Comparison of outcomes of patients with symptomatic peripheral artery disease with and without atrial fibrillation (the West Birmingham Atrial Fibrillation Project)

doi:10.1016/j.amjcard.2004.02.047

The American Journal of Cardiology

Volume 93, Issue 11, 1 June 2004, Pages 1422-1425

https://doi.org/10.1016/j.amjcard.2004.02.047 Get rights and content

Abstract

In a multiethnic cohort of 388 patients admitted with symptomatic peripheral artery disease, atrial fibrillation was associated with emergency admission and increased mortality. Despite a greater prevalence of hypertension and diabetes in Afro-Caribbeans and diabetes in Indo-Asians, no significant differences were found in atrial fibrillation prevalence or mortality among different ethnic groups. Patients with symptomatic peripheral artery disease and atrial fibrillation should be regarded as “high risk” and managed with optimal medical therapy, including appropriate thromboprophylaxis and close follow-up.

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Acknowledgements

We acknowledge the support of the Dowager Countess Eleanor Peel Trust and the Sandwell & West Birmingham Hospitals NHS Trust Research and Development Program.

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Cited by (58)

The Impact of Atrial Fibrillation on Outcomes of Peripheral Arterial Disease: Analysis of Routinely Collected Primary Care Data
2022, American Journal of Medicine
The combination of peripheral arterial disease and atrial fibrillation is linked with high risk of mortality and stroke. This study aims to investigate the impact of atrial fibrillation on patients with diagnosed peripheral arterial disease.
This is a retrospective study using The Health Improvement Network database, which contains prospectively collected data from participating primary care practices. Patients with a new diagnosis of peripheral arterial disease between January 8, 1995 and January 5, 2017 were identified in the database alongside relevant demographic information, clinical history, and medications. Every patient in the dataset with peripheral arterial disease and baseline atrial fibrillation (case) was matched to a patient without atrial fibrillation (control) with similar characteristics using propensity score matching. Cox-regression analysis was performed and hazard ratios (HR) calculated for the outcomes of death, stroke, ischemic heart disease, heart failure, and major amputation.
Prevalence of atrial fibrillation in this cohort was 10.2%. All patients with peripheral arterial disease and atrial fibrillation (n = 5685) were matched with 5685 patients without atrial fibrillation but otherwise similar characteristics. After multivariate analysis, atrial fibrillation was independently associated with mortality (HR 1.18; 95% confidence interval [CI], 1.12-1.26; P < .01), cerebrovascular events (HR 1.35; 95% CI, 1.17-1.57; P < .01), and heart failure (HR 1.87; 95% CI, 1.62-2.15; P < .01), but not with ischemic heart disease or limb loss.
In peripheral arterial disease patients, atrial fibrillation is a risk factor for mortality, stroke, and heart failure. This emphasizes the need for proactive surveillance and holistic management of these patients.
Atrial Fibrillation and Surgical Patients with Peripheral Arterial Disease
2020, Annals of Vascular Surgery
Citation Excerpt :
The patients with AF had a 2.24-fold increase in mortality, but the multivariate analysis of risk factors showed that this difference is due only to age. Managing patients with AF and PAD is a major challenge because these are frail patients at admission in-hospital, older, and consequently with a lesser survival rate.2,3,15,16 It is striking that the risk of amputation of the ischemic limb that motived the admission in-hospital was significantly increased in patients with AF.
Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice and its prevalence rate significantly increases with age. The prognostic implication of AF in surgical patients with peripheral arterial disease (PAD) has not been analyzed. The aims of this study were to analyze the prevalence of AF among patients operated on with symptomatic PAD, and to determine whether these patients are at a higher risk of death or amputation.
We designed a retrospective cohort study, from January 2013 to December 2017, in which we analyzed the medical records of all consecutive patients with symptomatic PAD admitted to our hospital and underwent a vascular procedure. We compared the outcomes of patients with and without AF. All statistically significant demographic variables that underwent a univariate analysis were inserted in the stepwise multivariate model along with AF. A survival analysis was performed to evaluate the factors associated with mortality through a Cox regression model. P-value of 0.05 was considered statistically significant.
Four hundred three patients were admitted in-hospital with symptomatic PAD and they underwent a vascular intervention. The mean follow-up was 2 years. Seventy-six patients (18.8%) had AF. These patients were older (78 ± 9.1 years) than the 327 patients without AF (68 ± 12.37 years) (P < 0.0001), and more likely to undergo emergency surgery (18.42% vs. 7.34%, P = 0.0029). Age and emergency admission were dependent associates of AF. The patients with AF were frequently men (69.7%) with previous hypertension (96% %). The presence of AF was associated with higher rate of all-cause mortality (55.26%, P < 0.0001, hazard ratio 2.24, confidence interval 1.55–3.25), but the multivariate analysis adjusted for risk factors showed that the mortality was only associated with age because these patients were older and with many comorbidities. The majority of this population with AF showed some tissue lesion when they were admitted in-hospital (Rutherford V–VI, AF 80.2%, P = 0.0004), and this fact justified that a 22.36% underwent a major amputation affecting the ischemic lower limb in admission (P = 0.018). During the follow-up the free amputation rate was similar between groups (60.5% AF vs. 78.3% non-AF).
This study showed the high prevalence of AF in patients with symptomatic PAD that required surgical admission in-hospital. The presence of AF was related with a greater and serious risk of mortality, but this was independently associated to age, because patients with AF were older and frailer. Clearly, this group of patients had a high risk of amputation when they arrived to the hospital and they needed emergency surgery.
Comparison of In-Hospital Outcomes in Patients Having Limb-Revascularization With Versus Without Atrial Fibrillation
2019, American Journal of Cardiology
The impact of atrial fibrillation (AF) on clinical outcomes among patients with peripheral artery disease (PAD) who undergo limb revascularization procedures is not well understood. We aim to compare in-hospital outcomes for patients with and without AF who underwent limb revascularization. We identified patients with PAD aged ≥18 years that underwent limb revascularization using endovascular or surgical approaches in the National Inpatient Sample between 2002 and 2014. Multivariate logistic regression analysis was performed to examine in-hospital outcomes. A total of 2,283,568 patients underwent limb revascularization during the study duration and 294,469 (12.9%) had AF. Patients with AF were older (mean age 76.1 ± 10.0 years), more likely to be women and white, compared with non-AF group. Among patients who had surgical revascularization, AF was associated with a higher rates of in-hospital mortality (6.4% vs 2.5%, adjusted odds ratio [aOR]: 1.09 [95% confidence interval {CI}: 1.05 to 1.12]) and major amputation (5.2% vs 3.8%, aOR: 1.05 [95% CI: 1.02 to 1.08]), compared with non-AF group. Among patients who had endovascular intervention (EVI), AF was associated with a higher rates of in-hospital mortality (3.8% vs 1.6%, aOR: 1.29 [95% CI: 1.24 to 1.33]) and major amputation (5.2% vs 3.9%, aOR: 1.07 [95% CI: 1.04 to 1.10]), compared with non-AF group. Within study period, EVI utilization increased in patients with and without AF (P_trend <0.001); whereas, surgical revascularization utilization decreased in patients with and without AF (P_trend <0.001). In conclusion, among patients with PAD who undergo limb revascularization, AF appears to be associated with poor in-hospital outcomes.
The CHA<inf>2</inf>DS<inf>2</inf>-VASc score: Not as simple as it seems
2018, International Journal of Cardiology
The CHA₂DS₂-VASc score has been widely adopted as a risk stratification tool for strokes in patients with atrial fibrillation and to help in deciding when anticoagulation therapy for stroke prophylaxis may be beneficial. The score as a whole has been well validated and has been included in the current major practice guidelines. An advantage of the CHA₂DS₂-VASc score is its ease of use, allowing clinicians to quickly estimate risk based on a short set of criteria. However, the benefit of simplicity may also be a weakness. Studies on individual components of the score suggest that only a subset of patients deemed to be at risk based on the current definition are actually at risk for stroke.
Thus, users of the score should be aware of the nuances based on available evidence and avoid over-generalization. Accurate assessment of stroke risk has important clinical implications as it influences decision-making on initiation of anticoagulation.
Atrial fibrillation is a risk marker for worse in-hospital and long-term outcome in patients with peripheral artery disease
2015, International Journal of Cardiology
Citation Excerpt :
Whether AF has a similar impact on outcome of patients with PAD as PAD has on patients with AF is less well known. One study on 388 patients with PAD who were admitted to a Birmingham hospital between 1998 and 2000 showed a 2.5-fold increased risk of in-hospital death if patients also had AF [8]. Recent registry data showed that patients with PAD had a high and similar incidence of stroke and myocardial infarction and the highest incidence of bleeding when compared to patients with coronary artery disease and cerebrovascular disease [14].
To investigate the relevance of atrial fibrillation or flutter (AF) for outcome of patients who are hospitalized for peripheral artery disease (PAD) and/or critical limb ischemia (CLI).
We compared baseline data, co-morbidities, procedural data as well as in-hospital and long-term outcome of 41,882 patients who were hospitalized with PAD or CLI between 2009 and 2011 according to whether they did or did not have atrial fibrillation/flutter. Follow-up was available until December 2012. Of these, 5622 patients (13.4%) had AF. AF patients were significantly older (78 ± 9 vs. 70 ± 11 years) and had significantly more comorbidities, such as diabetes (40.8 vs. 31.1%), chronic kidney disease (40.1 vs. 19.0%), coronary artery disease (38.0 vs. 23.0%) and chronic heart failure (26.9 vs. 7.2%, each p < 0.001). They had more advanced PAD as shown by higher Rutherford classes. In-hospital complications including acute renal failure, myocardial infarction, stroke sepsis and death occurred significantly more often (each p < 0.001). Duration of hospital stay was significantly longer and costs were markedly higher in patients with AF (each p < 0.001). Using multivariate Cox regression analyses regarding long-term outcomes, AF was an independent predictor for death (HRR 1.46; 95% CI 1.39–1.52, p < 0.001), ischemic stroke (HRR 1.63; 95% CI 1.44–1.85) and amputation (HRR 1.14; 95% CI 1.07–1.21).
Presence of AF in patients admitted for PAD and CLI is associated with worse in-hospital and long-term outcome than in patients without AF. This effect was independent of numerous other comorbidities and stage of vascular disease.
Heart rate significantly influences the relationship between atrial fibrillation and ankle-brachial index
2015, Journal of Cardiology
Citation Excerpt :
Atrial fibrillation (AF) has been shown to be a major risk factor of vascular disease [1–3] and vascular disease similarly has been found to increase the risk of AF [1,4].
Both atrial fibrillation (AF) and vascular disease share several risk factors and the two diseases often coexist. The patients with AF were reported to have a decreased ankle-brachial index (ABI). However, ABI was also reported to have an inverse relationship with heart rate (HR). Because AF patients often have a transiently or persistently rapid HR, this study aimed to assess whether AF was significantly associated with decreased ABI and whether HR could significantly influence the relationship between AF and ABI.
We included 166 AF and 1336 non-AF patients from subjects undergoing echocardiographic examinations. ABI was measured using an ABI-form device.
Compared to non-AF patients, AF patients had a decreased ABI (p < 0.001). In a multivariate model, including covariates of age, sex, blood pressures, etc., the presence of AF was significantly associated with low ABI (β = −0.069, p = 0.026). However, further adjustment for HR made this association disappear (p = 0.971).
This study demonstrated that the presence of AF was associated with decreased ABI, but this association became insignificant after further adjustment for HR, which suggested HR could significantly influence the relationship between AF and ABI.

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Comparison of outcomes of patients with symptomatic peripheral artery disease with and without atrial fibrillation (the West Birmingham Atrial Fibrillation Project)

Abstract

Section snippets

Acknowledgements

Atherosclerosis

Ethnicity and arrhythmias

Cardiac Electrophysiol Rev

Management of peripheral arterial disease (PAD)

Eur J Vasc Endovasc Surg

Ethnic differences in blood pressure and the prevalence of hypertension in England

J Hum Hypertens

Heart attack, stroke, diabetes and hypertension in West Indians, Asians and whites in Birmingham, England

BMJ