Oral Anticoagulant Use and Long-Term Follow-Up Results in Patients with Non-valvular Atrial Fibrillation in Turkey AFTER-2 Study

Predictive value of nutritional scores in non-valvular atrial fibrillation patients: Insights from the AFTER-2 study

BACKGROUND AND AIM

Many scoring systems are used to evaluate malnutrition, but there is no consensus on which scoring system would be more appropriate. We aimed to investigate the effect of malnutrition in patients with non-valvular atrial fibrillation (NVAF) and to compare three scoring systems.

METHODS AND RESULTS

A total of 2592 patients with non-valvular AF from 35 different centers in Turkey were included in this prospective study. All participants were divided into two groups: 761 patients who died and 1831 patients who were alive. The malnutrition status of all participants was evaluated with three scoring systems. The primary outcome was all-cause mortality. The mean age of the population was 68.7 ± 11.1 years, and 55.5 % were female. According to Cox regression analysis, the geriatric nutritional risk index (GNRI) (HR = 0.989, 95 % CI: 0.982-0.997, p = 0.007), controlling nutritional status (CONUT) score (HR = 1.121, 95 % CI: 1.060-1.185, p < 0.001), and prognostic nutritional index (PNI) (HR = 0.980, 95 % CI: 0.962-0.999, p = 0.036) were found to be significant mortality predictors. ROC curve analysis indicated GNRI (AUC = 0.568), CONUT (AUC = 0.572), and PNI (AUC = 0.547) had moderate predictive values. Kaplan-Meier analysis showed that increasing the risk class based on GNRI (p < 0.001) and CONUT (p < 0.001) was associated with decreased survival, while PNI staging had no statistically significant effect (p = 0.266).

CONCLUSIONS

Malnutrition, determined by three scoring systems, was found to be an independent predictor of all-cause mortality in NVAF patients. Nutritional examination may provide useful information for prognosis and risk stratification in patients with NVAF.

Development and Validation of a New Nomogram Model for Predicting Acute Ischemic Stroke in Elderly Patients with Non-Valvular Atrial Fibrillation: A Single-Center Cross-Sectional Study

Background and Aims

Non-valvular atrial fibrillation (NVAF) patients face a 3-5 times greater risk of acute ischemic stroke (AIS) compared to those without NVAF. This study aims to establish a novel clinical prediction model for AIS in elderly patients with NVAF by incorporating relevant biomarker indicators.

Methods

A total of 301 individuals diagnosed with NVAF were selected for this investigation at the Third Affiliated Hospital of Anhui Medical University. Based on the presence of AIS, patients were categorized into two groups: the Stroke Cohort and the Non-Stroke Cohort. Predictor screening was performed using the least absolute shrinkage and selection operation (LASSO) regression algorithm. The binary logistic regression equation was applied to fit the model, followed by internal validation using the bootstrap resampling method (1000 times). Receiver operating characteristic (ROC) curve, calibration degree curve plots, and clinical decision curve analysis (DCA) were generated, respectively. Finally, a nomogram was constructed to present the prediction model.

Results

The final results of this study revealed that neutrophil-to-lymphocyte ratio (NLR), red cell distribution width (RDW), lipoprotein(a) (Lp(a)), systolic pressure, history of stroke, hyperlipidemia were independent risk factors for AIS in elderly patients with NVAF (P<0.05). And the high-density lipoprotein cholesterol (HDL-C) was an independent protective factor (P<0.05). By incorporating these indicators, a nomogram prediction model for predicting AIS in elderly patients with NVAF was constructed. Comparative analysis between the nomogram predictive model and CHA2DS2-VASc score revealed that the AUC of the nomogram predictive model surpassed that of the CHA2DS2-VASc score (AUC: 0.881vs 0.850).

Conclusion

NLR, RDW, Lp(a), SP, history of stroke, hyperlipidemia, and HDL-C emerge as independent prognostic factors for acute ischemic stroke in elderly patients with non-valvular atrial fibrillation. The predictive utility of the nomogram model may potentially surpass that of the CHA2DS2-VASc scoring system.

Vascular Endothelial Dysfunction and Immunothrombosis in the Pathogenesis of Atrial Fibrillation

Atrial Fibrillation (AF) induces proinflammatory processes which incite vascular endothelial activation and dysfunction. This study seeks to examine the potential relationship between various endothelial, inflammatory, thrombotic, and renin-angiotensin-system (RAS) biomarkers in AF patients.Blood samples were from AF patients (n = 110) prospectively enrolled in this study prior to their first AF ablation. Control plasma samples (n = 100) were used as reference. All samples were analyzed for endothelial (NO, ICAM-1, VEGF, TF, TFPI, TM, Annexin V), inflammatory (IL-6, TNFα, CRP), thrombotic (vWF, tPA, PAI-1, TAFI, D-dimer), and RAS (Renin, Ang-II) biomarkers using ELISA methods. Biomarker average comparisons and Spearman correlations were performed.AF patients showed varying levels of biomarker increase compared to controls. We observed a significant decrease of Ang-II in the AF population relative to controls when stratified for the use of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) upon study enrollment. AF patients showed statistically significant correlations between the following biomarkers: TNFα vs IL-6 (rs = 0.317, p = .004), ICAM-1 vs TNFα (rs = 0.527, p = .012), Annexin V vs VEGF (rs = 0.620, p < .001), CRP vs VEGF (rs = 0.342, p = .031), Ang-II vs tPA (rs = -0.592, p = .010), and tPA vs PAI-1 (rs = 0.672, p < .001).Our study demonstrated significant elevation of endothelial, inflammatory, and thrombotic biomarkers in AF patients compared to controls, with significant correlations between these biomarkers in the AF population. Future investigations are required to better elucidate the mechanistic pathways that lead to endothelial dysfunction and thromboinflammation in AF. This may provide novel therapeutic targets, that in addition to current anticoagulation practices, can best curtail thrombogenicity in AF.

Disease-Related Knowledge and Need for Revision of Care for Patients with Atrial Fibrillation: A Cross Sectional Study

Purpose

To evaluate the disease-related knowledge of outpatients with atrial fibrillation (AF), and the relationship with health literacy and other background variables.

Patients and Methods

In this cross-sectional survey study, conducted in Iceland, patients with AF scheduled for an electrical cardioversion or AF catheter ablation were recruited from a hospital outpatient clinic. They completed the validated Atrial Fibrillation Knowledge Scale (AFKS), a 11-item instrument (with possible score 0-10, 10 being the best knowledge) which evaluates knowledge pertaining to AF in general, AF symptom detection and AF treatment. Health literacy was assessed with the 16 item European Health Literacy Survey Questionnaire (HLS-EU-Q) and patients answered questions about their background. Data was analysed with parametric tests.

Results

In total, 185 participants completed the questionnaire (mean age 63 ±10), 77% were male, 74% with previous electrical cardioversion and 76% were on non-vitamin K antagonist oral anticoagulants (NOAC) medication. The mean score on the AFKS was 6.5 (±1.8). The best knowledge was concerning oral anticoagulation therapy (96% answered correctly) and the least knowledge was regarding responses to AF episodes (17% answered correctly). Patients with sufficient health literacy (52%) had better knowledge of AF (M 6.8 ±1.7 vs M 6.3 ±1.9, p = 0.05). Age, educational level, health literacy and AF pattern explained 22% of the variance in AF knowledge.

Conclusion

Patients with AF have inadequate knowledge of their condition, potentially as a result of insufficient health literacy. AF knowledge may be improved using integrated management where patients are actively involved in the care and health literacy is considered in the provided patient education.

Management and Anticoagulation Treatment of Non-Valvular Atrial Fibrillation in Elderly Patients: The Dali Study

Background

Non-valvular atrial fibrillation (NVAF) is associated with increased stroke in elderly populations, yet anticoagulant therapy is underutilized. We analyzed clinical characteristics and anticoagulation treatment rates of elderly NVAF patients hospitalized in Dali, China, to identify potential contributing factors.

Methods

We collected data for 155 elderly patients with NVAF aged ≥60 years, from July 01, 2020, to December 31, 2021. We analyzed the awareness rate, clinical characteristics, and anticoagulant treatment rate of atrial fibrillation (AF), and identified factors influencing treatment. Patients were followed up one year after discharge to assess vital status, cardiovascular events, and anticoagulation therapy status.

Results

Among 155 patients, 52.26% were female, and the average age was 75.77 years. The awareness rate of AF was 47.74% at admission, and only 21.94% received anticoagulant therapy. After discharge, the rate of anticoagulant therapy significantly increased to 70.97%, and 89.09% used new oral anticoagulants. Thromboembolic history and persistent AF predicted anticoagulant therapy at discharge, while male gender, previous bleeding history, and antiplatelet therapy predicted non-anticoagulant therapy. Out of 133 patients who completed a one-year follow-up, 23.31% died, 3.01% had strokes, and 3.01% experienced bleeding. Anticoagulant therapy decreased to 51.96% during the follow-up year.

Conclusion

Our findings highlight the low awareness rate and anticoagulant treatment rate, and high mortality among elderly NVAF patients in Dali. The development of comprehensive intervention strategies is critical to standardize AF management and improve prognosis.

The effect of treatment strategy on long-term follow-up results in patients with nonvalvular atrial fibrillation in Turkey: AFTER-2 subgroup analysis

BACKGROUND

We performed a subanalysis of the data from the AFTER-2 registry. In our study, we aimed to compare the long-term follow-up results of nonvalvular atrial fibrillation (NVAF) patients in Turkey according to their treatment strategies.

METHODS

All consecutive patients older than 18 years of age who presented to cardiology outpatient clinics, had at least one AF attack and did not have rheumatic mitral valve stenosis or prosthetic heart valve disease were included in our prospective study. The patients were divided into two groups as rhythm control and rate control. Stroke, hospitalization and death rates were compared between the groups.

RESULTS

A total of 2592 patients from 35 centers were included in the study. Of these patients, 628 (24.2%) were in the rhythm control group and 1964 (75.8%) in the rate control group. New-onset ischemic cerebrovascular disease or transient ischemic attack (CVD/TIA) was detected at a lower rate in the rhythm control group (3.2% vs. 6.2% p = 0.004). However, there was no significant difference in one-year and five-year mortality rates (9.6% versus 9.0%, p = 0.682 and 31.8% versus 28.6%, p = 0.116, respectively). Hospitalization were found to be significantly higher in patients with rhythm control group (18% vs. 13%, p = 0.002).

CONCLUSION

It was found that rhythm control strategy is preferred in AF patients in Turkey. We found a lower rate of ischemic CVD/TIA in patients in the rhythm control group. Although no difference was observed in mortality rates, we found a higher rate of hospitalization in the rhythm control group.

Establishment of Risk Model and Analysis of Immunoinfiltration Based on Mitophagy-Related Associated Genes in Atrial Fibrillation

Objective

Atrial fibrillation (AF) is a common tachyarrhythmia whose pathogenesis remains elusive. In the present study, we aimed to investigate the pathological mechanism of mitophagy and immunoinfiltration in AF.

Methods

First, we identified differentially expressed mitophagy-related genes (DEMRGs) based on the GSE79768 and GSE115574 datasets, subjecting them to functional enrichment analysis. STRING, TRRUST, miRNet, miRwalk, and Cytoscape were used to explore the potential regulatory roles of downstream signaling pathways. Subsequently, the random forest method was used to construct the AF risk model, and the DEMRGs most correlated with AF risk were determined by combining the Gini index. ssGSEA algorithm, NMF algorithm, and unsupervised clustering were used to subdivide AF molecular types. We then studied the characteristics of mitophagy- and immune infiltration-related genes in AF. Ultimately, we detected the expression of key genes in canine atrial tissues and HL-1 cells by immunofluorescence and Western blot.

Results

Mitophagy and immune infiltration were significantly enriched and activated in AF samples. Thirty-seven DEMRGs were screened, of which MAPK1, VDAC1, MAPK14, and MTERF3 were most associated with AF risk. The risk model based on these could identify patients at a high risk of AF. The infiltration of immunocells such as mast cells and neutrophils was significantly different among AF types. Finally, expression verification indicated that the expression trend of four key genes in canine atrial muscle tissue and HL-1 cells was consistent.

Conclusion

We found that mitophagy may participate in AF progression through immune activation. In addition, the AF risk prediction model composed of VDAC1, MAPK1, MAPK14, and MTERF3 has a good AF prediction performance, which provides new ideas for the study of AF pathogenesis and potential therapeutic targets.

Thromboembolism and Major Bleeding in Patients with Atrial Fibrillation and EHRA Type 2 Valvular Heart Disease: The Jordan Atrial Fibrillation (JoFib) Study

Aim

The risks of thromboembolism and major bleeding in atrial fibrillation (AF) patients were assessed according to the "Evaluated Heartvalves, Rheumatic or Artificial" (EHRA) classification. Additionally, the safety and efficacy of vitamin K antagonists (VKAs) and non-VKA oral anticoagulants (NOACs) were compared in AF patients with EHRA type 2 valvular heart disease (VHD) versus those with no VHD.

Methods

AF patients enrolled in the "Jordan Atrial Fibrillation (JoFib)" study were followed up for thromboembolic events and major bleeding at 30, 180, and 365 days. Patients in the EHRA type 2 VHD and non-VHD groups were sub-grouped to compare different OACs.

Results

2020 AF patients were recruited. The thromboembolic risk was higher in EHRA type 2 VHD patients compared to non-VHD controls. Major bleeding also occurred at higher rates in EHRA type 2 patients. In addition, NOACs were more effective in preventing thromboembolic events than VKAs and non-anticoagulation in EHRA type 2 VHD patients. Furthermore, EHRA type 2 VHD patients taking rivaroxaban had significantly less thromboembolic risk than their non-anticoagulated counterparts. At the same time, apixaban and warfarin did not significantly lower the risk of thromboembolism compared to non-anticoagulation.

Conclusion

AF patients with EHRA type 2 VHD are at significant risk of thromboembolism and major bleeding. Furthermore, NOACs were more effective than VKAs in preventing thromboembolic events in this group of patients without conferring an added risk of major bleeding. Moreover, rivaroxaban appears to be particularly efficacious.