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Teppo K, Airaksinen KEJ, Jaakkola J, Halminen O, Salmela B, Kouki E, Haukka J, Putaala J, Linna M, Aro AL, Mustonen P, Hartikainen J, Lip GYH, Lehto M. Ischaemic stroke in women with atrial fibrillation: temporal trends and clinical implications. Eur Heart J 2024:ehae198. [PMID: 38606837 DOI: 10.1093/eurheartj/ehae198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/19/2024] [Accepted: 03/18/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND AND AIMS Female sex has been linked with higher risk of ischaemic stroke (IS) in atrial fibrillation (AF), but no prior study has examined temporal trends in the IS risk associated with female sex. METHODS The registry-linkage Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study included all patients with AF in Finland from 2007 to 2018. Ischaemic stroke rates and rate ratios were computed. RESULTS Overall, 229 565 patients with new-onset AF were identified (50.0% women; mean age 72.7 years). The crude IS incidence was higher in women than in men across the entire study period (21.1 vs. 14.9 events per 1000 patient-years, P < .001), and the incidence decreased both in men and women. In 2007-08, female sex was independently associated with a 20%-30% higher IS rate in the adjusted analyses, but this association attenuated and became statistically non-significant by the end of the observation period. Similar trends were observed when time with and without oral anticoagulant (OAC) treatment was analysed, as well as when only time without OAC use was considered. The decrease in IS rate was driven by patients with high IS risk, whereas in patients with low or moderate IS risk, female sex was not associated with a higher IS rate. CONCLUSIONS The association between female sex and IS rate has decreased and become non-significant over the course of the study period from 2007 to 2018, suggesting that female sex could be omitted as a factor when estimating expected IS rates and the need for OAC therapy in patients with AF.
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Affiliation(s)
- Konsta Teppo
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Jussi Jaakkola
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Birgitta Salmela
- Department of Internal Medicine, Heart Center, Päijät-Häme Central Hospital, Lahti, Finland
| | - Elis Kouki
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jari Haukka
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jukka Putaala
- Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Miika Linna
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
- Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland
| | - Aapo L Aro
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pirjo Mustonen
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Juha Hartikainen
- Heart Center, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Aalborg, Denmark
| | - Mika Lehto
- Department of Internal Medicine, Jorvi Hospital, HUS Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Teppo K, Langén V, Airaksinen KEJ, Kouki E, Jaakkola J, Halminen O, Haukka J, Putaala J, Linna M, Mustonen P, Hartikainen J, Lehto M. Temporal Trends in Hypertension-Related Ischemic Stroke Risk in Atrial Fibrillation from 2007 to 2018: A Nationwide Cohort Study. Eur J Prev Cardiol 2024:zwae103. [PMID: 38454795 DOI: 10.1093/eurjpc/zwae103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/24/2024] [Accepted: 03/07/2024] [Indexed: 03/09/2024]
Affiliation(s)
- Konsta Teppo
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Ville Langén
- Division of Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Elis Kouki
- University of Helsinki, Helsinki, Finland
| | - Jussi Jaakkola
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | | | | | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Miika Linna
- University of Eastern Finland, Kuopio, Finland; Aalto University, Espoo, Finland
| | - Pirjo Mustonen
- Turku University Hospital and University of Turku, Finland
| | | | - Mika Lehto
- Jorvi Hospital, Department of Internal Medicine, HUS Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Langén VL, Emidio A, Vire J, Viitanen M, Teppo K. Trends in Positive Life Orientation Among 70-Year-Olds: A Comparison of Two Finnish Cohorts Born 20 Years Apart. Clin Gerontol 2024:1-7. [PMID: 38414277 DOI: 10.1080/07317115.2024.2320927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
OBJECTIVES We assessed if positive life orientation (PLO) has increased among older individuals and explored gender disparities in PLO changes. METHODS Two cohorts of 70-year-olds from Turku, Finland were included: the 1920 birth cohort (examined in 1991; n = 1,032) and the 1940 birth cohort (examined in 2011; n = 956). Participants completed an identical questionnaire assessing life satisfaction, feeling needed, future plans, zest for life, depression, and loneliness. A composite PLO score (range 0-1) was computed. RESULTS The 2011 cohort had a higher mean PLO score than the 1991 cohort (.87 vs. .83, p < .001). The 2011 cohort reported higher sense of being needed, more future plans, and reduced loneliness (all p < .001). No significant differences were found in life satisfaction, zest for life, or depression. Gender disparities in PLO persisted across both cohorts, with men scoring slightly higher but following similar trends as women. DISCUSSION PLO appears to have increased among older individuals. CLINICAL IMPLICATIONS Recognizing the rising trend of PLO in recent decades may influence the development of societal and healthcare policies to further improve overall well-being among older individuals.
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Affiliation(s)
- Ville L Langén
- Department of Medicine, Turku University Hospital and University of Turku, Turku, Finland
- Department of Geriatric Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Adriana Emidio
- Department of Medicine, Turku University Hospital and University of Turku, Turku, Finland
- Department of Geriatric Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Jenni Vire
- Department of Geriatric Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Matti Viitanen
- Department of Neurobiology, Care sciences and Society, Karolinska Institutet, Huddinge, Sweden
- Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Sweden
| | - Konsta Teppo
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
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Karlsson E, Kiviniemi T, Halminen O, Lehtonen O, Teppo K, Haukka J, Mustonen P, Putaala J, Linna M, Hartikainen J, Airaksinen KEJ, Lehto M. Temporal Relation Between Myocardial Infarction and New-Onset Atrial Fibrillation: Results from a Nationwide Registry Study. Am J Cardiol 2024; 211:49-56. [PMID: 37924921 DOI: 10.1016/j.amjcard.2023.10.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 10/11/2023] [Accepted: 10/24/2023] [Indexed: 11/06/2023]
Abstract
Myocardial infarction (MI) and atrial fibrillation (AF) are commonly seen in the same patient. In this study, we evaluated the temporal relations and prognosis of MI and AF. This is a substudy of the nationwide registry-based Finnish Anticoagulation in Atrial Fibrillation (FinACAF) study, comprising all Finnish patients with new-onset AF from 2010 to 2017. Patients with MI and AF were divided into groups depending on the temporal relation between the disease onsets: (1) MI before AF (MI AF), and (4) no MI. The 1-year mortality in the groups were studied with the Cox proportional hazards model. Of the 153,207 patients with new-onset AF (mean age 72.7 years, 50.0% women), 16,265 (10.6%) were diagnosed with MI. Altogether, 8,889 (54.7%) of the patients with MI were in the MIAF group. Of all MIs, 42.2% were diagnosed within 1 year from new-onset AF. The MI>AF group had the worst survival, with an adjusted hazard ratio for death of 3.08 (confidence interval [CI] 2.89 to 3.27) compared with patients without MI. For the MI
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Affiliation(s)
- Elin Karlsson
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.
| | | | | | | | - Konsta Teppo
- Turku University Hospital, University of Turku, Turku, Finland
| | - Jari Haukka
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Pirjo Mustonen
- Turku University Hospital, University of Turku, Turku, Finland
| | - Jukka Putaala
- Faculty of Medicine, University of Helsinki, Helsinki, Finland; Helsinki University Hospital, Helsinki, Finland
| | - Miika Linna
- Kuopio University Hospital, University of Eastern Finland, Kuopio, Finland
| | - Juha Hartikainen
- Kuopio University Hospital, University of Eastern Finland, Kuopio, Finland
| | | | - Mika Lehto
- Faculty of Medicine, University of Helsinki, Helsinki, Finland; Helsinki University Hospital, Helsinki, Finland; Jorvi Hospital, Department of Internal Medicine, HUS Helsinki University Hospital, Espoo, Finland
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Teppo K, Airaksinen KEJ, Jaakkola J, Halminen O, Salmela B, Kalatsova K, Kouki E, Haukka J, Putaala J, Linna M, Aro AL, Mustonen P, Hartikainen J, Lehto M. Temporal trends of gender disparities in oral anticoagulant use in patients with atrial fibrillation. Eur J Clin Invest 2024; 54:e14107. [PMID: 37823410 DOI: 10.1111/eci.14107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/02/2023] [Accepted: 10/05/2023] [Indexed: 10/13/2023]
Abstract
AIMS To investigate sex-specific temporal trends in the initiation of oral anticoagulant (OAC) therapy among patients diagnosed with atrial fibrillation (AF) in Finland between 2007 and 2018. METHODS The registry-linkage Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) Study included all patients with incident AF in Finland from 2007 to 2018. The primary outcome was the initiation of any OAC therapy. RESULTS We identified 229,565 patients with new-onset AF (50.0% women; mean age 72.7 years). The initiation of OAC therapy increased continuously during the observation period. While women were more likely to receive OAC therapy overall, after adjusting for age, stroke risk factors and other confounding factors, female sex was associated with a marginally lower initiation of OACs (unadjusted and adjusted hazard ratios comparing women to men: 1.08 (1.07-1.10) and 0.97 (0.96-0.98), respectively). Importantly, the gender disparities in OAC use attenuated and reached parity by the end of the observation period. Furthermore, when only patients eligible for OAC therapy according to the contemporary guidelines were included in the analyses, the gender inequalities in OAC initiation appeared minimal. Implementation of direct OACs for stroke prevention was slightly slower among women. CONCLUSION This nationwide retrospective cohort study covering all patients with incident AF in Finland from 2007 to 2018 observed that although female sex was initially associated with a lower initiation of OAC therapy, the sex-related disparities resolved over the course of the study period.
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Affiliation(s)
- Konsta Teppo
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Jussi Jaakkola
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Birgitta Salmela
- Heart Center, Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland
| | | | - Elis Kouki
- University of Helsinki, Helsinki, Finland
| | | | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Miika Linna
- Aalto University, Espoo, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Aapo L Aro
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pirjo Mustonen
- Turku University Hospital and University of Turku, Turku, Finland
| | - Juha Hartikainen
- Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Mika Lehto
- Jorvi Hospital, Department of Internal Medicine, HUS Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Putaala J, Teppo K, Halminen O, Haukka J, Tiili P, Jaakkola J, Karlsson E, Linna M, Mustonen P, Kinnunen J, Kiviniemi T, Aro A, Hartikainen J, Airaksinen JK, Lehto M. Ischemic Stroke Temporally Associated With New-Onset Atrial Fibrillation: A Population-Based Registry-Linkage Study. Stroke 2024; 55:122-130. [PMID: 38063017 PMCID: PMC10734779 DOI: 10.1161/strokeaha.123.044448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 10/30/2023] [Accepted: 11/13/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Limited data exist on the temporal relationship between new-onset atrial fibrillation (AF) and ischemic stroke and its impact on patients' clinical characteristics and mortality. METHODS A population-based registry-linkage database includes all patients with new-onset AF in Finland from 2007 to 2018. Ischemic stroke temporally associated with AF (ISTAF) was defined as an ischemic stroke occurring within ±30 days from the first AF diagnosis. Clinical factors associated with ISTAF were studied with logistic regression and 90-day survival with Cox proportional hazards analysis. RESULTS Among 229 565 patients with new-onset AF (mean age, 72.7 years; 50% female), 204 774 (89.2%) experienced no ischemic stroke, 12 209 (5.3%) had past ischemic stroke >30 days before AF, and 12 582 (5.8%) had ISTAF. The annual proportion of ISTAF among patients with AF decreased from 6.0% to 4.8% from 2007 to 2018. Factors associated positively with ISTAF were higher age, lower education level, and alcohol use disorder, whereas vascular disease, heart failure, chronic kidney disease cancer, and psychiatric disorders were less probable with ISTAF. Compared with patients without ischemic stroke and those with past ischemic stroke, ISTAF was associated with ≈3-fold and 1.5-fold risks of death (adjusted hazard ratios, 2.90 [95% CI, 2.76-3.04] and 1.47 [95% CI, 1.39-1.57], respectively). The 90-day survival probability of patients with ISTAF increased from 0.79 (95% CI, 0.76-0.81) in 2007 to 0.89 (95% CI, 0.87-0.91) in 2018. CONCLUSIONS ISTAF depicts the prominent temporal clustering of ischemic strokes surrounding AF diagnosis. Despite having fewer comorbidities, patients with ISTAF had worse, albeit improving, survival than patients with a history of or no ischemic stroke. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04645537. URL: https://www.encepp.eu; Unique identifier: EUPAS29845.
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Affiliation(s)
- Jukka Putaala
- Department of Neurology (J.P., P.T., J.K.), Helsinki University Hospital and University of Helsinki, Finland
| | - Konsta Teppo
- Heart Center, Turku University Hospital and University of Turku, Finland (K.T., J.J., P.M., T.K., K.E.J.A.)
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland (O.H., M. Linna)
| | - Jari Haukka
- Department of Public Health, University of Helsinki, Finland (J. Haukka)
| | - Paula Tiili
- Department of Neurology (J.P., P.T., J.K.), Helsinki University Hospital and University of Helsinki, Finland
| | - Jussi Jaakkola
- Department of Neurology (J.P., P.T., J.K.), Helsinki University Hospital and University of Helsinki, Finland
| | | | - Miika Linna
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland (O.H., M. Linna)
| | - Pirjo Mustonen
- Heart Center, Turku University Hospital and University of Turku, Finland (K.T., J.J., P.M., T.K., K.E.J.A.)
| | - Janne Kinnunen
- Department of Neurology (J.P., P.T., J.K.), Helsinki University Hospital and University of Helsinki, Finland
| | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital and University of Turku, Finland (K.T., J.J., P.M., T.K., K.E.J.A.)
| | - Aapo Aro
- Heart and Lung Center (A.A.), Helsinki University Hospital and University of Helsinki, Finland
| | - Juha Hartikainen
- Heart Center, Kuopio University Hospital and University of Eastern Finland, Finland (J. Hartikainen)
| | - Juhani K.E. Airaksinen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland (O.H., M. Linna)
| | - Mika Lehto
- University of Helsinki, Finland (E.K., M. Lehto)
- Department of Internal Medicine, Jorvi Hospital and Helsinki University Hospital, Espoo, Finland (M. Lehto)
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Teppo K, Airaksinen KEJ, Jaakkola J, Halminen O, Linna M, Haukka J, Putaala J, Mustonen P, Kinnunen J, Hartikainen J, Aro AL, Lehto M. Trends in treatment and outcomes of atrial fibrillation during 2007-17 in Finland. Eur Heart J Qual Care Clin Outcomes 2023; 9:673-679. [PMID: 36542420 PMCID: PMC10627815 DOI: 10.1093/ehjqcco/qcac086] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 11/08/2023]
Abstract
AIMS Guidelines on the management of atrial fibrillation (AF) have evolved significantly during the past two decades, but the concurrent developments in real-life management and prognosis of AF are unknown. We assessed trends in the treatment and outcomes of patients with incident AF between 2007 and 2017. METHODS AND RESULTS The registry-based nationwide FinACAF (Finnish AntiCoagulation in Atrial Fibrillation) cohort covers all patients with AF in Finland from all levels of care. We determined the proportion of patients who were treated with oral anticoagulants (OACs) or rhythm control therapies, experienced an ischaemic stroke or bleeding event requiring hospitalization, or died within 1-year follow-up after AF diagnosis. We identified 206 909 patients (mean age 72.6 years) with incident AF. During the study period, use of OACs increased from 43.6 to 76.3%, and the increase was most evident in patients with at least moderate stroke risk. One-year mortality decreased from 13.3 to 10.6%, and the ischaemic stroke rate from 5.3 to 2.2%. The prognosis especially improved in patients over 75 years of age. Concurrently, a small increase in major bleeding events was observed. Use of catheter ablation increased continuously over the study period, but use of other rhythm-control therapies decreased after 2013. CONCLUSION Stroke prevention with OACs in patients with incident AF improved considerably from 2007 to 2017 in Finland. This development was accompanied by decreasing 1-year mortality and the reduction of the ischaemic stroke rate by more than half, particularly among elderly patients, whereas there was only slight increase in severe bleeding events.
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Affiliation(s)
- Konsta Teppo
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Jussi Jaakkola
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, EspooFinland
| | - Miika Linna
- Department of Industrial Engineering and Management, Aalto University, EspooFinland
- University of Eastern Finland, Kuopio, Finland
| | | | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | - Pirjo Mustonen
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Janne Kinnunen
- Department of Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | - Juha Hartikainen
- University of Eastern Finland, Kuopio, Finland
- Heart Centre, Kuopio University Hospital, Kuopio, Finland
| | - Aapo L Aro
- Heart and Lung Centre, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mika Lehto
- Heart and Lung Centre, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Jorvi Hospital, Department of Internal Medicine, Helsinki and Uusimaa Hospital District, Espoo, Finland
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Teppo K, Airaksinen KEJ, Halminen O, Linna M, Jaakkola J, Haukka J, Putaala J, Mustonen P, Langén VL, Kinnunen J, Hartikainen J, Lehto M. Oral Anticoagulant Therapy and Risk of Admission to Long-Term Care in patients With Atrial Fibrillation: A Nationwide Cohort Study. J Am Med Dir Assoc 2023; 24:1484-1489. [PMID: 37348842 DOI: 10.1016/j.jamda.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/14/2023] [Accepted: 05/17/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVES The impact of oral anticoagulants (OACs) on the need of long-term care (LTC) in the aging and multimorbid population of patients with atrial fibrillation (AF) is unknown. We conducted a nationwide cohort study to evaluate the effect of OACs on the need of LTC. DESIGN Retrospective nationwide cohort study. SETTING AND PARTICIPANTS The registry-based FinACAF cohort study covers all patients with incident AF from all levels of care in Finland from 2007 to 2018, as well as all their OAC purchases, LTC admissions, and information on previous home care acuity. METHODS Incidence rate ratios (IRRs) of LTC admission were calculated using Poisson regression models with a Lexis-type data structure based on 3 time scales: follow-up time from AF diagnosis, calendar year, and age. RESULTS We identified 188,752 patients (49.0% female; mean age 71.4 years; mean follow-up 3.6 years) with incident AF without prior LTC, of whom 143,534 (76.0 %) initiated OAC therapy and 11,775 (6.2 %) were admitted to LTC. OAC therapy was associated with lower rates of LTC admission (adjusted IRR 0.79, 95% CI 0.76-0.82). When compared to warfarin, direct oral anticoagulants (DOACs) were associated with lower LTC admission rate (adjusted IRR 0.69, 95% CI 0.61-0.79). No significant disparities were observed between different DOACs. CONCLUSIONS AND IMPLICATIONS OAC therapy, particularly with DOACs, is associated with a substantially lower risk of admission to LTC in patients with AF. Increasing guideline-based OAC coverage among patients with AF may prevent the need of LTC, lengthen survival at home, and potentially decrease health care costs.
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Affiliation(s)
- Konsta Teppo
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland.
| | | | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Miika Linna
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland; University of Eastern Finland, Kuopio, Finland
| | - Jussi Jaakkola
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Jukka Putaala
- Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | - Pirjo Mustonen
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Ville L Langén
- Department of Medicine, Turku University Hospital, Turku, Finland
| | - Janne Kinnunen
- Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | - Juha Hartikainen
- University of Eastern Finland, Kuopio, Finland; Heart Centre, Kuopio University Hospital, Kuopio, Finland
| | - Mika Lehto
- Heart and Lung Centre, Helsinki University Hospital and University of Helsinki, Helsinki, Finland; Department of Internal Medicine, Jorvi Hospital, Helsinki and Uusimaa Hospital District, Espoo, Finland
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Teppo K, Kouki E, Salmela B, Niskanen L, Jaakkola J, Halminen O, Haukka J, Putaala J, Linna M, Mustonen P, Hartikainen J, Juhani Airaksinen KE, Lehto M. Trends and burden of diabetes in patients with atrial fibrillation during 2007-2018: A Finnish nationwide cohort study. Diabetes Res Clin Pract 2023; 203:110875. [PMID: 37582425 DOI: 10.1016/j.diabres.2023.110875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/02/2023] [Accepted: 08/10/2023] [Indexed: 08/17/2023]
Abstract
AIMS We assessed the temporal trends in the prevalence of diabetes and in its associations with outcomes among patients with atrial fibrillation (AF). METHODS The registry-based FinACAF study covered all patients with incident AF in Finland between 2007 and 2018. Ischemic stroke (IS) and mortality rates were computed using Poisson regression model. RESULTS We identified 229565 patients (50.0% female; mean age 72.7 years; mean follow-up 4.0 years) patients with incident AF. The prevalence of diabetes increased steadily from 15.5% in 2007 to 26.3% in 2018. A decrease in IS and mortality rates was observed during the study period both in patients with and without diabetes. Diabetes was associated with IS and mortality (adjusted incidence rate ratios with 95% confidence intervals 1.22 (1.17-1.26) and 1.32 (1.29-1.34), respectively). The impact of diabetes on IS risk remained stable, while its effect on mortality increased slightly during the observation period. CONCLUSIONS The prevalence of diabetes has increased considerably among patients with AF between 2007 and 2018. There have been substantial improvements in the prognosis of AF patients with diabetes. However, diabetes remains a significant risk factor for IS and mortality in this patient population.
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Affiliation(s)
- Konsta Teppo
- Turku University Hospital and University of Turku, Turku, Finland.
| | - Elis Kouki
- University of Helsinki, Helsinki, Finland
| | - Birgitta Salmela
- Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland
| | - Leo Niskanen
- Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland; University of Eastern Finland, Kuopio, Finland
| | - Jussi Jaakkola
- Turku University Hospital and University of Turku, Turku, Finland
| | | | | | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Miika Linna
- Aalto University, Espoo, Finland; University of Eastern Finland, Kuopio, Finland
| | - Pirjo Mustonen
- Turku University Hospital and University of Turku, Turku, Finland
| | | | | | - Mika Lehto
- Jorvi Hospital, Department of Internal Medicine, HUS Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Teppo K, Airaksinen KEJ, Halminen O, Jaakkola J, Linna M, Haukka J, Putaala J, Mustonen P, Kinnunen J, Hartikainen J, Lehto M. Rural-urban and geographical differences in prognosis of atrial fibrillation in Finland: a nationwide cohort study. Scand J Public Health 2023:14034948231189918. [PMID: 37571929 DOI: 10.1177/14034948231189918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023]
Abstract
AIMS Rural-urban disparities have been reported in the outcomes of cardiovascular diseases. We assessed whether rural-urban or other geographical disparities exist in the risk of ischemic stroke (IS) and death in patients with atrial fibrillation (AF) in Finland. METHODS The registry-based FinACAF cohort study covers all patients with AF from all levels of care in Finland from 2007 to 2018. Patients were divided into rural-urban categories and into hospital districts (HDs) based on their municipality of residence. RESULTS We identified 222,051 patients (50.1% female; mean age 72.8 years; mean follow-up 3.9 years) with new-onset AF, of whom 15,567 (7.0%) patients suffered IS and 72,565 (32.7%) died during follow-up. The crude IS rate was similar between rural and urban areas, whereas the mortality rate was lower in urban areas (incidence rate ratios (IRRs) with 95% confidence intervals (CIs) 0.97 (0.93-1.00) and 0.92 (0.91-0.93), respectively). However, after adjustments, urban residence was associated with slightly higher IS and mortality rates (IRRs with 95% CIs 1.05 (1.01-1.08) and 1.06 (1.04-1.07), respectively). The highest crude IS rate was in the East Savo HD and the lowest in Åland, whereas the highest crude mortality rate was in the Länsi-Pohja HD and the lowest in the North Ostrobothnia HD (IRRs with 95% CIs compared to Helsinki and Uusimaa HD for IS 1.46 (1.28-1.67) and 0.79 (0.62-1.01), and mortality 1.24 (1.16-1.32) and 0.97 (0.93-1.00), respectively. CONCLUSIONS Rural-urban differences in prognosis of AF in Finland appear minimal, whereas considerable disparities exist between HDs.
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Affiliation(s)
- Konsta Teppo
- Heart Centre, Turku University Hospital and University of Turku, Finland
| | | | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Jussi Jaakkola
- Heart Centre, Turku University Hospital and University of Turku, Finland
| | - Miika Linna
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
- University of Eastern Finland, Kuopio, Finland
| | | | - Jukka Putaala
- Neurology, Helsinki University Hospital, and University of Helsinki, Finland
| | - Pirjo Mustonen
- Heart Centre, Turku University Hospital and University of Turku, Finland
| | - Janne Kinnunen
- Neurology, Helsinki University Hospital, and University of Helsinki, Finland
| | - Juha Hartikainen
- University of Eastern Finland, Kuopio, Finland
- Heart Centre, Kuopio University Hospital, Kuopio, Finland
| | - Mika Lehto
- Heart and Lung Centre, Helsinki University Hospital and University of Helsinki, Finland
- Jorvi Hospital, Department of Internal Medicine, Helsinki and Uusimaa Hospital District, Espoo, Finland
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11
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Teppo K, Airaksinen KEJ, Biancari F, Jaakkola J, Halminen O, Linna M, Haukka J, Putaala J, Mustonen P, Kinnunen J, Luojus A, Hartikainen J, Aro AL, Lehto M. Aortic Stenosis and Outcomes in Patients With Atrial Fibrillation: A Nationwide Cohort Study. J Am Heart Assoc 2023; 12:e029337. [PMID: 37119067 PMCID: PMC10227229 DOI: 10.1161/jaha.122.029337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/23/2023] [Indexed: 04/30/2023]
Abstract
Background Patients with aortic stenosis (AS) have been underrepresented in the trials evaluating direct oral anticoagulants (DOACs) in atrial fibrillation (AF). We aimed to assess whether AS impacts outcomes in patients with AF and estimate the effects of DOACs versus warfarin in patients with AF and AS. Methods and Results The registry-based FinACAF (Finnish Anticoagulation in Atrial Fibrillation) study covered all patients with AF diagnosed during 2007 to 2018 in Finland. Hazard ratios (HRs) of first-ever gastrointestinal bleeding, intracranial bleeding, any bleeding, ischemic stroke, and death were estimated with cause-specific hazards regression adjusted for anticoagulant exposure variables. We identified 183 946 patients (50.5% women; mean age, 71.7 [SD, 13.5] years) with incident AF without prior bleeding or ischemic stroke, of whom 5231 (2.8%) had AS. The crude incidence rate of all outcomes was higher in patients with AS than in patients without AS. After propensity score matching, AS was associated with the hazard of any bleeding, gastrointestinal bleeding, and death but not with intracranial bleeding or ischemic stroke (adjusted HRs, 1.36 [95% CI, 1.25-1.48], 1.63 [95% CI, 1.43-1.86], 1.32 [95% CI, 1.26-1.38], 0.96 [95% CI, 0.78-1.17], and 1.11 [95% CI, 0.99-1.25], respectively). Among patients with AS, DOACs were associated with a lower risk of ischemic stroke when compared with warfarin, while bleeding and mortality did not differ between DOACs and warfarin. Conclusions AS is associated with substantially higher risk of gastrointestinal bleeding in patients with AF. DOACs may be more effective in preventing ischemic stroke than warfarin in patients with AF and AS. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04645537.
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Affiliation(s)
- Konsta Teppo
- Heart CenterTurku University Hospital and University of TurkuTurkuFinland
| | | | - Fausto Biancari
- Department of Medicine, South‐Karelia Central HospitalUniversity of HelsinkiLappeenrantaFinland
| | - Jussi Jaakkola
- Heart CenterTurku University Hospital and University of TurkuTurkuFinland
| | - Olli Halminen
- Department of Industrial Engineering and ManagementAalto UniversityEspooFinland
| | - Miika Linna
- Department of Industrial Engineering and ManagementAalto UniversityEspooFinland
- Heart CenterKuopio University HospitalKuopioFinland
| | | | - Jukka Putaala
- NeurologyHelsinki University Hospital, and University of HelsinkiHelsinkiFinland
| | - Pirjo Mustonen
- Heart CenterTurku University Hospital and University of TurkuTurkuFinland
| | - Janne Kinnunen
- NeurologyHelsinki University Hospital, and University of HelsinkiHelsinkiFinland
| | | | - Juha Hartikainen
- Heart CenterKuopio University HospitalKuopioFinland
- University of Eastern FinlandKuopioFinland
| | - Aapo L. Aro
- Heart and Lung CenterHelsinki University Hospital, University of HelsinkiHelsinkiFinland
| | - Mika Lehto
- University of HelsinkiHelsinkiFinland
- Heart and Lung CenterHelsinki University Hospital, University of HelsinkiHelsinkiFinland
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12
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Teppo K, Jaakkola J, Biancari F, Halminen O, Linna M, Haukka J, Putaala J, Mustonen P, Kinnunen J, Hartikainen J, Airaksinen KEJ, Lehto M. Association of income and educational levels on initiation of oral anticoagulant therapy in patients with incident atrial fibrillation: A Finnish nationwide cohort study. Br J Clin Pharmacol 2023; 89:351-360. [PMID: 35986926 PMCID: PMC10087474 DOI: 10.1111/bcp.15501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 07/16/2022] [Accepted: 08/08/2022] [Indexed: 12/01/2022] Open
Abstract
AIMS Socioeconomic disparities have been reported in the outcomes of patients with atrial fibrillation (AF). We assessed the hypothesis that AF patients with higher income or educational level are more frequently initiated with oral anticoagulant (OAC) therapy for stroke prevention. METHODS The nationwide registry-based Finnish AntiCoagulation in Atrial Fibrillation cohort covers all patients with AF from all levels of care in Finland. Patients were divided into income quartiles according to their highest annual income during 2004-2018 and into three categories based on educational attainment. The outcome was the first redeemed OAC prescription. RESULTS We identified 239 222 patients (mean age 72.7 ± 13.2 years, 49.8% female) with incident AF during 2007-2018. Higher income was associated with higher OAC initiation rate: compared to the lowest income quartile the adjusted SHRs (95% CI) for OAC initiation were 1.09 (1.07-1.10), 1.13 (1.11-1.14) and 1.13 (1.12-1.15) in the second, third and fourth income quartiles, respectively. Patients in the highest educational category had a slightly lower OAC initiation rate than patients in the lowest educational category (adjusted SHR 0.92 [95% CI 0.90-0.93]). Income-related disparities were larger and education-related disparities only marginal among patients at high risk of ischemic stroke. The socioeconomic disparities in OAC initiation within 1-year follow-up decreased from 2007 to 2018. The adoption of direct OACs as the initial anticoagulant was faster among patients with higher income or educational levels. CONCLUSION These findings highlight potential missed opportunities in stroke prevention, especially among AF patients with low income, whereas the education-related disparities in OAC initiation appear controversial.
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Affiliation(s)
| | - Jussi Jaakkola
- University of Turku, Turku, Finland.,Heart Unit, Satakunta Central Hospital, Pori, Finland
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.,Clinica Montevergine, GVM Care & Research, Mercogliano, Italy
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Miika Linna
- Aalto University, Espoo, Finland.,University of Eastern Finland, Kuopio, Finland
| | - Jari Haukka
- University of Helsinki, Faculty of Medicine, Clinicum, Helsinki, Finland
| | - Jukka Putaala
- Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | | | - Janne Kinnunen
- Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | - Juha Hartikainen
- University of Eastern Finland, Kuopio, Finland.,Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - K E Juhani Airaksinen
- University of Turku, Turku, Finland.,Heart Center, Turku University Hospital, Turku, Finland
| | - Mika Lehto
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland.,University of Helsinki, Faculty of Medicine, Clinicum, Helsinki, Finland.,Department of Internal Medicine, Lohja Hospital, Lohja, Finland
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13
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Teppo K, Jaakkola J, Langén VL, Biancari F, Halminen O, Linna M, Haukka J, Putaala J, Mustonen P, Kinnunen J, Luojus A, Hartikainen J, Airaksinen KEJ, Lehto M. Rural-urban differences in the initiation of oral anticoagulant therapy in patients with incident atrial fibrillation: A Finnish nationwide cohort study. PLoS One 2022; 17:e0276612. [PMID: 36315505 PMCID: PMC9621410 DOI: 10.1371/journal.pone.0276612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 10/10/2022] [Indexed: 01/24/2023] Open
Abstract
AIMS Little is known about rural-urban differences in the treatment and outcomes in patients with atrial fibrillation (AF). We aimed to assess whether the initiation of oral anticoagulant (OAC) therapy in patients with AF differs between those with rural and urban residence. METHODS The registry-based FinACAF cohort covers all patients with AF from all levels of care in Finland. Patients were divided into rural and urban categories and into urbanization degree tertiles based on their municipality of residence at the time of AF diagnosis. The outcome was the first redeemed OAC prescription. RESULTS We identified 222 419 patients (50.1% female; mean age 72.8 (SD 13.2) years) with incident AF during 2007-2018. Urban residence was associated with a lower rate of OAC therapy initiation (adjusted subdistribution hazard ratio (SHR) (95% CI) 0.96 (0.95-0.97)). Correspondingly, an inverse graded dose-response relationship was observed between higher urbanization degree tertile and OAC initiation rate (highest tertile compared to lowest: adjusted SHR (95% CI) 0.94 (0.93-0.95)). The adoption of direct oral anticoagulants for stroke prevention was faster among patients with urban residence. CONCLUSION This nationwide cohort study documented that urban residence is associated with a slightly lower rate of OAC therapy initiation in patients with incident AF, but faster adoption of direct oral anticoagulant use.
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Affiliation(s)
| | - Jussi Jaakkola
- University of Turku, Turku, Finland
- Heart Unit, Satakunta Central Hospital, Pori, Finland
| | - Ville L. Langén
- Division of Medicine, Turku University Hospital, Turku, Finland
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
- Clinica Montevergine, GVM Care & Research, Mercogliano, Italy
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo Finland
| | - Miika Linna
- Aalto University, Espoo, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Jari Haukka
- Faculty of Medicine, Clinicum, University of Helsinki, Helsinki, Finland
| | - Jukka Putaala
- Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Janne Kinnunen
- Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Alex Luojus
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
- Faculty of Medicine, Clinicum, University of Helsinki, Helsinki, Finland
| | - Juha Hartikainen
- University of Eastern Finland, Kuopio, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | | | - Mika Lehto
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
- Faculty of Medicine, Clinicum, University of Helsinki, Helsinki, Finland
- Department of Internal Medicine, Lohja Hospital, Lohja, Finland
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14
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Teppo K, Jaakkola J, Biancari F, Halminen O, Linna M, Putaala J, Mustonen P, Kinnunen J, Jolkkonen S, Niemi M, Hartikainen J, Airaksinen KEJ, Lehto M. Socioeconomic factors and bleeding events in patients with incident atrial fibrillation: A Finnish nationwide cohort study. Int J Cardiol Heart Vasc 2022; 43:101131. [PMID: 36246774 PMCID: PMC9556928 DOI: 10.1016/j.ijcha.2022.101131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/18/2022] [Accepted: 10/04/2022] [Indexed: 11/16/2022]
Abstract
Background Low socioeconomic status has been associated with higher risk of ischemic stroke and death in patients with atrial fibrillation (AF). However, whether socioeconomic status affects risk of bleeding events is unknown. We assessed the hypothesis that low income and educational attainment are associated with higher risk of bleeding in patients with AF. Methods The registry-based FinACAF study covers all patients with AF in Finland during 2007-2018. Patients were divided into income quartiles and three categories based on their educational attainment. Outcomes of interest were the first-ever gastrointestinal (GI), intracranial (IC) and any bleeding. Results We identified 205 019 patients (50.9 % female; mean age 72.3 (SD 13.4) years) with incident AF without prior bleeding. Mean follow-up time was 4.0 (SD 3.2) years, during which 25 013 (12.2 %) patients experienced first-ever any bleeding (incidence rate 3.07 (95 % CI 3.03-3.10) /100 patient-years). Low income was independently associated with hazard of any bleeding as well as GI and IC bleeding (adjusted hazard ratios (HRs) comparing lowest vs highest income quartile: 1.13 (1.08-1.17), 1.32 (1.23-1.41) and 1.15 (1.06-1.24), respectively). Income-related bleeding disparities were larger among younger patients under 65 years and among men. Education-related bleeding disparities were smaller than income related-disparities (adjusted HRs comparing lowest vs highest educational category: any bleeding 1.06 (1.02-1.11), GI bleeding 1.16 (1.08-1.24), IC bleeding 1.10 (0.93-1.09)). Conclusions Patients with AF and low income are at higher risk of bleeding, especially GI bleeding.
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Affiliation(s)
- Konsta Teppo
- University of Turku, Turku, Finland,Corresponding author at: Turun Yliopisto, 20500, Finland.
| | - Jussi Jaakkola
- University of Turku, Turku, Finland,Heart Unit, Satakunta Central Hospital, Pori, Finland
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland,Clinica Montevergine, GVM Care & Research, Mercogliano, Italy
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo Finland
| | - Miika Linna
- Aalto University, Espoo, Finland,University of Eastern Finland, Kuopio, Finland
| | - Jukka Putaala
- Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | | | - Janne Kinnunen
- Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | | | - Mikko Niemi
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
| | - Juha Hartikainen
- University of Eastern Finland, Kuopio, Finland,Heart Center, Kuopio University Hospital, Kuopio, Finland
| | | | - Mika Lehto
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland,University of Helsinki, Faculty of Medicine, Helsinki, Finland,Lohja Hospital, Department of Internal Medicine, Lohja, Finland
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15
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Teppo K, Jaakkola J, Biancari F, Halminen O, Linna M, Haukka J, Putaala J, Mustonen P, Kinnunen J, Luojus A, Itäinen-Strömberg S, Hartikainen J, Aro AL, Airaksinen KEJ, Lehto M. Rural-Urban differences in Use of Rhythm Control Therapies in Patients with Incident Atrial Fibrillation: A Finnish Nationwide Cohort Study. Int J Environ Res Public Health 2022; 19:11191. [PMID: 36141456 PMCID: PMC9517432 DOI: 10.3390/ijerph191811191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 08/30/2022] [Accepted: 09/03/2022] [Indexed: 06/16/2023]
Abstract
Background: Rural-urban disparities have been reported in the access, utilization, and quality of healthcare. We aimed to assess whether use of antiarrhythmic therapies (AATs) in patients with atrial fibrillation (AF) differs between those with rural and urban residence. Methods: The registry-based FinACAF cohort covers all patients with AF from all levels of care in Finland. Patients were divided into rural and urban categories and into urbanization degree tertiles based on their municipality of residence at the time of AF diagnosis. The primary outcome was the use of any AAT, including cardioversion, catheter ablation, and fulfilled antiarrhythmic drug (AAD) prescription. Results: We identified 177,529 patients (49.9% female, mean age 73.0 (SD13.0) years) with incident AF during 2010-2018. Except for AADs, the differences in AAT use were nonsignificant when patients were stratified according to the rural-urban classification system (urban vs. rural adjusted incidence rate ratios (aIRRs) with 95% CIs for any AAT 1.01 (0.99-1.03), AADs 1.11 (1.07-1.15), cardioversion 1.01 (0.98-1.03), catheter ablation 1.05 (0.98-1.12)). However, slightly higher use of all rhythm control modalities was observed in the highest urbanization degree tertile when compared to the lowest tertile (aIRRs with 95% Cis for any AAT 1.06 (1.03-1.08), AADs 1.18 (1.14-1.23), cardioversion 1.05 (1.02-1.08), catheter ablation 1.10 (1.02-1.19)). Conclusions: This nationwide retrospective cohort study observed that urban residence is associated with higher use of AADs in patients with incident AF. Otherwise, the observed disparities were only marginal, suggesting that in the use of rhythm control therapies, no large rural-urban inequity exists in Finland.
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Affiliation(s)
- Konsta Teppo
- Faculty of Medicine, University of Turku, 20500 Turku, Finland
| | - Jussi Jaakkola
- Faculty of Medicine, University of Turku, 20500 Turku, Finland
- Heart Unit, Satakunta Central Hospital, 28500 Pori, Finland
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, 00014 Helsinki, Finland
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, 02150 Espoo, Finland
| | - Miika Linna
- Department of Industrial Engineering and Management, Aalto University, 02150 Espoo, Finland
- University of Eastern Finland, 70211 Kuopio, Finland
| | - Jari Haukka
- University of Helsinki, 00014 Helsinki, Finland
| | - Jukka Putaala
- Neurology, Helsinki University Hospital, University of Helsinki, 00014 Helsinki, Finland
| | - Pirjo Mustonen
- Heart Center, Turku University Hospital, 20014 Turku, Finland
| | - Janne Kinnunen
- Neurology, Helsinki University Hospital, University of Helsinki, 00014 Helsinki, Finland
| | - Alex Luojus
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, 00014 Helsinki, Finland
- University of Helsinki, 00014 Helsinki, Finland
| | - Saga Itäinen-Strömberg
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, 00014 Helsinki, Finland
- University of Helsinki, 00014 Helsinki, Finland
| | - Juha Hartikainen
- University of Eastern Finland, 70211 Kuopio, Finland
- Heart Center, Kuopio University Hospital, 70210 Kuopio, Finland
| | - Aapo L. Aro
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, 00014 Helsinki, Finland
- University of Helsinki, 00014 Helsinki, Finland
| | - K. E. Juhani Airaksinen
- Faculty of Medicine, University of Turku, 20500 Turku, Finland
- Heart Center, Turku University Hospital, 20014 Turku, Finland
| | - Mika Lehto
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, 00014 Helsinki, Finland
- University of Helsinki, 00014 Helsinki, Finland
- Department of Internal Medicine, Lohja Hospital, Lohja, Finland
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16
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Teppo K, Jaakkola J, Biancari F, Halminen O, Linna M, Putaala J, Mustonen P, Kinnunen J, Jolkkonen S, Niemi M, Hartikainen J, Airaksinen KEJ, Lehto M. Mental health conditions and bleeding events in patients with incident atrial fibrillation: A Finnish nationwide cohort study. Gen Hosp Psychiatry 2022; 78:117-122. [PMID: 36057233 DOI: 10.1016/j.genhosppsych.2022.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/23/2022] [Accepted: 08/25/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We assessed the hypothesis that mental health conditions (MHCs) are associated with higher risk of bleeding in patients with atrial fibrillation (AF). METHODS The registry-based FinACAF study covers all patients with AF diagnosed during 2007-2018 in Finland. MHCs of interest were depression, bipolar disorder, anxiety disorder, schizophrenia, and any MHC. The outcomes were first-ever gastrointestinal, intracranial, and any bleeding event. RESULTS We identified 205,019 patients (50.9% female; mean age 72.3 [standard deviation 13.4] years) with incident AF without prior bleeding, and the prevalence of any MHC was 6.1%. Any MHC, depression, and anxiety disorder were associated with the risk of any bleeding (adjusted hazard ratios (HRs) 1.19 [1.12-1.27], 1.21 [1.13-1.30], and 1.21 [1.08-1.35], respectively). Additionally, any MHC and depression were associated with the risk of gastrointestinal and intracranial bleeding and anxiety disorder with gastrointestinal bleeding. Bipolar disorder and schizophrenia were not associated with risk of bleeding. Use of oral anticoagulants was associated with the risk of any bleeding (adjusted HR 1.24 [95% CI 1.21-1.28)]), and this association was similar in patients with and without MHCs. Serotonin reuptake inhibitors were not associated with bleeding risk. CONCLUSIONS MHCs are associated with a higher risk of bleeding in patients with AF.
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Affiliation(s)
| | - Jussi Jaakkola
- University of Turku, Turku, Finland; Heart Unit, Satakunta Central Hospital, Pori, Finland
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland; Clinica Montevergine, GVM Care & Research, Mercogliano, Italy
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Miika Linna
- Aalto University, Espoo, Finland; University of Eastern Finland, Kuopio, Finland
| | - Jukka Putaala
- Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | | | - Janne Kinnunen
- Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | | | - Mikko Niemi
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
| | - Juha Hartikainen
- University of Eastern Finland, Kuopio, Finland; Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - K E Juhani Airaksinen
- University of Turku, Turku, Finland; Heart Center, Turku University Hospital, Turku, Finland
| | - Mika Lehto
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland; University of Helsinki, Faculty of Medicine, Helsinki, Finland; Lohja Hospital, Department of Internal Medicine, Lohja, Finland
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17
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Teppo K, Jaakkola J, Biancari F, Halminen O, Putaala J, Mustonen P, Haukka J, Linna M, Kinnunen J, Tiili P, Kouki E, Penttilä T, Hartikainen J, Aro AL, Airaksinen KEJ, Lehto M. Mental health conditions and risk of first-ever ischaemic stroke and death in patients with incident atrial fibrillation: A nationwide cohort study. Eur J Clin Invest 2022; 52:e13801. [PMID: 35484936 PMCID: PMC9539593 DOI: 10.1111/eci.13801] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/22/2022] [Accepted: 04/27/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) patients with mental health conditions (MHCs) have higher incidence of ischaemic stroke (IS) than patients without MHC, but whether this results from direct impact of MHCs or relates to higher prevalence of comorbidities and differences in the use of oral anticoagulant (OAC) therapy is unclear. We assessed the hypothesis that MHCs independently increase the risk of IS in patients with incident AF. METHODS The nationwide FinACAF cohort covered all 203,154 patients diagnosed with incident AF without previous IS or transient ischaemic attack in Finland during 2007-2018. MHCs of interest were depression, bipolar disorder, anxiety disorder, schizophrenia and any MHC. The outcomes were first-ever IS and all-cause death. RESULTS The patients' (mean age 73.0 ± 13.5 years, 49.0% female) mean follow-up time was 4.3 (SD 3.3) years and 16,272 (8.0%) experienced first-ever IS and 63,420 (31.2%) died during follow-up. After propensity score matching and adjusting for OAC use, no MHC group was associated with increased IS risk (adjusted SHRs (95% CI): depression 0.961 (0.857-1.077), bipolar disorder 1.398 (0.947-2.006), anxiety disorder 0.878 (0.718-1.034), schizophrenia 0.803 (0.594-1.085) and any MHC 1.033 (0.985-1.085)). Lower rate of OAC use partly explained the observed higher crude IS incidence in patients with any MHC. Depression, schizophrenia and any MHC were associated with higher all-cause mortality (adjusted HRs [95% CI]: 1.208 [1.136-1.283], 1.543 [1.352-1.761] and 1.149 [1.116-1.175], respectively). CONCLUSIONS In this nationwide retrospective cohort study, MHCs were not associated with the incidence of first-ever IS in patients with AF.
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Affiliation(s)
| | - Jussi Jaakkola
- University of Turku, Turku, Finland.,Heart Unit, Satakunta Central Hospital, Pori, Finland
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.,Clinica Montevergine, GVM Care & Research, Mercogliano, Italy
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Jukka Putaala
- Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | | | | | - Miika Linna
- Aalto University, Espoo, Finland.,University of Eastern Finland, Kuopio, Finland
| | - Janne Kinnunen
- Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | | | - Elis Kouki
- University of Helsinki, Helsinki, Finland
| | - Tero Penttilä
- Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - Juha Hartikainen
- University of Eastern Finland, Kuopio, Finland.,Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Aapo L Aro
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.,University of Helsinki, Helsinki, Finland
| | - K E Juhani Airaksinen
- University of Turku, Turku, Finland.,Heart Center, Turku University Hospital, Turku, Finland
| | - Mika Lehto
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.,University of Helsinki, Helsinki, Finland.,Lohja Hospital, Department of Internal Medicine, Lohja, Finland
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18
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Teppo K, Jaakkola J, Biancari F, Halminen O, Putaala J, Mustonen P, Haukka J, Linna M, Kinnunen J, Luojus A, Itäinen-Strömberg S, Penttilä T, Niemi M, Hartikainen J, Airaksinen KJ, Lehto M. Mental health conditions and use of rhythm control therapies in patients with atrial fibrillation: a nationwide cohort study. BMJ Open 2022; 12:e059759. [PMID: 36041755 PMCID: PMC9438075 DOI: 10.1136/bmjopen-2021-059759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES Mental health conditions (MHCs) have been associated with undertreatment of unrelated medical conditions, but whether patients with MHCs face disparities in receiving rhythm control therapies for atrial fibrillation (AF) is currently unknown. We assessed the hypothesis that MHCs are associated with a lower use of antiarrhythmic therapies (AATs). DESIGN A nationwide retrospective registry-based cohort study. SETTING The Finnish AntiCoagulation in Atrial Fibrillation cohort included records on all patients with AF in Finland during 2007-2018 identified from nationwide registries covering all levels of care as well as drug purchases. MHCs of interest were diagnosed depression, bipolar disorder, anxiety disorder, schizophrenia and any MHC. PARTICIPANTS We identified 239 222 patients (mean age 72.6±13.2 years; 49.8% women) with incident AF, in whom the prevalence of any MHC was 19.9%. OUTCOMES Primary outcome was use of any AAT, including cardioversion, catheter ablation, and fulfilled antiarrhythmic drug (AAD) prescription. RESULTS Lower overall use of any AAT emerged in patients with any MHC than in those without MHC (16.9% vs 22.9%, p<0.001). Any MHC, depression, bipolar disorder, anxiety disorder and schizophrenia were all associated with lower incidence of any AAT with adjusted subdistribution HRs of 0.790 (95% CI 0.771 to 0.809), 0.817 (0.796 to 0.838), 0.811 (0.789 to 0.835), 0.807 (0.785 to 0.830) and 0.795 (0.773 to 0.818), respectively. Adjusted rates of AAD, cardioversion and catheter ablation use were lower in all MHC groups compared with patients without MHC. The findings in patients with any MHC were confirmed in propensity score matching analysis. CONCLUSIONS Among patients with AF, a clear disparity exists in AAT use between those with and without MHCs. TRIAL REGISTRATION NUMBER ClinicalTrials Identifier: NCT04645537; ENCePP Identifier: EUPAS29845.
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Affiliation(s)
| | - Jussi Jaakkola
- University of Turku, Turku, Finland
- Satakunta Central Hospital, Pori, Finland
| | - Fausto Biancari
- Helsingin seudun yliopistollinen keskussairaala Sydän- ja keuhkokeskus, Helsinki, Finland
- Clinica Montevergine, GVM Care & Research, Mercogliano, Italy
| | | | - Jukka Putaala
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Pirjo Mustonen
- Heart Center, TYKS Turun yliopistollinen keskussairaala, Turku, Finland
| | | | | | - Janne Kinnunen
- Department of Neurology, University of Helsinki, Helsinki, Finland
| | | | | | | | - Mikko Niemi
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland
- Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland
| | - Juha Hartikainen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | | | - Mika Lehto
- Helsinki University Hospital Heart and Lung Center, Helsinki, Finland
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19
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Biancari F, Teppo K, Jaakkola J, Halminen O, Linna M, Haukka J, Putaala J, Mustonen P, Kinnunen J, Hartikainen J, Aro A, Airaksinen J, Lehto M. Income and outcomes of patients with incident atrial fibrillation. J Epidemiol Community Health 2022; 76:jech-2022-219190. [PMID: 35705362 PMCID: PMC9279743 DOI: 10.1136/jech-2022-219190] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/05/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Socioeconomic disparities can be associated with adverse outcomes in patients with cardiovascular diseases. The impact of personal income on the outcomes of patients with atrial fibrillation (AF) is unclear. METHODS Nationwide observational registry-based study on patients with incident AF in Finland during 2007-2018. RESULTS 203 154 patients (mean age 73.0±13.5; females 49.0%) were diagnosed with incident AF during the study period. Overall, 16 272 (8.0%) patients experienced first-ever ischaemic stroke and 63 420 (31.2%) died (mean follow-up 4.3±3.3 years). After adjusting for confounding factors, low personal income was associated with increased risk of overall mortality in all age strata and the incidence of first-ever stroke in patients aged <65 years and 65-74 years, but not in those ≥75 years. The magnitude of this effect was greatest in patients aged <65 years. After propensity score matching of patients <65 years in the lowest and highest quintiles of maximum personal annual income, at 10 years, those in the highest income quintile (≥€54 000) had significantly lower risk of first-ever stroke (subdistribution HR 0.495, 95% CI 0.391 to 0.628) and overall mortality (HR 0.307, 95% CI 0.269 to 0.351) compared with patients in the lowest income quintile (≤€12 000). CONCLUSIONS Personal annual income has a significant impact on the incidence of first-ever ischaemic stroke and overall mortality among patients with incident AF, particularly among patients of working age. Low-income indicate the need for intervention strategies to improve outcomes of AF. TRIAL REGISTRATION NUMBER NCT04645537.
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Affiliation(s)
- Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
- Clinica Montevergine, GVM Care & Research, Mercogliano, Italy
| | - Konsta Teppo
- Heart Center, University of Turku, Turku University Hospital, Turku, Finland
| | - Jussi Jaakkola
- Heart Center, University of Turku, Turku University Hospital, Turku, Finland
- Heart Unit, Satakunta Central Hospital, Pori, Finland
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Miika Linna
- University of Eastern Finland, Kuopio, Finland
- Aalto University, Espoo, Finland
| | - Jari Haukka
- Public Health, University of Helsinki, Helsinki, Finland
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Pirjo Mustonen
- Heart Center, University of Turku, Turku University Hospital, Turku, Finland
| | - Janne Kinnunen
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Juha Hartikainen
- Heart Center, Kuopio University Hospital, University of Eastern Finland, Kuopio, Finland
| | - Aapo Aro
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Juhani Airaksinen
- Heart Center, University of Turku, Turku University Hospital, Turku, Finland
| | - Mika Lehto
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
- Department of Internal Medicine, Lohja Hospital, Lohja, Finland
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20
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Teppo K, Jaakkola J, Biancari F, Halminen O, Linna M, Haukka J, Putaala J, Tiili P, Lehtonen O, Niemi M, Mustonen P, Kinnunen J, Hartikainen J, Airaksinen KEJ, Lehto M. Association of income and educational levels with adherence to direct oral anticoagulant therapy in patients with incident atrial fibrillation: A Finnish nationwide cohort study. Pharmacol Res Perspect 2022; 10:e00961. [PMID: 35599338 PMCID: PMC9124817 DOI: 10.1002/prp2.961] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/17/2022] [Indexed: 11/09/2022] Open
Abstract
Low socioeconomic status has been associated with poor outcomes in patients with atrial fibrillation (AF). However, little is known about socioeconomic disparities in adherence to stroke prevention with direct oral anticoagulants (DOACs). We assessed the hypothesis that AF patients with higher income or educational levels have better adherence to DOACs in terms of treatment implementation and persistence. The used nationwide registry‐based FinACAF cohort covers all patients with incident AF starting DOACs in Finland during 2011–2018. The implementation analyses included 74 222 (mean age 72.7 ± 10.5 years, 50.8% female) patients, and persistence analyses included 67 503 (mean age 75.3 ± 8.9 years, 53.6% female) patients with indication for permanent anticoagulation (CHA2DS2‐VASc score >1 in men and >2 in women). Patients were divided into income quartiles and into three categories based on their educational attainment. Therapy implementation was measured using the medication possession ratio (MPR), and patients with MPR ≥0.90 were defined adherent. Persistence was measured as the incidence of therapy discontinuation, defined as the first 135‐day period without DOAC purchases after drug initiation. Patients with higher income or education were consistently more likely adherent to DOACs in the implementation phase (comparing the highest income or educational category to the lowest: adjusted odds ratios 1.18 (1.12–1.25) and 1.21 (1.15–1.27), respectively). No association with income or educational levels was observed on the incidence of therapy discontinuation. In conclusion, we observed that income and educational levels both have independent positive association on the implementation of DOAC therapy but no association on therapy persistence in patients with AF.
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Affiliation(s)
| | - Jussi Jaakkola
- University of Turku, Turku, Finland.,Heart Unit, Satakunta Central Hospital, Pori, Finland
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.,Clinica Montevergine, GVM Care & Research, Mercogliano, Italy
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Miika Linna
- Aalto University, Espoo, Finland.,University of Eastern Finland, Kuopio, Finland
| | | | - Jukka Putaala
- Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | | | | | | | | | - Janne Kinnunen
- Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | - Juha Hartikainen
- University of Eastern Finland, Kuopio, Finland.,Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - K E Juhani Airaksinen
- University of Turku, Turku, Finland.,Heart Center, Turku University Hospital, Turku, Finland
| | - Mika Lehto
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.,University of Helsinki, Helsinki, Finland.,Department of Internal Medicine, Lohja Hospital, Lohja, Finland
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21
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Teppo K, Jaakkola J, Airaksinen KEJ, Biancari F, Halminen O, Putaala J, Mustonen P, Haukka J, Hartikainen J, Luojus A, Niemi M, Linna M, Lehto M. Mental Health Conditions and Nonpersistence of Direct Oral Anticoagulant Use in Patients With Incident Atrial Fibrillation: A Nationwide Cohort Study. J Am Heart Assoc 2022; 11:e024119. [PMID: 35229612 PMCID: PMC9075274 DOI: 10.1161/jaha.121.024119] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Mental health conditions (MHCs) are associated with poor outcomes in patients with atrial fibrillation. However, persistence of oral anticoagulation therapy in patients with atrial fibrillation and MHCs is unknown. We aimed to evaluate the effect of MHCs on the persistence of direct oral anticoagulant (DOAC) use in patients with atrial fibrillation based on a nationwide cohort. Methods and Results The nationwide registry‐based FinACAF (Finnish Anticoagulation in Atrial Fibrillation) cohort included 67 503 patients with incident atrial fibrillation and indication for permanent oral anticoagulation (CHA2DS2‐VASc score >1 in men and >2 in women) starting DOAC therapy between 2011 and 2018. MHCs of interest were depression, bipolar disorder, anxiety disorder, schizophrenia, and composite of any MHC. The main outcome was nonpersistence of DOAC use, defined as the first 120‐day period without DOAC purchases after drug initiation. The mean age of the patients was 75.3±8.9 years, 53.6% were women, and the prevalence of any MHC was 17.8%. Persistence after 1 year from DOAC initiation was 79.3% in patients without MHCs and 77.2% in patients with any MHC, and after 2 years were 64.4% and 60.6%, respectively (P<0.001). Higher incidence of nonpersistence to DOACs was observed in all MHC categories: adjusted subdistribution hazard ratios, 1.16 (95% CI, 1.11–1.21) for any MHC, 1.32 (95% CI, 1.22–1.42) for depression, 1.44 (95% CI, 1.15–1.80) for bipolar disorder, 1.25 (95% CI, 1.11–1.41) for anxiety disorder, and 1.30 (95% CI, 1.02–1.64) for schizophrenia. However, patients with only anxiety disorder without other MHCs were not at higher risk of nonpersistence. Conclusions MHCs are associated with nonpersistence of DOAC use. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04645537.
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Affiliation(s)
- Konsta Teppo
- Faculty of Medicine University of Turku Turku Finland
| | - Jussi Jaakkola
- Faculty of Medicine University of Turku Turku Finland.,Heart Center Turku University Hospital Turku Finland.,Heart Unit Satakunta Central Hospital Pori Finland
| | - K E Juhani Airaksinen
- Faculty of Medicine University of Turku Turku Finland.,Heart Center Turku University Hospital Turku Finland
| | - Fausto Biancari
- Clinica Montevergine Gruppo Villa Maria Care & Research Mercogliano Italy.,Heart and Lung Center Helsinki University Hospital Helsinki Finland
| | - Olli Halminen
- Department of Industrial Engineering and Management Aalto University Espoo Finland
| | - Jukka Putaala
- Department of Neurology Helsinki University Hospital Helsinki Finland.,Department of Neurology University of Helsinki Helsinki Finland
| | - Pirjo Mustonen
- Faculty of Medicine University of Turku Turku Finland.,Heart Center Turku University Hospital Turku Finland
| | - Jari Haukka
- Faculty of Medicine University of Helsinki Finland
| | - Juha Hartikainen
- Faculty of Medicine University of Eastern Finland Kuopio Finland.,Heart Center Kuopio University Hospital Kuopio Finland
| | - Alex Luojus
- Heart and Lung Center Helsinki University Hospital Helsinki Finland.,Faculty of Medicine University of Helsinki Finland
| | - Mikko Niemi
- Department of Clinical Pharmacology University of Helsinki Finland.,Individualized Drug Therapy Research Program University of Helsinki Finland.,Department of Clinical Pharmacology Diagnostic CenterHelsinki University Hospital Helsinki Finland
| | - Miika Linna
- Department of Industrial Engineering and Management Aalto University Espoo Finland
| | - Mika Lehto
- Heart and Lung Center Helsinki University Hospital Helsinki Finland.,Faculty of Medicine University of Helsinki Finland.,Department of Internal Medicine Lohja Hospital Lohja Finland
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22
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Teppo K, Jaakkola J, Airaksinen KEJ, Biancari F, Halminen O, Putaala J, Mustonen P, Haukka J, Hartikainen J, Luojus A, Niemi M, Linna M, Lehto M. Mental health conditions and adherence to direct oral anticoagulants in patients with incident atrial fibrillation: A nationwide cohort study. Gen Hosp Psychiatry 2022; 74:88-93. [PMID: 34999528 DOI: 10.1016/j.genhosppsych.2021.12.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/18/2021] [Accepted: 12/29/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Medication adherence is essential for effective stroke prevention in patients with atrial fibrillation (AF). We aimed to assess whether adherence to direct oral anticoagulants (DOACs) in AF patients is affected by the presence of mental health conditions (MHCs). METHODS The nationwide FinACAF cohort covered 74,222 AF patients from all levels of care receiving DOACs during 2011-2018 in Finland. Medication possession ratio (MPR) was used to quantify adherence. Patients with MPR ≥0.90 were defined adherent. MHCs of interest were depression, bipolar disorder, anxiety disorder and schizophrenia. RESULTS The patients' (mean age 75.4 ± 9.5 years, 50.8% female) mean MPR was 0.84 (SD 0.22), and 59.5% had MPR ≥0.90. Compared to patients without MHC, the adjusted ORs (95% CI) for adherent DOAC use emerged slightly lower in patients with depression (0.92 (0.84-0.99)) and bipolar disorder (0.77 (0.61-0.97)) and unsignificant in patients with anxiety disorder (1.08 (0.96-1.21)) and schizophrenia (1.13 (0.90-1.43)). However, when only persistent DOAC therapy was analyzed, no MHC was associated with poor adherence, and instead anxiety disorder was associated with adherent DOAC use (1.18 (1.04-1.34)). CONCLUSION Adherence to DOACs in AF patients in Finland was relatively high, and no meaningful differences between patients with and without MHCs were observed.
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Affiliation(s)
| | - Jussi Jaakkola
- University of Turku, Turku, Finland; Heart Center, Turku University Hospital, Turku, Finland; Heart Unit, Satakunta Central Hospital, Pori, Finland
| | - K E Juhani Airaksinen
- University of Turku, Turku, Finland; Heart Center, Turku University Hospital, Turku, Finland
| | - Fausto Biancari
- Clinica Montevergine, GVM Care & Research, Mercogliano, Italy; Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | | | - Jukka Putaala
- Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Pirjo Mustonen
- University of Turku, Turku, Finland; Heart Center, Turku University Hospital, Turku, Finland
| | | | - Juha Hartikainen
- University of Eastern Finland, Kuopio, Finland; Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Alex Luojus
- University of Helsinki, Helsinki, Finland; Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Mikko Niemi
- Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland; Individualized Drug Therapy Research Program, University of Helsinki, Helsinki, Finland; Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - Miika Linna
- Aalto University, Espoo, Finland; University of Eastern Finland, Kuopio, Finland
| | - Mika Lehto
- University of Helsinki, Helsinki, Finland; Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland; Lohja Hospital, Department of Internal Medicine, Lohja, Finland
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23
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Jaakkola J, Teppo K, Airaksinen J, Biancari F, Putaala J, Halminen O, Haukka J, Hartikainen J, Kinnunen J, Tiili P, Linna M, Mustonen P, Lehto M. Abstract 10464: Mental Health Conditions Are Associated with Underuse of Oral Anticoagulation Therapy in Patients with Atrial Fibrillation: The FinACAF Study. Circulation 2021. [DOI: 10.1161/circ.144.suppl_1.10464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Little is known about the effects of mental health conditions (MHC) on the utilization of oral anticoagulant (OAC) therapy in patients with atrial fibrillation (AF). We assessed the hypothesis that MHCs are associated with a lower rate of OAC initiation in patients with incident AF.
Methods:
The FinACAF registry included all 239 756 patients with incident AF during 2007-2018 in Finland identified from national registries covering all levels of care as well as their drug purchases. The main exposure was any MHC (previous diagnosis of depression, bipolar disorder, anxiety disorder or schizophrenia or fulfilled prescription of psychiatric medication within preceding year from first AF diagnosis) and the outcome OAC initiation (first fulfilled OAC prescription after AF diagnosis).
Results:
The patients’ mean age was 72.6 years (SD 13.2), 49.7% were female and 95.0% had CHA
2
DS
2
-VASc score ≥1. The prevalence of any MHC was 19.9%. A lower rate of OAC initiation was observed in patients with any MCH than in those without MHC (64.9% vs. 73.1%, p<0.001) during the entire follow-up. Any MHC was associated with lower cumulative incidence of OAC initiation (adjusted subdistribution hazard ratio (aSHR) 0.783; 95% CI 0.774-0.794, Figure) during the entire follow-up, as were depression (aSHR 0.833; 95% CI 0.813-0.852), bipolar disorder (aSHR 0.807; 95% CI 0.778-0.838), anxiety disorder (aSHR 0.816; 95% CI 0.758-0.878) and schizophrenia (aSHR 0.743; 95% CI 0.698-0.792) individually. By 2018, 89.9% of OAC initiations were with a non-vitamin K antagonist oral anticoagulant (NOAC) in patients with any MHC and 92.4% in patients with no MHC. Any MHC remained associated with impaired cumulative incidence of OAC initiation also in the NOAC-era during 2015-2018 (aSHR 0.821; 95% CI 0.805-0.837).
Conclusions:
MHCs are common among AF patients, and they are associated with a lower rate of OAC initiation even during the NOAC-era.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Miika Linna
- Aalto Univ and Univ of Eastern Finland, Helsinki, Finland
| | | | - Mika Lehto
- Helsinki Univ Hosp and Lohja Univ Hosp, Helsinki, Finland
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24
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Jaakkola J, Teppo K, Biancari F, Halminen O, Putaala J, Mustonen P, Haukka J, Linna M, Kinnunen J, Tiili P, Aro AL, Hartikainen J, Airaksinen KEJ, Lehto M. The effect of mental health conditions on the use of oral anticoagulation therapy in patients with atrial fibrillation: The FinACAF Study. Eur Heart J Qual Care Clin Outcomes 2021; 8:269-276. [PMID: 34677571 PMCID: PMC9071518 DOI: 10.1093/ehjqcco/qcab077] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/14/2021] [Accepted: 10/19/2021] [Indexed: 12/13/2022]
Abstract
Aims Little is known about the effects of mental health conditions (MHCs) on the utilization of oral anticoagulation (OAC) therapy in atrial fibrillation (AF) patients. We aimed to assess whether MHCs affect initiation of OAC therapy among AF patients with special focus on non-vitamin K antagonist oral anticoagulants (NOACs). Methods and results The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) registry included all 239 222 patients diagnosed with incident AF during 2007–18 in Finland identified from national registries covering primary to tertiary care and drug purchases. Patients with previous depression, bipolar disorder, anxiety disorder, or schizophrenia diagnosis or a fulfilled psychiatric medication prescription within the year preceding the AF diagnosis were classified to have any MHC. The main outcome was OAC initiation, defined as first fulfilled OAC prescription after AF diagnosis. The patients’ mean age was 72.7 years and 49.8% were female. The prevalence of any MHC was 19.9%. A lower proportion of patients with any MHC compared with those without MHCs were initiated on OAC therapy (64.9% vs. 73.3%, P < 0.001). Any MHC was associated with lower incidence of OAC initiation [adjusted subdistribution hazard ratio (aSHR) 0.867; 95% confidence interval (CI) 0.856–0.880], as were depression (aSHR 0.868; 95% CI 0.856–0.880), bipolar disorder (aSHR 0.838; 95% CI 0.824–0.852), anxiety disorder (aSHR 0.840; 95% CI 0.827–0.854), and schizophrenia (aSHR 0.838; 95% CI 0.824–0.851), during the entire follow-up. Any MHC remained associated with impaired incidence of OAC initiation also in the NOAC era during 2015–18 (aSHR 0.821; 95% CI 0.805–0.837). Conclusion MHCs are common among AF patients, and they are associated with a lower rate of OAC initiation even during the NOAC era.
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Affiliation(s)
- Jussi Jaakkola
- Heart Center, Turku University Hospital, and University of Turku, Hämeentie 11, Turku, Finland.,Heart Unit, Satakunta Central Hospital, Sairaalantie 3, Pori, Finland
| | - Konsta Teppo
- Heart Center, Turku University Hospital, and University of Turku, Hämeentie 11, Turku, Finland
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Haartmaninkatu 4, Helsinki, Finland.,University of Helsinki, Yliopistonkatu 4, Helsinki, Finland.,Research Unit of Surgery, Anesthesia and Critical Care, University of Oulu, Kajaanintie 50, Oulu, Finland.,Clinica Montevergine, GVM Care & Research, Via Mario Malzoni 5, Mercogliano, Italy
| | - Olli Halminen
- Clinica Montevergine, GVM Care & Research, Via Mario Malzoni 5, Mercogliano, Italy
| | - Jukka Putaala
- Neurology, Helsinki University Hospital, and University of Helsinki, Haartmaninkatu 4, Helsinki, Finland
| | - Pirjo Mustonen
- Heart Center, Turku University Hospital, and University of Turku, Hämeentie 11, Turku, Finland
| | - Jari Haukka
- University of Helsinki, Yliopistonkatu 4, Helsinki, Finland
| | - Miika Linna
- Clinica Montevergine, GVM Care & Research, Via Mario Malzoni 5, Mercogliano, Italy.,University of Eastern Finland, Yliopistonranta 1, Kuopio, Finland
| | - Janne Kinnunen
- Neurology, Helsinki University Hospital, and University of Helsinki, Haartmaninkatu 4, Helsinki, Finland
| | - Paula Tiili
- University of Helsinki, Yliopistonkatu 4, Helsinki, Finland
| | - Aapo L Aro
- Heart and Lung Center, Helsinki University Hospital, Haartmaninkatu 4, Helsinki, Finland.,University of Helsinki, Yliopistonkatu 4, Helsinki, Finland
| | - Juha Hartikainen
- Heart Center, Kuopio University Hospital, Puijonlaaksontie 2, Kuopio, Finland
| | - K E Juhani Airaksinen
- Heart Center, Turku University Hospital, and University of Turku, Hämeentie 11, Turku, Finland
| | - Mika Lehto
- Heart and Lung Center, Helsinki University Hospital, Haartmaninkatu 4, Helsinki, Finland.,University of Helsinki, Yliopistonkatu 4, Helsinki, Finland.,Lohja Hospital, Department of Internal Medicine, Sairaalatie 8, Lohja, Finland
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