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AimsTo clarify the influence of renal function on adverse outcomes in patients with non-valvular atrial fibrillation (NVAF), a post hoc analysis of the J-RHYTHM Registry was performed.Methods and resultsA consecutive series of outpatients with atrial fibrillation (AF) were enrolled from 158 institutions and followed for 2 years or until the occurrence of an event. Among 7406 patients with non-valvular AF, 6052 patients (69.8 ± 10.0 years, 71.2% men) with creatinine clearance (CrCl) value at baseline were divided into four groups according to CrCl level (<30, 30–49.9, 50–79.9, and ≥80 mL/min). Patients with CrCl <80 mL/min showed increased incidence of thromboembolism, major haemorrhage, all-cause and cardiovascular death, and composite events as compared with patients with CrCl ≥80 mL/min. After adjustment for multiple confounders, lower CrCl values emerged as independent predictors for thromboembolism [CrCl 30–49.9, hazard ratio (HR) 2.27, 95% confidence interval (CI) 1.09–4.72, P = 0.029; and CrCl 50–79.9, HR 1.99, 95% CI 1.07–3.72, P = 0.030] and all-cause death (CrCl <30, HR 6.44, 95% CI 3.03–13.7, P < 0.001; and CrCl 30–49.9, HR 3.14, 95% CI 1.54–6.41, P = 0.002), with CrCl ≥80 mL/min serving as a reference, whereas not for major haemorrhage. Warfarin treatment was associated with lower rates of composite events in patients with lower CrCl values of <80 mL/min.ConclusionRenal impairment was an independent predictor of adverse clinical outcomes except for major haemorrhage in Japanese patients with non-valvular AF. Warfarin was associated with lower rates of composite events in patients with lower CrCl values.Clinical Trial Registration: http://www.umin.ac.jp/ctr/. Unique identifier: UMIN000001569.

Background Atrial fibrillation (AF) is a heterogeneous condition caused by various underlying disorders and comorbidities. A cluster analysis is a statistical technique that attempts to group populations by shared traits. Applied to AF, it could be useful in classifying the variables and complex presentations of AF into phenotypes of coherent, more tractable subpopulations. Objectives This study aimed to characterize the clinical phenotypes of AF using a national AF patient registry using a cluster analysis. Methods We used data of an observational cohort that included 7406 patients with non-valvular AF enrolled from 158 sites participating in a nationwide AF registry (J-RHYTHM). The endpoints analyzed were all-cause mortality, thromboembolisms, and major bleeding. Results The optimal number of clusters was found to be 4 based on 40 characteristics. They were those with (1) a younger age and low rate of comorbidities (n = 1876), (2) a high rate of hypertension (n = 4579), (3) high bleeding risk (n = 302), and (4) prior coronary artery disease and other atherosclerotic comorbidities (n = 649). The patients in the younger/low comorbidity cluster demonstrated the lowest risk for all 3 endpoints. The atherosclerotic comorbidity cluster had significantly higher adjusted risks of total mortality (odds ratio [OR], 3.70; 95% confidence interval [CI], 2.37–5.80) and major bleeding (OR, 5.19; 95% CI, 2.58–10.9) than the younger/low comorbidity cluster. Conclusions A cluster analysis identified 4 distinct groups of non-valvular AF patients with different clinical characteristics and outcomes. Awareness of these groupings may lead to a differentiated patient management for AF.

-Subanalysis of the J-RHYTHM Registry - J-RHYTHM Registry InvestigatorsBackground: Determinants of warfarin use and anticoagulation levels in atrial fibrillation (AF) patients have not been clarified thoroughly. Methods and Results:A total of 6,324 patients with non-valvular AF and congestive heart failure, hypertension, age, diabetes, prior stroke (CHADS2) score ≥1 were used to investigate determinants of warfarin use, and 6,932 patients with AF receiving warfarin were used to investigate determinants of international normalized ratio (INR) of prothrombin time. Target INR levels for non-valvular AF patients were 1.6-2.6 for patients aged ≥70 years and 2-3 for patients aged <70 years. Those for patients with valvular AF were 2-3. Patients with non-valvular AF and CHADS2 score ≥1 receiving warfarin (n=5,614) more frequently had permanent AF, congestive heart failure, and stroke or transient ischemic attack (TIA), and had higher CHADS2 scores than those not receiving warfarin. Determinants of warfarin use were age (≥60 years), AF type (persistent and permanent), and comorbidities (congestive heart failure, diabetes mellitus, and prior stroke or TIA). Use of antiplatelet drugs was a negative determinant of warfarin use. Only 53% of patients met the target INR levels. Determinants for the meeting of the target INR level (vs. lower INR level) were age (≥60 years), permanent AF, hypertension, and prior stroke or TIA. Use of antiplatelet drugs was a negative determinant of the INR level. Conclusions:Currently in Japan, adherence to the guidelines regarding anticoagulation therapy is limited (UMIN Clinical Trials Registry UMIN000001569). (Circ J 2011; 75: 2357 - 2362

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