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Krittayaphong R, Boonyapisit W, Sairat P, Lip GYH. Visit-to-Visit Heart Rate Variability in the Prediction of Clinical Outcomes of Patients with Atrial Fibrillation. Thromb Haemost 2023; 123:920-929. [PMID: 37116533 DOI: 10.1055/s-0043-1768580] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
BACKGROUND Visit-to-visit heart rate variability (VVV-HR) has been associated with adverse cardiovascular outcomes. We aimed to determine the predictive value of VVV-HR for adverse clinical outcomes in patients with nonvalvular atrial fibrillation (AF). METHODS We used data from a prospective multicenter AF registry of 27 hospitals in Thailand during 2014 to 2017. After the baseline visit, patients were followed up every 6 months until 3 years. VVV-HR was calculated from the standard deviation of heart rate data from baseline visit and every follow-up visit. VVV-HR was categorized into four groups according to the quartiles. Clinical outcomes were all-cause death, ischemic stroke/systemic embolism (SE), and heart failure. Cox proportional hazard models were used for multivariable analysis. RESULTS There were a total of 3,174 patients (mean age: 67.7 years; 41.8% female). The incidence rates of all-cause death, ischemic stroke/SE, and heart failure were 3.10 (2.74-3.49), 1.42 (1.18-1.69), and 2.09 (1.80-2.42) per 100 person-years respectively. The average heart rate was 77.8 ± 11.0 bpm and the average of standard deviation of heart rate was 11.0 ± 5.9 bpm. VVV-HR Q4 was an independent predictor of all-cause death, ischemic stroke/SE, and heart failure with adjusted hazard ratios of 1.45 (95% confidence interval: 1.07-1.98), 2.02 (1.24-3.29), and 2.63 (1.75-3.96), respectively. VVV-HR still remained a significant predictor of clinical outcomes when analyzed based on coefficient of variation and variability independent of mean. CONCLUSION VVV-HR is an independent predictor for adverse clinical outcomes in patients with AF. A J-curve appearance was demonstrated for the effect of VVV-HR on all-cause death.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Warangkna Boonyapisit
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Poom Sairat
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Krittayaphong R, Pumprueg S, Kaewkumdee P, Yindeengam A, Lip GYH. Three-year outcomes of patients with non-valvular atrial fibrillation: the COOL-AF registry. J Geriatr Cardiol 2023; 20:163-173. [PMID: 37091259 PMCID: PMC10114190 DOI: 10.26599/1671-5411.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND Clinical outcomes of patients with non-valvular atrial fibrillation (AF) in Asian populations may be different from non-Asians. In this study, we aimed to determine the incidence of ischemic stroke/systemic embolism (SSE), major bleeding, and death, and the predictors for clinical outcomes in a contemporary Asian cohort of newly diagnosed AF patients. METHODS This is a prospective multicenter nationwide registry of patients with AF from 27 hospitals in Thailand. Baseline data and follow-up data were collected every 6 months until 3 years. Data collections included demographic, medical history, laboratory, and medication details. Clinical outcomes were SSE, major bleeding, and all-cause mortality. Incidence rates for each clinical outcome were calculated and presented as rate per 100 person-years. Univariate and multivariate analysis was performed to determine the independent predictors for clinical outcomes. RESULTS There was a total of 3405 patients: mean age was 67.8 ± 11.3 years, 1981 (58.2%) were male. During 30.8 ± 9.7 months follow-up, there was a total of 132 SSE (3.9%), 191 major bleeding (5.6%), and 357 all-cause deaths (10.5%). The incidence rates of SSE, major bleeding, and death were 1.56 (1.30-1.84), 2.26 (1.96-2.61), and 4.17 (3.33-4.25), per 100 person-years respectively. Independent predictors for clinical outcomes were age, type of AF, and the presence of comorbid conditions. CONCLUSION The incidence rate of SSE, major bleeding, and death remains high reflecting the unmet needs in AF management.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Satchana Pumprueg
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pontawee Kaewkumdee
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ahthit Yindeengam
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Gregory YH Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Krittayaphong R, Chichareon P, Komoltri C, Sairat P, Lip GYH. Predicting Heart Failure in Patients with Atrial Fibrillation: A Report from the Prospective COOL-AF Registry. J Clin Med 2023; 12:jcm12041265. [PMID: 36835801 PMCID: PMC9967148 DOI: 10.3390/jcm12041265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/13/2023] [Accepted: 01/20/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND This study aimed to determine risk factors and incidence rate and develop a predictive risk model for heart failure for Asian patients with atrial fibrillation (AF). METHODS This is a prospective multicenter registry of patients with non-valvular AF in Thailand conducted between 2014 and 2017. The primary outcome was the occurrence of an HF event. A predictive model was developed using a multivariable Cox-proportional model. The predictive model was assessed using C-index, D-statistics, Calibration plot, Brier test, and survival analysis. RESULTS There were a total of 3402 patients (average age 67.4 years, 58.2% male) with mean follow-up duration of 25.7 ± 10.6 months. Heart failure occurred in 218 patients during follow-up, representing an incidence rate of 3.03 (2.64-3.46) per 100 person-years. There were ten HF clinical factors in the model. The predictive model developed from these factors had a C-index and D-statistic of 0.756 (95% CI: 0.737-0.775) and 1.503 (95% CI: 1.372-1.634), respectively. The calibration plots showed a good agreement between the predicted and observed model with the calibration slope of 0.838. The internal validation was confirmed using the bootstrap method. The Brier score indicated that the model had a good prediction for HF. CONCLUSIONS We provide a validated clinical HF predictive model for patients with AF, with good prediction and discrimination values.
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Affiliation(s)
- Rungroj Krittayaphong
- Department of Medicine, Division of Cardiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
- Correspondence: ; Tel.: +66-2-419-6104; Fax: +66-2-412-7412
| | - Ply Chichareon
- Cardiology Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkla 90110, Thailand
| | - Chulalak Komoltri
- Department of Research Promotion, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Poom Sairat
- Department of Medicine, Division of Cardiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK
- Department of Clinical Medicine, Aalborg University, 9220 Aalborg, Denmark
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Ono K, Iwasaki Y, Akao M, Ikeda T, Ishii K, Inden Y, Kusano K, Kobayashi Y, Koretsune Y, Sasano T, Sumitomo N, Takahashi N, Niwano S, Hagiwara N, Hisatome I, Furukawa T, Honjo H, Maruyama T, Murakawa Y, Yasaka M, Watanabe E, Aiba T, Amino M, Itoh H, Ogawa H, Okumura Y, Aoki‐Kamiya C, Kishihara J, Kodani E, Komatsu T, Sakamoto Y, Satomi K, Shiga T, Shinohara T, Suzuki A, Suzuki S, Sekiguchi Y, Nagase S, Hayami N, Harada M, Fujino T, Makiyama T, Maruyama M, Miake J, Muraji S, Murata H, Morita N, Yokoshiki H, Yoshioka K, Yodogawa K, Inoue H, Okumura K, Kimura T, Tsutsui H, Shimizu W. JCS/JHRS 2020 Guideline on Pharmacotherapy of Cardiac Arrhythmias. J Arrhythm 2022; 38:833-973. [PMID: 36524037 PMCID: PMC9745564 DOI: 10.1002/joa3.12714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Ono K, Iwasaki YK, Akao M, Ikeda T, Ishii K, Inden Y, Kusano K, Kobayashi Y, Koretsune Y, Sasano T, Sumitomo N, Takahashi N, Niwano S, Hagiwara N, Hisatome I, Furukawa T, Honjo H, Maruyama T, Murakawa Y, Yasaka M, Watanabe E, Aiba T, Amino M, Itoh H, Ogawa H, Okumura Y, Aoki-Kamiya C, Kishihara J, Kodani E, Komatsu T, Sakamoto Y, Satomi K, Shiga T, Shinohara T, Suzuki A, Suzuki S, Sekiguchi Y, Nagase S, Hayami N, Harada M, Fujino T, Makiyama T, Maruyama M, Miake J, Muraji S, Murata H, Morita N, Yokoshiki H, Yoshioka K, Yodogawa K, Inoue H, Okumura K, Kimura T, Tsutsui H, Shimizu W. JCS/JHRS 2020 Guideline on Pharmacotherapy of Cardiac Arrhythmias. Circ J 2022; 86:1790-1924. [DOI: 10.1253/circj.cj-20-1212] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | - Yu-ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Masaharu Akao
- Department of Cardiovascular Medicine, National Hospital Organization Kyoto Medical Center
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School of Medicine
| | - Kuniaki Ishii
- Department of Pharmacology, Yamagata University Faculty of Medicine
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yoshinori Kobayashi
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital
| | | | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | | | - Tetsushi Furukawa
- Department of Bio-information Pharmacology, Medical Research Institute, Tokyo Medical and Dental University
| | - Haruo Honjo
- Research Institute of Environmental Medicine, Nagoya University
| | - Toru Maruyama
- Department of Hematology, Oncology and Cardiovascular Medicine, Kyushu University Hospital
| | - Yuji Murakawa
- The 4th Department of Internal Medicine, Teikyo University School of Medicine, Mizonokuchi Hospital
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center
| | - Eiichi Watanabe
- Department of Cardiology, Fujita Health University School of Medicine
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Mari Amino
- Department of Cardiovascular Medicine, Tokai University School of Medicine
| | - Hideki Itoh
- Division of Patient Safety, Hiroshima University Hospital
| | - Hisashi Ogawa
- Department of Cardiology, National Hospital Organisation Kyoto Medical Center
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Chizuko Aoki-Kamiya
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center
| | - Jun Kishihara
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Eitaro Kodani
- Department of Cardiovascular Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Takashi Komatsu
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University School of Medicine
| | | | | | - Tsuyoshi Shiga
- Department of Clinical Pharmacology and Therapeutics, The Jikei University School of Medicine
| | - Tetsuji Shinohara
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Atsushi Suzuki
- Department of Cardiology, Tokyo Women's Medical University
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute
| | - Yukio Sekiguchi
- Department of Cardiology, National Hospital Organization Kasumigaura Medical Center
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Noriyuki Hayami
- Department of Fourth Internal Medicine, Teikyo University Mizonokuchi Hospital
| | | | - Tadashi Fujino
- Department of Cardiovascular Medicine, Toho University, Faculty of Medicine
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Mitsunori Maruyama
- Department of Cardiovascular Medicine, Nippon Medical School Musashi Kosugi Hospital
| | - Junichiro Miake
- Department of Pharmacology, Tottori University Faculty of Medicine
| | - Shota Muraji
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | | | - Norishige Morita
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital
| | - Hisashi Yokoshiki
- Department of Cardiovascular Medicine, Sapporo City General Hospital
| | - Koichiro Yoshioka
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine
| | - Kenji Yodogawa
- Department of Cardiovascular Medicine, Nippon Medical School
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
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Krittayaphong R, Aroonsiriwattana S, Ngamjanyaporn P, Patmuk T, Kaewkumdee P. Outcomes of patients with atrial fibrillation with and without diabetes: A propensity score matching of the COOL-AF registry. Int J Clin Pract 2021; 75:e14671. [PMID: 34324768 DOI: 10.1111/ijcp.14671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/22/2021] [Accepted: 07/26/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND To investigate the clinical outcomes of patients with non-valvular atrial fibrillation (NVAF) compared between those with and without diabetes mellitus (DM). METHODS We conducted a prospective multicenter nationwide registry for patients with NVAF from 27 hospitals in Thailand. Patients were followed-up every 6 months until 3 years. The outcome measurements were ischemic stroke (IS) or transient ischemic attack (TIA), major bleeding, and heart failure (HF). All reported events were confirmed by the adjudication committee. DM was diagnosed by history or laboratory data. RESULTS We studied 3402 patients. DM was diagnosed in 923 patients (27.1%). The average follow-up duration was 25.74 ± 10.57 months (7912 persons-year). The rate of IS/TIA, major bleeding, and HF was 1.42, 2.11, and 3.03 per 100 person-years. Patients with DM had a significantly increased risk of IS/TIA, major bleeding, and HF. After adjusting for age, gender, comorbid conditions, and the use of oral anticoagulant (OAC) using propensity score matching, DM remained a significant predictor of ischemic stroke/TIA, major bleeding and HF with Hazard ratio and 95% confidence interval of 1.67 (1.02, 2.73), 1.65 (1.13, 2.40), and 1.87 (1.34, 2.59), respectively. The net clinical benefit of OAC was more pronounced in DM patients (0.88 events per 100 person-years) than in those without DM (-0.73 events per 100 person-years). CONCLUSIONS DM increases the risk of adverse clinical outcomes in NVAF patients. The benefit of OAC outweighs the risk in DM patients.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | | | - Thanasak Patmuk
- Department of Cardiology, Ratchaburi Hospital, Ratchaburi, Thailand
| | - Pontawee Kaewkumdee
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Krittayaphong R, Phrommintikul A, Winijkul A, Methavigul K, Komoltri C, Kaewkumdee P, Yindeengam A. Influence of gender on the clinical outcomes of Asian non-valvular atrial fibrillation patients: insights from the prospective multicentre COOL-AF registry. BMJ Open 2021; 11:e043862. [PMID: 33958338 PMCID: PMC8103947 DOI: 10.1136/bmjopen-2020-043862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To determine the effect of gender on clinical outcomes of Asian non-valvular atrial fibrillation patients. DESIGN This is a cohort study. SETTING 27 university and regional hospitals in Thailand. PARTICIPANTS Patients with non-valvular atrial fibrillation. PRIMARY AND SECONDARY OUTCOMES MEASURES The clinical outcomes were ischaemic stroke/transient ischaemic attack (TIA), major bleeding, intracerebral haemorrhage (ICH), heart failure and death. Follow-up data were recorded every 6 months until 3 years. Differences in clinical outcomes between males and females were determined. Multivariate analysis was performed to assess the effect of gender on clinical outcomes. Survival analysis and log-rank test were performed to determine the time-dependent effect of clinical outcomes, and the difference between males and females. Effect of oral anticoagulant (OAC) on outcomes and net clinical benefit of OAC was assessed. The analysis was performed both for the whole dataset and propensity score matching with multiple imputation. RESULTS A total of 3402 patients (mean age: 67.4±11.3 years; 58.2% male) were included. Average follow-up duration 25.7±10.6 months (7192.6 persons-year). Rate of ischaemic stroke/TIA, major bleeding, ICH, heart failure and death were 1.43 (1.17-1.74), 2.11 (1.79-2.48), 0.70 (0.52-0.92), 3.03 (2.64-3.46) and 3.77 (3.33-4.25) per 100 person-years. Females had increased risk for ischaemic stroke/TIA and heart failure and males had increased risk for major bleeding and ICH. Ischaemic stroke/TIA risk in females and major bleeding and ICH risk in males remained even after correction for age, comorbid conditions and anticoagulation treatment. OAC reduced the risk of ischaemic stroke/TIA in males and females, and markedly increased the risk of major bleeding and ICH in males. CONCLUSIONS Females had a higher risk of ischaemic stroke/TIA and heart failure, and a lower risk of major bleeding and ICH compared with males. OAC reduced risk of ischaemic stroke/TIA in females, and markedly increased risk of major bleeding and ICH in males.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Arintaya Phrommintikul
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Arjbordin Winijkul
- Division of Cardiology, Department of Medicine, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | | | - Chulalak Komoltri
- Division of Cardiology, Department of Medicine, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Pontawee Kaewkumdee
- Division of Cardiology, Department of Medicine, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Ahthit Yindeengam
- Division of Cardiology, Department of Medicine, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
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Krittayaphong R, Boonyapiphat T, Wongvipaporn C, Sairat P. Age-Related Clinical Outcomes of Patients with Non-Valvular Atrial Fibrillation: Insights from the COOL-AF Registry. Clin Interv Aging 2021; 16:707-719. [PMID: 33953549 PMCID: PMC8089026 DOI: 10.2147/cia.s302389] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/24/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE We aimed to compare the rate of clinical outcomes among three age groups (<65, 65-74, and ≥75 years) of adult patients with non-valvular atrial fibrillation (NVAF). PATIENTS AND METHODS We prospectively enrolled NVAF patients from 27 Thailand medical centers. The following were collected at baseline: demographic data, risk factors, comorbid conditions, laboratory data, and medications. The clinical outcomes were ischemic stroke (IS) or transient ischemic attack (TIA), major bleeding (MB), intracerebral hemorrhage (ICH), heart failure (HF), and death. All events were adjudicated. Patients were categorized according to age group into three groups; age <65, 65-74, and ≥75 years. RESULTS Among the 3402 patients that were enrolled during 2014-2017, the mean age was 67.4±11.3 years, and 2073 (60.9%) were older. The average follow-up was 25.7±10.6 months. Oral anticoagulants were given in 75.4% of patients (91.1% of OAC was warfarin). The incidence rate of IS/TIA, MB, ICH, HF, and death was 1.43 (1.17-1.74), 2.11 (1.79-2.48), 0.70 (0.52-0.92), 3.03 (2.64-3.46), and 3.77 (3.33-4.24) per 100 person-years, respectively. The risk of IS/TIA, MB, ICH, HF, and death increased with age both before and after adjustment for potential confounders. Even though OAC reduced the risk of IS/TIA, it increased the risk of MB. Net clinical benefit (NCB) analysis favored oral anticoagulant (OAC) in the high-risk subset of older adults. CONCLUSION Older adult NVAF patients had a significantly increased risk of IS/TIA, MB, ICH, HF, and death compared to younger NVAF before and after adjustment for potential confounders. Strategies to reduce overall risk, including OAC use and choice and integrated care, should be implemented.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thanita Boonyapiphat
- Division of Cardiology, Department of Medicine, Lampang Hospital, Lampang, Thailand
| | - Chaiyasith Wongvipaporn
- Division of Cardiology, Department of Medicine,Srinakarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Poom Sairat
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - On behalf of the COOL-AF Investigators
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Cardiology, Department of Medicine, Lampang Hospital, Lampang, Thailand
- Division of Cardiology, Department of Medicine,Srinakarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Kodani E, Akao M. Atrial fibrillation and stroke prevention: state of the art-epidemiology and pathophysiology: new risk factors, concepts and controversies. Eur Heart J Suppl 2020; 22:O1-O13. [PMID: 33380940 PMCID: PMC7753870 DOI: 10.1093/eurheartj/suaa176] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Atrial fibrillation (AF) increases the risk of thromboembolism, and risk assessment for thromboembolism is necessary for the management of AF patients. CHADS2 and CHA2DS2-VASc scores have been adopted in international guidelines for AF management, but the significance of each risk factor included in these risk scores are sometimes controversial, and the performance of these scores is only modest. There are several other risk factors not included in the scores such as renal dysfunction, low body weight, type of AF (paroxysmal or non-paroxysmal) as well as echocardiographic parameters and blood biomarkers, and physicians should assess patients risk in an integrated manner.
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Affiliation(s)
- Eitaro Kodani
- Department of Cardiovascular Medicine, Nippon Medical School Tama-Nagayama Hospital, 1-7-1, Nagayama, Tama-shi, Tokyo 206-8512, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto 612-8555, Japan
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Krittayaphong R, Kunjara-Na-Ayudhya R, Ngamjanyaporn P, Boonyaratavej S, Komoltri C, Yindeengam A, Sritara P, Lip GYH. Optimal INR level in elderly and non-elderly patients with atrial fibrillation receiving warfarin: a report from the COOL-AF nationwide registry in Thailand. J Geriatr Cardiol 2020; 17:612-620. [PMID: 33224180 PMCID: PMC7657951 DOI: 10.11909/j.issn.1671-5411.2020.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/20/2020] [Accepted: 10/12/2020] [Indexed: 06/11/2023] Open
Abstract
BACKGROUND Asian population are at increased risk of bleeding during the warfarin treatment, so the recommended optimal international normalized ratio (INR) level may be lower in Asians than in Westerners. The aim of this prospective multicenter study was to determine the optimal INR level in Thai patients with non-valvular atrial fibrillation (NVAF). METHODS Patients with NVAF who were on warfarin for stroke prevention were recruited from 27 hospitals in the nationwide COOL-AF registry in Thailand. We collected demographic data, medical history, risk factors for stroke and bleeding, concomitant disease, electrocardiogram and laboratory data including INR and antithrombotic medications. Outcome measurements included ischemic stroke/transient ischemic attack (TIA) and major bleeding. Optimal INR level was assessed by the calculation of incidence density for six INR ranges (< 1.5, 1.5-1.99, 2-2.49, 2.5-2.99, 3-3.49, and ≥ 3.5). RESULTS A total of 2, 232 patients were included. The mean age of patients was 68.5 ± 10.6 years. The mean follow-up duration was 25.7 ± 10.6 months. There were 63 ischemic stroke/TIA and 112 major bleeding events. The lowest prevalence of ischemic stroke/TIA and major bleeding events occurred within the INR range of 2.0-2.99 for patients < 70 years and 1.5-2.99 for patients ≥ 70 years. CONCLUSIONS The INR range associated with the lowest risk of ischemic stroke/TIA and bleeding in the Thai population was 2.0-2.99 for patients < 70 years and 1.5-2.99 for patients ≥ 70 years. The rates of major bleeding and ischemic stroke/TIA were both higher than the rates reported in Western population.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | | | - Smonporn Boonyaratavej
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chulalak Komoltri
- Department of Research Promotion, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ahthit Yindeengam
- Her Majesty Cardiac Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Piyamitr Sritara
- Division of Cardiology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Poor Time in Therapeutic Range Control is Associated with Adverse Clinical Outcomes in Patients with Non-Valvular Atrial Fibrillation: A Report from the Nationwide COOL-AF Registry. J Clin Med 2020; 9:jcm9061698. [PMID: 32498302 PMCID: PMC7355466 DOI: 10.3390/jcm9061698] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/22/2020] [Accepted: 05/26/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Warfarin remains the most commonly used oral anticoagulant (OAC) in Thailand for stroke prevention among patients with non-valvular atrial fibrillation (NVAF). The aim of this study was to investigate the relationship between time in therapeutic range (TTR) after warfarin initiation and clinical outcomes of NVAF. METHODS TTR was calculated by the Rosendaal method from international normalized ratio (INR) data acquired from a nationwide NVAF registry in Thailand. Patients were followed-up every six months. The association between TTR and clinical outcomes was analyzed. RESULTS There was a total of 2233 patients from 27 hospitals. The average age was 68.4 ± 10.6 years. The average TTR was 53.56 ± 26.37%. Rates of ischemic stroke/TIA, major bleeding, ICH, and death were 1.33, 2.48, 0.76, and 3.3 per 100 person-years, respectively. When patients with a TTR < 65% were compared with those with TTR ≥ 65%, the adjusted hazard ratios (aHR) for the increased risks of ischemic stroke/TIA, major bleeding, ICH, and death were 3.07, 1.90, 2.34, and 2.11, respectively. CONCLUSION Poor TTR control is associated with adverse clinical outcomes in patients with NVAF who were on warfarin. Efforts to ensure good TTR (≥65%) after initiation of warfarin are mandatory to minimize the risk of adverse clinical outcomes.
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Wu VCC, Wu M, Aboyans V, Chang SH, Chen SW, Chen MC, Wang CL, Hsieh IC, Chu PH, Lin YS. Female sex as a risk factor for ischaemic stroke varies with age in patients with atrial fibrillation. Heart 2019; 106:534-540. [DOI: 10.1136/heartjnl-2019-315065] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 08/22/2019] [Accepted: 08/27/2019] [Indexed: 01/08/2023] Open
Abstract
ObjectivesFemale sex is an inconsistent ischaemic stroke risk factor in patients with atrial fibrillation (AF). We hypothesised that the ischaemic stroke risk varies with age among women compared with men.MethodsWe retrieved the patients with newly diagnosed AF during 2001–2013 from Taiwan’s National Health Insurance Research Database. Patients with missing information, age <20 years, history of valvular heart disease and surgery, rheumatic heart disease, hyperthyroidism or anticoagulation and/or antiplatelet use were excluded. Propensity score matching (PSM) included patient comorbidities, medications and index date stratified by age and sex groups. Primary outcome was defined as ischaemic stroke at follow-up.ResultsAfter exclusion criteria, 87 369 men and 71 853 women remained for analysis (aged 73.1±14.4 years). After 1:1 PSM, we included 59 583 men (aged 73.5±13.7 years) and 59 583 women (aged 73.4±13.8 years) for analysis. We also stratified patients by age. The ischaemic stroke risk varied with age in women compared with men: lower in the ≤55 years (subdistribution HR (SHR)=0.75, 95% CI 0.62 to 0.90) and 56–65 years (SHR=0.87, 95% CI 0.78 to 0.98) groups, neutral in the 66–75 years group (SHR=1.01, 95% CI 0.94 to 1.08) and adverse in the >75 years group (SHR=1.14, 95% CI 1.09 to 1.19).ConclusionsThe female/male ischaemic stroke risk ratio varied with age. Only women aged >75 years had a higher risk, whereas women aged <65 years had a lower risk compared with men. These findings challenge the ‘sex category’ component of the CHA2DS2-VASc score, used to make decision regarding anticoagulation treatment in AF patients.
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