Blood Pressure and Brain Lesions in Patients With Atrial Fibrillation
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Zurich Open Repository and
Archive
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Main Library
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CH-8057 Zurich
www.zora.uzh.ch
Year: 2021
Blood Pressure and Brain Lesions in Patients With Atrial Fibrillation
Aeschbacher, Stefanie ; Blum, Steffen ; Meyre, Pascal B ; Coslovsky, Michael ; Vischer, Annina S ;
Sinnecker, Tim ; Rodondi, Nicolas ; Beer, Jürg H ; Moschovitis, Giorgio ; Moutzouri, Elisavet ;
Hunkeler, Christof ; Burkard, Thilo ; Eken, Ceylan ; Roten, Laurent ; Zuern, Christine S ; Sticherling,
Christian ; Wuerfel, Jens ; Bonati, Leo H ; Conen, David ; Osswald, Stefan ; Kühne, Michael
Abstract: The association of blood pressure (BP) and hypertension with the presence of different types
of brain lesions in patients with atrial fibrillation is unclear. BP values were obtained in a multicenter
cohort of patients with atrial fibrillation. Systolic and diastolic BP was categorized in predefined groups.
All patients underwent brain magnetic resonance imaging and neurocognitive testing. Brain lesions were
classified as large noncortical or cortical infarcts, small noncortical infarcts, microbleeds, or white matter
lesions. White matter lesions were graded according to the Fazekas scale. Overall, 1738 patients with
atrial fibrillation were enrolled in this cross-sectional analysis (mean age, 73 years, 73% males). Mean BP
was 135/79 mm Hg, and 67% of participants were taking BP-lowering treatment. White matter lesions
Fazekas 2 were found in 54%, large noncortical or cortical infarcts in 22%, small noncortical infarcts in
21%, and microbleeds in 22% of patients, respectively. Compared with patients with systolic BPAeschbacher, Stefanie; Blum, Steffen; Meyre, Pascal B; Coslovsky, Michael; Vischer, Annina S; Sinnecker,
Tim; Rodondi, Nicolas; Beer, Jürg H; Moschovitis, Giorgio; Moutzouri, Elisavet; Hunkeler, Christof;
Burkard, Thilo; Eken, Ceylan; Roten, Laurent; Zuern, Christine S; Sticherling, Christian; Wuerfel, Jens;
Bonati, Leo H; Conen, David; Osswald, Stefan; Kühne, Michael (2021). Blood Pressure and Brain Lesions
in Patients With Atrial Fibrillation. Hypertension, 77(2):662-671.
DOI: https://doi.org/10.1161/HYPERTENSIONAHA.120.16025
2Hypertension
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Blood Pressure and Brain Lesions in Patients
With Atrial Fibrillation
Stefanie Aeschbacher, Steffen Blum , Pascal B. Meyre, Michael Coslovsky, Annina S. Vischer , Tim Sinnecker,
Nicolas Rodondi, Jürg H. Beer , Giorgio Moschovitis , Elisavet Moutzouri , Christof Hunkeler, Thilo Burkard,
Ceylan Eken, Laurent Roten, Christine S. Zuern , Christian Sticherling , Jens Wuerfel , Leo H. Bonati , David Conen ,
Stefan Osswald, Michael Kühne ; for the Swiss-AF Investigators*
ABSTRACT: The association of blood pressure (BP) and hypertension with the presence of different types of brain lesions in
patients with atrial fibrillation is unclear. BP values were obtained in a multicenter cohort of patients with atrial fibrillation.
Systolic and diastolic BP was categorized in predefined groups. All patients underwent brain magnetic resonance imaging
and neurocognitive testing. Brain lesions were classified as large noncortical or cortical infarcts, small noncortical infarcts,
microbleeds, or white matter lesions. White matter lesions were graded according to the Fazekas scale. Overall, 1738
patients with atrial fibrillation were enrolled in this cross-sectional analysis (mean age, 73 years, 73% males). Mean BP was
135/79 mm Hg, and 67% of participants were taking BP-lowering treatment. White matter lesions Fazekas ≥2 were found
in 54%, large noncortical or cortical infarcts in 22%, small noncortical infarcts in 21%, and microbleeds in 22% of patients,
respectively. Compared with patients with systolic BPAeschbacher et al Blood Pressure and Brain Lesions
WHITE MATTER LESIONS
Novelty and Significance
What Is New? Summary
• Blood pressure (BP) and hypertension are associated Among patients with atrial fibrillation, BP is strongly
with white matter lesions but not with large noncortical associated with the presence and extent of white
or cortical infarcts in patients with atrial fibrillation (AF). matter lesions, but there is no association with large
• BP and hypertension are not associated with neuro- noncortical or cortical infarcts. Whether more aggres-
cognitive function after multivariable adjustment.
sive BP control may prevent different types of brain
lesions in patients with atrial fibrillation has to be
What Is Relevant? investigated.
• Optimal BP control is important to potentially prevent
brain lesions in patients with atrial fibrillation.
stroke prevention. However, its effect on the association
Nonstandard Abbreviation and Acronyms between BP and brain lesions is unknown. Finally, the
shape of the association between BP and brain lesions
AF atrial fibrillation in patients with AF is unclear. Therefore, the aim of this
bMRI brain magnetic resonance imaging analysis was to investigate brain lesion types accord-
BP blood pressure ing to BP and BP control in an unselected cohort of
LNCCI large noncortical or cortical infarcts patients with AF.
MoCA Montreal Cognitive Assessment
SNCI small noncortical infarcts
Swiss-AF Swiss Atrial Fibrillation Cohort Study
METHODS
The data that support the findings of this study are available
WML white matter lesions
from the corresponding author on reasonable request.
Data of the ongoing, prospective, observational, multicenter
Downloaded from http://ahajournals.org by on January 15, 2021
Swiss-AF (Swiss Atrial Fibrillation Cohort Study) were used for
The prevalence and volume of different clinical and
this cross-sectional analysis. The study design of the Swiss-AF
subclinical brain lesions has been reported to be sig- study was published previously.16 In brief, patients ≥65 years
nificant both in patients with and without AF.9–11 In the with documented AF were enrolled in 14 study centers in
general population, increased blood pressure (BP) was Switzerland between 2014 and 2017. A group of 250 patients
associated with the occurrence and the progression of with AFAeschbacher et al Blood Pressure and Brain Lesions
Other Study Variables To assess the associations of BP and hypertension with the
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Information on cardiovascular risk factors, lifestyle factors, med- prevalence of vascular brain lesions, multivariable-adjusted logis-
tic regression analyses were performed using the presence of
ical history, and medication was assessed using standardized
Fazekas score ≥2, LNCCI, SNCI, or microbleeds as the outcome
questionnaires. Weight and height were taken and body mass
variable. In a second step, the association of BP and hyperten-
index was calculated as the ratio of the weight in kg and the
sion with the volume of brain lesions was calculated using mul-
height in m2. Smoking status was categorized into current, for-
tivariable-adjusted linear regression analysis. Due to the skewed
mer, or never smoking. Educational status was classified accord-
distribution, the volumes of the respective brain lesions were
ing to the highest degree achieved. To assess neurocognitive
log-transformed. Results are presented as odds ratios (OR) or
function, the Montreal Cognitive Assessment (MoCA) score, the
β-coefficients with the corresponding 95% CI, and 2-sided
Trail Making Test (part A and B), the Semantic Fluency Test, and
P-values were calculated. The volume of microbleeds was not
the Digit Symbol Substitution Test were performed in all patients.
quantified due to an expected blooming effect of the volume when
In brief, the validated MoCA score is scaled from 0 (worse) to 30
using the current methods. All regression analyses were adjusted
(best) and is representing global cognitive functioning. Patients
for age and sex. A second model was additionally adjusted for
withAeschbacher et al Blood Pressure and Brain Lesions
Table 1. Baseline Characteristics Stratified by Blood Pressure Categories
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Overall Systolic blood pressureAeschbacher et al Blood Pressure and Brain Lesions
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Figure 1. Brain magnetic resonance imaging (fluid-attenuated inversion recovery) of 2 different patients with atrial fibrillation.
A, Normotensive man, 72 y old with a small amount of white matter lesions (Fazekas scoreAeschbacher et al Blood Pressure and Brain Lesions
Table 2. Prevalence and Volume of Brain Lesions Stratified by Blood Pressure Categories
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Prevalence Prevalence Volume LNCCI, Prevalence Volume Prevalence Number
n (%) Fazekas ≥2 Volume WML mm3 LNCCI mm3 SNCI SNCI, mm3 MB* MB
Overall 933 (53.7) 3918 (1455–9795) 390 (22.4) 1640 (258–7326) 372 (21.4) 63 (30–166) 373 (22.2) 1 (1–2)
Systolic blood pressureAeschbacher et al Blood Pressure and Brain Lesions
Table 3. Association Between Blood Pressure and WML
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Presence of Fazekas ≥ 2 Volume WML
OR (95% CI) model 1 OR (95% CI) model 2 β-coefficient (95% CI) model 1 β-coefficient (95% CI) model 2
Systolic blood pressureAeschbacher et al Blood Pressure and Brain Lesions
potential competing mechanisms involved in the patho- in the standard treatment group (systolic BP goal of
WHITE MATTER LESIONS
genesis of LNCCIs as well as the protective effect ofAeschbacher et al Blood Pressure and Brain Lesions
S.B., P.M., M.C., C.H., T.B., C.E., C.S.Z., C.S., S.O., M.K.), Department of Clinical gitta Mehmann, Sonja Meier, Myriam Roth, Andrea Ruckli-Kaeppeli, Ian Russi, Kai
WHITE MATTER LESIONS
Research (M.C.), Medical Outpatient Department, ESH Hypertension Centre of Schmidt, Mabelle Young, Melanie Zbinden. Ente Ospedaliero Cantonale Lugano:
Excellence (A.S.V., T.B.), and Department of Neurology and Stroke Center (T.S., Jane Frangi-Kultalahti, Anica Pin, Luisa Vicari University Hospital Geneva: Dipen
L.H.B.), University Hospital Basel, and Medical Image Analysis Center (MIAC AG) Shah, Georg Ehret, Hervé Gallet, Elise Guillermet, Francois Lazeyras, Karl-Olof
and Department of Biomedical Engineering (T.S., J.W.), University of Basel, Swit- Lovblad, Patrick Perret, Philippe Tavel, Cheryl Teres. University Hospital Lausanne:
zerland; Institute of Primary Health Care (BIHAM) (N.R., E.M.) and Department of Jürg Schläpfer, Nathalie Lauriers, Marie Méan, Sandrine Salzmann. Bürgerspital
General Internal Medicine (N.R., E.M.), Inselspital, Bern University Hospital, Uni- Solothurn: Frank-Peter Stephan, Andrea Grêt, Jan Novak, Sandra Vitelli. Ente
versity of Bern, Switzerland; Department of Medicine, Cantonal Hospital of Baden Ospedaliero Cantonale Bellinzona: Marcello Di Valentino, Jane Frangi-Kultalahti,
and Molecular Cardiology, University Hospital of Zurich, Switzerland (J.H.B.); Augusto Gallino. University of Zurich/University Hospital Zurich: Fabienne
Department of Cardiology, Ospedale Regionale di Lugano, Switzerland (G.M.); Witassek, Matthias Schwenkglenks. Medical Image Analysis Center AG Basel:
Department of Cardiology, Inselspital, Bern University Hospital and University of Anna Altermatt, Michael Amann, Petra Huber, Esther Ruberte, Vanessa Zu-
Bern, Switzerland (L.R.); and Population Health Research Institute, McMaster Uni- ber. Clinical Trial Unit Basel: Pascal Benkert, Gilles Dutilh, Milica Markovic, Pia
versity, Hamilton, Canada (D.C.). Neuschwander, Patrick Simon. Schiller AG Baar: Ramun Schmid.
Sources of Funding
The Swiss-AF study (Swiss Atrial Fibrillation Cohort Study) is supported by grants
of the Swiss National Science Foundation (Grant numbers 33CS30_148474, REFERENCES
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