[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 35.172.195.82. Please contact the publisher to request reinstatement.
[Skip to Content Landing]

Atrial Fibrillation, Type 2 Diabetes, and Non–Vitamin K Antagonist Oral AnticoagulantsA Review

Educational Objective
To understand the relationship between diabetes mellitus and atrial fibrillation, and the interaction between the 2 conditions on stroke risk.
1 Credit CME
Abstract

Importance  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.

Observations  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.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

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 (rgiugliano@partners.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.

References
1.
Chugh  SS, Havmoeller  R, Narayanan  K,  et al.  Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study.  Circulation. 2014;129(8):837-847.PubMedGoogle ScholarCrossref
2.
Mozaffarian  D, Benjamin  EJ, Go  AS,  et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee.  Heart disease and stroke statistics: 2015 update: a report from the American Heart Association.  Circulation. 2015;131(4):e29-e322.PubMedGoogle ScholarCrossref
3.
World Health Organization. Media Centre: diabetes. http://www.who.int/mediacentre/factsheets/fs312/en/. Accessed August 19, 2015.
4.
International Diabetes Federation. IDF diabetes atlas. http://www.idf.org/diabetesatlas. Accessed January 14, 2016.
5.
Centers for Disease Control and Prevention. National Vital Statistics Reports: deaths: final data for 2013. http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf. Accessed January 16, 2016.
6.
Hess  K, Grant  PJ.  Inflammation and thrombosis in diabetes.  Thromb Haemost. 2011;105(suppl 1):S43-S54.PubMedGoogle ScholarCrossref
7.
V Bandemer  S, Merkel  S, Nimako-Doffour  A, Weber  MM.  Diabetes and atrial fibrillation: stratification and prevention of stroke risks.  EPMA J. 2014;5(1):17.PubMedGoogle ScholarCrossref
8.
Rubler  S, Dlugash  J, Yuceoglu  YZ, Kumral  T, Branwood  AW, Grishman  A.  New type of cardiomyopathy associated with diabetic glomerulosclerosis.  Am J Cardiol. 1972;30(6):595-602.PubMedGoogle ScholarCrossref
9.
Liu  C, Fu  H, Li  J,  et al.  Hyperglycemia aggravates atrial interstitial fibrosis, ionic remodeling and vulnerability to atrial fibrillation in diabetic rabbits.  Anadolu Kardiyol Derg. 2012;12(7):543-550.PubMedGoogle Scholar
10.
Kato  T, Yamashita  T, Sekiguchi  A,  et al.  AGEs-RAGE system mediates atrial structural remodeling in the diabetic rat.  J Cardiovasc Electrophysiol. 2008;19(4):415-420.PubMedGoogle ScholarCrossref
11.
Goudis  CA, Korantzopoulos  P, Ntalas  IV, Kallergis  EM, Liu  T, Ketikoglou  DG.  Diabetes mellitus and atrial fibrillation: pathophysiological mechanisms and potential upstream therapies.  Int J Cardiol. 2015;184:617-622.PubMedGoogle ScholarCrossref
12.
Igarashi  T, Finet  JE, Takeuchi  A,  et al.  Connexin gene transfer preserves conduction velocity and prevents atrial fibrillation.  Circulation. 2012;125(2):216-225.PubMedGoogle ScholarCrossref
13.
van Heerebeek  L, Hamdani  N, Handoko  ML,  et al.  Diastolic stiffness of the failing diabetic heart: importance of fibrosis, advanced glycation end products, and myocyte resting tension.  Circulation. 2008;117(1):43-51.PubMedGoogle ScholarCrossref
14.
McGavock  JM, Victor  RG, Unger  RH, Szczepaniak  LS; American College of Physicians and the American Physiological Society.  Adiposity of the heart, revisited.  Ann Intern Med. 2006;144(7):517-524.PubMedGoogle ScholarCrossref
15.
Gerdts  E, Oikarinen  L, Palmieri  V,  et al; Losartan Intervention For Endpoint Reduction in Hypertension (LIFE) Study.  Correlates of left atrial size in hypertensive patients with left ventricular hypertrophy: the Losartan Intervention For Endpoint Reduction in Hypertension (LIFE) Study.  Hypertension. 2002;39(3):739-743.PubMedGoogle ScholarCrossref
16.
Hajhosseiny  R, Matthews  GK, Lip  GY.  Metabolic syndrome, atrial fibrillation, and stroke: tackling an emerging epidemic.  Heart Rhythm. 2015;12(11):2332-2343.PubMedGoogle ScholarCrossref
17.
Dublin  S, Glazer  NL, Smith  NL,  et al.  Diabetes mellitus, glycemic control, and risk of atrial fibrillation.  J Gen Intern Med. 2010;25(8):853-858.PubMedGoogle ScholarCrossref
18.
Otake  H, Suzuki  H, Honda  T, Maruyama  Y.  Influences of autonomic nervous system on atrial arrhythmogenic substrates and the incidence of atrial fibrillation in diabetic heart.  Int Heart J. 2009;50(5):627-641.PubMedGoogle ScholarCrossref
19.
Watanabe  M, Yokoshiki  H, Mitsuyama  H, Mizukami  K, Ono  T, Tsutsui  H.  Conduction and refractory disorders in the diabetic atrium.  Am J Physiol Heart Circ Physiol. 2012;303(1):H86-H95.PubMedGoogle ScholarCrossref
20.
Chang  SH, Wu  LS, Chiou  MJ,  et al.  Association of metformin with lower atrial fibrillation risk among patients with type 2 diabetes mellitus: a population-based dynamic cohort and in vitro studies.  Cardiovasc Diabetol. 2014;13:123.PubMedGoogle ScholarCrossref
21.
Eckel  RH, Kahn  SE, Ferrannini  E,  et al; Endocrine Society; American Diabetes Association; European Association for the Study of Diabetes.  Obesity and type 2 diabetes: what can be unified and what needs to be individualized?  Diabetes Care. 2011;34(6):1424-1430.PubMedGoogle ScholarCrossref
22.
Wang  TJ, Parise  H, Levy  D,  et al.  Obesity and the risk of new-onset atrial fibrillation.  JAMA. 2004;292(20):2471-2477.PubMedGoogle ScholarCrossref
23.
Tadic  M, Ivanovic  B, Cuspidi  C.  What do we currently know about metabolic syndrome and atrial fibrillation?  Clin Cardiol. 2013;36(11):654-662.PubMedGoogle ScholarCrossref
24.
Thanassoulis  G, Massaro  JM, O’Donnell  CJ,  et al.  Pericardial fat is associated with prevalent atrial fibrillation: the Framingham Heart Study.  Circ Arrhythm Electrophysiol. 2010;3(4):345-350.PubMedGoogle ScholarCrossref
25.
Rabkin  SW.  The relationship between epicardial fat and indices of obesity and the metabolic syndrome: a systematic review and meta-analysis.  Metab Syndr Relat Disord. 2014;12(1):31-42.PubMedGoogle ScholarCrossref
26.
Acet  H, Ertaş  F, Akıl  MA,  et al.  New inflammatory predictors for non-valvular atrial fibrillation: echocardiographic epicardial fat thickness and neutrophil to lymphocyte ratio.  Int J Cardiovasc Imaging. 2014;30(1):81-89.PubMedGoogle ScholarCrossref
27.
Vazzana  N, Ranalli  P, Cuccurullo  C, Davì  G.  Diabetes mellitus and thrombosis.  Thromb Res. 2012;129(3):371-377.PubMedGoogle ScholarCrossref
28.
Creager  MA, Lüscher  TF, Cosentino  F, Beckman  JA.  Diabetes and vascular disease: pathophysiology, clinical consequences, and medical therapy: part I.  Circulation. 2003;108(12):1527-1532.PubMedGoogle ScholarCrossref
29.
Colwell  JA, Nesto  RW.  The platelet in diabetes: focus on prevention of ischemic events.  Diabetes Care. 2003;26(7):2181-2188.PubMedGoogle ScholarCrossref
30.
Alessi  MC, Juhan-Vague  I.  Metabolic syndrome, haemostasis and thrombosis.  Thromb Haemost. 2008;99(6):995-1000.PubMedGoogle Scholar
31.
Huxley  RR, Alonso  A, Lopez  FL,  et al.  Type 2 diabetes, glucose homeostasis and incident atrial fibrillation: the Atherosclerosis Risk in Communities Study.  Heart. 2012;98(2):133-138.PubMedGoogle ScholarCrossref
32.
Benjamin  EJ, Levy  D, Vaziri  SM, D’Agostino  RB, Belanger  AJ, Wolf  PA.  Independent risk factors for atrial fibrillation in a population-based cohort: the Framingham Heart Study.  JAMA. 1994;271(11):840-844.PubMedGoogle ScholarCrossref
33.
Aksnes  TA, Schmieder  RE, Kjeldsen  SE, Ghani  S, Hua  TA, Julius  S.  Impact of new-onset diabetes mellitus on development of atrial fibrillation and heart failure in high-risk hypertension (from the VALUE Trial).  Am J Cardiol. 2008;101(5):634-638.PubMedGoogle ScholarCrossref
34.
Fatemi  O, Yuriditsky  E, Tsioufis  C,  et al.  Impact of intensive glycemic control on the incidence of atrial fibrillation and associated cardiovascular outcomes in patients with type 2 diabetes mellitus (from the Action to Control Cardiovascular Risk in Diabetes Study).  Am J Cardiol. 2014;114(8):1217-1222.PubMedGoogle ScholarCrossref
35.
Du  X, Ninomiya  T, de Galan  B,  et al; ADVANCE Collaborative Group.  Risks of cardiovascular events and effects of routine blood pressure lowering among patients with type 2 diabetes and atrial fibrillation: results of the ADVANCE study.  Eur Heart J. 2009;30(9):1128-1135.PubMedGoogle ScholarCrossref
36.
Ashburner  JM, Go  AS, Chang  Y,  et al.  Effect of diabetes and glycemic control on ischemic stroke risk in AF patients: ATRIA Study.  J Am Coll Cardiol. 2016;67(3):239-247.PubMedGoogle ScholarCrossref
37.
Bloomgarden  Z, Bansilal  S.  A diabetes-atrial fibrillation conundrum: does duration trump glycemia?  J Am Coll Cardiol. 2016;67(3):248-250.PubMedGoogle ScholarCrossref
38.
Anselmino  M, Matta  M, D’ascenzo  F,  et al.  Catheter ablation of atrial fibrillation in patients with diabetes mellitus: a systematic review and meta-analysis.  Europace. 2015;17(10):1518-1525.PubMedGoogle ScholarCrossref
39.
Lu  ZH, Liu  N, Bai  R,  et al.  HbA1c levels as predictors of ablation outcome in type 2 diabetes mellitus and paroxysmal atrial fibrillation.  Herz. 2015;40(suppl 2):130-136.PubMedGoogle ScholarCrossref
40.
Connolly  SJ, Ezekowitz  MD, Yusuf  S,  et al; RE-LY Steering Committee and Investigators.  Dabigatran versus warfarin in patients with atrial fibrillation.  N Engl J Med. 2009;361(12):1139-1151.PubMedGoogle ScholarCrossref
41.
Patel  MR, Mahaffey  KW, Garg  J,  et al; ROCKET AF Investigators.  Rivaroxaban versus warfarin in nonvalvular atrial fibrillation.  N Engl J Med. 2011;365(10):883-891.PubMedGoogle ScholarCrossref
42.
Giugliano  RP, Ruff  CT, Braunwald  E,  et al; ENGAGE AF-TIMI 48 Investigators.  Edoxaban versus warfarin in patients with atrial fibrillation.  N Engl J Med. 2013;369(22):2093-2104.PubMedGoogle ScholarCrossref
43.
Granger  CB, Alexander  JH, McMurray  JJ,  et al; ARISTOTLE Committees and Investigators.  Apixaban versus warfarin in patients with atrial fibrillation.  N Engl J Med. 2011;365(11):981-992.PubMedGoogle ScholarCrossref
44.
Brambatti  M, Darius  H, Oldgren  J,  et al.  Comparison of dabigatran versus warfarin in diabetic patients with atrial fibrillation: Results from the RE-LY trial.  Int J Cardiol. 2015;196:127-131.PubMedGoogle ScholarCrossref
45.
Bansilal  S, Bloomgarden  Z, Halperin  JL,  et al; ROCKET AF Steering Committee and Investigators.  Efficacy and safety of rivaroxaban in patients with diabetes and nonvalvular atrial fibrillation: the Rivaroxaban Once-daily, Oral, Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF Trial).  Am Heart J. 2015;170(4):675-682.e8.PubMedGoogle ScholarCrossref
46.
Ezekowitz  JAL, Lewis  BS, Lopes  RD,  et al.  Clinical outcomes of patients with diabetes and atrial fibrillation treated with apixaban: results from the ARISTOTLE trial.  Eur Heart J Cardiovasc Pharmacother. 2015;1(2):86-94.PubMedGoogle ScholarCrossref
47.
Ruff  CT, Giugliano  RP, Braunwald  E,  et al.  Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials.  Lancet. 2014;383(9921):955-962.PubMedGoogle ScholarCrossref
48.
January  CT, Wann  LS, Alpert  JS,  et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines.  2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.  J Am Coll Cardiol. 2014;64(21):e1-e76.PubMedGoogle ScholarCrossref
49.
Camm  AJ, Lip  GY, De Caterina  R,  et al; ESC Committee for Practice Guidelines (CPG).  2012 Focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation: developed with the special contribution of the European Heart Rhythm Association.  Eur Heart J. 2012;33(21):2719-2747.PubMedGoogle ScholarCrossref
50.
Friberg  L, Skeppholm  M, Terént  A.  Benefit of anticoagulation unlikely in patients with atrial fibrillation and a CHA2DS2-VASc score of 1.  J Am Coll Cardiol. 2015;65(3):225-232.PubMedGoogle ScholarCrossref
51.
Lip  GY, Nieuwlaat  R, Pisters  R, Lane  DA, Crijns  HJ.  Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation.  Chest. 2010;137(2):263-272.PubMedGoogle ScholarCrossref
52.
Saliba  W, Barnett-Griness  O, Elias  M, Rennert  G.  Glycated hemoglobin and risk of first episode stroke in diabetic patients with atrial fibrillation: a cohort study.  Heart Rhythm. 2015;12(5):886-892.PubMedGoogle ScholarCrossref
53.
Chao  TF, Liu  CJ, Wang  KL,  et al.  Should atrial fibrillation patients with 1 additional risk factor of the CHA2DS2-VASc score (beyond sex) receive oral anticoagulation?  J Am Coll Cardiol. 2015;65(7):635-642.PubMedGoogle ScholarCrossref
54.
O’Gara  PT, Kushner  FG, Ascheim  DD,  et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.  2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.  Circulation. 2013;127(4):e362-e425.PubMedGoogle ScholarCrossref
55.
Amsterdam  EA, Wenger  NK, Brindis  RG,  et al; ACC/AHA Task Force Members; Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons.  2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published correction appears in Circulation. 2014;130(25):e431-e432].  Circulation. 2014;130(25):2354-2394.PubMedGoogle ScholarCrossref
56.
Sørensen  R, Hansen  ML, Abildstrom  SZ,  et al.  Risk of bleeding in patients with acute myocardial infarction treated with different combinations of aspirin, clopidogrel, and vitamin K antagonists in Denmark: a retrospective analysis of nationwide registry data.  Lancet. 2009;374(9706):1967-1974.PubMedGoogle ScholarCrossref
57.
Andrade  JG, Deyell  MW, Khoo  C, Lee  M, Humphries  K, Cairns  JA.  Risk of bleeding on triple antithrombotic therapy after percutaneous coronary intervention/stenting: a systematic review and meta-analysis.  Can J Cardiol. 2013;29(2):204-212.PubMedGoogle ScholarCrossref
58.
Gao  F, Zhou  YJ, Wang  ZJ,  et al.  Meta-analysis of the combination of warfarin and dual antiplatelet therapy after coronary stenting in patients with indications for chronic oral anticoagulation.  Int J Cardiol. 2011;148(1):96-101.PubMedGoogle ScholarCrossref
59.
Bavishi  C, Koulova  A, Bangalore  S,  et al.  Evaluation of the efficacy and safety of dual antiplatelet therapy with or without warfarin in patients with a clinical indication for DAPT and chronic anticoagulation: a meta-analysis of observational studies.  Catheter Cardiovasc Interv. 2016;88(1):e12-e22.PubMedGoogle ScholarCrossref
60.
Lip  GY, Windecker  S, Huber  K,  et al; Document Reviewers.  Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary or valve interventions: a joint consensus document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS).  Eur Heart J. 2014;35(45):3155-3179.PubMedGoogle ScholarCrossref
61.
Roffi  M, Patrono  C, Collet  JP,  et al; Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology.  2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC).  Eur Heart J. 2016;37(3):267-315.PubMedGoogle ScholarCrossref
62.
Dewilde  WJ, Oirbans  T, Verheugt  FW,  et al; WOEST study investigators.  Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial.  Lancet. 2013;381(9872):1107-1115.PubMedGoogle ScholarCrossref
63.
Chamberlain  JJ, Rhinehart  AS, Shaefer  CF  Jr, Neuman  A.  Diagnosis and management of diabetes: synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes.  Ann Intern Med. 2016;164(8):542-552.PubMedGoogle ScholarCrossref
64.
Rydén  L, Grant  PJ, Anker  SD,  et al; Authors/Task Force Members; ESC Committee for Practice Guidelines (CPG); Document Reviewers.  ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: the task force on diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and developed in collaboration with the European Association for the Study of Diabetes (EASD) [published correction appears in Eur Heart J. 2014;35(27):1824].  Eur Heart J. 2013;34(39):3035-3087.PubMedGoogle ScholarCrossref
65.
Lip  GY, Skjøth  F, Rasmussen  LH, Larsen  TB.  Oral anticoagulation, aspirin, or no therapy in patients with nonvalvular AF with 0 or 1 stroke risk factor based on the CHA2DS2-VASc score.  J Am Coll Cardiol. 2015;65(14):1385-1394.PubMedGoogle ScholarCrossref
66.
Eckman  MH, Singer  DE, Rosand  J, Greenberg  SM.  Moving the tipping point: the decision to anticoagulate patients with atrial fibrillation.  Circ Cardiovasc Qual Outcomes. 2011;4(1):14-21.PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Topics
State Requirements