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Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with a 5-fold increase in the risk for stroke. Type 2 diabetes is an independent risk factor for both stroke and atrial fibrillation, and in the setting of AF, type 2 diabetes is independently associated with a 2% to 3.5% increase in absolute stroke rate per year. The overlap in the pathophysiologies of AF and type 2 diabetes are not well understood, and current practice guidelines provide few recommendations regarding patients with both conditions.
In this article, we review the epidemiology and pathophysiology of the nexus of AF and type 2 diabetes. Furthermore, we analyze the subgroup of patients with type 2 diabetes enrolled in phase 3 clinical trials of non–vitamin K antagonist oral anticoagulants in prevention of arterial thromboembolism in AF, highlighting the greater absolute benefit of non–vitamin K oral anticoagulants in patients with type 2 diabetes. Finally, we offer recommendations on risk stratification and therapy for patients with concomitant AF and type 2 diabetes.
Conclusions and Relevance
We highlight the increased thromboembolic risk with coexisting AF and type 2 diabetes. We recommend that further studies be done to evaluate the potential benefits of anticoagulation for all patients who have both and the potential for non–vitamin K oral anticoagulants to have greater benefits than risks over vitamin K antagonists.
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Accepted for Publication: November 11, 2016.
Corresponding Author: Robert P. Giugliano, MD, SM, TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, 350 Longwood Ave, 1st Floor Offices, Boston, MA 02115 (firstname.lastname@example.org).
Published Online: January 25, 2017. doi:10.1001/jamacardio.2016.5224
Author Contributions: Dr Giugliano had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: Plitt, Giugliano.
Drafting of the manuscript: Plitt, Giugliano.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Plitt, Giugliano.
Supervision: McGuire, Giugliano.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr McGuire reports honoraria for trial leadership from Boehringer Ingelheim, Janssen Research and Development LLC, Merck Sharp and Dohme Corp, Lilly USA, Novo Nordisk, GlaxoSmithKline, Takeda Pharmaceuticals North America, AstraZeneca, Lexicon, and Eisai, and honoraria for consultancy from Janssen Research and Development LLC, Sanofi Aventis Group, Merck Sharp and Dohme Corp, and Novo Nordisk. Dr Giugliano reports receiving consulting fees from the American College of Cardiology, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Janssen Pharmaceuticals, Lexicon, Merck, Portola, and Pfizer; lecture fees from Bristol-Myers Squibb, Daiichi Sankyo, Merck, and Sanofi; and grant support through his institution from Daiichi Sankyo and Merck. No other disclosures were reported.
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