Prevalence, clinical profile, and cardiovascular outcomes of atrial fibrillation patients with atherothrombosis

doi:10.1016/j.ahj.2008.06.029

American Heart Journal

Volume 156, Issue 5, November 2008, Pages 855-863.e2

https://doi.org/10.1016/j.ahj.2008.06.029 Get rights and content

Background

Atrial fibrillation (AF) is a major risk factor (RF) for ischemic stroke. Its prevalence and prognostic impact in patients with atherothrombosis are unclear.

Methods

Risk factors, drug usage, and 1-year cardiovascular (CV) outcomes (CV death, myocardial infarction [MI], and stroke) were compared in AF and non-AF patients from the REduction of Atherothrombosis for Continued Health (REACH) Registry, an international, prospective cohort of 68,236 stable outpatients with established atherothrombosis or ≥3 atherothrombotic RFs.

Results

Atrial fibrillation and 1-year follow-up data are available for 63,589 patients. The prevalence of AF was, 12.5%, 13.7%, 11.5%, and 6.2% among coronary artery disease, CV disease, peripheral artery disease, and RF-only patients, respectively. Of the 6,814 patients with AF, 6.7% experienced CV death, nonfatal MI, or nonfatal stroke within a year. The annual incidence of nonfatal stroke (2.4% vs 1.6%, P < .0001) and unstable angina (6.0% vs 4.0%, P < .00001) was higher, and CV death was more than double (3.2% vs 1.4%, P < .0001), in AF versus non-AF patients. In these patients with or at high risk of atherothrombosis, most patients with AF received antiplatelet agents, but only 53.1% were treated with oral anticoagulants. Even with high CHADS₂ (congestive heart failure, hypertension, aging, diabetes mellitus, and stroke) scores, anticoagulant use did not exceed (59%). The rate of bleeding requiring hospitalization was higher in AF versus non-AF patients (1.5% vs 0.8%, P < .0001), possibly related to the more frequent use of anticoagulants (53.1% vs 7.1%).

Conclusions

Atrial fibrillation is common in patients with atherothrombosis, associated with more frequent fatal and nonfatal CV outcomes, and underuse of oral anticoagulants.

Section snippets

Database of the REACH Registry

This study was conducted using data from the REACH Registry. The study design,¹² baseline characteristics, and main 1-year outcomes have been published previously.11, 13 Briefly, the REACH Registry is a large-scale, prospective, international cohort of stable outpatients aged ≥45 years with either established atherothrombotic disease (CAD, CVD, and/or PAD) or ≥3 risk factors for atherothrombosis (risk factors only [RFO]). The enrollment criteria were predefined and have been published elsewhere.

Baseline characteristics of AF and non-AF patients

Among 68,236 patients initially recruited to the REACH Registry, 1-year follow-up was available for 64,977 patients of whom 63,589 patients had information available regarding AF or non-AF at baseline and represent the analysis sample.¹² The prevalence of AF in the patient groups with established atherothrombotic disease was 12.5%, 13.7%, and 11.5% for patients with CAD, CVD, and PAD respectively, whereas it was 6.2% among patients with risk factors for atherothrombosis. The prevalence of AF in

Discussion

The primary finding of this study is the high prevalence of AF among patients with atherothrombosis, ranging from 11.5% in patients with PAD to 13.7% in patients with CVD. Indeed, the prevalence of AF in patients with symptomatic atherothrombotic disease (CAD, CVD, or PAD) was 11.7%. Even among RFO patients, the prevalence of AF (6.2%) is substantially higher than the estimated prevalence in the general population aged 40 years and older (2.3%) and also in the population aged 65 years and older

References (37)

WachtellK. et al.
Cardiovascular morbidity and mortality in hypertensive patients with a history of atrial fibrillation: The Losartan Intervention For End Point Reduction in Hypertension (LIFE) study
J Am Coll Cardiol
(2005)
FrostL. et al.
Overweight and obesity as risk factors for atrial fibrillation or flutter: the Danish Diet, Cancer, and Health Study
Am J Med
(2005)
OhmanEM et al.
The REduction of Atherothrombosis for Continued Health (REACH) Registry: an international, prospective, observational investigation in subjects at risk for atherothrombotic events—study design
Am Heart J
(2006)
MehtaS.R. et al.
Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study
Lancet
(2001)
BeinartS.C. et al.
Long-term cost effectiveness of early and sustained dual oral antiplatelet therapy with clopidogrel given for up to one year after percutaneous coronary intervention results: from the Clopidogrel for the Reduction of Events During Observation (CREDO) trial
J Am Coll Cardiol
(2005)
MantJ. et al.
Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial
Lancet
(2007)
LipG.Y. et al.
Stroke prevention with aspirin, warfarin and ximelagatran in patients with non-valvular atrial fibrillation: a systematic review and meta-analysis
Thromb Res
(2006)
TestaL. et al.
Adjusted indirect meta-analysis of aspirin plus warfarin at international normalized ratios 2 to 3 versus aspirin plus clopidogrel after acute coronary syndromes
Am J Cardiol
(2007)
SingerD.E. et al.
Antithrombotic therapy in atrial fibrillation: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy
Chest
(2004)
BenjaminE.J. et al.
Impact of atrial fibrillation on the risk of death: the Framingham Heart Study
Circulation
(1998)

MiyasakaY. et al.

Coronary ischemic events after first atrial fibrillation: risk and survival

Am J Med

(2007)

FeinbergW.M. et al.

Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications

Arch Intern Med

(1995)

HeeringaJ. et al.

Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study

Eur Heart J

(2006)

Lloyd-JonesD.M. et al.

Lifetime risk for development of atrial fibrillation: the Framingham Heart Study

Circulation

(2004)

BenjaminE.J. et al.

Independent risk factors for atrial fibrillation in a population-based cohort. The Framingham Heart Study

JAMA

(1994)

OstgrenC.J. et al.

Atrial fibrillation and its association with type 2 diabetes and hypertension in a Swedish community

Diabetes Obes Metab

(2004)

GoA.S. et al.

Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study

JAMA

(2001)

BhattD.L. et al.

International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis

JAMA

(2006)

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Background: Atrial fibrillation (AF) in patients aged ≥75 is one of the major risk factors for stroke, and prescription of oral anticoagulants (OACs) should be considered in these patients. We investigated the use of OAC' for patients certificated for long-term care (LTC) insurance, who have a high risk of bleeding among older patients.
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: Author conflict of interest information is available in Appendix A available online.

^q: For a list of REACH Registry Global Publication Committee members see Appendix A (available online).

View full text

Clinical InvestigationElectrophysiologyPrevalence, clinical profile, and cardiovascular outcomes of atrial fibrillation patients with atherothrombosis

Background

Methods

Results

Conclusions

Section snippets

Database of the REACH Registry

Baseline characteristics of AF and non-AF patients

Discussion

J Am Coll Cardiol

Am J Med

Am Heart J

Lancet

J Am Coll Cardiol

Lancet

Thromb Res

Am J Cardiol

Chest

Impact of atrial fibrillation on the risk of death: the Framingham Heart Study

Circulation

Coronary ischemic events after first atrial fibrillation: risk and survival

Am J Med

Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications

Arch Intern Med

Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study

Eur Heart J

Lifetime risk for development of atrial fibrillation: the Framingham Heart Study

Circulation

Independent risk factors for atrial fibrillation in a population-based cohort. The Framingham Heart Study

JAMA

Atrial fibrillation and its association with type 2 diabetes and hypertension in a Swedish community

Diabetes Obes Metab

Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study

JAMA

International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis

JAMA

Clinical Investigation
Electrophysiology
Prevalence, clinical profile, and cardiovascular outcomes of atrial fibrillation patients with atherothrombosis