Frequency of cardioversions as an additional risk factor for stroke in atrial fibrillation – the FinCV-4 study

BackgroundPatients with atrial fibrillation (AF) are selected for oral anticoagulation based on individual patient characteristics. There is little information on how clinical AF burden associates with the risk of ischaemic stroke or systemic embolism (SSE). The aim of this study was to explore the association of the frequency of cardioversions (CV) as a measure of clinical AF burden on the long-term SSE risk, with a focus on patients at intermediate stroke risk based on CHA₂DS₂-VASc score. For these patients, additional SSE risk stratification by assessing CV frequency may aid in the decision on whether to initiate oral anticoagulation.MethodsThis retrospective analysis of FinCV Study from years 2003–2010 included 2074 patients who were not using any oral anticoagulation (long term or temporary) after CVs and undergoing a total of 6534 CVs for AF from emergency departments of three hospitals. Two study groups were formed: high CV frequency (mean interval between CVs ≤12 months and low frequency (>12 months).ResultsA total of 107 SSEs occurred during a mean follow-up of 5.4 years. The event rates per 100 patient-years were 1.82 and 0.67 in high versus low CV frequency groups, respectively. After adjustment for CHA₂DS₂-VASc score, CV frequency independently predicted SSE (HR, 2.87 [95% CI, 1.47 to 5.64]; p = .002) at 3 years. Competing risk analysis also identified CV frequency (sHR, 2.70 [95% CI, 1.38–5.31]; p = .004) as an independent predictor for SSE. In patients with CHA₂DS₂-VASc score 1 and low CV frequency, the SSE risk was only 0.08 per 100 patient-years.ConclusionsFrequency of CVs for symptomatic AF episodes provides additional information on stroke risk in AF patients with CHA₂DS₂-VASc score 1.

Key messages

• This retrospective study offers a unique opportunity to observe the natural course of AF patients with infrequent episodes of clinical arrhythmia when they were not using OAC (before introduction of CHA₂DS₂-VASc score).
• Stroke or systemic embolism rate was very low (0.08 per 100 patient-years) in patients with one CHA₂DS₂-VASc point who visited the emergency room for cardioversion less than once a year.
• Frequency of cardioversions can be used for additional risk stratification in patients at intermediate risk of stroke based on CHA₂DS₂-VASc score.

     

Prognostic value of GRACE and CHA2DS2-VASc score among patients with atrial fibrillation undergoing percutaneous coronary intervention

AimsThe GRACE and CHA2DS2-VASc risk score are developed for risk stratification in patients with acute coronary syndrome and AF, respectively. We aimed to assess the predictive performance of the GRACE score and CHA2DS2-VASc score among patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI).MethodsConsecutive patients with a diagnosis of AF admitted to our hospital for PCI between January 2016 and December 2018 were included and followed up for at least 1 year. The primary endpoint was a composite of major adverse cardiac events (MACEs) including all-cause mortality, repeat revascularization, myocardial infarction, or ischaemic stroke.ResultsA total of 1452 patients were identified. Cox regression demonstrated that the GRACE (HR 1.014, 95% CI 1.008–1.020, p < 0.001) but not the CHA2DS2-VASc score was associated with the risk of MACEs. Both GRACE and CHA2DS2-VASc scores were predictive of all-cause mortality with HR of 1.028 (95% CI 1.020–1.037, p < 0.001) and 1.334 (95% CI 1.107–1.632, p = 0.003). Receiver operating characteristic analyses showed both scores had similar discrimination capacity for all-cause mortality (C-statistic: 0.708 for GRACE vs. 0.661 for CHA2DS2-VASc, p = 0.299). High GRACE score was also significantly associated with increased risk of ischaemic stroke (HR 1.018, 95% CI 1.005–1.031, p = 0.006) and major bleeding (HR 1.012, 95% CI 1.001–1.024, p = 0.039), whereas high CHA2DS2-VASc score was not.ConclusionsHigh GRACE score but not CHA2DS2-VASc score were both associated with an increased risk of MACEs after PCI in patients with AF. The GRACE and CHA2DS2-VASc scores have similar predictive performance for predicting all-cause mortality.

Key messages:

• In patients with AF undergoing PCI, increasing GRACE but not CHA2DS2-VASc scores was independently associated high risk of MACEs.
• The GRACE score could also help identify patients at higher risk of stroke and major bleeding.
• Both GRACE and CHA2DS2-VASc scores showed good ability in the prediction of all-cause mortality.

     

Atrial fibrillation and stroke prevention: brief observations on the last decade

Atrial fibrillation (AF) results in a substantial risk of mortality and morbidity from stroke and thromboembolism, and thus, a cornerstone of AF management requires appropriate and effective stroke prevention, which is oral anticoagulation. In the last decade, substantial changes in the landscape of stroke prevention in AF are evident. New knowledge has led to improved treatment options and guidelines have evolved. For example, stroke and bleeding risk assessment has now focused on use of the validated CHA₂DS₂-VASc and HAS-BLED scores, respectively to make clinical decisions. An important clinical practice shift is the initial identification of ‘low-risk’ patients, that is, CHA₂DS₂-VASc score = 0 (male) or 1 (females), who do not need any antithrombotic therapy. Subsequent to this step OAC can be offered to patients with ≥1 stroke risk factors. More recently, the SAMe-TT₂R₂ score has been proposed to aid decision-making, by using simple clinical variables by identifying those AF patients likely to do well on warfarin (SAMe-TT₂R₂ score 0-1) or those more likely to have poor anticoagulation control (SAMe-TT₂R₂ score >2), where a non-vitamin K antagonist oral anticoagulant may be a better option.     

Enhancing the ‘real world’ prediction of cardiovascular events and major bleeding with the CHA2DS2-VASc and HAS-BLED scores using multiple biomarkers

Background: Atrial fibrillation (AF)-European guidelines suggest the use of biomarkers to stratify patients for stroke and bleeding risks. We investigated if a multibiomarker strategy improved the predictive performance of CHA₂DS₂-VASc and HAS-BLED in anticoagulated AF patients.

Methods: We included consecutive patients stabilized for six months on vitamin K antagonists (INRs 2.0–3.0). High sensitivity troponin T, NT-proBNP, interleukin-6, von Willebrand factor concentrations and glomerular filtration rate (eGFR; using MDRD-4 formula) were quantified at baseline. Time in therapeutic range (TTR) was recorded at six months after inclusion. Patients were follow-up during a median of 2375 (IQR 1564–2887) days and all adverse events were recorded.

Results: In 1361 patients, adding four blood biomarkers, TTR and MDRD-eGFR, the predictive value of CHA₂DS₂-VASc increased significantly by c-index (0.63 vs. 0.65; p?=?.030) and IDI (0.85%; p?p?p?Conclusions: Addition of biomarkers enhanced the predictive value of CHA₂DS₂-VASc and HAS-BLED, although the overall improvement was modest and the added predictive advantage over original scores was marginal.

• Key Messages

• Recent atrial fibrillation (AF)-European guidelines for the first time suggest the use of biomarkers to stratify patients for stroke and bleeding risks, but their usefulness in real world for risk stratification is still questionable.

• In this cohort study involving 1361?AF patients optimally anticoagulated with vitamin K antagonists, adding high sensitivity troponin T, N-terminal pro-B-type natriuretic peptide, interleukin 6, von Willebrand factor, glomerular filtration rate (by the MDRD-4 formula) and time in therapeutic range, increased the predictive value of CHA₂DS₂-VASc for cardiovascular events, but not the predictive value of HAS-BLED for major bleeding. Reclassification analyses did not show improvement adding multiple biomarkers.

• Despite the improvement observed, the added predictive advantage is marginal and the clinical usefulness and net benefit over current clinical scores is lower.

     

Predictive role of CHADS2 and CHA2DS2-VASc scores on stroke and thromboembolism in patients without atrial fibrillation: a meta-analysis

Objective: CHA₂DS₂-VASc is the extension of the CHADS₂ score developed by Birmingham 2009. This risk stratification schema is often used in clinical setting when considering additional risk factors for developing stroke in AF patients. However, its role in the non-AF population is unknown. This study was designed to evaluate the accuracy of the CHADS₂ and the CHA₂DS₂-VASc scoring systems.

Methods: Studies designed for CHADS₂ and CHA₂DS₂-VASc score in stratifying the risks for stroke development in non-AF patients were included.

Results: Among the 114 studies identified, six trials were chosen finally and included for meta-analysis. The pooled diagnostic odds ratio (DOR) for CHADS₂ and CHA₂DS₂-VASc was 2.86 (95% CI =1.83–4.28) and 2.80 (95% CI =1.83–4.28), respectively. CHA₂DS₂-VASc score was of better sensitivity than CHADS₂ score (0.920 vs. 0.768). However, both scores were showed to have inherent heterogeneity and poor specificity.

Conclusions: Though having good diagnostic accuracy, the clinical application of the CHADS₂ and CHA₂DS₂-VASc scores in predicting risk of stroke development in non-AF patients still needs further validation.

• Key message

• The overall diagnostic accuracy of CHADS₂ and CHA₂DS₂-VASc in stroke-risk stratification was good in patients with non-atrial fibrillation.

     

Increased Risk of First-Ever Stroke in Younger Patients With Atrial Fibrillation Not Recommended for Antithrombotic Therapy by Current Guidelines: A Population-Based Study in an East Asian Cohort of 22 Million People

ObjectiveTo assess the risk of first-ever ischemic stroke in younger patients with atrial fibrillation (AF) who have none of the CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, previous stroke/transient ischemic attack, vascular disease, age 65-74 years, sex category [female sex]) risk factors (excluding female sex) by using the National Health Insurance research database in Taiwan.Patients and MethodsFrom 22,842,778 insured people, we identified 24,612 hospitalized patients with newly diagnosed AF between January 1, 2002, and December 31, 2004, as the AF group and randomly selected 98,448 age- and sex-matched persons without AF as the non-AF group. Both groups were followed up until December 31, 2010, to estimate ischemic stroke incidences in relation to other stroke risk factors.ResultsDuring a follow-up period of 89,468 person-years, the stroke rate was higher in patients with AF than in those without AF (5.79 per 100 person-years vs 2.25 per 100 person-years). The higher prevalence of CHA₂DS₂-VASc comorbidities (heart failure, hypertension, diabetes, coronary artery disease, and peripheral artery disease) in patients with AF further increased the stroke risk. In 790 patients with AF aged 30 to 55 years who had none of the CHA₂DS₂-VASc comorbidities at baseline and retained a “low risk,” that is, those with a CHA₂DS₂-VASc score of 0 in men and 1 in women during follow-up, the stroke rate remained considerably higher than that in their non-AF counterparts (1.00 per 100 person-years vs 0.25 per 100 person-years), with a sex-adjusted hazard ratio of 4.09 (95% CI, 2.97-5.62).ConclusionThis study finds an increased risk of stroke in younger patients with AF who are not recommended for prevention of thromboembolism by current guidelines. Better stroke risk stratification tools are needed to prioritize younger patients with AF for thromboprophylactic therapy in this population.     

Ischemic stroke risk in East Asian patients with CHA2DS2-VASc score of 1: systematic review and meta-analysis

Background: The use of anticoagulation for stroke prevention in patients with atrial fibrillation (AF) and CHA₂DS₂-VASc score of 1 has been debated, partially due to limited data on ischemic stroke risk and specific clinical trials in these patients. East Asian patients have a different stroke risk profile compared to non-East Asians. We performed a systematic review and meta-analysis of ischemic stroke risk in AF patients with a CHA₂DS₂-VASc score of 1 in East Asian countries.

Methods: A comprehensive literature search for studies evaluating ischemic stroke risk related with AF with CHA₂DS₂-VASc score of 1 was conducted by two reviewers. We used a fixed-effect model first, then a random-effect model if heterogeneity was assessed with I².

Results: After pooling 6 studies, the annual rate of ischemic stroke in East Asian patients with AF and a CHA₂DS₂-VASc score of 1 was 1.66% (95% CI: 0.71%-2.61%, I2 = 98.4%). There was a wide range in reported pooled rates between countries, from 0.59% to 3.13%. Significant difference existed not only in the community-based studies (Chinese: 2.10% vs. Japanese: 0.60%), but also from the hospital-based studies (Chinese: 3.55% vs. Japanese: 0.42%). Confining the analysis to those on no antithrombotic treatment had limited effect on the summary estimate (eg. Chinese: 4.28% vs. Japanese: 0.6%). In Chinese studies, ischemic stroke rate was lower in females than males (female: 1.40% vs. male: 1.79%). However, the low event rate in Japanese studies may reflect unrecorded anticoagulation status at follow-up.

Conclusions: Some regional differences between East Asian countries were observed for ischemic stroke risk in patients with a CHA₂DS₂-VASc score of 1. This may reflect methodological differences in studies and unrecorded anticoagulation use at followup, but further prospective studies are required to ascertain ischemic stroke risks, as well as the differences and reasons for this between East Asians and non-East Asians.     

Reviewing a Clinical Decision Aid for the Selection of Anticoagulation Treatment in Patients With Nonvalvular Atrial Fibrillation: Applications in a US Managed Care Health Plan Database

PurposeThe Clinical Decision Aid was created to assist in selecting anticoagulant therapies for patients with nonvalvular atrial fibrillation. The aid incorporates a patient’s absolute risk for stroke and bleeding, relative stroke risk reduction, and increase in relative bleeding risk to identify the agent with the lowest net risk. We describe theoretical implications of utilizing the aid at a US managed care population level.MethodsThis retrospective study used claims data from a large US managed care database including enrollees in commercial and Medicare Advantage plans. The distribution of patients across each possible combination of scores on the HAS-BLED scale (evidence of hypertension, abnormal renal or liver function, stroke, bleeding, labile INR, age >65 years, and drugs or alcohol abuse or dependence) and the CHA₂DS₂-VASc scale (CHADS₂ [congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism] with additional nonmajor stroke risk factors, including age 65–74 years, female sex, and vascular disease) was generated. We assessed the correlation between the HAS-BLED and CHA₂DS₂-VASc scores and derived the optimal treatment options based on various bleeding ratios.FindingsData from 48,260 patients were included in the analysis. The MAPD subset had a higher mean HAS-BLED score (2.17 vs 1.39; P < 0.001) and a higher mean CHA₂DS₂-VASc score (3.35 vs 2.05; P < 0.001) than did the commercial subset. Pearson coefficients suggested a moderate to strong positive correlation between the HAS-BLED and CHA₂DS₂-VASc scores among the commercial (0.730; P < 0.001) and MAPD (0.568; P < 0.001) enrollees. Based on a 2:1 bleeding-to-stroke risk ratio, 70.50% of patients would be recommended treatment with apixaban; 25.86%, no treatment; 3.62%, acetylsalicylic acid; and 0.01%, dabigatran 150 mg, if the Clinical Decision Aid were to be used for anticoagulant treatment selection.ImplicationsEvidence-based clinical decision–making tools utilizing risk assessment for recommending a treatment may be valuable for not only health care providers but also health care payers in optimizing care at the population level.     

Balancing bleeding and thrombotic risk with new oral anticoagulants in patients with atrial fibrillation

Atrial fibrillation (AF) markedly increases the risk of stroke. Warfarin is highly effective for the prevention of stroke in such patients, but it is difficult to use and causes bleeding. Three new oral anticoagulants have been approved for stroke prevention in AF patients, and are at least as effective as warfarin with better bleeding profiles. These new agents have changed and simplified our approach to stroke prevention, as the threshold for initiation of oral anticoagulation is lower. All patients with AF should be risk assessed using the CHA₂DS₂-VASc score, and all patients with a score of 1 or above (except women with female sex as their only risk factor on the CHA₂DS₂-VASc score) should be considered for oral anticoagulation with one of the new agents. Formal bleeding risk assessment is essential, and can be done by using the well-validated HAS-BLED score.     

Alcohol Abstinence and the Risk of Atrial Fibrillation in Patients With Newly Diagnosed Type 2 Diabetes Mellitus: A Nationwide Population-Based Study

OBJECTIVETo investigate the effects of alcohol abstinence on prevention of new-onset atrial fibrillation (AF) in patients with type 2 diabetes mellitus (T2DM).RESEARCH DESIGN AND METHODSA total of 1,112,682 patients newly diagnosed with T2DM between 2011 and 2014 were identified from the Korean National Health Insurance Service database. After excluding those with a history of AF, 175,100 patients were included. The primary outcome was new-onset AF.RESULTSDuring a mean follow-up of 4.0 years, AF occurred in 4,174 patients. Those with heavy alcohol consumption (alcohol intake ≥40 g/day) before T2DM diagnosis had a higher risk of AF (adjusted hazard ratio [aHR] 1.22; 95% CI 1.06–1.41) compared with patients with no alcohol consumption. After T2DM diagnosis, those with moderate to heavy alcohol consumption (alcohol intake ≥20 g/day) who abstained from alcohol had a lower risk of AF (aHR 0.81; 95% CI 0.68–0.97) compared with constant drinkers. Alcohol abstinence showed consistent trends toward lower incident AF in all subgroups and was statistically significant in men (aHR 0.80; 95% CI 0.67–0.96), those aged >65 years (aHR 0.69; 95% CI 0.52–0.91), those with CHA₂DS₂-VASc score <3 points (aHR 0.71; 95% CI 0.59–0.86), noninsulin users (aHR 0.77; 95% CI 0.63–0.94), and those with BMI <25 kg/m² (aHR 0.68; 95% CI 0.53–0.88).CONCLUSIONSIn patients with newly diagnosed T2DM, alcohol abstinence was associated with a low risk of AF development. Lifestyle modifications, such as alcohol abstinence, in patients newly diagnosed with T2DM should be recommended to reduce the risk of AF.     

Perception of the Risk of Stroke and the Risks and Benefits of Oral Anticoagulation for Stroke Prevention in Patients With Atrial Fibrillation: A Cross-Sectional Study

ObjectiveTo assess the perception of the risk of stroke and the risks and benefits of oral anticoagulation (OAC) in patients with atrial fibrillation (AF).Patients and MethodsConsecutive patients with chronic AF who presented for an outpatient cardiology visit or were admitted to a noncritical care cardiology ward service from September 15 through December 20, 2017, were invited to participate in this survey. Participants were asked to estimate their stroke risk without OAC and bleeding risk with OAC using a quantitative risk scale. The reported values were compared with subjectively estimated risks derived from the CHA₂DS₂-VASc and HAS-BLED scores. Similarly, we compared patient perception of the stroke risk reduction afforded with OAC compared with what is reported in the literature.ResultsA total of 227 patients were included in the analysis. The mean ± SD CHA₂DS₂-VASc score was 4.3±1.6, and HAS-BLED score was 2.3±1.2. Atrial fibrillation was paroxysmal in 53.3% and persistent/permanent in 46.7%. There was a negligible correlation between patient perceived and estimated risk of stroke (r=0.07; P=.32), and bleeding (r=0.16; P=.02). Most patients overestimated their risks of stroke and bleeding: 120 patients (52.9%) perceived an annual stroke risk greater than 20%, and 115 (53.5%) perceived an annual bleeding risk with OAC greater than 10%. Most patients (n=204; 89.9%) perceived that OAC would reduce their annual stroke risk by at least 50%.ConclusionPerceived risks of stroke and bleeding are markedly overestimated in most patients with AF. Further research is needed to discern the root causes and to identify effective methods of bridging this alarming disparity.     

Underuse of anticoagulation in patients with atrial fibrillation

Atrial fibrillation (AF) is a major risk factor for ischemic stroke. Guidelines recommend anticoagulation for patients with intermediate and high stroke risk (CHA₂DS₂-VASc score ≥2). Underuse of anticoagulants among eligible patients remains a persistent problem. Evidence demonstrates that the psychology of the fear of causing harm (omission bias) results in physicians’ hesitancy to initiate anticoagulation and an inaccurate estimation of stroke risk. The American Heart Association (AHA) initiated the Get With The Guidelines-AFIB (GWTG-AFIB) module in June 2013 to enhance guideline adherence for treatment and management of AF. Better quality of care for AF patients can be provided by increasing adherence to anticoagulation guidelines and improving patient compliance with anticoagulation therapy through education and established protocols. Nonvitamin K antagonist oral anticoagulants may facilitate better patient adherence due to ease of administration and reduced monitoring burden. In this review, we discuss the reasons for underuse, omission bias contributing to underuse, and different strategies to address this issue.     

CHADS2 and CHA2DS2-VASc score of patients with atrial fibrillation or flutter and newly detected left atrial thrombus

Background

The risk of developing a stroke or systemic embolus due to a left atrial (LA) thrombus in patients with atrial fibrillation (AF) and/or atrial flutter (AFL) is estimated by the CHADS₂ score and more recently the CHA₂DS₂-VASc score. We aimed to further characterize AF/AFL patients who were found to have a LA thrombus on a transesophageal echocardiogram (TEE).

Methods and results

Of 3,165 TEE between 2005 and 2011 for a broad spectrum of indications, we detected 65 AF patients with LA thrombus (2 %). There were 40 men and 25 women, mean age was 65 ± 13 years (range 36–88 years). Mean CHADS₂ score was 1.8 ± 1.1 and mean CHA₂DS₂-VASc score was 3.0 ± 1.6. 11 patients (17 %) had a CHADS₂ score of 0, 12 patients (18 %) of 1, 28 patients (43 %) of 2 and 12 patients (18 %) of 3. Hypertension was the most frequent risk factor (72 %), followed by congestive heart failure (32 %), diabetes (23 %) and age ≥75 years (23 %). Mean difference between CHADS₂ and CHA₂DS₂-VASc was 1.25 ± 0.91. Of the 11 patients (17 %) with a LA thrombus despite a CHADS₂ score of 0, five had a CHA₂DS₂-VASc score of 0, four a CHA₂DS₂-VASc score of 1 and two a CHA₂DS₂-VASc score of 2.

Conclusion

In an unselected TEE population with newly detected LA thrombus about one-third of patients fell into the low-risk group when classified based on the CHADS₂ score, while a much lower population fell in the same low-risk group when classified according to the CHA₂DS₂-VASc score. However, this does not prove clinical superiority of the CHA₂DS₂-VASc score over the established CHADS₂ score. Whether our observation has clinical implications (e.g. TEE prior to LA ablation irrespective of CHADS₂ score), or argues for use of the CHA₂DS₂-VASc score needs to be evaluated in prospective studies.     

Statistical shape analysis of the left atrial appendage predicts stroke in atrial fibrillation

The shape of the left atrium (LA) and left atrial appendage (LAA) have been shown to predict stroke in patients with atrial fibrillation (AF). Prior studies rely on qualitative assessment of shape, which limits reproducibility and clinical utility. Statistical shape analysis (SSA) allows for quantitative assessment of shape. We use this method to assess the shape of the LA and LAA and predict stroke in patients with AF. From a database of AF patients who had previously undergone MRI of the LA, we identified 43 patients with AF who subsequently had an ischemic stroke. We also identified a cohort of 201 controls with AF who did not have a stroke after the MRI. We performed SSA of the LA and LAA shape to quantify the shape of these structures. We found three of the candidate LAA shape parameters to be predictive of stroke, while none of the LA shape parameters predicted stroke. When the three predictive LAA shape parameters were added to a logistic regression model that included the CHA₂DS₂-VASc score, the area under the ROC curve increased from 0.640 to 0.778 (p?=?.003). The shape of the LA and LAA can be assessed quantitatively using SSA. LAA shape predicts stroke in AF patients, while LA shape does not. Additionally, LAA shape predicts stroke independent of CHA₂DS₂-VASc score. SSA for assessment of LAA shape may improve stroke risk stratification and clinical decision making for AF patients.

     

Atherosclerosis and thromboembolic risk in atrial fibrillation: Focus on peripheral vascular disease

Abstract

Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice. It results in a 5-fold increased risk for stroke and thromboembolism and is associated with a high morbidity and mortality. AF shares several risk factors and pathophysiological features with atherosclerosis. Hence AF is often complicated by a variety of other cardiovascular conditions. Indeed, peripheral vascular disease (PVD) is highly prevalent among AF patients and associates with increased mortality. Inclusion of PVD within stroke risk scoring systems such as the CHA₂DS₂-VASc score improves risk stratification of AF patients. Of note, PVD has not been previously well documented nor looked for in observational studies or clinical trials. The aim of this present review article is to provide an overview of the association between atherosclerosis (with particular focus on PVD) and AF as well as its complications.     

Descending aortic mechanics and atrial fibrillation: a two-dimensional speckle tracking transesophageal echocardiography study

Vascular mechanics assessed with two-dimensional speckle tracking echocardiography (2D-STE) could be used as a new imaging surrogate of vascular stiffening. The CHA₂DS₂-VASc score is considered accurate as an estimate of stroke risk in non-valvular AF, although many potential stroke risk factors have not been included in this scoring method. The purpose of this research is to study the feasibility of evaluating vascular mechanics at the descending aorta in non-valvular AF patients using transesophageal 2D-STE and to analyze the association between descending aortic mechanics and stroke. We prospectively recruited a group of 44 patients referred for a transesophageal echocardiogram (TEE) in the context of cardioversion for non-valvular AF. A short-axis view of the descending aorta, one to two centimeters after the aortic arch was selected for the vascular mechanics assessment with the 2D-STE methodology. The vascular mechanics parameters analyzed were circumferential aortic strain (CAS) and early circumferential aortic strain rate (CASR). A clinical assessment was performed with focus on the past stroke history and the CHA₂DS₂-VASc score. The mean age of our cohort was 65?±?13 years and 75% were men; AF was known for 2.8?±?2.5 years and it was considered paroxystic in 41% of cases. Waveforms adequate for measuring 2D-STE were present in 85% of the 264 descending aortic wall segments. The mean CAS was 3.5?±?1.2% and the mean CASR was 0.7?±?0.3 s^?1. The inter- and intra-observer variability for aortic mechanics was considered adequate. The median CHA₂DS₂VASc score was 2 (2–3). As the score increased we noted that both the CAS (r?=??0.38, P?=?0.01) and the CASR (r?=??0.42, P?<?0.01) decreased. Over 16% of the AF patients had a past history of stroke. These patients had lower values of both descending aortic strain [2.2 (1.8–2.6) vs. 3.9 (3.3–4.9)%, P?<?0.01] and strain rate [0.4 (0.3–0.4) vs. 0.7 (0.6–1.1) s^?1, P?<?0.01]. CAS remained independently associated with a past history of stroke after adjustment for the CHA₂DS₂VASc score. Our data showed that non-valvular AF patients with a past history of stroke had lower values of aortic mechanics assessed with transesophageal 2D-STE.     

Glycemic control and its association with sociodemographics,comorbid conditions,and medication adherence among patients with type 2 diabetes in southwestern Nigeria

ObjectiveWe determined the prevalence of poor glycemic control and associations with sociodemographics, comorbid conditions, and medication adherence among patients with type 2 diabetes mellitus (T2DM) at a tertiary hospital in southwestern Nigeria.MethodsWe conducted a retrospective observational study among 300 patients with T2DM using systematic random sampling. We used a semi-structured questionnaire to collect information on respondents’ sociodemographic profile, lifestyle, comorbid conditions, and antidiabetic medications. Adherence was determined using the Morisky Medication Adherence Scale. Fasting blood samples were tested using a glycated hemoglobin marker. Multivariate logistic regression was used to identify factors associated with poor glycemic control.ResultsRespondents’ mean age was 61.9 ± 11.8 years. The prevalence of poor glycemic control was 40.0% (95% confidence interval [CI]: 34.4%–45.8%). The adjusted odds ratio (95% CI) for factors associated with poor glycemic control was 2.522 (1.402–4.647) for older age, 1.882 (1.021–3.467) for low income, 1.734 (1.013–3.401) for obesity, 2.014 (1.269–5.336) for non-initiation of insulin therapy, and 1.830 (1.045–3.206) for poor medication adherence.ConclusionOlder age, lower income, obesity, non-initiation of insulin, and poor medication adherence were associated with poor glycemic control. These variables may help clinicians identify patients at high risk of poor glycemic control.     

Risk profile,antithrombotic treatment and clinical outcomes of patients in Nordic countries with atrial fibrillation – results from the GARFIELD-AF registry

AimsThe objective was to evaluate the clinical characteristics, management and two-year outcomes of patients with newly diagnosed non-valvular atrial fibrillation at risk for stroke in Nordic countries.MethodsWe examined the baseline characteristics, antithrombotic treatment, and two-year clinical outcomes of patients from four Nordic countries.ResultsA total of 52,080 patients were enrolled in the GARFIELD-AF. Out of 29,908 European patients, 2,396 were recruited from Nordic countries. The use of oral anticoagulants, alone or in combination with antiplatelet (AP), was higher in Nordic patients in all CHA₂DS₂-VASc categories: 0–1 (72.8% vs 60.3%), 2–3 (78.7% vs 72.9%) and ≥4 (79.2% vs 74.1%). In Nordic patients, NOAC ± AP was more frequently prescribed (32.0% vs 27.7%) and AP monotherapy was less often prescribed (10.4% vs 18.2%) when compared with Non-Nordic European patients. The rates (per 100 patient years) of all-cause mortality and non-haemorrhagic stroke/systemic embolism (SE) were similar in Nordic and Non-Nordic European patients [3.63 (3.11–4.23) vs 4.08 (3.91–4.26), p value = .147] and [0.98 (0.73–1.32) vs 1.02 (0.93–1.11), p value = .819], while major bleeding was significantly higher [1.66 (1.32–2.09) vs 1.01 (0.93–1.10), p value < .001].ConclusionNordic patients had significantly higher major bleeding than Non-Nordic-European patients. In contrast, rates of all-cause mortality and non-haemorrhagic stroke/SE were comparable. Clinical Trial RegistrationUnique identifier: NCT01090362. URL: http://www.clinicaltrials.gov. Key MessageNordic countries had significantly higher major bleeding than Non-Nordic-European countries. Rates of mortality and non-haemorrhagic stroke/SE were similar .     

Refinement of CHADS2 and CHA2DS2-VASc scores predict left atrial thrombus or spontaneous echo contrast in nonvalvular atrial fibrillation patients

ObjectiveTo investigate the risk factors of left atrial thrombus (LAT)/spontaneous echo contrast (SEC) in patients with nonvalvular atrial fibrillation (AF).MethodsThis retrospective study analysed the data from consecutive patients with nonvalvular AF that underwent transoesophageal echocardiography. Logistic regression analysis was performed to identify risk factors of LAT/SEC. Receiver operating characteristic curve analysis was undertaken compare the new scales with CHADS2 and CHA2DS2-VASc scores.ResultsA total of 558 patients with AF were included in the study. LAT/SEC was detected in 137 (24.6%) patients. The independent risk factors of LAT/SEC beyond CHADS2 or CHA2DS2-VASc scores included non-paroxysmal AF and left atrial diameter >37.5 mm. These two variables were added into the CHADS2 or CHA2DS2-VASc score to build new scales. Areas under the curve for the new scales based on CHADS2 and CHA2DS2-VASc scores were significantly higher than the CHADS2 or CHA2DS2-VASc score both in the overall study cohort and in patients at a high risk of thromboembolism.ConclusionsNon-paroxysmal AF and increased left atrial diameter beyond the CHADS2 or CHA2DS2-VASc score were independent risk factors of LAT/SEC and may help to improve the current risk stratification, especially for patients with nonvalvular AF at a high risk of thromboembolism.