Gender Differences in the Risk of Ischemic Stroke and Peripheral Embolism in Atrial Fibrillation: The AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA) Study Increased risk of first-ever stroke in younger patients with atrial fibrillation not recommended for antithrombotic therapy by current guidelines: a population-based study in an East Asian cohort of 22 million people. Dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation: NICE guidance Focused 2012 update of the Canadian Cardiovascular Society atrial fibrillation guidelines: recommendations for stroke prevention and rate/rhythm control. Gender differences in stroke risk of atrial fibrillation patients on oral anticoagulant treatment. Factors associated with ischemic stroke during aspirin therapy in atrial fibrillation: analysis of 2012 participants in the SPAF I-III clinical trials. The Stroke Prevention in Atrial Fibrillation (SPAF) Investigators. Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation cohort study. Patients with nonvalvular atrial fibrillation at low risk of stroke during treatment with aspirin: Stroke Prevention in Atrial Fibrillation III Study. The SPAF III Writing Committee for the Stroke Prevention in Atrial Fibrillation Investigators. Thromboembolism prophylaxis in chronic atrial fibrillation. Practice patterns in community and tertiary-care hospitals. Atrial Fibrillation Is a Major Risk Factor for Stroke, Especially in Women: The Jichi Medical School Cohort Study A risk score for predicting stroke or death in individuals with new-onset atrial fibrillation in the community: the Framingham Heart Study. Stroke with intermittent atrial fibrillation: incidence and predictors during aspirin therapy. Stroke Prevention in Atrial Fibrillation Investigators. Relation of Nonvalvular Atrial Fibrillation to Body Mass Index (from the SPORTIF Trials). A randomised controlled trial and cost effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in the over 65s: (SAFE) [ISRCTN19633732] Assessment of the CHA2DS2-VASc Score in Predicting Ischemic Stroke, Thromboembolism, and Death in Patients With Heart Failure With and Without Atrial Fibrillation. Pathophysiologic correlates of thromboembolism in nonvalvular atrial fibrillation: I. Reduced flow velocity in the left atrial appendage (The Stroke Prevention in Atrial Fibrillation [SPAF-III] study). Long-term cardiovascular outcomes in patients with atrial fibrillation and atherothrombosis in the REACH Registry. Higher risk of death and stroke in patients with persistent vs. paroxysmal atrial fibrillation: results from the ROCKET-AF Trial Prevalence of atrial fibrillation and eligibility for anticoagulants in the community Screening for atrial fibrillation in the community: a multicenter validation trial. Factors affecting bleeding risk during anticoagulant therapy in patients with atrial fibrillation: observations from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. Impact of gender on the prognosis of patients with nonvalvular atrial fibrillation. Prevalence, clinical profile, and cardiovascular outcomes of atrial fibrillation patients with atherothrombosis.
Background —Previous studies provide conflicting results about whether women are at higher risk than men for thromboembolism in the setting of atrial fibrillation ( AF ) . We examined data from a large contemporary cohort of AF patients to address this question . Methods and Results —We prospect ively studied 13 559 adults with AF and recorded data on patients ’ clinical characteristics and the occurrence of incident hospitalizations for ischemic stroke , peripheral embolism , and major hemorrhagic events through search ing vali date d computerized data bases and medical record review . We compared event rates by patient sex using multivariable log-linear regression , adjusting for clinical risk factors for stroke , and stratifying by warfarin use . We identified 394  ischemic stroke and peripheral embolic events during 15 494 person-years of follow-up off warfarin . After multivariable analysis , women had higher annual rates of thromboembolism off warfarin than did men ( 3.5 % versus 1.8 % ; adjusted rate ratio [ RR ] , 1.6 ; 95 % CI , 1.3 to 1.9 ) . There was no significant difference by sex in 30-day mortality after thromboembolism ( 23 % for both ) . Warfarin use was associated with significantly lower adjusted thromboembolism rates for both women and men ( RR , 0.4 ; 95 % CI , 0.3 to 0.5 ; and RR , 0.6 ; 95 % CI , 0.5 to 0.8 , respectively ) , with similar annual rates of major hemorrhage ( 1.0 % and 1.1 % , respectively ) . Conclusions —Women are at higher risk than men for AF-related thromboembolism off warfarin . Warfarin therapy appears be as effective in women , if not more so , than in men , with similar rates of major hemorrhage . Female sex is an independent risk factor for thromboembolism and should influence the decision to use anticoagulant therapy in persons with AF OBJECTIVE To assess the risk of first-ever ischemic stroke in younger patients with atrial fibrillation ( AF ) who have none of the CHA2DS2-VASc ( congestive heart failure , hypertension , age ≥75 years , diabetes mellitus , previous stroke/transient ischemic attack , vascular disease , age 65 - 74 years , sex category [ female sex ] ) risk factors ( excluding female sex ) by using the National Health Insurance research data base in Taiwan . PATIENTS AND METHODS From 22,842,778 insured people , we identified 24,612 hospitalized patients with newly diagnosed AF between January 1 , 2002 , and December 31 , 2004 , as the AF group and r and omly selected 98,448 age- and sex-matched persons without AF as the non-AF group . Both groups were followed up until December 31 , 2010 , to estimate ischemic stroke incidences in relation to other stroke risk factors . RESULTS During a follow-up period of 89,468 person-years , the stroke rate was higher in patients with AF than in those without AF ( 5.79 per 100 person-years vs 2.25 per 100 person-years ) . The higher prevalence of CHA2DS2-VASc comorbidities ( heart failure , hypertension , diabetes , coronary artery disease , and peripheral artery disease ) in patients with AF further increased the stroke risk . In 790 patients with AF aged 30 to 55 years who had none of the CHA2DS2-VASc comorbidities at baseline and retained a " low risk , " that is , those with a CHA2DS2-VASc score of 0 in men and 1 in women during follow-up , the stroke rate remained considerably higher than that in their non-AF counterparts ( 1.00 per 100 person-years vs 0.25 per 100 person-years ) , with a sex-adjusted hazard ratio of 4.09 ( 95 % CI , 2.97 - 5.62 ) . CONCLUSION This study finds an increased risk of stroke in younger patients with AF who are not recommended for prevention of thromboembolism by current guidelines . Better stroke risk stratification tools are needed to prioritize younger patients with AF for thromboprophylactic therapy in this population Atrial fibrillation ( AF ) is the commonest sustained cardiac arrhythmia , whose importance has been realised given its strong association with stroke and systemic embolism that can be significantly reduced by oral anticoagulation . Until recently , the only oral anticoagulant ( OAC ) available was the vitamin K antagonist ( VKA ) class of drugs — for example , warfarin . Indeed , warfarin provides highly effective prophylaxis against thromboembolism as shown by extensive evidence from r and omised controlled trials , but its effectiveness is dependent upon good anticoagulation control ( as reflected by its high length of time in the therapeutic range).1 The risk of stroke in AF is not homogeneous , and depends upon the presence or absence of several risk factors . These risk factors have been used to formulate stroke risk stratification schemes , so that the focus has been to identify ‘ high-risk ’ patients who could be targeted for this ‘ inconvenient ’ drug , warfarin . The numerous practical limitations which affect a clinician 's willingness to prescribe warfarin , and a patient 's willingness to comply with it ( box 1 ) , have result ed in large numbers of high-risk patients either unprotected against stroke or suboptimally protected with antiplatelet therapy2—despite evidence that aspirin is less effective for stroke prevention and is not without its own bleeding risk , especially in the elderly.3 Box 1 # # # Limitations of warfarin The limitations of warfarin have driven efforts to establish new OACs which can circumvent the shortcomings of the VKAs . The new OACs fall into two classes : the oral direct thrombin inhibitors ( eg , dabigatran ) and the oral factor Xa inhibitors ( eg . rivaroxaban , apixaban).4 The National Institute for Health The Canadian Cardiovascular Society ( CCS ) published the complete set of 2010 Atrial Fibrillation ( AF ) Guidelines in the January , 2011 issue of the Canadian Journal of Cardiology . During its deliberations , the CCS Guidelines Committee engaged to a timely review of future evidence , with periodic composition of focused up date s to address clinical ly important advances . In 2011 , results were published from 3 pivotal AF trials : the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonist for Prevention of Stroke and Embolism Trial in Atrial Fibrillation ( ROCKET-AF ) , the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation ( ARISTOTLE ) study , and the Permanent Atrial Fibrillation Outcome Study Using Dronedarone on Top of St and ard Therapy ( PALLAS ) , comparing dronedarone with placebo in patients with permanent AF and additional cardiovascular disease risk-factor burden . Each of these large r and omized trials provided clear results with major implication s for AF management . Other important evidence that has emerged since the 2010 Guidelines includes findings about prediction instruments for AF-associated stroke and bleeding risk , stroke risk in paroxysmal-AF patients , risk-benefit considerations related to oral anticoagulation in patients with chronic kidney disease , and risk/benefit considerations in the use of antiplatelet agents , alone and in combination with each other or with oral anticoagulants , in AF patients . The Guidelines Committee judged that this extensive and important new evidence required focused updating of the 2010 Guidelines with respect to stroke prevention and rate/rhythm control . This report presents the details of the new recommendations , along with the background and rationale The efficacy of adjusted-dose oral anticoagulant treatment ( OAT ) in the prevention of stroke in atrial fibrillation ( AF ) is well documented . Available data show that AF patients are widely heterogeneous in terms of ischaemic stroke risk . The role of female gender as a predictor of stroke risk is inconsistent , in particular it is unclear if warfarin treatment is able to prevent stroke equally in both sexes . We performed a prospect i ve study on 780 AF patients on OAT , followed by an Anticoagulation Clinic , to evaluate if female gender is a risk factor for stroke among patients on OAT  and if the quality of anticoagulation is different between genders . No difference was found in relation to the quality of anticoagulation between genders ( p=0.5 ) . During follow-up 33 patients had major bleedings ( rate 1.37 x 100 pt/yrs ) but no difference was found between genders in bleeding risk . Forty patients had ischaemic events [ rate 1.66 x 100 pt/yrs ; males rate 1.2 x 100 pt/yrs ; females rate 2.43 x 100 pt/yrs ; p=0.042 ; relative risk ( RR ) of females vs. males 2.0 ( 95 % confidence interval [ CI ] 1.3 - 3.1 ) ; p= 0.004 ] . The higher rate of ischaemic events in females with respect to males was confirmed at Cox regression analysis after correction for age ( p=0.009 ) . In addition , strokes occurring in females were more disabling , and RR for severe and fatal stroke , defined according to Modified Rankin scale , of females vs. males was 3.1 ( 95 % CI 1.3 - 6.5 ; p=0.001 ) . In conclusion , our data show a higher risk of stroke in anticoagulated AF females with respect to males , despite a similar quality of anticoagulation BACKGROUND AND PURPOSE Nonvalvular atrial fibrillation ( AF ) is a strong , independent risk factor for stroke , but the absolute rate of stroke varies widely among AF patients , importantly influencing the potential benefit of antithrombotic prophylaxis . We explore factors associated with ischemic stroke in AF patients taking aspirin .  METHODS We performed multivariate logistic regression analysis of 2012 participants given aspirin alone or in combination with low , inefficacious doses of warfarin in the Stroke Prevention in Atrial Fibrillation I-III trials followed for a mean of 2.0 years , during which 130 ischemic strokes were observed . RESULTS Age ( relative risk [RR]=1.8 per decade , P<0.001 ) , female sex ( RR=1.6 , P=0.01 ) , history of hypertension ( RR=2.0 , P<0.001 ) , systolic blood pressure > 160 mm Hg ( RR=2.3 , P<0.001 ) , and prior stroke or transient ischemic attack ( RR=2.9 , P<0.001 ) were independently associated with increased stroke risk . Regular consumption of > /=14 alcohol-containing drinks per week was associated with reduced stroke risk ( adjusted RR=0.4 , P=0.04 ) . Among SPAF III participants , estrogen hormone replacement therapy was associated with a higher risk of ischemic stroke ( adjusted RR=3.2 , P=0.007 ) . With the use of these variables , a risk stratification scheme for primary prevention separated participants into those with high ( 7.1%/y , 22 % of the cohort ) , moderate ( 2.6%/y , 37 % of the cohort ) , and low ( 0.9%/y , 41 % of the cohort ) rates of stroke . Ischemic strokes in low-risk participants were less often disabling ( P<0.001 ) . CONCLUSIONS Patients with AF who have high and low rates of stroke during treatment with  aspirin can be identified . However , validation of our risk stratification scheme is necessary before it can be applied with confidence to clinical management . Postmenopausal estrogen replacement therapy and moderate alcohol consumption may additionally modify the risk of stroke in AF , but these findings require confirmation AIMS The impact of some risk factors for stroke and bleeding , and the value of stroke and bleeding risk scores , in atrial fibrillation ( AF ) , has been debated , as clinical trial cohorts have not adequately tested these . Our objective was to investigate risk factors for stroke and bleeding in AF , and application of the new CHA(2)DS(2)-VASc and HAS-BLED schemes for stroke and bleeding risk assessment s , respectively . METHODS AND RESULTS We used the Swedish Atrial Fibrillation cohort study , a nationwide cohort study of 182 678 subjects with a diagnosis of AF at any Swedish hospital between 1 July 2005 and 31 December 2008 , who were prospect ively followed for an average of 1.5 years ( 260 000 years at risk ) . With the use of the National Swedish Drug Registry , all patients who used an oral anticoagulant  anytime during follow-up were identified . Most of the analyses were made on a subset of 90 490 patients who never used anticoagulants .  Risk factors for stroke , the composite thromboembolism endpoint ( stroke , TIA , or systemic embolism ) , and bleeding , and the performance of published stroke and bleeding risk stratification schemes were investigated . On multivariable analysis , significant associations were found between the following ' new ' risk factors and thromboembolic events ; peripheral artery disease [ hazard ratio ( HR ) 1.22 ( 95 % CI 1.12 - 1.32 ) ] , ' vascular disease ' [ HR 1.14 ( 1.06 - 1.23 ) ] , prior myocardial infa rct ion [ HR 1.09 ( 1.03 - 1.15 ) ] , and female gender [ HR 1.17 ( 1.11 - 1.22 ) ] . Previous embolic events , intracranial haemorrhage ( ICH ) , hypertension , diabetes , and renal failure were other independent predictors of the composite thromboembolism endpoint , while thyroid disease ( or hyperthyroidism ) was not an independent stroke risk factor . C-statistics for the composite thromboembolic endpoint with the CHADS(2 ) and CHA(2)DS(2)-VASc schemes were 0.66 ( 0.65 - 0.66 ) and 0.67 ( 0.67 - 0.68 ) , respectively . On multivariable analysis , age , prior ischaemic stroke or thromboembolism , prior major bleeding events , and hypertension were significant predictors of ICH and major bleeding . Heart failure , diabetes , renal failure , liver disease , anaemia or platelet/coagulation defect , alcohol abuse , and cancer were other significant predictors for major bleeding , but not ICH . The ability for predicting ICH and major bleeding with both bleeding risk schemes ( HEMORR(2)HAGES , HAS-BLED ) were similar , with c-statistics of ~0.6 . CONCLUSION Several independent risk factors ( prior ICH , myocardial infa rct ion , vascular disease , and renal failure ) predict ischaemic stroke and /or the composite thromboembolism endpoint in AF , but thyroid disease ( or hyperthyroidism ) was not an independent risk factor for stroke . There is a better performance for CHA(2)DS(2)-VASc over CHADS(2 ) schemes for the composite thromboembolism endpoint . While both tested bleeding risk schemes have similar predictive value , the HAS-BLED score has the advantage of simplicity CONTEXT Nonvalvular atrial fibrillation ( AF ) carries an increased risk for stroke , but absolute rates of stroke vary widely within the broad spectrum of AF patients . OBJECTIVE To prospect ively vali date a risk stratification scheme identifying patients with AF with low rates of stroke when given aspirin .  DESIGN Prospect i ve cohort study with mean duration of follow-up of 2.0 years , conducted between 1993 and 1997 . SETTING Outpatient clinics affiliated with academic medical centers . PATIENTS Patients with AF categorized as " low risk " based on the absence of 4 prespecified thromboembolic risk factors : recent congestive heart failure or left ventricular fractional shortening of 25 % or less , previous thromboembolism , systolic blood pressure greater than 160 mm Hg , or female sex at age older than 75 years . INTERVENTION All participants given aspirin , 325 mg/d . MAIN OUTCOME MEASURES Ischemic stroke ( considered disabling when Rankin score was II or worse 1 - 3 months later ) and systemic embolism ( primary events ) . RESULTS Among 892 participants , the mean ( SD ) age was 67 ( 10 ) years , 78 % were men , and histories of hypertension , diabetes , and ischemic heart disease were present in 46 % , 13 % , and 16 % , respectively . The rate of primary events was 2.2 % per year ( 95 % confidence interval [ CI ] , 1.6%-3.0 % ) , of ischemic stroke was 2.0 % per year ( 95 % CI , 1.5%-2.8 % ) , and of disabling ischemic strokes was 0.8 % per year ( 95 % CI , 0.5%-1.3 % ) . Those with a history of hypertension had a higher rate of primary events ( 3.6 % per year ) than those with no history of hypertension ( 1.1 % per year ) ( P<.001 ) . The rate of disabling ischemic stroke was low in those with and without a history of hypertension ( 1.4 % per year and 0.5 % per year , respectively ) . The rate of major bleeding during aspirin therapy was 0.5 % per year . CONCLUSION Patients with AF who have relatively low rates of ischemic stroke , particularly disabling stroke , during treatment with aspirin can be reliably identified BACKGROUND AND PURPOSE By 1992 , several prospect i ve trials established the efficacy of anticoagulation ( AC ) and to some extent antiplatelet ( AP ) agents in the prevention of stroke in the setting of atrial fibrillation ( AF ) . The objective of this study was to determine whether practice patterns in AF stroke prophylaxis reflect the findings of clinical trials and whether stroke prophylaxis in AF differs between community hospitals and tertiary teaching hospitals . METHODS Retrospectively , 1250 hospital charts were review ed . After patients who had undergone recent surgery , received treatment for malignancy , or were not in chronic AF on discharge were eliminated , 651 remaining records were analyzed for the presence of 26 clinical factors influencing the selection of thromboembolism prophylaxis . Descriptive statistics and logistic regression were used to analyze the association between clinical and demographic factors and the decision to treat with AC , AP , or no specific antiembolic therapy . RESULTS Of the 651 patients in AF , 273 ( 42 % ) received noemboli prophylaxis while 219 ( 34 % ) were treated with AC ( warfarin ) , 146 ( 22 % ) were treated with AP , and 13 ( 2 % ) received both agents .  Patients discharged in AF from community hospitals were significantly less likely to be treated with either AC or AP agents than patients discharged from tertiary centers . A strong bias against thromboembolism prophylaxis with either AC or AP agents in AF existed with age over 45 years . Multivariate logistic regression indicated that the decision to treat was associated only with the presence of prosthetic valve , history of prior stroke , mitral disease , and absence of a recent gastrointestinal bleed or occult blood in stool . Even after adjustment for these factors , a significant bias against treatment with either AC or AP agents with advancing age and discharge from community hospitals remained . CONCLUSIONS Thromboembolism prophylaxis with either AC or AP agents is underutilized in the setting of AF . Furthermore , factors known to increase the risk of embolization in AF such as age , hypertension , diabetes , and heart disease were not associated with decisions to treat with either AP or AC agents . This study suggests that the use of clinical guidelines suggested by trials of thromboembolism prophylaxis in AF could reduce the incidence of stroke Background Only a few population -based cohort studies have investigated the impact of  atrial fibrillation ( AF ) on stroke in Japan . Methods A total of 10 929 participants ( 4147 men and 6782 women ) were included in this population -based prospect i ve cohort study . Baseline data , including  electrocardiograms ( ECGs )  to ascertain AF status , were obtained from April 1992 through July 1995 in 12 areas in Japan . Cox proportional hazards models were used to analyze the association of AF with stroke . Results A total of 54 participants had AF ( 0.49 % ) . The mean follow-up period was 10.7 years , during which 405 strokes were identified ; 12 of these occurred in participants with AF . The crude incidence of stroke in participants with and without AF was 14.9 and 4.5 per 1000 person-years in men , respectively , and 39.3 and 2.7 per 1000 person-years in women . After adjusting for geographical area , sex , age , smoking status , drinking status , obesity , hypertension , dyslipidemia , and diabetes mellitus , the hazard ratios ( 95 % confidence interval ) of AF in all participants and in male and female participants were 4.11 ( 2.28–7.41 ) , 2.12 ( 0.77–5.84 ) , and 10.6 ( 5.01–22.4 ) , respectively . The population attributable fraction ( PAF ) of stroke caused by AF was 2.2 % ; the PAFs were 1.0 % and 3.6 % in men and women , respectively . Conclusions The present Japanese population -based prospect i ve cohort study showed that AF is a major risk factor for stroke , especially in women CONTEXT Prior risk stratification schemes for atrial fibrillation ( AF ) have been based on r and omized trial cohorts or Medicare administrative data bases , have included patients with established AF , and have focused on stroke as the principal outcome . OBJECTIVE To derive risk scores for stroke alone and stroke or death in community-based individuals with new-onset AF . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve , community-based , observational cohort in Framingham , Mass. We identified 868 participants with new-onset AF , 705 of whom were not treated with warfarin at baseline . Risk scores for stroke ( ischemic or hemorrhagic ) and stroke or death were developed with censoring when warfarin initiation occurred during follow-up . Event rates were examined in low-risk individuals , as defined by the risk score and 4 previously published risk schemes . MAIN OUTCOME MEASURES Stroke and the combination of stroke or death . RESULTS During a mean follow-up of 4.0 years free of warfarin use , stroke alone occurred in 83 participants and stroke or death occurred in 382 participants . A risk score for stroke was derived that included the following risk predictors : advancing age , female sex , increasing systolic blood pressure , prior stroke or transient ischemic attack , and diabetes . With the risk score , 14.3 % of the cohort had a predicted 5-year stroke rate < or = 7.5 % ( average annual rate < or = 1.5 % ) , and 30.6 % of the cohort had a predicted 5-year stroke rate < or = 10 % ( average annual rate < or = 2 % ) . Actual stroke rates in these low-risk groups were 1.1 and 1.5 per 100 person-years , respectively . Previous risk schemes classified 6.4 % to 17.3 % of subjects as low risk , with actual stroke rates of 0.9 to 2.3 per 100 person-years . A risk score for stroke or death is also presented . CONCLUSION These risk scores can be used to estimate the absolute risk of an adverse event in individuals with AF , which may be helpful in counseling patients and making treatment decisions OBJECTIVE This study was performed to characterize the risk of stroke in elderly patients with recurrent intermittent atrial fibrillation ( AF ) . BACKGROUND Although intermittent AF is common , relatively little is known about the attendant risk of stroke . METHODS A longitudinal cohort study was performed comparing 460 participants with intermittent AF with 1,552 with sustained AF treated with aspirin in the Stroke Prevention in Atrial Fibrillation studies and followed for a mean of two years . Independent risk factors for ischemic stroke were identified by multivariate analysis . RESULTS Patients with intermittent AF were , on average , younger ( 66 vs. 70 years , p < 0.001 ) , were more often women ( 37 % vs. 26 % p < 0.001 ) and less often had heart failure ( 11 % vs. 21 % , p < 0.001 ) than those with sustained AF . The annualized rate of ischemic stroke was similar for those with intermittent ( 3.2 % ) and sustained AF ( 3.3 % ) . In patients with intermittent AF , independent predictors of ischemic stroke were advancing age ( relative risk [ RR ] = 2.1 per decade , p < 0.001 ) , hypertension ( RR = 3.4 , p = 0.003 ) and prior stroke ( RR = 4.1 , p = 0.01 ) . Of those with intermittent AF predicted to be high risk ( 24 % ) , the observed stroke rate was 7.8 % per year ( 95 % confidence interval 4.5 to 14 ) . CONCLUSIONS In this large cohort of AF patients given aspirin , those with intermittent AF had stroke rates similar to patients with sustained AF and similar stroke risk factors . Many elderly patients with recurrent intermittent AF have substantial rates of stroke and likely benefit from anticoagulation . High-risk patients with intermittent AF can be identified using the same clinical criteria that apply to patients with sustained AF Obesity is well-established as a major cardiovascular ( CV ) risk factor . Obesity confers a greater risk for developing atrial fibrillation ( AF ) , but the relation between obesity and established nonvalvular AF for stroke and all-cause death is still unclear . To ascertain the prevalence of overweight and obesity in patients with nonvalvular AF , their influence on adverse events , and the relation with anticoagulation control , we performed this post hoc analysis of the pooled Stroke Prevention using an Oral Thrombin Inhibitor in patients with atrial Fibrillation ( SPORTIF ) III and V data sets . For this study , we analyzed all patients assigned to the warfarin arm with data on body mass index ( BMI ) . Time in therapeutic range was used as an index of the quality of anticoagulation control . The 3,630 patients eligible for this analysis were categorized as follows : ( 1 ) BMI 18.5 to 24.9 ( " normal weight " ) in 24.1 % ; ( 2 ) BMI 25.0 to 29.9 ( " overweight " ) in 39.8 % ; and BMI ≥30 ( " obese " ) in 36.1 % . Both overweight ( hazard ratio [ HR ] 0.70 ) and obese ( HR 0.59 ) categories were inversely associated with the composite outcome of stroke/all-cause death . A similar inverse association was seen for the end point of stroke ( HR 0.61 and 0.47 , respectively ) . Good anticoagulation control also attenuated the association between BMI categories and outcomes . In patients with time in therapeutic range > 70 % , BMI category was not significantly associated with the composite outcome of stroke/death and stroke . Stroke and all-cause death progressively reduced in overweight and obese anticoagulated patients with AF . The inverse relation of BMI categories to the risk of stroke and all-cause death was mitigated by good anticoagulation control Background Atrial fibrillation ( AF ) has been recognised as an important independent risk factor for thromboembolic disease , particularly stroke for which it provides a five-fold increase in risk . This study aim ed to determine the baseline prevalence and the incidence of AF based on a variety of screening strategies and in doing so to evaluate the incremental cost-effectiveness of different screening strategies , including targeted or whole population screening , compared with routine clinical practice , for detection of AF in people aged 65 and over . The value of clinical assessment and echocardiography as additional methods of risk stratification for thromboembolic disease in patients with AF were also evaluated . Methods The study design was a multi-centre r and omised controlled trial with a study population of patients aged 65 and over from 50 General Practice s in the West Midl and s. These purpose fully selected general practice s were r and omly allocated to 25 intervention practice s and 25 control practice s. GPs and practice nurses within the intervention practice s received education on the importance of AF detection and ECG interpretation . Patients in the intervention practice s were r and omly allocated to systematic ( n = 5000 ) or opportunistic screening ( n = 5000 ) . Prospect i ve identification of pre-existing risk factors for AF within the screened population enabled comparison between high risk targeted screening and total population screening . AF detection rates in systematic ally screened and opportunistically screened population s in the intervention practice s were compared to AF detection rate in 5,000 patients in the control practice IMPORTANCE The CHA2DS2-VASc score ( congestive heart failure , hypertension , age ≥75 years [ doubled ] , diabetes , stroke/transient ischemic attack/thromboembolism [ doubled ] , vascular disease [ prior myocardial infa rct ion , peripheral artery disease , or aortic plaque ] , age 65 - 75 years , sex category [ female ] ) is used clinical ly for stroke risk stratification in atrial fibrillation ( AF ) . Its usefulness in a population of patients with heart failure ( HF ) is unclear . OBJECTIVE To investigate whether CHA2DS2-VASc predicts ischemic stroke , thromboembolism , and death in a cohort of patients with HF with and without AF . DESIGN , SETTING , AND POPULATION Nationwide prospect i ve cohort study using Danish registries , including 42 987 patients ( 21.9 % with concomitant AF ) not receiving anticoagulation who were diagnosed as having incident HF during 2000 - 2012 . End of follow-up was December 31 , 2012 . EXPOSURES Levels of the CHA2DS2-VASc score ( based on 10 possible points , with higher scores indicating higher risk ) , stratified by concomitant AF at baseline . Analyses took into account the competing risk of death . MAIN OUTCOMES AND MEASURES Ischemic stroke , thromboembolism , and death within 1 year after HF diagnosis . RESULTS In patients without AF , the risks of ischemic stroke , thromboembolism , and death were 3.1 % ( n = 977 ) , 9.9 % ( n = 3187 ) , and 21.8 % ( n = 6956 ) , respectively ; risks were greater with increasing CHA2DS2-VASc scores as follows , for scores of 1 through 6 , respectively : ( 1 ) ischemic stroke with concomitant AF : 4.5 % , 3.7 % , 3.2 % , 4.3 % , 5.6 % , and 8.4 % ; without concomitant AF : 1.5 % , 1.5 % , 2.0 % , 3.0 % , 3.7 % , and 7 % and ( 2 ) all-cause death with concomitant AF : 19.8 % , 19.5 % , 26.1 % , 35.1 % , 37.7 % , and 45.5 % ; without concomitant AF : 7.6 % , 8.3 % , 17.8 % , 25.6 % , 27.9 % , and 35.0 % . At high CHA2DS2-VASc scores ( ≥4 ) , the absolute risk of thromboembolism was high regardless of presence of AF ( for a score of 4 , 9.7 % vs 8.2 % for patients without and with concomitant AF , respectively ; overall P<.001 for interaction ) . C statistics and negative predictive values indicate that the CHA2DS2-VASc score performed modestly in this HF population with and without AF ( for ischemic stroke , 1-year C statistics , 0.67 [ 95 % CI , 0.65 - 0.68 ] and 0.64 [ 95 % CI , 0.61 - 0.67 ] , respectively ; 1-year negative predictive values , 92 % [ 95 % CI , 91%-93 % ] and 91 % [ 95 % CI , 88%-95 % ] , respectively ) . CONCLUSIONS AND RELEVANCE Among patients with incident HF with or without AF , the CHA2DS2-VASc score was associated with risk of ischemic stroke , thromboembolism , and death . The absolute risk of thromboembolic complications was higher among patients without AF compared with patients with concomitant AF at high CHA2DS2-VASc scores . However , predictive accuracy was modest , and the clinical utility of the CHA2DS2-VASc score in patients with HF remains to be determined Stroke associated with atrial fibrillation ( AF ) is mainly due to embolism of thrombus formed during stasis of blood in the left atrial appendage ( LAA ) . Pathophysiologic correlates of appendage flow velocity as assessed by transesophageal echocardiography ( TEE ) in patients with AF have not been defined . To evaluate the hypothesis that reduced velocity is associated with spontaneous echocardiographic contrast and thrombus in the LAA and with clinical embolic events , we measured LAA flow velocity by TEE in 721 patients with nonvalvular AF entering the Stroke Prevention in Atrial Fibrillation ( SPAF-III ) study . Patient features , TEE findings , and subsequent cardioembolic events were correlated with velocity by multivariate analysis . Patients in AF during TEE displayed lower peak ante grade ( emptying ) flow velocity ( Anu(p ) ) than those with intermittent AF in sinus rhythm during TEE ( 33 cm/s vs 61 cm/s , respectively , P < .0001 ) . Anu(p ) < 20 cm/s was associated with dense spontaneous echocardiographic contrast ( P < .001 ) , appendage thrombus ( P < .01 ) , and subsequent cardioembolic events ( P < .01 ) . Independent predictors of Anu(p ) < 20 cm/s included age ( P = .009 ) , systolic blood pressure ( P < .001 ) , sustained AF ( P = .01 ) , ischemic heart disease ( P = .01 ) , and left atrial area ( P = .04 ) . Multivariate analysis found both Anu(p ) < 20 cm/s ( relative risk 2.6 , P = .02 ) and clinical risk factors ( relative risk 3.3 , P = .002 ) independently associated with LAA thrombus . LAA Anu(p ) is reduced in AF and associated with spontaneous echocardiographic contrast , appendage thrombus , and cardioembolic stroke . Systolic hypertension and aortic atherosclerosis , independent clinical predictors of stroke in patients with AF , also correlated with LAA Anu(p ) . Our results support the role of reduced LAA Anu(p ) in the generation of stasis , thrombus formation , and embolism in patients with AF , although other mechanisms also contribute to stroke BACKGROUND Patients with atrial fibrillation ( AF )  are at increased risk of thromboembolic events . The long-term prognostic implication s of AF in patients with atherothrombosis are unknown . METHODS We compared 4-year CV outcomes in patients with and without a history of AF recorded at their baseline visit in the REACH Registry , an international , prospect i ve cohort of patients with established atherosclerotic arterial disease ( CAD , CVD , PAD ) or at least 3 risk factors ( RFO ) . RESULTS AF status and 4 year follow-up data were available on 44,518 patients . The prevalence of AF at baseline was 10.3 % ( n=4582 ) . Overall , patients with AF had approximately a 2-fold increase in the composite of CV death , MI , or stroke compared with patients without AF after adjustment for age , gender , prior ischemic event , vascular disease , congestive heart failure , diabetes , smoking , body mass index , region , aspirin and statin use ( 18.9 % vs. 9.4 % , p<0.0001 ) . This increased risk was observed both in patients with established atherothrombosis ( CAD : 15.5 % vs. 8.0 % , p=0.0001 ; CVD : 23.6 % vs. 13.6 % , p<0.0001 ; PAD : 24.3 % vs. 13.5 % , p=0.089 ) and those with multiple risk factors ( RFO : 12.1 % vs. 5.9 % , p=0.017 ) . Only 52 % of patients with a history of AF at baseline were receiving anticoagulation at 4 years . CONCLUSIONS Patients with a history of both AF and atherothrombosis have particularly high long-term CV risk . Despite this increased risk , almost half of all patients with AF do not receive guideline recommended anticoagulation , highlighting an important public health priority Aim Anticoagulation prophylaxis for stroke is recommended for at-risk patients with either persistent or paroxysmal atrial fibrillation ( AF ) . We compared outcomes in patients with persistent vs. paroxysmal AF receiving oral anticoagulation . Methods and results Patients r and omized in the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation ( ROCKET-AF ) trial ( n = 14 264 ) were grouped by baseline AF category : paroxysmal or persistent . Multivariable adjustment was performed to compare thrombo-embolic events , bleeding , and death between groups , in high-risk subgroups , and across treatment assignment ( rivaroxaban or warfarin ) . Of 14 062 patients , 11 548 ( 82 % ) had persistent AF and 2514 ( 18 % ) had paroxysmal AF . Patients with persistent AF were marginally older ( 73 vs. 72 , P = 0.03 ) , less likely female ( 39 vs. 45 % , P < 0.0001 ) , and more likely to have previously used vitamin K antagonists ( 64 vs. 56 % , P < 0.0001 ) compared with patients with paroxysmal AF . In patients r and omized to warfarin , time in therapeutic range was similar ( 58 vs. 57 % , P = 0.94 ) . Patients with persistent AF had higher adjusted rates of stroke or systemic embolism ( 2.18 vs. 1.73 events per 100-patient-years , P = 0.048 ) and all-cause mortality ( 4.78 vs. 3.52 , P = 0.006 ) . Rates of major bleeding were similar ( 3.55 vs. 3.31 , P = 0.77 ) . Rates of stroke or systemic embolism in both types of AF did not differ by treatment assignment ( rivaroxaban vs. warfarin , Pinteraction = 0.6 ) . Conclusion In patients with AF at moderate-to-high risk of stroke receiving anticoagulation , those with persistent AF have a higher risk of thrombo-embolic events and worse survival compared with paroxysmal AF BACKGROUND Anticoagulants are effective in the prevention of stroke in atrial fibrillation and flutter ( AF ) . We aim ed to find out the prevalence of AF in the UK and to estimate the proportion of patients with AF who might benefit from anticoagulation . METHODS We screened with electrocardiography a r and om sample of 4843 people from the community aged 65 years and older for AF . Participants with AF had further investigations to identify risk factors for stroke and contraindications to anticoagulants . We used three sets of criteria to assess risk and eligibility for anticoagulation . FINDINGS 228 ( 4.7 % ) participants had AF . According to analyses derived from risk stratifications based on the Stroke Prevention in Atrial Fibrillation ( SPAF ) study 61 % of these patients would have benefited from anticoagulation , 49 % according to pooled analysis of trial results , and 41 % according to the inclusion criteria for the SPAF 3 study .  Anticoagulants  were used by 1114 ( 23 % ) of all patients and were least used among elderly women , who may be the most likely to benefit . Echocardiography would be useful to assess the need for anticoagulation only in patients younger than 75 years with no contraindications to treatment and no clinical risk factors for stroke . INTERPRETATION Anticoagulants seem to be underused and misdirected in treatment of AF , according to various criteria . Efforts to promote and support wider and more appropriate use of anticoagulants would seem to be justified , and should decrease the incidence of stroke amongst elderly patients BACKGROUND Atrial fibrillation ( AF ) is an important public health problem . This arrhythmia is common and associated with a high risk of stroke . Further , appropriate interventions in AF can reduce the risk of stroke by approximately 68 % . Population studies show that a large group of patients have intermittent or chronic AF that remains unrecognized . If a simple screening test for this arrhythmia could be developed and vali date d , application of the technique across population s might identify AF patients for early treatment , potentially reducing the incidence of stroke . In this study , we sought to determine whether individuals taken from the general community could be taught to find and classify the pulse of another as very irregular , implying AF , or regular , implying normal sinus rhythm ( NSR ) . The aim was to establish that pulse examination for potential AF could be performed by individuals with sufficient sensitivity and specificity to be effectively used as a screening procedure for this medically important arrhythmia . METHODS We enrolled 178 subjects selected from the general community from four centers . Subjects received st and ardized education on the medical importance of AF and its signature , a very irregular pulse . A technique for palpating and characterizing the rhythm of the radial pulse was also taught . Without further coaching , subjects were then asked to find their pulse and then to find and classify the pulse of two models r and omly presented who may or may not have had AF . RESULTS Of the 178 subjects tested , 92 % were able to find their own pulse ; 17 ( 9.6 % ) were unable to find the pulse of one or both patient models and were , therefore , excluded from the study . Of the remaining 161 subjects , 76 % ( 122 of 161 ) correctly identified the pulse in an AF model , and 86 % ( 139 of 161 ) correctly identified the pulse in an NSR model . Results did not statistically differ as a function of age , educational status , or location . DISCUSSION This multicenter trial established that given minimal st and ardized instructions , subjects from the general community can reliably and consistently find both their pulse as well as the pulse of another and to differentiate a regular pulse from a very irregular pulse . If similar educational programs were widely applied across large population s , periodic screening for AF might lead to earlier diagnosis and appropriate treatment for patients who have this major risk factor for stroke . These screening programs should be focused on the population over the age of 55 where the risk of stroke in AF increases with each decade BACKGROUND Stroke and systemic thromboembolism are serious problems for patients with atrial fibrillation ( AF ) , but their incidence can be substantially reduced by appropriate anticoagulation . Bleeding is the major complication of anticoagulant treatment , and the relative risks for bleeding vs stroke must be considered when starting anticoagulation . METHODS The AFFIRM trial included patients with AF and at least one risk factor for stroke , r and omly assigning them to either a rate-control or rhythm-control strategy . All patients were initially treated with warfarin . The incidence of protocol -defined major and minor bleeding was documented during follow-up . Variables associated with bleeding were determined using a Cox proportional hazards model , using baseline and time-dependent covariates . RESULTS The 4060 patients in the AFFIRM trial were followed for an average of 3.5 years . Major bleeding occurred in 260 patients , an annual incidence of approximately 2 % per year , with no significant difference between the rate-control and rhythm-control groups . Increased age , heart failure , hepatic or renal disease , diabetes , first AF episode , warfarin use , and aspirin use were significantly associated with major bleeding . Minor bleeding was common in both treatment arms , with 738 patients reporting this problem in one or more visits . CONCLUSIONS Bleeding is a significant problem that complicates management of patients with AF . Risk factors for bleeding can be identified , and knowledge of these risk factors can be used to plan therapy Treatment guidelines for atrial fibrillation ( AF ) used in Western countries describe female gender as a risk factor for thromboembolic events in patients with nonvalvular AF ( NVAF ) . The present study aim ed to determine the impact of gender on prognosis of Japanese patients with NVAF . A sub analysis of 7,406 patients with NVAF ( mean age 70 years ) who were followed-up prospect ively for 2 years was performed using data from the J-RHYTHM registry . The primary end points were thromboembolic events , major hemorrhaging , total mortality , and cardiovascular mortality . Compared with male subjects ( n = 5,241 ) , female subjects ( n = 2,165 ) were older and displayed greater prevalences of paroxysmal AF , heart failure , and hypertension but less prevalences of diabetes , previous cerebral infa rct ion , and coronary artery disease . Male and female patients had mean CHADS2 ( Congestive heart failure , Hypertension , Age of 75 years or more , Diabetes mellitus and prior Stroke or transient ischemic attack ) scores of 1.6 and 1.8 , respectively ( p < 0.001 ) . Warfarin was given to 87 % of male patients and 86 % of female patients ( p = 0.760 ) , and the 2 genders displayed similar mean international normalized ratio of prothrombin time values at baseline ( 1.91 vs 1.90 , respectively , p = 0.756 ) . Multivariate logistic regression analysis indicated that male gender was an independent risk factor for major hemorrhaging ( odds ratio 1.59 , 95 % confidence interval 1.05 to 2.40 , p = 0.027 ) and all-cause mortality ( odds ratio 1.78 , 95 % confidence interval 1.25 to 2.55 , p < 0.002 ) but not for thromboembolic events ( odds ratio 1.24 , 95 % confidence interval 0.83 to 1.86 , p = 0.297 ) or cardiovascular mortality ( odds ratio 0.96 , 95 % confidence interval 0.56 to 1.66 , p = 0.893 ) . In conclusion , female gender is not a risk factor for thromboembolic events among Japanese patients with NVAF who were treated mostly with warfarin . However , male gender is a risk factor for major hemorrhaging and all-cause mortality BACKGROUND Atrial fibrillation ( AF ) is a major risk factor ( RF ) for ischemic stroke . Its prevalence and prognostic impact in patients with atherothrombosis are unclear . METHODS Risk factors , drug usage , and 1-year cardiovascular ( CV ) outcomes ( CV death , myocardial infa rct ion [ MI ] , and stroke ) were compared in  AF and non-AF patients from the REduction of Atherothrombosis for Continued Health ( REACH ) Registry , an international , prospect i ve cohort of 68,236 stable out patients with established atherothrombosis or > or=3 atherothrombotic RFs . RESULTS Atrial fibrillation and 1-year follow-up data are available for 63,589 patients . The prevalence of AF was , 12.5 % , 13.7 % , 11.5 % , and 6.2 % among coronary artery disease , CV disease , peripheral artery disease , and RF-only patients , respectively . Of the 6,814 patients with AF , 6.7 % experienced CV death , nonfatal MI , or nonfatal stroke within a year . The annual incidence of nonfatal stroke ( 2.4 % vs 1.6 % , P<.0001 ) and unstable angina ( 6.0 % vs 4.0 % , P<.00001 ) was higher , and CV death was more than double ( 3.2 % vs 1.4 % , P<.0001 ) , in AF versus non-AF patients . In these patients with or at high risk of atherothrombosis , most patients with AF received antiplatelet agents , but only 53.1 % were treated with oral anticoagulants . Even with high CHADS2 ( congestive heart failure , hypertension , aging , diabetes mellitus , and stroke ) scores , anticoagulant use did not exceed ( 59 % ) . The rate of bleeding requiring hospitalization was higher in AF versus non-AF patients ( 1.5 % vs 0.8 % , P<.0001 ) , possibly related to the more frequent use of anticoagulants ( 53.1 % vs 7.1 % ) . CONCLUSIONS Atrial fibrillation is common in patients with atherothrombosis , associated with more frequent fatal and nonfatal CV outcomes , and underuse of oral anticoagulants
Women with AF are at increased risk of stroke , particularly elderly women .
BACKGROUND Atrial fibrillation ( AF ) increases the risk of stroke , but this risk is not homogenous .
Many risk factors contribute to stroke risk however , the evidence for female sex as a risk factor is less well-established .
AIM To perform a systematic review and meta- analysis of the available evidence to establish if female sex is a risk factor for stroke/thromboembolism among patients with AF .