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Salbach C, Yildirim M, Hund H, Biener M, Müller‐Hennessen M, Frey N, Katus HA, Giannitsis E, Milles BR. Design, Rationale and Initial Findings From HERA-FIB on 10 222 Patients With Atrial Fibrillation Presenting to an Emergency Department Over An 11-Year Period. J Am Heart Assoc 2024; 13:e033396. [PMID: 38639359 PMCID: PMC11179873 DOI: 10.1161/jaha.123.033396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 03/21/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND For the majority of patients with atrial fibrillation (AF), disease management has improved in recent years. However, there are still populations underrepresented or excluded in current registries and randomized controlled trials. HERA-FIB (Heidelberg Registry of Atrial Fibrillation) was planned to assess real-world evidence for the prevalence, demographic characteristics and management of patients with the diagnosis of AF presenting consecutively to a chest pain unit. METHODS AND RESULTS HERA-FIB is a retrospective, observational, single-center study on patients with a diagnosis of AF presenting to a chest pain unit from June 2009 until March 2020. This article describes the structure, governance, outcome assessment, quality and data collection processes of the registry. Additionally, characteristics of populations of special interest are described. The study consecutively enrolled 10 222 patients presenting with AF to the chest pain unit of the University Hospital of Heidelberg. Clinical parameters and patient characteristics were assessed retrospectively. Outcome parameters included rates for all-cause death, stroke, myocardial infarction and major bleedings. We were able to investigate patient cohorts of special interest such as advanced chronic kidney disease, octogenarians, and those with acute coronary syndrome who are often underrepresented in current studies and randomized controlled trials. CONCLUSIONS HERA-FIB is one of the largest real-world single-center retrospective registries on patients with AF, which captures the era of transition from vitamin K antagonists to non-vitamin K oral anticoagulation regimens in clinical practice and offers the possibility to investigate patient populations usually underrepresented or excluded in current available randomized controlled trials and registries. REGISTRATION URL: https://www.clinicaltrials.gov; unique identifier: NCT05995561.
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Affiliation(s)
- Christian Salbach
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Mustafa Yildirim
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Hauke Hund
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Moritz Biener
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | | | - Norbert Frey
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Hugo A. Katus
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Evangelos Giannitsis
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Barbara Ruth Milles
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
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Camm AJ, Steffel J, Virdone S, Bassand JP, Fox KAA, Goldhaber SZ, Goto S, Haas S, Turpie AGG, Verheugt FWA, Misselwitz F, Herreros RC, Kayani G, Pieper KS, Kakkar AK. Guideline-directed medical therapies for comorbidities among patients with atrial fibrillation: results from GARFIELD-AF. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead051. [PMID: 37293139 PMCID: PMC10246824 DOI: 10.1093/ehjopen/oead051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/10/2023] [Accepted: 04/20/2023] [Indexed: 06/10/2023]
Abstract
Aims This study aimed to identify relationships in recently diagnosed atrial fibrillation (AF) patients with respect to anticoagulation status, use of guideline-directed medical therapy (GDMT) for comorbid cardiovascular conditions (co-GDMT), and clinical outcomes. The Global Anticoagulant Registry in the FIELD (GARFIELD)-AF is a prospective, international registry of patients with recently diagnosed non-valvular AF at risk of stroke (NCT01090362). Methods and results Guideline-directed medical therapy was defined according to the European Society of Cardiology guidelines. This study explored co-GDMT use in patients enrolled in GARFIELD-AF (March 2013-August 2016) with CHA2DS2-VASc ≥ 2 (excluding sex) and ≥1 of five comorbidities-coronary artery disease, diabetes mellitus, heart failure, hypertension, and peripheral vascular disease (n = 23 165). Association between co-GDMT and outcome events was evaluated with Cox proportional hazards models, with stratification by all possible combinations of the five comorbidities. Most patients (73.8%) received oral anticoagulants (OACs) as recommended; 15.0% received no recommended co-GDMT, 40.4% received some, and 44.5% received all co-GDMT. At 2 years, comprehensive co-GDMT was associated with a lower risk of all-cause mortality [hazard ratio (HR) 0.89 (0.81-0.99)] and non-cardiovascular mortality [HR 0.85 (0.73-0.99)] compared with inadequate/no GDMT, but cardiovascular mortality was not significantly reduced. Treatment with OACs was beneficial for all-cause mortality and non-cardiovascular mortality, irrespective of co-GDMT use; only in patients receiving all co-GDMT was OAC associated with a lower risk of non-haemorrhagic stroke/systemic embolism. Conclusion In this large prospective, international registry on AF, comprehensive co-GDMT was associated with a lower risk of mortality in patients with AF and CHA2DS2-VASc ≥ 2 (excluding sex); OAC therapy was associated with reduced all-cause mortality and non-cardiovascular mortality, irrespective of co-GDMT use. Clinical Trial Registration Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362.
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Affiliation(s)
- Alan John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Institute, St. George's University of London, London, UK
| | | | | | - Jean-Pierre Bassand
- Thrombosis Research Institute, London, UK
- University of Besançon, Besançon, France
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Samuel Z Goldhaber
- Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Sylvia Haas
- Formerly Department of Medicine, Technical University of Munich, Munich, Germany
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Schak L, Petersen JK, Vinding NE, Andersson C, Weeke PE, Kristensen SL, Gundlund A, Schou M, Køber L, Fosbøl EL, Østergaard L. Temporal changes in incidence, treatment strategies and 1-year re-admission rates in patients with atrial fibrillation/flutter under 65 years of age: A Danish nationwide study. Int J Cardiol 2023; 382:23-32. [PMID: 37031708 DOI: 10.1016/j.ijcard.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/22/2023] [Accepted: 04/04/2023] [Indexed: 04/11/2023]
Abstract
AIM To examine temporal changes in incidence rates of atrial fibrillation/flutter (AF), treatment strategies, and AF readmission rates in patients <65 years. METHODS Using Danish nationwide registries, we identified patients <65 years with a first-time AF diagnosis from 2000 to 2018. The cohort was categorized according to calendar periods; 2000-2002, 2003-2006, 2007-2010, 2011-2014, and 2015-2018. In this retrospective cohort study the incidence rate (IR) of AF per 100,000 person years (PY), catheter ablation, electrical cardioversion, use of pharmacotherapy, and AF readmission, were investigated in the first year following AF diagnosis. RESULTS We identified 60,917 patients; 8150 (13.4%) in 2000-2002, 11,898 (19.5%) in 2003-2006, 13,560 (22.3%) in 2007-2010, 14,167 (23.3%) in 2011-2014, and 13,142 (21.6%) in 2015-2018. Apart from 2015 to 2018, a stepwise increase in the crude IR of AF was observed across calendar periods; 2000-2002: 78.7 (95% CI 77.0;80.4), 2003-2006: 86.3 (84.7;87.8), 2007-2010: 97.9 (96.3;99.6), 2011-2014: 102.3 (100.7;104.0), 2015-2018: 93.6 (92.0;95.2). Over the studied time-periods, we found a stepwise increase in the cumulative incidence of catheter ablation (1.2% to 7.6%) electrical cardioversion (2.0% to 8.7%) and treatment with oral anticoagulant therapy (OAC) (28.5% to 47.8%) within the first year of diagnosis. No temporal differences in incidence of 1-year AF readmission were identified (AF-readmissions: 2000-2002: 32.7%, 2003-2006: 31.1%, 2007-2010: 32.2%, 2011-2014: 32.1% and 2015-2018: 31.7%). CONCLUSION The incidence rate of AF in patients <65 years increased from 2000 to 2018, as did the use of catheter ablation, electrical cardioversion and OAC in the first year following AF diagnosis. 1-year AF readmission incidence remained stable around 32% over the study period.
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Affiliation(s)
- Lukas Schak
- Department of Cardiology, Centre B, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
| | - Jeppe Kofoed Petersen
- Department of Cardiology, Centre B, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Naja Emborg Vinding
- Department of Cardiology, Centre B, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Charlotte Andersson
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark; Cardiovascular Division, Brigham and Women's Hospital, Boston, USA
| | - Peter E Weeke
- Department of Cardiology, Centre B, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Søren Lund Kristensen
- Department of Cardiology, Centre B, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anna Gundlund
- Department of Cardiology, Centre B, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Centre B, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, Centre B, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Lauge Østergaard
- Department of Cardiology, Centre B, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Cannon CP, Kim JM, Lee JJ, Sutherland J, Bachireddy R, Valentine CM, Hearne S, Trebnick A, Jaffer S, Datta S, Semmel E, Thorpe F, Doros G, Cavender MA, Reynolds MR. Patients and Their Physician's Perspectives About Oral Anticoagulation in Patients With Atrial Fibrillation Not Receiving an Anticoagulant. JAMA Netw Open 2023; 6:e239638. [PMID: 37093601 PMCID: PMC10126870 DOI: 10.1001/jamanetworkopen.2023.9638] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 03/09/2023] [Indexed: 04/25/2023] Open
Abstract
Importance The underuse of oral anticoagulation in patients with nonvalvular atrial fibrillation (AF) is a major issue that is not well understood. Objective To understand the lack of anticoagulation by assessing the perceptions of patients with AF who are not receiving anticoagulation and their physician's about the risk of stroke and the benefits and risks of anticoagulation. Design, Setting, and Participants This cohort study included patients with nonvalvular AF and a CHA2DS2-VASc score of 2 or more (calculated as congestive heart failure, hypertension, age 75 years and older, diabetes, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, and sex category) who were not receiving anticoagulation and were enrolled from 19 sites within the National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence Registry (PINNACLE Registry) between January 18, 2017, and May 7, 2018. Data were collected from January 18, 2017, to September 30, 2019, and analyzed from April 2022 to March 2023. Exposure Each patient enrolled in the study completed a survey, and their treating physician then conducted a clinical review of their care. Main Outcomes and Measures Assessment of willingness for anticoagulation treatment and its appropriateness after central review by a panel of 4 cardiologists. Use of anticoagulation at 1 year follow-up was compared vs similar patients at other centers in the PINNACLE Registry. Results Of the 817 patients enrolled, the median (IQR) age was 76.0 (69.0-83.0) years, 369 (45.2%) were women, and the median (IQR) CHA2DS2-VASc score was 4.0 (3.0-6.0). The top 5 reasons physicians cited for no anticoagulation were low AF burden or successful rhythm control (278 [34.0%]), patient refusal (272 [33.3%]), perceived low risk of stroke (206 [25.2%]), fall risk (175 [21.4%]), and high bleeding risk (167 [20.4%]). After rereview, 221 physicians (27.1%) would reconsider prescribing oral anticoagulation as compared with 311 patients (38.1%), including 67 (24.6%) whose physician cited patient refusal. Of 647 patients (79.2%) adjudicated as appropriate or may be appropriate for anticoagulation, physicians would reconsider anticoagulation for only 177 patients (21.2%), while 527 patients (64.5%) would either agree to starting anticoagulation (311 [38.1%]) or were neutral (216 [27.3%]) to starting anticoagulation. Upon follow-up, 119 patients (14.6%) in the BOAT-AF study were prescribed anticoagulation, as compared with 55 879 of 387 975 similar patients (14.4%) at other centers in the PINNACLE Registry. Conclusions and Relevance The findings of this cohort study suggest that patients with AF who are not receiving anticoagulation are more willing to consider anticoagulation than their physicians. These data emphasize the need to revisit any prior decision against anticoagulation in a shared decision-making manner.
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Affiliation(s)
- Christopher P. Cannon
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Baim Institute for Clinical Research, Boston, Massachusetts
| | - Joseph M. Kim
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jane J. Lee
- Baim Institute for Clinical Research, Boston, Massachusetts
| | | | | | | | | | - April Trebnick
- Baim Institute for Clinical Research, Boston, Massachusetts
| | - Sara Jaffer
- Baim Institute for Clinical Research, Boston, Massachusetts
| | | | | | - Fran Thorpe
- American College of Cardiology, Washington, DC
| | - Gheorghe Doros
- Baim Institute for Clinical Research, Boston, Massachusetts
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Matthew A. Cavender
- Baim Institute for Clinical Research, Boston, Massachusetts
- University of North Carolina, Chapel Hill
| | - Matthew R. Reynolds
- Baim Institute for Clinical Research, Boston, Massachusetts
- Lahey Hospital and Medical Center, Burlington, Massachusetts
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Gunawardene M, Hartmann J, Willems S. [Asymptomatic atrial fibrillation : Screening and therapy]. Herzschrittmacherther Elektrophysiol 2023; 34:122-130. [PMID: 36912974 DOI: 10.1007/s00399-023-00933-8] [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: 01/23/2023] [Accepted: 03/06/2023] [Indexed: 03/14/2023]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia affecting millions of people worldwide and poses a significant burden to the health care system. AF screening of the general population or of a specific higher-risk population could not only lead to earlier detection of AF but also to a prompt initiation of an adequate therapy to prevent complications such as stroke or death and consecutively to a potential reduction of health care costs, especially in asymptomatic AF patients. To conduct screening programs, accessible new technology devices such as "wearables", smartwatches, and implantable event recorders provide an innovative solution. However, as data regarding screening are inconclusive, routine AF screening of the population is currently not recommended by the European Society of Cardiology. Recently published studies have indicated that anticoagulation and early rhythm control of asymptomatic AF could avoid occurrence of clinical endpoints. This article reports on the scientific results of the current literature as well as gaps of evidence and discusses possible treatment options of asymptomatic AF.
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Affiliation(s)
- Melanie Gunawardene
- Klinik für Kardiologie und internistische Intensivmedizin, Asklepios Klinik St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Deutschland.
| | - Jens Hartmann
- Klinik für Kardiologie und internistische Intensivmedizin, Asklepios Klinik St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Deutschland
| | - Stephan Willems
- Klinik für Kardiologie und internistische Intensivmedizin, Asklepios Klinik St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Deutschland
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Philippe E, Henrard S, Boland B, Marien S. Inappropriate Combined Antiplatelet and Anticoagulant Therapy in Older Patients with Atrial Fibrillation: Trend over Time (2009-18). Drugs Aging 2023; 40:273-283. [PMID: 36821028 DOI: 10.1007/s40266-023-01006-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND AND OBJECTIVES Antiplatelet therapy, when prescribed in combination with anticoagulant therapy to older patients with atrial fibrillation and no recent cardiovascular event, is inappropriate and a reversible risk factor of major bleeding. We aimed to assess the trend over time of the prevalence of inappropriate combined antiplatelet and anticoagulant therapy and to determine its associated factors during the direct oral anticoagulant era. METHODS This was a study of consecutive older patients (age ≥ 75 years) with atrial fibrillation, receiving anticoagulant therapy upon admission, and undergoing a comprehensive geriatric assessment during their first admission in a Belgian teaching hospital between 2009 and 2018. Antiplatelet therapy was considered inappropriate in the absence of a recent cardiovascular event. We studied the prevalence of inappropriate combined antiplatelet and anticoagulant therapy by 2-year periods and assessed its associated factors since the year 2013. RESULTS Inappropriate combined antiplatelet and anticoagulant therapy was identified in 21% of the 654 patients (median age 84 years, 51% women), with a prevalence decreasing (p ≤ 0.01) from 25% (2009-10) to 14.8% (2017-18). Among the 469 patients recruited during the direct oral anticoagulant era, inappropriate combined antiplatelet and anticoagulant therapy (19%) was associated in a multivariable analysis with a history of stroke/transient ischemic attack (odds ratio 2.13, p = 0.007), anticoagulation with low-molecular-weight heparin (odds ratio 3.44, p = 0.015), and a history of vascular disease (odds ratio 5.68, p < 0.001). CONCLUSIONS While inappropriate combined antiplatelet and anticoagulant therapy has declined over the last decade, there is still room for improvement. Antiplatelet deprescribing should be considered in all patients with inappropriate combined antiplatelet and anticoagulant therapy, including those with vascular disease and no recent cardiovascular event.
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Affiliation(s)
- Emilie Philippe
- Geriatric Medicine, Centre Hospitalier Universitaire Brugmann, 36, Rue du Foyer Schaerbeekois, 1030, Brussels, Belgium.
| | - Séverine Henrard
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
- Institute of Health and Society (IRSS), Université Catholique de Louvain, Brussels, Belgium
| | - Benoit Boland
- Institute of Health and Society (IRSS), Université Catholique de Louvain, Brussels, Belgium
- Geriatric Medicine, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Sophie Marien
- Institute of Health and Society (IRSS), Université Catholique de Louvain, Brussels, Belgium
- Geriatric Medicine, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
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Healthcare Resource Utilization in Patients with Newly Diagnosed Atrial Fibrillation: A Global Analysis from the GARFIELD-AF Registry. Healthcare (Basel) 2023; 11:healthcare11050638. [PMID: 36900643 PMCID: PMC10000823 DOI: 10.3390/healthcare11050638] [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: 01/25/2023] [Revised: 02/13/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023] Open
Abstract
The management of atrial fibrillation (AF), the most common sustained arrhythmia, impacts healthcare resource utilization (HCRU). This study aims to estimate global resource use in AF patients, using the GARFIELD-AF registry. A prospective cohort study was conducted to characterize HCRU in AF patients enrolled in sequential cohorts from 2012 to 2016 in 35 countries. Components of HCRU studied were hospital admissions, outpatient care visits, and diagnostic and interventional procedures occurring during follow-up. AF-related HCRU was reported as the percentage of patients demonstrating at least one event and was quantified as rate-per-patient-per-year (PPPY) over time. A total of 49,574 patients was analyzed, having an overall median follow-up of 719 days. Almost all patients (99.5%) had at least one outpatient care visit, while hospital admissions were the second most frequent medical contact, with similar proportions in North America (37.5%) and Europe (37.2%), and slightly higher in the other GARFIELD-AF countries (42.0%; namely Australia, Egypt, and South Africa). Asia and Latin America showed lower percentages of hospitalizations, outpatient care visits, and diagnostic and interventional procedures. Analyses of GARFIELD-AF highlighted the vast AF-related HCRU, underlying significant geographical differences in the type, quantity, and frequency of AF-related HCRU. These differences were likely attributable to health service availability and differing models of care.
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Abrignani MG, Lombardo A, Braschi A, Renda N, Abrignani V, Lombardo RM. Time trends in antithrombotic therapy prescription patterns: Real-world monocentric study in hospitalized patients with atrial fibrillation. World J Cardiol 2022; 14:576-598. [PMID: 36483763 PMCID: PMC9724000 DOI: 10.4330/wjc.v14.i11.576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 07/04/2022] [Accepted: 10/28/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Since 2010, the European Society of Cardiology has extended prescription criteria for oral antithrombotic therapy (OAT) in atrial fibrillation (AF). Direct oral anticoagulants (DOACs) were upgraded from an IIAa recommendation in 2012 to an IA in 2016. In real-world scenarios, however, OAC prescription is still suboptimal, mainly for DOACs.
AIM To evaluate OAT temporal prescription patterns in a cohort of patients hospitalized with AF in a Cardiology Department.
METHODS A retrospective observational study was conducted on a cohort of hospitalized patients in a secondary setting (Trapani, Italy) from 2010 to 2021 with AF as the main or secondary diagnosis. For 4089 consecutive patients, the variables extracted from the Cardiology department database were: Sex, age, time of hospitalization, antithrombotic therapy (warfarin, acenocoumarol, apixaban, dabigatran, edoxaban, rivaroxaban, aspirin, clopidogrel, other antiplatelet agents, low molecular weight heparin, and fondaparinux), diagnosis at discharge and used resources. Basal features are presented as percentage values for categorized variables and as mean +/- SD for categorized once.
RESULTS From January 1st, 2010 to October 6th, 2021, 25132 patients were hospitalized in our department; 4089 (16.27%, mean age 75.59+/-10.82) were discharged with AF diagnosis; of them, 2245 were males (54.81%, mean age 73.56+/-11.45) and 1851 females (45.19%, mean age 78.06+/-9.47). Average length of stay was 5.76+/-4.88 days; 154 patients died and 88 were moved to other Departments/Structures. AF was the main diagnosis in 899 patients (21.94%). The most frequent main diagnosis in patients with AF was acute myocardial infarction (1973 discharges, 48.19%). The most frequent secondary cardiac diagnosis was chronic coronary syndrome (1864 discharges, 45.51%), and the most frequent secondary associated condition was arterial hypertension (1010 discharges, 24.66%). For the analysis of antithrombotic treatments, the final sample included 3067 patients, after excluding in-hospital deaths, transferred out or self-discharged patients, as well as discharges lacking indications for prescribed treatments. OAC treatment increased significantly (35.63% in 2010-2012 vs 61.18% in 2019-2021, +25.55%, P < 0.0001), in spite of any antiplatelet agent use. This rise was due to increasing use of DOACs, with or without antiplatelet agents, from 3.04% in 2013-2015 to 50.06% in 2019-2021 (+47.02%, P < 0.0001) and was greater for factor Xa inhibitors, especially apixaban. In addition, treatment with a vitamin K antagonist, in spite of any antiplatelet agent use, decreased from 35.63% in 2010-2012 to 11.12% in 2019-2021 (-24.48%, P < 0.0001), as well as any antiplatelet therapy, alone or in double combination, (49.18% in 2010-2012 vs 34.18% in 2019-2021, -15.00%, P < 0.0001); and patients not receiving antithrombotic therapy declined with time (14.58% in 2010-2012 vs 1.97% in 2021, P < 0.0001).
CONCLUSION Real-world patients with AF are elderly and affected by cardiovascular and non-cardiovascular diseases. The percentage of patients on OAT and DOACs increased. These data suggest a slow, gradual guidelines implementation process.
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Affiliation(s)
- Maurizio Giuseppe Abrignani
- Operative Unit of Cardiology, Department of Medicine, S. Antonio Abate Hospital of Trapani, ASP Trapani, Trapani 91100, Trapani, Italy
| | - Alberto Lombardo
- Operative Unit of Cardiology, Department of Medicine, S. Antonio Abate Hospital of Trapani, ASP Trapani, Trapani 91100, Trapani, Italy
| | - Annabella Braschi
- Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo 90100, Palermo, Italy
| | - Nicolò Renda
- Department of Medicine and Surgery, University of Parma, Parma 43100, Parma, Italy
| | - Vincenzo Abrignani
- Operative Unit of Internal Medicine with Stroke Care, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE) "G. D'Alessandro", University of Palermo, Palermo 90100, Palermo, Italy
| | - Renzo M Lombardo
- Department of Cardiology, Operative Unit of Cardiology, Department of Medicine, S. Antonio Abate Hospital of Trapani, Trapani 91100, Trapani, Italy
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Woodman RJ, Horwood C, Kunnel A, Hakendorf P, Mangoni AA. Using electronic admission data to monitor temporal trends in local medication use: Experience from an Australian tertiary teaching hospital. Front Pharmacol 2022; 13:888677. [PMID: 36313311 PMCID: PMC9614045 DOI: 10.3389/fphar.2022.888677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 10/03/2022] [Indexed: 11/13/2022] Open
Abstract
Background and aims: Medication usage varies according to prescribing behavior, professional recommendations, and the introduction of new drugs. Local surveillance of medication usage may be useful for understanding and comparing prescribing practices by healthcare providers, particularly in countries such as Australia that are in the process of enhancing nationwide data linkage programs. We sought to investigate the utility of electronic hospital admission data to investigate local trends in medication use, to determine similarities and differences with other Australian studies, and to identify areas for targeted interventions. Methods: We performed a retrospective longitudinal analysis using combined data from a hospital admissions administrative dataset from a large tertiary teaching hospital in Adelaide, South Australia and a hospital administrative database documenting medication usage matched for the same set of patients. All adult admissions over a 12-year period, between 1 January 2007 and 31st December 2018, were included in the study population. Medications were categorized into 21 pre-defined drug classes of interest according to the ATC code list 2021. Results: Of the 692,522 total admissions, 300,498 (43.4%) had at least one recorded medication. The overall mean number of medications for patients that were medicated increased steadily from a mean (SD) of 5.93 (4.04) in 2007 to 7.21 (4.98) in 2018. Results varied considerably between age groups, with the older groups increasing more rapidly. Increased medication usage was partly due to increased case-complexity with the mean (SD) Charlson comorbidity index increasing from 0.97 (1.66) in 2007-to-2012 to 1.17 (1.72) in 2013-to-2018 for medicated patients. Of the 21 medication classes, 15 increased (p < 0.005), including antithrombotic agents; OR = 1.18 [1.16–1.21], proton pump inhibitors; OR = 1.14 [1.12–1.17], statins; OR = 1.12; [1.09–1.14], and renin-angiotensin system agents; OR = 1.06 [1.04–1.08], whilst 3 decreased (p < 0.005) including anti-inflammatory drugs (OR = 0.55; 99.5% CI = 0.53–0.58), cardiac glycosides (OR = 0.81; 99.5% CI = 0.78–0.86) and opioids (OR = 0.82; 99.5% CI = 0.79–0.83). The mean number of medications for all admissions increased between 2007 and 2011 and then declined until 2018 for each age group, except for the 18-to-35-year-olds. Conclusion: Increased medication use occurred in most age groups between 2007 and 2011 before declining slightly even after accounting for increased comorbidity burden. The use of electronic hospital admission data can assist with monitoring local medication trends and the effects of initiatives to enhance the quality use of medicines in Australia.
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Affiliation(s)
- Richard J. Woodman
- Centre of Epidemiology and Biostatistics, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Chris Horwood
- Department of Clinical Epidemiology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Aline Kunnel
- School of Mathematical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Paul Hakendorf
- Department of Clinical Epidemiology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Arduino A. Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Department of Clinical Pharmacology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, SA, Australia
- *Correspondence: Arduino A. Mangoni,
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10
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Shantsila A, Lip GYH, Lane DA. Contemporary management of atrial fibrillation in primary and secondary care in the UK: the prospective long-term AF-GEN-UK Registry. Europace 2022; 25:308-317. [PMID: 36037021 PMCID: PMC9934988 DOI: 10.1093/europace/euac153] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/04/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS This study established a prospective registry of contemporary management of UK patients with atrial fibrillation (AF) by cardiologists, general practitioners, and stroke, acute, and emergency medicine physicians at baseline and 1-year follow-up. METHODS AND RESULTS Data on patients with recently diagnosed AF (≤12 months) were collected from medical records from 101 UK sites to permit comparison of patient characteristics and treatments between specialities. The impact of guideline-adherent oral anticoagulation (OAC) use on outcomes was assessed using Cox regression analysis. One thousand five hundred and ninety-five AF patients [mean (standard deviation) age 70.5 (11.2) years; 60.1% male; 97.4% white] were recruited in June 2017-June 2018 and followed up for 1 year. Overall OAC prescription rates were 84.2% at baseline and 87.1% at 1 year, with non-vitamin K antagonist oral anticoagulants (NOACs) predominating (74.9 and 79.2% at baseline and 1 year, respectively). Vitamin K antagonist prescription was significantly higher in primary care, with NOAC prescription higher among stroke physicians. Guideline-adherent OAC (CHA2DS2-VASc ≥2) at baseline significantly reduced risk of death and stroke at 1 year [adjusted hazard ratio (95% confidence interval): 0.48 (0.27-0.84) and 0.11 (0.02-0.48), respectively]. Rhythm control is evident in ∼25%; only 1.6% received catheter ablation. CONCLUSION High OAC use (>80%, mainly NOACs) rates varied by speciality, with VKA prescription higher in primary care. Guideline-adherent OAC therapy at baseline was associated with significant reduction in death and stroke at 1 year, regardless of speciality. Rhythm-control management is evident in only one-quarter despite AF symptoms reported in 56.6%. This registry extends the knowledge of contemporary AF management outside cardiology and demonstrates good implementation of clinical guidelines for the management of AF, particularly for stroke prevention.
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Affiliation(s)
| | - Gregory Y H Lip
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool L7 8TX, UK,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool L7 8TX, UK,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deirdre A Lane
- Corresponding author. Tel:4 +44 151 794 9334. E-mail address:
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11
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Apenteng PN, Virdone S, Hobbs FR, Camm AJ, Fox KA, Pieper KS, Kayani G, Fitzmaurice D. Two-year outcomes of UK patients newly diagnosed with atrial fibrillation: findings from the prospective observational cohort study GARFIELD-AF. Br J Gen Pract 2022; 72:BJGP.2021.0548. [PMID: 35577587 PMCID: PMC9119814 DOI: 10.3399/bjgp.2021.0548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/19/2022] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The outcomes of patients newly diagnosed with atrial fibrillation (AF) following the introduction of direct-acting oral anticoagulants are not well known. AIM To determine the 2-year outcomes of patients newly diagnosed with AF, and the effectiveness of oral anticoagulants in everyday practice. DESIGN AND SETTING This was a prospective observational cohort study in UK primary care. METHOD In total, 3574 patients aged ≥18 years with a new AF diagnosis were enrolled. A propensity score was applied using an overlap weighting scheme to obtain unbiased estimates of the treatment effect of anticoagulation versus no anticoagulation on the occurrence of death, non-haemorrhagic stroke/systemic embolism, and major bleeding within 2 years of diagnosis. RESULTS Overall, 65.8% received anticoagulant therapy, 20.8% received an antiplatelet only, and 13.4% received neither. During the study period, the overall incidence rates of all-cause mortality, non-haemorrhagic stroke/systemic embolism, and major bleeding were 4.15 (95% confidence interval [CI] = 3.69 to 4.65), 1.45 (95% CI = 1.19 to 1.77), and 1.21 (95% CI = 0.97 to 1.50) per 100 person-years, respectively. Anticoagulation treatment compared with no anticoagulation treatment was associated with significantly lower all-cause mortality adjusted hazard ratio (aHR) 0.70 (95% CI = 0.53 to 0.93), significantly lower risk of non-haemorrhagic stroke/systemic embolism (aHR 0.39, 95% CI = 0.24 to 0.62), and a non-significant higher risk of major bleeding (aHR 1.31, 95% CI = 0.77 to 2.24). CONCLUSION The data support a benefit of anticoagulation in reducing stroke and death, without an increased risk of a major bleed in patients with new-onset AF. Anticoagulation treatment in patients at high risk of stroke who are not receiving anticoagulation may further improve outcomes.
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Affiliation(s)
| | | | - Fd Richard Hobbs
- Nuffield professor of primary care health sciences, Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, University of Oxford, Oxford
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Research Institute, St George's University of London, London
| | - Keith Aa Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh
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12
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Farinha JM, Jones ID, Lip GYH. Optimizing adherence and persistence to non-vitamin K antagonist oral anticoagulant therapy in atrial fibrillation. Eur Heart J Suppl 2022; 24:A42-A55. [PMID: 35185408 PMCID: PMC8850710 DOI: 10.1093/eurheartj/suab152] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke, which can be prevented by the use of oral anticoagulation. Although non-vitamin K antagonist oral anticoagulants (NOACs) have become the first choice for stroke prevention in the majority of patients with non-valvular AF, adherence and persistence to these medications remain suboptimal, which may translate into poor health outcomes and increased healthcare costs. Factors influencing adherence and persistence have been suggested to be patient-related, physician-related, and healthcare system-related. In this review, we discuss factors influencing patient adherence and persistence to NOACs and possible problem solving strategies, especially involving an integrated care management, aiming for the improvement in patient outcomes and treatment satisfaction.
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Affiliation(s)
- José Maria Farinha
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Ian D Jones
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- School of Nursing and Allied Health, Liverpool John Moores University, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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13
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Wou C, Crompton J, Ashworth M, Williams H, Dodhia H. Managing stroke risk in patients with atrial fibrillation: a cross-sectional analysis of socio-demographic inequalities in a London borough. J Public Health (Oxf) 2022; 44:e241-e248. [PMID: 35165726 DOI: 10.1093/pubmed/fdac004] [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: 03/15/2021] [Accepted: 01/12/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Stroke prevention is essential for patients with atrial fibrillation (AF), but some receive sub-optimal management. We reviewed those with a recorded AF diagnosis assessed with CHA2DS2-VASc stroke risk score (SRS) and socio-demographic determinants of anticoagulation prescribing. The objective was to compare with national guidance recommendations, which recommend anticoagulant therapy for SRS ≥ 2, to determine if there were inequalities in management. METHODS A cross-sectional design was used to analyze records from all (n = 41) general practices in one London borough. Patients were excluded if they were <18 years, had AF resolved or diagnosed < 3 months. Logistic regression identified socio-demographic factors associated with high SRS and anticoagulant prescribing. RESULTS Of 2913 patients, 2885 (99.0%) had an SRS, and 2411 (83.6%) a score ≥ 2 and 82.9% (1999 of 2411) were prescribed anticoagulation. Women (compared with men), Black and Mixed/Multiple ethnic groups (compared with White), and those living in most deprived areas (compared with least) were more likely to have a score ≥ 2. Patients with a high SRS from Black and Mixed/Multiple ethnic groups and aged 18-74 years were less likely to be prescribed anticoagulation. CONCLUSION We found evidence of age and ethnic inequity in anticoagulation prescribing for stroke prevention in patients with AF.
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Affiliation(s)
- Constance Wou
- Public Health Department, London Borough of Lambeth, 6 Brixton Hill, Brixton, London SW2 1EG, UK
| | - James Crompton
- Public Health Department, London Borough of Lambeth, 6 Brixton Hill, Brixton, London SW2 1EG, UK
| | - Mark Ashworth
- Faculty of Life Sciences, School of Life Course and Population Sciences, King's College London, Guy's Campus, Addison House, London SE1 1UL, UK
| | - Helen Williams
- Department of Medicines Optimisation, NHS South East London CCG, 160 Tooley Street, London SE1 2TZ, UK
| | - Hiten Dodhia
- Public Health Department, London Borough of Lambeth, 6 Brixton Hill, Brixton, London SW2 1EG, UK
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14
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Giron A, Lambert C, Berland M, Schmidt J, Poinas L, Charuel E, Ménini T, Pereira B, Vorilhon P. [Comparative study in primary care of the stability of INR in patients treated with warfarin or fluindione for atrial fibrillation. The FLOWER study (FLuindione Or WarfarinE - Result INR)]. Ann Cardiol Angeiol (Paris) 2022; 71:123-129. [PMID: 35039141 DOI: 10.1016/j.ancard.2021.09.013] [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: 07/31/2020] [Accepted: 09/10/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The aim of our study was to compare the time spent within the target INR or Time in Therapeutic Range (TTR) of patients treated with fluindione to that of patients treated with warfarin for non-valvular atrial fibrillation (NVAF) and followed in general practice, with the hypothesis of a better TTR with warfarin, which is the VKA most commonly prescribed in France. METHOD Liberal nurses and general practitioners working in the Auvergne region recruited patients treated with fluindione or warfarin for NVAF. Patients' INRs (International Normalized Ratios) were recorded by medical analysis laboratories for 6 months. The primary endpoint was TTR, the secondary endpoint the number of hemorrhagic and/or thromboembolic events. RESULTS Of the 342 participants with a mean age of 75.3 ± 9.8 years, 239 (70%) were treated with fluindione and 103 (30%) with warfarin. The mean number of INRs achieved per patient was 9.2 ± 4.0 in the fluindione group and 9.3 ± 4.0 in the warfarin group (p=0.73). The median TTR of fluindione was 81.9% [63.5; 94.1] and that of warfarin was 81.3% [65.6; 92.6] (p=0.98). Twenty-eight of 263 patients reported hemorrhage (10.6%) and 4 reported thromboembolic events (0.8%), with no significant difference between the groups. CONCLUSION The TTRs of patients treated for NVAF with fluindione versus warfarin do not differ significantly over an observation period of 6 consecutive months in a patient population comparable to that of the publications in this field. However, these TTRs are significantly higher than those reported in the literature, with no difference between the two treatments. The TTRs of patients treated for VANF with fluindione versus warfarin do not differ significantly over a 6-month observation period in a patient population comparable to that of the publications in this indication.
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Affiliation(s)
- Alexane Giron
- Département de médecine générale, UFR médecine et des professions paramédicales, Université Clermont Auvergne, 28, Place Henri Dunant, Clermont-Ferrand F
| | - Céline Lambert
- Direction de la Recherche Clinique de l'Innovation, CHU Clermont-Ferrand, 58, Bd Montalembert 63003 Clermont-Ferrand Cedex 1
| | - Marie Berland
- Département de médecine générale, UFR médecine et des professions paramédicales, Université Clermont Auvergne, 28, Place Henri Dunant, Clermont-Ferrand F
| | - Jeannot Schmidt
- Service médecine d'urgence, CHU Clermont-Ferrand, 58, Bd Montalembert 63003 Clermont-Ferrand Cedex 1
| | - Lauriane Poinas
- Département de médecine générale, UFR médecine et des professions paramédicales, Université Clermont Auvergne, 28, Place Henri Dunant, Clermont-Ferrand F
| | - Elodie Charuel
- Département de médecine générale, UFR médecine et des professions paramédicales, Université Clermont Auvergne, 28, Place Henri Dunant, Clermont-Ferrand F.; Université Clermont Auvergne, UR ACCePPT, 63000 Clermont-Ferrand, France
| | - Thibault Ménini
- Département de médecine générale, UFR médecine et des professions paramédicales, Université Clermont Auvergne, 28, Place Henri Dunant, Clermont-Ferrand F.; Université Clermont Auvergne, UR ACCePPT, 63000 Clermont-Ferrand, France
| | - Bruno Pereira
- Direction de la Recherche Clinique de l'Innovation, CHU Clermont-Ferrand, 58, Bd Montalembert 63003 Clermont-Ferrand Cedex 1
| | - P Vorilhon
- Département de médecine générale, UFR médecine et des professions paramédicales, Université Clermont Auvergne, 28, Place Henri Dunant, Clermont-Ferrand F.; Direction de la Recherche Clinique de l'Innovation, CHU Clermont-Ferrand, 58, Bd Montalembert 63003 Clermont-Ferrand Cedex 1; Université Clermont Auvergne, UR ACCePPT, 63000 Clermont-Ferrand, France..
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15
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Sussman M, Barnes GD, Guo JD, Tao CY, Gillespie JA, Ferri M, Adair N, Cato MS, Shirkhorshidian I, Di Fusco M. The burden of undertreatment and non-treatment among patients with non-valvular atrial fibrillation and elevated stroke risk: a systematic review. Curr Med Res Opin 2022; 38:7-18. [PMID: 34632887 DOI: 10.1080/03007995.2021.1982684] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Global treatment guidelines recommend treatment with oral anticoagulants (OACs) for patients with non-valvular atrial fibrillation (NVAF) and an elevated stroke risk. However, not all patients with NVAF and an elevated stroke risk receive guideline-recommended therapy. A literature review and synthesis of observational studies were undertaken to identify the body of evidence on untreated and undertreated NVAF and the association with clinical and economic outcomes. METHODS An extensive search (1/2010-4/2020) of MEDLINE, the Cochrane Library, conference proceedings, and health technology assessments (HTAs) was conducted. Studies must have evaluated rates of nontreatment or undertreatment in NVAF. Nontreatment was defined as absence of OACs (but with possible antiplatelet treatment), while undertreatment was defined as treatment with only antiplatelet agents. RESULTS Sixteen studies met our inclusion criteria. Rates of nontreatment for patients with elevated stroke risk ranged from 2.0-51.1%, while rates of undertreatment ranged from 10.0-45.1%. The clinical benefits of anticoagulation were reported in the evaluated studies with reductions in stroke and mortality outcomes observed among patients treated with anticoagulants compared to untreated or undertreated patients. Adverse events associated with all bleeding types (i.e. hemorrhagic stroke, major bleeding or gastrointestinal hemorrhaging) were found to be higher for warfarin patients compared to untreated patients in real-world practice. Healthcare resource utilization was found to be lower among patients highly-adherent to warfarin compared to untreated patients. CONCLUSIONS Rates of nontreatment and undertreatment among NVAF patients remain high and are associated with preventable cardiovascular events and death. Strategies to increase rates of treatment may improve clinical outcomes.
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Affiliation(s)
- Matthew Sussman
- Modeling and Strategy Services, Panalgo LLC, Boston, MA, USA
| | | | - Jennifer D Guo
- Patient and Health Impact, Bristol Myers Squibb, New Brunswick, NJ, USA
| | - Charles Y Tao
- Modeling and Strategy Services, Panalgo LLC, Boston, MA, USA
| | | | - Mauricio Ferri
- Patient and Health Impact, Bristol Myers Squibb, New Brunswick, NJ, USA
| | - Nicholas Adair
- Modeling and Strategy Services, Panalgo LLC, Boston, MA, USA
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16
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García Rodríguez LA, Cea Soriano L, de Abajo FJ, Valent F, Hallas J, Gil M, Cattaruzzi C, Rodriguez-Martin S, Vora P, Soriano-Gabarró M, Gaist D. Trends in the use of oral anticoagulants, antiplatelets and statins in four European countries: a population-based study. Eur J Clin Pharmacol 2021; 78:497-504. [PMID: 34791521 PMCID: PMC8818635 DOI: 10.1007/s00228-021-03250-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 11/07/2021] [Indexed: 11/28/2022]
Abstract
Purpose To evaluate time trends in the prevalence of antithrombotic and statin use in four European countries. Methods Using population-based data from the United Kingdom, Denmark, Spain and Italy between 2010 and 2018, we calculated standardized annual prevalence proportions of antithrombotics and statin use, and changes in prevalence proportions (2018 vs. 2010). Results Prevalence proportion of statins increased from 24.8% to 24.6% (UK), 21.0% to 22.3% (Region of Southern Denmark [RSD]), 12.9% to 14.3% (Udine, Italy), and 20.3% to 23.2% (Spain). Prevalence proportions of antithrombotics declined in all four countries: 18.7% to 15.9% (UK; − 2.8% points), 18.9% to 18.1% (RSD; − 0.8% points), 17.7% to 16.6% (Udine; − 1.1% points) and 15.0% to 13.6% (Spain; − 1.4% points). These declines were driven by reductions in low-dose aspirin use: 15.3% to 8.9% (UK; − 6.4% points), 16.3% to 9.5% (RSD; − 6.8% points), 13.5% to 11.6% (Udine; − 1.9% points), and 10.2% to 8.8% (Spain; − 1.4% points). In the UK, low-dose aspirin use declined from 9.1% to 4.3% (− 4.8% points) for primary CVD prevention, and from 49.6% to 36.9% (− 12.7% points) for secondary prevention. Oral anticoagulant use gradually increased but did not fully account for the decrease in low-dose aspirin use. Conclusions Antithrombotic use in the UK, RSD, Udine and Spain declined between 2010 and 2018, driven by a reduction in use of low-dose aspirin that is not completely explained by a gradual increase in OAC use. Use of statins remained constant in the UK, and increased gradually in the RSD, Udine and Spain. Supplementary Information The online version contains supplementary material available at 10.1007/s00228-021-03250-6.
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Affiliation(s)
| | - Lucía Cea Soriano
- Department of Public Health and Maternal and Child Health, Faculty of Medicine, Complutense University of Madrid), Madrid, Spain
| | - Francisco J de Abajo
- Clinical Pharmacology Unit, Department of Biomedical Sciences (Pharmacology Section), University Hospital Príncipe de Asturias, University of Alcalá (IRYCIS), Alcalá de Henares, Madrid, Spain
| | - Francesca Valent
- Institute of Hygiene and Clinical Epidemiology, Udine Integrated University Health Unit, Udine, Italy
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Miguel Gil
- División de Farmacoepidemiología Y Farmacovigilancia, Agencia Española de Medicamentos Y Productos Sanitarios, Madrid, Spain
| | - Chiara Cattaruzzi
- Pharmaceutical Service, Udine Integrated University Health Unit, Udine, Italy
| | - Sara Rodriguez-Martin
- Clinical Pharmacology Unit, Department of Biomedical Sciences (Pharmacology Section), University Hospital Príncipe de Asturias, University of Alcalá (IRYCIS), Alcalá de Henares, Madrid, Spain
| | | | | | - David Gaist
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
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17
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Grundtvig J, Ovesen C, Havsteen I, Christensen T, Gaist D, Iversen HK, Kruuse C, Lilja-Cyron A, Ægidius K, Rosenbaum S, Meden P, Marstrand J, Christensen L, Steiner T, Christensen H. Trends in incidence of oral anticoagulant-related intracerebral hemorrhage and sales of oral anticoagulants in Capital Region of Denmark 2010-2017. Eur Stroke J 2021; 6:143-150. [PMID: 34414289 DOI: 10.1177/23969873211008770] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/16/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction Non-vitamin K-antagonist oral anticoagulants (NOAC) have become first choice oral anticoagulant (OAC) with decreasing use of vitamin K antagonists (VKA), partly due to lower risk of intracerebral hemorrhage (ICH). Aim: to identify trends in sale of OACs and relate them to trends in OAC-related ICH (OAC-ICH). Patients and methods Study was based on the population in the Capital Region of Denmark (1.8 million inhabitants). We identified all patients admitted with a non-traumatic OAC-ICH in 2010-2017 and ascertained diagnosis and drug use through medical charts. We used information available in the public domain on sale of defined daily doses (DDD) of OAC in the Capital Region of Denmark. Results 453 patients with OAC-ICH out of a total of 2877 ICH-events were identified. From 2010 to 2017 sale of NOAC rose from 0.1 to 11.8 DDD/1000 inhabitants/day (p < 0.001); while VKA sale decreased from 7.6 to 5.2 DDD/1000 inhabitants/day (p < 0.001). The total number of ICH events was stable between 2010 and 2017, but the proportion of OAC-ICH events increased from 13% in 2010 to 22% in 2017 (p < 0.001). The proportion of ICH events related to NOAC had a significant increasing trend (p < 0.001), whereas a decreasing trend was observed for VKA (p = 0.04). Discussion In Denmark, the population on OACs has increased; resulting from increased use of NOACs. Parallel to this development, the proportion of OAC-ICH overall has increased based on an increasing trend in NOAC-related ICH. Conclusion Our findings document a need for further research on prevention and treatment of this complication.
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Affiliation(s)
| | - Christian Ovesen
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
| | | | | | - David Gaist
- Department of Neurology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, Neurology Research Unit, University of Southern Denmark, Odense, Denmark
| | - Helle K Iversen
- Department of Neurology, Rigshospitalet, Copenhagen, Denmark
| | | | | | - Karen Ægidius
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Sverre Rosenbaum
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Per Meden
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Jacob Marstrand
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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18
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Kozieł M, Teutsch C, Bayer V, Lu S, Gurusamy VK, Halperin JL, Rothman KJ, Diener H, Ma C, Huisman MV, Lip GYH. Changes in anticoagulant prescription patterns over time for patients with atrial fibrillation around the world. J Arrhythm 2021; 37:990-1006. [PMID: 34386125 PMCID: PMC8339088 DOI: 10.1002/joa3.12588] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 06/07/2021] [Accepted: 06/09/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Prescribing patterns for stroke prevention in atrial fibrillation (AF) patients evolved with approval of non-Vitamin K antagonist oral anticoagulants (NOACs) over time. OBJECTIVES To assess changes in anticoagulant prescription patterns in various geographical regions upon first approval of a NOAC and to analyze the evolution of oral anticoagulants (OACs) use over time in relation to CHA2DS2-VASc and HAS-BLED risk profiles. METHODS Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF) Phases II and III reported data on antithrombotic therapy for patients with newly diagnosed AF and ≥1 stroke risk factor. We focused on sites enrolling patients in both phases and reported treatment patterns for the first 4 years after initial NOAC approval. RESULTS From GLORIA-AF Phases II and III, 27 432 patients were eligible for this analysis. When contrasting the first year with the fourth year of enrolment, the proportion of NOAC prescriptions increased in Asia from 29.2% to 60.8%, in Europe from 53.4% to 75.8%, in North America from 49.0% to 73.9% and in Latin America from 55.7% to 71.1%. The proportion of Vitamin K antagonists (VKAs) use decreased across all regions over time, in Asia from 26.0% to 9.8%, in Europe from 35.5% to 16.8%, in North America from 28.9% to 12.1%, and in Latin America from 32.4% to 17.8%. In the multivariable analysis, factors associated with NOAC prescription were as follows: enrolment year, type of site, region, stroke and bleeding risk scores, and type and categorization of AF. CONCLUSIONS During 4 years after the approval of the first NOAC, NOAC use increased, while VKA use decreased, across all regions.
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Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart and Chest HospitalLiverpoolUK
- Department of Cardiology and AngiologySilesian Centre for Heart DiseasesZabrzePoland
| | - Christine Teutsch
- Department of Clinical Development and Medical AffairsTherapeutic Area CardiometabolismBoehringer Ingelheim International GmbHIngelheimGermany
| | - Valentina Bayer
- Biostatistics and Data Sciences DepartmentBoehringer Ingelheim Pharmaceuticals, Inc.RidgefieldCTUSA
| | - Shihai Lu
- Biostatistics and Data Sciences DepartmentBoehringer Ingelheim Pharmaceuticals, Inc.RidgefieldCTUSA
| | | | | | | | | | - Chang‐Sheng Ma
- University of Duisburg‐EssenEssenGermany
- Cardiology DepartmentAtrial Fibrillation CenterBeijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Menno V. Huisman
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart and Chest HospitalLiverpoolUK
- Department of Cardiology and AngiologySilesian Centre for Heart DiseasesZabrzePoland
- Aalborg Thrombosis Research UnitDepartment of Clinical MedicineAalborg UniversityAalborgDenmark
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19
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Phillips K, Subramanian A, Thomas GN, Khan N, Chandan JS, Brady P, Marshall T, Nirantharakumar K, Fabritz L, Adderley NJ. Trends in the pharmacological management of atrial fibrillation in UK general practice 2008-2018. Heart 2021; 108:517-522. [PMID: 34226195 DOI: 10.1136/heartjnl-2021-319338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/15/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The pharmacological management of atrial fibrillation (AF) comprises anticoagulation, for stroke prophylaxis, and rate or rhythm control drugs to alleviate symptoms and prevent heart failure. The aim of this study was to investigate trends in the proportion of patients with AF prescribed pharmacological therapies in the UK between 2008 and 2018. METHODS Eleven sequential cross-sectional analyses were performed yearly from 2008 to 2018. Data were derived from an anonymised UK primary care database. Outcomes were the proportion of patients with AF prescribed anticoagulants, rhythm and rate control drugs in the whole cohort, those at high risk of stroke and those with coexisting heart failure. RESULTS Between 2008 and 2018, the proportion of patients prescribed anticoagulants increased from 45.3% (95% CI 45.0% to 45.7%) to 71.1% (95% CI 70.7% to 71.5%) driven by increased prescription of non-vitamin K antagonist anticoagulants. The proportion of patients prescribed rate control drugs remained constant between 2008 and 2018 (69.3% (95% CI 68.9% to 69.6%) to 71.6% (95% CI 71.2% to 71.9%)). The proportion of patients prescribed rhythm control therapy by general practitioners (GPs) decreased from 9.5% (95% CI 9.3% to 9.7%) to 5.4% (95% CI 5.2% to 5.6%). CONCLUSIONS There has been an increase in the proportion of patients with AF appropriately prescribed anticoagulants following National Institute for Health and Care Excellence and European Society of Cardiology guidelines, which correlates with improvements in mortality and stroke outcomes. Beta-blockers appear increasingly favoured over digoxin for rate control. There has been a steady decline in GP prescribing rates for rhythm control drugs, possibly related to concerns over efficacy and safety and increased availability of AF ablation.
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Affiliation(s)
- Katherine Phillips
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - G Neil Thomas
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Nazish Khan
- Department of Cardiology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Joht Singh Chandan
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Paul Brady
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Tom Marshall
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Larissa Fabritz
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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20
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Gebreyohannes EA, Salter S, Chalmers L, Bereznicki L, Lee K. Non-adherence to Thromboprophylaxis Guidelines in Atrial Fibrillation: A Narrative Review of the Extent of and Factors in Guideline Non-adherence. Am J Cardiovasc Drugs 2021; 21:419-433. [PMID: 33369718 DOI: 10.1007/s40256-020-00457-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 01/24/2023]
Abstract
Atrial fibrillation is the most common arrhythmia. It increases the risk of thromboembolism by up to fivefold. Guidelines provide evidence-based recommendations to effectively mitigate thromboembolic events using oral anticoagulants while minimizing the risk of bleeding. This review focuses on non-adherence to contemporary guidelines and the factors associated with guideline non-adherence. The extent of guideline non-adherence differs according to geographic region, healthcare setting, and risk stratification tools used. Guideline adherence has gradually improved over recent years, but a significant proportion of patients are still not receiving guideline-recommended therapy. Physician-related and patient-related factors (such as patient refusals, bleeding risk, older age, and recurrent falls) also contribute to guideline non-adherence, especially to undertreatment. Quality improvement initiatives that focus on undertreatment, especially in the primary healthcare setting, may help to improve guideline adherence.
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Affiliation(s)
- Eyob Alemayehu Gebreyohannes
- Division of Pharmacy, School of Allied Health, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia.
| | - Sandra Salter
- Division of Pharmacy, School of Allied Health, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia
| | - Leanne Chalmers
- School of Pharmacy and Biomedical Sciences, Curtin University, Perth, WA, Australia
| | - Luke Bereznicki
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
| | - Kenneth Lee
- Division of Pharmacy, School of Allied Health, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
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21
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Brandes A, Crijns HJGM, Rienstra M, Kirchhof P, Grove EL, Pedersen KB, Van Gelder IC. Cardioversion of atrial fibrillation and atrial flutter revisited: current evidence and practical guidance for a common procedure. Europace 2021; 22:1149-1161. [PMID: 32337542 PMCID: PMC7399700 DOI: 10.1093/europace/euaa057] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/25/2020] [Indexed: 12/17/2022] Open
Abstract
Cardioversion is widely used in patients with atrial fibrillation (AF) and atrial flutter when a rhythm control strategy is pursued. We sought to summarize the current evidence on this important area of clinical management of patients with AF including electrical and pharmacological cardioversion, peri-procedural anticoagulation and thromboembolic complications, success rate, and risk factors for recurrence to give practical guidance.
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Affiliation(s)
- Axel Brandes
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Corresponding author. Tel: +45 30 43 36 50. E-mail address:
| | - Harry J G M Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Centre, Groningen, The Netherlands
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, UHB and Sandwell & West Birmingham Hospitals, NHS Trusts, Birmingham, UK
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Kenneth Bruun Pedersen
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark
| | - Isabelle C Van Gelder
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, University of Groningen, University Medical Centre, Groningen, The Netherlands
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22
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Kennedy C, Gabr A, McCormack J, Collins R, Barry M, Harbison J. The association between increasing oral anticoagulant prescribing and atrial fibrillation related stroke in Ireland. Br J Clin Pharmacol 2021; 88:178-186. [PMID: 34131941 DOI: 10.1111/bcp.14938] [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: 08/31/2020] [Revised: 02/12/2021] [Accepted: 05/24/2021] [Indexed: 11/26/2022] Open
Abstract
AIMS Recent increases in the number of patients with atrial fibrillation (AF) prescribed oral anticoagulants (OAC) are evident in Ireland and internationally, largely due to the availability of direct oral anticoagulants (DOACs). This study aimed to determine the rate of stroke in the context of increasing anticoagulation utilisation, with a focus on AF-related ischaemic stroke (IS). METHODS Dispensing data for OACs were identified for the period 2010-2018 as well as hospital discharges for IS (2005-2018). Irish National Stroke Register data were used to elucidate the characteristics of patients with acute ischaemic stroke. RESULTS The number of patients prescribed OACs increased by 94% from 2010-2018 with a significant change from 2013 (β = 2.57, P = .038), associated with a large increase in the number of patients on DOACs. There was 3.3-fold increase in expenditure on OACs nationally from 2013 to 2018, of which 94% was DOAC related. Using the 2013 timepoint, ischaemic stroke rates until 2018 did not show a significant deviation from the previous trend (β = 0.00, P = .898). The percentage of AF-related ischaemic stroke was stable from 2013 to 2017 with a 4.5% decrease in 2018. The percentage of ischaemic stroke patients with previously diagnosed AF decreased from 2013 to 2018; however, there was an increase in the percentage of ischaemic strokes while on OAC in this cohort. CONCLUSION Large increases in OAC utilisation have not resulted in changes in ischaemic stroke rates at a national level. The percentage of ischaemic strokes with a previous diagnosis of AF has decreased indicating a possible benefit from greater OAC utilisation. However, the percentage presenting with an ischaemic stroke while on OAC treatment is increasing. The increase in patients presenting with stroke while treated with OAC may largely reflect the national increase in patients prescribed DOACs but the findings raise concerns about treatment failures. The real-world effectiveness of DOACs requires further examination.
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Affiliation(s)
- Cormac Kennedy
- Department of Pharmacology and Therapeutics, Health Sciences Centre, Trinity College Dublin, Dublin 8, Ireland.,Department of Pharmacology, St James Hospital, Dublin 8, Ireland
| | - Ahmed Gabr
- Department of Pharmacology and Therapeutics, Health Sciences Centre, Trinity College Dublin, Dublin 8, Ireland
| | - Joan McCormack
- National Office of Clinical Audit, St Stephens Green, Dublin, Ireland
| | - Rónán Collins
- Department Geriatrics and Stroke Medicine, Tallaght University Hospital, Dublin, Ireland
| | - Michael Barry
- Department of Pharmacology and Therapeutics, Health Sciences Centre, Trinity College Dublin, Dublin 8, Ireland.,Department of Pharmacology, St James Hospital, Dublin 8, Ireland
| | - Joe Harbison
- Mercer's Institute for Successful Ageing, St James Hospital, Dublin, Ireland.,Discipline of Medical Gerontology, School of Medicine, Trinity College Dublin, Ireland
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23
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Ponamgi SP, Siontis KC, Rushlow DR, Graff-Radford J, Montori V, Noseworthy PA. Screening and management of atrial fibrillation in primary care. BMJ 2021; 373:n379. [PMID: 33846159 DOI: 10.1136/bmj.n379] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Atrial fibrillation is a common chronic disease seen in primary care offices, emergency departments, inpatient hospital services, and many subspecialty practices. Atrial fibrillation care is complicated and multifaceted, and, at various points, clinicians may see it as a consequence and cause of multi-morbidity, as a silent driver of stroke risk, as a bellwether of an acute medical illness, or as a primary rhythm disturbance that requires targeted treatment. Primary care physicians in particular must navigate these priorities, perspectives, and resources to meet the needs of individual patients. This includes judicious use of diagnostic testing, thoughtful use of novel therapeutic agents and procedures, and providing access to subspecialty expertise. This review explores the epidemiology, screening, and risk assessment of atrial fibrillation, as well as management of its symptoms (rate and various rhythm control options) and stroke risk (anticoagulation and other treatments), and offers a model for the integration of the components of atrial fibrillation care.
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Affiliation(s)
- Shiva P Ponamgi
- Division of Hospital Internal Medicine, Mayo Clinic Health System, Austin, MN, USA
| | | | - David R Rushlow
- Department of Family Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Victor Montori
- Division of Endocrinology, Mayo Clinic, Rochester, MN, USA
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Peter A Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
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24
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Wong KY, Davies B, Adeleke Y, Woodcock T, Matthew D, Sekelj S, Orlowski A, Porter B, Hashmy S, Mathew A, Grant R, Kaba A, Unger-Graeber B, Petrungaro B, Wallace J, Bell D, Cowie MR, Khan S. Hospital admissions for stroke and bleeding in Hounslow following a quality improvement initiative. Open Heart 2021; 8:openhrt-2020-001558. [PMID: 33649153 PMCID: PMC7925241 DOI: 10.1136/openhrt-2020-001558] [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] [Received: 01/01/2021] [Revised: 01/31/2021] [Accepted: 02/01/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Atrial fibrillation (AF) is the most common arrhythmia. Undiagnosed and poorly managed AF increases risk of stroke. The Hounslow AF quality improvement (QI) initiative was associated with improved quality of care for patients with AF through increased detection of AF and appropriate anticoagulation. This study aimed to evaluate whether there has been a change in stroke and bleeding rates in the Hounslow population following the QI initiative. METHODS Using hospital admissions data from January 2011 to August 2018, interrupted time series analysis was performed to investigate the changes in standardised rates of admission with stroke and bleeding, following the start of the QI initiative in October 2014. RESULTS There was a 17% decrease in the rate of admission with stroke as primary diagnosis (incidence rate ratio (IRR) 0.83; 95% CI 0.712 to 0.963; p<0.014). There was an even larger yet not statistically significant decrease in admission with stroke as primary diagnosis and AF as secondary diagnosis (IRR 0.75; 95% CI 0.550 to 1.025; p<0.071). No significant changes were observed in bleeding admissions. For each outcome, an additional regression model including both the level change and an interaction term for slope change was created. In all cases, the slope change was small and not statistically significant. CONCLUSION Reduction in stroke admissions may be associated with the AF QI initiative. However, the immediate level change and non-significant slope change suggests a lack of effect of the intervention over time and that the decrease observed may be attributable to other events.
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Affiliation(s)
- Kam Ying Wong
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Bethan Davies
- Cardiology, West Middlesex University Hospital, London, UK
| | - Yewande Adeleke
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Thomas Woodcock
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Dionne Matthew
- Chelsea and Westminster Healthcare NHS Trust, London, UK
| | - Sara Sekelj
- Imperial College Health Partners, London, UK
| | - Andi Orlowski
- Department of Primary Care and Public Health, Imperial College London, London, UK.,Imperial College Health Partners, London, UK
| | - Bradley Porter
- Cardiology Department, Guy's and Saint Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - Sophia Hashmy
- North West London Clinical Commissioning Group, London, UK
| | - Ammu Mathew
- Cardiology, West Middlesex University Hospital, London, UK
| | - Ron Grant
- Upbeat Heart Prevention and Support Group, London, UK
| | - Agnes Kaba
- Cardiology, West Middlesex University Hospital, London, UK
| | | | | | | | - Derek Bell
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Martin R Cowie
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Sadia Khan
- Cardiology, West Middlesex University Hospital, London, UK
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25
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Ng VWS, Siu CW, Chiu PKC, Kng CPL, Jamieson E, Wong ICK, Lam MPS. Understanding the barriers to using oral anticoagulants among long-term aspirin users with atrial fibrillation - a qualitative study. BMC Health Serv Res 2020; 20:1084. [PMID: 33238989 PMCID: PMC7691100 DOI: 10.1186/s12913-020-05947-3] [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] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite international treatment guidelines currently advocating oral anticoagulants (OACs) as the only appropriate stroke prevention therapy for patients with atrial fibrillation (AF) and evidence that OACs can greatly reduce the risk of stroke with similar risk of bleeding compared with aspirin, the underuse of OACs in patients with AF is common globally, especially in Asia. This study aimed to identify the barriers to prescribing and using OACs among long-term aspirin users with AF. METHOD Face-to-face interviews were conducted with fourteen eligible patients with AF using a semi-structured interview guide. The interview recordings were transcribed verbatim and data was analyzed according to the principles of thematic analysis. RESULTS Five themes were developed: awareness of AF symptoms and diagnosis; knowledge and understanding of AF and stroke prevention therapy; role of decision-making in prescribing; willingness to switch from aspirin to OACs; and impact of OAC regimen on daily living. The majority of the patients were not aware of the symptoms and diagnosis of AF and only had a vague understanding of the illness and stroke prevention therapy, leading to their minimal involvement in decisions relating to their treatment. Some patients and their caregivers were particularly concerned about the bleeding complications from OACs and perceived aspirin to be a suitable alternative as they find the adverse effects from aspirin manageable and so preferred to remain on aspirin if switching to OACs was not compulsory. Lastly, the lifestyle modifications required when using warfarin, e.g. alternative dosing regimen, diet restriction, were seen as barriers to some patients and caregivers. CONCLUSION The findings revealed patients' knowledge gap in AF management which may be targeted using educational interventions to improve patients' understanding of AF and its management and hence encourage active participation in the decision-making of their treatment in the future.
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Affiliation(s)
- Vanessa W S Ng
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
| | - Chung-Wah Siu
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Patrick K C Chiu
- Division of Geriatrics, Department of Medicine, Queen Mary Hospital, Hong Kong SAR, China
| | - Carolyn P L Kng
- Division of Geriatrics, Ruttonjee and Tang Shiu Kin Hospitals, Hong Kong SAR, China
| | - Elizabeth Jamieson
- Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
| | - Ian C K Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China.,Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
| | - May P S Lam
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China.
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26
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Reshetko OV, Sokolov AV, Furman NV, Agapov VV. Changes in Antithrombotic Therapy of Atrial Fibrillation in the Hospital in 2011-2012 and 2016-2017 (Pharmacoepidemiological Analysis). RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2020. [DOI: 10.20996/1819-6446-2020-10-10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Aim. To study the changes that have occurred in the pharmacotherapy of atrial fibrillation (AF) in the Saratov Region for 5 years by analyzing the antithrombotic therapy of patients who were admitted in a specialized department of the multidisciplinary hospital in Saratov in 2011-2012 and in 2016-2017.Material and methods. A pharmacoepidemiological retrospective study was conducted. The object of the study was the medical records of inpatients (Form 003/y) with the diagnosis “Atrial fibrillation” (ICD-X code I48), that consecutively admitted to the cardiology department of the multidisciplinary hospital in Saratov from January 1, 2011 to December, 31, 2012 (n=211) and from January 1, 2016 to December, 31, 2017 (n=227). Criteria for inclusion in the study: patients over 18 years of age, established diagnosis of non-valvular AF of ischemic genesis. Exclusion criteria from the study: non-ischemic cardiomyopathy, thyrotoxicosis, congenital heart defects, rheumatic heart damage, acute coronary syndrome, endocarditis, myocarditis, pericarditis, pulmonary thromboembolism, the presence of prosthetic heart valve. Pharmacoepidemiological analysis was carried out for the drugs prescribed during hospitalization and given by doctors at discharge of patients from the hospital. The risk of ischemic stroke was assessed using the CHA2DS2-VASc score, and the risk of bleeding – according to the HAS-BLED score.Results. When analyzing the risk of ischemic stroke, it was found that 100% of patients in 2011-2012 years and 98.2% in 2016-2017 years had indications for the prescription of oral anticoagulants (OAСs). In 2011-2012 there were no patients with a low risk of stroke (CHA2DS2-VASc=0). High risk of bleeding (HAS-BLED≥3) occurred in 4.7% of patients in 2011-2012 and in 10.6% in 2016-2017, however, due to the high risk of stroke, the refusal to prescribe OAC in these patients was inappropriate in accordance with the recommendations for the treatment of AF. In the group of patients with CHA2DS2-VASc=0 in 2016-2017 antiplatelet therapy was prescribed in 100% at the hospital stage and at discharge, which contradicts the guidelines, according to which antithrombotic therapy is not recommended to patients with CHA2DS2-VASc=0. In patients with CHA2DS2-VASc=1, a low percentage of anticoagulants prescription was noted. In 2016-2017 OACs were prescribed only in 12.5% of patients at all stages of observation. In 2011-2012 OAC alone was prescribed only to 1 person (20%) at the hospital stage, which does not comply with modern guidelines for the treatment of patients with AF, according to which patients with a risk score CHA2DS2-VASc=1 are recommended to receive OACs in the absence of contraindications. OACs prescription in group CHA2DS2-VASc≥2 occurred only in 15% of patients in 2011-2012 and in a third of patients in 2016-2017 (p<0.05). The frequency of isolated use of OACs significantly increased in 2016-2017 compared to 2011-2012 mainly due to the increase in the spectrum of direct OACs (DOACs) (p<0.05).Conclusion. For 5 years there have been significant changes in the antithrombotic therapy of AF in the Saratov Region. The frequency of prescribing OACs according to indications has increased mainly due to the introduction of the DOACs into clinical practice. However, prevention of stroke remains insufficient.
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Affiliation(s)
- O. V. Reshetko
- Saratov State Medical University named after V.I. Razumovsky
| | - A. V. Sokolov
- Saratov State Medical University named after V.I. Razumovsky
| | - N. V. Furman
- Saratov State Medical University named after V.I. Razumovsky
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27
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Rationale, considerations, and goals for atrial fibrillation centers of excellence: A Heart Rhythm Society perspective. Heart Rhythm 2020; 17:1804-1832. [DOI: 10.1016/j.hrthm.2020.04.033] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 12/19/2022]
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28
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Sagris D, Leventis I, Georgiopoulos G, Korompoki E, Makaritsis K, Vemmos K, Milionis H, Lip GYH, Ntaios G. Bleeding risk comparison between direct oral anticoagulants at doses approved for atrial fibrillation and aspirin: systematic review, meta-analysis and meta-regression. Eur J Intern Med 2020; 79:31-36. [PMID: 32409203 DOI: 10.1016/j.ejim.2020.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 04/28/2020] [Accepted: 05/01/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND A considerable proportion of patients with atrial fibrillation (AF) are still treated with aspirin despite current guidelines due to presumed favorable safety. AIM We performed a systematic review and meta-analysis of bleeding outcomes in randomized controlled trials (RCTs) comparing direct oral anticoagulants (DOACs) at doses approved for AF vs. aspirin. METHODS We searched PubMed and Scopus for phase-III RCTs of DOACs at AF-approved doses vs. aspirin. Outcomes assessed were major-, intracranial-, gastrointestinal-, clinically-relevant-non-major- and fatal bleeding. We performed two subgroup analyses: one per patient population i.e. those at high risk of arterial or venous thromboembolism, and one per DOAC. We also performed a meta-regression to assess the association with patient age. RESULTS In 4 eligible trials (20,440 patients) comparing DOACs vs. aspirin, the ORs were: 1.52 (95%CI: 0.91-2.53) for major bleeding in patients at high risk of arterial thromboembolism and 1.55 (95%CI:0.99-2.45, relative-risk-increase:55%, absolute-risk-increase:0.6%, number-needed-to-harm:170) in the overall analysis; 1.39 (95%CI:0.62-3.14) for intracranial bleeding in patients at high risk of arterial thromboembolism which was similar for the overall analysis; 1.27 (95%CI: 0.84-1.92) for gastrointestinal bleeding in patients at high risk of arterial thromboembolism and 1.26 (95%CI:0.86-1.85) in the overall analysis. Patient age was not a predictor of the magnitude of ORs for all bleeding outcomes. CONCLUSION The present meta-analysis does not support the use of aspirin over DOACs in AF. Accordingly, the level of evidence of the related recommendations should be upgraded, which in turn may reduce further the proportion of AF patients treated with antiplatelets.
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Affiliation(s)
- Dimitrios Sagris
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Ioannis Leventis
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | | | - Eleni Korompoki
- Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece; Division of Brain Sciences, Department of Stroke Medicine, Imperial College, London, United Kingdom
| | - Konstantinos Makaritsis
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Vemmos
- Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
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29
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Bassand JP, Apenteng PN, Atar D, Camm AJ, Cools F, Corbalan R, Fitzmaurice DA, Fox KA, Goto S, Haas S, Hacke W, Jerjes-Sanchez C, Koretsune Y, Heuzey JYL, Sawhney JP, Oh S, Stępińska J, Cate VT, Verheugt FW, Kayani G, Pieper KS, Kakkar AK, Garfield-Af Investigators FT. GARFIELD-AF: a worldwide prospective registry of patients with atrial fibrillation at risk of stroke. Future Cardiol 2020; 17:19-38. [PMID: 32696663 DOI: 10.2217/fca-2020-0014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The Global Anticoagulant Registry in the Field-Atrial Fibrillation (GARFIELD-AF) examined real-world practice in a total of 57,149 (5069 retrospective, 52,080 prospective) patients with newly diagnosed AF at risk of stroke/systemic embolism, enrolled at over 1000 centers in 35 countries. It aimed to capture data on AF burden, patients' clinical profile, patterns of clinical practice and antithrombotic management, focusing on stroke/systemic embolism prevention, uptake of new oral anticoagulants, impact on death and bleeding. GARFIELD-AF set new standards for quality of data collection and analysis. A total of 36 peer-reviewed articles were already published and 73 abstracts presented at international congresses, covering treatment strategies, geographical variations in baseline risk and therapies, adverse outcomes and common comorbidities such as heart failure. A risk prediction tool as well as innovative observational studies and artificial intelligence methodologies are currently being developed by GARFIELD-AF researchers. Clinical Trial Registration: NCT01090362 (ClinicalTrials.gov).
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Affiliation(s)
- Jean-Pierre Bassand
- Department of Cardiology, University of Besançon, Besançon 25000, France.,Department of Clinical Research, Thrombosis Research Institute, London SW3 6LR, UK
| | | | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevaal, Oslo PO Box 4956, Norway.,Institute of Clinical Science, University of Oslo, Oslo PO Box 4956, Norway
| | - A John Camm
- Molecular & Clinical Sciences Research Institute, St George's University of London, London SW17 0RE, UK
| | - Frank Cools
- Department of Cardiology, AZ Klina, Brasschaat 100, 2930, Belgium
| | - Ramon Corbalan
- Department of Cardiology, Catholic University, Santiago 8330024, Chile
| | | | - Keith Aa Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Shinya Goto
- Department of Medicine(Cardiology), Tokai University School of Medicine, Kanagawa 259-1143, Japan
| | - Sylvia Haas
- Department of Medicine, Formerly Technical University of Munich, Munich 80333, Germany
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg 69120, Germany
| | | | - Yukihiro Koretsune
- Institute for Clinical Research, Osaka National Hospital, Osaka 540-0006, Japan
| | - Jean-Yves Le Heuzey
- Department of Arrhythmia, European Hospital Georges Pompidou, René Descartes University, Paris 75015, France
| | | | - Seil Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 110-799, Republic of Korea
| | - Janina Stępińska
- Intensive Cardiac Therapy Clinic, Institute of Cardiology, Warsaw 04-628, Poland
| | - Vincent Ten Cate
- Cardiovascular Research Institute Maastricht, Maastricht 6200, The Netherlands
| | - Freek Wa Verheugt
- Depertment of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam NL-1091-AC, The Netherlands
| | - Gloria Kayani
- Department of Clinical Research, Thrombosis Research Institute, London SW3 6LR, UK
| | - Karen S Pieper
- Department of Clinical Research, Thrombosis Research Institute, London SW3 6LR, UK
| | - Ajay K Kakkar
- Department of Clinical Research, Thrombosis Research Institute, London SW3 6LR, UK.,Department of Surgery, University College London, London WC1E 6BT, UK
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Jones NR, Taylor CJ, Hobbs FDR, Bowman L, Casadei B. Screening for atrial fibrillation: a call for evidence. Eur Heart J 2020; 41:1075-1085. [PMID: 31811716 PMCID: PMC7060457 DOI: 10.1093/eurheartj/ehz834] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/15/2019] [Accepted: 11/08/2019] [Indexed: 02/06/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and prevalence is predicted to double over the next 30 years due to changing demographics and the rise in prevalence of risk factors such as hypertension and diabetes. Atrial fibrillation is associated with a five-fold increased stroke risk, but anticoagulation in eligible patients can reduce this risk by around 65%. Many people with AF currently go undetected and therefore untreated, either because they are asymptomatic or because they have paroxysmal AF. Screening has been suggested as one approach to increase AF detection rates and reduce the incidence of ischaemic stroke by earlier initiation of anticoagulation therapy. However, international taskforces currently recommend against screening, citing the cost implications and uncertainty over the benefits of a systematic screening programme compared to usual care. A number of large randomized controlled trials have commenced to determine the cost-effectiveness and clinical benefit of screening using a range of devices and across different populations. The recent AppleWatch study demonstrates how advances in technology are providing the public with self-screening devices that are increasingly affordable and accessible. Health care professionals should be aware of the implications of these emerging data for diagnostic pathways and treatment. This review provides an overview of the gaps in the current evidence and a summary of the arguments for and against screening.
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Affiliation(s)
- Nicholas R Jones
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Woodstock Road, Oxford OX2 6GG, UK
| | - Clare J Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Woodstock Road, Oxford OX2 6GG, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Woodstock Road, Oxford OX2 6GG, UK
| | - Louise Bowman
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
| | - Barbara Casadei
- Radcliffe Department of Medicine, University of Oxford, Level 6 West Wing, John Radcliffe Hospital, Oxford OX3 9DU, UK
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Kennedy C, Ni Choitir C, Clarke S, Bennett K, Barry M. Direct oral anticoagulants uptake and an oral anticoagulation paradox. Br J Clin Pharmacol 2020; 86:392-397. [PMID: 31747462 DOI: 10.1111/bcp.14171] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 10/23/2019] [Accepted: 10/29/2019] [Indexed: 01/05/2023] Open
Abstract
Oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation is underutilised. One of the impediments to warfarin therapy is the frequent monitoring required, usually at a specialised warfarin clinic. The advent of direct oral anticoagulants (DOACs) facilitates OAC therapy without an onerous monitoring regimen. This benefit may result in the more significant adoption of DOACs in areas without a warfarin clinic. This study analysed national administrative data for reimbursed pharmacy claims to assess OAC prescribing from 2010 to 2017 and compared the use of DOACs in areas with warfarin clinics compared to those without. Over the study period, the number of patients on OAC increased by 84%, due to a rapid increase in DOAC prescribing. The findings demonstrate that DOACs have resulted in an increase in the overall uptake of OAC therapy in Ireland. However, the increased utilisation was not evidently related to populations underserved by warfarin clinics.
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Affiliation(s)
- Cormac Kennedy
- Department of Pharmacology and Therapeutics, Health Sciences Centre, Trinity College, Dublin, Ireland
| | | | - Sarah Clarke
- Health Services Executive-Medicine Management Program, St James Hospital, Dublin, Ireland
| | - Kathleen Bennett
- Department of Population and Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Michael Barry
- Department of Pharmacology and Therapeutics, Health Sciences Centre, Trinity College, Dublin, Ireland.,National Centre for Pharmacoeconomics, St James Hospital, Dublin, Ireland.,Health Services Executive-Medicine Management Program, St James Hospital, Dublin, Ireland
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Kozieł M, Simovic S, Pavlovic N, Nedeljkovic M, Paparisto V, Music L, Goshev E, Dan AR, Manola S, Kusljugic Z, Trendafilova E, Dobrev D, Dan GA, Lip GY, Potpara TS. Management of patients with newly-diagnosed atrial fibrillation: Insights from the BALKAN-AF survey. IJC HEART & VASCULATURE 2019; 26:100461. [PMID: 32140551 PMCID: PMC7046541 DOI: 10.1016/j.ijcha.2019.100461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 12/18/2019] [Indexed: 12/13/2022]
Abstract
23.6% of patients in the survey had newly-diagnosed atrial fibrillation (AF). Those patients had different risk profiles than those with a history of AF. The specificity of the management of first-diagnosed AF patients was presented.
Background BALKAN-AF evaluated patterns of atrial fibrillation (AF) management in real-world clinical practice in the Balkans. The objectives were: to assess the proportion of patients with first-diagnosed AF in the BALKAN-AF cohort and to compare the management of patients with newly-diagnosed AF and those with previously known AF in clinical practice. Methods Consecutive patients from 7 Balkan countries were enrolled prospectively to the snapshot BALKAN-AF survey. Results Of 2712 enrolled patients, 2677 (98.7%) with complete data were included. 631 (23.6%) patients had newly-diagnosed AF and 2046 (76.4%) patients had known AF. Patients with newly-diagnosed AF were more likely to be hospitalized for AF and to receive single antiplatelet therapy (SAPT) alone and less likely to receive OACs than those with known AF (all p < 0.001). The use of OAC was not significantly associated with the CHA2DS2-VASc (p = 0.624) or HAS-BLED score (p = 0.225) on univariate analysis. Treatment in capital city, hypertension, dilated cardiomyopathy, mitral valve disease, country of residence or rate control strategy were independent predictors of OAC use, whilst non-emergency centre, treatment by cardiologist, paroxysmal AF, palpitations, symptoms attributable to AF (as judged by physician), mean heart rate and AF as the main reason for hospitalization were independent predictors of rhythm control strategy use. Conclusions In BALKAN-AF survey, patients with newly-diagnosed AF were more often hospitalized, less often received OAC and were more likely to receive SAPT alone. The use of OAC for stroke prevention has not been driven by the individual patient stroke risk.
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Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Stefan Simovic
- Cardiology Clinic, University Clinical Center of Kragujevac, Kragujevac, Serbia
| | | | - Milan Nedeljkovic
- Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, Belgrade University, Belgrade, Serbia
| | - Vilma Paparisto
- Clinic of Cardiology, University Hospital Center Mother Theresa, Tirana, Albania
| | - Ljilja Music
- Cardiology Clinic, University Clinical Center of Montenegro, University of Podgorica, Medical Faculty, Podgorica, Montenegro
| | - Evgenii Goshev
- National Heart Hospital, Coronary Care Unit, Sofia, Bulgaria
| | - Anca Rodica Dan
- Colentina University Hospital, Cardiology Department, Bucharest, Romania
| | - Sime Manola
- Clinical Center Sestre Milosrdnice, Zagreb, Croatia
| | - Zumreta Kusljugic
- Clinic of Internal Medicine, Cardiology Department, University Clinical Center Tuzla, Medical Faculty, Tuzla, Bosnia and Herzegovina
| | | | - Dobromir Dobrev
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
| | - Gheorghe-Andrei Dan
- Medicine University “Carol Davila”, Colentina University Hospital, Bucharest, Romania
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
- School of Medicine, Belgrade University, Belgrade, Serbia
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Tatjana S. Potpara
- Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, Belgrade University, Belgrade, Serbia
- Corresponding author at: Cardiology Clinic, Clinical Center of Serbia, Visegradska 26, 11000 Belgrade, Serbia.
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Dalgaard F, Pieper K, Verheugt F, Camm AJ, Fox KA, Kakkar AK, Pallisgaard JL, Rasmussen PV, Weert HV, Lindhardt TB, Torp-Pedersen C, Gislason GH, Ruwald MH, Harskamp RE. GARFIELD-AF model for prediction of stroke and major bleeding in atrial fibrillation: a Danish nationwide validation study. BMJ Open 2019; 9:e033283. [PMID: 31719095 PMCID: PMC6858250 DOI: 10.1136/bmjopen-2019-033283] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES To externally validate the accuracy of the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) model against existing risk scores for stroke and major bleeding risk in patients with non-valvular AF in a population-based cohort. DESIGN Retrospective cohort study. SETTING Danish nationwide registries. PARTICIPANTS 90 693 patients with newly diagnosed non-valvular AF were included between 2010 and 2016, with follow-up censored at 1 year. PRIMARY AND SECONDARY OUTCOME MEASURES External validation was performed using discrimination and calibration plots. C-statistics were compared with CHA2DS2VASc score for ischaemic stroke/systemic embolism (SE) and HAS-BLED score for major bleeding/haemorrhagic stroke outcomes. RESULTS Of the 90 693 included, 51 180 patients received oral anticoagulants (OAC). Overall median age (Q1, Q3) were 75 (66-83) years and 48 486 (53.5%) were male. At 1-year follow-up, a total of 2094 (2.3%) strokes/SE, 2642 (2.9%) major bleedings and 10 915 (12.0%) deaths occurred. The GARFIELD-AF model was well calibrated with the predicted risk for stroke/SE and major bleeding. The discriminatory value of GARFIELD-AF risk model was superior to CHA2DS2VASc for predicting stroke in the overall cohort (C-index: 0.71, 95% CI: 0.70 to 0.72 vs C-index: 0.67, 95% CI: 0.66 to 0.68, p<0.001) as well as in low-risk patients (C-index: 0.64, 95% CI: 0.59 to 0.69 vs C-index: 0.57, 95% CI: 0.53 to 0.61, p=0.007). The GARFIELD-AF model was comparable to HAS-BLED in predicting the risk of major bleeding in patients on OAC therapy (C-index: 0.64, 95% CI: 0.63 to 0.66 vs C-index: 0.64, 95% CI: 0.63 to 0.65, p=0.60). CONCLUSION In a nationwide Danish cohort with non-valvular AF, the GARFIELD-AF model adequately predicted the risk of ischaemic stroke/SE and major bleeding. Our external validation confirms that the GARFIELD-AF model was superior to CHA2DS2VASc in predicting stroke/SE and comparable with HAS-BLED for predicting major bleeding.
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Affiliation(s)
- Frederik Dalgaard
- Cardiology, Gentofte Hospital, Hellerup, Copenhagen, Denmark
- Duke Clinical Research Institute, Duke University, Durham, United States
| | - Karen Pieper
- Duke Clinical Research Institute, Duke University, Durham, United States
- Department of Clinical Research, Thrombosis Research Institute, London, UK
| | - Freek Verheugt
- Onze Lieve Vrouwe Gasthuis, Amsterdam, Noord-Holland, the Netherlands
| | - A John Camm
- Department of Cardiology, University of London St George's Molecular and Clinical Sciences Research Institute, London, UK
| | - Keith Aa Fox
- Cardiology, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ajay K Kakkar
- Department of Clinical Research, Thrombosis Research Institute, London, UK
- Department of Surgery, University College London, London, United Kingdom
| | | | | | - Henk van Weert
- Department of General Practice, Amsterdam UMC, Amsterdam Public Health and Amsterdam Cardiovascular Sciences Research Institutes, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Christian Torp-Pedersen
- Cardiology, Gentofte Hospital, Hellerup, Copenhagen, Denmark
- Department of Clinical Investigation and Cardiology, Nordsjællands Hospital, Hillerod, Denmark
| | - Gunnar H Gislason
- Cardiology, Gentofte Hospital, Hellerup, Copenhagen, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
- The National Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Martin H Ruwald
- Cardiology, Gentofte Hospital, Hellerup, Copenhagen, Denmark
| | - Ralf E Harskamp
- Department of General Practice, Amsterdam UMC, Amsterdam Public Health and Amsterdam Cardiovascular Sciences Research Institutes, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Paulin BK, Cedric KK, Tamomh AG, Hui YD. Assessment of cardiac biomarkers (troponin, B-type natriuretic peptide, and D-dimer) in patients with non-valvular atrial fibrillation and stroke. Int J Health Sci (Qassim) 2019; 13:3-12. [PMID: 31745392 PMCID: PMC6852499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Atrial fibrillation (AF) is the most common arrhythmia treated in clinical practice and the association of this arrhythmia with stroke has long been recognized. The combination of associated factors to identify stroke risk is still unclear; therefore, we aimed to determine the association between additional risk factors for non-valvular AF (NVAF) and the first onset stroke patients and investigate the predictive ability of additional risks factors such as cardiac biomarkers and AF status for odds of incident stroke. MATERIALS AND METHODS We included 455 patients who suffered from NVAF divided into two distinct groups (case-control observational study). Those two groups were based on whether the patients were having a first onset stroke (stroke group) or not having a stroke (non-stroke group). We made the baseline characteristic of our sample group from the substantial evidence of risk factors, lifestyle, and type of AF; to controversial risk described in the new international guideline of AF. RESULTS Statistically revealed that heart failure, coronary disease, cigarette smoking, type of AF, warfarin treatment, high sensitive troponin, and B-type natriuretic peptide (BNP) are associated with stroke in NVAF patients (P < 0.05). Otherwise, age, sex, hypertension, kidney disease, diabetes, thyroid disease, alcohol intake, season, aspirin, and D-dimer medication were not associated with stroke (P > 0.05). Multivariate analysis of age, smokers, coronary heart disease, heart failure, high sensitive troponin level, BNP, permanent AF, and warfarin was associated (P < 0.05). The combination of biomarkers with the clinical features can be useful (CHA2DS2-VASC/BS) for the prediction of stroke than CHA2DS2-VASC alone (P < 0.05). CONCLUSION Impact of all associated factors and biological markers as additional risk factors may carry a synergy in this life-threatening event. In addition, may hold a clinical role to redefine and predict stroke events better than the current CHA2DS2-VASC.
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Affiliation(s)
| | - Kabulo K. Cedric
- Department of Pathology and Stomatology, Dalian Medical University, Dalian, China
| | - Abdelhakam G. Tamomh
- Department of Microbiology and Immunology, College of Medical Laboratory, Dalian Medical University, Dalian, China
- Department of Parasitology and Medical Entomology, Faculty of Medical Laboratory Sciences University of El Imam El Mahdi, Kosti, Sudan
| | - Yang Dong Hui
- Department of Cardiology, Dalian Medical University, Dalian, China
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Wojszel ZB, Kasiukiewicz A. Determinants of anticoagulant therapy in atrial fibrillation at discharge from a geriatric ward: cross sectional study. J Thromb Thrombolysis 2019; 49:18-26. [PMID: 31471772 PMCID: PMC6954132 DOI: 10.1007/s11239-019-01937-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Oral anticoagulants (OACs) are effective in preventing stroke in older people with atrial fibrillation (AF), but they are often underused in this particularly high-risk population. The aim of the study was to identify health and functional determinants of oral anticoagulant therapy (OA) in AF at discharge from a geriatric sub-acute ward. A cross-sectional study was conducted and patients who presented with atrial fibrillation were analyzed. They were interviewed, examined, assessed with comprehensive geriatric assessment protocol, and had their hospital records analyzed. Relative risks for OA were counted and multivariable logistic regression model was built. 95 patients took part in the study (22.8% of 416 consecutively admitted to the department, 31.9% men, 73.7% 80 + year-old). 25.8% of them were on antiplatelet drugs and 58.9% on OACs. The percentage on OACs increased significantly to 73.7% at discharge (p = 0.004), mainly due to the new OACs prescription (from 11.8 to 33.3%; p < 0.001). Severe frailty (7 point Clinical Frailty Scale ≥ 6) and anemia presence, but not the risk of bleeding according to the HAS-BLED score, significantly decreased the probability of OACs prescription at discharge. There was also a trend for an association of OACs prescription with the higher total score of CHA2DS2-VASc scale. We conclude that in the real-life population of patients with AF comprehensive geriatric assessment might allow to increase significantly the number of patients on OACs, but it is limited by patient’s frailty status and anemia diagnosis.
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Affiliation(s)
- Z B Wojszel
- Department of Geriatrics, Medical University of Bialystok, Fabryczna Str. 27, 15-471, Bialystok, Poland. .,Department of Geriatrics, Hospital of the Ministry of Interior in Bialystok, Bialystok, Poland.
| | - A Kasiukiewicz
- Department of Geriatrics, Medical University of Bialystok, Fabryczna Str. 27, 15-471, Bialystok, Poland.,Department of Geriatrics, Hospital of the Ministry of Interior in Bialystok, Bialystok, Poland
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Schultze A, Graham S, Nordstrom BL, Mehmud F, Ramagopalan SV. Commonly used definitions in real-world studies may underestimate the prevalence of renal disease among nonvalvular atrial fibrillation patients. J Comp Eff Res 2019; 8:961-968. [PMID: 31317772 DOI: 10.2217/cer-2019-0070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To describe comorbidities among treated nonvalvular atrial fibrillation (NVAF) patients and assess the impact of using different time ('look back' windows) on the prevalence estimates. Patients & methods: We included all adult nonvalvular atrial fibrillation patients newly initiating treatment in the Clinical Practice Research Datalink. Comorbidities included in the Charlson Comorbidity Index were defined using an all available, 3- and 1-year look back window before the start of treatment. Results: The prevalence of comorbidities was high and increased when using longer look back windows; the largest difference was observed for renal disease (+15.6%). Conclusion: Our findings emphasize the importance of using all available data when characterizing chronic conditions and highlights the high comorbidity burden in this population.
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Affiliation(s)
| | | | | | - Faisal Mehmud
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, UK
| | - Sreeram V Ramagopalan
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, UK
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Predictors of NOAC versus VKA use for stroke prevention in patients with newly diagnosed atrial fibrillation: Results from GARFIELD-AF. Am Heart J 2019; 213:35-46. [PMID: 31128503 DOI: 10.1016/j.ahj.2019.03.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/27/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION A principal aim of the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) was to document changes in treatment practice for patients with newly diagnosed atrial fibrillation during an era when non-vitamin K antagonist oral anticoagulants (NOACs) were becoming more widely adopted. In these analyses, the key factors which determined the choice between NOACs and vitamin K antagonists (VKAs) are explored. METHODS Logistic least absolute shrinkage and selection operator regression determined predictors of NOAC and VKA use. Data were collected from 24,137 patients who were initiated on AC ± antiplatelet (AP) therapy (NOAC [51.4%] or VKA [48.6%]) between April 2013 and August 2016. RESULTS The most significant predictors of AC therapy were country, enrolment year, care setting at diagnosis, AF type, concomitant AP, and kidney disease. Patients enrolled in emergency care or in the outpatient setting were more likely to receive a NOAC than those enrolled in hospital (OR 1.16 [95% CI: 1.04-1.30], OR: 1.15 [95% CI: 1.05-1.25], respectively). NOAC prescribing seemed to be favored in lower-risk groups, namely, patients with paroxysmal AF, normotensive patients, and those with moderate alcohol consumption, but also the elderly and patients with acute coronary syndrome. By contrast, VKAs were preferentially used in patients with permanent AF, moderate to severe kidney disease, heart failure, vascular disease, and diabetes and with concomitant AP. CONCLUSION GARFIELD-AF data highlight marked heterogeneity in stroke prevention strategies globally. Physicians are adopting an individualized approach to stroke prevention where NOACs are favored in patients with a lower stroke risk but also in the elderly and patients with acute coronary syndrome.
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Abstract
PURPOSE OF REVIEW Despite the increasing use of NOACs, there is still uncertainty on how to treat NOAC patients presenting with neurological emergencies. Initial assessment of coagulation status is challenging but essential in these patients to provide best-possible treatment in case of ischemic or hemorrhagic stroke. Meanwhile, anticoagulation reversal strategies have been suggested; yet, the optimal management is still unestablished. The current review aims to provide up-to-date information on (i) how to identify patients with NOAC intake, (ii) which therapies are feasible in the setting of ischemic and hemorrhagic stroke as well as traumatic intracranial hemorrhage, and (iii) how to proceed with patients requiring emergency lumbar puncture. RECENT FINDINGS Despite several expert opinions, there is still an ongoing debate which NOAC patients presenting with ischemic stroke may benefit from recanalizing strategies and whether these treatment approaches can be performed safely. Results from two phase IV trials investigating the efficacy of NOAC-specific reversal agents in case of major bleeding seem promising with regard to hemostatic parameters, but these antidotes have not been verified to clinically benefit patients, and approval by authorities in parts is still pending. Specific reversal agents are on the way and will provide new treatment options in patients with NOAC-related ischemic and hemorrhagic stroke. Up to now, the decision which patients should undergo recanalizing treatment for ischemic stroke, or which specific pharmacological reversal treatment in hemorrhagic stroke should be initiated, has to be made cautiously on an individual basis after assessing hemostatic parameters.
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Affiliation(s)
- Stefan T Gerner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany.
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Thromboembolic and haemorrhagic events in patients with atrial fibrillation: a prospective cohort study in UK primary and secondary care. Br J Gen Pract 2019; 69:e407-e412. [PMID: 31015222 DOI: 10.3399/bjgp19x702269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 11/29/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Strong evidence on the long-term safety and efficacy of different types of anticoagulants would help clinicians to prevent thromboembolic events among patients with atrial fibrillation (AF) while minimising the risk of haemorrhages. AIM To estimate the risk of thromboembolic and haemorrhagic events for patients with AF on antiplatelets or anticoagulants. DESIGN AND SETTING This was a cohort study using routinely collected UK primary and secondary care clinical data from patients with AF, aged ≥18 years, and with an indication to receive anticoagulation before April 2012. METHOD The risk of ischaemic stroke or transient ischaemic attack (TIA), coronary heart disease (CHD), peripheral artery disease (PAD), or gastrointestinal (GI) haemorrhage, between 1 April 2012 and 1 April 2017, was estimated using multivariate Cox regression models for patients on antiplatelets only, a combination of antiplatelets and vitamin K antagonists (VKAs), or novel oral anticoagulants (NOACs), and compared with those on VKAs only. RESULTS Compared with VKAs, antiplatelets were associated with a higher risk of stroke or TIA, hazard ratio (HR) 1.51, 95% confidence interval (CI) = 1.09 to 2.09, and GI haemorrhage, HR 1.79, 95% CI = 1.01 to 3.18. The risk of thromboembolic and haemorrhagic events was similar for those on a combination of antiplatelets and VKAs, or those on VKAs only. The risk was also similar for those on NOACs or VKAs, except for CHD, where it was higher for patients on NOACs, HR 2.07, 95% CI = 1.35 to 3.19. CONCLUSION Anticoagulants are associated with lower risk of thromboembolic and haemorrhagic events among patients with AF than antiplatelets. More research is required on the risk associated with VKAs or NOACs.
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40
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Maura G, Billionnet C, Drouin J, Weill A, Neumann A, Pariente A. Oral anticoagulation therapy use in patients with atrial fibrillation after the introduction of non-vitamin K antagonist oral anticoagulants: findings from the French healthcare databases, 2011-2016. BMJ Open 2019; 9:e026645. [PMID: 31005934 PMCID: PMC6500377 DOI: 10.1136/bmjopen-2018-026645] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES To describe (i) the trend in oral anticoagulant (OAC) use following the introduction of non-vitamin K antagonist oral anticoagulant (NOAC) therapy for stroke prevention in atrial fibrillation (AF) patients and (ii) the current patterns of use of NOAC therapy in new users with AF in France. DESIGN (i) Repeated cross-sectional study and (ii) population-based cohort study. SETTING French national healthcare databases (50 million beneficiaries). PARTICIPANTS (i) Patients with identified AF in 2011, 2013 and 2016 and (ii) patients with AF initiating OAC therapy in 2015-2016. PRIMARY AND SECONDARY OUTCOME MEASURES: (i) Trend in OAC therapy use in patients with AF and (ii) patterns of use of NOAC therapy in new users with AF. RESULTS Between 2011 and 2016, use of OAC therapy moderately increased (+16%), while use of antiplatelet therapy decreased (-22%) among all patients with identified AF. In 2016, among the 1.1 million AF patients, 66% used OAC therapy and were more likely to be treated by vitamin K antagonist (VKA) than NOAC therapy, including patients at higher risk of stroke (63.5%), while 33% used antiplatelet therapy. Among 192 851 new users of OAC therapy in 2015-2016 with identified AF, NOAC therapy (66.3%) was initiated more frequently than VKA therapy, including in patients at higher risk of stroke (57.8%). Reduced doses were prescribed in 40% of NOAC new users. Several situations of inappropriate use at NOAC initiation were identified, including concomitant use of drugs increasing the risk of bleeding (one in three new users) and potential NOAC underdosing. CONCLUSIONS OAC therapy use in patients with AF remains suboptimal 4 years after the introduction of NOACs for stroke prevention in France and improvement in appropriate prescribing regarding NOAC initiation is needed. However, NOAC therapy is now the preferred drug class for initiation of OAC therapy in patients with AF, including in patients at higher risk of stroke.
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Affiliation(s)
- Géric Maura
- Department of Studies in Public Health, French National Health Insurance (Caisse Nationale de l’Assurance Maladie/Cnam), Paris, France
- University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology - UMR 1219, Bordeaux, France
| | - Cécile Billionnet
- Department of Studies in Public Health, French National Health Insurance (Caisse Nationale de l’Assurance Maladie/Cnam), Paris, France
| | - Jérôme Drouin
- Department of Studies in Public Health, French National Health Insurance (Caisse Nationale de l’Assurance Maladie/Cnam), Paris, France
| | - Alain Weill
- Department of Studies in Public Health, French National Health Insurance (Caisse Nationale de l’Assurance Maladie/Cnam), Paris, France
| | - Anke Neumann
- Department of Studies in Public Health, French National Health Insurance (Caisse Nationale de l’Assurance Maladie/Cnam), Paris, France
| | - Antoine Pariente
- University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology - UMR 1219, Bordeaux, France
- CHU Bordeaux, Bordeaux, France
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Pirlog AM, Pirlog CD, Maghiar MA. DOACs vs Vitamin K Antagonists: a Comparison of Phase III Clinical Trials and a Prescriber Support Tool. Open Access Maced J Med Sci 2019; 7:1226-1232. [PMID: 31049112 PMCID: PMC6490485 DOI: 10.3889/oamjms.2019.289] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 04/07/2019] [Accepted: 04/08/2019] [Indexed: 01/27/2023] Open
Abstract
AIM: The purpose of this article was to systematically review the literature assessing the efficacy and safety of phase III clinical trials for each direct oral anticoagulant versus vitamin K antagonists and to design a “go-to” table for the prescriber. MATERIAL AND METHODS: A systematic review of specialist literature was conducted to identify RCTs which compared direct oral anticoagulants (DOACs) with standard warfarin treatment. Medline, Em-base, and the Cochrane databases were searched from January 2005- January 2019. The inclusion criteria were randomised controlled trials of oral anticoagulants in patients with non-valvular atrial fibrillation (NVAF). Four publications were phase III randomised control trials (RCTs) included in the final analysis. RESULTS: Regarding the primary outcome in RELY the results were 1.69% per 100-year patients (p/y) for Warfarin compared to 1.11% p/y dabigatran etexilate 150mg BD (twice daily). In ROCKET AF the rates of the primary outcome were 2.2% p/y for warfarin compared to 1.7% p/y for rivaroxaban 20 mg OD (once daily). In ARISTOTLE trial the rates of the primary outcome were 1.60% p/y for warfarin compared to 1.27% p/y for apixaban 5 mg BD. In ENGAGE AF TIMI, the rates of the primary outcome were 1.50% p/y for warfarin compared to 1.18% p/y for edoxaban 60mg BD. CONCLUSION: DOACs showed to be either noninferior or superior to warfarin with regards to the primary outcome with better safety patterns. Our “go-to” table provides a supportive tool for physicians in preventing medical errors when managing patients on oral anticoagulants.
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Affiliation(s)
- Alina-Maria Pirlog
- University of Oradea, Faculty of Medicine and Pharmacy, Department of General Medicine, Oradea, Romania
| | - Cristian Daniel Pirlog
- University of Oradea, Faculty of Medicine and Pharmacy, Department of Dentistry, Oradea, Romania
| | - Marius Adrian Maghiar
- University of Oradea, Faculty of Medicine and Pharmacy, Department of General Surgery, Oradea, Romania
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42
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Lowres N, Giskes K, Hespe C, Freedman B. Reducing Stroke Risk in Atrial Fibrillation: Adherence to Guidelines Has Improved, but Patient Persistence with Anticoagulant Therapy Remains Suboptimal. Korean Circ J 2019; 49:883-907. [PMID: 31535493 PMCID: PMC6753021 DOI: 10.4070/kcj.2019.0234] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 12/24/2022] Open
Abstract
Atrial fibrillation (AF) is a significant risk factor for avoidable stroke. Among high-risk patients with AF, stroke risk can be mitigated using oral anticoagulants (OACs), however reduction is largely contingent on physician prescription and patient persistence with OAC therapy. Over the past decade significant advances have occurred, with revisions to clinical practice guidelines relating to management of stroke risk in AF in several countries, and the introduction of non-vitamin K antagonist OACs (NOACs). This paper summarises the evolving body of research examining guideline-based clinician prescription over the past decade, and patient-level factors associated with OAC persistence. The review shows clinicians' management over the past decade has increasingly reflected guideline recommendations, with an increasing proportion of high-risk patients receiving OACs, driven by an upswing in NOACs. However, a treatment gap remains, as 25–35% of high-risk patients still do not receive OAC treatment, with great variation between countries. Reduction in stroke risk directly relates to level of OAC prescription and therapy persistence. Persistence and adherence to OAC thromboprophylaxis remains an ongoing issue, with 2-year persistence as low as 50%, again with wide variation between countries and practice settings. Multiple patient-level factors contribute to poor persistence, in addition to concerns about bleeding. Considered review of individual patient's factors and circumstances will assist clinicians to implement appropriate strategies to address poor persistence. This review highlights the interplay of both clinician's awareness of guideline recommendations and understanding of individual patient-level factors which impact adherence and persistence, which are required to reduce the incidence of preventable stroke attributable to AF.
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Affiliation(s)
- Nicole Lowres
- Heart Research Institute, Charles Perkins Centre, Camperdown, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Katrina Giskes
- Heart Research Institute, Charles Perkins Centre, Camperdown, Australia.,School of Medicine, The University of Notre Dame, Sydney, Australia
| | - Charlotte Hespe
- School of Medicine, The University of Notre Dame, Sydney, Australia
| | - Ben Freedman
- Heart Research Institute, Charles Perkins Centre, Camperdown, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Department of Cardiology, Concord Hospital, The University of Sydney Concord Clinical School, Concord, Australia
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43
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Effectiveness of CHA 2DS 2-VASc based decision support on stroke prevention in atrial fibrillation: A cluster randomised trial in general practice. Int J Cardiol 2018; 273:123-129. [PMID: 30224261 DOI: 10.1016/j.ijcard.2018.08.096] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/23/2018] [Accepted: 08/30/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Guidelines on atrial fibrillation (AF) recommend the CHA2DS2-VASc rule for anticoagulant decision-making, but underuse exists. We studied the impact of an automated decision support on stroke prevention in patients with AF in a cluster randomised trial in general practice. METHODS Intervention practices were provided with a CHA2DS2-VASc based anticoagulant treatment recommendation. Reference practices provided care as usual. The primary outcome was incidence of ischaemic stroke, transient ischaemic attack (TIA) and/or thromboembolism (TE). Secondary outcomes were bleeding and the proportion of patients on guideline recommended anticoagulant treatment. RESULTS In total, 1129 AF patients were included in the 19 intervention practices and 1226 AF patients in the 19 reference practices. The median age was 77 (interquartile range (IQR) 68-75) years, the median CHA2DS2-VASc score was 3.0 (IQR 2.0-5.0). Underuse of anticoagulants in patients with CHA2DS2-VASc score ≥ 2 was 6.6%. After a median follow-up of 2.7 years (IQR 2.3-3.0), the incidence rate per 100 person-years of ischaemic stroke/TIA/TE was 1.96 in the intervention group and 1.42 in the reference group (hazard ratio (HR) 1.3, 95% C.I. 0.8-2.1). No difference was observed in the rate of bleeding (0.79 versus 0.82), or in the underuse (7.2% versus 8.2%) or overuse (8.0% versus 7.9%) of anticoagulation. CONCLUSIONS In this study in patients with AF in general practice, underuse of anticoagulants was relatively low. Providing practitioners with CHA2DS2-VASc based decision support did not result in a reduction in stroke incidence, affect bleeding risk or anticoagulant over- or underuse.
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Yokoyama S, Tanaka Y, Nakagita K, Hosomi K, Takada M. Bleeding Risk of Warfarin and Direct Oral Anticoagulants in Younger Population: A Historical Cohort Study Using a Japanese Claims Database. Int J Med Sci 2018; 15:1686-1693. [PMID: 30588192 PMCID: PMC6299405 DOI: 10.7150/ijms.28877] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 09/14/2018] [Indexed: 12/18/2022] Open
Abstract
A historical cohort analysis of the Japan medical data center (JMDC) claims databases was performed to compare the incidence rates of bleeding events with warfarin (WF) versus direct oral anticoagulant (DOAC) treatment in patients with non-valvular atrial fibrillation. The aim of this study is to clarify the risk factors for bleeding events in younger patients newly treated with WF or DOAC in clinical practice setting. Patients who newly initiated WF or DOAC treatment from April 2012 to March 2015 were selected from the JMDC claims database. A 1:1 propensity score matching analysis was used for new users of WF or DOAC. Kaplan-Meier curves were generated to depict the time to bleeding event (total bleeding events, gastrointestinal hemorrhage, and intracranial hemorrhage) during the follow-up period. Cox proportional regression models were used to estimate the hazard ratios for total bleeding events caused by oral anticoagulants. Overall, 2,046 patients (503 WF and 1,543 DOAC) were included. After applying propensity score matching, Kaplan-Meier analysis of the WF and DOAC groups displayed comparable incidences of total bleeding events, gastrointestinal hemorrhage, and intracranial hemorrhage. Cox proportional hazards modeling showed that the use of WF was not associated with total bleeding events compared with DOAC (hazard ratio: 1.21, 95% confidence interval: 0.93-1.54, p = 0.15). This historical cohort study using a claims database indicates that the bleeding risk of DOAC was comparable to that of WF in Japanese younger population.
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Affiliation(s)
- Satoshi Yokoyama
- Division of Clinical Drug Informatics, Faculty of Pharmacy Kindai University, Japan
| | - Yuki Tanaka
- Division of Clinical Drug Informatics, Faculty of Pharmacy Kindai University, Japan
| | - Kazuki Nakagita
- Division of Clinical Drug Informatics, Faculty of Pharmacy Kindai University, Japan.,Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kouichi Hosomi
- Division of Clinical Drug Informatics, Faculty of Pharmacy Kindai University, Japan
| | - Mitsutaka Takada
- Division of Clinical Drug Informatics, Faculty of Pharmacy Kindai University, Japan
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