Publications by authors named "Eunsun Jang"

50 Publications

Association of changes in cardiovascular health levels with incident cardiovascular events and mortality in patients with atrial fibrillation.

Clin Res Cardiol 2022 Jul 13. Epub 2022 Jul 13.

Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea.

Background: Risk factor management is crucial in the management of atrial fibrillation (AF). We investigated the association of changes in cardiovascular health (CVH) levels after AF diagnosis with incident cardiovascular events and mortality.

Methods: From the Korea National Health Insurance Service database, 76,628 patients newly diagnosed with AF (2005-2015) with information on health examinations before and after AF diagnosis were assessed. According to the change in the 12-point CVH score before and after AF diagnosis, patients were stratified into four groups: consistently low (score 0-7 to 0-7), high-to-low (8-12 to 0-7), low-to-high (0-7 to 8-12), and consistently high (8-12 to 8-12) CVH levels. Risks of cardiovascular events and death were analyzed using weighted Cox regression models with inverse probability of treatment weighting (IPTW) for balance across study groups.

Results: The mean age of study participants was 58.3 years, 50,285 were men (63.1%), and the mean follow-up was 5.5 years. After IPTW, low-to-high (hazard ratio [95% confidence interval], 0.83 [0.76-0.92]) and consistently high (0.80 [0.74-0.87]) CVH levels were associated with a lower risk of ischemic stroke than consistently low CVH. Low-to-high (0.66 [0.52-0.84]) and consistently high (0.52 [0.42-0.64]) CVH levels were associated with a lower risk of acute myocardial infarction. Maintaining high CVH was associated with reduced risks of heart failure hospitalization (0.85 [0.75-0.95]) and all-cause death (0.82 [0.77-0.88]), respectively, compared with consistently low CVH.

Conclusions: Improving CVH levels and maintaining high CVH levels after AF diagnosis is associated with lower risks of subsequent cardiovascular events and mortality.
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http://dx.doi.org/10.1007/s00392-022-02058-3DOI Listing
July 2022

Association between exercise habit changes and mortality following a cardiovascular event.

Heart 2022 May 19. Epub 2022 May 19.

Department of Internal Medicine, Yonsei University College of Medicine, Seodaemun-gu, Korea

Objective: To investigate the associations between exercise habit changes following an incident cardiovascular event and mortality in older adults.

Methods: We analysed the relationship between exercise habit change and all-cause, cardiovascular and non-cardiovascular deaths in adults aged ≥60 years between 2003 and 2012 who underwent two consecutive health examinations within 2 years before and after diagnosis of cardiovascular disease (CVD). They were categorised into four groups according to exercise habit changes: persistent non-exercisers, exercise dropouts, new exercisers and exercise maintainers. Differences in baseline characteristics were adjusted using inverse probability of treatment weighting.

Results: Of 6076 participants, the median age was 72 (IQR 69-76) years and men accounted for 50.6%. Compared with persistent non-exercisers (incidence rate (IR) 4.8 per 100 person-years), new exercisers (IR 3.5, HR 0.73, 95% CI 0.58 to 0.91) and exercise maintainers (IR 2.9, HR 0.53, 95% CI 0.38 to 0.73) were associated with reduced risk of all-cause death. The rate of non-cardiovascular death was significantly lower in new exercisers (IR 2.3, HR 0.73, 95% CI 0.56 to 0.95) and exercise maintainers (IR 2.3, HR 0.61, 95% CI 0.42 to 0.90) than in persistent non-exercisers (IR 3.2). Also, trends towards reduced cardiovascular death in new exercisers and exercise maintainers were observed (p value for trend <0.001).

Conclusions: More virtuous exercise trajectories in older adults with CVD are associated with lower mortality rates. Our results support public health recommendations for older adults with CVD to perform physical activity.
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http://dx.doi.org/10.1136/heartjnl-2022-320882DOI Listing
May 2022

Age and Outcomes of Early Rhythm Control in Patients With Atrial Fibrillation: Nationwide Cohort Study.

JACC Clin Electrophysiol 2022 05;8(5):619-632

Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea. Electronic address:

Objectives: This study sought to investigate whether the effects of early rhythm control differ according to age.

Background: Rhythm control, compared with usual care among patients recently diagnosed with atrial fibrillation (AF), was found to be associated with a lower risk of adverse cardiovascular outcomes. It is unclear whether the results can be generalized for older adults.

Methods: This retrospective population-based cohort study included 31,220 patients with AF, from the Korean National Health Insurance Service database, undergoing rhythm control (antiarrhythmic drugs or ablation) or rate control therapy, initiated within 1 year of AF diagnosis. A composite outcome of cardiovascular death, ischemic stroke, hospitalization for heart failure, or myocardial infarction was compared in subgroups stratified by age.

Results: Compared with rate control, early rhythm control was associated with a lower risk of the primary composite outcome in patients <75 years of age (HR: 0.80; 95% CI: 0.72-0.88). The protective association between early rhythm control and cardiovascular outcomes exhibited a linear decrease with advancing age, with declined benefits in patients ≥75 years of age (HR: 0.94; 95% CI: 0.87-1.03; P = 0.045). Trends toward lower risks of ischemic stroke (HR: 0.78; 95% CI: 0.67-0.90) and acute myocardial infarction (HR: 0.63; 95% CI: 0.41-0.97) were observed in the older adults. No significant differences in safety outcomes were found across different ages.

Conclusions: The beneficial association of early rhythm control with cardiovascular outcomes was attenuated with increasing age, with the larger benefits in younger patients <75 years of age. No differences were found by age in treatment-related safety outcomes.
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http://dx.doi.org/10.1016/j.jacep.2022.02.014DOI Listing
May 2022

Impact of Physical Activity on All-Cause Mortality According to Specific Cardiovascular Disease.

Front Cardiovasc Med 2022 4;9:811058. Epub 2022 Feb 4.

Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea.

Background: Patients with cardiovascular disease (CVD) tend to have higher mortality rates and reduced physical activity (PA). We aimed to evaluate the effect of PA on mortality in older adults with specific CVD.

Methods: We enrolled 68,223 participants ( = 23,871 with CVD, = 44,352 without CVD) aged ≥65 years with available physical activity data between 2005 and 2012 from the Korean National Health Insurance Service of Korea-Senior database. CVD was defined as a history of ischemic stroke, transient ischemic attack, heart failure, myocardial infarction, and peripheral artery disease.

Results: Patients with CVD were older than those without CVD. Compared with the sedentary group, the physically active groups with and without CVD had a lower incidence and risk of all-cause death during a median follow up period of 42 (interquartile range 30-51) months. A 500 metabolic equivalent task-min/week increase in PA resulted in an 11% and 16% reduction in the risk of mortality in the non-CVD and CVD groups, respectively. With regard to specific CVDs, the risk of mortality progressively reduced with increasing PA in patients with heart failure or myocardial infarction. However, the reduction reached a plateau in patients with stroke or peripheral artery disease, but was significantly greater in patients with stroke (20% vs. without stoke, 11%, P = 0.006) or heart failure (13% vs. without heart failure, 11%; P = 0.045).

Conclusions: PA was associated with a reduced risk of all-cause mortality in older adults with and without CVD. The benefits of PA in patients with CVD, especially patients with stroke or heart failure, were greater than those without.
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http://dx.doi.org/10.3389/fcvm.2022.811058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8855984PMC
February 2022

Effectiveness and Safety of Anticoagulation Therapy in Frail Patients With Atrial Fibrillation.

Stroke 2022 06 3;53(6):1873-1882. Epub 2022 Feb 3.

Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (D.K., E.J., H.T.Y., T.-H.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L.' B.J.).

Background: Frail patients with atrial fibrillation (AF) are less likely to receive anticoagulation than nonfrail patients with AF despite frailty being associated with poorer clinical outcomes including stroke. Using a population-based cohort, we sought to assess the effectiveness and safety of oral anticoagulants (OACs) in frail patients with AF.

Methods: This retrospective cohort study analyzed 83 635 patients aged at least 65 years with AF and frailty (≥5 Hospital Frailty Risk Score) between January 1, 2013 and December 31, 2016 from the Korean National Health Insurance Service database. To account for the differences between patients receiving OAC or not and across different OAC regimens, propensity score-weighting was used. Net adverse clinical event, defined as the first event of ischemic stroke, major bleeding, or cardiovascular death, was compared. In addition, each individual outcome was examined separately.

Results: In the study population (57.1% women; mean age, 78.5±7.2 years), a total of 14 968 net adverse clinical event, 3718 ischemic stroke, 5536 major bleeding, and 6188 cardiovascular death occurred. In comparison with no OAC use, OAC use was associated with lower risks of net adverse clinical event (hazard ratio, 0.78 [95% CI, 0.75-0.82]), ischemic stroke (hazard ratio, 0.91 [95% CI, 0.86-0.97]), and cardiovascular death (hazard ratio, 0.52 [95% CI, 0.49-0.55]), but no difference was observed for major bleeding (hazard ratio, 1.02 [95% CI, 0.95-1.10]). Compared with warfarin, all four individual direct OAC were associated with decreased risks of net adverse clinical event, ischemic stroke, major bleeding, and cardiovascular death. The associations for OAC use (compared to no OAC use) or direct OAC use (compared to warfarin) with favorable outcomes were more prominent in individuals with a higher CHADS-VASc score of at least 3.

Conclusions: Among frail patients with AF, OAC treatment was associated with a positive net clinical outcome. Direct OACs provided lower incidences of stroke, bleeding, and mortality, compared with warfarin.
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http://dx.doi.org/10.1161/STROKEAHA.121.036757DOI Listing
June 2022

Association of rhythm control with incident dementia among patients with atrial fibrillation: a nationwide population-based cohort study.

Age Ageing 2022 01;51(1)

Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.

Background: Atrial fibrillation (AF) increases the risk of dementia, and catheter ablation of AF may be associated with a lower risk of dementia. We investigated the association of a rhythm-control strategy for AF with the risk of dementia, compared with a rate-control strategy.

Methods: This population-based cohort study included 41,135 patients with AF on anticoagulation who were newly treated with rhythm-control (anti-arrhythmic drugs or ablation) or rate-control strategies between 1 January 2005 and 31 December 2015 from the Korean National Health Insurance Service database. The primary outcome was all-cause dementia, which was compared using propensity score overlap weighting.

Results: In the study population (46.7% female; median age: 68 years), a total of 4,039 patients were diagnosed with dementia during a median follow-up of 51.7 months. Rhythm control, compared with rate control, was associated with decreased dementia risk (weighted incidence rate: 21.2 versus 25.2 per 1,000 person-years; subdistribution hazard ratio [sHR] 0.86, 95% confidence interval [CI] 0.80-0.93). The associations between rhythm control and decreased dementia risk were consistently observed even after censoring for incident stroke (sHR 0.89, 95% CI 0.82-0.97) and were more pronounced in relatively younger patients and those with lower CHA2DS2-VASc scores. Among dementia subtypes, rhythm control was associated with a lower risk of Alzheimer's disease (sHR 0.86, 95% CI 0.79-0.95).

Conclusions: Among anticoagulated patients with AF, rhythm control was associated with a lower risk of dementia, compared with rate control. Initiating rhythm control in AF patients with fewer stroke risk factors might help prevent subsequent dementia.
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http://dx.doi.org/10.1093/ageing/afab248DOI Listing
January 2022

Association of Physical Activity Level With Risk of Dementia in a Nationwide Cohort in Korea.

JAMA Netw Open 2021 12 1;4(12):e2138526. Epub 2021 Dec 1.

Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.

Importance: Current guidelines recommend 500 to 999 metabolic equivalent (MET)-minutes per week (MET-min/wk) of regular physical activity. However, evidence regarding the association between light-intensity physical activity (LPA) and dementia in older adults is inconsistent.

Objective: To assess the association between physical activity and new-onset dementia, focusing on the dose-response association between physical activity and dementia and the association of LPA with the incidence of dementia.

Design, Setting, And Participants: For this nationwide retrospective cohort study, we analyzed 62 286 participants aged 65 years or older without preexisting dementia who had available health checkup data from the Korean National Health Insurance Service database from January 2009 to December 2012. Participants were followed up until December 31, 2013, and data analysis was performed from July 2020 to January 2021.

Exposures: Physical activity level was assessed using a standardized, self-reported questionnaire at baseline. Physical activity-related energy expenditure (in MET-min/wk) was calculated by summing the product of frequency, intensity, and duration.

Main Outcomes And Measures: Incidence of dementia. Incidence rates were calculated by dividing the number of events by the person-time at risk (presented as the incidence per 1000 person-years). Hazard ratios (HRs) and 95% CIs for dementia were analyzed according to physical activity level. Competing risk regression was performed by using the Fine-Gray subdistribution hazard model, with mortality as the competing risk for dementia events. Multivariable regression models were constructed with adjustment for various patient characteristics. Incident dementia occurring 2 years after enrollment was assessed, and separate analyses included all follow-up periods. Restricted cubic spline curves were used to examine the association of continuous values of physical activity with dementia.

Results: Among 62 286 participants, 60.4% were women, and the mean (SD) age was 73.2 (5.3) years. During a median follow-up of 42 months, 3757 participants (6.0%) developed dementia, and the overall incidence was 21.6 per 1000 person-years. Compared with inactive individuals (0 MET-min/wk), insufficiently active (1-499 MET-min/wk; mean, 284 MET-min/wk), active (500-999 MET-min/wk; mean, 675 MET-min/wk), and highly active participants (≥1000 MET-min/wk; mean, 1627 MET-min/wk) showed 10% (adjusted hazard ratio [HR], 0.90; 95% CI, 0.81-0.99), 20% (adjusted HR, 0.80; 95% CI, 0.71-0.92), and 28% (adjusted HR, 0.72; 95% CI, 0.60-0.83) reduced dementia risk, respectively. Thus, a progressive decrease in the adjusted HR of dementia was associated with increasing physical activity level, and a restricted cubic spline curve showed that this association started with a low amount of total physical activity. This association was consistent regardless of age, sex, and other comorbidities or after censoring for stroke. Compared with total sedentary behavior, even a low amount of LPA (1-299 MET-min/wk; mean, 189 MET-min/wk) was associated with reduced dementia risk (adjusted HR, 0.86; 95% CI, 0.74-0.99).

Conclusions And Relevance: In older adults, an increased physical activity level, including a low amount of LPA, was associated with a reduced risk of dementia. Promotion of LPA might reduce the risk of dementia in older adults.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.38526DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8678703PMC
December 2021

Comparative Effectiveness of Early Rhythm Control Versus Rate Control for Cardiovascular Outcomes in Patients With Atrial Fibrillation.

J Am Heart Assoc 2021 12 10;10(24):e023055. Epub 2021 Dec 10.

Division of Cardiology Department of Internal Medicine Severance Cardiovascular HospitalYonsei University College of Medicine Seoul Korea.

Background Rhythm control is associated with better cardiovascular outcomes than usual care among patients with recently diagnosed atrial fibrillation (AF). This study investigated the effects of rhythm control compared with rate control on the incidence of stroke, heart failure, myocardial infarction, and cardiovascular death stratified by timing of treatment initiation. Methods and Results We conducted a retrospective population-based cohort study including 22 635 patients with AF newly treated with rhythm control (antiarrhythmic drugs or ablation) or rate control in 2011 to 2015 from the Korean National Health Insurance Service database. Propensity overlap weighting was used. Compared with rate control, rhythm control initiated within 1 year of AF diagnosis decreased the risk of stroke. The point estimates for rhythm control initiated at selected time points after AF diagnosis are as follows: 6 months (hazard ratio [HR], 0.76; 95% CI, 0.66-0.87), 1 year (HR, 0.78; 95% CI, 0.66-0.93), and 5 years (HR, 1.00; 95% CI, 0.45-2.24). The initiation of rhythm control within 6 months of AF diagnosis reduced the risk of hospitalization for heart failure: 6 months (HR, 0.84; 95% CI, 0.74-0.95), 1 year (HR, 0.96; 95% CI, 0.82-1.13), and 5 years (HR, 2.88; 95% CI, 1.34-6.17). The risks of myocardial infarction and cardiovascular death did not differ between rhythm and rate control regardless of treatment timing. Conclusions Early initiation of rhythm control was associated with a lower risk of stroke and heart failure-related admission than rate control in patients with recently diagnosed AF. The effects were attenuated as initiating the rhythm control treatment later.
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http://dx.doi.org/10.1161/JAHA.121.023055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9075243PMC
December 2021

Association of proteinuria and hypertension with incident atrial fibrillation in an elderly population: nationwide data from a community-based elderly cohort.

J Hypertens 2022 01;40(1):128-135

Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul.

Objective: The excess risk of atrial fibrillation in relation to the presence of proteinuria associated with hypertension has not been well elucidated. We aimed to determine the effect of hypertension and/or proteinuria on the incidence of atrial fibrillation. Second, we evaluated whether the associations with temporal changes in proteinuria status on the incidence of atrial fibrillation.

Methods And Results: A total of 85 434 participants with hypertension and 125 912 participants without hypertension with age at least 60 years from the Korea National Health Insurance Service-Senior cohort were included. Amongst controls (participants without proteinuria and hypertension), hypertension only, proteinuria only, and hypertension with proteinuria groups, the adjusted incidences of atrial fibrillation were 0.51, 0.69. 0.78 and 0.99 per 100 person-years, respectively after inverse probability of treatment weighting. Compared with controls, the weighted risks of atrial fibrillation in the hypertension only, proteinuria only and hypertension with proteinuria groups were increased by 37% (hazard ratio 1.37, 95% confidence interval, CI 1.30-1.44, P = 0.001), 55% (hazard ratio 1.55, 95% CI 1.28-1.88, P < 0.001), and 98% (hazard ratio 1.98, 95% CI 1.62-2.43, P < 0.001), respectively. Populations who had proteinuria in the first examination had an increased risk of atrial fibrillation even in the group whereby the proteinuria was resolved on the second examination (hazard ratio 1.36, 95% CI 1.12-2.31, P < 0.001). The presence of proteinuria in first and second analysis had the highest risk of incident atrial fibrillation (hazard ratio 1.61, 95% CI 1.12-2.31).

Conclusion: In conclusion, hypertension and/or proteinuria were associated with increased risk of atrial fibrillation, with the greatest risks when both are present. Proteinuria could be a useful factor for predicting atrial fibrillation development.
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http://dx.doi.org/10.1097/HJH.0000000000002987DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8654251PMC
January 2022

Increased risk of ischemic stroke and systemic embolism in hyperthyroidism-related atrial fibrillation: A nationwide cohort study.

Am Heart J 2021 12 1;242:123-131. Epub 2021 Sep 1.

Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea. Electronic address:

Background: We aimed to evaluate the long-term risk of ischemic stroke/systemic embolism of hyperthyroidism-related AF.

Methods: This retrospective population-based cohort study included records of 1,034,099 atrial fibrillation patients between 2005 and 2016 from the Korean National Health Insurance Service database. After exclusion, we identified 615,724 oral anticoagulation-naïve patients aged ≥18 years with new-onset non-valvular atrial fibrillation, of whom 20,773 had hyperthyroidism-related atrial fibrillation. After 3:1 propensity score matching, ischemic stroke and systemic embolism occurrences were compared between hyperthyroidism-related and non-hyperthyroidism-related ("nonthyroidal") atrial fibrillation patients.

Results: After exclusion, we identified 615,724 oral anticoagulation-naïve AF patients of whom 20,773 had hyperthyroidism-related AF. Median follow-up duration was 5.9 years. Hyperthyroidism-related AF patients had significantly higher risks of ischemic stroke and systemic embolism than nonthyroidal AF patients (1.83 vs 1.62 per 100-person year, hazard ratio[HR], 1.13; 95% confidence interval[CI], 1.07 to 1.19; P < 0.001). This risk was 36% higher in hyperthyroidism-related than in nonthyroidal AF patients within 1 year of atrial fibrillation diagnosis (3.65 vs 2.67 per 100-person year, HR, 1.36; 95% CI, 1.24 - 1.50; P < 0.001). This difference was also observed in the CHADS-VASc score subgroup analysis. The risk of ischemic stroke and systemic embolism significantly decreased in patients treated for hyperthyroidism (HR, 0.64; 95% CI, 0.58 to 0.70; P < 0.001).

Conclusions: Hyperthyroidism-related AF patients have high risks of ischemic stroke and systemic embolism like nonthyroidal AF, especially when initially diagnosed. This risk is reduced by treating hyperthyroidism.
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http://dx.doi.org/10.1016/j.ahj.2021.08.018DOI Listing
December 2021

Risk of sick sinus syndrome in patients diagnosed with atrial fibrillation: A population-based cohort.

J Cardiovasc Electrophysiol 2021 10 16;32(10):2704-2714. Epub 2021 Aug 16.

Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.

Background: Sinoatrial node dysfunction and atrial fibrillation (AF) frequently coexist and interact with each other, often to initiate and perpetuate each other.

Objective: To determine the effect of AF on the incidence and risk of sick sinus syndrome (SSS).

Methods: The association of incident AF with the development of incident SSS was assessed from 2004 to 2014 in 302 229 SSS- and pacemaker-free subjects aged ≥60 years in the Korea National Health Insurance Service-Senior cohort.

Results: During an observation period of 1 854 800 person-years, incident AF was observed in a total of 12 797 subjects (0.69%/year). The incidence of SSS was 3.4 and 0.2 per 1000 person-years in the propensity score-matched incident AF and no-AF groups, respectively. After adjustment, the significantly increased risk of SSS was observed in the incident AF group, with a hazard ratio (HR) of 13.4 (95% confidence interval [CI]: 8.4-21.4). This finding was consistently observed after censoring for heart failure (HR: 16.0; 95% CI: 9.2-28.0) or heart failure/myocardial infarction (HR: 16.6; 95% CI: 9.3-29.7). Incident AF also was associated with an increased risk of pacemaker implantation related with both SSS (HR: 21.8; 95% CI: 8.7-18.4) and atrioventricular (AV) block (HR: 9.5; 95% CI: 4.9-18.4). These results were consistent regardless of sex and comorbidities.

Conclusion: Incident AF was associated with more than 10 times increased risk of SSS in an elderly population regardless of comorbidities. The risk of pacemaker implantations related with both sinus node dysfunction and AV block was increased in the elderly population with incident AF.
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http://dx.doi.org/10.1111/jce.15202DOI Listing
October 2021

Impact of abdominal obesity on outcomes of catheter ablation in Korean patients with atrial fibrillation.

Int J Clin Pract 2021 Oct 6;75(10):e14696. Epub 2021 Aug 6.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.

Background: Effects of abdominal obesity on outcomes of atrial fibrillation (AF) ablation remains ill-defined. Here, we evaluated the impact of abdominal obesity on the long-term efficacy and safety of catheter AF ablation among Korean patients.

Methods: We utilised the Korean National Health Insurance Service database to identify patients who underwent AF ablation. Abdominal obesity was defined as waist circumference ≥90 cm (males) and ≥85 cm (females). The primary endpoint was AF recurrence and secondary endpoints were ischaemic stroke, intracranial haemorrhage and death. Additionally, safety endpoints of peri-procedural complications were studied.

Results: Among 5397 patients (median age 58 [IQR 51-65] years; 23.6% females), abdominal obesity was present in 1759 (32.6%). The rate of AF recurrence was not statistically different between the groups at 1-year (10.3 vs 8.7 events/100-PYs, P = .078), though abdominal obesity was associated with significantly higher rates of AF recurrence at 3-year (7.6 vs 6.3 events/100-PYs, P = .008) and 6-year (6.3 vs 5.2 events/100-PYs, P = .004) follow-ups. Kaplan-Meier survival analysis found significantly higher rates of AF recurrence in patients with obesity based on body mass index (BMI) and waist circumference (log-rank for trend P = .006). Using multivariable regression analysis, obesity by both BMI and waist circumference was an independent predictor for AF recurrence (HR 1.21 [95% CI, 1.05-1.40]), after accounting for other risk factors. There was a trend for increased rates of ischaemic stroke at 3-year and 6-year follow-ups in patients with abdominal obesity. Furthermore, this group of patients had a greater rate of intracranial haemorrhage. All-cause death was comparable between both groups. Total peri-procedural complications were not associated with abdominal obesity.

Conclusion: Abdominal obesity as indicated by waist circumference was associated with a greater burden of concomitant diseases and an independent risk factor for long-term redo AF intervention following catheter ablation but had no effects on total peri-procedural complications.
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http://dx.doi.org/10.1111/ijcp.14696DOI Listing
October 2021

Safety and long-term outcomes of catheter ablation according to sex in patients with atrial fibrillation: A nationwide cohort study.

Int J Cardiol 2021 09 18;338:95-101. Epub 2021 Jun 18.

Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea. Electronic address:

Background: Catheter ablation is more effective than antiarrhythmic drug therapy alone in patients with atrial fibrillation (AF). However, there are limited data on the outcomes of AF ablation according to sex. The purpose of this study was to evaluate gender differences in the actual outcomes after catheter ablation for atrial fibrillation.

Methods: Of 801,710 patients with AF in the Korean National Health Insurance Service database, we identified 9175 patients without valvular heart disease who underwent AF ablation between 2006 and 2015 and assessed 30-day safety and one-year effectiveness outcomes according to sex.

Results: Of the 9175 patients who underwent AF ablation, 2206 (24%) were female. Women, compared to men, were older (60.8 ± 10.2 vs. 56.0 ± 10.5 years), had higher CHADS-VASc (3.5 ± 1.7 vs. 2.0 ± 1.6), higher HAS-BLED (2.6 ± 1.3 vs. 2.4 ± 1.2), and higher Charlson comorbidity index scores (3.8 ± 2.6 vs. 3.1 ± 2.5) (p < 0.001 for all). Following ablation, there was no significant difference in the risk of 30-day complications, including hemorrhage and tamponade, between women and men. In multivariable analyses, there were no significant differences in all-cause hospitalization (adjusted hazard ratio [HR] 1.05, 95% confidence interval [CI] 0.91-1.22, p = 0.489) and AF rehospitalization (adjusted HR 1.16, 95% CI 0.96-1.40, p = 0.135). Women were less likely to undergo cardioversion (adjusted HR 0.72, 95% CI 0.62-0.84, p < 0.001) but were more likely to be re-hospitalized for heart failure (adjusted HR 1.86, 95% CI 1.11-3.11, p = 0.019).

Conclusion: Women who underwent AF ablation did not differ from men in terms of the risk of complications and all-cause hospitalization in this study. The small increased risk in women reported in previous studies may be related to residual confounding, particularly from insufficient control for age and comorbidities.
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http://dx.doi.org/10.1016/j.ijcard.2021.06.021DOI Listing
September 2021

Associations of hypertension burden on subsequent dementia: a population-based cohort study.

Sci Rep 2021 06 10;11(1):12291. Epub 2021 Jun 10.

Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.

In this nationwide cohort study, we assessed the effects of hypertension burden and blood pressure (BP) control on dementia in different age subgroups. From the Korean National Health Insurance Service-Health Screening cohort from January 1, 2005 to December 31, 2013, we enrolled 428,976 subjects aged 40-79 years without previous diagnosis of dementia or stroke. During a mean follow-up of 7.3 ± 1.5 years, 9435 (2.2%) were diagnosed with dementia. Per 10 mmHg increase in systolic BP (SBP), risk of dementia was increased by 22% (95% confidence interval [CI] 1.15-1.30) in subjects aged 40-59 years and 8% (95% CI 1.04-1.11) in subjects aged 60-69 years. No significant associations were observed in subjects aged ≥ 70 years. Among subjects aged 40-59 years, both vascular and Alzheimer's dementia risks were increased with increasing SBP. Increasing hypertension burden (proportion of days with increased BP) was associated with higher dementia risk (hazard ratio [HR] 1.09 per 10% increase, 95% CI 1.08-1.10). Among patients with baseline SBP ≥ 140 mmHg, optimal follow-up SBP (120-139 mmHg) was associated with decreased dementia risk (HR 0.69, 95% CI 0.50-0.95). Hypertension burden was associated with higher risks of dementia. Adequate BP control was associated with lower risk of dementia in individuals aged < 70 years.
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http://dx.doi.org/10.1038/s41598-021-91923-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8192762PMC
June 2021

Changes in Cardiovascular Risk Factors and Cardiovascular Events in the Elderly Population.

J Am Heart Assoc 2021 06 15;10(11):e019482. Epub 2021 May 15.

Division of Cardiology Department of Internal Medicine Yonsei University College of Medicine Seoul Republic of Korea.

Background This study examines changes in the ideal cardiovascular health (CVH) status and whether these changes are associated with incident cardiovascular disease (CVD) and mortality in the elderly Asian population. Methods and Results In the Korea National Health Insurance Service-Senior cohort aged ≥60 years, 208 673 participants without prior CVD, including 109 431 who showed changes in CVH status, were assessed. The association of the changes in cardiovascular risk factors with incident CVD was assessed from 2004 to 2014 in the elderly (aged 60-74 years) and very elderly (≥75 years) groups. During the follow-up period (7.1 years for CVD and 7.2 years for mortality), 19 429 incident CVD events and 24 225 deaths occurred. In both the elderly and very elderly participants, higher CVH status resulted in a lower risk of CVD and mortality. In the very elderly participants, compared with consistently low CVH, consistently high CVH (subhazard ratio, 0.41; 95% CI, 0.23-0.73) was associated with a lower risk of CVD. This trend was consistently observed in the elderly population. In the very elderly participants, total cholesterol level was not informative enough for the prediction of CVD events. In both the elderly and very elderly groups, body mass index and total cholesterol were not informative enough for the prediction of all-cause mortality. Conclusions In both the elderly and very elderly Asian populations without CVD, a consistent relationship was observed between the improvement of a composite metric of CVH and the reduced risk of CVD. Body mass index and total cholesterol were not informative enough for the prediction of all-cause mortality in both the elderly and very elderly groups.
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http://dx.doi.org/10.1161/JAHA.120.019482DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8483545PMC
June 2021

Treatment timing and the effects of rhythm control strategy in patients with atrial fibrillation: nationwide cohort study.

BMJ 2021 05 11;373:n991. Epub 2021 May 11.

Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea

Objective: To investigate whether the results of a rhythm control strategy differ according to the duration between diagnosis of atrial fibrillation and treatment initiation.

Design: Longitudinal observational cohort study.

Setting: Population based cohort from the Korean National Health Insurance Service database.

Participants: 22 635 adults with atrial fibrillation and cardiovascular conditions, newly treated with rhythm control (antiarrhythmic drugs or ablation) or rate control strategies between 28 July 2011 and 31 December 2015.

Main Outcome Measure: A composite outcome of death from cardiovascular causes, ischaemic stroke, admission to hospital for heart failure, or acute myocardial infarction.

Results: Of the study population, 12 200 (53.9%) were male, the median age was 70, and the median follow-up duration was 2.1 years. Among patients with early treatment for atrial fibrillation (initiated within one year since diagnosis), compared with rate control, rhythm control was associated with a lower risk of the primary composite outcome (weighted incidence rate per 100 person years 7.42 in rhythm control 9.25 in rate control; hazard ratio 0.81, 95% confidence interval 0.71 to 0.93; P=0.002). No difference in the risk of the primary composite outcome was found between rhythm and rate control (weighted incidence rate per 100 person years 8.67 in rhythm control 8.99 in rate control; 0.97, 0.78 to 1.20; P=0.76) in patients with late treatment for atrial fibrillation (initiated after one year since diagnosis). No significant differences in safety outcomes were found between the rhythm and rate control strategies across different treatment timings. Earlier initiation of treatment was linearly associated with more favourable cardiovascular outcomes for rhythm control compared with rate control.

Conclusions: Early initiation of rhythm control treatment was associated with a lower risk of adverse cardiovascular outcomes than rate control treatment in patients with recently diagnosed atrial fibrillation. This association was not found in patients who had had atrial fibrillation for more than one year.
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http://dx.doi.org/10.1136/bmj.n991DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8111568PMC
May 2021

Association of cardiovascular health and incident atrial fibrillation in elderly population.

Heart 2021 Apr 2. Epub 2021 Apr 2.

Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea (the Republic of)

Objective: To evaluate whether baseline and changes in cardiovascular health (CVH) were related to incident atrial fibrillation (AF) risk in the elderly population.

Methods: From the Korea National Health Insurance Service-Senior cohort, we included 208 598 participants without prior AF (median age: 70 (IQR 66-74) years; 90 916 (43.6%) men) who underwent national health check-ups between 1 January 2005 and 31 December 2012. Using the six metrics of the American Heart Association, participants were categorised as having low, moderate and high CVH.

Results: Over a median follow-up of 7.2 years, 7818 cases of incident AF occurred. In multivariable analysis, moderate (HR: 0.90; 95% CI: 0.86 to 0.94) and high (HR: 0.81; 95% CI: 0.73 to 0.91) CVH status at baseline were associated with a lower risk of incident AF. However, in 109 695 participants with changes in CVH between the first and second check-ups, the direction of change in CVH scores showed no consistent association with future AF incidence. In newly diagnosed participants with AF, the incidence of the composite outcome (stroke, major bleeding and all-cause death) decreased with every 1-point increase in the baseline CVH score (HR: 0.94; 95% CI: 0.89 to 0.99).

Conclusions: In the general elderly population, better baseline CVH metrics were associated with lower incident AF risk. In participants with newly diagnosed AF, better CVH was also associated with lower incidence of future composite outcomes. However, the direction of change in CVH status within 2 years showed an inconsistent influence on incident AF risk.
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http://dx.doi.org/10.1136/heartjnl-2020-318858DOI Listing
April 2021

Changes in Cardiovascular Health Status and Risk of Sudden Cardiac Death in Older Adults.

Yonsei Med J 2021 Apr;62(4):298-305

Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.

Purpose: Cardiovascular health (CVH) status is associated with several cardiovascular outcomes; however, correlations between changes in CVH status and risk of sudden cardiac death (SCD) are unknown. We aimed to evaluate associations between changes in CVH status and risk of SCD and all-cause death in older adults.

Materials And Methods: We used data from the Korea National Health Insurance Service-Senior cohort database (2005-2012). Six metrics from the American Heart Association (smoking, body mass index, physical activity, blood pressure, total cholesterol, and fasting blood glucose) were used to calculate CVH scores. Changes in CVH status between two health checkups were categorized as low to low, low to high, high to low, and high to high.

Results: We included 105200 patients whose CVH status for an initial and follow-up health checkup (2-year interval) was available. During a median of 5.2 years of follow-up after a second health checkup, 688 SCDs occurred. Compared to patients with a persistent low CVH status, those with a consistently high CVH status had a reduced risk of SCD [adjusted hazard ratio (HR), 0.69; 95% confidence interval (CI), 0.56-0.86] and all-cause death (adjusted HR, 0.74; 95% CI, 0.69-0.78). The risk of all-cause death followed similar trends. However, an inconsistent linear relationship was observed for changes in CVH status and the risk of SCD, but not of all-cause death.

Conclusion: Maintaining a high CVH status was associated with future risks of SCD and all-cause death among an older adult population.
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http://dx.doi.org/10.3349/ymj.2021.62.4.298DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8007437PMC
April 2021

Frailty and the Effect of Catheter Ablation in the Elderly Population With Atrial Fibrillation - A Real-World Analysis.

Circ J 2021 07 16;85(8):1305-1313. Epub 2021 Mar 16.

Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine.

Background: It is unclear whether catheter ablation is beneficial for frail elderly patients with atrial fibrillation (AF). This study evaluated the effect of ablation on outcomes in frail elderly patients with AF.Methods and Results:From the Korean National Health Insurance Service database, 194,928 newly diagnosed AF patients were treated with ablation or medical therapy (rhythm or rate control) between 2005 and 2015. Among these patients, the study included 1,818 (ablation; n=119) frail and 1,907 (ablation; n=230) non-frail elderly (≥75 years) patients. Propensity score matching was used to correct for differences between groups. During 28 months (median) follow up, the risk of all-cause death, composite outcome (all-cause death, heart failure admission, stroke/systemic embolism, and sudden cardiac arrest), and each outcome did not change after ablation in frail elderly patients. However, in non-frail elderly patients, ablation was associated with a lower risk of all-cause death (3.5 and 6.2 per 100 person-years; hazard ratio [HR] 0.48; 95% confidence interval [CI] 0.30-0.79; P=0.004), and composite outcome (6.9 and 11.2 per 100 person-years; HR 0.54; 95% CI 0.38-0.75; P<0.001).

Conclusions: Ablation may be associated with a lower risk of death and composite outcome in non-frail elderly, but the beneficial effect of ablation was not significant in frail elderly patients with AF. The effect of frailty on the outcome of ablation should be evaluated in further studies.
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http://dx.doi.org/10.1253/circj.CJ-20-1062DOI Listing
July 2021

Reduction of mortality by catheter ablation in real-world atrial fibrillation patients with heart failure.

Sci Rep 2021 02 25;11(1):4694. Epub 2021 Feb 25.

Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.

Whether catheter ablation for atrial fibrillation (AF) improves survival and affects other outcomes in real-world heart failure (HF) patients is unclear. This study aimed to evaluate whether ablation reduces death, and other outcomes in real-world AF patients with HF. Among 834,735 patients with AF from 2006 to 2015 in the Korean National Health Insurance Service database, 3173 HF patients underwent AF ablation. Propensity score weighting was used to correct for differences between the groups. During median 54 months follow-up, the risk of all-cause death in ablated patients was less than half of that in patients with medical therapy (2.8 vs. 6.2 per 100 person-years; hazard ratio [HR] 0.42, 95% confidence interval [CI] 0.27-0.65, p < 0.001). Ablation was related with lower risk of cardiovascular death (HR 0.38, 95% CI 0.32-0.62, p < 0.001), HF admission (HR 0.39, 95% CI 0.33-0.46, p < 0.001) and stroke/systemic embolism (HR 0.44, 95% CI 0.37-0.53, p < 0.001). In subgroup analysis, the risk of all-cause death was reduced in most subgroups except in the elderly (≥ 75 years) and strictly anticoagulated patients. Ablation may be associated with reduced risk of all-cause death and cardiovascular death in real-world AF patients with HF, supporting the role of AF ablation in patients with HF.
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http://dx.doi.org/10.1038/s41598-021-84256-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7907229PMC
February 2021

Association of anticoagulant therapy with risk of dementia among patients with atrial fibrillation.

Europace 2021 02;23(2):184-195

Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonseiro, Seodaemun-gu, Seoul 03722, Republic of Korea.

Aims: To investigate the risk of dementia in atrial fibrillation (AF) patients treated with different oral anticoagulants (OACs).

Methods And Results: This observational, population-based cohort study enrolled 53 236 dementia-free individuals with non-valvular AF who were aged ≥50 years and newly prescribed OACs from 1 January 2013 to 31 December 2016 from the Korean National Health Insurance Service database. Propensity score matching was used to compare the rates of dementia between users of non-vitamin K antagonist oral anticoagulant (NOAC) (dabigatran, rivaroxaban, and apixaban) and warfarin and to compare each individual NOAC with warfarin. Propensity score weighting analyses were also performed. In the study population (41.3% women; mean age: 70.7 years), 2194 had a diagnosis of incident dementia during a mean follow-up of 20.2 months. Relative to propensity-matched warfarin users, NOAC users tended to be at lower risk of dementia [hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.69-0.90]. When comparing individual NOACs with warfarin, all the three NOACs were associated with lower dementia risk. In pairwise comparisons among NOACs, rivaroxaban was associated with decreased dementia risk, compared with dabigatran (HR 0.83, 95% CI 0.74-0.92). Supplemental propensity-weighted analyses showed consistent protective associations of NOACs with dementia relative to warfarin. The associations were consistent irrespectively of age, sex, stroke, and vascular disease and more prominent in standard dose users of NOAC.

Conclusion: In this propensity-matched and -weighted analysis using a real-world population-based cohort, use of NOACs was associated with lower dementia risk than use of warfarin among non-valvular AF patients initiating OAC treatment.
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http://dx.doi.org/10.1093/europace/euaa192DOI Listing
February 2021

Less dementia after catheter ablation for atrial fibrillation: a nationwide cohort study.

Eur Heart J 2020 12;41(47):4483-4493

Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.

Aims: Accumulating evidence shows that atrial fibrillation (AF) is associated with an increased risk of dementia. Catheter ablation for AF prolongs the duration of sinus rhythm, thereby improving the quality of life. We investigated the association of catheter ablation for AF with the occurrence of dementia.

Methods And Results: Using the Korean National Health Insurance Service database, among 194 928 adults with AF treated with ablation or medical therapy (antiarrhythmic or rate control drugs) between 1 January 2005 and 31 December 2015, we studied 9119 patients undergoing ablation and 17 978 patients managed with medical therapy. The time-at-risk was counted from the first medical therapy, and ablation was analysed as a time-varying exposure. Propensity score-matching was used to correct for differences between the groups. During a median follow-up of 52 months, compared with patients with medical therapy, ablated patients showed lower incidence and risk of overall dementia (8.1 and 5.6 per 1000 person-years, respectively; hazard ratio 0.73, 95% confidence interval 0.58-0.93). The associations between ablation and dementia risk were consistently observed after additionally censoring for incident stroke (hazard ratio 0.76, 95% confidence interval 0.61-0.95) and more pronounced in cases of ablation success whereas no significant differences observed in cases of ablation failure. Ablation was associated with lower risks of dementia subtypes including Alzheimer's disease and vascular dementia.

Conclusion: In this nationwide cohort of AF patients treated with catheter ablation or medical therapy, ablation was associated with decreased dementia risk. This relationship was evident after censoring for stroke and adjusting for clinical confounders.
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http://dx.doi.org/10.1093/eurheartj/ehaa726DOI Listing
December 2020

Long-term PM exposure and the clinical application of machine learning for predicting incident atrial fibrillation.

Sci Rep 2020 10 1;10(1):16324. Epub 2020 Oct 1.

Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.

Clinical impact of fine particulate matter (PM) air pollution on incident atrial fibrillation (AF) had not been well studied. We used integrated machine learning (ML) to build several incident AF prediction models that include average hourly measurements of PM for the 432,587 subjects of Korean general population. We compared these incident AF prediction models using c-index, net reclassification improvement index (NRI), and integrated discrimination improvement index (IDI). ML using the boosted ensemble method exhibited a higher c-index (0.845 [0.837-0.853]) than existing traditional regression models using CHADS-VASc (0.654 [0.646-0.661]), CHADS (0.652 [0.646-0.657]), or HATCH (0.669 [0.661-0.676]) scores (each p < 0.001) for predicting incident AF. As feature selection algorithms identified PM as a highly important variable, we applied PM for predicting incident AF and constructed scoring systems. The prediction performances significantly increased compared with models without PM (c-indices: boosted ensemble ML, 0.954 [0.949-0.959]; PM-CHADS-VASc, 0.859 [0.848-0.870]; PM-CHADS, 0.823 [0.810-0.836]; or PM-HATCH score, 0.849 [0.837-0.860]; each interaction, p < 0.001; NRI and IDI were also positive). ML combining readily available clinical variables and PM data was found to predict incident AF better than models without PM or even established risk prediction approaches in the general population exposed to high air pollution levels.
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http://dx.doi.org/10.1038/s41598-020-73537-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7530980PMC
October 2020

What Is the Ideal Blood Pressure Threshold for the Prevention of Atrial Fibrillation in Elderly General Population?

J Clin Med 2020 Sep 16;9(9). Epub 2020 Sep 16.

Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea.

Intensive blood pressure (BP) lowering in patients with hypertension at increased risk of cardiovascular disease has been associated with a lowered risk of incident atrial fibrillation (AF). It is uncertain whether maintaining the optimal BP levels can prevent AF in the general elderly population. We included 115,866 participants without AF in the Korea National Health Insurance Service-Senior (≥60 years) cohort from 2002 to 2013. We compared the influence of BP on the occurrence of new-onset AF between octogenarians (≥80 years) and non-octogenarians (<80 years) subjects. With up to 6.7 ± 1.7 years of follow-up, 4393 incident AF cases occurred. After multivariable adjustment for potentially confounding clinical covariates, the risk of AF in non-octogenarians was significantly higher in subjects with BP levels of <120/<80 and ≥140/90 mm Hg, with hazard ratios of 1.15 (95% confidence interval (CI), 1.03-1.28; < 0.001) and 1.14 (95% CI, 1.04-1.26; < 0.001), compared to the optimal BP levels (120-129/<80 mm Hg). In octogenarians, the optimal BP range was 130-139/80-89 mm Hg, higher than in non-octogenarians. A U-shaped relationship for the development of incident AF was evident in non-octogenarians, and BP levels of 120-129/<80 mm Hg were associated the lowest risk of incident AF. Compared to non-octogenarians, the lowest risk of AF was associated with higher BP levels of 130-139/80-89 mm Hg amongst octogenarians.
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http://dx.doi.org/10.3390/jcm9092988DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7563734PMC
September 2020

Application of the simple atrial fibrillation better care pathway for integrated care management in frail patients with atrial fibrillation: A nationwide cohort study.

J Arrhythm 2020 Aug 5;36(4):668-677. Epub 2020 Jun 5.

Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Republic of Korea.

Background: The benefit of integrated care management was unknown in frail atrial fibrillation (AF) patients. This study evaluated whether compliance with the atrial fibrillation Better Care (ABC) pathway for integrated care management would improve clinical outcomes in frail AF patients.

Methods: From the Korea National Health Insurance Service database, 262,987 nonvalvular AF patients were enrolled between 1 January 2005 and 31 December 2015. For each patient, the Hospital Frailty Risk Score and category were calculated retrospectively using all available ICD-10 diagnostic codes. Patients were divided into three frailty-based risk categories: low (<5 points, n = 221,542), intermediate (5-15 points, n = 37,341), and high risk (>15 points, n = 4,104).

Results: Over a mean follow-up of 5.9 (interquartile range 3.2, 9.4) years, in high frailty risk patients, the ABC group had lower rates of all-cause death (6.5 vs 17.5 per 100 person-years,  < .001; hazard ratio [HR] 0.74; 95% confidence interval [CI] 0.56-0.97) but was nonsignificant for the composite outcome (10.5 vs 26.0 per 100 person-years,  = .101; HR 0.79; 95% CI 0.59-1.05) compared with the Non-ABC group. When the three frailty categories were compared, the greatest benefit on mortality was seen in the high frailty group (p < 0.001), but for the composite outcome, there was no statistical interaction for the three frailty categories (p = 0.063).

Conclusions: Compliance with the simple ABC pathway is associated with improved outcomes in AF patients with high frailty risk. Given the high healthcare burden associated with frail AF patients, integrated AF management should be implemented to improve outcomes in these patients.
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http://dx.doi.org/10.1002/joa3.12364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7411200PMC
August 2020

The Effect of Integrated Care Management on Dementia in Atrial Fibrillation.

J Clin Med 2020 Jun 2;9(6). Epub 2020 Jun 2.

Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea.

Clinical outcomes of patients with atrial fibrillation (AF) can be improved by an integrated care approach. We analyzed whether adherence with the AF Better Care (ABC) pathway for integrated care management would reduce the risk of dementia in a nationwide AF cohort. Using the National Health Insurance Service database of Korea, 228,026 non-valvular AF patients were retrospectively evaluated between 2005 and 2015. Patients meeting all criteria of the ABC pathway were classified as the "ABC" group and those not classified as the "non-ABC" group. During a median (25th, 75th percentiles) follow-up of 6.0 (3.3, 9.5) years, the ABC group had lower rates and risk of overall dementia (0.17 vs. 1.11 per 100 person-years, < 0.001; hazard ratio (HR) 0.80; 95% CI 0.73-0.87) and both Alzheimer's (HR 0.79, 95% CI 0.71-0.88) and vascular dementia (HR 0.76, 95% CI 0.59-0.98) than the non-ABC group. The stratified analysis showed that the ABC pathway reduced the risk of dementia regardless of sex, comorbidities, and in patients with high stroke risk. Adherence with the ABC pathway is associated with a reduced risk of dementia in AF patients. Due to the high medical burden of AF, it is necessary to implement integrated AF management to reduce the risk of dementia.
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http://dx.doi.org/10.3390/jcm9061696DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7356978PMC
June 2020

Label Adherence of Direct Oral Anticoagulants Dosing and Clinical Outcomes in Patients With Atrial Fibrillation.

J Am Heart Assoc 2020 06 4;9(12):e014177. Epub 2020 Jun 4.

Division of Cardiology Department of Internal Medicine Yonsei University College of Medicine Seoul Republic of Korea.

Background Dose adjustment of non-vitamin K antagonist oral anticoagulants (NOACs) is indicated in some patients with atrial fibrillation (AF), based on selected patient factors or concomitant medications. We assessed the frequency of label adherence of NOAC dosing among AF patients and the associations between off-label NOAC dosing and clinical outcomes. Methods and Results We evaluated 53 649 AF patients treated with an NOAC using Korean National Health Insurance Service database during the period from 2013 to 2016. NOAC doses were classified as either underdosed or overdosed, consistent with Korea Food and Drug Administration labeling. Cox proportional hazards regression was performed to investigate the effectiveness and safety outcomes including stroke or systemic embolism, major bleeding, and all-cause mortality. Overall, 16 757 NOAC-treated patients (31.2%) were underdosed, 4492 were overdosed (8.4%), and 32 400 (60.4%) were dosed appropriately according to drug labeling. Compared with patients with label adherence, those who were underdosed or overdosed were older (aged 71±8 and 75±7 years versus 70±9 years, respectively; <0.001) and had higher CHADS-VASc scores (4.6±1.7 and 5.3±1.7 versus 4.5±1.8, respectively; <0.001). NOAC overdosing was associated with increased risk for stroke or systemic embolism (5.76 versus 4.03 events/100 patient-years, <0.001), major bleeding (4.77 versus 2.94 events/100 patient-years, <0.001), and all-cause mortality (5.43 versus 3.05 events/100 patient-years, <0.001) compared with label-adherent use. Conclusions In real-world practice, a significant proportion (almost 2 in 5) of AF patients received NOAC doses inconsistent with drug labeling. NOAC overdosing is associated with worse clinical outcomes in Asian AF patients.
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http://dx.doi.org/10.1161/JAHA.119.014177DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429045PMC
June 2020

Catheter Ablation Improves Mortality and Other Outcomes in Real-World Patients With Atrial Fibrillation.

J Am Heart Assoc 2020 06 19;9(11):e015740. Epub 2020 May 19.

Division of Cardiology Department of Internal Medicine Yonsei University College of Medicine Seoul Republic of Korea.

Background It is still controversial whether catheter ablation for atrial fibrillation (AF) improves survival and other outcomes in patients with AF. This study evaluated whether ablation reduces death and other events in nationwide real-world Asian patients with AF. Methods and Results From the Korean National Health Insurance Service database, 194 928 adult patients (aged ≥18 years) with newly diagnosed AF were treated with ablation or medical therapy (antiarrhythmic or rate control drugs) between January 1, 2005, and December 1, 2015. Among these patients, this study included 9185 with ablation and 18 770 with medical therapy. The time at risk was counted from the first medical therapy, and ablation was analyzed as a time-varying covariate. Inverse probability of treatment weighting was used to correct for differences between the groups. After weighting, the 2 cohorts had similar background characteristics. During a median (25th, 75th percentiles) follow-up of 43 (19, 81) months, ablation of AF was associated with lower incidence and risk of composite outcome, including death, heart failure admission, and stroke/systemic embolism (2.5 and 6.4 per 100 person-years, respectively; hazard ratio [HR], 0.47; 95% CI, 0.43-0.52; <0.001), all-cause death (1.0 and 3.6 per 100 person-years; HR, 0.41; 95% CI, 0.36-0.47; <0.001), heart failure admission (0.7 and 1.9 per 100 person-years; HR, 0.43; 95% CI, 0.37-0.50), and ischemic stroke/systemic embolism (1.1 and 2.8 per 100 person-years; HR, 0.39; 95% CI, 0.34-0.44) than medical therapy. Conclusions Ablation may be associated with lower risk of death, heart failure admission, and ischemic stroke/systemic embolism in real-world Asian patients with AF.
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http://dx.doi.org/10.1161/JAHA.119.015740DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429005PMC
June 2020

Blood Pressure Control and Dementia Risk in Midlife Patients With Atrial Fibrillation.

Hypertension 2020 05 16;75(5):1296-1304. Epub 2020 Mar 16.

From the Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (D.K., E.J., H.T.Y., T.-H.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L., B.J.).

Atrial fibrillation (AF) is associated with increased risk of cognitive impairment and dementia, even with no overt stroke. Hypertension has been a potentially modifiable risk factor for dementia, especially in midlife (<70 years) individuals. We aimed to investigate the associations of blood pressure (BP) and hypertension burden with dementia risk among midlife AF patients. From the Korean National Health Insurance Service database, we enrolled 171 228 incident AF patients aged 50 to 69 years with no prior dementia from 2005 to 2016. During a mean of 6.6 years of follow-up, 9909 patients received a first-time diagnosis of dementia. U-shaped relationships were noted between systolic or diastolic BP and dementia risk: A 10 mm Hg increase or decrease in systolic BP starting from 120 mm Hg was associated with 4.4% (95% CI, 2.7%-6.0%) and 4.6% (95% CI, 0.1%-8.2%) higher dementia risk, respectively. An increase or decrease in diastolic BP starting from 80 mm Hg also increased dementia risk. In subtype analyses, Alzheimer disease increases with BP decrease whereas vascular dementia increases according to BP increase. When BP changes over time were accounted for in time-updated models, BP of 120 to 129/80 to 84 mm Hg was associated with the lowest dementia risk. Increasing hypertension burden (the proportion of days with increased BP during follow-up) was associated with higher dementia risk (hazard ratio, 1.10 per 10% increase [95% CI, 1.08-1.12]). Among midlife AF patients, there were a U-shaped association of BP and a log-linear association of hypertension burden with dementia risk. Minimizing the burden of hypertension in AF patients might help to prevent dementia.
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http://dx.doi.org/10.1161/HYPERTENSIONAHA.119.14388DOI Listing
May 2020

Social Inequalities of Oral Anticoagulation after the Introduction of Non-Vitamin K Antagonists in Patients with Atrial Fibrillation.

Korean Circ J 2020 Mar;50(3):267-277

Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.

Background And Objectives: Nationwide social inequalities of oral anticoagulation (OAC) usage after the introduction of non-vitamin K antagonist oral anticoagulants (NOACs) have not been well identified in patients with atrial fibrillation (AF). This study assessed overall rate and social inequalities of OAC usage after the introduction of NOAC in Korea.

Methods: Between January 2002 and December 2016, we identified 888,540 patients with AF in the Korea National Health Insurance system database. The change of OAC rate in different medical systems after the introduction of NOAC were evaluated.

Results: In all population, overall OAC use increased from 13.2% to 23.4% (p for trend <0.001), and NOAC use increased from 0% to 14.6% (p for trend <0.001). Compared with pre-reimbursement (0.48%), the annual increase of OAC use was significantly higher after partial (1.16%, p<0.001), and full reimbursement of OAC (3.72%, p<0.001). Full reimbursement of NOAC (adjusted odds ratio, 2.10; 95% confidence interval, 2.04-2.15) was independently associated with higher OAC use. However, the difference of overall OAC usage between tertiary referral hospitals and nursing or public health centers increased from 17.9% in 2010 to 36.8% in 2016. Moreover, usage rate of NOAC was significantly different among different medical systems from 37.2% at the tertiary referral hospital and 5.5% at nursing or public health centers.

Conclusions: Introduction of NOACs in routine practice for stroke prevention in AF was associated with improved rates of overall OAC use. However, significant practice-level variations in OAC and NOAC use remain producing social inequalities of OAC despite full reimbursement.
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http://dx.doi.org/10.4070/kcj.2019.0207DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7043961PMC
March 2020
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