Hypertrophic Cardiomyopathy in Patients with Atrial Fibrillation: Prevalence and Associated Stroke Risks in a Nationwide Cohort StudyFunding This study was supported by a research grant from the Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Education, Science and Technology (NRF-2017R1A2B3003303) and grants from the Korean Healthcare Technology R&D project funded by the Ministry of Health & Welfare (HI16C0058, HI15C1200).
14 October 2018
06 November 2018
02 January 2019 (online)
Background There have been no prior nationwide reports on the prevalence of hypertrophic cardiomyopathy (HCM) among patients suffering from atrial fibrillation (AF). It is also unclear how much stroke risk is attributable to HCM compared with other stroke risks in patients with AF. This study assessed the prevalence of HCM among non-valvular AF (NVAF) patients and to assess the magnitude of increase in stroke risk in NVAF patients with HCM, compared with those without HCM.
Patients and Methods From the Korean National Health Insurance Service database from January 1, 2005 to December 31, 2016, we analysed 979,784 patients with prevalent NVAF aged 18 years or older.
Results The overall HCM prevalence in NVAF patients was 1.1%. Although HCM in these patients is an absolute indication for oral anticoagulant (OAC) prescription, only 1,622 (15.3%) patients were receiving OAC at the time of AF diagnosis. Among OAC-naïve patients with NVAF, compared with those without HCM, those with HCM had the increased risk of ischaemic stroke/systemic embolism with clinical variable adjusted hazard ratio of 1.55 (95% confidential interval, 1.48–1.63; p < 0.001). Ischaemic stroke/systemic embolism rate of NVAF patients with HCM without any non-gender CHA2DS2-VASc stroke risk factors was 4.02 per 100 person-years, and approached to that of NVAF patients without HCM with CHA2DS2-VASc score of 3 (4.07 per 100 person-years).
Conclusion Among all NVAF patients, 1.1% of patient has HCM. The risk of stroke in NVAF with HCM without any CHA2DS2-VASc stroke risk factors was similar to that of those patients without HCM with CHA2DS2-VASc score of 3. Despite this, the actual use of OACs among NVAF patients with HCM was sub-optimal, relative to their high stroke risk.
H. Jung and P.S. Yang performed the statistical analysis and interpretation of data; P.S. Yang, B. Joung and G.Y. Lip conceived the idea of the project; P.S. Yang and E. Jang established the database; H. Jung, P.S. Yang and B. Joung. wrote the manuscript with input from all other authors; J.H. Sung, H.T. Yu, T.H. Kim, J.S. Uhm, J.Y. Kim, H.N. Pak and M.H. Lee contributed in revising the intellectual content; B. Joung and G.Y. Lip gave final approval of the version to be published. All authors discussed the results and contributed to the final manuscript.
* These three authors contributed equally to this work.
** Joint senior authors.
- 1 Lip G, Freedman B, De Caterina R, Potpara TS. Stroke prevention in atrial fibrillation: past, present and future. Comparing the guidelines and practical decision-making. Thromb Haemost 2017; 117 (07) 1230-1239
- 2 Kim TH, Yang PS, Uhm JS. , et al. CHA2DS2-VASc score (Congestive Heart Failure, Hypertension, Age ≥75 [Doubled], Diabetes Mellitus, Prior Stroke or Transient Ischemic Attack [Doubled], Vascular Disease, Age 65-74, Female) for stroke in Asian patients with atrial fibrillation: a Korean nationwide sample cohort study. Stroke 2017; 48 (06) 1524-1530
- 3 Kim TH, Yang PS, Kim D. , et al. CHA2DS2-VASc score for identifying truly low-risk atrial fibrillation for stroke: a Korean nationwide cohort study. Stroke 2017; 48 (11) 2984-2990
- 4 Maron BJ, Olivotto I, Bellone P. , et al. Clinical profile of stroke in 900 patients with hypertrophic cardiomyopathy. J Am Coll Cardiol 2002; 39 (02) 301-307
- 5 Olivotto I, Cecchi F, Casey SA, Dolara A, Traverse JH, Maron BJ. Impact of atrial fibrillation on the clinical course of hypertrophic cardiomyopathy. Circulation 2001; 104 (21) 2517-2524
- 6 Siontis KC, Geske JB, Ong K, Nishimura RA, Ommen SR, Gersh BJ. Atrial fibrillation in hypertrophic cardiomyopathy: prevalence, clinical correlations, and mortality in a large high-risk population. J Am Heart Assoc 2014; 3 (03) e001002
- 7 Lee SE, Park JK, Uhm JS. , et al. Impact of atrial fibrillation on the clinical course of apical hypertrophic cardiomyopathy. Heart 2017; 103 (19) 1496-1501
- 8 Maron BJ, Casey SA, Poliac LC, Gohman TE, Almquist AK, Aeppli DM. Clinical course of hypertrophic cardiomyopathy in a regional United States cohort. JAMA 1999; 281 (07) 650-655
- 9 Guttmann OP, Rahman MS, O'Mahony C, Anastasakis A, Elliott PM. Atrial fibrillation and thromboembolism in patients with hypertrophic cardiomyopathy: systematic review. Heart 2014; 100 (06) 465-472
- 10 Doi Y, Kitaoka H. Hypertrophic cardiomyopathy in the elderly: significance of atrial fibrillation. J Cardiol 2001; 37 (Suppl. 01) 133-138
- 11 Kirchhof P, Benussi S, Kotecha D. , et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016; 18 (11) 1609-1678
- 12 Gersh BJ, Maron BJ, Bonow RO. , et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Association for Thoracic Surgery; American Society of Echocardiography; American Society of Nuclear Cardiology; Heart Failure Society of America; Heart Rhythm Society; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124 (24) e783-e831
- 13 Elliott PM, Anastasakis A, Borger MA. , et al; Authors/Task Force members. 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy: the Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC). Eur Heart J 2014; 35 (39) 2733-2779
- 14 Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest 2010; 137 (02) 263-272
- 15 Jung H, Sung JH, Yang PS. , et al. Stroke risk stratification for atrial fibrillation patients with hypertrophic cardiomyopathy. J Am Coll Cardiol 2018; 72 (19) 2409-2411
- 16 Baek YS, Yang PS, Kim TH. , et al. Associations of abdominal obesity and new-onset atrial fibrillation in the general population. J Am Heart Assoc 2017; 6 (06) e004705
- 17 Lee SS, Ae Kong K, Kim D. , et al. Clinical implication of an impaired fasting glucose and prehypertension related to new onset atrial fibrillation in a healthy Asian population without underlying disease: a nationwide cohort study in Korea. Eur Heart J 2017; 38 (34) 2599-2607
- 18 Chao TF, Liu CJ, Tuan TC. , et al. Rate-control treatment and mortality in atrial fibrillation. Circulation 2015; 132 (17) 1604-1612
- 19 Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 2007; 146 (12) 857-867
- 20 Gersh BJ, Maron BJ, Bonow RO. , et al. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2011; 58 (25) 2703-2738
- 21 Guttmann OP, Rahman MS, O'Mahony C, Anastasakis A, Elliott PM. Atrial fibrillation and thromboembolism in patients with hypertrophic cardiomyopathy: systematic review. Heart 2014; 100 (06) 465-472
- 22 Masri A, Kanj M, Thamilarasan M. , et al. Outcomes in hypertrophic cardiomyopathy patients with and without atrial fibrillation: a survival meta-analysis. Cardiovasc Diagn Ther 2017; 7 (01) 36-44
- 23 Noseworthy PA, Yao X, Shah ND, Gersh BJ. Stroke and bleeding risks in NOAC- and warfarin-treated patients with hypertrophic cardiomyopathy and atrial fibrillation. J Am Coll Cardiol 2016; 67 (25) 3020-3021
- 24 Group JCSJW; JCS Joint Working Group. Guidelines for pharmacotherapy of atrial fibrillation (JCS 2013). Circ J 2014; 78 (08) 1997-2021
- 25 Guttmann OP, Pavlou M, O'Mahony C. , et al; Hypertrophic Cardiomyopathy Outcomes Investigators. Predictors of atrial fibrillation in hypertrophic cardiomyopathy. Heart 2017; 103 (09) 672-678
- 26 Rowin EJ, Hausvater A, Link MS. , et al. Clinical profile and consequences of atrial fibrillation in hypertrophic cardiomyopathy. Circulation 2017; 136 (25) 2420-2436
- 27 Lee H, Kim TH, Baek YS. , et al. The trends of atrial fibrillation-related hospital visit and cost, treatment pattern and mortality in Korea: 10-year nationwide sample cohort data. Korean Circ J 2017; 47 (01) 56-64
- 28 Lee HY, Yang PS, Kim TH. , et al. Atrial fibrillation and the risk of myocardial infarction: a nation-wide propensity-matched study. Sci Rep 2017; 7 (01) 12716
- 29 Song S, Yang PS, Kim TH. , et al. Relation of chronic obstructive pulmonary disease to cardiovascular disease in the general population. Am J Cardiol 2017; 120 (08) 1399-1404