To Örebro University

BACKGROUND: Bone morphogenetic protein 10 (BMP10) has atrial-specific and vascular properties and may reflect both atrial and vascular pathophysiology. We investigated whether BMP10 levels were associated with new-onset atrial fibrillation (AF), major adverse cardiovascular events (MACE), and all-cause mortality after open revascularisation for symptomatic peripheral arterial disease (PAD) or carotid stenosis (CS).

METHODS: Patients scheduled for endarterectomy for symptomatic PAD or CS were enrolled. BMP10 concentrations were measured using a multiplex immunoassay. Clinical outcomes were obtained from medical records during one-year follow-up. Associations between BMP10 and outcomes were assessed using Cox proportional hazards regression.

RESULTS: A total of 210 patients were included (63% men; 61% underwent surgery for PAD). Women were older than men and had higher BMP10 levels. Forty patients had known preoperative AF. During one-year follow-up, 26 patients experienced MACE and 13 died. Among 170 patients without AF at baseline, 10 developed new-onset AF. In unadjusted Cox regression, higher BMP10 levels were associated with MACE (HR 1.01, 95% CI 1.00-1.03; p = 0.047) and all-cause mortality (HR 1.03, 95% CI 1.01-1.04; p < 0.001), but not with new-onset AF (HR 1.00, 95% CI 0.97-1.03; p = 0.80). Effect estimates were similar after adjustment for age and sex. Model-based point estimates of one-year cumulative incidence were numerically higher at higher BMP10 concentrations for MACE and all-cause mortality, although confidence intervals were wide; no corresponding pattern was observed for new-onset AF.

CONCLUSIONS: In this exploratory cohort, higher BMP10 levels were associated with MACE and all-cause mortality after endarterectomy for symptomatic PAD or CS. Women had higher BMP10 levels than men. These findings should be interpreted cautiously and considered hypothesis-generating; larger studies are required to validate the observed associations.

BACKGROUND: Socioeconomic factors are associated with cardiovascular morbidity. We investigated the association between education level and incident heart failure (HF), acute coronary events (AMI), and cerebrovascular events (stroke) following hospitalization with first-detected atrial fibrillation (AF).

METHODS: In this nationwide retrospective observational cohort study using linked Swedish national registers, we included patients who received a first diagnosis of AF during hospitalization from 1995 to 2008. Education levels were categorized as primary, secondary, or academic, and patients were followed for up to five years. Outcomes were first hospitalization for HF, AMI, or stroke. Associations were assessed using cause-specific Cox proportional hazard models, for men and women separately. Models were adjusted for age, calendar year of AF diagnosis, whether AF was the primary or secondary admission diagnosis, comorbidity diagnoses and thromboembolic risk.

RESULTS: The cohort comprised 263,172 patients (mean age 72.5 ± 10.4 years; 56.2% male). Compared with primary education, secondary and academic education levels were associated with lower adjusted risks of HF and AMI in both females and males. For HF, adjusted hazard ratios (HR) were 0.96 (95% CI 0.93-1.00) for secondary and 0.82 (95% CI 0.77-0.87) for academic education in females, and 0.93 (95% CI 0.90-0.96) and 0.76 (95% CI 0.72-0.80), respectively, in males. For AMI, adjusted HRs were 0.89 (95% CI 0.85-0.93) and 0.71 (95% CI 0.65-0.77) in females, and 0.91 (95% CI 0.87-0.94) and 0.75 (95% CI 0.71-0.80) in males. For stroke, lower adjusted risks were observed only in the academic education group. Baseline comorbidity burden and thromboembolic risk were higher in lower education groups.

CONCLUSIONS: In this large nationwide cohort of patients hospitalized with AF, higher education level was associated with lower adjusted hazards of incident HF and AMI over five years, while the association with stroke was weaker. Education level may be considered a risk marker when planning follow-up and preventive care after hospitalization with AF.

Background: Education level is an important socioeconomic factor affecting the incidence, symptoms, and treatment of atrial fibrillation (AF). Despite this, data on the association between education level and the incidence of major AF consequences – heart failure (HF), acute myocardial infarction (AMI), and stroke – are limited.     

Aim: To investigate the association between education level and the risk of HF, AMI, and stroke in patients hospitalized with AF.  

Methods: This retrospective cohort study is based on data generated by crosslinking of several Swedish national registries. All patients hospitalized between 1998 and 2003 with a diagnosis of AF were included. The relative risk for incident HF, AMI, and stroke were assessed according to education level categories during a 5–year follow–up. Education levels were categorised as primary, secondary, and academic. Kaplan-Meier curves and Cox regression models adjusted for age, sex, time of AF diagnosis, and the variables of Charlson´s Comorbidity Index were used to estimate the relative risk of the examined outcomes. Hazard ratios (HR) with 95% confidence intervals (CI) were used as estimate of associations and statistical significance level was 5%.Results: The study included 263,172 patients (56.2% male; mean age 72.5±10.4 years). There was a statistically significant dose-dependent association between education level and the risk of AMI and HF in both sexes. Compared to primary education, the HR for AMI was 0.89 (95% CI: 0.85-0.93) for secondary education and 0.71 (95% CI: 0.65-0.78) for academic education in women; and 0.91 (95% CI: 0.87-0.94) for secondary education and 0.75 (95% CI: 0.71-0.80) for academic education in men. The relative risk for HF was similar, with HRs of 0.96 (95% CI: 0.93-1.00) for secondary and 0.82 (95% CI: 0.77-0.87) for academic education in women, and HRs of 0.93 (95% CI: 0.90-0.96) for secondary and 0.76 (95% CI: 0.72-0.80) for academic education in men). Patients with academic education had a significantly lower risk for stroke compared to those with primary education (HR 0.77 (95% CI: 0.71-0.84) in women; HR 0.84 (95% CI: 0.79-0.90) in men), while patients with secondary education did not have a significantly different relative risk for stroke compared to those with primary education.    

Conclusion:  Secondary and academic education levels were associated with a significantly lower risk of HF and AMI in both women and men with AF compared to primary education. Furthermore, academic education was associated with a lower risk of stroke. In conclusion, higher education levels were associated with a lower 5-year risk of HF, AMI, and stroke compared to primary education.

The association of socioeconomic status with cardiovascular morbidity and mortality is well known, but data on the influence of education level on mortality in individuals with atrial fibrillation (AF) are scarce. We investigated education level as a predictor of all-cause mortality in patients diagnosed with AF. This retrospective cohort study used a database created from several Swedish nationwide registries to identify all patients hospitalized with a diagnosis of AF hospitalized from 1995 to 2008. Education level was categorized as primary, secondary, and academic. All-cause mortality risk was estimated in subpopulations defined by the Charlson Comorbidity Index and several comorbidities. A total of 272,182 patients (56% male; mean age 72 ± 10 years) were followed for five years. Cox regression models showed a reduction in all-cause mortality risk with increased education level. Hazard ratios (HR) relative to primary education remained significant after stratification and adjustment for several confounders: secondary education HR = 0.88; 95% CI: 0.86-0.89; P < 0.001; academic education HR = 0.70; 95% CI: 0.67-0.72; P < 0.001. Subpopulation analyses confirmed a significant reduction in relative risk with higher education level. Targeted screening and education programs could be effective in reducing mortality in AF patients with fewer years of formal education.

Introduction:

The association between social status and cardiovascular morbidity and mortality is well–known. Education level is an important socioeconomic factor which influences the incidence, symptoms, and treatments of atrial fibrillation (AF). However, data about the effects of education level on all-cause mortality in patients with AF are scarce.

Aim:

To explore any association between education level and all-cause mortality in patients hospitalized with AF.

Methods:

This retrospective cohort study is based on a database created by linking Swedish nationwide registries including all patients hospitalized with an AF diagnosis between 1995 and 2003. In all, 158 577 patients were included in the study (56% male and 44% female; mean age 72 ± 11 years). The follow-up was 5 years with an observation time of 636 597 person–years. Education level was described by 3 categories representing primary, secondary, and academic education. Kaplan-Meier curves and Cox proportional hazard models adjusted with age, sex, time of index hospitalization, categorized Charlson´s Comorbidity Index (CCI) score, and CHA2DS2-VASc score were used for statistical analysis. Hazard ratio (HR) with 95% confidence interval (CI) was used as estimate of association and P < 0.05 was regarded as statistically significant. The risk of all-cause mortality was estimated in subpopulations defined by mortality risk factors as CCI, CHA2DS2-VASc score, heart failure, coronary artery disease, chronic obstructive pulmonary disease, diabetes, chronic kidney disease, and cancer.

Results:

Patients with academic education had the lowest all–cause mortality, which was seen early during follow–up. Compared to patients with primary education, those with secondary or academic education showed lower relative mortality risk in the adjusted Cox regression model (secondary education HR: 0.875, 95% CI: 0.86 – 0.89, p<0.001; academic education HR: 0.695, 95% CI: 0.67 – 0.72; p<0.001). Among the subpopulations, the HR varied between 0.72 and 0.95 for secondary and between 0.43 and 0.79 for academic education respectively. All risk differences were statistically significant.

Conclusion:

Academic education was associated with the lowest and primary education with the highest risk of all-cause mortality. This pattern was consistent through all analyzed subpopulations.

BACKGROUND: Atrial fibrillation (AF) is a rapidly increasing global public health concern entailing a high risk for ischemic stroke that can largely be avoided with anticoagulation therapy. AF is often underdiagnosed and there is a need for a reliable method of detection in individuals with additional risk factors for stroke such as coronary artery disease. We aimed to validate an automatic rhythm interpretation algorithm in thumb ECG in subjects with recent coronary revascularization.

METHODS: Thumb ECG, a patient-operated handheld single-lead ECG recording device with an automatic interpretation algorithm, was performed three times daily for a month after coronary revascularization and 2-week periods 3, 12, and 24 months post-procedure. The detection of AF by the automatic algorithm on subject and single-strip ECG level was compared to manual interpretation.

RESULTS: 48,308 of 30 s thumb ECG recordings from 255 subjects (mean 212 ± 3.5 recordings per subject) were retrieved from a database (AF 47 subjects/655 recordings; non-AF 208 subjects/47,653 recordings). The algorithm sensitivity at subject level was 100%, specificity 11.2%, positive predictive value (PPV) 20.2%, and negative predictive value (NPV) 100%. At the single-strip ECG level, sensitivity was 87.6%, specificity 94.0%, PPV 16.8%, and NPV 99.8%. The most common reasons for false positive results were technical disturbance and frequent ectopic beats.

CONCLUSIONS: The automatic interpretation algorithm in a handheld thumb ECG device can rule out AF in patients recently undergoing coronary revascularization with high accuracy, but manual confirmation is needed to confirm the diagnose of AF because of high false positive rates.

Background: The incidence of atrial fibrillation (AF) has long been increasing, and AF is associated with increased mortality. Over time, mortality trends may differ between subgroups depending on their underlying risk patterns and treatments.

Aim: To explore all-cause-mortality trends over time in patients hospitalized for incident AF, and the effects of age, stroke risk, and education level.

Methods and results: Patients hospitalized for incident AF between January 1995 and December 2003 were selected from Swedish national registries. Based on date of index admission, patients were divided into four cohorts and followed for five years. Age- and sex-matched controls were selected. Kaplan-Meier estimates and Cox regressions with trend analysis were used for statistical evaluation. There were 64,489 patients (mean age 72 +/- 10.1 years) and 116,893 controls. There was a significantly decreasing trend in the relative risk of all-cause mortality in AF patients over time, with a trend hazard ratio of 0.94 (95 % confidence interval [CI] 0.92-0.96, p < 0.001) in women and 0.91 (95 % CI 0.89-0.93, p < 0.001) in men. The mortality trends did not differ significantly between AF patients and controls. The mortality risk remained unchanged in women aged 18-64 years, in patients with low stroke risk, and in patients with post-secondary education.

Conclusion: The all-cause mortality risk decreased over time in both patients and controls, but subgroup analysis revealed an unchanged mortality trend in women aged 18-64 years, in patients with low stroke risk, and in patients with post-secondary education.

Objectives: To evaluate the correlation of a' velocity by tissue-Doppler measurements with invasively measured mean left atrial pressure in patients with normal ejection fraction.

Design: In this retrospective study, we evaluated the septal a', lateral a' and average a' velocity by tissue-Doppler echocardiography, in 125 in-hospital patients, 1-12 h before an elective pulmonary vein isolation due to intermittent atrial fibrillation, and compared to invasively measured mean left atrial pressure (LAP) during the invasive procedure. The patients, aged 35-81 years, had to be in sinus rhythm at both examinations, no atrial fibrillation during two procedures, no or mild valve disease and normal ejection fraction (>50%).

Results: Invasively measured mean LAP correlated well to septal a' (r = -0.435), lateral a' (r = -0.473) and average a' velocity (r = -0.491). Normal mean LAP (<= 12 mmHg) was found in 95 patients and elevated mean LAP (>12 mmHg) in 30 patients. The patients with elevated mean LAP had a lower septal a' velocity (6.5 +/- 2.7 vs 8.6 +/- 2.3 cm/s; p < .01), lateral a' velocity (5.9 +/- 2.3 vs 8.6 +/- 2.1 cm/s; p < .01) and average a' velocity (6.2 +/- 2.4 vs 8.8 +/- 2.1 cm/s; p < .01) compared to patients with normal mean LAP. Septal a', lateral a' and average a' velocity were good predictors of elevated mean LAP with AUC of 0.78, 0.83 and 0.82. Average a' velocity with cut-off < 7.25 cm/s had a sensitivity of 83% and a specificity of 77% to predict elevated mean LAP.

Conclusion: The a' velocity is a good indicator of mean LAP and might be considered in the evaluation of left ventricle filling pressure in patients with normal ejection fraction.

Introduction: Atrial fibrillation (AF) is the most common arrythmia. Both its incidence and prevalence increased significantly during the last decades. AF is associated with high morbidity and mortality.

Purpose: The aim of this study was to describe and evaluate the trends of all-cause mortality in patients first-ever hospitalized for AF, and the effect of age, sex, stroke risk, and education level on mortality over time.

Methods: In this observational retrospective cohort study, we enrolled the patients who were hospitalized primarily and for the first time because of AF between 1st January 1995 and 31st December 2004. In regard to the date of the index admission patients were divided into four cohorts and they were followed up to five years. Patients were compared with an age and sex matched control population. All data were collected from Swedish national registries. Kaplan-Meier plots and Cox regression with trend analysis were used for statistical evaluation.

Results: In total 64 489 AF patients (mean age 72±10.1 year) were included in this study. The control group comprised 116 893 individuals. 81.9% of the women and 58.5% of the men were older than 65 years of age. 65.5% of women and 58.5% of the men had a stroke risk of CHADS2-VA2Sc ≥2.

We found a significantly decreasing trend of the relative risk for all-cause mortality in AF patients over time: trend HR: 0.94 (95% CI: 0.92–0.96, p<0.001) in women and trend HR: 0.91 (95% CI: 0.89–0.93 p<0.001) in men. The mortality trends between AF patients and their controls did not show significant difference: trend HR: 0.99 (95% CI: 0.96–1.02, p=0.59) in women and trend HR: 1.00 (95% CI: 0.97–1.03, p=0.98) in men. The subpopulation analysis showed that the mortality risk remained unchanged over the time in women aged 18–69 years (trend HR: 0.91 – 95% CI: 0.82–1.02, p=0.099), in patients with low stroke risk (trend HR: 1.08 – 95% CI: 0.92–1.26, p=0.36 in women and trend HR: 0.95 – 95% CI: 0.87–1.05, p=0.30 in men) and in patients with post-secondary level of education (trend HR: 0.93 – 95% CI 0.83–1.04, p=0.23 in women and trend HR: 1.04 – 95% CI: 0.96–1.12, p=0.32 in men).

Conclusion: The all-cause mortality risk of the AF hospitalized patients was higher compared to control population and had a decreasing tendency during the time of the study. However, this trend is not significantly different from the control population. We found unchanged mortality trend in younger patients, in those with lower stroke risk, and in patients with higher education level.