Elsevier

International Journal of Cardiology

Volume 167, Issue 6, 10 September 2013, Pages 2682-2687
International Journal of Cardiology

Pattern of atrial fibrillation and risk of outcomes: The Loire Valley Atrial Fibrillation Project

https://doi.org/10.1016/j.ijcard.2012.06.118Get rights and content

Abstract

Background

Risk of stroke and thromboembolism (TE) in patients with non-valvular atrial fibrillation (NVAF) is categorised in stroke risk stratification scores. The role of pattern of NVAF in risk prediction is unclear in contemporary ‘real world’ cohorts.

Methods and results

Patients with NVAF in a four-hospital-institution between 2000 and 2010 were included. Stroke/TE event rates were calculated according to pattern of AF, i.e. paroxysmal, persistent and permanent. Risk factors were investigated by Cox regression.

Among 7156 NVAF patients, 4176 (58.4%) patients with paroxysmal, 376 (5.3%) with persistent and 2604 (36.3%) with permanent patterns of NVAF were included. In non-anticoagulated patients, overall stroke/TE event rate per 100 person-years was 1.29 (95% CI 1.13–1.47). Compared with paroxysmal NVAF, rates of stroke/TE, bleeding and all-cause mortality (p < 0.001) were significantly higher in permanent NVAF patients but not in persistent NVAF patients.

In multivariate analyses, previous stroke (hazard ratio, HR 2.58, 95% CI 2.08–3.21), vascular disease (HR 1.34, 1.12–1.61), heart failure (HR 1.20, 1.00–1.44), age  75 years (HR 2.75, 2.16–3.50) and age 65–74 years (HR 1.60, 1.22–2.09) independently increased stroke/TE risk, but not persistent (HR 1.13, 0.76–1.70) and permanent (HR 1.44, 0.96–2.16) NVAF patterns.

Conclusion

In this large ‘real world’ NVAF cohort, rates of stroke, TE, death and bleeding differed significantly by patterns of NVAF. However, only previous stroke, age, heart failure and vascular disease (not pattern of NVAF) independently increased risk of adverse outcomes in multivariate analyses. Thus, stroke risk is similar across all patterns of NVAF and antithrombotic therapy should be based on clinical risk factors, not on arrhythmia pattern.

Section snippets

How does this advance the field?

  • Non-valvular atrial fibrillation (NVAF) increases risk of stroke and thromboembolism, but the role of pattern of NVAF in this prediction is less clear in contemporary ‘real world’ cohorts.

  • This study confirms that pattern of NVAF does not add incremental value to stroke risk prediction in these patients.

  • In patients with NVAF, age, previous stroke, heart failure and vascular disease are the strongest independent predictors of risk of stroke and thromboembolism, bleeding and all-cause mortality.

What are the clinical implications?

  • In patients with atrial fibrillation, pattern of atrial fibrillation is not useful in predicting risk of stroke and thromboembolism, bleeding or all-cause mortality.

Study population

At the Centre Hospitalier Régional et Universitaire in Tours (France), all patients diagnosed with NVAF or atrial flutter by the department of cardiology between 2000 and 2010 were identified retrospectively (Fig. 2) [12]. Treatment at discharge was obtained by screening hospitalisation reports, and information on comorbidities was obtained from the computerised coding system.

For each patient, the CHADS2 [8] and CHA2DS2-VASc [9] scores were calculated. The CHADS2 score was the sum of points

Results

Of 8962 patients with AF, 7156 had NVAF (4176 paroxysmal, 376 persistent and 2604 permanent) and were included in the analysis (Fig. 1). Baseline characteristics are displayed in Table 1, with age-adjustment. Patients with permanent NVAF were older (p < 0.001) and even after age-adjustment, several differences remained between the different patterns of NVAF. Paroxysmal NVAF patients were more likely to be female (p < 0.001) whilst those with persistent NVAF were less likely to be associated with

Discussion

This large ‘real world’ cohort of patients with NVAF has shown that NVAF patients had different risk factor profiles based on pattern of NVAF. Compared with patients with paroxysmal NVAF, those patients with permanent NVAF had higher rates of stroke, stroke/TE, bleeding and death, whilst those with persistent NVAF had similar rates. However, in multivariate analyses, the pattern of NVAF was not associated with the risk of stroke/TE, bleeding or all-cause mortality and pattern of NVAF does

Conclusions

In this large ‘real world’ cohort of NVAF patients, we report statistically significant differences in rates of stroke/TE, bleeding and death based on patterns of NVAF. Only age, previous stroke, heart failure and vascular disease independently increased the risk of stroke/TE. Thus, pattern of NVAF may not provide additional value to stroke risk prediction in patients with NVAF.

Funding sources

This study has received no financial or material support.

Disclosures

Dr. Olesen has received travel grants from AstraZeneca and Boehringer Ingelheim. Dr. Taillandier has received funding for research from Sanofi Aventis. Dr. Lane has received funding for research, conference travel, and educational symposia from Bayer Healthcare, BMS/Pfizer and Boehringer Ingelheim, and is a member of the ACCP9 Writing Committee. Prof Lip has served as a consultant for Bayer, Astellas, Merck, AstraZeneca, Sanofi Aventis, Biotronik, BMS/Pfizer, and Boehringher Ingelheim and has

Acknowledgements

LF, BL and ST made the primary contribution to data collection. AB, JBO, GYHL, DAL, and LF contributed to the study conception and design. AB performed the analyses. All authors contributed to interpretation of results, revising the manuscript critically for important intellectual content, and all approved the final manuscript. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.

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