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Canevelli M, Jackson-Tarlton C, Rockwood K. Frailty for neurologists: perspectives on how frailty influences care planning. Lancet Neurol 2024; 23:1147-1157. [PMID: 39276779 DOI: 10.1016/s1474-4422(24)00291-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 06/20/2024] [Accepted: 07/03/2024] [Indexed: 09/17/2024]
Abstract
The concept of frailty, now being adopted in most medical disciplines, is attracting growing interest in neurology. Every day, most neurologists care for patients with varying degrees of frailty, from very mild to very severe. Frailty exacerbates patients' health needs, complicates clinical decision making, and negatively affects their health outcomes. Increasing evidence suggests that frailty affects the risk, clinical presentation, and course of common age-related neurological disorders, including dementia, Parkinson's disease, stroke, and multiple sclerosis. Most neurologists should become familiar with assessing and measuring frailty. Doing so can provide information that is crucial for diagnosis, prognostication, and care planning. Consideration of frailty can help to elucidate the pathophysiological underpinnings of age-related neurological disorders, clarify the clinical validity and utility of candidate biomarkers, and identify novel therapeutic targets. Randomised controlled trials investigating late-life neurological diseases that address frailty have the potential to provide insight into these complex disorders.
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Affiliation(s)
- Marco Canevelli
- Department of Human Neuroscience, Sapienza University, Rome, Italy; National Center for Disease Prevention and Health Promotion, Italian National Institute of Health, Rome, Italy; Aging Research Center, Department of Neurobiology, Care Sciences, and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Caitlin Jackson-Tarlton
- Division of Neurology, Department of Medicine, Dalhousie University, Halifax, NS, Canada; Nova Scotia Health, Halifax, NS, Canada
| | - Kenneth Rockwood
- Division of Neurology, Department of Medicine, Dalhousie University, Halifax, NS, Canada; Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, NS, Canada; Frailty and Elder Care Network, Halifax, NS, Canada.
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2
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Colchado Vallejos JG, Quirós López GD, Tello Rodríguez T, Anchante Hernández H. Frailty prevalence in older adults with atrial fibrillation: A cross-sectional study in a resource-limited setting. PLoS One 2024; 19:e0312498. [PMID: 39446924 PMCID: PMC11500909 DOI: 10.1371/journal.pone.0312498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2024] [Accepted: 10/08/2024] [Indexed: 10/26/2024] Open
Abstract
BACKGROUND/OBJECTIVES Frailty is a common condition among older adults and is associated with an increased risk of adverse health outcomes, including mortality, disability, dysmobility, falls, and hospitalization. In patients with atrial fibrillation (AF), these risks are further exacerbated. However, evidence linking AF and frailty, particularly in the South American context, is limited. This study aimed to assess frailty and other geriatric conditions in older outpatients with atrial fibrillation in a resource-limited setting in Lima, Peru. METHODS In this cross-sectional study, we included adults aged 60 years and older diagnosed with atrial fibrillation who were attending outpatient check-ups. Patients who were hospitalized, receiving chemotherapy induction, or presenting with acute infections or exacerbations were excluded. Standardized questionnaires were used to assess frailty, cognitive impairment, and functional dependence. Statistical analysis was performed using R Studio version 4.3.1, with a significance level set at p < 0.05. RESULTS Among the 200 patients who agreed to participate (mean age 74.76 ± 8.42 years, 41% females), 28.5% exhibited frailty, and 46.5% were classified as prefrail. Frailty and prefrailty were significantly associated with older age (p<0.01), female gender (p = 0.01), illiteracy (p<0.01), heart failure (p<0.01), falls (p<0.05), cognitive impairment (p<0.01), and functional dependence (p<0.01). Multivariate analysis revealed significant associations between frailty and cognitive impairment (p<0.05), frailty and functional dependence (p<0.05), and cognitive impairment and functional dependence (p<0.05). CONCLUSIONS One-third of older outpatients with atrial fibrillation were identified as frail, while half were classified as prefrail. In this population, frailty frequently coexists with cognitive impairment and functional dependence, highlighting the need for timely screening and the implementation of evidence-based interventions for individuals with atrial fibrillation in resource-limited settings.
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Affiliation(s)
- José Guillermo Colchado Vallejos
- Instituto de Gerontología, Universidad Peruana Cayetano Heredia, Lima, Perú
- Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Perú
| | | | - Tania Tello Rodríguez
- Instituto de Gerontología, Universidad Peruana Cayetano Heredia, Lima, Perú
- Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Perú
- Departamento de Medicina, Hospital Nacional Cayetano Heredia, Lima, Perú
| | - Henry Anchante Hernández
- Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Perú
- Departamento de Medicina, Hospital Nacional Cayetano Heredia, Lima, Perú
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3
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van Deutekom C, Hendriks JML, Myrstad M, Van Gelder IC, Rienstra M. Managing elderly patients with atrial fibrillation and multimorbidity: call for a systematic approach. Expert Rev Cardiovasc Ther 2024:1-14. [PMID: 39441182 DOI: 10.1080/14779072.2024.2416666] [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: 04/26/2024] [Accepted: 10/10/2024] [Indexed: 10/25/2024]
Abstract
INTRODUCTION Atrial fibrillation (AF) is often accompanied by comorbidities. Not only cardiovascular, but also non-cardiovascular comorbidities have been associated with AF. Multimorbidity is therefore a common finding in patients with AF, especially in elderly patients. Multimorbidity is associated with adverse outcomes, adds complexity to AF management and poses a significant burden on healthcare costs. It is expected that the prevalence of elderly patients with multimorbidity will increase significantly. It is therefore crucial to outline implications for clinical practice and guide comprehensive multimorbidity management. AREAS COVERED This perspective article outlines multimorbidity in AF and the importance of comprehensive comorbidity management. It addresses current clinical practice guided by international guidelines and the need for integrated care including a patient-centered focus, comprehensive AF management, coordinated multidisciplinary care, and supporting technology. Moreover, it proposes a novel model of care delivery following a systematic approach to multimorbidity management. EXPERT OPINION Providing comprehensive care by means of a multidisciplinary team and patient engagement is crucial to provide optimal personalized care for elderly patients with AF and multimorbidity. A systematic integrated care approach seems promising, but further studies are needed to investigate the feasibility of a systematic approach and prioritization of comorbidity management in patients with multimorbidity.
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Affiliation(s)
- Colinda van Deutekom
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, the Netherlands
| | - Jeroen M L 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
| | - Marius Myrstad
- Department of Internal Medicine, Bærum Hospital Vestre Viken Hospital Trust, Norway
| | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, the Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, the Netherlands
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4
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Luo Y, Hao J, Zhu L, Huang Y, Liu Z, Chen Y, Qiu Y, Su Z, Sun R. Effects of multicomponent exercise nursing intervention in elderly stroke patients with frailty: a randomized controlled trial. Front Med (Lausanne) 2024; 11:1450494. [PMID: 39416863 PMCID: PMC11479928 DOI: 10.3389/fmed.2024.1450494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 09/23/2024] [Indexed: 10/19/2024] Open
Abstract
This study examines how multicomponent exercise nursing interventions affect the state of frailty, daily activities, and quality of life in elderly stroke patients with frailty. A total of 125 elderly stroke patients with frailty were randomly assigned to either a control group (n = 62) or an intervention group (n = 63). The control group received standard nursing care, while the intervention group received a multicomponent exercise nursing intervention in addition to standard care. Patients were assessed using the FRAIL Frailty Scale, Modified Barthel Index (MBI), and Short Form Health Survey (SF-36) before the intervention, 4 weeks after the intervention, and 12 weeks after the intervention. Significant differences were observed between the two groups in terms of frailty status, activities of daily living, and quality of life (p < 0.05). The intervention group had lower scores on the FRAIL Frailty Scale and higher scores on the MBI and SF-36 compared to the control group at both 4 and 12 weeks after the intervention (p < 0.05). These findings suggest that multicomponent exercise nursing interventions can effectively reduce frailty and improve activities of daily living and quality of life in elderly stroke patients with frailty.
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Affiliation(s)
- Yanfang Luo
- Department of Neurology, Affiliated Hospital of Jiangnan University, Wuxi, China
- Wuxi School of Medicine, Jiangnan University, Wuxi, China
| | - Jianru Hao
- Wuxi School of Medicine, Jiangnan University, Wuxi, China
| | - Lingyun Zhu
- Department of Neurology, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Yujuan Huang
- Department of Neurology, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Zhimin Liu
- Wuxi School of Medicine, Jiangnan University, Wuxi, China
| | - Yuping Chen
- Department of Basic Medicine, Jiangsu Vocational College of Medicine, Yancheng, China
| | - Yuyu Qiu
- Wuxi School of Medicine, Jiangnan University, Wuxi, China
| | - Zhenzhen Su
- Department of Neurology, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Renjuan Sun
- Department of Neurology, Affiliated Hospital of Jiangnan University, Wuxi, China
- Wuxi School of Medicine, Jiangnan University, Wuxi, China
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5
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Ali S, Kumar M, Khlidj Y, Hendricks E, Farooq F, Alruwaili W, Keisham B, Duhan S, Gonuguntla K, Sattar Y, Shaik A, Brar V, Asad ZUA, Sorajja D, Dominic P, Helmy T. Impact of frailty in hospitalized patients undergoing catheter ablation for atrial fibrillation. J Cardiovasc Electrophysiol 2024; 35:1929-1938. [PMID: 39075813 DOI: 10.1111/jce.16383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 06/28/2024] [Accepted: 07/20/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND Catheter Ablation (CA) is an effective treatment for atrial fibrillation (AF). However, frail elderly patients have been understudied due to their exclusion from landmark trials. OBJECTIVES Our study aims to evaluate outcomes in this population. METHODS The national readmission database (2016-2020) was queried, and frailty categories were defined based on hospital risk frailty scores ≦5 as low while >5 as intermediate/high frailty (IHF). We used multivariate regression and propensity-matched analysis to compare outcomes in patients undergoing CA for atrial fibrillation based on frailty index. RESULTS Among 55 936 CAs for AF, 33,248 patients had low frailty, while 22 688 had intermediate/high frailty (IHF). After propensity matching (N 12 448), IHF patients were found to have higher adverse events, including mortality (3% vs. 0.3%, p < .001), stroke (1.9% vs. 0.2%, p < .001), acute heart failure (53.8% vs. 42.2%, p < .001), AKI (42.5% vs. 6.8%, p < .001), pericardial complications (2.8 vs. 1.6%, p < .001), respiratory complications (27.8 vs. 7.2%, p < .001), major adverse cardiovascular events (21.2 vs. 9.4%, p < .001) and net adverse events (76.7 vs. 55%, p < .001). IHF patients had higher readmissions at 30 (15.5 vs. 12.6%, p < .001), 90 (31.9 vs. 25.1%, p < .001), and 180-day (41 vs. 34.7%, p < .001) intervals. A higher median length of stay (LOS) (7 vs. 3 days, p < .001) and cost ($44 287 vs. $27 517, p < .001) at index admission and subsequent readmissions were also observed (p < .001). CONCLUSION Intermediate/high frailty patients undergoing catheter ablation had worse clinical outcomes, higher healthcare burden, and readmission rates. LOS has decreased in both groups from 2016 to 2020; however, total cost has increased.
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Affiliation(s)
- Shafaqat Ali
- Department of Internal Medicine, Louisiana State University, Shreveport, Louisiana, USA
| | - Manoj Kumar
- Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois, USA
| | - Yehya Khlidj
- Department of Medicine, University of Algiers 1, Algiers, Algeria
| | - Emily Hendricks
- Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Faryal Farooq
- Department of Medicine, Allama Iqbal Medical College Lahore, Lahore, Pakistan
| | - Waleed Alruwaili
- Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Bijeta Keisham
- Department of Medicine, Weifang Medical University, Weifang, China
| | - Sanchit Duhan
- Department of Cardiology, Carle Foundation Hospital, Urbana, Illinois, USA
| | - Karthik Gonuguntla
- Department of Cardiology, West Virginia University, Morgantown, West Virginia, USA
| | - Yasar Sattar
- Department of Cardiology, West Virginia University, Morgantown, West Virginia, USA
| | - Ayesha Shaik
- Department of Cardiology, Hartford Hospital/University of Connecticut, Hartford, Connecticut, USA
| | - Vijaywant Brar
- Department of Cardiology, Louisiana State University, Shreveport, Louisiana, USA
| | - Zain Ul Abideen Asad
- Department of Cardiology, University of Oklahoma Medical Center, Oklahoma City, Oklahoma, USA
| | - Dan Sorajja
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Paari Dominic
- Department of Cardiology, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Tarek Helmy
- Department of Cardiology, Louisiana State University, Shreveport, Louisiana, USA
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Parks AL, Frankel DS, Kim DH, Ko D, Kramer DB, Lydston M, Fang MC, Shah SJ. Management of atrial fibrillation in older adults. BMJ 2024; 386:e076246. [PMID: 39288952 DOI: 10.1136/bmj-2023-076246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2024]
Abstract
Most people with atrial fibrillation are older adults, in whom atrial fibrillation co-occurs with other chronic conditions, polypharmacy, and geriatric syndromes such as frailty. Yet most randomized controlled trials and expert guidelines use an age agnostic approach. Given the heterogeneity of aging, these data may not be universally applicable across the spectrum of older adults. This review synthesizes the available evidence and applies rigorous principles of aging science. After contextualizing the burden of comorbidities and geriatric syndromes in people with atrial fibrillation, it applies an aging focused approach to the pillars of atrial fibrillation management, describing screening for atrial fibrillation, lifestyle interventions, symptoms and complications, rate and rhythm control, coexisting heart failure, anticoagulation therapy, and left atrial appendage occlusion devices. Throughout, a framework is suggested that prioritizes patients' goals and applies existing evidence to all older adults, whether atrial fibrillation is their sole condition, one among many, or a bystander at the end of life.
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Affiliation(s)
- Anna L Parks
- University of Utah, Division of Hematology and Hematologic Malignancies, Salt Lake City, UT, USA
| | - David S Frankel
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Dae H Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
| | - Darae Ko
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
- Richard A and Susan F Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center; Boston Medical Center, Section of Cardiovascular Medicine, Boston, MA, USA
| | - Daniel B Kramer
- Richard A and Susan F Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Melis Lydston
- Massachusetts General Hospital, Treadwell Virtual Library, Boston, MA, USA
| | - Margaret C Fang
- University of California, San Francisco, Division of Hospital Medicine, San Francisco, CA, USA
| | - Sachin J Shah
- Massachusetts General Hospital, Division of General Internal Medicine, Center for Aging and Serious Illness, and Harvard Medical School, Boston, MA, USA
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Chen SF, Li HH, Guo ZN, Ling KY, Yu XL, Liu F, Zhu XP, Zhu X. Association between pre-stroke frailty status and stroke risk and impact on outcomes: a systematic review and meta-analysis of 1,660,328 participants. Aging Clin Exp Res 2024; 36:189. [PMID: 39259235 PMCID: PMC11390839 DOI: 10.1007/s40520-024-02845-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 08/30/2024] [Indexed: 09/12/2024]
Abstract
The prevalence of frailty is increasing, and it is associated with increased risk of diseases and adverse outcomes. Although substantial research has focused on post-stroke frailty, understanding of pre-stroke frailty remains limited. Our aim was to synthesize literature on pre-stroke frailty and stroke risk to explore their relationship and impact on prognosis. A systematic search of multiple databases was conducted to identify cohort studies published until October 28, 2023. Meta-analysis was conducted using a random effects model. Heterogeneity was assessed with the I² statistic, and publication bias was evaluated using Begg's test. Finally, we included 11 studies (n = 1,660,328 participants). The pooled hazard ratios (HRs) for stroke risk associated with pre-stroke frailty compared to non-frail individuals was 1.72 (95% confidence interval, CI: 1.46-2.02, p = 0.002, I2 = 69.2%, Begg's test: p = 0.536). The pooled HRs for mortality and the pooled relative risk (RRs) modified Rankin Scale (mRs) associated with pre-stroke frailty were 1.68 (95% CI: 1.10-2.56, p = 0.136, I2 = 49.9%, Begg's test: p = 0.296) and 3.11 (95% CI: 1.77-5.46, p = 0.192, I2 = 39.4%, Begg's test: p = 1.000), respectively. In conclusion, pre-stroke frailty is strongly associated with stroke risk and impacts its prognosis, irrespective of the measurement method. Future research should focus on prospective studies to assess the effects of early intervention for frailty. This has significant implications for primary healthcare services and frailty management.
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Affiliation(s)
- Shu-Fan Chen
- Department of Nursing, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Road, Jing 'an District, Shanghai, China
- School of Nursing, Soochow University, Suzhou, China
| | - Hai-Han Li
- Department of Nursing, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Road, Jing 'an District, Shanghai, China
| | - Zi-Ning Guo
- Department of Nursing, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Road, Jing 'an District, Shanghai, China
| | - Ke-Yu Ling
- Department of Nursing, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Road, Jing 'an District, Shanghai, China
| | - Xiao-Li Yu
- Department of Nursing, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Road, Jing 'an District, Shanghai, China
| | - Fei Liu
- Department of Nursing, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Road, Jing 'an District, Shanghai, China
| | - Xiao-Ping Zhu
- Department of Nursing, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Road, Jing 'an District, Shanghai, China
| | - Xiaoping Zhu
- Department of Nursing, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Road, Jing 'an District, Shanghai, China.
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Liu JP, Zhang Y, Zhao Z, Zhang T, Na Y, Luo Y, Wan Y, Sun N, Wu C, Wang H, Yang J. Impact of Adverse Health Conditions on Clinical Outcomes of Older People with Atrial Fibrillation: Insights from a Prospective Cohort Study. Clin Interv Aging 2024; 19:1519-1528. [PMID: 39257680 PMCID: PMC11385685 DOI: 10.2147/cia.s464044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 07/24/2024] [Indexed: 09/12/2024] Open
Abstract
Objective To evaluate the impact of adverse health conditions, including multimorbidity, frailty, malnutrition, cognitive impairment, and polypharmacy, on clinical outcomes in older people with atrial fibrillation (AF). Patients and Methods This prospective cohort study focused on patients aged 65 years and older with AF. They were admitted to the hospital between September 2018 and April 2019 and followed up for 1 year. We evaluated these participants for adverse health conditions including multimorbidity, frailty, malnutrition, cognitive impairment, and polypharmacy. The primary clinical outcome measured was a combination of all-cause mortality or rehospitalization. Results 197 older patients (≥65 years) with AF (mean age, 77.5±7.1 years; 57.4% men) were enrolled. During 1-year follow-up, Primary endpoint events (all-cause mortality or rehospitalization) occurred in 82 patients (41.6%). Compared with the non-event group, the Charlson comorbidity index (CCI) was higher (2.5±1.9 vs 1.7±1.3, p=0.004), more heart failure (32.9% vs 17.4%, p=0.01) and chronic kidney disease (17.1% vs 7.0%, p=0.03), with lower systolic blood pressure (125.3±18.3 mmHg vs 132±17.9 mmHg, p=0.005) in the event group. On multivariate Cox regression showed that the CCI was associated with a higher odds ratio of the composite outcome of all-cause mortality and rehospitalization (HR: 1.26; 95% CI: 1.02-1.56, p=0.03). Other adverse health conditions showed no significant association with the composite outcome of all-cause mortality and rehospitalization. Conclusion Among adverse health conditions in older people with AF, multimorbidity appears to be a significant determinant of adverse clinical outcomes. Clinical Trial Registration ChiCTR1800017204; date of registration: 07/18/2018.
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Affiliation(s)
- Jun-Peng Liu
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Yatong Zhang
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Zinan Zhao
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Tianqi Zhang
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Yifan Na
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Yao Luo
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Yuhao Wan
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Ning Sun
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Cheng Wu
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Hua Wang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Jiefu Yang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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9
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Boriani G, Bonini N, Imberti JF, Vitolo M, Gerra L, Mantovani M, Serafini K, Birtolo C, Tartaglia E, Mei DA. Clinical decisions for appropriate management of patients with atrial fibrillation. Panminerva Med 2024; 66:266-280. [PMID: 38656767 DOI: 10.23736/s0031-0808.24.05114-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
The management of patients with atrial fibrillation (AF) requires intricate clinical decision-making to optimize outcomes. In everyday clinical practice, physicians undergo difficult choices to better manage patients with AF. They need to balance thromboembolic and bleeding risk to focus on patients' symptoms and to manage a variety of multiple comorbidities. In this review, we aimed to explore the multifaceted dimensions of clinical decision-making in AF patients, encompassing the definition and diagnosis of clinical AF, stroke risk stratification, oral anticoagulant therapy selection, consideration of bleeding risk, and the ongoing debate between rhythm and rate control strategies. We will also focus on possible grey zones for the management of AF patients. In navigating this intricate landscape, clinicians must reconcile the dynamic interplay of patient-specific factors, evolving guidelines, and emerging therapies. The review underscores the need for personalized, evidence-based clinical decision-making to tailor interventions for optimal outcomes according to specific AF patient profiles.
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Affiliation(s)
- Giuseppe Boriani
- Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, Polyclinic of Modena, University of Modena and Reggio Emilia, Modena, Italy -
| | - Niccolò Bonini
- Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, Polyclinic of Modena, University of Modena and Reggio Emilia, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Jacopo F Imberti
- Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, Polyclinic of Modena, University of Modena and Reggio Emilia, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Vitolo
- Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, Polyclinic of Modena, University of Modena and Reggio Emilia, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Luigi Gerra
- Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, Polyclinic of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Marta Mantovani
- Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, Polyclinic of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Kevin Serafini
- Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, Polyclinic of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Chiara Birtolo
- Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, Polyclinic of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Enrico Tartaglia
- Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, Polyclinic of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Davide A Mei
- Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, Polyclinic of Modena, University of Modena and Reggio Emilia, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
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10
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Ko D, Lin KJ, Lee SB, Lu Z, Cheng S, Shah SJ, Glynn RJ, Kim DH. Prospective Monitoring of New Drugs in Older Adults with and without Frailty: Near-Real-Time Assessment of Effectiveness and Safety of Oral Anticoagulants in Medicare Data. Drugs Aging 2024; 41:763-773. [PMID: 39259265 DOI: 10.1007/s40266-024-01142-9] [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] [Accepted: 08/11/2024] [Indexed: 09/12/2024]
Abstract
BACKGROUND AND OBJECTIVE Prospective sequential analyses after a new drug approval allow proactive surveillance of new drugs. In the current study, we demonstrate feasibility of frailty-specific sequential analyses for dabigatran, rivaroxaban, and apixaban versus warfarin. METHODS We partitioned Medicare data from 2011 to 2020 into datasets based on calendar year following the date of drug approval. Each calendar year of data was added sequentially for analysis. We used a new-user, active comparative design by comparing the initiators of dabigatran versus warfarin, rivaroxaban versus warfarin, and apixaban versus warfarin. Patients aged ≥ 65 years with atrial fibrillation without contraindication to the anticoagulants were included. Claims-based frailty index ≥ 0.25 was used to define frailty. The initiators of each direct oral anticoagulant were propensity-score matched to the initiators of warfarin within each frailty status. The effectiveness outcome was ischemic stroke or systemic thromboembolism, and the safety outcome was major bleeding. For each calendar year, we estimated hazard ratios (HRs) and 95% confidence intervals (CIs) from Cox proportional hazards models using all data available up to that year. RESULTS As an example of the results, in the 2020 dataset, compared with warfarin, apixaban was associated with a reduced risk of ischemic stroke or systemic thromboembolism (frail: HR 0.73, 95% CI 0.63-0.85; non-frail: HR 0.65, 95% CI 0.59-0.72) and major bleeding (frail: HR 0.63, 95% CI 0.57-0.69; non-frail: HR 0.59, 95% CI 0.56-0.63) in both frail and non-frail patients. We found evidence for apixaban's effectiveness and safety within 1-2 years after the drug approval in frail older patients. CONCLUSION Our frailty-specific sequential analyses can be applied to future near-real-time monitoring of newly approved drugs.
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Affiliation(s)
- Darae Ko
- Hinda and Arthur Marcus Institute for Aging Research, , Hebrew SeniorLife, 1200 Centre Street, Boston, MA, 02131, USA
- Harvard Medical School, Boston, MA, USA
- Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Kueiyu Joshua Lin
- Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Zhigang Lu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Susan Cheng
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sachin J Shah
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA, USA
| | - Robert J Glynn
- Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, , Hebrew SeniorLife, 1200 Centre Street, Boston, MA, 02131, USA.
- Harvard Medical School, Boston, MA, USA.
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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11
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Arcoraci V, Rottura M, Gianguzzo VM, Pallio G, Imbalzano E, Nobili A, Natoli G, Argano C, Squadrito G, Irrera N, Corrao S. Atrial fibrillation management in older hospitalized patients: Evidence of a poor oral anticoagulants prescriptive attitude from the Italian REPOSI registry. Arch Gerontol Geriatr 2024; 128:105602. [PMID: 39163746 DOI: 10.1016/j.archger.2024.105602] [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: 04/05/2024] [Revised: 07/31/2024] [Accepted: 08/11/2024] [Indexed: 08/22/2024]
Abstract
Atrial fibrillation (AF) prevalence increases in older patients which also show a high thromboembolic risk. Oral anticoagulants (OACs) are recommended to prevent cardioembolic events and direct oral anticoagulants (DOACs) improved anti-thrombotic treatment. However, the benefits/risks of anticoagulant in older patients still need to be completely defined. This retrospective observational study aimed to describe the treatment with OACs in older AF hospitalized patients, and to identify factors influencing OAC therapy or discontinuation using the REgistro Politerapie SIMI. Univariate and multivariate logistic regression models were applied to identify predictors of OACs treatment and discontinuation. Cox proportional hazards models were performed to evaluate one-year mortality by treatment groups. AF patients were 1,128(26.5 %) at discharge and 1,098(97.3 %) required OAC treatment; about half of them (N = 528;48.1 %) were no-OACs users; 236(21.5 %) and 334(30.4 %) used DOACs and VKA, respectively. Increasing DOACs use was observed during the study period. Predictors of OACs treatment were: BMI (OR:1.04; 95 %CI:1.01-1.07), Barthel index (OR:1.01; 95 %CI:1.01-1.02), medications number (OR:1.07; 95 %CI:1.01-1.13). Conversely, a lower probability was found in patients with a high CIR.S (OR:0.59; 95 %CI:0.36-0.97) and neoplasm (OR:0.57; 95 %CI:0.37-0.88). Hospital stay (OR:1.02; 95 %CI:1.01-1.05), neoplasm (OR:2.25; 95 %CI:1.07-4.70) and INR (OR:1.21; 95 %CI:1.05-1.40) increased OACs discontinuation. A lower discontinuation was observed in dyslipidemic patients (OR:0.18; 95 %CI:0.04-0.82) and heart failure (OR:0.38; 95 %CI:0.21-0.70). Among AF patients, 157(14.3 %) died during the follow-up year. Age (HR = 1.05; 95 %CI = 1.03-1.08) and CIR.S (HR = 2.54; 95 %CI = 1.53-4.21) were associated with a greater mortality risk. In conclusion, critical issues related to the underuse and discontinuation of OACs therapy in hospitalized older patients were highlighted.
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Affiliation(s)
- Vincenzo Arcoraci
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Michelangelo Rottura
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Viviana Maria Gianguzzo
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Messina, Italy
| | - Giovanni Pallio
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
| | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Alessandro Nobili
- Department of Neuroscience, IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Giuseppe Natoli
- Dipartimento di Promozione Della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", PROMISE, University of Palermo, Palermo, Italy
| | - Christiano Argano
- Dipartimento di Promozione Della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", PROMISE, University of Palermo, Palermo, Italy
| | - Giovanni Squadrito
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Natasha Irrera
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
| | - Salvatore Corrao
- Dipartimento di Promozione Della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", PROMISE, University of Palermo, Palermo, Italy; Department of Internal Medicine, National Relevance and High Specialization Hospital Trust ARNAS Civico, Di Cristina, Benfratelli, Palermo, Italy
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12
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Zhang Y, Liu M, Li J, Ruan L, Wu X, Zhang C, Chen L. Physical frailty, genetic predisposition, and incident arrhythmias. J Cachexia Sarcopenia Muscle 2024; 15:1463-1472. [PMID: 38853292 PMCID: PMC11294030 DOI: 10.1002/jcsm.13499] [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: 09/21/2023] [Revised: 03/15/2024] [Accepted: 04/10/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND Cross-sectional evidence suggests a possible link between frailty and atrial fibrillation (AF). It remains unclear whether frailty and incident arrhythmias are longitudinally associated. This study aimed to determine whether the frailty phenotype is longitudinally associated with incident arrhythmias, especially AF. METHODS In this prospective cohort of UK Biobank, individuals with arrhythmias at baseline, those without data for frailty phenotype, and no genetic data were excluded. Five domains of physical frailty, including weight loss, exhaustion, low physical activity, low grip strength, and slow gait speed, were assessed. A total of 142 single-nucleotide polymorphisms was used to calculate the polygenic risk score (PRS) for AF. Hospital inpatient records and death records were used to identify incident arrhythmias. RESULTS This study included 464 154 middle-aged and older adults (mean age 56.4 ± 8.1 years, 54.7% female) without arrhythmia at baseline. During a median follow-up of 13.4 years (over 5.9 million person-years), 46 454 new-onset arrhythmias cases were recorded. In comparison with non-frailty, the multivariable-adjusted hazard ratios (HRs) of AF were 1.12 (95% CI: 1.09, 1.15, P < 0.0001) and 1.44 (95% CI: 1.36, 1.51, P < 0.0001) for participants with pre-frailty and frailty, respectively. Similar associations were observed for other arrhythmias. We found that slow gait speed presented the strongest risk factor in predicting all arrhythmias, including AF (HR 1.34, 95% CI: 1.30, 1.39), bradyarrhythmias (HR 1.30, 95% CI: 1.22, 1.37), conduction system diseases (HR 1.29, 95% CI: 1.22, 1.36), supraventricular arrhythmias (HR 1.32, 95% CI: 1.19, 1.47), and ventricular arrhythmias (HR 1.37, 95% CI: 1.25, 1.51), with all P values <0.0001. In addition to slow gait speed, weight loss (HR 1.13, 95% CI: 1.09, 1.16, P < 0.0001) and exhaustion (HR 1.11, 95% CI: 1.07, 1.14, P < 0.0001) were significantly associated with incident AF, whereas insignificant associations were observed for physical activity (HR 1.03, 95% CI: 0.996, 1.08, P = 0.099) and low grip strength (HR 1.00, 95% CI: 0.97, 1.03, P = 0.89). We observed a significant interaction between genetic predisposition and frailty on incident AF (P for interaction <0.0001), where those with frailty and the highest tertile of PRS had the highest risk of AF (HR 3.34, 95% CI: 3.08, 3.61, P < 0.0001) compared with those with non-frailty and the lowest tertile of PRS. CONCLUSIONS Physical pre-frailty and frailty were significantly and independently associated with incident arrhythmias. Although direct causal inference still needs to be further validated, these results suggested the importance of assessing and managing frailty for arrhythmia prevention.
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Affiliation(s)
- Yucong Zhang
- Department of Geriatrics, Institute of Gerontology, Tongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Key Laboratory of Vascular Aging, Ministry of Education, Tongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Man Liu
- Department of Geriatrics, Institute of Gerontology, Tongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Key Laboratory of Vascular Aging, Ministry of Education, Tongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Jiajun Li
- Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Lei Ruan
- Department of Geriatrics, Institute of Gerontology, Tongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Key Laboratory of Vascular Aging, Ministry of Education, Tongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Xiaofen Wu
- Department of Geriatrics, Institute of Gerontology, Tongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Key Laboratory of Vascular Aging, Ministry of Education, Tongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Cuntai Zhang
- Department of Geriatrics, Institute of Gerontology, Tongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Key Laboratory of Vascular Aging, Ministry of Education, Tongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Liangkai Chen
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Ministry of Education Key Lab of Environment and Health, School of Public Health, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
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13
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Romiti GF, Proietti M. Impact of Frailty Dynamics in Patients With Atrial Fibrillation: Learning How Clinical Complexity Increases Risk in Cardiovascular Diseases. Circ Cardiovasc Qual Outcomes 2024; 17:e011174. [PMID: 39167769 DOI: 10.1161/circoutcomes.124.011174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/23/2024]
Affiliation(s)
- Giulio Francesco Romiti
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy (G.F.R.)
- Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, United Kingdom (G.F.R.)
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Italy (M.P.)
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy (M.P.)
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14
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Nakamaru R, Nishimura S, Kumamaru H, Shoji S, Nakatani E, Yamamoto H, Miyachi Y, Miyata H, Kohsaka S. Trajectories of Frailty and Clinical Outcomes in Older Adults With Atrial Fibrillation: Insights From the Shizuoka Kokuho Database. Circ Cardiovasc Qual Outcomes 2024; 17:e010642. [PMID: 39167767 DOI: 10.1161/circoutcomes.123.010642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 03/25/2024] [Indexed: 08/23/2024]
Abstract
BACKGROUND The increasing prevalence of frailty has gained considerable attention due to its profound influence on clinical outcomes. However, our understanding of the progression of frailty and long-term clinical outcomes in older individuals with atrial fibrillation remains scarce. METHODS Using data from 2012 to 2018 from a comprehensive claims database incorporating primary and hospital care records in Shizuoka, Japan, we selected patients aged ≥65 years with atrial fibrillation who initiated oral anticoagulant therapy. The trajectory of frailty was plotted using Sankey plots, illustrating the annual changes in their frailty according to the electronic frailty index during a 3-year follow-up after oral anticoagulant initiation, along with the incidence of clinical adverse outcomes. For deceased patients, we assessed their frailty status in the year preceding their death. RESULTS Of 6247 eligible patients (45.1% women; mean age, 79.3±8.0 years) at oral anticoagulant initiation, 7.7% were categorized as fit (electronic frailty index, 0-0.12), 30.1% as mildly frail (>0.12-0.24), 35.4% as moderately frail (>0.24-0.36), and 25.9% as severely frail (>0.36). Over the 3-year follow-up, 10.4% of initially fit patients transitioned to moderately frail or severely frail. Conversely, 12.5% of severely frail patients improved to fit or mildly frail. Death, stroke, and major bleeding occurred in 23.4%, 4.1%, and 2.2% of patients, respectively. Among the mortality cases, 74.8% (N=1183) and 3.5% (N=55) had experienced moderately or severely frail and either a stroke or major bleeding in the year preceding their death, respectively. CONCLUSIONS In a contemporary era of atrial fibrillation management, a minor fraction of older patients on oral anticoagulants died following a stroke or major bleeding. However, their frailty demonstrated a dynamic trajectory, and a substantial proportion of death was observed after transitioning to a moderately or severely frail state.
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Affiliation(s)
- Ryo Nakamaru
- Department of Healthcare Quality Assessment, The University of Tokyo, Japan (R.N., S.N., H.K., H.Y., H.M., S.K.)
- Shizuoka Graduate University of Public Health, Japan (R.N., S.N., H.K., S.S., E.N., H.Y., Y.M., H.M., S.K.)
| | - Shiori Nishimura
- Department of Healthcare Quality Assessment, The University of Tokyo, Japan (R.N., S.N., H.K., H.Y., H.M., S.K.)
- Shizuoka Graduate University of Public Health, Japan (R.N., S.N., H.K., S.S., E.N., H.Y., Y.M., H.M., S.K.)
| | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment, The University of Tokyo, Japan (R.N., S.N., H.K., H.Y., H.M., S.K.)
- Shizuoka Graduate University of Public Health, Japan (R.N., S.N., H.K., S.S., E.N., H.Y., Y.M., H.M., S.K.)
| | - Satoshi Shoji
- Shizuoka Graduate University of Public Health, Japan (R.N., S.N., H.K., S.S., E.N., H.Y., Y.M., H.M., S.K.)
- Department of Cardiology (S.S., S.K.), Keio University School of Medicine, Tokyo, Japan
- Duke Clinical Research Institute, Durham, NC (S.S.)
| | - Eiji Nakatani
- Shizuoka Graduate University of Public Health, Japan (R.N., S.N., H.K., S.S., E.N., H.Y., Y.M., H.M., S.K.)
| | - Hiroyuki Yamamoto
- Department of Healthcare Quality Assessment, The University of Tokyo, Japan (R.N., S.N., H.K., H.Y., H.M., S.K.)
- Shizuoka Graduate University of Public Health, Japan (R.N., S.N., H.K., S.S., E.N., H.Y., Y.M., H.M., S.K.)
| | - Yoshiki Miyachi
- Shizuoka Graduate University of Public Health, Japan (R.N., S.N., H.K., S.S., E.N., H.Y., Y.M., H.M., S.K.)
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, The University of Tokyo, Japan (R.N., S.N., H.K., H.Y., H.M., S.K.)
- Shizuoka Graduate University of Public Health, Japan (R.N., S.N., H.K., S.S., E.N., H.Y., Y.M., H.M., S.K.)
- Department of Health Policy and Management (H.M.), Keio University School of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Department of Healthcare Quality Assessment, The University of Tokyo, Japan (R.N., S.N., H.K., H.Y., H.M., S.K.)
- Shizuoka Graduate University of Public Health, Japan (R.N., S.N., H.K., S.S., E.N., H.Y., Y.M., H.M., S.K.)
- Department of Cardiology (S.S., S.K.), Keio University School of Medicine, Tokyo, Japan
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15
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Bernardini A, Bindini L, Antonucci E, Berteotti M, Giusti B, Testa S, Palareti G, Poli D, Frasconi P, Marcucci R. Machine learning approach for prediction of outcomes in anticoagulated patients with atrial fibrillation. Int J Cardiol 2024; 407:132088. [PMID: 38657869 DOI: 10.1016/j.ijcard.2024.132088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/15/2024] [Accepted: 04/19/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND The accuracy of available prediction tools for clinical outcomes in patients with atrial fibrillation (AF) remains modest. Machine Learning (ML) has been used to predict outcomes in the AF population, but not in a population entirely on anticoagulant therapy. METHODS AND AIMS Different supervised ML models were applied to predict all-cause death, cardiovascular (CV) death, major bleeding and stroke in anticoagulated patients with AF, processing data from the multicenter START-2 Register. RESULTS 11078 AF patients (male n = 6029, 54.3%) were enrolled with a median follow-up period of 1.5 years [IQR 1.0-2.6]. Patients on Vitamin K Antagonists (VKA) were 5135 (46.4%) and 5943 (53.6%) were on Direct Oral Anticoagulants (DOAC). Using Multi-Gate Mixture of Experts, a cross-validated AUC of 0.779 ± 0.016 and 0.745 ± 0.022 were obtained, respectively, for the prediction of all-cause death and CV-death in the overall population. The best ML model outperformed CHA2DSVA2SC and HAS-BLED for all-cause death prediction (p < 0.001 for both). When compared to HAS-BLED, Gradient Boosting improved major bleeding prediction in DOACs patients (0.711 vs. 0.586, p < 0.001). A very low number of events during follow-up (52) resulted in a suboptimal ischemic stroke prediction (best AUC of 0.606 ± 0.117 in overall population). Body mass index, age, renal function, platelet count and hemoglobin levels resulted the most important variables for ML prediction. CONCLUSIONS In AF patients, ML models showed good discriminative ability to predict all-cause death, regardless of the type of anticoagulation strategy, and major bleeding on DOAC therapy, outperforming CHA2DS2VASC and the HAS-BLED scores for risk prediction in these populations.
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Affiliation(s)
- Andrea Bernardini
- Cardiology and Electrophysiology Unit, Santa Maria Nuova Hospital, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Italy.
| | - Luca Bindini
- Department of Information Engineering, University of Florence, 50139 Florence, Italy
| | | | - Martina Berteotti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Betti Giusti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Sophie Testa
- Hemostasis and Thrombosis Center, Laboratory Medicine Department, Azienda Socio-Sanitaria Territoriale, Cremona, Italy
| | | | - Daniela Poli
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Paolo Frasconi
- Department of Information Engineering, University of Florence, 50139 Florence, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Italy
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16
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Krittayaphong R, Winijkul A, Methavigul K, Chichareon P, Lip GYH. Clinical outcomes of patients with atrial fibrillation in relation to multimorbidity status changes over time and the impact of ABC pathway compliance: a nationwide cohort study. J Thromb Thrombolysis 2024:10.1007/s11239-024-03007-9. [PMID: 38981981 DOI: 10.1007/s11239-024-03007-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2024] [Indexed: 07/11/2024]
Abstract
Patients with atrial fibrillation (AF) commonly have associated comorbidities. The primary aim was to determine the effect of increasing numbers of comorbidity on clinical outcomes. The secondary aims were (1) the association of comorbidities with oral anticoagulants (OAC) discontinuation, and quality control, (2) the impact of holistic care based on the ABC pathway on clinical outcomes. The primary outcome was the composite of all-cause death, ischemic stroke/systemic embolism, major bleeding, and heart failure. A total of 3405 patients were enrolled; mean age 67.8 ± 11.3 years, 41.8% female. Compared to low comorbidity group [n = 897 (26.3%)], hazard ratios (HR) and 95% confidence intervals (CI) for the composite outcome in the high [n = 929 (27.3%)] and moderate comorbidity [n = 1579 (46.4%)] groups were 5.40 (4.20-6.94) and 2.54 (1.97-3.27), respectively. ABC pathway adherence was associated with reduction of the composite outcome overall (HR 0.63; 0.54-0.74). High comorbidity adversely impacted on OAC use, OAC discontinuation, and quality of warfarin control. If quality of anticoagulation control was included as part of the ABC pathway adherence, the reduction in composite outcome risk was greater (HR 0.46; 0.36-0.58). During 3-year follow-up, 33.9% changed from low- to the moderate-high comorbidity groups and 22.3% changed from moderate- to the high comorbidity group. In conclusion, comorbidity burden in AF patients is an important determinant of clinical outcomes, and changed over time. OAC use, OAC discontinuation, and quality of OAC control were impacted by comorbidity burden. ABC pathway adherence was associated with a reduced risk of adverse clinical outcomes.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
| | - Arjbordin Winijkul
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Komsing Methavigul
- Department of Cardiology, Central Chest Institute of Thailand, Nonthaburi, Thailand
| | - Ply Chichareon
- Cardiology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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17
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Pimpini L, Biscetti L, Matacchione G, Giammarchi C, Barbieri M, Antonicelli R. Atrial High-Rate Episodes in Elderly Patients: The Anticoagulation Therapy Dilemma. J Clin Med 2024; 13:3566. [PMID: 38930095 PMCID: PMC11204811 DOI: 10.3390/jcm13123566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 05/27/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024] Open
Abstract
Atrial fibrillation (AF) has been associated with higher morbidity and mortality rates, especially in older patients. Subclinical atrial fibrillation (SCAF) is defined as the presence of atrial high-rate episodes (AHREs) > 190 bpm for 10 consecutive beats > 6 min and <24 h, as detected by cardiac implanted electronic devices (CIEDs). The selection of eligible patients for anticoagulation therapy among elderly individuals with AHREs detected through CIEDs remains a contentious issue. The meta-analysis of ARTESiA and NOAH-AFNET 6 clinical trials revealed that taking Edoxaban or Apixaban as oral anticoagulation therapy can reduce the risk of stroke by approximately 32% while increasing the risk of major bleeding by approximately 62%. However, it is still unclear which are, among patients with SCAF, those who can take the highest net clinical benefit from anticoagulant therapy. The present review summarizes the current evidence on this intriguing issue and suggests strategies to try to better stratify the risk of stroke and systemic embolism in patients with AHREs. We propose incorporating some parameters including chronic kidney disease (CKD), obesity, enlarged left atrial volume, the efficacy in blood pressure management, and frailty into the traditional CHA2DS2-VASc score. Future trials will be needed to verify the clinical usefulness of the proposed prognostic score mainly in the view of a personalized therapeutic approach in patients with SCAF.
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Affiliation(s)
- Lorenzo Pimpini
- Cardiology Unit, IRCCS INRCA, Via della Montagnola 81, 60127 Ancona, Italy;
| | | | - Giulia Matacchione
- Clinic of Laboratory and Precision Medicine, IRCCS INRCA, 60121 Ancona, Italy;
| | | | - Michelangela Barbieri
- Department of Advanced Medical and Surgical Sciences, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy;
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Ding H, Li X, Zhang X, Li J, Li Q. The association of a frailty index derived from laboratory tests and vital signs with clinical outcomes in critical care patients with septic shock: a retrospective study based on the MIMIC-IV database. BMC Infect Dis 2024; 24:573. [PMID: 38853273 PMCID: PMC11163768 DOI: 10.1186/s12879-024-09430-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 05/23/2024] [Indexed: 06/11/2024] Open
Abstract
PURPOSE Frailty is a vulnerable state to stressors due to the loss of physiological reserve as a result of multisystem dysfunction. The physiological and laboratory-based frailty index (FI-Lab), depending on laboratory values and vital signs, is a powerful tool to capture frailty status. The aim of this study was to assess the relationship between FI-Lab and in-hospital mortality in patients with septic shock. METHODS Baseline data for patients with sepsis in the intensive care unit were retrieved from the Critical Care Medicine Database (MIMIC-IV, v2.2). The primary outcome was mortality during hospitalization. The propensity score matching (PSM) method was used to analyze the basic conditions during hospitalization between groups.The FI-Lab was analysed for its relationship with in-hospital mortality using logistic regression according to continuous and categorical variables, respectively, and described using the restricted cubic spline (RCS). Survival was compared between groups using Kaplan-Meier (KM) curves. Subgroup analyses were used to improve the stability of the results. RESULTS A total of 9219 patients were included. A cohort score of 1803 matched patients was generated after PSM. The analyses showed that non-surviving patients with septic shock in the ICU had a high FI-Lab index (P<0.001). FI-Lab, whether used as a continuous or categorical variable, increased with increasing FI-Lab and increased in-hospital mortality (P<0.001).Subgroup analyses showed similar results. RCS depicts this non-linear relationship. KM analysis shows the cumulative survival time during hospitalisation was significantly lower as FI-Lab increased (log-rank test, P<0.001). CONCLUSION Elevated FI-Lab is associated with increased in-hospital mortality in patients with septic shock.
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Affiliation(s)
- Huafeng Ding
- Intensive Care Unit, Xuzhou Central Hospital, 199 South Jiefang Road, Xuzhou, 221009, Jiangsu Province, People's Republic of China
| | - Xiangquan Li
- Intensive Care Unit, Xuzhou Central Hospital, 199 South Jiefang Road, Xuzhou, 221009, Jiangsu Province, People's Republic of China
| | - Xianjiang Zhang
- Intensive Care Unit, Xuzhou Central Hospital, 199 South Jiefang Road, Xuzhou, 221009, Jiangsu Province, People's Republic of China
| | - Jiaqiong Li
- Intensive Care Unit, Xuzhou Central Hospital, 199 South Jiefang Road, Xuzhou, 221009, Jiangsu Province, People's Republic of China
| | - Qinfeng Li
- Medical Laboratory, Xuzhou Central Hospital, 199 South Jiefang Road, Xuzhou, 221009, Jiangsu Province, People's Republic of China.
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Bakal JA, Wilber D. Patient-Centered Rocket Science: Accurate but Imprecise. J Am Heart Assoc 2024; 13:e035100. [PMID: 38780174 PMCID: PMC11255640 DOI: 10.1161/jaha.124.035100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 05/25/2024]
Affiliation(s)
- Jeffrey A. Bakal
- Department of MedicineUniversity of Alberta, Edmonton Alberta and the Alberta Strategy for Patient Oriented Research Data and Research ServicesEdmontonAlbertaCanada
| | - David Wilber
- Department of MedicineLoyola University Chicago Stritch School of MedicineMaywoodILUSA
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20
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Stuby J, Haschke M, Tritschler T, Aujesky D. Oral anticoagulant therapy in older adults. Thromb Res 2024; 238:1-10. [PMID: 38636204 DOI: 10.1016/j.thromres.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 03/06/2024] [Accepted: 04/11/2024] [Indexed: 04/20/2024]
Abstract
Patients aged ≥65 years not only account for the majority of patients with atrial fibrillation (AF) and venous thromboembolism (VTE), they are also at a higher risk of morbidity, mortality, and undertreatment than younger patients. Several age-related physiological changes with effects on drug pharmacokinetics/-dynamics and blood vessel fragility as well as the higher prevalence of geriatric conditions such as frailty, multimorbidity, polypharmacy, fall risk, dementia, and malnutrition make older persons more vulnerable to disease- and anticoagulation-related complications. Moreover, because older patients with AF/VTE are underrepresented in oral anticoagulation (OAC) trials, evidence on OAC in older adults with AF/VTE is mainly based on subgroup analyses from clinical trials and observational studies. A growing body of such limited evidence suggests that direct oral anticoagulants (DOACs) may be superior in terms of efficacy and safety compared to vitamin K antagonists in older persons with AF/VTE and that specific DOACs may have a differing risk-benefit profile. In this narrative review, we summarize the evidence on epidemiology of AF/VTE, impact of age-related physiological changes, efficacy/safety of OAC, specifically considering individuals with common geriatric conditions, and review OAC guideline recommendations for older adults with AF/VTE. We also propose a research agenda to improve the evidence basis on OAC older individuals with AF/VTE, including the conduct of advanced age-specific and pragmatic studies using less restrictive eligibility criteria and patient-reported health outcomes, in order to compare the effectiveness and safety of different DOACs, and investigate lower-dose regimens and optimal OAC durations in older patients.
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Affiliation(s)
- J Stuby
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - M Haschke
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Clinical Pharmacology & Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - T Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - D Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
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21
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Li X, Cheng H, Tang Y, Tan S, Bai Z, Li T, Luo M, Wang Y, Jun L. The hospital frailty risk score effectively predicts adverse outcomes in patients with atrial fibrillation in the intensive care unit. RESEARCH SQUARE 2024:rs.3.rs-4368526. [PMID: 38798658 PMCID: PMC11118705 DOI: 10.21203/rs.3.rs-4368526/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Background Atrial fibrillation (AF) and frailty are significant global public health problems associated with advancing age. However, the relationship between frailty and older patients with AF in the intensive care unit (ICU) has not been thoroughly investigated. This study aimed to investigate whether the hospital frailty risk score (HFRS) is associated with adverse outcomes in older patients with AF in the ICU. Methods This was the first retrospective analysis of older patients with AF admitted to the ICU between 2008 and 2019 at a tertiary academic medical center in Boston. The HFRS was used to measure frailty severity. The outcomes of interest were in-hospital and 30-day mortality and the incidence of sepsis and ischemic stroke. Results There were 7,792 participants aged approximately 80 years, almost half (44.9%) of whom were female. Among this group, 2,876 individuals were identified as non-frail, while 4,916 were classified as frail. The analysis revealed a significantly greater incidence of in-hospital (18.8% compared to 7.6%) and 30-day mortality (24.5% versus 12.3%) in the frail group. After accounting for potential confounding factors, a multivariate Cox proportional hazards regression analysis revealed that frail participants had a 1.56-fold greater risk of mortality within 30 days (95% CI = 1.38-1.76, p < 0.001). Conclusions Frailty is an independent risk factor for adverse outcomes in older patients with AF admitted to the ICU. Therefore, prioritizing frailty assessment and implementing specific intervention strategies to improve prognostic outcomes are recommended.
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Affiliation(s)
| | | | | | - Shanyuan Tan
- the First Affiliated Hospital of Jinan University
| | - Zihong Bai
- the First Affiliated Hospital of Jinan University
| | | | | | | | - Lyu Jun
- the First Affiliated Hospital of Jinan University
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22
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Rosas Diaz AN, Troy AL, Kaplinskiy V, Pritchard A, Vani R, Ko D, Orkaby AR. Assessment and Management of Atrial Fibrillation in Older Adults with Frailty. Geriatrics (Basel) 2024; 9:50. [PMID: 38667517 PMCID: PMC11050611 DOI: 10.3390/geriatrics9020050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/28/2024] [Accepted: 04/06/2024] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is a major driver of morbidity and mortality among older adults with frailty. Moreover, frailty is highly prevalent in older adults with AF. Understanding and addressing the needs of frail older adults with AF is imperative to guide clinicians caring for older adults. In this review, we summarize current evidence to support the assessment and management of older adults with AF and frailty, incorporating numerous recent landmark trials and studies in the context of the 2023 US AF guideline.
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Affiliation(s)
| | - Aaron L. Troy
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA (A.L.T.)
| | | | - Abiah Pritchard
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA (A.L.T.)
| | - Rati Vani
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA (A.L.T.)
| | - Darae Ko
- Section of Cardiovascular Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, 1200 Center Street, Boston, MA 02131, USA
| | - Ariela R. Orkaby
- New England GRECC (Geriatric Research, Education and Clinical Center), VA Boston Healthcare System, Boston, MA 02130, USA
- Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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23
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Murakami Y, Todo K, Uchida K, Yamagami H, Sakai N, Gon Y, Okazaki S, Sasaki T, Yoshimura S, Morimoto T, Mochizuki H. One-year morbidity and mortality in patients treated with standard-dose and low-dose apixaban after acute large vessel occlusion stroke. J Thromb Thrombolysis 2024; 57:622-629. [PMID: 38556577 PMCID: PMC11026242 DOI: 10.1007/s11239-024-02954-7] [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] [Accepted: 01/25/2024] [Indexed: 04/02/2024]
Abstract
Although low-dose direct oral anticoagulants (DOACs) are recommended for patients at high risk of bleeding complications, it remains unclear whether the dose reduction in real-world setting is also appropriate in patients after large-vessel occlusion (LVO) stroke. This study hypothesized that patients with atrial fibrillation (AF) and LVO receiving low-dose DOACs have an increased risk of ischemic and hemorrhagic events. The study aimed to assess 1 year morbidity and mortality in patients treated with standard-dose and low-dose apixaban after LVO stroke. A post hoc analysis was performed using the acute LVO registry data, which enrolled patients with AF and LVO who received apixaban within 14 days of stroke onset. The incidences of ischemic events (ischemic stroke, acute coronary syndrome, acute myocardial infarction, and systemic embolism), major bleeding events, and death from any cause were compared between patients receiving standard- and low-dose apixaban. Of 643 patients diagnosed with LVO, 307 (47.7%) received low-dose apixaban. After adjustment for clinically relevant variables, no significant differences were observed in the incidence of ischemic events (adjusted hazard ratio [aHR]: 2.12, 95% confidence interval [CI] 0.75-6.02), major bleeding events (aHR: 1.17, 95% CI 0.50-2.73), and death from any cause (aHR: 1.95, 95% CI 0.78-4.89) between patients receiving standard- and low-dose apixaban. No significant differences were observed in the incidence of ischemic events, major bleeding events, or death from any cause between patients with AF and LVO receiving standard- and low-dose apixaban.
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Affiliation(s)
- Yasutaka Murakami
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Nishinomiya, Hyogo, Japan
| | - Yasufumi Gon
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Shuhei Okazaki
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tsutomu Sasaki
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
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24
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Ding J, Sun Y, Zhang K, Huang W, Tang M, Zhang D, Xing Y. Effects of Anticoagulant Therapy and Frailty in the Elderly Patients with Atrial Fibrillation. Clin Interv Aging 2024; 19:247-254. [PMID: 38375240 PMCID: PMC10875184 DOI: 10.2147/cia.s453527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/30/2024] [Indexed: 02/21/2024] Open
Abstract
Objective This study explored whether anticoagulation is safe for frail and non-frail elderly patients who have nonvalvular atrial fibrillation (NVAF). Methods At hospital discharge, the anticoagulant regimen and frailty status were recorded for 361 elderly patients (aged ≥75 y) with NVAF. The patients were followed for 12 months. The endpoints included occurrence of thrombosis; bleeding; all-cause death; and cardiovascular events. Results At hospital discharge, frailty affected 50.42% of the population and the anticoagulation rate was 44.04%. At discharge, age (OR 0.948, P = 0.006), paroxysmal NVAF (OR 0.384, P < 0.001), and bleeding history (OR 0.396, P = 0.001) were associated with a decrease in rate of receiving anticoagulation, while thrombotic events during hospitalization (OR 2.281, P = 0.021) were associated with an increase. Relative to non-frail patients, those with frailty showed a higher rate of ischemic stroke (5.33% cf. 3.01%), bleeding (P = 0.006) events, and all-cause mortality (P = 0.001). Relative to the group without anticoagulation, in those with anticoagulation the rate of thrombotic events was lower (6.99 cf. 10.98%) and bleeding events were higher (20.98 cf. 12.72%), but the risk of major bleeding was comparable. Conclusion In the elderly patients with NVAF, the decision toward anticoagulation therapy at hospital discharge was influenced by age, bleeding history, paroxysmal atrial fibrillation diagnosis, and absence of thrombosis. Frail patients were at greater risk of bleeding and all-cause mortality. Anticoagulation tended to reduce the risk of thrombotic events.
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Affiliation(s)
- Jiancao Ding
- Department of Geriatrics, First People’s Hospital of Zigong, Sichuan, People’s Republic of China
| | - Ying Sun
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Kan Zhang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Wei Huang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Mei Tang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Dai Zhang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yunli Xing
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
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25
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Hara K, Kanda M, Kobayashi Y, Miyamoto T, Inoue T. Factors affecting the length of hospital stay for total knee arthroplasty in Japan: a retrospective study using the diagnosis procedure combination database. Eur J Med Res 2024; 29:122. [PMID: 38355542 PMCID: PMC10865593 DOI: 10.1186/s40001-024-01714-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 02/05/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND We aimed to evaluate the length of hospital stay following total knee arthroplasty to determine the impact of relevant factors using data from the Diagnosis Procedure Combination database. METHODS This was a retrospective observational study. The study cohort included 5,831 patients who had osteoarthritis of the knee and had undergone total knee replacement between February 2018 and October 2022 at 38 hospitals. RESULTS Multivariate analysis showed that the factors influencing the length of stay included: age (p < 0.001), height (p < 0.001), weight (p = 0.049), body mass index (p = 0.008), Barthel index (p < 0.001), method of anesthesia (p < 0.001), bone transplant (p = 0.010), timing of postoperative rehabilitation (p < 0.001), atrial fibrillation (p < 0.001), chronic pain (p < 0.001), and number of institutionally treated cases (p < 0.001) (r = 0.451, p < 0.001). CONCLUSIONS Shorter or longer hospital stays were found to be associated with the patients' background characteristics and facility-specific factors; these can lead to more accurate estimates of the length of hospital stay and appropriate allocation of resources.
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Affiliation(s)
- Kentaro Hara
- Department of Operation Center, National Hospital Organization Nagasaki Medical Center, Nagasaki, 856-8562, Japan
- Department of Nursing, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, 852-8523, Japan
| | - Masato Kanda
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, 260-8677, Japan
- Department of Healthcare Management Research Center, Chiba University Hospital, 1-8-1 Inohana, Chuo-Ku, Chiba, Chiba, 260-8677, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, 260-8677, Japan
| | - Takashi Miyamoto
- Department of Orthopedic Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, 856-8562, Japan
| | - Takahiro Inoue
- Department of Healthcare Management Research Center, Chiba University Hospital, 1-8-1 Inohana, Chuo-Ku, Chiba, Chiba, 260-8677, Japan.
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26
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Corica B, Romiti GF, Proietti M. NOACs in Atrial Fibrillation Patients with Polypharmacy. Thromb Haemost 2024; 124:149-151. [PMID: 37989205 DOI: 10.1055/s-0043-1776900] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Affiliation(s)
- Bernadette Corica
- 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, Rome, Italy
| | - 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, Rome, Italy
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
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27
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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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28
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Shim GY, Kim M, Won CW. Cross-sectional and longitudinal association between atrial fibrillation and sarcopenia: Findings from the Korean frailty and aging cohort study. J Cachexia Sarcopenia Muscle 2024; 15:434-441. [PMID: 38057913 PMCID: PMC10834337 DOI: 10.1002/jcsm.13401] [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: 02/17/2023] [Revised: 09/22/2023] [Accepted: 11/02/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Sarcopenia is commonly observed in patients with cardiovascular diseases. However, studies on the association between sarcopenia and atrial fibrillation and their causal relationships are limited. We performed cross-sectional and longitudinal analyses to investigate the association between sarcopenia and atrial fibrillation among community-dwelling older adults. METHODS A total of 2225 participants from the Korean Frailty and Aging Cohort Study (KFACS) from 2016 to 2017 were included in this cross-sectional analysis. Sarcopenia was defined according to the Asian Working Group for Sarcopenia 2019 consensus. Atrial fibrillation was diagnosed on the basis of electrocardiographic findings. We investigated whether atrial fibrillation increased the risk of incident sarcopenia 2 years later and whether sarcopenia, in turn, increased the 2-year risk of developing atrial fibrillation using KFACS data from 2018 to 2019. RESULTS Of the 2225 participants (54.2% women; mean age 76.0 ± 3.9 years), 509 (22.9%) had sarcopenia at baseline. In the cross-sectional analysis, sarcopenia was associated with atrial fibrillation after multivariate adjustment [odd ratio (OR), 2.127; 95% confidence interval (CI), 1.240-3.648; P = 0.006]. Among the sarcopenia components, low physical performance was associated with atrial fibrillation (OR, 1.872; 95% CI, 1.123-3.120; P = 0.016). During the 2-year follow-up period, atrial fibrillation was not associated with new-onset of sarcopenia (OR, 1.483; 95% CI, 0.597-3.685; P = 0.396), and sarcopenia also did not significantly increase the risk of incident atrial fibrillation (OR, 1.120; 95% CI, 0.384-3.264; P = 0.836). CONCLUSIONS Although we found a significant association between sarcopenia and atrial fibrillation in a cross-sectional analysis, we could not establish a causal relationship between the two based on 2 years of follow-up. Further research with long-term follow-up is required to identify causal relationship between atrial fibrillation and sarcopenia.
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Affiliation(s)
- Ga Yang Shim
- Department of Physical and Rehabilitation MedicineKyung Hee University College of Medicine, Kyung Hee University HospitalSeoulRepublic of Korea
| | - Miji Kim
- Department of Biomedical Science and Technology, College of Medicine, East‐West Medical Research InstituteKyung Hee UniversitySeoulRepublic of Korea
| | - Chang Won Won
- Department of Family Medicine, Kyung Hee University college of MedicineKyung Hee University HospitalSeoulRepublic of Korea
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29
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Shantsila E, Choi EK, Lane DA, Joung B, Lip GY. Atrial fibrillation: comorbidities, lifestyle, and patient factors. THE LANCET REGIONAL HEALTH. EUROPE 2024; 37:100784. [PMID: 38362547 PMCID: PMC10866737 DOI: 10.1016/j.lanepe.2023.100784] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/25/2023] [Accepted: 11/02/2023] [Indexed: 02/17/2024]
Abstract
Modern anticoagulation therapy has dramatically reduced the risk of stroke and systemic thromboembolism in people with atrial fibrillation (AF). However, AF still impairs quality of life, increases the risk of stroke and heart failure, and is linked to cognitive impairment. There is also a recognition of the residual risk of thromboembolic complications despite anticoagulation. Hence, AF management is evolving towards a more comprehensive understanding of risk factors predisposing to the development of this arrhythmia, its' complications and interventions to mitigate the risk. This review summarises the recent advances in understanding of risk factors for incident AF and managing these risk factors. It includes a discussion of lifestyle, somatic, psychological, and socioeconomic risk factors. The available data call for a practice shift towards a more individualised approach considering an increasingly broader range of health and patient factors contributing to AF-related health burden. The review highlights the needs of people living with co-morbidities (especially with multimorbidity), polypharmacy and the role of the changing population demographics affecting the European region and globally.
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Affiliation(s)
- Eduard Shantsila
- Department of Primary Care and Mental Health, University of Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Brownlow Group GP Practice, Liverpool, United Kingdom
| | - Eue-Keun Choi
- Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Republic of Korea
| | - Deirdre A. Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Denmark
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Denmark
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Søgaard M, Jensen M, Højen AA, Larsen TB, Lip GYH, Ording AG, Nielsen PB. Net Clinical Benefit of Oral Anticoagulation Among Frail Patients With Atrial Fibrillation: Nationwide Cohort Study. Stroke 2024; 55:413-422. [PMID: 38252753 DOI: 10.1161/strokeaha.123.044407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 12/11/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Frail people with atrial fibrillation are often undertreated with oral anticoagulants (OACs), and evidence for the net clinical benefit (NCB) of OAC is sparse. We, therefore, examined the risk of thromboembolic events, major bleeding, and NCB of anticoagulation treatment. METHODS This was a nationwide cohort study including frail patients aged with incident atrial fibrillation between 2013 and 2018. Patients were categorized according to OAC treatment exposure. One-year risks of thromboembolic events and major bleeding were ascertained where death was treated as a competing risk. The NCB of anticoagulation was assessed by a bivariate trade-off between thromboembolism and bleeding. RESULTS We identified 36 223 frail patients with atrial fibrillation (median age, 79 years; 50.5% female), of whom 61.8% started OAC therapy, while 38.2% were untreated despite indication for stroke prevention. At 1 year, the risk of thromboembolic events was 2.1% (95% CI, 1.8%-2.3%) among patients not receiving OAC versus 1.5% (95% CI, 1.4%-1.7%) in patients with OAC. The bleeding risk was 3.2% (95% CI, 2.9%-3.5%) among patients without OAC versus 3.5% (95% CI, 3.2%-3.8%) among anticoagulated patients. The NCB was 0.70% (95% CI, 0.32%-1.08%), suggesting a benefit of OAC treatment; however, the NCB declined with age and increasing frailty and was lowest among patients >75 years of age or with high frailty level. CONCLUSIONS Frail patients with atrial fibrillation are often untreated with OAC in routine clinical care despite an indication for stroke prevention. The NCB balancing thromboembolic events and major bleeding was in favor of anticoagulation but decreased with advancing age and increasing frailty.
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Affiliation(s)
- Mette Søgaard
- Department of Cardiology (M.S., M.J., A.A.H., T.B.L., A.G.O., P.B.N.), Aalborg University Hospital, Denmark
- Danish Center for Health Services Research (M.S., A.A.H., A.G.O., G.Y.H.L., P.B.N.), Aalborg University Hospital, Denmark
| | - Martin Jensen
- Department of Cardiology (M.S., M.J., A.A.H., T.B.L., A.G.O., P.B.N.), Aalborg University Hospital, Denmark
| | - Anette Arbjerg Højen
- Department of Cardiology (M.S., M.J., A.A.H., T.B.L., A.G.O., P.B.N.), Aalborg University Hospital, Denmark
- Danish Center for Health Services Research (M.S., A.A.H., A.G.O., G.Y.H.L., P.B.N.), Aalborg University Hospital, Denmark
| | - Torben Bjerregaard Larsen
- Department of Cardiology (M.S., M.J., A.A.H., T.B.L., A.G.O., P.B.N.), Aalborg University Hospital, Denmark
| | - Gregory Y H Lip
- Danish Center for Health Services Research (M.S., A.A.H., A.G.O., G.Y.H.L., P.B.N.), Aalborg University Hospital, Denmark
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, United Kingdom (G.Y.H.L.)
| | - Anne Gulbech Ording
- Department of Cardiology (M.S., M.J., A.A.H., T.B.L., A.G.O., P.B.N.), Aalborg University Hospital, Denmark
- Danish Center for Health Services Research (M.S., A.A.H., A.G.O., G.Y.H.L., P.B.N.), Aalborg University Hospital, Denmark
| | - Peter Brønnum Nielsen
- Department of Cardiology (M.S., M.J., A.A.H., T.B.L., A.G.O., P.B.N.), Aalborg University Hospital, Denmark
- Danish Center for Health Services Research (M.S., A.A.H., A.G.O., G.Y.H.L., P.B.N.), Aalborg University Hospital, Denmark
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Krejzar Z, Sila D, Waldauf P, Kuriscak E, Mokrejs P, Spatenkova V. Impact of frailty, biomarkers and basic biochemical parameters on outcomes of comatose patients in status epilepticus: a single-center prospective pilot study. BMC Neurol 2024; 24:46. [PMID: 38279084 PMCID: PMC10811840 DOI: 10.1186/s12883-024-03537-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/14/2024] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND Status epilepticus (SE) is a severe acute condition in neurocritical care with high mortality. Searching for risk factors affecting the prognosis in SE remains a significant issue. The primary study's aim was to test the predictive values of the Clinical Frailty Scale (CFS) and the Modified 11-item Frailty Index (mFI-11), the biomarkers and basic biochemical parameters collected at ICU on the Glasgow Outcome Scale (GOS) assessed at hospital discharge (hosp), and three months later (3 M), in comatose patients with SE. The secondary aim was to focus on the association between the patient's state at admission and the duration of mechanical ventilation, the ICU, and hospital stay. METHODS In two years single-centre prospective pilot study enrolling 30 adult neurocritical care patients with SE classified as Convulsive SE, A.1 category according to the International League Against Epilepsy (ILAE) Task Force without an-/hypoxic encephalopathy, we evaluated predictive powers of CFS, mFI-11, admission Status Epilepticus Severity Score (STESS), serum protein S100, serum Troponin T and basic biochemical parameters on prognosticating GOS using univariate linear regression, logistic regression and Receiver Operating Characteristic (ROC) analysis. RESULTS Our study included 60% males, with a mean age of 57 ± 16 years (44-68) and a mean BMI of 27 ± 5.6. We found CFS, mFI-11, STESS, and age statistically associated with GOS at hospital discharge and three months later. Among the biomarkers, serum troponin T level affected GOS hosp (p = 0.027). Serum C-reactive protein significance in prognosticating GOS was found by logistic regression (hosp p = 0.008; 3 M p = 0.004), and serum calcium by linear regression (hosp p = 0.028; 3 M p = 0.015). In relation to secondary outcomes, we found associations between the length of hospital stay and each of the following: age (p = 0.03), STESS (p = 0.009), and serum troponin T (p = 0.029) parameters. CONCLUSIONS This pilot study found promising predictive powers of two frailty scores, namely CFS and mFI-11, which were comparable to age and STESS predictors regarding the GOS at hospital discharge and three months later in ICU patients with SE. Among biomarkers and biochemical parameters, only serum troponin T level affected GOS at hospital discharge.
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Affiliation(s)
- Zdenek Krejzar
- Department of Neurology, First Faculty of Medicine, Charles University in Prague, Katerinska 1660/32, Prague 2, 121 08, Czech Republic
- Centrum of Anaesthesiology, Resuscitation and Intensive Care, Regional Hospital, Husova 357/10, Liberec, 46001, Czech Republic
| | - David Sila
- Centrum of Anaesthesiology, Resuscitation and Intensive Care, Regional Hospital, Husova 357/10, Liberec, 46001, Czech Republic
- Emergency Medical Services, Klasterni 954/5, Liberec, 460 01, Czech Republic
- Faculty of Health Studies, Technical University in Liberec, Studentska 1402/2, 461 17, Liberec 1, Czech Republic
| | - Petr Waldauf
- Department of Anaesthesiology and Resuscitation, Third Faculty of Medicine, Charles University in Prague, Ruska 10, Prague, 100 00, Czechia
- University Hospital Kralovske Vinohrady, 110 34 Prague 10, Srobarova, 1050, Czech Republic
| | - Eduard Kuriscak
- Institute of Physiology, First Faculty of Medicine, Charles University in Prague, Albertov 5, Prague, 128 00, Czech Republic
| | - Petr Mokrejs
- Department of Neurology, First Faculty of Medicine, Charles University in Prague, Katerinska 1660/32, Prague 2, 121 08, Czech Republic
- Emergency Medical Services, Klasterni 954/5, Liberec, 460 01, Czech Republic
| | - Vera Spatenkova
- Faculty of Health Studies, Technical University in Liberec, Studentska 1402/2, 461 17, Liberec 1, Czech Republic.
- Department of Anaesthesiology and Resuscitation, Third Faculty of Medicine, Charles University in Prague, Ruska 10, Prague, 100 00, Czechia.
- University Hospital Kralovske Vinohrady, 110 34 Prague 10, Srobarova, 1050, Czech Republic.
- Institute of Physiology, First Faculty of Medicine, Charles University in Prague, Albertov 5, Prague, 128 00, Czech Republic.
- Neurocenter, Neurointensive Care Unit, Regional Hospital, Husova 357/10, Liberec, 46001, Czech Republic.
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Meyer M, Arnold A, Stein T, Niemöller U, Tanislav C, Erkapic D. Arrhythmias among Older Adults Receiving Comprehensive Geriatric Care: Prevalence and Associated Factors. Clin Pract 2024; 14:132-147. [PMID: 38248435 PMCID: PMC10801505 DOI: 10.3390/clinpract14010011] [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: 10/16/2023] [Revised: 12/25/2023] [Accepted: 12/29/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Cardiovascular diseases and arrhythmias are medical conditions that increase with age and are associated with significant morbidities and mortality. The aim of the present study was to investigate the prevalence of arrhythmias and clinical associations in the collective of older adults receiving comprehensive geriatric care (CGC). METHODS Holter ECG monitoring (HECG) of older patients hospitalized for CGC was analyzed. The prevalence of arrhythmias and the associations between the presence of arrhythmias, patients' characteristics and the functional status regarding basic activities of daily living (assessed by the Barthel index (BI)), walking ability (assessed by the timed up and go test (TUG)), and balance and gait (assessed by the Tinetti balance and gait test (TBGT)) were examined. RESULTS In the presented study, 626 patients were included (mean age: 83.9 ± 6.6 years, 67.7% were female). The most common arrhythmias detected in HECG were premature ventricular contractions (87.2%), premature atrial contractions (71.7%), and atrial fibrillation (22.7%). Atrial flutter was found in 1.0%, paroxysmal supraventricular tachycardia in 5.8%, non-sustained ventricular tachycardia in 12.5%, first-degree AV block in 0.8%, second-degree AV block type Mobitz I in 0.8%, second-degree AV block type Mobitz II in 0.3%, pause > 2.5 s any cause in 3.5%, and pause > 3 s any cause in 1.6% of the cases. Premature atrial contractions were associated with the female sex (74.8% vs. 65.3%, p = 0.018), whereas in male patients, the following arrhythmias were more common: premature ventricular contractions (91.6% vs. 85.1%, p = 0.029), ventricular bigeminus (8.4% vs. 3.8%, p = 0.021), and non-sustained ventricular tachycardia (17.3% vs. 10.1%, p = 0.014). Atrial fibrillation detected in HECG was more frequent in patients at high risk of falls, indicated by their TBGT score ≤ 18 (24.7% vs. 12.0%, p = 0.006), and premature ventricular contractions were more common in patients unable to walk (TUG score 5) compared to those with largely independent mobility (TUG score 1 or 2) (88.0% vs. 75.0%, p = 0.023). In a logistic regression analysis, atrial fibrillation detected in HECG was identified as a risk factor for a high risk of falls (odds ratio (OR): 2.35, 95% confidence interval (CI): 1.23-4.46). CONCLUSION In our study, investigation of HECG of older adults hospitalized for CGC revealed that premature atrial contractions, premature ventricular contractions, and atrial fibrillation were the most common arrhythmias. Premature atrial contractions were found to be more frequent in female patients, while male patients were more prone to premature ventricular contractions. In the investigated population, atrial fibrillation emerged as a risk factor associated with a high risk of falls.
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Affiliation(s)
- Marco Meyer
- Department of Geriatrics, Diakonie Hospital Jung-Stilling Siegen, Wichernstrasse 40, 57074 Siegen, Germany
| | - Andreas Arnold
- Department of Geriatrics, Diakonie Hospital Jung-Stilling Siegen, Wichernstrasse 40, 57074 Siegen, Germany
| | - Thomas Stein
- Department of Geriatrics, Diakonie Hospital Jung-Stilling Siegen, Wichernstrasse 40, 57074 Siegen, Germany
| | - Ulrich Niemöller
- Department of Geriatrics, Diakonie Hospital Jung-Stilling Siegen, Wichernstrasse 40, 57074 Siegen, Germany
| | - Christian Tanislav
- Department of Geriatrics, Diakonie Hospital Jung-Stilling Siegen, Wichernstrasse 40, 57074 Siegen, Germany
| | - Damir Erkapic
- Department of Cardiology and Rhythmology, Diakonie Hospital Jung-Stilling Siegen, Wichernstrasse 40, 57074 Siegen, Germany
- University Hospital, Justus Liebig University Giessen, 35392 Giessen, Germany
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Kessler A, Kolben Y, Puris G, Ellis M, Alperin M, Simovich V, Lerman Shivek H, Muszkat M, Maaravi Y, Biton Y. Direct Oral Anticoagulants in Special Patient Populations. J Clin Med 2023; 13:216. [PMID: 38202223 PMCID: PMC10779957 DOI: 10.3390/jcm13010216] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/25/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024] Open
Abstract
Anticoagulants are a cornerstone of treatment in atrial fibrillation. Nowadays, direct oral anticoagulants (DOACs) are extensively used for this condition in developed countries. However, DOAC treatment may be inappropriate in certain patient populations, such as: patients with chronic kidney disease in whom DOAC concentrations may be dangerously elevated; frail elderly patients with an increased risk of falls; patients with significant drug-drug interactions (DDI) affecting either DOAC concentration or effect; patients at the extremes of body mass in whom an "abnormal" volume of distribution may result in inappropriate drug concentrations; patients with recurrent stroke reflecting an unusually high thromboembolic tendency; and, lastly, patients who experience major hemorrhage on an anticoagulant and in whom continued anticoagulation is deemed necessary. Herein we provide a fictional case-based approach to review the recommendations for the use of DOACs in these special patient populations.
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Affiliation(s)
- Asa Kessler
- Heart Institute, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel; (A.K.); (Y.K.)
| | - Yotam Kolben
- Heart Institute, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel; (A.K.); (Y.K.)
| | - Gal Puris
- Faculty of Medicine, Institute for Research in Military Medicine, Hebrew University of Jerusalem, Israel Defense Force Medical Corps, Jerusalem 9112002, Israel;
| | - Martin Ellis
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba 4428164, Israel;
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Mordechai Alperin
- Department of Family Medicine, The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel;
- Clalit Health Services, Haifa and Western Galilee District, Tel Aviv 6209804, Israel
| | | | - Hila Lerman Shivek
- Hospital Pharmacy Department, Hospitals Division, Clalit Health Services, Tel Aviv 6209804, Israel;
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel
| | - Mordechai Muszkat
- Department of Medicine, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Mt. Scopus, Jerusalem 9112002, Israel;
| | - Yoram Maaravi
- The Jerusalem Institute of Aging Research, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel;
- Department of Geriatrics and Rehabilitation and the Center for Palliative Care, Hadassah Medical Center, Jerusalem 9371125, Israel
| | - Yitschak Biton
- Heart Institute, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel; (A.K.); (Y.K.)
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Kanda M, Sato T, Yoshida Y, Kuwabara H, Kobayashi Y, Inoue T. Effect of admission in the stroke care unit versus intensive care unit on in-hospital mortality in patients with acute ischemic stroke. BMC Neurol 2023; 23:402. [PMID: 37957571 PMCID: PMC10641943 DOI: 10.1186/s12883-023-03454-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/06/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND/OBJECTIVE Few reports have directly compared the outcomes of patients with acute ischemic stroke (AIS) who are managed in a stroke care unit (SCU) with those who are managed in an intensive care units (ICU). This large database study in Japan aimed to compare in-hospital mortality between patients with AIS admitted into SCU and those admitted into ICU. METHODS Patients with AIS who were admitted between April 1, 2014, and March 31, 2019, were selected from the administrative database and divided into the SCU and ICU groups. We calculated the propensity score to match groups for which the admission unit assignment was independent of confounding factors, including the modified Rankin scale (mRS) score. The primary outcome was in-hospital mortality, and secondary outcomes were the mRS score at discharge, length of stay (LOS), and total hospitalization cost. RESULTS Overall, 8,683 patients were included, and 960 pairs were matched. After matching, the in-hospital mortality rates of the SCU and ICU groups were not significantly different (5.9% vs. 7.9%, P = 0.106). LOS was significantly shorter (SCU = 20.9 vs. ICU = 26.2 days, P < 0.001) and expenses were significantly lower in the SCU group than in the ICU group (SCU = 1,686,588 vs. ICU = 1,998,260 yen, P < 0.001). mRS scores (score of 1-3 or 4-6) at discharge were not significantly different after matching. Stratified analysis showed that the in-hospital mortality rate was lower in the ICU group than in the SCU group among patients who underwent thrombectomy. CONCLUSIONS In-hospital mortality was not significantly different between the ICU and SCU groups, with significantly lower costs and shorter LOS in the SCU group than in the ICU group.
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Affiliation(s)
- Masato Kanda
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
- Healthcare Management Research Center, Chiba University Hospital, Chiba, Japan
| | - Takanori Sato
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yoichi Yoshida
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hiroyo Kuwabara
- Healthcare Management Research Center, Chiba University Hospital, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takahiro Inoue
- Healthcare Management Research Center, Chiba University Hospital, Chiba, Japan.
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Wu J, Nadarajah R, Nakao YM, Nakao K, Wilkinson C, Cowan JC, Camm AJ, Gale CP. Temporal trends of cause-specific mortality after diagnosis of atrial fibrillation. Eur Heart J 2023; 44:4422-4431. [PMID: 37624589 PMCID: PMC10635669 DOI: 10.1093/eurheartj/ehad571] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/14/2023] [Accepted: 08/21/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND AND AIMS Reports of outcomes after atrial fibrillation (AF) diagnosis are conflicting. The aim of this study was to investigate mortality and hospitalization rates following AF diagnosis over time, by cause and by patient features. METHODS Individuals aged ≥16 years with a first diagnosis of AF were identified from the UK Clinical Practice Research Datalink-GOLD dataset from 1 January 2001, to 31 December 2017. The primary outcomes were all-cause and cause-specific mortality and hospitalization at 1 year following diagnosis. Poisson regression was used to calculate rate ratios (RRs) for mortality and incidence RRs (IRRs) for hospitalization and 95% confidence intervals (CIs) comparing 2001/02 and 2016/17, adjusted for age, sex, region, socio-economic status, and 18 major comorbidities. RESULTS Of 72 412 participants, mean (standard deviation) age was 75.6 (12.4) years, and 44 762 (61.8%) had ≥3 comorbidities. All-cause mortality declined (RR 2016/17 vs. 2001/02 0.72; 95% CI 0.65-0.80), with large declines for cardiovascular (RR 0.46; 95% CI 0.37-0.58) and cerebrovascular mortality (RR 0.41; 95% CI 0.29-0.60) but not for non-cardio/cerebrovascular causes of death (RR 0.91; 95% CI 0.80-1.04). In 2016/17, deaths caused from dementia (67, 8.0%), outstripped deaths from acute myocardial infarction, heart failure, and acute stroke combined (56, 6.7%, P < .001). Overall hospitalization rates increased (IRR 2016/17 vs. 2001/02 1.17; 95% CI, 1.13-1.22), especially for non-cardio/cerebrovascular causes (IRR 1.42; 95% CI 1.39-1.45). Older, more deprived, and hospital-diagnosed AF patients experienced higher event rates. CONCLUSIONS After AF diagnosis, cardio/cerebrovascular mortality and hospitalization has declined, whilst hospitalization for non-cardio/cerebrovascular disease has increased.
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Affiliation(s)
- Jianhua Wu
- Centre for Primary Care, Wolfson Institute of Population Health, Queen Mary University of London, 58 Turner Street, London E1 2AB, UK
| | - Ramesh Nadarajah
- Leeds Institute of Data Analytics, University of Leeds, Leeds, UK
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Yoko M Nakao
- Leeds Institute of Data Analytics, University of Leeds, Leeds, UK
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Kazuhiro Nakao
- Leeds Institute of Data Analytics, University of Leeds, Leeds, UK
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Chris Wilkinson
- Academic Cardiovascular Unit, South Tees NHS Foundation Trust, Middlesbrough, UK
- Hull York Medical School, University of York, York, UK
| | - J Campbell Cowan
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - A John Camm
- Molecular and Clinical Sciences Research Institute, St George’s University of London, London, UK
| | - Chris P Gale
- Leeds Institute of Data Analytics, University of Leeds, Leeds, UK
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Corica B, Romiti GF, Proietti M. Anticoagulation in Patients With Atrial Fibrillation Who Are Frail-Toward Better Care. JAMA Netw Open 2023; 6:e2342258. [PMID: 37943562 DOI: 10.1001/jamanetworkopen.2023.42258] [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: 11/10/2023] Open
Affiliation(s)
- Bernadette Corica
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, 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
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, 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, Milan, Italy
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Lin KJ, Singer DE, Ko D, Glynn R, Najafzadeh M, Lee SB, Bessette LG, Cervone A, DiCesare E, Kim DH. Frailty, Home Time, and Health Care Costs in Older Adults With Atrial Fibrillation Receiving Oral Anticoagulants. JAMA Netw Open 2023; 6:e2342264. [PMID: 37943558 PMCID: PMC10636636 DOI: 10.1001/jamanetworkopen.2023.42264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/26/2023] [Indexed: 11/10/2023] Open
Abstract
Importance There are no data on patient-centered outcomes and health care costs by frailty in patients with atrial fibrillation (AF) taking oral anticoagulants (OACs). Objective To compare home time, clinical events, and health care costs associated with OACs by frailty levels in older adults with AF. Design, Setting, and Participants This community-based cohort study assessed Medicare fee-for-service beneficiaries 65 years or older with AF from January 1, 2013, to December 31, 2019. Data analysis was performed from January to December 2022. Exposures Apixaban, rivaroxaban, and warfarin use were measured from prescription claims. Frailty was measured using a validated claims-based frailty index. Main outcomes and measures Outcome measures were (1) home time (days alive out of the hospital and skilled nursing facility) loss greater than 14 days; (2) a composite end point of ischemic stroke, systemic embolism, major bleeding, or death; and (3) total cost per member per year after propensity score overlap weighting. Results The weighted population comprised 136 551 beneficiaries, including 45 950 taking apixaban (mean [SD] age, 77.6 [7.3] years; 51.3% female), 45 320 taking rivaroxaban (mean [SD] age, 77.6 [7.3] years; 51.9% female), and 45 281 taking warfarin (mean [SD] age, 77.6 [7.3] years; 52.0% female). Compared with apixaban, rivaroxaban was associated with increased risk of home time lost greater than 14 days (risk difference per 100 persons, 1.8 [95% CI, 1.5-2.1]), composite end point (rate difference per 1000 person-years, 21.3 [95% CI, 16.4-26.2]), and total cost (mean difference, $890 [95% CI, $652-$1127]), with greater differences among the beneficiaries with frailty. Use of warfarin relative to apixaban was associated with increased home time lost (risk difference per 100 persons, 3.2 [95% CI, 2.9-3.5]) and composite end point (rate difference per 1000 person-years, 29.4 [95% CI, 24.5-34.3]), with greater differences among the beneficiaries with frailty. Compared with apixaban, warfarin was associated with lower total cost (mean difference, -$1166 [95% CI, -$1396 to -$937]) but higher cost when excluding OAC cost (mean difference, $1409 [95% CI, $1177 to $1642]) regardless of frailty levels. Conclusions and Relevance In older adults with AF, apixaban was associated with increased home time and lower rates of clinical events than rivaroxaban and warfarin, especially for those with frailty. Apixaban was associated with lower total cost compared with rivaroxaban but higher cost compared with warfarin due to higher OAC cost. These findings suggest that apixaban may be preferred for older adults with AF, particularly those with frailty.
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Affiliation(s)
- Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Daniel E. Singer
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Darae Ko
- Section of Cardiovascular Medicine, Boston Medical Center, Boston, Massachusetts
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Robert Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mehdi Najafzadeh
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lily Gui Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alexander Cervone
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elyse DiCesare
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Bisson A, Lemrini Y, Romiti GF, Proietti M, Angoulvant D, Bentounes S, El-Bouri W, Lip GYH, Fauchier L. Prediction of early death after atrial fibrillation diagnosis using a machine learning approach: A French nationwide cohort study. Am Heart J 2023; 265:191-202. [PMID: 37595659 DOI: 10.1016/j.ahj.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 08/14/2023] [Indexed: 08/20/2023]
Abstract
AIMS Atrial fibrillation is associated with important mortality but the usual clinical risk factor based scores only modestly predict mortality. This study aimed to develop machine learning models for the prediction of death occurrence within the year following atrial fibrillation diagnosis and compare predictive ability against usual clinical risk scores. METHODS AND RESULTS We used a nationwide cohort of 2,435,541 newly diagnosed atrial fibrillation patients seen in French hospitals from 2011 to 2019. Three machine learning models were trained to predict mortality within the first year using a training set (70% of the cohort). The best model was selected to be evaluated and compared with previously published scores on the validation set (30% of the cohort). Discrimination of the best model was evaluated using the C index. Within the first year following atrial fibrillation diagnosis, 342,005 patients (14.4%) died after a period of 83 (SD 98) days (median 37 [10-129]). The best machine learning model selected was a deep neural network with a C index of 0.785 (95% CI, 0.781-0.789) on the validation set. Compared to clinical risk scores, the selected model was superior to the CHA2DS2-VASc and HAS-BLED risk scores and superior to dedicated scores such as Charlson Comorbidity Index and Hospital Frailty Risk Score to predict death within the year following atrial fibrillation diagnosis (C indexes: 0.597; 0.562; 0.643; 0.626 respectively. P < .0001). CONCLUSION Machine learning algorithms predict early death after atrial fibrillation diagnosis and may help clinicians to better risk stratify atrial fibrillation patients at high risk of mortality.
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Affiliation(s)
- Arnaud Bisson
- Service de Cardiologie, Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, Tours, France; EA4245, Transplantation Immunité Inflammation, Université de Tours, Tours, France; Service de Cardiologie, Centre Hospitalier Régional Universitaire d'Orléans, Orléans, France; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
| | - Yassine Lemrini
- Service de Cardiologie, Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, Tours, France
| | - 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
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Italy; Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milano, Italy
| | - Denis Angoulvant
- Service de Cardiologie, Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, Tours, France; EA4245, Transplantation Immunité Inflammation, Université de Tours, Tours, France
| | - Sidahmed Bentounes
- Service de Cardiologie, Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, Tours, France
| | - Wahbi El-Bouri
- 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; Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, Tours, France
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Zhang H, Wu F, Sun J, Liu Y, Zhou Z, Wu X, Liang B. The impact of frailty evaluation on the risk of venous thromboembolism in patients with hip fracture following surgery: a meta-analysis. Aging Clin Exp Res 2023; 35:2413-2423. [PMID: 37707745 DOI: 10.1007/s40520-023-02529-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/03/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Frailty has been associated with a higher incidence of overall postoperative complications and mortality. However, the influence of frailty on the risk of venous thromboembolism (VTE) in patients with hip fracture following surgery remains unclear. We performed a meta-analysis to systematically evaluate the above association. METHODS PubMed, Embase, Cochrane Library, Wanfang and CNKI were searched for relevant observational studies comparing the incidence of postoperative VTE in patients of hip fracture with and without frailty. Data collection, literature searching, and statistical analysis were conducted independently by two authors. Using a heterogeneity-incorporating random-effects model, the results were pooled. RESULTS In this meta-analysis, 9509 patients from nine cohort studies were included. Pooled results showed that compared to those without frailty, patients with frailty at admission had a higher incidence of postoperative VTE (odds ratio [OR]: 2.59, 95% confidence interval [CI]: 1.25-5.39, p = 0.01; I2 = 66%). Subgroup analysis suggested the association between frailty and postoperative VTE was more remarkable in studies of patients with frailty prevalence < 50% (OR 6.28, 95% CI 3.31-11.90, p < 0.001; I2 = 8%) as compared to those ≥ 50% (OR 1.30, 95% CI 0.80-2.11, p = 0.28; I2 = 0%; p for subgroup difference < 0.001). Further meta-analyses showed that frailty at baseline was associated with a higher incidence of deep venous thrombosis (OR 3.15, 95% CI 1.33-7.47, p = 0.009; I2 = 59%), but not pulmonary embolism (OR 1.13, 95% CI 0.59-2.16, p = 0.72; I2 = 0%). CONCLUSION Frailty is associated with a higher incidence of postoperative VTE in patients with hip fracture.
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Affiliation(s)
- Haixia Zhang
- Department of Anesthesia and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Fang Wu
- Department of Anesthesia and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Jianbin Sun
- Department of Hand, Foot and Ankle Surgery, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Yongchao Liu
- Department of Anesthesia and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Zifu Zhou
- Burn and Plastic Surgery Department, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Xuejun Wu
- Burn and Plastic Surgery Department, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Bin Liang
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, No. 301, Zhengyuan Beijie, Jinfeng District, Yinchuan, 750004, China.
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Grzeczka A, Graczyk S, Kordowitzki P. DNA Methylation and Telomeres-Their Impact on the Occurrence of Atrial Fibrillation during Cardiac Aging. Int J Mol Sci 2023; 24:15699. [PMID: 37958686 PMCID: PMC10650750 DOI: 10.3390/ijms242115699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in humans. AF is characterized by irregular and increased atrial muscle activation. This high-frequency activation obliterates the synchronous work of the atria and ventricles, reducing myocardial performance, which can lead to severe heart failure or stroke. The risk of developing atrial fibrillation depends largely on the patient's history. Cardiovascular diseases are considered aging-related pathologies; therefore, deciphering the role of telomeres and DNA methylation (mDNA), two hallmarks of aging, is likely to contribute to a better understanding and prophylaxis of AF. In honor of Prof. Elizabeth Blackburn's 75th birthday, we dedicate this review to the discovery of telomeres and her contribution to research on aging.
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Affiliation(s)
| | | | - Pawel Kordowitzki
- Department for Basic and Preclinical Sciences, Faculty of Biological and Veterinary Sciences, Nicolaus Copernicus University, Szosa Bydgoska 13, 87-100 Torun, Poland
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Trinks-Roerdink EM, Geersing GJ, van den Dries CJ, Hemels MEW, Rienstra M, van Gelder IC, van Smeden M, van Klaveren D, Kent DM, Rutten FH, van Doorn S. Integrated care in patients with atrial fibrillation- a predictive heterogeneous treatment effect analysis of the ALL-IN trial. PLoS One 2023; 18:e0292586. [PMID: 37856486 PMCID: PMC10586661 DOI: 10.1371/journal.pone.0292586] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/25/2023] [Indexed: 10/21/2023] Open
Abstract
INTRODUCTION Integrated care is effective in reducing all-cause mortality in patients with atrial fibrillation (AF) in primary care, though time and resource intensive. The aim of the current study was to assess whether integrated care should be directed at all AF patients equally. METHODS The ALL-IN trial (n = 1,240 patients, median age 77 years) was a cluster-randomized trial in which primary care practices were randomized to provide integrated care or usual care to AF patients aged 65 years and older. Integrated care comprised of (i) anticoagulation monitoring, (ii) quarterly checkups and (iii) easy-access consultation with cardiologists. For the current analysis, cox proportional hazard analysis with all clinical variables from the CHA2DS2-VASc score was used to predict all-cause mortality in the ALL-IN trial. Subsequently, the hazard ratio and absolute risk reduction were plotted as a function of this predicted mortality risk to explore treatment heterogeneity. RESULTS Under usual care, after a median of 2 years follow-up the absolute risk of all-cause mortality in the highest-risk quarter was 31.0%, compared to 4.6% in the lowest-risk quarter. On the relative scale, there was no evidence of treatment heterogeneity (p for interaction = 0.90). However, there was substantial treatment heterogeneity on the absolute scale: risk reduction in the lowest risk- quarter of risk 3.3% (95% CI -0.4% - 7.0) compared to 12.0% (95% CI 2.7% - 22.0) in the highest risk quarter. CONCLUSION While the relative degree of benefit from integrated AF care is similar in all patients, patients with a high all-cause mortality risk have a greater benefit on an absolute scale and should therefore be prioritized when implementing integrated care.
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Affiliation(s)
- Emmy M. Trinks-Roerdink
- Department of General Practice & Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Geert-Jan Geersing
- Department of General Practice & Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Carline J. van den Dries
- Department of General Practice & Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Martin E. W. Hemels
- Department of Cardiology, Rijnstate, Arnhem, the Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Isabelle C. van Gelder
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Maarten van Smeden
- Department of Epidemiology & Health Economics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - David van Klaveren
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston, MA, United States of America
| | - David M. Kent
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston, MA, United States of America
| | - Frans H. Rutten
- Department of General Practice & Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Sander van Doorn
- Department of General Practice & Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Romiti GF, Proietti M, Corica B, Bonini N, Boriani G, Huisman MV, Lip GYH. Implications of Clinical Risk Phenotypes on the Management and Natural History of Atrial Fibrillation: A Report From the GLORIA-AF. J Am Heart Assoc 2023; 12:e030565. [PMID: 37815118 PMCID: PMC10757542 DOI: 10.1161/jaha.123.030565] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 09/07/2023] [Indexed: 10/11/2023]
Abstract
Background Clinical risk factors are common among patients with atrial fibrillation (AF), but there are still limited data on their association with oral anticoagulant (OAC) treatment patterns and major outcomes. We aim to analyze the association between clinical risk phenotypes on AF treatment patterns and the risk of major outcomes. Methods and Results The GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation) phase 2 and 3 registries enrolled patients with a recent diagnosis of AF between 2011 and 2016. We defined 4 features of clinical risk among patients with CHA2DS2-VASc ≥2: elderly individuals (aged ≥80 years), chronic kidney disease (estimated glomerular filtration rate <45 mL/min), history of stroke, and history of bleeding. We analyzed the odds of receiving OAC and the risk of OAC discontinuation and adverse events at follow-up according to specific combinations and cumulative burden of these features. Primary outcome was the composite of all-cause death, thromboembolism, and major bleeding. Among 28 891 (mean±SD age, 70.1±10.5 years; 45.5% women) patients included, 10 797 (37.3%) had at least 1 clinical risk feature. OAC use was lower among patients in the elderly group (odds ratio [OR], 0.85 [95% CI, 0.75-0.96]), those with history of both stroke and bleeding (OR, 0.45 [95% CI, 0.35-0.56]), and those with multiple features (OR, 0.71 [95% CI, 0.62-0.82]). Increasing burden of clinical risk features was associated with OAC discontinuation, with highest magnitude in those with ≥3 features (hazard ratio [HR], 1.68 [95% CI, 1.31-2.15]). Groups with increasingly complex clinical risk phenotypes were associated with the occurrence of the primary composite outcome, with the highest figures observed for groups with a history of both stroke and bleeding (adjusted HR, 2.36 [95% CI, 1.83-3.04]) and multiple features (adjusted HR, 2.86 [95% CI, 2.52-3.25]). Conclusions In patients with AF, clinical risk phenotypes are multifaceted and heterogenous, and they are associated with differences in stroke prevention and worse prognosis.
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Affiliation(s)
- Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool, Liverpool John Moores University, and Liverpool Heart and Chest HospitalLiverpoolUnited Kingdom
- Department of Translational and Precision MedicineSapienza–University of RomeRomeItaly
| | - Marco Proietti
- Department of Clinical Sciences and Community HealthUniversity of MilanMilanItaly
- Division of Subacute CareIRCCS Istituti Clinici Scientifici MaugeriMilanItaly
| | - Bernadette Corica
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool, Liverpool John Moores University, and Liverpool Heart and Chest HospitalLiverpoolUnited Kingdom
- Department of Translational and Precision MedicineSapienza–University of RomeRomeItaly
| | - Niccolò Bonini
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool, Liverpool John Moores University, and Liverpool Heart and Chest HospitalLiverpoolUnited Kingdom
- Cardiology Division, Department of Biomedical, Metabolic and Neural SciencesUniversity of Modena and Reggio Emilia, Policlinico di ModenaModenaItaly
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural SciencesUniversity of Modena and Reggio Emilia, Policlinico di ModenaModenaItaly
| | - Menno V. Huisman
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool, Liverpool John Moores University, and Liverpool Heart and Chest HospitalLiverpoolUnited Kingdom
- Danish Center for Clinical Health Services Research, Department of Clinical MedicineAalborg UniversityAalborgDenmark
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Domínguez-Erquicia P, Raposeiras-Roubín S, Abu-Assi E, Lizancos-Castro A, Parada-Barcia JA, González-García A, Ledo-Piñeiro A, Noriega-Caro V, Iglesias-Otero C, Íñiguez-Romo A. Predictive value of bleeding risk scores in elderly patients with atrial fibrillation and oral anticoagulation. J Geriatr Cardiol 2023; 20:684-692. [PMID: 37840634 PMCID: PMC10568544 DOI: 10.26599/1671-5411.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Abstract
BACKGROUND The predictive value of bleeding risk scores for atrial fibrillation in older patients is not as well known. The goal of this study was to evaluate the predictive value of HASBLED, ORBIT and ATRIA for major bleeding (MB) and intracranial hemorrhage (ICH) in patients ≥ 75 years with atrial fibrillation and oral anticoagulation (OAC). METHODS A retrospective unicenter study including patients ≥ 75 years with atrial fibrillation (AF) and OAC. A total of 7613 patients ≥ 75 years with AF and OAC included between 2014 and 2018 (registry: NCT04364516). We analyzed the discriminative value of HASBLED, ATRIA and ORBIT scores for bleeding endpoints (major bleeding as primary endpoint and intracerebral hemorrhage as secondary). Cox regression was used to predict major bleeding with each scale and also for searching other variables potentially predictor of major bleeding. Model discrimination was assessed using Harrell's C-statistic. Calibration was assessed with goodness-of-fit test proposed by Gronnesby and Borgan. RESULTS During a mean follow up of 4.0 years (IQR: 2.4-5.7 years), 729 patients developed MB (2.61 per 100 patients/year) and 243 patients developed ICH (0.85 per 100 patients/year). Three scores showed a low discrimination for major bleeding, being ORBIT the best (HASBLED C statistic = 0.557; ATRIA C statistic = 0.568; ORBIT C statistic = 0.595) and also a low discrimination for ICH (HASBLED C statistic = 0.509; ATRIA C statistic = 0.522; ORBIT C statistic = 0.526). Among the variables that are part of the scores and other baseline characteristics, after multivariable adjustment only sex (male), dementia, prior admission for bleeding, anemia and liver disease were found as a predictors of MB. CONCLUSIONS In older patients under oral anticoagulation with atrial fibrillation, the risk scores HASBLED, ATRIA and ORBIT showed a weak discrimination for major bleeding and intracranial hemorrhage. Therefore, other better alternatives should be evaluated for this purpose.
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Affiliation(s)
- Pablo Domínguez-Erquicia
- Department of Cardiology, University Hospital Álvaro Cunqueiro, Vigo, Spain
- Health Research Institute Galicia Sur, Vigo, Spain
| | - Sergio Raposeiras-Roubín
- Department of Cardiology, University Hospital Álvaro Cunqueiro, Vigo, Spain
- Health Research Institute Galicia Sur, Vigo, Spain
| | - Emad Abu-Assi
- Department of Cardiology, University Hospital Álvaro Cunqueiro, Vigo, Spain
- Health Research Institute Galicia Sur, Vigo, Spain
| | | | | | | | - Ana Ledo-Piñeiro
- Department of Cardiology, University Hospital Álvaro Cunqueiro, Vigo, Spain
| | | | | | - Andrés Íñiguez-Romo
- Department of Cardiology, University Hospital Álvaro Cunqueiro, Vigo, Spain
- Health Research Institute Galicia Sur, Vigo, Spain
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Bamberg C, Ladegaard CT, Aalling M, Jensen DM, Madsen CL, Kamil S, Gudbergsen H, Saxild T, Schiøtz ML, Grew J, Castillo LS, Tousgaard I, Johansen RLR, Bardram JE, Frølich A, Domínguez H. Reaching the Frail Elderly for the Diagnosis and Management of Atrial Fibrillation-REAFEL. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6783. [PMID: 37754642 PMCID: PMC10530387 DOI: 10.3390/ijerph20186783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/13/2023] [Accepted: 09/16/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Frail elderly patients are exposed to suffering strokes if they do not receive timely anticoagulation to prevent stroke associated to atrial fibrillation (AF). Evaluation in the cardiological ambulatory can be cumbersome as it often requires repeated visits. AIM To develop and implement CardioShare, a shared-care model where primary care leads patient management, using a compact Holter monitor device with asynchronous remote support from cardiologists. METHODS CardioShare was developed in a feasibility phase, tested in a pragmatic cluster randomization trial (primary care clinics as clusters), and its implementation potential was evaluated with an escalation test. Mixed methods were used to evaluate the impact of this complex intervention, comprising quantitative observations, semi-structured interviews, and workshops. RESULTS Between February 2020 and December 2021, 314 patients (30% frail) were included, of whom 75% had AF diagnosed/not found within 13 days; 80% in both groups avoided referral to cardiologists. Patients felt safe and primary care clinicians satisfied. In an escalation test, 58 primary-care doctors evaluated 93 patients over three months, with remote support from four hospitals in the Capital Region of Denmark. CONCLUSIONS CardioShare was successfully implemented for AF evaluation in primary care.
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Affiliation(s)
- Carsten Bamberg
- Cardiology Department Y Bispebjerg and Frederiksberg Hospital, Capital Region, 2000 Frederiksberg, Denmark; (C.B.); (C.T.L.); (D.M.J.); (C.L.M.); (S.K.)
- Department of Biomedicine, University of Copenhagen, 1165 Copenhagen, Denmark
| | - Caroline Thorup Ladegaard
- Cardiology Department Y Bispebjerg and Frederiksberg Hospital, Capital Region, 2000 Frederiksberg, Denmark; (C.B.); (C.T.L.); (D.M.J.); (C.L.M.); (S.K.)
- Department of Biomedicine, University of Copenhagen, 1165 Copenhagen, Denmark
| | - Mathias Aalling
- VihTek Research Center for Welfare Technology Capital Region, 2600 Copenhagen, Denmark;
| | - Dorthea Marie Jensen
- Cardiology Department Y Bispebjerg and Frederiksberg Hospital, Capital Region, 2000 Frederiksberg, Denmark; (C.B.); (C.T.L.); (D.M.J.); (C.L.M.); (S.K.)
- Department of Biomedicine, University of Copenhagen, 1165 Copenhagen, Denmark
| | - Christoffer Læssøe Madsen
- Cardiology Department Y Bispebjerg and Frederiksberg Hospital, Capital Region, 2000 Frederiksberg, Denmark; (C.B.); (C.T.L.); (D.M.J.); (C.L.M.); (S.K.)
- Department of Biomedicine, University of Copenhagen, 1165 Copenhagen, Denmark
| | - Sadaf Kamil
- Cardiology Department Y Bispebjerg and Frederiksberg Hospital, Capital Region, 2000 Frederiksberg, Denmark; (C.B.); (C.T.L.); (D.M.J.); (C.L.M.); (S.K.)
- Department of Biomedicine, University of Copenhagen, 1165 Copenhagen, Denmark
| | - Henrik Gudbergsen
- Section of General Practice, Department of Public Health, University of Copenhagen, 1165 Copenhagen, Denmark;
| | - Thomas Saxild
- Grøndalslægerne Godthåbsvej 239a, Vanløse, 2720 Copenhagen, Denmark;
| | - Michaela Louise Schiøtz
- Center for Clinical Research and Prevention Bispebjerg and Frederiksberg Hospital, 2400 Copenhagen, Denmark; (M.L.S.); (J.G.)
| | - Julie Grew
- Center for Clinical Research and Prevention Bispebjerg and Frederiksberg Hospital, 2400 Copenhagen, Denmark; (M.L.S.); (J.G.)
| | | | - Iben Tousgaard
- Department of Quality and Education, Bispebjerg and Frederiksberg Hospital, 2400 Copenhagen, Denmark; (I.T.); (R.L.R.J.)
| | - Rie Laurine Rosenthal Johansen
- Department of Quality and Education, Bispebjerg and Frederiksberg Hospital, 2400 Copenhagen, Denmark; (I.T.); (R.L.R.J.)
| | - Jakob Eyvind Bardram
- Department of Health Technology, Digital Health, Personalized Health Technology, Technical University of Denmark, 2800 Copenhagen, Denmark;
| | - Anne Frølich
- Innovation and Research Centre for Multimorbidity, Slagelse Hospital, Region Zealand, 4180 Sorø, Denmark;
- Section of General Practice, Faculty of Health and Medical Sciences, University of Copenhagen, 1165 Copenhagen, Denmark
| | - Helena Domínguez
- Cardiology Department Y Bispebjerg and Frederiksberg Hospital, Capital Region, 2000 Frederiksberg, Denmark; (C.B.); (C.T.L.); (D.M.J.); (C.L.M.); (S.K.)
- Department of Biomedicine, University of Copenhagen, 1165 Copenhagen, Denmark
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Kravchenko G, Korycka-Bloch R, Stephenson SS, Kostka T, Sołtysik BK. Cardiometabolic Disorders Are Important Correlates of Vulnerability in Hospitalized Older Adults. Nutrients 2023; 15:3716. [PMID: 37686746 PMCID: PMC10490417 DOI: 10.3390/nu15173716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/17/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
With an increasingly aging population worldwide, the concept of multimorbidity has attracted growing interest over recent years, especially in terms of frailty, which leads to progressive multisystem decline and increased adverse clinical outcomes. The relative contribution of multiple disorders to overall frailty index in older populations has not been established so far. This study aimed to assess the association between the vulnerable elders survey-13 (VES-13) score, which is acknowledged to be one of the most widely used measures of frailty, and the most common accompanying diseases amongst hospitalized adults aged 60 years old and more. A total of 2860 participants with an average age of 83 years were included in this study. Multiple logistic regression with adjustment for age and nutritional status was used to assess the independent impact of every particular disease on vulnerability. Diabetes mellitus type 2, coronary artery disease, atrial fibrillation, heart failure, chronic kidney disease, osteoarthritis, fractures, eyes disorders, depression, dementia, pressure ulcers, and urinary incontinence were associated with higher scores of VES-13. Hospital admission of older subjects with those conditions should primarily draw attention to the risk of functional decline, especially while qualifying older patients for further treatment in surgery and oncology. At the same time, lipid disorders, gastrointestinal diseases, higher body mass index, and albumins level were related to a lower risk of being vulnerable, which may be attributed to a younger age and better nutritional status of those patients.
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Affiliation(s)
| | | | | | - Tomasz Kostka
- Department of Geriatrics, Healthy Aging Research Centre (HARC), Medical University of Lodz, Haller Sqr. No. 1, 90-647 Lodz, Poland; (G.K.); (R.K.-B.); (S.S.S.); (B.K.S.)
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Lip GYH, Proietti M, Potpara T, Mansour M, Savelieva I, Tse HF, Goette A, Camm AJ, Blomstrom-Lundqvist C, Gupta D, Boriani G. Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal. Europace 2023; 25:euad226. [PMID: 37622590 PMCID: PMC10451006 DOI: 10.1093/europace/euad226] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 08/26/2023] Open
Abstract
Stroke prevention in patients with atrial fibrillation (AF) is one pillar of the management of this common arrhythmia. Substantial advances in the epidemiology and associated pathophysiology underlying AF-related stroke and thrombo-embolism are evident. Furthermore, the introduction of the non-vitamin K antagonist oral anticoagulants (also called direct oral anticoagulants) has clearly changed our approach to stroke prevention in AF, such that the default should be to offer oral anticoagulation for stroke prevention, unless the patient is at low risk. A strategy of early rhythm control is also beneficial in reducing strokes in selected patients with recent onset AF, when compared to rate control. Cardiovascular risk factor management, with optimization of comorbidities and attention to lifestyle factors, and the patient's psychological morbidity are also essential. Finally, in selected patients with absolute contraindications to long-term oral anticoagulation, left atrial appendage occlusion or exclusion may be considered. The aim of this state-of-the-art review article is to provide an overview of the current status of AF-related stroke and prevention strategies. A holistic or integrated care approach to AF management is recommended to minimize the risk of stroke in patients with AF, based on the evidence-based Atrial fibrillation Better Care (ABC) pathway, as follows: A: Avoid stroke with Anticoagulation; B: Better patient-centred, symptom-directed decisions on rate or rhythm control; C: Cardiovascular risk factor and comorbidity optimization, including lifestyle changes.
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Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Irina Savelieva
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Hung Fat Tse
- Cardiology Division, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Andreas Goette
- Medizinische Klinik II: Kardiologie und Intensivmedizin, St. Vincenz-Krankenhaus Paderborn, Am Busdorf 2, 33098 Paderborn, Germany
| | - A John Camm
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Carina Blomstrom-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, via del Pozzo 71, 41125 Modena, Italy
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Schnabel RB, Ameri P, Siller-Matula JM, Diemberger I, Gwechenberger M, Pecen L, Manu MC, Souza J, De Caterina R, Kirchhof P. Outcomes of patients with atrial fibrillation on oral anticoagulation with and without heart failure: the ETNA-AF-Europe registry. Europace 2023; 25:euad280. [PMID: 37713182 PMCID: PMC10540669 DOI: 10.1093/europace/euad280] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/07/2023] [Accepted: 09/09/2023] [Indexed: 09/16/2023] Open
Abstract
AIMS Heart failure (HF) is a risk factor for major adverse events in atrial fibrillation (AF). Whether this risk persists on non-vitamin K antagonist oral anticoagulants (NOACs) and varies according to left ventricular ejection fraction (LVEF) is debated. METHODS AND RESULTS We investigated the relation of HF in the ETNA-AF-Europe registry, a prospective, multicentre, observational study with an overall 4-year follow-up of edoxaban-treated AF patients. We report 2-year follow-up for ischaemic stroke/transient ischaemic attack (TIA)/systemic embolic events (SEE), major bleeding, and mortality. Of the 13 133 patients, 1854 (14.1%) had HF. Left ventricular ejection fraction was available for 82.4% of HF patients and was <40% in 671 (43.9%) and ≥40% in 857 (56.1%). Patients with HF were older, more often men, and had more comorbidities. Annualized event rates (AnERs) of any stroke/SEE were 0.86%/year and 0.67%/year in patients with and without HF. Compared with patients without HF, those with HF also had higher AnERs for major bleeding (1.73%/year vs. 0.86%/year) and all-cause death (8.30%/year vs. 3.17%/year). Multivariate Cox proportional models confirmed HF as a significant predictor of major bleeding [hazard ratio (HR) 1.65, 95% confidence interval (CI): 1.20-2.26] and all-cause death [HF with LVEF <40% (HR 2.42, 95% CI: 1.95-3.00) and HF with LVEF ≥40% (HR 1.80, 95% CI: 1.45-2.23)] but not of ischaemic stroke/TIA/SEE. CONCLUSION Anticoagulated patients with HF at baseline featured higher rates of major bleeding and all-cause death, requiring optimized management and novel preventive strategies. NOAC treatment was similarly effective in reducing risk of ischaemic events in patients with or without concomitant HF.
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Affiliation(s)
- Renate B Schnabel
- Department of Cardiology, University Clinic Hamburg-Eppendorf, University Heart and Vascular Centre Hamburg-Eppendorf, Buildung O50, Martinistrasse 52, 20246 Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Potsdamer Str, 5810785 Berlin, Germany
| | - Pietro Ameri
- Department of Internal Medicine, University of Genova, Genova, Italy
- Cardiac, Thoracic and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | | | - Igor Diemberger
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy
- Unit of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | | | - Ladislav Pecen
- Czech Academy of Science, Institute of Computer Sciences, Prague, Czech Republic
- Department of Immunochemistry Diagnostics, University Hospital Pilsen, Pilsen, Czech Republic
| | | | - José Souza
- Daiichi Sankyo Europe GmbH, Munich, Germany
| | - Raffaele De Caterina
- Cardiology Division, Pisa University Hospital, Pisa, Italy
- Fondazione Villa Serena per la Ricerca, Pescara, Italy
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Cardiology, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Sciences (DZHK), partner site Hamburg/Kiel/Lübeck, Germany
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48
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Verma LA, Penson PE, Akpan A, Lip GYH, Lane DA. Managing older people with atrial fibrillation and preventing stroke: a review of anticoagulation approaches. Expert Rev Cardiovasc Ther 2023; 21:963-983. [PMID: 38088256 DOI: 10.1080/14779072.2023.2276892] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 10/25/2023] [Indexed: 12/18/2023]
Abstract
INTRODUCTION Oral anticoagulants (OACs) are the cornerstone of stroke prevention in atrial fibrillation (AF), but prescribing decisions in older people are complicated. Clinicians must assess the net clinical benefit of OAC in the context of multiple chronic conditions, polypharmacy, frailty and life expectancy. The under-representation of high-risk, older adult sub-populations in clinical trials presents the challenge of choosing the right OAC, where a 'one-size-fits-all' approach cannot be taken. AREAS COVERED This review discusses OAC approaches for stroke prevention in older people with AF and presents a prescribing aid to support clinicians' decision-making. High-risk older adults with multiple chronic conditions, specifically chronic kidney disease, dementia/cognitive impairment, previous stroke/transient ischemic attack or intracranial hemorrhage, polypharmacy, frailty, low body weight, high falls risk, and those aged ≥75 years are considered. EXPERT OPINION Non-vitamin K antagonist OACs are the preferred first-line OAC in older adults with AF, including high-risk subpopulations, after individual assessment of stroke and bleeding risk, except those with mechanical heart valves and moderate-to-severe mitral stenosis. Head-to-head comparisons of NOACs are not available, therefore the choice of drug (and dose) should be based on an individual's risk (stroke and bleeding) and incorporate their treatment preferences. Treatment decisions must be person-centered and principles of shared decision-making applied.
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Affiliation(s)
- Leona A Verma
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
| | - Peter E Penson
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
| | - Asangaedem Akpan
- Musculoskeletal and Ageing Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Medicine for Older People, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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49
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Hao B, Chen T, Qin J, Meng W, Bai W, Zhao L, Ou X, Liu H, Xu W. A comparison of three approaches to measuring frailty to determine adverse health outcomes in critically ill patients. Age Ageing 2023; 52:afad096. [PMID: 37326605 DOI: 10.1093/ageing/afad096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND studies comparing different frailty measures in intensive care unit settings are lacking. We aimed to compare the frailty index based on physiological and laboratory tests (FI-Lab), modified frailty index (MFI) and hospital frailty risk score (HFRS) to predict short-term outcomes for critically ill patients. METHODS we conducted a secondary analysis of data from the Medical Information Mart for Intensive Care IV database. Outcomes of interest included in-hospital mortality and discharge with need for nursing care. RESULTS the primary analysis was conducted with 21,421 eligible critically ill patients. After adjusting for confounding variables, frailty as diagnosed by all three frailty measures was found to be significantly associated with increased in-hospital mortality. In addition, frail patients were more likely to receive further nursing care after being discharged. All three frailty scores could improve the discrimination ability of the initial model generated by baseline characteristics for adverse outcomes. The FI-Lab had the best predictive ability for in-hospital mortality, whereas the HFRS had the best predictive performance for discharge with need for nursing care amongst the three frailty measures. A combination of the FI-Lab with either the HFRS or MFI improved the identification of critically ill patients at increased risk of in-hospital mortality. CONCLUSIONS frailty, as assessed by the HFRS, MFI and FI-Lab, was associated with short-term survival and discharge with need for nursing care amongst critically ill patients. The FI-Lab was a better predictor of in-hospital mortality than the HFRS and MFI. Future studies focusing on FI-Lab are warranted.
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Affiliation(s)
- Benchuan Hao
- Medical School of Chinese PLA, Beijing 100039, China
- Department of Cardiology, The Second Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
| | - Tao Chen
- Department of Cardiology, The Sixth Medical Centre, Chinese PLA General Hospital, Beijing 100037, China
| | - Ji Qin
- Medical School of Chinese PLA, Beijing 100039, China
- Department of Cardiology, The Second Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
| | - Wenwen Meng
- Department of Cardiology, The Sixth Medical Centre, Chinese PLA General Hospital, Beijing 100037, China
| | - Weimin Bai
- Department of Emergency, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou 463599, China
| | - Libo Zhao
- Medical School of Chinese PLA, Beijing 100039, China
- Department of Cardiology, The Second Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
| | - Xianwen Ou
- College of Information Science & Technology Haikou, Hainan University, Hainan 570100, China
| | - Hongbin Liu
- Department of Cardiology, The Second Medical Centre, Chinese PLA General Hospital, Beijing 100039, China
| | - Weihao Xu
- Haikou Cadre's Sanitarium of Hainan Military Region, Haikou 570203, China
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50
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Guo Y, Romiti GF, Sagris D, Proietti M, Bonini N, Zhang H, Lip GYH. Mobile health-technology integrated care in secondary prevention atrial fibrillation patients: a post-hoc analysis from the mAFA-II randomized clinical trial. Intern Emerg Med 2023; 18:1041-1048. [PMID: 36929347 PMCID: PMC10326104 DOI: 10.1007/s11739-023-03249-0] [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: 11/14/2022] [Accepted: 02/26/2023] [Indexed: 03/18/2023]
Abstract
AF patients with history of thromboembolic events are at higher risk of thromboembolic recurrences, despite appropriate antithrombotic treatment. We aimed to evaluate the effect of mobile health (mHealth) technology-implemented 'Atrial fibrillation Better Care' (ABC) pathway approach (mAFA intervention) in secondary prevention AF patients. The Mobile Health Technology for Improved Screening and Optimized Integrated Care in AF (mAFA-II) cluster randomized trial enrolled adult AF patients across 40 centers in China. The main outcome was the composite outcome of stroke or thromboembolism, all-cause death, and rehospitalization. Using Inverse Probability of Treatment Weighting (IPTW), we evaluated the effect of the mAFA intervention in patients with and without prior history of thromboembolic events (i.e., ischemic stroke or thromboembolism). Among the 3324 patients enrolled in the trial, 496 (14.9%, mean age: 75.1 ± 11.4 years, 35.9% females) had a previous episode of thromboembolic event. No significant interaction was observed for the effect of mAFA intervention in patients with vs. without history of thromboembolic events [Hazard ratio, (HR): 0.38, 95% confidence interval (CI):0.18-0.80 vs. HR 0.55, 95% CI 0.17-1.76, p for interaction = 0.587); however, a trend towards lower efficacy of mAFA intervention among AF patients in secondary prevention was observed for secondary outcomes, with significant interaction for bleeding events (p = 0.034) and the composite of cardiovascular events (p = 0.015). A mHealth-technology-implemented ABC pathway provided generally consistent reduction of the risk of primary outcome in both primary and secondary prevention AF patients. Secondary prevention patients may require further specific approaches to improve clinical outcomes such as bleeding and cardiovascular events.Trial registration: WHO International Clinical Trials Registry Platform (ICTRP) Registration number ChiCTR-OOC-17014138.
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Affiliation(s)
- Yutao Guo
- 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, Liverpool John Moores University and Liverpool Heart and Chest Hospital, William Henry Duncan Building, 6 West Derby St, Liverpool, L7 8TX, UK
| | - Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, William Henry Duncan Building, 6 West Derby St, Liverpool, L7 8TX, UK
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Dimitrios Sagris
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, William Henry Duncan Building, 6 West Derby St, Liverpool, L7 8TX, UK
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, William Henry Duncan Building, 6 West Derby St, Liverpool, L7 8TX, UK
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Niccolò Bonini
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, William Henry Duncan Building, 6 West Derby St, Liverpool, L7 8TX, UK
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, PoliclinicoDi Modena, Modena, Italy
| | - Hui Zhang
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Center, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Gregory Y H Lip
- 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, Liverpool John Moores University and Liverpool Heart and Chest Hospital, William Henry Duncan Building, 6 West Derby St, Liverpool, L7 8TX, UK.
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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