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Sposato LA, Field TS, Schnabel RB, Wachter R, Andrade JG, Hill MD. Towards a new classification of atrial fibrillation detected after a stroke or a transient ischaemic attack. Lancet Neurol 2024; 23:110-122. [PMID: 37839436 DOI: 10.1016/s1474-4422(23)00326-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/03/2023] [Accepted: 08/21/2023] [Indexed: 10/17/2023]
Abstract
Globally, up to 1·5 million individuals with ischaemic stroke or transient ischaemic attack can be newly diagnosed with atrial fibrillation per year. In the past decade, evidence has accumulated supporting the notion that atrial fibrillation first detected after a stroke or transient ischaemic attack differs from atrial fibrillation known before the occurrence of as stroke. Atrial fibrillation detected after stroke is associated with a lower prevalence of risk factors, cardiovascular comorbidities, and atrial cardiomyopathy than atrial fibrillation known before stroke occurrence. These differences might explain why it is associated with a lower risk of recurrence of ischaemic stroke than known atrial fibrillation. Patients with ischaemic stroke or transient ischaemic attack can be classified in three categories: no atrial fibrillation, known atrial fibrillation before stroke occurrence, and atrial fibrillation detected after stroke. This classification could harmonise future research in the field and help to understand the role of prolonged cardiac monitoring for secondary stroke prevention with application of a personalised risk-based approach to the selection of patients for anticoagulation.
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Affiliation(s)
- Luciano A Sposato
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada; Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada; Heart and Brain Laboratory, Western University, London, ON, Canada; Robarts Research Institute, Western University, London, ON, Canada; Lawson Health Research Institute, London, ON, Canada.
| | - Thalia S Field
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC, Canada
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Rolf Wachter
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany; Clinic for Cardiology and Pneumology, University Medicine Göttingen, Göttingen, Germany; German Cardiovascular Research Centre, Partner site Göttingen, Göttingen, Germany
| | - Jason G Andrade
- Division of Cardiology, Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Center for Cardiovascular Innovation, Vancouver, BC, Canada; Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Michael D Hill
- Department of Clinical Neuroscience and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Lopez J, Duarte G, Colombo RA, Ibrahim NE. Temporal Changes in Racial and Ethnic Disparities in the Utilization of Left Atrial Appendage Occlusion in the United States. Am J Cardiol 2023; 204:53-63. [PMID: 37536205 DOI: 10.1016/j.amjcard.2023.07.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/20/2023] [Accepted: 07/04/2023] [Indexed: 08/05/2023]
Abstract
Racial and ethnic disparities in the access to left atrial appendage occlusion (LAAO) have been previously described. However, it remains unclear if there have been any changes in these disparities over the years and if the disparities include other racial and ethnic groups not previously studied. We aimed to determine the temporal evolution of the racial and ethnic disparities in the utilization of LAAO from 2016 to 2019. We conducted a retrospective cohort study using the National Inpatient Sample from 2016 to 2019. International Classification of Diseases, 10th edition codes were used to identify all adult admissions with atrial fibrillation (AF) and those who underwent LAAO. The sample was divided into Asian American and Pacific Islander, Black, Hispanic, White, and other races/ethnicities. Our primary outcome was the utilization of LAAO in patients admitted with a diagnosis of AF. The Cochran-Armitage test was conducted to evaluate the yearly trend in LAAO utilization stratified by race/ethnicity. Multivariable regression analysis was conducted to assess the association of race/ethnicity with multiple end points. A total of 59,415 patients underwent LAAO. The highest yearly increase in LAAO utilization was seen in White patients (trend: 0.16%, p <0.001). Furthermore, compared with White patients, the yearly increase in LAAO utilization was lower in all other racial/ethnic groups. Black patients had the lowest odds of who underwent LAAO (odds ratio = 0.45, 95% confidence interval 0.40 to 0.50, p <0.001). In conclusion, significant gaps exist in the utilization of LAAO between racial and ethnic groups, and they appear to continue worsening from 2016 to 2019.
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Affiliation(s)
- Jose Lopez
- Division of Cardiovascular Disease, University of Miami Miller School of Medicine, JFK Hospital, Atlantis, Florida.
| | - Gustavo Duarte
- Division of Cardiology, Cleveland Clinic Florida, Weston, Florida
| | - Rosario A Colombo
- Division of Cardiovascular Disease, University of Miami Miller School of Medicine, Jackson Health System, Miami, Florida
| | - Nasrien E Ibrahim
- Division of Heart Failure and Transplant Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Khedagi A, Ugowe F, Jackson LR. Incidence and Prevalence of Atrial Fibrillation in Latinos: What's New Since the Study in Latinos (SOL)? Curr Cardiol Rep 2023; 25:901-906. [PMID: 37421552 PMCID: PMC10528177 DOI: 10.1007/s11886-023-01910-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2023] [Indexed: 07/10/2023]
Abstract
PURPOSE OF REVIEW To assess contemporary epidemiological trends in AF incidence and prevalence in the LatinX population after the Hispanic Community Health Study/Study of Latinos. RECENT FINDINGS Atrial fibrillation (AF) remains the most abnormal heart rhythm condition globally and disproportionately impacts morbidity and mortality of communities that have been historically disadvantaged. The incidence and prevalence of AF is lower in the LatinX population compared to White individuals despite a higher burden of classic risk factors associated with AF. Since the Hispanic Community Health Study/Study of Latinos study on AF, recent data continues to demonstrate a similar lower burden of AF in the LatinX population compared to White individuals. However, the rates of incident AF may be accelerating faster in the LatinX population compared to their White counterparts. Furthermore, studies have found environmental and genetic risk factors that are associated with the development of AF within LatinX individuals, which may help explain the rising development of AF among the LatinX community. Recent research continues to show that LatinX populations are less likely to be treated with stroke reduction and rhythm control strategies and have a disproportionately higher burden of poor outcomes associated with AF compared to White patients. Our review illuminates that further inclusion of LatinX individuals in AF randomized control trials and observational studies is imperative to understand the incidence and prevalence of AF in the LatinX community and improve overall morbidity and mortality.
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Affiliation(s)
- Apurva Khedagi
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Francis Ugowe
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Larry R Jackson
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA.
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA.
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Sposato LA, Chaturvedi S, Hsieh CY, Morillo CA, Kamel H. Atrial Fibrillation Detected After Stroke and Transient Ischemic Attack: A Novel Clinical Concept Challenging Current Views. Stroke 2022; 53:e94-e103. [PMID: 34986652 DOI: 10.1161/strokeaha.121.034777] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Atrial fibrillation (AF) can be newly detected in approximately one-fourth of patients with ischemic stroke and transient ischemic attack without previously recognized AF. We present updated evidence supporting that AF detected after stroke or transient ischemic attack (AFDAS) may be a distinct clinical entity from AF known before stroke occurrence (known atrial fibrillation). Data suggest that AFDAS can arise from the interplay of cardiogenic and neurogenic forces. The embolic risk of AFDAS can be understood as a gradient defined by the prevalence of vascular comorbidities, the burden of AF, neurogenic autonomic changes, and the severity of atrial cardiopathy. The balance of existing data indicates that AFDAS has a lower prevalence of cardiovascular comorbidities, a lower degree of cardiac abnormalities than known atrial fibrillation, a high proportion (52%) of very brief (<30 seconds) AF paroxysms, and is more frequently associated with insular brain infarction. These distinctive features of AFDAS may explain its recently observed lower associated risk of stroke than known atrial fibrillation. We present an updated ad-hoc meta-analysis of randomized clinical trials in which the association between prolonged cardiac monitoring and reduced risk of ischemic stroke was nonsignificant (incidence rate ratio, 0.90 [95% CI, 0.71-1.15]). These findings highlight that larger and sufficiently powered randomized controlled trials of prolonged cardiac monitoring assessing the risk of stroke recurrence are needed. Meanwhile, we call for further research on AFDAS and stroke recurrence, and a tailored approach when using prolonged cardiac monitoring after ischemic stroke or transient ischemic attack, focusing on patients at higher risk of AFDAS and, more importantly, at higher risk of cardiac embolism.
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Affiliation(s)
- Luciano A Sposato
- Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics and Anatomy and Cell Biology; Schulich School of Medicine and Dentistry, Western University, London, Canada. (L.A.S.).,Heart & Brain Laboratory, Western University, London, Canada. (L.A.S.).,Robarts Research Institute, Western University, London, Canada. (L.A.S.).,Lawson Health Research Institute, London, Canada (L.A.S.)
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore (S.C.)
| | - Cheng-Yang Hsieh
- Department of Neurology, Tainan Sin Lau Hospital, Taiwan (C.-Y.H.)
| | - Carlos A Morillo
- Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, AB, Canada (C.A.M.)
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York (H.K.)
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Healey JS, Roberts JD, Field TS. Who is at risk of atrial fibrillation? Heart Rhythm 2021; 18:853-854. [PMID: 33639297 DOI: 10.1016/j.hrthm.2021.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Jeff S Healey
- Population Health Research Institute, Hamilton, Ontario, Canada.
| | - Jason D Roberts
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Thalia S Field
- Vancouver Stroke Program, University of British Columbia, Vancouver, British Columbia, Canada
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