title: Higher risk of death and stroke in patients with persistent vs. paroxysmal atrial fibrillation: results from the ROCKET-AF Trial Risk of Early Death and Recurrent Stroke and Effect of Heparin in 3169 Patients With Acute Ischemic Stroke and Atrial Fibrillation in the International Stroke Trial Atrial flutter: Clinical risk factors and adverse outcomes in the Framingham Heart Study. 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 Myocardial Ischemic Events in Patients With Atrial Fibrillation Treated With Dabigatran or Warfarin in the RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) Trial Aortic plaque in atrial fibrillation: prevalence, predictors, and thromboembolic implications. Atrial fibrillation and the risk of myocardial infarction. Hemodynamic effects of an irregular sequence of ventricular cycle lengths during atrial fibrillation. Risk of Myocardial Infarction or Vascular Death After First Ischemic Stroke: The Northern Manhattan Study Predictors of major adverse cardiovascular events; results of population based MELEN study with prospective follow-up. Acute myocardial infarction in patients with atrial fibrillation with a CHA2DS2-VASc score of 0 or 1: a nationwide cohort study. Atrial fibrillation and mortality in an elderly population. Atrial fibrillation is associated with an increased risk for mortality and heart failure progression in patients with asymptomatic and symptomatic left ventricular systolic dysfunction: a retrospective analysis of the SOLVD trials. Studies of Left Ventricular Dysfunction. Incidence of myocardial infarction and vascular death in elderly patients with atrial fibrillation taking anticoagulants: relation to atherosclerotic risk factors. Risk of death and cardiovascular events in initially healthy women with new-onset atrial fibrillation. Prevalence, clinical profile, and cardiovascular outcomes of atrial fibrillation patients with atherothrombosis. Chronic atrial fibrillation--epidemiologic features and 14 year follow-up: a case control study. The association between atrial fibrillation and sudden cardiac death: the relevance of heart failure.
abstract: Aim Anticoagulation prophylaxis for stroke is recommended for at-risk patients with either persistent or paroxysmal atrial fibrillation ( AF ) . We compared outcomes in patients with persistent vs. paroxysmal AF receiving oral anticoagulation . Methods and results Patients r and omized in the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation ( ROCKET-AF ) trial ( n = 14 264 ) were grouped by baseline AF category : paroxysmal or persistent . Multivariable adjustment was performed to compare thrombo-embolic events , bleeding , and death between groups , in high-risk subgroups , and across treatment assignment ( rivaroxaban or warfarin ) . Of 14 062 patients , 11 548 ( 82 % ) had persistent AF and 2514 ( 18 % ) had paroxysmal AF . Patients with persistent AF were marginally older ( 73 vs. 72 , P = 0.03 ) , less likely female ( 39 vs. 45 % , P < 0.0001 ) , and more likely to have previously used vitamin K antagonists ( 64 vs. 56 % , P < 0.0001 ) compared with patients with paroxysmal AF . In patients r and omized to warfarin , time in therapeutic range was similar ( 58 vs. 57 % , P = 0.94 ) . Patients with persistent AF had higher adjusted rates of stroke or systemic embolism ( 2.18 vs. 1.73 events per 100-patient-years , P = 0.048 ) and all-cause mortality ( 4.78 vs. 3.52 , P = 0.006 ) . Rates of major bleeding were similar ( 3.55 vs. 3.31 , P = 0.77 ) . Rates of stroke or systemic embolism in both types of AF did not differ by treatment assignment ( rivaroxaban vs. warfarin , Pinteraction = 0.6 ) . Conclusion In patients with AF at moderate-to-high risk of stroke receiving anticoagulation , those with persistent AF have a higher risk of thrombo-embolic events and worse survival compared with paroxysmal AF Background and Purpose — We sought to investigate the apparently high risk of early death after an ischemic stroke among patients with atrial fibrillation ( AF ) , identify the main factors associated with early death , and assess the effect of treatment with different doses of subcutaneous unfractionated heparin ( UFH ) given within 48 hours . Methods — We studied the occurrence of major clinical events within 14 days among 18 451 patients from the International Stroke Trial , first for all treatment groups combined . Then , among patients with AF , we examined the effects of treatment with subcutaneous UFH started within 48 hours and continued until 14 days after stroke onset . Results — A total of 3169 patients ( 17 % ) had AF . Seven hundred eighty-four patients were allocated to UFH 12 500 IU SC BID , 773 to UFH 5000 IU SC BID , and 1612 to no heparin . Within each of these groups , half of the patients were r and omly assigned to aspirin 300 mg once daily . Compared with patients without AF , patients with AF were more likely to be female ( 56 % versus 45 % ) , to be old ( mean age , 78 versus 71 years ) , to have an infa rct on prer and omization CT ( 57 % versus 47 % ) , and to have impaired consciousness ( 37 % versus 20 % ) . The initial ischemic stroke type was more often a large-artery infa rct ( 36 % versus 21 % ) . A lacunar stroke syndrome was less common ( 13 % versus 26 % ) . Death within 14 days was more common in patients with AF ( 17 % versus 8 % ) and more often attributed to neurological damage from the initial stroke ( 10 % versus 4 % ) . The frequency of recurrent ischemic or undefined stroke was not significantly different ( 3.9 % versus 3.3 % ) . The proportion of AF patients with further events within 14 days allocated to UFH 12 500 IU ( n=784 ) , UFH 5000 IU ( n=773 ) , and to no-heparin ( n=1612 ) groups were as follows : ischemic stroke , 2.3 % , 3.4 % , 4.9 % ( P = 0.001 ) ; hemorrhagic stroke , 2.8 % , 1.3 % , 0.4 % ( P < 0.0001 ) ; and any stroke or death , 18.8 % , 19.4 % and 20.7 % ( P = 0.3 ) , respectively . No effect of heparin on the proportion of patients dead or dependent at 6 months was apparent . Conclusions — Acute ischemic stroke patients with AF have a higher risk of early death , which can be explained by older age and larger infa rcts but not by a higher risk of early recurrent ischemic stroke , although slightly more patients with AF died from a fatal recurrent stroke of ischemic or unknown type ( 1.3 % versus 0.9 % ) . In patients with AF the absolute risk of early recurrent stroke is low , and there is no net advantage to treatment with heparin . These data do not support the widespread use of intensive heparin regimens in the acute phase of ischemic stroke associated with AF BACKGROUND Few epidemiologic cohort studies have evaluated atrial flutter ( flutter ) as an arrhythmia distinct from atrial fibrillation ( AF ) . OBJECTIVE The purpose of this study was to examine the clinical correlates of flutter and its associated outcomes to distinguish them from those associated with AF in the Framingham Heart Study . METHODS We review ed  and adjudicated electrocardiograms ( ECGs ) previously classified as flutter or AF/flutter and another 100 ECGs r and omly selected from AF cases . We examined the clinical correlates of flutter by matching up to 5 AF and 5 referents to each flutter case using a nested case referent design . We determined the 10-year outcomes associated with flutter with Cox models . RESULTS During mean follow-up of 33.0 ± 12.2 years , 112 participants ( mean age 72 ± 10 years , 30 % women ) developed flutter . In multivariable analyses , smoking ( odds ratio [ OR ] 2.84 , 95 % confidence interval [ CI ] 1.54 - 5.23 ) , increased PR interval ( OR 1.28 per SD , 95 % CI 1.03 - 1.60 ) , myocardial infa rct ion ( OR 2.25 , 95 % CI 1.05 - 4.80 ) and heart failure ( OR 5.22 , 95 % CI 1.26 - 21.64 ) were associated with incident flutter . In age- and sex-adjusted models , flutter ( vs referents ) was associated with 10-year increased risk of AF ( hazard ratio [ HR ] 5.01 , 95 % CI 3.14 - 7.99 ) , myocardial infa rct ion ( HR 3.05 , 95 % CI 1.42 - 6.59 ) , heart failure ( HR 4.14 , 95 % CI 1.90 - 8.99 ) , stroke ( HR 2.17 , 95 % CI 1.13 - 4.17 ) , and mortality ( HR 2.00 , 95 % CI 1.44 - 2.79 ) . CONCLUSION We identified the clinical correlates associated with flutter and observed that flutter was associated with multiple adverse outcomes Background — Atrial fibrillation is associated with increased mortality , but the specific causes of death and their predictors have not been described among patients on effective anticoagulant therapy . Methods and Results — The R and omized Evaluation of Long-Term Anticoagulant Therapy ( RE-LY ) trial r and omized 18 113 patients ( age , 71.5±9 years ; male , 64 % ; CHADS2 score , 2.1±1 ) to receive dabigatran or warfarin .  Median follow-up was 2 years , and complete follow-up was achieved in 99.9 % of patients . All deaths were categorized by the investigators using prespecified definitions followed by central adjudication . Overall , 1371 deaths occurred ( annual mortality rate , 3.84 % ; 95 % confidence interval [ CI ] , 3.64–4.05 ) . Cardiac deaths ( sudden cardiac death and progressive heart failure ) accounted for 37.4 % of all deaths , whereas stroke- and hemorrhage-related deaths represented 9.8 % of the total mortality . An examination of the causes of death according to dabigatran or warfarin showed that dabigatran significantly reduced vascular ( embolism and hemorrhage-related ) mortality ( relative risk , 0.63 ; 95 % CI , 0.45–0.88 ; P=0.007 ) , whereas other causes of death were similar between treatments , including cardiac mortality ( relative risk , 0.96 ; 95 % CI , 0.80–1.15 ; P=0.638 ) . The two strongest independent predictors of cardiac death in this population were heart failure ( hazard ratio , 3.02 ; 95 % CI , 2.45–3.73 ; P<0.0001 ) , and prior myocardial infa rct ion ( hazard ratio , 2.05 ; 95 % CI , 1.61–2.62 ; P<0.0001 ) . Conclusions — The majority of deaths are not related to stroke in a contemporary anticoagulated atrial fibrillation population . These results emphasize the need to identify interventions beyond effective anticoagulation to further reduce mortality in atrial fibrillation . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00262600 Background — There is a modest risk of myocardial infa rct ion ( MI )  and myocardial ischemic events in patients with atrial fibrillation . Methods and Results — Data from the RE-LY study ( R and omized Evaluation of Long-Term Anticoagulation Therapy ) were used to report rates of MI , unstable angina , cardiac arrest , and cardiac death and the prespecified net clinical benefit and treatment effects of dabigatran versus warfarin .  MI occurred at annual rates of 0.82 % and 0.81 % with dabigatran 110 or 150 mg BID compared with 0.64 % with warfarin ( hazard ratio [ HR ] 1.29 , 95 % confidence interval [ CI ] 0.96–1.75 , P=0.09 for dabigatran 110 mg ; HR 1.27 , 95 % CI 0.94–1.71 , P=0.12 for dabigatran 150 mg ) . Annual rates of a composite of MI , unstable angina , cardiac arrest , and cardiac death were 3.16 % per year with dabigatran 110 mg , 3.33 % per year with dabigatran 150 mg , and 3.41 % per year with warfarin ( HR versus warfarin 0.93 , 95 % CI 0.80–1.06 , P=0.28 for dabigatran 110 mg and HR 0.98 , 95 % CI 0.85–1.12 , P=0.77 for dabigatran 150 mg ) . Events prespecified as “ net clinical benefit ” ( all strokes , systemic embolism , MI , pulmonary embolism , major bleeding , and all-cause death ) occurred at a rate of 7.34 % per year with dabigatran 110 mg , 7.11 % per year with dabigatran 150 mg , and 7.91 % per year with warfarin ( HR 0.92 , 95 % CI 0.84–1.01 , P=0.09 for dabigatran 110 mg and HR 0.90 , 95 % CI 0.82–0.99 , P=0.02 for dabigatran 150 mg ) . The relative effects of dabigatran versus warfarin on myocardial ischemic events were consistent in patients with or without a baseline history of MI or coronary artery disease . Conclusions — There was a nonsignificant increase in MI with dabigatran compared with warfarin , but other myocardial ischemic events were not increased . Treatment effects of dabigatran were consistent in patients at higher and lower risk of myocardial ischemic events . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT 00262600 BACKGROUND AND PURPOSE Thoracic aortic plaque identified by transesophageal echocardiography heightens the risk of stroke associated with atrial fibrillation ( AF ) . We sought to identify the prevalence , predictors , and implication s of aortic plaque in patients with nonvalvular AF . METHODS Thoracic aortic plaque was prospect ively sought in 770 persons with AF with the use of transesophageal echocardiography and classified as simple or complex on the basis of thickness > /=4 mm , ulceration , or mobility .  Clinical and echocardiographic features of thromboembolism were correlated by multivariate analysis . RESULTS Aortic plaque was detected in 57 % of the cohort , and complex plaque was detected in 25 % . Both were found more frequently in the descending than in the proximal aorta . Potentially etiologic patient characteristics independently associated with complex plaque included advanced age , history of hypertension , diabetes , and past or present tobacco use . Comorbidities associated with aortic plaque were prior thromboembolism , increased pulse pressure , ischemic heart disease , stenosis or sclerosis of the aortic valve , mitral annular calcification ( > 10 % ) , elevated serum creatinine concentration , spontaneous echo contrast in the left atrium or appendage , and left atrial appendage thrombus . The prevalence of complex plaque in patients aged < 70 years with < 10 % mitral annular calcification , without ischemic heart disease , or without pulse pressure > /=65 mm Hg was 4 % ( 95 % CI , 1 % to 6 % ) . CONCLUSIONS Aortic plaque is prevalent in patients with AF and is associated with atherosclerosis risk factors and with left atrial stasis or thrombosis , which are themselves independent stroke risk factors . Since the predominant location of complex plaque was in the descending aorta , the role of aortic plaque as a source of embolism in AF is uncertain IMPORTANCE Myocardial infa rct ion ( MI ) is an established risk factor for  atrial fibrillation ( AF ) .  However , the extent to which AF is a risk factor for MI has not been investigated . OBJECTIVE To examine the risk of incident MI associated with AF . DESIGN , SETTING , AND PARTICIPANTS A prospect i ve cohort of 23,928 participants residing in the continental United States and without coronary heart disease at baseline were enrolled from the Reasons for Geographic and Racial Differences in Stroke ( REGARDS ) cohort between 2003 and 2007 , with follow-up through December 2009 . MAIN OUTCOMES AND MEASURES Expert-adjudicated total MI events ( fatal and nonfatal ) . RESULTS Over 6.9 years of follow-up ( median 4.5 years ) , 648 incident MI events occurred . In a sociodemographic-adjusted model , AF was associated with about 2-fold increased risk of MI ( hazard ratio [ HR ] , 1.96 [ 95 % CI , 1.52 - 2.52 ] ) . This association remained significant ( HR , 1.70 [ 95 % CI , 1.26 - 2.30 ] ) after further adjustment for total cholesterol , high-density lipoprotein cholesterol , smoking status , systolic blood pressure , blood pressure-lowering drugs , body mass index , diabetes , warfarin use , aspirin use , statin use , history of stroke and vascular disease , estimated glomerular filtration rate , albumin to creatinine ratio , and C-reactive protein level . In subgroup analysis , the risk of MI associated with AF was significantly higher in women ( HR , 2.16 [ 95 % CI , 1.41 - 3.31 ] ) than in men ( HR , 1.39 [ 95 % CI , 0.91 - 2.10 ] ) and in blacks ( HR , 2.53 [ 95 % CI , 1.67 - 3.86 ] ) than in whites ( HR , 1.26 [ 95 % CI , 0.83 - 1.93 ] ) ; for interactions , P = .03 and P = .02 , respectively . On the other h and , there were no significant differences in the risk of MI associated with AF in older ( ≥75 years ) vs younger ( < 75 years ) participants ( HR , 2.00 [ 95 % CI , 1.16 - 3.35 ] and HR , 1.60 [ 95 % CI , 1.11 - 2.30 ] , respectively ) ; for interaction , P = .44 . CONCLUSIONS AND RELEVANCE AF is independently associated with an increased risk of incident MI , especially in women and blacks . These findings add to the growing concerns of the seriousness of AF as a public health burden : in addition to being a well-known risk factor for stroke , AF is also associated with increased risk of MI OBJECTIVES The aim of this study was to determine the independent hemodynamic effects of an irregular sequence of ventricular cycle lengths in patients with atrial fibrillation ( AF ) . BACKGROUND Atrial fibrillation may reduce cardiac output by several possible mechanisms , including loss of the atrial contribution to left ventricular filling , valvular regurgitation , increased ventricular rate or irregular RR intervals . This study was design ed to evaluate the effects of an irregular RR interval , independent of the average ventricular rate , on cardiac hemodynamic data during AF . METHODS Sixteen patients with AF were studied invasively . During intrinsically conducted AF ( mean rate 102 + /- 22 beats/ min ) , the right ventricular apex electrogram was recorded onto frequency-modulated ( FM ) tape . After atrioventricular node ablation , the right ventricular apex was stimulated in three pacing modes in r and omized sequence : 1 ) VVI at 60 beats/min ; 2 ) VVI at the same average rate as during intrinsically conducted AF ( 102 + /- 22 beats/min ) ; and 3 ) during VVT pacing in which the pacemaker was triggered by playback of the FM tape recording of the right ventricular apex electrogram previously recorded during intrinsically conducted AF ( VVT 102 + /- 22 beats/min ) . RESULTS Compared with VVI pacing at the same average rate , an irregular sequence of RR intervals decreased cardiac output ( 4.4 + /- 1.6 vs. 5.2 + /- 2.4 liters/min , p < 0.01 ) , increased pulmonary capillary wedge pressure ( 17 + /- 7 vs. 14 + /- 6 mm Hg , p < 0.002 ) and increased right atrial pressure ( 10 + /- 6 vs. 8 + /- 4 mm Hg , p < 0.05 ) . CONCLUSIONS An irregular sequence of RR intervals produces adverse hemodynamic consequences that are independent of heart rate Background and Purpose — In national guidelines , absolute long-term risk of myocardial infa rct ion ( MI ) or coronary death determines target low-density lipoprotein levels , but stroke patients are not explicitly addressed . We determined the absolute 5-year risk of cardiovascular outcomes and their predictors after first ischemic stroke in a multiethnic cohort . Methods — A population -based cohort of first ischemic stroke patients ≥40 years old was prospect ively followed annually for recurrent stroke , MI and cause-specific mortality . Kaplan-Meier 5-year risks for MI or vascular death ( primary outcome ) , and other cardiovascular events , were calculated . Univariate and multivariate Cox proportional hazards models were used to calculate hazard ratios and 95 % CI for predictors of cardiovascular outcomes . Results — Mean age ( n=655 ) was 69.7±12.7 years ; 55.4 % of participants were women , and 51.3 % Hispanic .  The 5-year risk of MI or vascular death was 17.4 % ( 95 % CI , 14.2 % to 20.6 % ) . Independent historical predictors of MI or vascular death were age > 70 years ( hazard ratio 1.62 , 1.07 to 2.44 ) , history of coronary artery disease ( hazard ratio 1.76 , 1.13 to 2.74 ) , and atrial fibrillation ( hazard ratio 1.76 , 1.05 to 2.94 ) . In the lowest risk group , those ≤70 years old without coronary artery disease , 5-year risk of MI or vascular death was 9.7 % . Conclusions — The absolute risk of MI or vascular death after ischemic stroke , even in those without high-risk features , approximates levels used by national organizations to design ate groups of patients at high risk of vascular events . The comparability of levels of absolute risk among stroke and cardiac patients may have treatment implication OBJECTIVE In healthy persons , cardiovascular risk is the result of multiple interacting risk associates including demographic , clinical , genetic and environmental factors . Several non-invasive tools such as echocardiography , ultrasonography and electrocardiography as well as new biochemical markers were shown to be applicable to predict cardiovascular events . However , implementation of all of these tools has not been tested before . The aim of the study was to evaluate the independent predictors of major adverse cardiovascular events in a prospect i ve population based study , with the use of bioempedance analysis , echocardiography , ultrasonography and ECG . PATIENTS AND METHODS The baseline measurements were conducted on 2230 participants ( 1427 women , 803 men with a mean age of 49 ± 15 ) . The follow-up was done 36 months after the baseline admission via telephone call . Major adverse event was defined as mortality or myocardial infa rct ion or stroke . RESULTS Follow-up data was possible in 1495 participants ( 65 % ) . During the follow-up of 36 months ( 4485 patient years ) , 42 major adverse events occurred ( 0.03 % ) . Among them , 16 were death ( 1 stroke , 2 cancer , 13 cardiac related ) , 12 were stroke and 14 were myocardial infa rct ion . Age , body mass index and atrial fibrillation were independent predictors of major adverse events ; AF being the most powerful ( Odds ratio 10.46 ; 95 % confidence interval [ 1.73 - 63.14 ] ; p = 0.010 ) . CONCLUSIONS Age , lower body mass index and atrial fibrillation were independent predictors of major cardiovascular events in our cohort BACKGROUND The risk of acute myocardial infa rct ion ( AMI ) in patients with atrial fibrillation ( AF ) with a CHA2DS2-VASc score of 0 ( for men ) or 1 ( for women ) has not been previously investigated . OBJECTIVE The objective of the present study was to compare the risk of AMI in AF and non-AF subjects with a low ( 0 or 1 ) CHA2DS2-VASc score . METHODS By using the National Health Insurance Research Data base in Taiwan , we identified 7254 men with AF ( with a CHA2DS2-VASc score of 0 ) and 4860 women with AF ( with a CHA2DS2-VASc score of 1 ) . For each study patient , 1 age- , sex- , and CHA2DS2-VASc score-matched subject  without AF was r and omly selected to constitute the control group ( n = 12,114 ) . The clinical end point was the occurrence of AMI . RESULTS During a mean follow-up period of 5.7 ± 3.6 years , 258 patients ( 1.1 % ) suffered an AMI , with an annual incidence of 0.29 % and 0.10 % for patients with and without AF . AF was an independent risk factor of AMI , with an adjusted hazard ratio ( HR ) of 2.93 ( 95 % confidence interval 2.21 - 3.87 ; P < .001 ) . The risk of AMI was higher in men with AF than in women with AF , with a hazard ratio of 2.24 ( 95 % confidence interval 1.61 - 3.11 ; P < .001 ) after adjustment for age and other comorbidities . CONCLUSION In patients with a CHA2DS2-VASc score of 0 or 1 , AF was an independent risk factor of AMI . The risk of AMI was higher in men with AF than in women with AF . Cardiovascular risk prevention should be performed as part of the holistic management of AF to minimize the risks of AMI associated with AF Prospect i ve data from Busselton , Western Australia , collected during triennial surveys from 1966 - 81 with follow-up of subjects to 1983 , showed that atrial fibrillation ( AF ) was frequent in elderly people and associated with increased mortality . Of 1770 people aged over 60 years , 40 were in atrial fibrillation when first seen and a further 47 developed it during follow-up . Atrial fibrillation was positively associated with angina , history of a myocardial infa rct ion and left bundle branch block . Relative mortality in those with atrial fibrillation compared with those without it , was 1.92 for all causes , 1.82 for death from cardiovascular causes ( excluding stroke ) and 3.78 for deaths from stroke , after adjustment by proportional hazards regression for confounding effects of age , sex , history of a myocardial infa rct ion , an abnormal electrocardiogram , angina , cholesterol level systolic blood pressure and Quetelet 's Index ( weight/height2 ) . The excess relative mortality declined with increasing age for both women and men . This raised relative mortality remained constant with time from the first detection of AF for all causes and cardiovascular causes but appeared to increase with time from detection for stroke death . The risk of death from stroke was greatest in the younger women . The observed risk of death from stroke in patients with AF suggests that anticoagulant use should be considered in selected patients OBJECTIVE This study undertook to determine if the presence of atrial fibrillation in patients with asymptomatic and symptomatic left ventricular dysfunction was associated with increased mortality and , if so , whether the increase could be attributed to progressive heart failure or arrhythmic death . BACKGROUND Atrial fibrillation is a common condition in heart failure with the potential to impact hemodynamics and progression of left ventricular systolic dysfunction as well as the electrophysiologic substrate for arrhythmias . The available data do not conclusively define the effect of atrial fibrillation on prognosis in heart failure . METHODS A retrospective analysis of the Studies of Left Ventricular Dysfunction Prevention and Treatment Trials was conducted that compared patients with atrial fibrillation to those in sinus rhythm at baseline  for the risk of all-cause mortality , progressive pump-failure death and arrhythmic death . RESULTS The patients with atrial fibrillation at baseline , compared to those in sinus rhythm , had greater all-cause mortality ( 34 % vs. 23 % , p < 0.001 ) , death attributed to pump-failure ( 16.7 % vs. 9.4 % , p < 0.001 ) and were more likely to reach the composite end point of death or hospitalization for heart failure ( 45 % vs. 33 % , p < 0.001 ) , but there was no significant difference between the groups in arrhythmic deaths . After multivariate analysis , atrial fibrillation remained significantly associated with all-cause mortality ( relative risk [ RR ] 1.34 , 95 % confidence interval [ CI ] 1.12 to 1.62 , p=0.002 ) , progressive pump-failure death ( RR 1.42 , 95 % CI 1.09 to 1.85 , p=0.01 ) , the composite end point of death or hospitalization for heart failure ( RR 1.26 , 95 % CI 1.03 to 1.42 , p=0.02 ) , but not arrhythmic death ( RR 1.13 ; 95 % CI 0.75 to 1.71 ; p=0.55 ) . CONCLUSIONS The presence of atrial fibrillation in patients with asymptomatic and symptomatic left ventricular systolic dysfunction is associated with an increased risk for all-cause mortality , largely explained by an increased risk for pump-failure death . These data suggest that atrial fibrillation is associated with progression of left ventricular systolic dysfunction BACKGROUND Recent findings suggest that patients with atrial fibrillation ( AF ) , in addition being at thromboembolic risk , are at risk of myocardial infa rct ion ( MI ) . Our aim was to investigate predictors of MI and cardiovascular death in a cohort of patients with AF who were taking anticoagulants .  METHODS We prospect ively followed up 1,019 patients with AF for a median of 33.7 months ( 3,223 person-years ) . All patients were treated with oral vitamin K antagonists . Primary outcome was a composite end point of cardiovascular events ( CVEs ) including fatal/nonfatal MI , cardiac revascularization , and cardiovascular death . RESULTS The mean age of the patients was 73.2 years , and 43.8 % were women . At follow-up , 111 CVEs ( 3.43%/y ) had occurred : 47 fatal-nonfatal MI/revascularization and 64 cardiovascular deaths . In addition , 31 stroke/transient ischemic attacks ( 0.96%/y ) were recorded . Patients experiencing CVEs were older ( P < .001 ) and had a higher prevalence of metabolic syndrome ( MetS ) ( P = .005 ) , heart failure ( P = .001 ) , and prior cardiac ( P < .001 ) and cerebrovascular events ( P < .001 ) . On a Cox proportional hazard analysis , age ( hazard ratio [ HR ] , 1.083 ; 95 % CI , 1.053 - 1.113 ; P < .001 ) , smoking ( HR , 2.158 ; 95 % CI , 1.193 - 3.901 ; P = .011 ) , history of cerebrovascular ( HR , 1.704 ; 95 % CI , 1.119 - 2.597 ; P = .013 ) and cardiac ( HR , 1.658 ; 95 % CI , 1.105 - 2.489 ; P = .015 ) events , MetS ( HR , 1.663 ; 95 % CI , 1.107 - 2.499 ; P = .014 ) , heart failure ( HR , 1.584 ; 95 % CI , 1.021 - 2.456 ; P = .040 ) , and male sex ( HR , 1.499 ; 95 % CI , 1.010 - 2.223 ; P = .044 ) predicted CVEs . CONCLUSIONS Patients with AF still experience a high rate of CVEs despite receiving anticoagulant treatment . MetS is a common clinical feature in patients with AF , which increases the risk of CVEs . A holistic approach is needed to reduce the cardiovascular risk in patients with AF . TRIAL REGISTRY Clinical Trials.gov ; No. : NCT01882114 ; URL : www . clinical trials.gov CONTEXT The risks associated with new-onset atrial fibrillation ( AF ) among middle-aged women and population s with a low comorbidity burden are poorly defined . OBJECTIVES To examine the association between incident AF and mortality in initially healthy women and to evaluate the influence of associated cardiovascular comorbidities on risk . DESIGN , SETTING , AND PARTICIPANTS Between 1993 and March 16 , 2010 , 34,722 women participating in the Women 's Health Study underwent prospect i ve follow-up . Participants were 95 % white , older than 45 years ( median , 53 [ interquartile range { IQR } , 49 - 59 ] years ) , and free of AF and cardiovascular disease at baseline .  Cox proportional hazards models with time-varying covariates were used to determine the risk of events among women with incident AF . Secondary analyses were performed among women with paroxysmal AF . MAIN OUTCOME MEASURES Primary outcomes included all-cause , cardiovascular , and noncardiovascular mortality . Secondary outcomes included stroke , congestive heart failure , and myocardial infa rct ion . RESULTS During a median follow-up of 15.4 ( IQR , 14.7 - 15.8 ) years , 1011 women developed AF . Incidence rates per 1000 person-years among women with and without AF were 10.8 ( 95 % confidence interval [ CI ] , 8.1 - 13.5 ) and 3.1 ( 95 % CI , 2.9 - 3.2 ) for all-cause mortality , 4.3 ( 95 % CI , 2.6 - 6.0 ) and 0.57 ( 95 % CI , 0.5 - 0.6 ) for cardiovascular mortality , and 6.5 ( 95 % CI , 4.4 - 8.6 ) and 2.5 ( 95 % CI , 2.4 - 2.6 ) for noncardiovascular mortality , respectively . In multivariable models , hazard ratios ( HRs ) of new-onset AF for all-cause , cardiovascular , and noncardiovascular mortality were 2.14 ( 95 % CI , 1.64 - 2.77 ) , 4.18 ( 95 % CI , 2.69 - 6.51 ) , and 1.66 ( 95 % CI , 1.19 - 2.30 ) , respectively . Adjustment for nonfatal cardiovascular events potentially on the causal pathway to death attenuated these risks , but incident AF remained associated with all mortality components ( all-cause : HR , 1.70 [ 95 % CI , 1.30 - 2.22 ] ; cardiovascular : HR , 2.57 [ 95 % CI , 1.63 - 4.07 ] ; and noncardiovascular : HR , 1.42 [ 95 % CI , 1.02 - 1.98 ] ) . Among women with paroxysmal AF ( n = 656 ) , the increase in mortality risk was limited to cardiovascular causes ( HR , 2.94 ; 95 % CI , 1.55 - 5.59 ) . CONCLUSION Among a group of healthy women , new-onset AF was independently associated with all-cause , cardiovascular , and noncardiovascular mortality , with some of the risk potentially explained by nonfatal cardiovascular events BACKGROUND Atrial fibrillation ( AF ) is a major risk factor ( RF ) for ischemic stroke . Its prevalence and prognostic impact in patients with atherothrombosis are unclear . METHODS Risk factors , drug usage , and 1-year cardiovascular ( CV ) outcomes ( CV death , myocardial infa rct ion [ MI ] , and stroke ) were compared in  AF and non-AF patients from the REduction of Atherothrombosis for Continued Health ( REACH ) Registry , an international , prospect i ve cohort of 68,236 stable out patients with established atherothrombosis or > or=3 atherothrombotic RFs . RESULTS Atrial fibrillation and 1-year follow-up data are available for 63,589 patients . The prevalence of AF was , 12.5 % , 13.7 % , 11.5 % , and 6.2 % among coronary artery disease , CV disease , peripheral artery disease , and RF-only patients , respectively . Of the 6,814 patients with AF , 6.7 % experienced CV death , nonfatal MI , or nonfatal stroke within a year . The annual incidence of nonfatal stroke ( 2.4 % vs 1.6 % , P<.0001 ) and unstable angina ( 6.0 % vs 4.0 % , P<.00001 ) was higher , and CV death was more than double ( 3.2 % vs 1.4 % , P<.0001 ) , in AF versus non-AF patients . In these patients with or at high risk of atherothrombosis , most patients with AF received antiplatelet agents , but only 53.1 % were treated with oral anticoagulants . Even with high CHADS2 ( congestive heart failure , hypertension , aging , diabetes mellitus , and stroke ) scores , anticoagulant use did not exceed ( 59 % ) . The rate of bleeding requiring hospitalization was higher in AF versus non-AF patients ( 1.5 % vs 0.8 % , P<.0001 ) , possibly related to the more frequent use of anticoagulants ( 53.1 % vs 7.1 % ) . CONCLUSIONS Atrial fibrillation is common in patients with atherothrombosis , associated with more frequent fatal and nonfatal CV outcomes , and underuse of oral anticoagulants In a r and omly selected population of 9067 individuals , 32 - 64 years of age in 1967 - 1970 , 25 ( 0.28 % ) had chronic atrial fibrillation ( CAF ) . Eight had lone atrial fibrillation .  In 1984 the cases were compared with an age- and sex-matched control group of 50 and found to have more cerebrovascular accidents ( 6 versus 2 ; P less than 0.05 ) , congestive heart failure ( 9 versus 1 ; P less than 0.001 ) , and valvular rheumatic heart disease ( 3 versus 0 ) or history consistent with rheumatic fever ( 6 versus 0 ; P less than 0.01 ) . The mortality in the CAF group was 60 % higher due to an excess in cardiovascular ( relative risk 6.1 ; P less than 0.05 ) and cerebrovascular ( relative risk 12.2 ; P less than 0.05 ) causes . The prevalence or incidence of ischaemic or hypertensive heart disease or the presence of coronary risk factors did not significantly differ in the two groups . By M-mode echocardiography the left atrial size , left ventricular enddiastolic dimension and left ventricular mass were increased in the CAF patients , while the systolic left ventricular shortening was significantly less . Thus , the prevalence of CAF is low in a r and omly selected population 32 - 64 years of age and CAF is not strongly associated with ischaemic heart disease or hypertension . The CAF patients have an increased risk of dying prematurely particularly from cerebrovascular causes , even in the absence of valve disease OBJECTIVES The purpose of this study was to evaluate the role of congestive heart failure ( CHF ) in the association between  atrial fibrillation ( AF ) and sudden cardiac death ( SCD ) .  BACKGROUND Recent studies have reported the possibility of an independent association between AF and SCD . We hypothesized that a history of CHF is a significant confounder of this association . METHODS In a prospect i ve case-control analysis from the community ( The Oregon-SUDS [ Sudden Unexpected Death Study ] , 2002 to 2012 ) , SCD cases ( n = 652 ) with clinical records available ( including electrocardiography and /or echocardiography ) were compared with age- and sex-matched control patients with coronary artery disease . The association between AF and SCD was analyzed using multivariable logistic regression and propensity score matching . RESULTS Cases ( age 67.3 ± 11.7 years , 65 % male ) were more likely than control patients ( age 67.2 ± 11.4 years , 65 % male ) to have a history of AF ( p = 0.0001 ) , myocardial infa rct ion ( p = 0.007 ) , CHF ( p < 0.0001 ) , stroke ( p < 0.0001 ) , and diabetes ( p < 0.0001 ) . In multivariate analysis without considering CHF , AF was a significant predictor of SCD ( odds ratio [ OR ] : 1.6 ; 95 % confidence interval [ CI ] : 1.2 to 2.0 ; p = 0.002 ) . However , in a model that included CHF , the AF-SCD association was no longer significant ( OR : 1.1 ; 95 % CI : 0.8 to 1.5 ; p = 0.45 ) , whereas CHF was a significant predictor of SCD ( OR : 3.1 ; 95 % CI : 2.4 to 4.1 ; p < 0.0001 ) . Results on the basis of propensity score matching were consistent . CONCLUSIONS Our findings suggest that a history of CHF , including both systolic and diastolic symptomatic dysfunction , may partially explain the AF-SCD association
target: These results showed that AF is an independent risk factor for MI , CV death , and CV events
background: This study aim ed to investigate whether  atrial fibrillation ( AF ) predicts myocardial infa rct ion ( MI ) or cardiovascular ( CV ) death .
  AF is a well-established risk factor for thrombotic stroke and all-cause mortality .