Mental health conditions in patients with atrial fibrillation – Impact on treatment quality and prognosis

Background: Patients with mental health conditions (MHCs) face barriers in health care and often have undertreated comorbidities. The purpose of this dissertation was to evaluate the treatment and prognosis of patients with atrial fibrillation (AF) suffering from MHCs. Methods: The nationwide registry-based Finnish Anticoagulation in Atrial Fibrillation cohort covers all patients diagnosed with AF in Finland during 2004–2018 at any level of care. The use of oral anticoagulant (OAC) therapy and rhythm control therapies, as well as ischemic stroke, bleeding and mortality outcomes, were assessed in patients with and without depression, anxiety disorder, bipolar disorder, schizophrenia or any MHC. Results: In total, 239,222 patients diagnosed with incident AF in Finland between 2007 and 2018 were identified in this study, with a 19.9% prevalence of any MHC. Patients with any MHC were less likely to initiate OAC therapy than patients without MHCs (64.9% vs. 73.3%, p Mielenterveyden häiriöt eteisvärinäpotilailla – yhteys hoidon laatuun ja ennusteeseen Tausta: Mielenterveyden häiriöitä sairastavien potilaiden somaattiset sairaudet ovat usein alihoidettuja. Tässä väitöskirjatyössä selvitetään mielenterveyden häiriöiden yhteyttä hoidon laatuun ja ennusteeseen eteisvärinäpotilailla. Menetelmät: Finnish Anticoagulation in Atrial Fibrillation -kohortti kattaa kaikki Suomen eteisvärinäpotilaat vuosilta 2004–2018. Tutkimuksessa tarkasteltiin antikoagulaatiohoidon (AK-hoidon) toteutumista, rytmikontrollihoitojen käyttöä sekä päätetapahtumien ilmaantuvuutta mielenterveyden häiriöitä sairastavilla potilailla. Tulokset: Tässä tutkimuksessa vuosien 2007 ja 2018 välillä uusi eteisvärinä todettiin yhteensä 239,222 potilaalla, joista 19,9 % sairasti jotain mielenterveyden häiriötä. Mielenterveyden häiriöitä sairastavat potilaat aloittivat muita harvemmin AK-hoidon (64,9 % vs. 73,3 %, p<0,001). Suoria antikoagulantteja käytettäessä mielenterveyden häiriötä sairastavat potilaat keskeyttivät hoidon 16 % muita useammin, mutta hoitoon sitoutuminen ei muutoin eronnut potilaiden välillä. Rytmihäiriön estolääkkeitä, rytminsiirtoa, sekä katetriablaatiota käytettiin harvemmin mielenterveyden häiriöitä sairastavilla potilailla kuin muilla. Mielenterveydenhäiriöitä sairastavilla oli suurempi vakioimaton aivoinfarktin, verenvuotojen, sekä kuoleman ilmaantuvuus. Mikään tutkituista mielenterveyden häiriöistä ei ollut itsenäisesti yhteydessä korkeampaan aivoinfarktin riskiin, mutta masennus, skitsofrenia sekä kaikkien mielenterveyden häiriöiden yhdistelmämuuttuja olivat yhteydessä korkeampaan kuolleisuuteen. Lisäksi masennus, ahdistuneisuushäiriö ja mikä tahansa mielenterveyden häiriö olivat yhteydessä korkeampaan verenvuotoriskiin. Vähäisempi AK-hoidon käyttö selitti osin mielenterveyden häiriöitä sairastavien potilaiden heikompaa ennustetta. Päätelmät: Aivoinfarktien ehkäisyyn AK-hoidolla tulisi kiinnittää enemmän huomiota mielenterveyden häiriöitä sairastavien eteisvärinäpotilaiden kohdalla. Mielenterveyden häiriöitä sairastavilla potilailla on huonompi ennuste kuin muilla eteisvärinäpotilailla, ja mielenterveyden häiriöt ovat itsenäisesti yhteydessä suurentuneeseen verenvuodon ja kuoleman riskiin. Mielenterveyden häiriöt eivät kuitenkaan itsenäisesti lisää iskeemisen aivohalvauksen riskiä eteisvärinäpotilailla

The impact of mental health conditions on oral anticoagulation therapy and outcomes in patients with atrial fibrillation: A systematic review and meta-analysis

One third of patients with atrial fibrillation (AF) are estimated to suffer from mental health conditions (MHCs). We conducted a systematic review and meta-analysis to investigate the impact of MHCs on the prevalence and quality of oral anticoagulation (OAC) therapy and outcomes in patients with AF. Medline database was searched for studies published before March 1st 2021 evaluating AF patients with comorbid MHCs reporting on the prevalence of OAC therapy, time in therapeutic range (TTR) in warfarin-receiving patients, adherence to OAC therapy or adverse outcomes (ischemic stroke, hemorrhage or mortality). Studies reporting on outcome events were included in the meta-analysis. The literature search yielded 17 studies including 977,535 patients that fulfilled the inclusion criteria of this review. AF patients with MHCs had a lower prevalence of OAC use and poorer TTR compared with patients without MHCs. Evidence on OAC quality in patients receiving direct oral anticoagulants (DOACs) was minimal and inconclusive. A decrease in depression-associated deficit in OAC prevalence was observed after the introduction of DOACs. Pooled analysis of five studies reporting on outcomes showed that MHCs were an independent risk factor for both stroke (RR 1.25, 95%CI 1.08-1.45, I2 0%) and major bleeding (RR 1.17, 95%CI 1.08-1.27, I2 27%). Data on mortality were lacking and therefore not included in the meta-analysis. Evidence on the impact of specific MHCs on the outcomes were inadequate. In conclusion, MHCs are independent risk factors for stroke and major bleeding in patients with AF. Future studies are needed to confirm the findings of this meta-analysis, to evaluate the prognostic impact of different MHCs and to clarify whether the introduction of DOACs might have improved the outcomes of these patients

Income and outcomes of patients with incident atrial fibrillation

Background Socioeconomic disparities can be associated with adverse outcomes in patients with cardiovascular diseases. The impact of personal income on the outcomes of patients with atrial fibrillation (AF) is unclear. Methods Nationwide observational registry-based study on patients with incident AF in Finland during 2007-2018. Results 203 154 patients (mean age 73.0 +/- 13.5; females 49.0%) were diagnosed with incident AF during the study period. Overall, 16 272 (8.0%) patients experienced first-ever ischaemic stroke and 63 420 (31.2%) died (mean follow-up 4.3 +/- 3.3 years). After adjusting for confounding factors, low personal income was associated with increased risk of overall mortality in all age strata and the incidence of first--ever stroke in patients aged = 75 years. The magnitude of this effect was greatest in patients aged Conclusions Personal annual income has a significant impact on the incidence of first-ever ischaemic stroke and overall mortality among patients with incident AF, particularly among patients of working age. Low-income indicate the need for intervention strategies to improve outcomes of AF.Peer reviewe

Mental Health Conditions and Nonpersistence of Direct Oral Anticoagulant Use in Patients With Incident Atrial Fibrillation : A Nationwide Cohort Study

BACKGROUND: Mental health conditions (MHCs) are associated with poor outcomes in patients with atrial fibrillation. However, persistence of oral anticoagulation therapy in patients with atrial fibrillation and MHCs is unknown. We aimed to evaluate the effect of MHCs on the persistence of direct oral anticoagulant (DOAC) use in patients with atrial fibrillation based on a nationwide cohort. METHODS AND RESULTS: The nationwide registry-based FinACAF (Finnish Anticoagulation in Atrial Fibrillation) cohort included 67 503 patients with incident atrial fibrillation and indication for permanent oral anticoagulation (CHA(2)DS(2)-VASc score >1 in men and >2 in women) starting DOAC therapy between 2011 and 2018. MHCs of interest were depression, bipolar disorder, anxiety disorder, schizophrenia, and composite of any MHC. The main outcome was nonpersistence of DOAC use, defined as the first 120-day period without DOAC purchases after drug initiation. The mean age of the patients was 75.3 +/- 8.9 years, 53.6% were women, and the prevalence of any MHC was 17.8%. Persistence after 1 year from DOAC initiation was 79.3% in patients without MHCs and 77.2% in patients with any MHC, and after 2 years were 64.4% and 60.6%, respectively (P CONCLUSIONS: MHCs are associated with nonpersistence of DOAC use.Peer reviewe

Socioeconomic factors and bleeding events in patients with incident atrial fibrillation : A Finnish nationwide cohort study

Background: Low socioeconomic status has been associated with higher risk of ischemic stroke and death in patients with atrial fibrillation (AF). However, whether socioeconomic status affects risk of bleeding events is unknown. We assessed the hypothesis that low income and educational attainment are associated with higher risk of bleeding in patients with AF.Methods: The registry-based FinACAF study covers all patients with AF in Finland during 2007-2018. Patients were divided into income quartiles and three categories based on their educational attainment. Outcomes of interest were the first-ever gastrointestinal (GI), intracranial (IC) and any bleeding.Results: We identified 205 019 patients (50.9 % female; mean age 72.3 (SD 13.4) years) with incident AF without prior bleeding. Mean follow-up time was 4.0 (SD 3.2) years, during which 25 013 (12.2 %) patients experienced first-ever any bleeding (incidence rate 3.07 (95 % CI 3.03-3.10) /100 patient-years). Low income was inde-pendently associated with hazard of any bleeding as well as GI and IC bleeding (adjusted hazard ratios (HRs) comparing lowest vs highest income quartile: 1.13 (1.08-1.17), 1.32 (1.23-1.41) and 1.15 (1.06-1.24), respectively). Income-related bleeding disparities were larger among younger patients under 65 years and among men. Education-related bleeding disparities were smaller than income related-disparities (adjusted HRs comparing lowest vs highest educational category: any bleeding 1.06 (1.02-1.11), GI bleeding 1.16 (1.08-1.24), IC bleeding 1.10 (0.93-1.09))Conclusions: Patients with AF and low income are at higher risk of bleeding, especially GI bleeding.Peer reviewe

Mental health conditions and adherence to direct oral anticoagulants in patients with incident atrial fibrillation : A nationwide cohort study

Objective: Medication adherence is essential for effective stroke prevention in patients with atrial fibrillation (AF). We aimed to assess whether adherence to direct oral anticoagulants (DOACs) in AF patients is affected by the presence of mental health conditions (MHCs). Methods: The nationwide FinACAF cohort covered 74,222 AF patients from all levels of care receiving DOACs during 2011-2018 in Finland. Medication possession ratio (MPR) was used to quantify adherence. Patients with MPR >= 0.90 were defined adherent. MHCs of interest were depression, bipolar disorder, anxiety disorder and schizophrenia. Results: The patients' (mean age 75.4 +/- 9.5 years, 50.8% female) mean MPR was 0.84 (SD 0.22), and 59.5% had MPR >= 0.90. Compared to patients without MHC, the adjusted ORs (95% CI) for adherent DOAC use emerged slightly lower in patients with depression (0.92 (0.84-0.99)) and bipolar disorder (0.77 (0.61-0.97)) and unsignificant in patients with anxiety disorder (1.08 (0.96-1.21)) and schizophrenia (1.13 (0.90-1.43)). However, when only persistent DOAC therapy was analyzed, no MHC was associated with poor adherence, and instead anxiety disorder was associated with adherent DOAC use (1.18 (1.04-1.34)). Conclusion: Adherence to DOACs in AF patients in Finland was relatively high, and no meaningful differences between patients with and without MHCs were observed.Peer reviewe

Mental health conditions and bleeding events in patients with incident atrial fibrillation : A Finnish nationwide cohort study

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The effect of mental health conditions on the use of oral anticoagulation therapy in patients with atrial fibrillation : the FinACAF study

Aims Little is known about the effects of mental health conditions (MHCs) on the utilization of oral anticoagulation (OAC) therapy in atrial fibrillation (AF) patients. We aimed to assess whether MHCs affect initiation of OAC therapy among AF patients with special focus on non-vitamin K antagonist oral anticoagulants (NOACs). Methods and results The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) registry included all 239 222 patients diagnosed with incident AF during 2007-18 in Finland identified from national registries covering primary to tertiary care and drug purchases. Patients with previous depression, bipolar disorder, anxiety disorder, or schizophrenia diagnosis or a fulfilled psychiatric medication prescription within the year preceding the AF diagnosis were classified to have any MHC. The main outcome was OAC initiation, defined as first fulfilled OAC prescription after AF diagnosis. The patients' mean age was 72.7 years and 49.8% were female. The prevalence of any MHC was 19.9%. A lower proportion of patients with any MHC compared with those without MHCs were initiated on OAC therapy (64.9% vs. 73.3%, P < 0.001). Any MHC was associated with lower incidence of OAC initiation [adjusted subdistribution hazard ratio (aSHR) 0.867; 95% confidence interval (CI) 0.856-0.880], as were depression (aSHR 0.868; 95% CI 0.856-0.880), bipolar disorder (aSHR 0.838; 95% CI 0.824-0.852), anxiety disorder (aSHR 0.840; 95% CI 0.827-0.854), and schizophrenia (aSHR 0.838; 95% CI 0.824-0.851), during the entire follow-up. Any MHC remained associated with impaired incidence of OAC initiation also in the NOAC era during 2015-18 (aSHR 0.821; 95% CI 0.805-0.837). Conclusion MHCs are common among AF patients, and they are associated with a lower rate of OAC initiation even during the NOAC era.Peer reviewe

Rural-urban differences in the initiation of oral anticoagulant therapy in patients with incident atrial fibrillation : A Finnish nationwide cohort study

Publisher Copyright: Copyright: © 2022 Teppo et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Aims Little is known about rural-urban differences in the treatment and outcomes in patients with atrial fibrillation (AF). We aimed to assess whether the initiation of oral anticoagulant (OAC) therapy in patients with AF differs between those with rural and urban residence. Methods The registry-based FinACAF cohort covers all patients with AF from all levels of care in Finland. Patients were divided into rural and urban categories and into urbanization degree tertiles based on their municipality of residence at the time of AF diagnosis. The outcome was the first redeemed OAC prescription. Results We identified 222 419 patients (50.1% female; mean age 72.8 (SD 13.2) years) with incident AF during 2007–2018. Urban residence was associated with a lower rate of OAC therapy initiation (adjusted subdistribution hazard ratio (SHR) (95% CI) 0.96 (0.95–0.97)). Correspondingly, an inverse graded dose-response relationship was observed between higher urbanization degree tertile and OAC initiation rate (highest tertile compared to lowest: adjusted SHR (95% CI) 0.94 (0.93–0.95)). The adoption of direct oral anticoagulants for stroke prevention was faster among patients with urban residence. Conclusion This nationwide cohort study documented that urban residence is associated with a slightly lower rate of OAC therapy initiation in patients with incident AF, but faster adoption of direct oral anticoagulant use.Peer reviewe

Association of income and educational levels with adherence to direct oral anticoagulant therapy in patients with incident atrial fibrillation : A Finnish nationwide cohort study

Low socioeconomic status has been associated with poor outcomes in patients with atrial fibrillation (AF). However, little is known about socioeconomic disparities in adherence to stroke prevention with direct oral anticoagulants (DOACs). We assessed the hypothesis that AF patients with higher income or educational levels have better adherence to DOACs in terms of treatment implementation and persistence. The used nationwide registry-based FinACAF cohort covers all patients with incident AF starting DOACs in Finland during 2011-2018. The implementation analyses included 74 222 (mean age 72.7 +/- 10.5 years, 50.8% female) patients, and persistence analyses included 67 503 (mean age 75.3 +/- 8.9 years, 53.6% female) patients with indication for permanent anticoagulation (CHA(2)DS(2)-VASc score >1 in men and >2 in women). Patients were divided into income quartiles and into three categories based on their educational attainment. Therapy implementation was measured using the medication possession ratio (MPR), and patients with MPR >= 0.90 were defined adherent. Persistence was measured as the incidence of therapy discontinuation, defined as the first 135-day period without DOAC purchases after drug initiation. Patients with higher income or education were consistently more likely adherent to DOACs in the implementation phase (comparing the highest income or educational category to the lowest adjusted odds ratios 1.18 (1.12-1.25) and 1.21(1.15-1.27), respectively). No association with income or educational levels was observed on the incidence of therapy discontinuation. In conclusion, we observed that income and educational levels both have independent positive association on the implementation of DOAC therapy but no association on therapy persistence in patients with AF.Peer reviewe