Year Of Atrial Fibrillation Diagnosis Research Articles

Early rhythm control on diabetes-related complications and mortality in patients with type 2 diabetes mellitus and atrial fibrillation

AimsWe evaluated the impact of early rhythm control (ERC) on diabetes-related complications and mortality in subjects with type 2 diabetes mellitus (T2DM) and atrial fibrillation (AF). MethodsThis observational cohort study based on the Korean National Health Insurance Service claims database from 2009 to 2016, divided newly diagnosed AF patients with T2DM into ERC or usual care groups based on receiving rhythm control treatment within 1 year of AF diagnosis. The primary outcome was ischemic stroke, and the secondary outcomes were macro/microvascular complications, and all-cause death. ResultsAmong 47,509 subjects (mean age 66.7 ± 10.5 years; 61.8 % men; mean CHA2DS2-VASc score 4.6 ± 1.8; mean follow-up 4.3 ± 2.3 years; mean DM duration 5.6 ± 4.7 years), 23.1 % received ERC, and 76.9 % did not (usual care group). ERC was associated with lower risks of ischemic stroke, macrovascular and microvascular complications, and all-cause death compared to usual care (adjusted hazard ratios [95 % confidence interval]: 0.77 [0.70–0.85], 0.79 [0.73–0.86], 0.86 [0.82–0.90], and 0.92 [0.87–0.98], p < 0.001, <0.001, <0.001, and 0.012, respectively). ConclusionsEarly rhythm control was associated with reduced risks of diabetes-related complications and mortality in subjects with T2DM and AF. Rhythm control within 1 year of AF diagnosis with proper anticoagulation should be considered to prevent adverse outcomes.

Amiodarone is associated with increased mortality compared with other antiarrhythmic drugs in female patients with atrial fibrillation

Abstract Objective Antiarrhythmic drug (AAD) is the first-line therapy in patients with atrial fibrillation (AF) to maintain sinus rhythm. Amiodarone is one of the commonly used AAD that is known to lead to cardiac and extra-cardiac toxicities including pulmonary fibrosis and thyroid function abnormalities. However, the effect of amiodarone as compared with other-AADs (mainly Ic sodium channel blockers) on all-cause mortality is not fully evaluated. Methods This study used nationwide healthcare insurance system data. Patients with new-onset AF between 2013 and 2019 were enrolled. Use of AADs were confirmed if the patient were prescribed with AAD for more than six months during first year of AF diagnosis (medication possession ratio &amp;gt; 0.5). Clinical follow-up duration was three years from the moment AAD prescription after AF diagnosis. All-cause mortality was compared between amiodarone vs. other-AAD users. Results A total of 770,977 new-onset AF cases were detected. Among these people, 15,142 and 38,707 were identified as amiodarone and other-AAD users, respectively. Significant differences were observed in mean age and prevalence of heart failure, myocardial infarction, chronic kidney disease, diabetes mellitus, and dyslipidemia. After propensity score matching, 9,672 amiodarone users were compared with other-AAD users with same sample size and baseline characteristics were well matched. In multivariate adjusted analysis, amiodarone was associated with 2.5-fold increase in all-cause mortality (hazard ratio=2.520; 95% confidence interval=2.202 – 2.883; p&amp;lt; 0.001). Amiodarone did not show any significant interactions with age, thyroid disease, chronic kidney disease, heart failure, myocardial infarction, diabetes mellitus, dyslipidemia, and hypertension. However, the association between amiodarone and increased mortality was more pronounced in women compared with men (HR=3.124 vs. 2.231; p for interaction=0.022). Conclusion This study showed that all-cause mortality was significantly higher in amiodarone users than other-AAD users due to the toxicities, not by underlying diseases, which was more profound in female. This findings suggests that avoiding amiodarone as a first-line therapy should be considered in AF patients who have no compelling indications such as significant coronary artery disease or heart failure.All-cause mortality

Perioperative atrial fibrillation in relation to major emergency abdominal surgery and non-perioperative new onset atrial fibrillation: is there a difference in outcome?

Abstract Background Major emergency abdominal surgery (e.g. ileus, perforation) is relatively common and associated with postoperative complications and mortality. Long-term management of patients with atrial fibrillation (AF) associated with a secondary precipitant has recently received increased attention. It is further unknown whether the conflicting results regarding long-term outcomes in patients with new onset AF depends on surgical subtype or the arrhythmia itself. Purpose The aim of this study was to compare long-term clinical outcomes (AF related hospitalization, stroke, and mortality) in patients with perioperative new onset AF in relation to major emergency abdominal surgery and patients with non-perioperative new onset AF. Methods We crosslinked data from Danish nationwide registries and identified all patients who underwent major emergency abdominal surgery (2000-2018) and were diagnosed with new onset AF perioperatively, and patients who developed new onset AF in a non-perioperative setting. Patients with new onset perioperative AF were matched in a 1:5 ratio on age, sex and year of AF diagnosis with patients with non-perioperative new onset AF. From discharge, we examined unadjusted rates of outcomes and adjusted hazard ratios of outcomes were assessed using multivariable Cox regression analysis. Results The study population comprised 794 (out of 42,021) patients with perioperative new onset AF and 3970 patients with non-perioperative new onset AF (median age of 78 years [interquartile range: 70-83] and 57.3% women in both groups). In general, patients with new-onset perioperative AF had lower comorbid burden compared with patients with non-perioperative new onset AF. During the first month after the hospital admission, 15.0% of the patients with perioperative AF and 36.1% of the patients with new onset AF initiated oral anticoagulation therapy (after 2010, 19.7% and 41.2%, respectively). Two years after discharge, 3.9% of patients with perioperative AF and 5.8% of patients with new onset AF (p = 0.031) had had a stroke, while 32.9% and 40.1% (p = 0.002) had had a new hospitalization with AF. Cumulative incidences of stroke and AF related hospitalization are depicted in the Figure. In the multivariable models, perioperative AF was associated with a similar rate of stroke and lower rate of AF related hospitalization compared with non-perioperative new onset AF (HR 1.03, 95% confidence interval, CI: 0.54-1.96 for stroke and HR 0.68, 95% CI: 0.50-0.92 for AF related hospitalization, respectively). Conclusion Perioperative new onset atrial fibrillation in relation to major emergency abdominal surgery was associated with long-term similar rates of stroke and lower rates of AF related hospitalization compared with new onset atrial fibrillation in the non-perioperative setting. This study demonstrates a need for more knowledge about the progress of atrial fibrillation in the setting of non-cardiac surgery.Cumulative Incidence - strokeCumulative Incidence - AF_re

Stroke and Myocardial Infarction in Patients with Abdominal Aortic Aneurysm and New-Onset Atrial Fibrillation.

We investigated the association between new-onset atrial fibrillation (AF) and risk of stroke and myocardial infarction (MI) in patients with abdominal aortic aneurysmal (AAA) disease. Observational crossover study using Danish nationwide data, including patients with AAA and incident AF between 1997 and 2018. We estimated the 1-year risk of stroke and MI and the within-individual odds ratios (ORs) of ischemic events before and after an AF diagnosis, stratified by year of AF diagnosis (1997-2010 and 2011-2018), and supplemented with analyses on changes in use of antithrombotic therapy. A total of 3,035 AAA patients were included: 1,040 diagnosed during 1997 to 2010, and 1,995 during 2011 to 2018 (22.2% females, median age 78 years; median CHA2DS2-VASc score 4; interquartile range: 3-5). One-year risk of ischemic events after AF was 5.9% (confidence interval [CI] 95%: 4.6-7.5%) and 4.5% (CI 95%: 3.7-5.5%) for stroke and 5.4% (CI 95%: 4.2-6.9%) and 4.0% (CI 95%: 3.2-4.9%) for MI during 1997 to 2010 and 2011 to 2018, respectively. The OR of ischemic stroke before and after incident AF was 2.8 (CI 95%: 1.6-5.2) during 1997 to 2010; and 2.4 (CI 95%: 1.5 to 3.9) during 2011 to 2018, and 3.5 (CI 95%: 1.7-7.5) and 1.5 (CI 95%: 0.9-2.4) for MI. One-year proportion of prescription claims for oral anticoagulants after AF changed from 66.1% in 1997 to 2010 to 82.6% in 2011 to 2018, while antiplatelet prescription claims changed from 80.8 to 60.9%. Cardiovascular prognosis has improved in patients with prevalent AAA disease and new-onset AF in concordance with optimization of antithrombotic therapy over time. A diagnosis of AF conferred residual risk of stroke and MI.

Impact of frailty on early rhythm control outcomes in older adults with atrial fibrillation: A nationwide cohort study.

Rhythm-control therapy administered early following the initial diagnosis of atrial fibrillation (AF) has superior cardiovascular outcomes compared to rate-control therapy. Frailty is a key factor in identifying older patients' potential for improvement after rhythm-control therapy. This study evaluated whether frailty affects the outcome of early rhythm-control therapy in older patients with AF. From the Korean National Health Insurance Service database (2005-2015), we collected 20,611 populations aged ≥65 years undergoing rhythm- or rate-control therapy initiated within 1 year of AF diagnosis. Participants were emulated by the EAST-AFNET4 trial, and stratified into non-frail, moderately frail, and highly frail groups based on the hospital frailty risk score (HFRS). A composite outcome of cardiovascular-related mortality, myocardial infarction, hospitalization for heart failure, and ischemic stroke was compared between rhythm- and rate-control. Early rhythm-control strategy showed a 14% lower risk of the primary composite outcome in the non-frail group [weighted incidence 7.3 vs. 8.6 per 100 person-years; hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.79-0.93, p < 0.001] than rate-control strategy. A consistent trend toward a lower risk of early rhythm-control was observed in the moderately frail (HR 0.91, 95% CI 0.81-1.02, p = 0.09) and highly frail (HR 0.93, 95% CI 0.75-1.17, p = 0.55) groups. Although the degree attenuated with increasing frailty, the superiority of cardiovascular outcomes of early rhythm-control in AF treatment was maintained without increased risk for safety outcomes. An individualized approach is required on the benefits of early rhythm-control therapy in older patients with AF, regardless of their frailty status.

Abstract 14016: Marked Geographic Variation in Atrial Fibrillation Ablation Rates in a Universal Single Payer Health Care System

Introduction: Atrial fibrillation (AF) ablation is increasingly commonly performed for patients with symptomatic AF. In Canada, AF ablation occurs at specialized electrophysiology centers (“EP centers”), which are clustered in major urban centers. Hypothesis: People with AF who live closer to an EP center are more likely to undergo an AF ablation. Methods: Data was compiled from Ontario Health datasets (e.g. emergency department (ED) visits, hospital discharges, physician billing) and Canadian census data for people presenting to an ED in Ontario, Canada with a new diagnosis of AF between 2007-16. The primary outcome was ablation within one year of the index ED visit. Secondary outcomes include ablation at two years. Multivariate logistic regression was conducted to assess the relationship between distance to EP centers and likelihood of ablation. We also studied ablation frequency in relation to material deprivation (e.g. income, housing quality and education). Geospatial analyses were performed using QGIS. Results: Of the 135,681 people with newly diagnosed AF, 3911 (2.9%) had an ablation within one year of AF diagnosis and 5827 (4.3%) within two. There was a significant inverse relationship between a doubling of distance to the closest EP center and ablation within one year (OR: 0.93, 95% CI: 0.91-0.94), and two years (OR: 0.95, 95% CI: 0.94-0.97). Higher deprivation (measured in standard deviations from the mean) was associated with significantly less ablation at one year (OR: 0.89, 95% CI: 0.85-0.92). There was wide regional variation with relatively low rates near the largest urban center (Figure 1). Conclusions: Living further from an EP center and greater material deprivation are associated with lower AF ablation rates. Ablation rates vary by region, with the highest rates not consistently observed in areas most concentrated with EP centers. Figure 1. Age and sex adjusted AF ablation rates per 100,000 patients within a year of AF diagnosis in Ontario, Canada

Abstract 15919: Adverse Outcomes Related Amiodarone Toxicity in Early Rhythm Control of Patients With Atrial Fibrillation: A Nationwide Cohort Study

Background: Early rhythm control therapy was associated with a lower risk of adverse cardiovascular outcomes than usual care among patients who had recently (within 1 year) been diagnosed with atrial fibrillation (AF). In real-world data, the most commonly selected initial rhythm control strategy was the Class III anti-arrhythmic drug (AAD) amiodarone, but adverse outcomes related amiodarone toxicity was not well reported in this population. This study sought to investigate the fatal and non-fatal adverse outcomes related amiodarone toxicity in early rhythm control of patients with AF. Methods: Using the database of Korean National Health Insurance Service, we analyzed the adverse outcomes related amiodarone toxicity in 140,908 (rhythm control: 57,148, rate control: 83,760) patients with AF undergoing rhythm control or rate control therapy, initiated within 1 year of AF diagnosis, between 2005 and 2015. Results: The most commonly used rhythm control strategy was the class III drug amiodarone (22,877 (40.0%) of 57,148 patients in early rhythm control), followed by class Ic drugs. Patients with amiodarone for initial rhythm control strategy showed higher rate of interstitial lung disease (1.43% vs. 0.75%, p&lt;0.001), sudden cardia arrest duet to Torsade de Pointes (0.31% vs. 0.17%, p=0.001), and hypothyroidism (16.5% vs. 8.12%, p&lt;0.001). But incidence rate of bradycardia needing a temporary pacemaker, bradycardia needing a permanent pacemaker, and toxic hepatitis were higher in early rhythm control patients with other AADs compared to patients with amiodarone. Conclusions: The most commonly used rhythm control strategy was amiodarone in AF patients undergoing early rhythm control. Using amiodarone for the initial rhythm control strategy showed a higher rate of interstitial lung disease, sudden cardia arrest duet to Torsade de Pointes, and hypothyroidism. Attention should be paid to amiodarone toxicity in selecting rhythm control strategy for these patients.

Age and Outcomes of Early Rhythm Control in Patients With Atrial Fibrillation

This study sought to investigate whether the effects of early rhythm control differ according to age. Rhythm control, compared with usual care among patients recently diagnosed with atrial fibrillation (AF), was found to be associated with a lower risk of adverse cardiovascular outcomes. It is unclear whether the results can be generalized for older adults. This retrospective population-based cohort study included 31,220 patients with AF, from the Korean National Health Insurance Service database, undergoing rhythm control (antiarrhythmic drugs or ablation) or rate control therapy, initiated within 1 year of AF diagnosis. A composite outcome of cardiovascular death, ischemic stroke, hospitalization for heart failure, or myocardial infarction was compared in subgroups stratified by age. Compared with rate control, early rhythm control was associated with a lower risk of the primary composite outcome in patients<75 years of age (HR: 0.80; 95%CI: 0.72-0.88). The protective association between early rhythm control and cardiovascular outcomes exhibited a linear decrease with advancing age, with declined benefits in patients≥75 years of age (HR: 0.94; 95%CI: 0.87-1.03; Pinteraction=0.045). Trends toward lower risks of ischemic stroke (HR: 0.78; 95%CI: 0.67-0.90) and acute myocardial infarction (HR: 0.63; 95%CI: 0.41-0.97) were observed in the older adults. No significant differences in safety outcomes were found across different ages. The beneficial association of early rhythm control with cardiovascular outcomes was attenuated with increasing age, with the larger benefits in younger patients<75 years of age. No differences were found by age in treatment-related safety outcomes.

Comparative Effectiveness of Early Rhythm Control Versus Rate Control for Cardiovascular Outcomes in Patients With Atrial Fibrillation.

BackgroundRhythm control is associated with better cardiovascular outcomes than usual care among patients with recently diagnosed atrial fibrillation (AF). This study investigated the effects of rhythm control compared with rate control on the incidence of stroke, heart failure, myocardial infarction, and cardiovascular death stratified by timing of treatment initiation.Methods and ResultsWe conducted a retrospective population‐based cohort study including 22 635 patients with AF newly treated with rhythm control (antiarrhythmic drugs or ablation) or rate control in 2011 to 2015 from the Korean National Health Insurance Service database. Propensity overlap weighting was used. Compared with rate control, rhythm control initiated within 1 year of AF diagnosis decreased the risk of stroke. The point estimates for rhythm control initiated at selected time points after AF diagnosis are as follows: 6 months (hazard ratio [HR], 0.76; 95% CI, 0.66–0.87), 1 year (HR, 0.78; 95% CI, 0.66–0.93), and 5 years (HR, 1.00; 95% CI, 0.45–2.24). The initiation of rhythm control within 6 months of AF diagnosis reduced the risk of hospitalization for heart failure: 6 months (HR, 0.84; 95% CI, 0.74–0.95), 1 year (HR, 0.96; 95% CI, 0.82–1.13), and 5 years (HR, 2.88; 95% CI, 1.34–6.17). The risks of myocardial infarction and cardiovascular death did not differ between rhythm and rate control regardless of treatment timing.ConclusionsEarly initiation of rhythm control was associated with a lower risk of stroke and heart failure–related admission than rate control in patients with recently diagnosed AF. The effects were attenuated as initiating the rhythm control treatment later.

Increased risk of ischemic stroke and systemic embolism in hyperthyroidism-related atrial fibrillation: A nationwide cohort study

We aimed to evaluate the long-term risk of ischemic stroke/systemic embolism of hyperthyroidism-related AF. This retrospective population-based cohort study included records of 1,034,099 atrial fibrillation patients between 2005 and 2016 from the Korean National Health Insurance Service database. After exclusion, we identified 615,724 oral anticoagulation-naïve patients aged ≥18 years with new-onset non-valvular atrial fibrillation, of whom 20,773 had hyperthyroidism-related atrial fibrillation. After 3:1 propensity score matching, ischemic stroke and systemic embolism occurrences were compared between hyperthyroidism-related and non-hyperthyroidism-related ("nonthyroidal") atrial fibrillation patients. After exclusion, we identified 615,724 oral anticoagulation-naïve AF patients of whom 20,773 had hyperthyroidism-related AF. Median follow-up duration was 5.9 years. Hyperthyroidism-related AF patients had significantly higher risks of ischemic stroke and systemic embolism than nonthyroidal AF patients (1.83 vs 1.62 per 100-person year, hazard ratio[HR], 1.13; 95% confidence interval[CI], 1.07 to 1.19; P < 0.001). This risk was 36% higher in hyperthyroidism-related than in nonthyroidal AF patients within 1 year of atrial fibrillation diagnosis (3.65 vs 2.67 per 100-person year, HR, 1.36; 95% CI, 1.24 - 1.50; P < 0.001). This difference was also observed in the CHA2DS2-VASc score subgroup analysis. The risk of ischemic stroke and systemic embolism significantly decreased in patients treated for hyperthyroidism (HR, 0.64; 95% CI, 0.58 to 0.70; P < 0.001). Hyperthyroidism-related AF patients have high risks of ischemic stroke and systemic embolism like nonthyroidal AF, especially when initially diagnosed. This risk is reduced by treating hyperthyroidism.

Comparison of Oral Anticoagulant Use and Stroke Risk Among Older Adults Newly-Diagnosed Atrial Fibrillation Living in Urban-Versus-Rural Areas

We aimed to assess the association between urban/rural residence and the risk of ischemic stroke in individuals with newly diagnosed atrial fibrillation (AF), and to quantify the role of oral anticoagulation (OAC) initiation in the variation in stroke risk between urban and rural residents with AF. Using 5% random samples of Medicare claims, we identified fee-for-service beneficiaries who were diagnosed with AF between January 2014 and December 2015. Beneficiaries were followed for 1 year since their AF diagnosis, and were categorized according to their initiation of OAC within the year. We used the Rural-Urban Continuum Codes to define urban (levels 1 to 3) and rural (levels 4 to 9) areas. We applied marginal structural models to examine to what extent the difference in stroke risk between rural and urban areas were attributable to the difference in OAC initiation. In the year of AF diagnosis, 52% of those residing in urban areas and 56% residing in rural areas initiated an OAC (p <0.001). Urban residence, compared with rural residence, was associated with a 22% (hazard ratio and 95% confidence interval: 1.22 [1.13, 1.31]) increased risk of stroke. The hazard ratio attributed to urban residence decreased to 1.14 (1.01, 1.30) after accounting for the mediating role of lack of OAC initiation. Lack of OAC initiation explained 34% of the increased stroke risk observed in urban areas. In conclusion, urban residents with newly diagnosed AF were less likely to initiate OAC than rural counterparts, which explained one third of the increased risk of stroke observed in urban areas.

Refining Prediction of Atrial Fibrillation-Related Stroke Using the P2-CHA2DS2-VASc Score.

In people with atrial fibrillation (AF), periods of sinus rhythm present an opportunity to detect prothrombotic atrial remodeling through measurement of P-wave indices (PWIs)-prolonged P-wave duration, abnormal P-wave axis, advanced interatrial block, and abnormal P-wave terminal force in lead V1. We hypothesized that the addition of PWIs to the CHA2DS2-VASc score would improve its ability to predict AF-related ischemic stroke. We included 2229 participants from the ARIC study (Atherosclerosis Risk in Communities) and 700 participants from MESA (Multi-Ethnic Study of Atherosclerosis) with incident AF who were not on anticoagulants within 1 year of AF diagnosis. PWIs were obtained from study visit ECGs before development of AF. AF was ascertained using study visit ECGs and hospital records. Ischemic stroke cases were based on physician adjudication of hospital records. We used Cox proportional hazards models to estimate hazard ratios and 95% CIs of PWIs for ischemic stroke. Improvement in 1-year stroke prediction was assessed by C-statistic, categorical net reclassification improvement, and relative integrated discrimination improvement. Abnormal P-wave axis was the only PWI associated with increased ischemic stroke risk (hazard ratio, 1.84; 95% CI, 1.33-2.55) independent of CHA2DS2-VASc variables, and that resulted in meaningful improvement in stroke prediction. The β estimate was approximately twice that of the CHA2DS2-VASc variables, and thus abnormal P-wave axis was assigned 2 points to create the P2-CHA2DS2-VASc score. This improved the C-statistic (95% CI) from 0.60 (0.51-0.69) to 0.67 (0.60-0.75) in ARIC and 0.68 (0.52-0.84) to 0.75 (0.60-0.91) in MESA (validation cohort). In ARIC and MESA, the categorical net reclassification improvements (95% CI) were 0.25 (0.13-0.39) and 0.51 (0.18-0.86), respectively, and the relative integrated discrimination improvement (95% CI) were 1.19 (0.96-1.44) and 0.82 (0.36-1.39), respectively. Abnormal P-wave axis-an ECG correlate of left atrial abnormality- improves ischemic stroke prediction in AF. Compared with CHA2DS2-VASc, the P2-CHA2DS2-VASc is a better prediction tool for AF-related ischemic stroke.

Patients with atrial fibrillation and permanent pacemaker: Temporal changes in patient characteristics and pharmacotherapy.

BackgroundThe management of patients with non-valvular atrial fibrillation (NVAF) with rate-lowering or anti-arrhythmic drugs has markedly changed over the last decade, but it is unknown how these changes have affected patients with NVAF with a permanent pacemaker (PPM).MethodsThrough Danish nationwide registries, patients with NVAF and a PPM were identified from 2001 to 2012. Changes in concomitant pharmacotherapy and comorbidities were tested using the Cochran–Armitage trend test and linear regression. Patients with NVAF were identified to calculate the proportional amount of PPM implants.ResultsA total of 12,231 NVAF patients with a PPM were included in the study, 55.6% of which were men. Median age was 78 years (interquartile range 70–84). From 2001 to 2012, the number of NVAF patients with a PPM increased from 850 to 1344, while the number of NVAF patients increased from 67,478 to 127,261. Thus, the proportional amount of NVAF patients with a PPM decreased from 1.3% to 1.1% (p = 0.015). Overall 45.9% had atrial fibrillation (AF) duration less than one year and the proportion declined from 55.5% to 42.4% (p <0.001). Diabetes mellitus increased from 7.2% to 16.8% (p <0.001). Heart failure (HF) decreased from 36.7% to 29.3% (p = 0.010) and ischemic heart disease (IHD) decreased from 32.4% to 26.1% (p <0.001). Beta-blocker use increased from 38.1% to 58.0% (p <0.001), while digoxin and anti-arrhythmic drug use decreased over time.ConclusionFrom 2001 to 2012, the absolute number of NVAF patients with a PPM increased while the proportional amount decreased. The number of NVAF patients receiving a PPM within one year of AF diagnosis decreased. The prevalence of DM increased, while the prevalence of HF and IHD was high but decreasing. The use of beta-blockers increased markedly, while use of digoxin and anti-arrhythmic drugs decreased over time.

No decline in the risk of heart failure after incident atrial fibrillation: A community study assessing trends overall and by ejection fraction

Patients with atrial fibrillation (AF) experience an increased risk of heart failure (HF). However, data are lacking on current trends in the risk of HF after AF. The purpose of this study was to describe the temporal trends in HF occurrence after AF in a community cohort of patients with incident AF from 2000 to 2013. Cox regression was used to examine the association of year of AF diagnosis with HF and the predictors of developing HF after AF. Among 3491 AF patients without prior HF, 750 (21%) developed incident HF over mean follow-up of 3.7 years. Among those with an echocardiogram, 422 (61%) had HF with preserved ejection fraction (HFpEF), and 270 (39%) had HF with reduced ejection fraction (HFrEF). After adjusting for demographics and comorbidities, the risk of developing HF did not change over time (hazard ratio [HR] (95% confidence interval [CI]) per year of AF diagnosis: 1.01 (0.98-1.03) overall; 1.00 (0.98-1.03) for HFpEF; 1.00 (0.96-1.03) for HFrEF). Increasing age, obesity, smoking, diabetes, chronic pulmonary disease, and renal disease were predictors of developing HF. Compared to the Olmsted County, Minnesota, population, a substantial excess risk of developing HF was observed after AF diagnosis [standardized morbidity ratio (95% CI): 9.60 (7.44-12.19), 2.13 (1.56-2.84), and 1.70 (1.34-2.14) at 90 days, 1 year, and 3 years after diagnosis]. In the community, HF is a frequent adverse outcome among patients with AF, and HFpEF is more common than HFrEF. The rates of HF after AF have not declined, thus highlighting the importance of continued efforts to improve outcomes in AF.

Risk of Malignant Cancer Among Women With New-Onset Atrial Fibrillation.

A substantial proportion of patients with atrial fibrillation (AF) die of noncardiovascular causes, and recent studies suggest a link between AF and cancer. To evaluate the associations between AF and cancer in a large, long-term prospective cohort study. In this cohort study, a total of 34 691 women 45 years or older and free of AF, cardiovascular disease, and cancer at baseline were prospectively followed up between 1993 and 2013, for incident AF and malignant cancer within the Women's Health Study, a randomized clinical trial of aspirin and vitamin E for the prevention of cardiovascular disease and cancer. Cox proportional hazards models using time-updated covariates were constructed to assess the association of new-onset AF with subsequent cancer and to adjust for potential confounders. Data analysis was performed from December 2014 to May 2015. New-onset AF. Incident malignant cancer confirmed by an end point committee. During a median follow-up of 19.1 years of 34 691 study participants (interquartile range [IQR], 17.6-19.7 years), new-onset AF and malignant cancer were confirmed among 1467 (4.2%) and 5130 (14.8%) participants, respectively. Median age at baseline among participants with new-onset AF and new-onset cancer during follow-up was 58 years (IQR, 52-64 years) and 55 years (IQR, 50-61 years), respectively. Atrial fibrillation was a significant risk factor for incident cancer in age-adjusted (hazard ratio [HR], 1.58; 95% CI, 1.34-1.87; P < .001) and multivariable-adjusted (HR, 1.48; 95% CI, 1.25-1.75; P < .001) models. The relative risk of cancer was highest in the first 3 months after new-onset AF (HR, 3.54; 95% CI, 2.05-6.10; P < .001) but remained significant beyond 1 year after new-onset AF (adjusted HR, 1.42; 95% CI, 1.18-1.71; P < .001), and a trend toward an increased cancer mortality was observed (adjusted HR, 1.32; 95% CI, 0.98-1.79; P = .07). In contrast, among women with new-onset cancer, the relative risk of AF was increased only within the first 3 months (HR, 4.67; 95% CI, 2.85-7.64; P < .001) but not thereafter (HR, 1.15; 95% CI, 0.95-1.39; P = .15). In this large, initially healthy cohort, women with new-onset AF had an elevated cancer risk beyond 1 year of AF diagnosis. Shared risk factors and/or common systemic disease processes might underlie this association.

Abstract 304: Nonfatal Outcomes Following Incident Atrial Fibrillation: A Community Study

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia in current clinical practice. Yet, contemporary community data on adverse outcomes, such as ischemic stroke (IS) and heart failure (HF), are scarce. Methods: We assembled a community-based cohort of incident AF among Olmsted County, MN residents ≥18 years of age from 2000-2010. IS, transient ischemic attack (TIA), and incident HF occurring through 12/31/2012 were identified using diagnosis codes and were manually validated. Cox proportional hazards regression was used to determine age- and sex-adjusted predictors of IS/TIA and HF, as well as the association of year of AF diagnosis with these outcomes after adjustment for demographics and comorbidities. Results: Among 3315 incident AF (mean age 72.6 years, 52% male), 346 (10%) developed a subsequent IS (n=230) or TIA (n=116) over a mean follow-up of 4.2 years. In the 2807 AF patients without prior HF, 782 (28%) developed HF over a mean of 3.9 years. Differences in the predictors of subsequent IS/TIA and HF were observed (Figure). Increasing age, female sex, and prior IS/TIA were associated with an increased risk of IS/TIA, whereas increasing age, obesity, smoking, prior myocardial infarction, diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, prior IS/TIA, and renal disease predicted the development of HF after AF. The risk of subsequent IS/TIA or HF did not differ by year of AF diagnosis. Compared to those diagnosed with AF in 2000-2003, the adjusted hazard ratios (HR) (95% CI) for ischemic IS/TIA were 0.84 (0.65-1.08) and 1.02 (0.76-1.36) for those diagnosed with AF in 2004-2007 and 2008-2010, respectively (P time trend =0.58); similar results were observed for IS alone. The corresponding HRs for HF were 0.99 (0.83-1.16) and 0.93 (0.76-1.13) for those diagnosed with AF in 2004-2007 and 2008-2010 compared to 2000-2003 (P time trend =0.43). Conclusions: In the community, adverse outcomes are frequent after AF, and HF occurs more frequently than IS/TIA. Risk factors differed for IS/TIA and HF, suggesting that pathways to the occurrence of these outcomes, as well as prevention strategies, may differ. Finally, the occurrence of these outcomes did not decline over the last decade, highlighting the importance of continued rigorous surveillance of adverse outcomes in AF.

Abstract P003: Survival after Incident Atrial Fibrillation: A Community-Based Study

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice, causes substantial morbidity, and is associated with an excess risk of mortality. However, information on contemporary time trends in survival after AF is lacking. Thus, we aimed to determine whether survival after incident AF has changed over the last decade in a community-based cohort of 3413 individuals with incident AF between 2000 and 2010. Methods: Olmsted County, MN residents 18 years of age and older with a first-ever AF or atrial flutter event between 2000 and 2010 were identified using inpatient and outpatient diagnostic codes and electrocardiograms. Deaths from any cause were ascertained through August 31, 2012 and time trends in survival after AF were examined using Kaplan-Meier curves and Cox proportional hazards regression. Results: Among 3413 individuals with incident AF (52% men, age range 18-104) between 2000 and 2010, 1561 deaths were observed over a median follow-up of 3.4 years. Survival did not differ by year of AF diagnosis (figure). In addition, the proportion of cardiovascular disease-related deaths compared to non-cardiovascular deaths did not differ over time. After adjustment for age, sex, and Charlson comorbidity index, the hazard ratios for all-cause mortality were 1.09 (95% CI 0.97-1.23) for those diagnosed with AF in 2004-2007 vs. 2000-2003 and 1.04 (95% CI 0.90-1.12) for 2008-2010 vs. 2000-2003. Furthermore, the risk of death did not differ by sex after adjustment for age and comorbidity (HR 1.00, 95% CI 0.90-1.11 for men vs. women). Conclusions: In the community, survival after AF has remained constant over the last decade despite substantial changes in the recommendations for treatment of AF. This underscores the importance of identification of prognostic factors and continued surveillance of outcomes in AF, as well as a better understanding of how to optimize the management of AF to improve outcomes in these patients.

Incidence and mortality risk of congestive heart failure in atrial fibrillation patients: a community-based study over two decades

We sought to determine whether the incidence of and survival following congestive heart failure (CHF) in patients with atrial fibrillation (AF) have changed over time. Olmsted County, Minnesota residents diagnosed with first AF during 1980-2000 were identified and followed in medical records to 2004. The trends of incidence and survival of CHF over time were assessed. Of the 3288 subjects (mean age 71+/-15 years) diagnosed with first AF and without CHF prior to or at AF diagnosis, 790 (24%) developed a first CHF during a mean follow-up of 6.1+/-5.2 years (unadjusted incidence, 44 per 1000 person years). Age- and sex-adjusted CHF incidence was unrelated to calendar year of AF diagnosis (P = 0.86). The age- and sex-adjusted mortality risk following CHF was higher than that in patients without CHF (hazard ratio 3.4, 95% confidence interval 3.1-3.8, P < 0.0001). There were no detectable changes over time with respect to the absolute (P = 0.94) or the relative (P = 0.68) mortality risk after CHF diagnosis. In this study spanning two decades, there appeared to have been no significant reduction in terms of the incidence and mortality risk of CHF following first AF diagnosis.

Time Trends of Ischemic Stroke Incidence and Mortality in Patients Diagnosed With First Atrial Fibrillation in 1980 to 2000

With the changes in management of atrial fibrillation (AF) over time, it is possible that the time trends of post-AF stroke incidence and mortality have changed. We sought to determine whether the incidence and survival of ischemic stroke after AF diagnosis have improved. We identified the Olmsted County, Minn, residents who developed first AF from 1980 to 2000 and followed them in medical records to 2004. The outcomes were first ischemic stroke and death. Of the 4117 subjects diagnosed with first AF and without previous stroke, 446 (11%) sustained a first ischemic stroke during a mean follow-up time of 5.5+/-5.0 years. The age- and sex-adjusted incidence of stroke decreased, on average, by 3.4% per year (P=0.0001), concurrent with an increase in warfarin and aspirin use (both P<0.0001) and reduction of systolic blood pressure (P<0.001). The age-adjusted ischemic stroke incidence was higher in women (P=0.039), but not after adjusting for systolic blood pressure (P=0.41). Compared with the general Minnesota white population, the relative mortality hazard ratio was 1.88 for men and 1.84 for women without stroke and 3.03 for men and 3.80 for women (P<0.05) with stroke. The relative mortality hazard did not vary by age or calendar year of AF diagnosis. Post-AF ischemic stroke incidence decreased significantly from 1980 to 2000, during which time a substantial increase in the use of antithrombotic therapy and reduction of systolic blood pressure was evident. The relative mortality risk of stroke, however, had not improved over time.