Publications by authors named "Gregory Y H Lip"

2,584 Publications

  • Page 1 of 1

Obstructive sleep apnoea and atrial fibrillation: a key omission in guidelines.

Br J Cardiol 2022 8;29(1):10. Epub 2022 Mar 8.

Respiratory Consultant and Sleep Physician, and Sleep and Ventilation Lead Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield Teaching Hospital, Herries Road, Sheffield, S5 7AU.

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http://dx.doi.org/10.5837/bjc.2022.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9196072PMC
March 2022

Monocytes are increased in pregnancy after gestational hypertensive disease.

Sci Rep 2022 Jun 20;12(1):10358. Epub 2022 Jun 20.

Liverpool Centre for Cardiovascular Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK.

Monocytes derive from bone marrow and circulate in the blood. They phagocytose, produce cytokines and present antigens. Individual monocyte subsets play distinct roles in the pathogenesis of cardiovascular disease, but their implications in gestational hypertensive disease are unclear. Our objective was to examine the difference in monocyte subsets between pregnant women with or without previous hypertension in pregnancy. Women were enrolled in a prospective observational study in which monoclonal antibodies against cell surface receptors were used to detect monocytes in the peripheral blood by flow cytometry. We compared 17 pregnant women with previous hypertension in pregnancy (Group 1) and 42 pregnant women without previous gestational hypertensive disease (Group 2) with 27 healthy, non-pregnant controls (Group 3). The pregnant women were studied at 13 ± 1 weeks gestation. Monocyte subsets were quantified by flow cytometry: Mon1 (CD14++CD16-CCR2+), Mon2 (CD14++CD16+CCR2+), Mon3 (CD14+CD16+CCR2-), their aggregates with platelets and expression of the surface markers. The groups were well-matched for age, body mass index and ethnicity (P > 0.05 for all). Mon1 counts were higher in women with a history of gestational hypertension or preeclampsia compared to other groups (Group 1 = 441 per µl (376-512); Group 2 = 357 (309-457); Group 3 = 323 (277-397); P < 0.001). Mon3 was higher in both groups of pregnant women compared to non-pregnant controls (Group 1 = 51 (38-62); Group 2 = 38 (29-58); Group 3 = 26 (20-40), P = 0.002). Increased monocytes in women with a previous hypertensive pregnancy generates a hypothesis that these cells may link hypertension in pregnancy, chronic inflammation and future cardiovascular risk.
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http://dx.doi.org/10.1038/s41598-022-13606-2DOI Listing
June 2022

Atrial fibrillation, a contemporary sign of multimorbidity and irregular social inequity.

Lancet Reg Health Eur 2022 Jun 4;17:100395. Epub 2022 May 4.

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

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http://dx.doi.org/10.1016/j.lanepe.2022.100395DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9198840PMC
June 2022

Type and Severity of Migraine Determines Risk of Atrial Fibrillation in Women.

Front Cardiovasc Med 2022 31;9:910225. Epub 2022 May 31.

Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.

Objective: To evaluate sex differences in the risk of atrial fibrillation (AF) according to the type and severity of migraine.

Methods: We analyzed the nationwide health screening recipients in 2009 without previous AF diagnosis from the Korean National Health Insurance Service data. The diagnosis, type, and severity of migraine were determined using claims data. Newly developed AF was identified during a 10-year follow-up. Sex-difference in the effect of migraine on AF was evaluated.

Results: A total of 4,020,488 subjects were enrolled from January 1, to December 31, 2009 and followed-up through December 31, 2018; 4,986 subjects had migraine with aura (age 50.6 ± 14.0 years, men 29.3%); and 105,029 had migraine without aura (age 51.6 ± 14.3 years, men 30.9%). Risk of AF in a mild degree of migraine was similar to that in the control group, regardless of sex or the presence of aura. Severe migraine without aura modestly but significantly increased the risk of AF in both men and women compared to controls, with increase in AF risk being most prominent in women who had severe migraine with aura [incidence rate () = 3.39, hazard ratio () = 1.48, 95% confidence intervals () = 1.18-1.85]. No significant association according to aura was observed in men with severe migraines ( for interaction 0.011).

Conclusion: Severe migraine with aura significantly increased the risk of incident AF in women, but not in men. Surveillance for incident AF and prompt lifestyle modification may be beneficial, particularly for young women suffering from severe migraine with aura.
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http://dx.doi.org/10.3389/fcvm.2022.910225DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9197451PMC
May 2022

Antithrombotic Therapy in Atrial Fibrillation and Coronary Artery Disease: Does Less Mean More?

JAMA Cardiol 2022 Jun 15. Epub 2022 Jun 15.

Liverpool Centre for Cardiovascular Science, Liverpool Heart & Chest Hospital, University of Liverpool, Liverpool, United Kingdom.

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http://dx.doi.org/10.1001/jamacardio.2022.1572DOI Listing
June 2022

Risk of Dementia After Smoking Cessation in Patients With Newly Diagnosed Atrial Fibrillation.

JAMA Netw Open 2022 Jun 1;5(6):e2217132. Epub 2022 Jun 1.

Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.

Importance: Incident atrial fibrillation (AF) is associated with an increased risk of dementia. However, data on the association between smoking cessation after AF diagnosis and dementia risk are limited.

Objective: To evaluate the association between changes in smoking status after AF diagnosis and dementia risk.

Design, Setting, And Participants: This nationwide cohort study with 126 252 patients used data from the Korean National Health Insurance Service database, including patients who had a national health checkup examination within 2 years before and after AF diagnosis between January 1, 2010, and December 31, 2016. Based on their smoking status, participants were classified as never smokers, ex-smokers, quit smokers, and current smokers. Ex-smokers were defined as those who had quit smoking before the first examination and remained quit until the second examination. Patients who were current smokers at the first health examination but had quit smoking before the second examination were classed as quit smokers. The index date was the second health examination. Patients were followed up until dementia, death, or the study period ended (December 31, 2017), whichever occurred first. Data were analyzed from January 13, 2020, to March 29, 2022.

Exposures: Smoking cessation after newly diagnosed AF.

Main Outcomes And Measures: Dementia, including Alzheimer disease and vascular dementia, was the primary outcome. Cox proportional hazards regression model was used to estimate hazard ratios.

Results: A total of 126 252 patients (mean [SD] age, 62.6 [12.0] years; 61.9% men) were included in the analysis. The mean (SD) CHA2DS2-VASc score, which measures the risk of ischemic stroke, was 2.7 (1.7). Smoking status of the total study population was as follows: 65 579 never smokers (51.9%), 34 670 ex-smokers (27.5%), 8919 quit smokers (7.1%), and 17 084 current smokers (13.5%). During a median of 3 years of follow-up, dementia occurred in 5925 patients (1.11 per 1000 person-years). After multivariable adjustment, the risk of quit smokers was significantly lower than that of current smokers (hazard ratio, 0.83 [95% CI, 0.72-0.95]).

Conclusions And Relevance: The findings of this cohort study suggest that all types of smoking were associated with a significantly higher risk of dementia in patients with new-onset AF. Smoking cessation after AF diagnosis was associated with a lower risk of dementia than among current smokers. These findings may support promoting smoking cessation to reduce dementia risk in patients with new-onset AF.
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http://dx.doi.org/10.1001/jamanetworkopen.2022.17132DOI Listing
June 2022

Clinical utility and prognostic implications of the 4S-AF scheme: Report from Asia Pacific Heart Rhythm Society Atrial Fibrillation Registry.

Eur J Clin Invest 2022 Jun 14:e13825. Epub 2022 Jun 14.

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

Background: The 4S-AF classification scheme comprises of four domains (stroke risk [St], symptoms [Sy], severity of atrial fibrillation (AF) burden [Sb] and substrate [Su]), which has been recommended in the 2020 ESC guidelines to characterize and evaluate patients with AF.

Objectives: We aimed to determine whether the 4S-AF scheme would be useful for AF characterization and provides prognostic information in a large contemporary prospective Asian registry conducted by the Asia Pacific Heart Rhythm Society (APHRS).

Methods: Among 4666 patients enrolled in APHRS registry, 3586 of them whose data about left atrial (LA) dimension and European Heart Rhythm Association (EHRA) symptom score were available have constituted as the study population. The 4S-AF score was calculated as the sum of each domain with a maximum score of 9. The clinical endpoint was defined as the 1-year composite risk of any thromboembolic event, ischaemic stroke, heart failure, acute coronary syndrome, significant coronary artery disease requiring coronary intervention and all-cause mortality.

Results: Based on the 4S-AF domains, 86.7% were 'non-low risk' for stroke; 94.3% had EHRA Class I-II, 48.5% were newly diagnosed or paroxysmal AF; and only 8.4% had no cardiovascular risk factors or LA enlargement. The risk of clinical events was higher in patients who were 'non-low risk' for stroke (aOR 2.175, 95% CI 1.060-4.461), with permanent AF (aOR 1.579, 95% CI 1.106-2.225) and increasing points for substrate (aORs 2.376-4.968 from score 2 to 4). When compared to the first tertile of 4S-AF score (0-3 points), patients in the second tertile (4-5 points) had approximately 2.5-fold increase in adverse events (OR 2.478, 95% CI 1.678-3.661, p < .001), while those in the third tertile (6-9 points), had a 3.5-fold increase (OR 3.484, 95% CI 2.322-5.226, p < .001), both without significant differences between the 5 participating countries (p for interaction > .05). If all 4S-AF domains were appropriately treated, this was associated with a lower risk of composite clinical outcomes (aOR 0.384, p < .001; p for interaction for different countries = .234).

Conclusions: Categorization according to the 4S-AF scheme can be related to the risk of the composite adverse event rate in Asian AF patients, and appropriate treatments based on the 4S-AF scheme resulted in better clinical outcomes. These observations support the characterization and management according to the 4S-AF scheme in Asian patients.
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http://dx.doi.org/10.1111/eci.13825DOI Listing
June 2022

Development and Validation of 3-Year Atrial Fibrillation Prediction Models Using Electronic Health Record With or Without Standardized Electrocardiogram Diagnosis and a Performance Comparison Among Models.

J Am Heart Assoc 2022 Jun 14;11(12):e024045. Epub 2022 Jun 14.

Korea University Research Institute for Medical Bigdata Science Korea University Seoul Republic of Korea.

Background Improved prediction of atrial fibrillation (AF) may allow for earlier interventions for stroke prevention, as well as mortality and morbidity from other AF-related complications. We developed a clinically feasible and accurate AF prediction model using electronic health records and computerized ECG interpretation. Methods and Results A total of 671 318 patients were screened from 3 tertiary hospitals. After careful exclusion of cases with missing values and a prior AF diagnosis, AF prediction models were developed from the derivation cohort of 25 584 patients without AF at baseline. In the internal/external validation cohort of 117 523 patients, the model using 6 clinical features and 5 ECG diagnoses showed the highest performance for 3-year new-onset AF prediction (C-statistic, 0.796 [95% CI, 0.785-0.806]). A more simplified model using age, sex, and 5 ECG diagnoses (atrioventricular block, fusion beats, marked sinus arrhythmia, supraventricular premature complex, and wide QRS complex) had comparable predictive power (C-statistic, 0.777 [95% CI, 0.766-0.788]). The simplified model showed a similar or better predictive performance than the previous models. In the subgroup analysis, the models performed relatively better in patients without risk factors. Specifically, the predictive power was lower in patients with heart failure or decreased renal function. Conclusions Although the 3-year AF prediction model using both clinical and ECG variables showed the highest performance, the simplified model using age, sex, and 5 ECG diagnoses also had a comparable prediction power with broad applicability for incident AF.
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http://dx.doi.org/10.1161/JAHA.121.024045DOI Listing
June 2022

Efficacy and safety of vitamin-K antagonists and direct oral anticoagulants for stroke prevention in patients with heart failure and sinus rhythm: an updated systematic review and meta-analysis of randomized clinical trials.

Int J Stroke 2022 Jun 10:17474930221109149. Epub 2022 Jun 10.

Department of Internal Medicine, Faculty of Health Sciences, University of Thessaly, Larissa, Greece.

Introduction: Heart failure is a major public health issue associated with significantly increased risk of stroke. It remains uncertain whether oral anticoagulation (OAC) in patients with heart failure and sinus rhythm (HF-SR) could improve prognosis.

Methods: We performed a systematic search of PubMed and Embase databases for randomized controlled clinical trials assessing oral anticoagulants versus antiplatelets or placebo in patients with heart failure or ventricular dysfunction/cardiomyopathy without clinical heart failure, and sinus rhythm. The outcomes assessed were stroke/systemic embolism, major bleeding, myocardial infarction, all-cause mortality, and heart failure hospitalization.

Results: Seven trials of 15,794 patients were eligible for our analyses. The overall follow-up duration was 32,367 patient-years corresponding to a mean follow-up of 2.05 years per patient. Four trials included patients treated with warfarin and three included patients treated with rivaroxaban. Oral anticoagulation was associated with reduced rate of stroke or systemic embolism compared to control (OR:0.57, 95% CI: 0.39, 0.82, NNT: 65.1) but higher rate of major bleeding (OR: 1.86, 95% CI: 1.32, 2.63, NNH: 58.1). In the subgroup analysis according to the type of OAC, rivaroxaban was associated with significantly reduced rate of stroke or systemic embolism (1.24 vs. 1.97 events per 100 patient-years, respectively, OR:0.63, 95% CI: 0.45, 0.88, NNT: 82) without excess risk of major bleeding (OR: 1.66, 95% CI: 0.26, 10.59) compared to antiplatelets or placebo. There was no significant differences between groups for the outcomes of myocardial infarction, all-cause mortality, and heart failure hospitalization.

Conclusions: This analysis shows that a non-VKA strategy of oral anticoagulation may be both efficacious and safe for stroke prevention in HF-SR patients. A well-designed randomized controlled trial of newer safer OACs is needed in this population.
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http://dx.doi.org/10.1177/17474930221109149DOI Listing
June 2022

Anticoagulation Control in Older Atrial Fibrillation Patients Receiving Vitamin K Antagonist Therapy for Stroke Prevention.

Int J Clin Pract 2022 31;2022:5951262. Epub 2022 Jan 31.

University of Birmingham Institute of Cardiovascular Sciences, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK.

Introduction: Efficacy and safety of vitamin K antagonists (VKAs) among atrial fibrillation (AF) patients are enhanced when the International Normalised Ratio (INR) is 2.0-3.0. Anticoagulation control among older patients is perceived to be lower and contributes to poorer initiation and uptake.

Objective: To examine the quality of INR control, adverse clinical outcomes, and factors associated with bleeding in older AF patients (≥80 years).

Methods: Anticoagulation control assessed by time in therapeutic range (TTR) (Rosendaal method) and percentage INRs in range (PINRR). Among the 205 patients aged ≥80 years, 58.5% were female, with mean (SD) CHADS-VASc 4.4 (1.3) and HAS-BLED 1.8 (0.8) scores.

Results: Mean (SD) TTR and PINRR were similar for those aged ≥80 vs. <80 years (66.7 (13.8) vs. 66.7 (13.1)) despite significantly lower INR monitoring intensity (51.2 (22.7) vs. 60.7 (25.8)) and shorter follow-up (4.4 (2.6-6.2) vs. 5.7 years (3.3-7.1)) in those ≥80 years of age. Good anticoagulation control (TTR and PINRR ≥70%) of 44% was seen in both age groups. No significant differences in composite major adverse clinical events were evident for those aged ≥80 vs. <80 years ( = 0.55). Cox regression analysis confirmed that age ≥80 years was associated with higher risk of bleeding (HR 1.90 (1.01-3.56);  = 0.047).

Conclusions: Suboptimal (TTR and PINRR <70%) anticoagulation control was evident in all patients. Risk of bleeding increased, but there was no difference in thromboembolic events and all-cause mortality in those aged ≥80 years. Improving TTR to ≥70% and enhancing anticoagulation monitoring of VKA use remain a clinical priority to prevent bleeding complications, particularly among those aged 80 years and above.
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http://dx.doi.org/10.1155/2022/5951262DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9159113PMC
June 2022

Chronic Oral Anticoagulation Therapy and Prognosis of Patients Admitted to Hospital for COVID-19: Insights from the HOPE COVID-19 Registry.

Int J Clin Pract 2022 26;2022:7325060. Epub 2022 May 26.

Hospital Clínico San Carlos Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain.

Background: Most evidence regarding anticoagulation and COVID-19 refers to the hospitalization setting, but the role of oral anticoagulation (OAC) before hospital admission has not been well explored. We compared clinical outcomes and short-term prognosis between patients with and without prior OAC therapy who were hospitalized for COVID-19.

Methods: Analysis of the whole cohort of the HOPE COVID-19 Registry which included patients discharged (deceased or alive) after hospital admission for COVID-19 in 9 countries. All-cause mortality was the primary endpoint. Study outcomes were compared after adjusting variables using propensity score matching (PSM) analyses.

Results: 7698 patients were suitable for the present analysis (675 (8.8%) on OAC at admission: 427 (5.6%) on VKAs and 248 (3.2%) on DOACs). After PSM, 1276 patients were analyzed (638 with OAC; 638 without OAC), without significant differences regarding the risk of thromboembolic events (OR 1.11, 95% CI 0.59-2.08). The risk of clinically relevant bleeding (OR 3.04, 95% CI 1.92-4.83), as well as the risk of mortality (HR 1.22, 95% CI 1.01-1.47; log-rank value = 0.041), was significantly increased in previous OAC users. Amongst patients on prior OAC only, there were no differences in the risk of clinically relevant bleeding, thromboembolic events, or mortality when comparing previous VKA or DOAC users, after PSM.

Conclusion: Hospitalized COVID-19 patients on prior OAC therapy had a higher risk of mortality and worse clinical outcomes compared to patients without prior OAC therapy, even after adjusting for comorbidities using a PSM. There were no differences in clinical outcomes in patients previously taking VKAs or DOACs. This trial is registered with NCT04334291/EUPAS34399.
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http://dx.doi.org/10.1155/2022/7325060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9158796PMC
June 2022

Inflammasome Signaling in Atrial Fibrillation: JACC State-of-the-Art Review.

J Am Coll Cardiol 2022 Jun;79(23):2349-2366

Shanghai Institute of Cardiovascular Diseases, Department of Cardiology, Zhongshan Hospital Fudan University, Shanghai, China; Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington USA. Electronic address:

As the most prevalent form of arrhythmia, atrial fibrillation (AF) increases the risk of heart failure, thromboembolism, and stroke, contributing to the raising mortality and morbidity in patients with cardiovascular diseases. Despite the multifaceted nature of AF pathogenesis and complexity of AF pathophysiology, a growing body of evidence indicates that the NLRP3 inflammasome activation contributes to onset and progression of AF. Herein, the authors aim at reviewing the current literature on the role of inflammasome signaling in AF pathogenesis, and novel therapeutic options in the management of AF.
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http://dx.doi.org/10.1016/j.jacc.2022.03.379DOI Listing
June 2022

Impact of anthropometric factors on outcomes in atrial fibrillation patients: analysis on 10 220 patients from the ESC-EHRA EORP AF general long-term registry.

Eur J Prev Cardiol 2022 Jun 7. Epub 2022 Jun 7.

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

Aim: To investigate the association of anthropometric parameters [height, weight, body mass index (BMI), body surface area (BSA) and lean body mass (LBM)] with outcomes in atrial fibrillation (AF).

Methods And Results: 10220 patients were enrolled [40.3% females, median age 70 (62-77) years, followed for 728 (IQR 653-745) days]. Sex-specific tertiles were considered for the 5 anthropometric variables. At the end of follow-up survival free from all-cause death was worse in the lowest tertiles for all the anthropometric variables analyzed. On multivariable Cox regression analysis, an independent association with all-cause death was found for the lowest vs. middle tertile when body weight (hazard ratio [HR] 1.66, 95%CI 1.23-2.23), BMI (HR 1.65, 95%CI 1.23-2.21), BSA (HR 1.49, 95%CI 1.11-2.01) were analysed in female sex, as well as for body weight in male patients (HR 1.61, 95%CI 1.25-2 .07). Conversely, the risk of MACE was lower for the highest tertile (vs. middle tertile) of BSA and LBM in males and for the highest tertile of weight and BSA in female patients. A higher occurrence of hemorrhagic events was found for female patients in the lowest tertile of height [odds ratio (OR) 1.90, 95%CI 1.23-2.94] and LBM (OR 2.13, 95%CI 1.40-3.26).  .

Conclusions: In AF patients height, weight, BMI, BSA and LBM were associated with clinical outcomes, with all-cause death being higher for patients presenting lower values of these variables, i.e in the lowest tertiles of distribution. The anthropometric variables independently associated with other outcomes were also different between male and female subjects.
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http://dx.doi.org/10.1093/eurjpc/zwac115DOI Listing
June 2022

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

Clin Epidemiol 2022 31;14:711-720. Epub 2022 May 31.

Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA.

Objective: Prior work estimated excess death rates associated with atrial fibrillation (AF) in heart failure (HF) with hazard ratios (HR). The aim was to estimate the life-years lost after newly diagnosed AF in HF patients.

Methods: Among patients diagnosed with HF in 2008-2018 in the nationwide Danish Heart Failure Registry, we compared patients with incident AF to referents matched on age, sex, and time since HF. We estimated the marginal hazard ratio (HR) for death and marginal difference in restricted mean survival times (RMST) between AF cases and referents at 10 years after AF diagnosis. We adjusted for sex, age at AF diagnosis, clinical and lifestyle risk factors, and medications.

Results: Among 4463 AF cases and 17,792 referents (mean age 73.7 years, 29% women), the HR was 1.41 (95% CI 1.38; 1.44) but there was evidence of non-proportional hazards. The difference in RMST was -18.2 months (95% CI -16.8; -19.6) at 10 years after AF diagnosis. There were differences in life-years lost between patients diagnosed with AF >1 year and ≤1 year after HF (-25.7 months, 95% CI -23.7; -27.7 vs -10.4 months, 95% CI -8.2; -12.5, p < 0.001), women and men (-20.3 months, 95% CI -17.7; -21.9 vs -17.2 months, 95% CI -15.5; -19.0, p = 0.05), patients with low, medium, and high CHADS-VASc (10.3 months, 95% CI -4.6; -16.1 vs -18.5 months, 95% CI -16.7; -20.4 vs 22.1, 95% CI -18.8; -22.3, p = 0.002).

Conclusion: HF patients with incident AF lost on average 1.5 life-years over 10 years after AF. Life-years lost were larger among patients diagnosed with AF >1 year after HF, women, and patients with higher CHADS-VASc.
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http://dx.doi.org/10.2147/CLEP.S365706DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9166900PMC
May 2022

Stroke in Older Adults Living in Care Homes: Results From a National Data Linkage Study in Wales.

J Am Med Dir Assoc 2022 Jun 3. Epub 2022 Jun 3.

Liverpool Center for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.

Objectives: To determine the proportion of older people moving to care homes with a recent stroke, incidence of stroke after moving to a care home, mortality following stroke, and secondary stroke prevention management in older care home residents.

Design: Retrospective cohort study using population-scale individual-level linked data sources between 2003 and 2018 in the Secure Anonymized Information Linkage (SAIL) Databank.

Setting And Participants: People aged ≥65 years residing in long-term care homes in Wales.

Methods: Competing risk models and logistic regression models were used to examine the association between prior stroke, incident stroke, and mortality following stroke.

Results: Of 86,602 individuals, 7.0% (n = 6055) experienced a stroke in the 12 months prior to care home entry. The incidence of stroke within 12 months after entry to a care home was 26.2 per 1000 person-years [95% confidence interval (CI) 25.0, 27.5]. Previous stroke was associated with higher risk of incident stroke after moving to a care home (subdistribution hazard ratio 1.83, 95% CI 1.57, 2.13) and 30-day mortality following stroke (odds ratio 2.18, 95% CI 1.59, 2.98). Severe frailty was not significantly associated with risk of stroke or 30-day mortality following stroke. Secondary stroke prevention included statins (51.0%), antiplatelets (61.2%), anticoagulants (52.4% of those with atrial fibrillation), and antihypertensives (92.1% of those with hypertension).

Conclusions And Implications: At the time of care home entry, individuals with history of stroke in the previous 12 months are at a higher risk of incident stroke and mortality following an incident stroke. These individuals are frequently not prescribed medications for secondary stroke prevention. Further evidence is needed to determine the optimal care pathways for older people living in long-term care homes with history of stroke.
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http://dx.doi.org/10.1016/j.jamda.2022.05.003DOI Listing
June 2022

USPSTF found insufficient evidence on the benefits and harms of screening adults ≥50 y for AF.

Ann Intern Med 2022 Jun 7;175(6):JC62. Epub 2022 Jun 7.

Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK (S.E.C., G.Y.L.).

Source Citation: Davidson KW, Barry MJ, Mangione CM, et al. JAMA. 2022;327:360-7. 35076659.
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http://dx.doi.org/10.7326/J22-0036DOI Listing
June 2022

Efficacy and Safety Considerations With Dose-Reduced Direct Oral Anticoagulants: A Review.

JAMA Cardiol 2022 Jun 1. Epub 2022 Jun 1.

Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom.

Importance: Dose-reduced regimens of direct oral anticoagulants (DOACs) may be used for 2 main purposes: dose-adjusted treatment intended as full-intensity anticoagulation (eg, for stroke prevention in atrial fibrillation [AF] in patients requiring dose reduction) or low-intensity treatment (eg, extended-duration treatment of venous thromboembolism [VTE]). We reviewed randomized clinical trials (RCTs) to understand the scenarios in which dose-adjusted or low-intensity DOACs were tested and reviewed the labeled indications by regulatory authorities, using data from large registries to assess whether the use of dose-reduced DOACs in routine practice aligned with the findings of RCTs.

Observations: Among 4191 screened publications, 35 RCTs that used dose-adjusted DOACs were identified for dabigatran, apixaban, rivaroxaban, and edoxaban. Of these 35 RCTs, 29 were related to stroke prevention in AF. Efficacy and safety results for dose-adjusted DOACs in large RCTs of AF were similar to those found for full-dose DOACs. To our knowledge, dabigatran, apixaban, and rivaroxaban have not been studied as dose-adjusted therapy for acute VTE treatment. Low-intensity DOACs were identified in 37 RCTs. Low-intensity DOACs may be used for extended-duration treatment of VTE (apixaban and rivaroxaban), primary prevention in orthopedic surgeries (dabigatran, apixaban, and rivaroxaban), primary prevention in ambulatory high-risk cancer patients (apixaban and rivaroxaban) or (postdischarge) high-risk medical patients (rivaroxaban), in stable atherosclerotic vascular disease, or after a recent revascularization for peripheral artery disease in conjunction with aspirin (rivaroxaban). Minor variations exist between regulatory authorities in different regions regarding criteria for dose adjustment of DOACs. Data from large registries indicated that dose-reduced DOACs were used occasionally with doses or for clinical scenarios different from those studied in RCTs or recommended by regulatory authorities.

Conclusions And Relevance: Dose adjustment and low-intensity treatment are 2 different forms of dose-reduced DOACs. Dose adjustment is mostly relevant for AF and should be done based on the approved criteria. Dose adjustment of DOACs should not be used for acute VTE treatment in most cases. In contrast, low-intensity DOACs may be used for primary or secondary VTE prevention for studied and approved indications. Attention should be given to routine practice patterns to align the daily clinical practice with existing evidence of safety and efficacy.
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http://dx.doi.org/10.1001/jamacardio.2022.1292DOI Listing
June 2022

Drug Interactions Affecting Oral Anticoagulant Use.

Circ Arrhythm Electrophysiol 2022 Jun 27;15(6):e007956. Epub 2022 May 27.

Division of Cardiology, Department of Medicine, University of Iowa, Iowa City (B.O.).

Oral anticoagulants (OACs) are medications commonly used in patients with atrial fibrillation and other cardiovascular conditions. Both warfarin and direct oral anticoagulants are susceptible to drug-drug interactions (DDIs). DDIs are an important cause of adverse drug reactions and exact a large toll on the health care system. DDI for warfarin mainly involve moderate to strong inhibitors/inducers of cytochrome P450 (CYP) 2C9, which is responsible for the elimination of the more potent S-isomer of warfarin. However, inhibitor/inducers of CYP3A4 and CYP1A2 may also cause DDI with warfarin. Recognition of these precipitating agents along with increased frequency of monitoring when these agents are initiated or discontinued will minimize the impact of warfarin DDI. Direct oral anticoagulants are mainly affected by medications strongly affecting the permeability glycoprotein (P-gp), and to a lesser extent, strong CYP3A4 inhibitors/inducers. Dabigatran and edoxaban are affected by P-gp modulation. Strong inducers of CYP3A4 or P-gp should be avoided in all patients taking direct oral anticoagulant unless previously proven to be otherwise safe. Simultaneous strong CYP3A4 and P-gp inhibitors should be avoided in patients taking apixaban and rivaroxaban. Concomitant antiplatelet/anticoagulant use confers additive risk for bleeding, but their combination is unavoidable in many cases. Minimizing duration of concomitant anticoagulant/antiplatelet therapy as indicated by evidence-based clinical guidelines is the best way to reduce the risk of bleeding.
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http://dx.doi.org/10.1161/CIRCEP.121.007956DOI Listing
June 2022

Thromboembolic Risk in Patients With Pneumonia and New-Onset Atrial Fibrillation Not Receiving Anticoagulation Therapy.

JAMA Netw Open 2022 May 2;5(5):e2213945. Epub 2022 May 2.

Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.

Importance: New-onset atrial fibrillation (AF) is commonly reported in patients with severe infections. However, the absolute risk of thromboembolic events without anticoagulation remains unknown.

Objective: To investigate the thromboembolic risks associated with AF in patients with pneumonia, assess the risk of recurrent AF, and examine the association of initiation of anticoagulation therapy with new-onset AF.

Design, Setting, And Participants: This population-based cohort study used linked Danish nationwide registries. Participants included patients hospitalized with incident community-acquired pneumonia in Denmark from 1998 to 2018. Statistical analysis was performed from August 15, 2021, to March 12, 2022.

Exposures: New-onset AF.

Main Outcomes And Measures: Thromboembolic events, recurrent AF, and all-cause death. Estimated risks were calculated for thromboembolism without anticoagulation therapy, new hospital or outpatient clinic contact with AF, initiation of anticoagulation therapy, and all-cause death at 1 and 3 years of follow-up. Death was treated as a competing risk, and inverse probability of censoring weights was used to account for patient censoring if they initiated anticoagulation therapy conditioned on AF.

Results: Among 274 196 patients hospitalized for community-acquired pneumonia, 6553 patients (mean age [SD], 79.1 [11.0] years; 3405 women [52.0%]) developed new-onset AF. The 1-year risk of thromboembolism was 0.8% (95% CI, 0.8%-0.8%) in patients without AF vs 2.1% (95% CI, 1.8%-2.5%) in patients with new-onset AF without anticoagulation; this risk was 1.4% (95% CI, 1.0%-2.0%) among patients with AF with intermediate stroke risk and 2.8% (95% CI, 2.3%-3.4%) in patients with AF with high stroke risk. Three-year risks were 3.5% (95% CI, 2.8%-4.3%) among patients with intermediate stroke risk and 5.3% (95% CI, 4.4%-6.5%) among patients with high stroke risk. Among patients with new-onset AF, 32.9% (95% CI, 31.8%-34.1%) had a new hospital contact with AF, and 14.0% (95% CI, 13.2%-14.9%) initiated anticoagulation therapy during the 3 years after incident AF diagnosis. At 3 years, the all-cause mortality rate was 25.7% (95% CI, 25.6%-25.9%) in patients with pneumonia without AF vs 49.8% (95% CI, 48.6%-51.1%) in patients with new-onset AF.

Conclusions And Relevance: This cohort study found that new-onset AF after community-acquired pneumonia was associated with an increased risk of thromboembolism, which may warrant anticoagulation therapy. Approximately one-third of patients had a new hospital or outpatient clinic contact for AF during the 3-year follow-up, suggesting that AF triggered by acute infections is not a transient, self-terminating condition that reverses with resolution of the infection.
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http://dx.doi.org/10.1001/jamanetworkopen.2022.13945DOI Listing
May 2022

A multinational European network to implement integrated care in elderly multimorbid atrial fibrillation patients: the AFFIRMO Consortium.

Eur Heart J 2022 May 22. Epub 2022 May 22.

Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark.

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http://dx.doi.org/10.1093/eurheartj/ehac265DOI 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

Oral anticoagulants and outcomes in adults ≥80 years with atrial fibrillation: A global federated health network analysis.

J Am Geriatr Soc 2022 May 19. Epub 2022 May 19.

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

Background: The objective of this study was to determine associations between use of oral anticoagulation (OAC) and stroke and bleeding-related outcomes for older people ≥80 years with atrial fibrillation (AF), and to determine trends over time in prescribing of OAC for this population.

Methods: A retrospective cohort study was conducted. People aged ≥80 years with AF receiving (1) no OAC; (2) warfarin; or (3) a non-vitamin-K antagonist oral anticoagulant (NOAC) between 2011 and 2019 were included. Propensity score matching was used to balance cohorts (no OAC, warfarin or a NOAC) on characteristics including age, sex, ethnicity, and co-morbidities. Cox proportional hazard models were used to derive hazard ratios (HRs) and 95% confidence intervals (CIs).

Results: The proportion of people aged ≥80 years receiving any OAC increased from 32.4% (n = 27,647) in 2011 to 43.6% (n = 110,412) in 2019. After propensity score matching, n = 169,067 individuals were included in the cohorts receiving no OAC or a NOAC. Compared to no OAC, participants receiving a NOAC had a lower risk of incident dementia (hazHR 0.68, 95% CI 0.65-0.71), all-cause mortality (HR 0.49, 95% CI 0.48-0.50), first-time ischaemic stroke (HR 0.87, 95% CI 0.83-0.91), and a higher risk of major bleeding (HR 1.08, 95% CI 1.05-1.11). Compared to participants receiving warfarin, participants receiving a NOAC had a lower risk of dementia (HR 0.90, 95% CI: 0.86-0.93), all-cause mortality (HR 0.74, 95% CI: 0.72-0.76), ischaemic stroke (HR 0.86, 95% CI: 0.82-0.90) and major bleeding (HR 0.88, 95% CI: 0.85-0.90). Similar results were observed when only including people with additional bleeding risk factors.

Conclusions: The proportion of people aged ≥80 years receiving OAC has increased since the introduction of NOACs, but remains low. Use of a NOAC was associated with improved outcomes compared to warfarin, and compared to no OAC, except for a small but statistically significant higher risk of major bleeding.
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http://dx.doi.org/10.1111/jgs.17884DOI Listing
May 2022

Impact of Integrated Care Management on Clinical Outcomes in Atrial Fibrillation Patients: A Report From the FANTASIIA Registry.

Front Cardiovasc Med 2022 2;9:856222. Epub 2022 May 2.

Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, CIBERCV, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain.

Background: An integrated and holistic approach is increasingly advocated in patients with atrial fibrillation (AF), based on the "Atrial fibrillation Better Care (ABC) pathway: A, Avoid stroke with anticoagulation; B, better symptom management; C, cardiovascular and comorbidity risk management." The aim of this study was to examine the prevalence of adherence to each component of the ABC pathway and to analyze its impact on long-term prognosis in the "real-world" cohort of AF patients from the FANTASIIA registry.

Methods: This prospective study included consecutive AF outpatients anticoagulated with direct oral anticoagulants (DOAC) or vitamin K antagonists (VKA) from June 2013 to October 2014. From the ABC pathway, adherence to the "A criterion" was defined by a time in the therapeutic range (TTR) ≥ 70% or correct dose with DOAC; "B criterion" adherence was defined by a European Heart Rhythm Association (EHRA) Symptom Scale I-II; and "C criterion" adherence was defined as optimized risk factors and comorbidity management. Baseline features and embolic events, severe bleeding, and all-cause and cardiovascular mortality rates up to 3 years of follow-up were analyzed, and a Cox multivariate analysis was performed to investigate the role of each component of the ABC pathway in predicting major events.

Results: A total of 1,955 AF patients (age: 74.4 ± 9.4 years; 43.2% female patients) were included in this study: adherence to A criterion was observed in 920 (47.1%) patients; adherence to B criterion was observed in 1,791 (91.6%) patients; and adherence to C criterion was observed in 682 (34.8%) patients. Only 394 (20.2%) of the whole population had good control of AF according to the ABC pathway. After a median follow-up of 1,078 days (IQR: 766-1,113), adherence to A criterion was independently associated with reduced cardiovascular mortality [HR: 0.67, 95%CI (0.45-0.99); = 0.048] compared with non-adherence. Adherence to the B criterion was independently associated with reduced stroke [HR: 0.28, 95%CI (0.14-0.59); < 0.001], all-cause mortality [HR: 0.49, 95%CI (0.35-0.69); < 0.001], cardiovascular mortality [HR: 0.39, 95%CI (0.25-0.62); < 0.001], and major adverse cardiovascular events (MACE) [HR: 0.41, 95%CI (0.28-0.62); < 0.001] compared with non-adherence. AF patients with C criterion adherence had a significantly lower risk of myocardial infarction [HR: 0.31, 95%CI (0.15-0.66); < 0.001]. Fully adherent ABC patients had a significant reduction in MACE [HR: 0.64, 95%CI (0.42-0.99); = 0.042].

Conclusion: In real-world anticoagulated AF patients from FANTASIIA registry, we observed a lack of adherence to integrated care management of AF following the ABC pathway. AF managed according to the ABC pathway was associated with a significant reduction in adverse outcomes during long follow-up, suggesting the benefit of a holistic and integrated approach to AF management.
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http://dx.doi.org/10.3389/fcvm.2022.856222DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9108173PMC
May 2022

Using the CHEST Score for Predicting Postoperative Atrial Fibrillation After Cardiac Surgery: A Report From the Western Denmark Heart Registry, the Danish National Patient Registry, and the Danish National Prescription Registry.

J Cardiothorac Vasc Anesth 2022 Apr 6. Epub 2022 Apr 6.

Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Atrial Fibrillation Study Group, Aalborg University Hospital, Aalborg, Denmark.

Objectives: New-onset postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery. A targeted approach is necessary for prophylactic handling of the complication. The authors tested the performance of the CHEST score to predict POAF in patients undergoing cardiac surgery.

Design: Register-based cohort study.

Setting: Three cardiothoracic centers.

Participants: All adult patients undergoing cardiac surgery in Western Denmark between January 1, 2010, and December 31, 2018, were included. Data on patient comorbidities before surgery were obtained from the Western Denmark Heart Registry, the Danish National Patient Registry, and the Danish National Prescription Registry.

Interventions: The CHEST score (C: Coronary Artery Disease/Chronic Obstructive Pulmonary Disease [1 point each]; H: Hypertension; E: Elderly [Age ≥75, 2 points]; S: Systolic Heart Failure [2 points]; T: Thyroid disease [hyperthyroidism]) was calculated for each patient. The primary outcome was POAF within the primary hospital stay. The CHEST score's discriminative ability was evaluated and compared with an age-stratified version (mCHEST) as well as 2 validated clinical risk models (CHADS and CHADS-VASc).

Measurements And Main Results: Among the 14,279 patients included, 4,298 (30.1%) developed POAF. The CHEST score's performance was not significantly better than the CHADS and CHADS-VASc scores (area under the curve [AUC] 0.553 [95% confidence interval {CI} 0.543; 0.563] v 0.543 [95% CI 0.535; 0.552] and 0.565 [95% CI 0.555; 0.574], respectively). The age-modified (mCHEST) score showed only modest improvement in the risk model, with an AUC of 0.580 (95% CI 0.570; 0.590).

Conclusion: The discriminative ability of the CHEST score, measured by the AUC, was limited in this population, and was not proven to be superior to the CHADS, CHADS-VASc, and mCHEST scores in predicting POAF after cardiac surgery.
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http://dx.doi.org/10.1053/j.jvca.2022.03.037DOI Listing
April 2022

Long-Term Cardiac Monitoring After Embolic Stroke of Undetermined Source: Search Longer, Look Harder.

Am J Med 2022 May 14. Epub 2022 May 14.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark. Electronic address:

Embolic stroke of undetermined source (ESUS) represents a heterogeneous subgroup of patients with cryptogenic stroke, in which despite an extensive diagnostic workup the cause of stroke remains uncertain. Identifying covert atrial fibrillation among patients with ESUS remains challenging. The increasing use of cardiac implanted electronic devices (CIED), such as pacemakers, implantable defibrillators, and implantable loop recorders (ILR), has provided important information on the burden of subclinical atrial fibrillation. Accumulating evidence indicate that long-term continuous monitoring, especially in selected patients with ESUS, significantly increases the possibility of atrial fibrillation detection, suggesting it may be a cost-effective tool in secondary stroke prevention. This review summarizes available evidence related to the use of long-term cardiac monitoring and the use of implantable cardiac monitoring devices in patients with ESUS.
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http://dx.doi.org/10.1016/j.amjmed.2022.04.030DOI Listing
May 2022

Effectiveness and safety of oral anticoagulants in non-valvular atrial fibrillation patients with prior bleeding events: a retrospective analysis of administrative claims databases.

J Thromb Thrombolysis 2022 May 17. Epub 2022 May 17.

Department of Hospital Medicine, Ochsner Clinic Foundation, New Orleans, LA, USA.

Introduction: There are a paucity of real-world data examining effectiveness and safety of non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin in nonvalvular atrial fibrillation (NVAF) patients with prior bleeding.

Methods: This retrospective analysis included data from 5 insurance claims databases and included NVAF patients prescribed OACs with prior bleeding. One-to-one propensity score matching was conducted between NOACs and warfarin and between NOACs in each database. Cox proportional hazards models were used to evaluate the risk of stroke/systemic embolism (SE) and MB.

Results: A total of 244,563 patients (mean age 77; 50% female) with prior bleeding included 55,094 (22.5%) treated with apixaban, 12,500 (5.1%) with dabigatran, 38,246 (15.6%) with rivaroxaban, and 138,723 (56.7%) with warfarin. Apixaban (hazard ratio [HR]: 0.76 [95% CI: 0.70, 0.83]) and rivaroxaban (HR: 0.79 [95% CI: 0.71, 0.87]) had a lower risk of stroke/SE vs. warfarin. Apixaban (HR: 0.67 [95% CI: 0.64, 0.70]) and dabigatran (HR: 0.88 [95% CI: 0.81, 0.96]) had a lower risk of MB vs. warfarin. Apixaban patients had a lower risk of stroke/SE vs. dabigatran (HR: 0.70 [95% CI: 0.57, 0.86]) and rivaroxaban (HR: 0.85 [95% CI: 0.76, 0.96]) and a lower risk of MB than dabigatran (HR: 0.73 [95% CI: 0.67, 0.81]) and rivaroxaban (HR: 0.64 [95% CI: 0.61, 0.68]).

Conclusions: In this real-world analysis of a large sample of NVAF patients with prior bleeding, NOACs were associated with similar or lower risk of stroke/SE and MB vs. warfarin and variable risk of stroke/SE and MB against each other.
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http://dx.doi.org/10.1007/s11239-022-02660-2DOI Listing
May 2022

Relationship between Serum 25-Hydroxyvitamin D Level and Risk of Recurrent Stroke.

Nutrients 2022 May 2;14(9). Epub 2022 May 2.

Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool L69 3BX, UK.

Evidence for the association between vitamin D and risk of recurrent stroke remains sparse and limited. We aimed to assess the relationship between serum circulating 25-hydroxyvitamin D (25(OH)D) level and risk of recurrent stroke in patients with a stroke history, and to identify the optimal 25(OH)D level in relation to lowest recurrent stroke risk. Data from the nationwide prospective United Kingdom Biobank were used for analyses. Primary outcome was time to first stroke recurrence requiring a hospital visit during follow-up. We used Cox proportional hazards regression model with restricted cubic splines to explore 25(OH)D level in relation to recurrent stroke. The dose-response relationship between 25(OH)D and recurrent stroke risk was also estimated, taking the level of 10 nmol/L as reference. A total of 6824 participants (mean age: 60.6 years, 40.8% females) with a baseline stroke were included for analyses. There were 388 (5.7%) recurrent stroke events documented during a mean follow-up of 7.6 years. Using Cox proportional hazards regression model with restricted cubic splines, a quasi J-shaped relationship between 25(OH)D and risk of recurrent stroke was found, where the lowest recurrent stroke risk lay at the 25(OH)D level of approximate 60 nmol/L. When compared with 10 nmol/L, a 25(OH)D level of 60 nmol/L was related with a 48% reduction in the recurrent stroke risk (hazard ratio = 0.52, 95% confidence interval: 0.33-0.83). Based on data from a large-scale prospective cohort, we found a quasi J-shaped relationship between 25(OH)D and risk of recurrent stroke in patients with a stroke history. Given a lack of exploring the cause-effect relationship in this observational study, more high-quality evidence is needed to further clarify the vitamin D status in relation to recurrent stroke risk.
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http://dx.doi.org/10.3390/nu14091908DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9099592PMC
May 2022

Integrated care for optimizing the management of stroke and associated heart disease: a position paper of the European Society of Cardiology Council on Stroke.

Eur Heart J 2022 May 13. Epub 2022 May 13.

School of Medicine, Belgrade University, Belgrade, Serbia.

The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient 'journey' or 'patient pathway,' supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management: • A: Appropriate Antithrombotic therapy. • B: Better functional and psychological status. • C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).
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http://dx.doi.org/10.1093/eurheartj/ehac245DOI Listing
May 2022

Assigning diagnosis codes using medication history.

Artif Intell Med 2022 06 20;128:102307. Epub 2022 Apr 20.

Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Unit of Clinical Biostatistics, Department of Research and Innovation, Aalborg University Hospital, Aalborg, Denmark. Electronic address:

Diagnosis assignment is the process of assigning disease codes to patients. Automatic diagnosis assignment has the potential to validate code assignments, correct erroneous codes, and register completion. Previous methods build on text-based techniques utilizing medical notes but are inapplicable in the absence of these notes. We propose using patients' medication data to assign diagnosis codes. We present a proof-of-concept study using medical data from an American dataset (MIMIC-III) and Danish nationwide registers to train a machine-learning-based model that predicts an extensive collection of diagnosis codes for multiple levels of aggregation over a disease hierarchy. We further suggest a specialized loss function designed to utilize the innate hierarchical nature of the disease hierarchy. We evaluate the proposed method on a subset of 567 disease codes. Moreover, we investigate the technique's generalizability and transferability by (1) training and testing models on the same subsets of disease codes over the two medical datasets and (2) training models on the American dataset while evaluating them on the Danish dataset, respectively. Results demonstrate the proposed method can correctly assign diagnosis codes on multiple levels of aggregation from the disease hierarchy over the American dataset with recall 70.0% and precision 69.48% for top-10 assigned codes; thereby being comparable to text-based techniques. Furthermore, the specialized loss function performs consistently better than the non-hierarchical state-of-the-art version. Moreover, results suggest the proposed method is language and dataset-agnostic, with initial indications of transferability over subsets of disease codes.
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http://dx.doi.org/10.1016/j.artmed.2022.102307DOI Listing
June 2022

Comparison Between the 24-hour Holter Test and 72-hour Single-Lead Electrocardiogram Monitoring With an Adhesive Patch-Type Device for Atrial Fibrillation Detection: Prospective Cohort Study.

J Med Internet Res 2022 05 9;24(5):e37970. Epub 2022 May 9.

Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.

Background: There is insufficient evidence for the use of single-lead electrocardiogram (ECG) monitoring with an adhesive patch-type device (APD) over an extended period compared to that of the 24-hour Holter test for atrial fibrillation (AF) detection.

Objective: In this paper, we aimed to compare AF detection by the 24-hour Holter test and 72-hour single-lead ECG monitoring using an APD among patients with AF.

Methods: This was a prospective, single-center cohort study. A total of 210 patients with AF with clinical indications for the Holter test at cardiology outpatient clinics were enrolled in the study. The study participants were equipped with both the Holter device and APD for the first 24 hours. Subsequently, only the APD continued ECG monitoring for an additional 48 hours. AF detection during the first 24 hours was compared between the two devices. The diagnostic benefits of extended monitoring using the APD were evaluated.

Results: A total of 200 patients (mean age 60 years; n=141, 70.5% male; and n=59, 29.5% female) completed 72-hour ECG monitoring with the APD. During the first 24 hours, both monitoring methods detected AF in the same 40/200 (20%) patients (including 20 patients each with paroxysmal and persistent AF). Compared to the 24-hour Holter test, the APD increased the AF detection rate by 1.5-fold (58/200; 29%) and 1.6-fold (64/200; 32%) with 48- and 72-hour monitoring, respectively. With the APD, the number of newly discovered patients with paroxysmal AF was 20/44 (45.5%), 18/44 (40.9%), and 6/44 (13.6%) at 24-, 48-, and 72-hour monitoring, respectively. Compared with 24-hour Holter monitoring, 72-hour monitoring with the APD increased the detection rate of paroxysmal AF by 2.2-fold (44/20).

Conclusions: Compared to the 24-hour Holter test, AF detection could be improved with 72-hour single-lead ECG monitoring with the APD.
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http://dx.doi.org/10.2196/37970DOI Listing
May 2022
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