Efficacy and Safety of Oral Anticoagulants for Atrial Fibrillation Patients With Chronic Kidney Disease:A Systematic Review and Meta-Analysis

BACKGROUND: Data on different direct oral anticoagulants (DOACs) in atrial fibrillation (AF) patients with renal impairment are insufficient. We aimed to perform pairwise and network meta-analysis comparing oral anticoagulants (OACs) in AF patients with renal impairment, including advanced chronic kidney disease (CKD) with creatinine clearance <30 mL/min. METHODS: PubMed, Embase, Cochrane Database, and references of related articles were searched up to April 2021. We included randomized trials and non-randomized studies using propensity-score or multivariable-model adjustments that compared clinical outcomes among OACs. Hazard ratios (HRs) for stroke or thromboembolism, major bleeding, and all-cause death were pooled using random-effects model. RESULTS: From 19 studies, 124,628 patients were included. In patients with AF and CKD, DOACs presented significantly lower risks of stroke or thromboembolism [HR(pooled) = 0.78, 95% confidence interval (CI) = 0.73–0.85, I(2) = 16.6%] and major bleeding [HR(pooled) = 0.76 (0.64–0.89), I(2) = 85.7%] when compared with warfarin, regardless of the severity of renal impairment. Results were consistent in advanced CKD patients for stroke or thromboembolism [HR(pooled) = 0.60 (0.43–0.85), I(2) = 0.0%] and major bleeding [HR(pooled) = 0.74 (0.59–0.93), I(2) = 30.4%]. In the network meta-analysis, edoxaban and apixaban presented the highest rank probability to reduce the risk of stroke or thromboembolism (edoxaban, P-score = 94.5%) and major bleeding (apixaban, P-score = 95.8%), respectively. Apixaban remained the safest OAC with the highest rank probability for major bleeding (P-score = 96.9%) in patients with advanced CKD. CONCLUSION: DOACs, particularly apixaban and edoxaban, presented superior efficacy and safety than warfarin in AF patients with CKD. Apixaban was associated with the lowest risk of major bleeding among OACs for patients with advanced CKD. SYSTEMATIC REVIEW REGISTRATION: [PROSPERO], identifier [CRD42021241718]

Type and Severity of Migraine Determines Risk of Atrial Fibrillation in Women

OBJECTIVE: To evaluate sex differences in the risk of atrial fibrillation (AF) according to the type and severity of migraine. METHODS: We analyzed the nationwide health screening recipients in 2009 without previous AF diagnosis from the Korean National Health Insurance Service data. The diagnosis, type, and severity of migraine were determined using claims data. Newly developed AF was identified during a 10-year follow-up. Sex-difference in the effect of migraine on AF was evaluated. RESULTS: A total of 4,020,488 subjects were enrolled from January 1, to December 31, 2009 and followed-up through December 31, 2018; 4,986 subjects had migraine with aura (age 50.6 ± 14.0 years, men 29.3%); and 105,029 had migraine without aura (age 51.6 ± 14.3 years, men 30.9%). Risk of AF in a mild degree of migraine was similar to that in the control group, regardless of sex or the presence of aura. Severe migraine without aura modestly but significantly increased the risk of AF in both men and women compared to controls, with increase in AF risk being most prominent in women who had severe migraine with aura [incidence rate (IR) = 3.39, hazard ratio (HR)(adjust) = 1.48, 95% confidence intervals (CI) = 1.18–1.85]. No significant association according to aura was observed in men with severe migraines (p for interaction 0.011). CONCLUSION: Severe migraine with aura significantly increased the risk of incident AF in women, but not in men. Surveillance for incident AF and prompt lifestyle modification may be beneficial, particularly for young women suffering from severe migraine with aura

Associations between obesity parameters and the risk of incident atrial fibrillation and ischaemic stroke in the different age groups

OBJECTIVE: Obesity and aging are important predisposing factors to atrial fibrillation (AF) and ischaemic stroke (IS). However, limited data comprehensively evaluated the relationships between obesity measurements and AF and IS in different ages. METHODS: A total of 9,432,332 adults from the Korean National Health Insurance Service Database were included. The study population was categorized into the six age subgroups by an increase every decade from the twenties. We evaluated AF and IS risk according to body mass index (BMI) and waist circumference (WC) in the different age groups. RESULTS: During a mean follow-up of 8.2 ± 1.0 years, BMI-AF presented a J-shaped association across ages. The highest hazard ratio (HR) of the BMI ≥ 30 kg/m(2) group was observed in subjects aged 30–39 years [HR 1.80, 95% CI 1.63–1.98, p 60 years. Among the BMI ≥ 30 kg/m(2) groups, subjects aged 20–29 years presented the highest risk of IS [HR 3.00, 95% CI (2.34–3.84), p < 0.001]. Overall, WC-AF and WC-IS showed positive linear correlations, but the WC-IS association was weak in subjects aged ≥ 40 years. CONCLUSION: The higher risks of AF and IS according to an increment of BMI and WC were most apparent among the young ages. The association between obesity measurements and IS was not significantly above the midlife. Weight management in the young and integrated risk factor management in the elderly are warranted

Congenital Atrophoderma of Pasini and Pierini

Idiopathic atrophoderma of Pasini and Pierini is a form of dermal atrophy of unknown etiology, usually affecting women during their adolescence and young adulthood. A 2-yr-old girl was presented with erythematous atrophic lesion on the right shoulder, which appeared from birth. The histologic findings were consistent with atrophoderma. This patient, to the best of our knowledge, is the first case of atrophoderma with an onset since birth

Comparison of Behçet's Disease and Recurrent Aphthous Ulcer According to Characteristics of Gastrointestinal Symptoms

Behçet's disease (BD) is a multisystemic chronic inflammatory disease. It is characterized by recurrent oral and genital ulcers, uveitis, skin lesions and other manifestations, including neurologic, vascular, joint, and gastrointestinal ulcers of variable severity. Recurrent aphthous ulcer (RAU) represents a very common, but poorly understood, mucosal disorder. If a patient of RAU without any other typical symptoms of BD has gastrointestinal symptoms, it is difficult to distinguish this RAU from true BD with gastrointestinal involvement. Because pathognomonic clinical features and tools are absent, the differential diagnosis of these two diseases relies on the characteristic clinical features and the judgement of an experienced physician. Sixty-five out of a total 960 RAU patients and forty-four of 556 BD patients with gastrointestinal symptoms between January 1996 and December 2003 participated in this study. All were evaluated with esophagogastroduodenoscopy and colonoscopy. Clinical, endoscopic and histopathologic findings were analyzed and ELISA tests were conducted to detect serum levels of ASCA and pANCA. No significant difference was found between the two groups. Differential diagnosis between RAU with gastrointestinal symptoms and BD with gastrointestinal involvement requires further prospective, large-scale study