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    Cerebral microbleeds and intracranial haemorrhage risk in patients anticoagulated for atrial fibrillation after acute ischaemic stroke or transient ischaemic attack (CROMIS-2): a multicentre observational cohort study. Wilson Duncan,Ambler Gareth,Shakeshaft Clare,Brown Martin M,Charidimou Andreas,Al-Shahi Salman Rustam,Lip Gregory Y H,Cohen Hannah,Banerjee Gargi,Houlden Henry,White Mark J,Yousry Tarek A,Harkness Kirsty,Flossmann Enrico,Smyth Nigel,Shaw Louise J,Warburton Elizabeth,Muir Keith W,Jäger Hans Rolf,Werring David J, The Lancet. Neurology BACKGROUND:Cerebral microbleeds are a potential neuroimaging biomarker of cerebral small vessel diseases that are prone to intracranial bleeding. We aimed to determine whether presence of cerebral microbleeds can identify patients at high risk of symptomatic intracranial haemorrhage when anticoagulated for atrial fibrillation after recent ischaemic stroke or transient ischaemic attack. METHODS:Our observational, multicentre, prospective inception cohort study recruited adults aged 18 years or older from 79 hospitals in the UK and one in the Netherlands with atrial fibrillation and recent acute ischaemic stroke or transient ischaemic attack, treated with a vitamin K antagonist or direct oral anticoagulant, and followed up for 24 months using general practitioner and patient postal questionnaires, telephone interviews, hospital visits, and National Health Service digital data on hospital admissions or death. We excluded patients if they could not undergo MRI, had a definite contraindication to anticoagulation, or had previously received therapeutic anticoagulation. The primary outcome was symptomatic intracranial haemorrhage occurring at any time before the final follow-up at 24 months. The log-rank test was used to compare rates of intracranial haemorrhage between those with and without cerebral microbleeds. We developed two prediction models using Cox regression: first, including all predictors associated with intracranial haemorrhage at the 20% level in univariable analysis; and second, including cerebral microbleed presence and HAS-BLED score. We then compared these with the HAS-BLED score alone. This study is registered with ClinicalTrials.gov, number NCT02513316. FINDINGS:Between Aug 4, 2011, and July 31, 2015, we recruited 1490 participants of whom follow-up data were available for 1447 (97%), over a mean period of 850 days (SD 373; 3366 patient-years). The symptomatic intracranial haemorrhage rate in patients with cerebral microbleeds was 9·8 per 1000 patient-years (95% CI 4·0-20·3) compared with 2·6 per 1000 patient-years (95% CI 1·1-5·4) in those without cerebral microbleeds (adjusted hazard ratio 3·67, 95% CI 1·27-10·60). Compared with the HAS-BLED score alone (C-index 0·41, 95% CI 0·29-0·53), models including cerebral microbleeds and HAS-BLED (0·66, 0·53-0·80) and cerebral microbleeds, diabetes, anticoagulant type, and HAS-BLED (0·74, 0·60-0·88) predicted symptomatic intracranial haemorrhage significantly better (difference in C-index 0·25, 95% CI 0·07-0·43, p=0·0065; and 0·33, 0·14-0·51, p=0·00059, respectively). INTERPRETATION:In patients with atrial fibrillation anticoagulated after recent ischaemic stroke or transient ischaemic attack, cerebral microbleed presence is independently associated with symptomatic intracranial haemorrhage risk and could be used to inform anticoagulation decisions. Large-scale collaborative observational cohort analyses are needed to refine and validate intracranial haemorrhage risk scores incorporating cerebral microbleeds to identify patients at risk of net harm from oral anticoagulation. FUNDING:The Stroke Association and the British Heart Foundation. 10.1016/S1474-4422(18)30145-5
    Real-life Performance of Edoxaban in Elderly Patients With Atrial Fibrillation: a Multicenter Propensity Score-Matched Cohort Study. Russo Vincenzo,Attena Emilio,Mazzone Carmine,Melillo Enrico,Rago Anna,Galasso Gennaro,Riegler Lucia,Parisi Valentina,Rotunno Raffaele,Nigro Gerardo,D'Onofrio Antonio Clinical therapeutics PURPOSE:The purpose of the current study was to compare the efficacy and safety of edoxaban versus vitamin K antagonist (VKA) therapy among a cohort of elderly patients (ie, those aged ≥75 years) with atrial fibrillation (AF) in a real-life setting. METHODS:A propensity score-matched cohort observational study was performed comparing the safety and efficacy of edoxaban versus VKA therapy among a cohort of elderly (aged ≥75 years) patients with AF in a real-life setting. Follow-up data were obtained through outpatient visits at 1, 3, and every 6 months. The primary safety outcome was major bleeding. The primary efficacy outcome was the composite of stroke, transient ischemic attack, and systemic embolism. FINDINGS:A total of 130 patients receiving edoxaban 60 mg (EDO) treatment were compared with the same number of VKA recipients. The mean follow-up was 16 (2.6) months. The cumulative incidence of thromboembolic events in the EDO and VKA groups was 1.5% (2 of 130) and 2.3% (3 of 130), respectively (P < 0.6). The cumulative incidence of major bleeding events was 1.5% (2 of 130) in the EDO group and 3.1% (4 of 130) in the VKA group (P < 0.4). The total anticoagulant therapy discontinuation rate was 2.3% (3 of 130) in the EDO group and 4.6% (6 of 130) in the VKA group (P < 0.3). A nonsignificant trend in improved adherence was observed between the EDO and VKA groups (81% vs 78%; P = 0.6). IMPLICATIONS:Edoxaban therapy showed a good real-life performance among elderly patients (aged ≥75 years) with AF. 10.1016/j.clinthera.2019.04.041
    Ischemic stroke rates decline in patients with atrial fibrillation as anticoagulants uptake improves: A Swedish cohort study. Mochalina Natalia,Isma Nazim,Svensson Peter J,Själander Anders,Carlsson Maj,Juhlin Tord,Wieloch Mattias Thrombosis research INTRODUCTION:The impact of the increased anticoagulants uptake on incidence rate of ischemic stroke is largely unknown. We assessed time trends in rates of ischemic stroke in patients with incident atrial fibrillation (AF) diagnosed between 2011 and 2013. MATERIALS AND METHODS:Population-based retrospective registry study of all 11,500 adults diagnosed with incident non-valvular atrial fibrillation in 2011-2013 in primary and secondary care and receiving oral anticoagulants (n=4847), aspirin (n=2850) or no treatment (n=3766) in Skåne County, Sweden. The primary outcome was the rate of ischemic stroke within 365days after AF diagnosis. RESULTS AND CONCLUSION:Cumulative incidence of ischemic stroke decreased from 2.87% (95% confidence interval (CI) 2.37-3.45%) to 1.93% (95% CI 1.54-2.41%) while the uptake of oral anticoagulants increased from 36.6% to 48.4% between 2011 and 2013 (regression coefficient -0.08; 95% CI, -0.09 to -0.07, p<0.001). The increased uptake of oral anticoagulants in the community is associated with decreased incidence of ischemic stroke in AF patients. 10.1016/j.thromres.2017.08.004
    Potential missed opportunities to prevent ischaemic stroke: prospective multicentre cohort study of atrial fibrillation-associated ischaemic stroke and TIA. Wilson Duncan,Ambler Gareth,Shakeshaft Clare,Banerjee Gargi,Charidimou Andreas,Seiffge David,White Mark,Cohen Hannah,Yousry Tarek,Salman Rustam,Lip Gregory Y H,Muir Keith,Brown Martin M,Jäger H R,Werring David J, BMJ open OBJECTIVE:We report on: (1) the proportion of patients with known atrial fibrillation (AF); and (2) demographic, clinical or radiological differences between patients with known AF (and not treated) and patients with newly diagnosed AF, in a cohort of patients who presented with ischaemic stroke or transient ischaemic attack (TIA) not previously treated with anticoagulation. DESIGN:We reviewed cross-sectional baseline demographic and clinical data from a prospective observational cohort study, (CROMIS-2). SETTING:Patients were recruited from 79 hospital stroke centres throughout the UK and one centre in the Netherlands. PARTICIPANTS:Patients were eligible if they were adults who presented with ischaemic stroke or TIA and AF and had not been previously treated with oral anticoagulation. MAIN OUTCOME MEASURES:Proportion of patients with known AF before index ischaemic stroke or TIA from a cohort of patients who have not been previously treated with oral anticoagulation. Secondary analysis includes the comparison of CHADS-VASc and HAS-BLED scores and other demographics and risk factors between those with newly diagnosed AF and those with previously known AF. RESULTS:Of 1470 patients included in the analysis (mean age 76 years (SD 10)), 622 (42%) were female; 999 (68%) patients had newly diagnosed AF and 471 (32%) patients had known AF. Of the 471 patients with known AF, 68% had a strong indication for anticoagulation and 89% should have been considered for anticoagulation based upon CHADS-VASc score. Patients with known AF were more likely to have a prior history of dementia (4% vs 2%, p=0.02) and had higher HAS-BLED scores (median 3 vs 2). CHADS-VASc, other risk factors and demographics were similar. CONCLUSIONS:About 1/3 of patients who present with stroke and have AF who have not been treated with oral anticoagulation have previously known AF. Of these patients, at least 68% were not adequately treated with oral anticoagulation. TRIAL REGISTRATION NUMBER:NCT02513316. 10.1136/bmjopen-2018-028387
    Pacemaker-detected atrial fibrillation burden and risk of ischemic stroke or thromboembolic events-A cohort study. Chu Song-Yun,Jiang Jie,Wang Yu-Ling,Sheng Qin-Hui,Zhou Jing,Ding Yan-Sheng Heart & lung : the journal of critical care BACKGROUND:Atrial fibrillation (AF) burden might link to increased risk of systemic embolism. Current scoring systems for evaluating stroke risks such as CHADS-VASc do not incorporate AF burden partly because of the difficulty to assess these data. Patients with dual-chamber pacemakers implanted have opportunities to acquire incidence and duration of AF. OBJECTIVES:We aimed to evaluate the AF burden and its association with thromboembolism in patients with dual-chamber pacemakers. METHODS:This retrospective cohort study enrolled patients who underwent dual-chamber pacemaker implantation at our center between October 2003 and May 2017. We excluded patients with prior thromboembolism or receiving anticoagulants. The incidence and duration of pacemaker-detected AF were compared between patients with and without thromboembolic outcomes. Propensity score matching (1:1) was conducted based on clinical characteristics. Multivariate regressions were performed to determine the predictors of thromboembolic outcomes. Survival free from stroke and thromboembolism was assessed using Kaplan-Meier analysis in groups with different AF burden. RESULTS:Among the 152 patients enrolled (43.4% women; age 73.2 ± 13.3 years), ten experienced thromboembolic events within a median follow-up of 67 months. Patients with thromboembolisms had higher CHADS-VASc scores but not higher AF burden. Higher CHADS-VASc score was associated with increased risk for systemic thromboembolism [hazard ratio (HR), 1.87; 95% confidence interval (CI), 1.07-3.24; P = 0.027). In the propensity score-matched cohort with comparable CHADS-VASc score, patients with thromboembolism had higher AF burden. Pacemaker-detected AF was associated with increased risk for thromboembolism (propensity-adjusted HR, 9.33; 95% CI, 1.19-72.99; P = 0.033). Experiencing AF episodes lasting >6 min was a predictor of significantly higher risk of future stroke or thromboembolism (propensity-adjusted HR, 6.75; 95% CI, 1.30-35.11; P = 0.023). CONCLUSION:In patients with dual-chamber pacemakers and comparable CHADS-VASc score, pacemaker-detected AF burden is associated with elevated risk for thromboembolism. Further research is needed to clarify how pacemaker-detected AF burden could incorporate with CHADS-VASc score variables and help to guide anticoagulation. 10.1016/j.hrtlng.2019.07.007
    Temporal variation in the diagnosis of resolved atrial fibrillation and the influence of performance targets on clinical coding: cohort study. Adderley Nicola,Nirantharakumar Krishnarajah,Marshall Tom BMJ open OBJECTIVES:To investigate whether the introduction of performance targets for anticoagulation in atrial fibrillation (AF) was associated with a change in use of the 'resolved AF' code. DESIGN:Retrospective cohort studies. SETTING:Data from The Health Improvement Network, a UK database of electronic patient records, from 2000 to 2016. PARTICIPANTS:250 788 adult patients aged ≥18 years with a diagnosis of AF, including 14 757 with an incident diagnosis of 'resolved AF'. MAIN OUTCOME MEASURES:Annual and monthly incidence of 'resolved AF' from 2000 to 2016. Among patients with 'resolved AF', for each year we calculated median duration of the preceding AF diagnosis and the proportion prescribed anticoagulants prior to 'resolved AF'. RESULTS:Incidence of 'resolved AF' increased from 5.7 to 26.3 per 1000 person-years between 2005 and the introduction of AF performance targets in 2006. Compared with the years prior to the introduction of the performance targets, incidence has remained higher in every year since their implementation. Since 2007, monthly incidence has been highest between January and March. Between 2005 and 2006, median duration between AF and 'resolved AF' diagnoses increased from 276 days (9 months) to 1343 days (3 years 8 months). Among 'resolved AF' patients with CHADS-VASc score ≥1, 81.9% (95% CI 81.1 to 82.6) had no current anticoagulant prescription, and 62.3% (95% CI 61.4 to 63.2) had no record of any anticoagulant prescription. CONCLUSION:The introduction of AF performance targets was followed by a large increase in use of the 'resolved AF' code, particularly in the months immediately before practices make their anticoagulant performance target submissions. Although most AF patients are prescribed anticoagulants, few patients diagnosed with 'resolved AF' are prescribed anticoagulants and most have never been prescribed them. Untreated patients are much more likely to be coded as having 'resolved AF'. 10.1136/bmjopen-2019-030454
    Impact of Low-Dose Hydrocortisone on the Incidence of Atrial Fibrillation in Patients With Septic Shock: A Propensity Score-Inverse Probability of Treatment Weighting Cohort Study. Launey Yoann,Lasocki Sigismond,Asehnoune Karim,Gaudriot Baptiste,Chassier Claire,Cinotti Raphael,Maguet Pascale Le,Laksiri Leila,Mimoz Olivier,Tawa Audrey,Nesseler Nicolas,Malledant Yannick,Perrot Bastien,Seguin Philippe Journal of intensive care medicine PURPOSE:Atrial fibrillation (AF) is common in the intensive care unit (ICU), notably in patients with septic shock for whom inflammation is an already identified risk factor. The aim of this study was to evaluate the effect of low-dose hydrocortisone on AF occurrence in patients with septic shock. METHODS:We performed a prospective nonrandomized observational study in 5 academic ICUs in France. From November 2012 to June 2014, all patients ≥16 years having septic shock were included, except those who had a history of AF, had a pacemaker, and/or experienced AF during hospitalization before the onset of shock or in whom the onset of shock occurred prior to admission to the ICU. Hydrocortisone was administered at the discretion of the attending physician. The incidence of AF was compared among patients who received hydrocortisone, and the effect of low-dose hydrocortisone on AF was estimated using the inverse probability treatment weighting method based on propensity scores. RESULTS:A total of 261 patients were included (no-hydrocortisone group, n = 138; hydrocortisone group, n = 123). Atrial fibrillation occurred in 57 (22%) patients. Atrial fibrillation rates were 33 (24%) and 24 (19%) in no-hydrocortisone patients and hydrocortisone patients, respectively. In the weighted sample, the proportion of patients who developed AF was 28.8% in the no-hydrocortisone group and 16.8% in the hydrocortisone group (difference: -11.9%; 95% confidence interval: -23.4% to -0.5%; = .040). CONCLUSION:In patients with septic shock, low-dose hydrocortisone was associated with a lower risk of developing AF during the acute phase. 10.1177/0885066617696847
    Long Sleep Duration Is an Independent Risk Factor for Incident Atrial Fibrillation in a Chinese Population: A Prospective Cohort Study. Song Qiaofeng,Liu Xiaoxue,Hu Wanning,Zhou Wenhua,Liu Aijuan,Wang Xizhu,Wu Shouling Scientific reports There is limited information on the relation between sleep duration and incident atrial fibrillation. We aimed to investigate this association in a Chinese population using cohort data from a study in Kailuan. The analysis included 87,693 participants (age range, 18-98 years) free of atrial fibrillation at the baseline survey. Participants were divided into three categories according to self-reported sleep duration: ≤6.0 hours, 7 hours (ref), ≥8.0 hours. Atrial fibrillation diagnosis was made on a standard 12-lead electrocardiogram and via self-reported history. Cox proportional hazards models were used to calculate hazard ratio (HR) and confidence interval (CI) for atrial fibrillation, according to sleep duration. During median follow-up of 7.89 (range, 6.36-8.57) years, 322 cases of atrial fibrillation had occurred. Using 7 hours of sleep as the reference group, multivariable adjusted HRs (95% CI) for atrial fibrillation were 1.07 (0.75-1.53), 1.0 (ref), and 1.50 (1.07-2.10), from lowest to highest category of sleep duration. Secondary analysis showed no evidence of interactions between sleep duration and sex and snoring on the risk of incident atrial fibrillation (p = 0.75/0.25). We conclude long sleep duration may be a potential predictor/marker for incident atrial fibrillation. 10.1038/s41598-017-04034-8
    Comparisons of changes in the adapted diabetes complications severity index and CHA2DS2-VASc score for atrial fibrillation risk stratification in patients with type 2 diabetes mellitus: A nationwide cohort study. Hu Wei-Syun,Hsieh Meng-Hsuen,Lin Cheng-Li International journal of cardiology PURPOSE:This study describes the risk prediction of atrial fibrillation (AF) after incident type 2 diabetes mellitus (DM) with either progression of adapted diabetes complications severity index (DCSI) or CHADS-VASc score in a large registry from Taiwan. METHODS:The authors performed a retrospective nationwide cohort study by analyzing a Longitudinal Health Insurance Dataset, observing the ability of dynamic adapted DSCI and CHADS-VASc score for AF risk discrimination in type 2 diabetic patients. The predictive performance of changes in the adapted DCSI and CHADS-VASc score with regard to AF events was assessed using area under the curve of receiver operating characteristics (AUROC); and the difference between them was examined using the Delong test. RESULTS:A total of 81,655 new-onset type 2 DM patients were included in the study cohort. Among them, the AUROC for the adapted DCSI change in predicting AF (0.79, 95% CI = 0.78-0.80) was significantly higher than the change in CHADS-VASc score (0.63, 95% CI = 0.62-0.64) with the DeLong test P < 0.001. CONCLUSIONS:Adapted DCSI change significantly outperforms the progression of CHADS-VASc score with regard to AF prediction in type 2 diabetic patients. 10.1016/j.ijcard.2018.07.010
    Different Implications of Heart Failure, Ischemic Stroke, and Mortality Between Nonvalvular Atrial Fibrillation and Atrial Flutter-a View From a National Cohort Study. Lin Yu-Sheng,Chen Tien-Hsing,Chi Ching-Chi,Lin Ming-Shyan,Tung Tao-Hsin,Liu Chi-Hung,Chen Yung-Lung,Chen Mien-Cheng Journal of the American Heart Association BACKGROUND:Atrial flutter (AFL) has been identified to be equivalent to atrial fibrillation (AF) in terms of preventing ischemic stroke, although differences exist in atrial rate, substrate, and electrophysiological mechanisms. This study aimed to investigate differences in clinical outcomes between nonvalvular AF and AFL. METHODS AND RESULTS:AF and AFL patients without any prescribed anticoagulation were enrolled from a 13-year national cohort database. Under series exclusion criteria, ischemic stroke, heart failure hospitalization, and all-cause mortality were compared between the groups in real-world conditions and after propensity score matching. We identified 175 420 patients in the AF cohort and 6239 patients in the AFL cohort, and the prevalence of most comorbidities and frequency of medications were significantly higher in the AF group than the AFL group. In the real-world setting the AF patients had higher incidence rates of ischemic stroke, heart failure hospitalization, and all-cause mortality than the AFL patients (all <0.001). After propensity score matching, the incidence rate of ischemic stroke in the AF cohort was 1.63-fold higher than in the AFL cohort (<0.001), the incidence rate of heart failure hospitalization in the AF cohort was 1.70-fold higher than in the AFL cohort (<0.001), and the incidence rate of all-cause mortality in the AF cohort was 1.08-fold higher than in the AFL cohort (=0.002). CONCLUSIONS:There were differences between AF and AFL in comorbidities and prognosis with regard to ischemic stroke, heart failure hospitalization, and all-cause mortality. 10.1161/JAHA.117.006406
    Use of oral anticoagulants in older people with atrial fibrillation in UK general practice: protocol for a cohort study using the Clinical Practice Research Datalink (CPRD) database. Mitchell Anneka,Welsh Tomas J,Watson Margaret C,Snowball Julia,McGrogan Anita BMJ open INTRODUCTION:Warfarin has frequently been underused in older people for stroke prevention in atrial fibrillation (AF). Direct oral anticoagulants (DOACs) entered the UK market from 2008 and have been recommended as an alternative to warfarin. This study aimed to describe any changes in the prescribing of oral anticoagulants (OACs) to people aged ≥75 years in UK general practice before and after the introduction of DOACs, to examine differences in patient characteristics which may influence prescribers' decisions regarding anticoagulation, to evaluate the time people stay on OACs and switching between OACs. METHODS AND ANALYSIS:A retrospective cohort study design will be used. Patients with a diagnosis of AF will be identified from the Clinical Practice Research Datalink (CPRD). The study period will run from 1 January 2003 to 27 December 2017. Patients enter the cohort at the latest date of the start of the study period, first AF diagnosis, 75th birthday or a year from when they started to contribute research standard data. Follow-up continues until they leave the practice, death, the date the practice stops contributing research standard data or the end of the study period (27 December 2017). Exposure to OACs will be defined as ≥1 prescription issued for an OAC of interest during the study period. Patients issued an OAC in the year preceding study entry will be defined as 'prevalent users'. Patients starting on an OAC during the study period will be defined as 'incident users'. Incidence and prevalence of OAC prescribing, patient demographics and characteristics will be described during three time periods: 2003-2007, 2008-2012 and 2013-2017. Persistence (defined as the time from initiation to discontinuation of medication) with and switching between different OACs will be described. ETHICS AND DISSEMINATION:The protocol for this study was approved by the CPRD Independent Scientific Advisory Committee. The results will be disseminated in a peer-reviewed journal and at conferences. TRIAL REGISTRATION NUMBER:EUPAS29923. 10.1136/bmjopen-2019-032646
    Alcohol consumption and risk of incident atrial fibrillation: A population-based cohort study. Johansson Cecilia,Lind Marcus M,Eriksson Marie,Wennberg Maria,Andersson Jonas,Johansson Lars European journal of internal medicine AIMS:Atrial fibrillation (AF) is a common tachyarrhythmia. High alcohol consumption is associated with increased AF risk. It remains unclear whether lower levels of alcohol consumption are also associated with AF risk, and whether the association differs between men and women. In this study, we investigated the association between low to moderate levels of alcohol consumption and AF risk in men and women. METHODS:We performed a population-based cohort study of 109,230 health examination participants in northern Sweden. Data regarding alcohol intake were obtained using a questionnaire administered at the health examination. Incident AF cases were identified from the Swedish National Patient Registry. RESULTS:AF was diagnosed in 5,230 individuals during a total follow-up of 1,484,547 person-years. Among men, AF risk increased over quartiles of weekly alcohol consumption (P for trend 0.001). Men with alcohol consumption in the highest quartile (≥4.83 standard drinks [each drink containing 12 gs of ethanol] per week; SDW) had a HR of 1.21 (95% CI 1.09-1.34) for AF compared to men in the lowest quartile (<0.90 SDW). In men, problem drinking was also associated with an increased AF risk (HR: 1.24; 95% CI: 1.10-1.39). Among women, AF risk was not significantly associated with alcohol consumption (P for trend 0.09 for decreasing risk of AF over quartiles of weekly alcohol consumption) or problem drinking (HR: 1.00; 95% CI 0.70-1.42). CONCLUSION:Self-reported alcohol consumption and problem drinking were associated with an increased risk of AF among men, but not in women. 10.1016/j.ejim.2020.02.022
    Patients with cancer and atrial fibrillation treated with doacs: A prospective cohort study. Vedovati Maria Cristina,Giustozzi Michela,Verdecchia Paolo,Pierpaoli Lucia,Conti Serenella,Verso Melina,Di Filippo Francesco,Marchesini Emanuela,Bogliari Giulio,Agnelli Giancarlo,Becattini Cecilia International journal of cardiology BACKGROUND:Limited data are available on the use of direct oral anticoagulants (DOACs) in patients with cancer and atrial fibrillation (AF). METHODS:Consecutive patients with non-valvular AF treated with DOACs were enrolled in a prospective cohort with the aim of evaluating thromboembolic (ischemic stroke or transient ischemic attack or systemic embolism) and major bleeding (MB) events according to presence and type of cancer. The risk of study outcomes over time was compared using Kaplan-Meier method and log-rank test or Cox proportional hazards regression. RESULTS:2304 patients with non-valvular AF receiving DOACs were enrolled and 16 excluded: 2288 analysed of whom 289 (12.6%) had cancer. Gastrointestinal (21%), genitourinary (15%), prostate (15%), haematological (14%), breast (13%), and lung (8%) were the more frequent sites of cancer. After a mean follow-up of 451 days, thromboembolic events occurred in 2.1% and 0.8% patient-year of cancer and non-cancer patients (adjusted-HR 2.58, 95% CI 1.08-6.16, p = 0.033). The rate of MB was 6.6% and 3.0% patient-year in cancer and non-cancer patients (adjusted-HR 2.02, 95% CI 1.25-3.27, p = 0.004). The differences in bleeding were mainly accounted for by bleeding at gastrointestinal and genitourinary sites. No significant differences were found concerning the rates of non-cancer-related mortality, fatal bleeding or fatal thrombotic events. CONCLUSIONS:In this study, the higher bleeding risk found in cancer compared to non-cancer patients was mainly due to an excess of bleeding at gastrointestinal and at genitourinary sites. Larger studies on the optimal management of cancer patients with AF are needed. 10.1016/j.ijcard.2018.07.138
    Risk of atrial fibrillation in persons with type 2 diabetes and the excess risk in relation to glycaemic control and renal function: a Swedish cohort study. Seyed Ahmadi Shilan,Svensson Ann-Marie,Pivodic Aldina,Rosengren Annika,Lind Marcus Cardiovascular diabetology BACKGROUND:To examine the incidence of atrial fibrillation in individuals with type 2 diabetes compared with age- and sex-matched controls from the general population and its variation in relation to glycaemic control and renal function. METHODS:A total of 421,855 patients with type 2 diabetes from the Swedish National Diabetes Registry and 2,131,223 controls from the Swedish Population Registry, matched for age, sex and county, were included and followed from January 1, 2001 to December 31, 2013. RESULTS:Overall, 8.9% of individuals with type 2 diabetes and 7.0% of controls were diagnosed with atrial fibrillation during follow-up, unadjusted incidence risk ratio (IRR) 1.35 (95% 1.33-1.36). Women < 55 years old with type 2 diabetes had an IRR of 2.36 (95% CI 2.10-2.66), in relation to controls, whereas the corresponding value for men < 55 years old with type 2 diabetes was IRR 1.78 (95% CI 1.67-1.90). In the fully adjusted Cox regression, the risk of type 2 diabetes on incident atrial fibrillation was 28% greater vs controls, hazard ratio (HR) 1.28 (95% CI 1.26-1.30), p < 0.0001. The excess risk of atrial fibrillation in individuals with type 2 diabetes increased with worsening glycaemic control and renal complications. For individuals with HbA1c ≤ 6.9% (≤ 52 mmol/mol) and normoalbuminuria the excess risk vs controls was still increased, adjusted HR 1.16 (95% CI 1.14-1.19); p < 0.0001. CONCLUSIONS:Individuals with type 2 diabetes had an overall 35% higher risk of atrial fibrillation compared to age- and sex-matched controls from the general population. The excess risk for atrial fibrillation increased with renal complications or with poor glycaemic control. Individuals with type 2 diabetes with good glycaemic control and normoalbuminuria had slightly increased risk. 10.1186/s12933-019-0983-1
    Brief episodes of rapid irregular atrial activity (micro-AF) are a risk marker for atrial fibrillation: a prospective cohort study. Fredriksson Tove,Gudmundsdottir Katrin Kemp,Frykman Viveka,Friberg Leif,Al-Khalili Faris,Engdahl Johan,Svennberg Emma BMC cardiovascular disorders BACKGROUND:Short supraventricular tachycardias with atrial fibrillation (AF) characteristics are associated with an increased risk of developing AF over time. The aim of this study is to determine if presence of very short-lasting episodes of AF-like activity (micro-AF) can also be used as a marker of undiagnosed silent atrial fibrillation. METHODS:In the STROKESTOP II study, a Swedish mass screening study for AF among 75- and 76-year-olds, participants with NT-proBNP ≥125 ng/L performed intermittent ECG recordings 30 s, four times daily for 2 weeks. Participants with micro-AF (sudden onset of irregular tachycardia with episodes of ≥5 consecutive supraventricular beats and total absence of p-waves, lasting less than 30 s) were invited to undergo extended AF screening using continuous event recording for 2 weeks. A control group of individuals without micro-AF was examined using the same ECG modalities. RESULTS:Out of 3763 participants in STROKESTOP II who had elevated NT-proBNP levels and were free of AF, n = 221 (6%) had micro-AF. The majority of participants with micro-AF (n = 196) accepted further investigation with continuous ECG monitoring which showed presence of AF in 26 of them. In the control group (n = 250), continuous monitoring detected 7 new AF cases. Thus, AF was significantly more common in the micro AF group (13%) compared to the control group (3%), p < 0.001. CONCLUSIONS:Presence of short-lasting episodes of AF-like activity (micro-AF) indicates increased likelihood for undetected AF. Continuous screening therefore seems recommendable if a finding of AF would change clinical management. TRAIL REGISTRATION:ClinicalTrials.gov, identifier: NCT02743416, registered April 19, 2016. 10.1186/s12872-020-01453-w
    Long-Term Impact of Newly Diagnosed Atrial Fibrillation During Critical Care: A South Korean Nationwide Cohort Study. Kim Kyu,Yang Pil-Sung,Jang Eunsun,Yu Hee Tae,Kim Tae-Hoon,Uhm Jae-Sun,Kim Jong-Youn,Sung Jung-Hoon,Pak Hui-Nam,Lee Moon-Hyoung,Lip Gregory Y H,Joung Boyoung Chest BACKGROUND:The long-term risks of thromboembolism and mortality are unknown in patients who survived following atrial fibrillation (AF) newly diagnosed during critical care. METHODS:Using the Korean National Health Insurance Service database, we identified 30,869 adults who survived for > 6 months following AF newly diagnosed during critical care (ICU-AF), 269,751 control subjects with non-ICU AF (AF-control), and 439,868 control subjects without AF (No-AF) from 2005 to 2013. We performed propensity score matching and compared the risks of stroke/systemic embolism and all-cause mortality. RESULTS:The adjusted hazard ratios (HRs) for long-term stroke/systemic embolism in the patients with ICU-AF were 0.93 (95% CI, 0.88-0.98) compared with the AF-control group and 1.50 (95% CI, 1.42-1.60) compared with the No-AF group. The adjusted HRs of the ICU-AF group for long-term mortality were 1.73 (95% CI, 1.70-1.83) and 3.20 (95% CI, 3.08-3.33) compared with the AF-control and No-AF groups, respectively. The risks of stroke/systemic embolism and mortality were significantly higher in the ICU-AF group than in the No-AF group after excluding patients with AF recurrence (adjusted HR, 1.08; 95% CI, 1.01-1.17), regardless of the causes of critical care and cardiovascular or noncardiovascular surgery. CONCLUSIONS:The patients who survived following AF newly diagnosed during critical care remained at a higher risk of long-term stroke/systemic embolism and mortality than the patients without AF regardless of AF recurrence and the causes of critical care. Close follow-up and continuous anticoagulation might be needed for these patients. 10.1016/j.chest.2019.04.011
    Incremental yield of ECG screening repeated annually over 4 years in an adult Japanese population without prior atrial fibrillation: a retrospective cohort study. Nagata Yoshiki,Yamagami Takashi,Nutbeam Don,Freedman Ben,Lowres Nicole BMJ open OBJECTIVES:International guidelines recommend opportunistic screening for atrial fibrillation (AF); however, there is no current data to inform how often to repeat screening. We aimed to investigate the incremental annual yield and stroke risk of new AF cases in individuals screened annually over 4 years. DESIGN:A retrospective cohort study. SETTING:Hokuriku Health Service Association, Toyama prefecture, Japan. PARTICIPANTS:Employees and their families receiving annual health examinations from Hokuriku Health Service Association. INTERVENTION:Each subject received an annual health examination (including 12-lead ECG) from 2014 to 2017. Only subjects with baseline ECGs in 2012 and/or 2013 were included. MAIN OUTCOME MEASURES:Rates (cases/100 person-years) of new AF identified each year for 4 consecutive years of screening (stratified according to gender and age groups). Calculated stroke risk of new AF cases using modified CHADS-VASc scores (without heart failure data) (CHADSVASc = C: congestive heart failure [1 point]; H: hypertension [1 point]; A2: age 65-74 years [1 point] or age ≥75 years [2 points]; D: diabetes mellitus [1 point]; S: prior stroke or transient ischemic attack [2 points]; VA: vascular disease [1 point]; and Sc: sex category [female] [1 point]) RESULTS: In 2014, 88 218 subjects had an ECG (46.8±12.5 years; 64% men): identifying 346 (0.39%) known AF and 69 (0.08%) new AF. The incidence rate of new AF increased with age from 0.01% (<50 years) to 0.98% (≥75 years) and was higher in men (0.1%) than women (0.05%). Repeated annual screening over 4 years identified a consistent new AF yield 0.06%-0.10% per year (0.33%-0.55% ≥65 years). Forty-two per cent of all new AF cases, and 76% of cases aged ≥65 years, had a class-1 oral anticoagulation (OAC) recommendation (modified CHADS-VASc score ≥2 men, ≥3 women). CONCLUSIONS:Repeated annual ECG screening of the same population provides a consistent yield of new AF each year. The majority of new AF (≥65 years) are eligible for anticoagulation for stroke prevention. Although AF prevalence and incidence are lower in Japan than Western countries, 2318 new cases would be identified in Toyama prefecture each year with annual screening, of whom ~927 would have a high stroke risk with a recommendation for OAC therapy. 10.1136/bmjopen-2019-035650
    Aplastic Anemia and Risk of Incident Atrial Fibrillation - A Nationwide Cohort Study. Hu Wei-Syun,Sung Fung-Chang,Lin Cheng-Li Circulation journal : official journal of the Japanese Circulation Society BACKGROUND:This retrospective cohort study sought to follow up patients with aplastic anemia (AA) to evaluate their risk of developing atrial fibrillation (AF).Methods and Results:From the National Health Insurance Research Database of Taiwan, this study identified an AA cohort (n=3,921), a general population cohort (n=17,617,843) and a propensity score-matched none AA cohort (PSM non-AA cohort in brief, n=15,684) in 2000-2010. By the end of 2011, the incident AF was higher in the AA cohort than in the general population and PSM non-AA cohorts (8.94 vs. 1.14 and 6.47 per 1,000 person-years, respectively). The adjusted hazards ratio of AF for the AA cohort was 2.12 (95% confidence interval 1.46-3.08) compared with the PSM non-AA cohort, after controlling for covariates. However, after further controlling for the competing risk of death, adjusted subhazard ratio was 1.21 (95% CI 0.97-1.50). Among those who developed AF, the AA cohort had a higher mortality rate (83.7 vs. 51.1 per 100), but a lower rate of incident stroke (26.0 vs. 41.5 per 100), compared with the PSM non-AA cohort. CONCLUSIONS:Patients with AA could have an elevated risk for AF. The mortality risk increased further for those who develop AF. 10.1253/circj.CJ-17-0519
    Incidence, Predictors, and Outcomes of New-Onset Atrial Fibrillation in Critically Ill Patients with Sepsis. A Cohort Study. Klein Klouwenberg Peter M C,Frencken Jos F,Kuipers Sanne,Ong David S Y,Peelen Linda M,van Vught Lonneke A,Schultz Marcus J,van der Poll Tom,Bonten Marc J,Cremer Olaf L, American journal of respiratory and critical care medicine RATIONALE:Patients admitted to intensive care units with sepsis are prone to developing cardiac dysrhythmias, most commonly atrial fibrillation. OBJECTIVES:To determine the incidence, risk factors, and outcomes of atrial fibrillation in a cohort of critically ill patients with sepsis. METHODS:We assessed the association between atrial fibrillation and mortality using time-dependent competing risks survival analysis. Subsequently, for development of a risk score estimating the probability of a first occurrence of atrial fibrillation within the following 24 hours, we performed logistic regression analysis. MEASUREMENTS AND MAIN RESULTS:Among 1,782 patients with sepsis admitted to two tertiary intensive care units in the Netherlands between January 2011 and June 2013, a total of 1,087 episodes of atrial fibrillation occurred in 418 (23%) individuals. The cumulative risk of new-onset atrial fibrillation was 10% (95% confidence interval [CI], 8-12), 22% (95% CI, 18-25), and 40% (95% CI, 36-44) in patients with sepsis, severe sepsis, and septic shock, respectively. New-onset atrial fibrillation was associated with a longer stay (hazard ratio [HR], 0.55; 95% CI, 0.48-0.64), an increased death rate (HR, 1.52; 95% CI, 1.16-2.00), and an overall increased mortality risk (subdistribution HR, 2.10; 95% CI, 1.61-2.73) when considering discharge as a competing event. A simple risk score for daily prediction of atrial fibrillation occurrence yielded good discrimination (C statistic, 0.81; 95% CI, 0.79-0.84) and calibration (chi-square, 9.38; P = 0.31), with similar performance in an independent validation cohort (C statistic, 0.80; 95% CI, 0.76-0.85). CONCLUSIONS:Atrial fibrillation is a common complication of sepsis and independently associated with excess mortality. A simple risk score may identify patients at high risk of this complication. Clinical trial registered with www.clinicaltrials.gov (NCT 01905033). 10.1164/rccm.201603-0618OC
    Sex Differences in the Association between Atrial Fibrillation and 90-Day Adverse Outcomes among Older Adults with Heart Failure: A Retrospective Cohort Study. Son Youn-Jung,Kim Da-Young,Won Mi Hwa International journal of environmental research and public health Sex differences in the prognostic impact of coexisting atrial fibrillation (AF) in older patients with heart failure (HF) have not been well-studied. This study, therefore, compared sex differences in the association between AF and its 90-day adverse outcomes (hospital readmissions and emergency room (ER) visits) among older adults with HF. Of the 250 older adult patients, the prevalence rates of coexisting AF between male and female HF patients were 46.0% and 31.0%, respectively. In both male and female older patients, patients with AF have a significantly higher readmission rate (male 46.0%, and female 34.3%) than those without AF (male 6.8%, and female 12.8%). However, there are no significant differences in the association between AF and ER visits in both male and female older HF patients. The multivariate logistic analysis showed that coexisting AF significantly increased the risk of 90-day hospital readmission in both male and female older patients. In addition, older age in males and longer periods of time after an HF diagnosis in females were associated with an increased risk of hospital readmission. Consequently, prospective cohort studies are needed to identify the impact of coexisting AF on short- and long-term outcomes in older adult HF patients by sex. 10.3390/ijerph18052237
    Long-chain n-3 and n-6 polyunsaturated fatty acids and risk of atrial fibrillation: Results from a Danish cohort study. Mortensen Lotte Maxild,Lundbye-Christensen Søren,Schmidt Erik Berg,Calder Philip C,Schierup Mikkel Heide,Tjønneland Anne,Parner Erik T,Overvad Kim PloS one BACKGROUND:Studies of the relation between polyunsaturated fatty acids and risk of atrial fibrillation have been inconclusive. The risk of atrial fibrillation may depend on the interaction between n-3 and n-6 polyunsaturated fatty acids as both types of fatty acids are involved in the regulation of systemic inflammation. OBJECTIVE:We investigated the association between dietary intake of long chain polyunsaturated fatty acids (individually and in combination) and the risk of atrial fibrillation with focus on potential interaction between the two types of polyunsaturated fatty acids. DESIGN:The risk of atrial fibrillation in the Diet, Cancer and Health Cohort was analyzed using the pseudo-observation method to explore cumulative risks on an additive scale providing risk differences. Dietary intake of long chain polyunsaturated fatty acids was assessed by food frequency questionnaires. The main analyses were adjusted for the dietary intake of n-3 α-linolenic acid and n-6 linoleic acid to account for endogenous synthesis of long chain polyunsaturated fatty acids. Interaction was assessed as deviation from additivity of absolute association measures (risk differences). RESULTS:Cumulative risks in 15-year age periods were estimated in three strata of the cohort (N = 54,737). No associations between intake of n-3 or n-6 long chain polyunsaturated fatty acids and atrial fibrillation were found, neither when analyzed separately as primary exposures nor when interaction between n-3 and n-6 long chain polyunsaturated fatty acids was explored. CONCLUSION:This study suggests no association between intake of long chain polyunsaturated fatty acids and risk of atrial fibrillation. 10.1371/journal.pone.0190262
    Sleep Apnea Increases the Risk of New Hospitalized Atrial Fibrillation: A Historical Cohort Study. Kendzerska Tetyana,Gershon Andrea S,Atzema Clare,Dorian Paul,Mangat Iqwal,Hawker Gillian,Leung Richard S Chest OBJECTIVES:This study examined the relationship between newly diagnosed OSA and incident hospitalized atrial fibrillation (AF) over the subsequent 10 years in a large arrhythmia-free cohort. METHODS:Adults referred between 1994 and 2010 to a large academic hospital with suspected OSA who were arrhythmia-free at the time of the first diagnostic sleep study were included. Clinical data were linked to provincial health administrative data to define outcome. Cox regressions were used to investigate the relationship between severity of OSA as measured by the apnea-hypopnea index (AHI) and degree of nocturnal hypoxemia, and incident hospitalized AF. RESULTS:In total, 8,256 subjects were included in this study. Their median age was 47 years, 62% were men; 28% had an AHI > 30 events per hour, and 6% spent > 30% of sleep time with oxygen saturation < 90%. Over a median follow-up of 10 years (interquartile range, 7-13 years), 173 participants (2.1%) were hospitalized with AF. Controlling for age, sex, alcohol consumption, smoking status, previous heart failure, COPD, and pulmonary embolism, nocturnal hypoxemia (but not AHI) was a significant predictor of incident AF: hazard ratio, 2.47 (95% CI, 1.64-3.71). After further controlling for BMI and hypertension, this association was attenuated but remained significant (hazard ratio, 1.77 [95% CI, 1.15-2.74]). CONCLUSIONS:In a large arrhythmia-free clinical cohort with suspected OSA, nocturnal hypoxemia was independently associated with a 77% increased hazard of incident hospitalized AF. These findings further support a relationship between OSA, nocturnal hypoxemia, and new-onset AF, and they may be used to enhance AF prevention in patients with OSA and severe nocturnal hypoxemia. 10.1016/j.chest.2018.08.1075
    Risk of New-Onset Atrial Fibrillation Among Asian Chronic Hepatitis C Virus Carriers: A Nationwide Population-Based Cohort Study. Yang Yao-Hsu,Chiang Hsin-Ju,Yip Hon-Kan,Chen Ko-Jung,Chiang John Y,Lee Mel S,Sung Pei-Hsun Journal of the American Heart Association Background Hepatitis C virus (HCV) infection not only links closely to systemic inflammation but also has numerous extrahepatic manifestations. Chronic inflammation also increases the risk of new-onset atrial fibrillation (AF). However, little is known regarding the clinical association between HCV infection and new-onset AF. Methods and Results We conducted a population-based cohort study using Taiwan's National Health Insurance Research Database during 1997 to 2013. A total of 11 771 HCV-infected patients were included in this study, and each of them was matched in a ratio of 1:4. Because of higher mortality among HCV cohorts, we used both Cox proportional hazard regression and competing risk regression models to compute the hazard ratios accompanying 95% CIs after adjustment for relevant confounder. The results demonstrated that the patients with chronic HCV infection had significantly higher incidence rate (332.0 versus 265.8 in 100 000 person-years, <0.0001) of new-onset AF compared with the non-HCV population. The adjusted hazard ratio of HCV for new-onset AF was 1.32 (95% CI, 1.20-1.44; <0.0001) and 1.20 (95% CI, 1.10-1.31; =0.0001) while calculated with Cox proportional hazard regression model and competing risk model, respectively. Intriguingly, we observed that the patients with HCV treated with antiviral agents had significantly lower incidental AF than those without anti-HCV treatment (1.2% versus 6.0%; <0.0001). Conclusions Chronic HCV infection was associated with an increased risk of incidental AF probably through sharing common pathology of chronic inflammation. Furthermore, a well-designed study is needed to clarify whether anti-HCV therapy can provide protection against the occurrence of AF. 10.1161/JAHA.119.012914
    Effectiveness and Safety of Standard-Dose Nonvitamin K Antagonist Oral Anticoagulants and Warfarin Among Patients With Atrial Fibrillation With a Single Stroke Risk Factor: A Nationwide Cohort Study. Lip Gregory Y H,Skjøth Flemming,Nielsen Peter Brønnum,Kjældgaard Jette Nordstrøm,Larsen Torben Bjerregaard JAMA cardiology Importance:The randomized clinical trials comparing nonvitamin K antagonist oral anticoagulants (NOACs) vs warfarin largely focused on recruiting high-risk patients with atrial fibrillation with more than 2 stroke risk factors, with only the trials testing dabigatran or apixaban including few patients with 1 stroke risk factor. Despite this, regulatory approvals of all NOACs have been based on stroke prevention for patients with atrial fibrillation with 1 or more stroke risk factors. Objective:To compare the effectiveness and safety study of standard-dose NOACs (dabigatran at 150 mg twice daily, rivaroxaban at 20 mg once daily, and apixaban at 5 mg twice daily) and warfarin in patients with atrial fibrillation with 1 low-risk, nonsex-related stroke risk factor. Design, Setting, and Participants:This nationwide observational cohort study used data from Danish registries to determine the inverse probability of treatment-weighted comparative effectiveness and safety of standard-dose NOACs (dabigatran at 150 mg twice daily, rivaroxaban at 20 mg once daily, and apixaban at 5 mg twice daily) compared with treatment with warfarin among 14 020 patients with atrial fibrillation with 1 low-risk, nonsex- related stroke risk factor. Main Outcomes and Measures:Rates of ischemic stroke/systemic embolism, death, and bleeding. Results:Of 14 020 participants, 5151 (36.7%) were women, and the median age for participants was 66.5 years. For the principal effectiveness end point of ischemic stroke/systemic embolism, no significant differences of the NOACs compared with treatment with warfarin across strata were evident. For the end point of "any bleeding," this was significantly lower for treatment with apixaban (hazard ratio [HR], 0.35; 95% CI, 0.17-0.72) and dabigatran (HR, 0.48; 95% CI, 0.30-0.77) compared with warfarin in the main analysis, and was not significantly different for treatment with rivaroxaban vs warfarin (HR, 0.84; 95% CI, 0.49-1.44). There was broad consistency across most subgroups in the sensitivity analyses and whether 1- or 2.5-year follow-up periods were analyzed. However, falsification end points generally did not falsify, indicating the possible presence of residual confounding across these comparisons, presumably related to selective prescribing and unobserved covariates. Conclusions and Relevance:In this Danish cohort study of patients with atrial fibrillation and a single stroke risk factor, there was no difference between NOACs compared with treatment with warfarin in terms of the risk of having an ischemic stroke/systemic embolism. For "any bleeding," this was lower for treatment with apixaban and dabigatran compared with warfarin. These data do not allow for a definitive statement of the comparative effectiveness or safety of NOACs because of the possible residual confounding that was unmasked with falsification outcomes. 10.1001/jamacardio.2017.1883
    Socioeconomic position and risk of atrial fibrillation: a nationwide Danish cohort study. Lunde Elin Danielsen,Joensen Albert Marni,Lundbye-Christensen Søren,Fonager Kirsten,Paaske Johnsen Søren,Larsen Mogens Lytken,Berg Johansen Martin,Riahi Sam Journal of epidemiology and community health AIM:To examine the association between socioeconomic position and the risk of atrial fibrillation (AF) in different stages of life in a population of Danish citizens. METHODS:Register-based study. We followed all individuals turning 35, 50, 65 or 80 years from 1 January 1996 to 31 December 2005 until AF, death, emigration or the end of study period (31 December 2015). Exposure was education and income. We used Cox regression for the HRs (95% CI) and the pseudo-observation method for the adjusted risk difference (RD) (%). RESULTS:A total of 2 173 857 participants were enrolled and 151 340 incident cases of AF occurred over a median of 13.6 years of follow-up. Adjusted HR (95% CI) of incident AF for the youngest age group with the highest education (ref lowest) was 0.62 (0.50 to 0.77) (women) and 0.85 (0.76 to 0.96) (men). The associations attenuated with increasing age, that is, HRs for the oldest age group were 1.04 (0.97 to 1.10) and 0.98 (0.96 to 1.04), respectively. The corresponding adjusted RDs (%) were: -0.28 (-0.43 to -0.14), -0.18 (-0.36 to -0.01), 3.04 (-0.55 to 6.64) and -0.74 (-3.38 to 2.49), respectively. Similar but weaker associations were found for income. CONCLUSION:Higher level of education and income was associated with a lower risk of being diagnosed with AF in young individuals but the association decreased with increasing age and was almost absent for the oldest age cohort. However, since AF is relatively rare in the youngest the RDs were low. 10.1136/jech-2019-212720
    Non-warfarin oral anticoagulant copayments and adherence in atrial fibrillation: A population-based cohort study. Rome Benjamin N,Gagne Joshua J,Avorn Jerry,Kesselheim Aaron S American heart journal BACKGROUND:In patients with atrial fibrillation, incomplete adherence to anticoagulants increases risk of stroke. Non-warfarin oral anticoagulants (NOACs) are expensive; we evaluated whether higher copayments are associated with lower NOAC adherence. METHODS:Using a national claims database of commercially-insured patients, we performed a cohort study of patients with atrial fibrillation who newly initiated a NOAC from 2012 to 2018. Patients were stratified into low (<$35), medium ($35-$59), or high (≥$60) copayments and propensity-score weighted based on demographics, insurance characteristics, comorbidities, prior health care utilization, calendar year, and the NOAC received. Follow-up was 1 year, with censoring for switching to a different anticoagulant, undergoing an ablation procedure, disenrolling from the insurance plan, or death. The primary outcome was adherence, measured by proportion of days covered (PDC). Secondary outcomes included NOAC discontinuation (no refill for 30 days after the end of NOAC supply) and switching anticoagulants. We compared PDC using a Kruskal-Wallis test and rates of discontinuation and switching using Cox proportional hazards models. RESULTS:After weighting patients across the 3 copayment groups, the effective sample size was 17,558 patients, with balance across 50 clinical and demographic covariates (standardized differences <0.1). Mean age was 62 years, 29% of patients were female, and apixaban (43%), and rivaroxaban (38%) were the most common NOACs. Higher copayments were associated with lower adherence (P < .001), with a PDC of 0.82 (Interquartile range [IQR] 0.36-0.98) among those with high copayments, 0.85 (IQR 0.41-0.98) among those with medium copayments, and 0.88 (IQR 0.41-0.99) among those with low copayments. Compared to patients with low copayments, patients with high copayments had higher rates of discontinuation (hazard ratio [HR] 1.13, 95% confidence interval [CI] 1.08-1.19; P < .001). CONCLUSIONS:Among atrial fibrillation patients newly initiating NOACs, higher copayments in commercial insurance were associated with lower adherence and higher rates of discontinuation in the first year. Policies to lower or limit cost-sharing of important medications may lead to improved adherence and better outcomes among patients receiving NOACs. 10.1016/j.ahj.2020.12.010
    Association Between Atrial Fibrillation and the Risk of Dementia in the Korean Elderly: A 10-Year Nationwide Cohort Study. Nah Min-Ah,Lee Kyeong Soo,Hwang Tae-Yoon Journal of preventive medicine and public health = Yebang Uihakhoe chi OBJECTIVES:The objective of this study was to determine the effect of atrial fibrillation (AF) on the risk of dementia in the Korean elderly. METHODS:A 10-year retrospective cohort study was conducted using the National Health Insurance Service-Senior Cohort database. We excluded those who were under 65 years of age as of January 2006 (n=46 113), those who were diagnosed with dementia between 2002 and 2005 (n=9086), and those with a history of stroke prior to AF diagnosis (n=8392). We used a Cox proportional hazards model with a time-varying covariate to determine whether AF is associated with the risk of dementia after adjusting for potential confounders. RESULTS:In univariable Cox regression, the hazard ratio (HR) of dementia according to AF status was 1.28 (95% confidence interval [CI], 1.23 to 1.33). After adjusting for potential confounders, AF was found to increase the risk of dementia (HR, 1.12; 95% CI, 1.07 to 1.17), Alzheimer dementia (HR, 1.12; 95% CI, 1.07 to 1.17), and vascular dementia (HR, 1.10; 95% CI, 1.03 to 1.18). In patients diagnosed with AF, the incidence of dementia was lower (HR, 0.50; 95% CI, 0.47 to 0.52) in patients who were treated with oral anticoagulants. CONCLUSIONS:Investigating the potential risk factors of dementia in an aged society is important. We found a slightly higher risk of dementia in those with AF than in those without AF, and we therefore concluded that AF is a potential risk factor for dementia. 10.3961/jpmph.19.117
    Safety and Effectiveness of Non-Vitamin K Antagonist Oral Anticoagulants for Stroke Prevention in Patients With Atrial Fibrillation and Anemia: A Retrospective Cohort Study. Wang Chun-Li,Wu Victor Chien-Chia,Huang Yu-Tung,Kuo Chang-Fu,Chu Pao-Hsien,Chen Yu-Ling,Wen Ming-Shien,Chang Shang-Hung Journal of the American Heart Association Background Major randomized trials assessing non-vitamin K antagonist oral anticoagulants ( NOAC s) for stroke prevention in atrial fibrillation generally excluded patients with hemoglobin <10 g/dL. This study evaluated the safety and effectiveness of NOAC s in patients with atrial fibrillation and anemia. Methods and Results A cohort study based on electronic medical records was conducted from 2010 to 2017 at a multicenter healthcare provider in Taiwan. It included 8356 patients with atrial fibrillation who had received oral anticoagulants (age, 77.0±7.3 years; 48.0% women). Patients were classified into 2 subgroups: 7687 patients with hemoglobin ≥10 g/ dL and 669 patients with hemoglobin <10 g/ dL . A Cox regression analysis was performed to assess the risks of ischemic stroke/systemic embolism, bleeding, and death associated with NOAC versus warfarin in both subgroups, respectively. In patients with hemoglobin ≥10 g/ dL , NOAC (n=4793) was associated with significantly lower risks of ischemic stroke/systemic embolism, major bleeding, and gastrointestinal tract bleeding than warfarin (n=2894); there was no difference in the risk of death. In patients with hemoglobin <10 g/ dL , NOAC (n=390) was associated with significantly lower risks of major bleeding (adjusted hazard ratio, 0.43; 95% CI, 0.30-0.62) and gastrointestinal tract bleeding than warfarin (n=279), but there was no difference in the risk of ischemic stroke/systemic embolism (adjusted hazard ratio, 0.79; 95% CI , 0.53-1.17) or death. Subgroup analyses suggested that NOAC was associated with fewer bleeding events, irrespective of cancer or peptic ulcer disease history. Conclusions In patients with atrial fibrillation with hemoglobin <10 g/ dL , NOAC was associated with lower bleeding risks than warfarin, with no difference in the risk of ischemic stroke/systemic embolism or death. 10.1161/JAHA.119.012029
    Association Between Treatment With Apixaban, Dabigatran, Rivaroxaban, or Warfarin and Risk for Osteoporotic Fractures Among Patients With Atrial Fibrillation: A Population-Based Cohort Study. Lau Wallis C Y,Cheung Ching-Lung,Man Kenneth K C,Chan Esther W,Sing Chor Wing,Lip Gregory Y H,Siu Chung-Wah,Lam Joanne K Y,Lee Alan C H,Wong Ian C K Annals of internal medicine BACKGROUND:It is unclear whether anticoagulant type is associated with the risk for osteoporotic fracture, a deleterious complication of anticoagulants among patients with atrial fibrillation (AF). OBJECTIVE:To compare the risk for osteoporotic fracture between anticoagulants. DESIGN:Population-based cohort study. SETTING:Territory-wide electronic health record database of the Hong Kong Hospital Authority. PARTICIPANTS:Patients newly diagnosed with AF between 2010 and 2017 who received a new prescription for warfarin or a direct oral anticoagulant (DOAC) (apixaban, dabigatran, or rivaroxaban). Follow-up ended on 31 December 2018. MEASUREMENTS:Osteoporotic hip and vertebral fractures in anticoagulant users were compared using propensity score-weighted cumulative incidence differences (CIDs). RESULTS:There were 23 515 patients identified (3241 apixaban users, 6867 dabigatran users, 3866 rivaroxaban users, and 9541 warfarin users). Overall mean age was 74.4 years (SD, 10.8), ranging from 73.1 years (warfarin) to 77.9 years (apixaban). Over a median follow-up of 423 days, 401 fractures were identified (crude event number [weighted rate per 100 patient-years]: apixaban, 53 [0.82]; dabigatran, 95 [0.76]; rivaroxaban, 57 [0.67]; and warfarin, 196 [1.11]). After 24-month follow-up, DOAC use was associated with a lower risk for fracture than warfarin use (apixaban CID, -0.88% [95% CI, -1.66% to -0.21%]; dabigatran CID, -0.81% [CI, -1.34% to -0.23%]; and rivaroxaban CID, -1.13% [CI, -1.67% to -0.53%]). No differences were seen in all head-to-head comparisons between DOACs at 24 months (apixaban vs. dabigatran CID, -0.06% [CI, -0.69% to 0.49%]; rivaroxaban vs. dabigatran CID, -0.32% [CI, -0.84% to 0.18%]; and rivaroxaban vs. apixaban CID, -0.25% [CI, -0.86% to 0.40%]). LIMITATION:Residual confounding is possible. CONCLUSION:Among patients with AF, DOAC use may result in a lower risk for osteoporotic fracture compared with warfarin use. Fracture risk does not seem to be altered by the choice of DOAC. These findings may help inform the benefit-risk assessment when choosing between anticoagulants. PRIMARY FUNDING SOURCE:The University of Hong Kong and University College London Strategic Partnership Fund. 10.7326/M19-3671
    Disease progression after ablation for atrial flutter compared with atrial fibrillation: A nationwide cohort study. Skjøth Flemming,Vadmann Henrik,Hjortshøj Søren Pihlkjaer,Riahi Sam,Lip Gregory Y H,Larsen Torben Bjerregaard International journal of clinical practice AIMS:The aim of this study was to study the risk of death and development of arrhythmia and/or subsequently heart failure after an atrial flutter ablation procedure compared with an atrial fibrillation (AF) ablation procedure. METHODS:This observational study is based on data from Danish nationwide health databases. Patients with a first-time ablation procedure for either atrial flutter or AF in the period 2000-2016 were included. Rates of renewed arrhythmia, heart failure or death were compared and reported as adjusted hazard ratios (HR). RESULTS:The study population consisted of 2,004 and 3,803 patients with an incident atrial flutter or AF ablation procedure, respectively. All-cause mortality among atrial flutter patients was significantly higher compared with the AF group (HR 1.80, 95% confidence interval [CI] 1.39-2.35). The incidence of renewed arrhythmia without heart failure was lower in atrial flutter (HR 0.76, 95% CI 0.69-0.84). Renewed atrial flutter ablation and pacemaker implantations were significantly more frequent (HR 2.42, 95% CI 2.02-2.91 and HR 1.42, 95% CI 1.13-1.79, respectively) in atrial flutter compared with AF. The risk of heart failure was higher for atrial flutter, both after the initial ablation (HR 1.48, 95% CI 1.08-2.03), and after a further arrhythmia management event (HR 1.98, 95% CI 1.33-2.94). CONCLUSION:There was a higher mortality risk after atrial flutter ablation procedures compared with patients undergoing AF ablation. Rates of heart failure and further renewed (non-AF) arrhythmia management were higher in atrial flutter. 10.1111/ijcp.13258
    Long working hours as a risk factor for atrial fibrillation: a multi-cohort study. Kivimäki Mika,Nyberg Solja T,Batty G David,Kawachi Ichiro,Jokela Markus,Alfredsson Lars,Bjorner Jakob B,Borritz Marianne,Burr Hermann,Dragano Nico,Fransson Eleonor I,Heikkilä Katriina,Knutsson Anders,Koskenvuo Markku,Kumari Meena,Madsen Ida E H,Nielsen Martin L,Nordin Maria,Oksanen Tuula,Pejtersen Jan H,Pentti Jaana,Rugulies Reiner,Salo Paula,Shipley Martin J,Suominen Sakari,Theorell Töres,Vahtera Jussi,Westerholm Peter,Westerlund Hugo,Steptoe Andrew,Singh-Manoux Archana,Hamer Mark,Ferrie Jane E,Virtanen Marianna,Tabak Adam G, European heart journal Aims:Studies suggest that people who work long hours are at increased risk of stroke, but the association of long working hours with atrial fibrillation, the most common cardiac arrhythmia and a risk factor for stroke, is unknown. We examined the risk of atrial fibrillation in individuals working long hours (≥55 per week) and those working standard 35-40 h/week. Methods and results:In this prospective multi-cohort study from the Individual-Participant-Data Meta-analysis in Working Populations (IPD-Work) Consortium, the study population was 85 494 working men and women (mean age 43.4 years) with no recorded atrial fibrillation. Working hours were assessed at study baseline (1991-2004). Mean follow-up for incident atrial fibrillation was 10 years and cases were defined using data on electrocardiograms, hospital records, drug reimbursement registers, and death certificates. We identified 1061 new cases of atrial fibrillation (10-year cumulative incidence 12.4 per 1000). After adjustment for age, sex and socioeconomic status, individuals working long hours had a 1.4-fold increased risk of atrial fibrillation compared with those working standard hours (hazard ratio = 1.42, 95% CI = 1.13-1.80, P = 0.003). There was no significant heterogeneity between the cohort-specific effect estimates (I2 = 0%, P = 0.66) and the finding remained after excluding participants with coronary heart disease or stroke at baseline or during the follow-up (N = 2006, hazard ratio = 1.36, 95% CI = 1.05-1.76, P = 0.0180). Adjustment for potential confounding factors, such as obesity, risky alcohol use and high blood pressure, had little impact on this association. Conclusion:Individuals who worked long hours were more likely to develop atrial fibrillation than those working standard hours. 10.1093/eurheartj/ehx324
    Adipose tissue content of saturated fatty acids and atrial fibrillation: A case-cohort study. Dinesen Pia T,Rix Thomas A,Joensen Albert M,Tjønneland Anne,Lundbye-Christensen Søren,Overvad Kim,Schmidt Erik B European journal of clinical investigation OBJECTIVES:The aim of this study was to investigate the association between adipose tissue content of total saturated fatty acids including myristic (C14:0), palmitic (C16:0) and stearic (C18:0) acid, as a measure of exposure to saturated fatty acids and the risk of incident atrial fibrillation. MATERIALS AND METHODS:A total of 57 053 Danish men and women aged 50-64 years participating in the Diet, Cancer and Health cohort had an adipose tissue biopsy taken at baseline, and this was analysed for saturated fatty acids content by gas chromatography. Follow-up was registry based and in this case-cohort study we used all cases and a randomly drawn subcohort of 3500 participants representative for the entire cohort. RESULTS:Data were analysed using weighted Cox proportional hazards regression. During a median follow-up of 14.6 years, a total of 4722 cases of incident atrial fibrillation were diagnosed. For both men and women, no association between adipose tissue content of total saturated fatty acids and the risk of atrial fibrillation could be demonstrated. CONCLUSION:We did not find an association between adipose tissue content of total saturated fatty acids and the risk of incident atrial fibrillation. 10.1111/eci.12836
    The study protocol for PREDICT AF RECURRENCE: a PRospEctive cohort stuDy of surveIllanCe for perioperaTive Atrial Fibrillation RECURRENCE in major non-cardiac surgery for malignancy. Higuchi Satoshi,Kabeya Yusuke,Matsushita Kenichi,Tachibana Keisei,Kawachi Riken,Takei Hidefumi,Suzuki Yutaka,Abe Nobutsugu,Imanishi Yorihisa,Moriyama Kiyoshi,Yorozu Tomoko,Saito Koichiro,Sugiyama Masanori,Kondo Haruhiko,Yoshino Hideaki BMC cardiovascular disorders BACKGROUND:A previous retrospective cohort study established the relationship between perioperative atrial fibrillation (POAF) and subsequent mortality and stroke. However, the details regarding the cause of death and etiology of stroke remain unclear. METHODS:The prospective cohort study of surveillance for perioperative atrial fibrillation recurrence in major non-cardiac surgery for malignancy (PREDICT AF RECURRENCE) registry is an ongoing prospective cohort study to elucidate the long-term recurrence rate and the clinical impact of new-onset POAF in the setting of head and neck, non-cardiac thoracic, and abdominal surgery for malignancy. In this study, cardiologists collaborate with a surgical team during the perioperative period, carefully observe the electrocardiogram (ECG) monitor, and treat arrhythmia as required. Furthermore, patients who develop new-onset POAF are followed up using a long-term Holter ECG monitor, SPIDER FLASH-t AFib, to assess POAF recurrence. DISCUSSION:Even if patients with malignancy survive by overcoming the disease, they may die from any preventable cardiovascular diseases. In particular, those with POAF may develop cardiogenic stroke in the future. Because details of the natural history of patients with POAF remain unclear, investigating the need to continue anticoagulation therapy for such patients is necessary. This study will provide essential information on the recurrence rate of POAF and new insights into the prediction and treatment of POAF. TRIAL REGISTRATION:University Hospital Medical Information Network Clinical Trial Registry (UMIN-CTR): UMIN000016146 ; Data of Registration: January 7, 2015. 10.1186/s12872-018-0862-9
    The risk of acute kidney injury in Asians treated with apixaban, rivaroxaban, dabigatran, or warfarin for non-valvular atrial fibrillation: A nationwide cohort study in Taiwan. Chan Yi-Hsin,Yeh Yung-Hsin,Hsieh Mei-Yun,Chang Chia-Yu,Tu Hui-Tzu,Chang Shang-Hung,See Lai-Chu,Kuo Chang-Fu,Kuo Chi-Tai International journal of cardiology BACKGROUND:Whether or not non-vitamin K antagonist oral anticoagulants (NOACs) are associated with a lower risk of acute kidney injury (AKI) in patients with non-valvular atrial fibrillation (NVAF) remains unknown in real world practice. METHODS:In this nationwide retrospective cohort study, 1507, 3200, 5765 and 4227 NVAF patients with chronic kidney disease (CKD) and 4368, 16,945, 22,301, and 16,908 NVAF patients without CKD taking apixaban, dabigatran, rivaroxaban, and warfarin, respectively, from June 1, 2012 to December 31, 2016 were enrolled from the Taiwan National Health Insurance Program. Propensity-score weighted method was used to balance covariates across study groups. Patients were followed until occurrence of AKI or end date of study. RESULTS:Three NOACs were all associated with a significantly lower risk of AKI compared with warfarin for both CKD-free (hazard ratio, [95% confidential interval]; 0.65, [0.60-0.72] for apixaban; 0.68, [0.64-0.74] for dabigatran; 0.73, [0.68-0.79] for rivaroxaban) and CKD cohorts (0.50, [0.45-0.56] for apixaban; 0.54, [0.49-0.59] for dabigatran; 0.53, [0.49-0.58] for rivaroxaban). The annual incidence of AKI for all NOACs and warfarin increased gradually as the increment of CHADS-VASc for both CKD-free and CKD cohorts after propensity score weighting. The reduced risk of AKI for three NOACs persisted in most subgroups in either CKD-free or CKD cohort. Multivariate analysis indicated that all three NOACs were all associated with lower risk of AKI than warfarin in either CKD-free or CKD cohort. CONCLUSIONS:All three NOACs are associated with a lower risk of AKI than warfarin among Asians with NVAF in real-world practice. 10.1016/j.ijcard.2018.02.075
    New-onset atrial fibrillation and associated outcomes and resource use among critically ill adults-a multicenter retrospective cohort study. Fernando Shannon M,Mathew Rebecca,Hibbert Benjamin,Rochwerg Bram,Munshi Laveena,Walkey Allan J,Møller Morten Hylander,Simard Trevor,Di Santo Pietro,Ramirez F Daniel,Tanuseputro Peter,Kyeremanteng Kwadwo Critical care (London, England) BACKGROUND:New-onset atrial fibrillation (NOAF) is commonly encountered in critically ill adults. Evidence evaluating the association between NOAF and patient-important outcomes in this population is conflicting. Furthermore, little is known regarding the association between NOAF and resource use or hospital costs. METHODS:Retrospective analysis (2011-2016) of a prospectively collected registry from two Canadian hospitals of consecutive ICU patients aged ≥ 18 years. We excluded patients with a known history of AF prior to hospital admission. Any occurrence of atrial fibrillation (AF) was prospectively recorded by bedside nurses. The primary outcome was hospital mortality, and we used multivariable logistic regression to adjust for confounders. We used a generalized linear model to evaluate contributors to total cost. RESULTS:We included 15,014 patients, and 1541 (10.3%) had NOAF during their ICU admission. While NOAF was not associated with increased odds of hospital death among the entire cohort (adjusted odds ratio [aOR] 1.02 [95% confidence interval [CI] 0.97-1.08]), an interaction was noted between NOAF and sepsis, and the presence of both was associated with higher odds of hospital mortality (aOR 1.28 [95% CI 1.09-1.36]) than either alone. Patients with NOAF had higher total costs (cost ratio [CR] 1.09 [95% CI 1.02-1.20]). Among patients with NOAF, treatment with a rhythm-control strategy was associated with higher costs (CR 1.24 [95% CI 1.07-1.40]). CONCLUSIONS:While NOAF was not associated with death or requiring discharge to long-term care among critically ill patients, it was associated with increased length of stay in ICU and increased total costs. 10.1186/s13054-020-2730-0
    Suicide attempt in patients with atrial fibrillation - A nationwide cohort study. Hu Wei-Syun,Lin Cheng-Li Progress in neuro-psychopharmacology & biological psychiatry BACKGROUND AND AIMS:We analyzed the incidence of suicide attempt in a Taiwanese population following admission to hospital between 2000 and 2010 for atrial fibrillation (AF). METHODS:Using the National Health Insurance Research Database in Taiwan, the study cohort and the comparison cohort were 1-fold matched according to propensity score method. Cox proportion hazard regression models were used to examine the effect of AF on the risk of suicide attempt, and were shown as hazard ratios (HRs) and 95% confidence intervals (CIs). Mortality for patients who have made suicide attempts was subsequently compared between the AF and the non-AF cohorts. RESULTS:The study included a cohort of 88,259 patients with AF and a non-AF cohort of 88,259 subjects. The overall incidence of suicide attempt for the AF and the non-AF cohorts were 5.75 and 3.97 per 10,000 person-years, respectively. AF patients were associated with an increased risk of suicide attempt compared with the non-AF controls [adjusted HR (aHR) = 1.47, 95% CI = 1.19-1.81] after controlling for the confounders. The incidence of mortality among patients who have made suicide attempts was not significantly higher in the AF cohort than in the non-AF cohort, with an adjusted HR of 1.11 (95% CI = 0.75-1.65). CONCLUSIONS:We concluded that in this large database AF patients were related with higher incidence of suicide attempt. 10.1016/j.pnpbp.2019.01.013
    Family History of Atrial Fibrillation and Risk of Cardiovascular Events: A Multicenter Prospective Cohort Study. Pastori Daniele,Menichelli Danilo,Lip Gregory Y H,Sciacqua Angela,Violi Francesco,Pignatelli Pasquale, Circulation. Arrhythmia and electrophysiology BACKGROUND:To investigate the association between family history of atrial fibrillation (AF) with cardiovascular events (CVEs), major adverse cardiac events (MACE), and cardiovascular mortality. METHODS:Multicenter prospective observational cohort study including 1722 nonvalvular AF patients from February 2008 to August 2019 in Italy. Family history of AF was defined as the presence of AF in a first-degree relative: mother, father, sibling, or children. Primary outcome was a composite of CVEs including fatal/nonfatal ischemic stroke and myocardial infarction, and cardiovascular death. Second, we analyzed the association with major adverse cardiac event. RESULTS:Mean age was 74.6±9.4 years; 44% of women. Family history of AF was detected in 368 (21.4%) patients, and 3.5% had ≥2 relatives affected by AF. Age of AF onset progressively decreased from patients without family history of AF, compared with those with single and multiple first-degree affected relatives (<0.001). During a mean follow-up of 23.7 months (4606 patients/y) 145 CVEs (3.15%/y), 98 major adverse cardiac event (2.13%/y), and 57 cardiovascular deaths (0.97%/y) occurred. After adjustment for cardiovascular risk factors, family history of AF was associated with a higher risk of CVEs (hazard ratio, 1.524 [95% CI, 1.021-2.274], =0.039), major adverse cardiac event (hazard ratio, 1.917 [95% CI, 1.207-3.045], =0.006), and cardiovascular mortality (hazard ratio, 2.008 [95% CI, 1.047-3.851], =0.036). Subgroup analysis showed that this association was modified by age, sex, and prior ischemic heart disease. CONCLUSIONS:In a cohort of elderly patients with a high atherosclerotic burden, family history of AF is evident in >20% of patients and was associated with an increased risk for CVEs and mortality. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01882114. 10.1161/CIRCEP.120.008477
    Efficacy and Safety of Non-Vitamin K Antagonist Oral Anticoagulants in Atrial Fibrillation Patients With Impaired Liver Function: A Retrospective Cohort Study. Wang Chun-Li,Wu Victor Chien-Chia,Kuo Chang-Fu,Chu Pao-Hsien,Tseng Hsiao-Jung,Wen Ming-Shien,Chang Shang-Hung Journal of the American Heart Association Background Patients with impaired liver function ( ILF ) were excluded from clinical trials that investigated non-vitamin K antagonist oral anticoagulants ( NOAC s) for stroke prevention in patients with atrial fibrillation. The aim of this study was to evaluate the efficacy and safety of NOAC s in atrial fibrillation patients with ILF . Methods and Results A cohort study based on electronic medical records was conducted from 2009 to 2016 at a multicenter healthcare provider in Taiwan and included 6451 anticoagulated atrial fibrillation patients (aged 76.7±7.0 years, 52.5% male). Patients were classified into 2 subgroups: patients with normal liver function (n=5818) and patients with ILF (n=633, 9.8%). Cox regression analysis was performed to investigate the risks of thromboembolism, bleeding, and death associated with use of NOAC s and warfarin in patients with normal liver function and ILF , respectively. In patients with normal liver function, compared with warfarin therapy (n=2928), NOAC therapy (n=4048) was associated with significantly lower risks of stroke or systemic embolism (adjusted hazard ratio: 0.75; 95% confidence interval, 0.65-0.88; P<0.001) and death (adjusted hazard ratio: 0.69; 95% confidence interval, 0.60-0.80; P<0.001) with no difference in major bleeding or gastrointestinal bleeding. In patients with ILF , compared with warfarin therapy (n=394), NOAC therapy (n=342) was associated with significantly lower risk of death (adjusted hazard ratio: 0.64; 95% confidence interval, 0.49-0.83; P<0.001), but no difference in stroke or systemic embolism, major bleeding, or gastrointestinal bleeding. Conclusions In atrial fibrillation patients with ILF , NOAC therapy and warfarin therapy were associated with similar risks of stroke or systemic embolism, major bleeding, and gastrointestinal bleeding. 10.1161/JAHA.118.009263
    Occurrence of death and stroke in patients in 47 countries 1 year after presenting with atrial fibrillation: a cohort study. Healey Jeff S,Oldgren Jonas,Ezekowitz Michael,Zhu Jun,Pais Prem,Wang Jia,Commerford Patrick,Jansky Petr,Avezum Alvaro,Sigamani Alben,Damasceno Albertino,Reilly Paul,Grinvalds Alex,Nakamya Juliet,Aje Akinyemi,Almahmeed Wael,Moriarty Andrew,Wallentin Lars,Yusuf Salim,Connolly Stuart J, Lancet (London, England) BACKGROUND:Atrial fibrillation is an important cause of morbidity and mortality worldwide, but scant data are available for long-term outcomes in individuals outside North America or Europe, especially in primary care settings. METHODS:We did a cohort study using a prospective registry of patients in 47 countries who presented to a hospital emergency department with atrial fibrillation or atrial flutter as a primary or secondary diagnosis. 15 400 individuals were enrolled to determine the occurrence of death and strokes (the primary outcomes) in this cohort over eight geographical regions (North America, western Europe, and Australia; South America; eastern Europe; the Middle East and Mediterranean crescent; sub-Saharan Africa; India; China; and southeast Asia) 1 year after attending the emergency department. Patients from North America, western Europe, and Australia were used as the reference population, and compared with patients from the other seven regions FINDINGS:Between Dec 24, 2007, and Oct 21, 2011, we enrolled 15 400 individuals to the registry. Follow-up was complete for 15 361 (99·7%), of whom 1758 (11%) died within 1 year. Fewer deaths occurred among patients presenting to the emergency department with a primary diagnosis of atrial fibrillation compared with patients who had atrial fibrillation as a secondary diagnosis (377 [6%] of 6825 patients vs 1381 [16%] of 8536, p<0·0001). Twice as many patients had died by 1 year in South America (192 [17%] of 1132) and Africa (225 [20%] of 1137) compared with North America, western Europe, and Australia (366 [10%] of 3800, p<0·0001). Heart failure was the most common cause of death (519 [30%] of 1758); stroke caused 148 (8%) deaths. 604 (4%) of 15361 patients had had a stroke by 1 year; 170 (3%) of 6825 for whom atrial fibrillation was a primary diagnosis and 434 (5%) of 8536 for whom it was a secondary diagnosis (p<0·0001). The highest number of strokes occurred in patients in Africa (89 [8%] of 1137), China (143 [7%] of 2023), and southeast Asia (88 [7%] of 1331) and the lowest occurred in India (20 [<1%] of 2536). 94 (3%) of 3800 patients in North America, western Europe, and Australia had a stroke. INTERPRETATION:Marked unexplained inter-regional variations in the occurrence of stroke and mortality suggest that factors other than clinical variables might be important. Prevention of death from heart failure should be a major priority in the treatment of atrial fibrillation. FUNDING:Boehringer Ingelheim. 10.1016/S0140-6736(16)30968-0
    Design and rationale of the atrial fibrillation occurring transiently with stress (AFOTS) follow-up cohort study. McIntyre William F,Mendoza Pablo A,Belley-Côté Emilie P,Whitlock Richard P,Um Kevin J,Maystrenko Natalie,Devereaux P J,Conen David,Wong Jorge A,Connolly Stuart J,Healey Jeff S Clinical cardiology Atrial fibrillation occurring transiently with stress (AFOTS) describes the first detection of AF in a patient who is hospitalized for a non-cardiac medical illness or following non-cardiac surgery. Uncertainty exists whether episodes of AFOTS are due to reversible precipitants and will not recur after recovery, or if they are paroxysmal atrial fibrillation (AF) that is detected during inpatient cardiac monitoring. Previous studies have used retrospective, non-systematic and ultimately low-sensitivity protocols to investigate the recurrence of AF in patients with AFOTS. The prospective, multi-center, investigator-initiated AFOTS Follow-Up Cohort Study will enroll 138 case patients with AFOTS in the setting of non-cardiac surgery or medical illness, matched 1:1 with control patients for age, sex, stressor, and hospital unit. Participants will wear a 14-day ECG heart monitor at 1 and 6 months after hospital discharge. Over 12 months of follow-up, we will collect data regarding participant's medications, and clinical events. The primary endpoint is detection of 30 or more seconds of AF after hospital discharge. To date, 50% of the target sample has been enrolled. The study is expected to complete enrolment in mid-2019 and conclude 1 year later. The AFOTS follow-up study will employ a systematic protocol to detect AF and will provide a precise and valid estimate of AF recurrence following AFOTS. This study will establish whether patients with AFOTS have an increased propensity to AF after hospitalization as compared to matched controls and may inform the management of this population. 10.1002/clc.23053
    Predicting postoperative atrial fibrillation after myocardial revascularization without cardiopulmonary bypass: A retrospective cohort study. Vidotti Edgar,Vidotti Lisia F K,Arruda Tavares Camila A G,Ferraz Érica D Z,Oliveira Vagner,de Andrade Augusto G,Cardoso Janaina M B,Cardoso Márcio H Journal of cardiac surgery INTRODUCTION:Considering the threat imposed by postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) and the potential benefits of off-pump CABG, the objective of this study was to describe the incidence and identify predictor factors for POAF in patients undergoing CABG without cardiopulmonary bypass (CPB). METHODS:In this retrospective cohort study, we enrolled patients undergoing CABG without CPB between December 2008 and December 2011. The independent variables evaluated in this study were major patients' characteristics (age, sex, and ethnia), associated comorbidities (systemic arterial hypertension, diabetes mellitus, thyroid dysfunction, chronic renal failure (CRF), chronic obstructive pulmonary disease, and ischemic stroke), and the revascularization approach (the number of grafts used, the revascularized branch, and the choice of vascular graft (arterial or venous). The dependent variable was the onset of atrial fibrillation after the procedure. RESULTS:Two hundred and eighty patients were included in the present study. The overall incidence of POAF after off-pump CABG was 5.0%. In the univariate analysis, the presence of chronic renal failure (odds ratio [OR], 3.01 [1.00-9.06], P = .049) and the use of venous-origin graft alone (OR, 9.67 [1.15-81.56], P = .037) were associated with an increased risk or POAF. These findings were confirmed after multivariate analysis, for both CRF (OR, 3.31 [1.05-10.46], P = .042) and the use of venous-origin graft alone (OR, 9.81 [1.13-85.35], P = .039). CONCLUSION:Off-pump coronary artery bypass grafting proved a safe and effective procedure, with low postoperative atrial fibrillation occurrence, for myocardial revascularization. Chronic renal insufficiency and the use of venous-origin graft solely proved to be independent predictor factors for PAOF. 10.1111/jocs.14088
    Trends in excess mortality associated with atrial fibrillation over 45 years (Framingham Heart Study): community based cohort study. Vinter Nicklas,Huang Qiuxi,Fenger-Grøn Morten,Frost Lars,Benjamin Emelia J,Trinquart Ludovic BMJ (Clinical research ed.) OBJECTIVE:To assess temporal trends in the association between newly diagnosed atrial fibrillation and death. DESIGN:Community based cohort study. SETTING:Framingham Heart Study cohort, in 1972-85, 1986-2000, and 2001-15 (periods 1-3, respectively), in Framingham, MA, USA. PARTICIPANTS:Participants with no atrial fibrillation, aged 45-95 in each time period, and identified with newly diagnosed atrial fibrillation (or atrial flutter) during each time period. MAIN OUTCOME MEASURES:The main outcome was all cause mortality. Hazard ratios for the association between time varying atrial fibrillation and all cause mortality were calculated with adjustment for time varying confounding factors. The difference in restricted mean survival times, adjusted for confounders, between participants with atrial fibrillation and matched referents at 10 years after a diagnosis of atrial fibrillation was estimated. Meta-regression was used to test for linear trends in hazard ratios and restricted mean survival times over the different time periods. RESULTS:5671 participants were selected in time period 1, 6177 in period 2, and 6174 in period 3. Adjusted hazard ratios for all cause mortality between participants with and without atrial fibrillation were 1.9 (95% confidence interval 1.7 to 2.2) in time period 1, 1.4 (1.3 to 1.6) in period 2, and 1.7 (1.5 to 2.0) in period 3 (P=0.70). Ten years after diagnosis of atrial fibrillation, the adjusted difference in restricted mean survival times between participants with atrial fibrillation and matched referents decreased by 31%, from -2.9 years (95% confidence interval -3.2 to -2.5) in period 1, to -2.1 years (-2.4 to -1.8) in period 2, to -2.0 years (-2.3 to -1.7) in period 3 (P=0.03). CONCLUSIONS:No evidence of a temporal trend in hazard ratios for the association between atrial fibrillation and all cause mortality was found. The mean number of life years lost to atrial fibrillation at 10 years had improved significantly, but a two year gap compared with individuals without atrial fibrillation still remained. 10.1136/bmj.m2724
    Does an interdisciplinary outpatient atrial fibrillation (AF) clinic affect the number of acute AF admissions? A retrospective cohort study. Frydensberg Vivi Skibdal,Brandes Axel Journal of clinical nursing AIMS AND OBJECTIVES:To investigate the impact of a multidisciplinary outpatient clinic for patients with atrial fibrillation-clinic on the number of acute hospitalisations for atrial fibrillation compared with usual outpatient care for this condition before the establishment of the atrial fibrillation-clinic. BACKGROUND:Guidelines recommend a structured outpatient clinic follow-up in multidisciplinary teams for patients with atrial fibrillation due to fewer hospitalisations and death. However, the evidence base is weak. DESIGN:The study is a retrospective cohort study including a total of 129 patients from the cardiac outpatient clinic at a large Danish University Hospital. The study population consisted of two groups: a usual care group before a dedicated atrial fibrillation-clinic was established (n = 73) and the atrial fibrillation-clinic group (n = 56). The primary endpoint was acute hospitalisation for atrial fibrillation. METHODS:Cox regression was used to assess the hazard ratio for acute hospitalisations for atrial fibrillation. RESULTS:When comparing the atrial fibrillation-clinic with the usual care group, adjusted for age and sex, this study showed a trend towards more frequent acute hospitalisations in the usual care group. CONCLUSION:The results of this study are hypothesis-generating and should lead to larger prospective trials to evaluate the impact of dedicated multidisciplinary atrial fibrillation-clinics on atrial fibrillation-related issues as acute hospitalisations for atrial fibrillation, symptoms and quality of life. RELEVANCE TO CLINICAL PRACTICE:Follow-up in a dedicated multidisciplinary AF-clinic might empower patients better to cope with acute arrhythmia symptoms. 10.1111/jocn.14373
    Risk of Atrial Fibrillation in Patients with Congenital Heart Disease: Results of a Propensity Score-Matched, Nationwide Cohort Study. Hu Wei-Syun,Lin Cheng-Li Journal of atherosclerosis and thrombosis AIM:The objective was to compare the rate of atrial fibrillation (AF) onset in patients with congenital heart disease (CHD) compared to controls. METHODS:Using a large number of samples extracted from nationwide cohort data in Taiwan, the authors used a propensity-matching procedure and multivariable Cox models to assess the risk of AF by CHD. RESULTS:A cohort of 19,439 CHD patients and a propensity-matched cohort of 19,439 control patients were included in this study. The cumulative incidence of AF was significantly higher in the CHD cohort than in the non-CHD cohort (p<0.001). After controlling for confounding factors, the adjusted hazard ratio (aHR) of AF was 4.23 (95% confidence interval [CI] 3.31-5.41) in the CHD cohort, compared to the non-CHD cohort. CONCLUSIONS:A significant association between CHD and AF risk was found. 10.5551/jat.48835
    Validation of Single Centre Pre-Mobile Atrial Fibrillation Apps for Continuous Monitoring of Atrial Fibrillation in a Real-World Setting: Pilot Cohort Study. Zhang Hui,Zhang Jie,Li Hong-Bao,Chen Yi-Xin,Yang Bin,Guo Yu-Tao,Chen Yun-Dai Journal of medical Internet research BACKGROUND:Atrial fibrillation is the most common recurrent arrhythmia in clinical practice, with most clinical events occurring outside the hospital. Low detection and nonadherence to guidelines are the primary obstacles to atrial fibrillation management. Photoplethysmography is a novel technology developed for atrial fibrillation screening. However, there has been limited validation of photoplethysmography-based smart devices for the detection of atrial fibrillation and its underlying clinical factors impacting detection. OBJECTIVE:This study aimed to explore the feasibility of photoplethysmography-based smart devices for the detection of atrial fibrillation in real-world settings. METHODS:Subjects aged ≥18 years (n=361) were recruited from September 14 to October 16, 2018, for screening of atrial fibrillation with active measurement, initiated by the users, using photoplethysmography-based smart wearable devices (ie, a smart band or smart watches). Of these, 200 subjects were also automatically and periodically monitored for 14 days with a smart band. The baseline diagnosis of "suspected" atrial fibrillation was confirmed by electrocardiogram and physical examination. The sensitivity and accuracy of photoplethysmography-based smart devices for monitoring atrial fibrillation were evaluated. RESULTS:A total of 2353 active measurement signals and 23,864 periodic measurement signals were recorded. Eleven subjects were confirmed to have persistent atrial fibrillation, and 20 were confirmed to have paroxysmal atrial fibrillation. Smart devices demonstrated >91% predictive ability for atrial fibrillation. The sensitivity and specificity of devices in detecting atrial fibrillation among active recording of the 361 subjects were 100% and about 99%, respectively. For subjects with persistent atrial fibrillation, 127 (97.0%) active measurements and 2240 (99.2%) periodic measurements were identified as atrial fibrillation by the algorithm. For subjects with paroxysmal atrial fibrillation, 36 (17%) active measurements and 717 (19.8%) periodic measurements were identified as atrial fibrillation by the algorithm. All persistent atrial fibrillation cases could be detected as "atrial fibrillation episodes" by the photoplethysmography algorithm on the first monitoring day, while 14 (70%) patients with paroxysmal atrial fibrillation demonstrated "atrial fibrillation episodes" within the first 6 days. The average time to detect paroxysmal atrial fibrillation was 2 days (interquartile range: 1.25-5.75) by active measurement and 1 day (interquartile range: 1.00-2.00) by periodic measurement (P=.10). The first detection time of atrial fibrillation burden of <50% per 24 hours was 4 days by active measurement and 2 days by periodic measurementThe first detection time of atrial fibrillation burden of >50% per 24 hours was 1 day for both active and periodic measurements (active measurement: P=.02, periodic measurement: P=.03). CONCLUSIONS:Photoplethysmography-based smart devices demonstrated good atrial fibrillation predictive ability in both active and periodic measurements. However, atrial fibrillation type could impact detection, resulting in increased monitoring time. TRIAL REGISTRATION:Chinese Clinical Trial Registry of the International Clinical Trials Registry Platform of the World Health Organization ChiCTR-OOC-17014138; http://www.chictr.org.cn/showprojen.aspx?proj=24191. 10.2196/14909
    Recurrent atrial flutter ablation and incidence of atrial fibrillation ablation after first-time ablation for typical atrial flutter: A nation-wide Danish cohort study. Giehm-Reese Mikkel,Kronborg Mads Brix,Lukac Peter,Kristiansen Steen Buus,Nielsen Jan Møller,Johannessen Arne,Jacobsen Peter Karl,Djurhuus Mogens Stig,Riahi Sam,Hansen Peter Steen,Nielsen Jens Cosedis International journal of cardiology BACKGROUND:Cavo tricuspid isthmus ablation (CTIA) is considered an effective first-line treatment for typical atrial flutter (AFL). However, many patients develop atrial fibrillation (AF) after successful CTIA. Knowledge about recurrent arrhythmia after CTIA mainly comes from small cohort studies with limited follow-up. OBJECTIVE:To describe incidences of re-ablation for AFL and ablation for AF after first-time CTIA in a nation-wide cohort. METHODS:In the Danish National Ablation Registry we identified patients undergoing first-time CTIA during 2010-2016. Subsequent CTIA and AF-ablation procedures were identified until March 1st, 2018. We collected information on patient comorbidities in the Danish National Patient Registry. RESULTS:We identified 2409 patients undergoing first-time CTIA. Median age was 66 (IQR 58-72) years, 1952 (81%) were men, and 78 (3%) patients had a history of previous ablation for AF. Acute procedural success was achieved in 2288 (95%) patients. During mean follow-up of 4.0 ± 1.7 years, 242 (10%) patients underwent CTI re-ablation and 326 (13.5%) underwent ablation for AF. Baseline characteristics associated with CTI re-ablation included prolonged procedural time, unsuccessful index CTIA, age <75 years and CHA2DS2-VASc score <2. Hypertension, history of AF-ablation, age <65 years use of a contact force sensing catheter and CHA2DS2-VASc score <2 were associated with later ablation for AF. CONCLUSION:In a nation-wide cohort undergoing first-time CTIA for AFL, 10% of patients underwent CTI re-ablation and 13.5% ablation for AF during mean follow-up of 4.0 ± 1.7 years. Probability of a second procedure was higher in younger patients with less comorbidities. 10.1016/j.ijcard.2019.07.077
    Risk Factors for Atrial Fibrillation in People With Type 1 Diabetes: An Observational Cohort Study of 36,258 Patients From the Swedish National Diabetes Registry. Hallström Sara,Pivodic Aldina,Rosengren Annika,Ólafsdóttir Arndís F,Svensson Ann-Marie,Lind Marcus Diabetes care OBJECTIVE:This study identified variables associated with increased risk of atrial fibrillation in people with type 1 diabetes. RESEARCH DESIGN AND METHODS:We performed a cohort study of people with type 1 diabetes from the Swedish National Diabetes Registry followed up between 1 January 2001 and 31 December 2013. Median follow-up was 9.7 years (interquartile range 5.2-13.0). The association between potential risk factors and incident atrial fibrillation was investigated using adjusted Cox regression. To compare the impact of each risk factor, the gradient of risk per 1 SD was estimated. RESULTS:In this cohort of 36,258 patients with type 1 diabetes, 749 developed atrial fibrillation during follow-up. Older age, male sex, renal complications, increased BMI and HbA, coronary artery disease, heart failure, and heart valve disease increased the risk of atrial fibrillation. Age, signs of renal dysfunction with macroalbuminuria, and decreasing estimated glomerular filtration rate were associated with the highest gradient of risk for atrial fibrillation. High blood pressure, severe obesity (BMI >35 kg/m), and elevated levels of HbA (>9.6%) were associated with increased risk, but no associations were found with hyperlipidemia or smoking. CONCLUSIONS:The most prominent risk factors for atrial fibrillation in people with type 1 diabetes were older age, cardiovascular comorbidities, and renal complications, while obesity, hypertension, and hyperglycemia had more modest affects. 10.2337/dc18-2457
    Timing of β-Blocker Reintroduction and the Occurrence of Postoperative Atrial Fibrillation after Cardiac Surgery: A Prospective Cohort Study. Couffignal Camille,Amour Julien,Ait-Hamou Nora,Cholley Bernard,Fellahi Jean-Luc,Duval Xavier,Costa De Beauregard Yolande,Nataf Patrick,Dilly Marie-Pierre,Provenchère Sophie,Montravers Philippe,Mentré France,Longrois Dan Anesthesiology BACKGROUND:For cardiac surgery patients under chronic β-blocker therapy, guidelines recommend their early postoperative reintroduction to decrease the incidence of postoperative atrial fibrillation. The authors hypothesized that the timing of β-blocker reintroduction affects their effectiveness on the incidence of postoperative atrial fibrillation. METHODS:This multicenter prospective French cohort study included patients on β-blockers (more than 30 days before surgery) in sinus rhythm without a pacemaker. The primary outcome, time sequence of β-blocker reintroduction, was analyzed for 192 h after surgery. The secondary outcome, relationship between the occurrence of postoperative atrial fibrillation and timing of β-blocker reintroduction, was analyzed based on pre- and intraoperative predictors (full and selected sets) according to landmark times (patients in whom atrial fibrillation occurred before a given landmark time were not analyzed). RESULTS:Of 663 patients, β-blockers were reintroduced for 532 (80%) but for only 261 (39%) patients in the first 48 h after surgery. Median duration before reintroduction was 49.5 h (95% CI, 48 to 51.5 h). Postoperative atrial fibrillation or death (N = 4) occurred in 290 (44%) patients. After performing a landmark analysis to take into account the timing of β-blocker reintroduction, the adjusted odds ratios (95% CI) for predictor full and selected (increased age, history of paroxysmal atrial fibrillation, and duration of aortic cross clamping) sets for the occurrence of postoperative atrial fibrillation were: adjusted odds ratio (full) = 0.87 (0.58 to 1.32; P = 0.517) and adjusted odds ratio (selected) = 0.84 (0.58 to 1.21; P = 0.338) at 48 h; adjusted odds ratio (full) = 0.64 (0.39 to 1.05; P = 0.076) and adjusted odds ratio (selected) = 0.58 (0.38 to 0.89; P = 0.013) at 72 h; adjusted odds ratio (full) = 0.58 (0.31 to 1.07; P = 0.079) and adjusted odds ratio (selected) = 0.53 (0.31 to 0.91; P = 0.021) at 96 h. CONCLUSIONS:β-Blockers were reintroduced early (after less than 48 h) in fewer than half of the cardiac surgery patients. Reintroduction decreased postoperative atrial fibrillation occurrence only at later time points and only in the predictor selected set model. These results are an incentive to optimize (timing, doses, or titration) β-blocker reintroduction after cardiac surgery. 10.1097/ALN.0000000000003064
    Atrial fibrillation diagnosed after stroke and dementia risk: cohort study of first-ever ischaemic stroke patients aged 65 or older. Krawczyk Michal,Fridman Sebastian,Cheng Yi,Fang Jiming,Saposnik Gustavo,Sposato Luciano A Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology AIMS:Atrial fibrillation (AF) is a risk factor for dementia among ischaemic stroke patients in whom the AF was known before the stroke (KAF). Atrial fibrillation detected after stroke (AFDAS) has a different profile compared to KAF, including less frequent cardiovascular comorbidities and lower CHA2-DS2-VASC scores. Currently, it is unknown if AFDAS is also associated with increased dementia risk. We assessed the association between AFDAS and the incident risk of dementia. We also evaluated whether the use of oral anticoagulants (OAC) was associated with lower dementia risk among AFDAS patients. METHODS AND RESULTS:In this cohort study, we classified 9791 first-ever ischaemic stroke patients from the Ontario Stroke Registry into four groups: (i) No AF, (ii) KAF, (iii) Inpatient AFDAS (diagnosed during admission), and (iv) Outpatient AFDAS (diagnosed after discharge). We used multivariable Cox proportional models to estimate hazard ratios (HR) for the association between AFDAS and incident dementia risk. Dementia was determined through administrative datasets based on previously validated algorithms. In adjusted analyses, the dementia risk was higher for inpatient AFDAS [HR 1.78, 95% confidence interval (CI) 1.51-2.10] and outpatient AFDAS (HR 1.74, 95% CI 1.47-2.05) relative to no AF. Oral anticoagulants use was associated with lower dementia risk among patients with inpatient AFDAS (HR 0.58, 95% CI 0.43-0.79) and outpatient AFDAS (HR 0.60, 95% CI 0.43-0.83). CONCLUSION:Atrial fibrillation detected after stroke was independently associated with higher risk of dementia relative to no AF. Among patients with AFDAS, the use of OACs was associated with lower dementia risk. 10.1093/europace/euz237
    New-Onset Atrial Fibrillation Among Patients With Infection in the Emergency Department: A Multicenter Cohort Study of 1-Year Stroke Risk. Hansen Tobias Graversgaard,Pottegård Anton,Brandes Axel,Ekelund Ulf,Jensen Helene Kildegaard,Forberg Jakob Lundager,Brabrand Mikkel,Lassen Annmarie Touborg The American journal of medicine BACKGROUND:Patients with new-onset atrial fibrillation in relation to infection are frequent in emergency departments (EDs) and may require antithrombotic therapy because of the increased risk of stroke. Our objective was to describe the 1-year risk of stroke in patients in the ED with infection, new-onset atrial fibrillation, and no antithrombotic therapy. METHODS:This was a population-based cohort study at 4 EDs in Denmark and Sweden. Atrial fibrillation was identified by electrocardiogram (ECG) upon arrival at the ED, and infection was identified by discharge diagnosis. Patient history was followed for 12 months or until initiation of oral anticoagulant therapy, ischemic stroke, or death. Primary outcome was stroke within 12 months compared to patients with infection and no atrial fibrillation. RESULTS:In the analysis, 15,505 patients were included; 48.7% were male and the median age was 71 (IQR, 56-83). Among the included patients, 2107 (13.6%) had atrial fibrillation of any kind and 822 (39.0%) of these had new-onset atrial fibrillation with a median CHADS-VASc score of 3 (IQR 2-4). New-onset atrial fibrillation during infection showed an absolute postdischarge 1-year risk of stroke of 2.7% (95% CI 1.6-4.2), corresponding to a crude hazard ratio (HR) of 1.4 (95% CI 0.9-2.3), a sex and age adjusted HR of 1.0 (95% CI 0.6-1.6), and a CHADS-VASc adjusted HR of 1.1 (95% CI, 0.7-1.8) compared to patients with infection but no atrial fibrillation. CONCLUSIONS:Patients in the ED with infection and new-onset atrial fibrillation without current oral anticoagulant therapy had a 2.7% absolute 1-year risk of stroke. Stroke events were mainly related to sex and age and risk factors identified by the CHADS-VASc score. 10.1016/j.amjmed.2019.06.048
    Type 1 versus type 2 diabetes and thromboembolic risk in patients with atrial fibrillation: A Danish nationwide cohort study. Fangel Mia V,Nielsen Peter B,Larsen Torben B,Christensen Bo,Overvad Thure F,Lip Gregory Y H,Goldhaber Samuel Z,Jensen Martin B International journal of cardiology BACKGROUND:Atrial fibrillation is a common cause of stroke, and diabetes increases stroke risk. Stroke risk may vary depending on the type of diabetes. We investigated whether type 1 and type 2 diabetes are associated with different risks of thromboembolism among patients with atrial fibrillation. METHODS:We used data from Danish nationwide registries to identify patients with a prior diagnosis of diabetes and an incident nonvalvular atrial fibrillation diagnosis in the period of January 1, 2005 to December 31, 2015. Cox regression analysis was used to estimate hazard ratios (HR) for the outcome thromboembolism. RESULTS:The study population included 10,058 patients with a prior diagnosis of diabetes and an incident diagnosis of atrial fibrillation. At three-year follow-up, type 2 diabetes was not associated with a higher risk of thromboembolism compared to type 1 diabetes, with an adjusted HR of 1.15 (95% CI: 0.91-1.44). In an age-stratified analysis, patients aged below 65 years of age had an adjusted HR of 1.97 (95% CI: 1.07-3.61), whereas patients aged 65-74 years or ≥75 years had adjusted HRs of 0.99 (95% CI: 0.67-1.46) and 1.10 (95% CI: 0.80-1.51), respectively. CONCLUSION:We found no overall credible association between the type of diabetes and risk of thromboembolism in this cohort of non-anticoagulated patients with incident atrial fibrillation. Nonetheless, the subset of patients aged below 65 years of age displayed a higher risk of thromboembolism among patients with type 2 diabetes as compared to patients with type 1 diabetes. 10.1016/j.ijcard.2018.05.037