Epidemiology of atrial fibrillation and risk of stroke in France. A study on french health insurance databases and Dijon stroke registry

La surveillance de la fibrillation atriale (FA) et de l’accident vasculaire cérébral (AVC) associé n’a pas encore été mise en place en France, or le poids en santé publique de la FA ne cesse de croître. En l’absence de registre populationnel de la FA, le système national des données de santé (SNDS) et le registre des accidents vasculaires cérébraux (AVC) de Dijon constituent deux sources utiles pour le suivi de cette pathologie et de sa complication principal, l’AVC. L’objectif de la thèse était d’explorer les indicateurs clés estimant le poids de la FA en France et des AVC associés à celle-ci. Dans une première partie, à partir d’un algorithme utilisant les données du SNDS, nous avons estimé le taux annuel de patients nouvellement traités par anticoagulants oraux (ACO) pour une FA et donc à haut risque d’AVC au sein de la population Française. Les modifications de la prise en charge ont engendré une augmentation importante de ce taux avec des variations suivant l’âge et le sexe. Dans une deuxième partie, nous avons restreint la population précédente aux patients initiant un traitement anticoagulant oral direct (AOD), classe d’anticoagulant désormais les plus utilisés dans la prévention du risque d’AVC chez les personnes atteintes de FA. Nous avons ensuite suivi ces patients sur deux ans afin d’étudier le risque d’AVC en compétition avec la mortalité. Entre autres, la non-adhérence au traitement anticoagulant, concernant près de 40% des patients deux ans après l’initiation de l’AOD, augmentait de près de 40% le risque d’AVC ou de mortalité. Un antécédent d’AVC, de syndrome coronaire aigu ou de diabète était associé à un risque élevé d’AVC et de décès, ces conditions nécessitant une vigilance particulière. Dans une troisième partie, nous nous sommes intéressés aux AVC associés à une FA dans le registre des AVC de Dijon. La prévalence de la FA parmi les AVC a augmenté sur la période 2006-2017, représentant plus de 30% des AVC ischémiques et 25% des hémorragies intracérébrales pour les périodes les plus récentes. Si la proportion de FA connue avant l’AVC ischémique et traitée par un ACO a augmenté, une part importante des AVC ischémiques avait une FA connue avant l’AVC mais non traitée par ACO en prévention du risque d’AVC. Par ailleurs, une part importante des AVC ischémiques présentait une FA nouvellement diagnostiquée au moment de l’AVC, posant la question du dépistage de la FA en population générale. Concernant les hémorragies intracérébrales, la part potentiellement liée aux traitements ACO est importante. Dans la mesure où ce nombre d’AVC hémorragiques est amené à croitre du fait d’une utilisation plus importante des traitements ACO en prévention de l’AVC ischémique, la prise en charge et le traitement de ces patients nécessitent d’être améliorés et la recherche accélérée. Enfin, dans une dernière partie, nous avons mis en regard la proportion d’AVC traités par ACO pour une FA dans le SNDS et le registre, et discuté de la complémentarité des deux bases de données. Si le SNDS peut s’avérer utile pour une surveillance globale et l’étude des tendances, le registre demeure un outil de référence permettant la pleine compréhension et avec précision de l’épidémiologie des AVC associés à la FA. L’ensemble de ces travaux seront poursuivis au sein du programme de surveillance des maladies cardiovasculaires et de l’AVC à Santé Publique France afin d’améliorer la surveillance de la FA et des AVC associés en France.The surveillance of atrial fibrillation (AF) and related stroke has not been implemented in France despite the increased burden of AF for public health systems. In the absence of population-based AF registry, the Système National des données de Santé (SNDS) and the Dijon Stroke Registry are two useful tools to study AF and its main complication, stroke. The purpose of the doctoral research was to explore key indicators for the estimation of AF and AF-related strokes burden in France. In the first section, we estimated in the French population annual rates of patients newly treated with oral anticoagulant (OAC) for an AF, patients at high risk of stroke. These estimations were derived from an algorithm using the SNDS databases. The change in AF management entailed an important increase in those rates, with age-and sex-differences. In the second section, we analyzed the incidence of stroke in patients who initiated a direct OAC (DOAC), the most prescribed OAC nowadays for the prevention of strokes and systemic embolisms in AF patients. Competitive models including death were used. Non-adherence to DOAC treatment was found in 40% of AF patients after 2-years of follow-up and was associated with a 40% increase in the stroke and death risk. A history of stroke, acute coronary syndrome or diabetes was associated with a higher risk of stroke and death. AF patients with these comorbidities therefore need a more accurate follow-up. In a third section, we interested in AF-related strokes recorded in the Dijon Stroke Registry. The prevalence of AF in stroke patients substantially increased over the study period 2006-2017, and reached 30% of ischemic strokes (IS) and 25% of spontaneous intracerebral haemorrhages (ICH) for the most recent period. If the proportion of AF patients treated with OAC prior-to IS has increased, an important proportion of IS patients had a known AF but were not anticoagulated. Furthermore, the proportion of IS with newly-diagnosed AF at time of stroke was high and raise the issue of AF screening in general population. Regarding ICH, the prevalence of premorbid OAC use was high and is expected to increase due to an increased use of OAC in AF patients. The management and treatment of ICH patients treated with OAC need further advancements as the case-fatality of these cases remains high. Finally, we compared the SNDS and the Dijon Stroke Registry on one indicator: the proportion of stroke cases treated with OAC for an AF. Although the SNDS is an interesting databases for global surveillance and time-trends analyses, the Dijon Stroke Registry remains a reference for a complete understanding of AF-related stroke epidemiology. We will continue this work in the Programme de surveillance des maladies cardiovasculaires et de l’AVC at Santé Publique France

Determinants of Case Fatality After Hospitalization for Stroke in France 2010 to 2015

International audienceBackground and Purpose —The aims of this study were to (1) describe early and late case fatality rates after stroke in France, (2) evaluate whether their determinants differed, and (3) analyze time trends between 2010 and 2015.Methods —Data were extracted from the Système National des données de santé database. Patients hospitalized for stroke each year from 2010 to 2015, aged ≥18 years, and affiliated to the general insurance scheme were selected. Cox regressions were used to separately analyze determinants of 30-day and 31- to 365-day case fatality rates for each stroke type (ischemic, intracerebral hemorrhage, and subarachnoid hemorrhage).Results —In 2015, of the 73 124 persons hospitalized for stroke, 26.8% died in the following year, with the majority of deaths occurring within the first 30 days (56.9%). Nonadmission to a stroke unit, older age, and having comorbidities were all associated with a poorer 30-day and 31- to 365-day prognosis. Female sex was associated with a lower 31- to 365-day case fatality rate for all patients with stroke. Living in an area with a high deprivation index was associated with both higher 30-day and 31- to 365-day case fatality rates for all stroke types. Between 2010 and 2015, significant decreases in both 30-day and 31- to 365-day case fatality rates for ischemic patients were observed.Conclusions —Case fatality rates after stroke remained high in 2015 in France, despite major improvements in stroke care and organization. Improvement in stroke awareness and preparedness, particularly in the most deprived areas, together with better follow-up after the acute phase are urgently needed

Patients Hospitalized for Ischemic Stroke and Intracerebral Hemorrhage in France: Time Trends (2008–2019), In-Hospital Outcomes, Age and Sex Differences

Background: Rates of patients hospitalized for stroke increased among people aged under 65 years in France, as has been found in other countries. Methods: To analyze time trends in the rates of patients hospitalized for ischemic stroke (IS) and intracerebral hemorrhage (ICH) in France between 2008 and 2019 and determine related short-term outcomes mainly, we selected all patients hospitalized for stroke using the French national hospital database. Results: The average annual percentage change in the rates of patients hospitalized for IS increased significantly in men and women aged 50–64 years (+2.0%) and in men aged 18–34 years (+1.5%) and 35–44 years (+2.2%). A decrease in the average annual percentage change was observed for IS among people aged over 75 years and among those over 50 years for ICH. After adjustment on confounding factors, women were less likely to die in hospital. Case fatality rates decreased overtime in all age groups for both sexes, with a more pronounced decrease for IS than ICH. Conclusions: The increasing trend of IS among adults under 65 years is ongoing, highlighting the urgent need for stroke prevention programs in that age. For the first time, we recorded a decrease in the rates of patients hospitalized for ICH among the population over 50 years

Underuse of lifestyle recommendations in hypertension management in France: The Esteban study

Abstract Lifestyle recommendations are first‐line elements in the management of arterial hypertension. This cross‐sectional study aimed to analyze the level to which lifestyle recommendations are used in hypertension management in France, using data from the Esteban study, which was implemented by Santé Publique France, France's public health agency, from 2014 to 2016 on a representative sample of the French population. The study sample comprised 440 adult Esteban participants who were aware they had hypertension and were aged 18–74 years old. The main outcomes were the proportion of participants who received lifestyle recommendations in their hypertension management plan, and the proportion of recommendations according to the three following dimensions: physical activity, weight loss, and changes in diet. Over half (57.0%) of the 440 participants declared they did not receive lifestyle recommendations as part of their hypertension management plan in the year preceding the study. Of these, 39.0% did not receive pharmacological treatment either. Physical activity was recommended to 31.8% of sedentary participants and weight loss to 26.8% of participants with overweight or obesity. One‐fifth of the study sample (20.1%) received dietary recommendations. Of these, 69% and 10.7% were advised to limit their salt and alcohol intake, respectively. Lifestyle interventions are too rarely recommended in hypertension management plans in France. Adherence to lifestyle recommendations needs in‐depth discussion not only at the time of diagnosis but also throughout follow‐up

Fourteen-Year Temporal Trends in Patients Hospitalized for Mitral Regurgitation: The Increasing Burden of Mitral Valve Prolapse in Men

Mitral regurgitation (MR) is the second most common valvular heart disease in Europe. The aging of the population and the increase in post-infarction survival could increase the prevalence of MR. To estimate the burden of patients hospitalized for MR in France in 2019 and temporal trends by etiology and sex from 2006 to 2020, we selected all patients hospitalized for MR using the national hospital database. In 2019, 49.2% of such patients had mitral valve prolapse (MVP), 17.1% had ischemic MR, 9.9% had rheumatic MR and 4.4% had MR with cardiomyopathy. The mean age of MVP patients was 67.8 years, and 34% were women. Among 89% of MVP inpatients who had received mitral valve repair or replacement, 55% received surgical repair, 13% received percutaneous repair and 25% received replacement. The all-cause mortality of one year after a mitral procedure of MVP was 5.4%. Among ischemic MR inpatients, 29% have had a mitral valve replacement, 16% a surgical repair and 19% a percutaneous repair. Between 2006 and 2019, the age-standardized rates of patients hospitalized for MVP have increased by 60%, especially in men (+80%) with 5.3/100,000 Person-Years (PY). The age-standardized rates of patients hospitalized for ischemic MR have increased by 25% with 1.8/100,000 PY; that of rheumatic MR has decreased by 36%. The study found that the burden of MVP in hospitals has increased substantially, especially among men. These results emphasize the need to monitor these temporal trends and anticipate care needs in the coming years

National Trends in Patients Hospitalized for Stroke and Stroke Mortality in France, 2008 to 2014

International audienceBackground and Purpose—Stroke is the leading cause of death in women and the third leading cause in men in France. In young adults (ie, <65 years old), an increase in the incidence of ischemic stroke was observed at a local scale between 1985 and 2011. After the implementation of the 2010 to 2014 National Stroke Action Plan, this study investigates national trends in patients hospitalized by stroke subtypes, in-hospital mortality, and stroke mortality between 2008 and 2014.Methods—Hospitalization data were extracted from the French national hospital discharge databases and mortality data from the French national medical causes of death database. Time trends were tested using a Poisson regression model.Results—From 2008 to 2014, the age-standardized rates of patients hospitalized for ischemic stroke increased by 14.3% in patients <65 years old and decreased by 1.5% in those aged ≥65 years. The rate of patients hospitalized for hemorrhagic stroke was stable (+2.0%), irrespective of age and sex. The proportion of patients hospitalized in stroke units substantially increased. In-hospital mortality decreased by 17.1% in patients with ischemic stroke. From 2008 to 2013, stroke mortality decreased, except for women between 45 and 64 years old and for people aged ≥85 years.Conclusions—An increase in cardiovascular risk factors and improved stroke management may explain the increase in the rates of patients hospitalized for ischemic stroke. The decrease observed for in-hospital stroke mortality may be because of recent improvements in acute-phase management

L’accident vasculaire cérébral en France : patients hospitalisés pour AVC en 2014 et évolutions 2008-2014

International audiencentroduction – In France, stroke is the first cause of death in women, and the third in men. The age-standardized rates of patients hospitalized for stroke increased in patients younger than 65 years between 2002 and 2008. After the implementation of the “National Stroke Action Plan” (2010-2014), this study analyzed trends in the rates of patients hospitalized for stroke and of patients hospitalized in stroke units since 2008.Methods – Data came from the French national hospital discharge databases (PMSI-MCO, 2008-2014). For each patient, the first annual hospitalization for stroke was selected. Crude hospitalized patients and in-hospital mortality rates were calculated by stroke subtypes, age group and sex, and then were age-standardized. Time trends were tested using a Poisson regression model.Results – In 2014, 110,438 patients were hospitalized for stroke. The proportion of patients hospitalized in a stroke unit was 51.5% for ischemic stroke (IS) and 33.2% for intracerebral hemorrhage. From 2008 to 2014, the age-standardized rate of patients hospitalized for IS increased by 14.3% in patients aged less than 65 years, and decreased by 2.1% in those aged 65 and over. In contrast, for hemorrhagic stroke, the rate barely changed (+2.0%). During the same period, in-hospital mortality decreased by 12.5% in IS patients. Important regional disparities were observed in the rates of patients hospitalized for stroke.Conclusion – The encouraging increase in the proportion of patients hospitalized in stroke units and the decrease in in-hospital mortality should not hide three major observations: the stabilization of the rates of hospitalized patients for stroke (overall) in a context of population aging, the increase in patients hospitalized rates for IS in young adults, and important regional disparities in patients hospitalized rates.Introduction – En France, l’accident vasculaire cérébral (AVC) est la première cause de mortalité chez les femmes et la troisième chez les hommes. Les taux de patients hospitalisés pour AVC ont augmenté chez les moins de 65 ans entre 2002 et 2008. Après la mise en œuvre du plan d’actions national AVC (2010-2014), cette étude analyse les évolutions des taux de patients hospitalisés et de la prise en charge en unités neuro-vasculaires (UNV) depuis 2008.Méthodes – Les données proviennent de la base nationale des hospitalisations du Programme de médicali-sation des systèmes d’information en médecine, chirurgie, obstétrique (PMSI-MCO, 2008-2014). Pour chaque patient, le premier séjour de l’année pour AVC a été sélectionné. Les taux bruts de patients hospitalisés et de létalité hospitalière par type d’AVC, par classe d’âge et par sexe ont été calculés puis standardisés sur l’âge. Les évolutions temporelles ont été analysées par régression de Poisson.Résultats – En 2014, 110 438 patients ont été hospitalisés pour AVC. La proportion de patients hospitalisés en UNV atteignait 51,5% pour les AVC ischémiques et 33,2% pour les hémorragies intracérébrales. De 2008 à 2014, le taux standardisé de patients hospitalisés pour AVC ischémique a augmenté de 14,3% chez les moins de 65 ans et baissé de 2,1% chez les 65 ans et plus. En revanche, pour les AVC hémorragiques, le taux a peu évolué (+2,0%). La létalité hospitalière des AVC ischémiques a diminué de 12,5% sur cette même période. D’importantes disparités régionales des taux de patients hospitalisés ont été observées.Conclusion – L’augmentation encourageante de la proportion de patients hospitalisés en UNV et la baisse de la létalité hospitalière ne doivent pas faire oublier trois constats préoccupants : la stabilité du taux global de patients hospitalisés pour AVC dans un contexte de vieillissement de la population, l’augmentation des taux d’adultes jeunes hospitalisés pour AVC ischémique et l’existence de fortes disparités régionales des taux de patients hospitalisés pour AVC

Prevalence of hypertensive disorders during pregnancy in France (2010‐2018): The nationwide CONCEPTION study

Hypertensive disorders of pregnancy (HDP) are one of the leading causes of maternal and fetal morbidity and mortality. We aimed to estimate the prevalence of each HDP in France and to study their associations. All pregnant women who delivered in France between 2010 and 2018 were included in a cohort and followed during their pregnancy and 6 weeks of postpartum. Each HDP occurring during the follow‐up was identified. Prevalence of each HDP and cumulative incidence by gestational age were estimated. Incidence rate ratio (IRR) and 95% confidence interval (CI) for preeclampsia among women with preexisting or gestational hypertension (GH) were estimated using Poisson regression and adjusted for age were estimated. Between 2010 and 2018, 6 302 810 deliveries were included. HDP complicated 7.4% of pregnancies. Preeclampsia and GH complicated 2.0% and 4.2% of pregnancies, respectively. Most of preeclampsia cases occurred without a prior HDP. HELLP syndrome represented 10.4% of preeclampsia cases. Compared to nulliparous pregnancies without HDP prior preeclampsia, the age‐adjusted IRR of preeclampsia was 6.2 [95% CI: 6.1‐6.4] in nulliparous pregnancies with preexisting hypertension and 2.9 [95% CI: 2.8‐3.0] in nulliparous pregnancies with GH. In France, HDP occurred in 7.4% of all pregnancies. Women with preexisting chronic hypertension are at high risk to present preeclampsia during pregnancy. Preeclampsia complicated 2.0% of pregnancies in France. Tailoring management of women according to the HDP is a major challenge to avoid complications related to these disorders