Pediculosis capitis risk factors in schoolchildren: hair thickness and hair length

The human head lice is a cosmopolitan ectoparasite that causes pediculosis. The main way of spreading lice is through direct head-to-head contact. It is popular knowledge that some individuals are more susceptible to contracting head lice than others. Reports of individuals who have never been affected by the disease are common, even living in the same environment and under the same conditions as people who regularly have lice infestations. Previous research has been carried out on the risk of this infection associated with different human factors like gender or age. However, studies on the influence of the individual hair characteristics are scarce. The objective of the study was to analyze the pediculosis risk using geographical location, gender, age and individual hair characteristics as variables. Pediculosis was diagnosed through the detection of living lice in the hair. This cross-sectional school-based epidemiological study was conducted in 310 schoolchildren aged 1 to 13 years of schools in 4 municipalities situated in the State of Paraná, Brazil. The prevalence of head louse infection in primary school students was 49.35 %. The Odds Ratio of presence of pediculosis (OR) was estimated using multivariate logistic regression analysis. The results obtained indicate that hair length and thickness increase the risk of infection. Furthermore, the inclusion of hair color, hair shape, kind of hair-scale as covariates increases the risk of pediculosis, indicating that these variables partly explain this susceptibility and that pediculosis is independent of gender. A smaller hair diameter may favor insect fixation to the hair in the nymphal phases. These results may explain why girls are a greater risk as they let their hair grow for cultural reasons, i.e., being of female gender is an agglutinating variable. The conclusions drawn may explain the discrepancies obtained in previous analyses.

A nationwide cohort study on the impact of gestational diabetes on future cardiovascular events

Background

The link between hypertensive disease in pregnancy and future cardiovascular events is well established, as is the increased risk of developing type 2 diabetes mellitus after gestational diabetes (GDM). What is less well understood is the impact of GDM on future cardiovascular events. The literature is conflicting although suggestive that the risk of cardiovascular events with a history of GDM is 2 fold higher.

Purpose

Using the largest cohort to date and utilising robust data acquisition procedures and follow up we assessed the prognostic value of GDM for future cardiovascular events.

Methods

All female patients discharged from French hospitals in 2013 with at least 5 years of subsequent follow-up were identified. Those with a previous major adverse cardiovascular event, history of hypertensive disease, pre-existing diabetes or under the age of 18 years old were excluded. They were grouped depending on their history of GDM. After propensity score matching, patients with GDM were matched 1:1 with patients with no GDM. Hazard ratios for cardiovascular events during follow-up were adjusted by age at baseline.

Results

A total of, 1,738,101 women were included in the analysis, leaving 1,141,743 women (mean age 52.2, SD 19.7) once exclusion criteria were applied: 6998 (0.6%) had a history of GDM and the mean follow-up was 5.1 years (SD 1.3 years). Those with a history of GDM had a lower risk of new onset heart failure (HF) (hazard ratio [HR] 0.66, 95% confidence interval [CI]: 0.45–0.98) and all-cause death (HR 0.61, 95% CI 0.47–0.79). There was no significant difference in risk for myocardial infarction (HR 0.88, 95% CI 0.38–2.03), ischaemic stroke (HR 0.94, 95% CI 0.55–1.63), new onset atrial fibrillation (AF) (HR 0.61, 95% CI 0.33–1.11), cardiovascular death (HR 1.25, 95% CI 0.47–3.36) and major cardiovascular events (i.e. in-hospital cardiovascular death, myocardial infarction, ischaemic stroke or new-onset HF (MACE-HF)) (HR 0.75, 95% CI 0.56–1.01).

Conclusions

In a large contemporary analysis of female patient seen in French hospitals and utilising a robust data set we present the largest population analysis of the association between GDM and future cardiovascular events. Those with a history of GDM do not have a higher risk of myocardial infarction, ischaemic stroke, new onset AF, cardiovascular death or MACE-HF. Contrary to what is widely thought, a history of GDM confers a lower risk of new onset HF and all-cause death when compared to those women with no history of GDM.

Funding Acknowledgement

Type of funding sources: None.

Prognoses of “high-profile” diseases: five-year survival following hospitalization with previous cancer compared to previous heart failure

Background

The prognostic impact of heart failure relative to that of “high-profile” disease states such as cancer within the whole population is poorly known. Some data reported 2 decades ago indicated that heart failure was as “malignant” as many common types of cancer (with the notable exception of lung cancer) and was associated with a comparable number of expected life-years lost. Whether this is also the case in more recent years is unknown.

Methods

In a nationwide cohort study including 5,123,193 patients seen in French hospitals in 2012 with at least 5 years of follow-up (or dying earlier), all patients with a first admission to any hospital with heart failure or cancer were identified. We assessed the incidence of all-cause death during follow-up (2,523,627person-years). We analysed the outcome for the most common types of cancer specific to men and women and the results were then age-adjusted in men and in women.

Results

In 2012, 409,210 men had a hospitalisation with heart failure (n=164,601) or cancer (n=244,609). Similarly, 325,410 women were admitted with heart failure (n=127,734), or cancer (n=197,676).

Heart failure was associated with a worse survival rate than urologic cancer in men and a worse survival rate than breast cancer, gynaecologic cancer and gastrointestinal cancer in women (Figure 1). On an age-adjusted basis, cancer was associated with a worse survival than heart failure in men except for urologic cancer (see adjusted hazard ratios in Table 1). Cancer was associated with a worse age-adjusted survival than heart failure in women except for breast cancer.

Conclusion

Heart failure may be as “malignant” as many common types of cancer in men and in women. However, it is possible that the prognosis of HF has improved compared to that of cancer in the 2 last decades since only breast cancer in women and urologic cancer in men had a better prognosis than heart failure in an age-adjusted analysis.

Funding Acknowledgement

Type of funding sources: None.

Bleeding risk prediction in a large cohort of patients with atrial fibrillation and cancer: a nationwide cohort study

Introduction

The association between cancer types and specific bleeding events in atrial fibrillation (AF) patients has been scarcely investigated. Also, the performance of bleeding risk scores in this high-risk subgroup of patients is unclear.

Purpose

We investigated the rate of intracranial haemorrhage (ICH), major (MB) and gastrointestinal bleeding (GB) according to cancer types in AF patients. We also tested the predictive value of HAS-BLED, ATRIA and ORBIT bleeding risk scores.

Methods

Observational retrospective cohort study including 399,344 AF patients with cancer (mean age 77.9±10.2 years; 63.2% men). MB was defined according to Bleeding Academic Research Consortium (BARC) definitions.

Results

The highest ICH rates were found in leukaemia (1.89%/year), myeloma (1.52%/year), lymphoma and liver (1.45%/year) and pancreas cancer (1.41%/year). GBs were highest in liver (7.54%/year), pancreas (7.42%/year) and gastric (5.51%/year). Receiver operating characteristic (ROC) analysis showed that an ORBIT score ≥4 had the highest predictivity for MBs (AUC 0.805) followed by HAS-BLED and ATRIA (AUC 0.716 and 0.700, respectively). HAS-BLED and ORBIT performed best for ICH (AUC 0.744 and 0.742, respectively), better than ATRIA (AUC 0.635). For GB, ORBIT ≥4 had the highest predictivity (AUC 0.756), followed by the HAS-BLED (AUC 0.702) and ATRIA (AUC 0.662).

Conclusions

Some cancer types carry a greater bleeding risk in AF patients. The identification and management of modifiable bleeding risk factors is crucial in these patients, as well as to flag up high bleeding risk patients for early review and follow-up

Conclusions

Some cancer types carry a greater bleeding risk in AF patients. The identification and management of modifiable bleeding risk factors is crucial in these patients, as well as to flag up high bleeding risk patients for early review and follow-up.

Funding Acknowledgement

Type of funding sources: None.

Changes in incidences of clinical outcomes in patients with newly diagnosed atrial fibrillation: a nationwide study since 2010

Background and aims

The integrated approach for management of atrial fibrillation (AF) has been proposed in recent years for reducing AF-related mortality, morbidity, and hospitalizations. We evaluated the trends in the risk of ischemic stroke, intracranial bleeding, hospitalization for heart failure, cardiovascular mortality and all-cause death among newly diagnosed patients with AF in a nationwide cohort study since 2010.

Methods

This French longitudinal cohort study was based on the national hospitalization database covering hospital care from for the entire population. All adults hospitalized in French hospitals with AF from January 1, 2010 to December 31, 2018, were identified. Among them, 1,938,269 newly diagnosed patients with AF who survived 60 days after AF was diagnosed were included in the analysis. The 1-year risk of ischemic stroke, intracranial bleeding, and mortality of patients with AF diagnosed in each year were compared to those diagnosed in 2010 using the logistic regression analysis adjusted for age, sex, hypertension, diabetes mellitus, heart failure, prior stroke, vascular diseases, chronic obstructive pulmonary disease, hyperlipidemia, inflammatory diseases, cancer, abnormal renal function, abnormal liver function, anemia, and history of bleeding.

Results

The age of newly diagnosed patients with AF was stable from 77.1±11.8 years in 2010 to 76.9±12.6 years in 2018. Mean CHA2DS2-VASc scores of patients with incident AF showed a significant increasing trend for each year (from 3.32 in 2010 to 3.54 in 2018, p<0.001).

Temporal trends for the risk of adverse events at 1-year follow-up in newly diagnosed patients with AF compared to 2010 are shown in the Figure 1. Compared with 2010, the risk of ischemic stroke was significantly lower in all subsequent years from 2011 to 2018 (adjusted hazard ratios [HR] 0.940 to 0.854; p ranging from p=0.001 to <0.0001). The risk of major bleeding was significantly lower in all subsequent years after 2010 (adjusted HRs 0.965 to 0.621; p ranging from p=0.002 to <0.0001). By contrast, the risk of intracranial bleeding was not different after 2010 (adjusted HRs 1.032 to 0.996; all p>0.50). The risk of hospitalization for heart failure was significantly lower in all subsequent years after 2010 (adjusted HRs 0.927 to 0.820; all p<0.0001). Finally, the risk of cardiovascular mortality and all-cause death were also significantly lower after 2010 (adjusted HRs 0.952 to 0.690; p ranging from p=0.001 to <0.0001 and adjusted HRs 0.948 to 0.715; all p<0.0001 respectively) (Figure 2).

Conclusion

We observed a constant reduction in the risk of ischemic stroke, major bleeding, hospitalization for HF, cardiovascular death and all-cause death in AF patients seen in French hospitals in recent years. This may be related to an increasing use of oral anticoagulants (including NOACs) and by a more holistic and integrated approach to AF management that has been proposed in the more recent guidelines.

Funding Acknowledgement

Type of funding sources: None.

Prediction of mortality and mode of death in heart failure using multimorbidity and clinical risk score systems: a nationwide analysis

 

Heart failure (HF) is associated with a higher mortality, but modes of death may vary and their respective predictors have been insufficiently defined. Charlson comorbidity index (CCI) is a tool to quantify multimorbidity and a strong estimator of mortality. The quantifiable frailty phenotype is also predictive of mortality and disability and claims data can be used to classify individuals as frail and non-frail using the Hospital Frailty Risk Score (HFRS). CHA2DS2-VASc score was originally employed as a risk assessment tool for stroke in patients with AF but this comprehensive risk assessment score may help identify HF patients who are at high risk for mortality. We evaluated whether these tools may help to predict mortality and the different modes of death in HF.

Methods

Based on the France nationwide administrative hospital-discharge database, the analysis focused on all patients with HF hospitalized in France in 2012, with at least 5 years of complete follow-up (or dead earlier) as described by others. We identified 371,848 consecutive patients hospitalized with HF seen in 2012 and followed until December 2019. Adverse outcomes were investigated during follow-up. CHA2DS2VASc score, CCI and HFRS were calculated for each patient.

Results

Among these 371,848 patients with HF, 220,774 patients died during a follow-up of 4.0±2.8 years (median 4.8) (yearly rate 14.8%, 31.3% cardiovascular and 68.6% non-cardiovascular deaths). Death occurred more often in patients with higher CHA2DS2VASc, CCI and HFRS scores. HFRS was a better predictor of total mortality than CCI and CHA2DS2VASc score (see C-statistics in Table 1). However, the CHA2DS2VASc score was a better predictor of cardiovascular mortality than CCI and HFRS. By contrast, HFRS was a better predictor of non-cardiovascular mortality than CCI and CHA2DS2VASc score. The optimal predictive performances were better for non-cardiovascular death than for cardiovascular death.

Conclusion

Multimorbidity and frailty assessed with HFRS demonstrated better performances in predicting total mortality and non-cardiovascular mortality than CCI and CHA2DS2VASc score in HF patients. By contrast, CHA2DS2VASc score was a better predictor of cardiovascular mortality than CCI and HFRS in these patients.

Funding Acknowledgement

Type of funding sources: None.

Infection and infective endocarditis according to type of diabetes mellitus after cardiac implantable electronic device implantation: a contemporary nationwide cohort study

Background

Patients with diabetes mellitus (DM) are at increased risk of infection. However, there are controversial reports about type 1 or 2 DM and their associations with infection and infective endocarditis (IE) following implantation of cardiac implantable electronic device (CIED). We evaluated the contemporary incidence of infections and infective endocarditis (IE) following implantation of a first-time, permanent CIED in DM patients compared to controls.

Methods

This French longitudinal cohort study was based on the national hospitalization database covering hospital care from for the entire population. All adults hospitalized in French hospitals from 2010 to 2019, who underwent a de novo permanent pacemaker (PM) or implantable cardioverter defibrillator (ICD) implantation were identified together with the occurrence of post-implantation infection and IE-events during follow-up.

Results

In total 688,007 CIED patients were identified (pacemakers 87.3%, ICDs 12.7%). History of diabetes was present in 162,490 patients: 8,041 (1.2%) with type 1 DM and 154,449 (22.5%) with type 2 DM. Patients with no DM were slightly older and had less prevalent associated comorbidities than those with DM. Patients with type 1 DM had less prevalent associated comorbidities than those with type 2 DM. Follow-up was 2.6±2.6 years (median 1.9, IQR 0.2–4.3 years). There were 9,804 patients with CIED-related infection during follow-up (incidence rate 5.48 per 1000 patient.year) among whom 2,658 had IE (incidence rate 1.49 per 1000 patient year).

The incidence rate (per 1000 PYs) of CIED-related infection and IE in the different subgroups of patients with no DM, type 1 DM and type 2 DM are in Table 1. Incidence rates were higher in patients with DM than in those with no DM, and numerically higher in those with type 2 DM than in those with type 1 DM.

In multivariable analysis (adjustment on baseline characteristics including age, cardiovascular and non-cardiovascular comorbidities and type of CIED), type 1 DM and type 2 DM were independent risk factors for CIED-related infection vs no DM. Type 1 DM was not associated with a statistically different risk of CIED-related infection than type 2 DM.

When analysing the risk of IE during FU, type 2 DM was an independent risk factors for IE vs no DM, whilst there was a non-statistical trend for type 1 DM vs no DM. Type 1 DM was however not associated with a statistically different risk of IE than type 2 DM. Results were similar when one considered separately the periods 2010–2014 and 2015–2019

Conclusion

The risk of CIED-related infection was significantly higher in patients with type 1 and type 2 DM than in those with no DM. Although there were differences in the profile and clinical history of patients with type 1 and type 2 DM, there was no statistical difference in the risk of CIED-related infection and IE in patients with type 1 and type 2 DM in this contemporary analysis at a nationwide level.

Funding Acknowledgement

Type of funding sources: None.

Evolving changes of outcomes in patients with newly diagnosed atrial fibrillation: a nationwide study

Funding Acknowledgements

Type of funding sources: None.

Background and aims. The integrated approach for management of atrial fibrillation (AF) has been proposed in recent years for reducing AF-related mortality, morbidity, and hospitalizations. We evaluated the trends in the risk of ischemic stroke, intracranial bleeding, hospitalization for heart failure, cardiovascular mortality and all-cause death among newly diagnosed patients with AF in a nationwide cohort study since 2010.

Methods

This French longitudinal cohort study was based on the national hospitalization database covering hospital care from for the entire population. All adults hospitalized in French hospitals with AF from January 1, 2010 to December 31, 2018, were identified. Among them, 1,938,269 newly diagnosed patients with AF who survived 60 days after AF was diagnosed were included in the analysis. The 1-year risk of ischemic stroke, intracranial bleeding, and mortality of patients with AF diagnosed in each year were compared to those diagnosed in 2010 using the logistic regression analysis adjusted for age, sex, hypertension, diabetes mellitus, heart failure, prior stroke, vascular diseases, chronic obstructive pulmonary disease, hyperlipidemia, inflammatory diseases, cancer, abnormal renal function, abnormal liver function, anemia, and history of bleeding.

Results

The age of newly diagnosed patients with AF was stable from 77.1±11.8 years in 2010 to 76.9±12.6 years in 2018. Mean CHA2DS2-VASc scores of patients with incident AF showed a significant increasing trend for each year (from 3.32 in 2010 to 3.54 in 2018, p<0.001).

Temporal trends for the risk of adverse events at 1-year follow-up in newly diagnosed patients with AF compared to 2010 are shown in the Figure. Compared with 2010, the risk of ischemic stroke was significantly lower in all subsequent years from 2011 to 2018 (adjusted hazard ratios [HR] 0.940 to 0.854; p ranging from p=0.001 to <0.0001). The risk of major bleeding was significantly lower in all subsequent years after 2010 (adjusted HRs 0.965 to 0.621; p ranging from p=0.002 to <0.0001). By contrast, the risk of intracranial bleeding was not different after 2010 (adjusted HRs 1.032 to 0.996; all p>0.50). The risk of hospitalization for heart failure was significantly lower in all subsequent years after 2010 (adjusted HRs 0.927 to 0.820; all p<0.0001). Finally, the risk of cardiovascular mortality and all-cause death were also significantly lower after 2010 (adjusted HRs 0.952 to 0.690; p ranging from p=0.001 to <0.0001 and adjusted HRs 0.948 to 0.715; all p<0.0001 respectively).

Conclusion

We observed a constant reduction in the risk of ischemic stroke, major bleeding, hospitalization for HF, cardiovascular death and all-cause death in AF patients seen in French hospitals in recent years. This may be related to an increasing use of oral anticoagulants (including NOACs) and by a more holistic and integrated approach to AF management that has been proposed in the more recent guidelines.

Prognostic impact of vascular disease in patients with atrial fibrillation: Insights from The Loire Valley Atrial Fibrillation Project

Funding Acknowledgements

Type of funding sources: None.

Background

Vascular disease which comprises peripheral artery disease, significant coronary artery disease and aortic disease is associated with both an increased risk of atrial fibrillation (AF) and ischaemic stroke in AF patients.

Purpose

We investigated the effect of vascular disease on the prognosis of AF patients.

Methods

In this retrospective analysis, all patients with AF were identified and classified into 2 groups depending on the presence of vascular disease. 3 patients were excluded due to missing data. Primary outcome was a composite of death, stroke and thromboembolic events. Secondary outcomes included all-cause mortality, stroke or systemic embolism (SSE), ischaemic stroke, haemorrhagic stroke and major bleeding.

Results

A total of 8962 patients were included; 3021 with vascular disease and 5941 without vascular disease and followed up over a mean period of 929±1082 days. On the univariate analysis, patients with vascular disease were at a higher risk of all-cause mortality hazard ratio (HR) 1.728 ((confidence interval (CI)1.549-1.928), SSE HR HR 1.477 (CI 1.274-1.714), ischaemic stroke HR 1.441 (CI 1.202-1.727), major bleeding HR 1.488 (CI 1.292-1.713) and a composite of death and SSE HR 1.643 (CI 1.489-1.812), compared to patients without vascular disease. On a multivariate analysis, after adjusting for components of the CHA2DS2VASc score, oral anticoagulation (warfarin) use and antiplatelet use, the increased risk of all-cause mortality HR 1.460 (CI 1.285-1.658), SSE HR 1.226 (CI 1.030-1.458) and major bleeding HR 1.186 (CI 1.005-1.400) remained statistically significant, but the risk of ischaemic stroke was no longer significant, HR 1.187 (CI 0.960-1.469). Compared to those without vascular disease, patients with vascular disease were at a lower risk of haemorrhagic strokes but this was not significant.

Conclusion

AF patients with vascular disease are at a higher risk of all-cause mortality, SSE and major bleeding compared to patients without vascular disease, indicating that patients with this combination require careful and holistic management in terms of risk factor control and treatment. Additional research is required to further characterise the relationship between the two.

Effect of cardiorenal syndrome and its different subtypes on incidence of atrial fibrillation in a nationwide analysis

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiorenal syndromes (CRS) are associated with increased risks of all-cause and cardiovascular death, end-stage kidney disease (ESKD), myocardial infarction (MI), heart failure (HF) and ischemic stroke. Whether CRS (and different subtypes of CRS) are more prone to develop atrial fibrillation (AF) is unclear.

Methods

This longitudinal cohort study was based on the national hospitalization database covering hospital care from the entire French population. The analysis focused on those with at least 5 years of complete follow-up (or dead earlier) as described by others. We identified 439,787 consecutive patients hospitalized in France in 2012 who had heart failure (HF), chronic kidney disease (CKD) and/or CRS. We estimated incidences of clinical events (including incident AF) during follow-up. Analysis were adjusted for 1) age and sex and 2) all baseline characteristics except cardiac and renal comorbidities.

Results

Overall, 58.2% were male, 67.7% had hypertension, 31.6% had diabetes mellitus and their mean age was 75.3±13.2; 329,154 had isolated HF, 67,939 had isolated CKD, 15,695 had acute concomitant CRS (which could be type 1, 3 or 5 CRS), 15,699 had type 2 CRS (cardiorenal) and 11,300 had type 4 CRS (renocardiac). History of AF was present in 36.4 % of the patients: 39.9% in those with isolated HF, 13.3% in those with isolated CKD, 43.0% in those with concomitant CRS, 57.2% in those with type 2 CRS, 35.3% in those with type 4 CRS (overall p<0.0001).

Incidence and adjusted hazard ratios for of all-cause death, cardiovascular death and incident AF are in Table 1. CRS was associated with a higher risk of death and patients with type 2 CRS had the highest risk of all-cause and cardiovascular mortality. Isolated HF was associated with a higher risk of incident AF than isolated CKD (Table 1). Patients with CRS had higher risk of incident AF than those with isolated HF or isolated CKD. Among patients with CRS, those with concomitant CRS had the numerically highest 5-year risk of incident AF, which was not statistically different than those with type 2 or type 4 CRS in adjusted analysis.

Conclusion

The long-term prognosis of CRS subtypes is poor and may vary, some CRS subtypes being more closely associated with risk of all-cause death and cardiovascular mortality than others. Risk of incident AF is higher in CRS than in isolated HF or isolated CKD and is not statistically different among the various subtypes of CRS.

Atrial fibrillation is associated with an increased risk of ventricular arrhythmias and sudden death in the general population

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation (AF) has been linked to an increase in the risk of ventricular arrhythmias.

Purpose

We aimed to investigate whether AF is associated with an increased risk of ventricular tachycardia (VT), ventricular fibrillation (VF) and sudden death (SD).

Methods

Hospitalised patients from 2013 with and without AF were identified from the French National database and included if they had at least 5 years of follow-up.

Results

Over a median follow-up period of 5.4 years (interquartile range (IQR) 5.0-5.8 years), a total of 3345638 patients were identified. Of these, 312226 had AF and 3033412 did not have AF. After multivariable analysis, the predictors significantly associated with VT, VF and SD included age, sex, hypertension, diabetes mellitus, heart failure, history of pulmonary oedema, valve disease, dilated cardiomyopathy, coronary artery disease, vascular disease, AF, smoking, dyslipidaemia, obesity, alcohol related diagnoses, chronic kidney disease, lung disease, liver disease, inflammatory diseases, anaemia, previous cancer, poor nutrition, cognitive impairment, and frailty.

The incidence of VT, VF and SD was higher in those with AF compared to those without AF (2.23%/year vs. 0.56%/year). AF was associated with a higher risk of incident outcomes compared to no AF, hazard ratio (HR) 3.657 (confidence interval (CI) 3.604-3.711). After adjustments were made for confounders (Figure 1), this increased risk was still significant HR 1.167 (CI 1.111-1.226). A 1:1 propensity score matched analysis was also performed (n=289,332 in each group), demonstrating the significantly increased risk of ventricular arrhythmias and SD in patients with AF compared to those without AF, HR 1.339 (CI 1.313-1.366).

Conclusion

The findings from our study AF indicate that AF is associated with an increased risk of VT, VF and sudden death in the general population.

Atrial fibrillation is associated with an increased risk of ventricular arrhythmias and sudden death in patients with pacemakers and implantable cardioverter defibrillators (ICDs)

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation (AF) has been linked to an increase in the risk of ventricular arrhythmias.

Purpose

We aimed to investigate whether AF is associated with an increased risk of ventricular tachycardia (VT), ventricular fibrillation (VF) and sudden death (SD) in patients with cardiac implantable electronic devices (CIEDs).

Methods

All patients hospitalised in France between 2011 and 2020 with a history of pacemakers (PPMs) and implantable cardioverter defibrillator (ICD) were identified from the French National database. Patients with a prior history of VT, VF and SD were excluded.

Results

A total of 701,195 patients were identified. Of these, 581,781 (90.1%) patients had PPMs and 63,726 (9.9%) had ICDs. In the PPM group, 248046 (42.6%) had AF and 333735 (57.4%) had no AF. After multivariable analysis, predictors for VT, VF and SD included sex, diabetes, heart failure, history of pulmonary oedema, valve disease, dilated cardiomyopathy, coronary artery disease (CAD), AF, vascular disease, intracranial bleeding, smoking, dyslipidaemia, alcohol related disorders, lung disease, chronic kidney disease (CKD), thyroid disorders, inflammatory diseases, anaemia, poor nutrition, cognitive impairment, previous cancer and frailty. The incidence of VT, VF and SD was higher in patients with AF (1.47%/year) compared to those without AF (0.94%/year), with the risk significantly elevated in the former group, hazard ratio (HR) 1.554 (confidence interval (CI) 1.508-1.601). After adjustment for confounders (Figure 1), AF was still associated with a significantly increased risk of VT, VF and SD, HR 1.236 (CI 1.198-1.276) in patients with PPMs. This was further demonstrated through a 1:1 propensity score matched (PSM) analysis (n=200977 in each group) where the risk of incident outcomes was significantly higher in PPM patients with AF, HR 1.230 (1.187-1.274), compared to those without AF.

In the ICD group, 20965 (32.9%) had AF and 42761 (67.1%) had no history of AF. Predictors of VT, VF and SD after multivariable analysis included age, sex, diabetes mellitus, heart failure, valve disease, CAD, previous percutaneous coronary intervention, vascular disease, AF, CKD, liver disease and frailty. Incidence of VT, VF and SD was higher in ICD patients with AF (5.30%/ year) compared to those without AF (4.21%/year), with a significantly higher risk, HR 1.261 (CI 1.204-1.320). After adjustment for confounders, this elevated risk was still significant HR 1.167 (1.111-1.226) (Figure 1). 1:1 PSM analysis (n=18349 in each group) demonstrated this further with a significantly elevated risk in ICD patients with AF, compared to ICD patients without AF, HR 1.134 (CI 1.071-1.200).

Conclusion

Our findings suggest that patients with PPM and ICD with concurrent AF are at a higher risk of VT, VF and sudden death compared to patients with PPM and ICD who do not have AF.

Cardiovascular events in metabolically healthy obese. A nationwide cohort study

Background

Obesity is a risk factor for cardiovascular disease (CVD) and has been increasing globally over the past 40 years in many countries worldwide. Metabolic abnormalities such as hypertension, dyslipidemia and diabetes mellitus are commonly associated and may mediate some of the deleterious effects of obesity. A subset of obese individuals without obesity-related metabolic abnormalities may be classified as being “metabolically healthy obese” (MHO). We aimed to evaluate the associations among MHO individuals and different types of incident cardiovascular events in a contemporary population at a nationwide level.

Methods

From the national hospitalization discharge database, all patients discharged from French hospitals in 2013 with at least 5 years or follow-up and without a history of major adverse cardiovascular event (myocardial infarction, heart failure [HF], ischemic stroke or cardiovascular death, MACE-HF) or underweight/ malnutrition were identified. They were categorized by phenotypes defined by obesity and 3 metabolic abnormalities (diabetes mellitus, hypertension, and hyperlipidemia). In total, 2,953,816 individuals were included in the analysis, among whom 272,838 (9.5%) were obese. We evaluated incidence rates and hazard ratios for MACE-HF, cardiovascular death, myocardial infarction, ischemic stroke, new-onset HF and new-onset atrial fibrillation (AF). Adjustments were made on age, sex and smoking status at baseline.

Results

During a mean follow-up of 4.9 years, obese individuals with no metabolic abnormalities had a higher risk of MACE-HF (multivariate-adjusted hazard ratio [HR] 1.22, 95% confidence interval [CI]: 1.19–1.24), new-onset HF (HR 1.34, 95% CI 1.31–1.37), and AF (HR 1.33, 95% CI 1.30–1.37) compared with non-obese individuals with 0 metabolic abnormalities. By contrast, risks were not higher for myocardial infarction (HR 0.92, 95% CI 0.87–0.98), ischemic stroke (HR 0.93, 95% CI 0.88–0.98) and cardiovascular death (HR 0.99, 95% CI 0.93–1.04). In the models fully adjusted on all baseline characteristics, obesity was independently associated with a higher risk of MACE-HF events (HR 1.13, 95% CI 1.12–1.14), of new-onset HF (HR 1.19, 95% CI 1.18–1.20) and new-onset AF (HR 1.29, 95% CI 1.28–1.31). This was not the case for the association of obesity with cardiovascular death (HR 0.96, 95% CI 0.94–0.98), myocardial infarction (HR 0.93, 95% CI 0.91–0.95) and ischemic stroke (HR 0.93, 95% CI 0.91–0.96).

Conclusions

Metabolically healthy obese individuals do not have a higher risk of myocardial infarction, ischemic stroke or cardiovascular death than metabolically healthy non-obese individuals. By contrast they have a higher risk of new-onset HF and new onset AF. Even individuals who are non-obese can have metabolic abnormalities and be at high risk of cardiovascular disease events. Our observations suggest that specific studies investigating different aggressive preventive measures in specific subgroups of patients are warranted.

Funding Acknowledgement

Type of funding sources: None.

Risk of ischemic stroke in patients with atrial fibrillation and concomitant hyperthyroidism: a nationwide cohort study

Background

Hyperthyroidism is strongly associated with atrial fibrillation (AF) and the latter confers a significant risk for stroke and mortality (1). However, there is conflicting evidence on the association between the hyperthyroidism and stroke in patients with AF (2–4).

Purpose

We aimed to investigate the incidence of stroke and bleeding, as well as the predictive accuracy of CHA2DS2VASc and HAS-BLED scores in the AF patients with hyperthyroidism.

Methods

Anonymised and coded information of patients who were admitted to French hospitals with AF between January 2010 and December 2019 were retrospectively collected from the French National Hospital Discharge Database. Incidence rates of ischaemic stroke and bleeding were calculated and compared in AF patients with and without concomitant hyperthyroidism. The associations of risk factors with ischaemic stroke were assessed by univariate and multivariate Cox regression analysis. The predictive value of CHA2DS2VASc and HAS-BLED scores in AF patients with and without hyperthyroidism were assessed using the receiver operating characteristic (ROC) curves and Harrell C indexes compared with the DeLong test.

Results

Concomitant hyperthyroidism was identified in 32,400 (1.3%) patients among the 2,421,087 AF patients included in this study. The yearly incidence of ischaemic stroke was 2.6 (95% confidence interval CI: 2.5–2.8) in hyperthyroid AF patients, and 2.3 (95% CI: 2.3–2.4) in non-thyroid AF patients over a mean follow-up of 2.0 (SD2.2) years. The incidence of ischemic stroke was higher in the first year after AF diagnosis (3.24%/year, 95% CI 3.21–3.26) than in the subsequent follow-up (1.95%/year, 95% CI 1.93–1.96) and this phenomenon was more marked in patients with hyperthyroidism. There was a stepwise increase in the incidence of stroke with increasing CHA2DS2VASc score, irrespective of sex groups and hyperthyroidism status. Hyperthyroidism was an independent risk factor for ischaemic stroke (adjusted hazard ratio HR: 1.133, 95% CI: 1.080–1.189, p<0.001) overall, particularly within the first year of hyperthyroidism diagnosis (HR 1.203, 95% CI 1.120–1.291), with a nonsignificant association beyond 1 year (HR 1.047, 95% CI 0.980–1.118). Major bleeding incidence was lower in hyperthyroid AF group (incidence ratio IR: 5.1%/year) as compared to non-thyroid AF group (IR: 5.4%/year, p<0.001). The predictive value of CHA2DS2VASc and HAS-BLED scores for ischaemic stroke and bleeding events respectively did not significantly differ between AF patients with or without hyperthyroidism diagnosis.

Conclusions

Hyperthyroidism was independent risk factor of ischaemic stroke among AF patients, within the first year of hyperthyroidism diagnosis. Beyond 1 year, there was no independent contribution of hyperthyroidism to ischaemic stroke in AF.

Funding Acknowledgement

Type of funding sources: None. Flow chart of the cohort studyCumulative incidence for ischemic stroke

Are the results of the RATE-AF trial reproducible in daily practice? Clinical outcomes with digoxin vs beta-blocker for heart rate control in permanent atrial fibrillation

Background

There is little evidence to support selection of heart rate control therapy in patients with permanent atrial fibrillation (AF), in particular those with coexisting heart failure. In the recent RATE-AF trial that included patients with permanent AF and symptoms of heart failure, treatment with low-dose digoxin or bisoprolol did not result in statistically significant difference in quality of life at 6 months. The purpose of the study was to analyse whether the clinical outcomes may differ among unselected patients with permanent AF treated with digoxin or beta-blocker seen in daily practice.

Methods

All patients with atrial fibrillation (AF) seen in an academic institution were identified in a database. We examined the clinical course of 8962 consecutive patients with AF seen over a 10-year period. The adverse outcomes were investigated during follow-up and we identified the causes of death. Among them 1,787 patients had the RATE-AF criteria of inclusion (permanent AF, age ≥60 and NYHA ≥2), of whom 512 patients (29%) were treated with beta-blocker alone, 425 (24%) were treated with digoxin alone and 237 (13%) were treated with both a beta-blocker and digoxin. Outcomes in patients treated with beta-blocker alone or digoxin alone were compared after 1:1 propensity-score matching.

Results

After propensity score matching, 270 patients treated with beta-blocker were matched 1:1 with 270 patients treated with digoxin. In these patients (age 79±8 years, CHA2DS2VASc score 4.0±1.3), 125 deaths were recorded during a follow-up of 2.2±2.7 years (median 1.1, interquartile 0.1–3.5 years, yearly rate of death 10.4%) including 72 cardiovascular deaths (yearly rate 6.0%). Major clinical events (all-cause death, myocardial infarction, ischemic stroke or major bleeding) were recorded in 192 patients (yearly rate 19.1%). In this matched analysis, risk was not statistically significant in the 2 groups for all-cause death (HR 0.95, 95% CI 0.67–1.35 for beta-blocker use vs digoxin use), cardiovascular death (HR 1.23, 95% CI 0.77–1.96 for beta-blocker use vs digoxin use) or major clinical events (HR 0.98, 95% CI 0.74–1.31 for beta-blocker use vs digoxin use).

Conclusion

Our analysis included more patients and had a longer follow-up than in the RATE-AF trial, resulting in a 10-fold higher number of clinical events. We found that among patients with permanent AF and symptoms of HF, there was no statistically significant difference in the risk of all-cause death, cardiovascular mortality and major clinical events between those treated with digoxin or beta-blocker. Concerns regarding the use of digoxin, such as the narrow therapeutic window and drug interactions, were not issues resulting in worse clinically relevant cardiovascular outcomes with the approach used in the current study.

Funding Acknowledgement

Type of funding sources: None.

Benefits for clinical outcomes associated with dual-chamber pacing versus ventricular pacing in patients with sinus-node dysfunction: a nationwide matched control study

Introduction

Evidence from randomized trials suggests that, in patients with sinus-node dysfunction (SND), physiologic pacing (dual-chamber, DDD) may be superior to single-chamber (ventricular, VVI) pacing because it is associated with lower risks of atrial fibrillation and stroke, better exercise capacity and lower risk of pacemaker syndrome. However, benefits on mortality and risk of heart failure have not been demonstrated and these issues have not been fully evaluated in large “real life” analyses. The aim of our study was to assess and compare clinical outcomes within the first 30 days and during a longer-term follow-up with the two types of pacing at a nationwide level for patients with SND.

Methods

Using the administrative hospital database in France 2010–2020, 52,974 patients with SND were included in the analysis: 4,069 patients had VVI pacing and 48,905 had DDD pacing. Patients with leadless VVI pacemakers were excluded of the analysis. After propensity score matching 2,213 patients with VVI pacemaker were matched 1:1 with 2,213 patients treated with DDD pacemaker.

Results

In the matched analysis, patients with DDD pacemakers had a lower rate of all-cause (hazard ratio HR 0.711, 95% CI 0.61–0.828) and cardiovascular death (HR 0.628, 95% CI 0.48–0.818) within the 30 days after implantation. There were no significant differences for incidence of tamponade (HR 0.666, 95% CI 0.11–3.992), pneumothorax (HR 1.000, 95% CI 0.32–3.105), hemothorax (HR 0.800, 95% CI 0.21–2.982), major bleeding (HR 0.824, 95% CI 0.68–1.005) and transfusion (HR 1.016, 95% CI 0.83–1.243). During subsequent follow-up (mean: 3.0±2.8 years), risk of all-cause death in the matched population was significantly lower in the DDD group than in the VVI pacemaker group (HR 0.683, 95% CI 0.60–0.784). Patients with SND treated DDD pacemakers also had a lower risk of cardiovascular death (HR 0.569, 95% CI 0.44–0.732), new-onset atrial fibrillation (HR 0.638, 95% CI 0.58–0.706), ischemic stroke (HR 0.685, 95% CI 0.53–0.887) and hospitalization for heart failure (HR 0.758, 95% CI 0.68–0.850) than those treated VVI pacemakers, whilst risk of endocarditis was not significantly different (HR 0.986, 95% CI 0.50–1.951).

Conclusion

Patients with SND treated with DDD pacemakers had better clinical outcomes compared to those treated with VVI pacemakers. DDD pacing was associated with lower risks of death, cardiovascular death, new-onset atrial fibrillation, ischemic stroke, hospitalization for heart failure. DDD pacing was neither associated with a higher risk of complication on the short-term nor of endocarditis on the longer-term.

Funding Acknowledgement

Type of funding sources: None.

Long-term clinical outcomes in patients after catheter ablation for atrial fibrillation or atrioventricular node ablation: a French nationwide cohort study

Background

Catheter ablation of atrial fibrillation (AF) has become a therapy of choice to treat symptomatic AF in current practice. As an alternative, atrioventricular node (AVN) ablation is an older but efficient procedure to control ventricular rate.

Purpose

To assess long-term clinical outcomes of AF ablation and AVN ablation in large cohort of patients with AF and to compare these two procedures.

Methods

This French multicentric retrospective study enrolled all patients hospitalized with a primary or secondary diagnosis of AF from 1st January 2010 to 31st December 2019, using an administrative hospital-discharge database. Clinical outcomes were analyzed in overall population and in propensity-matched samples.

Results

During follow-up (mean [SD] 2.0 [2.2], median [IQR] 1.0 [0.1–3.3] years), 2,438,015 patients were analysed (No ablation 2,360,833, AF ablation 62,490 and AVN ablation 14,692). Compared to patients treated without ablation, incidence of all-cause death was lower in patients treated with AF ablation (hazard ratio (HR) 0.272, 95% confidence interval (CI) 0.259–0.287, p<0.0001) or AVN ablation (HR 0.762, 95% CI 0.734–0.791, p<0.0001). After propensity-score matching, in patients treated with AF ablation, incidence of all-cause death (HR 0.662, 95% CI 0.557–0.788, p<0.0001), cardiovascular death (HR 0.617, 95% CI 0.471–0.807, p<0.0001) and hospitalization for heart failure (HF) (HR 0.732, 95% CI 0.620–0.865, p<0.0001) were lower compared to patients treated with AVN ablation, unlike incidence of ischemic stroke (HR 1.447, 95% CI 1.122–1.865, p<0.0001).

Conclusion

AF ablation and AVN ablation may be associated with better survival compared to non-invasive strategy. Compared to AVN ablation, AF ablation is associated with lower risk of all-cause death, cardiovascular death and hospitalization for HF, but higher incidence of ischemic stroke.

Funding Acknowledgement

Type of funding sources: None. Baseline characteristics matched cohortMain results

Antidiabetic drugs use and new-onset atrial fibrillation in patients with diabetes mellitus

Background

Diabetes is one of the most common chronic disorders worldwide and is an important cause of cardiovascular disease. Large studies investigating the risk of atrial fibrillation (AF) in diabetic patients taking different diabetes medications are still missing.

Methods

The analysis was based on the EGB (“Echantillon Généraliste des Bénéficiaires”) database, a 1/97 representative sample of the French nationwide claims and hospitalisation database. A cohort comprising 25,117 adult patients with diabetes and no previous AF seen between 2010 and 2018 was created and followed until December 2018 for incidence of new-onset AF. Among these diabetic patients, 36.0% were treated with metformin, 32.0% were treated with Sulfonylureas, 7.0% were treated with DPP4-inhibitors, 1.6% were treated with GLP1- analogues and 19.6% were treated with insulin. A Cox proportional hazards model was used to determine factors and different oral diabetes medications independently associated with the risk of AF during follow-up.

Results

During a follow-up of 4.8±3.5 years, there were 3,300 patients with new onset AF (yearly rate 2.7%). In multivariable analysis, among baseline characteristics, we found that older age, male sex, hypertension, heart failure, aortic stenosis, chronic kidney disease, anemia and diuretic use were independently associated with a higher risk of new AF. Among diabetes medications included in the multivariable model, use of sulfonylureas was independently associated with a lower risk of AF (HR 0.86, 95% CI 0.80–0.92, p<0.0001 vs no use). By contrast, use of GLP1-analogues (HR 2.27, 95% CI 1.49–3.46, p=0.0001 vs no use), DPP4-inhibitors (HR 1.88, 95% CI 1.59–2.22, p<0.0001 vs no use), metformin (HR 1.09, 95% CI 1.01–1.18, p=0.03 vs no use) and of insulin (HR 1.15, 95% CI 1.05–1.26, p=0.004 vs no use) were independently associated with a higher risk of AF.

Conclusions

Patients with different diabetes medications have significantly different long-term risk of AF. Specifically, sulfonylureas use was associated with a lower risk of incident AF whilst other antidiabetic drugs were associated with a higher risk of AF during follow-up.

Funding Acknowledgement

Type of funding sources: None.

Comparison of the HAS-BLED, ORBIT and ATRIA bleeding risk scores in 399,344 patients with atrial fibrillation and cancer

Background

The presence of cancer worsens the prognosis of patients with atrial fibrillation (AF). However, the association between cancer type and specific bleeding events has been scarcely investigated. Furthermore, the performance of bleeding risk scores, such HAS-BLED, ORBIT and ATRIA, in this high-risk subgroup of AF patients is unclear.

Purpose

To investigate the incidence rate (IR) of major, gastrointestinal (GI) bleeding and intracranial haemorrhage (ICH) according to cancer types. We also investigated the performance of HAS-BLED, ATRIA and ORBIT scores. HASBLED ≥3, ATRIA ≥5 and ORBIT ≥4 were defined as high-risk.

Methods

Observational retrospective cohort study including 399,344 patients with AF and cancer.

Results

Mean age was 77.9±10.2 years and 63.2% were men. During a mean follow-up of 2.0 years, the IR of major bleeding was as high as 8.41%/year, GI bleeding was 3.61%/year and ICH 1.33%/year. Major bleedings were more frequent in liver (12.68%/year), leukaemia (12.39%/year), pancreas (11.71%/year), bladder (11.67%/year) and myeloma (11.64%/year). GI bleeding were highest in liver (7.54%/year), pancreas (7.42%/year) and gastric (5.51%/year). The highest IR of ICH was found in leukaemia (1.89%/year), myeloma (1.52%/year), lymphoma and liver (1.45%/year) and pancreas cancer (1.41%/year).

Figure 1 shows the hazard ratios and AUC values for the three scores against each endpoint. All the three scores were significantly associated with major, GI and ICH. The HAS-BLED score performed better than others for ICH prediction, while the ORBIT score showed the best predictivity for major and GI bleedings (p<0.0001 for all AUC comparisons)

Conclusions

Cancer increases the risk of bleeding in patients with cancer, with specific differences according to each cancer type. HAS-BLED score identified patients at highest risk for ICH and the ORBIT score for major and GI bleeding.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Prevalences and incidences of cardiovascular and renal diseases in type 1 compared with type 2 diabetes: a nationwide observational study

Background

Type 1 diabetes (T1D) and type 2 diabetes (T2D) increase risks of cardiovascular (CV) and renal disease compared with diabetes-free populations. There are only few studies comparing T1D and T2D for the risk of these clinical events. We examined these issues in a nationwide analysis in France.

Methods

All patients aged ≥18 seen in French hospitals in 2013 with at least 5 years of follow-up were identified and categorized by their diabetes status. A total of 50,623 patients with T1D (age 61.4±18.6, 53% male) and 425,207 patients with T2D (age 68.6±14.3, 55% male) were followed over a mean period of 4.3±2.1 years (median 5.3, interquartile 2.8–5.8 years). Prevalence and event rates of myocardial infarction (MI), heart failure (HF), ischemic stroke, chronic kidney disease (CKD), all-cause death and CV death were assessed with age stratification of 10-year intervals. Cox regression analyses were used to estimate risk with adjustment on sex and age.

Results

The age and sex-adjusted prevalence of CV diseases was higher in T2D for ages above 40 years whereas the adjusted prevalence of CKD was more common in T1D between ages 18 and 69 years and higher in T2D for ages above 80 years.

During 2,033,239 person-years of follow-up, there were 27,497 patients with MIs (yearly rate 1.4%), 24,892 with ischemic strokes (yearly rate 1.2%), 100,769 with incident HF (yearly rate 5.4%), 65,928 with incident CKD (yearly rate 3.4%) and 197,858 deaths (yearly rate 9.7%) including 49,026 CV deaths (yearly rate 2.4%) were recorded. Age and sex-adjusted event rates comparing T1D versus T2D showed that MI risk was increased for ages above 60 (1.2-fold for T1D versus T2D) and HF between ages 18–29 and above 60 years (1.1–1.4-fold). Adjusted risk of ischemic stroke did not markedly differ between T1D and T2D. Risk of incident CKD was 1.1–2.4-fold higher in T1D between ages 18–49 and above 60 years. The all-cause death risk was 1.1-fold higher in T1D at age ≥60 years, the cardiovascular death risk being 1.1-fold higher in T1D between 60 and 69 years.

Conclusions

The adjusted prevalent burden and risk of incident renal disease are greater among patients with T1D compared with T2D patients across most ages. Although the prevalent burden of cardiovascular diseases may be lower in T1D than in T2D, patients with T1D may have a higher risk of incident MI, HF, all-cause death and cardiovascular death at middle-older ages, highlighting their need for improved prevention.

Funding Acknowledgement

Type of funding sources: None.

Exploring the temporal relationship between atrial fibrillation and heart failure development. Analysis from nationwide database

Background

Atrial fibrillation (AF) and heart failure (HF) often coexist and are closely intertwined, each condition worsening the other. The temporal relationships between these two disorders have not yet been fully explored. We assessed, on a nationwide scale, the prognosis of patients hospitalized with HF and AF, based on the timing of AF and HF development.

Methods

From the administrative database covering hospital care for the whole French population, we identified 1,349,638 patients diagnosed with both AF and HF between 2010 and 2018: 956,086 of these AF patients developed HF first (prevalent HF) and 393,552 developed HF after AF (incident HF). The outcome analysis (all-cause death, cardiovascular [CV] death, ischemic stroke or hospitalization for HF) was performed with follow-up starting at the time of last event between AF or HF in the whole cohort and in 427,848 propensity-score-matched patients (213,924 with incident HF and 213,924 with prevalent HF).

Results

During follow-up (mean follow-up 1.6±1.9 year), matched patients with prevalent HF had a higher risk of all-cause death (21.6 vs 19.2%/year), CV death (7.6 vs 6.5%/year) as well as non-cardiovascular death (13.9 vs 12.7%/year) than those with incident HF. The risk for ischemic stroke was lower in the prevalent HF group (1.2 vs 2.4%/year).

Conclusion

In patients hospitalized with both AF and HF, we identified two distinct clinical entities based on the chronological sequence of the two disorders. Patients in whom HF preceded AF (prevalent HF) had higher mortality and higher risk of rehospitalization for HF.

Funding Acknowledgement

Type of funding sources: None.

Conventional transvenous or leadless ventricular permanent pacemakers: post-operative complications and mid-term follow-up

Introduction/Background

Leadless ventricular permanent pacemakers (leadless VVI, LPM) were designed to reduce lead-related complications of conventional VVI pacemakers (CPM).

Purpose

The aim of our study was to assess and compare real-life clinical outcomes within the first 30 days and during a mid-term follow-up with the two techniques at a nationwide level.

Methods

This French longitudinal cohort study was based on the national hospitalization database covering hospital care from for the entire population. All adults (age ≥18 years) hospitalized in French hospitals From January 1, 2017 to September 1, 2020, who underwent a first LPM or CPM implantation were included. Importantly, patients with dual chamber pacemaker were not included in our study.

Results

Of 42,315 patients included in the cohort, 40,828 patients (96%) had a CPM and 1,487 had a LPM. Using propensity score, 1,344 patients with CPM were adequately matched in a 1:1 fashion with LPM patients.

Clinical outcomes at day 30

In the unmatched population, within the 30 days after implantation, patients with LPM had a lower rate of all-cause mortality (OR: 0.635, 95% CI: 0.527–0.765, p<0.0001) and from a cardiovascular cause (OR: 0.568, 95% CI: 0.405–0.797, p=0.001). They also had lower rates of major bleeding and need for transfusion. There was no significant difference between groups regarding tamponade, pneumothorax or hemothorax.

In the matched population, LPM implantation was still significantly associated with a lower rate of all-cause death (OR: 0.583, 95% CI: 0.456–0.744, p<0.0001), cardiovascular death (OR: 0.413, 95% CI: 0.271–0.629, p<0.0001), major bleeding (OR: 0.523, 95% CI: 0.348–0.786, p=0.002) or transfusion (OR: 0.481, 95% CI: 0.296–0.780, p<0.0001). However, tamponade, pneumothorax or hemothorax were not significantly different between the two groups.

Clinical outcomes during mid-term follow-up

In the unmatched patients, mean follow-up was 8.6±10.5 months. Annual incidence of all-cause death was high in both groups, and significantly higher in the LPM group than in CPM group (31%/year vs. 20%/year, p<0.0001) with a HR of 1.519 (95% CI: 1.296–1.780). Cardiovascular death was not significantly different between groups. Infective endocarditis was higher in the LPM group than in the CPM group with a HR of 2.108 (95% CI: 1.119–3.973).

In the matched patients, mean follow-up was 6.2±8.7 months. All-cause death, cardiovascular death and infective endocarditis were not significantly different between groups.

Conclusion

Mortality is high among unselected patients implanted with ventricular permanent pacemakers, whether leadless or conventional pacemaker are used.

Implantation of leadless pacemakers seems to be a safe procedure in this high-risk population, with better outcomes at 1 month.

Mid-term outcomes appear relatively similar in LPM and CPM patients.

Funding Acknowledgement

Type of funding sources: None. Central illustration

All-cause mortality and cardiovascular death in 52091 patients with hypertrophic cardiomyopathy. A nationwide cohort study

Background

Patients with hypertrophic cardiomyopathy (HCM) have high risk of death related to cardiovascular (CV) death. Improvements in risk stratification are needed to help identify those HCM patients at higher risk of all-cause death and cardiovascular death.

Methods

This French longitudinal cohort study from the database covering hospital care from 2010 to 2019 analyzed adultshospitalized with isolated HCM. The overall sample of 52,091 patients was randomly partitioned into derivation (n=26,067) and validation (n=26,024) populations. A logistic regression model was used to construct HCM death and CV-death scores in the derivation sample, which were compared to the Charlson index, Frailty index and CHA2DS2VASc scores using c-indexes and calibration analysis.

Results

In 52,091 patients with isolated HCM, 12,676 (24.0%) died during follow-up of 3.0±2.8 years (median 2.3, interquartile range 0.4–5.0). Rate of all-cause death was 8.10%/year (7.96–8.24) and was 2.76%/year (2.68–2.84) for CV death.Independent predictors of CV death in HCM were older age, diabetes mellitus, heart failure, history of pulmonary edema, atrial fibrillation, ventricular tachycardia or fibrillation, ischemic stroke, while smoking and poor nutrition were associated with better survival (all p<0.05). In addition to these, male sex, vascular disease, alcohol related diagnoses, kidney disease, lung disease, liver disease anemia and cancer were independent predictors of all-cause death. In the derivation cohort, c-indexes for the HCM death score were 0.720 (0.713–0.727) for all-cause death and 0.695 (0.685–0.705) for CV death. For the HCM CV-death score, c-indexes were 0.679 (0.671–0.686) for all-cause death and 0.723 (0.712–0.733) for CV death. Performances were very similar in the validation cohort. Both scores had good calibrations. Charlson and Frailty indexes however had a better clinical usefulness than the HCM death score and HCM CV-death scores for predicting all-cause death. Decision curve analysis for CV death demonstrated that the HCM CV-death score had the best clinical usefulness of all the tested risk scores.

Conclusion

HCM patients have a high risk of all-cause and CV mortality. Independent predictors of CV-mortality in HCM were used to derive and validate a simple risk prediction model (French HCM CV-mortality score) which performed better than clinical scores, Charlson Index and Frailty Index; showing the best clinical usefulness, with good calibration.

Funding Acknowledgement

Type of funding sources: None.

Trends in all-cause and cardiovascular mortality in patients with acute myocardial infarction: a nationwide analysis over 10 years

Background

The decline in mortality reported during last decades in patients with acute myocardial infarction (AMI) has been attributed mainly to improved use of reperfusion therapy. We sought to determine the trends in all-cause and cardiovascular mortality for patients with AMI seen at a nationwide level in recent years.

Methods

Based on the administrative hospital-discharge database, we collected information for all patients treated with AMI between 2010 and 2019 in France. Adverse outcomes including all-cause death and cardiovascular (CV) death were investigated during follow-up.

Results

We used the French administrative hospital-discharge database, including all patients admitted for AMI between 2010 and 2019 (n=797,212, mean age 69 years, 66% male). Among them, 520,258 patients (65%) had ST-segment elevation myocardial infarction (STEMI) and 276,954 (35%) had non-STEMI (NSTEMI). Reperfusion therapy with primary percutaneous coronary intervention increased from 40% in 2010 to 58% in 2019 for patients with STEMI. Revascularization between day 0 and day 8 increased from 38% in 2010 to 49% in 2019 for patients with NSTEMI. At day 30, all-cause death was recorded in 78,826 patients (9.9%), among whom 56,582 (72%) had CV death. The rate of all-cause death and CV death in patients with STEMI and NSTEMI are in the table. Our data showed higher reduction rates in NSTEMI vs STEMI patients regarding both all cause death (−18,4% vs −14,1%) and CV death (−24.21% vs −9.2%).

Conclusion

In a large and systematic nationwide analysis of patients with AMI, the rate of all-cause death and CV death at day 30 decreased from 2010 to 2019, both for those with STEMI and those with NSTEMI. Both death rate reductions were more important in NSTEMI patients despite a lower increase of reperfusion therapy compared to STEMI patients. Earlier diagnosis and management as well as improvement of pharmacological intervention and revascularization strategy may explain this difference.

Funding Acknowledgement

Type of funding sources: None.

Single-chamber transvenous and subcutaneous defibrillators: clinical outcomes

Introduction/Background

By using an entirely extra-thoracic lead placement, subcutaneous implantable cardioverter–defibrillators (S-ICD) were designed to avoid lead-related complications of single-chamber transvenous implantable cardioverter-defibrillators (VVI ICD).

Purpose

Our objective was to assess and compare outcomes following first VVI ICD or S-ICD implantation in an exhaustive nationwide matched cohort.

Methods

This French longitudinal cohort study was based on the national hospitalization database covering hospital care from for the entire population. All adults (age ≥18 years) hospitalized in French hospitals From January 1, 2010 to September 1, 2020, who underwent a VVI ICD or S-ICD implantation were included. Patients with a previous pacemaker or ICD or with a history of infective endocarditis were excluded.

Results

21,667 patients were included in the cohort, 19,493 patients had a transvenous VVI ICD and 2,174 had a subcutaneous ICD.

Mean follow-up was 28.8±31.8 months. S-ICD patients was associated with higher rate of all-cause death (HR: 1.684, 95% CI: 1.309–2.165, p<0.001). There were no significant differences in cardiovascular death (HR: 1.092, 95% CI: 0.697–1.711, p=0.70) and infective endocarditis (HR: 0.354, 95% CI: 0.067–1.433, p=0.15) between the two groups

Using propensity score, 1,582 patients with VVI ICD were matched 1:1 with S-ICD patients. Mean follow-up was 4.5±7.2 months. In the matched analysis, there were no significant differences in all-cause death (HR: 1.090, 95% CI: 0.728–1.633, p=0.68) and cardiovascular death (HR: 1.167, 95% CI: 0.603–2.260, p=0.65) between the two groups. A trend toward a lower risk of infective endocarditis in the S-ICD group was also observed without reaching significance (HR: 0.219, 95% CI: 0.047–1.017, p=0.053).

A sensitivty analysis in patients with coronary artery disease in the matched cohort was performed. 1,024 patients had a VVI ICD and 977 had a S-ICD. Same trends were observed without significant differences in all-cause death (HR: 0.966, 95% CI: 0.605–1.543, p=0.88) and cardiovascular death (HR: 1.307, 95% CI: 0.610–2.799, p=0.49).

Conclusion

Our nationwide study highlighted a higher risk of all-cause death in patients treated with subcutaneous which however was not statistically significant after propensity score matching. No differences regarding cardiovascular mortality was found. An interesting trend toward diminution of infective endocarditis was also observed without reaching significancy.

Funding Acknowledgement

Type of funding sources: None. Baseline characteristicsCardiovascular death

Clinical outcomes and death associated with cardiorenal syndromes. A comprehensive nationwide cohort study

Background

Cardiorenal syndromes (CRS) are associated with increased risks of all-cause and cardiovascular death, end-stage kidney disease (ESKD), myocardial infarction (MI), heart failure (HF) and ischemic stroke. Whether subtypes of CRS are more prone to develop specific complications is unclear.

Methods

This longitudinal cohort study was based on the national hospitalisation database covering hospital care from the entire French population. The analysis focused on those with at least 5 years of complete follow-up (or dead earlier) as described by others. We identified 385,687 consecutive patients hospitalized in France in 2012 who had heart failure (HF), chronic kidney disease (CKD) and/or CRS. We estimated incidence of cardiovascular and all-cause death, MI, hospitalization for HF, ischemic stroke, ESKD (chronic dialysis or transplantation). Analysis were adjusted for 1) age and sex and 2) all baseline characteristics except cardiac and renal comorbidities.

Results

Overall, 57.7% were male, 67.3% had hypertension, 31.1% had diabetes mellitus and their mean age was 75.3±13.2; 34,217 had isolated CKD, 324,141 had HF, 11,162 had acute concomitant CRS (which could be type 1, 3 or 5 CRS), 12,198 had type 2 CRS and 3,969 had type 4 CRS.

Type 2 CRS was associated with the highest 5-year incidence of all-cause (30.3/100 patient-years [29.7–30.9]) and cardiovascular (10.7 [10.4–11.1]) death and HF (46.9 [45.9–47.9]), type 4 CRS with the highest incidence of MI (2.50 [2.21–2.83]) and patients with acute CRS with the highest incidence of ischemic stroke (2.05 [1.89–2.21]). The incidence of ESKD was 7.43/100 patient-years [6.92–7.99] for type 4 and 6.31 [6.03–6.61] for type 2 CRS, 6.16 [5.88–6.45] for aCRS, 6.00 [5.87–6.14] for CKD and 1.17 [1.15–1.19] for HF.

As compared to CKD, the adjusted risk of ESKD was higher in type 4 (HR: 1.18 [1.10–1.28]) and aCRS (1.07 [1.02–1.13]) and similar for type 2 (HR: 0.99 [0.94–1.04]) CRS. The adjusted risk of all-cause and cardiovascular death and HF was higher in patients with type 2 CRS vs all other groups, and higher in aCRS and 4 CRS than isolated CKD.

Conclusion

The long-term prognosis of CRS subtypes is poor but varies widely, some CRS subtypes being more closely associated with specific complications than others.

Funding Acknowledgement

Type of funding sources: None. All-cause deathCardiovascular death

Comparison of bleeding risk scores in patients with atrial fibrillation and cancer

Funding Acknowledgements

Type of funding sources: None.

Background. Cancer may increase bleeding risk in atrial fibrillation (AF), but the association between cancer type and specific bleeding events has been scarcely investigated. Furthermore, the performance of bleeding risk scores in this high-risk subgroup of patients is unclear.

Purpose. To describe the incidence rate (IR) of major (MB), gastrointestinal (GI) bleeding and intracranial haemorrhage (ICH) according to cancer types. We also investigated the performance of HAS-BLED, ATRIA and ORBIT scores. 

Methods

Observational retrospective cohort study including 399,344 patients with AF and cancer.

Results. Mean age was 77.9 ± 10.2 years and 63.2% were men. During 2.0 years follow-up, the IR of MB was as high as 8.41%/y, GI bleeding was 3.61%/y and ICH 1.33%/y. MBs were more frequent in liver (12.68%/y), leukaemia (12.39%/y), pancreas (11.71%/y), bladder (11.67%/y) and myeloma (11.64%/y). GI bleedings were highest in liver (7.54%/y), pancreas (7.42%/y) and gastric (5.51%/y). ICH was highest in leukaemia (1.89%/y), myeloma (1.52%/y), lymphoma/liver (1.45%/y) and pancreas (1.41%/y) cancer.

The Table shows the hazard ratio and AUC values for each bleeding score. All the three scores significantly associated with bleeding outcomes, with the HAS-BLED score performing better than others for ICH prediction, and the ORBIT score predicting MB and GI bleedings (p < 0.0001 for all AUC comparisons).

Conclusions. Cancer increases the risk of bleeding in patients with cancer, with specific differences according to each cancer type. HAS-BLED score showed the best predictive value for ICH and the ORBIT score for MB and GI bleeding. MB GI bleeding ICH Hazard Ratio (95%CI) HASBLED score≥3 6.575 (6.390-6.765) 5.735 (5.502-5.978) 5.803 (5.416-6.218) ATRIA score≥5 5.372 (5.241-5.506) 3.617 (3.499-3.739) 1.469 (1.403-1.538) ORBIT score≥4 13.326 (12.977-13.686) 7.453 (7.202-7.712) 2.578 (2.463-2.699) AUC (95%CI) HASBLED score≥3 0.716 (0.714-0.718) 0.702 (0.699-0.704) 0.698 (0.694-0.702) ATRIA score≥5 0.700 (0.698-0.702) 0.662 (0.659-0.665) 0.563 (0.557-0.568) ORBIT score≥4 0.805 (0.804-0.807) 0.756 (0.753-0.758) 0.641 (0.635-0.646) AUC Difference (95% CI) HASBLED≥3 vs ATRIA≥5 0.016 (0.014-0.018) 0.040 (0.037-0.042) 0.136 (0.133-0.138) HASBLED≥3 vs ORBIT≥4 -0.089 (-0.091–0.087) -0.054 (-0.056–0.052) 0.057 (0.055-0.059) ATRIA≥5 vsORBIT≥4 -0.106 (-0.108–0.104) -0.094 (-0.095–0.092) -0.078 (-0.080–0.076)

Futility risk model for predicting outcome after cardiac resynchronization therapy defibrillator implantation: data from a nationwide analysis

Funding Acknowledgements

Type of funding sources: None.

Objective. Risk-benefit assessment for cardiac resynchronization therapy defibrillator (CRT-D) over a CRT pacemaker (CRT-P) is still a matter of debate. We aimed to identify patients with a bad outcome within one year after CRT-D implantation, and to develop a Futile CRT-D score.

Methods. Based on the administrative hospital-discharge database, all consecutive patients treated with CRT-D implantation in France between 2010 and 2019 were included. A prediction model was derived and validated for one-year all-cause death after CRT-D implantation (considered as futility) by using split-sample validation.

Results. 28,503 patients were included in the analysis (mean age 68 ± 10 years); 2,139 (7.5%) deaths were recorded in the first year. In the derivation cohort (n = 14,252), the final logistic regression model included as main predictors of futility older age, diabetes, mitral regurgitation, history of hospital stay with heart failure, history of pulmonary oedema, atrial fibrillation, renal, pulmonary, liver, or thyroid disease, denutrition and anemia. Based on Futile CRT-D score, 17% of these patients were categorized at high risk (Futile CRT-D score ≥13) and predicted futility at 17%.

Conclusion.  The futility CRT-D score, established from a large nationwide cohort of patients treated with CRT-D may provide a relevant tool for optimizing healthcare decision. Death at one year in patients with CRTD OR (95%CI)pPointsAge (quartile)1.353 (1.266-1.446)<0.00012Diabetes mellitus1.413 (1.225-1.629)<0.00012Heart failure with congestion1.908 (1.501-2.423)<0.00013History of pulmonary edema1.445 (1.194-1.749)<0.00012Mitral regurgitation1.259 (1.074-1.475)0.0042Atrial fibrillation1.601 (1.395-1.838)<0.00012Left BBB0.803 (0.698-0.924)0.002-1Dyslipidemia0.809 (0.696-0.940)0.006-1Denutrition1.709 (1.360-2.147)<0.00012Chronic kidney disease1.574 (1.321-1.875)<0.00012Lung disease1.230 (1.052-1.437)0.0092Sleep apnea syndrome0.740 (0.596-0.919)0.007-1Liver disease1.747 (1.384-2.206)<0.00012Anaemia1.325 (1.105-1.589)0.0022BBB = bundle branch block.; * age quartile: 1 point when age >61, 2 points when age >69, 3 points when age >75.Abstract Figure. AUC and incidences of all-causes death

Season of birth and cardiovascular mortality in atrial fibrillation: a population-based cohort study

Funding Acknowledgements

Type of funding sources: None.

Background. Month and season of birth may be indicators for a variety of prenatal and early postnatal exposures and they have been associated with life expectancy in adulthood. It is suggested that people born in the autumn on the northern hemisphere live longer than those born during the spring or summer, who may have an increase in cardiovascular disease specific mortality. Only few studies have followed populations longitudinally and no study has investigated the relation between season of birth and mortality in patients with established cardiac conditions.

Methods. All patients with atrial fibrillation (AF) seen in an academic institution were identified in a database. We examined the clinical course of 8962 consecutive patients with AF seen over a 10-year period. The adverse outcomes were investigated during follow-up and we identified the causes of death. The relation between season of birth (autumn, winter, spring and summer) and mortality risk was assessed using Cox proportional hazard regression models using autumn as the reference. Analyses were also made separately for men and women. 

Results. In these 8962 patients (age 70 ± 10 years, CHA2DS2VASc score 3.1 ± 1.7), 1253 deaths were recorded during a follow-up of 2.5 ± 3.0 years (median 1.2, interquartile 4.3 years, yearly rate of death 5.5%) and 97% of causes of death were identified. Cardiovascular deaths accounted for 54% and 43% for non-cardiovascular. The three main causes of death were heart failure (29%), infection (18%) and cancer (12%). 

Season of birth was a significant predictor of cardiovascular mortality (overall p = 0.0006). The lowest mortality was seen for people born in autumn or winter and the highest mortality in those born in spring and summer. This was mainly related to a higher cardiovascular mortality in males (hazard ratio [HR] 1.46, 95%CI 1.10-1.93, p = 0.009 for males born in spring and HR 1.44, 95%CI 1.08-1.91, p = 0.01 for those born in summer when compared to males born in autumn as the reference) while this effect was not seen in women. In a model adjusted for age, CHA2DS2VASc score, HASBLED score, cardiovascular risk factors, other comorbidities, AF pattern, antithrombotic use and other cardiovascular drugs use, a higher cardiovascular mortality was still seen in males born in spring (adjusted HR 1.43, 95%CI 1.05-1.96, p = 0.03) or in summer (adjusted HR 1.46, 95%CI 1.07-1.99, p = 0.02) when compared to those born in autumn while this was not seen in women.

Conclusion. Birth in spring or summer is associated with a higher risk of cardiovascular mortality in male AF patients. Further studies should aim at clarifying the mechanisms behind this association, which would support the so-called fetal origins hypothesis.

Incidence of atrial fibrillation in patients with diabetes mellitus: effect of sex, age and type of diabetes in a nationwide analysis

Funding Acknowledgements

Type of funding sources: None.

Background. There remain uncertainties regarding diabetes mellitus and the incidence of atrial fibrillation (AF), in relation to type of diabetes, and the interactions with sex and age. We investigated whether diabetes confers higher relative rates of AF in women compared to men, and whether these sex-differences depend on type of diabetes and age.

Methods. All patients aged > =18 seen in French hospitals in 2013 with at least 5 years of follow-up without a history of AF were identified and categorized by their diabetes status. We calculated overall and age-dependent incidence rates, hazard ratios, and women-to-men ratios for incidence of AF in patients with type 1 and type 2 diabetes (compared to no diabetes).

Results. In 2,921,407 patients with no history of AF (55% women), 45,389 had prevalent type 1 diabetes and 345,499 had prevalent type 2 diabetes. During 13.5 million person-years of follow-up, 327,012 patients with new-onset AF were identified. The incidence rates (IRs) of AF were higher in type 1 or type 2 diabetic patients than in non-diabetics, and increased with advancing age. Among individuals with diabetes, the absolute rate of AF was higher in men than in women. When comparing individuals with and without diabetes, women had a higher adjusted hazard ratio (HR) of AF than men: adjusted HR 1.32 (95% confidence interval 1.27-1.37) in women vs. 1.12(1.08-1.16) in men for type 1 diabetes, adjusted HR 1.17(1.16-1.19) in women vs. 1.10(1.09-1.12) in men for type 2 diabetes.  The adjusted HRs for women were significantly higher than the adjusted HRs for men as shown with the adjusted women-to-men ratios (adjusted WMR = adjusted HR women compared to adjusted HR men) = 1.18 (95%CI 1.12-1.24) for type 1 diabetes and 1.10 (95%CI 1.08-1.12) for type 2 diabetes. This phenomenon was seen across all ages in men and women with type 1 diabetes and progressively decreased with advancing age.  In type 2 diabetes, this phenomenon was seen after 50 years, increased until 60-65 years and then progressively decreased with advancing age.

Conclusion. Although men have higher absolute rates for incidence of AF, the relative rates of incident AF associated with diabetes are higher in women than in men for both type 1 and type 2 diabetes.

Risks of thromboembolism, mortality and bleeding in 2,435,541 atrial fibrillation patients with and without cancer: a nationwide cohort study

Funding Acknowledgements

Type of funding sources: None.

Background. Atrial fibrillation (AF) and cancer are frequently coexisting in clinical practice. The impact of cancer on outcomes in AF patients is unclear as well as the performance of HAS-BLED and CHA2DS2-VASc scores.

Purpose. To investigate the incidence rate (IR) of all-cause and cardiovascular mortality, ischemic stroke (IS), major bleeding and intracranial haemorrhage (ICH) according to the presence of cancer and cancer types.

Methods

Observational retrospective cohort study including 2,435,541 AF patients.

Results. Overall, 399,344 (16.4%) had cancer, the most common being metastatic, prostatic, colorectal, lung, breast, and bladder (figure). The table shows the IR of bleeding and ischemic outcomes according to the cancer type. During 2 years follow-up, the IS was higher with pancreas, uterine and breast cancers.

Cancer increased major bleeding (HR 1.27, 95%CI 1.26-1.28) and ICH (HR 1.07, 95%1.05-1.10), which progressively increased by HAS-BLED score, which showed generally good predictivity (c indexes >0.70). The CHA2DS2-VASc score showed slightly lower predictivity in AF cancer patients.

Conclusions. Cancer increased all-cause and cardiovascular mortality, major bleeding and ICH risk in AF patients. The association between cancer and IS differed among cancer types. All-cause deathCardiovascular deathISMajor bleedingICHNo Cancer10.8 (10.8-10.8)3.8 (3.8-3.8)2.4 (2.3-2.4)5.0 (5.0-5.1)1.2 (1.1-1.2)Cancer27.0 (26.8-27.1)4.4 (4.4-4.5)2.3 (2.2-2.3)8.4 (8.3-8.5)1.3 (1.3-1.4)Breast20.4 (20.1-20.8)4.2 (4.1-4.4)2.6 (2.5-2.8)5.5 (5.3-5.7)1.3 (1.2-1.4)Ovarian40.4 (38.7-42.2)3.8 (3.3-4.4)2.2 (1.8-2.6)8.6 (7.8-9.5)0.9 (0.7-1.2)Uterine27.0 (26.0-28.1)4.2 (3.8-4.7)2.6 (2.3-2.9)9.0 (8.4-9.6)1.1 (0.9-1.3)Prostatic20.4 (20.1-20.7)4.2 (4.1-4.3)2.2 (2.1-2.3)9.1 (8.9-9.3)1.4 (1.3-1.5)Renal24.2 (23.5-24.9)4.1 (3.8-4.4)2.1 (1.9-2.3)9.6 (9.1-10.1)1.5 (1.3-1.7)Bladder23.7 (23.3-24.1)3.9 (3.7-4.1)2.2 (2.1-2.4)11.7 (11.4-12.0)1.2 (1.1-1.3)Gastric41.2 (40.0-42.5)3.6 (3.3-4.0)2.2 (1.9-2.5)11.0 (10.3-11.7)0.9 (0.7-1.1)Colorectal22.5 (22.2-22.8)3.2 (3.1-3.4)2.1 (2.0-2.2)8.4 (8.2-8.6)1.1 (1.0-1.2)Liver59.8 (58.2-61.4)5.9 (5.4-6.5)1.9 (1.7-2.3)12.7 (11.9-13.5)1.5 (1.2-1.7)Pancreas72.4 (70.4-74.5)5.7 (5.2-6.3)2.8 (2.4-3.3)11.7 (10.9-12.6)1.4 (1.2-1.7)Lung60.7 (60.0-61.4)5.6 (5.4-5.9)1.9 (1.8-2.0)8.2 (7.9-8.5)1.0 (0.9-1.1)Leukaemia38.1 (37.3-38.9)6.1 (5.8-6.4)2.0 (1.8-2.2)12.4 (11.9-12.9)1.9 (1.7-2.1)Myeloma33.3 (32.4-34.1)5.1 (4.8-5.5)2.0 (1.8-2.2)11.6 (11.1-12.2)1.5 (1.4-1.7)Metastatic66.9 (66.3-67.4)6.0 (5.8-6.2)2.2 (2.1-2.3)10.4 (10.2-10.6)1.3 (1.2-1.4)Abstract Figure 1

Subcutaneous and single-chamber transvenous defibrillators: a nationwide matched control study

Funding Acknowledgements

Type of funding sources: None.

Introduction / Background

Subcutaneous implantable cardioverter–defibrillators (S-ICD) was designed to avoid complications of single-chamber transvenous implantable cardioverter-defibrillators (VVI ICD) by using an entirely extra-thoracic placement.

Purpose

Our objective was to compare outcomes following first VVI ICD or S-ICD implantation in an exhaustive nationwide matched cohort.

Methods

This French longitudinal cohort study was based on the national hospitalization database covering hospital care from for the entire population. All adults (age ≥18 years) hospitalized in French hospitals From January 1, 2010 to September 1, 2020, who underwent a VVI ICD or S-ICD implantation were included. Patients with a previous pacemaker or ICD or with a history of infective endocarditis were excluded. Multivariable analyses for clinical outcomes during the whole follow-up in the groups of interests were performed using a Cox model with all baseline characteristics and reporting hazard ratio. Owing to the non-randomized nature of the study, and considering for significant differences in baseline characteristics, propensity-score matching was also used to control for potential confounders of the treatment outcome relationship.

Results

21,667 patients were included in the cohort, 19,493 patients had a transvenous VVI ICD and 2,174 had a subcutaneous ICD. Mean age was 61.2 ± 13.2 years in the VVI ICD group and 52.3 ± 17.5 years in the S-ICD goup. Coronary artery disease was present in 71.6% of patients with a VVI ICD and 48.2% of patients with a S-ICD. Mean follow-up was 28.8 ± 31.8 months. S-ICD patients had a significant higher rate of all-cause death (HR: 1.684, 95%CI: 1.309-2.165, p < 0.001). There were no significant differences in cardiovascular death (HR: 1.092, 95%CI: 0.697-1.711, p = 0.70) and infective endocarditis (HR: 0.354, 95%CI: 0.067-1.433, p = 0.15) between the two groups

Using propensity score, 1,582 patients with VVI ICD were matched 1:1 with S-ICD patients. Mean follow-up was 4.5 ± 7.2 months. In the matched analysis, there were no significant differences in all-cause death (HR: 1.090, 95%CI: 0.728-1.633, p = 0.68) and cardiovascular death (HR: 1.167, 95%CI: 0.603-2.260, p = 0.65) between the two groups. A trend toward a lower risk of infective endocarditis in the S-ICD group was also observed without reaching significance (HR : 0.219, 95%CI: 0.047-1.017, p = 0.053). A sensitivity analysis in patients with coronary artery disease in the matched cohort was performed. Same trends were observed without significant differences in all-cause death and cardiovascular death.

Conclusion

Our nationwide study highlighted a higher risk of all-cause death in patients treated with subcutaneous which however was not statistically significant after propensity score matching. No differences regarding cardiovascular mortality was found. An interesting trend toward diminution of infective endocarditis was also observed without reaching significancy.

Acute dental periapical abscess and new-onset atrial fibrillation: A nationwide, population-based cohort study

Funding Acknowledgements

Type of funding sources: None.

Background

There are limited data on whether there is an association between hospitalisation with dental periapical abscess and new-onset atrial fibrillation (AF) which is independent of main cardiovascular risk factors.

Purpose

To investigate whether there is an association between hospitalisation with dental periapical abscess and new-onset AF.

Methods

A retrospective cohort study from a national database of patients hospitalised in 2013 (3.4 million patients) with at least five years of follow up, unless deceased. International Classification of Diseases (ICD) codes were used to compare the risk of developing new-onset AF for adults with and without dental periapical abscesses using univariate and multivariable analysis and hazard ratios (HR).

Results

In total, 4,693 patients classified as having dental periapical abscess, 435 (9.27%) developed AF, compared to 326,241 (10.69%) without dental periapical abscess over a mean follow-up of 4.8 ± 1.7 years.  Multivariable analysis indicated that dental periapical abscess acted as an independent predictor for new onset AF (p < 0.01).

Conclusions

An increased risk of new onset AF was identified for individuals hospitalised with dental periapical abscess. Careful follow up of patients with severe, acute dental periapical infections are needed for incident AF, as well as investigations of possible mechanisms linking these conditions.

Predictors of new-onset AF during FU Univariate analysis Multivariate analysis HR, 95%CI P HR, 95%CI P Age, years 1.077 (1.076-1.077) <0.0001 1.076 (1.075-1.076) <0.0001 Gender (male) 1.640 (1.629-1.651) <0.0001 1.0498 (1.487-1.509) <0.0001 Hypertension 2.849 (2.829-2.869) <0.0001 1.114 (1.487-1.509) <0.0001 Diabetes mellitus 1.951 (1.935-1.968) <0.0001 1.106 (1.096-1.116) <0.0001 Heart failure 3.893 (3.857-3.930) <0.0001 1.434 (1.416-1.452) <0.0001 Ischaemic stroke 2.289 (2.23902.340) <0.0001 1.140 (1.114-1.165) <0.0001 smoker 0.903 (0.891-0.917) <0.0001 1.052 (1.036-1.069) <0.0001 Liver disease 1.141 (1.119-1.164) <0.0001 1.082 (1.059-1.105) <0.0001 Previous myocardial infarction 2.128 (2.082-2.176) <0.0001 0.903 (0.880-0.926) <0.0001 Inflammatory disease 1.036 (1.020-1.052) <0.0001 0.978 (0.964-0.994) 0.005 Cognitive impairment 2.368 (2.326-2.410) <0.0001 0.821 (0.807-0.836) <0.0001 Illicit drug use 0.288 (0.263-0.317) <0.0001 0.940 (0.855-1032) 0.19 Dental periapical abscess 0.855 (0.778- 0.939) 0.001 1.107 (1.008-1.216) 0.03 At least 5 years of follow-up (mean follow-up 4.8 ± 1.7 years).

Abstract Figure. Flow Chart of the study patients

Prediction of mortality and mode of death by clinical risk score systems in 2.6 million patients with atrial fibrillation: a nationwide analysis

 

Atrial fibrillation (AF) is associated with a higher mortality, but modes of death may vary and their respective predictors have been insufficiently defined. Charlson comorbidity index (CCI) is a tool to quantify multimorbidity and a strong estimator of mortality. The quantifiable frailty phenotype is also predictive of mortality and disability and claims data can be used to classify individuals as frail and non-frail using the Claims-based Frailty Index (CFI). We evaluated whether these tools may help to predict mortality and the different modes of death in AF.

Methods

Based on the France nationwide administrative hospital-discharge database, we collected information for all AF patients treated between 2010 and 2019 in France. Adverse outcomes were investigated during follow-up. CHA2DS2VASc score, CCI and CFI were calculated for each patient.

Results

Among 2,641,626 patients with AF, 670,541 patients died during a follow-up of 2.0±2.3 years (median 1.1) (yearly rate 12.6%, 30.3% cardiovascular and 69.7% non-cardiovascular deaths). Death occurred more often in patients with higher CHA2DS2VASc, CCI and CFI scores. CCI was a better predictor of total mortality than CFI and CHA2DS2VASc score (see C-statistics in table); however, the CHA2DS2VASc score was a better predictor of cardiovascular mortality than CCI and CFI. By contrast, CCI was a better predictor of non-cardiovascular mortality than CFI and CHA2DS2VASc score. The optimal predictive performances were better for non-cardiovascular death than for cardiovascular death.

Conclusion

Multimorbidity assessed with CCI demonstrated better performances in predicting total mortality and non-cardiovascular mortality than CHA2DS2VASc score and Frailty assessed with CFI in AF patients. By contrast, CHA2DS2VASc score was a better predictor of cardiovascular mortality than CCI and CFI in these patients.

Funding Acknowledgement

Type of funding source: None

Outcomes of permanent pacemaker implantation following transcatheter aortic valve replacement

Background

Conduction abnormalities leading to permanent pacemaker (PPM) implantation are common complications following transcatheter aortic valve replacement (TAVR). Whether PPM implantation placement is associated with adverse outcomes is unclear. The purpose of this study was to evaluate the incidence, predictors, and clinical outcomes of PPI following TAVR.

Methods

Based on the administrative hospital-discharge database, we collected information for all patients treated with TAVR between 2010 and 2019 in France.

Results

A total of 49,201 patients with aortic stenosis treated with transcatheter aortic valve replacement (TAVR) using the balloon-expandable (BE) Edwards SAPIEN valve or the self-expanding (SE) Medtronic CoreValve were found in the database. Among them, 10,019 (20.4%) had prior PPM implantation, including 476 (4.8%) treated with cardiac resynchronization therapy (CRT). New PPM implantation was required within 30 days of TAVR in 11,010 patients (22.4%), which varied among those receiving self-expanding valves (24.7%) versus balloon-expanding valves (20.9%). There were 349/10,010 patients (3.1%) treated with cardiac resynchronization therapy (CRT) within 30 days following TAVR. In a multivariable analysis comprising 38 variables (including among others underlying conduction disorders, Euroscore 2, Charlson comorbidity index, frailty score and type of implanted valve), prior PPM implantation was associated with an increased risk of all-cause death (adjusted hazard ratio [HR]: 1.10 95% CI 1.04–1.16). New PPM implantation was associated with even higher risk of mortality (adjusted HR: 1.21 95% CI 1.15–1.28). By contrast, previous CRT was associated with a lower risk of death during follow-up (adjusted HR: 0.78 95% CI 0.63–0.96), while PPM with CRT within 30 days of TAVR was not associated with a different risk of death (adjusted HR: 1.00 95% CI 0.80–1.24). Prior PPM and new PPM implantation were also associated with an increased risk of rehospitalization for heart failure (adjusted HR: 1.26 95% CI 1.19–1.32 and 1.18 95% CI 1.12–1.24, respectively). Previous CRT was associated with a non-significant lower risk of rehospitalization for heart failure (adjusted HR: 0.92 95% CI 0.77–1.09).

Conclusions

Both previous PPM and early PPM implantation following TAVR are commonly seen in patients treated with TAVR, and they are associated with a higher risk of death and rehospitalisation for heart failure when compared to patients with no PPM. The fact that CRT when implanted before TAVR was associated with a better survival may deserve consideration when elaborating future optimal approaches for management of conduction disturbances in patients treated with TAVR.

Funding Acknowledgement

Type of funding source: None

Bleeding risks with frailty and multimorbidity in patients with atrial fibrillation. A nationwide analysis of 1.4 million subjects

Background

Frailty and multimorbidity are common in patients with atrial fibrillation (AF). The quantifiable frailty phenotype has been validated as predictive of mortality and disability, and patients can be categorised as frail and non-frail using the Claims-based Frailty Index (CFI). The Charlson comorbidity index (CCI) is a tool to quantify multimorbidity and also a strong estimator of mortality. We evaluated whether frailty and multimorbidity are associated with the risk of major bleeding in patients with AF.

Methods

Based on the administrative hospital-discharge database, we collected information for all patients with AF between 2010 and 2019 in France. CCI and CFI were calculated for each patient, and their associated risks of bleeding compared to 4 bleeding risk scores (HAS-BLED, HEMORR2HAGES, ATRIA and ORBIT). The analysis focused on patients with events or with at least one year of follow-up. Predictive abilities of the scores were compared in the whole population, and then separately in the subgroup of elderly patients (>75 yo).

Results

Among 1,372,567 patients with AF, 131,535 major bleeding events were recorded during a follow-up of 3.5±2.1 years (median 3.1, IQR 1.8–4.9) (yearly rate 2.7%). Bleeding occurred more commonly in patients with higher HAS-BLED, ATRIA, CCI and CFI scores. Those with high frailty and multimorbidity had markedly higher yearly incidences of bleeding events of 13.0% and 14.7%, respectively (vs low frailty and multimorbidity: 4.3%% and 4.1%, respectively; p<0.001). The 4 bleeding risk scores significantly had lower c-statistics than CCI and CFI for predicting major bleeding (table). In elderly patients (n=853,833), the c-statistics were all lower than in the whole population and were lower for the 4 scores than for the CCI and CFI scores (0.463, 0.473, 0.443, 0.445, 0.622 and 0.620 for HAS-BLED, ATRIA, ORBIT, HEMORR2HAGES, CCI and CFI, respectively).

Conclusion

Multimorbidity and frailty, respectively assessed with CCI and CFI, demonstrated statistically better performances in predicting major bleeding than the 4 established bleeding risk scores in AF.

Funding Acknowledgement

Type of funding source: None

Impact of the timing of coronary revascularization relative to the transcatheter aortic valve implantation procedure: insights from a propensity score analysis based on a nationwide analysis

Background

The significance and the management of coronary artery disease (CAD) are disputed in patients treated by transcatheter aortic valve implantation (TAVI). In the presence of a significant CAD eligible for percutaneous coronary intervention (PCI), the issue of the timing of PCI relative to TAVI is unsettled. To answer this question, the present study aimed at comparing the short-term and long-term outcome in patients treated by staged PCI within a 90-day time interval before or after TAVI.

Methods

Based on the French administrative hospital-discharge database, the study collected information for all consecutive patients treated with TAVI between 2014 and 2018. Patients treated with PCI in the preceding 90 days before the TAVI procedure (pre-TAVI PCI) or subsequent 90 days after the TAVI procedure (post-TAVI PCI) were included. All-cause mortality, cardiovascular mortality, stroke, myocardial infarction and a combined cardiovascular endpoint were assessed at 30 days after the last procedure (short-term) and during the whole follow-up (long-term). Propensity score matching was used for the analysis of outcomes.

Results

8613 patients met the inclusion criteria with a vast majority of pre-TAVI PCI patients (N=8324) as opposed to post-TAVI PCI (N=229). After propensity score matching, 2 groups of 227 patients with comparable characteristics were obtained. At 30 days, no significant difference was observed for any of the outcome tested with the exception of myocardial infarction more frequent in post-TAVI PCI (OR 2.43 [1.17–5.07]). After a mean [SD] follow-up of 459 [569] days, all outcomes were identical between subgroups. The figure below illustrates the Kaplan Meier curve for all-cause mortality.

Conclusions

Our study based on a French nationwide database shows that PCI is performed pre-TAVI in a majority of cases, with no significant impact on outcome. Deferring PCI after TAVI seems safe and may provide an opportunity to make the decision on more objective parameters while the stenosis has been removed (such as FFR or IFR). In any case, the timing of PCI relative to TAVI does not seem to represent a concern and should be decided on an individual basis.

Figure 1

Funding Acknowledgement

Type of funding source: None

Atrial fibrillation with or without structural abnormalities. Analysis from a nationwide database

Background

Atrial Fibrillation (AF) is often associated with underlying heart failure, valvular disease, ischemic heart disease, as well as other structural heart diseases, but can also occur as an independent entity which may be named pure AF or lone AF. Small cohort studies have suggested that lone AF patients may have a favorable prognosis in terms of mortality and ischemic stroke rates. We aimed to assess, at a nationwide scale, the prognosis of patients hospitalized with lone AF and AF associated with cardiac disease.

Methods

From the French administrative hospital-discharge PMSI database (Programme de Médicalisation des Systèmes d'Information) covering hospital care and representative of the whole French population, all consecutive patients with AF diagnosis hospitalized between 2010 and 2018 were included. From this huge database, 2,793,234 patients were included: group lone FA: 665,431, group AF and cardiac disease: 2,727,803. Incidence rates (%/year) for the outcomes (all-cause death, cardiovascular [CV] death, or ischemic stroke) during follow-up were compared between groups using incidence rate ratios (RR) for the whole cohort and also for a subgroup of 539,654 propensity score matched patients for non-cardiovascular conditions (269,827 with AF alone and 269,827 with AF and CD).

Results

The majority of this population had AF associated with a cardiac disease (n=2,127,803; 76.2%). At follow-up (median [IQR] 1.1 [0.1–3.4] years), patients with AF and CD were at higher risk of all-cause mortality (yearly incidence 13.6% vs 9.0%, RR [95% CI] 1.51 [1.50–1.52], p<0.00001) and CV death (4.4% vs 1.9%, RR 2.33 [2.30–2.36], p<0.00001) than those with lone AF. In the propensity score matched population (median follow-up [IQR] 1.9 [0.3–4.4] years), patients with AF and CD also had worse outcomes than patients with lone AF (yearly incidence rates for all-cause mortality: 10.6% vs 7.4%, RR 1.43 [1.42–1.45], p<0.00001; and for CV death: 3.3% vs 2.0%, RR 1.64 [1.61–1.68], p<0.00001). However, lone AF patients were at higher risk of ischemic stroke: yearly incidence rates 2.75% in those with lone AF vs 1.69% in patients with AF and CD (RR 0.62 [0.60–0.63], p<0.00001).

Conclusion

In our large study from a nationwide database about patients hospitalized with AF, two distinct clinical entities were identified, that could explain the results highlighted: 1) the consistently higher mortality in the group associating AF and underlying heart disease (AF may bea marker for poor outcome when there is a structural heart disease; 2) Lone AF group which prognosis may be related to a higher incidence of thromboembolic events. These results could have important implications in terms of thromboembolic prevention but further studies are still needed to investigate the underlying mechanisms of embolic pathophysiology and its specific management.

Funding Acknowledgement

Type of funding source: None

Development of a claims-based EuroSCORE II in patients with aortic stenosis needing surgical or transcatheter aortic valve replacement using electronic hospital records: a nationwide study

Background

Prediction of operative risk in patients with aortic stenosis (AS) undergoing surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) remains a challenge, particularly in high-risk patients. The EuroSCORE II is now commonly used to improve risk prediction. Large analyses from administrative database have provided opportunities for conducting health research in the field of structural heart disease interventions but may have a lack of granularity and do not routinely include EuroSCORE II, which may result in a risk of uncontrolled biases. We sought to approximate the EuroSCORE II using only administrative claims data to enable the operative risk to be assessed without clinical or paraclinical performance measures.

Methods

Based on the administrative hospital-discharge database, we collected information for all patients with AS treated with SAVR or TAVI between 2010 and 2019 in France. A total of 78,085 SAVR and 60,821 patients with AS treated with transcatheter aortic valve replacement (TAVR) were found in the database. For each patient, the EuroSCORE II was estimated using the formulas available at the EuroSCORE website. Age, gender, extracardiac arteriopathy, poor mobility, previous cardiac surgery, chronic lung disease, active endocarditis, diabetes on insulin, recent MI, dialysis are items available in the PMSI database using the ICD-10 or CCAM codes. For renal impairment, NYHA class, LVEF, pulmonary hypertension, “critical preoperative state” and urgent intervention, different proxies were built based on ICD-10 codes likely to represent increasing severity of these items.

Results

In the cohort of patients with SAVR, mean estimated EuroSCORE II was 3.3±1.1 while all-cause death at day 30 after SAVR was 3.8%. In the cohort of patients with TAVI, mean estimated EuroSCORE II was 3.8±1.0 while all-cause death at day 30 after TAVI was 5.5%. In the whole cohort, the area under the curve (AUC) of the estimated EuroSCORE II for predicting the risk of all-cause death at day 30 was 0.72 (95% CI 0.71–0.73) and was higher in patients treated with SAVR (AUC 0.76, 95% CI 0.75–0.77) than in those treated with TAVI (AUC 0.67, 95% CI 0.65–0.68, p<0.00001 for DeLong test). The observed versus predicted risks of all-cause death at day 30 post-TAVI OR SAVR within risk deciles are shown in Figure 1. Calibration of the prediction score was satisfying across the 10 deciles and a predicted 30-day mortality rate of approximately 15%.

Conclusions

Claims data alone can be used to identify individuals with AS at operative risk when they are considered for SAVR or TAVI. The Claims-based EuroSCORE II might be used in research with large datasets for confounding adjustment or risk prediction. It provides hospitals and health systems with a low-cost, systematic way to identify a group of patients who are at greater risk of adverse outcomes with these interventions and for whom a more specific approach might be useful.

Figure 1

Funding Acknowledgement

Type of funding source: None

All-cause mortality and cardiac resynchronization therapy with or without defibrillation in primary prevention

Aims

Cardiac resynchronization therapy with (CRTD) or without (CRTP) defibrillator is recommended in selected patient with systolic chronic heart failure and wide QRS. There is no guideline firmly indicating choice between CRTP and CRTD in primary prevention, particularly in older patients.

Methods

Based on the French administrative hospital-discharge database, information was collected from 2010 to 2017 for all patients implanted with CRTP or CRTD in primary prevention. Outcomes analyses were undertaken in the total study population and in propensity-matched samples.

Results

A total of 45,697 patients were analyzed (19,266 with CRTP and 26,431 with CRTD). The nationwide numbers of implantations increased between 2010 and 2017 (+29.6% for CRTD, +28.8% for CRTP). Proportion of CRTP implantation over CRTD remained similar over these years. During follow up (913 days, SD 841, median 701, IQR 151–1493), incidence rate (%patient/year) of all-cause mortality was higher in CRTP (11.6%) than in CRTD patients (6.8%) (Hazard Ratio [HR] 1.70, 95% CI 1.63–1.76, p<0.001). After propensity-matched analyses, mortality of patients over 75 years-old with non-ischemic cardiomyopathy (NICM) was not different with CRTP and CRTD (HR 0.93, 95% CI 0.80–1.09, p=0.39). CRTP patients under 75 yo with NICM had a higher mortality than CRTD patients (HR 1.22, 95% CI 1.08–1.37, p=0.01). Mortality rate was also higher with CRTP than with CRTD irrespectively of age in patients with ischemic cardiomyopathy (ICM) (<75 yo: HR 1.13, 95% CI 1.04–1.33, p<0.01; ≥75 yo: HR 1.22, 95% CI 1.08–1.37, p=0.01).

Conclusion

This real-life study gives up-to-date information about unselected patients implanted with CRTP and CRTD in primary prevention, and provides additional data which may help physicians choosing between CRTP and CRTD at the time of implantation. Benefit of CRTD seemed clear for all-cause mortality in patients with ICM and in patients with NICM under 75 yo. Patients over 75 yo with NICM seemed less likely to benefit from primary prevention CRTD implantation.

Event free curves for mortality outcomes

Funding Acknowledgement

Type of funding source: None

Risk of ischemic stroke in patients with acute myocardial infarction and new atrial fibrillation: a nationwide analysis

Background

In patients with acute myocardial infarction (AMI), history of atrial fibrillation (AF) and new onset AF during the early phase may be associated with a worse prognosis. Whether both conditions are associated with a similar risk of stroke and should be similarly managed is a matter of debate.

Methods

Based on the administrative hospital-discharge database, we collected information for all patients treated with AMI between 2010 and 2019 in France. The adverse outcomes were investigated during follow-up.

Results

Among 797,212 patients with STEMI or NSTEMI, 146,922 (18.4%) had history of AF, and 11,824 (1.5%) had new AF diagnosed between day 1 and day 30 after AMI. Patients with new AF were older and had more comorbidities than those with no AF but were younger and had less comorbidities than those with history of AF. Both groups with history of AF or new AF had less frequent STEMI and anterior MI, less frequent use of percutaneous coronary intervention but more frequent HF at the acute phase than patients with no AF. During follow-up (mean [SD] 1.8 [2.4] years, median [interquartile range] 0.7 [0.1–3.1] years), 163,845 deaths and 20,168 ischemic strokes were recorded.

Using Cox multivariable analysis, compared to patients with no AF, history of AF was associated with a higher risk of death during follow-up (adjusted hazard ratio HR 1.06 95% CI 1.05–1.08) while this was not the case for patients with new AF (adjusted HR 0.98 95% CI 0.95–1.02). By contrast, both history of AF and new AF were associated with a higher risk of ischemic stroke during follow-up compared to patients with no AF: adjusted hazard ratio HR 1.29 95% CI 1.25–1.34 for history of AF, adjusted HR 1.72 95% CI 1.59–1.85 for new AF. New AF was associated with a higher risk of ischemic stroke than history of AF (adjusted HR 1.38 95% CI 1.27–1.49).

Conclusion

In a large and systematic nationwide analysis, AF first recorded in the first 30 days after AMI was associated with an increased risk of ischemic stroke. Specific management should be considered in order to improve outcomes in these patients after AMI.

Funding Acknowledgement

Type of funding source: None

Outcomes in patients with acute myocardial infarction and a history of illicit drug use: a nationwide analysis

Background

Several reports suggest that illicit drug use may be a major cause of acute myocardial infarction (AMI) independently of smoking habits, and associated with a poorer prognosis.

Purpose

We sought to determine the frequency of history of illicit drug use in an AMI population and its impact on short- and mid-term prognosis.

Methods

Based on the administrative hospital-discharge database, we collected information for all patients treated with AMI between 2010 and 2018 in France. We identified patients with history of illicit drug use and the adverse outcomes were investigated during follow-up.

Results

Among 797,212 patients with ST-segment elevation myocardial infarction (STEMI) or non-STEMI (mean age 69 years, 66% male), 3827 patients (0.5%) had a known history of illicit drug use (cannabis, cocaine or opioid). Patients with illicit drug use were younger and had less comorbidities. They presented more frequently with STEMI and anterior localization compared to those with no history of illicit drug use. In univariate analysis, patients with illicit drug use had lower short-term mortality rates compared to those without history of illicit drug use: 4.9% vs 10.1% at one month (p<0.0001), respectively. However, this might be attributed to a younger age at the time of presentation. Using logistic multivariable analysis with adjustment on age, gender, other cardiovascular and non-cardiovascular comorbidities, type and localisation of MI and procedures of revascularization, history of illicit drug use was associated with a non-significant higher risk of death at one year (adjusted odds ratio OR 1.12 95% CI 0.98–1.29). This trend was supported by a significantly higher risk of death at one year in patients with a history of opioid use (OR 1.27 95% CI 1.04–1.29, p=0.01).

Conclusion

In a large and systematic nationwide analysis of patients with AMI, history of illicit drug use was associated with a non-significant higher overall odds of mortality, which was significant among those with opioid use.

Funding Acknowledgement

Type of funding source: None

Pacemaker implantation after balloon- or self-expandable transcatheter aortic valve replacement in patients with aortic stenosis

Background

The incidence of conduction abnormalities requiring permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR) with different devices available in recent years remains a matter of debate.

Methods

Based on the administrative hospital-discharge database, we collected information for all patients treated with TAVR between 2010 and 2019 in France. We compared the incidence of PPI after TAVR according to the type and generation of valve implanted.

Results

A total of 49,201 patients with aortic stenosis treated with transcatheter aortic valve replacement (TAVR) using the balloon-expandable (BE) Edwards SAPIEN valve or the self-expanding (SE) Medtronic CoreValve were found in the database. Patients treated with early BE or SE valves had higher Charlson comorbidity and frailty indexes than those treated with later BE or SE valves, and slightly higher EuroSCORE II. Patients treated with SE valves had higher rates of previous pacemaker or defibrillator than those treated with BE valves. Mean (SD) follow-up was 1.2 (1.5 years) (median [interquartile range] 0.6 [0.1–2.0] years). PPI after the procedure was reported in 13,289 patients, among whom 11,010 (22.4%) had implantation during the first 30 days (figure 1). In multivariable analysis, using early BE TAVR as reference, adjusted OR (95% CI) for PPI during the first 30 days was 0.88 (0.81–0.95) for latest BE TAVR, 1.40 (1.27–1.55) for early SE TAVR and 1.17 (1.07–1.27) for latest SE TAVR. Compared to early BE TAVR, adjusted HR for PPI during the whole follow-up was 1.01 (0.95–1.08) for latest BE TAVR, 1.30 (1.21–1.40) for early SE TAVR and 1.25 (1.18–1.34) for latest SE TAVR.

Conclusion

In patients with aortic stenosis treated with TAVR, our systematic analysis at a nationwide level found higher rates of PPI than previously reported. BE technology was independently associated with lower incidence rates of PPI both at the acute and chronic phases than SE technology. However, this was less apparent than previously reported in this large analysis of unselected patients seen in “real life” practice. Recent generations of TAVR were not independently associated with different rates of PPI than early generations during the overall follow-up.

Funding Acknowledgement

Type of funding source: None

Relationship of aging and incident comorbidities to stroke risk in 594,169 Patients with atrial fibrillation: a nationwide analysis

Background

When assessing ischemic stroke risk in patients with atrial fibrillation (AF), the CHA2DS2-VASc score is calculated based on the baseline risk factors, and the outcomes are determined after a follow-up period. However, the stroke risk in patients with AF does not remain static, and with time, patients get older and accumulate more comorbidities. This study hypothesized that the “Delta CHA2DS2-VASc score”, which reflects the change in score between baseline and follow-up, may be predictive of ischemic stroke compared with the baseline or follow-up assessments of the CHA2DS2-VASc score.

Methods

Based on the France nationwide administrative hospital-discharge database, we collected information for all patients treated with AF between 2010 and 2019 in France. Adverse outcomes were investigated during follow-up. A total of 594,169 patients with AF who did not have comorbidities of the CHA2DS2-VASc score except for age and sex, were studied. The Delta CHA2DS2-VASc score was defined as the change/difference between the baseline and follow-up CHA2DS2-VASc scores. During 1,290,721 person-years, 19,492 patients experienced ischemic stroke. The accuracies of baseline, follow-up, and Delta CHA2DS2-VASc scores in predicting ischemic stroke were analysed and compared.

Results

The mean baseline CHA2DS2-VASc score was 1.69, which increased to 2.33 during the follow-up, with a mean Delta CHA2DS2-VASc score of 0.64. The CHA2DS2-VASc score increased in 39.8% of patients. Among 19,492 patients who experienced ischemic stroke, 66.0% had a Delta CHA2DS2-VASc score ≥1 compared with only 38.9% in patients without ischemic stroke, and 5,811 (29.8%) patients had ≥2 new-onset comorbidity, the most common being hypertension. The follow-up CHA2DS2-VASc score and Delta CHA2DS2-VASc score were significant predictors of ischemic stroke (C-index 0.670 95% CI 0.667–0.674 and 0.637 95% CI 634–641 respectively) that performed better than baseline CHA2DS2-VASc score (C-index 0.613 95% CI 0.609–0.616, p<0.0001 for DeLong test).

Conclusions

In this AF cohort, we found that stroke risk (CHA2DS2-VASc score) was non-static, and that many patients developed ≥1 new stroke risk factor(s) before presentation with ischemic stroke. The follow-up CHA2DS2-VASc score and its change (ie Delta CHA2DS2-VASc, reflecting the change in stroke risk profile between baseline and follow-up) were better predictors of ischemic stroke than relying on the baseline CHA2DS2-VASc score. This emphasises how stroke risk in AF is a dynamic process due to increasing age and incident comorbidities, and regular re-assessment of risk is needed.

Funding Acknowledgement

Type of funding source: None

Incidence and outcomes of infective endocarditis after transcatheter aortic valve implantation versus surgical aortic valve replacement

OBJECTIVES

Transcatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement (AVR) in aortic stenosis (AS). Infective endocarditis (IE) in patients with prosthetic heart valves is associated with significant morbidity and mortality. Data on the incidence, risk factors, and outcomes of IE after TAVI are conflicting. We evaluated these issues in patients with percutaneous TAVI vs. isolated surgical AVR (SAVR) at a nationwide level.

METHODS

Based on the administrative hospital discharge database, the study collected information for all patients with aortic stenosis treated with AVR in France between 2010 and 2018.

RESULTS

A total of 47 553 patients undergoing TAVI and 60 253 patients undergoing isolated SAVR were identified. During a mean follow-up of 2.0 years (median (25th to 75th percentile) 1.2 (0.1-3.4) years), the incidence rates of IE were 1.89 (95% confidence interval (CI) 1.78-2.00) and 1.40 (95% CI 1.34-1.46) events per 100 person-years in unmatched TAVI and SAVR patients, respectively. In 32 582 propensity-matched patients (16 291 with TAVI and 16 291 with SAVR), risk of IE was not different in patients treated with TAVI vs. SAVR (incidence rates of IE 1.86 (95% CI 1.70-2.04) %/year vs 1.71 (95% CI 1.58-1.85) %/year respectively, relative risk (RR) 1.09, 95% CI 0.96-1.23). In these matched patients, total mortality was higher in TAVI patients with IE (43.0% 95% CI 37.3-49.3) than in SAVR patients with IE (32.8% 95% CI 28.6-37.3; RR 1.32, 95% CI 1.08-1.60).

DISCUSSION

In a nationwide cohort of patients with AS, treatment with TAVI was associated with a risk of IE similar to that following SAVR. Mortality was higher for patients with IE following TAVI than for those with IE following SAVR.

486Are the results of the CASTLE-AF trial reproducible in the real life? Clinical outcomes after catheter ablation for atrial fibrillation with heart failure in a nationwide cohort study

Background

Catheter ablation for atrial fibrillation (AF) is a validated therapy for patients with symptomatic AF to prevent recurrences. The CASTLE AF trial indicated that ablation for AF in patients with heart failure (HF) was associated with a lower rate of death from any cause or hospitalization for worsening HF than was medical therapy. The purpose of our study was to compare the incidence of these events in AF patients with HF after AF catheter ablation versus those not treated with AF ablation at a nationwide level in centers possibly less well experienced.

Methods

This French longitudinal cohort study was based on the national hospitalization PMSI (Programme de Médicalisation des Systèmes d'Information) database covering hospital care from the entire population. We included all patients, over 18 years old, with AF and HF from January 2010 to December 2015. Crude event rates were ascertained and hazard ratios (HR) were estimated using Cox proportional hazards risk model. Propensity-matched Cox regression was also used to compare event rates according to AF ablation usage status.

Results

Among the 261,449 patients identified with AF and HF, 1,270 patients were treated with AF ablation (24% female, mean age 63±10 yo) and 260,179 did not have AF ablation (45% female, mean age 79±11 yo). During follow-up (417±502 days), there were 56,981 hospitalizations with a primary diagnosis of HF and 81,393 deaths were recorded. Incidence of hospitalization for HF was significantly lower in patients with AF ablation than in those with no ablation (13.74% vs 51.11% person per year respectively, p<0.0001). Incidence of death was also significantly lower in patients with AF ablation than in those with no ablation (6.07% vs 27.42% person per year respectively, p<0.0001). These associations were confirmed in a multivariable analysis after adjustment on age and other comorbidities (HR 0.33, 95% CI 0.28–0.39, p<0.0001 for HF and HR 0.38, 95% CI 0.31–0.48, p<0.0001 for all-cause death). After 1:1 propensity score matching, AF ablation was also associated with a lower risk of hospitalization for HF (HR 0.38, 95% CI 0.31–0.47, p<0.0001) and a lower risk of death (HR 0.54, 95% CI 0.42–0.70, p<0.0001).

Conclusion

In the nationwide analysis of unselected AF patients with HF seen in hospitals, AF ablation was independently associated with a lower risk of hospitalization for HF and death. This provides “real world” data consistent with those observed in recent trials with lower numbers of highly selected patients