Zak Loring1, Peter Shrader2, Larry A Allen3, Rosalia Blanco2, Paul S Chan4, Michael D Ezekowitz5, Gregg C Fonarow6, James V Freeman7, Bernard J Gersh8, Kenneth W Mahaffey9, Gerald V Naccarelli10, Karen Pieper2, James A Reiffel11, Daniel E Singer12, Benjamin A Steinberg13, Laine E Thomas2, Eric D Peterson14, Jonathan P Piccini14. 1. Division of Cardiology, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC. Electronic address: zak.loring@duke.edu. 2. Duke Clinical Research Institute, Durham, NC. 3. Division of Cardiology, University of Colorado School of Medicine, Aurora, CO. 4. Department of Cardiovascular Research, St Luke's Mid America Institute, Kansas City, MO. 5. Lankenau Institute for Medical Research, Wynnewood, PA. 6. Department of Medicine, University of California, Los Angeles, CA. 7. Department of Medicine, Yale University School of Medicine, New Haven, CT. 8. Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN. 9. Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA. 10. School of Medicine, Penn State University, Hershey, PA. 11. Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY. 12. Harvard Medical School and Massachusetts General Hospital, Boston, MA. 13. University of Utah, Salt Lake City, UT. 14. Division of Cardiology, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC.
Abstract
BACKGROUND: Comorbidities are common in patients with atrial fibrillation (AF) and affect prognosis, yet are often undertreated. However, contemporary rates of use of guideline-directed therapies (GDT) for non-AF comorbidities and their association with outcomes are not well described. METHODS: We used the Outcomes Registry for Better Informed Treatment of AF (ORBIT-AF) to test the association between GDT for non-AF comorbidities and major adverse cardiac or neurovascular events (MACNE; cardiovascular death, myocardial infarction, stroke/thromboembolism, or new-onset heart failure), all-cause mortality, new-onset heart failure, and AF progression. Adjustment was performed using Cox proportional hazards models and logistic regression. RESULTS: Only 6,782 (33%) of the 20,434 patients eligible for 1 or more GDT for non-AF comorbidities received all indicated therapies. Use of all comorbidity-specific GDT was highest for patients with hyperlipidemia (75.6%) and lowest for those with diabetes mellitus (43.1%). Use of "all eligible" GDT was associated with a nonsignificant trend toward lower rates of MACNE (HR 0.90 [0.79-1.02]) and all-cause mortality (HR 0.90 [0.80-1.01]). Use of GDT for heart failure was associated with a lower risk of all-cause mortality (HR 0.77 [0.67-0.89]), and treatment of obstructive sleep apnea was associated with a lower risk of AF progression (OR 0.75 [0.62-0.90]). CONCLUSIONS: In AF patients, there is underuse of GDT for non-AF comorbidities. The association between GDT use and outcomes was strongest in heart failure and obstructive sleep apnea patients where use of GDT was associated with lower mortality and less AF progression.
BACKGROUND: Comorbidities are common in patients with atrial fibrillation (AF) and affect prognosis, yet are often undertreated. However, contemporary rates of use of guideline-directed therapies (GDT) for non-AF comorbidities and their association with outcomes are not well described. METHODS: We used the Outcomes Registry for Better Informed Treatment of AF (ORBIT-AF) to test the association between GDT for non-AF comorbidities and major adverse cardiac or neurovascular events (MACNE; cardiovascular death, myocardial infarction, stroke/thromboembolism, or new-onset heart failure), all-cause mortality, new-onset heart failure, and AF progression. Adjustment was performed using Cox proportional hazards models and logistic regression. RESULTS: Only 6,782 (33%) of the 20,434 patients eligible for 1 or more GDT for non-AF comorbidities received all indicated therapies. Use of all comorbidity-specific GDT was highest for patients with hyperlipidemia (75.6%) and lowest for those with diabetes mellitus (43.1%). Use of "all eligible" GDT was associated with a nonsignificant trend toward lower rates of MACNE (HR 0.90 [0.79-1.02]) and all-cause mortality (HR 0.90 [0.80-1.01]). Use of GDT for heart failure was associated with a lower risk of all-cause mortality (HR 0.77 [0.67-0.89]), and treatment of obstructive sleep apnea was associated with a lower risk of AF progression (OR 0.75 [0.62-0.90]). CONCLUSIONS: In AFpatients, there is underuse of GDT for non-AF comorbidities. The association between GDT use and outcomes was strongest in heart failure and obstructive sleep apneapatients where use of GDT was associated with lower mortality and less AF progression.
Authors: Faiez Zannad; John J V McMurray; Henry Krum; Dirk J van Veldhuisen; Karl Swedberg; Harry Shi; John Vincent; Stuart J Pocock; Bertram Pitt Journal: N Engl J Med Date: 2010-11-14 Impact factor: 91.245
Authors: Sana M Al-Khatib; Anne S Hellkamp; Adrian F Hernandez; Gregg C Fonarow; Kevin L Thomas; Hussein R Al-Khalidi; Paul A Heidenreich; Stephen Hammill; Clyde Yancy; Eric D Peterson Journal: Circulation Date: 2012-01-27 Impact factor: 29.690
Authors: Benjamin A Steinberg; Rosalia G Blanco; Donna Ollis; Sunghee Kim; DaJuanicia N Holmes; Peter R Kowey; Gregg C Fonarow; Jack Ansell; Bernard Gersh; Alan S Go; Elaine Hylek; Kenneth W Mahaffey; Laine Thomas; Paul Chang; Eric D Peterson; Jonathan P Piccini Journal: Am Heart J Date: 2014-04-18 Impact factor: 4.749
Authors: Stephan D Fihn; Julius M Gardin; Jonathan Abrams; Kathleen Berra; James C Blankenship; Apostolos P Dallas; Pamela S Douglas; Joanne M Foody; Thomas C Gerber; Alan L Hinderliter; Spencer B King; Paul D Kligfield; Harlan M Krumholz; Raymond Y K Kwong; Michael J Lim; Jane A Linderbaum; Michael J Mack; Mark A Munger; Richard L Prager; Joseph F Sabik; Leslee J Shaw; Joanna D Sikkema; Craig R Smith; Sidney C Smith; John A Spertus; Sankey V Williams Journal: J Am Coll Cardiol Date: 2012-11-19 Impact factor: 24.094
Authors: Matthew Nayor; Danielle M Enserro; Vanessa Xanthakis; Martin G Larson; Emelia J Benjamin; Jayashri Aragam; Gary F Mitchell; Ramachandran S Vasan Journal: JACC Heart Fail Date: 2018-03-07 Impact factor: 12.035
Authors: Rajeev K Pathak; Melissa E Middeldorp; Dennis H Lau; Abhinav B Mehta; Rajiv Mahajan; Darragh Twomey; Muayad Alasady; Lorraine Hanley; Nicholas A Antic; R Doug McEvoy; Jonathan M Kalman; Walter P Abhayaratna; Prashanthan Sanders Journal: J Am Coll Cardiol Date: 2014-11-24 Impact factor: 24.094
Authors: Ravi Kanagala; Narayana S Murali; Paul A Friedman; Naser M Ammash; Bernard J Gersh; Karla V Ballman; Abu S M Shamsuzzaman; Virend K Somers Journal: Circulation Date: 2003-05-12 Impact factor: 29.690
Authors: Anand N Ganesan; Derek P Chew; Trent Hartshorne; Joseph B Selvanayagam; Philip E Aylward; Prashanthan Sanders; Andrew D McGavigan Journal: Eur Heart J Date: 2016-02-16 Impact factor: 29.983
Authors: Fredrik Holmqvist; Sunghee Kim; Benjamin A Steinberg; James A Reiffel; Kenneth W Mahaffey; Bernard J Gersh; Gregg C Fonarow; Gerald V Naccarelli; Paul Chang; James V Freeman; Peter R Kowey; Laine Thomas; Eric D Peterson; Jonathan P Piccini Journal: Heart Date: 2015-03-02 Impact factor: 5.994