title: Predictors of early mortality in implantable cardioverter-defibrillator recipients Derivation and validation of QStroke score for predicting risk of ischaemic stroke in primary care and comparison with other risk scores: a prospective open cohort study Prognostic impact of types of atrial fibrillation in acute coronary syndromes. Effects of atrial fibrillation on long-term outcomes in patients hospitalized for heart failure in Japan: a report from the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD). Incidence and prognostic significance of atrial fibrillation in acute myocardial infarction: the GISSI-3 data Preoperative atrial fibrillation is an independent risk factor for mid-term mortality after concomitant aortic valve replacement and coronary artery bypass graft surgery. Detection of atrial fibrillation after stroke and the risk of recurrent stroke. 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 Epidemiology of ischemic stroke from atrial fibrillation in Dijon, France, from 1985 to 2006 Increased risk of sudden and non-sudden cardiovascular death in patients with atrial fibrillation/flutter following acute myocardial infarction. Atrial Fibrillation and Aortic Stenosis: Impact on Clinical Outcomes Among Patients Undergoing Transcatheter Aortic Valve Implantation Late incidence and determinants of stroke after aortic and mitral valve replacement. Association of left ventricular hypertrophy and chronic atrial fibrillation with the incidence of new thromboembolic stroke in 2,384 older persons. Relationship of Sudden Cardiac Death to New-Onset Atrial Fibrillation in Hypertensive Patients With Left Ventricular Hypertrophy Cause of Stroke Recurrence Is Multifactorial: Patterns, Risk Factors, and Outcomes of Stroke Recurrence in the South London Stroke Register Derivation, validation, and evaluation of a new QRISK model to estimate lifetime risk of cardiovascular disease: cohort study using QResearch database Previously known and newly diagnosed atrial fibrillation: a major risk indicator after a myocardial infarction complicated by heart failure or left ventricular dysfunction. Atrial Fibrillation Is a Major Risk Factor for Stroke, Especially in Women: The Jichi Medical School Cohort Study Atrial fibrillation and the risk of myocardial infarction. Mortality risk attributable to atrial fibrillation in middle-aged and elderly people in the Japanese general population: nineteen-year follow-up in NIPPON DATA80. Effect of lipid lowering on new-onset atrial fibrillation in patients with asymptomatic aortic stenosis: the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study. Impact of atrial fibrillation on mortality, stroke, and medical costs. Long-term cardiovascular outcomes in patients with atrial fibrillation and atherothrombosis in the REACH Registry. Long-term outcomes after transcatheter aortic valve replacement in high-risk patients with severe aortic stenosis: the U.K. Transcatheter Aortic Valve Implantation Registry. Prevalence of atrial fibrillation and association of atrial fibrillation with prior and new thromboembolic stroke in older patients. Close bidirectional relationship between chronic kidney disease and atrial fibrillation: the Niigata preventive medicine study. A new scoring system for evaluating the risk of heart failure events in Japanese patients with atrial fibrillation. Atrial fibrillation and mortality in an elderly population. The European CRT Survey: 1 year (9-15 months) follow-up results. Atrial fibrillation and risk of clinical events in chronic heart failure with and without left ventricular systolic dysfunction: results from the Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity (CHARM) program. 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. Risk of death and cardiovascular events in initially healthy women with new-onset atrial fibrillation. New atrial fibrillation after acute myocardial infarction independently predicts death: the GUSTO-III experience. Prognosis of congestive heart failure after prior myocardial infarction in older persons with atrial fibrillation versus sinus rhythm. Competing risk analysis of cause-specific mortality in patients with an implantable cardioverter-defibrillator: The EVADEF cohort study. [A prospective study of stroke recurrence and the risk factors]. Mortality and Cause of Death after Hospital Discharge in 10,981 Patients with Ischemic Stroke and Transient Ischemic Attack Associations of ankle-brachial index (ABI) with cerebral arterial disease and vascular events following ischemic stroke.
abstract: Aims Multiple trials have shown that implantable cardioverter defibrillators ( ICDs ) prolong survival in secondary and primary prevention population s. However , in spite of the efficacy of these devices in terminating life-threatening arrhythmias , total mortality remains high . Methods and results We evaluated 1703 patients ( mean age : 67 ± 12 years , 82 % male ) with conventional ICD indications , who were enrolled and followed between 2001 and 2004 at 128 US centres . Patients were followed for up to a year , and vital status was obtained for 1655 patients ( 97 % , median follow-up : 377 days ) . There were 183 deaths within 1 year of ICD implantation ( 1-year mortality rate : 16 % ) . Predictors of mortality included a history of atrial fibrillation ( AF , P < 0.0001 ) , diabetes ( P = 0.0001 ) , failure to use cholesterol-lowering medications ( P < 0.001 ) , use of digitalis and derivatives ( P < 0.0001 ) , use of diuretics ( P < 0.0001 ) , low body mass index ( BMI , P < 0.0001 ) , increasing age ( P < 0.0001 ) , low left ventricular ejection fraction ( P < 0.0001 ) , low activity hours ( P < 0.0001 ) , elevated resting heart rate ( P = 0.014 ) , low mean arterial pressure ( MAP , P = 0.007 ) , and poor functional status ( New York Heart Association class , P < 0.0001 ) . In multivariate modelling , AF ( P ≤ 0.001 ) , diabetes ( P = 0.004 ) , BMI ( P = 0.001 ) , MAP ( P = 0.040 ) , and functional class ( P = 0.006 ) predicted mortality . Conclusion In this population undergoing ICD implantation , poor functional status , low MAP , diabetes , low BMI , and AF were strongly associated with death within a year Objective To develop and vali date a risk algorithm ( QStroke ) to estimate risk of stroke or transient ischaemic attack in patients without prior stroke or transient ischaemic attack at baseline ; to compare ( a ) QStroke with CHADS2 and CHA2DS2VASc scores in patients with atrial fibrillation and ( b ) the performance of QStroke with the Framingham stroke score in the full population free of stroke or transient ischaemic attack . Design Prospect i ve open cohort study using routinely collected data from general practice during the study period 1 January 1998 to 1 August 2012 . Setting 451 general practice s in Engl and and Wales contributing to the national Q Research data base to develop the algorithm and 225 different Q Research practice s to vali date the algorithm . Participants 3.5 million patients aged 25 - 84 years with 24.8 million person years in the derivation cohort who experienced 77 578 stroke events . For the validation cohort , we identified 1.9 million patients aged 25 - 84 years with 12.7 million person years who experienced 38 404 stroke events . We excluded patients with a prior diagnosis of stroke or transient ischaemic attack and those prescribed oral anticoagulants at study entry . Main outcome measures Incident diagnosis of stroke or transient ischaemic attack recorded in general practice records or linked death certificates during follow-up . Risk factors Self assigned ethnicity , age , sex , smoking status , systolic blood pressure , ratio of total serum cholesterol to high density lipoprotein cholesterol concentrations , body mass index , family history of coronary heart disease in first degree relative under 60 years , Townsend deprivation score , treated hypertension , type 1 diabetes , type 2 diabetes , renal disease , rheumatoid arthritis , coronary heart disease , congestive cardiac failure , valvular heart disease , and atrial fibrillation Results The QStroke algorithm explained 57 % of the variation in women and 55 % in men without a prior stroke . The D statistic for QStroke was 2.4 in women and 2.3 in men . QStroke had improved performance on all measures of discrimination and calibration compared with the Framingham score in patients without a prior stroke . Among patients with atrial fibrillation , levels of discrimination were lower , but QStroke had some improved performance on all measures of discrimination compared with CHADS2 and CHA2DS2VASc . Conclusion QStroke provides a valid measure of absolute stroke risk in the general population of patients free of stroke or transient ischaemic attack as shown by its performance in a separate validation cohort . QStroke also shows some improvement on current risk scoring methods , CHADS2 and CHA2DS2VASc , for the subset of patients with atrial fibrillation for whom anticoagulation may be required . Further research is needed to evaluate the cost effectiveness of using these algorithms in primary care Atrial fibrillation ( AF ) has been established as an independent predictor of long-term mortality after acute myocardial infa rct ion . However , this is less well defined across the whole spectrum of acute coronary syndromes ( ACSs ) . The Acute Coronary Syndrome Prospect i ve Audit is a prospect i ve multicenter registry with 12-month outcome data for 3,393 patients ( 755 with ST-segment elevation myocardial infa rct ion , 1942 with high-risk non-ST-segment elevation ACS [ NSTE-ACS ] , and 696 with intermediate-risk NSTE-ACS ) . A total of 149 patients ( 4.4 % ) had new-onset AF and 387 ( 11.4 % ) had previous AF .  New-onset AF was more , and previous AF was less frequent in those with ST-segment elevation myocardial infa rct ion than in those with high-risk NSTE-ACS or intermediate-risk NSTE-ACS ( p < 0.001 ) . Compared to patients without arrhythmia , patients with new-onset AF and previous AF were significantly older and had more high-risk features at presentation ( p < 0.004 ) . Patients with new-onset AF more often had left main coronary artery disease , result ing in a greater rate of surgical revascularization ( p < 0.001 ) . Only new-onset AF result ed in adverse in-hospital outcomes ( p < 0.001 ) . Only patients with previous AF had greater long-term mortality ( hazard ratio 1.42 , p < 0.05 ) . New-onset AF was only associated with a worse long-term composite outcome ( hazard ratio 1.66 , p = 0.004 ) . However , the odds ratio for the composite outcome was greatest for patients with new-onset AF with intermediate-risk NSTE-ACS ( odds ratio 3.9 , p = 0.02 ) than for those with high-risk NSTE-ACS ( odds ratio 2.0 , p = 0.01 ) or ST-segment elevation myocardial infa rct ion ( odds ratio 1.4 , p = 0.4 ) . In conclusion , new-onset AF was associated with worse short-term outcomes and previous AF was associated with greater mortality even at long-term follow-up . The prognostic burden of new-onset AF differed with the type of ACS presentation BACKGROUND Atrial fibrillation ( AF ) is a common arrhythmia in patients with heart failure ( HF ) , but its prognostic importance is controversial . The effect of AF on long-term outcomes , including mortality and rehospitalization , among unselected HF patients hospitalized with HF in routine clinical practice in Japan was assessed in the present study . METHODS AND RESULTS The Japanese Cardiac Registry of Heart Failure in Cardiology ( JCARE-CARD ) prospect ively studied the characteristics and treatment strategies of a broad sample of patients hospitalized with worsening HF and the outcomes were followed with an average of 2.4 years of follow-up . The study cohort ( n=2,659 ) was grouped according to the presence ( n=937 ; 35.2 % ) or absence ( n=1,722 ; 64.8 % ) of AF at baseline . After multivariable adjustment , patients with and without AF had a comparable risk for all-cause death ( adjusted hazard ratio ( HR ) 0.931 , 95 % confidence interval ( CI ) 0.690 - 1.258 , P=0.643 ) , cardiac death ( adjusted HR 0.949 , 95%CI 0.655 - 1.377 , P=0.784 ) , rehospitalization because of the worsening HF ( adjusted HR 1.028 , 95%CI 0.816 - 1.295 , P=0.816 ) , and all-cause death or rehospitalization ( adjusted HR 1.039 , 95%CI 0.842 - 1.281 , P=0.722 ) . CONCLUSIONS Among patients hospitalized for HF in Japan , AF was common , but was not an independent risk for long-term adverse outcomes , including death or rehospitalization , in routine clinical practice BACKGROUND Atrial fibrillation is the most common supraventricular arrhythmia in patients with acute myocardial infa rct ion . Recent advances in pharmacological treatment of myocardial infa rct ion may have changed the impact of this arrhythmia . OBJECTIVE To assess the incidence and prognosis of atrial fibrillation complicating myocardial infa rct ion in a large population of patients receiving optimal treatment , including angiotensin converting enzyme ( ACE ) inhibitors .  METHODS Data were derived from the GISSI-3 trial , which included 17 944 patients within the first 24 hours after acute myocardial infa rct ion . Atrial fibrillation was recorded during the hospital stay , and follow up visits were planned at six weeks and six months . Survival of the patients at four years was assessed through census offices . RESULTS The incidence of in-hospital atrial fibrillation or flutter was 7.8 % . Atrial fibrillation was associated with indicators of a worse prognosis ( age > 70 years , female sex , higher Killip class , previous myocardial infa rct ion , treated hypertension , high systolic blood pressure at entry , insulin dependent diabetes , signs or symptoms of heart failure ) and with some adverse clinical events ( reinfa rct ion , sustained ventricular tachycardia , ventricular fibrillation ) . After adjustment for other prognostic factors , atrial fibrillation remained an independent predictor of increased in-hospital mortality : 12.6%v 5 % , adjusted relative risk ( RR ) 1.98 , 95 % confidence interval ( CI ) 1.67 to 2.34 . Data on long term mortality ( four years after acute myocardial infa rct ion ) confirmed the persistent negative influence of atrial fibrillation ( RR 1.78 , 95 % CI 1.60 to 1.99 ) . CONCLUSIONS Atrial fibrillation is an indicator of worse prognosis after acute myocardial infa rct ion , both in the short term and in the long term , even in an unselected population OBJECTIVES Preoperative atrial fibrillation ( PAF )  has been associated with poorer early and mid-term outcomes after isolated valvular or coronary artery bypass graft surgery . Few studies , however , have evaluated the impact of PAF on early and mid-term outcomes after  concomitant aortic valve replacement and coronary aortic bypass graft ( AVR-CABG ) surgery . METHODS Data obtained prospect ively between June 2001 and December 2009 by the Australian and New Zeal and Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Data base Program was retrospectively analysed . Patients who underwent concomitant atrial arrhythmia surgery/ablation were excluded . Demographic and operative data were compared between patients undergoing concomitant AVR-CABG  who presented with PAF and those who did not using chi-square and t-tests . The independent impact of PAF on 12 short-term complications and mid-term mortality was determined using binary logistic and Cox regression , respectively . RESULTS Concomitant AVR-CABG surgery was performed in 2563 patients ; 322 ( 12.6 % ) presented with PAF . PAF patients were generally older ( mean age 76 vs 74 years ; P < 0.001 ) and presented more often with comorbidities including congestive heart failure , chronic pulmonary disease and cerebrovascular disease ( all P < 0.05 ) . PAF was associated with 30-day mortality on univariate analysis ( P = 0.019 ) but not multivariate analysis ( P = 0.53 ) . The incidence of early complications was not significantly higher in the PAF group . PAF was independently associated with reduced mid-term survival ( HR , 1.58 ; 95 % CI , 1.14 - 2.19 ; P = 0.006 ) . CONCLUSIONS PAF is associated with reduced mid-term survival after concomitant AVR-CABG surgery .  Patients with PAF undergoing AVR-CABG  should be considered for a concomitant surgical ablation procedure Failure to expeditiously diagnose atrial fibrillation ( AF ) as the cause of ischemic stroke has unclear consequences . We studied the association between detection of AF after discharge and the risk of recurrent stroke . We followed a prospect ively assembled cohort of patients hospitalized for stroke for 1 year for new diagnoses of AF and recurrent stroke . We compared rates of recurrent stroke in patients with a new diagnosis of AF and those without a new diagnosis of AF after discharge using Kaplan-Meier survival statistics . We conducted Cox proportional hazards analysis of the diagnosis and timing of AF and recurrent stroke after adjustment for age , sex , race , preexisting AF , hypertension , dyslipidemia , diabetes , previous stroke , and use of antithrombotic and statin medications . Among 5575 patients with stroke , 113 ( 2.0 % ) received a new diagnosis of AF after discharge , and 221 ( 4.0 % ) had recurrent stroke . At 1 year , the Kaplan‒Meier rate of recurrent stroke was 18.9 % in those with a new diagnosis of AF and 4.5 % in others , including those with AF diagnosed before or during the index hospitalization ( P = .001 ) . The association between a new diagnosis of AF and stroke recurrence persisted after adjustment for potential confounders ( hazard ratio , 5.6 ; 95 % confidence interval , 3.4 - 9.1 ) . A new diagnosis of AF after discharge for stroke is associated with an increased risk of recurrent stroke , even compared with patients with known AF . These findings identify a subset of patients at high risk for recurrent stroke and highlight the importance of timely detection of AF in patients with stroke 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 : Atrial fibrillation ( AF ) is strongly associated with age , and epidemiologic studies are needed to evaluate the impact of both aging of the population and the use of anticoagulant therapy in patients with AF on the incidence of cardioembolic stroke with AF ( CE/AF stroke ) . Methods : We evaluated trends in incidence rates , risk factors , prestroke therapy , and survival in CE/AF stroke from a prospect i ve population -based registry , from 1985 to 2006 . Results : A total of 3,064 ischemic  strokes , including 572 ( 18.7 % ) CE/AF strokes , were recorded . Over the 22 years , a decrease in the incidence of overall CE/AF stroke was noted ( incidence rate ratio 0.9858 , 95 % confidence interval [ CI ] 0.9731–0.9986 ; p = 0.03 ) . We observed a higher prevalence of previous AF , previous myocardial infa rct ion , and patients aged > 70 years in CE/AF stroke ( p < 0.0001 ) whereas hypercholesterolemia was more prevalent in other ischemic strokes ( p = 0.003 ) . A significant increase in the use of anticoagulants and antiplatelet agents  was noted , and was particularly pronounced for CE/AF stroke with previous AF . For CE/AF stroke , survival rates were 72 % at 1 month ( 95 % CI 0.68–0.76 ) , 52 % at 1 year ( 95 % CI 0.48–0.56 ) , and 43 % at 2 years ( 95 % CI 0.39–0.48 ) , and remained lower than those of other ischemic stroke . Conclusions : The decrease in the incidence of cardioembolic/atrial fibrillation stroke in our study was probably due to a slight increase in the utilization of antithrombotic therapy in patients with atrial fibrillation , but the use of such therapies will have to increase further because of the expected aging of the population in coming years . AF = atrial fibrillation ; CE = cardioembolic ; CI = confidence interval ; IRR = incidence rate ratios AIMS Atrial fibrillation ( AF ) is a common complication in patients with acute myocardial infa rct ion and is associated with an increase in the risk of death . The excess mortality associated with AF complicating acute myocardial infa rct ion has not been studied in detail . Observations indicate that AF facilitates induction of ventricular arrhythmias , which may increase the risk of sudden cardiovascular death ( SCD ) . A close examination of the mode of death could potentially provide useful knowledge to guide further investigations and treatments . METHODS AND RESULTS We analysed the relation between AF/atrial flutter ( AFL )  and modes of death in 5983 consecutive patients discharged alive after an acute myocardial infa rct ion screened in the TR And olapril Cardiac Evaluation registry . This cohort of patients with an enzyme-verified acute myocardial infa rct ion was admitted to 27 centres in 1990 - 92 .  Survival status was obtained 2 years after screening of the last patient . An independent endpoint committee assessed the modes of death . Left ventricular ejection fraction was determined in all the screened patients and information about presence or absence of AF/AFL was prospect ively collected . Sustained or paroxysmal AF/AFL was observed in 1149 patients ( 19 % ) during hospitalization . During follow-up , 1659 patients ( 34 % ) died : 482 ( 50 % ) patients with AF/AFL and 1177 ( 30 % ) patients without AF/AFL , P<0.001 . SCD occurred in 536 , non-SCD occurred in 725 , and 398 died of non-cardiovascular causes ( includes 142 unclassifiable cases ) . The adjusted risk ratio of AF/AFL for total mortality was 1.33 ( 95 % CI : 1.19 - 1.49 ; P<0.0001 ) and the risk ratio for SCD was 1.31 ( 95 % CI : 1.07 - 1.60 ; P<0.009 ) . The adjusted risk ratio of AF/AFL for non-SCD was 1.43 ( 95 % CI : 1.21 - 1.70 ; P<0.0001 ) . CONCLUSION The excess mortality observed in patients with AF/AFL following acute myocardial infa rct ion is due to a significant increase in both SCD and non-SCD Background —Atrial fibrillation ( AF ) is an important risk factor for stroke and is common among elderly patients undergoing transcatheter aortic valve implantation .  The aim of this study was to assess the impact of AF on clinical outcomes among patients undergoing transcatheter aortic valve implantation .  Methods and Results —Between August 2007 and October 2011 , a total of 389 high-risk patients undergoing transcatheter aortic valve implantation  were included into a prospect i ve registry . AF was recorded in 131 patients ( 33.7 % ) with a mean CHA2DS2–VASC score of 4.5±1.2 and was paroxysmal in 26 ( 25.0 % ) , persistent in 8 ( 7.7 % ) , and permanent in 70 patients ( 67.3 % ) . Patients with and without AF had similar baseline characteristics except for fewer revascularization procedures ( coronary artery bypass grafting : 12 % versus 22 % ; P=0.03 ) among AF patients . At 1 year , all-cause mortality was higher among patients with AF ( 30.9 % ) compared with those without AF ( 13.9 % ; hazard ratio [ HR ] , 2.36 ; 95 % confidence interval [ CI ] , 1.43–3.90 ; P=0.0008 ) . This was observed irrespective of the type of AF ( permanent , HR , 2.47 ; 95 % CI , 1.40–4.38 ; persistent , HR , 3.60 ; 95 % CI , 1.10–11.78 ; paroxysmal , HR , 2.88 ; 95 % CI , 1.37–6.05 ) . Mortality gradually increased with higher CHA2DS2–VASC scores ( score 1–3 : HR , 2.20 ; 95 % CI , 0.92–5.27 ; score 6–8 : HR , 4.12 ; 95 % CI , 2.07–8.20 ) . The risks of stroke ( 3.9 % versus 5.1 % ; HR , 0.76 ; 95 % CI , 0.23–1.96 ; P=0.47 ) and life-threatening bleeding ( 19.8 % versus 14.7 % ; HR , 1.37 ; 95 % CI , 0.86–2.19 ; P=0.19 ) were similar among patients with and without AF . Conclusions —AF is common among high-risk patients with severe aortic stenosis undergoing transcatheter aortic valve implantation and is associated with a > 2-fold increased risk of all-cause and cardiovascular mortality , irrespective of the type of AF . The gradient of risk directly correlates with the CHA2DS2–VASC score BACKGROUND Stroke is a devastating complication in patients with prosthetic valves , but characterization of its late occurrence from a large cohort is lacking . METHODS Three thous and one hundred eighty-nine adult patients who underwent a total of 3,576 operations for left-heart valve replacement  were managed with contemporary anticoagulation guidelines and prospect ively followed in a dedicated clinic . Total follow-up was 20,096 patient years . Bootstrapped survival analysis was used to determine the impact of patient and valve related factors on the incidence of stroke . RESULTS Most strokes were embolic . Linearized embolic stroke rates were 1.3 % + /- 0.2 % per year for aortic bioprostheses , 1.4 % + /- 0.2 % per year for aortic mechanical valves , 1.3 % + /- 0.3 % per year for mitral bioprostheses , and 2.3 % + /- 0.4 % per year for mitral mechanical valves ( p = 0.002 , vs other implant types ) . Age more than 75 years , female gender , and smoking were independent risk factors after aortic and mitral valve replacement . Atrial fibrillation , coronary disease , and tilting-disc mechanical prostheses were independent predictors of embolic stroke after aortic valve replacement . Preoperative left ventricular ( LV ) dysfunction was an independent risk factor in patients with mitral prostheses .  Primary operative indication , diabetes , redo status , or the presence of two prosthetic valves were not associated with an increased hazard . The addition of acetyl salicylic or dipyridamole to warfarin anticoagulation did not significantly lower embolic stroke risk in patients with mechanical prostheses . CONCLUSIONS Approximately 20 % of patients with valve prostheses have an embolic stroke by 15 years after valve replacement . Some risk factors such as the avoidance of smoking , mitral mechanical prostheses , aortic tilting-disc valves , and proceeding to mitral surgery before LV dysfunction occurs are potentially modifiable In a prospect i ve study of 2,384 persons , mean age 81 years , at 44-month follow-up , new thromboembolic stroke developed in 510 of 2,384 persons ( 21 % ) . The Cox regression model showed that significant independent risk factors for new thromboembolic stroke were atrial fibrillation ( risk ratio 3.2 ) , left ventricular hypertrophy ( risk ratio 2.8 ) , prior stroke ( risk ratio 2.2 ) , and male gender ( risk ratio 1.2 ) Background —Prevalent atrial fibrillation ( AF ) is associated with a higher sudden cardiac death ( SCD ) rate in some population s , and incident AF predicts increased mortality risk in the general population and after myocardial infa rct ion . However , the relationship of SCD to new-onset AF is unclear . Methods and Results —The relationship of SCD to new-onset AF was evaluated in 8831 hypertensive patients with electrocardiographic left ventricular hypertrophy with no history of AF , in sinus rhythm on their baseline electrocardiogram , r and omly assigned to losartan- or atenolol-based treatment . During 4.7±1.1 years mean follow-up , new-onset AF occurred in 701 patients ( 7.9 % ) and SCD in 151 patients ( 1.7 % ) . In univariate Cox analyses , new-onset AF was associated with a > 4-fold higher risk of SCD ( hazard ratio , 4.69 ; 95 % CI interval , 2.96–7.45 ; P<0.001 ) . In multivariate Cox analyses adjusting for age , sex , race , diabetes mellitus , history of heart failure , myocardial infa rct ion , ischemic heart disease , stroke , smoking , serum high-density lipoprotein cholesterol , creatinine , glucose , and urine albumin/creatinine ratio as st and ard risk factors , and for incident myocardial infa rct ion , in-treatment use of digoxin , systolic and diastolic pressure , heart rate , QRS duration , Cornell voltage- duration product , and Sokolow-Lyon voltage left ventricular hypertrophy treated as time-varying covariates , new-onset AF remained associated with a > 3-fold increased risk of SCD ( hazard ratio , 3.13 ; 95 % confidence interval , 1.87–5.24 ; P<0.001 ) . Conclusions —Development of new-onset AF identifies hypertensive patients at  increased risk of SCD . Clinical Trial Registration —URL : http://www . clinical trials.gov . Unique identifier : NCT00338260 Background and Purpose — This article examines stroke recurrence and whether the subtype of the initial stroke influences the risk and subtypes of further strokes . The proportion of recurrences attributable to conventional risk factors is quantified . Methods — From January 1995 to August 2000 , all first-in-a-lifetime strokes ( n=1626 ) were identified and prospect ively followed up in a defined multiethnic inner city population of 234 533 . Twelve overlapping referral sources and face-to-face follow-up at 3 months and 1 and 3 years were used to attain complete registration of stroke recurrence . Index and recurrent stroke were classified according to the Oxford Community Stroke Project classification . Results — In 2744 person-years of follow-up , 153 recurrences were observed . At 5 years , the cumulative risk of first stroke recurrence was 16.6 % ( 95 % CI , 13.5 to 20.4 ) , and the combined risk of death or stroke recurrence was 65.3 % ( 95 % CI , 61.9 to 68.6 ) . Ethnicity and subtype of index stroke were not associated with stroke recurrence . A change in subtype between index and recurrent stroke occurred in 45.5 % ( 95 % CI , 35.8 to 55.2 ) of cases and was most frequent among index lacunar strokes and primary intracerebral hemorrhages . In multivariable analyses , diabetes mellitus and atrial fibrillation were associated with both stroke recurrence and recurrence-free survival . In the stroke population , 9.1 % ( 95 % CI , −2.0 to 20.2 ) of recurrences were attributable to diabetes and 4.9 % ( 95 % CI , −7.3 to 17.2 ) to atrial fibrillation during the first year after the index stroke . Conclusions — The cause of stroke recurrence is multifactorial , and the subtypes of index and recurrent strokes are often not identical . Most recurrences remain unexplained by conventional risk factors Objective To develop , vali date , and evaluate a new QRISK model to estimate lifetime risk of cardiovascular disease . Design Prospect i ve cohort study with routinely collected data from general practice . Cox proportional hazards models in the derivation cohort to derive risk equations accounting for competing risks . Measures of calibration and discrimination in the validation cohort . Setting 563 general practice s in Engl and and Wales contributing to the Q Research data base . Subjects Patients aged 30–84 years who were free of cardiovascular disease and not taking statins between 1 January 1994 and 30 April 2010 : 2 343 759 in the derivation data set , and 1 267 159 in the validation data set . Main outcomes measures Individualised estimate of lifetime risk of cardiovascular disease accounting for smoking status , ethnic group , systolic blood pressure , ratio of total cholesterol : high density lipoprotein cholesterol , body mass index , family history of coronary heart disease in first degree relative aged < 60 years , Townsend deprivation score , treated hypertension , rheumatoid arthritis , chronic renal disease , type 2 diabetes , and atrial fibrillation . Age-sex centile values for lifetime cardiovascular risk compared with 10 year risk estimated using QRISK2 ( 2010 ) . Results Across all the 1 267 159 patients in the validation data set , the 50th , 75th , 90th , and 95th centile values for lifetime risk were 31 % , 39 % , 50 % , and 57 % respectively . Of the 10 % of patients in the validation cohort classified at highest risk with either the lifetime risk model or the 10 year risk model , only 18 385(14.5 % ) were at high risk on both measures . Patients identified as high risk with the lifetime risk approach were more likely to be younger , male , from ethnic minority groups , and have a positive family history of premature coronary heart disease than those identified with the 10 year QRISK2 score . The lifetime risk calculator is available at www.qrisk.org/lifetime/. Conclusions Compared with using a 10 year QRISK2 score , a lifetime risk score will tend to identify patients for intervention at a younger age . Although lifestyle interventions at an earlier age could be advantageous , there would be small gains under the age of 65 , and medical interventions carry risks as soon as they are initiated . Research is needed to examine closely the cost effectiveness and acceptability of such an approach AIMS To characterize the relationship between known and newly diagnosed atrial fibrillation ( AF ) and the risk of death and major cardiovascular ( CV ) events in patients with acute myocardial infa rct ion ( MI ) complicated by heart failure ( HF ) and /or left ventricular systolic dysfunction ( LVSD ) . METHODS The VALIANT trial enrolled 14,703 individuals with acute MI complicated by HF and /or LVSD .  AF was assessed at presentation and at r and omization ( median 4.9 days after symptom onset ) . Primary outcomes were risk of death and major CV events 3 years following acute MI . RESULTS A total of 1812 with current AF ( AF between presentation and r and omization ) , 339 patients with prior AF ( history of AF without current AF ) , and 12,509 without AF were enrolled . Patients with AF were older ; had more prior HF , angina , and MI , and received beta-blockers and thrombolytics less often than those without AF . Three-year mortality estimates were 20 % in those without AF , 37 % with current AF , and 38 % with prior AF . Compared with patients without AF , the multivariable adjusted HR of death was 1.25 ( 1.03 - 1.52 ; p=0.03 ) for prior AF and 1.32 ( 1.20 - 1.45 ; p<0.0001 ) for current AF . HR for major CV events was 1.15 ( 0.98 - 1.35 ; p=0.08 ) and 1.21 ( 1.12 - 1.31 ; p<0.0001 ) . CONCLUSION AF is associated with greater long-term mortality and adverse CV events with acute MI complicated by HF or LVSD Background Only a few population -based cohort studies have investigated the impact of  atrial fibrillation ( AF ) on stroke in Japan . Methods A total of 10 929 participants ( 4147 men and 6782 women ) were included in this population -based prospect i ve cohort study . Baseline data , including  electrocardiograms ( ECGs )  to ascertain AF status , were obtained from April 1992 through July 1995 in 12 areas in Japan . Cox proportional hazards models were used to analyze the association of AF with stroke . Results A total of 54 participants had AF ( 0.49 % ) . The mean follow-up period was 10.7 years , during which 405 strokes were identified ; 12 of these occurred in participants with AF . The crude incidence of stroke in participants with and without AF was 14.9 and 4.5 per 1000 person-years in men , respectively , and 39.3 and 2.7 per 1000 person-years in women . After adjusting for geographical area , sex , age , smoking status , drinking status , obesity , hypertension , dyslipidemia , and diabetes mellitus , the hazard ratios ( 95 % confidence interval ) of AF in all participants and in male and female participants were 4.11 ( 2.28–7.41 ) , 2.12 ( 0.77–5.84 ) , and 10.6 ( 5.01–22.4 ) , respectively . The population attributable fraction ( PAF ) of stroke caused by AF was 2.2 % ; the PAFs were 1.0 % and 3.6 % in men and women , respectively . Conclusions The present Japanese population -based prospect i ve cohort study showed that AF is a major risk factor for stroke , especially in women 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 BACKGROUND The extent to which  atrial fibrillation ( AF ) contributes to mortality in the Japanese general population has not been clarified . METHODS AND RESULTS A r and omly sample d general population from all over Japan ( 4,154 men , 5,329 women ; age > or = 30 years ) was enrolled .  Single electrocardiogram recordings  were taken in the baseline survey . Stroke death , cardiovascular deaths and all-cause deaths during the subsequent 19 years were analyzed by the presence of AF at baseline . Cox 's regression analysis was carried out to estimate the hazard ratios ( HRs ) of each cause of death attributable to AF after adjusting for other risk factors . Prevalence of AF was 0.64 % in the study . The observed person-years were 162,980 among persons without AF and 699 among persons with AF . There were 1,919 deaths . Multivariate adjusted HRs for stroke death , cardiovascular death and all-cause death were 2.69 , 2.76 and 1.88 , respectively ( p<0.05 ) . These HRs were 14.7 , 9.63 and 4.00 among persons aged 64 years or younger ( p<0.05 ) . CONCLUSION AF affects stroke mortality , cardiovascular mortality and all-cause mortality in the Japanese general population . Careful attention should be paid to persons with AF in order to prevent future cardiovascular events BACKGROUND Lipid-lowering drugs , particularly statins , have anti-inflammatory and antioxidant properties that may prevent atrial fibrillation ( AF ) . This effect has not been investigated on new-onset AF in asymptomatic patients with aortic stenosis ( AS ) . METHODS Asymptomatic patients with mild-to-moderate AS ( n = 1,421 ) were r and omized ( 1:1 ) to double-blind  simvastatin 40 mg and ezetimibe 10 mg combination or placebo and followed up for a mean of 4.3 years . The primary end point was the time to new-onset AF adjudicated by 12-lead electrocardiogram  at a core laboratory reading center . Secondary outcomes were the correlates of new-onset AF with nonfatal nonhemorrhagic stroke and a combined end point of AS-related events . RESULTS During the course of the study , new-onset AF was detected in 85 ( 6 % ) patients ( 14.2/1,000 person-years of follow-up ) . At baseline , patients who developed AF were , compared with those remaining in sinus rhythm , older and had a higher left ventricular mass index a smaller aortic valve area index . Treatment with simvastatin and ezetimibe was not associated with less new-onset AF ( odds ratio 0.89 [ 95 % CI 0.57 - 1.97 ] , P = .717 ) . In contrast , age ( hazard ratio [ HR ] 1.07 [ 95 % CI 1.05 - 1.10 ] , P < .001 ) and left ventricular mass index ( HR 1.01 [ 95 % CI 1.01 - 1.02 ] , P < .001 ) were independent predictors of new-onset AF . The occurrence of new-onset AF was independently associated with 2-fold higher risk of AS-related outcomes ( HR 1.65 [ 95 % CI 1.02 - 2.66 ] , P = .04 ) and 4-fold higher risk of nonfatal nonhemorrhagic stroke ( HR 4.04 [ 95 % CI 1.18 - 13.82 ] , P = .03 ) . CONCLUSIONS Simvastatin and ezetimibe were not associated with less new-onset AF . Older age and greater left ventricular mass index were independent predictors of AF development . New-onset AF was associated with a worsening of prognosis BACKGROUND The impact of  atrial fibrillation ( AF ) on mortality , stroke , and medical costs is unknown . METHODS We conducted a prospect i ve cohort study of hospitalized Medicare patients with AF and 1 other cardiovascular diagnosis ( CVD ) compared with a matched group without AF ( n = 26,753 ) , r and omly selected in 6 age-sex strata from 1989 MedPAR files of more than 1 million patients diagnosed as having AF .  Stroke rates were also determined in another cohort free of CVD ( n = 14,267 ) .  Total medical costs after hospitalization were available from a 1991 cohort . Cumulative mortality , stroke rates , and costs following index admission were adjusted by multivariate and proportional hazard regression analyses . RESULTS Mortality rates were high in individuals with CVD , ranging from 19.0 % to 52.1 % in 1 year . Adjusted relative mortality risk was approximately 20 % higher in patients with AF in all age-sex strata during each of the 3 years studied ( P < .05 ) . Incidence of stroke was high in individuals with CVD , 6.2 % to 15.4 % in 1 year , with and without AF , and was at least 5-fold higher than in individuals without CVD . In those with CVD , stroke rates were approximately 25 % higher in women with AF ( P < .05 ) but only 10 % higher in men . Adjusted total Medicare spending in 1 year was 8.6- to 22.6-fold greater in men , and 9.8- to 11.2-fold greater in women with AF ( P < .05 ) . Second- and third-year costs were increased as well . CONCLUSION Prevention of AF and treatment of patients with AF and associated CVD may yield benefits in reduced mortality and stroke as well as reducing health care costs BACKGROUND Patients with atrial fibrillation ( AF )  are at increased risk of thromboembolic events . The long-term prognostic implication s of AF in patients with atherothrombosis are unknown . METHODS We compared 4-year CV outcomes in patients with and without a history of AF recorded at their baseline visit in the REACH Registry , an international , prospect i ve cohort of patients with established atherosclerotic arterial disease ( CAD , CVD , PAD ) or at least 3 risk factors ( RFO ) . RESULTS AF status and 4 year follow-up data were available on 44,518 patients . The prevalence of AF at baseline was 10.3 % ( n=4582 ) . Overall , patients with AF had approximately a 2-fold increase in the composite of CV death , MI , or stroke compared with patients without AF after adjustment for age , gender , prior ischemic event , vascular disease , congestive heart failure , diabetes , smoking , body mass index , region , aspirin and statin use ( 18.9 % vs. 9.4 % , p<0.0001 ) . This increased risk was observed both in patients with established atherothrombosis ( CAD : 15.5 % vs. 8.0 % , p=0.0001 ; CVD : 23.6 % vs. 13.6 % , p<0.0001 ; PAD : 24.3 % vs. 13.5 % , p=0.089 ) and those with multiple risk factors ( RFO : 12.1 % vs. 5.9 % , p=0.017 ) . Only 52 % of patients with a history of AF at baseline were receiving anticoagulation at 4 years . CONCLUSIONS Patients with a history of both AF and atherothrombosis have particularly high long-term CV risk . Despite this increased risk , almost half of all patients with AF do not receive guideline recommended anticoagulation , highlighting an important public health priority OBJECTIVES The U.K. Transcatheter Aortic Valve Implantation Registry reported 30-day and 1-year mortality rates of 7.1 % and 21.4 % , respectively , for patients who underwent transcatheter aortic valve replacement ( TAVR ) in the United Kingdom between 2007 and 2009 . The study aim was to report long-term outcomes in this same cohort of patients . BACKGROUND There are few data on outcomes beyond 3 years after TAVR in any notable number of patients . METHODS Data from all TAVR procedures performed in the United Kingdom between January 2007 and December 2009 were prospect ively collected . All-cause mortality status was reported in March 2014 . Mortality tracking was achieved in 97.7 % patients . RESULTS The minimal time from replacement to census was 4.1 years , and the maximal time was 7.0 years . The 3- and 5-year survival rates were 61.2 % and 45.5 % , respectively . Independent predictors of 3-year mortality were renal dysfunction ( hazard ratio [ HR ] : 1.65 ) , atrial fibrillation ( HR : 1.36 ) , logistic European System for Cardiac Operative Risk Evaluation ( EuroSCORE ) ≥18.5 ( HR : 1.33 ) , respiratory dysfunction ( HR : 1.28 ) , and ventricular dysfunction ( left ventricular ejection fraction < 30 % ) ( HR : 1.53 ) . Coronary artery disease ( HR : 1.28 ) and age ( HR : 1.03 ) were additional independent predictors of mortality at 5 years . Stroke within 30 days of TAVR was the only independent procedural predictor of mortality at 3 and 5 years ( HR : 2.17 at 3 years ) . Device type , access route , and paravalvular leak did not independently predict long-term outcome . CONCLUSIONS In the large U.K. Transcatheter Aortic Valve Implantation Registry , long-term outcomes after TAVR are favorable with 3- and 5-year survival rates of 61.2 % and 45.5 % , respectively . Long-term survival after TAVR is largely determined by intrinsic patient factors . Other than stroke , procedural variables , including paravalvular aortic leak , did not appear to be independent predictors of long-term survival OBJECTIVE To correlate atrial fibrillation with the incidence of new thromboembolic ( TE ) stroke  in older patients with and without prior TE stroke . DESIGN In a prospect i ve study of 2101 older patients ,  electrocardiograms  showed that atrial fibrillation was present in 283 patients ( 13 % ) . At 42-month mean follow-up , atrial fibrillation was associated with the incidence of new TE stroke in patients with and without prior TE stroke . SETTING A large long-term health care facility where 2101 older patients were studied . PATIENTS The 2101 patients included 1451 women and 650 men , mean age 81 + /- 8 years ( range 60 to 103 ) . MEASUREMENTS AND MAIN RESULTS Atrial fibrillation was present in 283 of 2101 patients ( 13 % ) . The mean age was 84 + /- 7 years in patients with atrial fibrillation and 81 + /- 8 years in patients with sinus rhythm ( P = .0001 ) . The prevalence of atrial fibrillation was 5 % in patients aged 60 to 70 years , 14 % in patients aged 71 to 80 years , 13 % in patients aged 81 to 90 years , and 22 % in patients aged 91 to 103 years ( P < .0001 ) . Mean follow-up was 31 + /- 18 months in patients with atrial fibrillation and 44 + /- 27 months in patients with sinus rhythm ( P = .0001 ) . Previous TE stroke occurred in 123 of 283 patients ( 43 % ) with atrial fibrillation and in 431 of 1818 patients ( 24 % ) with sinus rhythm ( P < .0001 ) . New TE stroke occurred in 131 of 283 patients ( 46 % ) with atrial fibrillation and in 303 of 1818 patients ( 17 % ) with sinus rhythm ( P < .0001 ) . The log-rank test showed that patients with atrial fibrillation had a significantly higher probability of developing new TE stroke than those with sinus rhythm ( P < .0001 ) . The multivariate Cox regression model showed that independent risk factors for new TE stroke were male sex ( relative risk = 1.3 ) , prior TE stroke ( relative risk = 3.1 ) , and atrial fibrillation ( relative risk = 3.3 ) . CONCLUSIONS Atrial fibrillation , prior TE stroke , and male sex are independent risk factors for the development of new TE stroke in older patients BACKGROUND Atrial fibrillation ( AF ) and chronic kidney disease share risk factors and pathophysiologic mechanisms , suggesting that two conditions have close relationships . METHODS This is a prospect i ve community-based observational cohort study including 235,818 subjects based upon a voluntary annual health check-up program in Japan . We studied the association of kidney dysfunction at entry with subsequent new-onset AF  and the association of AF at entry with the development of kidney disease . RESULTS During a follow-up of 5.9 + /- 2.4 years , AF developed in 2947 subjects ( 1.3 % ) .  Baseline serum creatinine and estimated glomerular filtration rate ( GFR ) were associated with risk of subsequent AF . The HRs ( 95 % CI ) for AF were 1.32 ( 1.08 - 1.62 ) and 1.57 ( 0.89 - 2.77 ) for GFR 30 to 59 and < 30 mL/min per 1.73 m(2 ) , respectively . The effect of kidney disease on risk of new-onset AF remained significant in subjects without treated hypertension or diabetes . During the follow-up , 7791 subjects ( 3.3 % ) developed kidney dysfunction ( GFR < 60 mL/min per 1.73 m(2 ) ) , and 11 307 subjects ( 4.9 % ) developed proteinuria .  Atrial fibrillation at entry was associated with development of kidney dysfunction ( HRs [ 95 % CI ] , 1.77 [ 1.50 - 2.10 ] ) and proteinuria ( HR [ 95 % CI ] , 2.20 [ 1.92 - 2.52 ] ) . The association persisted in subjects without treated hypertension or diabetes . CONCLUSIONS Kidney dysfunction increased the risk of new onset of AF , and AF increased the risk of development of kidney disease . This finding supports the concept that the two conditions share common abnormal molecular signaling pathways contributing to their pathogenesis Risk stratification for heart failure ( HF ) in patients with atrial fibrillation ( AF ) has not been well established . The aim of this study was to identify the predictors of HF events in patients with AF , consequently developing a new risk-scoring system that stratifies the risk for HF events . In this prospect i ve , single hospital-based cohort , all patients who presented from July 2004 to March 2010 were registered ( Shinken Data base 2004 - 2009 ) . Follow-up was maintained by being linked to the medical records or by sending study documents of prognosis . Of the 13,228 patients in the Shinken Data base 2004 - 2009 , 1,942 patients with AF were identified . Of the patients with AF , HF events ( hospitalization or death from HF ) occurred in 147 patients ( 7.6 % ) during a mean follow-up period of 776 ± 623 days . After identifying the parameters that were independently associated with the incidence of HF events ( coexistence of organic heart diseases , anemia [ hemoglobin level < 11 g/dl ] , renal dysfunction [ estimated glomerular filtration rate < 60 ml/min/m(2 ) ] , diabetes mellitus , and the use of diuretics ) , a new scoring system was developed , the H(2)ARDD score ( heart diseases = 2 points , anemia = 1 point , renal dysfunction = 1 point , diabetes = 1 point , and diuretic use = 1 point ; range 0 to 6 points ) . This scoring system discriminated the low- and high-risk population s well ( incidence in patients scoring 0 and 6 points of 0.2 % and 40.8 % per patient-year , respectively ) and showed high predictive ability ( area under the curve 0.840 , 95 % confidence interval 0.803 to 0.876 ) . In conclusion , the new H(2)ARDD score may help identify the population of patients with AF at high risk for HF events 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 AIMS The European CRT Survey is a joint initiative of the Heart Failure Association ( HFA ) and the European Heart Rhythm Association ( EHRA ) of the European Society of Cardiology evaluating the contemporary implantation practice of cardiac resynchronization therapy ( CRT ) in Europe . METHODS AND RESULTS Patients who had a successful CRT implantation were enrolled from 141 centres in 13 countries between November 2008 and June 2009 . Baseline demographics , clinical and implantation data were collected , with a follow-up of ∼1 year ( 9 - 15 months ) . The current report describes clinical outcomes including symptom severity , cardiovascular ( CV ) hospitalization , and survival . A total of 2438 patients were enrolled , and follow-up data were acquired from 2111 patients ( 87 % ) . The population included important groups of patients poorly represented in r and omized controlled trials , including very elderly patients and those with prior device implantation , atrial fibrillation , and /or QRS duration < 120 ms . Investigators reported substantial improvement in New York Heart Association ( NYHA ) functional class at follow-up . Patient self- assessment indicated that 81 % of the patients felt improved , 16 % reported no change , and 4 % reported deterioration . During follow-up , 207 ( 10 % ) patients died , 346 ( 16 % ) had a CV hospitalization , and 501 ( 24 % ) died or had CV hospitalization . Worse NYHA functional class , atrial fibrillation , ischaemic aetiology , and device type ( CRT-P , i.e. CRT alone ) were associated with poorer survival . Women had a better outcome , as did patients who had a  CRT-D  ( with an implantable cardioverter defibrillator function ) device . CONCLUSIONS Outcomes including death and hospitalization in this European CRT survey were consistent with results from clinical trials of CRT . At 1 year follow-up , most patients who received a CRT device considered their symptoms improved compared with their pre-implant assessment . Although prospect i ve , this is an observational study of successful CRT implantations , and outcomes in subgroup analyses must be interpreted with appropriate conservatism OBJECTIVES We assessed the risk of adverse cardiovascular ( CV ) outcomes associated with atrial fibrillation ( AF ) in the C and esartan in Heart failure- Assessment of Reduction in Mortality and morbidity ( CHARM ) program , which enrolled patients with chronic heart failure ( CHF ) and a broad range of ejection fractions ( EFs ) . BACKGROUND Atrial fibrillation is associated with an increased risk of adverse CV outcomes in patients with CHF and reduced EF . The risk of AF in patients with CHF and preserved left ventricular ejection fraction ( PEF ) is unknown . METHODS A total of 7,599 patients with symptomatic CHF were r and omized to c and esartan or placebo . Patients were divided by baseline EF ( < or = 40 % or > 40 % ) in low or preserved EF groups . Major outcomes were cardiovascular death or hospitalization for worsening heart failure , and all-cause mortality . Median follow-up was 37.7 months . RESULTS A total of 670 ( 17 % ) patients in the low EF group and 478 ( 19 % ) in the PEF group had AF at baseline . Atrial fibrillation predicted a high risk of cardiovascular morbidity and mortality regardless of baseline EF . Patients with AF and low EF had the highest absolute risk for adverse CV outcomes . However , AF was associated with greater relative increased risk of the major outcomes in patients with PEF than in patients with low EF : hazard ratio 1.72 ( 95 % confidence interval [ CI ] 1.45 to 2.06 ) versus 1.29 ( 95 % CI 1.14 to 1.46 ) , respectively . The same was true for the risk of all-cause mortality . C and esartan was associated with similar treatment effects regardless of baseline rhythm . CONCLUSIONS Atrial fibrillation is associated with an increased risk of CV outcomes in patients with CHF and either reduced EF or PEF . C and esartan improved outcomes similarly regardless of baseline rhythm 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 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 ) or flutter occurring after myocardial infa rct ion may occur alone or in association with other complications . Whether the arrhythmia portends a poor prognosis independent of other complications with contemporary therapy is unknown . METHODS AND RESULTS As part of the Global Use of Strategies To Open occluded coronary arteries ( GUSTO-III ) trial , we evaluated whether postinfa rct ion complications were associated with the subsequent development of  AF  and whether AF independently predicted death over periods of 30 days and 1 year . Information including exact timing was collected on deaths and major in-hospital postinfa rct ion complications up to 30 days . Of the 13,858 patients with sinus rhythm at enrollment , 906 later had AF or flutter and 12 , 952 did not . We compared outcomes between these 2 groups , adjusting for differences in baseline characteristics and prefibrillation complications . Worsening heart failure , hypotension , third-degree heart block , and ventricular fibrillation were independent predictors of new-onset AF . The unadjusted odds ratio ( OR ) for death among patients with versus those without AF was 2.74 ( 95 % confidence interval [ 95 % CI ] , 2.56 - 3.34 ) . After adjusting for baseline differences , the OR was reduced to 1.63 ( 95 % CI , 1.31 - 2.02 ) . Adjustment for other in-hospital complications before the onset of AF further reduced the OR to 1.49 ( 95 % CI , 1.17 - 1.89 ) . CONCLUSIONS Atrial fibrillation or flutter occurs secondary to other postinfa rct ion complications but independently portends a worse prognosis . Prevention and management may improve outcome In a prospect i ve study of 651 older persons with congestive heart failure after prior myocardial infa rct ion , persons with atrial fibrillation had a significantly higher mortality than those with sinus rhythm if they had an abnormal ( p = 0.005 ) or normal ( p = 0.0001 ) left ventricular ejection fraction . The Cox regression model showed that significant independent risk factors for total mortality were age ( risk ratio 1.03 for an increment of 1 year of age ) , hypertension ( risk ratio 1.2 ) , diabetes mellitus ( risk ratio 1.4 ) , abnormal left ventricular ejection fraction ( risk ratio 2.1 ) , and atrial fibrillation ( risk ratio 1.5 ) BACKGROUND Although implantable cardioverter-defibrillator ( ICD ) therapy has been evaluated in r and omized controlled trials , enrolling highly selected patients , mortality events in ICD patients have received little attention in routine medical care . We sought to assess the 24-month total and cause-specific mortality rates and their predictors in " real life " patients with an ICD . METHODS The Evaluation Médico-Economique du Défibrillateur Automatique Implantable study was a French multicenter , prospect i ve , observational cohort study of ICD patients with a 2-year follow-up . Cause-specific mortality rates and predictors at implantation of  sudden cardiac death ( SCD ) or progressive heart failure ( HF ) death were assessed using competing risk methodology . RESULTS From June 2001 to June 2003 , 2,296 unselected patients were implanted and followed until June 2005 . During a mean follow-up of 20.5 + /- 6.7 months , 274 deaths occurred : 29 ( 10.6 % ) were SCD and 146 ( 53.3 % ) were HF deaths , corresponding to 24-month cause-specific mortality rates of 1.4 % ( 95 % confidence interval 0.9%-1.9 % ) and 6.9 % ( 95 % confidence interval 5.8%-8.0 % ) , respectively . Among the characteristics at implantation , ejection fraction ( EF ) < 30 % and history of atrial fibrillation were independently associated with SCD ; age , high New York Heart Association class , systemic hypertension , prior atrial fibrillation , QRS duration , EF < 30 % , and lack of beta-blocker therapy were independently associated with HF death . CONCLUSIONS In this large cohort of " daily " patients , the 2-year incidence of SCD ( 1.4 % ) was comparable with the event rate observed in r and omized controlled trials ; HF remained the predominant mode of death . An EF < 30 % at implantation appears to be the most important predictor of ICD-unresponsive SCD OBJECTIVE To evaluate prognosis of stroke and identify the risk factors for stroke recurrence . METHODS Based on the West China Hospital stroke register data base , we conducted a prospect i ve follow-up study of stroke patients to record the potential risk factors of stroke recurrence and investigate stroke recurrence at 1 year . Analysis of the risk factors was performed using a logistic regression model . RESULTS A total of 1913 stroke consecutive patients admitted to our department were prospect ively registered . Of these patients , 599 ( 31.3 % ) were identified to have intracerebral hemorrhage ( ICH ) , and 1314 ( 68.7 % ) had ischemic stroke . The total recurrence rate at 1 year was 11.2 % , and was 10.5 % in ischemic patients and 12.7 % in ICH patients . Multivariate analysis adjusted for age and gender identified atrial fibrillation , hypertension , hyperlipemia , family history of stroke , and smoking as the risk factors of stroke recurrence at 1 year . CONCLUSION The 1 year recurrent rate is about 11 % , and monitoring the factors of atrial fibrillation , hyperlipemia , hypertension , and smoking may help reduce the recurrence of stroke Background : The aim of this study was to examine the 1-year cumulative mortality rate and cause of death , and to identify the predictive factors for death after hospital discharge following ischemic stroke and transient ischemic attack ( TIA ) using data from the Japan Multicenter Stroke Investigators ’ Collaboration study . Methods : We prospect ively registered 16,922 consecutive patients with acute ischemic stroke or TIA from May 1999 to April 2000 in 156 Japanese hospitals . We mailed a question naire to the 15,322 patients who were alive at hospital discharge . Results : 10,981 patients ( 6,945 men , 4,036 women , age 70 ± 11 years , median 71 , range 19–100 years ) were enrolled in the follow-up study . The mean follow-up period was 271 ± 110 days ( median 272 days ; range 1–487 days ) . The 1-year cumulative mortality was 6.8 % ( 7.0 % for 10,234 stroke patients and 3.5 % for 747 TIA patients ) . The causes of death were : cerebrovascular disease , 24.1 % ; pneumonia , 22.6 % ; heart disease , 18.1 % ; cancer , 11.0 % , and miscellaneous causes , 24.1 % . Multivariate analysis suggested that male gender , age , diabetes mellitus , atrial fibrillation , history of stroke , nonlacunar stroke , functional disability and transfer to another hospital or nursing home on discharge were significant independent predictors of death during the follow-up period . Conclusions : The major causes of death after hospital discharge were found to be cerebrovascular diseases , pneumonia and heart diseases . Thus , in order to improve survival after hospital discharge , in addition to appropriate management of vascular risk factors following stroke , it appears to be important to take measures to prevent pneumonia and to discharge patients to their own home , if possible OBJECTIVES Low ankle-brachial index ( ABI ) , indicative of peripheral arterial disease ( PAD ) , is a risk factor for stroke . ABI has been shown to be associated with cerebral arterial disease and prognosis following stroke . We studied the associations of the degree of ABI lowering with extracranial carotid disease ( ECD ) , intracranial large artery disease ( ICLAD ) , and subsequent vascular events in a prospect i ve cohort of acute ischemic stroke patients . METHODS  ABI , extracranial and intracranial cerebral arteries were assessed in a blinded manner . ABI  was categorized into 0.9 - 1.3 ( normal ) , 0.8 - 0.89 ( mildly lowered ) and < 0.8 ( severely lowered ) . Follow-up data at 1 year were obtained from st and ardized telephone interviews and verified with medical records . RESULTS Among the 1311 patients , 73 % had normal ABI , 13 % had ABI 0.8 - 0.89 and 13 % had ABI < 0.8 . Compared to patients with normal ABI , those with ABI<0.8 had higher prevalence of severe ECD ( 15 % vs. 5 % , p = 0.006 ) and ICLAD ( 72 % vs. 48 % , p = 0.003 ) , even after adjustment for age , gender , hypertension , diabetes , hyperlipidemia , smoking , ischemic heart disease and atrial fibrillation ( severe ECD p < 0.001 , ICLAD p < 0.001 ) . At 1 year , patients with ABI < 0.8 had a higher incidence of composite vascular events ( 19 % vs. 11 % , p = 0.02 ) , stroke ( 15 % vs. 10 % , p = 0.06 ) and myocardial infa rct ion ( 4 % vs. 2 % , p = 0.07 ) than patients with normal ABI . CONCLUSION Among ischemic stroke patients , large cerebral arterial disease and incidence of subsequent vascular events at 1 year were associated with severe ABI lowering < 0.8 , but not with mild ABI lowering ( 0.8 - 0.89 )
target: Among the outcomes examined , the highest absolute risk increase was for heart failure .
  Associations between atrial fibrillation and included outcomes were broadly consistent across subgroups and in sensitivity analyses .
  Atrial fibrillation is associated with an increased risk of death and an increased risk of cardiovascular and renal disease .
background: OBJECTIVE To quantify the association between  atrial fibrillation and cardiovascular disease , renal disease , and death .