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Hussen M, Woubshet K, Bacha S, Ketema W. Simple Criteria, Yet the Dearth Utilization-Antithrombotic Management Practice among Atrial Fibrillation Patients at Hawassa University Comprehensive Specialized Hospital, Hawassa, Sidama, Ethiopia. Cardiol Res Pract 2024; 2024:6665787. [PMID: 38835499 PMCID: PMC11150045 DOI: 10.1155/2024/6665787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 01/05/2024] [Accepted: 05/22/2024] [Indexed: 06/06/2024] Open
Abstract
Background Atrial fibrillation (AF) is associated with significant mortality and morbidity from stroke and thromboembolism. Despite the availability of effective oral anticoagulation medication, AF patients remain at a high risk of stroke if not treated properly. The purpose of this study was to evaluate antithrombotic therapy practices in patients with AF in the adult cardiac clinic at Hawassa University Comprehensive Specialized Hospital (HUCSH). Methods It was a retrospective document review study. Total charts of 119 patients who had follow-up at the adult cardiac clinic with a history of documented AF from January 1 to December 30, 2018, were included. Indicators for antithrombotic therapy based on the congestive heart failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74, and sex category (female) (CHA2DS2-VASc) score were recorded. A p value of 0.05 was considered statistically significant. Data analysis was done using SPSS 23 software. Results In this study, about 55% of patients with AF were receiving the appropriate antithrombotic treatment. The patients were 48 ± 18.2 years old. Of these, 70% were women. The most frequent underlying cardiac etiology was chronic rheumatic valvular heart disease (50%), followed by cardiomyopathy (14%). In nonvalvular AF, the mean CHA2DS2VASc score was 4.0 ± 1.07. In valvular AF compared to nonvalvular AF, the need for appropriate antithrombotic therapy was substantially greater (p 0.0001). Only 8 (13.6%) of the warfarin-using patients had adequate anticoagulation. Conclusion The study's findings in regard to antithrombotic usage and maintenance of appropriate antithrombotics for stroke prevention in our patients revealed a discrepancy between recommendations and practice. Therefore, we demand that patients with AF who meet the criteria utilize antithrombotics properly to prevent stroke. Warfarin-taking patients' subpar optimum anticoagulation has to be addressed. Lastly, we advocate proper CHA2DS2-VASc score utilization for nonvalvular heart disease. A regular INR follow-up is also advised for patients who have started taking warfarin.
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Affiliation(s)
- Mubarak Hussen
- Department of Internal Medicine, College of Medicine and Health Sciences, School of Medicine, P.O. Box 1560, Hawassa, Ethiopia
- New York Internal Medicine Specialty Clinic, Hawassa, Ethiopia
| | - Kindie Woubshet
- Department of Internal Medicine, College of Medicine and Health Sciences, School of Medicine, P.O. Box 1560, Hawassa, Ethiopia
- Panacea Primary Hospital, Hawassa, Ethiopia
| | - Seifu Bacha
- Department of Internal Medicine, Saint Paul Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Worku Ketema
- Department of Pediatrics, College of Medicine and Health Sciences, School of Medicine, P.O. Box 1560, Hawassa, Ethiopia
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Guo Y, Kotalczyk A, Imberti JF, Wang Y, Lip GYH. Poor adherence to guideline-directed anticoagulation in elderly Chinese patients with atrial fibrillation: a report from the Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 9:169-176. [PMID: 34370024 PMCID: PMC9972510 DOI: 10.1093/ehjqcco/qcab054] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 08/03/2021] [Indexed: 01/08/2023]
Abstract
AIMS Adherence to guideline-directed oral anticoagulation (OAC) in patients with atrial fibrillation (AF) improves outcomes, but limited data are available from China. We evaluated the adherence to guideline-directed anticoagulation and its impact on clinical outcomes in a high-risk cohort of elderly Chinese patients. METHODS AND RESULTS The Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry is a prospective, multicentre study conducted from October 2014 to December 2018. Endpoints of interest were all-cause death, thromboembolic (TE) events and major bleedings in patients with a guideline-directed indication for OACs (CHA2DS2-VASc ≥1 if male or ≥2 if female). The eligible cohort consisted of 5742 patients, of whom 2567 (44.7%) patients were treated with an OAC. Seven independent predictors of OAC undertreatment were identified: age [odds ratio (OR): 1.04; 95% confidence interval (CI): 1.03-1.05; P < 0.001], first diagnosed AF (OR: 1.71; 95%CI: 1.44-2.03; P < 0.001), chronic kidney disease (OR: 1.67; 95%CI: 1.36-2.06; P < 0.001), liver disease (OR: 1.69; 95%CI: 1.19-2.41; P = 0.003), dementia (OR: 1.67; 95%CI: 1.06-2.64; P = 0.026), prior extracranial bleeding (OR: 1.89; 95%CI: 1.35-2.64; P < 0.001), and the use of antiplatelet drug (OR: 6.97; 95%CI: 5.89-8.23; P < 0.001). On multivariate analysis, OAC undertreatment was significantly associated with a higher risk all-cause death (OR: 3.79; 95%CI: 2.61-5.53; P < 0.001) and TE events (OR: 2.28; 95%CI: 1.39-3.72; P = 0.001), and a similar risk of major bleeding as compared with guideline-directed OAC therapy. CONCLUSION Only 44.7% of all eligible patients were prescribed OAC in accordance with guideline recommendations. The independent predictors for OAC undertreatment were age, first diagnosed AF, chronic kidney disease, chronic obstructive pulmonary disease, prior extracranial bleeding, and the use of the antiplatelet drugs. Guideline-adherent thromboprophylaxis was safe and may be associated with improved survival and less TE among elderly Chinese patients with AF.
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Cheng WH, Chiang CE, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Liao JN, Chung FP, Chen TJ, Lip GYH, Chen SA, Chao TF. Non-Vitamin K Antagonist Oral Anticoagulants in Elderly (≥85 years) Patients With Newly Diagnosed Atrial Fibrillation: Changing Clinical Practice and Outcomes for Stroke Prevention in a Nationwide Cohort Study. Mayo Clin Proc 2021; 96:52-65. [PMID: 33413835 DOI: 10.1016/j.mayocp.2020.08.042] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 07/26/2020] [Accepted: 08/03/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To investigate the influences of non-vitamin K antagonist oral anticoagulants (NOACs) on rates of initiations of oral anticoagulants (OACs) and outcomes among elderly patients with atrial fibrillation (AF). METHODS From January 1, 2009, to December 31, 2015, 33,539 newly-diagnosed AF patients older than 85 years old who survived more than 180 days after AF diagnosis were studied. Temporal trends regarding OAC initiation rates after incident AF were analyzed. The 1-year risks of ischemic stroke, intracranial hemorrhage, and mortality of incident AF patients diagnosed each year were compared with that of the year 2009. RESULTS Initiation rates of OACs after AF was newly diagnosed in the elderly significantly increased from 9.5% to 34.3%, mainly due to the introduction of NOACs (from 0% to 26.2%). Several clinical factors were associated with OACs underuse, including chronic obstructive pulmonary disease, abnormal renal function, anemia, and history of bleeding. Compared with year 2009 (incidence rate, 5.55%/year), the 1-year risk of ischemic stroke after AF diagnosis decreased in the era of NOACs (incidence rate, 4.20%/year; adjusted hazard ratio [aHR], 0.748 in year 2012; 4.39%/year, aHR, 0.789 in 2014; 2.75%/year; aHR, 0.513 in year 2015; all P<.01, except for year 2013, 4.80%/year [P=.07]). Also, the risks of mortality were lower in years 2012 to 2015, while the risk of ICH remained unchanged. CONCLUSION Initiation rates of OACs after AF was newly diagnosed in the elderly significantly increased following the introduction of NOACs. A lower risk of ischemic stroke, mortality, and composite adverse events was observed, which was temporally associated with the increasing prescription rates of OACs.
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Affiliation(s)
- Wen-Han Cheng
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Chern-En Chiang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Lin Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Li-Wei Lo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Feng Hu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Fa-Po Chung
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Shih-Ann Chen
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Tze-Fan Chao
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.
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Yu HT, Yang PS, Hwang J, Ryu S, Jang E, Kim TH, Uhm JS, Kim JY, Pak HN, Lee MH, Lip GYH, Joung B. Social Inequalities of Oral Anticoagulation after the Introduction of Non-Vitamin K Antagonists in Patients with Atrial Fibrillation. Korean Circ J 2020; 50:267-277. [PMID: 32100483 PMCID: PMC7043961 DOI: 10.4070/kcj.2019.0207] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/30/2019] [Accepted: 11/13/2019] [Indexed: 12/13/2022] Open
Abstract
Background and Objectives Nationwide social inequalities of oral anticoagulation (OAC) usage after the introduction of non-vitamin K antagonist oral anticoagulants (NOACs) have not been well identified in patients with atrial fibrillation (AF). This study assessed overall rate and social inequalities of OAC usage after the introduction of NOAC in Korea. Methods Between January 2002 and December 2016, we identified 888,540 patients with AF in the Korea National Health Insurance system database. The change of OAC rate in different medical systems after the introduction of NOAC were evaluated. Results In all population, overall OAC use increased from 13.2% to 23.4% (p for trend <0.001), and NOAC use increased from 0% to 14.6% (p for trend <0.001). Compared with pre-reimbursement (0.48%), the annual increase of OAC use was significantly higher after partial (1.16%, p<0.001), and full reimbursement of OAC (3.72%, p<0.001). Full reimbursement of NOAC (adjusted odds ratio, 2.10; 95% confidence interval, 2.04–2.15) was independently associated with higher OAC use. However, the difference of overall OAC usage between tertiary referral hospitals and nursing or public health centers increased from 17.9% in 2010 to 36.8% in 2016. Moreover, usage rate of NOAC was significantly different among different medical systems from 37.2% at the tertiary referral hospital and 5.5% at nursing or public health centers. Conclusions Introduction of NOACs in routine practice for stroke prevention in AF was associated with improved rates of overall OAC use. However, significant practice-level variations in OAC and NOAC use remain producing social inequalities of OAC despite full reimbursement.
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Affiliation(s)
- Hee Tae Yu
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Pil Sung Yang
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Jinseub Hwang
- Department of Computer Science and Statistics, Daegu University, Gyeongsan, Korea
| | - Soorack Ryu
- Department of Computer Science and Statistics, Daegu University, Gyeongsan, Korea
| | - Eunsun Jang
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Sun Uhm
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Youn Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hui Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Moon Hyoung Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
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Risk and predictors of subsequent cancers of patients with newly-diagnosed atrial fibrillation — A nationwide population-based study. Int J Cardiol 2019; 296:81-86. [DOI: 10.1016/j.ijcard.2019.08.021] [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: 03/02/2019] [Revised: 07/14/2019] [Accepted: 08/07/2019] [Indexed: 11/19/2022]
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Kuo L, Chao TF, Liu CJ, Chen SJ, Tuan TC, Lin YJ, Chang SL, Lo LW, Hu YF, Chung FP, Liao JN, Chen TJ, Lip GYH, Chen SA. Usefulness of the CHA 2DS 2-VASc Score to Predict the Risk of Sudden Cardiac Death and Ventricular Arrhythmias in Patients With Atrial Fibrillation. Am J Cardiol 2018; 122:2049-2054. [PMID: 30342698 DOI: 10.1016/j.amjcard.2018.08.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 08/24/2018] [Accepted: 08/28/2018] [Indexed: 11/30/2022]
Abstract
Sudden cardiac death (SCD), the most devastating manifestation of ventricular arrhythmias (VAs), is the leading cause of mortality in patients with atrial fibrillation (AF). We hypothesized that the CHA2DS2-VASc score, consisting of age and several clinical risk factors, could be used to estimate the individual risk of SCD/VAs for AF patients. From year 2000 to 2011, 288,181 newly-diagnosed AF patients without antecedent SCD/VAs were identified from "Taiwan National Health Insurance Research Database." During the follow-up of 1,065,751 person-years, 11,166 patients experienced SCD/VAs with an annual risk of 1.05% which increased from 0.34% for patients with a CHA2DS2-VASc score of 0% to 2.63% for those with a score of 9. The CHA2DS2-VASc score was a significant predictor of SCD/VAs with an adjusted hazard ratio of 1.21 (95% confidence interval 1.20 to 1.22) per 1 point increment of the score. As the CHA2DS2-VASc score increased from 1 to 9, the hazard ratio of SCD/VAs continuously increased from 1.28 to 4.17 compared with patients with a CHA2DS2-VASc score of 0. In conclusion, CHA2DS2-VASc score was a convenient scoring system which could be used to predict the risk of SCD/VAs in AF patients in addition to its ability for stroke risk stratification.
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Affiliation(s)
- Ling Kuo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.
| | - Chia-Jen Liu
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Su-Jung Chen
- Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Lin Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Li-Wei Lo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Feng Hu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Fa-Po Chung
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom.
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
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Joung B, Lee JM, Lee KH, Kim TH, Choi EK, Lim WH, Kang KW, Shim J, Lim HE, Park J, Lee SR, Lee YS, Kim JB. 2018 Korean Guideline of Atrial Fibrillation Management. Korean Circ J 2018; 48:1033-1080. [PMID: 30403013 PMCID: PMC6221873 DOI: 10.4070/kcj.2018.0339] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 10/08/2018] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in the general population. The Korean Heart Rhythm Society organized a Korean AF Management Guideline Committee and analyzed all available studies regarding the management of AF, including studies on Korean patients. This guideline is based on recent data of the Korean population and the recent guidelines of the European Society of Cardiology, European Association for Cardio-Thoracic Surgery, American Heart Association, and Asia Pacific Heart Rhythm Society. Expert consensus or guidelines for the optimal management of Korean patients with AF were achieved after a systematic review with intensive discussion. This article provides general principles for appropriate risk stratification and selection of anticoagulation therapy in Korean patients with AF. This guideline deals with optimal stroke prevention, screening, rate and rhythm control, risk factor management, and integrated management of AF.
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Affiliation(s)
- Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
| | - Jung Myung Lee
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Medical College, Seoul, Korea
| | - Ki Hong Lee
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Tae Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Medical College, Seoul, Korea
| | - Eue Keun Choi
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Hyun Lim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ki Woon Kang
- Division of Cardiology, Eulji University College of Medicine, Daejeon, Korea
| | - Jaemin Shim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hong Euy Lim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Junbeom Park
- Department of Cardiology, Ewha Woman University, Seoul, Korea
| | - So Ryoung Lee
- Division of Cardiology, Department of Internal Medicine, Soon Chun Hyang University Hospital, Seoul, Korea
| | - Young Soo Lee
- Division of Cardiology, Department of Internal Medicine, Daegu Catholic University, Daegu, Korea
| | - Jin Bae Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Medical College, Seoul, Korea
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Chao TF, Liu CJ, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Liao JN, Chung FP, Chen TJ, Lip GYH, Chen SA. Oral Anticoagulation in Very Elderly Patients With Atrial Fibrillation: A Nationwide Cohort Study. Circulation 2018; 138:37-47. [PMID: 29490992 DOI: 10.1161/circulationaha.117.031658] [Citation(s) in RCA: 160] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 02/20/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stroke prevention with oral anticoagulants (OACs) is the cornerstone for the management of atrial fibrillation (AF). However, data about the use of OACs among patients ≥90 years of age are limited. We aimed to investigate the risk of ischemic stroke and intracranial hemorrhage (ICH) and the net clinical benefit of OAC treatment for very elderly patients with AF (≥90 years of age). METHODS This study used the National Health Insurance Research Database in Taiwan. Risks of ischemic stroke and ICH were compared between 11 064 and 14 658 patients with and without AF ≥90 years of age without antithrombotic therapy from 1996 to 2011. Patients with AF (n=15 756) were divided into 3 groups (no treatment, antiplatelet agents, and warfarin), and the risks of stroke and ICH were analyzed. The risks of ischemic stroke and ICH were further compared between patients treated with warfarin and nonvitamin K antagonist OACs (NOACs) from 2012 to 2015 when NOACs were available in Taiwan. RESULTS Compared with patients without AF, patients with AF had an increased risk of ischemic stroke (event number/patient number, incidence = 742/11 064, 5.75%/y versus 1399/14 658, 3.00%/y; hazard ratio, 1.93; 95% confidence interval, 1.74-2.14) and similar risk of ICH (131/11 064, 0.97%/y versus 206/14 658, 0.54%/y; hazard ratio, 0.85; 95% confidence interval, 0.66-1.09) in competing risk analysis for mortality. Among patients with AF, warfarin use was associated with a lower stroke risk (39/617, 3.83%/y versus 742/11 064, 5.75%/y; hazard ratio, 0.69; 95% confidence interval, 0.49-0.96 in a competing risk model), with no difference in ICH risk compared with nontreatment. When compared with no antithrombotic therapy or antiplatelet drugs, warfarin was associated with a positive net clinical benefit. These findings persisted in propensity-matched analyses. Compared with warfarin, NOACs were associated with a lower risk of ICH (4/978, 0.42%/y versus 19/768, 1.63%/y; hazard ratio, 0.32; 95% confidence interval, 0.10-0.97 in a competing risk model), with no difference in risk of ischemic stroke. CONCLUSIONS Among patients with AF ≥90 years of age, warfarin was associated with a lower risk of ischemic stroke and positive net clinical benefit. Compared with warfarin, NOACs were associated with a lower risk of ICH. Thus, OACs may still be considered as thromboprophylaxis for elderly patients, with NOACs being the more favorable choice.
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Affiliation(s)
- Tze-Fan Chao
- Division of Cardiology (T.-F.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.).,Institute of Clinical Medicine, Cardiovascular Research Center (T.-F.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.)
| | - Chia-Jen Liu
- Division of Hematology and Oncology (C.-J.L.), Department of Medicine.,Institute of Public Health, School of Medicine (C.-J.L.), National Yang-Ming University, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology (T.-F.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.).,Institute of Clinical Medicine, Cardiovascular Research Center (T.-F.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.)
| | - Shih-Lin Chang
- Division of Cardiology (T.-F.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.).,Institute of Clinical Medicine, Cardiovascular Research Center (T.-F.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.)
| | - Li-Wei Lo
- Division of Cardiology (T.-F.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.).,Institute of Clinical Medicine, Cardiovascular Research Center (T.-F.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.)
| | | | - Ta-Chuan Tuan
- Division of Cardiology (T.-F.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.).,Institute of Clinical Medicine, Cardiovascular Research Center (T.-F.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.)
| | - Jo-Nan Liao
- Division of Cardiology (T.-F.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.).,Institute of Clinical Medicine, Cardiovascular Research Center (T.-F.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.)
| | - Fa-Po Chung
- Division of Cardiology (T.-F.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.).,Institute of Clinical Medicine, Cardiovascular Research Center (T.-F.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.)
| | - Tzeng-Ji Chen
- Department of Family Medicine (T.-J.C.), Taipei Veterans General Hospital, Taiwan
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, UK (G.Y.H.L.).
| | - Shih-Ann Chen
- Division of Cardiology (T.-F.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.) .,Institute of Clinical Medicine, Cardiovascular Research Center (T.-F.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.)
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9
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Chao TF, Liu CJ, Tuan TC, Chen TJ, Hsieh MH, Lip GY, Chen SA. Lifetime Risks, Projected Numbers, and Adverse Outcomes in Asian Patients With Atrial Fibrillation. Chest 2018; 153:453-466. [DOI: 10.1016/j.chest.2017.10.001] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 09/20/2017] [Accepted: 10/02/2017] [Indexed: 01/10/2023] Open
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10
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Chao TF, Lip GY, Liu CJ, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Liao JN, Chung FP, Chen TJ, Chen SA. Relationship of Aging and Incident Comorbidities to Stroke Risk in Patients With Atrial Fibrillation. J Am Coll Cardiol 2018; 71:122-132. [DOI: 10.1016/j.jacc.2017.10.085] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 10/25/2017] [Accepted: 10/30/2017] [Indexed: 12/20/2022]
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11
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Yang PS, Joung B. Regional and Socioeconomic Inequality of Atrial Fibrillation with Regular Hospital Visit. Korean Circ J 2018; 48:635-636. [PMID: 29968436 PMCID: PMC6031723 DOI: 10.4070/kcj.2018.0116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 04/18/2018] [Indexed: 12/19/2022] Open
Affiliation(s)
- Pil Sung Yang
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Korea.
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12
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Meid AD, Mächler S, Haefeli WE, Mikus G. Real-world complexity of atrial fibrillation treatment with oral anticoagulants: design and interpretation of pharmacoepidemiological studies. Br J Clin Pharmacol 2017; 83:2321-2324. [PMID: 28734007 DOI: 10.1111/bcp.13348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 06/09/2017] [Accepted: 06/13/2017] [Indexed: 01/25/2023] Open
Affiliation(s)
- Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Sarah Mächler
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
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13
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Kuo L, Chao TF, Liu CJ, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Liao JN, Chung FP, Chen TJ, Lip GYH, Chen SA. Liver Cirrhosis in Patients With Atrial Fibrillation: Would Oral Anticoagulation Have a Net Clinical Benefit for Stroke Prevention? J Am Heart Assoc 2017; 6:e005307. [PMID: 28645935 PMCID: PMC5669162 DOI: 10.1161/jaha.116.005307] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 05/09/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with liver cirrhosis have been excluded from randomized clinical trials of oral anticoagulation therapy for stroke prevention in atrial fibrillation. We hypothesized that patients with liver cirrhosis would have a positive net clinical benefit for oral anticoagulation when used for stroke prevention in atrial fibrillation. METHODS AND RESULTS This study used the National Health Insurance Research Database in Taiwan. Among 289 559 atrial fibrillation patients aged ≥20 years, there were 10 336 with liver cirrhosis, and 9056 of them having a CHA2DS2-VASc score ≥2 were divided into 3 groups, that is, no treatment, antiplatelet therapy, and warfarin. Patients with liver cirrhosis had a higher risk of ischemic stroke (hazard ratio=1.10, P=0.046) and intracranial hemorrhage (hazard ratio=1.20, P=0.043) compared with those without. Among patients with liver cirrhosis, patients taking antiplatelet therapy had a similar risk of ischemic stroke (hazard ratio=1.02, 95%CI=0.88-1.18) compared to those without antithrombotic therapies, but the risk was significantly lowered among warfarin users (hazard ratio=0.76, 95%CI=0.58-0.99). For intracranial hemorrhage, there were no significant differences between those untreated and those taking antiplatelet therapy or warfarin. The use of warfarin was associated with a positive net clinical benefit compared with being untreated or receiving only antiplatelet therapy. CONCLUSIONS For atrial fibrillation patients with liver cirrhosis in the current analysis of an observational study, warfarin use was associated with a lower risk of ischemic stroke and a positive net clinical benefit compared with nontreatment, and thus, thromboprophylaxis should be considered for such patients.
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Affiliation(s)
- Ling Kuo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Chia-Jen Liu
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Lin Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Li-Wei Lo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Feng Hu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Fa-Po Chung
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences City Hospital, Birmingham, United Kingdom
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
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