What is the clinical evidence from this study?

Study design: Cohort. Population: Non-valvular atrial fibrillation (n=3046). Intervention: Paroxysmal atrial fibrillation vs. Persistent atrial fibrillation. Primary outcome: All-cause mortality (HR 0.66, 95% CI 0.46-0.96, p=0.029).

February 1, 2021Open Access

Mortality Risk and Temporal Patterns of Atrial Fibrillation in the Nationwide Registry

Key Result

Paroxysmal atrial fibrillation was associated with a lower rate of all-cause mortality compared to persistent atrial fibrillation (HR 0.66) and permanent atrial fibrillation (HR 0.71).

Study Design

Type

Cohort (n=3,046)

Multicenter

Yes

Structured PICO

Does the temporal pattern of atrial fibrillation (persistent/permanent vs paroxysmal) affect the risk of all-cause mortality and ischemic stroke in patients with non-valvular AF?

Population

3,046 patients with non-valvular atrial fibrillation consecutively enrolled in a prospective multicenter cohort. 75% of all patients and 83% of those with CHA2DS2-VASc score ≥2 in males or ≥3 in females were on anticoagulants.

Intervention

Persistent and permanent atrial fibrillation (temporal patterns)

Comparator

Paroxysmal atrial fibrillation

Outcome

All-cause mortality and ischemic strokehard clinical

Persistent and permanent atrial fibrillation are associated with a higher risk of all-cause mortality compared to paroxysmal atrial fibrillation, independent of baseline comorbidities.

Main Result

Effect estimate: HR 0.66 (95% CI 0.46-0.96)

Absolute Event Rate: 2.5% vs 4.4%

p-value: p=0.029

Limitations

Observational registry design can only demonstrate association, not causation
Baseline characteristics were not balanced and therapeutic strategy was not controlled
Residual confounders remained despite statistical adjustment
AF pattern was defined clinically at physician discretion, subject to misclassification error
Vitamin K antagonist was the main choice of anticoagulant; DOAC use was limited
Follow-up time was relatively short
Cause of death was undetermined in 20% of all deaths

Abstract

Aims Persistent and permanent atrial fibrillation (AF) often occurs in the presence of multiple comorbidities and is linked to adverse clinical outcomes. It is unclear whether the sustained pattern of AF itself is prognostic or if it is confounded by underlying comorbidities. Here, we tested the association between the temporal patterns of AF and the risks of ischemic stroke and all-cause mortality. Methods and Results In a prospective multicenter cohort, 3046 non-valvular AF patients were consecutively enrolled and followed for adverse outcomes of all-cause mortality and ischemic stroke. The risks of both outcomes were adjusted for underlying comorbidities, and compared between the patterns of AF. At baseline, the patients were classified as paroxysmal (N=963, 31.6%), persistent (N=604, 19.8%), and permanent AF (N=1479, 45.6%) according to the standard definition. Anticoagulants were administered in 75% of all patients and 83% of those with CHA2DS2-VASc score ≥2 in males or ≥3 in females . During a mean follow up of 26 (SD 10.5) months, all-cause mortality occurred less in paroxysmal AF (2.5 per 100 patient-years) than in persistent AF (4.4 per 100 patient-years; adjusted hazard ratio HR 0.66, 95% CI, 0.46-0.96; P = .029) and permanent AF (4.1 per 100 patient-years; adjusted HR 0.71, 95% CI, 0.52-0.98; P = .036). The risk of ischemic stroke was similar across all patterns of AF. Conclusions In this multicenter nationwide registry of AF patients, persistent and permanent AF was associated with higher all-cause mortality than paroxysmal AF, independent of baseline comorbidities.

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