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Anticoagulation in older people with atrial fibrillation moving to care homes: a data linkage study. Br J Gen Pract 2023; 73:e43-e51. [PMID: 36543561 PMCID: PMC9799341 DOI: 10.3399/bjgp.2022.0156] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 10/17/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Treatment decisions about oral anticoagulants (OACs) for atrial fibrillation (AF) are complex in older care home residents. AIM To explore factors associated with OAC prescription. DESIGN AND SETTING Retrospective cohort study set in care homes in Wales, UK, listed in the Care Inspectorate Wales Registry 2017/18. METHOD Analysis of anonymised individual-level electronic health and administrative data was carried out on people aged ≥65 years entering a care home between 1 January 2003 and 31 December 2018, provisioned from the Secure Anonymised Information Linkage Databank. RESULTS Between 2003 and 2018, 14 493 people with AF aged ≥65 years became new residents in care homes in Wales and 7057 (48.7%) were prescribed OACs (32.7% in 2003 compared with 72.7% in 2018) within 6 months before care home entry. Increasing age and prescription of antiplatelet therapy were associated with lower odds of OAC prescription (adjusted odds ratio [aOR] 0.96 per 1-year age increase, 95% confidence interval [CI] = 0.95 to 0.96 and aOR 0.91, 95% CI = 0.84 to 0.98, respectively). Conversely, prior venous thromboembolism (aOR 4.06, 95% CI = 3.17 to 5.20), advancing frailty (mild: aOR 4.61, 95% CI = 3.95 to 5.38; moderate: aOR 6.69, 95% CI = 5.74 to 7.80; and severe: aOR 8.42, 95% CI = 7.16 to 9.90), and year of care home entry from 2011 onwards (aOR 1.91, 95% CI = 1.76 to 2.06) were associated with higher odds of an OAC prescription. CONCLUSION There has been an increase in OAC prescribing in older people newly admitted to care homes with AF. This study provides an insight into the factors influencing OAC prescribing in this population.
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Ritchie LA, Oke OB, Harrison SL, Rodgers SE, Lip GYH, Lane DA. Prevalence of atrial fibrillation and outcomes in older long-term care residents: a systematic review. Age Ageing 2021; 50:744-757. [PMID: 33951148 DOI: 10.1093/ageing/afaa268] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND anticoagulation is integral to stroke prevention for atrial fibrillation (AF), but there is evidence of under-treatment in older people in long-term care (LTC). OBJECTIVE to synthesise evidence on the prevalence and outcomes (stroke, mortality or bleeding) of AF in LTC and the factors associated with the prescription of anticoagulation. METHODS studies were identified from Medline, CINAHL, PsycINFO, Scopus and Web of Science from inception to 31 October 2019. Two reviewers independently applied the selection criteria and assessed the quality of studies using the Newcastle Ottawa Scale. RESULTS twenty-nine studies were included. Prevalence of AF was reported in 21 studies, ranging from 7 to 38%. Two studies reported on outcomes based on the prescription of anticoagulation or not; one reported a reduction in the ischaemic stroke event rate associated with anticoagulant (AC) prescription (2.84 per 100 person years, 95% confidence interval [CI]: 1.98-7.25 versus 3.95, 95% CI: 2.85-10.08) and a non-significant increase in intracranial haemorrhage rate (0.71 per 100 person years, 95% CI: 0.29-2.15 versus 0.65, 95% CI: 0.29-1.93). The second study reported a 76% lower chance of ischaemic stroke with AC prescription and a low incidence of bleeding (n = 4 events). Older age, dementia/cognitive impairment and falls/falls risk were independently associated with the non-prescription of anticoagulation. Conversely, previous stroke/transient ischaemic attack and thromboembolism were independently associated with an increased prescription of anticoagulation. CONCLUSION estimates of AF prevalence and factors associated with AC prescription varied extensively. Limited data on outcomes prevent the drawing of definitive conclusions. We recommend panel data collection and systems for linkage to create longitudinal cohorts to provide more robust evidence.
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Affiliation(s)
- Leona A Ritchie
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Oluwakayode B Oke
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Stephanie L Harrison
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Sarah E Rodgers
- Institute of Population Health and the Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Gregory Y H Lip
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Deirdre A Lane
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Suzuki S, Wadi L, Moores L, Yuki I, Kim J, Xu J, Paganini-Hill A, Fisher M. Stroke Preventability in Large Vessel Occlusion Treated With Mechanical Thrombectomy. Front Neurol 2021; 12:608084. [PMID: 33763011 PMCID: PMC7982657 DOI: 10.3389/fneur.2021.608084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 01/28/2021] [Indexed: 12/01/2022] Open
Abstract
Objective: The preventability of strokes treated by mechanical thrombectomy is unknown. The purpose of this study was to analyze stroke preventability for patients treated with mechanical thrombectomy for large vessel occlusion. Methods: We conducted retrospective analyses of 300 patients (mean ± SE age 69 ± 0.9 years, range 18–97 years; 53% male) treated with mechanical thrombectomy for large vessel occlusion from January 2008 to March 2019. We collected data including demographics, NIH Stroke Scale (NIHSS) at onset, and (beginning in 2015) classified 90-day outcome by modified Rankin Scale (mRS). Patients were evaluated using a Stroke Preventability Score (SPS, 0 to 10 points) based on how well patients had been treated given their hypertension, hyperlipidemia, atrial fibrillation, and prior stroke history. We examined the relationship of SPS with NIHSS at stroke onset and with mRS outcome at 90 days. Results: SPS was calculated for 272 of the 300 patients, with mean ± SE of 2.1 ± 0.1 (range 0–8); 89 (33%) had no preventability (score 0), 120 (44%) had low preventability (score 1–3), and 63 (23%) had high preventability (score 4 or higher). SPS was significantly correlated with age (r = 0.32, p < 0.0001), while NIHSS (n = 267) was significantly higher (p = 0.03) for patients with high stroke preventability vs. low/no preventability [18.8 ± 0.92 (n = 62) vs. 16.5 ± 0.51 (n = 205)]. Among 118 patients with mRS, outcome was significantly worse (p = 0.04) in patients with high stroke preventability vs. low/no preventability [4.7 ± 0.29 (n = 28) vs. 3.8 ± 0.21 (n = 90)]. The vast majority of patients with high stroke preventability had inadequately treated atrial fibrillation (85%, 53/62). Conclusions: Nearly one quarter of stroke patients undergoing mechanical thrombectomy had highly preventable strokes. While stroke preventability showed some relationship to stroke severity at onset and outcome after treatment, preventability had the strongest association with age. These findings emphasize the need for improved stroke prevention in the elderly.
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Affiliation(s)
- Shuichi Suzuki
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Lara Wadi
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Lisa Moores
- UC Irvine Medical Center, Orange, CA, United States
| | - Ichiro Yuki
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Jeein Kim
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Jordan Xu
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Annlia Paganini-Hill
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Mark Fisher
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 5340] [Impact Index Per Article: 1780.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Alcusky M, McManus DD, Hume AL, Fisher M, Tjia J, Lapane KL. Changes in Anticoagulant Utilization Among United States Nursing Home Residents With Atrial Fibrillation From 2011 to 2016. J Am Heart Assoc 2020; 8:e012023. [PMID: 31046504 PMCID: PMC6512099 DOI: 10.1161/jaha.119.012023] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background Nursing home residents with atrial fibrillation are at high risk for ischemic stroke and bleeding events. The most recent national estimate (2004) indicated less than one third of this high‐risk population was anticoagulated. Whether direct‐acting oral anticoagulant (DOAC) use has disseminated into nursing homes and increased anticoagulant use is unknown. Methods and Results A repeated cross‐sectional design was used to estimate the point prevalence of oral anticoagulant use on July 1 and December 31 of calendar years 2011 to 2016 among Medicare fee‐for‐service beneficiaries with atrial fibrillation residing in long‐stay nursing homes. Nursing home residence was determined using Minimum Data Set 3.0 records. Medicare Part D claims for apixaban, dabigatran, edoxaban, rivaroxaban, and warfarin were identified and point prevalence was estimated by determining if the supply from the most recent dispensing covered each point prevalence date. A Cochran‐Armitage test was performed for linear trend in prevalence. On December 31, 2011, 42.3% of 33 959 residents (median age: 85; Q1 79, Q3 90) were treated with an oral anticoagulant, of whom 8.6% used DOACs. The proportion receiving treatment increased to 47.8% of 37 787 residents as of December 31, 2016 (P<0.01); 48.2% of 18 054 treated residents received DOACs. Demographic and clinical characteristics of residents using DOACs and warfarin were similar in 2016. Half of the 8734 DOAC users received standard dosages and most were treated with apixaban (54.4%) or rivaroxaban (35.8%) in 2016. Conclusions Increases in anticoagulant use among US nursing home residents with atrial fibrillation coincided with declining warfarin use and increasing DOAC use.
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Affiliation(s)
- Matthew Alcusky
- Department of Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
| | - David D. McManus
- Department of Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
- Division of Cardiovascular MedicineDepartment of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Anne L. Hume
- Department of Pharmacy PracticeCollege of PharmacyUniversity of Rhode IslandKingstonRI
| | - Marc Fisher
- Department of NeurologyBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMA
| | - Jennifer Tjia
- Department of Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Kate L. Lapane
- Department of Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
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Mittal VS, Wu B, Song J, Milentijevic D, Ashton V, Mahajan D. Healthcare resource utilization and costs among nonvalvular atrial fibrillation patients initiating rivaroxaban or warfarin in skilled nursing facilities: a retrospective cohort study. Curr Med Res Opin 2020; 36:529-536. [PMID: 31858841 DOI: 10.1080/03007995.2019.1706464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Objective: Atrial fibrillation (AF) is present in up to 17% of patients in skilled nursing facilities (SNFs). This study compared healthcare resource utilization (HRU) and costs between AF patients initiating rivaroxaban or warfarin in SNFs.Methods: Using de-identified claims from Optum Clinformatics Extended Data Mart (1 January 2013 to 31 December 2017), this retrospective cohort study indexed AF patients with first SNF admission during which rivaroxaban or warfarin was initiated within 3 days of admission. To adjust for selection bias, inverse probability of treatment weighting (IPTW) was applied for baseline characteristics. Logistic regression and generalized linear models were used to compare HRU and costs.Results: 519 rivaroxaban and 1129 warfarin patients met inclusion criteria. After IPTW, the cohorts were well balanced for baseline characteristics. The average length of index SNF stay was 32.07 and 37.44 days for rivaroxaban and warfarin patients, respectively. During SNF stay, rivaroxaban patients had 27% lower odds of hospitalization (p < .0001), 2.7 fewer international normalized ratio (INR) tests per-patient-per-month (PPPM; p < .001), and 2.3 fewer pathology/laboratory encounters PPPM (p < .0001) than warfarin patients. All-cause healthcare costs were $2638 lower with rivaroxaban versus warfarin (p < .0001) during the index SNF stay, with lower medical costs (p < .0001) but higher pharmacy costs (p < .0001). Total all-cause healthcare costs 100 days post-index SNF were $8746 lower with rivaroxaban versus warfarin (p < .0001).Conclusions: In the SNF setting, AF patients treated with rivaroxaban had 5-day shorter length of stay, lower HRU, and lower all-cause total and medical costs compared to warfarin, despite higher treatment costs. These findings may help inform clinical decision-making to reduce economic burden.
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Affiliation(s)
- V Simon Mittal
- Advanced Health Institute and LTC Professionals, Bloomington, MN, USA
| | - Bingcao Wu
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
| | - Ji Song
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
| | | | | | - Dheeraj Mahajan
- University of Illinois at Chicago and Advocate Illinois Masonic Medical Center, Melrose Park, IL, USA
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Alcusky M, Hume AL, Fisher M, Tjia J, Goldberg RJ, McManus DD, Lapane KL. Dabigatran Versus Rivaroxaban for Secondary Stroke Prevention in Patients with Atrial Fibrillation Rehabilitated in Skilled Nursing Facilities. Drugs Aging 2018; 35:1089-1098. [PMID: 30421391 PMCID: PMC6326174 DOI: 10.1007/s40266-018-0610-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Thromboembolic and bleeding risk are elevated in older patients with atrial fibrillation and prior stroke. We compared dabigatran with rivaroxaban for secondary prevention in a national population after skilled nursing facility (SNF) discharge. METHODS Medicare fee-for-service beneficiaries aged ≥ 65 years with atrial fibrillation hospitalized for ischemic stroke (November 2011-October 2013) and subsequently admitted to an SNF were studied. Dabigatran (n = 332) and rivaroxaban users (n = 378) were compared in a retrospective, active comparator, new-user cohort. The index medication claim occurred within 120 days after hospital discharge and exposure continued until a 14-day treatment gap ('as treated'). The primary net clinical benefit outcome was the time to recurrent stroke, transient ischemic attack, intracranial hemorrhage, extracranial bleed, myocardial infarction, venous thromboembolism, or death. All-cause mortality was evaluated separately as a secondary outcome. Multivariable adjusted Cox models stratified by dosage estimated hazard ratios (aHR). RESULTS Among those receiving low dosages, the crude composite event rate was 40.4/100 person-years among dabigatran users and 33.7/100 person-years among rivaroxaban users. The composite outcome [aHR 1.48; 95% confidence interval (CI) 0.87-2.51] and all-cause mortality (aHR 1.67; 95% CI 0.84-3.31) rates were higher among low-dose dabigatran users. For those receiving standard doses, the crude composite event rates were 19.5/100 person-years for dabigatran users and 37.1/100 person-years for rivaroxaban users. Although no difference in mortality was observed, the composite outcome rate was lower among standard-dose dabigatran users (aHR 0.65; 95% CI 0.36-1.15). CONCLUSIONS In older adults treated with direct-acting oral anticoagulants after ischemic stroke, outcome rates varied considerably by drug and dosage.
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Affiliation(s)
- Matthew Alcusky
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.
| | - Anne L Hume
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jennifer Tjia
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert J Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - David D McManus
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Kate L Lapane
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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Fawzy AM, Lip GYH. Anticoagulation in elderly patients with nonvalvular atrial fibrillation: A balancing act. Heart Rhythm 2018; 16:38-40. [PMID: 30240797 DOI: 10.1016/j.hrthm.2018.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Ameenathul M Fawzy
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
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Frain B, Castelino R, Bereznicki LR. The Utilization of Antithrombotic Therapy in Older Patients in Aged Care Facilities With Atrial Fibrillation. Clin Appl Thromb Hemost 2017; 24:519-524. [PMID: 28068791 DOI: 10.1177/1076029616686421] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Oral anticoagulants are essential drugs for the prevention of thromboembolic events in patients with atrial fibrillation (AF). Anticoagulants are, however, commonly withheld in older people due to the risk and fear of hemorrhage. Although the underutilization of anticoagulants in patients with AF has been demonstrated internationally, few studies have been conducted among aged care residents. The aim of this study was to determine the utilization of anticoagulants among people with AF residing in aged care facilities. We performed a non-experimental, retrospective analysis designed to evaluate antithrombotic usage in patients with AF in Australia residing in aged care facilities, using data collected by pharmacists while performing Residential Medication Management Reviews (RMMRs). The utilization of antithrombotic therapy and the appropriateness of therapy were determined based on the CHADS2, CHA2DS2-VASc, and HAS-BLED risk stratification schemes in consideration of documented contraindications to treatment. Predictors of anticoagulant use were determined using multivariate logistic regression. A total of 1952 RMMR patients with AF were identified. Only 35.6% of eligible patients (CHADS2 score ≥2 and no contraindications to anticoagulants) received an anticoagulant. As age increased, the likelihood of receiving an anticoagulant decreased and the likelihood of receiving an antiplatelet or no therapy increased. In patients at high risk of stroke (CHADS score ≥2), utilization of anticoagulants dropped by 19.7% when the HAS-BLED score increased from 2 to 3, suggesting that physicians placed a heavier weighting on bleeding risk rather than stroke risk. Prescribing of anticoagulants was influenced to a greater extent by bleeding risk than it was by the risk of stroke. Further research investigating whether the growing availability of direct oral anticoagulants influences practice in this patient population is needed.
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Affiliation(s)
- Bridget Frain
- 1 Unit for Medication Outcomes Research and Education, Division of Pharmacy, School of Medicine, Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
| | - Ronald Castelino
- 1 Unit for Medication Outcomes Research and Education, Division of Pharmacy, School of Medicine, Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
| | - Luke R Bereznicki
- 1 Unit for Medication Outcomes Research and Education, Division of Pharmacy, School of Medicine, Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
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Clinical Update on Nursing Home Medicine: 2015. J Am Med Dir Assoc 2015; 16:911-22. [DOI: 10.1016/j.jamda.2015.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 09/02/2015] [Indexed: 01/21/2023]
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Hanon O, Vidal JS, Pisica-Donose G, Benattar-Zibi L, Bertin P, Berrut G, Corruble E, Derumeaux G, Falissard B, Forette F, Pasquier F, Pinget M, Ourabah R, Becquemont L, Danchin N. Therapeutic management in ambulatory elderly patients with atrial fibrillation: the S.AGES cohort. J Nutr Health Aging 2015; 19:219-27. [PMID: 25651449 DOI: 10.1007/s12603-015-0444-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
UNLABELLED Few epidemiologic studies have specifically focused on very old community dwelling population with atrial fibrillation (AF). The objectives of the AF-S.AGES cohort were to describe real-life therapeutic management of non-institutionalized elderly patients with AF according to age groups, i.e., 65-79 and ≥ 80 and to determine the main factors associated with anticoagulant treatment in both groups. METHODS Observational study (N=1072) aged ≥ 65 years old, recruited by general practitioners. Characteristics of the sample were first evaluated in the overall sample and according to age (< 80 or ≥ 80 years) and to use of anticoagulant treatment at inclusion. Logistic models were used to analyze the determinants of anticoagulant prescription among age groups. RESULTS Mean age was 78.0 (SD=6.5) years and 42% were ≥ 80 years. Nineteen percent had paroxysmal AF, 15% persistent, 56% permanent and 10% unknown type, 77% were treated with vitamin K antagonists (VKA), 17% with antiplatelet therapy with no differences between age groups. Rate-control drugs were more frequently used than rhythm-control drugs (55% vs. 37%, p < 0.001). VKA use was associated with permanent AF, younger age and cancer in patients ≥ 80 years old and with permanent AF and preserved functional autonomy in patients < 80 years old. Hemorrhagic scores were independently associated with non-use of VKA whereas thromboembolic scores were not associated with VKA use. CONCLUSIONS In this elderly AF outpatient population, use of anticoagulant therapy was higher even after 80 years than in previous studies suggesting that recent international guidelines are better implemented in the elderly population.
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Affiliation(s)
- O Hanon
- Professor O. Hanon, Hôpital Broca, Service de Gérontologie, 54-56 rue Pascal, Paris, 75013, France. E-mail: , Tel: + 33 1 44 08 30 30, Fax: + 33 1 44 08 35 10
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Zhang JT, Chen KP, Zhang S. Efficacy and safety of oral anticoagulants versus aspirin for patients with atrial fibrillation: a meta-analysis. Medicine (Baltimore) 2015; 94:e409. [PMID: 25634169 PMCID: PMC4602973 DOI: 10.1097/md.0000000000000409] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The purpose of this study was to perform a meta-analysis comparing the effectiveness and safety of anticoagulation to antiplatelet therapy for the prevention of thromboembolic events in patients with atrial fibrillation (AF). MEDLINE, Cochrane, EMBASE, and Google Scholar databases were searched for studies published through May 31, 2014. Randomized controlled trials comparing anticoagulants (warfarin) and antiplatelet therapy in patients with AF were included. The primary outcomes were the rates of stroke and systemic embolism. Secondary outcomes included the rates of hemorrhage/major bleeding and death. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Nine reports of 8 trials that enrolled 4363 patients (2169 patients received anticoagulation and 2194 antiplatelet therapy) were included. All of the studies compared adjusted-dose warfarin or with aspirin, and the majority of the patients were >70 years of age. Anticoagulants were titrated to an international normalized ratio (INR) of 2.0 to 4.5, and aspirin was administered at a dosage of 75 to 325 mg/d. Death occurred in 206 participants treated with an anticoagulant and 229 participants treated with antiplatelet therapy. There was no significant difference in the overall stroke rate between the groups (OR = 0.667, 95% CI 0.426-1.045, P = 0.08); however, patients with nonrheumatic AF (NRAF) treated with an anticoagulant had a lower risk of stroke (OR = 0.557, 95% CI 0.411-0.753, P < 0.001). Anticoagulants were associated with a lower risk of embolism (OR = 0.616, 95% CI = 0.392-0.966, P = 0.04), and this finding persisted in patients with NRAF (OR = 0.581, 95% CI 0.359-0.941, P = 0.03). No significant difference in the rate of hemorrhage/major bleeding was noted (OR = 1.497, 95% CI 0.730-3.070, P = 0.27), and this finding persisted on subgroup analysis. Anticoagulants appear to be more effective than aspirin in preventing embolisms in patients with AF, as the risk of bleeding is not increased.
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Affiliation(s)
- Jing-Tao Zhang
- From the Cardiac Arrhythmia Center (J-TZ, K-PC, SZ), Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Beijing 100037, China
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Abstract
Atrial fibrillation (AF) is a major public health burden worldwide, and its prevalence is set to increase owing to widespread population ageing, especially in rapidly developing countries such as Brazil, China, India, and Indonesia. Despite the availability of epidemiological data on the prevalence of AF in North America and Western Europe, corresponding data are limited in Africa, Asia, and South America. Moreover, other observations suggest that the prevalence of AF might be underestimated-not only in low-income and middle-income countries, but also in their high-income counterparts. Future studies are required to provide precise estimations of the global AF burden, identify important risk factors in various regions worldwide, and take into consideration regional and ethnic variations in AF. Furthermore, in response to the increasing prevalence of AF, additional resources will need to be allocated globally for prevention and treatment of AF and its associated complications. In this Review, we discuss the available data on the global prevalence, risk factors, management, financial costs, and clinical burden of AF, and highlight the current worldwide inadequacy of its treatment.
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Frequency of acute changes found on head computed tomographies in critically ill patients: a retrospective cohort study. J Crit Care 2014; 29:884.e7-12. [PMID: 24927985 DOI: 10.1016/j.jcrc.2014.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 04/29/2014] [Accepted: 05/01/2014] [Indexed: 12/20/2022]
Abstract
PURPOSE The frequency of positive findings on computed tomography (CT) of the head in critically ill patients who develop neurologic dysfunction is not known. MATERIALS AND METHODS Cohort study of head CTs for patients admitted to 3 intensive care units from 2005 to 2010. We documented the frequency of acute changes for all head CTs and for the subgroup of patients with altered mental status (AMS). We also examined associations between patient characteristics or medications administered before head CT and the odds of an acute change on head CT using multivariate logistic regression. RESULTS During 11 338 intensive care unit admissions, there were 901 eligible head CTs on 706 patients (6% of patients). Among head CTs, 155 (17.2%) assessed concern of new focal deficit, 99 (11.0%) concern for a seizure, and 635 (70.5%) for AMS. Acute changes were found on 109 (12.1%; 95% confidence interval [CI], 10.0%-14.2%) of all head CTs, and 30% (22.4%-36.9%) of patients with focal deficits, 16.2% (8.8%-23.5%) of patients with seizures but only 7.4% (5.4%-9.4%) for patients with AMS. A diagnosis of sepsis was associated with a decreased odds of an acute change on head CT for all head CTs (odds ratio 0.61; 95% CI, 0.40-0.95; P = .028) but was not significantly associated with a decreased risk among the cohort of head CTs for AMS (odds ratio 0.82; 95% CI, 0.41-1.62; P = .56). No other factors were associated with an altered risk of acute change on head CT for all patients in our cohort or for those with AMS. CONCLUSIONS Acute changes on head CTs performed for concern regarding new focal neurologic deficit or seizures are frequent compared with those performed for AMS with a nonfocal examination. No specific patient characteristics or medications were associated with a large change in the likelihood of finding an acute change for patients with AMS.
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Reardon G, Nelson WW, Patel AA, Philpot T, Neidecker M. Warfarin for prevention of thrombosis among long-term care residents with atrial fibrillation: evidence of continuing low use despite consideration of stroke and bleeding risk. Drugs Aging 2013; 30:417-28. [PMID: 23456440 PMCID: PMC3663250 DOI: 10.1007/s40266-013-0067-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objectives The aims of the study were to evaluate usage rates of warfarin in stroke prophylaxis and the association with assessed stages of stroke and bleeding risk in long-term care (LTC) residents with atrial fibrillation (AFib). Methods A cross-sectional analysis of two LTC databases (the National Nursing Home Survey [NNHS] 2004 and an integrated LTC database: AnalytiCare) was conducted. The study involved LTC facilities across the USA (NNHS) and within 19 states (AnalytiCare). It included LTC residents diagnosed with AFib (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] diagnostic code 427.3X). Consensus guideline algorithms were used to classify residents by stroke risk categories: low (none or 1+ weak stroke risk factors), moderate (1 moderate), high (2+ moderate or 1+ high). Residents were also classified by number of risk factors for bleeding (0–1, 2, 3, 4+). Current use of warfarin was assessed. A logistic regression model predicted odds of warfarin use associated with the stroke and bleeding risk categories. Results The NNHS and AnalytiCare databases had 1,454 and 3,757 residents with AFib, respectively. In all, 34 % and 45 % of residents with AFib in each respective database were receiving warfarin. Only 36 % and 45 % of high-stroke-risk residents were receiving warfarin, respectively. In the logistic regression model for the NNHS data, when compared with those residents having none or 1+ weak stroke risk and 0–1 bleeding risk factors, the odds of receiving warfarin increased with stroke risk (odds ratio [OR] = 1.93, p = 0.118 [1 moderate risk factor]; OR = 3.19, p = 0.005 [2+ moderate risk factors]; and OR = 8.18, p ≤ 0.001 [1+ high risk factors]) and decreased with bleeding risk (OR = 0.83, p = 0.366 [2 risk factors]; OR = 0.47, p ≤ 0.001 [3 risk factors]; OR = 0.17, p ≤ 0.001 [4+ risk factors]). A similar directional but more constrained trend was noted for the AnalytiCare data: only 3 and 4+ bleeding risk factors were significant. Conclusions The results from two LTC databases suggest that residents with AFib have a high risk of stroke. Warfarin use increased with greater stroke risk and declined with greater bleeding risk; however, only half of those classified as appropriate warfarin candidates were receiving guideline-recommended anticoagulant prophylaxis.
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Fisher M. MRI screening for chronic anticoagulation in atrial fibrillation. Front Neurol 2013; 4:137. [PMID: 24109470 PMCID: PMC3790146 DOI: 10.3389/fneur.2013.00137] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 09/05/2013] [Indexed: 11/13/2022] Open
Abstract
Anticoagulation is highly effective in preventing stroke due to atrial fibrillation, but numerous studies have demonstrated low utilization of anticoagulation for these patients. Assessment of clinicians' attitudes on this topic indicate that fear of intracerebral hemorrhage (ICH), rather than appreciation of anticoagulation benefits, largely drives clinical decision-making for treatment with anticoagulation in atrial fibrillation. Risk stratification strategies have been used for anticoagulation benefits and hemorrhage risk, but ICH is not specifically addressed in the commonly used hemorrhage risk stratification systems. Cerebral microbleeds are cerebral microscopic hemorrhages demonstrable by brain MRI, indicative of prior microhemorrhages, and predictive of future risk of ICH. Prevalence of cerebral microbleeds increases with age; and cross-sectional and limited prospective studies generally indicate that microbleeds confer substantial risk of ICH in patients treated with chronic anticoagulation. MRI thus is a readily available and appealing modality that can directly assess risk of future ICH in patients receiving anticoagulants for atrial fibrillation. Incorporation of MRI into routine practice is, however, fraught with difficulties, including the uncertain relationship between number and location of microbleeds and ICH risk, as well as cost-effectiveness of MRI. A proposed algorithm is provided, and relevant advantages and disadvantages are discussed. At present, MRI screening appears most appropriate for a subset of atrial fibrillation patients, such as those with intermediate stroke risk, and may provide reassurance for clinicians whose concerns for ICH tend to outweigh benefits of anticoagulation.
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Affiliation(s)
- Mark Fisher
- Departments of Neurology, Anatomy & Neurobiology, and Pathology & Laboratory Medicine, UC Irvine School of Medicine , Irvine, CA , USA
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