Temporal changes in incidence, treatment strategies and 1-year re-admission rates in patients with atrial fibrillation/flutter under 65 years of age: A Danish nationwide study
Graphical abstract
Introduction
Worldwide, atrial fibrillation (AF) is the most common arrhythmia and associated with substantial morbidity such as ischemic stroke, heart failure, and mortality [[1], [2], [3]]. The lifetime risk estimation of AF has been raised to approximately 1 in 3 white people [1], and the prevalence is on the rise as the population becomes older [[4], [5], [6]]. In the younger population (<65 years of age), AF occurs less frequently and as a result, knowledge on incidence and treatment strategies from unselected cohorts is not well-established.
In the last decades, AF screening has gained increasingly more attention and with the introduction of direct oral anticoagulants (DOACs), and advancement within the techniques of catheter ablation one could hypothesise that the diagnosis of AF and use of therapies have been increasing over calendar time [3,7].
Aging is a well-recognized independent risk factor for the development of AF and the elderly population of AF patients is well investigated [8]. However, the younger patients are less well described [9]. AF most commonly presents itself alongside other comorbidities, but in a younger cohort, the burden of comorbidities is lower and AF may display as the only clinical condition or be a marker of severe underlying cardiac disease [1]. Thus, the symptom burden and heterogeneous character of AF may present as a clinical dilemma when deciding on antiarrhythmic medication, catheter ablation, or a watchful waiting strategy. For this reason, nationwide data on temporal trends in treatment and outcomes of younger patients with AF are of importance to further extend the epidemiological knowledge on this patient subgroup. We set out to investigate temporal changes in incidence, treatment strategies, and AF readmission rates among individuals younger than 65 years when diagnosed with AF.
Section snippets
Data sources
National healthcare registries have been linked on an individual level using the Danish Central Person Registry CPR-number (CPR), which is a unique personal identifier. We used the following registries: 1) The Danish National Patient Registry [10], which contains data on every in-hospital visit since 1977 plus out-patient and emergency room visits since 1994, using diagnosis codes based on International Classification of Diseases (ICD-10 and ICD-8), while using the Nordic Medico-Statistical
Study population and incidence rates of AF
We included 60,917 patients (4947 patients with atrial fibrillation, 573 with atrial flutter, and 55,397 with unspecified atrial fibrillation or flutter, Supplementary table 2) and the patients were distributed as following; 8150 (13.4%) in 2000–2002, 11,898 (19.5%) in 2003–2006, 13,560 (22.3%) in 2007–2010, 14,167 (23.3%) patients in 2011–2014 and 13,142 (21.6%) in 2015–2018 (Fig. 1). The patients in all five calendar periods had a similar age and burden of comorbidities at baseline, also no
Discussion
This nationwide study examined temporal changes from 2000 to 2018 in AF incidence rates, treatment strategies, and 1-year AF readmissions in first time AF younger than 65 years. We had three main findings. First, the incidence of AF increased over calendar time from 78.7 per 100,000 person years in 2000–2002 to 93.6 per 100,000 person years in 2015–2018. Second, our study showed an increase in the use of catheter ablation from 1.2% in 2000–2002 to 7.6% in 2015–2018 and electrical cardioversion
Conclusions
In a nationwide cohort from 2000 to 2018 examining patients under 65 years of age, we found an increment in the incidence of AF over calendar time. The use of catheter ablation, electrical cardioversion, and OAC treatment increased throughout the study period. No difference was identified in the use of rate- and rhythm medication treatment during the study period. We found no difference in the one-year AF readmission rates throughout the study period.
CRediT authorship contribution statement
Lukas Schak: Conceptualization, Methodology, Software, Formal analysis, Writing – original draft, Visualization. Jeppe Kofoed Petersen: Writing – review & editing, Supervision. Naja Emborg Vinding: Writing – review & editing. Charlotte Andersson: Writing – review & editing. Peter E. Weeke: Writing – review & editing. Søren Lund Kristensen: Writing – review & editing. Anna Gundlund: Writing – review & editing. Morten Schou: Writing – review & editing. Lars Køber: Writing – review & editing,
Declaration of Competing Interest
Lukas Schak, MB; None.
Jeppe Kofoed Petersen, MB; None.
Naja Emborg Vinding, MD; None.
Charlotte Andersson MD, PhD; None.
Peter E. Weeke MD, PhD; None.
Søren Lund Kristensen MD, PhD; Astra Zeneca speaker fee outside submitted work.
Anna Gundlund MD, PhD; None.
Morten Schou MD, PhD; Speaker fee outside submitted work from Astra Zeneca, Novo Nordisk, Boehringer and Novartis.
Lars Køber MD, DMSc; Speaker fee outside submitted work from Astra Zeneca, Bayer, Boehringer, Novartis and Novo Nordisk.
Emil
References (34)
- et al.
50 year trends in atrial fibrillation prevalence, incidence, risk factors, and mortality in the Framingham heart study: a cohort study
Lancet.
(Jul 11 2015) - et al.
2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation
Heart Rhythm.
(Oct 2017) - et al.
Temporal trends in medication use and outcomes in atrial fibrillation
Can. J. Cardiol.
(Oct 2013) - et al.
Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association
Circulation
(Mar 5 2019) - et al.
AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines and the Heart Rhythm Society
Circulation
(2014) - et al.
2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European heart rhythm association (EHRA) of the ESC
Eur. Heart J.
(Feb 1 2021) - et al.
Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and risk factors in atrial fibrillation (ATRIA) study
Jama.
(May 9 2001) - et al.
Epidemiology of atrial fibrillation: European perspective
Clin Epidemiol.
(2014) - et al.
Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications
Arch. Intern. Med.
(Mar 13 1995) - et al.
Increased use of oral anticoagulants in patients with atrial fibrillation: temporal trends from 2005 to 2015 in Denmark
Eur. Heart J.
(Mar 21 2017)