CC Cardiol Croat Cardiologia Croatica Cardiol. Croat. 1848-543X 1848-5448 Croatian Cardiac Society CC_13(11-12)_348 10.15836/ccar2018.348 Extended Abstract The annual risk profile for ischemic stroke/bleeding determined by CHA2DS2-VASc/HAS-BLED score and circulating levels of hs-troponin I and NT-proBNP at admission of patients with acutely decompensated heart failure and atrial fibrillation Profil godišnjeg rizika za ishemijski moždani udar/krvarenje određen CHA2DS2-VASc/HAS-BLED zbrojem te cirkulirajuće razine hs-troponina I i NT-proBNP-a kod prijema akutno dekompenziranih bolesnika sa zatajivanjem srca i fibrilacijom atrija https://orcid.org/0000-0002-4878-8146BorovacJosip Anđelo12*https://orcid.org/0000-0003-1634-0635BožićJoško1https://orcid.org/0000-0001-9999-7557GrabovacZora Sušilović2https://orcid.org/0000-0002-9843-6309BradarićAnteo12https://orcid.org/0000-0001-9272-6906MatetićAndrija1https://orcid.org/0000-0002-7174-0722NovakKatarina1http://orcid.org/0000-0003-2649-0936GlavašDuška12 Medicinski fakultet Sveučilišta u Splitu, Split, Hrvatska Klinički bolnički centar Split, Split, Hrvatska University of Split School of Medicine, Split, Croatia University Hospital of Split, Split, Croatia ADDRESS FOR CORRESPONDENCE: Josip Anđelo Borovac, Klinički bolnički centar Split, Spinčićeva 1, HR-210000 Split, Croatia. / Phone: +385-92-172-1314 / E-mail: jborovac@mefst.hr 112018 13 11-12 348 349 2109201805112018 2018 Croatian Cardiac Society KLJUČNE RIJEČI: fibrilacija atrijazatajivanje srcaishemijski moždani udar KEYWORDS: atrial fibrillationheart failureischemic stroke

Introduction: Atrial fibrillation (AF) is the most common arrhythmia associated with heart failure (HF). (1) Previous studies have shown correlation of cardiac markers such as NT-proBNP and high-sensitivity Troponin I (hsTnI) with increased risk for thromboembolic and adverse cardiovascular events in patients with AF. (2) Goals of this study were to evaluate the risk for ischemic stroke (IS) and significant bleeding, to examine clinical and laboratory characteristics, and to determine potential associations of NT-proBNP and hsTnI with aforementioned risks in patients with acute decompensated HF (ADHF) and AF.

Patients and Methods: This study included a total of 47 patients with ADHF and AF, diagnosed according to the current criteria of the European Society of Cardiology (ESC)1, which were hospitalized in University Hospital Centre Split during 2018 (Table 1). Patients with an acute coronary syndrome and/or infectious disease were excluded.

Baseline characteristics of heart failure patients with atrial fibrillation.
Variable Mean ± SD or N(%)or Median (IQR) Variable Mean ± SD or N(%) or Median (IQR)
Age (years) 73.3 ± 9.9 LAVI (mL/m2) 41.3 ± 15.7
BMI (kg/m2) 30.1 ± 4.1 Hemoglobin (g/L) 142 ± 17
Male sex 32 (68.1%) PT-INR 3.2 ± 2.4
Positive history of a prior ACS event 18 (38.3%) APTT (s) 30.6 ± 13.4
Prior stroke, TIA or thromboembolism 7 (14.9%) NT-proBNP at index admission (pg/mL) 6550 ± 3381
Prior CABG 8 (17.0%) hs-cTnI at index admission (ng/mL) 56.7 ± 40.6
Arterial hypertension 42 (89.4%) CRP at index admission (mg/L) 27.3 ± 29.2
Dyslipidemia 27 (57.4%) Mean HR at admission (bpm) 100 ± 27
Diabetes mellitus 16 (34.0%) Mean QRS duration (msec) 115 ± 33
Smoking (ex or current) 13 (26.5%) Mean QTc (msec) 433 ± 47
PAD 12 (25.5%) Prolonged QT interval 17 (36.2%)
Vascular disease (PAD, AMI, aortic plaque) 27 (57.4%) Oral anticoagulants 40 (85.1%)
CHA2DS2-VASc score 5 (4-5)    Warfarin 21/40 (52.5%)
   0-4% stroke or thromboembolism risk 17 (36.2%)    NOAC 19/40 (47.5%)
   4-8% stroke or thromboembolism risk 16 (34.0%) Antiplatelet agent 10 (21.3%)
   >8% stroke or thromboembolism risk 14 (29.8%) ACE inhibitor or ARB 38 (80.9%)
HAS-BLED score 2 (1-2) Beta-blocker 38 (80.9%)
NYHA functional class 3 (2-4) Loop and/or thiazide and/or thiazide-like diuretics 39 (82.9%)
SBP (mmHg) 132 ± 20 ARNi 8 (17.0%)
DBP (mmHg) 81 ± 11 Mineralocorticoid antagonist 14 (29.8%)
eGFR (mL/min/1.73 m2) 57.1 ± 22.5 Calcium channel blocker 10 (21.3%)
LVEF (%) 37 ± 14 Digoxin 15 (31.9%)
LA diameter (mm) 52 ± 10 Statin 18 (38.3%)
LA volume (mL) 72 ± 31 Allopurinol 7 (14.9%)
Abbreviations: ACE-angiotensin-converting enzyme; ACS-acute coronary syndrome; AMI-acute myocardial infarction; APTT-activated partial thromboplastin time; ARB-angiotensin II receptor blocker, ARNi-angiotensin receptor-neprilysin inhibitor; BMI-body mass index, CABG-coronary artery bypass grafting; CRP-C-reactive protein; DBP-diastolic blood pressure; eGFR-estimated glomerular filtration rate; HR-heart rate; hs-cTnI-high-sensitivity cardiac troponin I; LA-left atrium; LAVI-left atrial volume indexed by body surface; NT-proBNP-N-terminal prohormone of brain natriuretic peptide; NYHA-New York Heart Association functional classification of heart failure; PAD-peripheral artery disease; PT-INR-prothrombin time international standardized ratio; SBP-systolic blood pressure; TIA-transient ischemic attack.

Results: Mean annual risk for IS without therapy was 8.74% while bleeding risk was 0.60% (p<0.001). After risk adjustment for individual antithrombotic therapy, mean risks for IS and bleeding were 3.46% and 3.10%, respectively, without significant difference between these risks (p=0.430). Use of non-vitamin K oral anticoagulants was almost equated with warfarin use (47.5% vs. 52.5%). Mean levels of hsTnI and NT-proBNP on admission were 56.7 ng/mL and 6550 pg/mL, respectively. Levels of hsTnI above the upper reference limit adjusted by sex were found in 26 (55.3%) patients. Levels of NT-proBNP on admission were significantly higher (p=0.014) in patients with higher risk for IS, as well as levels of hsTnI but without statistical significance (p=0.388). hsTnI showed positive correlation with NT-proBNP (r=0.545, p=0.010) and C-reactive protein (r=0.559, p<0.001), while NT-proBNP exhibited positive correlation with mean annual risk for IS (r=0.587, p=0.002) (Figure 1).

Mean NT-proBNP plasma levels (pg/mL) according to the annual risk of stroke or thromboembolic event divided in three categories of risk (<4%, 4-8%, >8%).

Conclusion: The antithrombotic management reduced the risk for IS by nearly threefold, with an acceptable bleeding risk. Levels of hsTnI were increased in a large number of patients suggesting that myocardial injury is common during the hospitalization event of ADHF with AF. Levels of NT-proBNP on admission, in presented population, may aid in annual risk stratification for IS and thromboembolic event.

LITERATURE PonikowskiPVoorsAAAnkerSDBuenoHClelandJGCoatsAJ Authors/Task Force Members; Document Reviewers. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016 Aug;18(8):891–975. 10.1002/ejhf.59227207191 HijaziZOldgrenJSiegbahnAGrangerCBWallentinL. Biomarkers in atrial fibrillation: a clinical review. Eur Heart J. 2013 May;34(20):1475–80. 10.1093/eurheartj/eht02423386711