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Bisson A, M Fawzy A, Romiti GF, Proietti M, Angoulvant D, El-Bouri W, Y H Lip G, Fauchier L. Phenotypes and outcomes in non-anticoagulated patients with atrial fibrillation: An unsupervised cluster analysis. Arch Cardiovasc Dis 2023; 116:342-351. [PMID: 37422421 DOI: 10.1016/j.acvd.2023.06.001] [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: 02/23/2023] [Revised: 06/01/2023] [Accepted: 06/05/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Patients with atrial fibrillation are characterized by great clinical heterogeneity and complexity. The usual classifications may not adequately characterize this population. Data-driven cluster analysis reveals different possible patient classifications. AIMS To identify different clusters of patients with atrial fibrillation who share similar clinical phenotypes, and to evaluate the association between identified clusters and clinical outcomes, using cluster analysis. METHODS An agglomerative hierarchical cluster analysis was performed in non-anticoagulated patients from the Loire Valley Atrial Fibrillation cohort. Associations between clusters and a composite outcome comprising stroke/systemic embolism/death and all-cause death, stroke and major bleeding were evaluated using Cox regression analyses. RESULTS The study included 3434 non-anticoagulated patients with atrial fibrillation (mean age 70.3±17 years; 42.8% female). Three clusters were identified: cluster 1 was composed of younger patients, with a low prevalence of co-morbidities; cluster 2 included old patients with permanent atrial fibrillation, cardiac pathologies and a high burden of cardiovascular co-morbidities; cluster 3 identified old female patients with a high burden of cardiovascular co-morbidities. Compared with cluster 1, clusters 2 and 3 were independently associated with an increased risk of the composite outcome (hazard ratio 2.85, 95% confidence interval 1.32-6.16 and hazard ratio 1.52, 95% confidence interval 1.09-2.11, respectively) and all-cause death (hazard ratio 3.54, 95% confidence interval 1.49-8.43 and hazard ratio 1.88, 95% confidence interval 1.26-2.79, respectively). Cluster 3 was independently associated with an increased risk of major bleeding (hazard ratio 1.72, 95% confidence interval 1.06-2.78). CONCLUSION Cluster analysis identified three statistically driven groups of patients with atrial fibrillation, with distinct phenotype characteristics and associated with different risks for major clinical adverse events.
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Affiliation(s)
- Arnaud Bisson
- Service de cardiologie, centre hospitalier régional universitaire et faculté de médecine de Tours, 37000 Tours, France; Service de cardiologie, centre hospitalier régional universitaire d'Orléans, 45100 Orléans, France; EA4245, transplantation immunité inflammation, université de Tours, 37032 Tours, France; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, L7 8TX Liverpool, United Kingdom.
| | - Ameenathul M Fawzy
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, L7 8TX Liverpool, United Kingdom
| | - Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, L7 8TX Liverpool, United Kingdom; Department of Translational and Precision Medicine, Sapienza - University of Rome, 00185 Rome, Italy
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, L7 8TX Liverpool, United Kingdom; Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; IRCCS Istituti Clinici Scientifici Maugeri, 20138 Milan, Italy
| | - Denis Angoulvant
- Service de cardiologie, centre hospitalier régional universitaire et faculté de médecine de Tours, 37000 Tours, France; EA4245, transplantation immunité inflammation, université de Tours, 37032 Tours, France
| | - Wahbi El-Bouri
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, L7 8TX Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, L7 8TX Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark
| | - Laurent Fauchier
- Service de cardiologie, centre hospitalier régional universitaire et faculté de médecine de Tours, 37000 Tours, France
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Ibdah R, Obeidat O, Khader Y, Al-Nusair J, Abusurrah O, Obeidat A, Obeidat A, Rawashdeh S, Alrabadi N, Obiedat AF, Alnadi NN, Hammoudeh A. Validation of CHA2DS2 VASc Score Predictability of Stroke and Systemic Embolization in a Middle Eastern Population with AF: The Jordan Atrial Fibrillation (JoFib) Study. Vasc Health Risk Manag 2023; 19:255-264. [PMID: 37125391 PMCID: PMC10145451 DOI: 10.2147/vhrm.s404575] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/31/2023] [Indexed: 05/02/2023] Open
Abstract
Background and Purpose CHA2DS2-VASc score is one of the most widely used scoring systems to assess the risk of systemic embolization and stroke in patients suffering from atrial fibrillation (Afib); furthermore, it is important in guiding their treatment. This study aimed to evaluate the predictivity of this score in the Jordanian population, build a deeper understanding of patients' demographic and risk factors, and assess the usefulness of anticoagulation as a preventive measure. Methods A total of 2020 patients with Afib registered in the Jordanian Atrial Fibrillation (JoFib) registry were enrolled in this study. All patients were followed up for 1 year to assess their susceptibility to develop cerebrovascular accident (CVA) and systemic embolism (SE). The association between CHA2DS2-VASc score and risk of development of stroke or systemic embolization was analyzed based on bivariate and adjusted multivariate analyses. The ROC curve was used to assess the predictivity of the CHA2DS2-VASc score. Results The mean age of the study population was 67.8 years; 45.8% were males, and 81.8% were on anticoagulants. And, 71.8% had a CHA2DS2-VASc score of ≥3. During the follow-up period of 1 year; 69 developed new CVA (mean age, 72.8 years), and 9 developed SE. A total of 276 patients died; 18 patients died (6.5% out of all deceased)% from CVA. A moderate predictive power of the CHA2DS2-VASc score was demonstrated through ROC curve analysis with C statistics of 0.689 CI (0.634 to 0.744) for predicting the development of SE or CVA at 1 year. Conclusion CHA2DS2-VASc showed a moderate predictivity of stroke, SE, and all-cause mortality at 1 year. The study suggested disregarding gender differences in deciding to initiate anticoagulant therapy.
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Affiliation(s)
- Rasheed Ibdah
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
- Correspondence: Rasheed Ibdah, Division of Cardiology, Department of Internal Medicine, Jordan University for Science and Technology, Irbid, 22110, Jordan, Email
| | - Omar Obeidat
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Yousef Khader
- Department of Community Medicine, Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science & Technology, Irbid, 22110, Jordan
| | - Jowan Al-Nusair
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Obada Abusurrah
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Abedallah Obeidat
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Ali Obeidat
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Sukaina Rawashdeh
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Nasr Alrabadi
- Department of Pharmacology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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Paroxysmal and Non-Paroxysmal Atrial Fibrillation in Middle Eastern Patients: Clinical Features and the Use of Medications. Analysis of the Jordan Atrial Fibrillation (JoFib) Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19106173. [PMID: 35627709 PMCID: PMC9141457 DOI: 10.3390/ijerph19106173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/01/2022] [Accepted: 05/11/2022] [Indexed: 02/01/2023]
Abstract
(1) Background: Atrial fibrillation (AF) is the most common arrhythmia causing an increased risk of mortality and morbidity. It is classified into paroxysmal and non-paroxysmal AF depending on the duration and frequency of the episodes. (2) Aims: Our goal was to investigate and compare the clinical profiles, risk of co-morbidities, the use of oral anticoagulation, and outcomes of patients with paroxysmal and non-paroxysmal AF in inpatient and outpatient settings. (3) Methods: Data were extracted from 28 different hospitals and centers in Jordan with a total of 2160 patients enrolled in the study using an observational non-interventional study model. The clinical features and the use of oral anticoagulants were compared in patients with paroxysmal and non-paroxysmal AF. (4) Results: Paroxysmal AF was documented in 35.6% (769) of the patients and non-paroxysmal types in 63.9% (1380); in addition, the type of AF was unknown in 11 (0.5%) patients. Our results showed that non-paroxysmal AF patients tend to be older with more co-morbidities and higher CHA2DS2-VASC and HAS-BLED scores. They also have higher rates of hypertension and diabetes. Anticoagulant, antiarrhythmic, and diuretic agents, overall, were used more in non-paroxysmal AF than paroxysmal AF. Hospital admissions were also more frequent in non-paroxysmal AF due to various factors, some of which are heart failure, bleeding risk, and COPD. (5) Conclusions: Non-paroxysmal AF is more common among Jordanian AF patients. The prevalence of comorbidities and the use of different types of therapies, especially anticoagulants, were higher in these patients.
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Gong X, Chen H, Wang J, Zhong W, Chen L, Yan S, Lou M. Undertreatment of Anticoagulant Therapy in Hospitalized Acute Ischemic Stroke Patients With Atrial Fibrillation. Front Cardiovasc Med 2022; 9:841020. [PMID: 35433893 PMCID: PMC9005870 DOI: 10.3389/fcvm.2022.841020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/07/2022] [Indexed: 11/23/2022] Open
Abstract
Background This study aimed to investigate the prevalence and factors associated with the initiation of oral anticoagulation among patients with acute ischemic stroke (AIS) and concurrent atrial fibrillation (AF) at discharge in China. Methods We continuously included hospitalized patients with AIS with an AF diagnosis registered in the computer-based Online Database of Acute Stroke Patients for Stroke Management Quality Evaluation (CASE II) from January 2016 to December 2020 and divided them into a and non-anticoagulant groups according to the medications at discharge. Binary logistic regression was used to determine the factors associated with the prescription of anticoagulants in patients with AF. Results A total of 16,162 patients were enrolled. The mean age was 77 ± 9 years, 8,596 (53.2%) were males, and the median baseline National Institute of Health Stroke Scale score was 5 (2–12). Of the 14,838 patients without contraindications of antithrombotic therapy, 6,335 (42.7%) patients were initiated with anticoagulation treatment at discharge. Prior history of hemorrhagic stroke (OR 0.647, p < 0.001) and gastrointestinal bleeding (OR 0.607, p = 0.003) were associated with a lower rate of anticoagulation at discharge. Patients with any intracranial hemorrhage (OR 0.268, p < 0.001), gastrointestinal bleeding (OR 0.353, p < 0.001), or pneumonia during hospitalization (OR 0.601, p < 0.001) were less likely to receive anticoagulants at discharge. Among 7,807 patients with previously diagnosed AF and high risk of stroke (CHA2DS2-VASc ≥2), only 1,585 (20.3%) had been receiving anticoagulation treatment prior to the onset of stroke. However, the mean international normalized ratio (INR) was 1.5 on the first test during hospitalization in patients receiving warfarin. Patients complicated with a previous history of ischemic stroke/transient ischemic attack (TIA; OR 2.303, p < 0.001) and peripheral artery disease (OR 1.456, p = 0.003) were more common to start anticoagulants. Conclusions Less than half of patients with AIS and concurrent AF initiated guideline-recommended oral anticoagulation at discharge, while only 20% of patients with previously diagnosed AF with a high risk of stroke had been using anticoagulants prior to the onset of stroke, which highlights a large care gap in hospitalized stroke patients and the importance of AF management.
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Affiliation(s)
- Xiaoxian Gong
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Hongfang Chen
- Department of Neurology, Jinhua Hospital of Zhejiang University, Jinhua Municipal Central Hospital, Jinhua, China
| | - Jianan Wang
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Wansi Zhong
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Luowei Chen
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Shenqiang Yan
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Min Lou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
- *Correspondence: Min Lou ;
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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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6
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Saad M, Risha O, Sano M, Fink T, Heeger CH, Vogler J, Sciacca V, Eitel C, Stiermaier T, Joost A, Keelani A, Fuernau G, Meyer-Saraei R, Kuck KH, Eitel I, Richard Tilz R. Comparison between Amulet and Watchman left atrial appendage closure devices: A real-world, single center experience. IJC HEART & VASCULATURE 2021; 37:100893. [PMID: 34712772 PMCID: PMC8529070 DOI: 10.1016/j.ijcha.2021.100893] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 10/13/2021] [Indexed: 11/20/2022]
Abstract
Background Data reporting a head-to-head comparison between Amulet and Watchman devices are scarce. The aim of this study was to compare the Watchman™ versus Amulet™ left atrial appendage closure (LAAC) devices in a consecutive, industry-independent registry. Methods Patients who underwent LAAC using Watchman or Amulet devices from January 2014 to December 2019 at the University Heart Center Lübeck, Lübeck, Germany were included in the present analysis. Primary endpoints included periprocedural complications (in-hospital death, pericardial tamponade, device embolization, stroke, major bleeding and vascular access complications), and complications during long-term follow-up (ischemic stroke, hemorrhagic stroke, thromboembolism, device thrombus, bleeding and death). Results After matching the patients for age (±5 years), gender, CHA2DS2Vasc score (±1) and HASBLED score (±1), each of the Watchman and the Amulet groups included 113 patients. Patients in the Amulet group had significantly more periprocedural complications (2.7% vs 10.6%, p = 0.029; respectively) and more major bleeding complications (0% vs 5.3%, p = 0.029; respectively). During long-term follow-up, the rate of events was comparable between the Watchman and Amulet groups (18.3% versus 20.8%, p = 0.729; respectively). Conclusion Amulet LAAC device was associated with increased periprocedural complications as compared to Watchman LAAC device. On long-term follow-up, both devices showed comparable efficacy and safety.
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Affiliation(s)
- Mohammed Saad
- Medical Clinic III, University Hospital Schleswig-Holstein, Kiel, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Osama Risha
- Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Makoto Sano
- Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Thomas Fink
- Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany.,Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Christian-Hendrik Heeger
- Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Julia Vogler
- Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Vanessa Sciacca
- Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Charlotte Eitel
- Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Thomas Stiermaier
- Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Alexander Joost
- Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Ahmad Keelani
- Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Georg Fuernau
- Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Roza Meyer-Saraei
- Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany.,Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Karl-Heinz Kuck
- Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Ingo Eitel
- Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Roland Richard Tilz
- Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
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Lack of Sex Disparity in Oral Anticoagulation in Atrial Fibrillation Patients Presenting with Ischemic Stroke in a Rural Population. J Clin Med 2021; 10:jcm10204670. [PMID: 34682796 PMCID: PMC8537827 DOI: 10.3390/jcm10204670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/30/2021] [Accepted: 09/30/2021] [Indexed: 11/16/2022] Open
Abstract
Various studies on oral anticoagulants (OAC) use among atrial fibrillation (AF) patients have shown high rates of undertreatment and the presence of sex disparity. This study used the 'Geisinger Neuroscience Ischemic Stroke' (GNSIS) database to examine sex differences in OAC treatment among ischemic stroke patients with the pre-event diagnosis of AF in rural Pennsylvania between 2004 and 2019. We examined sex disparities in OAC undertreatment and associated risks based on age group and ischemic stroke year. A total of 1062 patients were included in the study and 1015 patients (96%) had CHA2DS2-VASc score ≥ 2, of which 549 (54.1%) were women. Undertreatment rates were not statistically significant between men and women in the overall cohort (50.0% vs. 54.5%, p = 0.18), and male sex was not found to be a significant factor in undertreatment (OR 0.82, 95% CI 0.62-1.09, p = 0.17). The result persisted even when patients were divided into four age groups and two groups based on the study time period. The undertreatment rates in both sex groups remained consistent following the introduction of novel oral anticoagulants. In conclusion, there was no evidence of sex disparity with respect to OAC treatment, even after stratifying the cohort by age and ischemic stroke year.
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8
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Wu J, Alsaeed ES, Barrett J, Hall M, Cowan C, Gale CP. Prescription of oral anticoagulants and antiplatelets for stroke prophylaxis in atrial fibrillation: nationwide time series ecological analysis. Europace 2021; 22:1311-1319. [PMID: 32778878 DOI: 10.1093/europace/euaa126] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/27/2020] [Indexed: 02/05/2023] Open
Abstract
AIMS To investigate trends in the prescription of oral anticoagulants (OACs) and antiplatelet agents for atrial fibrillation (AF). METHODS AND RESULTS Prescription data for 450 518 patients with AF from 3352 General Practices in England, was obtained from the GRASP-AF registry, 2009-2018. Annualized temporal trends for OAC and antiplatelet prescription were reported according to eligibility based on stroke risk (CHADS2 or CHA2DS2-VASc scores ≥1 or >2, respectively). From 2009 to 2018, the prevalence of AF increased from 1.6% [95% confidence interval (CI) 1.5-1.7%] to 2.4% (2.3-2.5%), and for those with AF the proportion prescribed OAC increased from 47.6% to 75.0% (P-trend < 0.001; relative risk 1.57, 95% CI 1.55-1.60) and for antiplatelet decreased from 37.4% to 9.2% (P-trend < 0.001). In early-years (2009-2013), eligible patients aged ≥80 years were less likely to be prescribed OAC than patients aged <80 years [odds ratio (OR) 0.55, 95% CI 0.51-0.59 for CHADS2≥1 in 2009] (all P-trends < 0.001). This 'OAC prescription gap' reduced over the study period (OR 0.93, 0.90-0.96 in 2018). Whilst the prescription of direct oral anticoagulant (DOAC) as a proportion of all OAC increased from 0.1% (95% CI 0.0-0.2%) in 2011 to 58.8% (58.4-59.2%) in 2018, it was inversely associated with patient age (P-trend < 0.001) and their risk of stroke. CONCLUSION Between 2009 and 2018, in England, the use of OAC for stroke prophylaxis in AF increased, with DOAC accounting for over half of OAC uptake in 2018. Despite a reduction in the OAC-prescription gap, a new paradox exists relating to DOAC prescription for the elderly and those at higher risk of stroke.
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Affiliation(s)
- Jianhua Wu
- School of Dentistry, University of Leeds, Leeds, UK.,Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Eman S Alsaeed
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK.,Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Worsley Building, Level 11, Clarendon Way, Leeds LS2 9JT, UK
| | - James Barrett
- PRIMIS, Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Marlous Hall
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK.,Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Worsley Building, Level 11, Clarendon Way, Leeds LS2 9JT, UK
| | - Campbell Cowan
- Department of Cardiology, Leeds General Infirmary, Leeds, UK
| | - Chris P Gale
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK.,Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Worsley Building, Level 11, Clarendon Way, Leeds LS2 9JT, UK.,Department of Cardiology, Leeds General Infirmary, Leeds, UK
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9
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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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10
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Diaz J, Koza E, Chaudhary D, Shahjouei S, Naved MMA, Malik MT, Li J, Adibuzzaman M, Griffin P, Abedi V, Zand R. Adherence to anticoagulant guideline for atrial fibrillation: A large care gap among stroke patients in a rural population. J Neurol Sci 2021; 424:117410. [PMID: 33770707 DOI: 10.1016/j.jns.2021.117410] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/12/2021] [Accepted: 03/18/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study aimed to investigate the prevalence and factors associated with oral anticoagulant undertreatment of atrial fibrillation (AF) among a cohort of rural patients with stroke outcomes and examine how undertreatment may influence a patient's one-year survival after stroke. METHODS This retrospective cohort study examined ischemic stroke patients with pre-stroke AF diagnosis from September 2003 to May 2019 and divided them into proper treatment and undertreatment group. Analysis included chi-square test, variance analysis, Kruskal-Wallis test, logistic regression, Kaplan-Meier estimator, and Cox proportional-hazards model. RESULTS Out of 1062 ischemic stroke patients with a pre-stroke AF diagnosis, 1015 patients had a CHA2DS2-VASc score ≥2, and 532 (52.4%) of those were undertreated. Median time from AF diagnosis to index stroke was significantly lower among undertreated patients (1.9 years vs. 3.6 years, p < 0.001). Other thromboembolism, excluding stroke, TIA, and myocardial infarction (OR 0.41, p < 0.001), the number of encounters per year (OR 0.90, p < 0.001), and the median time between AF diagnosis and stroke event (OR 0.86, p < 0.001) were negatively associated with undertreatment. Kaplan-Meier estimator showed no statistical difference in the one-year survival probability between groups (log-rank test, p = 0.29), while the Cox-Hazard model showed that age (HR 1.05, p < 0.001) and history of congestive heart failure (HR 1.88, p < 0.001) increased the risk of mortality. CONCLUSIONS More than half of our rural stroke patients with a pre-index AF diagnosis were not on guideline-recommended treatment. The study highlights a large care gap and an opportunity to improve AF management.
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Affiliation(s)
- Johan Diaz
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Eric Koza
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Durgesh Chaudhary
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, PA, USA
| | - Shima Shahjouei
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, PA, USA
| | | | - Muhammad Taimur Malik
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, PA, USA
| | - Jiang Li
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, PA, USA
| | - Mohammad Adibuzzaman
- Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Paul Griffin
- Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park, PA, USA
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, PA, USA; Biocomplexity Institute, Virginia Tech, Blacksburg, VA, USA
| | - Ramin Zand
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, PA, USA.
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11
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Abstract
Atrial fibrillation (AF) is the most common cardiac arrythmia and a major cause of stroke, heart failure, sudden death, and cardiovascular morbidity. AF increases risk of thromboembolic stroke via stasis in the left atrium and subsequent embolization to the brain. In patients with acute ischemic stroke, it is essential that clinicians undertake careful investigation to search for AF. In these patients, up to 23.7% eventually are found to have underlying AF. Oral anticoagulation is effective in prevention of strokes secondary to AF, reducing overall stroke numbers by approximately 64%. Left atrial appendage occlusion is promising for prevention of stroke in AF.
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Affiliation(s)
- Hani Essa
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Andrew M Hill
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Department of Medicine for Older People, St Helens and Knowsley Teaching Hospitals NHS Trust, Marshalls Cross Road, St Helens, Liverpool WA9 3DA, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Sondra Skovvej, 15, Aalborg 9000, Denmark.
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12
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Gronemann C, Hause S, Assmann A, Neumann J, Schreiber S, Heinze HJ, Goertler M. Modification of In-Hospital Recommendation and Prescription of Anticoagulants for Secondary Prevention of Stroke after Launch of Direct Oral Anticoagulants and Change of National Guidelines. Cerebrovasc Dis 2020; 49:412-418. [PMID: 32756054 DOI: 10.1159/000509416] [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: 09/12/2019] [Accepted: 06/08/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Approximately 1 out of 4 stroke patients suffers ischemic stroke secondary to atrial fibrillation (AF). Although indicated, withholding of anticoagulants for secondary prevention is a widespread phenomenon. OBJECTIVE We examined the longitudinal change of recommendation and prescription of secondary preventive anticoagulation in AF patients in an acute stroke center setting focusing on the impact of the introduction of direct oral anticoagulants (DOACs) and the change of national stroke prevention guidelines. METHODS Consecutive patients admitted with an acute cerebrovascular ischemic event underwent regular diagnostic work-up. Pseudonymized clinical data were entered into the institution's stroke registry. In those patients with AF, discharge letters were collected and evaluated for temporal trends and affecting factors of recommended and prescribed antithrombotic secondary medication at the time of discharge from hospital. RESULTS Of 7,175 patients admitted between January 2009 and December 2018, 1,812 (25.3%) suffered stroke caused by AF. Frequency of patients with recommended anticoagulation increased within the observation period from 66.7 to 95.8% (per year; adjusted odds ratio [OR], 1.309; confidence interval [CI], 1.153-1.486). Independently from this time trend, DOAC approval (adjusted OR, 4.026; CI 1.962-8.265) and guideline change (adjusted OR, 2.184; CI, 1.006-4.743) were associated with an increasing frequency of recommendation for anticoagulation. The rate of patients already receiving recommended anticoagulation for secondary prevention at discharge increased from 42.1 to 62.5%. Introduction of DOACs was not associated with this trend, and guideline change was even associated with decreasing frequency of anticoagulated patients at hospital discharge (adjusted OR, 0.641; CI, 0.414-0.991). Fear of early intracerebral bleeding was the most common reason for withholding anticoagulation (37%) at hospital discharge and stayed stable during the observation period. CONCLUSIONS Changing national guidelines with discard of contraindications for anticoagulation and the introduction of DOACs led to a broader recommendation of oral anticoagulation. However, both, new guidelines and DOACs, were not found to be associated with an increasing percentage of patients discharged from our hospital already on recommended anticoagulant prevention. This might be explained by the decreasing length of hospital stay during the study period and a missing evidence of early bleeding risk of DOACs in patients with acute brain infarction. Evidence-based data to close this therapeutic gap are needed.
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Affiliation(s)
- Christian Gronemann
- Department of Neurology, Magdeburg University Vascular and Stroke Center, Magdeburg, Germany
| | - Stephan Hause
- Department of Neurology, Magdeburg University Vascular and Stroke Center, Magdeburg, Germany,
| | - Anne Assmann
- Department of Neurology, Magdeburg University Vascular and Stroke Center, Magdeburg, Germany
| | - Jens Neumann
- Department of Neurology, Magdeburg University Vascular and Stroke Center, Magdeburg, Germany
| | - Stefanie Schreiber
- Department of Neurology, Magdeburg University Vascular and Stroke Center, Magdeburg, Germany
| | - Hans-Jochen Heinze
- Department of Neurology, Magdeburg University Vascular and Stroke Center, Magdeburg, Germany
| | - Michael Goertler
- Department of Neurology, Magdeburg University Vascular and Stroke Center, Magdeburg, Germany
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13
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Akao M, Shimizu W, Atarashi H, Ikeda T, Inoue H, Okumura K, Koretsune Y, Tsutsui H, Toyoda K, Hirayama A, Yasaka M, Yamashita T, Yamaguchi T, Teramukai S, Kimura T, Kaburagi J, Takita A. Oral Anticoagulant Use in Elderly Japanese Patients With Non-Valvular Atrial Fibrillation - Subanalysis of the ANAFIE Registry. Circ Rep 2020; 2:552-559. [PMID: 33693180 PMCID: PMC7932811 DOI: 10.1253/circrep.cr-20-0082] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background:
Oral anticoagulants (OACs) are effective in preventing stroke in patients with atrial fibrillation (AF), but are challenging for elderly patients because of the higher risk of bleeding complications. Methods and Results:
The ANAFIE Registry is a prospective multicenter observational study of elderly (≥75 years) Japanese AF patients. This subanalysis evaluated the current use of OACs. Of 32,713 patients (mean age 81.5 years), 30,068 (91.9%) were receiving OACs, including 8,354 (25.5%) on warfarin and 21,714 (66.4%) on direct OACs (DOACs); 2,645 (8.1%) were not receiving OACs. The most common prescribed dose was a reduced dose for all DOACs. A substantial proportion of patients receiving the reduced dose did not fulfill dose reduction criteria (underdosing): apixaban, 25.1%; rivaroxaban, 26.3%; and edoxaban, 13.7%. Some patients received a lower off-label dose rather than the reduced dose: apixaban, 5.9%; rivaroxaban, 0.3%; edoxaban, 5.3%; and dabigatran, 13.6%. In multivariate analyses, advanced age, history of hemorrhage, paroxysmal AF, and antiplatelet drug use were significantly associated with no OAC. Advanced age, persistent or permanent AF, chronic kidney disease, and concomitant antiplatelet drugs were associated with warfarin rather than DOAC use. Conclusions:
In the ANAFIE Registry, >90% of elderly Japanese AF patients received OAC therapy, mostly DOACs. Inappropriate low doses of DOACs that did not fulfill dose reduction criteria were prescribed in 20–30% of patients.
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Affiliation(s)
- Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center Kyoto Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School Tokyo Japan
| | | | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine Tokyo Japan
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center Kumamoto Japan
| | | | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Science Fukuoka Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center Osaka Japan
| | | | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Cerebrovascular Center, Clinical Research Institute, National Hospital Organization Kyushu Medical Center Fukuoka Japan
| | | | | | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine Kyoto Japan
| | | | | | - Atsushi Takita
- Biostatistics & Data Management Department, Daiichi Sankyo Tokyo Japan
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14
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Berg DD, Ruff CT, Jarolim P, Giugliano RP, Nordio F, Lanz HJ, Mercuri MF, Antman EM, Braunwald E, Morrow DA. Performance of the ABC Scores for Assessing the Risk of Stroke or Systemic Embolism and Bleeding in Patients With Atrial Fibrillation in ENGAGE AF-TIMI 48. Circulation 2019; 139:760-771. [PMID: 30586727 DOI: 10.1161/circulationaha.118.038312] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The ABC (age, biomarker, clinical history)-stroke and ABC-bleeding risk scores incorporate clinical variables and cardiovascular biomarkers to estimate risk of stroke or systemic embolic events and bleeding, respectively, in patients with atrial fibrillation. These scores have been proposed for routine clinical use, but their performance in external cohorts remains uncertain. METHODS ENGAGE AF-TIMI 48 (Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48) was a multinational randomized trial of the oral factor Xa inhibitor edoxaban in patients with atrial fibrillation and a CHADS2 score ≥2. We performed a nested prospective biomarker study in 8705 patients, analyzing baseline high-sensitivity troponin T (hsTnT), NT-proBNP (N-terminal B-type natriuretic peptide), and growth differentiation factor-15 (GDF-15), as well as in serial samples after 12 months. The ABC-stroke (age, prior stroke/transient ischemic attack, hsTnT, NT-proBNP) and ABC-bleeding (age, prior bleeding, hemoglobin, hsTnT, and GDF-15) scores were tested. Hazard ratios were adjusted for estimated glomerular filtration rate and the components of the CHA2DS2-VASc and HAS-BLED scores, respectively. Discrimination and reclassification were compared with these established scores. RESULTS Median baseline hsTnT, NT-proBNP, and GDF-15 levels were 13.7 ng/L (25th-75th percentiles, 9.6-20.4 ng/L), 811 pg/mL (386-1436 pg/mL), and 1661 pg/mL (1179-2427 pg/mL), respectively. Elevated hsTnT, NT-proBNP, and GDF-15 were independently associated with higher rates of stroke or systemic embolic events, and elevated hsTnT and GDF-15 were independently associated with higher rates of major bleeding ( P<0.001 for each). The ABC-stroke and ABC-bleeding scores were well calibrated and yielded higher c indexes than the CHA2DS2-VASc score for stroke or systemic embolic events (0.67 [95% CI, 0.65-0.70] versus 0.59 [95% CI, 0.57-0.62]; P<0.001) and HAS-BLED score for major bleeding (0.69 [95% CI, 0.66-0.71] versus 0.62 [95% CI, 0.60-0.64]; P<0.001), respectively. The ABC-stroke and ABC-bleeding scores stratified patients within CHA2DS2-VASc and HAS-BLED risk categories ( P<0.001 for both). Patients with ABC-bleeding scores predicting a high 1-year risk of bleeding (>2%) derived greater benefit from treatment with edoxaban compared with warfarin. CONCLUSIONS The ABC-stroke and ABC-bleeding scores evaluated in this anticoagulated clinical trial cohort were well calibrated and outperformed the CHA2DS2-VASc and HAS-BLED scores, respectively. These scores may help identify patients most likely to derive a benefit from treatment with non-vitamin K antagonist oral anticoagulants. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT00781391.
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Affiliation(s)
- David D Berg
- TIMI Study Group, Cardiovascular Division, Department of Medicine (D.D.B., C.T.R., R.P.G., F.N., E.M.A., E.B., D.A.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Christian T Ruff
- TIMI Study Group, Cardiovascular Division, Department of Medicine (D.D.B., C.T.R., R.P.G., F.N., E.M.A., E.B., D.A.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Petr Jarolim
- Department of Pathology (P.J.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Department of Medicine (D.D.B., C.T.R., R.P.G., F.N., E.M.A., E.B., D.A.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Francesco Nordio
- TIMI Study Group, Cardiovascular Division, Department of Medicine (D.D.B., C.T.R., R.P.G., F.N., E.M.A., E.B., D.A.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | | | - Elliott M Antman
- TIMI Study Group, Cardiovascular Division, Department of Medicine (D.D.B., C.T.R., R.P.G., F.N., E.M.A., E.B., D.A.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Department of Medicine (D.D.B., C.T.R., R.P.G., F.N., E.M.A., E.B., D.A.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Department of Medicine (D.D.B., C.T.R., R.P.G., F.N., E.M.A., E.B., D.A.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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15
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Risk of Hospital Admissions in Patients With Atrial Fibrillation: A Systematic Review and Meta-analysis. Can J Cardiol 2019; 35:1332-1343. [DOI: 10.1016/j.cjca.2019.05.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/21/2019] [Accepted: 05/21/2019] [Indexed: 11/21/2022] Open
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16
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Olivier CB, Fan J, Askari M, Mahaffey KW, Heidenreich PA, Perino AC, Leef GC, Ho PM, Harrington RA, Turakhia MP. Site Variation and Outcomes for Antithrombotic Therapy in Atrial Fibrillation Patients After Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2019; 12:e007604. [DOI: 10.1161/circinterventions.118.007604] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Patients with atrial fibrillation (AF) treated with percutaneous coronary intervention (PCI) require multiple antithrombotic therapies. The optimal strategy is debated suggesting increased treatment variation. This study sought to characterize site-level variation in antithrombotic therapies in AF patients after PCI and determine the association with outcomes.
Methods:
Using the retrospective TREAT-AF study (The Retrospective Evaluation and Assessment of Therapies in AF) from the Veterans Health Administration, patients with newly diagnosed, nonvalvular AF between 2004 and 2015 followed by a PCI with a P2Y
12
-antagonist prescription were identified. Patients were grouped according to the therapy dispensed 7 days before until 30 days after the PCI: oral anticoagulation plus platelet inhibition (OAC+PI) or platelet inhibition only. A combined outcome of death, myocardial infarction, stroke, or major bleeding was assessed 1 year after PCI and Cox regression was performed to estimate hazard ratios.
Results:
Of 230 762 patients with newly diagnosed AF, 4042 (1.8%) underwent PCI and received a P2Y
12
-antagonist during the observation period (age, 67±9 years; CHA
2
DS
2
-VASc, 2.7±1.7; HAS-BLED, 2.6±1.2). Among these, 47% were prescribed OAC+PI, and 53% platelet inhibition only 7 days before until 30 days after the PCI. Across 63 sites, the use of OAC+PI ranged from 19% to 66%. Prescription of OAC+PI was independently associated with a reduction in the combined outcome of death, myocardial infarction, stroke, or major bleeding compared with platelet inhibition only (adjusted hazard ratio, 0.85; 95% CI, 0.73–0.99;
P
=0.033).
Conclusions:
In patients with established AF undergoing PCI, the use of OAC+PI varied substantially across sites in the 30 days post-PCI. Anticoagulation appeared to be underutilized but was associated with improved outcomes. Strategies to promote OAC+PI and minimize site variation may be useful, particularly in light of recent randomized trials.
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Affiliation(s)
- Christoph B. Olivier
- Department of Medicine, Stanford Center for Clinical Research (C.B.O., K.W.M.), Stanford University School of Medicine, CA
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Germany (C.B.O.)
| | - Jun Fan
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, CA (J.F., M.A., P.A.H., A.C.P., G.C.L., M.P.T.)
| | - Mariam Askari
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, CA (J.F., M.A., P.A.H., A.C.P., G.C.L., M.P.T.)
| | - Kenneth W. Mahaffey
- Department of Medicine, Stanford Center for Clinical Research (C.B.O., K.W.M.), Stanford University School of Medicine, CA
| | - Paul A. Heidenreich
- Department of Medicine (P.A.H., A.C.P., G.C.L., R.A.H., M.P.T.), Stanford University School of Medicine, CA
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, CA (J.F., M.A., P.A.H., A.C.P., G.C.L., M.P.T.)
| | - Alexander C. Perino
- Department of Medicine (P.A.H., A.C.P., G.C.L., R.A.H., M.P.T.), Stanford University School of Medicine, CA
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, CA (J.F., M.A., P.A.H., A.C.P., G.C.L., M.P.T.)
| | - George C. Leef
- Department of Medicine (P.A.H., A.C.P., G.C.L., R.A.H., M.P.T.), Stanford University School of Medicine, CA
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, CA (J.F., M.A., P.A.H., A.C.P., G.C.L., M.P.T.)
| | - P. Michael Ho
- Division of Cardiology, Denver VA Medical Center, CO (P.M.H.)
| | - Robert A. Harrington
- Department of Medicine (P.A.H., A.C.P., G.C.L., R.A.H., M.P.T.), Stanford University School of Medicine, CA
- Department of Medicine, Center for Digital Health (R.A.H., M.P.T.), Stanford University School of Medicine, CA
| | - Mintu P. Turakhia
- Department of Medicine (P.A.H., A.C.P., G.C.L., R.A.H., M.P.T.), Stanford University School of Medicine, CA
- Department of Medicine, Center for Digital Health (R.A.H., M.P.T.), Stanford University School of Medicine, CA
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, CA (J.F., M.A., P.A.H., A.C.P., G.C.L., M.P.T.)
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Abstract
Background The pattern of stroke in rural population differs from that in urban ones. Although there are many studies on this condition in sub-Saharan Africa, few studies about stroke pattern in a Kenyan rural area exist.. This study therefore aims at describing the characteristics of stroke in a rural Kenyan hospital. Patients and Methods The study was conducted on 227 consecutive patients admitted with a World Health Organization (WHO) diagnosis of stroke in Kangundo Hospital, a level IV facility in Machakos, Eastern Kenya, between April 2015 and September 2016. The sub-type and anatomical distribution of stroke as well as the age, gender of the patients were recorded prospectively. Diagnosis was made through physical neurological examination and confirmed by Computerized Tomography (CT) scan imaging. Only those with complete bio-data, past medical and social history, clinical and physical findings of the patients and imaging results were included. The data were entered into a pre-formatted questionnaire, analysed for means, standard deviations and frequencies, and are presented in tables and bar charts. Results Out of 3200 medical admissions, 227 (7.09%) had a confirmed diagnosis of stroke. Ischaemic stroke was more common (67.4%) than haemorrhagic stroke (32.6%). It affected mainly the anterior circulation, especially the middle cerebral artery (39%). The mean age of patients was 68.8 years, (Range 32–96). It was more common in females (62%) than in males (38%). Hypertension was the most common (74%) risk factor followed by alcohol abuse (63%), tobacco smoking (48%) and diabetes mellitus (42%). Conclusion Ischaemic stroke was the more common major cause of morbidity in the rural hospital studied in Kenya. It occurred most commonly among elderly females, with the most frequent comorbidities being hypertension. In addition, modifiable lifestyle factors like alcohol abuse and cigarette smoking contributed to the prevalence; hence we recommend the control of blood pressure and glucose as well as lifestyle modification to reduce the scourge in our studied population.
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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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Yi X, Lin J, Han Z, Luo H, Shao M, Fan D, Zhou Q. Preceding Antithrombotic Treatment is Associated With Acute Ischemic Stroke Severity and Functional Outcome at 90 Days Among Patients With Atrial Fibrillation. J Stroke Cerebrovasc Dis 2019; 28:2003-2010. [PMID: 31047821 DOI: 10.1016/j.jstrokecerebrovasdis.2019.03.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/01/2019] [Accepted: 03/10/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Antithrombotic therapies are known to prevent ischemic stroke (IS) for patients with atrial fibrillation (AF), but are often underused in clinical practice. The aim of present study was to investigate the prevalence of patients with acute IS with known history of AF who were not receiving antithrombotic treatment before stroke and to evaluate the association of preceding antithrombotic treatment with stroke severity and outcomes at 90 days after admission. MATERIALS AND METHODS This was a retrospective, multi-center, observational study of 748 patients with acute IS and known history of AF admitted to 6 participating hospitals between March 2016 and October 2017. The primary outcome was stroke severity at admission as assessed using National Institutes of Health Stroke Scale (NIHSS) score. The secondary outcome was functional outcome at 90 days after admission as measured by modified Rankin Scale (mRS) score. RESULTS A total of 748 patients, 54 (7.2%) were receiving therapeutic warfarin (international normalized ratio [INR] ≥ 2) and 100 (13.4%) had subtherapeutic warfarin anticoagulation (INR < 2), 340 (45.5%) were receiving antiplatelet treatment, and 254 (34.0%) were not receiving any antithrombotic treatment prior to stroke. Compared with no antithrombotic treatment, therapeutic warfarin (OR: 0.64; 95% CI: 0.52-0.82; P = .022), and antiplatelet therapy only (OR: 0.89; 95% CI: 0.76-0.96; P = .041) were associated with lower odds ratio of moderate or severe stroke (NIHSS ≥ 16). Patients receiving preceding therapeutic warfarin (OR: 1.32; 95% CI: 1.22-3.57; P = .025), antiplatelet therapy only (OR: 1.13; 95% CI: 1.07-2.59; P = .043), and subtherapeutic warfarin with INR 1.5 to 1.99 (OR: 1.15; 95% CI: 1.10-2.66; P = .042) had higher odds ratio of better functional outcome (mRS ≤ 2) at 90 days. CONCLUSIONS Among patients with AF who had experienced an acute IS, inadequate therapeutic warfarin preceding the stroke was very prevalent in China. Therapeutic warfarin was associated with less severe stroke and better functional outcome at 90 days.
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Affiliation(s)
- Xingyang Yi
- Department of Neurology, People's Hospital of Deyang City, Deyang, Sichuan, China
| | - Jing Lin
- Department of Neurology, the Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China.
| | - Zhao Han
- Department of Neurology, the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Hua Luo
- Department of Neurology, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Minjie Shao
- Department of Neurology, the Affiliated Wenling Hospital of Wenzhou Medical University, Wenling, Zhejiang, China
| | - Daofeng Fan
- Department of Neurology, the Affiliated Longyan first Hospital of Fujian Medical University, Longyan, Zhejiang, China
| | - Qiang Zhou
- Department of Neurology, the Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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Pokorney SD, Gersh BJ, Ahmad A, Al-Khatib SM, Blank M, Coylewright M, DiBattiste P, Healey JS, Hedrich O, Hylek EM, Kline-Rogers E, Peterson ED, Mendys P, Mirro MJ, Naccarelli G, Patel P, Ruff CT, Rutman H, Stockbridge N, Temple R, Granger CB. Stroke prevention in atrial fibrillation: Closing the gap. Am Heart J 2019; 210:29-38. [PMID: 30731371 DOI: 10.1016/j.ahj.2018.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 10/12/2018] [Indexed: 10/28/2022]
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Grande SW, O'Neill ES, Sherman AE, Coylewright M. Are Older Adults Willing to Consider New Strategies to Reduce Stroke Risk? QUALITATIVE HEALTH RESEARCH 2019; 29:568-576. [PMID: 28985686 DOI: 10.1177/1049732317720682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Atrial fibrillation (AF) is a common arrhythmia that increases patients' risk of stroke, and determining an optimal prevention therapy is a preference-sensitive decision appropriate for shared decision making (SDM). Utilizing community-based focus groups, we explored beliefs and values around options for stroke prevention. Interview transcripts from five independent focus groups were qualitatively assessed and organized into themes. Most participants were taking a blood thinner (93%) and more than half of participants (64%) reported having AF. Few participants were familiar with newer therapies. Qualitative analysis revealed three themes: (a) fearing loss of self-control through debilitating stroke, (b) recognizing uncertainty in how to weigh risks and benefits of new treatments, and (c) needing mutual respect between clinicians and patients to consider new/alternative treatment regimens. These findings help direct future research efforts examining optimal timing for SDM and decision aids to promote mutual respect.
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Affiliation(s)
- Stuart W Grande
- Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | | | - Ariel E Sherman
- Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Megan Coylewright
- Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Pokorney SD, Bloom D, Granger CB, Thomas KL, Al-Khatib SM, Roettig ML, Anderson J, Heflin MT, Granger BB. Exploring patient–provider decision-making for use of anticoagulation for stroke prevention in atrial fibrillation: Results of the INFORM-AF study. Eur J Cardiovasc Nurs 2018; 18:280-288. [DOI: 10.1177/1474515118812252] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background: Atrial fibrillation is associated with stroke, yet approximately 50% of patients are not treated with guideline-directed oral anticoagulants (OACs). Aims: Given that the etiology of this gap in care is not well understood, we explored decision-making by patients and physicians regarding OAC use for stroke prevention in atrial fibrillation. Methods and results: We conducted a descriptive qualitative study among providers ( N=28) and their patients with atrial fibrillation for whom OACs were indicated ( N=25). We used purposive sampling across three outpatient settings in which atrial fibrillation patients are commonly managed: primary care ( n=14), geriatrics ( n=10), and cardiology ( n=4). Eligible patients were stratified by those prescribed OAC ( n=13) and not prescribed OAC ( n=12). Semi-structured, in-depth interviews assessed decision-making regarding risk and OAC use. Classical content analysis was used to code narratives and identify themes. Results among patients consisted of the overarching theme of trust in provider recommendations. Sub-themes included: awareness of increased risk of stroke with atrial fibrillation; willingness to accept medications recommended by their physician; and low demand for explanatory decision aids. Among physicians, the overarching theme was decisional conflict regarding the balance between stroke and bleeding risk, and the optimal medication to prescribe. Subthemes included: absence of decision aids for communication; and misperceptions around the assessment and management of stroke risk with atrial fibrillation. Conclusions: Patient involvement in decision-making around OAC use did not occur in this study of patients with atrial fibrillation. Improved access to decision aids may increase patient engagement in the decision-making process of OAC use for stroke prevention.
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Affiliation(s)
- Sean D Pokorney
- Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Diane Bloom
- University of North Carolina, Chapel Hill, NC, USA
| | - Christopher B Granger
- Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Kevin L Thomas
- Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Sana M Al-Khatib
- Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - John Anderson
- Duke University School of Medicine, Durham, NC, USA
- Duke Primary Care, Durham, NC, USA
| | - Mitchell T Heflin
- Duke University School of Medicine, Durham, NC, USA
- Duke Center for the Study of Aging and Human Development, Durham, NC, USA
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Domínguez H, Madsen CV, Westh ONH, Pallesen PA, Carrranza CL, Irmukhamedov A, Park-Hansen J. Does Left Atrial Appendage Amputation During Routine Cardiac Surgery Reduce Future Atrial Fibrillation and Stroke? Curr Cardiol Rep 2018; 20:99. [PMID: 30171381 PMCID: PMC6132740 DOI: 10.1007/s11886-018-1033-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Purpose of Review Stroke is the most feared complication of atrial fibrillation. To prevent stroke, left atrial appendage exclusion has been targeted, as it is the prevalent site for formation of heart thrombi during atrial fibrillation. We review the historic development of methods for exclusion of the left atrial appendage and the evidence to support its amputation during routine cardiac surgery. Recent Findings Evidence is not yet sufficient to routinely recommend left atrial exclusion during heart surgery, despite a high prevalence of postoperative atrial fibrillation. Observational studies indicate that electrical isolation of scarring from clip or suture techniques reduces the arrhythmogenic substrate. Summary Randomized studies comparing different methods of closure of the left atrial appendage before amputation do not exist. Such studies are therefore warranted, as well as studies that can elucidate whether amputation is superior to leaving the left atrial appendage stump. Potentially, thrombogenic remaining pouch after closure should be addressed.
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Affiliation(s)
- Helena Domínguez
- Department of Cardiology, Bispebjerg-Frederiksberg University Hospital, Nordre Fasanvej 57, vej 4, Building 3, 3rd Floor, DK-2000, Frederiksberg, Denmark. .,Department of Biomedicine, University of Copenhagen, Blegdamsvej 3B, Panum Building 10.5, DK-2400, Copenhagen, Denmark.
| | - Christoffer Valdorff Madsen
- Department of Cardiology, Bispebjerg-Frederiksberg University Hospital, Nordre Fasanvej 57, vej 4, Building 3, 3rd Floor, DK-2000, Frederiksberg, Denmark
| | - Oliver Nøhr Hjorth Westh
- Department of Cardiology, Bispebjerg-Frederiksberg University Hospital, Nordre Fasanvej 57, vej 4, Building 3, 3rd Floor, DK-2000, Frederiksberg, Denmark
| | - Peter Appel Pallesen
- Department of Heart, Lung and Vascular Surgery, Odense University Hospital, Sdr. Boulevard 29, DK-5000, Odense, Denmark
| | - Christian Lildal Carrranza
- Department of Cardio-thoracic Surgery, Blegdamsvej 9, 2100 København, Copenhagen, Rigshospitalet, Denmark
| | - Akhmadjon Irmukhamedov
- Department of Heart, Lung and Vascular Surgery, Odense University Hospital, Sdr. Boulevard 29, DK-5000, Odense, Denmark
| | - Jesper Park-Hansen
- Department of Cardiology, Bispebjerg-Frederiksberg University Hospital, Nordre Fasanvej 57, vej 4, Building 3, 3rd Floor, DK-2000, Frederiksberg, Denmark.,Department of Biomedicine, University of Copenhagen, Blegdamsvej 3B, Panum Building 10.5, DK-2400, Copenhagen, Denmark
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Krittayaphong R, Winijkul A, Methavigul K, Wongtheptien W, Wongvipaporn C, Wisaratapong T, Kunjara-Na-Ayudhya R, Boonyaratvej S, Komoltri C, Kaewcomdee P, Yindeengam A, Sritara P. Risk profiles and pattern of antithrombotic use in patients with non-valvular atrial fibrillation in Thailand: a multicenter study. BMC Cardiovasc Disord 2018; 18:174. [PMID: 30144802 PMCID: PMC6109333 DOI: 10.1186/s12872-018-0911-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 08/20/2018] [Indexed: 02/08/2023] Open
Abstract
Background Anticoagulation therapy is a standard treatment for stroke prevention in patients with non-valvular atrial fibrillation (NVAF) that have risk factors for stroke. However, anticoagulant increases the risk of bleeding, especially in Asians. We aimed to investigate the risk profiles and pattern of antithrombotic use in patients with NVAF in Thailand, and to study the reasons for not using warfarin in this patient population. Methods A nationwide multicenter registry of patients with NVAF was created that included data from 24 hospitals located across Thailand. Demographic data, atrial fibrillation-related data, comorbid conditions, use of antithrombotic drugs, and reasons for not using warfarin were collected. Data were recorded in a case record form and then transferred into a web-based system. Results A total of 3218 patients were included. Average age was 67.3 ± 11.3 years, and 58.2% were male. Average CHADS2, CHA2DS2-VASc, and HAS-BLED score was 1.8 ± 1.3, 3.0 ± 1.7, and 1.5 ± 1.0, respectively. Antiplatelet was used in 26.5% of patients, whereas anticoagulant was used in 75.3%. The main reasons for not using warfarin in those with CHA2DS2-VASc ≥2 included already taking antiplatelet (26.6%), patient preference (23.1%), and using non-vitamin K antagonist oral anticoagulants (NOACs) (22.7%). Anticoagulant was used in 32.3% of CHA2DS2-VASc 0, 56.8% of CHA2DS2-VASc 1, and 81.6% of CHA2DS2-VASc ≥2. The use of NOACs increased from 1.9% in 2014 to 25.6% in 2017. Conclusions Anticoagulation therapy was prescribed in 75.3% of patients with NVAF. Among those receiving anticoagulant, 90.9% used warfarin and 9.1% used NOACs. The use of NOACs increased over time. Electronic supplementary material The online version of this article (10.1186/s12872-018-0911-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
| | - Arjbordin Winijkul
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Komsing Methavigul
- Department of Cardiology, Central Chest Institute of Thailand, Nonthaburi, Thailand
| | | | | | | | | | | | - Chulalak Komoltri
- Department of Research Promotion, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pontawee Kaewcomdee
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Ahthit Yindeengam
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Piyamitr Sritara
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Fastner C, Hoffmann L, Aboukoura M, Behnes M, Lang S, Borggrefe M, Akin I, Nienaber CA. Real-world experience comparing two common left atrial appendage closure devices. BMC Cardiovasc Disord 2018; 18:171. [PMID: 30126370 PMCID: PMC6102880 DOI: 10.1186/s12872-018-0899-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 07/25/2018] [Indexed: 02/07/2023] Open
Abstract
Background The interventional left atrial appendage closure (LAAC) is a guideline-conform alternative to oral anticoagulation (OAC) in non-valvular atrial fibrillation patients with OAC ineligibility. It was aimed to directly compare two contemporary devices in a real-world patient population. Methods LAAC was conducted in two centres between 2010 and 2014 as well as between 2014 and 2017, respectively, in a standard fashion based on the specific manufacturer’s recommendations. Baseline characteristics, procedural data and event rates during intra-hospital and 6 months follow-up were registered in a retrospective approach, and analysed in device-related groups. Results A total of 189 patients presented for LAAC device implantation. Baseline characteristics were mostly evenly distributed. In 148 patients, a Watchman™ device (Boston Scientific, Natick, MA, USA) was successfully implanted, an Amplatzer™ Amulet™ (St. Jude Medical, St. Paul, MN, USA) in 34 patients (96.1 and 97.1%, respectively; p = 1.00). Major access site bleedings were more frequent in the Amplatzer™ Amulet™ group (8.9 versus 1.4%; p = 0.046). No intra-hospital thromboembolic event was present. During 6 months follow-up, peri-device leaks > 5 mm and thromboembolic events were uncommon (each p = n.s.). Conclusions While procedural success was equally high with both contemporary devices, complications during follow-up were rare, and evenly distributed.
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Affiliation(s)
- Christian Fastner
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Centre for AngioScience (ECAS), and DZHK (German Centre for Cardiovascular Research) partner site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Lea Hoffmann
- Department of Cardiology, University Hospital Rostock, Rostock, Germany
| | - Mohamed Aboukoura
- Department of Cardiology, University Hospital Rostock, Rostock, Germany
| | - Michael Behnes
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Centre for AngioScience (ECAS), and DZHK (German Centre for Cardiovascular Research) partner site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Siegfried Lang
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Centre for AngioScience (ECAS), and DZHK (German Centre for Cardiovascular Research) partner site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Centre for AngioScience (ECAS), and DZHK (German Centre for Cardiovascular Research) partner site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Centre for AngioScience (ECAS), and DZHK (German Centre for Cardiovascular Research) partner site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christoph A Nienaber
- Royal Brompton Hospital, London, United Kingdom and National Heart and Lung Institute, Imperial College London, London, UK
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Han TS, Fry CH, Fluck D, Affley B, Gulli G, Barrett C, Kakar P, Patel T, Sharma S, Sharma P. Anticoagulation therapy in patients with stroke and atrial fibrillation: a registry-based study of acute stroke care in Surrey, UK. BMJ Open 2018; 8:e022558. [PMID: 29997144 PMCID: PMC6089275 DOI: 10.1136/bmjopen-2018-022558] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Because of their high risk of stroke, anticoagulation therapy is recommended for most patients with atrial fibrillation (AF). The present study evaluated the use of anticoagulants in the community and in a hospital setting for patients with AF and its associations with stroke. METHODS Patients admitted with stroke to four major hospitals in County of Surrey, England were surveyed in the 2014-2016 Sentinel Stroke National Audit Programme. Descriptive statistics was used to summarise subject characteristics and χ² test to assess differences between categorical variables. RESULTS A total of 3309 patients, 1656 men (mean age: 73.1 years±SD 13.2) and 1653 women (79.3 years±13.0) were admitted with stroke (83.3% with ischaemic, 15.7% haemorrhagic stroke and 1% unspecified). AF occurred more frequently (χ2=62.4; p<0.001) among patients admitted with recurrent (30.2%) rather than with first stroke (17.1%). There were 666 (20.1%) patients admitted with a history of AF, among whom 304 (45.3%) were anticoagulated, 279 (41.9%) were untreated and 85 (12.8%) deemed unsuitable for anticoagulation. Of the 453 patients with history of AF admitted with a first ischaemic stroke, 138 (37.2%) were on anticoagulation and 41 (49.6%) were not (χ2 = 6.3; p<0.043) and thrombolysis was given more frequently for those without prior anticoagulation treatment (16.1%) or unsuitable for anticoagulation (23.6%) compared with those already on anticoagulation treatment (8.3%; χ2=10.0; p=0.007). Of 2643 patients without a previous history of AF, 171 (6.5%) were identified with AF during hospitalisation. Of patients with AF who presented with ischaemic stroke who were not anticoagulated or deemed unsuitable for anticoagulation prior to admission, 91.8% and 75.0%, respectively, were anticoagulated on discharge. CONCLUSIONS The study highlights an existing burden for patients with stroke and reflects inadequate treatment of AF which results in an increased stroke burden. There is significant scope to improve the rates of anticoagulation.
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Affiliation(s)
- Thang S Han
- Institute of Cardiovascular Research, Royal Holloway, University of London, London, UK
| | - Christopher Henry Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
| | - David Fluck
- Department of Cardiology, Ashford and St Peter's NHS Foundation Trust, Chertsey, UK
| | - Brendan Affley
- Department of Stroke, Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, UK
| | - Giosue Gulli
- Department of Stroke, Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, UK
| | | | - Puneet Kakar
- Department of Stroke, Epsom and St Helier University Hospitals, Epsom, UK
| | - Tasmin Patel
- Institute of Cardiovascular Research, Royal Holloway, University of London, London, UK
| | - Sapna Sharma
- Institute of Cardiovascular Research, Royal Holloway, University of London, London, UK
| | - Pankaj Sharma
- Institute of Cardiovascular Research, Royal Holloway, University of London, London, UK
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Lubitz SA, Khurshid S, Weng LC, Doros G, Keach JW, Gao Q, Gehi AK, Hsu JC, Reynolds MR, Turakhia MP, Maddox TM. Predictors of oral anticoagulant non-prescription in patients with atrial fibrillation and elevated stroke risk. Am Heart J 2018; 200:24-31. [PMID: 29898845 DOI: 10.1016/j.ahj.2018.03.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 03/07/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND Many patients with atrial fibrillation (AF) and elevated stroke risk are not prescribed oral anticoagulation (OAC) despite evidence of benefit. Identification of factors associated with OAC non-prescription could lead to improvements in care. METHODS AND RESULTS Using NCDR PINNACLE, a United States-based ambulatory cardiology registry, we examined factors associated with OAC non-prescription in patients with non-valvular AF at elevated stroke risk (CHA2DS2-VASc ≥2) between January 5, 2008 and December 31, 2014. Among 674,841 patients, 57% were treated with OAC (67% of whom were treated with warfarin). OAC prescription varied widely (28%-75%) across preselected strata of age, stroke risk (CHA2DS2-VASc), and bleeding risk (HAS-BLED), generally indicating that older patients at high stroke and low bleeding risk are commonly treated with OAC. Other factors associated with OAC non-prescription included reversible AF etiology; female sex; liver, renal, or vascular disease; and physician versus non-physician provider. Antiplatelet use was common (57%) and associated with the greatest risk of OAC non-prescription (odds ratio [OR] 4.44, 95% confidence interval [CI] 4.39-4.49). CONCLUSIONS In this registry of AF patients, older patients at elevated stroke and low bleeding risk were commonly treated with OAC. However, a variety of factors were associated with OAC non-prescription. Specifically, antiplatelet use was prevalent and associated with the highest likelihood of OAC non-prescription. Future studies are warranted to understand provider and patient rationale that may underlie observed associations with OAC non-prescription.
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Gundlund A, Xian Y, Peterson ED, Butt JH, Gadsbøll K, Bjerring Olesen J, Køber L, Torp-Pedersen C, Gislason GH, Loldrup Fosbøl E. Prestroke and Poststroke Antithrombotic Therapy in Patients With Atrial Fibrillation: Results From a Nationwide Cohort. JAMA Netw Open 2018; 1:e180171. [PMID: 30646049 PMCID: PMC6324317 DOI: 10.1001/jamanetworkopen.2018.0171] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
IMPORTANCE Antithrombotic therapies are effective in both primary and secondary stroke prophylaxis in high-risk patients with atrial fibrillation (AF), but they are often underused in community practice. OBJECTIVE To examine prestroke and poststroke antithrombotic treatment patterns and long-term outcomes in patients with AF presenting with ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of Danish patients with AF, with a prestroke CHA2DS2-VASc score of 1 or higher for men and 2 or higher for women, and presenting with ischemic stroke was conducted from January 1, 2004, to January 31, 2017. Data on hospital admission, prescription fillings, and vital status were assessed using several Danish nationwide registries. EXPOSURES Patients who survived 100 days after discharge were divided into 3 groups according to poststroke antithrombotic therapy: oral anticoagulation (OAC) therapy, antiplatelet therapy alone, or no antithrombotic therapy. MAIN OUTCOMES AND MEASURES Long-term outcomes (thromboembolic events and bleeding complications) were examined using multivariable Cox regression analyses across the 3 groups. RESULTS Among 30 626 patients with AF admitted with ischemic stroke, 11 139 patients (36.3%) received OAC therapy (44.3% female; median age, 79 years [interquartile range, 73-85 years]), 11 874 (38.8%) received antiplatelet therapy alone (55.0% female; median age, 82 years [interquartile range, 75-88 years]), and 7613 (24.9%) received no antithrombotic therapy before stroke (53.8% female; median age, 80 years [interquartile range, 71-86 years]). Following stroke, 31.3% of those receiving antiplatelet therapy alone and 43.7% of those receiving no antithrombotic therapy before stroke shifted to OAC therapy. Yet, 37.5% of patients with stroke did not receive OAC therapy following stroke. However, OAC treatment rates increased over time. During a maximum of 10 years of follow-up, 17.5%, 21.2%, and 21.5% experienced a new thromboembolic event and 72.7%, 86.4%, and 86.2% died among those treated with OAC therapy, antiplatelet therapy, or no antithrombotic therapy, respectively. Poststroke OAC therapy was associated with lower risk of recurrent thromboembolic events (adjusted hazard ratio, 0.81; 95% CI, 0.73-0.89) and no significant difference in bleeding complications (adjusted hazard ratio, 0.97; 95% CI, 0.86-1.10), compared with no poststroke antithrombotic therapy. In contrast, there were no significant differences for those treated with poststroke antiplatelet therapy and no antithrombotic therapy. CONCLUSIONS AND RELEVANCE Patients with AF receiving poststroke OAC therapy had lower risk of recurrent thromboembolic events. Our findings suggest a substantial opportunity for improving primary and secondary stroke prophylaxis in high-risk patients with AF.
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Affiliation(s)
- Anna Gundlund
- Department of Cardiology, Gentofte Hospital, Hellerup, Denmark
| | - Ying Xian
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Jawad H. Butt
- Department of Cardiology, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Kasper Gadsbøll
- Department of Cardiology, Gentofte Hospital, Hellerup, Denmark
| | | | - Lars Køber
- Department of Cardiology, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Epidemiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Gunnar H. Gislason
- Department of Cardiology, Gentofte Hospital, Hellerup, Denmark
- Danish Heart Foundation, Copenhagen, Denmark
- National Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, University Hospital of Copenhagen, Copenhagen, Denmark
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Liu S, Li X, Shi Q, Hamilton M, Friend K, Zhao Y, Horblyuk R, Hede S, Shi L. Outcomes associated with warfarin time in therapeutic range among US veterans with nonvalvular atrial fibrillation. Curr Med Res Opin 2018; 34:415-421. [PMID: 28945114 DOI: 10.1080/03007995.2017.1384370] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Poor quality of warfarin control (time in therapeutic range [TTR] < 65%) can lead to increased risk of adverse events. The objective of this study was to examine the overall quality of international normalized ratio (INR) control and the association of TTR with clinical outcomes including stroke, major bleeding, and all-cause mortality among US warfarin users. METHODS AND RESULTS This retrospective observational cohort study utilized the US Veterans Affairs electronic medical records database (VA EMR). Patients with NVAF who newly initiated warfarin from 1 January 2005 to 31 December 2015 were grouped into two cohorts based on TTR <65% or ≥65%. TTR was computed from INR test results. Clinical outcomes assessed were stroke/systemic embolism (SE), hemorrhagic stroke, ischemic stroke, and major bleeding, defined based on hospitalization with those conditions as primary diagnosis, as well as all-cause mortality. Patients were followed from warfarin initiation to the first occurrence of an outcome or censoring. Propensity score weighted time-varying Cox regression was used to evaluate the risk of the clinical events. A total of 127,385 NVAF patients with mean TTR of 51% were included. TTR <65% was observed in 65% of patients. Mean CHA2DS2-VASC score (SD) was 2.9 (1.5) in the low TTR cohort and 2.7 (1.4) in the high TTR cohort. Patients with TTR <65% had a higher risk for any stroke/SE (HR: 1.57; 95% CI: 1.41-1.75), major bleeding (HR: 2.78; 95% CI: 2.55-3.03) and all-cause mortality (HR: 1.73; 95% CI: 1.67-1.79). CONCLUSIONS The observed quality of warfarin control in VA EMR suggests room for improvement given the association with elevated risk of adverse clinical outcomes.
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Affiliation(s)
- Shuqian Liu
- a Tulane University School of Public Health and Tropical Medicine , New Orleans , LA , USA
| | - Xiaoyan Li
- b Bristol-Myers Squibb , Lawrence , NJ , USA
| | - Qian Shi
- a Tulane University School of Public Health and Tropical Medicine , New Orleans , LA , USA
| | | | | | - Yingnan Zhao
- c Xavier University of Louisiana , New Orleans , LA , USA
| | | | | | - Lizheng Shi
- a Tulane University School of Public Health and Tropical Medicine , New Orleans , LA , USA
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Yerasi C, Lazkani M, Kolluru P, Miryala V, Kim J, Moole H, Sawant AC, Morris M, Pershad A. An updated systematic review and meta-analysis of early outcomes after left atrial appendage occlusion. J Interv Cardiol 2018; 31:197-206. [DOI: 10.1111/joic.12502] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/24/2018] [Indexed: 12/31/2022] Open
Affiliation(s)
- Charan Yerasi
- St. Joseph's Hospital and Medical Center; Phoenix Arizona
| | - Mohamad Lazkani
- University of Arizona; Banner University Medical Center; Phoenix Arizona
| | - Prathik Kolluru
- MedStar Georgetown University/MedStar Washington Hospital Center; Washington District of Columbia
| | | | - Jae Kim
- MedStar Georgetown University/MedStar Washington Hospital Center; Washington District of Columbia
| | - Harsha Moole
- University of Illinois College of Medicine; Peoria Illinois
| | | | - Michael Morris
- University of Arizona; Banner University Medical Center; Phoenix Arizona
| | - Ashish Pershad
- University of Arizona; Banner University Medical Center; Phoenix Arizona
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Shendre A, Parmar GM, Dillon C, Beasley TM, Limdi NA. Influence of Age on Warfarin Dose, Anticoagulation Control, and Risk of Hemorrhage. Pharmacotherapy 2018; 38:588-596. [PMID: 29393514 DOI: 10.1002/phar.2089] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE We assessed the influence of age on warfarin dose, percentage time in target range (PTTR), and risk of major hemorrhage. DESIGN Warfarin users recruited into a large prospective inception cohort study were categorized into three age groups: young (younger than 50 yrs), middle aged (50-70 yrs), and elderly (older than 70 yrs). The influence of age on warfarin dose and PTTR was assessed using regression analysis; risk of major hemorrhage was assessed using proportional hazards analysis. Models were adjusted for demographic, clinical, and genetic factors. SETTING Two outpatient anticoagulation clinics. PARTICIPANTS A total of 1498 anticoagulated patients. OUTCOMES Warfarin dose (mg/day), PTTR, major hemorrhage. RESULTS Of the 1498 patients, 22.8% were young, 44.1% were middle aged, and 33.1% were elderly. After accounting for clinical and genetic factors, compared with young warfarin users, warfarin dose requirements were 10.6% lower among the middle aged and an additional 10.6% lower for the elderly. Compared with young patients, middle-aged and elderly patients spent more time in target international normalized ratio (INR) range (p<0.0001), despite having fewer INR assessments (p<0.0001). Compared with young warfarin users, absolute risk of hemorrhage was marginally higher among the middle aged (p=0.08) and significantly higher among the elderly (p=0.016). Compared with young warfarin users, after adjustment, the relative risk of hemorrhage increased by 31% for each age category (p=0.026). CONCLUSIONS In a real-world setting, despite achieving better anticoagulation control, elderly patients had a higher risk of major hemorrhagic events. As the population ages and the candidacy for oral anticoagulation increases, strategies that mitigate the elevated risk of hemorrhage need to be identified.
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Affiliation(s)
- Aditi Shendre
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana
| | - Gaurav M Parmar
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chrisly Dillon
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Timothy Mark Beasley
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nita A Limdi
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Joppa SA, Salciccioli J, Adamski J, Patel S, Wysokinski W, McBane R, Al-Saffar F, Esser H, Shamoun F. A Practical Review of the Emerging Direct Anticoagulants, Laboratory Monitoring, and Reversal Agents. J Clin Med 2018; 7:E29. [PMID: 29439477 PMCID: PMC5852445 DOI: 10.3390/jcm7020029] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/22/2018] [Accepted: 01/23/2018] [Indexed: 12/27/2022] Open
Abstract
Millions of patients in the United States use anticoagulation for a variety of indications, such as the prevention of stroke in those with atrial fibrillation (AF) and the treatment and prevention of venous thrombosis. For over six decades warfarin was the only available oral anticoagulant, but now several DOACs are available and their use has become more prevalent in recent years. In spite of this increased use, many physicians remain reluctant to prescribe DOACs due to concerns about bleeding and reversibility.
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Affiliation(s)
| | | | - Jill Adamski
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Salma Patel
- Center for Sleep Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | | | - Robert McBane
- Center for Sleep Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | - Farah Al-Saffar
- Department of Cardiology, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Heidi Esser
- Midwestern University, Glendale, AZ 85308, USA.
| | - Fadi Shamoun
- Department of Cardiology, Mayo Clinic, Phoenix, AZ 85054, USA.
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Safety and Efficacy of Transcatheter Left Atrial Appendage Closure for Stroke Prevention in Patients with Atrial Fibrillation. Prog Cardiovasc Dis 2018; 60:542-549. [PMID: 29339165 DOI: 10.1016/j.pcad.2018.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 01/10/2018] [Indexed: 12/13/2022]
Abstract
Atrial Fibrillation (AF) is associated with a substantial risk of thromboembolic stroke. Although long-term treatment with warfarin or the non-vitamin K oral anticoagulants can reduce this risk, such therapy is underutilized, and safe and consistent long-term treatment can be challenging. Transcatheter left atrial appendage (LAA) closure is an emerging alternative to long-term oral anticoagulation. Long-term follow-up of randomized clinical trials demonstrate that Watchman LAA closure provides significant reductions in hemorrhagic stroke, cardiovascular death, and all-cause mortality compared with continued warfarin therapy. Major bleeding is also reduced compared with continued warfarin therapy once the post-implant pharmacologic regimen is completed. This review summarizes the current dataset for the safety and efficacy of transcatheter LAA closure, and highlights the gaps in evidence and future directions for clinical research.
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Teramae T, Noda T, Morimoto J. EMG-Based Model Predictive Control for Physical Human–Robot Interaction: Application for Assist-As-Needed Control. IEEE Robot Autom Lett 2018. [DOI: 10.1109/lra.2017.2737478] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Münzel T, Konstantinides S. Apixaban. Hamostaseologie 2017; 32:203-11. [DOI: 10.5482/hamo-12-05-0010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 06/19/2012] [Indexed: 11/05/2022] Open
Abstract
SummaryApixaban is a potent reversible inhibitor of the activated human coagulation factor X. This new oral anticoagulant has favourable pharmacokinetic and pharmocodynamic properties which include a concentration-dependent anticoagulant effect, good oral bioavailability, balanced elimination and excretion, infrequent drug or food interactions, and the lack of liver toxicity. Apixaban has already completed a large part of its phase 3 clinical trial programme. In the ARISTOTLE study, which focused on stroke prevention in atrial fibrillation, apixaban showed a balanced efficacy and safety profile, being superior to warfarin both in the prevention of strokes and in the risk of causing major bleeding. A further trial related to this indication, AVERROES, demonstrated the clear superiority of apixaban compared to aspirin treatment. In the primary prophylaxis of venous thromboembolism after orthopaedic surgery, apixaban successfully completed the ADVANCE study programme and was approved in Europe for patients undergoing elective hip or knee replacement. The results of the AMPLIFY and AMPLIFY- EXT studies will soon show whether the inhibitor is also effective in the treatment and secondary prophylaxis after acute deep vein thrombosis and pulmonary embolism. On the other hand, the use of apixaban in the primary prophylaxis of venous thrombosis in hospitalised medical patients, and its administration on top of antiplatelet therapy to patients who have suffered an acute coronary syndrome, have not received support by the results of ADOPT and APPRAISE-II, respectively. In conclusion, on the basis of the available evidence, apixaban appears to be a valuable therapeutic option for the prevention of venous thrombosis and embolic stroke.
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Han TS, Fry CH, Fluck D, Affley B, Gulli G, Barrett C, Kakar P, Patel T, Sharma S, Sharma P. Evaluation of anticoagulation status for atrial fibrillation on early ischaemic stroke outcomes: a registry-based, prospective cohort study of acute stroke care in Surrey, UK. BMJ Open 2017; 7:e019122. [PMID: 29247109 PMCID: PMC5736041 DOI: 10.1136/bmjopen-2017-019122] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE The relationship of anticoagulation therapies with stroke severity and outcomes have been well documented in the literature. However, none of the previous research has reported the relationship of atrial fibrillation (AF)/anticoagulation therapies with urinary tract infection (UTI), pneumonia and length of stay in hyperacute stroke units (HASUs). The present study aimed to evaluate AF and anticoagulation status in relation to early outcomes in 1387 men (median age=75 years, IQR=65-83) and 1371 women (median age=83 years, IQR=74-89) admitted with acute ischaemic stroke to HASUs in Surrey between 2014 and 2016. METHODS We conducted this registry-based, prospective cohort study using data from the Sentinel Stroke National Audit Programme. Association between AF anticoagulation status with severe stroke on arrival (National Institutes of Health Stroke Scale score ≥16), prolonged HASU stay (>3 weeks), UTI and pneumonia within 7 days of admission, severe disability on discharge (modified Rankin Scale score=4 and 5) and inpatient mortality was assessed by logistic regression, adjusted for age, sex, hypertension, congestive heart failure, diabetes and previous stroke. RESULTS Compared with patients with stroke who are free from AF, those with AF without anticoagulation had an increased adjusted risk of having more severe stroke: 5.8% versus 14.0%, OR=2.4 (95% CI 1.6 to 3.6, P<0.001), prolonged HASU stay: 21.5% versus 32.0%, OR=1.4 (1.0-2.0, P=0.027), pneumonia: 8.2% versus 19.1%, OR=2.1 (1.4-2.9, P<0.001), more severe disability: 24.2% versus 40.4%, OR=1.6 (1.2-2.1, P=0.004) and mortality: 9.3% versus 21.7%, OR=1.9 (1.4-2.8, P<0.001), and AF patients with anticoagulation also had greater risk for having UTI: 8.6% versus 12.3%, OR=1.9 (1.2-3.0, P=0.004), pneumonia: 8.2% versus 11.5%, OR=1.6 (1.1-2.4, P=0.025) and mortality: 9.7% versus 21.7%, OR=1.9 (1.4-2.8, P<0.001). The median HASU stay for stroke patients with AF without anticoagulation was 10.6 days (IQR=2.8-26.4) compared with 5.8 days (IQR=2.3-17.5) for those free from AF (P<0.001). CONCLUSIONS Patients with AF, particularly those without anticoagulation, are at increased risk of severe stroke, associated with prolonged HASU stay and increased risk of early infection, disability and mortality.
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Affiliation(s)
- Thang S Han
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, UK
- Department of Endocrinology, Ashfordand St Peter's NHS Foundation Trust, Chertsey, UK
| | - Christopher H Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
| | - David Fluck
- Department of Cardiology, Ashford and St Peter's NHS Foundation Trust, Chertsey, UK
| | - Brendan Affley
- Department of Stroke, Ashford and St Peter's NHS Foundation Trust, Chertsey, UK
| | - Giosue Gulli
- Department of Stroke, Ashford and St Peter's NHS Foundation Trust, Chertsey, UK
| | | | - Puneet Kakar
- Department of Stroke, Epsom and St Helier University Hospitals, Epsom, UK
| | - Tasmin Patel
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, UK
| | - Sapna Sharma
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, UK
| | - Pankaj Sharma
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, UK
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Gallego P, Roldan V, Marín F, Romera M, Valdés M, Vicente V, Lip GYH. Cessation of oral anticoagulation in relation to mortality and the risk of thrombotic events in patients with atrial fibrillation. Thromb Haemost 2017; 110:1189-98. [PMID: 24096615 DOI: 10.1160/th13-07-0556] [Citation(s) in RCA: 169] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 08/19/2013] [Indexed: 11/05/2022]
Abstract
SummaryBleeding risk (often perceived, rather than actual) is a common reason for cessation of oral anticoagulation with Vitamin K antagonists (VKA). We investigate clinical outcomes in a consecutive population of VKA naïve atrial fibrillation (AF) patients, who initiated VKA therapy in our clinic. We included consecutive VKA-naíve patients with non valvular AF, initiated on VKA therapy in our anticoagulation outpatient clinic in 2009. During follow-up, adverse events [thrombotic/vascular events (stroke, acute coronary syndrome, acute heart failure and cardiac death), major bleeding and death], and VKA cessation were recorded. At the end of the follow-up, we determined time within therapeutic range (TTR), using a linear approximation (Rosendaal method). We studied 529 patients (49% male, median age 76), median follow-up 835 days (IQR 719−954). During this period 114 patients stopped VKA treatment. 63 patients suffered a thrombotic/cardiovascular event (5.17%/year, 27 thrombotic/ischaemic strokes), 51 major bleeding (4.19%/year) and 48 died (3.94%/year). Median TTR was 54% (34a57). On multivariate analysis (adjusted by CHA2DS2-VASc score), VKA cessation was associated with death [Hazard Ratio (HR) 3.43; p<0.001], stroke [4.21; p=0.001] and thrombotic/cardiovascular events [2.72; p<0.001]. Independent risk factors for major bleeding were age [1.08; p<0.001], previous stroke [1.85; p=0.049], and TTR [0.97; p=0.001], but not VKA cessation. In conclusion, in AF patients AF, VKA cessation is independently associated with mortality stroke and cardiovascular events. Specifically, VKA cessation independently increased the risk of stroke, even after adjusting for CHA2DS2-VASc score. TTR was an independent risk factor for major bleeding following initiation of VKA therapy.Note: The editorial process for this paper was fully handled by Prof Christian Weber, Editor in Chief.
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Rivera-Caravaca JM, Roldán V, Esteve-Pastor MA, Valdés M, Vicente V, Lip GYH, Marín F. Cessation of oral anticoagulation is an important risk factor for stroke and mortality in atrial fibrillation patients. Thromb Haemost 2017; 117:1448-1454. [DOI: 10.1160/th16-12-0961] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 02/23/2017] [Indexed: 12/15/2022]
Abstract
SummaryOral anticoagulation (OAC) is highly effective preventing stroke and mortality in AF, but withdrawal is common in the elderly, when high bleeding risk and when are difficulties achieving an optimal time in therapeutic range (TTR). We analysed the rate of OAC cessation, predisposing factors to cessation and the relation to clinical outcomes in a large ‘real world’ cohort of AF patients over a long follow-up period. Consecutive non-valvular AF outpatients clinically stables for six months were recruited. Rates of cardiovascular events, major bleeding and mortality were recorded and related to OAC cessation. We included 1361 patients (48.7 % male; aged 76, IQR 71–81), followed-up for a median of 6.5 years. During follow-up, 244 patients suffered thrombotic events, 250 suffered from major bleeding and 551 patients died. 10 % of patients stopped OAC. After OAC withdrawal, there were 36 thromboembolic events (22 strokes), 10 major bleedings and 75 deaths. OAC cessation was independently associated with adverse cardiovascular events (HR 1.45; 95 % CI 1.01–2.08), stroke/TIA (HR 1.85; 1.17–2.94) and all-cause mortality (HR 1.30; 1.02–1.67). Independent predictors of OAC cessation were age ≥80 (HR 2.29; 1.60–3.29), previous coronary artery disease (HR 0.32; 0.15–0.71), major bleeding (HR 5.00; 3.49–7.15), heart failure (HR 2.38; 1.26–4.47), cancer (HR 5.24; 3.25–8.44) and renal impairment developed during follow-up (HR 2.70; 1.26–5.75). In conclusion, in non-valvular AF patients, cessation of OAC was independently associated with the risk of stroke, adverse cardiovascular events and mortality. Bleeding events and some variables associated with higher bleeding risk are responsible for OAC cessation.Note: The review process for this manuscript was fully handled by Christian Weber, Editor in Chief.Supplementary Material to this article is available online at www.thrombosis-online.com.
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Jazayeri MA, Vuddanda V, Turagam MK, Parikh V, Lavu M, Atkins D, Earnest M, Di Biase L, Natale A, Wilber D, Reddy YM, Lakkireddy DR. Safety profiles of percutaneous left atrial appendage closure devices: An analysis of the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database from 2009 to 2016. J Cardiovasc Electrophysiol 2017; 29:5-13. [DOI: 10.1111/jce.13362] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/29/2017] [Accepted: 10/02/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Mohammad-Ali Jazayeri
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Venkat Vuddanda
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Mohit K. Turagam
- Division of Cardiovascular Disease; University of Missouri Hospital & Clinics; Columbia MO USA
| | - Valay Parikh
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Madhav Lavu
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Donita Atkins
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Matthew Earnest
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
- Mid-America Cardiology, Bloch Heart Rhythm Center; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Luigi Di Biase
- Electrophysiology Section; Albert Einstein College of Medicine at Montefiore Medical Center; Bronx NY USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center; Austin TX USA
| | - David Wilber
- Division of Cardiovascular Medicine; Loyola University Medical Center; Chicago IL
| | - Yeruva Madhu Reddy
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
- Mid-America Cardiology, Bloch Heart Rhythm Center; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Dhanunjaya R. Lakkireddy
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
- Mid-America Cardiology, Bloch Heart Rhythm Center; University of Kansas Hospital & Medical Center; Kansas City KS USA
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Khurshid S, Weng LC, Hulme OL, Ellinor PT, Lubitz SA. Factors Associated with Anticoagulation Delay Following New-Onset Atrial Fibrillation. Am J Cardiol 2017; 120:1316-1321. [PMID: 28823487 DOI: 10.1016/j.amjcard.2017.07.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/16/2017] [Accepted: 07/05/2017] [Indexed: 11/17/2022]
Abstract
Oral anticoagulation (OAC) is effective yet reportedly underutilized for stroke prevention in atrial fibrillation (AF). Factors associated with delayed OAC after incident AF are unknown. Using a large electronic medical record, we identified incident episodes of AF diagnosed in 2006 to 2014 using a validated algorithm. Among patients with a Congestive heart failure, Hypertension, Age, Diabetes, and Stroke (CHADS2) score ≥1 started on OAC within 1 year, we examined baseline characteristics at AF diagnosis and their association with time to OAC using multivariable Cox proportional hazards modeling. Of 4,388 patients with incident AF and CHADS2 score ≥1 who were started on OAC within 1 year, the mean age was 72.6, and 41% were women. Median time to OAC was 5 days (interquartile range 1 to 43), and most patients received warfarin (86.3%). Among patients without prevalent stroke, 98 strokes (2.2% of the sample) occurred between AF diagnosis and OAC initiation. In multivariable analyses, several factors were associated with delayed OAC including female gender (hazard ratio [HR] 1.08, 95% confidence interval [CI] 1.01 to 1.15), absence of hypertension (HR 1.15, 95% CI 1.03 to 1.27), previous fall (HR 1.53, 95% CI 1.08 to 2.17), and chronic kidney disease (HR 1.12, 95% CI 1.04 to 1.21). Among women, OAC prescription at 1, 3, and 6 months was 70.0%, 81.7%, and 89.5%, respectively, whereas for men, OAC prescription was 73.4%, 84.0%, and 91.5%, respectively. Most patients with new AF and elevated stroke risk started on OAC receive it within 1 week, although the promptness of initiation varies. The stroke rate is substantial in the period between AF diagnosis and OAC initiation. Interventions targeting identified risk factors for delayed OAC may result in improved outcomes.
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Affiliation(s)
- Shaan Khurshid
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Lu-Chen Weng
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Olivia L Hulme
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Patrick T Ellinor
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts; Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts
| | - Steven A Lubitz
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts; Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts.
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Bisson A, Clementy N, Bodin A, Angoulvant D, Babuty D, Lip GY, Fauchier L. Relationship of Preexisting Cardiovascular Comorbidities to Newly Diagnosed Atrial Fibrillation After Ischemic Stroke. Stroke 2017; 48:2878-2880. [DOI: 10.1161/strokeaha.117.018251] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 07/31/2017] [Accepted: 08/08/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Arnaud Bisson
- From the Cardiologie, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Tours, France (A.B., N.C., A.B., D.A., D.B., L.F.); and University of Birmingham Centre for Cardiovascular Sciences, United Kingdom (G.Y.H.L.)
| | - Nicolas Clementy
- From the Cardiologie, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Tours, France (A.B., N.C., A.B., D.A., D.B., L.F.); and University of Birmingham Centre for Cardiovascular Sciences, United Kingdom (G.Y.H.L.)
| | - Alexandre Bodin
- From the Cardiologie, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Tours, France (A.B., N.C., A.B., D.A., D.B., L.F.); and University of Birmingham Centre for Cardiovascular Sciences, United Kingdom (G.Y.H.L.)
| | - Denis Angoulvant
- From the Cardiologie, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Tours, France (A.B., N.C., A.B., D.A., D.B., L.F.); and University of Birmingham Centre for Cardiovascular Sciences, United Kingdom (G.Y.H.L.)
| | - Dominique Babuty
- From the Cardiologie, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Tours, France (A.B., N.C., A.B., D.A., D.B., L.F.); and University of Birmingham Centre for Cardiovascular Sciences, United Kingdom (G.Y.H.L.)
| | - Gregory Y.H. Lip
- From the Cardiologie, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Tours, France (A.B., N.C., A.B., D.A., D.B., L.F.); and University of Birmingham Centre for Cardiovascular Sciences, United Kingdom (G.Y.H.L.)
| | - Laurent Fauchier
- From the Cardiologie, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Tours, France (A.B., N.C., A.B., D.A., D.B., L.F.); and University of Birmingham Centre for Cardiovascular Sciences, United Kingdom (G.Y.H.L.)
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Lacoin L, Lumley M, Ridha E, Pereira M, McDonald L, Ramagopalan S, Lefèvre C, Evans D, Halcox JP. Evolving landscape of stroke prevention in atrial fibrillation within the UK between 2012 and 2016: a cross-sectional analysis study using CPRD. BMJ Open 2017; 7:e015363. [PMID: 28951401 PMCID: PMC5623501 DOI: 10.1136/bmjopen-2016-015363] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To describe the changes in prescribing of oral anticoagulant (AC) and antiplatelet (AP) agents in patients with non-valvular atrial fibrillation (NVAF) in the UK and to identify the characteristics associated with deviation from guideline-based recommendations. DESIGN Five cross-sectional analyses in a large retrospective population-based cohort study. SETTING General practices contributing data to the UK Clinical Practice Research Datalink. PARTICIPANTS The study included patients with a diagnosis of NVAF and eligible for anticoagulation (CHA2DS2-VASc score ≥2) on 1 April of 2012, 2013, 2014, 2015 and 1st January 2016. RESULTS The proportion of patients being treated with AC increased at each index date, showing an absolute rise of 16.7% over the study period. At the same time, the proportion of patients treated with an AP alone was reduced by half, showing an absolute decrease of 16.8%. The proportion of patients not receiving any antithrombotic (AT) treatment remained the same across the study period. A number of predictors were identified for AP alone or no treatment compared with AC treatment. CONCLUSION Major improvements in the AT management of patients with NVAF for stroke prevention in the UK were observed between April 2012 and January 2016. Despite this, nearly 20% of at-risk patients still received AP alone and over 15% were on no AT agents in January 2016.
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Affiliation(s)
- Laure Lacoin
- UK Medical Department, Bristol-Myers Squibb, Uxbridge, UK
| | | | - Essra Ridha
- UK Medical Department, Bristol-Myers Squibb, Uxbridge, UK
| | | | | | | | - Cinira Lefèvre
- Center of Observational Research and Data Sciences, Business Insights and Analytics, Bristol-Myers Squibb, Rueil Malmaison, France
- Worldwide Health Economics & Outcomes Research, Bristol-Myers Squibb, Rueil Malmaison, France
| | - David Evans
- Worldwide Health Economics & Outcomes Research, Bristol-Myers Squibb, Rueil Malmaison, France
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44
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O'Neill ES, Grande SW, Sherman A, Elwyn G, Coylewright M. Availability of patient decision aids for stroke prevention in atrial fibrillation: A systematic review. Am Heart J 2017; 191:1-11. [PMID: 28888264 DOI: 10.1016/j.ahj.2017.05.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 05/28/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND Atrial fibrillation is a common irregular heart rhythm that increases patients' risk of stroke. Aspirin, warfarin, direct oral anticoagulants, and an implantable device can reduce this risk. Given the availability of multiple comparable options, this decision depends on patient preferences and is appropriate for the use of decision aids and other efforts to promote shared decision making. The objective of this review was to examine the existence and accessibility of, as well as select outcomes associated with, published, formally evaluated patient decision aids for stroke prevention in atrial fibrillation. METHODS Six databases were searched from inception to March 2016 with a research librarian. Two authors independently reviewed potential articles, selected trials meeting inclusion criteria, and assessed outcome measures. Outcomes included patient knowledge, involvement, choice, and decisional conflict. RESULTS The search resulted in 666 articles; most were excluded for not examining stroke prevention in atrial fibrillation and 7 studies were eventually included. Six decision aids displayed combinations of aspirin, warfarin, or no therapy; 1 included a direct oral anticoagulant. Interventions were associated with increased patient knowledge, increased likelihood of making a choice, and low decisional conflict. Use of decision aids in this review was associated with less selection of warfarin. None of the tested decision aids are currently available. DISCUSSION Published patient decision aids for stroke prevention in atrial fibrillation are not accessible for clinical use. Given the availability of multiple comparable options, there is a need to develop and test new patient decision aids in this context.
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45
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Caliskan E, Cox JL, Holmes DR, Meier B, Lakkireddy DR, Falk V, Salzberg SP, Emmert MY. Interventional and surgical occlusion of the left atrial appendage. Nat Rev Cardiol 2017; 14:727-743. [DOI: 10.1038/nrcardio.2017.107] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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46
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Fastner C, Behnes M, Ansari U, El-Battrawy I, Borggrefe M. Interventional Left Atrial Appendage Closure: Focus on Practical Implications. Interv Cardiol 2017. [DOI: 10.5772/67773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Isaew A, Adderley NJ, Ryan R, Fitzmaurice D, Marshall T. The treatment of paroxysmal atrial fibrillation in UK primary care. Heart 2017; 103:1502-1507. [PMID: 28572399 DOI: 10.1136/heartjnl-2016-310927] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 03/15/2017] [Accepted: 03/15/2017] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To determine whether patients with paroxysmal atrial fibrillation (AF) are less likely to be treated with anticoagulants than patients with persistent/permanent AF and to investigate trends in treatment between 2000 and 2015. UK and European guidelines recommend that anticoagulants are offered to all patients with AF at increased risk of stroke, irrespective of AF type. METHODS Sixteen sequential cross-sectional analyses from 2000 to 2015 were carried out with index dates on 1st of May each year. The data source was primary care data from 648 practices across the UK contributing to The Health Improvement Network database. All patients with a diagnosis of AF aged ≥35 years and registered for at least 1 year were included. The main outcome measure was prescription of anticoagulant medication. RESULTS The proportion of patients with AF with a diagnosis of paroxysmal AF increased from 7.4% (95% CI 7.0 to 7.8) in 2000 to 14.0% (95% CI 13.7 to 14.3) in 2015. Among patients with a CHADS2 score of ≥1, between 2000 and 2015 the proportion prescribed anticoagulants increased from 18.8% (95% CI 16.4 to 21.4) to 56.2% (95% CI 55.0 to 57.3) and from 34.2% (95% CI 33.3 to 35.0) to 69.4% (95% CI 68.9 to 69.8) in patients with paroxysmal and other (persistent/permanent) AF, respectively; RR for treatment of patients with paroxysmal AF compared with patients with other AF increased from 0.48 (95% CI 0.42 to 0.55) to 0.76 (95% CI 0.74 to 0.77). Adjusting for age, sex, Townsend score and presence or absence of contraindications had little effect on the results. CONCLUSIONS In 2000, eligible patients with paroxysmal AF were half as likely to be treated with anticoagulants as patients with other AF; this has improved over time, but in 2015, eligible patients with paroxysmal AF were still around 20% less likely to be prescribed anticoagulant medication.
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Affiliation(s)
- Andrea Isaew
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Ronan Ryan
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - David Fitzmaurice
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Tom Marshall
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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48
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Yokokawa T, Yoshihisa A, Kanno Y, Sato T, Suzuki S, Misaka T, Oikawa M, Kobayashi A, Yamaki T, Kunii H, Nakazato K, Suzuki H, Saitoh SI, Takeishi Y. Clinical features of extremely elderly patients with heart failure. Geriatr Gerontol Int 2017; 17:2194-2199. [PMID: 28544166 DOI: 10.1111/ggi.13060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 01/25/2017] [Accepted: 02/20/2017] [Indexed: 01/23/2023]
Abstract
AIM To investigate the clinical features of heart failure in extremely elderly patients. METHODS We analyzed 1163 consecutive hospitalized heart failure patients. The patients were divided into an extremely elderly group (≥85 years-of-age, n = 88) and a non-extremely elderly group (<85 years-of-age, n = 1075). RESULTS The extremely elderly group had higher rates of hypertension, chronic kidney disease, anemia, higher systolic blood pressure and lower body mass index, and lower use of β-blockers and anticoagulants compared with the non-extremely elderly group. During the mean follow-up period of 1038 days, the extremely elderly group had higher mortality compared with the non-extremely elderly group (P < 0.001). In multivariate analysis, in the non-extremely elderly group, age (HR 1.027, P < 0.001), body mass index (HR 0.919, P < 0.001), New York Heart Association III or IV (HR 3.626, P < 0.001), preserved ejection fraction (HR 0.553, P < 0.001), anemia (HR 1.941, P < 0.001), β-blockers (HR 0.695, P = 0.028) and renin-angiotensin system inhibitors (HR 0.603, P = 0.001) were independent predictors for all-cause death. In contrast, atrial fibrillation (HR 2.042, P = 0.015) and renin-angiotensin system inhibitors (HR 0.470, P = 0.014) were independent predictors for all-cause death in the extremely elderly group, suggesting that the prognostic factors were different between the two groups. CONCLUSIONS We should be careful of atrial fibrillation and renin-angiotensin system inhibitors in managing extremely elderly patients with heart failure. Geriatr Gerontol Int 2017; 17: 2194-2199.
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Affiliation(s)
- Tetsuro Yokokawa
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Akiomi Yoshihisa
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Yuki Kanno
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Takamasa Sato
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Satoshi Suzuki
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Tomofumi Misaka
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Masayoshi Oikawa
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Atsushi Kobayashi
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Takayoshi Yamaki
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Hiroyuki Kunii
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Kazuhiko Nakazato
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Hitoshi Suzuki
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Shu-Ichi Saitoh
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Yasuchika Takeishi
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima City, Fukushima, Japan
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Hess PL, Kim S, Fonarow GC, Thomas L, Singer DE, Freeman JV, Gersh BJ, Ansell J, Kowey PR, Mahaffey KW, Chan PS, Steinberg BA, Peterson ED, Piccini JP. Absence of Oral Anticoagulation and Subsequent Outcomes Among Outpatients with Atrial Fibrillation. Am J Med 2017; 130:449-456. [PMID: 27888051 DOI: 10.1016/j.amjmed.2016.11.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 10/30/2016] [Accepted: 11/01/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Prior studies have shown a treatment gap in oral anticoagulation (OAC) use among patients with atrial fibrillation yet have incompletely characterized factors associated with failure to treat and subsequent outcomes in contemporary practice. METHODS Using data collected between June 2010 and August 2011 from 174 ambulatory care sites in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation, we identified factors associated with absence of OAC via stratified logistic regression. Using weighted Cox regression, we assessed the association between OAC non-use and subsequent outcomes over 2.5 years. RESULTS Among 9553 patients, 2202 (23.0%) were not on OAC. Among OAC nonrecipients, 1846 (83.8%) had a CHA2DS2-VASc score ≥2. Factors independently associated with OAC non-use included atrial fibrillation type (paroxysmal odds ratio [OR] 0.73, 95% confidence interval [CI] 0.54-0.99; persistent OR 0.14, 95% CI 0.10-0.21; permanent OR 0.35, 95% CI 0.25-0.49; reference = new-onset), left atrial diameter enlargement (mild OR 0.80, 95% CI 0.66-0.97; moderate 0.58, 95% CI 0.47-0.73; severe 0.53, 95% CI 0.42-0.68; reference = normal diameter), and age >80 years (OR 1.04, 95% CI 1.02-1.08). Untreated patients had a higher risk of death (adjusted hazard ratio [HR] 1.22, 95% CI 1.05-1.41), a lower bleeding risk (adjusted HR 0.35, 95% CI 0.15-0.81), and a nonsignificant trend toward higher risk of stroke/non-central nervous system embolism/transient ischemic attack than those treated (adjusted HR 1.18, 95% CI 0.91-1.54). CONCLUSIONS A majority of atrial fibrillation patients not treated with an OAC in current community practice meet guideline indications for treatment. Atrial fibrillation burden, chronicity, and comorbidity are associated with nontreatment. Untreated patients are at increased risk for adverse outcomes.
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Affiliation(s)
- Paul L Hess
- Cardiology Section, VA Eastern Colorado and Health Care System, Denver; Department of Medicine, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora.
| | - Sunghee Kim
- Duke Clinical Research Institute, Durham, NC
| | - Gregg C Fonarow
- Department of Medicine, University of California, Los Angeles
| | | | - Daniel E Singer
- Harvard Medical School and Massachusetts General Hospital, Boston
| | - James V Freeman
- Department of Medicine, Yale University School of Medicine, New Haven, Conn
| | - Bernard J Gersh
- Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minn
| | - Jack Ansell
- Department of Medicine, New York School of Medicine, Lenox Hill Hospital
| | - Peter R Kowey
- Lankenau Institute for Medical Research, Wynnewood, Penn
| | - Kenneth W Mahaffey
- Department of Medicine, Stanford University School of Medicine, Palo Alto, Calif
| | - Paul S Chan
- Department of Cardiovascular Research, St. Luke's Mid America Heart Institute, Kansas City, Mo; Department of Medicine, University of Missouri-Kansas City
| | - Benjamin A Steinberg
- Duke Clinical Research Institute, Durham, NC; University of Utah, Salt Lake City
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50
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Granger BB, Pokorney SD, Taft C. Blending Quality Improvement and Research Methods for Implementation Science, Part III: Analysis of the Effectiveness of Implementation. AACN Adv Crit Care 2017; 27:103-10. [PMID: 26909460 DOI: 10.4037/aacnacc2016267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Bradi B Granger
- Bradi B. Granger is Director, Heart Center Nursing Research Program, Duke University Health System, and Associate Professor, Duke University School of Nursing, 307 Trent Drive, DUMC Box 3322, Durham, NC 27710 . Sean D. Pokorney is Electrophysiology Fellow, Duke Heart Center, Duke University Medical Center, Durham, North Carolina. Charles Taft is Associate Professor of Psychology, University of Gothenburg Centre for Person-Centred Care (GPCC), Göteborg, Sweden
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