Vascular Health and Risk Management Dovepress open access to scientific and medical research Open Access Full Text Article ORIGINAL RESEARCH Risk of Atrial Fibrillation, Ischemic Stroke and Cognitive Impairment: Study of a Population Cohort ≥65 Years of Age This article was published in the following Dove Press journal: Vascular Health and Risk Management Jose-Luis Clua-Espuny, 1 Purpose: To evaluate a model for calculating the risk of AF and its relationship with the Eulalia Muria-Subirats, 2 incidence of ischemic stroke and prevalence of cognitive decline. Juan Ballesta-Ors, 3 Blanca Lorman- Materials and Methods: It was a multicenter, observational, retrospective, community-based Carbo, 4 Josep Clua-Queralt, 5 Elena Palà, 6 Iñigo Lechuga-Duran, 7 study of a cohort of general population ≥6ct 35 years, between 01/01/2016 and 31/12/2018. Delicia Gentille-Lorente, 7 Setting: Primary Care. Participants: 46,706 people ≥65 years with an active medical history in Alejandro Bustamante, 8 any of the primary care teams of the territory, information accessible through shared history and Miguel Ángel Muñoz, 9 Joan Montaner 6 without previous known AF. Interventions: The model to stratify the risk of AF (PI) has been On Behalf of the AFRICAT Research previously published and included the variables sex, age, mean heart rate, mean weight and Group CHA2DS2VASc score. Main measurements: For each risk group, the incidence density/1000 person/years of AF and stroke, number of cases required to detect a new AF, the prevalence of 1 EAP Tortosa 1-Est, Institut Català Salut, Servei cognitive decline, Kendall correlation, and ROC curve were calculated. Atenció Primària, UUDD Terres De l’Ebre. Universidad Rovira I Virgili, Programa Doctorat, Results: The prognostic index was obtained in 37,731 cases (80.8%) from lowest (Q1) to Tortosa, Spain; 2EAP Tortosa 1-Est, Institut Català highest risk (Q4). A total of 1244 new AFs and 234 stroke episodes were diagnosed. Q3-4 Salut, SAP Terres De l’Ebre, España Universidad Rovira I Virgili. Programa Doctorat, Tortosa, included 53.8% of all AF and 69.5% of strokes in men; 84.2% of all AF and 85.4% of Tarragona, Spain; 3EAP Tortosa 1-Est, Institut strokes in women; and 77.4% of cases of cognitive impairment. There was a significant Català Salut, SAP Terres De l’Ebre, Universidad linear correlation between the risk-AF score and the Rankin score (p < 0.001), the Pfeiffer Rovira I Virgili. Programa Doctorat. Tortosa, Tarragona, Spain; 4EAP Tortosa 1-Est, Institut score (p < 0.001), but not NIHSS score (p 0.150). The overall NNS was 1/19. Català Salut, SAP Terres De l’Ebre, España Conclusion: Risk stratification allows identifying high-risk individuals in whom to inter­ Universidad Rovira I Virgili. Programa Doctorat. vene on modifiable risk factors, prioritizing the diagnosis of AF and investigating cognitive Tortosa, Tarragona, Spain; 5Universitat De Lleida, Lérida, Spain; 6Neurovascular Research status. Laboratory, Vall d’Hebron Institute of Research Keywords: vascular risk score, atrial arrhythmia, cerebrovascular disease, silent stroke, (VHIR)-Universitat Autónoma De Barcelona, Barcelona, Spain; 7Servicio Cardiología, Hospital cognitive decline Virgen De La Cinta, Institut Català Salut Tortosa, Tarragona, Spain; 8Department of Neurology, Hospital Universitari Vall d’Hebron, Barcelona, Spain; 9Institut d’Investigació En Atenció Primària IDIAP Jordi Gol, Unitat De Suport a La Recerca Introduction De Barcelona, Barcelona, Spain The Action Plan in Europe (2018–2030)1 prioritizes the availability of detection and treatment programs to address the risk factors for stroke in all European countries. Due to demographic aging, it is estimated that the prevalence of AF Correspondence: Jose-Luis Clua-Espuny will increase from 1.9% (2008) to 3.5% (2050), and the number of AF-related EAP Tortosa 1-Est, Institut Català Salut, ischemic strokes in people >80 years will triple (2010–2060).2 If we consider that Servei Atenció Primària, UUDD Terres De l’Ebre. Universidad Rovira I Virgili, >60% of strokes occur in people >80 years of age,3,4 the proposed objective is Programa Doctorat, CAP Temple, extremely important. Carrilet Square s/Num. Tortosa, 43500, Spain Approximately one-third of ischemic strokes are related to the presence of Tel +34 977 510018 unknown atrial fibrillation (AF).5–7 In this case, strokes are more severe, more dis­ Fax +34 977 44 57 28 Email jlclua@telefonica.net abling, associated with cognitive decline, and with a higher risk of institutionalization submit your manuscript | www.dovepress.com Vascular Health and Risk Management 2020:16 445–454 445 DovePress © 2020 Clua-Espuny et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/ http://doi.org/10.2147/VHRM.S276477 terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Clua-Espuny et al Dovepress than strokes from other causes.8 Consequently, it is clear that general regulation on Spanish and European data protec­ the costs related to AF will increase, constituting a major tion (02/01/2017). There was no contact with the cases public health problem. included. The specific codes of the International While the strategy for detecting AF after a stroke Classification of Diseases (10th version; ICD-10) were episode accumulates evidence9,10 at the hospital level, used for atrial fibrillation (I48), cerebrovascular disease the same does not occur in the primary care setting before (I60-I69), and cognitive impairment (G31). the stroke episode. Although different screening strategies The model to stratify the risk of suffering AF at five have been recommended9 by international organizations,10 years has been previously published16 and it is intended to they have not demonstrated greater effectiveness in the be applied to the general population ≥65 years. It includes general population than their non-implementation,11 and the variables: sex, age, average heart rate, and average there is little evidence of their impact on the incidence of weight and CHA2DS2VASc value. The mathematical for­ comorbidities, especially the stroke.12 For all these rea­ mula of the model was applied to the population older than sons, the new priorities point towards the identification of 65 years without a diagnosis of AF and the quartiles of the individuals at high risk of having AF in whom to carry out distribution from lowest to highest risk were defined (Q1- screening and evaluate its effectiveness13,14 both in its Q4). For each risk group, the incidence density/1000 peo­ detection and in the incidence of strokes.15 ple/year (ID) was calculated; number of screening (NNS) The main objective of this study is to apply a five-year necessary to detect a new AF; the incidence of strokes and model for calculating the risk of AF16 in the general the registered prevalence of cognitive decline. The NNS population ≥65 years and to describe its possible relation­ was calculated on the number of new AFs/number of cases ship with the incidence of ischemic stroke and the preva­ with record of screening in each quartile. In the clinical lence of cognitive decline in the primary care setting. electronic records (E-cap) of people aged ≥60 years, opportunistic screening10 of the rhythm is registered as a variable “A” (arrhythmic) vs “R” (rhythmic) in the e-cap Materials and Methods (Basic Activities of Prevention and Promotion of Health in Type of Study Primary Care) accompanied by an alert (appears in a Multicenter, observational, retrospective, community- different colour if pending). The patient’s record indicated based study of a cohort of general population ≥65 years whether case finding was performed. Case finding or between 01/01/2016 - 12/31/2018 with no diagnosis of screening for AF was defined as pulse palpation during atrial fibrillation in the Primary Care setting. The research routine general practitioner consultations at least once a protocol of the study was approved by the Ethical year, together with a 12-lead ECG confirmation of an Committee of the Institut Universitari d’Investigació en irregular or regular pulse—for instance, during an annual Atenció Primària IDIAP Jordi Gol with the code number cardiac disease review, with the result recorded as either (P18/118). “rhythmic” or “arrhythmic” (AR). The AF diagnosis requires at least 30 sec of absolutely irregular RR intervals Territorial Scope and no discernible, distinct P waves on the electrocardio­ The SAP Terres de l’Ebre territory has 11 primary care gram (ECG). Its registration as made occurs when the teams, all managed by the Catalan Institute of Health professional performing the activity enters the option (ICS), in which 98.2% of the census population with an (rhythmic/arrhythmic). active medical history is assigned, and a reference general teaching public hospital for the entire territory and three Target Population regionally managed hospitals. All centres in the territory Subjects ≥65 years who met the inclusion criteria: active share clinical information (HC3). medical history in any of the health centres in the territory The data were obtained from the databases of the with information accessible through the shared history electronic clinical records (e-cap, E-SAP) by the (HC3), without prior AF, residence in the territory and Information Systems department for the exploitation of assignment to any of the Teams Primary Care (EAP) of the record known as the “Minimum Basic Data Set” the same. The non-availability or loss of accessibility to (CMBD) and delivered to the main researcher in an anon­ the information necessary for the study was considered as ymised format, supervised and analyzed according to the a reason for exclusion. The follow-up was carried out until 446 submit your manuscript | www.dovepress.com Vascular Health and Risk Management 2020:16 DovePress Dovepress Clua-Espuny et al the end of the study, the death of the patient or the clinical Results loss of records (new residence outside the scope of the Baseline Characteristics study) during follow-up. Forty-six thousand seven hundred and six people without known AF were included. Table 1 describes the baseline Variables characteristics according to the presence or absence of AF. The main variable was the incidence rate of new diagnosis Screening was performed in 53.2% of the population with­ of AF in the follow-up period and, secondarily, the incidence out AF and in 79.6% of the population diagnosed with a rate of ischemic stroke, simultaneous or subsequent to the new AF (p <0.001). The AF population presented a signifi­ diagnosis of AF. All cases of new AF were confirmed by cantly higher value in all parameters. The CHA2DS2VASc, referring Cardiology and clinical records. In each quartile, age and mortality are significantly higher in women. the cognitive impairment and dementia diagnoses were Mortality was significantly higher in both those with AF obtained from the different datasets got from the former and those with strokes. available records of all patients in the timeframe of the study. The Pfeiffer score represents the average of the included individuals in each quartile. Two researchers inde­ AF-Risk Stratification results pendently reviewed the record of stroke and cognitive The prognostic index was obtained in 37,731 cases impairment for confirmation and its severity according to (80.8%) distributed in risk levels (Table 2). One thousand the NIHSS and Rankin scales, considering them as the two hundred and forty-four new AFs (ID 10.5/1000/year simultaneous incidence of AF and stroke when the differ­ 95% CI 9.9–11.2) were identified, appreciating an increas­ ence in the diagnostic time of both was not greater than 30 ing case gradient as risk increases (p <0.001). The inci­ days. The Rankin and NIHSS scores are the only assessed in dence rate for the Q4/mean group was 1.61 [95% CI 1.45– individuals with stroke. Sociodemographic, clinical, comor­ 1.79 p <0.001]. Although the highest ID of AF occurs in bidities, Charlson and Pfeiffer scores, registration as a Q4 (17.0 95% CI 15.5–18.6), Q3-4 include 53.8% of all Chronic Complex Patient37 (PCC), if institutionalized in AF in men and 84.2% of all AF in women, with a global long-term stay (≥3 months), were included as independent NNS of 1/19. There was a significant difference between variables. The mortality rate is total from any cause and the risk-AF groups in the AF incidence (p <0.001), stroke evaluated by the Kaplan-Meier method. incidence (p <0.001), and cognitive impairment prevalence (p <0.001). The area under the curve was 61.9 (95% CI Statistic Analysis 60.3–63.4). The statistical analysis was descriptive to define the char­ acteristics of the population with basic statistics of centra­ Stroke Incidence Density lization and dispersion; and for the identification of Two hundred and thirty-four stroke episodes were con­ differences in registration and functional and risk assess­ firmed (Table 3), which presented higher comorbidity, ment among population subgroups. Other subgroups were higher mean number of visits and higher mortality than considered based on the emerging results. In the bivariate those without strokes. Stroke incidence increased progres­ analysis of normal distributions, the T test was used for sively with risk levels as well as the mean value (p <0.001) independent samples in the case of quantitative variables on the Rankin scale. The Q4/mean incidence ratio was and the Chi2 test or Fisher’s exact test in the case of 1.98 [95% CI 1.57–2.50 p <0.001]. In Q3-Q4 levels, categorical variables. The incidence density/1000 people/ 85.4% of episodes were concentrated in women, while in year, NNS to diagnose a new case AF, incidence rate, and men they represented 69.5% of the total. The percentage the ROC curve and the area under the curve were obtained of AF screening in those with strokes was significantly to evaluate the discriminative capacity of the model. The higher (72.6% vs 53.8%). Kendall correlation for AF risk, Pfeiffer, NIHSS, and Regarding the temporal relation between strokes/AF, Rankin scores because of a smaller gross error sensitivity most of the strokes (78.5%) occurred in people without and a smaller asymptotic variance. P ≤0.05 was considered AF, concentrated in Q3-Q4 risk levels, especially among a significant statistical difference, and 95% confidence women (88.17%). The cumulative percentage of strokes intervals (95% CI) were calculated. For statistical analysis, associated with the simultaneous diagnosis of AF was the IBM SPSS Statistics version 19.0 program was used. 9.8% of the total [ID 5.8 cases (95% CI 3.4–8.1)/1000] submit your manuscript | www.dovepress.com Vascular Health and Risk Management 2020:16 447 DovePress Clua-Espuny et al Dovepress Table 1 Baseline Characteristics of Cases with AF vs without AF Variables NO-AF1 AF1 p All All 45,462 1244 46,706 Women (n, %) 24,593 (54.1%) 584 (46.9%) <0.001 Age average (year) 79,3±10,6 81,02±8,26 <0,001 79,3±10.6 Screening AFa 24,195 (53.2%) 990 (79.6%) <0.001 25,185 (53.9%) Hypertension arterial 25,012 (55,0%) 930 (74.8%) <0,001 25,942 Diabetes mellitus 9603 (21.1%) 330 (26.5%) <0,001 9933 Weight average (kg) 75,04±17,0 79,3±16,5 <0,001 75,1±17,0 Heart rate (average/min) 73±10 73±9 0,164 73,7±9,5 Ischemic cardiomyopathy 2727 (6.0%) 156 (12.5%) <0,001 2883 Peripheral arterial disease 2576 (5.7%) 148 (11.9%) <0,001 2724 Heart failure 2400 (5.3%) 282 (22.7%) <0,001 2682 Stroke 208 (0.5%) 26 (2.1%) <0,001 234 NIHSS score average 4,60±5,6 4,30±6,4 0,820 4,5±5,7 Rankin score average 1,91±1.60 1,87±1,63 0,902 1,9±1,6 Cognitive impairment 3791 (8.3%) 126 (10.1%) <0,001 3917 Pfeiffer score average 3,73±3,5 2.51±2.8 <0,001 3,6±3,5 CHA2DS2-VASc score average 3.03±1.14 3.64±1,17 <0,001 3.0±1.1 Chronic renal insufficiency 4483 (9.9%) 267 (21.5%) <0,001 4750 Chronic liver disease 52 (0.1%) 7 (0.6%) <0,001 59 Charlson score average 1,03±1.20 1,56±1,35 <0,001 1,0±1,2 CCPb register 1838 (4.0%) 132 (10.6%) <0,001 1970 Institutionalization 1514 (3.3%) 76 (6.1%) <0,001 1590 Average number of prescribed drugs 4.73±4.03 7.95±4.18 <0,001 4.8±4.0 Anticoagulation 962 (77.3%) Statins 12,266 (27,0%) 439 (35.3%) <0,001 12,705 Average number of visits/year Primary Care (2016) 11,4±13.2 24,16±22,3 <0.001 11.8±13.7 Average number of visits/year Primary Care (2018) 12.2±14.3 34,11±24,0 <0.001 12.7±15.0 Average number of visits/year Hospital/Emergency (2018) 0.26±1.0 0,92±1,90 <0.001 0.28±1.04 Death 20,869 (45.9%) 660 (53.1%) <0.001 21,529 Notes: aAF, atrial fibrillation; bCCP, complex and chronic patient. new AFs/year. In addition, the 57.1% of simultaneous diag­ of incident strokes and prevalence of cognitive deteriora­ nosis of stroke and AF happened in the group Q4, presented tion in the different risk groups obtained during the same greater NIHSS (7.25 ± 8.62 vs 4.55±5.74, p 0.002). period of time, but excludes causal relationships. The clinical stratification model used16 can discriminate those Cognitive Impairment Prevalence individuals with a higher risk (17.0/1000/year) of suffering Eventually there was a progressive increase in the preva­ an AF at five years, who are associated with a higher lence of cognitive deterioration and the mean value on the prevalence of strokes and cognitive deterioration, as well Pfeiffer scale with the increase of the risk of AF. 77.4% of as differences by sex. Furthermore, the NNS (n 19) for the the cases with cognitive impairment were concentrated in diagnosis of a new case of AF was much lower than that the Q3-Q4 risk levels. There was a significant linear cor­ reported (n 147) by previous studies in the general relation between the risk-AF score and the Rankin score (p population.21,22 < 0.001), the Pfeiffer score (p < 0.001), but not NIHSS The risk stratification in Primary Care would identify score (p 0.150). those individuals with the highest risk: men [Q3-4 and/or CHA2DS2VASc ≥3], women [Q4 and/or CHA2DS2VASc Discussion ≥4] in which to intervene on modifiable risk factors, addi­ The study uses data from the general population ≥65 years tional explorations, and to investigate which methodology without previous atrial fibrillation to compare frequencies could be more effective13,14,17 for the diagnosis of AF before 448 submit your manuscript | www.dovepress.com Vascular Health and Risk Management 2020:16 DovePress Dovepress Clua-Espuny et al Table 2 Distribution of Cases According to Calculated AF Risk (N 37,731) Quartiles AF-Risk116 Q1 Q2 Q3 Q4 ALL MEN N 6150 4958 4150 1968 17,235 Atrial fibrillation 125 169 210 133 637 ID/1000/person-yearsa 7.6 (5.6–8.0) 10.2 (8.7–11.9) 16.9 (14.7–19.3) 22.5 (18.9–26.7) 12.3 (11.4–13.3) NNSb 49 30 20 15 27 Age average ±SD 70.14±4.1 77.26±6.7 83.7±7.1 88.7±7.6 78.5±10.2 CHA2DS2-VASc (average±SD) 1.80±0.66 2.73±0.66 3.27±0.77 4.02±0.93 2.52±1.05 Weight (Kg average±SD) 77.6±11.3 81.1±13.4 82.0±13.5 88.3±22.7 80.7±15.3 Heart rate (average±SD) 74.2±10.4 72.0±9.2 70.6±8.6 69.3±8.4 72.3±9.8 Ischaemic stroke (n) 14 22 46 31 118 Rankin score average±SD) 1.33±1.15 1.53±1.94 1.75±1.54 2.48±1.63 1.96±1.65 Pfeifer score (average±SD) 1.9±3.0 2.6±3.4 3.0±3.33 3.1±3.4 3.0±3.4 Cognitive impairment (%) 2.5% 5.6% 9.9% 12.1% 6.3% WOMEN Q1 Q2 Q3 Q4 ALL N 3400 4482 5254 7360 20,496 Atrial fibrillation 29 59 124 344 556 ID/1000/person-yearsa 2.8 (1.9–4.1) 4.4 (33.3–5.7) 7.9 (6.5–9.4) 15.6 (14.0–17.3) 9.0 (8.3–9.8) NNSb 117 76 42 21 37 Age average ±SD 68.6±3.0 72.3±5.0 79.3±6.6 87.2±7.4 80.0±10.8 CHA2DS2-VASc (average±SD) 2.31±0.48 3.05±0.57 3.74±0.61 4.45±0.82 3.49±1.03 Weight (kg average±SD) 63.3±9.7 70.2±12.0 70.4±14.0 74.5±21.0 70.4±17.0 Heart rate (average±SD) 77.2±9.7 74.8±8.6 74.9±8.5 73.3±8.0 75.0±9.0 Ischaemic stroke (n) 3 11 13 69 96 Rankin score average±SD) 0.00 0.44±0.72 1.86±1.77 2.15±1.48 1.84±1.55 Pfeifer score (average±SD) 2.5±3.2 2.8±3.5 3.3±3.3 4.0±3.4 4.0±3.5 Cognitive impairment (%) 2.8% 4.6% 10.9% 17.6% 10.6% ALL Q1 Q2 Q3 Q4 ALL N 9550 9440 9413 9328 37,731 Women (%) 35.6% 47.5% 55.8% 78.9% 54.3% Atrial fibrillation 154 228 334 477 1193 ID/1000/person-yearsa 5.4 (4.6–6.3) 8.1 (7.0–9.2) 11.8 (10.6–13.2) 17.0 (15.5–18.6) 10.5 (9.9–11.2) NNSb 62 41 28 19 31 Age average ±SD 69.6±3.8 74.9±6.4 81.2±7.1 87.5±7.4 79.3±10.6 CHA2DS2-VASc (average±SD) 1.98±0.66 2.88±0.64 3.53±0.72 4.36±0.87 3.04±1.15 Weight (kg average±SD) 72.5±12.7 76.0±14.0 75.5±15.0 77.5±22.0 75.1±17.0 Heart rate (average±SD) 75.3±10.2 73.7±9.0 73.0±8.8 72.4±8.3 73.7±9.5 Ischaemic stroke (n) 17 33 59 105 214 0.6 (0,33–0,96) 1.2 (0.8–1.63) 2.1 (1.6–2.7) 3.8 (3.1–4.6) 1.9 (1.63–2.16) Rankin score average±SD) 0,66±1,15 1.15±1.69 1.80±1.55 2.27±1.53 1.91±1.60 Pfeifer score (average±SD) 2,13±3.06 2.69±3.43 3.18±3.34 3.86±3.42 3.68±3.52 Cognitive impairment (%) 248 (2.6%) 485 (5.1%) 986 (10.5%) 1531 (16.4%) 3250 (8.6%) Notes: aIncidence rate: 1000/person-years; bNNS: number needed to screen to detect one case of AF. its debut associated with strokes and whether anticoagulation presence of ECG abnormalities,19,20 there is uncertainty should be started. The results of the CHA2DS2VASc are about the efficacy and safety of starting anticoagulation. similar to the previous evidence18 and although the combina­ Opportunistic screening in 79.6% of cases of new AF tion of the CHA2DS2VASc with an AF load >5–6 min is would support its performance over usual care,21,22 but its required to produce an increased risk of stroke or the impact on the incidence of stroke is unknown. Furthermore, submit your manuscript | www.dovepress.com Vascular Health and Risk Management 2020:16 449 DovePress Clua-Espuny et al Dovepress Table 3 Baseline Characteristics of Stroke vs Non-Stroke Cases Variables Stroke Non-Stroke p All 234 46,472 Women (n,%) 101 (43.16%) Men (n,%) 133 (56.8%) Age average (year) 79,7±8.44 79.3±10.62 0.606 Atrial fibrillation 26 (11.1%) 1218 (2.6%) <0.001 Screening AFa 170 (72.6%) 25,015 (53.8%) <0.001 Hypertension arterial 179 (76.5%) 25,763 (55.4%) <0.001 Diabetes mellitus 76 (32.5%) 9857 (21.2%) <0.001 Weight average (kg) 76,32±13.4 75.16±17.0 0.316 Heart rate (average/min) 73±10 73±9 0.154 Ischemic cardiomyopathy 17 (7.3%) 2866 (6.2%) 0.279 Peripheral arterial disease 23 (9.8%) 2701 (5.8%) 0.010 Heart Failure 24 (10.3%) 2658 (5.7%) <0.001 Cognitive impairment 36 (15.4%) 3881 (8.4%) <0.001 Pfeiffer score (average) 3.22±2.81 3,7±3.52 0.301 CHA2DS2-VASc score (average) 4.44±1.13 3.04±1,14 <0.001 Chronic renal insufficiency 36 (15.4%) 4714 (10.1%) <0.001 Chronic liver disease 0 59 (0.1%) 0.743 Charlson score (average) 2.4±1.36 1.03±1.21 <0.001 CCPb 28 (12%) 1942 (4.2%) <0.001 Institutionalization 23 (9.8%) 1567 (3.4%) <0.001 Average number of prescribed drugs 7.47±4.34 4.80±4.06 <0.001 Statins prescription 129 (55.1%) 12,576 (27.1%) <0.001 Average number of visits/year Primary Care (2016) 19.32±17.1 11.77±13.72 <0.001 Average number of visits/year Primary Care (2018) 23.07±21.14 12.72±15.02 <0.001 Average number of visits/year Hospital/Emergency (2018) 1.22±1.75 0.27±1.04 <0.001 Death 196 (83.8%) 36,274 (78.1%) 0.042 Notes: aPeople with opportunistic screening AF; bCCP, complex and chronic patient. the total NNC <20 is much lower than that published23 in the (19), biomarkers (27,28), and the use of different technolo­ general population; and, at least, it would allow interventions gies (13,14,17) will define different post-test probabilities on modifiable factors.24 There is little evidence about the (Figure 1). added value of using echocardiographic criteria and Given the AF meets the characteristics for population biomarkers25–28 in this higher-risk population. screening and opportunistic, pulse taking is recommended in Although the number of strokes is relatively low, there is primary care,30 we have no evidence of which diagnostic a higher incidence of AF and stroke in Q4, especially among protocol could be with better results or its impact on the women, reflecting different possible pathways of cardiovas­ prevention of strokes and deterioration cognitive. Although cular disease26,29 as well as differences in the CHA2DS2- we have technology that expands diagnostic opportunities in VASc value.15,26 The risk stratification of AF could also be a different contexts (population campaigns, clinical consultation criterion for deciding the type of monitoring after having and home) and we have data on high-risk population sub­ suffered a stroke, and the sensitivity of the existing scales groups, it would be necessary to develop research proposals in could be improved. Although the result in the ROC curve Primary Care that would allow not only to improve diagnostic may be a relative limitation, it will not modify the clinical effectiveness of AF but also to measure its burden and to decision to optimize the approach to modifiable risk factors; evaluate the cost-effectiveness on the prevention of stroke and the significantly incremental densities and incidence episodes and cognitive deterioration.8,31 The prevalence of ratios of both AF and stroke at the different risk levels should cognitive disorder is higher in each quartile in relation to be sufficient to test clinical stratification to improve AF that described in the general population.32 How studies screening results. The inclusion of echocardiographic criteria included individuals with the baseline dementia or prevalent 450 submit your manuscript | www.dovepress.com Vascular Health and Risk Management 2020:16 DovePress Dovepress Clua-Espuny et al Figure 1 Atrial fibrillation Primary Care Pathway (proposal). MCI may affect the prevalence figures. Finally, one must impairment with the risk of AF would support a possible consider that estimates for MCI from general population etiopathogenic interrelation between both processes in the studies include all cases, regardless of their likelihood of general population,33 as well as the need to protocolize its being detected in the health-care system or the underlying detection.34 A model of comprehensive care for AF has shown disease etiology. In addition to the epidemiological estimate a 45% reduction in mortality from any cause,35 but its analysis associated with demographic aging, the greater cardiovascular is subsequent to the diagnosis of AF. comorbidity, frequency, average drug consumption, mortality As potential limitations of the study, the authors and severity of stroke would confirm the estimate of the consider the under-registration of diagnoses; the cross- increase in costs associated with the treatment of AF asso­ sectional format does not allow defining causal relation­ ciated with a stroke episode. The presence of a progressive ships between AF and cognitive impairment even in the increase in the prevalence and severity of cognitive absence of stroke; and the results are limited to a generic submit your manuscript | www.dovepress.com Vascular Health and Risk Management 2020:16 451 DovePress Clua-Espuny et al Dovepress AF and cognitive decline without stratification according and/or analysed during the current study are available to the age, type of AF and cognitive dysfunction. Among from the corresponding author on reasonable request. its strengths, are remarkable the considerable number of cases, had with long follow-ups, and were conducted in Ethics Approval and Informed general population. The target population to screen has Consent yet to be established particularly with regards to the The research protocol of the study was approved by the impact of oral anticoagulation on cognitive outcomes. Ethical Committee of the Institut Universitari At present, ideal strategies to screen for AF remains to d’Investigació en Atenció Primària IDIAP Jordi Gol with be defined. This article aims to provide content that the code number (P18/118) and complies with the Helsinki allows new research including the interrelation of differ­ Declaration and the local ethics committee requirements for ent form of AF, cognitive impairment vs dementia and clinical research. Registry information was collected from age with the risk-AF model to be developed. the government-run healthcare provider responsible for all Future research should focus on the cost-effectiveness inpatient care in the county without contact with participants analysis of a protocol that includes the systematic identi­ in order to gather data from the study. For this type of study fication of patients at high risk of suffering from AF13,16 formal consent is not required and the requirement for the according to age-specific ranges, type and cognitive informed consent of patients was waived prior to the inclu­ impairment; the modification of risk factors; the use of sion of their medical data in this study. echocardiographic criteria and biomarkers;25–28 and the prevalence of cognitive disorder and dementia separately along the AF risk scale (Q1 to Q4) may resolve uncertain­ Acknowledgments The authors thank to Jesus Carot and Sistemes d’Informació i ties related to the most effective type of monitoring,17 Comunicació of the Territorial Management of l’ICS in whether to start anticoagulant treatment36 or not, and Terres de l’Ebre for their invaluable material and technical favour the definition of the potential mechanisms leading collaboration in the management of the bases of original data, to cognitive dysfunction37–39 and therapeutic strategies to as well as all the primary care professionals who participated prevent AF-related cognitive decline. directly or indirectly in the elaboration of the Results. Conclusions The clinical stratification model used16 can discriminate Author Contributions those individuals with a higher risk (17.0/1000/year) of All authors contributed to data analysis, drafting or revising suffering an AF at five years, who are associated with a the article, have agreed on the journal to which the article will higher prevalence of strokes and cognitive deterioration, as be submitted, gave final approval of the version to be pub­ well as differences by sex in whom to carry out screening lished, and agree to be accountable for all aspects of the work. and evaluate its effectiveness. Funding Abbreviations The study received a research grant by Fundació Marató AF, atrial fibrillation; CCP, complex chronic patient; CI, de TV3 in the research call “La Marató 2014: Malalties del confidence interval; e-SAP, electronic clinical records in Cor”. Grant number: 201528-30-31-3 and received fund­ primary care; CMBD, minimum basic data set – catalonian ing from the Spanish Society of Family and Community acronym for Conjunt Mínim Bàsic de Dades (CMBD); Medicine -semFYC- by being the winner of a grant for the ICD-10, International Classification of Diseases; ID, inci­ completion of doctoral theses Isabel Fernández 2020. dence rate, 1000/person-years; NNS, number needed to screen to detect one case of AF; SIRE, Integrated Disclosure Electronic Prescription System – catalonian acronym for The authors declare that they have no conflict of interest Sistema Integrat de Recepta Electrònica (SIRE). and have not received commercial sponsorship for the research and publication of the results. There are also no Data Sharing Statement direct or indirect financial interests. This research received Detailed information is available at the AFRICAT study no specific grant from funding agencies in the commercial protocol (NCT03188484). 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