Elsevier

Mayo Clinic Proceedings

Volume 94, Issue 12, December 2019, Pages 2427-2436
Mayo Clinic Proceedings

Original article
Long-Term Relationship Between Atrial Fibrillation, Multimorbidity and Oral Anticoagulant Drug Use

Data Previously Presented: These data were presented as an abstract at the 2018 European Society of Cardiology Meeting, August 25-29, 2018, Munich, Germany.
https://doi.org/10.1016/j.mayocp.2019.06.012Get rights and content

Abstract

Objectives

To analyze the relationship between atrial fibrillation (AF) and Charlson comorbidity index (CCI) in a population-based cohort study over a long-term follow-up period, in relation to oral anticoagulant (OAC) prescriptions and outcomes.

Patients and Methods

We used data from the administrative health databases of Lombardy. All patients with AF and age 40 years and older and who were admitted to the hospital in 2002 were considered for analysis and followed up to 2014. AF diagnosis and CCI were established according to codes from the International Classification of Diseases, Ninth Revision.

Results

In 2002, 24,040 patients were admitted with a diagnosis of AF. CCI was higher in patients with AF than in those without AF (1.8±2.1 vs 0.2±0.9; P<.001). Over 12 years of follow-up, AF was associated with an increased risk of higher CCI (beta coefficient, 1.69; 95% CI, 1.67-1.70). In patients with AF, CCI was inversely associated with OAC prescription at baseline (P<.001) and at the end of the follow-up (P=.03). Patients with AF and a high CCI (≥4) had a higher cumulative incidence of stroke, major bleeding, and all-cause death (all P<.001), compared with those with low CCI (range, 0-3). Adjusted Cox regression analysis revealed that time-dependent continuous CCI was associated with an increased risk for stroke, major bleeding, and all-cause death (all P<.001).

Conclusions

In hospitalized patients, AF is associated with an increase in CCI that is inversely associated with OAC prescriptions during follow-up. CCI is independently associated with an increased risk of stroke, major bleeding, and all-cause death.

Section snippets

Data Source and Study Population

This study used linkable administrative health databases from the Lombardy Region that include the demographic data of all residents and detailed information on hospital admissions and drug prescriptions. To date, with a population of more than 10 million inhabitants, Lombardy is the largest Italian region, comprising highly populated urban areas and industrial and rural ones. The Italian health care system is based on a public National Health Service, which provides free assistance to anyone

Results

In 2002, a cohort of patients with 24,040 and 240,400 subjects without AF was created. At baseline (Table 1), patients with AF had a significantly higher mean (±SD) CCI than did those without AF (1.8±2.1 vs 0.2±0.9; P<.001). Patients with AF were significantly older and more likely to be male, and they were more likely to be affected by comorbidities compared with subjects with AF. Accordingly, patients with AF had a significantly higher mean (±SD) CHA₂DS₂-VASc score (3.3±1.4 vs 1.4±1.2; P

Discussion

Our study showed that patients with AF are exposed to a higher burden of overall multimorbidity than are individuals without AF, showing a direct relationship between AF and increasing multimorbidity burden over long-term follow-up, regardless of age. Second, an increased burden of multimorbidity is inversely associated with OAC prescription, which could significantly affect the clinical history of patients with AF, despite not influencing treatment discontinuation. Third, an increased burden

Conclusion

In hospitalized patients, AF is associated with an independent increase in CCI that is inversely associated with OAC prescriptions during follow-up. CCI was independently associated with an increased risk of stroke, major bleeding, and all-cause death. New models of care that consider the burden of comorbidities in patients and offer holistic approaches to AF management are needed.

Acknowledgments

The authors thank Igor Monti from Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Simone Schiatti and Giovanna Rigotti from Lombardia Informatica S.p.A, and Alfredo Bevilacqua from SANTER Reply S.p.A.

References (36)

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For editorial comment, see page 2381

Dr Proietti and Dr Marzona contributed equally to this work.

Potential Competing Interests: Dr Proietti reports consultant activity for Boehringer Ingelheim. Dr Mannucci reports honoraria for lectures as speaker or chair symposia organized by Bayer, Grifols, Kedrion, LFB, Novo Nordisk, and Pfizer; he is also a scientific consultant for Bayer, Baxalta, and Kedrion. Dr Boriani reports speaker’s fees from Medtronic, Boston, Boehringer, and Bayer. Dr Lip reports consultant activity for Bayer/Janssen, BMS/Pfizer, Biotronik, Medtronic, Boehringer Ingelheim, Microlife, and Daiichi-Sankyo and speaker activity for Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim, Microlife, Roche, and Daiichi-Sankyo. No fees are received personally. All relationships disclosed are related to activities performed outside the submitted work. All other authors have no disclosures to declare.

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