Prognosis and antithrombotic practice patterns in patients with recurrent and transient atrial fibrillation following acute coronary syndrome: A nationwide study

BACKGROUND

First-time detected atrial fibrillation (AF) is associated with aggravated prognosis in patients admitted with acute coronary syndrome (ACS). Yet, among patients surviving beyond one year after ACS, it remains unclear how the recurrence of AF within the initial year after ACS affects the risk of stroke.

METHODS

With Danish nationwide data from 2000 to 2021, we identified all patients with first-time ACS who were alive one year after discharge (index date). Patients were categorized into: i) no AF; ii) first-time detected AF during ACS admission without a recurrent hospital contact with AF (transient AF); and iii) first-time detected AF during ACS admission with a subsequent recurrent hospital contact with AF (recurrent AF). From index date, two-year rates of ischemic stroke were compared using multivariable adjusted Cox regression analysis. Treatment with antithrombotic therapy was assessed as filled prescriptions between 12 and 15 months following ACS discharge.

RESULTS

We included 139,137 patients surviving one year post ACS discharge: 132,944 (95.6%) without AF, 3920 (2.8%) with transient AF, and 2273 (1.6%) with recurrent AF. Compared to those without AF, the adjusted two-year hazard ratios of ischemic stroke were 1.45 (95% CI, 1.22-1.71) for patients with transient AF and 1.47 (95% CI: 1.17-1.85) for patients with recurrent AF. Prescription rates of oral anticoagulation increased over calendar time, reaching 68.3% and 78.7% for transient and recurrent AF, respectively, from 2019 to 2021.

CONCLUSION

In patients surviving one year after ACS with first-time detected AF, recurrent and transient AF were associated with a similarly increased long-term rate of ischemic stroke.

Characteristics and Outcomes in Patients With Acute Aortic Dissection: A Nationwide Registry Study

BACKGROUND

We aimed to describe characteristics and outcomes in a nationwide population of patients with acute type A and type B aortic dissection.

METHODS

All patients in Denmark with a first-time diagnosis of acute aortic dissection between 2006 and 2015 were identified by national registries. The main outcomes were in-hospital mortality and long-term survival in hospital survivors.

RESULTS

The study population comprised 1157 (68%) patients with type A aortic dissection and 556 (32%) patients with type B aortic dissection, median age of 66 (57-74) years and 70 (61-79) years, respectively. Men accounted for 64%. Median follow-up was 8.9 (6.8-11.5) years. Of patients with type A aortic dissection, 74% were managed surgically, whereas 22% of the patients with type B aortic dissection were managed with surgery or endovascular technique. In-hospital mortality was 27% for type A aortic dissection overall (surgery, 18%; no surgery, 52%) and 16% for type B aortic dissection (surgery or endovascular treatment, 13%; conservative treatment, 17%; P < .001, type A vs type B). Of patients discharged alive, survival was persistently better for type A aortic dissection than for type B aortic dissection (P < .001). Unadjusted 1- and 3-year survival of patients with type A aortic dissection discharged alive was 96% and 91%, respectively, for surgically managed and 88% and 78% without surgery. For type B aortic dissection, the numbers were 89% and 83% for endovascular/surgically managed and 89% and 77% for conservatively managed.

CONCLUSIONS

We found higher in-hospital mortality for type A and type B aortic dissection than is reported from referral center registries. Type A aortic dissection had the highest mortality rate during the acute phase, whereas for patients who were discharged alive, the mortality rate was higher for patients with type B aortic dissection.

Perioperative Atrial Fibrillation and One-year Clinical Outcomes in Patients Following Major Emergency Abdominal Surgery

The prevalence and impact of perioperative atrial fibrillation (AF) during an admission for major emergency abdominal surgery are sparsely examined. Therefore, this study aimed to compare the 30-day and 1-year outcomes (AF-related hospitalization, stroke, and all-cause mortality) in patients with and without perioperative AF to their major emergency abdominal surgery. All patients without a history of AF who underwent major emergency abdominal surgery from 2000 to 2019 and discharged alive were identified using Danish nationwide registries. Patients with and without perioperative AF (defined as new-onset AF during the index hospitalization) were matched 1:4 on age, gender, year of surgery, and type of surgery. The cumulative incidences and hazard ratios of outcomes were assessed using a multivariable Cox regression analysis comparing patients with and without perioperative AF. A total of 2% of patients were diagnosed with perioperative AF. The matched cohort comprised 792 and 3,168 patients with and without perioperative AF, respectively (median age 78 years [twenty-fifth to seventy-fifth percentile 70 to 83 years]; 43% men). Cumulative incidences of AF-related hospitalizations, stroke, and mortality 1 year after discharge were 30% versus 3.4%, 3.4% versus 2.7%, and 35% versus 22% in patients with and without perioperative AF, respectively. The 30-day outcomes were similarly elevated among patients with perioperative AF. Perioperative AF during an admission for major emergency abdominal surgery was associated with higher 30-day and 1-year rates of AF-related hospitalization and mortality and similar rates of stroke. These findings suggest that perioperative AF is a prognostic marker of increased morbidity and mortality in relation to major emergency abdominal surgery and warrants further investigation.

Temporal changes in incidence, treatment strategies and 1-year re-admission rates in patients with atrial fibrillation/flutter under 65 years of age: A Danish nationwide study

AIM

To examine temporal changes in incidence rates of atrial fibrillation/flutter (AF), treatment strategies, and AF readmission rates in patients <65 years.

METHODS

Using Danish nationwide registries, we identified patients <65 years with a first-time AF diagnosis from 2000 to 2018. The cohort was categorized according to calendar periods; 2000-2002, 2003-2006, 2007-2010, 2011-2014, and 2015-2018. In this retrospective cohort study the incidence rate (IR) of AF per 100,000 person years (PY), catheter ablation, electrical cardioversion, use of pharmacotherapy, and AF readmission, were investigated in the first year following AF diagnosis.

RESULTS

We identified 60,917 patients; 8150 (13.4%) in 2000-2002, 11,898 (19.5%) in 2003-2006, 13,560 (22.3%) in 2007-2010, 14,167 (23.3%) in 2011-2014, and 13,142 (21.6%) in 2015-2018. Apart from 2015 to 2018, a stepwise increase in the crude IR of AF was observed across calendar periods; 2000-2002: 78.7 (95% CI 77.0;80.4), 2003-2006: 86.3 (84.7;87.8), 2007-2010: 97.9 (96.3;99.6), 2011-2014: 102.3 (100.7;104.0), 2015-2018: 93.6 (92.0;95.2). Over the studied time-periods, we found a stepwise increase in the cumulative incidence of catheter ablation (1.2% to 7.6%) electrical cardioversion (2.0% to 8.7%) and treatment with oral anticoagulant therapy (OAC) (28.5% to 47.8%) within the first year of diagnosis. No temporal differences in incidence of 1-year AF readmission were identified (AF-readmissions: 2000-2002: 32.7%, 2003-2006: 31.1%, 2007-2010: 32.2%, 2011-2014: 32.1% and 2015-2018: 31.7%).

CONCLUSION

The incidence rate of AF in patients <65 years increased from 2000 to 2018, as did the use of catheter ablation, electrical cardioversion and OAC in the first year following AF diagnosis. 1-year AF readmission incidence remained stable around 32% over the study period.

Incidence of atrial fibrillation/flutter, one-year re-admission rates, and practice patterns among patients &lt;65 years of age: a Danish nationwide study

Background/Introduction

The general atrial fibrillation/flutter (AF) population is well explored and described, but there is sparse data on temporal changes in the incidence, AF-readmission rates, and practice patterns in patients with AF under 65 years of age from unselected cohorts.

Purpose

To investigate temporal changes, AF readmission rates, and practice patterns in patients under 65 years of age with first-time AF diagnosed between 2000–2018.

Methods

Using Danish nationwide registries, we identified patients &gt;18 years and &lt;65 years with a first-time AF-diagnosis from 2000–2018. The cohort was categorized according to calendar periods; 2000–2002, 2003–2006, 2007–2010, 2011–2014 and 2015–2018. Incidence rate (IR) of AF per 100,000 person years (PY), AF-readmission, and practice patterns of medical treatment, electrical cardioversion, and catheter ablation was investigated in the first year following AF-diagnosis.

Results

In this study 60,917 patients were included; 8,150 patients (13.4%) in 2000–2002, 11,898 (19.5%) in 2003–2006, 13,560 (22.3%) in 2007–2010, 14,167 (23.3%) in 2011–2014 and 13,142 (21.6%) in 2015–2018. No major differences were seen in patient characteristics according to calendar period. A stepwise increase, as seen in the Table, in the crude IR of AF per 100,000 PY was observed across calendar periods, except for 2015–2018 (Crude IR [95% CI]: 2000–2002: 78.7 [77.0; 80.4], 2003–2006: 86.3 [84.7; 87.8], 2007–2010: 97.9 [96.3; 99.6], 2011–2014: 102.3 [100.7; 104.0], 2015–2018: 93.6 [92.0; 95.2], while no difference in AF readmission was identified (AF-readmissions: 2000–2002: 32.7%, 2003–2006: 31.1%, 2007–2010: 32.2%, 2011–2014: 32.1% and 2015–2018: 31.7%), as seen in the Figure, right panel. In the first year following AF-diagnosis, the cumulative incidence of catheter ablation increased stepwise from 1.2% in 2000–2002 to 7.6% in 2015–2018 and electrical cardioversion from 2.0% in 2000–2002 to 8.7% in 2015–2018 (Figure, left panel). Treatment with oral anticoagulant therapy (OAC) increased from 28.5% in 2000–2002 to 47.8% in 2015–2018, while there was no change in treatment with rhythm or rate medication therapy.

Conclusion

From 2000–2018, we found an increase in the incidence of atrial fibrillation/flutter (AF) in patients &lt;65 years from 78.7/100,000 person years (PY) to 93.6/100,000 PY and an increase in the use of catheter ablation, electrical cardioversion and OAC in the first year following first-time AF-diagnosis. AF readmission rates were stable over calendar periods.

Funding Acknowledgement

Type of funding sources: None.

Prognosis and antithrombotic practice patterns in recurrent and transient atrial fibrillation following acute coronary syndrome: a nationwide study

Background

First-time detected atrial fibrillation (AF) during acute coronary syndrome (ACS) aggravates the prognosis and increases the risk of ischemic stroke. In this setting, AF may present as brief and transient or with recurrent episodes after discharge. However, data on the association between transient or recurrent AF and ischemic stroke in patients with ACS are sparse. Further, despite being associated with ischemic stroke, first-time detected AF patients have been reported with low oral anticoagulation (OAC) rates.

Purpose

To examine the associated rate of ischemic stroke and mortality in ACS survivors with transient or recurrent AF and to assess the antithrombotic practice patterns one year after ACS.

Methods

Using data from Danish nationwide registries, we identified all patients with first-time ACS, without known AF prior to ACS, from 2000–2017 who were alive one year after ACS discharge (index date). According to a grace period between ACS discharge and one year after ACS discharge, patients were categorized into: i) no AF; ii) first-time detected AF during ACS admission without AF recurrence (transient AF); and iii) first-time detected AF during ACS admission with a subsequent recurrent AF episode (recurrent AF). Patients who developed AF during the grace period were excluded. Patients were followed from one year post ACS discharge, and two-year rates of ischemic stroke and mortality were compared using multivariable adjusted Cox proportional hazards analysis. Further, we assessed the prescribed OAC rates in a three-month period following the index date.

Results

We included 116,793 patients surviving one year post ACS discharge: 111,708 (95.6%) without AF (64.9% male, median age 64 years), 2,671 (2.3%) with transient AF (58.0% male, median age 74 years), and 2,414 (2.1%) with recurrent AF (55.2% male, median age 76 years). The cumulative two-year incidence of ischemic stroke was 0.9%, 1.5%, and 2.3% for patients without AF, transient AF, and recurrent AF, respectively (Figure 1). The cumulative two-year incidence of mortality was 7.4%, 12.1%, and 20.3% for patients without AF, transient AF, and recurrent AF, respectively (Figure 1). Compared to those without AF, the adjusted two-year rates of outcomes were as follows: ischemic stroke: HR 1.15 (95% CI: 0.81–1.61) for patients with transient AF and HR 1.50 (95% CI: 1.14–1.98) for patients with recurrent AF; mortality: HR 0.98 (95% CI: 0.87–1.10) for patients with transient AF and HR 1.35 (95% CI: 1.23–1.49) for patients with recurrent AF (Figure). We identified that 20.9% for transient AF and 42.2% for recurrent AF were prescribed OAC therapy in the three-month period after one year.

Conclusion

In patients surviving one year after ACS with first-time detected AF, a recurrent AF episode was associated with an increased long-term rate of ischemic stroke and mortality, while transient AF yielded no statistically difference as compared with patients without AF.

Funding Acknowledgement

Type of funding sources: None.

Rehospitalizations, repeated aortic surgery, and death in initial survivors of surgery for Stanford type A aortic dissection and the significance of age – a nationwide registry-based cohort study

Background

All patients with type A aortic dissections, regardless of age, are recommended urgent aortic surgery. However, studies exploring long term outcomes in survivors are sparse, and especially, the significance of age on long-term outcomes remain unclear.

Purpose

We described and compared incidences across age groups of post-discharge readmission, repeated aortic surgery, and death in patients who survived surgery and hospitalization for type A aortic dissection.

Methods

Using data from Danish nationwide registries, we identified patients hospitalized with Stanford type A aortic dissections from 2006–2018. Survivors of hospitalization and surgery on the ascending aorta and/or aortic arch comprised the study population (Figure 1). Using cumulative incidence plots taking death into account as a competing risk and Cox regression analysis, we described long-term outcomes (rehospitalizations, repeated aortic surgery, and death) and compared different age groups. The diagnosis of type A aortic dissection in the registries used, was validated from 191 clinical records to have a positive predictive value of 94.8%.

Results

Of 606 initial survivors of surgery and hospitalization with type A aortic dissection, 236 (38.9%) were &lt;60 years old (group I), 194 (32.0%) were 60–69 years old (group II), and 176 (29.1%) were &gt;69 years old (group III). Figure 2 shows cumulative incidences of outcomes according to age. During the first year, 62.5% were re-hospitalized (median number of days hospitalized was 2 days (IQR 1–8 days) and 1.4% underwent repeated aortic surgery with no significant differences across age groups (P=0.68 and P=0.39, respectively). Further, 5.9% died (group I: 3.0%, group II: 8.3%, group III: 7.4%, P=0.04). After 10 years of follow up, 8.0% had undergone repeated aortic surgery (group I: 11.5%, group II: 8.5%, group III: 1.6%, P=0.04) and 10.2% (group I), 17.0% (group II), and 22.2% (group III) had died (P=0.01). In adjusted analyses, no age differences were found in one-year outcomes, while age &gt;69 years (group III) compared with age &lt;60 years (group I) was associated with a lower rate of repeated aortic surgery (hazard ratio 0.17, 95% confidence interval 0.04–0.78) and a higher rate of all-cause mortality (hazard ratio 2.44, 95% confidence interval 1.37–4.34) in the 10-years analysis.

Conclusion

Among survivors of type A aortic dissections, rehospitalizations the first year after discharge were common among all age groups, but survival was high. Repeated aortic surgery was rare, and significantly more common among younger than older patients. Evaluations of quality of life in survivors of type A aortic dissections are needed.

Funding Acknowledgement

Type of funding sources: None.

Perioperative atrial fibrillation in major emergency abdominal surgery: does it affect postoperative outcome?

Background

Atrial fibrillation (AF) in relation to surgery remains a clinical challenge. Major emergency abdominal surgery (e.g. ileus, perforation) is associated with postoperative complications and mortality. However, the prevalence and impact of perioperative AF in this setting is not well examined.

Purpose

We compared 30-days and 1-year outcomes (i.e. hospitalization of any causes, AF-related hospitalization, thromboembolic events and all-cause mortality) in patients who did and did not develop perioperative AF (POAF) in relation to their major emergency abdominal surgery.

Methods

We crosslinked data from Danish nationwide registries and identified all patients who underwent major emergency abdominal surgery (2000–2018) and discharged alive. Patients who developed POAF during hospitalization were matched in a 1:3 ratio on age, sex, year of surgery and category of surgery with those without POAF. Starting follow up at discharge, we examined the rates of outcomes at 30-days and 1-year post-discharge. The cumulative incidences and ratios of outcomes were assessed with the Aalen Johanson estimator together with Kaplan-Meier estimator and multivariable Cox regression analysis, respectively.

Results

We identified 891 patients with POAF and 64,914 patients without POAF. The matched cohort were composed of 889 patients with POAF and 2667 patients without POAF with a median age of 79 years [25th-75th percentile; 72–84 years] and 45.2% males. In general, patients with POAF had higher comorbid burden compared with patients without POAF. The cumulative incidences of a hospitalization of any cause after 30-days post-discharge were 31.2% and 22.3% in patients with and without POAF, respectively. The corresponding numbers for AF-related hospitalization were 20.8% and 1.2%, respectively. In adjusted analyses, POAF was associated with a significantly higher risk of hospitalization of any causes together with AF-related hospitalization (Figure 1 and 2).

The cumulative incidences of a thromboembolic event after 30-days post-discharge were 2.2% and 0.9% in patients with and without POAF, respectively. The corresponding numbers for all-cause mortality were 9.7% and 3.2%, respectively. In adjusted analyses, POAF was associated with a significantly higher risk of a thromboembolic event together with all-cause mortality within 30-days of follow up as well as 1-year of follow up. However, the results regarding thromboembolic events did not reach statistical significance after 1-year of follow up (Figure 1 and 2).

Conclusions

Perioperative atrial fibrillation in relation to major emergency abdominal surgery was associated with higher 30-days and 1-year rates of hospitalizations of any causes, atrial fibrillation related hospitalization, a thromboembolic event and all-cause mortality. These findings suggest that perioperative atrial fibrillation is a strong prognostic marker of increased morbidity following major emergency abdominal surgery.

Funding Acknowledgement

Type of funding sources: None.

Rehospitalizations, repeated aortic surgery, and death in initial survivors of surgery for Stanford type A aortic dissection and the significance of age - a nationwide registry-based cohort study

AIMS

Describe and compare incidences across age groups of rehospitalization, repeated aortic surgery, and death in patients who survived surgery and hospitalization for type A aortic dissection.

METHODS AND RESULTS

From Danish nationwide registries, we identified patients hospitalized with Stanford type A aortic dissections (2006-2018). Survivors of hospitalization and surgery on the ascending aorta and/or aortic arch comprised the study population (n = 606, 36 (38.9%) <60 years old (group I), 194 (32.0%) 60-69 years old (group II), and 176 (29.1%) >69 years old (group III)). During the first year, 62.5% were re-hospitalized and 1.4% underwent repeated aortic surgery with no significant differences across age groups (P = 0.68 and P = 0.39, respectively). Further, 5.9% died (group I: 3.0%, group II: 8.3%, group III: 7.4%, P = 0.04). After 10 years, 8.0% had undergone repeated aortic surgery (group I: 11.5%, group II: 8.5%, group III: 1.6%, P = 0.04) and 10.2% (group I), 17.0% (group II), and 22.2% (group III) had died (P = 0.01). Using multivariable Cox regression analysis, we described long-term outcomes comparing age groups. No age differences were found in one-year outcomes, while age > 69 years compared with age < 60 years was associated with a lower rate of repeated aortic surgery (hazard ratio 0.17, 95% confidence interval 0.04-0.78) and a higher rate of all-cause mortality (hazard ratio 2.44, 95% confidence interval 1.37-4.34) in the 10-years analyses.

CONCLUSIONS

Rehospitalizations the first year after discharge were common in all age groups, but survival was high. Repeated aortic surgery was significantly more common among younger than older patients.

Association Between Inappropriately Dosed Anticoagulation Therapy With Stroke Severity and Outcomes in Patients With Atrial Fibrillation

Background

Oral anticoagulation (OAC) is effective for stroke prevention in patients with atrial fibrillation. However, some patients experience stroke despite OAC therapy, and knowledge about the impact of prior treatment quality is lacking.

Methods and Results

Patients with atrial fibrillation on OAC therapy who had a first‐time ischemic stroke were identified in the Danish Stroke Registry (2005–2018). Patients treated with vitamin K antagonist (VKA) therapy were compared according to the international normalized ratio just before stroke (international normalized ratio <2 [subtherapeutic], international normalized ratio 2–3 [therapeutic], international normalized ratio >3 [supratherapeutic]), and patients on underdosed, appropriately dosed, and overdosed direct OAC (DOAC) therapy were compared. Stroke severity was determined using the Scandinavia Stroke Scale (0–58 points), and the risk of very severe stroke (0–14 points) was analyzed by multivariable logistic regression. One‐year mortality was determined using multivariable Cox regression. A total of 2319 patients with atrial fibrillation and stroke were included; 1196 were taking a VKA (subtherapeutic [46%], therapeutic [43%], supratherapeutic [11%]), and 1123 were taking DOAC (underdosed [23%], appropriately dosed [60%], and overdosed [17%]). Subtherapeutic and supratherapeutic VKA therapy (compared with therapeutic) and underdosed DOAC therapy (compared with appropriate and underdosed DOAC) patients were older, more often women, and more comorbid. Subtherapeutic VKA therapy was associated with very severe stroke (odds ratio [OR], 2.06 [95% CI, 1.28–3.31]), whereas supratherapeutic VKA therapy was not (OR, 1.24 [95% CI, 0.60–2.57]) compared with therapeutic VKA therapy. Patients on subtherapeutic and supratherapeutic VKA therapy had a higher 1‐year mortality (hazard ratio [HR], 1.66 [95% CI, 1.29–2.13]); HR, 1.55 [95% CI, 1.08–2.22], respectively) than those on therapeutic VKA therapy. Treatment with underdosed or overdosed DOAC therapy was not associated with very severe stroke (OR, 1.27 [95% CI, 0.76–2.15]; OR, 0.73 [95% CI, 0.37–1.43], respectively) and was not associated with 1‐year mortality (HR, 1.09 [95% CI, 0.83–1.44]; HR, 0.82 [95% CI, 0.57–1.18], respectively) than appropriate DOAC.

Conclusions

Half of the patients with atrial fibrillation with stroke were on inappropriate OAC therapy. Subtherapeutic VKA was associated with worse stroke severity and higher mortality rate than therapeutic VKA therapy. Neither underdosed nor overdosed DOAC was associated with worse outcomes in adjusted models compared with appropriately dosed DOAC. This study supports DOAC as a first‐line therapy over VKA.

Incidence of ischaemic stroke and mortality in patients with acute coronary syndrome and first-time detected atrial fibrillation: a nationwide study

AIMS

The aim of this study was to examine contemporary data on the 1-year prognosis of patients surviving acute coronary syndrome (ACS) and concomitant first-time detected atrial fibrillation (AF).

METHODS AND RESULTS

Using Danish nationwide registries, we identified all patients surviving a first-time admission with ACS from 2000 to 2018 and grouped them into (i) those without AF prior to or during ACS; (ii) those with a history of AF; and (iii) those with first-time detected AF during admission with ACS. With 1 year of follow-up, rates of ischaemic stroke, death, and bleeding were compared between study groups using multivariable adjusted Cox proportional hazards analysis. We included 161 266 ACS survivors: 135 878 (84.2%) without AF, 18 961 (11.8%) with history of AF, and 6427 (4.0%) with first-time detected AF at admission with ACS. Compared to those without AF, the adjusted 1-year rates of outcomes were as follows: ischaemic stroke [hazard ratio (HR) 1.38 (95% CI 1.22-1.56) for patients with history of AF and HR 1.67 (95% CI 1.38-2.01) for patients with first-time detected AF]; mortality [HR 1.25 (95% CI 1.21-1.31) for patients with history of AF and HR 1.52 (95% CI 1.43-1.62) for patients with first-time detected AF]; and bleeding [HR 1.22 (95% CI 1.14-1.30) for patients with history of AF and HR 1.28 (95% CI 1.15-1.43) for patients with first-time detected AF].

CONCLUSION

In patients with ACS, first-time detected AF appeared to be at least as strongly associated with the 1-year rates of ischaemic stroke, mortality, and bleeding as compared with patients with a history of AF.

One-year outcomes in atrial fibrillation presenting during infections: a nationwide registry-based study

AIMS

Thromboprophylaxis guidelines for patients with concurrent atrial fibrillation (AF) during infections are unclear and not supported by data. We compared 1-year outcomes in patients with infection-related AF and infection without AF.

METHODS AND RESULTS

By crosslinking Danish nationwide registry data, AF naïve patients admitted with infection (1996-2016) were identified. Those with AF during the infection (infection-related AF) were matched 1:3 according to age, sex, type of infection, and year with patients with infection without AF. Outcomes (AF, thromboembolic events) were assessed by multivariable Cox regression. The study population comprised 30 307 patients with infection-related AF and 90 912 patients with infection without AF [median age 79 years (interquartile range 71-86), 47.6% males in both groups]. The 1-year absolute risk of AF and thromboembolic events were 36.4% and 7.6%, respectively (infection-related AF) and 1.9% and 4.4%, respectively (infection without AF). In the multivariable analyses, infection-related AF was associated with an increased long-term risk of AF and thromboembolic events compared with infection without AF: hazard ratio (HR) 25.98, 95% confidence interval (CI) 24.64-27.39 for AF and HR 2.10, 95% CI 1.98-2.22 for thromboembolic events. Further, differences in risks existed across different subtypes of infections.

CONCLUSION

During the first year after discharge, 36% of patients with infection-related AF had a new hospital contact with AF. Infection-related AF was associated with increased risk of thromboembolic events compared with infection without AF and our results suggest that AF related to infection may merit treatment and follow-up similar to that of AF not related to infection.

Long-term Thromboembolic Risk in Patients With Postoperative Atrial Fibrillation After Left-Sided Heart Valve Surgery

Importance

New-onset postoperative atrial fibrillation (POAF) is a common complication of cardiac surgery. However, data on the long-term risk of thromboembolism in patients who develop POAF after heart valve surgery are conflicting. In addition, data on stroke prophylaxis in this setting are lacking.

Objective

To assess the long-term risk of thromboembolism in patients developing new-onset POAF after isolated left-sided heart valve surgery relative to patients with nonsurgical, nonvalvular atrial fibrillation (NVAF).

Design, Setting, and Participants

This observational cohort study was conducted from January 1, 2000, through December 31, 2015, using Danish nationwide registries and the Eastern Danish Heart Surgery Database. Patients who developed POAF after isolated left-sided heart valve surgery (bioprosthetic aortic or mitral valve replacement and/or aortic or mitral valve repair) from 2000 through 2015 were included. These patients were matched with patients with nonsurgical NVAF in a 1:3 ratio by age, sex, heart failure, hypertension, diabetes, a history of thromboembolism, ischemic heart disease, and year of diagnosis. Data analyses took place from January to March 2019.

Main Outcomes and Measures

Rates of thromboembolism.

Results

Of the 1587 patients who underwent isolated left-sided heart valve surgery, 741 patients (46.7%) developed POAF during admission. Of the 712 patients with POAF who were eligible for matching, 675 patients were matched with 2025 patients with NVAF and made up the study population. In the matched study population, the median age was 71 (interquartile range, 65-77) years, and 1600 (59.3%) were men. Oral anticoagulation therapy was initiated within 30 days postdischarge in 420 patients with POAF (62.9%) and in 1030 patients with NVAF (51.4%). The crude incidence rates of thromboembolism were 21.9 (95% CI, 17.4-27.6) and 17.7 (95% CI, 15.2-20.6) events per 1000 person-years for patients with POAF and patients with NVAF, respectively. In the adjusted analysis, the long-term risk of thromboembolism was similar in patients with POAF and NVAF (hazard ratio, 1.22 [95% CI, 0.88-1.68]). Oral anticoagulation therapy during follow-up was associated with a lower risk of thromboembolic events in patients with POAF (hazard ratio, 0.45 [95% CI, 0.22-0.90]) as well as patients with NVAF (hazard ratio, 0.63 [95% CI, 0.45-0.87]) compared with no anticoagulation therapy.

Conclusions and Relevance

New-onset POAF after isolated left-sided heart valve surgery was associated with a similar long-term risk of thromboembolism as NVAF. These data warrant studies addressing the role of anticoagulation therapy in POAF after left-sided heart valve surgery.

Time trends and patient selection in the use of continuous electrocardiography for detecting atrial fibrillation after stroke: a nationwide cohort study

BACKGROUND AND PURPOSE

Clinical use of continuous electrocardiography (cECG) for detecting atrial fibrillation (AF) after stroke is unclear. In a Danish nationwide cohort, we described post-stroke time trends in outpatient cECG usage and AF incidence and characterized factors associated with cECG use.

METHODS

Patients without AF discharged after their first ischaemic stroke between 2010 and 2016 were identified from Danish nationwide registries. cECG included Holter or event recording within 120 days from discharge. Cumulative incidence analysis and multivariable adjusted logistic regression were used to assess time trends and factors associated with cECG usage and AF.

RESULTS

The study population comprised 39 641 patients. Cumulative use of cECG increased threefold from 3.3% [95% confidence intervals (CI), 2.8-3.8] in 2010 to 10.5% (95% CI, 9.7-11.3) in 2016. Correspondingly, cumulative incidence of post-stroke AF increased from 1.9% (95% CI, 1.5-2.3) to 2.8% (95% CI, 2.4-3.2). Of all cECG-evaluated patients, 6.3% received an AF diagnosis versus 2.2% of the unevaluated. Receiving cECG was associated with increased odds of AF (odds ratio, 3.4; 95% CI, 2.8-4.0). Lower age, milder strokes and less comorbidity were associated with increased odds of receiving cECG. In contrast, risk factors for AF were increasing age and more comorbidity.

CONCLUSIONS

Post-stroke outpatient cECG use and AF incidence have increased over time, but screening rates were low. cECG use was associated with tripled odds of detecting AF. There was a disparity between factors associated with cECG use and risk factors of AF. This raise questions as to the appropriateness of the current clinical approach to post-stoke AF detection.

Secondary stroke prophylaxis in atrial fibrillation patients with chronic kidney disease: a nationwide cohort study

AIMS

Oral anticoagulation (OAC) therapy as secondary stroke prophylaxis in atrial fibrillation (AF) patients with chronic kidney disease (CKD) remains unexplored and poses a clinical treatment dilemma. We assessed the long-term risk of thromboembolic events according to post-stroke OAC therapy in AF patients with CKD after their first ischaemic stroke.

METHODS AND RESULTS

We identified Danish AF patients with CKD who presented with first-time ischaemic stroke from 2005 to 2014. Chronic kidney disease was defined as a diagnosis code for CKD before baseline, defined as 100 days after stroke discharge. Post-stroke antithrombotic therapy (OAC therapy and antiplatelet therapy) was identified from prescription claims from discharge to baseline. Cumulative incidences and adjusted hazard ratios (HRs) of thromboembolic events according to post-stroke OAC therapy were examined. Of 1252 AF patients with CKD presenting with ischaemic stroke, 631 (50.4%) patients were on OAC therapy and 621 (49.6%) were on antiplatelet therapy alone at baseline [median age 76 (interquartile range, IQR 71-83) and 80 (IQR 72-86), respectively]. The median follow-up period was 1.9 years (IQR 0.8-3.6). Cumulative incidence rates of thromboembolic events and bleeding showed no significant difference between those on OAC therapy and antiplatelet therapy. The results from the multivariable analysis revealed similar results: thromboembolic risk was not modified by OAC treatment [adjusted HR 0.89, 95% confidence interval (CI) 0.73-1.09] nor was the risk of bleeding (adjusted HR 0.88, 95% CI 0.67-1.17).

CONCLUSION

Oral anticoagulation in patients with CKD and prior stroke was not associated with a reduced risk of recurrent thromboembolic events compared with antiplatelet therapy.

P4799Long-term thromboembolic risk in patients with postoperative atrial fibrillation after left-sided heart valve surgery

Background

New-onset postoperative atrial fibrillation (POAF) is a common complication of cardiac surgery. However, data on the long-term risk of thromboembolism in patients who develop POAF after heart valve surgery are sparse. In addition, data on stroke prophylaxis in this setting are lacking.

Objective

To assess the long-term risk of thromboembolism in patients developing new-onset POAF following isolated left-sided heart valve surgery relative to patients with nonsurgical, nonvalvular atrial fibrillation (NVAF).

Methods

Using data from the Eastern Danish Heart Surgery Database and Danish nationwide registries, we identified patients who developed POAF following isolated left-sided heart valve surgery (i.e. biologic aortic/mitral valve replacement or aortic/mitral valve repair) from 2000 through 2015. These patients were matched with patients with nonsurgical NVAF in a 1:4 ratio by age, sex, heart failure, hypertension, diabetes, a history of thromboembolism, ischemic heart disease, and year of diagnosis. Long-term risk of thromboembolism was examined by the Aalen-Johansen estimator and cause-specific Cox regression models adjusted for comorbidities, concomitant pharmacotherapy, and oral anticoagulation therapy as a time-dependent covariate.

Results

A total of 1,539 patients undergoing isolated left-sided heart valve surgery were identified. Of these, 716 (46.5%) patients developed POAF after surgery. A total of 630 patients with POAF were matched with 2,520 patients with NVAF. In the matched study population, the median age was 71 years (25th-75th percentile 66–77 years) and 59.5% were men. Oral anticoagulation therapy was initiated within 30 days post-discharge in 62.7% and 51.4% of these patients, respectively. Compared with NVAF, POAF was not associated with a significantly different 5-year absolute risk of thromboembolism (10.7% [95% confidence interval [CI], 8.0%-13.9%] versus 8.9% [95% CI, 7.6%-10.2%] in the POAF and NVAF group, respectively) (Figure). In the adjusted analysis, the long-term risk of thromboembolism was similar in patients with POAF and NVAF (hazard ratio [HR] 1.01 [95% CI, 0.71–1.44]). Anticoagulation therapy during follow-up was associated with a lower risk of thromboembolic events in patients with POAF (HR 0.45 [95% CI, 0.18–0.99]) as well as NVAF (HR 0.58 [95% CI, 0.42–0.80]) compared with no anticoagulation therapy.

Conclusions

New-onset POAF following isolated left-sided heart valve surgery was associated with a similar long-term risk of thromboembolism compared with NVAF. Future studies addressing the role of oral anticoagulation therapy in POAF after heart valve surgery are warranted to examine the efficacy and safety as well as the timing and duration of anticoagulation therapy.

Long-term Thromboembolic Risk in Patients With Postoperative Atrial Fibrillation After Coronary Artery Bypass Graft Surgery and Patients With Nonvalvular Atrial Fibrillation

Importance

New-onset postoperative atrial fibrillation (POAF) is a common complication of coronary artery bypass graft (CABG) surgery. However, the long-term risk of thromboembolism in patients who develop POAF after CABG surgery remains unknown. In addition, information on stroke prophylaxis in this setting is lacking.

Objective

To examine stroke prophylaxis and the long-term risk of thromboembolism in patients with new-onset POAF after first-time isolated CABG surgery compared with patients with nonsurgical, nonvalvular atrial fibrillation (NVAF).

Design, Setting, and Participants

This cohort study used data from a clinical cardiac surgery database and Danish nationwide registries to identify patients undergoing first-time isolated CABG surgery who developed new-onset POAF from January 1, 2000, through June 30, 2015. These patients were matched by age, sex, CHA2DS2-VASc score, and year of diagnosis to patients with nonsurgical NVAF in a 1 to 4 ratio. Data analysis was completed from February 2017 to January 2018.

Main Outcomes and Measures

The proportion of patients initiating oral anticoagulation therapy within 30 days and the rates of thromboembolism.

Results

A total of 2108 patients who developed POAF after CABG surgery were matched with 8432 patients with NVAF. In the full population of 10 540 patients, the median (interquartile range) age was 69.2 (63.7-74.7) years; 8675 patients (82.3%) were men. Oral anticoagulation therapy was initiated within 30 days postdischarge in 175 patients with POAF (8.4%) and 3549 patients with NVAF (42.9%). The risk of thromboembolism was lower in the POAF group than in the NVAF group (18.3 vs 29.7 events per 1000 person-years; adjusted hazard ratio [HR], 0.67; 95% CI, 0.55-0.81; P < .001). Anticoagulation therapy during follow-up was associated with a lower risk of thromboembolic events in both patients with POAF (adjusted HR, 0.55; 95% CI, 0.32-0.95; P = .03) and NVAF (adjusted HR, 0.59; 95% CI, 0.51-0.68; P < .001) compared with patients who did not receive any anticoagulation therapy. Further, the risk of thromboembolism was not significantly higher in patients with POAF compared with those who did not develop POAF after CABG surgery (adjusted HR, 1.11; 95% CI, 0.94-1.32; P < .24).

Conclusions and Relevance

New-onset POAF in patients who had undergone CABG surgery was associated with a lower long-term thromboembolic risk than that of patients who had NVAF. These data do not support the notion that new-onset POAF should be regarded as equivalent to primary NVAF in terms of long-term thromboembolic risk.

Comparative thromboembolic risk in atrial fibrillation with and without a secondary precipitant-Danish nationwide cohort study

OBJECTIVES

We compared long-term outcomes in patients with atrial fibrillation (AF) with and without a secondary precipitant.

DESIGN AND SETTING

Retrospective cohort study based on Danish nationwide registries.

PARTICIPANTS

Patients with AF with and without secondary precipitants (1996-2015) were matched 1:1 according to age, sex, calendar year, CHA₂DS₂-VASc score and oral anticoagulation therapy (OAC), resulting in a cohort of 39 723 patients with AF with a secondary precipitant and the same number of patients with AF without a secondary precipitant. Secondary precipitants included alcohol intoxication, thyrotoxicosis, myocardial infarction, surgery and infection in conjunction with AF.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome in this study was thromboembolic events. Secondary outcomes included AF rehospitalisation and death. Long-term risks of outcomes were examined by multivariable Cox regression analysis.

RESULTS

The most common precipitants were infection (55.0%), surgery (13.2%) and myocardial infarction (12.0%). The 5-year absolute risk of thromboembolic events (taking death into account as a competing risk) in patients with AF grouped according to secondary precipitants were 8.3% (alcohol intoxication), 8.5% (thyrotoxicosis), 12.1% (myocardial infarction), 11.6% (surgery), 12.2% (infection), 10.1% (>1 precipitant) and 12.3% (no secondary precipitant). In the multivariable analyses, AF with a secondary precipitant was associated with the same or an even higher thromboembolic risk than AF without a secondary precipitant. One exception was patients with AF and thyrotoxicosis: those not initiated on OAC therapy carried a lower thromboembolic risk the first year of follow-up than matched patients with AF without a secondary precipitant and no OAC therapy.

CONCLUSIONS

In general, AF with a secondary precipitant was associated with the same thromboembolic risk as AF without a secondary precipitant. Consequently, this study highlights the need for more research regarding the long-term management of patients with AF associated with a secondary precipitant.

Comparative thromboembolic risk in atrial fibrillation patients with and without a concurrent infection

BACKGROUND

The aim of this study was to compare long-term thromboembolic risk in infection-related and non-infection-related atrial fibrillation (AF).

METHODS

Using Danish nationwide registries, we identified patients with first-time AF from 1996-2015 and performed a retrospective cohort study. We did a 1:1 match (upon sex, age, calendar year, and oral anticoagulation (OAC) status at the beginning of follow-up) of patients with infection-related (concurrent discharge diagnosis code for infection) and non-infection-related AF. Long-term outcomes were examined using multivariable Cox regression analyses.

RESULTS

Our study population comprised 48,644 patients equally distributed on infection-related and non-infection-related AF. In both groups, those initiated on OAC therapy were younger than those not initiated on OAC therapy (median age 77 years, interquartile range 69-83 versus median age 79 years, interquartile range 71-86). During the 1st year of follow up, infection-related AF was associated with an increased risk of thromboembolic events compared with non-infection-related AF: adjusted hazard ratio (HR) 1.44 (95% confidence interval (CI) 1.16-1.78) for those initiated on OAC therapy and HR 1.17 (95% CI 1.06-1.28) for those not initiated on OAC therapy. In both groups, OAC therapy was associated with better outcomes than no OAC therapy (HR of thromboembolic events 0.75 (95% CI 0.68-0.83) and HR 0.70 (95% CI 0.63-0.78) for patients with infection-related and non-infection-related AF, respectively).

CONCLUSION

Infection was associated with an increased thromboembolic risk in patients with first-time AF. OAC therapy was associated with a similar risk-reduction in AF patients with and without a concurrent infection.

[Patent foramen ovale closure in patients with apoplexia]

Epidemiological studies have shown a larger prevalence of patent foramen ovale (PFO) in patients with cryptogenic ischaemic stroke (CIS) than in patients without CIS. In 2017, three randomised clinical trials showed a beneficial effect of PFO closure in patients with CIS. Among patients with CIS and PFO, those who underwent PFO closure, had a lower risk of stroke recurrence than those treated with antithrombotic therapy alone. In this review, we analyse the existing evidence and set up suggestions for future recommendations for PFO closure in patients with CIS.

Increased use of oral anticoagulants in patients with atrial fibrillation: temporal trends from 2005 to 2015 in Denmark

Aim

The aim of this study is to examine temporal trends in the use oral anticoagulants (OAC) as stroke prophylaxis in patients with atrial fibrillation (AF) and to examine factors associated with OAC initiation.

Methods and results

From Danish nationwide registries, we identified patients diagnosed with AF at Danish hospitals and outpatient clinics between January 2005 and June 2015. OAC initiation was assessed from prescription fills ±180 days from date of AF diagnosis. We identified a total of 108 410 patients with newly diagnosed AF. Before 2010, 40-50% initiated OAC treatment. From 2010, OAC initiation rates increased (P < 0.0001 for trend) and by June 2015, 66.5% of the incident AF patients were initiated on OAC (74.5% increase since December 2009). Increased OAC prescription was especially seen among females and 'fragile' patients (age > 75 years and high risk of stroke). The increased OAC initiation was accompanied by introduction and increased uptake of the NOACs. By the end of the study, NOACs accounted for 72.5% of all OACs prescribed in newly diagnosed AF patients. OAC initiation was associated with male gender, age 65-74 years, few comorbidities and increased risk of stroke.

Conclusion

Since 2010, more incident AF patients in Denmark were initiated on OAC therapy with predominant NOAC prescription. The increase was pronounced among females, among patients at high risk of stroke, and among older patients.

Prestroke and Poststroke Antithrombotic Therapy in Patients With Atrial Fibrillation: Results From a Nationwide Cohort

IMPORTANCE

Antithrombotic therapies are effective in both primary and secondary stroke prophylaxis in high-risk patients with atrial fibrillation (AF), but they are often underused in community practice.

OBJECTIVE

To examine prestroke and poststroke antithrombotic treatment patterns and long-term outcomes in patients with AF presenting with ischemic stroke.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study of Danish patients with AF, with a prestroke CHA2DS2-VASc score of 1 or higher for men and 2 or higher for women, and presenting with ischemic stroke was conducted from January 1, 2004, to January 31, 2017. Data on hospital admission, prescription fillings, and vital status were assessed using several Danish nationwide registries.

EXPOSURES

Patients who survived 100 days after discharge were divided into 3 groups according to poststroke antithrombotic therapy: oral anticoagulation (OAC) therapy, antiplatelet therapy alone, or no antithrombotic therapy.

MAIN OUTCOMES AND MEASURES

Long-term outcomes (thromboembolic events and bleeding complications) were examined using multivariable Cox regression analyses across the 3 groups.

RESULTS

Among 30 626 patients with AF admitted with ischemic stroke, 11 139 patients (36.3%) received OAC therapy (44.3% female; median age, 79 years [interquartile range, 73-85 years]), 11 874 (38.8%) received antiplatelet therapy alone (55.0% female; median age, 82 years [interquartile range, 75-88 years]), and 7613 (24.9%) received no antithrombotic therapy before stroke (53.8% female; median age, 80 years [interquartile range, 71-86 years]). Following stroke, 31.3% of those receiving antiplatelet therapy alone and 43.7% of those receiving no antithrombotic therapy before stroke shifted to OAC therapy. Yet, 37.5% of patients with stroke did not receive OAC therapy following stroke. However, OAC treatment rates increased over time. During a maximum of 10 years of follow-up, 17.5%, 21.2%, and 21.5% experienced a new thromboembolic event and 72.7%, 86.4%, and 86.2% died among those treated with OAC therapy, antiplatelet therapy, or no antithrombotic therapy, respectively. Poststroke OAC therapy was associated with lower risk of recurrent thromboembolic events (adjusted hazard ratio, 0.81; 95% CI, 0.73-0.89) and no significant difference in bleeding complications (adjusted hazard ratio, 0.97; 95% CI, 0.86-1.10), compared with no poststroke antithrombotic therapy. In contrast, there were no significant differences for those treated with poststroke antiplatelet therapy and no antithrombotic therapy.

CONCLUSIONS AND RELEVANCE

Patients with AF receiving poststroke OAC therapy had lower risk of recurrent thromboembolic events. Our findings suggest a substantial opportunity for improving primary and secondary stroke prophylaxis in high-risk patients with AF.

Initiation of anticoagulation in atrial fibrillation: which factors are associated with choice of anticoagulant?

BACKGROUND

The use of non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prophylaxis in atrial fibrillation (AF) is increasing rapidly. We compared characteristics of AF patients initiated on NOACs versus vitamin K antagonists (VKAs).

METHODS

Using Danish nationwide registry data, we identified AF patients initiating either a VKA or a NOAC from 22 August 2011 until 30 September 2016. We compared patient characteristics including age, gender, comorbidities, concomitant pharmacotherapy and CHA₂ DS₂ -VASc and HAS-BLED scores in patients initiated on a VKA, dabigatran, rivaroxaban or apixaban. Differences were examined using multivariable logistic regression models.

RESULTS

The study population comprised 51 981 AF patients of whom 19 989 (38.5%) were initiated on a VKA, 13 242 (25.5%) on dabigatran, 8475 (16.3%) on rivaroxaban and 10 275 (19.8%) on apixaban. Those patients initiated on apixaban had higher mean ± SD CHA₂ DS₂ -VASc scores than those initiated on a VKA (3.1 ± 1.6 vs. 2.9 ± 1.6). Those initiated on dabigatran had lower mean CHA₂ DS₂ -VASc scores (2.7 ± 1.6) than all other groups. Patients with a history of a prior stroke were significantly more likely to be initiated on a NOAC compared with a VKA [odds ratio (OR) 1.35, 95% confidence interval (CI) 1.28-1.43]. By contrast, patients with a history of myocardial infarction were less likely to be initiated on a NOAC compared with a VKA (OR 0.72, 95% CI 0.67-0.77).

CONCLUSIONS

Atrial fibrillation patients who were initiated on apixaban had higher stroke risk scores than patients initiated on VKAs. Interestingly, opposite results were found for dabigatran.

Familial clustering of atrial fibrillation and comparative longitudinal outcomes of familial and non-familial atrial fibrillation

Several studies have suggested that family history of atrial fibrillation (AF) is an important risk factor for AF, with several specific genetic regions now implicated through Genome Wide Association Studies. In addition, familial AF is associated with earlier age of onset and affects patients with fewer comorbid conditions than their non-familial counterparts. While those with familial AF have worse symptoms, all-cause mortality and risk of thromboembolic complications are similar among familial and non-familial AF patients.

Familial Clustering of Venous Thromboembolism - A Danish Nationwide Cohort Study

BACKGROUND

Identification of risk factors for venous thromboembolism (VTE) is of utmost importance to improve current prophylactic regimes and treatment guidelines. The extent to which a family history contributes to the risk of VTE needs further exploration.

OBJECTIVES

To examine the relative rate of VTE in first-degree relatives compared with the general population.

METHODS

By crosslinking Danish nationwide registries we identified patients with VTE between 1978 and 2012, and their familial relations. The first member in a family to acquire VTE was defined as the proband. All first-degree relatives to probands were followed from the VTE date of the proband and until an event (VTE), death, emigration, 100 year birthday or end of study: 31st of December 2012, whichever came first. The relative rate of VTE was estimated by standardized incidence ratios (SIR) using time-dependent Poisson regression models, with the general population as a fixed reference.

RESULTS

We identified 70,767 children of maternal probands, 66,065 children of paternal probands, and 29,183 siblings to sibling probands. Having a maternal proband or a paternal proband were associated with a significantly increased VTE rate of 2.15 (CI: 2.00-2.30) and 2.06 (CI: 1.92-2.21), respectively. The highest estimate of VTE was observed among siblings (adjusted SIR of 2.60 [CI: 2.38-2.83]). Noteworthy, the rate of VTE increased for all first-degree relatives when the proband was diagnosed with VTE in a young age (≤ 50 years).

CONCLUSION

A family history of VTE was associated with a significantly increased rate of VTE among first-degree relatives compared with the general population.

Outcomes Associated With Familial Versus Nonfamilial Atrial Fibrillation: A Matched Nationwide Cohort Study

Background

We examined all‐cause mortality and long‐term thromboembolic risk (ischemic stroke, transient ischemic attack, systemic thromboembolism) in patients with and without familial atrial fibrillation (AF).

Methods and Results

Using Danish nationwide registry data, we identified all patients diagnosed with AF (1995–2012) and divided them into those with familial AF (having a first‐degree family member with a prior AF admission) and those with nonfamilial AF. We paired those with and without familial AF according to age, year of AF diagnosis, and sex in a 1:1 match. Using cumulative incidence and multivariable Cox models, we examined the risk of long‐term outcomes. We identified 8658 AF patients (4329 matched pairs) with and without familial AF. The median age was 50 years (interquartile range 43–54 years), and 21.4% were women. Compared with nonfamilial AF patients, those with familial AF had slightly less comorbid illness but similar overall CHA₂DS₂‐VASc score (P=0.155). Median follow‐up was 3.4 years (interquartile range 1.5–6.5 years). Patients with familial AF had risk of death and thromboembolism similar to those with nonfamilial AF (adjusted hazard ratio 0.91 [95% CI 0.79–1.04] for death and 0.90 [95% CI 0.71–1.14] for thromboembolism).

Conclusions

Although family history of AF is associated with increased likelihood for development of AF, once AF developed, long‐term risks of death and thromboembolic complications were similar in familial and nonfamilial AF patients.

Family history of atrial fibrillation is associated with earlier-onset and more symptomatic atrial fibrillation: Results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry

BACKGROUND

We addressed whether patients with a family history of atrial fibrillation (AF) were diagnosed as having AF earlier in life, were more symptomatic, and had worse outcomes compared with those without a family history of AF.

METHODS

Using the ORBIT-AF, we compared symptoms and disease characteristics in those with and without a family history of AF. A family history of AF was defined as AF in a first-degree family member and obtained by patient self-reporting. Multivariable Cox proportional hazard analyses were performed to compare the incidence of cardiovascular outcomes, AF progression, all-cause hospitalization, and all-cause death.

RESULTS

Among 9,999 patients with AF from 176 US outpatient clinics, 1,481 (14.8%) had a family history of AF. Relative to those without, those with a family history of AF developed AF 5 years earlier on average (median age 65 vs 70 years, P < .01), with less comorbidity, and had more severe AF-related symptoms. No differences were found between the 2 groups in the risk of AF progression (adjusted hazard ratio [HR] 0.98, 95% CI 0.85-1.14), stroke, non-central nervous system embolism, or transient ischemic attack (adjusted HR 0.95, 95% CI 0.67-1.34), all-cause hospitalization (adjusted HR 1.03, 95% CI 0.94-1.12), and all-cause death (adjusted HR 1.05, 95% CI 0.86-1.27).

CONCLUSIONS

Patients with a family history of AF developed AF at a younger age, had less comorbidity, and were more symptomatic. Once AF developed, no significantly increased risks of AF progression and thromboembolism were associated with a family history of AF compared with no family history.

Stroke and recurrent haemorrhage associated with antithrombotic treatment after gastrointestinal bleeding in patients with atrial fibrillation: nationwide cohort study

STUDY QUESTION

What are the risks of all cause mortality, thromboembolism, major bleeding, and recurrent gastrointestinal bleeding associated with restarting antithrombotic treatment after gastrointestinal bleeding in patients with atrial fibrillation?

METHODS

This Danish cohort study (1996-2012) included all patients with atrial fibrillation discharged from hospital after gastrointestinal bleeding while receiving antithrombotic treatment. Restarted treatment regimens were single or combined antithrombotic drugs with oral anticoagulation and antiplatelets. Follow-up started 90 days after discharge to avoid confounding from use of previously prescribed drugs on discharge. Risks of all cause mortality, thromboembolism, major bleeding, and recurrent gastrointestinal bleeding were estimated with competing risks models and time dependent multiple Cox regression models.

STUDY ANSWER AND LIMITATIONS

4602 patients (mean age 78 years) were included. Within two years, 39.9% (95% confidence interval 38.4% to 41.3%, n=1745) of the patients had died, 12.0% (11.0% to 13.0%, n=526) had experienced thromboembolism, 17.7% (16.5% to 18.8%, n=788) major bleeding, and 12.1% (11.1% to 13.1%, n=546) recurrent gastrointestinal bleeding. 27.1% (n=924) of patients did not resume antithrombotic treatment. Compared with non-resumption of treatment, a reduced risk of all cause mortality was found in association with restart of oral anticoagulation (hazard ratio 0.39, 95% confidence interval 0.34 to 0.46), an antiplatelet agent (0.76, 0.68 to 0.86), and oral anticoagulation plus an antiplatelet agent (0.41, 0.32 to 0.52), and a reduced risk of thromboembolism was found in association with restart of oral anticoagulation (0.41, 0.31 to 0.54), an antiplatelet agent (0.76, 0.61 to 0.95), and oral anticoagulation plus an antiplatelet agent (0.54, 0.36 to 0.82). Restarting oral anticoagulation alone was the only regimen with an increased risk of major bleeding (1.37, 1.06 to 1.77) compared with non-resumption of treatment; however, the difference in risk of recurrent gastrointestinal bleeding was not significant between patients who restarted an antithrombotic treatment regimen and those who did not resume treatment.

WHAT THIS STUDY ADDS

Among patients with atrial fibrillation who experience gastrointestinal bleeding while receiving antithrombotic treatment; subsequent restart of oral anticoagulation alone was associated with better outcomes for all cause mortality and thromboembolism compared with patients who did not resume treatment. This was despite an increased longitudinal associated risk of bleeding.

FUNDING, COMPETING INTERESTS, DATA SHARING

This study was supported by a grant from Boehringer-Ingelheim. Competing interests are available in the full paper on bmj.com. The authors have no additional data to share.

Stillbirth and congenital anomalies in migrants in Europe

The risk of giving birth to a stillborn child or a child with severe congenital anomaly is higher for women who have immigrated to Europe as compared to the majority population in the receiving country. The literature, however, reveals great differences between migrant groups, even within migrants from low-income countries, although there is no clear pattern regarding refugee or non-refugee status. This heterogeneity argues against a particular migration-related explanation. There are social disparities in stillbirth risk worldwide, and it has been suggested that the demonstrated ethnic disparity is a result of the socioeconomic disadvantage most migrants face. Consanguinity has been considered as another cause for the increased stillbirth risk and the high risk of congenital anomaly observed in many migrant groups. Utilization and quality of care during pregnancy and childbirth is the third major aspect. All three factors seem to contribute to stillbirth risk, and they should be considered in clinical practice and public health.

A Register-Based Study of Diseases With an Autosomal Recessive Origin in Small Children in Denmark According to Maternal Country of Origin

BACKGROUND

Compared with children born of Danish mothers, the mortality of children, born and living in Denmark, is significantly increased in those with a mother from Afghanistan, Iraq, Pakistan, Somalia, and Turkey. Consanguinity has been suggested to account for part of this disparity. Since information on consanguinity is lacking, this suggestion is difficult to test. With an indirect approach, we addressed this question by comparing the risk of diseases with autosomal recessive inheritance in children born in Denmark of Danish-born women and of women born in these five countries, respectively.

METHODS

All children born in Denmark (1994-2010) were followed until 5 years of age or end-of-study period for the risk of hospitalisation with diseases of autosomal recessive aetiology, and therefore considered consanguinity-related. Diagnoses of autosomal recessive diseases were identified using two different methods: a literature review of consanguinity-associated diseases and a search in the Online Catalogue of Human Genes and Genetic Disorders. Risks were also calculated for diseases with known non-autosomal recessive aetiology (considered non-consanguinity-related). We estimated adjusted hazard ratios for the diseases in children of foreign-born women compared with children of Danish-born women.

RESULTS

Compared with offspring of Danish-born women, the risk of a consanguinity-related disease was significantly increased in children of foreign-born women, although the absolute risk was low. The risk of non-consanguinity-related diseases did not differ between the groups compared.

CONCLUSIONS

The findings support the hypothesis that consanguinity accounts for some, however a minor part, of the disparity in child mortality among migrants in Denmark.