge increased from 52.0% to 54.9% over the 10-year study period. CONCLUSION The in-hospital mortality of ICH patients improved, whereas the proportion of patients with dependent functional outcome at discharge increased, over the 10-year study period. Elucidating the mechanism underlying differences in in-hospital mortality reduction in men may provide insights into effective interventions in the future.
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Affiliation(s)
- Yuriko Nakaoku
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Soshiro Ogata
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Nice Ren
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tomotaka Tanaka
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Ryota Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Koji Iihara
- National Cerebral and Cardiovascular Center Hospital, Suita, Japan
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Ueno H, Tokugawa J, Saito R, Yamashiro K, Tsutsumi S, Yamamoto M, Ueno Y, Mieno M, Yamamoto T, Hishii M, Yasumoto Y, Maruki C, Kondo A, Urabe T, Hattori N, Arai H, Tanaka R. Trends in prior antithrombotic medication and risk of in-hospital mortality after spontaneous intracerebral hemorrhage: the J-ICH registry. Sci Rep 2024; 14:12009. [PMID: 38796624 PMCID: PMC11127931 DOI: 10.1038/s41598-024-62717-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/21/2024] [Indexed: 05/28/2024] Open
Abstract
Spontaneous intracerebral hemorrhage (SICH) remains a devastating form of stroke. Prior use of antiplatelets or warfarin before SICH is associated with poor outcomes, but the effects of direct oral anticoagulants (DOACs) remain unclear. This study aimed to clarify trends in prior antithrombotic use and to assess the associations between prior use of antithrombotics and in-hospital mortality using a multicenter prospective registry in Japan. In total, 1085 patients were analyzed. Prior antithrombotic medication included antiplatelets in 14.2%, oral anticoagulants in 8.1%, and both in 1.8%. Prior warfarin use was significantly associated with in-hospital mortality (odds ratio [OR] 5.50, 95% confidence interval [CI] 1.30-23.26, P < 0.05) compared to no prior antithrombotic use. No such association was evident between prior DOAC use and no prior antithrombotic use (OR 1.34, 95% CI 0.44-4.05, P = 0.606). Concomitant use of antiplatelets and warfarin further increased the in-hospital mortality rate (37.5%) compared to warfarin alone (17.2%), but no such association was found for antiplatelets plus DOACs (8.3%) compared to DOACs alone (11.9%). Prior use of warfarin remains an independent risk factor for in-hospital mortality after SICH in the era of DOACs. Further strategies are warranted to reduce SICH among patients receiving oral anticoagulants and to prevent serious outcomes.
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Affiliation(s)
- Hideaki Ueno
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan
| | - Joji Tokugawa
- Department of Neurosurgery, Juntendo University Nerima Hospital, 3-1-10 Takanodai, Nerima, Tokyo, 177-8521, Japan
| | - Rikizo Saito
- Department of Neurosurgery, Koshigaya Municipal Hospital, 10-47-1 Higashikoshigaya, Koshigaya, Saitama, 343-0023, Japan
| | - Kazuo Yamashiro
- Department of Neurology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Satoshi Tsutsumi
- Department of Neurosurgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Munetaka Yamamoto
- Department of Neurosurgery, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo, Tokyo, 113-8421, Japan
| | - Yuji Ueno
- Department of Neurology, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
- Department of Neurology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo, Tokyo, 113-8421, Japan
| | - Makiko Mieno
- Department of Medical Informatics, Center for Information, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Takuji Yamamoto
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan
| | - Makoto Hishii
- Department of Neurosurgery, Juntendo University Nerima Hospital, 3-1-10 Takanodai, Nerima, Tokyo, 177-8521, Japan
| | - Yukimasa Yasumoto
- Department of Neurosurgery, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Chikashi Maruki
- Department of Neurosurgery, Koshigaya Municipal Hospital, 10-47-1 Higashikoshigaya, Koshigaya, Saitama, 343-0023, Japan
| | - Akihide Kondo
- Department of Neurosurgery, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo, Tokyo, 113-8421, Japan
| | - Takao Urabe
- Department of Neurology, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo, Tokyo, 113-8421, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo, Tokyo, 113-8421, Japan
| | - Ryota Tanaka
- Department of Neurology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo, Tokyo, 113-8421, Japan.
- Stroke Center and Division of Neurology, Department of Medicine, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
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Nakamura M, Inoue H, Yamashita T, Akao M, Atarashi H, Ikeda T, Koretsune Y, Okumura K, Shimizu W, Suzuki S, Tsutsui H, Toyoda K, Yasaka M, Yamaguchi T, Teramukai S, Morishima Y, Fukuzawa M, Takita A, Hirayama A. Coronary events in elderly patients with non-valvular atrial fibrillation: a prespecified sub-analysis of the ANAFIE registry. Cardiovasc Interv Ther 2024; 39:145-155. [PMID: 38349574 PMCID: PMC10940374 DOI: 10.1007/s12928-024-00984-9] [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: 09/14/2023] [Accepted: 12/26/2023] [Indexed: 03/16/2024]
Abstract
Real-world data on coronary events (CE) in elderly patients with atrial fibrillation (AF) are lacking in the direct oral anticoagulant era. This prespecified sub-analysis of the ANAFIE Registry, a prospective observational study in > 30,000 Japanese patients aged ≥ 75 years with non-valvular AF (NVAF), investigated CE incidence and risk factors. The incidence and risk factors for new-onset CE (a composite of myocardial infarction [MI] and cardiac intervention for coronary heart diseases other than MI), MI, and cardiac intervention for coronary heart diseases other than MI during the 2-year follow-up were assessed. Bleeding events in CE patients were also examined. Among 32,275 patients, the incidence rate per 100 patient-years was 0.48 (95% confidence interval (CI): 0.42-0.53) for CE during the 2-year follow-up, 0.20 (0.16-0.23) for MI, and 0.29 (0.25-0.33) for cardiac intervention for coronary heart diseases other than MI; that of stroke/systemic embolism was 1.62 (1.52-1.73). Patients with CE (n = 287) likely had lower creatinine clearance (CrCL) and higher CHADS2 and HAS-BLED scores than patients without CE (n = 31,988). Significant risk factors associated with new-onset CE were male sex, systolic blood pressure of ≥ 130 mmHg, diabetes mellitus (glycated hemoglobin ≥ 6.0%), CE history, antiplatelet agent use, and CrCL < 50 mL/min. Major bleeding incidence was significantly higher in patients with new-onset CE vs without CE (odds ratio [95% CI], 3.35 [2.06-5.43]). In elderly patients with NVAF, CE incidence was lower than stroke/systemic embolism incidence. New-onset CE (vs no CE) was associated with a higher incidence of major bleeding.Trial registration: UMIN000024006.
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Affiliation(s)
- Masato Nakamura
- Division of Minimally Invasive Treatment in Cardiovascular Medicine, Toho University Ohashi Medical Center, 2-22-36, Ohashi, Meguro-Ku, Tokyo, 153-8515, Japan.
| | | | | | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | | | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tama Nagayama Hospital, Tokyo, Japan
| | | | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine, Fukuoka Neurosurgical Hospital, Fukuoka, Japan
| | - Takenori Yamaguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | | | - Masayuki Fukuzawa
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd, Tokyo, Japan
| | - Atsushi Takita
- Data Intelligence Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Atsushi Hirayama
- Department of Medicine, Osaka Fukujuji Hospital, Neyagawa, Japan
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Hamatani Y, Iguchi M, Okamoto K, Nakanishi Y, Minami K, Ishigami K, Ikeda S, Doi K, Yoshizawa T, Ide Y, Fujino A, Ishii M, Masunaga N, Esato M, Tsuji H, Wada H, Hasegawa K, Abe M, Akao M. Association of left atrial enlargement with heart failure events in non-valvular atrial fibrillation patients with preserved left ventricular ejection fraction. EUROPEAN HEART JOURNAL OPEN 2024; 4:oeae015. [PMID: 38487366 PMCID: PMC10939123 DOI: 10.1093/ehjopen/oeae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/27/2023] [Accepted: 02/08/2024] [Indexed: 03/17/2024]
Abstract
Aims Atrial fibrillation (AF) increases the risk of heart failure (HF); however, little is known regarding the risk stratification for incident HF in AF patients, especially with preserved left ventricular ejection fraction (LVEF). Methods and results The Fushimi AF Registry is a community-based prospective survey of AF patients. From the registry, 3002 non-valvular AF patients with preserved LVEF and with the data of antero-posterior left atrial diameter (LAD) at enrolment were investigated. Patients were stratified by LAD (<40, 40-44, 45-49, and ≥50 mm) with backgrounds and HF hospitalization incidences compared between groups. Of 3002 patients [mean age, 73.5 ± 10.7 years; women, 1226 (41%); paroxysmal AF, 1579 (53%); and mean CHA2DS2-VASc score, 3.3 ± 1.7], the mean LAD was 43 ± 8 mm. Patients with larger LAD were older and less often paroxysmal AF, with a higher CHA2DS2-VASc score (all P < 0.001). Heart failure hospitalization occurred in 412 patients during the median follow-up period of 6.0 years. Larger LAD was independently associated with a higher HF hospitalization risk [LAD ≥ 50 mm: hazard ratio (HR), 2.36; 95% confidence interval (CI), 1.75-3.18; LAD 45-49 mm: HR, 1.84; 95% CI, 1.37-2.46; and LAD 40-44 mm: HR, 1.34; 95% CI, 1.01-1.78, compared with LAD < 40 mm) after adjustment by age, sex, AF type, and CHA2DS2-VASc score. These results were also consistent across major subgroups, showing no significant interaction. Conclusion Left atrial diameter is significantly associated with the risk of incident HF in AF patients with preserved LVEF, suggesting the utility of LAD regarding HF risk stratification for these patients.
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Affiliation(s)
- Yasuhiro Hamatani
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Moritake Iguchi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Keita Okamoto
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Yumiko Nakanishi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Kimihito Minami
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Kenjiro Ishigami
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Syuhei Ikeda
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Kosuke Doi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Takashi Yoshizawa
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Yuya Ide
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Akiko Fujino
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Mitsuru Ishii
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Nobutoyo Masunaga
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Masahiro Esato
- Department of Arrhythmia, Ogaki Tokushukai Hospital, Gifu, Japan
| | | | - Hiromichi Wada
- Division of Translational Research, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Koji Hasegawa
- Division of Translational Research, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Mitsuru Abe
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
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Sakai K, Suda S, Iguchi Y, Abe A, Yagita Y, Kanzawa T, Okubo S, Fujimoto S, Kimura K. High pre-stroke CHADS 2 score predicts unfavorable functional outcome in acute cardioembolic stroke patients prescribed oral anticoagulant therapy: A sub-analysis of the PASTA registry study. J Stroke Cerebrovasc Dis 2024; 33:107519. [PMID: 38142567 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 11/24/2023] [Accepted: 11/27/2023] [Indexed: 12/26/2023] Open
Abstract
BACKGROUND AND PURPOSE The impact of CHADS2 score on outcome in patients with stroke taking an oral anticoagulant (OAC) has not yet been fully elucidated. We investigated the association between pre-stroke CHADS2 score and outcome at discharge in patients with acute cardioembolic (CE) stroke due to atrial fibrillation (AF) who were prescribed OAC. METHODS The data of 548 OAC-treated patients with AF and CE stroke who were registered in the multicenter Prospective Analysis of Stroke patients Taking oral Anticoagulants (PASTA) study were analyzed. High CHADS2 score was defined as a pre-stroke CHADS2 score ≥2. Unfavorable outcome was defined as a modified Rankin scale (mRS) of 3-6. The impacts of pre-stroke CHADS2 score on outcome at discharge were evaluated using multiple logistic regression analysis. RESULT A high CHADS2 score was found in 472/548 patients and unfavorable outcome was found in 330/548 patients. In patients with unfavorable outcome, age, male sex, pre-stroke CHADS2 score, initial National Institute Health Stroke Scale (NIHSS) score, and glucose level on admission were significantly higher, whereas creatinine clearance and body weight were significantly lower, than those with favorable outcome (each p < 0.001). Multivariate logistic regression analysis indicated that high CHADS2 score (OR 2.18, 95 %CI 1.08-4.42, p = 0.031), pre-stroke mRS (OR 2.21, 95 %CI 1.69-2.67, p < 0.001), and initial NIHSS score (OR 1.19, 95 %CI 1.17-1.24, p < 0.001) were independently associated with unfavorable outcome. CONCLUSION Pre-stroke CHADS2 score was associated with poor outcome in patients with cardioembolic stroke due to AF, even in those taking OAC.
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Affiliation(s)
- Kenichiro Sakai
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo 105-0003, Japan.
| | - Satoshi Suda
- Department of Neurology, Nippon Medical School, Tokyo, Japan; Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Saitama, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo 105-0003, Japan
| | - Arata Abe
- Department of Neurology and Stroke Medicine, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Yoshiki Yagita
- Department of Stroke Medicine, Kawasaki Medical School, Okayama, Japan
| | - Takao Kanzawa
- Department of Stroke Medicine, Institute of Brain and Blood Vessels, Mihara Memorial Hospital, Gunma, Japan and Institute of HM Network, Gunyukai Isesaki Clinic, Gunma, Japan
| | - Seiji Okubo
- Department of Cerebrovascular Medicine, NTT Medical Center Tokyo, Tokyo, Japan
| | - Shigeru Fujimoto
- Division of Neurology, Department of Medicine, Jichi Medical University Hospital, Tochigi, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
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Frost L, Joensen AM, Dam-Schmidt U, Qvist I, Brinck M, Brandes A, Davidsen U, Pedersen OD, Damgaard D, Mølgaard I, Bedsted R, Damgaard Møller Schlünsen A, Chousa MG, Andersen J, Pedersen AR, Johnsen SP, Vinter N. The Danish Atrial Fibrillation Registry: A Multidisciplinary National Pragmatic Initiative for Monitoring and Supporting Quality of Care Based on Data Retrieved from Administrative Registries. Clin Epidemiol 2023; 15:1259-1272. [PMID: 38149081 PMCID: PMC10750776 DOI: 10.2147/clep.s443473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/09/2023] [Indexed: 12/28/2023] Open
Abstract
Aim The Danish Atrial Fibrillation (AF) Registry monitors and supports improvement of quality of care for all AF patients in Denmark. This report describes the registry's administrative and organizational structure, data sources, data flow, data analyses, annual reporting, and feedback between the registry, clinicians, and the administrative system. We also report the selection process of the quality indicators and the temporal trends in results from 2017-2021. Methods and Results The Danish AF Registry aims for complete registration and monitoring of care for all patients diagnosed with AF in Denmark. Administrative registries provide data on contacts to general practice, contacts to private cardiology practice, hospital contacts, medication prescriptions, updated vital status information, and biochemical test results. The Danish Stroke Registry provides information on stroke events. From 2017 to 2021, the proportion with a reported echocardiography among incident AF patients increased from 39.9% (95% CI: 39.3-40.6) to 82.6% (95% CI: 82.1-83.1). The initiation of oral anticoagulant therapy among patients with incident AF and a CHA2DS2-VASc score of ≥1 in men and ≥2 in women increased from 85.3% (95% CI: 84.6-85.9) to 90.4% (95% CI: 89.9-91.0). The 1-year and 2-year persistence increased from 85.2% (95% CI: 84.5-85.9) to 88.7% (95% CI: 88.0-89.3), and from 85.4% (95% CI: 84.7-86.2) to 88.2% (95% CI: 87.5-88.8), respectively. The 1-year risk of ischemic stroke among prevalent patients with AF decreased from 0.88% (95% CI: 0.83-0.93) to 0.71% (95% CI: 0.66-0.75). Variation in clinical performance between the five administrative Danish regions was reduced. Conclusion Continuous nationwide monitoring of quality indicators for AF originating from administrative registries is feasible and supportive of improvements of quality of care.
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Affiliation(s)
- Lars Frost
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Ulla Dam-Schmidt
- Department of Cardiology, Bispebjerg Hospital, Copenhagen University Hospitals, Copenhagen, Denmark
| | - Ina Qvist
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Margit Brinck
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Axel Brandes
- Department of Cardiology, Esbjerg Hospital – University Hospital of Southern Denmark, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Ulla Davidsen
- Department of Cardiology, Bispebjerg Hospital, Copenhagen University Hospitals, Copenhagen, Denmark
| | - Ole Dyg Pedersen
- Department of Cardiology, Zealand University Hospital, Roskilde, Denmark
| | - Dorte Damgaard
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Inge Mølgaard
- Patient Representative, Aalborg and Roskilde, Denmark
| | | | | | - Miriam Grijota Chousa
- The Danish Clinical Quality Program – National Clinical Registries (RKKP), Aarhus, Denmark
| | - Julie Andersen
- The Danish Clinical Quality Program – National Clinical Registries (RKKP), Aarhus, Denmark
| | | | - Søren Paaske Johnsen
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Nicklas Vinter
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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7
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Nishimura T, Matsugaki R, Fujimoto K, Matsuda S. Atrial fibrillation and mortality after ischemic stroke: An observational study using an insurance claim database. Clin Neurol Neurosurg 2023; 235:108042. [PMID: 37939619 DOI: 10.1016/j.clineuro.2023.108042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/19/2023] [Accepted: 10/31/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVES In this study, we aimed to examine the association between atrial fibrillation and mortality after ischemic stroke and evaluate the use of anticoagulation therapy for atrial fibrillation before stroke onset in patients who experienced stroke. METHODS In this retrospective observational study, we used a combined database of medical and long-term care insurance claims data from one prefecture in Japan. The data of 25,352 patients aged ≥ 65 years who were hospitalized in acute care hospitals with a diagnosis of ischemic stroke between April 2012 and March 2015 were extracted. Cox proportional hazard modeling, with adjustment for age, sex, comorbidities, and long-term care dependency level (based on the activities of daily living), was performed to evaluate the relationship between mortality and atrial fibrillation. RESULTS The prevalence of atrial fibrillation was 21.8% in the study population. A significant association was noted between mortality and atrial fibrillation (adjusted hazard ratio: 1.28, 95% confidence interval: 1.16-1.41, p < 0.001). Anticoagulant drugs were used in 32.2% of the patients with atrial fibrillation. CONCLUSIONS These results indicate that atrial fibrillation is associated with mortality after stroke; however, the use of anticoagulation therapy for atrial fibrillation is unsatisfactory. Efforts to improve the use of atrial fibrillation therapy are required in Japan.
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Affiliation(s)
- Takehiro Nishimura
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, 1-1, Iseigaoka, Yahatanishiku, Kitakyushu 807-8555, Japan
| | - Ryutaro Matsugaki
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, 1-1, Iseigaoka, Yahatanishiku, Kitakyushu 807-8555, Japan.
| | - Kenji Fujimoto
- Occupational Health Data Science Centre, Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, 1-1, Iseigaoka, Yahatanishiku, Kitakyushu, 807-8555, Japan
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, 1-1, Iseigaoka, Yahatanishiku, Kitakyushu 807-8555, Japan; Occupational Health Data Science Centre, Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, 1-1, Iseigaoka, Yahatanishiku, Kitakyushu, 807-8555, Japan
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Akao M, Inoue H, Yamashita T, Atarashi H, Ikeda T, Koretsune Y, Okumura K, Suzuki S, Tsutsui H, Toyoda K, Hirayama A, Yasaka M, Yamaguchi T, Teramukai S, Kimura T, Morishima Y, Takita A, Shimizu W. Relationship Between Direct Oral Anticoagulant Doses and Clinical Outcomes in Elderly Patients With Non-Valvular Atrial Fibrillation - ANAFIE Registry Sub-Analysis. Circ J 2023; 87:1765-1774. [PMID: 37482411 DOI: 10.1253/circj.cj-23-0143] [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] [Indexed: 07/25/2023]
Abstract
BACKGROUND This sub-analysis of the ANAFIE Registry, a prospective, observational study of >30,000 Japanese non-valvular atrial fibrillation (NVAF) patients aged ≥75 years, assessed the prevalence of direct oral anticoagulant (DOAC) under-dose prevalence, identified the factors of under-dose prescriptions, and examined the relationship between DOAC dose and clinical outcomes.Methods and Results: Patients, divided into 5 groups by DOAC dose (standard, over-, reduced, under-, and off-label), were analyzed for background factors, cumulative incidences, and clinical outcome risk. Endpoints were stroke/systemic embolic events (SEE), major bleeding, and all-cause death during the 2-year follow-up. Of 18,497 patients taking DOACs, 20.7%, 3.8%, 51.6%, 19.6%, and 4.3%, were prescribed standard, over-, reduced, under-, and off-label doses. Factors associated with under-dose use were female sex, age ≥85 years, reduced creatinine clearance, history of major bleeding, polypharmacy, antiplatelet agents, heart failure, dementia, and no history of catheter ablation or cerebrovascular disease. After confounder adjustment, under-dose vs. standard dose was not associated with the incidence of stroke/SEE or major bleeding but was associated with a higher mortality rate. Patients receiving an off-label dose showed similar tendencies to those receiving an under-dose; that is, they showed the highest mortality rates for stroke/SEE, major bleeding, and all-cause death. CONCLUSIONS Inappropriate low DOAC doses (under- or off-label dose) were not associated with stroke/SEE or major bleeding but were associated with all-cause death.
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Affiliation(s)
- Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | | | | | | | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | | | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Cerebrovascular Center, National Hospital Organization Kyushu Medical Center
| | - Takenori Yamaguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Tetsuya Kimura
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tama Nagayama Hospital
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Morimoto T, Hoshino H, Matsuo Y, Ibuki T, Miyata K, Koretsune Y. Safety and Effectiveness of Apixaban Versus Warfarin in Japanese Patients with Nonvalvular Atrial Fibrillation Stratified by Renal Function: A Retrospective Cohort Study. Am J Cardiovasc Drugs 2023; 23:721-733. [PMID: 37847442 PMCID: PMC10625512 DOI: 10.1007/s40256-023-00611-7] [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] [Accepted: 08/31/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND We previously conducted a retrospective cohort study using chart review of oral anticoagulant-naïve Japanese patients with nonvalvular atrial fibrillation (NVAF) that assessed the risk of major bleeding and stroke/systemic embolism (SE) events of apixaban versus warfarin. METHODS In this subgroup analysis, we compared the risk of major bleeding and stroke/SE events by stratifying patients into four subgroups matched 1:1 using propensity score matching (PSM) according to baseline creatinine clearance (CrCl; mL/min): ≥ 15 to < 30, ≥ 30 to < 50, ≥ 50 to < 80, and ≥ 80. RESULTS Of the 7074 patients in the apixaban group and 4998 in the warfarin group eligible for inclusion in the analysis, 4385 were included in each group after PSM. Incidence rates of major bleeding and stroke/SE events were generally lower with apixaban versus warfarin across the CrCl subgroups. When all patients with a CrCl change of < 0 mL/min per year during the study period (apixaban, n = 3871; warfarin, n = 2635) were stratified into four subgroups based on the magnitude of CrCl decline (median CrCl change [mL/min] per year: - 1.09, - 3.48, - 7.54, and - 36.92 for apixaban, and - 1.10, - 3.65, - 7.85, and - 40.40 for warfarin), the incidence rates of major bleeding and stroke/SE events generally increased with an increasing CrCl decline per year in both groups. CONCLUSIONS In Japanese patients with NVAF, the safety and effectiveness of apixaban and warfarin were consistent across different renal subgroups, including those with severe renal impairment. Our results highlight the importance of monitoring renal function variations over time in patients with NVAF. CLINICALTRIALS GOV IDENTIFIER NCT03765242.
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Affiliation(s)
- Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo Medical University, 1-1 Mukogawacho, Nishinomiya, Hyogo, 663-8501, Japan.
| | - Haruhiko Hoshino
- Department of Neurology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Yukako Matsuo
- Medical Department, Bristol Myers Squibb K.K., Tokyo, Japan
| | | | - Kayoko Miyata
- Medical Department, Bristol Myers Squibb K.K., Tokyo, Japan
| | - Yukihiro Koretsune
- Cardiovascular Division, National Hospital Organization Osaka National Hospital, Osaka, Japan
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10
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Hamatani Y, Iguchi M, Minami K, Ishigami K, Esato M, Tsuji H, Wada H, Hasegawa K, Ogawa H, Abe M, Lip GY, Akao M. Utility of left ventricular ejection fraction in atrial fibrillation patients without pre-existing heart failure. ESC Heart Fail 2023; 10:3091-3101. [PMID: 37604489 PMCID: PMC10567650 DOI: 10.1002/ehf2.14500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 06/26/2023] [Accepted: 07/27/2023] [Indexed: 08/23/2023] Open
Abstract
AIMS Atrial fibrillation (AF) increases the risk of heart failure (HF); however, little focus has been placed on the prevention of HF in patients with AF. Left ventricular ejection fraction (LVEF) is an established echocardiographic parameter in HF patients. We sought to investigate the association of LVEF with HF events in AF patients without pre-existing HF. METHODS AND RESULTS The Fushimi AF Registry is a community-based prospective survey of AF patients in Fushimi-ku, Japan. In this analysis, we excluded patients with pre-existing HF (defined as having one of the following: prior HF hospitalization, New York Heart Association class ≥ 2 in association with heart disease, or LVEF < 40%). Among 3233 AF patients without pre-existing HF, we investigated 2459 patients with the data of LVEF at enrolment. We divided the patients into three groups stratified by LVEF [mildly reduced LVEF (40-49%), below normal LVEF (50-59%), and normal LVEF (≥60%)] and compared the backgrounds and incidence of HF hospitalization between the groups. Of 2459 patients [mean age: 72.4 ± 10.5 years, female: 917 (37%), paroxysmal AF: 1405 (57%), and mean CHA2 DS2 -VASc score: 3.0 ± 1.6], the mean LVEF was 66 ± 8% [mildly reduced LVEF: 114 patients (5%), below normal LVEF: 300 patients (12%), and normal LVEF: 2045 patients (83%)]. Patients with lower LVEF demonstrated lower prevalence of female and paroxysmal AF (both P < 0.01), but age and CHA2 DS2 -VASc score were comparable between the three groups (both P > 0.05). During the median follow-up period of 6.0 years, 255 patients (10%) were hospitalized for HF (annual incidence: 1.9% per person-year). Multivariable Cox regression analysis demonstrated that lower LVEF strata were independently associated with the risk of HF [mildly reduced LVEF (40-49%): hazard ratio = 2.98, 95% confidence interval = 1.99-4.45 and below normal LVEF (50-59%): hazard ratio = 2.01, 95% confidence interval = 1.44-2.82, compared with normal LVEF (≥60%)] after adjustment by age, sex, type of AF, and CHA2 DS2 -VASc score. LVEF < 60% was significantly associated with the higher risk of HF hospitalization across all major subgroups without significant interaction (P for interaction; all P > 0.05). LVEF had an independent and incremental prognostic value for HF hospitalization in addition to natriuretic peptide levels in AF patients without pre-existing HF. CONCLUSIONS Lower LVEF was significantly associated with the higher incidence of HF hospitalization in AF patients without pre-existing HF, leading to the future risk stratification for and prevention of incident HF in AF patients.
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Affiliation(s)
- Yasuhiro Hamatani
- Department of CardiologyNational Hospital Organization Kyoto Medical CenterKyotoJapan
| | - Moritake Iguchi
- Department of CardiologyNational Hospital Organization Kyoto Medical CenterKyotoJapan
| | - Kimihito Minami
- Department of CardiologyNational Hospital Organization Kyoto Medical CenterKyotoJapan
| | - Kenjiro Ishigami
- Department of CardiologyNational Hospital Organization Kyoto Medical CenterKyotoJapan
| | - Masahiro Esato
- Department of ArrhythmiaOgaki Tokushukai HospitalGifuJapan
| | | | - Hiromichi Wada
- Division of Translational ResearchNational Hospital Organization Kyoto Medical CenterKyotoJapan
| | - Koji Hasegawa
- Division of Translational ResearchNational Hospital Organization Kyoto Medical CenterKyotoJapan
| | - Hisashi Ogawa
- Department of CardiologyNational Hospital Organization Kyoto Medical CenterKyotoJapan
| | - Mitsuru Abe
- Department of CardiologyNational Hospital Organization Kyoto Medical CenterKyotoJapan
| | - Gregory Y.H. Lip
- Liverpool Center for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart and Chest HospitalLiverpoolUK
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Masaharu Akao
- Department of CardiologyNational Hospital Organization Kyoto Medical CenterKyotoJapan
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11
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Shiozawa M, Koga M, Inoue H, Yamashita T, Yasaka M, Suzuki S, Akao M, Atarashi H, Ikeda T, Okumura K, Koretsune Y, Shimizu W, Tsutsui H, Hirayama A, Nakahara J, Teramukai S, Kimura T, Morishima Y, Takita A, Yamaguchi T, Toyoda K. Risk of both intracranial hemorrhage and ischemic stroke in elderly individuals with nonvalvular atrial fibrillation taking direct oral anticoagulants compared with warfarin: Analysis of the ANAFIE registry. Int J Stroke 2023; 18:986-995. [PMID: 37154598 PMCID: PMC10507992 DOI: 10.1177/17474930231175807] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/21/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND AND AIMS Elderly patients with nonvalvular atrial fibrillation (NVAF) might have a higher risk of intracerebral hemorrhage. To investigate this, we compared the incidence of intracranial hemorrhage (ICH) and its subtypes, as well as ischemic stroke, in patients taking direct oral anticoagulants (DOACs) compared with warfarin in a real-world setting. We also determined the baseline characteristics associated with both ICH and ischemic stroke. METHODS Patients aged ⩾ 75 years with documented NVAF enrolled in the prospective, multicenter, observational All Nippon Atrial Fibrillation in the Elderly Registry between October 2016 and January 2018 were evaluated. The co-primary endpoints were the incidence of ischemic stroke and ICH. Secondary endpoints included subtypes of ICH. RESULTS Of 32,275 patients (13,793 women; median age, 81.0 years) analyzed, 21,585 (66.9%) were taking DOACs and 8233 (25.5%) were taking warfarin. During the median 1.88-year follow-up, 743 patients (1.24/100 person-years) developed ischemic stroke and 453 (0.75/100 person-years) developed ICH (intracerebral hemorrhage, 189; subarachnoid hemorrhage, 72; subdural/epidural hemorrhage, 190; unknown subtype, 2). The incidence of ischemic stroke (adjusted hazard ratio (aHR) 0.82, 95% confidence interval (CI) 0.70-0.97), ICH (aHR 0.68, 95% CI 0.55-0.83), and subdural/epidural hemorrhage (aHR 0.53, 95% CI 0.39-0.72) was lower in DOAC users versus warfarin users. The incidence of fatal ICH and fatal subarachnoid hemorrhage was also lower in DOAC users versus warfarin users. Several baseline characteristics other than anticoagulants were also associated with the incidence of the endpoints. Of these, history of cerebrovascular disease (aHR 2.39, 95% CI 2.05-2.78), persistent NVAF, (aHR 1.90, 95% CI 1.53-2.36), and long-standing persistent/permanent NVAF (aHR 1.92, 95% CI 1.60-2.30) was strongly associated with ischemic stroke; severe hepatic disease (aHR 2.67, 95% CI 1.46-4.88) was strongly associated with overall ICH; and history of fall within 1 year was strongly associated with both overall ICH (aHR 2.29, 95% CI 1.76-2.97) and subdural/epidural hemorrhage (aHR 2.90, 95% CI 1.99-4.23). CONCLUSION Patients aged ⩾ 75 years with NVAF taking DOACs had lower risks of ischemic stroke, ICH, and subdural/epidural hemorrhage than those taking warfarin. Fall was strongly associated with the risks of intracranial and subdural/epidural hemorrhage. DATA ACCESS STATEMENT The individual de-identified participant data and study protocol will be shared for up to 36 months after the publication of the article. Access criteria for data sharing (including requests) will be decided on by a committee led by Daiichi Sankyo. To gain access, those requesting data access will need to sign a data access agreement. Requests should be directed to yamt-tky@umin.ac.jp.
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Affiliation(s)
- Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | | | | | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Cerebrovascular Center, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | | | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | | | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tetsuya Kimura
- Primary Medical Science Department, Daiichi Sankyo, Tokyo, Japan
| | | | - Atsushi Takita
- Data Intelligence Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Takenori Yamaguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
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12
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Romiti GF, Corica B, Proietti M, Mei DA, Frydenlund J, Bisson A, Boriani G, Olshansky B, Chan YH, Huisman MV, Chao TF, Lip GY. Patterns of oral anticoagulant use and outcomes in Asian patients with atrial fibrillation: a post-hoc analysis from the GLORIA-AF Registry. EClinicalMedicine 2023; 63:102039. [PMID: 37753446 PMCID: PMC10518516 DOI: 10.1016/j.eclinm.2023.102039] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 09/28/2023] Open
Abstract
Background Previous studies suggested potential ethnic differences in the management and outcomes of atrial fibrillation (AF). We aim to analyse oral anticoagulant (OAC) prescription, discontinuation, and risk of adverse outcomes in Asian patients with AF, using data from a global prospective cohort study. Methods From the GLORIA-AF Registry Phase II-III (November 2011-December 2014 for Phase II, and January 2014-December 2016 for Phase III), we analysed patients according to their self-reported ethnicity (Asian vs. non-Asian), as well as according to Asian subgroups (Chinese, Japanese, Korean and other Asian). Logistic regression was used to analyse OAC prescription, while the risk of OAC discontinuation and adverse outcomes were analysed through Cox-regression model. Our primary outcome was the composite of all-cause death and major adverse cardiovascular events (MACE). The original studies were registered with ClinicalTrials.gov, NCT01468701, NCT01671007, and NCT01937377. Findings 34,421 patients were included (70.0 ± 10.5 years, 45.1% females, 6900 (20.0%) Asian: 3829 (55.5%) Chinese, 814 (11.8%) Japanese, 1964 (28.5%) Korean and 293 (4.2%) other Asian). Most of the Asian patients were recruited in Asia (n = 6701, 97.1%), while non-Asian patients were mainly recruited in Europe (n = 15,449, 56.1%) and North America (n = 8378, 30.4%). Compared to non-Asian individuals, prescription of OAC and non-vitamin K antagonist oral anticoagulant (NOAC) was lower in Asian patients (Odds Ratio [OR] and 95% Confidence Intervals (CI): 0.23 [0.22-0.25] and 0.66 [0.61-0.71], respectively), but higher in the Japanese subgroup. Asian ethnicity was also associated with higher risk of OAC discontinuation (Hazard Ratio [HR] and [95% CI]: 1.79 [1.67-1.92]), and lower risk of the primary composite outcome (HR [95% CI]: 0.86 [0.76-0.96]). Among the exploratory secondary outcomes, Asian ethnicity was associated with higher risks of thromboembolism and intracranial haemorrhage, and lower risk of major bleeding. Interpretation Our results showed that Asian patients with AF showed suboptimal thromboembolic risk management and a specific risk profile of adverse outcomes; these differences may also reflect differences in country-specific factors. Ensuring integrated and appropriate treatment of these patients is crucial to improve their prognosis. Funding The GLORIA-AF Registry was funded by Boehringer Ingelheim GmbH.
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Affiliation(s)
- Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Sciences at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Translational and Precision Medicine, Sapienza – University of Rome, Rome, Italy
| | - Bernadette Corica
- Liverpool Centre for Cardiovascular Sciences at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Translational and Precision Medicine, Sapienza – University of Rome, Rome, Italy
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Sciences at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Davide Antonio Mei
- Liverpool Centre for Cardiovascular Sciences at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Juliane Frydenlund
- Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | - Arnaud Bisson
- Liverpool Centre for Cardiovascular Sciences at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Service de Cardiologie, CHU Trousseau et Université François Rabelais, Tours, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Brian Olshansky
- Division of Cardiology, Department of Medicine, University of Iowa, Iowa City, USA
| | - Yi-Hsin Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan City Taiwan
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Sciences at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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13
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Frost L, Halminen O, Lehto M, Airaksinen KEJ, Andersson T, Wändell P, Holzmann M, Cordsen P, Vinter N, Johnsen SP. Geographical Variation in the Use of Oral Anticoagulation and Clinical Outcomes among Patients with Atrial Fibrillation in Denmark, Sweden, and Finland. TH OPEN 2023; 7:e133-e142. [PMID: 37288117 PMCID: PMC10243918 DOI: 10.1055/a-2080-6171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 04/19/2023] [Indexed: 06/09/2023] Open
Abstract
Background Geographical mapping of variations in the treatment and outcomes of a disease is a valuable tool for identifying inequity. We examined international and intranational variations in initiating oral anticoagulation (OAC) therapy and clinical outcomes among patients with atrial fibrillation (AF) in Nordic countries. We also tracked real-world trends in initiating OAC and the clinical outcomes. Methods We conducted a registry-based multinational cohort study of OAC-naive patients with an incident hospital diagnosis of AF in Denmark ( N = 61,345), Sweden ( N = 124,120), and Finland ( N = 59,855) and a CHA 2 DS 2 -VASc score of ≥1 in men and ≥2 in women between 2012 and 2017. Initiation of OAC therapy was defined as dispensing at least one prescription between 90 days before and 90 days after the AF diagnosis. Clinical outcomes included ischemic stroke, intracerebral hemorrhage, intracranial bleeding, other major bleeding, and all-cause mortality. Results The proportion of patients initiating OAC therapy ranged from 67.7% (95% CI: 67.5-68.0) in Sweden to 69.6% (95% CI: 69.2-70.0) in Finland, with intranational variation. The 1-year risk of stroke varied from 1.9% (95% CI: 1.8-2.0) in Sweden and Finland to 2.3% (95% CI: 2.2-2.4) in Denmark, with intranational variation. The initiation of OAC therapy increased with a preference for direct oral anticoagulants over warfarin. The risk of ischemic stroke decreased with no increase in intracranial and intracerebral bleeding. Conclusion We documented inter- and intranational variation in initiating OAC therapy and clinical outcomes across Nordic countries. Adherence to structured care of patients with AF could reduce future variation.
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Affiliation(s)
- Lars Frost
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Mika Lehto
- Department of Internal Medicine, Hospital District of Helsinki and Uusimaa, Lohja Hospital, Lohja, Finland
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Tomas Andersson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Per Wändell
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Martin Holzmann
- Functional Area of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Internal Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Pia Cordsen
- Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | - Nicklas Vinter
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
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14
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Akao M, Tsuji H, Kusano K, Matsui K, Hiramitsu S, Hatori Y, Odakura H, Ogawa H. Clinical characteristics and outcomes of Japanese atrial fibrillation patients with poor medication adherence: A sub-analysis of the GENERAL study. J Cardiol 2023; 81:209-214. [PMID: 35985869 DOI: 10.1016/j.jjcc.2022.07.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/12/2022] [Accepted: 07/25/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Oral anticoagulation therapy is essential for preventing stroke in patients with atrial fibrillation (AF). However, poor anticoagulant adherence may hamper medication safety and effective prevention of stroke. METHODS GENERAL is a prospective cohort study of AF patients taking rivaroxaban prescribed by general practitioners in Japan. In this study, anticoagulant adherence was calculated as the proportion of days covered (PDC), and patients were retrospectively divided into two groups: good adherence (PDC ≥80 %) and poor adherence (<80 %). RESULTS Of 5680 patients in the GENERAL study, the poor adherence group consisted of 223 patients (3.9 %). Baseline clinical characteristics were almost comparable regarding age (PDC ≥80 % vs. <80 %: 73.9 vs. 74.0 years, p = 0.92) and sex (male 64.6 % vs. 66.8 %, p = 0.52). The PDC <80 % group more often had various co-morbidities, and had significantly higher CHADS2 (2.14 vs. 2.28, p = 0.04) and CHA2DS2-VASc scores (3.12 vs. 3.31, p = 0.045). There was no significant difference in HAS-BLED score (1.41 vs. 1.47, p = 0.39). During 2-year follow-up, the incidences of stroke or systemic embolism (1.14 vs. 3.56 % per patient-year, p < 0.01), major bleeding (0.59 vs. 1.78 % per patient-year, p < 0.01), and net clinical outcome (the composite of stroke, systemic embolism, major bleeding, or death) (3.49 vs. 7.78 % per patient-year, p < 0.01) were significantly higher in the poor adherence group; however, there was no significant difference in all-cause (1.89 vs. 2.73 % per patient-year, p = 0.23) and cardiovascular mortality (0.86 vs. 1.49 % per patient-year, p = 0.18). Multivariate analysis revealed that the poor adherence group was independently associated with stroke or systemic embolism (adjusted hazard ratio 3.12, 95 % confidence interval 1.79-5.47), major bleeding (2.87, 1.31-6.34), and net clinical outcome, (2.02, 1.39-2.93), but not with all-cause (1.18, 0.64-2.17) or cardiovascular death (1.39, 0.60-2.93). CONCLUSIONS Poor anticoagulant adherence, as measured by PDC <80 %, was associated with higher incidence of stroke or systemic embolism and major bleeding in the GENERAL study.
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Affiliation(s)
- Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan.
| | | | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kunihiko Matsui
- Department of General Medicine and Primary Care, Kumamoto University Hospital, Kumamoto, Japan
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Hamatani Y, Nishi H, Iguchi M, Esato M, Tsuji H, Wada H, Hasegawa K, Ogawa H, Abe M, Fukuda S, Akao M. Machine Learning Risk Prediction for Incident Heart Failure in Patients With Atrial Fibrillation. JACC. ASIA 2022; 2:706-716. [PMID: 36444329 PMCID: PMC9700042 DOI: 10.1016/j.jacasi.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 07/01/2022] [Accepted: 07/16/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) increases the risk of heart failure (HF); however, little focus is placed on the risk stratification for, and prevention of, incident HF in patients with AF. OBJECTIVES This study aimed to construct and validate a machine learning (ML) prediction model for HF hospitalization in patients with AF. METHODS The Fushimi AF Registry is a community-based prospective survey of patients with AF in Fushimi-ku, Kyoto, Japan. We divided the data set of the registry into derivation (n = 2,383) and validation (n = 2,011) cohorts. An ML model was built to predict the incidence of HF hospitalization using the derivation cohort, and predictive ability was examined using the validation cohort. RESULTS HF hospitalization occurred in 606 patients (14%) during a median follow-up period of 4.4 years in the entire registry. Data of transthoracic echocardiography and biomarkers were frequently nominated as important predictive variables across all 6 ML models. The ML model based on a random forest algorithm using 7 variables (age, history of HF, creatinine clearance, cardiothoracic ratio on x-ray, left ventricular [LV] ejection fraction, LV end-systolic diameter, and LV asynergy) had high prediction performance (area under the receiver operating characteristics curve [AUC]: 0.75) and was significantly superior to the Framingham HF risk model (AUC: 0.67; P < 0.001). Based on Kaplan-Meier curves, the ML model could stratify the risk of HF hospitalization during the follow-up period (log-rank; P < 0.001). CONCLUSIONS The ML model revealed important predictors and helped us to stratify the risk of HF, providing opportunities for the prevention of HF in patients with AF.
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Affiliation(s)
- Yasuhiro Hamatani
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Hidehisa Nishi
- Division of Neurosurgery, St. Michael’s Hospital, Toronto, Canada
| | - Moritake Iguchi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Masahiro Esato
- Department of Arrhythmia, Ogaki Tokushukai Hospital, Gifu, Japan
| | | | - Hiromichi Wada
- Division of Translational Research, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Koji Hasegawa
- Division of Translational Research, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Hisashi Ogawa
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Mitsuru Abe
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Shunichi Fukuda
- Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
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