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

Objective Several studies have shown an increased risk for cardiovascular disease (CVD) in hyperthyroidism, but most studies have been too small to address the effect of hyperthyroidism on individual cardiovascular endpoints. Our main aim was to assess the association among hyperthyroidism, acute cardiovascular events and mortality. Design It is a nationwide population-based cohort study. Data were obtained from the Danish Civil Registration System and the Danish National Patient Registry, which covers all Danish hospitals. We compared the rate of all-cause mortality as well as venous thromboembolism (VTE), acute myocardial infarction (AMI), ischemic and non-ischemic stroke, arterial embolism, atrial fibrillation (AF) and percutaneous coronary intervention (PCI) in the two cohorts. Hazard ratios (HR) with 95% confidence intervals (95% CI) were estimated. Results The study included 85 856 hyperthyroid patients and 847 057 matched population-based controls. Mean follow-up time was 9.2 years. The HR for mortality was highest in the first 3 months after diagnosis of hyperthyroidism: 4.62, 95% CI: 4.40–4.85, and remained elevated during long-term follow-up (>3 years) (HR: 1.35, 95% CI: 1.33–1.37). The risk for all examined cardiovascular events was increased, with the highest risk in the first 3 months after hyperthyroidism diagnosis. The 3-month post-diagnosis risk was highest for atrial fibrillation (HR: 7.32, 95% CI: 6.58–8.14) and arterial embolism (HR: 6.08, 95% CI: 4.30–8.61), but the risks of VTE, AMI, ischemic and non-ischemic stroke and PCI were increased also 2- to 3-fold. Conclusions We found an increased risk for all-cause mortality and acute cardiovascular events in patients with hyperthyroidism.

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Bleeding and thromboembolism due to drug-drug interactions with non-vitamin K antagonist oral anticoagulants—a Swedish, register-based cohort study in atrial fibrillation outpatients

European Journal of Clinical Pharmacology ◽

10.1007/s00228-020-03015-7 ◽

2020 ◽

Author(s):

Johan Holm ◽

Buster Mannheimer ◽

Rickard E Malmström ◽

Erik Eliasson ◽

Jonatan D Lindh

Keyword(s):

Atrial Fibrillation ◽

Cohort Study ◽

Ischemic Stroke ◽

Vitamin K ◽

Cox Regression ◽

Oral Anticoagulants ◽

Outcome Data ◽

Vitamin K Antagonist ◽

Drug Register ◽

Increased Risk

Abstract Purpose To study the association between interacting drugs and bleeding or thromboembolism in atrial fibrillation outpatients treated with non-vitamin K antagonist oral anticoagulants (NOACs). Methods Population-based cohort study of outpatients treated with NOACs in Sweden from 2008 to 2017. Patients with atrial fibrillation and newly initiated NOAC treatment were identified in the Prescribed Drug Register. Comorbidities and outcome data were retrieved from the Patient Register and the Cause of Death Register. Cox-regression analyses were performed to evaluate the primary endpoints any severe bleed and ischemic stroke/transient ischemic attack/stroke unspecified during the first six months of treatment. Secondary endpoints were gastrointestinal bleeding, intracranial bleeding, ischemic stroke, and venous thromboembolism. Results Increased risk of any severe bleed was found when NOAC treatment, and drugs with pharmacodynamic effect on bleeding were combined, compared to NOAC only. An increased risk with these combinations was evident for apixaban (hazard ratio (HR) 1.47; 95% CI 1.33–1.63), rivaroxaban (HR 1.7; 95% CI 1.49–1.92), and dabigatran (HR 1.26; 95% CI 1.05–1.52). For apixaban, there was an increased risk of any severe bleed when combined with CYP3A4 and/or P-glycoprotein (P-gp) inhibitors (HR 1.23; 95% CI 1.01–1.5). The use of inducers of CYP3A4 and/or P-gp was low in this cohort, and effects on ischemic stroke/TIA/stroke unspecified could not be established. Conclusion Increased risk of bleeding was seen for pharmacodynamic and pharmacokinetic interactions with NOACs. Prescribers need to be vigilant of the effect of interacting drugs on the risk profile of patients treated with NOACs.

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Association between body mass index and the risk of atrial fibrillation and ischemic stroke according to age: a nationwide population-based cohort study

European Heart Journal ◽

10.1093/eurheartj/ehab724.2411 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

H J Ahn ◽

S R Lee ◽

E K Choi ◽

K D Han ◽

S I Kwon ◽

...

Keyword(s):

Atrial Fibrillation ◽

Body Mass Index ◽

Cohort Study ◽

Ischemic Stroke ◽

Body Mass ◽

Age Groups ◽

The Elderly ◽

Population Based ◽

Age Group ◽

Increased Risk

Abstract Background Atrial fibrillation (AF) and ischemic stroke (IS) are two significant cardiovascular diseases that confer an enormous healthcare burden. A limited study comprehensively evaluated the association between full ranges of body mass index (BMI), including underweight, and AF or IS risks, especially in the different age subgroups. Purpose We investigated the association between BMI and AF and IS incidence according to the Korean population's age groups. Methods This was a nationwide population-based cohort study using data from the Korea National Health Insurance Service, including 9 194 477 healthy adults who underwent a medical examination in 2009. We stratified the study population into three age subgroups: age 20–39 (young, 33.1%), age 40–64 (middle-aged, 56.3%), and age over 65 years (elderly, 10.6%). In each age group, the individuals were categorized based on BMI (kg/m2) into underweight (<18.5), normal (18.5 to <23), overweight (23 to <25), obese I (25 to <30), and obese II (≥30). The first occurrences of AF and IS were followed up until December 31, 2018. According to BMI in each age group, the risks of AF and IS were analyzed by Cox proportional hazards regression with 95% confidence intervals (CI) by adjusting age, sex, lifestyle behaviors, and comorbidities. Results Overall, both underweight and higher BMI were associated with an increased risk of AF and stroke across all age groups. The increased risk of AF for patients with obese II was slightly accentuated compared to patients with normal BMI in the young population than elderly population (hazard ratio [HR] 1.78, 95% CI 1.63–1.94 for age 20–39 years; HR 1.55, 95% CI 1.48–1.61 for age ≥65 years, respectively). For underweight individuals, however, the increased risk of AF became more prominent in the elderly: HR and 95% CI was 1.12 (1.07–1.17) in the age over 65 years old, and 1.05 (0.94–1.16) in the age 20–39. Regarding IS, the young group presented a considerable increment in the magnitude of HRs in both underweight and higher BMI groups. However, the association between the BMI and stroke risk became attenuated in the elderly: HRs and 95% CI in underweight and obese II individuals were 1.10 (0.93–1.30) and 2.223 (1.99–2.49) in the age 20–39 group, whereas 0.97 (0.93–1.01) and 1.03 (0.98–1.08) in the age over 65 years old. Conclusions Underweight as well as obesity was associated with increased risks of AF and IS in the general population. In both AF and IS, the gradient of risks according to BMI was apparent at young ages; thus, maintaining normal body weight should be warranted in early life. An interplay of several factors other than BMI may contribute to ischemic stroke in the old ages, requiring integrated risk management in older patients. FUNDunding Acknowledgement Type of funding sources: None.

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Incidence and risk of short episodes of atrial fibrillation detected with 14 days of continuous electrocardiographic monitoring

European Heart Journal ◽

10.1093/ehjci/ehaa946.0495 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

W.F McIntyre ◽

J Wang ◽

S.J Connolly ◽

I.C Van Gelder ◽

R.D Lopes ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Randomized Clinical Trials ◽

Screening Method ◽

Cox Proportional Hazards ◽

Older Individuals ◽

Systemic Embolism ◽

Electrocardiographic Monitoring ◽

Increased Risk

Abstract Background There is widespread interest in population-based screening for atrial fibrillation (AF). However, there is debate regarding the optimal screening method and duration. Objectives To estimate the incidence of short-duration AF detected by a single continuous 14-day electrocardiographic (ECG) monitor in older individuals without prior AF and to estimate the risk of ischemic stroke or systemic embolism associated with these episodes. Methods Pacemaker and defibrillator electrograms were reviewed from a cohort of individuals ≥65 years old, with a history of hypertension, but no prior AF. For each participant, we simulated a continuous 14-day ECG monitor by randomly selecting a 14-day window in the 6 months following enrolment and measured the total AF burden during that period. We repeated random sampling 1000 times to ensure a robust estimate of the likelihood of capturing AF in a single 14-day period. We used Cox proportional hazards models adjusted for CHA2DS2-VASc score to estimate the risk of ischemic stroke or systemic embolism associated with different burdens of AF. Results Among 2470 participants with at least 6 months of follow-up, the mean CHA2DS2-VASc score was 4.0±1.3. The proportion of participants with an AF burden of >6 min on a single 14-day monitor was estimated as 3.1%, while the proportion with burdens of >15 min and >30 min were 2.9% and 2.6%, respectively. Over a mean follow-up of 2.5 years, 44 participants had an ischemic stroke or systemic embolism; the rate among patients with an AF burden ≤6 mins was 0.70%/year. An AF burden >6 min was associated with an increased risk of stroke or systemic embolism (2.2%/year, HR 3.0; 95% CI 1.3–5.7), as were burdens >15 min (2.4%/year; HR 3.3; 95% CI 1.4–6.4) and >30 min (2.6%/year HR 3.5; 95% CI 1.5–6.7). Conclusion Approximately 3% of individuals aged 65 years and older and with hypertension may have previously undiagnosed asymptomatic AF detected by a single 14-day continuous ECG monitor. As little as 6 minutes of AF may be associated with an increased risk of stroke. Randomized clinical trials are required to definitively assess screening in this population. Funding Acknowledgement Type of funding source: None

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Acute Dental Periapical Abscess and New-Onset Atrial Fibrillation: A Nationwide, Population-Based Cohort Study

Journal of Clinical Medicine ◽

10.3390/jcm10132927 ◽

2021 ◽

Vol 10 (13) ◽

pp. 2927

Author(s):

Amaar Obaid Hassan ◽

Gregory Y. H. Lip ◽

Arnaud Bisson ◽

Julien Herbert ◽

Alexandre Bodin ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cohort Study ◽

Multivariable Analysis ◽

National Database ◽

Increased Risk ◽

Periapical Abscess ◽

The Relationship ◽

Onset Atrial Fibrillation ◽

New Onset

There are limited data on the relationship of acute dental infections with hospitalisation and new-onset atrial fibrillation (AF). This study aimed to assess the relationship between acute periapical abscess and incident AF. This was a retrospective cohort study from a French national database of patients hospitalized in 2013 (3.4 million patients) with at least five years of follow up. In total, 3,056,291 adults (55.1% female) required hospital admission in French hospitals in 2013 while not having a history of AF. Of 4693 patients classified as having dental periapical abscess, 435 (9.27%) developed AF, compared to 326,241 (10.69%) without dental periapical abscess that developed AF over a mean follow-up of 4.8 ± 1.7 years. Multivariable analysis indicated that dental periapical abscess acted as an independent predictor for new onset AF (p < 0.01). The CHA2DS2VASc score in patients with acute dental periapical abscess had moderate predictive value for development of AF, with Area Under the Curve (AUC) 0.73 (95% CI, 0.71–0.76). An increased risk of new onset AF was identified for individuals hospitalized with dental periapical abscess. Careful follow up of patients with severe, acute dental periapical infections is needed for incident AF, as well as investigations of possible mechanisms linking these conditions.

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Impact of atrial fibrillation pattern on outcomes after left atrial appendage closure: lessons from the prospective LAARGE registry

Clinical Research in Cardiology ◽

10.1007/s00392-021-01874-3 ◽

2021 ◽

Author(s):

Shinwan Kany ◽

Johannes Brachmann ◽

Thorsten Lewalter ◽

Ibrahim Akin ◽

Horst Sievert ◽

...

Keyword(s):

Atrial Fibrillation ◽

Left Atrial Appendage ◽

Systemic Embolism ◽

Long Term Outcomes ◽

Increased Risk ◽

History Of ◽

One Year ◽

The One

Abstract Background Non-paroxysmal (NPAF) forms of atrial fibrillation (AF) have been reported to be associated with an increased risk for systemic embolism or death. Methods Comparison of procedural details and long-term outcomes in patients (pts) with paroxysmal AF (PAF) against controls with NPAF in the prospective, multicentre observational registry of patients undergoing LAAC (LAARGE). Results A total of 638 pts (PAF 274 pts, NPAF 364 pts) were enrolled. In both groups, a history of PVI was rare (4.0% vs 1.6%, p = 0.066). The total CHA2DS2-VASc score was lower in the PAF group (4.4 ± 1.5 vs 4.6 ± 1.5, p = 0.033), while HAS-BLED score (3.8 ± 1.1 vs 3.9 ± 1.1, p = 0.40) was comparable. The rate of successful implantation was equally high (97.4% vs 97.8%, p = 0.77). In the three-month echo follow-up, LA thrombi (2.1% vs 7.3%, p = 0.12) and peridevice leak > 5 mm (0.0% vs 7.1%, p = 0.53) were numerically higher in the NPAF group. Overall, in-hospital complications occurred in 15.0% of the PAF cohort and 10.7% of the NPAF cohort (p = 0.12). In the one-year follow-up, unadjusted mortality (8.4% vs 14.0%, p = 0.039) and combined outcome of death, stroke and systemic embolism (8.8% vs 15.1%, p = 0.022) were significantly higher in the NPAF cohort. After adjusting for CHA2DS2-VASc and previous bleeding, NPAF was associated with increased death/stroke/systemic embolism (HR 1.67, 95% CI 1.02–2.72, p = 0.041). Conclusion Atrial fibrillation type did not impair periprocedural safety or in-hospital MACE patients undergoing LAAC. However, after one year, NPAF was associated with higher mortality. Graphic abstract

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Women With Osteoarthritis Are at Increased Risk of Ischemic Stroke: A Population-Based Cohort Study

Journal of Epidemiology ◽

10.2188/jea.je20200042 ◽

2021 ◽

Author(s):

Chung-Hsin Yeh ◽

Wei-Lun Chang ◽

Po-Chi Chan ◽

Chih-Hsin Mou ◽

Ko-Shih Chang ◽

...

Keyword(s):

Cohort Study ◽

Ischemic Stroke ◽

Population Based ◽

Increased Risk

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Comments on “A simple and easily implemented risk model to predict 1-year ischemic stroke and systemic embolism in Chinese patients with atrial fibrillation”

Chinese Medical Journal ◽

10.1097/cm9.0000000000001608 ◽

2021 ◽

Vol Publish Ahead of Print ◽

Author(s):

Yi-Gang Li ◽

Chang-Qi Gong

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Risk Model ◽

Chinese Patients ◽

Systemic Embolism

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Analysis of Influencing Factors of Compliance with Non-Vitamin K Antagonist Oral Anticoagulant in Patients with Nonvalvular Atrial Fibrillation and Correlation with the Severity of Ischemic Stroke

Evidence-based Complementary and Alternative Medicine ◽

10.1155/2021/1021127 ◽

2021 ◽

Vol 2021 ◽

pp. 1-7

Author(s):

Li Zhu ◽

Xiaodan Zhang ◽

Jing Yang

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Influencing Factors ◽

Clinical Supervision ◽

Vitamin K ◽

Pearson Correlation ◽

Anticoagulation Therapy ◽

Vitamin K Antagonist ◽

Nonvalvular Atrial Fibrillation ◽

Increased Risk

Nonvalvular atrial fibrillation (NVAF) is associated with an increased risk of stroke and thrombus, and anticoagulant therapy is a key link in the prevention of stroke. At present, the anticoagulation rate of atrial fibrillation in China is low, and there are many factors affecting the adherence of patients with atrial fibrillation to anticoagulation. Non-vitamin K antagonist oral anticoagulants (NOACs) are anticoagulant with high application value due to their high safety and low risk of intracranial hemorrhage, stroke, and death. However, the compliance of NOACs is poor, and the current situation of anticoagulants in China is not optimistic. In this study, a total of 156 patients with NVAF who received NOAC anticoagulation therapy in our hospital from January 2018 to January 2019 were retrospectively analyzed. The results showed that education background, place of residence, number of complications, CHA2DS2-VASc score, and HAS-BLED score were independent influencing factors for NOACS compliance of NVAF patients. Also, the Pearson correlation analysis showed that there was a negative correlation (r = −0.465, P < 0.001 ) between NOAC compliance and severity of ischemic stroke in patients with NVAF. Therefore, clinical supervision and management of patients with NVAF after NOACs should be strengthened to improve the compliance of patients with NVAF after NOACs, reduce the damage of ischemic stroke, and improve their prognosis.

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Edoxaban versus warfarin on stroke risk in patients with atrial fibrillation: a territory-wide cohort study

10.1101/2021.01.04.21249209 ◽

2021 ◽

Author(s):

Dicken Kong ◽

Jiandong Zhou ◽

Sharen Lee ◽

Keith Sai Kit Leung ◽

Tong Liu ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cohort Study ◽

Ischemic Stroke ◽

Propensity Score ◽

Ischaemic Stroke ◽

Propensity Score Matching ◽

Lower Risk ◽

Cox Regression ◽

Significant Risk ◽

Risk Predictors

AbstractBackgroundIn this territory-wide, observational, propensity score-matched cohort study, we evaluate the development of transient ischaemic attack and ischaemic stroke (TIA/Ischaemic stroke) in patients with AF treated with edoxaban or warfarin.MethodsThis was an observational, territory-wide cohort study of patients between January 1st, 2016 and December 31st, 2019, in Hong Kong. The inclusion were patients with i) atrial fibrillation, and ii) edoxaban or warfarin prescription. 1:2 propensity score matching was performed between edoxaban and warfarin users. Univariate Cox regression identifies significant risk predictors of the primary, secondary and safety outcomes. Hazard ratios (HRs) with corresponding 95% confidence interval [CI] and p values were reported.ResultsThis cohort included 3464 patients (54.18% males, median baseline age: 72 years old, IQR: 63-80, max: 100 years old), 664 (19.17%) with edoxaban use and 2800 (80.83%) with warfarin use. After a median follow-up of 606 days (IQR: 306-1044, max: 1520 days), 91(incidence rate: 2.62%) developed TIA/ischaemic stroke: 1.51% (10/664) in the edoxaban group and 2.89% (81/2800) in the warfarin group. Edoxaban was associated with a lower risk of TIA or ischemic stroke when compared to warfarin.ConclusionsEdoxaban use was associated with a lower risk of TIA or ischemic stroke after propensity score matching for demographics, comorbidities and medication use.

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