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Yabeyu AB, Mohammed SY, Legesse ES, Adugna M, Kifle ZD. The Prevalence and Determinants of Inappropriate Oral Anticoagulant Use in Patients with Atrial Fibrillation, in Resource-Limited Setting. BIOMED RESEARCH INTERNATIONAL 2023; 2023:6673397. [PMID: 38106993 PMCID: PMC10723925 DOI: 10.1155/2023/6673397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 07/26/2023] [Accepted: 10/19/2023] [Indexed: 12/19/2023]
Abstract
Introduction Anticoagulation treatment is routinely underused in patients with atrial fibrillation (AF), particularly in settings with limited resources. The current study is aimed at evaluating the appropriateness of oral anticoagulation treatment among AF patients at the Yekatit 12 Hospital Medical College (Y12HMC), Addis Ababa, Ethiopia. Methods Institutional-based retrospective cross-sectional study conducted in Y12HMC from November 2019 to March 2020. During the study period, 256 patients' medical records were found; 231 of them met the eligibility criteria and were included in the study. The data were analyzed using SPSS version 25, descriptive statistics were used to summarize the data, and binary logistic regression was performed to identify predictors of inappropriate anticoagulation management. Results The majority of study participants were males (55.8%), and over half of them (57.6%) had a nonvalvular type of AF. The majority of patients (61.9%) were receiving anticoagulant treatment, and of them, warfarin was prescribed to most of the study subjects (71.3%). Nearly half (47.6%) of the study participants had inappropriate anticoagulation treatment; among these, the majority of them (69.1%) were from a valvular type of AF. Patients with a valvular type of AF and having the diagnosis of congestive heart disease as comorbidity showed a statistically significant association towards inappropriate anticoagulation management. Conclusion According to the study, a significant portion of AF patients received inappropriate anticoagulant treatment, which may play a significant role for the increased risk of stroke in these groups of patients. All of the inappropriate cases were due to failure to start anticoagulant treatment.
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Affiliation(s)
- Abdella Birhan Yabeyu
- Department of Pharmacy, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopia
| | - Samiya Yassin Mohammed
- Yekatit 12 Hospital Medical College, College of Health Sciences, Clinical Pharmacist, Addis Ababa, Ethiopia
| | - Eshetu Shiferaw Legesse
- Yekatit 12 Hospital Medical College, College of Health Sciences, Clinical Pharmacist, Addis Ababa, Ethiopia
| | - Meaza Adugna
- Department of Pharmacology, School of Pharmacy, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Zemene Demelash Kifle
- Department of Pharmacology, School of Pharmacy, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
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Rathinam I, Anoopkumar-Dukie S, Badrick T, Teasdale T, Bernaitis N. Anticoagulant Initiation During Hospital Admissions for Atrial Fibrillation in South-East Queensland, Australia. Heart Lung Circ 2020; 29:e222-e230. [DOI: 10.1016/j.hlc.2020.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 02/20/2020] [Accepted: 03/08/2020] [Indexed: 12/14/2022]
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Ischemic stroke and dose adjustment of oral Factor Xa inhibitors in patients with atrial fibrillation. J Neurol 2020; 267:2007-2012. [PMID: 32206901 PMCID: PMC7320957 DOI: 10.1007/s00415-020-09795-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/11/2020] [Accepted: 03/13/2020] [Indexed: 10/31/2022]
Abstract
BACKGROUND Oral Factor Xa inhibitors for the prevention of stroke in atrial fibrillation require dose adjustment based on certain clinical criteria, but the off-label use of the reduced doses is common. METHODS Data from an observational registry including patients admitted with acute cerebral ischemia while taking oral Factor Xa inhibitors for atrial fibrillation between April 2016 and December 2018 were investigated. The dose regimen of the Xa inhibitor was classified as "appropriate", "underdosed" and "overdosed" in conformity with the European Medicines Agency labelling. The effect of underdosing on the functional factor Xa plasma level on admission, the clinical stroke severity and the functional outcome after 3 months were investigated. RESULTS 254 patients with cerebral ischemia while on Factor Xa inhibitors were included. The dose regimen of the Factor Xa inhibitor was appropriate in 166 patients (65%), underdosed in 67 patients (26%) and overdosed in 21 patients (8%). Underdosing was associated with female sex, diabetes mellitus and higher CHA2DS2-Vasc scores. Underdosing independently predicted lower anti-Xa plasma levels on admission [median 69.4 ng/ml (IQR 0.0-121.6) vs. 129.2 ng/ml (65.5-207.2); p < 0.001], was associated with higher NIHSS scores on admission [median 5 (IQR 1-10) vs. 3 (1-7); p = 0.041] and worse functional outcome after 3 months (favorable outcome 26.9% vs. 46.9%; p = 0.025). CONCLUSION One in three patients with ischemic stroke during treatment with oral Xa inhibitors used inappropriate dose regimens. Underdosing was associated with lower functional plasma levels, higher clinical stroke severity and worse functional outcome.
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Saczynski JS, Sanghai SR, Kiefe CI, Lessard D, Marino F, Waring ME, Parish D, Helm R, Sogade F, Goldberg R, Gurwitz J, Wang W, Mailhot T, Bamgbade B, Barton B, McManus DD. Geriatric Elements and Oral Anticoagulant Prescribing in Older Atrial Fibrillation Patients: SAGE-AF. J Am Geriatr Soc 2019; 68:147-154. [PMID: 31574165 DOI: 10.1111/jgs.16178] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/23/2019] [Accepted: 08/23/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Oral anticoagulants are the cornerstone of stroke prevention in high-risk patients with atrial fibrillation (AF). Geriatric elements, such as cognitive impairment and frailty, commonly occur in these patients and are often cited as reasons for not prescribing oral anticoagulants. We sought to systematically assess geriatric impairments in patients with AF and determine whether they were associated with oral anticoagulant prescribing. DESIGN Cross-sectional analysis of baseline data from the ongoing Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF) prospective cohort study. SETTING Multicenter study with site locations in Massachusetts and Georgia that recruited participants from cardiology, electrophysiology, and primary care clinics from 2016 to 2018. PARTICIPANTS Participants with AF age 65 years or older, CHA2 DS2 -VASc (congestive heart failure; hypertension; aged ≥75 y [doubled]; diabetes mellitus; prior stroke, transient ischemic attack, or thromboembolism [doubled]; vascular disease; age 65-74; female sex) score of 2 or higher, and no oral anticoagulant contraindications (n = 1244). MEASUREMENTS A six-component geriatric assessment included validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Oral anticoagulant use was abstracted from the medical record. RESULTS A total of 1244 participants (mean age = 76 y; 49% female; 85% white) were enrolled; 42% were cognitively impaired, 14% frail, 53% pre-frail, 12% socially isolated, and 29% had depressive symptoms. Oral anticoagulants were prescribed to 86% of the cohort. Oral anticoagulant prescribing did not vary according to any of the geriatric elements (adjusted odds ratios [ORs] for oral anticoagulant prescribing and cognitive impairment: OR = .75; 95% confidence interval [CI] = .51-1.09; frail OR = .69; 95% CI = .35-1.36; social isolation OR = .90; 95% CI = .52-1.54; depression OR = .79; 95% CI = .49-1.27; visual impairment OR = .98; 95% CI = .65-1.48; and hearing impairment OR = 1.05; 95% CI = .71-1.54). CONCLUSION Geriatric impairments, particularly cognitive impairment and frailty, were common in our cohort, but treatment with oral anticoagulants did not differ by impairment status. These geriatric impairments are commonly cited as reasons for not prescribing oral anticoagulants, suggesting that prescribers may either be unaware or deliberately ignoring the presence of these factors in clinical settings. J Am Geriatr Soc 68:147-154, 2019.
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Affiliation(s)
- Jane S Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts
| | - Saket R Sanghai
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Darleen Lessard
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Francesca Marino
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Molly E Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, Connecticut
| | - David Parish
- Department of Community Medicine/ Internal Medicine, Mercer University School of Medicine, Macon, Georgia
| | - Robert Helm
- Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Felix Sogade
- Department of Medicine, Mercer University School of Medicine, Mercer, Georgia
| | - Robert Goldberg
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jerry Gurwitz
- Geriatric Medicine Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Weijia Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Tanya Mailhot
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts.,Montreal Heart Institute Research Center, Montreal, Quebec, Canada
| | - Benita Bamgbade
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts
| | - Bruce Barton
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David D McManus
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
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Wisst T, Meincke F, Spangenberg T, Wienemann H, Reinholz C, Kreidel F, Kuck KH, Ghanem A. Safety and feasibility of interventional left atrial appendage closure without contrast agent. ASIAINTERVENTION 2018; 4:126-133. [PMID: 36484002 PMCID: PMC9706726 DOI: 10.4244/aij-d-17-00027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 05/09/2018] [Indexed: 06/17/2023]
Abstract
AIMS Interventional left atrial appendage closure (LAAC) is routinely performed under both echocardiographic and angiographic guiding. However, adverse outcomes, e.g., kidney injury and cerebral embolism, might be associated with injections of contrast agent into the LAA. Therefore, this prospective registry investigated the safety and feasibility of LAAC without the support of angiographic images as the default approach. METHODS AND RESULTS This single-centre registry included a total of 46 non-selected, consecutive patients. In the first 25 patients (54%), LAAC with the Amulet device was performed routinely with LAA angiography prior to implantation and after release of the device. The following 21 patients (46%) were treated without the use of contrast agent. The combination of successful implantation and lack of procedural complications was regarded as the primary endpoint. Procedure time, number of recapture manoeuvres, change of device size, compression, leakage, dose area product and late thrombosis on the device were investigated as secondary endpoints. Besides the longer fluoroscopy time and duration of the procedure in the group using angiography, no significant differences could be found. Major complications occurred equally often in both cohorts. CONCLUSIONS Interventional LAAC with the Amulet device can be performed safely without the use of contrast agent. This approach might help to enhance the use of LAAC in patients at high risk of contrast-induced nephropathy and procedural stroke.
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Affiliation(s)
- Theresa Wisst
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Felix Meincke
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | | | - Hendrik Wienemann
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Claudia Reinholz
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Felix Kreidel
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Karl-Heinz Kuck
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Alexander Ghanem
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
- Department of Cardiology, University Hospital Bonn, Bonn, Germany
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6
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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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Sposato LA, Stirling D, Saposnik G. Therapeutic Decisions in Atrial Fibrillation for Stroke Prevention: The Role of Aversion to Ambiguity and Physicians' Risk Preferences. J Stroke Cerebrovasc Dis 2018; 27:2088-2095. [PMID: 29650382 DOI: 10.1016/j.jstrokecerebrovasdis.2018.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 02/24/2018] [Accepted: 03/09/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Knowledge-to-action gaps influence therapeutic decisions in atrial fibrillation (AF). Physician-related factors are common, but the least studied. We evaluated the prevalence and determinants of physician-related factors and knowledge-to-action gaps among physicians involved in the management of AF patients. DESIGN In this cross-sectional study, participants from 6 South American countries recruited during an educational program answered questions regarding 16 case scenarios of patients with AF and completed experiments assessing 3 outcome measures: therapeutic inertia, herding, and errors in risk stratification knowledge translated into action (ERSKTA) based on commonly used stratification tools (Congestive heart failure, Hypertension, Age ≥75 years (double), Diabetes mellitus, previous Stroke/transient ischemic attack/thromboembolism (double), Vascular disease, Age 65-74 years, and female gender (score of 0 for males and 1 for female) (CHA2DS2-VASc) and Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, and previous Stroke/transient ischemic attack (double) (CHADS2)). Logistic regression analysis was conducted to determine factors associated with the outcomes. RESULTS Overall, 149 physicians were invited to participate, of which 88 (59.1%) completed the online assessment tool. Cardiology was the most frequent specialty (69.3%). Therapeutic inertia was present in 53 participants (60.2%), herding in 66 (75.0%), and ERSKTA in 46 (52.3%). Therapeutic inertia was inversely associated with willingness to take financial risks (odds ratio [OR] .72, 95% confidence interval [CI] .59-.89 per point in the financial risk propensity score), herding was associated with aversion to ambiguity in the medical domain (OR 5.35, 95% CI 1.40-20.46), and ERSKTA was associated with the willingness to take risks (OR 1.70, 95% CI 1.15-2.50, per point in score). CONCLUSIONS Among physicians involved in stroke prevention in AF, individual risk preferences and aversion to ambiguity lead to therapeutic inertia, herding, and errors in risk stratification and subsequent use of oral anticoagulants. Educational interventions, including formal training in risk management and decision-making are needed.
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Affiliation(s)
- Luciano A Sposato
- Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada; Stroke Dementia and Heart Disease Laboratory, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Department of Anatomy and Cell Biology, Western University, London, Ontario, Canada
| | - Devin Stirling
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Gustavo Saposnik
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Stroke Outcome Research Center, Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Laboratory for Social and Neural Systems Research, Department of Economics, University of Zurich, Zurich, Switzerland.
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8
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Barmano N, Walfridsson U, Walfridsson H, Karlsson JE. Structured care of patients with atrial fibrillation improves guideline adherence. J Atr Fibrillation 2017; 9:1498. [PMID: 29250257 DOI: 10.4022/jafib.1498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 11/19/2016] [Accepted: 12/22/2016] [Indexed: 11/10/2022]
Abstract
Aims There are many reports of lack of guideline adherence in the treatment of patients with atrial fibrillation (AF), and AF affects health-related quality of life (HRQoL) negatively. The aim of this study was to investigate whether structured care compared to standard care of a general AF population could improve guideline adherence and HRQoL, and reduce symptoms,anxiety and depression. Methods In total, 176 patients were recruited to the intervention and 146 patients to the control group.The intervention consisted of a structured follow-up program, while patients serving as controls received standard care. The primary outcome was guideline adherence evaluated through: appropriate use of oral anticoagulants (OAC) and antiarrhythmics, whether echocardiogram and thyroid lab tests were performed, and patient-reported outcome measures (PROMs), assessed with the questionnaires SF-36, EQ-5D, HADS and ASTA at baseline and after one year. Results Guideline adherence was significantly better in the intervention group, 91% vs. 63% (p < 0.01), mainly due to appropriate OAC treatment 94% vs. 74% (p < 0.01). Symptoms assessed with ASTA were less frequent and the negative impact of AF was reduced in the intervention group after one year/ at follow-up. Five scales in SF-36, and the visual analogue scale for current health status in EQ-5D (EQ-VAS), improved significantly in both groups. Conclusion Structured care of patients with AF significantly improved guideline adherence and patients reported fewer symptoms and a reduced negative impact on disease-specific HRQoL compared to standard care at one year follow-up.
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Affiliation(s)
- Neshro Barmano
- Department of Internal Medicine, County hospital Ryhov, Jönköping, Sweden.,Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.,Jönköping Academy, Jönköping University,Jönköping, Sweden
| | - Ulla Walfridsson
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.,Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Håkan Walfridsson
- Jönköping Academy, Jönköping University,Jönköping, Sweden.,Jönköping Academy, Jönköping University,Jönköping, Sweden
| | - Jan-Erik Karlsson
- Department of Cardiology, University hospital, Linköping, Sweden.,Department of Cardiology, University hospital, Linköping, Sweden.,Department of Cardiology, University hospital, Linköping, Sweden
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9
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Gilligan AM, Gandhi P, Song X, Wang C, Henriques C, Sander S, Smith DM. All-Cause, Stroke-, and Bleed-Specific Healthcare Costs: Comparison among Patients with Non-Valvular Atrial Fibrillation (NVAF) Newly Treated with Dabigatran or Warfarin. Am J Cardiovasc Drugs 2017; 17:481-492. [PMID: 28795348 PMCID: PMC5701952 DOI: 10.1007/s40256-017-0244-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Our objective was to compare all-cause and stroke- and bleed-specific healthcare costs among patients with non-valvular atrial fibrillation (NVAF) treated with dabigatran or warfarin. METHODS Administrative claims data from the MarketScan® Databases for 2009-2014 were used. Patients with NVAF newly treated with dabigatran were matched 1:1 to those treated with warfarin. All-cause and stroke- and bleed-specific costs per patient per month (PPPM) ($US, year 2015 values) up to a 12-month follow-up period were analyzed. Stroke- or bleed-specific costs were defined as hospitalizations with stroke or bleed as the primary discharge diagnosis and outpatient claims with stroke or bleed diagnosis in any position. Differences in costs between dabigatran and warfarin users were assessed using descriptive and multivariate analyses. RESULTS A total of 18,980 dabigatran-treated patients were matched to corresponding warfarin-treated patients. Adjusted all-cause total healthcare, inpatient, and outpatient costs were significantly lower for the dabigatran cohort ($US3053 vs. 3433; $US904 vs. 1194; $US1594 vs. 1894, respectively; all p < 0.001), but mean pharmacy costs were significantly higher ($US556 vs. 345, p < 0.001). Stroke-specific total healthcare and outpatient costs were significantly lower for the dabigatran than for the warfarin cohort ($US30.37 vs. 40.99 and $US7.36 vs. 12.20, respectively; p < 0.05 for both values). Similarly, bleed-specific total healthcare and inpatient costs were significantly lower for the dabigatran than for the warfarin cohort ($US50.00 vs. 73.49 and $US27.75 vs. 48.66, respectively; p < 0.01 for both values). CONCLUSION Patients receiving dabigatran had significantly lower total all-cause, inpatient, and outpatient costs but higher pharmacy costs than those receiving warfarin. In addition, stroke-specific total and outpatient costs and bleed-specific total and inpatient costs were significantly lower in dabigatran users compared with warfarin users.
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Affiliation(s)
- Adrienne M Gilligan
- Truven Health Analytics, an IBM Company, 150 Cambridge Park Dr, Cambridge, MA, 02140, USA.
| | - Pranav Gandhi
- Boehringer-Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Xue Song
- Truven Health Analytics, an IBM Company, 150 Cambridge Park Dr, Cambridge, MA, 02140, USA
| | - Cheng Wang
- Boehringer-Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Caroline Henriques
- Truven Health Analytics, an IBM Company, 150 Cambridge Park Dr, Cambridge, MA, 02140, USA
| | - Stephen Sander
- Boehringer-Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - David M Smith
- Truven Health Analytics, an IBM Company, 150 Cambridge Park Dr, Cambridge, MA, 02140, USA
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10
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Gosch M. [Oral anticoagulation in older adults with atrial fibrillation]. MMW Fortschr Med 2017; 159:70-76. [PMID: 29086256 DOI: 10.1007/s15006-017-9597-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Markus Gosch
- Paracelsus Medizinische Privatuniversität Nürnberg, Universitätsklinik für Geriatrie, Medizinische Klinik 2 - Schwerpunkt Geriatrie, Klinikum Nürnberg, Prof. Ernst Nathan Straße 1, D-90419, Nürnberg, Deutschland.
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11
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Song X, Gandhi P, Gilligan AM, Arora P, Wang C, Henriques C, Sander S, Smith DM. Comparison of all-cause, stroke, and bleed-specific healthcare resource utilization among patients with non-valvular atrial fibrillation (NVAF) and newly treated with dabigatran or warfarin. Expert Rev Pharmacoecon Outcomes Res 2017. [PMID: 28649894 DOI: 10.1080/14737167.2017.1347041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND We compared healthcare utilization outcomes and persistence among non-valvular atrial fibrillation (NVAF) patients newly treated with dabigatran or warfarin. METHODS Using a nationwide, US administrative claims database, a retrospective matched-cohort of newly diagnosed NVAF patients (age≥18 years) treated with dabigatran or warfarin (propensity score matched 1:1) in 01/01/2011-12/31/2013 was evaluated. All-cause, stroke-, and bleed-specific per patient per month (PPPM) healthcare resource utilization (HCRU), incidence rate of hospitalization for stroke or bleed, 30-day readmission, and persistence were reported. RESULTS In total, 18,890 dabigatran patients were matched to corresponding warfarin patients. Compared to warfarin users, dabigatran users PPPM had significantly fewer all-cause hospitalizations (0.04 vs 0.05), total outpatient visits (3.98 vs 5.87), and lower 30-day readmissions (14.5% vs 17.4%, all p < 0.001). Dabigatran users had lower incidence rate for stroke (0.65 vs 1.06) and bleed (1.69 vs 2.20), stroke (0.0006 vs 0.0011, p < 0.001) and bleed-specific hospitalizations (0.002 vs 0.003, p = 0.008), and stroke (0.03 vs 0.04, p < 0.001) and bleed-specific outpatient visits (0.07 vs 0.08, p = 0.018), and significantly lower non-persistence (62.1% vs 66.3%, p < 0.001). CONCLUSION Among newly diagnosed newly treated NVAF patients, dabigatran users had significantly lower all-cause, stroke- and bleed-specific HCRU, lower risk of hospitalization for stroke or bleed events, lower 30-day readmissions, and higher persistence than warfarin users.
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Affiliation(s)
- Xue Song
- a Department for Truven Health Analytics, an IBM Company , Cambridge , MA , USA
| | - Pranav Gandhi
- b Department for Boehringer-Ingelheim Pharmaceuticals, Inc ., Ridgefield , CT , USA
| | - Adrienne M Gilligan
- a Department for Truven Health Analytics, an IBM Company , Cambridge , MA , USA
| | - Prachi Arora
- b Department for Boehringer-Ingelheim Pharmaceuticals, Inc ., Ridgefield , CT , USA
| | - Cheng Wang
- b Department for Boehringer-Ingelheim Pharmaceuticals, Inc ., Ridgefield , CT , USA
| | - Caroline Henriques
- a Department for Truven Health Analytics, an IBM Company , Cambridge , MA , USA
| | - Stephen Sander
- b Department for Boehringer-Ingelheim Pharmaceuticals, Inc ., Ridgefield , CT , USA
| | - David M Smith
- a Department for Truven Health Analytics, an IBM Company , Cambridge , MA , USA
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12
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Shah R, Li S, Stamplecoski M, Kapral MK. Low Use of Oral Anticoagulant Prescribing for Secondary Stroke Prevention: Results From the Ontario Stroke Registry. Med Care 2017; 54:907-12. [PMID: 27367867 DOI: 10.1097/mlr.0000000000000589] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Oral anticoagulation reduces the risk of stroke in atrial fibrillation but is often underused. OBJECTIVES To identify factors associated with oral anticoagulant prescribing and adherence after stroke or transient ischemic attack (TIA). RESEARCH DESIGN Retrospective cohort study using linked Ontario Stroke Registry and prescription claims data. SUBJECTS Consecutive patients with atrial fibrillation and ischemic stroke/TIA admitted to 11 stroke centers in Ontario, Canada between 2003 and 2011. MEASURES We used modified Poisson regression models to determine predictors of anticoagulant prescribing and multiple logistic regression to determine predictors of 1-year adherence. RESULTS Of the 5781 patients in the study cohort, 4235 (73%) were prescribed oral anticoagulants at discharge. Older patients were less likely to receive anticoagulation [adjusted relative risk (aRR) for each additional year=0.997; 95% confidence interval (CI), 0.995-0.998], as were those with TIA compared with ischemic stroke (aRR=0.904; 95% CI, 0.865-0.945), prior gastrointestinal bleed (aRR=0.778; 95% CI, 0.693-0.873), dementia (aRR=0.912; 95% CI, 0.856-0.973), and those from a long-term care facility (aRR=0.810; 95% CI, 0.737-0.891). After limiting the sample to those without obvious contraindications to anticoagulation, age, dementia, and long-term care residence continued to be associated with lower prescription of oral anticoagulants. One-year adherence to therapy was similar across most patient groups. CONCLUSIONS Age, dementia, and long-term care residence are predictors of lower oral anticoagulant use for secondary stroke prevention and represent key target areas for quality improvement initiatives.
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Affiliation(s)
- Reema Shah
- *Department of Medicine, McMaster University, Hamilton †Institute for Clinical Evaluative Sciences ‡Institute of Health Policy, Management and Evaluation, University of Toronto §Division of General Internal Medicine, Women's Health Program, and Toronto General Research Institute, University Health Network ∥Department of Medicine, Division of General Internal Medicine, University of Toronto, Toronto, ON, Canada
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Frain B, Castelino R, Bereznicki LR. The Utilization of Antithrombotic Therapy in Older Patients in Aged Care Facilities With Atrial Fibrillation. Clin Appl Thromb Hemost 2017; 24:519-524. [PMID: 28068791 DOI: 10.1177/1076029616686421] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Oral anticoagulants are essential drugs for the prevention of thromboembolic events in patients with atrial fibrillation (AF). Anticoagulants are, however, commonly withheld in older people due to the risk and fear of hemorrhage. Although the underutilization of anticoagulants in patients with AF has been demonstrated internationally, few studies have been conducted among aged care residents. The aim of this study was to determine the utilization of anticoagulants among people with AF residing in aged care facilities. We performed a non-experimental, retrospective analysis designed to evaluate antithrombotic usage in patients with AF in Australia residing in aged care facilities, using data collected by pharmacists while performing Residential Medication Management Reviews (RMMRs). The utilization of antithrombotic therapy and the appropriateness of therapy were determined based on the CHADS2, CHA2DS2-VASc, and HAS-BLED risk stratification schemes in consideration of documented contraindications to treatment. Predictors of anticoagulant use were determined using multivariate logistic regression. A total of 1952 RMMR patients with AF were identified. Only 35.6% of eligible patients (CHADS2 score ≥2 and no contraindications to anticoagulants) received an anticoagulant. As age increased, the likelihood of receiving an anticoagulant decreased and the likelihood of receiving an antiplatelet or no therapy increased. In patients at high risk of stroke (CHADS score ≥2), utilization of anticoagulants dropped by 19.7% when the HAS-BLED score increased from 2 to 3, suggesting that physicians placed a heavier weighting on bleeding risk rather than stroke risk. Prescribing of anticoagulants was influenced to a greater extent by bleeding risk than it was by the risk of stroke. Further research investigating whether the growing availability of direct oral anticoagulants influences practice in this patient population is needed.
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Affiliation(s)
- Bridget Frain
- 1 Unit for Medication Outcomes Research and Education, Division of Pharmacy, School of Medicine, Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
| | - Ronald Castelino
- 1 Unit for Medication Outcomes Research and Education, Division of Pharmacy, School of Medicine, Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
| | - Luke R Bereznicki
- 1 Unit for Medication Outcomes Research and Education, Division of Pharmacy, School of Medicine, Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
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Real life anticoagulation treatment of patients with atrial fibrillation in Germany: extent and causes of anticoagulant under-use. J Thromb Thrombolysis 2016; 40:97-107. [PMID: 25218507 DOI: 10.1007/s11239-014-1136-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Oral anticoagulation (OAC) with either new oral anticoagulants (NOACs) or Vitamin-K antagonists (VKAs) is recommended by guidelines for patients with atrial fibrillation (AF) and a moderate to high risk of stroke. Based on a claims-based data set the aim of this study was to quantify the stroke-risk dependent OAC utilization profile of German AF patients and possible causes of OAC under-use. Our claims-based data set was derived from two German statutory health insurance funds for the years 2007-2010. All prevalent AF-patients in the period 2007-2009 were included. The OAC-need in 2010 was assumed whenever a CHADS2- or CHA2DS2-VASC-score was >1 and no factor that disfavored OAC use existed. Causes of OAC under-use were analyzed using multivariate logistic regression. 108,632 AF-prevalent patients met the inclusion criteria. Average age was 75.43 years, average CHA2DS2-VASc-score was 4.38. OAC should have been recommended for 56.1/62.9 % of the patients (regarding factors disfavouring VKA/NOAC use). For 38.88/39.20 % of the patient-days in 2010 we could not observe any coverage by anticoagulants. Dementia of patients (OR 2.656) and general prescription patterns of the treating physician (OR 1.633) were the most important factors increasing the risk of OAC under-use. Patients who had consulted a cardiologist had a lower risk of being under-treated with OAC (OR 0.459). OAC under-use still seems to be one of the major challenges in the real-life treatment of AF patients. Our study confirms that both patient/disease characteristics and treatment environment/general prescribing behaviour of physicians may explain the OAC under-use in AF patients.
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Haeusler KG, Gerth A, Limbourg T, Tebbe U, Oeff M, Wegscheider K, Treszl A, Ravens U, Meinertz T, Kirchhof P, Breithardt G, Steinbeck G, Nabauer M. Use of vitamin K antagonists for secondary stroke prevention depends on the treating healthcare provider in Germany - results from the German AFNET registry. BMC Neurol 2015; 15:129. [PMID: 26242880 PMCID: PMC4524411 DOI: 10.1186/s12883-015-0371-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 07/06/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Anticoagulation using vitamin K antagonists (VKAs) significantly reduces the risk of recurrent stroke in stroke patients with atrial fibrillation (AF) and is recommended by guidelines. METHODS The German Competence NETwork on Atrial Fibrillation established a nationwide prospective registry including 9,574 AF patients, providing the opportunity to analyse AF management according to German healthcare providers. RESULTS On enrolment, 896 (9.4 %) patients reported a prior ischaemic stroke or transient ischaemic attack. Stroke patients were significantly older, more likely to be female, had a higher rate of cardiovascular risk factors, and more frequently received anticoagulation (almost exclusively VKA) than patients without prior stroke history. Following enrolment, 76.4 % of all stroke patients without VKA contraindications received anticoagulation, which inversely associated with age (OR 0.95 per year; 95 % CI 0.92-0.97). General practitioners/internists (OR 0.40; 95 % CI 0.21-0.77) and physicians working in regional hospitals (OR 0.47; 95 % CI 0.29-0.77) prescribed anticoagulation for secondary stroke prevention less frequently than physicians working at university hospitals (reference) and office-based cardiologists (OR 1.40; 95 % CI 0.76-2.60). The impact of the treating healthcare provider was less evident in registry patients without prior stroke. CONCLUSIONS In the AFNET registry, anticoagulation for secondary stroke prevention was prescribed in roughly three-quarters of AF patients, a significantly higher rate than in primary prevention. We identified two factors associated with withholding oral anticoagulation in stroke survivors, namely higher age and-most prominently-treatment by a general practitioner/internist or physicians working at regional hospitals.
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Affiliation(s)
- Karl Georg Haeusler
- Center for Stroke Research Berlin and Department of Neurology, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, D-12200, Berlin, Germany.
| | - Andrea Gerth
- Medical Hospital I, Ludwig-Maximilians-University, Munich, Germany.
| | | | - Ulrich Tebbe
- Department of Cardiology, Hospital Detmold, Detmold, Germany.
| | - Michael Oeff
- Department of Medicine I, Brandenburg Municipal Hospital, Brandenburg, Germany.
| | - Karl Wegscheider
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - András Treszl
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Ursula Ravens
- Department of Pharmacology and Toxicology, Medical Faculty, Dresden University of Technology, Dresden, Germany.
| | - Thomas Meinertz
- Department of Cardiology/Angiology, University Hospital Eppendorf, Hamburg, Germany.
| | - Paulus Kirchhof
- Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany. .,University of Birmingham Centre for Cardiovascular Sciences and SWBH and UHB NHS Trusts, Birmingham, UK.
| | - Günter Breithardt
- Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany.
| | | | - Michael Nabauer
- Medical Hospital I, Ludwig-Maximilians-University, Munich, Germany.
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Akao M, Beyer-Westendorf J, Goto S, Peterson E. Stroke prevention in atrial fibrillation: evidence from real-life studies: Table 1. Eur Heart J Suppl 2015. [DOI: 10.1093/eurheartj/suv037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Wong CX, Lee SW, Gan SW, Mahajan R, Rangnekar G, Pathak RK, Twomey D, Schultz C, Ganesan AN, Brooks AG, Roberts-Thomson KC, Brown A, Lau DH, Sanders P. Underuse and overuse of anticoagulation for atrial fibrillation: A study in Indigenous and non-Indigenous Australians. Int J Cardiol 2015; 191:20-4. [DOI: 10.1016/j.ijcard.2015.03.064] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 02/10/2015] [Accepted: 03/03/2015] [Indexed: 11/29/2022]
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Maes F, Dalleur O, Henrard S, Wouters D, Scavée C, Spinewine A, Boland B. Risk scores and geriatric profile: can they really help us in anticoagulation decision making among older patients suffering from atrial fibrillation? Clin Interv Aging 2014; 9:1091-9. [PMID: 25053883 PMCID: PMC4105275 DOI: 10.2147/cia.s62597] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Anticoagulation for the prevention of cardio-embolism is most frequently indicated but largely underused in frail older patients with atrial fibrillation (AF). This study aimed at identifying characteristics associated with anticoagulation underuse. METHODS A cross-sectional study of consecutive geriatric patients aged ≥75 years, with AF and clear anticoagulation indication (CHADS₂ [Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack] ≥2) upon hospital admission. All patients benefited from a comprehensive geriatric assessment. Their risks of stroke and bleeding were predicted using CHADS₂ and HEMORR2HAGES (Hepatic or renal disease, Ethanol abuse, Malignancy, Older (age >75 years), Reduced platelet count or function, Rebleed risk, Hypertension (uncontrolled), Anemia, Genetic factors, Excessive fall risk, and Stroke) scores, respectively. RESULTS Anticoagulation underuse was observed in 384 (50%) of 773 geriatric patients with AF (median age 85 years; female 57%, cognitive disorder 33%, nursing home 20%). No geriatric characteristic was found to be associated with anticoagulation underuse. Conversely, anticoagulation underuse was markedly increased in the patients treated with aspirin (odds ratio [OR] [95% confidence interval]: 5.3 [3.8; 7.5]). Other independent predictors of anticoagulation underuse were ethanol abuse (OR: 4.0 [1.4; 13.3]) and age ≥90 years (OR: 2.0 [1.2; 3.4]). Anticoagulation underuse was not inferior in patients with a lower bleeding risk and/or a higher stroke risk and underuse was surprisingly not inferior either in the AF patients who had previously had a stroke. CONCLUSION Half of this geriatric population did not receive any anticoagulation despite a clear indication, regardless of their individual bleeding or stroke risks. Aspirin use is the main characteristic associated with anticoagulation underuse.
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Affiliation(s)
- Frédéric Maes
- Cardiology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Olivia Dalleur
- Pharmacy Department, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium ; Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - Séverine Henrard
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium
| | - Dominique Wouters
- Pharmacy Department, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Christophe Scavée
- Cardiology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Anne Spinewine
- Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium ; Pharmacy Department, CHU Dinant-Godinne, Université catholique de Louvain, Yvoir, Belgium
| | - Benoit Boland
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium ; Geriatric Medicine, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
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Pharmacology, benefits, unaddressed questions, and pragmatic issues of the newer oral anticoagulants for stroke prophylaxis in non-valvular atrial fibrillation and proposal of a management algorithm. Int J Cardiol 2014; 174:471-83. [DOI: 10.1016/j.ijcard.2014.04.179] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 03/06/2014] [Accepted: 04/17/2014] [Indexed: 12/16/2022]
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Pharmacotherapy prior to and in acute ischaemic stroke. The use of pharmacotherapy and drug-associated outcomes in real world practice - findings from the Polish Hospital Stroke Registry. Neurol Neurochir Pol 2014; 47:509-16. [PMID: 24374995 DOI: 10.5114/ninp.2013.39067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE Stroke is a preventable disease and acute ischaemic stroke can be effectively treated. Specific pharmacotherapy is recommended in either prevention or acute ischemic stroke treatment. We aimed to evaluate the use and the early and late outcomes impact of drugs administered before and in acute ischaemic stroke in a real world practice. MATERIAL AND METHODS Ischaemic stroke patients hospitalized between 1st March 2007 and 29th February 2008 and reported in Polish Hospital Stroke Registry were analysed. Fully anonymous data were collected with standardized, web-based questionnaire with authorized access. Multivariate regression models were used to adjust for case-mix and evaluate the impact of drugs used prior to or in acute ischaemic stroke on outcomes. The early outcomes were defined as in-hospital mortality or poor outcome (death or dependency - modified Rankin Scale 3) at hospital discharge, while late outcomes covered one-year survival. RESULTS A total number of 26 153 ischaemic stroke patients (mean age: 71.8 years; females: 51.6%) was reported. The ana-lysis of pharmacotherapy showed that preventive use of hypo-tensive agents, anticoagulants in atrial fibrillation, antiplatelets and statins is inadequate. Regression models confirmed some expected drug benefits and additionally revealed that antihypertensive drugs or aspirin used prior to stroke and oral anticoagulants or statins used in hospital were associated with better stroke outcome. CONCLUSIONS The prevention of ischaemic stroke needs to be monitored and improved. Evidence-based treatment of acute ischaemic stroke requires further promotion. The benefits of acute ischaemic stroke treatment with statins require to be confirmed in randomized controlled settings.
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Tavassoli N, Perrin A, Bérard E, Gillette S, Vellas B, Rolland Y. Factors associated with undertreatment of atrial fibrillation in geriatric outpatients with Alzheimer disease. Am J Cardiovasc Drugs 2013; 13:425-33. [PMID: 23943094 DOI: 10.1007/s40256-013-0040-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND According to international recommendations [from the American College of Cardiology/American Heart Association/European Society of Cardiology] and those of the Haute Autorité de Santé (HAS) in France, treatment with a vitamin K antagonist is recommended in patients with atrial fibrillation (AF) in the presence of a high thromboembolic risk factor [history of stroke, transient ischemic attack, systemic embolism, or valvular heart disease, or presence of a mechanical heart valve prosthesis] or at least two moderate risk factors (age ≥75 years, hypertension, congestive heart failure, or diabetes). In patients with a major contraindication, the vitamin K antagonist can be replaced by an antiplatelet agent (APA). These recommendations are not systematically observed in patients with Alzheimer disease (AD). The aim of our study was to determine the factors associated with undertreatment of AF in geriatric outpatients with AD. METHODS Use of oral anticoagulants or APAs was studied in 66 patients with AF who were included in the French Network on Alzheimer Disease (REAL.FR) cohort, consisting of 686 outpatients living at home, supported by an informal caregiver, and suffering from Alzheimer-type dementia, with a Mini Mental Status Examination (MMSE) score between 10 and 26. First, demographic characteristics (age, sex, body mass index [BMI], living arrangements, educational level), medical conditions (comorbidity, number of medications), disability (activities of daily living [ADL], instrumental activities of daily living [IADL]), risk of falls (one-leg balance test), cognitive status (according to MMSE, Alzheimer's Disease Assessment Scale-Cognitive Subscale [ADAS-Cog], and Clinical Dementia Rating [CDR] scores), risk factors for stroke (hypertension, history of stroke, congestive heart failure, diabetes, or age ≥75 years) and potential contraindications to oral anticoagulants (OACs) or APAs (polypharmacy, risk of falls, renal failure, gastrointestinal diseases) of patients receiving OACs were compared with those of patients receiving APAs and those of patients receiving no treatment for AF. Then the same characteristics were compared between patients receiving no treatment for AF and those receiving OACs or APAs. RESULTS Only 56 % (n = 37) of patients with AF were receiving OACs or APAs at the baseline visit, of whom 18 (49 %) were receiving OACs and 19 (51 %) were receiving APAs. Bivariate analysis showed that patients receiving OACs or APAs were significantly more likely to have a history of cardiovascular disease (p = 0.005)-in particular, hypertension (p = 0.037)-less likely to be living alone and unaided (p = 0.038), and less likely to be taking nonsteroidal anti-inflammatory drugs [NSAIDs] (p = 0.001). CONCLUSION Despite the national and international recommendations, nearly half of AD patients with AF do not receive OACs or APAs. A history of cardiovascular disease-in particular, hypertension-improves access to treatment, but use of NSAIDs and living alone without home care seem to be the main factors associated with non-prescription of OACs or APAs.
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Affiliation(s)
- Neda Tavassoli
- Gérontopôle de Toulouse, Département de Médecine Interne et Gérontologie Clinique, Centre Hospitalier Universitaire de Toulouse, Pavillon Junod, 170 avenue de Casselardit, 31300, Toulouse, France,
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The atrial fibrillation knowledge scale: Development, validation and results. Int J Cardiol 2013; 168:1422-8. [DOI: 10.1016/j.ijcard.2012.12.047] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2011] [Revised: 10/28/2012] [Accepted: 12/15/2012] [Indexed: 11/22/2022]
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Piccinocchi G, Laringe M, Guillaro B, Arpino G, Piccinocchi R, Nigro G, Calabrò P. Diagnosis and management of atrial fibrillation by primary care physicians in Italy : a retrospective, observational analysis. Clin Drug Investig 2013; 32:771-7. [PMID: 23018284 PMCID: PMC3693438 DOI: 10.1007/s40261-012-0005-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with a heavy burden of morbidity and mortality, mainly due to an increased risk of cerebrovascular events and cardiac failure. Oral anticoagulant (OAC) treatment prevents stroke and systemic thromboembolism in patients with AF and its use is strongly recommended in guidelines. However, its use in this patient group remains limited. Primary care physicians (PCPs) have an important role to play in this context. Objective The primary objective was to estimate prevalence and epidemiological features of AF in the primary care setting, focusing on ischaemic and bleeding risk assessment. A secondary objective was to examine the PCPs’ level of adherence to the guidelines for the prevention of thromboembolic risk in these patients. Methods This retrospective, observational study was based on data entered by 128 PCPs into the Health Search (HS) Thales database, identifying patients with a diagnosis of AF at the time of the analysis. Results Out of 167,056 patients analysed, 2,173 (1.3 %) were diagnosed with AF, with 86 % at high risk for ischaemic stroke, according to CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years [doubled], diabetes, stroke [doubled], vascular disease, age 65–74 years, sex category [female]) stratification. After the diagnosis of AF, 84 % of patients were prescribed OAC treatment. However, at 2 years’ follow-up, only 29.6 % were still being treated with OACs. Conclusion The prevalence of AF in this analysis was consistent with previously reported Italian national epidemiological data. Adherence to the European Society of Cardiology AF guidelines by PCPs was low, despite the high levels of stroke risk. At the end of the observation period less than one-third of patients were still on OAC therapy. Awareness of the benefits of OACs in stroke prevention in AF patients needs to be improved.
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Affiliation(s)
- Gaetano Piccinocchi
- Co.Me.Gen. Coop (Cooperativa Medicina Generale Napoli), Cooperative of Primary Care Physicians, Via Cintia Parco S. Paolo 45, 80126, Naples, Italy.
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Filippi A, Zoni-Berisso M, Ermini G, Landolina M, Brignoli O, D'Ambrosio G, Zingarini G, Pedrinazzi C. Stroke prophylaxis in high-risk patients with atrial fibrillation: rhythm vs. rate control strategy. Eur J Intern Med 2013; 24:314-7. [PMID: 23474251 DOI: 10.1016/j.ejim.2013.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 12/23/2012] [Accepted: 02/08/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE "Rhythm" and "Rate" control strategies require partially different organization, and a different involvement of Specialists and General Practitioners; we verified whether the strategy assignment modified the approach to stroke prophylaxis. METHODS Survey in general practice: 233 GPs identified all patients with codified atrial fibrillation (AF) diagnosis, checked the diagnosis (ECG/hospital discharge document), and filled a structured questionnaire on stroke risk-factors, prophylactic therapy, and reasons for warfarin non prescription in CHADS ≥2 patients. Data were collected as an "aggregate." RESULTS Population observed: 295,906 patients aged >14; 6,036 with confirmed AF; 5,888 with complete data about anti-thrombotic prophylaxis are analyzed here. In the "rhythm strategy" group 45.6% of the CHADS score ≥2 patients (594) were on warfarin, vs. 73.2% (1,741) in the "rate strategy" group (p<0.0001). Overall reasons for warfarin non-use were significantly different in the two groups: clinical contraindications (12.3% vs. 19.7%), side effects (5.5% vs. 8.5%), patients' refusal (12.2% vs. 15.2%), unreliable patient/care-giver (14.4% vs. 25.9%); reasons were unknown to the GP in 55.6% in rhythm control vs. 30.9% in rate control group. CONCLUSIONS Anti-thrombotic prophylaxis in CHADS ≥2 patients is different in subjects assigned to the Rhythm vs. the Rate control strategy, as well as reported reasons for warfarin non use. GPs do not know why warfarin is not used in a large percentage of cases, mainly in the rhythm control strategy group. Improving efforts should probably be differently tailored for patients assigned to the "rhythm" or the "rate" control strategy.
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Verheugt FWA. Advances in stroke prevention in atrial fibrillation: enhanced risk stratification combined with the newer oral anticoagulants. Clin Cardiol 2013; 36:312-22. [PMID: 23568790 PMCID: PMC6649625 DOI: 10.1002/clc.22122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 03/06/2013] [Indexed: 11/11/2022] Open
Abstract
Patients with atrial fibrillation (AF) have an increased stroke risk compared with those in sinus rhythm, although the absolute risk for individual patients is modulated by the presence of various additional risk factors. Patient selection for oral anticoagulation for stroke prevention is based on risks of stroke and bleeding. Although CHADS2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack) is the most widely used scheme for evaluating stroke risk in patients with AF, several other stroke risk factors are not included; therefore, many patients' stroke risk may be underestimated, contributing to the underuse of anticoagulants. Furthermore, a substantial proportion of patients are categorized as being at moderate risk (CHADS2 = 1), and there has been some ambiguity regarding optimum thromboprophylaxis in this group. The refinement of CHADS2 , CHA2 DS2 -VASc (Congestive heart failure, Hypertension, Age 75 years [2 points], Diabetes mellitus, Stroke or transient ischemic attack [2 points], Vascular disease, Age 65 to 74 years, Sex category [female]), considers additional risk factors. Its main advantage is its ability to identify patients truly at low risk of thromboembolism (CHA2 DS2 -VASc = 0), who are unlikely to benefit from antithrombotic therapy. For all others, an oral anticoagulant may be the preferred approach, simplifying clinical decision making. Implementation of CHA2 DS2 -VASc may also result in an increased proportion of patients receiving anticoagulation. The emergence of newer oral anticoagulants that can be given without routine coagulation monitoring, with improved benefit-risk profiles vs vitamin K antagonists, promises to simplify therapy for patients with AF at risk of stroke. This, coupled with advances in stroke risk stratification, is expected to improve patient outcomes and reduce the burden of AF-related stroke.
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Affiliation(s)
- Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands.
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Brandes A, Overgaard M, Plauborg L, Dehlendorff C, Lyck F, Peulicke J, Poulsen SV, Husted S. Guideline adherence of antithrombotic treatment initiated by general practitioners in patients with nonvalvular atrial fibrillation: a Danish survey. Clin Cardiol 2013; 36:427-32. [PMID: 23670894 DOI: 10.1002/clc.22133] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 04/05/2013] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The aim of this prospective survey was to describe the demographics, stroke risk profile, and the guideline adherence of antithrombotic treatment in a Danish primary care population of patients with nonvalvular atrial fibrillation (AF). HYPOTHESIS We hypothesized that a significant proportion of patients with nonvalvular AF do not receive guideline-adherent antithrombotic treatment in primary care. METHODS We performed a cross-sectional survey of antithrombotic treatment using data of AF patients from general practices. RESULTS Sixty-four general practitioners enrolled 1743 patients with a mean age of 74.8 ± 11.2 years. The mean CHADS2 and CHA2 DS2 -VASc scores were 1.9 ± 1.3 and 3.5 ± 1.8, respectively. Of the patients, 12.4% and 4.04%, respectively, were at truly low risk, with a CHADS2 and CHA2 DS2 -VASc score 0 (P < 0.001). A score of 1 was seen in 28.0% vs 9.0% (P < 0.001) of the patients. Of all patients, 66.3% were treated with oral anticoagulants, 18.7% with antiplatelet drugs only, and 15% received no antithrombotic therapy. Based on the CHADS2 score, 75.7% of the patients were treated in adherence with the guidelines, 16% were undertreated, and 8.4% overtreated. The corresponding numbers for the CHA2 DS2 -VASc score were 75.4%, 22.7%, and 1.8%, respectively. The differences in guideline adherence applying the 2 scores were significant (P < 0.001). Of patients receiving no antithrombotic therapy, 64.1% were treated in adherence to the guidelines according to the CHADS2 score. Applying the CHA2 DS2 -VASc score, this proportion was only 53.4%. Antiplatelet drug treatment was in adherence to the guidelines (CHADS2 and CHA2 DS2 -VASc score of 1) in only 31% and 12% of the patients, respectively. CONCLUSIONS Antithrombotic treatment of AF patients is in general well performed in primary care in Denmark. Further improvements may be achieved by thorough stroke risk stratification on the basis of current evidence-based guidelines.
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Affiliation(s)
- Axel Brandes
- Department of Cardiology, Odense University Hospital, Odense, Denmark.
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Yates SW. Novel oral anticoagulants for stroke prevention in atrial fibrillation: a focus on the older patient. Int J Gen Med 2013; 6:167-80. [PMID: 23687449 PMCID: PMC3610436 DOI: 10.2147/ijgm.s39379] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Atrial fibrillation (AF) is a common arrhythmia that is associated with an increased risk of stroke, particularly in the elderly. Traditionally, a vitamin K antagonist such as warfarin is prescribed for stroke prevention. Warfarin is effective at lowering stroke risk but has several limitations due to food restrictions, drug interactions, and a narrow therapeutic window. Various novel oral anticoagulants (NOACs) are available or under development to provide alternative treatment options. This article reviews the efficacy and safety of three NOACs (dabigatran etexilate, rivaroxaban, and apixaban) in addition to warfarin and aspirin, for prevention of stroke in patients with AF, focusing on the elderly population. Results of clinical trials demonstrate that the efficacy of NOACs for stroke prevention in patients with AF is as good as or better than that of warfarin. The NOACs are also associated with an equivalent or lower risk of bleeding. Regardless of the medication chosen, older patients with AF must be treated cautiously due to an increased risk of stroke and bleeding, as well as potential challenges related to drug interactions and monitoring requirements. NOACs may be suitable alternatives to warfarin for stroke prevention in older patients due to several advantages, including a faster onset of action, few drug or food interactions, and no requirement for regular monitoring. However, dose adjustments may be required for certain patients, such as those with severe renal impairment or in the setting of drug interactions.
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Sanoski CA. Current approaches to anticoagulation for reducing risk of atrial fibrillation-related stroke. J Pharm Pract 2012; 26:204-13. [PMID: 22842506 DOI: 10.1177/0897190012452309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Stroke is a major cause of death and disability and, as such, is associated with a heavy socioeconomic burden. Atrial fibrillation (AF) is an independent risk factor for ischemic stroke, and AF-related stroke tends to be more severe and poses a higher risk of recurrence than non-AF-related stroke. Anticoagulant prophylaxis with warfarin is effective in preventing stroke in eligible patients with AF, but in real-world practice this agent, though inexpensive, is underutilized. Moreover, warfarin has notable drawbacks that result in suboptimal anticoagulation and, as a result, greater disease burden and higher costs. Newer oral antithrombotic drugs with a wide therapeutic window and no requirement for routine coagulation monitoring may be as efficacious as warfarin and, given the costs associated with managing warfarin therapy, they may also prove to be more cost effective.
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Affiliation(s)
- Cynthia A Sanoski
- Department of Pharmacy Practice, Jefferson School of Pharmacy, Thomas Jefferson University, Philadelphia, Pennsylvania, PA, USA.
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30
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Randomized controlled trials of new oral anticoagulants for stroke prevention in atrial fibrillation. Curr Opin Cardiol 2012; 27:331-9. [DOI: 10.1097/hco.0b013e3283540857] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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31
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Cherubini A, Corsonello A, Lattanzio F. Underprescription of Beneficial Medicines in Older People. Drugs Aging 2012; 29:463-75. [DOI: 10.2165/11631750-000000000-00000] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Ferreira J, Ferreira D, Viana-Baptista M, Bettencourt P, Cernadas R, Crespo F. Dabigatran for stroke prevention in nonvalvular atrial fibrillation: answers to challenging "real-world" questions. THROMBOSIS 2012; 2012:867121. [PMID: 22645678 PMCID: PMC3356980 DOI: 10.1155/2012/867121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 02/28/2012] [Accepted: 02/29/2012] [Indexed: 12/18/2022]
Abstract
Dabigatran etexilate is a novel, oral, reversible, direct thrombin inhibitor that constitutes a major breakthrough for stroke prevention in patients with nonvalvular atrial fibrillation (AF). Dabigatran was the first new oral anticoagulant approved in Europe and became available in Portugal, for stroke prevention in nonvalvular AF, earlier than in most European countries. This paper is the joint effort of a panel of experts from different specialties and provides information on the use of dabigatran, in anticipation of the challenges that will come with increased usage.
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Affiliation(s)
- Jorge Ferreira
- Serviço de Cardiologia, Hospital de Santa Cruz, Avenida Prof. Reinaldo dos Santos, 2790-134 Carnaxide, Portugal
| | - Daniel Ferreira
- Serviço de Cardiologia, Hospital da Luz, Avenida Lusíada 100, 1500-650 Lisboa, Portugal
| | - Miguel Viana-Baptista
- CEDOC, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Rua da Junqueira 126, 1349-019 Lisboa, Portugal
- Serviço de Neurologia, Hospital Egas Moniz, 1349-019 Lisboa, Portugal
| | - Paulo Bettencourt
- Serviço de Medicina Interna, Hospital de São João, Al. Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Rui Cernadas
- Unidade de Saúde Familiar da Aguda, Avenida Padre Guilherme 21, 4405-010 Arcozelo, Portugal
| | - Francisco Crespo
- Hospital de Torres Vedras, Rua Dr. Ricardo Belo, 2560-324 Torres Vedras, Portugal
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Abstract
Among geriatric patients, atrial fibrillation is the most common cardiac arrhythmia. In patients over 80 years of age, the prevalence rises to approximately 10%. Atrial fibrillation is associated with serious health implications, including a 2-fold increase in mortality risk and a 5-fold increase in stroke risk. In contrast to these facts, the current guidelines on the management of atrial fibrillation of the European Society of Cardiology (ESC) contain only a short paragraph on these patients. Many relevant clinical aspects go without any comment. Thus, the purpose of our paper is to discuss those special needs of geriatric patients and their physicians which are not mentioned in the guidelines of the ESC. In our review, we discuss rhythm versus rate control, oral anticoagulation, outcome, prevention, falls, adherence, polypharmacy, dementia, nursing home patients, frailty, and geriatric assessment in consideration of geriatric patients. An extended search of the literature on Pubmed served as the basis for this review. Individual aspects of each geriatric patient should be considered when managing these complex patients; however, the complexity of each case must not lead to an individualized therapy that is not in accordance with current guidelines and the literature. A large number of papers which help us to answer most of the clinical questions regarding the management of trial fibrillation in geriatric patients have already been published.
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Benefits and risks of oral anticoagulation for stroke prevention in nonvalvular atrial fibrillation. Thromb Res 2012; 129:9-16. [DOI: 10.1016/j.thromres.2011.09.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 09/12/2011] [Accepted: 09/15/2011] [Indexed: 11/21/2022]
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35
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Carrington MJ, Ball J, Horowitz JD, Marwick TH, Mahadevan G, Wong C, Abhayaratna WP, Haluska B, Thompson DR, Scuffham PA, Stewart S. Navigating the fine line between benefit and risk in chronic atrial fibrillation: rationale and design of the Standard versus Atrial Fibrillation spEcific managemenT studY (SAFETY). Int J Cardiol 2011; 166:359-65. [PMID: 22079383 DOI: 10.1016/j.ijcard.2011.10.065] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Accepted: 10/18/2011] [Indexed: 10/15/2022]
Abstract
BACKGROUND Health outcomes associated with atrial fibrillation (AF) continue to be poor and standard management often does not provide clinical stability. The Standard versus Atrial Fibrillation spEcific managemenT studY (SAFETY) compares the efficacy of a post-discharge, nurse-led, multi-disciplinary programme to optimise AF management with usual care. METHODS SAFETY is a prospective, multi-centre, randomised controlled trial with blinded-endpoint adjudication. A target of 320 hospitalised patients with a chronic form of AF will be randomised (stratified by "rate" versus "rhythm" control) to usual post-discharge care or the SAFETY Intervention (SI). The SI involves home-based assessment, extensive clinical profiling and the application of optimal gold-standard pharmacology which is individually tailored according to a "traffic light" framework based on clinical stability, risk profile and therapeutic management. The primary endpoint is event-free survival from all-cause death or unplanned readmission during 18-36 months follow-up. Secondary endpoints include rate of recurrent hospital stay, treatment success (i.e. maintenance of rhythm or rate control and/or application of anti-thrombotic therapy without a bleeding event) and cost-efficacy. RESULTS With study recruitment to be completed in early 2012, the results of this study will be available in early 2014. CONCLUSIONS If positive, SAFETY will represent a potentially cost-effective and readily applicable strategy to improve health outcomes in high risk individuals discharged from hospital with chronic AF.
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Affiliation(s)
- Melinda J Carrington
- Preventative Health, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
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36
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Pugh D, Pugh J, Mead GE. Attitudes of physicians regarding anticoagulation for atrial fibrillation: a systematic review. Age Ageing 2011; 40:675-83. [PMID: 21821732 DOI: 10.1093/ageing/afr097] [Citation(s) in RCA: 185] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND the efficacy of warfarin for prevention of stroke in patients with atrial fibrillation (AF) is well established, but many people with AF who would benefit from warfarin are not receiving it. This systematic review aims to determine physicians' attitudes to the prescription of warfarin for AF, and identify reasons for its underuse. METHODS an electronic search of MEDLINE (1950-present), EMBASE (1980-present), CINAHL (1994-present), PsycINFO (1987-present) and Web of Knowledge (1970-present) was performed in November 2010 to identify all studies which addressed, via survey, physicians' attitudes regarding anticoagulation for patients with AF. RESULTS a total of 1,375 citations were identified. Of these citations, 44 full text studies were obtained for scrutinisation; 14 of these studies were rejected leaving 30 studies which were included in the review. All included studies were cross-sectional surveys and addressed physicians' opinions of anticoagulation in AF as a primary or secondary aim. Increasing age, increased bleeding risk, previous bleeds, falls risk, co-morbidities and ability to comply with treatment influenced whether physicians would prescribe anticoagulation for AF. CONCLUSION physicians are reticent to recommend warfarin for elderly patients in AF, despite evidence of increased benefit in these patients compared with younger patients. Risk of falls and previous bleeding were also shown to be disproportionate barriers to warfarin prescription. Further studies are required to determine how best to overcome these perceived barriers to appropriate anticoagulation.
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37
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De Caterina R, Hylek EM. Stroke prevention in atrial fibrillation: current status and near-future directions. Am J Med 2011; 124:793-9. [PMID: 21745652 DOI: 10.1016/j.amjmed.2011.03.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Revised: 03/10/2011] [Accepted: 03/15/2011] [Indexed: 10/18/2022]
Abstract
Prevention of atrial fibrillation-related stroke is an important part of atrial fibrillation management. However, stroke risk is not homogeneous and varies with associated morbidities and risk factors. Risk stratification schemes have been developed that categorize patients' stroke risk into classes based on a combination of risk factors. According to the calculated level of risk, guidelines recommend patients with atrial fibrillation receive antithrombotic therapy either as a vitamin K antagonist or aspirin. Despite recommendations, however, many patients with atrial fibrillation do not receive adequate thromboprophylaxis. We will discuss some of the underlying reasons, in part related to the drawbacks associated with vitamin K antagonists. These highlight the need for new anticoagulants in atrial fibrillation. The novel oral anticoagulants in development may overcome some of the limitations of vitamin K antagonists and address their underuse and safety concerns.
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Affiliation(s)
- Raffaele De Caterina
- Institute of Cardiology and Center of Excellence on Aging, G. d'Annunzio University, Chieti, Italy.
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38
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Rådholm K, Östgren CJ, Alehagen U, Falk M, Wressle E, Marcusson J, Nägga K. Atrial fibrillation (AF) and co-morbidity in elderly. A population based survey of 85 years old subjects. Arch Gerontol Geriatr 2011; 52:e170-5. [DOI: 10.1016/j.archger.2010.10.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2010] [Revised: 10/20/2010] [Accepted: 10/21/2010] [Indexed: 02/03/2023]
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39
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Mehra M, DiBello J, Fisher AC, Mills RM. Impact of relative contraindications on the use, benefits, and risks of anticoagulant prophylaxis in atrial fibrillation: analysis of a claims database. ACTA ACUST UNITED AC 2011. [DOI: 10.4236/ojim.2011.13013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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40
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Aliot E, Breithardt G, Brugada J, Camm J, Lip GYH, Vardas PE, Wagner M. An international survey of physician and patient understanding, perception, and attitudes to atrial fibrillation and its contribution to cardiovascular disease morbidity and mortality. Europace 2010; 12:626-33. [PMID: 20421224 PMCID: PMC2859877 DOI: 10.1093/europace/euq109] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Aims Atrial fibrillation (AF) is not always perceived as a serious health threat, but is the most common sustained arrhythmia, with a major impact on morbidity, mortality, and patient quality of life (QoL). A survey was undertaken to examine the level of understanding, perception, and attitudes of the cardiovascular risks associated with AF. Methods and results The AF AWARE group (an international coalition of organizations with an interest in AF) conducted an international quantitative survey in 11 countries in 2009, to investigate patients' (n = 825) and cardiologists' (n = 810) perceptions of AF, preferences for communicating information on AF and burden of AF. Both patients and physicians considered AF life-threatening (55 and 43%, respectively). Physicians were more concerned about the risk of stroke and hospitalizations than patients, whereas patients were most concerned about death risk. One in four patients felt unable to explain AF and >33% were worried or fearful about their disease. Many physicians (51%) wanted more patient information with >60% viewing available information as poor/difficult to find. Hospital specialists and GPs were identified as key information sources for patients. Most patients (83%) reported symptoms, yet 75% claimed to be satisfied with AF therapies. Atrial fibrillation patients, often with associated diseases, made an average of nine visits per year to their doctors, who consider AF difficult and time consuming to manage. Patients and physicians rated the QoL impact of AF as moderate to high. Conclusions A comprehensive international patient and professional information and support programme on AF is needed to improve management and consequently health outcomes.
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Affiliation(s)
- Etienne Aliot
- Brabois Hospital, University Hospital of Nancy, Nancy, France.
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41
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Fitzgerald SP, Bean NG. An analysis of the interactions between individual comorbidities and their treatments--implications for guidelines and polypharmacy. J Am Med Dir Assoc 2010; 11:475-84. [PMID: 20816335 DOI: 10.1016/j.jamda.2010.05.008] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Accepted: 05/26/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND With aging there is an increase in frailty and chronic disease leading to a potential increase in medication use. Most clinical trials have excluded old, frail individuals and have failed to take into account the effects of outcome interaction. METHODS AND RESULTS In this article we provide a mathematical model demonstrating that comorbidities, including old age, interact with therapies, reducing their effectiveness. CONCLUSION These findings question the validity of single disease guidelines in old persons or in persons with multiple chronic diseases.
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42
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Corea F, Spinelli M, Tambasco N, Silvestrelli G, Parnetti L. Secondary Prevention of Cardioembolic Stroke: Oldest and Newest Promises. Clin Exp Hypertens 2009; 28:413-20. [PMID: 16833054 DOI: 10.1080/10641960600549900] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Atrial fibrillation (AF) is the most common cause of cardioembolism. An update on secondary prevention strategies used to protect from the risk of stroke AF patients is presented. The main line of actions of stroke prevention in AF are antithrombotics (anticoagulant or antiplatelet), antiarrhythmics (for rate control and sinus rhythm restore), mechanical means (for occlusion of the left atrial appendage or protection of the internal carotid artery from emboli). Classic pharmacological prevention with K vitamin Kantagonists such as warfarin may be overcome by direct thrombin inhibitors like ximelagatran and melagatran. New ablation technologies promise to cure, at least a part of Nonvalvolae AF in the community, restoring sinus rhythm. Recent achievements on endovascular procedures deploying carotid artery implants provide an opportunity to divert emboli to nonhazardous locations, whereas cardiac devices can seal left atrial appendages and avoid risk of clot migration in the blood stream. In the next decade, the challenge will be to understand competitiveness between old and new drugs with endovascular implants.
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Affiliation(s)
- F Corea
- Stroke Unit, Department of Neurology, Università Vita Salute IRCCS, S. Raffaele, Milano, Italy.
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43
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McBride D, Mattenklotz AM, Willich SN, Brüggenjürgen B. The costs of care in atrial fibrillation and the effect of treatment modalities in Germany. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2009; 12:293-301. [PMID: 18657103 DOI: 10.1111/j.1524-4733.2008.00416.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Atrial fibrillation (AF) is an increasing burden on health-care systems because of an aging population. This study aimed to estimate health-care resource use and costs of treating AF in Germany. METHOD A 6-month multicenter prospective observational cohort study with additional 3-month retrospective clinical data collection was performed in physician practices. AF-related resource use was documented by 3-month retrospective and 6-month prospective clinical data from physician charts and prospectively by patient questionnaires at 3 and 6 months. Cost calculation was from the health-care payer perspective. RESULTS A total of 361 patients (mean age 71 +/- 9 years, 61% male) were recruited from 45 physician practices. Of 311 (86.1%) patients with complete data, 75% had persistent AF; oral anticoagulation and/or aspirin were prescribed in 98%. A rhythm-control strategy was applied in 27%, rate control in 58%, and 15% received neither antiarrhythmic medication nor cardioversion. A higher proportion of rhythm-control patients had paroxysmal AF (P < 0.001). Mean annual AF-related per-patient cost was 827 Euro +/- 1476 (median 386 Euro). 50% of total costs were incurred by 11% of patients, driven by AF-related hospitalizations (44%). Antiarrhythmics and stroke prophylaxis accounted for 20% and 15% of expenditures, respectively. Mean annualized costs were higher for rhythm-control patients than for rate-control patients or those without antiarrhythmic treatment (1572 vs. 780 vs. 544 Euro, P < 0.001). CONCLUSION This evaluation provides an overview of current treatment modalities and cost of AF management in Germany. Efforts to reduce the economic burden of AF should focus on avoidance of AF hospital admissions and optimization of stroke prevention and rhythm control.
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Affiliation(s)
- Doreen McBride
- Institute for Social Medicine, Epidemiology and Health Economics, Charité University Medical Center, Berlin, Germany.
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Gladstone DJ, Bui E, Fang J, Laupacis A, Lindsay MP, Tu JV, Silver FL, Kapral MK. Potentially Preventable Strokes in High-Risk Patients With Atrial Fibrillation Who Are Not Adequately Anticoagulated. Stroke 2009; 40:235-40. [PMID: 18757287 DOI: 10.1161/strokeaha.108.516344] [Citation(s) in RCA: 273] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Warfarin is the most effective stroke prevention medication for high-risk individuals with atrial fibrillation, yet it is often underused. This study examined the magnitude of this problem in a large contemporary, prospective stroke registry.
Methods—
We analyzed data from the Registry of the Canadian Stroke Network, a prospective database of consecutive patients with stroke admitted to 12 designated stroke centers in Ontario (2003 to 2007). We included patients admitted with an acute ischemic stroke who (1) had a known history of atrial fibrillation; (2) were classified as high risk for systemic emboli according to published guidelines; and (3) had no known contraindications to anticoagulation. Primary end points were the use of prestroke antithrombotic medications and admission international normalized ratio.
Results—
Among patients admitted with a first ischemic stroke who had known atrial fibrillation (n=597), strokes were disabling in 60% and fatal in 20%. Preadmission medications were warfarin (40%), antiplatelet therapy (30%), and no antithrombotics (29%). Of those taking warfarin, three fourths had a subtherapeutic international normalized ratio (<2.0) at the time of stroke admission. Overall, only 10% of patients with acute stroke with known atrial fibrillation were therapeutically anticoagulated (international normalized ratio ≥2.0) at admission. In stroke patients with a history of atrial fibrillation and a previous transient ischemic attack or ischemic stroke (n=323), only 18% were taking warfarin with therapeutic international normalized ratio at the time of admission for stroke, 39% were taking warfarin with subtherapeutic international normalized ratio, and 15% were on no antithrombotic therapy.
Conclusions—
In high-risk patients with atrial fibrillation admitted with a stroke, and who were candidates for anticoagulation, most were either not taking warfarin or were subtherapeutic at the time of ischemic stroke. Many were on no antithrombotic therapy. These findings should encourage greater efforts to prescribe and monitor appropriate antithrombotic therapy to prevent stroke in individuals with atrial fibrillation.
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Affiliation(s)
- David J. Gladstone
- From the Institute for Clinical Evaluative Sciences (D.J.G., J.F., A.L., M.P.L., J.V.T., F.L.S., M.K.K.), Toronto, Canada; Division of Neurology (D.J.G., E.B., F.L.S.), Department of Medicine (D.J.G., J.V.T.), Regional Stroke Centre and Neurosciences Program (D.J.G.), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Department of Medicine (A.L., J.V.T., F.L.S., M.K.K.), and the Department of Health Policy, Management and Evaluation (J.V.T., M.K.K.), University of Toronto,
| | - Esther Bui
- From the Institute for Clinical Evaluative Sciences (D.J.G., J.F., A.L., M.P.L., J.V.T., F.L.S., M.K.K.), Toronto, Canada; Division of Neurology (D.J.G., E.B., F.L.S.), Department of Medicine (D.J.G., J.V.T.), Regional Stroke Centre and Neurosciences Program (D.J.G.), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Department of Medicine (A.L., J.V.T., F.L.S., M.K.K.), and the Department of Health Policy, Management and Evaluation (J.V.T., M.K.K.), University of Toronto,
| | - Jiming Fang
- From the Institute for Clinical Evaluative Sciences (D.J.G., J.F., A.L., M.P.L., J.V.T., F.L.S., M.K.K.), Toronto, Canada; Division of Neurology (D.J.G., E.B., F.L.S.), Department of Medicine (D.J.G., J.V.T.), Regional Stroke Centre and Neurosciences Program (D.J.G.), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Department of Medicine (A.L., J.V.T., F.L.S., M.K.K.), and the Department of Health Policy, Management and Evaluation (J.V.T., M.K.K.), University of Toronto,
| | - Andreas Laupacis
- From the Institute for Clinical Evaluative Sciences (D.J.G., J.F., A.L., M.P.L., J.V.T., F.L.S., M.K.K.), Toronto, Canada; Division of Neurology (D.J.G., E.B., F.L.S.), Department of Medicine (D.J.G., J.V.T.), Regional Stroke Centre and Neurosciences Program (D.J.G.), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Department of Medicine (A.L., J.V.T., F.L.S., M.K.K.), and the Department of Health Policy, Management and Evaluation (J.V.T., M.K.K.), University of Toronto,
| | - M. Patrice Lindsay
- From the Institute for Clinical Evaluative Sciences (D.J.G., J.F., A.L., M.P.L., J.V.T., F.L.S., M.K.K.), Toronto, Canada; Division of Neurology (D.J.G., E.B., F.L.S.), Department of Medicine (D.J.G., J.V.T.), Regional Stroke Centre and Neurosciences Program (D.J.G.), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Department of Medicine (A.L., J.V.T., F.L.S., M.K.K.), and the Department of Health Policy, Management and Evaluation (J.V.T., M.K.K.), University of Toronto,
| | - Jack V. Tu
- From the Institute for Clinical Evaluative Sciences (D.J.G., J.F., A.L., M.P.L., J.V.T., F.L.S., M.K.K.), Toronto, Canada; Division of Neurology (D.J.G., E.B., F.L.S.), Department of Medicine (D.J.G., J.V.T.), Regional Stroke Centre and Neurosciences Program (D.J.G.), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Department of Medicine (A.L., J.V.T., F.L.S., M.K.K.), and the Department of Health Policy, Management and Evaluation (J.V.T., M.K.K.), University of Toronto,
| | - Frank L. Silver
- From the Institute for Clinical Evaluative Sciences (D.J.G., J.F., A.L., M.P.L., J.V.T., F.L.S., M.K.K.), Toronto, Canada; Division of Neurology (D.J.G., E.B., F.L.S.), Department of Medicine (D.J.G., J.V.T.), Regional Stroke Centre and Neurosciences Program (D.J.G.), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Department of Medicine (A.L., J.V.T., F.L.S., M.K.K.), and the Department of Health Policy, Management and Evaluation (J.V.T., M.K.K.), University of Toronto,
| | - Moira K. Kapral
- From the Institute for Clinical Evaluative Sciences (D.J.G., J.F., A.L., M.P.L., J.V.T., F.L.S., M.K.K.), Toronto, Canada; Division of Neurology (D.J.G., E.B., F.L.S.), Department of Medicine (D.J.G., J.V.T.), Regional Stroke Centre and Neurosciences Program (D.J.G.), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; Department of Medicine (A.L., J.V.T., F.L.S., M.K.K.), and the Department of Health Policy, Management and Evaluation (J.V.T., M.K.K.), University of Toronto,
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Abstract
Clinical trials and observational studies provide evidence for a wide range of interventions of proven value for preventing a first or recurrent stroke. The available data indicate that strategies for primordial, primary and secondary stroke prevention are not being optimally implemented. Although specific estimates are difficult to calculate, the impact of improving the use of the wide array of effective stroke preventive interventions would be substantial.
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Affiliation(s)
- Larry B Goldstein
- Department of Medicine Neurology, Center for Cerebrovascular Disease, Center for Clinical Health Policy Research, Duke University and Durham VA Medical Center, Durham, NC 27710, USA.
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Abstract
Background and Purpose—
In this study, linked, anonymous data from The National Hospital Discharge Register and the Swedish Prescribed Drug Register were used for studying to what extent recommended drugs for secondary prevention after stroke and TIA were purchased by patients in the region of Stockholm, Sweden (2 million inhabitants).
Methods—
Data on purchased drugs for secondary stroke prevention during July 2005 to June 2006 by 17 902 patients >18 years discharged after stroke or TIA during the period 1997 to June 2005 were analyzed by age, gender, and year of discharge.
Results—
Antiplatelets and warfarin were purchased by 87% of all stroke and 83% of all TIA patients, antihypertensives by 74% and 70%, and lipid lowering drugs by 41% and 39%, respectively.
Conclusion—
Time after discharge had only a minor influence on the proportion of patients purchasing the medicines.
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Affiliation(s)
- Björn Wettermark
- From the Division of Clinical Pharmacology, Department of Laboratory Medicine (B.W.), and the Division of Neurology, Department of Clinical Neuroscience (M.v.E.), Karolinska Institutet, Stockholm, Sweden; and the Department of Pharmaceutical Biosciences, Faculty of Pharmacy (A.P.), Uppsala University, Uppsala, Sweden
| | - Anna Persson
- From the Division of Clinical Pharmacology, Department of Laboratory Medicine (B.W.), and the Division of Neurology, Department of Clinical Neuroscience (M.v.E.), Karolinska Institutet, Stockholm, Sweden; and the Department of Pharmaceutical Biosciences, Faculty of Pharmacy (A.P.), Uppsala University, Uppsala, Sweden
| | - Mia von Euler
- From the Division of Clinical Pharmacology, Department of Laboratory Medicine (B.W.), and the Division of Neurology, Department of Clinical Neuroscience (M.v.E.), Karolinska Institutet, Stockholm, Sweden; and the Department of Pharmaceutical Biosciences, Faculty of Pharmacy (A.P.), Uppsala University, Uppsala, Sweden
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Short-term outcome of patients with cardiac- and thrombo-embolic cerebral infarcts. Clin Neurol Neurosurg 2008; 110:566-9. [PMID: 18378388 DOI: 10.1016/j.clineuro.2008.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2007] [Revised: 02/08/2008] [Accepted: 02/18/2008] [Indexed: 11/23/2022]
Abstract
OBJECTIVES It has already been demonstrated by previous studies that patients suffering from a cardiac-embolic stroke (CES) have a worse outcome than those with a thrombo-embolic stroke (TES). Many factors, such as age, initial stroke severity, stroke recurrence and vascular risk factors have been quoted as a possible explanation. The present retrospective study re-investigates more in detail which variables are the most important to explain the difference in disability between patients with CES and with TES on hospital discharge. PATIENTS AND METHODS Seven hundred forty-two consecutive patients with a territorial infarct were admitted to the Stroke Unit of the Ghent University Hospital between October 2002 and June 2007. The groups of CES and TES consisted, respectively of 283 and of 459 patients. Age, gender, vascular risk factors including previous strokes and pacemaker implantation, initial stroke severity and outcome, determined by the mean modified Rankin (mR) scale on hospital discharge, were compared between both groups. RESULTS Although the hospital stay of the patients with CES and TES was quite similar, the former group was much older with more females, more vascular risk factors, worse neurological deficit on admission and more disability on discharge. On logistic regression analysis coronary artery disease, isolated atrial fibrillation and cardiac valve disorder appear as independent predictors of stroke outcome. CONCLUSION The worse outcome in the CES patients is mainly due to the cardiac status of the patients.
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Campbell CL, Steinhubl SR. Atrial fibrillation in the setting of acute myocardial infarction--irregularly irregular treatment. Am Heart J 2008; 155:197-9. [PMID: 18215586 DOI: 10.1016/j.ahj.2007.10.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2007] [Accepted: 10/25/2007] [Indexed: 11/24/2022]
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Savage M, Teeling M, Bennett K, Feely J. Adherence to clinical guidance in the prescribing of oral antithrombotic medication in patients with atrial fibrillation. Ir J Med Sci 2007; 175:46-9. [PMID: 16872029 DOI: 10.1007/bf03167949] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Atrial fibrillation is the commonest cardiac rhythm disturbance and is an independent risk factor for stroke; however, use of oral antithrombotic therapy is reported to be suboptimal in clinical practice. AIM The aim of the study was to evaluate the prescribing rates of oral antithrombotic therapy in patients with atrial fibrillation to determine if prescribing patterns reflected published clinical guidance. METHOD Patients with atrial fibrillation, admitted to hospital over a 12-week period were identified and their antithrombotic therapy regimen was analysed using statistical methods. RESULTS Although 87/100 patients identified were prescribed OAT, the regimen was suboptimal in 35 patients. Patients aged 75 years and older were more likelyto be receiving suboptimal oral antithrombotic treatment compared with younger patients CONCLUSIONS The benefits and suitability of oral antithrombotic therapy for patients of all ages need to be more comprehensively communicated to prescribers.
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Affiliation(s)
- M Savage
- Dept of Pharmacology and Therapeutics, Trinity Centre for Health Sciences, St James's Hospital, Dublin
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