Incidence, Risk Factors, and Outcomes in Stressor-Associated Atrial Fibrillation: Insights From the VITAL-AF Trial.

However, risk factors, outcomes, and current management practices remain poorly understood.

然而，风险因素、结果和当前的管理实践仍然不为人所充分理解。

Methods

We analyzed data from VITAL-AF, a pragmatic, cluster-randomized AF screening trial conducted in 2018 and 2019 comprising adults ≥65 years of age across 16 primary care practices affiliated with Massachusetts General Hospital. All participants had longitudinal follow-up for adjudicated incident AF (including whether stressor-associated versus nonstressor-associated ["primary"]) and clinical outcomes.

我们分析了VITAL-AF的数据，这是一项在2018年和2019年进行的实用型、群组随机化房颤筛查试验，涵盖了马萨诸塞州总医院附属的16个初级保健实践中的≥65岁的成年人。所有参与者都有经过裁决的房颤（包括应激相关与非应激相关["原发性"]）和临床结果的纵向随访。

We compared associations between clinical AF risk factors and incident AF group (stressor-associated versus primary) using Fine-Gray models handling death and each AF group as competing risks.

我们使用Fine-Gray模型比较了临床房颤风险因素与新发房颤组（应激相关与原发性）之间的关联，将死亡和每个房颤组视为竞争风险。

We also quantified oral anticoagulant initiation rates after AF diagnosis.

我们还量化了房颤诊断后口服抗凝药物启动率。

We then fit Cox proportional hazards models to quantify associations between incident AF group (as a time-varying covariate) and a composite end point of major bleeding, stroke, and all-cause mortality, with adjustment for CHA₂DS₂-VASc (congestive heart failure, hypertension, age >74, diabetes, stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74, sex category; stroke) and ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation; bleeding) scores and time-varying oral anticoagulant exposure.

然后，我们拟合了Cox比例风险模型，以量化新发房颤组（作为时间变化的协变量）与主要出血、中风和全因死亡率复合终点之间的关联，并对CHA₂DS₂-VASc（充血性心力衰竭、高血压、年龄>74岁、糖尿病、中风或短暂性脑缺血发作或血栓栓塞、血管疾病、年龄65-74岁、性别类别；中风）和ATRIA（房颤的抗凝治疗和风险因素；出血）评分以及时间变化的口服抗凝药物暴露进行了调整。

Results

We analyzed 30 265 patients (41% men, 83% White, and mean age 74 years).

我们分析了30265名患者（男性占41%，白人占83%，平均年龄为74岁）。

Of 988 incident AF events, 290 (29%) were stressor associated.

在988起新发房颤事件中，有290起（29%）与压力因素相关。

Clinical risk factors, including age, hypertension, and heart failure, showed similar associations with both primary and stressor-associated AF.

临床风险因素，包括年龄、高血压和心力衰竭，与原发性和应激相关性房颤均显示出相似的关联。

Oral anticoagulant initiation within 90 days of new AF diagnosis was lower for stressor-associated versus primary AF (56% versus 75%, P<0.001).

在新诊断房颤后的90天内开始口服抗凝治疗的比例，应激相关性房颤低于原发性房颤（56%对75%，P<0.001）。

The incidenceof the composite end point was 2.30 per 100 person-years (95% CI, 2.17-2.44) for no AF, 15.09 (95% CI, 12.22-18.42) for primary AF, and 22.71 (95% CI, 16.91-29.87) for stressor-associated AF.

复合终点的发生率为无房颤（AF）时为每100人年2.30次（95%置信区间，2.17-2.44），原发性房颤（primary AF）为15.09（95%置信区间，12.22-18.42），应激相关性房颤（stressor-associated AF）为22.71（95%置信区间，16.91-29.87）。

In adjusted models and using no AF as the referent, both primary AF (hazard ratio[HR], 3.91 [95% CI, 2.89-5.28]) and stressor-associated AF (HR, 6.13 [95% CI, 4.31-8.72]) were associated with substantially higher risk of the composite end point.

在调整后的模型中，并以无房颤为参照，原发性房颤（hazard ratio [HR]，3.91 [95%置信区间，2.89-5.28]）和应激相关性房颤（HR，6.13 [95%置信区间，4.31-8.72]）都与复合终点的显著更高风险相关。

Conclusions

Among >30 000 primary care patients with adjudicated AF events, nearly one-third of incident AF cases were stressor associated.

在超过30,000名经过确诊的房颤事件的初级保健患者中，近三分之一的初发房颤病例与应激因素相关。

Despite similar risk factor profiles and comparably high rates of adverse outcomes, oral anticoagulant initiation is lower when AF is stressor associated.

尽管风险因素特征相似且不良结果的发生率较高，但当房颤与应激因素相关时，口服抗凝药物的使用率较低。

Future work is needed to define optimal approaches to prevention, surveillance, and management of stressor-associated AF.

未来的研究需要确定预防、监测和管理与压力相关的房颤的最佳方法。