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Manzi L, Florimonte D, Forzano I, Buongiorno F, Sperandeo L, Castiello DS, Paolillo R, Giugliano G, Giacoppo D, Sciahbasi A, Cirillo P, Esposito G, Gargiulo G. Antiplatelet Therapy in Patients Requiring Oral Anticoagulation and Undergoing Percutaneous Coronary Intervention. Interv Cardiol Clin 2024; 13:527-541. [PMID: 39245552 DOI: 10.1016/j.iccl.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor is fundamental in all patients undergoing percutaneous coronary intervention (PCI) to prevent coronary thrombosis. In patients with atrial fibrillation (AF), an oral anticoagulant gives protection against ischemic stroke or systemic embolism. AF-PCI patients are at high bleeding risk and decision-making regarding the optimal antithrombotic therapy remains challenging. Dual antithrombotic therapy (DAT) has been shown to reduce bleeding events but at the cost of a higher risk of stent thrombosis. Further studies are needed to clarify the optimal duration of triple antithrombotic therapy (TAT) or DAT and the role of more potent antiplatelet drugs.
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Affiliation(s)
- Lina Manzi
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Domenico Florimonte
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Imma Forzano
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Federica Buongiorno
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Luca Sperandeo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | | | - Roberta Paolillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Giuseppe Giugliano
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Daniele Giacoppo
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | | | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy.
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2
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Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM, De Potter TJR, Dwight J, Guasti L, Hanke T, Jaarsma T, Lettino M, Løchen ML, Lumbers RT, Maesen B, Mølgaard I, Rosano GMC, Sanders P, Schnabel RB, Suwalski P, Svennberg E, Tamargo J, Tica O, Traykov V, Tzeis S, Kotecha D. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024:ehae176. [PMID: 39210723 DOI: 10.1093/eurheartj/ehae176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Ma C, Wu S, Liu S, Han Y. Chinese guidelines for the diagnosis and management of atrial fibrillation. Pacing Clin Electrophysiol 2024; 47:714-770. [PMID: 38687179 DOI: 10.1111/pace.14920] [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: 11/22/2023] [Accepted: 11/30/2023] [Indexed: 05/02/2024]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of the guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice timely and fully, the Chinese Society of Cardiology of Chinese Medical Association and the Heart Rhythm Committee of Chinese Society of Biomedical Engineering jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2‑VASc‑60 stroke risk score based on the characteristics of the Asian AF population. The guidelines also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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Affiliation(s)
- Changsheng Ma
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shulin Wu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shaowen Liu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Yaling Han
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
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4
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MA CS, WU SL, LIU SW, HAN YL. Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. J Geriatr Cardiol 2024; 21:251-314. [PMID: 38665287 PMCID: PMC11040055 DOI: 10.26599/1671-5411.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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Yu D, Brown J, David Strain W, Simmons D. Real-world evidence that among atrial fibrillation patients warfarin is associated with reduced nonelective admissions compared with those on DOACs. Clin Cardiol 2023; 46:1544-1553. [PMID: 37681472 PMCID: PMC10716333 DOI: 10.1002/clc.24146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/21/2023] [Accepted: 08/24/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Randomized trials show inconsistent estimates on risks of direct-acting oral anticoagulants (DOACs) versus warfarin in bleeding and mortality for atrial fibrillation (AF) patients. Trials are confounded by additional DOAC adherence support, while warfarin has a low time in therapeutic range. Few real-world studies compared emergency hospitalization risk between DOAC and warfarin users in AF. This study aimed to determine emergency hospitalization risk for AF patients on DOACs or warfarin in real-world settings. METHODS A tapered-matched real-world cohort extracted data from 412 English general practices' primary care records linked with emergency department (ED) and hospitalization data from the ECLIPSE database. AF patients with new DOAC or warfarin prescriptions were included. The primary outcome was all-cause ED attendance; the secondary outcomes were ED re-attendance, nonelective hospitalization, and rehospitalization within 12 months. Weighted Cox regression estimated relative risk difference. RESULTS 39 201 DOAC patients were matched with 13 145 warfarin patients. DOAC patients had a 25% higher likelihood of attending ED (odds ratio 1.25; 95% confidence interval [CI] 1.01-1.55). DOAC use also associated with higher ED re-attendance, nonelective hospitalization, and rehospitalization within 12 months: 1.41 (95% CI 1.00-1.98), 1.26 (1.00-1.57), and 1.54 (1.01-2.34), respectively, with p-values < .05. CONCLUSIONS DOACs for AF thromboprophylaxis are associated with the increased risk of ED attendance, recurrent hospitalization, and numerical rise in ED re-attendance and first nonelective hospitalization compared to warfarin. However, these real-world data cannot establish if this difference results from medication adherence, lack of regular DOAC clinic monitoring, unmeasured confounders, or fundamental agent efficacy disparities.
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Affiliation(s)
- Dahai Yu
- Primary Care Centre Versus Arthritis, School of Medicine, Faculty of Medicine & Health Sciences, Keele UniversityKeeleUK
| | | | - W. David Strain
- Diabetes and Vascular Medicine Research Centre, Institute of Biomedical and Clinical Science and College of Medicine and Health, University of ExeterExeterUK
| | - David Simmons
- Macarthur Clinical School, School of MedicineWestern Sydney UniversitySydneyNew South WalesAustralia
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6
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Rottura M, Drago SFA, Molonia A, Irrera N, Marino S, Scoglio R, Orlando L, Gigliotti De Fazio M, Squadrito F, Arcoraci V, Imbalzano E. Prescriptive behavior of non-vitamin K oral anticoagulants in patients affected by atrial fibrillation in general practice. Biomed Pharmacother 2023; 165:115020. [PMID: 37352701 DOI: 10.1016/j.biopha.2023.115020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/01/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide and in recent years the pharmacological approach has been strongly implemented; in Italy, the prescription of the non-vitamin K oral anticoagulants (NOAC) was also extended to General Practitioners (GPs) since 2020. The aim of the present study was to investigate the GPs prescribing behaviour of NOACs. An observational study was performed by using the computerized medical record of 14 GPs in Sicily: patients affected by AF were selected and stratified according to the prescribed antithrombotic drugs. Patients were considered inadequately managed if antithrombotic treatment was not adherent to recent ESC guidelines. A total of 467 (2.7 %) patients were affected by AF, 276 (59.1 %) were treated with an oral anticoagulant (OAC) regardless the high stroke risk (OR 1.64; 95 %CI 0.74-3.62; p = 0.226). The NOAC users were 236 patients as follow: Rivaroxaban 33.5 %, Apixaban 33,1 %, Dabigatran 17,4 %, Edoxaban 16.1 %. In 7 patients an inappropriate NOAC treatment was observed. Among Vitamin-K antagonist users, 25.0 % were considered inappropriate. Patients not treated with OAC were 191, of them 81.7 % were at high stroke risk and did not receive any OAC despite the indication to treat. In addition, the probability to be not properly managed significantly increased in older and in patients with atherosclerosis. Conversely, patients with at least one reported cardiology counselling significantly reduced the likelihood to be not properly managed (OR 0.38, 95 %CI 0.25-0.58; p 0.01). Our results suggest the need to optimize the management of real-life AF patients by improving prescribing adherence to ESC guidelines.
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Affiliation(s)
- M Rottura
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - S F A Drago
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - A Molonia
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - N Irrera
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - S Marino
- Italian Society of General Practice (SIMG), Messina, Italy
| | - R Scoglio
- Italian Society of General Practice (SIMG), Messina, Italy
| | - L Orlando
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - M Gigliotti De Fazio
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - F Squadrito
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - V Arcoraci
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy.
| | - E Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
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7
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Greco A, Laudani C, Rochira C, Capodanno D. Antithrombotic Management in AF Patients Following Percutaneous Coronary Intervention: A European Perspective. Interv Cardiol 2023; 18:e05. [PMID: 37601736 PMCID: PMC10433110 DOI: 10.15420/icr.2021.30] [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: 10/19/2021] [Accepted: 03/20/2022] [Indexed: 08/22/2023] Open
Abstract
AF is a highly prevalent disease, often requiring long-term oral anticoagulation to prevent stroke or systemic embolism. Coronary artery disease, which is common among AF patients, is often referred for myocardial revascularisation by percutaneous coronary intervention (PCI), which requires dual antiplatelet therapy to minimise the risk of stent-related complications. The overlap of AF and PCI is a clinical conundrum, especially in the early post-procedural period, when both long-term oral anticoagulation and dual antiplatelet therapy are theoretically indicated as a triple antithrombotic therapy. However, stacking drugs is not a desirable option because of the increased bleeding risk. Several strategies have been investigated to mitigate this concern, including shortening triple antithrombotic therapy duration and switching to a dual antithrombotic regimen. This review analyses the mechanisms underlying thrombotic complications in AF-PCI, summarises evidence surrounding antithrombotic therapy regimens and reports and comments on the latest European guidelines.
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Affiliation(s)
- Antonio Greco
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
| | - Claudio Laudani
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
| | - Carla Rochira
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
| | - Davide Capodanno
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
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Patient Education Strategies to Improve Risk of Stroke in Patients with Atrial Fibrillation. CURRENT CARDIOVASCULAR RISK REPORTS 2022. [DOI: 10.1007/s12170-022-00709-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
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Hammett C, Badve SV, Kerr PG, Tran HA, Dundon BK, Lo S, Wong A, Joseph JE, Deague J, Perkovic V. Oral Anticoagulant Use in Patients With Atrial Fibrillation and Chronic Kidney Disease: A Review of the Evidence With Recommendations for Australian Clinical Practice. Heart Lung Circ 2022; 31:1604-1611. [PMID: 36336614 DOI: 10.1016/j.hlc.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/10/2022] [Accepted: 09/01/2022] [Indexed: 11/05/2022]
Abstract
Chronic kidney disease is common in patients with atrial fibrillation (AF) and is associated with heightened risks of stroke/systemic embolisation and bleeding. In this review we outline the evidence for AF stroke prevention in kidney disease, identify current knowledge gaps, and give recommendations for anticoagulation at various stages of chronic kidney disease. Overall, anticoagulation is underused. Warfarin use becomes increasingly difficult with advancing kidney disease, with difficulty maintaining international normalised ratio (INR) in therapeutic range, increased risk of intracranial and fatal bleeding compared to non-vitamin K oral anticoagulants (NOACs), and high rates of discontinuation. Similarly, the direct thrombin inhibitor dabigatran is not recommended as it is predominantly renally excreted with consequent increased plasma levels and bleeding risk with advanced kidney disease. The Factor Xa inhibitors apixaban and rivaroxaban have less renal excretion (25-35%), modest increases in plasma levels with advancing kidney disease, and are the preferred first line choice for anticoagulation in moderate kidney disease based on strong evidence from randomised clinical trials (RCTs). In severe kidney disease there is a paucity of RCT data, but extrapolation of the pharmacokinetic and RCT data for moderate kidney disease, and observational studies, support the considered use of dose-adjusted Factor Xa inhibitors unless the bleeding risk is prohibitive. In Australia, apixaban is approved for creatinine clearance down to 25 mL/min, and rivaroxaban down to 15 mL/min. For end-stage kidney disease warfarin is the only agent approved, but we recommend against anticoagulation (except in selected cases) due to high bleeding risk, multiple co-morbidities, and questionable benefit.
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Affiliation(s)
| | - Sunil V Badve
- Department of Nephrology, St George Hospital, and Renal and Metabolic Division, The George Institute for Global Health, Sydney, NSW, Australia
| | - Peter G Kerr
- Department of Nephrology, Monash Medical Centre and Monash University, Melbourne, Vic, Australia
| | - Huyen A Tran
- The Alfred Hospital & Monash University, Melbourne, Vic, Australia
| | - Benjamin K Dundon
- MonashHeart, Monash Health and Victorian Heart Institute, Monash University, Melbourne, Vic, Australia
| | - Sidney Lo
- Liverpool Hospital, SouthWest Sydney Local Health District and University of New South Wales, Sydney, NSW, Australia
| | - Andrew Wong
- Royal Brisbane and Women's Hospital and The University of Queensland, Brisbane, Qld, Australia
| | | | | | - Vlado Perkovic
- Royal North Shore Hospital and The George Institute for Global Health, Sydney, NSW, Australia
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Mareev YV, Polyakov DS, Vinogradova NG, Fomin IV, Mareev VY, Belenkov YN, Ageev FT, Artemjeva EG, Badin YV, Bakulina EV, Galyavich AS, Ionova TS, Kamalov GM, Kechedzhieva SG, Koziolova NA, Malenkova VY, Malchikova SV, Smirnova EA, Tarlovskaya EI, Shcherbinina EV, Yakushin SS. Epidemiology of atrial fibrillation in a representative sample of the European part of the Russian Federation. Analysis of EPOCH-CHF study. KARDIOLOGIIA 2022; 62:12-19. [PMID: 35569159 DOI: 10.18087/cardio.2022.4.n1997] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/04/2022] [Indexed: 06/15/2023]
Abstract
Aim To study true prevalence of atrial fibrillation (AF) in a representative sample from the European part of the Russian Federation; to describe characteristics of patients with AF; and to provide the frequency of anticoagulant treatment.Material and methods Cross-sectional data of the EPOCH epidemiological study (2017) were used. Data were collected in 8 constituent entities of the Russian Federation; the sample size was 11 453 people. The sample included all respondents who had given their consent for participation and were older than 10 years. Statistical tests were performed in the R system for statistical data analysis.Results The prevalence of AF in the representative sample from the European part of the Russian Federation was 2.04 %. The AF prevalence increased with age and reached a maximum value of 9.6% in the age group of 80 to 89 years. The AF prevalence among females was 1.5 times higher than among men. With age standardization, the AF prevalence was 18.95 and 21.33 per 1,000 people for men and women, respectively. The AF prevalence increased in the presence of concurrent cardiovascular diseases (CVDs) or diabetes mellitus as well as with an increased number of comorbidities in the same person and reached 70.3 and 60.0 % in patients with 4 and 5 comorbidities, respectively. Patients with AF had a greater number of comorbidities and higher CHA2DS2VASc scores (5.0 vs. 2.0, p<0.001) compared to patients with CVDs without AF. Only 22.6 % of patients with CVD and AF took anticoagulants. Only 23.9% of patients with absolute indications for the anticoagulant treatment received anticoagulants.Conclusion The AF prevalence in the European part of the Russian Federation was 2.04 %; it increased with age and in patients with concurrent CVDs or diabetes mellitus. Most of AF patients (93.2 %) required a mandatory treatment with oral anticoagulants.
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Affiliation(s)
- Yu V Mareev
- National Medical Research Center for Therapy and Preventive Medicine; Medical Research and Educational Center, Lomonosov Moscow State University
| | | | - N G Vinogradova
- Privolzhsky Research Medical University; Municipal Clinical Hospital #38 of the Nizhny Novgorod Region
| | - I V Fomin
- Privolzhsky Research Medical University
| | - V Yu Mareev
- Medical Research and Educational Center, Lomonosov Moscow State University; School of Fundamental Medicine, Lomonosov Moscow State University
| | | | - F T Ageev
- Scientific Medical Research Center of Cardiology
| | | | | | | | | | | | | | | | | | | | | | - E A Smirnova
- Academician Pavlov Ryazan State Medical University
| | | | | | - S S Yakushin
- Academician Pavlov Ryazan State Medical University
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Badescu MC, Badulescu OV, Butnariu LI, Floria M, Ciocoiu M, Costache II, Popescu D, Bratoiu I, Buliga-Finis ON, Rezus C. Current Therapeutic Approach to Atrial Fibrillation in Patients with Congenital Hemophilia. J Pers Med 2022; 12:519. [PMID: 35455634 PMCID: PMC9029474 DOI: 10.3390/jpm12040519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 11/21/2022] Open
Abstract
Cardiovascular disease in hemophiliacs has an increasing prevalence due to the aging of this population. Hemophiliacs are perceived as having a high bleeding risk due to the coagulation factor VIII/IX deficiency, but it is currently acknowledged that they also have an important ischemic risk. The treatment of atrial fibrillation (AF) is particularly challenging since it usually requires anticoagulant treatment. The CHA2DS2-VASc score is used to estimate the risk of stroke and peripheral embolism, and along with the severity of hemophilia, guide the therapeutic strategy. Our work provides the most complete, structured, and updated analysis of the current therapeutic approach of AF in hemophiliacs, emphasizing that there is a growing interest in therapeutic strategies that allow for short-term anticoagulant therapy. Catheter ablation and left atrial appendage occlusion have proven to be efficient and safe procedures in hemophiliacs, if appropriate replacement therapy can be provided.
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Affiliation(s)
- Minerva Codruta Badescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Oana Viola Badulescu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (O.V.B.); (M.C.)
- Hematology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Lacramioara Ionela Butnariu
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Mariana Floria
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
- Internal Medicine Clinic, “Dr. Iacob Czihac” Emergency Military Clinical Hospital Iasi, 700483 Iasi, Romania
| | - Manuela Ciocoiu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (O.V.B.); (M.C.)
| | - Irina-Iuliana Costache
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
- Cardiology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Diana Popescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
| | - Ioana Bratoiu
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Oana Nicoleta Buliga-Finis
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
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Akao M, Ogawa H, Masunaga N, Minami K, Ishigami K, Ikeda S, Doi K, Hamatani Y, Yoshizawa T, Ide Y, Fujino A, Ishii M, Iguchi M, Wada H, Hasegawa K, Tsuji H, Esato M, Abe M. 10-Year Trends of Antithrombotic Therapy Status and Outcomes in Japanese Atrial Fibrillation Patients ― The Fushimi AF Registry ―. Circ J 2022; 86:726-736. [DOI: 10.1253/circj.cj-22-0023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Hisashi Ogawa
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Nobutoyo Masunaga
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Kimihito Minami
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Kenjiro Ishigami
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Syuhei Ikeda
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Kosuke Doi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Yasuhiro Hamatani
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Takashi Yoshizawa
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Yuya Ide
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Akiko Fujino
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Mitsuru Ishii
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Moritake Iguchi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Hiromichi Wada
- Division of Translational Research, National Hospital Organization Kyoto Medical Center
| | - Koji Hasegawa
- Division of Translational Research, National Hospital Organization Kyoto Medical Center
| | | | - Masahiro Esato
- Department of Cardiology, Heart Rhythm Section, Ogaki Tokushukai Hospital
| | - Mitsuru Abe
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
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Polidori MC, Alves M, Bahat G, Boureau AS, Ozkok S, Pfister R, Pilotto A, Veronese N, Bo M. Atrial fibrillation: a geriatric perspective on the 2020 ESC guidelines. Eur Geriatr Med 2022; 13:5-18. [PMID: 34727362 PMCID: PMC8562074 DOI: 10.1007/s41999-021-00537-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/03/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The Task Force for the diagnosis and management of atrial fibrillation (AF) of the European Society of Cardiology (ESC) published in 2020 the updated Guidelines for the Diagnosis and Management of Atrial Fibrillation with the contribution of the European Heart Rhythm Association (EHRA) of the ESC and the European Association for Cardiothoracic Surgery (EACTS). METHODS AND RESULTS In this narrative viewpoint, we approach AF from the perspective of aging medicine and try to provide the readers with information usually neglected in clinical routine, mainly due to the fact that while the large majority of AF patients in real life are older, frail and cognitively impaired, these are mostly excluded from clinical trials, and physicians' attitudes often prevail over standardized algorithms. CONCLUSIONS On the basis of existing evidence, (1) opportunistic AF screening by pulse palpation or ECG rhythm strip is cost-effective, and (2) whereas advanced chronological age by itself is not a contraindication to AF treatment, a Comprehensive Geriatric Assessment (CGA) including frailty, cognitive impairment, falls and bleeding risk may assist in clinical decision making to provide the best individualized treatment.
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Affiliation(s)
- M Cristina Polidori
- Ageing Clinical Research, Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
- Cologne Excellence Cluster On Cellular Stress-Responses in Aging-Associated Diseases (CECAD), University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.
| | - Mariana Alves
- Serviço de Medicina III, Hospital Pulido Valente, CHULN, Lisbon, Portugal
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Gulistan Bahat
- Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Capa, 34390, Istanbul, Turkey
| | - Anne Sophie Boureau
- Department of Geriatrics, CHU Nantes and Université de Nantes, CNRS, INSERM, l'Institut du Thorax, 44000, Nantes, France
| | - Serdar Ozkok
- Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Capa, 34390, Istanbul, Turkey
| | - Roman Pfister
- Department of Cardiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Alberto Pilotto
- Department of Geriatric Care, Orthogeriatrics and Rehabilitation, Galliera Hospital, Genoa, Italy
- Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Nicola Veronese
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, Palermo, Italy
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette, Corso Bramante 88, 10126, Turin, Italy
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Westhoff-Bleck M, Klages C, Zwadlo C, Sonnenschein K, Sieweke JT, Bauersachs J, Bertram H, Grosse U. Thromboembolic characteristics and role of anticoagulation in long-standing Fontan circulation. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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16
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 5324] [Impact Index Per Article: 1774.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Neurologic complications of atrial fibrillation: Pharmacologic and interventional approaches to stroke prevention. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:143-149. [PMID: 33632432 DOI: 10.1016/b978-0-12-819814-8.00012-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Atrial fibrillation is a common cardiac arrhythmia that carries a risk of stroke. This is commonly stratified with the CHA2DS2-VASc score. Stroke risk can be reduced with anticoagulants or with interventions to close the left atrial appendage, the most common source of left atrial thrombi. While warfarin has been traditionally used as the only oral anticoagulant available, there are several direct oral anticoagulants that compare favorably with respect to both stroke and bleeding risk in randomized controlled trials. Multiple interventional options exist to close the left atrial appendage, but the Watchman device is the only one that compares favorably with warfarin in randomized controlled trials.
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Age threshold for anticoagulation in patients with atrial fibrillation: A Swedish nationwide observational study. Int J Cardiol 2020; 326:92-97. [PMID: 33152417 DOI: 10.1016/j.ijcard.2020.10.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 10/12/2020] [Accepted: 10/26/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND There is controversy as to whether patients with atrial fibrillation (AF) and perceived low risk of cerebral infarction should be treated with anticoagulants, especially at what age a cut-off treatment might be indicated. METHOD We performed a retrospective, nationwide cohort study based on the Swedish National Patient Register and the Prescribed Drugs Register. Patients with a diagnosis of AF between July 1, 2005, and December 31, 2014, were included and divided into age categories (<55, 55-59, 60-64 and 65-74 years) and CHA2DS2-VA score of 0 and 1. Incidence rates (IR) of cerebral infarction and cerebral bleeding were calculated. Associations between outcomes from anticoagulant therapy and no therapy were calculated with Cox regression and given as hazard ratios (HR) with 95% confidence intervals (CI). RESULTS The analyzed cohort consisted of 294,470 patients. All age categories older than 55 years on anticoagulants had lower IR and HR for cerebral infarction compared to patients off anticoagulants, from HR 0.72, 95% CI (0.54-0.96) for patients 55-59 years with 0 points according to the CHA2DS2-VA score, to HR 0.37, 95% CI (0.33-0.42) for patients 65-74 years with 1 point. Anticoagulant therapy was associated to an increased risk of cerebral bleeding in three of seven categories, <55 years with 0 point, 55-59 years with 1 point, and 65-74 years with 1 point. CONCLUSION Anticoagulant therapy in patients with AF and age 55 years and older may be considered even if the patient has no other known risk factors for cerebral infarction.
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Escudero-Martínez I, Ocete RF, Mancha F, Vega Á, Piñero P, López-Rueda A, Fajardo E, Algaba P, Fernández-Engo JR, Martín-Sánchez EM, Galvao-Carmona A, Zapata-Arriaza E, Lebrato L, Pardo-Galiana B, Cabezas JA, Ayuso MI, González A, Moniche F, Montaner J. Prevalence and risk factors of silent brain infarcts in patients with AF detected by 3T-MRI. J Neurol 2020; 267:2675-2682. [PMID: 32410017 DOI: 10.1007/s00415-020-09887-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/01/2020] [Accepted: 05/04/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Silent brain infarcts (SBI), a finding on neuroimaging, are associated with higher risk of future stroke. Atrial Fibrillation (AF) has been previously identified as a cause of SBI. OBJECTIVES The aim of this study is to determine the prevalence of and risk factors for SBI in patients with AF and low-to-moderate embolic risk according to CHADS2 and CHA2DS2VASc score. METHODS Patients with a history of AF based on medical records who scored 0-1 in the CHADS2 score were selected from the Seville urban area using the Andalusian electronic healthcare database (DIRAYA). Demographic and clinical data were collected and a 3T brain MRI was performed on patients older than 50 years and with absence of neurological symptoms. RESULTS 66 of the initial 443 patients (14.9%) and 41 of the 349 patients with low risk according to CHA2DS2VASc score (11.7%) presented at least 1 SBI. After adjusted multivariable analysis, an older age (OR 3.84, 95% CI 1.07-13.76) and left atrial (LA) enlargement (OR 3.13, 95% CI 1.15-8.55) were associated with SBI in the whole cohort, while only LA enlargement was associated with SBI in the low-risk cohort (OR 3.19, 95% CI 1.33-7.63). CONCLUSIONS LA enlargement on echocardiogram was associated with SBI in patients with AF and low or moderate embolic risk according to CHADS2 and in the low-risk population according to CHA2DS2VASc. Although further studies are needed, a neuroimaging screening might be justified in these patients to guide medical therapies to improve stroke prevention.
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Affiliation(s)
- Irene Escudero-Martínez
- Department of Neurology, Hospital Universitario Virgen del Rocío, Seville, Spain.,Neurovascular Research Group, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC, University of Seville, Av. Manuel Siurot s/n, 41013, Seville, Spain
| | - Rafael F Ocete
- Neurovascular Research Group, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC, University of Seville, Av. Manuel Siurot s/n, 41013, Seville, Spain.,Department of Radiology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Fernando Mancha
- Neurovascular Research Group, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC, University of Seville, Av. Manuel Siurot s/n, 41013, Seville, Spain
| | - Ángela Vega
- Neurovascular Research Group, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC, University of Seville, Av. Manuel Siurot s/n, 41013, Seville, Spain
| | - Pilar Piñero
- Department of Radiology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | - Elena Fajardo
- Department of Radiology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Pilar Algaba
- Neurovascular Research Group, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC, University of Seville, Av. Manuel Siurot s/n, 41013, Seville, Spain
| | | | - Eva M Martín-Sánchez
- Information Systems Coordination Service, Andalusian Healthcare System, Seville, Spain
| | | | - Elena Zapata-Arriaza
- Neurovascular Research Group, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC, University of Seville, Av. Manuel Siurot s/n, 41013, Seville, Spain.,Department of Radiology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Lucía Lebrato
- Department of Neurology, Hospital Universitario Virgen del Rocío, Seville, Spain.,Neurovascular Research Group, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC, University of Seville, Av. Manuel Siurot s/n, 41013, Seville, Spain
| | - Blanca Pardo-Galiana
- Department of Neurology, Hospital Universitario Virgen del Rocío, Seville, Spain.,Neurovascular Research Group, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC, University of Seville, Av. Manuel Siurot s/n, 41013, Seville, Spain
| | - Juan Antonio Cabezas
- Department of Neurology, Hospital Universitario Virgen del Rocío, Seville, Spain.,Neurovascular Research Group, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC, University of Seville, Av. Manuel Siurot s/n, 41013, Seville, Spain
| | - María Irene Ayuso
- Neurovascular Research Group, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC, University of Seville, Av. Manuel Siurot s/n, 41013, Seville, Spain
| | - Alejandro González
- Neurovascular Research Group, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC, University of Seville, Av. Manuel Siurot s/n, 41013, Seville, Spain.,Department of Radiology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Francisco Moniche
- Department of Neurology, Hospital Universitario Virgen del Rocío, Seville, Spain.,Neurovascular Research Group, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC, University of Seville, Av. Manuel Siurot s/n, 41013, Seville, Spain
| | - Joan Montaner
- Neurovascular Research Group, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC, University of Seville, Av. Manuel Siurot s/n, 41013, Seville, Spain. .,Department of Neurology, Hospital Universitario Virgen Macarena, Avenida Doctor Fedriani, No. 3, 41007, Seville, Spain.
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Inoue H, Umeyama M, Yamada T, Hashimoto H, Komoto A, Yasaka M. Safety and effectiveness of reduced-dose apixaban in Japanese patients with nonvalvular atrial fibrillation in clinical practice: A sub-analysis of the STANDARD study. J Cardiol 2020; 75:208-215. [DOI: 10.1016/j.jjcc.2019.07.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/26/2019] [Accepted: 07/09/2019] [Indexed: 01/19/2023]
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Verbrugge FH, Martin AC, Siegal D, Pieper K, Illingworth L, Camm AJ, Fox KAA. Impact of oral anticoagulation in patients with atrial fibrillation at very low thromboembolic risk. Heart 2019; 106:845-851. [DOI: 10.1136/heartjnl-2019-315873] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/28/2019] [Accepted: 11/03/2019] [Indexed: 01/30/2023] Open
Abstract
ObjectiveTo investigate reasons for and impact of oral anticoagulation (OAC) in patients with atrial fibrillation (AF) at very low thromboembolic risk.MethodsIndividuals with CHA2DS2-VASc score 0 (men) or 1 (women) from the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) were studied. Baseline characteristics according to OAC use were evaluated by logistic regression analysis. Non-haemorrhagic stroke or systemic embolism, major bleeding, cardiovascular and all-cause mortality were compared.ResultsFrom 2224 low CHA2DS2-VASc patients in GARFIELD-AF, 44% received OAC. In an adjusted model, increasing age up to 65 years (OR (95% CI)=1.31 (1.19 to 1.44)) and persistent AF (OR (95% CI)=3.25 (2.44 to 4.34)) or permanent AF (OR (95% CI)=2.29 (1.59 to 3.30)) versus paroxysmal/unclassified AF were associated with OAC use. Concomitant antiplatelet therapy (OR (95% CI)=0.21 (0.17 to 0.27)) was inversely associated. Crude incidence rates per 100 person-years over 2 years in patients on OAC versus not on OAC were 0.32 (95% CI 0.14 to 0.71) vs 0.30 (95% CI 0.14 to 0.63) for non-haemorrhagic stroke or systemic embolism, 0.21 (95% CI 0.08 to 0.57) vs 0.17 (95% CI 0.06 to 0.46) for major bleeding, 0.26 (95% CI 0.11 to 0.64) vs 0.26 (95% CI 0.12 to 0.57) for cardiovascular mortality and 0.74 (95% CI 0.44 to 1.25) vs 0.99 (95% CI 0.66 to 1.49) for all-cause mortality.ConclusionsIn contrast to guideline recommendations, almost half of real-world patients with AF at a very low thromboembolic risk according to the CHA2DS2-VASc score receive OAC. Persistent or permanent AF and increasing age up to 65 years are associated with OAC use, while concomitant antiplatelet therapy shows an inverse association. Regardless whether patients received OAC therapy, few thromboembolic and bleeding events occur, highlighting the low risk of this population.
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John RM, Sharma D. Contraindication to Anticoagulation in Nonvalvular Atrial Fibrillation: Are We Still to Fear the Clot and Not the Bleed? JACC Clin Electrophysiol 2019; 5:1393-1395. [PMID: 31857037 DOI: 10.1016/j.jacep.2019.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 07/18/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Roy M John
- Department of Cardiology, Arrhythmia Service, North Shore University Medical Center, Manhasset, New York.
| | - Deva Sharma
- Division of Hematology-Oncology, Department of Internal Medicine and Physiology, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Transfusion Medicine, Department of Internal Medicine and Physiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Murillo-Muñoz MM, Gaviria-Mendoza A, Machado-Alba JE. Potential prescribing omissions in patients with cardiovascular disease. Int J Clin Pract 2019; 73:e13428. [PMID: 31573715 DOI: 10.1111/ijcp.13428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 09/21/2019] [Indexed: 11/30/2022] Open
Abstract
Aims Potential prescribing omissions (PPOs) of medications are a frequent form of inadequate prescription drug practices. The objective of this study was to identify PPOs in a sample of elderly patients with cardiovascular disease. Methods Quasi-experimental study. Data were collected from a population database. We included patients who were older than 65 years and had a diagnosis of hypertension, dyslipidaemia, diabetes mellitus, coronary heart disease, heart failure or atrial fibrillation in Colombia. PPOs were determined in a random sample of patients by the START-2 (Screening Tool to Alert doctors to Right Treatment) criteria. The impact of the PPO was determined after an educational intervention with the doctors who were responsible for treating said patients. Results A total of 630 patients, with a median age of 72 years (interquartile range: 68-78 years), were included; 56.2% were women. The most frequent diagnoses were arterial hypertension (94.1%, n = 593) and dyslipidaemia (56.5%, n = 356). We identified 100 patients (15.9%) with omissions equalling 139 PPOs, and the most common PPOs were due to a lack of angiotensin-converting enzyme inhibitors in patients associated with heart failure or coronary heart disease (n = 23, 16.5%) and a lack of statins (n = 20; 14.4%) and aspirin (n = 20; 14.4%) in coronary heart disease. Prescription adjustments were achieved in 35 patients (25.2%). Conclusions Potential prescribing omissions are common in elderly patients with cardiovascular disease. Educational interventions may contribute to a reduced PPO frequency and improve the quality of prescription drug administration.
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Affiliation(s)
- María Mónica Murillo-Muñoz
- Grupo de Investigación Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Colombia
| | - Andrés Gaviria-Mendoza
- Grupo de Investigación Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Colombia
| | - Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Colombia
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Kang EYC, Lin YH, Wang NK, Yeung L, Luo C, Wu WC, Sun CC, Kang JH, Hung MJ, Chen TH. Aspirin use in central retinal arterial occlusion to prevent ischaemic stroke: a retrospective cohort study in Taiwan. BMJ Open 2019; 9:e025455. [PMID: 30819710 PMCID: PMC6398622 DOI: 10.1136/bmjopen-2018-025455] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To understand the efficacy of aspirin use for preventing ischaemic stroke after central retinal artery occlusion (CRAO). DESIGN The retrospective cohort study was conducted using the National Health Insurance Research Database from 1998 to 2013. SETTING A population-based study. PARTICIPANTS A total of 9437 participants with newly diagnosed CRAO were identified. Participants who had a previous stroke and/or retinal vascular occlusion, were aged <20 years and used aspirin 3 months before the event were excluded. There were 3778 eligible participants matched by propensity score, and they were divided into aspirin (n=434) and aspirin-naive (n=1736) groups after the matching. METHODS Cox proportional hazard models and cumulative survival curves were used to assess ischaemic stroke in the study groups, along with log-rank tests to compare group differences. MAIN OUTCOME MEASURES Incidence of ischaemic stroke in the aspirin and aspirin-naive groups 1 year after CRAO. RESULTS Of the 3778 patients with newly diagnosed CRAO, 151 (4%) had a subsequent ischaemic stroke within 1 year. The risk was especially high during the first week of the CRAO. No difference between the aspirin and aspirin-naive groups was found in risk of ischaemic stroke, haemorrhagic stroke, gastrointestinal bleeding, major bleeding, acute coronary syndrome, retinal vein occlusion, new-onset glaucoma, undergoing panretinal photocoagulation or all-cause mortality. Risk factors for ischaemic stroke within 1 year of CRAO included male gender (p=0.031; HR=1.46) and age (p=0.032; HR=1.14). CONCLUSIONS Aspirin use after a CRAO showed no benefit on attenuating the risk of ischaemic stroke. The risk of ischaemic stroke was increased after CRAO especially during the first week. Male gender and age were risk factors for ischaemic stroke after CRAO.
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Affiliation(s)
- Eugene Yu-Chuan Kang
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Yun-Hsuan Lin
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Nan-Kai Wang
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Edward S. Harkness Eye Institute, Department of Ophthalmology, Columbia University, New York, NY, USA
| | - Ling Yeung
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Caesar Luo
- Bay Area Retina Associates, Oakland, CA, USA
| | - Wei-Chi Wu
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Chi-Chin Sun
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan
- Biostatistical Consultation Center, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Je-Ho Kang
- Department of Internal Medicine, Yang Ming Hospital, Taoyuan, Taiwan
| | - Ming-Jui Hung
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Department of Cardiology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Tien-Hsing Chen
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Biostatistical Consultation Center, Chang Gung Memorial Hospital, Keelung, Taiwan
- Department of Cardiology, Chang Gung Memorial Hospital, Keelung, Taiwan
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Głowicki B, Matusik PT, Plens K, Undas A. Prothrombotic State in Atrial Fibrillation Patients With One Additional Risk Factor of the CHA 2DS 2-VASc Score (Beyond Sex). Can J Cardiol 2019; 35:634-643. [PMID: 30955928 DOI: 10.1016/j.cjca.2019.01.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/24/2019] [Accepted: 01/24/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND It is unclear whether a prothrombotic state occurs in atrial fibrillation (AF) with low stroke risk. METHODS We studied 118 patients with AF with the Congestive Heart Failure, Hypertension, Age (≥ 75 years), Diabetes, Stroke/Transient Ischemic Attack/Systemic Embolism, Vascular Disease, Age (65-74 years), Sex (Female) (CHA2DS2-VASc) score of 1 in men or 2 in women vs 52 patients with AF with the CHA2DS2-VASc score of 0 in men or 1 in women. Plasma clot permeability (Ks), a measure of fibrin clot density, and clot lysis time (CLT), endogenous thrombin potential (ETP), von Willebrand factor antigen, and plasminogen activator inhibitor-1 were evaluated in nonanticoagulated subjects. RESULTS Patients with the CHA2DS2-VASc score of 1 (beyond sex), compared with those with 0, had lower Ks, prolonged CLT, increased ETP, von Willebrand factor antigen, and plasminogen activator inhibitor-1 (all P < 0.001), without any sex-dependent differences. Heart failure (odds ratio [OR]: 10.28; 95% confidence interval [CI]: 2.32-45.41), age 65-74 years (OR: 4.37; 95% CI: 1.76-10.83), and hypertension (OR: 5.03; 95% CI: 1.81-13.94) were independently associated with low Ks (the lowest quartile, ≤ 6.4 × 10-9 cm2), whereas only age 65-74 years (OR: 3.33; 95% CI: 1.59-6.96) significantly predicted prolonged CLT (the top quartile, ≥ 108 minutes). Age 65-74 years (OR: 5.21; 95% CI: 2.12-12.80), heart failure (OR: 6.58; 95% CI: 1.49-29.06), and hypertension (OR: 4.33; 95% CI: 1.54-12.15) were independently associated with high ETP (the top quartile, ≥ 1681.3 nM × minutes). CONCLUSIONS A prothrombotic state (increased thrombin generation, denser fibrin clots, impaired fibrinolysis, and endothelial injury) characterizes patients with AF with 1 additional clinical stroke risk factor (beyond sex), with age 65-74 years being particularly associated with prothrombotic indices.
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Affiliation(s)
- Błażej Głowicki
- Department of Emergency Medicine, Poviat Hospital, Limanowa, Poland
| | - Paweł T Matusik
- Department of Electrocardiology, The John Paul II Hospital, Kraków, Poland; Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | | | - Anetta Undas
- Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland.
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Bellinge JW, Paul JJ, Walsh LS, Garg L, Watts GF, Schultz C. The impact of non-vitamin K antagonist oral anticoagulants (NOACs) on anticoagulation therapy in rural Australia. Med J Aust 2018; 208:18-23. [PMID: 29320668 DOI: 10.5694/mja17.00132] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 05/02/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To determine the use of different anticoagulation therapies in rural Western Australia; to establish whether remoteness from health care services affects the choice of anticoagulation therapy; to gather preliminary data on anticoagulation therapy safety and efficacy. DESIGN Retrospective cohort study of patients hospitalised with a principal diagnosis of atrial fibrillation/flutter (AF) or venous thromboembolism (VTE) during 2014-2015. SETTING Four hospitals serving two-thirds of the rural population of Western Australia. PARTICIPANTS 609 patients with an indication for anticoagulation therapy recorded in their hospital discharge summary for index admission. MAIN OUTCOME MEASURES Prescribing rates of anticoagulation therapies by indication for anticoagulation and distance of patient residence from their hospital. The primary safety outcome was re-hospitalisation with a major or clinically relevant non-major bleeding event; the primary lack-of-efficacy outcome was re-hospitalisation for a thromboembolic event. RESULTS The overall rates of prescription of NOACs and warfarin were similar (34% v 33%). A NOAC was prescribed more often than warfarin for patients with AF (56.0% v 42.2% of those who received an anticoagulant; P < 0.001), but less often for patients with VTE (29% v 48%; P < 0.001). Warfarin was prescribed for 38% of patients who lived locally, a NOAC for 31% (P = 0.013); for non-local patients, the respective proportions were 29% and 36% (P = 0.08). 69% of patients with AF and a CHA2DS2-VASc score ≥ 1 were prescribed anticoagulation therapy. Patients treated with NOACs had fewer bleeding events than patients treated with warfarin (nine events [4%] v 20 events [10%]; P = 0.027). CONCLUSIONS In rural WA, about one-third of patients with an indication for anticoagulation therapy receive NOACs, but one-third of patients with AF and at risk of stroke received no anticoagulant therapy, and may benefit from NOAC therapy.
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Larson EA, German DM, Shatzel J, DeLoughery TG. Anticoagulation in the cardiac patient: A concise review. Eur J Haematol 2018; 102:3-19. [PMID: 30203452 DOI: 10.1111/ejh.13171] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 08/28/2018] [Accepted: 08/30/2018] [Indexed: 01/12/2023]
Abstract
Anticoagulation has multiple roles in the treatment of cardiovascular disease, including in management of acute myocardial infarction, during percutaneous coronary intervention, as stroke prophylaxis in patients with atrial arrhythmias, and in patients with mechanical heart valves. Clinical anticoagulation choices in the aforementioned diseases vary widely, due to conflicting data to support established agents and the rapid evolution of evidence-based practice that parallels more widespread use of novel oral anticoagulants. This review concisely summarizes evidence-based guidelines for anticoagulant use in cardiovascular disease, and highlights new data specific to direct oral anticoagulants.
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Affiliation(s)
- Elise A Larson
- The Division of Hematology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
| | - David M German
- The Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Joseph Shatzel
- The Division of Hematology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
| | - Thomas G DeLoughery
- The Division of Hematology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
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Rivera-Caravaca JM, Esteve-Pastor MA, Marín F, Valdés M, Vicente V, Roldán V, Lip GYH. A Propensity Score Matched Comparison of Clinical Outcomes in Atrial Fibrillation Patients Taking Vitamin K Antagonists: Comparing the "Real-World" vs Clinical Trials. Mayo Clin Proc 2018; 93:1065-1073. [PMID: 29730090 DOI: 10.1016/j.mayocp.2018.01.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 01/05/2018] [Accepted: 01/18/2018] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To investigate the incidence and risk of adverse clinical outcomes in a "real-world" cohort of patients with atrial fibrillation (AF) anticoagulated with vitamin K antagonists (VKAs) from the Murcia AF Project in comparison with the warfarin arm of the randomized clinical trial (RCT) AMADEUS (Evaluating the Use of SR34006 Compared to Warfarin or Acenocoumarol in Patients With Atrial Fibrillation). PATIENTS AND METHODS We included 1361 patients with AF from the Murcia AF Project (recruitment from May 1, 2007, to December 1, 2007) and 2293 from the AMADEUS trial (started in September 2003 and primary completed in March 2006), all taking VKA treatment. After propensity score matching (PSM), we investigated differences in rates and risks of several events, including major bleeding, ischemic stroke, and all-cause mortality at 365 (interquartile range, 275-428) days of follow-up. RESULTS After PSM there were 1324 patients for the comparative analysis, whereby annual event rates for most adverse events were significantly higher in the "real-world" population. Cox regression analyses demonstrated that the risk of primary outcomes was also increased in the "real-world" (vs RCT: hazard ratio [HR], 6.32; 95% CI, 2.84-14.03 for major bleeding; HR, 3.56, 95% CI, 1.22-10.42 for ischemic stroke; HR, 5.13, 95% CI, 3.02-8.69 for all-cause mortality). The risk of all other adverse events was higher in the real-world cohort, except for cardiovascular mortality. CONCLUSION This study comparing the Murcia AF Project and the AMADEUS trial demonstrates that there is a great heterogeneity in both populations, which is translated into a higher risk of several adverse outcomes in the real-world cohort, including major bleeding, ischemic stroke, and mortality.
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Affiliation(s)
- José Miguel Rivera-Caravaca
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Mariano Valdés
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Vicente Vicente
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Alkhouli M, Noseworthy PA, Rihal CS, Holmes DR. Stroke Prevention in Nonvalvular Atrial Fibrillation. J Am Coll Cardiol 2018; 71:2790-2801. [DOI: 10.1016/j.jacc.2018.04.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 03/16/2018] [Accepted: 04/09/2018] [Indexed: 12/18/2022]
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Itzhaki Ben Zadok O, Eisen A. Use of non-vitamin K oral anticoagulants in people with atrial fibrillation and diabetes mellitus. Diabet Med 2018; 35:548-556. [PMID: 29438571 DOI: 10.1111/dme.13600] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2018] [Indexed: 11/30/2022]
Abstract
AIMS To examine the efficacy and safety of non-vitamin K oral anticoagulants in people with both atrial fibrillation and diabetes mellitus. METHODS We reviewed efficacy and safety data from the warfarin-controlled phase III non-vitamin K oral anticoagulants trials (ARISTOTLE, RE-LY, ROCKET-AF, ENGAGE AF-TIMI 48) and their post hoc analyses with regard to diabetes status. We also reviewed the updated literature regarding this population. RESULTS At baseline 20-40% of the participants in the phase III non-vitamin K oral anticoagulants trials had diabetes mellitus at baseline. This population, in comparison with those without diabetes, was more likely to have other comorbidities, such as hypertension and coronary artery disease; thus, their cardiovascular risk was higher. Participants with diabetes had higher rates of stroke and systemic embolism than participants without diabetes. This risk was decreased using non-vitamin K oral anticoagulants, with no significant interaction by diabetic status or the specific drug used. Overall, compared with warfarin, non-vitamin K oral anticoagulants were safe and reduced the incidence of major bleeding in people with atrial fibrillation and diabetes, although the results varied with the different non-vitamin K oral anticoagulants. CONCLUSIONS The efficacy and safety of non-vitamin K oral anticoagulants compared with warfarin generally extend to participants with diabetes mellitus, although dedicated randomized trials or real-world data are lacking.
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Affiliation(s)
- O Itzhaki Ben Zadok
- Department of Cardiology, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A Eisen
- Department of Cardiology, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Magnusson P, Koyi H, Mattsson G. A protocol for a prospective observational study using chest and thumb ECG: transient ECG assessment in stroke evaluation (TEASE) in Sweden. BMJ Open 2018; 8:e019933. [PMID: 29615448 PMCID: PMC5892735 DOI: 10.1136/bmjopen-2017-019933] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) causes ischaemic stroke and based on risk factor evaluation warrants anticoagulation therapy. In stroke survivors, AF is typically detected with short-term ECG monitoring in the stroke unit. Prolonged continuous ECG monitoring requires substantial resources while insertable cardiac monitors are invasive and costly. Chest and thumb ECG could provide an alternative for AF detection poststroke.The primary objective of our study is to assess the incidence of newly diagnosed AF during 28 days of chest and thumb ECG monitoring in cryptogenic stroke. Secondary objectives are to assess health-related quality of life (HRQoL) using short-form health survey (SF-36) and the feasibility of the Coala Heart Monitor in patients who had a stroke. METHODS Stroke survivors in Region Gävleborg, Sweden, will be eligible for the study from October 2017. Patients with a history of ischaemic stroke without documented AF before or during ECG evaluation in the stroke unit will be evaluated by the chest and thumb ECG system Coala Heart Monitor. The monitoring system is connected to a smartphone application which allows for remote monitoring and prompt advice on clinical management. Over a period of 28 days, patients will be monitored two times a day and may activate the ECG recording at symptoms. On completion, the system is returned by mail. This system offers a possibility to evaluate the presence of AF poststroke, but the feasibility of this system in patients who recently suffered from a stroke is unknown. In addition, HRQoL using SF-36 in comparison to Swedish population norms will be assessed. The feasibility of the Coala Heart Monitor will be assessed by a self-developed questionnaire. ETHICS AND DISSEMINATION The study was approved by The Regional Ethical Committee in Uppsala (2017/321). The database will be closed after the last follow-up, followed by statistical analyses, interpretation of results and dissemination to a scientific journal. TRIAL REGISTRATION NUMBER NCT03301662; Pre-results.
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Affiliation(s)
- Peter Magnusson
- Cardiology Research Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden
| | - Hirsh Koyi
- Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden
| | - Gustav Mattsson
- Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden
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Lee JM, Joung B, Cha MJ, Lee JH, Lim WH, Kim TH, Shin SY, Uhm JS, Lim HE, Kim JB, Kim JS. 2018 KHRS Guidelines for Stroke Prevention Therapy in Korean Patients with Nonvalvular Atrial Fibrillation. ACTA ACUST UNITED AC 2018. [DOI: 10.3904/kjm.2018.93.2.87] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Vinson DR, Warton EM, Mark DG, Ballard DW, Reed ME, Chettipally UK, Singh N, Bouvet SZ, Kea B, Ramos PC, Glaser DS, Go AS. Thromboprophylaxis for Patients with High-risk Atrial Fibrillation and Flutter Discharged from the Emergency Department. West J Emerg Med 2018; 19:346-360. [PMID: 29560065 PMCID: PMC5851510 DOI: 10.5811/westjem.2017.9.35671] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 08/23/2017] [Accepted: 09/05/2017] [Indexed: 12/18/2022] Open
Abstract
Introduction Many patients with atrial fibrillation or atrial flutter (AF/FL) who are high risk for ischemic stroke are not receiving evidence-based thromboprophylaxis. We examined anticoagulant prescribing within 30 days of receiving dysrhythmia care for non-valvular AF/FL in the emergency department (ED). Methods This prospective study included non-anticoagulated adults at high risk for ischemic stroke (ATRIA score ≥7) who received emergency AF/FL care and were discharged home from seven community EDs between May 2011 and August 2012. We characterized oral anticoagulant prescribing patterns and identified predictors of receiving anticoagulants within 30 days of the index ED visit. We also describe documented reasons for withholding anticoagulation. Results Of 312 eligible patients, 128 (41.0%) were prescribed anticoagulation at ED discharge or within 30 days. Independent predictors of anticoagulation included age (adjusted odds ratio [aOR] 0.89 per year, 95% confidence interval [CI] 0.82–0.96); ED cardiology consultation (aOR 1.89, 95% CI [1.10–3.23]); and failure of sinus restoration by time of ED discharge (aOR 2.65, 95% CI [1.35–5.21]). Reasons for withholding anticoagulation at ED discharge were documented in 139 of 227 cases (61.2%), the most common of which were deferring the shared decision-making process to the patient’s outpatient provider, perceived bleeding risk, patient refusal, and restoration of sinus rhythm. Conclusion Approximately 40% of non-anticoagulated AF/FL patients at high risk for stroke who presented for emergency dysrhythmia care were prescribed anticoagulation within 30 days. Physicians were less likely to anticoagulate older patients and those with ED sinus restoration. Opportunities exist to improve rates of thromboprophylaxis in this high-risk population.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente, Division of Research, Oakland, California.,Kaiser Permanente Sacramento Medical Center, Department of Emergency Medicine, Sacramento, California
| | | | - Dustin G Mark
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente, Division of Research, Oakland, California.,Kaiser Permanente Oakland Medical Center, Department of Emergency Medicine, Oakland, California
| | - Dustin W Ballard
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente, Division of Research, Oakland, California.,Kaiser Permanente San Rafael Medical Center, Department of Emergency Medicine, San Rafael, California
| | - Mary E Reed
- Kaiser Permanente, Division of Research, Oakland, California
| | - Uli K Chettipally
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente South San Francisco Medical Center, Department of Emergency Medicine, San Francisco, California
| | - Nimmie Singh
- Mercy Redding Family Practice Residency Program, Redding, California
| | - Sean Z Bouvet
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente Walnut Creek Medical Center, Department of Emergency Medicine, Walnut Creek, California
| | - Bory Kea
- Oregon Health and Science University, Department of Emergency Medicine, Portland, Oregon
| | - Patricia C Ramos
- Kaiser Permanente Sunnyside Medical Center, Northwest Permanente Physicians and Surgeons, Department of Emergency Medicine, Portland, Oregon
| | - David S Glaser
- Sisters of Charity of Leavenworth St. Joseph Hospital, Department of Emergency Medicine, Denver, Colorado
| | - Alan S Go
- The Permanente Medical Group, Oakland, California.,Kaiser Permanente, Division of Research, Oakland, California.,University of California, San Francisco, Departments of Epidemiology, Biostatistics, and Medicine, San Francisco, California.,Stanford University School of Medicine, Department of Health Research and Policy, Palo Alto, California
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Altamirano R. ALTERNATIVAS TERAPÉUTICAS EN FIBRILACIÓN AURICULAR. REVISTA MÉDICA CLÍNICA LAS CONDES 2018. [DOI: 10.1016/j.rmclc.2018.02.008] [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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Hammersley D, Signy M. Navigating the choice of oral anticoagulation therapy for atrial fibrillation in the NOAC era. Ther Adv Chronic Dis 2017; 8:165-176. [PMID: 29201334 PMCID: PMC5692140 DOI: 10.1177/2040622317720106] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 05/31/2017] [Indexed: 01/13/2023] Open
Abstract
Atrial fibrillation (AF) is a major cause of ischaemic stroke. The majority of these strokes can be prevented by treatment with oral anticoagulation therapy. The advent of non-vitamin K antagonist oral anticoagulants (NOACs) has resulted in a choice of therapeutic agents available to physicians for anticoagulation for stroke prevention in patients with AF beyond the long-established vitamin K antagonists (VKAs). Pivotal trials have demonstrated non-inferiority of NOACs compared with VKAs, and in some cases superiority, for the prevention of stroke and systemic embolism in non-valvular AF. Yet there are no direct head-to-head comparator trials for the efficacy of NOACs. Therefore, the question of which oral anticoagulant for each individual patient can present a challenge to physicians. In this review article, we assess which patients with AF require anticoagulation, review the available therapeutic options, assessing the evidence base for each and offering guidance as to patient-specific factors that can influence this choice.
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Affiliation(s)
- Daniel Hammersley
- Department of Cardiology, Frimley Park Hospital, Portsmouth Rd, Frimley, Camberley, GU16 7UJ
| | - Mark Signy
- Department of Cardiology, Worthing Hospital, Worthing, UK
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Admassie E, Chalmers L, Bereznicki LR. Changes in Oral Anticoagulant Prescribing for Stroke Prevention in Patients With Atrial Fibrillation. Am J Cardiol 2017; 120:1133-1138. [PMID: 28781025 DOI: 10.1016/j.amjcard.2017.06.055] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 06/03/2017] [Accepted: 06/20/2017] [Indexed: 11/17/2022]
Abstract
Suboptimal guideline adherence and underuse of anticoagulants in patients with atrial fibrillation (AF) have been reported worldwide. This study aimed to compare anticoagulation practice in Australia during the pre- and postdirect oral anticoagulant (DOAC) eras. Between January 2011 and July 2015, patients with nonvalvular AF (NVAF) admitted to the Royal Hobart Hospital, Tasmania, Australia, were retrospectively reviewed. The pre- and post-DOAC era cohorts included admissions from January 2011 to July 2013 and August 2013 to July 2015, respectively. Overall, 2,118 patients met our inclusion criteria. The overall rate of anticoagulation increased from 52.5% in the pre-DOAC era to 60.7% in the post-DOAC era (p <0.001). Moreover, prescribing of OACs among high-risk patients improved significantly (63.1% vs 55.2%, p = 0.001). OAC overprescribing in low-risk patients did not change significantly between the 2 cohorts (35.0% vs 42.9% in the pre- and post-DOAC eras, respectively, p = 0.59). In multivariate analysis, DOAC era (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.17 to 1.68 and CHA2DS2-VASc ≥2 (OR 1.95, 95% CI 1.36 to 2.80) were independent predictors of OAC prescribing in both eras and the whole study period. Conversely, aging and previous bleeding were inversely associated with OAC prescribing. In conclusion, there has been a significant increase in OAC prescribing in the post-DOAC era, potentially driven by the widespread availability of DOACs. However, OAC underuse in high-risk patients and overuse in low-risk patients was apparent throughout our study. These findings highlight the need to identify the drivers of anticoagulant underuse and overuse and address them accordingly.
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Affiliation(s)
- Endalkachew Admassie
- Division of Pharmacy, School of Medicine, University of Tasmania, Tasmania, Australia.
| | - Leanne Chalmers
- School of Pharmacy, Curtin University, Western Australia, Australia
| | - Luke R Bereznicki
- Division of Pharmacy, School of Medicine, University of Tasmania, Tasmania, Australia
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Rivera-Caravaca JM, Esteve-Pastor MA, Roldán V, Marín F, Lip GY. Non-vitamin K antagonist oral anticoagulants: impact of non-adherence and discontinuation. Expert Opin Drug Saf 2017; 16:1051-1062. [DOI: 10.1080/14740338.2017.1351542] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- José Miguel Rivera-Caravaca
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - María Asunción Esteve-Pastor
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Gregory Y.H. Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Breitenstein A, Steffel J. [Not Available]. PRAXIS 2017; 106:757-765. [PMID: 28677488 DOI: 10.1024/1661-8157/a002725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Zusammenfassung. Zusammenfassung: Das Vorhofflimmern ist die häufigste supraventrikuläre Rhythmusstörung und entwickelt sich typischerweise bei Patienten mit kardiovaskulären Risikofaktoren oder einer zugrunde liegenden Kardiopathie. Die Bandbreite an Symptomen ist sehr weit und reicht von vollkommen asymptomatischen Patienten bis zur schweren Herzinsuffizienz. Eine korrekte Dokumentation mittels EKG ist unabdingbar für die Diagnose. Für jeden Patienten mit Vorhofflimmern ist eine komplette internistisch-kardiologische Abklärung indiziert. Von zentraler Bedeutung in der Behandlung ist die Thromboembolie-Prophylaxe bei Patienten mit einem erhöhten Risiko für einen Schlaganfall, dies unabhängig von der übrigen Therapie des Vorhofflimmerns. Beim Letzteren ist neben der antiarrhythmischen Therapie die Kontrolle der kardiovaskulären Risikofaktoren sowie die Behandlung einer allfällig vorhandenen Herzinsuffizienz entscheidend. Neben der medikamentösen Rhythmuskontrolle hat sich die Ablationsbehandlung als effektive und sichere alternative Therapieoption etabliert.
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Affiliation(s)
| | - Jan Steffel
- 1 Elektrophysiologie, Universitäres Herzzentrum Zürich, Zürich
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Andersson T, Magnuson A, Bryngelsson IL, Frøbert O, Henriksson KM, Edvardsson N, Poçi D. Patients with atrial fibrillation and outcomes of cerebral infarction in those with treatment of warfarin versus no warfarin with references to CHA2DS2-VASc score, age and sex - A Swedish nationwide observational study with 48 433 patients. PLoS One 2017; 12:e0176846. [PMID: 28472091 PMCID: PMC5417522 DOI: 10.1371/journal.pone.0176846] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 04/18/2017] [Indexed: 12/26/2022] Open
Abstract
AIMS There is controversy in the guidelines as to whether patients with atrial fibrillation and a low risk of stroke should be treated with anticoagulation, especially those with a CHA2DS2-VASc score of 1 point. METHODS In a retrospective, nationwide cohort study, we used the Swedish National Patient Registry, the National Prescribed Drugs Registry, the Swedish Registry of Education and the Population and Housing Census Registry. 48 433 patients were identified between 1 January 2006 and 31 December 2008 with incident atrial fibrillation who were divided in age categories, sex and a CHA2DS2-VASc score of 0, 1, 2 and ≥3 and they were included in a time-varying analysis of warfarin treatment versus no treatment. The primary end-point was cerebral infarction and stroke, and patients were followed until 31 December 2009. RESULTS Patients with 1 point from the CHA2DS2-VASc score showed the following adjusted hazard ratios (HR) with a 95% confidence interval: men 65-74 years 0.46 (0.25-0.83), men <65 years 1.11 (0.56-2.23) and women <65 years 2.13 (0.94-4.82), where HR <1 indicates protection with warfarin. In patients <65 years and 2 points, HR in men was 0.35 (0.18-0.69) and in women 1.84 (0.86-3.94) while, in women with at least 3 points, HR was 0.31 (0.16-0.59). In patients 65-74 years and 2 points, HR in men was 0.37 (0.23-0.59) and in women 0.39 (0.21-0.73). Categories including age ≥65 years or ≥3 points showed a statistically significant protection from warfarin. CONCLUSIONS Our results support that treatment with anticoagulation may be considered in all patients with an incident atrial fibrillation diagnosis and an age of 65 years and older, i.e. also when the CHA2DS2-VASc score is 1.
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Affiliation(s)
- Tommy Andersson
- Department of Cardiology, Faculty of Health, Örebro University, Örebro, Sweden
| | - Anders Magnuson
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Ing-Liss Bryngelsson
- Department of Occupational and Environmental Medicine, Örebro University, Örebro, Sweden
| | - Ole Frøbert
- Department of Cardiology, Faculty of Health, Örebro University, Örebro, Sweden
| | | | - Nils Edvardsson
- Sahlgrenska Academy at Sahlgrenska University Hospital, Göteborg, Sweden
| | - Dritan Poçi
- Department of Cardiology, Faculty of Health, Örebro University, Örebro, Sweden
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Pankaala M, Koivisto T, Lahdenoja O, Kiviniemi T, Saraste A, Vasankari T, Airaksinen J. Detection of atrial fibrillation with seismocardiography. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2016:4369-4374. [PMID: 28269246 DOI: 10.1109/embc.2016.7591695] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In this paper we study the feasibility of seismocardiography (SCG) for the detection of Atrial Fibrillation (AF). In this preclinical study, data acquired from one patient having paroxysmal AF (no other heart diseases) is used to introduce specific changes in SCG signal due to AF. Observed changes and phenomena create a foundation for the development of SCG-based AF detection algorithms. SCG data was recorded from the sternum of an AF patient in dorso-ventral direction while at rest in a supine position using a three-axis high precision MEMS accelerometer simultaneously with a one-lead ECG. In contrast to ECG, the magnitude of beats registered with SCG varies considerably from beat to beat during AF. We show that the magnitude of the beats is not random but is in relation to beat intervals. It is shown that extra indicators for detecting AF become available when SCG data is combined with electrocardiographical (ECG) data; there is a certain behavior in the electromechanical delay characteristic of the AF. It is discussed how all this information can be taken advantage of in the detection of AF. Today electrocardiography (ECG) is the primary method for diagnosing arrhythmias, but there is a growing need for simpler and more convenient method for detecting asymptomatic AF. Given the very small dimensions of modern MEMS accelerometers (2mm×2mm), a reliable MEMS based measurement may provide totally new venues for arrhythmia detection.
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Wallerstedt SM, Hoffmann M. Evaluating beneficial drug effects in a non-interventional setting: a review of effectiveness studies based on Swedish Prescribed Drug Register data. Br J Clin Pharmacol 2017; 83:1309-1318. [PMID: 27928842 PMCID: PMC5427236 DOI: 10.1111/bcp.13206] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 12/02/2016] [Accepted: 12/02/2016] [Indexed: 12/15/2022] Open
Abstract
Aims To describe and assess current effectiveness studies published up to 2014 using Swedish Prescribed Drug Register (SPDR) data. Methods Study characteristics were extracted. Each study was assessed concerning the clinical relevance of the research question, the risk of bias according to a structured checklist, and as to whether its findings contributed to new knowledge. The biases encountered and ways of handling these were retrieved. Results A total of 24 effectiveness studies were included in the review, the majority on cardiovascular or psychiatric disease (n = 17; 71%). The articles linked data from four (interquartile range: three to four) registers, and were published in 21 different journals with an impact factor ranging from 1.58 to 51.66. All articles had a clinically relevant research question. According to the systematic quality assessments, the overall risk of bias was low in one (4%), moderate in eight (33%) and high in 15 (62%) studies. Overall, two (8%) studies were assessed as contributing to new knowledge. Frequently occurring problems were selection bias making the comparison groups incomparable, treatment bias with suboptimal handling of drug exposure and an intention‐to‐treat approach, and assessment bias including immortal time bias. Good examples of how to handle bias problems included propensity score matching and sensitivity analyses. Conclusion Although this review illustrates that effectiveness studies based on dispensed drug register data can contribute to new evidence of intended effects of drug treatment in clinical practice, the expectations of such data to provide valuable information need to be tempered due to methodological issues.
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Affiliation(s)
- Susanna M Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Pharmacology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mikael Hoffmann
- The NEPI foundation - Swedish Network for Pharmacoepidemiology, Linköping University, Linköping, Sweden
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Giner-Soriano M, Roso-Llorach A, Vedia Urgell C, Castells X, Capellà D, Ferreira-González I, Elorza-Ricart JM, Casajuana M, Troncoso Mariño A, Diògene E, Bolíbar B, Violan C, Morros R. Effectiveness and safety of drugs used for stroke prevention in a cohort of non-valvular atrial fibrillation patients from a primary care electronic database. Pharmacoepidemiol Drug Saf 2016; 26:97-107. [PMID: 27868275 DOI: 10.1002/pds.4137] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 10/04/2016] [Accepted: 10/25/2016] [Indexed: 12/17/2022]
Abstract
PURPOSE The aim of this study was to assess effectiveness and safety of antithrombotics for stroke prevention in non-valvular atrial fibrillation in real-use conditions. METHODS We used a population-based retrospective cohort study. Information emerges from SIDIAP, a database containing anonymized information from electronic health records from 274 primary healthcare centres of the Catalan Health Institute, Catalonia (Spain), with a reference population of 5 835 000 people. Population includes all adults with a new diagnosis of non-valvular atrial fibrillation registered in SIDIAP from 2007 to 2012. The main outcome of antithrombotics' effectiveness was stroke. The main outcomes of safety were cerebral and gastrointestinal haemorrhages. We also estimated all-cause mortality. We used multivariable Cox proportional hazard models to examine association between antithrombotic treatment and main outcomes. RESULTS We included 22 205 subjects with non-valvular atrial fibrillation; 40.8% initiated on vitamin K antagonists (VKA), 33.4% on antiplatelets and 25.8% untreated. We found stroke-risk reduction with VKA, hazard ratio (HR) 0.72 (95% confidence interval (CI), 0.58-0.91), also seen in patients with CHADS2 ≥ 2, HR 0.65 (95%CI, 0.49-0.86), and CHA2 DS2 -VASc ≥ 2, HR 0.66 (95%CI, 0.52-0.84). We observed a higher risk of digestive bleeding with antiplatelets, HR 1.32 (95%CI, 1.01-1.73). Both VKA and antiplatelets were associated with reduction of all-cause mortality risk; HR 0.55 (95%CI, 0.49-0.62) and HR 0.89 (95%CI, 0.80-0.97), respectively. CONCLUSIONS This study found a stroke-risk reduction associated with VKA and an increased risk of gastrointestinal bleeding associated with platelet-aggregation inhibitors in comparison with untreated patients. Both antithrombotic groups showed a reduction in all-cause mortality. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Maria Giner-Soriano
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Albert Roso-Llorach
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Cristina Vedia Urgell
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain.,Unitat de farmàcia, Servei d'Atenció Primària Barcelonès Nord i Maresme, Institut Català de la Salut, Badalona, Spain
| | - Xavier Castells
- Translab Research Group, Unitat de Farmacologia Clínica, Departament de Ciències Mèdiques, Facultat de Medicina, UdG, Girona, Spain
| | - Dolors Capellà
- Translab Research Group, Unitat de Farmacologia Clínica, Departament de Ciències Mèdiques, Facultat de Medicina, UdG, Girona, Spain
| | - Ignacio Ferreira-González
- Unidad de Epidemiología del Servicio de Cardiología, Hospital Vall d'Hebron y CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | | | - Marc Casajuana
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Amelia Troncoso Mariño
- Unitat de Coordinació i Estratègia del Medicament, Institut Català de la Salut, Barcelona, Spain
| | - Eduard Diògene
- Servei de Farmacologia, Hospital Vall d'Hebron, Barcelona, Spain
| | - Bonaventura Bolíbar
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Concepció Violan
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Rosa Morros
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
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Björck F, Ek A, Johansson L, Själander A. Warfarin persistence among atrial fibrillation patients - why is treatment ended? Cardiovasc Ther 2016; 34:468-474. [DOI: 10.1111/1755-5922.12224] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Fredrik Björck
- Department of Public Health and Clinical Medicine; Umeå University; Umeå Sweden
| | - Agnes Ek
- Department of Public Health and Clinical Medicine; Umeå University; Umeå Sweden
| | - Lars Johansson
- Department of Public Health and Clinical Medicine; Umeå University; Umeå Sweden
| | - Anders Själander
- Department of Public Health and Clinical Medicine; Umeå University; Umeå Sweden
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:2893-2962. [PMID: 27567408 DOI: 10.1093/eurheartj/ehw210] [Citation(s) in RCA: 4724] [Impact Index Per Article: 590.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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45
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg 2016; 50:e1-e88. [DOI: 10.1093/ejcts/ezw313] [Citation(s) in RCA: 602] [Impact Index Per Article: 75.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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46
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Voroneanu L, Ortiz A, Nistor I, Covic A. Atrial fibrillation in chronic kidney disease. Eur J Intern Med 2016; 33:3-13. [PMID: 27155803 DOI: 10.1016/j.ejim.2016.04.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/07/2016] [Accepted: 04/09/2016] [Indexed: 02/02/2023]
Affiliation(s)
- Luminita Voroneanu
- Nephrology Department, Dialysis and Renal Transplant Center, "C.I. Parhon" University Hospital, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.
| | - Alberto Ortiz
- Nephrology and Hypertension Department, IIS-Fundacion Jimenez Diaz and School of Medicine, Madrid, Spain
| | - Ionut Nistor
- Nephrology Department, Dialysis and Renal Transplant Center, "C.I. Parhon" University Hospital, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Adrian Covic
- Nephrology Department, Dialysis and Renal Transplant Center, "C.I. Parhon" University Hospital, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
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47
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016; 18:1609-1678. [PMID: 27567465 DOI: 10.1093/europace/euw295] [Citation(s) in RCA: 1318] [Impact Index Per Article: 164.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Stefan Agewall
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John Camm
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gonzalo Baron Esquivias
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Werner Budts
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Scipione Carerj
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Filip Casselman
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Antonio Coca
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raffaele De Caterina
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Spiridon Deftereos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Dobromir Dobrev
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - José M Ferro
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gerasimos Filippatos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Donna Fitzsimons
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Bulent Gorenek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Maxine Guenoun
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stefan H Hohnloser
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Philippe Kolh
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gregory Y H Lip
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Athanasios Manolis
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John McMurray
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Ponikowski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raphael Rosenhek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Frank Ruschitzka
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Irina Savelieva
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Sanjay Sharma
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Suwalski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Juan Luis Tamargo
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Clare J Taylor
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Isabelle C Van Gelder
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Adriaan A Voors
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stephan Windecker
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Jose Luis Zamorano
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Katja Zeppenfeld
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
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Freedman B, Potpara TS, Lip GYH. Stroke prevention in atrial fibrillation. Lancet 2016; 388:806-17. [PMID: 27560276 DOI: 10.1016/s0140-6736(16)31257-0] [Citation(s) in RCA: 275] [Impact Index Per Article: 34.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 07/06/2016] [Accepted: 07/12/2016] [Indexed: 02/08/2023]
Abstract
Atrial fibrillation is found in a third of all ischaemic strokes, even more after post-stroke atrial fibrillation monitoring. Data from stroke registries show that both unknown and untreated or under treated atrial fibrillation is responsible for most of these strokes, which are often fatal or debilitating. Most could be prevented if efforts were directed towards detection of atrial fibrillation before stroke occurs, through screening or case finding, and treatment of all patients with atrial fibrillation at increased risk of stroke with well-controlled vitamin K antagonists or non-vitamin K antagonist anticoagulants. The default strategy should be to offer anticoagulant thromboprophylaxis to all patients with atrial fibrillation unless defined as truly low risk by simple validated risk scores, such as CHA2DS2-VASc. Assessment of bleeding risk using the HAS-BLED score should focus attention on reversible bleeding risk factors. Finally, patients need support from physicians and various other sources to start anticoagulant treatment and to ensure adherence to and persistence with treatment in the long term.
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Affiliation(s)
- Ben Freedman
- Heart Research Institute, Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia; Department of Cardiology and Anzac Research Institute, Concord Hospital, Concord, NSW, Australia.
| | - Tatjana S Potpara
- Cardiology Clinic, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Science, City Hospital, Birmingham, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Wändell P, Carlsson AC, Holzmann MJ, Ärnlöv J, Johansson SE, Sundquist J, Sundquist K. Warfarin treatment and risk of stroke among primary care patients with atrial fibrillation. SCAND CARDIOVASC J 2016; 50:311-316. [PMID: 27460750 DOI: 10.1080/14017431.2016.1215519] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Our aim was to study the risk of a first ischaemic stroke (IS) in patients with atrial fibrillation (AF) treated in primary healthcare. DESIGN The study population included all adults (n = 11,517), 45 years and older diagnosed with AF, from 75 primary care centres in Sweden between 2001 and 2007. IS was defined as a hospital care event of stroke between 2001 and 2010. Association between incident stroke and warfarin treatment was explored using Cox regression analysis, with hazard ratios (HRs), and 95% confidence intervals (95%CIs). Adjustment was made for age, socioeconomic factors and co-morbidity. RESULTS Persistent treatment with warfarin was present among 33.7% of women and 40.0% among men. Persistent warfarin treatment, compared to no persistent treatment, was associated with a stroke preventing effect with fully adjusted HRs of 0.25 (95%CI 0.18-0.36) in women, and 0.25 (95%CI 0.19-0.32) in men. A CHA2DS2-VASc score of at least two among women, and three among men, was associated with a stroke risk exceeding 18% during a mean follow-up of 5.4 years. Risk of haemorrhagic stroke was not increased. CONCLUSIONS Warfarin is effective in preventing stroke in AF patients in primary healthcare.
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Affiliation(s)
- Per Wändell
- a Division of Family Medicine, Department of Neurobiology, Care Science and Society , Karolinska Institutet , Huddinge , Sweden.,b Academic Primary Healthcare Centre, Stockholm County Council , Huddinge , Sweden
| | - Axel C Carlsson
- a Division of Family Medicine, Department of Neurobiology, Care Science and Society , Karolinska Institutet , Huddinge , Sweden.,c Department of Medical Sciences , Cardiovascular Epidemiology, Uppsala University , Uppsala , Sweden
| | - Martin J Holzmann
- d Department of Emergency Medicine , Karolinska University Hospital , Stockholm , Sweden.,e Department of Internal Medicine , Karolinska Institutet , Stockholm , Sweden
| | - Johan Ärnlöv
- c Department of Medical Sciences , Cardiovascular Epidemiology, Uppsala University , Uppsala , Sweden.,f School of Health and Social Studies , Dalarna University , Falun , Sweden
| | | | - Jan Sundquist
- g Center for Primary Health Care Research, Lund University , Malmö , Sweden
| | - Kristina Sundquist
- g Center for Primary Health Care Research, Lund University , Malmö , Sweden
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50
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Wehbe RM, Yadlapati A. Underuse of Oral Anticoagulants for Nonvalvular Atrial Fibrillation: Past, Present, and Future. Tex Heart Inst J 2016; 43:287-90. [PMID: 27547134 DOI: 10.14503/thij-16-5785] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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