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Pimpini L, Biscetti L, Matacchione G, Giammarchi C, Barbieri M, Antonicelli R. Atrial High-Rate Episodes in Elderly Patients: The Anticoagulation Therapy Dilemma. J Clin Med 2024; 13:3566. [PMID: 38930095 PMCID: PMC11204811 DOI: 10.3390/jcm13123566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 05/27/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024] Open
Abstract
Atrial fibrillation (AF) has been associated with higher morbidity and mortality rates, especially in older patients. Subclinical atrial fibrillation (SCAF) is defined as the presence of atrial high-rate episodes (AHREs) > 190 bpm for 10 consecutive beats > 6 min and <24 h, as detected by cardiac implanted electronic devices (CIEDs). The selection of eligible patients for anticoagulation therapy among elderly individuals with AHREs detected through CIEDs remains a contentious issue. The meta-analysis of ARTESiA and NOAH-AFNET 6 clinical trials revealed that taking Edoxaban or Apixaban as oral anticoagulation therapy can reduce the risk of stroke by approximately 32% while increasing the risk of major bleeding by approximately 62%. However, it is still unclear which are, among patients with SCAF, those who can take the highest net clinical benefit from anticoagulant therapy. The present review summarizes the current evidence on this intriguing issue and suggests strategies to try to better stratify the risk of stroke and systemic embolism in patients with AHREs. We propose incorporating some parameters including chronic kidney disease (CKD), obesity, enlarged left atrial volume, the efficacy in blood pressure management, and frailty into the traditional CHA2DS2-VASc score. Future trials will be needed to verify the clinical usefulness of the proposed prognostic score mainly in the view of a personalized therapeutic approach in patients with SCAF.
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Affiliation(s)
- Lorenzo Pimpini
- Cardiology Unit, IRCCS INRCA, Via della Montagnola 81, 60127 Ancona, Italy;
| | | | - Giulia Matacchione
- Clinic of Laboratory and Precision Medicine, IRCCS INRCA, 60121 Ancona, Italy;
| | | | - Michelangela Barbieri
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy;
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Rosas Diaz AN, Troy AL, Kaplinskiy V, Pritchard A, Vani R, Ko D, Orkaby AR. Assessment and Management of Atrial Fibrillation in Older Adults with Frailty. Geriatrics (Basel) 2024; 9:50. [PMID: 38667517 PMCID: PMC11050611 DOI: 10.3390/geriatrics9020050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/28/2024] [Accepted: 04/06/2024] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is a major driver of morbidity and mortality among older adults with frailty. Moreover, frailty is highly prevalent in older adults with AF. Understanding and addressing the needs of frail older adults with AF is imperative to guide clinicians caring for older adults. In this review, we summarize current evidence to support the assessment and management of older adults with AF and frailty, incorporating numerous recent landmark trials and studies in the context of the 2023 US AF guideline.
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Affiliation(s)
| | - Aaron L. Troy
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA (A.L.T.)
| | | | - Abiah Pritchard
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA (A.L.T.)
| | - Rati Vani
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA (A.L.T.)
| | - Darae Ko
- Section of Cardiovascular Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, 1200 Center Street, Boston, MA 02131, USA
| | - Ariela R. Orkaby
- New England GRECC (Geriatric Research, Education and Clinical Center), VA Boston Healthcare System, Boston, MA 02130, USA
- Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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3
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Ijaz N, Jamil Y, Brown CH, Krishnaswami A, Orkaby A, Stimmel MB, Gerstenblith G, Nanna MG, Damluji AA. Role of Cognitive Frailty in Older Adults With Cardiovascular Disease. J Am Heart Assoc 2024; 13:e033594. [PMID: 38353229 PMCID: PMC11010094 DOI: 10.1161/jaha.123.033594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 12/19/2023] [Indexed: 02/21/2024]
Abstract
As the older adult population expands, an increasing number of patients affected by geriatric syndromes are seen by cardiovascular clinicians. One such syndrome that has been associated with poor outcomes is cognitive frailty: the simultaneous presence of cognitive impairment, without evidence of dementia, and physical frailty, which results in decreased cognitive reserve. Driven by common pathophysiologic underpinnings (eg, inflammation and neurohormonal dysregulation), cardiovascular disease, cognitive impairment, and frailty also share the following risk factors: hypertension, diabetes, obesity, sedentary behavior, and tobacco use. Cardiovascular disease has been associated with the onset and progression of cognitive frailty, which may be reversible in early stages, making it essential for clinicians to diagnose the condition in a timely manner and prescribe appropriate interventions. Additional research is required to elucidate the mechanisms underlying the development of cognitive frailty, establish preventive and therapeutic strategies to address the needs of older patients with cardiovascular disease at risk for cognitive frailty, and ultimately facilitate targeted intervention studies.
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Affiliation(s)
- Naila Ijaz
- Thomas Jefferson University HospitalPhiladelphiaPAUSA
| | - Yasser Jamil
- Yale University School of MedicineNew HavenCTUSA
| | | | | | - Ariela Orkaby
- New England GRECC, VA Boston Healthcare SystemBostonMAUSA
- Division of AgingBrigham & Women’s Hospital, Harvard Medical SchoolBostonMAUSA
| | | | | | | | - Abdulla A. Damluji
- Johns Hopkins University School of MedicineBaltimoreMDUSA
- The Inova Center of Outcomes ResearchInova Heart and Vascular InstituteFalls ChurchVAUSA
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4
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Shantsila E, Choi EK, Lane DA, Joung B, Lip GY. Atrial fibrillation: comorbidities, lifestyle, and patient factors. THE LANCET REGIONAL HEALTH. EUROPE 2024; 37:100784. [PMID: 38362547 PMCID: PMC10866737 DOI: 10.1016/j.lanepe.2023.100784] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/25/2023] [Accepted: 11/02/2023] [Indexed: 02/17/2024]
Abstract
Modern anticoagulation therapy has dramatically reduced the risk of stroke and systemic thromboembolism in people with atrial fibrillation (AF). However, AF still impairs quality of life, increases the risk of stroke and heart failure, and is linked to cognitive impairment. There is also a recognition of the residual risk of thromboembolic complications despite anticoagulation. Hence, AF management is evolving towards a more comprehensive understanding of risk factors predisposing to the development of this arrhythmia, its' complications and interventions to mitigate the risk. This review summarises the recent advances in understanding of risk factors for incident AF and managing these risk factors. It includes a discussion of lifestyle, somatic, psychological, and socioeconomic risk factors. The available data call for a practice shift towards a more individualised approach considering an increasingly broader range of health and patient factors contributing to AF-related health burden. The review highlights the needs of people living with co-morbidities (especially with multimorbidity), polypharmacy and the role of the changing population demographics affecting the European region and globally.
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Affiliation(s)
- Eduard Shantsila
- Department of Primary Care and Mental Health, University of Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Brownlow Group GP Practice, Liverpool, United Kingdom
| | - Eue-Keun Choi
- Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Republic of Korea
| | - Deirdre A. Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Denmark
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Denmark
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Grymonprez M, Petrovic M, De Backer TL, Steurbaut S, Lahousse L. Impact of frailty on the effectiveness and safety of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation: a nationwide cohort study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:55-65. [PMID: 36941126 PMCID: PMC10785587 DOI: 10.1093/ehjqcco/qcad019] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/04/2023] [Accepted: 03/17/2023] [Indexed: 03/23/2023]
Abstract
AIMS Data on non-vitamin K antagonist oral anticoagulants (NOACs) use in patients with atrial fibrillation (AF) and frailty are scarce. Therefore, the impact of frailty on AF-related outcomes and benefit-risk profiles of NOACs in patients with frailty were investigated. METHODS AND RESULTS AF patients initiating anticoagulation between 2013 and 2019 were included using Belgian nationwide data. Frailty was assessed with the Claims-based Frailty Indicator. Among 254 478 anticoagulated AF patients, 71 638 (28.2%) had frailty. Frailty was associated with higher all-cause mortality risks [adjusted hazard ratio (aHR) 1.48, 95% confidence interval (CI) (1.43-1.54)], but not with thromboembolism or bleeding. Among subjects with frailty (78 080 person-years of follow-up), NOACs were associated with lower risks of stroke or systemic embolism (stroke/SE) [aHR 0.77, 95%CI (0.70-0.86)], all-cause mortality [aHR 0.88, 95%CI (0.84-0.92)], and intracranial bleeding [aHR 0.78, 95%CI (0.66-0.91)], a similar major bleeding risk [aHR 1.01, 95%CI (0.93-1.09)], and higher gastrointestinal bleeding risk [aHR 1.19, 95%CI (1.06-1.33)] compared with VKAs. Major bleeding risks were lower with apixaban [aHR 0.84, 95%CI (0.76-0.93)], similar with edoxaban [aHR 0.91, 95%CI (0.73-1.14)], and higher with dabigatran [aHR 1.16, 95%CI (1.03-1.30)] and rivaroxaban [aHR 1.11, 95%CI (1.02-1.21)] compared with VKAs. Apixaban was associated with lower major bleeding risks compared with dabigatran [aHR 0.72, 95%CI (0.65-0.80)], rivaroxaban [aHR 0.78, 95%CI (0.72-0.84)] and edoxaban [aHR 0.74, 95%CI (0.65-0.84)], but mortality risk was higher compared with dabigatran and edoxaban. CONCLUSION Frailty was an independent risk factor of death. Non-vitamin K antagonist oral anticoagulants had better benefit-risk profiles than VKAs in patients with frailty, especially apixaban, followed by edoxaban.
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Affiliation(s)
- Maxim Grymonprez
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000Ghent, Belgium
| | - Mirko Petrovic
- Department of Geriatrics, Ghent University Hospital, C. Heymanslaan 10, 9000Ghent, Belgium
| | - Tine L De Backer
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000Ghent, Belgium
| | - Stephane Steurbaut
- Centre for Pharmaceutical Research, Research group of Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Jette, Belgium
- Department of Hospital Pharmacy, UZ Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000Ghent, Belgium
- Department of Epidemiology, Erasmus Medical Center, PO Box 2040, Rotterdam 3000CA, The Netherlands
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Liu M, Zhang Q, Liu L, Liu W. Enablers and Hindrances of Lifestyle Changes Among Patients With Atrial Fibrillation: A Qualitative Study. J Cardiovasc Nurs 2024; 39:38-48. [PMID: 37955370 DOI: 10.1097/jcn.0000000000001055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) seriously affects the health status and quality of life of affected patients. However, the lifestyle changes recommended by the guidelines for patients are not ideal. Hence, understanding the factors that promote and hinder healthy behavior changes in patients with AF is crucial for self-management. OBJECTIVE The aims of this study were to understand the factors enabling and hindering health behaviors in patients with AF and to provide a reference for promoting health management among these patients. METHODS Using the purposive sampling method, 22 patients with AF admitted to the Cardiac Center of Beijing Chaoyang Hospital, Capital Medical University, from March 2021 to June 2021 were selected for in-depth face-to-face interviews. The thematic analysis method was used to summarize and refine the themes. RESULTS The following 2 themes and 15 subthemes were eventually extracted by analyzing and summarizing the interview data. The 7 factors facilitating health behaviors in patients with AF were risk perception, outcome expectancy, behavioral intention, action plan, response plan, self-efficacy, and social support. There were 8 hindering factors: personal preferences and habits, specific customary culture, weak self-control, accessibility of exercise conditions, symptom-related distress, cognitive weakness, multiple medication use, and insufficient awareness of condition monitoring. CONCLUSIONS The factors affecting health behaviors in patients with AF are complex, and healthcare providers should reinforce the facilitators of health behaviors in these patients and provide them with targeted interventions against hindering factors. Results can be used to develop health behavior intervention programs for patients with AF.
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Schmidbauer M, Wischmann J, Dimitriadis K, Kellert L. [Secondary prophylaxis of ischemic stroke]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:1171-1183. [PMID: 37947810 DOI: 10.1007/s00108-023-01615-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 11/12/2023]
Abstract
The secondary prophylaxis of ischemic stroke provides an enormous therapeutic potential due to the high frequency of recurrent thrombembolic events and the exceptional importance of modifiable cardiovascular risk factors for the individual risk of stroke. In this respect, anti-thrombotic, interventional and surgical treatment options must be selected based on the respective etiology. Furthermore, meticulous optimization of risk factors is essential for effective long-term care. Close interdisciplinary and intersectoral collaboration is crucial, especially in the long-term treatment.
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Affiliation(s)
- Moritz Schmidbauer
- Klinik und Poliklinik für Neurologie, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland.
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Liu J, Chai K, Zhu W, DU M, Meng C, Yang L, Cui L, Guo D, Sun N, Wang H, Yang J. Implication of different frailty criteria in older people with atrial fibrillation: a prospective cohort study. BMC Geriatr 2023; 23:604. [PMID: 37759173 PMCID: PMC10537815 DOI: 10.1186/s12877-023-04330-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND the prevalence of physical and multidimensional frailty and their prognostic impact on clinical outcomes in patients with atrial fibrillation (AF) is unclear. OBJECTIVE to evaluated frailty in a cohort of patients with AF according to different criteria, and studied the prevalence and its prognostic impact on clinical outcomes. METHODS in this multicenter prospective cohort, 197 inpatients ≥ 65 years old with AF were recruited from September 2018 to April 2019.We used Fried Frailty phenotype (Fried) to assess physical frailty, and comprehensive geriatric assessment-frailty index (CGA-FI) to assess multidimensional frailty. The primary outcome was a composite of all-cause mortality or rehospitalization. RESULTS the prevalence of frailty was determined as 34.5% by Fried, 42.6% by CGA-FI. Malnutrition and ≥ 7 medications were independently associated with frailty. Kaplan-Meier survival curve showed that the presence of frailty by CGA-FI had significantly lower all-cause mortality or rehospitalization survival rate (log-rank P = 0.04) within 1 year. Multivariate Cox regression adjusted for age and sex showed that the frailty by CGA-FI was significantly associated with the risk of all-cause mortality or rehospitalization within 1 year (HR 1.79, 95% CI 1.10-2.90). However, those associations were absent with the physical frailty. After broader multivariate adjustment, those associations were no longer statistically significant for both types of frailty. CONCLUSIONS in older people with AF, Multidimensional frailty is more significantly associated with a composite of all-cause mortality or rehospitalization within 1 year than physical frailty, but these association are attenuated after multivariate adjustment. CLINICAL TRIAL REGISTRATION ChiCTR1800017204; date of registration: 07/18/2018.
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Affiliation(s)
- Junpeng Liu
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Ke Chai
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Wanrong Zhu
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China
- Peking University Fifth School of Clinical Medicine, Beijing, 100730, China
| | - Minghui DU
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Chen Meng
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Lin Yang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Lingling Cui
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Di Guo
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Ning Sun
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Hua Wang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China.
| | - Jiefu Yang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China
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Wang D, Xu X, Han X, Xie J, Zhou H, Peng W, Pan G. Clinical benefits of oral anticoagulants in atrial fibrillation patients with dementia: a systematic review and meta-analysis. Front Cardiovasc Med 2023; 10:1265331. [PMID: 37731522 PMCID: PMC10507720 DOI: 10.3389/fcvm.2023.1265331] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 08/25/2023] [Indexed: 09/22/2023] Open
Abstract
Background The management of atrial fibrillation (AF) with oral anticoagulants (OAC) is generally recommended to reduce the risk of stroke. However, the decision to prescribe these medications for patients with AF and dementia remains controversial. Methods A systematic review and meta-analysis of retrospective cohort studies were conducted. The search encompassed PubMed, Cochrane Library, Web of Science, and Embase databases from inception until May 1st, 2023, with language limited to English. Eligible studies included comparisons between exposure to OAC vs. non-OAC in the AF population with dementia or cognitive impairment. Studies that compared the effects of direct oral anticoagulants (DOAC) and vitamin-K antagonists were also included. The primary outcome was all-cause mortality, and the secondary outcomes were ischemic stroke and major bleeding. This study was registered with PROSPERO (No. CRD42023420678). Results A total of five studies (N = 21,962 patients) met the eligibility criteria and were included in this review. The follow-up duration ranged from 1 to 4 years. Meta-analysis demonstrated that OAC treatment was associated with a lower risk of all-cause mortality in AF patients with dementia with a hazard ratio (HR) of 0.79 and a 95% confidence interval (CI) ranging from 0.68 to 0.92, compared to non-OAC treatment. No statistical differences were observed in the risk of major bleeding (HR = 1.12, 95% CI: 0.88-1.42) or ischemic stroke (HR = 0.77, 95% CI: 0.58-1.00). Three studies reported comparisons between DOAC and warfarin; however, pooled analysis was not performed due to heterogeneity. Conclusion The use of OACs in individuals diagnosed with both AF and dementia holds the potential to reduce all-cause mortality rates, thereby improving the overall clinical prognosis within this specific population. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023420678, PROSPERO identifier, CRD42023420678.
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Affiliation(s)
- Dayang Wang
- Cardiovascular Institute, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Second Department of Cardiology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Xiaoqing Xu
- Department of Endocrinology, Beijing Hepingli Hospital, Beijing, China
| | - Xiaowan Han
- Second Department of Cardiology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jing Xie
- Second Department of Cardiology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Hufang Zhou
- Second Department of Cardiology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Wenhua Peng
- Second Department of Cardiology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Guozhong Pan
- Second Department of Cardiology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
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Wang W, Fan W, Su Y, Hong K. A comparison of the effects of NOAC and VKA therapy on the incidence of dementia in patients with atrial fibrillation: A systematic review and meta-analysis. Clin Cardiol 2023; 46:866-876. [PMID: 37366141 PMCID: PMC10436784 DOI: 10.1002/clc.24076] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023] Open
Abstract
Atrial fibrillation (AF) patients are more susceptible to dementia, but the results about the effect of oral anticoagulants (OACs) on the risk of dementia are not consistent. We hypothesize that OAC is associated with a reduced risk of dementia with AF and that nonvitamin K antagonist oral anticoagulants (NOAC) are superior to vitamin K antagonists (VKA). Four databases were systematically searched until July 1, 2022. Two reviewers independently selected literature, evaluated quality, and extracted data. Data were examined using pooled hazard ratios (HRs) and 95% confidence intervals (CIs). Fourteen research studies involving 910 patients were enrolled. The findings indicated that OACs were associated with a decreased risk of dementia (pooled HR: 0.68, 95% CI: 0.55-0.82, I2 = 87.7%), and NOACs had a stronger effect than VKAs (pooled HR: 0.87, 95% CI: 0.79-0.95, I2 = 72%), especially in participants with a CHA2DS2VASc score ≥ 2 (pooled HR: 0.85, 95% CI: 0.72-0.99). Subgroup analysis demonstrated no statistical significance among patients aged <65 years old (pooled HR: 0.83, 95% CI: 0.64-1.07), patients in "based on treatment" studies (pooled HR: 0.89, 95% CI: 0.75-1.06), or people with no stroke background (pooled HR: 0.90, 95% CI: 0.71-1.15). This analysis revealed that OACs were related to the reduction of dementia incidence in AF individuals, and NOACs were better than VKAs, remarkably in people with a CHA2DS2VASc score ≥ 2. The results should be confirmed by further prospective studies, particularly in patients in "based on treatment" studies aged <65 years old with a CHA2DS2VASc score < 2 or without a stroke background.
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Affiliation(s)
- Wenjie Wang
- Department of Cardiovascular MedicineThe Second Affiliated Hospital of Nanchang UniversityNanchangJiangxiChina
- Jiangxi Key Laboratory of Molecular MedicineNanchangJiangxiChina
| | - Weiguo Fan
- Department of Cardiovascular MedicineThe Second Affiliated Hospital of Nanchang UniversityNanchangJiangxiChina
- Jiangxi Key Laboratory of Molecular MedicineNanchangJiangxiChina
| | - Yuhao Su
- Department of Cardiovascular MedicineThe Second Affiliated Hospital of Nanchang UniversityNanchangJiangxiChina
- Jiangxi Key Laboratory of Molecular MedicineNanchangJiangxiChina
| | - Kui Hong
- Department of Cardiovascular MedicineThe Second Affiliated Hospital of Nanchang UniversityNanchangJiangxiChina
- Jiangxi Key Laboratory of Molecular MedicineNanchangJiangxiChina
- Department of Genetic MedicineThe Second Affiliated Hospital of Nanchang UniversityNanchangJiangxiChina
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11
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Zwart L, Germans T, Vogels R, Simsek S, Hemels M, Jansen R. Frail patients who fall and their risk on major bleeding and intracranial haemorrhage. Outcomes from the Fall and Syncope Registry. BMC Geriatr 2023; 23:422. [PMID: 37430207 DOI: 10.1186/s12877-023-04120-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 06/19/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Major bleeding, and intracranial bleeding specifically, are severe complications related to the use of anticoagulation. To what extent the risk for major bleeding is elevated among frail older people is not well known because they are underrepresented in the randomized clinical trials (RCTs). This study investigates the risk for major bleeding (MB) and intra cranial haemorrhage (ICH) in frail older people who fall. METHODS All patients 65 years and older visiting the Fall and Syncope Clinic, between November 2011 and January 2020, and underwent a MRI of the brain were eligible. Frailty was assessed with a Frailty Index, based on the accumulation of deficits model. Cerebral small vessel disease was described and evaluated as proposed in the position paper of Wardlaw and colleagues in 2013. RESULTS 479 patients were included in this analysis. Mean follow-up was 7 years per patient (ranging from 1 month to 8 years and 5 months). 368 patients (77%) were frail. A total of 81 patients used oral anticoagulation (OAC). 17 extracranial MB of which 3 were traumatic and 14 gastrointestinal, and 16 ICH occurred. There was a total of 603.4 treatment years with OAC, and 8 MBs occurred among patients on OAC (bleeding rate 1.32 per 100 treatment years), of which 2 ICHs (bleeding rate 0.33 per 100 treatment years). The risk for extracranial MB was increased by the use of antiplatelet agents (APA) (adjusted OR 6.9, CI 95% 1.2-38.3), and by the use of OAC (adjusted OR 9.8, CI 95% 1.7-56.1). The risk for ICH was only heightened by white matter hyperintensities (WMH) (adjusted OR 3.8, CI 95% 1.0-13.4). The use of APA (adjusted OR 0.9, CI 95% 0.3-3.3) or OAC (adjusted OR 0.6, CI 95% 0.1-3.3) did not elevate the risk for ICH. CONCLUSION In contrast to common belief, frail patients on OAC with repeated falls show a comparable bleeding rate as in the large RCTs, and the use of OAC did not increase the risk for ICH. However, the number of MBs was low, and of ICHs very low, despite extensive follow-up in this registry.
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Affiliation(s)
- Lar Zwart
- Department of Geriatric Medicine, Northwest Clinics, Alkmaar, The Netherlands.
- Aging and Public Health department, Amsterdam University Medical Centers, Amsterdam, The Netherlands.
- Department of Geriatric Medicine, Dijklander Hospital, Hoorn, The Netherlands.
| | - T Germans
- Department of Cardiology, Northwest Clinics, Alkmaar, The Netherlands
- Department of Cardiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - R Vogels
- Department of Neurology, Northwest Clinics, Alkmaar, The Netherlands
| | - S Simsek
- Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands
- Department of Internal Medicine/Endocrinology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Mew Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Rwmm Jansen
- Department of Geriatric Medicine, Northwest Clinics, Alkmaar, The Netherlands
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12
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Pundi K, Perino AC, Fan J, Din N, Szummer K, Heidenreich P, Turakhia MP. Association of CHA 2DS 2-VASc and HAS-BLED to frailty and frail outcomes: From the TREAT-AF study. Am Heart J 2023; 261:85-94. [PMID: 37024025 DOI: 10.1016/j.ahj.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Morbidity and mortality associated with high CHA2DS2-VASc and HAS-BLED scores is not specific to atrial fibrillation (AF). Frailty could be an important contributor to this morbidity and mortality while being mechanistically independent from AF. We sought to evaluate the association of stroke and bleeding risk to noncardiovascular frail events and the association of stroke prevention therapy to outcomes in frail patients with AF. METHODS Using the TREAT-AF (The Retrospective Evaluation and Assessment of Therapies in AF) study from the Veterans Health Administration, we identified patients with newly diagnosed AF from 2004 to 2014. Baseline frailty was identified using a previously validated claims-based index requiring ≥2 of 12 ICD-9 diagnoses. Logistic regressions modeled the association between CHA2DS2-VASc and modified HAS-BLED and frailty. Cox proportional hazard regressions were used to evaluate the association between CHA2DS2-VASc and modified HAS-BLED and a composite of noncardiovascular frail events (fractures, urinary tract infections, bacterial pneumonia, or dehydration). We also evaluated the association of oral anticoagulant (OAC) use with stroke, bleeding, and 1-year mortality in frail patients and non-frail patients. RESULTS In 213,435 patients (age 70 ± 11; 98% male; CHA2DS2-VASc 2.4 ± 1.7) with AF, 8,498 (4%) were frail. CHA2DS2-VASc > 0 and HAS-BLED > 0 were strongly associated with frailty (odds ratio [OR] 13.3 (95% CI: 11.6-15.2) for CHA2DS2-VASc 4+ and OR 13.4 (10.2-17.5) for HAS-BLED 3+). After adjusting for covariates, CHA2DS2-VASc, and HAS-BLED > 0 were associated with higher risk of non-cardiovascular frail events (hazard ratio [HR] 2.1 (95% CI: 2.0-2.2) for CHA2DS2-VASc 4+ and HR 1.4 (95% CI: 1.3-1.5) for HAS-BLED 3+). In frail patients, OAC use was associated with significantly lower risk of 1-year mortality (HR 0.82; 95% CI 0.72-0.94, P = .0031) but did not reach significance for risk of stroke (HR 0.80; 95% CI 0.55-1.18, P = .26) or major bleeding (HR 1.08; 95% CI 0.93-1.25, P = .34). CONCLUSIONS High CHA2DS2-VASc and HAS-BLED scores are strongly associated with frailty. However, in frail patients, OAC use was associated with reduction in 1-year mortality. For this challenging clinical population with competing risks of frailty and frail events, focused prospective studies are needed to support clinical decision-making. Until then, careful evaluation of frailty should inform shared decision-making.
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Affiliation(s)
- Krishna Pundi
- Department of Medicine, Stanford University School of Medicine, Stanford, CA.
| | - Alexander C Perino
- Department of Medicine, Stanford University School of Medicine, Stanford, CA; Center for Digital Health, Stanford University School of Medicine, Stanford, CA
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Natasha Din
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Karolina Szummer
- Karolinska University Hospital, Theme Heart and Vessel; Karolinska Institutet, Stockholm, Sweden
| | - Paul Heidenreich
- Department of Medicine, Stanford University School of Medicine, Stanford, CA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Mintu P Turakhia
- Department of Medicine, Stanford University School of Medicine, Stanford, CA; Center for Digital Health, Stanford University School of Medicine, Stanford, CA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
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13
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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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14
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Use of Direct Acting Oral Anticoagulants in Elderly Patients with Atrial Fibrillation: A Multicenter, Cross-Sectional Study in Spain. J Clin Med 2023; 12:jcm12031224. [PMID: 36769872 PMCID: PMC9917412 DOI: 10.3390/jcm12031224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/26/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023] Open
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) have substantially improved anticoagulation. However, data on NOAC use among elderly patients are scarce. We sought to describe NOAC use among elderly AF patients in Spain. We performed a non-interventional, multicenter, multispecialty, cross-sectional study in elderly (≥75 years) AF patients treated with NOACs for stroke prevention. Patients' characteristics by NOAC treatment were compared using standardized differences (SDD). NOAC dosing was classified according to the Spanish summary of products characteristics (SmPC) into appropriate (recommended dose) and inappropriate (under and overdosed). Multivariate logistic regression analyses were used to explore factors associated with inappropriate dosing. 500 patients were included. Mean (SD) age was 81.5 (4.7) years, and 50% were women. Mean (SD) creatinine clearance was 57.4 mL/min (18.8), and 23.6% were frail. Dabigatran treatment totaled 38.4%, rivaroxaban 15.2%, apixaban 33.2%, and edoxaban 13.2%. Almost one-fourth of elderly patients treated with NOACs in Spain were inappropriately dosed (underdosing 14.4% and overdosing 9.6%). Underdosing was significantly associated with weight (OR = 1.03, 95%CI = 1.0-1.1), while higher a EHRA score decreased the risk of underdosing (OR = 0.47, 95%CI = 0.2-1.0). Overdosing was significantly associated with a history of ischemic stroke (OR = 2.95, 95%CI = 1.1-7.7). Addressing incorrect dosing among elderly AF patients is relevant to improve patient outcomes.
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15
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Lomper K, Ross C, Uchmanowicz I. Anxiety and Depressive Symptoms, Frailty and Quality of Life in Atrial Fibrillation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1066. [PMID: 36673821 PMCID: PMC9858928 DOI: 10.3390/ijerph20021066] [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: 11/29/2022] [Revised: 12/27/2022] [Accepted: 01/04/2023] [Indexed: 06/17/2023]
Abstract
Introduction: Symptoms of atrial fibrillation (AF) can significantly affect functioning in daily life and reduce patients’ quality of life (QoL). The severity and type of AF symptoms affects not only patient’s QoL, but can be a cause of the development of emotional and psychological disorders. In addition, frailty syndrome (FS) plays important role from the point of view of developing disability and dependence on others, as well as reducing QoL. Aim: To assess the symptoms of anxiety and depression, to evaluate the co-occurrence of frailty syndrome and the impact of these factors on the quality of life of patients with AF. Methods: The study used a Polish adaptation of the Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmia part III (ASTA part III), the Tilburg Frailty Indicator (TFI) and the Hospital Anxiety Depression Scale (HADS). Results: Analysis showed that anxiety symptoms and depressive symptoms correlate significantly (p < 0.05) and positively with the physical (r = 0.24; p < 0.001, r = 0.29, p = 0.002, respectively), psychological (r = 0.34, p < 0.001, r = 0.49 p < 0.001, respectively) and total quality of life (r = 0.31, p = 0.001, r = 0.414; p < 0.001, respectively) ASTA III domains. A significant (p < 0.05) positive correlation was observed between the TFI total score and the physical (r = 0.34, p < 0.001), psychological (r = 0.36, p < 0.001) and overall quality of life (r = 0.38, p < 0.001) in ASTA III domains. Conclusions: Both FS and depressive and anxiety symptoms significantly affect QoL. Understanding the relationship between anxiety and depressive symptoms, FS and QoL may allow for a more targeted approach to the treatment and care of patients with AF.
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Affiliation(s)
- Katarzyna Lomper
- Department of Clinical Nursing, Medical University, K. Bartla 5, 51-616 Wroclaw, Poland
| | - Catherine Ross
- The Centre for Cardiovascular Health, School of Health and Social Care, Edinburgh Napier University, Edinburgh EH11 4BN, UK
| | - Izabella Uchmanowicz
- Department of Clinical Nursing, Medical University, K. Bartla 5, 51-616 Wroclaw, Poland
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16
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Snowdon JL, Scheufele EL, Pritts J, Le PT, Mensah GA, Zhang X, Dankwa-Mullan I. Evaluating Social Determinants of Health Variables in Advanced Analytic and Artificial Intelligence Models for Cardiovascular Disease Risk and Outcomes: A Targeted Review. Ethn Dis 2023; 33:33-43. [PMID: 38846264 PMCID: PMC11152155 DOI: 10.18865/1704] [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] [Indexed: 06/09/2024] Open
Abstract
Introduction/Purpose Predictive models incorporating relevant clinical and social features can provide meaningful insights into complex interrelated mechanisms of cardiovascular disease (CVD) risk and progression and the influence of environmental exposures on adverse outcomes. The purpose of this targeted review (2018-2019) was to examine the extent to which present-day advanced analytics, artificial intelligence, and machine learning models include relevant variables to address potential biases that inform care, treatment, resource allocation, and management of patients with CVD. Methods PubMed literature was searched using the prespecified inclusion and exclusion criteria to identify and critically evaluate primary studies published in English that reported on predictive models for CVD, associated risks, progression, and outcomes in the general adult population in North America. Studies were then assessed for inclusion of relevant social variables in the model construction. Two independent reviewers screened articles for eligibility. Primary and secondary independent reviewers extracted information from each full-text article for analysis. Disagreements were resolved with a third reviewer and iterative screening rounds to establish consensus. Cohen's kappa was used to determine interrater reliability. Results The review yielded 533 unique records where 35 met the inclusion criteria. Studies used advanced statistical and machine learning methods to predict CVD risk (10, 29%), mortality (19, 54%), survival (7, 20%), complication (10, 29%), disease progression (6, 17%), functional outcomes (4, 11%), and disposition (2, 6%). Most studies incorporated age (34, 97%), sex (34, 97%), comorbid conditions (32, 91%), and behavioral risk factor (28, 80%) variables. Race or ethnicity (23, 66%) and social variables, such as education (3, 9%) were less frequently observed. Conclusions Predictive models should adjust for race and social predictor variables, where relevant, to improve model accuracy and to inform more equitable interventions and decision making.
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Affiliation(s)
- Jane L. Snowdon
- Center for Artificial Intelligence, Research, and Evaluation, IBM Watson Health, Cambridge, MA 02142
| | - Elisabeth L. Scheufele
- Center for Artificial Intelligence, Research, and Evaluation, IBM Watson Health, Cambridge, MA 02142
| | - Jill Pritts
- Center for Artificial Intelligence, Research, and Evaluation, IBM Watson Health, Cambridge, MA 02142
| | - Phuong-Tu Le
- Division of Integrative Biological and Behavioral Sciences, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD 20892
| | - George A. Mensah
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892
| | - Xinzhi Zhang
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892
| | - Irene Dankwa-Mullan
- Center for Artificial Intelligence, Research, and Evaluation, IBM Watson Health, Cambridge, MA 02142
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17
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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: 0] [Impact Index Per Article: 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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18
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Candeloro M, Di Nisio M, Potere N, Di Pizio L, Secinaro E, De Flaviis C, Federici C, Guglielmi MD, Pardi S, Schulman S, Porreca E. Frailty phenotype as a predictor of bleeding and mortality in ambulatory patients receiving direct oral anticoagulants. J Am Geriatr Soc 2022; 70:3503-3512. [PMID: 35974661 DOI: 10.1111/jgs.18001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/13/2022] [Accepted: 07/27/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Limited prospective data exist about the clinical relevance of frailty in patients with atrial fibrillation (AF) or venous thromboembolism (VTE) receiving direct oral anticoagulants (DOACs). The aim of this study was to evaluate whether frailty phenotype identifies DOAC-treated patients at higher risk of adverse clinical outcomes. METHODS Consecutive, adult outpatients treated with DOACs for AF or VTE were prospectively enrolled. Patients were classified as frail, pre-frail, or non-frail according to frailty phenotype. Study outcomes were clinically relevant bleeding, including major and clinically relevant non-major bleeding, arterial and venous thromboembolism, and all-cause mortality. RESULTS 236 patients (median age 78 years, 44% females) were included, of whom 156 (66%) had AF and 80 (34%) VTE. Ninety-eight (41%) patients were frail, 115 (49%) pre-frail, and 23 (10%) non-frail. Inappropriately high or low dose DOAC was used in 33% of frail and in 20% of non-frail or pre-frail patients. Over a median follow-up of 304 days, the incidence of clinically relevant bleeding, thromboembolism, and mortality were 20%, 4%, 9% in frail, and 10%, 3%, and 2% in pre-frail, respectively, while no study outcome occurred among non-frail patients. Risk ratios (95% confidence intervals) for these outcomes in frail versus pre-frail and non-frail patients were respectively 2.5 (1.8, 3.7), 1.9 (0.9, 4.0), and 6.3 (2.9, 13.6). CONCLUSION In a prospective cohort of ambulatory patients receiving DOAC treatment for AF or VTE, frailty phenotype identified patients at higher risk of bleeding and all-cause mortality. Frailty assessment could be valuable to guide targeted interventions potentially improving patient prognosis.
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Affiliation(s)
- Matteo Candeloro
- Department of Innovative Technologies in Medicine and Dentistry, "G. D'Annunzio" University, Chieti, Italy.,Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, "G D'Annunzio" University, Chieti, Italy
| | - Nicola Potere
- Department of Innovative Technologies in Medicine and Dentistry, "G. D'Annunzio" University, Chieti, Italy
| | - Lorenzo Di Pizio
- Department of Innovative Technologies in Medicine and Dentistry, "G. D'Annunzio" University, Chieti, Italy
| | - Enzo Secinaro
- Department of Innovative Technologies in Medicine and Dentistry, "G. D'Annunzio" University, Chieti, Italy
| | - Claudia De Flaviis
- Department of Innovative Technologies in Medicine and Dentistry, "G. D'Annunzio" University, Chieti, Italy
| | - Camilla Federici
- Department of Innovative Technologies in Medicine and Dentistry, "G. D'Annunzio" University, Chieti, Italy
| | | | - Silvana Pardi
- Vascular Medicine Unit, "SS Annunziata" Hospital, Chieti, Italy
| | - Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.,Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Ettore Porreca
- Department of Innovative Technologies in Medicine and Dentistry, "G. D'Annunzio" University, Chieti, Italy
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Wang W, Saczynski JS, Lessard D, Goldberg RJ, Parish D, Helm R, Kiefe CI, Trymbulak K, Mehawej J, Abu H, Hayward R, Gore J, Gurwitz JH, McManus DD. Presence of Geriatric Conditions Is Prognostic of Major Bleeding in Older Patients with Atrial Fibrillation: a Cohort Study. J Gen Intern Med 2022; 37:3893-3899. [PMID: 35102482 PMCID: PMC9640487 DOI: 10.1007/s11606-022-07410-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/07/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND In older patients with atrial fibrillation (AF), physical, cognitive, and psychosocial limitations are prevalent. The prognostic value of these conditions for major bleeding is unclear. OBJECTIVE To determine whether geriatric conditions are prospectively associated with major bleeding in older patients with AF on anticoagulation. DESIGN Multicenter cohort study with 2-year follow-up from 2016 to 2020 in Massachusetts and Georgia from cardiology, electrophysiology, and primary care clinics. PARTICIPANTS Diagnosed with AF, age 65 years or older, CHA2DS2-VASc score of 2 or higher, and taking oral anticoagulant (n=1,064). A total of 6507 individuals were screened. MAIN MEASURES A six-component geriatric assessment of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Main outcome was major bleeding adjudicated by a physician panel. KEY RESULTS At baseline, participants were, on average, 75.5 years old and 49% were women. Mean CHA2DS2-VASc score was 4.5 and the mean HAS-BLED score was 3.3. During 2.0 (± 0.4) years of follow-up, 95 (8.9%) participants developed an episode of major bleeding. After adjusting for key covariates and accounting for competing risk from death, cognitive impairment (hazard ratio [HR] 1.62, 95% confidence interval [CI]: 1.02-2.56) and frailty (HR 2.77, 95% CI 1.38-5.58) were significantly associated with the development of major bleeding. CONCLUSIONS In older patients with AF taking anticoagulants, cognitive impairment and frailty were independently associated with major bleeding.
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Affiliation(s)
- Weijia Wang
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA.
| | - Jane S Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, USA
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert J Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - David Parish
- Department of Medicine, School of Medicine, Mercer University, Macon, GA, USA
| | - Robert Helm
- Department of Medicine, School of Medicine, Boston University, Boston, MA, USA
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Katherine Trymbulak
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, North Haven, CT, USA
| | - Jordy Mehawej
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Hawa Abu
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert Hayward
- Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA
| | - Joel Gore
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jerry H Gurwitz
- 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
- Meyers Health Care Institute, University of Massachusetts Medical School, Worcester, MA, USA
| | - David D McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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20
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Han S, Suh HS. Impact of Integrating Machine Learning in Comparative Effectiveness Research of Oral Anticoagulants in Patients with Atrial Fibrillation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12916. [PMID: 36232216 PMCID: PMC9566283 DOI: 10.3390/ijerph191912916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/02/2022] [Accepted: 10/06/2022] [Indexed: 06/16/2023]
Abstract
We aimed to compare the ability to balance baseline covariates and explore the impact of residual confounding between conventional and machine learning approaches to derive propensity scores (PS). The Health Insurance Review and Assessment Service database (January 2012-September 2019) was used. Patients with atrial fibrillation (AF) who initiated oral anticoagulants during July 2015-September 2018 were included. The outcome of interest was stroke/systemic embolism. To estimate PS, we used a logistic regression model (i.e., a conventional approach) and a generalized boosted model (GBM) which is a machine learning approach. Both PS matching and inverse probability of treatment weighting were performed. To evaluate balance achievement, standardized differences, p-values, and boxplots were used. To explore residual confounding, E-values and negative control outcomes were used. In total, 129,434 patients were identified. Although all baseline covariates were well balanced, the distribution of continuous variables seemed more similar when GBM was applied. E-values ranged between 1.75 and 2.70 and were generally higher in GBM. In the negative control outcome analysis, slightly more nonsignificant hazard ratios were observed in GBM. We showed GBM provided a better ability to balance covariates and had a lower impact of residual confounding, compared with the conventional approach in the empirical example of comparative effectiveness analysis.
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Affiliation(s)
- Sola Han
- College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
- Health Outcomes Division, College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
| | - Hae Sun Suh
- College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul 02447, Korea
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21
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Proietti M, Romiti GF, Raparelli V, Diemberger I, Boriani G, Dalla Vecchia LA, Bellelli G, Marzetti E, Lip GY, Cesari M. Frailty prevalence and impact on outcomes in patients with atrial fibrillation: A systematic review and meta-analysis of 1,187,000 patients. Ageing Res Rev 2022; 79:101652. [PMID: 35659945 DOI: 10.1016/j.arr.2022.101652] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/20/2022] [Accepted: 05/23/2022] [Indexed: 12/14/2022]
Abstract
Frailty is a clinical syndrome characterized by a reduced physiologic reserve, increased vulnerability to stressors and an increased risk of adverse outcomes. People with atrial fibrillation (AF) are often burdened by frailty due to biological, clinical, and social factors. The prevalence of frailty, its management and association with major outcomes in AF patients are still not well quantified. We systematically searched PubMed and EMBASE, from inception to September 13th, 2021, for studies reporting the prevalence of frailty in AF patients. The study was registered in PROSPERO (CRD42021235854). 33 studies were included in the systematic review (n = 1,187,651 patients). The frailty pooled prevalence was 39.7 % (95 %CI=29.9 %-50.5 %, I2 =100 %), while meta-regression analyses showed it is influenced by age, history of stroke, and geographical location. Meta-regression analyses showed that OAC prescription was influenced by study-level mean age, baseline thromboembolic risk, and study setting. Frail AF patients were associated with a higher risk of all-cause death (OR=5.56, 95 %CI=3.46-8.94), ischemic stroke (OR=1.59, 95 %CI=1.00-2.52), and bleeding (OR=1.64, 95 %CI=1.11-2.41), when compared to robust individuals. In this systematic review and meta-analysis, the prevalence of frailty was high in patients with AF. Frailty may influence the prognosis and management of AF patients, thus requiring person-tailored interventions in a holistic or integrated approach to AF care.
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Affiliation(s)
- Marco Proietti
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Italy; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
| | | | - Valeria Raparelli
- Department of Translational Medicine, University of Ferrara, Italy; University Center for Studies on Gender Medicine, University of Ferrara, Italy; University of Alberta, Faculty of Nursing, Edmonton, Alberta, Canada
| | - Igor Diemberger
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Italy
| | | | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Emanuele Marzetti
- Università Cattolica del Sacro Cuore, Department of Geriatrics and Orthopedics, Rome, Italy; Center for Geriatric Medicine (Ce.M.I.), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome,Italy
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Matteo Cesari
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Italy
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22
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Diemberger I, Fumagalli S, Mazzone AM, Bakhai A, Reimitz PE, Pecen L, Manu MC, Gordillo de Souza JA, Kirchhof P, De Caterina R. Perceived vs. objective frailty in patients with atrial fibrillation and impact on anticoagulant dosing: an ETNA-AF-Europe sub-analysis. Europace 2022; 24:1404-1411. [PMID: 35512229 PMCID: PMC9559908 DOI: 10.1093/europace/euac004] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS Frailty is common in patients with atrial fibrillation (AF), with possible impact on therapies and outcomes. However, definitions of frailty are variable, and may not overlap with frailty perception among physicians. We evaluated the prevalence of frailty as perceived by enrolling physicians in the Edoxaban Treatment in Routine Clinical Practice for Patients With Non-Valvular AF (ETNA-AF)-Europe registry (NCT02944019), and compared it with an objective frailty assessment. METHODS AND RESULTS ETNA-AF-Europe is a prospective, multi-centre, post-authorization, observational study. There we assessed the presence of frailty according to (i) a binary subjective investigators' judgement and (ii) an objective measure, the Modified Frailty Index. Baseline data on frailty were available in 13 621/13 980 patients. Prevalence of perceived frailty was 10.6%, with high variability among participating countries and healthcare settings (range 5.9-19.6%). Conversely, only 5.0% of patients had objective frailty, with minimal variability (range 4.5-6.7%); and only <1% of patients were identified as frail by both approaches. Compared with non-frailty-perceived, perceived frail patients were older, more frequently female, and with lower body weight; conversely, objectively frail patients had more comorbidities. Non-recommended edoxaban dose regimens were more frequently prescribed in both frail patient categories. CONCLUSIONS Physicians' perception of frailty in AF patients is variable, mainly driven by age, sex, and weight, and quite different compared with the results of an objective frailty assessment. Whatever the approach, frailty appears to be associated with non-recommended anticoagulant dosages. Whether this apparent inappropriateness influences hard outcomes remains to be assessed.
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Affiliation(s)
- Igor Diemberger
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, University of Bologna, Policlinico S.Orsola-Malpighi, 40138 Bologna, Italy
| | - Stefano Fumagalli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; and AOU Careggi, Florence, Italy
| | - Anna Maria Mazzone
- Cardiology Department, 'G. Pasquinucci' Heart Hospital, 'G. Monasterio' Foundation, Massa, Italy
| | - Ameet Bakhai
- Royal Free Hospital London NHS Foundation Trust, London, UK.,Cardiology Department, Barnet General Hospital, Thames House, Enfield, UK
| | | | - Ladislav Pecen
- Department of Immunochemistry Diagnostics, Faculty of Medicine in Pilsen of Charles University, Pilsen, Czech Republic
| | | | | | - Paulus Kirchhof
- University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany.,German Center for Cardiovascular REserach (DZHK), partner site Hamburg/Kiel/Lübeck, Germany.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Raffaele De Caterina
- Department of Surgical, Medical and Molecular Pathology and of Critical Sciences, University of Pisa, Pisa, Italy.,Division of Cardiology, Azienda Ospedaliero-Universitaria Pisana, via Paradisa, 2, 56124 Pisa, Italy.,Fondazione VillaSerena per la Ricerca, Città Sant'Angelo-Pescara, Pescara, Italy
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23
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Yuguero O, Cabello I, Arranz M, Guzman JA, Moreno A, Frances P, Santos J, Esquerrà A, Zarauza A, Mòdol JM, Jacob J. Emergency Department capacity to initiate thromboprophylaxis in patients with atrial fibrillation and thrombotic risk after discharge: URGFAICS cohort analysis. Intern Emerg Med 2022; 17:873-881. [PMID: 34677788 DOI: 10.1007/s11739-021-02864-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/28/2021] [Indexed: 11/24/2022]
Abstract
Atrial fibrillation (AF) is the most prevalent heart rhythm disorder in the general population. Stroke prevention is one of the leading management objectives in the treatment of AF patients. The variables associated with the non-initiation of thromboprophylaxis in patients with thrombotic risk consulting for an episode of AF in Emergency Departments (ED) were investigated. This was a multipurpose, analytical, non-interventionist, multicenter Spanish study with a prospective 30-day follow-up. All patients ≥ 18 years of age consulting to the ED for the casual finding of AF in an electrocardiogram (ECG) performed 12 h prior to the consultation or with symptoms related to AF were enrolled from September 1, 2016 to February 28, 2017. Patients not previously received thromboprophylaxis were selected. Multivariate analysis was performed to calculate the odds ratio (OR) and the 95% confidence interval (CI). A total of 634 patients, not received thromboprophylaxis and at high thrombotic risk, were included. Of these, 251 (39.6%) did not receive thromboprophylaxis at ED discharge. In the multivariate analysis, non-initiation of anticoagulation at discharge from the ED was mostly related to cognitive impairment (OR 3.95; (95% CI 2.02-7.72), cancer history (OR 2.12; (95%CI 1.18-3.81), AF duration < 48 h (OR 2.49; (95% CI 1.48-4.21) and patients with re-establishment of sinus rhythm (OR 3.65; (95% CI 1.47-9.06). Reinforcement of the use of CHA2DS2-VASC as a stroke risk scale and empowerment of ED physicians is a must to improve this gap in care.
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Affiliation(s)
- Oriol Yuguero
- Emergency Department, Hospital Arnau de Vilanova, Lleida, Spain
| | - Irene Cabello
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Feixa Llarga s/n. 08907, Barcelona, Spain.
| | - María Arranz
- Emergency Department, Hospital de Viladecans, Viladecans, Barcelona, Spain
| | | | - Anna Moreno
- Emergency Department, Hospital Arnau de Vilanova, Lleida, Spain
| | - Paloma Frances
- Emergency Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Julia Santos
- Emergency Department, Hospital de Viladecans, Viladecans, Barcelona, Spain
| | - Anna Esquerrà
- Emergency Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Alvaro Zarauza
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Feixa Llarga s/n. 08907, Barcelona, Spain
| | - Josep-Maria Mòdol
- Emergency Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Feixa Llarga s/n. 08907, Barcelona, Spain
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24
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Proietti M, Camera M, Gallieni M, Gianturco L, Gidaro A, Piemontese C, Pizzetti G, Redaelli F, Scimeca B, Tadeo CS, Cesari M, Bellelli G, Dalla Vecchia LA. Use and Prescription of Direct Oral Anticoagulants in Older and Frail Patients with Atrial Fibrillation: A Multidisciplinary Consensus Document. J Pers Med 2022; 12:jpm12030469. [PMID: 35330468 PMCID: PMC8955844 DOI: 10.3390/jpm12030469] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/08/2022] [Accepted: 03/12/2022] [Indexed: 11/25/2022] Open
Abstract
In the last twelve years the clinical management of patients with atrial fibrillation has been revolutionised by the introduction of direct oral anticoagulants. Despite the large amount of evidence produced, some populations remain relatively poorly explored regarding the effectiveness and safety of direct oral anticoagulants, such as the oldest and/or frailest individuals. Frailty is clinical syndrome characterized by a reduction of functions and physiological reserves which results in individuals having higher vulnerability. While current evidence underlines a relationship between atrial fibrillation and frailty, particularly in determining a higher risk of adverse outcomes, data regarding effectiveness and safety of direct oral anticoagulants in frailty atrial fibrillation patients are still lacking, leaving uncertainty about how to guide prescription in this specific subgroup. On these premises, this multidisciplinary consensus document explains why it would be useful to integrate the clinical evaluation performed through comprehensive geriatric assessment to gather further elements to guide prescription of direct oral anticoagulants in such a high-risk group of patients.
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Affiliation(s)
- Marco Proietti
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, 20138 Milan, Italy; (M.P.); (M.C.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L7 3FA, UK
| | - Marina Camera
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy;
- Department of Pharmaceutical Sciences, University of Milan, 20133 Milan, Italy
| | - Maurizio Gallieni
- Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, 20131 Milan, Italy;
- Department of Biomedical and Clinical Sciences ‘Luigi Sacco’, University of Milan, 20157 Milan, Italy;
| | - Luigi Gianturco
- Cardiology Unit, IRCCS Orthopedic Institute Galeazzi, 20161 Milan, Italy;
| | - Antonio Gidaro
- Department of Biomedical and Clinical Sciences ‘Luigi Sacco’, University of Milan, 20157 Milan, Italy;
| | - Carlo Piemontese
- Cardiology Unit, Sant’Anna Hospital, ASST Lariana, 22042 Como, Italy;
| | - Giuseppe Pizzetti
- Division of Cardiology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | | | - Barbara Scimeca
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Cà Granda Maggiore Hospital Foundation, 20122 Milan, Italy;
| | | | - Matteo Cesari
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, 20138 Milan, Italy; (M.P.); (M.C.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy;
- Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, 20900 Monza, Italy
| | - Laura Adelaide Dalla Vecchia
- Department of Cardiology, IRCCS Istituti Clinici Scientifici Maugeri, 20138 Milan, Italy
- Correspondence: ; Tel.: +39-02-50725120
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25
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Sanghai SR, Liu W, Wang W, Rongali S, Orkaby AR, Saczynski JS, Rose AJ, Kapoor A, Li W, Yu H, McManus DD. Prevalence of Frailty and Associations with Oral Anticoagulant Prescribing in Atrial Fibrillation. J Gen Intern Med 2022; 37:730-736. [PMID: 33948795 PMCID: PMC8904680 DOI: 10.1007/s11606-021-06834-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 04/14/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Frailty is often cited as a factor influencing oral anticoagulation (OAC) prescription in patients with non-valvular atrial fibrillation (NVAF). We sought to determine the prevalence of frailty and its association with OAC prescription in older veterans with NVAF. METHODS We used ICD-9 codes in Veterans Affairs (VA) records and Medicare claims data to identify patients with NVAF and CHA2DS2VASC ≥2 receiving care between February 2010 and September 2015. We examined rates of OAC prescription, further stratified by direct oral anticoagulant (DOAC) or vitamin K antagonist (VKA). Participants were characterized into 3 categories: non-frail, pre-frail, and frail based on a validated 30-item EHR-derived frailty index. We examined relations between frailty and OAC receipt; and frailty and type of OAC prescribed in regression models adjusted for factors related to OAC prescription. RESULTS Of 308,664 veterans with NVAF and a CHA2DS2VASC score ≥2, 121,839 (39%) were prescribed OAC (73% VKA). The mean age was 77.7 (9.6) years; CHA2DS2VASC and ATRIA scores were 4.6 (1.6) and 5.0 (2.9) respectively. Approximately a third (38%) were frail, another third (32%) were pre-frail, and the remainder were not frail. Veterans prescribed OAC were younger, had higher bleeding risk, and were less likely to be frail than participants not receiving OAC (all p's<0.001). After adjustment for factors associated with OAC use, pre-frail (OR: 0.89, 95% CI: 0.87-0.91) and frail (OR: 0.66, 95% CI: 0.64-0.68) veterans were significantly less likely to be prescribed OAC than non-frail veterans. Of those prescribed OAC, pre-frail (OR:1.27, 95% CI: 1.22-1.31) and frail (OR: 1.75, 95% CI: 1.67-1.83) veterans were significantly more likely than non-frail veterans to be prescribed a DOAC than a VKA. CONCLUSIONS There are high rates of frailty among older veterans with NVAF. Frailty using an EHR-derived index is associated with decreased OAC prescription.
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Affiliation(s)
- Saket R Sanghai
- Division of Cardiac Electrophysiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA.
| | - Weisong Liu
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Weijia Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | | | - Ariela R Orkaby
- New England GRECC, VA Boston Health Care System, Boston, MA, USA
- Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jane S Saczynski
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, USA
| | - Adam J Rose
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Alok Kapoor
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Wenjun Li
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Hong Yu
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- University of Massachusetts, Lowell, MA, USA
- Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA, USA
| | - David D McManus
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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26
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Wleklik M, Denfeld Q, Lisiak M, Czapla M, Kałużna-Oleksy M, Uchmanowicz I. Frailty Syndrome in Older Adults with Cardiovascular Diseases-What Do We Know and What Requires Further Research? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19042234. [PMID: 35206422 PMCID: PMC8872246 DOI: 10.3390/ijerph19042234] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 02/07/2023]
Abstract
Cardiovascular diseases (CVD) affect 60% of people over 60 years of age and are one of the main causes of death in the world. Diagnosed cardiovascular disease also triples the likelihood of Frailty syndrome (FS). FS has become increasingly relevant in cardiology and cardiac surgery and occurs in a significant number of patients with CVD, with prevalence ranging from 25% to 62%. Viewed in a multidimensional, biopsychosocial perspective, FS increases a patient's vulnerability, making them susceptible to several adverse clinical outcomes. Frailty syndrome also is a predictor of mortality in patients with CVD regardless of age, severity of disease, multi-morbidity, and disability. Frailty syndrome potentially can be prevented in patients with CVD and its early identification is important to avoid the development of disability, dependence on others and reduced quality of life. The aim of this paper is to show the relationship between FS and specific CVDs (coronary artery disease, hypertension, atrial fibrillation, heart failure) and cardiac procedures (device implantation, cardiac surgery, and transcatheter aortic valve implantation). Furthermore, we highlight those areas that require further research to fully understand the relationship between FS and CVD and to be able to minimize or prevent its adverse effects.
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Affiliation(s)
- Marta Wleklik
- Department of Nursing and Obstetrics, Faculty of Health Sciences, Wroclaw Medical University, 51-618 Wroclaw, Poland; (M.W.); (M.L.); (I.U.)
- Institute of Heart Diseases, University Hospital, 50-566 Wroclaw, Poland
| | - Quin Denfeld
- School of Nursing, Oregon Health and Science University, Portland, OR 97239, USA;
| | - Magdalena Lisiak
- Department of Nursing and Obstetrics, Faculty of Health Sciences, Wroclaw Medical University, 51-618 Wroclaw, Poland; (M.W.); (M.L.); (I.U.)
- Institute of Heart Diseases, University Hospital, 50-566 Wroclaw, Poland
| | - Michał Czapla
- Institute of Heart Diseases, University Hospital, 50-566 Wroclaw, Poland
- Laboratory for Experimental Medicine and Innovative Technologies, Department of Emergency Medical Service, Wroclaw Medical University, 51-616 Wroclaw, Poland
- Correspondence:
| | - Marta Kałużna-Oleksy
- 1st Department of Cardiology, University of Medical Sciences in Poznan, 61-848 Poznan, Poland;
| | - Izabella Uchmanowicz
- Department of Nursing and Obstetrics, Faculty of Health Sciences, Wroclaw Medical University, 51-618 Wroclaw, Poland; (M.W.); (M.L.); (I.U.)
- Institute of Heart Diseases, University Hospital, 50-566 Wroclaw, Poland
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27
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Kim D, Yang PS, Sung JH, Jang E, Yu HT, Kim TH, Uhm JS, Kim JY, Pak HN, Lee MH, Lip GYH, Joung B. Effectiveness and Safety of Anticoagulation Therapy in Frail Patients With Atrial Fibrillation. Stroke 2022; 53:1873-1882. [PMID: 35109686 DOI: 10.1161/strokeaha.121.036757] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Frail patients with atrial fibrillation (AF) are less likely to receive anticoagulation than nonfrail patients with AF despite frailty being associated with poorer clinical outcomes including stroke. Using a population-based cohort, we sought to assess the effectiveness and safety of oral anticoagulants (OACs) in frail patients with AF. METHODS This retrospective cohort study analyzed 83 635 patients aged at least 65 years with AF and frailty (≥5 Hospital Frailty Risk Score) between January 1, 2013 and December 31, 2016 from the Korean National Health Insurance Service database. To account for the differences between patients receiving OAC or not and across different OAC regimens, propensity score-weighting was used. Net adverse clinical event, defined as the first event of ischemic stroke, major bleeding, or cardiovascular death, was compared. In addition, each individual outcome was examined separately. RESULTS In the study population (57.1% women; mean age, 78.5±7.2 years), a total of 14 968 net adverse clinical event, 3718 ischemic stroke, 5536 major bleeding, and 6188 cardiovascular death occurred. In comparison with no OAC use, OAC use was associated with lower risks of net adverse clinical event (hazard ratio, 0.78 [95% CI, 0.75-0.82]), ischemic stroke (hazard ratio, 0.91 [95% CI, 0.86-0.97]), and cardiovascular death (hazard ratio, 0.52 [95% CI, 0.49-0.55]), but no difference was observed for major bleeding (hazard ratio, 1.02 [95% CI, 0.95-1.10]). Compared with warfarin, all four individual direct OAC were associated with decreased risks of net adverse clinical event, ischemic stroke, major bleeding, and cardiovascular death. The associations for OAC use (compared to no OAC use) or direct OAC use (compared to warfarin) with favorable outcomes were more prominent in individuals with a higher CHA2DS2-VASc score of at least 3. CONCLUSIONS Among frail patients with AF, OAC treatment was associated with a positive net clinical outcome. Direct OACs provided lower incidences of stroke, bleeding, and mortality, compared with warfarin.
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Affiliation(s)
- Daehoon Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (D.K., E.J., H.T.Y., T.-H.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L.' B.J.)
| | - Pil-Sung Yang
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea (P.S.Y., J.-H.S.)
| | - Jung-Hoon Sung
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea (P.S.Y., J.-H.S.)
| | - Eunsun Jang
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (D.K., E.J., H.T.Y., T.-H.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L.' B.J.)
| | - Hee Tae Yu
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (D.K., E.J., H.T.Y., T.-H.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L.' B.J.)
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (D.K., E.J., H.T.Y., T.-H.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L.' B.J.)
| | - Jae-Sun Uhm
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (D.K., E.J., H.T.Y., T.-H.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L.' B.J.)
| | - Jong-Youn Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (D.K., E.J., H.T.Y., T.-H.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L.' B.J.)
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (D.K., E.J., H.T.Y., T.-H.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L.' B.J.)
| | - Moon-Hyoung Lee
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (D.K., E.J., H.T.Y., T.-H.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L.' B.J.)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, United Kingdom (G.Y.H.L.)
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea (D.K., E.J., H.T.Y., T.-H.K., J.-S.U., J.-Y.K., H.-N.P., M.-H.L.' B.J.)
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Richard G, O’Halloran AM, Doody P, Harbison J, Kenny RA, Romero-Ortuno R. Atrial fibrillation and acceleration of frailty: findings from the Irish Longitudinal Study on Ageing. Age Ageing 2022; 51:6520511. [PMID: 35134844 DOI: 10.1093/ageing/afab273] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION both atrial fibrillation (AF) and frailty are increasingly prevalent with age. Cross-sectional studies have suggested a relationship between AF and frailty, but longitudinal data are lacking. We explored if the presence of AF was associated with accelerated progression of frailty over 8 years in community-dwelling older adults. METHODS a longitudinal retrospective case-control study was conducted using data from Waves 1 and 5 of the Irish Longitudinal Study on Ageing (TILDA). Participants with electrocardiographically detected AF at Wave 1 were matched to controls without AF (1:2) based on age and gender. Frailty was assessed using both the frailty phenotype (FP) and a 31-item frailty index (FI). Change in cases' and controls' FP and FI scores from Waves 1 to 5 were modelled using repeated measures analysis of variance (RM-ANOVA). RESULTS one hundred eighteen TILDA participants with AF at Wave 1 were matched to 236 controls. By FP, participants with AF were not significantly more frail than controls at Wave 1 (P = 0.166) but were at Wave 5 (P = 0.011), and RM-ANOVA suggested that frailty progressed more in participants with AF between Waves 1 and 5 compared with controls (P = 0.033). By FI, participants with AF were significantly more frail at Wave 1 (P < 0.001) and 5 (P = 0.010), and RM-ANOVA did not show a difference in frailty progression between groups (P = 0.955). CONCLUSION AF may drive the development of the FP. The FP is a pre-disability syndrome and hence may be better than the FI as a focus for disability prevention in adults with AF.
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Affiliation(s)
- Georgia Richard
- Department of General Internal Medicine, St. James’s Hospital, Dublin 8, D08 NYH1, Ireland
| | - Aisling M O’Halloran
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, D02 R590, Dublin, Ireland
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
| | - Paul Doody
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, D02 R590, Dublin, Ireland
| | - Joseph Harbison
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
- Mercer’s Institute for Successful Ageing (MISA), St James’s Hospital, D08 NYH1, Dublin, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, D02 R590, Dublin, Ireland
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
- Mercer’s Institute for Successful Ageing (MISA), St James’s Hospital, D08 NYH1, Dublin, Ireland
| | - Roman Romero-Ortuno
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, D02 R590, Dublin, Ireland
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
- Mercer’s Institute for Successful Ageing (MISA), St James’s Hospital, D08 NYH1, Dublin, Ireland
- Global Brain Health Institute, Trinity College Dublin, D02 DK07 Dublin, Ireland
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29
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Mehawej J, Saczynski JS, Kiefe CI, Abu HO, Tisminetzky M, Wang W, Bamgbade BA, Ding E, Lessard D, Otabil EM, Saleeba C, Goldberg RJ, McManus DD. Association between risk of obstructive sleep apnea and cognitive performance, frailty, and quality of life among older adults with atrial fibrillation. J Clin Sleep Med 2022; 18:469-475. [PMID: 34432629 PMCID: PMC8805012 DOI: 10.5664/jcsm.9622] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 02/03/2023]
Abstract
STUDY OBJECTIVES Geriatric impairments and obstructive sleep apnea (OSA) are prevalent among older patients with atrial fibrillation (AF). Little is known about the association between OSA and geriatric impairments, including frailty, cognitive performance, and AF-related quality of life. The objective of this study was to examine the associations of OSA with frailty, cognitive performance, and AF-related quality of life among older adults with AF. METHODS Data from the Systemic Assessment of Geriatrics Elements-AF study were used, which included AF participants 65 years and older and with a CHA2DS2-VASc ≥ 2. The STOP-BANG questionnaire was used to assess the risk of OSA. Multivariable logistic regression models were used to examine the association between risk of OSA and geriatric impairments, adjusting for sociodemographic, geriatric, and clinical characteristics. RESULTS A total of 970 participants (mean age 75 years; 51% male) were studied. Of the 680 participants without a medical history of OSA, 26% (n = 179) of participants had a low risk of OSA, 53% (n = 360) had an intermediate risk, and 21% (n = 141) had a high risk for OSA. Compared to those with low risk of OSA, participants with an intermediate or high risk of OSA were more likely to be frail (adjusted odds ratio = 1.67, 95% confidence interval: 1.08-2.56; adjusted odds ratio = 3.00, 95% confidence interval: 1.69-5.32, respectively) in the fully adjusted models. CONCLUSIONS Our findings identify a group of patients at high risk who would benefit from early screening for OSA. Future longitudinal studies are needed to assess the effect of OSA treatment on frailty, physical functioning, and quality of life among patients with AF. CITATION Mehawej J, Saczynski JS, Kiefe CI, et al. Association between risk of obstructive sleep apnea and cognitive performance, frailty, and quality of life among older adults with atrial fibrillation. J Clin Sleep Med. 2022;18(2):469-475.
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Affiliation(s)
- Jordy Mehawej
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jane S. Saczynski
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, Massachusetts
| | - Catarina I. Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Hawa O. Abu
- Department of Medicine, Saint Vincent Hospital, Worcester, Massachusetts
| | - Mayra Tisminetzky
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
- Division of Geriatrics, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Weijia Wang
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Benita A. Bamgbade
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, Massachusetts
| | - Eric Ding
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Edith Mensah Otabil
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Connor Saleeba
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Robert J. Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David D. McManus
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
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30
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He L, He R, Huang J, Zou C, Fan Y. Impact of frailty on all-cause mortality and major bleeding in patients with atrial fibrillation: A meta-analysis. Ageing Res Rev 2022; 73:101527. [PMID: 34839042 DOI: 10.1016/j.arr.2021.101527] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/27/2021] [Accepted: 11/15/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND Conflicting results have been reported on the impact of frailty on adverse outcomes in patients with atrial fibrillation (AF). The aim of this meta-analysis was to evaluate the impact of frailty on death and major bleeding in patients with AF. METHODS We comprehensively searched PubMed and Embase databases until June 30, 2021 for the relevant studies that investigated the impact of frailty on all-cause mortality and major bleeding in AF patients. Pooled multivariable-adjusted risk ratio (RR) and 95% confidence intervals (CI) was estimated for the frail vs. nonfrail patients using a random-effect model. RESULTS Ten studies involving 97,413 patients with AF satisfied the inclusion criteria. The prevalence of frailty in patients with AF ranged between 5.9% and 89.5%. Meta-analysis indicated that frailty was associated with higher risk of all-cause mortality (RR 2.77; 95% CI 1.68-4.57) and major bleeding (RR 1.83; 95% CI 1.24-2.71). Subgroup analysis showed that the impact of frailty on all-cause mortality was consistently found in each subgroup. CONCLUSION Frailty independently predicts all-cause mortality and major bleeding in patients with AF. Determination of frailty status may play an important role in risk classification of AF patients. However. lack of standardized definition of frailty is the most important limitations of this meta-analysis.
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31
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Kapoor A, Patel J, Chen Z, Crawford S, McManus D, Gurwitz J, Shireman TI, Zhang N. Geriatric conditions do not predict stroke or bleeding in long-term care residents with atrial fibrillation. J Am Geriatr Soc 2021; 70:1218-1227. [PMID: 34902164 DOI: 10.1111/jgs.17605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 11/05/2021] [Accepted: 11/13/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Long-term care (LTC) providers prescribe anticoagulation (AC) less frequently in residents with atrial fibrillation (AF) and geriatric conditions independent of CHA2 DS2 -VASc stroke risk score. Geriatric conditions include recent fall, activities of daily living dependency, mobility impairment, cognitive impairment, low body mass index, and weight loss. Multiple publications have suggested that patients with geriatric conditions are at increased risk for stroke. Understanding better the risk of stroke and bleeding in residents with AF and geriatric conditions would be valuable to LTC providers for AC decision-making. METHODS AND RESULTS We measured the association of geriatric conditions with composite of stroke/transient ischemic attack (TIA)/systemic embolism and bleeding in residents with AF and elevated stroke risk (CHA2 DS2 -VASc score ≥ 2) living in American LTC facilities in 2015. After merging nursing home assessments (Minimum Data Set) with medication and hospital utilization records, we identified 209,413 eligible residents. Using generalized estimating equations, we found that the incidence of stroke/TIA/systemic embolism ranged from 0.13% to 0.26% over 30 days (1.43%-3.08%/year) in residents off AC with and without geriatric conditions adjusting for other resident characteristics including CHA2 DS2 -VASc score and propensity to receive AC. Similarly, the monthly incidence of bleeding on AC ranged from 0.22% to 0.28% (2.61%-3.31%/year) without increased risk with geriatric conditions. Residents with a CHA2 DS2 -VASc score of ≥7 had a 2.4-fold increased risk of stroke compared with those with score of 2-4 (0.30% vs. 0.12%/month). CONCLUSION Calculating a CHA2 DS2 -VASc score can be helpful in AC decision-making for residents with and without geriatric conditions.
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Affiliation(s)
- Alok Kapoor
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Jay Patel
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Zhiyong Chen
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA.,Zem Data Science, LLC, North Potomac, Maryland, USA
| | - Sybil Crawford
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - David McManus
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Jerry Gurwitz
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Theresa I Shireman
- Department of Health Services, Policy and Practice, Center for Gerontology & Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Ning Zhang
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Health Policy and Promotion, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, USA
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32
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Polidori MC, Alves M, Bahat G, Boureau AS, Ozkok S, Pfister R, Pilotto A, Veronese N, Bo M. Atrial fibrillation: a geriatric perspective on the 2020 ESC guidelines. Eur Geriatr Med 2021; 13:5-18. [PMID: 34727362 PMCID: PMC8562074 DOI: 10.1007/s41999-021-00537-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/03/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The Task Force for the diagnosis and management of atrial fibrillation (AF) of the European Society of Cardiology (ESC) published in 2020 the updated Guidelines for the Diagnosis and Management of Atrial Fibrillation with the contribution of the European Heart Rhythm Association (EHRA) of the ESC and the European Association for Cardiothoracic Surgery (EACTS). METHODS AND RESULTS In this narrative viewpoint, we approach AF from the perspective of aging medicine and try to provide the readers with information usually neglected in clinical routine, mainly due to the fact that while the large majority of AF patients in real life are older, frail and cognitively impaired, these are mostly excluded from clinical trials, and physicians' attitudes often prevail over standardized algorithms. CONCLUSIONS On the basis of existing evidence, (1) opportunistic AF screening by pulse palpation or ECG rhythm strip is cost-effective, and (2) whereas advanced chronological age by itself is not a contraindication to AF treatment, a Comprehensive Geriatric Assessment (CGA) including frailty, cognitive impairment, falls and bleeding risk may assist in clinical decision making to provide the best individualized treatment.
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Affiliation(s)
- M 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 Str. 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, Cologne, Germany.
| | - Mariana Alves
- Serviço de Medicina III, Hospital Pulido Valente, CHULN, Lisbon, Portugal.,Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Gulistan Bahat
- Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Capa, 34390, Istanbul, Turkey
| | - Anne Sophie Boureau
- Department of Geriatrics, CHU Nantes and Université de Nantes, CNRS, INSERM, l'Institut du Thorax, 44000, Nantes, France
| | - Serdar Ozkok
- Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Capa, 34390, Istanbul, Turkey
| | - Roman Pfister
- Department of Cardiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Alberto Pilotto
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, Galliera Hospital, Genoa, Italy.,Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Nicola Veronese
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, Palermo, Italy
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette, Corso Bramante 88, 10126, Turin, Italy
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Kusano K, Sugishita N, Akao M, Tsuji H, Matsui K, Hiramitsu S, Hatori Y, Odakura H, Kamada H, Miyamoto K, Ogawa H. Effectiveness and Safety of Rivaroxaban by General Practitioners - A Multicenter, Prospective Study in Japanese Patients With Non-Valvular Atrial Fibrillation (GENERAL). Circ J 2021; 85:1275-1282. [PMID: 33814525 DOI: 10.1253/circj.cj-20-1244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Direct oral anticoagulants have become a standard therapy for non-valvular atrial fibrillation (NVAF). However, little is known about their effectiveness/safety when prescribed by general practitioners to treat high-risk populations such as the elderly, those who are frail or have cognitive dysfunction.Methods and Results:In this multicenter, prospective study, a total of 5,717 NVAF patients (mean age 73.9 years) receiving rivaroxaban were registered by general practitioners, with a maximum 3-year follow up (mean 2.0±0.5 years). The primary endpoint was a composite of stroke and systemic embolism (SE). The annual incidence (per 100 person-years) of stroke/SE was 1.23% and for major bleeding, it was 0.63%. Multivariate analyses identified age ≥75 years (hazard ratio [HR]; 2.67, P<0.001) and history of ischemic stroke (HR; 1.89, P=0.005) as significant risk factors of stroke/SE, with history of major bleeding (HR; 14.9, P<0.001) and warfarin use (HR; 2.15, P=0.002) as risk factors for major bleeding events. Neither cognitive dysfunction, defined by the receipt of anti-dementia medications, nor frailty, evaluated by the classification of the Japanese Long-term Care Insurance system, correlated with stroke/SE or major bleeding events. CONCLUSIONS The low incidence of adverse events, including stroke/SE and bleeding, in patients prescribed rivaroxaban by general practitioners supports its use as a safe and efficacious treatment in the standard clinical care of high-risk patient populations.
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Affiliation(s)
- Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | | | | | | | | | | | - Hiroyuki Kamada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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34
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Proietti M, Cesari M. Describing the relationship between atrial fibrillation and frailty: Clinical implications and open research questions. Exp Gerontol 2021; 152:111455. [PMID: 34153440 DOI: 10.1016/j.exger.2021.111455] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/13/2021] [Indexed: 11/26/2022]
Abstract
In the recent years a lot of attention has been gathered by the issue of frailty outside the boundaries of the geriatric medicine, for example in the field of cardiovascular medicine. Atrial fibrillation (AF) is known as a very common cardiological condition, often burdened by high level of clinical complexity. Aim of this narrative review is to examine the most relevant evidence about the relationship between frailty and AF, focusing also on its impact on clinical management and natural history of patients with this condition. Data reported underline how a relevant relationship exists between these two conditions, even though the burden of frailty among AF cohorts is still unclear. Frailty seems to affect the clinical management, even though no definitive data are yet available. Lastly, frailty significantly increases the risk of all-cause mortality but it's still unclear the impact on thromboembolic and bleeding events. Despite several data are already available, more research is still needed to fully elucidate the relationship between these two clinical entities.
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Affiliation(s)
- Marco Proietti
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Italy; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
| | - Matteo Cesari
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Italy
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35
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Bezabhe WM, Bereznicki LR, Radford J, Wimmer BC, Curtain C, Salahudeen MS, Peterson GM. Factors influencing oral anticoagulant use in patients newly diagnosed with atrial fibrillation. Eur J Clin Invest 2021; 51:e13457. [PMID: 33222261 DOI: 10.1111/eci.13457] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 11/16/2020] [Accepted: 11/16/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND We investigated factors that influenced oral anticoagulant (OAC) initiation and choice in Australian general practice patients newly diagnosed with AF. METHODS Using an Australian nationally representative general practice dataset, MedicineInsight, we identified patients newly diagnosed with AF between January 2009 and April 2019. Logistic regression analyses were used to examine factors associated with OAC initiation and choice. RESULTS A total of 63 212 patients with AF (53.7% males, mean age 72.4 years) were identified. Nearly two-thirds of these patients (40 854 [64.6%]) were initiated on an OAC, at a median time of 6 days after the documented diagnosis date. The proportion of patients who were initiated an OAC increased from 44.8% in 2009 to 72.2% in 2019 (P < .001). High risk of stroke (CHA2 DS2 -VASc, adjusted odds ratio (AOR), 4.39 [95% CI, 3.99-4.83]), low risk of bleeding (ORBIT, AOR, 1.87 [95% CI, 1.72-2.03]), not having a recorded history of dementia (AOR, 1.81 [95% CI, 1.65-1.98]) and male sex (AOR, 1.29 [95% CI, 1.22-1.35]) were independently associated with OAC initiation. Direct-acting oral anticoagulant (DOAC) use increased from 11.9% in 2011 to 94.0% of all OAC initiations in April 2019 (P < .001). CONCLUSIONS The proportion of newly diagnosed patients with AF initiated on OAC increased markedly following the introduction of the DOACs. Of those initiated, 9 in 10 were receiving a DOAC at the end of the study period. There is potential underuse in women and individuals with dementia.
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Affiliation(s)
| | - Luke R Bereznicki
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
| | - Jan Radford
- Launceston Clinical School, Tasmanian School of Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Barbara C Wimmer
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
| | - Colin Curtain
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
| | | | - Gregory M Peterson
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
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Boriani G, Vitolo M, Diemberger I, Proietti M, Valenti AC, Malavasi VL, Lip GYH. Optimizing indices of AF susceptibility and burden to evaluate AF severity, risk and outcomes. Cardiovasc Res 2021; 117:1-21. [PMID: 33913486 PMCID: PMC8707734 DOI: 10.1093/cvr/cvab147] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/15/2021] [Accepted: 04/29/2021] [Indexed: 02/06/2023] Open
Abstract
Atrial fibrillation (AF) has heterogeneous patterns of presentation concerning symptoms,
duration of episodes, AF burden, and the tendency to progress towards the terminal step of
permanent AF. AF is associated with a risk of stroke/thromboembolism traditionally
considered dependent on patient-level risk factors rather than AF type, AF burden, or
other characterizations. However, the time spent in AF appears related to an incremental
risk of stroke, as suggested by the higher risk of stroke in patients with clinical AF vs.
subclinical episodes and in patients with non-paroxysmal AF vs. paroxysmal AF. In patients
with device-detected atrial tachyarrhythmias, AF burden is a dynamic process with
potential transitions from a lower to a higher maximum daily arrhythmia burden, thus
justifying monitoring its temporal evolution. In clinical terms, the appearance of the
first episode of AF, the characterization of the arrhythmia in a specific AF type, the
progression of AF, and the response to rhythm control therapies, as well as the clinical
outcomes, are all conditioned by underlying heart disease, risk factors, and
comorbidities. Improved understanding is needed on how to monitor and modulate the effect
of factors that condition AF susceptibility and modulate AF-associated outcomes. The
increasing use of wearables and apps in practice and clinical research may be useful to
predict and quantify AF burden and assess AF susceptibility at the individual patient
level. This may help us reveal why AF stops and starts again, or why AF episodes, or
burden, cluster. Additionally, whether the distribution of burden is associated with
variations in the propensity to thrombosis or other clinical adverse events. Combining the
improved methods for data analysis, clinical and translational science could be the basis
for the early identification of the subset of patients at risk of progressing to a longer
duration/higher burden of AF and the associated adverse outcomes.
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Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Igor Diemberger
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, IRCCS Istituti Clinico Scientifici Maugeri, Milan, Italy
| | - Anna Chiara Valenti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Vincenzo Livio Malavasi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Steffel J, Collins R, Antz M, Cornu P, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Vanassche T, Potpara T, Camm AJ, Heidbüchel H, Lip GYH, Deneke T, Dagres N, Boriani G, Chao TF, Choi EK, Hills MT, Santos IDS, Lane DA, Atar D, Joung B, Cole OM, Field M. 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation. Europace 2021; 23:1612-1676. [PMID: 33895845 DOI: 10.1093/europace/euab065] [Citation(s) in RCA: 423] [Impact Index Per Article: 141.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Jan Steffel
- Department of Cardiology, Division of Electrophysiology, University Heart Center Zurich, Switzerland
| | - Ronan Collins
- Age-Related Health Care, Tallaght University Hospital / Department of Gerontology Trinity College, Dublin, Ireland
| | - Matthias Antz
- Department of Electrophysiology, Hospital Braunschweig, Braunschweig, Germany
| | - Pieter Cornu
- Faculty of Medicine and Pharmacy, Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lien Desteghe
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Holger Reinecke
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Münster, Germany
| | | | | | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St George's University, London, UK
| | - Hein Heidbüchel
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan & Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | | | - Itamar de Souza Santos
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil.,Departamento de Clínica Médica, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.,Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Boyoung Joung
- Yonsei University College of Medicine, Cardiology Department, Seoul, Republic of Korea
| | - Oana Maria Cole
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Mark Field
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
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Alboni P, Bo M, Fumagalli S, Vetta F, Isaia G, Brunetti E, Baldasseroni S, Boccanelli A, Desideri G, Marchionni N, Rozzini R, Terrosu P, Ungar A, Zito G. Evidence and uncertainties in the management of atrial fibrillation in older persons. Minerva Med 2021; 113:626-639. [PMID: 33832216 DOI: 10.23736/s0026-4806.21.07525-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Atrial fibrillation (AF) is the most common cardiac sustained arrhythmia, whose incidence and prevalence increase with age, representing a significant burden for health services in western countries. Older people contribute to the vast majority of patients affected from AF. EVIDENCE ACQUISITION Although oral anticoagulant therapy represents the cornerstone for the prevention of ischemic stroke and its disabling consequences, several other interventions - including left atrial appendage occlusion (LAAO), catheter ablation (CA) of AF, and rhythm control strategy (RCS) - have proved to be potentially effective in reducing the incidence of AF-associated clinical complications. Scientific literature focused on the three items will be discussed. EVIDENCE SYNTHESIS Practical treatment of older AF patients is presented, including approach and management of patients with geriatric syndromes, selection of the most appropriate individualized drug treatment, clinical indications and potential clinical benefit of LAAO and CA in selected older AF patients. CONCLUSIONS Older people carry the greatest burden of AF in real world practice. Within a shared decision making process, the patient centered approach need to be put in the context of a comprehensive assessment, in order to gain maximal net clinical benefit and avoid futility or harm.
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Affiliation(s)
- Paolo Alboni
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Mario Bo
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | | | - Francesco Vetta
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Gianluca Isaia
- Section of Geriatrics, Department of Medical Sciences, Città della Salute e della Scienza Molinette Hospital, University of Turin, Turin, Italy
| | - Enrico Brunetti
- Section of Geriatrics, Department of Medical Sciences, Città della Salute e della Scienza Molinette Hospital, University of Turin, Turin, Italy -
| | | | | | | | | | - Renzo Rozzini
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | | | - Andrea Ungar
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Giovanni Zito
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
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Wang W, Lessard D, Saczynski JS, Goldberg RJ, Mehawej J, Gracia E, McManus DD. Prognostic value of geriatric conditions for death and bleeding in older patients with atrial fibrillation. IJC HEART & VASCULATURE 2021; 33:100739. [PMID: 33728372 PMCID: PMC7935705 DOI: 10.1016/j.ijcha.2021.100739] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 01/20/2021] [Accepted: 02/08/2021] [Indexed: 11/24/2022]
Abstract
Background Geriatric conditions, such as frailty and cognitive impairment, are prevalent in older patients with atrial fibrillation (AF). We examined the prognostic value of geriatric conditions for predicting 1-year mortality and bleeding events in these patients. Methods SAGE (Systematic Assessment of Geriatric Elements)-AF study is a multicenter cohort study which enrolled individuals (mean age 75 years, 48% women, 86% taking oral anticoagulation) 65 years and older with AF and CHA2DS2 -VASc score of 2 or higher from clinics in Massachusetts and Georgia, USA between 2016 and 2018. A six-component geriatric assessment included validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing was performed at baseline. Study endpoints included all-cause mortality and clinically relevant bleeding. Results At 1 year, 1,097 (96.5%) individuals attended the follow up visit, 44 (3.9%) had died, and 56 (5.1%) had clinically relevant bleeding. After adjustment for demographic and clinical factors, social isolation (odds ratio [OR] 1.69, 95% confidence interval [CI]: 1.01–2.84), depression (OR 1.94, 95% CI: 1.28–2.95) and frailty (OR 2.55, 95% CI: 1.55–4.19) were significantly associated with the composite endpoint of death or clinically relevant bleeding. After multivariable adjustment, depression (OR 1.79, 95% CI 1.09–2.93) and frailty (OR 2.83, 95% CI 1.55–5.17) were significantly associated with clinically relevant bleeding. Conclusions Social isolation, depression, and frailty were prognostic of dying or experiencing clinically relevant bleeding during the coming year in older men and women with AF. Assessing geriatric impairments merits consideration in the care of these patients.
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Affiliation(s)
- Weijia Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jane S Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, USA
| | - Robert J Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jordy Mehawej
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Ely Gracia
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - 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
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40
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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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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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Trymbulak K, Ding E, Marino F, Wang Z, Saczynski JS. Mobile health assessments of geriatric elements in older patients with atrial fibrillation: The Mobile SAGE-AF Study (M-SAGE). CARDIOVASCULAR DIGITAL HEALTH JOURNAL 2020; 1:123-129. [PMID: 35265884 PMCID: PMC8890350 DOI: 10.1016/j.cvdhj.2020.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Geriatric conditions (eg, cognitive impairment, frailty) are increasingly recognized for their impact on clinical and quality-of-life outcomes in older patients with cardiovascular disease, but are not systematically assessed in the context of clinical visits owing to time constraints. Objective To examine feasibility of remote monitoring of the physical, cognitive, and psychosocial status of older adults with atrial fibrillation (AF) via a novel smartphone app over 6 months. Methods Forty participants with AF and eligible for anticoagulation therapy (CHA2DS2VASc ≥2) enrolled in an ongoing cohort study participated in a mobile health pilot study. A 6-component geriatric assessment, including validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing, was deployed via a smartphone app and 6-minute walk test was completed using a Fitbit. Adherence to mobile assessments was examined over 6 months. Results Participants were an average of 71 years old (range 65-86 years) and 38% were women. At 1 month, 75% (30/40) of participants completed the app-based geriatric assessment and 63% (25/40) completed the 6-minute walk test. At 6 months, 52% (15/29) completed the geriatric assessment and 28% (8/29) completed the walk test. There were no differences in demographic, clinical, or psychosocial factors between participants who completed the surveys at 6 months and those who did not. Participants, on average, required less than 10 minutes of telephone support over the 6-month period. Conclusion It is feasible, among smartphone users, to use a mobile health app and wearable activity monitor to conduct serial geriatric assessments in older patients with AF for up to 6 months.
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Affiliation(s)
- Katherine Trymbulak
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, North Haven, Connecticut
- Address reprint requests and correspondence: Ms Katherine Trymbulak, Frank H. Netter M.D. School of Medicine at Quinnipiac University, 370 Bassett Rd, North Haven, CT 06473.
| | - Eric Ding
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Francesca Marino
- Center for Clinical Investigation, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ziyue Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jane S. Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts
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43
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Abstract
Effective stroke prevention with oral anticoagulation (OAC) is the cornerstone of the management of patients with atrial fibrillation. The use of OAC reduces the risk of stroke and death. For most patients with atrial fibrillation without moderate or severe mitral valve stenosis or prosthetic mechanical heart valves, treatment options include vitamin K antagonists, such as warfarin, and non-vitamin K antagonist oral anticoagulants (NOACs). Although most guidelines generally recommend NOACs as the first-line OAC, caution is required in some groups of patients with atrial fibrillation at high risk of stroke and bleeding who have been under-represented or not studied in the randomized clinical trials on NOACs for stroke prevention. In addition to OAC, non-pharmacological, percutaneous therapies, including left atrial appendage occlusion, for stroke prevention have emerged, sometimes used in combination with catheter ablation for the treatment of the atrial fibrillation. High-risk groups of patients with atrial fibrillation include patients with end-stage renal failure (including those receiving dialysis), extremely old patients (such as those aged >80 years with multiple risk factors for bleeding), patients with dementia or those living in a long-term care home, patients with previous intracranial bleeding or recent acute bleeding (such as gastrointestinal bleeding), patients with acute ischaemic stroke and patients with an intracardiac thrombus. This Review provides an overview of stroke prevention strategies, including left atrial appendage occlusion, in patients with atrial fibrillation at high risk of stroke and bleeding.
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Kojima T, Mizokami F, Akishita M. Geriatric management of older patients with multimorbidity. Geriatr Gerontol Int 2020; 20:1105-1111. [PMID: 33084212 DOI: 10.1111/ggi.14065] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/17/2020] [Accepted: 09/27/2020] [Indexed: 01/08/2023]
Abstract
Older patients tend to have multimorbidity represented by multiple chronic diseases or geriatric conditions due to aging changes of organs, which require a variety of medical management. Currently, there are no sufficient disease treatment guidelines for older people with multimorbidity, therefore physicians have difficulty managing multimorbidity, such as which diseases should be treated intensively or to what extent the conditions should be improved. Furthermore, there are other points to be considered when initiating the treatment of diseases. For example, physicians must assess physical function. Some people have no difficulty with ambulation, but some are bedridden and have difficulty getting up on their own. As there are differences in disease severity, comorbid conditions and life expectancy, there should be differences in deciding treatment and prescribing drugs. It may be necessary to change the option for treatment depending on cognitive function, the living environment and the care environment, using comprehensive geriatric assessments. In addition, when treating multimorbidity, patients tend to have polypharmacy, which is a risk for adverse drug events. Because of this, it is necessary to consider dose reduction and drug discontinuation in patients with polypharmacy. Because of the global increase in older patients with multimorbidity, developing an essential method for managing multimorbidity is an urgent issue. More research and practices are necessary to achieve high-quality care in patients with multimorbidity. Geriatr Gerontol Int 2020; 20: 1105-1111.
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Affiliation(s)
- Taro Kojima
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Fumihiro Mizokami
- Department of Pharmacy, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Masahiro Akishita
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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45
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Abstract
The elderly population is increasing because of increasing life expectancy, and the prevalence of frailty increases with age. Frailty commonly coexists with cardiovascular diseases (CVDs), such as coronary artery disease (CAD), heart failure (HF), aortic stenosis (AS), and atrial fibrillation (AF). Frail patients who undergo revascularization for CAD have higher complication rates; those with HF have a high prevalence of poor outcomes, and those with AF are vulnerable to increased stroke incidence. Moreover, frailty and asymptomatic severe AS were independent factors for mortality. The presence of frailty can lead to poor clinical outcomes, and frailty has been identified as a risk factor for mortality. Thus, the identification of frail patients who are at higher risks of disability and adverse clinical outcomes is important. In this review, the relationship between frailty and CVD is appraised and optimal treatments for frail patients are discussed.
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Affiliation(s)
- Yoshihiro Uchikado
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Yoshiyuki Ikeda
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Mitsuru Ohishi
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University
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46
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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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47
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Multimorbidity, physical frailty, and self-rated health in older patients with atrial fibrillation. BMC Geriatr 2020; 20:343. [PMID: 32917137 PMCID: PMC7488548 DOI: 10.1186/s12877-020-01755-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 09/02/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Holistic care models emphasize management of comorbid conditions to improve patient-reported outcomes in treatment of atrial fibrillation (AF). We investigated relations between multimorbidity, physical frailty, and self-rated health (SRH) among older adults with AF. METHODS Patients (n = 1235) with AF aged 65 years and older were recruited from five medical centers in Massachusetts and Georgia between 2015 and 2018. Ten previously diagnosed cardiometabolic and 8 non-cardiometabolic conditions were assessed from medical records. Physical Frailty was assessed with the Cardiovascular Health Study frailty scale. SRH was categorized as either "excellent/very good", "good", and "fair/poor". Separate multivariable ordinal logistic models were used to examine the associations between multimorbidity and SRH, physical frailty and SRH, and multimorbidity and physical frailty. RESULTS Overall, 16% of participants rated their health as fair/poor and 14% were frail. Hypertension (90%), dyslipidemia (80%), and heart failure (37%) were the most prevalent cardiometabolic conditions. Arthritis (51%), anemia (31%), and cancer (30%), the most common non-cardiometabolic diseases. After multivariable adjustment, patients with higher multimorbidity were more likely to report poorer health status (Odds Ratio (OR): 2.15 [95% CI: 1.53-3.03], ≥ 8 vs 1-4; OR: 1.37 [95% CI: 1.02-1.83], 5-7 vs 1-4), as did those with more prevalent cardiometabolic and non-cardiometabolic conditions. Patients who were pre-frail (OR: 1.73 [95% CI: 1.30-2.30]) or frail (OR: 6.81 [95% CI: 4.34-10.68]) reported poorer health status. Higher multimorbidity was associated with worse frailty status. CONCLUSIONS Multimorbidity and physical frailty were common and related to SRH. Our findings suggest that holistic management approaches may influence SRH among older patients with AF.
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48
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Grymonprez M, Steurbaut S, De Backer TL, Petrovic M, Lahousse L. Effectiveness and Safety of Oral Anticoagulants in Older Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis. Front Pharmacol 2020; 11:583311. [PMID: 33013422 PMCID: PMC7509201 DOI: 10.3389/fphar.2020.583311] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/20/2020] [Indexed: 12/17/2022] Open
Abstract
Background and Objective Atrial fibrillation (AF), the most common cardiac arrhythmia, typically increases with age. Oral anticoagulants (OACs) are the cornerstone of treatment to reduce the associated risk for systemic thromboembolism. Four large randomized controlled trials (RCTs) have shown that non-vitamin K antagonist oral anticoagulants (NOACs) are non-inferior to vitamin K antagonists (VKAs) in preventing stroke and systemic embolism, as well as regarding their risk for major bleeding. However, as vulnerable geriatric patients with AF were largely underrepresented in these trials, physicians are faced with the challenge of choosing the right anticoagulant for geriatric patients in real-life clinical practice. In this vulnerable patient group, NOACs tend to be underused or underdosed due to concerns of excessive fall-related intracranial bleeding, cognitive impairment, multiple drug-drug interactions, low body weight or impaired renal function. As life expectancy continues to rise worldwide, the number of geriatric patients substantially increases. Therefore, there is an urgent need for a critical appraisal of the added value of NOACs in geriatric patients with AF at high thromboembolic and bleeding risk. Methods and Results This systematic review provides an overview of the literature on the impact of increased age (≥75 years), multimorbidity, polypharmacy, increased falling risk, frailty and dementia on the effectiveness and safety of NOACs as compared to VKAs, after searching the Medline database. Moreover, a meta-analysis on the impact of increased age ≥75 years old was performed after pooling results from 6 post hoc analyses of RCTs and 6 longitudinal observational cohort studies, highlighting the superior effectiveness (hazard ratio (HR) 0.83, 95% confidence interval (CI) [0.74–0.94] for stroke/SE; HR 0.77, 95%CI [0.65–0.92] for mortality) and non-inferior safety (HR 0.93, 95%CI [0.86–1.01] for major bleeding; HR 0.58, 95%CI [0.50–0.67] for intracranial bleeding; HR 1.17, 95%CI [0.99–1.38] for gastrointestinal bleeding) of NOACs versus VKAs in older AF patients. Conclusion Across geriatric subgroups, apixaban was consistently associated with the most favourable benefit-risk profile and should therefore be preferred in geriatric patients with AF. However, research gaps on the impact of increased falling risk, frailty and baseline dementia were identified, requiring careful consideration while awaiting more results.
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Affiliation(s)
- Maxim Grymonprez
- Pharmaceutical Care Unit, Department of Bioanalysis, Ghent University, Ghent, Belgium
| | - Stephane Steurbaut
- Centre for Pharmaceutical Research, Vrije Universiteit Brussel, Jette, Belgium
| | - Tine L De Backer
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Mirko Petrovic
- Department of Geriatrics, Ghent University Hospital, Ghent, Belgium
| | - Lies Lahousse
- Pharmaceutical Care Unit, Department of Bioanalysis, Ghent University, Ghent, Belgium.,Department of Epidemiology, Erasmus Medical Center, Rotterdam, Netherlands
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49
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Cognitive impairment in patients with atrial fibrillation: Implications for outcome in a cohort study. Int J Cardiol 2020; 323:83-89. [PMID: 32800908 DOI: 10.1016/j.ijcard.2020.08.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/20/2020] [Accepted: 08/07/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND The impact of cognitive status on outcomes of patients with atrial fibrillation (AF) is not well defined. AIMS To assess the prevalence of cognitive impairment in AF patients and evaluate its association with: i) all-cause mortality; ii) a composite endpoint of death, stroke/systemic embolism, hemorrhages, acute coronary syndrome, pulmonary embolism, new/worsening heart failure. METHODS In a cohort study, cognitive status was assessed at baseline by the Mini Mental State examination adjusted for age and education (aMMSE). aMMSE <24 was considered indicative of cognitive impairment. RESULTS The cohort included 437 patients (61.3% male, mean age 73.4 ± 11.7 years). Sixty-three patients (14.4%) had cognitive impairment at baseline aMMSE. Permanent AF (odds ratio [OR] 1.750; 95%CI 1.012-3.025; p = .045), haemoglobin levels (OR 0.827; 95%CI 0.707-0.967; p = .017) and previous treatment with antiplatelet drugs only, without oral anticoagulation, (OR 4.352; 95%CI 1.583-11.963; p = .004) were independently associated with cognitive impairment at baseline. After a median follow-up of 887 days (interquartile range 731-958) 30 patients died (7.1%), and 97 (22.9%) reached the composite endpoint. After adjustment for Elixhauser Comorbidy Measure, aMMSE <24 was significantly associated with all-cause mortality (hazard ratio [HR] 2.473, 95%CI 1.062-5.756, p = .036) and with the composite endpoint (HR 1.852, 95%CI 1.106-3.102, p = .019). CONCLUSIONS In patients with AF, cognitive impairment (aMMSE <24) is associated with worse outcomes, and the association of adverse outcomes with previous treatment with antiplatelet drugs only, without oral anticoagulation, highlights the potential role of appropriate antithrombotic treatment for improving patient prognosis.
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50
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de Groot JR, Weiss TW, Kelly P, Monteiro P, Deharo JC, de Asmundis C, López-de-Sá E, Waltenberger J, Steffel J, Levy P, Bakhai A, Zierhut W, Laeis P, Manu MC, Reimitz PE, De Caterina R, Kirchhof P. Edoxaban for stroke prevention in atrial fibrillation in routine clinical care: 1-year follow-up of the prospective observational ETNA-AF-Europe study. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:f30-f39. [PMID: 32790837 PMCID: PMC8117428 DOI: 10.1093/ehjcvp/pvaa079] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/28/2020] [Accepted: 08/05/2020] [Indexed: 01/16/2023]
Abstract
Aims Non-vitamin K oral anticoagulants are safe and effective for stroke prevention in patients with atrial fibrillation (AF). Data on the safety and efficacy of edoxaban in routine care are limited in Europe. We report 1-year outcomes in patients with AF treated with edoxaban in routine care. Methods and results ETNA-AF-Europe is a prospective, multicentre, post-authorization, observational study enrolling patients treated with edoxaban in 10 European countries, the design of which was agreed with the European Medicines Agency as part of edoxaban’s post-approval safety plan. Altogether 13 092 patients in 852 sites completed the 1-year follow-up [mean age: 73.6 ± 9.5 years; 57% male, mean follow-up: 352 ± 49 days (median: 366 days)]. Most patients had associated comorbidities (mean CHA2DS2-VASc score: 3.1 ± 1.4). Stroke or systemic embolism was reported in 103 patients (annualized event rate: 0.82%/year), and major bleeding events were reported in 132 patients (1.05%/year). Rates of intracranial haemorrhage were low [30 patients (0.24%/year)]. Death occurred in 442 patients (3.50%/year); cardiovascular (CV) death occurred in 206 patients (1.63%/year). The approved dosing of edoxaban was chosen in 83%. All-cause and CV mortality were higher in patients receiving edoxaban 30 mg vs. 60 mg, in line with the higher age and more frequent comorbidities of the 30 mg group. Major bleeding was also numerically more common in patients receiving edoxaban 30 mg vs. 60 mg. Conclusion The rates of stroke, systemic embolism, and major bleeding are low in this large unselected cohort of high-risk AF patients routinely treated with edoxaban.
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Affiliation(s)
- Joris R de Groot
- Department of Cardiology, Amsterdam University Medical Centres/University of Amsterdam, Spui 21 1012 WX Amsterdam, The Netherlands
| | - Thomas W Weiss
- Institute for Cardiometabolic Diseases, Karl Landsteiner Society, St. Pölten, Austria
| | - Peter Kelly
- Department of Neurology, HRB Stroke Clinical Trials Network Ireland, University College Dublin/Mater Misericordiae University Hospital, Eccles St, Northside, Dublin, Ireland
| | - Pedro Monteiro
- Department of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Mota Pinto 3000-075, Coimbra, Portugal
| | - Jean Claude Deharo
- AP-HM, Aix Marseille University, Hôpital Timone, Cardiologie, Rythmologie, 264 rue Saint-Pierre, 13005, Marseille, France
| | - Carlo de Asmundis
- Department of Cardiology, Universitair Ziekenhuis Brussels, Ninoofsesteenweg 134, 1700 Dilbeek, Belgium
| | - Esteban López-de-Sá
- Cardiological Intensive Care Unit, Cardiology Service, Hospital Universitario La Paz, IDIPAZ, CIBER-CV, Madrid, Spain
| | - Johannes Waltenberger
- Department of Cardiovascular Medicine, University of Munster, Schlossplatz 2, 48149 Münster, Germany.,Department of Internal Medicine I, SRH Central Hospital Suhl, Albert-Schweitzer-Straße 2, 98527 Suhl, Germany
| | - Jan Steffel
- Department of Cardiology, University Hospital of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Pierre Levy
- Department of Economics, Université Paris-Dauphine, PSL Research University, LEDa-LEGOS, Paris, France
| | - Ameet Bakhai
- Department of Cardiology, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, UK
| | - Wolfgang Zierhut
- Daiichi Sankyo Europe GmbH, Zielstattstr. 48, 81379 Munich, Germany
| | - Petra Laeis
- Daiichi Sankyo Europe GmbH, Zielstattstr. 48, 81379 Munich, Germany
| | | | | | - Raffaele De Caterina
- Chair of Cardiology, University of Pisa, Lungarno Antonio Pacinotti, 43, 56126 Pisa, Italy
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, SWBH and UHB NHS Trusts, IBR 136, Wolfson Drive, Birmingham B15 2TT, UK.,Department of Cardiology, University Heart and Vascular Centre Hamburg, Villa Garbrecht, Martinistraße 52, 20251 Hamburg, Germany.,The Atrial Fibrillation NETwork (AFNET), Münster, Germany
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