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Catalani F, Patetta LMA, Campello E, Fino R, Novello S, Occhipinti G, Zanforlini BM, Simioni P, Sergi G. DOACs for Older adults with Atrial Fibrillation and Falls: Results from the prospective single-centre DOAFF study. Thromb Res 2024; 238:78-84. [PMID: 38678866 DOI: 10.1016/j.thromres.2024.04.023] [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: 01/06/2024] [Revised: 03/02/2024] [Accepted: 04/22/2024] [Indexed: 05/01/2024]
Abstract
INTRODUCTION Falls are one of the most fearsome events in anticoagulated older adults. The evidence concerning safety of direct oral anticoagulants (DOACs) in falling elderly patients with atrial fibrillation (AF) is still limited. METHODS We prospectively enrolled consecutive anticoagulant-naïve patients aged 65 years and older, starting anticoagulation with DOACs for AF. The study cohort was stratified in fallers vs. non-fallers, according to the occurrence of at least one fall during the 2-year follow-up and bleeding outcomes were evaluated. RESULTS We enrolled 524 consecutive patients. Mean age was 80.8 years and they were mostly women (54.0%). Among the study cohort, 148 patients (28.2%) presented at least one fall episode during the study period. After the adjustment for potential confounders, no difference was found between fallers and non-fallers for all the study outcomes: major bleeding [HR: 1.04 (95%CI: 0.58-1.85)], intracranial haemorrhage [HR: 1.63 (95%CI: 0.69-3.80)], clinically relevant non-major bleeding [HR: 1.21 (95%CI: 0.83-1.76)], and all-cause death [HR: 1.51 (95%CI: 0.85-2.69)]. The presence of a prior cerebrovascular event [HR: 2.27 (95%CI: 1.12-4.62); p-value: 0.02] and polypharmacy [HR: 1.60 (95%CI: 1.08-2.39); p-value: 0.02] were the main drivers for major and clinically relevant non-major bleedings, respectively. CONCLUSIONS Falls in an anticoagulant-naïve population aged 65 years and over starting a DOAC for AF do not increase the bleeding risk. Thus, the presence of falls should not discourage clinicians from prescribing DOACs also in this subset of patients.
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Affiliation(s)
- Filippo Catalani
- Geriatric Unit, Department of Medicine, University Hospital of Padova, Padova, Italy; General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, University Hospital of Padova, Padova, Italy.
| | | | - Elena Campello
- General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, University Hospital of Padova, Padova, Italy
| | | | - Stefano Novello
- Internal Medicine Unit, Hospital of Valdagno, Valdagno, Italy
| | - Giuseppina Occhipinti
- Geriatric Unit, Department of Medicine, University Hospital of Padova, Padova, Italy
| | | | - Paolo Simioni
- General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, University Hospital of Padova, Padova, Italy
| | - Giuseppe Sergi
- Geriatric Unit, Department of Medicine, University Hospital of Padova, Padova, Italy
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Alboni P, Bo M, Fumagalli S, Vetta F, Isaia G, Brunetti E, Baldasseroni S, Boccanelli A, Desideri G, Marchionni N, Rozzini R, Terrosu P, Ungar A, Zito G. Evidence and uncertainties in the management of atrial fibrillation in older persons. Minerva Med 2021; 113:626-639. [PMID: 33832216 DOI: 10.23736/s0026-4806.21.07525-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Atrial fibrillation (AF) is the most common cardiac sustained arrhythmia, whose incidence and prevalence increase with age, representing a significant burden for health services in western countries. Older people contribute to the vast majority of patients affected from AF. EVIDENCE ACQUISITION Although oral anticoagulant therapy represents the cornerstone for the prevention of ischemic stroke and its disabling consequences, several other interventions - including left atrial appendage occlusion (LAAO), catheter ablation (CA) of AF, and rhythm control strategy (RCS) - have proved to be potentially effective in reducing the incidence of AF-associated clinical complications. Scientific literature focused on the three items will be discussed. EVIDENCE SYNTHESIS Practical treatment of older AF patients is presented, including approach and management of patients with geriatric syndromes, selection of the most appropriate individualized drug treatment, clinical indications and potential clinical benefit of LAAO and CA in selected older AF patients. CONCLUSIONS Older people carry the greatest burden of AF in real world practice. Within a shared decision making process, the patient centered approach need to be put in the context of a comprehensive assessment, in order to gain maximal net clinical benefit and avoid futility or harm.
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Affiliation(s)
- Paolo Alboni
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Mario Bo
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | | | - Francesco Vetta
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Gianluca Isaia
- Section of Geriatrics, Department of Medical Sciences, Città della Salute e della Scienza Molinette Hospital, University of Turin, Turin, Italy
| | - Enrico Brunetti
- Section of Geriatrics, Department of Medical Sciences, Città della Salute e della Scienza Molinette Hospital, University of Turin, Turin, Italy -
| | | | | | | | | | - Renzo Rozzini
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | | | - Andrea Ungar
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Giovanni Zito
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
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Müller M, Chanias I, Nagler M, Exadaktylos AK, Sauter TC. Falls in ED patients: do elderly patients on direct oral anticoagulants bleed less than those on vitamin K antagonists? Scand J Trauma Resusc Emerg Med 2021; 29:56. [PMID: 33823884 PMCID: PMC8022425 DOI: 10.1186/s13049-021-00866-6] [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: 08/12/2020] [Accepted: 03/09/2021] [Indexed: 11/23/2022] Open
Abstract
Background Falls from standing are common in the elderly and are associated with a significant risk of bleeding. We have compared the proportional incidence of bleeding complications in patients on either direct oral anticoagulants (DOAC) or vitamin K antagonists (VKA). Methods Our retrospective cohort study compared elderly patients (≥65 years) on DOAC or VKA oral anticoagulation who presented at the study site – a Swiss university emergency department (ED) – between 01.06.2012 and 01.07.2017 after a fall. The outcomes were the proportional incidence of any bleeding complication and its components (e.g. intracranial haemorrhage), as well as procedural and clinical parameters (length of hospital stay, admission to intensive care unit, in-hospital-mortality). Uni- and multivariable analyses were used to compare the studied outcomes. Results In total, 1447 anticoagulated patients were included – on either VKA (n = 1021) or DOAC (n = 426). There were relatively more bleeding complications in the VKA group (n = 237, 23.2%) than in the DOAC group (n = 69, 16.2%, p = 0.003). The difference persisted in multivariable analysis with 0.7-fold (95% CI: 0.5–0.9, p = 0.014) lower odds for patients under DOAC than under VKA for presenting with any bleeding complications, and 0.6-fold (95% 0.4–0.9, p = 0.013) lower odds for presenting with intracranial haemorrhage. There were no significant differences in the other studied outcomes. Conclusions Among elderly, anticoagulated patients who had fallen from standing, those under DOACs had a lower proportional incidence of bleeding complications in general and an even lower incidence of intracranial haemorrhage than in patients under VKAs. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00866-6.
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Affiliation(s)
- Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland.
| | - Ioannis Chanias
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Michael Nagler
- University Institute of Clinical Chemistry, Inselspital Bern University Hospital, and University of Bern, Bern University, Bern, Switzerland
| | - Aristomenis K Exadaktylos
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
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Schoaps RS, Quintili A, Bonavia A, Carr ZJ, Lehman EB, Abendroth T, Karamchandani K. Stroke prophylaxis in critically-ill patients with new-onset atrial fibrillation. J Thromb Thrombolysis 2020; 48:394-399. [PMID: 30963394 DOI: 10.1007/s11239-019-01854-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Despite a high incidence of new onset atrial fibrillation (NOAF) in critically ill patients and its association with short and long-term incidence of stroke, there is limited data assessing anticoagulation on hospital discharge in these patients. We retrospectively reviewed electronic medical records of all adult patients admitted to non-cardiac ICUs at our institution between January 2009 and March 2016. Patients with NOAF were identified and CHA2DS2-VASc score of ICU survivors was calculated. Prescription of oral anticoagulant therapy on hospital discharge was analyzed. A total of 640 (1.7% [38,708 patients]; 95% CI 1.5%, 1.8%) patients developed NOAF during the study period. CHA2DS2-VASc score was calculated for 615 patients, of which 82.2% had a CHA2DS2-VASc score ≥ 2. Of the 428 eligible patients, only 96 patients (22.4%) were discharged on oral anticoagulant therapy. Patients with a history of congestive heart failure (33.7% vs. 19.7%) and stroke/TIA or other thromboembolic disease (35.9% vs. 18.0%) were more likely to be discharged on an oral anticoagulant. Patients with a higher score were also more likely to be discharged on an oral anticoagulant (OR 1.27; 95% CI 1.10, 1.47). NOAF is common in critically ill patients admitted to non-cardiac ICUs and a significant proportion of these patients have a CHA2DS2-VASc score ≥ 2. However, only a minority of them are discharged on an oral anticoagulant. There is a need to identify ways to improve implementation of effective stroke prophylaxis in these patients.
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Affiliation(s)
- Robert S Schoaps
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ashley Quintili
- Department of Pharmacy, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Anthony Bonavia
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, P.O Box 850, MC H187, Hershey, PA, 17033, USA
| | - Zyad J Carr
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, P.O Box 850, MC H187, Hershey, PA, 17033, USA
| | - Erik B Lehman
- Department of Public Health Sciences, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Thomas Abendroth
- Center for Quality Innovation, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Kunal Karamchandani
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, P.O Box 850, MC H187, Hershey, PA, 17033, USA.
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Bo M, Marchionni N. Practical use of Direct Oral Anti Coagulants (DOACs) in the older persons with atrial fibrillation. Eur J Intern Med 2020; 71:32-38. [PMID: 31740104 DOI: 10.1016/j.ejim.2019.10.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/16/2019] [Accepted: 10/22/2019] [Indexed: 02/06/2023]
Abstract
Direct Oral Anticoagulants (DOACs) consistently demonstrated a greater net clinical benefit compared to Vitamin K Antagonists (VKAs) also in persons aged 75 years and over, who account for the largest proportion of AF patients; however, major uncertainties in DOACs prescription have to do with this age group. In this review, persistent uncertainties and implications of frailty and geriatric syndromes on DOACs prescription, and practical use of DOACs in real-world older persons, and will be discussed.
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Affiliation(s)
- Mario Bo
- Section of Geriatric, Department of Medical Sciences, AOU Città della Salute e della Scienza, Molinette, Turin, Italy.
| | - Niccolò Marchionni
- University of Florence, Head, Division of General Cardiology, Director, Cardiothoracovascular Department, AOU Careggi, Florence, Italy
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Efficacy and safety of left atrial appendage closure in non-valvular atrial fibrillation in patients over 75 years. Heart Vessels 2019; 34:1858-1865. [PMID: 31144099 DOI: 10.1007/s00380-019-01428-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Accepted: 05/15/2019] [Indexed: 01/05/2023]
Abstract
Percutaneous left atrial appendage closure (LAAC) may decrease risks of stroke and bleeding in elderly patients with non-valvular atrial fibrillation (NVAF), but it is still lacking of evidence. The present study aimed at evaluating the efficacy and safety of LAAC in patients with NVAF over 75 years. 351 patients with NVAF who underwent LAAC were retrospectively analyzed on the LAAC procedure characteristics and the clinical follow-up according to age (age ≥ 75 years or < 75 years). Out of the 351 patients, LAA were successfully closed in 347 patients (98.9%), including 341 with Watchman (WM) device and 6 with Amplatzer cardiac plug (ACP) device because of the WM device-incompatible anatomy. There were no significant differences in total LAAC success rate and procedure-related major complications within 7 days between the groups aged ≥ 75 years and aged < 75 years. After a nearly 2-year follow-up, there was an increased trend of major bleedings and all bleedings in the group aged ≥ 75 years, but there were no significant differences between both groups in all-cause death, cardiovascular death, stroke/TIA/system embolism, device thrombus and device gap (> 5 mm). Kaplan-Meier analysis revealed that the relative risk of annual thromboembolic events between the observed values and the expected ones based on CHA2DS2-VASc score in the group aged ≥ 75 years decreased more obviously (61.9% vs. 54.3%); however, the relative risk of bleedings between the observed values and the expected ones based on HAS-BLED score in the younger group aged < 75 years decreased more significantly (59.6% vs. 29.2%). LAAC in patients with advanced age (age ≥ 75 years), has the same level of efficacy, safety and feasibility as in the younger patients aged < 75 years. Thus, LAAC may be an ideal choice to prevent stroke in NVAF patients with advanced age.
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Fanning L, Ryan-Atwood TE, Bell JS, Meretoja A, McNamara KP, Dārziņš P, Wong IC, Ilomäki J. Prevalence, Safety, and Effectiveness of Oral Anticoagulant Use in People with and without Dementia or Cognitive Impairment: A Systematic Review and Meta-Analysis. J Alzheimers Dis 2018; 65:489-517. [DOI: 10.3233/jad-180219] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Laura Fanning
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Department of Pharmacy, Eastern Health, Melbourne, Australia
- Geriatric Medicine, Eastern Health, Melbourne, Australia
| | - Taliesin E. Ryan-Atwood
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - J. Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Hornsby, Australia
| | - Atte Meretoja
- Neurocenter, Helsinki University Hospital, Helsinki, Finland
- Department of Medicine at The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Kevin P. McNamara
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
- Deakin Rural Health, School of Medicine and Centre for Population Health, Deakin University, Melbourne, Australia
| | - Pēteris Dārziņš
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Geriatric Medicine, Eastern Health, Melbourne, Australia
| | - Ian C.K. Wong
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, China
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
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Rao MP, Vinereanu D, Wojdyla DM, Alexander JH, Atar D, Hylek EM, Hanna M, Wallentin L, Lopes RD, Gersh BJ, Granger CB. Clinical Outcomes and History of Fall in Patients with Atrial Fibrillation Treated with Oral Anticoagulation: Insights From the ARISTOTLE Trial. Am J Med 2018; 131:269-275.e2. [PMID: 29122636 DOI: 10.1016/j.amjmed.2017.10.036] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 10/10/2017] [Accepted: 10/17/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE We assessed outcomes among anticoagulated patients with atrial fibrillation and a history of falling, and whether the benefits of apixaban vs warfarin are consistent in this population. METHODS Of the 18,201 patients in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) study, 16,491 had information about history of falling-753 with history of falling and 15,738 without history of falling. The primary efficacy outcome was stroke or systemic embolism; the primary safety outcome was major bleeding. RESULTS When compared with patients without a history of falling, patients with a history of falling were older, more likely to be female and to have dementia, cerebrovascular disease, depression, diabetes, heart failure, osteoporosis, fractures, and higher CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, prior Stroke or TIA or thromboembolism, Vascular disease, Age 65-74 years, Sex category female) and HAS-BLED (Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile international normalized ratio, Elderly, Drugs or alcohol) scores. Patients with a history of falling had higher rates of major bleeding (adjusted hazard ratio [HR] 1.39; 95% confidence interval [CI], 1.05-1.84; P = .020), including intracranial bleeding (adjusted HR 1.87; 95% CI, 1.02-3.43; P = .044) and death (adjusted HR 1.70; 95% CI, 1.36-2.14; P < .0001), but similar rates of stroke or systemic embolism and hemorrhagic stroke. There was no evidence of a differential effect of apixaban compared with warfarin on any outcome, regardless of history of falling. Among those with a history of falling, subdural bleeding occurred in 5 of 367 patients treated with warfarin and 0 of 386 treated with apixaban. CONCLUSIONS Patients with atrial fibrillation and a history of falling receiving anticoagulation have a higher risk of major bleeding, including intracranial, and death. The efficacy and safety of apixaban compared with warfarin were consistent, irrespective of history of falling.
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Affiliation(s)
- Meena P Rao
- Cape Fear Heart Associates, New Hanover Regional Medical Center, Wilmington, NC
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital of Bucharest, Romania.
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | | | - Lars Wallentin
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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Cantú-Brito C, Silva GS, Ameriso SF. Use of Guidelines for Reducing Stroke Risk in Patients With Nonvalvular Atrial Fibrillation: A Review From a Latin American Perspective. Clin Appl Thromb Hemost 2017; 24:22-32. [PMID: 28992764 PMCID: PMC5726608 DOI: 10.1177/1076029617734309] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Atrial fibrillation (AF) is a prominent risk factor for stroke and a leading cause of death and disability throughout Latin America. Contemporary evidence-based guidelines for the management of AF and stroke incorporate the use of practical and relatively simple scoring methods to estimate both stroke and bleeding risk, in order to assist in matching patients with appropriate interventions. This review examines consistencies and differences among guidelines for reducing stroke risk in patients with AF, assessing the role of user-friendly scoring methods to determine appropriate patients for anticoagulation and other treatment options. Current options include warfarin and direct oral anticoagulants such as dabigatran, rivaroxaban, apixaban, and edoxaban. These agents have been found to be superior or noninferior to standard vitamin K antagonist anticoagulation in large randomized trials. Potential benefits of these agents mainly include lower ischemic stroke rates, reduced intracranial bleeding, no need for regular monitoring, and fewer drug-drug and drug-food interactions. Expert opinions regarding clinical situations for which data are presently lacking, such as emergency bleeding and stroke in anticoagulated patients, are also provided. Enhanced attention and adherence to evidence-based guidelines are essential components for a strategy to reduce stroke morbidity and mortality across Latin America.
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Affiliation(s)
- Carlos Cantú-Brito
- 1 Department of Neurology, National Institute of Medical Science and Nutrition Salvador Zubirán, Mexico City, Mexico
| | - Gisele Sampaio Silva
- 2 Hospital Israelita Albert Einstein/UNIFESP (Universidade Federal de São Paulo), São Paulo, Brazil
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Adderley N, Ryan R, Marshall T. The role of contraindications in prescribing anticoagulants to patients with atrial fibrillation: a cross-sectional analysis of primary care data in the UK. Br J Gen Pract 2017; 67:e588-e597. [PMID: 28630059 PMCID: PMC5569738 DOI: 10.3399/bjgp17x691685] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 11/30/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Underuse of anticoagulants in atrial fibrillation (AF) is an international problem, which has often been attributed to the presence of contraindications to treatment. No studies have assessed the influence of contraindications on anticoagulant prescribing in the UK. AIM To determine the influence of contraindications on anticoagulant prescribing in patients with AF in the UK. DESIGN AND SETTING Cross-sectional analysis of primary care data from 645 general practices contributing to The Health Improvement Network, a large UK database of electronic primary care records. METHOD Twelve sequential cross-sectional analyses were carried out from 2004 to 2015. Patients with a diagnosis of AF aged ≥35 years and registered for at least 1 year were included. Outcome measure was prescription of anticoagulant medication. RESULTS Over the 12 study years, the proportion of eligible patients with AF with contraindications who were prescribed anticoagulants increased from 40.1% (95% confidence interval [CI] = 38.3 to 41.9) to 67.2% (95% CI = 65.6 to 68.8), and the proportion of those without contraindications prescribed anticoagulants increased from 42.1% (95% CI = 41.6 to 42.6) to 67.7% (95% CI = 67.2 to 68.1). In patients with a recent history of major bleeding or aneurysm, prescribing rates increased from 44.3% (95% CI = 42.2 to 46.5) and 34.8% (95% CI = 29.4 to 40.6) in 2004 to 71.7% (95% CI = 69.9 to 73.5) and 63.2% (95% CI = 58.3 to 67.8) in 2015, respectively, comparable with rates in patients without contraindications. CONCLUSION The presence or absence of recorded contraindications has little influence on the decision to prescribe anticoagulants for the prevention of stroke in patients with AF. The study analysis suggests that, nationally, 38 000 patients with AF with contraindications are treated with anticoagulants. This has implications for patient safety.
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Affiliation(s)
- Nicola Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham
| | - Ronan Ryan
- Institute of Applied Health Research, University of Birmingham, Birmingham
| | - Tom Marshall
- Institute of Applied Health Research, University of Birmingham, Birmingham
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Molteni M, Bo M, Di Minno G, Di Pasquale G, Genovesi S, Toni D, Verdecchia P. Dabigatran etexilate: appropriate use in patients with chronic kidney disease and in the elderly patients. Intern Emerg Med 2017; 12:425-435. [PMID: 28439778 DOI: 10.1007/s11739-017-1660-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 03/29/2017] [Indexed: 12/16/2022]
Abstract
Dabigatran etexilate (DE) is a direct thrombin inhibitor, which has been approved for the treatment of non-valvular atrial fibrillation (AF), and for the prevention and treatment of venous thromboembolism (VTE). Despite large randomized clinical trials and independent observational studies providing robust data concerning DE safety and efficacy, some physicians still perceive mild-to-moderate renal impairment and old age as a relative contraindication to its use. In this article, we review the available scientific evidence supporting the use of DE in these clinical situations. Patients with AF and chronic kidney disease (CKD) are per se at high risk of stroke, bleeding and mortality. Although there is evidence of clinical benefit of anticoagulation in these patients, anticoagulant therapy requires caution and demands careful clinical monitoring, regardless of the drug used. In patients with no contraindication to its use, the clinical benefit of DE versus warfarin is independent of renal function. The elderly with AF are frequently undertreated because of the perception of high bleeding risk and limited clinical benefit. However, the clinical benefit of anticoagulation is independent of patient age, and age per se should not represent a contraindication to anticoagulation. DE has been extensively studied in the elderly, both in randomized clinical trials and in observational studies: DE 150 mg BID should not be used in patients 80 years of age or older, while DE 110 mg BID is as safe as warfarin. Intracranial haemorrhages reduction by DE compared with warfarin is preserved in the elderly. Therefore, mild and moderate CKD and being elderly should not deter physicians from prescribing DE. Furthermore, the availability of a specific antidote is expected to improve the safety of the use of DE in clinical practice.
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Affiliation(s)
- Mauro Molteni
- Internal Medicine, Vimercate Hospital, Vimercate, MB, Italy.
| | - Mario Bo
- Geriatrics and Bone Metabolic Diseases Division, Città della Salute e della Scienza-Molinette University Hospital, Turin, Italy
| | - Giovanni Di Minno
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | | | - Simonetta Genovesi
- Nephrology Unit, Department of Medicine and Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, MB, Italy
| | - Danilo Toni
- Department of Neurology and Psychiatry, Policlinico Umberto I Hospital, Sapienza University of Rome, Rome, Italy
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Bo M, Grisoglio E, Brunetti E, Falcone Y, Marchionni N. Oral anticoagulant therapy for older patients with atrial fibrillation: a review of current evidence. Eur J Intern Med 2017; 41:18-27. [PMID: 28343849 DOI: 10.1016/j.ejim.2017.03.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 03/08/2017] [Accepted: 03/13/2017] [Indexed: 12/11/2022]
Abstract
Atrial fibrillation is more frequent in older patients, who have a higher risk of cardioembolic stroke and thromboembolism. Oral anticoagulant therapy is the standard of treatment for stroke prevention; however, under-prescription is still very common in older patients. The reasons underlying this phenomenon have not been systematically investigated, and true contraindications only partially account for it. An intimate skepticism on the real benefit-risk balance of oral anticoagulant therapy in the oldest patients seems to derive from the fact that most studies supporting it were conducted decades ago and included younger patients, with overall better functional and clinical status. In this review we will focus on the main barriers to anticoagulant therapy prescription in older patients and summarize the available evidences on the efficacy and safety of vitamin K antagonists and direct oral anticoagulants in this population. The encouraging evidence of a higher net clinical benefit of direct oral anticoagulants compared with warfarin should hopefully widen the treatment options also for frail individuals, thereby allowing a greater number of patients to be treated according to current international guidelines.
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Affiliation(s)
- Mario Bo
- Section of Geriatrics and Bone Metabolic Diseases, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Enrica Grisoglio
- Section of Geriatrics and Bone Metabolic Diseases, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Enrico Brunetti
- Section of Geriatrics and Bone Metabolic Diseases, Department of Medical Sciences, University of Turin, Turin, Italy.
| | - Yolanda Falcone
- Section of Geriatrics and Bone Metabolic Diseases, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Niccolò Marchionni
- Division of Geriatric Cardiology and Medicine, University of Florence, Florence, Italy
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15
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Massaro A, Giugliano RP, Norrving B, Oto A, Veltkamp R. Overcoming global challenges in stroke prophylaxis in atrial fibrillation: The role of non-vitamin K antagonist oral anticoagulants. Int J Stroke 2016; 11:950-967. [DOI: 10.1177/1747493016660106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 05/16/2016] [Indexed: 01/04/2023]
Abstract
Atrial fibrillation is the world's most common sustained cardiac arrhythmia and is associated with a significantly increased risk of stroke. The global burden of atrial fibrillation is rising, commensurate with the ageing population. Well-controlled vitamin K antagonist-based anticoagulation has been shown to reduce the risk of stroke secondary to atrial fibrillation by two-thirds. However, patients with atrial fibrillation have frequently been denied anticoagulation because of a variety of perceived risks related to bleeding, falls, chronological age, and poor compliance. Even when vitamin K antagonists are used, maximum benefit and safety are only delivered when high quality control of therapy (TTR > 70%) is achieved, which has proven remarkably difficult in many health-care systems and amongst many patient groups. The non-vitamin K antagonist oral anticoagulants (NOACs) offer solutions to many of the challenges of achieving widespread, safe, and effective anticoagulation for stroke prophylaxis in atrial fibrillation, yet their uptake into routine clinical practice remains variable. The evidence supporting their more widespread use to overcome the challenges of stroke prophylaxis for atrial fibrillation is reviewed in this article.
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Affiliation(s)
- Ayrton Massaro
- Department of Neurology, Hospital Sirio-Libanes, São Paulo, Brazil
- Neurovascular Research Unit, Brain Institute of Rio Grande do Sul (BraIns), PUCRS, Porto Alegre – RS – Brazil
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bo Norrving
- Department of Clinical Neuroscience (B.N.), Section of Neurology, Lund University, Lund, Sweden
| | - Ali Oto
- Faculty of Medicine, Department of Cardiology, Hacettepe University, Ankara, Turkey
| | - Roland Veltkamp
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
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16
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Steffel J, Giugliano RP, Braunwald E, Murphy SA, Mercuri M, Choi Y, Aylward P, White H, Zamorano JL, Antman EM, Ruff CT. Edoxaban Versus Warfarin in Atrial Fibrillation Patients at Risk of Falling. J Am Coll Cardiol 2016; 68:1169-1178. [DOI: 10.1016/j.jacc.2016.06.034] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 06/02/2016] [Accepted: 06/08/2016] [Indexed: 10/21/2022]
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17
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Steinberg BA, Greiner MA, Hammill BG, Curtis LH, Benjamin EJ, Heckbert SR, Piccini JP. Contraindications to anticoagulation therapy and eligibility for novel anticoagulants in older patients with atrial fibrillation. Cardiovasc Ther 2016; 33:177-83. [PMID: 25930214 DOI: 10.1111/1755-5922.12129] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
AIMS Oral anticoagulation therapy prevents stroke and improves survival in patients with atrial fibrillation, but the therapy is underutilized. We sought to identify the prevalence of contraindications for oral anticoagulation and the proportion of patients potentially eligible for different agents. METHODS We identified patients with nonacute atrial fibrillation in a nationally representative 5% sample of 2009 Medicare data. We divided the population into patients ineligible for any oral anticoagulant, patients eligible for warfarin only, and patients eligible for any anticoagulant. We compared patient characteristics and the use of anticoagulation among the subgroups. RESULTS Among 86,671 patients with atrial fibrillation, 1872 (2.2%) were ineligible for anticoagulation because of an absolute contraindication, most frequently a history of intracranial hemorrhage (60%). Patients ineligible for any anticoagulant were the same age as the overall group (mean age, 80.5 vs. 80.4 years). However, they had higher rates of dementia (19% vs. 8.6%) and heart failure (59% vs. 43%) and higher mean CHADS2 scores (3.8 vs. 2.8). Of the remaining 84,799 patients eligible for anticoagulation, 7146 (8.4%) were eligible for warfarin only (most commonly because of mechanical heart valves [66%] and end-stage renal disease [12%]). Sixty-five percent of patients eligible for anticoagulation received warfarin, and the proportion was similar for patients with a relatively high risk of bleeding. CONCLUSIONS Older adults with atrial fibrillation rarely have absolute contraindications to oral anticoagulation therapy. Among patients without contraindications, most appeared to be eligible for any anticoagulant, and relatively high-risk features appeared not to influence warfarin use.
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Affiliation(s)
- Benjamin A Steinberg
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Lesley H Curtis
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Emelia J Benjamin
- Framingham Heart Study, Framingham, Massachusetts, USA.,Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Susan R Heckbert
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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18
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Akinboboye O. Use of oral anticoagulants in African-American and Caucasian patients with atrial fibrillation: is there a treatment disparity? J Multidiscip Healthc 2015; 8:217-28. [PMID: 26056467 PMCID: PMC4445875 DOI: 10.2147/jmdh.s74529] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Atrial fibrillation (AF) is a very common cardiac arrhythmia, and its prevalence is increasing along with aging in the developed world. This review discusses racial differences in the epidemiology and treatment of AF between African-American and Caucasian patients. Additionally, the effect of race on warfarin and novel oral anticoagulant use is discussed, as well as the role that physicians and patients play in achieving optimal treatment outcomes. Despite having a lower prevalence of AF compared with Caucasians, African-Americans suffer disproportionately from stroke and its sequelae. The possible reasons for this paradox include poorer access to health care, lower health literacy, and a higher prevalence of other stroke-risk factors among African-Americans. Consequently, it is important for providers to evaluate the effects of race, health literacy, access to health care, and cultural barriers on the use of anticoagulation in the management of AF. Warfarin-dose requirements vary across racial groups, with African-American patients requiring a higher dose than Caucasians to maintain a therapeutic international normalized ratio; the novel oral anticoagulants (dabigatran, rivaroxaban, and apixaban) seem to differ in this regard, although data are currently limited. Minority racial groups are not proportionally represented in either real-world studies or clinical trials, but as more information becomes available and other social issues are addressed, the treatment disparities between African-American and Caucasian patients should decrease.
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19
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Cook DA, Enders F, Caraballo PJ, Nishimura RA, Lloyd FJ. An automated clinical alert system for newly-diagnosed atrial fibrillation. PLoS One 2015; 10:e0122153. [PMID: 25849969 PMCID: PMC4388495 DOI: 10.1371/journal.pone.0122153] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 02/13/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Clinical decision support systems that notify providers of abnormal test results have produced mixed results. We sought to develop, implement, and evaluate the impact of a computer-based clinical alert system intended to improve atrial fibrillation stroke prophylaxis, and identify reasons providers do not implement a guideline-concordant response. MATERIALS AND METHODS We conducted a cohort study with historical controls among patients at a tertiary care hospital. We developed a decision rule to identify newly-diagnosed atrial fibrillation, automatically notify providers, and direct them to online evidence-based management guidelines. We tracked all notifications from December 2009 to February 2010 (notification period) and applied the same decision rule to all patients from December 2008 to February 2009 (control period). Primary outcomes were accuracy of notification (confirmed through chart review) and prescription of warfarin within 30 days. RESULTS During the notification period 604 notifications were triggered, of which 268 (44%) were confirmed as newly-diagnosed atrial fibrillation. The notifications not confirmed as newly-diagnosed involved patients with no recent electrocardiogram at our institution. Thirty-four of 125 high-risk patients (27%) received warfarin in the notification period, compared with 34 of 94 (36%) in the control period (odds ratio, 0.66 [95% CI, 0.37-1.17]; p = 0.16). Common reasons to not prescribe warfarin (identified from chart review of 151 patients) included upcoming surgical procedure, choice to use aspirin, and discrepancy between clinical notes and the medication record. CONCLUSIONS An automated system to identify newly-diagnosed atrial fibrillation, notify providers, and encourage access to management guidelines did not change provider behaviors.
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Affiliation(s)
- David A. Cook
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, United States of America
- Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, United States of America
- Mayo Clinic Online Learning, Mayo Clinic College of Medicine, Rochester, MN, United States of America
| | - Felicity Enders
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, United States of America
- Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, MN, United States of America
| | - Pedro J. Caraballo
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, United States of America
- Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, United States of America
| | - Rick A. Nishimura
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, United States of America
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, United States of America
| | - Farrell J. Lloyd
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, United States of America
- Division of Hospital Medicine, Mayo Clinic College of Medicine, Rochester, MN, United States of America
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20
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Vannucci A, Rathor R, Vachharajani N, Chapman W, Kangrga I. Atrial fibrillation in patients undergoing liver transplantation-a single-center experience. Transplant Proc 2015; 46:1432-7. [PMID: 24935310 DOI: 10.1016/j.transproceed.2014.02.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 01/21/2014] [Accepted: 02/27/2014] [Indexed: 02/09/2023]
Abstract
BACKGROUND As the prevalence of atrial fibrillation rises with age and older patients increasingly receive transplants, the perioperative management of this common arrhythmia and its impact on outcomes in liver transplantation is of relevance. METHODS Retrospective review of 757 recipients of liver transplantation from January 2002 through December 2011. RESULTS Nineteen recipients (2.5%) had documented pre-transplantation atrial fibrillation. Sixteen patients underwent liver and 3 a combined liver-kidney transplantation. Three patients died within 30 days (84.2% 1-month survival) and another 3 within 1 year of transplantation (68.4% 1-year survival). Compared with patients without atrial fibrillation, the relative risk of death in the atrial fibrillation group was 5.29 at 1 month (P = .0034; 95% confidence interval [CI], 1.73-16.18) and 3.28 at 1 year (P = .0008; 95% CI, 1.63-6.59). Time to extubation and intensive care unit (ICU) and hospital readmissions were not different from the control cohort. Rapid ventricular response requiring treatment occurred in 4 patients during surgery and 7 after surgery, resulting in 3 ICU and 3 hospital readmissions. CONCLUSIONS The results suggest that patients with atrial fibrillation may be at increased risk of mortality after liver transplantation. Optimization of medical therapy may decrease ICU and hospital readmission due to rapid ventricular response.
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Affiliation(s)
- A Vannucci
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - R Rathor
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - N Vachharajani
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - W Chapman
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - I Kangrga
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri.
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21
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Banerjee A, Clementy N, Haguenoer K, Fauchier L, Lip GYH. Prior history of falls and risk of outcomes in atrial fibrillation: the Loire Valley Atrial Fibrillation Project. Am J Med 2014; 127:972-8. [PMID: 24929021 DOI: 10.1016/j.amjmed.2014.05.035] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 05/23/2014] [Accepted: 05/28/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with nonvalvular atrial fibrillation are often denied oral anticoagulation due to falls risk. The latter is variably defined, and existing studies have not compared the associated risk of bleeding with other cardiovascular events. There are no data about outcomes in individuals with nonvalvular atrial fibrillation with a prior history of (actual) falls, rather than being "at risk of falls." Our objective was to evaluate the risk of cardiovascular outcomes associated with prior history of falls in patients with atrial fibrillation in a contemporary "real world" cohort. METHODS Patients with nonvalvular atrial fibrillation in a 4-hospital institution between 2000 and 2010 were included. Stroke/thromboembolism event rates were calculated according to prior history of falls. Risk factors were investigated by Cox regression. RESULTS Among 7156 atrial fibrillation patients, prior history of falls/trauma was uncommon (n = 76; 1.1%). Compared with patients without history of falls, those patients were older and less likely to be on oral anticoagulation; they also had higher risk scores for stroke/thromboembolism but not for bleeding. Compared with no prior history of falls, rates of stroke/thromboembolism (P = .01) and all-cause mortality (P < .0001) were significantly higher in patients with previous falls. In multivariable analyses, prior history of falls was independently associated with stroke/thromboembolism (hazard ratio [HR] 5.19; 95% confidence interval [CI], 2.1-12.6; P < .0001), major bleeding (HR 3.32 [1.23-8.91]; P = .02), and all-cause mortality (HR 3.69; 95% CI, 1.52-8.95; P = .04), but not hemorrhagic stroke (HR 4.20; 95% CI, 0.58-30.48; P = .16) in patients on oral anticoagulation. CONCLUSION In this large "real world" atrial fibrillation cohort, prior history of falls was uncommon but independently increased risk of stroke/thromboembolism, bleeding, and mortality, but not hemorrhagic stroke in the presence of anticoagulation. Prior history of (actual) falls may be a more clinically useful risk prognosticator than "being at risk of falls."
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Affiliation(s)
- Amitava Banerjee
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Nicolas Clementy
- Service de Cardiologie, Pôle Coeur Thorax Vasculaire, Centre Hospitalier, Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France
| | - Ken Haguenoer
- Service de Cardiologie, Pôle Coeur Thorax Vasculaire, Centre Hospitalier, Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France
| | - Laurent Fauchier
- Service de Cardiologie, Pôle Coeur Thorax Vasculaire, Centre Hospitalier, Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France
| | - Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK.
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22
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Molteni M, Cimminiello C. Warfarin and atrial fibrillation: from ideal to real the warfarin affaire. Thromb J 2014; 12:5. [PMID: 24548437 PMCID: PMC3937065 DOI: 10.1186/1477-9560-12-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 11/05/2013] [Indexed: 02/08/2023] Open
Abstract
Vitamin K Antagonists (VKAs) are widely used in clinical practice and nearly 1% of the entire population receives oral anticoagulation at least once in life. However, the rate of prescription of anticoagulation is low, compared to what it should be. No more than 50-60% of patients affected by atrial fibrillation (AF) receive anticoagulation. In the setting of AF, VKAs are safe and effective when properly managed, reducing stroke and systemic embolism by more than 60%. VKAs safety and effectiveness are closely related to the quality of anticoagulation (e.g. time in therapeutic range), and anticoagulation clinics offer the best management of anticoagulant therapy. However, a sizeable proportion of patients are managed elsewhere. In clinical practice, in the setting of AF, a low prescription rate of VKAs is frequently observed and this is due also to difficulties in managing laboratory monitoring and drug dose adjustment. The suboptimal management of therapy with VKAs leads to a lesser efficacy than that reported in clinical trials, and to an increase in adverse reactions. VKAs still remain the first and only available therapy for a number of diseases (e.g. valvular atrial fibrillation and mechanical prosthetic heart valves). Now, since approval of the new oral anticoagulants (NOAs), the choice of anticoagulant therapy in definite settings, such as stroke prevention in non-valvular atrial fibrillation (SPAF) or treatment of venous thromboembolism, has surely become more intriguing but also more problematic. In light of these new therapeutic options, we reviewed VKAs therapy, in the setting of atrial fibrillation, focusing on VKAs impact in real life. We analyzed the data about efficacy and safety of warfarin at three levels: clinical trial and real life, outside and inside anticoagulation clinics.
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Affiliation(s)
- Mauro Molteni
- Internal Medicine, Vimercate Hospital, Azienda Ospedaliera di Desio e Vimercate, Italy
| | - Claudio Cimminiello
- Internal Medicine, Vimercate Hospital, Azienda Ospedaliera di Desio e Vimercate, Italy
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23
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Ryan M, Merrick EL, Hodgkin D, Horgan CM, Garnick DW, Panas L, Ritter G, Blow FC, Saitz R. Drinking patterns of older adults with chronic medical conditions. J Gen Intern Med 2013; 28:1326-32. [PMID: 23609178 PMCID: PMC3785666 DOI: 10.1007/s11606-013-2409-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 01/10/2013] [Accepted: 02/27/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Understanding alcohol consumption patterns of older adults with chronic illness is important given the aging baby boomer generation, the increase in prevalence of chronic conditions and associated medication use, and the potential consequences of excessive drinking in this population. OBJECTIVES To estimate the prevalence of alcohol consumption patterns, including at-risk drinking, in older adults with at least one of seven common chronic conditions. DESIGN/METHODS This descriptive study used the nationally representative 2005 Medicare Current Beneficiary Survey linked with Medicare claims. The sample included community-dwelling, fee-for-service beneficiaries 65 years and older with one or more of seven chronic conditions (Alzheimer's disease and other senile dementia, chronic obstructive pulmonary disease, depression, diabetes, heart failure, hypertension, and stroke; n = 7,422). Based on self-reported alcohol consumption, individuals were categorized as nondrinkers, within-guidelines drinkers, or at-risk drinkers (exceeds guidelines). RESULTS Overall, 30.9 % (CI 28.0-34.1 %) of older adults with at least one of seven chronic conditions reported alcohol consumption in a typical month in the past year, and 6.9 % (CI 6.0-7.8 %) reported at-risk drinking. Older adults with higher chronic disease burdens were less likely to report alcohol consumption and at-risk drinking. CONCLUSIONS Nearly one-third of older adults with selected chronic illnesses report drinking alcohol and almost 7 % drink in excess of National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines. It is important for physicians and patients to discuss alcohol consumption as a component of chronic illness management. In cases of at-risk drinking, providers have an opportunity to provide brief intervention or to offer referrals if needed.
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Affiliation(s)
- Marian Ryan
- Heller School for Social Policy and Management, Brandeis University, 415 South Street, MS035, Waltham, MA, 02454-9110, USA,
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Berardi C, Chamberlain AM, Bursi F, Redfield MM, McNallan SM, Weston SA, Jiang R, Roger VL. Heart failure performance measures: eligibility and implementation in the community. Am Heart J 2013; 166:76-82. [PMID: 23816025 PMCID: PMC3701162 DOI: 10.1016/j.ahj.2013.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 03/14/2013] [Indexed: 06/02/2023]
Abstract
BACKGROUND The goal of heart failure (HF) performance measures is to improve quality of care by assessing the implementation of guidelines in eligible patients. Little is known about the proportion of eligible patients and how performance measures are implemented in the community. METHODS We determined the eligibility for and adherence to performance measures and β-blocker therapy in a community-based cohort of hospitalized HF patients from January 2005 to June 2011. RESULTS All of the 465 HF inpatients (median age 76 years, 48% men) included in the study received an ejection fraction assessment. Only 164 had an ejection fraction <40% thus were candidates for β-blocker and angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blocker (ARB) therapy. Considering absolute contraindications, 99 patients were eligible to receive ACE inhibitors/ARB, and 162 to receive β-blockers. Among these, 85% received ACE inhibitors/ARBs and 91% received β-blockers. Among the 261 individuals with atrial fibrillation, 89 were eligible for warfarin and 54% received it. Of 52 current smokers, 69% received cessation counseling during hospitalization. CONCLUSION In the community, among eligible hospitalized HF patients, the implementation of performance measures can be improved. However, as most patients are not candidates for current performance measures, other approaches are needed to improve care and outcomes.
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Affiliation(s)
- Cecilia Berardi
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN 55905, USA
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