Prior history of falls and risk of outcomes in atrial fibrillation: the Loire Valley Atrial Fibrillation Project

Clinical outcomes in patients with atrial fibrillation and a history of falls using non-vitamin K antagonist oral anticoagulants: A nationwide cohort study

Background

Data on non-vitamin K antagonist oral anticoagulant (NOAC) use in patients with atrial fibrillation (AF) and a history of falls are limited. Therefore, we investigated the impact of a history of falls on AF-related outcomes, and the benefit-risk profiles of NOACs in patients with a history of falls.

Methods

Using Belgian nationwide data, AF patients initiating anticoagulation between 2013 and 2019 were included. Previous falls that occurred ≤ 1 year before anticoagulant initiation were identified.

Results

Among 254,478 AF patients, 18,947 (7.4%) subjects had a history of falls, which was associated with higher risks of all-cause mortality (adjusted hazard ratio (aHR) 1.11, 95%CI (1.06-1.15)), major bleeding (aHR 1.07, 95%CI (1.01-1.14)), intracranial bleeding (aHR 1.30, 95%CI (1.16-1.47)) and new falls (aHR 1.63, 95%CI (1.55-1.71)), but not with thromboembolism. Among subjects with a history of falls, NOACs were associated with lower risks of stroke or systemic embolism (aHR 0.70, 95%CI (0.57-0.87)), ischemic stroke (aHR 0.59, 95%CI (0.45-0.77)) and all-cause mortality (aHR 0.83, 95%CI (0.75-0.92)) compared to vitamin K antagonists (VKAs), while major, intracranial, and gastrointestinal bleeding risks were not significantly different. Major bleeding risks were significantly lower with apixaban (aHR 0.77, 95%CI (0.63-0.94)), but similar with other NOACs compared to VKAs. Apixaban was associated with lower major bleeding risks compared to dabigatran (aHR 0.78, 95%CI (0.62-0.98)), rivaroxaban (aHR 0.78, 95%CI (0.68-0.91)) and edoxaban (aHR 0.74, 95%CI (0.59-0.92)), but mortality risks were higher compared to dabigatran and edoxaban.

Conclusions

A history of falls was an independent predictor of bleeding and death. NOACs had better benefit-risk profiles than VKAs in patients with a history of falls, especially apixaban.

Development and external validation of a risk prediction model for falls in patients with an indication for antihypertensive treatment: retrospective cohort study

OBJECTIVE

To develop and externally validate the STRAtifying Treatments In the multi-morbid Frail elderlY (STRATIFY)-Falls clinical prediction model to identify the risk of hospital admission or death from a fall in patients with an indication for antihypertensive treatment.

DESIGN

Retrospective cohort study.

SETTING

Primary care data from electronic health records contained within the UK Clinical Practice Research Datalink (CPRD).

PARTICIPANTS

Patients aged 40 years or older with at least one blood pressure measurement between 130 mm Hg and 179 mm Hg.

MAIN OUTCOME MEASURE

First serious fall, defined as hospital admission or death with a primary diagnosis of a fall within 10 years of the index date (12 months after cohort entry). Model development was conducted using a Fine-Gray approach in data from CPRD GOLD, accounting for the competing risk of death from other causes, with subsequent recalibration at one, five, and 10 years using pseudo values. External validation was conducted using data from CPRD Aurum, with performance assessed through calibration curves and the observed to expected ratio, C statistic, and D statistic, pooled across general practices, and clinical utility using decision curve analysis at thresholds around 10%.

RESULTS

Analysis included 1 772 600 patients (experiencing 62 691 serious falls) from CPRD GOLD used in model development, and 3 805 366 (experiencing 206 956 serious falls) from CPRD Aurum in the external validation. The final model consisted of 24 predictors, including age, sex, ethnicity, alcohol consumption, living in an area of high social deprivation, a history of falls, multiple sclerosis, and prescriptions of antihypertensives, antidepressants, hypnotics, and anxiolytics. Upon external validation, the recalibrated model showed good discrimination, with pooled C statistics of 0.833 (95% confidence interval 0.831 to 0.835) and 0.843 (0.841 to 0.844) at five and 10 years, respectively. Original model calibration was poor on visual inspection and although this was improved with recalibration, under-prediction of risk remained (observed to expected ratio at 10 years 1.839, 95% confidence interval 1.811 to 1.865). Nevertheless, decision curve analysis suggests potential clinical utility, with net benefit larger than other strategies.

CONCLUSIONS

This prediction model uses commonly recorded clinical characteristics and distinguishes well between patients at high and low risk of falls in the next 1-10 years. Although miscalibration was evident on external validation, the model still had potential clinical utility around risk thresholds of 10% and so could be useful in routine clinical practice to help identify those at high risk of falls who might benefit from closer monitoring or early intervention to prevent future falls. Further studies are needed to explore the appropriate thresholds that maximise the model's clinical utility and cost effectiveness.

Prescribing of anticoagulation for atrial fibrillation in primary care

Atrial fibrillation (AF) is common in primary care patients. Many patients who could benefit from anticoagulation do not receive it. The objective of this study was to describe anticoagulation prescribing by primary care physicians. We conducted an observational study in the Cleveland Clinic Health System among patients with AF and ≥ 1 primary care appointment between 2015 and 2018 and their physicians. We estimated differences in the odds of an eligible patient receiving anticoagulation versus not and a DOAC versus warfarin using two mixed effects logistic regression models, adjusted for patient sociodemographic factors, history of falls or dementia, and CHA2DS2-VASc and HAS-BLED scores. We categorized physicians into prescribing tertiles, based on their adjusted prescribing rate, which we included as predictors in the models. Among 5253 patients, 47% received anticoagulation. Of those, 56% received a DOAC. CHA2DS2-VASc and HAS-BLED scores were not associated with anticoagulation prescription. Black race was negatively associated with receiving anticoagulation overall (aOR:0.71; 95%CI:0.56-0.89) and with prescription for a DOAC (aOR:0.65; 95%CI:0.45-0.93). Among 195 physicians, the anticoagulation prescribing rate ranged from 27% to 57% and DOAC rates ranged from 34% to 69%. Physician prescribing tertile was associated with odds of a patient receiving anticoagulation overall (aOR:1.51; 95%CI: 1.13-2.01 for the highest versus lowest tertile), but not DOAC prescriptions. When prescribing anticoagulation, physicians appear not to consider risk of stroke or bleeding but patient race is an important determinant. Seeing a physician with a high anticoagulation prescribing rate was strongly associated with a patient receiving it, suggesting a lack of individualization.

Two-year outcomes of more than 30 000 elderly patients with atrial fibrillation: results from the All Nippon AF In the Elderly (ANAFIE) Registry

AIMS

To clarify the real-world clinical status and prognosis of elderly and very elderly non-valvular atrial fibrillation (NVAF) patients, more than 30 000 elderly patients with NVAF aged ≥75 years were enrolled in the ANAFIE Registry.

METHODS AND RESULTS

This multicentre, prospective, observational study followed elderly NVAF patients in Japan for ∼2 years. Among 32 275 patients (mean age, 81.5 years; men, 57.3%; mean CHA2DS2-VASc score, 4.5), 2445 (7.6%) were not receiving oral anticoagulants (OACs) and 29 830 (92.4%) were given OACs. Of these, 21 585 (66.9%) were receiving direct OACs (DOACs) and 8233 (25.5%), warfarin (mean time in therapeutic range: ∼75%). In total, the 2-year incidence rate was 3.01% for stroke/systemic embolic events (SEE); 2.00%, major bleeding; and 6.95%, all-cause death. When compared with the warfarin group, the DOAC group had a lower hazard ratio (HR) for stroke/SEE, major bleeding, and all-cause death after adjusting for confounders. The group without OACs had a higher HR for stroke/SEE and all-cause death, with a lower HR for major bleeding. History of falls within 1 year at enrolment and of catheter ablation were positive and negative independent risk factors, respectively, for stroke/SEE, major bleeding, and all-cause death.

CONCLUSION

In Japan, a large proportion of elderly and very elderly NVAF patients were receiving DOACs, which was significantly associated with lower rates of stroke/SEE, major bleeding, and all-cause death vs. well-controlled warfarin. History of falls and of catheter ablation were independently associated with stroke/SEE, major bleeding, and all-cause death.

Characteristics of warfarin under-prescription in older adults with atrial fibrillation

Background

The prevalence of atrial fibrillation (AF) and atrial flutter (AFl) increases with age. Under-prescription of anticoagulants in older adults can lead to increased morbidity and mortality. We analyzed warfarin prescription patterns in older adults.

Methods

In this observational single-center study, we analyzed 2179 consecutive patients with admission diagnosis of AF or AFl. Patients were divided into “older” (≥ 75 years old) and “younger” (<75 years old) groups. Prescription patterns of warfarin were analyzed. Patients discharged from the hospital on a non-warfarin anticoagulation were excluded.

Results

Of the 1988 patients analyzed, 46.9% were ≥75 years old, of which 50.8% were prescribed warfarin. There was no association between mean CHA₂DS₂-VASc score and warfarin prescription on discharge (OR = 1.06 (95% CI 0.93–1.21), p = 0.388) in the older group. After adjusting for hypertension, renal function, and Black race, warfarin prescription in older adults was independently associated with lower aspirin prescription rates (OR = 0.57 (95% CI 0.43–0.75), p < 0.001), lower body mass index (OR = 1.03 (95% CI 1.01–1.06), p = 0.018), and lower hemoglobin levels (OR = 1.11 (95% CI 1.04–1.19), p = 0.002).

Conclusions

In our study, older adults (≥75 years old) with AF and AFl tended to have lower rates of warfarin prescription despite higher CHA₂DS₂-VASc score and higher risk of thromboembolic events. Anemia, lower body weight, and aspirin use were characteristics associated with warfarin under-prescription.

Evidence and uncertainties in the management of atrial fibrillation in older persons

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.

Falls in ED patients: do elderly patients on direct oral anticoagulants bleed less than those on vitamin K antagonists?

Background

Falls from standing are common in the elderly and are associated with a significant risk of bleeding. We have compared the proportional incidence of bleeding complications in patients on either direct oral anticoagulants (DOAC) or vitamin K antagonists (VKA).

Methods

Our retrospective cohort study compared elderly patients (≥65 years) on DOAC or VKA oral anticoagulation who presented at the study site – a Swiss university emergency department (ED) – between 01.06.2012 and 01.07.2017 after a fall. The outcomes were the proportional incidence of any bleeding complication and its components (e.g. intracranial haemorrhage), as well as procedural and clinical parameters (length of hospital stay, admission to intensive care unit, in-hospital-mortality). Uni- and multivariable analyses were used to compare the studied outcomes.

Results

In total, 1447 anticoagulated patients were included – on either VKA (n = 1021) or DOAC (n = 426). There were relatively more bleeding complications in the VKA group (n = 237, 23.2%) than in the DOAC group (n = 69, 16.2%, p = 0.003). The difference persisted in multivariable analysis with 0.7-fold (95% CI: 0.5–0.9, p = 0.014) lower odds for patients under DOAC than under VKA for presenting with any bleeding complications, and 0.6-fold (95% 0.4–0.9, p = 0.013) lower odds for presenting with intracranial haemorrhage. There were no significant differences in the other studied outcomes.

Conclusions

Among elderly, anticoagulated patients who had fallen from standing, those under DOACs had a lower proportional incidence of bleeding complications in general and an even lower incidence of intracranial haemorrhage than in patients under VKAs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00866-6.

Anticoagulant Therapy for Frail Patients with Atrial Fibrillation

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.

Atrial fibrillation in the elderly: a risk factor beyond stroke

Atrial fibrillation (AF) represents the most common arrhythmia worldwide and its prevalence exponentially increases with age. It is related to increased risk of ischemic stroke or systemic embolism, which determines a significant burden of morbidity and mortality, as widely documented in the literature. AF also constitutes a risk factor for other less investigated conditions, such as heart failure, pulmonary embolism, impairment in physical performance, reduced quality of life, development of disability, mood disorders and cognitive impairment up to dementia. In the elderly population, the management of AF and its complications is particularly complex due to the heterogeneity of the ageing process, the lack of specific evidence-based recommendations, as well as the high grade of comorbidity and disability characterizing the over 65 years aged people. In the present review, we aim to summarize the pieces of the most updated evidence on AF complications beyond stoke, mainly focusing on the elderly population.

Stroke and Bleeding Risk Assessments in Patients With Atrial Fibrillation: Concepts and Controversies

Risk assessments are an important element in the management of patients with atrial fibrillation (AF). In this review, we aim to discuss the concepts and controversies surrounding the various risk factors for stroke and bleeding in AF. Indeed, there are a variety of clinical, electrical, biological, and genetic markers to guide stroke and bleeding risk assessments in AF. The more common factors have been used to formulate risk stratification scores. Some risk factors have shown promise, but others remain less well-defined. Our aim is to discuss concepts and controversies surrounding current evidence of risk factors for stroke and bleeding assessments in AF.

Practical use of Direct Oral Anti Coagulants (DOACs) in the older persons with atrial fibrillation

Direct Oral Anticoagulants (DOACs) consistently demonstrated a greater net clinical benefit compared to Vitamin K Antagonists (VKAs) also in persons aged 75 years and over, who account for the largest proportion of AF patients; however, major uncertainties in DOACs prescription have to do with this age group. In this review, persistent uncertainties and implications of frailty and geriatric syndromes on DOACs prescription, and practical use of DOACs in real-world older persons, and will be discussed.

When to withhold oral anticoagulation in atrial fibrillation - an overview of frequent clinical discussion topics

Stroke prevention with oral anticoagulants in patients with atrial fibrillation predisposes for bleeding. As a result, in select patient groups anticoagulation is withheld because of a perceived unfavorable risk-benefit ratio. Reasons for withholding anticoagulation can vary greatly between clinicians, often leading to discussion in daily clinical practice on the best approach. To guide clinical decision-making, we have reviewed available evidence on the most frequently reported reasons for withholding anticoagulation: previous bleeding, frailty and age, and an overall high bleeding risk.

Left atrial appendage closure: A therapy uniquely suited for specific populations of patients with atrial fibrillation

Atrial fibrillation (AF) is the most common clinically relevant arrhythmia and confers a fivefold increased risk for stroke. Cardioembolic stroke secondary to AF is a devastating event, but is largely preventable with appropriate oral anticoagulation (OAC). The PROTECT and PREVAIL trials demonstrated that the WATCHMAN left atrial appendage closure (LAAC) device in combination with short-term warfarin therapy is noninferior to long-term warfarin with respect to a composite endpoint of stroke, cardiovascular death, and systemic embolism. Importantly, the WATCHMAN confers a significant reduction in life-threatening bleeding compared to OAC. Although direct-acting oral anticoagulant (DOAC) are superior to warfarin in eligible patients, several important AF populations exist in whom left atrial appendage (LAA) closure may be preferable to DOAC. Populations warranting strong consideration of LAAC include patients with contraindications to DOAC, end-stage renal disease, prior intracranial hemorrhage, recurrent gastrointestinal bleeding, and patients undergoing transcatheter aortic valve replacement or left atrial electrical isolation. Device-related thrombosis is an important complication of LAAC, and DOAC may be preferential to warfarin for prevention and treatment of this complication remains unexplored. Prospective clinical trials comparing DOAC to LAAC in these unique populations are either ongoing or needed.

Overview of oral antithrombotic treatment in elderly patients with atrial fibrillation

Atrial fibrillation (AF) is an age-related arrhythmia, particularly affecting elderly patients. The ultimate goals in the treatment of AF are to improve prognosis and quality of life. Anticoagulants are effective for stroke prevention in AF patients, however, managing anticoagulation in elderly patients is especially challenging; requiring a comprehensive assessment of the patient and deep understanding of available therapies and doses to maximize the net benefit. This review summarizes available evidence on the efficacy and safety of anticoagulation therapy, and provides contemporary updates on the management of elderly patients with AF.

Clinical pharmacist implementation of a medication assessment tool for long-term management of atrial fibrillation in older persons

BACKGROUND

Optimisation of drug therapy is important in the older population and may be facilitated by medication assessment tools (MATs).

OBJECTIVE

The purpose of the study was to evaluate whether appropriateness of drug therapy and clinical pharmacist intervention documentation improved following implementation of a previously developed MAT for the long-term management of atrial fibrillation (MAT-AF).

METHODS

Adherence to MAT-AF review criteria and clinical pharmacist intervention documentation was assessed by the researcher pre-MAT implementation in 150 patients aged ≥60 years admitted to a rehabilitation hospital with a diagnosis of atrial fibrillation. MAT-AF was introduced as a clinical tool in the hospital for identification of pharmaceutical care issues in atrial fibrillation patients. Adherence to MAT-AF and pharmacist intervention documentation were assessed by the researcher post-MAT implementation for a further 150 patients with the same inclusion criteria. Logistic regression analysis and measurement of odds ratio was used to identify differences in adherence to MAT-AF pre- and post-MAT implementation. The differences between two population proportions z-test was used to compare pharmacist intervention documentation pre- and post-MAT implementation.

RESULTS

Adherence to MAT-AF criteria increased from 70.9% pre-implementation to 89.6% post-implementation. MAT-AF implementation resulted in a significant improvement in prescription of anticoagulant therapy (OR 4.07, p<0.001) and monitoring of laboratory parameters for digoxin (OR 10.40, p<0.001). Clinical pharmacist intervention documentation improved significantly post-implementation of MAT-AF (z-score 20.249, p<0.001).

CONCLUSIONS

Implementation of MAT-AF within an interdisciplinary health care team significantly improved the appropriateness of drug therapy and pharmacist intervention documentation in older patients with atrial fibrillation.

Factors associated with discontinuing or not starting oral anticoagulant therapy in older hospitalized patients with non-valvular atrial fibrillation

AIM

To determine the factors associated with discontinuing or not starting oral anticoagulation (OA) therapy in older patients with non-valvular atrial fibrillation (NVAF).

METHODS

A prospective, multicenter cohort study was carried out of patients aged >75 years with NVAF hospitalized in internal medicine departments in Spain. For each patient, we recorded creatinine, hemoglobin and platelets levels, as well as CHA2DS2-VASc and HAS-BLED scores and the Charlson Comorbidity Index. We measured the ability to carry out basic activities of daily life with the Barthel Index, and the cognitive state with the Short Portable Mental Status questionnaire.

RESULTS

We included 723 patients with NVAF, with a mean age of 84.8 years (SD 5.2 years); 390 (53.9%) of the patients were women. Before admission, 375 (51.9%) patients were treated with OA. Previously diagnosed NVAF (OR 4.099, 95% CI 1.824-9.211, P = 0.001), the number of errors in the Short Portable Mental Status questionnaire (OR 1.180, 95% CI 1.020-1.365, P = 0.026), peripheral arterial disease (OR 0.285, 95% CI 0.114-0.711, P = 0.007) and hemoglobin levels (OR 0.812, 95% CI 0.682-0.966, P = 0.019) were independently associated with not starting OA therapy at discharge. Of the 375 patients treated with OA at admission, 87 (23.2%) had their OA discontinued at discharge. The HAS-BLED score (OR 1.516, 95% CI 1.211-1.897, P < 0.001) and previous acute myocardial infarction (OR 0.327, 95% CI 0.121-0.883, P = 0.027) were associated with the discontinuation of OA.

CONCLUSIONS

There are factors associated with discontinuing or not starting OA in older patients with NVAF, which often have no clinical justification. Geriatr Gerontol Int 2018; 18: 1219-1224.

Stroke-prevention strategies in North American patients with atrial fibrillation: The GLORIA-AF registry program

Background

Antithrombotic prophylaxis with oral anticoagulation (OAC) substantially reduces stroke and mortality in patients with atrial fibrillation (AF).

Hypothesis

Analysis of data in the Global Registry on Long‐Term Antithrombotic Treatments in Patients With Atrial Fibrillation (GLORIA‐AF), an international, observational registry of patients with newly diagnosed AF, can identify factors associated with treatment decisions and outcomes.

Methods

Multivariable regression identified patient, physician, and temporal factors associated with OAC prescription, compared with management with antiplatelet drugs or no antithrombotic drugs in North American patients enrolled between November 2011 and February 2014.

Results

Of 3320 eligible patients (mean age, 71 ± 11 years; 1879 males with CHA₂DS₂‐VASc ≥1 and 1441 females with CHA₂DS₂‐VASc ≥2), 79.3%, 12.5%, and 7.4% received OAC, antiplatelet drugs, or no antithrombotic therapy, respectively. Of those prescribed OAC, 66.4% received non–vitamin K antagonist oral anticoagulation and 24.5% received concomitant therapy with antiplatelet drugs. Independent predictors of OAC therapy were nonparoxysmal AF (odds ratio, 95% confidence interval: 2.02, 1.56–2.63), prior stroke/transient ischemic attack (2.00, 1.37–2.92), specialist care (1.50, 1.04–2.17), more concomitant medications (1.47, 1.13–1.92), commercial insurance (1.41, 1.07–1.85), and heart failure (1.44, 1.07–1.92). Antiplatelet drugs (0.18, 0.14–0.23), prior falls (0.41, 0.27–0.63), and prior bleeding (0.50, 0.35–0.72) were inversely associated with OAC prescription.

Conclusions

In GLORIA‐AF, 20% of the population comprising males with CHA₂DS₂‐VASc ≥1 and females with CHA₂DS₂‐VASc ≥2 did not receive OAC therapy. Patient characteristics associated with a lower likelihood of OAC prescription were use of antiplatelet drugs, paroxysmal pattern of AF, history of falls, and prior bleeding.

Clinical Outcomes and History of Fall in Patients with Atrial Fibrillation Treated with Oral Anticoagulation: Insights From the ARISTOTLE Trial

PURPOSE

We assessed outcomes among anticoagulated patients with atrial fibrillation and a history of falling, and whether the benefits of apixaban vs warfarin are consistent in this population.

METHODS

Of the 18,201 patients in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) study, 16,491 had information about history of falling-753 with history of falling and 15,738 without history of falling. The primary efficacy outcome was stroke or systemic embolism; the primary safety outcome was major bleeding.

RESULTS

When compared with patients without a history of falling, patients with a history of falling were older, more likely to be female and to have dementia, cerebrovascular disease, depression, diabetes, heart failure, osteoporosis, fractures, and higher CHA₂DS₂-VASc (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, prior Stroke or TIA or thromboembolism, Vascular disease, Age 65-74 years, Sex category female) and HAS-BLED (Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile international normalized ratio, Elderly, Drugs or alcohol) scores. Patients with a history of falling had higher rates of major bleeding (adjusted hazard ratio [HR] 1.39; 95% confidence interval [CI], 1.05-1.84; P = .020), including intracranial bleeding (adjusted HR 1.87; 95% CI, 1.02-3.43; P = .044) and death (adjusted HR 1.70; 95% CI, 1.36-2.14; P < .0001), but similar rates of stroke or systemic embolism and hemorrhagic stroke. There was no evidence of a differential effect of apixaban compared with warfarin on any outcome, regardless of history of falling. Among those with a history of falling, subdural bleeding occurred in 5 of 367 patients treated with warfarin and 0 of 386 treated with apixaban.

CONCLUSIONS

Patients with atrial fibrillation and a history of falling receiving anticoagulation have a higher risk of major bleeding, including intracranial, and death. The efficacy and safety of apixaban compared with warfarin were consistent, irrespective of history of falling.

Editor's Choice - Frailty and the management of patients with acute cardiovascular disease: A position paper from the Acute Cardiovascular Care Association

Frailty is increasingly seen among patients with acute cardiovascular disease. A combination of an ageing population, improved disease survival, treatable long-term conditions as well as a greater recognition of the syndrome has accelerated the prevalence of frailty in the modern world. Yet, this has not been matched by an expansion of research. National and international bodies have identified acute cardiovascular disease in the frail as a priority area for care and an entity that requires careful clinical decisions, but there remains a paucity of guidance on treatment efficacy and safety, and how to manage this complex group. This position paper from the Acute Cardiovascular Care Association presents the latest evidence about frailty and the management of frail patients with acute cardiovascular disease, and suggests avenues for future research.

Assessing appropriateness of drug therapy in older persons: Development and application of a medication assessment tool for long-term management of atrial fibrillation

Background:

Atrial fibrillation (AF) is highly prevalent in older persons and is associated with considerable morbidity and mortality. Assessing appropriateness of drug therapy in AF may be facilitated by application of medication assessment tools (MATs).

Objective:

To develop, psychometrically evaluate and apply an innovative MAT for the long-term management of AF with particular relevance to older persons.

Methods:

Key recommendations from clinical practice guidelines for the long-term management of AF were selected and review criteria defining appropriate drug therapy were constructed as a ‘qualifying statement’ followed by a ‘standard’. The developed MAT was given the designation MAT-AF. An application guide was compiled where justifications for non-adherence were specified. Content validity was tested by an expert group using a three-round Delphi process. Inter- and intra-observer reliability testing was conducted with agreement expressed by Cohen’s kappa and application time measured to assess feasibility. MAT-AF was applied to 150 patients with a diagnosis of AF admitted to a rehabilitation hospital.

Results:

MAT-AF consists of 15 criteria sectioned into antithrombotic, rate control and rhythm control therapy. Content validity was demonstrated for all criteria. Reliability was confirmed with kappa values of 0.84 and 0.91 for inter- and intra-observer agreements. Mean application time for the two observers was 3.9 and 2.4 minutes, which decreased significantly in the second application conducted after a four-week interval (p<0.001). Overall adherence to applicable criteria was 59.8%. Non-adherence was evident for prescription of anticoagulation in patients with a CHA₂DS₂VASc score ≥1 (29.5%). Monitoring of laboratory parameters for digoxin was suboptimal. Ophthalmic and pulmonary monitoring and patient counselling regarding amiodarone therapy could not be assessed since relevant records were not readily available.

Conclusion:

MAT-AF application highlighted key aspects which need to be addressed to improve patient care.

Anticoagulation for Stroke Prevention in Older Adults with Atrial Fibrillation and Comorbidity: Current Evidence and Treatment Challenges

The burden of atrial fibrillation (AF) is projected to increase substantially over the next decade in parallel with the aging of the population. The increasing age, level of comorbidity, and polypharmacy will complicate the treatment of older adults with AF. For instance, advanced age and chronic kidney disease have been shown to increase the risk of both thromboembolism and bleeding in patients with AF. Frailty, recurrent falls and polypharmacy, while very common among elderly patients with AF, are often overlooked in the clinical decision making despite their significant interaction with oral anticoagulant (OAC) and profound impact on the patient's clinical outcomes. Such factors should be recognized, evaluated and considered in a comprehensive decision-making process. The introduction of non-vitamin K oral anticoagulants has radically changed the management of AF allowing for a more individualized selection of OAC. An understanding of the available data regarding the performance of each of the available OAC in a variety of at risk patient populations is paramount for the safe and effective management of this patient population. The aim of this review is to appraise the current evidence, point out the gaps in knowledge, and provide recommendations regarding stroke prevention in older adults with AF and comorbid conditions.

Clinical conundrums in antithrombotic therapy management: A Delphi Consensus panel

BACKGROUND

Anticoagulants are recommended for the prevention of stroke/systemic embolism for most patients with atrial fibrillation (AF) and for the treatment of patients with venous thromboembolism (VTE). Regulatory-driven randomized trials, however, typically exclude extreme patient scenarios involving, for instance, severe bleeding, ischaemic risk, frailty or renal impairment, despite their common occurrence in clinical practice. Uncertainty in the management of such cases leads to a high degree of variability in therapeutic approaches. Consensus conferences or panels may provide insights and help bridge the gaps that separate clinical guidelines from real-world practice. In the present study, a description of challenging AF and VTE patients was submitted to a large panel of experts to investigate areas of common or divergent management.

METHOD

A modified-Delphi method was used to obtain consensus among 178 Italian AF and VTE specialists. A questionnaire was sent on the appropriateness of anticoagulant therapy in AF and VTE cases, including CHA₂DS₂-VASc=1, comorbid coronary artery disease, frailty, advanced age, risk of falling, prior haemorrhagic stroke, and low- or intermediate-risk pulmonary embolism. Strategies to improve guideline adherence were also investigated.

RESULTS

All participants completed the questionnaire. Consensus was reached on many, but not all cases, leaving uncertainty on some debated topics (conundrums) where decisions are unsupported by clinical studies or driven by controversial results.

CONCLUSIONS

The indications emerging from this large panel of experts may help guide the management of challenging AF or VTE cases. Studies are needed addressing treatment options in those cases for whom no consensus was reached.

Oral anticoagulant therapy for older patients with atrial fibrillation: a review of current evidence

Atrial fibrillation is more frequent in older patients, who have a higher risk of cardioembolic stroke and thromboembolism. Oral anticoagulant therapy is the standard of treatment for stroke prevention; however, under-prescription is still very common in older patients. The reasons underlying this phenomenon have not been systematically investigated, and true contraindications only partially account for it. An intimate skepticism on the real benefit-risk balance of oral anticoagulant therapy in the oldest patients seems to derive from the fact that most studies supporting it were conducted decades ago and included younger patients, with overall better functional and clinical status. In this review we will focus on the main barriers to anticoagulant therapy prescription in older patients and summarize the available evidences on the efficacy and safety of vitamin K antagonists and direct oral anticoagulants in this population. The encouraging evidence of a higher net clinical benefit of direct oral anticoagulants compared with warfarin should hopefully widen the treatment options also for frail individuals, thereby allowing a greater number of patients to be treated according to current international guidelines.

Clinical Stroke prevention in atrial fibrillation

Oral anticoagulation therapy has reduced the risk of ischaemic stroke and improved the outcomes for patients with atrial fibrillation considerably. The emergence of the non-vitamin K oral anticoagulants as alternatives to vitamin K antagonists has significantly changed the practice of stroke prevention in atrial fibrillation. As the main complication with antithrombotic therapy is bleeding, physicians should always balance the risk of ischaemic stroke against intracranial haemorrhage and intervene where appropriate to reduce both risks. Individual approach is often mandatory due to heterogeneity of the risks and patient preferences. The purpose of this review is to summarise the current knowledge of the oral anticoagulation therapy in atrial fibrillation patients and guide physicians with the management of anticoagulants based on data from clinical trials and systematic reviews.

Emerging Tools for Stroke Prevention in Atrial Fibrillation

Ischaemic strokes resulting from atrial fibrillation (AF) constitute a devastating condition for patients and their carers with huge burden on health care systems. Prophylactic treatment against systemic embolization and ischaemic strokes is the cornerstone for the management of AF. Effective stroke prevention requires the use of the vitamin K antagonists or non-vitamin K oral anticoagulants (NOACs). This article summarises the latest developments in the field of stroke prevention in AF and aims to assist physicians with the choice of oral anticoagulant for patients with non-valvular AF with different risk factor profile.

Oral anticoagulant therapy in atrial fibrillation patients at high stroke and bleeding risk

Atrial fibrillation (AF) is associated with a 5-fold greater risk of ischemic stroke or systemic embolism compared with normal sinus rhythm. Cardioembolic AF-related strokes are often more severe, fatal or associated with greater permanent disability and higher recurrence rates than strokes of other aetiologies. These strokes may be effectively prevented with oral anticoagulant (OAC) therapy, using either vitamin K antagonists (VKAs) or non-vitamin K antagonist OACs (NOACs) such as the direct thrombin inhibitor dabigatran or direct factor Xa inhibitors rivaroxaban, apixaban or edoxaban. Most AF patients have a positive net clinical benefit from OAC, excluding those with AF and no conventional stroke risk factors. Balancing the risks of stroke and bleeding is necessary for optimal use of OAC in clinical practice, and modifiable bleeding risk factors must be addressed. Concerns remain over 'non-changeable' bleeding risk factors such as older age, significant renal or hepatic impairment, prior stroke(s) or prior bleeding event(s) and active malignancies. Such AF patients are often termed 'special' AF populations, due to their 'special' risk profile that includes increased risks of both thromboembolic and bleeding events, and due to fear of bleeding complications these AF patients are often denied OAC. Evidence shows, however, that the absolute benefits of OAC are the greatest in patients at the highest risk, and NOACs may offer even a greater net clinical benefit compared to warfarin particularly in these high risk patients. In this review article, we summarize available data on stroke prevention in AF patients at increased risk of both stroke and bleeding and discuss the use of NOACs for thromboprophylaxis in these 'special' AF populations.

Results from the Registry of Atrial Fibrillation (AFABE): Gap between Undiagnosed and Registered Atrial Fibrillation in Adults--Ineffectiveness of Oral Anticoagulation Treatment with VKA

Objective. This study aimed to examine the effectiveness of the use of oral anticoagulation (OAC) medication, recommended by national guidelines for stroke prevention but reportedly underused in AF patients with moderate to high stroke risk. Method. A multicentre and cross-sectional study of undiagnosed AF among out-of-hospital patients over 60 years old was carried out, visiting 3,638 patients at primary health centres or at home for AF diagnosis using the IDC-10 classification. The main outcome measures were CHA₂DS₂VAS_C, HAS-BLED scores, cardiovascular comorbidity, pharmacological information, TTR, and SAMe-TT2R2 scores. Results. The main findings were undiagnosed AF in 26.44% of cases; 31.04% registered with AF but not using OAC despite 95.6% having a CHA₂DS₂VAS_C ≥ 2 score; a risk of bleeding in important subgroups using OAC without indication (37.50% CHA₂DS₂VAS_C < 2 score); the use of OAC with TTR < 60% (33.1%), of whom 47.6% had a HAS-BLED score ≥3. Thus, 35.4% of the expected AF prevalence achieved an optimal time in the therapeutic range. Conclusions. The expected AF prevalence was 10.9% (n 5267), but the registered prevalence was 7.5% (n 3638). Only 35.04% (CI = 95%, 33.7–36.3) of AF patients treated with vitamin K antagonists (VKAs) achieve the goal of TTR > 60%.

Traumatic fatal cerebral hemorrhage in an old patient with a history of multiple sclerosis under dabigatran: a case report and review of the literature

One disadvantage of direct anticoagulant drug is the lack of an antidote, which may become relevant in patients with traumatic brain injury. A 77-years old man with atrial fibrillation and syncope received dabigatran despite recurrent falls. Due to a ground-level-fall, he suffered from subarachnoidal and intraparenchymal hemorrhages, subdural hematoma and brain edema with a midline shift. Despite osteoclastic trepanation and hematoma-evacuation he remained comatose and died seven days later without regaining consciousness. Most probably, decreased dabigatran clearance due to increased age might have contributed to the fatal course. We suggest withholding anticoagulant therapy in patients with unexplained falls. If anticoagulant therapy is deemed necessary, vitamin-K-antagonists with their potential for laboratory monitoring and reversal of anticoagulant activity should be preferred.