Stroke risk in AF: do AF patterns matter?
Stroke risk in AF: do AF patterns matter?
复制标题
房颤中的中风风险：房颤模式重要吗？
DOI：
10.1093/eurheartj/ehq074
复制
发表时间：
2010
影响因子：
39.3
通讯作者：
Benjamin,EmeliaJ
中科院分区：
文献类型：
--
作者：
Lubitz,StevenA;Rosen,AlisaB;Ellinor,PatrickT;Benjamin,EmeliaJ
Atrial fibrillation (AF) is accompanied by substantial morbidity 1 and is increasing in both incidence and prevalence. 2, 3 Stroke is the chief hazard from AF, and is five times more likely among individuals with AF than among those without the condition. 4 Moreover, AF-related strokes are associated with an 50% increased odds of disability and a 60% increased odds of death at 3 months compared with strokes of other aetiologies. 5 The need for effective therapies that reduce morbidity from AF is underscored by the presence of an increasingly ageing population, particularly because the elderly are at increased risk for AF-related complications such as stroke. 6 Although several stroke risk stratification schemes exist, which facilitate personalized thrombo-embolism prophylaxis for individuals with AF, 1 the underprescription of thrombo-embolism prophylaxis represents an established barrier to care. 7–9 The current AF classification scheme endorsed by the American College of Cardiology, American Heart Association, and European Society of Cardiology does not explicitly take stroke risk into account. 1 Rather, the AF classification scheme emphasizes rhythmbased patterns of disease. AF is classified as paroxysmal if it selfterminates within 1 week, persistent if it continues beyond this period and is not self-terminating, or permanent if attempts to terminate the rhythm fail or no attempts are made. Friberg et al. have now attempted to discern whether the incidence of stroke in AF differs according to AF pattern. 10 The investigators performed a retrospective, observational analysis among patients diagnosed with AF at a single hospital or primary care centre in the vicinity of Stockholm, Sweden. AF status was ascertained by chart review and patterns were classified in accordance with existing consensus guidelines, although definitions were altered so that subjects who were cardioverted were not included among those classified as having paroxysmal disease. AF classifications were based on review of medical records from subjects’ encounters at the hospital and primary care centre. Those with persistent AF were excluded from the analysis. Stroke was ascertained by the National Register of Hospital Discharges, and medication administration was based on the last recorded follow-up. The study sample consisted of 855 subjects with paroxysmal AF and 1126 with permanent AF. After a follow-up of 3 years, 77 strokes occurred among those with paroxysmal AF, and 116 among those with permanent AF. The primary finding was that the incidence of ischaemic stroke was similar between those with paroxysmal AF and those with permanent AF (incidence rate 26 vs. 29 per 1000 patient-years, P ¼ 0.54). The hazard ratio (HR) for ischaemic stroke was similar for paroxysmal and permanent AF, even after adjusting for established stroke risk factors and warfarin use [HR 1.1, 95% confidence interval (CI) 0.78–1.56]. Moreover, the investigators observed an 2-fold increase in the standardized incidence of ischaemic stroke for both paroxysmal and permanent AF as compared with the general population. Although the authors also assessed the incidence and hazard of haemorrhagic stroke, the analysis was underpowered to detect true differences, as only 23 subjects experienced a haemorrhagic stroke in the entire sample. As expected, warfarin use at last follow-up was associated with a substantially diminished incidence of stroke (HR 0.44, 95% CI 0.30–0.65) relative to those who were not taking warfarin. As acknowledged by the authors, retrospective analyses have limitations. Among the drawbacks of such a study design is the potential for misclassification of the pattern …
