Frailty to predict unplanned hospitalization, stroke, bleeding, and death in atrial fibrillation

Abstract Aims Atrial fibrillation (AF) and frailty are common, and the prevalence is expected to rise further. We aimed to investigate the prevalence of frailty and the ability of a frailty index (FI) to predict unplanned hospitalizations, stroke, bleeding, and death in patients with AF. Methods and results Patients with known AF were enrolled in a prospective cohort study in Switzerland. Information on medical history, lifestyle factors, and clinical measurements were obtained. The primary outcome was unplanned hospitalization; secondary outcomes were all-cause mortality, bleeding, and stroke. The FI was measured using a cumulative deficit approach, constructed according to previously published criteria and divided into three groups (non-frail, pre-frail, and frail). The association between frailty and outcomes was assessed using multivariable-adjusted Cox regression models. Of the 2369 included patients, prevalence of pre-frailty and frailty was 60.7% and 10.6%, respectively. Pre-frailty and frailty were associated with a higher risk of unplanned hospitalizations [adjusted hazard ratio (aHR) 1.82, 95% confidence interval (CI) 1.49–2.22; P < 0.001; and aHR 3.59, 95% CI 2.78–4.63, P < 0.001], all-cause mortality (aHR 5.07, 95% CI 2.43–10.59; P < 0.001; and aHR 16.72, 95% CI 7.75–36.05; P < 0.001), and bleeding (aHR 1.53, 95% CI 1.11–2.13; P = 0.01; and aHR 2.46, 95% CI 1.61–3.77; P < 0.001). Frailty, but not pre-frailty, was associated with a higher risk of stroke (aHR 3.29, 95% CI 1.2–8.39; P = 0.01). Conclusion Over two-thirds of patients with AF are pre-frail or frail. These patients have a high risk for unplanned hospitalizations and other adverse events. These findings emphasize the need to carefully evaluate these patients. However, whether screening for pre-frailty and frailty and targeted prevention strategies improve outcomes needs to be shown in future studies. Clinical trial registration Clinicaltrials.gov identifier number: NCT02105844.

Download Full-text

P3782Frailty to predict unplanned hospitalizations, stroke, bleeding and death in atrial fibrillation

European Heart Journal ◽

10.1093/eurheartj/ehz745.0631 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

P Meyre ◽

R Gugganig ◽

S Aeschbacher ◽

D P Leong ◽

S Blum ◽

...

Keyword(s):

Atrial Fibrillation ◽

Clinical Outcomes ◽

Frailty Index ◽

Adverse Outcomes ◽

Cardiovascular Research ◽

All Cause Mortality ◽

Cox Proportional Hazard Models ◽

Cumulative Deficit ◽

Clinical Measurements ◽

Unplanned Hospitalizations

Abstract Aim We investigated the prevalence of frailty, and the relationships between frailty and the risk of adverse clinical outcomes in patients with atrial fibrillation (AF). Methods Patients with known AF were enrolled in a nation-wide observational cohort study in Switzerland. Information on medical history, medication, lifestyle factors and clinical measurements were obtained. The primary outcome was unplanned hospitalizations, secondary outcomes were all-cause mortality, bleeding and stroke. The frailty index (FI) was measured using a cumulative deficit approach according to previously published criteria. Participants were divided into three groups (non-frail, pre-frail and frail) according to their FI at study entry. The association between frailty and clinical outcomes was assessed using multivariable adjusted Cox proportional hazard models. Results We included 2369 patients with a mean age of 73±8 years (27.3% female). The prevalence of frailty and pre-frailty was 10.6% and 60.7%, respectively. Frailty was associated with unplanned hospitalization (adjusted hazard ratio [HR] 3.59; 95% confidence interval [95% CI], 2.78–4.63; p<0.001), all-cause mortality (adjusted HR 16.72; 95% CI 7.75–36.05; p<0.001), bleeding (adjusted HR 2.46; 95% CI 1.61–3.77; p<0.001), and stroke (adjusted HR 3.29; 95% CI 1.29–8.39; p=0.01) (Figure). Similarly, pre-frailty was significantly associated with unplanned hospitalization (adjusted HR 1.82; 95% CI 1.49–2.22; p<0.001), all-cause mortality (adjusted HR 5.07; 95% CI 2.43–10.59; p<0.001) and bleeding (adjusted HR 1.53; 95% CI 1.11–2.13; p=0.01), but not with stroke. Cumulative incidence of adverse events Conclusion In our cohort, more than two thirds of AF patients were either pre-frail or frail. These patients have a high risk of unplanned hospitalizations and other adverse outcomes, indicating that frailty is a powerful tool to predict adverse clinical outcomes in AF patients. Acknowledgement/Funding Swiss National Science Foundation; Foundation for Cardiovascular Research Basel; University of Basel

Download Full-text

Abstract 13613: Combination of Atrial Fibrillation and Frailty: Association With All-cause Mortality in Older Veterans

Circulation ◽

10.1161/circ.142.suppl_3.13613 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Marlena Fernandez ◽

Marie Pitteloud ◽

Angelica Torres ◽

Sergio Ruiz ◽

Victor Cevallos ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cox Regression ◽

Frailty Index ◽

Community Dwelling ◽

Sensory Loss ◽

All Cause Mortality ◽

Physiological Reserve ◽

Icd Codes ◽

The Impact

Background: Atrial fibrillation (AF), the commonest arrhythmia among older adults, is associated with increased mortality. Frailty constitutes a state of vulnerability to stressors resulting from multisystemic loss of physiological reserve. The study aim was to determine whether concurrent frailty and AF increases all-cause mortality in older Veterans. Methods: Retrospective cohort study of community-dwelling Veterans 60 years and older identified as having baseline AF (ICD codes) or frailty through a 30-item VA Frailty Index (VA-FI). The VA-FI was generated as a proportion of morbidity, function, sensory loss, cognition/mood and other variables. The VA-FI categorized Veterans into non-frail (robust FI≤.10, prefrail FI=>.10,<.21) and frail (FI≥.21). The combination resulted in 4 groups: Neither AF nor frailty (NoAF-F), atrial fibrillation (AF), frailty (F), and AF and frailty (AF-F). At the end of follow-up, data on mortality was aggregated and adjusted for age, gender, race, ethnicity, marital status, and BMI, the association of concurrent AF and/or frailty with all-cause mortality was determined using a Cox regression model including testing for interaction effects. Results: A total of 16391 Veterans were included, mean age 72.06 (SD=9.23) years 74.2% White, 86.7% non-Hispanic, and 97.9% male. There were 1534 (9.4%) Veterans with AF and the proportion of robust, pre-frail and frail patients was 44.3% (n=7255), 37.2% (n=6095) and 18.6% (n=3041) respectively. The 4 resulting groups were NoAF-F (12357, 75.4%), AF (993, 6.1%), F (2500, 15.3%) and AF-F (541, 3.3%). Over a median follow-up of 2025 days (IQR=245) 3917 deaths occurred. As compared with NoAF-F, AF-F, F and AF in that order had higher all-cause mortality, adjusted hazard ratio (HR)=3.24 (95%CI:2.88-3.66), p<.0005; HR=2.06 (95%CI:1.90-2.22), p<.0005; and HR=1.47 (95%CI:1.31-1.64), p<.0005 respectively. When frailty and AF were considered jointly they did not interact. Conclusions: The combination of AF and frailty at baseline represents the group with highest risk for all-cause mortality in older Veterans. Further studies may be needed to assess the impact on mortality of clinical interventions targeting both conditions.

Download Full-text

Mortality in patients with atrial fibrillation with or without heart failure following hospital discharge

European Heart Journal ◽

10.1093/ehjci/ehaa946.0362 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A Kartas ◽

A Samaras ◽

D Vasdeki ◽

G Dividis ◽

G Fotos ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Primary Endpoint ◽

Cox Regression ◽

Cross Sectional ◽

Tertiary Center ◽

All Cause Mortality ◽

Endpoint Event ◽

Secondary Endpoints ◽

Sectional Analysis

Abstract Background The association of heart failure (HF) with the prognosis of atrial fibrillation (AF) remains unclear. OBJECTIVES To assess all-cause mortality in patients following hospitalization with comorbid AF in relation to the presence of HF. Methods We performed a cross-sectional analysis of data from 977 patients discharged from the cardiology ward of a single tertiary center between 2015 and 2018 and followed for a median of 2 years. The association between HF and the primary endpoint of death from any cause was assessed using multivariable Cox regression. Results HF was documented in 505 (51.7%) of AF cases at discharge, including HFrEF (17.9%), HFmrEF (16.5%) and HFpEF (25.2%). A primary endpoint event occurred in 212 patients (42%) in the AF-HF group and in 86 patients (18.2%) in the AF-no HF group (adjusted hazard ratio [aHR] 2.27; 95% confidence interval [CI], 1.65 to 3.13; P<0.001). HF was associated with a higher risk of the composite secondary endpoint of death from any cause, AF or HF-specific hospitalization (aHR 1.69; 95% CI 1.32 to 2.16 p<0.001). The associations of HF with the primary and secondary endpoints were significant and similar for AF-HFrEF, AF-HFmrEF, AF-HFpEF. Conclusions HF was present in half of the patients discharged from the hospital with comorbid AF. The presence of HF on top of AF was independently associated with a significantly higher risk of all-cause mortality than did absence of HF, irrespective of HF subtype. Funding Acknowledgement Type of funding source: None

Download Full-text

Cardiovascular risk after hospitalisation for unexplained syncope and orthostatic hypotension

Heart ◽

10.1136/heartjnl-2017-311857 ◽

2017 ◽

Vol 104 (6) ◽

pp. 487-493 ◽

Cited By ~ 14

Author(s):

Ekrem Yasa ◽

Fabrizio Ricci ◽

Martin Magnusson ◽

Richard Sutton ◽

Sabina Gallina ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Cardiovascular Disease ◽

Orthostatic Hypotension ◽

Cardiovascular Events ◽

Hospital Admissions ◽

Cox Regression ◽

All Cause Mortality ◽

Unexplained Syncope ◽

The Impact

ObjectiveTo investigate the relationship of hospital admissions due to unexplained syncope and orthostatic hypotension (OH) with subsequent cardiovascular events and mortality.MethodsWe analysed a population-based prospective cohort of 30 528 middle-aged individuals (age 58±8 years; males, 40%). Adjusted Cox regression models were applied to assess the impact of unexplained syncope/OH hospitalisations on cardiovascular events and mortality, excluding subjects with prevalent cardiovascular disease.ResultsAfter a median follow-up of 15±4 years, 524 (1.7%) and 504 (1.7%) participants were hospitalised for syncope or OH, respectively, yielding 1.2 hospital admissions per 1000 person-years for each diagnosis. Syncope hospitalisations increased with age (HR, per 1 year: 1.07, 95% CI 1.05 to 1.09), higher systolic blood pressure (HR, per 10 mm Hg: 1.06, 95% CI 1.01 to 1.12), antihypertensive treatment (HR: 1.26, 95% CI 1.00 to 1.59), use of diuretics (HR: 1.77, 95% CI 1.31 to 2.38) and prevalent cardiovascular disease (HR: 1.59, 95% CI 1.14 to 2.23), whereas OH hospitalisations increased with age (HR: 1.11, 95% CI 1.08 to 1.12) and prevalent diabetes (HR: 1.82, 95% CI 1.23 to 2.70). After exclusion of 1399 patients with prevalent cardiovascular disease, a total of 473/464 patients were hospitalised for unexplained syncope/OH before any cardiovascular event. Hospitalisation for unexplained syncope predicted coronary events (HR: 1.85, 95% CI 1.49 to 2.30), heart failure (HR: 2.24, 95% CI 1.65 to 3.04), atrial fibrillation (HR: 1.84, 95% CI 1.50 to 2.26), aortic valve stenosis (HR: 2.06, 95% CI 1.28 to 3.32), all-cause mortality (HR: 1.22, 95% CI 1.09 to 1.37) and cardiovascular death (HR: 1.72, 95% CI 1.23 to 2.42). OH-hospitalisation predicted stroke (HR: 1.66, 95% CI 1.24 to 2.23), heart failure (HR: 1.78, 95% CI 1.21 to 2.62), atrial fibrillation (HR: 1.89, 95% CI 1.48 to 2.41) and all-cause mortality (HR: 1.14, 95% CI 1.01 to 1.30).ConclusionsPatients discharged with the diagnosis of unexplained syncope or OH show higher incidence of cardiovascular disease and mortality with only partial overlap between these two conditions.

Download Full-text

P1885Cha2ds-2vasc score lacks of ability to predict mortality in patients attending the emergency department with atrial fibrillation in the presence of troponin i

European Heart Journal ◽

10.1093/eurheartj/ehz748.0633 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

M I Gonzalez Del Hoyo ◽

G Cediel ◽

A Carrasquer ◽

G Bonet ◽

K Vasquez-Nunez ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Emergency Department ◽

Regression Analysis ◽

Troponin I ◽

Cox Regression ◽

Cox Regression Analysis ◽

All Cause Mortality

Abstract Background CHA2DS2-VASc score has been used as a surrogate marker for predicting outcomes beyond thromboembolic risk in patients with atrial fibrillation (AF). Likewise, cardiac troponin I (cTnI) is a predictor of mortality in AF. Purpose This study aimed to investigate the association of cTnI and CHA2DS2-VASc score with long-term prognosis in patients admitted to the emergency department with AF. Methods A retrospective cohort study conducted between January 2012 and December 2013, enrolling patients admitted to the emergency department with AF and having documented cTnI measurements. CHA2DS2-VASc score was estimated. Primary endpoint was 5-year all-cause mortality, readmission for heart failure (HF), readmission for myocardial infarction (MI) and the composite end point of major adverse cardiac events defined as death, readmission for HF or readmission for MI (MACE). Results A total of 578 patients with AF were studied, of whom 252 patients had elevated levels of cTnI (43.6%) and 334 patients had CHA2DS2-VASc score >3 (57.8%). Patients with elevated cTnI tended to be oldercompared with those who did not have cTnI elevation and were more frequently comorbid and of higher ischemic risk, including hypertension, prior MI, prior HF, chronic renal failure and peripheral artery disease. The overall median CHA2DS2-VASc score was higher in those with cTnI elevation compared to those patients elevated cTnI levels (4.2 vs 3.3 points, p<0.001). Main diagnoses at hospital discharge were tachyarrhythmia 30.3%, followed by heart failure 17.7%, respiratory infections 9.5% and acute coronary syndrome 7.3%. At 5-year follow-up, all-cause death was significantly higher for patients with cTnI elevation compared with those who did not have cTnI elevation (56.4% vs. 27%; logrank test p<0.001). Specifically, for readmissions for HF and readmissions for MI there were no differences in between patients with or without cTnI elevation. In addition, MACE was reached in 165 patients (65.5%) with cTnI elevation, compare to 126 patients (38.7%) without cTnI elevation (p<0.001). On multivariable Cox regression analysis, cTnI elevation was an independent predictor of all-cause death (hazard ratio, 1.67, 95% confidence interval [CI]: 1.24–2.26, p=0.001) and of MACE (hazard ratio 1.47, 95% confidence interval 1.15–1.88; P=0.002), but it did not reach statistical significance for readmissions for MI and readmissions for HF. CHA2DS2-VASc score was a predictor on univariate Cox regression analysis for each endpoint, but it did not reach significance on multivariable Cox regression analysis for any endpoint. Conclusions cTnI is independently associated with long-term all-cause mortality in patients attending the emergency department with AF. cTnI compared to CHA2DS2-VASc score is thus a biomarker with predictive capacity for mortality in late follow-up, conferring utility in the risk stratification of patients with atrial fibrillation.

Download Full-text

P4792Dabigatran versus vitamin K antagonists in patients with atrial fibrillation and valvular heart disease

European Heart Journal ◽

10.1093/eurheartj/ehz745.1168 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

J E Strange ◽

C Sindet-Pedersen ◽

L Staerk ◽

E L Grove ◽

T A Gerds ◽

...

Keyword(s):

Atrial Fibrillation ◽

Heart Disease ◽

Vitamin K ◽

Valvular Heart Disease ◽

Cox Regression ◽

Absolute Risk ◽

Risk Difference ◽

Increased Risk ◽

Significant Difference ◽

All Cause Mortality

Abstract Background Atrial fibrillation (AF) and valvular heart disease (VHD) are both associated with an increased risk of stroke. Outside post-hoc analyses of randomized controlled trials, knowledge on the effectiveness and safety of dabigatran in patients with AF and VHD is scarce. Objectives To compare the risk of all-cause mortality, stroke, and bleeding in patients with AF and VHD treated with dabigatran or a vitamin K antagonist (VKA). Methods All Danish residents are provided a unique personal identification number enabling cross-linking of data from Danish nationwide registries. We identified all patients with AF and VHD initiating treatment with dabigatran or VKA between the 22nd of August 2011 and the 31st of December 2014. We defined VHD as aortic stenosis/regurgitation, mitral regurgitation, bioprosthetic heart valves, mitral-, and aortic valve repair. Outcomes were all-cause mortality, stroke, and bleeding. 2-year standardized absolute risks were calculated from cause-specific Cox regression models with death as competing risk. Results In total, 599 (27.3%) and 1,596 (72.7%) patients initiated treatment with dabigatran and VKA. The 2-year standardized absolute risk of all-cause mortality (95% CI) for VKA was 27.6% (25.1% to 30.1%) and 25.4% (21.8% to 29.0%) for dabigatran with a corresponding absolute risk difference of −2.2% (−6.3% to 1.9%) (Figure 1). The 2-year standardized absolute risk of stroke for VKA was 3.4% (2.3% to 4.5%) and 3.9% (2.2% to 5.5%) for dabigatran with a corresponding absolute risk difference of 0.5% (−1.6% to 2.5%). Lastly, the 2-year standardized absolute risk of bleeding for VKA was 8.2% (6.6% to 9.7%) and 7.6% (5.1% to 10.1%) for dabigatran with a corresponding absolute risk difference of −0.5% (−3.4% to 2.4%). Figure 1 Conclusions In this nationwide cohort study, we found no significant difference in the risk of all-cause mortality, stroke, or bleeding in patients with AF and VHD when comparing VKA to dabigatran.

Download Full-text

Relationship between frailty and all-cause mortality in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational research programme AF general long-term registry

European Heart Journal ◽

10.1093/ehjci/ehaa946.2834 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M Proietti ◽

M Vitolo ◽

S Harrison ◽

G.A Dan ◽

A.P Maggioni ◽

...

Keyword(s):

Atrial Fibrillation ◽

Frailty Index ◽

Primary Study ◽

Funding Source ◽

Private Company ◽

Kaplan Meier ◽

Increased Risk ◽

All Cause Mortality

Abstract Introduction Frailty is a major health determinant for cardiovascular disease. Thus far, data on frailty in patients with atrial fibrillation (AF) are limited. Aims To evaluate frailty in a large contemporary cohort of European AF patients, the relationship with oral anticoagulant (OAC) prescription and with risk of all-cause death. Methods We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. A 38-items frailty index (FI) was derived from baseline characteristics according to the accumulation of deficits model proposed by Rockwood and Mitnitsky. All-cause mortality was the primary study outcome. Results Out of the 11096 AF enrolled patients, data for evaluating frailty were available for 6557 (59.1%) patients who have been included in this analysis (mean [SD] age 68.9 [11.5], 37.7% females). Baseline median [IQR] CHA2DS2-VASc and HAS-BLED were 3 [2–4] and 1 [1–2], respectively. At baseline, median [IQR] FI was 0.16 (0.12–0.23), with 1276 (19.5%) patients considered “not-frail” (FI<0.10), 4033 (61.5%) considered “pre-frail” (FI 0.10–0.25) and 1248 (19.0%) considered “frail” (FI≥0.25). Age, female prevalence, CHA2DS2-VASc and HAS-BLED progressively increased across the FI classes (all p<0.001). Use of OAC progressively increased among FI classes; after adjustments FI was not associated with OAC prescription (odds ratio [OR]: 1.09, 95% confidence interval [CI]: 0.98–1.19 for each 0.10 FI increase). Conversely, FI was directly associated with vitamin K antagonist (VKA) use (OR: 1.26, 95% CI: 1.18–1.34 for each 0.10 FI increase) and inversely associated with non-VKA OACs (NOACs) use (OR: 0.82, 95% CI: 0.77–0.88). FI was significantly correlated with CHA2DS2-VASc (Rho= 0.516, p<0.001). Over a median [IQR] follow-up of 731 [704–749] days, there were 569 (8.7%) all-cause death events. Kaplan-Meier curves [Figure] showed an increasing cumulative risk for all-cause death according to FI categories. A Cox multivariable analysis, adjusted for age, sex, type of AF and use of OAC, found that increasing FI as a continuous variable was associated with an increased risk of all-cause death (hazard ratio [HR]: 1.56, 95% CI: 1.40–1.73 for each 0.10 FI increase). An association with all-cause death risk was found across the FI categories (HR: 1.71, 95% CI: 1.23–2.38 and HR: 2.88, 95% CI: 2.02–4.12, respectively for pre-frail and frail patients compared to non-frail ones). FI was also predictive of all-cause death (c-index: 0.660, 95% CI: 0.637–0.682; p<0.001). Conclusions In a European contemporary cohort of AF patients the burden of frailty is significant, with almost 1 out of 5 patients found to be “frail”. Frailty influenced significantly the choice of OAC therapy and was associated with (and predictive of) all-cause death at follow-up. Kaplan-Meier Curves Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Since the start of EORP programme, several companies have supported it with unrestricted grants.

Download Full-text

P2524Extent and outcomes of frailty in older people with atrial fibrillation: a nationwide study using primary care data

European Heart Journal ◽

10.1093/eurheartj/ehz748.0853 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

C Wilkinson ◽

O Todd ◽

M Yadegarfar ◽

A Clegg ◽

C P Gale ◽

...

Keyword(s):

Atrial Fibrillation ◽

Primary Care ◽

Older People ◽

Proportional Hazards ◽

Frailty Index ◽

Community Setting ◽

Cox Proportional Hazards ◽

Adverse Outcomes ◽

All Cause Mortality

Abstract Background The prevalence of atrial fibrillation (AF) in older people is increasing, as is frailty. Frailty describes an increased vulnerability to adverse outcomes, whereby the balance of risk and benefit associated with an intervention may be more nuanced. However, there are limited data from a community setting on the prevalence of AF and frailty in older people. It is important to understand the burden of AF and frailty, and the associated impact on mortality and stroke disease in order to inform shared decision making with patients, and also inform guidelines for this increasing group of older people. Purpose To estimate the prevalence of AF and the burden of frailty in patients with AF, in a large primary care dataset. To report stroke and mortality by frailty group. Methods We used electronic health records of 537,051 patients in England aged 65 years or older on 31/12/2015, with follow-up for all-cause mortality and ischaemic or unclassified stroke to 11/04/2017. Patients with a history of AF were identified using Clinical Terms Version 3 (CTV-3) codes. Frailty was identified up to the point of study entry using the electronic frailty index (eFI, the proportion of deficits out of 36 possible deficits), and categorised into robust (0–0.12), mild (>0.12–0.24), moderate (>0.24–0.36) or severe (>0.36) frailty. Median CHA2DS2-VASc and ATRIA scores for patients with frailty were compared with the robust group using Mann-Whitney. The association between frailty status, all-cause mortality and stroke was calculated using Cox proportional hazards models, adjusted for age and sex. Results Of the cohort, 61,177 patients (11.4%) had AF. Of those with AF, 27,987 (45.8%) were female, and 54,734 (89.5%) had frailty. 6,443 (10.5%) were classified as robust; 20,352 (33.3%) mildly frail; 20,315 (33.2%) moderately frail; and 14,067 (23.0%) severely frail. The median number of eFI-defined deficits among patients with AF was 9 (interquartile range [IQR] 6–12). Median stroke and bleeding scores were higher in those with frailty compared with the robust group (CHA2DS2-VASc 4 [IQR 3–5] v 2 [2–3], p≤0.001; ATRIA 4 [2–6] v 1 [0–2], p≤0.001). During 73,338 patient-years of follow-up, there were 6,805 (11.1%) deaths and 945 (1.54%) strokes. Compared with the robust group, all-cause mortality and stroke were higher with increasing frailty. Mortality: mild frailty hazard ratio 1.53 (95% confidence interval 1.29–1.80); moderate frailty 2.50 (2.13–2.94); severe frailty 4.26 (3.63–5.01). Stroke: mild frailty 1.36 (0.99–1.85); moderate frailty 1.67 (1.23–2.28); severe 1.99 (1.45–2.73). Kaplan-Meier survival curves by frailty Conclusion The prevalence of AF among those aged over 65 years in primary care in England is high, the majority of whom are frail. Increasing severity of frailty was associated with higher mortality and stroke rates. The extent to which the judicious use of oral anticoagulation may improve clinical outcomes for patients with AF and frailty is currently unknown. Acknowledgement/Funding CPG: Bayer, BMS, AstraZeneca, Novartis Vifor Pharma, Menerini

Download Full-text

Clinical application of the novel 4S-AF scheme for the characterisation of patients with atrial fibrillation: a report from the ESC-EHRA EORP Atrial Fibrillation General Long-Term (AFGen LT) registry

European Heart Journal ◽

10.1093/eurheartj/ehab724.0440 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

W.Y Ding ◽

M Proietti ◽

G Boriani ◽

F Marin ◽

C Blomstrom-Lundqvist ◽

...

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Left Atrial ◽

Thromboembolic Event ◽

Stroke Risk ◽

Cox Regression ◽

Cox Regression Analysis ◽

All Cause Mortality ◽

Atrial Enlargement

Abstract Background Current classification systems recommended by major international guidelines are based on a single domain of atrial fibrillation (AF): temporal pattern, symptom severity or underlying comorbidity. Lack of integration between these various elements limits our approach to patients with AF and acts as a barrier against the delivery of better holistic care. The 4S-AF classification scheme was recently introduced as a means for the characterisation of patients with AF. It comprises of 4 domains: stroke risk (St), symptoms (Sy), severity of AF burden (Sb) and substrate (Su). We sought to examine the implementation of the 4S-AF scheme in the EORP-AF General Long-Term Registry and effects of individual domains on outcomes in AF. Methods Patients with AF from 250 centres across 27 participating European countries were included. All patients were over 18 years old and had electrocardiographic confirmation of AF within 12 months prior to enrolment. Data on demographics and comorbidities were collected at baseline. Individual domains of the 4S-AF scheme were assessed using the CHA2DS2-VASc score (St), European Heart Rhythm Association classification (Sy), temporal classification of AF (Sb), and cardiovascular risk factors and the degree of left atrial enlargement (Su). Each of these domains were used during multivariable cox regression analysis. Results A total of 6321 patients were included in the present analysis, corresponding to 57.0% of the original cohort of 11096 patients. The median age of patients was 70 (interquartile range [IQR] 62–77) years with 2615 (41.4%) females. Among these patients, 528 (8.4%) had low stroke risk (St=0), 3002 (47.5%) no or mild symptoms (Sy=0), 2558 (40.5%) newly diagnosed or paroxysmal AF (Sb=0), and 322 (5.1%) no cardiovascular risk factors or left atrial enlargement (Su=0). Median follow-up was 24 months. Using multivariable cox regression analysis, independent predictors of all-cause mortality were (St) (adjusted hazard ratio [aHR] 8.21 [95% CI, 2.60–25.9]), (Sb) (aHR 1.21 [95% CI, 1.08–1.35]) and (Su) (aHR 1.27 [95% CI, 1.14–1.41]). For cardiovascular mortality and any thromboembolic event, only (Su) (aHR 1.73 [95% CI, 1.45–2.06]) and (Sy) (aHR 1.29 [95% CI, 1.00–1.66]) were statistically important, respectively. None of the domains were independently linked to ischaemic stroke or major bleeding. Conclusion Overall, we demonstrated that the 4S-AF scheme may be used to provide clinical characterisation of patients with AF using routinely collected data, and each of the domains within the 4S-AF scheme were independently associated with adverse long-term outcomes of all-cause mortality, cardiovascular mortality and/or any thromboembolic event. FUNDunding Acknowledgement Type of funding sources: None.

Download Full-text

Readmissions, Death and Its Associated Predictors in Heart Failure With Preserved Versus Reduced Ejection Fraction

Journal of the American Heart Association ◽

10.1161/jaha.121.021414 ◽

2021 ◽

Author(s):

Wan Ting Tay ◽

Tiew‐Hwa Katherine Teng ◽

Oliver Simon ◽

Wouter Ouwerkerk ◽

Jasper Tromp ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Ejection Fraction ◽

Recurrent Events ◽

Cox Regression ◽

Beta Blockers ◽

Unique Identifier ◽

Reduced Ejection Fraction ◽

Asian Patients ◽

All Cause Mortality

Background Data on rehospitalizations for heart failure (HF) in Asia are scarce. We sought to determine the burden and predictors of HF (first and recurrent) rehospitalizations and all‐cause mortality in patients with HF and preserved versus reduced ejection fraction (preserved EF, ≥50%; reduced EF, <40%), in the multinational ASIAN‐HF (Asian Sudden Cardiac Death in Heart Failure) registry. Methods and Results Patients with symptomatic (stage C) chronic HF were followed up for death and recurrent HF hospitalizations for 1 year. Predictors of HF hospitalizations or all‐cause mortality were examined with Cox regression for time to first event and other methods for recurrent events analyses. Among 1666 patients with HF with preserved EF (mean age, 68±12 years; 50% women), and 4479 with HF with reduced EF (mean age, 61±13 years; 22% women), there were 642 and 2302 readmissions, with 28% and 45% attributed to HF, respectively. The 1‐year composite event rate for first HF hospitalization or all‐cause death was 11% and 21%, and for total HF hospitalization and all‐cause death was 17.7 and 38.7 per 100 patient‐years in HF with preserved EF and HF with reduced EF, respectively. In HF with preserved EF, consistent independent predictors of these clinical end points included enrollment as an inpatient, Southeast Asian location, and comorbid chronic kidney disease or atrial fibrillation. The same variables were predictive of outcomes in HF with reduced EF except atrial fibrillation, and also included Northeast Asian location, older age, elevated heart rate, decreased systolic blood pressure, diabetes, smoking, and non‐usage of beta blockers. Conclusions One‐year HF rehospitalization and mortality rates were high among Asian patients with HF. Predictors of outcomes identified in this study could aid in risk stratification and timely interventions. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01633398.

Download Full-text