Use of antithrombotic medications among elderly ischemic stroke patients

Impact of Age, Multimorbidity and Frailty on the Prescription of Preventive Antiplatelet Therapy in Older Population

Platelet aggregation inhibitors (PAI) have widely proven their efficiency for the prevention of ischemic cardiovascular events. We aimed to describe PAI prescription in an elderly multimorbid population and to determine the factors that influence their prescription, including the impact of age, comorbidities and frailty, evaluated through a comprehensive geriatric assessment. This cross-sectional study included all patients admitted to the acute geriatric department of a university hospital from November 2016 to January 2017. We included 304 consecutive hospitalized patients aged 88.7 ± 5.5 years. One third of the population was treated with PAI. A total of 133 (43.8%) patients had a history of cardiovascular disease, 77 of whom were on PAI. For 16 patients, no indication was identified. The prescription or the absence of PAI were consistent with medical history in 61.8% of patients. In the multivariate analysis, among the 187 patients with an indication for PAI, neither age (odds ratio (OR) = 1.00; 95% confidence interval (CI): [0.91-1.08], per year of age), nor comorbidities (OR = 0.97; 95% CI: [0.75-1.26], per point of Charlson comorbidity index), nor cognitive disorders (OR = 0.98; 95% CI [0.91-1.06] per point of Mini Mental State Examination), nor malnutrition (OR = 1.07; 95% CI [0.96-1.18], per g/L of albumin) were significantly associated with the therapeutic decision. PAI were less prescribed in primary prevention situations, in patients taking anticoagulants and in patients with a history of bleeding. In conclusion, a third of our older comorbid population of inpatients was taking PAI. PAI prescription was consistent with medical history for 61.8% of patients. Age, multimorbidity and frailty do not appear to have a significant influence on therapeutic decision-making. Further research is needed to confirm such a persistence of cardiovascular preventive strategies in frail older patients from other settings and to assess whether these strategies are associated with a clinical benefit in this specific population.

Dabigatran Versus Rivaroxaban for Secondary Stroke Prevention in Patients with Atrial Fibrillation Rehabilitated in Skilled Nursing Facilities

BACKGROUND

Thromboembolic and bleeding risk are elevated in older patients with atrial fibrillation and prior stroke. We compared dabigatran with rivaroxaban for secondary prevention in a national population after skilled nursing facility (SNF) discharge.

METHODS

Medicare fee-for-service beneficiaries aged ≥ 65 years with atrial fibrillation hospitalized for ischemic stroke (November 2011-October 2013) and subsequently admitted to an SNF were studied. Dabigatran (n = 332) and rivaroxaban users (n = 378) were compared in a retrospective, active comparator, new-user cohort. The index medication claim occurred within 120 days after hospital discharge and exposure continued until a 14-day treatment gap ('as treated'). The primary net clinical benefit outcome was the time to recurrent stroke, transient ischemic attack, intracranial hemorrhage, extracranial bleed, myocardial infarction, venous thromboembolism, or death. All-cause mortality was evaluated separately as a secondary outcome. Multivariable adjusted Cox models stratified by dosage estimated hazard ratios (aHR).

RESULTS

Among those receiving low dosages, the crude composite event rate was 40.4/100 person-years among dabigatran users and 33.7/100 person-years among rivaroxaban users. The composite outcome [aHR 1.48; 95% confidence interval (CI) 0.87-2.51] and all-cause mortality (aHR 1.67; 95% CI 0.84-3.31) rates were higher among low-dose dabigatran users. For those receiving standard doses, the crude composite event rates were 19.5/100 person-years for dabigatran users and 37.1/100 person-years for rivaroxaban users. Although no difference in mortality was observed, the composite outcome rate was lower among standard-dose dabigatran users (aHR 0.65; 95% CI 0.36-1.15).

CONCLUSIONS

In older adults treated with direct-acting oral anticoagulants after ischemic stroke, outcome rates varied considerably by drug and dosage.

Effects of Pre-Injury Anti-Platelet Agents on Short-Term Outcome of Patients with Mild Traumatic Brain Injury: A Cohort Study

OBJECTIVE

To determine the effects of pre-injury consumption of anti-platelet agents on the 30-day outcomes of patients with mild traumatic brain injury (TBI).

METHODS

This prospective cohort study was conducted at three general hospitals in Tehran, Iran between July 2013 and July 2014. The study population included all patients with mild TBI aged over 18 years that medicated with aspirin or clopidogrel before occurring trauma. Within hospitalization, all patients were assessed with respect to in-hospital conditions especially complications and adverse events. After discharge, the individuals were followed for 30 days by telephone to assess mortality and disability using the Glasgow outcome scale (GOS).

RESULTS

Of 1140 patients with mild TBI, only 135 had previously received aspirin and/or clopidogrel. The mean age was dramatically higher in those who were taking aspirin or clopidogrel (p<0.001). The patients with previously use of anti-platelets were more transferred by ambulance when compared to another group (p=0.006). The patients on anti-platelets had significantly lower GCS on admission when compared to others (p<0.001). Length of hospitalization was significantly longer in those receiving anti-platelets (p=0.003). In follow-up, 30-day mortality and disability was revealed in 2.8% of patients that received only aspirin and 7.5% in aspirin with clopidogrel and in 1.6 % of those who did not receive drugs without any significant difference between aspirin and control group (p=0.208) and significant difference in aspirin with clopidogrel group (p<0.001).

CONCLUSION

The premedication by anti-platelets (aspirin and/or clopidogrel) in patients with mild TBI leads to prolonged hospital stay, and increase rate of disability. Age and on admission GCS are the independent risk factors for predicting the outcome in patients with mild TBI receiving anti-platelet agents.

Disparities in a provision of in-hospital post-arrest interventions for out-of-hospital cardiac arrest (OHCA) in the elderly population-protocol for a systematic review

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a significant cause of death in developed countries. The majority of OHCA patients are elderly (≥65 years), and it was documented that they were less likely than younger patients to receive the evidence-based interventions, even though the improvement in survival in the elderly age group was higher than in younger population. Our goal is to investigate any disparity in the provision of post-arrest care for the elderly with OHCA and a sustained return of spontaneous circulation (ROSC).

METHODS/DESIGN

Eight relevant, electronic databases will be systematically searched to identify eligible studies. The searches will be supplemented with gray literature searching of theses, dissertations, and hand searching of pertinent journals. Two independent reviewers will screen the titles and abstracts and select studies for full text analysis using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) method, and both will extract information from the selected studies employing a form based on the Data Extraction Template for Cochrane Reviews. A team of three reviewers will assess the quality of the studies with the modified Downs and Black scale. Statistical methods for evidence synthesis, such as meta-analysis and meta-regression, will be applied to compare and combine the evidence regarding the association between age and intervention provision/utilization, adjusting for a number of significant confounders, such as patient characteristics and co-morbidities and availability of intervention techniques, as well as study specific characteristics. The strength of evidence from the selected studies will be assessed using a modified Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system.

DISCUSSION

The findings obtained from this systematic review should inform whether disparity exists in the provision of post-arrest care for the elderly (≥ 65 years old) with OHCA or not. Addressing this problem has a potential to substantially increase the number of > 65-year-old, long-term survivors. The results of our review might also point to the gaps in the published literature that specifically examines disparity in provision of care for this population. This systematic review was designed in accordance with the Preferred Reporting Guidelines for Systematic reviews and Meta-analyses (PRISMA statement), while the protocol follows the Preferred Reporting items for Systematic review and Meta-analysis protocols (PRISMA-P) statement.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015027822.

Secondary prevention of stroke in the elderly: focus on drug therapy

Secondary stroke prevention in the elderly in many cases requires the use of drug therapy to maximize risk factor control. However, the elderly (≥65 years) are most likely to receive care that is not evidence-based, because of concerns for adverse events. In this review, we provide evidence to the practitioner in support of the value of blood pressure control with drug therapy to decrease recurrent stroke risk. This review also highlights evidence for the importance of statin therapy in stroke prevention among the elderly. Finally, the appropriate use of antiplatelet therapy and oral anticoagulation is addressed.

Most important outcomes research papers in cardiovascular disease in the elderly

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the Editor, that have published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes and general cardiology audience. The studies included in this article represent the most significant research in the area of cardiovascular disease in the elderly.

Regional Variation in Recommended Treatments for Ischemic Stroke and TIA

Background and Purpose—

Secondary stroke prevention treatments vary in different regions of the US. We determined the degree to which guideline-recommended stroke treatments vary by region for patients treated at hospitals participating in a voluntary national quality improvement program, Get With The Guidelines-Stroke.

Methods—

Receipt of 8 guideline-recommended treatments (intravenous tissue-type plasminogen activator, antihypertensives, antithrombotics, anticoagulants for atrial fibrillation, deep vein thrombosis prophylaxis, lipid-lowering medications at discharge, smoking cessation counseling, weight loss education) and defect-free care were compared in 4 US regions among eligible patients with ischemic stroke and transient ischemic attack; there was adjustment for patient demographics, medical history, and hospital characteristics.

Results—

Among 991 995 admissions (South, 37%; Northeast, 27.6%; Midwest, 19.3%; West, 15.9%). Receipt varied regionally for tissue-type plasminogen activator (58.2%–67.8%), lipid-lowering medications (72.5%–75.7%), antihypertensives (80.1%–83.6%), antithrombotics (95.6%–96.8%), deep vein thrombosis prophylaxis (88.0%–91.4%), weight loss education (49.3%–54.7%), and defect-free care (72.1%–76.5%). In adjusted analyses, patients in the South had lower odds of use of intravenous tissue-type plasminogen activator (OR [95% CI]; 0.82 [0.69–0.97]), antihypertensives (0.82 [0.67–0.99]), and defect-free care (0.83 [0.75–0.92]); but, they were more likely to receive lipid-lowering medications (1.28 [1.05–1.54]) compared with those in the Northeast. Patients in the Midwest had lower odds of intravenous tissue-type plasminogen activator administration (0.82 [0.68–0.99]) and defect-free care (0.81 [0.72–0.92]). Those in the West had lower odds of antihypertensives (0.81 [0.67–0.99]), but had greater odds of receiving lipid-lowering medications (1.26 [1.03–1.53]).

Conclusions—

Despite relatively high rates of adherence to stroke-related therapies in Get With The Guidelines-Stroke hospitals, regional variations exist, with over one quarter of patients receiving suboptimal care. Systematic improvements may lead to better patient outcomes.

Sexual dimorphism in ischemic stroke: lessons from the laboratory

Ischemic stroke is emerging as a major health problem for elderly women. Women have lower stroke incidence than men until an advanced age, when the epidemiology of ischemic stroke shifts and incidence rises dramatically in women. Experimental models of rodent stroke have replicated this clinical epidemiology, with exacerbated injury in older compared with young female rodents. Many of the detrimental effects of aging on ischemic stroke outcome in females can be replicated by ovariectomy, suggesting that hormones such as estrogen play a neuroprotective role. However, emerging data suggest that the molecular mechanisms leading to ischemic cell death differ in the two sexes, and these effects may be independent of circulating hormone levels. This article highlights recent clinical and experimental literature on sex differences in stroke outcomes and mechanisms.