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ALLHAT. ATRIAL FIBRILLATION AT BASELINE AND DURING FOLLOW-UP in The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial November 9, 2003. L. Julian Haywood, Charles E. Ford , Richard S. Crow, Barry R. Davis, Paula T. Einhorn, Angela Williard, and Barry Massie. ALLHAT.

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Allhat

ALLHAT

ATRIAL FIBRILLATION AT BASELINEAND DURING FOLLOW-UPinThe Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack TrialNovember 9, 2003

L. Julian Haywood, Charles E. Ford, Richard S. Crow, Barry R. Davis,

Paula T. Einhorn, Angela Williard, and Barry Massie


Purpose

ALLHAT

Purpose

  • To document the prevalence of atrial fibrillation (AF) or atrial flutter (AFL) at baseline and its new appearance during follow-up in ALLHAT.

  • To determine the influence of AF/AFL at baseline on outcome in ALLHAT.


Background

ALLHAT

Background

  • Randomized, double-blind, multicenter trial

  • Determined whether fatal CHD or nonfatal MI was lower for high-risk hypertensives treated with amlodipine (CCB), lisinopril (ACEI), doxazosin (alpha blocker) vs chlorthalidone (diuretic)

  • Atrial fibrillation (AF) is the most common serious arrhythmia affecting morbidity and mortality.


Methods

ALLHAT

Methods

  • Standard 12-lead ECGs, recorded at baseline and at 2-year intervals during follow-up, were coded for Q-wave abnormalities, ST-segment depression, T-wave inversion, LVH, bundle branch block, and atrial fibrillation or flutter, using the Minnesota Code.

  • Univariate and multivariate statistical methods were used to determine prevalence, incidence, and prognosis as relates to multiple clinical parameters, and according to treatment group.


Allhat

ALLHAT

Sample Size and Number (%) of Participants with AF

  • Missing a baseline ECG, but with one or more follow-up ECGs on file.

  • Sample size less those with no ECGs and no baseline ECG.


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ALLHAT

Sample Size and Number (%) of Participants with AF,Excluding Doxazosin Group

  • The doxazosin arm of ALLHAT was stopped in January 2000 due to higher CV events and

  • virtually no chance to show a difference in CHD.

  • b.Missing baseline ECG but one or more follow-up ECGs on file.

  • c.Atrial fibrillation and flutter, combined.


Allhat

ALLHAT

Baseline Characteristics Stratified By Atrial Fibrillation Status

* Indicates statistical significance of difference (p < 0.05).

** Indicates statistical significance of difference (p < 0.01).


Allhat

ALLHAT

Baseline Characteristics Stratified By Atrial Fibrillation Status

* Indicates statistical significance of difference (p < 0.05).

** Indicates statistical significance of difference (p < 0.01).


Allhat

ALLHAT

Prevalence of Atrial Fibrillation Per 1000

Participants, by Randomized Treatment Group

AF prevalence was 10.9 per 1000, overall (334/30,704).

Events per 1000

* Compared with chlorthalidone, neither the amlodipine nor lisinopril group differed significantly.


Allhat

ALLHAT

Prevalence of Atrial Fibrillation Per 1000

Participants, by Baseline Characteristics

Events per 1000

Age at Entry, years

* Subgroup differs significantly from comparison group (55-69, women, black) before and

after adjusting for age, race, and sex (p < 0.01).


Allhat

ALLHAT

Prevalence of Atrial Fibrillation Per 1000

Participants, by Baseline Characteristics

Events per 1000

* ASCVD subgroup differs significantly from comparison group (no ASCVD) before and

after adjusting for age, race, and sex (p < 0.01).


Allhat

ALLHAT

Prevalence of Atrial Fibrillation Per 1000

Participants, by Baseline Characteristics

Events per 1000

Subgroups do not differ significantly from comparison groups after adjustment for age, race, and sex differences.


Allhat

ALLHAT

Occurrence of New Atrial Fibrillation


Allhat

ALLHAT

Occurrence of Atrial Fibrillation Per 1000

Participants, by Randomized Treatment Group

AF incidence was 17.2 per 1000, overall (551/32,042).

Events per 1000

* Compared with chlorthalidone, neither the amlodipine nor lisinopril group differed significantly.


Allhat

ALLHAT

Occurrence of Atrial Fibrillation Per 1000

Participants, by Baseline Characteristics

Events per 1000

Age, years


Allhat

ALLHAT

Occurrence of Atrial Fibrillation Per 1000

Participants, by Baseline Characteristics

Events per 1000

Left Ventricular Hypertrophy

by ECG.


Allhat

ALLHAT

Occurrence of Atrial Fibrillation Per 1000

Participants, by Baseline Characteristics

Events per 1000

BMI = Body Mass Index

Serum potassium at 3-month visit.


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ALLHAT

Cumulative Event Rates for All-Cause Mortality

by Entry AF Status

0.40

0.35

0.30

0.25

AF Present

0.20

Cumulative Event Rate

0.15

0.10

AF Absent

0.05

0.00

0

1

2

3

4

5

6

Years to Death


Allhat

ALLHAT

Cumulative Event Rates for Fatal CHD or

Nonfatal MI, by Entry AF Status

0.20

0.15

AF Present

0.10

Cumulative Event Rate

AF Absent

0.05

0.00

0

1

2

3

4

5

6

Years to Fatal CHD or Nonfatal MI


Allhat

ALLHAT

Cumulative Event Rates for Stroke

by Entry AF Status

0.20

0.17

0.15

AF Present

0.13

0.10

Cumulative Event Rate

AF Absent

0.07

0.05

0.03

0.00

0

1

2

3

4

5

6

Years to Stroke


Allhat

ALLHAT

Cumulative Event Rates for All-Cause Mortality

in Those with AF at Entry, by Treatment Group

0.40

0.35

0.30

0.25

0.20

Cumulative Event Rate

Chlorthalidone

0.15

Amlodipine

0.10

Lisinopril

0.05

0.00

0

1

2

3

4

5

6

Years to Death


Allhat

ALLHAT

Cumulative Event Rates for Fatal CHD or Nonfatal MI

in Those with AF, by Treatment Group

0.20

0.15

0.10

Cumulative Event Rate

Chlorthalidone

Amlodipine

0.05

Lisinopril

0.00

0

1

2

3

4

5

6

Years to Fatal CHD or Nonfatal MI


Allhat

ALLHAT

Cumulative Event Rates for Stroke by Treatment

Group In Participants with AF at Baseline

0.30

0.25

0.20

0.15

Cumulative Event Rate

0.10

Chlorthalidone

Amlodipine

0.05

Lisinopril

0.00

0

1

2

3

4

5

6

Years to Stroke


Conclusion 1

ALLHAT

Conclusion-1

In high-risk hypertensive patients :

  • Prevalence of AF in ALLHAT at baseline was increased by: age, non-Black status, male gender, and presence of ASCVD.

  • AF at baseline was associated during follow-up with:

    increased overall mortality

    increased fatal CHD and MI

    increased stroke


Conclusion 2

ALLHAT

Conclusion-2

  • Likelihood of new onset of AF during follow-up was increased by: Age, male gender, non-Black race, CHD, ASCVD, LVH

  • Randomization to chlorthalidone, amlodipine and lisinopril did not influence prevalence of AF at baseline or its new appearance during follow-up.

  • Among participants with AF/AFL at baseline, there were no differences among randomized groups for mortality, major CHD events, or stroke.


Thank you

Thank You


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