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Hauge MG, Linde JJ, Kofoed KF, Ersbøll AS, Johansen M, Sigvardsen PE, Fuchs A, Mikkelsen AP, Gustafsson F, Damm P. Early-onset versus late-onset preeclampsia and risk of coronary atherosclerosis later in life: a clinical follow-up study. Am J Obstet Gynecol MFM 2024:101371. [PMID: 38588914 DOI: 10.1016/j.ajogmf.2024.101371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/26/2024] [Accepted: 04/01/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Younger women with previous preeclampsia have an increased risk of coronary atherosclerosis. It is unknown if this risk is associated with the time of onset of preeclampsia. OBJECTIVES The aim of the study was to investigate if women with early-onset preeclampsia have a higher risk of coronary atherosclerosis compared to women with late-onset preeclampsia, independent of other perinatal risk factors. STUDY DESIGN A total of 911 women with previous preeclampsia aged 35-55 years participated in a clinical follow-up study, including clinical examination, comprehensive questionnaires, and cardiac computed tomography scan 13 years (range 0-28) after index pregnancy. Early-onset preeclampsia versus late-onset preeclampsia was defined as gestational age at delivery < versus ≥ 34+0 gestational weeks, respectively. The primary outcome of the study was the presence of coronary atherosclerosis on the cardiac computed tomography. A logistic regression analysis was performed to investigate the association between time of onset of preeclampsia, perinatal risk factors and the primary outcome. RESULTS Women with early-onset preeclampsia (N=139) were older (46.2±5.7 vs. 44.4±5.5 years, P<0.001), more likely to have hypertension (51.1% vs. 35.1%, P=<0.001), and had a higher body mass index (27.9±6.3 vs. 26.9±5.5 kg/m2, P=0.051) compared to women with late-onset preeclampsia (N=772) at follow-up. The prevalence of the primary outcome coronary atherosclerosis on the cardiac computed tomography was 28.8% vs. 22.2% (P=0.088) with an adjusted OR=1.74, 95% CI (1.01-3.01), P=0.045 after adjustment for maternal age at index pregnancy, pre-pregnancy body mass index, parity, diabetes in pregnancy, smoking in pregnancy, offspring birth weight and sex, and follow-up length. CONCLUSIONS Women with early-onset preeclampsia had a slightly higher risk of coronary atherosclerosis compared to women with late-onset preeclampsia. However, based on the current evidence it does not seem indicated to limit screening, diagnostic and preventive measures for cardiovascular disease only to women with early-onset preeclampsia.
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Affiliation(s)
- Maria G Hauge
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Jesper J Linde
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Klaus F Kofoed
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Radiology, The Diagnostic Center, Rigshospitalet, Copenhagen, University Hospital, Copenhagen, Denmark
| | - Anne S Ersbøll
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marianne Johansen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Per E Sigvardsen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Andreas Fuchs
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anders P Mikkelsen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Gynaecology & Obstetrics, Herlev-Gentofte University Hospital, Herlev
| | - Finn Gustafsson
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Peter Damm
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Greiber IK, Viuff JH, Storgaard L, Karlsen MA, Lidegaard Ø, Mikkelsen AP, Mellemkjær L, Hjortshøj CS. Long-Term Morbidity and Mortality in Children After In Utero Exposure to Maternal Cancer. J Clin Oncol 2022; 40:3975-3984. [PMID: 35797496 DOI: 10.1200/jco.22.00599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE In utero exposure to maternal cancer and cancer treatment might influence the child's short- and long-term health and development. The objective of the study was to investigate short- and long-term somatic and psychiatric outcomes in children exposed to maternal cancer in utero. METHODS This nationwide cohort study identified all liveborn children in Denmark between January 1978 and December 2018. Exposure was defined as maternal cancer diagnosis during pregnancy, and in a subgroup analysis, exposure to chemotherapy in utero. The main outcomes of interest were overall mortality, somatic diagnoses, and psychiatric diagnoses identified in the National Health Registers. Follow-up started at birth and ended at an event, death, emigration, or end of 2018. Hazard ratios of end points adjusted for potential confounders were estimated using Cox regression analysis. RESULTS Of 2,526,163 included liveborn children, 690 (0.03%) were exposed to maternal cancer in utero. Compared with unexposed fetuses, children exposed in utero had no higher overall mortality, adjusted hazard ratio 0.8 (95% CI, 0.4 to 1.5), nor increased risk of congenital malformations, overall somatic or psychiatric disease. During the period 2002-2018, of 378 (0.03%) children exposed to cancer in utero, 42 (12.5%) were exposed to chemotherapy. Among these 42 children, in utero exposure to chemotherapy was not associated with selected somatic diseases nor to congenital malformations when compared with in utero exposure to maternal cancer without chemotherapy. CONCLUSION Overall, findings did not indicate excess risk of mortality or severe morbidity among children exposed to cancer in utero. Fetal exposure to chemotherapy was not associated with adverse health outcomes in childhood.
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Affiliation(s)
- Iben K Greiber
- Department of Gynecology and Obstetrics, Rigshospitalet Section 4031, Copenhagen, Denmark.,Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Jakob H Viuff
- Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Lone Storgaard
- Department of Gynecology and Obstetrics, Rigshospitalet Section 4031, Copenhagen, Denmark
| | - Mona A Karlsen
- Department of Gynecology and Obstetrics, Rigshospitalet Section 4031, Copenhagen, Denmark
| | - Øjvind Lidegaard
- Department of Gynecology and Obstetrics, Rigshospitalet Section 4031, Copenhagen, Denmark
| | - Anders P Mikkelsen
- Department of Gynecology and Obstetrics, Rigshospitalet Section 4031, Copenhagen, Denmark
| | | | - Cristel S Hjortshøj
- Department of Pediatrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Greiber IK, Mikkelsen AP, Karlsen MA, Storgaard L, Viuff JH, Mellemkjaer L, Hjortshøj CS, Lidegaard Ø. Cancer in pregnancy increases the risk of venous thromboembolism: a nationwide cohort study. BJOG 2021; 128:1151-1159. [PMID: 33314607 DOI: 10.1111/1471-0528.16627] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To investigate if cancer in pregnancy causes a higher risk of venous thromboembolism (VTE) during pregnancy and postpartum compared with pregnant women without cancer. DESIGN A historical prospective cohort study using data from nationwide registries. SETTING AND POPULATION We assessed all pregnancies in Denmark between 1 January 1977 and 31 December 2017. METHODS We linked information concerning cancer diagnosis, pregnancy and VTE diagnosis and potential confounders. Event rates of VTE for women with pre-pregnancy cancer, cancer in pregnancy and without cancer were calculated per 10 000 pregnancies and compared using logistic regression analysis. MAIN OUTCOME MEASURES Occurrence of VTE during pregnancy or the postpartum period. RESULTS A total of 3 581 214 pregnancies were included in the study and we found 1330 women with cancer in pregnancy. In pregnant women with cancer, the event rate of VTE was 75.2 per 10 000 pregnancies compared with 10.7 per 10 000 pregnancies in the no cancer group. The findings correspond to an increased adjusted odds ratio of 6.50 (95% CI3.5-12.1) in the cancer in pregnancy group in comparison with the no cancer group. CONCLUSIONS Women with cancer in pregnancy have a markedly higher risk of pregnancy-associated VTE compared with women without cancer. In pregnancy-related VTE risk assessment, the presence of cancer alone may be sufficient to indicate thromboprophylaxis. TWEETABLE ABSTRACT Cancer in pregnancy increases the risk of VTE during pregnancy and the postpartum period.
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Affiliation(s)
- I K Greiber
- Department of Gynaecology and Obstetrics, Rigshospitalet, Copenhagen O, Denmark
| | - A P Mikkelsen
- Department of Gynaecology and Obstetrics, Rigshospitalet, Copenhagen O, Denmark
| | - M A Karlsen
- Department of Gynaecology and Obstetrics, Rigshospitalet, Copenhagen O, Denmark
| | - L Storgaard
- Department of Gynaecology and Obstetrics, Rigshospitalet, Copenhagen O, Denmark
| | - J H Viuff
- Unit of Virus Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen O, Denmark
| | - L Mellemkjaer
- Unit of Virus Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen O, Denmark
| | - C S Hjortshøj
- Department of Paediatrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ø Lidegaard
- Department of Gynaecology and Obstetrics, Rigshospitalet, Copenhagen O, Denmark
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Egerup P, Mikkelsen AP, Kolte AM, Westergaard D, Rasmussen S, Knop FK, Lidegaard Ø, Nielsen HS. Pregnancy loss is associated with type 2 diabetes: a nationwide case-control study. Diabetologia 2020; 63:1521-1529. [PMID: 32424542 DOI: 10.1007/s00125-020-05154-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 03/10/2020] [Indexed: 01/20/2023]
Abstract
AIMS/HYPOTHESIS Type 2 diabetes is killing more people than ever, and early-life predictors remain critical for the development of effective preventive strategies. Pregnancy loss is a common event associated with later atherosclerotic disease and ischaemic heart failure and might constitute a predictor for type 2 diabetes. The objective of this study was to investigate whether pregnancy loss is associated with later development of type 2 diabetes. METHODS Using a Danish nationwide cohort, we identified all women born from 1957 through to 1997 and who had a diagnosis of type 2 diabetes during the period 1977 to 2017. The women were matched 1:10 on year of birth and educational level to women without diabetes in the general Danish population. Conditional logistic regression models provided odds ratios for type 2 diabetes with different numbers of pregnancy losses. RESULTS We identified 24,774 women with type 2 diabetes and selected 247,740 controls without diabetes. Women who had ever been pregnant (ever-pregnant women) with 1, 2 and ≥ 3 pregnancy losses had ORs of type 2 diabetes of 1.18 (95% CI 1.13, 1.23), 1.38 (95% CI 1.27, 1.49) and 1.71 (95% CI 1.53, 1.92) compared with ever-pregnant women with no pregnancy losses, respectively. Women who never achieved a pregnancy had an OR of type 2 diabetes of 1.56 (95% CI 1.51, 1.61) compared with ever-pregnant women with any number of losses. Similar results were found after adjustment for obesity and gestational diabetes. CONCLUSIONS/INTERPRETATION We found a significant and consistent association between pregnancy loss and later type 2 diabetes that increased with increasing number of losses. Thus, pregnancy loss and recurrent pregnancy loss are significant risk factors for later type 2 diabetes. Future studies should explore whether this association is due to common background factors or whether prediabetic metabolic conditions are responsible for this association. Graphical abstract.
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Affiliation(s)
- Pia Egerup
- The Recurrent Pregnancy Loss Unit, The Capital Region, Rigshospitalet and Hvidovre, Copenhagen University Hospital, Copenhagen, Denmark.
- Department of Obstetrics and Gynecology, Hvidovre Hospital, Copenhagen University Hospital, Kettegård Allé 30, 2650, Hvidovre, Denmark.
| | - Anders P Mikkelsen
- Department of Gynecology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Astrid Marie Kolte
- The Recurrent Pregnancy Loss Unit, The Capital Region, Rigshospitalet and Hvidovre, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - David Westergaard
- The Recurrent Pregnancy Loss Unit, The Capital Region, Rigshospitalet and Hvidovre, Copenhagen University Hospital, Copenhagen, Denmark
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Methods and Analysis, Statistics Denmark, Copenhagen, Denmark
| | - Steen Rasmussen
- Department of Gynecology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Filip K Knop
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | - Øjvind Lidegaard
- Department of Gynecology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Henriette S Nielsen
- The Recurrent Pregnancy Loss Unit, The Capital Region, Rigshospitalet and Hvidovre, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Obstetrics and Gynecology, Hvidovre Hospital, Copenhagen University Hospital, Kettegård Allé 30, 2650, Hvidovre, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Lidegaard Ø, Mikkelsen AP, Egerup P, Kolte AM, Rasmussen SC, Nielsen HS. Pregnancy loss: A 40‐year nationwide assessment. Acta Obstet Gynecol Scand 2020; 99:1492-1496. [DOI: 10.1111/aogs.13860] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 02/17/2020] [Accepted: 03/23/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Øjvind Lidegaard
- Department of Gynecology 4232 Rigshospitalet University HospitalUniversity of Copenhagen Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Anders P. Mikkelsen
- Department of Gynecology 4232 Rigshospitalet University HospitalUniversity of Copenhagen Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Pia Egerup
- The Fertility Clinic and the Danish Recurrent Pregnancy Loss Unit Rigshospitalet University HospitalUniversity of Copenhagen Copenhagen Denmark
- Department of Obstetrics and Gynecology Hvidovre Hospital Hvidovre Denmark
| | - Astrid M. Kolte
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
- The Fertility Clinic and the Danish Recurrent Pregnancy Loss Unit Rigshospitalet University HospitalUniversity of Copenhagen Copenhagen Denmark
| | - Steen Christian Rasmussen
- Department of Gynecology 4232 Rigshospitalet University HospitalUniversity of Copenhagen Copenhagen Denmark
| | - Henriette S. Nielsen
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
- The Fertility Clinic and the Danish Recurrent Pregnancy Loss Unit Rigshospitalet University HospitalUniversity of Copenhagen Copenhagen Denmark
- Department of Obstetrics and Gynecology Hvidovre Hospital Hvidovre Denmark
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Mikkelsen AP, Egerup P, Ebert JF, Kolte AM, Nielsen HS, Lidegaard Ø. Pregnancy Loss and Cancer Risk: A Nationwide Observational Study. EClinicalMedicine 2019; 15:80-88. [PMID: 31709417 PMCID: PMC6833468 DOI: 10.1016/j.eclinm.2019.08.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/27/2019] [Accepted: 08/27/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Cancer is the second leading cause of death worldwide. Few studies have investigated if recurrent pregnancy loss is associated with an increased risk of cancer. We aimed to assess whether pregnancy loss is associated with later cancer development. METHODS We identified all invasive cancers after age 40, among all Danish women born between January 1957 and December 1972, ensuring a full reproductive history. Cases were matched by birth year 1:10 to cancer-free controls. Women were followed until the end of 2017. The number of pregnancy losses (miscarriages or still births) was correlated to long-term cancer risk using conditional logistic regression, providing odds ratios for specific cancers with different numbers of pregnancy losses, all adjusted for age, education, and other potential confounders. FINDINGS The study included 28,785 women with cancer (mean age 48.7 [SD 5.0]) and 283,294 matched controls (mean age 48.6 [SD 5.0]). We found no overall association between pregnancy loss and later development of 11 site-specific types of cancer or cancer overall. Taking the sequence of pregnancy losses into account, primary recurrent pregnancy loss (three consecutive pregnancy losses without prior live birth) was associated with later overall cancer by an odds ratio of 1.27 (1.04-1.56). Secondary recurrent pregnancy loss showed no association to cancer. INTERPRETATION Pregnancy loss was not associated with later cancer development. Women with primary recurrent pregnancy loss had a borderline significant association to later cancer overall, this may be a chance finding. FUNDING Ole Kirk's Foundation and Copenhagen University Hospital Rigshospitalet's Research Grant.
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Affiliation(s)
- Anders P. Mikkelsen
- Department of Gynaecology and Obstetrics 4232, Copenhagen University Hospital Rigshospitalet, Denmark
- Corresponding author.
| | - Pia Egerup
- Department of Clinical Oncology, Zealand University Hospital, Roskilde, Denmark
| | - Julie F.M. Ebert
- Department of Gynaecology and Obstetrics 4232, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Astrid M. Kolte
- The Recurrent Pregnancy Loss Unit, Fertility Clinic 4071, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Henriette S. Nielsen
- Fertility Clinic 4071, Copenhagen University Hospital Rigshospitalet, Denmark
- The Recurrent Pregnancy Loss Unit, Fertility Clinic 4071, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Øjvind Lidegaard
- Department of Gynaecology and Obstetrics 4232, Copenhagen University Hospital Rigshospitalet, Denmark
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Olesen JB, Sørensen R, Hansen ML, Lamberts M, Weeke P, Mikkelsen AP, Køber L, Gislason GH, Torp-Pedersen C, Fosbøl EL. Non-vitamin K antagonist oral anticoagulation agents in anticoagulant naïve atrial fibrillation patients: Danish nationwide descriptive data 2011-2013. Europace 2014; 17:187-93. [PMID: 25236181 DOI: 10.1093/europace/euu225] [Citation(s) in RCA: 142] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
AIMS Non-vitamin K antagonist oral anticoagulation (NOAC) agents have been approved for stroke prophylaxis in atrial fibrillation (AF). We investigated 'real-world' information on how these drugs are being adopted. METHODS AND RESULTS Using Danish nationwide administrative registers, we identified all oral anticoagulation-naïve AF patients initiating oral anticoagulation from 22 August 2011 through 31 October 2013. Using logistic regression analysis, baseline characteristics and temporal utilization trends were compared between initiators of warfarin vs. one of the N OACs: dabigatran, rivaroxaban, or apixaban. We identified 18 611 oral anticoagulation-naïve AF patients of which 9902 (53%) initiated warfarin treatment, 7128 (38%) dabigatran, 1303 (7%) rivaroxaban, and 278 (1%) apixaban. Overall, 40% of newly initiated patients were started on dabigatran within the first 4 months of when the drug came on market. By October, 2013, 40% were being started on warfarin and dabigatran, respectively, and another 20% were started on either rivaroxaban or apixaban. Rivaroxaban and apixaban users generally had a higher predicted risk of stroke and bleeding compared with warfarin and dabigatran users. Older age, female gender, and prior stroke were some of the factors associated with NOAC use vs. warfarin, whereas chronic kidney disease, myocardial infarction, and heart failure showed the opposite association. CONCLUSION Among oral anticoagulation-naïve AF patients initiated on oral anticoagulation in Denmark, warfarin initiation has declined since the introduction of dabigatran in August 2011. Dabigatran is the most frequently used alternative option to warfarin; however, use of rivaroxaban and apixaban is increasing. Patients initiated with rivaroxaban or apixaban in general have a higher predicted stroke and bleeding risks compared with warfarin or dabigatran initiators.
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Affiliation(s)
- Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital Gentofte, Niels Andersens Vej 65, 2900 Hellerup, Denmark Department of Cardiology, Copenhagen University Hospital Hvidovre, Kettegård Allé 30, 2650 Hvidovre, Denmark
| | - Rikke Sørensen
- Department of Cardiology, Copenhagen University Hospital Gentofte, Niels Andersens Vej 65, 2900 Hellerup, Denmark
| | - Morten Lock Hansen
- Department of Cardiology, Copenhagen University Hospital Gentofte, Niels Andersens Vej 65, 2900 Hellerup, Denmark
| | - Morten Lamberts
- Department of Cardiology, Copenhagen University Hospital Gentofte, Niels Andersens Vej 65, 2900 Hellerup, Denmark
| | - Peter Weeke
- Department of Cardiology, Copenhagen University Hospital Gentofte, Niels Andersens Vej 65, 2900 Hellerup, Denmark
| | - Anders P Mikkelsen
- Department of Cardiology, Copenhagen University Hospital Gentofte, Niels Andersens Vej 65, 2900 Hellerup, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 3, 2100 København Ø, Denmark
| | - Gunnar H Gislason
- Department of Cardiology, Copenhagen University Hospital Gentofte, Niels Andersens Vej 65, 2900 Hellerup, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Aalborg University, Aalborg Hospital, Hobrovej 18-22, 9100 Aalborg, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Copenhagen University Hospital Gentofte, Niels Andersens Vej 65, 2900 Hellerup, Denmark Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 3, 2100 København Ø, Denmark
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Lamberts M, Gislason GH, Lip GYH, Lassen JF, Olesen JB, Mikkelsen AP, Sørensen R, Køber L, Torp-Pedersen C, Hansen ML. Antiplatelet therapy for stable coronary artery disease in atrial fibrillation patients taking an oral anticoagulant: a nationwide cohort study. Circulation 2014; 129:1577-85. [PMID: 24470482 DOI: 10.1161/circulationaha.113.004834] [Citation(s) in RCA: 205] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The optimal long-term antithrombotic treatment of patients with coexisting atrial fibrillation and stable coronary artery disease is unresolved, and commonly, a single antiplatelet agent is added to oral anticoagulation. We investigated the effectiveness and safety of adding antiplatelet therapy to vitamin K antagonist (VKA) in atrial fibrillation patents with stable coronary artery disease. METHODS AND RESULTS Atrial fibrillation patients with stable coronary artery disease (defined as 12 months from an acute coronary event) between 2002 and 2011 were identified. The subsequent risk of cardiovascular events and serious bleeding events (those that required hospitalization) was examined with adjusted Cox regression models according to ongoing antithrombotic therapy. A total of 8700 patients were included (mean age, 74.2 years; 38% women). During a mean follow-up of 3.3 years, crude incidence rates were 7.2, 3.8, and 4.0 events per 100 person-years for myocardial infarction/coronary death, thromboembolism, and serious bleeding, respectively. Relative to VKA monotherapy, the risk of myocardial infarction/coronary death was similar for VKA plus aspirin (hazard ratio, 1.12 [95% confidence interval, 0.94-1.34]) and VKA plus clopidogrel (hazard ratio, 1.53 [95% confidence interval, 0.93-2.52]). The risk of thromboembolism was comparable in all regimens that included VKA, whereas the risk of bleeding increased when aspirin (hazard ratio, 1.50 [95% confidence interval, 1.23-1.82]) or clopidogrel (hazard ratio, 1.84 [95% confidence interval, 1.11-3.06]) was added to VKA. CONCLUSIONS In atrial fibrillation patients with stable coronary artery disease, the addition of antiplatelet therapy to VKA therapy is not associated with a reduction in risk of recurrent coronary events or thromboembolism, whereas risk of bleeding is increased significantly. The common practice of adding antiplatelet therapy to oral VKA anticoagulation in patients with atrial fibrillation and stable coronary artery disease warrants reassessment.
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Affiliation(s)
- Morten Lamberts
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark (M.L., G.H.G., J.B.O., A.P.M., R.S., M.L.H.); National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark (G.H.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Cardiology B, Aarhus University Hospital, Skejby, Denmark (J.F.L.); Department of Cardiology, the Heart Centre, Copenhagen University Hospital Rigshospitalet, Denmark (L.K.); and Institute of Health, Science and Technology, Aalborg University, Denmark (C.T.-P.)
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Mikkelsen AP, Lindhardsen J, Lip GYH, Gislason GH, Torp-Pedersen C, Olesen JB. Female sex as a risk factor for stroke in atrial fibrillation: a nationwide cohort study. J Thromb Haemost 2012; 10:1745-51. [PMID: 22805071 DOI: 10.1111/j.1538-7836.2012.04853.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Female sex has been suggested as a risk factor for stroke/thromboembolism in patients with non-valvular atrial fibrillation (AF) and has therefore been included within risk scores, e.g., the CHA2 DS2 -VASc score, and guidelines. OBJECTIVES To investigate the risk of stroke/thromboembolism associated with female sex in non-valvular AF patients. PATIENTS/METHODS Using the national Danish registers, we identified non-anticoagulated patients discharged with non-valvular AF (1997-2008), and subdivided the population into three age intervals: < 65, 65-74 and ≥ 75 years. We calculated stroke rates according to sex, and assessed the stroke risk associated with female sex by using Cox regression analysis. RESULTS We included 87,202 AF patients, and 44,744 (51.3%) were female. The rate of stroke/thromboembolism for females aged < 65 and 65-74 years was not increased as compared with men, whereas the rate for females aged ≥ 75 years was increased. At both 1-year and 12-year follow-up, female sex did not increase the risk of stroke for patients aged < 75 years. At 1-year follow-up, the hazard ratios associated with female sex were 0.89 (95% confidence interval [CI] 0.70-1.13) and 0.91 (95 CI 0.79-1.05) for patients aged < 65 and 65-74 years, respectively, and being female and aged ≥ 75 years was associated with an increased risk of stroke of 1.20 (95 CI 1.12-1.28). CONCLUSION Female sex was only associated with an increased risk of stroke for AF patients aged ≥ 75 years. Our study suggests that female sex should not be automatically included as an independent stroke/thromboembolic risk factor in guidelines or in the CHA2 DS2 -VASc score, without careful prior consideration of the 'age < 65 and lone AF' criterion.
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Affiliation(s)
- A P Mikkelsen
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark.
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