Abstract
Background
Oral anticoagulation (OAC) is paramount to effective thromboprophylaxis; yet adherence to OAC remains largely suboptimal in patients with atrial fibrillation (AF).
Purpose
We ...aimed to assess the impact of an educational, motivational intervention on the adherence to OAC in patients with non-valvular AF.
Methods
Hospitalised patients with non-valvular AF who received OAC were randomly assigned to usual medical care or a proactive intervention, comprising motivational interviewing and tailored counseling on medication adherence. The primary study outcome was adherence to OAC at 1-year, evaluated as Proportion of Days Covered (PDC) by OAC regimens and assessed through nationwide prescription registers. Secondary outcomes included the rate of persistence to OAC, gaps in treatment, proportion of VKA-takers with labile INR (defined as time to therapeutic range<70%) and clinical events.
Results
A total of 1009 patients were randomised, 500 in the intervention group and 509 in the control group. At 1-year follow-up, 77.2% (386/500) of patients in the intervention group had good adherence (PDC>80%), compared with 55% (280/509) in the control group (adjusted odds ratio 2.84, 95% confidence interval 2.14–3.75; p<0.001). Mean PDC±SD was 0.85±0.26 and 0.75±0.31, respectively (p<0.001). Patients that received the intervention were more likely to persist in their OAC therapy at 1 year, while usual medical care was associated with more major (≥3 months) treatment gaps Figure. Among 212 VKA-takers, patients in the intervention group were less likely to have labile INR compared with those in the control group 21/120 (17.1%) vs 34/92 (37.1%), OR 0.33 95% CI 1.15–0.72, p=0.005. Clinical events over a median follow-up period of 2 years occurred at a numerically lower, yet non-significant, rate in the intervention group Table.
Conclusions
In patients receiving OAC therapy for non-valvular AF, a motivational intervention significantly improved patterns of medication adherence, without significantly affecting clinical outcomes.
Primary and secondary outcomes
Funding Acknowledgement
Type of funding source: None
Abstract
Background
The association of heart failure (HF) with the prognosis of atrial fibrillation (AF) remains unclear.
OBJECTIVES
To assess all-cause mortality in patients following ...hospitalization with comorbid AF in relation to the presence of HF.
Methods
We performed a cross-sectional analysis of data from 977 patients discharged from the cardiology ward of a single tertiary center between 2015 and 2018 and followed for a median of 2 years. The association between HF and the primary endpoint of death from any cause was assessed using multivariable Cox regression.
Results
HF was documented in 505 (51.7%) of AF cases at discharge, including HFrEF (17.9%), HFmrEF (16.5%) and HFpEF (25.2%). A primary endpoint event occurred in 212 patients (42%) in the AF-HF group and in 86 patients (18.2%) in the AF-no HF group (adjusted hazard ratio aHR 2.27; 95% confidence interval CI, 1.65 to 3.13; P<0.001). HF was associated with a higher risk of the composite secondary endpoint of death from any cause, AF or HF-specific hospitalization (aHR 1.69; 95% CI 1.32 to 2.16 p<0.001). The associations of HF with the primary and secondary endpoints were significant and similar for AF-HFrEF, AF-HFmrEF, AF-HFpEF.
Conclusions
HF was present in half of the patients discharged from the hospital with comorbid AF. The presence of HF on top of AF was independently associated with a significantly higher risk of all-cause mortality than did absence of HF, irrespective of HF subtype.
Funding Acknowledgement
Type of funding source: None
Abstract
Background
Prior risk stratification schemes for atrial fibrillation (AF) have extensively focused on stroke as the principal outcome. However, an accurate estimation of the risk of death in ...patients with AF has received disproportional attention.
Purpose
The aim of this study was to develop and validate a risk score for predicting mortality in patients with AF who underwent a hospitalization for cardiac reasons.
Methods
The new risk score was developed and internally validated in 887 patients with AF, who were followed up for a median of 2 years. The outcome measure was all-cause mortality. Biomarker samples, echocardiographic data and renal function values were obtained at the date closest to hospital discharge. A Cox-model that determined the variables that significantly contributed to the prediction of all-cause mortality, was adapted to a risk points system through weighting of the model coefficients. The model was internally validated by bootstrapping, assessing both discrimination and calibration.
Results
311 all-cause deaths were reported during 1755 person-years of follow-up (incidence rate 17.7 events per 100 person-years). The most important predictors of death were N-terminal pro B-type natriuretic peptide (NT-proBNP), high-sensitivity troponin-T (hs-TnT), left atrial area indexed to body surface area (LAAi), prior cardiac arrest, kidney impairment, congestive heart failure and age, and were included in the BLACCK (AF) death risk score. The score was well-calibrated (observed probabilities adjusted to predicted probabilities) and showed good discriminative ability c-index 0.87 (95% CI 0.85–0.90). The internal validation of the score reported minimal over-fitting (optimism-corrected c-index of 0.85). The 1, 2 and 3-year risk of death derived by the score's total points may be calculated immediately through the nomogram (Figure 1).
BLACCK (AF) risk score nomogram
Conclusions
We developed a simple, well-calibrated and internally validated novel risk score for predicting 1, 2 and 3-year risk of death in patients with AF after a hospitalization for cardiac reasons. The BLACCK (AF) death risk score included both cardiac biomarkers and clinical information, performed well and may assist physicians in decision-making when treating patients with AF.
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