Female “Paradox” in Atrial Fibrillation—Role of Left Truncation Due to Competing Risks
Female sex in patients with atrial fibrillation (AF) is a controversial and paradoxical risk factor for stroke—controversial because it increases the risk of stroke only among older women of some ethnicities and paradoxical because it appears to contradict male predominance in cardiovascular disease...
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MDPI AG
2023-05-01
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| Series: | Life |
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| Online Access: | https://www.mdpi.com/2075-1729/13/5/1132 |
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| author | Tomoki Nakamizo Munechika Misumi Tetsuya Takahashi Satoshi Kurisu Masayasu Matsumoto Akira Tsujino |
| author_facet | Tomoki Nakamizo Munechika Misumi Tetsuya Takahashi Satoshi Kurisu Masayasu Matsumoto Akira Tsujino |
| author_sort | Tomoki Nakamizo |
| collection | DOAJ |
| description | Female sex in patients with atrial fibrillation (AF) is a controversial and paradoxical risk factor for stroke—controversial because it increases the risk of stroke only among older women of some ethnicities and paradoxical because it appears to contradict male predominance in cardiovascular diseases. However, the underlying mechanism remains unclear. We conducted simulations to examine the hypothesis that this sex difference is generated non-causally through left truncation due to competing risks (CR) such as coronary artery diseases, which occur more frequently among men than among women and share common unobserved causes with stroke. We modeled the hazards of stroke and CR with correlated heterogeneous risk. We assumed that some people died of CR before AF diagnosis and calculated the hazard ratio of female sex in the left-truncated AF population. In this situation, female sex became a risk factor for stroke in the absence of causal roles. The hazard ratio was attenuated in young populations without left truncation and in populations with low CR and high stroke incidence, which is consistent with real-world observations. This study demonstrated that spurious risk factors can be identified through left truncation due to correlated CR. Female sex in patients with AF may be a paradoxical risk factor for stroke. |
| first_indexed | 2024-03-11T03:34:33Z |
| format | Article |
| id | doaj.art-8629bfad2c7e4ece8a2eefc8213e71f3 |
| institution | Directory Open Access Journal |
| issn | 2075-1729 |
| language | English |
| last_indexed | 2024-03-11T03:34:33Z |
| publishDate | 2023-05-01 |
| publisher | MDPI AG |
| record_format | Article |
| series | Life |
| spelling | doaj.art-8629bfad2c7e4ece8a2eefc8213e71f32023-11-18T02:09:08ZengMDPI AGLife2075-17292023-05-01135113210.3390/life13051132Female “Paradox” in Atrial Fibrillation—Role of Left Truncation Due to Competing RisksTomoki Nakamizo0Munechika Misumi1Tetsuya Takahashi2Satoshi Kurisu3Masayasu Matsumoto4Akira Tsujino5Department of Clinical Studies, Radiation Effects Research Foundation (RERF), Nagasaki 850-0013, JapanDepartment of Statistics, Radiation Effects Research Foundation (RERF), Hiroshima 732-0815, JapanFaculty of Rehabilitation, Hiroshima International University, Hiroshima 739-2695, JapanDepartment of Clinical Studies, Radiation Effects Research Foundation (RERF), Hiroshima 732-0815, JapanIseikai Hospital, Osaka 533-0022, JapanDepartment of Neurology and Strokology, Nagasaki University Hospital, Nagasaki 852-8501, JapanFemale sex in patients with atrial fibrillation (AF) is a controversial and paradoxical risk factor for stroke—controversial because it increases the risk of stroke only among older women of some ethnicities and paradoxical because it appears to contradict male predominance in cardiovascular diseases. However, the underlying mechanism remains unclear. We conducted simulations to examine the hypothesis that this sex difference is generated non-causally through left truncation due to competing risks (CR) such as coronary artery diseases, which occur more frequently among men than among women and share common unobserved causes with stroke. We modeled the hazards of stroke and CR with correlated heterogeneous risk. We assumed that some people died of CR before AF diagnosis and calculated the hazard ratio of female sex in the left-truncated AF population. In this situation, female sex became a risk factor for stroke in the absence of causal roles. The hazard ratio was attenuated in young populations without left truncation and in populations with low CR and high stroke incidence, which is consistent with real-world observations. This study demonstrated that spurious risk factors can be identified through left truncation due to correlated CR. Female sex in patients with AF may be a paradoxical risk factor for stroke.https://www.mdpi.com/2075-1729/13/5/1132atrial fibrillationstroke riskrisk factorssex differencerace/ethnicity differencesurvival analysis |
| spellingShingle | Tomoki Nakamizo Munechika Misumi Tetsuya Takahashi Satoshi Kurisu Masayasu Matsumoto Akira Tsujino Female “Paradox” in Atrial Fibrillation—Role of Left Truncation Due to Competing Risks Life atrial fibrillation stroke risk risk factors sex difference race/ethnicity difference survival analysis |
| title | Female “Paradox” in Atrial Fibrillation—Role of Left Truncation Due to Competing Risks |
| title_full | Female “Paradox” in Atrial Fibrillation—Role of Left Truncation Due to Competing Risks |
| title_fullStr | Female “Paradox” in Atrial Fibrillation—Role of Left Truncation Due to Competing Risks |
| title_full_unstemmed | Female “Paradox” in Atrial Fibrillation—Role of Left Truncation Due to Competing Risks |
| title_short | Female “Paradox” in Atrial Fibrillation—Role of Left Truncation Due to Competing Risks |
| title_sort | female paradox in atrial fibrillation role of left truncation due to competing risks |
| topic | atrial fibrillation stroke risk risk factors sex difference race/ethnicity difference survival analysis |
| url | https://www.mdpi.com/2075-1729/13/5/1132 |
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