Prognosis and antithrombotic practice patterns in recurrent and transient atrial fibrillation following acute coronary syndrome: a nationwide study

Background

First-time detected atrial fibrillation (AF) during acute coronary syndrome (ACS) aggravates the prognosis and increases the risk of ischemic stroke. In this setting, AF may present as brief and transient or with recurrent episodes after discharge. However, data on the association between transient or recurrent AF and ischemic stroke in patients with ACS are sparse. Further, despite being associated with ischemic stroke, first-time detected AF patients have been reported with low oral anticoagulation (OAC) rates.

Purpose

To examine the associated rate of ischemic stroke and mortality in ACS survivors with transient or recurrent AF and to assess the antithrombotic practice patterns one year after ACS.

Methods

Using data from Danish nationwide registries, we identified all patients with first-time ACS, without known AF prior to ACS, from 2000–2017 who were alive one year after ACS discharge (index date). According to a grace period between ACS discharge and one year after ACS discharge, patients were categorized into: i) no AF; ii) first-time detected AF during ACS admission without AF recurrence (transient AF); and iii) first-time detected AF during ACS admission with a subsequent recurrent AF episode (recurrent AF). Patients who developed AF during the grace period were excluded. Patients were followed from one year post ACS discharge, and two-year rates of ischemic stroke and mortality were compared using multivariable adjusted Cox proportional hazards analysis. Further, we assessed the prescribed OAC rates in a three-month period following the index date.

Results

We included 116,793 patients surviving one year post ACS discharge: 111,708 (95.6%) without AF (64.9% male, median age 64 years), 2,671 (2.3%) with transient AF (58.0% male, median age 74 years), and 2,414 (2.1%) with recurrent AF (55.2% male, median age 76 years). The cumulative two-year incidence of ischemic stroke was 0.9%, 1.5%, and 2.3% for patients without AF, transient AF, and recurrent AF, respectively (Figure 1). The cumulative two-year incidence of mortality was 7.4%, 12.1%, and 20.3% for patients without AF, transient AF, and recurrent AF, respectively (Figure 1). Compared to those without AF, the adjusted two-year rates of outcomes were as follows: ischemic stroke: HR 1.15 (95% CI: 0.81–1.61) for patients with transient AF and HR 1.50 (95% CI: 1.14–1.98) for patients with recurrent AF; mortality: HR 0.98 (95% CI: 0.87–1.10) for patients with transient AF and HR 1.35 (95% CI: 1.23–1.49) for patients with recurrent AF (Figure). We identified that 20.9% for transient AF and 42.2% for recurrent AF were prescribed OAC therapy in the three-month period after one year.

Conclusion

In patients surviving one year after ACS with first-time detected AF, a recurrent AF episode was associated with an increased long-term rate of ischemic stroke and mortality, while transient AF yielded no statistically difference as compared with patients without AF.

Funding Acknowledgement

Type of funding sources: None.

Cardiac resynchronisation therapy and implantable cardioverter-defibrillator in non-ischaemic systolic heart failure: extended follow-up of the DANISH trial

Background

In the Danish Study to Assess the Efficacy of Implantable Cardioverter-Defibrillators [ICDs] in Patients with Non-ischaemic Systolic Heart Failure on Mortality (DANISH) trial, ICD implantation did not provide an overall survival benefit in patients with non-ischaemic systolic heart failure. A high proportion of patients in the DANISH trial received a cardiac resynchronisation therapy (CRT) device, which improves the prognosis in patients with heart failure. Therefore, it is of interest to examine whether the effect of ICD implantation in patients with non-ischaemic systolic heart failure is modified by CRT.

Purpose

Adding 4 years of additional follow-up to the DANISH trial, we examined the effect of ICD implantation according to status with respect to CRT implantation at baseline.

Methods

In the DANISH trial, 556 patients with non-ischaemic systolic heart failure were randomised to receive an ICD and 560 to receive usual clinical care (control). Patients fulfilling indications for a CRT device received a CRT-defibrillator (if randomised to ICD arm) or CRT-pacemaker (if randomised to control arm). In the ICD group, 322 patients (57.9%) received a CRT device; in the control group, 323 patients (57.7%) received a CRT device. In this extended follow-up study, patients were followed until May 18, 2020. The primary outcome was death from any cause; secondary outcomes were cardiovascular death and sudden cardiovascular death.

Results

During a median follow-up of 9.5 years, the ICD group did not have significantly lower all-cause mortality compared with the control group (hazard ratio [HR] 0.89 [95% CI, 0.74–1.08]). The results were independent of whether the patient received a CRT device at randomisation (patients with a CRT device: HR 0.92 [95% CI, 0.72–1.18]; patients without a CRT device: HR 0.86 [95% CI, 0.64–1.14]; P for interaction, 0.72). Similarly, ICD implantation did not reduce rates of cardiovascular death overall (HR 0.87 [95% CI, 0.70–1.09]), and this association was not modified by CRT (patients with a CRT device: HR 0.89 [95% CI, 0.66–1.19]; patients without a CRT device: HR 0.85 [95% CI, 0.60–1.20]; P for interaction, 0.86). The ICD group had significantly lower rates of sudden cardiovascular death in the overall population (HR, 0.60 [95% CI, 0.40–0.92]), and this association was not modified by CRT (patients with a CRT device: HR 0.69 [95% CI, 0.40–1.21]; patients without a CRT device: HR 0.51 [95% CI, 0.26–0.97]; P for interaction, 0.47). See Figure 1 for all results.

Conclusions

In this extended follow-up study of the DANISH trial, the effect of ICD implantation in patients with non-ischaemic systolic heart failure was not modified by CRT.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The DANISH trial was supported by unrestricted grants from Medtronic, St Jude Medical, Tryg Fonden, and the Danish Heart Foundation. No further funding was obtained for this follow-up study.

Age- and Sex-Specific Rates of Heart Failure and other Adverse Cardiovascular Outcomes in Systemic Sclerosis

Background

Age at disease onset and sex appear to modify the disease course in patients with systemic sclerosis (SSc). Although patients with SSc have a higher risk of adverse cardiovascular outcomes than people without SSc, there are few data on age- and sex-specific risks of heart failure (HF) and other adverse cardiovascular outcomes in patients with SSc.

Objectives

To investigate the long-term rates of HF and other adverse cardiovascular outcomes (including arrhythmias, myocardial infarction, ischemic stroke, venous thromboembolism, and pulmonary hypertension) in a nationwide cohort of patients with SSc compared with the background population according to age and sex, separately.

Methods

Using Danish nationwide registries, all patients >18 years with newly diagnosed SSc (1996–2018) were identified. SSc patients were matched at a 1:4 ratio by age, sex, and comorbidities with controls from the background population without SSc. Rates of outcomes according to age (above/below median age) and sex were compared between cases and controls using Cox regression.

Results

Of the 2,019 patients diagnosed with SSc, 1,569 patients were matched with 6,276 controls from the background population (median age 55 years, 80.4% women). SSc was associated with a higher rate of HF in both women (HR 2.99 [95% CI, 2.18–4.09]) and men (HR 3.01 [1.83–4.95]) (Pfor interaction=0.88), with similar findings for other cardiovascular outcomes.For age interaction, SSc was associated with an increased rate of HF in patients <55 years (HR 4.14 [2.54–6.74]) and ≥55 years (HR 2.74 [1.98–3.78]), with similar effect of younger and older groups on HF (P for interaction=0.21), and other cardiovascular outcomes.

Conclusions

SSc was associated with an increased long-term rate of cardiovascular outcomes compared with a matched background population, with similar extent in different gender and age groups.

Funding Acknowledgement

Type of funding sources: None. Adjusted hazard ratios according to sexAdjusted hazard ratios according to age

Increased long-term risk of heart failure and other adverse cardiac outcomes in dermatomyositis and polymyositis: Insights from a nationwide cohort

BACKGROUND

Mounting evidence suggests that dermatomyositis/polymyositis (DM/PM) are associated with increased risk of atherosclerotic events and venous thromboembolism. However, data on the association between DM/PM and other cardiac outcomes, especially heart failure (HF), are scarce.

OBJECTIVES

To examine the long-term risk and prognosis associated with adverse cardiac outcomes in patients with DM/PM.

METHODS

Using Danish administrative registries, we included all patients ≥18 years with newly diagnosed DM/PM (1996-2018). Risks of incident outcomes were compared with non-DM/PM controls from the background population (matched 1:4 by age, sex, and comorbidity). In a secondary analysis, we compared mortality following HF diagnosis between DM/PM patients with HF and non-DM/PM patients with HF (matched 1:4 by age and sex).

RESULTS

The study population included 936 DM/PM patients (median age 58.5 years, 59.0% women) and 3744 matched non-DM/PM controls. The median follow-up was 6.9 years. Absolute 10-year risks of incident outcomes for DM/PM patients vs matched controls were as follows: HF, 6.98% (CI, 5.16-9.16%) vs 4.58% (3.79-5.47%) (P = 0.002); atrial fibrillation, 10.17% (7.94-12.71%) vs 7.07% (6.09-8.15%) (P = 0.005); the composite of ICD implantation/ventricular arrhythmias/cardiac arrest, 1.99% (1.12-3.27%) vs 0.64% (0.40-0.98%) (P = 0.02); and all-cause mortality, 35.42% (31.64-39.21%) vs 16.57% (15.10-18.10%) (P < 0.0001). DM/PM with subsequent HF was associated with higher mortality compared with HF without DM/PM (adjusted hazard ratio 1.58 [CI, 1.01-2.47]).

CONCLUSION

Patients with DM/PM had a higher associated risk of HF and other adverse cardiac outcomes compared with matched controls. Among patients developing HF, a history of DM/PM was associated with higher mortality.

Risk factors for mortality within one-year after implantable cardioverter defibrillator implantation: a nationwide study

Background

Current guidelines do not recommend implantable cardioverter defibrillator (ICD) implantation in patients with an estimated survival probability of less than one year. There is still an unmet need to identify patients who are unlikely to benefit from an ICD.

Purpose

We determined one-year mortality after ICD implantation and associated risk factors of one-year mortality.

Methods

Using Danish nationwide registries from 2000–2016, we identified patients ≥18 years old undergoing first-time ICD implantation for primary or secondary prevention. Patients were followed for up to one-year from time of ICD implantation. Risk factors associated with one-year mortality after time of ICD implantation were evaluated in multivariable logistic regression models.

Results

A total of 13,344 patients underwent first-time ICD implantation (median age: 66 years [25th-75th percentile 58–72 years], male=81.3%, secondary prevention=54.6%), of which 647 died (4.8%) within one year of follow-up. Compared with ICD patients who survived for one year, those who died were significantly older (72 years vs. 66 years, p&lt;0.001) and had more comorbidities, including congestive heart failure (70.8% vs. 63.4%), atrial fibrillation (36.6% vs. 23.6%), diabetes (30.8% vs. 19.9%), chronic obstructive pulmonary disease (COPD) (17.0% vs. 8.2%), chronic renal disease (13.0% vs. 4.4%), malignancy (9.9% vs. 5.4%), and dialysis (7.3% vs. 2.4%) (p&lt;0.001 for all).

Results from the multivariable logistic regression model are depicted in the Figure. There was a graded relationship between age and one-year mortality, with a greater risk of all-cause mortality with increasing age.

In addition, dialysis, chronic renal disease, COPD, malignancy, diabetes, and congestive heart failure were strongly associated with increased risk of one-year all-cause mortality. However, ischaemic heart disease was associated with a lower risk of all-cause mortality (Figure). The one-year risk of death was 13.2% for both patients receiving dialysis and patients with chronic renal disease, respectively.

The majority of deaths within one year were attributed to cardiovascular causes (408/647, 63.1%) of which chronic ischaemic heart disease (68/647, 10.5%), acute myocardial infarction (50/647, 7.7%), and atherosclerosis (40/647, 6.2%) were the most common. The most common non-cardiovascular cause of death was malignancy (10.5%).

Conclusion

In patients with a first-time ICD implantation, 95% survived for more than one year after implantation. While low mortality rates are indicative of relevant patient selection for ICD implantation, advanced age, dialysis, and several comorbidities were all strongly associated with increased one-year mortality, whereas ischaemic heart disease was associated with a lower risk of one-year mortality. Potential benefit of an ICD in such patients should be carefully evaluated before implantation.

Funding Acknowledgement

Type of funding source: None

Increasing time to thrombolysis is associated with worse long-term outcomes in patients with ischaemic stroke: a nationwide study

Background

It is well-established that the short-term benefits of intravenous thrombolytic therapy are reduced with increasing treatment delay in patients with acute ischaemic stroke. However, there is a paucity of contemporary data on the association between time from symptom onset to initiation of thrombolysis and long-term outcomes. With improving post-stroke survival in the Western world, data on time to thrombolysis and subsequent long-term outcomes are warranted in order to provide further insight into the importance of time to treatment.

Purpose

To examine the long-term risk of adverse outcomes according to time from symptom onset to intravenous thrombolytic therapy in patients with acute ischaemic stroke.

Methods

In this observational cohort study, we identified all patients with first-time ischaemic stroke treated with intravenous thrombolysis between 2011–2015 and alive at discharge through the Danish National Stroke Registry. Patients who received thrombolysis after &gt;270 min were excluded. Using multivariable Cox regression, we examined associations between time from symptom onset to thrombolysis and risks of the composite of death, recurrent ischaemic stroke, and dementia, as well as each of these components separately. Patients were followed until the outcome of interest, emigration, or December 31, 2017.

Results

Of the 4,313 patients with first-time ischaemic stroke treated with intravenous thrombolysis, 4,119 were alive at discharge (median age 69 years [25th-75th percentile 59–78 years], 60% males). The median follow-up was 3.3 years (25th-75th percentile 2.3–4.7 years). The median time from symptom onset to initiation of thrombolytic therapy was 140 min (25th-75th percentile 106–187 min), and the median National Institutes of Health Stroke Scale score at presentation was 5 (25th-75th percentile 3–10). The unadjusted absolute 3-year risks of the composite outcome, death, recurrent ischaemic stroke, and dementia according to time to thrombolysis are displayed in the figure. Compared with thrombolysis within 90 min, time to thrombolysis &gt;90 min was associated with a higher relative risk of the composite outcome (91–180 min: adjusted hazard ratio [HR] 1.37 [95% confidence interval [CI], 1.13–1.68]; 181–270 min: adjusted HR 1.42 [95% CI 1.15–1.76]). The risks of each component of the composite outcome according to time to thrombolysis were similar to results for the composite endpoint, as illustrated in the figure.

Conclusions

In this nationwide cohort of patients with acute ischaemic stroke treated with thrombolysis, increasing time from symptom onset to initiation of intravenous thrombolytic therapy was associated with higher long-term risks of the composite of death, recurrent ischaemic stroke, and dementia, as well as all three outcomes separately. These data indicate that long-term outcomes of patients with ischaemic stroke treated with intravenous thrombolysis can be greatly improved by reducing treatment delay.

Time to thrombolysis and outcomes

Funding Acknowledgement

Type of funding source: None

Declining incidence and mortality of ischaemic stroke between 1996–2016: a nationwide study

Background

The incidence and mortality of ischaemic heart disease have been declining over many years. The development with ischaemic stroke is less well studied, and with an increasing elderly population, there is a need for large-scale studies. Recent changes in stroke prevention and treatments may have affected the incidence and mortality of ischaemic stroke.

Purpose

To examine time trends and sex and age differences in the incidence and mortality of first-time ischaemic stroke in Denmark between 1996–2016.

Methods

In this observational cohort study, we used Danish nationwide registries to identify all individuals &gt;18 years of age admitted with a first-time diagnosis of ischaemic stroke between 1996–2016. We calculated age- and sex-stratified annual incidence rates and absolute 30-day and 1-year mortality risks. Further, we calculated annual incidence rate ratios using multivariable Poisson regression, odds ratios for 30-day mortality using multivariable logistic regression, and hazard ratios for 1-year mortality using multivariable Cox regression.

Results

The study population consisted of 224,617 individuals &gt;18 years of age with first-time ischaemic stroke between 1996–2016. The figure displays the unadjusted incidence rates and 1-year mortality risks of ischaemic stroke by calendar year. The overall unadjusted incidence rates of ischaemic stroke per 1,000 person-years increased from 1996 (2.43 [95% confidence interval [CI], 2.38–2.47]) to 2002 (2.91 [95% CI, 2.86–2.96]) and then gradually decreased to below the initial level until 2016 (1.99 [95% CI, 1.95–2.03]). Men had higher incidence rates than women in all age groups except in patients between 18–30 years and &gt;85 years. The absolute mortality risk decreased between 1996–2016 (30-day mortality from 17.1% to 7.6% and 1-year mortality from 30.9% to 17.3%). Women had higher mortality than men in the age groups 55–64 years and &gt;85 years. Similar trends were observed for all analyses after multivariable adjustment.

Conclusions

The overall incidence of first-time hospitalization for ischaemic stroke increased from 1996–2002 and then gradually decreased to below the initial level until 2016. The absolute 30-day and 1-year mortality risk decreased between 1996–2016. These findings correspond to the increased awareness of stroke prevention and introduction of new treatment options during the study period.

Trends in stroke incidence and mortality

Funding Acknowledgement

Type of funding source: None