Cardiopatia ischemica Sintomatica ad esordio negli ultimi 12 mesi in paziente...
1 fibrillazione atriale non solo stroke
1. FIBRILLAZIONE ATRIALE: NON
SOLO STROKE
FRANCESCO ARRIGO
I SESSIONE Ore 11.00
MODERATORI:
MARCO DI FRANCO- CARMELO PASQUALE-
GIANCARLO SELVAGGIO
2. Ictus e fibrillazione atriale: un
legame pericoloso
«I fattori di rischio noti per l’ictus -
spiega Mauro Silvestrini,
Responsabile della Stroke Unit
dell’Azienda Ospedaliero
Universitaria Ospedali Riuniti di
Ancona e presidente di regione
Marche di A.L.I.Ce. Italia Onlus-
sono diversi. Ai più conosciuti come
l’ipertensione, l’obesità, il fumo,
l’ipercolesterolemia, il diabete e
molto altro, la fibrillazione atriale
rappresenta ne rappresenta uno dei
principali».
4. Epidemiology of atrial fibrillation:
European perspective
Prevalence of atrial fibrillation in
European countries.
• Prevalence of AF in the
general adult population
of Europe is more than
double that reported just
one decade earlier,
ranging from 1.9% in Italy,
Iceland, and England to
2.3% in Germany and
2.9% in Sweden
• Incidence 0.23–0.41 per
1,000 person/years
Zoni-Berisso M et al Clinical Epidemiology 2014:6 213–220
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Epidemiologia
5. Risk for Atrial Fibrillation according to age and
risk factor burden
Staerk L et al, BMJ 2018;360:k1453
Il rischio di FA cresce con l’età indipendentemente dai fattori di rischio
Naccarelli GV et al. Am J Cardiol. 2009;104(11):1534-9
MarketScan research databases from Thomson Reuters
Of the 21,648,681 patients in the databases, 242,903 (1.12%)
had nontransient AF and/or AFL
Cumulative risk (%) for atrial fibrillation according to
risk factor burden (optimal, borderline, or elevated)
at index age 55 years. the Framingham Heart Study
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Epidemiologia
6. Epidemiology of atrial fibrillation
• Projected
number of
adults with atrial
fibrillation in the
European Union
between 2000
and 2060.
• From Krijthe BP et al.
Eur Heart J
2013;34:2746–2751.
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Epidemiologia
Questo andamento può essere spiegato con l’aumento dell’età nella popolazione
generale, la crescente prevalenza di obesità, la maggiore sopravvivenza dopo un
primo evento cardiovascolare e la disponibilità di una tecnologia sempre più
efficiente nel riconoscere la FA.
7. Odutayo A et al. BMJ 2016;354:i4482
Association between AF and all cause mortality and CV renal disease. Systematic review and
meta-analysis. 104 eligible cohort studies involving 9.686.513 participants (587.867 with AF)
FIBRILLAZIONE ATRIALE: NON SOLO STROKE I rischi della FA
Atrial fibrillation as Risk factor
9. 75 – 94 anni
There was a significant AF-sex interaction: AF diminished the
female advantage in survival.
We examined the mortality of subjects 55 to 94 years of age who
developed AF during 40 years of follow-up of the original
Framingham Heart Study cohort.
By pooled logistic regression, after adjustment for age,
hypertension, smoking, diabetes, left ventricular hypertrophy,
myocardial infarction, congestive heart failure, valvular heart
disease, and stroke or transient ischemic attack, AF was associated
with an OR for death of 1.5 (95% CI, 1.2 to 1.8) in men and 1.9
(95% CI, 1.5 to 2.2) in women.
55 – 74 anni
Benjamin EJ, Circulation 1998; 98: 946
ORfordeath
1.5(95%CI,1.2to1.8)inmen
1.9(95%CI,1.5to2.2)inwomen
10. Atrial fibrillation and the risk for myocardial infarction, all-cause
mortality and heart failure:
A systematic review and meta-analysis
Forest plots for the risk of
all-cause mortality
associated with atrial
fibrillation.
ES (95% CI): risk ratio (95% confidence
interval).
OVERALL
HR 1.95 (1.50- 2.54)
Ruddox V et al Eur J Prev Cardiol. 2017 Sep;24(14):1555-1566.
First author
%
Weight
ES
(95% CI)
Mortalità
11. Il tasso di mortalità
attribuibile a FA,
corretto per l’età, è
4 (3.9-4.2)/100.000.
In 10 anni, ha subito
un incremento del
2.6%, mentre quello
per altre patologie
ha registrato una
riduzione.
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Mortalità
12. Patterns della Fibrillazione Atriale e rischio di Mortalità
Lubitz SA et al. J Am Heart Assoc. 2013
Oct; 2(5): e000126
Risk of death stratified by type of AF
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Mortalità
Siontis K, Gersh B, Killian Jea. Heart Rhythm.
2016;13:1418–1424.
Survival stratified by AF presentation
Atipical/asymptomatic at presentation had an
increased risk for
CV death (HR, 3.12; 95% CI 1.50–6.45)
All-cause mortality (HR, 2.96; 95% CI, 1.89–4.64)
• recurrent AF HR 2.04 P=0.003)
• sustained AF HR 2.36, P=0.003)
(Framingham Heart Study)
13. Causes of Death in Patients With AF
2-Year Outcome Data From GARFIELD-AF
Bassand P et al. European Heart Journal (2016) 37, 2882–2889
40,47 %
35,81 %
14. Relationship of Sudden Cardiac Death to New-Onset Atrial
Fibrillation
Okin PM et al. Circ Arrhythm Electrophysiol. 2013;6:243-251
8831 hypertensive patients with ecgraphic LV hypertrophy with no history of AF
Risk of SCD
multivariate HR 3.13
(1.87–5.24;P<0.001).
• During 4.7±1.1 years mean follow-
up, new-onset AF occurred in 701
patients (7.9%) and SCD in 151
patients (1.7%).
• New-onset AF was associated with a
>4-fold higher risk of SCD (HR 4.69;
95% CI, 2.96–7.45; P<0.001).
• In multivariate Cox analyses, new-
onset AF remained associated with a
>3-fold increased risk of SCD (HR
3.13; 95% CI, 1.87–5.24; P<0.001).
15. Fattori indipendenti che predicono la Morte
Improvvisa ina pazienti con Fibrillazione atriale
RE-LY Trial ENGAGE AF-TIMI-48 Trial
16. Sintesi Fibrillazione atriale e Mortalità
• Nei pazienti con fibrillazione atriale la mortalità per tutte le cause
è circa doppia rispetto ai soggetti senza FA, anche dopo correzione
per l’età.
• L’aumento di mortalità in soggetti con FA è crescente a livello
globale, mentre l’incidenza relativa di decessi per le principali
malattie CV è in riduzione.
• Nel 40% è dovuta a cause CV, e fra queste una quota non
trascurabile (circa 20%) è costituita da morte improvvisa o
aritmica.
• È più frequente nelle forme asintomatiche o con sintomi atipici e
nella FA sostenuta o ricorrente.
18. Potenziali meccanismi dello scompenso nella FA
•
“AF is more often a risk factor for HF than the reverse”
Staerk L, et al Circ Res. 2017;120:1501–17.
Anter E et al. Circulation. 2009;119:2516-2525
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Scompenso Cardiaco
19. Kaplan–Meier event-free survival curves for the composite endpoint of
death or hospitalization for heart failure from the SOLVD trial based on
presence/absence of atrial fibrillation (AF).
• In SOLVD, patients with LVEF 35%
and symptomatic or asymptomatic
CHF were randomized to enalapril
treatment or placebo.
• In retrospective analyses of this
trial, survival free of heart failure
hospitalization or death was
compared for the 419 patients with
AF at baseline versus the 6,098
patients without baseline AF.
Dries DL et al J Am Coll Cardiol. 1998 Sep;32(3):695-703
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Scompenso Cardiaco
20. Atrial fibrillation and the risk for myocardial infarction, all-cause
mortality and heart failure:
A systematic review and meta-analysis
Forest plots for the risk of
Heart Failure associated
with atrial fibrillation.
ES (95% CI): risk ratio (95% confidence
interval).
OVERALL
HR 4.62 (3.13- 6.83)
Ruddox V et al Eur J Prev Cardiol. 2017
Sep;24(14):1555-1566.
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Scompenso Cardiaco
First author
%
Weight
ES
(95% CI
21. Nei pazienti con FA la forma più frequente di scompenso
è quella a FE normale
38
32
18
12
45.34883721
23.4496124
18.21705426
12.98449612
no AF previous AF current AF future AF
Temporal association of AF and HF
subtypes
HFpEF
HFrEF
Santhanakrishnan R et al. Circulation. 2016; 133(5): 484–492
64
13.5
22.5
EF
preserved
EF reduced EF missing
%
Pandley A et al. JACC Heart Fail.
2017 Jan;5(1):44-52.
ORBIT-AF registry
236 participants (3.6%) over the
2-year follow-up period;
Framingham Heart Study
Prevalent AF was more strongly associated with incident HFpEF (HR
2.34, ([1.48–3.70) vs HFrEF (HR 1.32, 95%CI 0.83–2.10), with a trend
toward difference between HF subtypes (P =0.06).
PERCENTAGE
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Scompenso Cardiaco
22. History of Atrial Fibrillation as a Risk Factor in Patients
With HFpEF
• Patients with HFpEF in the Irbesartan in Heart Failure with Preserved
Ejection Fraction Trial (I-PRESERVE) were analyzed in relation to AFib.
• At baseline, 1209 (29.3%) had a history of AFib.
Oluleye et al Atrial Fibrillation in I-PRESERVE. Circ Heart Fail. 2014;7:960-966.)
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Scompenso Cardiaco
23. Atrial Fibrillation and Mortality in Heart Failure
Chamberlain AM et al Circ Heart Fail. 2011;4:740-746
Of 1664 individuals with HF diagnosed between 1983 and 2006 (mean age, 76.2 years; 45.6%
men), 553 had a history of AF and 384 developed AF after HF diagnosis.
• 450 deaths occurred among persons
with prior AF, 314 among those with
AF after HF, and 572 among patients
without AF.
• HR for death in individuals with AF
compared with those without AF:
• prior AF 1.48 (95% CI, 1.31–1.68)
• AF after HF 2.35 (95% CI, 2.04-2.71)
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Scompenso Cardiaco
553 384
24. Ablazione della Atriale Fibrillazione.
Effetti sullo scompenso cardiaco
Gentlesk PJ, et al . J Cardiovasc Electrophysiol. 2007; 18:9 –14. Marrouche NF et al N Engl J Med 2018;378:417-27
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Scompenso Cardiaco
CASTLE-AF
25. Sintesi Fibrillazione atriale e Scompenso
• Il rischio di SC è quadruplo nei pazienti con FA rispetto ai soggetti in
ritmo sinusale ed è particolarmente rilevante nelle forme
ricorrenti.
• La relazione tra FA e scompenso cardiaco è bidirezionale: la
fibrillazione atriale può precedere lo scompenso o verificarsi in
conseguenza di questo.
• La forma di scompenso che si manifesta più frequentemente nei
pazienti con FA è quella a FE conservata e in questi casi la prognosi
è peggiore.
• L’ablazione transcatetere della FA ha effetti favorevoli sullo SC.
27. Fattori patogenetici potenziali dello stroke nella FA
• La tromboembolia può avere origine da altre
sedi (trombosi ventricolare, placche carotidee
e aortiche).
• La coesistenza nei pz con FA di numerosi FR di
rischio comuni alle due condizioni rende
complessa la comprensione del meccanismo
patogenetico.
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Stroke
• Il Tromboembolismo per trombosi dell’auricola sinistra
è il meccanismo più accreditato.
28. Prevalence of atrial fibrillation (AF) and strokes
attributable to AF: findings from the Framingham Study.
Wolf P.A., Abbott R.D., Kannel W.B., "Atrial fibrillation as an independent risk factor for stroke - the Framingham Study",
Stroke, (1991), : 22, 983-988
age-adjusted relative risk of stroke for
men (open bars) and women (filled bars)
with AF compared with those without AF
in presence of cardiac failure or coronary
heart disease. **p
1,5
23,5
572 initial strokes, 122 of which were TIA.
• 256 atherothrombotic brain infarction
• 114 stroke from cerebral embolism
• 27 intracerebral hemorrhage
• 39 subarachnoid hemorrhage
• 14 strokes due to miscellaneous causes
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Stroke
I dati del FHS sono importanti perché sono stati per molto tempo i valori di riferimento.
Generalmente si è attribuito alla FA un Rischio Relativo per stroke di 5, valore
soprastimato per aver incluso tutte le forme di ictus e per non avere considerato il
rischio dovuto alle malattie coesistenti.
Nella metanalisi di Odutayo (2016) il rischio di stroke ischemico è
2.33 (1.84 -2.94)
29. Risk of Stroke and Death in Untreated Screen-Detected AF
5555 patients with asymptomatic clinical AF detected
incidentally in general practice. 1.5 years of follow-up
FU 1.5 years adjusted stroke
rate
all-cause
mortality
1460 untreated
AF patients
4% 7%
controls
without AF
1% 2.5%
Martinez C, et al. Thromb Haemost. 2014;112:276–286.
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Stroke
Incidence Rate per 1000/pts/yr
• AF cohort 19.4 (17.1-21.9)
• No AF cohort 8.4 ( 7.7 - 9.1)
HR=2.3
30. FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Stroke
Relazione temporale tra FA subclinica e stroke in pazienti con
devices impiantati
Time trend of risk of stroke
for AF in 60 days before
stroke.
nonsignificant increases for AF >21 days
before stroke
Turakhia MP, et al Circ Arrhythm Electrophysiol. 2015;8:1040–1047.
Studio ASSERT
31. (Circ J 2015; 79: 432–438)
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Stroke
32. Medscape's Atrial Fibrillation CHADS2 Score for Stroke Risk calculator.
Score CHA2DS2-VASc Risk Criteria
1 point Congestive heart failure
1 point Hypertension
2 points Age ≥75 years
1 point Diabetes mellitus
2 points Stroke/Transient Ischemic
Attack/Thromboembolic event
1 point Vascular disease (prior MI, PAD, or
aortic plaque)
1 point Age 65 to 74 years
1 point Sex category (ie, female sex)
CHA2DS2-VASc Score Adjusted Stroke
Risk(% per year)
0 0
1 1.3
2 2.2
3 3.2
4 4.0
5 6.7
6 9.8
7 9.6
8 6.7
9 15.2
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Stroke
33. • Annual risk of ischemic stroke in AF patients
with CHA2 DS2 -VASc score of 1 is 1.61%
with substantial uncertainty remaining (95%
CI 0%–3.23%).
• Additionally, the summary annual risk was
• 0.68% for CHA2 DS2 -VASc score of 0
• 2.49% for CHA2 DS2 -VASc score of 2.
• A limitation of meta-analysis was the
heterogeneity between studies.
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Stroke
Ischemic Stroke Risk in Patients With
Atrial Fibrillation and CHA2DS2-VASc Score of 1
Systematic Review and Meta-Analysis
Joundi RA et al. Stroke. 2016;47:1364-1367
Summary measure of 7 studies
34. CAABL-AF (California Study of Ablation for Atrial Fibrillation)
Circ Arrhythm Electrophysiol. 2018;11:e005739.
• L’ablazione riduce il Rischio di stroke ischemico (30gg-5 anni) del 32 % (HR 0.68, p<0.035)
Results comparing Ablation vs no-Ablation for Atrial Fibrillation
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Stroke
Ablazione della Atriale Fibrillazione.
Effetti sullo Stroke
35. Korsholm K et al EuroIntervention 2017;12:2075-2082
Transcatheter left atrial appendage occlusion in patients with atrial fibrillation and a
high bleeding risk using aspirin alone for post-implant antithrombotic therapy
LAAC
• 110 pz
• Motivo dell’impianto: Rischio
emorragico
• Device: AMPLATZER (ACP) o Amulet
Figure 2. Predicted and observed rates of
stroke and major bleeding.
Effectiveness of LAAO in reducing the risk of
stroke and bleeding among 107 high-risk AF
patients.
ASA was used as monotherapy for post-implant
antithrombotic therapy. Both periprocedural
and follow-up events were included.
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Stroke
36. Sintesi Fibrillazione atriale e Stroke
• La FA aumenta il rischio di stroke ischemico di 2-3 volte (HR 2.3).
• Nei pazienti con CHA2 DS2 -VASc-score 1 non c’è eccesso di
stroke.
• Il Rapporto di Rischio è più alto se la FA è presente nei 10 giorni
precedenti lo stroke (HR >15); dopo si stabilizza a 3-4.
• La relazione patogenetica diretta fra FA e stroke (tromboembolia
da formazioni dell’auricola sinistra) è dimostrata dai rilievi
ecocardiografici e dal rischio connesso alla cardioversione della
FA, ma non è generalizzabile.
• In alcuni studi iniziali, le procedure interventistiche (ablazione e
chiusura dell’auricola) hanno ridotto l’incidenza di stroke.
38. Fibrillazione atriale e rischio di infarto miocardico
Soliman, EZ et al. JAMA Intern
Med. 2014 Jan;174(1):107-14.
• FA e IMA hanno fattori di rischio simili.
• La cardiopatia ischemica subclinica è associata
ad alta prevalenza di FA ed elevato rischio di
IMA.
• Livelli elevati di markers infiammatori sono
associati ad aumentato rischio sia di FA sia di IMA
• Il tromboembolismo coronarico può essere
un’altra potenziale causa.
• Alcuni pazienti con FA presentano elevata
risposta ventricolare, causando un IMA «da
domanda» (IM tipo 2).
Possibili Meccanismi
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Infarto Miocardico Acuto
39. Atrial fibrillation and the risk for myocardial infarction, all-cause mortality
and heart failure: A systematic review and meta-analysis
Forest plots for the risk of
Myocardial Infarction
associated with atrial
fibrillation.
ES (95% CI): risk ratio (95% confidence interval).
OVERALL
HR 1.54 (1.28-1.85)
Ruddox V et al Eur J Prev Cardiol. 2017 Sep;24(14):1555-1566.
First author
%
Weight
ES
(95% CI
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Infarto Miocardico Acuto
40. Atrial fibrillation and the risk of
Miocaridal infarction
JAMA Internal Medicine Published online November 4, 2013
• A prospective cohort of 23 928 participants residing in the continental United States and without
CAD at baseline were enrolled from the Reasons for Geographic and Racial Differences in Stroke
(REGARDS) cohort between 2003 and 2007, with follow-up through December 2009.
• The risk of MI associated with AF was significantly higher in women (HR, 2.16 [95%CI, 1.41-3.31])
than in men (HR, 1.39 [95% CI, 0.91-2.10]) and in blacks (HR, 2.53 [95% CI, 1.67-3.86]) than in
whites (HR, 1.26 [95% CI, 0.83-1.93]).
Soliman, EZ et al. JAMA Intern Med. 2014 Jan;174(1):107-14.
Age-adjusted incidence rate of MI
without AF 6.0
°/°° person-years
with AF 12.0 °/°°
person-years
(P < .001)
Sex-Race Stratified Age-Adjusted
Incidence Rates of MI by AF Status
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Infarto Miocardico Acuto
41. Atrial fibrillation and the risk of myocardial infarction: a
nationwide propensity-matched study
Lee HY et al. Sci Rep. 2017 Oct 5;7(1):12716
Association between AF
and incident MI in 497,366
adults from the Korean
National Health Insurance
Service database.
AF was associated with 3-
fold increased risk of MI
(HR, 3.1; 95% CI, 2.23–
4.36) in both men (HR,
2.88; 95% CI 1.89–4.39)
and women (HR, 3.65; 95%
CI 2.09–6.38).
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Infarto Miocardico Acuto
42. Risk of Myocardial
Infarction in
Anticoagulated
Patients With
Atrial Fibrillation
• 31,739 Patients with
atrial fibrillation
were identified using
Danish health care
registers and
stratified by initial
oral anticoagulant
treatment.
Standardized 1-year risk of MI
• VKA 1.6% (1.3 to 1.8)
• apixaban 1.2% (0.9 to 1.4)
• dabigatran 1.2% (1.0 to
1.5)
• rivaroxaban 1.1% (0.8 to
1.3)
The risk differences for DOACs versus
VKA were all significant
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Infarto Miocardico Acuto
43. • La relazione tra FA e IMA è bidirezionale: l’infarto può precedere o
complicare il decorso clinico della fibrillazione atriale.
• La FA è comune nel periodo postinfartuale e si verifica nel 6-21% dei
pazienti , abitualmente nelle prime 72 ore. Lo sviluppo di FA
comporta un aumento dlela mortalità a 30 giorni e a lungo termine.
• Il rischio di IMA in pazienti con FA è circa doppio rispetto a quelli
senza FA (dopo correzione per età e fattori di rischio) ed è maggiore
nelle donne e nei soggetti di colore.
• L’insorgenza di IM in pazienti con FA comporta difficoltà nel
trattamento dei pazienti per la complessa gestione delle terapie
antitrombotiche, specie in relazione agli interventi percutanei.
Sintesi Fibrillazione atriale e Infarto Miocardico
45. Different mechanisms through which atrial fibrillation may
contribute to cognitive impairment (dementia)
Potential interventions
are shown in red.
Some of the reported
brain morphometric
changes include:
hippocampus
atrophy, white matter
hyperintensities, and
frontal medial lobe
atrophy.
N. Dagres et al. Europace (2018) 0, 1–23
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Demenza
CO, cardiac output; CRP, C-reactive protein; DM, diabetes mellitus; HF, heart
failure; HTN, hypertension; IL, interleukin; OSA, obstructive sleep apnoea.
46. AF is associated with a higher risk for cognitive impairment and
dementia, with or without a history of clinical stroke.
N. Dagres et al. Europace (2018) 0, 1–23
• Two meta-analyses that included both cross-sectional and
prospective studies specifically examined the incidence of dementia
in patients with AF and strokes.
• These meta-analyses found similar estimates of the RR of cognitive
impairment or dementia of 2.43 and 2.70.
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Demenza
47. La FA si associa in modo significativo a
declino della funzione cognitiva globale β = -0,24 (-0,31 a -0,16)
demenza per ogni causa HR 1.40 (1,11-1,77)
demenza per cause vasc. e mista HR 1,88 (1,09-3,23)
malattia di Alzheimer HR 1,33 (0,92-1,94)
L’uso di anticoagulanti orali si associa a
rischio di demenza HR 0,40 (0,18-0,92)
Atrial fibrillation, antithrombotic treatment, and cognitive aging.
A population-based study
• 2.685 partecipanti dello studio SNAC-K, anziani ≥60 anni non affetti da demenza.
• Al basale, i pazienti con FA erano 243 (9,1%); durante i 9 anni di follow-up, 279
partecipanti (11,4%) hanno sviluppato FA e 399 (14,9%) hanno sviluppato demenza.
Ding M, Fratiglioni L, et al. Neurology 2018;91:e1732-e1740.
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Demenza
49. OVERVIEW
• La fibrillazione atriale è una malattia progressiva e clinicamente molto
complessa.
• Ha importanti conseguenze emodinamiche e miocardiche e comporta
significativi aumenti di mortalità e morbilità CV.
• Il peso epidemiologico e prognostico delle forme clinicamente silenti o
riscontrate con monitoraggio prolungato non è ancora ben noto.
• Le strategie di intervento devono includere, oltre all’anticoagulazione,
misure per ridurre il rischio delle malattie epidemiologicamente associate.
• Le procedure interventistiche di ablazione e chiusura dell’auricola
sembrano avere un potenziale beneficio, ma richiedono ulteriori verifiche.
FIBRILLAZIONE ATRIALE: NON SOLO STROKE
50. • Grazie per l’attenzione
Grazie per
l’attenzione
51. Atrial Fibrillation and Mortality in Heart Failure
Chamberlain AM et al Circ Heart Fail. 2011;4:740-746
Of 1664 individuals with HF diagnosed between 1983 and 2006 (mean age, 76.2 years; 45.6%
men), 553 had a history of AF and 384 developed AF after HF diagnosis.
• 450 deaths occurred among persons
with prior AF, 314 among those with
AF after HF, and 572 among patients
without AF.
• HR for death in individuals with AF
compared with those without AF:
• prior AF 1.48 (95% CI, 1.31–1.68)
• AF after HF 2.35 (95% CI, 2.04–
2.71),
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Scompenso Cardiaco
52. New ESC Guidelines on
Atrial Fibrillation 2016
Cardiovascular
morbidity and
mortality associated
with AF
FIBRILLAZIONE ATRIALE: NON SOLO STROKE I rischi della FA
ESC Congress Rome 2016
53. Different mechanisms through which atrial fibrillation may
contribute to cognitive impairment (dementia)
N. Dagres et al. Europace (2018) 0, 1–23
• Evidence suggests that AF is associated with a higher risk for
cognitive impairment and dementia, with or without a history of
clinical stroke.
• Two meta-analyses that included both cross-sectional and
prospective studies specifically examined the incidence of dementia
in patients with AF and strokes.24,25
• These meta-analyses found similar estimates of the RR of cognitive
impairment or dementia of 2.43 and 2.70 (Table 6).
FIBRILLAZIONE ATRIALE: NON SOLO STROKE Patologie associate: Demenza
Editor's Notes
Epidemiology of atrial fibrillation: European perspective
DA Lifetime risk of atrial fibrillation Framingham Heart Study - collegamento
Da Epidemiology of atrial fibrillation 2018 – collegamento
Questo andamento può essere spiegato con l’aumento dell’età nella popolazione generale, la crescente prevaleenza di obesità, la maggiore sopravvivenza dopo un primo evento cardiovascolare e la disponibilità di una tecnologia sempre più efficiente nel riconoscere la FA.
Staerk L et al. Circ Res. 2017 April 28; 120(9): 1501–1517 Da Atrial Fibrillation Epidemiology, Pathophysiology, and Clinical outcome 2017 - collegamento (2)
Da Atrial fibrillation and risks of cardiovascular disease
Da Atrial fibrillation and risks of cardiovascular disease
Da Atrial fibrillation and risks of cardiovascular disease
Tze-Fan Chao et al. Lifetime Risks, Projected Numbers, and Adverse Outcomes in Asian Patients With Atrial Fibrillation, Chest (2017). Chest. 2018 Feb;153(2):453-466
Send to
Chest. 2018 Feb;153(2):453-466. doi: 10.1016/j.chest.2017.10.001. Epub 2017 Oct 7.
Lifetime Risks, Projected Numbers, and Adverse Outcomes in Asian Patients With AtrialFibrillation: A Report From the Taiwan Nationwide AF Cohort Study.
Chao TF1, Liu CJ2, Tuan TC1, Chen TJ3, Hsieh MH4, Lip GYH5, Chen SA1.
Author information
Abstract
BACKGROUND:
Most data on the clinical epidemiology of atrial fibrillation (AF) come from Western populations, and data for Asians are limited. We investigated the lifetime risk and projected number of AF among Asians. The annual risks of adverse events among patients with AF, time trends, and the risks compared with patients without AF were analyzed.
METHODS:
Between 2000 and 2011, 289,559 patients aged ≥ 20 years experienced new-onset AF in Taiwan. The incidence, prevalence, and lifetime risk of AF were calculated. The risk of adverse events among patients with AF were analyzed and compared with that of age- and sex-matched patients without AF.
RESULTS:
The incidence of AF in year 2011 was 1.51 per 1,000 person-years, with a lifetime risk of AF being appropriately 1 in 7 for subjects aged > 20 years. The prevalence of AF is estimated to be 4.01% in 2050. Compared with patients without AF, AF was associated with an increased risk of mortality (adjusted hazard ratio [aHR], 2.61), heart failure (aHR, 3.31), ischemic stroke (aHR, 3.34), dementia (aHR, 1.56), sudden cardiac death (aHR, 1.83), and myocardial infarction (aHR, 1.62); all P < .01. The risks of ischemic stroke, heart failure, and mortality were especially higher compared with patients without AF in the initial period (approximately 6 months) after AF was first diagnosed.
CONCLUSIONS:
The burden of AF among Asian patients is increasing, with a lifetime risk of AF being 1 in 7. Optimized management of any associated comorbidities should be part of the holistic management approach for AF.
Dati del framingham
J Am Heart Assoc. 2013 Oct; 2(5): e000126.
Published online 2013 Oct 25. doi: 10.1161/JAHA.113.000126
PMCID: PMC3835216
Atrial Fibrillation Patterns and Risks of Subsequent Stroke, Heart Failure, or Death in the Community
Steven A. Lubitz, MD, MPH, Carlee Moser, PhD, Lisa Sullivan, PhD, Michiel Rienstra, MD, PhD, João D. Fontes, MD,Mark L. Villalon, MD, Manju Pai, MD, David D. McManus, MD, ScM, Renate B. Schnabel, MD, MSc, Jared W. Magnani, MD, MSc, Xiaoyan Yin, PhD, Daniel Levy, MD, Michael J. Pencina, PhD, Martin G. Larson, ScD, Patrick T. Ellinor, MD, PhD, and Emelia J. Benjamin, MD, ScM
10,7 25,3 7,5 17,7 7,9 18,7 5,1 12,1 11,1 26,2
Cv 40,47 %
Non CV 35,81 %
Non detemianta 23,7
Da Sudden Cardiac Death and Afibr
In multivariate Cox analyses adjusting for age, sex, race, diabetes mellitus, history of heart failure, myocardial infarction, ischemic heart disease,
stroke, smoking, serum high-density lipoprotein cholesterol, creatinine, glucose, and urine albumin/creatinine ratio as
standard risk factors, and for incident myocardial infarction, in-treatment use of digoxin, systolic and diastolic pressure,
heart rate, QRS duration, Cornell voltage-duration product, and Sokolow-Lyon voltage left ventricular hypertrophy
treated as time-varying covariates, new-onset AF remained associated with a >3-fold increased risk of SCD (hazard ratio,
3.13; 95% confidence interval, 1.87–5.24; P<0.001).
Heart failure occurs in up to one third of patients with AF (Santhanakrishnan et al., 2016), which may be as a direct result of rapid ventricular rates in AF [known as a tachycardiainduced cardiomyopathy (Fujino et al., 2007)] or the association of risk factors common to both conditions such as hypertension (Benjamin et al., 1994; Levy et al., 1996). I
American College of Cardiology 1998; 32:695–703.
J Am Coll Cardiol. 1998 Sep;32(3):695-703
J Am Heart Assoc. 2013 Oct; 2(5): e000126.
Published online 2013 Oct 25. doi: 10.1161/JAHA.113.000126
PMCID: PMC3835216
Atrial Fibrillation Patterns and Risks of Subsequent Stroke, Heart Failure, or Death in the Community
Steven A. Lubitz, MD, MPH, Carlee Moser, PhD, Lisa Sullivan, PhD, Michiel Rienstra, MD, PhD, João D. Fontes, MD,Mark L. Villalon, MD, Manju Pai, MD, David D. McManus, MD, ScM, Renate B. Schnabel, MD, MSc, Jared W. Magnani, MD, MSc, Xiaoyan Yin, PhD, Daniel Levy, MD, Michael J. Pencina, PhD, Martin G. Larson, ScD, Patrick T. Ellinor, MD, PhD, and Emelia J. Benjamin, MD, ScM
Methods and Results—We studied Framingham Heart Study participants with new-onset AF and/or HF between 1980–2012. Among 1737 individuals with new AF, (mean-age 75±12, 48% women) more than one third (37%) had HF. Conversely among 1166 individuals with new HF (mean-age 79±11, 53% women), more than half (57%) had AF. Prevalent AF was more strongly associated with incident HFpEF (multivariable-adjusted hazard ratio [HR] 2.34, 95% confidence interval [CI] 1.48–3.70, no AF as referent) vs HFrEF (HR 1.32, 95%CI 0.83–2.10), with a trend toward difference between HF subtypes (P for difference 0.06). Prevalent HF was associated with incident AF (HR 2.18, 95%CI 1.26–3.76, no HF as referent). The presence of both AF and HF portended greater mortality risk compared with those without either condition, particularly among individuals with new HFrEF and prevalent AF (HR 2.72, 95%CI 2.12–3.48) compared with new HFpEF and prevalent AF (HR 1.83, 95%CI 1.41–2.37, P for difference 0.02).
Da Atrial Fibrillation and Mortality in Heart Failure
Bar graph of estimated age-adjusted relative risk of stroke for men (open bars) and women (filled bars) with atrial fibrillation compared with those without atrial fibrillation in presence of cardiac failure or coronary heart disease. **p
Da 2017 Freedman Screening for Atrial Fibrillation Circ – collegamento
In 5555 patients with asymptomatic clinical AF detected incidentally in general practice, the adjusted stroke
rate in the 1460 untreated patients was 4% and all-cause mortality 7% over 1.5 years of follow-up compared with
1% and 2.5%, respectively, in matched controls without AF.22,23
22 Martinez C, Katholing A, Freedman SB. Adverse prognosis of incidentally detected ambulatory atrial fibrillation: a cohort study. Thromb Haemost. 2014;112:276–286. doi: 10.1160/TH4-04-0383. Non parla di scompenso
23. Freedman B, Martinez C, Katholing A, Rietbrock S. Residual risk
of stroke and death in anticoagulant-treated patients with atrial
fibrillation. JAMA Cardiol. 2016;1:366–368. doi: 10.1001/jamacardio.
Da Incidence of Ischemic Stroke in Japanese Patients
Ischemic Stroke Risk in Patients With
Our estimated annual risk of ischemic stroke in AF patients with CHA2 DS2 -VASc score of 1 based on the summary measure of 7 studies is 1.61% with substantial uncertainty remaining (95% CI 0%–3.23%). Additionally, the summary annual risk was 0.68% for CHA2 DS2 -VASc score of 0 and 2.49% for CHA2 DS2 -VASc score of 2. To our knowledge, this is the first meta-analysis specifically addressing the annual ischemic stroke rate by CHA2 DS2 -VASc, and it provides an improved estimate for the risk of ischemic stroke to guide clinical decision-making.
Da CAABL-AF ablation
dopo ablazione riduzione della mortalità superiore alla ricorrenza di stroke . Esistono meccanismi nocivi oltre lo stroke
CASTLE-AF trial: l'ablazione con catetere della fibrillazione atriale in
pazienti con insufficienza cardiaca è stata associata ad una
significativa riduzione di morte per qualsiasi causa o ospedalizzazione
Da CAABL-AF ablation
dopo ablazione riduzione della mortalità superiore alla ricorrenza di stroke . Esistono meccanismi nocivi oltre lo stroke
CASTLE-AF trial: l'ablazione con catetere della fibrillazione atriale in
pazienti con insufficienza cardiaca è stata associata ad una
significativa riduzione di morte per qualsiasi causa o ospedalizzazione
Transcatheter left atrial appendage occlusion in patients with atrial fibrillation and a high bleeding risk using aspirin alone for post-implant antithrombotic therapy .
Kasper Korsholm1 et al EuroIntervention 2017;12:2075-2082
LAAO with the AMPLATZER Cardiac Plug (ACP) or Amulet using aspirin alone (ASA) as post-implantation antithrombotic treatment
Da atrial fib e rischio di IMA
Ascertainment of AF Details of ascertainment of AF have been published elsewhere.20
Briefly, AF was identified at baseline from 2 sources:
(1) a study-scheduled ECG recorded during the inhome visit that was centrally read by electrocardiographers blinded to clinical data; and
(2) a history of physician diagnosis of AF reported by the participants during the computer assisted telephone surveys assessing medical history and health status. These 2 AF ascertainment methods have been equally predictive of stroke in the REGARDS study.20
Vermond RR. Does myocardial infarction beget atrial fibrillation and atrial fibrillation beget myocardial infarction?. Circulation (New York, N.Y.). 2015-05;131:1824-1826.
Da atrial fib e rischio di IMA
Ascertainment of AF
Details of ascertainment of AF have been published elsewhere.20
Briefly, AF was identified at baseline from 2 sources:
(1) a study-scheduled ECG recorded during the inhome visit that was centrally read by electrocardiographers blinded to clinical data; and
(2) a history of physician diagnosis of AF reported by the participants during the computer assisted telephone surveys assessing medical history and health status. These 2 AF ascertainment methods have been equally predictive of stroke in the REGARDS study.20
Da Atrial fibrillation and the risk of MI 2017
Lee HY et al. Sci Rep. 2017 Oct 5;7(1):12716
Da Atrial fibrillation and the risk of MI 2017
Lee HY et al. Sci Rep. 2017 Oct 5;7(1):12716
J Am Coll Cardiol. 2018 Jul 3;72(1):17-26. doi: 10.1016/j.jacc.2018.04.036.
Risk of Myocardial Infarction in Anticoagulated Patients With Atrial Fibrillation.
Lee CJ1, Gerds TA2, Carlson N3, Bonde AN4, Gislason GH5, Lamberts M6, Olesen JB4, Pallisgaard JL4, Hansen ML4, Torp-Pedersen C7.
Author information
Abstract
BACKGROUND:
Evidence is conflicting as to the efficacy of direct oral anticoagulation (DOAC) and vitamin K antagonist (VKA) for prevention of myocardial infarction (MI).
OBJECTIVES:
This study aimed to investigate the risk of MI associated with the use of apixaban, dabigatran, rivaroxaban, and VKA in patients with atrial fibrillation.
METHODS:
Patients with atrial fibrillation were identified using Danish health care registers and stratified by initial oral anticoagulant treatment. Standardized absolute 1-year risks were estimated based on Cox regression for hazard rates of MI hospitalizations and mortality. Reported were absolute risks separately for the oral anticoagulation treatments and standardized to the characteristics of the study population.
RESULTS:
Of the 31,739 patients included (median age, 74 years; 47% females), the standardized 1-year risk of MI for VKA was 1.6% (95% confidence interval [CI]: 1.3 to 1.8), apixaban was 1.2% (95% CI: 0.9 to 1.4), dabigatran was 1.2% (95% CI: 1.0 to 1.5), and rivaroxaban was 1.1% (95% CI: 0.8 to 1.3). No significant risk differences were observed in the standardized 1-year risks of MI among the DOACs: dabigatran versus apixaban (0.04%; 95% CI: -0.3 to 0.4), rivaroxaban versus apixaban (0.1%; 95% CI: -0.4 to 0.3), and rivaroxaban versus dabigatran (-0.1%; 95% CI: -0.5 to 0.2). The risk differences for DOACs versus VKA were all significant: -0.4% (95% CI: -0.7 to -0.1) for apixaban, -0.4% (95% CI: -0.7 to -0.03) for dabigatran, and -0.5% (95% CI: -0.8 to -0.2) for rivaroxaban.
CONCLUSIONS:
No significant risk differences of MI were found in the direct comparisons of DOACs, and DOACs were all associated with a significant risk reduction of MI compared with VKA.
Da arrhythmias and Cognition EHRAHRS Consensus 2018
Reproduced with modification after permission from Ref.64
Da arrhythmias and Cognition EHRAHRS Consensus 2018
Reproduced with modification after permission from Ref.64
Da Gli anticoagulanti orali riducono il rischio di demenza negli anziani con fibrillazione atriale _ Univadis
Ding M, Fratiglioni L, et al. Atrial fibrillation, antithrombotic treatment, and cognitive aging: A population-based study. Neurology 2018;91:e1732-
e1740.
SCAF subclinical AF
AHRE Atrial high-rate episodes