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Sandhu RK, Fradette M, Lin M, Youngson E, Lau D, Bungard TJ, Tsuyuki RT, Dolovich L, Healey JS, McAlister FA. Stroke Risk Reduction in Atrial Fibrillation Through Pharmacist Prescribing: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2421993. [PMID: 39046741 PMCID: PMC11270136 DOI: 10.1001/jamanetworkopen.2024.21993] [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] [Received: 02/09/2024] [Accepted: 05/14/2024] [Indexed: 07/25/2024] Open
Abstract
Importance Major gaps in the delivery of appropriate oral anticoagulation therapy (OAC) exist, leaving a large proportion of persons with atrial fibrillation (AF) unnecessarily at risk for stroke and its sequalae. Objective To investigate whether pharmacist-led OAC prescription can increase the delivery of stroke risk reduction therapy in individuals with AF. Design, Setting, and Participants This prospective, open-label, patient-level randomized clinical trial of early vs delayed pharmacist intervention from January 1, 2019, to December 31, 2022, was performed in 27 community pharmacies in Alberta, Canada. Pharmacists identified patients 65 years or older with 1 additional stroke risk factor and known, untreated AF (OAC nonprescription or OAC suboptimal dosing) or performed screening using a 30-second single-lead electrocardiogram to detect previously unrecognized AF. Patients with undertreated or newly diagnosed AF eligible for OAC therapy were considered to have actionable AF. Data were analyzed from April 3 to November 30, 2023. Interventions In the early intervention group, pharmacists prescribed OAC using guideline-based algorithms with follow-up visits at 1 and 3 months. In the delayed intervention group, which served as the usual care control, the primary care physician (PCP) was sent a notification of actionable AF along with a medication list (both enhancement over usual care). After 3 months, patients without OAC optimization in the control group underwent delayed pharmacist intervention. Main Outcomes and Measures The primary outcome was the difference in the rate of guideline-concordant OAC use in the 2 groups at 3-month follow-up ascertained by a research pharmacist blinded to treatment allocation. Results Eighty patients were enrolled with actionable AF (9 [11.3%] newly diagnosed in 235 individuals screened). The mean (SD) age was 79.7 (7.4) years, and 45 patients (56.3%) were female. The median CHADS2 (congestive heart failure, hypertension, age, diabetes, and stroke or transient ischemic attack) score was 2 (IQR, 2-3). Seventy patients completed follow-up. Guideline-concordant OAC use at 3 months occurred in 36 of 39 patients (92.3%) in the early intervention group vs 23 of 41 (56.1%) in the control group (P < .001), with an absolute increase of 34% and number needed to treat of 3. Of the 23 patients who received appropriate OAC prescription in the control group, the PCP called the pharmacist for prescribing advice in 6 patients. Conclusions and Relevance This randomized clinical trial found that pharmacist OAC prescription is a potentially high-yield opportunity to effectively close gaps in the delivery of stroke risk reduction therapy for AF. Scalability and sustainability of pharmacist OAC prescription will require larger trials demonstrating effectiveness and safety. Trial Registration ClinicalTrials.gov Identifier: NCT03126214.
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Affiliation(s)
- Roopinder K. Sandhu
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Division of Cardiology, University of Alberta, Edmonton, Canada
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Miriam Fradette
- Division of Cardiology, University of Alberta, Edmonton, Canada
| | - Meng Lin
- Alberta Strategy for Patient-Oriented Research, University of Alberta, Edmonton, Canada
| | - Erik Youngson
- Alberta Strategy for Patient-Oriented Research, University of Alberta, Edmonton, Canada
- Alberta Health Services Provincial Research Data Services, Edmonton, Canada
| | - Darren Lau
- Division of General Internal Medicine, University of Alberta, Edmonton, Canada
| | | | - Ross T. Tsuyuki
- Division of Cardiology, University of Alberta, Edmonton, Canada
| | - Lisa Dolovich
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Jeff S. Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Finlay A. McAlister
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
- Division of General Internal Medicine, University of Alberta, Edmonton, Canada
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Situ M, Schwarz UI, Zou G, McArthur E, Kim RB, Garg AX, Sarma S. Does prescribing apixaban or rivaroxaban versus warfarin for patients diagnosed with atrial fibrillation save health system costs? A multivalued treatment effects analysis. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2024; 25:397-409. [PMID: 37195343 DOI: 10.1007/s10198-023-01594-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 04/25/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Non-valvular atrial fibrillation (AF) is a common heart arrhythmia in the elderly population. AF patients are at high-risk of ischemic strokes, but oral anticoagulant (OAC) therapy reduces such risks. Warfarin had been the standard OAC for AF patients, however its effectiveness is highly variable and dependent on close monitoring of the anticoagulant response. Newer OACs such as rivaroxaban and apixaban address these drawbacks but are more costly. It is uncertain which OAC therapy for AF is cost-saving from the healthcare system perspective. METHODS We followed a cohort of patients in Ontario, Canada, aged ≥ 66 who were newly diagnosed with AF and prescribed OACs between 2012 and 2017. We used a two-stage estimation procedure. First, we account for the patient selection into OACs using a multinomial logit regression model and estimated propensity scores. Second, we used an inverse probability weighted regression adjustment approach to determine cost-saving OAC options. We also examined component-specific costs (i.e., drug, hospitalization, emergency department and physician) to understand the drivers of cost-saving OACs. RESULTS We found that compared to warfarin, rivaroxaban and apixaban treatments were cost-saving options, with per-patient 1-year healthcare cost savings at $2436 and $1764, respectively. These savings were driven by cost-savings in hospitalization, emergency department visits, and physician visits, outweighing higher drug costs. These results were robust to alternative model specifications and estimation procedures. CONCLUSIONS Treating AF patients with rivaroxaban and apixaban than warfarin reduces healthcare costs. OAC reimbursement policies for AF patients should consider rivaroxaban or apixaban over warfarin as the first-line treatment.
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Affiliation(s)
- Michael Situ
- Department of Epidemiology and Biostatistics, Western Centre for Public Health and Family Medicine, Schulich School of Medicine and Dentistry, Western University, 1465 Richmond Street, ON, N6G 2M1, London, Canada
| | - Ute I Schwarz
- Division of Clinical Pharmacology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, ON, London, Canada
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, ON, London, Canada
| | - Guangyong Zou
- Department of Epidemiology and Biostatistics, Western Centre for Public Health and Family Medicine, Schulich School of Medicine and Dentistry, Western University, 1465 Richmond Street, ON, N6G 2M1, London, Canada
- Alimentiv Inc, London, ON, Canada
| | - Eric McArthur
- ICES (Formerly the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
| | - Richard B Kim
- Division of Clinical Pharmacology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, ON, London, Canada
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, ON, London, Canada
- Lawson Health Research Institute, London, ON, Canada
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, ON, London, Canada
| | - Amit X Garg
- ICES (Formerly the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, ON, London, Canada
| | - Sisira Sarma
- Department of Epidemiology and Biostatistics, Western Centre for Public Health and Family Medicine, Schulich School of Medicine and Dentistry, Western University, 1465 Richmond Street, ON, N6G 2M1, London, Canada.
- ICES (Formerly the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada.
- Lawson Health Research Institute, London, ON, Canada.
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Weber C, Tedt J, Husser O, Holz FG, Liegl R. [Survey on blood thinning therapy in patients with age-related macular degeneration]. DIE OPHTHALMOLOGIE 2024; 121:216-222. [PMID: 38361015 DOI: 10.1007/s00347-024-01992-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 12/21/2023] [Accepted: 01/17/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Patients with age-related macular degeneration (AMD) often receive concomitant systemic blood thinning medications. These are known to increase the risk of severe hemorrhage also in connection with AMD, which can lead to extensive subretinal hemorrhaging. OBJECTIVE The purpose of this study was to investigate the proportion of patients with AMD and concomitant blood thinning treatment, including the type and reason for blood thinning treatment. METHODS This survey was prospectively conducted at the University Eye Hospital, Bonn, Germany. Volunteers were recruited during retinal consultations and the consultations for intravitreal injections (IVOM). RESULTS The questionnaire was completed by 178 patients. The mean age was 81.7 years (58-100) and 101 patients (57.7%) were undergoing blood thinning treatment. The majority of patients were taking antiplatelet agents (n = 59; 58.4%), especially ASA (n = 55; 54.5%). Direct oral anticoagulants (DOAC) were taken by 33 patients (32.7%), including most frequently apixaban (17.8%). Vitamin K antagonists (VKA) was taken by 4 patients (4%). The most common reason for blood thinning treatment was atrial fibrillation (n = 32, 31.7%), followed by stent implantation (n = 20, 19.8%) and stroke (n = 12, 11.9%) but 13 patients (12.9%) did not know why they were undergoing blood thinning treatment. No clear indications for the use of blood thinners were found in 31 patients (30.7%). CONCLUSION A large proportion of patients with AMD undergo blood thinning treatment; however, not every patient has a clear indication. Due to the increased risk of bleeding, the use of blood thinners should be critically evaluated in close cooperation with primary care physicians and cardiologists.
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Affiliation(s)
- Constance Weber
- Universitäts-Augenklinik Bonn, Ernst-Abbe-Str. 2, 53117, Bonn, Deutschland
| | - Jezabel Tedt
- Universitäts-Augenklinik Bonn, Ernst-Abbe-Str. 2, 53117, Bonn, Deutschland
| | - Oliver Husser
- Kardiologie und Intensivmedizin, Augustinum Klinik München, München, Deutschland
| | - Frank G Holz
- Universitäts-Augenklinik Bonn, Ernst-Abbe-Str. 2, 53117, Bonn, Deutschland
| | - Raffael Liegl
- Universitäts-Augenklinik Bonn, Ernst-Abbe-Str. 2, 53117, Bonn, Deutschland.
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van der Horst SFB, van Rein N, van Mens TE, Huisman MV, Klok FA. Inappropriate prescriptions of direct oral anticoagulants (DOACs) in hospitalized patients: A narrative review. Thromb Res 2023; 231:135-140. [PMID: 37005194 DOI: 10.1016/j.thromres.2023.03.007] [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: 02/03/2023] [Revised: 03/14/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023]
Abstract
Direct oral anticoagulants (DOACs) have become the cornerstone for prevention of thromboembolic events in patients with atrial fibrillation and patients with a history of venous thromboembolism. However, studies show that DOAC prescriptions are commonly inconsistent with guideline recommendations. DOAC dosing in the acutely ill patient could impose an even greater challenge. In this review, we describe the prevalence of inappropriate inpatient prescribing of DOACs and the associated rationales, predictors and clinical consequences. With the aim of promoting appropriate prescriptions of DOACs to hospitalized patients, we further outline DOAC dose reduction criteria justified by various guidelines, illustrating the complexities of appropriate dosing, especially in acutely ill patients. Moreover, we will discuss the impact of anticoagulant stewardship programs and the vital role that pharmacists may play in optimizing inpatient DOAC treatment.
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Affiliation(s)
- S F B van der Horst
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, Netherlands.
| | - N van Rein
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - T E van Mens
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, Netherlands; Amsterdam UMC, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development, University of Amsterdam, Amsterdam, Netherlands
| | - M V Huisman
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, Netherlands
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Saw J, Inohara T, Gilhofer T, Uchida N, Pearce C, Dehghani P, Kass M, Ibrahim R, Morillo C, Wardell S, Paradis JM, O’Hara GE. The Canadian WATCHMAN Registry for Percutaneous Left Atrial Appendage Closure. CJC Open 2023; 5:522-529. [PMID: 37496779 PMCID: PMC10366627 DOI: 10.1016/j.cjco.2023.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/21/2023] [Indexed: 07/28/2023] Open
Abstract
Background Access to left atrial appendage closure (LAAC) in Canada is limited, due to funding restrictions. This work aimed to assess Canadian clinical practice on patient selection, postprocedural antithrombotic therapy, and safety and/or efficacy with WATCHMAN device implantation. Methods Seven Canadian centres implanting the WATCHMAN device participated in this prospective multicentre, observational registry. All procedures were done under general anesthesia with transesophageal echocardiography guidance. Patients were prospectively followed for 2years. The long-term stroke rate was compared with the expected rate based on the CHA2DS2-VASc score. Results A total of 272 patients who underwent LAAC with the WATCHMAN device between December 2013 and August 2019 (mean age: 75.4 years [standard deviation {SD}: 8.75]; male, 63.2%; CHA2DS2-VASc score: 4.35 [SD: 1.64]; HAS-BLED score: 3.55 [SD: 0.94]) were included. Most patients (90.4%) had prior history of bleeding (major, 80.5%; minor, 21.7%). The WATCHMAN device was successfully implanted in 269 patients (98.9%), with a few procedure-related complications, including 5 pericardial effusions requiring drainage (1.8%), and 1 death (0.4%; 22 days post-LAAC from respiratory failure). Post-LAAC antithrombotic therapy included dual antiplatelet therapy in 70.6%, single antiplatelet therapy in 18.4%, and oral anticoagulation in 13.6%. During the follow-up period (mean: 709.7 days [SD: 467.2]), an 81.4% reduction of the ischemic stroke rate occurred, based on the expected rate from the CHA2DS2-VASc score (6.0% expected vs 1.1% observed). Device-related thrombus was detected in 1.8%. Conclusions The majority of Canadian patients who underwent LAAC had oral anticoagulation contraindication due to prior bleeding, and most were safely treated with antiplatelet therapy post-LAAC, with a low device-related thrombus incidence. Long-term follow-up demonstrated that LAAC achieved a significant reduction in ischemic stroke rate.
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Affiliation(s)
- Jacqueline Saw
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Taku Inohara
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Thomas Gilhofer
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Naomi Uchida
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Colin Pearce
- Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - Payam Dehghani
- Prairie Vascular Research Inc., Regina, Saskatchewan, Canada
- Regina Regional Hospital, Regina, Saskatchewan, Canada
| | - Malek Kass
- St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Reda Ibrahim
- Montreal Heart Institute, Montreal, Quebec, Canada
| | - Carlos Morillo
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Stephan Wardell
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jean-Michel Paradis
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Québec, Québec, Canada
| | - Gilles E. O’Hara
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Québec, Québec, Canada
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Kaliyev BB, Rakhimzhanova RI, Sinitsyn VE, Dautov TB, Abdrakhmanov AS. Left lateral decubitus computed tomography before catheter ablation in patients with atrial fibrillation. KARDIOLOGIIA 2023; 63:61-68. [PMID: 37470735 DOI: 10.18087/cardio.2023.6.n2453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 04/27/2023] [Indexed: 07/21/2023]
Abstract
Aim The study aimed to determine the efficacy of cardiac computed tomography angiography (CCTA) for diagnosing left atrial appendage (LAA) thrombus before catheter ablation with the patient in the left lateral decubitus position and, also, to evaluate the risk factors for thrombus formation.Material and methods This retrospective, cohort study included 101 patients with atrial fibrillation. All patients underwent transthoracic echocardiography (TTE) and left lateral decubitus CCTA. Transesophageal echocardiography (TEE) was performed to confirm or exclude LAA thrombus. Patients with allergic reactions to iodinated contrast media, increased serum creatinine, hyperthyroidism, pregnancy, and age<18 years were excluded. The CHA2‑DS2‑VASc and HAS-BLED scores were calculated for each patient.Results All LAA thrombi detected on CCTA were confirmed by TEE. Higher CHA2‑DS2‑VASc, HAS-BLED scores, enlarged LA, and the anteroposterior dimension of the left atrium were significantly associated with the presence of LAA thrombus. A LAA cauliflower shape was a predictor of thrombus. An increase of LAA volume by 1 ml increased the chances of LAA thrombus and cerebral ischemic infarct by 2 %. The growth of the LAA anteroposterior diameter by 1 cm increased the risk of LAA thrombus by 190 % and of cerebral infarct by 78 %. An increase in the CHA2DS2‑VASc score by 1 point increased the risk of thromboembolism and cerebral infarction by 12 %.Conclusions CCTA performed in the left lateral decubitus position of the patient is an optimal screening tool to detect or exclude LAA thrombus before catheter ablation because of atrial fibrillation. CCTA has predictive value for risk of thrombosis formation in LAA.
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Affiliation(s)
- Bauyrzhan Bakhytovich Kaliyev
- National Research Cardiac Surgery Center, Department of Interventional Cardiology and Radiology, Ministry of Health of the Kazakhstan
| | | | | | - Tairkhan Bekpolatovich Dautov
- National Research Cardiac Surgery Center, Department of Interventional Cardiology and Radiology, Ministry of Health of the Kazakhstan
| | - Ayan Suleimenovich Abdrakhmanov
- National Research Cardiac Surgery Center, Department of Interventional Cardiology and Radiology, Ministry of Health of the Kazakhstan
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Abrignani MG, Lombardo A, Braschi A, Renda N, Abrignani V, Lombardo RM. Time trends in antithrombotic therapy prescription patterns: Real-world monocentric study in hospitalized patients with atrial fibrillation. World J Cardiol 2022; 14:576-598. [PMID: 36483763 PMCID: PMC9724000 DOI: 10.4330/wjc.v14.i11.576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 07/04/2022] [Accepted: 10/28/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Since 2010, the European Society of Cardiology has extended prescription criteria for oral antithrombotic therapy (OAT) in atrial fibrillation (AF). Direct oral anticoagulants (DOACs) were upgraded from an IIAa recommendation in 2012 to an IA in 2016. In real-world scenarios, however, OAC prescription is still suboptimal, mainly for DOACs.
AIM To evaluate OAT temporal prescription patterns in a cohort of patients hospitalized with AF in a Cardiology Department.
METHODS A retrospective observational study was conducted on a cohort of hospitalized patients in a secondary setting (Trapani, Italy) from 2010 to 2021 with AF as the main or secondary diagnosis. For 4089 consecutive patients, the variables extracted from the Cardiology department database were: Sex, age, time of hospitalization, antithrombotic therapy (warfarin, acenocoumarol, apixaban, dabigatran, edoxaban, rivaroxaban, aspirin, clopidogrel, other antiplatelet agents, low molecular weight heparin, and fondaparinux), diagnosis at discharge and used resources. Basal features are presented as percentage values for categorized variables and as mean +/- SD for categorized once.
RESULTS From January 1st, 2010 to October 6th, 2021, 25132 patients were hospitalized in our department; 4089 (16.27%, mean age 75.59+/-10.82) were discharged with AF diagnosis; of them, 2245 were males (54.81%, mean age 73.56+/-11.45) and 1851 females (45.19%, mean age 78.06+/-9.47). Average length of stay was 5.76+/-4.88 days; 154 patients died and 88 were moved to other Departments/Structures. AF was the main diagnosis in 899 patients (21.94%). The most frequent main diagnosis in patients with AF was acute myocardial infarction (1973 discharges, 48.19%). The most frequent secondary cardiac diagnosis was chronic coronary syndrome (1864 discharges, 45.51%), and the most frequent secondary associated condition was arterial hypertension (1010 discharges, 24.66%). For the analysis of antithrombotic treatments, the final sample included 3067 patients, after excluding in-hospital deaths, transferred out or self-discharged patients, as well as discharges lacking indications for prescribed treatments. OAC treatment increased significantly (35.63% in 2010-2012 vs 61.18% in 2019-2021, +25.55%, P < 0.0001), in spite of any antiplatelet agent use. This rise was due to increasing use of DOACs, with or without antiplatelet agents, from 3.04% in 2013-2015 to 50.06% in 2019-2021 (+47.02%, P < 0.0001) and was greater for factor Xa inhibitors, especially apixaban. In addition, treatment with a vitamin K antagonist, in spite of any antiplatelet agent use, decreased from 35.63% in 2010-2012 to 11.12% in 2019-2021 (-24.48%, P < 0.0001), as well as any antiplatelet therapy, alone or in double combination, (49.18% in 2010-2012 vs 34.18% in 2019-2021, -15.00%, P < 0.0001); and patients not receiving antithrombotic therapy declined with time (14.58% in 2010-2012 vs 1.97% in 2021, P < 0.0001).
CONCLUSION Real-world patients with AF are elderly and affected by cardiovascular and non-cardiovascular diseases. The percentage of patients on OAT and DOACs increased. These data suggest a slow, gradual guidelines implementation process.
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Affiliation(s)
- Maurizio Giuseppe Abrignani
- Operative Unit of Cardiology, Department of Medicine, S. Antonio Abate Hospital of Trapani, ASP Trapani, Trapani 91100, Trapani, Italy
| | - Alberto Lombardo
- Operative Unit of Cardiology, Department of Medicine, S. Antonio Abate Hospital of Trapani, ASP Trapani, Trapani 91100, Trapani, Italy
| | - Annabella Braschi
- Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo 90100, Palermo, Italy
| | - Nicolò Renda
- Department of Medicine and Surgery, University of Parma, Parma 43100, Parma, Italy
| | - Vincenzo Abrignani
- Operative Unit of Internal Medicine with Stroke Care, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE) "G. D'Alessandro", University of Palermo, Palermo 90100, Palermo, Italy
| | - Renzo M Lombardo
- Department of Cardiology, Operative Unit of Cardiology, Department of Medicine, S. Antonio Abate Hospital of Trapani, Trapani 91100, Trapani, Italy
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Chew DS, Au F, Xu Y, Manns BJ, Tonelli M, Wilton SB, Hemmelgarn B, Kong S, Exner DV, Quinn AE. Geographic and temporal variation in the treatment and outcomes of atrial fibrillation: a population-based analysis of national quality indicators. CMAJ Open 2022; 10:E702-E713. [PMID: 35918151 PMCID: PMC9352379 DOI: 10.9778/cmajo.20210246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Assessment of potential geographic variation in quality indicators of atrial fibrillation care may identify opportunities for improvement in the quality of atrial fibrillation care. The objective of this study was to assess for potential geographic variation in the quality of atrial fibrillation care in Alberta, Canada. METHODS In a population-based cohort of adults (age ≥ 18 yr) with incident nonvalvular atrial fibrillation (NVAF) diagnosed between Apr. 1, 2008, and Mar. 31, 2016, in Alberta, we investigated the variation in national quality indicators of atrial fibrillation care developed by the Canadian Cardiovascular Society. Specifically, we assessed the geographic and temporal variation in the proportion of patients with initiation of oral anticoagulant therapy, persistence with therapy, ischemic stroke and major bleeding outcomes 1 year after atrial fibrillation diagnosis using linked administrative data sets. We defined stroke risk using the CHADS2 score. We assessed geographic variation using small-area variation statistics and geospatial data analysis. RESULTS Of the 64 093 patients in the study cohort (35 019 men [54.6%] and 29 074 women [45.4%] with a mean age of 69 [standard deviation 15.9] yr), 36 199 were at high risk for stroke and 14 411 were at moderate risk. Within 1 year of NVAF diagnosis, 20 180 patients (55.7%) in the high-risk group and 6448 patients (44.7%) in the moderate-risk group were prescribed anticoagulation. A total of 2187 patients (3.4%) had an ischemic stroke, and 2996 patients (4.7%) experienced a major bleed. There was substantial regional variation observed in initiation of oral anticoagulant therapy but not in the proportion of patients with ischemic stroke or major bleeding. Among the 64 Health Status Areas in Alberta, therapy initiation rates ranged from 22.6% to 71.2% among patients at high stroke risk and from 22.7% to 55.8% among those at moderate stroke risk, with clustering of lower therapy initiation rates in rural northern regions. INTERPRETATION The rate of initiation of oral anticoagulant therapy among adults with incident atrial fibrillation was less than 60% in patients in whom oral anticoagulant therapy would be considered guideline-appropriate care. The large geographic variation in oral anticoagulant prescribing warrants additional study into patient, provider and health care system factors that contribute to variation and drive disparities in high-quality, equitable atrial fibrillation care.
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Affiliation(s)
- Derek S Chew
- Duke Clinical Research Institute (Chew), Duke University, Durham, NC; Libin Cardiovascular Institute (Chew, Manns, Tonelli, Wilton, Exner) and O'Brien Institute of Public Health (Au, Manns, Tonelli, Wilton, Exner), University of Calgary; Departments of Community Health Sciences (Au, Xu, Manns, Tonelli, Wilton, Hemmelgarn, Kong, Exner, Quinn), Oncology (Xu, Kong), Surgery (Xu, Kong) and Medicine (Manns, Tonelli), University of Calgary, Calgary, Alta.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta.
| | - Flora Au
- Duke Clinical Research Institute (Chew), Duke University, Durham, NC; Libin Cardiovascular Institute (Chew, Manns, Tonelli, Wilton, Exner) and O'Brien Institute of Public Health (Au, Manns, Tonelli, Wilton, Exner), University of Calgary; Departments of Community Health Sciences (Au, Xu, Manns, Tonelli, Wilton, Hemmelgarn, Kong, Exner, Quinn), Oncology (Xu, Kong), Surgery (Xu, Kong) and Medicine (Manns, Tonelli), University of Calgary, Calgary, Alta.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Yuan Xu
- Duke Clinical Research Institute (Chew), Duke University, Durham, NC; Libin Cardiovascular Institute (Chew, Manns, Tonelli, Wilton, Exner) and O'Brien Institute of Public Health (Au, Manns, Tonelli, Wilton, Exner), University of Calgary; Departments of Community Health Sciences (Au, Xu, Manns, Tonelli, Wilton, Hemmelgarn, Kong, Exner, Quinn), Oncology (Xu, Kong), Surgery (Xu, Kong) and Medicine (Manns, Tonelli), University of Calgary, Calgary, Alta.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Braden J Manns
- Duke Clinical Research Institute (Chew), Duke University, Durham, NC; Libin Cardiovascular Institute (Chew, Manns, Tonelli, Wilton, Exner) and O'Brien Institute of Public Health (Au, Manns, Tonelli, Wilton, Exner), University of Calgary; Departments of Community Health Sciences (Au, Xu, Manns, Tonelli, Wilton, Hemmelgarn, Kong, Exner, Quinn), Oncology (Xu, Kong), Surgery (Xu, Kong) and Medicine (Manns, Tonelli), University of Calgary, Calgary, Alta.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Marcello Tonelli
- Duke Clinical Research Institute (Chew), Duke University, Durham, NC; Libin Cardiovascular Institute (Chew, Manns, Tonelli, Wilton, Exner) and O'Brien Institute of Public Health (Au, Manns, Tonelli, Wilton, Exner), University of Calgary; Departments of Community Health Sciences (Au, Xu, Manns, Tonelli, Wilton, Hemmelgarn, Kong, Exner, Quinn), Oncology (Xu, Kong), Surgery (Xu, Kong) and Medicine (Manns, Tonelli), University of Calgary, Calgary, Alta.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Stephen B Wilton
- Duke Clinical Research Institute (Chew), Duke University, Durham, NC; Libin Cardiovascular Institute (Chew, Manns, Tonelli, Wilton, Exner) and O'Brien Institute of Public Health (Au, Manns, Tonelli, Wilton, Exner), University of Calgary; Departments of Community Health Sciences (Au, Xu, Manns, Tonelli, Wilton, Hemmelgarn, Kong, Exner, Quinn), Oncology (Xu, Kong), Surgery (Xu, Kong) and Medicine (Manns, Tonelli), University of Calgary, Calgary, Alta.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Brenda Hemmelgarn
- Duke Clinical Research Institute (Chew), Duke University, Durham, NC; Libin Cardiovascular Institute (Chew, Manns, Tonelli, Wilton, Exner) and O'Brien Institute of Public Health (Au, Manns, Tonelli, Wilton, Exner), University of Calgary; Departments of Community Health Sciences (Au, Xu, Manns, Tonelli, Wilton, Hemmelgarn, Kong, Exner, Quinn), Oncology (Xu, Kong), Surgery (Xu, Kong) and Medicine (Manns, Tonelli), University of Calgary, Calgary, Alta.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Shiying Kong
- Duke Clinical Research Institute (Chew), Duke University, Durham, NC; Libin Cardiovascular Institute (Chew, Manns, Tonelli, Wilton, Exner) and O'Brien Institute of Public Health (Au, Manns, Tonelli, Wilton, Exner), University of Calgary; Departments of Community Health Sciences (Au, Xu, Manns, Tonelli, Wilton, Hemmelgarn, Kong, Exner, Quinn), Oncology (Xu, Kong), Surgery (Xu, Kong) and Medicine (Manns, Tonelli), University of Calgary, Calgary, Alta.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Derek V Exner
- Duke Clinical Research Institute (Chew), Duke University, Durham, NC; Libin Cardiovascular Institute (Chew, Manns, Tonelli, Wilton, Exner) and O'Brien Institute of Public Health (Au, Manns, Tonelli, Wilton, Exner), University of Calgary; Departments of Community Health Sciences (Au, Xu, Manns, Tonelli, Wilton, Hemmelgarn, Kong, Exner, Quinn), Oncology (Xu, Kong), Surgery (Xu, Kong) and Medicine (Manns, Tonelli), University of Calgary, Calgary, Alta.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Amity E Quinn
- Duke Clinical Research Institute (Chew), Duke University, Durham, NC; Libin Cardiovascular Institute (Chew, Manns, Tonelli, Wilton, Exner) and O'Brien Institute of Public Health (Au, Manns, Tonelli, Wilton, Exner), University of Calgary; Departments of Community Health Sciences (Au, Xu, Manns, Tonelli, Wilton, Hemmelgarn, Kong, Exner, Quinn), Oncology (Xu, Kong), Surgery (Xu, Kong) and Medicine (Manns, Tonelli), University of Calgary, Calgary, Alta.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
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9
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Daniel RC, Atzema CL, Cho DD, Davis PJ, Costello LL. Which Recommendations Are You Using? A Survey of Emergency Physician Management of Paroxysmal Atrial Fibrillation. CJC Open 2022; 4:466-473. [PMID: 35607488 PMCID: PMC9123374 DOI: 10.1016/j.cjco.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/16/2022] [Indexed: 10/29/2022] Open
Abstract
Background Both the Canadian Cardiovascular Society (CCS) and the Canadian Association of Emergency Physicians (CAEP) have published documents to guide atrial fibrillation (AF) management. In 2021, the CAEP updated its AF checklist. Prior to this update, the recommendations of the 2 organizations differed in several key areas, including the suggested cardioversion timeframe, the factors determining cardioversion eligibility, and anticoagulant initiation after cardioversion. Whether emergency physicians (EPs) are aware of, or adhering to, one, both, or neither of these documents is unknown. Methods We assessed document awareness, adherence, and EP practice using a piloted questionnaire administered to EPs at 5 emergency departments in 3 provinces. Results Of 166 survey recipients, 123 (74.1%) responded. The majority (64.7%) worked at an academic site, 38.8% identified as female, and median years in practice was 10.0. Most (93.1%) were aware of at least one of the documents; 45.7% were aware of both. Reported awareness was higher for the CCS (77.6%) vs the CAEP (61.2%) guidelines. Respondents varied in their adherence, with 40.5% using parts of both documents. Considerable practice variability occurred when recommendations conflicted. Despite its use not being recommended by either organization, half of respondents (50.0%) reported using the CHA2DS2-VASc score as their stroke-risk assessment tool. Conclusions Although most surveyed EPs were aware of at least one organization's AF documents, many reported using parts of both. When recommendations conflicted, EPs were divided in their decision-making. These findings emphasize the need to improve consensus between organizations and further improve knowledge translation.
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Affiliation(s)
- Ryan C. Daniel
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Clare L. Atzema
- Division of Emergency Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Dennis D. Cho
- Division of Emergency Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Philip J. Davis
- Department of Emergency Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Lorne L. Costello
- Division of Emergency Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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10
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Rakhimova I, Semenova Y, Khaibullin T, Kuanysheva A, Kovalchuk V, Abdrakhmanov A. Cryptogenic Stroke and Embolic Stroke of Undetermined Source: Risk Factors and Approaches for Detection of Atrial Fibrillation. Curr Cardiol Rev 2022; 18:e211221199213. [PMID: 34939547 PMCID: PMC9893140 DOI: 10.2174/1573403x18666211221145714] [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: 06/15/2021] [Revised: 08/17/2021] [Accepted: 11/03/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Stroke is a problem worldwide because of its high mortality and disability rates. Almost 90% of strokes are ischemic, and more than half of the deaths are caused by an ischemic stroke. Most risk factors for stroke are manageable so that it can be avoided with proper prevention. Despite the success in determining the causes of stroke in recent years, selectively, the "culprit" causing stroke remains unsolved. In such cases, a diagnosis of undetermined etiology (cryptogenic stroke) or embolic stroke of undetermined source (ESUS) is generated, resulting the prevention of a recurrent cerebrovascular occurrence impossible. Atrial fibrillation (AF) can be a cause of stroke by causing blood clots in the chambers of the heart. PURPOSE The aim was to determine the optimal method of heart rate monitoring in patients with ischemic stroke, as methods and approaches for detecting AF are very diverse, but there is still no single opinion, which would be universal. PROCEDURES In our review, we consider epidemiology, risk factors for the stroke of undetermined etiology, as well as analytical methods for detecting heart rhythm disturbances in this category of patients. FINDINGS Atrial fibrillation (AF) is detected by thorough monitoring of heart rate of patients with cryptogenic stroke and ESUS can be diagnosed in up to 46% of patients. . CONCLUSION After AF detection, consideration should be given to prescribing anticoagulants, instead of antiplatelet agents, for the secondary prevention of stroke.
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Affiliation(s)
- Idaliya Rakhimova
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Yuliya Semenova
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Talgat Khaibullin
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Anargul Kuanysheva
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Vitalii Kovalchuk
- Department of Semashko City Hospital, Saint Petersburg, Russian Federation
| | - Ayan Abdrakhmanov
- National Research Cardiac Surgery Center, Nur-Sultan 010000, Kazakhstan
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11
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Sinyavskaya L, Renoux C, Durand M. Defining the duration of the dispensation of oral anticoagulants in administrative healthcare databases. Pharmacoepidemiol Drug Saf 2021; 31:105-109. [PMID: 34714965 DOI: 10.1002/pds.5378] [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: 05/11/2021] [Revised: 10/16/2021] [Accepted: 10/26/2021] [Indexed: 11/09/2022]
Abstract
PURPOSE In clinical practice, warfarin therapy requires frequent dose adjustments. In pharmacy claims, the days supplied value may not reflect the true duration of warfarin dispensation. This may affect the measures of association comparing the safety of direct oral anticoagulants (DOACs) versus warfarin. METHODS Using Quebec healthcare administrative databases, we formed a cohort of 55 230 patients newly treated with oral anticoagulants between 2010 and 2016. The duration of dispensations was defined using two approaches: the recorded days supplied value, and the longitudinal coverage approximation (data-driven) that may account for individual variation in drug usage patterns. Propensity scores adjusted Cox proportional hazards regression models were used to estimate the hazard ratio (HR) of major bleeding with dabigatran or rivaroxaban versus warfarin. RESULTS Using the days supplied, the mean (and standard deviation) dispensation durations for dabigatran, rivaroxaban, and warfarin were 19 (15), 19 (14), and 13 (12) days, respectively. Using the data-driven approach, the durations were 20 (16), 19 (15), and 15 (16) days, respectively. The choice of the approach had no impact on the HR estimates. CONCLUSIONS In our settings, the data-driven approach closely approximated the recorded days supplied value for the standard dose therapies such as dabigatran and rivaroxaban. For warfarin, the data-driven approach captured more variability in the duration of dispensations compared to the days supplied value, which may better reflect the true drug-taking behavior of warfarin. Both approaches may provide valid estimates when comparing the safety of DOACs versus warfarin.
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Affiliation(s)
- Liliya Sinyavskaya
- Research Center, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Québec, Canada
| | - Christel Renoux
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada.,Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Québec, Canada.,Department of Neurology and Neurosurgery, McGill University, Montreal, Québec, Canada
| | - Madeleine Durand
- Research Center, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Québec, Canada
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12
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Dickson EL, Ding EY, Saczynski JS, Han D, Moonis M, Fitzgibbons TP, Barton B, Chon K, McManus DD. Smartwatch monitoring for atrial fibrillation after stroke—The Pulsewatch Study: Protocol for a multiphase randomized controlled trial. CARDIOVASCULAR DIGITAL HEALTH JOURNAL 2021; 2:231-241. [PMID: 35265913 PMCID: PMC8890084 DOI: 10.1016/j.cvdhj.2021.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Atrial fibrillation (AF) is a common heart rhythm disorder that elevates stroke risk. Stroke survivors undergo routine heart rhythm monitoring for AF. Smartwatches are capable of AF detection and potentially can replace traditional cardiac monitoring in stroke patients. Objective The goal of Pulsewatch is to assess the accuracy, usability, and adherence of a smartwatch-based AF detection system in stroke patients. Methods The study will consist of two parts. Part I will have 6 focus groups with stroke patients, caretakers, and physicians, and a Hack-a-thon, to inform development of the Pulsewatch system. Part II is a randomized clinical trial with 2 phases designed to assess the accuracy and usability in the first phase (14 days) and adherence in the second phase (30 days). Participants will be randomized in a 3:1 ratio (intervention to control) for the first phase, and both arms will receive gold-standard electrocardiographic (ECG) monitoring. The intervention group additionally will receive a smartphone/smartwatch dyad with the Pulsewatch applications. Upon completion of 14 days, participants will be re-randomized in a 1:1 ratio. The intervention group will receive the Pulsewatch system and a handheld ECG device, while the control group will be passively monitored. Participants will complete questionnaires at enrollment and at 14- and 44-day follow-up visits to assess various psychosocial measures and health behaviors. Results Part I was completed in August 2019. Enrollment for Part II began September 2019, with expected completion by the end of 2021. Conclusion Pulsewatch aims to demonstrate that a smartwatch can be accurate for real-time AF detection, and that older stroke patients will find the system usable and will adhere to monitoring.
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13
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Durand M, Schnitzer ME, Pang M, Carney G, Eltonsy S, Filion KB, Fisher A, Jun M, Kuo IF, Matteau A, Paterson JM, Quail J, Renoux C. Effectiveness and safety among direct oral anticoagulants in nonvalvular atrial fibrillation: A multi-database cohort study with meta-analysis. Br J Clin Pharmacol 2020; 87:2589-2601. [PMID: 33242339 DOI: 10.1111/bcp.14669] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/29/2020] [Accepted: 11/14/2020] [Indexed: 11/30/2022] Open
Abstract
AIMS There are conflicting signals in the literature about comparative safety and effectiveness of direct oral anticoagulants (DOACs) for nonvalvular atrial fibrillation (NVAF). METHODS We conducted multicentre matched cohort studies with secondary meta-analysis to assess safety and effectiveness of dabigatran, rivaroxaban and apixaban across 9 administrative healthcare databases. We included adults with NVAF initiating anticoagulation therapy (dabigatran, rivaroxaban or apixaban), and constructed 3 cohorts to compare DOACs pairwise. The primary outcome was pooled hazard ratio (pHR) of ischaemic stroke or systemic thromboembolism. Secondary outcomes included pHR of major bleeding, and a composite of stroke, major bleeding, or all-cause mortality. We used proportional hazard Cox regressions models, and pooled estimates were obtained with random effect meta-analyses. RESULTS The cohorts included 73 414 new users of dabigatran, 92 881 of rivaroxaban, and 61 284 of apixaban. After matching, the pHRs (95% confidence intervals) comparing rivaroxaban initiation to dabigatran were: 1.11 (0.93, 1.32) for ischaemic stroke or systemic thromboembolism, 1.26 (1.09, 1.46) for major bleeding, and 1.17 (1.05, 1.30) for the composite endpoint. For apixaban vs dabigatran, they were: 0.91 (0.74, 1.12) for ischaemic stroke or systemic thromboembolism, 0.89 (0.75, 1.05) for major bleeding, and 0.94 (0.78 to 1.14) for the composite endpoint. For apixaban vs rivaroxaban, they were: 0.85 (0.74, 0.99) for ischaemic stroke or systemic thromboembolism, 0.61 (0.53, 0.70) for major bleeding, and 0.82 (0.76, 0.88) for the composite endpoint. CONCLUSION We found that apixaban use is associated with lower risks of stroke and bleeding compared with rivaroxaban, and similar risks compared with dabigatran.
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Affiliation(s)
- Madeleine Durand
- Internal Medicine service, Centre Hospitalier de l'Université de Montréal (CHUM) and CHUM Research Center, Montreal, QC, Canada
| | - Mireille E Schnitzer
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada.,Department of Social and Preventive Medicine, Université de Montréal, Montreal, QC, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Menglan Pang
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Greg Carney
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Sherif Eltonsy
- College of Pharmacy, Faculty of Health Sciences, University of Manitoba, Canada
| | - Kristian B Filion
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.,Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, QC, Canada.,Department of Medicine, McGill University, Montreal, QC, Canada
| | | | - Min Jun
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - I Fan Kuo
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Alexis Matteau
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Cardiology service, Centre Hospitalier de l'Université de Montréal (CHUM) and CHUM Research Center, Montreal, QC, Canada
| | - J Michael Paterson
- ICES, Toronto, ON, Canada (JMP). Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Jacqueline Quail
- Health Quality Council, Saskatoon, SK, Canada.,Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Christel Renoux
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.,Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, QC, Canada.,Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
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14
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Kugamoorthy P, Spears DA. Management of tachyarrhythmias in pregnancy - A review. Obstet Med 2020; 13:159-173. [PMID: 33343692 PMCID: PMC7726166 DOI: 10.1177/1753495x20913448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 02/16/2020] [Indexed: 11/16/2022] Open
Abstract
The most common arrhythmias detected during pregnancy include sinus tachycardia, sinus bradycardia, and sinus arrhythmia, identified in 0.1% of pregnancies. Isolated premature atrial or ventricular arrhythmias are observed in 0.03% of pregnancies. Arrhythmias may become more frequent during pregnancy or may manifest for the first time.
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Affiliation(s)
| | - Danna A Spears
- University Health Network – Toronto General Hospital, Toronto, Canada
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15
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The Canadian Cardiovascular Society Atrial Fibrillation Guidelines Program: A Look Back Over the Last 10 Years and a Look Forward. Can J Cardiol 2020; 36:1839-1842. [DOI: 10.1016/j.cjca.2020.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 10/02/2020] [Indexed: 01/30/2023] Open
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16
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A specific combination of P wave duration and morphology accurately predicts the presence of left atrial low voltage area in patients with atrial fibrillation. J Electrocardiol 2020; 63:173-180. [DOI: 10.1016/j.jelectrocard.2019.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/03/2019] [Accepted: 10/11/2019] [Indexed: 01/03/2023]
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17
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Andrade JG, Aguilar M, Atzema C, Bell A, Cairns JA, Cheung CC, Cox JL, Dorian P, Gladstone DJ, Healey JS, Khairy P, Leblanc K, McMurtry MS, Mitchell LB, Nair GM, Nattel S, Parkash R, Pilote L, Sandhu RK, Sarrazin JF, Sharma M, Skanes AC, Talajic M, Tsang TSM, Verma A, Verma S, Whitlock R, Wyse DG, Macle L. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2020; 36:1847-1948. [PMID: 33191198 DOI: 10.1016/j.cjca.2020.09.001] [Citation(s) in RCA: 319] [Impact Index Per Article: 79.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/05/2020] [Accepted: 09/05/2020] [Indexed: 12/20/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | - Martin Aguilar
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jafna L Cox
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Paul Khairy
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stanley Nattel
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Jean-François Sarrazin
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Mukul Sharma
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Mario Talajic
- Montreal Heart Institute, University of Montreal, Montréal, Quebec, Canada
| | - Teresa S M Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
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18
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Nery PB, Alqarawi W, Nair GM, Sadek MM, Redpath CJ, Golian M, Al Dawood W, Chen L, Hansom SP, Klein A, Wells GA, Birnie DH. Catheter Ablation of Low-Voltage Areas for Persistent Atrial Fibrillation: Procedural Outcomes Using High-Density Voltage Mapping. Can J Cardiol 2020; 36:1956-1964. [PMID: 32738208 DOI: 10.1016/j.cjca.2020.03.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 03/25/2020] [Accepted: 03/25/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Several approaches have been proposed to address the challenge of catheter ablation of persistent atrial fibrillation (AF). However, the optimal ablation strategy is unknown. We sought to evaluate the efficacy of pulmonary vein isolation (PVI) plus low-voltage area (LVA) ablation using contemporary high-density mapping to identify LVA in patients with persistent AF. METHODS Consecutive patients accepted for AF catheter ablation were studied. High-density bipolar voltage mapping data were acquired in sinus rhythm using multipolar catheters to detect LVA (defined as bipolar voltage < 0.5 mV). Semiautomated impedance-based software was used to ensure catheter contact during data collection. Patients underwent PVI + LVA ablation (if LVA present). RESULTS A total of 145 patients were studied; 95 patients undergoing PVI + LVA ablation were compared with 50 controls treated with PVI only. Average age was 61 ± 10 years, and 80% were male. Baseline characteristics were comparable. Freedom from atrial tachycardia/AF at 18 months was 72% after PVI + LVA ablation vs 58% in controls (P = 0.022). Median procedure duration (273 [240, 342] vs 305 [262, 360] minutes; P = 0.019) and radiofrequency delivery (50 [43, 63] vs 55 [35, 68] minutes; P = 0.39) were longer in the PVI + LVA ablation group. Multivariable analysis showed that the ablation strategy (PVI + LVA) was the only independent predictor of freedom from atrial tachycardia/AF (hazard ratio, 0.53; 95% confidence interval, 0.29-0.96; P = 0.036). There were no adverse safety outcomes associated with LVA ablation. CONCLUSIONS An individualized strategy of high-density mapping to assess the atrial substrate followed by PVI combined with LVA ablation is associated with improved outcomes. Adequately powered randomized clinical trials are needed to determine the role of PVI + LVA ablation for persistent AF.
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Affiliation(s)
- Pablo B Nery
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | - Wael Alqarawi
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Girish M Nair
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Mouhannad M Sadek
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Calum J Redpath
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Mehrdad Golian
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Wafa Al Dawood
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Li Chen
- Cardiovascular Research Methods Center, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Simon P Hansom
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Andres Klein
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - George A Wells
- Cardiovascular Research Methods Center, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David H Birnie
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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19
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Hill K, Sucha E, Rhodes E, Carrier M, Garg AX, Harel Z, Hundemer GL, Clark EG, Knoll G, McArthur E, Sood MM. Risk of Hospitalization With Hemorrhage Among Older Adults Taking Clarithromycin vs Azithromycin and Direct Oral Anticoagulants. JAMA Intern Med 2020; 180:1052-1060. [PMID: 32511684 PMCID: PMC7281381 DOI: 10.1001/jamainternmed.2020.1835] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Clarithromycin is a commonly prescribed antibiotic associated with higher levels of direct oral anticoagulants (DOACs) in the blood, with the potential to increase the risk of hemorrhage. OBJECTIVE To assess the 30-day risk of a hospital admission with hemorrhage after coprescription of clarithromycin compared with azithromycin among older adults taking a DOAC. DESIGN, SETTING, AND PARTICIPANTS This population-based, retrospective cohort study was conducted among adults of advanced age (mean [SD] age, 77.6 [7.2] years) who were newly coprescribed clarithromycin (n = 6592) vs azithromycin (n = 18 351) while taking a DOAC (dabigatran, apixaban, or rivaroxaban) in Ontario, Canada, from June 23, 2009, to December 31, 2016. Cox proportional hazards regression was used to examine the association between hemorrhage and antibiotic use (clarithromycin vs azithromycin). Statistical analysis was performed from December 23, 2019, to March 25, 2020. MAIN OUTCOMES AND MEASURES Hospital admission with major hemorrhage (upper or lower gastrointestinal tract or intracranial). Outcomes were assessed within 30 days of a coprescription. RESULTS Among the 24 943 patients (12 493 women; mean [SD] age, 77.6 [7.2] years) in the study, rivaroxaban was the most commonly prescribed DOAC (9972 patients [40.0%]), followed by apixaban (7953 [31.9%]) and dabigatran (7018 [28.1%]). Coprescribing clarithromycin vs azithromycin with a DOAC was associated with a higher risk of a hospital admission with major hemorrhage (51 of 6592 patients [0.77%] taking clarithromycin vs 79 of 18 351 patients [0.43%] taking azithromycin; adjusted hazard ratio, 1.71 [95% CI, 1.20-2.45]; absolute risk difference, 0.34%). Results were consistent in multiple additional analyses. CONCLUSIONS AND RELEVANCE This study suggests that, among adults of advanced age taking a DOAC, concurrent use of clarithromycin compared with azithromycin was associated with a small but statistically significantly greater 30-day risk of hospital admission with major hemorrhage.
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Affiliation(s)
- Kevin Hill
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ewa Sucha
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Emily Rhodes
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Marc Carrier
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Amit X Garg
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, Health Sciences Centre, London, Ontario, Canada.,Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Ziv Harel
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, St Michael's Hospital, Toronto, Canada
| | - Gregory L Hundemer
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Edward G Clark
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Greg Knoll
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Eric McArthur
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Manish M Sood
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
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20
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Antoniou CK, Manolakou P, Arsenos P, Dilaveris P, Gatzoulis K, Tousoulis D. Antithrombotic Treatment after Atrial Fibrillation Ablation. Curr Pharm Des 2020; 26:2703-2714. [DOI: 10.2174/1381612826666200407154329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/17/2020] [Indexed: 01/06/2023]
Abstract
:Atrial fibrillation is a major cause of debilitating strokes and anticoagulation is an established and indispensable therapy for reducing their rate. Ablation of the arrhythmia has emerged as a putative means of disrupting its natural course by isolating its triggers and modifying its substrate, dependent on the chosen method. An important dilemma lies in the need for continuation of anticoagulation therapy in those previously receiving it following an, apparently, successful intervention, purportedly preventing arrhythmia recurrence with considerably high rates. Current guidance, given scarcity of high-quality data from randomized trials, focuses on established knowledge and recommends anticoagulation continuation based solely on estimated thromboembolic risk. In the present review, it will be attempted to summarize the pathophysiological rationale for maintaining anticoagulation post-successful ablation, along with the latter’s definition, including the two-fold effects of the procedure per se on thrombogenicity. Available evidence pointing to an overall clinical benefit of anticoagulation withdrawal following careful patient assessment will be discussed, including ongoing randomized trials aiming to offer definitive answers. Finally, the proposed mode of post-ablation anticoagulation will be presented, including the emerging, guideline-endorsed, role of direct oral anticoagulants in the field, altering cost/benefit ratio of anticoagulation and potentially affecting the very decision regarding its discontinuation.
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Affiliation(s)
| | - Panagiota Manolakou
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, Athens, Greece
| | - Petros Arsenos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, Athens, Greece
| | - Polychronis Dilaveris
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, Athens, Greece
| | - Konstantinos Gatzoulis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, Athens, Greece
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21
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Atzema CL, Jackevicius CA, Chong A, Dorian P, Ivers NM, Parkash R, Austin PC. Prescribing of oral anticoagulants in the emergency department and subsequent long-term use by older adults with atrial fibrillation. CMAJ 2020; 191:E1345-E1354. [PMID: 31818927 DOI: 10.1503/cmaj.190747] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Patients with atrial fibrillation frequently seek emergency care. Rates of guideline-concordant oral anticoagulant therapy for stroke prevention are suboptimal in the community. We assessed the association between prescribing of oral anticoagulants in the emergency department (relative to referral to a longitudinal care provider for treatment initiation) and long-term use of oral anticoagulants. METHODS This retrospective cohort study performed at 15 hospitals in Ontario, Canada, involved patients aged 65 years or older who visited the emergency department between 2009 and 2014, who had a primary diagnosis of atrial fibrillation, were discharged home, and were eligible for and willing to take stroke-prevention therapy. We used inverse probability-of-treatment weighting based on the propensity score to compare patients who were and were not given a prescription for an oral anticoagulant. The primary outcome was a prescription fill for an oral anticoagulant 6 months later. Secondary outcomes included a prescription fill at 1 year, all-cause mortality, and strokes or bleeding events leading to hospital admission. RESULTS Of 2132 eligible patients, 402 (18.9%) were given a prescription for an oral anticoagulant in the emergency department. After weighting, 67.8% of these patients had filled a prescription for an oral anticoagulant at 6 months versus 37.2% of those who did not receive a prescription in the emergency department (absolute risk increase [ARI] 30.6%, number needed to treat [NNT] 3). At 1 year, the ARI was 23.2% and the NNT was 4. Rates of death, stroke and bleeding events did not differ significantly. INTERPRETATION In patients with atrial fibrillation who were eligible for stroke prevention, prescribing an oral anticoagulant in the emergency department was associated with substantially higher long-term use of oral anticoagulants compared with deferring to the longitudinal care provider to initiate this therapy. Physicians working in the emergency department should consider initiating oral anticoagulation in eligible patients who are being discharged to home.
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Affiliation(s)
- Clare L Atzema
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
| | - Cynthia A Jackevicius
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
| | - Alice Chong
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
| | - Paul Dorian
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
| | - Noah M Ivers
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
| | - Ratika Parkash
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
| | - Peter C Austin
- ICES Central (Atzema, Jackevicius, Chong, Ivers, Austin); Division of Emergency Medicine, Department of Medicine (Atzema), Division of Cardiology, Department of Medicine (Dorian), Department of Family Medicine (Ivers) and Institute for Health Policy, Management and Evaluation (Jackevicius, Dorian, Ivers, Austin), University of Toronto; Sunnybrook Health Sciences Centre (Atzema); Women's College Hospital (Ivers); St. Michael's Hospital (Dorian), Toronto, Ont.; Western University of Health Sciences, Pomona, Calif. (Jackevicius); QEII Health Sciences Centre (Parkash), Halifax, NS
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22
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Atzema CL, Fang J, Cox JL, Chong AS, Tu K, Austin PC. Assessment of an Algorithm for Prescription of Oral Anticoagulation for Patients With Atrial Fibrillation in Emergency Departments. JAMA Netw Open 2020; 3:e200306. [PMID: 32125425 PMCID: PMC7054828 DOI: 10.1001/jamanetworkopen.2020.0306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
This retrospective study uses a Canadian reporting system to validate an algorithm that identifies oral anticoagulation prescriptions given to patients with atrial fibrillation treated in emergency departments.
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Affiliation(s)
- Clare L. Atzema
- ICES, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Division of Emergency Medicine, Department of Medicine
- Institute for Health Policy, Management and Evaluation
| | | | - Jafna L. Cox
- Division of Cardiology, Department of Medicine
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Karen Tu
- Institute for Health Policy, Management and Evaluation
- Department of Family and Community Medicine, the University of Toronto, Toronto, Ontario, Canada
- University Health Network-Toronto Western Hospital Family Health Team, Toronto, Ontario, Canada
| | - Peter C. Austin
- ICES, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation
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23
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Boriani G, Colella J, Imberti J, Fantecchi E, Vitolo M. Female sex and stroke in atrial fibrillation: an intriguing relationship. Intern Emerg Med 2020; 15:175-179. [PMID: 31396922 DOI: 10.1007/s11739-019-02169-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 07/29/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.
- Cardiology Division, Policlinico di Modena, Azienda Ospedaliero-Universitaria di Modena, Largo del Pozzo, 71, 41125, Modena, Italy.
| | - Jacopo Colella
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Jacopo Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Elisa Fantecchi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
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24
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Salmasi S, Kapanen AI, Kwan L, Andrade JG, De Vera MA, Loewen P. Atrial fibrillation patients' experiences and perspectives of anticoagulation therapy changes. Res Social Adm Pharm 2020; 16:1409-1415. [PMID: 31983624 DOI: 10.1016/j.sapharm.2020.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 01/02/2020] [Accepted: 01/12/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) patients' experiences with changes in their oral anticoagulant (OAC) therapy are understudied. OBJECTIVE The objective of this study was to qualitatively describe AF patients' experiences and perspectives of changes made to their OAC therapy (switches or discontinuations). METHODS A thematic analysis was performed on systematically-collected qualitative data from AF patients who experienced a therapy change (switching or discontinuing an OAC) as part of their participation in a large 2-year prospective observational study. RESULTS A total of 56 participants met the inclusion criteria. Six themes emerged from the data: 1. reasons for switch or discontinuation of therapy, 2. attitudes towards changes in therapy attributes, 3. challenges with taking medications after therapy change, 4. relief from perceived burden of medication after discontinuation, 5. patients' limited involvement in decision-making, and 6. inadequate education and follow up. Patients were found to request changes in therapy based on their subjective experience with it (rather than clinically justified reasons). They were found to have limited knowledge about their medications, differing reactions to changes in their therapy attributes after a switch, an overall negative attitude towards taking medications, adherence challenges after switching from once daily to twice daily medication, feelings of being excluded from the decision-making process about their therapy changes and feelings of being unsupported after these changes. CONCLUSIONS There are clear opportunities to improve patients' experiences with OAC therapy changes through improved shared decision-making and patient education/counselling.
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Affiliation(s)
- Shahrzad Salmasi
- Collaboration for Outcomes Research and Evaluation (CORE), University of British Columbia, Vancouver, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Anita I Kapanen
- Collaboration for Outcomes Research and Evaluation (CORE), University of British Columbia, Vancouver, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Leanne Kwan
- Atrial Fibrillation Clinic, Royal Columbian Hospital, New Westminster, Canada
| | - Jason G Andrade
- Atrial Fibrillation Clinic, Vancouver General Hospital, Vancouver, Canada; Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Mary A De Vera
- Collaboration for Outcomes Research and Evaluation (CORE), University of British Columbia, Vancouver, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Peter Loewen
- Collaboration for Outcomes Research and Evaluation (CORE), University of British Columbia, Vancouver, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada.
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25
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Stroke Prophylaxis in Patients with Atrial Fibrillation and End-Stage Renal Disease. J Clin Med 2020; 9:jcm9010123. [PMID: 31906546 PMCID: PMC7019832 DOI: 10.3390/jcm9010123] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 12/24/2019] [Accepted: 12/30/2019] [Indexed: 02/07/2023] Open
Abstract
Atrial fibrillation (AF) is an important comorbidity in patients with end-stage renal disease (ESRD) undergoing dialysis that portends increased health care utilization, morbidity, and mortality in this already high-risk population. Patients with ESRD have a particularly high stroke risk, which is further compounded by AF. However, the role of anticoagulation for stroke prophylaxis in ESRD and AF is debated. The ESRD population presents a unique challenge because of the combination of elevated stroke and bleeding risks. Warfarin has been traditionally used in this population, but it is associated with significant risks of minor and major bleeding, particularly intracranial, thus leading many clinicians to forgo anticoagulation altogether. When anticoagulation is prescribed, rates of adherence and persistence are poor, leaving many patients untreated. The direct oral anticoagulants (DOACs) may offer an alternative to warfarin in ESRD patients, but these agents have not been extensively studied in this population and uncertainties regarding comparative effectiveness (versus warfarin, each other, and no treatment) remain. In this review, we discuss the current evidence on the risk and benefits of anticoagulants in this challenging population and comparisons between warfarin and DOACs, and review future directions including options for non-pharmacologic stroke prevention.
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26
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Mace-Brickman T, Eddeen AB, Carrero JJ, Mark PB, Molnar AO, Lam NN, Zimmerman D, Harel Z, Sood MM. The Risk of Stroke and Stroke Type in Patients With Atrial Fibrillation and Chronic Kidney Disease. Can J Kidney Health Dis 2019; 6:2054358119892372. [PMID: 31839975 PMCID: PMC6893926 DOI: 10.1177/2054358119892372] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/20/2019] [Indexed: 01/03/2023] Open
Abstract
Background: Atrial fibrillation (AF) and chronic kidney disease (CKD) are known to increase the risk of stroke. Objectives: We set out to examine the risk of stroke by kidney function and albuminuria in patients with and without AF. Design: Retrospective cohort study. Settings: Ontario, Canada. Participants: A total of 736 666 individuals (>40 years) from 2002 to 2015. Measurements: New-onset AF, albumin-to-creatinine ratio (ACR), and an estimated glomerular filtration rate (eGFR). Methods: A total of 39 120 matched patients were examined for the risk of ischemic, hemorrhagic, or any stroke event, accounting for the competing risk of all-cause mortality. Interaction terms for combinations of ACR/eGFR and the outcome of stroke with and without AF were examined. Results: In a total of 4086 (5.2%) strokes (86% ischemic), the presence of AF was associated with a 2-fold higher risk for any stroke event and its subtypes of ischemic and hemorrhagic stroke. Across eGFR levels, the risk of stroke was 2-fold higher with the presence of AF except for low levels of eGFR (eGFR < 30 mL/min/1.73 m2, hazard ratio [HR]: 1.38, 95% confidence interval [CI]: 0.99-1.92). Similarly across ACR levels, the risk of stroke was 2-fold higher except for high levels of albuminuria (ACR > 30 mg/g, HR: 1.61, 95% CI: 1.31-1.99). The adjusted risk of stroke with AF differed by combinations of ACR and eGFR categories (interaction P value = .04) compared with those without AF. Both stroke types were more common in patients with AF, and ischemic stroke rates differed significantly by eGFR and ACR categories. Limitations: Medication information was not included. Conclusions: Patients with CKD and AF are at a high risk of total, ischemic, and hemorrhagic strokes; the risk is highest with lower eGFR and higher ACR and differs based on eGFR and the degree of ACR.
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Affiliation(s)
| | | | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Patrick B Mark
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, UK
| | - Amber O Molnar
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ngan N Lam
- Division of Nephrology, University of Alberta, Edmonton, Canada
| | | | - Ziv Harel
- Division of Nephrology, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Manish M Sood
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Division of Nephrology, University of Alberta, Edmonton, Canada.,Division of Nephrology, St. Michael's Hospital, University of Toronto, ON, Canada.,Ottawa Hospital Research Institute, The Ottawa Hospital, Civic Campus, ON, Canada
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27
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Qamar SR, Jalal S, Nicolaou S, Tsang M, Gilhofer T, Saw J. Comparison of cardiac computed tomography angiography and transoesophageal echocardiography for device surveillance after left atrial appendage closure. EUROINTERVENTION 2019; 15:663-670. [PMID: 31217149 DOI: 10.4244/eij-d-18-01107] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Device surveillance after left atrial appendage (LAA) closure (LAAC) is important to assess device positioning, peri-device leak (PDL) and device-related thrombus (DRT). There are limited data on the role of cardiac CT angiography (CCTA) after LAAC. We therefore sought to compare CCTA to transoesophageal echocardiography (TEE) in patients who successfully underwent LAAC. METHODS AND RESULTS We report our consecutive series of non-valvular atrial fibrillation patients who underwent LAAC and had CCTA and TEE post LAAC. Prospective cardiac-gated CCTA was performed with the Toshiba 320-detector or Siemens second-generation 128-slice dual-source scanner, and post-processing was performed with IMPAX 3D reformats. Glomerular filtration rate <30 mL/min/1.73 m² was an exclusion for CCTA. Device positioning, PDL or fabric leak, ratio of left atrial (LA) to LAA linear attenuation coefficient, and DRT were analysed. One hundred and two patients underwent LAAC (79 WATCHMAN, 17 Amulet, 6 ACP). Mean age was 76.4±7.5 years, CHADS2 score 3.0±1.3, and CHADS-VASc score 4.6±1.6. CCTA was performed at a mean of 105.2±54.8 days, and TEE at a mean of 124.9±100.3 days post LAAC. LAA patency was observed in 52/100 (52%), with 45 (86.5%) via PDL and seven (13.5%) through fabric leak. Linear attenuation coefficient <100 HU and LA:LAA ratio <0.25 were seen in occluded devices. PDL was only observed in 35/102 (34.3%) on TEE. Mean device compression was greater with sealed devices (11.3±4.3% versus 8.2±4.0%, p<0.001). There was only one DRT, which was observed on both TEE and CCTA. CONCLUSIONS CCTA is a suitable alternative to TEE for device surveillance post LAAC. CCTA was more sensitive than TEE for assessing PDL and can delineate the cause of residual LAA contrast patency.
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Affiliation(s)
- Sadia R Qamar
- Department of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
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28
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Saczynski JS, Sanghai SR, Kiefe CI, Lessard D, Marino F, Waring ME, Parish D, Helm R, Sogade F, Goldberg R, Gurwitz J, Wang W, Mailhot T, Bamgbade B, Barton B, McManus DD. Geriatric Elements and Oral Anticoagulant Prescribing in Older Atrial Fibrillation Patients: SAGE-AF. J Am Geriatr Soc 2019; 68:147-154. [PMID: 31574165 DOI: 10.1111/jgs.16178] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/23/2019] [Accepted: 08/23/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Oral anticoagulants are the cornerstone of stroke prevention in high-risk patients with atrial fibrillation (AF). Geriatric elements, such as cognitive impairment and frailty, commonly occur in these patients and are often cited as reasons for not prescribing oral anticoagulants. We sought to systematically assess geriatric impairments in patients with AF and determine whether they were associated with oral anticoagulant prescribing. DESIGN Cross-sectional analysis of baseline data from the ongoing Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF) prospective cohort study. SETTING Multicenter study with site locations in Massachusetts and Georgia that recruited participants from cardiology, electrophysiology, and primary care clinics from 2016 to 2018. PARTICIPANTS Participants with AF age 65 years or older, CHA2 DS2 -VASc (congestive heart failure; hypertension; aged ≥75 y [doubled]; diabetes mellitus; prior stroke, transient ischemic attack, or thromboembolism [doubled]; vascular disease; age 65-74; female sex) score of 2 or higher, and no oral anticoagulant contraindications (n = 1244). MEASUREMENTS A six-component geriatric assessment included validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Oral anticoagulant use was abstracted from the medical record. RESULTS A total of 1244 participants (mean age = 76 y; 49% female; 85% white) were enrolled; 42% were cognitively impaired, 14% frail, 53% pre-frail, 12% socially isolated, and 29% had depressive symptoms. Oral anticoagulants were prescribed to 86% of the cohort. Oral anticoagulant prescribing did not vary according to any of the geriatric elements (adjusted odds ratios [ORs] for oral anticoagulant prescribing and cognitive impairment: OR = .75; 95% confidence interval [CI] = .51-1.09; frail OR = .69; 95% CI = .35-1.36; social isolation OR = .90; 95% CI = .52-1.54; depression OR = .79; 95% CI = .49-1.27; visual impairment OR = .98; 95% CI = .65-1.48; and hearing impairment OR = 1.05; 95% CI = .71-1.54). CONCLUSION Geriatric impairments, particularly cognitive impairment and frailty, were common in our cohort, but treatment with oral anticoagulants did not differ by impairment status. These geriatric impairments are commonly cited as reasons for not prescribing oral anticoagulants, suggesting that prescribers may either be unaware or deliberately ignoring the presence of these factors in clinical settings. J Am Geriatr Soc 68:147-154, 2019.
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Affiliation(s)
- Jane S Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts
| | - Saket R Sanghai
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Darleen Lessard
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Francesca Marino
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Molly E Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, Connecticut
| | - David Parish
- Department of Community Medicine/ Internal Medicine, Mercer University School of Medicine, Macon, Georgia
| | - Robert Helm
- Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Felix Sogade
- Department of Medicine, Mercer University School of Medicine, Mercer, Georgia
| | - Robert Goldberg
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jerry Gurwitz
- Geriatric Medicine Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Weijia Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Tanya Mailhot
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts.,Montreal Heart Institute Research Center, Montreal, Quebec, Canada
| | - Benita Bamgbade
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts
| | - Bruce Barton
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David D McManus
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
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Abstract
PURPOSE OF REVIEW This article provides updated information regarding the diagnosis and treatment (specifically critical care management) of acute ischemic stroke. This article also discusses the increased use of thrombolysis and thrombectomy in clinical practice. RECENT FINDINGS Stroke is the leading cause of disability in the United States. A significant proportion of patients with acute ischemic stroke require critical care management. Much has changed in the early evaluation and treatment of patients presenting with acute ischemic stroke. The introduction of embolectomy in large vessel occlusions for up to 24 hours post-symptom onset has resulted in one in every three eligible patients with acute ischemic stroke with the potential to lead an independent lifestyle. These patients increasingly require recognition of complications and initiation of appropriate interventions as well as earlier admission to dedicated neurocritical care units to ensure better outcomes. SUMMARY This article emphasizes issues related to the management of patients with acute ischemic stroke undergoing mechanical thrombectomy and thrombolysis and addresses the complex physiologic changes affecting neurologic and other organ systems.
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30
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Andrade JG, Verma A, Mitchell LB, Parkash R, Leblanc K, Atzema C, Healey JS, Bell A, Cairns J, Connolly S, Cox J, Dorian P, Gladstone D, McMurtry MS, Nair GM, Pilote L, Sarrazin JF, Sharma M, Skanes A, Talajic M, Tsang T, Verma S, Wyse DG, Nattel S, Macle L. 2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2019; 34:1371-1392. [PMID: 30404743 DOI: 10.1016/j.cjca.2018.08.026] [Citation(s) in RCA: 173] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 08/14/2018] [Accepted: 08/15/2018] [Indexed: 11/19/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) Atrial Fibrillation Guidelines Committee provides periodic reviews of new data to produce focused updates that address clinically important advances in atrial fibrillation (AF) management. This 2018 Focused Update addresses: (1) anticoagulation in the context of cardioversion of AF; (2) the management of antithrombotic therapy for patients with AF in the context of coronary artery disease; (3) investigation and management of subclinical AF; (4) the use of antidotes for the reversal of non-vitamin K antagonist oral anticoagulants; (5) acute pharmacological cardioversion of AF; (6) catheter ablation for AF, including patients with concomitant AF and heart failure; and (7) an integrated approach to the patient with AF and modifiable cardiovascular risk factors. The recommendations were developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) standards. Individual studies and literature were reviewed for quality and bias; the literature review process and evidence tables are included as Supplementary Material and are available on the CCS Web site. Details of the updated recommendations are presented, along with their background and rationale. This document is linked to an updated summary of all CCS AF guidelines recommendations, from 2010 to the present 2018 Focused Update, which is provided in the Supplementary Material.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Atul Verma
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - L Brent Mitchell
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Ratika Parkash
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kori Leblanc
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Clare Atzema
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Jeff S Healey
- McMaster University, Hamilton, Ontario, Canada; Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Stuart Connolly
- McMaster University, Hamilton, Ontario, Canada; Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Jafna Cox
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David Gladstone
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - M Sean McMurtry
- University of Alberta, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Louise Pilote
- McGill University Health Centre, Montréal, Quebec, Canada
| | | | - Mike Sharma
- McMaster University, Hamilton, Ontario, Canada; Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Allan Skanes
- London Heart Institute, Western University, London, Ontario, Canada
| | - Mario Talajic
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Teresa Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Subodh Verma
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - D George Wyse
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Stanley Nattel
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Laurent Macle
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
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31
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Wan D, Healey JS, Simpson CS. The Guideline-Policy Gap in Direct-Acting Oral Anticoagulants Usage in Atrial Fibrillation: Evidence, Practice, and Public Policy Considerations. Can J Cardiol 2019; 34:1412-1425. [PMID: 30404747 DOI: 10.1016/j.cjca.2018.07.476] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 06/26/2018] [Accepted: 07/09/2018] [Indexed: 12/15/2022] Open
Abstract
Atrial fibrillation has a high disease burden-both in prevalence and associated consequences. Despite anticoagulation being an effective treatment in atrial fibrillation, stroke prevention is slow to reflect evidence-based practice. Real-world data reveal a substantial portion of patients who would benefit from anticoagulation, yet do not receive it adequately or at all. A large part of this suboptimal treatment is due to the underutilization of direct oral anticoagulants (DOACs). In response to abundant evidence published over a short timeframe, international guidelines have adopted DOAC usage ahead of policy and fund holders. This paper reviews the evidence and values that influence published guidelines, patient-physician decision making, and policy framework on DOAC usage. An important factor is the access gap between patients who qualify for DOAC according to evidence-based guidelines and the subset of this cohort who are eligible for DOAC based on government funded policy. We analyse the Canadian health system in detail-including drug approval and funding process. Health care systems in other countries are explored, with emphasis on similar universal health care systems that may help overcome barriers common to Canada. We will discuss strategies to: (1) improve awareness of the risk and preventability of stroke; (2) enable physicians to provide evidence-based DOAC usage; (3) empower patients to improve adherence and persistence; (4) collect real-life data that encourages patient self-monitoring, physician outcomes auditing, and building evidence that is useful for policy makers; and (5) use postmarketing data in negotiating shared risk management between pharmaceuticals and government to improve access to DOACs.
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Affiliation(s)
- Douglas Wan
- Department of Medicine, Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Jeff S Healey
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ontario, Canada
| | - Chris S Simpson
- Department of Medicine, Division of Cardiology, Queen's University, Kingston, Ontario, Canada.
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32
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Triple antithrombotic therapy ought to be reviewed in pulmonary thromboembolism guidelines. J Crit Care 2019; 54:274-275. [PMID: 31153736 DOI: 10.1016/j.jcrc.2019.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 05/15/2019] [Indexed: 11/23/2022]
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33
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Santise G, Nardella S, Migliano F, Testa A, Maselli D. The HAS-BLED Score is Associated With Major Bleeding in Patients After Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:1601-1606. [DOI: 10.1053/j.jvca.2019.01.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Indexed: 11/11/2022]
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34
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Active management of atrial fibrillation or flutter in emergency department patients with renal impairment is associated with a higher risk of adverse events and treatment failure. CAN J EMERG MED 2019; 21:352-360. [DOI: 10.1017/cem.2018.475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTObjectiveAtrial fibrillation or flutter (AFF) patients with renal impairment have poor long-term prognosis, but their emergency department (ED) management has not been described. We investigated the association of renal impairment upon outcomes after rate or rhythm control (RRC) including ED-based adverse events (AE) and treatment failure.MethodsThis cohort study used an electrocardiogram database from two urban centres to identify consecutive AFF patients and reviewed charts to obtain comorbidities, ED management, including RRC, prespecified AE, and treatment failure. Patients were dichotomized into a normal estimated glomerular filtration rate (eGFR) > 60 mL/min/1.73 m2) or impaired renal function (“low eGFR”). Primary and secondary outcomes were prespecified AEs and treatment failure, respectively. We calculated 1) adjusted excess AE risk for patients with decreased renal function receiving RRC; and 2) adjusted odds ratio of RRC treatment failure.ResultsOf 1,112 consecutive ED AFF patients, 412 (37.0%) had a low eGFR. Crude AE rates for RRC were 27/238 (11.3%) for patients with normal renal function and 26/103 (25.2%) for patients with low eGFR. For patients with low eGFR receiving RRC, adjusted excess AE risk was 13.7%. (95% CI 1.7 to 25.1%). For patients with low eGFR, adjusted odds ratio for RRC failure was 3.07. (95% CI 1.74 to 5.43)ConclusionsIn this cohort of ED AFF patients receiving RRC, those with low eGFR had significantly increased adjusted excess risk of AE compared with patients with normal renal function. Odds of treatment failure were also significantly increased.
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35
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Proietti M, Lane DA, Boriani G, Lip GY. Stroke Prevention, Evaluation of Bleeding Risk, and Anticoagulant Treatment Management in Atrial Fibrillation Contemporary International Guidelines. Can J Cardiol 2019; 35:619-633. [DOI: 10.1016/j.cjca.2019.02.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/15/2019] [Accepted: 02/15/2019] [Indexed: 12/17/2022] Open
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36
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Parkash R, Magee K, McMullen M, Clory M, D’Astous M, Robichaud M, Andolfatto G, Read B, Wang J, Thabane L, Atzema C, Dorian P, Kaczorowski J, Banner D, Nieuwlaat R, Ivers N, Huynh T, Curran J, Graham I, Connolly S, Healey J. The Canadian Community Utilization of Stroke Prevention Study in Atrial Fibrillation in the Emergency Department (C-CUSP ED). Ann Emerg Med 2019; 73:382-392. [DOI: 10.1016/j.annemergmed.2018.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/13/2018] [Accepted: 09/04/2018] [Indexed: 10/28/2022]
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37
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Monagle SR, Hirsh J, Bhagirath VC, Ginsberg JS, Bosch J, Kruger P, Eikelboom JW. Impact of cost on use of non-vitamin K antagonists in atrial fibrillation patients in Ontario, Canada. J Thromb Thrombolysis 2019; 46:310-315. [PMID: 29873002 DOI: 10.1007/s11239-018-1692-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Canadian guidelines recommend non vitamin K antagonists (NOACs) in preference to vitamin K antagonists (VKAs) for stroke prevention in patients with atrial fibrillation (AF), but NOACs are more expensive than VKAs. Canada has a universal healthcare system that covers the cost of NOACs for select patient groups. Ability to pay for NOACs may influence their use. We reviewed medical charts of Hamilton General Hospital outpatients under the age of 65 with a new diagnosis of AF who were referred for initiation of OAC therapy. We contacted these patients by phone and asked them to complete a questionnaire regarding their OAC choice, economic factors that may have influenced this choice (income, insurance) and the financial burden of OAC therapy. We included 110 patients, mean age 56 years, and 26.4% females. NOAC users had a higher median neighborhood income than VKA users (p = 0.0144, n = 110). 73 patients responded to the questionnaire. NOAC users reported higher annual household income (p = 0.0038, n = 73). Patients with private insurance were more likely to use NOACs than those without insurance (p = 0.0496, n = 73). The cost of NOACs and ability to pay is a determinant of their use Ontario patients under the age of 65. This two tiered provision of care appears to contradict the values of Canada's universal healthcare system.
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Affiliation(s)
- Sarah R Monagle
- Population Health Research Institute, Hamilton, ON, Canada. .,Monash University, Clayton, VIC, Australia. .,St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.
| | - Jack Hirsh
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | - Jackie Bosch
- Population Health Research Institute, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Paul Kruger
- Population Health Research Institute, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - John W Eikelboom
- Population Health Research Institute, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada
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38
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Loewen PS, Bansback N, Hicklin J, Andrade JG, Kapanen AI, Kwan L, Lynd LD, McClean A, MacGillivray J, Salmasi S. Evaluating the Effect of a Patient Decision Aid for Atrial Fibrillation Stroke Prevention Therapy. Ann Pharmacother 2019; 53:665-674. [PMID: 30724102 DOI: 10.1177/1060028019828420] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Stroke prevention therapy decisions for patients with atrial fibrillation (AF) are complex and require trade-offs, but few validated patient decision aids (PDAs) are available to facilitate shared decision making. OBJECTIVE To evaluate the effects of a novel PDA on decision-making parameters for AF patients choosing stroke prevention therapy. METHODS We developed an evidence-based individualized online AF PDA for stroke prevention therapy and evaluated it in a prospective observational pilot study. The primary outcome was decisional conflict. Secondary outcomes were knowledge, usability/acceptability, patient preferences, effects on therapy choices, and participant feedback. RESULTS 37 participants completed the PDA. The PDA could be completed independently and was well accepted. It significantly decreased the mean decisional conflict score ( P < 0.001) and all its subscales and increased participant AF knowledge ( P = 0.02). 76% of participants indicated that their individualized therapy attribute ranking was congruent with their values. The PDA-generated best-match therapy was chosen by 70% of participants in decision 1 (no therapy, aspirin, or oral anticoagulant), and 17% for decision 2 (choice of anticoagulant). Among AF patients, 60% chose a different drug than that currently prescribed to them. Conclusion and Relevance: Our PDA was effective for reducing decisional conflict, increasing patient knowledge, eliciting patients' values, and presenting therapy options that aligned with patients' values and preferences. Using the PDA revealed that many patients have therapy preferences different from their currently prescribed treatment. The PDA is a practical and potentially valuable tool to facilitate decision making about stroke prevention therapy for AF.
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Affiliation(s)
- Peter S Loewen
- 1 The University of British Columbia, Vancouver, BC, Canada
| | - Nick Bansback
- 1 The University of British Columbia, Vancouver, BC, Canada.,2 Providence Health Research Institute, Vancouver, BC, Canada
| | - James Hicklin
- 1 The University of British Columbia, Vancouver, BC, Canada
| | | | | | - Leanne Kwan
- 4 Royal Columbian Hospital, New Westminster, BC, Canada
| | - Larry D Lynd
- 1 The University of British Columbia, Vancouver, BC, Canada.,2 Providence Health Research Institute, Vancouver, BC, Canada
| | - Alison McClean
- 1 The University of British Columbia, Vancouver, BC, Canada
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39
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Esmolol Compared with Amiodarone in the Treatment of Recent-Onset Atrial Fibrillation (RAF): An Emergency Medicine External Validity Study. J Emerg Med 2019; 56:308-318. [PMID: 30711368 DOI: 10.1016/j.jemermed.2018.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 10/18/2018] [Accepted: 12/08/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Recent-onset atrial fibrillation (RAF) is the most frequent supraventricular dysrhythmia in emergency medicine. Severely compromised patients require acute treatment with injectable drugs OBJECTIVE: The main purpose of this external validity study was to compare the short-term efficacy of esmolol with that of amiodarone to treat severe RAF in an emergency setting. METHODS This retrospective survey was conducted in mobile intensive care units by analyzing patient records between 2002 and 2013. We included RAF with (one or more) severity factors including: clinical shock, angina pectoris, ST shift, and very rapid ventricular rate. A blind matching procedure was used to constitute esmolol group (n = 100) and amiodarone group (n = 200), with similar profiles for age, gender, initial blood pressure, heart rate, severity factors, and treatment delay. The main outcome measure was the percentage of patients with a ventricular rate control defined as heart frequency ≤ 100 beats/min. More stringent (rhythm control) and more humble indicators (20% heart rate reduction) were analyzed at from 10 to 120 min after treatment initiation. RESULTS Patient characteristics were comparable for both groups: age 66 ± 16 years, male 71%, treatment delay < 1 h 36%, 1-2 h 29%, > 2 h 35%, chest pain 61%, ST shift 62%, ventricular rate 154 ± 26 beats/min, and blood pressure 126/73 mm Hg. The superiority of esmolol was significant at 40 min (64% rate control with esmolol vs. 25% with amiodarone) and for all indicators from 10 to 120 min after treatment onset. CONCLUSION In "real life emergency medicine," esmolol is better than amiodarone in the treatment of RAF.
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40
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Tajfard M, Tavakoly Sany SB, Avan A, Latiff LA, Rahimi HR, Moohebati M, Hasanzadeh M, Ghazizadeh H, Esmaeily H, Doosti H, Taghipour A, Ghayour-Mobarhan M, Ferns GA, Emamian M, Bin Abd Mutalib MS. Relationship between serum high sensitivity C-reactive protein with angiographic severity of coronary artery disease and traditional cardiovascular risk factors. J Cell Physiol 2018; 234:10289-10299. [PMID: 30548615 DOI: 10.1002/jcp.27945] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 10/09/2018] [Indexed: 12/25/2022]
Abstract
Serum high-sensitivity C-reactive protein (hs-CRP) is predictive of coronary artery disease (CAD). The aim of this study was to examine the possible association of hs-CRP with presence and severity of CAD and traditional CAD risk factors. This case-control study was carried out on 2,346 individuals from September 2011 to May 2013. Of these 1,187 had evidence of coronary disease, and were subject to coronary angiography, and the remainder were healthy controls (n = 1,159). Characteristics were determined using standard laboratory techniques and serum Hs-CRP levels were estimated using enzyme-linked immunosorbent assay (ELISA) kits, and severity of CAD was assessed according to the score of obstruction in coronary artery. Serum hs-CRP levels were higher in those with severe coronary disease, who had stenosis ≥ 50% stenosis of at least one coronary artery (all p < 0.001 vs. individuals in healthy control), and correlated significantly with the score for coronary artery disease (all p < 0.01). After adjustment for conventional risk factors, regression analysis revealed that smoking habits, fasting blood glucose, total cholesterol, high-density lipoprotein, hs-CRP, blood pressure, anxiety, dietary intake of vitamin E, and cholesterol remained as independent determinants for angiographic severity of CAD. The area under the receiving operating characteristic (ROC) curve for serum hs-CRP was 0.869 (CI 95% 0.721-0.872, p < 0.001). The optimal values for the cut-off point was a serum hs-CRP of 2.78 mg/l (sensitivity 80.20%, specificity 85%) to predict severity of CAD. Increased serum hs-CRP levels are significantly associated with angiographic severity of CAD, suggesting its value as a biomarkers for predicting CAD.
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Affiliation(s)
- Mohammad Tajfard
- Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Department of Health Education and Health Promotion, School of Health, Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyedeh Belin Tavakoly Sany
- Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Department of Health Education and Health Promotion, School of Health, Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amir Avan
- Metabolic Syndrome Research Centre, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Latiffah A Latiff
- Department of Community Health, Faculty of Medicine and Health Sciences, University Putra Malaysia, Seri Kembangan, Malaysia
| | - Hamid Reza Rahimi
- Department of Modern Sciences and Technologies, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.,Vascular and Endovascular Surgery Research Centre, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohsen Moohebati
- Department of Cardiology, Ghaem Educational Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mehdi Hasanzadeh
- Department of Biostatistics and Epidemiology, Faculty of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamideh Ghazizadeh
- Metabolic Syndrome Research Centre, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Habibollah Esmaeily
- Department of Biostatistics and Epidemiology, Faculty of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hassan Doosti
- Department of Statistics, School of Health, Macquarie University, Sydney, Australia
| | - Ali Taghipour
- Department of Biostatistics and Epidemiology, Faculty of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Majid Ghayour-Mobarhan
- Metabolic Syndrome Research Centre, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Gordon A Ferns
- Brighton & Sussex Medical School, Division of Medical Education, Falmer, Brighton, Sussex BN1 9PH, UK
| | - Marzie Emamian
- Biochemistry Department, School of Medicine, Mashhad University of Medical Science, Mashhad, Iran
| | - Mohd Sokhini Bin Abd Mutalib
- Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, University Putra Malaysia, Malaysia
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Xu D, Su C, Pan J. Advances and Application of a Novel Oral Anticoagulant in Specific Populations: Dabigatran Etexilate. Curr Drug Metab 2018; 21:106-111. [PMID: 30317993 DOI: 10.2174/1389200219666181011160133] [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: 11/01/2017] [Revised: 05/31/2018] [Accepted: 08/06/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Dabigatran etexilate (DE) was approved by the FDA in 2010 to reduce the risk of stroke and systemic embolism in adults with Non-valvular Atrial Fibrillation (NVAF). Compared with warfarin, a traditional anticoagulant drug, DE exhibits a shorter half-life, improved dose-effect relationship, fewer food and drug interactions, and can be taken orally without monitoring the conventional coagulation index. DE can also prevent or reduce the severity of adverse events, such as attenuated drug efficacy or bleeding. It is convenient for patients to take DE due to low levels of individual variation. This review aims to application of Dabigatran etexilate in specific populations. METHODS Fifty-five papers were included in the review. RESULTS We review the pharmacological mechanisms, pharmacokinetics and drug interactions, as well as the application of DE for different clinical populations, and provide clinical guidelines. CONCLUSION When using DE, one should consider the risk of bleeding, age, renal function, drug interactions, and other factors.
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Affiliation(s)
- Delai Xu
- Department of Pharmacy, The Second Affiliated Hospital of Soochow University, Jiangsu, China
| | - Cujin Su
- Department of Pharmacy, The Second Affiliated Hospital of Soochow University, Jiangsu, China
| | - Jie Pan
- Department of Pharmacy, The Second Affiliated Hospital of Soochow University, Jiangsu, China
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Ancedy Y, Berthelot E, Lang S, Ederhy S, Boyer-Chatenet L, Di Angelantonio E, Soulat-Dufour L, Etienney A, Adavane-Scheublé S, Boccara F, Cohen A. Is von Willebrand factor associated with stroke and death at mid-term in patients with non-valvular atrial fibrillation? Arch Cardiovasc Dis 2018; 111:357-369. [PMID: 29685722 DOI: 10.1016/j.acvd.2017.08.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 08/07/2017] [Accepted: 08/31/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Heart failure and atrial fibrillation share common mechanisms that may contribute to hypercoagulability and thrombotic risk. Elevated von Willebrand factor (vWF) concentration has been associated with increased risk of thromboembolism and cardiovascular events. AIM To investigate whether increased vWF plasma concentration predicts occurrence of a composite endpoint (all-cause death and stroke) in patients with non-valvular atrial fibrillation (NVAF). METHODS We prospectively studied 122 patients (mean age 70±14years; 46% men) hospitalized with NVAF, and followed over a median (interquartile range) of 5.4 (2.3-9.0)years. Cox proportional models were used to estimate the association of vWF concentration with time to stroke and death. RESULTS Forty-three patients (35%) had at least a stroke or died during the 5-year follow-up. Kaplan-Meier curves using vWF plasma concentration tertiles (≤191IU/dL;>191 to≤295IU/dL;>295IU/dL) showed that vWF plasma concentrations discriminated groups of patients with higher cardiovascular event rates (log-rank P=0.01). In the multivariable analysis, higher vWF concentrations (middle tertile hazard ratio [HR] 4.59, 95% confidence interval [CI] 1.55-13.50 [P=0.006]; upper tertile HR 4.10, 95% CI 1.43-11.75 [P=0.009]), age≥75years (HR 5.02, 95% CI 1.53-16.49; P=0.008), heart failure (HR 2.05, 1.01-4.19; P=0.048), C-reactive protein, log2 per unit increase (HR 1.29, 95% CI 1.04-1.61; P=0.021), no warfarin at discharge (HR 4.96, 95% CI 2.02-12.20; P<0.0001) and no aspirin at discharge (HR 4.41, 95% CI 1.71-11.97; P=0.002) were independently associated with an increased risk of stroke and all-cause death, whereas female sex was a protective factor (HR 0.35, 0.16-0.78; P=0.01). CONCLUSIONS High vWF plasma concentrations may discriminate patients with NVAF at greater risk of stroke or all-cause death.
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Affiliation(s)
- Yann Ancedy
- Service de cardiologie, hôpital Saint-Antoine, hôpitaux de l'Est parisien, AP-HP, 75012 Paris cedex 12, France; Université Pierre-et-Marie-Curie (UPMC), Sorbonne universités, 75005 Paris, France
| | - Emmanuelle Berthelot
- Service de cardiologie, hôpital Saint-Antoine, hôpitaux de l'Est parisien, AP-HP, 75012 Paris cedex 12, France; Université Pierre-et-Marie-Curie (UPMC), Sorbonne universités, 75005 Paris, France
| | - Sylvie Lang
- Service de cardiologie, hôpital Saint-Antoine, hôpitaux de l'Est parisien, AP-HP, 75012 Paris cedex 12, France; Université Pierre-et-Marie-Curie (UPMC), Sorbonne universités, 75005 Paris, France
| | - Stéphane Ederhy
- Service de cardiologie, hôpital Saint-Antoine, hôpitaux de l'Est parisien, AP-HP, 75012 Paris cedex 12, France; Université Pierre-et-Marie-Curie (UPMC), Sorbonne universités, 75005 Paris, France
| | - Louise Boyer-Chatenet
- Service de cardiologie, hôpital Saint-Antoine, hôpitaux de l'Est parisien, AP-HP, 75012 Paris cedex 12, France; Université Pierre-et-Marie-Curie (UPMC), Sorbonne universités, 75005 Paris, France
| | - Emanuele Di Angelantonio
- Department of Public Health & Primary Care, Strangeways Research Laboratory, CB1 8RN Cambridge, UK
| | - Laurie Soulat-Dufour
- Service de cardiologie, hôpital Saint-Antoine, hôpitaux de l'Est parisien, AP-HP, 75012 Paris cedex 12, France; Université Pierre-et-Marie-Curie (UPMC), Sorbonne universités, 75005 Paris, France
| | - Arnaud Etienney
- Service de cardiologie, hôpital Saint-Antoine, hôpitaux de l'Est parisien, AP-HP, 75012 Paris cedex 12, France; Université Pierre-et-Marie-Curie (UPMC), Sorbonne universités, 75005 Paris, France
| | - Saroumadi Adavane-Scheublé
- Service de cardiologie, hôpital Saint-Antoine, hôpitaux de l'Est parisien, AP-HP, 75012 Paris cedex 12, France; Université Pierre-et-Marie-Curie (UPMC), Sorbonne universités, 75005 Paris, France
| | - Franck Boccara
- Université Pierre-et-Marie-Curie (UPMC), Sorbonne universités, 75005 Paris, France; Department of Public Health & Primary Care, Strangeways Research Laboratory, CB1 8RN Cambridge, UK; Centre de Recherche Saint-Antoine, Inserm, UMR S 938, 75012 Paris, France
| | - Ariel Cohen
- Service de cardiologie, hôpital Saint-Antoine, hôpitaux de l'Est parisien, AP-HP, 75012 Paris cedex 12, France; Université Pierre-et-Marie-Curie (UPMC), Sorbonne universités, 75005 Paris, France; Centre de Recherche Saint-Antoine, Inserm, UMR S 938, 75012 Paris, France; Inserm, U856, « Thrombose, Athérothrombose et Pharmacologie Appliquée », 75012 Paris, France.
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Ezekowitz JA, Lewis BS, Lopes RD, Wojdyla DM, McMurray JJV, Hanna M, Atar D, Cecilia Bahit M, Keltai M, Lopez-Sendon JL, Pais P, Ruzyllo W, Wallentin L, Granger CB, Alexander JH. Clinical outcomes of patients with diabetes and atrial fibrillation treated with apixaban: results from the ARISTOTLE trial. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2018; 1:86-94. [PMID: 27533976 DOI: 10.1093/ehjcvp/pvu024] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 12/22/2014] [Indexed: 11/14/2022]
Abstract
AIMS We compared clinical outcomes in patients with AF with and without diabetes in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation trial. METHODS AND RESULTS The main efficacy endpoints were SSE and mortality; safety endpoints were major and major/clinically relevant non-major bleeding. A total of 4547/18 201 (24.9%) patients had diabetes who were younger (69 vs. 70 years), more had coronary artery disease (39 vs. 31%), and higher mean CHADS2 (2.9 vs. 1.9) and HAS-BLED scores (1.9 vs. 1.7) (all P < 0.0001) than patients without diabetes. Patients with diabetes receiving apixaban had lower rates of SSE [hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.53-1.05), all-cause mortality (HR 0.83, 95% CI 0.67-1.02), cardiovascular mortality (HR 0.89, 95% CI 0.66-1.20), intra-cranial haemorrhage (HR 0.49, 95% CI 0.25-0.95), and a similar rate of myocardial infarction (HR 1.02, 95% CI 0.62-1.67) compared with warfarin. For major bleeding, a quantitative interaction was seen (P-interaction = 0.003) with a greater reduction in major bleeding in patients without diabetes even after multivariable adjustment. Other measures of bleeding showed a consistent reduction with apixaban compared with warfarin without a significant interaction based on diabetes status. CONCLUSION Apixaban has similar benefits on reducing stroke, decreasing mortality, and causing less intra-cranial bleeding than warfarin in patients with and without diabetes.
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Affiliation(s)
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, Technion-IIT, Haifa, Israel
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke Medicine, Durham, NC, USA
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke Medicine, Durham, NC, USA
| | | | | | - Dan Atar
- Oslo University Hospital, Oslo, Norway
| | | | - Matyas Keltai
- Semmelweis University, Hungarian Institute of Cardiology, Budapest, Hungary
| | | | - Prem Pais
- St. John's Medical College, Bangalore, India
| | | | - Lars Wallentin
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - John H Alexander
- Duke Clinical Research Institute, Duke Medicine, Durham, NC, USA
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Xafran, a drug utilization study of rivaroxaban in stroke prevention in atrial fibrillation in France using a claim database. Therapie 2018; 73:449-460. [PMID: 30075870 DOI: 10.1016/j.therap.2018.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 05/23/2018] [Accepted: 06/11/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND Little is known about the utilization of rivaroxaban in real life treatment settings in France. AIMS Objectives of this study were to describe the conditions of use and treatment persistence in patients with atrial fibrillation and treated with rivaroxaban for stroke prevention (SP-AF). METHODS A cohort study was performed using a representative sample of the French nationwide database. All adults who initiated rivaroxaban for SP-AF between 01/08/2012 and 31/12/2014 were included and followed for one year. Inappropriate use of rivaroxaban's was defined as use inconsistent with the summary of product characteristics. RESULTS In this study, 1278 patients were included, 687 (53.8%) were men and the mean age was 73.4years; 123 patients (9.6%) had a stroke and 78 (6.1%) a major bleeding event in the three years before rivaroxaban initiation. At treatment initiation 236 (18.5%) had chronic congestive heart failure, 991 (77.5%) hypertension, 247 (19.3%) diabetes and 9 (0.7%) HIV, hepatitis B or C infection. No anticoagulant had been administered in the six previous months for 777 patients (60.8%); 160 patients (12.5%) had an inappropriate use of rivaroxaban in SP-AF. At 6 and 12 months after the first delivery with rivaroxaban, 62.8%, and 51.7% (68.5% and 60.5% in sensitivity analyses) of the patients were still treated with rivaroxaban. The proportion of patients with a continuous medication availability above 80% was 96.1%. CONCLUSION The characteristics of patients in this study are similar to patients treated with this drug in other observational studies. Adherence and persistence with rivaroxaban can be considered good.
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Nery PB, Al Dawood W, Nair GM, Redpath CJ, Sadek MM, Chen L, Green MS, Wells G, Birnie DH. Characterization of Low-Voltage Areas in Patients With Atrial Fibrillation: Insights From High-Density Intracardiac Mapping. Can J Cardiol 2018; 34:1033-1040. [PMID: 30056843 DOI: 10.1016/j.cjca.2018.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 03/21/2018] [Accepted: 04/08/2018] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND There is limited data on the scar burden in patients with atrial fibrillation (AF). In this study, we sought to evaluate the presence and extent of an abnormal left atrial (LA) substrate in patients with paroxysmal or persistent AF. METHODS Consecutive patients who underwent initial AF catheter ablation were prospectively enrolled. Endocardial voltage mapping was acquired in sinus rhythm using multipolar mapping catheters. Automated software was used to ensure homogeneous data collection. Assessment of low-voltage area (LVA) was performed by a reviewer blinded to clinical details. RESULTS One hundred and four patients were prospectively enrolled; 69 had paroxysmal and 35 persistent AF. The mean LA volume was 159 ± 48 mL, and the average number of LA points collected was 1308 ± 1065. Atrial LVAs were present in 23 of 69 (33%) subjects with paroxysmal and 20 of 35 (57%) with persistent AF (P = 0.02). Amongst 43 of 104 patients with scar, the average extent of LVA was 19.4 ± 21.6 cm2 and the mean percentage area was 7.6 ± 8.8%. Univariate analysis showed that age, LA volume, and persistent AF were associated with the presence of LVA. Multivariable analysis showed that age (odds ratio [OR] 1.05; 95% confidence interval [CI] 1.00-1.11; P = 0.046) and LA volume (OR 1.02; 95% CI 1.01-1.04; P < 0.001) remained predictors of LVA. AF classification (persistent vs paroxysmal) was not a predictor of an abnormal atrial substrate (OR 1.34; 95% CI 0.4-3.9; P = 0.56). CONCLUSIONS There is wide variability in the presence and extent of LVA in patients with paroxysmal or persistent AF. Age and LA volume were predictors of LVA. There was no correlation between AF classification and the presence of LVA.
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Affiliation(s)
- Pablo B Nery
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | - Wafa Al Dawood
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Girish M Nair
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Calum J Redpath
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Mouhannad M Sadek
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Li Chen
- Cardiovascular Research Methods Center, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Martin S Green
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - George Wells
- Cardiovascular Research Methods Center, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David H Birnie
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Cox JL, Parkash R, Abidi SS, Thabane L, Xie F, MacKillop J, Abidi SR, Ciaccia A, Choudhri SH, Abusharekh A, Nemis-White J. Optimizing primary care management of atrial fibrillation: The rationale and methods of the Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF) study. Am Heart J 2018; 201:149-157. [PMID: 29807323 DOI: 10.1016/j.ahj.2018.04.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 04/02/2018] [Indexed: 11/29/2022]
Abstract
The Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF) is an investigator designed, prospective, randomized, un-blinded, cluster design clinical trial, conducted in the primary care setting of Nova Scotia, Canada. Its aim is to evaluate whether an electronic Clinical Decision Support System (CDSS) designed to assist both practitioners and patients with evidence-based management strategies for Atrial Fibrillation (AF) can improve process of care and outcomes in a cost-efficient manner as compared to usual AF care. At least 200 primary care providers are being recruited and randomized at the level of the practice to control (usual care) or intervention (eligible to access to CDSS) cohorts. Over 1,000 patients of participating providers with confirmed AF will be managed per their provider's respective assignment. The targeted primary clinical outcome is a reduction in the composite of unplanned cardiovascular (CV) or major bleeding hospitalizations and AF-related emergency department visits. Secondary clinical outcomes, process of care, patient and provider satisfaction as well as economic costs at the system and patient levels are being examined. The trial is anticipated to report in 2018.
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Affiliation(s)
- Jafna L Cox
- Division of Cardiology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada; Heart and Stroke Foundation of Nova Scotia Endowed Chair in Cardiovascular Outcomes Research.
| | - Ratika Parkash
- Division of Cardiology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Syed Sr Abidi
- Faculty of Computer Science, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Departments of Anesthesia/Pediatrics, McMaster University, Hamilton, Ontario, Canada; Biostatistics Unit, Centre for Evaluation of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute (PHRI), Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada; System-Linked Research Unit (SLRU), McMaster University, Hamilton, Ontario, Canada
| | - Feng Xie
- Departments of Anesthesia/Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - James MacKillop
- Sydney Primary Care Medical Clinic, Sydney, Nova Scotia, Canada; Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Samina R Abidi
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Antonio Ciaccia
- Medical Affairs - Cardiovascular Medicine, Bayer Inc, Mississauga, Ontario, Canada
| | - Shurjeel H Choudhri
- Medical & Scientific Affairs, Bayer Inc, Mississauga, Ontario, Canada; Canadian Clinical Trial Coordinating Centre (CCTCC); Medical Advisory Team (MAT), Innovative Medicines, Canada; Canadian Arrhythmia Network (CANet)
| | - A Abusharekh
- NICHE Research Group, Faculty of Computer Science, Dalhousie University, Halifax, Canada
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Optimal antithrombotic treatment in patients with atrial fibrillation and coronary stents: an update. Curr Opin Cardiol 2018; 31:356-65. [PMID: 27205887 DOI: 10.1097/hco.0000000000000306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The optimal antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention (PCI) is still debated. This review is an update of a previous review and aims to summarize new published data regarding the management of this group of atrial fibrillation patients. RECENT FINDINGS Recent data report an underuse of oral anticoagulation in patients with atrial fibrillation undergoing PCI while indicated. However, tools for risk assessment and thus better guidance for decision-making are lacking, especially for elderly atrial fibrillation patients. New evidence suggests that the combination of oral anticoagulation and clopidogrel without aspirin may improve clinical outcomes in comparison with triple therapy; however, there is little data regarding the role of non-vitamin K oral anticoagulants and newer P2Y12 inhibitors in these regimens. SUMMARY Despite accumulating data on the assessment of bleeding and thrombotic risk, the management of elderly atrial fibrillation patients, new treatment regimens, and the role of more potent antithrombotic agents, the optimal antithrombotic therapy for patients with atrial fibrillation after PCI is still unclear. In the meantime, careful assessment of both thrombotic and bleeding risk and individualized decision-making are paramount to ensure the best patient outcomes.
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Ye JB, Sul YH, Lee JY, Go SJ, Choi JH. Adaptation of New Oral Anticoagulants for Warfarin Anticoagulated Patient with Traumatic Ongoing Hemorrhage. JOURNAL OF ACUTE CARE SURGERY 2018. [DOI: 10.17479/jacs.2018.8.1.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Jin Bong Ye
- Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Young Hoon Sul
- Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Jin Young Lee
- Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Seung Je Go
- Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Jung Hee Choi
- Department of Anesthesiology and Pain Medicine, Chungbuk National University Hospital, Cheongju, Korea
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Chartrand M, Guénette L, Brouillette D, Côté S, Huot R, Landry J, Martineau J, Perreault S, White-Guay B, Williamson D, Martin É, Gagnon MM, Lalonde L. Development of Quality Indicators to Assess Oral Anticoagulant Management in Community Pharmacies for Patients with Atrial Fibrillation. J Manag Care Spec Pharm 2018; 24:357-365. [PMID: 29578847 PMCID: PMC10397915 DOI: 10.18553/jmcp.2018.24.4.357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Few studies have evaluated the quality of oral anticoagulant management by community pharmacists. There is no complete set of quality indicators available for this purpose. OBJECTIVE To develop a set of specific quality indicators to assess oral anticoagulant management by community pharmacists for patients with atrial fibrillation (AF). METHODS Quality indicators were developed in 3 phases. In phase 1, potential quality indicators were generated based on clinical guidelines and a literature review. In phase 2, a modified RAND appropriateness method involving 2 rounds was implemented with 9 experts, who judged the appropriateness of quality indicators generated in phase 1 based on the extent to which they were accurate, based on evidence, relevant, representative of best practices, and measurable in community pharmacies. Phase 3 consisted of a feasibility assessment in 5 community pharmacies on 2 patients each. RESULTS The final set included 38 quality indicators grouped into 6 categories: documentation (n = 29), risk assessment (n = 3), clinical control (n = 1), clinical follow-up (n = 15), choice of therapy (n = 11), and interaction management (n = 8). The quality indicators referred to process of care (n = 34), clinical outcomes (n = 2), or structure of care (n = 2). There were 24 quality indicators related to vitamin K antagonists (VKAs), and 17 were related to direct oral anticoagulants (DOACs). To assess quality indicators, a questionnaire was developed for completion by community pharmacists for each patient, which included 17 questions about VKA patients and 12 questions about DOAC patients. CONCLUSIONS A first set of quality indicators is now available to assess the quality of oral anticoagulant management by community pharmacists for patients with AF. DISCLOSURES This research was supported by the Réseau Québécois de recherche sur le médicament (RQRM); the Blueprint for Pharmacy in collaboration with Pfizer Canada; and the Cercle du Doyen of the Faculty of Pharmacy, University of Montreal. The study sponsors were not involved in the study design, data collection, data interpretation, the writing of the article, or the decision to submit the report for publication. Chartrand received a scholarship from the Fonds de Recherche du Québec en Santé (FRQ-S), the Réseau Québécois de recherche sur l'usage des médicaments with Pfizer, and the Faculty of Pharmacy, University of Montreal. Guénette holds a Junior-1 Clinician Researcher Award from the FRQ-S in partnership with the Société québécoise d'hypertension artérielle. Williamson holds a Junior-1 Career Award from the FRQ-S. Côté reported being a medical speaker for Bayer, Boehringer Ingelheim Canada, and Pfizer Canada. The other authors reported no conflicts of interest. Study concept and design were contributed by Lalonde, Chartrand, and Martin. Chartrand, Martin, and Lalonde collected the data, along with Brouillette, Côté, Huot, Landry, Martineau, Perreault, Williamson, and White-Guay. Data interpretation was performed by Chartrand, Gagnon, and Lalonde, along with Guénette and Martin. The manuscript was primarily written by Chartrand, along with Guénette and Lalonde, and revised by Chartrand, Guénette, and Lalonde, along with the other authors. A portion of this study's results was presented at the 4th RQRM Annual Meeting on September 22-23, 2014, in Orford, Quebec, Canada, in the form of an abstract, which was published in the Journal of Population Therapeutics and Clinical Pharmacology, 2014;21(2):e312.
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Affiliation(s)
- Mylène Chartrand
- University of Montreal Hospital Research Center and Faculty of Pharmacy, University of Montreal, Quebec, Canada
| | - Line Guénette
- Faculty of Pharmacy, Université Laval, and Population Health and Optimal Health Practices Research Unit, Centre de recherche du Centre hospitalier universitaire de Québec-Université Laval, Quebec, Canada
| | | | | | - Roger Huot
- Montreal Heart Institute and Faculty of Medicine, University of Montreal, Quebec, Canada
| | - Jérôme Landry
- Pharmacy Veronic Comtois, Gabrielle Landry & Nathalie Ouellet pharmaciennes, Saint-Jean-de-Matha, Quebec, Canada
| | - Josée Martineau
- Department of Pharmacy Services, Hôpital de la Cité-de-la-Santé de Laval, Laval, Canada
| | | | - Brian White-Guay
- Faculty of Pharmacy and Faculty of Medicine, University of Montreal, and UMF-GMF Clinique de médecine familiale Notre-Dame, Montreal, Quebec, Canada
| | - David Williamson
- Faculty of Pharmacy, University of Montreal, and Department of Pharmacy Services and Research Center, Hôpital du Sacré-Coeur de Montréal, Quebec, Canada
| | | | | | - Lyne Lalonde
- University of Montreal Hospital Research Center and Faculty of Pharmacy, University of Montreal, Quebec, Canada
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Chatelain B, Chatelain C, Wallemacq P, Dogné JM, Douxfils J, Tamigniau A, Mullier F. Comparison of calibrated chromogenic anti-Xa assay and PT tests with LC-MS/MS for the therapeutic monitoring of patients treated with rivaroxaban. Thromb Haemost 2017; 110:723-31. [DOI: 10.1160/th13-04-0274] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 06/02/2013] [Indexed: 01/19/2023]
Abstract
SummaryPossibilities to monitor rivaroxaban therapy could be useful in certain circumstances. Prothrombin time (PT) or chromogenic anti-Xa assays such as the Biophen Direct Factor Xa Inhibitor® (DiXaI) have been proposed to estimate rivaroxaban concentrations but are mainly based on in vitro studies. The study aim was to compare PT and Biophen DiXaI® measurements with liquid chromatography-tandem mass spectrometry (LC-MS/MS) measurements in plasma samples from patients treated with Xarelto®. Fifty-two plasma samples were included. PT was performed using Innovin® and Triniclot PT Excel S®. Biophen DiXaI® was performed according to instructions from the manufacturer. The rivaroxaban plasma concentration ranged between 0 and 485 ng/ml as measured by LC-MS/MS. The limits of quantification were 30 ng/ml and 5 ng/ml for Biophen DiXaI® and LC-MS/MS, respectively. The linear correlation between Biophen DiXaI® and LC-MS/ MS analyses was high for all rivaroxaban concentrations (r2 = 0.95). For concentrations ≤100 ng/ml, r2-value was 0.83. The Bland-Altman analysis showed a mean difference of −16 ng/ml (SD: 25 ng/ml). The PT methods did not correlate well with plasma concentrations measured by LC-MS/MS (r2 ≈ 0.60). In conclusion, the important interindividual variability and the poor correlation with LC-MS/MS preclude the use of PT to estimate rivaroxaban concentrations. Thanks to its small inter-individual variability and good agreement with LC-MS/ MS measurements, we recommend the use of Biophen DiXaI® assays to estimate concentrations of rivaroxaban >30 ng/ml. Quantification of low rivaroxaban levels (<30 ng/ml) requires the LC-MS/MS method.
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