Alan S Go1,2,3, Kristi Reynolds4, Jingrong Yang1, Nigel Gupta5, Judith Lenane6, Sue Hee Sung1, Teresa N Harrison4, Taylor I Liu7, Matthew D Solomon1,8. 1. Division of Research, Kaiser Permanente Northern California, Oakland. 2. Departments of Epidemiology, Biostatistics and Medicine, University of California-San Francisco, San Francisco. 3. Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California. 4. Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena. 5. Department of Cardiac Electrophysiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California. 6. iRhythm Technologies Inc, San Francisco, California. 7. Department of Cardiac Electrophysiology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California. 8. Department of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, California.
Abstract
Importance: Atrial fibrillation is a potent risk factor for stroke, but whether the burden of atrial fibrillation in patients with paroxysmal atrial fibrillation independently influences the risk of thromboembolism remains controversial. Objective: To determine if the burden of atrial fibrillation characterized using noninvasive, continuous ambulatory monitoring is associated with the risk of ischemic stroke or arterial thromboembolism in adults with paroxysmal atrial fibrillation. Design, Setting, and Participants: This retrospective cohort study conducted from October 2011 and October 2016 at 2 large integrated health care delivery systems used an extended continuous cardiac monitoring system to identify adults who were found to have paroxysmal atrial fibrillation on 14-day continuous ambulatory electrocardiographic monitoring. Exposures: The burden of atrial fibrillation was defined as the percentage of analyzable wear time in atrial fibrillation or flutter during the up to 14-day monitoring period. Main Outcomes and Measures: Ischemic stroke and other arterial thromboembolic events occurring while patients were not taking anticoagulation were identified through November 2016 using electronic medical records and were validated by manual review. We evaluated the association of the burden of atrial fibrillation with thromboembolism while not taking anticoagulation after adjusting for the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) or CHA2DS2-VASc stroke risk scores. Results: Among 1965 adults with paroxysmal atrial fibrillation, the mean (SD) age was 69 (11.8) years, 880 (45%) were women, 496 (25%) were persons of color, the median ATRIA stroke risk score was 4 (interquartile range [IQR], 2-7), and the median CHA2DS2-VASc score was 3 (IQR, 1-4). The median burden of atrial fibrillation was 4.4% (IQR ,1.1%-17.23%). Patients with a higher burden of atrial fibrillation were less likely to be women or of Hispanic ethnicity, but had more prior cardioversion attempts compared with those who had a lower burden. After adjusting for either ATRIA or CHA2DS2-VASc stroke risk scores, the highest tertile of atrial fibrillation burden (≥11.4%) was associated with a more than 3-fold higher adjusted rate of thromboembolism while not taking anticoagulants (adjusted hazard ratios, 3.13 [95% CI, 1.50-6.56] and 3.16 [95% CI, 1.51-6.62], respectively) compared with the combined lower 2 tertiles of atrial fibrillation burden. Results were consistent across demographic and clinical subgroups. Conclusions and Relevance: A greater burden of atrial fibrillation is associated with a higher risk of ischemic stroke independent of known stroke risk factors in adults with paroxysmal atrial fibrillation.
Importance: Atrial fibrillation is a potent risk factor for stroke, but whether the burden of atrial fibrillation in patients with paroxysmal atrial fibrillation independently influences the risk of thromboembolism remains controversial. Objective: To determine if the burden of atrial fibrillation characterized using noninvasive, continuous ambulatory monitoring is associated with the risk of ischemic stroke or arterial thromboembolism in adults with paroxysmal atrial fibrillation. Design, Setting, and Participants: This retrospective cohort study conducted from October 2011 and October 2016 at 2 large integrated health care delivery systems used an extended continuous cardiac monitoring system to identify adults who were found to have paroxysmal atrial fibrillation on 14-day continuous ambulatory electrocardiographic monitoring. Exposures: The burden of atrial fibrillation was defined as the percentage of analyzable wear time in atrial fibrillation or flutter during the up to 14-day monitoring period. Main Outcomes and Measures: Ischemic stroke and other arterial thromboembolic events occurring while patients were not taking anticoagulation were identified through November 2016 using electronic medical records and were validated by manual review. We evaluated the association of the burden of atrial fibrillation with thromboembolism while not taking anticoagulation after adjusting for the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) or CHA2DS2-VASc stroke risk scores. Results: Among 1965 adults with paroxysmal atrial fibrillation, the mean (SD) age was 69 (11.8) years, 880 (45%) were women, 496 (25%) were persons of color, the median ATRIA stroke risk score was 4 (interquartile range [IQR], 2-7), and the median CHA2DS2-VASc score was 3 (IQR, 1-4). The median burden of atrial fibrillation was 4.4% (IQR ,1.1%-17.23%). Patients with a higher burden of atrial fibrillation were less likely to be women or of Hispanic ethnicity, but had more prior cardioversion attempts compared with those who had a lower burden. After adjusting for either ATRIA or CHA2DS2-VASc stroke risk scores, the highest tertile of atrial fibrillation burden (≥11.4%) was associated with a more than 3-fold higher adjusted rate of thromboembolism while not taking anticoagulants (adjusted hazard ratios, 3.13 [95% CI, 1.50-6.56] and 3.16 [95% CI, 1.51-6.62], respectively) compared with the combined lower 2 tertiles of atrial fibrillation burden. Results were consistent across demographic and clinical subgroups. Conclusions and Relevance: A greater burden of atrial fibrillation is associated with a higher risk of ischemic stroke independent of known stroke risk factors in adults with paroxysmal atrial fibrillation.
Authors: Yoko Miyasaka; Marion E Barnes; Bernard J Gersh; Stephen S Cha; Kent R Bailey; Walter P Abhayaratna; James B Seward; Teresa S M Tsang Journal: Circulation Date: 2006-07-03 Impact factor: 29.690
Authors: Craig T January; L Samuel Wann; Joseph S Alpert; Hugh Calkins; Joaquin E Cigarroa; Joseph C Cleveland; Jamie B Conti; Patrick T Ellinor; Michael D Ezekowitz; Michael E Field; Katherine T Murray; Ralph L Sacco; William G Stevenson; Patrick J Tchou; Cynthia M Tracy; Clyde W Yancy Journal: J Am Coll Cardiol Date: 2014-03-28 Impact factor: 24.094
Authors: Susan Colilla; Ann Crow; William Petkun; Daniel E Singer; Teresa Simon; Xianchen Liu Journal: Am J Cardiol Date: 2013-07-04 Impact factor: 2.778
Authors: Taya V Glotzer; Emile G Daoud; D George Wyse; Daniel E Singer; Michael D Ezekowitz; Christopher Hilker; Clayton Miller; Dongfeng Qi; Paul D Ziegler Journal: Circ Arrhythm Electrophysiol Date: 2009-08-04
Authors: Andrew S Levey; Lesley A Stevens; Christopher H Schmid; Yaping Lucy Zhang; Alejandro F Castro; Harold I Feldman; John W Kusek; Paul Eggers; Frederick Van Lente; Tom Greene; Josef Coresh Journal: Ann Intern Med Date: 2009-05-05 Impact factor: 25.391
Authors: Taya V Glotzer; Emile G Daoud; D George Wyse; Daniel E Singer; Reece Holbrook; Khadeeja Pruett; Kenneth Smith; Christopher E Hilker Journal: J Interv Card Electrophysiol Date: 2006-01 Impact factor: 1.759
Authors: Nesan Shanmugam; Annegret Boerdlein; Jochen Proff; Peter Ong; Oswaldo Valencia; Sebastian K G Maier; Wolfgang R Bauer; Vince Paul; Stefan Sack Journal: Europace Date: 2011-09-20 Impact factor: 5.214
Authors: Giuseppe Boriani; Taya V Glotzer; Massimo Santini; Teena M West; Mirko De Melis; Milan Sepsi; Maurizio Gasparini; Thorsten Lewalter; John A Camm; Daniel E Singer Journal: Eur Heart J Date: 2013-12-11 Impact factor: 29.983
Authors: Nathan E Wineinger; Paddy M Barrett; Yunyue Zhang; Ikram Irfanullah; Evan D Muse; Steven R Steinhubl; Eric J Topol Journal: Heart Rhythm Date: 2018-08-14 Impact factor: 6.343
Authors: Sana M Al-Khatib; Emelia J Benjamin; Alfred E Buxton; Hugh Calkins; Mina K Chung; Anne B Curtis; Patrice Desvigne-Nickens; Pierre Jais; Douglas L Packer; Jonathan P Piccini; Yves Rosenberg; Andrea M Russo; Paul J Wang; Lawton S Cooper; Alan S Go Journal: Circulation Date: 2019-11-20 Impact factor: 29.690
Authors: Niraj Varma; Iwona Cygankiewicz; Mintu P Turakhia; Hein Heidbuchel; Yu-Feng Hu; Lin Yee Chen; Jean-Philippe Couderc; Edmond M Cronin; Jerry D Estep; Lars Grieten; Deirdre A Lane; Reena Mehra; Alex Page; Rod Passman; Jonathan P Piccini; Ewa Piotrowicz; Ryszard Piotrowicz; Pyotr G Platonov; Antonio Luiz Ribeiro; Robert E Rich; Andrea M Russo; David Slotwiner; Jonathan S Steinberg; Emma Svennberg Journal: Circ Arrhythm Electrophysiol Date: 2021-02-12
Authors: Aakash A Bavishi; Rachel M Kaplan; Graham Peigh; Celso L Diaz; Jayson R Baman; Amar Trivedi; Jeremiah Wasserlauf; Mark J Shen; Prasongchai Sattayaprasert; Alexandru B Chicos; Susan Kim; Nishant Verma; Rishi Arora; Albert Lin; Bradley P Knight; Rod S Passman Journal: Pacing Clin Electrophysiol Date: 2019-04-09 Impact factor: 1.976
Authors: Stavros Stavrakis; Julie A Stoner; Mary Beth Humphrey; Lynsie Morris; Adrian Filiberti; Justin C Reynolds; Khaled Elkholey; Isma Javed; Nicholas Twidale; Pavel Riha; Subha Varahan; Benjamin J Scherlag; Warren M Jackman; Tarun W Dasari; Sunny S Po Journal: JACC Clin Electrophysiol Date: 2020-01-29
Authors: Emelia J Benjamin; Alan S Go; Patrice Desvigne-Nickens; Christopher D Anderson; Barbara Casadei; Lin Y Chen; Harry J G M Crijns; Ben Freedman; Mellanie True Hills; Jeff S Healey; Hooman Kamel; Dong-Yun Kim; Mark S Link; Renato D Lopes; Steven A Lubitz; David D McManus; Peter A Noseworthy; Marco V Perez; Jonathan P Piccini; Renate B Schnabel; Daniel E Singer; Robert G Tieleman; Mintu P Turakhia; Isabelle C Van Gelder; Lawton S Cooper; Sana M Al-Khatib Journal: Circulation Date: 2021-01-25 Impact factor: 29.690
Authors: Jonathan Kim; Wendy Wang; Faye L Norby; Michael Zhang; Alvaro Alonso; Pamela L Lutsey; Elsayed Z Soliman; Julian Wolfson; Lin Y Chen Journal: J Electrocardiol Date: 2020-10-30 Impact factor: 1.438