Cambios en el perfil clínico de los pacientes anticoagulados durante la década de los noventa

Mortality in a cohort of primary care patients treated with vitamin K antagonist anticoagulants

INTRODUCTION AND OBJECTIVES

The use of anticoagulants to prevent embolic events in Spain is very high, tending to a progressive increase. For this reason, we intend to analyse the mortality of patients from a metropolitan area of Granada treated with vitamin K antagonist anticoagulants (VKA), over 2 non-consecutive years.

PATIENTS AND METHODS

Longitudinal, observational, retrospective study of 205 patients treated with VKA. Sociodemographic data, previous clinical conditions, pathology causing VKA treatment, degree of control and mortality were collected 2 years after the start of the study.

RESULTS

Average age, 76±11.8 years (57.56% women). Two-year mortality was 22.4%, with a significant increase depending on age (p<.001) and years of treatment (p<.001). Patients with dementia (p<.05), with chronic kidney disease (p<.01) or with chronic obstructive pulmonary disease (p<.01) also presented higher mortality. Multivariate analysis showed significant effect of chronic kidney disease (odds ratio=4.075), chronic obstructive pulmonary disease (odds ratio=3.694), and years of treatment (odds ratio=1.236).

CONCLUSIONS

At 2 years of follow-up, 1 in 5 patients treated with VKA died. The presence of chronic kidney disease, chronic obstructive pulmonary disease and a longer treatment time were independently associated with this increase of mortality. Most of the patients were anticoagulated by atrial fibrillation, they were elderly and had a high prevalence of comorbidities.

Evaluación del programa piloto de descentralización del control del tratamiento anticoagulante oral en el Servicio Navarro de Salud-Osasunbidea

BACKGROUND AND OBJECTIVE

The objective of this study was the evaluation of the pilot programme of decentralization of oral anticoagulant therapy (OAT) in eight basic health zones (ZBS) for the first six months and then a year after the programme was put into practice.

PATIENTS AND METHOD

Descriptive transversal study. It includes all patients aged 14 years or older in the OAT (540 in the initial period and then 640 more) in eight ZBS (five urban and three rural). The evaluation was done including: prevalence of INR in control (2-3 or 2.5-3.5, according to indications), clinically suitable INR (INR in control +/- 0.2) and INR in control +/- 0.5, accumulated thrombosis and bleeding incidence. Source data: ANTICOAGN computer programme.

RESULTS

Comparison of INR control between both periods: 59% against 63.9% of INR in the range of INR in control (p < 0.001), 72.8% against 78.8% for clinically suitable INR (p < 0.001), and 86.6% against 91.4% for INR in control +/- 0.5 (p < 0.001). Accumulated incidence of bleeding episodes in 6 months: Pilot: 1.1% (0.7% majors and 0.4% minors). Subsequent period: 3.6% (0.6% majors and 3% minors).

CONCLUSIONS

The decentralization of control of the OAT with adequate resources implies a greater accessibility for the patient. The control of INR is acceptable and has improved significantly over the second period. We have detected an improvement in the increase of the INR below that of the range of the control INR. The incidence of minor hemorrhages has increased, owing probably to a better recording.

Patrones clínicos de presentación de la fibrilación auricular en los pacientes hospitalizados

INTRODUCTION AND OBJECTIVES

The ACC/AHA/ESC 2001 guidelines for the management of atrial fibrillation (AF) establish 4 categories: first episode, paroxysmal, persistent and permanent. The aim of this study was to analyze the frequency of the different clinical patterns of presentation of AF in hospitalized patients.

PATIENTS AND METHOD

We analyzed the pattern of AF in 300 hospitalized patients, 200 of whom were admitted to the cardiology and 100 to the internal medicine department. We determined the clinical profile and evaluated the factors influencing therapeutic management.

RESULTS

The permanent form was present in 30% of the patients admitted to the cardiology department and in 51% if those admitted to the internal medicine department. The first episode pattern was the most frequent in cardiology department patients (41%). In patients hospitalized the in cardiology the percentage use of anticoagulants (57.9% vs. 41%; p < 0.01) and beta blockers was greater than in internal medicine patients, and digitalis use was lower. In the multivariate analysis, admission to the cardiology department was an independent predictor of treatment with beta blockers (OR = 3.8; 95% CI, 1.3-11.1; p < 0.05), and discharge from the hospital with AF was a predictor of anticoagulant prescription (OR = 4.8; 95% CI, 2.5-9.2; p < 0.001).

CONCLUSIONS

a) Atrial fibrillation is an arrhythmia with a heterogeneous clinical pattern that varies depending on the type of care provided; b) on admission to cardiology, only 30% of the patients present with permanent arrhythmia, and the most frequent clinical pattern is first episode; and c) discharge from the hospital with AF was the principal determinant of therapeutic management.

Un protocolo prospectivo permite incrementar la utilización de anticoagulación oral en pacientes con fibrilación auricular crónica no valvular

INTRODUCTION AND OBJECTIVES

Observational studies have shown that oral anticoagulants (OAC) prescription is suboptimal in patients with nonvalvular atrial fibrillation (NVAF). Our objective was to evaluate the usefulness of a prospective protocol for increasing OAC usage in these patients.

PATIENTS AND METHOD

From 1 February 2000 until 31 October 2002 we enrolled all patients with chronic NVAF seen in two outpatient cardiology clinics, excluding candidates for cardioversion. Each patient was studied to identify cardioembolic risk factors (CERF) and contraindications for OAC. Anticoagulation was suggested to all patients with > or =2 CERF and without contraindications for OAC. The decision to prescribe OAC was made by the physician in charge when there was only one CERF.

RESULTS

721 patients fulfilled the inclusion criteria. Mean age was 73 +/- 8 years; 44% were men. In most cases NVAF was related with hypertension (57%), followed by no structural heart disease (25%) or ischemic heart disease (9%). The most frequent CERFs were hypertension (66%), age > or =75 years (45%) and diabetes (24%). A total of 663 patients had > or =1 CERF (92%), and 125 (19%) of these presented at least one contraindication for OAC. Of the 538 remaining patients (90%), 485 (67% of the whole series) were treated with anticoagulation. Of the patients with > or =2 CERF and without contraindications for OAC, 95% were treated.

CONCLUSIONS

A prospective protocol for use in the outpatient cardiology clinic allows to prescribe OAC in a large percentage of patients with NVAF.