The diabetes-atrial fibrillation paradox

Tan, Esther; Tay, Wan Ting; Teng, Tiew‐Hwa Katherine; Richards, A. Mark; Doughty, Robert N.; Lam, Carolyn S.P.

doi:10.1136/heartjnl-2019-315018

Cited by 3 publications

(4 citation statements)

References 7 publications

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“…In a recent study investigating the ethnic differences in HF patients with AF reported that Asian HF patients with AF were older and showed higher rates of HT, stroke, and COPD and lower rates of diabetes, which were similar to our study results. The authors regarded this condition a "diabetes-AF paradox" and suggested that diabetes is a protector of left atrium remodeling and that it can be associated with a lower risk of AF development (41,42).…”

Section: Discussionmentioning

confidence: 99%

Clinical characteristics and in-hospital outcomes of acute decompensated heart failure patients with and without atrial fibrillation

et al. 2020

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Clinical characteristics and in-hospital outcomes of acute decompensated heart failure patients with and without atrial fibrillation Introduction Atrial fibrillation (AF) is the most common chronic cardiac arrhythmia and heart failure (HF) is an important cause of cardio-vascular mortality (1, 2). The prevalence of AF and HF increases with age and often coexist (3). The coexistence of AF and HF is associated with an increased rehospitalization, morbidity, and mortality risk (4). AF directly causes the worsening of HF and Objective: Atrial fibrillation (AF) and heart failure (HF) are common cardiovascular diseases. The impact of AF on in-hospital outcomes in acute decompensated heart failure (ADHF) is controversial. The aim of this study is to determine the prevalence of AF among hospitalized patients with ADHF and describe the clinical characteristics and in-hospital outcomes of these patients with and without AF. Methods: We examined the multicenter, observational data from the real-life data of hospitalized patients with HF: Journey HF-TR study in Turkey that studied the clinical characteristics and in-hospital outcomes of hospitalized patients with ADHF between September 2015 and September 2016. Results: Of the 1,606 patients hospitalized with ADHF, 626 (39%) had a history of AF or developed new-onset AF during hospitalization. The patients with AF were older (71±12 vs. 65±13 years; p<0.001) and more likely to have a history of hypertension, valvular heart disease, and stroke. The AF patients were less likely to have coronary artery disease and diabetes. In-hospital adverse event rates and length of in-hospital stay were similar in ADHF patients, both with and without AF. In-hospital all-cause mortality rate was higher in patients with AF than in patients without AF, although the difference was not statistically significant (8.9% vs. 6.8%; p=0.121). Conclusion: AF has been found in more than one-third of the patients hospitalized with ADHF, and it has varied clinical features and comorbidities. The presence of AF is not associated with increased adverse events or all-cause mortality during the hospitalization time.

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Section: Discussionmentioning

confidence: 99%

Clinical characteristics and in-hospital outcomes of acute decompensated heart failure patients with and without atrial fibrillation

et al. 2020

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“…We now extend this paradoxical association for the first time to a larger cohort across Asia in both HFrEF and HFpEF. The exact mechanisms remain unknown, although we have previously thought it unlikely to be an effect of collider bias 17 . Separately, diabetic medications had been reported to decrease the risk of AF.…”

Section: Discussionmentioning

confidence: 95%

“…The exact mechanisms remain unknown, although we have previously thought it unlikely to be an effect of collider bias. 17 Separately, diabetic medications had been reported to decrease the risk of AF. Modulation of electrical and mechanical properties of pulmonary veins and atria by dipeptidyl peptidase-4 inhibitors, inhibition of inflammation and oxidation by metformin and reduction of proarrhythmic substrates via inhibition of ATP-sensitive potassium channels by glibenclamide and tolbutamide have been suggested to confer protective benefits against AF.…”

Section: Diabetes-atrial Fibrillation Paradoxmentioning

confidence: 99%

Ethnic differences in atrial fibrillation among patients with heart failure in Asia

et al. 2020

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Aims We aimed to characterize ethnic differences in prevalence, clinical correlates, and outcomes of atrial fibrillation (AF) in heart failure (HF) with preserved and reduced ejection fraction (HFpEF and HFrEF) across Asia. Methods and results Among 5504 patients with HF prospectively recruited across 11 Asian regions using identical protocols in the Asian Sudden Cardiac Death in Heart Failure study (mean age 61 ± 13 years, 27% women, 83% HFrEF), 1383 (25%) had AF defined as a history of AF and/or AF/flutter on baseline electrocardiogram. Clinical correlates of AF were similar across ethnicities and included older age, prior stroke, higher NT-proBNP, and larger left atria. Diabetes was associated with lower odds of AF in HFrEF [adjusted odds ratio (AOR) 0.79, 95% CI 0.66-0.95] and HFpEF (AOR 0.58, 95% CI 0.39-0.84) regardless of ethnicity. Compared with Chinese ethnicity, Japanese/Koreans had higher odds of AF in HFrEF (AOR 1.76, 95% CI 1.40-2.21), while Indians had lower odds in HFrEF (AOR 0.18, 95% CI 0.13-0.24) and HFpEF (AOR 0.28, 95% CI 0.16-0.49) even after adjusting for clinical covariates. Interaction between ethnicity and region was observed among Indians, with Southeast Asian Indians having higher odds of AF (AOR 3.01, 95% CI 1.60-5.67) compared with South Asian Indians. AF was associated with poorer quality of life and increased risk of 1 year all-cause mortality or HF hospitalisation (adjusted hazard ratio 1.39, 95% CI 1.18-1.63) regardless of ethnicity. Conclusions Among patients with HF across Asia, clinical correlates and adverse outcomes associated with AF are similar across ethnicities; however, there are striking ethnic variations in the prevalence of AF that are not accounted for by known risk factors.

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“…Burden and Timpson raise the concern that collider bias might be present; specifically, that the inclusion of only patients with HF leads to an apparent relationship between two variables (ie, AF and diabetes) that are both causally related to the variable used to select the study cohort (ie, HF) (figure 4). Tan and colleagues5 respond in a letter: ’If collider bias from HF-only selection explains the diabetes–AF paradox, it is difficult to understand why collider bias would apply to Asians but not NZ–Europeans, or to preserved but not reduced ejection fraction HF (regardless of ethnicity), in cohorts simultaneously recruited using identical protocols. Also difficult to explain is why collider bias would not similarly impact hypertension and other HF risk factors.…”

mentioning

confidence: 99%

Heartbeat: Diagnosis of subclinical atrial fibrillation by physicians and patients

Otto

2019

Heart

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The diabetes-atrial fibrillation paradox

Cited by 3 publications

References 7 publications

Clinical characteristics and in-hospital outcomes of acute decompensated heart failure patients with and without atrial fibrillation

Clinical characteristics and in-hospital outcomes of acute decompensated heart failure patients with and without atrial fibrillation

Ethnic differences in atrial fibrillation among patients with heart failure in Asia

Heartbeat: Diagnosis of subclinical atrial fibrillation by physicians and patients

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