Abstract
Objectives
To analyze the relationship between atrial fibrillation (AF) and Charlson comorbidity
index (CCI) in a population-based cohort study over a long-term follow-up period,
in relation to oral anticoagulant (OAC) prescriptions and outcomes.
Patients and Methods
We used data from the administrative health databases of Lombardy. All patients with
AF and age 40 years and older and who were admitted to the hospital in 2002 were considered
for analysis and followed up to 2014. AF diagnosis and CCI were established according
to codes from the International Classification of Diseases, Ninth Revision.
Results
In 2002, 24,040 patients were admitted with a diagnosis of AF. CCI was higher in patients
with AF than in those without AF (1.8±2.1 vs 0.2±0.9; P<.001). Over 12 years of follow-up, AF was associated with an increased risk of higher
CCI (beta coefficient, 1.69; 95% CI, 1.67-1.70). In patients with AF, CCI was inversely
associated with OAC prescription at baseline (P<.001) and at the end of the follow-up (P=.03). Patients with AF and a high CCI (≥4) had a higher cumulative incidence of stroke,
major bleeding, and all-cause death (all P<.001), compared with those with low CCI (range, 0-3). Adjusted Cox regression analysis
revealed that time-dependent continuous CCI was associated with an increased risk
for stroke, major bleeding, and all-cause death (all P<.001).
Conclusions
In hospitalized patients, AF is associated with an increase in CCI that is inversely
associated with OAC prescriptions during follow-up. CCI is independently associated
with an increased risk of stroke, major bleeding, and all-cause death.
Abbreviations and Acronyms:
ABC (Atrial Fibrillation Better Care), AF (atrial fibrillation), CCI (Charlson Comorbidity Index), CV (cardiovascular), ICD-9 (International Classification of Diseases, Ninth Revision), HR (hazard ratio), NOAC (non–vitamin K antagonist oral anticoagulant), OAC (oral anticoagulant), OR (odds ratio), VKA (vitamin K antagonist.)To read this article in full you will need to make a payment
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References
- 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.Eur Heart J. 2016; 37: 2893-2962
- Global epidemiology of atrial fibrillation.Nat Rev Cardiol. 2014; 11: 639-654
- Increased burden of comorbidities and risk of cardiovascular death in atrial fibrillation patients in Europe over ten years: a comparison between EORP-AF pilot and EHS-AF registries.Eur J Intern Med. 2018; 55: 28-34
- Multimorbidity in general practice: prevalence, incidence, and determinants of co-occurring chronic and recurrent diseases.J Clin Epidemiol. 1998; 51: 367-375
- Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study.Lancet. 2012; 380: 37-43
- Complexity science: the challenge of complexity in health care.BMJ. 2001; 323: 625-628
- Multimorbidity in older adults with cardiovascular disease.J Am Coll Cardiol. 2018; 71: 2149-2161
- A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.J Chronic Dis. 1987; 40: 373-383
- Impact of co-morbid burden on mortality in patients with coronary heart disease, heart failure, and cerebrovascular accident: a systematic review and meta-analysis.Eur Hear J Qual Care Clin Outcomes. 2016; 3: 20-36
- Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation.Chest. 2010; 137: 263-272
- Relationship of stroke and bleeding risk profiles to efficacy and safety of dabigatran dual therapy versus warfarin triple therapy in atrial fibrillation after percutaneous coronary intervention: an ancillary analysis from the RE-DUAL PCI trial.Am Heart J. 2019; 212: 13-22
- Practical considerations on the use of the Charlson comorbidity index with administrative data bases.J Clin Epidemiol. 1996; 49: 1429-1433
- Atrial fibrillation prevention: an appraisal of current evidence.Heart. 2018; 104: 882-887
- European Heart Rhythm Association (EHRA)/European Association of Cardiovascular Prevention and Rehabilitation (EACPR) position paper on how to prevent atrial fibrillation endorsed by the Heart Rhythm Society (HRS) and Asia Pacific Heart Rhythm Society (APHRS).Europace. 2017; 19: 190-225
- Contemporary stroke prevention strategies in 11 096 European patients with atrial fibrillation: A report from the EURObservational Research Programme on Atrial Fibrillation (EORP-AF) Long-Term General Registry.Europace. 2018; 20: 747-757
- Association of atrial fibrillation clinical phenotypes with treatment patterns and outcomes: a multicenter registry study.JAMA Cardiol. 2018; 3: 54-63
- Association between atrial fibrillation, anticoagulation, risk of cerebrovascular events and multimorbidity in general practice: a registry-based study.BMC Cardiovasc Disord. 2016; 16: 61
- Multimorbidity and co-morbidity in atrial fibrillation and effects on survival: findings from UK Biobank cohort.Europace. 2018; 20: f329-f336
- Factors associated with non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with new-onset atrial fibrillation: results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II (ORBIT-AF II).Am Heart J. 2017; 189: 40-47
- Causes of death and influencing factors in patients with atrial fibrillation: a competing-risk analysis from the randomized evaluation of long-term anticoagulant therapy study.Circulation. 2013; 128: 2192-2201
- Causes of death and influencing factors in patients with atrial fibrillation.Am J Med. 2016; 129: 1278-1287
- Cause of death and predictors of all-cause mortality in anticoagulated patients with nonvalvular atrial fibrillation: data from ROCKET AF.J Am Heart Assoc. 2016; 5: e00297
- “Real-world” atrial fibrillation management in Europe: observations from the 2-year follow-up of the EURObservational Research Programme-Atrial Fibrillation General Registry Pilot Phase.Europace. 2017; 19: 722-733
- Changes to oral anticoagulant therapy and risk of death over a 3-year follow-up of a contemporary cohort of European patients with atrial fibrillation final report of the EURObservational Research Programme on Atrial Fibrillation (EORP-AF) pilot general registry.Int J Cardiol. 2018; 271: 68-74
- ACTIVE A Steering Committee and Investigators. Predictors of mortality in patients with atrial fibrillation (from the Atrial Fibrillation Clopidogrel Trial With Irbesartan for Prevention of Vascular Events [ACTIVE A]).Am J Cardiol. 2018; 121: 584-589
- Atrial fibrillation without comorbidities: prevalence, incidence, and prognosis (from the Framingham Heart Study).Am Heart J. 2016; 177: 138-144
- Validity of Charlson Comorbidity Index in patients hospitalised with acute coronary syndrome. Insights from the nationwide AMIS Plus registry 2002-2012.Heart. 2014; 100: 288-294
- Charlson index comorbidity adjustment for ischemic stroke outcome studies.Stroke. 2004; 35: 1941-1945
- Integrated care in atrial fibrillation: a systematic review and meta-analysis.Heart. 2017; 103: 1947-1953
- The future of atrial fibrillation management: integrated care and stratified therapy.Lancet. 2017; 390: 1873-1887
- Integrating new approaches to atrial fibrillation management: The 6th AFNET/EHRA Consensus Conference.Europace. 2018; 20: 395-407
- The ABC pathway: an integrated approach to improve AF management.Nat Rev Cardiol. 2017; 14: 627-628
- Improved outcomes by integrated care of anticoagulated patients with atrial fibrillation using the simple ABC (Atrial Fibrillation Better Care) pathway.Am J Med. 2018; 131: 1359-1366
- Big data analytics to improve cardiovascular care: promise and challenges.Nat Rev Cardiol. 2016; 13: 350-359
- The importance of mean time in therapeutic range for complication rates in warfarin therapy of patients with atrial fibrillation: a systematic review and meta-regression analysis.PLoS One. 2017; 12: e0188482
- How to measure comorbidity. a critical review of available methods.J Clin Epidemiol. 2003; 56: 221-229
Article info
Publication history
Published online: October 23, 2019
Footnotes
For editorial comment, see page 2381
Dr Proietti and Dr Marzona contributed equally to this work.
Potential Competing Interests: Dr Proietti reports consultant activity for Boehringer Ingelheim. Dr Mannucci reports honoraria for lectures as speaker or chair symposia organized by Bayer, Grifols, Kedrion, LFB, Novo Nordisk, and Pfizer; he is also a scientific consultant for Bayer, Baxalta, and Kedrion. Dr Boriani reports speaker’s fees from Medtronic, Boston, Boehringer, and Bayer. Dr Lip reports consultant activity for Bayer/Janssen, BMS/Pfizer, Biotronik, Medtronic, Boehringer Ingelheim, Microlife, and Daiichi-Sankyo and speaker activity for Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim, Microlife, Roche, and Daiichi-Sankyo. No fees are received personally. All relationships disclosed are related to activities performed outside the submitted work. All other authors have no disclosures to declare.
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© 2019 Mayo Foundation for Medical Education and Research
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Access this article on ScienceDirectLinked Article
- Atrial Fibrillation and MultimorbidityMayo Clinic ProceedingsVol. 94Issue 12
- PreviewIn this issue of Mayo Clinic Proceedings, Proietti et al1 evaluate the relationship between the Charlson comorbidity index (CCI) and atrial fibrillation (AF) in patients admitted to the hospital in the Lombardy region of Italy during the year 2002. The included patients were required to have AF as a discharge diagnosis and were analyzed for up to 14 years using data from the Italian National Health Service. As a control, a population 10-fold larger than the study group without AF was studied. Of 6 million eligible patients, more than 24,000 patients with a diagnosis of AF were included for analysis.
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