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Papakonstantinou PE, Kalogera V, Charitos D, Polyzos D, Benia D, Batsouli A, Lampropoulos K, Xydonas S, Gupta D, Lip GYH. When anticoagulation management in atrial fibrillation becomes difficult: Focus on chronic kidney disease, coagulation disorders, and cancer. Blood Rev 2024; 65:101171. [PMID: 38310007 DOI: 10.1016/j.blre.2024.101171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/11/2024] [Accepted: 01/11/2024] [Indexed: 02/05/2024]
Abstract
Anticoagulation therapy (AT) is fundamental in atrial fibrillation (AF) treatment but poses challenges in implementation, especially in AF populations with elevated thromboembolic and bleeding risks. Current guidelines emphasize the need to estimate and balance thrombosis and bleeding risks for all potential candidates of antithrombotic therapy. However, administering oral AT raises concerns in specific populations, such as those with chronic kidney disease (CKD), coagulation disorders, and cancer due to lack of robust data. These groups, excluded from large direct oral anticoagulants trials, rely on observational studies, prompting physicians to adopt individualized management strategies based on case-specific evaluations. The scarcity of evidence and specific guidelines underline the need for a tailored approach, emphasizing regular reassessment of risk factors and anticoagulation drug doses. This narrative review aims to summarize evidence and recommendations for challenging AF clinical scenarios, particularly in the long-term management of AT for patients with CKD, coagulation disorders, and cancer.
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Affiliation(s)
| | - Vasiliki Kalogera
- Third Cardiology Department, School of Medicine, National and Kapodistrian University of Athens, "Sotiria" Chest Hospital, Mesogeion Ave 152, 11527 Athens, Greece
| | - Dimitrios Charitos
- First Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dimitrios Polyzos
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dimitra Benia
- Cardiology Department, General Hospital-Health Center of Kithira, Aroniadika, 80200 Kithira Island, Greece
| | - Athina Batsouli
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Konstantinos Lampropoulos
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece; School of Medicine, European University of Cyprus, Diogenous 6, 2404 Egkomi, Cyprus
| | - Sotirios Xydonas
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Heart and Chest Hospital, L14 3PE Liverpool, United Kingdom.
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Thomas Dr., L14 3PE Liverpool, United Kingdom; Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Selma Lagerløfs Vej 249, 9260 Gistrup, Aalborg, Denmark.
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Tsiachris D, Papakonstantinou PE, Doundoulakis I, Tsioufis P, Botis M, Dimitriadis K, Leontsinis I, Kordalis A, Antoniou CK, Mantzouranis E, Iliakis P, Vlachakis PK, Gatzoulis KA, Tsioufis K. Anticoagulation Status and Left Atrial Appendage Occlusion Indications in Hospitalized Cardiology Patients with Atrial Fibrillation: A Hellenic Cardiorenal Morbidity Snapshot (HECMOS) Sub-Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1881. [PMID: 37893599 PMCID: PMC10608124 DOI: 10.3390/medicina59101881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 09/21/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023]
Abstract
Background and Objectives: The proper use of oral anticoagulants is crucial in the management of non-valvular atrial fibrillation (AF) patients. Left atrial appendage closure (LAAC) may be considered for stroke prevention in patients with AF and contraindications for long-term anticoagulant treatment. We aimed to assess anticoagulation status and LAAC indications in patients with AF from the HECMOS (Hellenic Cardiorenal Morbidity Snapshot) survey. Materials and Methods: The HECMOS was a nationwide snapshot survey of cardiorenal morbidity in hospitalized cardiology patients. HECMOS used an electronic platform to collect demographic and clinically relevant information from all patients hospitalized on 3 March 2022 in 55 different cardiology departments. In this substudy, we included patients with known AF without mechanical prosthetic valves or moderate-to-severe mitral valve stenosis. Patients with prior stroke, previous major bleeding, poor adherence to anticoagulants, and end-stage renal disease were considered candidates for LAAC. Results: Two hundred fifty-six patients (mean age 76.6 ± 11.7, 148 males) were included in our analysis. Most of them (n = 159; 62%) suffered from persistent AF. The mean CHA2DS2-VASc score was 4.28 ± 1.7, while the mean HAS-BLED score was 1.47 ± 0.9. Three out of three patients with a a CHA2DS2-VASc score of 0 or 1 (female) were inappropriately anticoagulated. Sixteen out of eighteen patients with a CHA2DS2-VASc score 1 or 2 (if female) received anticoagulants. Thirty-one out of two hundred thirty-five patients with a CHA2DS2-VASc score > 1 or 2 (if female) were inappropriately not anticoagulated. Relative indications for LAAC were present in 68 patients with NVAF (63 had only one risk factor and 5 had two concurrent risk factors). In detail, 36 had a prior stroke, 17 patients had a history of major bleeding, 15 patients reported poor or no adherence to the anticoagulant therapy and 5 had an eGFR value < 15 mL/min/1.73 m2 for a total of 73 risk factors. Moreover, 33 had a HAS-BLED score ≥ 3. No LAAC treatment was recorded. Conclusions: Anticoagulation status was nearly optimal in a high-thromboembolic-risk population of cardiology patients who were mainly treated using NOACs. One out of four AF patients should be screened for LAAC.
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Affiliation(s)
- Dimitris Tsiachris
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
- Athens Heart Center, Athens Medical Center, 15125 Athens, Greece
| | - Panteleimon E. Papakonstantinou
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Ioannis Doundoulakis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Panagiotis Tsioufis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Michail Botis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Kyriakos Dimitriadis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Ioannis Leontsinis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Athanasios Kordalis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Christos-Konstantinos Antoniou
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
- Athens Heart Center, Athens Medical Center, 15125 Athens, Greece
| | - Emmanouil Mantzouranis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Panagiotis Iliakis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Panayotis K. Vlachakis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Konstantinos A. Gatzoulis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Konstantinos Tsioufis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
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Bolt J, Barry AR, Yuen J, Madden K, Dhillon M, Inglis C. Retrospective Cross-sectional Analysis of Older Adults Living with Frailty and Anticoagulant Use for Atrial Fibrillation. Can Geriatr J 2023; 26:259-265. [PMID: 37265983 PMCID: PMC10198680 DOI: 10.5770/cgj.26.643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
Background Oral anticoagulation (OAC) is recommended for most individuals with atrial fibrillation (AF), including those who are frail. Based on previous literature, those who are frail may be less likely to be prescribed OAC, and up to one-third may receive an inappropriate dose if prescribed a direct oral anticoagulant (DOAC). The objectives of this study were to determine the proportion of frail ambulatory older adults with AF who are prescribed OAC, compare the rates of OAC use across the frailty spectrum, assess the appropriateness of DOAC dosing, and identify if frailty and geriatric syndromes impact OAC prescribing patterns. Methods Retrospective cross-sectional review of individuals with AF referred to an ambulatory clinic for older adults living with frailty and/or geriatric syndromes. Rockwood clinical frailty score of ≥4 was used to define frailty and DOAC appropriateness was assessed based on the Canadian Cardiovascular Society AF guidelines. Results Two hundred and ten participants were included. The mean age was 84 years, 49% were female and the median frailty score was 5. Of the 185 participants who were frail, 82% were prescribed an OAC (83% with frailty score of 4, 85% with a frailty score of 5, and 78% with a frailty score of 6). Of those prescribed a DOAC, 70% received a guideline-approved dose. Conclusions Over 80% of ambulatory older adults with frailty and AF were prescribed an OAC. However, of those prescribed a DOAC, 30% received an unapproved dose, suggesting more emphasis should be placed on initial and ongoing dosage selection.
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Affiliation(s)
- Jennifer Bolt
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver
- Pharmacy Services, Interior Health Authority, Kelowna
| | - Arden R. Barry
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver
- Pharmacy Services, Fraser Health Authority, Surrey
- Faculty of Medicine, University of British Columbia, Vancouver
| | - Jamie Yuen
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver
| | - Kenneth Madden
- Faculty of Medicine, University of British Columbia, Vancouver
- Geriatric Medicine, Vancouver General Hospital, Vancouver
| | - Manrubby Dhillon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver
| | - Colleen Inglis
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver
- Island Health Authority, Courtenay, BC, Canada
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Presta R, Brunetti E, Polidori MC, Bo M. Impact of frailty models on the prescription of oral anticoagulants and on the incidence of stroke, bleeding, and mortality in older patients with atrial fibrillation: a systematic review. Ageing Res Rev 2022; 82:101761. [PMID: 36270605 DOI: 10.1016/j.arr.2022.101761] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/30/2022] [Accepted: 10/14/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Frailty is common in older patients with atrial fibrillation (AF). Current guidelines recommend oral anticoagulant therapy (OAT) except in case of severe frailty or reduced life expectancy, but definitive evidence on which "frailty" tools may help to identify older AF patients expected to derive little or no benefit from OAT is still lacking. Some persistent uncertainties may derive from the different clinical implications that the two major models of frailty, namely the frail phenotype (FP) and the deficit accumulation model (DAM), underlie. We thus conducted a systematic review of published studies to examine the association of the presence of frailty, categorized according to the FP and DAM, with 1) OAT prescription and 2) incidence of clinical outcomes (all-cause mortality, stroke and/or systemic embolism and major or clinically relevant non-major bleeding) in patients receiving OAT. METHODS Embase and MEDLINE were searched from inception until May 31st, 2022, for studies using a validated tool to identify frailty in subjects aged 65 years or older with a diagnosis of non-valvular AF; only studies on patients prescribed an OAT were considered eligible for the analyses involving clinical outcomes. The protocols for each review question have been registered in PROSPERO database (CRD42022308623 and CRD42022308628). FINDINGS Twenty-three studies exploring the association between frailty and OAT prescription on a total of 504 719 subjects were included. Patients with increasing severity of DAM frailty showed consistently lower OAT prescription rates than non-frail patients, whereas use of OAT did not significantly differ between patients with the FP compared with non-frail subjects. Eleven studies exploring the association between frailty and clinical outcomes on a total of 41 985 individuals receiving oral anticoagulation were included. Compared with non-frail subjects, a higher risk of all-cause mortality and clinical outcomes could be observed for AF patients prescribed with OAT with severe frailty according to the DAM, with inconclusive findings for the FP. High levels of heterogeneity were observed in both groups of studies; therefore, a meta-analysis was not performed. CONCLUSIONS Due to the great heterogeneity among different validated frailty measures, indiscriminately relying on "frailty" should not be regarded as the gold standard for clinical decision-making about stroke prevention in older AF patients. Present findings suggest that severe frailty according to the DAM is associated with less use of OAT and increased risk of all-cause mortality, thereby representing at the moment the most reasonable tool to efficiently recognize patients with limited life expectancy and for whom there is so far scant, if any, evidence of a clinical benefit of OAT.
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Affiliation(s)
- Roberto Presta
- Section of Geriatrics, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Molinette, Corso Bramante 88-90, 10126 Turin, Italy.
| | - Enrico Brunetti
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; Section of Internal Medicine, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Sant'Anna, Corso Bramante 88-90, 10126 Turin, Italy.
| | - Maria Cristina Polidori
- Ageing Clinical Research, Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937 Cologne, Germany; Cologne Excellence Cluster On Cellular Stress-Responses in Aging-Associated Diseases (CECAD), University of Cologne, Faculty of Medicine and University Hospital Cologne, Joseph-Stelzmann Straße 26, 50931 Cologne, Germany.
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Molinette, Corso Bramante 88-90, 10126 Turin, Italy.
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Granata N, Vigoré M, Steccanella A, Ranucci L, Sarzi Braga S, Baiardi P, Pierobon A. The Clinical Frailty Scale (CFS) employment in the frailty assessment of patients suffering from Non-Communicable Diseases (NCDs): A systematic review. Front Med (Lausanne) 2022; 9:967952. [PMID: 36052327 PMCID: PMC9425100 DOI: 10.3389/fmed.2022.967952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background The Clinical Frailty Scale (CFS) is a well-established tool that has been widely employed to assess patients' frailty status and to predict clinical outcomes in the acute phase of a disease, but more information is needed to define the implications that this tool have when dealing with Non-Communicable Diseases (NCDs). Methods An electronic literature search was performed on PubMed, Scopus, EMBASE, Web of Science, and EBSCO databases to identify studies employing the CFS to assess frailty in patients with NCDs. Findings After database searching, article suitability evaluation, and studies' quality assessment, 43 studies were included in the systematic review. Researches were conducted mostly in Japan (37.5%), and half of the studies were focused on cardiovascular diseases (46.42%), followed by cancer (25.00%), and diabetes (10.71%). Simplicity (39.29%), efficacy (37.5%), and rapidity (16.07%) were the CFS characteristics mostly appreciated by the authors of the studies. The CFS-related results indicated that its scores were associated with patients' clinical outcomes (33.92%), with the presence of the disease (12.5%) and, with clinical decision making (10.71%). Furthermore, CFS resulted as a predictor of life expectancy in 23 studies (41.07%), clinical outcomes in 12 studies (21.43%), and hospital admissions/readmissions in 6 studies (10.71%). Discussion CFS was found to be a well-established and useful tool to assess frailty in NCDs, too. It resulted to be related to the most important disease-related clinical characteristics and, thus, it should be always considered as an important step in the multidisciplinary evaluation of frail and chronic patients. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/display_record.asp? PROSPERO 2021, ID: CRD42021224214.
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Affiliation(s)
- Nicolò Granata
- Department of Cardiac Respiratory Rehabilitation of Tradate Institute, Istituti Clinici Scientifici Maugeri IRCCS, Varese, Italy
| | - Martina Vigoré
- Istituti Clinici Scientifici Maugeri IRCCS, Psychology Unit of Montescano Institute, Montescano, Italy
- *Correspondence: Martina Vigoré
| | - Andrea Steccanella
- Istituti Clinici Scientifici Maugeri IRCCS, Psychology Unit of Montescano Institute, Montescano, Italy
| | - Luca Ranucci
- Istituti Clinici Scientifici Maugeri IRCCS, Psychology Unit of Montescano Institute, Montescano, Italy
| | - Simona Sarzi Braga
- Cardio-vascular Department, MultiMedica IRCCS, Sesto San Giovanni, Italy
| | - Paola Baiardi
- Central Scientific Direction, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Antonia Pierobon
- Istituti Clinici Scientifici Maugeri IRCCS, Psychology Unit of Montescano Institute, Montescano, Italy
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Doody P, Asamane EA, Aunger JA, Swales B, Lord JM, Greig CA, Whittaker AC. The prevalence of frailty and pre-frailty among geriatric hospital inpatients and its association with economic prosperity and healthcare expenditure: A systematic review and meta-analysis of 467,779 geriatric hospital inpatients. Ageing Res Rev 2022; 80:101666. [PMID: 35697143 DOI: 10.1016/j.arr.2022.101666] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 04/27/2022] [Accepted: 06/06/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Frailty is a common and clinically significant condition among geriatric populations. Although well-evidenced pooled estimates of the prevalence of frailty exist within various settings and populations, presently there are none assessing the overall prevalence of frailty among geriatric hospital inpatients. The purpose of this review was to systematically search and analyse the prevalence of frailty among geriatric hospital inpatients within the literature and examine its associations with national economic indicators. METHODS Systematic searches were conducted on Ovid, Web of Science, Scopus, CINAHL Plus, and the Cochrane Library, encompassing all literature published prior to 22 November 2018, supplemented with manual reference searches. Included studies utilised a validated operational definition of frailty, reported the prevalence of frailty, had a minimum age ≥ 65 years, attempted to assess the whole ward/clinical population, and occurred among hospital inpatients. Two reviewers independently extracted data and assessed study quality. RESULTS Ninety-six studies with a pooled sample of 467,779 geriatric hospital inpatients were included. The median critical appraisal score was 8/9 (range 7-9). The pooled prevalence of frailty, and pre-frailty, among geriatric hospital inpatients was 47.4% (95% CI 43.7-51.1%), and 25.8% (95% CI 22.0-29.6%), respectively. Significant differences were observed in the prevalence of frailty stratified by age, prevalent morbidity, ward type, clinical population, and operational definition. No significant differences were observed in stratified analyses by sex or continent, or significant associations between the prevalence of frailty and economic indicators. CONCLUSIONS Frailty is highly prevalent among geriatric hospital inpatients. High heterogeneity exists within this setting based on various clinical and demographic characteristics. Pooled estimates reported in this review place the prevalence of frailty among geriatric hospital inpatients between that reported for community-dwelling older adults and older adults in nursing homes, outlining an increase in the relative prevalence of frailty with progression through the healthcare system.
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Affiliation(s)
- Paul Doody
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, United Kingdom; The Irish Longitudinal Study on Ageing, School of Medicine, Trinity College Dublin, Dublin 2, Ireland; Mercer's Institute for Successful Ageing, St. James Hospital, Dublin 8, Ireland.
| | - Evans A Asamane
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, United Kingdom; Institute of Applied Health Research, University of Birmingham, United Kingdom
| | - Justin A Aunger
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, United Kingdom; School of Health Sciences, University of Surrey, United Kingdom
| | - Bridgitte Swales
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, United Kingdom; Faculty of Health Sciences and Sport, University of Stirling, United Kingdom
| | - Janet M Lord
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Institute of Inflammation and Ageing, University of Birmingham, United Kingdom; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, United Kingdom
| | - Carolyn A Greig
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, United Kingdom; MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Institute of Inflammation and Ageing, University of Birmingham, United Kingdom; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, United Kingdom
| | - Anna C Whittaker
- School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham, United Kingdom; Faculty of Health Sciences and Sport, University of Stirling, United Kingdom
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Vrettos I, Voukelatou P, Panayiotou S, Kyvetos A, Kalliakmanis A, Makrilakis K, Sfikakis PP, Niakas D. Validation of the revised 9-scale clinical frailty scale (CFS) in Greek language. BMC Geriatr 2021; 21:393. [PMID: 34187373 PMCID: PMC8243421 DOI: 10.1186/s12877-021-02318-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 06/02/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Among many screening tools that have been developed to detect frailty in older adults, Clinical Frailty Scale (CFS) is a valid, reliable and easy-to-use tool that has been translated in several languages. The aim of this study was to develop a valid and reliable version of the CFS to the Greek language. METHODS A Greek version was obtained by translation (English to Greek) and back translation (Greek to English). The "known-group" construct validity of the CFS was determined by using test for trends. Criterion concurrent validity was assessed by evaluating the extent that CFS relates to Barthel Index, using Pearson's correlation coefficient. Both inter-rater and test-retest reliability were assessed using intraclass correlation coefficient. RESULTS Known groups comparison supports the construct validity of the CFS. The strong negative correlation between CFS and Barthel Index (rs = - 0,725, p ≤ 0.001), supports the criterion concurrent validity of the instrument. The intraclass correlation was good for both inter-rater (0.87, 95%CI: 0.82-0.90) and test-retest reliability (0.89: 95%CI: 0.85-0.92). CONCLUSION The Greek version of the CFS is a valid and reliable instrument for the identification of frailty in the Greek population.
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Affiliation(s)
- Ioannis Vrettos
- 2nd Department of Internal Medicine, General and Oncology Hospital of Kifissia “Agioi Anargyroi”, Noufaron and 14 Timiou Stavrou street, Athens, Greece
- Department of Health Economics, School of Health Sciences, National and Kapodistrian University of Athens, 75 Mikras Asias street, Athens, Greece
| | - Panagiota Voukelatou
- 2nd Department of Internal Medicine, General and Oncology Hospital of Kifissia “Agioi Anargyroi”, Noufaron and 14 Timiou Stavrou street, Athens, Greece
| | - Stefani Panayiotou
- 2nd Department of Internal Medicine, General and Oncology Hospital of Kifissia “Agioi Anargyroi”, Noufaron and 14 Timiou Stavrou street, Athens, Greece
| | - Andreas Kyvetos
- 2nd Department of Internal Medicine, General and Oncology Hospital of Kifissia “Agioi Anargyroi”, Noufaron and 14 Timiou Stavrou street, Athens, Greece
| | - Andreas Kalliakmanis
- 2nd Department of Internal Medicine, General and Oncology Hospital of Kifissia “Agioi Anargyroi”, Noufaron and 14 Timiou Stavrou street, Athens, Greece
| | - Konstantinos Makrilakis
- 1st Department of Propedeutic Internal Medicine, Laikon General Hospital, 17 Agiou Thoma street, Athens, Greece
- School of Medicine, National and Kapodistrian University of Athens, 75 Mikras Asias street, Athens, Greece
| | - Petros P. Sfikakis
- School of Medicine, National and Kapodistrian University of Athens, 75 Mikras Asias street, Athens, Greece
- 1st Department of Propedeutic Internal Medicine-Rheumatology Unit, Laikon General Hospital, 17 Agiou Thoma street, Athens, Greece
| | - Dimitris Niakas
- Department of Health Economics, School of Health Sciences, National and Kapodistrian University of Athens, 75 Mikras Asias street, Athens, Greece
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8
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Abstract
The prevalence of atrial fibrillation (AF) increases with age, as does the proportion of patients with frailty. AF patients with frailty have a higher risk of stroke than those without frailty, and progressive frailty caused by stroke is also associated with a worse prognosis. Despite this, anticoagulant therapy tends to not be used in frail patients because of the risk of falls and bleeding complications. However, some studies have shown that anticoagulant therapy improves the prognosis in patients with frailty. An accurate assessment of the "net-clinical-benefits" is needed in patients with frailty, with the aim of improving the prognoses of patients with frailty by selecting those who will benefit from anticoagulant therapy and actively reducing the risk of bleeding. A comprehensive intervention that includes a team of doctors and social resources is required. We herein review the effectiveness and bleeding risk associated with anticoagulant therapy in frail patients investigated in clinical studies.
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Affiliation(s)
- Hiroshi Hori
- Division of General Medicine, Department of Comprehensive Medicine 1, Saitama Medical Center, Jichi Medical University, Japan
| | - Takahiko Fukuchi
- Division of General Medicine, Department of Comprehensive Medicine 1, Saitama Medical Center, Jichi Medical University, Japan
| | - Hitoshi Sugawara
- Division of General Medicine, Department of Comprehensive Medicine 1, Saitama Medical Center, Jichi Medical University, Japan
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9
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Mailhot T, McManus DD, Waring ME, Lessard D, Goldberg R, Bamgbade BA, Saczynski JS. Frailty, Cognitive Impairment, and Anticoagulation Among Older Adults with Nonvalvular Atrial Fibrillation. J Am Geriatr Soc 2020; 68:2778-2786. [PMID: 32780497 PMCID: PMC8567309 DOI: 10.1111/jgs.16756] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 07/21/2023]
Abstract
BACKGROUND/OBJECTIVES Oral anticoagulation (OAC) is challenging in older patients with nonvalvular atrial fibrillation (NVAF) who are often frail and have cognitive impairment. We examined the characteristics of older NVAF patients associated with higher odds of physical and cognitive impairments. We also examined if these high-risk patients have different OAC prescribing patterns and their satisfaction with treatment because it may impact optimal management of their NVAF. METHODS The patients in the Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF study cohort 2016-2018) had NVAF, were aged 65 and older, and eligible for the receipt of OAC. Measures included frailty (Fried Frailty scale), cognitive impairment (Montreal Cognitive Assessment Battery), OAC prescribing and type (direct oral anticoagulant [DOAC] or vitamin K antagonist [VKA]), depressive symptoms (Patient Health Questionnaire-9), bleeding, stroke risk, and treatment benefit (Anti-Clot Treatment Scale). RESULTS Patients (n = 1,244) were 49% female, aged 76 (standard deviation = 7) years. A total of 14% were frail, and 42% had cognitive impairment. Frailty and cognitive impairment co-occurred in 9%. Odds of having both impairments versus none were higher with depression (odds ratio [OR] = 4.62; 95% confidence interval [CI] = 2.59-8.26), older age (OR = 1.56; 95% CI = 1.29-1.88), lower education (OR = 3.81; 95%CI = 2.13-6.81), race/ethnicity other than non-Hispanic White (OR = 7.94; 95% CI = 4.34-14.55), bleeding risk (OR = 1.43; 95% CI = 1.12-1.81), and stroke risk (OR = 1.35; 95% CI = 1.13-1.62). OAC prescribing was not associated with CI and frailty status. Among patients taking OACs (85%), those with both impairments were more likely to take DOAC than VKA (OR = 1.69; 95% CI = 1.01-2.80). Having both impairments (OR = 1.87; 95% CI = 1.08-3.27) or cognitive impairment (OR = 1.56; 95% CI = 1.09-2.24) was associated with higher odds of reporting lower treatment benefit. CONCLUSION In a large cohort of older NVAF patients, half were frail or cognitively impaired, and 9% had both impairments. We highlight the characteristics of patients who may benefit from cognitive and physical function screenings to maximize treatment and enhance prognosis. Finally, the co-occurrence of impairment was associated with low perceived benefit of treatment that may impede optimal management.
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Affiliation(s)
- Tanya Mailhot
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - David D. McManus
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Molly E. Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Benita A. Bamgbade
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - Jane S. Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
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10
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Bielecka-Dabrowa A, Ebner N, Dos Santos MR, Ishida J, Hasenfuss G, von Haehling S. Cachexia, muscle wasting, and frailty in cardiovascular disease. Eur J Heart Fail 2020; 22:2314-2326. [PMID: 32949422 DOI: 10.1002/ejhf.2011] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 12/16/2022] Open
Abstract
The last several years have seen increasing interest in understanding cachexia, muscle wasting, and physical frailty across the broad spectrum of patients with cardiovascular illnesses. This interest originally started in the field of heart failure, but has recently been extended to other areas such as atrial fibrillation, coronary artery disease, peripheral artery disease as well as to patients after cardiac surgery or transcatheter aortic valve implantation. Tissue wasting and frailty are prevalent among many of the affected patients. The ageing process itself and concomitant cardiovascular illness decrease lean mass while fat mass is relatively preserved, making elderly patients particularly prone to develop wasting syndromes and frailty. The aim of this review is to provide an overview of the available knowledge of body wasting and physical frailty in patients with cardiovascular illness, particularly focussing on patients with heart failure in whom most of the available data have been gathered. In addition, mechanisms of wasting and possible therapeutic targets are discussed.
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Affiliation(s)
- Agata Bielecka-Dabrowa
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother's Memorial Hospital Research Institute (PMMHRI), Lodz, Poland.,Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Lodz, Poland
| | - Nicole Ebner
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | | | - Junishi Ishida
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Gerd Hasenfuss
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
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11
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Shah SJ, Fang MC, Jeon SY, Gregorich SE, Covinsky KE. Geriatric Syndromes and Atrial Fibrillation: Prevalence and Association with Anticoagulant Use in a National Cohort of Older Americans. J Am Geriatr Soc 2020; 69:349-356. [PMID: 32989731 DOI: 10.1111/jgs.16822] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/14/2020] [Accepted: 08/16/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although guidelines recommend focusing primarily on stroke risk to recommend anticoagulants in atrial fibrillation (AF), physicians report that geriatric syndromes (e.g., falls and disability) are important when considering anticoagulants. Little is known about the prevalence of geriatric syndromes in older adults with AF or the association with anticoagulant use. METHODS We performed a cross-sectional analysis of the 2014 Health and Retirement Study, a nationally representative study of older Americans. Participants were asked questions to assess domains of aging, including function, cognition, and medical conditions. We included participants 65 years and older with 2 years of continuous Medicare enrollment who met AF diagnosis criteria by claims codes. We examined five geriatric syndromes: one or more falls within the last 2 years, receiving help with activities of daily living (ADLs) or instrumental ADLs (IADL), experienced incontinence, and cognitive impairment. We determined the prevalence of geriatric syndromes and their association with anticoagulant use, adjusting for ischemic stroke risk (i.e., CHA2 DS2 -VASc score [congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, and sex]). RESULTS In this study of 779 participants with AF (median age = 80 years; median CHA2 DS2 -VASc score = 4), 82% had one or more geriatric syndromes. Geriatric syndromes were common: 49% reported falls, 38% had ADL impairments, 42% had IADL impairments, 37% had cognitive impairments, and 43% reported incontinence. Overall, 65% reported anticoagulant use; guidelines recommend anticoagulant use for 97% of participants. Anticoagulant use rate decreased for each additional geriatric syndrome (average marginal effect = -3.7%; 95% confidence interval = -1.4% to -5.9%). Lower rates of anticoagulant use were reported in participants with ADL dependency, IADL dependency, and dementia. CONCLUSION Most older adults with AF had at least one geriatric syndrome, and geriatric syndromes were associated with reduced anticoagulant use. The high prevalence of geriatric syndromes may explain the lower than expected anticoagulant use in older adults.
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Affiliation(s)
- Sachin J Shah
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Margaret C Fang
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sun Y Jeon
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Steven E Gregorich
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Kenneth E Covinsky
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
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12
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Papakonstantinou PE, Tsioufis C, Konstantinidis D, Iliakis P, Leontsinis I, Tousoulis D. Anticoagulation in Deep Venous Thrombosis: Current Trends in the Era of Non- Vitamin K Antagonists Oral Anticoagulants. Curr Pharm Des 2020; 26:2692-2702. [DOI: 10.2174/1381612826666200420150517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 05/13/2020] [Indexed: 12/20/2022]
Abstract
:
Anticoagulation therapy is the cornerstone of treatment in acute vein thrombosis (DVT) and it aims to
reduce symptoms, thrombus extension, DVT recurrences, and mortality. The treatment for DVT depends on its
anatomical extent, among other factors. Anticoagulation therapy for proximal DVT is clearly recommended (at
least for 3 months), while AT for isolated distal DVT should be considered, especially in the presence of high
thromboembolic risk factors. The optimal anticoagulant and duration of therapy are determined by the clinical
assessment, taking into account the thromboembolic and bleeding risk in each patient in a case-by-case decision
making. Non-Vitamin K antagonists oral anticoagulants (NOACs) were a revolution in the anticoagulation management
of DVT. Nowadays, NOACs are considered as first-line therapy in the anticoagulation therapy for DVT
and are recommended as the preferred anticoagulant agents by most scientific societies. NOACs offer a simple
route of administration (oral agents), a rapid onset-offset of their action along with a good efficacy and safety
profile in comparison with Vitamin K Antagonists (VKAs). However, there are issues about their efficacy and
safety profile in specific populations with high thromboembolic and bleeding risks, such as renal failure patients,
active-cancer patients, and pregnant women, in which VKAs and heparins were the standard care of treatment.
Since the available data are promising for the use of NOACs in end-stage chronic kidney disease and cancer
patients, several ongoing randomized trials are currently trying to solve that issues and give evidence about the
safety and efficacy of NOACs in these populations.
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Affiliation(s)
- Panteleimon E. Papakonstantinou
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Costas Tsioufis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Dimitris Konstantinidis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Panagiotis Iliakis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Ioannis Leontsinis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Dimitrios Tousoulis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
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13
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Zathar Z, Karunatilleke A, Fawzy AM, Lip GYH. Atrial Fibrillation in Older People: Concepts and Controversies. Front Med (Lausanne) 2019; 6:175. [PMID: 31440508 PMCID: PMC6694766 DOI: 10.3389/fmed.2019.00175] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/19/2019] [Indexed: 12/18/2022] Open
Abstract
Atrial fibrillation (AF) is the commonest cardiac rhythm abnormality and has a significant disease burden. Amongst its devastating complications is stroke, the risk of which increases with age. The stroke risk in an older person with AF is therefore tremendous, and oral-anticoagulation (OAC) therapy is central to minimizing this risk. The presence of age-associated factors such as frailty and multi-morbidities add complexity to OAC prescription decisions in older patients and often, OAC is needlessly withheld from them despite a lack of evidence to support this practice. Generally, this is driven by an over-estimation of the bleeding risk. This review article provides an overview of the concepts and controversies in managing AF in older people, with respect to the existing evidence and current practice. A literature search was conducted on Pubmed and Cochrane using keywords, and relevant articles published by the 1st of May 2019 were included. The article will shed light on common misconceptions that appear to serve as rationale for precluding OAC and focus on clinical considerations that may aid OAC prescription decisions where appropriate, to optimize AF management using an integrated, multi-disciplinary care approach. This is crucial for all patients, particularly older individuals who are most vulnerable to the deleterious consequences of this condition.
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Affiliation(s)
- Zafraan Zathar
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Anne Karunatilleke
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Ameenathul M Fawzy
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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14
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Papakonstantinou PE, Simantirakis EN. Long-term rhythm monitoring with an implantable loop recorder in patients after the first clinical atrial fibrillation episode. Towards an individualized management. Minerva Cardioangiol 2019; 67:121-130. [PMID: 30724269 DOI: 10.23736/s0026-4725.19.04883-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Although atrial fibrillation (AF) is an arrhythmia with a variable clinical profile (symptomatic and asymptomatic episodes), the first symptomatic episode leads to its initial diagnosis in most cases. Nowadays, continuous and remote long-term cardiac rhythm monitoring is feasible by the use of implantable loop recorders. The data concerning the AF recurrences and progression after the first electrocardiographic-documented clinical AF episode demonstrates that a high percentage of patients may not suffer any other AF recurrence, or may present a low recurrence rate of the arrhythmia in the future. The AF burden may play a key role in the management of the arrhythmia as far as the decision-making for anticoagulation, rate and/or rhythm control therapy is concerned. There is evidence that a higher AF burden is associated with a higher risk of ischemic stroke. Non-vitamin K antagonists (NOACs) anticoagulants are increasingly used in the management of AF, providing a more predictable effect with rapid onset and offset of their action. The use of these agents in combination with devices that provide a continuous remote rhythm monitoring capability has encouraged anticoagulation strategies based on the AF burden. Data from tailored anticoagulation studies in AF are in favor of the long-term rhythm monitoring, ensuring a patient-centered approach with a better evaluation and more individualized management of AF, especially in patients with intermediate thromboembolic risk and high bleeding risk. Further large randomized trials are needed, not only to evaluate such strategies but also to elucidate the long-term cardiac rhythm monitoring in the AF management.
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Affiliation(s)
- Panteleimon E Papakonstantinou
- Department of Cardiology, University Hospital of Heraklion, Heraklion, Greece.,School of Medicine, University of Crete, Heraklion, Greece
| | - Emmanuel N Simantirakis
- Department of Cardiology, University Hospital of Heraklion, Heraklion, Greece - .,School of Medicine, University of Crete, Heraklion, Greece
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