Average Systolic Blood Pressure and Clinical Outcomes in Patients with Atrial Fibrillation: Prospective Data from COOL-AF Registry

Figures & data

Table 1 Baseline Demographic and Clinical Characteristics Among the Three Average SBP Groups

Characteristics	All Patients (N=3402)	SBP Average <120 (n=922)	SBP Average 120 to <140 (n=1866)	SBP Average ≥140 (n=614)	p-value
Age (years)	67.4±11.3	65.6±12.4	67.5±10.8	69.5±10.5	<0.001
Female gender	1422 (41.8%)	368 (39.9%)	760 (40.7%)	294 (47.9%)	0.003
Time after diagnosis of AF (years)	3.36±4.33	3.43±4.03	3.46±4.58	2.95±3.91	0.022
Atrial fibrillation					0.002
- Paroxysmal	1148 (33.7%)	271 (29.4%)	640 (34.3%)	237 (38.6%)
- Persistent	643 (18.9%)	189 (20.5%)	336 (18.0%)	118 (19.2%)
- Permanent	1611 (47.4%)	462 (50.1%)	890 (47.7%)	259 (42.2%)
Symptomatic AF	2618 (77.0%)	728 (79.0%)	1430 (76.6%)	460 (74.9%)	0.163
History of heart failure	912 (26.8%)	320 (34.7%)	436 (23.4%)	156 (25.4%)	<0.001
History of coronary artery disease	547 (16.1%)	167 (8.1%)	279 (15.0%)	101 (16.4%)	0.098
Cardiac implantable electronic device	341 (10.0%)	104 (11.3%)	189 (10.1%)	48 (7.8%)	0.084
History of ischemic stroke/TIA	592 (17.4%)	173 (18.8%)	322 (17.3%)	97 (15.8%)	0.314
Diabetes mellitus	839 (24.7%)	165 (17.9%)	483 (25.9%)	191 (31.1%)	<0.001
History of hypertension	2328 (68.4%)	466 (50.6%)	1330 (71.3%)	532 (86.6%)	<0.001
Smoking	678 (19.9%)	205 (22.2%)	370 (19.8%)	103 (16.8%)	0.032
Dyslipidemia	1915 (56.3%)	468 (50.8%)	1084 (58.1%)	363 (59.1%)	<0.001
CKD (n = 2538)	1594 (62.8%)	429 (62.2%)	879 (63.3%)	286 (62.3%)	0.860
Renal replacement therapy	40 (1.2%)	7 (0.8%)	23 (1.2%)	10 (1.6%)	0.285
Dementia	29 (0.9%)	8 (0.9%)	16 (0.9%)	5 (0.8%)	0.993
History of bleeding	323 (9.5%)	89 (9.7%)	181 (9.7%)	53 (8.6%)	0.722
CHA2DS2-VASc score					<0.001
− 0	196 (5.8%)	68 (7.4%)	114 (6.1%)	14 (2.3%)
− 1	422 (12.4%)	462 (50.1%)	890 (47.7%)	259 (42.2%)
- ≥2	2784 (81.8%)	711 (77.1%)	1525 (81.7%)	548 (89.3%)
HAS-BLED score					<0.001
− 0	490 (14.4%)	155 (16.8%)	270 (14.5%)	65 (10.6%)
− 1–2	2373 (69.8%)	634 (98.8%)	1319 (70.7%)	420 (68.4%)
- ≥3	539 (15.8%)	133 (14.4%)	277 (14.8%)	129 (21.0%)
Antiplatelet	890 (26.2%)	253 (27.4%)	458 (24.5%)	179 (29.2%)	0.046
Anticoagulant	2566 (75.4%)	695 (75.4%)	1419 (76.0%)	452 (73.6%)
- Warfarin	2338 (68.7%)	638 (69.2%)	1288 (69.0%)	412 (67.1%)
- NOACs	228 (6.7%)	57 (6.2%)	131 (7.0%)	40 (6.5%)
Antihypertensive agents	3091 (90.9%)	842 (91.3%)	1681 (90.1%)	568 (92.5%)	0.166
-Beta-blockers	2476 (72.8%)	727 (78.9%)	1318 (70.6%)	431 (70.2%)	<0.001*
-Calcium channel blockers	934 (27.5%)	141 (15.3%)	558 (29.9%)	235 (38.3%)	<0.001*
-ACEI	758 (22.3%)	230 (24.9%)	382 (20.5%)	146 (23.8%)	0.017*
-ARB	814 (23.9%)	159 (17.2%)	449 (24.1%)	206 (33.6%)	<0.001*
-Aldosterone blockade	280 (8.2%)	149 (16.2%)	101 (5.4%)	30 (4.9%)	<0.001*
-Diuretics	1030 (30.3%)	358 (38.8%)	506 (27.1%)	166 (27.0%)	<0.001*

Notes: Data presented as mean ± standard deviation or number and percentage. *A p-value<0.05 indicates statistical significance.

Abbreviations: SBP, systolic blood pressure; AF, atrial fibrillation; TIA, transient ischemic attack; NOAC, non-vitamin K antagonist oral anticoagulant; ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker.

Table 2 Rate of Clinical Outcomes Among the Tthree Different Baseline SBP Groups and Among the Three Different Average SBP Groups

SBP Groups	Number of Patients	Number of Events	100 Person-Years	Rate per 100 Person-Years (95% CI)	Absolute 2-Year Risk (95% CI) (Death as Competing Risk)
Ischemic Stroke/TIA
Baseline SBP (mmHg)
<120	1097	29	22.64	1.28 (0.86–1.84)	2.32 (1.68–3.12)
120–140	1426	38	30.41	1.25 (0.88–1.72)	2.86 (2.28–3.54)
≥140	879	36	18.87	1.91 (1.34–2.64)	3.52 (2.46–4.85)
Average SBP (mmHg)
<120	922	18	18.88	0.95 (0.57–1.51)	2.41 (1.80–3.16)
120–140	1866	55	40.21	1.37 (1.03–1.78)	3.00 (2.36–3.76)
≥140	614	30	12.83	2.34 (1.58–3.34)	3.73 (2.45–5.40)
ICH
Baseline SBP (mmHg)
<120	1097	7	22.64	0.31 (0.12–0.64)	1.15 (0.70–1.79)
120–140	1426	22	30.41	0.72 (0.45–1.10)	1.41 (1.02–1.90)
≥140	879	21	18.87	1.11 (0.69–1.70)	1.73 (1.02–2.78)
Average SBP (mmHg)
<120	922	5	18.88	0.26 (0.09–0.62)	1.28 (0.84–1.86)
120–140	1866	30	40.21	0.75 (0.50–1.07)	1.44 (1.02–2.00)
≥140	614	15	12.83	1.17 (0.65–1.93)	1.63 (0.84–2.88)
Death
Baseline SBP (mmHg)
<120	1097	85	22.64	3.75 (3.00–4.64)
120–140	1426	102	30.41	3.35 (2.73–4.07)
≥140	879	84	18.87	4.45 (3.55–5.51)
Average SBP (mmHg)
<120	922	90	18.88	4.77 (3.83–5.86)
120–140	1866	125	40.21	3.11 (2.59–3.70)
≥140	614	56	12.83	4.37 (3.30–5.57)

Abbreviations: SBP, systolic blood pressure; CI, confidence interval; TIA, transient ischemic attack; ICH, intracranial hemorrhage.

Figure 1 Rate of ischemic stroke/transient ischemic attack (TIA), intracerebral hemorrhage (ICH), and death compared among the three average systolic blood pressure (SBP) groups (<120, 120–140, and ≥140 mmHg).

Figure 2 (A) Cumulative event rate over time for ischemic stroke/transient ischemic attack (TIA), (B) intracerebral hemorrhage (ICH), and (C) death (C) among the three average systolic blood pressure (SBP) groups (<120, 120–140, and ≥140 mmHg).

Figure 3 Hazard ratio (HR) and 95% confidence interval (CI) for (A) ischemic stroke/transient ischemic attack (TIA), (B) intracerebral hemorrhage (ICH), and (C) death (C) among the three average systolic blood pressure (SBP) groups (<120, 120–140, and ≥140 mmHg) with and without adjustment for baseline and time-varying covariates.

Figure 4 Cubic spline graph showing the adjusted hazard ratio (HR) and 95% confidence interval (CI) for (A) ischemic stroke/transient ischemic attack (TIA), (B) intracerebral hemorrhage (ICH), and (C) death relative to average systolic blood pressure (SBP) as a continuous variable.

Figure 5 Forest plot of Hazard ratio and 95% confidence interval selected subgroups of patients with atrial fibrillation on clinical outcomes (A–C).