Clinical characteristics and impact of diabetes mellitus on outcomes in patients with nonvalvular atrial fibrillation

Oral anticoagulation across diabetic subtypes in patients with newly diagnosed atrial fibrillation: A report from the GARFIELD-AF registry

AIMS

This study aims to describe both management and prognosis of patients with diabetes mellitus (DM) and newly diagnosed atrial fibrillation (AF), overall as well as by antidiabetic treatment, and to assess the influence of oral anticoagulation (OAC) on outcomes by DM status.

METHODS

The study population comprised 52 010 newly diagnosed patients with AF, 11 542 DM and 40 468 non-DM, enrolled in the GARFIELD-AF registry. Follow-up was truncated at 2 years after enrolment. Comparative effectiveness of OAC versus no OAC was assessed by DM status using a propensity score overlap weighting scheme and weights were applied to Cox models.

RESULTS

Patients with DM [39.3% oral antidiabetic drug (OAD), 13.4% insulin ± OAD, 47.2% on no antidiabetic drug] had higher risk profile, OAC use, and rates of clinical outcomes compared with patients without DM. OAC use was associated in patients without DM and patients with DM with lower risk of all-cause mortality [hazard ratio 0.75 (0.69-0.83), 0.74 (0.64-0.86), respectively] and stroke/systemic embolism (SE) [0.69 (0.58-0.83), 0.70 (0.53-0.93), respectively]. The risk of major bleeding with OAC was similarly increased in patients without DM and those with DM [1.40 (1.14-1.71), 1.37 (0.99-1.89), respectively]. Patients with insulin-requiring DM had a higher risk of all-cause mortality and stroke/SE [1.91 (1.63-2.24)], [1.57 (1.06-2.35), respectively] compared with patients without DM, and experienced significant risk reductions of all-cause mortality and stroke/SE with OAC [0.73 (0.53-0.99); 0.50 (0.26-0.97), respectively].

CONCLUSIONS

In both patients with DM and patients without DM with AF, OAC was associated with lower risk of all-cause mortality and stroke/SE. Patients with insulin-requiring DM derived significant benefit from OAC.

Prevalence and factors associated with atrial fibrillation in older patients with obstructive sleep apnea

Purpose

This study sought to identify the prevalence and factors associated with atrial fibrillation (AF) in older patients with obstructive sleep apnea (OSA) in China. 

Methods

This was an explorative cross-sectional study. Between January 2015 and October 2017, we continuously recruited 1285 older patients with OSA who underwent overnight polysomnography from sleep centers of multiple hospitals. They were assessed using 12-lead ECG or 24-h dynamic ECG, and their baseline demographics, clinical characteristics, sleep parameters, and medical history were determined. Multivariate binary logistic regression analysis was used to investigate the factors related to AF in these older patients with OSA.

Results

The clinician classified 122 (9.5%) patients as having AF. The prevalence of AF significantly increased with age (P < 0.05) but did not significantly differ between the mild, moderate, and severe OSA groups. Additionally, the prevalence of paroxysmal AF was 7.2% among the overall study population, and it increased with OSA severity or advanced age (P < 0.05). Persistent AF was noted in 2.3% participants, and the prevalence also increased with age. The logistic regression analysis showed that age (OR = 1.054, 95%CI: 1.027–1.018, P < 0.001), history of drinking (OR = 1.752, 95%CI: 1.070–2.867, P < 0.05), chronic heart disease (OR = 1.778, 95%CI: 1.156–2.736, P < 0.01), diabetes mellitus (OR = 1.792, 95%CI: 1.183–2.713, P < 0.01), and reduced diastolic function (OR = 2.373, 95%CI = 1.298–4.337, P < 0.01) were relevant to AF among participants with OSA.

Conclusion

The prevalence of AF is significantly common in older patients with OSA. Age, history of drinking, chronic heart disease, diabetes mellitus, and reduced diastolic function are independently related to AF in these patients.

Glycemic control and atrial fibrillation: an intricate relationship, yet under investigation

Atrial fibrillation (AF) and diabetes mellitus (DM) constitute two major closely inter-related chronic cardiovascular disorders whose concurrent prevalence rates are steadily increasing. Although, the pathogenic mechanisms behind the AF and DM comorbidity are still vague, it is now clear that DM precipitates AF occurrence. DM also affects the clinical course of established AF; it is associated with significant increase in the incidence of stroke, AF recurrence, and cardiovascular mortality. The impact of DM on AF management and prognosis has been adequately investigated. However, evidence on the relative impact of glycemic control using glycated hemoglobin levels is scarce. This review assesses up-to-date literature on the association between DM and AF. It also highlights the usefulness of glycated hemoglobin measurement for the prediction of AF and AF-related adverse events. Additionally, this review evaluates current anti-hyperglycemic treatment in the context of AF, and discusses AF-related decision-making in comorbid DM. Finally, it quotes significant remaining questions and sets some future strategies with the potential to effectively deal with this prevalent comorbidity.

Impact of preexisting diabetes mellitus on cardiovascular and all-cause mortality in patients with atrial fibrillation: A meta-analysis

OBJECTIVE

To determine the impact of preexisting diabetes mellitus on cardiovascular and all-cause mortality in patients with atrial fibrillation (AF) by conducting a meta-analysis.

METHODS

PubMed and Embase databases were comprehensively searched for relevant studies publishing until May 19, 2022. Cohort studies or post-hoc analyses of clinical trials that investigated the association of diabetes mellitus with cardiovascular or all-cause mortality in AF patients were included.

RESULTS

A total of 21 studies with 526,136 AF patients were identified. The pooled prevalence of diabetes mellitus in patients with AF was 26%. The summary multivariable-adjusted risk ratio (RR) of all-cause mortality was 1.37 (95% confidence intervals [CIs] 1.23-1.53) for patients with diabetes versus those without diabetes. Moreover, diabetes mellitus was also associated with an increased risk of cardiovascular mortality (RR 1.46; 95% CI 1.34-1.58). Stratified analyses suggested that the impact of diabetes on all-cause and cardiovascular mortality was consistently observed in each named subgroup.

CONCLUSION

The presence of diabetes mellitus in patients with AF is associated with an increased risk of cardiovascular and all-cause mortality, even after adjustment for important confounding factors.

Diabetes and atrial fibrillation in hospitalized patients in the United States

BACKGROUND

Data on the burden of atrial fibrillation (AF) associated with diabetes among hospitalized patients are scarce. We assessed the AF-related hospitalizations trends in patients with diabetes, and compared AF outcomes in patients with diabetes to those without diabetes.

HYPOTHESIS

AF-related health outcomes differ between patient with diabetes and without diabetes.

METHODS

Using the National Inpatient Sample (NIS) 2004-2014, we studied trends in AF hospitalization rate among diabetic patients, and compared in-hospital case fatality rate, length of stay (LOS), cost and utilization of rhythm control therapies, and 30-day readmission rate between patients with and without diabetes. Logistic or Cox regression models were used to assess the differences in AF outcomes by diabetes status.

RESULTS

Over the study period, there were 4 325 522 AF-related hospitalizations, of which 1 075 770 (24.9%) had a diagnosis of diabetes. There was a temporal increase in AF hospitalization rate among diabetic patients (10.4 to 14.4 per 1000 hospitalizations among patients with diabetes; +4.4% yearly change, p-trend < .0001). Among AF patients, those with diabetes had a lower in-hospital mortality (adjusted odds ratio [aOR]: 0.68; 95% CI: 0.65-0.72) and LOS (aOR: 0.95; 95% CI: 0.94-0.96), but no difference in costs (aOR: 0.95; 95% CI: 0.94-0.96) and a higher 30-day rate of readmissions compared with no diabetes (aHR 1.05; 95% CI: 1.01-1.08), compared to individuals without diabetes.

CONCLUSION

AF and diabetes coexist among hospitalized patients, with rising trends over the last decade. Diabetes is associated with lower rates in-hospital adverse AF outcomes, but a higher 30-day readmission risk.

Prognostic significance of diabetes mellitus in patients with atrial fibrillation

Background

There are limited data on the association of diabetes mellitus (DM) and levels of glycated hemoglobin (HbA1c) with outcomes in patients with atrial fibrillation (AF).

Methods

This retrospective cohort study included patients who were recently hospitalized with a primary or secondary diagnosis of AF from December 2015 through June 2018. Kaplan–Meier curves and Cox-regression adjusted hazard ratios (aHR) were calculated for the primary outcome of all-cause mortality and for the secondary outcomes of cardiovascular (CV) mortality and the composite outcome of CV death or hospitalization. Competing-risk regression analyses were performed to calculate the cumulative risk of stroke, major bleeding, AF- or HF-hospitalizations adjusted for the competing risk of all-cause death. Spline curve models were fitted to investigate associations of HbA1c values and mortality among patients with AF and DM.

Results

In total 1109 AF patients were included, of whom 373 (33.6%) had DM. During a median follow-up of 2.6 years, 414 (37.3%) patients died. The presence of DM was associated with a higher risk of all-cause mortality (aHR = 1.40 95% confidence intervals [CI] 1.11–1.75), CV mortality (aHR = 1.39, 95% CI 1.07–1.81), sudden cardiac death (aHR = 1.73, 95% CI 1.19–2.52), stroke (aHR = 1.87, 95% CI 1.01–3.45) and the composite outcome of hospitalization or CV death (aHR = 1.27, 95% CI 1.06–1.53). In AF patients with comorbid DM, the spline curves showed a positive linear association between HbA1c levels and outcomes, with values 7.6–8.2% being independent predictors of increased all-cause mortality, and values < 6.2% predicting significantly decreased all-cause and CV mortality.

Conclusions

The presence of DM on top of AF was associated with substantially increased risk for all-cause or CV mortality, sudden cardiac death and excess morbidity. HbA1c levels lower than 6.2% were independently related to better survival rates suggesting that optimal DM control could be associated with better clinical outcomes in AF patients with DM.

Considerations and treatment options for patients with comorbid atrial fibrillation and diabetes mellitus

INTRODUCTION

Atrial fibrillation (AF) and diabetes mellitus (DM) are common worldwide and their incidence is increasing, representing a significant public health and economic burden as well as an increase in individual increased morbidity and mortality risk profiles. Both conditions are closely related, as patients with DM are at increased risk of incident AF, and AF patients with DM are at higher risk of cardiovascular events compared to non-AF patients. Areas covered: This review article aims to provide an overview of the current evidence linking DM and AF, as well as the impact of obesity, weight loss and stroke on these coexisting conditions. Second, the effects of new oral anti hyperglycaemic medications on cardiovascular risk will be considered. Expert opinion: In conclusion, coexisting AF and DM represent a high risk population of patients requiring aggressive risk factor identification and treatment optimisation. The multifactorial interplay between these conditions requires individual assessment of patient risk profiles with the aim of minimising the impact of each modifiable risk factor.

Comparison of the Incidence of Major Bleeding With Rivaroxaban Use Among Nonvalvular Atrial Fibrillation Patients With Versus Without Diabetes Mellitus

Diabetes mellitus (DM) is a common co-morbidity in those with nonvalvular atrial fibrillation (NVAF). Most patients with DM and NVAF have a CHA₂DS₂-VASc score of ≥1 and should be considered for oral anticoagulation therapy for stroke prevention per treatment guidelines. The most important risk associated with anticoagulation is bleeding, which may be higher in those with NVAF plus DM. Our objective was to evaluate the incidence and characteristics of major bleeding (MB) in rivaroxaban users diagnosed with NVAF, further comparing those with DM versus those without DM, in a real-world clinical setting. Electronic medical records of >10 million patients from the Department of Defense Military Health System were queried to identify rivaroxaban users with NVAF over a 2.5-year period. Major bleeding-related hospitalization was identified by a validated case-finding algorithm. Patient characteristics, incidence and management of MB, and fatal outcomes were assessed by DM status. Of 44,793 rivaroxaban users with NVAF, 12,039 (26.9%) had DM, who were more likely men, younger, with more co-morbidity and higher CHA₂DS₂-VASc scores. Major bleeding incidence was higher among those with DM compared with those without, 3.68 (95% confidence interval [CI] 3.37 to 4.03) versus 2.51 (95% CI 2.34 to 2.69) per 100 person-years, and intracranial bleeding incidence was 0.19 (95% CI 0.13 to 0.28) versus 0.25 (95% CI 0.20 to 0.31) per 100 person-years. Fatal outcomes were rare for both cohorts, 0.09 per 100 person-years. In conclusion, in this post-marketing study of 44,793 rivaroxaban users with NVAF, patients with DM had more co-morbidities and higher incidence of MB compared with those without DM.

NT-proBNP values in elderly heart failure patients with atrial fibrillation and diabetes

AIM

To evaluate N-terminal pro-BNP-type natriuretic peptide (NT-proBNP) plasmatic levels in heart failure patients with/without atrial fibrillation (AFib) and with/without diabetes (DM).

METHODS

The study enrolled 120 patients with heart failure, age 71.26±9.14, 48.3% AFib and 30.8% with DM. The patients were divided into 4 groups according to the presence or absence of AFib and DM: group 1, 46 patients in sinus rhythm (SR) without DM; group 2, 16 patients in SR with DM; group 3, 37 patients with AFib and without DM; group 4, 21 patients with both AFib and DM.

RESULTS

The patients in SR with DM displayed lower NT-proBNP levels than those with AFib without DM (1196.75±1183.11 vs 1940.59±963.665, p=0.02). We recorded no significant difference in comparison with the patients who had both AFib and DM (1196.75±1183.11 vs 1452.67±1257.94, p=NS). There was no significant difference between groups 3 and 4. Statistically significant correlations between ejection fraction, namely NYHA class and NT-proBNP levels were recorded only in the patients in SR-group 1 (r=-0.42, p<0.01) and group 2 (r=-0.66, p<0.01).

CONCLUSIONS

Correlations between plasma NT-proBNP levels and ejection fraction, namely NYHA class, were evinced only in patients in SR.