Browsing by Author "Mustonen, Pirjo"

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  • Alcohol use disorder and initiation of oral anticoagulant therapy in patients with atrial fibrillation : A nationwide cohort study
    (2025-03-01) Vanhanen, Miika; Jaakkola, Jussi; Airaksinen, Juhani K.E.; Halminen, Olli; Putaala, Jukka; Mustonen, Pirjo; Haukka, Jari; Hartikainen, Juha; Luojus, Alex; Niemi, Mikko; Linna, Miika; Lehto, Mika; Teppo, Konsta
     A1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä
    Objective: Patients with alcohol use disorders (AUD) often receive inferior care for somatic comorbidities. Our objective was to explore whether AUDs influence oral anticoagulant (OAC) initiation for stroke prevention among atrial fibrillation (AF) patients, using a nationwide dataset to assess treatment disparities. Methods: The Finnish AntiCoagulation in Atrial Fibrillation registry includes data on all 229,565 patients diagnosed with incident AF in Finland during 2007–2018, identified from national registries covering all levels of care. The main outcome was OAC initiation compared between patients with and without AUD. Results: The patients' mean age was 72.7 years, 50 % were female, 85.0 % were eligible for OAC therapy (CHA2DS2-VA score ≥ 1), and 4.7 % had AUD. OAC therapy was initiated in a smaller proportion of patients with AUD compared to those without (52.5 % vs. 71.4 %, p < 0.001). This disparity remained significant even after adjusting for comorbidities, socioeconomic status, and laboratory values influencing OAC initiation (adjusted hazard ratio [HR] 0.68; 95 % confidence interval [0.66–0.71]). The absolute difference in OAC initiation between groups stayed consistent at approximately 20 % throughout the study period. Interaction analyses indicated that the association between AUD and lower OAC initiation was stronger in patients with lower income, lower educational attainment, and lower thrombocyte levels, but there was no significant interaction with sex, bleeding history, or hemoglobin levels. Conclusions: AUDs are associated with a significantly lower rate of OAC initiation even after accounting for comorbidities that influence OAC initiation.
  • Aortic Stenosis and Outcomes in Patients With Atrial Fibrillation : A Nationwide Cohort Study
    (2023-05-02) Teppo, Konsta; Juhani Airaksinen, K. E.; Biancari, Fausto; Jaakkola, Jussi; Halminen, Olli; Linna, Miika; Haukka, Jari; Putaala, Jukka; Mustonen, Pirjo; Kinnunen, Janne; Luojus, Alex; Hartikainen, Juha; Aro, Aapo L.; Lehto, Mika
     A1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä
    BACKGROUND: Patients with aortic stenosis (AS) have been underrepresented in the trials evaluating direct oral anticoagulants (DOACs) in atrial fibrillation (AF). We aimed to assess whether AS impacts outcomes in patients with AF and estimate the effects of DOACs versus warfarin in patients with AF and AS. METHODS AND RESULTS: The registry-based FinACAF (Finnish Anticoagulation in Atrial Fibrillation) study covered all patients with AF diagnosed during 2007 to 2018 in Finland. Hazard ratios (HRs) of first-ever gastrointestinal bleeding, intracranial bleeding, any bleeding, ischemic stroke, and death were estimated with cause-specific hazards regression adjusted for anticoagulant exposure variables. We identified 183 946 patients (50.5% women; mean age, 71.7 [SD, 13.5] years) with incident AF without prior bleeding or ischemic stroke, of whom 5231 (2.8%) had AS. The crude incidence rate of all outcomes was higher in patients with AS than in patients without AS. After propensity score matching, AS was associated with the hazard of any bleeding, gastrointestinal bleeding, and death but not with intracranial bleeding or ischemic stroke (adjusted HRs, 1.36 [95% CI, 1.25–1.48], 1.63 [95% CI, 1.43–1.86], 1.32 [95% CI, 1.26–1.38], 0.96 [95% CI, 0.78–1.17], and 1.11 [95% CI, 0.99–1.25], respectively). Among patients with AS, DOACs were associated with a lower risk of ischemic stroke when compared with warfarin, while bleeding and mortality did not differ between DOACs and warfarin. CONCLUSIONS: AS is associated with substantially higher risk of gastrointestinal bleeding in patients with AF. DOACs may be more effective in preventing ischemic stroke than warfarin in patients with AF and AS. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04645537.
  • Association of income and educational levels on initiation of oral anticoagulant therapy in patients with incident atrial fibrillation: A Finnish nationwide cohort study
    (2023-01) Teppo, Konsta; Jaakkola, Jussi; Biancari, Fausto; Halminen, Olli; Linna, Miika; Haukka, Jari; Putaala, Jukka; Mustonen, Pirjo; Kinnunen, Janne; Hartikainen, Juha; Airaksinen, K. E.Juhani; Lehto, Mika
     A1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä
    Aims: Socioeconomic disparities have been reported in the outcomes of patients with atrial fibrillation (AF). We assessed the hypothesis that AF patients with higher income or educational level are more frequently initiated with oral anticoagulant (OAC) therapy for stroke prevention. Methods: The nationwide registry-based Finnish AntiCoagulation in Atrial Fibrillation cohort covers all patients with AF from all levels of care in Finland. Patients were divided into income quartiles according to their highest annual income during 2004-2018 and into three categories based on educational attainment. The outcome was the first redeemed OAC prescription. Results: We identified 239 222 patients (mean age 72.7 ± 13.2 years, 49.8% female) with incident AF during 2007-2018. Higher income was associated with higher OAC initiation rate: compared to the lowest income quartile the adjusted SHRs (95% CI) for OAC initiation were 1.09 (1.07-1.10), 1.13 (1.11-1.14) and 1.13 (1.12-1.15) in the second, third and fourth income quartiles, respectively. Patients in the highest educational category had a slightly lower OAC initiation rate than patients in the lowest educational category (adjusted SHR 0.92 [95% CI 0.90-0.93]). Income-related disparities were larger and education-related disparities only marginal among patients at high risk of ischemic stroke. The socioeconomic disparities in OAC initiation within 1-year follow-up decreased from 2007 to 2018. The adoption of direct OACs as the initial anticoagulant was faster among patients with higher income or educational levels. Conclusion: These findings highlight potential missed opportunities in stroke prevention, especially among AF patients with low income, whereas the education-related disparities in OAC initiation appear controversial.
  • Association of income and educational levels with adherence to direct oral anticoagulant therapy in patients with incident atrial fibrillation: A Finnish nationwide cohort study
    (2022-06) Teppo, Konsta; Jaakkola, Jussi; Biancari, Fausto; Halminen, Olli; Linna, Miika; Haukka, Jari; Putaala, Jukka; Tiili, Paula; Lehtonen, Ossi; Niemi, Mikko; Mustonen, Pirjo; Kinnunen, Janne; Hartikainen, Juha; Airaksinen, K. E.Juhani; Lehto, Mika
     A1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä
    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 (CHA2DS2-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.
  • Comparing CHA2DS2-VA and CHA2DS2-VASc scores for stroke risk stratification in patients with atrial fibrillation : a temporal trends analysis from the retrospective Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) cohort
    (2024-08) Teppo, Konsta; Lip, Gregory Yoke Hong; Airaksinen, Kari Eino Juhani; Halminen, Olli; Haukka, Jari; Putaala, Jukka; Mustonen, Pirjo; Linna, Miika; Hartikainen, Juha; Lehto, Mika
     A1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä
    Background: Contemporary data have shown a decrease in the ischaemic stroke risk associated with female sex in patients with atrial fibrillation (AF). We evaluated temporal trends in the predictive value of a non-sex CHA2DS2-VASc risk score (ie. CHA2DS2-VA). Methods: The FinACAF study covers all patients with incident AF between 2007 and 2018 in Finland from all levels of care. The CHA2DS2-VA score was compared with the CHA2DS2-VASc using continuous and category-based net reclassification indices (NRIs), integrated discrimination improvement (IDI), c-statistics and decision curve analyses. Findings: We identified 144,879 anticoagulant naïve patients with new-onset AF between 2007 and 2018 (49.9% women; mean age 72.1 years), of whom 3936 (2.7%) experienced ischaemic stroke during one-year follow-up. Based on both continuous and category-based NRIs, the CHA2DS2-VA score was inferior to the CHA2DS2-VASc in the early years (−0.333 (95% CI −0.411 to −0.261) and −0.118 (95% CI −0.137 to −0.099), respectively). However, the differences attenuated over time, and by the end of the study period, the continuous NRI became non-significant (−0.093 (95% CI −0.165 to 0.032)), whereas the category-based NRI reversed in favor of the CHA2DS2-VA (0.070 (95% CI 0.048–0.087)). The IDI was non-significant in early years (0.0009 (95% CI −0.0024 to 0.0037)), but over time became statistically significant in favor of the CHA2DS2-VA score (0.0022 (95% CI 0.0001–0.0044)). The Cox models fitted with the CHA2DS2-VA and the CHA2DS2-VASc scores exhibited comparable discriminative capability in the beginning of the study (p-value 0.63), but over time marginal differences in favor of the CHA2DS2-VA score emerged (p-value 0.0002). Interpretation: In 2007–2008 (when females had higher AF-related stroke risks than males), the CHA2DS2-VASc score outperformed the CHA2DS2-VA score, but the initial differences between the scores attenuated over time. By the end of the study period in 2017–2018 (with limited/no sex differences in AF-related stroke), there was marginal superiority for the CHA2DS2-VA score. Funding: This work was supported by the Aarne Koskelo Foundation, The Finnish Foundation for Cardiovascular Research, The Finnish State Research funding, and Helsinki and Uusimaa Hospital District research fund.
  • Comprehensive nationwide incidence and prevalence trends of atrial fibrillation in Finland
    (2022-11-22) Lehto, Mika; Haukka, Jari; Aro, Aapo; Halminen, Olli; Putaala, Jukka; Linna, Miika; Mustonen, Pirjo; Kinnunen, Janne; Kouki, Elis; Niiranen, Jussi; Luojus, Alex; Tiili, Paula; Itäinen-Strömberg, Saga; Hartikainen, Juha; Airaksinen, Juhani K.E.
     A1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä
    Objective: Atrial fibrillation (AF) is a worldwide healthcare challenge owing to population ageing. In this study, we assessed the current trends in the incidence and prevalence of AF for the first time in an unselected, nationwide population. Methods: In the Finnish Anticoagulation in Atrial Fibrillation study, we gathered comprehensive data including all primary, secondary and tertiary healthcare visits and drug reimbursement from national healthcare registers to identify all patients with incident AF between 2004 and 2018 in Finland. Incident AF was defined as new-onset AF occurring after 2007. Time trends for the incidence and prevalence of AF were calculated and stratified by sex and age. Results: A total of 411 387 patients with AF diagnosis were documented in Finland during 2004-2018. In 2018, the incidence and prevalence of AF in the total Finnish population were 469/100 000 and 4.1%, respectively. The incidence of new-onset AF in the adult population (≥20 years) increased from 471/100 000 in 2007 to 604/100 000 in 2018, but the age-adjusted incidence remained stable. The prevalence of AF increased in the adult population from 2.5% to 5.2%, and was higher in men than in women (5.9% vs 4.6%, p<0.001). The incidence and prevalence of AF increased with age and were 3194/100 000 and 23.4% in patients older than 75 years. Conclusions: Based on comprehensive nationwide data including primary care, we observed an increasing incidence and prevalence of AF over time. This increase was strongly age-dependent with the age-standardised incidence remaining stable during 2007-2018.
  • The effect of mental health conditions on the use of oral anticoagulation therapy in patients with atrial fibrillation: the FinACAF study
    (2022-05) Jaakkola, Jussi; Teppo, Konsta; Biancari, Fausto; Halminen, Olli; Putaala, Jukka; Mustonen, Pirjo; Haukka, Jari; Linna, Miika; Kinnunen, Janne; Tiili, Paula; Aro, Aapo L.; Hartikainen, Juha; Airaksinen, K. E. Juhani; Lehto, Mika
     A1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä
    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 Conclusion MHCs are common among AF patients, and they are associated with a lower rate of OAC initiation even during the NOAC era.
  • How to extend value-based healthcare to population-based healthcare systems? Defining an outcome-based segmentation model for health authority
    (2023-11-15) Torkki, Paulus; Leskelä, Riikka-Leena; Mustonen, Pirjo; Linna, Miika; Lillrank, Paul
     A1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä
    Objectives Value-based healthcare (VBHC) is considered the most promising guiding principle for a new generation of health service production. Many countries have attempted to apply VBHC to managerial and clinical decision-making. However, implementation remains in its infancy and varies between countries. The objective of the study is to help health systems implement a value-based approach by building an outcome-based population segmentation model for health authorities (HAs). Design First, we define the principles according to which segmentation models in healthcare could be developed. Second, we merge the theoretical characteristics of outcomes with population segmentation dimensions identified in previous literature and design a flow model that establishes population segments from these combinations. We then estimate the size of the segments based on national register data. Results The population can be divided into 10 different segments based on relevant outcomes, goals and the outcome measurement logic. These segments consist of healthy, help, increased risk, mild curable without risk, mild curable with risk, severe curable without risk, severe curable with risk, single chronic, multimorbid and terminal. The representatives of Finnish HAs found the segments meaningful for evaluating and managing the healthcare system towards improved population health. Conclusions An outcome-based segmentation model for the entire population is needed if an HA wants to steer the healthcare system employing the principles of VBHC. Segmentation should be based on the outcome measurement logic and outcome measurements relevant to each segment and the number of segments has to be limited.
  • Income and outcomes of patients with incident atrial fibrillation
    (2022-08-01) Biancari, Fausto; Teppo, Konsta; Jaakkola, Jussi; Halminen, Olli; Linna, Miika; Haukka, Jari; Putaala, Jukka; Mustonen, Pirjo; Kinnunen, Janne; Hartikainen, Juha; Aro, Aapo; Airaksinen, Juhani; Lehto, Mika
     A1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä
    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 <65 years and 65-74 years, but not in those ≥75 years. The magnitude of this effect was greatest in patients aged <65 years. After propensity score matching of patients <65 years in the lowest and highest quintiles of maximum personal annual income, at 10 years, those in the highest income quintile (≥€54 000) had significantly lower risk of first-ever stroke (subdistribution HR 0.495, 95% CI 0.391 to 0.628) and overall mortality (HR 0.307, 95% CI 0.269 to 0.351) compared with patients in the lowest income quintile (≤€12 000). 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. Trial registration number NCT04645537.
  • Ischaemic stroke in women with atrial fibrillation : temporal trends and clinical implications
    (2024-05-21) Teppo, Konsta; Airaksinen, K. E. Juhani; Jaakkola, Jussi; Halminen, O; Salmela, Birgitta; Kouki, Elis; Haukka, Jari; Putaala, Jukka; Linna, Miika; Aro, Aapo L.; Mustonen, Pirjo; Hartikainen, Juha; Lip, Gregory Y. H.; Lehto, Mika
     A1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä
    Background and Aims Female sex has been linked with higher risk of ischaemic stroke (IS) in atrial fibrillation (AF), but no prior study has examined temporal trends in the IS risk associated with female sex. Methods The registry-linkage Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study included all patients with AF in Finland from 2007 to 2018. Ischaemic stroke rates and rate ratios were computed. Results Overall, 229 565 patients with new-onset AF were identified (50.0% women; mean age 72.7 years). The crude IS incidence was higher in women than in men across the entire study period (21.1 vs. 14.9 events per 1000 patient-years, P < .001), and the incidence decreased both in men and women. In 2007–08, female sex was independently associated with a 20%–30% higher IS rate in the adjusted analyses, but this association attenuated and became statistically non-significant by the end of the observation period. Similar trends were observed when time with and without oral anticoagulant (OAC) treatment was analysed, as well as when only time without OAC use was considered. The decrease in IS rate was driven by patients with high IS risk, whereas in patients with low or moderate IS risk, female sex was not associated with a higher IS rate. Conclusions The association between female sex and IS rate has decreased and become non-significant over the course of the study period from 2007 to 2018, suggesting that female sex could be omitted as a factor when estimating expected IS rates and the need for OAC therapy in patients with AF.
  • Ischemic Stroke Temporally Associated with New-Onset Atrial Fibrillation : A Population-Based Registry-Linkage Study
    (2024-01-01) Putaala, Jukka; Teppo, Konsta; Halminen, Olli; Haukka, Jari; Tiili, Paula; Jaakkola, Jussi; Karlsson, Elin; Linna, Miika; Mustonen, Pirjo; Kinnunen, Janne; Kiviniemi, Tuomas; Aro, Aapo; Hartikainen, Juha; Airaksinen, Juhani K.E.; Lehto, Mika
     A1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä
    BACKGROUND: Limited data exist on the temporal relationship between new-onset atrial fibrillation (AF) and ischemic stroke and its impact on patients' clinical characteristics and mortality. METHODS: A population-based registry-linkage database includes all patients with new-onset AF in Finland from 2007 to 2018. Ischemic stroke temporally associated with AF (ISTAF) was defined as an ischemic stroke occurring within ±30 days from the first AF diagnosis. Clinical factors associated with ISTAF were studied with logistic regression and 90-day survival with Cox proportional hazards analysis. RESULTS: Among 229 565 patients with new-onset AF (mean age, 72.7 years; 50% female), 204 774 (89.2%) experienced no ischemic stroke, 12 209 (5.3%) had past ischemic stroke >30 days before AF, and 12 582 (5.8%) had ISTAF. The annual proportion of ISTAF among patients with AF decreased from 6.0% to 4.8% from 2007 to 2018. Factors associated positively with ISTAF were higher age, lower education level, and alcohol use disorder, whereas vascular disease, heart failure, chronic kidney disease cancer, and psychiatric disorders were less probable with ISTAF. Compared with patients without ischemic stroke and those with past ischemic stroke, ISTAF was associated with ≈3-fold and 1.5-fold risks of death (adjusted hazard ratios, 2.90 [95% CI, 2.76-3.04] and 1.47 [95% CI, 1.39-1.57], respectively). The 90-day survival probability of patients with ISTAF increased from 0.79 (95% CI, 0.76-0.81) in 2007 to 0.89 (95% CI, 0.87-0.91) in 2018. CONCLUSIONS: ISTAF depicts the prominent temporal clustering of ischemic strokes surrounding AF diagnosis. Despite having fewer comorbidities, patients with ISTAF had worse, albeit improving, survival than patients with a history of or no ischemic stroke. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04645537. URL: https://www.encepp.eu; Unique identifier: EUPAS29845.
  • Mental health conditions and adherence to direct oral anticoagulants in patients with incident atrial fibrillation: A nationwide cohort study
    (2022-01-01) Teppo, Konsta; Jaakkola, Jussi; Airaksinen, K. E.Juhani; Biancari, Fausto; Halminen, Olli; Putaala, Jukka; Mustonen, Pirjo; Haukka, Jari; Hartikainen, Juha; Luojus, Alex; Niemi, Mikko; Linna, Miika; Lehto, Mika
     A1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä
    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.
  • Mental health conditions and bleeding events in patients with incident atrial fibrillation: A Finnish nationwide cohort study
    (2022-09-01) Teppo, Konsta; Jaakkola, Jussi; Biancari, Fausto; Halminen, Olli; Linna, Miika; Putaala, Jukka; Mustonen, Pirjo; Kinnunen, Janne; Jolkkonen, Santeri; Niemi, Mikko; Hartikainen, Juha; Airaksinen, K. E.Juhani; Lehto, Mika
     A1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä
    Objective: We assessed the hypothesis that mental health conditions (MHCs) are associated with higher risk of bleeding in patients with atrial fibrillation (AF). Methods: The registry-based FinACAF study covers all patients with AF diagnosed during 2007–2018 in Finland. MHCs of interest were depression, bipolar disorder, anxiety disorder, schizophrenia, and any MHC. The outcomes were first-ever gastrointestinal, intracranial, and any bleeding event. Results: We identified 205,019 patients (50.9% female; mean age 72.3 [standard deviation 13.4] years) with incident AF without prior bleeding, and the prevalence of any MHC was 6.1%. Any MHC, depression, and anxiety disorder were associated with the risk of any bleeding (adjusted hazard ratios (HRs) 1.19 [1.12–1.27], 1.21 [1.13–1.30], and 1.21 [1.08–1.35], respectively). Additionally, any MHC and depression were associated with the risk of gastrointestinal and intracranial bleeding and anxiety disorder with gastrointestinal bleeding. Bipolar disorder and schizophrenia were not associated with risk of bleeding. Use of oral anticoagulants was associated with the risk of any bleeding (adjusted HR 1.24 [95% CI 1.21–1.28)]), and this association was similar in patients with and without MHCs. Serotonin reuptake inhibitors were not associated with bleeding risk. Conclusions: MHCs are associated with a higher risk of bleeding in patients with AF.
  • Mental Health Conditions and Nonpersistence of Direct Oral Anticoagulant Use in Patients With Incident Atrial Fibrillation: A Nationwide Cohort Study
    (2022-03-15) Teppo, Konsta; Jaakkola, Jussi; Airaksinen, K. E.Juhani; Biancari, Fausto; Halminen, Olli; Putaala, Jukka; Mustonen, Pirjo; Haukka, Jari; Hartikainen, Juha; Luojus, Alex; Niemi, Mikko; Linna, Miika; Lehto, Mika
     A1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä
    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 (CHA2DS2-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<0.001). Higher incidence of nonpersistence to DOACs was observed in all MHC categories: adjusted subdistribution hazard ratios, 1.16 (95% CI, 1.11-1.21) for any MHC, 1.32 (95% CI, 1.22-1.42) for depression, 1.44 (95% CI, 1.15-1.80) for bipolar disorder, 1.25 (95% CI, 1.11-1.41) for anxiety disorder, and 1.30 (95% CI, 1.02-1.64) for schizophrenia. However, patients with only anxiety disorder without other MHCs were not at higher risk of nonpersistence. Conclusions: MHCs are associated with nonpersistence of DOAC use. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04645537.
  • Mental health conditions and risk of first-ever ischaemic stroke and death in patients with incident atrial fibrillation: A nationwide cohort study
    (2022-09) Teppo, Konsta; Jaakkola, Jussi; Biancari, Fausto; Halminen, Olli; Putaala, Jukka; Mustonen, Pirjo; Haukka, Jari; Linna, Miika; Kinnunen, Janne; Tiili, Paula; Kouki, Elis; Penttilä, Tero; Hartikainen, Juha; Aro, Aapo L.; Airaksinen, K. E.Juhani; Lehto, Mika
     A1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä
    Background: Atrial fibrillation (AF) patients with mental health conditions (MHCs) have higher incidence of ischaemic stroke (IS) than patients without MHC, but whether this results from direct impact of MHCs or relates to higher prevalence of comorbidities and differences in the use of oral anticoagulant (OAC) therapy is unclear. We assessed the hypothesis that MHCs independently increase the risk of IS in patients with incident AF. Methods: The nationwide FinACAF cohort covered all 203,154 patients diagnosed with incident AF without previous IS or transient ischaemic attack in Finland during 2007–2018. MHCs of interest were depression, bipolar disorder, anxiety disorder, schizophrenia and any MHC. The outcomes were first-ever IS and all-cause death. Results: The patients' (mean age 73.0 ± 13.5 years, 49.0% female) mean follow-up time was 4.3 (SD 3.3) years and 16,272 (8.0%) experienced first-ever IS and 63,420 (31.2%) died during follow-up. After propensity score matching and adjusting for OAC use, no MHC group was associated with increased IS risk (adjusted SHRs (95% CI): depression 0.961 (0.857–1.077), bipolar disorder 1.398 (0.947–2.006), anxiety disorder 0.878 (0.718–1.034), schizophrenia 0.803 (0.594–1.085) and any MHC 1.033 (0.985–1.085)). Lower rate of OAC use partly explained the observed higher crude IS incidence in patients with any MHC. Depression, schizophrenia and any MHC were associated with higher all-cause mortality (adjusted HRs [95% CI]: 1.208 [1.136–1.283], 1.543 [1.352–1.761] and 1.149 [1.116–1.175], respectively). Conclusions: In this nationwide retrospective cohort study, MHCs were not associated with the incidence of first-ever IS in patients with AF.
  • Mental health conditions and use of rhythm control therapies in patients with atrial fibrillation: a nationwide cohort study
    (2022-08-30) Teppo, Konsta; Jaakkola, Jussi; Biancari, Fausto; Halminen, Olli; Putaala, Jukka; Mustonen, Pirjo; Haukka, Jari; Linna, Miika; Kinnunen, Janne; Luojus, Alex; Itäinen-Strömberg, Saga; Penttilä, Tero; Niemi, Mikko; Hartikainen, Juha; Airaksinen, Ke Juhani; Lehto, Mika
     A1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä
    OBJECTIVES: Mental health conditions (MHCs) have been associated with undertreatment of unrelated medical conditions, but whether patients with MHCs face disparities in receiving rhythm control therapies for atrial fibrillation (AF) is currently unknown. We assessed the hypothesis that MHCs are associated with a lower use of antiarrhythmic therapies (AATs). DESIGN: A nationwide retrospective registry-based cohort study. SETTING: The Finnish AntiCoagulation in Atrial Fibrillation cohort included records on all patients with AF in Finland during 2007-2018 identified from nationwide registries covering all levels of care as well as drug purchases. MHCs of interest were diagnosed depression, bipolar disorder, anxiety disorder, schizophrenia and any MHC. PARTICIPANTS: We identified 239 222 patients (mean age 72.6±13.2 years; 49.8% women) with incident AF, in whom the prevalence of any MHC was 19.9%. OUTCOMES: Primary outcome was use of any AAT, including cardioversion, catheter ablation, and fulfilled antiarrhythmic drug (AAD) prescription. RESULTS: Lower overall use of any AAT emerged in patients with any MHC than in those without MHC (16.9% vs 22.9%, p<0.001). Any MHC, depression, bipolar disorder, anxiety disorder and schizophrenia were all associated with lower incidence of any AAT with adjusted subdistribution HRs of 0.790 (95% CI 0.771 to 0.809), 0.817 (0.796 to 0.838), 0.811 (0.789 to 0.835), 0.807 (0.785 to 0.830) and 0.795 (0.773 to 0.818), respectively. Adjusted rates of AAD, cardioversion and catheter ablation use were lower in all MHC groups compared with patients without MHC. The findings in patients with any MHC were confirmed in propensity score matching analysis. CONCLUSIONS: Among patients with AF, a clear disparity exists in AAT use between those with and without MHCs. TRIAL REGISTRATION NUMBER: ClinicalTrials Identifier: NCT04645537; ENCePP Identifier: EUPAS29845.
  • The nationwide Finnish anticoagulation in atrial fibrillation (FinACAF): study rationale, design, and patient characteristics
    (2022-01) Lehto, Mika; Halminen, Olli; Mustonen, Pirjo; Putaala, Jukka; Linna, Miika; Kinnunen, Janne; Kouki, Elis; Niiranen, Jussi; Hartikainen, Juha; Haukka, Jari; Airaksinen, Kari Eino Juhani
     A1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä
    Atrial fibrillation (AF) is a major cause of ischemic stroke and the number of AF patients is increasing. Thus, up-to-date multifaceted data about the characteristics of AF patients, their treatments, and outcomes are urgently needed. The Finnish anticoagulation in atrial fibrillation (FinACAF) study has collected comprehensive data on all Finnish AF patients from 1st January 2004 to 31st December 2018. The aim of this paper is to describe the study rationale, the process of integrating data from the applied resources and to define the study cohort. Using national unique personal identification number, individual patient data is linked from nationwide health care registries (primary, secondary, and tertiary care), drug purchases, education, and socio-economic status as well as places of domicile, incomes, and taxes. Six regional laboratory databases (~ 282,000, 77% of the patients) are also included. The study cohort comprises of a total of 411,000 patients. Since the introduction of the national primary care register in 2012, 9% of all AF patients were identified outside hospital care registers. The prevalence of AF in Finland—4.1% of whole population—is for the first time now established. The FinACAF study allows a unique possibility to investigate the epidemiology and socio-medico-economic impact of AF as well as the cost effectiveness of different AF management strategies in a completely unselected, nationwide population. This article provides the rationale and design of the study together with a summary of the characteristics of the cohort.
  • Oral Anticoagulant Therapy and Risk of Admission to Long-Term Care in patients With Atrial Fibrillation : A Nationwide Cohort Study
    (2023-10) Teppo, Konsta; Airaksinen, K. E.Juhani; Halminen, Olli; Linna, Miika; Jaakkola, Jussi; Haukka, Jari; Putaala, Jukka; Mustonen, Pirjo; Langén, Ville L.; Kinnunen, Janne; Hartikainen, Juha; Lehto, Mika
     A1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä
    Objectives: The impact of oral anticoagulants (OACs) on the need of long-term care (LTC) in the aging and multimorbid population of patients with atrial fibrillation (AF) is unknown. We conducted a nationwide cohort study to evaluate the effect of OACs on the need of LTC. Design: Retrospective nationwide cohort study. Setting and Participants: The registry-based FinACAF cohort study covers all patients with incident AF from all levels of care in Finland from 2007 to 2018, as well as all their OAC purchases, LTC admissions, and information on previous home care acuity. Methods: Incidence rate ratios (IRRs) of LTC admission were calculated using Poisson regression models with a Lexis-type data structure based on 3 time scales: follow-up time from AF diagnosis, calendar year, and age. Results: We identified 188,752 patients (49.0% female; mean age 71.4 years; mean follow-up 3.6 years) with incident AF without prior LTC, of whom 143,534 (76.0 %) initiated OAC therapy and 11,775 (6.2 %) were admitted to LTC. OAC therapy was associated with lower rates of LTC admission (adjusted IRR 0.79, 95% CI 0.76-0.82). When compared to warfarin, direct oral anticoagulants (DOACs) were associated with lower LTC admission rate (adjusted IRR 0.69, 95% CI 0.61-0.79). No significant disparities were observed between different DOACs. Conclusions and Implications: OAC therapy, particularly with DOACs, is associated with a substantially lower risk of admission to LTC in patients with AF. Increasing guideline-based OAC coverage among patients with AF may prevent the need of LTC, lengthen survival at home, and potentially decrease health care costs.
  • Rural–urban and geographical differences in prognosis of atrial fibrillation in Finland : a nationwide cohort study
    (2024-11) Teppo, Konsta; Airaksinen, K. E.Juhani; Halminen, Olli; Jaakkola, Jussi; Linna, Miika; Haukka, Jari; Putaala, Jukka; Mustonen, Pirjo; Kinnunen, Janne; Hartikainen, Juha; Lehto, Mika
     A1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä
    Aims: Rural–urban disparities have been reported in the outcomes of cardiovascular diseases. We assessed whether rural–urban or other geographical disparities exist in the risk of ischemic stroke (IS) and death in patients with atrial fibrillation (AF) in Finland. Methods: The registry-based FinACAF cohort study covers all patients with AF from all levels of care in Finland from 2007 to 2018. Patients were divided into rural–urban categories and into hospital districts (HDs) based on their municipality of residence. Results: We identified 222,051 patients (50.1% female; mean age 72.8 years; mean follow-up 3.9 years) with new-onset AF, of whom 15,567 (7.0%) patients suffered IS and 72,565 (32.7%) died during follow-up. The crude IS rate was similar between rural and urban areas, whereas the mortality rate was lower in urban areas (incidence rate ratios (IRRs) with 95% confidence intervals (CIs) 0.97 (0.93–1.00) and 0.92 (0.91–0.93), respectively). However, after adjustments, urban residence was associated with slightly higher IS and mortality rates (IRRs with 95% CIs 1.05 (1.01–1.08) and 1.06 (1.04–1.07), respectively). The highest crude IS rate was in the East Savo HD and the lowest in Åland, whereas the highest crude mortality rate was in the Länsi-Pohja HD and the lowest in the North Ostrobothnia HD (IRRs with 95% CIs compared to Helsinki and Uusimaa HD for IS 1.46 (1.28–1.67) and 0.79 (0.62–1.01), and mortality 1.24 (1.16–1.32) and 0.97 (0.93–1.00), respectively. Conclusions: Rural–urban differences in prognosis of AF in Finland appear minimal, whereas considerable disparities exist between HDs.
  • Rural-urban differences in the initiation of oral anticoagulant therapy in patients with incident atrial fibrillation : A Finnish nationwide cohort study
    (2022) Teppo, Konsta; Jaakkola, Jussi; Langén, Ville L.; Biancari, Fausto; Halminen, Olli; Linna, Miika; Haukka, Jari; Putaala, Jukka; Mustonen, Pirjo; Kinnunen, Janne; Luojus, Alex; Hartikainen, Juha; Airaksinen, K. E.Juhani; Lehto, Mika
     A1 Alkuperäisartikkeli tieteellisessä aikakauslehdessä
    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.