Publications

Abstract Background: Evidence of adverse clinical outcomes for non-vitamin K antagonist oral anticoagulant (NOACs) and warfarin in patients with atrial fibrillation (AF) and diabetes mellitus are limited. We investigated the effectiveness, safety, and major adverse limb events for NOACs versus warfarin among diabetic AF patients. Methods: In this nationwide retrospective cohort study collected from Taiwan National Health Insurance Research Database, we identified a total of 20,967 and 5,812 consecutive AF patients with diabetes taking NOACs and warfarin from June 1, 2012, to December 31, 2017, respectively. We used propensity-score stabilized weighting to balance covariates across study groups. Results: NOAC was associated with a lower risk of major adverse cardiovascular events (MACE) (adjusted hazard ratio (aHR):0.88; [95% confidential interval (CI):0.78-0.99]; P =0.0283), major adverse limb events (aHR:0.72;[95%CI:0.57-0.92]; P =0.0083), and major bleeding (aHR:0.67;[95%CI:0.59-0.76]; P <.0001) compared to warfarin. NOACs decreased MACE in patients of 75 but not in those aged <75 years ( P interaction=0.01), and in patients with ischemic heart disease (IHD) compared to those without IHD ( P interaction<0.01). For major adverse limb events, the advantage of risk reduction for NOAC over warfarin persisted in high risk subgroups including age 75 years, chronic kidney disease, IHD, peripheral artery disease, or use of concomitant antiplatelet drugs. Conclusion: NOACs were associated with a lower risk of effectiveness, safety, and major adverse limb events than warfarin among diabetic AF patients. Thromboprophylaxis with NOACs should be considered in the diabetic AF population with a high atherosclerotic burden.

This work was supported by the Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (grant 2017-I2M-1-004), the Projects in the Chinese National Science & Technology Pillar Program during the Twelfth Five-year Plan Period (No.: 2011BAI11B01), and the Project Entrusted by the National Health Commission of the People's Republic of China (NHC2020-609).

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More than one-third of patients in the BALKAN-AF survey received a rhythm control strategy, and these patients tended to be younger with less comorbidities than those managed with rate control. EHRA symptom score is not significantly associated with rhythm control strategy. The most commonly used antiarrhythmic agents were amiodarone, followed by propafenone.

Abstract Background Several risk factors are common between atrial fibrillation (AF) and atherosclerosis. The brachial-ankle pulse wave velocity (baPWV) is a marker of arterial stiffness. Objectives To investigate the predictive value of baPWV for new-onset AF. Methods All participants without AF as of December 31, 2020 from the Kailuan cohort were included. Demographic characteristics and baPWV were recorded. The primary endpoint was new-onset AF. Participants were divided into three groups according to baPWV. We analyzed the predictive value when baPWV was as a continuous variable. Results A total of 49872 subjects (mean age: 47.57 years old, 74.2% male) were included with follow-up of 6.17(3.95-8.46) years. Compared with normal baPWV group, the risk of AF increased with increasing baseline baPWV, whereby the adjusted hazard ratio (aHR) of the high baPWV group and the atherosclerotic group were 1.82 (95% confidence interval [CI]: 1.18-2.80) and 2.08 (95% CI: 1.31-3.30), respectively. As a continuous variable, for every 361 cm/s increase in baseline baPWV, the risk of AF increased by 21.7% (aHR:1.22; 95% CI: 1.08-1.37). In subgroup analysis of non-hypertensive patients, the risks of AF in the high baPWV group (aHR: 3.16, 95% CI: 1.74-5.74) and atherosclerotic group (aHR: 2.26, 95% CI: 1.02-5.05) were significantly higher, compared with normal baPWV group. In overweight patients, the risk of AF in atherosclerotic group was significantly higher than that in normal baPWV group (aHR: 1.69, 95% CI: 1.00-2.83). Conclusions The risk of AF increases with the increase of baPWV, and baPWV is of predictive value in occurrence of AF.

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In patients with IS or transient ischaemic attack, impaired kidney function was associated with a higher risk of recurrent stroke and higher microbleeds burden, compared with those with normal kidney function. Further research is needed to investigate potential additional measures for secondary prevention in this high-risk group.

The technological evolution and widespread availability of wearables and handheld ECG devices capable of screening for atrial fibrillation (AF), and their promotion directly to consumers, has focused attention of health care professionals and patient organizations on consumer-led AF screening. In this Frontiers review, members of the AF-SCREEN International Collaboration provide a critical appraisal of this rapidly evolving field to increase awareness of the complexities and uncertainties surrounding consumer-led AF screening. Although there are numerous commercially available devices directly marketed to consumers for AF monitoring and identification of unrecognized AF, health care professional-led randomized controlled studies using multiple ECG recordings or continuous ECG monitoring to detect AF have failed to demonstrate a significant reduction in stroke. Although it remains uncertain if consumer-led AF screening reduces stroke, it could increase early diagnosis of AF and facilitate an integrated approach, including appropriate anticoagulation, rate or rhythm management, and risk factor modification to reduce complications. Companies marketing AF screening devices should report the accuracy and performance of their products in high- and low-risk populations and avoid claims about clinical outcomes unless improvement is demonstrated in randomized clinical trials. Generally, the diagnostic yield of AF screening increases with the number, duration, and temporal dispersion of screening sessions, but the prognostic importance may be less than for AF detected by single-time point screening, which is largely permanent, persistent, or high-burden paroxysmal AF. Consumer-initiated ECG recordings suggesting possible AF always require confirmation by a health care professional experienced in ECG reading, whereas suspicion of AF on the basis of photoplethysmography must be confirmed with an ECG. Consumer-led AF screening is unlikely to be cost-effective for stroke prevention in the predominantly young, early adopters of this technology. Studies in older people at higher stroke risk are required to demonstrate both effectiveness and cost-effectiveness. The direct interaction between companies and consumers creates new regulatory gaps in relation to data privacy and the registration of consumer apps and devices. Although several barriers for optimal use of consumer-led screening exist, results of large, ongoing trials, powered to detect clinical outcomes, are required before health care professionals should support widespread adoption of consumer-led AF screening.

Abstract Background Life-long oral anticoagulation therapy with warfarin or direct oral anticoagulants (DOACs) is the mainstay for stroke prevention in patients with non-valvular atrial fibrillation (AF). The DOACs might potentially have lower risk on decline in renal function than warfarin. The aim of this study was to examine the renal outcomes among rivaroxaban, edoxaban, dabigatran and warfarin. Method Using a clinical database from a single-center, this cohort study identified 2203 adults with AF who started anticoagulation therapy between July 1, 2013 and December 31, 2020. Inverse probability of treatment weighting was adopted to balance baseline characteristics among four groups. The primary outcome was a composite of cardiorenal outcomes, involving ≥ 30% decline in estimated glomerular filtration rate (eGFR), renal failure, cardiovascular death, and renal death. Other renal outcomes of interest including ≥ 30% decline in eGFR, doubling of serum creatinine, the incidence of acute kidney injury (AKI) and renal failure, were analyzed. Result We studied 595 patients on warfarin, who were compared to 244, 1070 and 289 patients on dabigatran, rivaroxaban and edoxaban, respectively. After propensity score weighting, dabigatran was associated with significantly lower risk of ≥ 30% decline in eGFR (hazard ratio [HR]: 0.69; 95% confidence interval [CI]: 0.497 to 0.951; p = 0.0237), doubling of serum creatinine (HR:0.49; 95% CI: 0.259 to 0.927; p = 0.0282), and the composite of cardiorenal outcomes (HR:0.67; 95% CI: 0.485 – 0.913; p = 0.0115) compared with warfarin. Rivaroxaban and edoxaban did not show statistically significant protective effects on any renal outcomes, compared to warfarin. Conclusion In this retrospective, single center study, patients treated with dabigatran had significantly reduced risk of decline in renal function and cardiorenal events, when compared to those treated with warfarin. In contrast, rivaroxaban and edoxaban were not associated with lower risk of AKI and renal failure when compared to warfarin.