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Koretsune Y, Yamashita T, Akao M, Atarashi H, Ikeda T, Okumura K, Shimizu W, Tsutsui H, Toyoda K, Hirayama A, Yasaka M, Yamaguchi T, Teramukai S, Kimura T, Kaburagi J, Takita A, Inoue H. Baseline Demographics and Clinical Characteristics in the All Nippon AF in the Elderly (ANAFIE) Registry. Circ J 2019; 83:1538-1545. [DOI: 10.1253/circj.cj-19-0094] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Falcinelli E, Iannone A, Mezzasoma AM, Amato L, Fierro T, Guglielmini G, Cagini C, Gresele P. Inhibition of platelet function after ocular administration of non-steroidal anti-inflammatory drugs. Thromb Res 2019; 175:1-5. [PMID: 30660018 DOI: 10.1016/j.thromres.2019.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/19/2018] [Accepted: 01/09/2019] [Indexed: 12/31/2022]
Abstract
INTRODUCTION The use of topical NSAIDs is frequent in ophthalmology to reduce the local inflammatory reaction resulting from surgical procedures. Ocular use of some drugs was previously found to lead to significant systemic absorption with possible systemic effects. NSAIDs may enhance the hemorrhagic risk of anticoagulant and antiplatelet drugs. Aim of our study was to evaluate the systemic effects of two NSAIDs given by eyedrops on platelet COX-1 and on ex vivo and in vivo platelet activation. MATERIALS AND METHODS 20 patients planned to undergo cataract surgery were randomized to the use of an ophthalmic solution containing Diclofenac or Indomethacin. Blood was taken at enrollment (baseline) and after 3 days of therapy (1 drop, 4 times a day). Arachidonic Acid (AA)-induced light transmission aggregometry (LTA), PFA-100® C-EPI, circulating platelet P-Selectin expression by flow cytometry and serum and AA-induced TxB2 production were evaluated before and after eyedrop therapy. RESULTS AA (0.1-0.2 mM)-induced LTA was significantly reduced after ocular indomethacin but not after diclofenac. PFA-100® C-EPI closure time was also significantly prolonged in the indomethacin group but not in the diclofenac group. Circulating platelet P-selectin expression was significantly reduced after treatment with indomethacin compared with diclofenac. Finally, treatment with eyedrop indomethacin, but not with diclofenac, strikingly suppressed AA-induced TxB2 generation, while treatment with diclofenac did not modify it. CONCLUSIONS Our data show that indomethacin administered by ophthalmic eye drops has a relevant systemic antiplatelet effect. This should be taken into account in patients under concurrent therapy with antiplatelet or anticoagulant agents.
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Affiliation(s)
- Emanuela Falcinelli
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - Alessia Iannone
- Department of Surgical and Biomedical Science, Section of Ophthalmology, University of Perugia, Perugia, Italy
| | - Anna Maria Mezzasoma
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - Lavinia Amato
- Department of Surgical and Biomedical Science, Section of Ophthalmology, University of Perugia, Perugia, Italy
| | - Tiziana Fierro
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - Giuseppe Guglielmini
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - Carlo Cagini
- Department of Surgical and Biomedical Science, Section of Ophthalmology, University of Perugia, Perugia, Italy
| | - Paolo Gresele
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy.
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[Oral anticoagulation therapy in the elderly population with atrial fibrillation. A review article]. Rev Esp Geriatr Gerontol 2018; 53:344-355. [PMID: 30072184 DOI: 10.1016/j.regg.2018.04.450] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/17/2018] [Accepted: 04/25/2018] [Indexed: 12/31/2022]
Abstract
Aging is an important risk factor for patients with atrial fibrillation. The estimated prevalence of atrial fibrillation in patients aged ≥80 years is 9-10%, and is associated with a four to five fold increased risk of embolic stroke, and with an estimated increased stroke risk of 1.45-fold per decade in aging. Older age is also associated with an increased risk of major bleeding with oral anticoagulant therapy. This review will focus on the role of oral anticoagulation with new oral anticoagulants, non-vitamin K antagonist in populations with common comorbid conditions, including age, chronic kidney disease, coronary artery disease, on multiple medication, and frailty. In patients 75 years and older, randomised trials have shown new oral anticoagulants to be as effective as warfarin, or in some cases superior, with an overall better safety profile, consistently reducing rates of intracranial haemorrhages. Prior to considering oral anticoagulant therapy in an elderly frail patient, a comprehensive assessment should be performed to include the risks and benefits, stroke risk, baseline kidney function, cognitive status, mobility and fall risk, multiple medication, nutritional status assessment, and life expectancy.
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Maestre-Moreno J, Fernández-Pérez M, Triguero-Cueva L, Gutiérrez-Zúñiga R, Herrera-García J, Espigares-Molero A, Mínguez-Castellanos A. Stroke-related mortality in a tertiary care hospital in Andalusia: Analysis and reflections. NEUROLOGÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.nrleng.2016.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Maestre-Moreno J, Fernández-Pérez M, Triguero-Cueva L, Gutiérrez-Zúñiga R, Herrera-García J, Espigares-Molero A, Mínguez-Castellanos A. Mortalidad asociada al ictus en un hospital andaluz de tercer nivel. Análisis y reflexiones. Neurologia 2017; 32:559-567. [DOI: 10.1016/j.nrl.2016.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 02/29/2016] [Accepted: 03/05/2016] [Indexed: 11/28/2022] Open
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Patti G, Lucerna M, Pecen L, Siller-Matula JM, Cavallari I, Kirchhof P, De Caterina R. Thromboembolic Risk, Bleeding Outcomes and Effect of Different Antithrombotic Strategies in Very Elderly Patients With Atrial Fibrillation: A Sub-Analysis From the PREFER in AF ( PREvention o F Thromboembolic Events- European Registry in Atrial Fibrillation). J Am Heart Assoc 2017; 6:e005657. [PMID: 28736385 PMCID: PMC5586290 DOI: 10.1161/jaha.117.005657] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 05/15/2017] [Indexed: 01/15/2023]
Abstract
BACKGROUND Increasing age predisposes to both thromboembolic and bleeding events in patients with atrial fibrillation; therefore, balancing risks and benefits of antithrombotic strategies in older populations is crucial. We investigated 1-year outcome with different antithrombotic approaches in very elderly atrial fibrillation patients (age ≥85 years) compared with younger patients. METHODS AND RESULTS We accessed individual patients' data from the prospective PREFER in AF (PREvention oF thromboembolic events-European Registry in Atrial Fibrillation), compared outcomes with and without oral anticoagulation (OAC), and estimated weighed net clinical benefit in different age groups. A total of 6412 patients, 505 of whom were aged ≥85 years, were analyzed. In patients aged <85 years, the incidence of thromboembolic events was 2.8%/year without OAC versus 2.3%/year with OAC (0.5% absolute reduction); in patients aged ≥85 years, it was 6.3%/year versus 4.3%/year (2% absolute reduction). In very elderly patients, the risk of major bleeding was higher than in younger patients, but similar in patients on OAC and in those on antiplatelet therapy or without antithrombotic treatment (4.0%/year versus 4.2%/year; P=0.77). OAC was overall associated with weighted net clinical benefit, assigning weights to nonfatal events according to their prognostic implication for subsequent death (-2.19%; CI, -4.23%, -0.15%; P=0.036). We found a significant gradient of this benefit as a function of age, with the oldest patients deriving the highest benefit. CONCLUSIONS Because the risk of stroke increases with age more than the risk of bleeding, the absolute benefit of OAC is highest in very elderly patients, where it, by far, outweighs the risk of bleeding, with the greatest net clinical benefit in such patients.
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Affiliation(s)
- Giuseppe Patti
- Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Italy
| | | | - Ladislav Pecen
- Institute of Informatics, Academy of Sciences of Czech Republic, Prague, Czech Republic
| | | | - Ilaria Cavallari
- Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Italy
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
- SWBH and UHB NHS Trust, Birmingham, United Kingdom
| | - Raffaele De Caterina
- G. d'Annunzio University of Chieti and Center of Excellence on Aging CeSI-Met, Chieti, Italy
- Fondazione G. Monasterio, Pisa, Italy
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Hanon O, Vidal JS, Le Heuzey JY, Kirchhof P, De Caterina R, Schmitt J, Laeis P, Mannucci PM, Marcucci M. Oral anticoagulant use in octogenarian European patients with atrial fibrillation: A subanalysis of PREFER in AF. Int J Cardiol 2017; 232:98-104. [PMID: 28111055 DOI: 10.1016/j.ijcard.2017.01.046] [Citation(s) in RCA: 14] [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: 07/27/2016] [Revised: 12/05/2016] [Accepted: 01/04/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Few studies describe oral anticoagulant (OAC) prescription practices in very elderly patients with atrial fibrillation (AF). METHODS In this sub-analysis of the PREFER in AF study, performed in 2012, patients were stratified according to age (<80 [n=5565] and ≥80years [n=1660]) and OAC treatment. Factors associated with OAC prescription were analyzed in a multivariate logistic regression model with backward elimination of variables least associated with OAC use. RESULTS Patients ≥80years presented with permanent AF more often (p<0.0001) and reported fatigue and dyspnea more frequently (p<0.0001) and palpitations less frequently (p<0.0001) than patients <80years. Hypertension, stroke, heart failure, coronary heart disease, peripheral arterial disease, cancer, chronic kidney disease, and prior major bleeding were significantly more frequent in ≥80years. Most patients were treated with OACs in both age groups. The overall use of vitamin K antagonists was similar in both groups (78.2% vs.78.2% p=0.98), while the use of non-vitamin K antagonist OACs was lower in the ≥80years old group than in the <80years group (4.5% vs. 6.6% p=0.001). Among patients ≥80years, prior stroke and heart failure were significantly associated with OAC use, whereas higher age, prior bleeding, paroxysmal AF, chronic hepatic disease, and difficulties with self-care were associated with no OAC use. CONCLUSIONS The current use of OAC in European AF patients was satisfactorily high in octogenarians, suggesting reasonable implementation of current guidelines. Interestingly, patients with poor quality of life were less often anticoagulated. This may warrant further studies.
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Affiliation(s)
- Olivier Hanon
- APHP, Hôpital Broca, 54-56 Pascal, 75013 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Equipe d'Accueil 4468, Paris, France
| | - Jean-Sébastien Vidal
- APHP, Hôpital Broca, 54-56 Pascal, 75013 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Equipe d'Accueil 4468, Paris, France
| | | | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham and SWBH and UHB NHS Trusts, Birmingham, UK; Department of Cardiovascular Medicine, Hospital of the University of Münster, Münster, Germany; AFNET, Münster, Germany
| | - Raffaele De Caterina
- Institute of Cardiology, Center of Excellence on Aging, G. d'Annunzio University, Chieti-Pescara, Italy; Ospedale SS. Annunziata, Chieti, Italy
| | | | | | - Pier Mannuccio Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, IRCCS Ca' Granda Maggiore Policlinico Hospital Foundation, Milan, Italy; University of Milan, Milan, Italy
| | - Maura Marcucci
- University of Milan, Milan, Italy; Geriatric Unit, IRCCS Ca' Granda Maggiore Policlinico Hospital Foundation, Milan, Italy
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Nishtala PS, Castelino RL, Peterson GM, Hannan PJ, Salahudeen MS. Residential medication management reviews of antithrombotic therapy in aged care residents with atrial fibrillation: assessment of stroke and bleeding risk. J Clin Pharm Ther 2016; 41:279-84. [DOI: 10.1111/jcpt.12385] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 03/11/2016] [Indexed: 01/22/2023]
Affiliation(s)
- P. S. Nishtala
- School of Pharmacy; University of Otago; Dunedin New Zealand
| | - R. L. Castelino
- Pharmacy, School of Medicine; University of Tasmania; Hobart TAS Australia
| | - G. M. Peterson
- Pharmacy, School of Medicine; University of Tasmania; Hobart TAS Australia
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Kruse-Jarres R. Acquired bleeding disorders in the elderly. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:231-236. [PMID: 26637727 DOI: 10.1182/asheducation-2015.1.231] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The hemostatic balance changes with advancing age which may be due to factors such as platelet activation, increase of certain clotting factor proteins, slowing of the fibrinolytic system, and modification of the endothelium and blood flow. Generally, this predisposes the elderly to thrombosis rather than bleeding. It often necessitates antiplatelet or anticoagulation therapy, which can cause significant bleeding problems in an aging population. Additionally, changing renal function, modification in immune regulation, and a multitude of other disease processes, can give rise to acquired bleeding disorders. Bleeding can prove difficult to treat in a dynamic environment and in a population that may have underlying thrombotic risk factors.This article discusses some specific challenges of acquired bleeding arising in the elderly. The use of anticoagulation and nonsteroidal anti-inflammatory medications is prevalent in the treatment of the elderly and predisposes them to increased bleeding risk as their physiology changes. When prescribing and monitoring these therapies, it is exceedingly important to weigh thrombotic versus bleeding risks. There are additional rare acquired bleeding disorders that predominantly affect the elderly. One of them is acquired hemophilia, which is an autoimmune disorder arising from antibodies against factor VIII. The treatment challenge rests in the use of hemostatic agents in a population that is already at increased risk for thrombotic complications. Another rare disorder of intensifying interest, acquired von Willebrand syndrome, has a multitude of etiologic mechanisms. Understanding the underlying pathophysiology is essential in making a treatment decision for this disorder.
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Affiliation(s)
- Rebecca Kruse-Jarres
- Washington Center for Bleeding Disorders at Bloodworks Northwest and University of Washington, Seattle, WA
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