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Ghajar M, Ghafourian MS, Tarkiani S, Tork AN, Ramezani A, Zolfaghari B, Palangi MG. The Application of Machine Learning in Warfarin Dose Precision for Diabetic Patients Treated with Statins: A Comparative Study. Cardiovasc Drugs Ther 2025:10.1007/s10557-025-07690-5. [PMID: 40448807 DOI: 10.1007/s10557-025-07690-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2025] [Indexed: 06/02/2025]
Abstract
PURPOSE To evaluate the impact of statin therapy on warfarin dose requirements in diabetic patients and to assess the performance of various machine learning algorithms in predicting optimal warfarin dosing. METHODS The datasets available for total participants of 628 (216 diabetics and 412 non-diabetic patients) were analyzed. We categorized the patients according to height, weight, gender, race, and age, plasma international normalized ratio (INR) on reported therapeutic dose of warfarin, target INR, warfarin dose, statin therapy, and indications for warfarin. Various models were tested on data of patients from the International Warfarin Pharmacogenetics Consortium (IWPC). Data preprocessing involves structuring and handling missing values. Six predictive models, including least absolute shrinkage and selection operator (LASSO), k-nearest neighbors (KNN), support vector regression (SVR), linear regression (LR), decision tree, and random forest (RF), were employed in predicting optimal warfarin dosage. The best dose for each patient will be predicted using one of the six regression models. RESULTS This comparative study showed that the mean (and the standard deviation) of warfarin dose for diabetic and non-diabetic patients were 38.73 (15.37) and 34.50 (18.27) mg per week, respectively. Furthermore, the impact of various statin they use is considered and patient undergoing atorvastatin and rosuvastatin therapy against the necessity of high dose warfarin if the diabetic patients use lovastatin and fluvastatin. CONCLUSION Diabetic patients under statin therapy, considering the specific statin used, require different warfarin dose. Through the application of advanced machine learning, models as dosing predictors may attenuate the adverse effects of warfarin.
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Affiliation(s)
- Mobina Ghajar
- Department of Cardiology, Zanjan University of Medical Science, Zanjan, Iran
| | - Mandana Sadat Ghafourian
- Electrical Engineering Department, Faculty of Engineering, Ferdowsi University of Mashhad, Mashhad, Iran
| | - Sara Tarkiani
- Department of Cardiology, Zanjan University of Medical Science, Zanjan, Iran
| | - Atousa Naser Tork
- Department of Civil & Environmental Engineering, Amir Kabir University of Technology (Tehran Polytechnic), Tehran, Iran
| | - Amin Ramezani
- Department of Medicine (HSRD), Cardiac Surgery, Brigham and Women Hospital Harvard Medical School, Boston, MA, USA.
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Alhawiti NM, Elsokkary EM, Aldali JA, Alotaibi BA. Investigating the impact of glycated hemoglobin levels on stroke severity in patients with acute ischemic stroke. Sci Rep 2025; 15:12114. [PMID: 40204797 PMCID: PMC11982240 DOI: 10.1038/s41598-025-95305-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2024] [Accepted: 03/20/2025] [Indexed: 04/11/2025] Open
Abstract
Stroke is a sudden neurological decline caused by cerebrovascular diseases or impaired blood circulation. Research investigating the connection between glycated hemoglobin A1c (HbA1c) levels and stroke severity is limited. This study examined the connection between HbA1c levels and stroke severity in patients with acute ischemic stroke. A retrospective cross-sectional analysis of the medical records of 1103 patients with acute ischemic stroke from January 2020 to January 2024 was conducted. Patients were divided into seven groups on the basis of their HbA1c levels. Stroke severity within these groups was assessed via the National Institutes of Health Stroke Scale (NIHSS), with the aim of identifying correlations between stroke severity and glycemic status. This study examined the impact of various HbA1c levels on a range of demographic and clinical characteristics in stroke patients. The patients were grouped into seven categories on the basis of their HbA1c levels, and characteristics such as age; body mass index (BMI); LDL, HDL, and creatinine levels; and NIHSS scores at hospital admission were compared across these groups. Significant differences were observed in age, LDL levels (F = 3.999, P < 0.001), and creatinine levels (F = 1.303, P = 0.253) among the HbA1c categories. However, there were no significant differences in BMI, HDL levels, or length of hospital stay. A positive correlation was found between HbA1c levels and NIHSS scores, indicating that higher HbA1c levels are associated with greater stroke severity. This study revealed that the risk of severe stroke increases significantly when HbA1c levels exceed 6.5%. In contrast, maintaining HbA1c levels below 6.5% is linked to a reduced risk of severe stroke and lower mortality. Additionally, older adults are at greater risk and tend to experience more severe strokes.
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Affiliation(s)
- Naif M Alhawiti
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
| | - Emadeldin M Elsokkary
- Department of Psychology, College of Social Sciences, Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, 13317, Saudi Arabia
| | - Jehad A Aldali
- Department of Pathology, College of Medicine, Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, 13317, Saudi Arabia
| | - Badi A Alotaibi
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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Zubair M, Kainat Raza Naqvi S, Aslam R, Ahmad H, Farooq A, Islam S. Role of HbA1c in Mortality Among Patients With a Medical History of Ischemic Stroke and Paroxysmal Atrial Fibrillation: A Systematic Review. Cureus 2024; 16:e75925. [PMID: 39830535 PMCID: PMC11740002 DOI: 10.7759/cureus.75925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2024] [Indexed: 01/22/2025] Open
Abstract
Elevated HbA1c, a marker of poor glycemic control, is associated with adverse cardiovascular outcomes and mortality. HbA1c influences outcomes through distinct mechanisms of vascular dysfunction and atherosclerosis in ischemic stroke, during atrial remodeling and thrombus formation in paroxysmal atrial fibrillation (PAF). Optimal HbA1c thresholds are generally below optimal levels, with levels above this being linked to higher mortality in both populations. At extremes of glycemic control in ischemic stroke, patients face recurrence and poor recovery, while PAF patients experience amplified thromboembolic risks. In patients with both conditions, poor HbA1c control synergistically raises mortality. This systematic review explores how HbA1c levels directly contribute to mortality in patients with ischemic stroke and PAF, aiming to establish a causal link between elevated HbA1c and increased mortality risk. This review includes a comprehensive analysis of four cross-sectional studies, five randomized controlled trials (RCTs), and 17 cohort studies, providing a diverse range of evidence on the topic. The inclusion of these study designs offers a well-rounded understanding of the impact and outcomes observed in the research. Mortality metrics include short-term mortality, such as 30-day or 90-day, and long-term mortality over one, three, or five years. Specific metrics, like cardiovascular mortality, focus on deaths from stroke; some studies link mortality to functional decline post-stroke, where complications from immobility or recurrent vascular events contribute to outcomes. Secondary outcomes include survival metrics, functional recovery metrics, and complications. Studies use narrative synthesis due to its ability to accommodate heterogeneity in study designs, populations, and outcome measures, enabling a nuanced interpretation of complex, context-dependent data. HbA1c levels' impact on stroke outcomes, considering age, gender, and severity, is also examined. Confounding factors, functional recovery, and complications are also considered. A narrative synthesis was chosen. The study emphasizes the importance of strict glycemic control in patients with ischemic stroke or PAF, especially those with elevated HbA1c levels. It supports clinical guidelines for individualized HbA1c targets, with most stroke patients having a target of <7%. Clinicians should prioritize close monitoring and tailor treatment plans to avoid extreme HbA1c levels, which could inform more personalized and effective treatment strategies. Tight control of HbA1c levels entails individualized targets based on patient characteristics, with an emphasis on personalized treatment strategies that may include lifestyle modifications, oral hypoglycemics, or insulin therapy to optimize glycemic control.
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Affiliation(s)
- Muhammad Zubair
- Otorhinolaryngology, M. Islam Teaching Hospital, Gujranwala, PAK
| | | | - Rehan Aslam
- Internal Medicine, Islamic International Medical College, Rawalpindi, PAK
| | - Hooria Ahmad
- Internal Medicine, National Hospital and Medical Centre, Lahore, PAK
| | - Ayesha Farooq
- Urology, Pakistan Kidney and Liver Institute, Lahore, PAK
| | - Samra Islam
- Medicine, Jinnah Hospital, Lahore, Lahore, PAK
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Peng JR, Hsieh JCH, Chang CH, Chuang C, Wang YC, Chen TY, Su HC, Lee HF. Cardiovascular and venous thromboembolism risks in cancer patients treated with immune checkpoint inhibitors compared to non-users- a multi-center retrospective study. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2024; 10:59. [PMID: 39244552 PMCID: PMC11380216 DOI: 10.1186/s40959-024-00264-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 09/03/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND Immune Checkpoint Inhibitors (ICIs) have revolutionized cancer therapy. This study examines the cardiovascular risks of ICIs compared to non-ICI therapies. METHODS Utilizing the Chang Gung Research Database (CGRD) of Taiwan, this retrospective study analyzed 188,225 cancer patients, with 1,737 undergoing ICI treatment from January 1, 2008, to June 30, 2021. Through 1:1 propensity score matching (PSM), we compared specific outcomes between patients treated with ICIs and those who were not. The analysis also accounted for the competing risk of mortality in assessing the results after PSM. The observation period spanned from this index date to whichever came first: the date of the specific outcomes, the last follow-up recorded, or the end date of the study on June 30, 2022. RESULTS The study found no significant increase in the risk of cardiac death, non-fatal myocardial infarction, heart failure hospitalization, deep vein thrombosis, or pulmonary embolism in patients treated with ICIs as compared to those receiving non-ICI therapy. Interestingly, ICI treatment was linked to a lower risk of non-fatal stroke (0.27% per year vs. 0.46% per year; subdistribution hazard ratio = 0.59; 95% confidence interval = 0.35-0.98; P = 0.0430). Furthermore, subgroup analysis revealed that the ICI group had a decreased risk of cardiac death in patients with cancers other than head and neck cancer, and a reduced risk of stroke among diabetic patients. CONCLUSIONS ICIs do not significantly elevate the risk of cardiovascular events in cancer patients and may lower the stroke risk, underscoring the need for additional prospective studies to clarify these findings.
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Affiliation(s)
- Jian-Rong Peng
- Division of Cardiology, Department of Internal Medicine, New Taipei City Municipal Tucheng Hospital, No. 6, Sec. 2, Jincheng Rd., Tucheng Dist, New Taipei City, 23652, Taiwan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan
| | - Jason Chia-Hsun Hsieh
- College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan
- Division of Hematology-Oncology, Department of Internal Medicine, New Taipei City Municipal Tucheng Hospital, New Taipei City, 23652, Taiwan
| | - Chih-Hao Chang
- College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, New Taipei City Municipal Tucheng Hospital, New Taipei City, 23652, Taiwan
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan City, 33305, Taiwan
| | - Chi Chuang
- Division of Cardiology, Department of Internal Medicine, New Taipei City Municipal Tucheng Hospital, No. 6, Sec. 2, Jincheng Rd., Tucheng Dist, New Taipei City, 23652, Taiwan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan
| | - Yu-Ching Wang
- Center for Big Data Analytics and Statistics, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Tzu-Yang Chen
- Division of Cardiology, Department of Internal Medicine, New Taipei City Municipal Tucheng Hospital, No. 6, Sec. 2, Jincheng Rd., Tucheng Dist, New Taipei City, 23652, Taiwan
| | - Hung-Chi Su
- Division of Cardiology, Department of Internal Medicine, New Taipei City Municipal Tucheng Hospital, No. 6, Sec. 2, Jincheng Rd., Tucheng Dist, New Taipei City, 23652, Taiwan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan
| | - Hsin-Fu Lee
- Division of Cardiology, Department of Internal Medicine, New Taipei City Municipal Tucheng Hospital, No. 6, Sec. 2, Jincheng Rd., Tucheng Dist, New Taipei City, 23652, Taiwan.
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan City, 33305, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan.
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan City, 33302, Taiwan.
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Ledo Piñeiro A, Abu-Assi E, González Bermúdez I, Noriega Caro V, Íñiguez-Romo A, Raposeiras-Roubín S. Is pre-diabetes a predictor of events in patients with atrial fibrillation? Int J Cardiol 2024; 407:132086. [PMID: 38648915 DOI: 10.1016/j.ijcard.2024.132086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/14/2024] [Accepted: 04/19/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Diabetes mellitus (DM) increases the probability of presenting atrial fibrillation (AF) and it is a predictor of its ischemic stroke. There is limited information of the association between glycated hemoglobin (HbA1c) levels and ischemic, embolic or bleeding events in patients with pre-DM and AF. METHODS To investigate whether the presence of pre-DM in patients with AF predicts ischemic or bleeding events, myocardial infarction or mortality, we performed a retrospective study with a final cohort of 2993 non-diabetic patients with AF and data of glycated hemoglobin (HbA1c). We divided the cohort in two groups: those with normal glucose (n = 1351) and those with pre-diabetes (n = 1642). Incidence rates were calculated as the number of events per 100 person-years and were then compared between groups. Competitive hazard regression analysis for non-fatal events(death as the competing event) and conventional Cox regression for mortality were performed. RESULTS There was not difference between groups for incidence rates of the different events per 100 person-years. Even considering HbA1c as continuous variable, the unadjusted analysis showed no relation between levels of HbA1c and more risk of events. This association remained not significant after adjustment for CHA2DS2-VASc score, HAS-BLED score and anticoagulation therapy. CONCLUSION In this study of 2993 non-diabetic patients with new-onset AF, we have not found an association between HbA1c and worse prognosis when it is in the range of pre-diabetes.
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Affiliation(s)
- Ana Ledo Piñeiro
- Department of Cardiology, University Hospital Álvaro Cunqueiro, Vigo, Spain; Health Research Institute Galicia Sur, Vigo, Spain.
| | - Emad Abu-Assi
- Department of Cardiology, University Hospital Álvaro Cunqueiro, Vigo, Spain; Health Research Institute Galicia Sur, Vigo, Spain
| | | | | | - Andrés Íñiguez-Romo
- Department of Cardiology, University Hospital Álvaro Cunqueiro, Vigo, Spain; Health Research Institute Galicia Sur, Vigo, Spain
| | - Sergio Raposeiras-Roubín
- Department of Cardiology, University Hospital Álvaro Cunqueiro, Vigo, Spain; Health Research Institute Galicia Sur, Vigo, Spain; Health Sciences Department, Vigo University, Spain.
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Terauchi Y, Inoue H, Yamashita T, Akao M, Atarashi H, Ikeda T, Koretsune Y, Okumura K, Suzuki S, Tsutsui H, Toyoda K, Hirayama A, Yasaka M, Yamaguchi T, Teramukai S, Kimura T, Morishima Y, Takita A, Shimizu W. Impact of glycated hemoglobin on 2-year clinical outcomes in elderly patients with atrial fibrillation: sub-analysis of ANAFIE Registry, a large observational study. Cardiovasc Diabetol 2023; 22:175. [PMID: 37438827 DOI: 10.1186/s12933-023-01915-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 07/03/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND This ANAFIE Registry sub-analysis investigated 2-year outcomes and oral anticoagulant (OAC) use stratified by glycated hemoglobin (HbA1c) levels among Japanese patients aged ≥ 75 years with non-valvular atrial fibrillation (NVAF) with and without clinical diagnosis of diabetes mellitus (DM). METHODS The ANAFIE Registry was a large-scale multicenter, observational study conducted in Japan; this sub-analysis included patients with baseline HbA1c data at baseline. The main endpoints evaluated (stroke/systemic embolic events [SEE], major bleeding, intracranial hemorrhage, cardiovascular death, all-cause death, and net clinical outcome [a composite of stroke/SEE, major bleeding, and all-cause death]) were stratified by HbA1c levels (< 6.0%; 6.0% to < 7.0%; 7.0% to < 8.0%; and ≥ 8.0%). RESULTS Of 17,526 patients with baseline HbA1c values, 8725 (49.8%) patients had HbA1c < 6.0%, 6700 (38.2%) had 6.0% to < 7.0%, 1548 (8.8%) had 7.0% to < 8.0%, and 553 (3.2%) had ≥ 8.0%. Compared with other subgroups, patients with HbA1c ≥ 8.0% were more likely to have lower renal function, higher CHA2DS2-VASc and HAS-BLED scores, higher prevalence of non-paroxysmal AF, and lower direct OAC (DOAC) administration, but higher warfarin administration. The HbA1c ≥ 8.0% subgroup had higher event rates for all-cause death (log-rank P = 0.003) and net clinical outcome (log-rank P = 0.007). Similar trends were observed for stroke/SEE. In multivariate analysis, risk of all-cause death (adjusted hazard ratio [aHR]: 1.46 [95% confidence interval 1.11-1.93]) and net clinical outcome (aHR 1.33 [1.05-1.68]) were significantly higher in the HbA1c ≥ 8.0% subgroup. No significant differences were observed in risks of major bleeding or other outcomes in this and other subgroups. No interaction was observed between HbA1c and OACs. Use/non-use of antidiabetic drugs was not associated with risk reduction; event risks did not differ with/without injectable antidiabetic drugs. CONCLUSIONS Among elderly Japanese patients with NVAF, only HbA1c ≥ 8.0% was associated with increased all-cause death and net clinical outcome risks; risks of the events did not increase in other HbA1c subgroups. Relative event risks between patients treated with DOACs and warfarin were not modified by HbA1c level. TRIAL REGISTRATION UMIN000024006; date of registration: September 12, 2016.
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Affiliation(s)
- Yasuo Terauchi
- Department of Endocrinology and Metabolism, Graduate School of Medicine, Yokohama City University, Kanagawa, Japan.
| | | | | | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | | | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | | | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | | | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Takenori Yamaguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tetsuya Kimura
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd, Tokyo, Japan
| | | | - Atsushi Takita
- Data Intelligence Department, Daiichi Sankyo Co., Ltd, Tokyo, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
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Discharge status validation of the Chang Gung Research database in Taiwan. Biomed J 2022; 45:907-913. [PMID: 34971827 PMCID: PMC9795345 DOI: 10.1016/j.bj.2021.12.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 11/07/2021] [Accepted: 12/21/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The Chang Gung Research Database (CGRD) is the largest multi-institutional electronic medical records database in Taiwan and has been widely used to establish evidence studies. However, the accuracy of CGRD has rarely been validated. This study aims to validate the discharge status, especially with a focus on mortality, of admission data under CGRD. METHODS We constructed an observational study using CGRD linked with TDR to validate the discharge status. The CGRD and TDR data were obtained from the Chang Gung Memorial Hospital system and the Health and Welfare Data Science Center, respectively. The accuracy, positive predictive value (PPV), and underestimated mortality rate (UEM) were employed as indicators for validation. Year, sex, age, and the primary cause for admission (PCA) were analyzed. RESULTS A total of 1,972,044 admission records under CGRD were analyzed. The overall accuracy for mortality coding on discharge status was higher than 97% within one week after discharge. The accuracy increased by year and was more than 98% after 2010. A similar result was observed in UEM; the UEM within one week was lower than 10% after 2010. These indicators varied by age group and PCA-elderly patients had relatively lower accuracy and higher UEM (approximately 11%). The presence of UEM within one week was better but varied by disease. CONCLUSIONS Considering the data accuracy and UEM discharge status, prioritizing the use of inpatient data after 2010 under CGRD for mortality outcome follow-up studies is recommended.
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Bae NY, Lee SR, Choi EK, Ahn HJ, Ahn HJ, Kwon S, Han KD, Lee KN, Oh S, Lip GYH. Impact of mental disorders on the risk of atrial fibrillation in patients with diabetes mellitus: a nationwide population-based study. Cardiovasc Diabetol 2022; 21:251. [PMID: 36397079 PMCID: PMC9673441 DOI: 10.1186/s12933-022-01682-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 10/20/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND It is unclear whether mental disorders are an independent risk factor for atrial fibrillation (AF) in patients with diabetes. We aimed to investigate whether patients with diabetes who have mental disorders have an increased risk for AF. METHODS Using the Korea National Health Insurance Service database, we enrolled 2,512,690 patients diagnosed with diabetes without AF between 2009 and 2012. We assessed five mental disorders: depression, insomnia, anxiety, bipolar disorder, and schizophrenia. Newly diagnosed AF was identified during the follow-up period, and multivariate Cox regression analysis was performed. RESULTS Among the 2,512,690 patients (mean age 57.2 ± 12.3 years; 60.1% men), 828,929 (33.0%) had mental disorders. Among the five mental disorders, anxiety (68.1%) was the most common, followed by insomnia (40.0%). During a median follow-up duration of 7.1 years, new-onset AF was diagnosed in 79,525 patients (4.66 per 1,000 person-years). Patients with diabetes who had mental disorders showed a higher risk for AF (adjusted hazard ratio [HR] 1.19; 95% confidence interval [CI] 1.17-1.21; p-value < 0.001). Depression, insomnia, and anxiety were significantly associated with higher risk for AF (adjusted HR [95% CI]: 1.15 [1.12-1.17], 1.15 [1.13-1.18], and 1.19 [1.67-1.21], respectively; all p-values < 0.001), whereas bipolar disorder and schizophrenia were not. CONCLUSIONS Mental disorders, especially depression, insomnia, and anxiety, were associated with an increased risk for AF in patients with diabetes. Greater awareness with a prompt diagnosis of AF should be considered for patients with both DM and mental disorders.
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Affiliation(s)
- Nan Young Bae
- grid.412484.f0000 0001 0302 820XDepartment of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - So-Ryoung Lee
- grid.412484.f0000 0001 0302 820XDepartment of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - Eue-Keun Choi
- grid.412484.f0000 0001 0302 820XDepartment of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea ,grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun Jin Ahn
- grid.412484.f0000 0001 0302 820XDepartment of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - Hyo-Jeong Ahn
- grid.412484.f0000 0001 0302 820XDepartment of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - Soonil Kwon
- grid.412484.f0000 0001 0302 820XDepartment of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea
| | - Kyung-Do Han
- grid.263765.30000 0004 0533 3568Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Kyu-Na Lee
- grid.263765.30000 0004 0533 3568Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Seil Oh
- grid.412484.f0000 0001 0302 820XDepartment of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080 Republic of Korea ,grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y. H. Lip
- grid.31501.360000 0004 0470 5905Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea ,grid.10025.360000 0004 1936 8470Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Chest & Heart Hospital, Liverpool, UK ,grid.5117.20000 0001 0742 471XDepartment of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Chuang C, Hsiao FC, Cheng YW, Lin CP, Tung YC, Wu CT, Chen CY, Chu PH. Benzodiazepines in Patients with Heart Failure and Reduced Ejection Fraction. ACTA CARDIOLOGICA SINICA 2022; 38:573-583. [PMID: 36176374 PMCID: PMC9479043 DOI: 10.6515/acs.202209_38(5).20220406a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 04/06/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND In patients with heart failure (HF), anxiety or insomnia is prevalent and associated with poor clinical outcomes. Benzodiazepines (BZDs) are one of the most commonly prescribed medications for anxiety or insomnia in Taiwan. Evidence regarding the effects of BZDs on patients with heart failure and reduced ejection fraction (HFrEF) is inconclusive. OBJECTIVES To evaluate whether BZDs can mitigate the adverse effects of anxiety or insomnia on the prognosis of patients with HFrEF. METHODS Patients with HFrEF were identified from the Chang Gung Research Database between January 1, 2007 and December 31, 2018. Those who received BZD prescriptions were defined as the BZD group; patients in the BZD group were then paired with those who had never been prescribed BZDs after matching for age, sex, and baseline left ventricular ejection fraction, defined as the no-BZD group. Propensity score matching was used to balance baseline characteristics. Cox proportional hazards model and the Fine-Gray subdistribution hazard model were used to examine the association between BZD prescription and the risks of adverse cardiovascular outcomes. RESULTS After propensity score matching, there were 1,941 patients in both BZD and no-BZD groups. The composite of cardiovascular (CV) death or HF hospitalization (HFH) occurred in 64.4% and 54.4% of the patients in the BZD and no-BZD groups, respectively [hazard ratio (HR): 1.44; 95% confidence interval (CI): 1.32-1.56], which was mainly driven by HFH (HR: 1.52; 95% CI: 1.39-1.67). CONCLUSIONS In the patients with HFrEF, those who received BZD were at a higher overall risk of CV death and HFH.
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Affiliation(s)
- Chi Chuang
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center; College of Medicine, Chang Gung University, Taoyuan
| | - Fu-Chih Hsiao
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center; College of Medicine, Chang Gung University, Taoyuan
| | - Yu-Wen Cheng
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center; College of Medicine, Chang Gung University, Taoyuan
| | - Chia-Pin Lin
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center; College of Medicine, Chang Gung University, Taoyuan
| | - Ying-Chang Tung
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center; College of Medicine, Chang Gung University, Taoyuan
| | - Chia-Tung Wu
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center; College of Medicine, Chang Gung University, Taoyuan
| | - Ching-Yen Chen
- Department of Psychiatry, Chang Gung Memorial Hospital at Keelung, Keelung; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pao-Hsien Chu
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center; College of Medicine, Chang Gung University, Taoyuan
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10
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Yildiz M, Lavie CJ, Morin DP, Oktay AA. The complex interplay between diabetes mellitus and atrial fibrillation. Expert Rev Cardiovasc Ther 2022; 20:707-717. [PMID: 35984314 DOI: 10.1080/14779072.2022.2115357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
INTRODUCTION : A growing body of evidence suggests that diabetes mellitus (DM) is associated with an increased risk of new-onset atrial fibrillation (AF) and contributes to suboptimal arrhythmia control and poor prognosis in patients with AF. The high prevalence of AF among patients with DM is primarily attributed to common risk factors, shared pathophysiological mechanisms, and associated atrial remodeling and autonomic dysfunction. AREAS COVERED : This comprehensive review covers the current data on the role of DM in the development and prognosis of AF. In addition, we review the impact of anti-DM medications on AF prevention and the role of anticoagulation in patients with coexisting DM and AF. EXPERT OPINION : DM is independently associated with new-onset AF, and the coexistence of these two conditions contributes to poor outcomes, from reduced quality of life to increased risks of thromboembolic events, heart failure, and mortality. Despite this strong link, the current evidence is insufficient to recommend routine screening for AF in patients with DM. Although some observations exist on preventing AF with anti-DM medications, randomized controlled trials are warranted to explore the proposed benefits of novel anti-DM medicines in reducing the risk of incident AF.
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Affiliation(s)
- Mehmet Yildiz
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, LA
| | - Daniel P Morin
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, LA
| | - Ahmet Afsin Oktay
- The Heart and Vascular Institute, Rush University Medical Center, Chicago, IL
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11
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Kezerle L, Haim M, Akriv A, Senderey AB, Bachrach A, Leventer-Roberts M, Tsadok MA. Relation of Hemoglobin A1C Levels to Risk of Ischemic Stroke and Mortality in Patients With Diabetes Mellitus and Atrial Fibrillation. Am J Cardiol 2022; 172:48-53. [PMID: 35361475 DOI: 10.1016/j.amjcard.2022.02.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 01/25/2022] [Accepted: 02/01/2022] [Indexed: 12/01/2022]
Abstract
Diabetes mellitus (DM) is associated with an increased risk of complications in atrial fibrillation (AF). This study aimed to assess the incidence and risks of ischemic stroke and mortality according to baseline HbA1c levels in patients with DM and AF. We conducted a cohort study using Clalit Health Services electronic medical records. The study population included all Clalit Health Services members aged ≥25 years, with the first diagnosis of AF between January 1, 2010, and December 31, 2016, who had a diagnosis of DM. The risk of stroke and all-cause death were compared according to HbA1c levels at the time of AF diagnosis: <7.0%, between 7% and 9%, and ≥9%. A total of 44,451 patients with DM and AF were identified. The median age was 75 years (interquartile 65 to 83), and 52.5% were women. During a mean follow-up of 38 months, higher levels of HbA1c were associated with an increased risk of stroke with a dose-dependent response when compared with patients with HbA1c <7% (Adjusted hazard ratio [aHR] =1.30 [95% confidence interval 1.10 to 2.05] for levels between 7% and 9% and 1.60 (95% confidence interval 1.25 to 2.03) for HbA1c >9%, even after adjusting for CHA2DS2-Vasc risk factors and use of oral anticoagulants. The risk for overall mortality was significantly higher in the HBA1C >9% group (aHR = 1.17 [1.07 to 1.28]). In conclusion, in this cohort of patients with AF and DM, HbA1c levels were associated with the risk of stroke in a dose-dependent manner even after accounting for other recognized risk factors for stroke.
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Affiliation(s)
- Louise Kezerle
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - Moti Haim
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Amichay Akriv
- Clalit Research Institute, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
| | - Adi Berliner Senderey
- Clalit Research Institute, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
| | - Asaf Bachrach
- Clalit Research Institute, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
| | - Maya Leventer-Roberts
- Clalit Research Institute, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
| | - Meytal Avgil Tsadok
- Clalit Research Institute, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
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12
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Lifestyle Modification and Atrial Fibrillation: Critical Care for Successful Ablation. J Clin Med 2022; 11:jcm11092660. [PMID: 35566788 PMCID: PMC9099891 DOI: 10.3390/jcm11092660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/21/2022] [Accepted: 04/26/2022] [Indexed: 02/07/2023] Open
Abstract
Management of atrial fibrillation (AF) requires a comprehensive approach due to the limited success of medical or procedural approaches in isolation. Multiple modifiable risk factors contribute to the development and progression of the underlying substrate, with a heightened risk of progression evident with inadequate risk factor management. With increased mortality, stroke, heart failure and healthcare utilisation linked to AF, international guidelines now strongly support risk factor modification as a critical pillar of AF care due to evidence demonstrating the efficacy of this approach. Effective lifestyle management is key to arrest and reverse the progression of AF, in addition to increasing the likelihood of freedom from arrhythmia following catheter ablation.
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13
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Huang HK, Liu PPS, Lin SM, Hsu JY, Yeh JI, Lai ECC, Peng CCH, Munir KM, Loh CH, Tu YK. Diabetes-Related Complications and Mortality in Patients With Atrial Fibrillation Receiving Different Oral Anticoagulants : A Nationwide Analysis. Ann Intern Med 2022; 175:490-498. [PMID: 35157495 DOI: 10.7326/m21-3498] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Evidence about the association between types of oral anticoagulants and hazards of diabetes complications is limited in patients with atrial fibrillation (AF) and diabetes mellitus (DM). OBJECTIVE To compare the hazards of diabetes complications and mortality between patients with AF and DM receiving non-vitamin K antagonist oral anticoagulants (NOACs) and those receiving warfarin. DESIGN A retrospective cohort study. SETTING Nationwide data obtained from Taiwan's National Health Insurance Research Database. PATIENTS Patients with AF and DM receiving NOACs or warfarin between 2012 and 2017 in Taiwan were enrolled. Treatment groups were determined by patients' first initiation of oral anticoagulants. MEASUREMENTS Hazards of diabetes complications (macrovascular complications, microvascular complications, and glycemic emergency) and mortality in the NOAC and warfarin users were investigated with a target trial design. Cause-specific Cox proportional hazards models were used to estimate hazard ratios (HRs). Propensity score methods with stabilized inverse probability of treatment weighting were applied to balance potential confounders between treatment groups. RESULTS In total, 19 909 NOAC users and 10 300 warfarin users were included. Patients receiving NOACs had significantly lower hazards of developing macrovascular complications (HR, 0.84 [95% CI, 0.78 to 0.91]; P < 0.001), microvascular complications (HR, 0.79 [CI, 0.73 to 0.85]; P < 0.001), glycemic emergency (HR, 0.91 [CI, 0.83 to 0.99]; P = 0.043), and mortality (HR, 0.78 [CI, 0.75 to 0.82]; P < 0.001) than those receiving warfarin. Analyses with propensity score matching showed similar results. Several sensitivity analyses further supported the robustness of our findings. LIMITATION The claims-based data did not allow for detailed data on patients' lifestyles and laboratory examinations to be obtained. CONCLUSION Non-vitamin K antagonist oral anticoagulants were associated with lower hazards of diabetes complications and mortality than warfarin in patients with AF and DM. PRIMARY FUNDING SOURCE Hualien Tzu Chi Hospital.
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Affiliation(s)
- Huei-Kai Huang
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, and Department of Family Medicine and Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan (H.K.H.)
| | - Peter Pin-Sung Liu
- Center for Aging and Health, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, and Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan (P.P.S.L.)
| | - Shu-Man Lin
- Department of Physical Medicine and Rehabilitation, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, and School of Medicine, Tzu Chi University, Hualien, Taiwan (S.M.L.)
| | - Jin-Yi Hsu
- Center for Aging and Health, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, and School of Medicine, Tzu Chi University, Hualien, Taiwan (J.Y.H., C.H.L.)
| | - Jih-I Yeh
- Department of Family Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, and School of Medicine, Tzu Chi University, Hualien, Taiwan (J.I.Y.)
| | - Edward Chia-Cheng Lai
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan (E.C.C.L.)
| | - Carol Chiung-Hui Peng
- Section of Endocrinology, Diabetes, Nutrition & Weight Management, Boston University School of Medicine, Boston, Massachusetts (C.C.H.P.)
| | - Kashif M Munir
- Division of Endocrinology, Diabetes and Nutrition, University of Maryland School of Medicine, Baltimore, Maryland (K.M.M.)
| | - Ching-Hui Loh
- Center for Aging and Health, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, and School of Medicine, Tzu Chi University, Hualien, Taiwan (J.Y.H., C.H.L.)
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, and Department of Dentistry, National Taiwan University Hospital and School of Dentistry, National Taiwan University, Taipei, Taiwan (Y.K.T.)
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14
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Papazoglou AS, Kartas A, Moysidis DV, Tsagkaris C, Papadakos SP, Bekiaridou A, Samaras A, Karagiannidis E, Papadakis M, Giannakoulas G. Glycemic control and atrial fibrillation: an intricate relationship, yet under investigation. Cardiovasc Diabetol 2022; 21:39. [PMID: 35287684 PMCID: PMC8922816 DOI: 10.1186/s12933-022-01473-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 02/25/2022] [Indexed: 12/26/2022] Open
Abstract
Atrial fibrillation (AF) and diabetes mellitus (DM) constitute two major closely inter-related chronic cardiovascular disorders whose concurrent prevalence rates are steadily increasing. Although, the pathogenic mechanisms behind the AF and DM comorbidity are still vague, it is now clear that DM precipitates AF occurrence. DM also affects the clinical course of established AF; it is associated with significant increase in the incidence of stroke, AF recurrence, and cardiovascular mortality. The impact of DM on AF management and prognosis has been adequately investigated. However, evidence on the relative impact of glycemic control using glycated hemoglobin levels is scarce. This review assesses up-to-date literature on the association between DM and AF. It also highlights the usefulness of glycated hemoglobin measurement for the prediction of AF and AF-related adverse events. Additionally, this review evaluates current anti-hyperglycemic treatment in the context of AF, and discusses AF-related decision-making in comorbid DM. Finally, it quotes significant remaining questions and sets some future strategies with the potential to effectively deal with this prevalent comorbidity.
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Affiliation(s)
- Andreas S Papazoglou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
- Athens Naval Hospital, Athens, Greece
| | - Anastasios Kartas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Dimitrios V Moysidis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | | | - Stavros P Papadakos
- First Department of Pathology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandra Bekiaridou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Athanasios Samaras
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Efstratios Karagiannidis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Marios Papadakis
- University Hospital Witten-Herdecke, University of Witten-Herdecke, Heusnerstrasse 40, 42283, Wuppertal, Germany.
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
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15
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Abdel-Qadir H, Gunn M, Lega IC, Pang A, Austin PC, Singh SM, Jackevicius CA, Tu K, Dorian P, Lee DS, Ko DT. Association of Diabetes Duration and Glycemic Control With Stroke Rate in Patients With Atrial Fibrillation and Diabetes: A Population-Based Cohort Study. J Am Heart Assoc 2022; 11:e023643. [PMID: 35132863 PMCID: PMC9245806 DOI: 10.1161/jaha.121.023643] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background There are limited data on the association of diabetes duration and glycemic control with stroke risk in atrial fibrillation (AF). Our objective was to study the association of diabetes duration and glycated hemoglobin (HbA1c) with the rate of stroke in people with diabetes and newly diagnosed AF. Methods and Results This was a population‐based cohort study using linked administrative data sets. We studied 37 209 individuals aged ≥66 years diagnosed with AF in Ontario between April 2009 and March 2019, who had diabetes diagnosed 1 to 16 years beforehand. The primary outcome was hospitalization for stroke at 1 year. Cause‐specific hazard regression was used to model the association of diabetes duration and glycated hemoglobin (HbA1c) with the rate of stroke. Restricted cubic spline analyses showed increasing hazard ratios (HR) for stroke with longer diabetes duration that plateaued after 10 years and increasing HRs for stroke with HbA1c levels >7%. Relative to patients with <5 years diabetes duration, stroke rates were significantly higher for patients with ≥10 years duration (HR, 1.45; 95% CI, 1.16–1.82; P=0.001), while diabetes duration 5 to <10 years was not significantly different. Relative to glycated hemoglobin 6% to <7%, values ≥8% were associated with higher stroke rates (HR, 1.44; 95% CI, 1.12–1.84; P=0.004), while other HbA1c categories were not significantly different. Conclusions Longer diabetes duration and higher glycated hemoglobin were associated with significantly higher stroke rates in patients with AF and diabetes. Models for stroke risk prediction and preventive care in AF may be improved by considering patients’ diabetes characteristics.
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Affiliation(s)
- Husam Abdel-Qadir
- Women's College Hospital Toronto Canada.,University Health Network Toronto Canada.,ICES (Formerly Known as the Institute for Clinical Evaluative Sciences) Toronto Canada.,Institute of Health Policy Management, and Evaluation University of Toronto Canada.,Department of Medicine University of Toronto Canada
| | - Madison Gunn
- Schulich School of Medicine Western University London ON Canada
| | - Iliana C Lega
- Women's College Hospital Toronto Canada.,ICES (Formerly Known as the Institute for Clinical Evaluative Sciences) Toronto Canada.,Department of Medicine University of Toronto Canada
| | - Andrea Pang
- ICES (Formerly Known as the Institute for Clinical Evaluative Sciences) Toronto Canada
| | - Peter C Austin
- ICES (Formerly Known as the Institute for Clinical Evaluative Sciences) Toronto Canada.,Institute of Health Policy Management, and Evaluation University of Toronto Canada
| | - Sheldon M Singh
- Department of Medicine University of Toronto Canada.,Schulich Heart Centre Sunnybrook Health Sciences Centre Toronto Canada
| | - Cynthia A Jackevicius
- University Health Network Toronto Canada.,ICES (Formerly Known as the Institute for Clinical Evaluative Sciences) Toronto Canada.,Institute of Health Policy Management, and Evaluation University of Toronto Canada.,College of Pharmacy Western University of Health Sciences Pomona CA
| | - Karen Tu
- University Health Network Toronto Canada.,Institute of Health Policy Management, and Evaluation University of Toronto Canada.,North York General Hospital Toronto Canada.,Department of Family and Community Medicine University of Toronto Canada
| | - Paul Dorian
- Department of Medicine University of Toronto Canada.,Division of Cardiology Unity Health Toronto Canada
| | - Douglas S Lee
- University Health Network Toronto Canada.,ICES (Formerly Known as the Institute for Clinical Evaluative Sciences) Toronto Canada.,Institute of Health Policy Management, and Evaluation University of Toronto Canada.,Department of Medicine University of Toronto Canada
| | - Dennis T Ko
- ICES (Formerly Known as the Institute for Clinical Evaluative Sciences) Toronto Canada.,Institute of Health Policy Management, and Evaluation University of Toronto Canada.,Department of Medicine University of Toronto Canada.,Schulich Heart Centre Sunnybrook Health Sciences Centre Toronto Canada
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16
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Fauchier L, Boriani G, de Groot JR, Kreutz R, Rossing P, Camm AJ. Medical therapies for prevention of cardiovascular and renal events in patients with atrial fibrillation and diabetes mellitus. Europace 2021; 23:1873-1891. [PMID: 34411235 DOI: 10.1093/europace/euab184] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/05/2021] [Indexed: 02/06/2023] Open
Abstract
Atrial fibrillation (AF), type 2 diabetes mellitus (DM), and chronic kidney disease (CKD) are three global epidemics with significant effects on morbidity and mortality. Diabetes is a risk factor for AF, and a risk factor for thromboembolism, comorbidity, and mortality when AF is present. The pathophysiology of diabetes-related AF and interrelationships with cardiovascular events and renal events is not fully understood but is in part related to structural, electrical, electromechanical, and autonomic remodelling. The current practice guidelines offer limited recommendations on the management of patients with AF (or risk of AF) and diabetes with its own heterogeneity for the prevention of cardiovascular and renal events. This document discusses possible clinical approaches for these patients. In the last decade, there have been major improvements for the prevention of stroke in AF patients with direct oral anticoagulants, which are preferable to vitamin K antagonists for stroke prevention in DM. Because of the increased risk rate for several cardiovascular adverse events in diabetic patients, a similar relative risk reduction generally translates into greater absolute risk reduction in the diabetic population. Recent trials with non-insulin diabetes drugs using glucagon-like peptide-1 agonists and sodium-glucose cotransporter-2 inhibitors showed a significant reduction for the risk of major adverse cardiovascular events in patients with type 2 DM. Sodium-glucose cotransporter-2 inhibitors also showed a large reduction in hospitalization for heart failure and renal events, which need to be more completely evaluated in patients with AF. Mechanisms, risks, and optimal management of AF patients with DM who have or are under risk of developing heart failure or CKD are also discussed in this document. The benefits of medical therapies for these patients still need to be put into perspective, and gaps in evidence on some of these issues are likely to be addressed in future years.
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Affiliation(s)
- Laurent Fauchier
- Department of Cardiology, Centre Hospitalier Universitaire Trousseau et Université de Tours, Tours 37044, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Joris R de Groot
- Department of Cardiology, Amsterdam University Medical Centres/University of Amsterdam, Amsterdam, The Netherlands
| | - Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Clinical Pharmacology and Toxicology, Charité University Medicine, Berlin, Germany
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - A John Camm
- Cardiology Clinical Academic Group Molecular and Clinical Sciences Institute, St George's University of London, London, UK
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17
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Wei Y, Cui M, Liu S, Yu H, Feng J, Gao W, Li L. Increased hemoglobin A1c level associates with low left atrial appendage flow velocity in patients of atrial fibrillation. Nutr Metab Cardiovasc Dis 2021; 31:3176-3183. [PMID: 34629254 DOI: 10.1016/j.numecd.2021.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 07/15/2021] [Accepted: 07/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS High hemoglobin A1c (HbAlc) level is associated with increased cardiovascular disease risk and thromboembolic events [1]. The study sought to explored the association between HbAlc and left atrial appendage flow velocity (LAAV) among non-valvular atrial fibrillation (AF) patients. METHODS AND RESULTS A total of 249 consecutive non-valvular AF patients who underwent transesophageal echocardiography (TEE) were divided into two subgroups according to the median of LAAV level (<45 cm/s, ≥45 cm/s). Blood samples and other baseline clinical data of all patients were collected and analyzed. The low LAAV group included 126 patients and the high LAAV group included 123 patients. Patients in the low LAAV group were older and had a higher percentage of persistent AF, chronic heart failure, and higher CHA2DS2-VASc score (P < 0.05). HbAlc level in the low LAAV group was significantly higher than the high LAAV group [6.1 (5.7-6.5)% vs 5.9 (5.6-6.2)%, P = 0.010]. The low LAAV group had larger left atrial diameter (LAD), left atrial area (LAA), higher left atrial pressure (LAP), and lower left ventricular ejection fraction (LVEF) (P < 0.05). Spearman rank correlation analysis showed that the HbAlc level was negatively correlated with LAAV (r = -0.211, P = 0.001). Multivariate analysis indicated that female gender (OR = 2.233, 95% CI 1.110-4.492, P = 0.024), persistent AF (OR = 6.610, 95% CI 3.109-14.052, P < 0.001), and HbAlc (OR = 1.903, 95% CI 1.092-3.317, P = 0.023) were independent factors that associated with low LAAV in AF patients. CONCLUSION Increased HbAlc level is associated with decreased LAAV and may reflect a low contractile function of the left atrial appendage.
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Affiliation(s)
- Ying Wei
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China
| | - Ming Cui
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China
| | - Shuwang Liu
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China
| | - Haiyi Yu
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China
| | - Jieli Feng
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China
| | - Wei Gao
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China
| | - Lei Li
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China.
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18
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Matos-Ribeiro J, Castro-Chaves P, Oliveira-Ferreira M, Fonseca L, Pintalhao M. Early anticoagulation in atrial fibrillation-related acute ischaemic stroke: efficacy and safety profile. J Neurol 2021; 269:2099-2112. [PMID: 34499205 DOI: 10.1007/s00415-021-10788-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/15/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To evaluate the effects of early anticoagulation on functional outcome, recurrent ischaemic events and haemorrhagic complications in Atrial Fibrillation (AF)-related acute ischaemic strokes (AIS). MATERIALS AND METHODS We retrospectively evaluated patients hospitalised in a Stroke Unit due to AF-related AIS. Patients were divided according to anticoagulation initiation timing (0-4 days, 5-14 days, no anticoagulation by the 14th day). We assessed the following outcomes at 3 months: favourable functional outcome [modified Rankin Scale (mRS) score 0-2 or equal to pre-stroke], recurrent ischaemic events and haemorrhagic complications after anticoagulation initiation. RESULTS We included 395 patients. Anticoagulation was initiated at days 0-4 in 33.9% of patients, days 5-14 in 25.3% and not initiated by the day 14 in 40.8%. Factors associated with earlier anticoagulation included lower previous mRS, valvular AF and lower stroke severity. Favourable functional outcome occurred in 40.2% of patients, with lower odds in those anticoagulated at 5-14 versus 0-4 days (OR: 0.47, 95% CI: 0.23-0.94), independently of age, previous mRS and stroke severity. Recurrent ischaemic events occurred in 8.3% of patients, with higher odds in non-anticoagulated patients by the 14th day, compared to the remainder groups (OR: 3.26, 95% CI: 1.29-8.22 vs. 0-4 days and OR: 8.16, 95% CI: 1.76-37.9 vs. 5-14 days). In patients who started anticoagulation (n = 288), haemorrhagic complications occurred in 10.8%, being more frequent in those who started at 0-4 days vs. > 14 days. However, it did not abolish the 0-4-day initiation's benefit on functional outcome. CONCLUSIONS Early anticoagulation was associated with lower ischaemic recurrence and better functional outcome at 3 months. Additional studies are needed to better clarify its haemorrhagic risk.
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Affiliation(s)
- Joao Matos-Ribeiro
- Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.
| | - Paulo Castro-Chaves
- Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Cardiovascular Research Centre (UnIC), Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Stroke Unit, Department of Internal Medicine, São João Hospital Centre, Porto, Portugal
| | | | - Luísa Fonseca
- Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Department of Medicine, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mariana Pintalhao
- Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Cardiovascular Research Centre (UnIC), Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Stroke Unit, Department of Internal Medicine, São João Hospital Centre, Porto, Portugal
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19
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Gallagher C, Fitzgerald JL, Stokes MB, Noubiap JJ, Elliott AD, Hendriks JM, Middeldorp ME, Sanders P, Lau DH. Risk Factor Management in Atrial Fibrillation: How to Deliver a Successful Clinic. CURRENT CARDIOVASCULAR RISK REPORTS 2021. [DOI: 10.1007/s12170-021-00671-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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20
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Korgaonkar S, Yang Y, Banahan B, Bentley JP. Comparative effectiveness and safety of non-vitamin-K antagonist oral anticoagulants and warfarin in older adults with atrial fibrillation and diabetes. Curr Med Res Opin 2021; 37:343-356. [PMID: 33327796 DOI: 10.1080/03007995.2020.1865748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate comparative effectiveness and safety of non-vitamin-K antagonist oral anticoagulants (NOACs) versus warfarin in Medicare beneficiaries with non-valvular atrial fibrillation (NVAF) and comorbid diabetes mellitus (DM). METHODS A retrospective cohort study using 2014-2016 5% national Medicare data was undertaken. NVAF patients with DM aged ≥65 years having at least one prescription for NOACs or warfarin between July 2014 and December 2015 were included in the study. Propensity score matching was used to balance demographic and baseline clinical characteristics of patients in two treatment groups. Cardiovascular outcomes including stroke/systemic embolism (SE) and myocardial infarction (MI) were evaluated to measure effectiveness. Assessment of safety outcomes included intracranial hemorrhage (ICH), major gastrointestinal bleeding (MGB), bleeding from other sites (OB) and all-cause mortality. Stratified Cox proportional hazards models were used to estimate hazard ratios for the outcomes in the matched cohort. RESULTS The matched sample consisted of 4582 patients (2291 pairs). Compared to warfarin, NOACs had a significantly lower risk of stroke/SE (hazard ratio (HR): 0.373, 95% confidence interval (CI): 0.247-0.564, p < .001) and all-cause mortality (HR: 0.783, CI: 0.656-0.873, p = .007). NOACs were found to significantly reduce the risk of ICH (HR: 0.500, CI: 0.300-0.834, p = .008) and OB (HR: 0.608, CI: 0.424-0.870, p = .007), but no difference was observed in the risk of MGB (HR: 0.862, CI: 0.640-1.160, p = .326) between NOACs and warfarin. The composite outcome demonstrated superior overall effectiveness and safety of NOAC therapy compared to warfarin therapy (HR: 0.685, CI: 0.587-0.801, p < .001). CONCLUSION Oral anticoagulation therapy with NOACs was found to be more effective than warfarin therapy among older adults with NVAF and comorbid DM.
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Affiliation(s)
- Siddhi Korgaonkar
- Department of Pharmacy Administration, The University of Mississippi, University, MS, USA
| | - Yi Yang
- Department of Pharmacy Administration, The University of Mississippi, University, MS, USA
- Center for Pharmaceutical Marketing and Management, The University of Mississippi, University, MS, USA
| | - Benjamin Banahan
- Department of Pharmacy Administration, The University of Mississippi, University, MS, USA
- Center for Pharmaceutical Marketing and Management, The University of Mississippi, University, MS, USA
| | - John P Bentley
- Department of Pharmacy Administration, The University of Mississippi, University, MS, USA
- Center for Pharmaceutical Marketing and Management, The University of Mississippi, University, MS, USA
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21
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Papazoglou AS, Kartas A, Samaras A, Vouloagkas I, Vrana E, Moysidis DV, Akrivos E, Kotzampasis G, Baroutidou A, Papanastasiou A, Liampas E, Botis M, Karagiannidis E, Stalikas N, Karvounis H, Tzikas A, Giannakoulas G. Prognostic significance of diabetes mellitus in patients with atrial fibrillation. Cardiovasc Diabetol 2021; 20:40. [PMID: 33573666 PMCID: PMC7879654 DOI: 10.1186/s12933-021-01232-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 01/29/2021] [Indexed: 02/08/2023] Open
Abstract
Background There are limited data on the association of diabetes mellitus (DM) and levels of glycated hemoglobin (HbA1c) with outcomes in patients with atrial fibrillation (AF). Methods This retrospective cohort study included patients who were recently hospitalized with a primary or secondary diagnosis of AF from December 2015 through June 2018. Kaplan–Meier curves and Cox-regression adjusted hazard ratios (aHR) were calculated for the primary outcome of all-cause mortality and for the secondary outcomes of cardiovascular (CV) mortality and the composite outcome of CV death or hospitalization. Competing-risk regression analyses were performed to calculate the cumulative risk of stroke, major bleeding, AF- or HF-hospitalizations adjusted for the competing risk of all-cause death. Spline curve models were fitted to investigate associations of HbA1c values and mortality among patients with AF and DM. Results In total 1109 AF patients were included, of whom 373 (33.6%) had DM. During a median follow-up of 2.6 years, 414 (37.3%) patients died. The presence of DM was associated with a higher risk of all-cause mortality (aHR = 1.40 95% confidence intervals [CI] 1.11–1.75), CV mortality (aHR = 1.39, 95% CI 1.07–1.81), sudden cardiac death (aHR = 1.73, 95% CI 1.19–2.52), stroke (aHR = 1.87, 95% CI 1.01–3.45) and the composite outcome of hospitalization or CV death (aHR = 1.27, 95% CI 1.06–1.53). In AF patients with comorbid DM, the spline curves showed a positive linear association between HbA1c levels and outcomes, with values 7.6–8.2% being independent predictors of increased all-cause mortality, and values < 6.2% predicting significantly decreased all-cause and CV mortality. Conclusions The presence of DM on top of AF was associated with substantially increased risk for all-cause or CV mortality, sudden cardiac death and excess morbidity. HbA1c levels lower than 6.2% were independently related to better survival rates suggesting that optimal DM control could be associated with better clinical outcomes in AF patients with DM. ![]()
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Affiliation(s)
- Andreas S Papazoglou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Anastasios Kartas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Athanasios Samaras
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Ioannis Vouloagkas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Eleni Vrana
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Dimitrios V Moysidis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Evangelos Akrivos
- Laboratory of Computing, Medical Informatics and Biomedical Imaging Technologies, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Kotzampasis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Amalia Baroutidou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Anastasios Papanastasiou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Evangelos Liampas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Michail Botis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Efstratios Karagiannidis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Nikolaos Stalikas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Haralambos Karvounis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Apostolos Tzikas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece.,Interbalkan European Medical Center, Asklipiou 10, Pylaia, Thessaloniki, Greece
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece.
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22
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Yu D, Zhao Z, Simmons D. Cardiovascular risks and bleeding with non-vitamin K antagonist oral anticoagulant versus warfarin in patients with type 2 diabetes: a tapered matching cohort study. Cardiovasc Diabetol 2020; 19:174. [PMID: 33038936 PMCID: PMC7548035 DOI: 10.1186/s12933-020-01152-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/05/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND We compared the risk of bleeding and cardiovascular disease (CVD) events between non-vitamin K antagonist oral anticoagulant (NOAC) and warfarin in people with type 2 diabetes (T2DM). METHODS 862 Incident NOAC users and 626 incident warfarin users with T2DM were identified from within 40 UK general practice (1/4/2017-30/9/2018). Outcomes included incident hospitalisation for bleeding, CVD and re-hospitalisation for CVD within 12 months since first anticoagulant prescription, identified from linked hospitalisation data. A tapered matching method was applied to form comparison cohorts: coarsened exact matching restricted the comparison to areas of sufficient overlap in missingness and characteristics: (i) demographic characteristics; (ii) clinical measurements; (iii) prior bleeding and CVD history; (iv) prescriptions with bleeding; (v) anti-hypertensive treatment(s); (vi) anti-diabetes treatment(s). Entropy balancing sequentially balanced NOAC and warfarin users on their distribution of (i-vi). Weighted logistic regression modelling estimated outcome odds ratios (ORs), using entropy balancing weights from steps i-vi. RESULTS The 12-month ORs of bleeding with NOAC (n = 582) vs matched/balanced warfarin (n = 486) were 1.93 (95% confidence interval 0.97-3.84), 2.14 (1.03-4.44), 2.31 (1.10-4.85), 2.42 (1.14-5.14), 2.41 (1.12-5.18), and 2.51 (1.17-5.38) through steps i-vi. ORs for CVD re-hospitalisation was increased with NOAC treatment through steps i-vi: 2.21 (1.04-4.68), 2.13 (1.01-4.52), 2.47 (1.08-5.62), 2.46 (1.02-5.94), 2.51 (1.01-6.20), and 2.66 (1.02-6.94). CONCLUSIONS Incident NOAC use among T2DM is associated with increased risk of bleeding hospitalisation and CVD re-hospitalisation compared with incident warfarin use. For T2DM, caution is required in prescribing NOACs as first anticoagulant treatment. Further large-scale replication studies in external datasets are warranted.
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Affiliation(s)
- Dahai Yu
- Department of Nephrology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, ST5 5BG, UK
| | - Zhanzheng Zhao
- Department of Nephrology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China.
| | - David Simmons
- Department of Nephrology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China.
- Macarthur Clinical School, School of Medicine, Western Sydney University, Locked Bag 1797, Campbelltown, Sydney, NSW, 2751, Australia.
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