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Bul M, Shaikh F, McDonagh J, Ferguson C. Frailty and oral anticoagulant prescription in adults with atrial fibrillation: A systematic review. Aging Med (Milton) 2023; 6:195-206. [PMID: 37287671 PMCID: PMC10242262 DOI: 10.1002/agm2.12214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/08/2022] [Accepted: 05/12/2022] [Indexed: 11/10/2022] Open
Abstract
Objectives The objectives of this study were to determine the prevalence of frailty in the context of atrial fibrillation (AF); to identify the most commonly used frailty instruments in AF; and to describe the effect of frailty on non-vitamin K oral anticoagulant (NOAC) prescription for stroke prevention in adults with AF. Methods A systematic search of databases, including Medline, Embase, Web of Science, Cochrane Library, Scopus, and CINAHL, was conducted using search terms including "atrial fibrillation," "frailty," and "anticoagulation." A narrative synthesis was undertaken. Results A total of 92 articles were screened, and 12 articles were included. The mean age of the participants (n = 212,111) was 82 years (range = 77-85 years) with 56% of participants identified as frail and 44% identified non-frail. A total of five different frailty instruments were identified: the Frailty Phenotype (FP; n = 5, 42%), the Clinical Frailty Scale (CFS; n = 4, 33%), Cumulative Deficit Model of Frailty (CDM; n = 1, 8%), Edmonton Frail Scale (n = 1, 8%) and the Resident Assessment Instrument - Minimum Data Set (RAI-MDS 2.0; n = 1, 8%). Frailty was identified as an important barrier to anticoagulant therapy with 52% of the frail population anticoagulated vs 67% non-frail. Conclusion Frailty is an important consideration in anticoagulation decision making for stroke prevention in patients with AF. There is scope to improve frailty screening and treatment. Frailty status is an important risk marker and should be considered when evaluating stroke risk alongside congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke, transient ischemic attack, or thromboembolism, vascular disease, age 65-74 years, sex category (CHA2DS2-VASc) and Hypertension, Abnormal renal/liver function, Stroke, Bleeding, Labile, Elderly, and Drugs (HAS-BLED) scores.
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Affiliation(s)
- Mary Bul
- Western Sydney UniversityParramattaNew South WalesAustralia
| | - Fahad Shaikh
- Western Sydney UniversityParramattaNew South WalesAustralia
- Western Sydney Nursing and Midwifery Research CentreWestern Sydney Local Health District and Western Sydney University, Blacktown Clinical and Research School, Blacktown HospitalBlacktownNew South WalesAustralia
| | - Julee McDonagh
- School of Nursing and Midwifery/College of Health, Medicine and WellbeingThe University of Newcastle, Central Coast Clinical School, Gosford HospitalGosfordNew South WalesAustralia
| | - Caleb Ferguson
- Western Sydney UniversityParramattaNew South WalesAustralia
- Western Sydney Nursing and Midwifery Research CentreWestern Sydney Local Health District and Western Sydney University, Blacktown Clinical and Research School, Blacktown HospitalBlacktownNew South WalesAustralia
- School of Nursing, Faculty of Science, Medicine and HealthUniversity of WollongongWollongongNew South WalesAustralia
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Presta R, Brunetti E, Polidori MC, Bo M. Impact of frailty models on the prescription of oral anticoagulants and on the incidence of stroke, bleeding, and mortality in older patients with atrial fibrillation: a systematic review. Ageing Res Rev 2022; 82:101761. [PMID: 36270605 DOI: 10.1016/j.arr.2022.101761] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/30/2022] [Accepted: 10/14/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Frailty is common in older patients with atrial fibrillation (AF). Current guidelines recommend oral anticoagulant therapy (OAT) except in case of severe frailty or reduced life expectancy, but definitive evidence on which "frailty" tools may help to identify older AF patients expected to derive little or no benefit from OAT is still lacking. Some persistent uncertainties may derive from the different clinical implications that the two major models of frailty, namely the frail phenotype (FP) and the deficit accumulation model (DAM), underlie. We thus conducted a systematic review of published studies to examine the association of the presence of frailty, categorized according to the FP and DAM, with 1) OAT prescription and 2) incidence of clinical outcomes (all-cause mortality, stroke and/or systemic embolism and major or clinically relevant non-major bleeding) in patients receiving OAT. METHODS Embase and MEDLINE were searched from inception until May 31st, 2022, for studies using a validated tool to identify frailty in subjects aged 65 years or older with a diagnosis of non-valvular AF; only studies on patients prescribed an OAT were considered eligible for the analyses involving clinical outcomes. The protocols for each review question have been registered in PROSPERO database (CRD42022308623 and CRD42022308628). FINDINGS Twenty-three studies exploring the association between frailty and OAT prescription on a total of 504 719 subjects were included. Patients with increasing severity of DAM frailty showed consistently lower OAT prescription rates than non-frail patients, whereas use of OAT did not significantly differ between patients with the FP compared with non-frail subjects. Eleven studies exploring the association between frailty and clinical outcomes on a total of 41 985 individuals receiving oral anticoagulation were included. Compared with non-frail subjects, a higher risk of all-cause mortality and clinical outcomes could be observed for AF patients prescribed with OAT with severe frailty according to the DAM, with inconclusive findings for the FP. High levels of heterogeneity were observed in both groups of studies; therefore, a meta-analysis was not performed. CONCLUSIONS Due to the great heterogeneity among different validated frailty measures, indiscriminately relying on "frailty" should not be regarded as the gold standard for clinical decision-making about stroke prevention in older AF patients. Present findings suggest that severe frailty according to the DAM is associated with less use of OAT and increased risk of all-cause mortality, thereby representing at the moment the most reasonable tool to efficiently recognize patients with limited life expectancy and for whom there is so far scant, if any, evidence of a clinical benefit of OAT.
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Affiliation(s)
- Roberto Presta
- Section of Geriatrics, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Molinette, Corso Bramante 88-90, 10126 Turin, Italy.
| | - Enrico Brunetti
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; Section of Internal Medicine, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Sant'Anna, Corso Bramante 88-90, 10126 Turin, Italy.
| | - Maria Cristina Polidori
- Ageing Clinical Research, Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937 Cologne, Germany; Cologne Excellence Cluster On Cellular Stress-Responses in Aging-Associated Diseases (CECAD), University of Cologne, Faculty of Medicine and University Hospital Cologne, Joseph-Stelzmann Straße 26, 50931 Cologne, Germany.
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Molinette, Corso Bramante 88-90, 10126 Turin, Italy.
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Characteristics of warfarin under-prescription in older adults with atrial fibrillation. IJC HEART & VASCULATURE 2021; 37:100914. [PMID: 34825049 PMCID: PMC8603017 DOI: 10.1016/j.ijcha.2021.100914] [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: 08/07/2021] [Revised: 10/27/2021] [Accepted: 10/31/2021] [Indexed: 12/04/2022]
Abstract
Background The prevalence of atrial fibrillation (AF) and atrial flutter (AFl) increases with age. Under-prescription of anticoagulants in older adults can lead to increased morbidity and mortality. We analyzed warfarin prescription patterns in older adults. Methods In this observational single-center study, we analyzed 2179 consecutive patients with admission diagnosis of AF or AFl. Patients were divided into “older” (≥ 75 years old) and “younger” (<75 years old) groups. Prescription patterns of warfarin were analyzed. Patients discharged from the hospital on a non-warfarin anticoagulation were excluded. Results Of the 1988 patients analyzed, 46.9% were ≥75 years old, of which 50.8% were prescribed warfarin. There was no association between mean CHA2DS2-VASc score and warfarin prescription on discharge (OR = 1.06 (95% CI 0.93–1.21), p = 0.388) in the older group. After adjusting for hypertension, renal function, and Black race, warfarin prescription in older adults was independently associated with lower aspirin prescription rates (OR = 0.57 (95% CI 0.43–0.75), p < 0.001), lower body mass index (OR = 1.03 (95% CI 1.01–1.06), p = 0.018), and lower hemoglobin levels (OR = 1.11 (95% CI 1.04–1.19), p = 0.002). Conclusions In our study, older adults (≥75 years old) with AF and AFl tended to have lower rates of warfarin prescription despite higher CHA2DS2-VASc score and higher risk of thromboembolic events. Anemia, lower body weight, and aspirin use were characteristics associated with warfarin under-prescription.
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The impact of mental health conditions on oral anticoagulation therapy and outcomes in patients with atrial fibrillation: A systematic review and meta-analysis. Am J Prev Cardiol 2021; 7:100221. [PMID: 34611647 PMCID: PMC8387298 DOI: 10.1016/j.ajpc.2021.100221] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/02/2021] [Accepted: 06/24/2021] [Indexed: 12/14/2022] Open
Abstract
One third of patients with atrial fibrillation (AF) are estimated to suffer from mental health conditions (MHCs). We conducted a systematic review and meta-analysis to investigate the impact of MHCs on the prevalence and quality of oral anticoagulation (OAC) therapy and outcomes in patients with AF. Medline database was searched for studies published before March 1st 2021 evaluating AF patients with comorbid MHCs reporting on the prevalence of OAC therapy, time in therapeutic range (TTR) in warfarin-receiving patients, adherence to OAC therapy or adverse outcomes (ischemic stroke, hemorrhage or mortality). Studies reporting on outcome events were included in the meta-analysis. The literature search yielded 17 studies including 977,535 patients that fulfilled the inclusion criteria of this review. AF patients with MHCs had a lower prevalence of OAC use and poorer TTR compared with patients without MHCs. Evidence on OAC quality in patients receiving direct oral anticoagulants (DOACs) was minimal and inconclusive. A decrease in depression-associated deficit in OAC prevalence was observed after the introduction of DOACs. Pooled analysis of five studies reporting on outcomes showed that MHCs were an independent risk factor for both stroke (RR 1.25, 95%CI 1.08-1.45, I2 0%) and major bleeding (RR 1.17, 95%CI 1.08-1.27, I2 27%). Data on mortality were lacking and therefore not included in the meta-analysis. Evidence on the impact of specific MHCs on the outcomes were inadequate. In conclusion, MHCs are independent risk factors for stroke and major bleeding in patients with AF. Future studies are needed to confirm the findings of this meta-analysis, to evaluate the prognostic impact of different MHCs and to clarify whether the introduction of DOACs might have improved the outcomes of these patients.
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Mostaza JM, Suarez C, Cepeda JM, Manzano L, Sánchez D. Demographic, clinical, and functional determinants of antithrombotic treatment in patients with nonvalvular atrial fibrillation. BMC Cardiovasc Disord 2021; 21:384. [PMID: 34372782 PMCID: PMC8351138 DOI: 10.1186/s12872-021-02019-0] [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: 09/21/2020] [Accepted: 04/15/2021] [Indexed: 11/10/2022] Open
Abstract
Background This study assessed the sociodemographic, functional, and clinical determinants of antithrombotic treatment in patients with nonvalvular atrial fibrillation (NVAF) attended in the internal medicine setting. Methods A multicenter, cross-sectional study was conducted in NVAF patients who attended internal medicine departments for either a routine visit (outpatients) or hospitalization (inpatients).
Results A total of 961 patients were evaluated. Their antithrombotic management included: no treatment (4.7%), vitamin K antagonists (VKAs) (59.6%), direct oral anticoagulants (DOACs) (21.6%), antiplatelets (6.6%), and antiplatelets plus anticoagulants (7.5%). Permanent NVAF and congestive heart failure were associated with preferential use of oral anticoagulation over antiplatelets, while intermediate-to high-mortality risk according to the PROFUND index was associated with a higher likelihood of using antiplatelet therapy instead of oral anticoagulation. Longer disease duration and institutionalization were identified as determinants of VKA use over DOACs. Female gender, higher education, and having suffered a stroke determined a preferential use of DOACs. Conclusions This real-world study showed that most elderly NVAF patients received oral anticoagulation, mainly VKAs, while DOACs remained underused. Antiplatelets were still offered to a proportion of patients. Longer duration of NVAF and institutionalization were identified as determinants of VKA use over DOACs. A poor prognosis according to the PROFUND index was identified as a factor preventing the use of oral anticoagulation.
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Affiliation(s)
- Jose María Mostaza
- Department of Internal Medicine, Hospital Carlos III, Calle Sinesio Delgado, 10, 28029, Madrid, Spain.
| | - Carmen Suarez
- Department of Internal Medicine, Hospital Universitario de La Princesa, Madrid, Spain
| | - Jose María Cepeda
- Department of Internal Medicine, Hospital Vega Baja, Orihuela, Alicante, Spain
| | - Luis Manzano
- Department of Internal Medicine, Hospital Ramón Y Cajal, Universidad de Alcalá, Ramón Y Cajal Health Research Institute (IRYCIS), Madrid, Spain
| | - Demetrio Sánchez
- Department of Internal Medicine, Hospital Nuestra Señora De Sonsoles, Ávila, Spain
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Depression and Uptake of Oral Anticoagulation Therapy in Patients With Atrial Fibrillation: A Danish Nationwide Cohort Study. Med Care 2020; 58:216-224. [PMID: 31876644 DOI: 10.1097/mlr.0000000000001268] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Oral anticoagulation therapy (OAT) in patients with atrial fibrillation (AF) is a highly important preventive intervention, perhaps especially in those with comorbid depression, who have a worse prognosis. However, OAT may pose particular challenges in depressed patients. OBJECTIVES To assess whether AF patients with depression have lower OAT uptake. METHODS This nationwide register-based 2005-2016 cohort study of all Danes with AF and OAT indication (CHA2DS2VASc stroke risk score ≥2) assessed OAT initiation within 90 days in those with incident AF (N=147,162) and OAT prevalence in those with prevalent AF (N=192,656). The associations of depression with both outcomes were estimated in regression analyses with successive adjustment for socioeconomic characteristics and somatic and psychiatric comorbidity. RESULTS Comorbid depression was significantly associated with lower frequency of OAT initiation in incident AF patients {adjusted proportion differences (aPDs): -6.6% [95% confidence interval (CI), -7.4 to -5.9]} and lower prevalence of OAT [aPD: -4.2% (95% CI, -4.7 to -3.8)] in prevalent AF patients. Yet, the OAT uptake increased substantially during the period, particularly in depressed patients [aPD for OAT prevalence in 2016: -0.8% (95% CI, -1.6 to -0.0)]. CONCLUSIONS Comorbid depression was associated with a significantly lower OAT uptake in patients with AF, which questions whether depressed patients receive sufficient support to manage this consequential cardiac condition. However, a substantial increase in the overall OAT uptake and a decrease of the depression-associated deficit in OAT were seen over the period during which OAT was developed through the introduction of new oral anticoagulation therapy.
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7
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Alpert JS. Bleeding Risk in Elderly Patients Receiving Anticoagulant Therapy: Should Dosage Be Reduced? Am J Med 2020; 133:523-524. [PMID: 31751527 DOI: 10.1016/j.amjmed.2019.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 11/13/2019] [Indexed: 01/17/2023]
Affiliation(s)
- Joseph S Alpert
- Professor of Medicine, Department of Medicine, University of Arizona, Tucson, AZ; Editor in Chief, The American Journal of Medicine.
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Wilkinson C, Todd O, Clegg A, Gale CP, Hall M. Management of atrial fibrillation for older people with frailty: a systematic review and meta-analysis. Age Ageing 2019; 48:196-203. [PMID: 30445608 PMCID: PMC6424377 DOI: 10.1093/ageing/afy180] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 09/18/2018] [Accepted: 10/24/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND despite a large and growing population of older people with frailty and atrial fibrillation (AF), there is a lack of guidance on optimal AF management in this high-risk group. OBJECTIVE to synthesise the existing evidence base on the association between frailty, AF and clinical outcomes. METHODS a systematic review of studies examining the association between validated measures of frailty, AF and clinical outcomes, and meta-analysis of the association between frailty and oral anticoagulation (OAC) prescription. RESULTS twenty studies (30,883 patients) were included, all observational. Fifteen were in hospital, four in the community, one in nursing care. Risk of bias was low-to-moderate. AF prevalence was 3%-38%. In people with AF, frailty was associated with increased stroke incidence, all-cause mortality, symptom severity and length of hospital stay.Meta-analysis of six studies showed frailty was associated with decreased OAC prescription at hospital admission (pooled adjusted OR 0.45 [95%CI 0.22-0.93], three studies), but not at discharge (pooled adjusted OR 0.40 [95%CI 0.13-1.23], three studies). A community-based study showed increased OAC prescription associated with frailty (OR 2.33 [95%CI 1.03-5.23]). CONCLUSION frailty is common, and associated with adverse clinical outcomes in patients with AF. There is evidence of an association between frailty status and OAC prescription, with different direction of effect in community compared with hospital cohorts. Despite the majority of care for older people being provided in the community, there is a lack of evidence on the association between frailty, AF, anticoagulation and clinical outcomes to guide optimal care in this setting.
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Affiliation(s)
- Chris Wilkinson
- Department of Clinical and Population Sciences, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Worsley Building, Level 11, Clarendon Way, Leeds, UK
- York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, UK
| | - Oliver Todd
- Academic Unit of Eldery Care and Rehabilitation, Bradford Institute for Health Research, University of Leeds, Bradford Royal Infirmary, Duckworth Lane, Bradford, UK
| | - Andrew Clegg
- Academic Unit of Eldery Care and Rehabilitation, Bradford Institute for Health Research, University of Leeds, Bradford Royal Infirmary, Duckworth Lane, Bradford, UK
| | - Chris P Gale
- Department of Clinical and Population Sciences, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Worsley Building, Level 11, Clarendon Way, Leeds, UK
- York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, UK
| | - Marlous Hall
- Department of Clinical and Population Sciences, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Worsley Building, Level 11, Clarendon Way, Leeds, UK
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Theou O, Squires E, Mallery K, Lee JS, Fay S, Goldstein J, Armstrong JJ, Rockwood K. What do we know about frailty in the acute care setting? A scoping review. BMC Geriatr 2018; 18:139. [PMID: 29898673 PMCID: PMC6000922 DOI: 10.1186/s12877-018-0823-2] [Citation(s) in RCA: 169] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/22/2018] [Indexed: 12/21/2022] Open
Abstract
Background The ability of acute care providers to cope with the influx of frail older patients is increasingly stressed, and changes need to be made to improve care provided to older adults. Our purpose was to conduct a scoping review to map and synthesize the literature addressing frailty in the acute care setting in order to understand how to tackle this challenge. We also aimed to highlight the current gaps in frailty research. Methods This scoping review included original research articles with acutely-ill Emergency Medical Services (EMS) or hospitalized older patients who were identified as frail by the authors. We searched Medline, CINAHL, Embase, PsycINFO, Eric, and Cochrane from January 2000 to September 2015. Results Our database search initially resulted in 8658 articles and 617 were eligible. In 67% of the articles the authors identified their participants as frail but did not report on how they measured frailty. Among the 204 articles that did measure frailty, the most common disciplines were geriatrics (14%), emergency department (14%), and general medicine (11%). In total, 89 measures were used. This included 13 established tools, used in 51% of the articles, and 35 non-frailty tools, used in 24% of the articles. The most commonly used tools were the Clinical Frailty Scale, the Frailty Index, and the Frailty Phenotype (12% each). Most often (44%) researchers used frailty tools to predict adverse health outcomes. In 74% of the cases frailty predicted the outcome examined, typically mortality and length of stay. Conclusions Most studies (83%) were conducted in non-geriatric disciplines and two thirds of the articles identified participants as frail without measuring frailty. There was great variability in tools used and more recently published studies were more likely to use established frailty tools. Overall, frailty appears to be a good predictor of adverse health outcomes. For frailty to be implemented in clinical practice frailty tools should help formulate the care plan and improve shared decision making. How this will happen has yet to be determined. Electronic supplementary material The online version of this article (10.1186/s12877-018-0823-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Olga Theou
- Department of Medicine, Dalhousie University, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada. .,Geriatric Medicine, QEII Health Sciences Centre, Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada.
| | - Emma Squires
- Geriatric Medicine, QEII Health Sciences Centre, Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada
| | - Kayla Mallery
- Geriatric Medicine, QEII Health Sciences Centre, Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada
| | - Jacques S Lee
- Sunnybrook Health Service, 2075 Bayview Avenue, BG-04, Toronto, ON, M4N 3M5, Canada
| | - Sherri Fay
- Geriatric Medicine, QEII Health Sciences Centre, Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada
| | - Judah Goldstein
- Emergency Health Services, 239 Brownlow Avenue, Suite 300, Dartmouth, NS, B3B 2B2, Canada
| | - Joshua J Armstrong
- Department of Health Sciences, Lakehead University, 955 Oliver Road, Thunder Bay, ON, P7B 5E1, Canada
| | - Kenneth Rockwood
- Geriatric Medicine, QEII Health Sciences Centre, Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada.,Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada
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Induruwa I, Amis E, Hannon N, Khadjooi K. The increasing burden of atrial fibrillation in acute medical admissions, an opportunity to optimise stroke prevention. J R Coll Physicians Edinb 2018. [PMID: 29537402 DOI: 10.4997/jrcpe.2017.405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Atrial fibrillation is a major risk factor for ischaemic stroke. We investigated whether active screening for atrial fibrillation in secondary care, followed by careful evaluation of risk factors and communication to general practitioners from stroke specialists, could increase appropriate anticoagulation prescription. Methods Between 1/9/14 and 28/2/15 all acute medical admissions were screened for atrial fibrillation at Cambridge University Hospital. Individualised letters were sent to the general practitioners of patients who it was felt would benefit from anticoagulation. Results In total, 847 patients with atrial fibrillation (15% prevalence, 52% female, median age 81.9 years, median CHA2DS2-VASc 4.4) were identified; 671 (79.2%) had known atrial fibrillation, and 176 (20.8%) were diagnosed on admission. After screening and identifying 'at risk' patients, 112 individualised letters were sent to GPs. A 91% response rate was achieved, resulting in an additional 43 individuals being appropriately anticoagulated. Conclusions Atrial fibrillation prevalence is significantly increasing among acute hospital admissions; these patients have high risk of cardioembolic stroke. Careful screening and identification in secondary care can lead to improved rates of anticoagulation.
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Affiliation(s)
- I Induruwa
- I Induruwa, Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK.
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Gosch M. [Oral anticoagulation in older adults with atrial fibrillation]. MMW Fortschr Med 2017; 159:70-76. [PMID: 29086256 DOI: 10.1007/s15006-017-9597-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Markus Gosch
- Paracelsus Medizinische Privatuniversität Nürnberg, Universitätsklinik für Geriatrie, Medizinische Klinik 2 - Schwerpunkt Geriatrie, Klinikum Nürnberg, Prof. Ernst Nathan Straße 1, D-90419, Nürnberg, Deutschland.
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Henrard S, Vandenabeele C, Marien S, Boland B, Dalleur O. Underuse of Anticoagulation in Older Patients with Atrial Fibrillation and CHADS2 Score ≥ 2: Are We Doing Better Since the Marketing of Direct Oral Anticoagulants? Drugs Aging 2017; 34:841-850. [DOI: 10.1007/s40266-017-0493-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Induruwa I, Evans NR, Aziz A, Reddy S, Khadjooi K, Romero-Ortuno R. Clinical frailty is independently associated with non-prescription of anticoagulants in older patients with atrial fibrillation. Geriatr Gerontol Int 2017; 17:2178-2183. [DOI: 10.1111/ggi.13058] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 01/18/2017] [Accepted: 02/20/2017] [Indexed: 12/29/2022]
Affiliation(s)
- Isuru Induruwa
- Department of Medicine for the Elderly; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
- Department of Clinical Neurosciences; University of Cambridge; Cambridge UK
| | - Nicholas R. Evans
- Department of Clinical Neurosciences; University of Cambridge; Cambridge UK
| | - Ayesha Aziz
- Department of Medicine for the Elderly; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Snigdha Reddy
- Department of Medicine for the Elderly; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Kayvan Khadjooi
- Department of Stroke Medicine; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Roman Romero-Ortuno
- Department of Medicine for the Elderly; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
- Clinical Gerontology Unit, Department of Public Health and Primary Care; University of Cambridge, Addenbrooke's Hospital; Cambridge UK
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Canavero I, Cavallini A, Sacchi L, Quaglini S, Arnò N, Perrone P, DeLodovici ML, Marcheselli S, Micieli G. Safely Addressing Patients with Atrial Fibrillation to Early Anticoagulation after Acute Stroke. J Stroke Cerebrovasc Dis 2016; 26:7-18. [PMID: 27614403 DOI: 10.1016/j.jstrokecerebrovasdis.2016.08.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 07/25/2016] [Accepted: 08/12/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND It has been widely reported that anticoagulants (ACs) are underused for primary and secondary prevention of ischemic stroke in patients with atrial fibrillation (AFib). Furthermore, precise evidence-based guidelines about the best timing for AC initiation after acute stroke are currently lacking. METHODS AND RESULTS In this retrospective, observational study, we analyzed prescription trends in AFib patients with acute ischemic stroke who were hospitalized in four neurologic stroke units of our region (Lombardia, Italy). In-hospital antithrombotic prescription was performed in highly heterogeneous patterns. A prestroke treatment with AC was the leading factor enhancing AC prescription during hospitalization. The other factors promoting AC were male gender, younger age, lower prestroke disability and stroke severity, and smaller stroke volumes. AFib subtype influenced AC prescription only in AC-naïve patients. Interestingly, Congestive heart failure, Hypertension, Age higher than 75 years, Diabetes, previous Stroke or TIA or thromboembolism, Vascular disease, Age 64-75 years, female Sex (CHA2DS2-VASc) and Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile INRs, Elderly, Drugs and alcohol (HAS-BLED) scores were not associated with AC prescription. However, patients who were treated with AC, including early treatment (<48 hours), showed a low rate of bleeding. CONCLUSIONS Our findings potentially suggest that, although apparently neglecting the common risk stratification tools, our neurologists were able to select the more suitable candidates for prompt AC treatment. Further studies are needed to develop new scoring systems to aid ischemic and hemorrhagic risk estimation in the secondary prevention of stroke.
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Affiliation(s)
- Isabella Canavero
- Department of Emergency Neurology and Stroke Unit, National Neurological Institute "Casimiro Mondino" IRCCS, Pavia, Italy.
| | - Anna Cavallini
- Department of Emergency Neurology and Stroke Unit, National Neurological Institute "Casimiro Mondino" IRCCS, Pavia, Italy
| | - Lucia Sacchi
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Silvana Quaglini
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Natale Arnò
- Department of Emergency Neurology and Stroke Unit, National Neurological Institute "Casimiro Mondino" IRCCS, Pavia, Italy
| | - Patrizia Perrone
- Department of Neurosciences, Neurology Unit, "Ospedale Civile", Legnano, Italy
| | - Maria Luisa DeLodovici
- Stroke Unit, Department of Neurology, "Fondazione Macchi-Ospedale di Circolo", Insubria University, Varese, Italy
| | - Simona Marcheselli
- Emergency Neurology and Stroke Unit, "Istituto Clinico Humanitas", Milan, Italy
| | - Giuseppe Micieli
- Department of Emergency Neurology and Stroke Unit, National Neurological Institute "Casimiro Mondino" IRCCS, Pavia, Italy
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15
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Suárez Fernández C, Fernández S, Formiga F, Camafort M, Cepeda Rodrigo M, Rodrigo JC, Díez-Manglano J, Pose Reino A, Reino P, Tiberio G, Mostaza JM. Antithrombotic treatment in elderly patients with atrial fibrillation: a practical approach. BMC Cardiovasc Disord 2015; 15:143. [PMID: 26530138 PMCID: PMC4632329 DOI: 10.1186/s12872-015-0137-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 10/26/2015] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) in the elderly is a complex condition. It has a direct impact on the underuse of antithrombotic therapy reported in this population. DISCUSSION All patients aged ≥75 years with AF have an individual yearly risk of stroke >4 %. However, the risk of hemorrhage is also increased. Moreover, in this population it is common the presence of other comorbidities, cognitive disorders, risk of falls and polymedication. This may lead to an underuse of anticoagulant therapy. Direct oral anticoagulants (DOACs) are at least as effective as conventional therapy, but with lesser risk of intracranial hemorrhage. The simplification of treatment with these drugs may be an advantage in patients with cognitive impairment. The great majority of elderly patients with AF should receive anticoagulant therapy, unless an unequivocal contraindication. DOACs may be the drugs of choice in many elderly patients with AF. In this manuscript, the available evidence about the management of anticoagulation in elderly patients with AF is reviewed. In addition, specific practical recommendations about different controversial issues (i.e. patients with anemia, thrombocytopenia, risk of gastrointestinal bleeding, renal dysfunction, cognitive impairment, risk of falls, polymedication, frailty, etc.) are provided.
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Affiliation(s)
| | - Suárez Fernández
- Hospital Universitario de La Princesa, Grupo de Riesgo Vascular de la SEMI, Madrid, España.
- Servicio de Medicina Interna, Hospital Universitario de La Princesa, C/Diego de León 62, 28006, Madrid, Spain.
| | - Francesc Formiga
- Hospital Universitari de Bellvitge, Grupo de Riesgo Vascular de la SEMI, Hospitalet de Llobregat, Barcelona, España
| | - Miguel Camafort
- Atrial Fibrillation Unit (UFA), Internal Medicine Department, Hospital Clinic. University of Barcelona. Research Group in Cardiovascular Risk, Nutrition and Aging. Area. 'August Pi i Sunyer' Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | | | - Jose Cepeda Rodrigo
- Hospital Vega Baja de Orihuela, Grupo de Riesgo Vascular de la SEMI, Orihuela, Alicante, España
| | - Jesús Díez-Manglano
- Hospital Royo Villanova, Grupo de Riesgo Vascular de la SEMI, Zaragoza, España
| | | | - Pose Reino
- Complexo Hospitalario Universitario de Santiago, Grupo de Riesgo Vascular de la SEMI, Santiago de Compostela, España
| | - Gregorio Tiberio
- Hospital Virgen del Camino, Grupo de Riesgo Vascular de la SEMI, Pamplona, España
| | - Jose María Mostaza
- Hospital Carlos III, Grupo de Riesgo Vascular de la SEMI, Madrid, España
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16
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Infrautilización de la anticoagulación oral en el paciente octogenario con fibrilación auricular: perspectiva desde la práctica clínica real. REVISTA COLOMBIANA DE CARDIOLOGÍA 2015. [DOI: 10.1016/j.rccar.2015.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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