Impact of vascular disease in predicting stroke and death in patients with atrial fibrillation: the Danish Diet, Cancer and Health cohort study

Abstract

Summary. Background: The presence of vascular disease (peripheral artery disease [PAD] and/or myocardial infarction [MI]) may impact on the risk of stroke and death among patients with incident atrial fibrillation (AF). To test this hypothesis, we analyzed data from a large Danish prospective cohort, the Danish Diet, Cancer and Health (DCH) study, to assess the risk of stroke or death among those who developed AF according to concomitant presence of vascular disease. Methods: A prospective cohort study of 57 053 persons (27 178 men and 29 876 women, respectively), aged between 50 and 64 years. The risk of stroke or death for patients with vascular disease was assessed amongst 3315 patients with incident AF (mean age, 67.1 years; 2130 men, 1185 women) using Cox proportional hazard models, after a median follow‐up of 4.8 years. Results: Of the subjects with AF, 417 (12.6%) had ‘vascular disease’ (PAD and/or prior MI). The risk of the primary endpoint (stroke or death) was significantly higher in patients with vascular disease at 1‐year follow‐up (crude hazard ratio [HR] 2.51 [1.91–3.29]), with corresponding crude HRs for PAD and MI being 3.51 (2.40–5.13), and 1.99 (1.46–2.72), respectively. For the secondary endpoints of death or stroke individually, these risk estimates were similar (crude HR 2.48 [1.89–3.26] and 1.77 [1.18–2.66], respectively). After adjustment for risk factors within the CHADS2 score, the adjusted HR for the primary endpoint (stroke or death) in patients with vascular disease was 1.91 (1.44–2.54), which was also significant for death (1.97 [1.48–2.62]). Conclusion: Vascular disease (prior MI and PAD) is an independent risk factor for the primary endpoint of ‘stroke or death’ in patients with AF, even after adjustment for the CHADS2 risk score, although this is driven by the impact on mortality. This reaffirms that patients with vascular disease represent a ‘high‐risk’ population, which necessitates proactive management of all cardiovascular risk factors and effective thromboprophylaxis (i.e. oral anticoagulation), which has been shown to significantly reduce the risk of stroke and death in AF.

Atrial Fibrillation and Vascular Disease—A Bad Combination

“…Vascular disease, including peripheral artery disease, was also a risk factor of subsequent stroke in AF patients age <65 years in the Loire Valley Atrial Fibrillation Project, 6 and peripheral artery disease was an independent predictor of stroke and death in the Danish Diet, Cancer, and Health Study. 7 Rasmussen et al found an incidence rate of stroke at 1-year follow-up of 10.9 per 100 person-years in patients with new-onset AF and peripheral artery disease, vs a rate of 4.6 in new-onset AF patients without vascular disease. 7 The results are summarized in Table 1.…”

“…7 Rasmussen et al found an incidence rate of stroke at 1-year follow-up of 10.9 per 100 person-years in patients with new-onset AF and peripheral artery disease, vs a rate of 4.6 in new-onset AF patients without vascular disease. 7 The results are summarized in Table 1.…”

Seasonality, incidence and prognosis in atrial fibrillation and stroke in Denmark and New Zealand

“…[1][2][3] A seasonal variation in acute presentation with various cardiovascular disorders has been reported, with data on acute presentations with myocardial infarction, sudden death, rupture/dissection of aortic aneurysms, heart failure hospitalisations and venous thromboembolism [4][5][6][7][8][9] all showing a seasonal peak during winter. Acute stroke and transient ischaemic attack show a similar pattern.…”

Balancing bleeding and thrombotic risk with new oral anticoagulants in patients with atrial fibrillation

“…Female AF patients have also been shown to have a higher risk of stroke in the setting of AF than their male counterparts [40][41][42]. Additionally, the presence of vascular disease, defined as previous myocardial infarction, peripheral artery disease or aortic plaque, is also associated with a higher risk of stroke [43,44]. In 2010 the CHA 2 DS 2 -VASc score was introduced as a supplement to the widely used CHADS 2 score by adding other common stroke risk factors and modifying the age criterion (TABLE 1) [45].…”