Prognostic implications of valvular heart disease in patients with non-valvular atrial fibrillation.

BACKGROUND: Valvular heart disease (VHD) in non-valvular atrial fibrillation (AF) is a puzzling clinical entity. The aim of this study was to evaluate the prognostic effect of significant VHD (sVHD) among patients with non-valvular AF. METHODS: This is a post-hoc analysis of the MISOAC-AF trial (NCT02941978). Consecutive inpatients with non-valvular AF who underwent echocardiography were included. sVHD was defined as the presence of at least moderate aortic stenosis (AS) or aortic/mitral/tricuspid regurgitation (AR/MR/TR). Cox regression analyses with covariate adjustments were used for outcome prediction. RESULTS: In total, 983 patients with non-valvular AF (median age 76 [14] years) were analyzed over a median follow-up period of 32 [20] months. sVHD was diagnosed in 575 (58.5%) AF patients. sVHD was associated with all-cause mortality (21.6%/yr vs. 6.5%/yr; adjusted HR [aHR] 1.55, 95% confidence interval [CI] 1.17-2.06; p = 0.02), cardiovascular mortality (16%/yr vs. 4%/yr; aHR 1.70, 95% CI 1.09-2.66; p = 0.02) and heart failure-hospitalization (5.8%/yr vs. 1.8%/yr; aHR 2.53, 95% CI 1.35-4.63; p = 0.02). The prognostic effect of sVHD was particularly evident in patients aged < 80 years and in those without history of heart failure (p for interaction < 0.05, in both subgroups). After multivariable adjustment, moderate/severe AS and TR were associated with mortality, while AS and MR with heart failure-hospitalization. CONCLUSION: Among patients with non-valvular AF, sVHD was highly prevalent and beared high prognostic value across a wide spectrum of clinical outcomes, especially in patients aged < 80 years or in the absence of heart failure. Predominantly AS, as well as MR and TR, were associated with worse prognosis.

A novel prognostic tool to predict mortality in patients with atrial fibrillation: The BASIC-AF risk score.

BACKGROUND: This study sought to develop and validate a risk score to predict mortality in patients with atrial fibrillation (AF) after a hospitalization for cardiac reasons. METHODS: The new risk score was derived from a prospective cohort of hospitalized patients with concurrent AF. The outcome measures were all-cause and cardiovascular mortality. Random forest was used for variable selection. A risk points model with predictor variables was developed by weighted Cox regression coefficients and was internally validated by bootstrapping. RESULTS: In total, 1130 patients with AF were included. During a median follow-up of 2 years, 346 (30.6%) patients died and 250 patients had a cardiovascular cause of death. N-terminal pro-B-type natriuretic peptide and high-sensitivity troponin-T were the most important predictors of mortality, followed by indexed left atrial volume, history and type of heart failure, age, history of diabetes mellitus, and intraventricular conduction delay, all forming the BASIC-AF risk score (Biomarkers, Age, ultraSound, Intraventricular conduction delay, and Clinical history). The score had good discrimination for all-cause (c-index = 0.85 and 95% CI 0.82-0.88) and cardiovascular death (c-index = 0.84 and 95% CI 0.81-0.87). The predicted probability of mortality varied more than 50-fold across deciles and adjusted well to observed mortality rates. A decision curve analysis revealed a significant net benefit of using the BASIC-AF risk score to predict the risk of death, when compared with other existing risk schemes. CONCLUSIONS: We developed and internally validated a well-performing novel risk score for predicting death in patients with AF. The BASIC-AF risk score included routinely assessed parameters, selected through machine-learning algorithms, and may assist in tailored risk stratification and management of these patients.

Motivational Interviewing to Support Oral AntiCoagulation adherence in patients with non-valvular Atrial Fibrillation (MISOAC-AF): a randomized clinical trial.

AIMS: We aimed to assess the impact of an educational, motivational intervention on the adherence to oral anticoagulation (OAC) in patients with non-valvular atrial fibrillation (AF). METHODS AND RESULTS: Hospitalized patients with non-valvular AF who received OAC were randomly assigned to usual medical care or a proactive intervention, comprising motivational interviewing, and tailored counselling on medication adherence. The primary study outcome was adherence to OAC at 1 year, which was evaluated according to proportion of days covered (PDC) by OAC regimens and was assessed through nationwide registers of prescription claims. Secondary outcomes included the rate of persistence to OAC, gaps in treatment, and clinical events. A total of 1009 patients were randomized, 500 in the intervention group and 509 in the control group. At 1-year follow-up, 77.2% (386/500) of patients in the intervention group were adherent (PDC > 80%), compared with 55% (280/509) in the control group [adjusted odds ratio (aOR) 2.84, 95% confidence interval (CI) 2.14-3.75; P < 0.001]. Mean PDC ± standard deviation was 0.85 ± 0.26 and 0.75 ± 0.31, respectively (P < 0.001). Patients that received the intervention were more likely to persist in their OAC therapy at 1 year (aOR 2.42, 95% CI 1.71-3.41; P < 0.001). Usual medical care was associated with more major (≥3 months) treatment gaps (aOR 2.39, 95% CI 1.76-3.26; P < 0.001). Clinical events over a median follow-up period of 2 years did not differ among treatment groups. CONCLUSION: In patients receiving OAC therapy for non-valvular AF, a multilevel motivational intervention significantly improved medication adherence and rate of therapy persistence, and reduced major gaps in treatment. No significant impact on clinical outcomes was observed. TRIAL REGISTRATION NUMBER: NCT02941978.

Hospitalization affects the anticoagulation patterns of patients with atrial fibrillation.

Scarce data are available on the effects of hospitalization on oral anticoagulation (OAC) patterns in patients with atrial fibrillation (AF). This study aimed to capture the evolving OAC patterns of patients with known non-valvular AF at high risk for stroke (CHA2DS2-Vasc score ≥ 2 for males and ≥ 3 for females) during hospitalization. A total of 561 eligible patients who were admitted to the cardiology ward of a tertiary hospital were studied. Pre- and post-hospitalization OAC patterns [vitamin-K antagonist (VKA), non-vitamin K oral anticoagulants (NOAC), no OAC], changes between these patterns (initiation, switch, discontinuation, no change) and the respective patient profiles and discharge diagnoses were assessed. During hospitalization, OAC administration increased from 73.1 to 86.6% of patients (p for trend < 0.001). NOAC use increased significantly (42.2-56.1%, p for trend < 0.001), whereas VKA use remained stable (30.8-30.5%). Of patients, 17.3% initiated OAC, 7.1% switched between OACs, 3.7% discontinued OAC treatment, while the rest underwent no change in anticoagulation status. Bleeding risk, use of concomitant antiplatelet therapy and incidence of primary discharge diagnosis of AF or ST-elevation myocardial infarction differed significantly between groups of initiation, switch, discontinuation and no change in OAC therapy. In conclusion, in patients with known AF at high risk for stroke, hospitalization was associated with an increase in OAC uptake, driven mainly by NOAC initiation. Three out of 10 patients initiated, switched or discontinued OAC treatment during hospitalization and this was associated with discrete epidemiologic parameters.

Flaws in Anticoagulation Strategies in Patients With Atrial Fibrillation at Hospital Discharge.

BACKGROUND: Proper anticoagulation is a crucial therapeutic regimen in atrial fibrillation (AF). OBJECTIVES: To evaluate the real-life anticoagulation prescriptions of AF patients upon hospital discharge. METHODS: We studied 768 patients with comorbid AF who were discharged from the cardiology ward of a tertiary hospital. We assessed the appropriateness of oral anticoagulation (OAC) regimens at discharge based on stroke risk (CHA2DS2-Vasc score), SAMe-TT2R2 (sex, age, medical history, treatment, tobacco, race) score for vitamin K antagonists (VKA), and European labeling for nonvitamin K oral anticoagulant (NOAC) dosing. Logistic regression identified factors associated with suboptimal OAC use. RESULTS: Of 734 patients at significant (moderate or high) stroke risk, 107 (14.6%) were not prescribed OAC, which was administered to 23 (67.6%) of 34 patients at low risk. Nonprescribing of OAC to high-risk patients was associated with paroxysmal AF (adjusted odds ratio [OR]: 2.42, 95% confidence interval [CI]: 1.47-3.99, P < .001), history of major bleeding (adjusted OR: 1.89, 95% CI: 1.03-3.47, P = .039), and concomitant antiplatelet use (adjusted OR: 5.78, 95% CI: 3.51-9.51, P < .001). Anticoagulation control was inadequate (SAMe-TT2R2 score > 2) in 102 (50.2%) VKA-treated patients. Off-label dosing was evident in 118 (28.9%) NOAC-treated patients and was associated with a prior stroke/transient ischemic attack (adjusted OR: 2.06, 95% CI: 1.10-3.85, P = .023). Both outcomes were independently associated with low creatinine clearance. CONCLUSIONS: One of 6 patients with AF newly discharged from the hospital was treated discordantly for the corresponding risk of stroke. Suboptimal OAC use was evident in half of VKA regimens, twice as common compared to NOACs, and could be predicted by several clinical parameters.