Characteristics and outcomes of atrial fibrillation in patients without traditional risk factors: an RE-LY AF registry analysis

ABSTRACT: Aims Data on patient characteristics, prevalence, and outcomes of atrial fibrillation (AF) patients without traditional risk factors, often labelled 'lone AF', are sparse. METHODS AND RESULTS: The RE-LY AF registry included 15 400 individuals who presented to emergency departments with AF in 47 countries. This analysis focused on patients without traditional risk factors, including age ≥60 years, hypertension, coronary artery disease, heart failure, left ventricular hypertrophy, congenital heart disease, pulmonary disease, valve heart disease, hyperthyroidism, and prior cardiac surgery. Patients without traditional risk factors were compared with age- and region-matched controls with traditional risk factors (1:3 fashion). In 796 (5%) patients, no traditional risk factors were present. However, 98% (779/796) had less-established or borderline risk factors, including borderline hypertension (130-140/80-90 mmHg; 47%), chronic kidney disease (eGFR < 60 mL/min; 57%), obesity (body mass index > 30; 19%), diabetes (5%), excessive alcohol intake (>14 units/week; 4%), and smoking (25%). Compared with patients with traditional risk factors (n = 2388), patients without traditional risk factors were more often men (74% vs. 59%, P < 0.001) had paroxysmal AF (55% vs. 37%, P < 0.001) and less AF persistence after 1 year (21% vs. 49%, P < 0.001). Furthermore, 1-year stroke occurrence rate (0.6% vs. 2.0%, P = 0.013) and heart failure hospitalizations (0.9% vs. 12.5%, P < 0.001) were lower. However, risk of AF-related re-hospitalization was similar (18% vs. 21%, P = 0.09). CONCLUSION: Almost all patients without traditionally defined AF risk factors have less-established or borderline risk factors. These patients have a favourable 1-year prognosis, but risk of AF-related re-hospitalization remains high. Greater emphasis should be placed on recognition and management of less-established or borderline risk factors.

Occurrence of death and stroke in patients in 47 countries 1 year after presenting with atrial fibrillation: a cohort study

Background Atrial fi brillation is an important cause of morbidity and mortality worldwide, but scant data are availablefor long-term outcomes in individuals outside North America or Europe, especially in primary care settings. Methods We did a cohort study using a prospective registry of patients in 47 countries who presented to a hospital emergency department with atrial fi brillation or atrial fl utter as a primary or secondary diagnosis. 15 400 individuals were enrolled to determine the occurrence of death and strokes (the primary outcomes) in this cohort over eight geographical regions (North America, western Europe, and Australia; South America; eastern Europe; the Middle Eastand Mediterrane an crescent; sub-Saharan Africa; India; China; and southeast Asia) 1 year after attending the emergency department. Patients from North America, western Europe, and Australia were used as the reference population, and compared with patients from the other seven regions...

Risk of ischaemic stroke according to pattern ofatrial fibrillation: analysis of 6563 aspirin-treatedpatients in ACTIVE-A and AVERROES

The pattern of atrial fibrillation (AF) occurrence—paroxysmal, persistent, or permanent—is associated with progressivestages of atrial dysfunction and structural changes and may therefore be associated with progressively higher stroke risk.However, previous studies have not consistently shown AF pattern to predict stroke but have been hampered bymethodological shortcomings of low power, variable event ascertainment, and variable anticoagulant use.Methodsand resultsWe analysed the rates of stroke and systemic embolism in 6563 aspirin-treated patients with AF from the ACTIVE-A/AVERROESdatabases. Therewas thorough searching for events and adjudication. Multivariable analyses were performedwith the adjustment for known risk factors for stroke. Mean age of patients with paroxysmal, persistent, and permanentAFwas 69.0+9.9, 68.6+10.2, and 71.9+9.8 years (P , 0.001). TheCHA2DS2-VASc scorewas similar in patients withparoxysmal and persistent AF (3.1+1.4), but was higher in patients with permanent AF (3.6+1.5, P , 0.001). Yearlyischaemic stroke rates were 2.1, 3.0, and 4.2% for paroxysmal, persistent, and permanent AF, respectively, with adjustedhazard ratio of 1.83 (P , 0.001) for permanent vs. paroxysmal and 1.44 (P » 0.02) for persistent vs. paroxysmal.Multivariable analysis identified age ≥ 75 year, sex, history of stroke or TIA, and AF pattern as independent predictorsof stroke, with AF pattern being the second strongest predictor after prior stroke or TIA.Conclusion In a large population of non-anticoagulated AF patients, pattern of AF was a strong independent predictor of stroke riskand may be helpful to assess the risk/benefit for anticoagulant therapy, especially in lower risk patients.

Risk of ischaemic stroke according to pattern ofatrial fibrillation: analysis of 6563 aspirin-treatedpatients in ACTIVE-A and AVERROES

The pattern of atrial fibrillation (AF) occurrence—paroxysmal, persistent, or permanent—is associated with progressivestages of atrial dysfunction and structural changes and may therefore be associated with progressively higher stroke risk.However, previous studies have not consistently shown AF pattern to predict stroke but have been hampered by methodologicalshortcomings of low power, variable event ascertainment, and variable anticoagulant use.Methodsand resultsWe analysed the rates of stroke and systemic embolism in 6563 aspirin-treated patients with AF from the ACTIVE-A/AVERROESdatabases. Therewas thorough searching for events and adjudication. Multivariable analyses were performedwith the adjustment for known risk factors for stroke. Mean age of patients with paroxysmal, persistent, and permanentAFwas 69.0+9.9, 68.6+10.2, and 71.9+9.8 years (P , 0.001). TheCHA2DS2-VASc scorewas similar in patients withparoxysmal and persistent AF (3.1+1.4), but was higher in patients with permanent AF (3.6+1.5, P , 0.001). Yearlyischaemic stroke rates were 2.1, 3.0, and 4.2% for paroxysmal, persistent, and permanent AF, respectively, with adjustedhazard ratio of 1.83 (P , 0.001) for permanent vs. paroxysmal and 1.44 (P » 0.02) for persistent vs. paroxysmal. Multivariableanalysis identified age ≥ 75 year, sex, history of stroke or TIA, and AF pattern as independent predictors ofstroke, with AF pattern being the second strongest predictor after prior stroke or TIA.Conclusion In a large population of non-anticoagulated AF patients, pattern of AF was a strong independent predictor of stroke riskand may be helpful to assess the risk/benefit for anticoagulant therapy, especially in lower risk patients.

Periprocedural bleeding and thromboembolic events with dabigatran compared with warfarin: results from the randomized evaluation of long-term anticoagulation therapy (RE-LY) randomized trial

Background—Dabigatran reduces ischemic stroke in comparison with warfarin; however, given the lack of antidote, there is concern that it might increase bleeding when surgery or invasive procedures are required.Methods and Results—The current analysis was undertaken to compare the periprocedural bleeding risk of patients in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial treated with dabigatran and warfarin. Bleeding rates were evaluated from 7 days before until 30 days after invasive procedures, considering only the first procedure for each patient. A total of 4591 patients underwent at least 1 invasive procedure: 24.7% of patients received dabigatran 110 mg, 25.4% received dabigatran 150 mg, and 25.9% received warfarin, P 0.34. Procedures included: pacemaker/defibrillator insertion (10.3%), dental procedures (10.0%), diagnostic procedures (10.0%), cataract removal (9.3%), colonoscopy (8.6%), and joint replacement (6.2%). Among patients assigned to either dabigatran dose, the last dose of study drug was given 49 (35– 85) hours before the procedure on comparison with 114 (87–144) hours in patients receiving warfarin, P 0.001. There was no significant difference in the rates of periprocedural major bleeding between patients receiving dabigatran 110 mg (3.8%) or dabigatran 150 mg (5.1%) or warfarin (4.6%); dabigatran 110 mg versus warfarin: relative risk, 0.83; 95% CI, 0.59 to 1.17; P 0.28; dabigatran 150 mg versus warfarin: relative risk, 1.09; 95% CI, 0.80 to 1.49; P 0.58. Among patients having urgent surgery, major bleeding occurred in 17.8% with dabigatran 110 mg, 17.7% with dabigatran 150 mg, and 21.6% with warfarin: dabigatran 110 mg; relative risk, 0.82; 95% CI, 0.48 to1.41; P 0.47; dabigatran 150 mg: relative risk, 0.82; 95% CI, 0.50 to 1.35; P 0.44.Conclusions— ...

Periprocedural bleeding and thromboembolic events with dabigatran compared with warfarin

Dabigatran reduces ischemic stroke in comparison with warfarin; however, given the lack of antidote, thereis concern that it might increase bleeding when surgery or invasive procedures are required.Methods and Results—The current analysis was undertaken to compare the periprocedural bleeding risk of patients in theRandomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial treated with dabigatran and warfarin.Bleeding rates were evaluated from 7 days before until 30 days after invasive procedures, considering only the firstprocedure for each patient. A total of 4591 patients underwent at least 1 invasive procedure: 24.7% of patients receiveddabigatran 110 mg, 25.4% received dabigatran 150 mg, and 25.9% received warfarin, P 0.34. Procedures included:pacemaker/defibrillator insertion (10.3%), dental procedures (10.0%), diagnostic procedures (10.0%), cataract removal(9.3%), colonoscopy (8.6%), and joint replacement (6.2%). Among patients assigned to either dabigatran dose, the lastdose of study drug was given 49 (35– 85) hours before the procedure on comparison with 114 (87–144) hours in patientsreceiving warfarin, P 0.001. There was no significant difference in the rates of periprocedural major bleeding betweenpatients receiving dabigatran 110 mg (3.8%) or dabigatran 150 mg (5.1%) or warfarin (4.6%); dabigatran 110 mg versuswarfarin: relative risk, 0.83; 95% CI, 0.59 to 1.17; P 0.28; dabigatran 150 mg versus warfarin: relative risk, 1.09; 95%CI, 0.80 to 1.49; P 0.58. Among patients having urgent surgery, major bleeding occurred in 17.8% with dabigatran 110mg, 17.7% with dabigatran 150 mg, and 21.6% with warfarin: dabigatran 110 mg; relative risk, 0.82; 95% CI, 0.48 to1.41; P 0.47; dabigatran 150 mg: relative risk, 0.82; 95% CI, 0.50 to 1.35; P 0.44.Conclusions—Dabigatran and warfarin were associated with similar rates of periprocedural bleeding, including patientshaving urgent surgery. Dabigatran facilitated a shorter interruption...

Positive predictive value of device-detected atrial high-rateepisodes at different rates and durations: an analysis from ASSERT

BACKGROUND Pacemakers can automatically identify and catalogatrial high-rate episodes (AHREs). While most AHREs represent true atrial tachyarrhythmia/atrial fibrillation (AT/AF), a review of stored electrograms suggests that a substantial proportion do not. As AHREs may lead to the initiation of oral anticoagulation, it iscrucial to understand the relationship between AHREs and true AT/AF.OBJECTIVE To compare the positive predictive value of AHREs forelectrogram-confirmed AT/AF for various atrial rates and episodedurations.METHODS By using data from 2580 patients who participated in the ASymptomatic atrial fibrillation and Stroke Evaluation in pacemakerpatients and the AF Reduction atrial pacing Trial, all AHREs 6 minutes and 190 beats/min with available electrograms were reviewed to determine whether they represented true AT/AF. The positive predictive value of these AHREs was assessed for episodedurations of 6 minutes, 30 minutes, 6 hours, and 24 hours at atrial rates of 190 and 250 beats/min.RESULTS Of 5769 AHREs 6 minutes and 190 beats/min, 82.7% were true AT/AF and 17.3% were false positives (predominantly due to repetitive non–re-entrant ventriculoatrial synchrony).False positives dropped to 6.8%, 3.3%, and 1.8% when the threshold duration was increased to 30 minutes, 6 hours, and 24 hours, respectively. Increasing the threshold heart rate to 250beats/min added little to the positive predictive value when longerthreshold durations were used.CONCLUSIONS By using a cutoff of 6 minutes and 190 beats/min, the rate of false-positive AHREs is 17.3%, making physicianreview of electrograms essential. For AHREs lasting 6 hours, therate of false positives is 3.3%, making physician review less crucial.

Do Omega-3 fatty acids prevent atrial fibrillation after open heart surgery? A meta-analysis of randomized controlled trials

OBJECTIVES: N-3 polyunsaturated fatty acids have been proposed as a novel treatment for preventing postoperative atrial fibrillation due to their potential anti-inflammatory and anti-arrhythmic effects. However, randomized studies have yielded conflicting results. The objective of this study is to review randomized trials of N-3 polyunsaturated fatty acid use for postoperative atrial fibrillation. METHODS: Using the CENTRAL, PUBMED, EMBASE, and LILACS databases, a literature search was conducted to identify all of the studies in human subjects that reported the effects of N-3 polyunsaturated fatty acids on the prevention of postoperative atrial fibrillation in cardiac surgery patients. The final search was performed on January 30, 2011. There was no language restriction, and the search strategy only involved terms for N-3 polyunsaturated fatty acids (or fish oil), atrial fibrillation, and cardiac surgery. To be included, the studies had to be randomized (open or blinded), and the enrolled patients had to be >18 years of age. RESULTS: Four randomized studies (three double-blind, one open-label) that enrolled 538 patients were identified. The patients were predominantly male, the mean age was 62.3 years, and most of the patients exhibited a normal left atrial size and ejection fraction. N-3 polyunsaturated fatty acid use was not associated with a reduction in postoperative atrial fibrillation. Similar results were observed when the open-label study was excluded. CONCLUSIONS: There is insufficient evidence to suggest that treatment with N-3 polyunsaturated fatty acids reduces postoperative atrial fibrillation. Therefore, their routine use in patients undergoing cardiac surgery is not recommended.