Time trends in atrial fibrillation-related stroke during 2001–2020 in Sweden: a nationwide, observational study

Contemporary trends in incident ischaemic stroke, intracranial haemorrhage, and mortality in individuals with atrial fibrillation

BACKGROUND

The prognosis for atrial fibrillation (AF) patients is based on data that is decades old. Given evolving standards of clinical practice, we sought to evaluate temporal trends in clinically important outcomes among patients with AF.

METHODS AND RESULTS

California's Department of Health Care Access and Information databases were used to identify adults aged ≥18 years with AF receiving hospital-based care in California. We compared three time-periods: 2005-2009, 2010-2014, and 2015-2019. International Classification of Diseases codes were used to identify chronic diseases and acute events. The outcomes were incident ischaemic stroke, intracranial haemorrhage, and overall mortality. We included 2 009 832 patients with AF (52.7% males, 70.7% Whites, and mean age of 75.0 years), divided in three cohorts: 2005-2009 (n = 738 954), 2010-2014 (n = 609 447), and 2015-2019 (n = 661 431). Each outcome became substantially less common with time: compared with 2005-2009, AF patients diagnosed in 2015-2019 experienced a 34% (adjusted hazard ratio [HR] 0.66, 95% confidence interval 0.64-0.69), 22% (HR 0.78, 0.75-0.82), and 24% (HR 0.76, 0.75-0.77) reduction in risk of incident ischaemic stroke, intracranial haemorrhage, and mortality, respectively. Between 2005-2009 and 2015-2019, patients aged ≥65 years experienced more reductions in each outcome compared with younger patients (P < 0.001 for all), and declines in each outcome were significantly lower for Hispanics and Blacks compared with white patients.

CONCLUSION

The risks of stroke, intracranial haemorrhage, and death have significantly declined among AF patients, although differences in the magnitude of improvement of these outcomes by demographic groups were observed. Commonly described estimates of the prognosis for AF patients should be updated to reflect contemporary care.

Predicting Atrial Fibrillation After Stroke by Combining Polygenic Risk Scores and Clinical Features

BACKGROUND

Because treatment with anticoagulants can prevent recurrent strokes, identification of patients at risk for incident atrial fibrillation (AF) after stroke is crucial. We aimed to investigate whether the addition of AF polygenic risk scores (PRSs) to existing clinical risk predictors could improve prediction of AF after stroke.

METHODS

Patients diagnosed with ischemic stroke at the Massachusetts General Hospital between 2003 and 2017 were included. Clinical AF risk was estimated using the Recalibrated Cohorts for Heart and Aging Research in Genomic Epidemiology Atrial Fibrillation model, and genetic risk was estimated using a contemporary AF PRS from 1 093 050 variants. Patients were divided into clinical and genetic risk tertiles. Cox proportional hazards models at different follow-up windows were fit, and C indices and percentile-based net reclassification index were used to determine the improvement of clinical risk models with the addition of AF PRS.

RESULTS

Of 1004 stroke survivors, 900 (90%) were non-Hispanic White, 413 (41%) were female, and the mean age was 67 (SD, 14) years. Of 1004 survivors, 239 (23.8%) had prevalent AF and 87 of 765 (11.4%) remaining patients developed incident AF during 5 years of follow-up. AF PRS was associated with greater risk of incident AF after stroke (hazard ratio, 1.21 [95% CI, 0.97-1.50] per 1-SD increase), although the association was not statistically significant. PRS improved discrimination in the first month (area under the curve, 0.78 [95% CI, 0.70-0.82] versus 0.71 [95% CI, 0.60-0.82]; P=0.05), with more modest estimates across longer time windows.

CONCLUSIONS

Addition of an AF PRS to clinical risk models may improve identification of individuals at risk of AF after stroke, particularly within the first month.

Prevalence of large vessel occlusions in an unselected hospital-based stroke cohort in Sweden

Introduction

Determining the prevalence of large vessel occlusions (LVOs) is important for planning and accessing mechanical thrombectomy treatment. Previous estimates vary greatly in studies, which might be related to different inclusion criteria and/or selection bias. In this cohort study, we aimed to determine the presence of LVO in an unselected, i.e., untriaged, hospital-based stroke cohort in Sweden.

Methods

Stroke patients treated at Karolinska Huddinge University Hospital were consecutively collected during the years 2008 through 2015, identified by an ICD-10 diagnosis of ischemic stroke (I63). Patients with LVO were selected through radiology reports indicating LVO.

Results

A total of 3,152 consecutive patient events had received a diagnosis of ischemic stroke during the study period. A total of 356 occlusion events were found in the internal carotid artery, the first two segments of the middle cerebral artery (M1, M2), and anterior cerebral artery (A1, A2), the vertebral artery, basilar artery and the first two segments of the posterior cerebral artery (P1, P2). This resulted in an LVO prevalence of 11.3% in this cohort. Seventy-six percent of occlusions were located in the anterior circulation, and 24% in the posterior circulation. The most frequent occluded vessel was M1 (n = 166, 39%).

Conclusion

In this study of consecutively collected stroke patients the prevalence of LVO was lower compared to other studies, possibly related to our unselected patient cohort, limited use of CT angiography, and/or the LVO definition used. These results are of importance for decision-making regarding the capacity of comprehensive stroke centers.

Early statin use is associated with improved survival and cardiovascular outcomes in patients with atrial fibrillation and recent ischaemic stroke: A propensity-matched analysis of a global federated health database

INTRODUCTION

Statins reduce recurrent stroke and cardiovascular events in patients with non-cardioembolic stroke. The benefits of statins in patients with AF and recent IS remain unclear. We aimed to investigate the benefits of statins in patients with AF and recent IS.

PATIENTS AND METHODS

This retrospective, cohort study was conducted using deidentified electronic medical records within TriNetX platform. Patients with AF and recent IS, who received statins within 28 days of their index stroke were propensity score-matched with those who did not. Patients were followed up for up to 2 years. Primary outcomes were the 2-year risk of recurrent IS, all-cause mortality and the composite outcome of all-cause mortality, recurrent IS, transient ischaemic attack (TIA), and acute myocardial infarction (MI). Secondary outcomes were the 2-year risk of TIA, intracranial haemorrhage (ICH), acute MI, and hospital readmission. Cox regression analyses were used to calculate hazard ratios (HRs) with 95% confidence intervals (95%CI).

RESULTS

Of 20,902 patients with AF and recent IS, 7500 (35.9%) received statins within 28 days of their stroke and 13,402 (64.1%) did not. 11,182 patients (mean age 73.7 ± 11.5; 5277 (47.2%) female) remained after propensity score matching. Patients who received early statins had significantly lower risk of recurrent IS (HR: 0.45, 95%CI: 0.41-0.48, p < 0.001), mortality (HR: 0.75, 95%CI: 0.66-0.84, p < 0.001), the composite outcome (HR: 0.48, 95%CI: 0.45-0.52, p < 0.001), TIA (HR: 0.37, 95%CI: 0.30-0.44, p < 0.001), ICH (HR: 0.59, 95%CI: 0.47-0.72, p < 0.001 ), acute MI (HR: 0.35, 95%CI: 0.30-0.42, p < 0.001) and hospital readmission (HR: 0.46, 95%CI: 0.42-0.50, <0.001). Beneficial effects of early statins were evident in the elderly, different ethnic groups, statin dose intensity, and AF subtypes, large vessel occlusion and embolic strokes and within the context of statin lipophilicity, optimal LDL-cholesterol levels, various cardiovascular comorbidities, treatment with intravenous thrombolysis or endovascular thrombectomy, and NIHSS 0-5 and NIHSS > 5 subgroups.

DISCUSSION AND CONCLUSION

Patients with AF and recent IS, who received early statins, had a lower risk of recurrent stroke, death, and other cardiovascular outcomes including ICH, compared to those who did not.

National Trends in Mortality Due to Ischemic Stroke Among Older Adults With Atrial Fibrillation in the USA, 1999-2020

BACKGROUND

Atrial fibrillation (AF) is a significant contributor to ischemic stroke risk and mortality, particularly in aging populations. This study examines mortality trends from ischemic stroke secondary to AF in the U.S. from 1999 to 2020, focusing on demographic and regional disparities.

METHODS

Using data from the CDC WONDER database, this cross-sectional analysis included individuals aged ≥ 65 years with death certificates indicating ischemic stroke (ICD I63) and AF (ICD I48) as contributing causes. Age-adjusted mortality rates (AAMR) were calculated, and temporal trends were analyzed using join-point regression to estimate annual percentage changes (APC). Data were stratified by age, sex, race/ethnicity, urbanization, and geographic regions.

RESULTS

From 1999 to 2020, ischemic stroke with AF caused 62,443 deaths (AAMR: 6.75/100,000; 95% CI: 6.70-6.80). Mortality rates increased significantly after 2010, peaking between 2014 and 2017 (APC: 31.3 for females, 28.1 for males). Older adults (≥ 85 years) exhibited the highest AAMR (43.2/100,000; 95% CI: 41.6-44.8). Nonmetropolitan areas consistently showed higher mortality compared to metropolitan regions. Demographic disparities were evident, with higher AAMRs in females, Whites, and the Western U.S., though Hispanics had the sharpest APC increase during 2014-2017.

CONCLUSION

Mortality rates from ischemic stroke with AF are rising in older adults, with significant demographic and regional disparities. The findings underscore the need for targeted public health strategies to mitigate AF-related stroke risks and improve healthcare equity.

Temporal Trends of Ischemic Stroke Risk in Patients With Incident Atrial Fibrillation Before Anticoagulation

BACKGROUND

Atrial fibrillation (AF) is a major risk factor for ischemic stroke (IS), but whether the magnitude of this risk has changed over time is unknown.

OBJECTIVES

This study sought to investigate temporal trends in IS rates in patients with incident AF before oral anticoagulant agent (OAC) therapy.

METHODS

The nationwide FinACAF (Finnish Anticoagulation in Atrial Fibrillation) study covers patients with AF at all levels of care in Finland from 2007 to 2018. A 4-week quarantine period from AF diagnosis was applied, and only follow-up time without OAC therapy was included. Incidence rates of IS were computed in 4-year intervals in relation to sex and non-sex CHA2DS2-VASc (ie, CHA2DS2-VA) score values.

RESULTS

In total, 129,789 patients with new-onset AF were identified (49.2% women; mean age: 71.4 ± 14.5 years). Between the calendar year intervals of 2007-2010 and 2015-2018, the patients' mean CHA2DS2-VA score increased from 2.5 to 3.0, and concurrently the overall IS rate decreased by 25% from 36.7 to 27.6 events per 1,000 patient-years. This trend was driven by a 32% decrease of IS rate in women, particularly among those with higher age and CHA2DS2-VA scores. The IS rate in patients with a CHA2DS2-VA score of 1 was 8.2 events per 1,000 patient-years and remained stable across the study period.

CONCLUSIONS

The initial IS risk in AF patients, before the initiation of OAC therapy, has decreased by 25% between 2007 and 2018 despite an increase in both age and stroke risk scores. The decrease has been most pronounced in older women with high stroke risk scores.

Forecasting stroke and stroke-driven dementia in a rapidly ageing population: a model-based analysis of alternative projection scenarios for Ireland

OBJECTIVE

Understanding future population needs is key for informing stroke service planning. This study aims to evaluate scenarios for future trends in stroke age-specific incidence and case fatality, and estimate their impact on projected stroke and poststroke dementia prevalence in Ireland.

DESIGN

This is an epidemiological modelling study based on a probabilistic Markov model. We extrapolated trends in age-specific stroke incidence and case fatality from 1990 to 2019 and applied these to 2016 to 2046. We defined trend scenarios based on stability and low and high decline, broadly based on the lower and upper bounds of evidence for trends to date. We also examined nonlinear trends involving decelerating decline over time and varying trends by age.

SETTING/PARTICIPANTS

The study is conducted on the Irish population aged 40-89 years in the period 2022-2046. We used multiple data sources, including systematic review and observational evidence.

INTERVENTIONS

Not applicable.

PRIMARY AND SECONDARY OUTCOME MEASURES

We projected the incidence and prevalence of stroke (International Classification of Disease (ICD) codes I60-I61, I63-I64), poststroke dementia (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria) and poststroke disability (modified Rankin Scale 3-5).

RESULTS

The stable scenario indicated a projected 85 834 stroke survivors in 2046 (95% uncertainty interval (UI)=82 366-89 655), an increase of 45.7% from 2022. Assuming a high incidence decline and low case-fatality decline indicated a 5.4% increase in prevalence. Intermediate scenarios based on lower rates of decline, or decline rates slowing over time, implied an increase between 25.8% and 40.3%. Results did not differ substantially when we varied trends by age.In the stable scenario, we projected 16 978 poststroke dementia prevalent cases in 2046 (95% UI 14 958-19 157), an increase of 58.9% from 2022. In the high decline scenario, the increase would be 24.5%, with intermediate scenarios implying an increase between 41.3% and 56.3%.

CONCLUSIONS

Future stroke healthcare needs will vary substantially depending on epidemiological trends. There is an urgent need to both invest in prevention strategies and plan for likely increases in future stroke care needs.

Patterns of pharmacological treatment in patients with atrial fibrillation: an analysis from the prospective GLORIA-AF Registry Phase III

BACKGROUND

Polypharmacy (i.e., treatment with ≥ 5 drugs) is common in patients with atrial fibrillation (AF) and has been associated with suboptimal management and worse outcomes. Little is known about how prescribed drug patterns affect management and prognosis in patients with AF.

METHODS

Based on data from the prospective global GLORIA-AF Registry Phase III (recruiting patients with AF and CHA2DS2-VASc score ≥ 1), we performed a latent class analysis to identify treatment patterns based on 14 drug classes including cardiovascular (CV) and non-CV drugs. We analysed associations with oral anticoagulant (OAC) use and risk of a composite primary outcome (all-cause death and major adverse cardiovascular events (MACE)) and secondary outcomes.

RESULTS

Among 21,245 patients (mean age 70.2 ± 10.3 years, 44.9% females), we identified 6 patterns: i) Low Medicated pattern (18.3%); ii) Hypertension pattern (21.1%); iii) Heart Failure pattern (20.0%); iv) CV Prevention pattern (21.0%); v) Mixed Morbidity pattern (4.5%); and vi) High Medicated pattern (15.0%). All groups had higher odds of OAC use vs the Low Medicated pattern, with highest prevalences in the Heart Failure pattern (OR [95%CI]: 2.17 [1.90-2.48]) and the High Medicated pattern (OR [95%CI]: 2.08 [1.77-2.44]). Over 3-year follow-up, Heart Failure, Mixed Morbidity and High Medicated patterns were associated with higher risk of the primary composite outcome (aHR [95%CI]: 1.32 [1.14-1.53]; 1.45 [1.17-1.80] and 1.35 [1.14-1.60], respectively). Similar results were observed for all-cause mortality.

CONCLUSIONS

In patients with AF, different treatment patterns can be identified. Each pattern was associated with unique OAC use and long-term clinical outcomes.

Number of Previous Strokes and the Association With Clinical Outcomes of Patients With Atrial Fibrillation: Longitudinal Data From the GLORIA-AF Registry

BACKGROUND

Patients with atrial fibrillation (AF) who suffered a previous stroke are at increased risk of recurrent thromboembolic events and other major outcomes. The impact of the number of stroke episodes on the natural history of patients with AF is still unclear.

METHODS AND RESULTS

Using data from the international, multicenter, and prospective GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation) Registry Phase III, we categorized patients with a recent diagnosis of non-valvular AF according to the number of previous strokes (either 0, 1, or ≥2 episodes). We analyzed use of oral anticoagulants through multiple logistic regression model, and risk of major outcomes using multiple Cox-regression models; our primary outcome was all-cause death. Among 21 223 patients (mean age: 70.2±10.3 years; 44.9% female) included, 2251 (10.6%) had a previous history of stroke, and 216 (1.0%) had ≥2 or more strokes. Oral anticoagulants were used in ≥80% of patients regardless of the numbers of previous stroke, although those with 1 (versus >1) prior stroke showed lower odds of receiving oral anticoagulants (odds ratio [95% CI]: 0.83 [0.73-0.94]). During 3-years follow-up, the risk of all-cause mortality increased with the number of previous strokes (hazard ratio [95% CI]: 1.46 [1.28-1.67] and 2.43 [1.79-3.29] for 1 versus 0 and ≥2 versus 0 previous strokes, respectively). Similar results were observed for other secondary outcomes, including thromboembolism, but not for major bleeding.

CONCLUSIONS

History of stroke still represents a key risk factor in patients with AF. Patients who suffered more than 1 episodes of stroke had significantly worse prognosis and further efforts may be required to improve their clinical outcomes.

Temporal Trends in Mortality Related to Stroke and Atrial Fibrillation in the United States: A 21-Year Retrospective Analysis of CDC-WONDER Database

AIMS

Atrial Fibrillation (AF) is one of the most strongly associated risk factors for stroke. Our study aims to analyze changes in mortality from 1999 to 2020 in patients with AF and stroke.

METHODS

Using the Centre for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC-WONDER), we retrospectively analyzed annual age-adjusted mortality rates (AAMR) per million from 1999 to 2020 in stroke patients with AF. Temporal trends were analyzed, and Annual Percentage Change (APC) was calculated using the JoinPoint regression model across variations in demographics (sex, race) and regional subgroups.

RESULTS

Around 490 000 deaths were reported between 1999 and 2020 from stroke and AF across the 25-85+ age group. AAMR initially decreased until 2008 (APC = -0.9), followed by an increase till 2020 (APC = 1.1). Women had a higher AAMR than men throughout the years. Non-Hispanic white patients had a marginally higher AAMR than all other races and ethnicities. The highest AAMR was observed in the western region. States like Vermont, Oregon, Washington, Alaska, Minnesota, and West Virginia were in the top 90th percentile, while Nevada, Louisiana, Florida, New York, New Mexico, and Arizona were in the bottom 10th percentile. Nonmetropolitan areas had consistently higher AAMRs throughout the 2 decades.

CONCLUSION

An overall rise in mortality has been observed in stroke and AF patients, with a greater surge in 2019. The need for healthcare policy changes, especially in areas with high mortality and awareness of healthier lifestyle factors, can be an essential preventative measure to help mitigate growing mortality rates.

Peak left atrial longitudinal strain and incident atrial fibrillation in the general population: a systematic review and meta-analysis

BACKGROUND

Atrial fibrillation (AF) is the commonest supraventricular arrhythmia in adults. Timely AF diagnosis seems to ameliorate patients prognosis.

PURPOSE

To investigate the association between peak left atrial longitudinal strain (PALS) and new onset AF in the general population.

OBJECTIVES

We searched major electronic databases for articles assessing the relationship between PALS and incident AF.

RESULTS

Eight studies (11,145 patients) were analysed. Lower levels of PALS were significantly associated with higher risk of incident AF (HR: 0.95; 95%CI: 0.92-0.97, I2: 83%). According to the diagnostic accuracy meta-analysis, PALS <33.4% presents 64% (95%CI: 46-79%) sensitivity and 69% (95%CI: 63-75%) specificity.

CONCLUSIONS

In a relatively healthy population, lower levels of PALS were significantly associated with incident AF. The overall diagnostic accuracy was moderate. Lower levels of PALS seem to justify an opportunistic - rather than a systematic-screening approach. These findings could allow more efficient utilisation of healthcare resources.

Neurofilament Light Chain and Risk of Stroke in Patients With Atrial Fibrillation

BACKGROUND

Biomarkers reflecting brain injury are not routinely used in risk assessment of stroke in atrial fibrillation (AF). Neurofilament light chain (NFL) is a novel biomarker released into blood after cerebral insults. We investigated the association between plasma concentrations of NFL, other biomarkers, and risk of stroke and death in patients with AF not receiving oral anticoagulation.

METHODS

For this observational study, baseline plasma samples were available from 3077 patients with AF randomized to aspirin in ACTIVE A (Atrial Fibrillation Clopidogrel Trial With Irbesartan for Prevention of Vascular Events; 2003 to 2008) and AVERROES (Apixaban Versus Acetylsalicylic Acid [ASA] to Prevent Stroke in Atrial Fibrillation Patients Who Have Failed or Are Unsuitable for Vitamin K Antagonist Treatment; 2007 to 2009). Median follow-up was 1.5 years. NFL was analyzed with a Single Molecule Array (Simoa). Associations with outcomes (total stroke or systemic embolism, ischemic stroke, cardiovascular death, and all-cause death) were explored with Cox regression models.

RESULTS

In the combined cohort, the median NFL level was 16.9 ng/L (interquartile range, 11.1-26.5 ng/L), the median age was 71 years, 58% were men, and 13% had a history of previous stroke. NFL was associated with older age, higher creatinine, lower body mass index, previous stroke, female sex, and diabetes but not cardiac rhythm. Higher NFL was associated with a higher risk of stroke or systemic embolism (n=206) independently of clinical characteristics (hazard ratio, 1.27 [95% CI, 1.10-1.46] per doubling of NFL) and other biomarkers (hazard ratio, 1.18 [95% CI, 1.01-1.37]) and including in patients without previous stroke (hazard ratio, 1.23 [95% CI, 1.02-1.48]). NFL was also independently associated with cardiovascular (n=219) and all-cause (n=311) death. The C index for stroke using only NFL was 0.642, on par with the currently used clinical risk scores. Addition of information on NFL improved discrimination in a model also including clinical information, NT-proBNP (N-terminal pro-B-type natriuretic peptide), and high-sensitivity cardiac troponin T, yielding a C index of 0.727.

CONCLUSIONS

NFL reflects overt and covert episodes of cerebral ischemia and improves risk assessment of stroke and death in patients with AF without oral anticoagulation, including in patients without previous stroke. The combination of NFL with information on age, history of stroke, and other biomarkers should be explored as a future avenue for stroke risk assessments in patients with AF.

Elevated plasma protein carbonylation increases the risk of ischemic cerebrovascular events in patients with atrial fibrillation: association with a prothrombotic state

INTRODUCTION

Plasma protein carbonylation that reflects oxidative stress has been demonstrated to be associated with the prothrombotic fibrin clot phenotype. However, the role of protein carbonyls (PC) in predicting ischemic stroke in atrial fibrillation (AF) is largely unknown. This study aimed to investigate whether PC increase the risk of stroke in anticoagulated AF patients during follow-up.

METHODS

In 243 AF patients on anticoagulation (median age 69 years; median CHA2DS2-VASc of 4), we measured plasma PC using the assay by Becatti, along with plasma clot permeability (Ks), clot lysis time (CLT), thrombin generation, and fibrinolytic proteins, including plasminogen activator inhibitor type 1 (PAI-1) and thrombin activatable fibrinolysis inhibitor (TAFI). Ischemic stroke, major bleeding, and mortality were recorded during a median follow-up of 53 months.

RESULTS

Plasma PC levels (median, 3.16 [2.54-3.99] nM/mg protein) at baseline showed positive associations with age (P < 0.001), CHA2DS2-VASc (P = 0.003), and N-terminal B-type natriuretic peptide (P = 0.001), but not with type of AF or comorbidities except for heart failure (P = 0.007). PC levels were correlated with CLT (r = 0.342, P < 0.001), endogenous thrombin potential (r = 0.217, P = 0.001) and weakly with Ks (r = -0.145, P = 0.024), but not with fibrinogen, PAI-1, or TAFI levels. Stroke was recorded in 20 patients (1.9%/year), who had at baseline 36% higher PC levels (P < 0.001). Elevated PC (P = 0.003) at baseline were independently associated with stroke risk.

CONCLUSION

Our findings suggest that in patients with AF enhanced protein carbonylation is associated with increased "residual" risk of stroke despite anticoagulation, which is at least in part due to unfavorably altered fibrin clot phenotype.

Racial Differences in Ischemic and Hemorrhagic Stroke: An Ecological Epidemiological Study

BACKGROUND

 This study aimed to evaluate racial differences in the incidence of stroke by conducting an ecological epidemiological study using UK Biobank and Korean nationwide data.

METHODS

 This study used individual data from the Korean National Health Insurance Service-Health Screening and UK Biobank, which included participants who underwent health examinations between 2006 and 2010. We included 112,750 East Asians (50.7% men, mean age: 52.6 years) and 210,995 Caucasians (44.7% men, mean age: 55.0 years) who were not diagnosed with atrial fibrillation, cardiovascular diseases, chronic kidney disease, chronic obstructive pulmonary disease, or cancer. The primary outcome was defined as a composite of ischemic and hemorrhagic stroke.

RESULTS

 East Asians tended to have a lower body mass index (23.7 vs. 26.4 kg/m2, p < 0.001) and a higher proportion of participants who did not engage in moderate-to-vigorous physical activity (49.6% vs. 10.7%, p < 0.001) than Caucasians. During the follow-up, East Asians had higher 5-year incidence rates (presented as per 1,000 person-years) for primary outcome (1.73 vs. 0.50; IR ratio [IRR]: 3.48, 95% confidence interval [CI]: 3.13-3.88), ischemic stroke (1.23 vs. 0.33; IRR: 3.70, 95% CI: 3.25-4.21), hemorrhagic stroke (0.56 vs. 0.18; IRR: 3.20, 95% CI: 2.67-3.84), and atrial fibrillation-related stroke (0.19 vs. 0.09; IRR: 2.04, 95% CI: 1.55-2.68).

CONCLUSION

 Based on this ecological epidemiological study, racial differences in stroke incidence were robust to a variety of statistical analyses, regardless of the subtype. This suggests the need for region-specific approaches to stroke prevention.

Natriuretic Peptides to Classify Risk of Atrial Fibrillation Detection After Stroke: Analysis of the BIOSIGNAL and PRECISE Cohort Studies

BACKGROUND AND OBJECTIVES

Prolonged cardiac monitoring (PCM) increases atrial fibrillation (AF) detection after ischemic stroke, but access is limited, and it is burdensome for patients. Our objective was to assess whether midregional proatrial natriuretic peptide (MR-proANP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) could classify people who are unlikely to have AF after ischemic stroke and allow better targeting of PCM.

METHODS

We analyzed people from the Biomarker Signature of Stroke Aetiology (BIOSIGNAL) study with ischemic stroke, no known AF, and ≥3 days cardiac monitoring. External validation was performed in the Preventing Recurrent Cardioembolic Stroke: Right Approach, Right Patient (PRECISE) study of 28 days of cardiac monitoring in people with ischemic stroke or transient ischemic attack and no known AF. The main outcome is no AF detection. We assessed the discriminatory value of MR-proANP and NT-proBNP combined with clinical variables to identify people with no AF. A decision curve analysis was performed with combined data to determine the net reduction in people who would undergo PCM using the models based on a 15% threshold probability for AF detection.

RESULTS

We included 621 people from the BIOSIGNAL study. The clinical multivariable prediction model included age, NIH Stroke Scale score, lipid-lowering therapy, creatinine, and smoking status. The area under the receiver-operating characteristic curve (AUROC) for clinical variables was 0.68 (95% CI 0.62-0.74), which improved with the addition of log10MR-proANP (0.72, 0.66-0.78; p = 0.001) or log10NT-proBNP (0.71, 0.65-0.77; p = 0.009). Performance was similar for the models with log10MR-proANP vs log10NT-proBNP (p = 0.28). In 239 people from the PRECISE study, the AUROC for clinical variables was 0.68 (0.59-0.76), which improved with the addition of log10NT-proBNP (0.73, 0.65-0.82; p < 0.001) or log10MR-proANP (0.79, 0.72-0.86; p < 0.001). Performance was better for the model with log10MR-proANP vs log10NT-proBNP (p = 0.03). The models could reduce the number of people who would undergo PCM by 30% (clinical and log10MR-proANP), 27% (clinical and log10NT-proBNP), or 20% (clinical only).

DISCUSSION

MR-proANP and NT-proBNP help classify people who are unlikely to have AF after ischemic stroke. Measuring MR-proANP or NT-proBNP could reduce the number of people who need PCM by 30%, without reducing the amount of AF detected.

TRIAL REGISTRATION INFORMATION

NCT02274727; clinicaltrials.gov/study/NCT02274727.

Risk of stroke in male and female patients with atrial fibrillation in a nationwide cohort

Female sex has been suggested as a risk modifier for stroke in patients with atrial fibrillation (AF) with comorbid prevalent stroke risk factors. Management has evolved over time towards a holistic approach that may have diminished any sex difference in AF-related stroke. In a nationwide cohort of AF patients free from oral anticoagulant treatment, we examine the time trends in stroke risk overall and in relation to risk differences between male and female patients. Here we show that among 158,982 patients with AF (median age 78 years (IQR: 71 to 85); 52% female) the 1-year thromboembolic risk was highest between 1997-2000 with a risk of 5.6% and lowest between 2013-2016 with a risk of 3.8%, declining over the last two decades. The excess stroke risk for female vs male patients has also been declining, with risk-score adjusted relative risk estimates suggesting limited sex-difference in recent years.

Atrial High-Rate Episodes and Subclinical Atrial Fibrillation: State of the Art and Clinical Questions with Complex Solutions

Atrial high-rate episodes (AHREs) and subclinical atrial fibrillation (AF) are frequently registered in asymptomatic patients with cardiac implantable electronic devices (CIEDs) and insertable cardiac monitors (ICMs). While an increased risk of thromboembolic events (e.g., stroke) and benefits from anticoagulation have been widely assessed in the setting of clinical AF, concerns persist about optimal clinical management of subclinical AF/AHREs. As a matter of fact, an optimal threshold of subclinical episodes' duration to predict stroke risk is still lacking and recently published randomized clinical trials assessing the impact of anticoagulation on thromboembolic events in this specific setting have shown contrasting results. The aim of this review is to summarize current evidence regarding classification and clinical impact of subclinical AF/AHREs and to discuss the latest evidence regarding the potential benefit of anticoagulation in this setting, highlighting which clinical questions are still unanswered.

Comparing CHA2DS2-VA and CHA2DS2-VASc scores for stroke risk stratification in patients with atrial fibrillation: a temporal trends analysis from the retrospective Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) cohort

Background

Contemporary data have shown a decrease in the ischaemic stroke risk associated with female sex in patients with atrial fibrillation (AF). We evaluated temporal trends in the predictive value of a non-sex CHA2DS2-VASc risk score (ie. CHA2DS2-VA).

Methods

The FinACAF study covers all patients with incident AF between 2007 and 2018 in Finland from all levels of care. The CHA2DS2-VA score was compared with the CHA2DS2-VASc using continuous and category-based net reclassification indices (NRIs), integrated discrimination improvement (IDI), c-statistics and decision curve analyses.

Findings

We identified 144,879 anticoagulant naïve patients with new-onset AF between 2007 and 2018 (49.9% women; mean age 72.1 years), of whom 3936 (2.7%) experienced ischaemic stroke during one-year follow-up. Based on both continuous and category-based NRIs, the CHA2DS2-VA score was inferior to the CHA2DS2-VASc in the early years (-0.333 (95% CI -0.411 to -0.261) and -0.118 (95% CI -0.137 to -0.099), respectively). However, the differences attenuated over time, and by the end of the study period, the continuous NRI became non-significant (-0.093 (95% CI -0.165 to 0.032)), whereas the category-based NRI reversed in favor of the CHA2DS2-VA (0.070 (95% CI 0.048-0.087)). The IDI was non-significant in early years (0.0009 (95% CI -0.0024 to 0.0037)), but over time became statistically significant in favor of the CHA2DS2-VA score (0.0022 (95% CI 0.0001-0.0044)). The Cox models fitted with the CHA2DS2-VA and the CHA2DS2-VASc scores exhibited comparable discriminative capability in the beginning of the study (p-value 0.63), but over time marginal differences in favor of the CHA2DS2-VA score emerged (p-value 0.0002).

Interpretation

In 2007-2008 (when females had higher AF-related stroke risks than males), the CHA2DS2-VASc score outperformed the CHA2DS2-VA score, but the initial differences between the scores attenuated over time. By the end of the study period in 2017-2018 (with limited/no sex differences in AF-related stroke), there was marginal superiority for the CHA2DS2-VA score.

Funding

This work was supported by the Aarne Koskelo Foundation, The Finnish Foundation for Cardiovascular Research, The Finnish State Research funding, and Helsinki and Uusimaa Hospital District research fund.

Pharmacy-Led Management of Atrial Fibrillation: Improving Treatment Adherence and Patient Outcomes

The world's population is ageing, with the number of those over 60 years expected to represent a fifth of the total population by 2050. Increases in chronic long-term health conditions (LTCs) associated with ageing, and requiring regular but often avoidable medical intervention, are pressurising already overloaded, health and social care systems. Atrial fibrillation (AF) is an LTC, which is most frequently diagnosed in the elderly. An often, asymptomatic condition, AF is associated with a 3- to 5-fold increased risk of severe ischemic stroke. Stroke prevention, with risk-stratified oral anticoagulants (OACs) is the standard recommended care for patients with AF. Stroke avoidance is, however, dependent on persistent adherence to OAC medication, with an adherence rate of >80% considered necessary to achieve optimal health outcomes. Suboptimal adherence to OACs is common, with a third of all AF patients not taking their medication as prescribed. This combined with the short half-life of OACs can result in poor clinical outcomes for patients. Policy makers now consider improving adherence to prescribed medicines for LTCs, a public health priority, to ensure better health outcomes for patients, whilst minimising unnecessary health system costs. Prescribing medicines to treat LTCs, such as AF, is not enough, particularly when the patient may not experience any measurable benefit to the treatment and may instead, experience medication-associated adverse events, including a risk of bleeding. Pharmacists who are experts in medicines management are ideally placed to support medication adherence, to educate, and to improve health outcomes for patients with AF. In this review, I will consider the evidence for poor medication adherence in LTCs and in particular adherence to OACs in patients with AF and highlight the role that pharmacists can play in ensuring optimal adherence and showcase pharmacist-led interventions that effectively address this problem.

Early detection of atrial fibrillation in the digital era, risk factors, treatment options, and the need for new definitions

Graphical abstract.

Comparison of cardiac function and structure after left atrial appendage occlusion without versus with ablation in patients with non-valvular atrial fibrillation: a retrospective study

The Aim of this study was to investigate the long-term impact of left atrial appendage occlusion (LAAO) on cardiac function and structure in patients with non-valvular atrial fibrillation (NVAF). 157 patients with NVAF who underwent LAAO or combined with ablation were included and divided into simple LAAO group or combined group. Long term impact of LAAO on cardiac function and structure were evaluated. Results showed that the procedures were performed successfully with 6.4% complications. During follow-up, there was a significant decrease of left atrial anteroposterior diameter (LAAD) at 6 months and a significant increase of left ventricular end-diastolic dimension (LVEDD) at 12 months after LAAO. A significant decrease in plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) was noted at 3 months, 6 months and 12 months after procedure. There was a significant decrease of LAAD, LVEDD, left ventricular end-systolic dimension (LVESD) and NT-proBNP levels in combined group at 3 months, 6 months and 12 months post- procedure, while an increase of left ventricular ejection fraction (LVEF). Meanwhile, no significant change of LAAD, LVEDD, LVESD, NT-proBNP and LVEF was seen in simple LAAO group at 3 months follow-up, but a decrease of NT-proBNP during 6 months and 12 months follow-up. Compared with simple LAAO group, combined group was associated with a significant increase of residual flow. In conclusion, LAAO has no significant effect on cardiac structure and function but can significantly reduce NT-proBNP. The improvement of cardiac structure and function in combined therapy comes from the result of ablation, not LAAO.

Plateauing atrial fibrillation burden in acute ischemic stroke admissions in the United States from 2010 to 2020

BACKGROUND

Utilization of oral anticoagulants for acute ischemic stroke (AIS) prevention in patients with atrial fibrillation (AF) increased in the United States over the last decade. Whether this increase has been accompanied by any change in AF prevalence in AIS at the population level remains unknown. The aim of this study is to evaluate trends in AF prevalence in AIS hospitalizations in various age, sex, and racial subgroups over the last decade.

METHODS

We used data contained in the 2010-2020 National Inpatient Sample to conduct a serial cross-sectional study. Primary AIS hospitalizations with and without comorbid AF were identified using International Classification of Diseases Codes. Joinpoint regression was used to compute annualized percentage change (APC) in prevalence and to identify points of change in prevalence over time.

RESULTS

Of 5,190,148 weighted primary AIS hospitalizations over the study period, 25.1% had comorbid AF. The age- and sex-standardized prevalence of AF in AIS hospitalizations increased across the entire study period 2010-2020 (average APC: 1.3%, 95% confidence interval (CI): 0.8-1.7%). Joinpoint regression showed that prevalence increased in the period 2010-2015 (APC: 2.8%, 95% CI: 1.9-3.9%) but remained stable in the period 2015-2020 (APC: -0.3%, 95% CI: -1.0 to 1.9%). Upon stratification by age and sex, prevalence increased in all age/sex groups from 2010 to 2015 and continued to increase throughout the entire study period in hospitalizations in men 18-39 years (APC: 4.0%, 95% CI: 0.2-7.9%), men 40-59 years (APC: 3.4%, 95% CI: 1.9-4.9%) and women 40-59 years (APC: 4.4%, 95% CI: 2.0-6.8%). In contrast, prevalence declined in hospitalizations in women 60-79 (APC: -1.0%, 95% CI: -0.5 to -1.5%) and women ⩾ 80 years over the period 2015-2020 but plateaued in hospitalizations in similar-aged men over the same period.

CONCLUSION

AF prevalence in AIS hospitalizations in the United States increased over the period 2010-2015, then plateaued over the period 2015-2020 due to declining prevalence in hospitalizations in women ⩾ 60 years and plateauing prevalence in hospitalizations in men ⩾ 60 years.

Ischaemic stroke in women with atrial fibrillation: temporal trends and clinical implications

BACKGROUND AND AIMS

Female sex has been linked with higher risk of ischaemic stroke (IS) in atrial fibrillation (AF), but no prior study has examined temporal trends in the IS risk associated with female sex.

METHODS

The registry-linkage Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study included all patients with AF in Finland from 2007 to 2018. Ischaemic stroke rates and rate ratios were computed.

RESULTS

Overall, 229 565 patients with new-onset AF were identified (50.0% women; mean age 72.7 years). The crude IS incidence was higher in women than in men across the entire study period (21.1 vs. 14.9 events per 1000 patient-years, P < .001), and the incidence decreased both in men and women. In 2007-08, female sex was independently associated with a 20%-30% higher IS rate in the adjusted analyses, but this association attenuated and became statistically non-significant by the end of the observation period. Similar trends were observed when time with and without oral anticoagulant (OAC) treatment was analysed, as well as when only time without OAC use was considered. The decrease in IS rate was driven by patients with high IS risk, whereas in patients with low or moderate IS risk, female sex was not associated with a higher IS rate.

CONCLUSIONS

The association between female sex and IS rate has decreased and become non-significant over the course of the study period from 2007 to 2018, suggesting that female sex could be omitted as a factor when estimating expected IS rates and the need for OAC therapy in patients with AF.

Screening for atrial fibrillation in care homes using pulse palpation and the AliveCor Kardia Mobile® device: a comparative cross-sectional pilot study

BACKGROUND

Atrial fibrillation (AF) is a major cause of stroke in older people. Exacerbated by age and co-morbidities, residents of care homes are more likely to develop AF and less likely to receive oral anticoagulants.

AIM

To determine the prevalence of AF using the design and methodology of the Pharmacists Detecting Atrial Fibrillation (PDAF) study in a care home setting.

METHOD

A cross-sectional AF screening pilot study within four UK care homes, three residential and one residential/nursing. Screening followed the original PDAF protocol: a manual pulse check, followed by a single-Lead ECG (SLECG, AliveCor Kardia Mobile (KMD)) delivered by a pharmacist. All recorded SLECG were reviewed by a cardiologist and any residents requiring follow-up investigations were referred to their general practitioner.

RESULTS

Fifty-three of 112 care home residents participated. From 52 SLECGs recorded, the cardiologist interpreted 13.5% (7/52) as having possible AF of which 9.6% (5/52) were previously unknown. One resident with previously unknown AF received anticoagulation.

CONCLUSION

This study has shown a need for AF screening in care homes and that elements of the PDAF screening protocol are transferable in this setting. Early diagnosis and treatment of AF are essential to reduce the risk of stroke in this population.

Development and Validation of a New Nomogram Model for Predicting Acute Ischemic Stroke in Elderly Patients with Non-Valvular Atrial Fibrillation: A Single-Center Cross-Sectional Study

Background and Aims

Non-valvular atrial fibrillation (NVAF) patients face a 3-5 times greater risk of acute ischemic stroke (AIS) compared to those without NVAF. This study aims to establish a novel clinical prediction model for AIS in elderly patients with NVAF by incorporating relevant biomarker indicators.

Methods

A total of 301 individuals diagnosed with NVAF were selected for this investigation at the Third Affiliated Hospital of Anhui Medical University. Based on the presence of AIS, patients were categorized into two groups: the Stroke Cohort and the Non-Stroke Cohort. Predictor screening was performed using the least absolute shrinkage and selection operation (LASSO) regression algorithm. The binary logistic regression equation was applied to fit the model, followed by internal validation using the bootstrap resampling method (1000 times). Receiver operating characteristic (ROC) curve, calibration degree curve plots, and clinical decision curve analysis (DCA) were generated, respectively. Finally, a nomogram was constructed to present the prediction model.

Results

The final results of this study revealed that neutrophil-to-lymphocyte ratio (NLR), red cell distribution width (RDW), lipoprotein(a) (Lp(a)), systolic pressure, history of stroke, hyperlipidemia were independent risk factors for AIS in elderly patients with NVAF (P<0.05). And the high-density lipoprotein cholesterol (HDL-C) was an independent protective factor (P<0.05). By incorporating these indicators, a nomogram prediction model for predicting AIS in elderly patients with NVAF was constructed. Comparative analysis between the nomogram predictive model and CHA2DS2-VASc score revealed that the AUC of the nomogram predictive model surpassed that of the CHA2DS2-VASc score (AUC: 0.881vs 0.850).

Conclusion

NLR, RDW, Lp(a), SP, history of stroke, hyperlipidemia, and HDL-C emerge as independent prognostic factors for acute ischemic stroke in elderly patients with non-valvular atrial fibrillation. The predictive utility of the nomogram model may potentially surpass that of the CHA2DS2-VASc scoring system.

Temporal trends in anticoagulation use and clinical outcomes among medicare beneficiaries with non-valvular atrial fibrillation

PURPOSE

Oral anticoagulants effectively prevent stroke/systemic embolism among patients with non-valvular atrial fibrillation but remain under-prescribed. This study evaluated temporal trends in oral anticoagulant use, the incidence of stroke/systemic embolism and major bleeding, and economic outcomes among elderly patients with non-valvular atrial fibrillation and CHA2DS2-VASc scores ≥ 2.

METHODS

Retrospective analyses were conducted on Medicare claims data from January 1, 2012 through December 31, 2017. Non-valvular atrial fibrillation patients aged ≥ 65 years with CHA2DS2-VASc scores ≥ 2 were stratified by calendar year (2013-2016) of care to create calendar-year cohorts. Patient characteristics were evaluated across all cohorts during the baseline period (12 months before diagnosis). Treatment patterns and clinical and economic outcomes were evaluated during the follow-up period (from diagnosis through 12 months).

RESULTS

Baseline patient characteristics remained generally similar between 2013 and 2016. Although lack of oral anticoagulant prescriptions among eligible patients remained relatively high, utilization did increase progressively (53-58%). Among treated patients, there was a progressive decrease in warfarin use (79-52%) and a progressive increase in overall direct oral anticoagulant use (21-48%). There were progressive decreases in the incidence of stroke/systemic embolism 1.9-1.4 events per 100 person years) and major bleeding (4.6-3.3 events per 100 person years) as well as all-cause costs between 2013 and 2016.

CONCLUSIONS

The proportions of patients with non-valvular atrial fibrillation who were not prescribed an oral anticoagulant decreased but remained high. We observed an increase in direct oral anticoagulant use that coincided with decreased incidence of clinical outcomes as well as decreasing total healthcare costs.

Atrial Fibrillation and Reperfusion Therapy in Acute Ischaemic Stroke Patients: Prevalence and Outcomes-A Comprehensive Systematic Review and Meta-Analysis

Atrial fibrillation (AF) significantly contributes to acute ischaemic stroke (AIS), yet its precise influence on clinical outcomes post-intravenous thrombolysis (IVT) and post-endovascular thrombectomy (EVT) has remained elusive. Furthermore, the overall prevalence of AF in AIS patients undergoing reperfusion therapy has not been clearly determined. Employing random-effects meta-analyses, this research aimed to estimate the pooled prevalence of AF among AIS patients undergoing reperfusion therapy, while also examining the association between AF and clinical outcomes such as functional outcomes, symptomatic intracerebral haemorrhage (sICH) and mortality. Studies comparing AF and non-AF patient groups undergoing reperfusion therapy were identified and included following an extensive database search. Forty-nine studies (n = 66,887) were included. Among IVT patients, the prevalence of AF was 31% (Effect Size [ES] 0.31 [95%CI 0.28-0.35], p < 0.01), while in EVT patients, it reached 42% (ES 0.42 [95%CI 0.38-0.46], p < 0.01), and in bridging therapy (BT) patients, it stood at 36% (ES 0.36 [95%CI 0.28-0.43], p < 0.01). AF was associated with significantly lower odds of favourable 90-day functional outcomes post IVT (Odds Ratio [OR] 0.512 [95%CI 0.376-0.696], p < 0.001), but not post EVT (OR 0.826 [95%CI 0.651-1.049], p = 0.117). Our comprehensive meta-analysis highlights the varying prevalence of AF among different reperfusion therapies and its differential impact on patient outcomes. The highest pooled prevalence of AF was observed in EVT patients, followed by BT and IVT patients. Interestingly, our analysis revealed that AF was significantly associated with poorer clinical outcomes following IVT. Such an association was not observed following EVT.

Diverging Trends in the Incidence of Spontaneous Intracerebral Hemorrhage in Sweden 2010-2019: An Observational Study from the Swedish Stroke Register (Riksstroke)

INTRODUCTION

Although ischemic stroke incidence has decreased in Sweden over the past decade, trends in spontaneous intracerebral hemorrhage (ICH) incidence are less well delineated. In this time period, there has been a dramatic increase in use of oral anticoagulants (OAC). The aim of our study was to investigate incidence trends in spontaneous first-ever ICH in Sweden between 2010 and 2019, with a focus on non-OAC-associated and OAC-associated ICH.

METHODS

We included patients (≥18 years) with first-ever ICH registered in the hospital-based Swedish Stroke Register (Riksstroke) 2010-2019. Data were stratified by non-OAC and OAC ICH and analyzed for 2010-2012, 2013-2016, and 2017-2019. Incidence rates are shown as crude and age-specific per 100,000 person-years.

RESULTS

Between 2010 and 2019, 22,289 patients with first-ever ICH were registered; 18,325 (82.2%) patients with non-OAC ICH and 3,964 (17.8%) patients with OAC ICH. Annual crude incidence (per 100,000) of all first-ever ICH decreased by 10% from 29.5 (95% CI 28.8-30.3) to 26.7 (95% CI 26.0-27.3) between 2010-2012 and 2017-2019. The crude incidence rate of non-OAC ICH decreased by 20% from 25.7 (95% CI 25.0-26.3) to 20.7 (95% CI 20.1-21.2), whereas OAC ICH increased by 56% from 3.86 (95% CI 3.61-4.12) to 6.01 (95% CI 5.70-6.32). The proportion of OAC ICH of all first-ever ICH increased between 2010-2012 and 2017-2019 from 13.1% to 22.5% (p < 0.001). Proportional changes were largest in the age group ≥85 years with a decrease in non-OAC ICH by 32% from 155 (95% CI 146-164) to 106 (95% CI 98.6-113) and an increase in OAC ICH by 155% from 25.7 (95% CI 22.1-29.4) to 65.5 (95% CI 59.9-71.2).

CONCLUSION

Incidence of first-ever ICH in Sweden decreased by 10% between 2010 and 2019. We found diverging trends with a 20% decrease in non-OAC-associated ICH and a 56% increase in OAC-associated ICH. Further research on ICH epidemiology, analyzing non-OAC and OAC-associated ICH separately, is needed to follow up these diverging trends including underlying risk factors.