Peripheral Arterial Disease in Patients with Atrial Fibrillation: The AFFIRM Study

Abstract Background Peripheral arterial disease is a marker of aggressive atherosclerosis. The ankle brachial index (ABI) is a simple and non-invasive tool to diagnose peripheral arterial disease (PAD). Patients with PAD are at increased risk for ischemic strokes and other cardiovascular diseases. Purpose To evaluate the association of abnormal ABI and poorly compressible vessels with ischemic stroke in a large patient cohort. Methods We analyzed lower extremity vascular studies of all patients with ABI measurements at a tertiary care hospital between January 1996 and August 2018. PAD is defined as ABI<1.0, and poorly or non-compressible (PC/NC) arteries as ABI>1.4 while ABI between 1.0–1.4 is normal. Association of these ABIs with new ischemic stroke events post ABI measurement were analyzed after adjusting for high risk confounders such as atrial fibrillation. Hazard ratios (HR) were calculated using multivariable Cox proportional regression with 95% confidence intervals. Results In total, 38,016 unique patients (mean age 66.1±14.8 years, female 42.3%) were included. Abnormal ABI was found to be more prevalent among elderly male patients compared to patients with normal ABI. In contrast to non-PAD patients, both PAD and PC/NC patients as defined by ABI had a statistically significant risk of ischemic stroke, with PAD conferring the greatest risk compared to PC/NC vessels. The data is summarized in Table 1. Table 1 Unadjusted HR p-value Adjusted HR p-value PAD vs. No PAD 2.77 (2.62, 2.92) <0.001 2.10 (1.98, 2.22) <0.001 PC/NC vs. No PAD 2.11 (1.95, 2.28) <0.001 1.38 (1.26, 1.51) <0.001 PAD vs. PC/NC 1.37 (1.28, 1.46) <0.001 1.37 (1.28, 1.48) <0.001 Adjusted and unadjusted hazard ratios with p-values. HR adjusted for age, sex, atrial fibrillation, ischemic stroke, transient ischemic attack, chronic heart failure, diabetes mellitus, hyperlipidemia, hypertension, and coronary artery disease. PAD = Peripheral artery disease and PC/NC = poorly compressible/non-compressible. Conclusion This study adds to the growing body of evidence that PAD and poorly-compressible vessels are independently associated with an increased risk of ischemic stroke. Given the associated risk of cerebrovascular disease, clinicians should aggressively treat to minimize risk factors in those with abnormal ABIs.

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Atrial fibrillation in a cohort of patients with peripheral arterial disease. A retrospective study of a healthcare database in UK

European Heart Journal ◽

10.1093/ehjci/ehaa946.2366 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A.V Vitalis ◽

A.S Shantsila ◽

R.T Thayakaran ◽

K.N Nirantharakumar ◽

G.Y.L Lip

Keyword(s):

Atrial Fibrillation ◽

Retrospective Study ◽

Peripheral Arterial Disease ◽

Arterial Disease ◽

Limb Loss ◽

Lipid Lowering ◽

Health Improvement ◽

Healthcare Database ◽

Baseline Characteristics ◽

Peripheral Arterial

Abstract Atrial fibrillation in a cohort of patients with peripheral arterial disease. A retrospective study of a healthcare database in UK. Background There is strong evidence that peripheral arterial disease (PAD) is linked with worse outcomes in patients with atrial fibrillation (AF), which has led vascular disease to be included as one of the components of CHA2DS2-VASc score for risk stratification in AF. On the other hand, very limited evidence exists on the prognostic implication of AF in patients with PAD. Purpose The aim of this study is to identify the prevalence of AF in a cohort of PAD patients and demonstrate its association with adverse cardiovascular outcomes, limb loss and mortality. Methods This is a retrospective study of The Health Improvement Network (THIN) database, which contains computerized records from primary care physicians, covering more than 11 million patients from over 600 general practices in the UK. During the studied period from 1995 to 2017, 55540 patients with newly diagnosed PAD have been detected in the database and baseline characteristics, coexisting medical diagnoses (including AF), relevant medication and subsequent outcomes have been recorded using appropriately selected clinical codes (READ codes). A comparison of baseline characteristics was made between patients with PAD and AF and those without AF using descriptive statistics. Multivariate cox regression analysis was then performed and hazard rations for mortality, stroke or transient ischaemic attack (TIA), ischaemic heart disease (IHD), heart failure (HF) and major lower limb amputation at presence of AF were calculated, after adjustment for age, sex, ethnicity, BMI, smoking, Townsend comorbidity index, diabetes, hypertension, kidney function, and medication (lipid- lowering, antiplatelets, anticoagulants). Results From the 55540 patients with new diagnosis of PAD during the study period, 5685 (10.2%) had coexisting AF. Patients with AF were older, had higher prevalence of diabetes, hypertension and renal failure, were more likely to be on anticoagulants, antiplatelets and lipid lowering agents, were more likely to be ex-smokers but less likely to be active smokers. Mean follow up period was 5.1 (SD= 4) years. After adjustment for confounders, AF patients were at higher risk for death (HR: 1.30, 95% CI 1.24- 1.37, p<0.01) for stroke or TIA (HR: 1.46, 95% CI 1.29- 1.65, p<0.01) and for HF (HR: 1.85, 95% CI 1.65- 2.08, p<0.01). There was no significant association between AF and development of IHD (p=0.34) and limb loss (p=0.14) in this cohort. Conclusion AF is a predictor of worse prognosis in patients with PAD. Close monitoring and medical optimization of these patients is warranted. Funding Acknowledgement Type of funding source: None

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Adverse outcomes in patients with atrial fibrillation and peripheral arterial disease: a report from the EURObservational research programme pilot survey on atrial fibrillation

EP Europace ◽

10.1093/europace/euw169 ◽

2016 ◽

Vol 19 (9) ◽

pp. 1439-1448 ◽

Cited By ~ 25

Author(s):

Marco Proietti ◽

Valeria Raparelli ◽

Cécile Laroche ◽

Georghe-Andrei Dan ◽

Marianna Janion ◽

...

Keyword(s):

Atrial Fibrillation ◽

Peripheral Arterial Disease ◽

Research Programme ◽

Arterial Disease ◽

Adverse Outcomes ◽

Pilot Survey ◽

Peripheral Arterial

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Abstract 11471: Peripheral Arterial Disease and Risk of Atrial Fibrillation and Stroke: The Multi-Ethnic Study of Atherosclerosis

Circulation ◽

10.1161/circ.130.suppl_2.11471 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Wesley T O’Neal ◽

Jimmy T Efird ◽

Saman Nazarian ◽

Alvaro Alonso ◽

Susan R Heckbert ◽

...

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Peripheral Arterial Disease ◽

Cox Regression ◽

Ankle Brachial Index ◽

Arterial Disease ◽

Ethnic Study ◽

Hazard Ratios ◽

Increased Risk ◽

Peripheral Arterial

Introduction: Peripheral arterial disease (PAD) shares several risk factors with atrial fibrillation (AF) and persons with PAD have an increased risk of stroke. It is unclear if PAD is associated with an increased risk for AF and whether such an association explains the increased risk of stroke associated with PAD. Methods: We examined the association between PAD, as measured by the ankle-brachial index (ABI), and incident AF and incident stroke, separately, in 6,568 participants (mean age 62 ± 10; 53% women; 62% non-white) from the Multi-Ethnic Study of Atherosclerosis (MESA). ABI values <1.0 or >1.4 defined PAD in this analysis. Participants were free of baseline clinical cardiovascular disease and AF. AF was ascertained by review of hospital discharge records and from Medicare claims data until December 31, 2010. An independent adjudication committee ascertained stroke events. Cox regression was used to compute hazard ratios (HR) and 95% confidence intervals (95%CI) for the association between PAD and AF and stroke. Results: A total of 774 (12%) participants had baseline PAD. Over a median follow-up of 8.5 years, 301 (4.6%) participants developed AF and 140 (2.1%) developed stroke. In a model adjusted for socio-demographics, cardiovascular risk factors, and potential confounders, PAD was associated with an increased risk of AF (HR=1.5, 95%CI=1.1, 2.0). In a similar model, PAD was associated with incident stroke (HR=1.7, 95%CI=1.1, 2.5) and the magnitude of risk was not different after inclusion of AF as a time-dependent covariate (HR=1.7, 95%CI=1.1, 2.5). Similar results were obtained in subgroup analyses stratified by age, sex, and race/ethnicity. Conclusions: PAD is independently associated with an increased risk of AF and stroke in the MESA study. The relationship between PAD and stroke is not mediated by AF.

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