Catheter ablation versus medical therapy for atrial fibrillation with prior stroke history:a prospective propensity score-matched cohort study

BACKGROUND Patients with atrial fibrillation(AF)and prior stroke history have a high risk of cardiovascular events despite anticoagulation therapy.It is unclear whether catheter ablation(CA)has further benefits in these patients.METHODS AF patients with a previous history of stroke or systemic embolism(SE)from the prospective Chinese Atrial Fibrillation Registry study between August 2011 and December 2020 were included in the analysis.Patients were matched in a 1:1 ratio to CA or medical treatment(MT)based on propensity score.The primary outcome was a composite of all-cause death or ischemic stroke(IS)/SE.RESULTS During a total of 4.1±2.3 years of follow-up,the primary outcome occurred in 111 patients in the CA group(3.3 per 100 person-years)and in 229 patients in the MT group(5.7 per 100 person-years).The CA group had a lower risk of the primary outcome compared to the MT group[hazard ratio(HR)=0.59,95%CI:0.47–0.74,P<0.001].There was a significant decreasing risk of all-cause mortality(HR=0.43,95%CI:0.31–0.61,P<0.001),IS/SE(HR=0.73,95%CI:0.54–0.97,P=0.033),cardiovascular mortality(HR=0.32,95%CI:0.19–0.54,P<0.001)and AF recurrence(HR=0.33,95%CI:0.30–0.37,P<0.001)in the CA group compared to that in the MT group.Sensitivity analysis generated consistent results when adjusting for time-dependent usage of anticoagulants.CONCLUSIONS In AF patients with a prior stroke history,CA was associated with a lower combined risk of all-cause death or IS/SE.Further clinical trials are warranted to confirm the benefits of CA in these patients.

Catheter ablation for atrial fibrillation is associated with reduced risk of mortality in the elderly:a prospective cohort study and propensity score analysis

Background It is unclear whether catheter ablation(CA)for atrial fibrillation(AF)affects the long-term prognosis in the elderly.This study aims to evaluate the relationship between CA and long-term outcomes in elderly patients with AF.Methods Patients more than 75 years old with non-valvular AF were prospectively enrolled between August 2011 and December 2017 in the Chinese Atrial Fibrillation Registry Study.Participants who underwent CA at baseline were propensity score matched(1:1)with those who did not receive CA.The outcome events included all-cause mortality,cardiovascular mortality,stroke/transient ischemic attack(TIA),and cardiovascular hospitalization.Results Overall,this cohort included 571 ablated patients and 571 non-ablated patients with similar characteristics on 18 dimensions.During a mean follow-up of 39.75±19.98 months(minimum six months),24 patients died in the ablation group,compared with 60 deaths in the non-ablation group[hazard ratio(HR)=0.49,95%confidence interval(CI):0.30-0.79,P=0.0024].Besides,6 ablated and 29 non-ablated subjects died of cardiovascular disease(HR=0.25,95%CI:0.11-0.61,P=0.0022).A total of 27 ablated and 40 non-ablated patients suffered stroke/TIA(HR=0.79,95%CI:0.48-1.28,P=0.3431).In addition,140 ablated and 194 non-ablated participants suffered cardiovascular hospitalization(HR=0.84,95%CI:0.67-1.04,P=0.1084).Subgroup analyses according to gender,type of AF,time since onset of AF,and anticoagulants exposure in initiation did not show significant heterogeneity.Conclusions In elderly patients with AF,CA may be associated with a lower incidence of all-cause and cardiovascular mortality.

Chronic kidney disease and risks of adverse clinical events in patients with atrial fibrillation

BACKGROUND Chronic kidney disease(CKD)is highly prevalent in patients with atrial fibrillation(AF).However,the asso-ciation between CKD and clinical consequences in AF patients is still under debate.METHODS We included 19,079 nonvalvular AF patients with available estimated glomerular filtration rate(eGFR)values in the Chinese Atrial Fibrillation Registry from 2011 to 2018.Patients were classified into no CKD(eGFR≥90 mL/min per 1.73 m2),mild CKD(60≤eGFR<90 mL/min per 1.73 m2),moderate CKD(30≤eGFR<60 mL/min per 1.73 m2),and severe CKD(eGFR<30 mL/min per 1.73 m2)groups.The risks of thromboembolism,major bleeding,and cardiovascular mortality were estimated with Fine-Gray regression analysis according to CKD status.Cox regression was performed to assess the risk of all-cause mortal-ity associated with CKD.RESULTS Over a mean follow-up of 4.1±1.9 years,there were 985 thromboembolic events,414 major bleeding events,956 car-diovascular deaths,and 1,786 all-cause deaths.After multivariate adjustment,CKD was not an independent risk factor of throm-boembolic events.As compared to patients with no CKD,those with mild CKD,moderate CKD,and severe CKD had a 45%,47%,and 133%higher risk of major bleeding,respectively.There was a graded increased risk of cardiovascular mortality associated with CKD status compared with no CKD group:adjusted hazard ratio[HR]was 1.34(95%CI:1.07−1.68,P=0.011)for mild CKD group,2.17(95%CI:1.67−2.81,P<0.0001)for moderate CKD group,and 2.95(95%CI:1.97−4.41,P<0.0001)for severe CKD group,respectively.Risk of all-cause mortality also increased among patients with moderate or severe CKD.CONCLUSIONS CKD status was independently associated with progressively higher risks of major bleeding and mortality,but didn’t seem to be an independent predictor of thromboembolism in AF patients.

A simple and easily implemented risk model to predict 1-year ischemic stroke and systemic embolism in Chinese patients with atrial fibrillation

Background:Accurate prediction of ischemic stroke is required for deciding anticoagulation use in patients with atrial fibrillation(AF).Even though only 6%to 8%of AF patients die from stroke,about 90%are indicated for anticoagulants according to the current AF management guidelines.Therefore,we aimed to develop an accurate and easy-to-use new risk model for 1-year thromboembolic events(TEs)in Chinese AF patients.Methods:From the prospective China Atrial Fibrillation Registry cohort study,we identified 6601 AF patients who were not treated with anticoagulation or ablation at baseline.We selected the most important variables by the extreme gradient boosting(XGBoost)algorithm and developed a simplified risk model for predicting 1-year TEs.The novel risk score was internally validated using bootstrapping with 1000 replicates and compared with the CHA2DS2-VA score(excluding female sex from the CHA2DS2-VASc score).Results:Up to the follow-up of 1 year,163 TEs(ischemic stroke or systemic embolism)occurred.Using the XGBoost algorithm,we selected the three most important variables(congestive heart failure or left ventricular dysfunction,age,and prior stroke,abbreviated as CAS model)to predict 1-year TE risk.We trained a multivariate Cox regression model and assigned point scores proportional to model coefficients.The CAS scheme classified 30.8%(2033/6601)of the patients as low risk for TE(CAS score=0),with a corresponding 1-year TE risk of 0.81%(95%confidence interval[CI]:0.41%–1.19%).In our cohort,the C-statistic of CAS model was 0.69(95%CI:0.65–0.73),higher than that of CHA2DS2-VA score(0.66,95%CI:0.62–0.70,Z=2.01,P=0.045).The overall net reclassification improvement from CHA2DS2-VA categories(low=0/high≥1)to CAS categories(low=0/high≥1)was 12.2%(95%CI:8.7%–15.7%).Conclusion:In Chinese AF patients,a novel and simple CAS risk model better predicted 1-year TEs than the widely-used CHA2DS2-VA risk score and identified a large proportion of patients with low risk of TEs,which could potentially improve anticoagulation decision-making.Trial Registration:www.chictr.org.cn(Unique identifier No.ChiCTR-OCH-13003729).

Whether Warfarin Therapy is Associated with Damage on Renal Function in Chinese Patients with Nonvalvular Atrial Fibrillation

Background： Warfarin is the most common oral anticoagulant to decrease the stroke risk associated with atrial fibrillation （AF）. There are very few prospective studies that have explored whether warfarin has an association with damage on renal function in Chinese patients with nonvalvular AF （NVAF）. The aim of this study was to evaluate the effects of warfarin on renal function and study the factors associated with kidney dysfunction in Chinese adult NVAF patients without dialysis therapy. Methods： From January 2011 to December 2013, a total of 951 NVAF patients from 18 hospitals were enrolled. The estimated glomerular filtration rate （eGFR） was calculated from baseline and fbllow-up serum creatinine levels. Kaplan-Meier survival curves compared the survival of a 〉25% decline in eGFR （hereafter, endpoint）~ while Cox models estimated hazard ratios （HRs） and 95% confidence intervals for this event after adjustment for age, gender, and selected potential risk factors for renal dysfunction. Cox regression analysis of the various clinical potential variables was performed to identify the predictors of a -〉25% decline in eGFR. Results： After a 58-month follow-up, 951 NVAF patients were divided by observation into warfarin （n = 655） and no anticoagulation groups （n = 296） and 120 （12.6%） patients experienced renal endpoint. Kaplan-Meier survival curves showed that the survival period was not different in the two groups （χ2 = 0.178, log-rank P = 0.67）, but patients with systolic blood pressure （SBP） 〈140 mmHg have significant difference with patients with SBP ≥140 mmHg （χ2 = 4.903, log-rank P = 0.03）. Multivariate Cox regression analysis revealed baseline eGFR and SBP as independent predictors of the endpoint, with HRs of 1.00, and 1.02, respectively. Conclusion： In patients with NVAF, eGFR and SBP are associated with the deterioration of kidney function while Warfarin is not the risk factor of the ≥25% decline in eGFR.