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Stuby J, Haschke M, Tritschler T, Aujesky D. Oral anticoagulant therapy in older adults. Thromb Res 2024; 238:1-10. [PMID: 38636204 DOI: 10.1016/j.thromres.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 03/06/2024] [Accepted: 04/11/2024] [Indexed: 04/20/2024]
Abstract
Patients aged ≥65 years not only account for the majority of patients with atrial fibrillation (AF) and venous thromboembolism (VTE), they are also at a higher risk of morbidity, mortality, and undertreatment than younger patients. Several age-related physiological changes with effects on drug pharmacokinetics/-dynamics and blood vessel fragility as well as the higher prevalence of geriatric conditions such as frailty, multimorbidity, polypharmacy, fall risk, dementia, and malnutrition make older persons more vulnerable to disease- and anticoagulation-related complications. Moreover, because older patients with AF/VTE are underrepresented in oral anticoagulation (OAC) trials, evidence on OAC in older adults with AF/VTE is mainly based on subgroup analyses from clinical trials and observational studies. A growing body of such limited evidence suggests that direct oral anticoagulants (DOACs) may be superior in terms of efficacy and safety compared to vitamin K antagonists in older persons with AF/VTE and that specific DOACs may have a differing risk-benefit profile. In this narrative review, we summarize the evidence on epidemiology of AF/VTE, impact of age-related physiological changes, efficacy/safety of OAC, specifically considering individuals with common geriatric conditions, and review OAC guideline recommendations for older adults with AF/VTE. We also propose a research agenda to improve the evidence basis on OAC older individuals with AF/VTE, including the conduct of advanced age-specific and pragmatic studies using less restrictive eligibility criteria and patient-reported health outcomes, in order to compare the effectiveness and safety of different DOACs, and investigate lower-dose regimens and optimal OAC durations in older patients.
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Affiliation(s)
- J Stuby
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - M Haschke
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Clinical Pharmacology & Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - T Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - D Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
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Corica B, Romiti GF, Proietti M. NOACs in Atrial Fibrillation Patients with Polypharmacy. Thromb Haemost 2024; 124:149-151. [PMID: 37989205 DOI: 10.1055/s-0043-1776900] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Affiliation(s)
- Bernadette Corica
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Translational and Precision Medicine, Sapienza-University of Rome, Rome, Italy
| | - Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Translational and Precision Medicine, Sapienza-University of Rome, Rome, Italy
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
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Slater N, White S, Frisher M. Polypharmacy in atrial fibrillation: A prospective analysis of mortality and ischemic stroke using the Clinical Practice Research Datalink. J Arrhythm 2024; 40:47-56. [PMID: 38333403 PMCID: PMC10848617 DOI: 10.1002/joa3.12961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/16/2023] [Accepted: 11/07/2023] [Indexed: 02/10/2024] Open
Abstract
Background Observational studies of polypharmacy and the risk of death or stroke in individuals with atrial fibrillation (AF) have produced inconsistent findings. By using propensity score matching (PSM) and Cox regression, this study aimed to determine whether polypharmacy (five to nine medicines) in the 3 months following AF diagnosis, is associated with an increased risk of death or ischemic stroke, compared to non-polypharmacy (one to four medicines). Methods A prospective cohort study using data from the Clinical Practice Research Datalink (2006-2019). Data from 23 629 individuals with AF were analyzed. Cox regression models were adjusted for age, gender, morbidities, obesity, alcohol, smoking, and wealth. In the PSM models, cases and controls with near identical health profiles were selected from the study pool. The risk of death and stroke were presented as hazard ratios (HRs) with 95% confidence intervals (CIs). Results 68.9% (n = 16 271) of the participants had polypharmacy. PSM showed that polypharmacy was associated with an increased risk of death during follow-up (HR 1.32; 95% CI: 1.19-1.47, p < .01), but not ischemic stroke (HR 0.84; 95% CI: 0.69-1.02, p = .08). Conclusion Polypharmacy was associated with an increased risk of death during follow-up, but not ischemic stroke, in individuals with AF. The effects of comorbidity and other confounding factors were reduced by using PSM. This study focused on the overall medication burden; however, further research is needed to identify which specific medications in polypharmacy regimens increase the risk of mortality in AF. These findings could inform prescribing practices in the future.
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Affiliation(s)
- Natasha Slater
- School of Pharmacy and Bioengineering Keele University Staffordshire UK
| | - Simon White
- School of Pharmacy and Bioengineering Keele University Staffordshire UK
| | - Martin Frisher
- School of Pharmacy and Bioengineering Keele University Staffordshire UK
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Zheng Y, Li S, Liu X, Lip GYH, Guo L, Zhu W. Effect of Oral Anticoagulants in Atrial Fibrillation Patients with Polypharmacy: A Meta-analysis. Thromb Haemost 2023. [PMID: 37399842 DOI: 10.1055/s-0043-1770724] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
BACKGROUND The aim of the present meta-analysis was to evaluate the effectiveness and safety of non-vitamin K antagonist oral anticoagulants (NOACs) versus vitamin K antagonists (VKAs) in atrial fibrillation (AF) patients with polypharmacy. METHODS AND RESULTS Randomized controlled trials or observational studies reporting the data of NOACs versus VKAs among AF patients with polypharmacy were included. The search was performed in the PubMed and Embase databases up to November 2022. A total of 12 studies involving 767,544 AF patients were included. For the primary outcomes, the use of NOACs compared with VKAs was significantly associated with a reduced risk of stroke or systemic embolism in AF patients with moderate polypharmacy (hazard ratio [HR]: 0.77 [95% confidence interval [CI]: 0.69-0.86]) and severe polypharmacy (HR: 0.76 [95% CI: 0.69-0.82]), but there was no significant difference in major bleeding (moderate polypharmacy: HR: 0.87 [95% CI: 0.74-1.01]; severe polypharmacy: HR: 0.91 [95% CI: 0.79-1.06]) between the two groups. In secondary outcomes, there were no differences in the rates of ischemic stroke, all-cause death, and gastrointestinal bleeding between the NOAC- and VKA- users, but NOAC users had a reduced risk of any bleeding compared with VKA- users. Compared with VKAs, the risk of intracranial hemorrhage was reduced in NOAC- users with moderate polypharmacy but not severe polypharmacy. CONCLUSION In patients with AF and polypharmacy, NOACs showed advantages over VKAs in stroke or systemic embolism and any bleeding, and were comparable to VKAs for major bleeding, ischemic stroke, all-cause death, intracranial hemorrhage, and gastrointestinal bleeding.
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Affiliation(s)
- Yuxiang Zheng
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Siyuan Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao Liu
- Department of Cardiology, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Linjuan Guo
- Department of Cardiology, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang of Jiangxi, China
| | - Wengen Zhu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
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Martínez-Montesinos L, Rivera-Caravaca JM, Agewall S, Soler E, Lip GYH, Marín F, Roldán V. Polypharmacy and adverse events in atrial fibrillation: Main cause or reflection of multimorbidity? Biomed Pharmacother 2023; 158:114064. [PMID: 36495662 DOI: 10.1016/j.biopha.2022.114064] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/24/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Previous evidence indicated that atrial fibrillation (AF) patients with polypharmacy presented increased probability of adverse events. We investigated the prevalence of polypharmacy, risk factors for polypharmacy, and the impact of polypharmacy in clinical outcomes in a 'real-world' cohort of AF patients starting vitamin K antagonists (VKAs). METHODS Prospective study including AF outpatients starting VKA therapy from July, 2016 to June, 2018. At inclusion, all concomitant drugs were carefully collected and recorded. Polypharmacy was defined as the intake of ≥ 5 concomitant drugs. During 2-years of follow-up, ischemic strokes/transient ischemic attacks (TIAs), fatal/nonfatal myocardial infarctions (MIs), bleeding events, venous thromboembolisms, and all-cause deaths were recorded. RESULTS 1050 patients (51.5 % females, median age 77 [69-83] years) were included, and the prevalence of polypharmacy was 32.9 % (345). Female sex (OR 1.5; 95 % CI 1.11-2.03), hypertension (OR 2.53; 95 % CI 1.51-4.22), diabetes (OR 3.11; 95 % CI 2.31-4.17), vascular disease (OR 3.08; 95 % CI 2.19-4.33), heart failure (OR 1.86; 95 % CI 1.35-2.58) and dyslipidemia (OR 2.61; 95 % CI 1.9-3.58) were independently associated to the polypharmacy. Patients with polypharmacy showed significantly higher incidence of major bleeding, net clinical outcomes (composite of major bleeding, ischemic stroke/TIA, and mortality), MACE (composite of ischemic stroke/TIA, MI, and cardiovascular death), and composite thrombotic/thromboembolic events; being an independent risk factor for major bleeding (HR 1.77, 95 % CI 1.07-2.92), and composite thrombotic/thromboembolic events (HR 1.55, 95 % CI 1.05-2.31). CONCLUSION In this "real world" AF cohort, polypharmacy was highly prevalent and conditioned worse prognosis due to its association with bleeding and thromboembolic events.
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Affiliation(s)
- Lorena Martínez-Montesinos
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - José Miguel Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain; Faculty of Nursing, University of Murcia, Murcia, Spain; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
| | - Stefan Agewall
- Department of Cardiology, Oslo University Hospital, Ullevål and University of Oslo, Faculty of Medicine, Institute of Clinical Medicine, Oslo, Norway
| | - Eva Soler
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Denmark
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
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Polypharmacy and Major Adverse Events in Atrial Fibrillation. J Cardiovasc Pharmacol 2022; 80:826-831. [PMID: 35921643 DOI: 10.1097/fjc.0000000000001339] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 07/02/2022] [Indexed: 12/13/2022]
Abstract
ABSTRACT Patients with atrial fibrillation (AF) often receive multiple medications daily. The purpose of this study was to examine the prognostic implications of polypharmacy in patients with AF. This is a retrospective post hoc analysis of 1113 AF patients, enrolled in a randomized trial during an acute hospitalization (MISOAC-AF, NCT02941978). The presence of polypharmacy (use of >4 drugs daily) was assessed at hospital discharge. Regression analyses were performed to identify clinical predictors of polypharmacy and compare the outcomes of patients with or without confirmed polypharmacy. The coprimary outcomes were all-cause and cardiovascular (CV) mortality. Among patients with polypharmacy, the difference in the risk of mortality was also assessed per each added drug as a numeric variable. Polypharmacy was found in 36.9% of participants. Dyslipidemia, coronary artery disease, lower left ventricular ejection fraction, and higher glomerular filtration rates were independent predictors of polypharmacy. Polypharmacy was an independent predictor for all-cause death (adjusted hazard ratio [aHR]: 1.29, 95% confidence interval [CI]: 1.01-1.64) and CV death (aHR: 1.39, 95% CI: 1.05-1.84). Among patients with polypharmacy, each additional concomitant medication was independently associated with a 4% increased risk of all-cause mortality (aHR = 1.04, 95% CI: 1.00-1.08) and a 5% increased risk of CV mortality (aHR = 1.05, 95% CI: 1.00-1.10). Polypharmacy was common among patients with AF hospitalized in a tertiary hospital and was incrementally associated with higher rates of mortality.
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Wang J, Yang YM, Zhu J, Zhang H, Shao XH. Multimorbidity and Polypharmacy in Chinese Emergency Department Patients With Atrial Fibrillation and Impacts on Clinical Outcomes. Front Cardiovasc Med 2022; 9:806234. [PMID: 35155632 PMCID: PMC8831736 DOI: 10.3389/fcvm.2022.806234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/06/2022] [Indexed: 11/21/2022] Open
Abstract
Background and Objects Few studies focus on multimorbidity and polypharmacy in Chinese atrial fibrillation (AF) patients. We examined the impact of multimorbidity, polypharmacy, and treatment strategies on outcomes in Chinese emergency department (ED)AF patients. We also assessed factors associated with vitamin K antagonist (VKA) non-use in AF patients with multimorbidity or polypharmacy. Methods 2015 AF patients who presented to emergency department (ED) were enrolled from Nov 2008 to Oct 2011, mean follow-up of 12-months. Cox regressions were performed to identify the impact of multimorbidity and polypharmacy on clinical outcomes. Results Six hundred and sixty-five patients in low morbidity group (≤1 comorbidity), 608 patients in moderate morbidity group (2 comorbidities), 742 patients in high morbidity group (≥3 comorbidities). Five hundred and seventy patients (28.3%) had polypharmacy (≥5 medications). High and moderate morbidity groups were significantly associated with a higher risk of all-cause death (HR 2.083, 95%CI 1.482–2.929; HR 1.713, 95%CI 1.198–2.449), CV death (HR 2.457, 95%CI 1.526–3.954; HR 1.974, 95%CI 1.206–3.232) and major bleeding (HR 4.126, 95%CI 1.022–16.664; HR 6.142, 95%CI 1.6789–22.369) compared with low morbidity group. In VKA subgroup, only high morbidity group was associated with a higher risk of all-cause death (HR 2.521, 95%CI 1.482–2.929), but not significantly in other events. For polypharmacy category, there were no significant statistics among these endpoints. Coronary artery disease (CAD), hypertension, chronic obstructive pulmonary disease, and antiplatelet therapy were independent predictors for VKA non-use in whole cohort, and patients with multimorbidity. CAD and antiplatelet therapy were independent predictors for VKA non-use in patients with polypharmacy. Conclusion Multimorbidity was associated with worse outcomes in Chinese ED AF patients. Polypharmacy showed no significant statistics among these outcomes. CAD and antiplatelet therapy were independent risk factors of VKA non-use in Chinese ED AF patients with multimorbidity or polypharmacy.
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Laliberté F, Ashton V, Kharat A, Lejeune D, Moore KT, Jung Y, Lefebvre P, Berger JS. Economic burden of rivaroxaban and warfarin among nonvalvular atrial fibrillation patients with obesity and polypharmacy. J Comp Eff Res 2021; 10:1235-1250. [PMID: 34378989 DOI: 10.2217/cer-2021-0150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Evaluate healthcare resource utilization (HRU) and costs associated with rivaroxaban and warfarin among nonvalvular atrial fibrillation (NVAF) patients with obesity and polypharmacy. Materials & methods: IQVIA PharMetrics® Plus (January 2010-September 2019) data were used to identify NVAF patients with obesity (BMI ≥30 kg/m2) and polypharmacy (≥5 medications) initiated on rivaroxaban or warfarin. Weighted rate ratios and cost differences were evaluated post-treatment initiation. Results: Rivaroxaban was associated with significantly lower rates of HRU, including hospitalization (rate ratio [95% CI]: 0.83 [0.77, 0.92]). Medical costs were reduced in rivaroxaban users (difference [95% CI]: -US$6868 [-US$10,628, -US$2954]), resulting in significantly lower total healthcare costs compared with warfarin users (difference [95% CI]: -US$4433 [-US$8136, -US$582]). Conclusion: Rivaroxaban was associated with lower HRU and costs compared with warfarin among NVAF patients with obesity and polypharmacy in commercially insured US patients.
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Affiliation(s)
| | | | - Akshay Kharat
- Janssen Scientific Affairs, LLC, Titusville, NJ 08560, USA
| | | | | | - Young Jung
- Groupe d'analyse Ltée, Montréal, QC H3B 0G7, Canada
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Berger JS, Laliberté F, Kharat A, Lejeune D, Moore KT, Jung Y, Lefebvre P, Ashton V. Comparative Effectiveness and Safety of Rivaroxaban and Warfarin Among Nonvalvular Atrial Fibrillation (NVAF) Patients with Obesity and Polypharmacy in the United States (US). Adv Ther 2021; 38:3771-3788. [PMID: 34031859 PMCID: PMC8280049 DOI: 10.1007/s12325-021-01746-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 04/13/2021] [Indexed: 12/19/2022]
Abstract
Introduction Current evidence indicates that rivaroxaban may be a safe and effective alternative to warfarin among patients with nonvalvular atrial fibrillation (NVAF) and obesity. However, evidence regarding the impact of polypharmacy is limited in this population. The present study evaluated the effectiveness and safety of rivaroxaban versus warfarin among NVAF patients with obesity and polypharmacy in the US. Methods De-identified health insurance claims data from the IQVIA PharMetrics® Plus data (01/2010–09/2019) were used to identify NVAF patients with obesity (BMI ≥ 30 kg/m2) and polypharmacy (≥ 5 medications) initiated on rivaroxaban or warfarin. Inverse probability of treatment weighting (IPTW) was used to adjust for imbalances between groups. Study outcomes were evaluated up to 36 months post-treatment initiation and included the composite of stroke or systemic embolism (stroke/SE) and major bleeding. Subgroup analyses were conducted stratified by polypharmacy category (5–9 or ≥ 10 medications). Outcomes were assessed using Cox proportional hazards regression models with hazard ratios (HR) and 95% confidence intervals (CIs). Results A total of 7000 and 3920 NVAF patients with obesity and polypharmacy were initiated on rivaroxaban and warfarin, respectively. At 36 months of follow-up, rivaroxaban was associated with a 29% lower risk of stroke/SE relative to warfarin (HR 0.71, 95% CI 0.57, 0.90). Major bleeding risk was not significantly different among rivaroxaban- compared to warfarin-treated patients (HR 0.85, 95% CI 0.70, 1.03). Subgroup analyses yielded results that were largely consistent with the overall polypharmacy analysis. Conclusions These results suggest that rivaroxaban is an effective and safe treatment option among NVAF patients with obesity and polypharmacy in a commercially-insured US population. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01746-2.
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Affiliation(s)
- Jeffrey S Berger
- New York University School of Medecine, New York, NY, 10016, USA
| | | | - Akshay Kharat
- Janssen Scientific Affairs, LLC, Titusville, NJ, 08560, USA
| | | | | | - Young Jung
- Groupe d'analyse Ltée, Montréal, QC, H3B 0G7, Canada
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Clinical Impact of the Time in Therapeutic Range on Early Hospital Readmission in Patients with Acute Heart Failure Treated with Oral Anticoagulation in Internal Medicine. ACTA ACUST UNITED AC 2021; 57:medicina57040365. [PMID: 33918627 PMCID: PMC8069311 DOI: 10.3390/medicina57040365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/27/2021] [Accepted: 04/07/2021] [Indexed: 11/17/2022]
Abstract
Background and objectives: Patients with heart failure (HF) often present with non-valvular atrial fibrillation and require oral anticoagulation with coumarin anticoagulants such as acenocoumarol. The objective of this study was to evaluate the relationship between time in therapeutic range (TTR) and the risk of early readmission. Materials and Methods: A retrospective descriptive study was carried out on hospitalized patients with a diagnosis of HF between 2014 and 2018 who had adverse effects due to oral anticoagulation with acenocoumarol (underdosing, overdosing, or hemorrhage). Clinical, analytical, therapeutic, and prognostic variables were collected. TTR is defined as the duration of time in which the patient’s International Normalized Ratio (INR) values were within a desired range. Early readmission was defined as readmission within 30 days after hospital discharge. Patients were divided into two groups depending on whether or not they had a TTR less than 60% (TTR < 60%) over the 6 months prior to the adverse event. Results: In the cohort of 304 patients, the mean age was 82 years, 59.9% of the patients were female, and 54.6% had a TTR < 60%. Patients with TTR < 60% had a higher HAS-BLED score (4.04 vs. 2.59; p < 0.001) and INR (6 vs. 5.31; p < 0.05) but lower hemoglobin (11.67 vs. 12.22 g/dL; p < 0.05). TTR < 60% was associated with early readmission after multivariate analysis (OR: 2.05 (CI 95%: 1.16–3.61)). They also had a higher percentage of hemorrhagic events and in-hospital mortality but without reaching statistical significance. Conclusions: Patients with HF and adverse events due to acenocoumarol often have poor INR control, which is independently associated with a higher risk of early readmission.
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Kleibert KRU, Hermann EF, Nunes PL, Schneider A, Stumm EMF, Colet CDF. Polimedicação em usuários de varfarina sódica do Sistema Único de Saúde e variáveis associadas. REVISTA CIÊNCIAS EM SAÚDE 2020. [DOI: 10.21876/rcshci.v10i2.900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Objetivo: Verificar o uso da polimedicação em usuários de varfarina e sua associação com variáveis clínicas. Métodos: estudo transversal, com usuários de varfarina, de ambos os sexos. Para a coleta dos dados foi utilizado questionário estruturado, com perguntas abertas e fechadas, sobre dados socioeconômicos, clínicos e aspectos relacionados à farmacoterapia (reações adversas, interações medicamentosas, índices de pressão arterial sistêmica, valores de glicemia de jejum, prática de automedicação, sobrepeso, episódios de sangramento e de tromboembolismo). Resultados: a média de idade dos participantes foi de 69,1 ± 13,6 anos, maioria do sexo feminino (64,6%), casado (43,8%), e de etnia branca (85,4%). Quanto a escolaridade, 41,7% cursaram ensino fundamental incompleto. Os pacientes polimedicados totalizaram 89,6%, e os pacientes em uso de dez ou mais medicamentos, 31,3%. A média de medicamentos foi 8,2 ± 3,5 fármacos/paciente. Ocorreu associação entre polimedicação, ocorrência de reações adversas (94,7% vs 5,3%; p = 0,042) e o número de potenciais interações medicamentosas, totais (8,9 ± 5,0 vs 1,2 ± 1,6; p = 0,001) e graves (3,1 ± 2,4 vs 0,4 ± 0,6; p = 0,017). As demais variáveis estudadas não foram associadas com a polimedicação. Conclusão: os resultados demonstraram interferência negativa da polimedicação na ocorrência de reações adversas, e nas potenciais interações medicamentosas totais e graves. Há necessidade de conhecer o impacto destas variáveis no paciente anticoagulado polimedicado para o planejamento de estratégias de redução de riscos e para a otimização dos benefícios.
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Gallagher C, Nyfort-Hansen K, Rowett D, Wong CX, Middeldorp ME, Mahajan R, Lau DH, Sanders P, Hendriks JM. Polypharmacy and health outcomes in atrial fibrillation: a systematic review and meta-analysis. Open Heart 2020; 7:e001257. [PMID: 32509316 PMCID: PMC7254112 DOI: 10.1136/openhrt-2020-001257] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/26/2020] [Accepted: 03/03/2020] [Indexed: 01/27/2023] Open
Abstract
Objective To undertake a systematic review and meta-analysis examining the impact of polypharmacy on health outcomes in atrial fibrillation (AF). Data sources PubMed and Embase databases were searched from inception until 31 July 2019. Studies including post hoc analyses of prospective randomised controlled trials or observational design that examined the impact of polypharmacy on clinically significant outcomes in AF including mortality, hospitalisations, stroke, bleeding, falls and quality of life were eligible for inclusion. Results A total of six studies were identified from the systematic review, with three studies reporting on common outcomes and used for a meta-analysis. The total study population from the three studies was 33 602 and 37.2% were female. Moderate and severe polypharmacy, defined as 5–9 medicines and >9 medicines, was observed in 42.7% and 20.7% of patients respectively, and was associated with a significant increase in all-cause mortality (Hazard ratio [HR] 1.36, 95% CI 1.20 to 1.54, p<0.001; HR 1.84, 95% CI 1.40 to 2.41, p<0.001, respectively), major bleeding (HR 1.32, 95% CI 1.14 to 1.52, p<0.001; HR 1.68, 95% CI 1.35 to 2.09, p<0.001, respectively) and clinically relevant non-major bleeding (HR 1.12, 95% CI 1.03 to 1.22, p<0.01; HR 1.48, 95% CI 1.33 to 1.64, p<0.01, respectively). There was no statistically significant association between polypharmacy and stroke or systemic embolism or intracranial bleeding. Among other examined outcomes, polypharmacy was associated with cardiovascular death, hospitalisation, reduced quality of life and poorer physical function. Conclusions Polypharmacy is highly prevalent in the AF population and is associated with numerous adverse outcomes. PROSPERO registration number CRD42018105298.
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Affiliation(s)
- Celine Gallagher
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Karin Nyfort-Hansen
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Debra Rowett
- School of Pharmacy and Medical Sciences, University of South Australia and Drug and Therapeutics Information Service, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Christopher X Wong
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Melissa E Middeldorp
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Rajiv Mahajan
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jeroen M Hendriks
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
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13
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Sirois C, Simard M, Gosselin E, Gagnon ME, Roux B, Laroche ML. Mixed Bag “Polypharmacy”: Methodological Pitfalls and Challenges of This Exposure Definition. CURR EPIDEMIOL REP 2019. [DOI: 10.1007/s40471-019-00214-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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