Institute of Health Informatics, University College London, 222 Euston Road, London NW1 2DA, UK.
Institute of Cardiovascular Sciences, Medical School, University of Birmingham, Birmingham B15 2TT, UK.
Europace. 2019 Dec 1;21(12):1776-1784. doi: 10.1093/europace/euz220.
To evaluate population-based electronic health record (EHR) definitions of atrial fibrillation (AF) and valvular heart disease (VHD) subtypes, time trends in prevalence and prognosis.
A total of 76 019 individuals with AF were identified in England in 1998-2010 in the CALIBER resource, linking primary and secondary care EHR. An algorithm was created, implemented, and refined to identify 18 VHD subtypes using 406 diagnosis, procedure, and prescription codes. Cox models were used to investigate associations with a composite endpoint of incident stroke (ischaemic, haemorrhagic, and unspecified), systemic embolism (SSE), and all-cause mortality. Among individuals with AF, the prevalence of AF with concomitant VHD increased from 11.4% (527/4613) in 1998 to 17.6% (7014/39 868) in 2010 and also in individuals aged over 65 years. Those with mechanical valves, mitral stenosis (MS), or aortic stenosis had highest risk of clinical events compared to AF patients with no VHD, in relative [hazard ratio (95% confidence interval): 1.13 (1.02-1.24), 1.20 (1.05-1.36), and 1.27 (1.19-1.37), respectively] and absolute (excess risk: 2.04, 4.20, and 6.37 per 100 person-years, respectively) terms. Of the 95.2% of individuals with indication for warfarin (men and women with CHA2DS2-VASc ≥1 and ≥2, respectively), only 21.8% had a prescription 90 days prior to the study.
Prevalence of VHD among individuals with AF increased from 1998 to 2010. Atrial fibrillation associated with aortic stenosis, MS, or mechanical valves (compared to AF without VHD) was associated with an excess absolute risk of stroke, SSE, and mortality, but anticoagulation was underused in the pre-direct oral anticoagulant (DOAC) era, highlighting need for urgent clarity regarding DOACs in AF and concomitant VHD.
评估基于人群的电子健康记录（EHR）对心房颤动（AF）和瓣膜性心脏病（VHD）亚型的定义，以及患病率和预后的时间趋势。
在 1998 年至 2010 年期间，英格兰的 CALIBER 资源共确定了 76019 例 AF 患者，这些患者通过初级和二级保健 EHR 进行了链接。创建、实施和改进了一种算法，使用 406 个诊断、程序和处方代码来识别 18 种 VHD 亚型。Cox 模型用于研究与复合终点（包括卒中（缺血性、出血性和未明确）、系统性栓塞（SSE）和全因死亡率）的相关性。在患有 AF 的患者中，伴有 VHD 的 AF 患病率从 1998 年的 11.4%（527/4613）增加到 2010 年的 17.6%（7014/39868），且在 65 岁以上的患者中也增加了。与无 VHD 的 AF 患者相比，患有机械瓣膜、二尖瓣狭窄（MS）或主动脉瓣狭窄的患者发生临床事件的风险最高，相对风险比（95%置信区间）分别为 1.13（1.02-1.24）、1.20（1.05-1.36）和 1.27（1.19-1.37），绝对风险（超额风险）分别为 2.04、4.20 和 6.37/100 人年。在 95.2%有华法林适应证的患者中（男性和女性的 CHA2DS2-VASc 分别为≥1 和≥2），只有 21.8%在研究前 90 天内有处方。
从 1998 年到 2010 年，AF 患者中 VHD 的患病率增加。与无 VHD 的 AF 相比，伴有主动脉瓣狭窄、MS 或机械瓣膜的 AF（与 AF 不伴 VHD 相比）与卒中、SSE 和死亡率的绝对超额风险相关，但在直接口服抗凝剂（DOAC）时代，华法林的使用不足，这突显了迫切需要明确 DOAC 在 AF 和并发 VHD 中的作用。
