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Patil T, Ali S, Eppes D, Lee A, Jarmukli N. Evaluating the safety and effectiveness of direct oral anticoagulants compared with warfarin in very elderly patients with atrial fibrillation with and without low bodyweight. J Thromb Haemost 2024:S1538-7836(24)00428-8. [PMID: 39047944 DOI: 10.1016/j.jtha.2024.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 06/19/2024] [Accepted: 07/09/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Limited data exist on the safety and effectiveness of using direct oral anticoagulants (DOACs) in patients with atrial fibrillation aged 80 years or more with and without low bodyweight (LBW). OBJECTIVES We aimed to evaluate the safety and effectiveness of using DOACs in this population compared with warfarin. METHODS This retrospective active comparator new-user cohort study included veteran patients with atrial fibrillation who were newly initiated on either warfarin or DOACs between January 1, 2015, and January 1, 2021. The primary outcome was incidence of major bleeding and ischemic stroke. All outcomes were compared between treatment groups in 2 propensity score-matched cohorts of patients aged 80 years older with (AW) and without LBW (age-only cohort). Cox proportional hazard models were used to estimate adjusted hazard ratios (aHRs). RESULTS Matched AW and age-only cohorts included 493 and 11 909 patients, respectively, in each of the DOAC and warfarin exposure groups. Greater than 90% were male, with a mean age of ∼87 years. The rate of major bleeding was lower in the DOAC group compared with warfarin in both the AW (aHR, 0.63; 95% CI, 0.46-0.87) and age-only cohorts (aHR, 0.58; 95% CI, 0.49-0.77). A significantly lower rate of ischemic stroke occurred in the DOAC group compared with warfarin in the AW cohort (aHR, 0.62; 95% CI, 0.45-0.84) and age-only cohort (aHR, 0.63; 95% CI, 0.58-0.68). CONCLUSION DOAC use was associated with lower risk of major bleeding and ischemic stroke compared with warfarin in patients aged 80 years or older with and without LBW.
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Affiliation(s)
- Tanvi Patil
- Salem Veterans Affairs Health Care System, Salem, Virginia, USA.
| | - Salihah Ali
- Salem Veterans Affairs Health Care System, Salem, Virginia, USA
| | - Davida Eppes
- Salem Veterans Affairs Health Care System, Salem, Virginia, USA
| | - Aliza Lee
- Department of Podiatry, Salem Veterans Affairs Health Care System, Salem, Virginia, USA
| | - Nabil Jarmukli
- Department of Cardiology, Salem Veterans Affairs Health Care System, Salem, Virginia, USA
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Zhang K, Sun Y, Ding J, Ma Q, Zhang D, Huang W, Xing Y. Effect of nutritional status on adverse clinical events in elderly patients with nonvalvular atrial fibrillation: A retrospective cohort study. Ann Noninvasive Electrocardiol 2024; 29:e13130. [PMID: 38932572 PMCID: PMC11208721 DOI: 10.1111/anec.13130] [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: 08/24/2023] [Revised: 04/02/2024] [Accepted: 05/21/2024] [Indexed: 06/28/2024] Open
Abstract
OBJECTIVE To explore the influence of nutritional status on adverse clinical events in elderly patients with nonvalvular atrial fibrillation. METHODS This retrospective observational cohort study included 196 patients, 75-102-years-old, with nonvalvular atrial fibrillation, hospitalized in our hospital. The nutritional status was assessed using Mini-Nutritional Assessment-Short Form (MNA-SF). Patients with MNA-SF scores of 0-11 and 12-14 were included in the malnutrition and nonmalnutrition groups, respectively. RESULTS The average age of the malnutrition group was higher than that of the nonmalnutrition group, and the levels of body mass index (BMI), hemoglobin (HGB), and albumin (ALB) were significantly lower than those of the nonmalnutrition group, with statistical significance (p < .05). The incidence of all-cause death in the malnutrition group was higher than that in the nonmalnutrition group (p = .007). Kaplan-Meier curve indicated that malnutrition patients have a higher risk of all-cause death (log-rank test, p = .001) and major bleeding events (p = .017). Multivariate Cox proportional hazard regression analysis corrected for confounders showed that malnutrition was an independent risk factor of all-cause death (HR = 1.780, 95%CI:1.039-3.050, p = .036). The malnutrition group had a significantly high incidence of major bleeding than the nonmalnutrition group (p = .026), and there was no significant difference in the proportion of anticoagulation therapy (p = .082) and the incidence of ischemic stroke/systemic embolism (p = .310) between the two groups. CONCLUSIONS Malnutrition is an independent risk factor of all-cause death in elderly patients with atrial fibrillation. The incidence of major bleeding in malnourished elderly patients with atrial fibrillation is high, and the benefit of anticoagulation therapy is not obvious.
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Affiliation(s)
- Kan Zhang
- Department of Geriatrics, Affiliated Beijing Friendship HospitalCapital Medical UniversityBeijingChina
| | - Ying Sun
- Department of Geriatrics, Affiliated Beijing Friendship HospitalCapital Medical UniversityBeijingChina
| | - Jiancao Ding
- Department of Geriatrics, Affiliated Beijing Friendship HospitalCapital Medical UniversityBeijingChina
| | - Qing Ma
- Department of Geriatrics, Affiliated Beijing Friendship HospitalCapital Medical UniversityBeijingChina
| | - Dai Zhang
- Department of Geriatrics, Affiliated Beijing Friendship HospitalCapital Medical UniversityBeijingChina
| | - Wei Huang
- Department of Geriatrics, Affiliated Beijing Friendship HospitalCapital Medical UniversityBeijingChina
| | - Yunli Xing
- Department of Geriatrics, Affiliated Beijing Friendship HospitalCapital Medical UniversityBeijingChina
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Lin KJ, Singer DE, Ko D, Glynn R, Najafzadeh M, Lee SB, Bessette LG, Cervone A, DiCesare E, Kim DH. Frailty, Home Time, and Health Care Costs in Older Adults With Atrial Fibrillation Receiving Oral Anticoagulants. JAMA Netw Open 2023; 6:e2342264. [PMID: 37943558 PMCID: PMC10636636 DOI: 10.1001/jamanetworkopen.2023.42264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/26/2023] [Indexed: 11/10/2023] Open
Abstract
Importance There are no data on patient-centered outcomes and health care costs by frailty in patients with atrial fibrillation (AF) taking oral anticoagulants (OACs). Objective To compare home time, clinical events, and health care costs associated with OACs by frailty levels in older adults with AF. Design, Setting, and Participants This community-based cohort study assessed Medicare fee-for-service beneficiaries 65 years or older with AF from January 1, 2013, to December 31, 2019. Data analysis was performed from January to December 2022. Exposures Apixaban, rivaroxaban, and warfarin use were measured from prescription claims. Frailty was measured using a validated claims-based frailty index. Main outcomes and measures Outcome measures were (1) home time (days alive out of the hospital and skilled nursing facility) loss greater than 14 days; (2) a composite end point of ischemic stroke, systemic embolism, major bleeding, or death; and (3) total cost per member per year after propensity score overlap weighting. Results The weighted population comprised 136 551 beneficiaries, including 45 950 taking apixaban (mean [SD] age, 77.6 [7.3] years; 51.3% female), 45 320 taking rivaroxaban (mean [SD] age, 77.6 [7.3] years; 51.9% female), and 45 281 taking warfarin (mean [SD] age, 77.6 [7.3] years; 52.0% female). Compared with apixaban, rivaroxaban was associated with increased risk of home time lost greater than 14 days (risk difference per 100 persons, 1.8 [95% CI, 1.5-2.1]), composite end point (rate difference per 1000 person-years, 21.3 [95% CI, 16.4-26.2]), and total cost (mean difference, $890 [95% CI, $652-$1127]), with greater differences among the beneficiaries with frailty. Use of warfarin relative to apixaban was associated with increased home time lost (risk difference per 100 persons, 3.2 [95% CI, 2.9-3.5]) and composite end point (rate difference per 1000 person-years, 29.4 [95% CI, 24.5-34.3]), with greater differences among the beneficiaries with frailty. Compared with apixaban, warfarin was associated with lower total cost (mean difference, -$1166 [95% CI, -$1396 to -$937]) but higher cost when excluding OAC cost (mean difference, $1409 [95% CI, $1177 to $1642]) regardless of frailty levels. Conclusions and Relevance In older adults with AF, apixaban was associated with increased home time and lower rates of clinical events than rivaroxaban and warfarin, especially for those with frailty. Apixaban was associated with lower total cost compared with rivaroxaban but higher cost compared with warfarin due to higher OAC cost. These findings suggest that apixaban may be preferred for older adults with AF, particularly those with frailty.
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Affiliation(s)
- Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Daniel E. Singer
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Darae Ko
- Section of Cardiovascular Medicine, Boston Medical Center, Boston, Massachusetts
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Robert Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mehdi Najafzadeh
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lily Gui Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alexander Cervone
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elyse DiCesare
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Pundi K, Perino AC, Fan J, Din N, Szummer K, Heidenreich P, Turakhia MP. Association of CHA 2DS 2-VASc and HAS-BLED to frailty and frail outcomes: From the TREAT-AF study. Am Heart J 2023; 261:85-94. [PMID: 37024025 DOI: 10.1016/j.ahj.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Morbidity and mortality associated with high CHA2DS2-VASc and HAS-BLED scores is not specific to atrial fibrillation (AF). Frailty could be an important contributor to this morbidity and mortality while being mechanistically independent from AF. We sought to evaluate the association of stroke and bleeding risk to noncardiovascular frail events and the association of stroke prevention therapy to outcomes in frail patients with AF. METHODS Using the TREAT-AF (The Retrospective Evaluation and Assessment of Therapies in AF) study from the Veterans Health Administration, we identified patients with newly diagnosed AF from 2004 to 2014. Baseline frailty was identified using a previously validated claims-based index requiring ≥2 of 12 ICD-9 diagnoses. Logistic regressions modeled the association between CHA2DS2-VASc and modified HAS-BLED and frailty. Cox proportional hazard regressions were used to evaluate the association between CHA2DS2-VASc and modified HAS-BLED and a composite of noncardiovascular frail events (fractures, urinary tract infections, bacterial pneumonia, or dehydration). We also evaluated the association of oral anticoagulant (OAC) use with stroke, bleeding, and 1-year mortality in frail patients and non-frail patients. RESULTS In 213,435 patients (age 70 ± 11; 98% male; CHA2DS2-VASc 2.4 ± 1.7) with AF, 8,498 (4%) were frail. CHA2DS2-VASc > 0 and HAS-BLED > 0 were strongly associated with frailty (odds ratio [OR] 13.3 (95% CI: 11.6-15.2) for CHA2DS2-VASc 4+ and OR 13.4 (10.2-17.5) for HAS-BLED 3+). After adjusting for covariates, CHA2DS2-VASc, and HAS-BLED > 0 were associated with higher risk of non-cardiovascular frail events (hazard ratio [HR] 2.1 (95% CI: 2.0-2.2) for CHA2DS2-VASc 4+ and HR 1.4 (95% CI: 1.3-1.5) for HAS-BLED 3+). In frail patients, OAC use was associated with significantly lower risk of 1-year mortality (HR 0.82; 95% CI 0.72-0.94, P = .0031) but did not reach significance for risk of stroke (HR 0.80; 95% CI 0.55-1.18, P = .26) or major bleeding (HR 1.08; 95% CI 0.93-1.25, P = .34). CONCLUSIONS High CHA2DS2-VASc and HAS-BLED scores are strongly associated with frailty. However, in frail patients, OAC use was associated with reduction in 1-year mortality. For this challenging clinical population with competing risks of frailty and frail events, focused prospective studies are needed to support clinical decision-making. Until then, careful evaluation of frailty should inform shared decision-making.
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Affiliation(s)
- Krishna Pundi
- Department of Medicine, Stanford University School of Medicine, Stanford, CA.
| | - Alexander C Perino
- Department of Medicine, Stanford University School of Medicine, Stanford, CA; Center for Digital Health, Stanford University School of Medicine, Stanford, CA
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Natasha Din
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Karolina Szummer
- Karolinska University Hospital, Theme Heart and Vessel; Karolinska Institutet, Stockholm, Sweden
| | - Paul Heidenreich
- Department of Medicine, Stanford University School of Medicine, Stanford, CA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Mintu P Turakhia
- Department of Medicine, Stanford University School of Medicine, Stanford, CA; Center for Digital Health, Stanford University School of Medicine, Stanford, CA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
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Savelieva I, Fumagalli S, Kenny RA, Anker S, Benetos A, Boriani G, Bunch J, Dagres N, Dubner S, Fauchier L, Ferrucci L, Israel C, Kamel H, Lane DA, Lip GYH, Marchionni N, Obel I, Okumura K, Olshansky B, Potpara T, Stiles MK, Tamargo J, Ungar A. EHRA expert consensus document on the management of arrhythmias in frailty syndrome, endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA). Europace 2023; 25:1249-1276. [PMID: 37061780 PMCID: PMC10105859 DOI: 10.1093/europace/euac123] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 04/17/2023] Open
Abstract
There is an increasing proportion of the general population surviving to old age with significant chronic disease, multi-morbidity, and disability. The prevalence of pre-frail state and frailty syndrome increases exponentially with advancing age and is associated with greater morbidity, disability, hospitalization, institutionalization, mortality, and health care resource use. Frailty represents a global problem, making early identification, evaluation, and treatment to prevent the cascade of events leading from functional decline to disability and death, one of the challenges of geriatric and general medicine. Cardiac arrhythmias are common in advancing age, chronic illness, and frailty and include a broad spectrum of rhythm and conduction abnormalities. However, no systematic studies or recommendations on the management of arrhythmias are available specifically for the elderly and frail population, and the uptake of many effective antiarrhythmic therapies in these patients remains the slowest. This European Heart Rhythm Association (EHRA) consensus document focuses on the biology of frailty, common comorbidities, and methods of assessing frailty, in respect to a specific issue of arrhythmias and conduction disease, provide evidence base advice on the management of arrhythmias in patients with frailty syndrome, and identifies knowledge gaps and directions for future research.
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Affiliation(s)
- Irina Savelieva
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Stefano Fumagalli
- Department of Experimental and Clinical Medicine, Geriatric Intensive Care Unit and Geriatric Arrhythmia Unit, University of Florence and AOU Careggi, Florence, Italy
| | - Rose Anne Kenny
- Mercer’s Institute for Successful Ageing, Department of Medical Gerontology, St James’s Hospital, Dublin, Ireland
| | - Stefan Anker
- Department of Cardiology (CVK), Germany
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Germany
- German Centre for Cardiovascular Research (DZHK) partner site Berlin, Germany
- Charité Universitätsmedizin Berlin, Germany
| | - Athanase Benetos
- Department of Geriatric Medicine CHRU de Nancy and INSERM U1116, Université de Lorraine, Nancy, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Jared Bunch
- (HRS representative): Intermountain Medical Center, Cardiology Department, Salt Lake City,Utah, USA
- Stanford University, Department of Internal Medicine, Palo Alto, CA, USA
| | - Nikolaos Dagres
- Heart Center Leipzig, Department of Electrophysiology, Leipzig, Germany
| | - Sergio Dubner
- (LAHRS representative): Clinica Suizo Argentina, Cardiology Department, Buenos Aires Capital Federal, Argentina
| | - Laurent Fauchier
- Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France
| | | | - Carsten Israel
- Evangelisches Krankenhaus Bielefeld GmbH, Bielefeld, Germany
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medical College, New York, NY, USA
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, General Cardiology Division, University of Florence and AOU Careggi, Florence, Italy
| | - Israel Obel
- (CASSA representative): Milpark Hospital, Cardiology Unit, Johannesburg, South Africa
| | - Ken Okumura
- (APHRS representative): Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Brian Olshansky
- University of Iowa Hospitals and Clinics, Iowa CityIowa, USA
- Covenant Hospital, Waterloo, Iowa, USA
- Mercy Hospital Mason City, Iowa, USA
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Serbia
- Cardiology Clinic, Clinical Center of Serbia, Serbia
| | - Martin K Stiles
- (APHRS representative): Waikato Clinical School, University of Auckland and Waikato Hospital, Hamilton, New Zealand
| | - Juan Tamargo
- Department of Pharmacology, School of Medicine, CIBERCV, Universidad Complutense, Madrid, Spain
| | - Andrea Ungar
- Department of Experimental and Clinical Medicine, Geriatric Intensive Care Unit and Geriatric Arrhythmia Unit, University of Florence and AOU Careggi, Florence, Italy
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Carbone A, Bottino R, D’Andrea A, Russo V. Direct Oral Anticoagulants for Stroke Prevention in Special Populations: Beyond the Clinical Trials. Biomedicines 2023; 11:biomedicines11010131. [PMID: 36672639 PMCID: PMC9856013 DOI: 10.3390/biomedicines11010131] [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: 11/17/2022] [Revised: 12/19/2022] [Accepted: 12/29/2022] [Indexed: 01/06/2023] Open
Abstract
Currently, direct oral anticoagulants (DOACs) are the first-line anticoagulant strategy in patients with non-valvular atrial fibrillation (NVAF). They are characterized by a more favorable pharmacological profile than warfarin, having demonstrated equal efficacy in stroke prevention and greater safety in terms of intracranial bleeding. The study population in the randomized trials of DOACs was highly selected, so the results of these trials cannot be extended to specific populations such as obese, elderly, frail, and cancer patients, which, on the other hand, are sub-populations widely represented in clinical practice. Furthermore, due to the negative results of DOAC administration in patients with mechanical heart valves, the available evidence in subjects with biological heart valves is still few and often controversial. We sought to review the available literature on the efficacy and safety of DOACs in elderly, obese, underweight, frail, cancer patients, and in patients with bioprosthetic heart valves with NVAF to clarify the best anticoagulant strategy in these special and poorly studied subpopulations.
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Affiliation(s)
- Andreina Carbone
- Department of Cardiology, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
| | - Roberta Bottino
- Department of Cardiology, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
| | - Antonello D’Andrea
- Unit of Cardiology and Intensive Coronary Care, “Umberto I” Hospital, 84014 Nocera Inferiore, Italy
| | - Vincenzo Russo
- Department of Cardiology, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
- Monaldi Hospital, P.zzale Ettore Ruggeri, 80131 Naples, Italy
- Correspondence: ; Tel.: +39-081-5665144
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Presta R, Brunetti E, Polidori MC, Bo M. Impact of frailty models on the prescription of oral anticoagulants and on the incidence of stroke, bleeding, and mortality in older patients with atrial fibrillation: a systematic review. Ageing Res Rev 2022; 82:101761. [PMID: 36270605 DOI: 10.1016/j.arr.2022.101761] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/30/2022] [Accepted: 10/14/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Frailty is common in older patients with atrial fibrillation (AF). Current guidelines recommend oral anticoagulant therapy (OAT) except in case of severe frailty or reduced life expectancy, but definitive evidence on which "frailty" tools may help to identify older AF patients expected to derive little or no benefit from OAT is still lacking. Some persistent uncertainties may derive from the different clinical implications that the two major models of frailty, namely the frail phenotype (FP) and the deficit accumulation model (DAM), underlie. We thus conducted a systematic review of published studies to examine the association of the presence of frailty, categorized according to the FP and DAM, with 1) OAT prescription and 2) incidence of clinical outcomes (all-cause mortality, stroke and/or systemic embolism and major or clinically relevant non-major bleeding) in patients receiving OAT. METHODS Embase and MEDLINE were searched from inception until May 31st, 2022, for studies using a validated tool to identify frailty in subjects aged 65 years or older with a diagnosis of non-valvular AF; only studies on patients prescribed an OAT were considered eligible for the analyses involving clinical outcomes. The protocols for each review question have been registered in PROSPERO database (CRD42022308623 and CRD42022308628). FINDINGS Twenty-three studies exploring the association between frailty and OAT prescription on a total of 504 719 subjects were included. Patients with increasing severity of DAM frailty showed consistently lower OAT prescription rates than non-frail patients, whereas use of OAT did not significantly differ between patients with the FP compared with non-frail subjects. Eleven studies exploring the association between frailty and clinical outcomes on a total of 41 985 individuals receiving oral anticoagulation were included. Compared with non-frail subjects, a higher risk of all-cause mortality and clinical outcomes could be observed for AF patients prescribed with OAT with severe frailty according to the DAM, with inconclusive findings for the FP. High levels of heterogeneity were observed in both groups of studies; therefore, a meta-analysis was not performed. CONCLUSIONS Due to the great heterogeneity among different validated frailty measures, indiscriminately relying on "frailty" should not be regarded as the gold standard for clinical decision-making about stroke prevention in older AF patients. Present findings suggest that severe frailty according to the DAM is associated with less use of OAT and increased risk of all-cause mortality, thereby representing at the moment the most reasonable tool to efficiently recognize patients with limited life expectancy and for whom there is so far scant, if any, evidence of a clinical benefit of OAT.
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Affiliation(s)
- Roberto Presta
- Section of Geriatrics, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Molinette, Corso Bramante 88-90, 10126 Turin, Italy.
| | - Enrico Brunetti
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; Section of Internal Medicine, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Sant'Anna, Corso Bramante 88-90, 10126 Turin, Italy.
| | - Maria Cristina Polidori
- Ageing Clinical Research, Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937 Cologne, Germany; Cologne Excellence Cluster On Cellular Stress-Responses in Aging-Associated Diseases (CECAD), University of Cologne, Faculty of Medicine and University Hospital Cologne, Joseph-Stelzmann Straße 26, 50931 Cologne, Germany.
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Molinette, Corso Bramante 88-90, 10126 Turin, Italy.
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8
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Granata N, Vigoré M, Steccanella A, Ranucci L, Sarzi Braga S, Baiardi P, Pierobon A. The Clinical Frailty Scale (CFS) employment in the frailty assessment of patients suffering from Non-Communicable Diseases (NCDs): A systematic review. Front Med (Lausanne) 2022; 9:967952. [PMID: 36052327 PMCID: PMC9425100 DOI: 10.3389/fmed.2022.967952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background The Clinical Frailty Scale (CFS) is a well-established tool that has been widely employed to assess patients' frailty status and to predict clinical outcomes in the acute phase of a disease, but more information is needed to define the implications that this tool have when dealing with Non-Communicable Diseases (NCDs). Methods An electronic literature search was performed on PubMed, Scopus, EMBASE, Web of Science, and EBSCO databases to identify studies employing the CFS to assess frailty in patients with NCDs. Findings After database searching, article suitability evaluation, and studies' quality assessment, 43 studies were included in the systematic review. Researches were conducted mostly in Japan (37.5%), and half of the studies were focused on cardiovascular diseases (46.42%), followed by cancer (25.00%), and diabetes (10.71%). Simplicity (39.29%), efficacy (37.5%), and rapidity (16.07%) were the CFS characteristics mostly appreciated by the authors of the studies. The CFS-related results indicated that its scores were associated with patients' clinical outcomes (33.92%), with the presence of the disease (12.5%) and, with clinical decision making (10.71%). Furthermore, CFS resulted as a predictor of life expectancy in 23 studies (41.07%), clinical outcomes in 12 studies (21.43%), and hospital admissions/readmissions in 6 studies (10.71%). Discussion CFS was found to be a well-established and useful tool to assess frailty in NCDs, too. It resulted to be related to the most important disease-related clinical characteristics and, thus, it should be always considered as an important step in the multidisciplinary evaluation of frail and chronic patients. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/display_record.asp? PROSPERO 2021, ID: CRD42021224214.
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Affiliation(s)
- Nicolò Granata
- Department of Cardiac Respiratory Rehabilitation of Tradate Institute, Istituti Clinici Scientifici Maugeri IRCCS, Varese, Italy
| | - Martina Vigoré
- Istituti Clinici Scientifici Maugeri IRCCS, Psychology Unit of Montescano Institute, Montescano, Italy
- *Correspondence: Martina Vigoré
| | - Andrea Steccanella
- Istituti Clinici Scientifici Maugeri IRCCS, Psychology Unit of Montescano Institute, Montescano, Italy
| | - Luca Ranucci
- Istituti Clinici Scientifici Maugeri IRCCS, Psychology Unit of Montescano Institute, Montescano, Italy
| | - Simona Sarzi Braga
- Cardio-vascular Department, MultiMedica IRCCS, Sesto San Giovanni, Italy
| | - Paola Baiardi
- Central Scientific Direction, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Antonia Pierobon
- Istituti Clinici Scientifici Maugeri IRCCS, Psychology Unit of Montescano Institute, Montescano, Italy
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9
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Bul M, Shaikh F, McDonagh J, Ferguson C. Frailty and oral anticoagulant prescription in adults with atrial fibrillation: A systematic review. Aging Med (Milton) 2022. [DOI: 10.1002/agm2.12214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Mary Bul
- Western Sydney University Parramatta New South Wales Australia
| | - Fahad Shaikh
- Western Sydney University Parramatta New South Wales Australia
- Western Sydney Nursing and Midwifery Research Centre Western Sydney Local Health District and Western Sydney University, Blacktown Clinical and Research School, Blacktown Hospital Blacktown New South Wales Australia
| | - Julee McDonagh
- School of Nursing and Midwifery/College of Health, Medicine and Wellbeing The University of Newcastle, Central Coast Clinical School, Gosford Hospital Gosford New South Wales Australia
| | - Caleb Ferguson
- Western Sydney University Parramatta New South Wales Australia
- Western Sydney Nursing and Midwifery Research Centre Western Sydney Local Health District and Western Sydney University, Blacktown Clinical and Research School, Blacktown Hospital Blacktown New South Wales Australia
- School of Nursing, Faculty of Science, Medicine and Health University of Wollongong Wollongong New South Wales Australia
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10
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Proietti M, Romiti GF, Raparelli V, Diemberger I, Boriani G, Dalla Vecchia LA, Bellelli G, Marzetti E, Lip GY, Cesari M. Frailty prevalence and impact on outcomes in patients with atrial fibrillation: A systematic review and meta-analysis of 1,187,000 patients. Ageing Res Rev 2022; 79:101652. [PMID: 35659945 DOI: 10.1016/j.arr.2022.101652] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/20/2022] [Accepted: 05/23/2022] [Indexed: 12/14/2022]
Abstract
Frailty is a clinical syndrome characterized by a reduced physiologic reserve, increased vulnerability to stressors and an increased risk of adverse outcomes. People with atrial fibrillation (AF) are often burdened by frailty due to biological, clinical, and social factors. The prevalence of frailty, its management and association with major outcomes in AF patients are still not well quantified. We systematically searched PubMed and EMBASE, from inception to September 13th, 2021, for studies reporting the prevalence of frailty in AF patients. The study was registered in PROSPERO (CRD42021235854). 33 studies were included in the systematic review (n = 1,187,651 patients). The frailty pooled prevalence was 39.7 % (95 %CI=29.9 %-50.5 %, I2 =100 %), while meta-regression analyses showed it is influenced by age, history of stroke, and geographical location. Meta-regression analyses showed that OAC prescription was influenced by study-level mean age, baseline thromboembolic risk, and study setting. Frail AF patients were associated with a higher risk of all-cause death (OR=5.56, 95 %CI=3.46-8.94), ischemic stroke (OR=1.59, 95 %CI=1.00-2.52), and bleeding (OR=1.64, 95 %CI=1.11-2.41), when compared to robust individuals. In this systematic review and meta-analysis, the prevalence of frailty was high in patients with AF. Frailty may influence the prognosis and management of AF patients, thus requiring person-tailored interventions in a holistic or integrated approach to AF care.
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Affiliation(s)
- Marco Proietti
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Italy; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
| | | | - Valeria Raparelli
- Department of Translational Medicine, University of Ferrara, Italy; University Center for Studies on Gender Medicine, University of Ferrara, Italy; University of Alberta, Faculty of Nursing, Edmonton, Alberta, Canada
| | - Igor Diemberger
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Italy
| | | | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Emanuele Marzetti
- Università Cattolica del Sacro Cuore, Department of Geriatrics and Orthopedics, Rome, Italy; Center for Geriatric Medicine (Ce.M.I.), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome,Italy
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Matteo Cesari
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Italy
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11
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Sanghai SR, Liu W, Wang W, Rongali S, Orkaby AR, Saczynski JS, Rose AJ, Kapoor A, Li W, Yu H, McManus DD. Prevalence of Frailty and Associations with Oral Anticoagulant Prescribing in Atrial Fibrillation. J Gen Intern Med 2022; 37:730-736. [PMID: 33948795 PMCID: PMC8904680 DOI: 10.1007/s11606-021-06834-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 04/14/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Frailty is often cited as a factor influencing oral anticoagulation (OAC) prescription in patients with non-valvular atrial fibrillation (NVAF). We sought to determine the prevalence of frailty and its association with OAC prescription in older veterans with NVAF. METHODS We used ICD-9 codes in Veterans Affairs (VA) records and Medicare claims data to identify patients with NVAF and CHA2DS2VASC ≥2 receiving care between February 2010 and September 2015. We examined rates of OAC prescription, further stratified by direct oral anticoagulant (DOAC) or vitamin K antagonist (VKA). Participants were characterized into 3 categories: non-frail, pre-frail, and frail based on a validated 30-item EHR-derived frailty index. We examined relations between frailty and OAC receipt; and frailty and type of OAC prescribed in regression models adjusted for factors related to OAC prescription. RESULTS Of 308,664 veterans with NVAF and a CHA2DS2VASC score ≥2, 121,839 (39%) were prescribed OAC (73% VKA). The mean age was 77.7 (9.6) years; CHA2DS2VASC and ATRIA scores were 4.6 (1.6) and 5.0 (2.9) respectively. Approximately a third (38%) were frail, another third (32%) were pre-frail, and the remainder were not frail. Veterans prescribed OAC were younger, had higher bleeding risk, and were less likely to be frail than participants not receiving OAC (all p's<0.001). After adjustment for factors associated with OAC use, pre-frail (OR: 0.89, 95% CI: 0.87-0.91) and frail (OR: 0.66, 95% CI: 0.64-0.68) veterans were significantly less likely to be prescribed OAC than non-frail veterans. Of those prescribed OAC, pre-frail (OR:1.27, 95% CI: 1.22-1.31) and frail (OR: 1.75, 95% CI: 1.67-1.83) veterans were significantly more likely than non-frail veterans to be prescribed a DOAC than a VKA. CONCLUSIONS There are high rates of frailty among older veterans with NVAF. Frailty using an EHR-derived index is associated with decreased OAC prescription.
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Affiliation(s)
- Saket R Sanghai
- Division of Cardiac Electrophysiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA.
| | - Weisong Liu
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Weijia Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | | | - Ariela R Orkaby
- New England GRECC, VA Boston Health Care System, Boston, MA, USA
- Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jane S Saczynski
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, USA
| | - Adam J Rose
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Alok Kapoor
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Wenjun Li
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Hong Yu
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- University of Massachusetts, Lowell, MA, USA
- Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA, USA
| | - David D McManus
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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12
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Richard G, O’Halloran AM, Doody P, Harbison J, Kenny RA, Romero-Ortuno R. Atrial fibrillation and acceleration of frailty: findings from the Irish Longitudinal Study on Ageing. Age Ageing 2022; 51:6520511. [PMID: 35134844 DOI: 10.1093/ageing/afab273] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION both atrial fibrillation (AF) and frailty are increasingly prevalent with age. Cross-sectional studies have suggested a relationship between AF and frailty, but longitudinal data are lacking. We explored if the presence of AF was associated with accelerated progression of frailty over 8 years in community-dwelling older adults. METHODS a longitudinal retrospective case-control study was conducted using data from Waves 1 and 5 of the Irish Longitudinal Study on Ageing (TILDA). Participants with electrocardiographically detected AF at Wave 1 were matched to controls without AF (1:2) based on age and gender. Frailty was assessed using both the frailty phenotype (FP) and a 31-item frailty index (FI). Change in cases' and controls' FP and FI scores from Waves 1 to 5 were modelled using repeated measures analysis of variance (RM-ANOVA). RESULTS one hundred eighteen TILDA participants with AF at Wave 1 were matched to 236 controls. By FP, participants with AF were not significantly more frail than controls at Wave 1 (P = 0.166) but were at Wave 5 (P = 0.011), and RM-ANOVA suggested that frailty progressed more in participants with AF between Waves 1 and 5 compared with controls (P = 0.033). By FI, participants with AF were significantly more frail at Wave 1 (P < 0.001) and 5 (P = 0.010), and RM-ANOVA did not show a difference in frailty progression between groups (P = 0.955). CONCLUSION AF may drive the development of the FP. The FP is a pre-disability syndrome and hence may be better than the FI as a focus for disability prevention in adults with AF.
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Affiliation(s)
- Georgia Richard
- Department of General Internal Medicine, St. James’s Hospital, Dublin 8, D08 NYH1, Ireland
| | - Aisling M O’Halloran
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, D02 R590, Dublin, Ireland
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
| | - Paul Doody
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, D02 R590, Dublin, Ireland
| | - Joseph Harbison
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
- Mercer’s Institute for Successful Ageing (MISA), St James’s Hospital, D08 NYH1, Dublin, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, D02 R590, Dublin, Ireland
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
- Mercer’s Institute for Successful Ageing (MISA), St James’s Hospital, D08 NYH1, Dublin, Ireland
| | - Roman Romero-Ortuno
- The Irish Longitudinal Study on Ageing (TILDA), School of Medicine, Trinity College Dublin, D02 R590, Dublin, Ireland
- Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, D02 R590 Dublin, Ireland
- Mercer’s Institute for Successful Ageing (MISA), St James’s Hospital, D08 NYH1, Dublin, Ireland
- Global Brain Health Institute, Trinity College Dublin, D02 DK07 Dublin, Ireland
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13
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Orlandi M, Dover DC, Sandhu RK, Hawkins NM, Kaul P, McAlister FA. The Introduction of Direct Oral Anticoagulants Has Not Resolved Treatment Gaps for Frail Patients With Nonvalvular Atrial Fibrillation. Can J Cardiol 2022; 38:77-84. [DOI: 10.1016/j.cjca.2021.09.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/17/2021] [Accepted: 09/18/2021] [Indexed: 11/02/2022] Open
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14
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Bonanad C, García-Blas S, Torres Llergo J, Fernández-Olmo R, Díez-Villanueva P, Ariza-Solé A, Martínez-Sellés M, Raposeiras S, Ayesta A, Bertomeu-González V, Tarazona Santabalbina F, Facila L, Vivas D, Gabaldón-Pérez A, Bodi V, Nuñez J, Cordero A. Direct Oral Anticoagulants versus Warfarin in Octogenarians with Nonvalvular Atrial Fibrillation: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:5268. [PMID: 34830548 PMCID: PMC8618042 DOI: 10.3390/jcm10225268] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/04/2021] [Accepted: 11/05/2021] [Indexed: 11/17/2022] Open
Abstract
Direct oral anticoagulants (DOACs) have been demonstrated to be more effective and safer than vitamin-K antagonist (VKA) for stroke prevention in patients with nonvalvular atrial fibrillation (AF). This meta-analysis aims to assess the effect of DOACS vs. VKA in patients ≥ 80 and AF. Primary endpoints were stroke or systemic embolism and all-cause death. Secondary endpoints included major bleeding, intracranial bleeding, and gastrointestinal bleeding. A random-effects model was selected due to significant heterogeneity. A total of 147,067 patients from 16 studies were included, 71,913 (48.90%) treated with DOACs and 75,154 with VKA (51.10%). The stroke rate was significantly lower in DOACs group compared with warfarin group (Relative risk (RR): 0.72; 95% confidence interval (CI): 0.63-0.82; p < 0.001). All-cause mortality was significantly lower in DOACs group compared with warfarin group (RR: 0.82; 95% CI: 0.70-0.96; p = 0.012). Compared to warfarin, DOACs were not associated with reductions in major bleeding (RR: 0.85, 95% CI 0.69-1.04; p = 0.108) or gastrointestinal bleeding risk (RR: 1.08, 95% CI 0.76-1.53; p = 0.678) but a 43% reduction of intracranial bleeding (RR: 0.47, IC 95% 0.36-0.60; p < 0.001) was observed. Our meta-analysis demonstrates that DOACs are effective and safe with statistical superiority when compared with warfarin in octogenarians with AF.
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Affiliation(s)
- Clara Bonanad
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (C.B.); (S.G.-B.); (A.G.-P.); (V.B.); (J.N.)
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain
- Department of Medicine, Medicine Faculty, 46010 Valencia, Spain
| | - Sergio García-Blas
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (C.B.); (S.G.-B.); (A.G.-P.); (V.B.); (J.N.)
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), 28029 Madrid, Spain; (M.M.-S.); (V.B.-G.)
| | - Javier Torres Llergo
- Cardiology Department, Hospital Universitario de Jaén, 23007 Jaén, Spain; (J.T.L.); (R.F.-O.)
| | - Rosa Fernández-Olmo
- Cardiology Department, Hospital Universitario de Jaén, 23007 Jaén, Spain; (J.T.L.); (R.F.-O.)
| | | | - Albert Ariza-Solé
- Cardiology Department, Hospital Universitari de Bellvitge, 08907 L’Hospitalet de Llobregat, Spain;
| | - Manuel Martínez-Sellés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), 28029 Madrid, Spain; (M.M.-S.); (V.B.-G.)
- Cardiology Department, Hospital Universitario Gregorio Marañón, 28007 Madrid, Spain
| | - Sergio Raposeiras
- Cardiology Department, Hospital Álvaro Cunqueiro, 36213 Vigo, Spain;
| | - Ana Ayesta
- Cardiology Department, Hospital Central de Asturias, 33011 Oviedo, Spain;
| | - Vicente Bertomeu-González
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), 28029 Madrid, Spain; (M.M.-S.); (V.B.-G.)
- Cardiology Department, Hospital Universitario de San Joan, 03550 Alicante, Spain
- Department of Clinical Medicine, Universidad Miguel Hernandez, 03550 Alicante, Spain
| | | | - Lorenzo Facila
- Cardiology Department, Hospital General Universitario de Valencia, 46014 Valencia, Spain;
| | - David Vivas
- Instituto Cardiovascular, Hospital Clínico San Carlos, 28040 Madrid, Spain;
| | - Ana Gabaldón-Pérez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (C.B.); (S.G.-B.); (A.G.-P.); (V.B.); (J.N.)
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain
| | - Vicente Bodi
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (C.B.); (S.G.-B.); (A.G.-P.); (V.B.); (J.N.)
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain
- Department of Medicine, Medicine Faculty, 46010 Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), 28029 Madrid, Spain; (M.M.-S.); (V.B.-G.)
| | - Julio Nuñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (C.B.); (S.G.-B.); (A.G.-P.); (V.B.); (J.N.)
- Instituto de Investigación Sanitaria INCLIVA, 46010 Valencia, Spain
- Department of Medicine, Medicine Faculty, 46010 Valencia, Spain
| | - Alberto Cordero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), 28029 Madrid, Spain; (M.M.-S.); (V.B.-G.)
- Cardiology Department, Hospital Universitario de San Joan, 03550 Alicante, Spain
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15
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Polidori MC, Alves M, Bahat G, Boureau AS, Ozkok S, Pfister R, Pilotto A, Veronese N, Bo M. Atrial fibrillation: a geriatric perspective on the 2020 ESC guidelines. Eur Geriatr Med 2021; 13:5-18. [PMID: 34727362 PMCID: PMC8562074 DOI: 10.1007/s41999-021-00537-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/03/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The Task Force for the diagnosis and management of atrial fibrillation (AF) of the European Society of Cardiology (ESC) published in 2020 the updated Guidelines for the Diagnosis and Management of Atrial Fibrillation with the contribution of the European Heart Rhythm Association (EHRA) of the ESC and the European Association for Cardiothoracic Surgery (EACTS). METHODS AND RESULTS In this narrative viewpoint, we approach AF from the perspective of aging medicine and try to provide the readers with information usually neglected in clinical routine, mainly due to the fact that while the large majority of AF patients in real life are older, frail and cognitively impaired, these are mostly excluded from clinical trials, and physicians' attitudes often prevail over standardized algorithms. CONCLUSIONS On the basis of existing evidence, (1) opportunistic AF screening by pulse palpation or ECG rhythm strip is cost-effective, and (2) whereas advanced chronological age by itself is not a contraindication to AF treatment, a Comprehensive Geriatric Assessment (CGA) including frailty, cognitive impairment, falls and bleeding risk may assist in clinical decision making to provide the best individualized treatment.
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Affiliation(s)
- M Cristina Polidori
- Ageing Clinical Research, Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany. .,Cologne Excellence Cluster On Cellular Stress-Responses in Aging-Associated Diseases (CECAD), University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.
| | - Mariana Alves
- Serviço de Medicina III, Hospital Pulido Valente, CHULN, Lisbon, Portugal.,Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Gulistan Bahat
- Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Capa, 34390, Istanbul, Turkey
| | - Anne Sophie Boureau
- Department of Geriatrics, CHU Nantes and Université de Nantes, CNRS, INSERM, l'Institut du Thorax, 44000, Nantes, France
| | - Serdar Ozkok
- Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Capa, 34390, Istanbul, Turkey
| | - Roman Pfister
- Department of Cardiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Alberto Pilotto
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, Galliera Hospital, Genoa, Italy.,Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Nicola Veronese
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, Palermo, Italy
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette, Corso Bramante 88, 10126, Turin, Italy
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16
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Kim DH, Pawar A, Gagne JJ, Bessette LG, Lee H, Glynn RJ, Schneeweiss S. Frailty and Clinical Outcomes of Direct Oral Anticoagulants Versus Warfarin in Older Adults With Atrial Fibrillation : A Cohort Study. Ann Intern Med 2021; 174:1214-1223. [PMID: 34280330 PMCID: PMC8453126 DOI: 10.7326/m20-7141] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The role of differing levels of frailty in the choice of oral anticoagulants for older adults with atrial fibrillation (AF) is unclear. OBJECTIVE To examine the outcomes of direct oral anticoagulants (DOACs) versus warfarin by frailty levels. DESIGN 1:1 propensity score-matched analysis of Medicare data, 2010 to 2017. SETTING Community. PATIENTS Medicare beneficiaries with AF who initiated use of dabigatran, rivaroxaban, apixaban, or warfarin. MEASUREMENTS Composite end point of death, ischemic stroke, or major bleeding by frailty levels, defined by a claims-based frailty index. RESULTS In the dabigatran-warfarin cohort (n = 158 730; median follow-up, 72 days), the event rate per 1000 person-years was 63.5 for dabigatran initiators and 65.6 for warfarin initiators (hazard ratio [HR], 0.98 [95% CI, 0.92 to 1.05]; rate difference [RD], -2.2 [CI, -6.5 to 2.1]). For nonfrail, prefrail, and frail persons, HRs were 0.81 (CI, 0.68 to 0.97), 0.98 (CI, 0.90 to 1.08), and 1.09 (CI, 0.96 to 1.23), respectively. In the rivaroxaban-warfarin cohort (n = 275 944; median follow-up, 82 days), the event rate per 1000 person-years was 77.8 for rivaroxaban initiators and 83.7 for warfarin initiators (HR, 0.98 [CI, 0.94 to 1.02]; RD, -5.9 [CI, -9.4 to -2.4]). For nonfrail, prefrail, and frail persons, HRs were 0.88 (CI, 0.77 to 0.99), 1.04 (CI, 0.98 to 1.10), and 0.96 (CI, 0.89 to 1.04), respectively. In the apixaban-warfarin cohort (n = 218 738; median follow-up, 84 days), the event rate per 1000 person-years was 60.1 for apixaban initiators and 92.3 for warfarin initiators (HR, 0.68 [CI, 0.65 to 0.72]; RD, -32.2 [CI, -36.1 to -28.3]). For nonfrail, prefrail, and frail persons, HRs were 0.61 (CI, 0.52 to 0.71), 0.66 (CI, 0.61 to 0.70), and 0.73 (CI, 0.67 to 0.80), respectively. LIMITATIONS Residual confounding and lack of clinical frailty assessment. CONCLUSION For older adults with AF, apixaban was associated with lower rates of adverse events across all frailty levels. Dabigatran and rivaroxaban were associated with lower event rates only among nonfrail patients. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Dae Hyun Kim
- Brigham and Women's Hospital, Harvard Medical School, Hebrew SeniorLife, and Beth Israel Deaconess Medical Center, Boston, Massachusetts (D.H.K.)
| | - Ajinkya Pawar
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (A.P., J.J.G., L.G.B., H.L., R.J.G., S.S.)
| | - Joshua J Gagne
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (A.P., J.J.G., L.G.B., H.L., R.J.G., S.S.)
| | - Lily G Bessette
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (A.P., J.J.G., L.G.B., H.L., R.J.G., S.S.)
| | - Hemin Lee
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (A.P., J.J.G., L.G.B., H.L., R.J.G., S.S.)
| | - Robert J Glynn
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (A.P., J.J.G., L.G.B., H.L., R.J.G., S.S.)
| | - Sebastian Schneeweiss
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (A.P., J.J.G., L.G.B., H.L., R.J.G., S.S.)
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Escobar C, Camm AJ. Changing paradigms: from prevention of thromboembolic events to improved survival in patients with atrial fibrillation. Europace 2021; 23:837-843. [PMID: 33221894 DOI: 10.1093/europace/euaa324] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 12/18/2022] Open
Abstract
Atrial fibrillation is associated with a five-fold increase in the risk of stroke. Current guidelines recommend the use of the CHA2DS2-VASc score to stratify the risk of stroke. In addition, guidelines recommend the identification of the conditions that increase the risk of haemorrhage to be modified and thus decrease the risk of bleeding. Nevertheless, many patients with a high thromboembolic risk are prescribed antiplatelet treatment or do not receive any antithrombotic therapy. In addition, therapeutic inertia is common in anticoagulated patients taking vitamin K antagonists, and underdosing is an emerging problem with direct oral anticoagulants, probably because many physicians consider the risk of stroke and the risk of major bleeding to be equal. It is necessary to develop a new approach to risk stratification, an approach that moves from morbidity to mortality, i.e., from stratification of the risk of stroke and major bleeding to stratification of the risk of mortality associated with stroke and the risk of mortality associated with bleeding. In this article, we propose a novel risk stratification approach based on the mortality associated with stroke and bleeding, illustrated by data derived from the literature.
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Affiliation(s)
- Carlos Escobar
- Cardiology Department, Hospital Universitario La Paz, Madrid, Spain
| | - A John Camm
- Cardiovascular Clinical Academic Group, St. George's University of London, London, UK
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Hupfer M, Gosch M. Anticoagulation in Very Old Patients with Atrial Fibrillation (AVOPA): A Descriptive Observational Study. Drugs Real World Outcomes 2021; 8:603-614. [PMID: 34115332 PMCID: PMC8605956 DOI: 10.1007/s40801-021-00263-6] [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] [Accepted: 05/14/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND In older patients with nonvalvular atrial fibrillation, oral anticoagulation is challenging, especially among very old patients. Even though positive effects of oral anticoagulation have been described in this age group (> 85 years), there is still a high rate of inappropriate dosing. OBJECTIVE This study examines the quality of care for very old hospitalized patients. The aims of this study were to (1) describe the percentage of patients receiving oral anticoagulation at discharge, (2) describe the quality of drug management at discharge, regarding dosing and contraindications, and (3) provide additional data towards establishing a benchmark for the quality of care in very old patients with atrial fibrillation. METHODS This study is a single-center descriptive observational study. The data from 407 patients aged > 85 years who were hospitalized in 2018 with nonvalvular atrial fibrillation were collected retrospectively from the patient charts. The assessment included specific geriatric aspects, such as falls, the Charlson Comorbidity Index, and nursing categorization. RESULTS During hospitalization, the proportion of anticoagulated patients increased from 57.5% (n = 234) to 67.3% (n = 274). We found an increasing trend in the use of direct oral anticoagulants, with an increase from 39.8% (n = 162) to 46.2% (n = 188). Regarding the quality of drug management, 13.8% (n = 56) of the patients were not anticoagulated even in the absence of a recognizable contraindication, whereas a contraindication was ignored in only 0.8% (n = 2 out of 188). Dosing was appropriate among all patients taking rivaroxaban, edoxaban, and dabigatran. The dose of apixaban was not reduced in 23.6% (n = 21 out of 89), although this dose reduction was necessary according to the dose adjustment criteria. An underdose of a direct oral anticoagulant was found in 26.1% of the patients (n = 49 out of 188). CONCLUSIONS Compared to the results reported in the literature, the percentage of very old patients with atrial fibrillation receiving anticoagulants was high. During hospitalization, the proportion of patients receiving a direct oral anticoagulant increased, which was in contrast to the trend in the proportion of patients taking phenprocoumon. Our results could help to find a benchmark for anticoagulation management among hospitalized very old patients.
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Affiliation(s)
- Maximilian Hupfer
- Faculty of Medicine, Paracelsus Medical University Nuremberg, General Hospital Nuremberg, Prof.-Ernst-Nathan-Str. 1, 90419, Nuremberg, Germany.
| | - Markus Gosch
- Faculty of Medicine, Paracelsus Medical University Nuremberg, General Hospital Nuremberg, Prof.-Ernst-Nathan-Str. 1, 90419, Nuremberg, Germany.,Department of Geriatrics, Paracelsus Medical University Nuremberg, General Hospital Nuremberg, Nuremberg, Germany
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19
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Campitelli MA, Bronskill SE, Huang A, Maclagan LC, Atzema CL, Hogan DB, Lapane KL, Harris DA, Maxwell CJ. Trends in Anticoagulant Use at Nursing Home Admission and Variation by Frailty and Chronic Kidney Disease Among Older Adults with Atrial Fibrillation. Drugs Aging 2021; 38:611-623. [PMID: 33880747 DOI: 10.1007/s40266-021-00859-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is relatively common among nursing home residents, and decisions regarding anticoagulant therapy in this setting may be complicated by resident frailty and other factors. OBJECTIVES The aim of this study was to examine trends and correlates of oral anticoagulant use among newly admitted nursing home residents with AF following the approval of direct-acting oral anticoagulants (DOACs). METHODS We conducted a retrospective cohort study of all adults aged > 65 years with AF who were newly admitted to nursing homes in Ontario, Canada, between 2011 and 2018 (N = 36,466). Health administrative databases were linked with comprehensive clinical assessment data captured shortly after admission, to ascertain resident characteristics. Trends in prevalence of anticoagulant use (any, warfarin, DOAC) at admission were captured with prescription claims and examined by frailty and chronic kidney disease (CKD). Log-binomial regression models estimated crude percentage changes in use over time and modified Poisson regression models assessed factors associated with anticoagulant use and type. RESULTS The prevalence of anticoagulant use at admission increased from 41.1% in 2011/2012 to 58.0% in 2017/2018 (percentage increase = 41.1%, p < 0.001). Warfarin use declined (- 67.7%, p < 0.001), while DOAC use increased. Anticoagulant use was less likely among residents with a prior hospitalization for hemorrhagic stroke (adjusted risk ratio [aRR] 0.65, 95% confidence interval [CI] 0.60-0.70) or gastrointestinal bleed (aRR 0.80, 95% CI 0.78-0.83), liver disease (aRR 0.78, 95% CI 0.69-0.89), severe cognitive impairment (aRR 0.89, 95% CI 0.85-0.94), and non-steroidal anti-inflammatory drug (aRR 0.76, 95% CI 0.71-0.81) or antiplatelet (aRR 0.25, 95% CI 0.23-0.27) use, but more likely for those with a prior hospitalization for ischemic stroke or thromboembolism (aRR 1.30, 95% CI 1.27-1.33). CKD was associated with a reduced likelihood of DOAC versus warfarin use in both the early (aRR 0.62, 95% CI 0.54-0.71) and later years (aRR 0.79, 95% CI 0.76-0.83) of our study period. Frail residents were significantly less likely to receive an anticoagulant at admission, although this association was modest (aRR 0.95, 95% CI 0.92-0.98). Frailty was not associated with anticoagulant type. CONCLUSIONS While the proportion of residents with AF receiving oral anticoagulants at admission increased following the approval of DOACs, over 40% remained untreated. Among those treated, use of a DOAC increased, while warfarin use declined. The impact of these recent treatment patterns on the balance between benefit and harm among residents warrant further investigation.
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Affiliation(s)
| | - Susan E Bronskill
- ICES, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | | | | | - Clare L Atzema
- ICES, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - David B Hogan
- Division of Geriatric Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kate L Lapane
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Daniel A Harris
- ICES, Toronto, ON, Canada.,Public Health Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Colleen J Maxwell
- ICES, Toronto, ON, Canada. .,Division of Geriatric Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada. .,Schools of Pharmacy and Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada.
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20
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Calsolaro V, Okoye C, Antognoli R, Dell'Agnello U, Calabrese AM, Monzani F. Long-term effectiveness and safety of anticoagulation therapy in oldest old, frail people with atrial fibrillation. Eur J Intern Med 2021; 86:91-97. [PMID: 33551290 DOI: 10.1016/j.ejim.2021.01.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Atrial Fibrillation (AF) represents a major cause of mortality and morbidity in older people; however, oldest-old frail patients are usually excluded from clinical trials. Aim of the study is to evaluate the impact of oral anticoagulation (OAC) therapy on long-term overall survival and clinically relevant bleedings in a large cohort of hospitalised frail, oldest-old patients with AF. PATIENTS AND METHODS Prospective, observational, cohort study, evaluating patients consecutively hospitalized for acute illnesses in our Geriatrics Unit (January 2013-July 2017). Participants were divided in two groups, AF and sinus rhythm (SR). Besides recording demographic characteristics and clinical history, comprehensive geriatric assessment (CGA) was obtained. RESULTS AF patients [1808/5093 (35.5%), 58.5% women] were older, with higher burden of comorbidity than those with SR. At discharge, HAS-BLED [OR 0.77 (95%CI 0.67-0.90), cognitive impairment [OR 0.92 (95%CI 0.90-0.95)], malnutrition [OR 0.74 (95%CI 0.57-0.97)] and CHA2DS2VASc [OR 1.33 (95%CI 1.20-1.47)] emerged as significant independent predictors of anticoagulant prescription. AF patients showed significantly reduced overall survival (OS) than those with SR (11.4 vs 19.4 months, p<.001). However, anticoagulated AF patients (75.2%) had three-times longer OS than those not anticoagulated (15.0 vs 5.6 months, p<.001), comparable to SR patients after adjustment for potential confounders [HR 1.04 (95%CI 0.99-1.10)]. ED readmittance risk for clinically relevant bleeding did not differ between AF patients receiving or not anticoagulation [HR 1.04 (95%CI 0.76-1.14)] CONCLUSION: anticoagulation therapy was associated with significant increase of long-term OS without increased risk of clinically relevant bleeding. CGA resulted an useful tool in OAC therapy decision-making.
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Affiliation(s)
- Valeria Calsolaro
- Geriatrics Unit, Department of Clinical & Experimental Medicine, Pisa University Hospital, Italy
| | - Chukwuma Okoye
- Geriatrics Unit, Department of Clinical & Experimental Medicine, Pisa University Hospital, Italy
| | - Rachele Antognoli
- Geriatrics Unit, Department of Clinical & Experimental Medicine, Pisa University Hospital, Italy
| | - Umberto Dell'Agnello
- Geriatrics Unit, Department of Clinical & Experimental Medicine, Pisa University Hospital, Italy
| | - Alessia Maria Calabrese
- Geriatrics Unit, Department of Clinical & Experimental Medicine, Pisa University Hospital, Italy
| | - Fabio Monzani
- Geriatrics Unit, Department of Clinical & Experimental Medicine, Pisa University Hospital, Italy.
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21
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Abstract
The prevalence of atrial fibrillation (AF) increases with age, as does the proportion of patients with frailty. AF patients with frailty have a higher risk of stroke than those without frailty, and progressive frailty caused by stroke is also associated with a worse prognosis. Despite this, anticoagulant therapy tends to not be used in frail patients because of the risk of falls and bleeding complications. However, some studies have shown that anticoagulant therapy improves the prognosis in patients with frailty. An accurate assessment of the "net-clinical-benefits" is needed in patients with frailty, with the aim of improving the prognoses of patients with frailty by selecting those who will benefit from anticoagulant therapy and actively reducing the risk of bleeding. A comprehensive intervention that includes a team of doctors and social resources is required. We herein review the effectiveness and bleeding risk associated with anticoagulant therapy in frail patients investigated in clinical studies.
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Affiliation(s)
- Hiroshi Hori
- Division of General Medicine, Department of Comprehensive Medicine 1, Saitama Medical Center, Jichi Medical University, Japan
| | - Takahiko Fukuchi
- Division of General Medicine, Department of Comprehensive Medicine 1, Saitama Medical Center, Jichi Medical University, Japan
| | - Hitoshi Sugawara
- Division of General Medicine, Department of Comprehensive Medicine 1, Saitama Medical Center, Jichi Medical University, Japan
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22
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Alcusky M, Baek J, Tjia J, McManus DD, Lapane KL. Geographic Variation in Anticoagulant Use and Resident, Nursing Home, and County Characteristics Associated With Treatment Among US Nursing Home Residents. J Am Med Dir Assoc 2021; 22:164-172.e9. [PMID: 33357746 PMCID: PMC8092949 DOI: 10.1016/j.jamda.2020.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/01/2020] [Accepted: 10/04/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To quantify geographic variation in anticoagulant use and explore what resident, nursing home, and county characteristics were associated with anticoagulant use in a clinically complex population. DESIGN A repeated cross-sectional design was used to estimate current oral anticoagulant use on December 31, 2014, 2015, and 2016. SETTING AND PARTICIPANTS Secondary data for United States nursing home residents during the period 2014-2016 were drawn from the Minimum Data Set 3.0 and Medicare Parts A and D. Nursing home residents (≥65 years) with a diagnosis of atrial fibrillation and ≥6 months of Medicare fee-for-service enrollment were eligible for inclusion. Residents in a coma or on hospice were excluded. METHODS Multilevel logistic models evaluated the extent to which variation in anticoagulant use between counties could be explained by resident, nursing home, and county characteristics and state of residence. Proportional changes in cluster variation (PCVs), intraclass correlation coefficients (ICCs), and adjusted odds ratios (aORs) were estimated. RESULTS Among 86,736 nursing home residents from 11,860 nursing homes and 1694 counties, 45% used oral anticoagulants. The odds of oral anticoagulant use were 18% higher in 2016 than 2014 (aOR: 1.18; 95% confidence interval: 1.14-1.22). Most states had counties in the highest (51.3-58.9%) and lowest (31.1%-41.4%) deciles of anticoagulant use. Compared with the null model, adjustment for resident characteristics explained one-third of the variation between counties (PCV: 34.8%). The full model explained 65.5% of between-county variation. Within-county correlation was a small proportion (ICC < 2.2%) of total variation. CONCLUSIONS AND IMPLICATIONS In this older adult population at high risk for ischemic stroke, less than half of the residents received treatment with anticoagulants. Variation in treatment across counties was partially attributable to the characteristics of residents, nursing homes, and counties. Comparative evidence and refinement of predictive algorithms specific to the nursing home setting may be warranted.
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Affiliation(s)
- Matthew Alcusky
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.
| | - Jonggyu Baek
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jennifer Tjia
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - David D McManus
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA; Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Kate L Lapane
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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23
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Mailhot T, McManus DD, Waring ME, Lessard D, Goldberg R, Bamgbade BA, Saczynski JS. Frailty, Cognitive Impairment, and Anticoagulation Among Older Adults with Nonvalvular Atrial Fibrillation. J Am Geriatr Soc 2020; 68:2778-2786. [PMID: 32780497 PMCID: PMC8567309 DOI: 10.1111/jgs.16756] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 07/21/2023]
Abstract
BACKGROUND/OBJECTIVES Oral anticoagulation (OAC) is challenging in older patients with nonvalvular atrial fibrillation (NVAF) who are often frail and have cognitive impairment. We examined the characteristics of older NVAF patients associated with higher odds of physical and cognitive impairments. We also examined if these high-risk patients have different OAC prescribing patterns and their satisfaction with treatment because it may impact optimal management of their NVAF. METHODS The patients in the Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF study cohort 2016-2018) had NVAF, were aged 65 and older, and eligible for the receipt of OAC. Measures included frailty (Fried Frailty scale), cognitive impairment (Montreal Cognitive Assessment Battery), OAC prescribing and type (direct oral anticoagulant [DOAC] or vitamin K antagonist [VKA]), depressive symptoms (Patient Health Questionnaire-9), bleeding, stroke risk, and treatment benefit (Anti-Clot Treatment Scale). RESULTS Patients (n = 1,244) were 49% female, aged 76 (standard deviation = 7) years. A total of 14% were frail, and 42% had cognitive impairment. Frailty and cognitive impairment co-occurred in 9%. Odds of having both impairments versus none were higher with depression (odds ratio [OR] = 4.62; 95% confidence interval [CI] = 2.59-8.26), older age (OR = 1.56; 95% CI = 1.29-1.88), lower education (OR = 3.81; 95%CI = 2.13-6.81), race/ethnicity other than non-Hispanic White (OR = 7.94; 95% CI = 4.34-14.55), bleeding risk (OR = 1.43; 95% CI = 1.12-1.81), and stroke risk (OR = 1.35; 95% CI = 1.13-1.62). OAC prescribing was not associated with CI and frailty status. Among patients taking OACs (85%), those with both impairments were more likely to take DOAC than VKA (OR = 1.69; 95% CI = 1.01-2.80). Having both impairments (OR = 1.87; 95% CI = 1.08-3.27) or cognitive impairment (OR = 1.56; 95% CI = 1.09-2.24) was associated with higher odds of reporting lower treatment benefit. CONCLUSION In a large cohort of older NVAF patients, half were frail or cognitively impaired, and 9% had both impairments. We highlight the characteristics of patients who may benefit from cognitive and physical function screenings to maximize treatment and enhance prognosis. Finally, the co-occurrence of impairment was associated with low perceived benefit of treatment that may impede optimal management.
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Affiliation(s)
- Tanya Mailhot
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - David D. McManus
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Molly E. Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Benita A. Bamgbade
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - Jane S. Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
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Incident frailty and cognitive impairment by heart failure status in older patients with atrial fibrillation: the SAGE-AF study. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2020; 17:653-658. [PMID: 33343643 PMCID: PMC7729184 DOI: 10.11909/j.issn.1671-5411.2020.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Atrial fibrillation (AF) and heart failure (HF) frequently co-occur in older individuals. Among patients with AF, HF increases risks for stroke and death, but the associations between HF and incident cognition and physical impairment remain unknown. We aimed to examine the cross-sectional and prospective associations between HF, cognition, and frailty among older patients with AF. Methods The SAGE-AF (Systematic Assessment of Geriatric Elements in AF) study enrolled 1244 patients with AF (mean age 76 years, 48% women) from five practices in Massachusetts and Georgia. HF at baseline was identified from electronic health records using ICD-9/10 codes. At baseline and 1-year, frailty was assessed by Cardiovascular Health Survey score and cognition was assessed by the Montreal Cognitive Assessment. Results Patients with prevalent HF (n = 463, 37.2%) were older, less likely to be non-Hispanic white, had less education, and had greater cardiovascular comorbidity burden and higher CHA2DS2VASC and HAS-BLED scores than patients without HF (all P's < 0.01). In multivariable adjusted regression models, HF (present vs. absent) was associated with both prevalent frailty (adjusted odds ratio [aOR]: 2.38, 95% confidence interval [CI]: 1.64-3.46) and incident frailty at 1 year (aOR: 2.48, 95% CI: 1.37-4.51). HF was also independently associated with baseline cognitive impairment (aOR: 1.60, 95% CI: 1.22-2.11), but not with developing cognitive impairment at 1 year (aOR 1.04, 95%CI: 0.64-1.70). Conclusions Among ambulatory older patients with AF, the co-existence of HF identifies individuals with physical and cognitive impairments who are at higher short-term risk for becoming frail. Preventive strategies to this vulnerable subgroup merit consideration.
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Hauta-Aho M, Teperi S, Korhonen MJ, Bell JS, Farinola N, Johns S, Shakib S, Huupponen R. Frailty and Co-Prescribing of Potentially Interacting Drugs in New Users of Warfarin. Drugs Aging 2020; 37:373-382. [PMID: 32147805 PMCID: PMC7190596 DOI: 10.1007/s40266-020-00755-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Warfarin is underutilised in frail older people because of the fear of bleeding complications. Drug interactions are an independent bleeding risk factor. However, the extent to which potential drug interactions are taken into account at warfarin therapy initiation in frail patients is not known. Objective The objective of this study was to investigate the use of potentially interacting drugs increasing the bleeding risk before and after warfarin initiation in frail and non-frail patients. Methods We conducted an observational study including inpatients aged ≥ 60 years initiated on warfarin in a tertiary hospital in Adelaide, South Australia. Frailty status was assessed with the Reported Edmonton Frail Scale. Medication charts were reviewed before and after warfarin initiation. Results In total, 151 patients (102 non-frail and 49 frail) were included. Before warfarin initiation, the use of clopidogrel and acetaminophen was more common in frail patients compared with non-frail patients (25.5% vs 10.2%, p = 0.0135, 63.8% vs 35.7% p = 0.0014, respectively). The use of non-steroidal anti-inflammatory drugs, 9.2% in non-frail patients and 6.4% in frail patients before warfarin initiation, was completely stopped after warfarin initiation in both groups. The use of antiplatelet drugs decreased from 56.1% in non-frail patients and 66.0 % in frail patients to 12.2% and 14.9%, respectively. Instead, the use of drugs affecting the metabolism of warfarin or vitamin K increased in both groups. No statistically significant difference was seen in the exposure to interacting drugs between study groups after warfarin initiation. Acetaminophen, senna glycosides and cytochrome P450 2C9 inhibiting drugs were the most common interacting drugs at discharge used in 49.0%, 18.4% and 20.4% of non-frail patients and 53.2%, 29.8% and 19.1% of frail patients, respectively. Conclusions The overall frequency of potential drug interactions was moderate and frail patients were not exposed to warfarin drug interactions more often than non-frail patients. Further studies in larger study populations are required to verify these results. Electronic supplementary material The online version of this article (10.1007/s40266-020-00755-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Milka Hauta-Aho
- Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, University of Turku, Kiinamyllynkatu 10, 20014, Turku, Finland. .,Clinical Pharmacology Unit, Turku University Hospital, Turku, Finland. .,Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA, Australia.
| | - Simo Teperi
- Department of Biostatistics, University of Turku, Turku, Finland
| | - Maarit J Korhonen
- Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, University of Turku, Kiinamyllynkatu 10, 20014, Turku, Finland.,Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Melbourne, VIC, Australia
| | - J Simon Bell
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Melbourne, VIC, Australia.,NHMRC Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, SA, Australia
| | - Nicholas Farinola
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Sally Johns
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Sepehr Shakib
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA, Australia.,Department of Clinical Pharmacology, Faculty of Health Science, University of Adelaide, Adelaide, SA, Australia
| | - Risto Huupponen
- Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, University of Turku, Kiinamyllynkatu 10, 20014, Turku, Finland.,Clinical Pharmacology Unit, Turku University Hospital, Turku, Finland
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26
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Shah SJ, Fang MC, Jeon SY, Gregorich SE, Covinsky KE. Geriatric Syndromes and Atrial Fibrillation: Prevalence and Association with Anticoagulant Use in a National Cohort of Older Americans. J Am Geriatr Soc 2020; 69:349-356. [PMID: 32989731 DOI: 10.1111/jgs.16822] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/14/2020] [Accepted: 08/16/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although guidelines recommend focusing primarily on stroke risk to recommend anticoagulants in atrial fibrillation (AF), physicians report that geriatric syndromes (e.g., falls and disability) are important when considering anticoagulants. Little is known about the prevalence of geriatric syndromes in older adults with AF or the association with anticoagulant use. METHODS We performed a cross-sectional analysis of the 2014 Health and Retirement Study, a nationally representative study of older Americans. Participants were asked questions to assess domains of aging, including function, cognition, and medical conditions. We included participants 65 years and older with 2 years of continuous Medicare enrollment who met AF diagnosis criteria by claims codes. We examined five geriatric syndromes: one or more falls within the last 2 years, receiving help with activities of daily living (ADLs) or instrumental ADLs (IADL), experienced incontinence, and cognitive impairment. We determined the prevalence of geriatric syndromes and their association with anticoagulant use, adjusting for ischemic stroke risk (i.e., CHA2 DS2 -VASc score [congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, and sex]). RESULTS In this study of 779 participants with AF (median age = 80 years; median CHA2 DS2 -VASc score = 4), 82% had one or more geriatric syndromes. Geriatric syndromes were common: 49% reported falls, 38% had ADL impairments, 42% had IADL impairments, 37% had cognitive impairments, and 43% reported incontinence. Overall, 65% reported anticoagulant use; guidelines recommend anticoagulant use for 97% of participants. Anticoagulant use rate decreased for each additional geriatric syndrome (average marginal effect = -3.7%; 95% confidence interval = -1.4% to -5.9%). Lower rates of anticoagulant use were reported in participants with ADL dependency, IADL dependency, and dementia. CONCLUSION Most older adults with AF had at least one geriatric syndrome, and geriatric syndromes were associated with reduced anticoagulant use. The high prevalence of geriatric syndromes may explain the lower than expected anticoagulant use in older adults.
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Affiliation(s)
- Sachin J Shah
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Margaret C Fang
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sun Y Jeon
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Steven E Gregorich
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Kenneth E Covinsky
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
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Shanah L, Kabashneh S, Alkassis S, Ali H, Mir T. Use of Anticoagulants in Patients With Non-Valvular Atrial Fibrillation Who Are at Risk of Falls. Cureus 2020; 12:e10336. [PMID: 33052296 PMCID: PMC7546592 DOI: 10.7759/cureus.10336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Atrial fibrillation (AF) is a relatively common clinical entity with significant morbidity and mortality, particularly in the elderly. Stroke is one of the most significant complications of AF, which can be prevented with the use of anticoagulation. Elder population are at an increased risk of falls and the use of anticoagulation in this group can lead to intracranial hemorrhage. Therefore, it is unclear whether patients at high risk of falls should be anticoagulated. This review article discusses the epidemiology of AF and falls in the elder population, and whether the benefit of anticoagulation outweighs the risks in this group.
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Affiliation(s)
- Layla Shanah
- Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, USA
| | - Sohaip Kabashneh
- Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, USA
| | - Samer Alkassis
- Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, USA
| | - Hammad Ali
- Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, USA
| | - Tanveer Mir
- Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, USA
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Mlynarska A, Mlynarski R, Marcisz C, Golba KS. Modified Frailty as a Novel Factor in Predicting the Maintenance of the Sinus Rhythm After Electrical Cardioversion of Atrial Fibrillation in the Elderly Population. Clin Interv Aging 2020; 15:1193-1199. [PMID: 32764905 PMCID: PMC7381784 DOI: 10.2147/cia.s255853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 06/13/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction Frailty is a common geriatric syndrome that causes an elevated risk of catastrophic declines in the health and function among older adults – we hypothesized that frailty may be related to the maintenance of sinus rhythm after cardioversion. Methods The study sample was a group of 199 consecutive patients over 60 (average age 71.41 ± 6.99; 40.2% women) with AF who were hospitalized in order to perform electrical cardioversion. The Tilburg Frailty Indicator (TFI) was used to assess frailty before cardioversion. The six-month visit after the electrical cardioversion was a follow-up. The follow-up period for the maintenance of sinus rhythm after electrical cardioversion was 180 ± 14 days. Results Patients in whom cardioversion was effective had a statistically significantly lower severity of frailty syndrome (3.44 ± 1.83 vs 5.87 ± 1.12; p=0.000) and its components: physical components (2.14 ± 1.33 vs 3.62 ± 1.05 p=0.000); emotional components (0.92 ± 0.79 vs 1.29 ± 0.86 p=0.037) and social components (0.37 ± 0.56 vs 0.96 ± 0.46; p=0.000) compared to those patients in which cardioversion was ineffective. In the logistic regression, frailty (OR: 0.65, 95% CI:0.5010–0.8330; p=0.000) was observed to be an independent predictor for maintaining sinus rhythm. Conclusion Frailty is a novel, independent factor that can be used to predict the effectiveness of electrical cardioversion and the maintenance of sinus rhythm in the elderly population. Modifying the level of recognition in the Tilburg Frailty Indicator to a 4 improved the prediction of the effectiveness of electrical cardioversion as well as the maintenance of sinus rhythm.
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Affiliation(s)
- Agnieszka Mlynarska
- Department of Gerontology and Geriatric Nursing, School of Health Sciences, Medical University of Silesia, Katowice, Poland.,Department of Electrocardiology, Upper Silesian Heart Centre, Katowice, Poland
| | - Rafal Mlynarski
- Department of Electrocardiology, Upper Silesian Heart Centre, Katowice, Poland.,Department of Electrocardiology and Heart Failure, School of Health Sciences, Medical University of Silesia, Katowice, Poland
| | - Czeslaw Marcisz
- Department of Gerontology and Geriatric Nursing, School of Health Sciences, Medical University of Silesia, Katowice, Poland
| | - Krzysztof S Golba
- Department of Electrocardiology, Upper Silesian Heart Centre, Katowice, Poland.,Department of Electrocardiology and Heart Failure, School of Health Sciences, Medical University of Silesia, Katowice, Poland
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De Simone V, Mugnolo A, Zanotto G, Morando G. Direct oral anticoagulants for patients aged over 80 years in nonvalvular atrial fibrillation: the impact of frailty. J Cardiovasc Med (Hagerstown) 2020; 21:562-569. [PMID: 32520853 DOI: 10.2459/jcm.0000000000000986] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS In patients aged at least 80 years, atrial fibrillation is responsible for significant morbidity and mortality, with a high incidence of stroke. Four new direct oral anticoagulants (DOACs) have been introduced in Italy for the prevention of thromboembolism. Their safety and efficacy in the elderly have already been confirmed. Frailty is frequently associated with aging, but only a few studies have paid attention to interactions between frailty and anticoagulation therapy. METHODS We retrospectively evaluated the effectiveness and safety of DOACs in a population aged at least 80 years. Frailty was appraised using an adaptation of the Reported Edmonton Frail Scale, considering a value at least 8 (on a scale from 0 to 18). RESULTS The majority (644/731) of patients remained on DOACs for more than 1 year. A total of 19 patients experienced a thrombotic event while on anticoagulation (1.11 events per 100 person-years) and 26 patients a major bleeding episode (1.52 events per 100 person-years). The probability of interrupting therapy increased significantly with frailty [hazard ratio 2.91 with confidence interval (CI) 2.15-3.92 at univariate analysis, hazard ratio 2.80 with CI 2.03-3.86 at multivariate]; frailty showed a significant impact also on major bleeding (hazard ratio 3.28 with CI 1.45-7.37 at univariate analysis, hazard ratio 3.56 with CI 1.58-8.01 at multivariate). CONCLUSION Our study highlights how DOACs are a safe and effective option for anticoagulation, even in frail elderly people; the introduction of these drugs is leading to an increased use of anticoagulation therapy in this population. Prospective trials will be needed to reinforce these results and to consider new variables in the thrombotic and hemorrhagic risk scores underlying the prescription of DOACs.
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Affiliation(s)
- Vincenzo De Simone
- Department of Cardiology, Mater Salutis Hospital, Legnago, Verona, Italy
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30
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Fernández CS, Gullón A, Formiga F. The problem of underdosing with direct-acting oral anticoagulants in elderly patients with nonvalvular atrial fibrillation. J Comp Eff Res 2020; 9:509-523. [PMID: 32329353 DOI: 10.2217/cer-2019-0197] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Unless contraindicated, anticoagulant therapy should be prescribed to elderly patients with atrial fibrillation. Direct-acting oral anticoagulants (DOACs) are superior to vitamin K antagonists for preventing stroke. This, together with their higher net clinical benefit, makes DOACs the treatment of choice in this population. However, due to the concerns about bleeding and the need for dose adjustment based on clinical variables, underdosing of DOACs is common and the risk of stroke high. Drugs with more easily adjusted doses are likely associated with a lower risk of dosing errors and, therefore, a greater protective effect. Correct dosing can ensure a maximal net benefit of DOACs in elderly patients with atrial fibrillation.
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Affiliation(s)
| | - Alejandra Gullón
- Servicio de Medicina Interna, Hospital Universitario de La Princesa, Madrid, Spain
| | - Francesc Formiga
- Unidad de Geriatría, Servicio de Medicina Interna, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
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31
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Formiga F, Polo J, Fernández de Cabo S, Arumí D. Why are antithrombotic drugs not prescribed to octogenarian patients with atrial fibrillation at risk of stroke? Semergen 2020; 46:392-399. [PMID: 32234282 DOI: 10.1016/j.semerg.2020.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 01/22/2020] [Accepted: 02/11/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE In non-valvular atrial fibrillation (NVAF) patients at risk of stroke, anticoagulant drugs are less likely to be received by older patients than younger patients. In this study, an attempt is made to discover whether the reasons reported by physicians for denying anticoagulant drugs prescription differ between older and younger atrial fibrillation patients. MATERIALS AND METHODS A retrospective, cross-sectional, multicentre study was conducted from October 2014 to July 2015. The study comprised patients aged ≥18 years diagnosed with NVAF, with a moderate to high stroke risk (CHADS2 score ≥2). Patients were stratified according to age (<80 and ≥80 years). RESULTS A total of 1309 NVAF patients were evaluated, of whom 40.1% were ≥80 years old. Older patients were predominantly women with higher mean time since diagnosis of AF, with a higher rate of permanent NVAF, and with higher thromboembolic risk. In patients for whom physicians decided not to prescribe any anticoagulant agents, the following reasons were significantly more frequent in patients aged ≥80 years compared to younger patients: cognitive impairment, perceived high bleeding risk, falls, difficult access to monitoring, non-neoplastic terminal illness, and perceived low thromboembolic risk. Uncontrolled hypertension was a significantly more frequent reason for non-prescription of anticoagulant agents in patients aged <80 year. CONCLUSIONS Octogenarian patients with NVAF and a moderate to high risk of stroke had a different as regards reasons for not being prescribed anticoagulant agents, which should be taken into account in order to improve.
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Affiliation(s)
- F Formiga
- Internal Medicine Service of the Hospital Universitari de Bellvitge, IDIDELL, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - J Polo
- Cañaveral Health Center, Cáceres, Spain
| | | | - D Arumí
- Medical Department, Pfizer, Madrid, Spain
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Ehrlinder H, Orsini N, Modig K, Hofman-Bang C, Wallén H, Gigante B. Clinical characteristics and antithrombotic prescription in elderly hospitalized atrial fibrillation patients: A cross-sectional analysis of a Swedish single-center clinical cohort. IJC HEART & VASCULATURE 2020; 27:100505. [PMID: 32258363 PMCID: PMC7114891 DOI: 10.1016/j.ijcha.2020.100505] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/27/2020] [Accepted: 03/18/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Antithrombotic treatment represents a dilemma in elderly patients with atrial fibrillation since both risk of thromboembolism and bleeding are age-dependent complications. A paradigm shift occurred over the past 10 years when aspirin was overcome by warfarin and further by the direct oral anticoagulants. Here we present a clinical practice-based analysis of a cohort of elderly inpatient atrial fibrillation patients and investigate the influence of clinical factors in the choice of antithrombotic strategy. METHODS Study participants (n = 2943) are consecutive patients aged 75-104 years discharged from a Swedish university hospital with atrial fibrillation or atrial flutter as main diagnosis between November 1st 2010 and December 31st 2017. Cardiovascular risk factors, comorbidities and antithrombotic treatment at discharge were manually extracted from medical charts. A logistic regression analysis was performed to estimate predictors of the probability to receive direct oral anticoagulants (DOACs) compared to warfarin. RESULTS Patients aged ≥90 y (n = 446, women 73%) showed the highest prevalence of cardiovascular comorbidities and the highest bleeding and thromboembolic risk. DOACs became more commonly prescribed than warfarin in 2016/2017 across all ages. However, the probability to receive DOAC as compared to warfarin was lower in the presence of high bleeding risk (OR 0,55; 95% CI 0,40-0,77; p = 0,00) and high thromboembolic risk (OR 0,74; 95% CI 0,59-0,94; p = 0,01). CONCLUSION Elderly atrial fibrillation patients represent a heterogenous group where the oldest (≥90 years) show both a very high thromboembolic and bleeding risk profile. In the presence of high thromboembolic and bleeding risk, warfarin was still preferred over DOAC.
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Affiliation(s)
- Hanne Ehrlinder
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Nicola Orsini
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Karin Modig
- Unit of Epidemiology. Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Claes Hofman-Bang
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Wallén
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Bruna Gigante
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
- Cardiovascular Medicine Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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33
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Bernaitis N, Bowden M, La Caze A. A clinical audit of oral anticoagulant therapy in aged care residents with atrial fibrillation. Int J Clin Pharm 2020; 42:474-481. [DOI: 10.1007/s11096-020-01025-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 04/01/2020] [Indexed: 11/30/2022]
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Casagranda I, Ungar A, Prevaldi C, Abete P, Biagioni S, Del Rosso A, Diamanti M, Fanciulli A, Fumagalli S, Furlan R, Lerza R, Locatelli C, Maggi R, Mussi C, Numeroso F, Rabajoli F, Testa S, Tomaino M, Brignole M. Anticoagulation therapy in older patients at risk for syncopal and not-syncopal fall and/or frailty. An AcEMC-GIMSI multidisciplinary consensus document. EMERGENCY CARE JOURNAL 2020. [DOI: 10.4081/ecj.2020.8838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
In aged patients, the most frequent indications for anticoagulation are atrial fibrillation (AF) and venous thromboembolism for stroke and systemic embolism prevention. Despite systemic anticoagulation recommended by current guidelines for patients over 65 years, in clinical practice up to 50 % of elderly patients do not receive maintenance anticoagulation therapy. This is particularly evident in frail subjects at risk of syncopal and not-syncopal fall, fearing intracranial bleeding following a fall. As the risk of bleeding associated with falls is still debated, the boards of the Academy of Emergency Medicine and Care (AcEMC) and the Italian Multidisciplinary Working Group on Syncope (GIMSI), in order to write a consensus document, submitted to a panel of experts eight statement which could represent as many controversial topics for anticoagulant prescription in patients over 75 years. The Delphi method was used to obtain consensus between 15 physicians from different medical specialties; some of them were expert in syncope management and worked in a Syncope Unit. All had experience in prescribing oral anticoagulation. A questionnaire was sent on the appropriateness of oral anticoagulation in eight clinical situations where the risk of fall is present (frailty, cognitive impairment, previous falls, absence of caregiver, chronic renal impairment, nonvalvular AF with HAS-BLED score ≥3 or CHA2DS2-VASc score ≥3). All experts completed the questionnaire within three rounds and the consensus was reached on many but not all statements, leaving room for debate on some clinical situations. The consensus document gives useful advice for elderly patients’ management, who need oral anticoagulant therapy but are at risk of syncopal or not-syncopal fall. Nonetheless, there are some unresolved issues where an individual decision should be taken by the physician in agreement with the patient.
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35
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Ceccofiglio A, Fumagalli S, Mussi C, Mossello E, Bo M, Martone AM, Bellelli G, Nicosia F, Riccio D, Langellotto A, Tava G, Boccardi V, Tonon E, Abete P, Ungar A. Atrial Fibrillation in Older Patients with Syncope and Dementia: Insights from the Syncope and Dementia Registry. J Am Med Dir Assoc 2020; 21:1238-1242. [PMID: 32179002 DOI: 10.1016/j.jamda.2020.01.110] [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: 09/18/2019] [Revised: 01/22/2020] [Accepted: 01/26/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate the clinical characteristics and the long-term outcome of atrial fibrillation (AF) patients with dementia and history of syncope or falls. DESIGN Observational: analysis of a prospective registry. SETTING AND PARTICIPANTS Between 2012 and 2016, the Syncope and Dementia Registry enrolled patients in 12 geriatric departments. Follow-up evaluation was at 12 months. MEASURES Clinical, functional, and cognitive assessment. RESULTS Of the 522 patients (women, 62.1%; Mini-Mental State Examination 17 ± 6), 26.4% have or presented an AF history. Patients with AF were older (85 ± 6 vs 83 ± 6 years, P = .012), with higher heart rate (78 ± 17 vs. 73 ± 14 bpm, P < .001), prescribed drugs (6.9 ± 2.9 vs 5.9 ± 2.7, P < .001), and an increased number (3.9 ± 2.0 vs 3.0 ± 1.8, P < .001) and severity of comorbidities. Oral anticoagulant therapy was underprescribed (39.9%). Cardiac syncope was more frequently diagnosed (18.8 vs 4.9%, P < .001). At multivariate analysis, AF patients were characterized by advanced age, a higher severity of comorbidities, a greater number of prescribed drugs, an increased heart rate, and a more frequent presence of cardiac symptoms. One-year mortality differed little between patients with and without AF (27.7 vs 22.1%, P = .229). In the arrhythmia group, multivariate predictors of prognosis were disability (number of lost BADLs; P = .020) and a higher heart rate (P = .006). CONCLUSIONS AND IMPLICATIONS AF and postural stability-related issues often co-exist in persons with dementia. This complex of conditions is associated with an intricate clinical picture, underprescription of oral anticoagulants, and high long-term mortality. Future studies are needed to evaluate the effects of therapy optimization in this population.
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Affiliation(s)
- Alice Ceccofiglio
- Department of Medicine and Geriatrics, Careggi Hospital and University of Florence, Florence, Italy
| | - Stefano Fumagalli
- Department of Medicine and Geriatrics, Careggi Hospital and University of Florence, Florence, Italy.
| | - Chiara Mussi
- Centro di Valutazione e Ricerca Gerontologica, Chair of Geriatrics, University of Modena and Reggio Emilia, Modena, Italy
| | - Enrico Mossello
- Department of Medicine and Geriatrics, Careggi Hospital and University of Florence, Florence, Italy
| | - Mario Bo
- SCDU Geriatria e Malattie Metaboliche dell'Osso, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Anna Maria Martone
- Department of Geriatrics, Neurosciences and Orthopedics, Catholic University of the Sacred Heart, Rome, Italy
| | - Giuseppe Bellelli
- Department of Health Sciences, University of Milano Bicocca and Acute Geriatric Unit, San Gerardo Hospital, Monza, Italy
| | - Franco Nicosia
- Medicine and Geriatric Unit, Spedali Civili of Brescia, Brescia, Italy
| | - Daniela Riccio
- Geriatric Department, SS. Trinità Hospital, Cagliari, Italy
| | | | - Gianni Tava
- Geriatric Unit, Santa Chiara Hospital, Trento, Italy
| | - Virginia Boccardi
- Institute of Gerontology and Geriatrics, Department of Medicine, University of Perugia, S. Maria della Misericordia Hospital, Perugia, Italy
| | | | - Pasquale Abete
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Andrea Ungar
- Department of Medicine and Geriatrics, Careggi Hospital and University of Florence, Florence, Italy
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Comprehensive Geriatric Assessment in Cardiovascular Disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1216:87-97. [PMID: 31894550 DOI: 10.1007/978-3-030-33330-0_10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Frailty and cardiovascular disease (CVD) are both highly prevalent in older adults. Cardiovascular disease has been identified as the most frequent cause of death, while frailty has been identified as one of geriatric giants characterized by decreased physiological reserves and increased vulnerability. However, the exact pathobiological links between the two conditions have not been fully elucidated. Consequently, we observe a relevant difficulty not only in accurately defining cardiovascular risk in vulnerable elderly patients (and the other way around), but also a lack of consensus regarding CVD management in the very old. Nowadays, considering the enormous technical innovation, many elderly patients, if appropriately selected, could be eligible even for the most complex treatments, including invasive cardiological procedures. Identification of frail patients at risk of negative outcomes can allow the customization of therapeutic interventions in elderly patients with CVD, allowing the elderly who can benefit from them to undergo even invasive procedures and avoiding futile or dangerous treatments for the most vulnerable patients. A large number of tools and definitions for assessing frailty have been proposed; different scales and assessment tools can be useful for different purposes, but at present there is no clear indication for their use in CVD. In this chapter, we will describe the main geriatric approach to ascertain frailty, the assessment tools used in patients with cardiovascular diseases, and propose an operational strategy to evaluate frailty and identify patients eligible for pharmacologic or surgical interventions.
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Krivoshapova KE, Vegner EA, Barbarash OL. [Frailty syndrome. What physicians and cardiologists need to know?]. TERAPEVT ARKH 2020; 92:62-68. [PMID: 32598665 DOI: 10.26442/00403660.2020.01.000279] [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: 04/16/2020] [Indexed: 11/22/2022]
Abstract
The review presents the data and evidences from recent clinical studies on the frailty syndrome - one of the most relevant clinical syndromes, though not studied well yet. The latest data on the prevalence of frailty and various factors contributing to its onset are reported. The presence of frailty is considered as an independent predictor of poor prognosis and high mortality rate. The role of frailty in the development of cardiovascular diseases, their progression and complicated course has been analyzed using the latest studies. In addition, the tendency towards higher incidence of frailty among the population of different countries and the poor prognosis of frail patients requires a series of clinical studies aimed at developing measures for primary and secondary prevention, as well as effective treatment strategies for frailty. The PubMed was used for a literature review.
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Affiliation(s)
- K E Krivoshapova
- Federal State Budgetary Institution "Research Institute for Complex Issues of Cardiovascular Disease"
| | - E A Vegner
- Federal State Budgetary Educational Institution of Higher Education "Kemerovo State Medical University"
| | - O L Barbarash
- Federal State Budgetary Institution "Research Institute for Complex Issues of Cardiovascular Disease".,Federal State Budgetary Educational Institution of Higher Education "Kemerovo State Medical University"
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38
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Liu J, Du X, Li M, Jia Z, Lu S, Chang S, Tang R, Bai R, Dong J, Lip GYH, Ma C. Frailty and Anticoagulant Therapy in Patients Aged 65 Years or Older with Atrial Fibrillation. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2020. [DOI: 10.15212/cvia.2019.0562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Elderly adults with atrial fibrillation (AF) are at increased risk of frailty and thromboembolic complications. However, studies on the prevalence of frailty in AF patients and data on the relationship between frailty and the use of anticoagulants are limited.Methods:
We conducted a cross-sectional study involving 500 participants. Patients aged 65 years or older were consecutively selected from the Chinese Atrial Fibrillation Registry study. The patient’s frailty status was assessed with use of the Canadian Study of Health and Aging Clinical Frailty
Scale. We assessed the prevalence of and factors associated with frailty, and how frailty affects anticoagulant therapy.Results: In 500 elderly adults with AF (age 75.2±6.7 years; 51.6% female), 201 patients (40.2%) were frail. The prevalence of frailty was higher in females
(P=0.002) and increased with age and CHA2DS2-VASc score (P for trend less than 0.001 for both). The factors associated with frailty were a history of heart failure (odds ratio [OR] 2.40, 95% confidence interval [CI] 1.39‐4.14), female sex (OR 2.09, 95% CI 1.27‐3.43),
and advanced age (OR 1.13, 95% CI 1.09‐1.17). Frail patients were significantly less likely to have ever been prescribed anticoagulants compared with nonfrail patients (81.7 vs. 54.9%, P<0.001).Conclusions: Frailty is prevalent in elderly adults with AF, especially in
females, those of advanced age, and those with heart failure. Frailty status has a significant impact on prescription of anticoagulants for high-risk AF patients.
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Affiliation(s)
- Jiapeng Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Mengmeng Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Zhaoxu Jia
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Shangxin Lu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Sanshuai Chang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Ribo Tang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Rong Bai
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Jianzeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
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Bo M, Marchionni N. Practical use of Direct Oral Anti Coagulants (DOACs) in the older persons with atrial fibrillation. Eur J Intern Med 2020; 71:32-38. [PMID: 31740104 DOI: 10.1016/j.ejim.2019.10.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/16/2019] [Accepted: 10/22/2019] [Indexed: 02/06/2023]
Abstract
Direct Oral Anticoagulants (DOACs) consistently demonstrated a greater net clinical benefit compared to Vitamin K Antagonists (VKAs) also in persons aged 75 years and over, who account for the largest proportion of AF patients; however, major uncertainties in DOACs prescription have to do with this age group. In this review, persistent uncertainties and implications of frailty and geriatric syndromes on DOACs prescription, and practical use of DOACs in real-world older persons, and will be discussed.
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Affiliation(s)
- Mario Bo
- Section of Geriatric, Department of Medical Sciences, AOU Città della Salute e della Scienza, Molinette, Turin, Italy.
| | - Niccolò Marchionni
- University of Florence, Head, Division of General Cardiology, Director, Cardiothoracovascular Department, AOU Careggi, Florence, Italy
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40
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Shinohara M, Wada R, Yao S, Yano K, Akitsu K, Koike H, Kinoshita T, Yuzawa H, Suzuki T, Fujino T, Ikeda T. Evaluation of oral anticoagulants in atrial fibrillation patients over 80 years of age with nonsevere frailty. J Arrhythm 2019; 35:795-803. [PMID: 31844468 PMCID: PMC6898529 DOI: 10.1002/joa3.12231] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 07/23/2019] [Accepted: 08/15/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The safety and efficacy of an oral anticoagulant (OAC) treatment and the difference between direct OACs (DOACs) and warfarin in nonsevere frail elderly patients with AF are unclear. METHODS This was a retrospective and observational study of 354 patients over 80 years of age with nonsevere frailty who were diagnosed with AF and treated with OACs. Nonsevere frailty was defined as a clinical frailty scale score of <7. Bleeding and thromboembolic events during the OAC treatment were followed up. RESULTS Of 354 patients enrolled, 273 (77.1%) received DOACs and 81 (22.9%) received warfarin. Of 273 patients receiving DOACs, there were 210 (76.9%) prescribed with appropriate doses of DOACs. Of 81 warfarin-treated patients, 53 (65.4%) were prescribed an appropriate dose of warfarin. During a follow-up of 33.1 (14.0-51.0) months, 15 patients (1.5/100 person-years) had bleeding events and 10 (1.0/100 person-years) had thromboembolic events while on an OAC treatment. The incidence ratio of bleeding events in patients receiving DOACs was lower than that in those receiving warfarin (1.0/100 person-years vs 2.9/100 person-years, hazard ratio [HR]: 0.26, 95% confidence interval [CI]: 0.07-0.91, P = .036). There was no significant difference in the incidence of thromboembolic events between the DOAC and warfarin treatment groups (0.88/100 person-years vs 1.4/100 person-years, HR: 0.63, 95% CI: 0.16-2.57, P = .52). CONCLUSIONS OACs are substantially safe and effective for preventing thromboembolic events in nonsevere frail patients over 80 years of age. Particularly, DOACs can be used more safely than warfarin.
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Affiliation(s)
- Masaya Shinohara
- Department of Cardiovascular MedicineToho University Graduate School of MedicineTokyoJapan
| | - Ryou Wada
- Department of Cardiovascular MedicineToho University Graduate School of MedicineTokyoJapan
| | - Shintaro Yao
- Department of Cardiovascular MedicineToho University Graduate School of MedicineTokyoJapan
| | - Kensuke Yano
- Department of Cardiovascular MedicineToho University Graduate School of MedicineTokyoJapan
| | - Katsuya Akitsu
- Department of Cardiovascular MedicineToho University Graduate School of MedicineTokyoJapan
| | - Hideki Koike
- Department of Cardiovascular MedicineToho University Graduate School of MedicineTokyoJapan
| | - Toshio Kinoshita
- Department of Cardiovascular MedicineToho University Graduate School of MedicineTokyoJapan
| | - Hitomi Yuzawa
- Department of Cardiovascular MedicineToho University Graduate School of MedicineTokyoJapan
| | - Takeya Suzuki
- Department of Cardiovascular MedicineToho University Graduate School of MedicineTokyoJapan
| | - Tadashi Fujino
- Department of Cardiovascular MedicineToho University Graduate School of MedicineTokyoJapan
| | - Takanori Ikeda
- Department of Cardiovascular MedicineToho University Graduate School of MedicineTokyoJapan
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Bean DM, Teo J, Wu H, Oliveira R, Patel R, Bendayan R, Shah AM, Dobson RJB, Scott PA. Semantic computational analysis of anticoagulation use in atrial fibrillation from real world data. PLoS One 2019; 14:e0225625. [PMID: 31765395 PMCID: PMC6876873 DOI: 10.1371/journal.pone.0225625] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 11/09/2019] [Indexed: 12/03/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia and significantly increases stroke risk. This risk is effectively managed by oral anticoagulation. Recent studies using national registry data indicate increased use of anticoagulation resulting from changes in guidelines and the availability of newer drugs. The aim of this study is to develop and validate an open source risk scoring pipeline for free-text electronic health record data using natural language processing. AF patients discharged from 1st January 2011 to 1st October 2017 were identified from discharge summaries (N = 10,030, 64.6% male, average age 75.3 ± 12.3 years). A natural language processing pipeline was developed to identify risk factors in clinical text and calculate risk for ischaemic stroke (CHA2DS2-VASc) and bleeding (HAS-BLED). Scores were validated vs two independent experts for 40 patients. Automatic risk scores were in strong agreement with the two independent experts for CHA2DS2-VASc (average kappa 0.78 vs experts, compared to 0.85 between experts). Agreement was lower for HAS-BLED (average kappa 0.54 vs experts, compared to 0.74 between experts). In high-risk patients (CHA2DS2-VASc ≥2) OAC use has increased significantly over the last 7 years, driven by the availability of DOACs and the transitioning of patients from AP medication alone to OAC. Factors independently associated with OAC use included components of the CHA2DS2-VASc and HAS-BLED scores as well as discharging specialty and frailty. OAC use was highest in patients discharged under cardiology (69%). Electronic health record text can be used for automatic calculation of clinical risk scores at scale. Open source tools are available today for this task but require further validation. Analysis of routinely collected EHR data can replicate findings from large-scale curated registries.
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Affiliation(s)
- Daniel M. Bean
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, England, United Kingdom
- Health Data Research UK London, University College London, London, England, United Kingdom
| | - James Teo
- Department of Stroke and Neurology, King’s College Hospital NHS Foundation Trust, London, England, United Kingdom
| | - Honghan Wu
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Scotland, United Kingdom
- School of Computer and Software, Nanjing University of Information Science and Technology, Nanjing, China
- Health Data Research UK Scotland, Edinburgh, Scotland, United Kingdom
| | - Ricardo Oliveira
- Unidade de Doenças Imunomediadas Sistémicas (UDIMS), S. Medicina IV, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Raj Patel
- Department of Haematology, King’s College Hospital NHS Foundation Trust, London, England, United Kingdom
| | - Rebecca Bendayan
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, England, United Kingdom
- NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London, London, England, United Kingdom
| | - Ajay M. Shah
- British Heart Foundation Centre, King’s College London, London, England, United Kingdom
- Department of Cardiology, King’s College Hospital NHS Foundation Trust, London, England, United Kingdom
| | - Richard J. B. Dobson
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, England, United Kingdom
- Health Data Research UK London, University College London, London, England, United Kingdom
- NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London, London, England, United Kingdom
- Institute of Health Informatics, University College London, London, England, United Kingdom
| | - Paul A. Scott
- British Heart Foundation Centre, King’s College London, London, England, United Kingdom
- Department of Cardiology, King’s College Hospital NHS Foundation Trust, London, England, United Kingdom
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42
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Yavelov IS. [Rivaroxaban in prevention of stroke in elderly patients with non-valvular atrial fibrillation]. ACTA ACUST UNITED AC 2019; 59:4-11. [PMID: 31995720 DOI: 10.18087/cardio.n892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 11/17/2019] [Accepted: 11/17/2019] [Indexed: 11/18/2022]
Abstract
Data regarding efficacy and safety of direct oral anticoagulant rivaroxaban in prevention of stroke in elderly polymorbid patients with non-valvular atrial fibrillation are presented. In this aspect results of randomized clinical trial in direct comparison of rivaroxaban and warfarin in patients with non-valvular atrial fibrillation ROCKET-AF are discussed. Results of rivaroxaban use in elderly patients in real medical practice are also considered.
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Affiliation(s)
- I S Yavelov
- National Medical Research Center for Preventive Medicine of the Ministry of Health of the Russian Federation
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43
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Requena Calleja M, Arenas Miquélez A, Díez-Manglano J, Gullón A, Pose A, Formiga F, Mostaza J, Cepeda J, Suárez C. Sarcopenia, frailty, cognitive impairment and mortality in elderly patients with non-valvular atrial fibrillation. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2019.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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44
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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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45
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Acanfora D, Ciccone MM, Scicchitano P, Ricci G, Acanfora C, Uguccioni M, Casucci G. Efficacy and Safety of Direct Oral Anticoagulants in Patients With Atrial Fibrillation and High Thromboembolic Risk. A Systematic Review. Front Pharmacol 2019; 10:1048. [PMID: 31607911 PMCID: PMC6761253 DOI: 10.3389/fphar.2019.01048] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 08/19/2019] [Indexed: 12/20/2022] Open
Abstract
Background: The aim of the study was to evaluate the efficacy and safety of direct oral anticoagulants (DOACs) in a subgroup of patients with atrial fibrillation (AF), CHADS2 score ≥3, advanced age, and heart failure (HF) coming from the main DOACs randomized clinical trials. Methods: We searched MEDLINE, MEDLINE In-Process, and Other Non-Indexed Citations, EMBASE, PubMed, and the Cochrane Central Register of Controlled Trials. English-language articles published from 2002 to March 2019 dealing with DOACs for preventing thrombotic events in AF were considered. We did not conduct any statistical analyses, as indirect comparison between DOACs represents hypothesis generators. Results: This systematic review was restricted to the subgroup of patients with CHADS2 score ≥3 (n = 31,203), elderly (n = 24,788), and with HF (n = 29,297) derived from the pivotal trials. Risk index (RI) was calculated. The RI for stroke/systemic embolism was similar in all of the patients treated with DOACs or warfarin. The lowest RI was in rivaroxaban patients (CHADS2 score ≥3: RI = 0.04; elderly: RI = 0.09; HF: RI = 0.05). The RIs for bleeding were higher in patients treated with dabigatran (CHADS2 score ≥3: RI110 = 0.23; elderly: RI110 = 0.22; HF: RI110 = 0.16; CHADS2score ≥3: RI150 = 0.30; elderly: RI150 = 0.24; HF: RI150 = 0.16). The bleeding RIs were higher with apixaban (CHADS2 score ≥3: RI = 0.23; elderly: RI = 0.25; HF: RI = 0.14) and dabigatran (CHADS2 score ≥3: RI = 0.28; elderly: RI = 0.21; HF: RI = 0.19). Conclusions: The use of DOACs is a reasonable alternative to vitamin K antagonists in AF patients with CHADS2 score ≥3, advanced age, and HF. The RI constitutes a useful, additional tool to facilitate clinicians in choosing DOACs or warfarin in particular category of AF patients.
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Affiliation(s)
- Domenico Acanfora
- Unit of Internal Medicine, San Francesco Hospital, Telese Terme, Italy
| | - Marco Matteo Ciccone
- Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, School of Medicine, University of Bari, Bari, Italy
| | - Pietro Scicchitano
- Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, School of Medicine, University of Bari, Bari, Italy.,Cardiology Unit, Hospital "F. Perinei" Altamura (BA)-ASL BA, Bari, Italy
| | - Giovanni Ricci
- Unit of Internal Medicine, Cardarelli Hospital, Campobasso, Italy
| | - Chiara Acanfora
- Unit of Internal Medicine, San Francesco Hospital, Telese Terme, Italy
| | | | - Gerardo Casucci
- Unit of Internal Medicine, San Francesco Hospital, Telese Terme, Italy
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46
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Zathar Z, Karunatilleke A, Fawzy AM, Lip GYH. Atrial Fibrillation in Older People: Concepts and Controversies. Front Med (Lausanne) 2019; 6:175. [PMID: 31440508 PMCID: PMC6694766 DOI: 10.3389/fmed.2019.00175] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/19/2019] [Indexed: 12/18/2022] Open
Abstract
Atrial fibrillation (AF) is the commonest cardiac rhythm abnormality and has a significant disease burden. Amongst its devastating complications is stroke, the risk of which increases with age. The stroke risk in an older person with AF is therefore tremendous, and oral-anticoagulation (OAC) therapy is central to minimizing this risk. The presence of age-associated factors such as frailty and multi-morbidities add complexity to OAC prescription decisions in older patients and often, OAC is needlessly withheld from them despite a lack of evidence to support this practice. Generally, this is driven by an over-estimation of the bleeding risk. This review article provides an overview of the concepts and controversies in managing AF in older people, with respect to the existing evidence and current practice. A literature search was conducted on Pubmed and Cochrane using keywords, and relevant articles published by the 1st of May 2019 were included. The article will shed light on common misconceptions that appear to serve as rationale for precluding OAC and focus on clinical considerations that may aid OAC prescription decisions where appropriate, to optimize AF management using an integrated, multi-disciplinary care approach. This is crucial for all patients, particularly older individuals who are most vulnerable to the deleterious consequences of this condition.
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Affiliation(s)
- Zafraan Zathar
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Anne Karunatilleke
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Ameenathul M Fawzy
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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47
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Curtis AB, Karki R, Hattoum A, Sharma UC. Arrhythmias in Patients ≥80 Years of Age: Pathophysiology, Management, and Outcomes. J Am Coll Cardiol 2019; 71:2041-2057. [PMID: 29724357 DOI: 10.1016/j.jacc.2018.03.019] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/12/2018] [Accepted: 03/12/2018] [Indexed: 12/14/2022]
Abstract
Advances in medical care have led to an increase in the number of octogenarians and even older patients, forming an important and unique patient subgroup. It is clear that advancing age is an independent risk factor for the development of most arrhythmias, causing substantial morbidity and mortality. Patients ≥80 years of age have significant structural and electrical remodeling of cardiac tissue; accrue competing comorbidities; react differently to drug therapy; and may experience falls, frailty, and cognitive impairment, presenting significant therapeutic challenges. Unfortunately, very old patients are under-represented in clinical trials, leading to critical gaps in evidence to guide effective and safe treatment of arrhythmias. In this state-of-the-art review, we examine the pathophysiology of aging and arrhythmias and then present the available evidence on age-specific management of the most common arrhythmias, including drugs, catheter ablation, and cardiac implantable electronic devices.
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Affiliation(s)
- Anne B Curtis
- Department of Medicine, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, New York.
| | - Roshan Karki
- Department of Medicine, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Alexander Hattoum
- Department of Medicine, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Umesh C Sharma
- Department of Medicine, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, New York
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48
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Sarcopenia, frailty, cognitive impairment and mortality in elderly patients with non-valvular atrial fibrillation. Rev Clin Esp 2019; 219:424-432. [PMID: 31109685 DOI: 10.1016/j.rce.2019.04.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/20/2019] [Accepted: 04/01/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To determine the prevalence of sarcopenia, frailty and cognitive impairment in elderly patients with nonvalvular atrial fibrillation (NVAF) and the factors' influence on survival. METHODS Prospective, multicentre cohort study of patients older than 75 years with NVAF hospitalised in internal medicine departments in Spain. For each patient, we recorded the creatinine, haemoglobin and platelet levels, the scores on the CHA2DS2-VASc and HAS-BLED scales and Charlson index, as well as the use of oral anticoagulants. We measured sarcopenia with the SARC-F scale, frailty with the FRAIL scale and cognitive impairment with the Short Portable Mental State Questionnaire. We also conducted a 1-year follow-up. RESULTS The study included 596 patients with NVAF, with a mean age of 84.9 (SD: 5.2) years. Of these, 295 (49.5%) presented sarcopenia, 305 (51.2%) presented frailty, and 251 (42.1%) presented cognitive impairment. At the end of 1year, 226 (37.9%) patients had died. Mortality was greater for the patients with sarcopenia, frailty and cognitive impairment. In the multivariate analysis, sarcopenia (HR: 1.775; 95%CI: 1.270-2.481), age, comorbidity and a history of peripheral embolism were associated with increased mortality, and the use of oral anticoagulants at discharge (HR: 0.415; 95%CI: 0.307-0.560) was associated with lower mortality. CONCLUSIONS Sarcopenia, frailty and cognitive impairment are very common in elderly patients with NVAF and are frequently associated. Sarcopenia was associated with increased mortality.
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49
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Prevention and Treatment of Acute Stroke in the Nonagenarians and Beyond: Medical and Ethical Issues. Curr Treat Options Neurol 2019; 21:27. [PMID: 31065827 DOI: 10.1007/s11940-019-0567-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE OF REVIEW As one of the fastest growing portions of the population, nonagenarians will constitute a significant percentage of the stroke patient population in the near future. Nonagenarians are nevertheless not specifically targeted by most clinical guidelines. In this review, we aimed to summarise the available evidence guiding stroke prevention and treatment in this age group. RECENT FINDINGS Several recent observational studies have shown that the benefits of anticoagulation for the oldest old patients with atrial fibrillation may outweigh the bleeding risk. A sub-analysis of the IST-3 trial has shown for the first time that thrombolysis treatment in acute ischaemic stroke may be beneficial and safe even in octogenarian patients and older. Several recent observational studies have assessed thrombolysis in nonagenarians. The latest of these has shown better disability outcomes without increased rates of symptomatic intracerebral haemorrhage with thrombolysis. Nonagenarian stroke patients may benefit from similar preventative and therapeutic strategies as their younger counterparts. A few important exceptions include primary prevention using aspirin or statins. Patient selection is nevertheless essential given the increased adverse event rates. Patient preference should play a key role in the decision-making process. Clinical trials including more nonagenarian patients are required to yield more robust evidence.
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50
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Madhavan M, Holmes DN, Piccini JP, Ansell JE, Fonarow GC, Hylek EM, Kowey PR, Mahaffey KW, Thomas L, Peterson ED, Chan P, Allen LA, Gersh BJ. Association of frailty and cognitive impairment with benefits of oral anticoagulation in patients with atrial fibrillation. Am Heart J 2019; 211:77-89. [PMID: 30901602 DOI: 10.1016/j.ahj.2019.01.005] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 01/15/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND The incidence of cognitive impairment and frailty increase with age and may impact both therapy and outcomes in atrial fibrillation (AF). METHODS We examined the prevalence of clinically recognized cognitive impairment and frailty (as defined by the American Geriatric Society Criteria) in the Outcomes Registry for Better Informed Care in AF (ORBIT AF) and associated adjusted outcomes via multivariable Cox regression. The interaction between cognitive impairment and frailty and oral anticoagulation (OAC) in determining outcomes was examined. RESULTS Among 9749 patients with AF [median (IQR) age 75 (67-82) y, 57% male], cognitive impairment and frailty was identified in 293 (3.0%) and 575 (5.9%) patients respectively. Frail patients (68 vs 77%, P < .001) and those with cognitive impairment (70 vs 77%, P = .006) were both less likely to receive an OAC. Both cognitive impairment [HR (95% CI) 1.34 (1.05-1.72), P = .0198] and frailty [HR 1.29 (1.08-1.55), P = .0060] were associated with increased risk of death. Cognitive impairment and frailty were not associated with stroke/transient ischemic attack (TIA) or major bleeding. In multivariable analysis, there was no interaction between OAC use and cognitive impairment or frailty in their associations with mortality, major bleeding and a composite end point of stroke, non-central nervous system systemic embolism, TIA, myocardial infarction or cardiovascular death. CONCLUSION Those with cognitive impairment or frailty in AF had higher predicted risk for stroke and higher observed mortality, yet were less likely to be treated with OAC. Despite this, the benefits of OAC were similar in patients with and without cognitive impairment or frailty.
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