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Guillot J, Justice AC, Gordon KS, Skanderson M, Pariente A, Bezin J, Rentsch CT. Contribution of Potentially Inappropriate Medications to Polypharmacy-Associated Risk of Mortality in Middle-Aged Patients: A National Cohort Study. J Gen Intern Med 2024:10.1007/s11606-024-08817-4. [PMID: 38831248 DOI: 10.1007/s11606-024-08817-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 05/10/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND The role of potentially inappropriate medications (PIMs) in mortality has been studied among those 65 years or older. While middle-aged individuals are believed to be less susceptible to the harms of polypharmacy, PIMs have not been as carefully studied in this group. OBJECTIVE To estimate PIM-associated risk of mortality and evaluate the extent PIMs explain associations between polypharmacy and mortality in middle-aged patients, overall and by sex and race/ethnicity. DESIGN Observational cohort study. SETTING Department of Veterans Affairs (VA), the largest integrated healthcare system in the US. PARTICIPANTS Patients aged 41 to 64 who received a chronic medication (continuous use of ≥ 90 days) between October 1, 2008, and September 30, 2017. MEASUREMENT Patients were followed for 5 years until death or end of study period (September 30, 2019). Time-updated polypharmacy and hyperpolypharmacy were defined as 5-9 and ≥ 10 chronic medications, respectively. PIMs were identified using the Beers criteria (2015) and were time-updated. Cox models were adjusted for demographic, behavioral, and clinical characteristics. RESULTS Of 733,728 patients, 676,935 (92.3%) were men, 479,377 (65.3%) were White, and 156,092 (21.3%) were Black. By the end of follow-up, 104,361 (14.2%) patients had polypharmacy, 15,485 (2.1%) had hyperpolypharmacy, and 129,992 (17.7%) were dispensed ≥ 1 PIM. PIMs were independently associated with mortality (HR 1.11, 95% CI 1.04-1.18). PIMs also modestly attenuated risk of mortality associated with polypharmacy (HR 1.07, 95% CI 1.03-1.11 before versus HR 1.05, 95% CI 1.01-1.09 after) and hyperpolypharmacy (HR 1.18, 95% CI 1.09-1.28 before versus HR 1.12, 95% CI 1.03-1.22 after). Patterns varied when stratified by sex and race/ethnicity. LIMITATIONS The predominantly male VA patient population may not represent the general population. CONCLUSION PIMs were independently associated with increased mortality, and partially explained polypharmacy-associated mortality in middle-aged people. Other mechanisms of injury from polypharmacy should also be studied.
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Affiliation(s)
- Jordan Guillot
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, CT, 06516, USA.
- Department of General Internal Medicine, Yale School of Medicine, New Haven, CT, 06511, USA.
- Department of Methodology and Innovation in Prevention, CHU de Bordeaux, Pôle de Santé Publique, 33000, Bordeaux, France.
- Team Pharmacoepidemiology, Univ. Bordeaux, INSERM, CHU de Bordeaux, Service de Pharmacologie Médicale, Pôle de Santé Publique, U1219F-33000, Bordeaux, BPH, France.
- Bakar Computational Health Sciences Institute, University of California, San Francisco, San Francisco, CA, USA.
| | - Amy C Justice
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, CT, 06516, USA
- Department of General Internal Medicine, Yale School of Medicine, New Haven, CT, 06511, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, 06511, USA
| | - Kirsha S Gordon
- Department of General Internal Medicine, Yale School of Medicine, New Haven, CT, 06511, USA
- VA Connecticut Healthcare System, West Haven, CT, 06516, USA
| | - Melissa Skanderson
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, CT, 06516, USA
- Department of General Internal Medicine, Yale School of Medicine, New Haven, CT, 06511, USA
| | - Antoine Pariente
- Team Pharmacoepidemiology, Univ. Bordeaux, INSERM, CHU de Bordeaux, Service de Pharmacologie Médicale, Pôle de Santé Publique, U1219F-33000, Bordeaux, BPH, France
| | - Julien Bezin
- Team Pharmacoepidemiology, Univ. Bordeaux, INSERM, CHU de Bordeaux, Service de Pharmacologie Médicale, Pôle de Santé Publique, U1219F-33000, Bordeaux, BPH, France
| | - Christopher T Rentsch
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, CT, 06516, USA
- Department of General Internal Medicine, Yale School of Medicine, New Haven, CT, 06511, USA
- Faculty of Epidemiology & Population Health, School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
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Ding J, Sun Y, Zhang K, Huang W, Tang M, Zhang D, Xing Y. Effects of Anticoagulant Therapy and Frailty in the Elderly Patients with Atrial Fibrillation. Clin Interv Aging 2024; 19:247-254. [PMID: 38375240 PMCID: PMC10875184 DOI: 10.2147/cia.s453527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/30/2024] [Indexed: 02/21/2024] Open
Abstract
Objective This study explored whether anticoagulation is safe for frail and non-frail elderly patients who have nonvalvular atrial fibrillation (NVAF). Methods At hospital discharge, the anticoagulant regimen and frailty status were recorded for 361 elderly patients (aged ≥75 y) with NVAF. The patients were followed for 12 months. The endpoints included occurrence of thrombosis; bleeding; all-cause death; and cardiovascular events. Results At hospital discharge, frailty affected 50.42% of the population and the anticoagulation rate was 44.04%. At discharge, age (OR 0.948, P = 0.006), paroxysmal NVAF (OR 0.384, P < 0.001), and bleeding history (OR 0.396, P = 0.001) were associated with a decrease in rate of receiving anticoagulation, while thrombotic events during hospitalization (OR 2.281, P = 0.021) were associated with an increase. Relative to non-frail patients, those with frailty showed a higher rate of ischemic stroke (5.33% cf. 3.01%), bleeding (P = 0.006) events, and all-cause mortality (P = 0.001). Relative to the group without anticoagulation, in those with anticoagulation the rate of thrombotic events was lower (6.99 cf. 10.98%) and bleeding events were higher (20.98 cf. 12.72%), but the risk of major bleeding was comparable. Conclusion In the elderly patients with NVAF, the decision toward anticoagulation therapy at hospital discharge was influenced by age, bleeding history, paroxysmal atrial fibrillation diagnosis, and absence of thrombosis. Frail patients were at greater risk of bleeding and all-cause mortality. Anticoagulation tended to reduce the risk of thrombotic events.
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Affiliation(s)
- Jiancao Ding
- Department of Geriatrics, First People’s Hospital of Zigong, Sichuan, People’s Republic of China
| | - Ying Sun
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Kan Zhang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Wei Huang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Mei Tang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Dai Zhang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yunli Xing
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
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Moura A, Baliafa E, Alexandropoulos C, Papazoglou AS, Kartas A, Samaras A, Solovou C, Kontopyrgou D, Ioannou M, Moysidis DV, Bekiaridou A, Tzikas A, Ziakas A, Giannakoulas G. Association of Length of Stay With the Clinical Trajectory of Hospitalized Patients With Atrial Fibrillation: Staying Less Is More? Am J Cardiol 2023; 206:254-261. [PMID: 37716224 DOI: 10.1016/j.amjcard.2023.08.066] [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: 07/23/2023] [Accepted: 08/14/2023] [Indexed: 09/18/2023]
Abstract
Data predicting the length of stay (LOS) in patients with concurrent atrial fibrillation (AF) are scarce. This study aimed to investigate the potential predictors for prolonged LOS and its prognostic value. In this observational post hoc analysis of the MISOAC-AF (Motivational Interviewing to Support Oral AntiCoagulation adherence in patients with non-valvular Atrial Fibrillation) randomized trial logistic regression analyses were conducted to identify the parameters associated with prolonged LOS (defined as >7 days according to diagnostic accuracy analyses). Kaplan-Meier and Cox regression analyses were performed to generate survival curves and adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) for the primary end point of all-cause mortality and for the secondary end points during a median 3.7-year follow-up. Of the 1,057 patients studied, 462 (43.7%) were hospitalized for ≥7 days. Heart failure with reduced ejection fracture (aHR 1.75, 95% CI 1.17 to 2.63), permanent AF (aHR 1.72, 95% CI 1.29 to 2.31), history of coronary artery disease (aHR 2.32, 95% CI 1.59 to 3.39), and advanced or end-stage chronic kidney disease (aHR 1.54, 95% CI 1.15 to 2.06) were independently associated with prolonged hospitalization. Prolonged LOS was independently linked with increased all-cause mortality rates (aHR 1.68, 95% CI 1.25 to 2.26), cardiovascular mortality (aHR 1.92, 95% CI 1.36 to 2.72), major bleeding (aHR 3.07, 95% CI 1.07 to 8.78), and the composite outcome of cardiovascular death or rehospitalization (aHR 1.31, 95% CI 1.04 to 1.66). Each extra day of LOS was an independent predictor of all-cause mortality (aHR 1.03, 95% CI 1.02 to 1.04). Hospitalized patients with concurrent AF carry a substantial morbidity burden being prone to extended LOS. A jointed approach seems reasonable to reduce the LOS in patients with AF.
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Affiliation(s)
- Andreanna Moura
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Baliafa
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christos Alexandropoulos
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Anastasios Kartas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Chrysi Solovou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitra Kontopyrgou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Ioannou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios V Moysidis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Bekiaridou
- Elmezzi Graduate School of Molecular Medicine, Northwell Health, Manhasset, New York; Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Apostolos Tzikas
- Second Department of Cardiology, Hippokrateion, Thessaloniki, Greece; Interbalkan European Medical Center, Thessaloniki, Greece
| | - Antonios Ziakas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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