Response by Fauchier et al to Letter Regarding Article, "Incidence, Prevalence, and Trends in Mortality and Stroke Among Medicare Beneficiaries With Atrial Fibrillation: 2013 to 2019".

Atrial fibrillation (AF) is known to be associated with increased risks of stroke and death, but contemporary studies of this association are lacking. We evaluated trends in stroke and death among Medicare beneficiaries with AF between 2013 and 2019. Medicare fee-for-service beneficiaries >65 years old (2011-2019) were included. AF incidence and prevalence were calculated overall and by age group, sex, race, and rurality. Within incident cohorts, the 1-year stroke rate was assessed. Age- and sex-adjusted mortality at 30 days, 1 year, and 3 years was calculated in each incident cohort. The mean number of Medicare beneficiaries with incident AF per year was 572 630 from 2013 to 2019 (30.44 per 1000 patient-years). The study cohort on average was 79±7.7 years old, 52% female, 88% white, and 83% urban dwelling. Incidence and prevalence of AF increased with age and was highest among White beneficiaries; the incidence was greater in male compared with female beneficiaries. Differences by rurality were not seen. Overall AF prevalence per 1000 beneficiaries increased minimally but steadily from 2013 to 2019 reflecting an increase among male (104-109 per 1000) but not female beneficiaries (82.5 per 1000). The 1-year rate of stroke after incident AF peaked in the 2015 cohort (50.5 per 1000); the rate was at its lowest among the 2018 cohort (41.89 per 1000). Incident AF was associated with mortality that was 3.2× greater than expected at 1 year, but overall mortality and the magnitude of the AF-related mortality risk decreased steadily over time from 22% to 20%. From 2013 to 2019, AF incidence and prevalence among Medicare beneficiaries were relatively stable but have varied by important demographic subgroups with age and sex remaining powerful risk factors. In contrast, mortality and stroke after incident AF have decreased significantly throughout this era.

Stroke risk in AF: do AF patterns matter?

AHA 2012: Prevention a key focus of meeting

Letter by Fauchier et al Regarding Article, "Incidence, Prevalence and Trends in Mortality and Stroke Among Medicare Beneficiaries With Atrial Fibrillation: 2013 to 2019".

The trends in stroke incidence reported so far have not been entirely consistent, although declining trends in mortality from stroke have been reported from a number of studies around the world. This study aims to evaluate the 10-year trends (from 1983 through 1992) in incidence, attack rate, and mortality of stroke in the Finnish population. A population-based stroke register was set up in the early 1980s to collect data on all suspected events of acute stroke that occurred in the population aged 25 to 74 years permanently residing in three geographic areas of Finland: the provinces of Kuopio and North Karelia in eastern Finland and the Turku-Loimaa area in southwestern Finland. Trends in age-standardized attack rates, incidence, and mortality were calculated for the period studied. During the 10-year study period, 11 392 acute stroke events occurred in the monitored populations. A statistically significant decline was observed in the pooled FINMONICA data, both in the incidence of stroke (-1.7% with 95% confidence interval [CI], -3.0% to -0.5% per year in men; -2.2% with 95% CI, -3.6% to -0.7% per year in women) and in mortality from stroke (-5.2% with 95% CI, -8.2% to -2.2% per year; -4.7% with 95% CI, -8.2% to -1.2% per year). The attack rate of stroke also declined significantly in both sexes. When the areas were considered separately, the declining trends were observed within each area. The decline in incidence of stroke was, however, statistically significant only among men and women in Kuopio and among women in Turku/Loimaa. Mortality declined significantly in all three areas among men but among women only in Kuopio. The incidence to mortality rate ratio increased during the study period, indicating a steeper fall in mortality than in incidence. A substantial decline in both stroke incidence and mortality was observed in the adult and elderly population in the FINMONICA study areas. Part but not all of the decline in stroke mortality, observed also in the official mortality statistics, can be attributed to the decline in stroke incidence during this 10-year period.

Background: Atrial fibrillation (AF) increases the risks of stroke. Previous studies revealed patients with paroxysmal AF (PAF) have a risk of stroke similar to that in patients with sustained (persistent or permanent) AF (SAF). Methods: The Fushimi AF Registry, a community-based prospective survey, was designed to enroll all of the AF patients in Fushimi-ku, Kyoto, Japan. At present, we have enrolled 3,985 patients from March 2011 to April 2014. One-year follow-up was completed in 3,189 patients as of April 2014. We compared the baseline clinical characteristics and one-year outcome between PAF (n=1,534, 48.1%) and SAF (n=1,655, 51.9%). Results: Patients with PAF were younger (PAF vs. SAF: 72.3±11.7 vs. 74.9±9.9 years; p<0.01), less likely to have a history of stroke (15.0% vs. 22.1%; p<0.01), heart failure (17.3% vs. 34.9%; p<0.01), and had lower CHADS2 score (1.82±1.29 vs. 2.22±1.35; p<0.01). During the one-year follow-up period, there was no significant difference in all-cause death (116 (7.6%) vs. 137 (8.3%); p=0.45) or major bleeding (25 (1.6%) vs. 29 (1.8%); p=0.78) between PAF and SAF. In patients with PAF, incidence of stroke or systemic embolism (SE) was less (29 (1.9%) vs. 52 (3.1%); p=0.02) and so was the hospitalization for heart failure (43 (2.8%) vs. 83 (5.0%); p<0.01). In subgroup of patients with CHADS2 score ≥2, there was no significant difference in the incidence of stroke or SE between PAF and SAF (p=0.58) (figure B). In contrast, PAF was associated with lower incidence of stroke or SE in patients with CHADS2 score 0 or 1 (p=0.02) (figure A). After the adjustment by gender and established risk factors (components of CHADS2 score) in multiple logistic regression models, PAF was independently associated with lower incidence of stroke or SE in CHADS2 score 0 or 1 (adjusted odds ratio, 0.22; 95% confidence interval, 0.05 to 0.72; p=0.01). Conclusion: PAF was independently associated with lower incidence of stroke or SE in low risk patients with CHADS2 score 0 or 1.

Studies have revealed a higher incidence of atrial fibrillation among well-trained athletes. We aim to investigate associations of endurance training with incidence of atrial fibrillation and stroke and to establish potential sex differences of such associations in a cohort of endurance trained athletes. All Swedish skiers (208 654) completing 1 or more races in the 30 to 90 km cross-country skiing event Vasaloppet (1989-2011) and a matched sample (n=527 448) of nonskiers were followed until first event of atrial fibrillation or stroke. Cox regression was used to investigate associations of number of completed races and finishing time with incidence of atrial fibrillation and stroke. Female skiers in Vasaloppet had a lower incidence of atrial fibrillation than did female nonskiers (hazard ratio [HR], 0.55; 95% CI, 0.48-0.64), independent of finishing time and number of races. Male skiers had a similar incidence to that of nonskiers (HR, 0.98; 95% CI, 0.93-1.03). Skiers with the highest number of races or fastest finishing times had the highest incidence. Skiers of either sex had a lower incidence of stroke than did nonskiers (HR, 0.64; 95% CI, 0.60-0.67), independent of the number of races and finishing time. Skiers with atrial fibrillation had higher incidence of stroke than did skiers and nonskiers without atrial fibrillation (men: HR, 2.28; 95% CI, 1.93-2.70; women: HR, 3.51; 95% CI, 2.17-5.68; skiers with atrial fibrillation vs. skiers without atrial fibrillation). After diagnosis of atrial fibrillation, skiers with atrial fibrillation had a lower incidence of stroke (HR, 0.73; 95% CI, 0.50-0.91) and lower mortality compared with nonskiers with atrial fibrillation (HR, 0.57; 95% CI, 0.49-0.65). Female skiers in Vasaloppet had lower incidence of atrial fibrillation and stroke. Male skiers had similar incidence of atrial fibrillation and lower risk of stroke. Men with higher number of races and faster finishing times had the highest incidence of atrial fibrillation. After diagnosis of atrial fibrillation, skiers had lower incidence of stroke and death than did nonskiers with atrial fibrillation. This indicates that although on an individual level atrial fibrillation in well-trained individuals is associated with higher incidence of stroke, on population level, risk of stroke is low and that exercise should not be avoided.

Stroke ranks as the third leading cause of death in the United States. It is now estimated that there are more than 700 000 incident strokes annually and 4.4 million stroke survivors.1 2 The economic burden of stroke was estimated by the American Heart Association to be $51 billion (direct and indirect costs) in 1999.3 Despite the advent of treatment of selected patients with acute ischemic stroke with tissue plasminogen activator and the promise of other experimental therapies, the best approach to reducing the burden of stroke remains prevention.4 5 High-risk or stroke-prone individuals can be identified and targeted for specific interventions.6 This is important because epidemiological data suggest a substantial leveling off of prior declines in stroke-related mortality and a possible increase in stroke incidence.7 8 The Stroke Council of the American Heart Association formed an ad hoc writing group to provide a clear and concise overview of the evidence regarding various established and potential stroke risk factors. The writing group was chosen based on expertise in specific subject areas, and it used literature review, reference to previously published guidelines, and expert opinion to summarize existing evidence and formulate recommendations (Table 1⇓). View this table: Table 1. Levels of Evidence and Grading of Recommendations As given in Tables 2 through 4⇓⇓⇓, risk factors or risk markers for a first stroke were classified according to potential for modification (nonmodifiable, modifiable, or potentially modifiable) and strength of evidence (well documented, less well documented).5 The tables give the estimated prevalence, population attributable risk, relative risk, and risk reduction with treatment for each factor when known. Population attributable risk reflects the proportion of ischemic strokes in the population that can be attributed to a particular risk factor and is given by the formula 100×[prevalence(relative risk−1)/prevalence(relative risk−1)+1]). …

Concomitant Surgical Ablation in Paroxysmal vs Persistent Atrial Fibrillation During Mitral Surgery

Stroke is the third leading cause of death in the United States.1 2 3 4 A decline in the age-adjusted death rate for nonwhite women began in 1924, for nonwhite men in 1930, and for whites by 1918.5 The rate of decline accelerated in the 1970s, probably because of improved hypertension control, but slowed in the 1980s for reasons that remain unclear.6 Recently published statistics suggest that the long-term decline in stroke mortality rates in the United States may have ceased. There is unmistakable evidence for a marked slowdown in the decline in stroke mortality.6 The age-adjusted US stroke mortality rate increased between 1992 and 1993; a recent report documented another rise in the preliminary rate for 1995 (percent change from 1994 to 1995, +0.8).7 Age-adjusted rates per 100 000 for 1991 to 1995 were 26.8, 26.2, 26.5, 26.5, and 26.7, respectively (Table 1⇓). It is important to view these increases in proper perspective while in no way diminishing the serious impact of the slowdown in the decline of stroke mortality in the United States since 1978.6 To this end, we tested the hypotheses (1) that the rate of decline of age-adjusted mortality rates in 1987 to 1994, the period since the previous report,6 has returned to that seen in the 1960s before the widespread availability of antihypertensive therapy, and (2) that this occurred in each sex/race group. In 1987 to 1994, the mean annual absolute and percent decline in age-adjusted death rates for stroke was less than observed in 1979 to 1986 for each sex/race group (Table 2⇓).6 It was comparable to that observed in the 1960s, before the rapid decline of the 1970s that was commonly attributed to marked improvements in hypertension detection and treatment.2 This …

We aimed to investigate temporal trends in all-cause mortality, heart failure (HF) hospitalization, and stroke from 1997 to 2018 in patients diagnosed with both HF and atrial fibrillation (AF). From Danish nationwide registers, we identified 152059 patients with new-onset HF between 1997 and 2018. Patients were grouped according to year of new-onset HF and AF-status: Prevalent AF (n=34734), New-onset AF (n=12691), and No AF (n=104634). Median age decreased from 76 to 73 years between 1997 and 2018. The proportion of patients with prevalent or new-onset AF increased from 24.7% (n=9256) to 35.8% (n=14970). Five-year risk of all-cause mortality went from 69.1% [confidence interval (CI): 67.9-70.2%] to 51.3% (CI: 49.9-52.7%), 62.3% (CI: 60.5-64.4%) to 43.0% (CI: 40.5-45.5%), and 61.9% (CI: 61.3-62.4%) to 36.7% (CI: 35.9-37.6%) for the Prevalent AF, New-onset AF, and No AF-group, respectively. Minimal changes were observed in the risk of HF-hospitalization. Five-year stroke risk decreased from 8.5% (CI: 7.8-9.1%) to 5.0% (CI: 4.4-5.5%) for the prevalent AF group, 8.2% (CI: 7.2-9.2%) to 4.6% (CI: 3.7-5.5%) for new-onset AF, and 6.3% (CI: 6.1-6.6%) to 4.9% (CI: 4.6-5.3%) for the No AF group. Simultaneously, anticoagulant therapy increased for patients with prevalent (from 42.7 to 93.1%) and new-onset AF (from 41.9 to 92.5%). From 1997 to 2018, we observed an increase in patients with HF and co-existing AF. Mortality decreased for all patients, regardless of AF-status. Anticoagulation therapy increased, and stroke risk for patients with AF was reduced to a similar level as patients without AF in 2013-2018.

Trends in mortality after first hospitalization with Atrial Fibrillation diagnosis in Sweden 1987 to 2006

Perceptions of Perioperative Stroke Among Chinese Anesthesiologists: Starting a Long March to Eliminate This Underappreciated Complication.

Trends in incidence and mortality in the hospital diagnosis of atrial fibrillation or flutter in Denmark, 1980–1999

in controlled trials, anticoagulation with warfarin reduces stroke risk by nearly two thirds, but the benefit has been less pronounced in clinical practice. This report describes the extent of warfarin use, its effectiveness, and its impact on medical costs among Medicare patients with nonvalvular atrial fibrillation. using claims from >2 million beneficiaries in the Centers for Medicare and Medicaid Services 5% Sample Standard Analytic Files, we identified patients with nonvalvular atrial fibrillation from 2004 to 2005. Warfarin use was inferred from 3 or more tests of the international normalized ratio within 1 year. Incidence of ischemic/hemorrhagic stroke and major bleeding was evaluated. Adjusted risk was calculated by Cox proportional-hazards regression. Medical costs (reimbursed amounts in 2006 US dollars) were estimated by multivariate linear regression. of patients with nonvalvular atrial fibrillation (N=119 764, mean age=79.3 years), 58.5% were categorized as warfarin users based on the study definition. During an average of 2.1 years' follow-up, the rate of ischemic stroke was 3.9 per 100 patient-years. After multivariate adjustment, ischemic stroke incidence was 27% lower in patients taking warfarin than in patients not taking warfarin (P<0.0001), with no increase in hemorrhagic stroke and a slightly elevated risk of a major bleed. Use of warfarin was independently associated with lower total medical costs, averaging $9836 per patient per year. these results indicate that 41.5% of Medicare patients with nonvalvular atrial fibrillation are not anticoagulated with warfarin. The incidence of stroke and overall medical costs were significantly lower in patients treated with warfarin.