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  • 1.
    Andersson, T.
    et al.
    Department of Cardiology, Örebro University Hospital, Örebro, Sweden.
    Bryngelsson, I. L.
    Department of Occupational and Environmental Medicine, Örebro University, Örebro, Sweden.
    Magnuson, A.
    Clinical Epidemiology and Biostatistics, Örebro University, Örebro, Sweden.
    Fröbert, Ole
    Department of Cardiology, Örebro University Hospital, Örebro, Sweden.
    Henriksson, K.
    Department of Medical Science, Uppsala University, Uppsala, Sweden.
    Edvardsson, N.
    Sahlgrenska University Hospital, Gothenburg, Sweden.
    Poci, Dritan
    Örebro University, School of Medical Sciences. Department of Cardiology, Örebro University Hospital, Örebro, Sweden.
    What do patients with incident atrial fibrillation and no comorbidities at the time of diagnosis die of?2017Conference paper (Refereed)
    Abstract [en]

    Introduction: Little is known about the long-term mortality risk and the causes of death in patients without comorbidities at the time of diagnosis of atrial fibrillation (AF).

    Purposes: To identify the causes of death in patients with AF and without comorbidities at the time of AF diagnosis.

    Methods: We identified 9 519 patients with first diagnosed AF and no co-morbidities at the time of AF diagnosis in a nation-wide registry of patients hospitalized between 1995 and 2008. They represented 3.5% of the original cohort of 271186 patients hospitalized with incident AF. Patients with any diagnosis from ICD9 and ICD10 at the time of AF diagnosis wereexcluded. They were matched for age, sex and calendar year of AF diagnosis with 12 468 controls. The follow-up continued until December 2008. Causes of death were classified according to the ICD-10 codes.

    Results: During follow-up, 11.1% and 8.3% of patients with AF and controls died, HR 1.3, 95% CI 1.2–1.4. Most of the difference was explained by deaths of cardiovascular causes, 8.3% versus 3.9%, (HR 2.0, 95% CI 1.8–2.3). The cause of death pattern was the same in controls although at much lower rates. The age adjusted relative risk was higher in women than in men, HR 2.3, 95% CI 1.9–2.8 versus HR 1.7, 95% CI 1.4–2.0. Myocardial infarction was the most common cardiovascular cause of death but was less common among patients with AF than in controls, 20.5% versus 32.0%. Stroke was a more common cause among patients with AF, 13.1% versus 9.7% (HR 2.7, 95% CI 1.8–4.0), while cerebral hemorrhage was more common among controls, 4.7% versus 10.2% (HR 0.9, 95% CI 0.6–1.5). The time from AF diagnosis to death was 6.0±3.1 years, as compared to the time from inclusion to death, 5.8±3.1 years, in controls.

    Conclusions: Only cardiovascular diseases were more often causes of death than in controls. Women carried a significantly higher relative risk than men. The duration between AF diagnosis and death suggests that there is often time enough for early intervention with antithrombotic therapy, rhythm and/or rate control and treatment of risk factors as they appear. Interestingly, controls had the same cause of death pattern although at much lower rates.

  • 2.
    Andersson, Tommy
    et al.
    Dept Cardiology, Örebro Univ Hospital, Örebro, Sweden.
    Magnuson, Anders
    Bryngelsson, Ing-Liss
    Dept. Occupational & Environmental Medicine, Örebro Univ Hospital, Örebro, Sweden.
    Fröbert, Ole
    Örebro University Hospital, Örebro, Sweden.
    Henriksson, Karin M.
    Dept. Laboratory Medicine, Lund Univ, Lund, Sweden; The Sahlgrenska Academy, Sahlgrenska Univ. Hospital, Gothenburg, Sweden.
    Edvardsson, Nils
    The Sahlgrenska Academy, Sahlgrenska Univ. Hospital, Gothenburg, Sweden.
    Poci, Dritan
    Örebro University Hospital.
    All-cause mortality in 272 186 patients hospitalized with incident atrial fibrillation 1995-2008: a Swedish nationwide long-term case-control study2013In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 34, no 14, p. 1061-1067Article in journal (Refereed)
    Abstract [en]

    Aims To evaluate long-term all-cause risk of mortality in women and men hospitalized for the first time with atrial fibrillation (AF) compared with matched controls. Methods and results A total of 272 186 patients (44% women) <= 85 years at the time of hospitalization with incidental AF 1995-2008 and 544 344 matched controls free of in-hospital diagnosis of AF were identified. Patients were followed via record linkage of the Swedish National Patient Registry and the Cause of Death Registry. Using Cox regression models, the long-term relative all-cause mortality risk, adjusted for concomitant diseases, in women vs. controls was 2.15, 1.72, and 1.44 (P < 0.001) in the age categories <= 65, 65-74, and 75-85 years, respectively. The corresponding figures for men were 1.76, 1.36, and 1.24 (P < 0.001). Among concomitant diseases, neoplasm, chronic renal failure, and chronic obstructive pulmonary disease contributed most to the increased all-cause mortality vs. controls. In patients with AF as the primary diagnosis, the relative risk of mortality was 1.63, 1.46, and 1.28 (P < 0.001) in women and 1.45, 1.17, and 1.10 (P < 0.001) in men. Conclusion Atrial fibrillation was an independent risk factor of all-cause mortality in patients with incident AF. The concomitant diseases that contributed most were found outside the thromboembolic risk scores. The highest relative risk of mortality was seen in women and in the youngest patients compared with controls, and the differences between genders in each age category were statistically significant.

  • 3.
    Andersson, Tommy
    et al.
    Dept Cardiol, Örebro Univ Hosp, Örebro, Sweden.
    Magnuson, Anders
    Clin Epidemiol & Biostat Unit, Örebro University Hospital, Örebro, Sweden.
    Bryngelsson, Ing-Liss
    Dept Occupat & Environm Med, Örebro University Hospital, Örebro, Sweden.
    Fröbert, Ole
    Örebro University Hospital. Dept Cardiol, Örebro University Hospital, Örebro, Sweden.
    Henriksson, Karin M.
    Dept Med Sci, Uppsala Univ, Uppsala, Sweden; AstraZeneca R&D, Mölndal, Sweden.
    Edvardsson, Nils
    Sahlgrenska Univ Hosp, Sahlgrenska Acad, Gothenburg, Sweden.
    Poci, Dritan
    Örebro University Hospital. Dept Cardiol, Örebro University Hospital, Örebro, Sweden.
    Gender-related differences in risk of cardiovascular morbidity and all-cause mortality in patients hospitalized with incident atrial fibrillation without concomitant diseases: A nationwide cohort study of 9519 patients2014In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 177, no 1, p. 91-99Article in journal (Refereed)
    Abstract [en]

    Background: Previous studies of patients with "lone" and "idiopathic" atrial fibrillation (AF) have provided conflicting evidence concerning the development, management and prognosis of this condition.

    Methods: In this nation-wide, retrospective, cohort study, we studied patients diagnosed with incidental AF recorded in national Swedish registries between 1995 and 2008. Controls were matched for age, sex and calendar year of the diagnosis of AF in patients. All subjects were free of any in-hospital diagnosis from 1987 and until patients were diagnosed with AF and also free of any diagnosis within one year from the time of inclusion. Follow-up continued until 2009. We identified 9519 patients (31% women) and 12,468 matched controls.

    Results: Relative risks (RR) versus controls for stroke or transient ischemic attack (TIA) in women were 19.6, 4.4, 3.4 and 2.5 in the age categories <55, 55-64, 65-74 and 75-85, years respectively. Corresponding figures for men were 3.4, 2.5, 1.7 and 1.9. RR for heart failure were 6.6, 6.6, 6.3 and 3.8 in women and 7.8, 4.6, 4.9 and 2.9 in men. All RR were statistically significant with p < 0.01. RR for myocardial infarction and all-cause mortality were statistically significantly increased only in the two oldest age categories in women and 65-74 years in men.

    Conclusions: Patients with AF and no co-morbidities at inclusion had at least a doubled risk of stroke or TIA and a tripled risk of heart failure, through all age categories, as compared to controls. Women were at higher RR of stroke or TIA than men. (C) 2014 The Authors. Published by Elsevier Ireland Ltd. This is an open access article under the CC BY-NC-SA license (http://creativecommons.org/licenses/by-nc-sa/3.0/).

  • 4.
    Andersson, Tommy
    et al.
    Örebro University, School of Medical Sciences. Department of Cardiology, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Magnuson, Anders
    Örebro University Hospital.
    Bryngelsson, Ing-Liss
    Örebro University Hospital. Department of Occupational and Environmental Medicine, Örebro University Hospital, Örebro, Sweden.
    Fröbert, Ole
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiology, Örebro University Hospital, Örebro, Sweden.
    Henriksson, Karin M.
    Department of Medical Science, Uppsala University, Uppsala, Sweden.
    Edvardsson, Nils
    Sahlgrenska Academy at Sahlgrenska University Hospital, Göteborg, Sweden.
    Poci, Dritan
    Örebro University, School of Medical Sciences. Department of Cardiology, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Patients with atrial fibrillation and outcomes of cerebral infarction in those with treatment of warfarin versus no warfarin with references to CHA(2)DS(2)-VASc score, age and sex: A Swedish nationwide observational study with 48 433 patients2017In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 12, no 5, article id e0176846Article in journal (Refereed)
    Abstract [en]

    Aims: There is controversy in the guidelines as to whether patients with atrial fibrillation and a low risk of stroke should be treated with anticoagulation, especially those with a CHA(2)DS(2)-VASc score of 1 point.

    Methods: In a retrospective, nationwide cohort study, we used the Swedish National Patient Registry, the National Prescribed Drugs Registry, the Swedish Registry of Education and the Population and Housing Census Registry. 48 433 patients were identified between 1 January 2006 and 31 December 2008 with incident atrial fibrillation who were divided in age categories, sex and a CHA(2)DS(2)-VASc score of 0, 1, 2 and >= 3 and they were included in a time-varying analysis of warfarin treatment versus no treatment. The primary end-point was cerebral infarction and stroke, and patients were followed until 31 December 2009.

    Results: Patients with 1 point from the CHA(2)DS(2)-VASc score showed the following adjusted hazard ratios (HR) with a 95% confidence interval: men 65-74 years 0.46 (0.25-0.83), men < 65 years 1.11 (0.56-2.23) and women < 65 years 2.13 (0.94-4.82), where HR < 1 indicates protection with warfarin. In patients < 65 years and 2 points, HR in men was 0.35 (0.18-0.69) and in women 1.84 (0.86-3.94) while, in women with at least 3 points, HR was 0.31 (0.16-0.59). In patients 65-74 years and 2 points, HR in men was 0.37 (0.23-0.59) and in women 0.39 ( 0.21-0.73). Categories including age >= 65 years or >= 3 points showed a statistically significant protection from warfarin.

    Conclusions: Our results support that treatment with anticoagulation may be considered in all patients with an incident atrial fibrillation diagnosis and an age of 65 years and older, i.e. also when the CHA(2)DS(2)-VASc score is 1.

  • 5.
    Andersson, Tommy
    et al.
    Örebro University, School of Medical Sciences.
    Magnuson, Anders
    School of Medical Sciences, Örebro University, Örebro, Sweden.
    Bryngelsson, Ing-Liss
    Department of Occupational and Environmental Medicine, School of Medical Sciences, Örebro University, Örebro, Sweden.
    Frøbert, Ole
    Örebro University, School of Medical Sciences. Department of Cardiology, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Henriksson, Karin M.
    Department of Medical Science, Uppsala University, Uppsala and AstraZeneca R&D, Mölndal, Sweden.
    Edvardsson, Nils
    Sahlgrenska Academy at Sahlgrenska University Hospital, Göteborg, Sweden.
    Poçi, Dritan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiology, Örebro University Hospital, Örebro, Sweden.
    Patients without comorbidities at the time of diagnosis of atrial fibrillation: causes of death during long-term follow-up compared to matched controls2017In: Clinical Cardiology, ISSN 0160-9289, E-ISSN 1932-8737, Vol. 40, no 11, p. 1076-1082Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Little is known about the long-term, cause-specific mortality risk in patients without comorbidities at the time of diagnosis of atrial fibrillation (AF).

    METHODS: From a nation-wide registry of patients hospitalized with incident AF between 1995 and 2008 we identified 9 519 patients with a first diagnosed AF and no comorbidities at the time of AF diagnosis. They were matched with 12 468 controls. The follow-up continued until December 2008. Causes of death were classified according to the ICD-10 codes.

    RESULTS: During follow-up, 11.1% of patients with AF and 8.3% of controls died. Cardiovascular diseases were the most common causes of death and the only diagnoses which showed significantly higher relative risk in patients with AF than controls (HR 2.0, 95% CI 1.8-2.3), and the relative risk was significantly higher in women than in men. Stroke was a more common cause among patients with AF, 13.1% versus 9.7% (HR 2.7, 95% CI 1.8-4.0), while cerebral hemorrhage was more common among controls, 4.7% versus 10.2% (HR 0.9, 95% CI 0.6-1.5). The time from AF diagnosis to death was 6.0 ± 3.1 years.

    CONCLUSIONS: In patients with incident AF and no known comorbidities at the time of AF diagnosis, only cardiovascular diseases were more often causes of death as compared to controls. Women carried a significantly higher relative risk than men.

  • 6.
    Björkenheim, Anna
    et al.
    Department of Cardiology, Örebro University Hospital, Örebro, Sweden.
    Brandes, A.
    Department of Cardiology, Odense University Hospital, Odense, Denmark.
    Magnuson, A.
    Örebro University Hospital, Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden.
    Chemnitz, A.
    Department of Cardiology, Odense University Hospital, Odense, Denmark.
    Svedberg, L.
    Department of Cardiology, Örebro University Hospital, Örebro, Sweden.
    Edvardsson, N.
    Sahlgrenska Academy at Sahlgrenska University Hospital, Göteborg, Sweden.
    Poçi, Dritan
    Department of Cardiology, Örebro University Hospital, Örebro, Sweden.
    Does zero atrial fibrillation burden after atrial fibrillation ablation mean that patients are free of symptoms?2017In: Europace, Supplements, ISSN 1099-6044, E-ISSN 1749-365X, Vol. 19, no Duppl. 3, p. iii264-iii264, article id 1361Article in journal (Refereed)
    Abstract [en]

    Introduction: Success of atrial fibrillation (AF) ablation is usually defined as freedom of AF, although symptomatic relief often is what the patient’s desire. After ablation the proportion of ‘silent’ AF increases and success based on symptomatic AF recurrence may be overestimated.

    Purpose: To investigate the symptomatology of patients who are truly free of AF after ablation.

    Methods: In 57 patients the symptomatology after AF ablation was assessed as perceived by the patient using a validated AF-specific symptom questionnaire (AF6) and the overall treatment effect (OTE), and as classified by the physician using the EHRA score, at baseline, 6, 12 and 24 months. The cardiac rhythm was continuously monitored by an implantable loop recorder throughout the 2-year follow-up.

    Results: At 6, 12 and 24 months 14 (26%), 23 (43%) and 23 (43%) patients had an AF burden 0% during the past 6 months, and 13 of them had an AF burden 0% during the entire 2 year follow-up. All patients reported ‘OTE better’ at all time-points. All patients were also classified into EHRA I at 6 months. Being completely free of AF for six months periods did not mean complete freedom of symptoms, but the median AF6 sum score was consistently low with a narrowing IQR over time, 0 (IQR 0-27), 0.5 (IQR 0-7) and 0 (IQR 0-11) at 6, 12 and 24 months. At 6 months 8/14 patients (57%) scored AF6=0, the others 6, 11, 26, 28, 30 and 46 points. At 12 months 13/23 patients (56%) scored AF6=0, the others 1,1,3,3,5,7,7,7,14 and 22 points. At 24 months 12/23 (52%) patients scored AF6=0, the others 1, 1, 2, 4, 9, 11, 17, 20, 24, 32 and 42 points. Among the AF6 items, ‘worry/anxiety due to AF’ was the most common, while ‘tiredness due to AF’ was the highest scoring item. In the patients with AF burden 0% during the entire 2-year follow-up all patients were improved in OTE and all patients were classified into EHRA class I at all times after ablation and the median AF6 sum score was 4 (IQR0-28), 0.5 (IQR 0-8) and 1 (0-5) at 6, 12 and 24 months after ablation.

    Conclusions: Sudden elimination of AF by ablation does not automatically eliminate all symptoms that the patients associated with AF, but all patients felt better and were classified in EHRA class I at all time-points. Less than a half of the patients at any time-point scored some symptoms, but the symptoms gradually decreased over time, especially between 6 and 12 months.

  • 7.
    Björkenheim, Anna
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Cardiology, Örebro University Hospital, Örebro, Sweden.
    Brandes, Axel
    Department of Cardiology, Odense University Hospital, Odense, Denmark.
    Andersson, Tommy
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Cardiology, Örebro University Hospital, Örebro, Sweden.
    Magnuson, Anders
    Clinical Epidemiology and Biostatistics Unit, Örebro University Hospital, Örebro, Sweden.
    Edvardsson, Nils
    Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Sweden.
    Wandt, Birger
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Pedersen, Henriette Sloth
    Department of Cardiology, Odense University Hospital, Odense, Denmark.
    Poci, Dritan
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital. Dept Cardiol, Örebro University Hospital, Örebro, Sweden.
    Predictors of hospitalization for heart failure and of all-cause mortality after atrioventricular nodal ablation and right ventricular pacing for atrial fibrillation2014In: Europace, ISSN 1099-5129, E-ISSN 1532-2092, Vol. 16, no 12, p. 1772-1778Article in journal (Refereed)
    Abstract [en]

    Aims: Atrioventricular junction ablation (AVJA) is a highly effective treatment in patients with therapy refractory atrial fibrillation (AF) but renders the patient pacemaker dependent. We aimed to analyse the long-term incidence of hospitalization for heart failure (HF) and all-cause mortality in patients who underwent AVJA because of AF and to determine predictors for HF and mortality.

    Methods and results: We retrospectively enrolled 162 consecutive patients, mean age 67 +/- 9 years, 48% women, who underwent AVJA because of symptomatic AF refractory to pharmacological treatment (n = 117) or unsuccessful repeated pulmonary vein isolation (n = 45). Hospitalization for HF occurred in 32 (20%) patients and 35 (22%) patients died, representing a cumulative incidence for hospitalization for HF and mortality over the first 2 years after AVJA of 9.1 and 5.2%, respectively. Hospitalization for HF occurred to the same extent in patients who failed pharmacological treatment as in patients with repeated pulmonary vein isolation (PVI), although the mortality was slightly higher in the former group. QRS prolongation >= 120 ms and left atrial diameter were independent predictors of hospitalization for HF, while hypertension and previous HF were independent predictors of death.

    Conclusion: The long-term hospitalization rate for HF and all-cause mortality was low, which implies that long-term ventricular pacing was not harmful in this patient population, including patients with unsuccessful repeated PVI.

  • 8.
    Björkenheim, Anna
    et al.
    Örebro University, School of Medical Sciences. Department of Cardiology, Örebro University Hospital, Örebro, Sweden.
    Brandes, Axel
    Department of Cardiology, Odense University Hospital, Odense, Denmark.
    Chemnitz, Alexander
    Department of Cardiology, Odense University Hospital, Odense, Denmark.
    Magnuson, Anders
    Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Edvardsson, Nils
    Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Sweden.
    Poçi, Dritan
    Örebro University, School of Medical Sciences. Department of Cardiology, Örebro University Hospital, Örebro, Sweden.
    Rhythm Control and its Relation to Symptoms During the First Two Years After Radiofrequency Ablation for Atrial Fibrillation2016In: Pacing and Clinical Electrophysiology, ISSN 0147-8389, E-ISSN 1540-8159, Vol. 39, no 9, p. 914-925Article in journal (Refereed)
    Abstract [en]

    Objective: To evaluate rhythm control up to two years after AF ablation and its relation to reported symptoms.

    Background: The implantable loop recorder (ILR) continuously records the ECG, has an automatic AF detection algorithm and a possibility for patients to activate an ECG recording during symptoms.

    Methods: Fifty-seven patients (mean age 57±9 years, 60% male, 88% paroxysmal AF) underwent AF ablation following ILR implantation. Device data were downloaded at the ablation and three, six, 12, 18 and 24 months after ablation.

    Results: Fifty-four patients completed the two-year follow-up. Thirteen (24%) patients had no AF episodes detected by ILR during follow-up. Ten of 41 patients (24%) with AF recurrence were only detected by ILR and AF recurrences were detected earlier by ILR (P<0.001). The median AF burden in patients with AF recurrence was 5.7% (IQR 0.4-14.4) and was even lower in patients with AF only detected by ILR (P = 0.001). Forty-eight % of the patients indicated symptoms via the patient activator but 33% of those recordings were not due to AF. Early AF recurrence (within 3 months) was highly associated with later AF recurrence (P<0.001). AF burden >0.5% and longest >6h before the ablation were independent predictors of AF recurrence during intermittent but not continuous monitoring.

    Conclusions: After AF ablation, the AF burden was low throughout the 24 months follow-up. Nevertheless, symptoms were commonly indicated but one third of patient activated recordings did not show AF. Continuous monitoring was superior to intermittent follow-up in detecting AF episodes and assessing the AF burden.

    Clinical trial registration: URL: http://clinicaltrials.gov. Unique Identifier: NCT00697359.

  • 9.
    Björkenheim, Anna
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiology.
    Brandes, Axel
    Odense University Hospital, Odense, Denmark.
    Magnuson, Anders
    Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden.
    Chemnitz, Alexander
    Department of Cardiology, Odense University Hospital, Odense, Denmark, Odense, Denmark.
    Edvardsson, Nils G.
    Sahlgrenska University Hospital, Gothenburg, Sweden.
    Poci, Ditran
    University Hospital Orebro, Örebro, Sweden.
    Patient-reported Outcomes In Relation To Continuously Monitored Rhythm Before And During Two Years After Atrial Fibrillation Ablation Using A Disease-specific And A Generic Instrument2018Conference paper (Refereed)
    Abstract [en]

    Background: Patients with AF have a lower health-related quality of life (HRQoL) than the general population.

    Objective: To assess the effect of AF ablation on AF-specific and generic patient-reported outcomes (PRO), compare it to a Swedish age- and sex-matched population and evaluate any association with the AF burden.

    Methods: Patients scheduled for AF ablation completed the generic SF-36 and the AF-specific PRO questionnaires before and six, 12 and 24 months after AF ablation. All patients underwent continuous ECG monitoring via an implantable loop recorder.

    Results: 54 patients completed the follow-up. After ablation, the generic SF-36 improved and both summary scores reached normative levels at 24 months, while physical functioning, role-physical and vitality remained lower than norms. Responders with an AF burden ≤0.5% at each visit after ablation reached the norms in all domains, while non-responders reached norms in only social functioning and MCS. All AF6 items and the sum score showed moderate to large improvement in both responders and non-responders. Higher AF burden was independently associated with poorer PCS and AF6 sum score. The AF sum score correlated with all SF-36 domains, but all AF6 items did not correlate with the SF-36 summary scores.

    Conclusion: The AF-specific AF6 questionnaire was more sensitive to changes in PRO related to AF burden than was the generic SF-36. Higher AF burden after ablation was associated with poorer AF-specific PRO and poorer generic physical but not mental health. Focusing on AF-specific symptoms and their impact on quality of life as an outcome after AF ablation is reasonable, as improving PROs is the main goal of AF ablation.

  • 10.
    Björkenheim, Anna
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiology.
    Brandes, Axel
    Department of Cardiology, Odense University Hospital, Odense, Denmark.
    Magnuson, Anders
    Örebro University Hospital, Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden.
    Chemnitz, Alexander
    Department of Cardiology, Odense University Hospital, Odense, Denmark.
    Edvardsson, Nils
    Sahlgrenska Academy at Sahlgrenska University Hospital, Göteborg, Sweden.
    Poci, Dritan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiology.
    Patient-reported outcomes in relation to continuously monitored rhythm before and during two years after atrial fibrillation ablation using a disease-specific and a generic instrument2018Conference paper (Refereed)
    Abstract [en]

    Background: Atrial fibrillation (AF) ablation improves patient-reported outcomes (PROs), irrespective of mode of intermittent rhythm monitoring.

    Purpose: To evaluate the use of an AF-specific and a generic PRO instrument during continuous rhythm monitoring two years after AF ablation.

    Methods: Fifty-four patients completed the generic SF-36 and the AF-specific AF6 questionnaires before and six, 12 and 24 months after AF ablation. All patients underwent continuous ECG monitoring via an implantable loop recorder. The generic PRO scores were compared to those of a Swedish age- and sex-matched population.

    Results: After ablation both summary scores reached normative levels at 24 months, while physical functioning, role-physical and vitality remained lower than norms. Responders to ablation (AF burden <0.5%) reached the norms in all individual SF-36 domains, while non-responders (AF burden >0.5%) reached norms only in social functioning. All AF6 items and the sum score showed moderate to large improvement in both responders and non-responders, although responders had significantly lower scores 24 months after ablation. Higher AF burden was independently associated with poorer PCS and AF6 sum score.

    Conclusions: The AF-specific AF6 questionnaire was more sensitive to changes related to AF burden than the generic SF-36. Patients improved as documented by both instruments, but a higher AF burden after ablation was associated with poorer AF-specific PROs and poorer generic physical but not mental health. Our results support the use of an AF-specific instrument, alone or in combination with a generic instrument, to assess the effect of ablation.

  • 11.
    Björkenheim, Anna
    et al.
    Örebro University, School of Medical Sciences. Department of Cardiology, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Brandes, Axel
    Department of Cardiology, Odense University Hospital, Odense, Denmark.
    Magnuson, Anders
    Chemnitz, Alexander
    Department of Cardiology, Odense University Hospital, Odense, Denmark.
    Edvardsson, Nils
    Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Sweden.
    Poçi, Dritan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiology, Örebro University Hospital, Örebro, Sweden.
    Patient-Reported Outcomes in Relation to Continuously Monitored Rhythm Before and During 2 Years After Atrial Fibrillation Ablation Using a Disease-Specific and a Generic Instrument2018In: Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease, ISSN 2047-9980, E-ISSN 2047-9980, Vol. 7, no 5, article id e008362Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Atrial fibrillation (AF) ablation improves patient-reported outcomes, irrespective of mode of intermittent rhythm monitoring. We evaluated the use of an AF-specific and a generic patient-reported outcomes instrument during continuous rhythm monitoring 2 years after AF ablation.

    METHODS AND RESULTS: Fifty-four patients completed the generic 36-Item Short-Form Health Survey and the AF-specific AF6 questionnaires before and 6, 12, and 24 months after AF ablation. All patients underwent continuous ECG monitoring via an implantable loop recorder. The generic patient-reported outcomes scores were compared with those of a Swedish age- and sex-matched population. After ablation, both summary scores reached normative levels at 24 months, while role-physical and vitality remained lower than norms. Responders to ablation (AF burden <0.5%) reached the norms in all individual 36-Item Short-Form Health Survey domains, while nonresponders (AF burden >0.5%) reached norms only in social functioning and mental component summary. All AF6 items and the sum score showed moderate to large improvement in both responders and nonresponders, although responders showed significantly greater improvement in all items except item 1 from before to 24 months after ablation. Higher AF burden was independently associated with poorer physical component summary and AF6 sum score.

    CONCLUSIONS: The AF-specific AF6 questionnaire was more sensitive to changes related to AF burden than the generic 36-Item Short-Form Health Survey. Patients improved as documented by both instruments, but a higher AF burden after ablation was associated with poorer AF-specific patient-reported outcomes and poorer generic physical but not mental health. Our results support the use of an AF-specific instrument, alone or in combination with a generic instrument, to assess the effect of ablation.

    CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00697359.

  • 12.
    Björkenheim, Anna
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Brandes, Axel
    Magnuson, Anders
    Chemnitz, Alexander
    Svedberg, L.
    Edvardsson, Nils
    Poci, Dritan
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Is AF burden <0.5% a clinically meaningful criterion of success after AF ablation?2017Conference paper (Refereed)
  • 13.
    Björkenheim, Anna
    et al.
    Örebro University, School of Medical Sciences.
    Brandes, Axel
    Odense University Hospital, Odense, Denmark.
    Magnuson, Anders
    Chemnitz, Alexander
    Odense University Hospital, Odense, Denmark.
    Svedberg, Lena
    Department of Cardiology, School of Medical Sciences, Örebro University, Örebro, Sweden.
    Edvardsson, Nils
    Sahlgrenska Academy, Sahlgrenska University Hospital, Göteborg, Sweden.
    Poçi, Dritan
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Assessment of Atrial Fibrillation–Specific Symptoms Before and 2 Years After Atrial Fibrillation Ablation: Do Patients and Physicians Differ in Their Perception of Symptom Relief?2017In: JACC: Clinical Electrophysiology, ISSN 2405-500X, Vol. 3, no 10, p. 1168-1176Article in journal (Refereed)
    Abstract [en]

    Objectives: The aim of this study was to evaluate patient-reported and physician-assessed atrial fibrillation (AF)–related symptoms after AF ablation.

    Background: Success of AF ablation is usually defined as freedom from AF, although symptom relief is often patients’ desire.

    Methods: Symptom relief was assessed as perceived by patients using the short, validated, AF-specific symptom questionnaire AF6 and as classified by physicians using the European Heart Rhythm Association (EHRA) classification at baseline and 6, 12, and 24 months after AF ablation. Recurrence of arrhythmia was documented by continuous electrocardiographic monitoring.

    Results: In total, 54 patients completed the 24-month follow-up. All 6 items on the AF6, AF6 sum score, and EHRA class improved significantly over time. The greatest improvement was seen during the first 6 months after ablation, but AF6 scores showed continued improvement up to 12 months, in contrast to EHRA class. There was a low correlation between AF6 score and EHRA class, but the predictive ability was low. Both AF6 scores and EHRA class were significantly correlated with AF burden at all times after ablation. A change of >9 points in AF6 sum score corresponded to a meaningful reduction in symptom severity.

    Conclusion: Patient-reported and physician-assessed outcomes were both useful in assessing symptom relief after AF ablation, although patient-reported outcomes were more sensitive tools. There was also a discrepancy between patient-reported and physician-assessed outcomes after ablation. Freedom from AF and a low AF burden most often resulted in a reduction of symptoms, but symptom relief also occurred despite little effect on the arrhythmia.

  • 14.
    Holmqvist, Fredrik
    et al.
    Skåne University Hospital, Lund, Sweden.
    Jonsson, Anders
    Linköping University Hospital, Linköping, Sweden.
    Kennebäck, Göran
    Karolinska University Stockholm, Sweden.
    Blomström Lundqvist, Carina
    Uppsala University, Uppsala, Sweden.
    Sigurjonsdottir, Runa
    Sahlgrenska University Hospital, Gothenburg, Sweden.
    Kesek, Milos
    Umeå University Hospital, Umeå, Sweden.
    Englund, Anders
    Arrhythmia Center Stockholm, Stockholm, Sweden.
    Poci, Dritan
    University Hospital Örebro, Örebro, Sweden.
    Samo-Ayou, Romeo
    Skaraborg Hospital, Skövde, Sweden.
    Ringborn, Michael
    Blekinge County Hospital, Karlskrona, Sweden.
    Herczku, Csaba
    Norra Älvsborg County Hospital, Trollhättan, Sweden.
    Insulander, Per
    Karolinska University Hospital, Solna, Sweden.
    Increasing Ablation Volumes And A Shift Towards More Complex Arrhythmias: Data From The Swedish National Catheter Ablation Registry2018Conference paper (Refereed)
    Abstract [en]

    Background: Catheter ablation has become the treatment of choice for many tachyarrhythmias. The ablation techniques are continuously refined and the indications expanded, enabling treatment of more complex substrates. Hence, the spectrum of treated arrhythmias is likely to have changed over time, but compelling data on this are lacking.

    Objective: The present study set out to explore the changing pattern of ablations performed in the setting of a universal, single-payer healthcare system, using data from the Swedish national catheter ablation registry.

    Methods: The Swedish National Catheter Ablation Registry covers virtually all (>97%) catheter ablations performed in Sweden since 2005 and comprises 42,192 ablations on 32,237 individual patients. In the present analysis, all ablations performed between 2005 and 2016 were included.

    Results: In 2005, there were 7 ablation centers in Sweden performing a total of 1,584 ablations (226/center; 175/million). In 2016, 11 ablation centers performed 5,022 ablations (457/center; 502/million). Ablation of atrial fibrillation increased from 326 ablations (21% of all) in 2005 to 2,063 (41%) in 2016. Although, the number of ablation procedures for ventricular tachycardia and premature ventricular contractions is increasing, it is still on a relatively modest level (Figure). In contrast to other reports, there is no apparent decline in the number of accessory pathway ablations.

    Conclusion: In the setting of a universal, single-payer healthcare system, the number of ablations more than tripled over a 10-year period. Ablation of atrial fibrillation is the main driver behind this increase and accounted for 41% of all ablations in Sweden in 2016.

  • 15.
    Poci, Dritan
    et al.
    Örebro University Hospital. Dept Cardiol, Örebro University Hospital, Örebro, Sweden; Sahlgrenska Univ Hosp & Academy, Dept Mol & Clin Med Cardiol, Univ Gothenburg, Gothenburg, Sweden.
    Abrahamsson, Britt-Marie
    Dept Mol & Clin Med Cardiol, Sahlgrenska Univ Hosp, Sahlgrenska Academy, Univ Gothenburg, Gothenburg, Sweden.
    Edvardsson, Nils
    Dept Mol & Clin Med Cardiol, Sahlgrenska Univ Hosp, Sahlgrenska Acad, Univ Gothenburg, Gothenburg, Sweden.
    Bergfeldt, Lennart
    Dept Mol & Clin Med Cardiol, Sahlgrenska Univ Hosp, Sahlgrenska Acad, Univ Gothenburg, Gothenburg, Sweden.
    Sinus Bradycardia and Sinus Pauses Immediately after Electrical Cardioversion of Persistent Atrial FibrillationWhat Do They Mean?2013In: Annals of Noninvasive Electrocardiology, ISSN 1082-720X, E-ISSN 1542-474X, Vol. 18, no 3, p. 281-287Article in journal (Refereed)
    Abstract [en]

    Background To determine the role of sinus bradyarrhythmia (SB) immediately after electrical cardioversion of persistent atrial fibrillation (AF) on the short-term recurrence rate and long-term pacemaker need and all-cause mortality. Methods SB defined as sinus bradycardia (sinus rate <40 bpm for 2 consecutive cycles) and/or sinus pauses (>2 s), were recorded during 5 minutes immediately after successful DC cardioversion in 140 consecutive patients with persistent AF. Results SB was observed during the first minute of SR in 31 patients (22%). Sinus bradycardia was present in 27 patients, sinus pauses in 16 (>3 s in 10) patients, and both in 12 patients. Compared to patients without SB, the mean heart rate during the first minute after cardioversion was lower, 57 +/- 13 versus 63 +/- 11 bpm; P < 0.05, while the mean heart rates during the subsequent 4 minutes were not statistically significantly different. The AF recurrence rates were not significantly different at 1 week (45% vs. 40%), or at 3 months (68% vs. 53%) in patients with or without SB. After a mean follow-up of 86 +/- 6 months the pacemaker implantation rate was 10% versus 11% (NS) and an all-cause mortality of 26 versus 18% (NS). Conclusions SB immediately after electrical cardioversion of persistent AF had no significant impact on the 3-month AF recurrence rate, the long-term need for pacemaker or all-cause mortality.

  • 16.
    Poci, Dritan
    et al.
    University Hospital Örebro, Örebro, Sweden.
    Andersson, Tommy
    University Hospital Örebro, Örebro, Sweden.
    Bryngelsson, Ing-Liss
    University Hospital Örebro, Örebro, Sweden.
    Magnuson, Anders
    University Hospital Örebro, Örebro, Sweden.
    Fröbert, Ole
    University Hospital Örebro, Örebro, Sweden.
    Henriksson, Karin
    Department Medical Science, Uppsala University, Uppsala, Sweden.
    Edvardsson, Nils G.
    Sahlgrenska University Hospital, Gothenburg, Sweden.
    Do Some Patients Younger Than 65 Years Old And With Incident Atrial Fibrillation Need Anticoagulation Treatment?: Conclusions From A Swedish Nationwide Registry Study2018Conference paper (Refereed)
    Abstract [en]

    Background: It is still under debate whether patients with atrial fibrillation (AF) and a low risk of cerebral infarction would benefit from anticoagulation.

    Objective: We aimed to assess whether younger patients with AF and lower CHA2DS2-VASc score would benefit from anticoagulation treatment.

    Methods: In a retrospective, nationwide cohort study, using the Swedish national registries, 59981 hospitalized patients were identified with incident AF. After exclusion of 11548 patients because of warfarin use before the AF diagnosis, or death, emigration or stroke within 30 days of AF diagnosis, the remaining 48 433 patients, among whom 27166 patients had no warfarin treatment, were, after adjustment for age, sex and year of AF diagnosis, divided according to age, sex and CHA2DS2-VASc score 0, 1, 2 and ≥3 and included in a time-varying analysis of warfarin treatment versus no treatment. Patients were followed up to 48 months after the inclusion.

    Results: In men <65 years and with a CHA2DS2-VASc score 2 or ≥3, the relative risk of having a stroke or cerebral infarction was lower when they received warfarin treatment, HR 0.35 (95% CI 0.18-0.69) and HR 0.37 (95% CI 0.23-0.59) respectively, as compared to HR 1.11 (95% CI 0.56-2.23) when the score was 1. Women younger than 65 years had a low relative risk when CHA2DS2-VASc score was ≥3 points, HR 0.31 (95% CI 0.16-0.59), as compared to HR 1.84 (95% CI 0.86-3.94) and HR 2.13 (95% CI 0.94-4.84) when the score was 2 and 1 respectively. The risk of intracranial bleeding was low and similar in all subgroups on anticoagulation except in the youngest men without risk factors.

    Conclusion: Women and men <65 years had a beneficial effect of warfarin if they had two risk factors other than age and sex, without an increased risk of bleeding. Our results support prophylactic anticoagulation treatment in patients under 65 years and a CHA2DS2-VASc score ≥2, other than age and sex.

  • 17.
    Poci, Dritan
    et al.
    Department of Cardiology, University Hospital Örebro, Örebro, Sweden.
    Hartford, Marianne
    Department of Molecular and Clinical Medicine/Cardiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Karlsson, Thomas
    Department of Molecular and Clinical Medicine/Cardiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Edvardsson, Nils
    Caidahl, Kenneth
    Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden ; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden .
    Effect of New Versus Known Versus No Atrial Fibrillation on 30-Day and 10-Year Mortality in Patients With Acute Coronary Syndrome2012In: American Journal of Cardiology, ISSN 0002-9149, E-ISSN 1879-1913, Vol. 110, no 2, p. 217-221Article in journal (Refereed)
    Abstract [en]

    Coronary artery disease promotes the development of atrial fibrillation (AF). The aim of this study was to determine short- and long-term mortality in patients with acute coronary syndromes (ACS) and AF, depending on the AF presentation. A total of 2,335 consecutive patients with ACS were included. AF was classified as known persistent or permanent AF, known paroxysmal AF, new AF at admission, and new AF during hospitalization for ACS. Four hundred forty-two patients had any AF: 54 with known persistent or permanent AF, 150 with known paroxysmal AF, 54 with new AF at admission, and 184 with new AF during hospitalization. Statistically significant differences among subgroups related to previous heart failure (p <0.0001), stroke (p = 0.04), myocardial infarction (p <0.0001), angina pectoris (p <0.0001), hypercholesterolemia (p = 0.007), coronary artery bypass grafting (p <0.0001), and percutaneous coronary intervention (p = 0.03) were observed. Thirty-day mortality differed among the subgroups (p = 0.02) and was lowest in patients with known paroxysmal AF (7.3%). Ten-year mortality ranged from 53% to 78% among the subgroups. There were 5 predictors of long-term mortality across the subgroups: age (hazard ratio [HR] 1.06, 95% confidence interval [CI] 1.04 to 1.09, p <0.0001), previous myocardial infarction (HR 1.4, 95% CI 1.0 to 1.8, p = 0.04), heart failure (HR 1.8, 95% CI 1.3 to 2.4, p = 0.0002), diabetes (HR 1.7, 95% CI 1.2 to 2.2, p = 0.0005), and smoking (HR 1.7, 95% CI 1.2 to 2.3, p = 0.001). In conclusion, patient characteristics and 30-day mortality differed significantly among the subgroups, but long-term mortality did not. Any AF associated with ACS almost doubled the long-term mortality risk. AF in patients with ACS should therefore be regarded as an important risk factor irrespective of its presentation. (C) 2012 Elsevier Inc. All rights reserved. (Am J Cardiol 2012;110:217-221)

  • 18.
    Saliu, Sokol
    et al.
    Chalmers University of Technology, Lindholmen College, Göteborg, Sweden.
    Poçi, Dritan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Sahlgrenska University Hospital, Division of Cardiology, Göteborg, Sweden.
    Edwardsson, Nils
    Sahlgrenska University Hospital, Division of Cardiology, Göteborg, Sweden.
    Parametric time-domain measures of long-term heart rate variability signal2001In: 2001 Conference Proceedings of the 23rd Annual International Conference of the IEEE Engineering in Medicine and Biology Society, IEEE, 2001, Vol. 2, p. 1929-1932, article id 247Conference paper (Refereed)
  • 19.
    Själander, Sara
    et al.
    Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
    Holmqvist, Fredrik
    Arrhythmia Clinic, Skåne University Hospital, Lund, Sweden; Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden .
    Smith, J. Gustav
    Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden; Department of Heart Failure and Valvular Disease, Skåne University Hospital, Lund, Sweden .
    Platonov, Pyotr G.
    Arrhythmia Clinic, Skåne University Hospital, Lund, Sweden; Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden .
    Kesek, Milos
    Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
    Svensson, Peter J.
    Department for Coagulation Disorders, Lund University, Malmö, Sweden.
    Blomström-Lundqvist, Carina
    Department of Cardiology, Institution of Medical Science, Uppsala University, Uppsala, Sweden.
    Tabrizi, Fariborz
    Department of Clinical Sciences, South Hospital, Karolinska Institute, Stockholm, Sweden; Arrhythmia Center Stockholm, Stockholm, Sweden.
    Tapanainen, Jari
    Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
    Poci, Dritan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiology, Örebro University Hospital, Örebro, Sweden.
    Jönsson, Anders
    Department of Cardiology, Linköping University Hospital, Linköping, Sweden.
    Själander, Anders
    Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
    Assessment of Use vs Discontinuation of Oral Anticoagulation After Pulmonary Vein Isolation in Patients With Atrial Fibrillation2017In: JAMA cardiology, ISSN 2380-6583, E-ISSN 2380-6591, Vol. 2, no 2, p. 146-152Article in journal (Refereed)
    Abstract [en]

    IMPORTANCE: Pulmonary vein isolation (PVI) is a recommended treatment for patients with atrial fibrillation, but it is unclear whether it results in a lower risk of stroke.

    OBJECTIVES: To investigate the proportion of patients discontinuing anticoagulation treatment after PVI in association with the CHA(2)DS(2)-VASc (congestive heart failure, hypertension, age >= 75 years [doubled], diabetes, stroke [doubled], vascular disease, age 65-74 years, sex category [female]) score, identify factors predicting stroke after PVI, and explore the risk of cardiovascular events after PVI in patients with and without guideline-recommended anticoagulation treatment.

    DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort studywas conducted using Swedish national health registries from January 1, 2006, to December 31, 2012, with a mean-follow up of 2.6 years. A total of 1585 patients with atrial fibrillation undergoing PVI from the Swedish Catheter Ablation Register were included, with information about exposure to warfarin in the national quality register Auricula. Data analysis was performed from January 1, 2015, to April 30, 2016.

    EXPOSURES: Warfarin treatment.

    MAIN OUTCOMES AND MEASURES: Ischemic stroke, intracranial hemorrhage, and death.

    RESULTS: In this cohort of 1585 patients, 73.0% were male, the mean (SD) age was 59.0 (9.4) years, and the mean (SD) CHA(2)DS(2)-VASc score was 1.5 (1.4). Of the 1585 patients, 1175 were followed up for more than 1 year after PVI. Of these, 360 (30.6%) discontinued warfarin treatment during the first year. In patients with a CHA(2)DS(2)-VASc score of 2 or more, patients discontinuing warfarin treatment had a higher rate of ischemic stroke (5 events in 312 years at risk [1.6% per year]) compared with those continuing warfarin treatment (4 events in 1192 years at risk [0.3% per year]) (P = .046). Patients with a CHA(2)DS(2)-VASc score of 2 or more or those who had previously experienced an ischemic stroke displayed a higher risk of stroke if warfarin treatment was discontinued (hazard ratio, 4.6; 95% CI, 1.2-17.2; P = .02 and hazard ratio, 13.7; 95% CI, 2.0-91.9; P = .007, respectively).

    CONCLUSIONS AND RELEVANCE: These findings indicate that discontinuation ofwarfarin treatment after PVI is not safe in high-risk patients, especially those who have previously experienced an ischemic stroke.

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