Abstract
The authors aim to investigate retrospectively the association between acupuncture and risk of stroke in patients with atrial fibrillation (AF). Using the Taiwan National Health Insurance Research Database, AF patients without any acupuncture treatment record were classified as non-acupuncture cohort and 1:1 matching with acupuncture cohort by age, gender, and all comorbidities. To calculate the risk of stroke in case and control groups, cox proportional hazard models were used and presented by hazard ratios, adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs). Two equally distributed groups of AF individuals with and without acupuncture were included. After adjusting for risk factors, AF subjects with acupuncture conferred a lower risk of stroke (aHR = 0.46, 95% confidence intervals [CI] = 0.38–0.54), ischemic stroke (aHR = 0.47, 95% CI = 0.39–0.56) and hemorrhagic stroke (aHR = 0.35, 95% CI = 0.19–0.67), compared to the controls. AF patients receiving acupuncture was associated with a decreased risk of stroke.
Keywords: acupuncture, atrial fibrillation, stroke
1. Introduction
Acupuncture, a traditional herb medicine therapy, is a popular treatment approach in the Chinese population; indeed, several cardiovascular disease modifying effects of acupuncture have been reported.[1–5] Global burden of atrial fibrillation (AF) has been reported, mainly through adverse cerebral and heart diseases.[6–8] AF – all paroxysmal, persistent and chronic subtypes, are known to have an increased risk of stroke.[9,10] To this end, several easy-to-use, validated and well-established tools for risk determination have been made and reported to be of high capacity and reliability.[11–15] The disease modifying approaches would be of interesting in clinical practice concerning the risk estimation of stroke in this AF population. Hence, the authors present the results of a retrospective database analysis of the Taiwan National Health Research Institute and argue whether there is an association between acupuncture use for stroke risk in patients with AF.
2. Methods
2.1. Data source
We conducted this study by using the Longitudinal Health Insurance Database 2000, which was the subset of NHIRD, and randomly selected 1 million individuals as the sampled patients.[16–18] All diagnoses in the database were coded according to the International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM). The Research Ethics Committee of China Medical University and Hospital in Taiwan approved the study (CMUH-104-REC2-115-CR7).
2.2. Study population
We identified acupuncture and non-acupuncture cohort to clarify the association between acupuncture therapies in AF patients and the risk of stroke. The acupuncture cohort was defined as patients firstly received acupuncture treatment after a new diagnosis of AF between January 1, 2000 and December 31, 2012. The acupuncture procedure code included B41, B42, B45, B46, B80-B84, B90-B94, P27041, P31103, P32103, P33031 and electro acupuncture: B43, B44, B86-B89, and P33032. The index date for the patient receiving acupuncture was determined by the date of the initial receiving date of acupuncture. AF patients without any acupuncture treatment record were classified as non-acupuncture cohort and 1:1 matching with acupuncture cohort by age, gender, and all comorbidities. The study period was from the first acupuncture date (index date) to the occurrence date of stroke, withdrawn from NHIRD, death or until December 31, 2013. Patients who were less than 18 years old or having a diagnosis of stroke before acupuncture treatment or ever received anticoagulation therapy were excluded in this study. In this study, we included age, gender and comorbidities, which were important confounding factors. We measured patients with at least 2 claims for outpatient visits or at least 1 claims hospitalization visit at the baseline by the principal and secondary diagnoses for diseases considered possible comorbidities associated with stroke. The comorbidities were defined before index date and contained hypertension, coronary artery disease, peripheral arterial occlusion disease, diabetes mellitus, hyperlipidemia, congestive heart failure, hyperthyroidism, sleep disorder, anxiety, alcoholism, tobacco use, obesity, gout, chronic obstructive pulmonary disease, chronic kidney disease or end stage renal disease, anemia, cancer, and rheumatologic diseases. ICD codes for the diseases are shown in the Supplementary Table, Supplemental Digital Content, http://links.lww.com/MD/H970.
2.3. Statistical analysis
We compared the difference of continuous and categorical variable by t-test and chi-square test, respectively, between 2 cohorts. To calculate the risk of stroke in case and control groups, cox proportional hazard models were used and presented by hazard ratios, adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs). We plotted the cumulative incidence curves was by Kaplan–Meier method and the difference of curves assessed by log-rank test. All statistical analyses were performed using SAS statistical software, version 9.4 (SAS Institute Inc, Cary, NC). The figure of cumulative incidence curve was plotted by R software. The significant criteria set up at 2 side P-value < .05.
3. Results
Of total 3558 eligible study subjects, 1779 patients were with acupuncture treatment after a diagnosis of AF, and the others were AF patients without any medical record of acupuncture treatment. The dominant age group in this study were aged more than 65 years. Patients with acupuncture treatment had 1680 (94.4%) patients coexisting rheumatologic disease, 1379 (77.5%) had hypertension and 1211 (68.1%) had coronary artery disease, which were the most frequent comorbidities in case group. No significant difference was shown between 2 groups (Table 1).
Table 1.
Characteristics of AF patients according to accept acupuncture.
| Variables | Accepted acupuncture | P-value | |||
|---|---|---|---|---|---|
| No (n = 1779) | Yes (n = 1779) | ||||
| n | % | n | % | ||
| Age group | .35 | ||||
| 18–49 | 289 | 16.3 | 258 | 14.5 | |
| 50–64 | 546 | 30.7 | 563 | 31.7 | |
| More than 65 | 944 | 53.1 | 958 | 53.9 | |
| Mean ± SD(a) | 64.4(14.7) | 64.4(13.9) | .94 | ||
| Sex | |||||
| Female | 840 | 47.2 | 867 | 48.7 | |
| Male | 939 | 52.8 | 912 | 51.3 | |
| Comorbidity | |||||
| Hypertension | 1377 | 77.4 | 1379 | 77.5 | .94 |
| Coronary artery disease | 1162 | 65.3 | 1211 | 68.1 | .08 |
| Peripheral arterial occlusion disease | 207 | 11.6 | 191 | 1.7 | .39 |
| Diabetes mellitus | 354 | 19.9 | 335 | 18.8 | .42 |
| Hyperlipidemia | 905 | 50.9 | 871 | 49.0 | .25 |
| Congestive heart failure | 721 | 40.5 | 715 | 4.2 | .84 |
| Hyperthyroidism | 146 | 8.21 | 140 | 7.87 | .71 |
| Sleep disorder | 893 | 50.2 | 908 | 51.0 | .62 |
| Anxiety | 826 | 46.4 | 838 | 47.1 | .69 |
| Alcoholism | 124 | 6.97 | 117 | 6.58 | .64 |
| Tobacco use | 41 | 2.30 | 37 | 2.08 | .65 |
| Obesity | 49 | 2.75 | 43 | 2.42 | .53 |
| Gout | 497 | 27.9 | 489 | 27.5 | .76 |
| COPD | 693 | 39.0 | 692 | 38.9 | .97 |
| CKD or ESRD | 171 | 9.61 | 150 | 8.43 | .22 |
| Anemia | 276 | 15.5 | 289 | 16.3 | .55 |
| Cancer | 122 | 6.86 | 92 | 5.17 | .03 |
| Rheumatologic disease | 1688 | 94.9 | 1680 | 94.4 | .55 |
Chi-Square Test.
t test.
AF = atrial fibrillation, CKD = chronic kidney disease, COPD = chronic obstructive pulmonary disease, ESRD = end stage renal disease, SD = standard deviation.
Table 2 presented the number of stroke and hazard ratio between with and without acupuncture treatment among AF patients. Patients with acupuncture treatment had decreased risk (aHR = 0.46, 95% confidence intervals [CI] = 0.38–0.54) of developing stroke compared to the comparison cohort. Other risk factors of stroke included increasing age, female (aHR = 1.22, 95% CI = 1.01–1.47), with hypertension (aHR = 1.52, 95% CI = 1.15–2.01), diabetes (aHR = 1.29, 95% CI = 1.05–1.57), congestive heart failure (aHR = 1.25, 95% CI = 1.05–1.50) and alcoholism (aHR = 1.54, 95% CI = 1.01–2.34) after adjusted for age, gender and comorbidities.
Table 2.
Cox model with hazard ratios and 95% confidence intervals of stroke associated with accepted acupuncture and covariates among AF patients.
| Variable | Stroke | Crude | Adjusted† | ||||
|---|---|---|---|---|---|---|---|
| no. (n = 539) | HR | (95% CI) | P-value | HR | (95% CI) | P-value | |
| Accepted acupuncture | |||||||
| No | 292 | 1.00 | Reference | 1.00 | Reference | ||
| Yes | 247 | 0.50 | (0.42, 0.59 | <.001 | 0.46 | (0.38, 0.54) | <.001 |
| Age group | |||||||
| 18–49 | 31 | 1.00 | Reference | 1.00 | Reference | ||
| 50–64 | 146 | 2.58 | (1.75, 3.80) | <.001 | 2.22 | (1.49, 3.32) | <.001 |
| More than 65 | 362 | 4.44 | (3.08, 6.41) | <.001 | 3.57 | (2.40, 5.32) | <.001 |
| Sex | |||||||
| Female | 292 | 1.28 | (1.08, 1.52) | .004 | 1.22 | (1.01, 1.47) | .04 |
| Male | 247 | 1.00 | Reference | 1.00 | Reference | ||
| Comorbidity (ref = non-) | |||||||
| Hypertension | 473 | 2.34 | (1.81, 3.03) | <.001 | 1.52 | (1.15, 2.01) | .003 |
| Coronary artery disease | 404 | 1.51 | (1.24, 1.84) | <.001 | 1.10 | (0.90,1.36) | .36 |
| Peripheral arterial occlusion disease | 68 | 1.35 | (1.04, 1.74) | .02 | 1.02 | (0.78, 1.32) | .91 |
| Diabetes mellitus | 142 | 1.62 | (1.34, 1.97) | <.001 | 1.29 | (1.05, 1.57) | .01 |
| Hyperlipidemia | 283 | 1.20 | (1.01, 1.42) | .04 | 0.95 | (0.79, 1.14) | .55 |
| Congestive heart failure | 261 | 1.61 | (1.36, 1.90) | <.001 | 1.25 | (1.05, 1.50) | .01 |
| Hyperthyroidism | 31 | 0.67 | (0.47, 0.96) | .03 | 0.79 | (0.55, 1.14) | .20 |
| Sleep disorder | 259 | 0.99 | (0.84, 1.17) | .90 | 0.90 | (0.75, 1.08) | .24 |
| Anxiety | 243 | 0.92 | (0.77, 1.09) | .31 | 0.83 | (0.70, 1.00) | .05 |
| Alcoholism | 32 | 1.01 | (0.71, 1.44) | .96 | 1.54 | (1.01, 2.34) | .04 |
| Tobacco use | 8 | 0.92 | (0.46, 1.85) | .82 | 0.87 | (0.39, 1.95) | .74 |
| Obesity | 8 | 0.62 | (0.31, 1.25) | .18 | 0.78 | (0.39, 1.58) | .49 |
| Gout | 168 | 1.26 | (1.05, 1.52) | .01 | 1.12 | (0.93, 1.36) | .24 |
| COPD | 219 | 1.24 | (1.04, 1.47) | .02 | 1.00 | (0.83, 1.20) | .96 |
| CKD or ESRD | 39 | 1.11 | (0.80, 1.54) | .54 | 1.18 | (0.93, 1.49) | .18 |
| Anemia | 90 | 1.24 | (0.99, 1.55) | .06 | 1.18 | (0.93, 1.49) | .18 |
| Cancer | 16 | 0.68 | (0.41, 1.12) | .13 | 0.63 | (0.38, 1.03) | .07 |
| Rheumatologic disease | 519 | 1.80 | (1.15, 2.82) | .01 | 1.26 | (0.80, 1.99) | .32 |
AF = atrial fibrillation, CI = confidence interval, CKD = chronic kidney disease, COPD = chronic obstructive pulmonary disease, ESRD = end stage renal disease, HR = hazard ratio.
Crude HR represented relative hazard ratio; Adjusted HR† represented adjusted hazard ratio: mutually adjusted for age sex and, comorbidities.
Figure 1 demonstrated the cumulative incidence curves of stroke between case and control group, and the cumulative incidence of stroke were significantly lower than non-acupuncture group (P < .001).
Figure 1.
Cumulative incidence of stroke between the acupuncture cohort and the non-acupuncture cohort. The cumulative incidence of stroke in the acupuncture cohort is significantly lower than in the non-acupuncture cohort (log-rank test, P < .0001).
Table 3 showed the incidence and risk of stroke after stratified with different group. Patients with acupuncture showed lower risk of stroke (aHR = 0.46, 95% CI = 0.38–0.54), ischemic stroke (aHR = 0.47, 95% CI = 0.39–0.56) and hemorrhagic stroke (aHR = 0.35, 95% CI = 0.19–0.67), compared to non-acupuncture treatment cohort. Patients in aged 18 to 49 (aHR = 0.43, 95% CI = 0.20–0.96), 49 to 64 (aHR = 0.42, 95% CI = 0.30–0.59), more than 65 years (aHR = 0.46, 95% CI = 0.37–0.57), female (aHR = 0.37, 95% CI = 0.29–0.47), male (aHR = 0.55, 95% CI = 0.43–0.71) and with comorbidity (aHR = 0.46, 95% CI = 0.39–0.55) showed lower risk of stroke in case group.
Table 3.
Incidence and Cox proportional hazard regression with hazard ratios and 95% confidence intervals of stroke among AF patients with and without acupuncture stratified by age group, sex, and comorbidity.
| Variable | Accepted acupuncture | Crude HR | Adjusted HR‡ | |||||
|---|---|---|---|---|---|---|---|---|
| No | Yes | |||||||
| Event | Person years | IR† | Event | Person years | IR† | |||
| Total | 292 | 3954 | 73.8 | 247 | 7466 | 33.1 | 0.50 (0.42, 0.59) | 0.46 (0.38, 0.54) |
| Ischemic stroke | 267 | 67.5 | 230 | 30.8 | 0.51 (0.42, 0.61) | 0.47 (0.39, 0.56) | ||
| Hemorrhagic stroke | 25 | 6.32 | 17 | 2.28 | 0.38 (0.20, 0.70) | 0.35 (0.19, 0.67) | ||
| Age group | ||||||||
| 18–49 | 21 | 866 | 24.3 | 10 | 1314 | 7.61 | 0.38 (0.18, 0.81) | 0.43 (0.20, 0.96) |
| 49–64 | 82 | 1364 | 60.1 | 64 | 2503 | 25.6 | 0.46 (0.33, 0.65) | 0.42 (0.30, 0.59) |
| More than 65 | 189 | 1725 | 109.6 | 173 | 3649 | 47.4 | 0.47 (0.38, 0.58) | 0.46 (0.37, 0.57) |
| Sex | ||||||||
| Female | 167 | 1748 | 95.5 | 125 | 3734 | 33.5 | 0.39 (0.30, 0.49) | 0.37 (0.29, 0.47) |
| Male | 125 | 2206 | 56.7 | 122 | 3731 | 32.7 | 0.64 (0.50, 0.83) | 0.55 (0.43, 0.71) |
| Comorbidity | ||||||||
| No | 0 | 8 | 0.00 | 0 | 72 | 0.00 | - | - |
| Yes | 292 | 3946 | 74.0 | 244 | 7393 | 33.4 | 0.50 (0.42, 0.59) | 0.46 (0.39, 0.55) |
AF = atrial fibrillation, CI = confidence interval, HR = hazard ratio.
IR, incidence rates, per 1000 person-years.
: represented adjusted hazard ratio: mutually adjusted for, age, sex, and comorbidities.
Table 4 showed the categories of diagnoses among patients who received acupuncture treatment. The most frequent diseases categories were musculoskeletal system and connective tissue (ICD-9-CM: 710–739, 65.8%) and injury and poisoning (ICD-9-CM: 800–999, 57.6%) in this study. Among patients with AF, the risk of stroke exhibited a dose-dependent response with increasing use of acupuncture treatment (Table 5).
Table 4.
The distribution of acupuncture cohort by disease categories/diagnosis in patients with AF.
| Disease (ICD-9-CM) | Acupuncture users | |
|---|---|---|
| (n = 1779) | ||
| n | % | |
| Infectious and parasitic disease (001–139) | 7 | 0.39 |
| Neoplasms (140–239) | 7 | 0.39 |
| Malignant (140–208) | 5 | 0.28 |
| Benign (210–229) | 1 | 0.06 |
| Endocrine, nutritional and metabolic disease and immunity disorder (240–279) | 18 | 1.01 |
| Blood and blood-forming organs (280–289) | 1 | 0.06 |
| Mental disorder (290–319) | 10 | 0.56 |
| Nervous system (320–389) | 123 | 6.91 |
| Circulatory system (390–459) | 63 | 3.54 |
| Respiratory system (460–519) | 38 | 2.14 |
| Digestive system (520–579) | 74 | 4.16 |
| Genitourinary system (580–629) | 23 | 1.29 |
| Complications of pregnancy, childbirth and the puerperium (630–676) | 0 | 0.00 |
| Skin and subcutaneous tissue (680–709) | 7 | 0.39 |
| Musculoskeletal system and connective tissue (710–739) | 1171 | 65.8 |
| Congenital anomalies (740–759) | 13 | 0.73 |
| Certain conditions originating in the perinatal period (760–779) | 0 | 0.00 |
| Symptoms, signs and ill-defined conditions (780–799) | 163 | 9.16 |
| Injury and poisoning (800–999) | 1024 | 57.6 |
Table 5.
Hazard Ratios and 95% confidence intervals of stroke risk associated with cumulative frequency of accepted acupuncture among AF patients.
| Stroke | Hazard Ratio (95% CI) | |||
|---|---|---|---|---|
| N | No. of Event | Crude | Adjusted† | |
| Non-users | 1779 | 292 | 1 (Reference) | 1 (Reference) |
| Acupuncture users‡ | ||||
| ≦6 | 575 | 82 | 0.65 (0.51, 0.83) | 0.58 (0.45, 0.75) |
| 7–18 | 408 | 54 | 0.53 (0.39, 0.70) | 0.49 (0.45, 0.75) |
| >18 | 796 | 111 | 0.65 (0.51, 0.83) | 0.38 (0.30, 0.48) |
| P for trend | <.001 | <.001 | ||
CI = confidence interval.
Crude HR represented relative hazard ratio; Adjusted HR† represented adjusted hazard ratio: mutually adjusted for age sex and, comorbidities.
4. Discussion
In this study, the authors investigated whether acupuncture could decrease the risk of stroke in Taiwanese patients with AF, using data from the national Taiwan health database with Cox proportional hazard model. Moreover, the decreased risk was more dominant in the subgroup of female gender and hemorrhagic stroke.
The major advantage of this study is that the investigated problem is clearly identified. Moreover, the study methods are clearly explained. Furthermore, the large number of patients included in the analysis is one of the principal strengths of the investigation, making the present research reliable.
The global burden of AF on cardiac prognosis is clear, such as stroke, cardiac failure, thromboembolism disorders and mortality.[6–10] Indeed, several efforts are made for risk stratification of stroke in this population.[11–15] However, compared to risk stratification, it is more important to explore the possible modifying factors between AF and stroke development. Acupuncture, a common therapy in Chinese population, has already been reported to have positive impact on stroke risk modification in cardiac arrhythmia.[19] But to our knowledge, there is no research concerning this issue specifically on AF patients since there is a wide diversity of mechanism of stroke development between AF and non-AF individuals.[20,21] Several hypothetic theories underlying this observation, including anti-inflammatory effect, antioxidant effect, autonomic system modulating effect, rhythm converting effect or comorbidity modifying effects are possible explanations.[1–5,22–26] Nonetheless, the association investigation precludes accurate dedicate biomechanical mechanisms; further large scales bench and clinical studies are awaited.
In this study, acupuncture was shown to reduce stroke risk across all subgroups, especially among female gender and hemorrhagic stroke. Although this might be an interesting observation, such association is probably not causal, but related to comorbidities, medications and other variables that may be difficult to adjust, making a firm conclusion difficult to be made. Whether this observation is a novel finding or just an incidental finding secondary to the limitations of robust adjustment should be taken into account and still needs to be verified in future studies.
5. Limitations
Regarding the weaknesses, there is probably a selection bias with using the diagnosis code and selecting patients from a large database. Also, the study is retrospective; therefore, it is unlikely that strict criteria have been followed. As there is no medication record, it cannot be controlled by this. Finally, the reported strength of this association may not be so clinically relevant, despite being original, a clear biological base for this observation is difficult to make.
6. Conclusion
We found that acupuncture could decrease risk of stroke development in patients suffering AF.
Author contributions
Wei-Syun Hu: study concept and design, acquisition of data, analysis and interpretation, manuscript writing, critical revision of the manuscript for important intellectual content and study supervision.
Cheng-Li Lin: acquisition of data, analysis and interpretation.
Supplementary Material
Abbreviations:
- AF =
- atrial fibrillation
- aHR =
- adjusted hazard ratios
- CI =
- confidence interval
- NHIRD =
- National Health Insurance Research Database
Supplemental Digital Content is available for this article.
The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.
The authors have no funding and conflicts of interest to disclose.
How to cite this article: Hu W-S, Lin C-L. Acupuncture decreases risk of stroke among patients with atrial fibrillation: A nationwide investigation. Medicine 2022;101:48(e31889).
References
- [1].Abdi H, Tayefi M, Moallem SR, et al. Abdominal and auricular acupuncture reduces blood pressure in hypertensive patients. Complement Ther Med. 2017;31:20–6. [DOI] [PubMed] [Google Scholar]
- [2].Liu Y, Park JE, Shin KM, et al. Acupuncture lowers blood pressure in mild hypertension patients: a randomized, controlled, assessor-blinded pilot trial. Complement Ther Med. 2015;23:658–65. [DOI] [PubMed] [Google Scholar]
- [3].Wu MY, Huang MC, Chiang JH, et al. Acupuncture decreased the risk of coronary heart disease in patients with fibromyalgia in Taiwan: a nationwide matched cohort study. Arthritis Res Ther. 2017;19:37. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [4].Kathy Lee SM, Yoon KH, Park J, et al. Additional effects of Back-Shu electroacupuncture and moxibustion in cardioprotection of Rat Ischemia-Reperfusion Injury. Evid Based Complement Alternat Med. 2015;2015:625645. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [5].Ma L, Cui B, Shao Y, et al. Electroacupuncture improves cardiac function and remodeling by inhibition of sympathoexcitation in chronic heart failure rats. Am J Physiol Heart Circ Physiol. 2014;306:H1464–71. [DOI] [PubMed] [Google Scholar]
- [6].Chugh SS, Havmoeller R, Narayanan K, et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation. 2014;129:837–47. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [7].Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics-2016 update: a report from the American Heart Association. Circulation. 2016;133:e38–360. [DOI] [PubMed] [Google Scholar]
- [8].Alonso A, Bengtson LG. A rising tide: the global epidemic of atrial fibrillation. Circulation. 2014;129:829–30. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [9].Alpert JS, Petersen P, Godtfredsen J. Atrial fibrillation: natural history, complications, and management. Annu Rev Med. 1988;39:41–52. [DOI] [PubMed] [Google Scholar]
- [10].Marini C, De Santis F, Sacco S, et al. Contribution of atrial fibrillation to incidence and outcome of ischemic stroke: results from a population-based study. Stroke. 2005;36:1115–9. [DOI] [PubMed] [Google Scholar]
- [11].January CT, Wann LS, Alpert JS, et al. 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:e1–76. [DOI] [PubMed] [Google Scholar]
- [12].Ogawa S, Aonuma K, Tse HF, et al.. TheAPHRS’s 2013 statementon antithrombotic therapy of patients with nonvalvular atrial fibrillation. J Arrhythm. 2013;29:190–200. [Google Scholar]
- [13].Camm AJ, Lip GY, De Caterina R, et al. 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;33:2719–47. [DOI] [PubMed] [Google Scholar]
- [14].Lip GY, Nieuwlaat R, Pisters R, et al. 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;137:263–72. [DOI] [PubMed] [Google Scholar]
- [15].Fuster V, Rydén LE, Cannom DS, et al. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Am Coll Cardiol. 2011;57:e101–98. [DOI] [PubMed] [Google Scholar]
- [16].Database NHIR. Taiwan. Available at: http://nhird.nhri.org.tw/en/index.html [access date 2015].
- [17].Hu WS, Lin CL. Hemorrhoid is associated with increased risk of peripheral artery occlusive disease: a nationwide cohort study. J Epidemiol. 2017;27:574–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [18].Hu WS, Lin CL. Association between cataract and risk of incident atrial fibrillation: a nationwide population-based retrospective cohort study. Mayo Clin Proc. 2017;92:370–5. [DOI] [PubMed] [Google Scholar]
- [19].Chuang SF, Liao CC, Yeh CC, et al. Reduced risk of stroke in patients with cardiac arrhythmia receiving traditional Chinese medicine: a nationwide matched retrospective cohort study. Complement Ther Med. 2016;25:34–8. [DOI] [PubMed] [Google Scholar]
- [20].Ntaios G, Lip GY, Makaritsis K, et al. CHADS₂, CHA₂S₂DS₂-VASc, and long-term stroke outcome in patients without atrial fibrillation. Neurology. 2013;80:1009–17. [DOI] [PubMed] [Google Scholar]
- [21].Kamel H, Okin PM, Elkind MS, et al. Atrial fibrillation and mechanisms of stroke: time for a new model. Stroke. 2016;47:895–900. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [22].Zijlstra FJ, van den Berg-de Lange I, Huygen FJ, et al. Anti-inflammatory actions of acupuncture. Mediators Inflamm. 2003;12:59–69. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [23].Liu CZ, Zhou SF, Guimarães SB, et al. Acupuncture and oxidative stress. Evid Based Complement Alternat Med. 2015;2015:424762. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [24].Sakatani K, Kitagawa T, Aoyama N, et al. Effects of acupuncture on autonomic nervous function and prefrontal cortex activity. Adv Exp Med Biol. 2010;662:455–60. [DOI] [PubMed] [Google Scholar]
- [25].VanWormer AM, Lindquist R, Sendelbach SE. The effects of acupuncture on cardiac arrhythmias: a literature review. Heart Lung. 2008;37:425–31. [DOI] [PubMed] [Google Scholar]
- [26].Liu J, Li SN, Liu L, et al. Conventional acupuncture for cardiac arrhythmia: a systematic review of randomized controlled trials. Chin J Integr Med. 2018;24:218–26. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.