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Lu Z, Ntlapo N, Tilly MJ, Geurts S, Aribas E, Ikram MK, de Groot NMS, Kavousi M. Burden of cardiometabolic disorders and lifetime risk of new-onset atrial fibrillation among men and women: the Rotterdam Study. Eur J Prev Cardiol 2024; 31:1141-1149. [PMID: 38307013 DOI: 10.1093/eurjpc/zwae045] [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: 05/31/2023] [Revised: 01/14/2024] [Accepted: 01/21/2024] [Indexed: 02/04/2024]
Abstract
AIMS To examine the association between the burden of cardiometabolic disorders with new-onset atrial fibrillation (AF) and lifetime risk of AF incidence among men and women. METHODS AND RESULTS Four thousand one hundred and one men and 5421 women free of AF at baseline (1996-2008) from the population-based Rotterdam Study were included. Sex-specific Cox proportional-hazards regression models were used to assess the association between the burden of cardiometabolic disorders and risk of new-onset AF. The remaining lifetime risk for AF was estimated at index ages of 55, 65, and 75 years up to age 108. Mean age at baseline was 65.5 ± 9.4 years. Median follow-up time was 12.8 years. In the fully adjusted model, a stronger association was found between a larger burden of cardiometabolic disorders and incident AF among women [hazard ratio (HR): 1.33% and 95% conference interval (CI): 1.22-1.46], compared to men [1.18 (1.08-1.29)] (P for sex-interaction <0.05). The lifetime risk for AF significantly increased with the number of cardiometabolic disorders among both sexes. At an index age of 55 years, the lifetime risks (95% CIs) for AF were 27.1% (20.8-33.4), 26.5% (22.8-30.5), 29.9% (26.7-33.2), 30.8% (25.7-35.8), and 33.3% (23.1-43.6) among men, for 0, 1, 2, 3, and ≥4 comorbid cardiometabolic disorders. Corresponding risks were 15.8% (10.5-21.2), 23.0% (19.8-26.2), 29.7% (26.8-32.6), 26.2% (20.8-31.6), and 34.2% (17.3-51.1) among women. CONCLUSION We observed a significant combined impact of cardiometabolic disorders on AF risk, in particular among women. Participants with cardiometabolic multimorbidity had a significantly higher lifetime risk of AF, especially at a young index age.
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Affiliation(s)
- Zuolin Lu
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, office Na-2714, PO Box 2040, 3000 CA Rotterdam, The Netherlands
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Noluthando Ntlapo
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, office Na-2714, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Martijn J Tilly
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, office Na-2714, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Sven Geurts
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, office Na-2714, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Elif Aribas
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, office Na-2714, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - M Kamran Ikram
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, office Na-2714, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Natasja M S de Groot
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Maryam Kavousi
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, office Na-2714, PO Box 2040, 3000 CA Rotterdam, The Netherlands
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Marçal IR, Vidal-Almela S, Blanchard C, Prince SA, Way KL, Reed JL. Sex Differences in Physical Activity Levels and Sitting Time in Patients With Atrial Fibrillation. J Cardiopulm Rehabil Prev 2024; 44:280-288. [PMID: 38836648 DOI: 10.1097/hcr.0000000000000867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
PURPOSE While research demonstrates low levels of physical activity (PA) among adults living with atrial fibrillation (AF), there is limited evidence investigating sex differences in moderate to vigorous intensity physical activity (MVPA) and sedentary time in this population. The primary aim was to examine sex differences in MVPA levels and sitting time between women and men with AF. Secondary aims explored sex differences in sociodemographic factors, outcome expectations, and task self-efficacy toward PA levels. METHODS This was a subanalysis of the CHAMPLAIN-AF cohort study. Women and men with AF completed a survey, including the Short-Form International Physical Activity Questionnaire. RESULTS A total of 210 women (median = 66.0 yr: 95% CI, 63.5-68.0) and 409 men (median = 66.0 yr: 95% CI, 64.0-67.0) were included. No sex differences were observed in median weekly MVPA (60 min/wk: 95% CI, 0-120 in women vs 120 min/wk: 95% CI, 85-150 in men) and daily sitting time (5.5 hr/d: 95% CI, 5.0-6.0 in women vs 6.0 hr/d: 95% CI, 5.0-6.0 in men). Women engaged in significantly less vigorous-intensity PA than men ( P = .03) and demonstrated significantly lower task self-efficacy ( P < .01). Significant positive correlations in PA levels with outcome expectations (mostly weak) and task self-efficacy (mostly strong) were observed in both sexes. CONCLUSION Most women and men with AF did not meet the global MVPA guidelines but met the sitting time recommendation. Women presented with lower vigorous-intensity physical activity levels and confidence than men. Strategies to increase physical activity behavior, considering sociodemographic factors and task self-efficacy, are needed and may differ between sexes.
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Affiliation(s)
- Isabela R Marçal
- Author Affiliations: Exercise Physiology and Cardiovascular Health Laboratory, Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, (Mss Marçal and Vidal-Almela, and Drs Way and Reed); Faculty of Health Sciences, School of Human Kinetics, University of Ottawa, (Ms Marçal and Dr Reed); Faculty of Medicine, Dalhousie University, Halifax, Canada (Dr Blanchard); Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Canada (Dr Prince); Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia (Dr Way); and Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada (Dr Reed)
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Springer J, Pejska M, Homenda W, Zdrojewski T, Daniłowicz-Szymanowicz L, Kozłowski D. Effectiveness of antazoline versus amiodarone, flecainide and propafenone in restoring sinus rhythm at the emergency department. Adv Med Sci 2024; 69:248-255. [PMID: 38649031 DOI: 10.1016/j.advms.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 02/13/2024] [Accepted: 04/15/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Little is known about the effectiveness of pharmacological cardioversion (PCV) with antazoline in comparison to flecainide. The aim of this study was to compare the effectiveness of antazoline in restoring sinus rhythm (SR) versus amiodarone, flecainide and propafenone in a group of emergency department (ED) patients. MATERIALS/METHODS This was a single-centre retrospective analysis of patient records from an ED in a large hospital in Poland. We analysed a total of 1878 patient records, divided based on the anti-arrhythmic drug (AAD) administered during PCV: antazoline (n = 1080), antazoline + β-blocker (n = 479), amiodarone (n = 129), flecainide (n = 102), propafenone (n = 88). Of the patients, 63.5 % were female (median 65 years, [19-100]). RESULTS The percentage of successful PCV was significantly higher in the antazoline group (84.3 %) than in the antazoline + β-blocker (75.8 %, p = 0.0001), propafenone (75.6 %, p = 0.0364) and amiodarone (68.8 %, p < 0.0001) groups. Post-hoc analysis revealed that patients who received PCV with antazoline, antazoline + β-blocker, flecainide and propafenone had significantly shorter time to SR than those who received amiodarone (p < 0.0001). Univariate regression analysis revealed that patients who underwent PCV with antazoline were almost twice as likely to return to SR compared to the other groups (p < 0.0001, OR 1.81, 95 % CI 1.44-2.27). CONCLUSIONS This is the first study comparing the effectiveness of antazoline in PCV versus flecainide in addition to the previously studied amiodarone and propafenone. Our results indicate that antazoline is more effective in restoring SR than amiodarone, flecainide and propafenone. In addition, antazoline restored SR significantly faster than amiodarone or propafenone.
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Affiliation(s)
- Janusz Springer
- Division of Preventive Medicine and Education, Medical University of Gdańsk, Gdańsk, Poland.
| | - Michalina Pejska
- Institute of Health Sciences, Pomeranian University in Słupsk, Słupsk, Poland
| | - Wojciech Homenda
- Institute of Health Sciences, Pomeranian University in Słupsk, Słupsk, Poland
| | - Tomasz Zdrojewski
- Division of Preventive Medicine and Education, Medical University of Gdańsk, Gdańsk, Poland
| | | | - Dariusz Kozłowski
- Department of Cardiology and Electrotherapy, Medical University of Gdańsk, Gdańsk, Poland
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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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Sex and Gender Bias as a Mechanistic Determinant of Cardiovascular Disease Outcomes. Can J Cardiol 2022; 38:1865-1880. [PMID: 36116747 DOI: 10.1016/j.cjca.2022.09.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 08/21/2022] [Accepted: 09/11/2022] [Indexed: 12/14/2022] Open
Abstract
Defined as a prejudice either for or against something, biases at the provider, patient, and societal level all contribute to differences in cardiovascular disease recognition and treatment, resulting in outcome disparities between sexes and genders. Provider bias in the under-recognition of female-predominant cardiovascular disease and risks might result in underscreened and undertreated patients. Furthermore, therapies for female-predominant phenotypes including nonobstructive coronary artery disease and heart failure with preserved ejection fraction are less well researched, contributing to undertreated female patients. Conversely, women are less likely to seek urgent medical attention, potentially related to societal bias to put others first, which contributes to diagnostic delays. Furthermore, women are less likely to have discussions around risk factors for coronary artery disease compared with men, partially because they are less likely to consider themselves at risk for heart disease. Provider bias in interpreting a greater number of presenting symptoms, some of which have been labelled as "atypical," can lead to mislabelling presentations as noncardiovascular. Furthermore, providers might avoid discussions around certain therapies including thrombolysis for stroke, and cardiac resynchronization therapy in heart failure, because it is incorrectly assumed that women are not interested in pursuing options deemed more invasive. To mitigate bias, organizations should aim to increase the visibility and involvement of women in research, health promotion, and clinical and leadership endeavours. More research needs to be done to identify effective interventions to mitigate sex and gender bias and the resultant cardiovascular outcome discrepancies.
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Siddiqi HK, Vinayagamoorthy M, Gencer B, Ng C, Pester J, Cook NR, Lee IM, Buring J, Manson JE, Albert CM. Sex Differences in Atrial Fibrillation Risk: The VITAL Rhythm Study. JAMA Cardiol 2022; 7:1027-1035. [PMID: 36044209 PMCID: PMC9434484 DOI: 10.1001/jamacardio.2022.2825] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 07/12/2022] [Indexed: 11/14/2022]
Abstract
Importance Women have a lower incidence of atrial fibrillation (AF) compared with men in several studies, but it is unclear whether this sex difference is independent of sex differences in prevalent cardiovascular disease (CVD), body size, and other risk factors. Objective To examine sex differences in AF incidence and whether AF risk factors differ by sex in a contemporary cohort of men and women without prevalent CVD. Design, Setting, and Participants This was a prospective cohort analysis within the Vitamin D and Omega-3 Trial (VITAL) Rhythm Study, a randomized trial that examined the effect of vitamin D and ω-3 fatty acid supplementation on incident AF among men 50 years or older and women 55 years or older without a prior history of prevalent AF, CVD, or cancer at baseline. Data were analyzed from September 29, 2020, to June 29, 2021. Exposures Sex, height, weight, body mass index (BMI), body surface area (BSA), and other AF risk factors at study enrollment. Main Outcomes and Measures Incident AF confirmed by medical record review. Results A total of 25 119 individuals (mean [SD] age, 67.0 [7.1] years; 12 757 women [51%]) were included in this study. Over a median (IQR) follow-up of 5.3 (5.1-5.7) years, 900 confirmed incident AF events occurred among 12 362 men (495 events, 4.0%) and 12 757 women (405 events, 3.2%). After adjustment for age and treatment assignment, women were at lower risk for incident AF than men (hazard ratio [HR], 0.68; 95% CI, 0.59-0.77; P < .001). The inverse association between female sex and AF persisted after adjustment for race and ethnicity, smoking, alcohol intake, hypertension, diabetes (type 1, type 2, gestational), thyroid disease, exercise, and BMI (HR, 0.73; 95% CI, 0.63-0.85; P <.001). However, female sex was positively associated with AF when height (HR, 1.39; 95% CI, 1.14-1.72; P = .001), height and weight (HR 1.49, 95% CI, 1.21-1.82; P <.001), or BSA (HR, 1.25; 95% CI, 1.06-1.49; P = .009) were substituted for BMI in the multivariate model. In stratified models, risk factor associations with incident AF were similar for women and men. Conclusions and Relevance In this cohort study, findings suggest that after controlling for height and/or body size, women without CVD at baseline were at higher risk for AF than men, suggesting that sex differences in body size account for much of the protective association between female sex and AF. These data underscore the importance of AF prevention in women.
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Affiliation(s)
- Hasan K. Siddiqi
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Manickavasagar Vinayagamoorthy
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Baris Gencer
- Division of Cardiology, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | - Chee Ng
- Division of Cardiovascular Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Julie Pester
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nancy R. Cook
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - I-Min Lee
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Julie Buring
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - JoAnn E. Manson
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Christine M. Albert
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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Tan JL, Johnson L, Dziubinski M, Napiorkowski N, Witkowska O, Slusarczyk ME, Healey JS, Russo AM. Sex differences in presentation of atrial fibrillation: Findings from 30-day ambulatory monitoring in real-world practice. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 22:100208. [PMID: 38558904 PMCID: PMC10978428 DOI: 10.1016/j.ahjo.2022.100208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/04/2022] [Accepted: 09/14/2022] [Indexed: 04/04/2024]
Abstract
Background Women are less likely to receive oral anticoagulation or ablation for treatment of atrial fibrillation (AF). Identification of sex differences in arrhythmia characteristics and symptoms may lead to a better understanding of potential reasons for these differences. Objectives To determine sex differences in AF with respect to heart rate, duration, burden, and symptoms in patients undergoing mobile cardiac telemetry (MCT) monitoring. Methods All patients who registered for ≤30-day MCT using PocketECG (MediLynx) in the USA in 2017 were included (n = 27,512, 58 % women). PocketECG records and transmits a three-lead ambulatory electrocardiogram (ECG) with real-time beat-to-beat analysis. Sex-related differences were analyzed with Chi2 and Spearmans rho. Results Fewer women than men were diagnosed with AF lasting ≥30s (13.7 % versus [vs] 19.0 %, p < 0.001). AF burden was lower in women in all age groups <90 years (all p < 0.01). Women were older at the time of AF diagnosis (median 76 vs 73 years, p < 0.001), had faster heart rate during AF (mean: 104.7 ± 26.0 vs 96.7 ± 26.7 bpm, p < 0.001), and shorter AF duration (mean: 96.2 ± 176.0 vs 121.6 ± 189.9 min, p < 0.001). There was a non-significant trend toward more symptoms (such as dizziness, racing heart, fatigue, or palpitations) during AF in women compared to men (46.5 % vs 43.7 %, p = 0.062). Conclusions AF was less prevalent and occurred at lower burdens in women than men in each age strata. Despite faster heart rates in AF in women, there were no significant sex differences in reported symptoms during AF. Sex differences in therapy cannot be explained by differences in symptoms or rates in AF. Condensed abstract Real-world data on sex differences in AF using a 30-day MCT monitoring device remain scarce. We aim to determine the sex differences in AF with respect to prevalence, burden, heart rate, and symptom in patients undergoing ≤30-day MCT monitoring. Our data analysis suggests that fewer women than men had AF, women were older at diagnosis of AF, and women with AF had higher mean heart rate, shorter mean AF duration, and lower mean AF burden than men. Further studies are needed to examine reasons for sex differences, specifically in relation to AF therapy and its impact on clinical outcomes.
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Affiliation(s)
- Jian Liang Tan
- Cardiovascular Division, Cooper University Health System, Cooper Medical School of Rowan University, United States of America
| | - Linda Johnson
- Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
| | | | | | | | | | - Jeff S. Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Andrea M. Russo
- Cardiovascular Division, Cooper University Health System, Cooper Medical School of Rowan University, United States of America
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Budde H, Hassoun R, Mügge A, Kovács Á, Hamdani N. Current Understanding of Molecular Pathophysiology of Heart Failure With Preserved Ejection Fraction. Front Physiol 2022; 13:928232. [PMID: 35874547 PMCID: PMC9301384 DOI: 10.3389/fphys.2022.928232] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/20/2022] [Indexed: 12/15/2022] Open
Abstract
Heart Failure (HF) is the most common cause of hospitalization in the Western societies. HF is a heterogeneous and complex syndrome that may result from any dysfunction of systolic or diastolic capacity. Abnormal diastolic left ventricular function with impaired relaxation and increased diastolic stiffness is characteristic of heart failure with preserved ejection fraction (HFpEF). HFpEF accounts for more than 50% of all cases of HF. The prevalence increases with age: from around 1% for those aged <55 years to >10% in those aged 70 years or over. Nearly 50% of HF patients have HFrEF and the other 50% have HFpEF/HFmrEF, mainly based on studies in hospitalized patients. The ESC Long-Term Registry, in the outpatient setting, reports that 60% have HFrEF, 24% have HFmrEF, and 16% have HFpEF. To some extent, more than 50% of HF patients are female. HFpEF is closely associated with co-morbidities, age, and gender. Epidemiological evidence suggests that HFpEF is highly represented in older obese women and proposed as ‘obese female HFpEF phenotype’. While HFrEF phenotype is more a male phenotype. In addition, metabolic abnormalities and hemodynamic perturbations in obese HFpEF patients appear to have a greater impact in women then in men (Sorimachi et al., European J of Heart Fail, 2022, 22). To date, numerous clinical trials of HFpEF treatments have produced disappointing results. This outcome suggests that a “one size fits all” approach to HFpEF may be inappropriate and supports the use of tailored, personalized therapeutic strategies with specific treatments for distinct HFpEF phenotypes. The most important mediators of diastolic stiffness are the cardiomyocytes, endothelial cells, and extracellular matrix (ECM). The complex physiological signal transduction networks that respond to the dual challenges of inflammatory and oxidative stress are major factors that promote the development of HFpEF pathologies. These signalling networks contribute to the development of the diseases. Inhibition and/or attenuation of these signalling networks also delays the onset of disease. In this review, we discuss the molecular mechanisms associated with the physiological responses to inflammation and oxidative stress and emphasize the nature of the contribution of most important cells to the development of HFpEF via increased inflammation and oxidative stress.
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Affiliation(s)
- Heidi Budde
- Institut für Forschung und Lehre (IFL), Molecular and Experimental Cardiology, Ruhr University Bochum, Bochum, Germany
- Department of Cardiology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Roua Hassoun
- Institut für Forschung und Lehre (IFL), Molecular and Experimental Cardiology, Ruhr University Bochum, Bochum, Germany
- Department of Cardiology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Andreas Mügge
- Department of Cardiology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Árpád Kovács
- Institut für Forschung und Lehre (IFL), Molecular and Experimental Cardiology, Ruhr University Bochum, Bochum, Germany
- Department of Cardiology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Nazha Hamdani
- Institut für Forschung und Lehre (IFL), Molecular and Experimental Cardiology, Ruhr University Bochum, Bochum, Germany
- Department of Cardiology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
- *Correspondence: Nazha Hamdani,
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Barcellona D, Schirru P, Mameli A, Cornacchini S, Fenu L, Marongiu F. Over-anticoagulation by vitamin K antagonists and gender differences. Int J Cardiol 2022; 362:147-151. [DOI: 10.1016/j.ijcard.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/10/2022] [Accepted: 05/02/2022] [Indexed: 11/25/2022]
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Albertsen N, Riahi S, Pedersen ML, Skovgaard N, Andersen S. The prevalence of atrial fibrillation in Greenland: a register-based cross-sectional study based on disease classifications and prescriptions of oral anticoagulants. Int J Circumpolar Health 2022; 81:2030522. [PMID: 35086441 PMCID: PMC8803055 DOI: 10.1080/22423982.2022.2030522] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Previous studies of the prevalence of atrial fibrillation (AF) in Greenland are based on either single-point electrocardiograms (ECGs) or patients admitted with stroke. This study estimates the prevalence of AF based on disease classifications in the electronic medical record system (EMR) and prescriptions of oral anticoagulants (OACs). Patients given a diagnose classification code for AF or atrial flutter or prescribed the vitamin K antagonist Warfarin or the direct-acting oral anticoagulant Rivaroxaban were identified in the EMR. Descriptive data and selected laboratory values were extracted, and a minimum CHA2DS2-VASc score was calculated for the 790 patients identified in the EMR (66% men). A total prevalence of AF of 1.4% was found in the general population (1.8% among men and 1.0% among women), with a significantly lower prevalence among women younger than 70 years. There was a significant increase in AF-prevalence with advancing age (p<0.001) for both men and women. A minimum CHA2DS2-VASc was estimated and app. 10% of the patients may be undertreated with OACs. The prevalence of AF found in this study is higher than that found in previous studies in Greenland and comparable to the prevalence found in other Western countries, indicating that AF is common in Greenland.
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Affiliation(s)
- N Albertsen
- Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, University of Aalborg, Aalborg, Denmark.,Arctic Health Research Centre, Aalborg University Hospital, Aalborg, Denmark
| | - S Riahi
- Department of Clinical Medicine, University of Aalborg, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - M L Pedersen
- Steno Diabetes Centre, Nuuk, Greenland.,Greenland Centre for Health Research, University of Greenland, Nuuk, Greenland
| | - N Skovgaard
- Greenland Centre for Health Research, University of Greenland, Nuuk, Greenland
| | - S Andersen
- Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, University of Aalborg, Aalborg, Denmark.,Arctic Health Research Centre, Aalborg University Hospital, Aalborg, Denmark.,Greenland Centre for Health Research, University of Greenland, Nuuk, Greenland
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11
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Alipour P, Azizi Z, Norris CM, Raparelli V, McMurtry MS, Macle L, Andrade J, Pilote L. Representation of Females in Atrial Fibrillation Clinical Practice Guidelines. Can J Cardiol 2022; 38:729-735. [PMID: 35007706 DOI: 10.1016/j.cjca.2021.12.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/07/2021] [Accepted: 12/26/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common arrhythmia in males and females worldwide, and its prevalence is increasing. Management of AF is guided by evidence-based clinical practice guidelines which provide recommendations based on available evidence. The extent of sex-specific data in the AF literature used to provide guideline recommendations has not been investigated. Therefore, using the 2020 Canadian Cardiovascular Society (CCS) Atrial Fibrillation Management Guidelines as example, the purpose of this study was to review female representation and the reporting of sex-disaggregated data in the studies referenced in AF guidelines. METHODS Randomized controlled trials (RCTs), prospective and retrospective cohorts, were screened to calculate the proportion of study participants who were female and to establish whether studies provided sex disaggregated analyses. The participant prevalence ratio (PPR), a quotient of the female participant rate and the prevalence of females in the AF population, was calculated for each study. RESULTS A total of 885 studies included in the CCS guidelines were considered. Of those, 467 met the inclusion criteria. Overall, females represented 39.1% of the population in all studies and RCTs had the lowest proportions of females (33.8%, PPR: 0.70). Of studies with sex-disaggregated analyses (n=140 (29.9%)), single centered RCTs, and retrospective cohorts had the lowest and highest rate of sex-specific analyses respectively (11.5% vs 32.5%). CONCLUSION The evidence used to derive guideline recommendations may be inadequate for sex-specific recommendations. Until enough data can support female specific guidelines, increased inclusion of females in AF studies, may aid in the precision of recommendations.
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Affiliation(s)
- Pouria Alipour
- Centre for Outcomes Research and Evaluation, McGill University Health Centre Research Institute, Montreal, QC, Canada
| | - Zahra Azizi
- Centre for Outcomes Research and Evaluation, McGill University Health Centre Research Institute, Montreal, QC, Canada
| | - Colleen M Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada; Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada; Cardiovascular & Stroke SCN, Alberta Health Systems, Alberta Canada
| | - Valeria Raparelli
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy; University Center for Studies on Gender Medicine University of Ferrara, Ferrara, Italy
| | - M Sean McMurtry
- Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Laurent Macle
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Jason Andrade
- Heart Rhythm Services, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Louise Pilote
- Centre for Outcomes Research and Evaluation, McGill University Health Centre Research Institute, Montreal, QC, Canada.
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12
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Hu LX, Tang M, Hua W, Ren XQ, Jia YH, Chu JM, Zhang JT, Liu XN. Psychological Disturbances and Their Association with Sleep Disturbance in Patients Admitted for Arrhythmia Diseases. Neuropsychiatr Dis Treat 2022; 18:1739-1750. [PMID: 36000025 PMCID: PMC9393031 DOI: 10.2147/ndt.s370128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 07/21/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES This study aimed to assess the depression and anxiety status and their association with sleep disturbance among one single center Chinese inpatients with arrhythmia and help cardiologists better identify patients who need psychological care. METHODS A cross-sectional survey was conducted among 495 inpatients with arrhythmia treated in Fuwai Hospital from October to December 2019. The psychological status and sleep quality were assessed using the Zung Self-Rating Anxiety Scale (SAS), the Zung Self-Rating Depression Scale (SDS) and the Pittsburgh Sleep Quality Index (PSQI). Multivariate logistic regression was used to identify the potential risk factors for anxiety and depression. RESULTS The mean age of the participants was 52.8 ± 14.4 years, and 58.0% were male. Approximately 18.3% were in an anxious state, and 33.5% were in a depressive state. In multivariate logistic regression, age from 50 to 59 (p = 0.03), unemployment (p = 0.026) and sleep disturbance (p < 0.001) were the risk factors for anxiety status. Cardiac implanted electronic devices (CIEDs) (p = 0.004) and sleep disturbance (p < 0.001) were the risk factors for depression status. A total of 150 patients (30.3%) were categorized as having poor sleep quality (PSQI > 7). The adjusted odds ratio (OR) of having poor sleep quality was 4.30-fold higher in patients with both anxiety and depression (OR: 4.30; 95% confidence interval [CI]: 2.52-7.35); 2.67-fold higher in patients with depression (OR: 2.67; 95% CI: 1.78-4.00); and 3.94-fold higher in patients with anxiety (OR: 3.94; 95% CI: 2.41-6.44). CONCLUSIONS Psychological intervention is critical for Chinese inpatients with arrhythmia, especially for patients aged 50-59, unemployed, or those using CIEDs. Poor sleep quality could be an important risk factor linked to psychological disturbances.
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Affiliation(s)
- Li-Xing Hu
- Center of Arrhythmia, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, People's Republic of China
| | - Min Tang
- Center of Arrhythmia, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, People's Republic of China
| | - Wei Hua
- Center of Arrhythmia, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, People's Republic of China
| | - Xiao-Qing Ren
- Center of Arrhythmia, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, People's Republic of China
| | - Yu-He Jia
- Center of Arrhythmia, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, People's Republic of China
| | - Jian-Min Chu
- Center of Arrhythmia, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, People's Republic of China
| | - Jing-Tao Zhang
- Center of Arrhythmia, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, People's Republic of China
| | - Xiao-Ning Liu
- Center of Arrhythmia, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, People's Republic of China
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13
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Ciarambino T, Giannico OV, Campanile A, Fischetti A, Barabgelata E, Ambrosino I, Para O, Politi C, Giordano M. Gender differences in ischemic stroke intra-hospital mortality: a systematic review. ITALIAN JOURNAL OF MEDICINE 2021. [DOI: 10.4081/itjm.2021.1378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The aim was to evaluate whether intra-hospital mortality from ischemic stroke is different in female patients. Methods. Studies were found in PubMed, Web of Science. We excluded 119 records because they did not include relevant reports or data. Studies were eligible for inclusion if enrolled adult patients with ischemic stroke and if the odds ratio (OR) of intra-hospital mortality in females compared to males is provided. Three retrospective cohort studies were eligible for inclusion criteria and so were included in the analysis. Findings: the random effect model showed a pooled significant higher risk of intra-hospital mortality [OR 1.34 (95% confidence interval 1.04, 1.74), P=0.026] in the female group compared to the male group. Our systematic review shows that intra-hospital mortality was significantly higher in female subjects compared to male.
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14
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Al-Khayatt BM, Salciccioli JD, Marshall DC, Krahn AD, Shalhoub J, Sikkel MB. Paradoxical impact of socioeconomic factors on outcome of atrial fibrillation in Europe: trends in incidence and mortality from atrial fibrillation. Eur Heart J 2021; 42:847-857. [PMID: 33495788 DOI: 10.1093/eurheartj/ehaa1077] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 06/01/2020] [Accepted: 12/16/2020] [Indexed: 12/28/2022] Open
Abstract
AIMS The aim of this study was to understand the changing trends in atrial fibrillation (AF) incidence and mortality across Europe from 1990 to 2017, and how socioeconomic factors and sex differences play a role. METHODS AND RESULTS We performed a temporal analysis of data from the 2017 Global Burden of Disease Database for 20 countries across Europe using Joinpoint regression analysis. Age-adjusted incidence, mortality, and mortality-to-incidence ratios (MIRs) to approximate case fatality rate are presented. Incidence and mortality trends were heterogenous throughout Europe, with Austria, Denmark, and Sweden experiencing peaks in incidence in the middle of the study period. Mortality rates were higher in wealthier countries with the highest being Sweden for both men and women (8.83 and 8.88 per 100 000, respectively) in 2017. MIRs were higher in women in all countries studied, with the disparity increasing the most over time in Germany (43.6% higher in women vs. men in 1990 to 74.5% higher in women in 2017). CONCLUSION AF incidence and mortality across Europe did not show a general trend, but unique patterns for some nations were observed. Higher mortality rates were observed in wealthier countries, potentially secondary to a survivor effect where patients survive long enough to suffer from AF and its complications. Outcomes for women with AF were worse than men, represented by higher MIRs. This suggests that there is widespread healthcare inequality between the sexes across Europe, or that there are biological differences between them in terms of their risk of adverse outcomes from AF.
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Affiliation(s)
- Becker M Al-Khayatt
- Cardiothoracic Intensive Care, Department of Intensive Care Medicine, St George's University Hospital, 1st Floor, Atkinson Morley Wing, Blackshaw Road, London SW17 0QT, UK
| | | | - Dominic C Marshall
- Critical Care Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Joseph Shalhoub
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK.,Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Markus B Sikkel
- Division of Cardiology, University of British Columbia, Vancouver, Canada.,Royal Jubilee Hospital, Vancouver, Canada.,Division of Medical Sciences, University of Victoria, Victoria, Canada
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15
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Shiyovich A, Chodick G, Azani L, Tirosh M, Shuvy M, Pereg D, Katz A, Minha S. Sex-specific contemporary trends in incidence, prevalence and survival of patients with non-valvular atrial fibrillation: A long-term real-world data analysis. PLoS One 2021; 16:e0247097. [PMID: 33600504 PMCID: PMC7891766 DOI: 10.1371/journal.pone.0247097] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/29/2021] [Indexed: 12/19/2022] Open
Abstract
Introduction Atrial fibrillation (AF) is a major increasing public health problem worldwide, with clinical and epidemiological differences between men and women. However, contemporary population-level data on incidence and survival are scarce. Aim To evaluate sex-specific contemporary trends in the incidence, prevalence, and long-term survival of non-valvular AF in a real-world setting Methods AF patients diagnosed between 2007–2015, insured by a large, state-mandated health organization in Israel (Maccabi Healthcare Services) were included. AF was diagnosed based on registered diagnoses. Patients with valvular disease, active malignancy, cardiac surgery ≤ 6 months, or recent pregnancy, were excluded. Annual incidence rate, period prevalence, and 5-year survival for each calendar year during the study period, were calculated. Results A total of 15,409 eligible patients (8,288 males, 7,121 females) were identified. Males were more likely to be younger, have higher rates of underlying diseases (ischemic heart disease, heart failure, and chronic obstructive pulmonary disease), but with lower rates of hypertension and chronic kidney diseases as compared to female patients. During the study period, age-adjusted incidence decreased both in men: (-0.020/1,000-person year, p-for trend = 0.033) and, women (-0.025/1,000 person-year p = 0.009). The five-year survival rate was significantly higher among men vs. women (77.1% vs. 71.5%, respectively, p<0.001). Age-adjusted prevalence increased significantly among men (+0.102 per year, p-for trend<0.001) yet decreased among women (-0.082 per year, p-for trend = 0.005). A significant trend toward improved long-term survival was observed in women and not in men. Conclusions The current study shows significant sex-related disparities in the incidence, prevalence, and survival of AF patients between 2007–2015; while the adjusted incidence of both has decreased over-time, prevalence and mortality decreased significantly only in women.
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Affiliation(s)
- Arthur Shiyovich
- Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- * E-mail:
| | - Gabriel Chodick
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Kahn-Sagol-Maccabi Research and Innovation Institute, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Liat Azani
- Kahn-Sagol-Maccabi Research and Innovation Institute, Maccabi Healthcare Services, Tel Aviv, Israel
| | | | - Mony Shuvy
- Heart Institute, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - David Pereg
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Meir Medical Center, Kfar-Saba, Israel
| | - Amos Katz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Sa’ar Minha
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Shamir Medical Center, Zerifin, Israel
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16
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Siland JE, Nguyen BO, de With RR, Van Gelder IC, van der Harst P, Rienstra M. Genetically-determined body mass index and the risk of atrial fibrillation progression in men and women. PLoS One 2021; 16:e0246907. [PMID: 33600500 PMCID: PMC7891778 DOI: 10.1371/journal.pone.0246907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/27/2021] [Indexed: 11/19/2022] Open
Abstract
Aims Limited causal evidence is available on the relationship between body mass index (BMI) and atrial fibrillation (AF) progression. Sex differences have been noted and may be relevant for AF progression. We investigated the association between the BMI Genetic Risk Score (GRS) and AF progression in men and women of the Groningen Genetic Atrial Fibrillation (GGAF) cohort. Methods and results The GGAF cohort (n = 2207) is a composite of 5 prospective cohorts with individuals of European ancestry. AF patients with genetic information, with at least 12 months follow-up and AF progression data were included. AF progression was defined as progression from paroxysmal to persistent/permanent AF, or persistent to permanent AF. A BMI GRS was constructed of genetic variants associated with BMI. Univariate and multivariate Cox proportional hazard regression analyses were performed in the total population and in men and women, separately. During a median follow-up of 34 [interquartile range 19–48] months 630 AF patients (mean age 62±11, 36% women, BMI of 28±5) were analyzed, and men and women developed similar AF progression rates (respectively 6.5% versus 6.1%). The BMI GRS was not associated with AF progression either as a continuous variable or in tertiles in the overall population. However, the BMI GRS was associated with the tertile of the highest BMI GRS in women (n = 225), also after multivariable adjustments of clinical risk factors (Hazard ratio 2.611 (95% confidence interval 1.151–5.924) p = 0.022). Conclusions Genetically-determined BMI is only associated with women at risk of AF progression. The results may be supporting evidence for a causal link between observed BMI and AF progression in women. We emphasize the need for further investigation of genetically determined BMI and observed BMI to optimize AF management in women with increased risk for AF progression.
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Affiliation(s)
- J. E. Siland
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - B. O. Nguyen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R. R. de With
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - I. C. Van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - P. van der Harst
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Heart and Lungs, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - M. Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- * E-mail:
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17
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Zelniker TA, Ardissino M, Andreotti F, O'Donoghue ML, Yin O, Park JG, Murphy SA, Ruff CT, Lanz HJ, Antman EM, Braunwald E, Giugliano RP, Merlini PA. Comparison of the Efficacy and Safety Outcomes of Edoxaban in 8040 Women Versus 13 065 Men With Atrial Fibrillation in the ENGAGE AF-TIMI 48 Trial. Circulation 2021; 143:673-684. [PMID: 33587659 PMCID: PMC7884089 DOI: 10.1161/circulationaha.120.052216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Female sex is an independent risk factor for stroke and systemic embolic events in patients with atrial fibrillation. This study aimed to examine the efficacy and safety profile of edoxaban in women versus men. Methods: The ENGAGE AF-TIMI 48 trial (Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48) randomly assigned 21 105 patients (8040 women) with atrial fibrillation and CHADS2 score ≥2 either to a higher-dose edoxaban regimen, a lower-dose edoxaban regimen, or warfarin. The primary end points of the trial were the composite of stroke or systemic embolic events (efficacy), and International Society on Thrombosis and Haemostasis–defined major bleeding (safety). Results: In comparison with men, women were older, had lower body weight, were more likely to have hypertension and renal dysfunction, but less likely to smoke, drink alcohol, or have diabetes or coronary artery disease. Pretreatment endogenous factor Xa activity was significantly higher in women than in men (92.5% versus 86.1%, P<0.001). Treatment with edoxaban in women resulted in greater peak edoxaban concentration and inhibition of endogenous factor Xa in comparison with men, resulting in similar endogenous factor Xa activity between the sexes 2 to 4 hours after dose. Treatment with higher-dose edoxaban regimen (versus warfarin) resulted in similar reduction in the risk of stroke/systemic embolic events (women: hazard ratio [HR], 0.87 [0.69–1.11], men: HR, 0.87 [0.71–1.06]; P-interaction=0.97) and major bleeding (women: HR, 0.74 [0.59–0.92], men: HR, 0.84 [0.72–0.99]; P-interaction=0.34) in women and men. However, women assigned to higher-dose edoxaban regimen experienced greater reductions in hemorrhagic stroke (HR, 0.30 [95% CI, 0.15–0.59] versus HR, 0.70 [95% CI, 0.46–1.06]), intracranial bleeding (HR, 0.20 [95% CI, 0.10–0.39] versus HR, 0.63 [95% CI, 0.44–0.89]), and life-threatening or fatal bleeding (HR, 0.25 [95% CI, 0.15–0.42] versus HR, 0.72 [95% CI, 0.54–0.96]) than men (each P-interaction<0.05). Conclusions: Despite many differences in baseline characteristics between women and men and higher baseline endogenous factor Xa levels in women, the intensity of anticoagulation achieved with edoxaban between the sexes was similar. Treatment with higher-dose edoxaban regimen resulted in an even greater reduction in hemorrhagic stroke and several serious bleeding outcomes in women than in men, whereas the efficacy profile was similar between sexes.
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Affiliation(s)
- Thomas A Zelniker
- Division of Cardiology, Medical University of Vienna, Austria (T.A.Z.)
| | | | - Felicita Andreotti
- Fondazione Policlinico Universitario Gemelli IRCCS, Rome, Italy (F.A.).,Institute of Cardiology, Catholic University Medical School, Rome, Italy (F.A.)
| | - Michelle L O'Donoghue
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
| | - Ophelia Yin
- Daiichi Sankyo Inc, Basking Ridge, NJ (O.Y.)
| | - Jeong-Gun Park
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
| | - Christian T Ruff
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
| | - Hans J Lanz
- Daiichi Sankyo Europe GmbH, Munich, Germany (H.J.L.)
| | - Elliott M Antman
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L.O., J.-G.P., S.A.M., C.T.R., E.M.A., E.B., R.P.G.)
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18
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Viana CC, Praxedes MFDS, de Sousa WJFN, Bartolazzi F, Vianna MS, Silva JLPD, Martins MAP. Influence of sex-based differences on oral anticoagulation control in patients taking coumarin derivatives: a systematic review protocol. JBI Evid Synth 2021; 19:477-483. [DOI: 10.11124/jbies-20-00168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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19
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Moqeem K, Beeharry MW, Fang T, Lim KJM, Tsouklidis N. Factors Influencing Sex-Related Differences in the Quality of Life of Patients With Atrial Fibrillation: A Systematic Review. Cureus 2020; 12:e12341. [PMID: 33457142 PMCID: PMC7797428 DOI: 10.7759/cureus.12341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Atrial fibrillation (AF) is a growing public health concern, the impact of which is frequently underestimated. It has a profound effect on the quality of life (QoL) which appears to be disproportionately lower in female patients compared to men. We aim to explore the factors contributing to sex-related disparities in the QoL of AF patients by conducting a systematic review using the PubMed electronic search database. We used the following combination of medical subject heading (MeSH) parameters: “atrial fibrillation” and “sex” and “quality of life” with specific inclusion and exclusion criteria. We identified 13 relevant studies published between 2010 and 2020 for our review. These studies evaluated sex-related differences in QoL scores, symptom burden, and AF-related complications originating across different continents in Asia, Europe, and North America. We found that female patients reported a reduced QoL as compared to men and they were more likely to be older with multiple co-morbidities at presentation. Women also reported more frequent and severe symptoms, potentially explained by the greater prevalence of anxiety and depression and thus enhancing symptom perception. Moreover, they were less likely to be managed by anti-arrhythmic medications and invasive rhythm control strategies such as catheter ablation. Female patients with AF experienced more severe strokes, but no sex disparities were found in AF-related cognitive decline. We determined that the more prominent contributory factors towards a lowered QoL in female AF patients appear to be secondary to a higher burden and perception of symptoms as well as under-utilization of invasive treatment modalities. However, further studies are warranted to confirm these findings.
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Affiliation(s)
- Komal Moqeem
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Medicine, Royal Surrey County Hospital, Guidford, GBR
| | - Mohammad Waseem Beeharry
- Medicine and Surgery, California Institute of Behavioral Neurosciences & Psychology, London, GBR.,Trauma and Orthopaedics, Barts Health NHS Trust, London, GBR
| | - Tiffany Fang
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Khei Jazzle M Lim
- Neurosciences and Psychology, California Institute of Behavioral Neurosciences & Psychology, California, USA
| | - Nicholas Tsouklidis
- Health Care Administration, University of Cincinnati Health, Cincinnati, USA.,Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Medicine, Atlantic University School of Medicine, Gros Islet, LCA
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Andrade JG, Aguilar M, Atzema C, Bell A, Cairns JA, Cheung CC, Cox JL, Dorian P, Gladstone DJ, Healey JS, Khairy P, Leblanc K, McMurtry MS, Mitchell LB, Nair GM, Nattel S, Parkash R, Pilote L, Sandhu RK, Sarrazin JF, Sharma M, Skanes AC, Talajic M, Tsang TSM, Verma A, Verma S, Whitlock R, Wyse DG, Macle L. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2020; 36:1847-1948. [PMID: 33191198 DOI: 10.1016/j.cjca.2020.09.001] [Citation(s) in RCA: 299] [Impact Index Per Article: 74.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/05/2020] [Accepted: 09/05/2020] [Indexed: 12/20/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | - Martin Aguilar
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jafna L Cox
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Paul Khairy
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stanley Nattel
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Jean-François Sarrazin
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Mukul Sharma
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Mario Talajic
- Montreal Heart Institute, University of Montreal, Montréal, Quebec, Canada
| | - Teresa S M Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
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21
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Branyan TE, Sohrabji F. Sex differences in stroke co-morbidities. Exp Neurol 2020; 332:113384. [PMID: 32585156 PMCID: PMC7418167 DOI: 10.1016/j.expneurol.2020.113384] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/06/2020] [Accepted: 06/15/2020] [Indexed: 12/12/2022]
Abstract
Males and females possess distinct biological differences that manifest in diverse risk profiles for acute and chronic diseases. A well-documented example of this is ischemic stroke. It has been demonstrated that older females have greater prevalence of, and worse outcome after, ischemic stroke than do males and younger females. Loss of estrogen after menopause is heavily implicated as a contributing factor for this phenomenon; however, there is mounting evidence to suggest that certain risk factors tend to occur more often in older females, such as hypertension and atrial fibrillation, while others more adversely affect females than they do males, such as diabetes and smoking. Sex-specific risk factors, such as oral contraceptive use and menopause, could also contribute to the discrepancy in stroke prevalence and outcome. Additionally, there is evidence to suggest that females tend to present with more nontraditional symptoms of acute stroke than do males, making it more difficult for clinicians to correctly identify the occurrence of a stroke, which may delay the administration of thrombolytic intervention. Finally, certain sociodemographic factors, such as the fact that females were more likely to live alone prior to stroke, may contribute to poorer recovery in females. This review will explore the various co-morbidities and sociodemographic factors that contribute to the greater prevalence of and poorer outcome after stroke in older females and will highlight the critical need for considering sex as a predisposing biological variable in stroke studies.
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Affiliation(s)
- Taylor E Branyan
- Women's Health in Neuroscience Program, Department of Neuroscience and Experimental Therapeutics, Texas A&M HSC College of Medicine, Bryan, TX 77807, USA; Texas A&M Institute for Neuroscience, College Station, TX 77840, USA
| | - Farida Sohrabji
- Women's Health in Neuroscience Program, Department of Neuroscience and Experimental Therapeutics, Texas A&M HSC College of Medicine, Bryan, TX 77807, USA; Texas A&M Institute for Neuroscience, College Station, TX 77840, USA.
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22
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Yao RJR, Macle L, Deyell MW, Tang L, Hawkins NM, Sedlak T, Nault I, Verma A, Khairy P, Andrade JG. Impact of Female Sex on Clinical Presentation and Ablation Outcomes in the CIRCA-DOSE Study. JACC Clin Electrophysiol 2020; 6:945-954. [PMID: 32819529 DOI: 10.1016/j.jacep.2020.04.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/13/2020] [Accepted: 04/21/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This study sought to evaluate sex-specific differences in atrial fibrillation (AF) presentation and catheter ablation outcomes in the prospective, multicenter, randomized CIRCA-DOSE (Cryoballoon vs. Irrigated Radiofrequency Catheter Ablation: Double Short vs. Standard Exposure Duration) study. BACKGROUND Similar to other cardiovascular conditions, significant sex-specific differences have been observed in the epidemiology, pathophysiology, presentation, and natural history of AF. Unfortunately, there are major gaps in our understanding of the pathophysiological basis for the observed sex-specific differences and their implications on therapy and prognosis. METHODS This study examined sex-specific differences in AF presentation, symptom severity and health-related quality of life, symptomatic and asymptomatic arrhythmia recurrence, AF burden, and health care utilization. RESULTS Freedom from any atrial tachyarrhythmia and symptomatic atrial tachyarrhythmia were similar between male (hazard ratio: 1.18; 95% confidence interval: 0.85 to 1.64; p = 0.39) and female patients (hazard ratio: 1.00; 95% confidence interval: 0.62 to 1.59; p = 0.92). Post-ablation, the median AF burden (percentage time in AF) was 0.00% (interquartile range: 0.00% to 0.16%) in male patients and 0.00% (interquartile range: 0.00% to 0.17%) in female patients, with no difference observed between the sexes (p = 0.30). Periprocedural complications occurred twice as frequently in female patients (3.5% vs. 7.0%; p = 0.18). In comparison to male patients, female patients reported a significantly worse symptom score and quality of life at baseline and all follow-up intervals, but they derived similar magnitude of improvement post-ablation. There was no difference between male and female patients with respect to emergency department visits, hospitalization, cardioversion, or repeat ablation. CONCLUSIONS When compared with male patients, female patients have significantly worse symptom scores and quality of life at baseline. Despite this, female patients with symptomatic paroxysmal AF derive similar benefit in freedom from recurrent arrhythmia and similar improvements in quality of life following AF ablation. (Cryoballoon vs. Irrigated Radiofrequency Catheter Ablation: Double Short vs. Standard Exposure Duration [CIRCA-DOSE]; NCT01913522).
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Affiliation(s)
- Ren Jie Robert Yao
- Heart Rhythm Services, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Laurent Macle
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Marc W Deyell
- Heart Rhythm Services, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa Tang
- Data Science Institute, Vancouver, British Columbia, Canada
| | - Nathaniel M Hawkins
- Heart Rhythm Services, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tara Sedlak
- Heart Rhythm Services, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Atul Verma
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Paul Khairy
- Heart Rhythm Services, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason G Andrade
- Heart Rhythm Services, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Quebec, Canada.
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23
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Kavousi M. Differences in Epidemiology and Risk Factors for Atrial Fibrillation Between Women and Men. Front Cardiovasc Med 2020; 7:3. [PMID: 32118043 PMCID: PMC7025483 DOI: 10.3389/fcvm.2020.00003] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 01/08/2020] [Indexed: 01/09/2023] Open
Abstract
Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is one of the most frequent cardiovascular diseases among both women and men. Although age-adjusted AF incidence and prevalence is larger among men, women are older at the time of AF diagnosis and have larger risk for AF-associated adverse outcomes such as morality and stroke. Based on evidence from epidemiological studies, elevated body mass index seems to confer a higher risk of AF among men. However, evidence regarding sex differences in the association between diabetes mellitus, elevated blood pressure, and dysglycemia with AF remains conflicting. While men with AF have larger burden of coronary artery disease, women with AF tend to have a larger prevalence of heart failure and valvular heart disease. Recently, several women-specific risk factors including pregnancy and its complications and number of children have been associated with AF. Earlier age at menopause, despite being a strong marker of adverse cardiometabolic risk, does not seem to be associated with increased risk of AF. To reduce the AF burden in both genders, better understanding of the differences between women and men with regard to AF is central. Large-scale studies are needed to separately investigate and report on women and men. Besides observations from epidemiological and clinical studies, to improve our understanding of sexual dimorphism in AF, sufficiently large genome-wide association studies as well as well-powered Mendelian randomization studies are essential to shed light on the sex-specific nature of the associations of risk factors with AF.
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Affiliation(s)
- Maryam Kavousi
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
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24
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Grewal P, Dobbs MR, Pennypacker K, Kryscio RJ, Kitzman P, Wolfe M, Elkins K, Bix GJ, Fraser JF. Evaluation of Patients with High National Institutes of Health Stroke Scale as Thrombectomy Candidates Using the Kentucky Appalachian Stroke Registry. Cerebrovasc Dis 2019; 48:251-256. [PMID: 31851968 DOI: 10.1159/000504834] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 11/18/2019] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Mechanical thrombectomy has become standard of care for emergent large vessel occlusive stroke. Estimates of incidence for thrombectomy eligibility vary significantly. National Institutes of Health Stroke Scale (NIHSS) of 10 or greater is highly predictive of large vessel occlusion. Using our Kentucky Appalachian Stroke Registry (KApSR), we evaluated temporal trends in stroke admissions with NIHSS ≥10 to determine patient characteristics among that group along with effects and needs in thrombectomy utilization. METHODS Using the KApSR database that captures patients throughout the Appalachian region in our stroke network, we evaluated patients admitted with ischemic stroke with NIHSS ≥10. We recorded demographics, comorbidities, treatment (thrombectomy, decompressive craniectomy), and county of origin. Change in NIHSS from admission to discharge was used as an indicator of inpatient outcome. RESULTS Between 2010 and 2016, 1,510 patients were admitted with NIHSS ≥10. 87.2% had high blood pressure, 69.6% had dyslipidemia, and 41.7% used tobacco. There were significant sex differences in the types of patients presenting with NIHSS ≥10 with females being older on average and having more atrial fibrillation and obesity. There was an increase in thrombectomy utilization from 2010 to 2016, but only 7.5% of the potentially eligible patients underwent the procedure. In comparison to the period 2010-2014, the 2015-2016 period had higher rates of obesity and tobacco abuse. CONCLUSION Among patients with significant burden of ischemic stroke, the most common coexisting medical condition was high blood pressure. Patients who underwent thrombectomy had significantly better inpatient clinical improvement. These data support the need to maximize utilization of thrombectomy along with need to devote increased resources on modifiable stroke risk factors.
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Affiliation(s)
- Parneet Grewal
- Department of Neurology, Rush University Medical Center, Chicago, Illinois, USA
| | - Michael R Dobbs
- Department of Neurology, University of Texas Rio Grande, Rio Grande, Texas, USA
| | - Keith Pennypacker
- Department of Neurology, Rush University Medical Center, Chicago, Illinois, USA
| | - Richard J Kryscio
- Department of Statistics, College of Arts and Sciences/University of Kentucky, Lexington, Kentucky, USA
| | - Patrick Kitzman
- Department of Neurology, University of Texas Rio Grande, Rio Grande, Texas, USA
| | - Marc Wolfe
- Department of Neurology, University of Texas Rio Grande, Rio Grande, Texas, USA.,Norton Healthcare/UK HealthCare Stroke Network, Lexington, Kentucky, USA
| | - Kelley Elkins
- Norton Healthcare/UK HealthCare Stroke Network, Lexington, Kentucky, USA
| | - Gregory J Bix
- Department of Neurosurgery, Tulane University, New Orleans, Louisiana, USA
| | - Justin F Fraser
- Department of Neurology, Rush University Medical Center, Chicago, Illinois, USA, .,Department of Neurological Surgery, College of Medicine/University of Kentucky, Lexington, Kentucky, USA, .,Department of Radiology, College of Medicine/University of Kentucky, Lexington, Kentucky, USA,
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25
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Fan SM, Fann A, Nah G, Pletcher MJ, Olgin JE, Marcus GM. Characteristics of Atrial Fibrillation Patients with a Family History of Atrial Fibrillation. J Atr Fibrillation 2019; 12:2198. [PMID: 31687072 DOI: 10.4022/jafib.2198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 12/14/2018] [Accepted: 02/26/2019] [Indexed: 11/10/2022]
Abstract
Background Family history has been shown to be associated with increased risk of atrial fibrillation (AF). However, the specific AF characteristics that travel with a family history have not yet been elucidated. The purpose of this study was to determine whether a family history of AF is associated with specific patient characteristics in a worldwide, remote cohort. Methods From the Health eHeart Study, an internet-based prospective cohort, we performed a cross-sectional analysis of AF participants who reported their family history and completed questionnaires regarding their medical conditions and AF symptoms. We assessed demographics, cardiovascular comorbidities, and AF symptom characteristics in AF participants with and without a family history of AF. Results In multivariable analysis of 5,884 participants with AF (mean age 59.9 ± 14.5, 59% male, 92% white), female sex (odds ratio [OR]=1.35, 95% CI, 1.17-1.54, p<0.0001) and birth in the U.S. (OR=2.54, 95% CI, 2.12-3.05, p<0.0001) were independently associated with having a family history of AF. Having a family history of AF was also more commonly associated with symptoms of shortness of breath (OR=1.40, 95% CI, 1.07-1.82, p=0.014), chest pain, pressure, or discomfort (OR=1.95, 95% CI, 1.22-3.13, p=0.0052), and feeling generally "off" about oneself (OR=1.84, 95% CI, 1.27-2.67, p=0.0013). Conclusions Patients with a family history of AF are more likely to be female, be US-born, and experience symptoms of AF, suggesting underlying mechanistic differences between those with and without family history of AF.
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Affiliation(s)
- Shannon M Fan
- Division of Cardiology, Department of Medicine, University of California, San Francisco, California
| | - Amy Fann
- Division of Cardiology, Department of Medicine, University of California, San Francisco, California
| | - Gregory Nah
- Division of Cardiology, Department of Medicine, University of California, San Francisco, California
| | - Mark J Pletcher
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Jeffrey E Olgin
- Division of Cardiology, Department of Medicine, University of California, San Francisco, California
| | - Gregory M Marcus
- Division of Cardiology, Department of Medicine, University of California, San Francisco, California
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26
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Kostopoulou A, Zeljko HM, Bogossian H, Ciudin R, Costa F, Heijman J, Kochhaeuser S, Manola S, Scherr D, Sohal M, Wakili R, Wolf M, Irfan G. Atrial fibrillation-related stroke in women: Evidence and inequalities in epidemiology, mechanisms, clinical presentation, and management. Clin Cardiol 2019; 43:14-23. [PMID: 31691981 PMCID: PMC6954380 DOI: 10.1002/clc.23284] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/10/2019] [Accepted: 10/17/2019] [Indexed: 12/17/2022] Open
Abstract
Background Atrial fibrillation (AF) is the most common clinical arrhythmia and one of the major causes of stroke, heart failure, sudden death, and cardiovascular morbidity. Despite substantial advances in (interventional) rhythm control treatment during the last decade, anticoagulation for stroke prevention remains a major component of AF treatment. Hypothesis There are important sex‐specific differences in AF‐related stroke, resulting from sex‐specific mechanisms and therapeutic differences. Methods This review summarizes available data on sex differences in risk assessment and prevention of stroke and highlights current knowledge gaps in AF‐related stroke mechanisms, prevention and management that warrant further research. Results Increased thrombotic risk in women is multifactorial, involving hormonal changes after menopause, structural, endocrine and lifestyle/social factors and their interactions. It is clear from randomized studies that women benefit from anticoagulant treatment and that their bleeding risk is similar to men. Women should therefore receive equivalent treatment to men, based on the validated criteria for anticoagulation therapy. However, women are not represented equally in the large randomized studies and sex‐related information in many fields is lacking. Conclusions Female sex is an established risk factor for stroke in AF patients. The evidence for sex‐specific differences in stroke risk assessment and stroke prevention is accumulating. However, the underlying biological mechanisms remain incompletely understood and further studies are required in order to decrease AF‐related morbidity and mortality.
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Affiliation(s)
- Anna Kostopoulou
- Department of Electrophysiology and Pacing, Onassis Cardiac Surgery Center, Athens, Greece.,Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Hrvojka M Zeljko
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Croatia.,Cardiology Department, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - Harilaos Bogossian
- Department of Cardiology and Angiology, Klinikum Lüdenscheid, Witten/Herdecke University, Germany
| | - Radu Ciudin
- Department of Cardiology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Cardiology, Prof C. C. Iliescu Institute of Cardiovascular Diseases, Bucharest, Romania
| | - Francisco Costa
- Department of Cardiology, Hospital Santa Cruz, Lisbon, Portugal
| | - Jordi Heijman
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Simon Kochhaeuser
- Department of Cardiology II-Electrophysiology, University Hospital of Muenster, Muenster, Germany
| | - Sime Manola
- Department of Cardiovascular Disease, "Sestre Milosrdnice" University Hospital Centre, Zagreb, Croatia
| | - Daniel Scherr
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, The Netherlands.,Division of Cardiology, Department of Medicine, Medical University of Graz, Austria
| | - Manav Sohal
- Department of Cardiology, Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, UK
| | - Reza Wakili
- Department of Cardiology and Angiology, Universitätsklinikum Essen, Westdeutsches Herz und Gefäßzentrum Essen, Germany
| | - Michael Wolf
- Department of Cardiology, ZNA Middelheim, Antwerp, Belgium
| | - Ghazala Irfan
- Department of Cardiac Electrophysiology, National Institute of Cardiovascular Diseases, Karachi, Pakistan
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27
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Li YM, Jiang C, He L, Li XX, Hou XX, Chang SS, Lip GY, Du X, Dong JZ, Ma CS. Sex Differences in Presentation, Quality of Life, and Treatment in Chinese Atrial Fibrillation Patients: Insights from the China Atrial Fibrillation Registry Study. Med Sci Monit 2019; 25:8011-8018. [PMID: 31738742 PMCID: PMC6825395 DOI: 10.12659/msm.919366] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
<strong>BACKGROUND</strong> There is a growing recognition of sex-related disparities in atrial fibrillation (AF). However, limited data is available in Chinese AF patients. <strong>MATERIAL AND METHODS</strong> We compared symptoms, quality of life (QoL), and treatment of AF according to sex from the China AF Registry study. <strong>RESULTS</strong> We studied 14 723 patients with non-valvular AF, of whom 5645 patients (38.3%) were female. Women were older than men (67.5±10.6 vs. 62.2±12.2). Compared to men, women had more comorbidities and a higher proportion of CHA₂DS₂-VASC score ≥2. Women with AF experienced more severe or disabling symptoms than men (33.7% vs. 22.9% in age <75 group; 40.3% vs. 28.7% in age ≥75 group; both P<0.0001). After multivariate analysis, women with AF still had lower QoL (OR 0.69; 95%CI, 0.63-0.76; P<0.0001). Women tended to have lower rates of ablation and rhythm-control drug use in those aged <75 years. Oral anticoagulant use was low and had no sex difference in AF patients with a CHA₂DS₂-VASC score ≥2. <strong>CONCLUSIONS</strong> In Chinese AF patients, women were older and more symptomatic, and had worse QoL. Despite all these differences, women tended to receive less rhythm-control treatment in those aged <75 years. Oral anticoagulant was substantially underused in high stroke risk patients, regardless of sex.
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Affiliation(s)
- Yan-Ming Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, P.R. China
- Department of Cardiology, Beijing Tongren Hospital, Capital Medical University, Beijing, P.R. China
| | - Chao Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, P.R. China
| | - Liu He
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, P.R. China
| | - Xin-Xu Li
- Chinese Center for Disease Control and Prevention, Beijing, P.R. China
| | - Xiao-Xia Hou
- Department of Cardiology, Beijing Tongren Hospital, Capital Medical University, Beijing, P.R. China
| | - San-Shuai Chang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, P.R. China
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, U.K
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, P.R. China
- Heart Health Research Center, Beijing, P.R. China
| | - Jian-Zeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, P.R. China
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, P.R. China
| | - Chang-Sheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, P.R. China
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28
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Tian XT, Xu YJ, Yang YQ. Gender Differences in Arrhythmias: Focused on Atrial Fibrillation. J Cardiovasc Transl Res 2019; 13:85-96. [PMID: 31637585 DOI: 10.1007/s12265-019-09918-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 09/20/2019] [Indexed: 01/08/2023]
Abstract
There are significant differences in clinical presentation and treatment of atrial fibrillation (AF) between women and men. The primary goal of AF management is to restore sinus rhythm and to prevent various complications, including stroke and heart failure. In many areas of AF, such as prevalence, clinical manifestations, morbidity, risk factors, pathophysiology, treatment strategies, and complications, gender-specific variability is observed and needs to be further addressed by large-scale population researches or randomized clinical trials, which help to promote the customization of AF treatment programs, hence to maximize the success rate of AF therapy in both sexes. This review highlights our current understanding of these gender differences in AF and how these differences affect treatment decisions on AF.
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Affiliation(s)
- Xiao-Ting Tian
- Department of Cardiology, Cardiovascular Research Laboratory, and Center Laboratory, The Fifth People's Hospital of Shanghai, Fudan University, No. 801 Heqing Road, Shanghai, 200240, China
| | - Ying-Jia Xu
- Department of Cardiology, Cardiovascular Research Laboratory, and Center Laboratory, The Fifth People's Hospital of Shanghai, Fudan University, No. 801 Heqing Road, Shanghai, 200240, China
| | - Yi-Qing Yang
- Department of Cardiology, Cardiovascular Research Laboratory, and Center Laboratory, The Fifth People's Hospital of Shanghai, Fudan University, No. 801 Heqing Road, Shanghai, 200240, China.
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29
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Groh CA, Faulkner M, Getabecha S, Taffe V, Nah G, Sigona K, McCall D, Hills MT, Sciarappa K, Pletcher MJ, Olgin JE, Marcus GM. Patient-reported triggers of paroxysmal atrial fibrillation. Heart Rhythm 2019; 16:996-1002. [DOI: 10.1016/j.hrthm.2019.01.027] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Indexed: 11/29/2022]
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30
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Bose A, O'Neal WT, Wu C, McClure LA, Judd SE, Howard VJ, Howard G, Soliman EZ. Sex Differences in Risk Factors for Incident Atrial Fibrillation (from the Reasons for Geographic and Racial Differences in Stroke [REGARDS] Study). Am J Cardiol 2019; 123:1453-1457. [PMID: 30771859 DOI: 10.1016/j.amjcard.2019.01.056] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/24/2019] [Accepted: 01/31/2019] [Indexed: 01/08/2023]
Abstract
We examined whether the sex differences in atrial fibrillation (AF) is related to difference in risk factors leading to AF or due to a differential impact of the same risk factors in 11,806 participants (55.2 % women) from the REGARDS study. Incident AF was ascertained by electrocardiograms and medical history at a follow-up examination. Backwards elimination logistic regression was used to identify AF risk factors in men and women, separately. Over a median follow-up of 9.0years, 588 (11.1%) men and 428 (6.6%) women (p value <0.001) developed AF. Men had a higher risk of AF than women (age and race adjusted odds ratio [OR] [95% confidence interval (CI)]: 1.61 [1.26, 1.75]). Age, white race, height, weight, use of blood pressure lowering medications and history of cardiovascular disease were identified by backward elimination as AF risk factors shared by both sexes. On the other hand, diabetes was an AF risk factor in women but not in men. Among the shared risk factors between men and women, only age showed a stronger association in women than in men [Interaction p-value = 0.003]. Adjustment for the shared risk factors eliminated the sex difference in AF risk (OR [95% CI]: 0.90 [0.74, 1.09]), which was more noticeable in those younger than the median age (62 years) compared to those who were older (interaction p value 0.003). In conclusion, women and men share several AF risk factors, and these shared risk factors explain the sex differences. However, age association with AF differs by sex, and age modifies the associations between sex and other AF risk factors.
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Deng H, Shantsila A, Guo P, Potpara TS, Zhan X, Fang X, Liao H, Liu Y, Wei W, Fu L, Xue Y, Wu S, Lip GYH. Sex-related risks of recurrence of atrial fibrillation after ablation: Insights from the Guangzhou Atrial Fibrillation Ablation Registry. Arch Cardiovasc Dis 2019; 112:171-179. [PMID: 30683618 DOI: 10.1016/j.acvd.2018.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 10/06/2018] [Accepted: 10/08/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Female sex has been linked with worse prognosis in patients with atrial fibrillation (AF). Clinical risk stratification of women with AF may help decision-making before catheter ablation (CA). AIM To evaluate arrhythmia outcomes and the predictive value of clinical scores for arrhythmia recurrence in a large cohort of Chinese patients with AF undergoing CA. METHODS A total 1410 of patients (68.1% men) who underwent AF ablation with scheduled follow-up were analysed retrospectively. Baseline characteristics and ablation outcome were compared between men and women. The predictive values of risk scoring systems for AF recurrence were assessed in women. RESULTS Recurrence, early recurrence and complications after CA were similar in women and men over similar follow-up periods (20.7±8.0 vs 20.7±9.1 months; P>0.05). Compared with men, women with AF recurrence were older and had a larger left atrial diameter (LAD), less paroxysmal AF, lower left ventricular ejection fraction, lower estimated glomerular filtration rate (eGFR) and higher serum concentrations of B-type natriuretic peptide (BNP) and C-reactive protein (CRP) (all P<0.01). Multivariable analysis showed that age, non-paroxysmal AF, body mass index, coronary artery disease, LAD, early recurrence, eGFR, BNP and CRP were independent risk factors with sex differences (all P<0.05) in the whole cohort. In women, only non-paroxysmal AF, early recurrence, BNP, CRP (all P<0.01) and history of stroke/transient ischaemic attack (P=0.016) were independent risk factors. Of the clinical scoring systems tested, MB-LATER, APPLE, CAAP-AF and BASE-AF2 scores (C-indexes 0.73, 0.72, 0.68 and 0.72, respectively; all P<0.01) had a modest predictive value for AF recurrence after CA in women. CONCLUSIONS CA for AF has similar recurrence risks in women and men, but there are sex differences in the clinical characteristics and risk factors associated with AF recurrence.
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Affiliation(s)
- Hai Deng
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK; Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Science, Guangzhou 510100, PR China
| | - Alena Shantsila
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Pi Guo
- Department of Public Health, Medical College of Shantou University, Shantou 515041, PR China
| | - Tatjana S Potpara
- School of Medicine, Belgrade University, Belgrade 11000, Serbia; Cardiology Clinic, Clinical Centre of Serbia, Belgrade 11000, Serbia
| | - Xianzhang Zhan
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Science, Guangzhou 510100, PR China
| | - Xianhong Fang
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Science, Guangzhou 510100, PR China
| | - Hongtao Liao
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Science, Guangzhou 510100, PR China
| | - Yang Liu
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Science, Guangzhou 510100, PR China
| | - Wei Wei
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Science, Guangzhou 510100, PR China
| | - Lu Fu
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Science, Guangzhou 510100, PR China
| | - Yumei Xue
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Science, Guangzhou 510100, PR China
| | - Shulin Wu
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Science, Guangzhou 510100, PR China
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK; School of Medicine, Belgrade University, Belgrade 11000, Serbia; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg DK-9000, Denmark.
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32
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Bushnell CD, Chaturvedi S, Gage KR, Herson PS, Hurn PD, Jiménez MC, Kittner SJ, Madsen TE, McCullough LD, McDermott M, Reeves MJ, Rundek T. Sex differences in stroke: Challenges and opportunities. J Cereb Blood Flow Metab 2018; 38:2179-2191. [PMID: 30114967 PMCID: PMC6282222 DOI: 10.1177/0271678x18793324] [Citation(s) in RCA: 186] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 05/25/2018] [Accepted: 06/19/2018] [Indexed: 12/19/2022]
Abstract
Biologic sex influences many variables that are important to brain health in general, and to stroke or cerebral ischemia in particular, such as general health status, cerebrovascular anatomy and function, unique risk factors such as pregnancy and preeclampsia, symptomatology, and therapeutic response. A more complete understanding of the scale and depth of sexual dimorphism in the brain and the role of more general sex-based factors is crucial to reducing the burden of stroke in women and men. This focused review highlights recent findings in stroke, including sex differences in epidemiology, risk factor reduction, comparative use of stroke therapeutics in both sexes, the importance of frailty in women, and the biologic basis for sex differences in stroke. Such findings show tremendous promise for the future of personalized medicine in stroke prevention and treatment.
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Affiliation(s)
| | - Seemant Chaturvedi
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kathy R Gage
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Paco S Herson
- Department of Anesthesiology, University of Colorado, Denver, CO, USA
| | - Patricia D Hurn
- School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Monik C Jiménez
- Division of Women’s Health, Brigham and Women’s Hospital, Boston, MA, USA
| | - Steven J Kittner
- Baltimore Veterans Administration Medical Center and Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tracy E Madsen
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | | | | | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, Lansing, MI, USA
| | - Tatjana Rundek
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
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Odening KE, Deiß S, Dilling-Boer D, Didenko M, Eriksson U, Nedios S, Ng FS, Roca Luque I, Sanchez Borque P, Vernooy K, Wijnmaalen AP, Yorgun H. Mechanisms of sex differences in atrial fibrillation: role of hormones and differences in electrophysiology, structure, function, and remodelling. Europace 2018; 21:366-376. [DOI: 10.1093/europace/euy215] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 09/03/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
- Katja E Odening
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Hugstetter Str. 55, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, HX Maastricht, The Netherlands
| | - Sebastian Deiß
- Asklepios Medical Center Altona, Department of Cardiology, Arrhythmia Unit, Hamburg, Germany
| | | | - Maxim Didenko
- Department of Surgical and Interventional Arrhythmology, Kuprianov's Cardiovascular Surgery Clinic, Military Medical Academy, St. Petersburg, Russia
| | - Urs Eriksson
- Rhythmology Division, Department of Medicine, GZO Regional Health Center, Wetzikon, Switzerland
- Cardioimmunology, Center for Molecular Cardiology, University of Zurich, Zurich-Schlieren, Switzerland
| | - Sotirios Nedios
- Heart Center, University of Leipzig, Leipzig, Germany
- Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Fu Siong Ng
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Ivo Roca Luque
- Arrhythmia Unit, Cardiology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, HX Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Center, GA Nijmegen, The Netherlands
| | - Adrianus P Wijnmaalen
- Department of Cardiology, Leiden University Medical Center, ZA Leiden, The Netherlands
| | - Hikmet Yorgun
- Department of Cardiology, Electrophysiology Unit, Hacettepe University, Ankara, Turkey
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Abstract
Women have a longer QT interval than men, which appears to evolve after puberty suggesting that sex hormones have an influence on cardiac electrophysiology. Sex hormones do in fact regulate cardiac ion channels via genomic and nongenomic pathways. Women are at greater risk for life-threatening arrhythmias under conditions that prolong the QT interval. In addition, women exhibit greater sensitivity to QT interval–prolonging drugs. Female sex has also an impact on propensity to cardiovascular disease, including atrial fibrillation. However, ex vivo recorded atrial action potentials (APs) from female and male patients in atrial fibrillation did not exhibit significant differences in shape, except that APs from women had slower upstroke velocity. It is concluded that sex-related differences should be taken into account not only in the clinics, but also in basic research.
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Affiliation(s)
- Ursula Ravens
- Institute of Experimental Cardiovascular Medicine, University Heart Center Freiburg • Bad Krozingen, Medical Faculty, University of Freiburg, Germany; Institute of Physiology, Medical Faculty Carl Gustav Carus, TU Dresden, Germany
- Institute of Experimental Cardiovascular Medicine, University Heart Center Freiburg • Bad Krozingen, Medical Faculty, University of Freiburg, Germany; Institute of Physiology, Medical Faculty Carl Gustav Carus, TU Dresden, Germany
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35
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Adigun RO, Boler AN, Mankad R. Disparities in Cardiac Care of Women: Current Data and Possible Solutions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:87. [PMID: 30242773 DOI: 10.1007/s11936-018-0688-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Cardiovascular disease remains the leading cause of death in women. The goal of this review is to address known disparities in cardiovascular care with regard to diagnosis and treatment of heart disease in women. RECENT FINDINGS Gender-specific differences in regard to the incidence, treatment, and outcomes of common cardiovascular pathology are increasingly recognized. Particular attention to ischemic heart disease, arrhythmia, congestive heart failure, and structural heart disease are reviewed in this article. There is a clear racial and ethnic discrepancy among women which is particularly concerning with a progressively diverse patient population. Medical and surgical treatment differences between men and women must be addressed by providers in order to optimize long-term outcomes among all patients. Understanding the unique cardiovascular risk profile and barriers to optimal treatment outcomes in women is imperative to eliminate the current disparities in cardiovascular disease.
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Affiliation(s)
- Rosalyn O Adigun
- Department of Cardiovascular Disease, 200 1st street SW, Rochester, MN, 55901, USA
| | - Amber N Boler
- Department of Cardiovascular Disease, 200 1st street SW, Rochester, MN, 55901, USA
| | - Rekha Mankad
- Department of Cardiovascular Disease, 200 1st street SW, Rochester, MN, 55901, USA.
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36
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Ball J, Løchen ML, Wilsgaard T, Schirmer H, Hopstock LA, Morseth B, Mathiesen EB, Njølstad I, Tiwari S, Sharashova E. Sex Differences in the Impact of Body Mass Index on the Risk of Future Atrial Fibrillation: Insights From the Longitudinal Population-Based Tromsø Study. J Am Heart Assoc 2018; 7:JAHA.117.008414. [PMID: 29674336 PMCID: PMC6015294 DOI: 10.1161/jaha.117.008414] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Atrial fibrillation (AF) prevalence is increasing, and body mass index (BMI) is a risk factor for AF. However, sex differences in the impact of BMI on AF risk have not been fully elucidated. Methods and Results Data from the fourth survey (1994–1995) of the Tromsø Study (Norway) were used to investigate the association of single‐measurement BMI on future AF risk. To analyze the influence of BMI changes on AF risk, data from individuals who attended the third and fourth study surveys were used. AF diagnosis was derived from record linkage and end point adjudication. Cox regression analysis was conducted using fractional polynomials of BMI and BMI change with models adjusted for age, baseline BMI (change analyses), risk factors, comorbidities, and antihypertensive medications. Data were available for 24 799 individuals from the fourth survey (mean age, 45.5±14.2 years; 52.9% women). Over 15.7±5.5 years, 811 women (6.2%) and 918 men (7.9%) developed AF. In men, lower BMI decreased AF risk and higher BMI increased risk (hazard ratios [95% confidence intervals] for BMI 18 or 40 kg/m2 compared with 23 kg/m2 were 0.75 [0.70–0.81] and 4.42 [3.00–6.53], respectively). The same pattern was identified in women. Two surveys were attended by 14 652 individuals. In men and women, a decrease in BMI over time was associated with decreased AF risk and an increase in BMI was associated with increased AF risk. Conclusions Within a population cohort, BMI was positively associated with AF risk. Change in BMI over time influenced AF risk in both men and women.
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Affiliation(s)
- Jocasta Ball
- Pre-Clinical Disease and Prevention, Baker Heart and Diabetes Institute, Melbourne, Australia .,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Maja-Lisa Løchen
- Pre-Clinical Disease and Prevention, Baker Heart and Diabetes Institute, Melbourne, Australia.,Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Tom Wilsgaard
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Henrik Schirmer
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Clinical Medicine, University of Oslo, Norway.,Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
| | - Laila A Hopstock
- Department of Health and Care Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Bente Morseth
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,School of Sport Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Ellisiv B Mathiesen
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Neurology, University Hospital of North Norway, Tromsø, Norway
| | - Inger Njølstad
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Sweta Tiwari
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Ekaterina Sharashova
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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37
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Andrade JG, Deyell MW, Lee AY, Macle L. Sex Differences in Atrial Fibrillation. Can J Cardiol 2018; 34:429-436. [DOI: 10.1016/j.cjca.2017.11.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 11/09/2017] [Accepted: 11/19/2017] [Indexed: 12/13/2022] Open
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Abstract
BACKGROUND Symptom clusters have not previously been explored among individuals with atrial fibrillation of any type. OBJECTIVE The purpose of this study is to determine the number of symptom clusters present among adults with chronic atrial fibrillation and to explore sociodemographic and clinical factors potentially associated with cluster membership. METHODS This was a cross-sectional secondary data analysis of 335 Australian community-dwelling adults with chronic (recurrent paroxysmal, persistent, or permanent) atrial fibrillation. We used self-reported symptoms and agglomerative hierarchical cluster analysis to determine the number and content of symptom clusters present. RESULTS There were slightly more male (52%) than female participants, with a mean (SD) age of 72 (11.25) years. Three symptom clusters were evident, including a vagal cluster (nausea and diaphoresis), a tired cluster (fatigue/lethargy, weakness, syncope/dizziness, and dyspnea/breathlessness), and a heart cluster (chest pain/discomfort and palpitations/fluttering). We compared patient characteristics among those with all the symptoms in the cluster, those with some of the symptoms in the cluster, and those with none of the symptoms in the cluster. The only statistically significant differences were in age, gender, and the use of antiarrhythmic medications for the heart cluster. Women were more likely to have the heart symptom cluster than men were. Individuals with all of the symptoms in the heart cluster were younger (69.6 vs 73.7 years; P = .029) than those with none of the symptoms in the heart cluster and were more likely to be on antiarrhythmic medications. CONCLUSION Three unique atrial fibrillation symptom clusters were identified in this study population.
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Anxiety and Depression in Patients with Permanent Atrial Fibrillation: Prevalence and Associated Factors. Cardiol Res Pract 2018; 2018:7408129. [PMID: 29670767 PMCID: PMC5836417 DOI: 10.1155/2018/7408129] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 01/11/2018] [Indexed: 01/27/2023] Open
Abstract
Atrial fibrillation (AF) is an important public health problem that is increasing at an alarming rate, worldwide. The most common type is permanent AF followed by the paroxysmal and persistent AF. Purpose. This study was aimed at exploring anxiety and depression and the associated factors in patients with permanent AF. Materials and Methods. The sample of the study included 170 AF patients. Data collection was performed by the method of interview using the "Hospital Anxiety and Depression Scale" (HADS) to assess anxiety and depression and a questionnaire including patients' characteristics. Results. 70% of the participants were men, and 32.4% were above 70 years old. Furthermore, 34.9% of the patients had high levels of anxiety, and 20.2% had high levels of depression. Anxiety levels were statistically significantly associated with gender (p=0.022), age (p=0.022), educational level (p=0.025), years having the disease (p=0.005), and relations with nursing staff (p=0.040). Depression levels were statistically significantly associated with age (p=0.037), degree of information of the state of health (p < 0.001), years having the disease (p < 0.001), and relations with medical staff (p=0.041). Conclusions. Patients' characteristics are associated with anxiety and depression and need to be evaluated when treating this frequently encountered arrhythmia.
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40
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Mohanty S, Trivedi C, Gianni C, Natale A. Gender specific considerations in atrial fibrillation treatment: a review. Expert Opin Pharmacother 2018; 19:365-374. [DOI: 10.1080/14656566.2018.1434144] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
- Department of Internal Medicine, Dell Medical School, Austin, TX, USA
| | - Chintan Trivedi
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
| | - Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
- Department of Internal Medicine, Dell Medical School, Austin, TX, USA
- Electrophysiology and Arrhythmia Services, California Pacific Medical Center, San Francisco, CA, USA
- Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Division of Cardiology, Stanford University, Stanford, CA, USA
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41
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Velásquez JE, Naranjo S, Gaviria MC, Duque M. La fibrilación auricular y su comportamiento en la mujer. REVISTA COLOMBIANA DE CARDIOLOGÍA 2018. [DOI: 10.1016/j.rccar.2017.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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42
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Magnussen C, Niiranen TJ, Ojeda FM, Gianfagna F, Blankenberg S, Njølstad I, Vartiainen E, Sans S, Pasterkamp G, Hughes M, Costanzo S, Donati MB, Jousilahti P, Linneberg A, Palosaari T, de Gaetano G, Bobak M, den Ruijter HM, Mathiesen E, Jørgensen T, Söderberg S, Kuulasmaa K, Zeller T, Iacoviello L, Salomaa V, Schnabel RB. Sex Differences and Similarities in Atrial Fibrillation Epidemiology, Risk Factors, and Mortality in Community Cohorts: Results From the BiomarCaRE Consortium (Biomarker for Cardiovascular Risk Assessment in Europe). Circulation 2017; 136:1588-1597. [PMID: 29038167 DOI: 10.1161/circulationaha.117.028981] [Citation(s) in RCA: 267] [Impact Index Per Article: 38.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 08/10/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is a common cardiac disease in aging populations with high comorbidity and mortality. Sex differences in AF epidemiology are insufficiently understood. METHODS In N=79 793 individuals without AF diagnosis at baseline (median age, 49.6 years; age range, 24.1-97.6 years; 51.7% women) from 4 community-based European studies (FINRISK, DanMONICA, Moli-sani Northern Sweden) of the BiomarCaRE consortium (Biomarker for Cardiovascular Risk Assessment in Europe), we examined AF incidence, its association with mortality, common risk factors, biomarkers, and prevalent cardiovascular disease, and their attributable risk by sex. Median follow-up time was 12.6 (to a maximum of 28.2) years. RESULTS Fewer AF cases were observed in women (N=1796; 4.4%), than in men (N=2465; 6.4%). Cardiovascular risk factor distribution and lipid profile at baseline were less beneficial in men than in women, and cardiovascular disease was more prevalent in men. Cumulative incidence increased markedly after the age of 50 years in men and after 60 years in women. The lifetime risk was similar (>30%) for both sexes. Subjects with incident AF had a 3.5-fold risk of death in comparison with those without AF. Multivariable-adjusted models showed sex differences for the association of body mass index and AF (hazard ratio per standard deviation increase, 1.18; 95% confidence interval [CI], 1.12-1.23 in women versus 1.31; 95% CI 1.25-1.38 in men; interaction P value of 0.001). Total cholesterol was inversely associated with incident AF with a greater risk reduction in women (hazard ratio per SD, 0.86; 95% CI, 0.81-0.90 versus 0.92; 95% CI, 0.88-0.97 in men; interaction P value of 0.023). No sex differences were seen for C-reactive protein and N-terminal pro B-type natriuretic peptide. The population-attributable risk of all risk factors combined was 41.9% in women and 46.0% in men. About 20% of the risk was observed for body mass index. CONCLUSIONS Lifetime risk of AF was high, and AF was strongly associated with increased mortality both in women and men. Body mass index explained the largest proportion of AF risk. Observed sex differences in the association of body mass index and total cholesterol with AF need to be evaluated for underlying pathophysiology and relevance to sex-specific prevention strategies.
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Affiliation(s)
- Christina Magnussen
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Teemu J Niiranen
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Francisco M Ojeda
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Francesco Gianfagna
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Stefan Blankenberg
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Inger Njølstad
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Erkki Vartiainen
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Susana Sans
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Gerard Pasterkamp
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Maria Hughes
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Simona Costanzo
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Maria Benedetta Donati
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Pekka Jousilahti
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Allan Linneberg
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Tarja Palosaari
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Giovanni de Gaetano
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Martin Bobak
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Hester M den Ruijter
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Ellisiv Mathiesen
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Torben Jørgensen
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Stefan Söderberg
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Kari Kuulasmaa
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Tanja Zeller
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Licia Iacoviello
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Veikko Salomaa
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.)
| | - Renate B Schnabel
- From Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany (C.M., F.M.O., S.B., T.Z., R.B.S.); DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (C.M., S.B., T.Z., R.B.S.); National Heart, Lung and Blood Institute's and Boston University's Framingham Heart Study, MA (T.J.N.); Department of Community Medicine, University of Tromso The Arctic University of Norway, Tromsø (I.N.); Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy (F.G., S.C., M.B.D., G.d.G., L.I.); EPIMED Research Center, Department of Medicine and Surgery, University of Insubria, Varese, Italy (F.G.); National Institute for Health and Welfare, Helsinki, Finland (T.J.N., E.V., P.J., T.P., K.K., V.S.); Catalan Department of Health, Barcelona, Spain (S. Sans); Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Netherlands (G.P.); Center of Excellence for Public Health, Institute of Clinical Sciences, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Northern Ireland (M.H.); Research Center for Prevention and Health, the Capital Region of Denmark, Copenhagen (A.L.); Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark (A.L.); Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (A.L., T.J.); Department of Epidemiology and Public Health, University College London, UK (M.B.); Laboratory of Experimental Cardiology, University Medical Center Utrecht, Netherlands (H.M.d.R.); Department of Clinical Medicine, Brain and Circulation Research Group, UiT The Arctic University of Norway, Tromsø (E.M.); Research Center for Prevention and Health, Glostrup University Hospital, Denmark (T.J.); Faculty of Medicine, Aalborg University, Denmark (T.J.); Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Sweden (S. Söderberg); and Department of Medicine and Surgery, University of Insubria, Varese, Italy (L.I.).
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Shehab A, Zubaid M, Bhagavathula AS, Rashed WA, Alsheikh-Ali AA, AlMahmeed W, Sulaiman K, Al-Zakwani I, AlQudaimi A, Asaad N, Amin H. Sex differences in management and outcomes of patients with atrial fibrillation in the Middle East: Gulf survey of atrial fibrillation events (Gulf SAFE). PLoS One 2017; 12:e0175405. [PMID: 28520719 PMCID: PMC5435140 DOI: 10.1371/journal.pone.0175405] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 03/24/2017] [Indexed: 11/24/2022] Open
Abstract
Differences in the management of atrial fibrillation (AF) between men and women were investigated by using Gulf SAFE data in the Middle East. The study included 2,043 patients presenting with AF to emergency room (ER) were prospectively enrolled and followed for one-year. Women were older, have higher body mass index (BMI), comorbidities, and health complications than men. With regard to management of AF, cardioversion was recommended more often for men (16.7% vs. 9.3%), and underwent electrical cardioversion (2.2% vs. 1.1%). Women were prescribed digoxin more frequently than men (25.6% vs. 17.4%) and a significant number women received warfarin alone (31.1% vs. 8.7%). No difference between the sexes was noticed in One-year rates of stroke/transient ischemic attacks (TIA) and all-cause of mortality after one-year follow-up (3.1% men vs. 3.3% women, and 7.5% vs. 7.4%). Older age (≥ 65 years), smoking, alcohol use, CHADS2 scores ≥5 were some of the significant risk factors in men with AF. Suboptimal use of anticoagulants, higher mortality and stroke/TIA events at one year are high but similar between the sexes. ER management revealed high use of rate control strategy and high rate of hospital admission was noticed in women.
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Affiliation(s)
- Abdulla Shehab
- Department of Internal Medicine, Faculty of Medicine, UAE University, Al Ain, United Arab Emirates
- * E-mail:
| | - Mohammad Zubaid
- Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | | | - Wafa A. Rashed
- Department of Medicine, Mubarak Al-Kabeer Hospital, Ministry of Health, Kuwait University, Kuwait City, Kuwait
| | - Alawi A. Alsheikh-Ali
- Division of Cardiology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Wal AlMahmeed
- Division of Cardiology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | | | - Ibrahim Al-Zakwani
- Department of Pharmacology and Clinical Pharmacy, College of Medicine and Health Sciences, Sultan Qaboos University and Gulf Health Research, Muscat, Oman
| | | | - Nidal Asaad
- Department of Cardiology and Cardiovascular Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Haitham Amin
- Mohammed Bin Khalifa Cardiac Center, Manama, Bahrain
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Gillis AM. Atrial Fibrillation and Ventricular Arrhythmias: Sex Differences in Electrophysiology, Epidemiology, Clinical Presentation, and Clinical Outcomes. Circulation 2017; 135:593-608. [PMID: 28153995 DOI: 10.1161/circulationaha.116.025312] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sex-specific differences in the epidemiology, pathophysiology, clinical presentation, clinical treatment, and clinical outcomes of atrial fibrillation (AF), sustained ventricular arrhythmias, and sudden cardiac death are recognized. Sex hormones cause differences in cardiac electrophysiological parameters between men and women that may affect the risk for arrhythmias. The incidence and prevalence of AF is lower in women than in men. However, because women live longer and AF prevalence increases with age, the absolute number of women with AF exceeds that of men. Women with AF are more symptomatic, present with more atypical symptoms, and report worse quality of life in comparison with men. Female sex is an independent risk factor for death or stroke attributable to AF. Oral anticoagulation therapy for stroke prevention has similar efficacy for men and women, but older women treated with warfarin have a higher residual risk of stroke in comparison with men. Women with AF are less likely to receive rhythm control antiarrhythmic drug therapy, electric cardioversion, or catheter ablation in comparison with men. The incidence and prevalence of sustained ventricular arrhythmias and sudden cardiac death are lower in women than in men. Women receiving implantable cardioverter defibrillators for primary prevention of sudden cardiac death are less likely to experience sustained ventricular arrhythmias in comparison with men. In contrast, women receiving a cardiac resynchronization therapy implantable cardioverter defibrillator for the treatment of heart failure are more likely to benefit than men. Women are less likely to be referred for implantable cardioverter defibrillator therapy despite current guideline recommendations. Women are more likely to experience a significant complication related to implantable cardioverter defibrillator implantation in comparison with men. Whether sex differences in treatment decisions reflect patient preferences or treatment biases requires further study.
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Affiliation(s)
- Anne M Gillis
- From Department of Cardiac Sciences, University of Calgary and Libin Cardiovascular Institute of Alberta, Calgary, Canada.
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45
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Ko D, Rahman F, Martins MAP, Hylek EM, Ellinor PT, Schnabel RB, Benjamin EJ, Christophersen IE. Atrial fibrillation in women: treatment. Nat Rev Cardiol 2016; 14:113-124. [PMID: 27786235 DOI: 10.1038/nrcardio.2016.171] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Sex-specific differences in the epidemiology, pathophysiology, presentation, prognosis, and treatment of atrial fibrillation (AF) are increasingly recognized. Women with AF generally experience worse symptoms, poorer quality of life, and have higher risk of stroke and death than men with AF. Effective treatment of the arrhythmia in women is critical to reduce the rate of adverse events. We review the current evidence on sex-specific differences in the utilization and outcomes of treatments for AF, including rate-control and rhythm-control strategies, and stroke-prevention therapy. In addition, we provide a critical evaluation of potential disparities and biases in health-care use that might be associated with differences in the outcomes between women and men. We underscore current knowledge gaps that need to be addressed in future studies to improve the management of AF in women. In particular, we suggest several strategies to produce high-quality evidence from randomized clinical trials for women with AF.
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Affiliation(s)
- Darae Ko
- Department of Internal Medicine, Boston Medical Center, Boston University School of Medicine, 72 East Concord Street, Boston, Massachusetts 02118, USA
| | - Faisal Rahman
- Department of Internal Medicine, Boston Medical Center, Boston University School of Medicine, 72 East Concord Street, Boston, Massachusetts 02118, USA
| | - Maria A P Martins
- Departamento de Produtos Farmacêuticos, Faculdade de Farmácia da Universidade Federal de Minas Gerais, Av. Pres. Antônio Carlos, 6627 - Pampulha, Belo Horizonte - MG, 31270-901, Brazil.,Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, 73 Mount Wayte Avenue, Framingham, Massachusetts 01702, USA
| | - Elaine M Hylek
- Department of Internal Medicine, Boston Medical Center, Boston University School of Medicine, 72 East Concord Street, Boston, Massachusetts 02118, USA
| | - Patrick T Ellinor
- Cardiac Arrhythmia Service and Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, Massachusetts 02114, USA
| | - Renate B Schnabel
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Oudenarder Strasse 16, D/04 (1. floor), 13347 Berlin, Germany
| | - Emelia J Benjamin
- Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, 73 Mount Wayte Avenue, Framingham, Massachusetts 01702, USA.,Sections of Cardiovascular Medicine and Preventive Medicine, Boston Medical Center, Boston University School of Medicine, 72 East Concord Street, Boston, Massachusetts 02118, USA.,Department of Epidemiology, Boston University School of Public Health, 715 Albany Street, Boston, Massachusetts 02118, USA
| | - Ingrid E Christophersen
- Cardiac Arrhythmia Service and Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, Massachusetts 02114, USA.,Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Sogneprest Munthe-Kaas vei 100, 1346 Gjettum, Norway
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46
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:2893-2962. [PMID: 27567408 DOI: 10.1093/eurheartj/ehw210] [Citation(s) in RCA: 4698] [Impact Index Per Article: 587.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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47
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg 2016; 50:e1-e88. [DOI: 10.1093/ejcts/ezw313] [Citation(s) in RCA: 602] [Impact Index Per Article: 75.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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48
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016; 18:1609-1678. [PMID: 27567465 DOI: 10.1093/europace/euw295] [Citation(s) in RCA: 1305] [Impact Index Per Article: 163.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Stefan Agewall
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John Camm
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gonzalo Baron Esquivias
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Werner Budts
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Scipione Carerj
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Filip Casselman
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Antonio Coca
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raffaele De Caterina
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Spiridon Deftereos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Dobromir Dobrev
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - José M Ferro
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gerasimos Filippatos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Donna Fitzsimons
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Bulent Gorenek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Maxine Guenoun
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stefan H Hohnloser
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Philippe Kolh
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gregory Y H Lip
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Athanasios Manolis
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John McMurray
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Ponikowski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raphael Rosenhek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Frank Ruschitzka
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Irina Savelieva
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Sanjay Sharma
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Suwalski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Juan Luis Tamargo
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Clare J Taylor
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Isabelle C Van Gelder
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Adriaan A Voors
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stephan Windecker
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Jose Luis Zamorano
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Katja Zeppenfeld
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
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49
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Ko D, Rahman F, Schnabel RB, Yin X, Benjamin EJ, Christophersen IE. Atrial fibrillation in women: epidemiology, pathophysiology, presentation, and prognosis. Nat Rev Cardiol 2016; 13:321-32. [PMID: 27053455 DOI: 10.1038/nrcardio.2016.45] [Citation(s) in RCA: 194] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia in women and men worldwide. During the past century, a range of risk factors has been associated with AF, severe complications from the arrhythmia have been identified, and its prevalence has been increasing steadily. Whereas evidence has accumulated regarding sex-specific differences in coronary heart disease and stroke, the differences between women and men with AF has received less attention. We review the current literature on sex-specific differences in the epidemiology of AF, including incidence, prevalence, risk factors, and genetics, and in the pathophysiology and the clinical presentation and prognosis of patients with this arrhythmia. We highlight current knowledge gaps and areas that warrant future research, which might advance understanding of variation in the risk factors and complications of AF, and ultimately aid more-tailored management of the arrhythmia.
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Affiliation(s)
- Darae Ko
- Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine
| | - Faisal Rahman
- Department of Internal Medicine, Boston Medical Center, Boston University School of Medicine
| | - Renate B Schnabel
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Oudenarder Strasse 16, 13347 Berlin, Germany
| | - Xiaoyan Yin
- Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, 73 Mount Wayte Avenue Framingham, Massachusetts 01702, USA.,Department of Biostatistics, Boston University School of Public Health
| | - Emelia J Benjamin
- Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, 73 Mount Wayte Avenue Framingham, Massachusetts 01702, USA.,Sections of Cardiovascular Medicine and Preventive Medicine, Boston Medical Center, Boston University School of Medicine, 72 East Concord Street, Boston, Massachusetts 02118, USA.,Department of Epidemiology, Boston University School of Public Health, 715 Albany Street, Boston, Massachusetts 02118, USA
| | - Ingrid E Christophersen
- Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, Charlestown, Massachusetts, 02129, USA.,Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Sogneprest Munthe-kaas vei 100, 1346 Gjettum, Norway
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50
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Wändell P, Carlsson AC, Gasevic D, Wahlström L, Sundquist J, Sundquist K. Depression or anxiety and all-cause mortality in adults with atrial fibrillation--A cohort study in Swedish primary care. Ann Med 2016; 48:59-66. [PMID: 26758363 PMCID: PMC4790080 DOI: 10.3109/07853890.2015.1132842] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Our aim was to study depression and anxiety in atrial fibrillation (AF) patients as risk factors for all-cause mortality in a primary care setting. METHODS The study population included adults (n = 12 283) of 45 years and older diagnosed with AF in 75 primary care centres in Sweden. The association between depression or anxiety and all-cause mortality was explored using Cox regression analysis, with hazard ratios (HRs) and 95% confidence intervals (95% CIs). Analyses were conducted in men and women, adjusted for age, educational level, marital status, neighborhood socio-economic status (SES), change of neighborhood status and anxiety or depression, respectively, and cardiovascular co-morbidities. As a secondary analysis, background factors and their association with depression or anxiety were explored. RESULTS The risk of all-cause mortality was higher among men with depression compared to their counterparts without depression even after full adjustment (HR = 1.28, 95% CI 1.08-1.53). For anxiety among men and anxiety or depression among women with AF, no associations were found. Cerebrovascular disease was more common among depressed AF patients. CONCLUSIONS Increased awareness of the higher mortality among men with AF and subsequent depression is called for. We suggest a tight follow-up and treatment of both ailments in clinical practice.
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Affiliation(s)
- Per Wändell
- a Division of Family Medicine, Department of Neurobiology , Care Sciences and Society (NVS), Karolinska Institutet , Huddinge , Sweden ;,b Academic Primary Care Centre, Stockholm County Council , Huddinge , Sweden
| | - Axel C Carlsson
- a Division of Family Medicine, Department of Neurobiology , Care Sciences and Society (NVS), Karolinska Institutet , Huddinge , Sweden ;,b Academic Primary Care Centre, Stockholm County Council , Huddinge , Sweden ;,c Department of Medical Sciences, Molecular Epidemiology and Science for Life Laboratory , Uppsala University , Uppsala , Sweden
| | - Danijela Gasevic
- d Centre for Population Health Sciences, College of Medicine and Veterinary Medicine, University of Edinburgh , Edinburgh , UK
| | - Lars Wahlström
- e Centre for Psychiatry Research, Karolinska Institutet , Stockholm , Sweden
| | - Jan Sundquist
- f Center for Primary Health Care Research, Lund University , Malmö , Sweden ;,g Stanford Prevention Research Center, Stanford University School of Medicine , Palo Alto , California , USA
| | - Kristina Sundquist
- f Center for Primary Health Care Research, Lund University , Malmö , Sweden ;,g Stanford Prevention Research Center, Stanford University School of Medicine , Palo Alto , California , USA
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