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. 2019 Sep 20;9(9):e028468.
doi: 10.1136/bmjopen-2018-028468.

Comparative thromboembolic risk in atrial fibrillation with and without a secondary precipitant-Danish nationwide cohort study

A Gundlund  1 , Thomas Kümler  2 , Anders Nissen Bonde  2 , Jawad Haider Butt  3 , Gunnar Hilmar Gislason  2   4   5 , Christian Torp-Pedersen  6   7 , Lars Køber  3 , Jonas Bjerring Olesen  2 , Emil Loldrup Fosbøl  3
Affiliations

Comparative thromboembolic risk in atrial fibrillation with and without a secondary precipitant-Danish nationwide cohort study

A Gundlund et al. BMJ Open. .

Abstract

Objectives: We compared long-term outcomes in patients with atrial fibrillation (AF) with and without a secondary precipitant.

Design and setting: Retrospective cohort study based on Danish nationwide registries.

Participants: Patients with AF with and without secondary precipitants (1996-2015) were matched 1:1 according to age, sex, calendar year, CHA2DS2-VASc score and oral anticoagulation therapy (OAC), resulting in a cohort of 39 723 patients with AF with a secondary precipitant and the same number of patients with AF without a secondary precipitant. Secondary precipitants included alcohol intoxication, thyrotoxicosis, myocardial infarction, surgery and infection in conjunction with AF.

Primary and secondary outcomes: The primary outcome in this study was thromboembolic events. Secondary outcomes included AF rehospitalisation and death. Long-term risks of outcomes were examined by multivariable Cox regression analysis.

Results: The most common precipitants were infection (55.0%), surgery (13.2%) and myocardial infarction (12.0%). The 5-year absolute risk of thromboembolic events (taking death into account as a competing risk) in patients with AF grouped according to secondary precipitants were 8.3% (alcohol intoxication), 8.5% (thyrotoxicosis), 12.1% (myocardial infarction), 11.6% (surgery), 12.2% (infection), 10.1% (>1 precipitant) and 12.3% (no secondary precipitant). In the multivariable analyses, AF with a secondary precipitant was associated with the same or an even higher thromboembolic risk than AF without a secondary precipitant. One exception was patients with AF and thyrotoxicosis: those not initiated on OAC therapy carried a lower thromboembolic risk the first year of follow-up than matched patients with AF without a secondary precipitant and no OAC therapy.

Conclusions: In general, AF with a secondary precipitant was associated with the same thromboembolic risk as AF without a secondary precipitant. Consequently, this study highlights the need for more research regarding the long-term management of patients with AF associated with a secondary precipitant.

Keywords: recurrence; reversible atrial fibrillation; secondary precipitant.

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Conflict of interest statement

Competing interests: AG: none. TK: consultant fees from BMS, Astra Zeneca, Roche, Boehringer-Ingelheim, Bayer, MSD. JBO: speaker for Bristol-Myers Squibb, Boehringer Ingelheim, Bayer, and AstraZeneca. Consultant for Boehringer Ingelheim and Novo Nordisk. Funding for research from Bristol-Myers Squibb and The Capital Region of Denmark, Foundation for Health Research. ANB: none. JHB: none. GHG: research grants from Bayer, Bristol-Myers Squibb, AstraZeneca and Boehring Ingelheim. CT-P: consultant fees and research funding from Bayer and Biotronic. LK: none. ELF: has previously received research funding from Janssen and Janssen and Bristol-Myers Squibb.

Figures

Figure 1
Figure 1
Patient selection. AF, atrial fibrillation.
Figure 2
Figure 2
Number of events, incidence rates, and crude and adjusted HRs of long-term outcomes in patients with atrial fibrillation (AF) with and without a secondary precipitant. OAC, oral anticoagulation.
Figure 3
Figure 3
Cumulative incidence of thromboembolic (TE) events outcomes by secondary precipitant and oral anticoagulation (OAC) therapy at the index date. AF, atrial fibrillation.
Figure 4
Figure 4
Cumulative incidence of death events outcomes by secondary precipitant and oral anticoagulation (OAC) therapy at the index date. AF, atrial fibrillation.
Figure 5
Figure 5
Adjusted HRs of long-term outcomes in patients with atrial fibrillation (AF) initiated versus not initiated on oral anticoagulation (OAC) therapy (stratified according to type of AF).
See this image and copyright information in PMC

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