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Multicenter Study
. 2021 Sep 7;10(17):e021467.
doi: 10.1161/JAHA.121.021467. Epub 2021 Aug 28.

Association Between Preexisting Versus Newly Identified Atrial Fibrillation and Outcomes of Patients With Acute Pulmonary Embolism

Behnood Bikdeli  1   2   3 , David Jiménez  4   5   6 , Jorge Del Toro  7 , Gregory Piazza  1 , Agustina Rivas  8 , José Luis Fernández-Reyes  9 , Ángel Sampériz  10 , Remedios Otero  11 , José María Suriñach  12 , Carmine Siniscalchi  13 , Javier Miguel Martín-Guerra  14 , Joaquín Castro  15 , Alfonso Muriel  16 , Gregory Y H Lip  17   18 , Samuel Z Goldhaber  1 , Manuel Monreal  19   20 ; RIETE Investigators †
Collaborators, Affiliations
Multicenter Study

Association Between Preexisting Versus Newly Identified Atrial Fibrillation and Outcomes of Patients With Acute Pulmonary Embolism

Behnood Bikdeli et al. J Am Heart Assoc. .

Abstract

Background Atrial fibrillation (AF) may exist before or occur early in the course of pulmonary embolism (PE). We determined the PE outcomes based on the presence and timing of AF. Methods and Results Using the data from a multicenter PE registry, we identified 3 groups: (1) those with preexisting AF, (2) patients with new AF within 2 days from acute PE (incident AF), and (3) patients without AF. We assessed the 90-day and 1-year risk of mortality and stroke in patients with AF, compared with those without AF (reference group). Among 16 497 patients with PE, 792 had preexisting AF. These patients had increased odds of 90-day all-cause (odds ratio [OR], 2.81; 95% CI, 2.33-3.38) and PE-related mortality (OR, 2.38; 95% CI, 1.37-4.14) and increased 1-year hazard for ischemic stroke (hazard ratio, 5.48; 95% CI, 3.10-9.69) compared with those without AF. After multivariable adjustment, preexisting AF was associated with significantly increased odds of all-cause mortality (OR, 1.91; 95% CI, 1.57-2.32) but not PE-related mortality (OR, 1.50; 95% CI, 0.85-2.66). Among 16 497 patients with PE, 445 developed new incident AF within 2 days of acute PE. Incident AF was associated with increased odds of 90-day all-cause (OR, 2.28; 95% CI, 1.75-2.97) and PE-related (OR, 3.64; 95% CI, 2.01-6.59) mortality but not stroke. Findings were similar in multivariable analyses. Conclusions In patients with acute symptomatic PE, both preexisting AF and incident AF predict adverse clinical outcomes. The type of adverse outcomes may differ depending on the timing of AF onset.

Keywords: atrial fibrillation; mortality; outcome; pulmonary embolism.

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Conflict of interest statement

Dr Bikdeli reports that he is a consulting expert, on behalf of the plaintiff, for litigation related to 2 specific brand models of inferior vena cava filters. Dr Jimenez has served as an advisor or consultant for Bayer HealthCare Pharmaceuticals, Boehringer Ingelheim, Bristol‐Myers Squibb, Daiichi Sankyo, Leo Pharma, Pfizer, ROVI, and Sanofi; served as a speaker or a member of a speakers' bureau for Bayer HealthCare Pharmaceuticals, Boehringer Ingelheim, Bristol‐Myers Squibb, Daiichi Sankyo, Leo Pharma, ROVI, and Sanofi; and received grants for clinical research from Daiichi Sankyo, Sanofi, and ROVI. Dr Piazza has received significant research grant support from BTG International, Bristol Myers Squibb, Daiichi‐Sankyo, Bayer, Portola, and Janssen and modest consulting fees from Pfizer and Thrombolex. Dr Lip reports that he is a consultant for Bayer/Janssen, BMS/Pfizer, Medtronic, Boehringer Ingelheim, Novartis, Verseon, and Daiichi‐Sankyo and a speaker for Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim, and Daiichi‐Sankyo. No fees are directly received personally. Dr Goldhaber reports grants from Bayer, Boehringer‐Ingelheim, BMS, BTG EKOS, Daiichi Sankyo, Janssen, US National Heart Lung and Blood Institute, and Thrombosis Research Institute; and personal fees from Bayer and Boehringer‐Ingelheim, outside the submitted work. Dr Monreal has served as an advisor or consultant for Sanofi, Leo Pharma, and Daiichi‐Sankyo and has received a nonrestricted educational grant by Sanofi and Bayer to sponsor the RIETE registry.

Figures

Figure 1
Figure 1. Patient selection flow diagram.
AF indicates atrial fibrillation; DVT, deep vein thrombosis; PE, pulmonary embolism; and RIETE, Registro Informatizado de Enfermedad Tromboembólica.
Figure 2
Figure 2. Ninety‐day clinical outcomes based on presence of preexisting or incident AF.
Patients with no AF were the reference group in all analyses. *Adjusted for age, sex, simplified Pulmonary Embolism Severity Index, and history of diabetes mellitus, heart failure, prior ischemic stroke, and arterial vascular disease (either coronary or peripheral artery disease). AF indicates atrial fibrillation; and PE, pulmonary embolism.
Figure 3
Figure 3. Kaplan Meier curve for all‐cause death (A) and competing risk regression (Fine and Grey) for PE‐related death (B).
AF indicates atrial fibrillation; and PE, pulmonary embolism.
Figure 4
Figure 4. One‐year outcomes based on presence of preexisting or incident AF.
Patients with no AF were the reference group in all analyses. (A) all‐cause mortality ((B)) PE‐related mortality, (C) ischemic stroke, (D) recurrent VTE (E) composite thrombotic outcome. In all models other than all‐cause mortality, competing risk of death was considered; see text for details. In models where the number of events were very few, multivariable adjustment was not pursued. *Adjusted for age, sex, simplified Pulmonary Embolism Severity Index, and history of diabetes mellitus, heart failure, prior ischemic stroke, and arterial vascular disease (either coronary or peripheral artery disease). †No patient with incident AF developed ischemic stroke during follow‐up. AF indicates atrial fibrillation; PE, pulmonary embolism; and VTE, venous thromboembolism.
See this image and copyright information in PMC

References

    1. Barco S, Mahmoudpour SH, Valerio L, Klok FA, Münzel T, Middeldorp S, Ageno W, Cohen AT, Hunt BJ, Konstantinides SV. Trends in mortality related to pulmonary embolism in the European Region, 2000–15: analysis of vital registration data from the WHO Mortality Database. Lancet Respir Med. 2020;8:277–287. DOI: 10.1016/S2213-2600(19)30354-6. - DOI - PubMed
    1. Bikdeli B, Wang Y, Jimenez D, Parikh SA, Monreal M, Goldhaber SZ, Krumholz HM. Pulmonary embolism hospitalization, readmission, and mortality rates in US older adults, 1999–2015. JAMA. 2019;322:574–576. DOI: 10.1001/jama.2019.8594. - DOI - PMC - PubMed
    1. Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, Huisman M, King CS, Morris TA, Sood N, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016;149:315–352. DOI: 10.1016/j.chest.2015.11.026. - DOI - PubMed
    1. Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing G‐J, Harjola V‐P, Huisman MV, Humbert M, Jennings CS, Jiménez D, et al. 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020;41:543–603. DOI: 10.1093/eurheartj/ehz405. - DOI - PubMed
    1. Zondag W, Mos ICM, Creemers‐schild D, Hoogerbrugge ADM, Dekkers OM, Dolsma J, Eijsvogel M, Faber LM, Hofstee HMA, Hovens MMC, et al. Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study. J Thromb Haemost. 2011;9:1500–1507. DOI: 10.1111/j.1538-7836.2011.04388.x. - DOI - PubMed

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