Renal dysfunction as a predictor of stroke and systemic embolism in patients with nonvalvular atrial fibrillation: validation of the R(2)CHADS(2) index in the ROCKET AF (Rivaroxaban Once-daily, oral, direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation) and ATRIA (AnTicoagulation and Risk factors In Atrial fibrillation) study cohorts

Thromboembolic and Bleeding Risk in Atrial Fibrillation Patients with Chronic Kidney Disease: Role of Anticoagulation Therapy

Atrial fibrillation (AF) and chronic kidney disease (CKD) are strictly related; several independent risk factors of AF are often frequent in CKD patients. AF prevalence is very common among these patients, ranging between 15% and 20% in advanced stages of CKD. Moreover, the results of several studies showed that AF patients with end stage renal disease (ESRD) have a higher mortality rate than patients with preserved renal function due to an increased incidence of stroke and an unpredicted elevated hemorrhagic risk. Direct oral anticoagulants (DOACs) are currently contraindicated in patients with ESRD and vitamin K antagonists (VKAs), remaining the only drugs allowed, although they show numerous critical issues such as a narrow therapeutic window, increased tissue calcification and an unfavorable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. The purpose of this review is to shed light on the applications of DOAC therapy in CKD patients, especially in ESRD patients.

Concomitant diabetes with atrial fibrillation and anticoagulation management considerations

Atrial fibrillation is a highly prevalent cardiac arrhythmia. It is associated with numerous co mobilities. Approximately 30% of diabetic patients have atrial fibrillation and 15% of atrial fibrillation regulation patients have diabetes mellitus. Diabetes increases the likelihood of the development of atrial fibrillation and contributes to the high risk of thromboembolism seen in patients with both diabetes and atrial fibrillation. Chronic kidney disease is often a consequence of diabetes and presents an additional challenge to the management of patients with both atrial fibrillation and diabetes. All non-vitamin K oral anticoagulants are partially eliminated via the kidney and must be carefully prescribed according to strict dosing schedules to avoid anticoagulation overdose. However, NOACs have the advantage of being associated with less progressive impairment of renal function compared with vitamin K antagonist therapy in both diabetics and non-diabetics. Otherwise, diabetic patients benefit from NOAC therapy as opposed to vitamin K antagonists to a similar extent as patients without diabetes. This review deals with anticoagulation treatment in patients with fibrillation and diabetes mellitus, often complicated by progressive renal impairment.

Atrial fibrillation and stroke prevention: state of the art-epidemiology and pathophysiology: new risk factors, concepts and controversies

Atrial fibrillation (AF) increases the risk of thromboembolism, and risk assessment for thromboembolism is necessary for the management of AF patients. CHADS2 and CHA2DS2-VASc scores have been adopted in international guidelines for AF management, but the significance of each risk factor included in these risk scores are sometimes controversial, and the performance of these scores is only modest. There are several other risk factors not included in the scores such as renal dysfunction, low body weight, type of AF (paroxysmal or non-paroxysmal) as well as echocardiographic parameters and blood biomarkers, and physicians should assess patients risk in an integrated manner.

Trends in the Prescription of Non-Vitamin K Antagonist Oral Anticoagulants for Atrial Fibrillation: Results of the Polish Atrial Fibrillation (POL-AF) Registry

Background: Current guidelines do not suggest in which groups of patients with atrial fibrillation (AF) individual non-vitamin K antagonist oral anticoagulants (NOACs) should be used for the prevention of thromboembolic complications. The aim of this study was to evaluate the frequency of use of apixaban, dabigatran, and rivaroxaban, and attempt to identify factors predisposing their administration. Methods: The Polish Atrial Fibrillation (POL-AF) registry is a prospective, non-interventional study, including consecutive patients with AF hospitalized in ten Polish cardiology centers during the period ranging from January to December 2019. In this study, all patients were treated with NOACs. Results: Among the 2971 patients included in the analysis, 40.4% were treated with rivaroxaban, 32% with apixaban, and 27.6% with dabigatran. The mean age of the total population was 72 ± 11.5 years and 43% were female. A reduced dose of NOAC was used in 35% of patients treated with apixaban, 39.7% of patients treated with dabigatran, and 34.4% of patients treated with rivaroxaban. Independent predictors of the use of apixaban were previous bleeding (OR 2.37, CI 1.67–3.38), GFR < 60 mL/min (OR 1.38, CI 1.25–1.64), heart failure (OR 1.38, CI 1.14–1.67) and age (per 5 years) (OR 1.14, CI 1.09–1.19). GFR < 60 mL/min (OR 0.79, CI 0.66–0.95), female (OR 0.8, CI 0.67–0.96) and age (per 5 years) (OR 0.95, CI 0.91–0.99) diminished the chance of using dabigatran. Previous bleeding (OR 0.43, CI 0.28–0.64), vascular disease (OR 0.84, CI 0.70–0.99), and age (per 5 years) (OR 0.94, CI 0.90–0.97) diminished the chance of choosing rivaroxaban. Conclusions: In hospitalized patients with AF, the most frequently chosen NOAC was rivaroxaban. Apixaban was chosen more often in patients after bleeding, and in those who were advanced in years, with heart failure and impaired renal function. Impaired renal function and female gender were factors that diminished the chance of using dabigatran. Previous bleeding and vascular disease was the factor that diminished the chance of using rivaroxaban. Dabigatran and rivaroxaban have been used less frequently in elderly patients.

Prolonged ECG with a novel recorder utilizing electrode belt and mobile device in patients with recent embolic stroke of undetermined source: A pilot study

BACKGROUND

Paroxysmal atrial fibrillation (pAF) is a major risk factor for ischemic stroke, but challenging to detect with routine short-term monitoring methods. In this pilot study, we present a novel method for prolonged ECG and screening for pAF in patients with a recent embolic stroke of unknown source (ESUS).

METHODS

Fifteen patients aged ≥ 50 years with a recent ESUS were assigned to wear an external electrode belt-based 1-lead ECG device (Beat2Phone) continuously for 2 weeks (wear time). The device was operated via a mobile phone application in nonhospital conditions. The primary outcome was patient adherence to monitoring. Secondary outcomes were incidence of new pAF, quality-wise comparison to Holter, and usability of the novel ECG monitoring method with Systems Usability Scale (SUS). We also performed a 24- to 48-hr comparison between simultaneous Beat2Phone ECG and a standard Holter in 6 patients.

RESULTS

Wear time of Beat2Phone device was over 80% in 5 (33.3%) patients, 50%-80% in 7 (46.6%) patients, and less than 50% in 3 (20%) patients. We detected pAF ≥ 30 s in 1 patient (6.7%). In the simultaneous monitoring with Beat2Phone and Holter, there were a total of 817 (out of 1979) analyzable periods of sinus rhythm or premature atrial or ventricular beats (Cohen's Kappa coefficient 0.92 ± 0.02 between Beat2Phone and Holter), and no pAF events. Beat2Phone ECG showed remarkable SUS scores in user evaluations (average score: 81.4 out of 100 on SUS).

CONCLUSIONS

Beat2Phone device was easy to use among ESUS patients and in optimal conditions provided high-quality 1-lead ECG signal for diagnosing pAF.

CLINICAL TRIAL REGISTRATION

The study was not registered, as it was a nonrandomized single-arm pilot study.

Application of net reclassification index to non-nested and point-based risk prediction models: a review

Much of medical risk prediction involves externally derived prediction equations, nomograms, and point-based risk scores. These settings are vulnerable to misleading findings of incremental value based on versions of the net reclassification index (NRI) in common use. By applying non-nested models and point-based risk scores in the setting of stroke risk prediction in patients with atrial fibrillation (AF), we demonstrate current recommendations for presentation and interpretation of the NRI. We emphasize pitfalls that are likely to occur with point-based risk scores that are easy to neglect when statistical methodology is focused on continuous models. In order to make appropriate decisions about risk prediction and personalized medicine, physicians, researchers, and policy makers need to understand the strengths and limitations of the NRI.

Prediction of acute-coronary-syndrome using newly-defined R2-CHA2DS2-VASc score among patients with chest pain

BACKGROUND

Chest-pain patients with no evidence of acute coronary syndrome might still be at risk for adverse outcomes. Adding renal function to the classic scoring of CHADS and CHA₂DS₂ VASC may improve risk stratification of chest-pain patients discharged from internal medicine wards after acute coronary syndrome (ACS) rule-out.

METHODS

We accessed medical records of patients admitted to internal medicine wards during 2010-2016 and discharged following ACS rule-out. A R₂CHA₂DS₂-VASc score model that included higher scores as kidney function deteriorated was calculated and compared to CHADS and CHA₂DS₂ VASC scores. The primary endpoint was the composite of 30-day ACS and mortality. One-year ACS and 1-year mortality were the secondary endpoints. The study included 12,449 patients, stratified into three risk groups according to their R₂CHA₂DS₂-VASc score.

RESULTS

Participants were stratified into 3 groups according to R₂CHA₂DS₂-VASc score. R₂CHA₂DS₂-VASc score predicted better the composite outcome of ACS and 30-day and 1-year mortality after discharge (OR: 4, 95%, CI 2.3-7, p < 0.01 and OR: 13.3, 95% CI 7.8-22.7, p < 0.01, respectively). Receiver operating characteristic curve analysis showed better risk stratification of the R₂CHA₂DS₂-VASc compared with both CHADS and CHA₂DS₂ VASC score.

CONCLUSIONS

The R₂CHA₂DS₂-VASc score is a better predictor of short- and long-term cardiovascular morbidity and mortality after hospital discharge.

Left Atrial Appendage Thrombus Formation Despite Continuous Non-Vitamin K Antagonist Oral Anticoagulant Therapy in Atrial Fibrillation Patients Undergoing Electrical Cardioversion or Catheter Ablation: A Comparison of Dabigatran and Rivaroxaban

Left atrial appendage thrombus (LAAT) may be detected by transesophageal echocardiography (TOE) in patients with atrial fibrillation (AF) despite continuous anticoagulation therapy. We examined the factors predisposing to LAAT in patients treated with the anticoagulants dabigatran and rivaroxaban. We retrospectively evaluated 1,256 AF patients from three centres who underwent TOE before electrical cardioversion (n = 611, 51.4%) or catheter ablation (n = 645, 48.6%) from January 2013 to December 2019 and had been on at least three weeks of continuous dabigatran (n = 603, 48%) or rivaroxaban (n = 653, 52%) therapy. Preprocedural TOE diagnosed LAAT in 51 patients (4.1%), including 30 patients (5%) treated with dabigatran and 21 patients (3.2%) treated with rivaroxaban (p=0.1145). In multivariate logistic regression, predictors of LAAT in patients treated with dabigatran were non-paroxysmal AF (vs. paroxysmal AF) (OR = 6.2, p=0.015), heart failure (OR = 3.22, p=0.003), and a eGFR <60 ml/min/1.73 m2 (OR = 2.65, p=0.012); the predictors in patients treated with rivaroxaban were non-paroxysmal AF (vs. paroxysmal AF) (OR = 5.73, p=0.0221) and heart failure (OR = 3.19, p=0.116). In ROC analysis of the dabigatran group, the area under the curve (AUC) for the CHA2DS2-VASc-RAF score was significantly higher (0.78) than those for the CHADS2, CHA2DS2-VASc, and R2CHADS2 scores (0.67, 0.70, and 0.72, respectively). In the rivaroxaban group, the CHA2DS2-VASc-RAF score also performed significantly better (AUC of 0.77) than the CHADS2, CHA2DS2-VASc, and R2CHADS2 scores (AUC of 0.66, 0.64, and 0.67, respectively). The risk of LAAT was the same for patients in both treatment groups. In all patients, non-paroxysmal AF or heart failure, and in patients treated with dabigatran an eGFR <60 ml/min/1.73 m2, were independent predictors of LAAT. The new CHA2DS2-VASc-RAF scale had the highest predictive value for LAAT in the entire study population.

Prevalence and risk factors of left atrial thrombus in patients with atrial fibrillation and lower class (IIa) recommendation to anticoagulants

Background

Oral anticoagulation therapy (OAT) prevents ischaemic incidents in patients with atrial fibrillation (AF). CHA₂DS₂-VASc risk score of ≥2 points in men and ≥3 in women is a class I indication for OAT. OAT should also be considered as a prevention of thromboembolism in AF men with a CHA₂DS₂-VASc score of 1 point and women with 2 points, but the class of recommendation is lower (IIa). This study aims to assess the occurrence of left atrial appendage thrombus (LAAT) and risk factors of its formation in patients with lower class recommendation to oral antiocoagulation treatment.

Methods

The study group consisted of 1,858 patients: 555 patients with class IIa indication to OAT (IIa group) and 1,303 patients with class I indication as a control group (I group). Patients were admitted to three cardiology departments. All subjects underwent transoesophageal echocardiography.

Results

The incidence of LAAT was comparable in both IIa and I group: LAAT was confirmed in 30 (5.4%) subjects of IIa group and in 77 (5.9%) of I group. The prevalence of LAAT in IIa group was higher on treatment with VKAs (in comparison to NOACs) (8.4% vs. 3.4%, P=0.010), and lower in case of paroxysmal AF (in comparison to non-paroxysmal AF) (2.4% vs. 9.8%, P=0.0002). Multivariate logistic regression revealed the following variables as the independent predictors of LAAT in IIa group: treatment with VKAs (OR 2.99, 95% CI: 1.33-6.69; P=0.007), paroxysmal AF (OR 0.26, 95% CI: 0.11-0.62; P=0.002) and eGFR <60 mL/min/1.73 m² (OR 3.19, 95% CI: 1.42-7.16; P=0.005).

Conclusions

The prevalence of LAAT in AF patients with lower class (IIa) recommendation to anticoagulants was comparable to higher (I). Treatment with VKAs, along with non-paroxysmal type of AF and eGFR <60 mL/min/1.72 m² were identified as the strongest predictors of LAAT in IIa group.

Chronic Kidney Disease and Its Impact on a Prothrombotic State in Patients with Atrial Fibrillation

It is unclear whether chronic kidney disease (CKD) increases thromboembolism in atrial fibrillation (AF). We conducted a retrospective cross-sectional analysis of 502 non-anticoagulated AF patients (median age, 66 (60–73) years, median CHA₂DS₂-VASc score, 3.0 (2.0–4.0)) with an estimated glomerular filtration rate (eGFR) ≥ 15 mL/min/1.73 m². Endogenous thrombin potential (ETP), clot permeability (K_s), and clot lysis time (CLT), among others, were determined. Patients with stage 4 CKD (n = 87; 17.3%) had higher ETP and prolonged CLT compared with those with stage 3 CKD. In patients with stages 3 to 4 CKD (n = 180; 35.9%) N-terminal pro-B-type natriuretic peptide predicted low K_s (the lowest quartile, odds ratio [OR] per 100 pg/mL: 1.03, 95% confidence interval [CI]: 1.01–1.06) and prolonged CLT (the top quartile, OR per 100 pg/mL: 1.05, 95% CI: 1.02–1.08), but not high ETP. In the whole cohort, after adjustment for CHA₂DS₂-VASc score, stage 4 CKD, but not stage 3 CKD, predicted high ETP (OR: 9.06; 95% CI: 4.44−18.46) and prolonged CLT (OR: 3.58; 95% CI: 1.76–7.28), but not low K_s. compared to the reference eGFR category. This study is the first to demonstrate the prothrombotic and antifibrinolytic alterations in AF patients with stage 4 CKD, but not stage 3 CKD irrespective of clinical stroke risk factors.

Increased Incident Ischemic Stroke Risk in Advanced Kidney Disease: A Large-Scale Real-World Data Study

INTRODUCTION

Evidence using real-world data is sparse regarding the effects of oral anticoagulants (OACs) among patients with kidney disease. The aim of this study was to investigate the effects of kidney disease on ischemic stroke (IS) or systemic embolism (SE) among patients taking OAC, using large-scale real-world data in Japan.

METHODS

This was a retrospective cohort study using claims data and health checkup data from health insurance associations in Japan, from January 2005 to June 2017. We enrolled 21,581 patients diagnosed with atrial fibrillation (AF). Of the total population, 11,848 (54.9%) patients were taking OAC. A Cox proportional hazards model was used to examine the effect of kidney disease on IS/SE with or without OAC.

RESULTS

During follow-up, 208 participants who were not taking OAC (mean follow-up 2.6 years) and 200 who were taking OAC (mean follow-up 3.0 years) experienced IS/SE. The % IS/SE incidence rates with and without kidney disease were 2.42/person-year and 0.63/person-year in the total population, 3.66/person-year and 0.76/person-year in the group without OAC use, and 1.52/person-year and 0.55/person-year in patients with OAC use, respectively. Hazard ratios (HRs) and 95% confidence intervals (CIs) of kidney disease for IS/SE were high, irrespective of OAC, even after adjustment: adjusted HR 2.62 (95% CI: 1.72-3.99) without OAC and adjusted HR 2.03 (95% CI: 1.20-3.44) with OAC; p = 0.193 for interaction between no OAC and OAC. Although bleeding risk was also high for kidney disease irrespective of OAC use (HR 2.93 [95% CI: 2.27-3.77] in the total population, HR 3.08 [95% CI: 2.15-4.43] in the group without OAC, and HR 2.73 [95% CI: 1.90-3.91] in the group with OAC use), net clinical benefit indicated that the benefit of OAC use exceeded the risk of bleeding: HR 4.50 (95% CI: 0.76-8.23) among those with kidney disease and HR 0.35 (95% CI: 0.04-0.66) among those without kidney disease.

CONCLUSION

Although we found that OAC use was effective and recommended for patients with AF, advanced kidney disease is still an independent risk factor for IS/SE, even in patients taking OAC. Physicians should be aware of this risk and strictly control modifiable risk factors, regardless of OAC use.

Does the CHA2DS2-VASc scale sufficiently predict the risk of left atrial appendage thrombus in patients with diagnosed atrial fibrillation treated with non-vitamin K oral anticoagulants?

The CHA2DS2-VASc scale does not include potential risk factors for left atrial appendage thrombus (LAAT) formation such as a form of atrial fibrillation (AF) and impaired kidney function. The real risk of thromboembolic complications in AF patients is still unclear as well as an optimal anticoagulant treatment in males with a CHA2DS2-VASc score of 1 and females with a CHA2DS2-VASc score of 2.The aim of this study was to compare the predictive value of the CHA2DS2-VASc scale and other scales to estimate the risk of LAAT formation in AF patients treated with non-vitamin K oral anticoagulants (NOACs) and to assess the prevalence of thrombi in patients at intermediate risk of stroke.The observational study included consecutive patients with a diagnosis of non-valvular AF treated with NOACs, admitted to 3 high-reference institutions between 2013 and 2018. All individuals underwent transoesophageal echocardiography before cardioversion or ablation.Out of 1163 enrolled AF patients (62.1% male, mean age 62 years) the LAAT had been detected in 50 individuals (4.3%). Among patients with LAAT, 1 patient (2.0%) was classified as a low-risk category, 9 (18.0%) were at intermediate-risk, and 40 (80.0%) were at high risk of thromboembolic complications according to CHA2DS2-VASc scale. All patients were treated with NOACs: 51.0% rivaroxaban, 47.1% dabigatran, and 1.9% apixaban.Patients at intermediate stroke-risk with detected LAAT had higher R2CHADS2 score (2.1 ± 1.2 vs 1.2 ± 0.8, P = .007), higher CHA2DS2-VASc-RAF score (6.4 ± 4.4 vs 3.7 ± 2.6, P = .027) and more often had an estimated glomerular filtration rate below 56 mL/min/1.73 m (44.4% vs 13.2%, P = .026) compared to patients without LAAT. The receiver operating characteristics revealed that the CHA2DS2-VASc-RAF scale had better predictive ability to distinguish between patients with and without LAAT in the study group than CHA2DS2-VASc (P = .0006), CHADS2 (P = .0006) and R2CHADS2 scale (P = .0140).The CHA2DS2-VASc scale should be supplemented with an assessment of renal function and form of AF to improve stroke risk estimation. The application of additional scales to estimate the risk of LAAT might be especially useful among males with a CHA2DS2-VASc score of 1 and females with a CHA2DS2-VASc score of 2.

Epidemiology of Atrial Fibrillation in the 21st Century: Novel Methods and New Insights

Accompanying the aging of populations worldwide, and increased survival with chronic diseases, the incidence and prevalence of atrial fibrillation (AF) are rising, justifying the term global epidemic. This multifactorial arrhythmia is intertwined with common concomitant cardiovascular diseases, which share classical cardiovascular risk factors. Targeted prevention programs are largely missing. Prevention needs to start at an early age with primordial interventions at the population level. The public health dimension of AF motivates research in modifiable AF risk factors and improved precision in AF prediction and management. In this review, we summarize current knowledge in an attempt to untangle these multifaceted associations from an epidemiological perspective. We discuss disease trends, preventive opportunities offered by underlying risk factors and concomitant disorders, current developments in diagnosis and risk prediction, and prognostic implications of AF and its complications. Finally, we review current technological (eg, eHealth) and methodological (artificial intelligence) advances and their relevance for future prevention and disease management.

Thrombus in the left atrial appendage in patients with atrial fibrillation treated with non-vitamin K antagonist oral anticoagulants in clinical practice-A multicenter registry

BACKGROUND

The prevalence and predictors of left atrial appendage thrombus (LAAT) in patients with non-valvular atrial fibrillation (AF) who have been treated with non-vitamin K antagonist oral anticoagulants (NOACs) are not well defined. We aimed to assess the occurrence and predictors of LAAT on transesophageal echocardiography (TOE) in patients with non-valvular AF treated with NOACs for at least 3 weeks.

METHODS

Consecutive patients with non-valvular AF who underwent TOE before catheter ablation or electrical cardioversion in three high-reference centers between 2014 and 2018 were included. Patients on apixaban were excluded from the study due to low numbers in this category. All patients received NOACs for at least 3 weeks before TOE.

RESULTS

A total of 1148 patients (female, 38.1%; mean age, 62.1 years) referred to our centers for catheter ablation of AF (52.1%) or electrical cardioversion (47.9%) were included. Patients were on rivaroxaban (51.9%) or dabigatran (48.1%). Preprocedural TOE revealed LAAT in 4.4% of all patients. Multivariable logistic regression analysis showed the CHA2DS2-VASc score ≥2 points (OR = 2.11; 95% CI, 1.15-3.88; P = .0161), non-paroxysmal AF (OR = 6.30; 95% CI, 2.22-17.91; P = .0005), and GFR <60 mL/min/1.73 m² (OR = 2.05; 95% CI, 1.14-3.67; P = .0160) were independent predictors of LAAT in patients treated with NOACs.

CONCLUSIONS

In non-valvular AF patients treated with NOACs, the prevalence of LAAT was 4.4% before electrical cardioversion or ablation. In addition to the CHA2DS2-VASc score, the type of AF and renal function should be considered in the stratification of thromboembolism risk in AF patients and qualification for a preprocedural TOE.

Oral Anticoagulation for Atrial Fibrillation Thromboembolism Prophylaxis in the Chronic Kidney Disease Population: the State of the Art in 2019

Atrial fibrillation (AF) is the most common cardiac rhythm disturbance and is associated with increased risk of thromboembolism. Oral anticoagulants are effective at reducing rates of thromboembolism in patients with AF in the general population. Patients with AF and concurrent chronic kidney disease (CKD) have higher risk of thromboembolism and bleeding compared with patients with normal renal function. Among moderate CKD and end-stage renal disease (ESRD) patients on chronic dialysis, the use of oral anticoagulants is controversial. Use of warfarin, while beneficial in non-CKD patients, raises a number of concerns such as increased bleeding risk, labile anticoagulant effect, and calciphylaxis, especially in the ESRD population. The newer direct oral anticoagulant (DOAC) agents have demonstrated comparable efficacy and improved safety profiles compared with coumadin but are not as well studied in the CKD population. This review highlights the efficacy and safety of coumadin and the DOACs for thromboembolism prophylaxis in non-valvular AF patients with CKD.

Direct Anticoagulants Versus Vitamin K Antagonists in Patients Aged 80 Years or Older With Atrial Fibrillation in a "Real-world" Nationwide Registry: Insights From the FANTASIIA Study

OBJECTIVE

To describe major events at follow up in octogenarian patients with atrial fibrillation (AF) according to anticoagulant treatment: direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs).

METHODS

A total of 578 anticoagulated patients aged ≥80 years with AF were included in a prospective, observational, multicenter study. Basal features, embolic events (stroke and systemic embolism), severe bleedings, and all-cause mortality at follow up were investigated according to the anticoagulant treatment received.

RESULTS

Mean age was 84.0 ± 3.4 years, 56% were women. Direct oral anticoagulants were prescribed to 123 (21.3%) patients. Compared with 455 (78.7%) patients treated with VKAs, those treated with DOACs presented a lower frequency of permanent AF (52.9% vs 61.6%, P = .01), cancer history (4.9% vs 10.9%, P = .046), renal failure (21.1% vs 32.2%, P = .02), and left ventricular dysfunction (2.4% vs 8.0%, P = .03); and higher frequency of previous stroke (26.0% vs 16.6%, P = .02) and previous major bleeding (8.1% vs 3.6%, P = .03). There were no significant differences in Charlson, CHA2DS2VASc, nor HAS-BLED scores. At 3-year follow up, rates of embolic events, severe bleedings, and all-cause death (per 100 patients-year) were similar in both groups (DOACs vs VKAs): 0.34 vs 1.35 (P = .15), 3.45 vs 4.41 (P = .48), and 8.2 vs 11.0 (P = .18), respectively, without significant differences after multivariate analysis (hazard ratio [HR]: 0.25, 95% confidence interval [CI]: 0.03-1.93, P = .19; HR: 0.88, 95% CI: 0.44-1.76, P = .72 and HR: 0.84, 95% CI: 0.53-1.33, P = .46, respectively).

CONCLUSION

In this "real-world" registry, the differences in major events rates in octogenarians with AF were not statistically significant in those treated with DOACs versus VKAs.

Factors Associated with a Large Decline in Renal Function or Progression to Renal Insufficiency in Hospitalized Atrial Fibrillation Patients with Early-Stage CKD

Clinicians must consider renal function when administering anticoagulants for atrial fibrillation (AF). Determination of risk factors for renal function decline may enable identification of patients who require closer monitoring. We investigated the characteristics associated with renal function decline in patients with AF. The study cohort consisted of 631 AF patients who had at least one readmission during the follow-up period and stages 1-3 chronic kidney disease (CKD). The primary outcome measure was large renal function decline (≥30% decrease from baseline estimated glomerular filtration rate [eGFR]). The secondary outcome measure was a final eGFR < 60 mL/minute/1.73 m² for those with a baseline eGFR above this level. The mean eGFR was 74.4 ± 18.5 mL/minute/1.73 m², and the mean follow-up time was 30.2 ± 13.2 months. The primary outcome occurred in 155 patients (24.6%) and was associated with congestive heart failure (CHF), proteinuria, type of AF, and left atrial diameter (LAD) ≥ 45 mm. Among 478 patients with a baseline eGFR ≥ 60 mL/minute/1.73 m², 137 (28.7%) progressed to renal failure (eGFR < 60 mL/minute/1.73 m²). A decreasing eGFR was associated with age ≥ 75 years, CHF, lower baseline eGFR, and LAD ≥ 45 mm. CHF, proteinuria, type of AF, and LAD ≥ 45 mm were associated with eGFR decline ≥ 30% in AF patients with CKD stages 1-3. Advanced age, CHF, lower baseline eGFR, and LAD ≥ 45 mm were associated with progression to renal insufficiency. These results should be considered when identifying patients who require more frequent monitoring of eGFR.

Wild P, H. Prochaska J. Specialized Management of Oral Anticoagulation Therapy Improves Outcome in Patients with Chronic Renal Insufficiency

Oral anticoagulation (OAC) is effective at preventing and treating thromboses and thromboembolism in patients with normal renal function. We aimed to research the impact of severe renal failure (RF) on patient outcome and to determine the potential benefit of caring for these patients in a specialized coagulation service (CS). A total of 1516 usual medical care patients and 756 CS-managed patients of the thrombEVAL multicenter (21 centers), prospective, cohort study (NCT01809015) were analyzed in a 3-year follow-up. Patients with RF (serum creatinine >3 mg/dL, no renal replacement therapy) were compared to patients without RF in usual care and a CS. The fluctuations in the international normalized ratios were significantly lower in CS-managed patients, and regardless of treatment in usual care or a CS, the time in therapeutic range was significantly lower in RF patients. Cox regression-adjusted hazard ratios for long-term outcome (1.5, 95% CI: 1.22–1.83, p < 0.001), death (1.62, CI: 1.27–2.08, p < 0.001), and hospitalization (1.21, CI: 1.02–1.44, p = 0.032) were significantly higher in RF patients in usual care. Furthermore, there was a trend of more bleeding events in RF patients. CS-treated patients had significantly lower adjusted hazard ratios for death (0.24, CI: 0.14–0.39, p < 0.001), hospitalizations (0.41, CI: 0.34–0.5, p < 0.001), clinically relevant bleeding (0.29, CI: 0.18–0.47, p < 0.001), and major bleeding (0.33, CI: 0.18–0.59, p < 0.001). Thus, patients who required oral anticoagulation therapy benefitted significantly from being managed in a specialized coagulation service, regardless of their renal function.

Stroke and Bleeding Risk Assessments in Patients With Atrial Fibrillation: Concepts and Controversies

Risk assessments are an important element in the management of patients with atrial fibrillation (AF). In this review, we aim to discuss the concepts and controversies surrounding the various risk factors for stroke and bleeding in AF. Indeed, there are a variety of clinical, electrical, biological, and genetic markers to guide stroke and bleeding risk assessments in AF. The more common factors have been used to formulate risk stratification scores. Some risk factors have shown promise, but others remain less well-defined. Our aim is to discuss concepts and controversies surrounding current evidence of risk factors for stroke and bleeding assessments in AF.

Efficacy and Safety of Direct Oral Anticoagulants Versus Warfarin in Patients with Atrial Fibrillation Across BMI Categories: A Systematic Review and Meta-Analysis

OBJECTIVES

Concerns have arisen recently over the relationship between body mass index (BMI) and outcomes in atrial fibrillation (AF) patients with direct oral anticoagulants (DOACs). This meta-analysis aimed to explore if there is an "obesity paradox" in anticoagulated AF patients, and compare the treatment effects between DOACs and warfarin in AF patients across BMI categories.

METHODS

We systematically searched the PubMed and Embase databases until February 26, 2019 for relevant studies. Risk ratios (RRs) with 95% confidence intervals (CIs) were extracted and pooled by a random-effects model.

RESULTS

A total of nine studies were included. Compared with normal weight, underweight was associated with an increased risk of stroke or systemic embolism (SSE) (RR 1.98, 95% CI 1.19-3.28), whereas either overweight or obesity was related with reduced rates of SSE (overweight: RR 0.81, 95% CI 0.71-0.91; obesity: RR 0.69, 95% CI 0.61-0.78) and all-cause death (overweight: RR 0.73, 95% CI 0.64-0.83; obesity: RR 0.72, 95% CI 0.66-0.79). Compared with patients receiving warfarin, patients receiving DOACs who were underweight, normal weight or overweight all had decreased risks of SSE (underweight: RR 0.61, 95% CI 0.46-0.80; normal weight: RR 0.72, 95% CI 0.58-0.91; overweight: RR 0.87, 95% CI 0.76-0.99) and major bleeding (underweight: RR 0.67, 95% CI 0.55-0.81; normal weight: RR 0.72, 95% CI 0.58-0.90; overweight: RR 0.83, 95% CI 0.71-0.96), while obese DOAC users were at no higher risks for SSE and major bleeding.

CONCLUSIONS

There may be an obesity paradox in anticoagulated patients with AF. DOACs have better efficacy and safety profiles than warfarin in underweight, normal weight and overweight patients, and are not inferior to warfarin in obese patients.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

[Atrial Fibrillation in Patients on Dialysis Therapy: Epidemiology, Prognosis and Choice of Anticoagulant Therapy]

The review presents data on the prevalence of atrial fibrillation in patients on dialysis therapy. It is shown that dialysis-dependent patients with non-valve atrial fibrillation prognosis is extremely unfavorable, significantly increased risk of death due to both ischemic and hemorrhagic complications. Scales to assess the risk of thromboembolic and hemorrhagic complications in patients with atrial fibrillation on program dialysis are not validated. The lack of data from randomized clinical trials makes it much more difficult to choose anticoagulant therapy in patients with terminal stage of chronic kidney disease on dialysis who have undergone kidney transplantation. Therefore, the need for anticoagulant therapy and the choice of drugs in patients in this category should be made on the basis of a personalized multidisciplinary approach, taking into account comorbid pathology and the patient's preferences.

Ischemic Stroke Risk in Patients With Nonvalvular Atrial Fibrillation: JACC Review Topic of the Week

The last decade has witnessed remarkable advances in pharmacological and nonpharmacological strategies for stroke prevention in patients with atrial fibrillation. However, the currently available clinical stroke risk prediction models do not account for key nonclinical factors (arrhythmia burden, left atrial physiology and anatomy, chemical and electrocardiographic markers) and other competing clinical risks. Hence, their ability to identify patients who will derive the most benefit from pharmacological and mechanical risk prevention strategies remain limited. In this paper, the authors review the current and evolving ischemic stroke risk prediction schemes in patients with nonvalvular atrial fibrillation, highlight the strengths and weaknesses of the models, and discuss the unmet needs in this field.

The Risk of Stroke and Stroke Type in Patients With Atrial Fibrillation and Chronic Kidney Disease

Background:

Atrial fibrillation (AF) and chronic kidney disease (CKD) are known to increase the risk of stroke.

Objectives:

We set out to examine the risk of stroke by kidney function and albuminuria in patients with and without AF.

Design:

Retrospective cohort study.

Settings:

Ontario, Canada.

Participants:

A total of 736 666 individuals (>40 years) from 2002 to 2015.

Measurements:

New-onset AF, albumin-to-creatinine ratio (ACR), and an estimated glomerular filtration rate (eGFR).

Methods:

A total of 39 120 matched patients were examined for the risk of ischemic, hemorrhagic, or any stroke event, accounting for the competing risk of all-cause mortality. Interaction terms for combinations of ACR/eGFR and the outcome of stroke with and without AF were examined.

Results:

In a total of 4086 (5.2%) strokes (86% ischemic), the presence of AF was associated with a 2-fold higher risk for any stroke event and its subtypes of ischemic and hemorrhagic stroke. Across eGFR levels, the risk of stroke was 2-fold higher with the presence of AF except for low levels of eGFR (eGFR < 30 mL/min/1.73 m², hazard ratio [HR]: 1.38, 95% confidence interval [CI]: 0.99-1.92). Similarly across ACR levels, the risk of stroke was 2-fold higher except for high levels of albuminuria (ACR > 30 mg/g, HR: 1.61, 95% CI: 1.31-1.99). The adjusted risk of stroke with AF differed by combinations of ACR and eGFR categories (interaction P value = .04) compared with those without AF. Both stroke types were more common in patients with AF, and ischemic stroke rates differed significantly by eGFR and ACR categories.

Limitations:

Medication information was not included.

Conclusions:

Patients with CKD and AF are at a high risk of total, ischemic, and hemorrhagic strokes; the risk is highest with lower eGFR and higher ACR and differs based on eGFR and the degree of ACR.

Clinical outcomes and treatment patterns among Medicare patients with nonvalvular atrial fibrillation (NVAF) and chronic kidney disease

Background

Patients with nonvalvular atrial fibrillation (NVAF) and chronic kidney disease (CKD) have increased risk of adverse outcomes. This study evaluated treatment with oral anticoagulants and outcomes in elderly NVAF patients with CKD.

Methods

Retrospective observational cohort study of US Medicare fee-for-service patients aged ≥66 years with comorbid CKD (advanced: Stage 4 and higher; less advanced: Stages 1–3) and a new NVAF diagnoses from 2011–2013. All-cause mortality, stroke, major bleeding, and myocardial infarction rates were estimated for 1 year post-NVAF diagnosis. Associations between CKD stage and outcomes were evaluated with multivariate-adjusted Cox regression. We assessed oral anticoagulant (OAC) receipt within 90 days post-NVAF diagnosis and associations between OAC receipt and outcomes.

Results

There were 198,380 eligible patients (79,681 with advanced CKD). After adjustment for age, gender, and comorbidities, advanced CKD was associated with increased mortality (Stage 5 HR 1.47; 95% CI 1.42–1.52), MI (HR 1.48; 95% CI 1.33–1.64), stroke (HR 1.23; 95% CI 1.11–1.37) and major bleed (HR 1.44; 95% CI 1.36–1.53) risks. Among Medicare Part D enrollees who survived ≥90 days post-NVAF diagnosis, 65–71% received no OACs in the first 90 days. Those receiving warfarin (HR 0.73; 95% CI 0.71–0.75) or DOACs (HR 0.52; 95% CI 0.49–0.56) within the first 90 days had reduced mortality in the period 90 days to 1 year following NVAF diagnosis compared to those without.

Conclusion

Elderly NVAF patients with advanced CKD (Stage 4 or higher) had higher mortality risks and serious clinical outcomes than those with less advanced CKD (Stage 1–3). OAC use was low across all CKD stages, but was associated with a lower mortality risk than no OAC use in the first year post-NVAF diagnosis.

Efficacy and Safety of Oral Anticoagulants in Patients With Atrial Fibrillation and Stages 4 or 5 Chronic Kidney Disease

PURPOSE

The aim of this study was to investigate whether oral anticoagulants can provide efficacy and safety profiles better than no anticoagulant in patients with stages 4 or 5 chronic kidney disease and atrial fibrillation.

METHODS

From 2001 to 2017, a cohort of patients with stages 4 or 5 chronic kidney disease and atrial fibrillation based on electronic medical records were selected from Chang Gung Memorial Hospital system in Taiwan. Patients were divided into nonvitamin K antagonist oral anticoagulants (NOACs), warfarin, and nonanticoagulated groups. They were followed from the index date to the occurrence of the study outcomes or for 5 years, whichever occurred first. The outcomes were admissions due to ischemic stroke or systemic embolism or major bleedings. Survival analyses were conducted to estimate the incidence rates of outcomes.

RESULTS

A total of 3771 patients with atrial fibrillation and estimated glomerular filtration rate less than 30 mL/min/1.73m² were enrolled, of whom 2971 were in the nonanticoagulated group, 280 in the NOAC group, and 520 in the warfarin group. About 25% of all subjects (940 patients) were on dialysis. The mean follow-up was 3.2 years. After adjusting for sex, age, comorbidities, and comedication, the warfarin group had a significantly higher risk of ischemic stroke or systemic embolism (adjusted hazard ratio [aHR] 3.1, 95% confidence interval [CI] 2.1-4.6) than the nonanticoagulated group. The NOAC group had a similar risk of ischemic stroke or systemic embolism (aHR 1.1; 95% CI 0.3-3.4) to that of the nonanticoagulated group. Both the warfarin and the NOAC groups had a significantly higher major bleeding risk than the noncoagulated group (aHR 2.8 [95% CI 2.0-3.8] for warfarin; aHR 3.1 [95% CI 1.9-5.2] for NOAC).

CONCLUSION

The use of NOACs or warfarin is not more effective than using no anticoagulants at all in reducing the risk of ischemic stroke or systemic embolism. Both NOACs and warfarin are associated with increased risk of major bleeding. Our results do not support the use of anticoagulants in patients with atrial fibrillation and stages 4-5 chronic kidney disease.

Worsening renal function, adverse clinical events and major determinants for changes of renal function in patients with atrial fibrillation: a Japanese multicenter registry substudy

Objective: To explore factors related to changing renal function and the prognostic effect of worsening renal function in patients with atrial fibrillation (AF). Methods: The present substudy was based on the SAKURA AF Registry, a Japanese multicenter prospective observational registry that includes 3267 AF patients from 63 institutions in the Tokyo area. Worsening renal function was defined as an estimated glomerular filtration rate (eGFR) decrease equaling more than 20% of the patient's baseline eGFR. Results: During a median 39.3 month follow-up period, patients' eGFR decreased annually by a mean value of 1.07 mL/min/1.73 m². Multivariable analysis showed that age ≥75 years, body weight ≤50 kg, a history of heart failure and initially preserved renal function (creatinine clearance [CrCl] ≥ 60 mL/min) were significantly associated with a decrease in eGFR, whereas a history of AF ablation was associated with a maintain in eGFR. The 194 patients with worsening renal function were at significantly increased risk of death, stroke and major bleeding (adjusted hazard ratios [HRs]: 2.06, 1.97 and 2.23, respectively). Conclusion: Age ≥75 years, body weight ≤50 kg, a history of heart failure and initially preserved renal function appear to promote renal dysfunction in patients with AF, but a history of AF ablation seems to have a favorable effect. Worsening renal function seems to increase AF patients' risk of adverse clinical events. Renal function can decline quickly; thus, early intervention including AF ablation is warranted.

The impact of renal function on efficacy and safety of new oral anticoagulant in atrial fibrillation patients: A systemic review and meta-analysis

BACKGROUND AND OBJECTIVES

This meta-analysis was to investigate the efficacy and safety of new oral anticoagulant (NOAC) in atrial fibrillation (AF) patients with renal function insufficiency, and to explore whether renal decline occurs in AF patients with NOAC and its impact on outcomes.

METHODS AND RESULTS

In AF patients with mild renal insufficiency, the NOAC was associated with significantly lower rates of stroke (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.67-0.91; P < .05). Lower rates of bleeding were significantly observed in NOAC group (OR, 0.85; 95% CI, 0.75-0.97; P < .05). In AF patients with moderate renal impairment, similar results were revealed (OR for stroke or systemic embolism, 0.80; 95% CI, 0.67-0.95, P < .05; OR for major bleeding, 0.78; 95% CI, 0.59-1.03; P = .07). During the follow-up, pooled data revealed that NOAC showed a less renal toxicity, but the difference did not reach statistical significance (creatinine clearance decline: -0.12 mL/min [-0.84, 0.61 mL/min]). We have revealed that the NOACs were associated with significantly lower rates of stroke or systemic embolism (hazard ratio [HR], 0.66; 95% CI, 0.42-0.89; P < .05) and lower rates of bleeding (HR, 0.93; 95% CI, 0.70-1.16; P = .153) in AF patients with worsening renal function.

CONCLUSIONS

NOAC may have the potentiality to be at least as effective as warfarin and may equal safety outcomes in AF patients with renal impairment. Renal decline during therapeutics may be less likely happened in NOAC than warfarin dose. NOAC may reveal good efficacy and safety outcomes in these scenarios. Further detailed research is needed to gain more clear profile on this new anticoagulant.

Anticoagulation combined with antiplatelet therapy in patients with left ventricular thrombus after first acute myocardial infarction

Aims

There are limited data about the optimal anti-thrombotic therapy for preventing embolism while minimizing bleeding events in patients with first acute myocardial infarction (AMI) complicated by left ventricular thrombus (LVT).

Methods and results

Among 2301 consecutive patients with AMI hospitalized between 2001 and 2014, we studied 1850 patients with first AMI who discharged alive to investigate clinical characteristics, incidence of systemic embolism (SE), and association between anticoagulation and embolic or bleeding events. Left ventricular thrombus was diagnosed by echocardiography, left ventriculography, or cardiac magnetic resonance imaging in 92 (5.0%) patients (62 ± 12 years). During a median follow-up period of 5.4 years (interquartile range 2.1-9.1 years), SE occurred in 15 of 92 patients with LVT (16.3%) and 51 of 1758 patients without LVT (2.9%), respectively. Kaplan-Meier analysis showed a significantly higher incidence of SE in the LVT group (log-rank test, P < 0.001). Multivariate analysis showed that LVT was an independent predictor of SE. Among the LVT patients treated with vitamin K antagonists (n = 84), we compared the patients with therapeutic range (TTR) ≥50% (n = 34) and those with TTR <50% (n = 50). Only one embolic event developed in the TTR ≥50% group and nine embolic events developed in the TTR <50% group (2.9% vs. 19%, P = 0.036). There was no difference in major bleeding events (TTR ≥50%; 9% vs. TTR <50%; 8%, P = 0.89).

Conclusion

Appropriate anticoagulation therapy may decrease the incidence of embolic events without increasing the incidence of bleeding events in patients with first AMI complicated by LV thrombus.

Atrial Fibrillation Burden Signature and Near-Term Prediction of Stroke: A Machine Learning Analysis

BACKGROUND

Atrial fibrillation (AF) increases the risk of stroke 5-fold and there is rising interest to determine if AF severity or burden can further risk stratify these patients, particularly for near-term events. Using continuous remote monitoring data from cardiac implantable electronic devices, we sought to evaluate if machine learned signatures of AF burden could provide prognostic information on near-term risk of stroke when compared to conventional risk scores.

METHODS AND RESULTS

We retrospectively identified Veterans Health Administration serviced patients with cardiac implantable electronic device remote monitoring data and at least one day of device-registered AF. The first 30 days of remote monitoring in nonstroke controls were compared against the past 30 days of remote monitoring before stroke in cases. We trained 3 types of models on our data: (1) convolutional neural networks, (2) random forest, and (3) L1 regularized logistic regression (LASSO). We calculated the CHA₂DS₂-VASc score for each patient and compared its performance against machine learned indices based on AF burden in separate test cohorts. Finally, we investigated the effect of combining our AF burden models with CHA₂DS₂-VASc. We identified 3114 nonstroke controls and 71 stroke cases, with no significant differences in baseline characteristics. Random forest performed the best in the test data set (area under the curve [AUC]=0.662) and convolutional neural network in the validation dataset (AUC=0.702), whereas CHA₂DS₂-VASc had an AUC of 0.5 or less in both data sets. Combining CHA₂DS₂-VASc with random forest and convolutional neural network yielded a validation AUC of 0.696 and test AUC of 0.634, yielding the highest average AUC on nontraining data.

CONCLUSIONS

This proof-of-concept study found that machine learning and ensemble methods that incorporate daily AF burden signature provided incremental prognostic value for risk stratification beyond CHA₂DS₂-VASc for near-term risk of stroke.

Performance and validation of R-CHA2DS2VASc score for thromboembolism in patients with hypertrophic cardiomyopathy

OBJECTIVE

To validate the modified R-CHA₂DS₂VASc score as a predictor of thromboembolism in HCM patients.

METHODS

A total of 446 HCM patients were enrolled in our study, thirty-one (6.95%) patients experienced thromboembolic events during the follow-up time of 1786.7 person-years. The association between R-CHA₂DS₂VASc score and risk of thromboembolism was assessed by Cox's proportional hazard analysis. The discriminatory power of R-CHA₂DS₂VASc score for thromboembolism prediction was assessed by Harrell's C-statistic and validated internally by bootstrapping methods. Calibration plot was plotted by observed versus expected probabilities of thromboembolism.

RESULTS

The R-CHA₂DS₂VASc score was well calibrated with 0.84 thromboembolic events per 100 person-years in the predefined low risk (R-CHA₂DS₂VASc score ≤2) group, 1.84 in the low to moderate risk (R-CHA₂DS₂VASc score 3-4) group, 4.67 in the moderate to high risk (R-CHA₂DS₂VASc score 5-7) group, and 17.54 in the high risk (R-CHA₂DS₂VASc score ≥8) group. Hazard ratios for thromboembolism were 2.88 (95%CI: 1.06-7.82, P=0.038) for low to moderate versus low risk group, 5.30 (95%CI: 2.14-13.12, P=0.0003) for moderate to high versus low risk group, and 16.57 5.30 (95%CI: 4.96-55.33, P<0.0001) for high versus low risk group after adjusting left atria size. The Harrell's C statistic was 0.7737 (95% CI: 0.65-0.89) for R-CHA₂DS₂VASc score.

CONCLUSION

The R-CHA₂DS₂VASc score has shown good calibration and discriminative power in the prediction of thromboembolism for HCM patients. It should be considered as a potential decision support tool for HCM patients during clinical practice.

Effects of Prevalent and Incident Chronic Kidney Disease on Cardiovascular Events in Patients with Atrial Fibrillation

Background: Chronic kidney disease (CKD) is a well-known complication of atrial fibrillation (AF) but how the incident CKD affects the clinical outcomes amongst AF patients is not clear. Methods: Our study data were retrieved from National Health Insurance Research Data for the period from 1996 to 2013. Incident AF patients were classified as non-CKD group (n = 7272), prevalent CKD group (n = 2104), and incident CKD group (n = 1507) based on administrative codes. Patients with prevalent CKD were those participants who already had CKD ahead of the index date of AF, whereas patients with incident CKD were those who developed CKD after the index date and the remaining patients were designated as non-CKD. Multivariate-adjusted time-dependent Cox models were conducted to estimate the associations of CKD status with the outcomes of interest, including heart failure (HF), acute myocardial infarction (AMI), stroke or systemic thromboembolism, all-cause mortality, and cardiovascular (CV) mortality, expressed as hazard ratio (HR) and 95% confidence interval (CI). Results: The mean age was 70.8 ± 13.3 years, and 55.4% of the studied population were men. In Cox models, the adjusted rate of HF, AMI, all-cause mortality, and CV mortality was greater in the prevalent and incident CKD groups, ranging from 1.31-fold to 4.28-fold, compared with non-CKD group. Notably, incident CKD was associated with higher rates of HF (HR, 1.8; 95% CI, 1.67–1.93), stroke or systemic thromboembolism (HR, 1.33; 95% CI, 1.22–1.45), AMI (HR, 1.46; 95% CI, 1.25–1.71), all-cause mortality (HR, 1.76; 95% CI, 1.68–1.85), and CV mortality (HR, 2.13; 95% CI, 1.92–2.36) compared with prevalent CKD. Conclusion: The presence of CKD was associated with higher risks of subsequent adverse clinical outcomes in patients with AF. Our study was even highlighted by the finding that incident CKD was linked to higher risks of outcome events compared with prevalent CKD.

Is anticoagulant therapy always indicated in "medium-risk" patients with first diagnosed atrial fibrillation? Insights from a real world, 10-year observational study

BACKGROUND

The choice of antithrombotic prophylaxis in the so-called "medium-risk" patients (i.e., CHA₂DS₂-VASc score = 1 in males or 2 in females) is one of the major enigmatic issues in clinical management of atrial fibrillation (AF).

METHODS

We retrospectively evaluated 30-day and 1-year thromboembolic events in all consecutive medium-risk patients visited for first diagnosed AF in the local Emergency Department during a 10-year period. The main aim was to establish whether anticoagulant or antiplatelet therapy was effective to lower the thromboembolic risk in patients receiving these drugs. Bleeding events, related to anticoagulant or antiplatelet therapy, was defined as secondary end point.

RESULTS

The final study population consisted of 6389 (3640 males and 2749 females) patients for whom a complete dataset regarding targeted follow-up was available. Patients were then subdivided into two subgroups, according to performance of cardioversion and spontaneous sinus rhythm restoring. In both genders, no significant difference in thromboembolic or bleeding events was noted between patients who underwent cardioversion and were discharged with oral anticoagulant therapy or antiplatelet treatment versus those who were not treated with antithrombotic drugs. Moreover, no difference was also observed in thromboembolic or hemorrhagic event rate between low risk and "medium-risk" patients.

CONCLUSIONS

The results of this study suggest that anticoagulant or antiplatelet therapy would not produce clinical benefits in "medium-risk" AF patients.

Stroke Risk in Atrial Fibrillation: Beyond the CHA2DS2-VASc Score

PURPOSE OF REVIEW

Stroke prevention is the cornerstone of atrial fibrillation (AF) management and the anticoagulation decision is currently based on CHA₂DS₂-VASc risk score. We discuss several novel risk factors besides those included in CHA₂DS₂-VASc score and alternative models for stroke prediction.

RECENT FINDINGS

Several clinical markers including obstructive sleep apnea and renal failure, laboratory markers like brain natriuretic peptide, imaging criteria including left atrial appendage morphology, spontaneous echo contrast, and coronary artery calcium score may predict stroke in AF patients. Addition of African American ethnicity to CHA₂DS₂-VASc score also improves stroke prediction in AF. Finally, novel models including TIMI-AF score, ATRIA score, and GARFIELD-AF scores have potential roles in risk stratification for stroke. While CHA₂DS₂-VASc score is the currently recommended risk stratification model for stroke prediction in AF, use of additional clinical, laboratory, imaging markers, ethnicity, and novel stroke prediction models may further assist in decision to anticoagulate the AF patient for stroke prevention.

A novel score in the prediction of rhythm outcome after ablation of atrial fibrillation: The SUCCESS score

Objective:

The aim of the present study was to assess the predictive value of the CHADS₂, CHA₂DS₂-VASc, R₂CHADS₂, and APPLE scores for rhythm outcome in patients with atrial fibrillation (AF) after catheter ablation.

Methods:

The cohort of the present study consisted of 192 patients with AF who underwent a total of 265 ablations. Rhythm outcome was documented between 3 and 24 month after ablation. The mentioned scores were calculated for every patient.

Results:

Of the patients, 139 (72%) were successfully treated having freedom of any atrial tachyarrhythmia, whereas 21 (11%) had partial success, and 32 (17%) had failure. For univariate analysis, the APPLE score was the only significant predictor of outcome after ablation with an odds ratio (OR) of 1.485 [95% confidence interval (CI) 1.075–2.052, p-value 0.017]. A multivariate binary regression corrected for possible confounders showed that the APPLE score (OR 1.527, 95% CI 1.082–2.153, p-value 0.016) along with the number of previous ablations (OR 5.831, 95% CI 1.356–25.066, p-value 0.018) is a significant predictor of outcome. A novel score (SUCCESS) was created by adding one point to the APPLE score for each previously performed ablation. This novel score demonstrated an improvement in receiver operating characteristic curve analysis (area under the curve 0.657 vs. 0.620). However, these findings were not significant in our study (p-value 0.219).

Conclusion:

Both the APPLE and the novel SUCCESS scores are superior to the CHADS₂, CHA₂DS₂-VASc, and R₂CHADS₂ scores in predicting AF recurrence after catheter ablation. The SUCCESS score appears to have a higher predictive value than the APPLE score and might be a valuable tool to estimate the risk of AF recurrence in patients eligible for catheter ablation.

A comparison of four risk models for the prediction of cardiovascular complications in patients with a history of atrial fibrillation undergoing non-cardiac surgery

It is unclear how best to predict peri-operative cardiovascular risk in patients with atrial fibrillation undergoing non-cardiac surgery. This study examined the accuracy of the revised cardiac risk index and three atrial fibrillation thrombo-embolic risk models for predicting 30-day cardiovascular events after non-cardiac surgery in patients with a pre-operative history of atrial fibrillation. We conducted a prospective cohort study in 28 centres from 2007 to 2013 of 40,004 patients ≥ 45 years of age undergoing inpatient non-cardiac surgery who were followed until 30 days after surgery for cardiovascular events (defined as myocardial injury, heart failure, stroke, resuscitated cardiac arrest or cardiovascular death). The 2088 patients with a pre-operative history of atrial fibrillation were at higher risk of peri-operative cardiovascular events compared with the 34,830 patients without a history of atrial fibrillation (29% vs. 13%, respectively, adjusted odds ratio 1.30 (95%CI 1.17-1.45). Compared with the revised cardiac risk index (c-index 0.60), all atrial fibrillation thrombo-embolic risk scores were significantly better at predicting peri-operative cardiovascular events: CHADS₂ (c-index 0.62); CHA₂ DS₂ -VASc (c-index 0.63); and R₂ CHADS₂ (c-index 0.65), respectively. Although the three thrombo-embolic risk prediction models were significantly better than the revised cardiac risk index for prediction of peri-operative cardiovascular events, none of the four models exhibited strong discrimination metrics. There remains a need to develop a better peri-operative risk prediction model.

Usefulness of transesophageal echocardiography before cardioversion in atrial arrhythmias

BACKGROUND

Although many thromboembolism risk factors are well defined, formation of thrombus or dense spontaneous contrast (sludge) in the left atrium remains enigmatic and confounding. Exclusion of the thrombus is extremely important with respect to planned reversal of sinus rhythm. Data regarding the routine transesophagal echocardiography (TEE) before cardioversion are inconclusive. The authors focused on analyzing the usefulness of TEE before cardioversion by assessment of factors influencing the risk of thrombus and/or dense spontaneous echo contrast with the intention of extending indications for TEE in the group with a high risk of thrombus or to forgo TEE in the low risk group.

METHODS

Two hundred sixty-nine consecutive patients with persistent (> 48 h) atrial fibrillation or atrial flutter, in whom a direct current cardioversion was planned, were undergoing TEE for the detection of the left atrial thrombus or dense spontaneous echo contrast. Additional clinical and echocardiographic data were collected. The relationship between both thrombus and dense spontaneous echo contrast and covariates was analyzed with the use of binary logistic regression.

RESULTS

Left atrium (LA) appendage (LAA) thrombus and/or sludge were detected in 79 (29%) patients. Signs of dementia in mini-mental state examination (hazard ratio [HR]: 1.16; p = 0.005), low velocities in LAA (HR: 3.38; p = 0.032); presence of spontaneous echo contrast in LA (HR: 3.38; p = 0,003) consecutive episode of AF (HR: 2.27; p = 0,046); longer duration of atrial fibrillation (HR: 1.009; p = 0.022); were significant predictors of thrombus and/or dense spontaneous echo contrast. None of the patients with a CHA2DS2VASc score ≤ 1 had thrombus or sludge in the LAA. Among patients with a CHA2DS2VASc score > 1, the prevalence of thrombus or sludge in LAA was independent of the CHA2DS2VASc score value.

CONCLUSIONS

Amongst many factors, including an established as risk for thromboembolism only a few of them increased the risk for the presence of thrombus in LAA: low velocities in LAA, presence of spontaneous echo contrast, longer duration of arrhythmia, consecutive (not first) arrhythmia episode and signs of dementia from a mini-mental state examination questionnaire. It was believed that there could be a need for an extension of indications of TEE in vast majority of the patients with atrial arrhythmias, due most often to an unpredictable occurrence of thrombus and potentially disastrous thromboembolism. The only exception could have been the group of the patients with a CHA2DS2VASc score ≤ 1.

Comparison of Stroke Risk Stratification Scores for Atrial Fibrillation

Several stroke risk stratification scores have been developed to guide clinical decision-making in patients with nonvalvular atrial fibrillation (AF). The aim of this study was to compare the performance of the CHADS₂, CHA₂DS₂-VASc and R₂CHADS₂ risk scores to predict stroke. This retrospective cohort study was based on electronic medical records from Clalit Health Services (CHS), the largest payer provider healthcare organization in Israel. Data of CHS members with AF diagnosis between 2004 and 2015 were extracted. Demographic and co-morbidity data were used to calculate the 3 risk scores, and the performance of the scores to predict stroke were compared using area under the curve and net reclassification index. Of the 89,213 CHS members with AF, 52.3% were women and median age was 76 years. The proportions of patients at high risk were 66.2%, 86.7%, and 71.1% in the CHADS_2, CHA₂DS₂-VASc, and R₂CHADS₂, respectively, with stroke incidence rates of 2.91, 2.35, and 2.80 per 100 person-years, respectively. Area under the curves for stroke prediction were 0.61 for both CHADS₂ and CHA₂DS₂-VASc and 0.59 for R₂CHADS₂. Net reclassification index analysis demonstrated a net improvement of 0.089 in the index when CHA₂DS₂-VASc was compared with CHADS₂ and a net reduction of 0.083 when R₂CHADS₂ was compared with CHADS₂. In conclusion, current stroke stratification scores have comparable but limited ability to predict stroke in patients with AF. Stroke prevention strategies may vary depending on the applied stratification. There is a need for a better stroke risk stratification score for patients with AF.