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Thromboembolic Events and Vascular Dementia in Patients With Atrial Fibrillation and Low Apparent Stroke Risk
abstract
This abstract is available on the publisher's site.
Access this abstract nowThe prevention of thromboembolism in atrial fibrillation (AF) is typically restricted to patients with specific risk factors and ignores outcomes such as vascular dementia. This population-based cohort study used electronic healthcare records from 5,199,994 primary care patients (UK; 2005–2020). A total of 290,525 (5.6%) had a diagnosis of AF and were aged 40–75 years, of which 36,340 had no history of stroke, a low perceived risk of stroke based on clinical risk factors and no oral anticoagulant prescription. Matching was performed for age, sex and region to 117,298 controls without AF. During 5 years median follow-up (831,005 person-years), incident stroke occurred in 3.8% with AF versus 1.5% control (adjusted hazard ratio (HR) 2.06, 95% confidence interval (CI) 1.91–2.21; P < 0.001), arterial thromboembolism 0.3% versus 0.1% (HR 2.39, 95% CI 1.83–3.11; P < 0.001), and all-cause mortality 8.9% versus 5.0% (HR 1.44, 95% CI 1.38–1.50; P < 0.001). AF was associated with all-cause dementia (HR 1.17, 95% CI 1.04–1.32; P = 0.010), driven by vascular dementia (HR 1.68, 95% CI 1.33–2.12; P < 0.001) rather than Alzheimer's disease (HR 0.85, 95% CI 0.70–1.03; P = 0.09). Death and thromboembolic outcomes, including vascular dementia, are substantially increased in patients with AF despite a lack of conventional stroke risk factors.
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Thromboembolic events and vascular dementia in patients with atrial fibrillation and low apparent stroke risk
Nat. Med. 2024 Jun 05;[EPub Ahead of Print], AR Mobley, A Subramanian, A Champsi, X Wang, P Myles, P McGreavy, KV Bunting, D Shukla, K Nirantharakumar, D KotechaFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Dementia is one of the most concerning health outcomes for the public, patients, and healthcare services. Cardiovascular conditions, such as atrial fibrillation (AF), have been associated with a higher risk of vascular dementia and could provide an opportunity to direct preventative strategies. However, the association between AF and dementia is substantively confounded by cardiovascular risk factors.
The present study uses real-world cohort data from primary care to assess this question in patients with a low burden of conventional cardiovascular risk factors. The study found that patients with AF were twofold more likely to have a stroke or arterial thromboembolism than age- and sex-matched controls without AF (aHR, 2.06; 95% CI, 1.91–2.21; P < .001 and aHR, 2.39; 95% CI, 1.83–3.11; P < .001, respectively). Incident vascular dementia was similarly high in patients with AF despite their low vascular risk status (aHR, 1.68; 95% CI, 1.33–2.12; P < .001). Based on information from routine electronic healthcare records, the study involved 36,340 patients with AF and 117,298 controls, with outcomes extracted during 831,005 patient-years of follow-up. The patients with an AF diagnosis also had excess mortality after adjustment for confounding factors (aHR, 1.44; 95% CI, 1.38–1.50; P < .001).
The take-home message is that vascular dementia is increased in patients with AF and may be another thromboembolic complication, similar to ischemic stroke. The lack of association in this study between AF and Alzheimer’s disease would support that mechanism; however, observational studies are only exploratory and do not provide clinicians or patients with the scope for prevention. The DaRe2THINK trial is currently recruiting patients with AF aged 55 to 73 years and a low perceived risk of stroke, randomizing them to earlier prescription of direct oral anticoagulants versus the usual clinical approach to wait for other risk factors. DaRe2THINK will establish whether anticoagulation can prevent thromboembolic disease and cognitive decline, which have such a profound effect on patients and their families, as well as the cost and sustainability of global health services.
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