scholarly journals Metabolic Syndrome and Risk of Ischemic Stroke in Atrial Fibrillation

Stroke ◽  
2019 ◽  
Vol 50 (11) ◽  
pp. 3045-3050 ◽  
Author(s):  
Joseph J. Decker ◽  
Faye L. Norby ◽  
Mary R. Rooney ◽  
Elsayed Z. Soliman ◽  
Pamela L. Lutsey ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Metabolic Syndrome ◽  
Ischemic Stroke ◽  
Stroke Risk ◽  
Proportional Hazards ◽  
International Diabetes Federation ◽  
Cox Proportional Hazards ◽  
Hazard Ratio ◽  
Increased Risk ◽  
Low Hdl

Background and Purpose— Metabolic syndrome (MetS), a prothrombotic state, is associated with an increased risk of atrial fibrillation (AF) and stroke. The CHA 2 DS 2 -VASc score does not account for the MetS components of prehypertension, prediabetes mellitus, abdominal obesity, elevated triglycerides, and low HDL (high-density lipoprotein). Data are limited on the association of MetS with stroke in AF, independent of CHA 2 DS 2 -VASc variables. Our aim was to identify MetS components associated with ischemic stroke in participants with AF in the ARIC study (Atherosclerosis Risk in Communities). Methods— We included 1172 participants with incident AF within 5 years of measurement of MetS components. MetS was defined by ATP criteria and International Diabetes Federation criteria. Incident ischemic stroke was physician adjudicated. Multivariable Cox proportional hazards regression was used to assess the association of MetS components with stroke. Results— After a median follow-up of 14.8 years, there were 113 ischemic stroke cases. Of the individual MetS components, low HDL was borderline associated with increased stroke risk (hazard ratio, 1.48 [95% CI, 0.99–2.21]) after adjustment for CHA 2 DS 2 -VASc variables while the remaining MetS variables were not associated with stroke risk. The presence of ≥3 components of MetS was not significantly associated with ischemic stroke after adjustment for CHA 2 DS 2 -VASc variables (hazard ratio, 1.38 [95% CI, 0.91–2.11]). The risk of stroke increased by 13% for each additional component of MetS; however, this association was borderline significant (hazard ratio, 1.13 [95% CI, 0.99–1.28]). Conclusions— The presence of MetS was not significantly associated with ischemic stroke after adjustment for CHA 2 DS 2 -VASc variables. Consideration of MetS is unlikely to improve stroke prediction in AF.

scholarly journals Electrocardiographic ST-T Abnormities Are Associated With Stroke Risk in the REGARDS Study

Stroke ◽  
2020 ◽  
Vol 51 (4) ◽  
pp. 1100-1106
Author(s):  
Mitsuaki Sawano ◽  
Ya Yuan ◽  
Shun Kohsaka ◽  
Taku Inohara ◽  
Takeki Suzuki ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Racial Differences ◽  
Stroke Risk ◽  
Proportional Hazards ◽  
The United States ◽  
Incidence Rates ◽  
Cox Proportional Hazards ◽  
Hazard Ratio ◽  
Common Finding ◽  
Increased Risk

Background and Purpose— In previous studies, isolated nonspecific ST-segment and T-wave abnormalities (NSSTTAs), a common finding on ECGs, were associated with greater risk for incident coronary artery disease. Their association with incident stroke remains unclear. Methods— The REGARDS (Reasons for Geographic and Racial Differences in Stroke) study is a population-based, longitudinal study of 30 239 white and black adults enrolled from 2003 to 2007 in the United States. NSSTTAs were defined from baseline ECG using the standards of Minnesota ECG Classification (Minnesota codes 4-3, 4-4, 5-3, or 5-4). Participants with prior stroke, coronary heart disease, and major and minor ECG abnormalities other than NSSTTAs were excluded from analysis. Multivariable Cox proportional hazards regression was used to examine calculate hazard ratios of incident ischemic stroke by presence of baseline NSSTTAs. Results— Among 14 077 participants, 3111 (22.1%) had NSSTTAs at baseline. With a median of 9.6 years follow-up, 106 (3.4%) with NSSTTAs had ischemic stroke compared with 258 (2.4%) without NSSTTAs. The age-adjusted incidence rates (per 1000 person-years) of stroke were 2.93 in those with NSSTTAs and 2.19 in those without them. Adjusting for baseline age, sex, race, geographic location, and education level, isolated NSSTTAs were associated with a 32% higher risk of ischemic stroke (hazard ratio, 1.32 [95% CI, 1.05–1.67]). With additional adjustment for stroke risk factors, the risk of stroke was increased 27% (hazard ratio, 1.27 [95% CI, 1.00–1.62]) and did not differ by age, race, or sex. Conclusions— Presence of NSSTTAs in persons with an otherwise normal ECG was associated with a 27% increased risk of future ischemic stroke.

scholarly journals Migraine with visual aura is a risk factor for incident atrial fibrillation

Neurology ◽  
2018 ◽  
Vol 91 (24) ◽  
pp. e2202-e2210 ◽  
Author(s):  
Souvik Sen ◽  
X. Michelle Androulakis ◽  
Viktoriya Duda ◽  
Alvaro Alonso ◽  
Lin Yee Chen ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Confidence Interval ◽  
Stroke Risk ◽  
Proportional Hazards ◽  
Cox Proportional Hazards ◽  
Hazard Ratio ◽  
Visual Aura ◽  
Atherosclerosis Risk In Communities ◽  
Increased Risk ◽  
Atherosclerosis Risk

ObjectiveMigraine with visual aura is associated with cardioembolic stroke risk. The aim of this study was to test association between migraine with visual aura and atrial fibrillation (AF), in the Atherosclerosis Risk in Communities study.MethodsIn the Atherosclerosis Risk in Communities study, a longitudinal, community-based cohort study, participants were interviewed for migraine history in 1993–1995 and were followed for incident AF through 2013. AF was adjudicated using ECGs, discharge codes, and death certificates. Multivariable Cox proportional hazards models were used to study the relation between migraine and its subtypes with incident AF, compared with controls without headaches. Mediation analysis was conducted to test whether AF was a mediator of migraine with visual aura-associated stroke risk.ResultsOf 11,939 participants assessed for headache and without prior AF or stroke, 426 reported migraines with visual aura, 1,090 migraine without visual aura, 1,018 nonmigraine headache, and 9,405 no headache. Over a 20-year follow-up period, incident AF was noted in 232 (15%) of 1,516 with migraine and 1,623 (17%) of 9,405 without headache. After adjustment for multiple confounders, migraine with visual aura was associated with increased risk of AF compared to no headache (hazard ratio 1.30, 95% confidence interval 1.03–1.62) as well as when compared to migraine without visual aura (hazard ratio 1.39, 95% confidence interval 1.05–1.83). The data suggest that AF may be a potential mediator of migraine with visual aura–stroke risk.ConclusionsMigraine with aura was associated with increased risk of incident AF. This may potentially lead to ischemic strokes.

scholarly journals Risk of Ischemic Stroke Increases Over the Spectrum of Metabolic Syndrome Severity

Stroke ◽  
2020 ◽  
Vol 51 (8) ◽  
pp. 2548-2552 ◽  
Author(s):  
Mark D. DeBoer ◽  
Stephanie L. Filipp ◽  
Mario Sims ◽  
Solomon K. Musani ◽  
Matthew J. Gurka
Keyword(s):  
Metabolic Syndrome ◽  
Ischemic Stroke ◽  
Stroke Risk ◽  
Proportional Hazards ◽  
Lifestyle Modification ◽  
Cox Proportional Hazards ◽  
Hazard Ratio ◽  
The Metabolic Syndrome ◽  
Cox Proportional Hazards Models ◽  
Ischemic Stroke Risk

Background and Purpose: Ischemic stroke is associated with the metabolic syndrome (MetS) as diagnosed using dichotomous criteria; however, these criteria exhibit racial/ethnic discrepancies. Our goal was to assess whether ischemic stroke risk extended over the spectrum of worsening MetS severity using a sex- and race/ethnicity-specific MetS-severity Z score. Methods: We used Cox-proportional hazards models to assess the relationship between baseline MetS- Z score and incident ischemic stroke among participants of the Atherosclerosis Risk in Communities study and Jackson Heart Study who were free from diabetes, coronary heart disease or stroke at baseline, evaluating 13 141 white and black individuals with mean follow-up of 18.6 years. Results: We found that risk of ischemic stroke increased consistently with MetS severity, with a hazard ratio of 1.75 (95% CI, 1.35–2.27) for those >75th percentile compared to those <25th percentile. This risk was highest for white females (hazard ratio, 2.63 [CI, 1.70–4.07]) though without significant interaction by sex and race. Relationships between stroke and all the individual components of MetS were only noted for white females, though again without sex-race interactions. Hazard ratio’s for systolic blood pressure and stroke were significant among all sex/racial subgroups. Conclusions: Ischemic stroke risk increased over the spectrum of MetS severity in the absence of baseline diabetes mellitus, further implicating potential etiologic risks from processes underlying MetS. Individuals with elevated MetS severity should be counselled toward lifestyle modification to lower ischemic stroke risk.

Abstract 2646: Aortic Arch Plaques and Risk of Vascular Events in Subjects Without Prior Stroke

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Cesare Russo ◽  
Zhezhen Jin ◽  
Ralph L Sacco ◽  
Shunichi Homma ◽  
Tatjana Rundek ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Aortic Arch ◽  
Proportional Hazards ◽  
Cox Proportional Hazards ◽  
Study Cohort ◽  
Vascular Events ◽  
Increased Risk ◽  
Prior Stroke

BACKGROUND: Aortic arch plaques (AAP) are a risk factor for cardiovascular embolic events. However, the risk of vascular events associated with AAP in the general population is unclear. AIM: To assess whether AAP detected by transesophageal echocardiography (TEE) are associated with an increased risk of vascular events in a stroke-free cohort. METHODS: The study cohort consisted of stroke-free subjects over age 50 from the Aortic Plaques and Risk of Ischemic Stroke (APRIS) study. AAP were assessed by multiplane TEE, and considered large if ≥ 4 mm in thickness. Vascular events including myocardial infarction, ischemic stroke and vascular death were recorded during the follow-up. The association between AAP and outcomes was assessed by univariate and multivariate Cox proportional hazards models. RESULTS: A group of 209 subjects was studied (mean age 67±9 years; 45% women; 14% whites, 30% blacks, 56% Hispanics). AAP of any size were present in 130 subjects (62%); large AAP in 50 (24%). Subjects with AAP were older (69±8 vs. 63±7 years), had higher systolic BP (146±21 vs.139±20 mmHg), were more often white (19% vs. 8%), smokers (20% vs. 9%) and more frequently had a history of coronary artery disease (26% vs. 14%) than those without AAP (all p<0.05). Lipid parameters, prevalence of atrial fibrillation and diabetes mellitus were not significantly different between the two groups. During the follow up (94±29 months) 30 events occurred (13 myocardial infarctions, 11 ischemic strokes, 6 vascular deaths). After adjustment for other risk factors, AAP of any size were not associated with an increased risk of combined vascular events (HR 1.07, 95% CI 0.44 to 2.56). The same result was observed for large AAP (HR 0.94, CI 0.34 to 2.64). Age (HR 1.05, CI 1.01 to 1.10), body mass index (HR 1.08, CI 1.01 to 1.15) and atrial fibrillation (HR 3.52, CI 1.07 to 11.61) showed independent association with vascular events. In a sub-analysis with ischemic stroke as outcome, neither AAP of any size nor large AAP were associated with an increased risk. CONCLUSIONS: In this cohort without prior stroke, the incidental detection of AAP was not associated with an increased risk of future vascular events. Associated co-factors may affect the AAP-related risk of vascular events reported in previous studies.

Abstract WP213: Association Between Thoracic Aorta Surgery and Long Term Risk of Stroke in Adults

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Tashfin Huq ◽  
Marialaura Simonetto ◽  
Babak B Navi ◽  
Hooman Kamel
Keyword(s):  
Ischemic Stroke ◽  
Thoracic Aorta ◽  
Stroke Risk ◽  
Proportional Hazards ◽  
Perioperative Period ◽  
Cox Proportional Hazards ◽  
Medicare Beneficiaries ◽  
Increased Risk ◽  
Nationally Representative

Introduction: Thoracic aorta surgery carries a risk of perioperative stroke, but the long-term incidence of stroke after the perioperative period in these patients remains unclear. We therefore assessed the long-term risk of stroke in patients who underwent thoracic aorta repair. Methods: We performed a retrospective cohort study using 2008-2015 claims data from a nationally representative 5% sample of Medicare beneficiaries. Our exposure of interest was thoracic aorta surgery, defined using ICD-9-CM hospital procedure codes for endovascular graft implantation (39.73) or surgical resection and replacement (38.45). Our primary outcome was ischemic stroke, defined using previously validated ICD-9-CM diagnosis codes. Patients with stroke during the index surgical hospitalization were excluded, since our focus was on long-term stroke risk after the perioperative period . Cox proportional hazards analysis was used to examine the association between thoracic aorta surgery and stroke risk after adjustment for demographics and vascular risk factors. Given a clear violation of the proportional hazards assumption, we calculated period-specific risk estimates. Results: Among 1,751,719 beneficiaries (mean age 73 ±8 years), 1,402 underwent thoracic aorta repair. During 4.6 ±2.2 years of follow-up, 62,702 patients were diagnosed with ischemic stroke. The incidence of stroke was 1.24% (95% CI, 0.93-1.66%) per year after thoracic aorta repair compared to 0.77% (95% CI, 0.76-0.78%) per year in patients without thoracic aorta surgery. In adjusted models, there was an increased risk of stroke in the first 120 days after discharge from thoracic aorta surgery (HR, 2.1; 95% CI, 1.2-3.7), but no heightened risk was seen beyond 120 days after discharge from surgery (HR, 0.7; 95% CI, 0.5-1.0). Conclusions: In a large sample of Medicare beneficiaries, thoracic aorta surgery was associated with an increased risk of ischemic stroke in the first 120 days after hospital discharge, but there was no excess risk beyond that time point.

scholarly journals Gastrointestinal Disorders and Risk of First-Ever Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (12) ◽  
pp. 3577-3583
Author(s):  
William H. Roth ◽  
Anna Cai ◽  
Cenai Zhang ◽  
Monica L. Chen ◽  
Alexander E. Merkler ◽  
...  
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Gut Microbiome ◽  
Stroke Risk ◽  
Proportional Hazards ◽  
Gastrointestinal Diseases ◽  
Cox Proportional Hazards ◽  
Gastrointestinal Disorders ◽  
Stroke Risk Factors ◽  
Increased Risk

Background and Purpose: Recent studies suggest that alteration of the normal gut microbiome contributes to atherosclerotic burden and cardiovascular disease. While many gastrointestinal diseases are known to cause disruption of the normal gut microbiome in humans, the clinical impact of gastrointestinal diseases on subsequent cerebrovascular disease remains unknown. We conducted an exploratory analysis evaluating the relationship between gastrointestinal diseases and ischemic stroke. Methods: We performed a retrospective cohort study using claims between 2008 and 2015 from a nationally representative 5% sample of Medicare beneficiaries. We included only beneficiaries ≥66 years of age. We used previously validated diagnosis codes to ascertain our primary outcome of ischemic stroke. In an exploratory manner, we categorized gastrointestinal disorders by anatomic location, disease chronicity, and disease mechanism. We used Cox proportional hazards models to examine associations of gastrointestinal disorder categories and ischemic stroke with adjustment for demographics and established vascular risk factors. Results: Among a mean of 1 725 246 beneficiaries in each analysis, several categories of gastrointestinal disorders were associated with an increased risk of ischemic stroke after adjustment for established stroke risk factors. The most notable positive associations included disorders of the stomach (hazard ratio, 1.17 [95% CI, 1.15–1.19]) and functional (1.16 [95% CI, 1.15–1.17]), inflammatory (1.13 [95% CI, 1.12–1.15]), and infectious gastrointestinal disorders (1.13 [95% CI, 1.12–1.15]). In contrast, we found no associations with stroke for diseases of the anus and rectum (0.97 [95% CI, 0.94–1.00]) or neoplastic gastrointestinal disorders (0.97 [95% CI, 0.94–1.00]). Conclusions: In exploratory analyses, several categories of gastrointestinal disorders were associated with an increased risk of future ischemic stroke after adjustment for demographics and established stroke risk factors.

scholarly journals Cumulative burden of metabolic syndrome and its components on the risk of atrial fibrillation: a nationwide population-based study

2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Hyo-Jeong Ahn ◽  
Kyung-Do Han ◽  
Eue-Keun Choi ◽  
Jin-Hyung Jung ◽  
Soonil Kwon ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Metabolic Syndrome ◽  
Proportional Hazards ◽  
Cox Proportional Hazards ◽  
Health Examination ◽  
Cumulative Number ◽  
Mets Component ◽  
The Metabolic Syndrome ◽  
Increased Risk ◽  
The Impact

Abstract Background The metabolic syndrome (MetS) and its components are associated with the development of atrial fibrillation (AF). However, the impact of time-burden of MetS on the risk of AF is unknown. We investigated the effect of the cumulative longitudinal burden of MetS on the development of AF. Methods We included 2 885 189 individuals without AF who underwent four annual health examinations during 2009–2013 from the database of the Korean national health insurance service. Metabolic burdens were evaluated in the following three ways: (1) cumulative number of MetS diagnosed at each health examination (0–4 times); (2) cumulative number of each MetS component diagnosed at each health examination (0–4 times per MetS component); and (3) cumulative number of total MetS components diagnosed at each health examination (0 to a maximum of 20). The risk of AF according to the metabolic burden was estimated using Cox proportional-hazards models. Results Of all individuals, 62.4%, 14.8%, 8.7%, 6.5%, and 7.6% met the MetS diagnostic criteria 0, 1, 2, 3, and 4 times, respectively. During a mean follow-up of 5.3 years, the risk of AF showed a positive association with the cumulative number of MetS diagnosed over four health examinations: adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of 1, 2, 3, and 4 times compared to 0 times were 1.18 (1.13–1.24), 1.31 (1.25–1.39), 1.46 (1.38–1.55), and 1.72 (1.63–1.82), respectively; P for trend < 0.001. All five components of MetS, when diagnosed repeatedly, were independently associated with an increased risk of AF: adjusted HR (95% CI) from 1.22 (1.15–1.29) for impaired fasting glucose to 1.96 (1.87–2.07) for elevated blood pressure. As metabolic components were accumulated from 0 to 20 counts, the risk of AF also gradually increased up to 3.1-fold (adjusted HR 3.11, 95% CI 2.52–3.83 in those with 20 cumulative components of MetS), however, recovery from MetS was linked to a decreased risk of AF. Conclusions Given the positive correlations between the cumulative metabolic burdens and the risk of incident AF, maximal effort to detect and correct metabolic derangements even before MetS development might be important to prevent AF and related cardiovascular diseases.

scholarly journals Cumulative Burden of Metabolic Syndrome and Its Components on the Risk of Atrial Fibrillation: A Nationwide Population-based Study

2020 ◽  
Author(s):  
Hyo-Jeong Ahn ◽  
Kyung-Do Han ◽  
Eue-Keun Choi ◽  
Jin-Hyung Jung ◽  
Soonil Kwon ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Metabolic Syndrome ◽  
Proportional Hazards ◽  
Cox Proportional Hazards ◽  
Health Examination ◽  
Cumulative Number ◽  
Mets Component ◽  
The Metabolic Syndrome ◽  
Increased Risk ◽  
The Impact

Abstract Background: The metabolic syndrome (MetS) and its components are associated with the development of atrial fibrillation (AF). However, the impact of time-burden of MetS on the risk of AF is unknown. We investigated the effect of the cumulative longitudinal burden of MetS on the development of AF. Methods: We included 2 885 189 individuals without AF who underwent four annual health examinations during 2009–2013. Metabolic burdens were evaluated in the following three ways: (1) cumulative number of MetS diagnosed at each health examination (0–4 times); (2) cumulative number of each MetS component diagnosed at each health examination (0–4 times per MetS component); and (3) cumulative number of total MetS components diagnosed at each health examination (0 to a maximum of 20). The risk of AF according to the metabolic burden was estimated using Cox proportional-hazards models.Results: Of all individuals, 62.4%, 14.8%, 8.7%, 6.5%, and 7.6% met the MetS diagnostic criteria 0, 1, 2, 3, and 4 times, respectively. During a mean follow-up of 5.3 years, the risk of AF showed a positive association with the cumulative number of MetS diagnosed over four health examinations: adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of 1, 2, 3, and 4 times compared to 0 times were 1.18 (1.13–1.24), 1.31 (1.25–1.39), 1.46 (1.38–1.55), and 1.72 (1.63–1.82), respectively; P for trend < 0.001. All five components of MetS, when diagnosed repeatedly, were independently associated with an increased risk of AF: adjusted HR (95% CI) from 1.22 (1.15–1.29) for impaired glucose intolerance to 1.96 (1.87–2.07) for elevated blood pressure. As metabolic components were accumulated from 0 to 20 counts, the risk of AF also gradually increased up to 3.1-fold (adjusted HR 3.11, 95% CI 2.52–3.83 in those with 20 cumulative components of MetS), however, recovery from MetS was linked to a decreased risk of AF. Conclusions: Given the positive correlations between the cumulative metabolic burdens and the risk of incident AF, maximal effort to detect and correct metabolic derangements even before MetS development might be important to prevent AF and related cardiovascular diseases.

P3762The impact of type and burden of atrial fibrillation on stroke occurrence in patients with atrial fibrillation: from a prospective cohort of atrial fibrillation patients (CODE-AF Registry)

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
S Cho ◽  
T Kim ◽  
J Uhm ◽  
M Cha ◽  
J Lee ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Stroke Risk ◽  
Hazard Ratio ◽  
Interquartile Range ◽  
Clinical Variable ◽  
P Value ◽  
Clinical Variables ◽  
Increased Risk

Abstract Background and purpose Although several studies reported that stroke risk in patients with paroxysmal atrial fibrillation (AF) is similar to those with persistent or permanent AF, there is still controversy on the relationship of AF type and stroke occurrence. We investigated the effect of AF type on AF burden and stroke risk in patients with non-valvular AF. Methods Within the CODE-AF prospective, outpatient registry (COmparison study of Drugs for symptom control and complication prEvention of Atrial Fibrillation), we identified 8,883 patients ≥18 years of age with non-valvular AF and eligible follow-up visits. We compared AF burden and stroke risk among patients with 3 types of AF: paroxysmal (n=5,808) or persistent (n=2,806) or permanent (n=269). Results The median age of the overall population was 68.0 (interquartile range, 60.0–75.0); 36.0% were female. Patients with persistent and permanent AF were older and had higher CHA2DS2-VASc scores and anticoagulation rate than those with paroxysmal AF. Compared with permanent AF (5.2±16.4%), the arrhythmic burden of AF on 24hrs Holter monitoring was significantly lower in paroxysmal AF (2.1±7.2%, p<0.001) and persistent AF (2.0±7.5%, p<0.001). During median follow-up period of 1.38 years (interquartile range: 0.96–1.67), total 82 (0.92%) patients experienced ischemic stroke with incidence rates of 0.51, 1.04 and 1.69 events per 100 person-years for paroxysmal, persistent and permanent AF, respectively. Compared with paroxysmal AF, the risk of ischemic stroke was increased in persistent AF with clinical variable adjusted hazard ratio (aHR) of 1.94 (95% confidence intervals [CI], 1.23–3.07; P=0.005) and permanent AF with aHR of 2.64 (95% CI, 1.09–6.41; P=0.03). AF type and HR of stroke occurrence Paroxysmal (n=5,808) Persistent (n=2,806) Permanent (n=269) Stoke events 39 37 6 Person years (PYs) 7673 3544 356 /100 PYs 0.51 1.04 1.69 HR (95% CI), p-value HR (95% CI), p-value HR (95% CI), p-value Unadjusted HR 1 (Reference) 2.05 (1.27–3.31), 0.003 3.32 (1.15–7.90), 0.02 Clinical variables adjusted HR 1 (Reference) 1.94 (1.23–3.07), 0.005 2.64 (1.09–6.41), 0.03 PYs: Person years; HR: Hazard ratio. Conclusion Persistent and permanent AF was associated with the increased risk of stroke than paroxysmal AF, after adjustment of clinical variables including age, sex, comorbidities and anticoagulation rate. These results suggest that AF type and burden might be related with the risk of ischemic stroke and should be considered in the stroke prevention of AF.

Abstract 11900: Influence of Competing Risks on the Association Between Warfarin and Ischemic Stroke in Atrial Fibrillation: The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Jeffrey M Ashburner ◽  
Alan S Go ◽  
Yuchiao Chang ◽  
Margaret C Fang ◽  
Lisa Fredman ◽  
...  
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Competing Risks ◽  
Stroke Risk ◽  
Proportional Hazards ◽  
Cox Proportional Hazards ◽  
Subdistribution Hazard ◽  
Risk Of Death

Introduction: Studies examining the association between warfarin therapy and incidence of ischemic stroke in adults with atrial fibrillation (AF) have not accounted for patients who die of non-stroke causes. Hypothesis: Accounting for the competing risk of death may provide greater understanding of the “real world” impact of warfarin on stroke risk during multiyear follow-up in a large, diverse cohort of AF patients. Methods: We assessed this association in the ATRIA community-based cohort of AF patients (n=13,559; study years 1996-2003), with thromboembolic (>90% ischemic stroke) events (TEE) being clinician-adjudicated. Extended Cox proportional hazards regression with time-varying warfarin exposure estimated the cause-specific hazard ratio (HR) for TEE while adjusting for stroke risk factors. Fine and Gray subdistribution regression was used to estimate this association while also accounting for competing death events. Results: Patients using warfarin were younger, more likely to have had a prior stroke, and to have known diabetes, coronary disease, and heart failure, and also had higher mean CHA2DS2VASc scores (3.68 vs. 3.22). The death rate was much higher in the non-warfarin group (8.1 deaths/100 person-years; 2637 deaths vs. 5.5 deaths/100 person-years; 1777 deaths on warfarin). The cause-specific HR indicated a large reduction in TE with warfarin use (adjusted HR: 0.57, 95% CI: 0.50-0.65). In subdistribution hazard models accounting for competing death events over the full follow-up of 6 years, this association was substantially attenuated (adjusted HR: 0.87, 95% CI: 0.77-0.99). In analyses limited to 1-year follow-up with only 648 competing death events, the results without accounting for competing risks (adjusted cause-specific HR: 0.55, 95% CI: 0.43-0.71) were similar to the results that did account for competing risks (adjusted subdistribution HR: 0.59, 95% CI: 0.46-0.75). Conclusions: By accounting for competing death events, our results reflect a more realistic estimate of the multi-year stroke prevention benefits of warfarin for patients with AF. Many old/frail individuals with AF will not live long enough to gain substantial benefit from warfarin.

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