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Developing Population-Level Methods for Cardiovascular Risk Management in Atrial Fibrillation / FATEMEH TORABI

Swansea University Author: FATEMEH TORABI

  • E-Thesis under embargo until: 31st May 2027

DOI (Published version): 10.23889/SUThesis.71746

Abstract

Background: Stroke is a critical medical emergency associated with substantial lifelong complications and economic burden. Atrial Fibrillation (AF) escalates stroke risk by five-fold. This thesis used comprehensive population-level data to develop methods for assessment of cardiovascular risk manage...

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Published: Swansea 2026
Institution: Swansea University
Degree level: Doctoral
Degree name: Ph.D
Supervisor: Gravenor, M., and Halcox, J.
URI: https://cronfa.swan.ac.uk/Record/cronfa71746
first_indexed 2026-04-15T11:46:59Z
last_indexed 2026-04-17T03:55:23Z
id cronfa71746
recordtype RisThesis
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Methods: A range of advance methods were developed using a comprehensive national AF cohort achieved through linkage of major national datasets including primary care, secondary care and drug dispensing dataset from SAIL Databank, enabling retrospective observational cohort studies.Results: Assessment of anticoagulation (AC) therapy between 2012 and 2018 revealed that achieving 90% AC coverage significantly reduced risk of stroke and systemic embolism (SSE). However, a notable treatment gap persisted, representing a missed opportunity for preventive care over the study period. Mathematical modelling of future scenarios demonstrated the opportunity for substantial (9%) reductions in hospitalisation rates if guideline targets could be met.Further investigations focused on international normalised ration (INR) control in warfarin-treated AF patients. Time-varying analysis of the cohort, revealed 34% of time was spent under poor INR control levels (according to NICE guidelines). Statistical analysis revealed poor INR control was significantly associated with increased risk of both SSE (Hazard Ratio=1.69, 95% CI: 1.54=, 1.86) and bleeding (HR=1.40, 95% CI: 1.33,1.48), providing additional prognostic information inaddition to recognised risk factors. The tracking of cardiovascular pharmaceutical dispensing was extended during the pandemic to all medications to investigate the impact of COVID-19 treatment patterns across over 70 million drug items, using the all-Wales population cohort. A 1% declinein overall dispensing was noted in 2020 compared to 2019, with notable disruption of cardiovascular medication across all age-groups. Finally, a validation study of two conventional bleeding risk scores, HAS-BLED and ORBIT, was conducted in a cohort of over 100,000 AF patients. Predicted bleeding rates were compared to those observed in the cohort, and stratified by bleed type and anticoagulation regime. Both scores had limited predictive performance (61% and 62%). Although performance was good for low-risk and aspirin treated patients, HAS-BLED tended to overestimate, and ORBIT underestimate, the bleed risk for DOAC and vitamin K treated populations. 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Distributed under the terms of a Creative Commons Attribution 4.0 License (CC BY 4.0).</documentNotes><copyrightCorrect>true</copyrightCorrect><language>eng</language><licence>https://creativecommons.org/licenses/by/4.0/</licence></document></documents><OutputDurs/></rfc1807>
spelling 2026-04-15T12:56:03.4436378 v2 71746 2026-04-15 Developing Population-Level Methods for Cardiovascular Risk Management in Atrial Fibrillation 396747ee5d94325f0bf6d04735401fd6 FATEMEH TORABI FATEMEH TORABI true false 2026-04-15 Background: Stroke is a critical medical emergency associated with substantial lifelong complications and economic burden. Atrial Fibrillation (AF) escalates stroke risk by five-fold. This thesis used comprehensive population-level data to develop methods for assessment of cardiovascular risk management in a large AF population. Methods: A range of advance methods were developed using a comprehensive national AF cohort achieved through linkage of major national datasets including primary care, secondary care and drug dispensing dataset from SAIL Databank, enabling retrospective observational cohort studies.Results: Assessment of anticoagulation (AC) therapy between 2012 and 2018 revealed that achieving 90% AC coverage significantly reduced risk of stroke and systemic embolism (SSE). However, a notable treatment gap persisted, representing a missed opportunity for preventive care over the study period. Mathematical modelling of future scenarios demonstrated the opportunity for substantial (9%) reductions in hospitalisation rates if guideline targets could be met.Further investigations focused on international normalised ration (INR) control in warfarin-treated AF patients. Time-varying analysis of the cohort, revealed 34% of time was spent under poor INR control levels (according to NICE guidelines). Statistical analysis revealed poor INR control was significantly associated with increased risk of both SSE (Hazard Ratio=1.69, 95% CI: 1.54=, 1.86) and bleeding (HR=1.40, 95% CI: 1.33,1.48), providing additional prognostic information inaddition to recognised risk factors. The tracking of cardiovascular pharmaceutical dispensing was extended during the pandemic to all medications to investigate the impact of COVID-19 treatment patterns across over 70 million drug items, using the all-Wales population cohort. A 1% declinein overall dispensing was noted in 2020 compared to 2019, with notable disruption of cardiovascular medication across all age-groups. Finally, a validation study of two conventional bleeding risk scores, HAS-BLED and ORBIT, was conducted in a cohort of over 100,000 AF patients. Predicted bleeding rates were compared to those observed in the cohort, and stratified by bleed type and anticoagulation regime. Both scores had limited predictive performance (61% and 62%). Although performance was good for low-risk and aspirin treated patients, HAS-BLED tended to overestimate, and ORBIT underestimate, the bleed risk for DOAC and vitamin K treated populations. Conclusion: This thesis strengthens the case for optimising clinical outcomes and cardiovascular risk management in AF by applying pharmacoepidemiologic approaches to improve adherence to evidence-based therapies and enhanced risk stratification, harnessing longitudinal population-level patient data. E-Thesis Swansea Cardiovascular risk management, Atrial Fibrillation, Advance modelling, Predictive modelling 24 3 2026 2026-03-24 10.23889/SUThesis.71746 COLLEGE NANME COLLEGE CODE Swansea University Gravenor, M., and Halcox, J. Doctoral Ph.D 2026-04-15T12:56:03.4436378 2026-04-15T12:03:14.1325817 Faculty of Medicine, Health and Life Sciences Swansea University Medical School - Health Data Science FATEMEH TORABI 1 Under embargo Under embargo 2026-04-15T12:42:29.0159914 Output 8010915 application/pdf E-Thesis true 2027-05-31T00:00:00.0000000 Copyright: The author, Fatemeh Torabi, 2025. Distributed under the terms of a Creative Commons Attribution 4.0 License (CC BY 4.0). true eng https://creativecommons.org/licenses/by/4.0/
title Developing Population-Level Methods for Cardiovascular Risk Management in Atrial Fibrillation
spellingShingle Developing Population-Level Methods for Cardiovascular Risk Management in Atrial Fibrillation
FATEMEH TORABI
title_short Developing Population-Level Methods for Cardiovascular Risk Management in Atrial Fibrillation
title_full Developing Population-Level Methods for Cardiovascular Risk Management in Atrial Fibrillation
title_fullStr Developing Population-Level Methods for Cardiovascular Risk Management in Atrial Fibrillation
title_full_unstemmed Developing Population-Level Methods for Cardiovascular Risk Management in Atrial Fibrillation
title_sort Developing Population-Level Methods for Cardiovascular Risk Management in Atrial Fibrillation
author_id_str_mv 396747ee5d94325f0bf6d04735401fd6
author_id_fullname_str_mv 396747ee5d94325f0bf6d04735401fd6_***_FATEMEH TORABI
author FATEMEH TORABI
author2 FATEMEH TORABI
format E-Thesis
publishDate 2026
institution Swansea University
doi_str_mv 10.23889/SUThesis.71746
college_str Faculty of Medicine, Health and Life Sciences
hierarchytype
hierarchy_top_id facultyofmedicinehealthandlifesciences
hierarchy_top_title Faculty of Medicine, Health and Life Sciences
hierarchy_parent_id facultyofmedicinehealthandlifesciences
hierarchy_parent_title Faculty of Medicine, Health and Life Sciences
department_str Swansea University Medical School - Health Data Science{{{_:::_}}}Faculty of Medicine, Health and Life Sciences{{{_:::_}}}Swansea University Medical School - Health Data Science
document_store_str 0
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description Background: Stroke is a critical medical emergency associated with substantial lifelong complications and economic burden. Atrial Fibrillation (AF) escalates stroke risk by five-fold. This thesis used comprehensive population-level data to develop methods for assessment of cardiovascular risk management in a large AF population. Methods: A range of advance methods were developed using a comprehensive national AF cohort achieved through linkage of major national datasets including primary care, secondary care and drug dispensing dataset from SAIL Databank, enabling retrospective observational cohort studies.Results: Assessment of anticoagulation (AC) therapy between 2012 and 2018 revealed that achieving 90% AC coverage significantly reduced risk of stroke and systemic embolism (SSE). However, a notable treatment gap persisted, representing a missed opportunity for preventive care over the study period. Mathematical modelling of future scenarios demonstrated the opportunity for substantial (9%) reductions in hospitalisation rates if guideline targets could be met.Further investigations focused on international normalised ration (INR) control in warfarin-treated AF patients. Time-varying analysis of the cohort, revealed 34% of time was spent under poor INR control levels (according to NICE guidelines). Statistical analysis revealed poor INR control was significantly associated with increased risk of both SSE (Hazard Ratio=1.69, 95% CI: 1.54=, 1.86) and bleeding (HR=1.40, 95% CI: 1.33,1.48), providing additional prognostic information inaddition to recognised risk factors. The tracking of cardiovascular pharmaceutical dispensing was extended during the pandemic to all medications to investigate the impact of COVID-19 treatment patterns across over 70 million drug items, using the all-Wales population cohort. A 1% declinein overall dispensing was noted in 2020 compared to 2019, with notable disruption of cardiovascular medication across all age-groups. Finally, a validation study of two conventional bleeding risk scores, HAS-BLED and ORBIT, was conducted in a cohort of over 100,000 AF patients. Predicted bleeding rates were compared to those observed in the cohort, and stratified by bleed type and anticoagulation regime. Both scores had limited predictive performance (61% and 62%). Although performance was good for low-risk and aspirin treated patients, HAS-BLED tended to overestimate, and ORBIT underestimate, the bleed risk for DOAC and vitamin K treated populations. Conclusion: This thesis strengthens the case for optimising clinical outcomes and cardiovascular risk management in AF by applying pharmacoepidemiologic approaches to improve adherence to evidence-based therapies and enhanced risk stratification, harnessing longitudinal population-level patient data.
published_date 2026-03-24T06:01:55Z
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score 11.102912

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