bluuebunny/crossref_metadata_2025_split huggingface dataset:
P4755Sex differences in admission rates, use of anticoagulation, and outcomes for emergency department presentations of atrial fibrillation
Authors: Daniele P , Dover D C , Islam S , Hawkins N , Kaul P , Sandhu R K 
Published: October 2019

Abstract

Background
Studies in non-Emergency Department (ED) settings have shown women with non-valvular atrial fibrillation (NVAF) differ in presentation, treatment, and outcomes compared to men. Despite AF being a common reason for ED visit, little is known regarding sex differences in patients presenting to ED.

Purpose
We sought to determine whether sex differences exist in rates of admission among NVAF patients presenting to the ED and if oral anticoagulant (OAC) use and outcomes differ by ED discharge status.

Methods
Patients≥18 years old, presenting to the ED with incident NVAF in two western Canadian provinces (Alberta and British Columbia) from April 2012 to March 2015 were included. ED records were linked to hospital records to identify patients admitted to hospital versus discharged from the ED. Outcomes of interest were 30-day mortality and 1-year stroke, heart failure (HF) and mortality. Pharmaceutical claims were queried for OAC use within 90 days following NVAF ED event.

Results
Of 16,991 ED NVAF patients, 7,770 (46%) were women and 9,221 (54%) were men (p<0.001). Compared to men, women were older (73.9 vs 65.6 years, p<0.001) and presented with higher CHA2DS2-VASc scores (4.0 vs 2.0, p<0.001). Overall, 41% of women and 37% of men were admitted to hospital (p<0.001). OAC rate was 50% among admitted and 37% among discharged (p<0.001). OAC rates were 53% in women and 48% in men among admitted (p<0.001), and 39% in women and 35% in men among discharged (p<0.001). OAC rates were higher in patients with CHA2DS2-VASc ≥1 who were admitted (53% in women (n=2,781) and 52% in men (n=2,683), p=0.63) than in those who were discharged (39% in women (n=4,435) and 45% in men (n=3,866), p<0.01). Women had higher rates of mortality at 30-days and 1-year, and stroke at 1-year compared to men, irrespective of ED discharge status (all p<0.02). Women admitted had higher HF rates at 1-year compared to men (p=0.002). (Table)
Outcomes by Sex and ED Discharge Status Outcome Discharged Admitted Women (N=4,560) Men (N=5,780) p-value Women (N=3,210) Men (N=3,441) p-value 30 Day Mortality, n (%) 63 (1.4) 50 (0.9) 0.01 261 (8.1) 228 (6.6) 0.019 1 Year Mortality, n (%) 270 (5.9) 248 (4.7) <0.001 717 (22.3) 604 (17.6) <0.001 Stroke*, rate (SE) 1.7 (0.19) 0.9 (0.13) <0.001 4.0 (0.37) 2.6 (0.28) 0.001 Heart Failure*, rate (SE) 3.6 (0.28) 3.1 (0.23) 0.16 12.9 (0.62) 10.4 (0.54) 0.002 *Censored on death.

Conclusions
In this population-based study of patients presenting to ED with NVAF, we found women were more likely to be admitted to hospital than men. Women had a worse prognosis than men, irrespective of ED discharge status. Use of OAC was suboptimal, regardless of patient sex.

Acknowledgement/Funding
Heart and Stroke Foundation of Canada, UBC Cardiology, Servier Alberta Innovation Health Fund
P4757Vitamin k antagonists are associated with higher risk of osteoporotic fractures compared to non-vitamin k antagonist oral anticoagulants among atrial fibrillation patients: a nationwide cohort study
Authors: Binding C , Olesen J B , Abrahamsen B , Staerk L , Gislason G , Bonde A N 
Published: October 2019

Abstract

Background/Introduction
Osteoporotic fractures are associated with high mortality and reduced life quality in an elderly population. Several studies report an increased risk of fractures among patients treated with oral anticoagulants (OAC), however, only sparse research has been made to clarify the difference between treatment with vitamin K antagonists (VKA) and non-VKA oral anticoagulants (NOACs) regarding the risk of osteoporotic fractures.

Purpose
The purpose of this study was to evaluate the risk of osteoporotic fractures among patients with atrial fibrillation (AF) in long-term VKA or NOAC treatment.

Methods
Patients with AF were identified using Danish national registries and were included when they had undergone 180 days OAC treatment, and only if they had no prior use of osteoporosis medication. The study period was from 1 January 2013 until 30 June 2017, and patients were followed for 2 years, or until death, outcome or emigration. Outcomes were hip fracture, major osteoporotic fracture, any fracture, initiation of osteoporosis medication, and a combined endpoint. G-formula was used to determine standardized absolute risk, and multiple covariate adjusted Cox regressions were used to calculate hazard ratios (HR).

Results
Overall, 37,350 patients with AF were included; 32.6% received VKA treatment (median age 72 years, 61.8% men) and 67.4% received NOAC treatment (median age 73 years, 55.9% men). The standardized absolute 2-year risk of any fracture was low among NOAC treated patients (3.1%; 95% CI: 2.9% to 3.3%), and among VKA treated patients (3.8%; 95% CI: 3.4% to 4.2%).
NOAC was associated with a significantly lower relative risk of any fracture (HR: 0.85; 95% CI: 0.74 to 0.97), of major osteoporotic fractures (HR: 0.85; 95% CI: 0.72 to 0.99), and of initiating osteoporotic medication (HR: 0.82; 95% CI: 0.71 to 0.95). A combined endpoint showed that patients treated with NOAC had a significantly lower risk of suffering from any fracture or initiating osteoporosis medication (HR: 0.84; 95% CI: 0.76 to 0.93).
Adjusted relative two-year risks

Conclusion
In a nationwide population, the absolute risk of osteoporotic fractures was low among AF patients on OAC, but NOAC was associated with a significantly lower risk of osteoporotic fractures compared to VKA.

Acknowledgement/Funding
Scholarship from The Copenhagen University Hospital Herlev and Gentofte
P4777Mortality in patients with non-valvular atrial fibrillation in South America. Warfarin has significant higher global mortality rates versus dabigatran and rivaroxaban
Authors: Arocena M J , Vanerio G 
Published: October 2019

Abstract

Background
Oral anticoagulants are the cornerstone for the management of atrial fibrillation (AF) to reduce cardioembolic stroke
Randomized controlled trials of anticoagulants have shown non-inferiority of direct oral anticoagulants (DOACs) compared to warfarin
Most DOACs represent an advance in therapeutic safety when compared to warfarin for prevention of thromboembolism in patients with AF.

Objectives
Determine long term survival, total mortality rates and mortality cause between patients with non-valvular atrial fibrillation (AF) receiving anticoagulants (warfarin, dabigatran and rivaroxaban)

Methods
Retrospective analysis of consecutive patients with AF receiving anticoagulants in two Hospitals in Montevideo, using electronic registries. Demographics, co-morbidities, CHA2DS2VASc scores and mortality cause were annotated. Follow-up started on Jan 2011 and finished on Dec 2017. Anticoagulation quality was expressed as the standard deviation of INRs (SD-INRs). We performed global mortality and mortality cause analysis on patients with anti-VitK versus direct anticoagulants.
Statistical analysis: Survival analysis was performed using Kaplan-Meier (log rank) and Cox regression model. All differences between groups were considered significant if the p value was <0.001.

Results
We studied 4501 pts., 3627 patients were on warfarin (80.6%), 456 (10.1%) were on dabigatran and 418 (9.3%) on rivaroxaban. Those receiving direct anticoagulants were older, 79±9 vs 77±11 years, (p=0.0001), 51.3% were female, with a significantly higher prevalence of HTN; 93.7% vs 88.8% and a CHA2DS2VASc score ≥2 (96% vs 91%), and a lower prevalence of CHD (5.8% vs 10.4%), CHF (3.7% vs 9.5%) and CKD (2.3% vs 6.3%).Total mortality was 818 (18%); patients receiving warfarin had significantly higher mortality rates, 727 (20.1%) vs 91 (10.4%); 63 and 28 (13.8%, 6.7% dabigatran and rivaroxaban respectively) Kaplan-Meier curves were significantly different (Figure 1) showing higher survival rates for those on DOACs. The SD-INRs were 0.85±0.47 (n=1726 alive) vs 1.05±0.46 (n=548 dead), mean difference 0.2 (99% CI 0.14–0.26). Mortality could be analysed in 759 patients (92,7%). The most important cause of death was cardiovascular disease in 26.5%. We could not find significant differences in the cause of death between groups. Using Cox regression model, variables with significant increased mortality were HTN, CHD, CHF, CKD and history of previous CVA. The only variable with a significant decrease in mortality was the use of dabigatran or rivaroxaban; HR 0.55 (95% CI 0.44–0.69)
Figure 1

Conclusions
In this large cohort of patients, those receiving warfarin have significantly higher mortality rates. Mortality differences were not related to stroke or major bleeding but could be explained by a higher prevalence of CHD, CHF and CKD in the warfarin group despite a significant lower CHA2DS2VASc score.
P4778Effectiveness and safety of rivaroxaban versus warfarin in nonvalvular atrial fibrillation patients with coronary or peripheral artery disease
Authors: Coleman C I , Sood N , Bunz T J , Eriksson D , Meinecke A.-K , Baker W J 
Published: October 2019

Abstract

Background
The efficacy and safety of rivaroxaban use for the prevention of major thrombotic vascular events (MTVEs) has been demonstrated in randomized trials of nonvalvular atrial fibrillation (NVAF), coronary artery disease (CAD) and peripheral artery disease (PAD) patients.

Purpose
To assess the effectiveness and safety of rivaroxaban versus warfarin in preventing MTVEs in NVAF patients with concomitant CAD and/or PAD in routine practice.

Methods
Using MarketScan data from 1/2012–12/2017, we identified oral anticoagulant (OAC)-naïve NVAF patients with comorbid CAD and/or PAD and ≥12-months of insurance coverage before OAC initiation. Differences in baseline covariates between cohorts were adjusted using inverse probability-of-treatment weights based on propensity-scores (standardized differences <0.1 achieved for all covariates after adjustment). The primary effectiveness endpoint was the composite of any MTVE including ischemic stroke, myocardial infarction or adverse limb event (revascularization or amputation). The primary safety endpoint was major bleeding defined using the Cunningham algorithm. Patients were followed until a MTVE, discontinuation or switch of index OAC, insurance disenrollment or end-of-data availability. Hazard ratios (HRs) and 95% confidence intervals (CIs) comparing the cohorts were calculated using Cox regression.

Results
We identified 3,257 rivaroxaban (30.4% received a reduced dose) and 5,046 warfarin users with NVAF and comorbid CAD and/or PAD. Median (25%-75% range) age was 74 (65–81) years, CHA2DS2-VASc score was 3 (2–4). Rivaroxaban was associated with a 32% (95% CI=8–50%) reduction in the composite of any MTVE (Figure). No significant difference in major bleeding was observed (HR=1.13, 95% CI=0.84–1.52).
Figure 1. Event Rates and Hazard Ratios

Conclusions
In patients with NVAF and comorbid CAD and/or PAD treated in routine practice, rivaroxaban use appears to reduce patients' risk of MTVEs compared to warfarin, without increasing their risk of major bleeding. This study lends further support to RCT findings that suggest rivaroxaban is effective in preventing major events in multiple vascular beds.

Acknowledgement/Funding
Bayer AG, Berlin, Germany
P4795Comparative safety of factor-xa inhibitors vs phenprocoumon in patients with non-valvular atrial fibrillation and renal disease - insights from the RELOADED study
Authors: Bonnemeier H , Kreutz R , Enders D , Schmedt N , Vaitsiakhovich T , Kloss S 
Published: October 2019

Abstract

Background
Data on safety of Factor-Xa inhibitors and phenprocoumon in patients with non-valvular atrial fibrillation (NVAF) and renal disease is scarce. Among others, our study aimed to investigate the safety risks of fatal bleeding and intracranial haemorrhage (ICH) in new users of Factor-Xa inhibitors vs. phenprocoumon, the vitamin-K antagonist (VKA) of choice in Germany.

Methods
We conducted a new user cohort study (one year washout period) in patients with NVAF and renal disease. German claims data between January 1st, 2013 and June 30th, 2017 were utilized and a multiple Cox-regression was performed to calculate confounder-adjusted hazard ratios (HRs) for the risk of fatal bleeding and ICH in Factor-Xa inhibitors and phenprocoumon initiators. Additionally, a propensity score matching and an inverse probability of treatment weight analysis were performed as sensitivity analyses. Cases of fatal bleeding were defined as hospitalization with a primary hospital discharge diagnoses for bleeding with documented death as reason for hospital discharge or within 30 days after hospital discharge.

Results
The overall population comprised 23,552 phenprocoumon initiators, 22,338 rivaroxaban initiators and 16,201 apixaban initiators, where the number of patients with renal disease initiating these agents were 7,289 for phenprocoumon, 5,121 patients for rivaroxaban 15mg or 20mg and 4,750 patients for apixaban 2.5mg or 5mg, respectively. In the confounder-adjusted analysis, a beneficial effect for rivaroxaban and apixaban over phenprocoumon was observed for the risk of ICH and fatal bleeding (figure 1) for both the overall and renal disease population. Hazard ratios for rivaroxaban and the risk of ICH were calculated as 0.57 (0.43; 0.75) for the overall population and 0.62 (0.37; 1.01) for the renal disease population where hazard ratios for apixaban were calculated as 0.43 (0.31; 0.60) for the overall population and 0.41 (0.23; 0.74) for the renal disease population, respectively. There was not sufficient data to conduct the analyses for edoxaban.
Figure 1

Conclusion
This large retrospective database study conducted in Germany confirms the safety profile of rivaroxaban and apixaban over VKA in patients overall and specifically in patients with renal disease when assessing the risk of ICH and fatal bleeding. Our study adds evidence in a relevant subgroup of patients where anticoagulation is often challenging.

Acknowledgement/Funding
This study was funded by Bayer AG
P4797Genetic testing in 101 consecutive lone atrial fibrillation patients is able to identify a subgroup with increased severity
Authors: D'Arezzo Pessente G , Darrieux F D , Sacilotto L S , Olivetti N O , Wulkan F W , Oliveira T O , Hachul D H , Wu T W , Scavacca M S , Krieger J K , Pereira A P 
Published: October 2019

Abstract

Introduction
Atrial fibrillation (AF) is the most common arrhythmia and the cause of 15% of all strokes and up to 6% of medical admissions. It is estimated that currently about 2.0 million Brazilians, and 30 million individuals worldwide, are affected by the disease. It is a complex and multifactorial disease, and the mechanisms are still not well understood. Between 10–20% of AF patients do not have any known predisposing factors, a condition once called “lone AF”. The role of genetic testing still remains controversial in this clinical scenario.

Purpose
The aim of this study was to identify the occurrence of pathogenic genetic variants in patients with atrial fibrillation without known risk factors.

Methods
In a tertiary hospital, 101 young patients with apparent “lone AF” were screened with genetic testing by NGS using a custom genetic panel with 159 channelopathy and cardiomyopathy related genes. Variants found were classified according to the American College of Genetic and Genomic (ACMG) criteria. Subjects were evaluated with clinical and familial history, electrocardiogram, 24 hours Holter monitoring, echocardiogram, cardiac MRI and treatment response. Multivariate analyses were performed by logistic linear regression model.

Results
During an inclusion period of 4 years, 101 consecutive patients, with mean age of 38.6 years old, were classified as “lone AF” (78% male); 76% presented paroxysmal AF and 24% persistent/permanent AF. Family history of early sudden death (bellow 60 years old) was reported in 37% of cases (78% below 50 years old); 10% had family members with pacemakers; and 44% reported having family members with early AF onset. Genetic testing demonstrated that 14/101 (13.8%) of patients presented genetic variants classified as pathogenic or likely pathogenic (P/LP) according to ACMG criteria. The genes most frequently affected were LMNA (3/101), ANK2 (3/101) and truncating variants in TTN (3/101). Two variables were significantly associated with harboring a pathogenic mutation: family history of sudden death (OR: 5.58; 1,19–26,12 CI; p=0.029) and pacemaker reported in the family history (OR: 6.83; 1.11–42.04 CI; p=0.038).

Conclusion
Our data showed that approximately 15% of “lone AF” patients are carriers of known pathogenic mutations in genes associated with inherithed cardiomyopathy. In addition, we show that being a carrier is potentially associated with a more severe phenotype. These findings suggest that genetic testing in “lone AF” patients may be able to identify a subgroup with a more severe phenotype are for whom a different management strategy might be indicated.

Acknowledgement/Funding
National Council for Scientific and Technological Development (CNPq)
4879Is intensive blood pressure strategy effective and safe in patients with cardiovascular disease? The two sides of the coin
Authors: Vlachopoulos C , Terentes-Printzios D , Aznaouridis K , Ioakeimidis N , Xaplanteris P , Lazaros G , Tousoulis D 
Published: October 2019

Abstract

Background/Lntroduction
Recent data advocate the adoption of a more intensive treatment strategy for the management of blood pressure (BP).

Purpose
We sought to investigate whether the overall effects of the Systolic Blood Pressure Intervention Trial (SPRINT) are applicable to cardiovascular disease (CVD) patients.

Methods
In the present post-hoc analysis we analyzed data from SPRINT that randomly assigned 9361 individuals to systolic blood pressure (SBP) target of less than 120 mm Hg (intensive treatment) or a target of less than 140 mm Hg (standard treatment). 1562 patients had clinically evident CVD (age=70.3±9.3 years, 24% females) at study entry and were followed for 3.1 years. Further, we assessed the effect of low (<150 mm Hg) baseline SBP on clinical endpoints.

Results
In CVD patients, there was no benefit from the intensive treatment regarding all endpoints, except for a marginally significant benefit on all-cause mortality (hazard ratio [HR]: 0.67; 95% confidence interval [CI], 0.45 to 1.00; P=0.0509) (Figure). Further, while there was no increase in serious adverse events (SAE) in the intensive group, there was an increased HR for study-related SAE in the intensive management group (HR: 2.00; 95% CI: 1.22 to 3.26; p=0.006), a greater incidence of acute renal failure (HR: 1.57; 95% CI: 1.01 to 2.44; P=0.044), electrolyte abnormalities (HR: 1.77; 95% CI: 1.03 to 3.02; P=0.038) and specifically hyponatremia (HR: 2.24; 95% CI: 1.13 to 4.46; p=0.021). In patients with low baseline SBP there was a beneficial effect on all-cause mortality (HR: 0.56; 95% CI: 0.33 to 0.96; P=0.033), but with greater stroke incidence (HR: 2.94; 95% CI: 1.04 to 8.29; P=0.042). As far as adverse events are concerned, patients with SBP<150 mm Hg had increased risk only for study-related SAE and electrolyte abnormalities.
Survival curves for the main endpoints

Conclusions
We confirm the beneficial effect of the intensive strategy in SPRINT study on all-cause mortality and the harmful effect on other than serious adverse outcomes in patients with CVD. However, in patients with low baseline SBP stroke increases.

Acknowledgement/Funding
This manuscript was prepared using SPRINT_POP Research Materials obtained from the National Heart, Lung, and Blood Institute
4933Comparison of left ventricular global longitudinal strain measurements using contrast-enhanced and non-contrast echocardiographic images
Authors: Liang S 
Published: October 2019

Abstract

Background
Left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) are two important index for the quantification of left ventricular systolic function. With the help of ultrasound contrast agents, we can improve the definition of endocardial borders and allow the quantification of LVEF in patients with poor image quality. However, the feasibility of GLS measurements in contrast-enhanced images is still controversial.

Purpose
Our study aimed to explore the feasibility of GLS measured by velocity vector imaging (VVI) in contrast-enhanced images, compare the difference of measurements in contrast-enhanced and non-contrast images, and analyze the relation between LVEF and GLS in both conditions.

Methods
A total of 133 patients with cancer, who were registered for transthoracic echocardiography as well as contrast-enhanced echocardiography were studied. LVEF was measured using the biplane modified Simpson's rule and GLS was measured with offline VVI analysis of the three standard apical views in non-contrast and contrast-enhanced images respectively. Linear regression was performed to derive correlation coefficients between LVEF and GLS both in non-contrast and contrast-enhanced images.

Results
GLS measurements in non-contrast images were discarded in 2/133 patients (1.5%), while in contrast-enhanced images were obtained in all patients. LVEF (64.12±7.47% vs. 66.25±8.61%, respectively; P<0.01) and GLS (−20.99±4.67% vs. −23.40±4.58%, respectively; P<0.01) were both significantly higher in the presence of contrast agents. A linear regression between LVEF and GLS in non-contrast images (r=0.627, P<0.001) was observed, as well as in contrast-enhanced images (r=0.649, P<0.001).

Conclusions
GLS measured by VVI in contrast-enhanced echocardiography is a feasible and reliable index for the quantification of left ventricular systolic function, even in patients with poor image quality. Compared with the measurements in non-contrast images, both LVEF and GLS measurements are higher in the presence of contrast agents.