Atherosclerosis in Atrial Fibrillation

Study Overview
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Brief Summary
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The prevalence of metabolic syndrome in patients suffering from non valvular atrial fibrillation is derived from studies regarding recurrences of atrial fibrillation after catheter ablation. Prospective studies in european countries are lacking. Furthermore, the impact of metabolic syndrome on cardiovascular events in patients with non valvular atrial fibrillation is still unknown.

Detailed Description
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Atrial fibrillation (AF) is the most common cardiac arrhythmia that is associated with a high risk of cardiovascular events and increased morbidity and mortality. Cardiovascular events are prevalently localized in the cerebral circulation in which AF is responsible for ischemic stroke. Clinical characteristics of ischemic stroke from AF are almost severe and thromboembolism is considered the most important cause. Thus, ischemic stroke is deemed to origin from thrombus formation generated in the left atrium with ensuing embolism in the cerebral circulation. Patients with AF are typically associated with different risk factors of atherothrombosis including, overall, hypertension which may be detected in about 70-80% of the population; other risk factors are diabetes and dyslipidemia. This accounts for instrumental evidence of systemic atherosclerosis associated to AF. Thus, signs of atherosclerosis have been detected in the thoracic aorta, as represented by aortic plaque assessed by trans-esophageal echocardiography; patients with complex aortic plaque had fourfold increased rate of stroke compared to plaque-free patients. Metabolic syndrome (MetS) is a constellation of atherosclerotic risk factors including, according to the modified National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATPIII), hypertension, low HDL, impaired glycaemic control, hypertriglyceridemia and central obesity as assessed by waist circumference; the presence of MetS is associated with an increased risk of developing cardiac and cerebral ischemic events. An higher risk to develop atrial fibrillation (AF) has been well recognized in patients with MetS. In a prospective, community-based, observational cohort study with annual health check-up 28449 subjects without AF the age-adjusted rates of AF were higher in subjects with compared to those without metabolic syndrome during a mean follow-up of 4.5 years. Few studies reported on the prevalence of MetS in AF population are still lacking. Some data can be inferred from studies regarding recurrence of AF after catheter ablation reporting a prevalence ranging from 18.8% to 49.4% . The only population study so far published included 741 chinese patients and reported a prevalence of the MetS in AF of 46.3%. Taking into account the thresholds of waist circumference recommended by international societies for different ethnic groups, it is unclear if such prevalence can be extrapolated to population of western countries. Furthermore the impact of MetS on the incidence of cardiovascular events in patients with non valvular AF (NVAF) taking oral anticoagulant therapy (OAT) has never been investigated. Therefore, our aim was to investigate the prevalence of MetS in a population of NVAF patients under oral coagulation treatment and its impact on cardiovascular events during a prospective study. The study has been modified and approved by local ethical board of Sapienza University of Rome to include patients treated with non-vitamin K oral anticoagulants (dabigatran, apixaban, edoxaban, rivaroxaban) on April 11, 2014 (Prot. 417/14).

Official Title
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Study of Atherosclerotic Risk Factors and Oxidative Stress in Atrial Fibrillation. Relation to Cardiovascular Events

Conditions
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Atrial Fibrillation, Metabolic Syndrome, Oxidative Stress, Atherosclerosis, Disorders, Blood Coagulation

Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: non valvular atrial fibrillation age >18 years any antithrombotic treatment Exclusion Criteria: prosthetic heart valves, or the presence of any severe valvulopathies, severe cognitive impairment, chronic infectious (HIV, hepatitis C, HBV) or autoimmune systemic disease. Furthermore, subjects were excluded from the study if they had active neoplastic diseases or liver insufficiency (eg, cirrhosis).

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Prevalence of metabolic syndrome in anticoagulated nonvalvular atrial fibrillation patients | To assess the prevalence of metabolic syndrome in a population of patients suffering from nonvalvular atrial fibrillation receiving oral anticoagulants. The relationship between metabolic syndrome and vascular events will be described. Vascular events included a composite outcome of fatal and non fatal acute myocardial infarction, acute fatal and non fatal ischemic stroke, cardiac revascularization (stent/cabg), cardiovascular death. | At baseline | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Progression of atherosclerosis in non valvular atrial fibrillation patients receiving oral anticoagulant therapy. | To assess the progression of atherosclerosis in nonvalvular atrial fibrillation patients defined by some surrogate markers. In particular ankle brachial index, intima media thickness, flow mediated dilation and transthoracic echocardiogram will be performed to all enrolled patients. | One year | 
| Analysis of oxidative stress markers in atrial fibrillation | Oxidative stress markers such as plasmatic and urinary isoprostanes, thromboxane, platelet recruitment, reactive species of oxygen, nadph oxidase(nox2)will be measured. Differences of these markers among patients experiencing or not a vascular outcome will be described | At baseline | 
| Changing in glomerular filtration rate of anticoagulated patients with non valvular atrial fibrillation | To assess changes in renal function after one year of follow up in patients with non valvular atrial fibrillation receiving oral anticoagulants | One year | 
| Determinants of Time in Therapeutic Range | To assess the determinants of time in therapeutic range (TTR) in patients receiving oral anticoagulants | Patients will be followed for an expected mean time of 25 months | 
| Use of digoxin in atrial fibrillation | Use of digoxin will be assessed at baseline. The relationship with vascular outcomes will be described | At baseline | 
| Echocardiographic characteristics in patients with paroxysmal or persistent/permanent atrial fibrillation | Transthoracic echocardiography will be performed at baseline. Morphologic and functional measures will be registered. The relationship with vascular outcome will be described | At baseline | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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atherosclerosis, cardiovascular events, ankle-brachial index, carotid disease, echocardiography, mediterranean diet, platelet activation