Bleeding and embolic risk in patients with atrial fibrillation and cancer

INTRODUCTION AND OBJECTIVES

The impact of cancer on clinical outcomes in patients with atrial fibrillation (AF) is unclear. The aim of this study was to assess how cancer influences the prediction and risk of embolic and hemorrhagic events in patients with AF.

METHODS

The study population comprised 16 056 patients from a Spanish health area diagnosed with AF between 2014 and 2018. Of these, 1137 (7.1%) had a history of cancer. During a median follow-up of 4.9 years, we assessed the relationship between cancer and bleeding and embolic events by competing risk analysis, considering death as a competing risk.

RESULTS

No association was detected between an increased risk of embolic events and cancer overall (sHR, 0.73; 95%CI, 0.41-1.26), active cancer, or any subgroup of cancer. However, cancer was associated with an increased risk of bleeding, although only in patients with active cancer (sHR, 1.42; 95%CI, 1.20-1.67) or prior radiotherapy (sHR, 1.40; 95%CI, 1.19-1.65). Both the CHA₂DS₂-VASc and HAS-BLED scores showed suboptimal performance to predict embolic and bleeding risk (c-statistic <0.50), respectively, in nonanticoagulated patients with active cancer. The ratio between the increase in bleeding and the decrease in embolisms with anticoagulation was similar in patients with and without cancer (5.6 vs 7.8; P <.001).

CONCLUSIONS

Cancer was not associated with an increased risk of embolic events in AF patients, only with an increased risk of bleeding. However, active cancer worsened the ability of the CHA₂DS₂-VASc and HAS-BLED scores to predict embolic and bleeding events, respectively, in nonanticoagulated patients.

Nutrition status, obesity and outcomes in patients with atrial fibrillation

INTRODUCTION AND OBJECTIVES

A paradoxical protective effect of obesity has been previously reported in patients with atrial fibrillation (AF). The aim of this study was to determine the impact of nutritional status and body mass index (BMI) on the prognosis of AF patients.

METHODS

We conducted a retrospective population-based cohort study of patients with AF from 2014 to 2017 from a single health area in Spain. The CONUT score was used to assess nutritional status. Cox regression models were used to estimate the association of BMI and CONUT score with mortality. The association with embolism and bleeding was assessed by a competing risk analysis.

RESULTS

Among 14 849 AF patients, overweight and obesity were observed in 42.6% and 46.0%, respectively, while malnutrition was observed in 34.3%. During a mean follow-up of 4.4 years, 3335 patients died, 984 patients had a stroke or systemic embolism, and 1317 had a major bleeding event. On univariate analysis, BMI was inversely associated with mortality, embolism, and bleeding; however, this association was lost after adjustment by age, sex, comorbidities, and CONUT score (HR for composite endpoint, 0.98; 95%CI, 0.95-1.01; P=.719). Neither obesity nor overweight were predictors of mortality, embolism, and bleeding events. In contrast, nutritional status-assessed by the CONUT score-was associated with mortality, embolism and bleeding after multivariate analysis (HR for composite endpoint, 1.15; 95%CI, 1.14-1.17; P<.001).

CONCLUSIONS

BMI was not an independent predictor of events in patients with AF in contrast to nutritional status, which showed a strong association with mortality, embolism, and bleeding. The study was registered at ClinicalTrials.gov (Identifier: NCT04364516).

Trade-off between the effects of embolic versus bleeding events on mortality in elderly patients with atrial fibrillation

INTRODUCTION AND OBJECTIVES

Clinical decision-making on anticoagulation in elderly patients with atrial fibrillation (AF) requires clinicians to consider not only the incidence of embolic and bleeding events, but also the risk of death following these adverse events. We aimed to analyze the trade-off between embolic and bleeding events with respect to mortality in elderly patients with AF.

METHODS

The study cohort comprised all patients aged ≥ 75 years from a Spanish health area diagnosed with AF between 2014 and 2017 (n=9365). The risk of death was investigated using Cox proportional hazards models, including embolic and bleeding events as time-dependent binary indicators.

RESULTS

During a median follow-up of 4.0 years, both embolic and bleeding events were associated with a higher risk of death (adjusted HR, 2.39; 95%CI, 2.12-2.69; and adjusted HR, 1.79; 95%CI, 1.64-1.96, respectively). The relative risk of death was 33% higher following an embolism than following a bleeding event (rRR, 1.33; 95%CI, 1.15-1.55), although for transient ischemic attack the risk was lower than for bleeding (rRR, 0.79; 95%CI, 0.63-0.99). The risk of death associated with intracranial hemorrhage was similar to that of major embolisms (RR, 1.00; 95%CI, 0.75-1.29).

CONCLUSIONS

In elderly AF patients, embolic events appeared to be associated with a higher risk of mortality than extracranial bleeding, except for transient ischemic attacks, which have a better prognosis. For ICH, the mortality risk was similar to that of major embolism.

Prevalence and Prognostic Significance of Malnutrition in Patients With Acute Coronary Syndrome

BACKGROUND

Malnutrition is associated with poor prognosis in a wide range of illnesses. However, its prognostic impact in patients with acute coronary syndrome (ACS) is not well known.

OBJECTIVES

This study sought to report the prevalence, clinical associations, and prognostic consequences of malnutrition in patients with ACS.

METHODS

In this study, the Controlling Nutritional Status (CONUT) score, the Nutritional Risk Index (NRI), and the Prognostic Nutritional Index (PNI) was applied to 5,062 consecutive patients with ACS. The relationships between malnutrition risk and all-cause mortality and major cardiovascular events (MACEs) (cardiovascular mortality, reinfarction, or ischemic stroke) were examined.

RESULTS

According to the CONUT score, NRI, and PNI, 11.2%, 39.5%, and 8.9% patients were moderately or severely malnourished, respectively; 71.8% were at least mildly malnourished by at least 1 score. Although worse scores were most strongly related to lower body mass index, between 8.4% and 36.7% of patients with a body mass index of ≥25 kg/m² were moderately or severely malnourished, depending on the nutritional index used. During a median follow-up of 3.6 years (interquartile range: 1.3 to 5.3 years), 830 (16.4%) patients died, and 1,048 (20.7%) had MACEs. Compared with good nutritional status, malnutrition was associated with significantly increased risk for all-cause death (adjusted hazard ratio for moderate and severe degrees of malnutrition, respectively: 2.02 [95% confidence interval (CI): 1.65 to 2.49] and 3.65 [95% CI: 2.41 to 5.51] for the CONUT score, 1.40 [95% CI: 1.17 to 1.68] and 2.87 [95% CI: 2.17 to 3.79] for the NRI, and 1.71 [95% CI: 1.37 to 2.15] and 1.95 [95% CI: 1.55 to 2.45] for the PNI score; p values <0.001 for all nutritional indexes). Similar results were found for the CONUT score and PNI regarding MACEs. All risk scores improve the predictive ability of the GRACE (Global Registry of Acute Coronary Events) risk score for both all-cause mortality and MACEs.

CONCLUSIONS

Malnutrition is common among patients with ACS and is strongly associated with increased mortality and cardiovascular events. Clinical trials are needed to prospectively evaluate the efficacy of nutritional interventions on outcomes in patients with ACS.

New Cancer Diagnosis After Bleeding in Anticoagulated Patients With Atrial Fibrillation

Background Bleeding is frequent in patients with atrial fibrillation (AF) treated with oral anticoagulant therapy, and may be the first manifestation of underlying cancer. We sought to investigate to what extent bleeding represents the unmasking of an occult cancer in patients with AF treated with oral anticoagulants. Methods and Results Using data from CardioCHUVI-AF (Retrospective Observational Registry of Patients With Atrial Fibrillation From Vigo's Health Area), 8753 patients with AF aged ≥75 years with a diagnosis of AF between 2014 and 2017 were analyzed. Of them, 2171 (24.8%) experienced any clinically relevant bleeding, and 479 (5.5%) were diagnosed with cancer during a follow-up of 3 years. Among 2171 patients who experienced bleeding, 198 (9.1%) were subsequently diagnosed with cancer. Patients with bleeding have a 3-fold higher hazard of being subsequently diagnosed with new cancer compared with those without bleeding (4.7 versus 1.4 per 100 patient-years; adjusted hazard ratio [HR], 3.2 [95% CI, 2.6-3.9]). Gastrointestinal bleeding was associated with a 13-fold higher hazard of new gastrointestinal cancer diagnosis (HR, 13.4; 95% CI, 9.1-19.8); genitourinary bleeding was associated with an 18-fold higher hazard of new genitourinary cancer diagnosis (HR, 18.1; 95% CI, 12.5-26.2); and bronchopulmonary bleeding was associated with a 15-fold higher hazard of new bronchopulmonary cancer diagnosis (HR, 15.8; 95% CI, 6.0-41.3). For other bleeding (nongastrointestinal, nongenitourinary, nonbronchopulmonary), the HR for cancer was 2.3 (95% CI, 1.5-3.6). Conclusions In patients with AF treated with oral anticoagulant therapy, any gastrointestinal, genitourinary, or bronchopulmonary bleeding was associated with higher rates of new cancer diagnosis. These bleeding events should prompt investigation for cancers at those sites.

Incidence, predictors and prognostic impact of intracranial bleeding within the first year after an acute coronary syndrome in patients treated with percutaneous coronary intervention

Background:

The rate of intracranial haemorrhage after an acute coronary syndrome has been studied in detail in the era of thrombolysis; however, in the contemporary era of percutaneous coronary intervention, most of the data have been derived from clinical trials. With this background, we aim to analyse the incidence, timing, predictors and prognostic impact of post-discharge intracranial haemorrhage in patients with acute coronary syndrome undergoing percutaneous coronary intervention.

Methods:

We analysed data from the BleeMACS registry (patients discharged for acute coronary syndrome and undergoing percutaneous coronary intervention from Europe, Asia and America, 2003–2014). Analyses were conducted using a competing risk framework. Uni and multivariate predictors of intracranial haemorrhage were assessed using the Fine–Gray proportional hazards regression analysis. The endpoint was 1-year post-discharge intracranial haemorrhage.

Results:

Of 11,136 patients, 30 presented with intracranial haemorrhage during the first year (0.27%). The median time to intracranial haemorrhage was 150 days (interquartile range 55.7–319.5). The fatality rate of intracranial haemorrhage was very high (30%). After multivariate analysis, only age (subhazard ratio 1.05, 95% confidence interval 1.01–1.07) and prior stroke/transient ischaemic attack (hazard ratio 3.29, 95% confidence interval 1.36–8.00) were independently associated with a higher risk of intracranial haemorrhage. Hypertension showed a trend to associate with higher intracranial haemorrhage rate. The combination of older age (⩾75 years), prior stroke/transient ischaemic attack, and/or hypertension allowed us to identify most of the patients with intracranial haemorrhage (86.7%). The annual rate of intracranial haemorrhage was 0.1% in patients with no risk factors, 0.2% in those with one factor, 0.6% in those with two factors and 1.3% in those with three factors.

Conclusion:

The incidence of intracranial haemorrhage in the first year after an acute coronary syndrome treated with percutaneous coronary intervention is low. Advanced age, previous stroke/transient ischaemic attack, and hypertension are the main predictors of increased intracranial haemorrhage risk.

Impact of malnutrition in the embolic–haemorrhagic trade-off of elderly patients with atrial fibrillation

Aims

Nutrition is an important determinant of health above the age of 80 years. Malnutrition in the elderly is often underdiagnosed. The aim of this study was to report the prevalence and prognostic value of malnutrition in patients ≥80 years old with atrial fibrillation (AF) with and without anticoagulant therapy.

Methods and results

We assessed the nutritional status of 4724 octogenarian patients with diagnoses of AF in a single centre from Spain between 2014 and 2017 with the CONUT score. Malnutrition was confirmed in 2036 patients (43.1%). Anticoagulation prescription was more frequent in patients with good nutrition than in those malnourished (79.5% vs. 71.7%, P &lt; 0.001). The impact of malnutrition on mortality was evaluated by Cox regression, whereas its association with ischaemic stroke and major bleeding was studied through competing risk analysis. After multivariate adjusting, malnutrition was associated with mortality [hazard ratio (HR) 1.36, 95% confidence interval (CI) 1.24–1.49], stroke [sub-distribution HR (sHR) 1.37, 95% CI 1.10–1.69], and major bleeding (sHR 1.29, 95% CI 1.02–1.64). In anticoagulated patients, the embolic–haemorrhagic trade-off event was virtually neutral for those who had normal nutritional status [average daily rates (ADRs) for stroke and bleeding: 4.70 and 4.69 per 100 000 patients/day, respectively; difference = +0.01 per 100 000 patients/day; P = 0.99] and negative for those with malnutrition (ADR for stroke and bleeding: 5.38 and 7.61 per 100 000 patients/day, respectively; difference = −2.23 per 100 000 patients/day; P = 0.07).

Conclusion

Malnutrition is very common in octogenarian patients with AF, being a clinical predictor for poor prognosis. For anticoagulated patients, malnutrition was associated with a negative embolic–haemorrhagic balance.

Impact of anticoagulation in patients with dementia and atrial fibrillation. Results of the CardioCHUVI-FA registry

INTRODUCTION AND OBJECTIVES

Population aging is associated with an increased prevalence of atrial fibrillation (AF) and dementia. This study aimed to analyze the impact of oral anticoagulation in elderly patients with AF and moderate-severe dementia.

METHODS

We conducted a single-center retrospective study analyzing patients aged ≥ 85 years with a diagnosis of AF between 2013 and 2018. The impact of anticoagulation on mortality, embolisms, and bleeding events was assessed by multivariate Cox analysis. In patients with dementia, this analysis was complemented by propensity score matching, depending on whether the patients were prescribed anticoagulant treatment or not.

RESULTS

Of the 3549 patients aged ≥ 85 years with AF, 221 had moderate-severe dementia (6.1%), of whom 88 (60.2%) were anticoagulated. During a follow-up of 2.8 ±1.7 years, anticoagulation was associated with lower embolic risk and higher bleeding risk both in patients with dementia (hazard ratio [HR]_embolisms, 0.36; 95%CI, 0.15-0.84; HR_bleeding, 2.44; 95%CI, 1.04-5.71) and in those without dementia (HR_embolisms, 0.58; 95%CI, 0.45-0.74; HR_bleeding, 1.55, 95%CI, 1.21-1.98). However, anticoagulation was associated with lower mortality only in patients without dementia (HR, 0.63; 95%CI, 0.53-0.75) and not in those with dementia (adjusted HR, 1.04; 95%CI, 0.63-1.72; P=.541; HR after propensity score matching 0.91, 95%CI, 0.45-1.83; P=.785).

CONCLUSIONS

In patients aged ≥ 85 years with moderate-severe dementia and AF, oral anticoagulation was significantly associated with a lower embolic risk and a higher bleeding risk, with no differences in total mortality.

High-Sensitivity C-Reactive Protein is a Predictor of In-Hospital Cardiac Events in Acute Myocardial Infarction Independently of GRACE Risk Score

High-sensitivity CRP (hsCRP) is being increasingly used as a marker for cardiac risk assessment and as a prognostic tool in acute coronary syndrome. We analyzed the relation between hsCRP values at admission and in-hospital outcomes in 98 consecutive patients with acute myocardial infarction (AMI) undergoing catheterization. Patients with cardiac events had more advanced Killip class, more proportion of depressed left ventricular ejection fraction (LVEF), higher Global Registry of Acute Coronary Events (GRACE) risk score, and higher hsCRP levels. High-sensitivity CRP and GRACE risk score showed a significant positive correlation ( r = .320, P = .002). In multivariate analysis, hsCRP resulted as a predictor of worse in-hospital outcomes independently of GRACE risk score (OR 1.122, CI95%:1.005-1.252, P = .040). The hsCRP value showing the maximum likelihood ratio for predicting cardiac events was 1.45 mg/dL. High levels of hsCRP were also associated with development of contrast-induced nephropathy but not with bleeding events.