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Barkhordarian M, Montazerin SM, Tran HHV, Amin T, Frishman WH, Aronow WS. Atrial Fibrillation and Cognitive Disorders. Cardiol Rev 2024:00045415-990000000-00280. [PMID: 38814075 DOI: 10.1097/crd.0000000000000733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
The prevalence of atrial fibrillation among older adults is increasing. Research has indicated that atrial fibrillation is linked to cognitive impairment disorders such as Alzheimer and vascular dementia, as well as Parkinson disease. Various mechanisms are believed to be shared between atrial fibrillation and cognitive impairment disorders. The specific pathologies and mechanisms of different cognitive disorders are still being studied. Potential mechanisms include cerebral hypoperfusion, ischemic or hemorrhagic infarction, and cerebrovascular reactivity to carbon dioxide. Additionally, circulatory biomarkers and certain infectious organisms appear to be involved. This review offers an examination of the overlapping epidemiology between atrial fibrillation and cognitive disorders, explores different cognitive disorders and their connections with this arrhythmia, and discusses trials and guidelines for preventing and treating atrial fibrillation in patients with cognitive disorders. It synthesizes existing knowledge on the management of atrial fibrillation and identifies areas that require further investigation to bridge the gap in understanding the complex relationship between dementia and atrial fibrillation.
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Affiliation(s)
- Maryam Barkhordarian
- From the Department of Internal Medicine, Hackensack Meridian Health- Palisades Medical Center, North Bergen, NJ
| | - Sahar Memar Montazerin
- Department of Internal Medicine, New York Medical College, Saint Michael Medical Center, Newark, NJ
| | - Hadrian Hoang-Vu Tran
- From the Department of Internal Medicine, Hackensack Meridian Health- Palisades Medical Center, North Bergen, NJ
| | - Toka Amin
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital, New York, NY
| | | | - Wilbert S Aronow
- Department of Medicine, New York Medical College, Valhalla, NY
- Departments of Cardiology and Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
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Presta R, Brunetti E, Polidori MC, Bo M. Impact of frailty models on the prescription of oral anticoagulants and on the incidence of stroke, bleeding, and mortality in older patients with atrial fibrillation: a systematic review. Ageing Res Rev 2022; 82:101761. [PMID: 36270605 DOI: 10.1016/j.arr.2022.101761] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/30/2022] [Accepted: 10/14/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Frailty is common in older patients with atrial fibrillation (AF). Current guidelines recommend oral anticoagulant therapy (OAT) except in case of severe frailty or reduced life expectancy, but definitive evidence on which "frailty" tools may help to identify older AF patients expected to derive little or no benefit from OAT is still lacking. Some persistent uncertainties may derive from the different clinical implications that the two major models of frailty, namely the frail phenotype (FP) and the deficit accumulation model (DAM), underlie. We thus conducted a systematic review of published studies to examine the association of the presence of frailty, categorized according to the FP and DAM, with 1) OAT prescription and 2) incidence of clinical outcomes (all-cause mortality, stroke and/or systemic embolism and major or clinically relevant non-major bleeding) in patients receiving OAT. METHODS Embase and MEDLINE were searched from inception until May 31st, 2022, for studies using a validated tool to identify frailty in subjects aged 65 years or older with a diagnosis of non-valvular AF; only studies on patients prescribed an OAT were considered eligible for the analyses involving clinical outcomes. The protocols for each review question have been registered in PROSPERO database (CRD42022308623 and CRD42022308628). FINDINGS Twenty-three studies exploring the association between frailty and OAT prescription on a total of 504 719 subjects were included. Patients with increasing severity of DAM frailty showed consistently lower OAT prescription rates than non-frail patients, whereas use of OAT did not significantly differ between patients with the FP compared with non-frail subjects. Eleven studies exploring the association between frailty and clinical outcomes on a total of 41 985 individuals receiving oral anticoagulation were included. Compared with non-frail subjects, a higher risk of all-cause mortality and clinical outcomes could be observed for AF patients prescribed with OAT with severe frailty according to the DAM, with inconclusive findings for the FP. High levels of heterogeneity were observed in both groups of studies; therefore, a meta-analysis was not performed. CONCLUSIONS Due to the great heterogeneity among different validated frailty measures, indiscriminately relying on "frailty" should not be regarded as the gold standard for clinical decision-making about stroke prevention in older AF patients. Present findings suggest that severe frailty according to the DAM is associated with less use of OAT and increased risk of all-cause mortality, thereby representing at the moment the most reasonable tool to efficiently recognize patients with limited life expectancy and for whom there is so far scant, if any, evidence of a clinical benefit of OAT.
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Affiliation(s)
- Roberto Presta
- Section of Geriatrics, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Molinette, Corso Bramante 88-90, 10126 Turin, Italy.
| | - Enrico Brunetti
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; Section of Internal Medicine, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Sant'Anna, Corso Bramante 88-90, 10126 Turin, Italy.
| | - Maria Cristina Polidori
- Ageing Clinical Research, Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937 Cologne, Germany; Cologne Excellence Cluster On Cellular Stress-Responses in Aging-Associated Diseases (CECAD), University of Cologne, Faculty of Medicine and University Hospital Cologne, Joseph-Stelzmann Straße 26, 50931 Cologne, Germany.
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Molinette, Corso Bramante 88-90, 10126 Turin, Italy.
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Wilkinson C, Todd O, Clegg A, Gale CP, Hall M. Management of atrial fibrillation for older people with frailty: a systematic review and meta-analysis. Age Ageing 2019; 48:196-203. [PMID: 30445608 PMCID: PMC6424377 DOI: 10.1093/ageing/afy180] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 09/18/2018] [Accepted: 10/24/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND despite a large and growing population of older people with frailty and atrial fibrillation (AF), there is a lack of guidance on optimal AF management in this high-risk group. OBJECTIVE to synthesise the existing evidence base on the association between frailty, AF and clinical outcomes. METHODS a systematic review of studies examining the association between validated measures of frailty, AF and clinical outcomes, and meta-analysis of the association between frailty and oral anticoagulation (OAC) prescription. RESULTS twenty studies (30,883 patients) were included, all observational. Fifteen were in hospital, four in the community, one in nursing care. Risk of bias was low-to-moderate. AF prevalence was 3%-38%. In people with AF, frailty was associated with increased stroke incidence, all-cause mortality, symptom severity and length of hospital stay.Meta-analysis of six studies showed frailty was associated with decreased OAC prescription at hospital admission (pooled adjusted OR 0.45 [95%CI 0.22-0.93], three studies), but not at discharge (pooled adjusted OR 0.40 [95%CI 0.13-1.23], three studies). A community-based study showed increased OAC prescription associated with frailty (OR 2.33 [95%CI 1.03-5.23]). CONCLUSION frailty is common, and associated with adverse clinical outcomes in patients with AF. There is evidence of an association between frailty status and OAC prescription, with different direction of effect in community compared with hospital cohorts. Despite the majority of care for older people being provided in the community, there is a lack of evidence on the association between frailty, AF, anticoagulation and clinical outcomes to guide optimal care in this setting.
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Affiliation(s)
- Chris Wilkinson
- Department of Clinical and Population Sciences, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Worsley Building, Level 11, Clarendon Way, Leeds, UK
- York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, UK
| | - Oliver Todd
- Academic Unit of Eldery Care and Rehabilitation, Bradford Institute for Health Research, University of Leeds, Bradford Royal Infirmary, Duckworth Lane, Bradford, UK
| | - Andrew Clegg
- Academic Unit of Eldery Care and Rehabilitation, Bradford Institute for Health Research, University of Leeds, Bradford Royal Infirmary, Duckworth Lane, Bradford, UK
| | - Chris P Gale
- Department of Clinical and Population Sciences, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Worsley Building, Level 11, Clarendon Way, Leeds, UK
- York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, UK
| | - Marlous Hall
- Department of Clinical and Population Sciences, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Worsley Building, Level 11, Clarendon Way, Leeds, UK
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Lunde ED, Nielsen PB, Riahi S, Larsen TB, Lip GYH, Fonager K, Larsen ML, Joensen AM. Associations between socioeconomic status, atrial fibrillation, and outcomes: a systematic review. Expert Rev Cardiovasc Ther 2018; 16:857-873. [PMID: 30293472 DOI: 10.1080/14779072.2018.1533118] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 10/01/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a growing epidemic and evidence of a relationship to socioeconomic status (SES) is inconsistent. We aimed to summarize the literature about SES and AF and defined two objectives: (1) To examine the association between SES and the risk of AF; (2) To examine the association between SES and AF-related outcomes in an AF-population. METHODS We performed a separate search for each objective in Ovid-MEDLINE and Ovid-Embase. For objective 1, the population included was healthy participants and outcome of interest was AF. For objective 2, the population included were patients with AF and outcome of interest was mortality, treatment, ablation for AF, knowledge about AF, and morbidity. RESULTS For objective 1, 12 studies were included. No consistent pattern for an association between SES and the risk of AF was discovered. For objective 2, 39 studies comprising 42 outcomes were included. The majority of studies showed an association between low SES and increased mortality and morbidity. CONCLUSION Low SES was associated with poorer outcomes when AF was present. These findings may imply that health-care professionals and policy interventions should focus on the promotion of AF-education and management among patients with AF and low SES.
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Affiliation(s)
| | - Peter Brønnum Nielsen
- a Department of Cardiology , Aalborg University Hospital , Aalborg , Denmark
- b Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health , Aalborg University , Aalborg , Denmark
| | - Sam Riahi
- a Department of Cardiology , Aalborg University Hospital , Aalborg , Denmark
- c Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
- d Atrial Fibrillation Study Group , Aalborg University Hospital , Aalborg , Denmark
| | - Torben Bjerregaard Larsen
- a Department of Cardiology , Aalborg University Hospital , Aalborg , Denmark
- b Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health , Aalborg University , Aalborg , Denmark
- d Atrial Fibrillation Study Group , Aalborg University Hospital , Aalborg , Denmark
| | - Gregory Y H Lip
- b Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health , Aalborg University , Aalborg , Denmark
- e Institute of Cardiovascular Sciences , University of Birmingham , UK
| | - Kirsten Fonager
- c Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
- f Department of Social Medicine , Aalborg University Hospital , Aalborg , Denmark
| | - Mogens Lytken Larsen
- a Department of Cardiology , Aalborg University Hospital , Aalborg , Denmark
- c Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
- g Danish Centre of Inequality in Health, Department of Cardiology , Aalborg University Hospital , Aalborg , Denmark
| | - Albert Marni Joensen
- a Department of Cardiology , Aalborg University Hospital , Aalborg , Denmark
- c Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
- d Atrial Fibrillation Study Group , Aalborg University Hospital , Aalborg , Denmark
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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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Abstract
Greater use of evidence-based therapies has improved outcomes for patients with acute coronary syndromes (ACS) in recent decades. Consequently, more ACS patients are surviving beyond 12 months; however, limited data exist to guide treatment in these patients. Long-term outcomes have not improved in non-ST-segment elevation myocardial infarction (NSTEMI) patients at the same rate seen in ST-segment elevation myocardial infarction patients, possibly reflecting NSTEMI patients’ more complex clinical phenotype, including older age, greater burden of comorbidities and higher likelihood of a previous myocardial infarction (MI). This complexity impacts clinical decision-making, particularly in high-risk NSTEMI patients, in whom risk–benefit assessments are problematical. This review examines the need for more effective long-term management of NSTEMI patients who survive ≥12 months after MI. Ongoing risk assessment using objective measures of risk (for bleeding and ischemia) should be used in all post-MI patients. While 12 months appears to be the optimal duration of dual antiplatelet therapy for most patients, this may not be the case for high-risk patients, and more research is urgently needed in this population. A recent subgroup analysis from the DAPT study in patients with or without MI who had undergone coronary stenting (31 % presented with MI; 53 % had NSTEMI) and the prospective PEGASUS-TIMI 54 trial in patients with a prior MI and at least one other risk factor (40 % had NSTEMI) demonstrated that long-term dual antiplatelet therapy improved cardiovascular outcomes but increased bleeding. Further studies will help clarify the role of dual antiplatelet therapy in stable post-NSTEMI patients.
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Mazzone A, Bo M, Lucenti A, Galimberti S, Bellelli G, Annoni G. The role of comprehensive geriatric assessment and functional status in evaluating the patterns of antithrombotic use among older people with atrial fibrillation. Arch Gerontol Geriatr 2016; 65:248-54. [DOI: 10.1016/j.archger.2016.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 04/11/2016] [Accepted: 04/12/2016] [Indexed: 10/21/2022]
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Real-world characteristics of hospitalized frail elderly patients with atrial fibrillation: can we improve the current prescription of anticoagulants? JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2016; 13:226-32. [PMID: 27103917 PMCID: PMC4826892 DOI: 10.11909/j.issn.1671-5411.2016.03.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND In elderly patients, especially those older than 80 years, atrial fibrillation (AF) is associated with an almost 25% increased risk of stroke. Stroke prophylaxis with anticoagulants is therefore highly recommended. The prevalence of factors that have been associated with a lower rate of prescription and adherence to anticoagulant therapy in these patients is little known. The objective of this study was to explore the clinical characteristics of elderly subjects, with and without AF, consecutively admitted to an acute geriatric unit, discussing factors that may decrease the persistence on stroke prophylaxis therapy. We also highlight possible strategies to overcome the barriers conditioning the current underuse of oral anticoagulants in this segment of the population. METHODS A retrospective observational study was performed on a cohort of elderly patients with and without AF admitted to the Acute Geriatric Unit of San Gerardo Hospital (Monza, Italy). RESULTS Compared to patients without AF (n = 1216), those with AF (n = 403) had a higher Charlson Comorbidity Index (3 vs. 2, P < 0.001), number of administered drugs (4 vs. 3, P < 0.001), rate of heart failure (36.5% vs. 12%, P < 0.001) and chronic kidney disease (20.6 vs. 13.2, P < 0.001). Many patients with AF were frail (54%) or pre-frail (29%). CONCLUSIONS Elderly patients with AF have higher rates of conditions that affect adherence to traditional anticoagulant therapy (vitamin K antagonists, VKA). New direct oral anticoagulants (DOAs) can help overcome this problem. In order to prescribe the most appropriate VKA or DOAs, with the best efficacy/safety profile and the highest compliance, a comprehensive geriatric assessment should always accompany the scores for thrombotic and hemorrhagic risk stratification.
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Mavaddat N, Roalfe A, Fletcher K, Lip GY, Hobbs FR, Fitzmaurice D, Mant J. Warfarin Versus Aspirin for Prevention of Cognitive Decline in Atrial Fibrillation. Stroke 2014; 45:1381-6. [DOI: 10.1161/strokeaha.113.004009] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Nahal Mavaddat
- From the Primary Care Unit, Strangeways Laboratory, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom (N.M., J.M.); Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom (A.R., K.F., D.F.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); and Department of Primary Care Health Sciences, New Radcliffe House, Radcliffe Observatory Quarter, University
| | - Andrea Roalfe
- From the Primary Care Unit, Strangeways Laboratory, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom (N.M., J.M.); Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom (A.R., K.F., D.F.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); and Department of Primary Care Health Sciences, New Radcliffe House, Radcliffe Observatory Quarter, University
| | - Kate Fletcher
- From the Primary Care Unit, Strangeways Laboratory, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom (N.M., J.M.); Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom (A.R., K.F., D.F.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); and Department of Primary Care Health Sciences, New Radcliffe House, Radcliffe Observatory Quarter, University
| | - Gregory Y.H. Lip
- From the Primary Care Unit, Strangeways Laboratory, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom (N.M., J.M.); Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom (A.R., K.F., D.F.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); and Department of Primary Care Health Sciences, New Radcliffe House, Radcliffe Observatory Quarter, University
| | - F.D. Richard Hobbs
- From the Primary Care Unit, Strangeways Laboratory, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom (N.M., J.M.); Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom (A.R., K.F., D.F.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); and Department of Primary Care Health Sciences, New Radcliffe House, Radcliffe Observatory Quarter, University
| | - David Fitzmaurice
- From the Primary Care Unit, Strangeways Laboratory, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom (N.M., J.M.); Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom (A.R., K.F., D.F.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); and Department of Primary Care Health Sciences, New Radcliffe House, Radcliffe Observatory Quarter, University
| | - Jonathan Mant
- From the Primary Care Unit, Strangeways Laboratory, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom (N.M., J.M.); Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom (A.R., K.F., D.F.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); and Department of Primary Care Health Sciences, New Radcliffe House, Radcliffe Observatory Quarter, University
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Cadiou G, Adam M, Caussin M, Landrin I, Mariette N, Capet C, Mouton-Schleifer D, Remy E, Kadri N, Doucet J. Antiplatelet drugs in the elderly: prescriptions often inappropriate and reduced tolerance by associated diseases and drugs. Fundam Clin Pharmacol 2011; 26:307-13. [PMID: 21241362 DOI: 10.1111/j.1472-8206.2010.00915.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
To assess the conditions of prescriptions and tolerance of antiplatelet drugs (APD) in the elderly and to detail the parameters that influence the tolerance of these drugs. Prospective survey in a Department of Geriatric Medicine. Two hundred nineteen patients 70 years and older treated with one or two APD prior to admission were included during 7 months in 2008. We recorded the type of APD, associated diseases, main associated or co-prescribed drugs which could interact with APD and the bleeding adverse events including cutaneous bleeding. The mean age of the 219 patients was 84.5 ± 6.7 years (70-101 years), women 59.4%. Among patients 64.8% received aspirin (mainly 75 mg), 28.3% received clopidogrel and 6.8% received their combination; 16.9% of prescriptions were off-label; 51.6% of patients had an associated disease and/or an associated drug which could have increased risk of bleeding event. Among the patients who received a gastric-protective drug, the prescription followed the recommendations of the French Health Authority in 38.9%. We recorded bleeding events in 24.2% of patients at admission and in 18.3% of patients during the hospitalization. Bleeding events were significantly more frequent in patients treated with aspirin than clopidogrel (40.8 vs. 24.2%, P < 0.05) and/or with an associated drug (OR = 2.36, 95% CI 1.34-4.14, P < 0.01) and/or an associated disease (OR = 1.22, 95% CI 1.01-3.42, P < 0.05). APD treatment was stopped in 28.8% of patients, mainly because lack of indication or bleeding adverse events. Off-label prescriptions of APD were not rare in the elderly, and adverse events are frequent. The results of this preliminary study evoke that medical situations at increased risk of bleeding are perhaps insufficiently evaluated, either in case of prescription of associated drugs with increased bleeding risk or during the follow-up of patients with associated diseases. Cutaneous bleeding events should be more taken into account in prospective studies.
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Affiliation(s)
- Gwénaëlle Cadiou
- Service de Médecine Interne Gériatrique, Centre Hospitalo-Universitaire de Rouen, Rouen University Hospital, Rouen F-76031, France
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Preventing serious sequelae after an acute coronary syndrome: the consequences of thrombosis versus bleeding with antiplatelet therapy. J Cardiovasc Pharmacol 2010; 55:585-94. [PMID: 20224426 DOI: 10.1097/fjc.0b013e3181d9f81f] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Acute coronary syndrome (ACS) is associated with a persistent prothrombotic state, placing patients at high risk of subsequent ischemic events. Guidelines recommend the use of dual antiplatelet therapy with aspirin + a thienopyridine (clopidogrel) for at least a year after ACS in most patients, except those who undergo coronary artery bypass grafting. Clinical studies demonstrate that this strategy significantly reduces the risk of ischemic events at the expense of a small increase in the risk of bleeding. Physicians must balance the risk of bleeding against the benefit of ischemia prevention, bearing in mind that ischemic events are generally more common than major bleeding and often associated with more catastrophic consequences or ongoing morbidity. The relationship between bleeding and mortality is complicated by the fact that many risk factors for bleeding are also those for mortality and that bleeding may lead to discontinuation of antiplatelet therapy, thereby increasing the risk for an ischemic event. Data suggest that physicians tend to overestimate the risk of bleeding and underestimate the risk of ischemia. Careful patient selection and thorough patient education are the keys to managing antiplatelet therapy after ACS, especially as newer more potent antiplatelet agents, such as prasugrel, become available.
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Tulner LR, Van Campen JPCM, Kuper IMJA, Gijsen GJPT, Koks CHW, Mac Gillavry MR, van Tinteren H, Beijnen JH, Brandjes DPM. Reasons for undertreatment with oral anticoagulants in frail geriatric outpatients with atrial fibrillation: a prospective, descriptive study. Drugs Aging 2010; 27:39-50. [PMID: 20030431 DOI: 10.2165/11319540-000000000-00000] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVES The main aims of the study were to explore whether oral anticoagulation (OAC) for atrial fibrillation (AF) in geriatric outpatients is prescribed in accordance with international (American College of Cardiology/American Heart Association/European Society of Cardiology [ACC/AHA/ESC]) and Dutch national guidelines for the general practitioner (GP) and to identify whether age and selected co-morbid conditions are associated with undertreatment. As a secondary objective, we wanted to establish how many patients discontinue OAC because of major bleeding. METHODS In 2004, at the first visit of all patients to the geriatric day clinic of the Slotervaart Hospital in Amsterdam, the Netherlands, demographic data, Mini-Mental State Examination score, medical history, Charlson Comorbidity Index score, and data on medication use and changes were documented. The presence of AF was established by assessment of medical history information obtained by the GP, the history taken from patients and their caregivers, and the results of clinical evaluation, including ECG findings. Associations between the use of OAC, demographic data and co-morbid conditions registered in the Dutch NHG (Nederlands Huisartsen Genootschap [Dutch College of General Practitioners]) standard for GPs as risk factors for stroke or contraindications to the use of OAC were analysed. The reasons for discontinuing OAC were assessed after 4 years by requesting the information from the anticoagulation services or the GP. RESULTS At the time of the initial visit, 17.5% of the 807 outpatients had chronic AF (n = 135) or were known to have paroxysmal AF (n = 6). The mean age of the 141 patients in this cohort was 84.3 years (SD 6.2 years). Co-morbid conditions increasing the risk of stroke were present in 129 patients (91.5%). Contraindications to the use of OAC were observed in 118 patients (83.7%). Of the 116 patients with AF in their history before their visit, 57.8% were being treated with OAC at the time of their visit. After comprehensive geriatric assessment, 73 (51.8%) of the 141 patients with chronic or paroxysmal AF were continued on OAC. Of the 141 patients with chronic or paroxysmal AF, 110 (78.0%) had both extra stroke risk factors and contraindications to the use of OAC. Only increasing age was significantly and independently associated with not being prescribed anticoagulants (p < 0.001). At the 4-year follow-up, OAC had been discontinued in 5.5% of patients because of major bleeding; three patients (4.1%) taking OAC had died as a result of major bleeding, and one other patient had discontinued treatment because of a major, non-lethal bleeding episode. CONCLUSION Applying the NHG standard for appropriate prescription, and disregarding age as a risk factor or contraindication, in this population, 14 of 141 patients (9.9%) were inappropriately prescribed OAC, salicylates or no prophylaxis. Since only patient age was associated with not prescribing OAC in this study, higher age still seems to be considered the most important contraindication to anticoagulation therapy. Implementation of better models for stratifying bleeding risk in the frail elderly is needed. After 4 years, the cumulative rate of bleeding causing discontinuation of anticoagulation therapy in this usual-care study of frail older patients was not alarmingly higher than in other usual-care studies.
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Affiliation(s)
- Linda R Tulner
- Department of Geriatric Medicine, Slotervaart Hospital, Louwesweg 6, 1066 EC Amsterdam, The Netherlands.
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