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Proietti M, Hijazi Z, Andersson U, Connolly SJ, Eikelboom JW, Ezekowitz MD, Lane DA, Oldgren J, Roldan V, Yusuf S, Wallentin L. Comparison of bleeding risk scores in patients with atrial fibrillation: insights from the RE-LY trial. J Intern Med 2018; 283:282-292. [PMID: 29044861 DOI: 10.1111/joim.12702] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Oral anticoagulation is the mainstay of stroke prevention in atrial fibrillation (AF), but must be balanced against the associated bleeding risk. Several risk scores have been proposed for prediction of bleeding events in patients with AF. OBJECTIVES To compare the performance of contemporary clinical bleeding risk scores in 18 113 patients with AF randomized to dabigatran 110 mg, 150 mg or warfarin in the RE-LY trial. METHODS HAS-BLED, ORBIT, ATRIA and HEMORR2 HAGES bleeding risk scores were calculated based on clinical information at baseline. All major bleeding events were centrally adjudicated. RESULTS There were 1182 (6.5%) major bleeding events during a median follow-up of 2.0 years. For all the four schemes, high-risk subgroups had higher risk of major bleeding (all P < 0.001). The ORBIT score showed the best discrimination with c-indices of 0.66, 0.66 and 0.62, respectively, for major, life-threatening and intracranial bleeding, which were significantly better than for the HAS-BLED score (difference in c-indices: 0.050, 0.053 and 0.048, respectively, all P < 0.05). The ORBIT score also showed the best calibration compared with previous data. Significant treatment interactions between the bleeding scores and the risk of major bleeding with dabigatran 150 mg BD versus warfarin were found for the ORBIT (P = 0.0019), ATRIA (P < 0.001) and HEMORR2 HAGES (P < 0.001) scores. HAS-BLED score showed a nonsignificant trend for interaction (P = 0.0607). CONCLUSIONS Amongst the current clinical bleeding risk scores, the ORBIT score demonstrated the best discrimination and calibration. All the scores demonstrated, to a variable extent, an interaction with bleeding risk associated with dabigatran or warfarin.
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Affiliation(s)
- M Proietti
- Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Rome, Italy.,Department of Neuroscience, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Z Hijazi
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - U Andersson
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - S J Connolly
- Population Health Research Institute, Hamilton, ON, Canada
| | - J W Eikelboom
- Population Health Research Institute, Hamilton, ON, Canada
| | - M D Ezekowitz
- Sidney Kimmel Medical College, Thomas Jefferson University, Wynnewood, PA, USA
| | - D A Lane
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - J Oldgren
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - V Roldan
- Department of Hematology and Clinical Oncology, Hospital Universitario Morales Meseguer, University of Murcia, Murcia, Spain.,Instituto Murciano de Investigación Biosanitaria Virgen de la Arrixaca (IMIB), Murcia, Spain
| | - S Yusuf
- Population Health Research Institute, Hamilton, ON, Canada
| | - L Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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Nishtala PS, Castelino RL, Peterson GM, Hannan PJ, Salahudeen MS. Residential medication management reviews of antithrombotic therapy in aged care residents with atrial fibrillation: assessment of stroke and bleeding risk. J Clin Pharm Ther 2016; 41:279-84. [DOI: 10.1111/jcpt.12385] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 03/11/2016] [Indexed: 01/22/2023]
Affiliation(s)
- P. S. Nishtala
- School of Pharmacy; University of Otago; Dunedin New Zealand
| | - R. L. Castelino
- Pharmacy, School of Medicine; University of Tasmania; Hobart TAS Australia
| | - G. M. Peterson
- Pharmacy, School of Medicine; University of Tasmania; Hobart TAS Australia
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Maes F, Dalleur O, Henrard S, Wouters D, Scavée C, Spinewine A, Boland B. Risk scores and geriatric profile: can they really help us in anticoagulation decision making among older patients suffering from atrial fibrillation? Clin Interv Aging 2014; 9:1091-9. [PMID: 25053883 PMCID: PMC4105275 DOI: 10.2147/cia.s62597] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Anticoagulation for the prevention of cardio-embolism is most frequently indicated but largely underused in frail older patients with atrial fibrillation (AF). This study aimed at identifying characteristics associated with anticoagulation underuse. METHODS A cross-sectional study of consecutive geriatric patients aged ≥75 years, with AF and clear anticoagulation indication (CHADS₂ [Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack] ≥2) upon hospital admission. All patients benefited from a comprehensive geriatric assessment. Their risks of stroke and bleeding were predicted using CHADS₂ and HEMORR2HAGES (Hepatic or renal disease, Ethanol abuse, Malignancy, Older (age >75 years), Reduced platelet count or function, Rebleed risk, Hypertension (uncontrolled), Anemia, Genetic factors, Excessive fall risk, and Stroke) scores, respectively. RESULTS Anticoagulation underuse was observed in 384 (50%) of 773 geriatric patients with AF (median age 85 years; female 57%, cognitive disorder 33%, nursing home 20%). No geriatric characteristic was found to be associated with anticoagulation underuse. Conversely, anticoagulation underuse was markedly increased in the patients treated with aspirin (odds ratio [OR] [95% confidence interval]: 5.3 [3.8; 7.5]). Other independent predictors of anticoagulation underuse were ethanol abuse (OR: 4.0 [1.4; 13.3]) and age ≥90 years (OR: 2.0 [1.2; 3.4]). Anticoagulation underuse was not inferior in patients with a lower bleeding risk and/or a higher stroke risk and underuse was surprisingly not inferior either in the AF patients who had previously had a stroke. CONCLUSION Half of this geriatric population did not receive any anticoagulation despite a clear indication, regardless of their individual bleeding or stroke risks. Aspirin use is the main characteristic associated with anticoagulation underuse.
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Affiliation(s)
- Frédéric Maes
- Cardiology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Olivia Dalleur
- Pharmacy Department, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium ; Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - Séverine Henrard
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium
| | - Dominique Wouters
- Pharmacy Department, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Christophe Scavée
- Cardiology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Anne Spinewine
- Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium ; Pharmacy Department, CHU Dinant-Godinne, Université catholique de Louvain, Yvoir, Belgium
| | - Benoit Boland
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium ; Geriatric Medicine, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
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Corvol A, Gulsvik A, Kuper I, Phylaktou P, Myrstad M, Somme D, Cruz-Jentoft A. Use of anticoagulants for atrial fibrillation in older subjects across different countries: Cyprus, France, Netherlands, Norway. Eur Geriatr Med 2014. [DOI: 10.1016/j.eurger.2013.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Masotti L, Di Napoli M, Godoy DA, Rafanelli D, Liumbruno G, Koumpouros N, Landini G, Pampana A, Cappelli R, Poli D, Prisco D. The practical management of intracerebral hemorrhage associated with oral anticoagulant therapy. Int J Stroke 2011; 6:228-40. [PMID: 21557810 DOI: 10.1111/j.1747-4949.2011.00595.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Oral anticoagulant-associated intracerebral hemorrhage is increasing in incidence and is the most feared complication of therapy with vitamin K1 antagonists. Anticoagulant-associated intracerebral hemorrhage has a high risk of ongoing bleeding, death, or disability. The most important aspect of clinical management of anticoagulant-associated intracerebral hemorrhage is represented by urgent reversal of coagulopathy, decreasing as quickly as possible the international normalized ratio to values ≤1·4, preferably ≤1·2, together with life support and surgical therapy, when indicated. Protocols for anticoagulant-associated intracerebral hemorrhage emphasize the immediate discontinuation of anticoagulant medication and the immediate intravenous administration of vitamin K1 (mean dose: 10-20 mg), and the use of prothrombin complex concentrates (variable doses calculated estimate circulating functional prothrombin complex) or fresh-frozen plasma (15-30 ml/kg) or recombinant activated factor VII (15-120 μg/kg). Because of cost and availability, there is limited randomized evidence comparing different reversal strategies that support a specific treatment regimen. In this paper, we emphasize the growing importance of anticoagulant-associated intracerebral hemorrhage and describe options for acute coagulopathy reversal in this setting. Additionally, emphasis is placed on understanding current consensus-based guidelines for coagulopathy reversal and the challenges of determining best evidence for these treatments. On the basis of the available knowledge, inappropriate adherence to current consensus-based guidelines for coagulopathy reversal may expose the physician to medico-legal implications.
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Affiliation(s)
- Luca Masotti
- Internal Medicine, Cecina Hospital, Cecina, Italy Neurological Service, San Camillo de' Lellis General Hospital, Rieti, Italy.
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