Predictors for Stroke and Death in Non-Anticoagulated Asian Patients with Atrial Fibrillation: The Fushimi AF Registry

External Validation of the HELT-E2S2 Score in Japanese Patients With Nonvalvular Atrial Fibrillation - A Pooled Analysis of the RAFFINE and SAKURA Registries

BACKGROUND

The HELT-E2S2score, which assigns 1 point to Hypertension, Elderly aged 75-84 years, Low body mass index <18.5 kg/m2, and Type of atrial fibrillation (AF: persistent/permanent), and 2 points to Extreme Elderly aged ≥85 years and previous Stroke, has been proposed as a new risk stratification for strokes in Japanese AF patients, but has not yet undergone external validation.

METHODS AND RESULTS

We evaluated the prognostic performance of the HELT-E2S2score for stroke risk stratification using 2 large-scale registries in Japanese AF patients (n=7,020). During 23,241 person-years of follow-up (mean follow-up 1,208±450 days), 287 ischemic stroke events occurred. The C-statistic using the HELT-E2S2score was 0.661 (95% confidence interval [CI], 0.629-0.692), which was numerically higher than with the CHADS2score (0.644, 95% CI 0.613-0.675; P=0.15 vs. HELT-E2S2) or CHA2DS2-VASc score (0.650, 95% CI, 0.619-0.680; P=0.37 vs. HELT-E2S2). In the SAKURA AF Registry, the C-statistic of the HELT-E2S2score was consistently higher than the CHADS2and CHA2DS2-VASc scores across all 3 types of facilities comprising university hospitals, general hospitals, and clinics. However, in the RAFFINE Study, its superiority was only observed in general hospitals.

CONCLUSIONS

The HELT-E2S2score demonstrated potential value for risk stratification, particularly in a super-aged society such as Japan. However, its superiority over the CHADS2or CHA2DS2-VASc scores may vary across different hospital settings.

Predictive value of neutrophil-to-apolipoprotein A1 ratio in all-cause and cardiovascular death in elderly non-valvular atrial fibrillation patients

Neutrophil-to-apolipoprotein AI ratio's (NAR's) predictive value for the elderly non-valvular atrial fibrillation (NVAF) patients' death has not been fully recognized. We consecutively enrolled 1224 elderly patients with NVAF (≥75 years). With an average follow-up of 733.35 ± 271.39 days, 222 all-cause deaths were identified. Among these, 101 were caused by cardiovascular diseases. Cox regression showed that after correcting for potential confounders, patients in the Q4 group had an increased all-cause (hazard ratio [HR] = 1.90, 95% confidence interval [CI]: 1.20-2.99) and cardiovascular death (HR = 2.59, 95% CI: 1.30-5.15) risk compared to those in the lowest NAR quartile. Kaplan-Meier analysis indicated that all-cause and cardiovascular death were higher in the high NAR than those in the lowest NAR category (log rank, all, P < 0.001). A nonlinear association was observed between death and NAR. NAR may be a promising predictive biomarker for identifying elderly NVAF patients with poor clinical prognoses.

Characteristics and health-status outcomes in patients with atrial fibrillation detected via health screening

BACKGROUND

Early detection of atrial fibrillation (AF) is important. Japan has a universal screening system, and regular health screening (HS) is available to support AF detection without a hospital visit. However, health-related outcomes and other characteristics of HS-detected and conventionally diagnosed AF remain unknown.

HYPOTHESIS

That the characteristics and health-related outcomes of patients with HS-detected AF may differ from those of patients whose AF was detected by other procedures.

METHODS

In total, 3318 consecutive newly referred AF cases were enrolled; demographic characteristics and health-related and clinical outcomes were compared between two groups created based on the mode of AF detection (the HS and non-HS groups). Health-related outcomes were assessed using the AF Effect on QualiTy-of-life (AFEQT) questionnaire at baseline and after 1 year of follow-up.

RESULTS

AF was detected by HS in 25.0% of patients; these patients had lower CHADS₂ scores (1.01 vs. 1.50, p < .001), higher prevalence of persistent AF (odds ratio, 95% confidence interval; 2.21, 1.88-2.60) and asymptomatic presentation (3.19, 2.71-3.76), and better baseline QoL scores (83.6 vs. 75.0; p < .001). Catheter ablation was more frequently performed in the HS group at follow-up (44.4% vs. 34.1%; p < .001). At 1-year follow-up, the AFEQT scores of the HS group were significantly better in most subdomains.

CONCLUSIONS

In the Japanese registry, AF was detected via HS in 25% of patients referred to specialty centers for management. Notably, the overall health status of patients with HS-detected AF improved after medical interventions, including catheter ablations.

A Novel Risk Stratification System for Ischemic Stroke in Japanese Patients With Non-Valvular Atrial Fibrillation

BACKGROUND

Recently, identification of independent risk factors for ischemic stroke in Japanese non-valvular atrial fibrillation (NVAF) patients was made by analyzing the 5 major Japanese registries: J-RHYTHM Registry, Fushimi AF Registry, Shinken Database, Keio interhospital Cardiovascular Studies, and the Hokuriku-Plus AF Registry.

METHODS AND RESULTS

The predictive value of the risk scheme in Japanese NVAF patients was assessed. Of 16,918 patients, 12,289 NVAF patients were analyzed (mean follow up, 649±181 days). Hazard ratios (HRs) of each significant, independent risk factor were determined by using adjusted Cox-hazard proportional analysis. Scoring system for ischemic stroke was created by transforming HR logarithmically and was estimated by c-statistic. During the 21,820 person-years follow up, 241 ischemic stroke events occurred. Significant risk factors were: being elderly (aged 75-84 years [E], HR=1.74), extreme elderly (≥85 years [EE], HR=2.41), having hypertension (H, HR=1.60), previous stroke (S, HR=2.75), type of AF (persistent/permanent) (T, HR=1.59), and low body mass index <18.5 kg/m2(L, HR=1.55) after adjusting for oral anticoagulant treatment. The score was assigned as follows: 1 point to H, E, L, and T, and 2 points to EE and S (HELT-E2S2score). The C-statistic, using this score, was 0.681 (95% confidence interval [CI]=0.647-0.714), which was significantly higher than those using CHADS2(0.647; 95% CI=0.614-0.681, P=0.027 for comparison) and CHA2DS2-VASc scores (0.641; 95% CI=0.608-0.673, P=0.008).

CONCLUSIONS

The HELT-E2S2score may be useful for identifying Japanese NVAF patients at risk of ischemic stroke.

The impact of underweight and obesity on outcomes in anticoagulated patients with atrial fibrillation: A systematic review and meta-analysis on the obesity paradox

Although obesity is associated with the development and progression of atrial fibrillation (AF), an obesity paradox may be present, illustrated by seemingly protective effects of obesity on AF-related outcomes. Body mass index (BMI) has an impact on outcomes in AF patients using oral anticoagulants. After searching Medline and Embase, meta-analysis of results of four randomized and five observational studies demonstrated significantly lower risks of stroke or systemic embolism (RR 0.80, 95%CI [0.73-0.87]; RR 0.63, 95%CI [0.57-0.70]; and RR 0.42, 95%CI [0.31-0.57], respectively) and all-cause mortality (RR 0.73, 95%CI [0.64-0.83]; RR 0.61, 95%CI [0.52-0.71]; and RR 0.56, 95%CI [0.47-0.66], respectively) in overweight, obese and morbidly obese anticoagulated AF patients (BMI 25 to <30, ≥30 and ≥40 kg/m2 , respectively) compared to normal BMI anticoagulated AF patients (BMI 18.5 to <25 kg/m2 ). In contrast, thromboembolic (RR 1.92, 95%CI [1.28-2.90]) and mortality (RR 3.57, 95%CI [2.50-5.11]) risks were significantly increased in underweight anticoagulated AF patients (BMI <18.5 kg/m2 ). In overweight and obese anticoagulated AF patients, the risks of major bleeding (RR 0.86, 95%CI [0.76-0.99]; and RR 0.88, 95%CI [0.79-0.98], respectively) and intracranial bleeding (RR 0.75, 95%CI [0.58-0.97]; and RR 0.57, 95%CI [0.40-0.80], respectively) were also significantly lower compared to normal BMI patients, while similar risks were observed in underweight and morbidly obese patients. This meta-analysis demonstrated lower thromboembolic and mortality risks with increasing BMI. However, as this paradox was driven by results from randomized studies, while observational studies rendered more conflicting results, these seemingly protective effects should still be interpreted with caution.

Atrial fibrillation and stroke prevention: state of the art-epidemiology and pathophysiology: new risk factors, concepts and controversies

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.

Prognostic significance of natriuretic peptide levels in atrial fibrillation without heart failure

OBJECTIVES

Natriuretic peptides are an important prognostic marker in patients with heart failure (HF). However, little is known regarding their prognostic significance in patients with atrial fibrillation (AF) without HF and natriuretic peptides levels are underused in these patients in daily practice.

METHODS

The Fushimi AF Registry is a community-based prospective survey of patients with AF in Fushimi-ku, Kyoto, Japan. We investigated patients with AF without HF (defined as prior HF hospitalisation, New York Heart Association functional class≥2 or left ventricular ejection fraction<40%) using the data of B-type natriuretic peptide (BNP, n=388) or N-terminal pro-B-type natriuretic peptide (NT-proBNP, n=771) at enrolment. BNPs were converted to NT-proBNP using a conversion formula. We divided the patients according to quartiles of NT-proBNP levels and compared the backgrounds and outcomes.

RESULTS

Of 1159 patients (mean age: 72.1±10.2 years, median CHA₂DS₂-VASc score: 3 and oral anticoagulant (OAC) prescription: 671 (56%)), the median NT-proBNP level was 488 (IQR 169-1015) ng/L. Patients with high NT-proBNP levels were older, had higher CHA₂DS₂-VASc scores and had more OAC prescription (all p<0.001). Kaplan-Meier curves demonstrated that NT-proBNP levels were significantly associated with higher incidences of stroke/systemic embolism, all-cause death and HF hospitalisation during a median follow-up period of 5.0 years (log rank, all p<0.001). Multivariable Cox regression analyses revealed that NT-proBNP levels were an independent predictor of adverse outcomes even after adjustment by various confounders.

CONCLUSION

NT-proBNP levels are a significant prognostic marker for adverse outcomes in patients with AF without HF and may have clinical value.

TRIAL REGISTRATION NUMBER

UMIN000005834.

Low Body Weight Increases the Risk of Ischemic Stroke and Major Bleeding in Atrial Fibrillation: The COOL-AF Registry

We aimed to determine if low body weight (LBW) status (<50 kg) is independently associated with increased risk of ischemic stroke and bleeding in Thai patients with non-valvular atrial fibrillation (NVAF). (1) Background: It has been unclear whether LBW influence clinical outcome of patients with NVAF. (2) Methods: This prospective multicenter cohort study included patients enrolled in the COOL-AF Registry. The following data were collected: demographic data, medical history, risk factors and comorbid conditions, laboratory and investigation data, and medications. Follow-up data were collected every 6 months. Clinical events during follow-up were confirmed by the adjudication committee. (3) Results: A total of 3367 patients were enrolled. The mean age was 67.2 ± 11.2 years. LBW was present in 338 patients (11.3%). Anticoagulant and antiplatelet was prescribed in 75.3% and 26.2% of patients, respectively. Ischemic stroke, major bleeding, intracerebral hemorrhage (ICH), and death occurred during follow-up in 2.9%, 4.4%, 1.4%, and 7.7% of patients, respectively, during 25.7 months follow-up. LBW was an independent predictor of ischemic stroke, major bleeding, ICH, and death, with a hazard ratio of 2.40, 1.79, 2.37, and 2.65, respectively. (4) Conclusions: LBW was independently associated with increased risk of adverse outcomes in Thai patients with NVAF. This should be carefully considered when balancing the risks and benefits of stroke prevention among patients with different body weights.

The Characteristics and Clinical Outcomes of Direct Oral Anticoagulantsin Patients with Atrial Fibrillation and Chronic Kidney Disease: From the Database of A Single-Center Registry

BACKGROUND

This study aimed to evaluate the characteristics and clinical outcomes (major bleeding [MB] and thromboembolic events [TEEs]) of atrial fibrillation (AF) patients with chronic kidney disease (CKD)who receiveddirect oral anticoagulant (DOAC) therapy.

METHODS

Data prospectivelycollected from a single-center registry containing 2,272 patients with DOAC prescription for AF (apixaban [n=1,014], edoxaban [n=267], rivaroxaban [n=498], and dabigatran[n=493]) were retrospectively analyzed. Patients were monitored for two years and classified into the CKD (n=1460) andnon-CKD groups(n=812). MB and TEEs were evaluated.

RESULTS

The mean age was 72±10 years, with the CHADS2,CHA2DS2-VASc, and HAS-BLED scores being 1.95±1.32, 3.21±1.67, and 1.89±0.96,respectively.Incidence rates of MB and TEEs were 2.3%/year and 2.1%/year, respectively. The CKD groupwasolderand had lower body weight and higher CHADS2,CHA2DS2-VASc, and HAS-BLED scoresthanthe non-CKD group.Kaplan-Meier curve analysis revealed that the incidence of MB and TEEs was higher in the CKD group. Multiple logistic regression analysis in the CKD group revealed thatage andstroke history were independent determinants of TEEs, and low body weighttended to be a determinant of MB.The inappropriate low dose use was higher for apixaban than other DOACs in the CKD group. Consequently, for apixaban, the incidence of stroke was significantly higherin the CKD group than in the non-CKD group.

CONCLUSIONS

Patients with CKDwere characterized by factors that predisposed them to MB and TEEs, such as older age and low body weight. In a single-center registry, only treatment with apixaban in the CKD group led to a higher incidence of TEEs.

Rivaroxaban, a Direct Factor Xa Inhibitor, Ameliorates Hypertensive Renal Damage Through Inhibition of the Inflammatory Response Mediated by Protease-Activated Receptor Pathway

Background

An enhanced renin‐angiotensin system causes hypertensive renal damage. Factor Xa not only functions in the coagulation cascade but also activates intracellular signaling through protease‐activated receptors (PAR). We investigated the effects of rivaroxaban, a factor Xa inhibitor, on hypertensive renal damage in hypertensive mice overexpressing renin (Ren‐TG).

Methods and Results

The 12‐ to 16‐week‐old Ren‐TG and wild‐type mice were orally administered with or without 6 or 12 mg/kg of rivaroxaban for 1 or 4 months. Plasma factor Xa was significantly increased in the Ren‐TG compared with the wild‐type mice and was reduced by 12 mg/kg of rivaroxaban (P<0.05). Urinary albumin excretion (UAE) was higher in the nontreated 8‐month‐old Ren‐TG than in the wild‐type mice (69.6±29 versus 20.1±8.2 μg/day; P<0.01). Treatment with 12 mg/kg of rivaroxaban for 4 months decreased the UAE to 38.1±13.2 μg/day (P<0.01). Moreover, rivaroxaban treatment attenuated histologic changes of glomerular hypertrophy, mesangial matrix expansion, effacement of the podocyte foot process, and thickened glomerular basement membrane in the Ren‐TG. The renal expression of PAR‐2 was increased in the Ren‐TG, but was inhibited with rivaroxaban treatment. In vitro study using the human podocytes showed that the expressions of PAR‐2 and inflammatory genes and nuclear factor–‐κB activation were induced by angiotensin II stimulation, but were inhibited by rivaroxaban. PAR‐2 knockdown by small interfering RNA also attenuated the PAR‐2‐related inflammatory gene expressions.

Conclusions

These findings indicate that rivaroxaban exerts protective effects against angiotensin II–induced renal damage, partly through inhibition of the PAR‐2 signaling‐mediated inflammatory response.

Risk Factors Associated With Ischemic Stroke in Japanese Patients With Nonvalvular Atrial Fibrillation

IMPORTANCE

Despite the development of risk stratification schemes that have been widely used to determine the risk for thromboembolism in patients with nonvalvular atrial fibrillation (NVAF), risk stratification schemes in Asian patients with NVAF remain undetermined.

OBJECTIVE

To determine risk factors for ischemic stroke in Japanese patients with NVAF.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed individual patient data from 5 AF registries in Japan: J-RHYTHM (Japanese Rhythm Management Trial for Atrial Fibrillation) Registry, Fushimi AF Registry, Shinken Database, Keio Interhospital Cardiovascular Studies (Keio Study), and Hokuriku-Plus AF Registry. Patients with atrial fibrillation were registered from 158 institutions in the J-RHYTHM Registry, 80 in the Fushimi AF Registry, a single hospital in Shinken Database, 11 in the Keio Study, and 19 in the Hokuriku-Plus AF Registry. Patients with valvular AF or lacking data were excluded. Data were collected and integrated in March 2016, and those from the Keio Study were updated in April 2018. Data were analyzed from April 2018 to February 2020.

MAIN OUTCOMES AND MEASURES

Significant risk factors for ischemic stroke were determined by adjusted Cox proportional hazards analysis.

RESULTS

In total, 12 289 patients with NVAF (3758 [31%] female; mean [SD] age 70.2 [11] years) were analyzed with a mean (SD) follow-up period of 649 (181) days (1.8 [0.5] years). During 21 820 person-years of follow-up, 241 cases of ischemic stroke were reported. Risk factors associated with ischemic stroke after adjustment for oral anticoagulant use at enrollment were age (75-84 years: hazard ratio [HR], 1.74; 95% CI, 1.32-2.30; P < .001; and ≥85 years: HR, 2.41; 1.63-3.56; P < .001), hypertension (HR, 1.60; 95% CI, 1.15-2.23; P = .006), previous stroke (HR, 2.75; 95% CI, 2.09-3.62; P < .001), persistent or permanent AF (HR, 1.59; 95% CI, 1.21-2.10; P = .001), and body mass index less than 18.5 (HR, 1.55; 95% CI, 1.05-2.29; P = .03). Neither diabetes nor heart failure were identified as risk factors for ischemic stroke.

CONCLUSIONS AND RELEVANCE

Previous stroke, advanced age, hypertension, persistent or permanent AF, and low body mass index were independent risk factors associated with ischemic stroke in Japanese patients with NVAF.

Impact of hemoglobin concentration and platelet count on outcomes of patients with non-valvular atrial fibrillation: A subanalysis of the J-RHYTHM Registry

BACKGROUND

To clarify the influence of hemoglobin concentration and platelet count on adverse outcomes of Japanese patients with non-valvular atrial fibrillation (NVAF), a post hoc analysis of the J-RHYTHM Registry was performed.

METHODS

A consecutive series of outpatients with atrial fibrillation were enrolled from 158 institutions and followed up for 2 years or until an event occurred (thromboembolism, major hemorrhage, or all-cause death). Among 7406 patients with NVAF, 6536 with complete blood count data (69.8 ± 9.9 years, 71.0% men) were divided into 4 groups according to the baseline hemoglobin level (<10.0, 10.0-11.9, 12.0-13.9, and ≥14.0 g/dL) or platelet count (<10.0, 10.0-19.9, 20.0-29.9, and ≥30.0 × 10⁴/μL).

RESULTS

Incidence rates of major hemorrhage (p = 0.004 for trend), all-cause death (p < 0.001 for trend), and composite events (p < 0.001 for trend) increased as hemoglobin levels decreased, and composite events (p = 0.045 for trend) increased as platelet counts decreased. After adjusting for multiple confounders, the incidence of all-cause death and composite events was higher with hemoglobin levels <12.0 g/dL than a hemoglobin level ≥14.0 g/dL. In contrast, platelet count was not associated with any events. This was also true when multivariate analysis was performed using the stepwise forward method.

CONCLUSIONS

A low hemoglobin level (<12.0 g/dL) was an independent risk factor for all-cause death and composite events in Japanese patients with NVAF. However, platelet count did not impact outcomes.

CLINICAL TRIAL REGISTRATION

http://www.umin.ac.jp/ctr/ (unique identifier: UMIN000001569).

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

Aims

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

Methods and results

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

Conclusion

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

Antithrombotic Treatment May Reduce Mortality Among New-Onset Atrial Fibrillation Patients with Gray-Zone Risk of Stroke

In clinical practice, some atrial fibrillation (AF) patients were classified as having low and moderate stroke risk by the CHADS2 score (≤ 1) in 2001 but in 2012 they were not truly classified as low risk of stroke according to the CHA2DS2-VASc score (≥ 2) (defined gray zone). Therefore, a treatment gap exists in gray zone AF patients. This study aimed to evaluate whether gray zone AF patients could benefit from reduced all-cause mortality under antithrombotic treatment. This was a longitudinal cohort study performed using data from claim forms submitted to the Taiwan Bureau of National Health Insurance from January 2000 to December 2011. The new-onset AF patients consisted of a gray zone cohort with a total of 1237 patients being enrolled. The primary outcome was all-cause mortality between 2001 and 2011. Patients in the gray zone receiving antithrombotic treatment had a significant reduction in all-cause mortality [hazard ratio (HR): 0.21; 95% confidence interval (CI): 0.16-0.28] compared with the no treatment group [warfarin only: HR, 0.28 (95% CI, 0.15-0.52); warfarin + Aspirin: HR, 0.21 (95% CI, 0.15-0.30); and Aspirin only: HR, 0.22 (95% CI, 0.16-0.29) ]. All-cause mortality was notably increased when any of the following risk factors were present: age 65-74 years, age ≥ 75 years, chronic kidney disease, and vascular disease. We concluded that AF patients in the gray zone must receive either anticoagulant and/or antiplatelet treatment and there is a lower mortality in these groups during long-term follow-up. Further investigation is needed to observe whether the antithrombotic drugs have benefits for patients with AF with a CHA2DS2-VASc score < 2.

Comparison of Clinical Outcomes Among Patients With Atrial Fibrillation or Atrial Flutter Stratified by CHA2DS2-VASc Score

Importance

Current guidelines support treating atrial fibrillation (AF) and atrial flutter (AFL) as equivalent risk factors for ischemic stroke stratified by CHA2DS2-VASc scores, recommending anticoagulation therapy for patients with a CHA2DS2-VASc score of 2 or higher, but some studies found differences in clinical outcomes.

Objective

To investigate differences in clinical outcomes among AF, AFL, and matched control cohorts.

Design, Setting, and Participants

This nationwide cohort study analyzed data from the Taiwan National Health Insurance Research Database from January 1, 2001, through December 31, 2012. Follow-up and data analysis ended December 31, 2012. A total of 219 416 age- and sex-matched individuals participated in the study. Clinical outcomes were compared after stratification by CHA2DS2-VASc score (possible score range, 0-9; higher scores indicate greater risk of ischemic stroke).

Main Outcomes and Measures

Ischemic stroke, heart failure hospitalization, and all-cause mortality among the AF, AFL, and matched control cohorts were analyzed using Cox proportional hazards regression.

Results

This study comprised 188 811 patients in the AF cohort (mean [SD] age, 73.8 [13.4] years; 104 703 [55.5%] male), 6121 patients in the AFL cohort (mean [SD] age, 67.7 [15.8] years; 3735 [61.0%] male), and 24 484 patients in the matched control cohort (mean [SD] age, 67.3 [15.6] years; 14 940 [61.0%] male). The patients with AF were older, were more predominantly female, and had higher CHA2DS2-VASc scores than the patients with AFL and the control participants. After stratification by CHA2DS2-VASc score, the incidence densities (IDs; events per 100 person-years) of ischemic stroke (AF cohort: ID, 3.08; 95% CI, 3.03-3.13; AFL cohort: ID, 1.45; 95% CI, 1.28-1.62; controls: ID, 0.97; 95% CI, 0.92-1.03), heart failure hospitalization (AF cohort: ID, 3.39; 95% CI, 3.34-3.44; AFL cohort: ID, 1.57; 95% CI, 1.39-1.74; controls: ID, 0.32; 95% CI, 0.29-0.35), and all-cause mortality (AF cohort: ID, 17.8; 95% CI, 17.7-17.9; AFL cohort: ID, 13.9; 95% CI, 13.4-14.4; controls: ID, 4.2; 95% CI, 4.1-4.4) were significantly higher in the AF cohort than in the matched control cohort. For the AFL cohort vs the matched control cohort, the incidences of heart failure hospitalization and all-cause mortality were significantly higher across all levels, but the incidence of ischemic stroke was only significantly higher at CHA2DS2-VASc scores of 5 to 9. For the AF cohort vs the AFL cohort, the incidences of ischemic stroke and heart failure hospitalization were significantly higher at a CHA2DS2-VASc score of 1 or higher, but the incidence of all-cause mortality was significantly higher only at CHA2DS2-VASc scores of 1 to 3.

Conclusions and Relevance

This study found different clinical outcomes between patients with AFL and AF and those without AF and AFL. The current recommended level of the CHA2DS2-VASc score in preventing ischemic stroke in patients with AFL should be reevaluated.

Clinical profile and outcomes in octogenarians with atrial fibrillation: A community-based study in a specific European health care area

BACKGROUND

Age increases risk of stroke and bleeding. Clinical trial data have had relatively low proportions of elderly subjects. We sought to study a Spanish population of octogenarians with atrial fibrillation (AF) by combining different sources of electronic clinical records from an area where all medical centres utilized electronic health record systems.

METHODS

Data was derived from the Galician Healthcare Service information system.

RESULTS

From 383,000 subjects, AF was coded in 7990 (2.08%), 3640 (45.6%) of whom were ≥80 and 4350 (54.4%)<80. All CHA2DS2-VASc's components were more prevalent in the elderly except for diabetes. Of those ≥80, 2178 (59.8%) were women. Mean CHA₂DS₂-VASc was 4.2±1.1. Distribution of CHA₂DS₂-VASc components varied between genders. 2600 (71.4%) were on oral anticoagulant (OA). During a median follow up of 696days (124.23), all-cause mortality was higher in ≥80 (1011/3640 (27.8%) vs 350/4350 (8.05%) (p<0.001). There were differences in rate of thromboembolic (TE) and haemorrhagic events (2.3% vs 0.9%, p<0.01 and 2.5% vs 1.7%, p=0.01 respectively). In octogenarian, differences between genders were observed with regard to TE, but not in haemorrhagic or all-cause mortality rates. Age, heart failure, non-valvular AF, dementia, and OA were independent predictors of all-cause mortality. In regard to TE, female gender, hypertension, previous TE and OA were independent predictive factors.

CONCLUSIONS

Octogenarians with AF had very different characteristics and outcomes from their younger counterparts. These results also provide reassurance about the effectiveness of OA in preventing TE events and maintaining a reasonable haemorrhagic event rate in the extremely elderly.

Association of body weight with efficacy and safety outcomes in phase III randomized controlled trials of direct oral anticoagulants: a systematic review and meta-analysis

Essentials The association of body weight and patient-important outcomes remains unknown. Phase III randomized controlled trials of direct oral anticoagulants (DOACs) were searched. Risk of outcomes varying among body weight subgroups is not attributable to anticoagulant type. Dose adjustment of DOACs, outside that recommended, is unlikely to improve the outcomes. Click to hear Dr Braunwald's perspective on antithrombotic therapy in cardiovascular disease SUMMARY: Background Concerns have arisen in direct oral anticoagulant (DOAC)-treated patients about safety and efficacy in extremes of body weight. The aims of this systematic review were to investigate the association of body weight and patient-important outcomes in patients treated with DOACs or warfarin, and to demonstrate the fixed-dose effect of DOACs. Methods MEDLINE and EMBASE were searched until November 2016. Phase III randomized controlled trials (RCTs) using DOACs in atrial fibrillation (AF) and acute venous thromboembolism (VTE) were included. Relative risk and 95% confidence interval were calculated. The pooled estimates were performed using a Mantel-Haenszel random effects model. Results A total of 11 phase III RCTs were included. Low body weight was associated with increased risk of thromboembolism compared with non-low body weight (relative risk [RR], 1.57; 95% confidence interval [CI], 1.34-1.85). High body weight was not associated with risk of thromboembolism compared with non-high body weight (RR, 0.88; 95% CI, 0.63-1.23). The subgroup of AF patients with high body weight had a lower risk of thromboembolism compared with non-high body weight (RR, 0.43; 95% CI, 0.28-0.67). Bleeding outcomes were comparable for all body weight comparisons. There were no clear interactions between types of anticoagulant in all outcomes. Conclusion The pooled effect of both the DOAC and comparison arms was likely to be attributable to differences in baseline thrombotic risk in each body weight category, rather than an effect of the type or dose of DOAC used for each indication. Dose adjustment of DOACs, outside that recommended in the package insert, is unlikely to improve safety or efficacy.

Registries in Atrial Fibrillation: From Trials to Real-Life Clinical Practice

BACKGROUND

Recent improvements in atrial fibrillation diagnosis and management have prompted the initiation of various registries, predominantly to assess adherence to new guidelines but also to address the pending questions of safety and effectiveness of newly introduced management options in "real-world" clinical practice settings. In this review, we appraise antithrombotic treatment patterns for stroke prevention in atrial fibrillation registries.

METHODS

We searched PubMed, Science Direct, and the Cochrane databases for registries focusing on stroke thromboprophylaxis in atrial fibrillation.

RESULTS

Registry data show that over the last decade, the proportion of patients receiving oral anticoagulation has increased (from ∼67% to >80%), whereas the proportion of those treated with aspirin only or untreated has diminished. Vitamin K antagonists are being replaced gradually by non-vitamin K antagonist oral anticoagulants as the more prevalent option. Regional and country differences in anticoagulation are evident, with its highest uptake in Europe (90.2%) and lowest in Asia (57.4%). Moreover, oral anticoagulation is given to approximately 50% of patients with no stroke risk factors, whereas more than one third of high-risk subjects are not anticoagulated but often prescribed antiplatelet therapy alone or untreated. Guideline-nonadherent thromboprophylaxis results in an increase in all-cause mortality and thromboembolism.

CONCLUSIONS

Registry data show that despite an increase in anticoagulation rates over the last decade, management gaps in stroke prevention are still evident with approximately one third of patients not treated in line with the guidelines. Mortality rates of atrial fibrillation patients remain relatively high, mostly because of the comorbid disease.

Relation of Body Mass Index With Adverse Outcomes Among Patients With Atrial Fibrillation: A Meta-Analysis and Systematic Review

BACKGROUND

Several studies have investigated the impact of body mass index (BMI) on the prognosis of atrial fibrillation, but the results remain controversial. We sought to estimate the association of BMI with atrial fibrillation-related outcomes.

METHODS AND RESULTS

We systematically searched the Cochrane Library, PubMed, and Elsevier databases for all studies reporting associations between BMI and atrial fibrillation-related outcomes. Relative risks (RRs) and 95% CIs were extracted and pooled. Nine studies with 49 364 participants were included. Underweight BMI was associated with an increased risk of stroke or systemic embolism (RR 1.67, 95% CI 1.12-2.49), all-cause mortaliity (RR 2.61, 95% CI 2.21-3.09), and cardiovascular death (RR 2.49, 95% CI 1.38-4.50). Nevertheless, the pooled RRs of overweight and obese patients were lower than those of normal-weight patients for stroke or systemic embolism (overweight: RR 0.91, 95% CI 0.80-1.04; obese: RR 0.84, 95% CI 0.72-0.98; grade 1 obesity: RR 0.89, 95% CI 0.71-1.11; grade 2 obesity: RR 0.64, 95% CI 0.45-0.91; grade 3 obesity: RR 0.82, 95% CI 0.54-1.25), all-cause death (overweight: RR 0.78, 95% CI 0.62-0.96; obese: RR 0.84, 95% CI 0.64-1.10; grade 1 obesity: RR 0.64, 95% CI 0.57-0.73; grade 2 obesity: RR 0.70, 95% CI 0.47-1.03; grade 3 obesity: RR 0.72, 95% CI 0.59-0.88), and cardiovascular death (overweight: RR 0.79, 95% CI 0.58-1.08; obese: RR 0.99, 95% CI 0.79-1.24).

CONCLUSIONS

Underweight BMI is associated with an increased risk of stroke or systemic embolism, cardiovascular death, and all-cause death in Asian patients with atrial fibrillation, whereas in all atrial fibrillation patients, overweight and obese BMI was not associated with increased risks of these outcomes.

Clinical significance of nutritional status in patients with atrial fibrillation: An overview of current evidence

BACKGROUND

Obesity is a well-known atherosclerosis risk factor; however, its role and the importance of undernutrition in atrial fibrillation (AF) pathogenesis are still not well understood. The aim of this study was to present the current state of knowledge on this issue in different groups of patients.

METHODS

Systematic review of papers published between 1980 and 2016.

RESULTS

The literature shows contradicting views regarding the impact of nutritional status on the risk, course, and complications of AF. On the one hand, it has been revealed that overweight, obesity, and high birth mass increase the risk of AF, and that their reduction is linked to an improved course of AF and reduced all-cause and cardiovascular mortality. On the other hand, a so-called obesity paradox has been found, which shows lower all-cause mortality in overweight patients with AF compared to those of normal weight or who are underweight. It has also been shown, although based on a small number of studies, that the relationship between nutritional status and risk of AF and its complication may be U-shaped, which means that not only patients with obesity, but also individuals with underweight, cachexia, and low birth weight may have an increased risk and poor outcome of AF.

CONCLUSIONS

The relationship between patients' nutritional status and the course of AF has become clearer but it requires further studies examining the importance of weight reduction on AF course.

Impact of moderate to severe renal impairment on long-term clinical outcomes in patients with atrial fibrillation

BACKGROUND

The deleterious effect of renal impairment in non-valvular atrial fibrillation (AF) patients has recently been reported. We investigated the impact of moderate to severe renal impairment on long-term clinical outcomes in AF patients.

METHODS

A total of 2126 AF patients were enrolled and divided into two groups according to ≥ or <60mL/min estimated glomerular filtration rate (eGFR). Clinical outcomes including all-cause death, cardiac death, ischemic stroke (IS), bleeding, and admission for heart failure (HF) were analyzed.

RESULTS

Compared to the ≥60mL/min eGFR group, <60mL/min eGFR patients were older; had a higher proportion of females; were more likely to have diabetes, hypertension, and history of stroke; and had higher CHADS₂, CHA₂DS₂-VAS_c, and HAS-BLED scores. During the follow-up period (median 6.23 years), all-cause death, bleeding, admission for HF, and progression to persistent or permanent AF were significantly increased in the <60mL/min eGFR group compared to the ≥60mL/min eGFR group. After multivariate Cox regression analyses, <60mL/min eGFR increased the risk of all-cause death [hazard ratio (HR): 1.84; 95% confidence interval (CI): 1.03-3.28, p=0.04] and bleeding (HR: 1.28; 95% CI: 1.04-1.57, p=0.02). IS was only significantly increased in the <60mL/min eGFR group not receiving antithrombotic treatment.

CONCLUSION

Moderate to severe renal impairment is a poor prognostic factor of long-term clinical outcomes in AF patients.

Asian Patients with Stroke plus Atrial Fibrillation and the Dose of Non-Vitamin K Oral Anticoagulants

After recent randomized control trials (RCTs), non-vitamin K oral anticoagulants (NAOAs) are now widely being used in patients with atrial fibrillation (AF) worldwide. However, current guidelines for the use of NOACs in patients with AF are derived mostly using a Caucasian population and non-stroke patients. Relatively few Asian patients with AF and stroke are included in the recent RCTs. As a result, the optimal use of NOACs in this particular group of patients is remains to be settled. The optimal dose of NOACs and response to current dose of NOACs of Asian patients with AF and stroke may differ from those of westerners and patients without stroke. We reviewed available research on NOACs by searching PubMed and ClinicalTrials.gov published in English up to December 2015. In this review, the characteristics of Asian AF patients with prior stroke/transient ischemic attack, which might influence the efficacy and safety profiles of NOACs, are discussed. In addition, we summarize the risk factors for bleeding complications on NOACs, which are related or unrelated with the blood level of NOACs. Lastly, we provide recent data of reduced dose of NOACs from RCTs or large cohorts. The results reviewed herein call for clinical trials to test whether a reduced dose of NOACs is beneficial in Asian patients with AF and stroke. In the meantime, further researches are needed to establish the safety and efficacy of dose-adjusted NOACs considering both blood levels of NOACs and fragility of patients in Asian patients with AF and stroke.