Edouard Simeon

Prognosis in Patients Hospitalized With Permanent and Nonpermanent Atrial Fibrillation in Heart Failure

Atrial fibrillation (AF) and heart failure (HF) frequently coexist and are associated with an increased mortality. This study evaluated the prognosis of permanent and nonpermanent AF in patients with both AF and HF. All AF patients seen in our institution were identified and followed up. We included 1,906 patients suffering from AF and HF: 839 patients (44%) had preserved left ventricular ejection fraction (LVEF) and 1,067 patients (56%) had decreased LVEF; 1,056 patients (55%) had nonpermanent AF and 850 patients (45%) had permanent AF. During a median follow-up of 1.9 years (interquartile range 0.3 to 5.0), 377 patients died, 462 were readmitted for HF, and 200 had stroke or thromboembolic events. In patients with decreased LVEF, the rate of death was similar in patients with permanent or nonpermanent AF. In patients with preserved LVEF, permanent AF was associated with a higher risk of death and a higher risk of HF hospitalization. Stroke risk did not differ with permanent AF whatever the LVEF. NYHA functional class was an independent predictor of death (risk ratio [RR]=1.33, 95% confidence interval [CI] 1.12 to 1.59, p=0.001), as was permanent AF (RR=1.79, 95%CI 1.32 to 2.42, p=0.0002). Permanent AF (RR=1.52, 95% CI 1.20 to 1.93, p=0.0006) was also an independent predictor of readmission for HF. In conclusion, in patients with AF and HF, the risk of admission for HF and risk of death were higher when AF was permanent, particularly in patients with preserved LVEF. Stroke risk did not differ according to the pattern of AF, whatever the LVEF.

History of Thyroid Disorders in Relation to Clinical Outcomes in Atrial Fibrillation

BACKGROUND Atrial fibrillation is the most common cardiac complication of hyperthyroidism. The association between history of hyperthyroidism and stroke remains unclear. We sought to determine whether history of thyroid dysfunction is a thromboembolic risk factor in patients with atrial fibrillation. METHODS Patients with atrial fibrillation seen in an academic institution between 2000 and 2010 were identified and followed-up. Clinical events (stroke/systemic embolism, bleeding, all-cause death) were recorded and related to thyroid status and disorders. Associations were examined in time-dependent models with adjustment for relevant confounders. RESULTS Among 8962 patients, 141 patients had a history of hyperthyroidism, 540 had a history of hypothyroidism, and 8271 had no thyroid dysfunction. Mean follow-up was 929 ± 1082 days. A total of 715 strokes/systemic embolism were recorded, with no significant difference in the rates of these events in patients with a history of thyroid dysfunction vs those without thyroid problems in either univariate or multivariable analysis (hazard ratio [HR] 0.85; 95% confidence interval [CI], 0.41-1.76 for hyperthyroidism; HR 0.98; 95% CI, 0.73-1.34 for hypothyroidism). There were 791 bleeding events; history of hypothyroidism was independently related to a higher rate of bleeding events (HR 1.35; 95% CI, 1.02-1.79). No significant difference among the 3 groups was observed for the incidence of death. CONCLUSIONS History of hyperthyroidism was not an independent risk factor for stroke/systemic embolism in atrial fibrillation, whereas hypothyroidism was associated with a higher risk of bleeding events. These data suggest no additional benefit from the inclusion of thyroid dysfunction in thromboembolic prediction models in atrial fibrillation.

THYROID DISORDERS AND OUTCOMES IN PATIENTS WITH ATRIAL FIBRILLATION IN A COHORT STUDY

Atrial fibrillation (AF) is the most common cardiac complication of hyperthyroidism. The association between hyperthyroidism and stroke remains unclear. Our aims were to determine if thyroid dysfunction and especially hyperthyroidism was a thromboembolic risk factor among AF patients with

0370: Effect of smoking on comparative efficacy of antithrombotic therapy in patients with atrial fibrillation. A community based cohort study

Smoking is incorporated in a simple score (SAMe-TT2R2) that can predict poor INR control in patients with atrial fibrillation (AF) treated with vitamin K antagonists (VKA). Moreover, the clinical benefit of clopidogrel in reducing myocardial infarction and stroke in randomized clinical trials of antiplatelet drugs (APD) was seen primarily in smokers, with little benefit in nonsmokers. We made the hypothesis that active smoking may differently influence 1) the risk of stroke and 2) the risk of bleeding in AF patients treated with VKA or with APD. Methods We examined the clinical course of 7.948 consecutive patients with AF and/or atrial flutter seen between 2000-2010. The outcomes in patients with active smoking were compared with those in other patients. Results Among 7.948 patients with AF (age 71±15 years), 1034 (13%) had active smoking. APD was prescribed on an individual basis for 2761 patients (35%) and VKA for 4534 (57%). During a follow-up of 929±1082 days, 631 strokes/thromboembolic events, 707 severe bleedings and 248 major BARC bleedings were recorded. Smoking was not independently associated with a higher risk of stroke in these AF patients (relative risk=0.94, 95% CI 0.75-1.18, p=0.62). By contrast, after adjustment on age, CHADS2 score, HASBLED bleeding risk score, VKA use and APD use, smoking was independently associated with a worse prognosis for the risk of severe bleeding (relative risk=1.23, 95% CI 1,02- 1,50, p=0.03) and for the risk of major BARC bleeding (relative risk=1.40, 95% CI 1.03-1.91, p=0.03). Smoking was independently associated with a higher risk of bleeding in patients treated with VKA (relative risk= 1.32, 95% CI 1.04-1.66. p=0.02) whilst this association did not reach significance in patients treated with APD (relative risk=1.31, 95% CI 0.97-1.76. p=0.07). Conclusion In AF, there was a higher risk of bleeding in smokers, mainly in those treated with VKA

Antiplatelet therapy strategies after percutaneous coronary intervention in patients needing oral anticoagulation

Long-term oral anticoagulant (OAC) and dual-antiplatelet therapy are commonly needed in patients with atrial fibrillation and in patients undergoing percutaneous coronary intervention (PCI), respectively. The combination of atrial fibrillation and PCI is frequent, and leads to a dilemma for antithrombotic therapy, where risk of stroke or stent thrombosis must be balanced with bleeding risk. In the WOEST study, 573 patients on OAC undergoing PCI were randomly assigned to receive clopidogrel alone or clopidogrel plus aspirin. The primary end point was the occurrence of any bleeding episode during 1-year follow-up. Clopidogrel alone administered to patients taking OAC after PCI was associated with a significantly lower rate of bleeding complications than clopidogrel plus aspirin. Moreover, a composite secondary end point of death, myocardial infarction and stent thrombosis was significantly lower in the dual-therapy group compared with the triple-therapy group. In spite of its limitations, the WOEST study constitutes a major breakthrough, showing that long-term aspirin after PCI may be obsolete in certain circumstances. This needs to be confirmed in further studies.