Ghamari, Seyyed‐Hadi

Abstract Background Current risk assessment tools for guiding direct oral anticoagulant (DOAC) therapy for patients with atrial fibrillation (AF) based on clinical risk factors demonstrate modest predictive performance limiting clinical impact. Additionally, while guidelines recommend periodic reassessment of risk over time, there remains an absence of modelling solutions for capturing evolving risk in AF patients. Methods Using UK electronic health records, we developed and validated the Transformer-based Risk assessment survival model (TRisk), an artificial intelligence model that predicts 12-month thromboembolic and bleeding events in AF patients by leveraging temporal patient journeys up to baseline. A cohort of 411,850 prevalent non-valvular AF patients aged ≥18 years between 2010 and 2020 was identified from 1,442 English general practices. Practices were randomly allocated to derivation (n=1,079) and external validation (n=363) cohorts. TRisk was compared with CHA 2 DS 2 -VASc and CHA 2 DS 2 -VA for thromboembolic event prediction, and HAS-BLED and ORBIT for bleeding prediction, with subgroup analyses by sex, age, and baseline characteristics. A second validation of TRisk was also performed on 16,218 US AF patients between 2010 and 2023. A decision model compared outcomes and healthcare costs for TRisk versus standard care. Findings TRisk achieved higher discrimination for thromboembolic event prediction (C-index: 0.82; 95% confidence interval [CI]: [0.81, 0.83]) as compared to CHA 2 DS 2 -VASc (0.71 [0.70, 0.73]) in UK validation. Application of TRisk to US data yielded similar C-index: 0.82 (0.80, 0.84). For bleeding prediction, TRisk (C-index: 0.70 [0.69–0.71]) outperformed both HAS-BLED (0.63; [0.61, 0.64]) and ORBIT (0.64; [0.63, 0.65]), with comparable US results (0.71; [0.69, 0.74]). The model remained well-calibrated across both populations and performed equitably across subgroups, including by race and during the COVID-19 pandemic. Impact analyses showed TRisk could reduce DOAC prescriptions by 8% in the UK and 7% in the US relative to guideline-recommended approaches, while preventing at least as many thromboembolic events. This refined approach would generate annual healthcare savings of £5.5 million and $456.2 million in the UK and US respectively among patients initiating DOACs, rising to £48.6 million and $1.8 billion when extended to all AF patients on DOACs. Interpretation TRisk enabled more precise prediction for both thromboembolic and bleeding events across AF populations in UK and US compared to established clinical scoring systems. Incorporating TRisk into routine AF care would result in substantial cost savings without compromising the identification of true high-risk patients. Funding None

Abstract Background and objective Smoking is recognised as a critical public health priority due to its enormous health and economic consequences. Constant monitoring of the effectiveness of tobacco control programs calls for timely population-based data. This study reports the national and sub-national patterns in tobacco consumption among Iranian adults based on the results from the STEPwise approach to chronic disease risk factor surveillance (STEPS) survey 2021. Methods This study was performed through an analysis of the results of the STEPS survey 2021 which had been conducted as a nationally representative cross-sectional study. Participants included Iranian adults aged ≥ 18 years in all provinces of Iran, who were selected via multistage cluster sampling method. Data were analyzed via survey analysis while considering population weights. Results The total number of participants was 27874, including 15395 (55.23%) women and 12479 (44.77%) men. The all-ages prevalence (95% CI) of current tobacco smoking was 14.01% (13.56–14.48): 4.44% (4.09–4.82) among women and 25.88% (25.03–26.75) among men. The all-ages prevalence of current cigarette smoking was 9.33% (8.95–9.72): 0.77% (0.62–0.95) among women and 19.95% (19.17–20.75) among men. The all-ages prevalence of current hookah smoking was 4.5% (4.23–4.78): 3.64% (3.33, 3.98) among women and 5.56% (5.12–6.03) among men. The mean (SD) number of cigarettes smoked per day among current cigarettes smokers was 11.4 (9.82): 5.9 (6.76) among women and 11.65 (9.87) among men. The mean (SD) monthly times of hookah use was 23.87 (44.95): 29.93 (48.26) among women and 19.02 (41.52) among men. The national all-ages prevalence of second-hand smoking at home was 24.65 (24.06–25.25): 27.39 (26.6-28.19) among women and 20.28 (19.4-21.18) among men. The national all-ages prevalence of second-hand smoking at work was 20.73% (20.11–21.36): 17.96% (17.21–18.73) among women and 25.15% (24.07–26.26) among men. Conclusion The tobacco consumption in Iran remains alarmingly high, indicating the current tobacco control policy implementation level is ineffective and insufficient. This calls for adopting, implementing, and enforcing comprehensive packages of evidence-based tobacco control policies.