Atrial fibrillation (AF) is the most common sustained arrhythmia, causing a 2‐fold increase in mortality and a 5‐fold increase in stroke. The Asian population is rapidly aging, and in 2050, the ...estimated population with AF will reach 72 million, of whom 2.9 million may suffer from AF‐associated stroke. Therefore, stroke prevention in AF is an urgent issue in Asia. Many innovative advances in the management of AF‐associated stroke have emerged recently, including new scoring systems for predicting stroke and bleeding risks, the development of non‐vitamin K antagonist oral anticoagulants (NOACs), knowledge of their special benefits in Asians, and new techniques. The Asia Pacific Heart Rhythm Society (APHRS) aimed to update the available information, and appointed the Practice Guideline sub‐committee to write a consensus statement regarding stroke prevention in AF. The Practice Guidelines sub‐committee members comprehensively reviewed updated information on stroke prevention in AF, emphasizing data on NOACs from the Asia Pacific region, and summarized them in this 2017 Consensus of the Asia Pacific Heart Rhythm Society on Stroke Prevention in AF. This consensus includes details of the updated recommendations, along with their background and rationale, focusing on data from the Asia Pacific region. We hope this consensus can be a practical tool for cardiologists, neurologists, geriatricians, and general practitioners in this region. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician׳s decision remains the most important factor in the management of AF.
Abstract
The consensus of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation (AF) has been published in 2017 which provided useful clinical guidance for ...cardiologists, neurologists, geriatricians, and general practitioners in the Asia-Pacific region. In these years, many important new data regarding stroke prevention in AF were reported. The practice guidelines subcommittee members comprehensively reviewed updated information on stroke prevention in AF, and summarized them in this 2021 focused update of the 2017 consensus guidelines of the APHRS on stroke prevention in AF. We highlighted and focused on several issues, including the importance of the AF Better Care pathway, the advantages of non-vitamin K antagonist oral anticoagulants (NOACs) for Asians, the considerations of use of NOACs for Asian AF patients with single one stroke risk factor beyond gender, the role of lifestyle factors on stroke risk, the use of oral anticoagulants during the “coronavirus disease 2019” pandemic, etc. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician's decision remains the most important factor in the management of AF.
When assessing ischemic stroke risk in patients with atrial fibrillation (AF), the CHA2DS2-VASc score is calculated based on the baseline risk factors, and the outcomes are determined after a ...follow-up period. However, the stroke risk in patients with AF does not remain static, and with time, patients get older and accumulate more comorbidities.
This study hypothesized that the “Delta CHA2DS2-VASc score,” which reflects the change in score between baseline and follow-up, would be more predictive of ischemic stroke compared with the baseline CHA2DS2-VASc score.
A total of 31,039 patients with AF who did not receive antiplatelet agents or oral anticoagulants, and who did not have comorbidities of the CHA2DS2-VASc score except for age and sex, were studied. The Delta CHA2DS2-VASc scores were defined as the differences between the baseline and follow-up CHA2DS2-VASc scores. During 171,956 person-years, 4,103 patients experienced ischemic stroke. The accuracies of baseline, follow-up, and Delta CHA2DS2-VASc scores in predicting ischemic stroke were analyzed and compared.
The mean baseline CHA2DS2-VASc score was 1.29, which increased to 2.31 during the follow-up, with a mean Delta CHA2DS2-VASc score of 1.02. The CHA2DS2-VASc score remained unchanged in only 40.8% of patients. Among 4,103 patients who experienced ischemic stroke, 89.4% had a Delta CHA2DS2-VASc score ≥1 compared with only 54.6% in patients without ischemic stroke, and 2,643 (64.4%) patients had ≥1 new-onset comorbidity, the most common being hypertension. The Delta CHA2DS2-VASc score was a significant predictor of ischemic stroke that performed better than baseline or follow-up CHA2DS2-VASc scores, as assessed by the C-index and the net reclassification index.
In this AF cohort, the authors demonstrated that the CHA2DS2-VASc score was not static, and that most patients with AF developed ≥1 new stroke risk factor before presentation with ischemic stroke. The Delta CHA2DS2-VASc score, reflecting the change in score between baseline and follow-up, was strongly predictive of ischemic stroke, reflecting how stroke risk in AF is a dynamic process due to increasing age and incident comorbidities.
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The consensus of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation (AF) has been published in 2017 which provided useful clinical guidance for cardiologists, ...neurologists, geriatricians, and general practitioners in Asia‐Pacific region. In these years, many important new data regarding stroke prevention in AF were reported. The Practice Guidelines subcommittee members comprehensively reviewed updated information on stroke prevention in AF, and summarized them in this 2021 focused update of the 2017 consensus guidelines of the APHRS on stroke prevention in AF. We highlighted and focused on several issues, including the importance of AF Better Care (ABC) pathway, the advantages of non–vitamin K antagonist oral anticoagulants (NOACs) for Asians, the considerations of use of NOACs for Asian patients with AF with single 1 stroke risk factor beyond gender, the role of lifestyle factors on stroke risk, the use of oral anticoagulants during the “coronavirus disease 2019” (COVID‐19) pandemic, etc. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician's decision remains the most important factor in the management of AF.
We aim to publish the APHRS consensus simultaneously with the APHRS annual scientific meeting.
The health crisis due to coronavirus disease 2019 (COVID-19) has shocked the world, with more than 1 million infections and casualties. COVID-19 can present from mild illness to multi-organ ...involvement, but especially acute respiratory distress syndrome. Cardiac injury and arrhythmias, including atrial fibrillation (AF), are not uncommon in COVID-19. COVID-19 is highly contagious, and therapy against the virus remains premature and largely unknown, which makes the management of AF patients during the pandemic particularly challenging. We describe a possible pathophysiological link between COVID-19 and AF, and therapeutic considerations for AF patients during this pandemic.
Aim
To investigate the impact of initial decline in estimated glomerular filtration rate (eGFR) in patients with type 2 diabetes (T2D) following sodium‐glucose co‐transporter‐2 inhibitor (SGLT2i) ...treatment.
Materials and Methods
We used medical data from a multicentre healthcare provider in Taiwan and recruited 11 769 patients with T2D with baseline/follow‐up eGFR data available after 1 to 3 months of SGLT2i treatment from 1 June 2016 to 31 December 2018. Patients were followed up from the drug index date until the occurrence of adverse clinical events, SGLT2i discontinuation or the end of the study period, whichever took place first.
Results
Overall, SGLT2i treatment was associated with an initial eGFR decline of 3.5% ± 14.0% after a median treatment period of 10 weeks. A total of 37.1% (n = 4371) of patients experienced no eGFR decline, and 30.5% (n = 3593), 20.2% (n = 2376), 8.5% (n = 999) and 3.7% (n = 430) of patients experienced an eGFR decline of 0%‐10%, 10%‐20%, 20%‐30% and more than 30%, respectively. The mean eGFR over time became stable after 6 months in all eGFR decline categories, even in the group with a pronounced eGFR decline of more than 30%. Compared with no eGFR decline, an initial eGFR decline of 0%‐10%, 10%‐20% or 20%‐30% was not associated with a higher risk of atrial fibrillation (AF), major adverse cardiovascular events (MACE, including ischaemic stroke, systemic embolism and acute myocardial infarction)/heart failure (HF) and composite renal outcome (doubling of the serum creatinine level/end‐stage kidney disease), whereas an eGFR decline of more than 30% was associated with a higher risk of new‐onset AF (adjusted hazard ratio aHR = 2.20, 95% confidence interval CI = 1.40‐3.47), MACE/HF (aHR = 2.09, 95% CI = 1.04‐4.17) and composite renal outcome (aHR = 1.82, 95% CI = 1.18‐2.83). The multivariate analysis indicated that the use of a diuretic or insulin, presence of stroke, older age, female sex, a higher HbA1c level, and a lower body mass index of less than 25 kg/m2 were independent factors associated with an eGFR decline of more than 30% following SGLT2i initiation.
Conclusions
A pronounced eGFR decline of more than 30% following SGLT2i treatment was associated with adverse cardiovascular or renal events among patients with T2D.
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