| 1. |
- Aronsson, Mattias, et al.
(författare)
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Cost-effectiveness of mass screening for untreated atrial fibrillation using intermittent ECG recording
- 2015
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Ingår i: Europace. - : Oxford University Press (OUP): Policy B - Oxford Open Option B - CC-BY. - 1099-5129 .- 1532-2092. ; 17:7, s. 1023-1029
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Tidskriftsartikel (refereegranskat)abstract
- Aims The aim of this study was to estimate the cost-effectiveness of 2 weeks of intermittent screening for asymptomatic atrial fibrillation (AF) in 75/76-year-old individuals. Methods and results The cost-effectiveness analysis of screening in 75-year-old individuals was based on a lifelong decision analytic Markov model. In this model, 1000 hypothetical individuals, who matched the population of the STROKESTOP study, were simulated. The population was analysed for different parameters such as prevalence, AF status, treatment with oral anticoagulation, stroke risk, utility, and costs. In the base-case scenario, screening of 1000 individuals resulted in 263 fewer patient-years with undetected AF. This implies eight fewer strokes, 11 more life-years, and 12 more quality-adjusted life years (QALYs) per 1000 screened individuals. The screening implies an incremental cost of (sic)50 012, resulting in a cost of (sic)4313 per gained QALY and (sic)6583 per avoided stroke. Conclusions With the use of a decision analytic simulation model, it has been shown that screening for asymptomatic AF in 75/76-year-old individuals is cost-effective.
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| 2. |
- Dimberg, Ivar, et al.
(författare)
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Computerised assistance for warfarin dosage - Effects on treatment quality
- 2012
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Ingår i: European Journal of Internal Medicine. - : Elsevier BV. - 1879-0828 .- 0953-6205. ; 23:8, s. 742-744
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Tidskriftsartikel (refereegranskat)abstract
- Background: Well-managed warfarin treatment with a high time in therapeutic range (TTR) corresponds to fewer bleedings or thromboembolic complications. Many small centres manage their warfarin dosing manually, with little or no knowledge of their treatment quality as measured by TTR. AuriculA is a Swedish National web-based anticoagulation dosing system. Our hypothesis was that the web based dosing system, compared to manual dosing, would improve the TTR. Methods: Retrospective cohort study of medical records from patients with atrial fibrillation on warfarin treatment from two centres, with previously manual warfarin dosing regimens. Data for calculation of TTR was extracted manually from medical records from the time when using manual dosing and compared with the computerised regimen. Results: In centre 1, the mean TTR was significantly increased after the introduction of AuriculA, from 64.3% (95% CI 58.8-69.8) to 71.3% (95% CI 67.7-74.8), p=0.03. In centre 2, a high TTR of 73.6% (95% CI 71.3-75.9) was maintained after the implementation, 74.0% (95% CI 71.6-76.3). INR tests were prescribed significantly more frequent after the introduction of AuriculA in both centres; 20% more often at centre 1 and 21% at centre 2. Conclusion: Computerised dosing assistance within the Swedish national quality registry AuriculA improves or maintains a high treatment quality with warfarin as measured by TTR. (C) 2012 European Federation of Internal Medicine. Published by Elsevier B. V. All rights reserved.
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| 3. |
- Easton, J. Donald, et al.
(författare)
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Apixaban compared with warfarin in patients with atrial fibrillation and previous stroke or transient ischaemic attack : a subgroup analysis of the ARISTOTLE trial
- 2012
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Ingår i: Lancet Neurology. - 1474-4422 .- 1474-4465. ; 11:6, s. 503-511
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundIn the ARISTOTLE trial, the rate of stroke or systemic embolism was reduced by apixaban compared with warfarin in patients with atrial fibrillation (AF). Patients with AF and previous stroke or transient ischaemic attack (TIA) have a high risk of stroke. We therefore aimed to assess the efficacy and safety of apixaban compared with warfarin in prespecified subgroups of patients with and without previous stroke or TIA.MethodsBetween Dec 19,2006, and April 2,2010, patients were enrolled in the ARISTOTLE trial at 1034 clinical sites in 39 countries. 18 201 patients with AF or atrial flutter were randomly assigned to receive apixaban 5 mg twice daily or warfarin (target international normalised ratio 2.0-3.0). The median duration of follow-up was 1.8 years (IQR 1.4-2.3). The primary efficacy outcome was stroke or systemic embolism, analysed by intention to treat. The primary safety outcome was major bleeding in the on-treatment population. All participants, investigators, and sponsors were masked to treatment assignments. In this subgroup analysis, we estimated event rates and used Cox models to compare outcomes in patients with and without previous stroke or TIA. The ARISTOTLE trial is registered with ClinicalTrials.gov, number NTC00412984.FindingsOf the trial population, 3436 (19%) had a previous stroke or TIA. In the subgroup of patients with previous stroke or TIA, the rate of stroke or systemic embolism was 2.46 per 100 patient-years of follow-up in the apixaban group and 3.24 in the warfarin group (hazard ratio [HR] 0.76, 95% CI 0.56 to 1.03); in the subgroup of patients without previous stroke or TLA, the rate of stroke or systemic embolism was 1.01 per 100 patient-years of follow-up with apixaban and 1.23 with warfarin (HR 0.82, 95% CI 0.65 to 1.03; p for interaction=0.71). The absolute reduction in the rate of stroke and systemic embolism with apixaban versus warfarin was 0.77 per 100 patient-years of follow-up (95% CI -0.08 to 1.63) in patients with and 0.22 (-0.03 to 0.47) in those without previous stroke or TIA. The difference in major bleeding with apixaban compared with warfarin was 1.07 per 100 patient-years (95% CI 0.09-2.04) in patients with and 0.93 (0.54-1.32) in those without previous stroke or TIA.InterpretationThe effects of apixaban versus warfarin were consistent in patients with AF with and without previous stroke or TIA. Owing to the higher risk of these outcomes in patients with previous stroke or TIA, the absolute benefits of apixaban might be greater in this population.FundingBristol-Myers Squibb and Pfizer.
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| 4. |
- Eklind-Cervenka, Maria, et al.
(författare)
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Association of Candesartan vs Losartan With All-Cause Mortality in Patients With Heart Failure
- 2011
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Ingår i: JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. - : Ama American Medical Association. - 0098-7484 .- 1538-3598. ; 305:2, s. 175-182
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Tidskriftsartikel (refereegranskat)abstract
- Context Angiotensin II receptor blockers (ARBs) reduce combined mortality and hospitalization in patients with heart failure (HF) with reduced left ventricular ejection fraction. Different agents have different affinity for the AT(1) receptor and may have different clinical effects, but have not been tested against each other in HF. Objective To assess the association of candesartan vs losartan with all-cause mortality in patients with HF. Design, Setting, and Patients An HF registry (the Swedish Heart Failure Registry) of 30 254 unique patients registered from 62 hospitals and 60 outpatient clinics between 2000 and 2009. A total of 5139 patients (mean [SD] age, 74 [11] years; 39% women) were treated with candesartan (n=2639) or losartan (n=2500). Survival as of December 14, 2009, by ARB agent was analyzed by Kaplan-Meier method and predictors of survival determined by univariate and multivariate proportional hazard regression models, with and without adjustment for propensity scores and interactions. Stratified analyses and quantification of residual confounding were also performed. Main Outcome Measures All-cause mortality at 1 and 5 years. Results One-year survival was 90% (95% confidence interval [CI], 89%-91%) for patients receiving candesartan and 83% (95% CI, 81%-84%) for patients receiving losartan, and 5-year survival was 61% (95% CI, 54%-68%) and 44% (95% CI, 41%-48%), respectively (log-rank Pandlt;.001). In multivariate analysis with adjustment for propensity scores, the hazard ratio for mortality for losartan compared with candesartan was 1.43 (95% CI, 1.23-1.65; Pandlt;.001). The results persisted in stratified analyses. Conclusion In this registry of patients with HF, the use of candesartan compared with losartan was associated with a lower mortality risk.
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| 5. |
- Engdahl, Johan, et al.
(författare)
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Uptake of atrial fibrillation screening aiming at stroke prevention: geo-mapping of target population and non-participation
- 2013
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Ingår i: BMC Public Health. - : Springer Science and Business Media LLC. - 1471-2458. ; 35, s. 163-164
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Tidskriftsartikel (refereegranskat)abstract
- Background: In a screening study for silent atrial fibrillation (AF), which is a frequent source of cardiac emboli with ischemic stroke, the proportion of non-participants was considerable and their clinical profile differed from the participants' profile. We intended to geo-map the target population and non-participation in an attempt to understand factors related to screening uptake and, thereby, obtain useful information needed to intervene for improved uptake. Method: In the municipality of Halmstad, Sweden, all residents born in 1934-1935 were invited to the screening study during April 2010 to February 2012. The total study group included 848 participants and 367 non-participants from 12 parishes. Geo-maps displaying participation, along with target-population-based geo-maps displaying proportion of immigrants and ischemic stroke incidence, were used. Results: Smoothed non-participation ratios (SmNPR) varied from 0.81 to 1.24 across different parishes (SmNRP = 1 corresponds to the expected participation based on the total study group). Among high risk individuals, the geographical variation was more pronounced (SmNPR range 0.75-1.51). Two parishes with higher share of immigrants and elevated population-based ischemic stroke incidence showed markedly lower participation, particularly among high-risk individuals. Conclusion: AF screening uptake varied evidently between parishes, particularly among high-risk individuals. Geo-mapping of target population and non-participation yielded useful information needed to intervene for improved screening uptake.
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| 6. |
- Freedman, Ben, et al.
(författare)
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Screening for Atrial Fibrillation A Report of the AF-SCREEN International Collaboration
- 2017
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Ingår i: Circulation. - : LIPPINCOTT WILLIAMS & WILKINS. - 0009-7322 .- 1524-4539. ; 135:19, s. 1851-
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Tidskriftsartikel (refereegranskat)abstract
- Approximately 10% of ischemic strokes are associated with atrial fibrillation (AF) first diagnosed at the time of stroke. Detecting asymptomatic AF would provide an opportunity to prevent these strokes by instituting appropriate anticoagulation. The AF-SCREEN international collaboration was formed in September 2015 to promote discussion and research about AF screening as a strategy to reduce stroke and death and to provide advocacy for implementation of country-specific AF screening programs. During 2016, 60 expert members of AF-SCREEN, including physicians, nurses, allied health professionals, health economists, and patient advocates, were invited to prepare sections of a draft document. In August 2016, 51 members met in Rome to discuss the draft document and consider the key points arising from it using a Delphi process. These key points emphasize that screen-detected AF found at a single timepoint or by intermittent ECG recordings over 2 weeks is not a benign condition and, with additional stroke factors, carries sufficient risk of stroke to justify consideration of anticoagulation. With regard to the methods of mass screening, handheld ECG devices have the advantage of providing a verifiable ECG trace that guidelines require for AF diagnosis and would therefore be preferred as screening tools. Certain patient groups, such as those with recent embolic stroke of uncertain source (ESUS), require more intensive monitoring for AF. Settings for screening include various venues in both the community and the clinic, but they must be linked to a pathway for appropriate diagnosis and management for screening to be effective. It is recognized that health resources vary widely between countries and health systems, so the setting for AF screening should be both country-and health system-specific. Based on current knowledge, this white paper provides a strong case for AF screening now while recognizing that large randomized outcomes studies would be helpful to strengthen the evidence base.
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| 7. |
- Friberg, Leif, et al.
(författare)
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High prevalence of atrial fibrillation among patients with ischemic stroke
- 2014
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Ingår i: Stroke. - 0039-2499 .- 1524-4628. ; 45:9, s. 2599-
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Tidskriftsartikel (refereegranskat)abstract
- Background and Purpose-Atrial fibrillation (AF) is a common cause of devastating but potentially preventable stroke. Estimates of the prevalence of AF among patients with stroke vary considerably because of difficulties in detection of intermittent, silent AF. Better recognition of AF in this patient group may help to identify and offer protection to individuals at risk. Our aim was to determine the nationwide prevalence of AF among patients with ischemic stroke, as well as their use of oral anticoagulation. Methods-Cross-sectional study of unselected patients in cross-linked nationwide Swedish health registers. All 94 083 patients with a diagnosis of ischemic stroke in the nationwide stroke register Riks-Stroke between 2005 and 2010 were studied. Information about previously diagnosed AF, and comorbidity, was obtained from the nationwide Patient Register and cross-referenced with the national Drug Register containing data on all dispensed pharmacological prescriptions in Sweden. Results-Combination of data from Riks-Stroke and from the Patient Register showed that 31 428 (33.4%) patients with ischemic stroke had previously known, or newly diagnosed, AF. Of those, only 16.2% had received warfarin in a pharmacy within 6 months before stroke onset. After hospital discharge, only 35.0% of the survivors received warfarin within the first 3 months after discharge. The likelihood for underlying AF was strongly correlated to the CHA(2)DS(2)-VASC score, which is a point based scheme for assessment of stroke risk in AF but which also predicts likelihood of AF. In this scheme points are given for age, previous stroke or transient ischemic attack, hypertension, heart failure, diabetes, vascular disease and female sex. Conclusions-Access to nationwide register data shows that AF is more common among patients with ischemic stroke than those previously reported. Few patients with stroke and AF had anticoagulant treatment before the event, and few got it after the event. CHA(2)DS(2)-VASc could be a useful monitoring tool to intensify efforts to diagnose AF among patients with cryptogenic stroke.
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| 8. |
- Friberg, Leif, et al.
(författare)
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Population screening of 75- and 76-year-old men and women for silent atrial fibrillation (STROKESTOP)
- 2013
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Ingår i: Europace. - : Oxford University Press (OUP): Policy B. - 1099-5129 .- 1532-2092. ; 15:1, s. 135-140
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Tidskriftsartikel (refereegranskat)abstract
- Atrial fibrillation (AF) is important because it is common and is a major cause of stroke unless treated with oral anticoagulant. The prevalence of AF increases with age as does the risk of stroke. At 75 years the risk from age alone is so high that current guidelines recommend anticoagulation even in the absence of other risk factors. Atrial fibrillation is often asymptomatic and only discovered by chance or when a stroke already has occurred. less thanbrgreater than less thanbrgreater thanWe have launched a major screening study for silent AF in which 25 000 Swedes aged 75 and 76 years are randomized to either participate in a screening programme using ambulant intermittent electrocardiogram (ECG) recording to detect silent AF, or act as a control group. Patients in whom AF is detected are offered cardiological examination and anticoagulant treatment according to current guidelines. The cohort and the controls will be followed prospectively for 5 years after the inclusion of the first participant. An interim analysis will be made after 3 years. less thanbrgreater than less thanbrgreater thanOur hypothesis is that screening for AF will reduce stroke incidence in the screened population, and that this screening will prove to be cost effective. Secondary endpoints are: any thromboembolic event, intracranial bleeding, other major bleeding, first ever diagnosis of dementia, death from any cause, and a composite of these endpoints.
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| 9. |
- Ghazal, Faris, et al.
(författare)
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Cost-effectiveness of screening for atrial fibrillation in a single primary care center at a 3-year follow-up
- 2022
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Ingår i: Scandinavian Cardiovascular Journal. - Abingdon, Oxfordshire, United Kingdom : Taylor & Francis. - 1401-7431 .- 1651-2006. ; 56:1, s. 35-41
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Tidskriftsartikel (refereegranskat)abstract
- ObjectivesThe aim of this study was to estimate the cost-effectiveness of intermittent electrocardiogram (ECG) screening for atrial fibrillation (AF) among 70-74-year old individuals in primary care. We also aimed to assess adherence to anticoagulants, severe bleeding, stroke and mortality among screening-detected AF cases at three-year follow-up.MethodsA post hoc analysis based on a cross-sectional screening study for AF among 70-74-year old patients, who were registered at a single primary care center, was followed for three years for mortality. Data about adherence to anticoagulants, incidence of stroke and severe bleeding among screening-detected AF cases, were collected from patients records. Markov model and Monte Carlo simulation were used to assess the cost-effectiveness of the screening program.ResultsThe mortality rate among screening-detected AF cases (n = 16) did not differ compared to the 274 individuals with no AF (hazard ratio 0.86, CI 0.12-6.44). Adherence to anticoagulants was 92%. There was no stroke or severe bleeding. The incremental cost-effectiveness ratio of screening versus no screening was EUR 2389/quality-adjusted life year (QALY) gained. The screening showed a 99% probability of being cost-effective compared to no screening at a willingness-to-pay threshold of EUR 20,000 per QALY.ConclusionScreening for AF among 70-74-year olds in primary care using intermittent ECG appears to be cost-effective at 3-year follow-up with high anticoagulants adherence and no increased mortality.
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| 10. |
- Höglund, Niklas, et al.
(författare)
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The predictive value of C-reactive protein on recurrence of atrial fibrillation after cardioversion with or without treatment with atorvastatin
- 2013
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Ingår i: International Journal of Cardiology. - : Elsevier. - 0167-5273 .- 1874-1754. ; 167:5, s. 2088-2091
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Tidskriftsartikel (refereegranskat)abstract
- Background: The aim of this study was to investigate whether high-sensitivity C-reactive protein (hsCRP) levels prior to cardioversion (CV) predict recurrence of atrial fibrillation (AF) in patients randomized to treatment with either atorvastatin or placebo 30 and 180 days after CV. Methods: This was a prespecified substudy of 128 patients with persistent AF randomized to treatment with atorvastatin 80 mg/day or placebo, initiated 14 days before CV, and continued 30 days after CV. HsCRP levels were measured at randomization, at the time of CV, and 2 days and 30 days after CV. Results: In univariate analysis of those who were in sinus rhythm 2 h after CV, hsCRP did not significantly (odds ratio [OR] 1.11, 95% confidence interval [CI] 0.99-1.25) predict recurrence of AF at 30 days. However, after adjusting for treatment with atorvastatin, hsCRP predicted the recurrence of AF (OR 1.14, 95% CI 1.01-1.27). In a multivariate logistic regression analysis with gender, age, body mass index (BMI), smoking, cholesterol, and treatment with atorvastatin as covariates, the association was still significant (OR 1.14, 95% CI 1.01-1.29). Six months after CV, hsCRP at randomization predicted recurrence of AF in both univariate analysis (OR 1.30, 95% CI 1.06-1.60) and in multivariate logistic regression analysis (OR 1.33, 95% CI 1.06-1.67). Conclusion: HsCRP was associated with AF recurrence one and six months after successful CV of persistent AF. However, the association at one month was significant only after adjusting for atorvastatin treatment.
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| 11. |
- Nielsen-Kudsk, Jens Erik, et al.
(författare)
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Left atrial appendage occlusion versus standard medical care in patients with atrial fibrillation and intracerebral haemorrhage : a propensity score-matched follow-up study
- 2017
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Ingår i: EuroIntervention. - : EUROPA EDITION. - 1774-024X .- 1969-6213. ; 13:3, s. 371-378
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Tidskriftsartikel (refereegranskat)abstract
- Aims: The aim of this study was to investigate the prognosis in patients with atrial fibrillation (AF) and intracerebral haemorrhage (ICH) having a left atrial appendage occlusion (LAAO) versus patients receiving standard medical therapy. Methods and results: A total of 151 patients from the Nordic countries with AF and previous ICH who underwent LAAO using the AMPLATZER Cardiac Plug or the AMPLATZER AMULET were compared to a propensity score-matched group of 151 patients receiving standard medical therapy. The two groups were matched so that their risks for stroke and bleeding were similar (CHA2DS2-VASc and HAS-BLED scores). The standard care patients were identified from the Danish Stroke Registry among 787 patients with AF and ICH. The primary endpoint was a composite of all-cause mortality, ischaemic stroke and major bleeding. Patients with AF and a prior ICH treated with LAAO had a lower risk of the composite outcome as compared to patients treated with standard medical care (events/1,000 years [95% confidence interval]: 53.3 [44.3-64.1] vs. 366.7 [298.2-450.9]; hazard ratio 0.16 [0.07-0.37]). Conclusions: LAAO is suggested to be of major clinical benefit in AF patients having sustained an ICH. These results have to be confirmed in a randomised clinical trial.
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| 12. |
- Stridh, Martin, et al.
(författare)
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Automatic Screening of Atrial Fibrillation in Thumb-ECG Recordings
- 2012
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Ingår i: 2012 Computing in Cardiology (Cinc), Vol 39. - 0276-6574. ; , s. 193-196
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Konferensbidrag (refereegranskat)abstract
- The present study proposes a novel sorting algorithm for identification of patients with atrial fibrillation in large one-lead ECG repositories. Repeated measurements at home with automatic transmission of data to a central database is presently tested in the search for atrial fibrillation for the long-term purpose to reduce the incidence of stroke. Such screening rapidly generates large databases of signals waiting to be sorted and prioritized. The one-lead ECGs were first preprocessed to remove baseline wander followed by beat detection and beat classification. A rhythm analysis stage was employed to perform RR interval analysis with negligible influence of ectopic beats and disturbances. RR interval information in combination with a waveform clustering procedure applied to the expected P wave intervals were used to sort the database into a low priority group containing mainly sinus rhythm, a high priority group containing all ECGs with irregular beat patterns, and a third group showing an unreliable RR series. The outcome of the algorithm was compared to an annotated database containing 2837 one-lead ECG recordings from 103 patients where each recording was visually inspected by a physician. The proposed method was able to divide the database into a low-priority group containing 93% (n=2357) of the sinus rhythm cases and a high priority group containing 98% (n=55) of the atrial fibrillation cases. In addition, 3.7% were found to have an unreliable RR series. In conclusion, automatic analysis of one-lead ECG databases can quickly guide the physician to find recordings with high probability to contain atrial fibrillation and can automatically indicate if a recording needs to be remade due to quality problems.
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| 13. |
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| 14. |
- Wieloch, Mattias, et al.
(författare)
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Anticoagulation control in Sweden : reports of time in therapeutic range, major bleeding, and thrombo-embolic complications from the national quality registry AuriculA
- 2011
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Ingår i: European Heart Journal. - London : Academic Press. - 0195-668X .- 1522-9645. ; 32:18, s. 2282-2289
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Tidskriftsartikel (refereegranskat)abstract
- Aims: In anticoagulation treatment with warfarin, the risk of thrombo-embolic events must be weighed against the risk of bleeding. Time in therapeutic range (TTR) is an important tool to assess the quality of anticoagulation treatment, and has been shown to correlate with less bleeding and thrombo-embolic complications. AuriculA, the Swedish national quality registry for atrial fibrillation and anticoagulation, is used for follow-up and dosage control of warfarin. This is the first report of TTR in AuriculA and, in a subgroup of two centres, bleeding and thrombo-embolic complications during 2008. Methods and results: Prothrombin complex (International normalized ratio) values from 18 391 patients in 67 different centres were analysed. The mean (SD) age was 70 (12) years. The main indications for warfarin treatment were: atrial fibrillation (64%), venous thromboembolism (19%), and heart valve dysfunction (13%). Time in therapeutic range for all patients was 76.2%. The mean weekly dose of warfarin decreased with age and TTR increased with age. In 4273 patients from two centres in AuriculA, the frequency of major bleedings and venous/arterial thrombo-embolism were 2.6 and 1.7% and for atrial fibrillation, 2.6 and 1.4%, per treatment year, respectively. A correlation between age and the risk of major bleeding (P< 0.001), but not thrombo-embolic complications (P= 0.147), was seen. Conclusion: Compared with prospective randomized trials of warfarin treatment, TTR in the AuriculA population was higher. Complications were low, probably due to the organization of anticoagulation treatment in Sweden. Use of the AuriculA dosing programme could have contributed to the results by keeping dosing regimens consistent over all centres.
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