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Kaiser JH, Zhang C, Kamel H, Navi BB, Razzak J, Liberman AL. Stroke Risk After Emergency Department Treat-and-Release Visit for a Fall. Stroke 2024; 55:2247-2253. [PMID: 38994584 PMCID: PMC11382293 DOI: 10.1161/strokeaha.124.046988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 06/18/2024] [Accepted: 06/24/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Previous cohort studies of hospitalized patients with a delayed diagnosis of ischemic stroke found that these patients often had an initial emergency department (ED) diagnosis of a fall. We sought to evaluate whether ED visits for a fall resulting in discharge to home (ie, treat-and-release visits) were associated with increased short-term ischemic stroke risk. METHODS A case-crossover design was used to compare ED visits for falls during case periods (0-15, 16-30, 31-90, and 91-180 days before stroke) and control periods (equivalent time periods exactly 1 year before stroke) using administrative data from the Healthcare Cost and Utilization Project on all hospital admissions and ED visits across 10 states from 2016 to 2020. To identify ED treat-and-release visits for a fall and patients hospitalized for acute ischemic stroke, we used previously validated International Classification of Diseases, Tenth Revision, Clinical Modification codes. Odds ratios and 95% CIs were calculated using conditional logistic regression. RESULTS Among 90 592 hospitalized patients with ischemic stroke, 5230 (5.8%) had an ED treat-and-release visit for a fall within 180 days before their stroke. Patients with an ED treat-and-release visit for a fall were older (mean age, 74.7 [SD, 14.6] versus 70.8 [SD, 15.1] years), more often female (61.9% versus 53.4%), and had higher rates of vascular comorbidities than other patients with stroke. ED treat-and-release visits for a fall were significantly more common in the 15 days before stroke compared with the 15-day control period 1 year earlier (odds ratio, 2.7 [95% CI, 2.4-3.1]). The association between stroke and a preceding ED treat-and-release visit for a fall decreased in magnitude with increasing temporal distance from stroke. CONCLUSIONS ED treat-and-release visits for a fall are associated with significantly increased short-term ischemic stroke risk. These visits may be opportunities to improve stroke diagnostic accuracy and treatment in the ED.
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Affiliation(s)
- Jed H Kaiser
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute (J.H.K., C.Z., H.K., B.B.N., A.L.L.), Weill Cornell Medicine, New York, NY
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute (J.H.K., C.Z., H.K., B.B.N., A.L.L.), Weill Cornell Medicine, New York, NY
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute (J.H.K., C.Z., H.K., B.B.N., A.L.L.), Weill Cornell Medicine, New York, NY
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute (J.H.K., C.Z., H.K., B.B.N., A.L.L.), Weill Cornell Medicine, New York, NY
| | - Junaid Razzak
- Department of Emergency Medicine (J.R.), Weill Cornell Medicine, New York, NY
| | - Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute (J.H.K., C.Z., H.K., B.B.N., A.L.L.), Weill Cornell Medicine, New York, NY
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Brunetti E, Presta R, Okoye C, Filippini C, Raspo S, Bruno G, Marabotto M, Monzani F, Bo M. Predictors and Outcomes of Oral Anticoagulant Deprescribing in Geriatric Inpatients With Atrial Fibrillation: A Retrospective Multicenter Cohort Study. J Am Med Dir Assoc 2024; 25:545-551.e4. [PMID: 38359897 DOI: 10.1016/j.jamda.2024.01.011] [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: 07/18/2023] [Revised: 11/28/2023] [Accepted: 01/11/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE To investigate prevalence and predictors of oral anticoagulant therapy (OAT) deprescribing in older inpatients with atrial fibrillation (AF), and its association with 1-year incidence of major clinical outcomes. DESIGN Multicenter retrospective cohort study. SETTING AND PARTICIPANTS Inpatients aged ≥75 years with known AF on OAT at admission discharged from 3 Italian acute geriatric wards between January 2014 and July 2018. METHODS Data from a routine Comprehensive Geriatric Assessment (CGA), along with OAT status at discharge were recorded. One-year incidence of all-cause death, stroke or systemic embolism (SSE), and major and clinically relevant nonmajor bleeding (MB/CRNMB) were retrieved from administrative databases. Associations were explored through multilevel analysis. RESULTS Among 1578 patients (median age 86 years, 56.3% female), OAT deprescription (341 patients, 21.6%) was associated with bleeding risk, functional dependence and cognitive impairment, and inversely, with previous SSE and chronic AF. Incidences of death, SSE, and MB/CRNMB were 56.6%, 1.5%, and 4.1%, respectively, in OAT-deprescribed patients, and 37.6%, 2.9%, and 4.9%, respectively, in OAT-continued patients, without significant differences between groups. OAT deprescription was associated with all-cause mortality [adjusted odds ratio (aOR) 1.41, 95% CI 1.68-1.85], along with older age, comorbidity burden, cognitive impairment, and functional dependence, but with neither SSE nor MB/CRNMB incidence, as opposed to being alive and free from SSE and MB/CNRMB, respectively (aOR 0.68, 95% CI 0.25-1.82, and aOR 0.95 95% CI 0.49-1.85, respectively). Conversely, OAT deprescription was associated with higher odds of being dead than alive both in patients free from SSE and in those free from MB/CRNMB. CONCLUSIONS AND IMPLICATIONS CGA-based OAT deprescribing is common in acute geriatric wards and is not associated with increased SSE. The net clinical benefit of OAT in geriatric patients is strongly related with the competing risk of death, suggesting that functional and cognitive status, as well as residual life expectancy, should be considered in clinical decision making in this population.
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Affiliation(s)
- Enrico Brunetti
- Geriatrics Unit, Department of Medical Sciences, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Roberto Presta
- Geriatrics Unit, Department of Medical Sciences, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Chukwuma Okoye
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy; University of Milano-Bicocca, School of Medicine and Surgery, Milan, Italy
| | | | - Silvio Raspo
- Geriatrics Unit, Hospital Santa Croce e Carle, Cuneo, Italy
| | - Gerardo Bruno
- Geriatrics Unit, Hospital Santa Croce e Carle, Cuneo, Italy
| | | | - Fabio Monzani
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Mario Bo
- Geriatrics Unit, Department of Medical Sciences, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
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Nagaratnam SA, Edwards L, Blair C, Evans J, O'Brien W. Functional outcomes of patients with ischaemic stroke with known atrial fibrillation not on therapeutic anticoagulation. Intern Med J 2023; 53:1987-1993. [PMID: 36872853 DOI: 10.1111/imj.16044] [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: 12/05/2022] [Accepted: 02/07/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Anticoagulation significantly reduces the risk of ischaemic stroke in patients with atrial fibrillation (AF). There are a proportion of patients with known AF who remain off anticoagulation. Aims This study aims to retrospectively compare the baseline characteristics, treatments and functional outcomes between patients with ischaemic stroke and known AF based on their anticoagulation status. METHODS A single-centre, retrospective review of consecutive patients with an ischaemic stroke and a known history of AF was conducted. RESULTS Two hundred four patients with an ischaemic stroke had documented AF prior to the index admission, of which 126 were anticoagulated. Median admission National Institutes of Health Stroke Scale score was lower for anticoagulated patients, though not statistically significant (5.1 vs 7.0, P = 0.09). Median baseline modified Rankin score (mRS) did not significantly differ. Nonanticoagulated patients were more likely to have large vessel occlusions (37.2% vs 23.8%, P = 0.04) and more likely to receive intravenous thrombolysis (15.4% vs 1.6%, P < 0.01). There was no difference in rates of endovascular clot retrieval between groups (P > 0.05). Unfavourable functional outcome at 90 days (mRS ≥ 3) did not significantly differ between groups (P = 0.51). A total of 38.5% of nonanticoagulated patients had no documented reason for this. Of the patients who survived the index admission, 81.5% of patients who were not anticoagulated on admission received anticoagulation. CONCLUSIONS Baseline anticoagulation was associated with milder stroke severity in ischaemic stroke patients with known AF. There was no significant difference in functional outcomes at 90 days between groups. Larger observational studies are required to further assess this cohort.
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Affiliation(s)
- Sai A Nagaratnam
- Department of Neurology, Gosford Hospital, Gosford, New South Wales, Australia
| | - Leon Edwards
- Department of Neurology, Gosford Hospital, Gosford, New South Wales, Australia
| | - Christopher Blair
- Department of Neurology, Gosford Hospital, Gosford, New South Wales, Australia
| | - James Evans
- Department of Neurology, Gosford Hospital, Gosford, New South Wales, Australia
| | - William O'Brien
- Department of Neurology, Gosford Hospital, Gosford, New South Wales, Australia
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Lee KH, Chen YF, Yeh WY, Yeh JT, Yang TH, Chou CY, Chang YL, Wang WT, Chiang CE, Chen CH, Cheng HM. Optimal stroke preventive strategy for patients aged 80 years or older with atrial fibrillation: a systematic review with traditional and network meta-analysis. Age Ageing 2022; 51:6931851. [PMID: 36571776 DOI: 10.1093/ageing/afac292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND An optimal antithrombotic strategy for patients aged 80 years or older with atrial fibrillation (AF) remains elusive. OBJECTIVE Using a systematic review with traditional and network meta-analysis, we investigated outcomes in AF patients ≥80 years treated with different antithrombotic strategies. METHODS We searched eligible randomised controlled trials (RCTs) and observational studies from MEDLINE, EMBASE, Cochrane Library and Web of Science databases from inception to 16 December 2021. Research comparing treatment outcomes of novel oral anticoagulants (NOACs), aspirin, vitamin K antagonists (VKAs) or no oral anticoagulant/placebo therapy in patients ≥80 years with AF were included. Outcomes were stroke or systemic embolism (SSE), major bleeding, all-cause mortality, intracranial bleeding (ICH) and gastrointestinal bleeding. Traditional and network meta-analyses were performed. Net clinical benefit integrating SSE and major bleeding was calculated. RESULTS Fifty-three studies were identified for analysis. In the meta-analysis of RCTs, risk of SSE (risk ratio [RR]: 0.82; 95% confidence interval [CI]: 0.73-0.99) and ICH (RR: 0.38; 95% CI: 0.28-0.52) was significantly reduced when NOACs were compared with VKAs. Network meta-analysis of RCTs demonstrated that edoxaban (P-score: 0.8976) and apixaban (P-score: 0.8528) outperformed other antithrombotic therapies by showing a lower major bleeding risk and better net clinical benefit. Both traditional and network meta-analyses from RCTs combining with observational studies showed consistent results. CONCLUSIONS In patients aged 80 years or older with AF, NOACs have better outcomes than VKAs regarding efficacy and safety profiles. Edoxaban and apixaban may be preferred treatment options since they are safer than other antithrombotic strategies.
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Affiliation(s)
- Kun-Han Lee
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ying-Fan Chen
- Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yu Yeh
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Division of Evidence-based Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jiunn-Tyng Yeh
- Department of Internal Medicine, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Tzu-Han Yang
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chian-Ying Chou
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Pharmacy, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yuh-Lih Chang
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Pharmacy, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department and Institute of Pharmacology, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Ting Wang
- Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chern-En Chiang
- School of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan.,General Clinical Research Center, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chen-Huan Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan.,Institute of Public Health, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan
| | - Hao-Min Cheng
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Division of Evidence-based Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan.,Institute of Public Health, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan
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Kapoor A, Patel J, Chen Z, Crawford S, McManus D, Gurwitz J, Shireman TI, Zhang N. Geriatric conditions do not predict stroke or bleeding in long-term care residents with atrial fibrillation. J Am Geriatr Soc 2021; 70:1218-1227. [PMID: 34902164 DOI: 10.1111/jgs.17605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 11/05/2021] [Accepted: 11/13/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Long-term care (LTC) providers prescribe anticoagulation (AC) less frequently in residents with atrial fibrillation (AF) and geriatric conditions independent of CHA2 DS2 -VASc stroke risk score. Geriatric conditions include recent fall, activities of daily living dependency, mobility impairment, cognitive impairment, low body mass index, and weight loss. Multiple publications have suggested that patients with geriatric conditions are at increased risk for stroke. Understanding better the risk of stroke and bleeding in residents with AF and geriatric conditions would be valuable to LTC providers for AC decision-making. METHODS AND RESULTS We measured the association of geriatric conditions with composite of stroke/transient ischemic attack (TIA)/systemic embolism and bleeding in residents with AF and elevated stroke risk (CHA2 DS2 -VASc score ≥ 2) living in American LTC facilities in 2015. After merging nursing home assessments (Minimum Data Set) with medication and hospital utilization records, we identified 209,413 eligible residents. Using generalized estimating equations, we found that the incidence of stroke/TIA/systemic embolism ranged from 0.13% to 0.26% over 30 days (1.43%-3.08%/year) in residents off AC with and without geriatric conditions adjusting for other resident characteristics including CHA2 DS2 -VASc score and propensity to receive AC. Similarly, the monthly incidence of bleeding on AC ranged from 0.22% to 0.28% (2.61%-3.31%/year) without increased risk with geriatric conditions. Residents with a CHA2 DS2 -VASc score of ≥7 had a 2.4-fold increased risk of stroke compared with those with score of 2-4 (0.30% vs. 0.12%/month). CONCLUSION Calculating a CHA2 DS2 -VASc score can be helpful in AC decision-making for residents with and without geriatric conditions.
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Affiliation(s)
- Alok Kapoor
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Jay Patel
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Zhiyong Chen
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA.,Zem Data Science, LLC, North Potomac, Maryland, USA
| | - Sybil Crawford
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - David McManus
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Jerry Gurwitz
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Theresa I Shireman
- Department of Health Services, Policy and Practice, Center for Gerontology & Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Ning Zhang
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Health Policy and Promotion, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, USA
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6
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Zhang N, Patel J, Chen Z, Zhou Y, Crawford S, McManus DD, Gurwitz J, Shireman TI, Kapoor A. Geriatric Conditions Are Associated With Decreased Anticoagulation Use in Long-Term Care Residents With Atrial Fibrillation. J Am Heart Assoc 2021; 10:e021293. [PMID: 34387127 PMCID: PMC8475043 DOI: 10.1161/jaha.121.021293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Anticoagulation is the mainstay for stroke prevention in patients with atrial fibrillation, but concerns about bleeding inhibit its use in residents of long‐term care facilities. Risk‐profiling algorithms using comorbid disease information (eg, CHADS2 and ATRIA [Anticoagulation and Risk Factors in Atrial Fibrillation]) have been available for years. In the long‐term care setting, however, providers and residents may place more value on geriatric conditions such as mobility impairment, activities of daily living dependency, cognitive impairment, low body mass index, weight loss, and fall history. Methods and Results Using a retrospective cohort design, we measured the association between geriatric conditions and anticoagulation use and type. After merging nursing home assessments containing information about geriatric conditions (Minimum Data Set 2015) with Medicare Part A 2014 to 2015 claims and prescription claims (Medicare Part D) 2015 to 2016, we identified 228 741 residents with atrial fibrillation and elevated stroke risk (CHA2DS2‐VASc score ≥2) for our main analysis. Recent fall, activities of daily living dependency, moderate and severe cognitive impairment, low body mass index, and unintentional weight loss were all associated with lower anticoagulation use even after adjustment for multiple predictors of stroke and bleeding (odds ratios ranging from 0.51 to 0.91). Residents with recent fall, low body mass index, and unintentional weight loss were more likely to be using a direct oral anticoagulant, although the magnitude of this effect was smaller. Conclusions Geriatric conditions were associated with lower anticoagulation use. Preventing stroke in these residents with potential for further physical and cognitive impairment would appear to be of paramount significance, although the net benefit of anticoagulation in these individuals warrants further research.
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Affiliation(s)
- Ning Zhang
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,Department of Health Policy and Promotion School of Public Health and Health Sciences University of Massachusetts Amherst Amherst MA
| | - Jay Patel
- University of Massachusetts Medical School Worcester MA
| | - Zhiyong Chen
- University of Massachusetts Medical School Worcester MA.,Zem Data Science North Potomac MD
| | - Yanhua Zhou
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,University of Massachusetts Medical School Worcester MA
| | - Sybil Crawford
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,University of Massachusetts Medical School Worcester MA
| | - David D McManus
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,University of Massachusetts Medical School Worcester MA
| | - Jerry Gurwitz
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,University of Massachusetts Medical School Worcester MA
| | - Theresa I Shireman
- Department of Health Services, Policy and Practice Center for Gerontology & Healthcare Research School of Public Health Brown University Providence RI
| | - Alok Kapoor
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,University of Massachusetts Medical School Worcester MA
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Abstract
The prevalence of atrial fibrillation (AF) increases with age, as does the proportion of patients with frailty. AF patients with frailty have a higher risk of stroke than those without frailty, and progressive frailty caused by stroke is also associated with a worse prognosis. Despite this, anticoagulant therapy tends to not be used in frail patients because of the risk of falls and bleeding complications. However, some studies have shown that anticoagulant therapy improves the prognosis in patients with frailty. An accurate assessment of the "net-clinical-benefits" is needed in patients with frailty, with the aim of improving the prognoses of patients with frailty by selecting those who will benefit from anticoagulant therapy and actively reducing the risk of bleeding. A comprehensive intervention that includes a team of doctors and social resources is required. We herein review the effectiveness and bleeding risk associated with anticoagulant therapy in frail patients investigated in clinical studies.
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Affiliation(s)
- Hiroshi Hori
- Division of General Medicine, Department of Comprehensive Medicine 1, Saitama Medical Center, Jichi Medical University, Japan
| | - Takahiko Fukuchi
- Division of General Medicine, Department of Comprehensive Medicine 1, Saitama Medical Center, Jichi Medical University, Japan
| | - Hitoshi Sugawara
- Division of General Medicine, Department of Comprehensive Medicine 1, Saitama Medical Center, Jichi Medical University, Japan
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8
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Abstract
Effective stroke prevention with oral anticoagulation (OAC) is the cornerstone of the management of patients with atrial fibrillation. The use of OAC reduces the risk of stroke and death. For most patients with atrial fibrillation without moderate or severe mitral valve stenosis or prosthetic mechanical heart valves, treatment options include vitamin K antagonists, such as warfarin, and non-vitamin K antagonist oral anticoagulants (NOACs). Although most guidelines generally recommend NOACs as the first-line OAC, caution is required in some groups of patients with atrial fibrillation at high risk of stroke and bleeding who have been under-represented or not studied in the randomized clinical trials on NOACs for stroke prevention. In addition to OAC, non-pharmacological, percutaneous therapies, including left atrial appendage occlusion, for stroke prevention have emerged, sometimes used in combination with catheter ablation for the treatment of the atrial fibrillation. High-risk groups of patients with atrial fibrillation include patients with end-stage renal failure (including those receiving dialysis), extremely old patients (such as those aged >80 years with multiple risk factors for bleeding), patients with dementia or those living in a long-term care home, patients with previous intracranial bleeding or recent acute bleeding (such as gastrointestinal bleeding), patients with acute ischaemic stroke and patients with an intracardiac thrombus. This Review provides an overview of stroke prevention strategies, including left atrial appendage occlusion, in patients with atrial fibrillation at high risk of stroke and bleeding.
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Shah SJ, Fang MC, Jeon SY, Gregorich SE, Covinsky KE. Geriatric Syndromes and Atrial Fibrillation: Prevalence and Association with Anticoagulant Use in a National Cohort of Older Americans. J Am Geriatr Soc 2020; 69:349-356. [PMID: 32989731 DOI: 10.1111/jgs.16822] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/14/2020] [Accepted: 08/16/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although guidelines recommend focusing primarily on stroke risk to recommend anticoagulants in atrial fibrillation (AF), physicians report that geriatric syndromes (e.g., falls and disability) are important when considering anticoagulants. Little is known about the prevalence of geriatric syndromes in older adults with AF or the association with anticoagulant use. METHODS We performed a cross-sectional analysis of the 2014 Health and Retirement Study, a nationally representative study of older Americans. Participants were asked questions to assess domains of aging, including function, cognition, and medical conditions. We included participants 65 years and older with 2 years of continuous Medicare enrollment who met AF diagnosis criteria by claims codes. We examined five geriatric syndromes: one or more falls within the last 2 years, receiving help with activities of daily living (ADLs) or instrumental ADLs (IADL), experienced incontinence, and cognitive impairment. We determined the prevalence of geriatric syndromes and their association with anticoagulant use, adjusting for ischemic stroke risk (i.e., CHA2 DS2 -VASc score [congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, and sex]). RESULTS In this study of 779 participants with AF (median age = 80 years; median CHA2 DS2 -VASc score = 4), 82% had one or more geriatric syndromes. Geriatric syndromes were common: 49% reported falls, 38% had ADL impairments, 42% had IADL impairments, 37% had cognitive impairments, and 43% reported incontinence. Overall, 65% reported anticoagulant use; guidelines recommend anticoagulant use for 97% of participants. Anticoagulant use rate decreased for each additional geriatric syndrome (average marginal effect = -3.7%; 95% confidence interval = -1.4% to -5.9%). Lower rates of anticoagulant use were reported in participants with ADL dependency, IADL dependency, and dementia. CONCLUSION Most older adults with AF had at least one geriatric syndrome, and geriatric syndromes were associated with reduced anticoagulant use. The high prevalence of geriatric syndromes may explain the lower than expected anticoagulant use in older adults.
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Affiliation(s)
- Sachin J Shah
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Margaret C Fang
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sun Y Jeon
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Steven E Gregorich
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Kenneth E Covinsky
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
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Grymonprez M, Steurbaut S, De Backer TL, Petrovic M, Lahousse L. Effectiveness and Safety of Oral Anticoagulants in Older Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis. Front Pharmacol 2020; 11:583311. [PMID: 33013422 PMCID: PMC7509201 DOI: 10.3389/fphar.2020.583311] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/20/2020] [Indexed: 12/17/2022] Open
Abstract
Background and Objective Atrial fibrillation (AF), the most common cardiac arrhythmia, typically increases with age. Oral anticoagulants (OACs) are the cornerstone of treatment to reduce the associated risk for systemic thromboembolism. Four large randomized controlled trials (RCTs) have shown that non-vitamin K antagonist oral anticoagulants (NOACs) are non-inferior to vitamin K antagonists (VKAs) in preventing stroke and systemic embolism, as well as regarding their risk for major bleeding. However, as vulnerable geriatric patients with AF were largely underrepresented in these trials, physicians are faced with the challenge of choosing the right anticoagulant for geriatric patients in real-life clinical practice. In this vulnerable patient group, NOACs tend to be underused or underdosed due to concerns of excessive fall-related intracranial bleeding, cognitive impairment, multiple drug-drug interactions, low body weight or impaired renal function. As life expectancy continues to rise worldwide, the number of geriatric patients substantially increases. Therefore, there is an urgent need for a critical appraisal of the added value of NOACs in geriatric patients with AF at high thromboembolic and bleeding risk. Methods and Results This systematic review provides an overview of the literature on the impact of increased age (≥75 years), multimorbidity, polypharmacy, increased falling risk, frailty and dementia on the effectiveness and safety of NOACs as compared to VKAs, after searching the Medline database. Moreover, a meta-analysis on the impact of increased age ≥75 years old was performed after pooling results from 6 post hoc analyses of RCTs and 6 longitudinal observational cohort studies, highlighting the superior effectiveness (hazard ratio (HR) 0.83, 95% confidence interval (CI) [0.74–0.94] for stroke/SE; HR 0.77, 95%CI [0.65–0.92] for mortality) and non-inferior safety (HR 0.93, 95%CI [0.86–1.01] for major bleeding; HR 0.58, 95%CI [0.50–0.67] for intracranial bleeding; HR 1.17, 95%CI [0.99–1.38] for gastrointestinal bleeding) of NOACs versus VKAs in older AF patients. Conclusion Across geriatric subgroups, apixaban was consistently associated with the most favourable benefit-risk profile and should therefore be preferred in geriatric patients with AF. However, research gaps on the impact of increased falling risk, frailty and baseline dementia were identified, requiring careful consideration while awaiting more results.
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Affiliation(s)
- Maxim Grymonprez
- Pharmaceutical Care Unit, Department of Bioanalysis, Ghent University, Ghent, Belgium
| | - Stephane Steurbaut
- Centre for Pharmaceutical Research, Vrije Universiteit Brussel, Jette, Belgium
| | - Tine L De Backer
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Mirko Petrovic
- Department of Geriatrics, Ghent University Hospital, Ghent, Belgium
| | - Lies Lahousse
- Pharmaceutical Care Unit, Department of Bioanalysis, Ghent University, Ghent, Belgium.,Department of Epidemiology, Erasmus Medical Center, Rotterdam, Netherlands
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11
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Shih RD, Ouslander JG. Intracranial Hemorrhage in Older Adults: Implications for Fall Risk Assessment and Prevention. J Am Geriatr Soc 2020; 68:953-955. [PMID: 32142160 DOI: 10.1111/jgs.16399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/05/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Richard D Shih
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Joseph G Ouslander
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
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12
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Ouslander JG. Improving Drug Therapy for Patients With Life‐Limiting Illnesses: Letʼs Take Care of Some Low Hanging Fruit. J Am Geriatr Soc 2020; 68:682-685. [DOI: 10.1111/jgs.16395] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 02/03/2020] [Indexed: 01/07/2023]
Affiliation(s)
- Joseph G. Ouslander
- Clinical Biomedical Science Charles E. Schmidt College of Biomedical Science Boca Raton Florida
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