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Lebovitz S, Estryk M, Zimmerman DR, Pollak A, Luria D, Amir O, Biton Y. Trends in Atrial Fibrillation Management-Results from a National Multi-Center Urgent Care Network Registry. J Clin Med 2023; 12:6704. [PMID: 37959170 PMCID: PMC10650842 DOI: 10.3390/jcm12216704] [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: 09/05/2023] [Revised: 10/18/2023] [Accepted: 10/18/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is a common diagnosis in patients presenting to urgent care centers (UCCs), yet there is scant research regarding treatment in these centers. While some of these patients are managed within UCCs, some are referred for further care in an emergency department (ED). OBJECTIVES We aimed to identify the rate of patients referred to an ED and define predictors for this outcome. We analyzed the rates of AF diagnosis and hospital referral over the years. Finally, we described trends in patient anticoagulation (AC) medication use. METHODS This retrospective study included 5873 visits of patients over age 18 visiting the TEREM UCC network with a diagnosis of AF over 11 years. Multivariate analysis was used to identify predictors for ED referral. RESULTS In a multivariate model, predictors of referral to an ED included vascular disease (OR 1.88 (95% CI 1.43-2.45), p < 0.001), evening or night shifts (OR 1.31 (95% CI 1.11-1.55), p < 0.001; OR 1.68 (95% CI 1.32-2.15), p < 0.001; respectively), previously diagnosed AF (OR 0.31 (95% CI 0.26-0.37), p < 0.001), prior treatment with AC (OR 0.56 (95% CI 0.46-0.67), p < 0.001), beta blockers (OR 0.63 (95% CI 0.52-0.76), p < 0.001), and antiarrhythmic medication (OR 0.58 (95% CI 0.48-0.69), p < 0.001). Visits diagnosed with AF increased over the years (p = 0.030), while referrals to an ED decreased over the years (p = 0.050). The rate of novel oral anticoagulant prescriptions increased over the years. CONCLUSIONS The rate of referral to an ED from a UCC over the years is declining but remains high. Referrals may be predicted using simple clinical variables. This knowledge may help to reduce the burden of hospitalizations.
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Affiliation(s)
- Shalom Lebovitz
- Department of Cardiology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91904, Israel (O.A.)
- TEREM—Emergency Medical Centers, Jerusalem 97775, Israel
| | | | | | - Arthur Pollak
- Department of Cardiology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91904, Israel (O.A.)
| | - David Luria
- Department of Cardiology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91904, Israel (O.A.)
| | - Offer Amir
- Department of Cardiology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91904, Israel (O.A.)
| | - Yitschak Biton
- Department of Cardiology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91904, Israel (O.A.)
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Skibniewski M, Venetsanos D, Ahlsson A, Batra G, Friberg Ö, Hofmann R, Janzon M, Karlsson LO, Lawesson SS, Nielsen SJ, Jeppsson A, Alfredsson J. Long-term antithrombotic therapy after coronary artery bypass grafting in patients with preoperative atrial fibrillation. A nationwide observational study from the SWEDEHEART registry. Am Heart J 2023; 257:69-77. [PMID: 36481448 DOI: 10.1016/j.ahj.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/28/2022] [Accepted: 12/01/2022] [Indexed: 05/11/2023]
Abstract
AIMS To provide data guiding long-term antithrombotic therapy after coronary artery by-pass grafting (CABG) in patients with preoperative atrial fibrillation (AF). METHODS AND RESULTS From the SWEDEHEART registry, we included all patients, between January 2006 and September 2016, with preoperative AF and CHA2DS2-VASC score ≥2, undergoing CABG. Based on dispensed prescriptions 12 to 18 months after CABG, patients were divided in 3 groups: use of platelet inhibitors (PI) only, oral anticoagulant (OAC) only or a combination of OAC + PI. Outcomes were: Major adverse cardiac and cerebrovascular events (MACCE, [all-cause death, myocardial infarction, or stroke]), net adverse clinical events (NACE, [MACCE or bleeding]) and the individual components of NACE. Inverse probability of treatment weighting was used to adjust for the non-randomized study design. Among 2,564 patients, 1,040 (41%) were treated with PI alone, 1,064 (41%) with OAC alone, and 460 (18%) with PI + OAC. Treatment with PI alone was associated with higher risk for MACCE (adjusted HR 1.43, 95% CI 1.09-1.88), driven by higher risk for stroke and MI, compared with OAC alone. Treatment with PI + OAC, was associated with higher risk for NACE (adjusted HR 1.40, 95% CI 1.06-1.85), driven by higher risk for bleeds, compared with OAC alone. CONCLUSION In this real-world observational study, a high proportion of patients with AF, undergoing CABG, did not receive a long-term OAC therapy. Treatment with OAC alone was associated with a net clinical benefit, compared with PI alone or PI + OAC.
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Affiliation(s)
- Mikolaj Skibniewski
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden
| | - Dimitrios Venetsanos
- Division of Cardiology, Department of Medicine, Karolinska Institutet Solna and Karolinska University hospital, Stockholm, Sweden
| | - Anders Ahlsson
- Dept of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Gorav Batra
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Örjan Friberg
- Department of Health, Medicine and Caring Sciences and Department of Cardiothoracic and Vascular Surgery, Linköping University, Linköping, Sweden
| | - Robin Hofmann
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Magnus Janzon
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden
| | - Lars O Karlsson
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden
| | - Sofia Sederholm Lawesson
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden
| | - Susanne J Nielsen
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Joakim Alfredsson
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden.
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Shiyovich A, Shalev V, Chodick G, Tirosh M, Katz A, Klar MM, Shuvy M, Pereg D, Minha S. Shifting from vitamin K antagonists to non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: predictors, patterns and temporal trends. BMC Cardiovasc Disord 2021; 21:493. [PMID: 34645389 PMCID: PMC8513259 DOI: 10.1186/s12872-021-02295-w] [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: 06/24/2021] [Accepted: 09/30/2021] [Indexed: 11/10/2022] Open
Abstract
Background Non-Vitamin K antagonist oral anticoagulants (NOACs) emerged as an alternative with comparable or superior efficacy and safety to vitamin K antagonists (VKAs) for stroke prevention in patients with non-valvular atrial fibrillation (AF). Objectives The aim of the current study was to investigate the patterns, predictors, timelines and temporal trends of shifting from VKAs to NOACs. Methods In this retrospective observational study, the computerized database of a large healthcare provider in Israel, Maccabi Healthcare Services, was searched to identify patients with AF for whom either a VKA or NOAC was prescribed between 2012 and 2015. Time from diagnosis to therapy initiation and to shifting between therapies was evaluated. Results Out of 6987 eligible AF incident patients, 2338 (33.4%) initiated treatment with a VKA and 2221 (31.7%) with a NOAC. In addition, 5259 prevalent patients were analyzed. During the study period, NOAC prescriptions proportion among the newly diagnosed cases increased from 32 to 68.4% (p for trend < 0.001). The median time from diagnosis to first dispensing was greater in NOAC than VKA and decreased among patients treated with NOAC during the study period (2012: 1.9 and 0.3 months, 2015: 0.7 and 0.2 months, respectively). During follow-up, 3737 (49%) patients (54.3% and 47.1% of the incident and prevalent cases, respectively), shifted from a VKA to a NOAC, after a median of 22 months and 39 months in the incident and prevalent cases, respectively, decreasing throughout the study period. Female gender, younger age, southern district, higher CHADS2 and CHA2DS2-VASC score, non-smoking, and treatment with antiplatelets were associated with a greater likelihood for therapy shift. Shifting from a NOAC to a VKA decreased over time from 8 to 4.5% in 2012 to 0.5% and 0.7% in 2015 in the incident and prevalent groups, p < 0.001 respectively. Conclusions Shifting from VKA to NOAC occurred in 50% of the cases, more frequently among incident cases, and younger patients with greater stroke risk. Shifting from a NOAC to a VKA was much less frequent, yet it occurred more often in incident cases and decreased over time. A socially and economically sensitive program to optimize the initiation of OAC therapy upon diagnosis is warranted. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02295-w.
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Affiliation(s)
- Arthur Shiyovich
- Department of Cardiology, Rabin Medical Center, 39 Jabotinsky St., 49100, Petah Tikva, Israel. .,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Varda Shalev
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Maccabi Healthcare Services, Kahn-Sagol-Maccabi Research and Innovation Institute, Tel Aviv, Israel
| | - Gabriel Chodick
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Maccabi Healthcare Services, Kahn-Sagol-Maccabi Research and Innovation Institute, Tel Aviv, Israel
| | | | - Amos Katz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Miriam M Klar
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA.,Department of Cardiology, Shamir Medical Center, Zerifin, Israel
| | - Mony Shuvy
- Heart Institute, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - David Pereg
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Cardiology, Meir Medical Center, Kfar-Saba, Israel
| | - Sa'ar Minha
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Cardiology, Shamir Medical Center, Zerifin, Israel
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