Factors influencing mortality in atrial fibrillation. Post hoc analysis of an observational study in outpatients

Quivering hand and heart: Parkinson's disease is not associated with increased in-hospital mortality in atrial fibrillation hospitalizations: A nationwide analysis

Background

Autonomic dysfunction in Parkinson's disease (PD) includes cardiovascular dysregulations which may manifest as an increased risk of atrial fibrillation (AF). However, data on the impact of PD in AF patients is lacking. Our study aimed to investigate the differences in in-hospital mortality of patients admitted for AF with underlying PD versus those without PD.

Methods

We examined the National Inpatient Sample (NIS) database from 2016 to 2019 for hospitalizations of AF as a principal diagnosis with and without PD as a secondary diagnosis. The primary outcome was inpatient mortality. The secondary endpoints were ventricular tachycardia (VT), ventricular fibrillation (VF), acute heart failure (AHF), cardiogenic shock (CS), cardiac arrest (CA), total hospital charge (THC), and length of stay (LOS).

Results

Of 1,861,859 A F hospitalizations, 0.01% (19,490) had coexisting PD. Cohorts of PD vs No-PD had a mean age of 78.1 years [CI 77.9-78.4] vs 70.5 years [CI 70.4-70.5]; male (56.3% vs 50.7%), female (43.7% vs 49.3%). The PD category had similar in-hospital mortality with the no-PD category (OR_Adj = 1.18 [0.89-1.57] P = 0.240). The PD group had a lesser incidence of AHF (OR_Adj = 0.79 [0.72-0.86] P < 0.001) and VT (OR_Adj = 0.77 [0.62-0.95] P = 0.015).

Conclusion

Co-existing PD in patients admitted for AF was not associated with increased in-hospital mortality; however, there were lower odds of AHF and VT. The diminished arrhythmogenic neurohormonal axis may explain these cardiovascular benefits. Notwithstanding, to better understand the outcomes of AF in patients with PD, additional studies are required.

Associations of Atrial Fibrillation Patterns With Mortality and Cardiovascular Events: Implications of the MISOAC-AF Trial

AIM

This retrospective cohort study aimed to evaluate the prognostic implications of the distinct atrial fibrillation (AF) temporal patterns: first diagnosed, paroxysmal, and persistent or permanent AF.

METHODS

In this post hoc analysis of the MISOAC-AF trial (NCT02941978), a total of 1052 patients with AF (median age 76 years), discharged from the cardiology ward between 2015 and 2018, were analyzed. Kaplan-Meier and Cox-regression analyses were performed to compare the primary outcome of all-cause mortality, the secondary outcomes of stroke, major bleeding and the composite outcome of cardiovascular (CV) mortality or hospitalization among AF patterns.

RESULTS

Of patients, 121 (11.2%) had first diagnosed, 356 (33%) paroxysmal, and 575 (53.2%) persistent or permanent AF. During a median follow-up of 31 months (interquartile range 10 to 52 months), 37.3% of patients died. Compared with paroxysmal AF, patients with persistent or permanent AF had higher mortality rates (adjusted hazard ratio (aHR), 1.37; 95% confidence interval [CI], 1.08-1.74, P = .009), but similar CV mortality or hospitalization rates (aHR, 1.09; 95% CI, 0.91-1.31, P = .35). Compared with first diagnosed AF, patients with persistent or permanent AF had similar mortality (aHR, 1.26; 95% CI, 0.87-1.82, P = .24), but higher CV mortality or hospitalization rates (aHR, 1.35; 95% CI, 1.01-1.8, P = .04). Stroke and major bleeding events did not differ across AF patterns (all P > .05).

CONCLUSIONS

In conclusion, in recently hospitalized patients with comorbid AF, the presence of persistent or permanent AF was associated with a higher incidence of mortality and morbidity compared with paroxysmal and first diagnosed AF.

Atrial fibrillation in women: epidemiology, pathophysiology, presentation, and prognosis

Atrial fibrillation (AF) is the most common sustained arrhythmia in women and men worldwide. During the past century, a range of risk factors has been associated with AF, severe complications from the arrhythmia have been identified, and its prevalence has been increasing steadily. Whereas evidence has accumulated regarding sex-specific differences in coronary heart disease and stroke, the differences between women and men with AF has received less attention. We review the current literature on sex-specific differences in the epidemiology of AF, including incidence, prevalence, risk factors, and genetics, and in the pathophysiology and the clinical presentation and prognosis of patients with this arrhythmia. We highlight current knowledge gaps and areas that warrant future research, which might advance understanding of variation in the risk factors and complications of AF, and ultimately aid more-tailored management of the arrhythmia.

The Convergent Procedure - A Standardised and Anatomic Approach Addresses the Clinical and Economic Unmet Needs of the Persistent Atrial Fibrillation Population

A standardised treatment management approach is needed to address the escalating worldwide prevalence of atrial fibrillation (AF). The persistent and longstanding persistent AF patient population particularly needs this standardised treatment option to manage their AF. These patients have underlying structural heart disease that result in increased hospitalizations, long-term medical management that increases the cost burden of the healthcare system. Approximately 100 patients have undergone the Convergent Procedure at our center since its introduction 2 years ago, as a treatment option for AF patients. The epicardial and endocardial ablation procedures performed sequentially in a single setting has shown a single procedure success rate of 80%, similar to published success rates at other centers. The epicardial posterior wall isolation silences a majority of known substrates and the endocardial procedure completes the pulmonary vein isolation, creates the cavotricuspid line and provides diagnostic confirmation. The Convergent Procedure should be considered as a first line treatment option for the persistent and longstanding persistent AF patient population who have very limited or no treatment options for the long-term successful management of their AF.

Safety of dronedarone in routine clinical care

OBJECTIVES

The aim of this study was to examine mortality and liver disease among patients exposed to dronedarone.

BACKGROUND

There has been concern about the safety of dronedarone, especially for patients with heart failure and permanent atrial fibrillation (AF). There have also been suspicions about liver toxicity.

METHODS

All 174,995 patients with a diagnosis of AF during 2010 to 2012 were identified in the Swedish Patient Register. Of these, 4,856 patients had received dronedarone according to the Swedish Drug Register, and 170,139 patients who had not were used as a control population. Mean follow-up was 1.6 years, with a minimal follow-up of 6 months.

RESULTS

Patients prescribed dronedarone were younger (age 65.5 years vs. 75.7 years, p < 0.0001) and healthier than control patients. The annual mortality rate among patients who received dronedarone was 1.3% compared with 14.0% in the control population. There were no sudden cardiac deaths and no deaths related to liver failure among patients who received treatment with dronedarone. After propensity score matching and adjustment for cofactors, patients who received dronedarone had lower mortality than other AF patients (hazard ratio [HR]: 0.41; 95% confidence interval [CI]: 0.33 to 0.51). Dronedarone patients with heart failure had lower mortality than other heart failure patients (HR: 0.40; 95% CI: 0.30 to 0.53). They also had lower mortality than expected from the general population (standardized mortality ratio: 0.67; 95% CI: 0.55 to 0.78), which indicates the selection of low-risk patients. The risk of liver disease was not increased (HR: 0.57; 95% CI: 0.34 to 0.92).

CONCLUSIONS

Dronedarone, as prescribed to AF patients in Sweden, has not exposed patients to increased risks of death or liver disease.

[Relationship between mortality of patients with atrial fibrillation and mortality of general population in Serbia]

INTRODUCTION

Large population-based observational trials have shown atrial fibrillation (AF) to be an independent risk factor for increased mortality.

OBJECTIVE

To examine all-cause mortality and cardiovascular mortality of patients with AF compared to corresponding mortality in general population of Serbia.

METHODS

This longitudinal observational study included patients with nonvalvular AF as the main indication for in-hospital and/or outpatient treatment at the Clinical Centre of Serbia, Belgrade, during the period 1992-2007, if the latest date of the first diagnosed AF was early January 2003, so that the total follow-up could last at least 5 years (minimum 1 year prospectively), or until death. Patients with acute causes of AF, advanced left ventricular systolic dysfunction (LVEF < or = 25%), preexcitation, known malignancy or any advanced chronic disease and patients with poorly documented history of previous AF were not included. To compare mortality of study population with mortality of general population, we used standardized mortality ratio (SMR) and chi-square test, p < 0.05.

RESULTS

Out of 1100 patients (389 females, 35.4%), aged 52.7 +/- 12.2 years, with total follow-up 9.94 +/- 6.05 years (prospective 5.75 +/- 4.28, retrospective 4.21 +/- 5.51), 40% had no underlying disease; others most frequently had arterial hypertension. AF was paroxysmal in 665 (60.5%), persistent in 225 (20.5%) and permanent in 210 patients (19.1%). Newly diagnosed AF was documented in 1058 patients (96.2%). Until the end of the study, 85 patients died (7.7%). Cardiovascular death was noted in 62 patients (72.9%), most frequently in form of sudden death (27/85, 31.7%), death from congestive heart failure (18/85, 21.2%) and stroke (14/85, 16.5%). Most patients (67/85, 78.8%) had AF at the time of death. SMR for all-cause mortality was 2.43 (p < 0.0001) and for cardiovascular mortality 3.03 (p < 0.0001).

CONCLUSION

All-cause mortality and cardiovascular mortality of AF patients are higher than corresponding mortality in general population of Serbia, despite active treatment.

Mortality of patients with lone and idiopathic atrial fibrillation is similar to mortality in general population of Serbia

Background/Aim. Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in general population. The aim of the study was to compare all-cause mortality and cardiovascular mortality in patients with lone and idiopathic AF to correspondent mortality in general population of Serbia. Methods. A longitudinal observational study included the patients with nonvalvular AF as the main indication for inhospital and/or outpatient treatment in the Clinical Center of Serbia, during a period 1992-2007, if the latest date of first diagnosed AF was early January 2003; in that way, the total follow- up could last at least 5 years (minimum 1 year prospectively), or until death. Principles of oral anticoagulation, heart rhythm and frequency control during the study period were conducted according to the latest international guidelines for diagnosis and treatment of AF in the study period. Lone and idiopathic AF were defined as AF in patients without any underlying disease, younger than 60 years (lone AF) or older (idiopathic AF). To compare mortality of the study population with mortality of general population we used the standardized mortality ratio (SMR) and chi-square test with p < 0.05 as a level of statistical significance. Results. Out of 442 patients with AF and no underlying disease, aged 47 ? 12.6 years, with mean follow-up of 11.5 ? 7.2 years, 12 patients (2.7%) died: 7 patients of non-cardiovascular causes and 5 patients (1.1%) of cardiovascular death. When compared to the general population of Serbia, all-cause mortality and cardiovascular mortality in the patients with lone and idiopathic AF were not higher than in general population (p < 0.05). Conclusion. All-cause mortality and cardiovascular mortality of patients with lone and idiopathic AF are similar to all-cause mortality and cardiovascular mortality in general population of Serbia.

Prevention of embolic stroke by catheter ablation of atrial fibrillation

BACKGROUND AND PURPOSE

Radiofrequency-catheter-ablation of atrial fibrillation is now commonly performed. Aim of this short review is to summarize questions and uncertainties concerning radiofrequency ablation of atrial fibrillation with respect to therapeutic mechanisms, long-term efficacy and stroke-prevention.

RESULTS

The majority of atrial fibrillation patients is too old for radiofrequency ablation. Candidates for radiofrequency ablation belong to a subgroup with a low embolic risk. The radiofrequency ablation procedure itself may increase the embolic risk, and at present it is uncertain how long this embolic risk persists after the procedure.

CONCLUSION

We doubt if radiofrequency ablation prevents embolism in atrial fibrillation.

New onset atrial fibrillation developing in medical inpatients

BACKGROUND

The outcome of patients who develop new onset atrial fibrillation (AF) after admission to an Internal Medicine service for acute medical illnesses is unknown.

METHODS

In a retrospective review, we compared patients in the study group: patients who were admitted to hospital for acute medical illnesses and subsequently developed new onset AF during hospitalization, with a control group 1: patients whose admitting diagnosis was new onset AF and a control group 2: patients who were admitted for acute medical illnesses and never developed AF. We analyzed clinical characteristics and all-cause mortality rate during the first 30 days, 6 months, and 1 year after admission.

RESULTS

The 1-year mortality rates in study group were significantly higher than control group 1 (62% versus 8%, P < 0.001) and control group 2 (62% versus 29%, P < 0.05). These results suggest that AF and acute medical illness both are risk factors for increased mortality. The odds ratios were 4.05 (P = 0.023) and 18.33 (P = 0.001) for AF and acute medical illnesses, respectively, indicating that acute medical illness is the better predictor for mortality. Troponin I levels were elevated in 46% of patients in study group versus 12% in control group 1 and 42% in control group 2 (P < 0.05).

CONCLUSIONS

Medical inpatients who develop new onset AF during hospitalization for acute medical illnesses have an increased mortality when compared with patients who were admitted solely for new onset AF. Acute medical illness rather than AF plays a more important role on the increased mortality in this subset of patient population.

[Prognostic factors in patients admitted with type 2 diabetes in Internal Medicine Services: hospital mortality and readmission in one year (DICAMI study)]

INTRODUCTION

Type II diabetes mellitus (T2DM) is a prevalent Public Health Care problem that causes an increase in morbidity, mortality and number of hospital admissions as well as increased costs in care services in this population group. The clinical indicator that determine readmission and/or death are analyzed in a 12 month follow-up period.

METHODS

All T2DM patients admitted in Spanish Internal Medicine Services between two different periods (june 1-15, 2003 and november 1-15) were enrolled in a prospective cohort study. Primary endpoint were readmission and/or death in the year following the first admission.

RESULTS

Population of the study (n = 482) was distributed in 229 males (47.5%) and 253 females (52.5%). Mean age was 73.48 +/- 8.86 years. A total of 210 (43.6%) were not readmitted to the hospital and/or died in the follow-up and 272 (56.4%) were readmitted and/or died. The latter 272 patients had a significantly greater percentage of heart failure (odds ratio [OR] 1.760; 1.073-2.886), atrial fibrillation (OR 1.747; 1.010- 3.022) and previous history of systolic blood pressure (OR 0.400; 0.241-0.666). They also showed increased levels of plasma glucose (OR 1.004; 1.001-1.007), and lower concentration of plasma hemoglobin (OR 0.756; 0.677-0.845) and creatinine clearance (OR 0.985; 0.976-0.994).

CONCLUSIONS

T2DM patients who are admitted to the Internal Medicine Services in Spain are elderly patients with elevated indices of readmission and death in a short follow-up period (one year). The coexistence of heart failure, atrial fibrillation, renal dysfunction deterioration and decrease in hemoglobin levels may predict this worse outcome.

Anatomical remodeling of left atria in subjects with chronic and paroxysmal atrial fibrillation evaluated by multislice computed tomography

PURPOSE

We used ECG-gated enhance multislice computed tomography (MSCT) to evaluate and compare anatomical change to left atria (LA) including left atrial appendage (LAA) in subjects with chronic and paroxysmal atrial fibrillation (CAF and PAF, respectively).

MATERIALS AND METHODS

Retrospective ECG-gated MSCT (Light Speed Ultra 16, General Electric) was performed in 16 subjects with CAF (10 male, median age 68/period of CAF 6 years, 3 severe or moderate mitral stenosis (MS), 3 mitral regurgitation (MR)) and 17 with PAF (11 male, median age 62/period of PAF 3 years, one MS, one MR) 30 s and 8 min after injection of contrast. We evaluated: qualified observed morphology of pectinate muscles (PM) in LAA (well/poorly/non-developed); absolute thickness of LA anterior wall; presence of abnormal late enhancement (LE) of LA wall suggesting fibrotic changes; defect of contrast in LAA only in early phase and LAA enlargement; comparison of LA diameter evaluated by 4-chamber view obtained by transthoracic echocardiogram.

RESULTS

CAF group: well-developed PM (19% subjects), poor PM (43%), no PM (38%). PAF group: well-developed PM (41%), poor PM (47%), no PM (12%). Incidences of well- and non-developed PM were significantly less and more in CAF group, respectively. CAF subjects with no PM had longer periods of CAF and larger LA diameter than those with developed PM (p<0.01). By contrast, there was no relation between PM morphology and PAF periods or LA diameter. Incidence and mean thickness of abnormal LE of LA wall were similar in both groups (2.6 mm): 25% (CAF); 24% (PAF). There was a negative correlation in the CAF group between thickness of LA wall and LA diameter (R2=0.19), but not in the PAF group. Contrast defect in LAA only in early phase and enlargement of LAA were observed in 56%, 88% (CAF) and 24%, 41% (PAF); ratios were significantly higher in CAF group (p<0.01).

CONCLUSIONS

There were anatomical differences between CAF and PAF groups in MSCT. In CAF group, depending on the period of CAF or degree of LA diameter enlargement, anatomical remodeling (e.g. recession of PM, thinning of LA wall, enlargement of LAA) may appear, which may cause blood flow stagnation, seen as contrast defect in LAA in early phase.

Fracture risk in patients treated with amiodarone or digoxin for cardiac arrhythmias: a nation-wide case-control study

BACKGROUND

Cardiac arrhythmias and osteoporotic fractures are common in the elderly.

AIM

We studied whether tachyarrhythmia and/or the drugs used to treat arrhythmias affect risk of fracture.

METHODS

In a population-based nation-wide pharmaco-epidemiological case-control design, we compared 124,655 patients that sustained a fracture during 2000 with 373,962 age- and gender-matched controls. We used computerized registers to assess individual drug use and related these data to individual fracture data and information on confounders.

RESULTS

Risk of any fracture was increased in patients with atrial fibrillation [Odds ratio (OR): 1.14; 95% confidence interval (95%CI): 1.08-1.21] and in patients currently treated with amiodarone (OR: 1.47; 95%CI: 1.21-1.78). Conversely, current use of digoxin decreased fracture risk (OR: 0.75; 95%CI: 0.71-0.79). Subanalysis showed similar effects in men and in women, but drug treatment only affected fracture risk in subjects older than 65 years of age. In current users of digoxin, risk of any fracture and risk of hip and forearm fracture decreased dose-dependently with increased dose. The use of other antiarrhythmics did not affect fracture risk.

CONCLUSION

Special attention should be paid to patients on treatment with amiodarone and/or a diagnosis of atrial fibrillation as they may have an increased risk of fracture. Conversely, treatment with digoxin may reduce fracture risk.