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Peripheral Arterial Disease, Stroke, and Mortality in Patients with Atrial Fibrillation

  • Tomoyuki Kawada
    Correspondence
    Requests for reprints should be addressed to Tomoyuki Kawada, MD, Department of Hygiene and Public Health, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo 113-8602, Japan.
    Affiliations
    Department of Hygiene and Public Health, Nippon Medical School, Bunkyo-Ku, Tokyo, Japan
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      To the Editor:
      I read the paper by Vitalis et al
      • Vitalis A
      • Shantsila A
      • Proietti M
      • et al.
      Peripheral arterial disease in patients with atrial fibrillation: the AFFIRM Study.
      with great interest. The authors assessed the impact of peripheral arterial disease on mortality and stroke in patients with atrial fibrillation. The adjusted hazard ratio (HR) (95% confidence interval [CI]) of peripheral arterial disease in patients with atrial fibrillation for all-cause mortality was 1.34 (1.06-1.70). In addition, the adjusted HR (95% CI) of peripheral arterial disease in patients with nonanticoagulated atrial fibrillation for ischemic stroke was 3.37 (1.25-9.09). Peripheral arterial disease and atrial fibrillation share common risk factors. I have 2 comments about their study with causal directions.
      First, Vrsalović et al
      • Vrsalović M
      • Presečki AV.
      Atrial fibrillation and risk of cardiovascular events and mortality in patients with symptomatic peripheral artery disease: a meta-analysis of prospective studies.
      conducted a meta-analysis to evaluate the association of atrial fibrillation with major adverse cardiac events (MACE) and mortality in patients with peripheral arterial disease. The pooled odds ratios (95% CIs) of atrial fibrillation for mortality and MACE were 2.52 (1.91-3.34) and 2.54 (1.78-3.63), respectively. I suppose that synergic effects with peripheral arterial disease and atrial fibrillation for MACE and mortality might have existed, and selecting appropriate statistical model is important for the analysis. In any case, atrial fibrillation and peripheral arterial disease are significant contributors for vascular events.
      Second, Tseng et al
      • Tseng AS
      • Girardo M
      • Firth C
      • et al.
      Lower extremity arterial disease as a predictor of incident atrial fibrillation and cardiovascular events.
      evaluated the relationship between peripheral arterial disease and incident atrial fibrillation with special reference to ischemic stroke and all-cause mortality. The adjusted HR (95% CI) of low ankle-brachial index (ABI) (<1.0) and elevated ABI (≥1.4) for incident atrial fibrillation were 1.14 (1.06-1.22) and 1.18 (1.06-1.31), respectively. In addition, there was a dose-dependent relationship between severity of peripheral arterial disease and incident atrial fibrillation. They concluded that patients with peripheral arterial disease had an increased risk of ischemic stroke and all-cause mortality, which was consistent with data by Vitalis et al. As they pointed out, monitoring ABI may be useful to prevent clinical events.
      From the viewpoint of prevention, tobacco smoking is a major risk factor for atrial fibrillation, peripheral arterial disease, and cardiovascular disease events.
      • Klein A
      • Shenasa M
      • Baranchuk A.
      Social risk factors and atrial fibrillation.
      I think that interaction analysis with causal direction may be important for the risk assessment.

      References

        • Vitalis A
        • Shantsila A
        • Proietti M
        • et al.
        Peripheral arterial disease in patients with atrial fibrillation: the AFFIRM Study.
        Am J Med. 2021; 134: 514-518
        • Vrsalović M
        • Presečki AV.
        Atrial fibrillation and risk of cardiovascular events and mortality in patients with symptomatic peripheral artery disease: a meta-analysis of prospective studies.
        Clin Cardiol. 2017; 40: 1231-1235
        • Tseng AS
        • Girardo M
        • Firth C
        • et al.
        Lower extremity arterial disease as a predictor of incident atrial fibrillation and cardiovascular events.
        Mayo Clin Proc. 2021; 96: 1175-1183
        • Klein A
        • Shenasa M
        • Baranchuk A.
        Social risk factors and atrial fibrillation.
        Card Electrophysiol Clin. 2021; 13: 165-172