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Wang Y, Guo Y, Qin M, Fan J, Tang M, Zhang X, Wang H, Li X, Lip GYH. 2024 Chinese Expert Consensus Guidelines on the Diagnosis and Treatment of Atrial Fibrillation in the Elderly, Endorsed by Geriatric Society of Chinese Medical Association (Cardiovascular Group) and Chinese Society of Geriatric Health Medicine (Cardiovascular Branch): Executive Summary. Thromb Haemost 2024; 124:897-911. [PMID: 38744425 DOI: 10.1055/a-2325-5923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
The consensus guidelines of the Geriatric Society of Chinese Medical Association on the management of atrial fibrillation (AF) in the elderly was first published in 2011 and updated in 2016, with endorsement by Chinese Society of Geriatric Health Medicine. Since then, many important studies regarding the screening and treatment in the elderly population have been reported, necessitating this updated expert consensus guideline. The writing committee members comprehensively reviewed updated evidence pertaining to elderly patients with AF, and formulated this 2024 update. The highlighted issues focused on the following: screening for AF, geriatric comprehensive assessment, use of the Atrial fibrillation Better Care (ABC) pathway for the elderly patients, and special clinical settings related to elderly patients with AF. New recommendations addressing smart technology facilitated AF screening, ABC pathway based management, and optimal anticoagulation were developed, with a focus on the elderly.
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Affiliation(s)
- Yutang Wang
- Department of Cardiology, Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Yutao Guo
- Pulmonary Vessel and Thrombotic Disease, Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Mingzhao Qin
- Department of Geriatrics, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Jin Fan
- Department of Cardiology, Beijing Taikang Yanyuan Rehabilitation Hospital, Beijing, China
| | - Ming Tang
- Arrhythmia Center, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinjun Zhang
- Geriatric Center, West China Hospital, Sichuan University, Chengdu, China
| | - Hao Wang
- Department of Cardiology, Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Xiaoying Li
- Department of Cardiology, Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Aalborg, Denmark
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Lip GYH. Atrial Fibrillation and Stable Coronary Artery Disease. N Engl J Med 2024. [PMID: 39225269 DOI: 10.1056/nejme2409696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Affiliation(s)
- Gregory Y H Lip
- From the Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, and Liverpool Heart and Chest Hospital - all in Liverpool, United Kingdom
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Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM, De Potter TJR, Dwight J, Guasti L, Hanke T, Jaarsma T, Lettino M, Løchen ML, Lumbers RT, Maesen B, Mølgaard I, Rosano GMC, Sanders P, Schnabel RB, Suwalski P, Svennberg E, Tamargo J, Tica O, Traykov V, Tzeis S, Kotecha D. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024:ehae176. [PMID: 39210723 DOI: 10.1093/eurheartj/ehae176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Khalife R, Burnett AE, Tritschler T, Waldron B, Xu Y. Practical Prescribing: Direct oral anticoagulants. BMJ 2024; 386:e079520. [PMID: 39214564 DOI: 10.1136/bmj-2024-079520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Affiliation(s)
- Roy Khalife
- Department of Medicine (Hematology), The Ottawa Hospital, University of Ottawa, Ottawa, Canada
| | - Allison E Burnett
- University of New Mexico Hospital, UNM College of Pharmacy, Albuquerque, NM, USA
| | | | | | - Yan Xu
- Department of Medicine (Hematology), The Ottawa Hospital, University of Ottawa, Ottawa, Canada
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Harrison SL, Buckley BJR, Lane DA, Fazio-Eynullayeva E, Underhill P, Hill A, Werring DJ, Lip GYH. Antiplatelet Agents and Oral Anticoagulant Use in Patients with Atrial Fibrillation and Carotid Artery Disease After First-Time Ischaemic Stroke. Cardiovasc Drugs Ther 2024; 38:731-737. [PMID: 36692658 PMCID: PMC11266273 DOI: 10.1007/s10557-023-07433-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 01/25/2023]
Abstract
INTRODUCTION People with atrial fibrillation (AF) frequently have competing mechanisms for ischaemic stroke, including extracranial carotid atherosclerosis. The objective of this study was to determine associations between use of oral anticoagulants (OACs) plus antiplatelet agents (APA) after ischaemic stroke and outcomes for patients with AF and carotid artery disease. PATIENTS AND METHODS A retrospective cohort study was conducted. Participants receiving OACs with or without APA were propensity score-matched for age, sex, ethnicity, co-morbidities and presence of cardiac and vascular implants and grafts. Outcomes were 1-year mortality, recurrent stroke and major bleeding. RESULTS Of 5708 patients, 24.1% (n=1628) received non-vitamin K antagonist OACs (NOACs) with no APA, 26.0% (n=1401) received NOACs plus APA, 20.7% (n=1243) received warfarin without APA and 29.2% (n=1436) received warfarin plus APA. There was no significant difference in risk of recurrent stroke between the groups. Compared to receiving NOACs without APA, receiving warfarin plus APA was associated with a higher risk of mortality (hazard ratio (HR) 1.51 (95% confidence interval (CI) 1.20, 1.89)) and major bleeding (HR 1.66 (95% CI 1.40, 1.96)). Receiving NOACs plus APA was also associated with a higher risk of major bleeding compared to NOACs without APA (HR 1.27 (95% CI 1.07, 1.51), respectively). CONCLUSIONS The results suggest for patients with AF and carotid artery disease after ischaemic stroke, receiving NOACs without APA is associated with a lower risk of major bleeding with no negative impact on recurrent stroke or mortality. Evidence from randomised trials is needed to confirm this finding.
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Affiliation(s)
- Stephanie L Harrison
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, William Henry Duncan Building, L7 8TX, Liverpool, UK.
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
| | - Benjamin J R Buckley
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, William Henry Duncan Building, L7 8TX, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, William Henry Duncan Building, L7 8TX, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | | | - Andrew Hill
- Department of Medicine for Older People, Whiston Hospital, St Helens & Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, William Henry Duncan Building, L7 8TX, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Liao JN, Chan YH, Kuo L, Tsai CT, Liu CM, Chen TJ, Lip GYH, Chen SA, Chao TF. Association between antithrombotic drug regimen changes and clinical outcomes after stroke in atrial fibrillation. Heart Rhythm 2024:S1547-5271(24)03094-7. [PMID: 39094727 DOI: 10.1016/j.hrthm.2024.07.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 07/22/2024] [Accepted: 07/27/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND The impact of post-stroke antithrombotic regimen in atrial fibrillation is uncertain. OBJECTIVE This study aimed to describe antithrombotic therapy prescribing patterns after ischemic stroke and the impact on outcomes. METHODS A total of 23,165 patients with atrial fibrillation experiencing ischemic stroke were identified. Subsequent post-stroke events included recurrent ischemic stroke, intracranial hemorrhage, major bleeding, mortality, and composite outcomes. RESULTS Of those who were nonanticoagulated before a stroke, 33.5% remained nonanticoagulated and 39.2% were prescribed only antiplatelet agents (APs) after a stroke. Compared with non-vitamin K antagonist oral anticoagulants (NOACs) after stroke, there was a significant increase in ischemic stroke and mortality in nonanticoagulated patients (adjusted hazard ratio [aHR], 2.09 and 3.92) and AP users (aHR, 1.32 and 1.28). Post-stroke warfarin was associated with a significantly increased risk of major bleeding compared with NOACs (aHR, 1.23). Of 769 patients receiving NOACs before stroke and continuing NOACs after stroke, those switching to a different NOAC were associated with significantly higher risk of ischemic stroke (aHR, 2.07) and composite outcomes (aHR, 1.36-1.85) with no difference in intracranial hemorrhage, major bleeding, or mortality compared with those receiving the same NOAC after stroke. Of patients receiving NOACs before stroke, the risks of clinical events were similar between patients taking NOACs alone and those taking NOAC plus AP after stroke. CONCLUSION NOAC alone after stroke was associated with a better clinical outcome compared with nonanticoagulation, AP, or warfarin. Of patients already taking NOACs before stroke, the addition of AP did not confer additional benefits compared with NOACs alone. A change of NOAC types after stroke was associated with a 2-fold higher risk of ischemic stroke and composite outcomes.
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Affiliation(s)
- Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsin Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Ling Kuo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chuan-Tsai Tsai
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chih-Min Liu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan; Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - 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 Chiao Tung University, Taipei, Taiwan.
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Ferguson C, Shaikh F, Allida SM, Hendriks J, Gallagher C, Bajorek BV, Donkor A, Inglis SC. Clinical service organisation for adults with atrial fibrillation. Cochrane Database Syst Rev 2024; 7:CD013408. [PMID: 39072702 PMCID: PMC11285297 DOI: 10.1002/14651858.cd013408.pub2] [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] [Indexed: 07/30/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) is an increasingly prevalent heart rhythm condition in adults. It is considered a common cardiovascular condition with complex clinical management. The increasing prevalence and complexity in management underpin the need to adapt and innovate in the delivery of care for people living with AF. There is a need to systematically examine the optimal way in which clinical services are organised to deliver evidence-based care for people with AF. Recommended approaches include collaborative, organised multidisciplinary, and virtual (or eHealth/mHealth) models of care. OBJECTIVES To assess the effects of clinical service organisation for AF versus usual care for people with all types of AF. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL to October 2022. We also searched ClinicalTrials.gov and the WHO ICTRP to April 2023. We applied no restrictions on date, publication status, or language. SELECTION CRITERIA We included randomised controlled trials (RCTs), published as full texts and as abstract only, involving adults (≥ 18 years) with a diagnosis of any type of AF. We included RCTs comparing organised clinical service, disease-specific management interventions (including e-health models of care) for people with AF that were multicomponent and multidisciplinary in nature to usual care. DATA COLLECTION AND ANALYSIS Three review authors independently selected studies, assessed risk of bias, and extracted data from the included studies. We calculated risk ratio (RR) for dichotomous data and mean difference (MD) or standardised mean difference (SMD) for continuous data with 95% confidence intervals (CIs) using random-effects analyses. We then calculated the number needed to treat for an additional beneficial outcome (NNTB) using the RR. We performed sensitivity analyses by only including studies with a low risk of selection and attrition bias. We assessed heterogeneity using the I² statistic and the certainty of the evidence according to GRADE. The primary outcomes were all-cause mortality and all-cause hospitalisation. The secondary outcomes were cardiovascular mortality, cardiovascular hospitalisation, AF-related emergency department visits, thromboembolic complications, minor cerebrovascular bleeding events, major cerebrovascular bleeding events, all bleeding events, AF-related quality of life, AF symptom burden, cost of intervention, and length of hospital stay. MAIN RESULTS We included 8 studies (8205 participants) of collaborative, multidisciplinary care, or virtual care for people with AF. The average age of participants ranged from 60 to 73 years. The studies were conducted in China, the Netherlands, and Australia. The included studies involved either a nurse-led multidisciplinary approach (n = 4) or management using mHealth (n = 2) compared to usual care. Only six out of the eight included studies could be included in the meta-analysis (for all-cause mortality and all-cause hospitalisation, cardiovascular mortality, cardiovascular hospitalisation, thromboembolic complications, and major bleeding), as quality of life was not assessed using a validated outcome measure specific for AF. We assessed the overall risk of bias as high, as all studies had at least one domain at unclear or high risk of bias rating for performance bias (blinding) in particular. Organised AF clinical services probably result in a large reduction in all-cause mortality (RR 0.64, 95% CI 0.46 to 0.89; 5 studies, 4664 participants; moderate certainty evidence; 6-year NNTB 37) compared to usual care. However, organised AF clinical services probably make little to no difference to all-cause hospitalisation (RR 0.94, 95% CI 0.88 to 1.02; 2 studies, 1340 participants; moderate certainty evidence; 2-year NNTB 101) and may not reduce cardiovascular mortality (RR 0.64, 95% CI 0.35 to 1.19; 5 studies, 4564 participants; low certainty evidence; 6-year NNTB 86) compared to usual care. Organised AF clinical services reduce cardiovascular hospitalisation (RR 0.83, 95% CI 0.71 to 0.96; 3 studies, 3641 participants; high certainty evidence; 6-year NNTB 28) compared to usual care. Organised AF clinical services may have little to no effect on thromboembolic complications such as stroke (RR 1.14, 95% CI 0.74 to 1.77; 5 studies, 4653 participants; low certainty evidence; 6-year NNTB 588) and major cerebrovascular bleeding events (RR 1.25, 95% CI 0.79 to 1.97; 3 studies, 2964 participants; low certainty evidence; 6-year NNTB 556). None of the studies reported minor cerebrovascular events. AUTHORS' CONCLUSIONS Moderate certainty evidence shows that organisation of clinical services for AF likely results in a large reduction in all-cause mortality, but probably makes little to no difference to all-cause hospitalisation compared to usual care. Organised AF clinical services may not reduce cardiovascular mortality, but do reduce cardiovascular hospitalisation compared to usual care. However, organised AF clinical services may make little to no difference to thromboembolic complications and major cerebrovascular events. None of the studies reported minor cerebrovascular events. Due to the limited number of studies, more research is required to compare different models of care organisation, including utilisation of mHealth. Appropriately powered trials are needed to confirm these findings and robustly examine the effect on inconclusive outcomes. The findings of this review underscore the importance of the co-ordination of care underpinned by collaborative multidisciplinary approaches and augmented by virtual care.
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Affiliation(s)
- Caleb Ferguson
- Centre for Chronic & Complex Care Research, Western Sydney Local Health District, Sydney, Australia
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Fahad Shaikh
- Centre for Chronic & Complex Care Research, Western Sydney Local Health District, Sydney, Australia
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Sabine M Allida
- Centre for Chronic & Complex Care Research, Western Sydney Local Health District, Sydney, Australia
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Jeroen Hendriks
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health and Medical Research Institute and Royal Adelaide Hospital, Adelaide, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health and Medical Research Institute and Royal Adelaide Hospital, Adelaide, Australia
| | - Beata V Bajorek
- Heart and Brain Program, Hunter Medical Research Institute, Newcastle, Australia
- College of Health, Medicine, and Wellbeing, University of Newcastle, Newcastle, Australia
- Department of Pharmacy, Hunter New England Local Health District, Newcastle, Australia
| | - Andrew Donkor
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Sally C Inglis
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia
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Soler-Espejo E, Rivera-Caravaca JM. Navigating the bleeding risk dilemma in patients with atrial fibrillation on therapy with direct-acting oral anticoagulants: Comparing the HAS-BLED vs. DOAC Score. Eur J Intern Med 2024:S0953-6205(24)00328-5. [PMID: 39068124 DOI: 10.1016/j.ejim.2024.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Accepted: 07/23/2024] [Indexed: 07/30/2024]
Affiliation(s)
- Eva Soler-Espejo
- Department of Hematology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - José Miguel Rivera-Caravaca
- Faculty of Nursing, University of Murcia, Murcia, Spain; Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain; Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
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Mei DA, Imberti JF, Bonini N, Romiti GF, Corica B, Proietti M, Vitolo M, Lip GYH, Boriani G. Performance of HAS-BLED and DOAC scores to predict major bleeding events in atrial fibrillation patients treated with direct oral anticoagulants: A report from a prospective European observational registry. Eur J Intern Med 2024:S0953-6205(24)00277-2. [PMID: 38969571 DOI: 10.1016/j.ejim.2024.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 06/17/2024] [Accepted: 06/25/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND The DOAC score has been recently proposed for bleeding risk stratification of patients with atrial fibrillation treated with direct oral anticoagulants (DOAC). OBJECTIVE To compare the performance of HAS-BLED and DOAC score in predicting major bleeding events in a contemporary cohort of European AF patients treated with DOAC. METHODS We included patients derived from a prospective observational registry of European AF patients. HAS-BLED and DOAC scores were calculated as per the original schemes. Our primary endpoint was major bleeding events. Receiver operating characteristic (ROC) curves were used to compare the predictive ability of the scores. RESULTS A total of 2834 AF patients (median age [IQR] 69 [62-77] years; 39.6 % female) treated with DOAC were included in the analysis. According to the HAS-BLED score, 577 patients (20.4 %) were categorized as very low risk of bleeding, as compared to 1276 (45.0 %) according to DOAC score. A total of 55 major bleeding events occurred with an overall incidence of 1.04 per 100 patient-years. Both scores showed only a modest ability for the prediction of bleeding events (HAS-BLED area under the curve [AUC], 0.65, 95 % confidence interval [CI] 0.55-0.70; DOAC score AUC 0.62, 95 % CI 0.59-0.71, p for difference = 0.332]. At calibration analysis, the DOAC score showed modest calibration, especially for patients at high risk, when compared to HAS-BLED. CONCLUSION In a contemporary cohort of DOAC-treated AF patients, both HAS-BLED and DOAC scores only modestly predicted the occurrence of major bleeding events. Our results do not support the preferential use of DOAC score over HAS-BLED.
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Affiliation(s)
- Davide Antonio Mei
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, Modena, Modena 41121, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Jacopo Francesco Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, Modena, Modena 41121, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Niccolò Bonini
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, Modena, Modena 41121, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Translational and Precision Medicine, Sapienza - University of Rome, Italy
| | - Bernadette Corica
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, Modena, Modena 41121, Italy; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milani, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, Modena, Modena 41121, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, Modena, Modena 41121, Italy.
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Tsai CT, Chan YH, Liao JN, Chen TJ, Lip GYH, Chen SA, Chao TF. The optimal antithrombotic strategy for post-stroke patients with atrial fibrillation and extracranial artery stenosis-a nationwide cohort study. BMC Med 2024; 22:113. [PMID: 38475752 DOI: 10.1186/s12916-024-03338-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 03/05/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND In post-stroke atrial fibrillation (AF) patients who have indications for both oral anticoagulant (OAC) and antiplatelet agent (AP), e.g., those with carotid artery stenosis, there is debate over the best antithrombotic strategy. We aimed to compare the risks of ischemic stroke, composite of ischemic stroke/major bleeding and composite of ischemic stroke/intracranial hemorrhage (ICH) between different antithrombotic strategies. METHODS This study included post-stroke AF patients with and without extracranial artery stenosis (ECAS) (n = 6390 and 28,093, respectively) identified from the Taiwan National Health Insurance Research Database. Risks of clinical outcomes and net clinical benefit (NCB) with different antithrombotic strategies were compared to AP alone. RESULTS The risk of recurrent ischemic stroke was higher for patients with ECAS than those without (12.72%/yr versus 10.60/yr; adjusted hazard ratio [aHR] 1.104, 95% confidence interval [CI] 1.052-1.158, p < 0.001). For patients with ECAS, when compared to AP only, non-vitamin K antagonist oral anticoagulant (NOAC) monotherapy was associated with lower risks for ischaemic stroke (aHR 0.551, 95% CI 0.454-0.669), the composite of ischaemic stroke/major bleeding (aHR 0.626, 95% CI 0.529-0.741) and the composite of ischaemic stroke/ICH (aHR 0.577, 95% CI 0.478-0.697), with non-significant difference for major bleeding and ICH. When compared to AP only, warfarin monotherapy was associated with higher risks of major bleeding (aHR 1.521, 95% CI 1.231-1.880), ICH (aHR 2.045, 95% CI 1.329-3.148), and the composite of ischaemic stroke and major bleeding. With combination of AP plus warfarin, there was an increase in ischaemic stroke, major bleeding, and the composite outcomes, when compared to AP only. NOAC monotherapy was the only approach associated with a positive NCB, while all other options (warfarin, combination of AP-OAC) were associated with negative NCB. CONCLUSIONS For post-stroke AF patients with ECAS, NOAC monotherapy was associated with lower risks of adverse outcomes and a positive NCB. Combination of AP with NOAC or warfarin did not offer any benefit, but more bleeding especially with AP-warfarin combination therapy.
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Affiliation(s)
- Chuan-Tsai Tsai
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Shih-Ann Chen
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan.
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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11
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Serna MJ, Rivera-Caravaca JM, López-Gálvez R, Soler-Espejo E, Lip GYH, Marín F, Roldán V. Dynamic assessment of CHA 2DS 2-VASc and HAS-BLED scores for predicting ischemic stroke and major bleeding in atrial fibrillation patients. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024:S1885-5857(24)00076-8. [PMID: 38460882 DOI: 10.1016/j.rec.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 02/20/2024] [Indexed: 03/11/2024]
Abstract
INTRODUCTION AND OBJECTIVES Stroke and bleeding risks in atrial fibrillation (AF) are often assessed at baseline to predict outcomes years later. We investigated whether dynamic changes in CHA2DS2-VASc and HAS-BLED scores over time modify risk prediction. METHODS We included patients with AF who were stable while taking vitamin K antagonists. During a 6-year follow-up, all ischemic strokes/transient ischemic attacks (TIAs) and major bleeding events were recorded. CHA2DS2-VASc and HAS-BLED were recalculated every 2-years and tested for clinical outcomes at 2-year periods. RESULTS We included 1361 patients (mean CHA2DS2-VASc and HAS-BLED 4.0±1.7 and 2.9±1.2). During the follow-up, 156 (11.5%) patients had an ischemic stroke/TIA and 269 (19.8%) had a major bleeding event. Compared with the baseline CHA2DS2-VASc, the CHA2DS2-VASc recalculated at 2 years had higher predictive ability for ischemic stroke/TIA during the period from 2 to 4 years. Integrated discrimination improvement (IDI) and net reclassification improvement (NRI) showed improvements in sensitivity and better reclassification. The CHA2DS2-VASc recalculated at 4 years had better predictive performance than the baseline CHA2DS2-VASc during the period from 4 to 6 years, with an improvement in IDI and an enhancement of the reclassification. The recalculated HAS-BLED at 2-years had higher predictive ability than the baseline score for major bleeding during the period from 2 to 4 years, with significant improvements in sensitivity and reclassification. A slight enhancement in sensitivity was observed with the HAS-BLED score recalculated at 4 years compared with the baseline score. CONCLUSIONS In AF patients, stroke and bleeding risks are dynamic and change over time. The CHA2DS2-VASc and HAS-BLED scores should be regularly reassessed, particularly for accurate stroke risk prediction.
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Affiliation(s)
- María José Serna
- Servicio de Hematología y Oncología Médica, Hospital General Universitario Morales Meseguer, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - José Miguel Rivera-Caravaca
- Facultad de Enfermería, Universidad de Murcia, Murcia, Spain; Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), El Palmar, Murcia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
| | - Raquel López-Gálvez
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), El Palmar, Murcia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Eva Soler-Espejo
- Servicio de Hematología y Oncología Médica, Hospital General Universitario Morales Meseguer, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Denmark
| | - Francisco Marín
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), El Palmar, Murcia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Vanessa Roldán
- Servicio de Hematología y Oncología Médica, Hospital General Universitario Morales Meseguer, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
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12
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Varma N, Han JK, Passman R, Rosman LA, Ghanbari H, Noseworthy P, Avari Silva JN, Deshmukh A, Sanders P, Hindricks G, Lip G, Sridhar AR. Promises and Perils of Consumer Mobile Technologies in Cardiovascular Care: JACC Scientific Statement. J Am Coll Cardiol 2024; 83:611-631. [PMID: 38296406 DOI: 10.1016/j.jacc.2023.11.024] [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: 11/01/2023] [Accepted: 11/16/2023] [Indexed: 02/08/2024]
Abstract
Direct-to-consumer (D2C) wearables are becoming increasingly popular in cardiovascular health management because of their affordability and capability to capture diverse health data. Wearables may enable continuous health care provider-patient partnerships and reduce the volume of episodic clinic-based care (thereby reducing health care costs). However, challenges arise from the unregulated use of these devices, including questionable data reliability, potential misinterpretation of information, unintended psychological impacts, and an influx of clinically nonactionable data that may overburden the health care system. Further, these technologies could exacerbate, rather than mitigate, health disparities. Experience with wearables in atrial fibrillation underscores these challenges. The prevalent use of D2C wearables necessitates a collaborative approach among stakeholders to ensure effective integration into cardiovascular care. Wearables are heralding innovative disease screening, diagnosis, and management paradigms, expanding therapeutic avenues, and anchoring personalized medicine.
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Affiliation(s)
- Niraj Varma
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.
| | - Janet K Han
- Department of Cardiology, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA; Department of Cardiology, David Geffen School of Medicine at the University of California-Los Angeles, Los Angeles, California, USA
| | - Rod Passman
- Department of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lindsey Anne Rosman
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Hamid Ghanbari
- Department of Cardiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Peter Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Abhishek Deshmukh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Prashanthan Sanders
- Department of Cardiology, University of Adelaide, South Australia, Australia
| | | | - Gregory Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | - Arun R Sridhar
- Department of Cardiology, Pulse Heart Institute, Seattle, Washington, USA; Department of Clinical Medicine, Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
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13
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Chao TF, Potpara TS, Lip GY. Atrial fibrillation: stroke prevention. THE LANCET REGIONAL HEALTH. EUROPE 2024; 37:100797. [PMID: 38362551 PMCID: PMC10867001 DOI: 10.1016/j.lanepe.2023.100797] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 11/11/2023] [Accepted: 11/15/2023] [Indexed: 02/17/2024]
Abstract
Stroke prevention is central to the management of patients with atrial fibrillation (AF) which has moved towards a more holistic or integrative care approach. The published evidence suggests that management of AF patients following such a holistic approach based on the Atrial fibrillation Better Care (ABC) pathway is associated with a lower risk of stroke and adverse events. Risk assessment, re-assessment and use of direct oral anticoagulants (DOACs) are important for stroke prevention in AF. The stroke and bleeding risks of AF patients are not static and should be re-assessed regularly. Bleeding risk assessment is to address and mitigate modifiable bleeding risk factors, and to identify high bleeding risk patients for early review and follow-up. Well-controlled comorbidities and healthy lifestyles also play an important role to achieve a better clinical outcome. Digital health solutions are increasingly relevant in the diagnosis and management of patients with AF, with the potential to improve stroke prevention. In this review, we provide an update on stroke prevention in AF, including importance of holistic management, risk assessment/re-assessment, and stroke prevention for special AF populations. Evidence-based and structured management of AF patients would reduce the risk of stroke and other adverse events.
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Affiliation(s)
- 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 Chiao Tung University, Taipei, Taiwan
| | - Tatjana S. Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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14
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Linz D, Gawalko M, Betz K, Hendriks JM, Lip GY, Vinter N, Guo Y, Johnsen S. Atrial fibrillation: epidemiology, screening and digital health. THE LANCET REGIONAL HEALTH. EUROPE 2024; 37:100786. [PMID: 38362546 PMCID: PMC10866942 DOI: 10.1016/j.lanepe.2023.100786] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/12/2023] [Accepted: 11/02/2023] [Indexed: 02/17/2024]
Abstract
Atrial fibrillation (AF) is highly prevalent with a lifetime risk of about 1 in 3-5 individuals after the age of 45 years. Between 2010 and 2019, the global prevalence of AF has risen markedly from 33.5 million to 59 million individuals living with AF. Early detection of AF and implementation of appropriate treatment could reduce the frequency of complications associated with AF. International AF management guidelines recommend opportunistic and systematic screening for AF, but additional data are needed. Digital approaches and pathways have been proposed for early detection and for the transition to early AF management. Mobile health (mHealth) devices provide an opportunity for digital screening and should be part of novel models of care delivery based on integrated AF care pathways. For a broad implementation of mHealth-based, integrated care for patients with chronic diseases as AF, further high quality evidence is necessary. In this review, we present an overview of the present data on epidemiology, screening techniques, and the contribution of digital health solutions to the integrated management of AF. We also provide a systemic review on current data of digital and integrated AF management.
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Affiliation(s)
- Dominik Linz
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Monika Gawalko
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
- Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Konstanze Betz
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
- Department of Internal Medicine, Eifelklinik St. Brigida, Simmerath, Germany
| | - Jeroen M. Hendriks
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Nicklas Vinter
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Yutao Guo
- Six Medical Center, Department of Pulmonary Vessel and Thrombotic Disease, Chinese PLA General Hospital, Beijing, China
| | - Søren Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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15
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Zhang H, Jin Z, Wang H, Guo Y, Lip GYH. Structured Rehabilitation for Patients with Atrial Fibrillation Based on an Integrated Care Approach: Protocol for a Prospective, Observational Cohort Study. Vasc Health Risk Manag 2023; 19:485-494. [PMID: 37547280 PMCID: PMC10402885 DOI: 10.2147/vhrm.s407974] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 07/27/2023] [Indexed: 08/08/2023] Open
Abstract
Background Guideline-recommended integrated care based on the ABC (Atrial fibrillation Better Care) pathway for "general" patients with atrial fibrillation (AF) improves clinical outcomes, as demonstrated in our prior mobile Atrial Fibrillation Application (mAFA)-II cluster randomized trial. The present study aims to investigate whether mAFA III-supported structured follow-up rehabilitation packages adapted to patient risk profiles and different treatment patterns (eg, for patients receiving drug treatment only, AF ablation, or left atrial appendage occlusion [LAAO]) will improve guideline adherence and reduce the risk of adverse cardiovascular events. Methods and Analysis In this prospective, observational mAFA III pilot cohort study, patients with AF aged ≥ 18 years will be enrolled using the mAFA III App for self-management. Assuming an annual rate of composite outcome of "ischaemic stroke or systemic embolism, all-cause death and cardiovascular hospitalization" of 29.3% for non-ABC pathway compliance compared with 20.8% for ABC pathway compliance, at least 1475 patients would be needed to detect the outcome of the A, B and C components of the ABC pathway, assuming a withdrawal rate of 20% in the first year. The primary endpoint is adherence to guidelines regarding the A, B and C components of the ABC pathway. Ancillary analyses will be performed to determine the impact of the ABC pathway using smart technologies on the outcomes among the "high-risk" population (eg, ≥75 years old, with multimorbidities, with polypharmacy) and the application of artificial intelligence machine-learning AF risk prediction management in assessing AF recurrence. The individualised anticoagulants with AF burden will be monitored by smart devices. Trial Registration Number ISRCTN13724416.
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Affiliation(s)
- Hui Zhang
- Medical School of Chinese PLA, Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Center, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Zhigeng Jin
- Medical School of Chinese PLA, Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Center, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Hao Wang
- Department of Cardiology, Second Medical Centre, National Clinical Research Centre for Geriatric Diseases, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Yutao Guo
- Medical School of Chinese PLA, Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Center, Chinese PLA General Hospital, Beijing, People’s Republic of China
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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16
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Piazza G, Hurwitz S, Campia U, Bikdeli B, Lou J, Khairani CD, Bejjani A, Snyder JE, Pfeferman M, Barns B, Rizzo S, Glezer A, Goldhaber SZ. Electronic alerts for ambulatory patients with atrial fibrillation not prescribed anticoagulation: A randomized, controlled trial (AF-ALERT2). Thromb Res 2023; 227:1-7. [PMID: 37182298 DOI: 10.1016/j.thromres.2023.05.006] [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: 04/06/2023] [Revised: 05/01/2023] [Accepted: 05/05/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Despite widely available risk stratification tools, safe and effective anticoagulants, and guideline recommendations, anticoagulation for stroke prevention in atrial fibrillation (AF) is under-prescribed in ambulatory patients. To assess the impact of alert-based computerized decision support (CDS) on anticoagulation prescription in ambulatory patients with AF and high-risk for stroke, we conducted this randomized controlled trial. METHODS Patients with AF and CHA2DS2-VASc score ≥ 2 who were not prescribed anticoagulation and had a clinic visit at Brigham and Women's Hospital were enrolled. Patients were randomly allocated, according to Attending Physician of record, to intervention (alert-based CDS) versus control (no notification). The primary efficacy outcome was the frequency of anticoagulant prescription. RESULTS The CDS tool assigned 395 and 403 patients to the alert and control groups, respectively. Alert patients were more likely to be prescribed anticoagulation within 48 h of the clinic visit (15.4 % vs. 7.7 %, p < 0.001) and at 90 days (17.2 % vs. 9.9 %, p < 0.01). Direct oral anticoagulants were the predominantly prescribed form of anticoagulation. No significant differences were observed in stroke, TIA, or systemic embolic events (0 % vs. 0.8 %, p = 0.09), symptomatic VTE (0.5 % vs. 1 %, p = 0.43), all-cause mortality (2 % vs. 0.7 %, p = 0.12), or major adverse cardiovascular events (2.8 % vs. 2.5 %, p = 0.79) at 90 days. CONCLUSIONS An alert-based CDS strategy increased a primary efficacy outcome of anticoagulation in clinic patients with AF and high-risk for stroke who were not receiving anticoagulation at the time of the office visit. The study was likely underpowered to assess an impact on clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier- NCT02958943.
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Affiliation(s)
- Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Shelley Hurwitz
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Umberto Campia
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Behnood Bikdeli
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Yale New Haven Hospital (YNHH), Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - Junyang Lou
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Candrika D Khairani
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Antoine Bejjani
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Julia E Snyder
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mariana Pfeferman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Briana Barns
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samantha Rizzo
- Georgetown University School of Medicine, Washington, DC, USA
| | - Alexandra Glezer
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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17
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Leiner J, König S, Mouratis K, Kim I, Schmitz P, Joshi T, Schanner C, Wohlrab L, Hohenstein S, Pellissier V, Nitsche A, Kuhlen R, Hindricks G, Bollmann A. A Digital Infrastructure for Cardiovascular Patient Care Based on Mobile Health Data and Patient-Reported Outcomes: Concept Details of the Helios TeleWear Project Including Preliminary Experiences. JMIR Form Res 2023; 7:e41115. [PMID: 36867450 PMCID: PMC10029859 DOI: 10.2196/41115] [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: 07/18/2022] [Revised: 12/02/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Mobile health (mHealth) approaches are already having a fundamental impact on clinical practice in cardiovascular medicine. A variety of different health apps and wearable devices for capturing health data such as electrocardiograms (ECGs) exist. However, most mHealth technologies focus on distinct variables without integrating patients' quality of life, and the impact on clinical outcome measures of implementing those digital solutions into cardiovascular health care is still to be determined. OBJECTIVE Within this document, we describe the TeleWear project, which was recently initiated as an approach for contemporary patient management integrating mobile-collected health data and the standardized mHealth-guided measurement of patient-reported outcomes (PROs) in patients with cardiovascular disease. METHODS The specifically designed mobile app and clinical frontend form the central elements of our TeleWear infrastructure. Because of its flexible framework, the platform allows far-reaching customization with the possibility to add different mHealth data sources and respective questionnaires (patient-reported outcome measures). RESULTS With initial focus on patients with cardiac arrhythmias, a feasibility study is currently carried out to assess wearable-recorded ECG and PRO transmission and its evaluation by physicians using the TeleWear app and clinical frontend. First experiences made during the feasibility study yielded positive results and confirmed the platform's functionality and usability. CONCLUSIONS TeleWear represents a unique mHealth approach comprising PRO and mHealth data capturing. With the currently running TeleWear feasibility study, we aim to test and further develop the platform in a real-world setting. A randomized controlled trial including patients with atrial fibrillation that investigates PRO- and ECG-based clinical management based on the established TeleWear infrastructure will evaluate its clinical benefits. Widening the spectrum of health data collection and interpretation beyond the ECG and use of the TeleWear infrastructure in different patient subcohorts with focus on cardiovascular diseases are further milestones of the project with the ultimate goal to establish a comprehensive telemedical center entrenched by mHealth.
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Affiliation(s)
- Johannes Leiner
- Department of Electrophysiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
- Real World Evidence and Health Technology Assessment, Helios Health Institute, Berlin, Germany
| | - Sebastian König
- Department of Electrophysiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
- Real World Evidence and Health Technology Assessment, Helios Health Institute, Berlin, Germany
| | - Konstantinos Mouratis
- Real World Evidence and Health Technology Assessment, Helios Health Institute, Berlin, Germany
| | - Igor Kim
- Real World Evidence and Health Technology Assessment, Helios Health Institute, Berlin, Germany
| | - Pia Schmitz
- Real World Evidence and Health Technology Assessment, Helios Health Institute, Berlin, Germany
| | - Tanvi Joshi
- Real World Evidence and Health Technology Assessment, Helios Health Institute, Berlin, Germany
| | - Carolin Schanner
- Real World Evidence and Health Technology Assessment, Helios Health Institute, Berlin, Germany
| | - Lisa Wohlrab
- Real World Evidence and Health Technology Assessment, Helios Health Institute, Berlin, Germany
| | - Sven Hohenstein
- Real World Evidence and Health Technology Assessment, Helios Health Institute, Berlin, Germany
| | - Vincent Pellissier
- Real World Evidence and Health Technology Assessment, Helios Health Institute, Berlin, Germany
| | - Anne Nitsche
- Real World Evidence and Health Technology Assessment, Helios Health Institute, Berlin, Germany
| | - Ralf Kuhlen
- Helios Health GmbH, Berlin, Germany
- Helios Health Institute, Berlin, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Andreas Bollmann
- Department of Electrophysiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
- Real World Evidence and Health Technology Assessment, Helios Health Institute, Berlin, Germany
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18
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Syed T, Patel NR. How can atrial fibrillation be detected and treated effectively? TRENDS IN UROLOGY & MEN'S HEALTH 2023. [DOI: 10.1002/tre.898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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19
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Esteve-Pastor MA, Rivera-Caravaca JM, Roldán V, Sanmartin Fernández M, Arribas F, Masjuan J, Barrios V, Cosin-Sales J, Freixa-Pamias R, Recalde E, Pérez-Cabeza AI, Manuel Vázquez Rodríguez J, Ràfols Priu C, Anguita Sánchez M, Lip GYH, Marin F. Predicting performance of the HAS-BLED and ORBIT bleeding risk scores in patients with atrial fibrillation treated with Rivaroxaban: Observations from the prospective EMIR Registry. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 9:38-46. [PMID: 36318457 DOI: 10.1093/ehjcvp/pvac060] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/22/2022] [Accepted: 10/28/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Assessing bleeding risk during the decision-making process of starting oral anticoagulation (OAC) therapy in atrial fibrillation (AF) patients is essential. Several bleeding risk scores have been proposed for vitamin K antagonist users but, few studies have focused on validation of these bleeding risk scores in patients taking direct oral anticoagulants (DOACs). The aim was to compare the predictive ability of HAS-BLED and ORBIT bleeding risk scores in AF patients taking rivaroxaban in the EMIR ('Estudio observacional para la identificación de los factores de riesgo asociados a eventos cardiovasculares mayores en pacientes con fibrilación auricular no valvular tratados con un anticoagulante oral directo [Rivaroxaban]) Study. METHODS AND RESULTS EMIR Study was an observational, multicenter, post-authorization, and prospective study that involved AF patients under OAC with rivaroxaban at least 6 months before enrolment. We analysed baseline clinical characteristics and adverse events after 2.5 years of follow-up and validated the predictive ability of HAS-BLED and ORBIT scores for major bleeding (MB) events.We analysed 1433 patients with mean age of 74.2 ± 9.7 (44.5% female). Mean HAS-BLED score was 1.6 ± 1.0 and ORBIT score was 1.1 ± 1.2. The ORBIT score categorised a higher proportion of patients as 'low-risk' (87.1%) compared with 53.5% using the HAS-BLED score. There were 33 MB events (1.04%/year) and 87 patients died (2.73%/year). Both HAS-BLED and ORBIT had a good predictive ability for MB{Area under the curve (AUC) 0.770, [95% confidence interval (CI) 0.693-0.847; P <0.001] and AUC 0.765 (95% CI 0.672-0.858; P <0.001), respectively}. There was a non-significant difference for discriminative ability of the two tested scores (P = 0.930) and risk reclassification in terms of net reclassification improvement (NRI) -5.7 (95% CI -42.4-31.1; P = 0.762). HAS-BLED score showed the best calibration and ORBIT score showed the largest mismatch in calibration, particularly in higher predicted risk patients. CONCLUSION In a prospective real-world AF population under rivaroxaban from EMIR registry, the HAS-BLED score had good predictive performance and calibration compared with ORBIT score for MB events. ORBIT score presented worse calibration than HAS-BLED in this DOAC treated population.
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Affiliation(s)
- María A Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain
| | - José M Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, IMIB-Arrixaca, 30008 Murcia, Spain
| | | | - Fernando Arribas
- Department of Cardiology, Hospital Universitario 12 de Octubre; Department of Medicine, Facultad de Medicina, Universidad Complutense de Madrid (UCM); Instituto de Investigacion Sanitaria Hospital 12 de Octubre (IMAS 12); CIBERCV, 28041 Madrid, Spain
| | - Jaime Masjuan
- Department of Neurology, University Hospital Ramón y Cajal, Madrid. Alcalá University, 28034 Madrid, Spain
| | - Vivencio Barrios
- Department of Cardiology, University Hospital Ramón y Cajal, Madrid. Alcalá University, 28034 Madrid, Spain
| | - Juan Cosin-Sales
- Department of Cardiology, Hospital Arnau de Vilanova, 46015 Valencia, Spain
| | | | - Esther Recalde
- Department of Cardiology, Hospital Universitario de Basurto, 48013 Bilbao, Spain
| | - Alejandro I Pérez-Cabeza
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, CIBERCV, 29010 Málaga, Spain
| | | | | | - Manuel Anguita Sánchez
- Department of Cardiology, Hospital Reina Sofía Córdoba, IMIBIC, University of Cordoba, 14004 Córdoba, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, L69 7TX Liverpool, UK.,Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark
| | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain
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20
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Pastori D, Marang A, Bisson A, Herbert J, Lip GYH, Fauchier L. Performance of the HAS-BLED, ORBIT, and ATRIA Bleeding Risk Scores on a Cohort of 399 344 Hospitalized Patients With Atrial Fibrillation and Cancer: Data From the French National Hospital Discharge Database. J Am Heart Assoc 2022; 11:e026388. [PMID: 36444864 PMCID: PMC9851457 DOI: 10.1161/jaha.121.026388] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background The association between cancer types and specific bleeding events in patients with atrial fibrillation has been scarcely investigated. Also, the performance of bleeding risk scores in this high-risk subgroup of patients is unclear. We investigated the rate of any bleeding, intracranial hemorrhage, major bleeding, and gastrointestinal bleeding according to cancer types in patients with atrial fibrillation. We also tested the predictive value of HAS-BLED, ATRIA, and ORBIT bleeding risk scores. Methods and Results Observational retrospective cohort study including hospitalized patients with atrial fibrillation and cancer from the French National Hospital Discharge Database (Programme de Medicalisation des Systemes d'Information) from January 2010 to December 2019. Major bleeding was defined according to Bleeding Academic Research Consortium definitions. Patients with HAS-BLED ≥3, ATRIA ≥5, or ORBIT ≥4 were classified as at high bleeding risk. Receiver operating characteristic analysis for each score against any bleeding, major bleeding, gastrointestinal bleeding, and intracranial hemorrhage was performed. Areas under the curve (AUCs) were then compared. We included 399 344 patients. Mean age was 77.9±10.2 years, and 63.2% were men. The highest intracranial hemorrhage rates were found in leukemia (1.89%/year), myeloma (1.52%/year), lymphoma and liver (1.45%/year), and pancreas cancer (1.41%/year). Receiver operating characteristic analysis showed that ORBIT score predicted best for any bleeding. In addition, ORBIT score ≥4 had the highest predictivity for major bleeding (AUC, 0.805), followed by HAS-BLED ≥3 and ATRIA ≥5 (AUCs, 0.716 and 0.700, respectively). HAS-BLED and ORBIT performed best for intracranial hemorrhage (AUCs, 0.744 and 0.742 for continuous scores, respectively), better than ATRIA (AUC, 0.635). For gastrointestinal bleeding, ORBIT ≥4 had the highest predictivity (AUC, 0.756), followed by the HAS-BLED ≥3 (AUC, 0.702) and ATRIA ≥5 (AUC, 0.662). Conclusions Some cancer types carry a greater bleeding risk in patients with atrial fibrillation. The identification and management of modifiable bleeding risk factors is crucial in these patients, as well as to flag up high bleeding risk patients for early review and follow-up.
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Affiliation(s)
- Daniele Pastori
- Emergency Medicine Unit ‐ Department of Clinical, Internal, Anesthesiological and Cardiovascular SciencesSapienza University of RomeRomeItaly,Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United KingdomLiverpoolUnited Kingdom
| | - Amélie Marang
- Service de CardiologieCentre Hospitalier Universitaire Trousseau et EA7505, Faculté de Médecine, Université François RabelaisToursFrance
| | - Arnaud Bisson
- Service de CardiologieCentre Hospitalier Universitaire Trousseau et EA7505, Faculté de Médecine, Université François RabelaisToursFrance
| | - Julien Herbert
- Service de CardiologieCentre Hospitalier Universitaire Trousseau et EA7505, Faculté de Médecine, Université François RabelaisToursFrance,Service d’information médicale, d’épidémiologie et d’économie de la santéCentre Hospitalier Universitaire et EA7505, Faculté de Médecine, Université François RabelaisToursFrance
| | - Gregory Yoke Hong Lip
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United KingdomLiverpoolUnited Kingdom
| | - Laurent Fauchier
- Service de CardiologieCentre Hospitalier Universitaire Trousseau et EA7505, Faculté de Médecine, Université François RabelaisToursFrance
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21
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Bai J, Lu Y, Wang H, Zhao J. How synergy between mechanistic and statistical models is impacting research in atrial fibrillation. Front Physiol 2022; 13:957604. [PMID: 36111152 PMCID: PMC9468674 DOI: 10.3389/fphys.2022.957604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Atrial fibrillation (AF) with multiple complications, high morbidity and mortality, and low cure rates, has become a global public health problem. Although significant progress has been made in the treatment methods represented by anti-AF drugs and radiofrequency ablation, the therapeutic effect is not as good as expected. The reason is mainly because of our lack of understanding of AF mechanisms. This field has benefited from mechanistic and (or) statistical methodologies. Recent renewed interest in digital twin techniques by synergizing between mechanistic and statistical models has opened new frontiers in AF analysis. In the review, we briefly present findings that gave rise to the AF pathophysiology and current therapeutic modalities. We then summarize the achievements of digital twin technologies in three aspects: understanding AF mechanisms, screening anti-AF drugs and optimizing ablation strategies. Finally, we discuss the challenges that hinder the clinical application of the digital twin heart. With the rapid progress in data reuse and sharing, we expect their application to realize the transition from AF description to response prediction.
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Affiliation(s)
- Jieyun Bai
- Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Information Technology, Jinan University, Guangzhou, China
- College of Information Science and Technology, Jinan University, Guangzhou, China
| | - Yaosheng Lu
- Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Information Technology, Jinan University, Guangzhou, China
- College of Information Science and Technology, Jinan University, Guangzhou, China
| | - Huijin Wang
- College of Information Science and Technology, Jinan University, Guangzhou, China
| | - Jichao Zhao
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
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22
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Chiang CE, Chao TF, Choi EK, Lim TW, Krittayaphong R, Li M, Chen M, Guo Y, Okumura K, Lip GY. Stroke Prevention in Atrial Fibrillation: A Scientific Statement of JACC: Asia (Part 1). JACC. ASIA 2022; 2:395-411. [PMID: 36339361 PMCID: PMC9627863 DOI: 10.1016/j.jacasi.2022.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/09/2022] [Accepted: 05/27/2022] [Indexed: 06/16/2023]
Abstract
Atrial fibrillation is the most common sustained cardiac arrhythmia and is associated with substantial increases in the risk of stroke and systemic thromboembolism. With the successful introduction of the first non-vitamin K antagonist direct oral anticoagulant (NOAC) in 2009, the role of vitamin K antagonists has been replaced in most clinical settings except in a few conditions when NOACs are contraindicated. Data for the use of NOACs in different clinical scenarios have been accumulating in the recent decade, and a more sophisticated strategy for atrial fibrillation patients is now warranted. JACC: Asia recently appointed a working group to summarize the most updated information regarding stroke prevention in AF. This statement aimed to provide possible treatment option in daily practice. Local availability, cost, and patient comorbidities should also be considered. Final decisions may still need to be individualized and based on clinicians' discretion. This is the part 1 of the whole statement.
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Affiliation(s)
- Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - 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 Chiao Tung University, Taipei, Taiwan
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Toon Wei Lim
- National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Mingfang Li
- Division of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Minglong Chen
- Division of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Centre, Chinese PLA General Hospital, Beijing, China
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Gregory Y.H. Lip
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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23
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Svennberg E, Tjong F, Goette A, Akoum N, Di Biase L, Bordachar P, Boriani G, Burri H, Conte G, Deharo JC, Deneke T, Drossart I, Duncker D, Han JK, Heidbuchel H, Jais P, de Oliviera Figueiredo MJ, Linz D, Lip GYH, Malaczynska-Rajpold K, Márquez M, Ploem C, Soejima K, Stiles MK, Wierda E, Vernooy K, Leclercq C, Meyer C, Pisani C, Pak HN, Gupta D, Pürerfellner H, Crijns HJGM, Chavez EA, Willems S, Waldmann V, Dekker L, Wan E, Kavoor P, Turagam MK, Sinner M. How to use digital devices to detect and manage arrhythmias: an EHRA practical guide. Europace 2022; 24:979-1005. [PMID: 35368065 DOI: 10.1093/europace/euac038] [Citation(s) in RCA: 113] [Impact Index Per Article: 56.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Emma Svennberg
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Fleur Tjong
- Heart Center, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Andreas Goette
- St. Vincenz Hospital Paderborn, Paderborn, Germany
- MAESTRIA Consortium/AFNET, Münster, Germany
| | - Nazem Akoum
- Heart Institute, University of Washington School of Medicine, Seattle, WA, USA
| | - Luigi Di Biase
- Albert Einstein College of Medicine at Montefiore Hospital, New York, NY, USA
| | | | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Haran Burri
- Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Giulio Conte
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Jean Claude Deharo
- Assistance Publique-Hôpitaux de Marseille, Centre Hospitalier Universitaire La Timone, Service de Cardiologie, Marseille, France
- Aix Marseille Université, C2VN, Marseille, France
| | - Thomas Deneke
- Heart Center Bad Neustadt, Bad Neustadt an der Saale, Germany
| | - Inga Drossart
- European Society of Cardiology, Sophia Antipolis, France
- ESC Patient Forum, Sophia Antipolis, France
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Janet K Han
- Cardiac Arrhythmia Centers, Veterans Affairs Greater Los Angeles Healthcare System and University of California, Los Angeles, CA, USA
| | - Hein Heidbuchel
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
- Cardiovascular Research Group, Antwerp University, Antwerp, Belgium
| | - Pierre Jais
- Bordeaux University Hospital, Bordeaux, France
| | | | - Dominik Linz
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Manlio Márquez
- Department of Electrocardiology, Instituto Nacional de Cardiología, Mexico City, Mexico
| | - Corrette Ploem
- Department of Ethics, Law and Medical Humanities, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Kyoko Soejima
- Kyorin University School of Medicine, Mitaka, Tokyo, Japan
| | - Martin K Stiles
- Waikato Clinical School, University of Auckland, Hamilton, New Zealand
| | - Eric Wierda
- Department of Cardiology, Dijklander Hospital, Hoorn, the Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Christian Meyer
- Division of Cardiology/Angiology/Intensive Care, EVK Düsseldorf, Teaching Hospital University of Düsseldorf, Düsseldorf, Germany
| | - Cristiano Pisani
- Arrhythmia Unit, Heart Institute, InCor, University of São Paulo Medical School, São Paulo, Brazil
| | - Hui Nam Pak
- Yonsei University, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Dhiraj Gupta
- Faculty of Health and Life Sciences, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, UK
| | | | - H J G M Crijns
- Em. Professor of Cardiology, University of Maastricht, Maastricht, Netherlands
| | - Edgar Antezana Chavez
- Division of Cardiology, Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, C1155AHB Buenos Aires, Argentina
- Division of Cardiology, Hospital Belga, Antezana 455, C0000 Cochabamba, Bolivia
| | | | - Victor Waldmann
- Electrophysiology Unit, European Georges Pompidou Hospital, Paris, France
- Adult Congenital Heart Disease Unit, European Georges Pompidou Hospital, Paris, France
| | - Lukas Dekker
- Catharina Ziekenhuis Eindhoven, Eindhoven, Netherlands
| | - Elaine Wan
- Cardiology and Cardiac Electrophysiology, Columbia University, New York, NY, USA
| | - Pramesh Kavoor
- Cardiology Department, Westmead Hospital, Westmead, New South Wales, Australia
| | | | - Moritz Sinner
- Univ. Hospital Munich, Campus Grosshadern, Munich, Germany
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24
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Gorog DA, Gue YX, Chao TF, Fauchier L, Ferreiro JL, Huber K, Konstantinidis SV, Lane DA, Marin F, Oldgren J, Potpara T, Roldan V, Rubboli A, Sibbing D, Tse HF, Vilahur G, Lip GYH. Assessment and Mitigation of Bleeding Risk in Atrial Fibrillation and Venous Thromboembolism: Executive Summary of a European and Asia-Pacific Expert Consensus Paper. Thromb Haemost 2022; 122:1625-1652. [PMID: 35793691 DOI: 10.1055/s-0042-1750385] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
While there is a clear clinical benefit of oral anticoagulation in patients with atrial fibrillation (AF) and venous thromboembolism (VTE) in reducing the risks of thromboembolism, major bleeding events (especially intracranial bleeds) may still occur and be devastating. The decision for initiating and continuing anticoagulation is often based on a careful assessment of both thromboembolism and bleeding risk. The more common and validated bleeding risk factors have been used to formulate bleeding risk stratification scores, but thromboembolism and bleeding risk factors often overlap. Also, many factors that increase bleeding risk are transient and modifiable, such as variable international normalized ratio values, surgical procedures, vascular procedures, or drug-drug and food-drug interactions. Bleeding risk is also not a static "one-off" assessment based on baseline factors but is dynamic, being influenced by aging, incident comorbidities, and drug therapies. In this executive summary of a European and Asia-Pacific Expert Consensus Paper, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in patients with AF and VTE, with a view to summarizing "best practice" when approaching antithrombotic therapy in these patients. We address the epidemiology and size of the problem of bleeding risk in AF and VTE, and review established bleeding risk factors and summarize definitions of bleeding. Patient values and preferences, balancing the risk of bleeding against thromboembolism, are reviewed, and the prognostic implications of bleeding are discussed. We propose consensus statements that may help to define evidence gaps and assist in everyday clinical practice.
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Affiliation(s)
- Diana A Gorog
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hertfordshire, United Kingdom.,Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Ying X Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - 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 Chiao Tung University, Taipei, Taiwan
| | | | - Jose Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge and Ciber Cardiovascular (CIBERCV), L'Hospitalet de Llobregat, Spain.,BIOHEART-Cardiovascular Diseases Group, Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Spain
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital and Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Stavros V Konstantinidis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Arrixaca), CIBERCV, Universidad de Murcia, Murcia, Spain
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Vanessa Roldan
- Servicio de Hematología, Hospital Universitario Morales Meseguer, Universidad de Murcia, IMIB-Arrixaca, Murcia, Spain
| | - Andrea Rubboli
- Department of Cardiovascular Diseases - AUSL Romagna, Division of Cardiology, S. Maria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians-Universität München, München, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Gemma Vilahur
- Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain.,CIBERCV Instituto de Salud Carlos III, Barcelona, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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25
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Best JG, Cardus B, Klijn CJM, Lip G, Seiffge DJ, Smith EE, Werring DJ. Antithrombotic dilemmas in stroke medicine: new data, unsolved challenges. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2020-325249. [PMID: 35728935 DOI: 10.1136/jnnp-2020-325249] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 05/16/2022] [Indexed: 11/04/2022]
Abstract
Antithrombotic therapy is a key element of secondary prevention in patients who have had an ischaemic stroke or transient ischaemic attack. However, its use in clinical practice is not always straightforward. This review provides an update on certain difficult scenarios in antithrombotic management, with a focus on recent clinical trials and large observational studies. We discuss the approach to patients with an indication for antithrombotic treatment who also have clinical or radiological evidence of previous intracranial bleeding, patients with indications for both anticoagulant and antiplatelet treatment, and patients in whom antithrombotic treatment fails to prevent stroke. We also review the timing of anticoagulation initiation after cardioembolic stroke, and the use of antithrombotics in patients with asymptomatic cerebrovascular disease. Despite a wealth of new evidence, numerous uncertainties remain and we highlight ongoing trials addressing these.
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Affiliation(s)
- Jonathan G Best
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Beatrix Cardus
- Royal Surrey County Hospital, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Catharina J M Klijn
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, Netherlands
| | - Gregory Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - David J Seiffge
- Department of Neurology, Inselspital University Hospital, Bern, Switzerland
| | - Eric E Smith
- Calgary Stroke Program, Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
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26
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Gebreyohannes EA, Salter SM, Chalmers L, Radford J, Lee K. Use of thromboprophylaxis guidelines and risk stratification tools in atrial fibrillation: A survey of general practitioners in Australia. J Eval Clin Pract 2022; 28:483-492. [PMID: 35385183 PMCID: PMC9324914 DOI: 10.1111/jep.13685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/16/2022] [Accepted: 03/23/2022] [Indexed: 11/28/2022]
Abstract
RATIONALE AND OBJECTIVES Clinical guidelines produced by cardiology societies (henceforth referred to simply as 'clinical guidelines') recommend thromboprophylaxis with oral anticoagulants (OACs) in patients with atrial fibrillation (AF) who have moderate-to-high stroke risk. However, deviations from these recommendations are observed, especially in the primary healthcare setting. The primary aims of this study were to evaluate the self-reported use of AF clinical guidelines and risk stratification tools among Australian general practitioners (GPs), and their perceptions regarding the available resources. METHOD We conducted an online survey of Australian GPs. Descriptive statistics were used to summarise the findings. RESULTS Responses from 115 GPs were included for analysis. Respondents reported various ways of accessing thromboprophylaxis-related information (n = 113), including clinical guidelines (13.3%), 'Therapeutic Guidelines© ' (37.2%) and Royal Australian College of General Practitioners websites (16.8%). Of those who reported reasons against accessing information from clinical guidelines (n = 97), the most frequent issues were: too many AF guidelines to choose from (34.0%; 33/97), different guidelines for different diseases (32.0%; 31/97), time-consuming to read guidelines (21.6%; 21/97), disagreements between different guideline recommendations (20.0%; 19/97), conflict with criteria for government subsidy (17.5%; 17/97) and GPs' busy schedules (15.5%; 15/97). When assessing patients' risk of stroke (n = 112) and bleeding (n = 111), the majority of the respondents reported primarily relying on a formal stroke risk (67.0%) and bleeding risk (55.0%) assessment tools, respectively. Respondents reported using formal stroke and bleeding risk assessment tools mainly when newly initiating patients on therapy (72.4%; 76/105 and 65.3%; 65/101, respectively). CONCLUSION Among our small sample of Australian GPs, most did not access thromboprophylaxis-related information directly from AF-specific clinical guidelines developed by cardiology societies. Although the majority reported using formal stroke and bleeding assessment tools, these were typically used on OAC initiation only. More focus is needed on formal risk reassessment as clinically indicated and at regular review.
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Affiliation(s)
- Eyob Alemayehu Gebreyohannes
- Division of Pharmacy, School of Allied Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Sandra M Salter
- Division of Pharmacy, School of Allied Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Leanne Chalmers
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
| | - Jan Radford
- Launceston Clinical School, Tasmanian School of Medicine, University of Tasmania, Launceston, Tasmania, Australia
| | - Kenneth Lee
- Division of Pharmacy, School of Allied Health, The University of Western Australia, Perth, Western Australia, Australia
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27
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Bonini N, Vitolo M, Imberti JF, Proietti M, Romiti GF, Boriani G, Paaske Johnsen S, Guo Y, Lip GYH. Mobile health technology in atrial fibrillation. Expert Rev Med Devices 2022; 19:327-340. [PMID: 35451347 DOI: 10.1080/17434440.2022.2070005] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Mobile health (mHealth) solutions in atrial fibrillation (AF) are becoming widespread, thanks to everyday life devices such as smartphones. Their use is validated both in monitoring and in screening scenarios. In the published literature, the diagnostic accuracy of mHealth solutions wide differs, and their current clinical use is not well established in principal guidelines. AREAS COVERED mHealth solutions have progressively built an AF-detection chain to guide patients from the device's alert signal to the health care practitioners' (HCPs) attention. This review aims to critically evaluate the latest evidence regarding mHealth devices and the future possible patient's uses in everyday life. EXPERT OPINION The patients are the first to be informed of the rhythm anomaly, leading to the urgency of increasing the patients' AF self-management. Furthermore, HCPs need to update themselves about mHealth devices use in clinical practice. Nevertheless, these are promising instruments in specific populations, such as post-stroke patients, to promote an early arrhythmia diagnosis in the post-ablation/cardioversion period, allowing checks on the efficacy of the treatment or intervention.
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Affiliation(s)
- Niccolò Bonini
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Marco Vitolo
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Jacopo Francesco Imberti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, 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 Clinici Scientifici Maugeri, Milan, Italy
| | - Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Department of Translational and Precision Medicine, Sapienza-University of Rome, Rome, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia despite substantial efforts to understand the pathophysiology of the condition and develop improved treatments. Identifying the underlying causative mechanisms of AF in individual patients is difficult and the efficacy of current therapies is suboptimal. Consequently, the incidence of AF is steadily rising and there is a pressing need for novel therapies. Research has revealed that defects in specific molecular pathways underlie AF pathogenesis, resulting in electrical conduction disorders that drive AF. The severity of this so-called electropathology correlates with the stage of AF disease progression and determines the response to AF treatment. Therefore, unravelling the molecular mechanisms underlying electropathology is expected to fuel the development of innovative personalized diagnostic tools and mechanism-based therapies. Moreover, the co-creation of AF studies with patients to implement novel diagnostic tools and therapies is a prerequisite for successful personalized AF management. Currently, various treatment modalities targeting AF-related electropathology, including lifestyle changes, pharmaceutical and nutraceutical therapy, substrate-based ablative therapy, and neuromodulation, are available to maintain sinus rhythm and might offer a novel holistic strategy to treat AF.
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Affiliation(s)
- Bianca J J M Brundel
- Department of Physiology, Amsterdam University Medical Centers, VU Universiteit, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands.
| | - Xun Ai
- Department of Physiology and Cell Biology, College of Medicine/Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | | | - Myrthe F Kuipers
- AFIPonline.org, Atrial Fibrillation Innovation Platform, Amsterdam, Netherlands
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Kotalczyk A, Guo Y, Stefil M, Wang Y, Lip GYH. Effects of the Atrial Fibrillation Better Care Pathway on Outcomes Among Clinically Complex Chinese Patients With Atrial Fibrillation With Multimorbidity and Polypharmacy: A Report From the ChiOTEAF Registry. J Am Heart Assoc 2022; 11:e024319. [PMID: 35377169 PMCID: PMC9075471 DOI: 10.1161/jaha.121.024319] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Patients with atrial fibrillation commonly have complex clinical backgrounds of multimorbidity and polypharmacy. The Atrial Fibrillation Better Care (ABC) pathway has been developed to help deliver integrated and holistic care for patients with atrial fibrillation. In this ancillary analysis, we assessed the adherence to and the effectiveness of the ABC pathway at reducing adverse outcomes in Chinese patients with atrial fibrillation with a complex clinical background of multimorbidity or polypharmacy. Methods and Results The ChiOTEAF (Optimal Thromboprophylaxis in Elderly Chinese Patients With Atrial Fibrillation) registry is a prospective, multicenter, nationwide study conducted from October 2014 to December 2018. The primary outcomes of interest were the composite end point of all-cause death and thromboembolic events, as well as individual end points of all-cause death, thromboembolic events, and major bleeding. Multimorbidity was defined as the presence of ≥2 comorbidities, and polypharmacy was defined as the concomitant use of ≥5 medications. The eligible cohort included 4644 patients with multimorbidity, of whom 2610 (56.2%) had available data to assess the ABC pathway usage (mean age, 74.4±10.2; 42.8% women). Among patients with polypharmacy (n=2262; mean age, 74.6±10.1; 43.3% women), 1328 (58.7%) had available data to assess the use of the ABC pathway. Adherence to the ABC pathway was associated with a lower risk of the primary composite outcome among patients with multimorbidity (odds ratio, 0.48; 95% CI, 0.29-0.79) and in the polypharmacy group (odds ratio, 0.39; 95% CI, 0.19-0.78). Health-related quality of life was lower in the non-ABC-adherent group compared with the ABC-treated patients. Conclusions This nationwide real-world registry shows that adherence to the ABC pathway is associated with improved clinical outcomes and health-related quality of life in clinically complex Chinese patients with atrial fibrillation with multimorbidity or polypharmacy.
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Affiliation(s)
- Agnieszka Kotalczyk
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool United Kingdom.,Department of Cardiology Congenital Heart Diseases and Electrotherapy Medical University of SilesiaSilesian Centre for Heart Diseases Zabrze Poland
| | - Yutao Guo
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool United Kingdom.,Department of Pulmonary Vessel and Thrombotic Disease Sixth Medical CentreChinese PLA General Hospital Beijing China
| | - Maria Stefil
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool United Kingdom.,Liverpool University Hospitals NHS Foundation Trust Liverpool United Kingdom
| | - Yutang Wang
- Department of Cardiology Second Medical Centre Chinese PLA General Hospital Beijing China
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool United Kingdom.,Department of Cardiology Congenital Heart Diseases and Electrotherapy Medical University of SilesiaSilesian Centre for Heart Diseases Zabrze Poland.,Department of Clinical Medicine Aalborg University Aalborg Denmark
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30
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van Husen G, Virdone S, Pieper K, Kayani G, Fox KAA. Universal Clinician Device for improving risk prediction and management of patients with atrial fibrillation: an assumed benefit analysis. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2022; 3:181-194. [PMID: 36713019 PMCID: PMC9707904 DOI: 10.1093/ehjdh/ztac011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/23/2022] [Accepted: 03/01/2022] [Indexed: 02/01/2023]
Abstract
Aim Atrial fibrillation (AF) management guidelines advise using risk tools to optimize AF treatment. This study aims to develop a dynamic and clinically applicable digital device to assess stroke and bleeding risk, and to facilitate outcome improvements in AF patients. The device will provide tailored treatment recommendations according to easily attainable individual patient data. Methods and Results This Universal Clinician Device (UCD) was created using the GARFIELD-AF registry using a split sample approach. The GARFIELD-AF risk tool was adapted with two modifications. First, predictors with ≥1000 missing data points were separated, allowing expected risks estimation. Second, recommendations for modifiable risk factors and associated 2-year outcome estimates were incorporated. Outcomes of interest were all-cause mortality, non-haemorrhagic stroke/systemic embolism (SE), and major bleeding. All patients were randomized to a derivation (n = 34853) and validation cohort (n = 17165). In the derivation cohort, predictors were identified using least absolute shrinkage and selection operator regression. Cox models were fitted with the selected parameters. The UCD demonstrated superior predictive power compared with CHA2DS2VASc for all-cause mortality [0.75(0.75-0.76) vs. 0.71(0.70-0.72)] and non-haemorrhagic stroke/SE [0.68(0.66-0.70) vs. 0.65(0.63-0.67)], and with HAS-BLED for major bleeding [0.69(0.67-0.71) vs. 0.64(0.62-0.65)]. Universal Clinician Device recommendations reduced all-cause mortality (8.45-5.42%) and non-haemorrhagic stroke/SE (2.58-1.50%). Patients with concomitant diabetes and chronic kidney disease benefitted further, reducing mortality risk from 13.15% to 8.67%. One-third of patients with a CHA2DS2VASc score of >1 had the lowest risk of stroke. Conclusion The UCD simultaneously predicts mortality, stroke, and bleeding risk in patients using easily attainable individual clinical data and guideline-based optimized treatment plans. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier for GARFIELD-AF: NCT01090362.
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Affiliation(s)
| | - Saverio Virdone
- Department of Statistics, The Thrombosis Research Institute, London, UK
| | - Karen Pieper
- Department of Statistics, The Thrombosis Research Institute, London, UK
| | - Gloria Kayani
- Department of Statistics, The Thrombosis Research Institute, London, UK
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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31
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Gorog DA, Gue YX, Chao TF, Fauchier L, Ferreiro JL, Huber K, Konstantinidis SV, Lane DA, Marin F, Oldgren J, Potpara T, Roldan V, Rubboli A, Sibbing D, Tse HF, Vilahur G, Lip GYH. Assessment and mitigation of bleeding risk in atrial fibrillation and venous thromboembolism: A Position Paper from the ESC Working Group on Thrombosis, in collaboration with the European Heart Rhythm Association, the Association for Acute CardioVascular Care and the Asia-Pacific Heart Rhythm Society. Europace 2022; 24:1844-1871. [PMID: 35323922 DOI: 10.1093/europace/euac020] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/08/2022] [Indexed: 12/26/2022] Open
Abstract
Whilst there is a clear clinical benefit of oral anticoagulation (OAC) in patients with atrial fibrillation (AF) and venous thromboembolism (VTE) in reducing the risks of thromboembolism, major bleeding events (especially intracranial bleeds) may still occur and be devastating. The decision to initiate and continue anticoagulation is often based on a careful assessment of both the thromboembolism and bleeding risk. The more common and validated bleeding risk factors have been used to formulate bleeding risk stratification scores, but thromboembolism and bleeding risk factors often overlap. Also, many factors that increase bleeding risk are transient and modifiable, such as variable international normalized ratio values, surgical procedures, vascular procedures, or drug-drug and food-drug interactions. Bleeding risk is also not a static 'one off' assessment based on baseline factors but is dynamic, being influenced by ageing, incident comorbidities, and drug therapies. In this Consensus Document, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in patients with AF and VTE, with the view to summarizing 'best practice' when approaching antithrombotic therapy in these patients. We address the epidemiology and size of the problem of bleeding risk in AF and VTE, review established bleeding risk factors, and summarize definitions of bleeding. Patient values and preferences, balancing the risk of bleeding against thromboembolism are reviewed, and the prognostic implications of bleeding are discussed. We propose consensus statements that may help to define evidence gaps and assist in everyday clinical practice.
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Affiliation(s)
- Diana A Gorog
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, College Lane, Hatfield, UK.,Faculty of Medicine, National Heart & Lung Institute, Imperial College, London, UK
| | - Ying X Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | | | - Jose Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge, Ciber Cardiovascular (CIBERCV), L'Hospitalet de Llobregat, Barcelona, Spain.,BIOHEART-Cardiovascular Diseases Group, Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital and Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Stavros V Konstantinidis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Arrixaca), CIBERCV, Universidad de Murcia, Murcia, Spain
| | - Jonas Oldgren
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Vanessa Roldan
- Servicio de Hematología, Hospital Universitario Morales Meseguer, Universidad de Murcia, IMIB-Arrixaca, Murcia, España
| | - Andrea Rubboli
- Division of Cardiology, Department of Cardiovascular Diseases-AUSL Romagna, SMaria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians-Universität München, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Gemma Vilahur
- Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain.,CIBERCV Instituto de Salud Carlos III, Barcelona, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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32
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Lüscher TF, Davies A, Beer JH, Valgimigli M, Nienaber CA, Camm JA, Baumgartner I, Diener HC, Konstantinides SV. Towards personalized antithrombotic management with drugs and devices across the cardiovascular spectrum. Eur Heart J 2022; 43:940-958. [PMID: 34624084 DOI: 10.1093/eurheartj/ehab642] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 05/06/2021] [Accepted: 09/01/2021] [Indexed: 01/10/2023] Open
Abstract
Intravascular thrombus formation and embolization are among the most frequent events leading to a number of cardiovascular conditions with high morbidity and mortality. The underlying causes are stasis of the circulating blood, genetic and acquired coagulation disorders, and reduced antithrombotic or prothrombotic properties of the vascular wall (Virchow's triad). In the venous system, intravascular thrombi can cause venous thrombosis and pulmonary and even peripheral embolism including ischaemic stroke [through a patent foramen ovale (PFO)]. Thrombi in the left atrium and its appendage or ventricle form in the context of atrial fibrillation and infarction, respectively. Furthermore, thrombi can form on native or prosthetic aortic valves, within the aorta (in particular at sites of ulcers, aortic dissection, and abdominal aneurysms), and in cerebral and peripheral arteries causing stroke and critical limb ischaemia, respectively. Finally, thrombotic occlusion may occur in arteries supplying vital organs such the heart, brain, kidney, and extremities. Thrombus formation and embolization can be managed with anticoagulants and devices depending on where they form and embolize and on patient characteristics. Vitamin K antagonists are preferred in patients with mechanical valves, while novel oral anticoagulants are first choice in most other cardiovascular conditions, in particular venous thromboembolism and atrial fibrillation. As anticoagulants are associated with a risk of bleeding, devices such as occluders of a PFO or the left atrial appendage are preferred in patients with an increased bleeding risk. Platelet inhibitors such as aspirin and/or P2Y12 antagonists are preferred in the secondary prevention of coronary artery disease, stroke, and peripheral artery disease either alone or in combination depending on the clinical condition. A differential and personalized use of anticoagulants, platelet inhibitors, and devices is recommended and reviewed in this article.
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Affiliation(s)
- Thomas F Lüscher
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Allan Davies
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK
| | - Juerg H Beer
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Marco Valgimigli
- CardioCentro, Lugano, Switzerland.,University of Bern, Bern, Switzerland
| | - Christoph A Nienaber
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK
| | - John A Camm
- St. Georges University and Imperial College, London, UK
| | | | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty of the University Duisburg-Essen, Duisburg-Essen, Germany
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Use of Anticoagulant Therapy in Patients with Acute Myocardial Infarction and Atrial Fibrillation. Medicina (B Aires) 2022; 58:medicina58030338. [PMID: 35334514 PMCID: PMC8955052 DOI: 10.3390/medicina58030338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/11/2022] [Accepted: 02/12/2022] [Indexed: 12/02/2022] Open
Abstract
The incidence of atrial fibrillation (AF) in acute coronary syndrome (ACS) ranges from 2.3–23%. This difference in the incidence of AF is explained by the different ages of the patients in different studies and the different times of application of both reperfusion and drug therapies in acute myocardial infarction (AMI). About 6–8% of patients who underwent percutaneous intervention within AMI have an indication for oral anticoagulant therapy with vitamin K antagonists or new oral anticoagulants (NOAC).The use of oral anticoagulant therapy should be consistent with individual risk of bleeding as well as ischemic risk. Both HAS-BLED and CHA2DS2VASc scores are most commonly used for risk assessment. Except in patients with mechanical valves and antiphospholipid syndrome, NOACs have an advantage over vitamin K antagonists (VKAs). One of the advantages of NOACs is the use of fixed doses, where there is no need for successive INR controls, which increases the patient’s compliance in taking these drugs. The use of triple therapy in ACS is indicated in the case of patients with AF, mechanical valves as well as venous thromboembolism. The results of the studies showed that when choosing a P2Y12 receptor blocker, less potent P2Y12 blockers such as Clopidogrel should be chosen, due to the lower risk of bleeding. It has been proven that the presence of AF within AMI is associated with a higher degree of reinfarction, more frequent stroke, high incidence of heart failure, and there is a correlation with an increased risk of sudden cardiac death. With the appearance of AF in ACS, its rapid conversion into sinus rhythm is necessary, and in the last resort, good control of heart rate in order to avoid the occurrence of adverse clinical events.
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Grymonprez M, Vanspranghe K, Capiau A, Boussery K, Steurbaut S, Lahousse L. Impact of P-glycoprotein and/or CYP3A4-interacting drugs on effectiveness and safety of NOACs in patients with atrial fibrillation: a meta-analysis. Br J Clin Pharmacol 2022; 88:3039-3051. [PMID: 35132677 DOI: 10.1111/bcp.15265] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 12/24/2021] [Accepted: 02/03/2022] [Indexed: 12/01/2022] Open
Abstract
AIM P-glycoprotein (P-gp) and CYP3A4-interacting drugs influence plasma levels of non-vitamin K antagonist oral anticoagulants (NOACs). However, the clinical relevance is questioned. Therefore, the impact of pharmacokinetically-interacting drugs on the effectiveness and safety of NOACs in patients with atrial fibrillation (AF) was investigated. METHODS A meta-analysis was performed based on randomized controlled trials and observational studies retrieved from Pubmed and Embase, that investigated the impact of concomitantly used P-gp/CYP3A4-interacting drugs on the risk-benefit profile of NOACs in AF patients. RESULTS Fifteen studies were included, investigating 21,711 and 306,421 NOAC-treated AF patients with and without P-gp/CYP3A4 inhibitor use respectively, while only one study included P-gp/CYP3A4 inducers. In NOAC-treated AF patients, concomitant use of P-gp/CYP3A4 inhibitors was associated with significantly higher major bleeding (relative risk (RR) 1.10, 95% confidence interval (CI) (1.01-1.19)) and all-cause mortality risks (RR 1.14, 95%CI (1.05-1.23)) compared to not using P-gp/CYP3A4 inhibitors, while the risks of stroke/SE (RR 0.88, 95%CI (0.77-1.01)), intracranial bleeding (RR 0.89, 95%CI (0.68-1.15)) and gastro-intestinal bleeding (RR 1.09, 95%CI (0.91-1.30)) were not significantly different. Concomitant use of amiodarone with NOACs was associated with lower thromboembolic (RR 0.75, 95%CI (0.61-0.92)), similar major bleeding (RR 0.92, 95%CI (0.80-1.07)), but higher mortality risks (RR 1.21, 95%CI (1.05-1.39)). Co-administration of verapamil or diltiazem was associated with higher major bleeding risks (RR 1.64, 95%CI (1.31-2.06)), but comparable thromboembolic (RR 1.10, 95%CI (0.75-1.61)) and mortality risks (RR 1.01, 95%CI (0.77-1.33)). CONCLUSION Given the higher bleeding and mortality risks in NOAC-treated AF patients concomitantly using P-gp/CYP3A4 inhibitors, close monitoring is warranted.
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Affiliation(s)
- Maxim Grymonprez
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Kevin Vanspranghe
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Andreas Capiau
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Koen Boussery
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Stephane Steurbaut
- Centre for Pharmaceutical Research, Research group of Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Jette, Belgium.,Department of Hospital Pharmacy, UZ Brussel, Jette, Belgium
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium.,Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
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35
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Hermans ANL, Gawałko M, Hillmann HAK, Sohaib A, van der Velden RMJ, Betz K, Verhaert D, Scherr D, Meier J, Sultan A, Steven D, Terentieva E, Pisters R, Hemels M, Voorhout L, Lodziński P, Krzowski B, Gupta D, Kozhuharov N, Gruwez H, Vernooy K, Pluymaekers NAHA, Hendriks JM, Manninger M, Duncker D, Linz D. Self-Reported Mobile Health-Based Risk Factor and CHA 2DS 2-VASc-Score Assessment in Patients With Atrial Fibrillation: TeleCheck-AF Results. Front Cardiovasc Med 2022; 8:757587. [PMID: 35127847 PMCID: PMC8809453 DOI: 10.3389/fcvm.2021.757587] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/13/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The TeleCheck-AF approach is an on-demand mobile health (mHealth) infrastructure incorporating mobile app-based heart rate and rhythm monitoring through teleconsultation. We evaluated feasibility and accuracy of self-reported mHealth-based AF risk factors and CHA2DS2-VASc-score in atrial fibrillation (AF) patients managed within this approach. MATERIALS AND METHODS Consecutive patients from eight international TeleCheck-AF centers were asked to complete an app-based 10-item questionnaire related to risk factors, associated conditions and CHA2DS2-VASc-score components. Patient's medical history was retrieved from electronic health records (EHR). RESULTS Among 994 patients, 954 (96%) patients (38% female, median age 65 years) completed the questionnaire and were included in this analysis. The accuracy of self-reported assessment was highest for pacemaker and anticoagulation treatment and lowest for heart failure and arrhythmias. Patients who knew that AF increases the stroke risk, more often had a 100% or ≥80% correlation between EHR- and app-based results compared to those who did not know (27 vs. 14% or 84 vs. 77%, P = 0.001). Thromboembolic events were more often reported in app (vs. EHR) in all countries, whereas higher self-reported hypertension and anticoagulant treatment were observed in Germany and heart failure in the Netherlands. If the app-based questionnaire alone was used for clinical decision-making on anticoagulation initiation, 26% of patients would have been undertreated and 6.1%-overtreated. CONCLUSION Self-reported mHealth-based assessment of AF risk factors is feasible. It shows high accuracy of pacemaker and anticoagulation treatment, nevertheless, displays limited accuracy for some of the CHA2DS2-VASc-score components. Direct health care professional assessment of risk factors remains indispensable to ensure high quality clinical-decision making.
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Affiliation(s)
- Astrid N. L. Hermans
- Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Monika Gawałko
- Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Henrike A. K. Hillmann
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Afzal Sohaib
- Barts Heart Center, St Bartholomew's Hospital, London, United Kingdom
- Department of Cardiology, King George Hospital, Ilford, United Kingdom
| | - Rachel M. J. van der Velden
- Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Konstanze Betz
- Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Dominique Verhaert
- Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Daniel Scherr
- Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
- Department of Cardiology, University Clinic of Medicine, Medical University of Graz, Graz, Austria
| | - Julia Meier
- Department of Cardiology, University Clinic of Medicine, Medical University of Graz, Graz, Austria
| | - Arian Sultan
- Department of Electrophysiology, University of Cologne, Heart Center, Cologne, Germany
| | - Daniel Steven
- Department of Electrophysiology, University of Cologne, Heart Center, Cologne, Germany
| | - Elena Terentieva
- Department of Electrophysiology, University of Cologne, Heart Center, Cologne, Germany
| | - Ron Pisters
- Department of Cardiology, Rijnstate Hospital, Arnhem, Netherlands
| | - Martin Hemels
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Cardiology, Rijnstate Hospital, Arnhem, Netherlands
| | - Leonard Voorhout
- Department of Cardiology, Rijnstate Hospital, Arnhem, Netherlands
| | - Piotr Lodziński
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Bartosz Krzowski
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Dhiraj Gupta
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Nikola Kozhuharov
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Henri Gruwez
- Department of Cardiology, Hospital East-Limburg, Genk, Belgium
- Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium
| | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Nikki A. H. A. Pluymaekers
- Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Jeroen M. Hendriks
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
- Center for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Martin Manninger
- Department of Cardiology, University Clinic of Medicine, Medical University of Graz, Graz, Austria
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Dominik Linz
- Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
- Center for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, SA, Australia
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Lip GYH, Lane DA, Lenarczyk R, Boriani G, Doehner W, Benjamin LA, Fisher M, Lowe D, Sacco RL, Schnabel R, Watkins C, Ntaios G, Potpara T. OUP accepted manuscript. Eur Heart J 2022; 43:2442-2460. [PMID: 35552401 PMCID: PMC9259378 DOI: 10.1093/eurheartj/ehac245] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/11/2022] [Accepted: 04/27/2022] [Indexed: 11/12/2022] Open
Abstract
The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient ‘journey’ or ‘patient pathway,’ supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management:
A: Appropriate Antithrombotic therapy. B: Better functional and psychological status. C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).
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Affiliation(s)
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Radosław Lenarczyk
- Division of Medical Sciences in Zabrze, Department of Cardiology, Congenital Heart Diseases and Electrotherapy, The Medical University of Silesia, Silesian Center of Heart Diseases, Curie-Sklodowska Str 9, 41-800 Zabrze, Poland
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Wolfram Doehner
- BIH Center for Regenerative Therapies (BCRT) and Department of Internal Medicine and Cardiology (Virchow Klinikum), German Centre for Cardiovascular Research (DZHK) partner site Berlin and Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Laura A Benjamin
- Laboratory of Molecular and Cell Biology, University College London National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Marc Fisher
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Deborah Lowe
- Wirral University Teaching Hospital NHS Foundation Trust, Wirral CH49 5PE, UK
| | - Ralph L Sacco
- UM Clinical & Translational Science Institute, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Renate Schnabel
- University Heart & Vascular Center Hamburg Eppendorf, German Center for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Caroline Watkins
- Faculty of Health and Care, University of Central Lancashire, Preston PR1 2HE, UK
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
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Gao X, Cai X, Yang Y, Zhou Y, Zhu W. Diagnostic Accuracy of the HAS-BLED Bleeding Score in VKA- or DOAC-Treated Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2021; 8:757087. [PMID: 34881309 PMCID: PMC8648046 DOI: 10.3389/fcvm.2021.757087] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/12/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Several bleeding risk assessment models have been developed in atrial fibrillation (AF) patients with oral anticoagulants, but the most appropriate tool for predicting bleeding remains uncertain. Therefore, we aimed to assess the diagnostic accuracy of the Hypertension, Abnormal liver/renal function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs/alcohol concomitantly (HAS-BLED) score compared with other risk scores in anticoagulated patients with AF. Methods: We comprehensively searched the PubMed and Embase databases until July 2021 to identify relevant pieces of literature. The predictive abilities of risk scores were fully assessed by the C-statistic, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) values, calibration data, and decision curve analyses. Results: A total of 39 studies met the inclusion criteria. The C-statistic of the HAS-BLED score for predicting major bleeding was 0.63 (0.61–0.65) in anticoagulated patients regardless of vitamin k antagonists [0.63 (0.61–0.65)] and direct oral anticoagulants [0.63 (0.59–0.67)]. The HAS-BLED had the similar C-statistic to the Hepatic or renal disease, Ethanol abuse, Malignancy, Older, Reduced platelet count or function, Re-bleeding risk, Hypertension (uncontrolled), Anemia, Genetic factors, Excessive fall risk, Stroke (HEMORR2HAGES), the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA), the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT), the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF), or the Age, Biomarkers, Clinical History (ABC) scores, but significantly higher C-statistic than the Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, Stroke/transient ischemic attack history (CHADS2) or the Congestive heart failure/left ventricular ejection fraction ≤ 40%, Hypertension, Age ≥75 years, Diabetes mellitus, Stroke/transient ischemic attack/thromboembolism history, Vascular disease, Age 65–74 years, Sex (female) (CHA2DS2-VASc) scores. NRI and IDI values suggested that the HAS-BLED score performed better than the CHADS2 or the CHA2DS2-VASc scores and had similar or superior predictive ability compared with the HEMORR2HAGES, the ATRIA, the ORBIT, or the GARFIELD-AF scores. Calibration and decision curve analyses of the HAS-BLED score compared with other scores required further assessment due to the limited evidence. Conclusion: The HAS-BLED score has moderate predictive abilities for bleeding risks in patients with AF regardless of type of oral anticoagulants. Current evidence support that the HAS-BLED score is at least non-inferior to the HEMORR2HAGES, the ATRIA, the ORBIT, the GARFIELD-AF, the CHADS2, the CHA2DS2-VASc, or the ABC scores.
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Affiliation(s)
- Xinxing Gao
- Division of Cardiology, Department of Internal Medicine, People's Hospital of Zhuzhou, Changsha Medical University, Zhuzhou, China
| | - Xingming Cai
- Department of Geriatric, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yunyao Yang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yue Zhou
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Wengen Zhu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Yao Y, Guo Y, Lip GYH. The Effects of Implementing a Mobile Health-Technology Supported Pathway on Atrial Fibrillation-Related Adverse Events Among Patients With Multimorbidity: The mAFA-II Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2140071. [PMID: 34932104 PMCID: PMC8693229 DOI: 10.1001/jamanetworkopen.2021.40071] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE The Mobile Health Technology for Improved Screening and Optimized Integrated Care in Atrial Fibrillation (mAFA-II) trial is a prospective cluster randomized trial that found a significant reduction in the composite clinical outcome of stroke or thromboembolism, all-cause death, and rehospitalization among patients with atrial fibrillation (AF) who used a mobile health (mHealth) technology that implemented the Atrial Fibrillation Better Care (ABC) pathway (ie, A, anticoagulation/avoid stroke; B, better symptom control; and C, cardiovascular disease and comorbidity management) compared with those receiving usual care. Multimorbidity (defined as ≥2 chronic long-term conditions) is common in older patients with AF, but the impact of integrated or holistic care (based on the ABC pathway) on clinical outcomes in this population is uncertain. OBJECTIVE To evaluate whether implementation of the integrated ABC pathway, supported by mHealth technology, would reduce AF-related adverse events in patients with multimorbidity. DESIGN, SETTING, AND PARTICIPANTS This prespecified ancillary analysis of data from the extended follow-up of the mAFA II trial was conducted between June 2018 and April 2021. Adult patients with AF were included in the analysis if they had at least 2 comorbidities. Participants were enrolled across 40 centers in China. INTERVENTION Integrated care supported by mHealth technology (mAFA intervention) vs usual care. MAIN OUTCOMES AND MEASURES The main outcome was the composite outcome of stroke or thromboembolism, all-cause death, and rehospitalization. Cox proportional hazard modeling was performed for adverse outcomes after adjusting for cluster effect and baseline risk factors. RESULTS Of 1890 patients, 833 (mean [SD] age, 72.0 [12.0] years; 278 [33.4%] women) with multimorbidity were allocated to the intervention group (ABC pathway), with a mean (SD) follow-up of 419 (257) days, and 1057 patients (mean [SD] age, 72.8 [13.0] years; 443 [41.9%] women) with multimorbidity were allocated to usual care, with a mean (SD) follow-up of 457 (154) days. Compared with usual care, the composite outcome of stroke or thromboembolism, all-cause death, and rehospitalization was significantly reduced in the intervention group (hazard ratio [HR], 0.37; 95% CI, 0.26-0.53; P < .001), as were rehospitalizations alone (HR, 0.42; 95% CI, 0.27-0.64; P < .001). For the C criterion of the ABC pathway, rates of acute coronary syndrome, heart failure, and uncontrolled blood pressure during follow-up were lower in the intervention group than the usual care group (27 patients [3.2%] vs 145 patients [13.7%]; HR, 0.29; 95% CI, 0.19-0.45; P < .001). Subgroup analyses by age, prior stroke, and sex demonstrated consistently lower HRs for the primary composite outcome and rehospitalization for patients with AF allocated to the intervention group compared with patients receiving usual care. CONCLUSIONS AND RELEVANCE In this study, mHealth technology-based integrated care that facilitated the implementation of the ABC pathway reduced meaningful clinical adverse events in older patients with AF and multimorbidity vs usual care. TRIAL REGISTRATION WHO International Clinical Trials Registry Platform (ICTRP) Registration number: ChiCTR-OOC-17014138.
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Affiliation(s)
- Yuan Yao
- Institute for Hospital Management Research, Chinese PLA General Hospital, Beijing, China
| | - Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease, Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Gregory Y. H. Lip
- Department of Pulmonary Vessel and Thrombotic Disease, Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Chao T, Joung B, Takahashi Y, Lim TW, Choi E, Chan Y, Guo Y, Sriratanasathavorn C, Oh S, Okumura K, Lip GYH. 2021 Focused update of the 2017 consensus guidelines of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation. J Arrhythm 2021; 37:1389-1426. [PMID: 34887945 PMCID: PMC8637102 DOI: 10.1002/joa3.12652] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 10/22/2021] [Indexed: 12/19/2022] Open
Abstract
The consensus of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation (AF) has been published in 2017 which provided useful clinical guidance for cardiologists, neurologists, geriatricians, and general practitioners in Asia-Pacific region. In these years, many important new data regarding stroke prevention in AF were reported. The Practice Guidelines subcommittee members comprehensively reviewed updated information on stroke prevention in AF, and summarized them in this 2021 focused update of the 2017 consensus guidelines of the APHRS on stroke prevention in AF. We highlighted and focused on several issues, including the importance of AF Better Care (ABC) pathway, the advantages of non-vitamin K antagonist oral anticoagulants (NOACs) for Asians, the considerations of use of NOACs for Asian patients with AF with single 1 stroke risk factor beyond gender, the role of lifestyle factors on stroke risk, the use of oral anticoagulants during the "coronavirus disease 2019" (COVID-19) pandemic, etc. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician's decision remains the most important factor in the management of AF.
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Affiliation(s)
- Tze‐Fan Chao
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- Institute of Clinical Medicine, and Cardiovascular Research CenterNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Boyoung Joung
- Division of CardiologyDepartment of Internal MedicineYonsei University College of MedicineSeoulRepublic of Korea
| | - Yoshihide Takahashi
- The Department of Advanced Arrhythmia ResearchTokyo Medical and Dental UniversityTokyoJapan
| | - Toon Wei Lim
- National University Heart CentreNational University HospitalSingaporeSingapore
| | - Eue‐Keun Choi
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
| | - Yi‐Hsin Chan
- Microscopy Core LaboratoryChang Gung Memorial HospitalLinkouTaoyuanTaiwan
- College of MedicineChang Gung UniversityTaoyuanTaiwan
- Microscopy Core LaboratoryChang Gung Memorial HospitalLinkouTaoyuanTaiwan
| | - Yutao Guo
- Pulmonary Vessel and Thrombotic DiseaseChinese PLA General HospitalBeijingChina
| | | | - Seil Oh
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
| | - Ken Okumura
- Division of CardiologySaiseikai Kumamoto HospitalKumamotoJapan
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool & Liverpool Heart and Chest HospitalLiverpoolUK
- Aalborg Thrombosis Research UnitDepartment of Clinical MedicineAalborg UniversityAalborgDenmark
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Wattanaruengchai P, Nathisuwan S, Karaketklang K, Wongcharoen W, Phrommintikul A, Lip GYH. Comparison of the HAS-BLED versus ORBIT scores in predicting major bleeding among Asians receiving direct-acting oral anticoagulants. Br J Clin Pharmacol 2021; 88:2203-2212. [PMID: 34783372 DOI: 10.1111/bcp.15145] [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: 08/23/2021] [Revised: 10/28/2021] [Accepted: 11/01/2021] [Indexed: 11/26/2022] Open
Abstract
AIMS This study aimed to evaluate the performance of HAS-BLED and ORBIT scores in predicting bleeding risk among Asian patients with nonvalvular atrial fibrillation (NVAF) using direct-acting oral anticoagulants (DOACs). METHODS A retrospective chart review was conducted among adult patients receiving DOACs for ≥6 months during January 2013 to December 2017 in 10 tertiary care hospitals in Thailand. The area under the receiver operating curve (AUROC) method or C-statistic was used to test the diagnostic accuracy for bleeding risk classification of HAS-BLED and ORBIT scores. The predictive performances of the two scores were compared using DeLong's method. RESULTS A total of 961 NVAF patients, 52.5% warfarin-naïve and 47.5% warfarin-experienced, with mean age of 74.25 ± 10.08 years, were included in the analysis. Mean HAS-BLED and ORBIT scores of the cohort were 1.98 ± 1.10 and 2.37 ± 1.71, respectively. During the mean follow-up time of 1.55 ± 1.13 years, 34 patients experienced major bleeding (2.28 events/100 patient-year). For the overall cohort, both the HAS-BLED and ORBIT scores showed similarly moderate predictive performance on bleeding with C-statistic (95% confidence interval) of 0.65 (0.57-0.74) and 0.64 (0.56-0.71), respectively. There was no statistical significance between the two scores (P = .62). Analysis based on the status of previous warfarin use was consistent with the overall cohort. Based on the calibration analysis, both HAS-BLED and ORBIT scores possessed moderate ability to identify those who experienced major bleeding from those who did not. CONCLUSION Both HAS-BLED and ORBIT bleeding risk scores had moderate predictive performance in Asian NVAF patients receiving DOACs.
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Affiliation(s)
| | - Surakit Nathisuwan
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Khemajira Karaketklang
- Department of Medicine, Faculty of Medicine at Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wanwarang Wongcharoen
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Arintaya Phrommintikul
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
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Lip GYH, Gue Y, Zhang J, Chao TF, Calkins H, Potpara T. Stroke Prevention in Atrial Fibrillation. Trends Cardiovasc Med 2021; 32:501-510. [PMID: 34619337 DOI: 10.1016/j.tcm.2021.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/30/2021] [Accepted: 10/01/2021] [Indexed: 10/20/2022]
Abstract
Atrial fibrillation (AF) is the commonest sustained cardiac rhythm disorder associated with an increased risk of stroke and systemic embolic events. The prevention of stroke using oral anticoagulants has been a pivotal component of AF management. The purpose of this review is to summarize recent advances in the treatment and prevention of stroke in AF over the last 5 years. We performed a comprehensive structured literature search using MEDLINE for publications from 11th March 2015 through to 31st December 2020. We focused mainly on primarily published research articles and systematic reviews including updates in different international guidelines. We found that improved awareness and detection of AF and use of clinical risk stratification are central to the identification of patients at risk of stroke who would benefit from oral anticoagulation. The recommendation of non-vitamin K antagonist oral anticoagulants over warfarin in both efficacy and safety perspective is represented in all international guidelines. Beyond stroke prevention, there is a move to more holistic or integrated care management of AF, which has been shown to improve outcomes. We conclude that stroke prevention remains a dominant part of the management of patients with AF. Not all stroke risk factors carry equal weight, and many require additional scrutiny (e.g. severity of CAD, type of diabetes, duration of hypertension). The utilization of clinical risk scores to help decision-making should take into account that these scores are mere simplification tools to aid decision-making and the additional clinical benefit with more complex risk scores and addition of biomarkers is limited. Also, stroke and bleeding risks are dynamic and require regular review. Instead of arbitrarily categorizing patients into (artificial) low, moderate, and high stroke risk strata, anticoagulation should be offered to all patients with AF unless they are low risk with no risk factors for stroke. Stroke prevention is also part of the proactive, integrated care approach to holistic management of patients with AF, which can be simplified in the ABC (Atrial fibrillation Better Care) pathway: 'A' Avoid stroke/Anticoagulation; 'B' Better symptom management emphasising patient-centred symptom directed decisions on rate or rhythm control strategies; and 'C' refers to Cardiovascular risk and comorbidity optimization, including lifestyle changes and attention to patient values and preferences, as well as the psychological morbidity associated with AF.
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Affiliation(s)
- 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.
| | - Ying Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Juqian Zhang
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - 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
| | - Hugh Calkins
- Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore MD USA
| | - Tatjana Potpara
- School of Medicine, Belgrade University; Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
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Guo Y, Wang H, Kotalczyk A, Wang Y, Lip GYH. One-year Follow-up Results of the Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry. J Arrhythm 2021; 37:1227-1239. [PMID: 34621421 PMCID: PMC8485828 DOI: 10.1002/joa3.12608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/07/2021] [Accepted: 07/21/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The high prevalence of atrial fibrillation (AF) in the very elderly population (aged >80 years) might be underestimated. The elderly are at increased risk of both fatal stroke and bleeding. The Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry provides contemporary management strategies among the elderly Chinese patients in the new era of non-vitamin K antagonists. OBJECTIVE To present the 1-year follow-up data from the ChiOTEAF registry, focusing on the use of antithrombotic therapy, rate vs. rhythm control strategies, and determinants of mortality and stroke. METHODS The ChiOTEAF registry analyzed consecutive AF patients presenting in 44 centers from 20 Chinese provinces from October 2014 to December 2018. Endpoints of interest were mortality, thromboembolism, major bleedings, cardiovascular comorbidities, and hospital re-admissions. RESULTS Of the 7077 patients enrolled at baseline, 657 patients (9.3%) were lost to the follow-up and 435 deaths (6.8%) occurred. The overall use of anticoagulants remains low, approximately 38% of the entire cohort at follow-up, with similar proportions of vitamin K antagonists (VKA) and non-vitamin K antagonists (NOACs). Antiplatelet therapy was used in 38% of the entire cohort at follow-up, and more commonly among high-risk patients (41%). Among those on a NOAC at baseline, 22.4% switched to antiplatelet therapy alone after one year.Independent predictors of stroke/transient ischemic attack/peripheral embolism and/or mortality were age, heart failure, chronic kidney disease, prior ischemic stroke, dementia, and chronic obstructive pulmonary disease. CONCLUSIONS The ChiOTEAF registry provides contemporary data on AF management, including stroke prevention. The poor adherence of NOACs and common use of antiplatelet in these high-risk elderly population calls for multiple comorbidities management.
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Affiliation(s)
- Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease Sixth Medical Centre Chinese PLA General Hospital Beijing China
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool UK
| | - Hao Wang
- Department of Cardiology Second Medical Center Chinese PLA General Hospital Beijing China
| | - Agnieszka Kotalczyk
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool UK
- Department of Cardiology Congenital Heart Diseases and Electrotherapy Medical University of Silesia Silesian Centre for Heart Diseases Zabrze Poland
| | - Yutang Wang
- Department of Cardiology Second Medical Center Chinese PLA General Hospital Beijing China
| | - Gregory Y H Lip
- Department of Pulmonary Vessel and Thrombotic Disease Sixth Medical Centre Chinese PLA General Hospital Beijing China
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool UK
- Aalborg Thrombosis Research Unit Department of Clinical Medicine Aalborg University Aalborg Denmark
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Proietti M, Romiti GF, Vitolo M, Potpara TS, Boriani G, Lip GYH. Comparison of HAS-BLED and ORBIT Bleeding Risk Scores in AF Patients treated with NOACs: A Report from the ESC-EHRA EORP-AF General Long-Term Registry. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 8:778-786. [PMID: 34555148 DOI: 10.1093/ehjqcco/qcab069] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Bleeding risk assessment is recommended in guidelines for the management of atrial fibrillation (AF). HAS-BLED score was proposed prior to non-vitamin K antagonist oral anticoagulants (NOACs) and has been suggested that the ORBIT score may be superior in predicting bleeds in NOAC users. We aimed to compare the HAS-BLED and ORBIT scores in contemporary AF patients treated with NOACs. METHODS AND RESULTS We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. HAS-BLED and ORBIT scores were computed based on original schemes. The primary outcome was the occurrence of Major Bleeding (MB). A total of 3018 patients (median age 70; 39.6% females) were included: median [IQR] HAS-BLED and ORBIT scores were 1 [1-2] and 1 [0-2], respectively; 356 (11.8%) patients were at high risk for MB using HAS-BLED (≥3) and 123 (4.1%) using ORBIT (≥4). Overall, 60 (2.0%) MB events were recorded, with an incidence of 1.1 per 100 patient-years.Both HAS-BLED and ORBIT were associated with outcome, modestly predicting MB (AUC 0.653, 95% CI 0.593-0.714 and AUC 0.601, 95% CI 0.526-0.677, respectively). Calibration plots showed that both scores were poorly calibrated, particularly the ORBIT score, which showed consistent poorer calibration. Time-dependent reclassification analysis showed a trend towards incorrect lower risk reclassification using ORBIT compared to HAS-BLED. CONCLUSION In this real-life contemporary cohort of AF patients treated with NOACs, the ORBIT score did not provide reclassification improvement, showing even poorer calibration compared to HAS-BLED. Our findings do not support the preferential use of ORBIT in NOAC-treated AF patients.
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Affiliation(s)
- Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,IRCCS Istituti Clinici Scientifici Maugeri, Milano, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Italy
| | | | - Marco Vitolo
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Intensive Arrhythmia Care, Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Italy
| | - Gregory Y H 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.,See Appendix in Supplementary Materials
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Tang CPS, Lip GYH, McCormack T, Lyon AR, Hillmen P, Iyengar S, Martinez-Calle N, Parry-Jones N, Patten PEM, Schuh A, Walewska R. Management of cardiovascular complications of bruton tyrosine kinase inhibitors. Br J Haematol 2021; 196:70-78. [PMID: 34498258 DOI: 10.1111/bjh.17788] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 08/04/2021] [Accepted: 08/07/2021] [Indexed: 12/01/2022]
Affiliation(s)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | | | | | | | | | | | | | - Anna Schuh
- Oxford University Hospitals NHS Trust, Oxford, UK
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Lip GYH, Ntaios G. "Novel Clinical Concepts in Thrombosis": Integrated Care for Stroke Management-Easy as ABC. Thromb Haemost 2021; 122:316-319. [PMID: 34474499 DOI: 10.1055/a-1632-1777] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Gregory Y H 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
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Lip GYH, Genaidy A, Tran G, Marroquin P, Estes C. Incident atrial fibrillation and its risk prediction in patients developing COVID-19: A machine learning based algorithm approach. Eur J Intern Med 2021; 91:53-58. [PMID: 34023150 PMCID: PMC8118660 DOI: 10.1016/j.ejim.2021.04.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 04/20/2021] [Accepted: 04/22/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The elderly multi-morbid patient is at high risk of adverse outcomes with COVID-19 complications, and in the general population, the development of incident AF is associated with worse outcomes in such patients. There is therefore the need to identify those patients with COVID-19 who are at highest risk of developing incident AF. We therefore investigated incident AF risks in a large prospective population of elderly patients with/without incident COVID-19 cases and baseline cardiovascular/non-cardiovascular multi-morbidities. We used two approaches: main effect modeling and secondly, a machine-learning (ML) approach, accounting for the complex dynamic relationships among comorbidity variables. METHODS We studied a prospective elderly US cohort of 280,592 patients from medical databases in an 8-month investigation of with/without newly incident COVID19 cases. Incident AF outcomes were examined in relationship to diverse multi-morbid conditions, COVID-19 status and demographic variables, with ML accounting for the dynamic nature of changing multimorbidity risk factors. RESULTS Multi-morbidity contributed to the onset of confirmed COVID-19 cases with cognitive impairment (OR 1.69; 95%CI 1.52-1.88), anemia (OR 1.41; 95%CI 1.32-1.50), diabetes mellitus (OR 1.35; 95%CI 1.27-1.44) and vascular disease (OR 1.30; 95%CI 1.21-1.39) having the highest associations. A main effect model (C-index value 0.718) showed that COVID-19 had the highest association with incident AF cases (OR 3.12; 95%CI 2.61-3.710, followed by congestive heart failure (1.72; 95%CI 1.50-1.96), then coronary artery disease (OR 1.43; 95%CI 1.27-1.60) and valvular disease (1.42; 95%CI 1.26-1.60). The ML algorithm demonstrated improved discriminatory validity incrementally over the statistical main effect model (training: C-index 0.729, 95%CI 0.718-0.740; validation: C-index 0.704, 95%CI 0.687-0.72). Calibration of the ML based formulation was satisfactory and better than the main-effect model. Decision curve analysis demonstrated that the clinical utility for the ML based formulation was better than the 'treat all' strategy and the main effect model. CONCLUSION COVID-19 status has major implications for incident AF in a cohort with diverse cardiovascular/non-cardiovascular multi-morbidities. Our ML approach accounting for dynamic multimorbidity changes had good prediction for new onset AF amongst incident COVID19 cases.
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Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
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Proietti M, Vitolo M, Harrison SL, Lane DA, Fauchier L, Marin F, Nabauer M, Potpara TS, Dan GA, Boriani G, Lip GYH. Real-world applicability and impact of early rhythm control for European patients with atrial fibrillation: a report from the ESC-EHRA EORP-AF Long-Term General Registry. Clin Res Cardiol 2021; 111:70-84. [PMID: 34448931 PMCID: PMC8766399 DOI: 10.1007/s00392-021-01914-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/20/2021] [Indexed: 12/12/2022]
Abstract
Background Use of rate/rhythm control is essential to control symptoms in patients with atrial fibrillation (AF). Recently, the EAST-AFNET 4 trial described how early rhythm control strategy was associated with a lower risk of adverse clinical outcomes. Objectives The aim was to evaluate the real-world applicability and impact of an early rhythm control strategy in patients with AF. Methods Use of an early rhythm control strategy was assessed in a European cohort of AF patients derived from the EHRA-ESC EORP-AF General Long-Term Registry. Early rhythm control was defined as use of antiarrhythmic drugs or cardioversion/catheter ablation. The primary outcome included cardiovascular death, stroke, acute coronary syndrome, and worsening of heart failure. Quality of life and health-care resource usage were also assessed as outcomes. Results Among the 10,707 patients evaluated for eligibility to EAST-AFNET 4, a total of 3774 (34.0%) were included. Early rhythm control was associated with better quality of life, but with greater use of health-care resources. During follow-up, the primary outcome occurred less often in early rhythm control patients than in those with no rhythm control (13.6% vs. 18.5%, p < 0.001). In the multivariate adjusted Cox regression model, no significant difference was found between no rhythm control and early rhythm control, for the primary outcome. No difference in the primary outcome between early rhythm control and ‘no rhythm control patients’ adherent to Atrial fibrillation Better Care (ABC) pathway’ was evident (p = 0.753) Conclusions Use of an early rhythm control strategy was associated with a lower rate of major adverse events, but this difference was non-significant on multivariate analysis, being mediated by differences in baseline characteristics and clinical risk profile. Early rhythm control was associated with a higher use of health-care resources and risk of hospital admission, despite showing better quality of life. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s00392-021-01914-y.
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Affiliation(s)
- Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK. .,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy. .,Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy.
| | - Marco Vitolo
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.,Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Stephanie L Harrison
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Tours, France
| | - Francisco Marin
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, CIBERCV, Murcia, Spain
| | - Michael Nabauer
- Department of Cardiology, Ludwig-Maximilians-University, Munich, Germany
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Intensive Arrhythmia Care, Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Gheorghe-Andrei Dan
- Colentina University Hospital, 'Carol Davila' University of Medicine, Bucharest, Romania
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK. .,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Kotalczyk A, Lip GY, Calkins H. The 2020 ESC Guidelines on the Diagnosis and Management of Atrial Fibrillation. Arrhythm Electrophysiol Rev 2021; 10:65-67. [PMID: 34401177 PMCID: PMC8335854 DOI: 10.15420/aer.2021.07] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/12/2021] [Indexed: 12/20/2022] Open
Affiliation(s)
- Agnieszka Kotalczyk
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Hugh Calkins
- Electrophysiology Laboratory and Arrhythmia Service, Johns Hopkins Hospital, Baltimore, MD, US
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Guo Y, Kotalczyk A, Imberti JF, Wang Y, Lip GYH. Quality indicators in the management of elderly Chinese patients with atrial fibrillation: A report from the Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 8:651-658. [PMID: 34390242 DOI: 10.1093/ehjqcco/qcab057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/03/2021] [Accepted: 08/09/2021] [Indexed: 02/07/2023]
Abstract
AIMS The management of patients with atrial fibrillation (AF) requires a holistic, multidisciplinary approach. Quality indicators have been proposed to assess the quality of care in 'real-world' clinical practice when managing patients with AF. AIM To evaluate the quality measures and clinical performance indicators among elderly Chinese patients with AF. METHODS AND RESULTS The Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry is a prospective, observational, large-scale multicentre registry conducted between October 2014 and December 2018 in China. Data were collected at the enrolment and during the follow-up visits by the local investigators.In the ChiOTEAF registry, 14 of primary and 8 of secondary indicators from six domains of care were assessed. 6420 patients who completed the 1-year follow-up were included in the analysis. Median age was 76 years, and the majority of patients were male (60.8%). Overall, 3246 patients (54.8%) were not treated with oral anticoagulants (OACs) appropriate to their risk of stroke; specifically, among those at highest risk of stroke, OACs were prescribed in only 43.3% patients (1258/2905). Among patients with permanent AF, 32 (3.6%) were prescribed antiarrhythmic drugs (AADs), and among those with paroxysmal AF, catheter ablation was performed in 20.7%. Patients were overburdened with multi-morbidities, including hypertension, diabetes mellitus, obesity and sleep apnea. During 1-year follow-up, 435 deaths (6.8%) and 89 thromboembolic events (1.4%) occurred. Patient-reported outcomes showed that 55% of patients had indicators of reduced quality of life. CONCLUSIONS Assessment of quality indicators revealed the gaps in AF care among Chinese patients, highlighting the need for a more integrated or holistic approach to AF management.
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Affiliation(s)
- Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Centre, Chinese PLA General Hospital, Beijing, 100142.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Agnieszka Kotalczyk
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Jacopo F Imberti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Yutang Wang
- Department of Cardiology, Second Medical Centre, Chinese PLA General Hospital, Beijing, 100853
| | - Gregory Y H Lip
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Centre, Chinese PLA General Hospital, Beijing, 100142.,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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Lip GYH, Keshishian AV, Zhang Y, Kang A, Dhamane AD, Luo X, Klem C, Ferri M, Jiang J, Yuce H, Deitelzweig S. Oral Anticoagulants for Nonvalvular Atrial Fibrillation in Patients With High Risk of Gastrointestinal Bleeding. JAMA Netw Open 2021; 4:e2120064. [PMID: 34398204 PMCID: PMC8369361 DOI: 10.1001/jamanetworkopen.2021.20064] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Many patients with nonvalvular atrial fibrillation (NVAF) are at a high risk of gastrointestinal (GI) bleeding due to conditions including older age; stage III to V chronic kidney disease (CKD); HAS-BLED (hypertension, kidney or liver disease, stroke history, prior bleeding, unstable international normalized ratio, age >65, drug or alcohol use) score of 3 or greater; corticosteroid, antiplatelet or nonsteroidal anti-inflammatory drug (NSAID) use; or GI conditions. OBJECTIVE To compare the risk of stroke and/or systemic embolism (SE) and major bleeding (MB) among patients with NVAF and high risk of GI bleeding who received non-vitamin K antagonist oral anticoagulants (NOACs) vs those who received warfarin. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included patients with NVAF who were 75 years and older; had stage III to V CKD; had an HAS-BLED score of 3 or greater; used corticosteroids, antiplatelets, or NSAIDs; or had GI conditions. Data were collected from the Centers for Medicare & Medicaid Services and 4 commercial insurance databases between January 1, 2012, and September 30, 2015. Data analysis was conducted from January 2012 to September 2015. EXPOSURES New prescription for apixaban, dabigatran, rivaroxaban, or warfarin between January 1, 2013, and September 30, 2015 (identification period). MAIN OUTCOMES AND MEASURES Six propensity score-matched cohorts were created to compare between study drugs. For the primary objective, Cox models were used to estimate stroke and/or SE and MB hazard ratios (HRs). RESULTS A total of 381 054 patients (187 489 [49.2%] women) with NVAF and at least 1 high-risk GI bleeding factor were identified (HAS-BLED score ≥3: 284 527 [74.7%]; aged ≥75 years: 252 835 [66.4%]; corticosteroid, antiplatelet, or NSAID therapy: 107 675 [28.3%]; prior GI bleeding conditions: 74 818 [19.6%]; and stage III-V CKD: 56 892 [14.9%]). All NOACs were associated with a lower risk of stroke and/or SE vs warfarin (apixaban: HR, 0.60; 95% CI, 0.52-0.68; dabigatran: HR, 0.75; 95% CI, 0.64-0.88; rivaroxaban: HR, 0.79; 95% CI, 0.73-0.86). Compared with warfarin, apixaban and dabigatran were associated with a lower risk of MB (apixaban: HR, 0.59; 95% CI, 0.56-0.63; dabigatran: HR, 0.78; 95% CI, 0.70-0.86), while rivaroxaban was associated with a higher risk (HR, 1.11; 95% CI, 1.05-1.16). CONCLUSIONS AND RELEVANCE In this study of patients with NVAF and high risk of GI bleed, NOACs were associated with lower rates of stroke and/or SE, but NOACs had varying risks of MB compared with warfarin. These results may help inform treatment options in this patient population.
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Affiliation(s)
- 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
- Ochsner Clinic Foundation, Department of Hospital Medicine, New Orleans, Louisiana
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana
| | - Allison V. Keshishian
- STATinMED Research, Ann Arbor, Michigan
- New York City College of Technology, City University of New York
| | - Yan Zhang
- Bristol Myers Squibb Company, Lawrenceville, New Jersey
| | - Amiee Kang
- Bristol Myers Squibb Company, Lawrenceville, New Jersey
| | | | | | | | | | - Jenny Jiang
- Bristol Myers Squibb Company, Lawrenceville, New Jersey
| | - Huseyin Yuce
- New York City College of Technology, City University of New York
| | - Steven Deitelzweig
- Ochsner Clinic Foundation, Department of Hospital Medicine, New Orleans, Louisiana
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana
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