Temporal trends in lifetime risks of atrial fibrillation and its complications between 2000 and 2022: Danish, nationwide, population based cohort study.

OBJECTIVES: To examine how the lifetime risks of atrial fibrillation and of complications after atrial fibrillation changed over time. DESIGN: Danish, nationwide, population based cohort study. SETTING: Population of Denmark from 1 January 2000 to 31 December 2022. PARTICIPANTS: 3.5 million individuals (51.7% women and 48.3% men) who did not have atrial fibrillation at 45 years of age or older were followed up until incident atrial fibrillation, migration, death, or end of follow-up, whichever came first. All 362 721 individuals with incident atrial fibrillation (46.4% women and 53.6% men), but with no prevalent complication, were further followed up until incident heart failure, stroke, or myocardial infarction. MAIN OUTCOME MEASURES: Lifetime risk of atrial fibrillation and lifetime risks of complications after atrial fibrillation over two prespecified periods (2000-10 v 2011-22). RESULTS: The lifetime risk of atrial fibrillation increased from 24.2% in 2000-10 to 30.9% in 2011-22 (difference 6.7% (95% confidence interval 6.5% to 6.8%)). After atrial fibrillation, the most frequent complication was heart failure with a lifetime risk of 42.9% in 2000-10 and 42.1% in 2011-22 (-0.8% (-3.8% to 2.2%)). Individuals with atrial fibrillation lost 14.4 years with no heart failure. The lifetime risks of stroke and of myocardial infarction after atrial fibrillation decreased slightly between the two periods, from 22.4% to 19.9% for stroke (-2.5% (-4.2% to -0.7%)) and from 13.7% to 9.8% for myocardial infarction (-3.9% (-5.3% to -2.4%). No evidence was reported of a differential decrease between men and women. CONCLUSION: Lifetime risk of atrial fibrillation increased over two decades of follow-up. In individuals with atrial fibrillation, about two in five developed heart failure and one in five had a stroke over their remaining lifetime after atrial fibrillation diagnosis, with no or only small improvement over time. Stroke risks and heart failure prevention strategies are needed for people with atrial fibrillation.

Birth cohort effects on diagnosed atrial fibrillation incidence: nationwide cohort study from 1980 to 2018.

BACKGROUND: The incidence of atrial fibrillation (AF) shows substantial temporal trends, but the contribution of birth cohort effects is unknown. These effects refer to the relationship between birth year and the likelihood of developing AF. We aimed to assess trends in cumulative incidence of diagnosed AF across birth cohorts and to disentangle the effects of age, birth cohort and calendar period by using age-period-cohort analyses. METHODS: In a Danish nationwide population-based cohort study, 4.7 million individuals were selected at a given index age (45, 55, 65 and 75 years) free of AF and followed up for diagnosed AF. For each index age, we assessed trends in 10-year cumulative incidence of AF across six 5-year birth cohorts. An age-period-cohort model was estimated using Poisson regression with constrained spline functions collapsing data into 1-year intervals across ages and calendar years. RESULTS: Cumulative incidence of AF diagnosis increased across birth cohorts for all index ages (ptrend<0.001). Compared with the first birth cohort, the diagnosed AF incidence rate ratio in the last birth cohort was 3.0 (95% CI 2.9 to 3.2) for index age 45 years, 2.9 (2.8 to 3.0) for 55 years, 2.8 (2.7 to 2.8) for 65 years and 2.7 (2.6 to 2.7) for 75 years. Age-period-cohort analyses showed substantial birth cohort effects independent of age, with no clear period effect. Compared with individuals born in 1930, the diagnosed AF incidence rate was 0.125 smaller among individuals born in 1885 and was four times larger among individuals born in 1975. CONCLUSION: Substantial birth cohort effects, independent of age and calendar period, influence trends in diagnosed AF incidence.

Atrial fibrillation: epidemiology, screening and digital health.

Atrial fibrillation (AF) is highly prevalent with a lifetime risk of about 1 in 3-5 individuals after the age of 45 years. Between 2010 and 2019, the global prevalence of AF has risen markedly from 33.5 million to 59 million individuals living with AF. Early detection of AF and implementation of appropriate treatment could reduce the frequency of complications associated with AF. International AF management guidelines recommend opportunistic and systematic screening for AF, but additional data are needed. Digital approaches and pathways have been proposed for early detection and for the transition to early AF management. Mobile health (mHealth) devices provide an opportunity for digital screening and should be part of novel models of care delivery based on integrated AF care pathways. For a broad implementation of mHealth-based, integrated care for patients with chronic diseases as AF, further high quality evidence is necessary. In this review, we present an overview of the present data on epidemiology, screening techniques, and the contribution of digital health solutions to the integrated management of AF. We also provide a systemic review on current data of digital and integrated AF management.

The Danish Atrial Fibrillation Registry: A Multidisciplinary National Pragmatic Initiative for Monitoring and Supporting Quality of Care Based on Data Retrieved from Administrative Registries.

Aim: The Danish Atrial Fibrillation (AF) Registry monitors and supports improvement of quality of care for all AF patients in Denmark. This report describes the registry's administrative and organizational structure, data sources, data flow, data analyses, annual reporting, and feedback between the registry, clinicians, and the administrative system. We also report the selection process of the quality indicators and the temporal trends in results from 2017-2021. Methods and Results: The Danish AF Registry aims for complete registration and monitoring of care for all patients diagnosed with AF in Denmark. Administrative registries provide data on contacts to general practice, contacts to private cardiology practice, hospital contacts, medication prescriptions, updated vital status information, and biochemical test results. The Danish Stroke Registry provides information on stroke events. From 2017 to 2021, the proportion with a reported echocardiography among incident AF patients increased from 39.9% (95% CI: 39.3-40.6) to 82.6% (95% CI: 82.1-83.1). The initiation of oral anticoagulant therapy among patients with incident AF and a CHA2DS2-VASc score of ≥1 in men and ≥2 in women increased from 85.3% (95% CI: 84.6-85.9) to 90.4% (95% CI: 89.9-91.0). The 1-year and 2-year persistence increased from 85.2% (95% CI: 84.5-85.9) to 88.7% (95% CI: 88.0-89.3), and from 85.4% (95% CI: 84.7-86.2) to 88.2% (95% CI: 87.5-88.8), respectively. The 1-year risk of ischemic stroke among prevalent patients with AF decreased from 0.88% (95% CI: 0.83-0.93) to 0.71% (95% CI: 0.66-0.75). Variation in clinical performance between the five administrative Danish regions was reduced. Conclusion: Continuous nationwide monitoring of quality indicators for AF originating from administrative registries is feasible and supportive of improvements of quality of care.

Electrical energy by electrode placement for cardioversion of atrial fibrillation: a systematic review and meta-analysis.

OBJECTIVE: Electrode patch position may not be critical for success when cardioverting atrial fibrillation (AF), but the relevance of applied electrical energy is unclarified. Our objective was to perform a meta-analysis of randomised trials to examine the dose-response relation between energy level and cardioversion success by electrode position in elective cardioversion. METHODS: We searched PubMed, Embase, The Cochrane Library, Google Scholar and Scopus Citations. Inclusion criteria were randomised controlled trials using biphasic shock waves and self-adhesive patches, and publication date from 2000 to 2023. We used random-effects dose-response models to meta-analyse the relation between energy level and cardioversion success by anterolateral and anteroposterior position. Random-effects models estimated pooled risk ratios (RR) for cardioversion success after the first and the final shocks between the two electrode positions. RESULTS: We included five randomised controlled trials (N=1078). After the first low-energy shock, the electrode position was not significantly associated with the likelihood of successful cardioversion (pooled RR anterolateral vs anteroposterior placement 1.28, 95% CI 0.93 to 1.76, with considerable heterogeneity). After a high-energy final shock, there was no evidence of an association between the electrode position and the cumulative chance of cardioversion success (pooled RR anterolateral vs anteroposterior 1.05, 95% CI 0.97 to 1.14). Regardless of electrode position, cardioversion success was significantly less likely with shock energy levels < 200J compared with 200J. CONCLUSION: Evidence from contemporary randomised trials suggests that higher level of electrical energy is associated with higher conversion rate when cardioverting AF with a biphasic shockwave. Positioning of electrodes can be based on convenience.

Geographical Variation in the Use of Oral Anticoagulation and Clinical Outcomes among Patients with Atrial Fibrillation in Denmark, Sweden, and Finland.

Background Geographical mapping of variations in the treatment and outcomes of a disease is a valuable tool for identifying inequity. We examined international and intranational variations in initiating oral anticoagulation (OAC) therapy and clinical outcomes among patients with atrial fibrillation (AF) in Nordic countries. We also tracked real-world trends in initiating OAC and the clinical outcomes. Methods We conducted a registry-based multinational cohort study of OAC-naive patients with an incident hospital diagnosis of AF in Denmark ( N = 61,345), Sweden ( N = 124,120), and Finland ( N = 59,855) and a CHA 2 DS 2 -VASc score of ≥1 in men and ≥2 in women between 2012 and 2017. Initiation of OAC therapy was defined as dispensing at least one prescription between 90 days before and 90 days after the AF diagnosis. Clinical outcomes included ischemic stroke, intracerebral hemorrhage, intracranial bleeding, other major bleeding, and all-cause mortality. Results The proportion of patients initiating OAC therapy ranged from 67.7% (95% CI: 67.5-68.0) in Sweden to 69.6% (95% CI: 69.2-70.0) in Finland, with intranational variation. The 1-year risk of stroke varied from 1.9% (95% CI: 1.8-2.0) in Sweden and Finland to 2.3% (95% CI: 2.2-2.4) in Denmark, with intranational variation. The initiation of OAC therapy increased with a preference for direct oral anticoagulants over warfarin. The risk of ischemic stroke decreased with no increase in intracranial and intracerebral bleeding. Conclusion We documented inter- and intranational variation in initiating OAC therapy and clinical outcomes across Nordic countries. Adherence to structured care of patients with AF could reduce future variation.

Geographical variation in persistence to oral anticoagulation therapy and clinical outcomes among patients with atrial fibrillation initiating therapy in Denmark, Sweden, Norway and Finland.

AIM: To examine inter-national and regional variations in persistence of oral anticoagulation (OAC) therapy and incidence of clinical outcomes and mortality, among patients with incident atrial fibrillation (AF) in the Nordic countries. METHODS: We conducted a registry-based multinational cohort study of OAC-naïve patients diagnosed with AF that redeemed at least one prescription of OAC after AF in Denmark (N = 25 585), Sweden (N = 59 455), Norway (N = 40 046) and Finland (N = 22 415). Persistence was dispensing at least one prescription of OAC from Day 365 after the first prescription and 90 days forward. RESULTS: Persistence was 73.6% (95% confidence interval 73.0-74.1) in Denmark, 71.1% (70.7-71.4) in Sweden, 89.3% (88.2-90.1) in Norway and 68.6% (68.0-69.3) in Finland. One-year risk of ischemic stroke varied between 2.0% (1.8-2.1) in Norway and 1.5% (1.4-1.6) in Sweden and 1.5% (1.3-1.6) in Finland. One-year risk of major bleeding other than intracranial bleeding varied between 2.1% (1.9-2.2) in Norway and 5.9% (5.6-6.2) in Denmark. One-year mortality risk varied between 9.3% (8.9-9.6) in Denmark and 4.2% (4.0-4.4) in Norway. CONCLUSION: In OAC-naïve patients with incident AF, persistence of OAC therapy and clinical outcomes vary across Denmark, Sweden, Norway and Finland. Initiation of real-time efforts are warranted to ensure uniform high-quality care across nations and regions.

Small-Area Analysis of Treatment and Clinical Outcomes in Patients with Venous Thromboembolism in Denmark: A Nationwide Cohort Study.

OBJECTIVES: To investigate geographical variation in initiation and extended treatment with anticoagulants and clinical outcomes among patients hospitalized with first-time venous thromboembolism (VTE) in Denmark between 2007 and 2018. METHODS: Using nationwide health care registries, we identified all patients with a first-time VTE hospital diagnosis supported by imaging data from 2007 to 2018. Patients were grouped according to residential region (5) and municipality (98) at the time of VTE diagnosis. Cumulative incidence of initiation of and extended (beyond 365 days) anticoagulation treatment as well as clinical outcomes, including recurrent VTE, major bleeding, and all-cause death, were assessed. Sex- and age-adjusted relative risks (RRs) of the outcomes were computed when comparing across individual regions and municipalities. Overall geographic variation was quantified by computing the median RR. RESULTS: We identified 66,840 patients with a first-time VTE hospitalization. A difference in initiation of anticoagulation treatment of more than 20 percentage points between regions was observed (range: 51.9-72.4%, median RR: 1.09, 95% confidence interval [CI]: 1.04-1.13). Variation was also observed for extended treatment (range: 34.2-46.9%, median RR: 1.08, 95% CI: 1.02-1.14). The cumulative incidence of recurrent VTE ranged from 3.6 to 5.3% at 1 year (median RR: 1.08, 95% CI: 1.01-1.15). The difference remained after 5 years, and variation was also observed for major bleeding (median RR: 1.09, 95% CI: 1.03-1.15), whereas it appeared smaller for all-cause mortality (median RR: 1.03, 95% CI: 1.01-1.05). CONCLUSION: Substantial geographical variation in anticoagulation treatment and clinical outcomes occurs in Denmark. These findings indicate a need for initiatives to ensure uniform high-quality care for all VTE patients.

Development and validation of prediction models for incident atrial fibrillation in heart failure.

OBJECTIVES: Accurate prediction of heart failure (HF) patients at high risk of atrial fibrillation (AF) represents a potentially valuable tool to inform shared decision making. No validated prediction model for AF in HF is currently available. The objective was to develop clinical prediction models for 1-year risk of AF. METHODS: Using the Danish Heart Failure Registry, we conducted a nationwide registry-based cohort study of all incident HF patients diagnosed from 2008 to 2018 and without history of AF. Administrative data sources provided the predictors. We used a cause-specific Cox regression model framework to predict 1-year risk of AF. Internal validity was examined using temporal validation. RESULTS: The population included 27 947 HF patients (mean age 69 years; 34% female). Clinical experts preselected sex, age at HF, NewYork Heart Association (NYHA) class, hypertension, diabetes mellitus, chronic kidney disease, obstructive sleep apnoea, chronic obstructive pulmonary disease and myocardial infarction. Among patients aged 70 years at HF, the predicted 1-year risk was 9.3% (95% CI 7.1% to 11.8%) for males and 6.4% (95% CI 4.9% to 8.3%) for females given all risk factors and NYHA III/IV, and 7.5% (95% CI 6.7% to 8.4%) and 5.1% (95% CI 4.5% to 5.8%), respectively, given absence of risk factors and NYHA class I. The area under the curve was 65.7% (95% CI 63.9% to 67.5%) and Brier score 7.0% (95% CI 5.2% to 8.9%). CONCLUSION: We developed a prediction model for the 1-year risk of AF. Application of the model in routine clinical settings is necessary to determine the possibility of predicting AF risk among patients with HF more accurately and if so, to quantify the clinical effects of implementing the model in practice.

Social determinants of health and recurrence of atrial fibrillation after catheter ablation: a Danish nationwide cohort study.

AIMS: To examine the associations between three social determinants of health (SDOH) and recurrence of AF after ablation. METHODS AND RESULTS: We selected patients who underwent a first ablation after an incident hospital diagnosis of AF between 2005 and 2018 from the entire Danish population. Educational attainment, family income, and whether the patient was living alone were assessed at the time of ablation. We used cause-specific proportional hazard models to estimate hazard ratios (HR) with 95% confidence interval (CI) adjusted for age and sex. In secondary analyses, we adjusted for comorbidities, antiarrhythmic medication, and prior electrical cardioversion.We selected 9728 patients (mean age 61 years, 70% men), and 5881 patients had AF recurrence over an average of 1.37 years after ablation (recurrence rate 325.7 (95% CI 317.6-334.2) per 1000 person-years). Lower education (HR 1.09 [1.02-1.17] and 1.07 [1.01-1.14] for lower and medium vs. higher), lower income [HR 1.14 (1.06-1.22) and 1.09 (1.03-1.17) for lower and medium vs. higher], and living alone [HR 1.07 (1.00-1.13)] were associated with increased rates of recurrence of AF. We found no evidence of interaction between sex or prior HF with SDOH. The association between family income and AF recurrence was stronger among patients < 65 years compared with those aged ≥ 65 years. The associations between SDOH and AF recurrence did not persist in the multivariable model. CONCLUSION: AF was more likely to recur among patients with lower educational attainment, lower family income, or those living alone. Multidisciplinary efforts are needed to reduce socioeconomic inequity in the effect of ablation.

Social determinants of health and catheter ablation after an incident diagnosis of atrial fibrillation: a Danish nationwide cohort study.

AIMS: To examine (i) the sex-specific associations between three social determinants of health (SDOH) and use of ablation after incident atrial fibrillation (AF), and (ii) the temporal trends in these associations. METHODS AND RESULTS: We conducted a nationwide cohort study of patients with an incident hospital diagnosis of AF between 2005 and 2018. SDOH at the time of AF diagnosis included three levels of educational attainment, tertile groups of family income, and whether the patient was living alone. Outcome was catheter ablation for AF. We used cause-specific proportional hazard models to estimate hazard ratios (HR) with 95% CI and adjusted for age. To examine temporal trends, we included an interaction term between the exposure and calendar years. Among 122 276 men, those with lower education [HR 0.49 (95%CI 0.45-0.53)] and 0.72 (0.68-0.77) for lower and medium vs. higher], lower income [HR 0.31 (0.27-0.34) and 0.56 (0.52-0.60) for lower and medium vs. higher], and who lived alone [HR 0.60 (0.55-0.64)] were less likely to receive AF ablation. Among 98 476 women, those with lower education [HR 0.45 (0.40-0.50) and 0.83 (0.75-0.91) for lower and medium vs. higher], lower income [HR 0.34 (0.28-0.40) and 0.51 (0.46-0.58) for lower and medium vs. higher], and who lived alone [HR 0.67 (0.61-0.74)] were less likely to receive AF ablation. We found no evidence of temporal trends in the associations. CONCLUSION: In the Danish universal healthcare system, patients with AF who had lower educational attainment, lower family income, or were living alone were less likely to undergo AF ablation.

Social determinants of health and cardiovascular outcomes in patients with heart failure.

BACKGROUND: We examined the associations between family income and educational attainment with incident atrial fibrillation (AF), myocardial infarction (MI), stroke and cardiovascular (CV) death among patients with newly-diagnosed heart failure (HF). METHODS: In a nationwide Danish registry of HF patients diagnosed between 2008 and 2018, we established a cohort for each outcome. When examining AF, MI and stroke, respectively, patients with a history of these outcomes at diagnosis of HF were excluded. We used cause-specific proportional hazard models to estimate hazard ratios for tertile groups of family income and three levels of educational attainment. RESULTS: Among 27,947 AF-free patients, we found no association between income or education and incident AF. Among 27,309 MI-free patients, we found that lower income (hazard ratio 1.28 [95% CI 1.11-1.48] and 1.11 [0.96-1.28] for lower and medium vs. higher income) and education (1.23 [1.04-1.45] and 1.15 [0.97-1.36] for lower and medium vs. higher education) were associated with MI. Among 36,801 stroke-free patients, lower income was associated with stroke (1.38 [1.23-1.56] and 1.27 [1.12-1.44] for lower and medium vs. higher income) but not education. Lower income (1.56 [1.46-1.67] and 1.32 [1.23-1.42] for lower and medium vs. higher income) and education (1.20 [1.11-1.29] and 1.07 [0.99-1.15] for lower and medium vs. higher education) were associated with CV death. CONCLUSIONS: In patients with newly-diagnosed HF, lower family income was associated with higher rates of acute MI, stroke and cardiovascular death. Lower educational attainment was associated with higher rates of acute MI and cardiovascular death. There was no evidence of associations between income and education with incident AF.

Life-Years Lost After Newly Diagnosed Atrial Fibrillation in Patients with Heart Failure.

Objective: Prior work estimated excess death rates associated with atrial fibrillation (AF) in heart failure (HF) with hazard ratios (HR). The aim was to estimate the life-years lost after newly diagnosed AF in HF patients. Methods: Among patients diagnosed with HF in 2008-2018 in the nationwide Danish Heart Failure Registry, we compared patients with incident AF to referents matched on age, sex, and time since HF. We estimated the marginal hazard ratio (HR) for death and marginal difference in restricted mean survival times (RMST) between AF cases and referents at 10 years after AF diagnosis. We adjusted for sex, age at AF diagnosis, clinical and lifestyle risk factors, and medications. Results: Among 4463 AF cases and 17,792 referents (mean age 73.7 years, 29% women), the HR was 1.41 (95% CI 1.38; 1.44) but there was evidence of non-proportional hazards. The difference in RMST was -18.2 months (95% CI -16.8; -19.6) at 10 years after AF diagnosis. There were differences in life-years lost between patients diagnosed with AF >1 year and ≤1 year after HF (-25.7 months, 95% CI -23.7; -27.7 vs -10.4 months, 95% CI -8.2; -12.5, p < 0.001), women and men (-20.3 months, 95% CI -17.7; -21.9 vs -17.2 months, 95% CI -15.5; -19.0, p = 0.05), patients with low, medium, and high CHA2DS2-VASc (10.3 months, 95% CI -4.6; -16.1 vs -18.5 months, 95% CI -16.7; -20.4 vs 22.1, 95% CI -18.8; -22.3, p = 0.002). Conclusion: HF patients with incident AF lost on average 1.5 life-years over 10 years after AF. Life-years lost were larger among patients diagnosed with AF >1 year after HF, women, and patients with higher CHA2DS2-VASc.

Trends in the incidence and mortality of intracerebral hemorrhage, and the associated risk factors, in Denmark from 2004 to 2017.

BACKGROUND AND PURPOSE: The distribution of the major modifiable risk factors for intracerebral hemorrhage (ICH) changes rapidly. These changes call for contemporary data from large-scale population-based studies. The aim of the present study was to examine trends in incidence, risk factors, and mortality in ICH patients from 2004 to 2017. METHODS: In a population-based cohort study, we calculated age- and sex-standardized incidence rates (SIRs), incidence rates (IRs) stratified by age and sex per 100,000 person-years, and trends in risk profiles. We estimated absolute mortality risk, and the Cox proportional hazards regression multivariable-adjusted hazard ratios for 30-day and 1-year mortality. RESULTS: We included 16,902 patients (53% men; median age 75 years) from 2004 to 2017. The SIR of ICH decreased from 33 (95% confidence interval [CI] 32-34) in 2004/2005 to 28 (95% CI 27-29) in 2016/2017. Among patients aged ≥70 years, the IR decreased from 137 (95% CI 130-144) in 2004/2005 to 112 (95% CI 106-117) in 2016/2017. The IR in patients aged <70 years was unchanged. From 2004 to 2017, the proportion of patients with hypertension increased from 49% to 66%, the use of oral anticoagulants increased from 7% to 18%, and the use of platelet inhibitors decreased from 40% to 28%. The adjusted hazard ratio for 30-day mortality in 2016/2017 was 0.94 (95% CI 0.89-1.01) and 1-year mortality was 0.98 (95% CI 0.93-1.04) compared with 2004/2005. CONCLUSION: The incidence of spontaneous ICH decreased from 2004 to 2017, with no clear trend in mortality. The risk profile of ICH patients changed substantially, with increasing proportions of hypertension and anticoagulant treatment. Given the high mortality rate of ICH, further advances in prevention and treatment are urgently needed.

Quality of care and risk of incident atrial fibrillation in patients with newly diagnosed heart failure: a nationwide cohort study.

AIMS: Incident atrial fibrillation (AF) is an adverse prognostic indicator in heart failure (HF); identifying modifiable targets may be relevant to reduce the incidence and morbidity of AF. Therefore, we examined the association between quality of HF care and risk of AF. METHODS AND RESULTS: Using the Danish Heart Failure Registry, we conducted a nationwide registry-based cohort study of all incident HF patients diagnosed between 2008 and 2018 and without history of AF. Quality of HF care was assessed by seven process performance measures, including echocardiographic examination, New York Heart Association classification, treatment with angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, beta-blockers, and mineralocorticoid antagonists, physical training, and patient education. In the main analysis, we examined adherence with all measures in a cohort of 25 100 patients (mean age 68.5 ± 13.2 years; 33.6% women). The median follow-up was 3.1 years. Cox proportional hazard regressions estimated the hazard ratios (HRs) with 95% confidence intervals (95% CIs) between the number of fulfilled measures and incident AF. In a multivariable-adjusted analysis with 0 fulfilled performance measures as reference, the HRs (95% CIs) were 1: 0.78 (0.61-1.00), 2: 0.63 (0.49-0.80), 3: 0.53 (0.36-0.80), 4: 0.64 (0.44-0.94), 5: 0.56 (0.39-0.82), 6: 0.51 (0.35-0.74), and 7: 0.49 (0.33-0.73), with a significant decreasing linear trend (P < 0.001). CONCLUSION: In patients with incident HF, fulfilment of guideline-based process performance measures was associated with decreased long-term risk of AF. This study supports initiatives to improve the quality of care for patients with HF to prevent incident AF.

Newly diagnosed atrial fibrillation and hospital utilization in heart failure: a nationwide cohort study.

AIMS: Atrial fibrillation (AF) constitutes a major burden to health services, but the importance of incident AF in patients with heart failure (HF) is unclear. We examined the associations between incident AF and hospital utilization in patients with HF. METHODS AND RESULTS: In a nationwide matched-cohort study of HF patients, we identified patients diagnosed with incident AF between 2008 and 2018 in the Danish Heart Failure Registry (N = 4463), and we compared them to matched referents without AF (N = 17 802). Incident AF was associated with a multivariable-adjusted 4.8-fold increase (95% CI 4.1-5.6) and 4.3-fold increase (95% CI 3.9-4.8) in the cumulative incidence of inpatient and outpatient contacts within 30 days, respectively. At 1 year, the cumulative incidence ratios were 1.8 (95% CI 1.7-1.9) and 1.4 (95% CI 1.4-1.5). Incident AF was also associated with increases in the total numbers of inpatient and outpatient hospital contacts within 30 days (multivariable-adjusted rate ratio 1.4, 95% CI 1.4-1.5, and 1.6, 95% CI 1.6-1.7, respectively). At 1 year, the ratios were 2.2 (95% CI 2.1-2.3) and 2.0 (95% CI 1.9-2.1). The multivariable-adjusted proportion of bed-day use among HF patients with incident AF was 10.9-fold (95% CI 9.3-12.9) higher at 30 days and 5.3-fold (95% CI 4.3-6.4) higher at 1 year compared with AF-free referents. CONCLUSIONS: Incident AF in HF is associated with earlier hospital contact, more hospital contacts, and more hospital bed-days. More evidence on interventions that may prevent the risk and subsequent burden of AF in HF is urgently needed.

Death of a Partner and Risks of Ischemic Stroke and Intracerebral Hemorrhage: A Nationwide Danish Matched Cohort Study.

Background Stress has been reported to trigger stroke, and the death of a loved one is a potentially extremely stressful experience. Yet, previous studies have yielded conflicting findings of whether bereavement is associated with stroke risk, possibly because of insufficient distinction between ischemic stroke (IS) and intracerebral hemorrhage (ICH). We therefore examined the associations between bereavement and IS and ICH separately in contemporary care settings using nationwide high-quality register resources. Methods and Results The study cohort included all Danish individuals whose partner died between 2002 and 2016 and a reference group of cohabiting individuals matched 1:2 on sex, age, and calendar time. Cox proportional hazards regression was used to estimate adjusted hazard ratios (aHRs) and corresponding 95% CIs during up to 5 years follow-up. During the study period, 278 758 individuals experienced partner bereavement, of whom 7684 had an IS within the subsequent 5 years (aHR, 1.11; CI, 1.08-1.14 when compared with nonbereaved referents) and 1139 experienced an ICH (aHR, 1.13; CI, 1.04-1.23). For ICH, the estimated association tended to be stronger within the initial 30 days after partner death (aHR, 1.66; CI, 1.06-2.61), especially in women (aHR, 1.99; CI, 1.06-3.75), but the statistical precision was low. In absolute numbers, the cumulative incidence of IS at 30 days was 0.73 per 1000 in bereaved individuals versus 0.63 in their referents, and the corresponding figures for ICH were 0.13 versus 0.08. Conclusions Statistically significant positive associations with partner bereavement were documented for both IS and ICH risk, for ICH particularly in the short term. However, absolute risk differences were small.