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The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation
Published on: February 28, 2012
Stroke, Timing of Atrial Fibrillation Diagnosis, and Risk of Death
Anjali Bhatla1, Yuliya Borovskiy1, Ronit Katz1
1From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN.
Insights
Diagnosing atrial fibrillation (AF) after stroke increases mortality risk. Patients with AF diagnosed after stroke (AFDAS) showed the highest risk of death, independent of other factors.
Area of Science:
- Cardiology
- Neurology
- Public Health
Background:
- Atrial fibrillation (AF) is a common risk factor for ischemic stroke.
- The prognostic impact of the timing of AF diagnosis relative to stroke onset is not fully understood.
Purpose of the Study:
- To evaluate the prognosis of patients with ischemic stroke based on the timing of atrial fibrillation (AF) diagnosis.
- To compare the risk of death among patients with stroke and sinus rhythm, known AF (KAF), or AF diagnosed after stroke (AFDAS).
Main Methods:
- An inception cohort of incident ischemic stroke events was created.
- Mortality data were linked with the National Death Index.
- Cox proportional hazards models were used to assess the association between stroke subtypes and mortality.
Main Results:
- The study included 1,489 patients: 985 with no AF, 215 with KAF, and 289 with AFDAS (160 diagnosed ≤6 months post-stroke, 129 >6 months).
- Annualized mortality rates were 8.8% (no AF), 12.2% (KAF), 15.8% (AFDAS ≤6 months), and 12.7% (AFDAS >6 months).
- Patients with AFDAS diagnosed ≤6 months after stroke had the highest independent risk of all-cause mortality (HR 1.62).
Conclusions:
- Diagnosing atrial fibrillation after an ischemic stroke is associated with the highest risk of death.
- This increased mortality risk in the AFDAS group was not attributable to comorbidities or antithrombotic therapy use.
- The timing of AF diagnosis significantly impacts stroke patient prognosis.
Objective:
To evaluate the prognosis of patients with ischemic stroke according to the timing of an atrial fibrillation (AF) diagnosis, we created an inception cohort of incident stroke events and compared the risk of death between patients with stroke with (1) sinus rhythm, (2) known AF (KAF), and (3) AF diagnosed after stroke (AFDAS).
Methods:
We used the Penn AF Free study to create an inception cohort of patients with incident stroke. Mortality events were identified after linkage with the National Death Index through June 30, 2017. We also evaluated initiation of anticoagulants and antiplatelets across the study duration. Cox proportional hazards models evaluated associations between stroke subtypes and death.
Results:
We identified 1,489 individuals who developed an incident ischemic stroke event: 985 did not develop AF at any point during the study period, 215 had KAF before stroke, 160 had AF detected ≤6 months after stroke, and 129 had AF detected >6 months after stroke. After a median follow-up of 4.9 years (interquartile range 1.9-6.8), 686 deaths occurred. The annualized mortality rate was 8.8% in the stroke, no AF group; 12.2% in the KAF group; 15.8% in the AFDAS ≤6 months group; and 12.7% in the AFDAS >6 months group. Patients in the AFDAS ≤6 months group had the highest independent risk of all-cause mortality even after multivariable adjustment for demographics, clinical risk factors, and the use of antithrombotic therapies (hazard ratio 1.62 [1.22-2.14]). Compared to the stroke, no AF group, those with KAF had a higher mortality risk that was rendered nonsignificant after adjustment.
Conclusions:
The AFDAS group had the highest risk of death, which was not explained by comorbidities or use of antithrombotic therapies.
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