Search

Background: Arrhythmogenic ventricular cardiomyopathy (AVC) is a common cause of ventricular arrhythmias and mortality, but limited data are available from large Asian cohorts. Our aim was to explore the current status of AVC and second, we examined the prevalence of ventricular tachycardia (VT), heart failure (HF) and mortality in patients with AVC in the Chinese population. Hypothesis: At present, some studies have reported that the incidence of AVC is on the rise, which may be due to the increasing number of diagnostic methods for AVC. However, there is no epidemiological data on AVC in the Chinese population, so we speculate that the incidence of AVC in the Chinese population is increasing. Methods and Results: We studied 15 888 adults from the Beijing Municipal Health Commission Information Center (BMHCIC) registry database in China from January 2010 to December 2020, and calculated the average annual percentage change (AAPC). Second, we determined the incidence of VT, HF and mortality in patients with AVC. Of the 10 318 men and 5570 women who were screened by cardiac magnetic resonance or examined by myocardial biopsy, there were a total of 256 newly diagnosed AVC patients (mean [SD]: 37.54[17.10]; 39.45% female). The incidence of AVC increased from 7.60 (3.12‐12.06) in 2010 to 19.62 (11.51‐27.75) per 1000 person‐years in 2020. Males had higher incidence of AVC than females. The AAPC for the rising incidence of AVC was 8.9 %. Males had similar VT prevalence (70.32% vs. 62.38%, p = 0.19) and mortality (1.94% vs. 1.98%, p = 0.98) but lower HF prevalence (42.58% vs. 60.40%, p = 0.006), when compared to females. Radiofrequency ablation (RFA) was more likely to be performed in males (p = 0.006). Conclusions: The rising trend in AVC incidence was evident, with two‐fold increase by 2020. Males with AVC had similar VT prevalence and mortality rate, but HF prevalence were lower than females, perhaps impacted by RFA use. [ABSTRACT FROM AUTHOR]

Background: The Mobile Health Technology for Improved Screening and Optimized Integrated Care in AF (mAFA‐II) prospective randomized trial showed the efficacy of a mobile health (mHealth) implemented 'Atrial fibrillation Better Care' (ABC) pathway for the integrated care management of patients with atrial fibrillation (AF). In this ancillary analysis, we evaluated the effect of mAFA intervention according to the history of diabetes mellitus (DM). Methods: The mAFA‐II trial enrolled 3324 AF patients across 40 centres in China, between June 2018 and August 2019. In this analysis, we assessed the interaction between history of DM and the effect of mAFA intervention on the risk of the primary composite outcome of stroke, thromboembolism, all‐cause death and rehospitalizations. Results were expressed as adjusted hazard ratio (aHR) and 95% confidence intervals (95%CI). The effect of mAFA intervention on exploratory secondary outcomes was also assessed. Results: Overall, 747 (22.5%) patients had DM (mean age: 72.7 ± 12.3, 39.6% females; 381 allocated to mAFA intervention). mAFA intervention was associated with a significant risk reduction for the primary composite outcome both in patients with and without DM (aHR [95%CI]:.36 [.18–.73] and.37 [.23–.61], respectively, p for interaction =.941). A significant interaction was found only for the composite of recurrent AF, heart failure and acute coronary syndromes (pint =.025), with lower effect of mAFA intervention in patients with DM. Conclusions: A mHealth‐technology implemented ABC pathway showed a consistent effect in reducing the risk of the primary composite outcome in AF patients with and without DM. Trial Registration: WHO International Clinical Trials Registry Platform (ICTRP) Registration number: ChiCTR‐OOC‐17014138. [ABSTRACT FROM AUTHOR]

Background: Stroke prevention with oral anticoagulant (OAC) therapy, including non-vitamin K antagonist oral anticoagulants (NOACs), is recommended in patients with atrial fibrillation (AF). This analysis describes the antithrombotic prescription patterns for Chinese patients enrolled post-dabigatran approval during Phase II and III of the Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF) program in China. Methods: Patients aged ≥ 18 years with newly diagnosed (< 3 months before baseline visit) nonvalvular AF at risk of stroke (CHA2DS2-VASc score ≥ 1) were consecutively enrolled in the GLORIA-AF registry. This cross-sectional analysis provides descriptive comparison of Chinese patients in Phase III (2015–2016) with those enrolled in Phase II (2013–2014). Results: Overall, 1,018 and 1,911 Chinese patients were eligible for analysis in Phase II and III, respectively. Most patients (69.6% and 69.1%, respectively) had high stroke risk (CHA2DS2-VASc score ≥ 2 for males and ≥ 3 for females). High bleeding risk (HAS-BLED score ≥ 3) rates were similar (17.3% for Phase II, 17.6% for Phase III). In Phase II, 5.8%, 15.2%, 36.7% and 42.2% of patients were prescribed NOACs, vitamin K antagonists (VKAs), antiplatelet therapies or no antithrombotic treatment, respectively. The corresponding figures were 17.2%, 23.5%, 37.4% and 21.8% for patients in Phase III, with an overall increase in OAC prescriptions (NOACs or VKAs). In patients with high stroke risk, the prescription patterns in Phase II were 5.6%, 14.4%, 41.0% and 38.9% for NOACs, VKAs, antiplatelets or no antithrombotic treatment, respectively. The respective proportions in Phase III were 15.1%, 23.5%, 40.9% and 20.5%. Conclusions: Since the availability of dabigatran in China, the overall trend of OAC, including NOAC, prescriptions in Chinese patients with nonvalvular AF has increased over time, albeit with VKAs as the most common antithrombotic treatment. Most patients, including those at high stroke risk, remain undertreated according to best practice guidelines. Trial registration: ClinicalTrials.gov NCT01468701. [ABSTRACT FROM AUTHOR]

Background: The atrial fibrillation better care (ABC) pathway is a simple, comprehensive framework that facilitates provision of integrated care for atrial fibrillation (AF) patients. Objective: We evaluated management of AF patients in a secondary prevention cohort using the ABC pathway and examined the impact of ABC adherence on clinical outcomes. Methods: The Chinese Patients with Atrial Fibrillation registry is a prospective registry conducted in 44 sites across China between October 2014 and December 2018. The primary outcome was the composite of all‐cause mortality/any thromboembolism (TE), all‐cause death, any TE and major bleeding at 1 year. Results: Of the 6420 patients, 1588 (24.7%) had a prior stroke or transient ischemic attack and were identified as the secondary prevention cohort. After excluding 793 patients due to insufficient data, 358 (22.5%) were ABC compliant and 437 (27.5%) ABC noncompliant. ABC adherence was associated with a significantly lower risk of the composite outcome of all‐cause death/TE, odds ratio (OR) 0.28 (95% confidence interval [CI]: 0.11–0.71) and all‐cause death, OR 0.29 (95% CI: 0.09–0.90). Significant differences were not observed for TE, OR 0.27 (95% CI: 0.06–1.27) and major bleeding, OR 2.09 (95% CI: 0.55–7.97). Age and prior major bleeding were significant predictors of ABC noncompliance. Health‐related quality of life (QOL) was higher in the ABC compliant group versus the noncompliant group (EQ score 0.83 ± 0.17 vs. 0.78 ± 0.20; p =.004). Conclusion: ABC pathway adherence in secondary prevention AF patients was associated with a significantly lower risk of the composite outcome of all‐cause death/TE and all‐cause death, as well as better health‐related QOL. [ABSTRACT FROM AUTHOR]

Identifying existing care pathways is the first step for understanding how services can be improved to enable early diagnosis and effective follow-up care for non-communicable diseases (NCDs); however, evidence on how care pathways can and should be identified in low- and middle-income countries (LMICs) is lacking. To describe generalisability and lessons learned from recruitment and data collection for the quantitative component of a mixed methods study designed to determine the care pathway for atrial fibrillation (AF) in Brazil, China and Sri Lanka. Adults (≥18 years) that spoke the local language and with an AF diagnosis were eligible. We excluded anyone with a hearing or cognitive impairment or ineligible address. Eligible participants were identified using electronic records in Brazil and China; in Sri Lanka, researchers attended the outpatient clinics to identify eligible participants. Data were collected using two quantitative questionnaires administered at least 2-months apart. A minimum sample size of 238 was required for each country. The required sample size was met in Brazil (n = 267) and China (n = 298), but a large proportion of AF patients could not be contacted (47% and 27%, respectively) or refused to participate (36% and 38%, respectively). In Sri Lanka, recruitment was challenging, resulting in a reduced sample (n = 151). Mean age of participants from Brazil, China and Sri Lanka was 69 (SD = 11.3), 65 (SD = 12.8) and 58 (SD = 11.7), respectively. Females accounted for 49% of the Brazil sample, 62% in China and 70% in Sri Lanka. Generalisability was an issue in Brazil and China, as was selection bias. Recruitment bias was highlighted in Sri Lanka. Additional or alternative recruitment methods may be required to ensure generalisability and reduce bias in future studies aimed at identifying NCD care pathways in LMICs. [ABSTRACT FROM AUTHOR]

There are limited studies on the prevalence and incidence of clinically diagnosed hypertrophic myocardiopathy (HCM) and its mortality in the Chinese population, and the projected population burden of HCM over the next decades. We collected data on HCM and its mortality from the Beijing Municipal Health Commission Information Center (BMHCIC) database and estimated the prevalence and incidence based on the whole Beijing population. Calculation of population trends was performed using annual percentage change (APC) and average annual percentage change (AAPC). Finally, future HCM incidence was built by modelling projection of HCM to the next decades using Poisson regression analysis and Gray Model 1,1(GM [1,1]). The prevalence of HCM was 0.0069% (95%CI, 0.0065–0.0072%; N = 1343) in 2010, rising to 0.076% (95% CI, 0.074–0.077%; N = 16,616) in 2019, and the incidence of HCM was 6.85 per 100 000 person-year in 2010, rising to 11.76 per 100 000 person-year in 2019. Males had higher prevalence and incidence of HCM than females. The APPC for the rising incidence of HCM was 5.8% and the expected numbers will double increase in 2029 by assuming the same increase trend as the last decades. HCM had increased annual incidence of HF (APPC: 8.4, 4.4–12.6, p < 0.05), and relatively stable annual incidence of mortality (APPC: 1.2%, − 2.3% to 4.8%, p > 0.05) during the studied period. Males had lower mortality (2.70% vs. 4.20%, p < 0.001) than females. The calculated HCM prevalence was much lower compared to prior screening studies from 2004, although the predicted HCM incidence would double over the next decades. HCM was associated with a stable risk of mortality during the studied period. [ABSTRACT FROM AUTHOR]

Background The Mobile Health Technology for Improved Screening and Optimized Integrated Care in AF (mAFA-II) randomised trial demonstrated the efficacy of a mobile health (mHealth) technology-implemented 'Atrial fibrillation Better Care' (ABC) pathway-approach (mAFA intervention) in reducing the risk of adverse events in patients with atrial fibrillation (AF). Whether these benefits also apply to older patients is unclear. In this ancillary analysis, we evaluated the effect of mAFA intervention among older AF patients. Methods The mAFA-II trial enrolled adult AF patients across 40 centres in China. For this analysis, we defined older patients as those aged ≥75 years. Primary outcome was the composite of ischemic stroke or thromboembolism, all-cause death and rehospitalisation. The effect of mAFA intervention was assessed through multivariable Cox-regression models. We also evaluated the interaction between age and effect of the mAFA intervention in the main trial population. Results In this analysis, we included 1,163 AF patients ≥75 years (mean age: 82.6 ± 5.3 years, 43.1% females); 520 were allocated to mAFA intervention, 643 to usual care. mAFA intervention was associated with a significant reduction of the primary composite outcome (adjusted hazard ratio [aHR]: 0.58, 95% confidence interval [CI]: 0.35–0.97) and rehospitalisations alone (aHR: 0.47, 95%CI: 0.24–0.91). Significant interaction between age and mAFA intervention effect was observed for both the composite outcome (P  = 0.002) and rehospitalisation alone (P  = 0.015), with the effect decreasing as age increased, particularly among patients ≥80 years old. Conclusions A mHealth technology-implemented ABC pathway is effective in reducing adverse clinical outcomes in older AF patients. The benefits obtained with mAFA intervention were attenuated at extreme ages. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) and coronary artery disease (CAD) are closely related; CAD may precede or complicate the clinical course of AF. Objective: To evaluate the impact of CAD on clinical outcomes among elderly Chinese AF patients. Methods: The ChiOTEAF registry is a prospective registry conducted in 44 sites from 20 provinces in China between October 2014 and December 2018. Primary outcome was the composite of all‐cause mortality/any thromboembolism (TE)/major bleeding/acute coronary syndrome (ACS). Results: The eligible cohort for this analysis included 6403 individuals (mean age 74.8 ± 10.7; 39.2% female); of these, 3058 (47.8%) had a history of CAD. On multivariate analysis, CAD was independently associated with a higher odds ratio for ACS (OR: 1.98; 95% CI: 1.12–3.52) without a significant impact on other adverse outcomes. Independent variables associated with the composite outcome among CAD patients were: (i) the use of OAC (OR: 0.55; 95% CI: 0.42–0.72), age (OR: 1.09; 95% CI: 1.08–1.11), heart failure (OR: 1.95; 95% CI: 1.51–2.50), prior ischemic stroke (OR: 1.29; 95% CI: 1.02–1.64), chronic kidney disease (OR: 1.71; 95% CI: 1.32–2.22), and chronic obstructive pulmonary disease (OR: 1.42; 95% CI: 1.06–1.89). Conclusions: AF patients with CAD were at an increased risk of developing ACS but there was no significant difference in the composite outcome, all cause death, cardiovascular death, thromboembolic events or major bleeding compared to the non‐CAD group. OAC use was inversely associated with adverse events, yet their uptake was poor in the AF‐CAD population. [ABSTRACT FROM AUTHOR]

Aims: Prior studies have reported conflicting results on digoxin's impact on clinical outcomes and quality of life, and there are limited data from Asia. The aim of this study is to evaluate the use of digoxin and its impact on clinical outcomes and quality of life in a high-risk cohort of elderly Chinese atrial fibrillation (AF) patients.Methods and Results: The Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry is a prospective, multicentre nationwide study conducted from October 2014 to December 2018. Endpoints of interest were the composite outcome of all-cause death/any thromboembolism (TE), all-cause death, cardiovascular death, sudden cardiac death, and TE events, as well as the quality of life. The eligible cohort for this analysis included 6391 individuals, of whom 751 (11.8%) patients were treated with digoxin. On multivariate analysis, the use of digoxin was associated with a higher odds ratio (OR) of composite outcome [OR: 1.71; 95% confidence interval (CI): 1.32-2.22], all-cause death (OR: 1.62; 95% CI: 1.23-2.14), and any TE (OR: 1.78; 95% CI: 1.08-2.95). Results were consistent in a subgroup of patients with diagnosed heart failure (HF) and patients with permanent AF. The use of digoxin was associated with worse health-related quality of life (mean EQ index: 0.76 ± 0.19 vs. 0.84 ± 0.18; P < 0.001).Conclusions: In this nationwide cohort study, digoxin use was associated with an overall higher risk of the composite outcome of all-cause death/any TE, all-cause death, and any TE, regardless of HF diagnosis. Patients treated with digoxin had a worse health-related quality of life. [ABSTRACT FROM AUTHOR]

Background: Electrocardiogram (ECG) interpretation is an integral part of the clinical ECG workflow; however, this process is often time‐consuming and labor‐intensive. We aim to develop a rapid, inexpensive means to detect abnormal ECGs using artificial intelligence (AI) from scanned ECG printouts. Methods: The study included 1172 12‐lead ECG scans performed in 1172 individuals from a community in Guangzhou, China; 878 (74.9%) were diagnosed with sinus rhythm, and the remaining 294 (25.1%) with abnormal rhythms. A deep learning model consisting of a convolutional neural network based on InceptionV3 and a fully connected layer followed by a GEV activation was trained to classify scanned tracings as either normal or abnormal. Results: In a hold‐out testing set, the model achieved a area under curve (AUC), sensitivity, specificity, PPV, and NPV of 0.932 (95% confidence interval [CI]: 0.890, 0.976), 0.816 (95% CI: 0.657, 0.923), 0.993 (95% CI: 0.959, 1.0), 0.969 (95% CI: 0.838, 0.999), and 0.950 (95% CI: 0.90, 0.980) respectively, when using a probability threshold of 0.5. When compared with a physiological expert, these results show comparable performance with a statistically significant increase in specificity and a non‐significant decrease in sensitivity at the 95% level. Conclusions: We have developed a rapid, inexpensive, accurate means to detect abnormal ECGs using AI. Easy and accurate identification of such "abnormal" ECGs could allow the mass automated review of ECGs in community settings where abnormal ones could be flagged using AI for detailed clinical review by healthcare professionals. [ABSTRACT FROM AUTHOR]

Background: Adherence to oral anticoagulant therapy in patients with atrial fibrillation (AF) in China is low. Patient preference, one of the main reasons for discontinuation of oral anticoagulant therapy, is an unfamiliar concept in China.Methods and Findings: A discrete choice experiment (DCE) was conducted to quantify patient preference on 7 attributes of oral anticoagulant therapy: antidote (yes/no), food-drug interaction (yes/no), frequency of blood monitoring (no need, every 6/3/1 month[s]), risk of nonfatal major bleeding (0.7/3.1/5.5/7.8[%]), risk of nonfatal stroke (ischemic/hemorrhagic) or systemic embolism (0.6/3.2/5.8/8.4[%]), risk of nonfatal acute myocardial infarction (AMI) (0.2/1.0/1.8/2.5[%]), and monthly out-of-pocket cost (0/120/240/360 RMB) (0 to 56 USD). A total of 16 scenarios were generated by using D-Efficient design and were randomly divided into 2 blocks. Eligible patients were recruited and interviewed from outpatient and inpatient settings of 2 public hospitals in Beijing and Shenzhen, respectively. Patients were presented with 8 scenarios and asked to select 1 of 3 options: 2 unlabeled hypothetical treatments and 1 opt-out option. Mixed logit regression model was used for estimating patients' preferences of attributes of oral anticoagulants and willingness to pay (WTP) with adjustments for age, sex, education level, income level, city, self-evaluated health score, histories of cardiovascular disease/other vascular disease/any stroke/any bleeding, and use of anticoagulant/antiplatelet therapy. A total of 506 patients were recruited between May 2018 and December 2019 (mean age 70.3 years, 42.1% women). Patients were mainly concerned about the risks of AMI (β: -1.03; 95% CI: -1.31, -0.75; p < 0.001), stroke or systemic embolism (β: -0.81; 95% CI: -0.90, -0.73; p < 0.001), and major bleeding (β: -0.69; 95% CI: -0.78, -0.60; p < 0.001) and were willing to pay more, from up to 798 RMB to 536 RMB (124 to 83 USD) monthly. The least concerning attribute was frequency of blood monitoring (β: -0.31; 95% CI: -0.39, -0.24; p < 0.001). Patients had more concerns about food-drug interactions even exceeding preferences on the 3 risks, if they had a history of stroke or bleeding (β: -2.47; 95% CI: -3.92, -1.02; p < 0.001), recruited from Beijing (β: -1.82; 95% CI: -2.56, -1.07; p < 0.001), or men (β: -0.96; 95% CI: -1.36, -0.56; p < 0.001). Patients with lower educational attainment or lower income weighted all attributes lower, and their WTP for incremental efficacy and safety was minimal. Since the patients were recruited from 2 major hospitals from developed cities in China, further studies with better representative samples would be needed.Conclusions: Patients with AF in China were mainly concerned about the safety and effectiveness of oral anticoagulant therapy. The preference weighting on food-drug interaction varied widely. Patients with lower educational attainment or income levels and less experience of bleeding or stroke had more reservations about paying for oral anticoagulant therapies with superior efficacy, safety, and convenience of use. [ABSTRACT FROM AUTHOR]

Background: An understanding of the risk factors for atrial fibrillation (AF) progression and the associated impacts on clinical prognosis are important for the future management of this common arrhythmia. We aimed to investigate the rate of progression from paroxysmal (PAF) to more sustained subtypes of AF (SAF), the associated risk factors for this progression, and its impact on adverse clinical outcomes. Methods and Results: Using data from the Chinese trial Fibrillation Registry study, we included 8290 PAF patients. Half of them underwent initial AF ablation at enrollment. The main outcomes were ischemic stroke/systemic embolism (IS/SE), cardiovascular hospitalization, cardiovascular death, and all‐cause mortality. The median follow‐up duration was 1091 (704, 1634) days, and progression from PAF to SAF occurred in 881 (22.5%) nonablated patients, while 130 (3.0%) ablated patients had AF recurrence and developed SAF. The incidence rate of AF progression for the cohort was 3.87 (95% confidence interval [CI] = 3.64–4.12) per 100 patient‐years, being higher in nonablated compared to ablated patients. Older age, longer AF history, heart failure, hypertension, coronary artery disease, respiratory diseases, and larger atrial diameter were associated with a higher incidence of AF progression, while antiarrhythmic drug use and AF ablation were inversely related to it. For nonablated patients, AF progression was independently associated with an increased risk of IS/SE (hazard ratio [HR] = 1.52, 95% CI = 1.15–2.01) and cardiovascular hospitalizations (HR = 1.40, 95% CI = 1.23–1.58). Conclusion: AF progression was common in its natural course. It was related to comorbidities and whether rhythm control strategies were used, and was associated with an increased risk of IS/SE and cardiovascular hospitalization. [ABSTRACT FROM AUTHOR]

Aims: We aimed to investigate the safety of discontinuing oral anticoagulation (OAC) therapy after apparently successful atrial fibrillation (AF) ablation, using data from the Chinese Atrial Fibrillation Registry study.Methods and Results: We identified 4512 consecutive patients who underwent successful AF ablation between August 2011 and December 2017. Of them, 3149 discontinued OAC 3 months post-ablation (Off-OAC group) and 1363 continued OAC beyond this period (On-OAC group). Regular follow-up examinations were undertaken to detect AF recurrence, monitor OAC therapy, and measure clinical outcomes. Primary outcomes included thromboembolic and major bleeding (MB) events experienced beyond 3 months after ablation. Low thromboembolic and MB event rates were noted in the on-treatment analysis. The incidence rates for thromboembolism were 0.54 [95% confidence interval (CI) 0.39-0.76] and 0.86 (95% CI 0.56-1.30) per 100 patient-years, and that for MB events were 0.19 (95% CI 0.11-0.34) and 0.35 (95% CI 0.18-0.67) per 100 patient-years, for the Off-OAC and On-OAC groups over mean follow-up periods of 24.2 ± 14.7 and 23.0 ± 13.6 months, respectively. Similar results were observed in the intention-to-treat analysis. Previous history of ischaemic stroke (IS)/transient ischaemic attack (TIA)/systemic embolism (SE) [hazard ratio (HR) 3.40, 95% CI 1.92-6.02; P < 0.01] and diabetes mellitus (HR 2.06, 95% CI 1.20-3.55, P = 0.01) were independently associated with thromboembolic events, while OAC discontinuation (HR 0.71, 95% CI 0.41-1.23, P = 0.21) remained insignificant in multivariable analysis.Conclusions: This study suggests that it may be safe to discontinue OAC in post-ablation patients under diligent monitoring, in the absence of AF recurrence, history of IS/TIA/SE, and diabetes mellitus. However, further large-scale randomized trials are required to confirm this.Trial Registration: Chinese Clinical Trial Registry ChiCTR-OCH-13003729. URL: http://www.chictr.org.cn/showproj.aspx?proj=5831. [ABSTRACT FROM AUTHOR]

Aims: The introduction of non-VKA oral anticoagulants (NOACs), which differ from the earlier vitamin K antagonist (VKA) treatments, has changed the approach to stroke prevention in atrial fibrillation (AF). GLORIA-AF is a prospective, global registry programme describing the selection of antithrombotic treatment in newly diagnosed AF patients at risk of stroke. It comprises three phases: Phase I, before the introduction of NOACs; Phase II, during the time of the introduction of dabigatran, the first NOAC; and Phase III, once NOACs have been established in clinical practice.Methods and Results: In Phase I, 1063 patients were eligible from the 1100 enrolled (54.3% male; median age 70 years); patients were from China (67.1%), Europe (EU; 27.4%), and the Middle East (ME; 5.6%). The majority of patients using VKAs had high stroke risk (CHA2DS2-VASc ≥ 2; 86.5%); 13.5% had moderate risk (CHA2DS2-VASc = 1). Vitamin K antagonist use was higher for persistent/permanent AF (47.7%) than that for paroxysmal (23.9%). Most patients in China were treated with antiplatelet agents (53.7%) vs. 27.1% in EU and 28.8% in ME. In China, 25.9% of patients had no antithrombotic therapy, vs. 8.6% in EU and 8.5% in ME.Conclusion: Phase I of GLORIA-AF shows that VKAs were mostly used in patients with persistent/permanent (vs. paroxysmal) AF and in those with high stroke risk. Furthermore, there were meaningful geographical differences in the use of VKA therapy in the era before the availability of NOACs, including a much lower use of VKAs in China, where most patients either received antiplatelet agents or no antithrombotic treatment. [ABSTRACT FROM AUTHOR]

Background: Robust data on the contemporary management of atrial fibrillation (AF) patients in China are limited. Importantly current practice in AF management has changing dramatically in recent years. Data from a large registry study will enable us to evaluate the uptake and outcomes with different therapies in a large Chinese AF population.Methods/design: The Chinese Atrial Fibrillation Registry study (CAFR) aims to enroll 20,000 consecutive atrial fibrillation (AF) patients from 32 tertiary and non-tertiary hospitals in Beijing, China, and follow up these patients every 6 months until 2020. Key data collected includes basic sociodemographic information, symptoms and signs, medical history, results of physical examination and laboratory test, details of treatments and personal insurance status. For patients who consent, 5 ml of blood sample will be stored at -80 °C for future analyses of biomarkers. At each 6 month follow up visit, data relating to clinical outcomes will be collected. Data from a randomly selected 10 % of patients will be internally validated with their raw source data. Ischemic stroke events will be adjudicated by an independent endpoint committee.Discussion: CAFR will be one of the largest registries of Asian AF patients (and the largest in Chinese AF patients), as well as providing the longest follow up. This study would provide a valuable opportunity for 'real world' clinical epidemiology with insights into the uptake (and outcomes) of contemporary AF management.Trial Registration: Chinese Clinical Trial Registry ChiCTR-OCH-13003729 . Registered 22 October 2013. [ABSTRACT FROM AUTHOR]

The article reports on the epidemiology of atrial fibrillation (AF) in China. Topics discussed include the prevalence of AF and associated stroke in the country, the overall incidence of the disease, as well as the lifetime risks of AF in Chinese males and females and the influence of clinical risk factors to the development of AF. Also mentioned is the prevalence of the disease among China's elder population.

Objective: No study has systematically investigated the quality of long-term care delivered to the rural older people with chronic diseases, such as atrial fibrillation (AF) in China. This study aims to provide contemporary data on the prevalence and awareness of AF among the older population in rural China and to evaluate healthcare knowledge and delivery by village doctors., Design: A cross-sectional study., Setting: Rural villages in Daqiao and Xiaoji towns of Jiangsu Province, China., Participants: Rural population aged ≥65 years., Outcome Measures: AF was identified using 12-lead electrocardiography in the first-step (government-led health examination) and single-lead electrocardiography in the second-step (in-house AF screening). Questionnaire surveys were designed for the AF patients and their village doctors., Results: Among 31,342 permanent residents, 12,630 (40.3 %) declined, 7,956 (25.3 %) participated in the first-step and 10,756 (34.3 %) in the second-step. The overall AF detection rate was 4.3 % (810/18,712). Of the 810 AF patients (mean age 76.1±5.9 years; 51.4 % female), 51.5 % were illiterate, only 2.6 % could use smartphone applications, and 8.1 % lived with their children. Common risk factors were older age, men, hypertension, diabetes, prior stroke, vascular disease, and congestive heart failure. Among the 402 patients with known AF, 367 were at high risk of stroke and 10.9 % (40/367) were anticoagulated. Only 17.6 % patients with known hypertension had blood pressure level <140/90 mmHg, and 6.0 % with known diabetes had a fasting blood glucose level ≤6.1 mmol/L. Only 7.3 % (9/122) village doctors reported having the knowledge of integrated care AF management., Conclusions: This study identified AF in 4.3 %, but AF management was suboptimal in rural China. The current village doctor-dominant rural healthcare system is far from delivering standardized AF management for older patients in rural China. There is an urgent need to empower the village doctors in optimising the care of AF patients., Competing Interests: Declaration of competing interest MLC reported receiving lecture fee from Boehringer Ingelheim. All other authors declare no competing interests., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The consensus guidelines of the Geriatric Society of Chinese Medical Association on the management of atrial fibrillation (AF) in the elderly was first published in 2011 and updated in 2016, with endorsement by Chinese Society of Geriatric Health Medicine. Since then, many important studies regarding the screening and treatment in the elderly population have been reported, necessitating this updated expert consensus guideline. The writing committee members comprehensively reviewed updated evidence pertaining to elderly patients with AF, and formulated this 2024 update. The highlighted issues focused on the following: screening for AF, geriatric comprehensive assessment, use of the Atrial fibrillation Better Care (ABC) pathway for the elderly patients, and special clinical settings related to elderly patients with AF. New recommendations addressing smart technology facilitated AF screening, ABC pathway based management, and optimal anticoagulation were developed, with a focus on the elderly., Competing Interests: G.Y.H.L. is a consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, Daiichi-Sankyo, Anthos. No fees are received personally. He is a National Institute for Health and Care Research (NIHR) Senior Investigator and co-PI of the AFFIRMO project on multimorbidity in AF (grant agreement No 899871), TARGET project on digital twins for personalised management of atrial fibrillation and stroke (grant agreement No 101136244) and ARISTOTELES project on artificial intelligence for management of chronic long term conditions (grant agreement No 101080189), which are all funded by the EU's Horizon Europe Research & Innovation programme. There is no competing interest from any other author., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Aims: There are no nationwide epidemiological data on heart failure (HF) stages in China. Knowledge of the prevalence of HF stages is crucial for planning HF prevention and management strategies. We aimed to evaluate the prevalence of HF stages in the general Chinese population and the specific prevalence by age, sex, and urbanity., Methods and Results: This is a cross-sectional study and national representative general population aged ≥ 35 years (n = 31 494, mean age 57.4 years, women 54.1%) were obtained from the China Hypertension Survey. Participants were divided into Stage A (at-risk for HF), Stage B (pre-HF), and Stage C (symptomatic HF). Survey weights were calculated based on the 2010 China population census data. The prevalence of Stage A was 35.8% (≈245.1 million), Stage B 42.8% (≈293.1 million), and Stage C 1.1% (≈7.5 million). The prevalence of Stages B and C increased with increasing age (P < 0.0001). Women had lower prevalence of Stage A (32.6% vs. 39.3%; P < 0.0001) but higher prevalence of Stage B (45.9% vs. 39.5%; P < 0.0001) than men. People from rural area had lower prevalence of Stage A (31.9% vs. 41.0%; P < 0.0001) but higher prevalence of Stage B (47.8% vs. 36.2%; P < 0.0001) than people from urban. The prevalence of Stage C was similar by sex and urbanity., Conclusion: The burdens of pre-clinical and clinical HF are high and vary by age, sex, and urbanity in China. Targeted interventions are needed to reduce the high burden of pre-clinical and clinical HF., Competing Interests: Conflict of interests: Dr Fonarow reports consulting for Abbott, Amgen, AstraZeneca, Bayer, Cytokinetics, Janssen, Medtronic, Merck, and Novartis. The other authors declare that they have no competing interests., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

China has a large population of elderly in rural areas. Village doctors are acting as health-care gatekeepers for the rural elderly in China and are encouraged to provide more long-term care for patients with chronic diseases such as atrial fibrillation (AF). The data of AF registries from the rural elderly are limited. The present registry aims to provide contemporary data on the current AF-related health status of the rural elderly and the gaps in management of AF by village doctors. This study has two phases. The first phase is a cross-sectional study of AF screening in two rural towns of eastern China. All the residents aged ≥65 years are eligible and will be invited to attend a government-led health examination or an in-house AF screening program. The AF detection rate, the awareness of AF and the usage of oral anticoagulants and smartphones by AF patients, and the ability to diagnose and manage AF by village doctors will be assessed. Participants with AF detected in the first phase are eligible for the second phase. A variety of modes of intensified education will be provided to all AF patients and their family members to enrich their AF-related knowledge. Their village doctors will be offered a lecture-based training program focusing on Atrial fibrillation Better Care (ABC) pathway. Follow-up will be conducted for 1 year. The primary endpoint is the composite of all stroke and all-cause mortality. The first phase of AF screening was conducted between April 2019 and June 2019, and 18,712 participants with the mean age of 73.1±5.8 years were enrolled. The second phase that includes 810 patients with AF, started on 1 May 2019. This study will provide a perspective of primary care system and would indirectly reflect the current status of chronic disease care in rural China., Competing Interests: All the authors have nothing to declare except for GYHL and MLC. GYHL is a consultant and speaker for Boehringer Ingelheim, BMS/Pfizer and Daiichi-Sankyo. MLC reports receiving lecture fee from Biosense Webster, St. Jude Medical, Medtronic, Bayer and Boehringer Ingelheim; also reports grants from The Clinical Medicine Expert Team Project of Xuzhou, grants from The Key Clinical Study Project of Jiangsu Province, during the conduct of the study. No fees are received personally., (© 2022 Li et al.)

Aims: Prior studies have reported conflicting results on digoxin's impact on clinical outcomes and quality of life, and there are limited data from Asia. The aim of this study is to evaluate the use of digoxin and its impact on clinical outcomes and quality of life in a high-risk cohort of elderly Chinese atrial fibrillation (AF) patients., Methods and Results: The Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry is a prospective, multicentre nationwide study conducted from October 2014 to December 2018. Endpoints of interest were the composite outcome of all-cause death/any thromboembolism (TE), all-cause death, cardiovascular death, sudden cardiac death, and TE events, as well as the quality of life. The eligible cohort for this analysis included 6391 individuals, of whom 751 (11.8%) patients were treated with digoxin. On multivariate analysis, the use of digoxin was associated with a higher odds ratio (OR) of composite outcome [OR: 1.71; 95% confidence interval (CI): 1.32-2.22], all-cause death (OR: 1.62; 95% CI: 1.23-2.14), and any TE (OR: 1.78; 95% CI: 1.08-2.95). Results were consistent in a subgroup of patients with diagnosed heart failure (HF) and patients with permanent AF. The use of digoxin was associated with worse health-related quality of life (mean EQ index: 0.76 ± 0.19 vs. 0.84 ± 0.18; P < 0.001)., Conclusions: In this nationwide cohort study, digoxin use was associated with an overall higher risk of the composite outcome of all-cause death/any TE, all-cause death, and any TE, regardless of HF diagnosis. Patients treated with digoxin had a worse health-related quality of life., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please email: journals.permissions@oup.com.)

Background Patients with atrial fibrillation commonly have complex clinical backgrounds of multimorbidity and polypharmacy. The Atrial Fibrillation Better Care (ABC) pathway has been developed to help deliver integrated and holistic care for patients with atrial fibrillation. In this ancillary analysis, we assessed the adherence to and the effectiveness of the ABC pathway at reducing adverse outcomes in Chinese patients with atrial fibrillation with a complex clinical background of multimorbidity or polypharmacy. Methods and Results The ChiOTEAF (Optimal Thromboprophylaxis in Elderly Chinese Patients With Atrial Fibrillation) registry is a prospective, multicenter, nationwide study conducted from October 2014 to December 2018. The primary outcomes of interest were the composite end point of all-cause death and thromboembolic events, as well as individual end points of all-cause death, thromboembolic events, and major bleeding. Multimorbidity was defined as the presence of ≥2 comorbidities, and polypharmacy was defined as the concomitant use of ≥5 medications. The eligible cohort included 4644 patients with multimorbidity, of whom 2610 (56.2%) had available data to assess the ABC pathway usage (mean age, 74.4±10.2; 42.8% women). Among patients with polypharmacy (n=2262; mean age, 74.6±10.1; 43.3% women), 1328 (58.7%) had available data to assess the use of the ABC pathway. Adherence to the ABC pathway was associated with a lower risk of the primary composite outcome among patients with multimorbidity (odds ratio, 0.48; 95% CI, 0.29-0.79) and in the polypharmacy group (odds ratio, 0.39; 95% CI, 0.19-0.78). Health-related quality of life was lower in the non-ABC-adherent group compared with the ABC-treated patients. Conclusions This nationwide real-world registry shows that adherence to the ABC pathway is associated with improved clinical outcomes and health-related quality of life in clinically complex Chinese patients with atrial fibrillation with multimorbidity or polypharmacy.

Background: Anemia is a common comorbidity in patients with atrial fibrillation (AF). Reports on the association of anemia and adverse events in patients with AF, especially from Asia, are limited., Methods and Results: Based on data from the Chinese Atrial Fibrillation Registry Study (CAFR), a total of 18,106 AF patients enrolled between August 2011 and December 2018 had hemoglobin (Hb) values recorded at baseline. Patients were classified into three groups according to Hb levels: 15,606 patients (86.2%) into the no anemia group (male Hb≥130 g/L; female Hb≥120 g/L), 1800 (9.9%) with mild anemia (male 110≤Hb<129 g/L; female 110≤Hb<119 g/L), and 700 (3.9%) with moderate to severe anemia (Hb≤109 g/L). Multivariable Cox regression models were used to determine if anemia was independently associated with all-cause death, cardiovascular death, or major bleeding, after adjusting for confounders. Anemia was present in 13.8% of the population at baseline. During a median follow-up of 4.01 years, the incidences of all-cause death (1.8, 4.9, and 8.9 per 100 person-years), cardiovascular death (1.0, 2.9, and 4.5 per 100 person-years), and major bleeding (0.5, 0.6, and 0.7 per 100 person-years) were gradually accentuated in patients with no anemia, mild anemia, and moderate to severe anemia, respectively. Compared with patients with no anemia, those with anemia had higher risks for all-cause death (mild anemia; adjusted hazard ratio [HR]: 1.22, 95% confidence interval [CI]: 1.08-1.38; moderate to severe anemia; adjusted HR: 1.53, 95% CI: 1.31-1.77); and cardiovascular death (mild anemia; adjusted HR: 1.29, 95% CI: 1.10-1.52; moderate to severe anemia; adjusted HR: 1.27, 95% CI: 1.03-1.57), but not for major bleeding. The association between anemia and all-cause death was similar among subgroups stratified by sex, kidney function, anticoagulant, or ablation therapy., Conclusions: Anemia was associated with increased risks of all-cause death, cardiovascular death, but no major bleeding in AF patients. The effect of anemia correction on the prognosis of patients with AF requires further study., (© 2021 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

Background: High incidence of asymptomatic venous thromboembolism (VTE) has been observed in severe COVID-19 patients, but the characteristics of symptomatic VTE in general COVID-19 patients have not been described., Objectives: To comprehensively explore the prevalence and reliable risk prediction for VTE in COVID-19 patients., Methods/results: This retrospective study enrolled all COVID-19 patients with a subsequent VTE in 16 centers in China from January 1 to March 31, 2020. A total of 2779 patients were confirmed with COVID-19. In comparison to 23,434 non-COVID-19 medical inpatients, the odds ratios (ORs) for developing symptomatic VTE in severe and non-severe hospitalized COVID-19 patients were 5.94 (95% confidence interval [CI] 3.91-10.09) and 2.79 (95% CI 1.43-5.60), respectively. When 104 VTE cases and 208 non-VTE cases were compared, pulmonary embolism cases had a higher rate for in-hospital death (OR 6.74, 95% CI 2.18-20.81). VTE developed at a median of 21 days (interquartile range 13.25-31) since onset. Independent factors for VTE were advancing age, cancer, longer interval from symptom onset to admission, lower fibrinogen and higher D-dimer on admission, and D-dimer increment (DI) ≥1.5-fold; of these, DI ≥1.5-fold had the most significant association (OR 14.18, 95% CI 6.25-32.18, p = 2.23 × 10 -10 ). A novel model consisting of three simple coagulation variables (fibrinogen and D-dimer levels on admission, and DI ≥1.5-fold) showed good prediction for symptomatic VTE (area under the curve 0.865, 95% CI 0.822-0.907, sensitivity 0.930, specificity 0.710)., Conclusions: There is an excess risk of VTE in hospitalized COVID-19 patients. This novel model can aid early identification of patients who are at high risk for VTE., (© 2021 International Society on Thrombosis and Haemostasis.)

Background and Purpose: Complete P wave disappearance (CPWD) in patients without atrial fibrillation is an uncommon clinical phenomenon. We aimed to study the relationship between CPWD and thromboembolism., Methods: Between July 2007 and December 2018, consecutive patients with CPWD on surface ECG and 24-hour Holter recording were recruited into the study from 4 centers in China. All recruited patients underwent transesophageal echocardiography or cardiac computed tomography to screen for atrial thrombus. Atrial electrical activity and scar were assessed by electrophysiological study (EPS) and 3-dimensional electroanatomic mapping. Cardiac structure and function were assessed by multimodality cardiac imaging., Results: Twenty-three consecutive patients (8 male; mean age 48.5±14.7 years) with CPWD were included. Only 3 patients demonstrated complete atrial electrical silence with atrial noncapture. Thirteen patients who had invasive atrial endocardial mapping demonstrated extensive scar. Pulse-wave mitral inflow Doppler demonstrated absent and dampened A waves in 18 and 5 patients, respectively. Pulse-wave tricuspid inflow Doppler showed absent and dampened A waves in 19 and 4 patients, respectively. Upon recruitment, 8 patients had previous stroke and 3 patients had atrial thrombus. Warfarin was prescribed to all patients. During median follow-up of 42.0 months, 2 patients developed massive ischemic stroke due to warfarin discontinuation., Conclusions: Our study suggested that CPWD reflects extensive atrial electrical silence and significantly impaired atrial mechanical function. It was strongly associated with thromboembolism and the clinical triad of CPWD-atrial paralysis-stroke was proposed. Anticoagulation should be recommended in such patients.

Background: Current management of patients with atrial fibrillation (AF) is limited by low detection of AF, non-adherence to guidelines, and lack of consideration of patients' preferences, thus highlighting the need for a more holistic and integrated approach to AF management., Objective: The objective of this study was to determine whether a mobile health (mHealth) technology-supported AF integrated management strategy would reduce AF-related adverse events, compared with usual care., Methods: This is a cluster randomized trial of patients with AF older than 18 years of age who were enrolled in 40 cities in China. Recruitment began on June 1, 2018 and follow-up ended on August 16, 2019. Patients with AF were randomized to receive usual care, or integrated care based on a mobile AF Application (mAFA) incorporating the ABC (Atrial Fibrillation Better Care) Pathway: A, Avoid stroke; B, Better symptom management; and C, Cardiovascular and other comorbidity risk reduction. The primary composite outcome was a composite of stroke/thromboembolism, all-cause death, and rehospitalization. Rehospitalization alone was a secondary outcome. Cardiovascular events were assessed using Cox proportional hazard modeling after adjusting for baseline risk., Results: There were 1,646 patients allocated to mAFA intervention (mean age, 67.0 years; 38.0% female) with mean follow-up of 262 days, whereas 1,678 patients were allocated to usual care (mean age, 70.0 years; 38.0% female) with mean follow-up of 291 days. Rates of the composite outcome of 'ischemic stroke/systemic thromboembolism, death, and rehospitalization' were lower with the mAFA intervention compared with usual care (1.9% vs. 6.0%; hazard ratio [HR]: 0.39; 95% confidence interval [CI]: 0.22 to 0.67; p < 0.001). Rates of rehospitalization were lower with the mAFA intervention (1.2% vs. 4.5%; HR: 0.32; 95% CI: 0.17 to 0.60; p < 0.001). Subgroup analyses by sex, age, AF type, risk score, and comorbidities demonstrated consistently lower HRs for the composite outcome for patients receiving the mAFA intervention compared with usual care (all p < 0.05)., Conclusions: An integrated care approach to holistic AF care, supported by mHealth technology, reduces the risks of rehospitalization and clinical adverse events. (Mobile Health [mHealth] technology integrating atrial fibrillation screening and ABC management approach trial; ChiCTR-OOC-17014138)., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: We aimed to investigate the safety of discontinuing oral anticoagulation (OAC) therapy after apparently successful atrial fibrillation (AF) ablation, using data from the Chinese Atrial Fibrillation Registry study., Methods and Results: We identified 4512 consecutive patients who underwent successful AF ablation between August 2011 and December 2017. Of them, 3149 discontinued OAC 3 months post-ablation (Off-OAC group) and 1363 continued OAC beyond this period (On-OAC group). Regular follow-up examinations were undertaken to detect AF recurrence, monitor OAC therapy, and measure clinical outcomes. Primary outcomes included thromboembolic and major bleeding (MB) events experienced beyond 3 months after ablation. Low thromboembolic and MB event rates were noted in the on-treatment analysis. The incidence rates for thromboembolism were 0.54 [95% confidence interval (CI) 0.39-0.76] and 0.86 (95% CI 0.56-1.30) per 100 patient-years, and that for MB events were 0.19 (95% CI 0.11-0.34) and 0.35 (95% CI 0.18-0.67) per 100 patient-years, for the Off-OAC and On-OAC groups over mean follow-up periods of 24.2 ± 14.7 and 23.0 ± 13.6 months, respectively. Similar results were observed in the intention-to-treat analysis. Previous history of ischaemic stroke (IS)/transient ischaemic attack (TIA)/systemic embolism (SE) [hazard ratio (HR) 3.40, 95% CI 1.92-6.02; P < 0.01] and diabetes mellitus (HR 2.06, 95% CI 1.20-3.55, P = 0.01) were independently associated with thromboembolic events, while OAC discontinuation (HR 0.71, 95% CI 0.41-1.23, P = 0.21) remained insignificant in multivariable analysis., Conclusions: This study suggests that it may be safe to discontinue OAC in post-ablation patients under diligent monitoring, in the absence of AF recurrence, history of IS/TIA/SE, and diabetes mellitus. However, further large-scale randomized trials are required to confirm this., Trial Registration: Chinese Clinical Trial Registry ChiCTR-OCH-13003729. URL: http://www.chictr.org.cn/showproj.aspx?proj=5831., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Background: Lifestyle and risk factor management may improve outcomes in patients with atrial fibrillation (AF). We aim to evaluate the prevalence of modifiable risk factors and how these factors impact clinical outcomes in patients with AF., Methods and Results: Data on 17 898 AF cohort patients with AF enrolled between 2011 and 2016 was analyzed. A healthy lifestyle was defined as not smoking, not drinking, a healthy body mass index (BMI), untreated total cholesterol less than 200 mg/dL, untreated blood pressure (BP) less than 120/80 mm Hg, and untreated fasting plasma glucose (FPG) less than 100 mg/dL. The association between risk factors and risk of the composite endpoint of all-cause mortality and nonfatal ischemic stroke were assessed using Cox proportional hazards regression model. Only 4.0% of patients achieved a healthy lifestyle. In multivariate analysis, current smoking, a low BMI, not well-controlled FPG were independently and significantly associated with higher risk of all-cause mortality and nonfatal ischemic stroke, with corresponding hazard ratio (HR) estimates 1.22 (95% confidence interval [CI], 1.00-1.47), HR = 1.72 (95% CI, 1.34-2.20), and HR = 1.25 (95% CI, 1.06-1.46), respectively. High BP was also associated with higher risk with the outcomes (HR = 1.15, 95% CI, 1.00-1.34). Compared with patients with no risk factor, those who failed to maintained or achieved optimal risk factor control had a progressively higher risk of death and nonfatal ischemic stroke (HR for 1 risk factor = 1.44; 95% CI, 1.07-1.92; and more than 2 risk factors =  1.75; 95% CI, 0.99-3.09)., Conclusions: Maintenance of well-controlled risk factors may substantially lower the risk of death and ischemic stroke in patients with AF., (© 2019 Wiley Periodicals, Inc.)

Background: Low detection and nonadherence are major problems in current management approaches for patients with suspected atrial fibrillation (AF). Mobile health devices may enable earlier AF detection and improved AF management., Objectives: This study sought to investigate the effectiveness of AF screening in a large population-based cohort using smart device-based photoplethysmography (PPG) technology, combined with a clinical care AF management pathway using a mobile health approach., Methods: AF screening was performed with smart devices using PPG technology, which were made available for the population ≥18 years of age across China. Monitoring for at least 14 days with a wristband (Honor Band 4) or wristwatch (Huawei Watch GT, Honor Watch, Huawei Technologies Co., Ltd., Shenzhen, China) was allowed. The patients with "possible AF" episodes using the PPG algorithm were further confirmed by health providers among the MAFA (mobile AF app) Telecare center and network hospitals, with clinical evaluation, electrocardiogram, or 24-h Holter monitoring., Results: There were 246,541 individuals who downloaded the PPG screening app, and 187,912 individuals used smart devices to monitor their pulse rhythm between October 26, 2018, and May 20, 2019. Among those with PPG monitoring (mean age 35 years, 86.7% male), 424 (of 187,912, 0.23%) (mean age 54 years, 87.0% male) received a "suspected AF" notification. Of those effectively followed up, 227 individuals (of 262, 87.0%) were confirmed as having AF, with the positive predictive value of PPG signals being 91.6% (95% confidential interval [CI]: 91.5% to 91.8%). Both suspected AF and identified AF markedly increased with age (p for trend <0.001), and individuals in Northeast China had the highest proportion of detected AF of 0.28% (95% CI: 0.20% to 0.39%). Of the individuals with identified AF, 216 (of 227, 95.1%) subsequently entered a program of integrated AF management using a mobile AF application; approximately 80% of high-risk patients were successfully anticoagulated., Conclusions: Based on the present study, continuous home monitoring with smart device-based PPG technology could be a feasible approach for AF screening. This would help efforts at screening and detection of AF, as well as early interventions to reduce stroke and other AF-related complications. (Mobile Health [mHealth] Technology for Improved Screening, Patient Involvement and Optimizing Integrated Care in Atrial Fibrillation [MAFA II]; ChiCTR-OOC-17014138)., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Current management of patients with atrial fibrillation (AF) is limited by low detection of AF, non-adherence to guidelines and lack of consideration of patient's preferences, thus highlighting the need for a holistic and integrated approach to AF management. This study aims to determine whether a mHealth technology-supported AF integrated management strategy will reduce AF-related adverse events., Methods/design: The mAFA II trial is a prospective, cluster randomised controlled trial. The 40 sites will be randomised to mAFA-integrated care intervention or usual care arms. Prior to randomisation, study sites will be paired to be matched in size and the proportion of study eligible patients. All AF patients aged over 18 years old with CHA 2 DS 2 -VASc score ≥ 2 will be enrolled. Assuming a composite adverse event rate of 10% pre-intervention, reduced to 5% after intervention, we aim to recruit 3660 patients assuming a 10% loss to follow-up. The primary study endpoint is a composite of stroke/thromboembolism, all-cause death and rehospitalisation. Ancillary analyses would determine patient-related outcome measures, health economics and cost effectiveness, as well as an embedded qualitative study., Discussion: The mAFA II trial will provide evidence for an integrated care approach to holistic AF care, supported by mobile health technology to improve screening, patient involvement and optimisation of management., (© 2019 John Wiley & Sons Ltd.)

BACKGROUND Several factors determine the efficacy of warfarin anticoagulation in patients with non-valvular atrial fibrillation (NVAF). This study aimed to use data from the Chinese Atrial Fibrillation Registry study to assess the control of anticoagulation therapy in Chinese patients with NVAF treated with warfarin. MATERIAL AND METHODS From the Chinese Atrial Fibrillation Registry study the anticoagulant use and dosing, the time in therapeutic range (TTR) of the international normalized ratio (INR), and standard deviation of the observed INR values (SDINR), and their influencing factors were evaluated. RESULTS The median INR and SDINR were 2.04 (IQR 1.71-2.41) and 0.50 (IQR, 0.35-0.69), respectively. The median TTR was 51.7% (IQR, 30.6-70.1%) and only 25.1% had a TTR ≥70%. Age was ≥70 years (OR, 0.72; 95% CI, 0.55-0.94; P=0.015), bleeding history (OR 0.48; 95% CI, 0.23-0.89; P=0.029), the use of a single drug (OR, 0.62; 95% CI, 0.42-0.92; P=0.016), more than drug (OR, 0.60; 95% CI, 0.41-0.88; P=0.009), and lack of assessment of bleeding risk (OR, 0.72; 95% CI, 0.54-0.97; P=0.033) were associated with TTR <70% (INR 2.0-3.0). Coronary heart disease (CHD) and peripheral artery disease (PAD) (OR, 0.69; 95% CI, 0.52-0.90; P=0.007) and diabetes mellitus (OR, 0.79; 95% CI, 0.62-0.99; P=0.044) were associated with increased variability in INR (SDINR ≥0.5). CONCLUSIONS In Chinese patients with NVAF, warfarin anticoagulation was associated with lower TTR and less stable anticoagulation than in current guidelines, and risk factors for reduced safety and efficacy were identified.

Introduction: Chronic kidney disease (CKD) has been associated with incident atrial fibrillation (AF) and its complications, but data from Asian cohorts are limited., Aim: To explore the relationship of AF recurrence after catheter ablation (CA) with eGFR as a continuous variable, and with different renal function categories (normal: estimated glomerular filtration rate [eGFR] ≥90mL/min/1.73 m 2 ; mild CKD: eGFR 60-89mL/min/1.73 m 2 ; moderate CKD: eGFR 45-59mL/min/1.73 m 2 ; severe CKD: <45mL/min/1.73 m 2 ), using data from the Guangzhou Atrial Fibrillation Ablation Registry., Methods: We studied consecutive symptomatic adult patients with non-valvular AF, refractory to at least one antiarrhythmic drug and eligible for CA, in Guangdong General Hospital between June 2011 and August 2015., Results: Data were available from 1407 consecutive patients (mean age 57.3±11.5 years; 68% men) with non-valvular AF undergoing radiofrequency or cryoballoon ablation. During a mean follow-up of 20.7±8.8 months, 18.6% of patients with paroxysmal AF and 50.5% with non-paroxysmal AF had AF recurrence. On multivariable analysis, eGFR (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.96-0.97) was an independent risk factor for AF recurrence, with a good predictive value (area under the curve 0.74, 95% CI 0.72-0.77; P<0.01). In the normal renal function, and mild, moderate and severe CKD categories, AF recurrence rates were 11.5%, 29.3%, 72.0% and 93.3%, respectively. Compared with normal renal function, there were stepwise increased risks of AF recurrence with mild CKD (HR 3.30, 95% CI 2.55-4.26; P<0.01), moderate CKD (HR 9.43, 95% CI 6.76-13.16; P<0.01) and severe CKD (HR 12.35, 95% CI 6.93-21.99; P<0.01)., Conclusions: In a large cohort of Asian patients with AF, renal dysfunction increased the risk of AF recurrence after CA. AF recurrence gradually increased with worsening kidney function in this cohort., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

BACKGROUND Oral anticoagulants (OACs) such as warfarin and non-VKA oral anticoagulants (NOACs) have been recommended for patients with atrial fibrillation (AF) who are at risk for stroke. Whether NOACs have a higher persistence than warfarin is still unclear. This is especially true in China. MATERIAL AND METHODS Data from a large hospital-based cohort in China (China-AF Registry) from 2011 to 2017 were used for this study. Non-valvular AF patients with newly initiated OACs were included. A time-to-event approach was used to analyze patient persistence. The survival distributions of persistence were compared using the log-rank test. A multivariable Cox regression model was used to explore predictors of warfarin and NOACs non-persistence. RESULTS Patients with newly initiated warfarin (n=4845) or NOACs (n=854) were included in this study. Persistence rates at 1, 2, and 3 years were 93.2%, 89.4%, and 87.2% in the warfarin group and 88.8%, 84.3%, and 81.3% in the NOAC group respectively. Non-persistence was significantly higher with NOACs than with warfarin. On multivariate analysis, age <75 years old, outpatient clinic visits, asymptomatic AF, paroxysmal AF, duration of AF <3 years, history of peptic ulcer, and no previous TIA, stroke or thromboembolism were strong predictors of warfarin non-persistence, while in the NOACs group, age <75 years old, outpatient clinic visits, lower education status and no history of congestive heart failure were predictors. CONCLUSIONS Treatment persistence of NOACs was lower than that of warfarin among Chinese patients with AF. Patients with characteristics of non-persistence predictors need special attention to maintain their therapy.

Background: The incidence of atrial fibrillation (AF) is increasing, conferring a major health-care issue in Asia. No risk score for predicting incident AF has been specifically developed in Asian subjects. Our aim was to investigate risk factors for incident AF in Asian subjects and to combine them into a simple clinical risk score., Methods: Risk factors for incident AF were analyzed in 471,446 subjects from the Chinese Yunnan Insurance Database (internal derivation cohort) and then combined into a simple clinical risk score. External application of the new score was performed in 451,199 subjects from the Korean National Health Insurance Service (external cohort)., Results: In the internal cohort, structural heart disease (SHD), heart failure (HF), age ≥ 75 years, coronary artery disease (CAD), hyperthyroidism, COPD, and hypertension were associated with incident AF. Given the low prevalence and the strong association of SHD with incident AF (hazard ratio, 26.07; 95% CI, 18.22-37.30; P < .001), these patients should be independently considered as high risk for AF and were excluded from the analysis. The remaining predictors were combined into the new simple C 2 HEST score: C 2 : CAD/COPD (1 point each); H: hypertension (1 point); E: elderly (age ≥ 75 years, 2 points); S: systolic HF (2 points); and T: thyroid disease (hyperthyroidism, 1 point). The C 2 HEST score showed good discrimination with the area under the curve (AUC) of 0.75 (95% CI, 0.73-0.77) and had good calibration (P = .774). The score was internally validated by bootstrap sampling procedure, giving an AUC of 0.75 (95% CI, 0.73-0.77). External application gave an AUC of 0.65 (95% CI, 0.65-0.66). The C 2 HEST score was superior to CHADS 2 and CHA 2 DS 2 -VASc scores in both cohorts in predicting incident AF., Conclusions: We have developed and validated the C 2 HEST score as a simple clinical tool to assess the individual risk of developing AF in the Asian population without SHD., (Copyright © 2018 American College of Chest Physicians. All rights reserved.)

Background Previous studies have provided conflicting results as to whether women are at higher risk than men for thromboembolism in the setting of atrial fibrillation ( AF ). We investigated whether women with AF were at higher risk of ischemic stroke in the China-AF (China Atrial Fibrillation Registry) Study. Methods and Results A total of 19 515 patients were prospectively enrolled between August 2011 and December 2016 in the China- AF Study. After exclusion of patients receiving anticoagulation or ablation therapy, 6239 patients (2574 women) with results from at least 6 months of follow-up were used for the analysis. Cox proportional hazards models were performed to evaluate whether female sex was an independent risk factor for thromboembolism after multivariate adjustment. The primary outcome was the time to the first occurrence of ischemic stroke or systemic embolism. After a mean follow-up of 2.81±1.46 years, 152 female patients reached the primary outcome, as compared with 172 male patients. Crude incidence rates of thromboembolism between women and men were of borderline statistical significance (2.08 versus 1.68 per 100 patient-years, P=0.058). After multivariable analysis, female sex was not independently associated with an increased thromboembolism risk (hazard ratio 1.09, 95% confidence interval 0.86-1.39). There was no significant difference in thromboembolism risk by sex stratified by age and presence or absence of risk factors ( P for interaction all >0.1). Conclusions Although crude incidence rates of thromboembolism were higher in Chinese female patients with AF compared with male patients, female sex did not emerge as an independent risk factor for thromboembolism on multivariate analysis. Clinical Trial Registration URL : http://www.chictr.org.cn/ . Unique identifier: Chi CTR - OCH -13003729.

Background: Obesity or overweight is related to worse outcomes in patients with atrial fibrillation (AF) following catheter ablation (CA). The role of being underweight in relation to recurrent arrhythmias post AF ablation is less certain. We conducted a retrospective study to investigate the association of body mass index (BMI) with arrhythmia outcomes in AF patients undergoing CA., Methods: In a cohort of 1410 AF patients (mean age 57.2 ± 11.6 years; 68% male) undergoing single CA, the association between BMI and AF ablation outcome was analyzed using BMI as a continuous variable and by four BMI categories (<18.5 kg/m 2 , 18.5-24 kg/m 2 , 25-29 kg/m 2 , and ≥ 30 kg/m 2 )., Result: We observed a positive association between a cut off value of BMI and risk of AF recurrence post AF ablation. BMI ≥26.36 kg/m 2 was related to more AF recurrence (c-statistic 0.55, 95%CI 0.51-0.58; P < 0.01) with 50% increased risk of AF recurrence (HR 1.50, 95% CI 1.22-1.86; P < 0.01). Recurrence rates in the four BMI categories were 33.3%, 23.2%, 27.2 and 41.8%, respectively (P < 0.01). Kaplan-Meier analysis showed that BMI categories of <18.5 kg/m 2 and ≥ 30 kg/m 2 were all associated with more AF recurrence (P = 0.01). Both underweight (HR 1.85, 95%CI 1.12-3.08; P = 0.02) and obesity (HR 1.78, 95%CI 1.17-2.72; P = 0.01) significantly increased the risk of AF recurrence in a Cox proportional hazard model., Conclusion: BMI had good predictive value for AF ablation outcomes with a cut off value of ≥26.36 kg/m 2 . Apart from being obese/overweight, being underweight might also be a risk factor for AF recurrence post ablation., (Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.)

Introduction: Atrial fibrillation (AF) is a worldwide healthcare burden that is associated with the ageing population. Elderly patients with AF with multiple comorbidities usually present with a high risk of thromboembolism and bleeding. Limited prospective data are available from Asian cohorts on the epidemiology and complications of AF. The present prospective cohort study aims to explore contemporary antithrombotic strategies among the elderly Chinese population in the new era of non-vitamin K antagonist oral anticoagulants and to compare the clinical characteristics and outcomes between Chinese and European AF populations., Methods and Analysis: The Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry will recruit 5000 patients with AF over 65 years of age in China. AF-related risks, including stroke/systemic thromboembolism and bleeding outcomes, will be assessed. Medical history, risk factors, demographic information and management will be collected at baseline, and clinical events during 1 year follow-up will be recorded. Follow-up will be conducted for at least 1 year and then annually thereafter. As our registry has a common protocol to the European Society of Cardiology EURObservational Research Programme AF general registry programme, preplanned analyses comparing the clinical profiles and outcomes will be performed. The ChiOTEAF registry offers an opportunity to provide a better understanding of the clinical profiles and adverse outcomes of patients with AF in China and allow for comparisons with a contemporary European population., Ethics and Dissemination: Ethics approval was granted by the Central Medical Ethic Committee of Chinese PLA General Hospital (approval no S2014-065-01). The (inter)national research presentations, peer-reviewed publications and media coverage of the research will be sued for dissemination of the results., Competing Interests: Competing interests: GYHL is a consultant for Bayer/Janssen, BMS/Pfizer, Biotronik, Medtronic, Boehringer Ingelheim, Microlife and Daiichi Sankyo and a speaker for Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim, Microlife, Roche and Daiichi Sankyo. No fees are received personally., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Introduction Although guideline-adherent antithrombotic therapy (ATT) for stroke prevention in atrial fibrillation (AF) is associated with lower mortality and thromboembolism, ATT uptake shows geographic variation worldwide. We aimed to assess thromboembolic risk and baseline ATT by geographic region and identify factors associated with prescription of ATT in a large, truly global registry of patients with recently diagnosed AF. Methods and Results Our analysis comprises 15,092 patients newly diagnosed with non-valvular AF at risk for stroke, enrolled in Phase II of Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF). Global oral anticoagulation (OAC) use was 79.9%, being highest in Europe (90.1%), followed by Africa/Middle East (87.4%) and Latin America (85.3%), North America (78.3%) and Asia (55.2%). Among OAC users, vitamin K antagonists (VKAs) have been replaced by non-VKA OACs (NOACs) as the more prevalent OAC option in all regions, with highest use in North America (66.5%) and lowest in Asia (50.2%). In Asia, OAC was 80.4% in community hospitals but only 49.8% in university hospitals and 42.6% in specialist offices, and varied from 21.0% in China to 89.7% in Japan (NOACs at 5.8% in China and 83.3% in Japan). Globally, 76.5% of low-risk patients were prescribed ATT (46.1% OAC), whereas 17.7% high-risk patients were not anticoagulated (Europe 8.8%; North America 18.9%; Asia 42.4%). Conclusion Substantial inter- and intra-regional differences in ATT for stroke prevention in AF are evident in this global registry. While guideline-adherent ATT can be further improved, NOACs are the main contributor to high OAC use worldwide., Competing Interests: Conflicts of Interest: M.M. declared no conflict of interest. M.V.H. has received honoraria for presentations and research grants from Boehringer Ingelheim, Bayer HealthCare, Pfizer, GlaxoSmithKline (GSK) and Actelion Pharmaceuticals. K.J.R. is an employee of RTI Health Solutions, an independent non-profit research organization that does work for government agencies and pharmaceutical companies. S.J.D. has received consultancy fees for serving as a steering committee member for Boehringer Ingelheim. He also holds research grants from St Jude Medical. C.S.M. has received honoraria for presentations as well as research grants from BMS, Boehringer Ingelheim, Bayer HealthCare, Pfizer, AstraZeneca and Johnson & Johnson. H.C.D. has received honoraria for participation in clinical trials, contribution to advisory boards or oral presentations from the following: Abbott, Allergan, AstraZeneca, Bayer Vital, BMS, Boehringer Ingelheim, CoAxia, Corimmun, Covidien, Daiichi-Sankyo, D-Pharm, Fresenius, GSK, Janssen-Cilag, Johnson & Johnson, Knoll, Lilly, MSD, Medtronic, MindFrame, Neurobiological Technologies, Novartis, Novo-Nordisk, Paion, Parke-Davis, Pfizer, Sanofi-Aventis, Schering-Plough, Servier, Solvay, St Jude, Syngis, Talecris, Thrombogenics, WebMD Global, Wyeth and Yamanouchi. Financial support for research projects was provided by AstraZeneca, GSK, Boehringer Ingelheim, Lundbeck, Novartis, Janssen-Cilag, Sanofi-Aventis, Syngis and Talecris. The Department of Neurology at the University Duisburg-Essen received research grants from the German Research Council (DFG), the German Ministry of Education and Research (BMBF), the European Union, the National Institutes of Health (NIH), the Bertelsmann Foundation and the Heinz-Nixdorf Foundation. H.C.D. has no ownership interest and does not own stocks of any pharmaceutical company; within the past year, he served as the editor of Aktuelle Neurologie, Arzneimitteltherapie, Kopfschmerznews, Stroke News, as the co-editor of Cephalalgia and was on the editorial board of Lancet Neurology, Stroke, European Neurology and Cerebrovascular Disorders; he chairs the Treatment Guidelines Committee of the German Society of Neurology and has contributed to the European Heart Rhythm Association (EHRA) and the European Society of Cardiology (ESC) guidelines for the treatment of atrial fibrillation. J.L.H. is currently conducting research sponsored by Boehringer Ingelheim as a member of the Executive Steering Committee for the GLORIA-AF Registry, and has received consulting fees from Bayer HealthCare, Janssen-Ortho-McNeil, and Pfizer for advisory activities involving the development of anticoagulant drugs. M.P., S.L., K.Z., C.T. and A.E. are employees of Boehringer Ingelheim. G.Y.H.L. has been a consultant for Bayer/Janssen, Astellas, Merck, Sanofi, Bristol-Myers Squibb (BMS)/Pfizer, Biotronik, Medtronic, Portola, Boehringer Ingelheim, Microlife and Daiichi-Sankyo. He has also been a speaker for Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim, Microlife, Roche and Daiichi-Sankyo.

Ischaemic stroke risk rises with the increasing cardiovascular risk factors. How atrial fibrillation (AF) incrementally contributes to the risk for ischaemic stroke with increasing age and multiple cardiovascular risk factors is unclear. In an individual patient with AF the mechanism of ischaemic stroke may be related directly to AF itself or to risk factors associated with AF. It was this study's objective to investigate incident ischaemic stroke in relation to age and increasing cardiovascular risk factor(s), and the incremental impact of AF on stroke rates. We studied a 5% random sampling from Chinese medical insurance data covering more than 10 million individuals, for the years 2001 to 2012. The rate of ischaemic stroke was calculated amongst the individuals with no prior history of ischaemic stroke, in relation to age groups (aged < 65, 65-74, ≥ 75 years old; n = 348,431, n = 56,952, n = 20,217, respectively), and increasing risk factors using the CHA2DS2-VASc score. Among the randomly sampled 425,600 individuals with total follow-up of 1,864,232 patient-years [63.8% male, mean age 60 years; 880 with AF, vs 424,720 non-AF], there were 13,242 (3.1%) ischaemic strokes after 64,834 person-years follow-up. Overall, ischaemic stroke incidence (per 100 person-years) was 0.35 (95%CI 0.34-0.35) in the non-AF population and 1.11 (0.84-1.45) with AF. The AF population age < 65 and 65-74 had higher CHA2DS2-VASc scores than the non-AF population (p< 0.001), but this was non-significant between the non-AF and AF population age ≥ 75 (p=0.086). For the population age ≥ 75 years, incident stroke rates were 2.07 (0.86-4.76) and 4.29 (4.08-4.51) in non-AF and AF populations, respectively. The non-AF population age ≥ 65 years with ≥ 2 additional comorbidities (hypertension, vascular disease, diabetic, or heart failure) had ischaemic stroke rates similar to an AF population with CHA2DS2-VASc ≥ 4. In both non-AF and AF populations, those with CHA2DS2-VASc =1 had a 1.9 fold increase in stroke risk, and those with CHA2DS2-VASc ≥ 2 had more than four-fold increased risk for stroke, compared with those with CHA2DS2-VASc=0. In conclusion, an increasing cluster of multiple cardiovascular risk factors (besides AF) contributes to a greater risk for ischaemic stroke, especially in the elderly population. If elderly and with multiple risk factors, non-AF patients may have a risk of incident ischaemic stroke that is comparable or even higher than patients with AF, suggesting that the incremental stroke risk attributable to AF is marginal in such 'high risk' patients.

Background: Limited data exists on the impact of sex on clinical characteristics and outcomes among nonvalvular AF patients from China. We investigated the impact of gender on risk factors and inpatient mortality in a hospitalized nonvalvular AF cohort in Nanchang, China., Methods: We studied consecutive patients hospitalized with nonvalvular AF between May 2011 and December 2013. Predictors of inpatient mortality were evaluated using multivariate regression analyses., Results: We studied 2442 patients (43.7% female; mean age 71.8), with a median hospital stay of 10 days (IQR: 7-14). Inpatient mortality was 2.2%. Mean age, CHADS2 and CHA2DS2-VASc scores were higher in females vs. males (all p<0.0001). Oral anticoagulation use during hospitalization was 33.3% without sex differences, and length of stay and inpatient outcomes were comparable between sexes. On multivariate analyses, the significant risk factors of inpatient death in females were previous ischemic stroke/transient ischemic attack (TIA)/thromboembolism (TE) (Odds Ratio (OR): 2.27; 95% Confidence Intervals (CI): 1.43-3.61), peripheral artery disease (OR: 5.75, 95% CI: 1.49-22.16) and chronic renal disease (OR: 5.68, 95% CI: 1.46-22.13). Among males, only age (OR: 1.06, 95% CI: 1.02-1.11) and previous ischemic stroke/TIA/TE (OR: 1.81, 95% CI: 1.25-2.63) were independent predictors of inpatient mortality., Conclusion: Sex related differences in clinical characteristics and stroke risk profile were evident in Chinese nonvalvular AF patients, but no sex disparity was evident in the low antithrombotic therapy use or inpatient mortality. Previous ischemic stroke/TIA/TE was an important predictor of inpatient mortality in both female and male patients., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Much of the clinical epidemiology and treatment patterns for patients with atrial fibrillation (AF) are derived from Western populations. Limited data are available on antithrombotic therapy use over time and its impact on the stroke or bleeding events in newly diagnosed Chinese patients with AF. The present study investigates time trends in warfarin and aspirin use in China in relation to stroke and bleeding events in a Chinese population., Methods: We used a medical insurance database involving > 10 million individuals for the years 2001 to 2012 in Yunnan, a southwestern province of China, and performed time-trend analysis on those with newly diagnosed AF. Cox proportional hazards time-varying exposures were used to determine the risk of stroke or bleeding events associated with antithrombotic therapy among patients with AF., Results: Among the randomly sampled 471,446 participants, there were 1,237 patients with AF, including 921 newly diagnosed with AF, thus providing 4,859 person-years of experience (62% men; mean attained age, 70 years). The overall rate of antithrombotic therapy was 37.7% (347 of 921 patients), with 4.1% (38 of 921) on warfarin and 32.3% (298 of 921) on aspirin. Antithrombotic therapy was not related to stroke/bleeding risk scores (CHADS2 [congestive heart failure, hypertension, age ≥ 75 years, diabetes, stroke (doubled)] score, P = .522; CHA2DS2-VASc [congestive heart failure, hypertension, age ≥ 75 years (doubled), diabetes mellitus, stroke or transient ischemic attack (doubled), vascular disease, age 65 to 74 years, and female sex] score, P = .957; HAS-BLED [hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly (> 65 years), drugs/alcohol concomitantly] score, P = .095). The use of antithrombotic drugs (mainly aspirin) increased in both women and men over time, with the rate of aspirin increasing from 4.0% in 2007 to 46.1% in 2012 in the former, and from 7.7% in 2007 to 61.9% in 2012 in the latter (P for trend for both, < .005). In the overall cohort, the annual stroke rate was approximately 6% and the annual major bleeding rate was about 1%. Compared with nonantithrombotic therapy, the hazard ratio for ischemic stroke was 0.68 (95% CI, 0.39-1.18) for aspirin and 1.39 (0.54-3.59) for warfarin., Conclusions: Aspirin use increased among Chinese patients newly diagnosed with AF, with no relationship to the patient's stroke or bleeding risk. Warfarin use was very low. Given the health-care burden of AF and its complications, our study has major implications for health-care systems in non-Western countries, given the global burden of this common arrhythmia.

Background: Much of the epidemiology of atrial fibrillation (AF) is based on data from Western populations. Despite the huge population of Asia, data on the clinical epidemiology of AF in Asian countries are limited. The current study aimed to investigate the prevalence and incidence of newly diagnosed (ie, incident) AF, as well as lifetime risk, in China and to determine the clinical risk factors contributing to its development., Methods: Using a medical insurance database involving > 10 million individuals for the years 2001 to 2012 in the southwest of China, trends in incident AF were calculated using Kaplan-Meier analysis and Cox regression. The usefulness of the CHADS2 (congestive heart failure, hypertension, age, diabetes, stroke [doubled]) and CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 [doubled], diabetes, stroke [doubled], vascular disease, age 65-74, and sex category [female]) scores was tested in predicting the occurrence of incident AF., Results: A total of 471,446 individuals (aged ≥ 20 years) were studied, with 1,924,975 person-years of experience. We identified 921 patients with incident AF (62% male; mean age, 62 years). The prevalence of incident AF in subjects aged ≥ 20 years was 0.2 per 100 people, with an incidence of AF of 0.05 per 100 person-years overall. Over an 11-year period, the prevalence of AF increased 20-fold, whereas AF-related stroke increased 13-fold. The lifetime risk of AF was approximately one in five among Chinese adults, and it increased with advancing age. The CHA2DS2-VASc score was superior to the CHADS2 score in predicting the risk of incident AF in our Chinese population (DeLong test, Z = 6.621, P < .001)., Conclusions: The AF burden, as well as the risk of AF-related stroke, has increased significantly over the past 11 years in the southwest of China. The public health burden of AF and its complications are greatest in the very elderly, with major implications for health-care systems given the global burden of this common arrhythmia.

Background and Purpose: Little is known about the impact of quality of anticoagulation control, as reflected by time in therapeutic range (TTR), on the effectiveness and safety of warfarin therapy in Chinese patients with atrial fibrillation. We investigated the risks of ischemic stroke and intracranial hemorrhage (ICH) in relation to warfarin at various TTRs in a real-world cohort of Chinese patients with atrial fibrillation receiving warfarin and compared with those on dabigatran, aspirin, and no therapy., Methods: This is an observational study., Results: Of 8754 Chinese patients with atrial fibrillation and CHA2DS2-VASc ≥1 (79.5±9.2 years; CHA2DS2-VASc, 4.1±1.5; and Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile International Normalized Ratio, Elderly (>65 years), Drugs/Alcohol Concomitantly [HAS-BLED], 2.2±0.9), 16.3% received warfarin, 41.1% aspirin, 4.5% dabigatran, and 38.1% received no therapy. The incidence of ischemic stroke was highest in patients with no therapy (10.38%/y), followed by patients on aspirin (7.95%/y). The incidence of stroke decreased progressively with increasing TTR quartiles (<17.9%, 17.9%-38.8%, 38.8%-56.2%, and >56.2%) from 7.34%/y (first quartile) to 3.10%/y (fourth quartile). Patients on dabigatran had the lowest incidence of stroke among all groups (2.24%/y). The incidence of ICH was lowest in patients on dabigatran (0.32%/y) compared with those on warfarin (0.90%/y), aspirin (0.80%/y), and no therapy (0.53%/y). ICH incidence decreased with increasing TTR from 1.37%/y (first quartile) to 0.74%/y (fourth quartile)., Conclusions: In Chinese patients with atrial fibrillation, the benefits of warfarin therapy for stroke prevention and ICH risk are closely dependent on the quality of anticoagulation, as reflected by TTR. Even at the top TTR quartile, warfarin was associated with a higher stroke and ICH risk than dabigatran., (© 2014 American Heart Association, Inc.)

Background: Renal dysfunction has been proposed for the risk factor for stroke and bleeding in atrial fibrillation (AF). The impact of changes in renal dysfunction over time and the relationship to stroke and bleeding risk in these patients remain unknown. We investigated sequential change in renal function (estimated glomerular filtration rate, eGFR) and the risk for clinical events (ischaemic stroke, death and major bleeding) over time in a cohort of 617 AF patients followed up for 2 years., Methods: eGFR was estimated at baseline, 6 months and 12 months using three formulas (Modification of Diet in Renal Disease equation, MDRD, Chronic Kidney Disease Epidemiology Collaboration, CKD-EPI, and Cockcroft-Gault equation). Changes in eGFR and the risk for clinical events were analysed by Cox models, receiver operating curves (ROC), and Kaplan-Meier survival curves., Results: When patients with eGFR≤60 ml/min/1.73 m(2) were compared to patients with eGFR>60 ml/min/1.73 m(2), there was an increase over time in stroke or death, or death, with impaired renal function (all p<0.05). An absolute decrease in eGFR≥15 ml/min/1.73 m(2) on Cockcroft-Gault and CKD-EPI and ≥25 ml/min/1.73 m(2) on MDRD were associated with an increased risk for stroke or death, death, and ischaemic stroke at 6 months (all p<0.05), but not major bleeding. A relative reduction (decline of ≥25%) in eGFR was also an independent risk. ROC analysis showed that a relative reduction in eGFR ≥25% at 6 months and 12 months modestly predicted the occurrence of stroke or death in patients with AF (c-indexes: 0.57 to 0.61, p<0.05)., Conclusion: In patients with AF, an absolute decrease in eGFR ≥15 ml/min/1.73 m(2) on Cockcroft-Gault and CKD-EPI, and ≥25 ml/min/1.73 m(2) on MDRD, or a relative reduction (≥25%) in eGFR, independently predicted the risk for the endpoints 'stroke or death', 'death' or (at 6 months) ischaemic stroke. Deteriorating renal function increases the risk of death in AF patients., (© 2013.)

Background: There are established differences in cardiovascular disease in different racial groups. Worldwide, the literature regarding the clinical epidemiology of congestive heart failure (CHF) in non-white populations is scarce., Objectives: To document the prevalence of CHF in the multiracial population of Malaysia, and to describe the clinical features and management of these patients., Setting: Busy city centre general hospital in Kuala Lumpur, Malaysia., Results: Of 1435 acute medical admissions to Kuala Lumpur General Hospital over the 4-week study period, 97 patients (6.7%) were admitted with the primary diagnosis of CHF. Coronary artery disease was the main aetiology of CHF, accounting for almost half (49.5%) the patients, followed by hypertension (18.6%). However, there were variations in associated aetiological factors between ethnic groups, with diabetes mellitus affecting the majority of Indians-as well as underutilisation of standard drugs for CHF, such as the angiotensin converting enzyme (ACE) inhibitors, which were only used in 43.3%., Conclusion: Amongst acute medical admissions to a single centre in Malaysia the prevalence of CHF was 6.7%. Coronary artery disease was the major aetiological factor in heart failure accounting for almost half the admissions. The under-prescription of ACE inhibitors was similar to other clinical surveys carried out amongst Caucasian populations in the West.