Risk of Stroke and Death in Anticoagulated Patients With Atrial Fibrillation
abstract
This abstract is available on the publisher's site.
Access this abstract nowBackground and Purpose
Atrial fibrillation (AF) and heart failure frequently coexist and are associated with increased morbidity and mortality. We investigated the prognosis of anticoagulated patients with permanent AF and nonpermanent AF according to pre-existing heart failure in the AMADEUS (Evaluating the Use of SR34006 Compared to Warfarin or Acenocoumarol in Patients With Atrial Fibrillation) trial.
Methods
The primary outcome was a composite of cardiovascular death and stroke or systemic embolism, analyzed using a Cox proportional hazards model, adjusted for baseline age, sex, diabetes mellitus, hypertension, creatinine, and previous cardiovascular diseases. The median follow-up was 11.6 months (interquartile range, 6.2–15.2).
Results
Nonpermanent AF was present in 2072 patients (46% of cohort), of which 339 (16%) had pre-existing heart failure. A total of 2484 patients had permanent AF (54% of cohort), with a higher burden of heart failure including 730 patients (29%; P<0.001). Overall, death because of cardiovascular causes occurred in 57 patients and 45 had stroke or systemic embolism (1.4/100 person-years for each). Overall, the adjusted incidence of the composite outcome was higher in patients with permanent AF than in patients with nonpermanent AF. In multivariate analysis, permanency of AF, creatinine, prior cerebrovascular events, and previous coronary disease were independently associated with the primary outcome. The hazard ratio for permanent versus nonpermanent AF was 1.68 (95% confidence interval, 1.08–2.55; P=0.02). The presence of heart failure increased the risk of adverse outcomes in a similar way in both permanent and nonpermanent AF (interaction P value=0.76).
Conclusions
The risk of cardiovascular death, stroke, or systemic embolism is higher in anticoagulated patients with permanent AF than in those with nonpermanent AF, regardless of pre-existing heart failure.
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Additional Info
Residual Risk of Stroke and Death in Anticoagulated Patients According to the Type of Atrial Fibrillation: AMADEUS Trial
Stroke 2015 Jul 23;[EPub Ahead of Print], K Senoo, GY Lip, DA Lane, HR Büller, D KotechaFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
We know that atrial fibrillation (AF) is not a uniform disease and can progress from paroxysmal, to persistent, to permanent forms with different anatomic and electrophysiologic substrates for each stage as the atria remodel. The paper by Senoo and colleagues1 reviewing data from the AMADEUS trial2 demonstrates that a different clinical outcome accompanies the different AF types. They showed that the risk of cardiovascular death, stroke, or systemic embolism is higher in anticoagulated patients with permanent AF than in those with nonpermanent AF, regardless of preexisting heart failure. This is consistent with the observations in the ROCKET-AF trial.3
The accompanying article on management of anticoagulation in AF patients by Moss and Cifu recommends warfarin or direct thrombin or factor Xa inhibitor for AF patients regardless of the type if they have had a prior stroke, transient ischemic attack, or CHA2DS2-VASc score of ≥2.4 This applies to patients with atrial flutter as well. Finally, the review by Prystowsky et al offers a nice summary of treatment for AF patients.5
AF is such an important clinical entity that the clinician needs to be familiar with the information in all three articles to properly care for the AF patients.1,4,5
References