Prevalence of atrial fibrillation and its risk factors in rural China: A cross-sectional study

Risk Factors and a Prediction Model for Hemorrhagic Transformation in Acute Ischemic Stroke With Atrial Fibrillation

OBJECTIVES

To identify the risk factors of hemorrhagic transformation (HT) and to establish a prediction model for HT in patients with acute ischemic stroke (AIS) and atrial fibrillation (AF).

METHODS

From January 2015 to December 2018, patients with AIS and AF were enrolled. Demographics, lesion features, and blood test results were collected. Univariate and multivariate logistic regression analyses were used to identify the independent risk factors of HT. The receiver operating curve (ROC) curve was utilized to determine the cutoff values and the efficiency of the variables. A predictive model was subsequently developed based on the identified independent risk factors.

RESULTS

A total of 259 patients were included. Age [odds ratio (OR): 1.094; 95% CI: 1.048-1.142; P <0.001], LDL-C (OR: 0.633; 95% CI: 0.407-0.983; P =0.042), uric acid (OR: 0.996; 95% CI: 0.991-0.999; P =0.031), Alberta Stroke Program Early CT Score (ASPECTS) (OR: 0.700; 95% CI: 0.563-0.870; P <0.001), cerebral cortex infarction (OR: 0.294; 95% CI: 0.168-0.515; P <0.001), and massive cerebral infarction (OR: 3.683; 95% CI: 3.025-5.378; P <0.001) were independently associated with HT. We have developed a model incorporating these variables. The area under the curve of the predictive model was 0.87 (95% CI: 0.83-0.92), demonstrating satisfactory predictive ability with a sensitivity of 83.5% and a specificity of 76.4%.

CONCLUSIONS

Our predictive model, which integrates age, LDL-C, uric acid, ASPECTS, cerebral cortex infarction, and massive cerebral infarction, can be used to predict HT after AIS in patients with AF, thereby facilitating the mitigation of adverse outcomes.

Generalisability of and lessons learned from a mixed-methods study conducted in three low- and middle-income countries to identify care pathways for atrial fibrillation

BACKGROUND

Identifying existing care pathways is the first step for understanding how services can be improved to enable early diagnosis and effective follow-up care for non-communicable diseases (NCDs); however, evidence on how care pathways can and should be identified in low- and middle-income countries (LMICs) is lacking.

OBJECTIVE

To describe generalisability and lessons learned from recruitment and data collection for the quantitative component of a mixed methods study designed to determine the care pathway for atrial fibrillation (AF) in Brazil, China and Sri Lanka.

METHODS

Adults (≥18 years) that spoke the local language and with an AF diagnosis were eligible. We excluded anyone with a hearing or cognitive impairment or ineligible address. Eligible participants were identified using electronic records in Brazil and China; in Sri Lanka, researchers attended the outpatient clinics to identify eligible participants. Data were collected using two quantitative questionnaires administered at least 2-months apart. A minimum sample size of 238 was required for each country.

RESULTS

The required sample size was met in Brazil (n = 267) and China (n = 298), but a large proportion of AF patients could not be contacted (47% and 27%, respectively) or refused to participate (36% and 38%, respectively). In Sri Lanka, recruitment was challenging, resulting in a reduced sample (n = 151). Mean age of participants from Brazil, China and Sri Lanka was 69 (SD = 11.3), 65 (SD = 12.8) and 58 (SD = 11.7), respectively. Females accounted for 49% of the Brazil sample, 62% in China and 70% in Sri Lanka.

CONCLUSIONS

Generalisability was an issue in Brazil and China, as was selection bias. Recruitment bias was highlighted in Sri Lanka. Additional or alternative recruitment methods may be required to ensure generalisability and reduce bias in future studies aimed at identifying NCD care pathways in LMICs.

Relationship between the Ratio of Red Cell Distribution Width to Albumin and 28-Day Mortality among Chinese Patients over 80 Years with Atrial Fibrillation

INTRODUCTION

Atrial fibrillation (AF) is a prevalent heart arrhythmia in elderly adults aged 80 years or older. The red cell distribution width (RDW) to albumin ratio has been acknowledged as a reliable prognostic marker for poor outcomes in a variety of disorders. However, there exists limited scientific evidence on the association of RDW to albumin (RAR) with mortality in geriatric individuals with AF.

METHODS

From January 2015 to June 2020, a retrospective study was conducted in a tertiary academic institution that diagnosed 1,141 elderly adults with AF. The RAR value was calculated as the ratio of RDW (%) to albumin (g/dL). The potential association between RAR and cardiovascular mortality and the risk of all-cause mortality within 28 days was evaluated by means of multivariable Cox regression analysis.

RESULTS

The 28-day all-cause and cardiovascular mortality rates were 8.7% and 3.3%, respectively. Increased RAR tertiles were found to be significantly associated with greater all-cause mortality (T1: 1.6%; T2: 6.2%; T3: 18.1%, p < 0.001) and cardiovascular mortality (T1: 0.8%; T2: 2.9%; T3: 6.3%, p < 0.001) using Kaplan-Meier analysis. Continuous RAR had a positive association with all-cause mortality (hazard ratios [HR] = 1.42, 95% confidence interval [CI] 1.23-1.65) and cardiovascular mortality (HR = 1.31, 95% CI: 1.05-1.64), even after accounting for numerous confounding variables. In comparison to the T1 group, individuals with the highest RAR levels displayed a greater risk of all-cause mortality (HR = 2.73, 95% CI: 1.11-6.74) and cardiovascular mortality (HR = 2.59, 95% CI: 0.69-9.78). Increased RAR levels were related to higher rates of cardiovascular and all-cause mortality across almost all subgroups.

CONCLUSION

RAR is independently correlated with 28-day all-cause mortality and cardiovascular mortality in AF-affected individuals aged ≥80.

Prevalence and prognosis of atrial fibrillation in a hypertensive population: A prospective cohort study

Identifying risk factors for atrial fibrillation (AF) and evaluating their impact are essential to avoid the occurrence of adverse events. However, few studies to date have explored the prevalence, risk factors, and prognosis of AF in hypertensive patients. The objective of this study was to investigate the epidemiology of AF in a hypertensive population and determine the relationship between AF and all-cause mortality. At baseline, a total of 8541 Chinese patients with hypertension were enrolled from the Northeast Rural Cardiovascular Health Study. A logistic regression model was established to assess the relationship between blood pressure and AF, and Kaplan-Meier survival curve analysis and multivariate Cox regression were used to explore the relationship between AF and all-cause mortality. Meanwhile, subgroup analyses illustrated the robustness of results. This study found that the overall prevalence rate of AF was 1.4% in its Chinese hypertensive population. After adjusting for the confounding factors, every standard deviation increase in diastolic blood pressure (DBP) was associated with a 37% increase in the prevalence of AF (95% confidence interval: 1.152-1.627, p < .001). Compared to hypertensive patients without AF, those with AF had an increased risk of all-cause mortality (hazard ratio = 1.866, 95% confidence interval: 1.117-3.115, p = .017) in the adjusted model. The results show that the burden of AF is quite large in rural-dwelling Chinese hypertensive patients. Focusing on the control of DBP to prevent the occurrence of AF can be helpful. Meanwhile, AF increases risk of all-cause mortality in hypertensive patients. Our results indicated a huge burden of AF. Considering that most of the risk factors of AF were unmodifiable in hypertensive individuals and given their high risk of mortality, long-term interventions, including AF education, timely screening, and widespread use of anticoagulant drugs, should be emphasized in hypertensive populations.

Association of chronic kidney disease with all-cause mortality in patients hospitalized for atrial fibrillation and impact of clinical and socioeconomic factors on this association

Background

Atrial fibrillation (AF) and chronic kidney disease (CKD) often co-occur, and many of the same clinical factors and indicators of socioeconomic status (SES) are associated with both diseases. The effect of the estimated glomerular filtration rate (eGFR) on all-cause mortality in AF patients and the impact of SES on this relationship are uncertain.

Materials and methods

This retrospective study examined 968 patients who were admitted for AF. Patients were divided into four groups based on eGFR at admission: eGFR-0 (normal eGFR) to eGFR-3 (severely decreased eGFR). The primary outcome was all-cause mortality. Cox regression analysis was used to identify the effect of eGFR on mortality, and subgroup analyses to determine the impact of confounding factors.

Results

A total of 337/968 patients (34.8%) died during follow-up. The average age was 73.70 ± 10.27 years and there were 522 males (53.9%). More than 39% of these patients had CKD (eGFR < 60 mL/min/1.73 m²), 319 patients with moderately decreased eGFR and 67 with severely decreased eGFR. After multivariate adjustment and relative to the eGFR-0 group, the risk for all-cause death was greater in the eGFR-2 group (HR = 2.416, 95% CI = 1.366-4.272, p = 0.002) and the eGFR-3 group (HR = 4.752, 95% CI = 2.443-9.242, p < 0.00001), but not in the eGFR-1 group (p > 0.05). Subgroup analysis showed that moderately to severely decreased eGFR only had a significant effect on all-cause death in patients with low SES.

Conclusion

Moderately to severely decreased eGFR in AF patients was independently associated with increased risk of all-cause mortality, especially in those with lower SES.

Epidemiology of atrial fibrillation and risk of CVD mortality among hypertensive population: A prospective cohort study in Northeast China

Background

Determining risk factors of cardiovascular disease (CVD)-related mortality and evaluating their influence are important for effectively reducing corresponding mortality. However, few research findings have estimated the relationship between atrial fibrillation (AF) and CVD-related mortality among hypertension individuals.

Objective

The objective of this study was to investigate the epidemiology of AF in a hypertension population and determine the relationship between AF and CVD-related mortality.

Methods

Using a multistage, stratified, and cluster random sampling method, the prospective cohort study with a median follow-up of 3.51 years enrolled 10,678 hypertensive participants at baseline. The prevalence, awareness, and anticoagulation data of AF in this focal population were carefully assessed. Stepwise logistic regression and Cox regression analysis were respectively performed to evaluate the determinants of AF and the association between AF and CVD-related mortality.

Results

The overall prevalence of AF was 1.3% (95% CI, 1.1%−1.6%) in the hypertensive population, and it was higher in men than in women (1.8% vs. 1.0%, respectively; p=0.001). The awareness of AF was 53.1%, and the rate of oral anticoagulant (OAC) therapy was only 4.2%, although all AF participants should have required according to the European Society of Cardiology guidelines. The determinants of AF included elder, male, and history of coronary heart disease in the hypertensive population. Besides, compared with individuals without AF, the risk of CVD-related mortality significantly increased in the hypertensive population with AF (HR 3.37, 95% CI 2.10–5.40).

Conclusion

Our results indicated a huge burden of AF and underuse of OAC therapy for them in a community-based hypertensive population. Considering that most of the risk factors of AF were unmodifiable in hypertensive individuals, as well as its high risk of mortality, long-term interventions including AF education, timely screening, and widespread use of OACs should be emphasized in the focal populations.

Epidemiology, management, and outcomes of atrial fibrillation among 30 million citizens in Shanghai, China from 2015 to 2020: A medical insurance database study

BACKGROUND

Atrial fibrillation(AF) has become a significant public health concern in China, with population aging and urbanization.

METHODS

Data screening was performed for 30,244,930 subjects with medical insurance in the Shanghai Municipal Health Commission database between 2015 and 2020. Patients diagnosed with AF were identified and further assessed for treatment information and clinical outcomes, as well as sex differences and impact of COVID-19 pandemic on AF managment.

FINDINGS

AF prevalence was 0.88% in Shanghai, which increased with age and reached 6.70% at subjects 80 years and over. AF was more prevalent in women compared with men (0.89% vs. 0.88%, p<0.0001), which could be attributed to higher AF burden in women over 80 years. Driven by increased prescription of non-vitamin K antagonist oral anticoagulants, anticoagulant use increased from 19.46% in 2015 to 56.57% in 2020. The number of left atrial appendage closure increased from 0.16% in 2015 to 1.23% in 2020. Rhythm control strategy was increasingly adopted, as the use of antiarrhythmic drugs doubled and ablation increased by 21% in 2020 compared to 2015. Compared with men, women were less prone to receive rhythm control treatments, including antiarrhythmics, ablation and cardioversion, but more likely to adopt rate control drugs. During the 5.5 years follow-up, the incidences of stroke, transient ischemic attack, systemic embolism, bleeding, myocardial infarction, and in-hospital death were 6.09%, 5.74%, 1.44%, 5.11%, 8.41%, and 12.84% in patients with index diagnosis of AF in 2015, respectively.

INTERPRETATION

The burdens of AF and AF-related outcomes in Shanghai are high. Management of AF is markedly improved in recent years, and was not or only slightly impeded by the COVID-19 pandemic. There are sex differences in the prevalence, management, and outcomes of AF.

FUNDING

Shanghai Hospital Development Center, National Natural Science Foundation of China and Shanghai Municipal Science and Technology Commission.

The Chinese burden of atrial fibrillation review of atrial fibrillation studies in China

BACKGROUND

Atrial fibrillation (AF) is one of the most common heart rate disorders, but most relevant studies are mainly focused on Europe and The United States, while information about AF in the Chinese population is scarce. The purpose of this study was to provide a review of the literature on atrial fibrillation in China.

METHODS

A literature search (Medline 2001-2021) identified studies reporting the prevalence or incidence of AF, risk factors for AF, comorbidities of AF, and use of antithrombotic therapy in China. This report focuses on descriptive analytical data.

RESULTS

Studies reported a wide variation in the prevalence of AF, with a range of community-based and hospital-based AF rates (from 0.49% to 8.8% and 4.4% to 35.7%). Aspirin and warfarin use was found to be particularly low in community-based studies in China, and warfarin and amiodarone use was higher in hospital-based studies than in other countries. Stroke is the most common complication of atrial fibrillation.

CONCLUSIONS

More high-quality studies are needed to improve our understanding of the burden of atrial fibrillation in China. Efforts should be made to improve community delivery and monitoring of antithrombotic therapy after AF. Due to China's large population, the number of patients with untreated AF and the risk of accompanying complications can be high, so the impact on healthcare resources can be significant.

Association Between Atrial Fibrillation and the Risk of Cardiovascular Mortality Among Elderly Adults With Ischemic Stroke in Northeast China: A Community-Based Prospective Study

Background

Elderly people are susceptible to atrial fibrillation (AF) and ischemic stroke (IS); however, less information is known about the association between AF and the risk of cardiovascular disease (CVD) mortality in elderly population with IS. We aimed to investigate the features of AF among aged people with IS and to illustrate whether AF accounted for CVD mortality.

Methods

At baseline, 790 patients with IS were enrolled from the general northeast Chinese elderly population (>60 years) between September 2017 to March 2019. The prevalence, awareness, and treatment of AF in each age group were analyzed, as well as major-related cardiovascular risk factors. The population was followed until July 31, 2021, and information on CVD death was obtained.

Results

A total of 25 people had AF, and the prevalence of AF in the elderly population with IS was 3.2%. The AF prevalence grew along with age from 1% (60–64 years) to 4.3% (70–74 years) and 4.2% (≥75 years), which was higher in the urban residents than in the rural residents (5.7 vs. 2.2%, P = 0.014). The awareness and treatment rates of patients with AF were 80 and 8%. After a median follow-up period of 3.3 years, 58 subjects died due to CVD and 5 subjects were accompanied with AF (rate 70.6/1,000 person-years). Elderly IS patients with AF had a 3.65-fold increased risk of CVD death in the fully adjusted model when compared with non-AF participants.

Conclusion

The AF prevalence increased with age among the elderly population with IS. Moreover, elderly patients with IS in northeast China with AF had a higher CVD mortality. Therefore, early screening and prompt management of AF in elderly population with IS in northeast China are required.

Refinement of CHADS2 and CHA2DS2-VASc scores predict left atrial thrombus or spontaneous echo contrast in nonvalvular atrial fibrillation patients

Objective

To investigate the risk factors of left atrial thrombus (LAT)/spontaneous echo contrast (SEC) in patients with nonvalvular atrial fibrillation (AF).

Methods

This retrospective study analysed the data from consecutive patients with nonvalvular AF that underwent transoesophageal echocardiography. Logistic regression analysis was performed to identify risk factors of LAT/SEC. Receiver operating characteristic curve analysis was undertaken compare the new scales with CHADS2 and CHA2DS2-VASc scores.

Results

A total of 558 patients with AF were included in the study. LAT/SEC was detected in 137 (24.6%) patients. The independent risk factors of LAT/SEC beyond CHADS2 or CHA2DS2-VASc scores included non-paroxysmal AF and left atrial diameter >37.5 mm. These two variables were added into the CHADS2 or CHA2DS2-VASc score to build new scales. Areas under the curve for the new scales based on CHADS2 and CHA2DS2-VASc scores were significantly higher than the CHADS2 or CHA2DS2-VASc score both in the overall study cohort and in patients at a high risk of thromboembolism.

Conclusions

Non-paroxysmal AF and increased left atrial diameter beyond the CHADS2 or CHA2DS2-VASc score were independent risk factors of LAT/SEC and may help to improve the current risk stratification, especially for patients with nonvalvular AF at a high risk of thromboembolism.

Association between red blood cell distribution width and non-valvular atrial fibrillation in hemodialysis patients: a single-center Chinese population study

Background

Red blood cell distribution width (RDW) has emerged as a prognostic marker of atrial fibrillation (AF) in various clinical settings. However, the relationship by which RDW was linked to AF in hemodialysis (HD) patients was not clear. We sought to reveal the relationship between RDW and AF occurrence in HD patients.

Methods

We enrolled 170 consecutive maintenance HD patients, including 86 AF patients and 84 non-AF patients. All participants’ medical history and detailed clinical workup were recorded before the first dialysis session of the week. Electrocardiography, laboratory and transthoracic echocardiography examination indices were compared between the AF group and non-AF group. Multivariable logistic regression analysis was performed to identify the independent predictors of AF occurrence in HD patients.

Results

There were all paroxysmal AF patients in AF group. Compared to the non-AF group, patients with AF group had a significantly older age (61.0 ± 1.48 vs. 49.71 ± 1.79, p < 0.001), lower BMI (24.3 ± 4.11 vs. 25.8 ± 3.87, p < 0.05), higher RDW (15.10 ± 0.96 vs. 14.26 ± 0.82, p < 0.001) and larger LAD (39.87 ± 3.66 vs. 37.68 ± 5.08, p < 0.05). Multivariable logistic regression analyses demonstrated that values of age (OR: 1.030, 95%CI: 1.004-1.057, per one- year increase), BMI (OR: 0.863, 95%CI: 0.782–0.952, per 1 kg/m² increase), RDW (OR: 2.917, 95%CI: 1.805–4.715, per 1% increase) and LAD (OR: 1.097, 95%CI: 1.004–1.199, per 1 mm increase) were independently associated with AF occurrence (p < 0.05, respectively). The best cutoff value of RDW to predict AF occurrence was 14.65% with a sensitivity of 68.6% and a specificity of 72.6%.

Conclusions

The increased RDW was significantly associated with the paroxysmal AF occurrence in HD patients.

Effect of different alcohol consumption levels on the left atrial size: A cross-sectional study in rural China

OBJECTIVE

Previous studies have investigated the relationship between alcohol and ventricular structure; however, few studies have evaluated the relation between alcohol consumption and the atrium size. In this study, we aimed to test the association between alcohol consumption and left atrium (LA) size in the general population.

METHODS

A population-based sample of 10,211 subjects aged ≥35 years and free from hypertension at baseline were followed from January 2012 to August 2013. Left atrial enlargement (LAE) was defined as the ratio of LA diameter to body surface area exceeding 2.4 cm/m2 in both the sexes. Independent factors for LAE were estimated by multiple logistic regression analyses.

RESULTS

The study included 10,211 participants (4,751 men and 5,460 women). Left atrial diameter/body surface area (LAD/BSA) was higher in the moderate and heavy alcohol consumption groups than in the non-drinker group (non-drinker, 20.5±0.03 cm/m2; moderate, 20.8±0.09 cm/m2; and heavy, 20.6±0.06 cm/m2; p<0.001). Both the groups of moderate and heavy drinkers had a higher incidence of LAE than the non-drinker group (6.9% of non-drinkers, 9.9% of moderate drinkers, and 8.4% of heavy drinkers; p<0.001). After adjusting for related risk factors, multiple logistic regression analyses showed that moderate drinkers had an approximately 1.4-fold higher risk of LAE [odds ratio (OR): 1.387, 95% confidence interval (CI) 1.056-1.822, p=0.019] compared with the non-drinkers, and the heavy drinkers had an approximately 1.2-fold higher risk of LAE (OR: 1.229, 95% CI: 1.002-1.508, p=0.047) compared with that of the non-drinkers.

CONCLUSION

Both heavy and moderate drinkers had increased odds for LAE compared with participants with no alcohol consumption in the general population.

Warfarin Adherence Among Patients with Atrial Fibrillation in Rural Area of Dongyang, China: A Questionnaire-Based Study

INTRODUCTION

Adherence to warfarin is associated with improved outcome in patients with atrial fibrillation (AF), but the adherence status of patients in rural areas of China is not known.

METHODS

A questionnaire-based study evaluating warfarin adherence of rural residents with AF was carried out in Dongyang, China. Potentially eligible patients were screened and contacted by telephone, and their demographic characteristics were collected. Illness perception was assessed using the Brief Illness Perception Questionnaire (BIPQ), and warfarin adherence was assessed using a Chinese-version adherence scale. Univariate and multivariate analyses were conducted to identify factors associated with unsatisfactory adherence.

RESULTS

A total of 201 patients (male, n=99; mean age, 70.3±8.12 years) were included, among whom 95 (47.3%) patients showed good adherence and 63 (31.3%) poor adherence. Number of co-dispensed drugs (multivariate analysis: odds ratio [OR]=3.64, 95% confidence interval [CI] 1.35-9.81, p=0.011) and BIPQ score (OR=1.25, 95% CI 1.17-1.33, p<0.001) were identified as factors associated with good adherence.

CONCLUSION

Medical adherence to warfarin needs to improve in rural patients with AF. Efforts that can reduce the number of co-dispensed drugs and increase illness perception may improve warfarin adherence. This study may benefit future management of warfarin administration to rural patients with AF.

ECG Predictors for New-Onset Atrial Fibrillation Within a Year After Radiofrequency Ablation of Counterclockwise-Rotating Atrial Flutter

Background: New-onset atrial fibrillation (AF) after ablation of typical atrial flutter (AFL) is not rare. This study aimed to investigate the predictive value of electrocardiographic parameters on new-onset AF post-typical AFL ablation.

Methods: A total of 158 consecutive patients (79.1% males, mean age 57.8 ± 14.3 years) with typical AFL were enrolled between January 2012 and August 2017 in this single-center study. Patients with a history of AF before ablation were excluded. ECGs during sinus rhythm (SR) and AFL were collected. The duration of the negative component of flutter wave in lead II (D_FNII), proportion of the D_FNII of the total circle length of AFL (D_FNII%), amplitude of the negative component of flutter wave in lead II (A_FNII), duration (D_PNV1), and amplitude (A_PNV1) of negative component of the P wave in lead V1, and P wave duration in lead II (D_PII) during sinus rhythm were measured.

Results: During a median follow-up of 26.9 ± 11.8 months, 22 cases (13.9%) developed new-onset AF. D_FNII was significantly longer in patients with new-onset AF compared to patients without AF (114.7 ± 29.6 ms vs. 82.7 ± 12.8 ms, p < 0.0001). A_FNII was significantly lower (0.118 ± 0.034 mV vs. 0.168 ± 0.051 mV, p < 0.0001), D_PII (144.21 ± 23.77 ms vs. 111.46 ± 14.19 ms, p < 0.0001), and D_PNV1 was significantly longer (81.07 ± 16.87 ms vs. 59.86 ± 14.42 ms, p < 0.0001) in patients with new-onset AF. In the multivariate analysis, D_FNII [odds ratio (OR), 1.428; 95% CI, 1.039–1.962; p = 0.028] and D_PII (OR, 1.429; 95% CI, 1.046–1.953; p = 0.025) were found to be independently associated with new-onset AF after typical AFL ablation.

Conclusion: Parameters representing left atrial activation time under both the SR and AFL were independently associated with new-onset AF post-typical AFL ablation and may be useful in risk prediction, which needs to be confirmed by further prospective studies.

Performance of a novel ECG criterion for improving detection of left ventricular hypertrophy: a cross-sectional study in a general Chinese population

OBJECTIVES

The sensitivity of ECG for detecting left ventricular hypertrophy (LVH) is low. The aim of this study was to explore a better ECG criterion for screening LVH in a large general Chinese population.

DESIGN

Case-control study.

SETTING

China Medical University in Shenyang, China.

PARTICIPANTS

All permanent residents in Dawa, Zhangwu and Liaoyang aged 35 years or older were invited. Participants with unqualified data, pacemaker rhythm, frequent premature ventricular beats, Wolff-Parkinson-White syndrome, complete bundle branch block, myocardial infarction or hypertrophic cardiomyopathy were excluded. A total of 10 360 subjects (4630 males) were recruited.

INTERVENTIONS

A novel ECG criterion (Northeast China Rural Cardiovascular Health Study (NCRCHS)) composed of different ratios of maximum R wave in lead V₅ or V₆ (R_V5/V6), S wave in lead V₃ (S_V3) and R wave in lead aVL (R_aVL) was proposed and validated using multiple linear regression. Receiver-operating characteristic curves were used to compare the NCRCHS criterion with traditional criteria for LVH detection.

RESULTS

An optimised model (15^*R_aVL+8^*S_V3+7^*R_V5/V6) was constructed (R² 0.192, p<0.001) with the cut-off values of 36.8 mV for males and 26.1 mV for females. The maximum area under the curve was obtained using the NCRCHS criterion (male 0.74, 95% CI 0.73 to 0.75; female 0.73, 95% CI 0.72 to 0.75), followed by Cornell voltage criterion, Sokolow-Lyon criterion, Peguero-Lo Presti criterion, multi-ethnic study of atherosclerosis (MESA)-specific criterion and Syst-Eur voltage criterion. Compared with the Cornell voltage criterion, the NCRCHS criterion had a significantly higher sensitivity for detecting LVH at the same level of specificity (p<0.05).

CONCLUSIONS

The NCRCHS criterion significantly improved sensitivity for LVH detection in a general Chinese population, with cut-off values of 36.8 and 26.1 mV for males and females, respectively. This criterion can detect LVH earlier and better and may prevent subsequent cardiovascular diseases.

Atrial fibrillation in low- and middle-income countries: a narrative review

Preventing premature non-communicable disease mortality necessitates a thorough review of one of the most important risk factors for stroke, which is atrial fibrillation (AF). The latter and AF-related stroke are still considered to be problems of high-income countries and are frequently overlooked in low- and middle-income countries (LMICs). In this narrative review, we provide an overview of studies that evaluated at least one of the following determinants of AF burden in LMICs: current epidemiology and trends, stroke prevention, health outcomes, and economic burden. Studies focusing on samples close to the general population (including community- and primary care-based samples) indicate sex-specific prevalence rates up to 7.4% in LMICs. Although AF prevalence is still higher in high-income countries than LMICs, the gap in AF burden between these two groups has been reducing in the past three decades. Oral anticoagulant (OAC) therapy for stroke prevention is underused in LMICs, and there are little data on OAC therapy in relation to stroke risk scores, such as CHA2DS2-VASc. Available data also points to higher morbidity and mortality for patient with AF in LMICs than their counterparts in high-income countries. Data on the consequent economic burden in LMICs is scarce, but it is reasonable to consider it will follow the same trend as that observed for health outcomes. Raising the visibility of AF as a public health problem in LMICs is necessary as a first step to providing adequate care for patients with this condition.

Estimate of prevalent ischemic stroke from triglyceride glucose-body mass index in the general population

Background

To investigate the relationship between triglyceride glucose-body mass index (TyG-BMI) and ischemic stroke.

Methods

Leveraging two Chinese general population surveys, the Northeast China Rural Cardiovascular Health Study (NCRCHS, N = 11,097) and the National Stroke Screening and Intervention Program in Liaoning (NSSIPL, N = 10,862), we evaluated the relationship between TyG-BMI and ischemic stroke by a restricted cubic spline and multivariate logistic regression after adjusting age, sex, level of education, exercise regularly, current smoking, current drinking, atrial fibrillation, hypertension, coronary artery disease, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol. The category-free analysis was used to determine whether TyG-BMI enhanced the capacity of estimating ischemic stroke.

Results

A total of 596 and 347 subjects, respectively, from NSSIPL and NCRCHS were survivors of ischemic stroke. In NSSIPL, the relationship between TyG-BMI and ischemic stroke was linear and did not have a threshold or saturation effect according to the results of the restricted cubic spline. The regression analysis indicated that the risk of ischemic stroke increased 20% for per SD increase of TyG-BMI after multivariate adjustment [odds ratio (OR): 1.20, 95% confidence interval (CI): 1.10–1.32]. Compared with those in the lowest tertile, the risk of ischemic stroke in subjects with intermediate and high TyG-BMI was significantly higher [OR (95% CI): 1.39 (1.10–1.74); OR (95% CI) 1.72 (1.37–2.17), respectively]. Category-free analysis indicated that TyG-BMI had a remarkable improvement in the ability to estimate prevalent ischemic stroke [NRI (95% CI): 0.188 (0.105–0.270)]. These abovementioned relationships were confirmed in NCRCHS.

Conclusions

The present study found the robust correlation between TyG-BMI and ischemic stroke, independently of a host of conventional risk factors. Meanwhile, our findings also suggested the potential usefulness of TyG-BMI to improve the risk stratification of ischemic stroke.

Comparison of the efficacy and safety of different doses of nifekalant in the instant cardioversion of persistent atrial fibrillation during radiofrequency ablation

Nifekalant has been used in the treatment of atrial arrhythmia recently. However, there is no consensus on the preferable nifekalant dose to treat atrial fibrillation (AF). The purpose of this study was to explore efficacy and safety of different doses of nifekalant in the cardioversion of persistent AF. The study was a single-centre, randomized controlled trial. All subjects received nifekalant or placebo intravenously, and the nifekalant was given at the dosage of 0.3, 0.4 or 0.5 mg/kg. Primary efficacy end-point: compared with 0.3 mg group, the rate of cardioversion to sinus rhythm from AF in 0.4 and 0.5 mg group was higher. The 0.4 and 0.5 mg/kg doses were associated with a similar magnitude of efficacy (P > .05). Secondary efficacy end-point: termination rates of AF in the group of 0.4 mg and 0.5 mg were higher than 0.3 mg. Primary safety end-point: the rate of Torsades de Pointes or ventricular fibrillation was numerically lower in the 0.4 mg group than 0.5 mg group (P = .02). Secondary safety end-point: The rates of the majority of other common drug-related adverse events in the group of 0.5 and 0.4 mg were higher than the 0.3 mg group. A 0.4 mg/kg dose of intravenous nifekalant may be recommended during the radiofrequency ablation for persistent AF considering the benefit-risk profile.

Cost-effectiveness of Dabigatran Compared With Rivaroxaban for Prevention of Stroke and Systemic Embolism in Patients With Atrial Fibrillation in China

PURPOSE

In China, dabigatran and rivaroxaban are the only approved non-vitamin K antagonist oral anticoagulants for the treatment of atrial fibrillation (AF). The goal of this article was to assess the cost-effectiveness of dabigatran versus rivaroxaban for the prevention of stroke and systemic embolism in Chinese patients with AF from the perspective of the Chinese health care system.

METHODS

A Markov model was constructed to estimate the cost-effectiveness of dabigatran versus rivaroxaban. Clinical events were modeled for a lifetime horizon, based on clinical efficacy data from indirect treatment comparisons. The weighted average of the most recent prices of these 2 drugs was used as the drug acquisition cost. Other costs, including follow-up costs and event costs, were collected by using a survey from a panel of local experts. Utility inputs (health state utilities, clinical event disutilities, and event history utility) were obtained from published literature. Sensitivity analyses that included scenario analyses and a probabilistic sensitivity analysis were conducted to examine the robustness of the economic model.

FINDINGS

Over a lifetime, patients treated with dabigatran experienced fewer ischemic strokes (2.14 dabigatran vs 2.61 rivaroxaban) and fewer intracranial hemorrhage (0.48 vs 0.94) per 100 patient-years. In the base case analysis, dabigatran had an incremental cost of ¥28,128 but with higher life years (10.38 vs 10.14) and quality-adjusted life years (QALYs) (7.95 vs 7.70). The resulting incremental cost-effectiveness ratio of ¥112,910 per QALY gained and net monetary benefit of ¥12,214 versus rivaroxaban showed that dabigatran was a cost-effective alternative to rivaroxaban. Extensive sensitivity analyses indicated that the results were robust over a wide range of inputs. The probabilistic sensitivity analysis indicated that dabigatran was cost-effective in 84.2% of the 10,000 Monte Carlo simulations compared with rivaroxaban.

IMPLICATIONS

Dabigatran reduced the occurrence of clinical events and increased QALYs compared with rivaroxaban. The use of dabigatran for the prevention of stroke and systemic embolism is a cost-effective option compared with rivaroxaban among patients with AF in China.

Epidemiology of atrial fibrillation in northeast China: a cross-sectional study, 2017–2019

Objective

To evaluate the epidemiology of atrial fibrillation (AF) in northeast China.

Methods

This cross-sectional survey using a multistage, stratified and cluster random sampling method was conducted in Liaoning Province between September 2017 and March 2019. A total of 18 796 participants (28.9% urban, 71.1% rural) aged ≥40 years were included. All participants completed a questionnaire and underwent a physical examination and ECG. AF was diagnosed according to history and ECG findings.

Results

The overall AF prevalence was 1.1%; it increased steeply with age. AF was more prevalent in men than in women (1.5% vs 0.9%, p<0.001); however, the difference between urban and rural areas was not significant (1.3% vs 1.1%, p=0.228). Among the AF population, the overall AF awareness rate was 52.6%, higher in women than in men (61.5% vs 44.1%, p=0.011); however, the difference between areas was not statistically significant (60.0% vs 49.0%, p=0.129). According to the CHA2DS-VASc score, almost all (90.2%, 194/215) of our subjects required oral anticoagulant (OAC) therapy; however, only 4.1% actually received it. Moreover, hypertension (66.5%), dyslipidaemia (32.6%) and diabetes (24.2%) were highly prevalent in patients with AF, but their control rates were unacceptably low (7.0%, 8.6% and 28.8%, respectively).

Conclusions

The burden of AF in northeast China was substantial. Underuse of OAC therapy and uncontrolled comorbidities will likely contribute to the cardiovascular outcomes of patients with AF in the coming decades. Long-term management strategies for AF and related risk factors are required in northeast China.

Independent associations of blood pressure and body mass index with interatrial block: a cross-sectional study in general Chinese population

OBJECTIVES

This current study was performed to characterise the independent associations of obesity and hypertension with interatrial block (IAB) after adjusting for cardiovascular risk factors, echocardiographic left atrial diameter (LAD) and left ventricular mass index (LVMI) in a large general Chinese population.

DESIGN

A cross-sectional study.

SETTING AND PARTICIPANTS

A total of 11 956 permanent residents (≥35 years of age) from Liaoning Province in China were included in this study. Following the completion of a questionnaire, the enrolled participants were subjected to physical examinations, laboratory analyses, ECG and echocardiogram. Linear and logistic regression analyses were performed to evaluate the associations of hypertension and obesity with IAB.

OUTCOME MEASURES

IAB was defined as a prolongation of the P wave duration ≥120 ms on a digital 12-lead ECG.

RESULTS

The prevalence of IAB in hypertensive individuals was higher than the normotensive in both men (9.5 vs 5.9%; p<0.001) and women (6.6 vs 3.6%; p<0.001). In addition, the prevalence of IAB exhibited a sharp increase with advancing body mass index (BMI) in both men (from 4.9% to 13.0%) and women (from 3.5% to 6.9%) (ps- for trend <0.001). Multiple relevant clinical covariates, echocardiographic LAD and LVMI were adjusted in the multivariate linear and logistic regression analyses. The results revealed that systolic blood pressure, diastolic blood pressure and BMI were all independently associated with P wave duration (β=0.02, 0.09 and 0.25, respectively; all ps <0.005). Furthermore, hypertension was found to be independently associated with IAB (OR=1.27; p=0.018), while both overweight and obesity exhibited higher odds of IAB (OR=1.42 and 1.67, respectively; ps <0.005), compared with BMI <24.0 kg/m².

CONCLUSIONS

The key findings of this study highlighted that hypertension and overweight/obesity were independently and significantly associated with IAB in general Chinese population.

The relationship between decreased pulmonary function and atrial fibrillation in general population: Findings from Ansung-Ansan cohort of the Korean Genome and Epidemiology Study

BACKGROUND

Decreased pulmonary function is a possible risk factor for atrial fibrillation (AF). However, data on this relationship in Asian populations are scant. The aim of this study was to evaluate the relationship between decreased pulmonary function and the incidence of AF in a prospective cohort of Koreans aged 40-69 years.

METHODS

We assessed AF in 9631 Korean people enrolled in the community-based cohort who were followed for up to 12 years. AF at baseline was identified by electrocardiography (ECG) performed during the baseline visit and/or the self-reported history of physician-determined diagnosis made before the baseline visit. Similarly, AF newly developed after the baseline visit was also identified by biennially performed ECGs and/or the self-reported history of physician-determined diagnosis that occurred between each biennial visit. If AF was identified by both ECGs and the history in the same subject, the earlier identification date was considered the time of AF development.

RESULTS

The median age was 50 (interquartile range, 44-60) years, and 4633 (48.1%) were male. The prevalence of AF at baseline was significantly higher in subjects with lower quartiles of forced expiratory volume in second (FEV₁)% predicted (1.2% in the lowest quartile versus 0.3% in the highest quartile; p<0.001). After adjustment for cardiovascular risk factors, FEV₁% predicted and forced vital capacity (FVC)% predicted were independent risk factors for AF at baseline. Over a median follow-up period of 138 (interquartile range, 70-141) months, AF was newly documented in 162 subjects (1.7%). The lowest quartiles of FEV₁% predicted (adjusted hazard ratio, 1.59; 95% confidence interval, 1.02-2.50) was associated with a higher risk of incident AF than the highest quartiles.

CONCLUSIONS

In this large community-based cohort study with a long-term follow-up, decreased pulmonary function was found to be an independent risk factor for AF in the general Korean population.

Modelling projections for the risks related with atrial fibrillation in East Asia: a focus on ischaemic stroke and death

Aims

In the Far East, there has generally been low uptake of oral anticoagulants (OACs) using vitamin K antagonists (VKA, e.g. warfarin) for stroke prevention in atrial fibrillation (AF), but OAC use has been increasing more recently, with the introduction of the non-vitamin K antagonist oral anticoagulants (NOACs). To explore the risks of ischaemic stroke (IS) and death related to AF in East Asia using modelling projections.

Methods and results

We performed a modelling analysis of possible trends of IS and death rates in AF patients from the time period of only VKA use to current increasing trends of NOAC use projecting until 2050 in East Asia. Data from published articles on the prevalence of AF, IS, and death were used to model estimated event rates. In 2030, the estimated AF population in East Asia will be 608 100, with the use of NOACs leading to a reduction of 82 259 ISs and 16 917 deaths. There was an estimated annual risk reduction of 5484 ISs and 1128 deaths from 2016 to 2030, respectively. The AF population is estimated to reach 861 900 in 2050, with a reduction of 206 315 ISs and 139 353 deaths.

Conclusion

This modelling analysis suggests that the transition from VKA to NOACs may greatly help in reducing the burden of IS and death caused by AF in the East Asian region.

Prevalence and risk factors for atrial fibrillation and its anticoagulant requirement in adults aged ≥40 in Jimma Town, Southwest Ethiopia: A community based cross-sectional study

BACKGROUND

There is no information on the prevalence and incidence of atrial fibrillation in Ethiopia. We aimed to investigate the prevalence, risk factors and anticoagulant requirements of atrial fibrillation in an elderly Jimma population.

METHODS

In a community-based cross-sectional study in 634 adult (≥40 years) Jimma population, we performed cardiovascular health examinations including a 12-lead electrocardiogram to estimate AF prevalence. A standardized questionnaire was used to collect information on medical history, lifestyle and use of medications. Stroke risk stratification was done using CHA2DS2-VASc score. We used logistic regressions to determine the potential risk factors of AF.

RESULTS

The overall prevalence of AF was 4.3%. AF was associated with sex, current smoking, hypertension and BMI. Nineteen out of twenty seven participants with AF were in need of anticoagulation to prevent risk of stroke.

CONCLUSION

The prevalence of AF is high and common risk factors were sex, current smoking, hypertension, and higher BMI in this cohort. More than two-third of study participants with AF were at higher need of oral anticoagulants.

Management and 1-Year Outcomes of Patients With Newly Diagnosed Atrial Fibrillation and Chronic Kidney Disease: Results From the Prospective GARFIELD - AF Registry

Background Using data from the GARFIELD - AF (Global Anticoagulant Registry in the FIELD -Atrial Fibrillation), we evaluated the impact of chronic kidney disease ( CKD ) stage on clinical outcomes in patients with newly diagnosed atrial fibrillation ( AF ). Methods and Results GARFIELD - AF is a prospective registry of patients from 35 countries, including patients from Asia (China, India, Japan, Singapore, South Korea, and Thailand). Consecutive patients enrolled (2013-2016) were classified with no, mild, or moderate-to-severe CKD , based on the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative guidelines. Data on CKD status and outcomes were available for 33 024 of 34 854 patients (including 9491 patients from Asia); 10.9% (n=3613) had moderate-to-severe CKD , 16.9% (n=5595) mild CKD , and 72.1% (n=23 816) no CKD . The use of oral anticoagulants was influenced by stroke risk (ie, post hoc assessment of CHA 2 DS 2- VAS c score), but not by CKD stage. The quality of anticoagulant control with vitamin K antagonists did not differ with CKD stage. After adjusting for baseline characteristics and antithrombotic use, both mild and moderate-to-severe CKD were independent risk factors for all-cause mortality. Moderate-to-severe CKD was independently associated with a higher risk of stroke/systemic embolism, major bleeding, new-onset acute coronary syndrome, and new or worsening heart failure. The impact of moderate-to-severe CKD on mortality was significantly greater in patients from Asia than the rest of the world ( P=0.001). Conclusions In GARFIELD - AF , moderate-to-severe CKD was independently associated with stroke/systemic embolism, major bleeding, and mortality. The effect of moderate-to-severe CKD on mortality was even greater in patients from Asia than the rest of the world. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 01090362.

Atrial fibrillation in athletes and general population: A systematic review and meta-analysis

BACKGROUND

Atrial fibrillation (AF) is the most common type of heart arrhythmia, but the impact of long-term, high-intensity endurance exercise on the risk of AF remains uncertain.

METHODS

PubMed, EMBASE, and Cochrane library databases were searched till Nov 2017 to retrieve the articles. The included studies were summarized, pooled odds ratio (OR) and its 95% confidence interval (CI) were calculated. Both fixed and random effects models were used to combine the data. Stratified and logistic meta-regression analyses were performed to explore the sources of heterogeneity across studies.

RESULTS

Nine studies including 2308 athletes and 6593 controls were eligible. Our results showed that the risk of AF was significantly higher in athletes than in general population (OR = 2.34, 95% CI = 1.04-5.28, Pheterogeneity<.001, I = 92.3%). Subgroup analysis based on gender and mean age demonstrated a significantly increased risk in men (OR = 4.03, 95% CI = 1.73-9.42, Pheterogeneity<.001, I = 82.7%) and participants with mean age <60 (OR = 3.24, 95% CI = 1.23-8.55, Pheterogeneity<.001, I = 84.3%). Furthermore, subgroup analysis based on type of athletes demonstrated a significantly increased risk of AF in participants with single type of sport (OR = 3.97, 95% CI = 1.16-13.62, Pheterogeneity = .018, I = 70.4%). Results remained unchanged after performing sensitivity analysis. Meta-regression showed that gender, age, type of study, sample size, and sports mode were unrelated to heterogeneity.

CONCLUSION

Our study confirmed that the risk of AF was significantly higher in athletes than in general population, especially among men and participants aged <60.

The Disease Burden of Atrial Fibrillation in China from a National Cross-sectional Survey

Atrial fibrillation (AF) is the most common type of arrhythmia, which is a significant public health issue. We aimed to determine the disease burden of AF in China. We used a recent national survey with stratified multistage random sampling from general Chinese population to estimate the AF disease burden, which enrolled 34,994 people aged 35 years or older all over China. The AF patients were detected by electrocardiogram during the survey or medical history taking. The quality of life in AF patients was assessed by a questionnaire similar to EQ-5D to estimate the weight of disability. Disability-adjusted life years was then calculated by adding years of life lost to years lived with disability. Overall, 31,230 samples were included in the final analysis, the weighted prevalence of AF in the Chinese population aged 35 years or older was 0.71%. Thirty-four percent of AF patients were newly diagnosed in the survey and unaware of their pathological condition beforehand. The prevalence of AF significantly increased with age. The health-related quality of life was impaired in Chinese AF patients with an overall utility value of 0.53. The total disability-adjusted life years of Chinese AF patient is estimated to be 665,400. In conclusion, the disease burden of AF in the general Chinese population was a significant public health issue in China.

Development and validation of a Health Policy Model of Type 2 diabetes in Chinese setting

Aim: Due to the difference in epidemiology and outcomes between eastern and western populations with Type 2 diabetes mellitus (T2DM), an important challenge is determining how useful the outcomes from diabetes models based on western populations are for eastern patients. Consequently, the principal aim of this study was to develop and validate a Health Policy Model (Chinese Outcomes Model for T2DM [COMT]) for supporting Chinese medical and health economic studies. Methods: The model is created to simulate a series of important complications of T2DM diabetes based on the latest Risk Equations for Complications of Type 2 Diabetes, which was adjusted by adding the adjustment regulator to the linear predictor within the risk equation. The validity of the model was conducted by using a total of 171 validation outcomes from seven studies in eastern populations and ten studies in western populations. The simulation cohorts in the COMT model were generated by copying each validation study's baseline characteristics. Concordance was tested by assessing the difference between the identity (45°) line and the best-fitting regression of the scatterplots for the predicted versus observed outcomes. Results: The slope coefficients of the best-fitting regression line between the predicted and corresponding observed actual outcomes was 0.9631 and the R² was 0.8701. There were major differences between western and eastern populations. The slope and R² of predictions were 0.9473 and 0.9272 in the eastern population and 1.0566 and 0.8863 in the western population, which showed more perfect agreement with the observed values in the eastern population than the western populations. The subset of macro-vascular and micro-vascular outcomes in the eastern population showed an identical tendency (the slope coefficient was close to 1), and mortality outcomes showed a slight tendency toward overestimation (the slope coefficient was close to 0.9208). Some degree of underprediction of macro-vascular and micro-vascular end points and overprediction of mortality end point was found in the western population. Conclusion: The COMT diabetes model simulated the long-term patient outcomes observed in eastern Asian T2DM patients with prediction accuracy. This study supports the COMT as a credible tool for Chinese healthcare decision makers. Further work is necessary to incorporate new local data to improve model validity and credibility.

Hyperuricemia is associated with atrial fibrillation prevalence in very elderly - a community based study in Chengdu, China

Hyperuricemia is a risk factor for cardiovascular diseases. However, in very elderly, the relationship between hyperuricemia and the prevalence of atrial fibrillation (AF) is not clear. This study aimed to investigate hyperuricemia and the risk of AF in community very elderly. In this cross-sectional study, 1056 very elderly in community were enrolled. Serum uric acid (SUA) were measured and rest 12-lead electrocardiogram was performed. Multiple logistic regression models were used to explore risk factors for AF in very elderly. Finally, 1038 participants were included in analysis and the mean age of the study participants were 83.6 ± 3.4 years (age range 80–100 years). The mean SUA level was 350.1 ± 84.5 µmol/L. The estimated prevalence of AF was 5.3%, and there was no significant sex difference (5.8% for men and 4.8% for women, p = 0.401). Multiple logistic regression found that participants with hyperuricemia (SUA >416 µmol/L in men and >357 µmol/L in women) had a higher risk (odds ratio: 2.080, 95% confidence interval: 1.103–4.202, P = 0.007) of suffering AF in very elderly Chinese. In conclusion, AF is relatively frequent in this community very elderly Chinese in Chengdu. Hyperuricemia is associated with the prevalence of AF in general very elderly.

A Machine Learning Aided Systematic Review and Meta-Analysis of the Relative Risk of Atrial Fibrillation in Patients With Diabetes Mellitus

Background: Meta-analysis is a widely used tool in which weighted information from multiple similar studies is aggregated to increase statistical power. However, the exponential growth of publications in key areas of medical science has rendered manual identification of relevant studies increasingly time-consuming. The aim of this work was to develop a machine learning technique capable of robust automatic study selection for meta-analysis. We have validated this approach with an up-to-date meta-analysis to investigate the association between diabetes mellitus (DM) and new-onset atrial fibrillation (AF). Methods: The PubMed online database was searched from 1960 to September 2017 where 4,177 publications that mentioned both DM and AF were identified. Relevant studies were selected as follows. First, publications were clustered based on common text features using an unsupervised K-means algorithm. Clusters that best matched the selected set of potentially relevant studies (a "training" set of 139 articles) were then identified by using maximum entropy classification. The 139 articles selected automatically on this basis were screened manually to identify potentially relevant studies. To determine the validity of the automated process, a parallel set of studies was also assembled by manually screening all initially searched publications. Finally, detailed manual selection was performed on the full texts of the studies in both sets using standard criteria. Quality assessment, meta-regression random-effects models, sensitivity analysis and publication bias assessment were then conducted. Results: Machine learning-assisted screening identified the same 29 studies for meta-analysis as those identified by using manual screening alone. Machine learning enabled more robust and efficient study selection, reducing the number of studies needed for manual screening from 4,177 to 556 articles. A pooled analysis using the most conservative estimates indicated that patients with DM had ~49% greater risk of developing AF compared with individuals without DM. After adjusting for three additional risk factors i.e., hypertension, obesity and heart disease, the relative risk was 23%. Using multivariate adjusted models, the risk for developing AF in patients with DM was similar for all DM subtypes. Women with DM were 24% more likely to develop AF than men with DM. The risk for new-onset AF in patients with DM has also increased over the years. Conclusions: We have developed a novel machine learning method to identify publications suitable for inclusion in meta-analysis.This approach has the capacity to provide for a more efficient and more objective study selection process for future such studies. We have used it to demonstrate that DM is a strong, independent risk factor for AF, particularly for women.

Accuracy of cardiac CT in evaluating severity of left atrial appendage spontaneous echo contrast: comparison with transesophageal echocardiography

To investigate the capacity of biphasic cardiac CT (CCT) for qualitative and quantitative evaluation of different grades of left atrial appendage spontaneous echo contrast (LAASEC). The study included 267 inpatients with confirmed atrial fibrillation who underwent both CCT and transesophageal echocardiography (TEE). CT numbers for LAA, ascending aorta (AA), and left atrium (LA) were identified, and ROC curves for LAA, LAA/AA, and LAA/LA were plotted. With TEE as the standard, the sensitivity, specificity, PPV, NPV, and accuracy of CCT for LAASEC grade ≥ 1 were 60.3, 92.9, 92.4, 64.8, and 75.7%; and for grade ≥ 2 were 100.0, 84.4, 71.4, 100.0, and 88.8% respectively. The values of LAA, LAA/AA, and LAA/LA were significantly larger in LAASEC grade 0 versus 1 and in grade 1 versus 2, but were similar in grades 2 and 3 or in grades 3 and 4. The values of LAA/AA were larger in grade 2 versus 4. When the cutoff value for LAA/AA = 0.897, sensitivity, specificity, PPV, NPV, and accuracy of CCT for LAASEC grade ≥ 1 was 89.6, 83.2, 87.9, 85.5, and 86.9% and with a cutoff for LAA/AA of 0.524, the sensitivity, specificity, PPV, NPV, and accuracy for LAASEC grade ≥ 2 was 98.7, 92.7, 84.1, 99.4, and 94.4%. Although CCT showed limited diagnostic accuracy for grade 1 LAASEC, grade ≥ 2 LAASEC could be excluded when there was no LAA filling defect on first-phase CCT, and TEE can be avoided. CCT has an excellent accuracy in diagnosing LAASEC, and quantitative analysis (in particular LAA/AA) is superior.

Data on prevalence of atrial fibrillation and its association with stroke in low-, middle-, and high-income regions of China

Data presented in this article are supplementary material to our research article entitled " Prevalence of Atrial Fibrillation in Different Socioeconomic Regions of China and Its Association with Stroke: Results from a National Stroke Screening Survey" (Wang et al., 2018) [1]. This data article summarizes previous studies of Atrial Fibrillation (AF) prevalence in China, and estimates the association between AF and stroke in different socioeconomic regions of China through a national survey.

Prevalence of high bloodpressure, hyperglycemia, dyslipidemia, metabolic syndrome and their determinants in Ethiopia: Evidences from the National NCDs STEPS Survey, 2015

The prevalence of diabetes, dyslipidemias, and high blood pressure is increasing worldwide especially in low and middle income countries. World Health Organization has emphasized the importance of the assessment of the magnitude of the specific disease in each country. We determined the prevalence and determinant factors of high blood pressure, hyperglycemia, dyslipidemias and metabolic syndrome in Ethiopia. A community based survey was conducted from -April to June 2015 using WHO NCD STEPS instrument version 3.1. 2008. Multistage stratified systemic random sampling was used to select representative samples from 9 regions of the country. A total of 10,260 people aged 15–69 years participated in the study. Blood pressure (BP) was measured for 9788 individuals. A total of 9141 people underwent metabolic screening. The prevalence of raised blood pressure (SBP ≥140 and/or DBP ≥ 90 mmHg) was 15.8% (16.3% in females and 15.5% in males). The prevalence of diabetes mellitus (FBS ≥ 126 mg /dl) including those on medication was 3.2% (3.5% males and 3.0% females). The prevalence of impaired fasting glucose was 9.1% with ADA criteria and 3.8% with WHO criteria. Hypercholesterolemia was found in 5.2%, hypertriglyceridemia in 21.0%, high LDL cholesterol occurred in 14.1% and low HDL cholesterol occurred in 68.7%. The prevalence of metabolic syndrome using IDF definition was 4.8% (8.6% in females and vs. 1.8% in males). Advanced age, urban residence, lack of physical exercise, raised waist circumference, raised waist hip ratio, overweight or obesity, and total blood cholesterol were significantly associated with raised blood pressure (BP) and diabetes mellitus. Increased waist- hip ratio was an independent predictor of raised blood pressure, hyperglycemia and raised total cholesterol. Our study showed significantly high prevalence of raised blood pressure, hyperglycemia and dyslipidemia in Ethiopia. Community based interventions are recommended to control these risk factors.

Survey of Antithrombotic Treatment in Rural Patients (>60 years) with Atrial Fibrillation in East China

The prevalence and antithrombotic treatment of atrial fibrillation (AF) in Chinese rural population is not well known. The aim of this study was to investigate the extent to which antithrombotic treatment was prescribed for rural AF patients >60 years. We identified 828 AF patients from 36734 rural residents >60 years in Shanghai China. Our data indicated the overall prevalence rate of AF was 2.3% in rural population >60 years in East China and 38.9% of AF patients underwent antithrombotic therapy, including warfarin (5.9%), aspirin (29.6%), clopidogrel (2.9%) and aspirin combined with clopidogrel (0.5%). Of enrolled subjects, 98.4% had CHA₂DS₂-VASc score ≥1, 72.0% had HAS-BLED score <3 and 59.2% had CHA₂DS₂-VASc score ≥2 with HAS-BLED score <3. Missing early detection (34.9%), delay in seeking treatment for asymptomatic AF (25.5%) and doctors’s incomplete inform of AF-related risk of stroke to patients (21.7%) were three dominant causes for failing anticoagulant usage. In conclusion, most AF patients were with a high risk of thrombosis and a low risk of bleeding in China, but a large majority of them failed to take anticoagulants mainly for missing an early screening of AF and lack of awareness on AF for both patients and primary care physicians.

Physical activity volume in relation to risk of atrial fibrillation. A non-linear meta-regression analysis

Background Light physical activity is known to reduce atrial fibrillation risk, whereas moderate to vigorous physical activity may result in an increased risk. However, the question of what volume of physical activity can be considered beneficial remains poorly understood. The scope of the present work was to examine the relation between physical activity volume and atrial fibrillation risk. Design A comprehensive systematic review was performed following the PRISMA guidelines. Methods A non-linear meta-regression considering the amount of energy spent in physical activity was carried out. The first derivative of the non-linear relation between physical activity and atrial fibrillation risk was evaluated to determine the volume of physical activity that carried the minimum atrial fibrillation risk. Results The dose-response analysis of the relation between physical activity and atrial fibrillation risk showed that physical activity at volumes of 5-20 metabolic equivalents per week (MET-h/week) was associated with significant reduction in atrial fibrillation risk (relative risk for 19 MET-h/week = 0.92 (0.87, 0.98). By comparison, physical activity volumes exceeding 20 MET-h/week were unrelated to atrial fibrillation risk (relative risk for 21 MET-h/week = 0.95 (0.88, 1.02). Conclusion These data show a J-shaped relation between physical activity volume and atrial fibrillation risk. Physical activity at volumes of up to 20 MET-h/week is associated with reduced atrial fibrillation risk, whereas volumes exceeding 20 MET-h/week show no relation with risk.

Low prevalence of atrial fibrillation in Amerindians: a population-based study in frequent fish consumers living in rural coastal Ecuador (The Atahualpa Project)

BACKGROUND

Information on the burden of atrial fibrillation (AF) in rural areas of developing countries is limited. Here, we aimed to assess AF prevalence in community-dwelling older adults living in rural Ecuador.

METHODS

Atahualpa residents aged ≥60 years (mean age 70.5 ± 8.1 years) underwent 24-h Holter monitoring. Participants belong to the Amerindian ethnic group. The mean height in the study population was 147.9 ± 8.9 cm. Oily fish was a major source of food (mean intake: 8 ± 4 servings/week).

RESULTS

Seven of 298 participants (2.3%) had AF. Persons with AF were older than those without (p = 0.051), but there were no differences in cardiovascular risk factors across groups. None of the seven AF cases had been detected in routine 12-lead ECGs taken at enrollment.

CONCLUSIONS

Prevalence of AF in older Amerindians living in rural Ecuador is low. Both, racially-determined short stature and frequent dietary oily fish intake might explain the low prevalence of AF in this rural setting.

Contribution of non-traditional lipid profiles to reduced glomerular filtration rate in H-type hypertension population of rural China

BACKGROUND

Despite current interest in the unfavourable impact of non-traditional lipid profiles on cardiovascular disease, information regarding its relations to reduced glomerular filtration rate (GFR) in H-type hypertension population has not been systemically elucidated.

METHODS

Analyses were based upon a cross-sectional study of 3259 participants with H-type hypertension who underwent assessment of biochemical, anthropometric and blood pressure values. Reduced GFR was considered if meeting estimated GFR <60 ml/min/1.73 m².

RESULTS

A stepwise multivariate regression analysis indicated that non-traditional lipid parameters remained as independent determinants of estimated GFR (all p < .001). In multivariable models, we observed a 50%, 51%, 31%, and 24% higher risk for decreased GFR with each SD increment in TC/HDL-C, TG/HDL-C, LDL-C/HDL-C ratios and non-HDL-C levels, respectively. The highest quartile of TC/HDL-C, TG/HDL-C and LDL-C/HDL-C ratios carried reduced GFR odds (confidence intervals) of 5.50 (2.50 to 12.09), 6.63 (2.58 to 17.05) and 2.22 (1.15 to 4.29), respectively.

CONCLUSIONS

The relative independent contribution of non-traditional lipid profiles, as indexed by TC/HDL-C, TG/HDL-C, LDL-C/HDL-C ratios and non-HDL-C, towards reduced GFR putting research evidence at the very heart of lipoprotein-mediated renal injury set a vital example for applying a clinical and public health recommendation for reducing the burden of chronic kidney disease. KEY MESSAGES Non-traditional lipid profiles has been linked with the occurrence of cardiovascular disease, but none of the studies that address the effect of non-traditional lipid profiles on reduced GFR risk in H-type hypertension population has been specifically established. A greater emphasis of this study resided in the intrinsic value of TC/HDL-C, TG/HDL-C, LDL-C/HDL-C ratios and non-HDL-C that integrate atherogenic and anti-atherogenic lipid molecules to predict the risk of reduced GFR among H-type hypertension population and provide insight into the pathophysiology of subsequent cardio-cerebrovascular outcomes. In a large Chinese H-type hypertension adults, the relative independent contribution of non-traditional lipid profiles, as indexed by TC/HDL-C, TG/HDL-C, LDL-C/HDL-C ratios and non-HDL-C, towards reduced GFR putting research evidence at the very heart of lipoprotein-mediated renal injury set a vital example for applying a clinical and public health recommendation for reducing the burden of CKD.

Matrine reduces susceptibility to postinfarct atrial fibrillation in rats due to antifibrotic properties

This study aimed to investigate whether matrine could prevent atrial fibrillation (AF) after myocardial infarction by reducing left atrial fibrosis, and to determine the underlying mechanisms in isolated cardiac fibroblasts (CFs). Five weeks after MI, matrine-treated rats had lower rates of AF inducibility and shorter AF duration than MI rats. Matrine improved the left atrial conduction velocity and homogeneity. Matrine decreased the fibrosis positive areas and the protein levels of type I collagen and type III collagen in the left atrium. Matrine inhibited CFs differentiation to myofibroblasts and the expression of transforming growth factor-beta 1 and matrix metalloproteinase 9. In vitro, matrine inhibited the CFs proliferation, migration, differentiation, and secretion ability. These in vitro and in vivo data demonstrated that matrine has the potential to reduce susceptibility to AF after MI due, at least in part, to reduced atrial fibrosis via inhibiting CFs proliferation, migration, differentiation, and secretion ability.

Effectiveness and safety of oral anticoagulants in older patients with atrial fibrillation: a systematic review and meta-regression analysis

Background and objective

the study analysed the effectiveness and safety of warfarin use compared with warfarin non-use and non-vitamin K antagonist oral anticoagulants (NOACs) in atrial fibrillation (AF) patients aged ≥65 years.

Methods

after searching PubMed and the Cochrane Library, 26 studies were included, with 10 comparing warfarin with warfarin non-use and 16 comparing warfarin with NOACs, in older AF patients (≥65 years).

Results

warfarin use was superior to no antithrombotic therapy [relative risk (RR) 0.59, 95% confidence interval (CI) 0.51-0.76, I2 = 12.3%, n = 8] and aspirin (RR 0.44, 95% CI 0.24-0.64, I2 = 0.0%, n = 5) for stroke/thromboembolism (TE) prevention. Warfarin use was associated with a non-significant increase in risk of major bleeding compared with no antithrombotic therapy (RR 1.26, 95% CI 0.99-1.52, I2 = 0.0%, n = 7) and aspirin (RR 1.20, 95% CI 0.91-1.50, I2 = 0.0%, n = 5). NOACs were superior to warfarin for stroke/TE prevention [hazard ratio (HR) 0.81, 95% CI 0.73-0.89, I2 = 56.6%, n = 9], and also were associated with reduced risk of major bleeding compared to warfarin (HR 0.87, 0.77-0.97, I2 = 86.1%, n = 9).

Conclusions

warfarin use was superior to warfarin non-use, aspirin and no antithrombotic therapy in reducing the risk of stroke/TE in older AF patients, but with a possible increase in major bleeding. NOACs were superior to warfarin for stroke/TE prevention, with reduced risk of major bleeding.

Review of screening studies for atrial fibrillation in rural populations of 11 countries

Atrial fibrillation (AF) is a common cardiac arrhythmia, and pathological burden can be influenced by environmental factors. The rural environment may influence the burden of AF, although no systematic review studies have been conducted to address this issue. We performed a systematic review of AF screening studies conducted in rural global populations to determine the burden, risk factors, and screening methods surrounding AF in these settings. Out of the 1792 articles gathered from a keyword search of medical databases and reference lists, 18 publications from 11 countries were included in our analysis. The pooled prevalence of AF across the studies was 2.05% (95% confidence interval, 1.97%-2.13%) and ranged from 0.3% to 10.87%. Only one study utilized a handheld electrocardiogram to screen AF, while the rest used the 12-lead electrocardiogram. AF risk factors reported across studies varied and included increasing age, male gender, hypertension, diabetes, prior myocardial infarction or stroke, obesity, hyperlipidemia/hypercholesterolemia, alcohol consumption, and heart failure. However, none of the studies assessed all risk factors. We suggest that future research on AF in rural communities examine a complete checklist of AF risk factors to better understand their influence on AF burden and development. This will aid in understanding rural prevention strategies and the management of detected AF cases specific to rural areas. At present, the burden of AF in rural communities is poorly understood and has been underreported.

Plasma homocysteine levels associated with a corrected QT interval

BACKGROUND

Little is known about the relationship between homocysteine (Hcy) levels and the QT interval. We examined the association of different Hcy levels with corrected QT (QTc) intervals in a general population.

METHODS

Plasma levels of Hcy were assessed in a population-based study of 7002 participants 35 years of age and older from 2012 to 2013. Twelve-lead ECGs were performed on all participants and analyzed automatically.

RESULTS

The distribution of Hcy levels was determined for an entire population after the data were grouped into quartiles (Q1: <=11.1umol/L; Q2: 11.1-13.8umol/L; Q3: 13.8-18.2 umol/L; Q4 > 18.2 umol/L). The mean value of the QTc interval in each quartile was 433.2 ± 23.8 ms, 430.0 ± 24.6 ms, 429.2 ± 24.5 ms and 430.6 ± 25.7 ms. Multiple logistic regression analyses showed that, compared with the second quartile, and after fully adjusting for potential confounding factors, the odds for QTc > 440 ms in the first and fourth quartile increased (P < 0.05), (OR: 1.23, 95% CI: 1.05-1.43 for Q1; OR: 1.40, 95% CI: 1.19-1.65 for Q4).

CONCLUSIONS

QTc interval was associated with the Hcy level in this general population.

Sex Differences in Outcomes among Stroke Survivors with Non-Valvular Atrial Fibrillation in China

Atrial fibrillation (AF) significantly increases the risk of stroke and disease burden and is an established predictor of poor outcomes after stroke. However, data regarding sex differences in long-term outcomes following stroke in patients with AF are scarce. We thus aimed to assess these differences. We recruited 951 consecutive patients with acute ischemic stroke and non-valvular atrial fibrillation (NVAF) treated at three hospitals in Tianjin, China, from January 2006 to September 2014. Information regarding stroke subtype, severity, risk factors, and outcomes (mortality, dependency, and recurrence) at 3, 12, and 36 months after stroke was recorded. The prevalence of NVAF was 8.4% overall, with a higher frequency in women than in men (11.3 vs. 6.9%, P < 0.001). Among patients with NVAF, women were older than men. Women were more likely than men to have severe stroke (38.8 vs. 29.5%, P < 0.001), high levels of total cholesterol and high- and low-density lipoprotein cholesterol (all P < 0.001), hypertension (69.1 vs. 61.2%, P = 0.012), dyslipidemia (29.8 vs. 20.7%, P = 0.001), and obesity (18.5 vs. 11.6%, P = 0.003); they were less likely than men to be current smokers (12.2 vs. 33.6%, P < 0.001) and to consume alcohol (0.9 vs. 13.9%, P < 0.001). There were greater risks of dependency and recurrence at 36 months after stroke in women than in men [odds ratios (95% confidence intervals), 1.64 (1.02–2.64) for dependency, P = 0.043; and 2.03 (1.28–3.20) for recurrence, P = 0.002] after adjustment for stroke subtype, severity, and risk factors. These findings suggest that it is crucial to emphasize the need for individualized stroke prevention education and promotion of healthy lifestyles in order to improve NVAF-related stroke outcomes and reduce disease burden in women.

The Global Burden of Atrial Fibrillation and Stroke: A Systematic Review of the Clinical Epidemiology of Atrial Fibrillation in Asia

BACKGROUND

Our previous review reported great variability in the incidence and prevalence of atrial fibrillation (AF) in non-Western cohorts, especially from Asian countries; in recent years, epidemiologic studies on AF have been increasingly reported from Asia.

METHODS

The goal of this updated systematic review was to present the current knowledge base of AF epidemiology in Asian countries since our previous review. We also explored AF incidence and the risk of stroke in AF by using a meta-analysis, with I² testing the heterogeneity. Third, "real-world" antithrombotic drug use for ischemic stroke (IS) prevention associated with AF was studied.

RESULTS

A total of 58 articles from eight countries in Asia were included in the analysis. The summary annual incidence of AF was 5.38 (95% CI, 4.53-6.24; I² = 99.5%; n = 10) per 1,000 person-years, and the IS annual risk in AF was 3.0% (1.60%-4.95%; I² = 99.8%; n = 8) when meta-analysis was performed on hospital- and community-based studies. Hospital- and community-based AF prevalence ranged from 0.37% to 3.56% and 2.8% to 15.8%, respectively. IS prevalence in AF ranged from 1.9% to 6.0% and 0.36% to 28.3% in community- and hospital-based studies. Warfarin use in Chinese subjects is relatively low (1.0%-4.1%) compared with Japanese subjects (49.1%-70.0%) in community-based studies. The rate of warfarin use was < 50% in hospital-based studies.

CONCLUSIONS

The incidence and prevalence of AF have increased in recent years, although great variability still exists in Asian countries. Variability in annual IS risk in patients with AF was apparent between hospital- and community-based studies. However, the rate of warfarin use was < 50% in hospital studies from Asian countries.