'Comprehensive' management approach needed for AF

By Eleanor McDermid

Death is a bigger risk than stroke among patients with atrial fibrillation (AF), particularly during the first 4 months after diagnosis, research shows.

The all-cause mortality rate among 17,162 patients from the GARFIELD-AF cohort over 2 years was 3.83 per 100 person-years, whereas the stroke/systemic embolism rate was 1.25 per 100 person-years, report Jean-Pierre Bassand (University of Besançon, France) and study co-authors.

Congestive heart failure was the second-most common event, at a rate of 2.41 per 100 person-years, while major bleeding and acute coronary syndromes occurred at respective rates of 0.70 and 0.63 per 100 person-years.

The patients were aged an average of 69.8 years and 43.8% were women. Death was most commonly from cardiovascular causes, accounting for 40.5% of deaths, but congestive heart failure and other vascular causes were most frequent among these, accounting for 10.8% and 11.1% of all deaths, respectively, whereas only 5.1% of deaths were caused by ischaemic stroke.

"Such a low rate of stroke-related death may be because >60% of the population was anticoagulated", the researchers write in the European Heart Journal. Indeed, use of anticoagulation was associated with a significant 35% reduction in mortality risk.

The relative infrequency of stroke mortality leads them to suggest that "a more comprehensive approach" may be needed to manage AF patients, beyond anticoagulation.

"This could include interventions targeting other modifiable, cause-specific risk factors for death", they say, noting that congestive heart failure, acute coronary syndromes, sudden/unwitnessed death, cancer, respiratory failure and infection/sepsis accounted for 65% of all deaths.

Cancer accounted for 10.3% of deaths, but the most common category was undetermined, at 23.7%.

The team notes that the rates of death, stroke/embolism and major bleeding were markedly higher during the first 4 months of follow-up than overall, by 29%, 35% and 56%, respectively, with the effect most marked among patients with new-onset/newly diagnosed AF.

This suggests that new-onset AF "may occur as a complication of a chronic or acute cardiovascular or non-cardiovascular underlying disease that impairs early evolution", they say.

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