Events In Atrial Fibrillation Patients Research Articles

Longitudinal Analysis of Predictive Factors for Stroke and Bleeding Events in Atrial Fibrillation Patients: Insights From a Tertiary Care Center Cohort

Longitudinal Analysis of Predictive Factors for Stroke and Bleeding Events in Atrial Fibrillation Patients: Insights From a Tertiary Care Center Cohort

Atrial Fibrillation and Early Vascular Aging: Clinical Implications, Methodology Issues and Open Questions-A Review from the VascAgeNet COST Action.

Atrial fibrillation (AF), the most common cardiac arrhythmia, is associated with adverse CV outcomes. Vascular aging (VA), which is defined as the progressive deterioration of arterial function and structure over a lifetime, is an independent predictor of both AF development and CV events. A timing identification and treatment of early VA has therefore the potential to reduce the risk of AF incidence and related CV events. A network of scientists and clinicians from the COST Action VascAgeNet identified five clinically and methodologically relevant questions regarding the relationship between AF and VA and conducted a narrative review of the literature to find potential answers. These are: (1) Are VA biomarkers associated with AF? (2) Does early VA predict AF occurrence better than chronological aging? (3) Is early VA a risk enhancer for the occurrence of CV events in AF patients? (4) Are devices measuring VA suitable to perform subclinical AF detection? (5) Does atrial-fibrillation-related rhythm irregularity have a negative impact on the measurement of vascular age? Results showed that VA is a powerful and independent predictor of AF incidence, however, its role as risk modifier for the occurrence of CV events in patients with AF is debatable. Limited and inconclusive data exist regarding the reliability of VA measurement in the presence of rhythm irregularities associated with AF. To date, no device is equipped with tools capable of detecting AF during VA measurements. This represents a missed opportunity to effectively perform CV prevention in people at high risk. Further advances are needed to fill knowledge gaps in this field.

Prediabetes: An overlooked risk factor for major adverse cardiac and cerebrovascular events in atrial fibrillation patients.

Prediabetes is a well-established risk factor for major adverse cardiac and cerebrovascular events (MACCE). However, the relationship between prediabetes and MACCE in atrial fibrillation (AF) patients has not been extensively studied. Therefore, this study aimed to establish a link between prediabetes and MACCE in AF patients. To investigate a link between prediabetes and MACCE in AF patients. We used the National Inpatient Sample (2019) and relevant ICD-10 CM codes to identify hospitalizations with AF and categorized them into groups with and without prediabetes, excluding diabetics. The primary outcome was MACCE (all-cause inpatient mortality, cardiac arrest including ventricular fibrillation, and stroke) in AF-related hospitalizations. Of the 2965875 AF-related hospitalizations for MACCE, 47505 (1.6%) were among patients with prediabetes. The prediabetes cohort was relatively younger (median 75 vs 78 years), and often consisted of males (56.3% vs 51.4%), blacks (9.8% vs 7.9%), Hispanics (7.3% vs 4.3%), and Asians (4.7% vs 1.6%) than the non-prediabetic cohort (P < 0.001). The prediabetes group had significantly higher rates of hypertension, hyperlipidemia, smoking, obesity, drug abuse, prior myocardial infarction, peripheral vascular disease, and hyperthyroidism (all P < 0.05). The prediabetes cohort was often discharged routinely (51.1% vs 41.1%), but more frequently required home health care (23.6% vs 21.0%) and had higher costs. After adjusting for baseline characteristics or comorbidities, the prediabetes cohort with AF admissions showed a higher rate and significantly higher odds of MACCE compared to the non-prediabetic cohort [18.6% vs 14.7%, odds ratio (OR) 1.34, 95% confidence interval 1.26-1.42, P < 0.001]. On subgroup analyses, males had a stronger association (aOR 1.43) compared to females (aOR 1.22), whereas on the race-wise comparison, Hispanics (aOR 1.43) and Asians (aOR 1.36) had a stronger association with MACCE with prediabetes vs whites (aOR 1.33) and blacks (aOR 1.21). This population-based study found a significant association between prediabetes and MACCE in AF patients. Therefore, there is a need for further research to actively screen and manage prediabetes in AF to prevent MACCE.

The effect of COVID-19 on the thromboembolic outcomes in atrial fibrillation patients in the long run

Background While there has been a wealth of reports concerning the acute effects of the coronavirus disease 2019 (COVID-19), further information is needed to see how things unfold in the long run. This research aimed to ascertain whether the COVID-19 pandemic has increased the probability of thromboembolic events in atrial fibrillation (AF) patients. Methods In this retrospective study, we scanned 952 AF patients and classified 643 eligible ones per their history of catching COVID-19. Two hundred thirty-nine of 643 patients had a history of COVID-19 (Group 1), and 404 did not (Group 2). We then compared two years of thromboembolic events between the groups. Results Composite thromboembolic outcomes were seen in 76 (11.8%) patients. Of those, 32 (13.4%) were in Group 1, and 44 (10.8%) were in Group 2 (p = .03). 10 of 32 patients (31%) in Group 1 and 11 of 44 (25%) in Group 2 died because of thromboembolic events (p = .02). Histories of diabetes mellitus, chronic obstructive pulmonary disease, and COVID-19 independently predicted thromboembolic events in AF patients. Conclusions Having caught COVID-19 is likely to be associated with increased long-term thromboembolic outcomes in AF patients. Albeit the study design does not permit us to infer causality, our results question the necessity of more intensive anticoagulant therapy and closer follow-up in AF patients with past COVID-19.

Clinical outcomes and predictors of long-term mortality, hemorrhagic and thromboembolic events in atrial fibrillation patients at different stages of chronic kidney disease: The CRAFT trial

Background Chronic kidney disease (CKD) coexisting with atrial fibrillation (AF) increases the risk of hemorrhage and ischemia. The study aimed to determine the relationship between different CKD stages and clinical outcomes of patients suffering from both CKD and AF and to determine the predictors of outcome. Methods The data was derived from multicenter CRAFT trial (NCT02987062). We have conducted a retrospective analysis of hospital records of 2663 AF patients divided in three groups according to their estimated glomerular filtration rate (eGFR) which was <30ml/min/1,73 m2 for group I (n=63), ≥30 and <60 ml/min/1,73 m2 for group II (n=947) and ≥60 ml/min/1,73 m2 for group III (n=1653). The primary study endpoint was major adverse event (MAE) during the mean four-year follow-up. Results The highest rate of MAE was observed in group I followed by group II and III. The rate of all-cause death was 60% in group I, 32% in group II and 15% in group III (p<0.001). Bleeding complications occurred in 25% of patients from group I, 23% from group II and 21% from group III (p=0.14). Thromboembolic events occurred in those groups at the rate of 21%, 14% and 12% respectively (p=0.011). The risk of death was 5 times higher in patients with eGFR<30 treated with vitamin K antagonists (VKA) (HR: 5.016, 95% CI: 1.533-16.417; p=0.007). Conclusions AF patients with CKD are at higher risk of MAE and that risk depends on the CKD stage. VKA treatment was linked to a higher mortality in AF patients with the lowest eGFR values.

Coffee consumption and adverse outcome events in patients with atrial fibrillation

Abstract Background/Introduction Moderate coffee consumption has been associated with a lower risk of major adverse cardiovascular events (MACE) in the general population. However, there are some concerns that coffee consumption might be harmful for patients with atrial fibrillation (AF). Purpose The aim of this study was to investigate the association of coffee consumption with MACE and other adverse outcome events in AF patients. Methods Data of AF patients from two large prospective, multicenter cohort studies (yearly based follow-up data from Swiss-AF and Beat-AF) were used for this analysis. Coffee consumption was assessed and categorized into two main groups "not-daily" and "daily" consumers and subcategories (&amp;lt;1, 1, 2-3 and ≥4cups/day). The primary endpoint was defined as a composite of stroke or systemic embolism, myocardial infarction, hospitalization for acute heart failure and cardiovascular death (MACE). We performed time-updated multivariable adjusted Cox regression analyses to investigate the association of coffee consumption with MACE and other adverse outcome events. Results Among 3,835 patients (mean age 71.4 years, 28.0% females), 3,095 (80.7%) reported daily coffee consumption. The incidence rate for MACE was 5.09 in daily and 7.49 per 100py in not-daily consumers. Cumulative incidence curves are presented in Figure 1. After comprehensive multivariable adjustment, daily coffee consumption was associated with a 23% relative risk reduction for MACE compared to not-daily consumption (hazard ratio (HR) (95% confidence interval (CI)) 0.77 (0.67-0.89), p&amp;lt;0.001;). Compared to patients with not-daily coffee consumption, patients with moderate coffee consumption (2-3 cups/day) had the lowest hazard for MACE (HR (95%CI) 0.73 (0.62; 0.85), p&amp;lt;0.001). The associations between coffee consumption and all adverse outcome events are presented in Figure 2. Conclusion In a population of AF patients, daily coffee consumption was associated with a lower risk of MACE and other adverse outcomes. These findings seem to be similar to those in the general population.

Abstract 13820: Association of Cardiothoracic Ratio With Heart Failure Events in Atrial Fibrillation Without Heart Failure: The Fushimi AF Registry

Background: The cardiothoracic ratio (CTR) is a readily available and non-invasive tool with which to assess cardiac volume status. We previously reported that N-terminal pro-B-type natriuretic peptide (NT-proBNP) level was associated with higher incidence of clinical events in patients with atrial fibrillation (AF) without pre-existing heart failure (HF). However, it remains unknown whether CTR on chest radiography is associated with the incidence of HF events in AF patients without HF. Methods: The Fushimi AF Registry is a community-based prospective survey of AF patients in Fushimi-ku, Kyoto, Japan. After excluding patients with pre-existing HF (defined as having one of the following; prior HF hospitalization, New York Heart Association class ≥2, or left ventricular ejection fraction &lt;40%), we divided 1,049 patients into four groups according to their CTR and NT-proBNP level (median value: 495 ng/L) at baseline, and compared the incidence of HF events (composite of cardiac death or HF hospitalization) among the groups; G1 (Lower CTR&lt;50% and Lower NT-proBNP&lt;495, n=256), G2 (Higher CTR≥50% and Lower NT-proBNP&lt;495, n=268), G3 (Lower CTR&lt;50% and Higher NT-proBNP≥495, n=117) and G4 (Higher CTR≥50% and Higher NT-proBNP≥495, n=408). Results: During the median follow-up of 5.4 years, the incidence rates of HF events in the groups either having higher NT-pro BNP group or higher CTR group were higher, as compared with patients with lower CTR and lower NT-proBNP (G1: 0.5% per person-year, G2: 1.3%, G3: 1.6% and G4: 2.5%; p&lt;0.01) (Figure). Multivariate Cox regression analysis revealed that higher CTR (≥50%) was independently associated with the incidence of HF events in AF patients without prior HF hospitalization (hazard ratio: 1.47, 95% confidence interval: 1.09-2.00). Conclusion: In Japanese AF patients without pre-existing HF, higher CTR was associated with higher incidence of HF events irrespective of NT-proBNP level.

Comparative Effectiveness of Different Anticoagulation Strategies in Atrial Fibrillation and Renal Dysfunction: A Systematic Review.

Atrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of stroke and thromboembolism. Anticoagulation therapy can reduce this risk, but the optimal choice of anticoagulant in patients with AF and renal dysfunction is challenging. Renal dysfunction is a common comorbidity seen in patients with AF. Renal dysfunction would affect the pharmacokinetics and pharmacodynamics of anticoagulants and make the patient more prone to bleeding complications. This complicates the assessment of the risks, benefits, and ratio for starting anticoagulant drugs in patients with renal dysfunction. Therefore, there is always a therapeutic conundrum due to the increased risk of bleeding and thromboembolic events in AF patients with renal dysfunction. We conducted a systematic review to summarize the current literature and identify the challenges of anticoagulation strategies in AF with renal dysfunction. We examined 180 articles from reputable journals published from 2018 to June 2023 and selected eight papers for detailed analysis. The studies we chose included a variety of drug treatments, such as traditional therapies like vitamin K antagonists, factor Xa inhibitors, heparins, and direct thrombin inhibitors. This systematic review will provide comprehensive information on the latest data on the effectiveness of various pharmacological treatments (anticoagulation strategies) in AF patients with renal dysfunction. The aim is to help doctors and other healthcare decision-makers choose the best anticoagulation strategy in AF patients with renal dysfunction and to overcome their dilemma between bleeding risk and systemic thromboembolic events.

Utility of left ventricular ejection fraction in atrial fibrillation patients without pre-existing heart failure.

Atrial fibrillation (AF) increases the risk of heart failure (HF); however, little focus has been placed on the prevention of HF in patients with AF. Left ventricular ejection fraction (LVEF) is an established echocardiographic parameter in HF patients. We sought to investigate the association of LVEF with HF events in AF patients without pre-existing HF. The Fushimi AF Registry is a community-based prospective survey of AF patients in Fushimi-ku, Japan. In this analysis, we excluded patients with pre-existing HF (defined as having one of the following: prior HF hospitalization, New York Heart Association class≥2 in association with heart disease, or LVEF<40%). Among 3233 AF patients without pre-existing HF, we investigated 2459 patients with the data of LVEF at enrolment. We divided the patients into three groups stratified by LVEF [mildly reduced LVEF (40-49%), below normal LVEF (50-59%), and normal LVEF (≥60%)] and compared the backgrounds and incidence of HF hospitalization between the groups. Of 2459 patients [mean age: 72.4±10.5years, female: 917 (37%), paroxysmal AF: 1405 (57%), and mean CHA2 DS2 -VASc score: 3.0±1.6], the mean LVEF was 66±8% [mildly reduced LVEF: 114 patients (5%), below normal LVEF: 300 patients (12%), and normal LVEF: 2045 patients (83%)]. Patients with lower LVEF demonstrated lower prevalence of female and paroxysmal AF (both P<0.01), but age and CHA2 DS2 -VASc score were comparable between the three groups (both P>0.05). During the median follow-up period of 6.0years, 255 patients (10%) were hospitalized for HF (annual incidence: 1.9% per person-year). Multivariable Cox regression analysis demonstrated that lower LVEF strata were independently associated with the risk of HF [mildly reduced LVEF (40-49%): hazard ratio=2.98, 95% confidence interval=1.99-4.45 and below normal LVEF (50-59%): hazard ratio=2.01, 95% confidence interval=1.44-2.82, compared with normal LVEF (≥60%)] after adjustment by age, sex, type of AF, and CHA2 DS2 -VASc score. LVEF<60% was significantly associated with the higher risk of HF hospitalization across all major subgroups without significant interaction (P for interaction; all P>0.05). LVEF had an independent and incremental prognostic value for HF hospitalization in addition to natriuretic peptide levels in AF patients without pre-existing HF. Lower LVEF was significantly associated with the higher incidence of HF hospitalization in AF patients without pre-existing HF, leading to the future risk stratification for and prevention of incident HF in AF patients.

Heart Failure and Major Adverse Cardiovascular Events in Atrial Fibrillation Patients: A Retrospective Primary Care Cohort Study.

Atrial fibrillation (AF) is a common cardiac arrhythmia that is associated with an increased risk of major adverse cardiovascular events (MACE). The main goal was to analyze the links and associations between AF and MACE. A multicenter, observational, retrospective, community-based study of a cohort (n = 40,297) of the general population aged 65-95 years between 1 January 2015 and 31 December 2021 without a previous diagnosis of AF or MACE in the Primary Care setting. 2574 people (6.39%) developed a first AF event, resulting in an overall incidence of 8.9/1000 people-years [CI95% 8.6-9.2]. The incidence of MACE among those with AF was 75.1/1000 people-years [CI95% 70.8-79.5], whereas among those without AF, it was 20.6/1000 people-years [CI 95% 20.2-21.1], resulting in a rate ratio of 3.65 [CI 95% 3.43-3.88, p < 0.001]. Besides, the incidence of HF with AF was 40.1 people-years [CI 95% 37.1-43.2], while in the group without AF, it was 8.3 people-years [CI 95% 7.9-8.6, p < 0.001], with a rate ratio of 4.85 [CI 95% 4.45-55.3, p < 0.001]. Before an AF diagnosis, there is already a higher risk of chronic kidney disease, ischemic cardiopathy, and peripheral artery disease. A higher risk of poor nutritional status was detected among those with MACE (49.7% vs. 26.6%, p < 0.001). AF diagnosis increases the incidence of heart failure fourfold. Additional information is required to establish the connection between AF, major adverse cardiovascular events, and nutritional status.

Transesophageal Echocardiogram Before Cardioversion in Atrial Fibrillation Patients.

Transesophageal echocardiography (TEE) offers an invaluable, non-invasive avenue for diagnosing and managing various cardiac conditions, including atrial fibrillation (AF). As the most common cardiac arrhythmia, AF affects millions and can lead to severe complications. Cardioversion, a procedure to restore the heart's normal rhythm, is frequently conducted on AF patients resistant to medication. Due to inconclusive data, TEE's utility prior to cardioversion in AF patients remains ambiguous. Understanding TEE's potential benefits and limitations in this population could significantly influence clinical practice. This review aims to scrutinize the current literature on the use of TEE before cardioversion in AF patients. The principal objective is to understand TEE's potential benefits and limitations comprehensively. The study seeks to offer a clear understanding and practical recommendations for clinical practice, thereby improving the management of AF patients before cardioversion using TEE. A literature search of databases was conducted using the keywords "Atrial Fibrillation," "Cardioversion" and "Transesophageal echocardiography," resulting in 640 articles. These were narrowed to 103 following title and abstract reviews. After applying exclusion and inclusion criteria with a quality assessment, 20 papers were included: seven retrospective studies, 12 prospective observational studies, and one randomized controlled trial (RCT). Stroke risk associated with direct-current cardioversion (DCC) potentially results from post-cardioversion atrial stunning. Thromboembolic events occur post cardioversion, with or without prior atrial thrombus or cardioversion complications. Generally, cardiac thrombus localizes in the left atrial appendage (LAA), a clear contraindication to cardioversion. Atrial sludge without LAA thrombus in TEE is a relative contraindication. TEE before electrical cardioversion (ECV) in anticoagulated AF individuals is uncommon. In AF patients planned for cardioversion, contrast enhancement facilitates thrombus exclusion in TEE images, reducing embolic events. Left atrial thrombus (LAT) frequently occurs in AF patients, necessitating TEE examination. Despite the increased use of pre-cardioversion TEE, thromboembolic events persist. Notably, patients with post-DCC thromboembolic events had no LA thrombus or LAA sludge. The use of TEE-guided DCC has grown due to its ability to detect atrial thrombi pre-cardioversion, aiding risk stratification. Thrombus in the left atrium also signals an elevated risk of future thromboembolic events in AF patients. While atrial stunning post cardioversion detected by TEE is a significant risk factor for future thromboembolic events, further evidence is required. Therapeutic anticoagulation is essential during and post cardioversion, even if no atrial thrombus is detected. Current data recommends cardioversion guided by TEE, particularly in outpatient settings.

Mortality and ventricular arrhythmias in patients with atrial fibrillation on sotalol

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Karolinska Institue at Stockholm South hospital. Background In atrial fibrillation (AF), anti-arrhythmic drugs are an option for rhythm control. Guidelines regarding treatment with sotalol varies worldwide. The risk of serious adverse events in AF patients on sotalol is estimated from small studies, with short follow-up, not designed for mortality analysis. Purpose To evaluate mortality in patients with a rhythm control strategy for AF. Methods In Swedish registries, 7473 sotalol-treated and 107255 patients on betablockers underwent cardioversion or were diagnosed with paroxysmal AF between 2006 and 2017. Mortality and ventricular arrhythmias were estimated in unadjusted, and propensity score matched cohorts. Results Mean follow up was 474 (SD 599) and 481 (SD 515) days in sotalol/betablocker respectively. Crude all-cause mortality was lower in the sotalol group (HR 0.3 CI 0.3-0.4), also in multi-adjusted analysis (HR 0.6 CI 0.5-0.6). In the propensity-matched comparison, HR remained lower on sotalol (0.6 CI 0.5-0.7). Ventricular arrhythmias were more common among patients on sotalol (1.5 vs 1,0%, p&amp;lt;0,001. 1,1% vs 0,8%/100 personyears). There were no significant differences in CPR or sudden cardiac death. Conclusions This real-world data did not show increased mortality in sotalol-treated patients. Ventricular arrhythmias were relatively rare. Careful patient selection and follow-up probably reduce the proarrhythmic risk during sotalol-treatment.

PERBANDINGAN EFEKTIVITAS RIVAROXABAN DAN WARFARIN DALAM MENGATASI KEJADIAN EMBOLI PADA PASIEN DENGAN ATRIAL FIBRILASI

Atrial Fibrillation (AF) is one of the most common types of cardiac arrhythmias caused by abnormal electrical activity in the heart's atria. A study conducted in Indonesia on the urban population in Jakarta obtained an AF incidence rate of 0.2% with a male to female ratio of 3:2. Oral anticoagulant therapy is the standard therapy for AF to prevent stroke and systemic embolism. The most widely used oral anticoagulants are Vitamin K Antagonist (VKA) such as Warfarin and Direct Oral Anticoagulants such as Rivaroxaban. This literature author conducted to compare the effectiveness. Warfarin and Rivaroxaban in dealing with embolic events in AF patients to find out which type of anticoagulant should be used. The literature sources used were Pubmed, Google Scholar, Medline, Ebsco, Hindawi, Science Direct and Cochrane. Anticoagulants have been used to prevent embolic disease in AF patients and the drug classes used are DOAC and VKA. Based on a literature search it was found that Rivaroxaban can reduce the risk of stroke and systemic embolism as well as major bleeding events compared to Warfarin. Rivaroxaban has been shown to have superior effectiveness compared to warfarin and can be used as an alternative drug in treating embolic events in AF patients.

Safety and efficacy of direct oral anticoagulants versus vitamin K antagonists in atrial fibrillation electrical cardioversion: An update systematic review and meta-analysis

BackgroundA systematic evaluation focused on efficacy and safety for electrical cardioversion of atrial fibrillation (AF) among different Direct Oral Anticoagulants (DOACs) has not been previously performed. In this setting, we conducted a meta-analysis of studies evaluating DOACs vs vitamin K antagonists (VKA) as common comparator. MethodsWe searched Cochrane Library, Pubmed, Web Of Science and Scopus databases for all English-only articles concerning studies that have estimated the effect of DOACs and VKA on stroke, transient ischemic attack or systemic embolism (SSE) and major bleeding (MB) events in AF patients undergoing electrical cardioversion. We selected 22 articles comprising 66 cohorts and 24,322 procedures (12,612 with VKA). ResultsDuring follow-up (studies' median 42 days), 135 SSE (52 DOACs and 83 VKA) and 165 MB (60 DOACs and 105 VKA) were recorded. The overall pooled effects, DOACs vs VKA, was estimated by an univariate Odds Ratio of 0.92 (0.63–1.33; p = 0.645) for SSE and 0.58 (0.41–0.82; p = 0.002) for MB; at bivariate evaluation, adjusting for study type, were respectively 0.94 (0.55–1.63; p = 0.834) and 0.63 (0.43–0.92, p = 0.016). Each single DOAC showed similar and non statistically different results in outcome occurrence compared to VKA as well as when Apixaban, Dabigatran, Edoxaban and Rivaroxaban were indirectly compared to each other. ConclusionsIn patients undergoing electrical cardioversion, compared to VKA, DOACs have similar thromboembolic protection with lower major bleeding incidence. Single molecule does not show difference in event rate compared to each other. Our findings, provide useful information about safety and efficacy profile of DOACs and VKA.

Edoxaban Anticoagulation in Atrial Fibrillation: Real-World Data and Evidence.

Atrial fibrillation (AF) and stroke are two prevalent health conditions with many shared risk factors. Over the past two decades, non-vitamin K antagonist oral anticoagulants (NOACs) have emerged as important alternatives to vitamin K antagonists, owing to their efficacy, safety profile, and the absence of a need for frequent international normalized ratio monitoring. Introduced as the most recent NOAC, edoxaban has been approved for stroke prevention in non-valvular AF in numerous countries since 2014. The pivotal phase III Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48 (ENGAGE AF-TIMI 48) trial demonstrated that edoxaban is as efficacious as warfarin in preventing strokes and systemic embolic events. Furthermore, it is linked to reduced rates of major, life-threatening, intracranial, major, or clinically relevant non-major bleeding events and decreased cardiovascular mortality in AF when compared to warfarin. Growing data highlights the utilization of edoxaban in treating AF patients in clinical settings. This article provides an overview of real-world evidence regarding edoxaban's use in preventing stroke and systemic embolic events in AF patients, emphasizing the concerns that physicians factor into their clinical decision-making.

Riesgo hemorrágico y embólico de los pacientes con fibrilación auricular y cáncer

Introduction and objectivesThe impact of cancer on clinical outcomes in patients with atrial fibrillation (AF) is unclear. The aim of this study was to assess how cancer influences the prediction and risk of embolic and hemorrhagic events in patients with AF. MethodsThe study population comprised 16 056 patients from a Spanish health area diagnosed with AF between 2014 and 2018. Of these, 1137 (7.1%) had a history of cancer. During a median follow-up of 4.9 years, we assessed the relationship between cancer and bleeding and embolic events by competing risk analysis, considering death as a competing risk. ResultsNo association was detected between an increased risk of embolic events and cancer overall (sHR, 0.73; 95%CI, 0.41-1.26), active cancer, or any subgroup of cancer. However, cancer was associated with an increased risk of bleeding, although only in patients with active cancer (sHR, 1.42; 95%CI, 1.20-1.67) or prior radiotherapy (sHR, 1.40; 95%CI, 1.19-1.65). Both the CHA2DS2-VASc and HAS-BLED scores showed suboptimal performance to predict embolic and bleeding risk (c-statistic <0.50), respectively, in nonanticoagulated patients with active cancer. The ratio between the increase in bleeding and the decrease in embolisms with anticoagulation was similar in patients with and without cancer (5.6 vs 7.8; P <.001). ConclusionsCancer was not associated with an increased risk of embolic events in AF patients, only with an increased risk of bleeding. However, active cancer worsened the ability of the CHA2DS2-VASc and HAS-BLED scores to predict embolic and bleeding events, respectively, in nonanticoagulated patients.Full English text available from:www.revespcardiol.org/en

Bleeding and thrombotic events in atrial fibrillation patients with cancer: a systematic review and meta-analysis.

Atrial fibrillation (AF) and cancer are frequently coexisting in elderly patients. Pooled metanalytic data on the impact of cancer on clinical outcomes in AF patients are lacking.We performed a systematic review and meta-regression analysis of clinical studies retrieved from Medline (PubMed) and Cochrane (CENTRAL) databases according to PRISMA guidelines. Bleeding endpoints included any, major, gastrointestinal (GI) bleeding and intracranial haemorrhage (ICH). Cardiovascular (CV) endpoints included myocardial infarction (MI), ischemic stroke/systemic embolism (IS/SE), CV and all-cause death. PROSPERO registration number: CRD42022315678.We included 15 studies with 2,868,010 AF patients, of whom 479,571 (16.7%) had cancer. The pooled hazard ratio (HR) for cancer was 1.43 (95% confidence interval [95%CI] 1.42-1.44) for any bleeding, 1.27 (95% CI 1.26-1.29) for major bleeding, 1.17 (95% CI 1.14-1.19) for GI bleeding, and 1.07 (95% CI 1.04-1.11) for ICH. The risk of major bleeding increased with the proportion of breast cancer. Cancer increased the risk of all-cause death (HR 2.00, 95% CI 1.99-2.02) whereas no association with MI and CV death was found. Patients with AF and cancer were less likely to suffer from IS/SE (HR 0.91, 95% CI 0.89-0.94). Cancer complicates the clinical history of AF patients, mainly increasing the risk of bleeding. Further analyses according to the type and stage of cancer are necessary to better stratify bleeding risk in these patients.

Abstract 13234: Prediabetes, an Important Predictor of Major Adverse Cardiac and Cerebrovascular Events in Atrial Fibrillation Patients: A National Inpatient Sample Analysis, 2019

Background: Prediabetes is an established risk factor for major adverse cardiac and cerebrovascular events (MACCE). However, the association between prediabetes (pDM) and MACCE in atrial fibrillation (AF) patients remains understudied. We aim to establish a relation between prediabetes and MACCE in AF patients. Methods: Using the National Inpatient Sample (2019) and relevant ICD-10 codes, we identified hospitalizations with AF and categorized them into groups with and without pDM excluding diabetics. The primary outcome was MACCE (All-cause inpatient mortality, Cardiac Arrest including Ventricular Fibrillation, and Stroke) in AF-related hospitalizations. Results: Of 2,965,875 AF-related hospitalizations for MACCE, 47,505 (1.6%) were among pre-diabetics. The pDM cohort was relatively younger (median 75 vs 78 years), often consisted of males (56.3% vs 51.4%), blacks (9.8.% vs 7.9%), Hispanics (7.3% vs 4.3%), and API (4.7% vs 1.6%) than the nonprediabetic cohort (p&lt;0.001). The pDM group often had significantly higher rates of HTN, hyperlipidemia, smoking, obesity, drug abuse, prior MI, PVD, and hyperthyroidism (all p&lt;0.05). The pDM cohort was often discharged routinely (51.1% vs 41.1%) but more frequently required home health care (23.6% vs 21.0%) and had higher costs. After adjusting for baseline characteristics or comorbidities, pDM cohort with AF admissions showed higher rate and significantly higher odds of MACCE vs Non-pDM cohort (18.6% vs. 14.7%, OR 1.34, 95CI 1.26-1.42, p&lt;0.001). On subgroup analyses, Males had stronger association (aOR 1.43) compared to females (aOR 1.22) whereas on race-wise comparison, Hispanics (aOR 1.43) and Asians (aOR 1.36) had stronger association with MACCE with pDM vs. whites (aOR 1.33) and blacks (aOR 1.21). Conclusions: We found a significant association between prediabetes and MACCE in AF patients. There is a need for further research to actively screen and manage pDM in AF to curtail MACCE.

The importance of cancer in the prediction of embolic and hemorrhagic risk in patients with atrial fibrillation

Abstract Introduction Cancer is a prevalent disease and is associated with a two-fold greater risk of developing cardiovascular disease. Atrial fibrillation (AF) is a common cardiovascular comorbidity among oncologic patients and the co-occurrence of these two represents several clinical challenges. Many cancers interact with the coagulation system and the representation of this population in clinical trials with cardiovascular drugs is scarce. Thus the impact of cancer regarding clinical outcomes in patients with AF is unclear. Purpose The aim of this study was to assess how cancer influences the prediction ability of embolic and hemorrhagic risk in patients with AF. Methods The study population comprised 16,056 patients from a Spanish health area diagnosed with AF between 2014 and 2018 of whom 1,137 (7.1%) had a history of cancer. During a median follow-up of 4.9 years we assessed the relationship between cancer and bleeding and embolic events by competing risk analysis considering death a competing risk. Results After adjusting for age, sex, CHA2DS2-VASC score, HAS-BLED score and anticoagulation therapy, cancer was not associated with a higher risk of embolic events (sHR 0.73, 95% CI 0.41–1.26; p=0.256). Neither was an association between an increased rate of embolic events and cancer detected, overall (sHR 0.73, 95% CI 0.41–1.26), regarding active cancer, or any subgroup of cancer. However, cancer was associated with an increased risk of bleeding specifically in patients with active cancer (sHR 1.42, 95% CI 1.20–1.67) or prior radiotherapy (sHR 1.40, 95% CI 1.19–1.65). Both CHA2DS2-VASC and HAS-BLED scores showed a suboptimal performance to predict embolic and bleeding risk in non-anticoagulated patients with active cancer (c-statistic &amp;lt;0.50). Discrimination and calibration ability of ATRIA and HEMORR2HAGES bleeding risk scores was also poor in patients with cancer (c-statistic &amp;lt;0.6 and Brier score &amp;gt;0.1). Moreover, the ratio between the increase in bleeding and decrease in embolic events in anticoagulated patients was similar in those with and without cancer (5.6 vs 7.8 bleeding events, p&amp;lt;0.001). Conclusion Cancer was associated with an increased risk of bleeding but not an increased risk of embolic events. Neither the CHA2DS2-VASC nor the HAS-BLED scores showed a good performance for predicting embolic and hemorrhagic events in AF patients with active cancer. The embolic-hemorrhagic ratio profile of anticoagulation was similar in patients with and without cancer, and parallel to cancer-free patients, anticoagulation significantly reduced embolic events while increasing bleeding risk in oncological patients. Funding Acknowledgement Type of funding sources: None.

Low major bleeding, pump thrombosis and death rates in continuous flow left ventricular assist devices patients with good anticoagulation control

Abstract Background Continuous-flow left ventricular assist device (CF-LVAD) patients require anticoagulation with vitamin K antagonists (VKAs). Good versus suboptimal anticoagulation control expressed as high versus low time in target range (TTR) of international normalized ratio results in less clinical events in atrial fibrillation patients. However, data in CF-LVAD patients are lacking. Purpose To study the association between TTR and clinical events in patients with CF-LVAD as destination therapy. Methods Single-centre cohort study in patients receiving CF-LVAD between 2010–2021. Patients were followed from start of VKAs until outcome or end of follow-up. Outcomes were combined major adverse events, thromboembolisms, major bleedings, neurologic events and all-cause mortality. The TTR (low vs. high; &amp;lt;50% vs. &amp;gt;50%) was calculated during the overall study period and over 1-month periods by the Rosendaal-method. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated by Cox regression with time-dependent covariables, adjusted for confounding. Results 74 patients were included; median age 63 years [interquartile range 58–68], 77% males and 60%ischemic heart failure. During 191 years follow-up, 39 combined major adverse events, 14 thromboembolisms, 21 major bleeding, 22 neurologic events and 38 deaths occurred. For 1-month periods, high TTR was associated with less combined major adverse events (HR 0.3 95% CI 0.2–0.7), major bleeding (HR 0.4 95% CI 0.2–1.1), thromboembolism (HR 0.3 95% CI 0.1–1.3) and death (HR 0.2 95% CI 0.1–0.5) (Table 1). Results considering the overall study period were similar. Conclusion Good anticoagulation compared with suboptimal control during 1-month and the overall study period in CF-LVAD patients with destination therapy is associated with lower rates of combined major adverse events, major bleedings, pump thrombosis and death. Funding Acknowledgement Type of funding sources: None.