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Fernández CS, Gullón A, Formiga F. The problem of underdosing with direct-acting oral anticoagulants in elderly patients with nonvalvular atrial fibrillation. J Comp Eff Res 2020; 9:509-523. [PMID: 32329353 DOI: 10.2217/cer-2019-0197] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Unless contraindicated, anticoagulant therapy should be prescribed to elderly patients with atrial fibrillation. Direct-acting oral anticoagulants (DOACs) are superior to vitamin K antagonists for preventing stroke. This, together with their higher net clinical benefit, makes DOACs the treatment of choice in this population. However, due to the concerns about bleeding and the need for dose adjustment based on clinical variables, underdosing of DOACs is common and the risk of stroke high. Drugs with more easily adjusted doses are likely associated with a lower risk of dosing errors and, therefore, a greater protective effect. Correct dosing can ensure a maximal net benefit of DOACs in elderly patients with atrial fibrillation.
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Affiliation(s)
| | - Alejandra Gullón
- Servicio de Medicina Interna, Hospital Universitario de La Princesa, Madrid, Spain
| | - Francesc Formiga
- Unidad de Geriatría, Servicio de Medicina Interna, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
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Hiasa KI, Kaku H, Inoue H, Yamashita T, Akao M, Atarashi H, Koretsune Y, Okumura K, Shimizu W, Ikeda T, Toyoda K, Hirayama A, Yasaka M, Yamaguchi T, Teramukai S, Kimura T, Kaburagi J, Takita A, Tsutsui H. Age-Related Differences in the Clinical Characteristics and Treatment of Elderly Patients With Atrial Fibrillation in Japan - Insight From the ANAFIE (All Nippon AF In Elderly) Registry. Circ J 2020; 84:388-396. [PMID: 31969518 DOI: 10.1253/circj.cj-19-0898] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is increasing as the global population ages. Elderly AF patients (≥75 years) have a worse prognosis than younger patients, and effective management is often difficult due to multiple comorbidities. This analysis examined the age-related differences in clinical characteristics and treatment in real-world elderly Japanese AF patients.Methods and Results:The ANAFIE Registry is a multicenter, prospective, observational registry of 32,726 non-valvular AF patients aged ≥75 years. The present study assessed the age-related differences in baseline clinical status and anticoagulant therapy between age groups 75-<80, 80-<85, 85-<90, and ≥90 years. The prevalence of persistent or permanent AF increased, and that of paroxysmal AF decreased, with increasing age (trend P<0.0001). The risk of stroke, based on CHADS2and CHA2DS2-VASc scores, and bleeding, based on HAS-BLED score, increased with age. Both warfarin and apixaban were used more often as age increased (trend P<0.0001, for each), while other anticoagulants were used less. Anticoagulant doses were significantly lower in older patients. CONCLUSIONS Permanent/persistent AF, comorbidities, and cardiovascular and bleeding risk all increased significantly with age. Furthermore, use of warfarin and apixaban increased with age, accompanied by a decrease in other oral anticoagulant usage.
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Affiliation(s)
- Ken-Ichi Hiasa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
| | - Hidetaka Kaku
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
| | | | | | | | | | | | | | | | | | - Kazunori Toyoda
- National Cerebral and Cardiovascular Research Center Hospital
| | | | | | | | | | | | | | - Atsushi Takita
- Biostatistics and Data Management Department, Daiichi Sankyo Co., Ltd
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
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Riera-Mestre A, Camafort M, María Suriñach J, Muñoz Rodríguez FJ, Padilla F, Francisco-Pascual J, Mateo Arranz J, Martínez Rubio A, Villuendas Sabaté R, Freixa-Pamias R, Suárez Fernández C, Santamaría A. Anticoagulación del paciente anciano pluripatológico con fibrilación auricular no valvular: papel del rivaroxabán. REVISTA ESPAÑOLA DE CARDIOLOGÍA SUPLEMENTOS 2020. [DOI: 10.1016/s1131-3587(20)30011-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Novo-Veleiro I, Pose-Reino A, Gullón A, Díez-Manglano J, Cepeda JM, Formiga F, Camafort M, Mostaza JM, Suárez C. Acute kidney injury is linked to higher mortality in elderly hospitalized patients with non-valvular atrial fibrillation. Aging Clin Exp Res 2019; 31:455-461. [PMID: 30019264 DOI: 10.1007/s40520-018-1001-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 07/06/2018] [Indexed: 12/29/2022]
Abstract
AIM Renal insufficiency is associated with medical complications in patients with non-valvular atrial fibrillation (NVAF). However, data for elderly patients are scarce. Thus, the main objectives of the present study were to analyze the characteristics of elderly patients with NVAF and acute or chronic renal disease, describe their management in real-life conditions, and detect factors associated with complications. METHODS The NONAVASC registry includes patients > 75 years with NVAF, hospitalized by any cause in 64 Spanish Internal Medicine departments. Patients were categorized into acute kidney injury (AKI), chronic kidney disease (CKD) or preserved renal function (PRF). All variables associated with in-hospital mortality with P < 0.10 in univariate analysis were included to develop a multivariate logistic-regression model. RESULTS The study included 804 patients (53.9% women), 352 (43.8%) of whom met diagnostic criteria for CKD. AKI was detected in 119 (14.8%) patients. AKI was associated with greater length of stay, higher mortality and an increased rate of patient transfer to nursing homes. After logistic-regression analysis, we found an association between mortality and AKI (OR 2.4, 95% CI 1.03-5.53; P = 0.045). The increase in creatinine values (OR 1.8, 95% CI 1.19-2.73; P = 0.005) and the decrease in albumin values (OR 2.0, 95% CI 1.05-3.73; P = 0.033) were also linked to mortality. CONCLUSIONS Our study shows the relationship between AKI and creatinine value increase and a higher mortality in elderly patients with NVAF. In light of our findings, the detection of renal function impairment in these patients should alert physicians and consider them as high-risk patients.
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Affiliation(s)
- Ignacio Novo-Veleiro
- Internal Medicine Department, University Hospital of Santiago de Compostela, 15701, A Coruña, Spain.
| | - Antonio Pose-Reino
- Internal Medicine Department, University Hospital of Santiago de Compostela, 15701, A Coruña, Spain
| | - Alejandra Gullón
- Internal Medicine Department, University Hospital of La Princesa, Madrid, Spain
| | - Jesús Díez-Manglano
- Internal Medicine Department, University Hospital Miguel Servet, Zaragoza, Spain
| | - José-María Cepeda
- Internal Medicine Department, Vega Baja Hospital, Orihuela, Alicante, Spain
| | - Francesc Formiga
- Geriatric Unit, Internal Medicine Department, L'Hospitalet de Llobregat, University Hospital of Bellvitge, Barcelona, Spain
| | - Miguel Camafort
- Internal Medicine Department, Clinic University Hospital, Barcelona, Spain
| | - José-María Mostaza
- Internal Medicine Department, University Hospital of La Paz-Carlos III, Madrid, Spain
| | - Carmen Suárez
- Internal Medicine Department, University Hospital of La Princesa, Madrid, Spain
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Suárez Fernández C, Mostaza JM, Castilla Guerra L, Cantero Hinojosa J, Suriñach JM, Acosta de Bilbao F, Tamarit JJ, Diaz Diaz JL, Hernandez JL, Cazorla D, Ràfols C. Adherence to recommendations of the Therapeutic Positioning Report about treatment with oral anticoagulants in elderly patients with atrial fibrillation. The ESPARTA study. Med Clin (Barc) 2018; 151:8-15. [PMID: 28992980 DOI: 10.1016/j.medcli.2017.07.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 07/19/2017] [Accepted: 07/27/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE To evaluate the adherence to the recommendations in clinical practice performed by the Therapeutic Positioning Report (TPR) of the Spanish Agency of Medicines and Sanitary Products about the treatment with oral anticoagulants in patients aged≥75 years old with nonvalvular atrial fibrillation (NVAF) treated in Internal Medicine departments in Spain. PATIENTS AND METHODS Observational, cross-sectional and multicenter study in which 837 patients aged≥75 years old with NVAF, with stable treatment with oral anticoagulants at least 3 months before inclusion, and that had started treatment with oral anticoagulants before the inclusion period were included. RESULTS Mean age was 83.0±5.0 years old, mean CHADS2 score 3.2±1.2, mean CHA2DS2-VASc score 5.0±1.4, and mean HAS-BLED score 2.1±0.9. A percentage of 70.8 of patients were treated with vitamin K antagonists (VKA) and the rest of patients with direct oral anticoagulants (DOACs). A percentage of 65.6 of patients treated with VKA did not follow the recommendations made by the TPR compared with 43.0% of patients treated with DOACs (P<.0001). In the case of VKA, the main reason for being considered as not appropriate according to the TPR was having poor control of anticoagulation and not switching to DOACs, whereas in the case of DOACs, it was not receiving the adequate dose according to the TPR. CONCLUSIONS In a high proportion of anticoagulated elderly patients with NVAF in Spain, the recommendations performed by the TPR are not followed, particularly with VKA, since patients are not switched to DOACs despite time in therapeutic range.
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Affiliation(s)
| | | | - Luis Castilla Guerra
- Servicio de Medicina Interna, Hospital Universitario Virgen Macarena, Sevilla, España
| | | | | | - Fernando Acosta de Bilbao
- Servicio de Medicina Interna, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, Las Palmas, España
| | - Juan José Tamarit
- Servicio de Medicina Interna, Hospital General de Valencia, Valencia, España
| | - José Luis Diaz Diaz
- Servicio de Medicina Interna, Complejo Universitario Hospitalario de A Coruña, La Coruña, España
| | - Jose Luis Hernandez
- Servicio de Medicina Interna, Hospital Marqués de Valdecilla, Universidad de Cantabria, Santander, España
| | - Daniel Cazorla
- Departamento Médico, Bayer Hispania S. L., Barcelona, España
| | - Carles Ràfols
- Departamento Médico, Bayer Hispania S. L., Barcelona, España
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Suárez Fernández C, Mostaza JM, Castilla Guerra L, Cantero Hinojosa J, Suriñach JM, Acosta de Bilbao F, Tamarit JJ, Diaz Diaz JL, Hernandez JL, Cazorla D, Ràfols C. Adherence to recommendations of the Therapeutic Positioning Report about treatment with oral anticoagulants in elderly patients with atrial fibrillation. The ESPARTA study. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.medcle.2018.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Batalla Insenser B, Pertierra Uriel U, Sánchez Biosca A, Sobrino Martínez J. Anticoagulation control in hospitalized patients with nonvalvular atrial fibrillation undergoing long-term oral anticoagulant therapy. Rev Clin Esp 2018. [DOI: 10.1016/j.rceng.2018.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Batalla Insenser B, Pertierra Uriel U, Sánchez Biosca A, Sobrino Martínez J. Anticoagulation control in hospitalised patients with nonvalvular atrial fibrillation undergoing long-term oral anticoagulant therapy. Rev Clin Esp 2018; 218:267-269. [PMID: 29622369 DOI: 10.1016/j.rce.2018.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 02/27/2018] [Accepted: 03/03/2018] [Indexed: 11/30/2022]
Affiliation(s)
- B Batalla Insenser
- Servicio de Medicina Interna, Fundació Hospital de l'Esperit Sant, Santa Coloma de Gramenet (Barcelona), España
| | - U Pertierra Uriel
- Servicio de Medicina Interna, Fundació Hospital de l'Esperit Sant, Santa Coloma de Gramenet (Barcelona), España
| | - A Sánchez Biosca
- Servicio de Medicina Interna, Fundació Hospital de l'Esperit Sant, Santa Coloma de Gramenet (Barcelona), España
| | - J Sobrino Martínez
- Servicio de Medicina Interna, Fundació Hospital de l'Esperit Sant, Santa Coloma de Gramenet (Barcelona), España.
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Antithrombotic treatment and characteristics of elderly patients with non-valvular atrial fibrillation hospitalized at Internal Medicine departments. NONAVASC registry. Med Clin (Barc) 2016; 148:204-210. [PMID: 27993408 DOI: 10.1016/j.medcli.2016.10.042] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 10/06/2016] [Accepted: 10/13/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND OBJETIVES The prevalence of non-valvular atrial fibrillation (NVAF) increases with the patient's age and is associated with high morbi-mortality rates. The main goal of this study was to describe the characteristics of hospitalized elderly patients with NVAF and to identify the clinical and functional factors which determine the use of different antithrombotic strategies. PATIENTS AND METHODS Observational, prospective, multicentre study carried out on patients with NVAF over the age of 75, who had been admitted for any medical condition to Internal Medicine departments. RESULTS We evaluated 804 patients with a mean age of 85 years (range 75-101), of which 53.9% were females. The prevalence of risk factors and cardiovascular disease was high: hypertension (87.6%), heart failure (65.4%), ischemic cardiomyopathy (24.4%), cerebrovascular disease (22.4%) and chronic kidney disease (45%). Among those cases with previous diagnoses of NVAF, antithrombotic treatment was prescribed in 86.2% of patients: anticoagulants (59.7%), antiplatelet medication (17.8%) and double therapy (8.7%). The factors associated with the use of antithrombotic treatment were history of acute coronary syndrome and atrial fibrillation progression longer than one year. Older age, atrial fibrillation for less than one year, higher HAS-BLED scores and severe cognitive impairment were associated with the use of anti-platelet drugs. Permanent atrial fibrillation favoured the use of anticoagulants. CONCLUSIONS Hospitalized patients older than 75 years old with NVAF showed numerous comorbidities. The percentage of anticoagulation was small and 18% received only anti-platelet therapy. The patient's age, atrial fibrillation's progression time and the severity of the cognitive impairment influenced this therapy choice.
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Hernández Martín J, Vial Escolano R, Correa Ballester M. Hematoma subdural agudo en un paciente en tratamiento con apixaban y ácido acetilsalicílico. Med Clin (Barc) 2016; 147:e39-40. [DOI: 10.1016/j.medcli.2016.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 05/24/2016] [Accepted: 05/26/2016] [Indexed: 10/21/2022]
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Formiga F, Ferrer A, Mestre D, Brasé A, Soldevila L, Corbella X. High rate of mortality in Spanish community-dwelling population aged 85 with atrial fibrillation after three years of follow-up: The Octabaix study. Australas J Ageing 2016; 35:216-9. [PMID: 26991145 DOI: 10.1111/ajag.12261] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To assess the possible association between three-year global mortality and atrial fibrillation (AF) in 328 community-dwelling participants aged 85 at baseline. METHODS Sociodemographic data, comorbidity and geriatric assessment tools, thromboembolic risk, and AF therapy were assessed. We compared the patients who survived with those who died. RESULTS At baseline, 41 (12.5%) of participants had permanent AF, and 13 of them died (31.7%) after the three-year follow-up period compared with 44 (15.3%) of the rest of cohort (P = 0.01). Cox regression analysis identified two significant clinical variables as independent predictors of three-year risk of global mortality: Lawton Index (hazard ratio 0.82, 95% confidence interval 0.75-0.91) and AF (hazard ratio 1.90, 95% confidence interval 1.01-3.56). None of the other of variables evaluated showed predictive value of global mortality in the AF patients. CONCLUSION In oldest old community-dwelling participants, AF is an independent risk factor for global mortality after a three-year follow-up period.
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Affiliation(s)
- Francesc Formiga
- Geriatric Unit, Internal Medicine Service, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Assumpta Ferrer
- Primary Healthcare Centre 'El Plà' CAP -I, Sant Feliu de Llobregat, Barcelona, Spain
| | - Delia Mestre
- Primary Healthcare Centre 'El Plà' CAP -I, Sant Feliu de Llobregat, Barcelona, Spain
| | - Ariadna Brasé
- Geriatric Unit, Internal Medicine Service, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Laura Soldevila
- Geriatric Unit, Internal Medicine Service, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Xavier Corbella
- Geriatric Unit, Internal Medicine Service, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute. IDIBELL, L'Hospitalet de Llobregat, Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain
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Suárez Fernández C, Fernández S, Formiga F, Camafort M, Cepeda Rodrigo M, Rodrigo JC, Díez-Manglano J, Pose Reino A, Reino P, Tiberio G, Mostaza JM. Antithrombotic treatment in elderly patients with atrial fibrillation: a practical approach. BMC Cardiovasc Disord 2015; 15:143. [PMID: 26530138 PMCID: PMC4632329 DOI: 10.1186/s12872-015-0137-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 10/26/2015] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) in the elderly is a complex condition. It has a direct impact on the underuse of antithrombotic therapy reported in this population. DISCUSSION All patients aged ≥75 years with AF have an individual yearly risk of stroke >4 %. However, the risk of hemorrhage is also increased. Moreover, in this population it is common the presence of other comorbidities, cognitive disorders, risk of falls and polymedication. This may lead to an underuse of anticoagulant therapy. Direct oral anticoagulants (DOACs) are at least as effective as conventional therapy, but with lesser risk of intracranial hemorrhage. The simplification of treatment with these drugs may be an advantage in patients with cognitive impairment. The great majority of elderly patients with AF should receive anticoagulant therapy, unless an unequivocal contraindication. DOACs may be the drugs of choice in many elderly patients with AF. In this manuscript, the available evidence about the management of anticoagulation in elderly patients with AF is reviewed. In addition, specific practical recommendations about different controversial issues (i.e. patients with anemia, thrombocytopenia, risk of gastrointestinal bleeding, renal dysfunction, cognitive impairment, risk of falls, polymedication, frailty, etc.) are provided.
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Affiliation(s)
| | - Suárez Fernández
- Hospital Universitario de La Princesa, Grupo de Riesgo Vascular de la SEMI, Madrid, España.
- Servicio de Medicina Interna, Hospital Universitario de La Princesa, C/Diego de León 62, 28006, Madrid, Spain.
| | - Francesc Formiga
- Hospital Universitari de Bellvitge, Grupo de Riesgo Vascular de la SEMI, Hospitalet de Llobregat, Barcelona, España
| | - Miguel Camafort
- Atrial Fibrillation Unit (UFA), Internal Medicine Department, Hospital Clinic. University of Barcelona. Research Group in Cardiovascular Risk, Nutrition and Aging. Area. 'August Pi i Sunyer' Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | | | - Jose Cepeda Rodrigo
- Hospital Vega Baja de Orihuela, Grupo de Riesgo Vascular de la SEMI, Orihuela, Alicante, España
| | - Jesús Díez-Manglano
- Hospital Royo Villanova, Grupo de Riesgo Vascular de la SEMI, Zaragoza, España
| | | | - Pose Reino
- Complexo Hospitalario Universitario de Santiago, Grupo de Riesgo Vascular de la SEMI, Santiago de Compostela, España
| | - Gregorio Tiberio
- Hospital Virgen del Camino, Grupo de Riesgo Vascular de la SEMI, Pamplona, España
| | - Jose María Mostaza
- Hospital Carlos III, Grupo de Riesgo Vascular de la SEMI, Madrid, España
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