The association between alcohol intake and incident atrial fibrillation in older adults: The ARIC cohort

Louis Y. Li; Linzi Li; Lin Yee Chen; Elsayed Z. Soliman; Alvaro Alonso

doi:10.1371/journal.pone.0314207

Peer Review History

Original SubmissionMay 23, 2024
29 Aug 2024 Decision Letter - Ricardas Radisauskas, Editor PONE-D-24-19326The Association between Alcohol Intake and Incident Atrial Fibrillation in Older Adults: The ARIC CohortPLOS ONE Dear Dr. Louis Y Li, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Oct 13 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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(Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: This study assessed the association between alcohol intake and incident atrial fibrillation (AF) among older participants of the ARIC study (persons age >65 years). 1. The study has limitations in determination of the alcohol intake status (self-reported) and quantity of alcohol consumed (potential recall bias). This was appropriately acknowledged in the limitations. 2. There may also be problems in AF determination. The methodology of determining AF by ICD codes may miss paroxysmal episodes. I would be more explicit in acknowledging this limitation in the manuscript 3. In the Discussion section authors have tried to explain alcohol’s negative association with AF among older individuals vs. positive association among younger individuals. One possibility could be that in the older individuals other, more powerful predictors of AF drawn weaker predictors such as alcohol. 4. Why does Figure 2 have 4 panels when panel A is providing the whole picture? Furthermore, changing the color scheme in each panel is confusing. I would only present panel A 5. Line 356, “that” repeated twice Reviewer #2: I have no particular concern about the manuscript. The argument is very interesting, the data are abundant and derive by a well-known study, English language is plain and clear, strength and limitations are well exposed. Reviewer #3: -No echocardiographic data to diagnose the AF etiology and presence of structural heart disease -Thrombotic risk as CHADS VASC score and presentation with systemic embolization as CVA is not included. -No documented evidence of presence of AF as ECG or holter monitoring. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. 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Revision 1
13 Sep 2024 Author Response Reviewer #1 1. The study has limitations in determination of the alcohol intake status (self-reported) and quantity of alcohol consumed (potential recall bias). This was appropriately acknowledged in the limitations. Acknowledged and no response required. 2. There may also be problems in AF determination. The methodology of determining AF by ICD codes may miss paroxysmal episodes. I would be more explicit in acknowledging this limitation in the manuscript Included language to explicitly acknowledge limitations of AF acquisition: Next, due to incident AF being ascertained from ECGs and ICD codes and without echocardiographic data, the severity and type of AF, such as paroxysmal, persistent, or permanent were not captured. In cases such as paroxysmal episodes, incident AF may be missed entirely. 3. In the Discussion section authors have tried to explain alcohol’s negative association with AF among older individuals vs. positive association among younger individuals. One possibility could be that in the older individuals other, more powerful predictors of AF drawn weaker predictors such as alcohol. Included language to clarify this statement: In this study of older adults, other risk factors may be more powerful predictors of AF that led to weaker associations between alcohol intake and AF. 4. Why does Figure 2 have 4 panels when panel A is providing the whole picture? Furthermore, changing the color scheme in each panel is confusing. I would only present panel A The panels were initially provided to show the statistical significance of results between comparisons. Panel A showed that there was statistically significant difference when all 3 groups were compared together whereas Panels B-D show that the difference between the comparisons: current vs. former, current vs. never, and former vs. never. These additional panels show that there was not statistically significant difference between current vs. former and current vs. never drinkers, and that the main contributing reason for the statistically significant difference in Panel A is a result of the differences between former vs. never drinkers (Panel D, p<0.05). Changed Figure 2 to present only Panel A with an updated caption and additional explanation in the text as follows: With an alpha level of 0.05, there was a statistically significant difference in the risk of incident AF between categories due to the difference in risk between former and never drinkers (Fig 2). The difference in risk between former vs. never drinkers was statistically significant (p=0.006). The differences between current vs. former and current vs. never drinkers were not statistically significant (p=0.067 and 0.152, respectively). 5. Line 356, “that” repeated twice Removed “that”. Reviewer #2 I have no particular concern about the manuscript. The argument is very interesting, the data are abundant and derive by a well-known study, English language is plain and clear, strength and limitations are well exposed. Acknowledged and no response required. Reviewer #3 1. No echocardiographic data to diagnose the AF etiology and presence of structural heart disease Even though echocardiographic data was collected in a subset of ARIC participants at visit 5 (baseline for this analysis), we do not have echocardiographic data at the time of AF diagnosis. We understand this lack of data to characterize AF etiology and determine the presence of structural heart disease is a limitation and we now note it in the Discussion as a limitation: Next, incident AF was ascertained from ICD codes and death certificates without ECG, Holter monitoring, or echocardiographic data. While this may affect our results by missing cases, such as in paroxysmal episodes where AF may be missed entirely, previous studies have validated the use of hospital discharge codes and death certificates for AF ascertainment. 2. Thrombotic risk as CHADS VASC score and presentation with systemic embolization as CVA is not included. The primary focus of our analysis is on the link between alcohol consumption and development of new onset AF, rather than on the risk of thromboembolic events in people with AF. Thus, inclusion of the CHA2DS2-Vasc score and consideration of thromboembolic outcomes is not directly relevant to our primary study question. 3. No documented evidence of presence of AF as ECG or holter monitoring. Prevalent AF was ascertained via ECGs performed at study visits and hospital discharge codes prior to baseline for this analysis, as Holter monitoring was not conducted as part of the ARIC examinations. Similarly, incident AF relied on hospital discharge codes and death certificates. This is not the gold standard for AF diagnosis, which would require evidence of the arrhythmia in an ECG recording. However, validation studies, including our work in the ARIC cohort (Alonso et al, 2009, PMID: 19540400; Jensen et al, 2012, PMID: 22262600), have demonstrated the excellent validity of this approach to identify AF in large epidemiologic studies in which Holter monitoring and repeated ECGs is not logistically feasible. We mention lack of ECG confirmation of all AF cases and Holter monitoring in the study as limitations that could affect our results: Next, incident AF was ascertained from ICD codes and death certificates without ECG, Holter monitoring, or echocardiographic data. While this may affect our results by missing cases, such as in paroxysmal episodes where AF may be missed entirely, previous studies have validated the use of hospital discharge codes and death certificates for AF ascertainment.19,28 Data on the severity and type of AF, such as paroxysmal, persistent, or permanent were not captured, and these characteristics may be important distinctions in the effects of alcohol consumption on AF incidence. Attachments Attachment Submitted filename: Response to Reviewers_2.docx https://doi.org/10.1371/journal.pone.0314207.r002
7 Nov 2024 Decision Letter - Ricardas Radisauskas, Editor The Association between Alcohol Intake and Incident Atrial Fibrillation in Older Adults: The ARIC Cohort PONE-D-24-19326R1 Dear Dr. Louis Y Li, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Ricardas Radisauskas Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0314207.r003
Formally Accepted
11 Nov 2024 Acceptance Letter - Ricardas Radisauskas, Editor PONE-D-24-19326R1 PLOS ONE Dear Dr. Li, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Professor Ricardas Radisauskas Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0314207.r004

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