1
|
Eckardt L, Wolfes J, Frommeyer G. Benefits of early rhythm control of atrial fibrillation. Trends Cardiovasc Med 2024; 34:288-294. [PMID: 37054762 DOI: 10.1016/j.tcm.2023.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 03/29/2023] [Accepted: 04/07/2023] [Indexed: 04/15/2023]
Abstract
In contrast to current guidelines and earlier trials, recent studies demonstrated superiority of rhythm- over rate-control and challenged the strategy of "rate versus rhythm" therapy in patients with atrial fibrillation. These newer studies have started to shift the use of rhythm-control therapy from the symptom-driven therapy of current guidelines to a risk-reducing strategy aimed at restoring and maintaining sinus rhythm. This review discusses recent data and presents an overview on the current discourse: The concept of early rhythm control seems attractive. Patients with rhythm control may undergo less atrial remodeling compared to those with rate control. In addition, in EAST-AFNET 4 an outcome-reducing effect of rhythm control was achieved by delivering therapy with relatively few complications early after the initial AF diagnosis. Successful rhythm control therapy and most likely reduced AF burden, estimated by the presence of sinus rhythm at 12 months after randomization, explained most of the reduction in cardiovascular outcomes achieved by rhythm control. However, it is too early to call for early rhythm control for all AF patients. Rhythm control may raise concerns regarding the generalizability of trial results in routine practice involving important questions on the definition of "early" and "successful", and the relevant issue of antiarrhythmic drugs versus catheter ablation. Further information is required to select patients who will benefit from an early ablative or non-ablative rhythm management.
Collapse
Affiliation(s)
- L Eckardt
- Department of Cardiology II - Electrophysiology, University Hospital Münster, Albert Schweitzer Campus 1, Münster 48149, Germany; Atrial Fibrillation Network (AFNET), Münster, Germany.
| | - J Wolfes
- Department of Cardiology II - Electrophysiology, University Hospital Münster, Albert Schweitzer Campus 1, Münster 48149, Germany; Atrial Fibrillation Network (AFNET), Münster, Germany
| | - G Frommeyer
- Department of Cardiology II - Electrophysiology, University Hospital Münster, Albert Schweitzer Campus 1, Münster 48149, Germany; Atrial Fibrillation Network (AFNET), Münster, Germany
| |
Collapse
|
2
|
Steinberg BA. Atrial Fibrillation Symptom Assessment-It's Us, We're (Part of) the Problem. JAMA Netw Open 2024; 7:e2356660. [PMID: 38393733 DOI: 10.1001/jamanetworkopen.2023.56660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2024] Open
Affiliation(s)
- Benjamin A Steinberg
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City
| |
Collapse
|
3
|
Romiti GF, Corica B, Mei DA, Frost F, Bisson A, Boriani G, Bucci T, Olshansky B, Chao TF, Huisman MV, Proietti M, Lip GYH. Impact of chronic obstructive pulmonary disease in patients with atrial fibrillation: an analysis from the GLORIA-AF registry. Europace 2023; 26:euae021. [PMID: 38266129 PMCID: PMC10825625 DOI: 10.1093/europace/euae021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/11/2024] [Indexed: 01/26/2024] Open
Abstract
AIMS Chronic obstructive pulmonary disease (COPD) may influence management and prognosis of atrial fibrillation (AF), but this relationship has been scarcely explored in contemporary global cohorts. We aimed to investigate the association between AF and COPD, in relation to treatment patterns and major outcomes. METHODS AND RESULTS From the prospective, global GLORIA-AF registry, we analysed factors associated with COPD diagnosis, as well as treatment patterns and risk of major outcomes in relation to COPD. The primary outcome was the composite of all-cause death and major adverse cardiovascular events (MACEs). A total of 36 263 patients (mean age 70.1 ± 10.5 years, 45.2% females) were included; 2,261 (6.2%) had COPD. The prevalence of COPD was lower in Asia and higher in North America. Age, female sex, smoking, body mass index, and cardiovascular comorbidities were associated with the presence of COPD. Chronic obstructive pulmonary disease was associated with higher use of oral anticoagulant (OAC) [adjusted odds ratio (aOR) and 95% confidence interval (CI): 1.29 (1.13-1.47)] and higher OAC discontinuation [adjusted hazard ratio (aHR) and 95% CI: 1.12 (1.01-1.25)]. Chronic obstructive pulmonary disease was associated with less use of beta-blocker [aOR (95% CI): 0.79 (0.72-0.87)], amiodarone and propafenone, and higher use of digoxin and verapamil/diltiazem. Patients with COPD had a higher hazard of primary composite outcome [aHR (95% CI): 1.78 (1.58-2.00)]; no interaction was observed regarding beta-blocker use. Chronic obstructive pulmonary disease was also associated with all-cause death [aHR (95% CI): 2.01 (1.77-2.28)], MACEs [aHR (95% CI): 1.41 (1.18-1.68)], and major bleeding [aHR (95% CI): 1.48 (1.16-1.88)]. CONCLUSION In AF patients, COPD was associated with differences in OAC treatment and use of other drugs; Patients with AF and COPD had worse outcomes, including higher mortality, MACE, and major bleeding.
Collapse
Affiliation(s)
- Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Translational and Precision Medicine, Sapienza – University of Rome, Rome, Italy
| | - Bernadette Corica
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Translational and Precision Medicine, Sapienza – University of Rome, Rome, Italy
| | - Davide Antonio Mei
- Department of Translational and Precision Medicine, Sapienza – University of Rome, Rome, Italy
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Frederick Frost
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Arnaud Bisson
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Service de Cardiologie, Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, Tours, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Tommaso Bucci
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of General Surgery and Surgical Specialties ‘Paride Stefanini’, Sapienza – University of Rome, Rome, Italy
| | - Brian Olshansky
- Division of Cardiology, Department of Medicine, University of Iowa, Iowa City, USA
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| |
Collapse
|
4
|
Verheugt FWA, Fox KAA, Virdone S, Ambrosio G, Gersh BJ, Haas S, Pieper KS, Kayani G, Camm AJ, Parkhomenko A, Misselwitz F, Ragy H, Ten Cate H, Keltai M, Kakkar AK. Outcomes of Oral Anticoagulation in Atrial Fibrillation Patients With or Without Comorbid Vascular Disease: Insights From the GARFIELD-AF Registry. Am J Med 2023; 136:1187-1195.e15. [PMID: 37704071 DOI: 10.1016/j.amjmed.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/07/2023] [Accepted: 08/11/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Many patients with atrial fibrillation suffer from comorbid vascular disease. The comparative efficacy and safety of different types of oral anticoagulation (OAC) in this patient group have not been widely studied. METHODS Adults with newly diagnosed atrial fibrillation were recruited into the prospective observational registry, GARFIELD-AF, and followed for 24 months. Associations of vascular disease with clinical outcomes were analyzed using adjusted hazard ratios (HR) obtained via Cox proportional-hazard modeling. Outcomes of OAC vs no OAC, and of non-vitamin K antagonist OAC (NOAC) vs vitamin K antagonist (VKA) treatment, were compared by overlap propensity-weighted Cox proportional-hazard models. RESULTS Of 51,574 atrial fibrillation patients, 25.9% had vascular disease. Among eligible atrial fibrillation patients, those with vascular disease received OAC less frequently than those without (63% vs 73%). Over 2-year follow-up, patients with vascular disease showed a higher risk of all-cause mortality (HR 1.30; 95% confidence interval [CI], 1.16-1.47) and cardiovascular mortality (HR 1.59; 95% CI, 1.28-1.97). OAC was associated with a significant decrease in all-cause mortality and non-hemorrhagic stroke, and increased risk of major bleeding in non-vascular disease. In vascular disease, similar but non-significant trends existed for stroke and major bleeding. A significantly lower risk of all-cause mortality (HR 0.74; 95% CI, 0.61-0.90) and major bleeding (HR 0.45; 95% CI, 0.29-0.70) was observed in vascular disease patients treated with NOACs, compared with VKAs. CONCLUSIONS Atrial fibrillation patients with a history of vascular disease have worse long-term outcomes than those without. The association of NOACs vs VKA with clinical outcomes was more evident in atrial fibrillation patients with vascular disease.
Collapse
Affiliation(s)
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, UK
| | | | - Giuseppe Ambrosio
- Division of Cardiology, University of Perugia School of Medicine Cardiology, Italy
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minn, USA
| | - Sylvia Haas
- [Formerly] Department of Medicine, Technical University of Munich, Germany
| | | | | | - A John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St. George's University of London, UK
| | - Alexandr Parkhomenko
- National Scientific Centre "MD Strazhesko Institute of Cardiology", Kyiv, Ukraine
| | | | - Hany Ragy
- Department of Cardiology, National Heart Institute, Cairo, Egypt
| | - Hugo Ten Cate
- Maastricht University Medical Center (MUMC+) and Cardiovascular Research Institute (CARIM), Maastricht University, Netherlands; Center for Thrombosis and Hemostasis (CTH), Gutenberg University Medical Center, Mainz, Germany
| | - Matyas Keltai
- Semmelweis University, Hungarian Cardiovascular Institute, Budapest, Hungary
| | | |
Collapse
|
5
|
Daw JM, Armbruster T, Deyo Z, Walker J, Rosman LA, Sears SF, Mazzella AJ, Jin W, Li Q, Gehi AK. Development and Feasibility of a Primary Care Provider Training Intervention to Improve Atrial Fibrillation Management. Am J Cardiol 2023; 207:184-191. [PMID: 37742538 DOI: 10.1016/j.amjcard.2023.08.184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/29/2023] [Accepted: 08/31/2023] [Indexed: 09/26/2023]
Abstract
The disparities in atrial fibrillation (AF) care are partially attributed to inadequate access to providers with specialized training in AF. Primary care providers (PCPs) are often the sole providers of AF care in under-resourced regions. As such, we sought to create a virtual education intervention for PCPs and to evaluate its impact on the use of stroke risk reduction strategies in patients with AF. A multidisciplinary team mentored PCPs on AF management over 6 months using a virtual case-based training format. Surveys of participant knowledge and confidence in AF care were compared before and after the intervention. Hierarchical logistic regression modeling was used to evaluate change in oral anticoagulation (OAC) therapy in the patients seen by participants before or after training. Of 41 participants trained, 49% worked in family medicine, 41% internal medicine, and 10% general cardiology. Participants attended a mean of 14 1-hour sessions. Overall, the appropriate use of OAC (for CHA2DS2-VASc score ≥1 man, ≥2 women) increased from 37% to 46% (p <0.001) comparing the patients seen before (n = 1,739) versus after (n = 610) intervention. The factors independently associated with appropriate OAC use included participant training (odds ratio [OR] 1.4, p = 0.002) and participant competence in AF management. The factors associated with decreased OAC use included patient age (OR 0.8 per 10 year, p = 0.008) and nonwhite race (OR 0.7, p = 0.028). Provider knowledge and confidence in AF care improved (p <0.001). In conclusion, we show that a virtual PCP training intervention improves the use of stroke risk reduction therapy in outpatients with AF and could be a widely scalable intervention to improve AF care in under-resourced communities.
Collapse
Affiliation(s)
- J Michael Daw
- Division of Cardiology, Department of Medicine, University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Tiffany Armbruster
- Division of Cardiology, Department of Medicine, University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Zack Deyo
- Department of Pharmacy, University of North Carolina Hospitals, Chapel Hill, North Carolina; Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Jennifer Walker
- Division of Cardiology, Department of Medicine, University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Lindsey A Rosman
- Division of Cardiology, Department of Medicine, University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Samuel F Sears
- Department of Psychology and Cardiovascular Sciences, East Carolina University, Greenville, North Carolina
| | - Anthony J Mazzella
- Division of Cardiology, Department of Medicine, University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Wanting Jin
- Department of Biostatistics, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Quefeng Li
- Department of Biostatistics, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Anil K Gehi
- Division of Cardiology, Department of Medicine, University of North Carolina Medical Center, Chapel Hill, North Carolina.
| |
Collapse
|
6
|
Delesie M, Knaepen L, Dendale P, Vijgen J, Ector J, Desteghe L, Heidbuchel H. Baseline demographics of a contemporary Belgian atrial fibrillation cohort included in a large randomised clinical trial on targeted education and integrated care (AF-EduCare/AF-EduApp study). Front Cardiovasc Med 2023; 10:1186453. [PMID: 37332586 PMCID: PMC10272799 DOI: 10.3389/fcvm.2023.1186453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/09/2023] [Indexed: 06/20/2023] Open
Abstract
Background As the prevalence of atrial fibrillation (AF) increases worldwide and AF management becomes ever more diversified and personalised, insights into (regional) AF patient demographics and contemporary AF management are needed. This paper reports the current AF management and baseline demographics of a Belgian AF population recruited for a large multicenter integrated AF study (AF-EduCare/AF-EduApp study). Methods We analyzed data from 1,979 AF patients, assessed between 2018 and 2021 for the AF-EduCare/AF-EduApp study. The trial randomised consecutive patients with AF (irrespective of AF history duration) into three educational intervention groups (in person-, online-, and application-based), compared with standard care. Baseline demographics of both the included and excluded/refused patients are reported. Results The mean age of the trial population was 71.2 ± 9.1 years, with a mean CHA2DS2-VASc score of 3.4 ± 1.8. Of all screened patients, 42.4% were asymptomatic at presentation. Being overweight was the most common comorbidty, present in 68.9%, while 65.0% were diagnosed with hypertension. Anticoagulation therapy was prescribed in 90.9% of the total population and in 94.0% of the patients with an indication for thromboembolic prophylaxis. Of the 1,979 assessed AF patients, 1,232 (62.3%) were enrolled in the AF-EduCare/AF-EduApp study, with transportation problems (33.4%) as the main reason for refusal/non-inclusion. About half of the included patients were recruited at the cardiology ward (53.8%). AF was first diagnosed, paroxysmal, persistent and permanent in 13.9%, 47.4%, 22.8% and 11.3%, respectively. Patients who refused or were excluded were older (73.3 ± 9.2 vs. 69.8 ± 8.9 years, p < 0.001) and had more comorbidities (CHA2DS2-VASc 3.8 ± 1.8 vs. 3.1 ± 1.7, p < 0.001). The four AF-EduCare/AF-EduApp study groups were comparable across the vast majority of parameters. Conclusions The population showed high use of anticoagulation therapy, in line with current guidelines. In contrast to other AF trials about integrated care, the AF-EduCare/AF-EduApp study managed to incorporate all types of AF patients, both out-patient and hospitalised, with very comparable patient demographics across all subgroups. The trial will analyze whether different approaches to patient education and integrated AF care have an impact on clinical outcomes. Clinical Trial Registration https://clinicaltrials.gov/ct2/show/NCT03707873?term=af-educare&draw=2&rank=1, identifier: NCT03707873; https://clinicaltrials.gov/ct2/show/NCT03788044?term=af-eduapp&draw=2&rank=1, identifier: NCT03788044.
Collapse
Affiliation(s)
- Michiel Delesie
- Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Lieselotte Knaepen
- Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - Paul Dendale
- Department of Cardiology, Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Johan Vijgen
- Department of Cardiology, Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Joris Ector
- Department of Cardiology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Lien Desteghe
- Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - Hein Heidbuchel
- Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| |
Collapse
|
7
|
Liu SH, Chao TF, Chan YH, Liao JN, Chen SA. Clinical outcomes of patients with incident atrial fibrillation diagnosed by cardiologists compared to non-cardiologists. Eur J Intern Med 2023; 112:140-142. [PMID: 36906476 DOI: 10.1016/j.ejim.2023.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 03/01/2023] [Indexed: 03/12/2023]
Affiliation(s)
- Shin-Huei Liu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Division of Holistic and Multidisciplinary Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan; Faculty of Medicine, National Chung Hsing University, Taichung, Taiwan
| |
Collapse
|
8
|
Dickow J, Kany S, Cardoso VR, Ellinor PT, Gkoutos GV, Van Houten HK, Kirchhof P, Metzner A, Noseworthy PA, Yao X, Rillig A. Outcomes of Early Rhythm Control Therapy in Patients With Atrial Fibrillation and a High Comorbidity Burden in Large Real-World Cohorts. Circ Arrhythm Electrophysiol 2023; 16:e011585. [PMID: 36942567 PMCID: PMC10205477 DOI: 10.1161/circep.122.011585] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/24/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND A recent subanalysis of the EAST-AFNET 4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial) suggests a stronger benefit of early rhythm control (ERC) in patients with atrial fibrillation and a high comorbidity burden when compared to patients with a lower comorbidity burden. METHODS We identified 109 739 patients with newly diagnosed atrial fibrillation in a large United States deidentified administrative claims database (OptumLabs) and 11 625 patients in the population-based UKB (UK Biobank). ERC was defined as atrial fibrillation ablation or antiarrhythmic drug therapy within the first year after atrial fibrillation diagnosis. Patients were classified as (1) ERC and high comorbidity burden (CHA2DS2-VASc score ≥4); (2) ERC and lower comorbidity burden (CHA2DS2-VASc score 2-3); (3) no ERC and high comorbidity burden; and (4) no ERC and lower comorbidity burden. Patients without an elevated comorbidity burden (CHA2DS2-VASc score 0-1) were excluded. Propensity score overlap weighting and cox proportional hazards regression were used to balance patients and compare groups for the primary composite outcome of all-cause mortality, stroke, or hospitalization with the diagnoses heart failure or myocardial infarction as well as for a primary composite safety outcome of death, stroke, and serious adverse events related to ERC. RESULTS In both cohorts, ERC was associated with a reduced risk for the primary composite outcome in patients with a high comorbidity burden (OptumLabs: hazard ratio, 0.83 [95% CI 0.72-0.95]; P=0.006; UKB: hazard ratio, 0.77 [95% CI, 0.63-0.94]; P=0.009). In patients with a lower comorbidity burden, the difference in outcomes was not significant (OptumLabs: hazard ratio, 0.92 [95% CI, 0.54-1.57]; P=0.767; UKB: hazard ratio, 0.94 [95% CI, 0.83-1.06]; P=0.310). The comorbidity burden interacted with ERC in the UKB (interaction- P=0.027) but not in OptumLabs (interaction-P=0.720). ERC was not associated with an increased risk for the primary safety outcome. CONCLUSIONS ERC is safe and may be more favorable in a population-based sample of patients with high a comorbidity burden (CHA2DS2-VASc score ≥4).
Collapse
Affiliation(s)
- Jannis Dickow
- Dept of Cardiology, Univ Heart & Vascular Center Hamburg, Univ Hospital Hamburg Eppendorf, Hamburg
- DZHK (German Ctr for Cardiovascular Rsrch), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Shinwan Kany
- Dept of Cardiology, Univ Heart & Vascular Center Hamburg, Univ Hospital Hamburg Eppendorf, Hamburg
- DZHK (German Ctr for Cardiovascular Rsrch), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
- Cardiovascular Disease Initiative, The Broad Inst of MIT & Harvard, Cambridge, MA
| | - Victor Roth Cardoso
- Institute of Cardiovascular Sciences
- Institute of Cancer & Genomic Sciences, Univ of Birmingham
- Health Data Rsrch UK, Midlands Site, Birmingham, United Kingdom
| | - Patrick T. Ellinor
- Cardiovascular Disease Initiative, The Broad Inst of MIT & Harvard, Cambridge, MA
- Cardiovascular Rsrch Ctr, Massachusetts General Hospital, Boston, MA
| | - Georgios V. Gkoutos
- Institute of Cardiovascular Sciences
- Institute of Cancer & Genomic Sciences, Univ of Birmingham
- Health Data Rsrch UK, Midlands Site, Birmingham, United Kingdom
| | - Holly K. Van Houten
- OptumLabs, Eden Prairie
- Robert D. & Patricia E. Kern Ctr for the Science of Health Care Delivery
| | - Paulus Kirchhof
- Dept of Cardiology, Univ Heart & Vascular Center Hamburg, Univ Hospital Hamburg Eppendorf, Hamburg
- DZHK (German Ctr for Cardiovascular Rsrch), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
- Institute of Cardiovascular Sciences
| | - Andreas Metzner
- Dept of Cardiology, Univ Heart & Vascular Center Hamburg, Univ Hospital Hamburg Eppendorf, Hamburg
- DZHK (German Ctr for Cardiovascular Rsrch), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Peter A. Noseworthy
- Robert D. & Patricia E. Kern Ctr for the Science of Health Care Delivery
- Dept of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Xiaoxi Yao
- Robert D. & Patricia E. Kern Ctr for the Science of Health Care Delivery
- Dept of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Andreas Rillig
- Dept of Cardiology, Univ Heart & Vascular Center Hamburg, Univ Hospital Hamburg Eppendorf, Hamburg
- DZHK (German Ctr for Cardiovascular Rsrch), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
| |
Collapse
|
9
|
Daw JM, Armbruster T, Deyo Z, Walker J, Rosman LA, Sears SF, Mazzella AJ, Gehi AK. Development and Feasibility of a Primary Care Provider Training Intervention to Improve Atrial Fibrillation Management. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.21.23287553. [PMID: 36993684 PMCID: PMC10055598 DOI: 10.1101/2023.03.21.23287553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Background Disparities in atrial fibrillation (AF) care are partially attributed to inadequate access to providers with specialized training in AF. Primary care providers (PCPs) are often the sole providers of AF care in under-resourced regions. Objective To create a virtual education intervention for PCPs and evaluate its impact on use of stroke risk reduction strategies in AF patients. Methods A multi-disciplinary team mentored PCPs on AF management over 6 months using a virtual case-based training format. Surveys of participant knowledge and confidence in AF care were compared pre- and post-intervention. Hierarchical logistic regression modeling was used to evaluate change in stroke risk reduction therapies among patients seen by participants before or after training. Results Of 41 participants trained, 49% worked in family medicine, 41% internal medicine, and 10% general cardiology. Participants attended a mean of 14 one-hour sessions. Overall, appropriate use of oral anticoagulation (OAC) therapy (CHA 2 DS 2 -VASc score ≥1 men, ≥2 women) increased from 37% to 46% (p<.001) comparing patients seen pre- (n=1739) to post- (n=610) intervention. Factors independently associated with appropriate OAC use included participant training (OR 1.4, p=.002) and participant competence in AF management (by survey). Factors associated with decreased OAC use included patient age (OR 0.8 per 10 years, p=.008), nonwhite race (OR 0.7, p=.028). Provider knowledge and confidence in AF care both improved (p<.001). Conclusions A virtual case-based PCP training intervention improved use of stroke risk reduction therapy in outpatients with AF. This widely scalable intervention could improve AF care in under-resourced communities. CONDENSED ABSTRACT A virtual educational model was developed for primary care providers to improve competency in AF care in their community. Following a 6-month training intervention, the rate of appropriate oral anticoagulation (OAC) therapy among patients cared for by participating providers increased from 37% to 46% (p<.001). Among participants, knowledge and confidence in AF care improved. These findings suggest a virtual AF training intervention can improve PCP competency in AF care. This widely scalable intervention could help improve AF care in under-resourced communities.
Collapse
|
10
|
Norby FL, Lutsey PL, Shippee ND, Chen LY, Henning-Smith C, Alonso A, Walker RF, Folsom AR. Direct Oral Anticoagulants and Warfarin for Atrial Fibrillation Treatment: Rural and Urban Trends in Medicare Beneficiaries. Am J Cardiovasc Drugs 2022; 22:207-217. [PMID: 34633646 PMCID: PMC9833644 DOI: 10.1007/s40256-021-00502-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Data are needed on the use of oral anticoagulation in patients with atrial fibrillation (AF) in rural versus urban areas, including the initiation of direct oral anticoagulants (DOACs). OBJECTIVE We used Medicare data to examine rural/urban differences in anticoagulation use in patients with AF. METHODS We identified incident AF in a 20% sample of fee-for-service Medicare beneficiaries (aged ≥ 65 years) from 2011 to 2016 and collected ZIP code and covariates at the time of AF. We identified the first anticoagulant prescription filled, if any, following AF diagnosis. We categorized beneficiaries into four rural/urban areas using rural-urban commuting area codes and used Poisson regression models to compare anticoagulant use. RESULTS We included 447,252 patients with AF (mean age 79 ± 8 years), of which 82% were urban, 9% large rural, 5% small rural, and 4% isolated. The percentage who initiated an anticoagulant rose from 34% in 2011 to 53% in 2016, paralleling the uptake of DOACs. In a multivariable-adjusted analysis, those in rural areas (vs. urban) were more likely to initiate an anticoagulant. However, rural beneficiaries (vs. urban) were less likely to initiate a DOAC; those in isolated areas were 17% less likely (95% confidence interval [CI] 13-20), those in small rural areas were 12% less likely (95% CI 9-15), and those in large rural areas were 10% less likely (95% CI 8-12). CONCLUSION Among Medicare beneficiaries with AF, anticoagulation use was low but increased over time with the introduction of DOACs. Rural beneficiaries were less likely to receive a DOAC.
Collapse
Affiliation(s)
- Faye L. Norby
- Department of Cardiology, Center for Cardiac Arrest Prevention, Smidt Heart Institute, Cedars-Sinai Health System, Advanced Health Sciences Pavilion, Suite A9220, 127 S. San Vicente Blvd, Los Angeles, CA 90048, USA,Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Pamela L. Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Nathan D. Shippee
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA
| | - Lin Y. Chen
- Cardiovascular Division, Department of Medicine, Cardiac Arrhythmia Center, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Carrie Henning-Smith
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA,Rural Health Research Center, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Rob F. Walker
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Aaron R. Folsom
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
11
|
Hernandez I, Gabriel N, He M, Guo J, Tadrous M, Suda KJ, Magnani JW. COVID-19 and Anticoagulation for Atrial Fibrillation: An Analysis of US Nationwide Pharmacy Claims Data. J Am Heart Assoc 2021; 10:e023235. [PMID: 34913359 PMCID: PMC9075244 DOI: 10.1161/jaha.121.023235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Adherence to oral anticoagulation (OAC) is critical for stroke prevention in atrial fibrillation. However, the COVID‐19 pandemic may have disrupted access to such therapy. We hypothesized that our analysis of a US nationally representative pharmacy claims database would identify increased incidence of lapses in OAC refills during the COVID‐19 pandemic. Methods and Results We identified individuals with atrial fibrillation prescribed OAC in 2018. We used pharmacy dispensing records to determine the incidence of 7‐day OAC gaps and 15‐day excess supply for each 30‐day interval from January 1, 2019 to July 8, 2020. We constructed interrupted time series analyses to test changes in gaps and supply around the pandemic declaration by the World Health Organization (March 11, 2020), and whether such changes differed by medication (warfarin or direct OAC), prescription payment type, or prescriber specialty. We identified 1 301 074 individuals (47.5% women; 54% age ≥75 years). Immediately following the COVID‐19 pandemic declaration, we observed a 14% decrease in 7‐day OAC gaps and 56% increase in 15‐day excess supply (both P<0.001). The increase in 15‐day excess supply was more marked for direct OAC (69% increase) than warfarin users (35%; P<0.001); Medicare beneficiaries (62%) than those with commercial insurance (43%; P<0.001); and those prescribed OAC by a cardiologist (64%) rather than a primary care provider (48%; P<0.001). Conclusions Our analysis of nationwide claims data demonstrated increased OAC possession after the onset of the COVID‐19 pandemic. Our findings may have been driven by waivers of early refill limits and patients’ tendency to stockpile medications in the first weeks of the pandemic.
Collapse
Affiliation(s)
- Inmaculada Hernandez
- Division of Clinical Pharmacy Skaggs School of Pharmacy and Pharmaceutical Sciences University of California, San Diego La Jolla CA
| | - Nico Gabriel
- Division of Clinical Pharmacy Skaggs School of Pharmacy and Pharmaceutical Sciences University of California, San Diego La Jolla CA
| | - Meiqi He
- Division of Clinical Pharmacy Skaggs School of Pharmacy and Pharmaceutical Sciences University of California, San Diego La Jolla CA
| | - Jingchuan Guo
- Department of Pharmaceutical Outcomes and Policy University of Florida College of Pharmacy Gainesville FL
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy University of Toronto and Women's College Hospital Toronto Canada
| | - Katie J Suda
- Center for Health Equity Research and Promotion VA Pittsburgh Healthcare System Pittsburgh Pittsburgh PA.,Division of General Internal Medicine University of Pittsburgh School of Medicine Pittsburgh PA
| | - Jared W Magnani
- Division of Cardiology Department of Medicine University of Pittsburgh School of Medicine Pittsburgh PA
| |
Collapse
|
12
|
Kozieł M, Mihajlovic M, Nedeljkovic M, Pavlovic N, Paparisto V, Music L, Trendafilova E, Rodica Dan A, Kusljugic Z, Dan GA, Lip GYH, Potpara TS. Symptom management strategies: Rhythm vs rate control in patients with atrial fibrillation in the Balkan region: Data from the BALKAN-AF survey. Int J Clin Pract 2021; 75:e14080. [PMID: 33548075 DOI: 10.1111/ijcp.14080] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/03/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Symptom-focused management is one of the cornerstones of optimal atrial fibrillation (AF) therapy. OBJECTIVES To evaluate the use of rhythm control and rate control strategy. Second, to identify predictors of the use of amiodarone in patients with rhythm control and of the use of rhythm control strategy in patients with paroxysmal AF in the Balkans. METHODS Prospective enrolment of consecutive patients from seven Balkan countries to the BALKAN-AF survey was performed. RESULTS Of 2712 enrolled patients, 2522 (93.0%) with complete data were included: 1622 (64.3%) patients were assigned to rate control strategy and 900 (35.7%) to rhythm control. Patients with rhythm control were younger, more often hospitalised for AF and with less comorbidities (all P < .05) than those with rate control. Symptom score [European Heart Rhythm Association (EHRA)] was not an independent predictor of a rhythm control strategy [odds ratio (OR) 0.99, 95% confidence interval (CI) 0.90-1.10, P = .945]. The most commonly chosen antiarrhythmic agents were amiodarone (49.7%), followed by propafenone (24.3%). CONCLUSION More than one-third of patients in the BALKAN-AF survey received a rhythm control strategy, and these patients tended to be younger with less comorbidities than those managed with rate control. EHRA symptom score is not significantly associated with rhythm control strategy. The most commonly used antiarrhythmic agents were amiodarone, followed by propafenone.
Collapse
Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- 1stDepartment of Cardiology and Angiology, Silesian Centre for Heart Diseases, Zabrze, Poland
| | | | - Milan Nedeljkovic
- Cardiology Clinic, Clinical Centre 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
| | | | - Anca Rodica Dan
- Cardiology Department, Colentina University Hospital, Bucharest, Romania
| | - Zumreta Kusljugic
- Clinic of Internal Medicine, Cardiology Department, University Clinical Center Tuzla, Medical Faculty, Tuzla, Bosnia and Herzegovina
| | - 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, UK
- 1stDepartment of Cardiology and Angiology, 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 Centre of Serbia, Belgrade, Serbia
- School of Medicine, Belgrade University, Belgrade, Serbia
| |
Collapse
|
13
|
Chang AY, Cullen MR, Harrington RA, Barry M. The impact of novel coronavirus COVID-19 on noncommunicable disease patients and health systems: a review. J Intern Med 2021; 289:450-462. [PMID: 33020988 PMCID: PMC7675448 DOI: 10.1111/joim.13184] [Citation(s) in RCA: 114] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/08/2020] [Indexed: 02/06/2023]
Abstract
Coronavirus disease 2019 (COVID-19) is an ongoing global pandemic affecting all levels of health systems. This includes the care of patients with noncommunicable diseases (NCDs) who bear a disproportionate burden of both COVID-19 itself and the public health measures enacted to combat it. In this review, we summarize major COVID-19-related considerations for NCD patients and their care providers, focusing on cardiovascular, pulmonary, renal, haematologic, oncologic, traumatic, obstetric/gynaecologic, operative, psychiatric, rheumatologic/immunologic, neurologic, gastrointestinal, ophthalmologic and endocrine disorders. Additionally, we offer a general framework for categorizing the pandemic's disruptions by disease-specific factors, direct health system factors and indirect health system factors. We also provide references to major NCD medical specialty professional society statements and guidelines on COVID-19. COVID-19 and its control policies have already resulted in major disruptions to the screening, treatment and surveillance of NCD patients. In addition, it differentially impacts those with pre-existing NCDs and may lead to de novo NCD sequelae. Likely, there will be long-term effects from this pandemic that will continue to affect practitioners and patients in this field for years to come.
Collapse
Affiliation(s)
- Andrew Y Chang
- From the, Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA.,Department of Medicine, Stanford University, Stanford, CA, USA.,Center for Innovation in Global Health, Stanford University, Stanford, CA, USA
| | - Mark R Cullen
- Department of Medicine, Stanford University, Stanford, CA, USA.,Division of Primary Care and Population Health, Stanford University, Stanford, CA, USA
| | | | - Michele Barry
- Department of Medicine, Stanford University, Stanford, CA, USA.,Center for Innovation in Global Health, Stanford University, Stanford, CA, USA
| |
Collapse
|
14
|
Ouali S, Ben Halima A, Chabrak S, Chettaoui R, Ben Halima M, Haggui A, Krichane S, Noureddine L, Marrakchi S, Charfeddine S, Hassine M, Sayahi K, Abbes Mohamed F, Nasraoui W, Ajmi H, Ben Miled M, Jebbari Z, Meghaieth MA, Allouche E, Mechmeche R, Zakhama L, Sdiri W, Ben Khalfallah A, Gharbi A, Milouchi S, Neji A, Antit S, Battikh K, Drissa M, Kaabachi S, Najar T, Tlili R, Chahbani I, Charfeddine H, Ben MM, Braham S, Maatouk F, Abdesselem S, Ayari M, Garbaa R, Hamrouni N, Mbarek D, Rekik H, Zaghdoudi H, Ayadi W, Baraket F, Ben Brahim K, Ben Romdhane M, Bousadia H, Brahim W, Mezri M, Guesmi A, Ounissi T, Kammoun S, Smati W, Tlili S, Zoughi K, Zemni J, Cheikh Bouhlel M, Islem S, Jemli R, Joulak A, Mzoughi K, Naanea H, Hached L, Hadrich M, Hmem M, Kacem S, Kammoun I, Othmani R, Ouerghi A, Abid S, Ennouri R, Haidar S, Heraiech S, Jammali M, Jarrar M, Riahi L, Trimech B, Azaiez MA, Azzouzi F, Ben Jemaa K, Ben Rejab O, Chrigui R, Wechtati W, Boughzela E, Jridi G, Bezdah L, Kraiem S, Drissa H, Ben Youssef S, Fehri W, Kachboura S, Gamra H, Kammoun S, Mourali MS, Addad F, Abid L. Epidemiological characteristics, management, and outcomes of atrial fibrillation in TUNISIA: Results from the National Tunisian Registry of Atrial Fibrillation (NATURE-AF). Clin Cardiol 2021; 44:501-510. [PMID: 33704830 PMCID: PMC8027580 DOI: 10.1002/clc.23558] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/18/2021] [Accepted: 01/27/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Contemporary registries on atrial fibrillation (AF) are scare in North African countries. HYPOTHESIS In the context of the epidemiological transition, prevalence of valvular AF in Tunisia has decreased and the quality of management is still suboptimal. METHODS NATURE-AF is a prospective Tunisian registry, involving consecutive patients with AF from March 1, 2017 to May 31, 2017, with a one-year follow-up period. All the patients with an Electrocardiogram-documented AF, confirmed in the year prior to enrolment were eligible. The epidemiological characteristics and outcomes were described. RESULTS A total of 915 patients were included in this study, with a mean age of 64.3 ± 22 years and a male/female sex ratio of 0.93. Valvular AF was identified in 22.4% of the patients. The mean CHA2 DS2 VASC score in nonvalvular AF was 2.4 ± 1.6. Monotherapy with antiplatelet agents was prescribed for 13.8% of the patients. However, 21.7% of the subjects did not receive any antithrombotic agent. Oral anticoagulants were prescribed for half of the patients with a low embolic risk score. In 341 patients, the mean time in therapeutic range was 48.87 ± 28.69%. Amiodarone was the most common antiarrhythmic agent used (52.6%). During a 12-month follow-up period, 15 patients (1.64%) had thromboembolism, 53 patients (5.8%) had major hemorrhage, and 52 patients (5.7%) died. CONCLUSIONS NATURE-AF has provided systematic collection of contemporary data regarding the epidemiological and clinical characteristics as well as the management of AF by cardiologists in Tunisia. Valvular AF is still prevalent and the quality of anticoagulation was suboptimal.
Collapse
Affiliation(s)
| | - Afef Ben Halima
- Abderrahman Mami Pneumology and Phthisiology Hospital, Ariana, Tunisia
| | | | | | | | | | | | | | - Sonia Marrakchi
- Abderrahman Mami Pneumology and Phthisiology Hospital, Ariana, Tunisia
| | | | - Majed Hassine
- Fattouma Bourguiba University Hospital, Monastir, Tunisia
| | | | | | | | | | | | | | | | | | | | - Lilia Zakhama
- La Marsa Internal Security Forces Hospital, La Marsa, Tunisia
| | | | | | | | | | - Ali Neji
- Ben Guerdane Hospital, Medenine, Tunisia
| | - Saoussen Antit
- La Marsa Internal Security Forces Hospital, La Marsa, Tunisia
| | | | | | | | | | - Rami Tlili
- University Hospital Center Mongi Slim, La Marsa, Tunisia
| | | | | | | | | | - Faouzi Maatouk
- Fattouma Bourguiba University Hospital, Monastir, Tunisia
| | | | | | | | | | - Dorra Mbarek
- University Hospital Center Mongi Slim, La Marsa, Tunisia
| | | | | | | | | | | | | | | | | | | | - Ali Guesmi
- Mohamed Ben Sassi Hospital, Gabes, Tunisia
| | - Taha Ounissi
- Mohamed Taher Al Maamouri Hospital, Nabeul, Tunisia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ikram Kammoun
- Abderrahman Mami Pneumology and Phthisiology Hospital, Ariana, Tunisia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Wafa Fehri
- Hôpital Militaire Principal d'instruction de Tunis, Tunis, Tunisia
| | - Salem Kachboura
- Abderrahman Mami Pneumology and Phthisiology Hospital, Ariana, Tunisia
| | - Habib Gamra
- Fattouma Bourguiba University Hospital, Monastir, Tunisia
| | | | | | - Faouzi Addad
- Abderrahman Mami Pneumology and Phthisiology Hospital, Ariana, Tunisia
| | | |
Collapse
|
15
|
Abbas SS, Majeed T, Nair BR, Forder PM, Biostatistics M, Weaver N, Byles JE. Patterns of Medications for Atrial Fibrillation Among Older Women: Results From the Australian Longitudinal Study on Women's Health. J Cardiovasc Pharmacol Ther 2020; 26:59-66. [PMID: 32757782 DOI: 10.1177/1074248420947278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE Examine patterns of medication use, changes in medication patterns over time, and investigate factors associated with medication patterns among older Australian women with Atrial Fibrillation (AF). METHODS It is a retrospective analysis of the 1921-26 birth cohort of the Australian Longitudinal Study on Women's Health (ALSWH), diagnosed with AF between 2000-2015 (N = 1206). Survey data of these women was linked with national registries for medications and death. Latent Transition Analysis (LTA) identified distinct patterns of medication use and transitions among these patterns for 3 consecutive years following AF diagnosis. LTA with co-variates determined the factors associated with latent status membership. RESULTS One-tenth (9.6%, 11.7%, 11.4%) of the study population did not receive any medication for AF in all 3 years following AF diagnosis and about 60% did not receive any medication for the prevention of thromboembolism. Among those who received medications, almost three-quarters (76.6%, 68.4%, 68.5%) received some kind of combination of medications. LTA indicated at least 6 different patterns of AF medications. These patterns had transition probabilities >85% for most of the latent statuses. All factors but diabetes mellitus among the CHA2DS2-VA scoring scheme were independently associated with latent status membership at the time of AF diagnosis. CONCLUSIONS Evaluation of pharmacological treatment indicates that prevention of thromboembolism is inadequate among women with AF. There exists wide variations in medication patterns. However, once in a particular pattern, women are likely to continue the same medications long-term. This underscores the importance of initial assessment of patient profile and stroke risk score in determining the treatment for AF. Failure to assess risk makes women susceptible to devastating AF complications.
Collapse
Affiliation(s)
- Shazia Shehzad Abbas
- School of Medicine and Public Health, Faculty of Health and Medicine, 64834University of Newcastle, Newcastle, Australia
| | - Tazeen Majeed
- School of Medicine and Public Health, Faculty of Health and Medicine, 64834University of Newcastle, Newcastle, Australia
| | - Balakrishnan R Nair
- School of Medicine and Public Health, Faculty of Health and Medicine, 64834University of Newcastle, Newcastle, Australia
| | | | - M Biostatistics
- School of Medicine and Public Health, Faculty of Health and Medicine, 64834University of Newcastle, Newcastle, Australia
| | - Natasha Weaver
- School of Medicine and Public Health, Faculty of Health and Medicine, 64834University of Newcastle, Newcastle, Australia
| | - Julie E Byles
- School of Medicine and Public Health, Faculty of Health and Medicine, 64834University of Newcastle, Newcastle, Australia
| |
Collapse
|
16
|
Tedla YG, Schwartz SM, Silberman P, Greenland P, Passman RS. Racial Disparity in the Prescription of Anticoagulants and Risk of Stroke and Bleeding in Atrial Fibrillation Patients. J Stroke Cerebrovasc Dis 2020; 29:104718. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.104718] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 01/31/2020] [Indexed: 10/24/2022] Open
|
17
|
Fralick M, Colacci M, Schneeweiss S, Huybrechts KF, Lin KJ, Gagne JJ. Effectiveness and Safety of Apixaban Compared With Rivaroxaban for Patients With Atrial Fibrillation in Routine Practice: A Cohort Study. Ann Intern Med 2020; 172:463-473. [PMID: 32150751 DOI: 10.7326/m19-2522] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Apixaban and rivaroxaban are the most commonly prescribed direct oral anticoagulants for adults with atrial fibrillation, but head-to-head data comparing their safety and effectiveness are lacking. Objective To compare the safety and effectiveness of apixaban versus rivaroxaban for patients with nonvalvular atrial fibrillation. Design New-user, active-comparator, retrospective cohort study. Setting A U.S. nationwide commercial health care claims database from 28 December 2012 to 1 January 2019. Patients Adults newly prescribed apixaban (n = 59 172) or rivaroxaban (n = 40 706). Measurements The primary effectiveness outcome was a composite of ischemic stroke or systemic embolism. The primary safety outcome was a composite of intracranial hemorrhage or gastrointestinal bleeding. Results 39 351 patients newly prescribed apixaban were propensity score matched to 39 351 patients newly prescribed rivaroxaban. Mean age was 69 years, 40% of patients were women, and mean follow-up was 288 days for new apixaban users and 291 days for new rivaroxaban users. The incidence rate of ischemic stroke or systemic embolism was 6.6 per 1000 person-years for adults prescribed apixaban compared with 8.0 per 1000 person-years for those prescribed rivaroxaban (hazard ratio [HR], 0.82 [95% CI, 0.68 to 0.98]; rate difference, 1.4 fewer events per 1000 person-years [CI, 0.0 to 2.7]). Adults prescribed apixaban also had a lower rate of gastrointestinal bleeding or intracranial hemorrhage (12.9 per 1000 person-years) compared with those prescribed rivaroxaban (21.9 per 1000 person-years), corresponding to an HR of 0.58 (CI, 0.52 to 0.66) and a rate difference of 9.0 fewer events per 1000 person-years (CI, 6.9 to 11.1). Limitation Unmeasured confounding, incomplete laboratory data. Conclusion In routine care, adults with atrial fibrillation prescribed apixaban had a lower rate of both ischemic stroke or systemic embolism and bleeding compared with those prescribed rivaroxaban. Primary Funding Source Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital.
Collapse
Affiliation(s)
- Michael Fralick
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, and Sinai Health System and University of Toronto, Toronto, Ontario, Canada (M.F.)
| | - Michael Colacci
- Sinai Health System and University of Toronto, Toronto, Ontario, Canada (M.C.)
| | - Sebastian Schneeweiss
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.S., K.F.H., K.J.L., J.J.G.)
| | - Krista F Huybrechts
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.S., K.F.H., K.J.L., J.J.G.)
| | - Kueiyu Joshua Lin
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.S., K.F.H., K.J.L., J.J.G.)
| | - Joshua J Gagne
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.S., K.F.H., K.J.L., J.J.G.)
| |
Collapse
|
18
|
Affiliation(s)
- Benjamin A Steinberg
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Durham, NC, USA.,Cardiology Division, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
19
|
Lee KH. How to Overcome Social Inequalities of Oral Anticoagulation Usage in Korea? Korean Circ J 2020; 50:278-280. [PMID: 32100484 PMCID: PMC7043959 DOI: 10.4070/kcj.2020.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/15/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Ki Hong Lee
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea.
| |
Collapse
|
20
|
Domek M, Li YG, Gumprecht J, Asaad N, Rashed W, Alsheikh-Ali A, Nabrdalik K, Gumprecht J, Zubaid M, Lip GY. One-year all-cause mortality risk among atrial fibrillation patients in Middle East with and without diabetes: The Gulf SAFE registry. Int J Cardiol 2020; 302:47-52. [DOI: 10.1016/j.ijcard.2019.12.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 12/08/2019] [Accepted: 12/29/2019] [Indexed: 12/17/2022]
|
21
|
Creatinine monitoring patterns in the setting of direct oral anticoagulant therapy for non-valvular atrial fibrillation. J Thromb Thrombolysis 2020; 48:500-505. [PMID: 31111434 DOI: 10.1007/s11239-019-01883-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Guidelines and experts note that patients with atrial fibrillation require regular renal function monitoring to ensure safe use of direct oral anticoagulants (DOACs). Insufficient monitoring could lead to inappropriate dosing and adverse events. Our objective was to describe the frequency of insufficient creatinine monitoring among patients on DOACs, and to describe clinical factors associated with insufficient monitoring. We hypothesized that renal impairment would be associated with insufficient monitoring. A retrospective cohort study was performed with data from the Michigan Anticoagulant Quality Improvement Initiative. Patients were included if they initiated DOAC therapy for stroke prevention related to atrial fibrillation, remained on therapy for ≥ 1 year, and had baseline creatinine and weight measurements. Creatinine clearance (CrCl) was calculated via Cockcroft-Gault equation. Our outcome was the presence of insufficient creatinine monitoring, defined as: < 1 creatinine level/year for patients with CrCl > 50, or < 2 creatinine levels/year for patients with CrCl ≤ 50. Multivariable analysis was done via logistic regression. Study population included 511 patients. In overall, 14.0% of patients received insufficient monitoring. Among patients with CrCl > 50, 11.5% had < 1 creatinine level/year. Among patients with CrCl ≤ 50, 27.1% received < 2 creatinine levels/year. Baseline renal dysfunction was associated with a higher likelihood of insufficient creatinine monitoring (adjusted odds ratio 3.64, 95% confidence interval 1.81-7.29). This shows a significant gap in the monitoring of patients on DOACs-patients with renal impairment are already at higher risk for adverse events. Future studies are needed to describe the barriers in monitoring these patients and to identify how to optimally address them.
Collapse
|
22
|
Yu HT, Yang PS, Hwang J, Ryu S, Jang E, Kim TH, Uhm JS, Kim JY, Pak HN, Lee MH, Lip GYH, Joung B. Social Inequalities of Oral Anticoagulation after the Introduction of Non-Vitamin K Antagonists in Patients with Atrial Fibrillation. Korean Circ J 2020; 50:267-277. [PMID: 32100483 PMCID: PMC7043961 DOI: 10.4070/kcj.2019.0207] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/30/2019] [Accepted: 11/13/2019] [Indexed: 12/13/2022] Open
Abstract
Background and Objectives Nationwide social inequalities of oral anticoagulation (OAC) usage after the introduction of non-vitamin K antagonist oral anticoagulants (NOACs) have not been well identified in patients with atrial fibrillation (AF). This study assessed overall rate and social inequalities of OAC usage after the introduction of NOAC in Korea. Methods Between January 2002 and December 2016, we identified 888,540 patients with AF in the Korea National Health Insurance system database. The change of OAC rate in different medical systems after the introduction of NOAC were evaluated. Results In all population, overall OAC use increased from 13.2% to 23.4% (p for trend <0.001), and NOAC use increased from 0% to 14.6% (p for trend <0.001). Compared with pre-reimbursement (0.48%), the annual increase of OAC use was significantly higher after partial (1.16%, p<0.001), and full reimbursement of OAC (3.72%, p<0.001). Full reimbursement of NOAC (adjusted odds ratio, 2.10; 95% confidence interval, 2.04–2.15) was independently associated with higher OAC use. However, the difference of overall OAC usage between tertiary referral hospitals and nursing or public health centers increased from 17.9% in 2010 to 36.8% in 2016. Moreover, usage rate of NOAC was significantly different among different medical systems from 37.2% at the tertiary referral hospital and 5.5% at nursing or public health centers. Conclusions Introduction of NOACs in routine practice for stroke prevention in AF was associated with improved rates of overall OAC use. However, significant practice-level variations in OAC and NOAC use remain producing social inequalities of OAC despite full reimbursement.
Collapse
Affiliation(s)
- Hee Tae Yu
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Pil Sung Yang
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Jinseub Hwang
- Department of Computer Science and Statistics, Daegu University, Gyeongsan, Korea
| | - Soorack Ryu
- Department of Computer Science and Statistics, Daegu University, Gyeongsan, Korea
| | - Eunsun Jang
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Sun Uhm
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Youn Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hui Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Moon Hyoung Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
23
|
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.
Collapse
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.
| | | |
Collapse
|
24
|
Hawkins NM, Scheuermeyer FX, Youngson E, Sandhu RK, Ezekowitz JA, Kaul P, McAlister FA. Impact of cardiology follow-up care on treatment and outcomes of patients with new atrial fibrillation discharged from the emergency department. Europace 2019; 22:695-703. [DOI: 10.1093/europace/euz302] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 10/15/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aims
The first presentation of atrial fibrillation (AF) is often to an emergency department (ED). We evaluated the association of subsequent specialist care with morbidity and mortality.
Methods and results
Retrospective cohort study of all adults in Alberta, Canada, with a new primary diagnosis of AF treated and released during an index ED visit between 2009 and 2015. Types of physician follow-up within 3 months of ED visit was analysed using Cox proportional hazards models with time-varying covariates. Outcomes were evaluated at 1 year. Of 7986 patients, 476 (6.0%) had no physician follow-up within 3 months, whereas 2730 (34.2%) attended a non-specialist only, 1277 (16.0%) an internal medicine specialist, and 3503 (43.9%) cardiology. An increasing gradient of cardiac investigations occurred across these groups. Cardiology compared with non-cardiologist care was associated with approximately two-fold greater electrophysiology interventions and revascularization, and increased use of beta-blockers (48.9% vs. 43.0%, P < 0.0001), statins (31.4% vs. 26.7%, P < 0.0001), and oral anticoagulation in patients with CHADS2 scores ≥1 (53.7% vs. 43.6%, P < 0.0001). In the subsequent year, cardiology care was associated with fewer deaths [adjusted hazard ratio (aHR) 0.72, 95% confidence interval (CI) 0.55–0.93], strokes (aHR 0.60, 95% CI 0.37–0.96), or major bleeds (aHR 0.69, 95% CI 0.53–0.89). No differences in the risk of hospitalization or ED visits were associated with cardiology care.
Conclusion
Cardiology care after an ED visit for symptomatic new-onset AF is associated with better prognosis. The benefit may be mediated through more intensive investigation, identification, and treatment of cardiovascular risk factors and disease.
Collapse
Affiliation(s)
- Nathaniel M Hawkins
- Division of Cardiology, University of British Columbia, Vancouver, BC V6Z 1Y6, Canada
| | - Frank X Scheuermeyer
- Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Health Evaluation and Outcomes Science, Vancouver, BC, Canada
| | - Erik Youngson
- Alberta SPOR Support Unit Data Platform, University of Alberta, Edmonton, AB, Canada
| | - Roopinder K Sandhu
- Division of Cardiology and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
- Canadian Vigour Centre, University of Alberta, Edmonton, AB, Canada
| | - Justin A Ezekowitz
- Division of Cardiology and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
- Canadian Vigour Centre, University of Alberta, Edmonton, AB, Canada
| | - Padma Kaul
- Division of Cardiology and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
- Canadian Vigour Centre, University of Alberta, Edmonton, AB, Canada
| | - Finlay A McAlister
- Alberta SPOR Support Unit Data Platform, University of Alberta, Edmonton, AB, Canada
- Canadian Vigour Centre, University of Alberta, Edmonton, AB, Canada
- Division of General Internal Medicine, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
25
|
Bean DM, Teo J, Wu H, Oliveira R, Patel R, Bendayan R, Shah AM, Dobson RJB, Scott PA. Semantic computational analysis of anticoagulation use in atrial fibrillation from real world data. PLoS One 2019; 14:e0225625. [PMID: 31765395 PMCID: PMC6876873 DOI: 10.1371/journal.pone.0225625] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 11/09/2019] [Indexed: 12/03/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia and significantly increases stroke risk. This risk is effectively managed by oral anticoagulation. Recent studies using national registry data indicate increased use of anticoagulation resulting from changes in guidelines and the availability of newer drugs. The aim of this study is to develop and validate an open source risk scoring pipeline for free-text electronic health record data using natural language processing. AF patients discharged from 1st January 2011 to 1st October 2017 were identified from discharge summaries (N = 10,030, 64.6% male, average age 75.3 ± 12.3 years). A natural language processing pipeline was developed to identify risk factors in clinical text and calculate risk for ischaemic stroke (CHA2DS2-VASc) and bleeding (HAS-BLED). Scores were validated vs two independent experts for 40 patients. Automatic risk scores were in strong agreement with the two independent experts for CHA2DS2-VASc (average kappa 0.78 vs experts, compared to 0.85 between experts). Agreement was lower for HAS-BLED (average kappa 0.54 vs experts, compared to 0.74 between experts). In high-risk patients (CHA2DS2-VASc ≥2) OAC use has increased significantly over the last 7 years, driven by the availability of DOACs and the transitioning of patients from AP medication alone to OAC. Factors independently associated with OAC use included components of the CHA2DS2-VASc and HAS-BLED scores as well as discharging specialty and frailty. OAC use was highest in patients discharged under cardiology (69%). Electronic health record text can be used for automatic calculation of clinical risk scores at scale. Open source tools are available today for this task but require further validation. Analysis of routinely collected EHR data can replicate findings from large-scale curated registries.
Collapse
Affiliation(s)
- Daniel M. Bean
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, England, United Kingdom
- Health Data Research UK London, University College London, London, England, United Kingdom
| | - James Teo
- Department of Stroke and Neurology, King’s College Hospital NHS Foundation Trust, London, England, United Kingdom
| | - Honghan Wu
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Scotland, United Kingdom
- School of Computer and Software, Nanjing University of Information Science and Technology, Nanjing, China
- Health Data Research UK Scotland, Edinburgh, Scotland, United Kingdom
| | - Ricardo Oliveira
- Unidade de Doenças Imunomediadas Sistémicas (UDIMS), S. Medicina IV, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Raj Patel
- Department of Haematology, King’s College Hospital NHS Foundation Trust, London, England, United Kingdom
| | - Rebecca Bendayan
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, England, United Kingdom
- NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London, London, England, United Kingdom
| | - Ajay M. Shah
- British Heart Foundation Centre, King’s College London, London, England, United Kingdom
- Department of Cardiology, King’s College Hospital NHS Foundation Trust, London, England, United Kingdom
| | - Richard J. B. Dobson
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, England, United Kingdom
- Health Data Research UK London, University College London, London, England, United Kingdom
- NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London, London, England, United Kingdom
- Institute of Health Informatics, University College London, London, England, United Kingdom
| | - Paul A. Scott
- British Heart Foundation Centre, King’s College London, London, England, United Kingdom
- Department of Cardiology, King’s College Hospital NHS Foundation Trust, London, England, United Kingdom
| |
Collapse
|
26
|
Invited review: hypertension and atrial fibrillation: epidemiology, pathophysiology, and implications for management. J Hum Hypertens 2019; 33:824-836. [DOI: 10.1038/s41371-019-0279-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/09/2019] [Accepted: 10/15/2019] [Indexed: 02/08/2023]
|
27
|
Rush KL, Burton L, Van Der Merwe F, Hatt L, Galloway C. Atrial fibrillation care in rural communities: a mixed methods study of physician and patient perspectives. BMC FAMILY PRACTICE 2019; 20:144. [PMID: 31651259 PMCID: PMC6813979 DOI: 10.1186/s12875-019-1029-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 09/20/2019] [Indexed: 02/04/2023]
Abstract
Background Atrial fibrillation (AF) is a serious heart arrhythmia associated with devastating outcomes such as stroke. Inequitable rural AF care may put patients at risk. Virtually delivered specialty AF care offers a viable option, but stakeholder perceptions of this option within the context of rural AF care is unknown. The study purpose was to obtain patient and primary care physician perspectives of rural AF care and virtually delivered AF care as a potential option. Methods Using a mixed methods design, AF patients (n = 101) and physicians (n = 15) from three rural communities participated in focus groups and/or surveys. Focus group data were thematically analyzed, survey data were descriptively analyzed, and data were triangulated. Results Findings captured patients’ and physicians’ perceptions of prioritized, needs, concerns and problems in AF management, available/unavailable services, and their ideas about virtual AF care. Patients and physicians identified eclectic problems in managing AF. Overall, patients felt ill informed about managing their AF and their most salient problems related to fatigue, exercise intolerance, weight maintenance, sleep apnea, and worry about stroke and bleeding. Physicians found treating patients with co-morbidities and cognitive decline problematic and balancing risks related to anticoagulation challenging. Patients and physicians identified education as a pressing need, which physicians lacked time and resources to meet. Despite available rural services, access to primary and cardiology care was a recurring challenge, and emergency department (ED) use highly contentious but often the only option for accessing care. Physicians’ managed AF care and varied in the referrals they made, often reserving them for complex situations to avoid patient travel. Patients and providers supported a broad approach to virtual AF care, tailored to an inclusive rural patient demographic. Conclusions The study offered valuable physician and patient perspectives on AF care in rural communities including diverse management challenges, gaps in access to primary and specialty services that made ED an often used but contentious option. Findings point to the potential value of virtual care designed to reach patients with AF across the spectrum and geared to local contexts that preserve the vital role of primary care physicians in AF care in their communities.
Collapse
Affiliation(s)
- Kathy L Rush
- School of Nursing, University of British Columbia Okanagan, 1147 Research Road, Kelowna, BC, V1V 1V7, Canada.
| | - Lindsay Burton
- School of Nursing, University of British Columbia Okanagan, 1147 Research Road, Kelowna, BC, V1V 1V7, Canada
| | | | - Linda Hatt
- University of British Columbia Okanagan, Psychology, 1147 Research Road, Kelowna, BC, V1V 1V7, Canada
| | - Camille Galloway
- School of Nursing, University of British Columbia Okanagan, 1147 Research Road, Kelowna, BC, V1V 1V7, Canada
| |
Collapse
|
28
|
O'Neal WT, Claxton JS, Sandesara PB, MacLehose RF, Chen LY, Bengtson LGS, Chamberlain AM, Norby FL, Lutsey PL, Alonso A. Provider Specialty, Anticoagulation, and Stroke Risk in Patients With Atrial Fibrillation and Cancer. J Am Coll Cardiol 2019; 72:1913-1922. [PMID: 30309468 DOI: 10.1016/j.jacc.2018.07.077] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 07/17/2018] [Accepted: 07/23/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND It is unknown whether early cardiology involvement shortly after atrial fibrillation (AF) diagnosis is associated with favorable outcomes in AF patients who have cancer. OBJECTIVES The purpose of this study was to examine the relationship between early cardiology involvement after AF diagnosis in patients with history of cancer. METHODS This study examined associations of early cardiology involvement with oral anticoagulation use, stroke, and bleeding among nonvalvular AF patients (n = 388,045; mean age 68 ± 15 years; 59% male) with a history of cancer (past or active) from the MarketScan database (2009 to 2014). International Classification of Disease-9th Revision-Clinical Modification codes in any position were used to identify cancer diagnosis prior to AF diagnosis. Provider specialty and filled anticoagulant prescriptions 3 months prior to and 6 months after AF diagnosis were obtained. Poisson regression models were used to compute the probability of an oral anticoagulant prescription fill, and Cox regression was used to estimate the risks of stroke and major bleeding. RESULTS A total of 64,016 (17%) AF patients had a history of cancer. Cardiology involvement was less likely to occur among patients with a history of cancer than those without (relative risk [RR]: 0.92 [95% confidence interval (CI): 0.91 to 0.93]). Patients with history of cancer were less likely to fill prescriptions for anticoagulants (RR: 0.89 [95% CI: 0.88 to 0.90]) than those without cancer, and similar results were observed across cancer types. Patients with cancer were more likely to fill prescriptions for anticoagulants (RR: 1.48 [95% CI: 1.45 to 1.52]) if seen by a cardiologist. A reduced risk of stroke (hazard ratio: 0.89 [95% CI: 0.81 to 0.99]) was observed among all cancer patients who were seen by a cardiology provider, without an increased risk of bleeding (hazard ratio: 1.04 [95% CI: 0.95 to 1.13]). Similar results were observed when the analysis was stratified by active versus remote history of cancer. CONCLUSIONS Although AF patients with cancer were less likely to see a cardiologist, or fill anticoagulant prescriptions, cardiology involvement was associated with increased anticoagulant prescription fills and favorable AF-related outcomes in AF patients with cancer.
Collapse
Affiliation(s)
- Wesley T O'Neal
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
| | - J'Neka S Claxton
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Pratik B Sandesara
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Lin Y Chen
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Lindsay G S Bengtson
- Health Economics and Outcomes Research, Life Sciences, Optum, Eden Prairie, Minnesota
| | | | - Faye L Norby
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| |
Collapse
|
29
|
Claxton JS, Lutsey PL, MacLehose RF, Chen LY, Lewis TT, Alonso A. Geographic Disparities in the Incidence of Stroke among Patients with Atrial Fibrillation in the United States. J Stroke Cerebrovasc Dis 2018; 28:890-899. [PMID: 30583824 DOI: 10.1016/j.jstrokecerebrovasdis.2018.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 10/26/2018] [Accepted: 12/06/2018] [Indexed: 12/12/2022] Open
Abstract
AIM To determine whether regional variation in stroke incidence exists among individuals with AF. METHODS Using healthcare utilization claims from 2 large US databases, MarketScan (2007-2014) and Optum Clinformatics (2009-2015), and the 2010 US population as the standard, we estimated age-, sex-, race- (only in Optum) standardized stroke incidence rates by the 9 US census divisions. We also used Poisson regression to examine incidence rate ratios (IRR) of stroke and the probability of anticoagulation prescription fills across divisions. RESULTS Both databases combined included 970,683 patients with AF who experienced 15,543 strokes, with a mean follow-up of 23 months. In MarketScan, the age- and sex-standardized stroke incidence rate was highest in the Middle Atlantic and East South Central divisions at 3.8/1000 person-years (PY) and lowest in the West North Central at 3.2/1000 PY. The IRR of stroke and the probability of anticoagulation fills were similar across divisions. In Optum Clinformatics, the age-, sex-, and race-standardized stroke incidence rate was highest in the East North Central division at 5.0/1000 PY and lowest in the New England division at 3.3/1000 PY. IRR of stroke and the probability of anticoagulation fills differed across divisions when compared to New England. CONCLUSIONS These findings suggest regional differences in stroke incidence among AF patients follow a pattern that differs from the hypothesized trend found in the general population and that other factors may be responsible for this new pattern. Cross-database differences provide a cautionary tale for the identification of regional variation using health claims data.
Collapse
Affiliation(s)
- J'Neka S Claxton
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia. j'
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Lin Y Chen
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Tené T Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| |
Collapse
|
30
|
Chang AY, Askari M, Fan J, Heidenreich PA, Michael Ho P, Mahaffey KW, Ullal AJ, Perino AC, Turakhia MP. Association of Healthcare Plan with atrial fibrillation prescription patterns. Clin Cardiol 2018; 41:1136-1143. [PMID: 30098034 DOI: 10.1002/clc.23042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/08/2018] [Accepted: 08/08/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is treated by many types of physician specialists, including primary care physicians (PCPs). Health plans have different policies for how patients encounter these providers, and these may affect selection of AF treatment strategy. HYPOTHESIS We hypothesized that healthcare plans with PCP-gatekeeping to specialist access may be associated with different pharmacologic treatments for AF. METHODS We performed a retrospective cohort study using a commercial pharmaceutical claims database. We utilized logistic regression models to compare odds of prescription of oral anticoagulant (OAC), non-vitamin K-dependent oral anticoagulant (NOAC), rate control, and rhythm control medications used to treat AF between patients with PCP-gated healthcare plans (eg, HMO, EPO, POS) and patients with non-PCP-gated healthcare plans (eg, PPO, CHDP, HDHP, comprehensive) between 2007 and 2012. We also calculated median time to receipt of therapy within 90 days of index AF diagnosis. RESULTS We found similar odds of OAC prescription at 90 days following new AF diagnosis in patients with PCP-gated plans compared to those with non-PCP-gated plans (OR: OAC 1.01, P = 0.84; warfarin 1.05, P = 0.08). Relative odds were similar for rate control (1.17, P < 0.01) and rhythm control agents (0.93, P = 0.03). However, PCP-gated plan patients had slightly lower likelihood of being prescribed NOACs (0.82, P = 0.001) than non-gated plan patients. Elapsed time until receipt of medication was similar between PCP-gated and non-gated groups across drug classes. CONCLUSIONS Pharmaceutical claims data do not suggest that PCP-gatekeeping by healthcare plans is a structural barrier to AF therapy, although it was associated with lower use of NOACs.
Collapse
Affiliation(s)
- Andrew Young Chang
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Mariam Askari
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Paul A Heidenreich
- Department of Medicine, Stanford University School of Medicine, Stanford, California.,Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - P Michael Ho
- Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado.,Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Kenneth W Mahaffey
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Aditya Jathin Ullal
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | | | - Mintu P Turakhia
- Department of Medicine, Stanford University School of Medicine, Stanford, California.,Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| |
Collapse
|
31
|
Non-vitamin k antagonist oral anticoagulants in a European primary care physician survey. BJGP Open 2018; 2:bjgpopen18X101602. [PMID: 30564735 PMCID: PMC6189775 DOI: 10.3399/bjgpopen18x101602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 05/25/2018] [Indexed: 12/11/2022] Open
Abstract
Background Familiarity and competency in the options for stroke prevention in atrial fibrillation (AF) and the role of non-vitamin K antagonist oral anticoagulants (NOACs) may vary among primary care physicians (PCPs) from different European countries. Aims To investigate PCP views on prescribing and managing NOACs across Europe and identify perceived unmet needs. Design & setting Web-based survey including PCPs with particular interest in cardiovascular medicine. Method A questionnaire was drawn up, containing 10 questions on initiation and ongoing management of NOACs; use of AF stroke guidelines on NOACs and anticoagulant switching; and perceived information needs. Results The overall response rate was 42%. The majority of PCPs declared they are responsible for and confident in both initiating and managing NOAC therapy. In some countries, PCPs are not able to initiate NOAC therapy due to administrative barriers (namely, Italy and Slovakia). No single set of guidelines is referred to across all countries and over a fifth of responders indicate they do not follow specific guidelines. The main learning needs reported were more related to initiation than to ongoing management of anticoagulant therapy. Conclusion According to this self-assessment survey, the experience of most PCPs in management of different aspects of AF appears good and only some felt the need for further training. However, in the light of the importance of this topic as public health issue, intensified efforts aiming at better equipping PCPs to meet their key roles in an integrated service across Europe are overdue.
Collapse
|
32
|
Influence of Sociodemographic Factors and Provider Specialty on Anticoagulation Prescription Fill Patterns and Outcomes in Atrial Fibrillation. Am J Cardiol 2018; 122:388-394. [PMID: 29961563 DOI: 10.1016/j.amjcard.2018.04.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/13/2018] [Accepted: 04/17/2018] [Indexed: 11/21/2022]
Abstract
Early cardiology involvement after atrial fibrillation (AF) diagnosis is associated with increased oral anticoagulant prescription fills and reduced stroke risk. It is unknown if this association varies by race, sex, or education. We examined anticoagulant fills in 223,891 patients with incident nonvalvular AF (mean age = 71 years; 44% women; 84% white; 9% black; 5% Hispanic; 2% Asian) from the Optum Clinformatics database (2009 to 2014). Provider specialty and filled anticoagulant prescriptions 3 months before and 6 months after AF diagnosis were obtained. Poisson regression was used to compute the probability of oral anticoagulant prescription fill and Cox regression was used to estimate the risk of stroke and major bleeding. Cardiology involvement was less likely among nonwhites (white = Referent; black = relative risk = 0.96, 95% confidence interval (0.95 to 0.97); Hispanic = 0.99 (0.98 to 1.00); Asian = 0.95 (0.93 to 0.97)) and women (0.92 (0.91 to 0.93)), but more likely with higher education level (high school or less = Referent; some college = 1.03 (1.02 to 1.04); college or more = 1.08 (1.07 to 1.09)). Patients seen by cardiology providers were more likely to fill anticoagulant prescriptions (Any = 1.67 (1.64 to 1.69); direct oral anticoagulants = 2.59 (2.49 to 2.68); warfarin = 1.38 (1.35 to 1.41)) compared with patients not seen by a cardiology provider. Patients seen by a cardiologist had a reduced stroke risk (hazard ratio = 0.84 (0.79 to 0.88)) and similar bleeding risk (1.01 (0.96 to 1.06)). Outcomes did not vary by race, sex, or education level. In conclusion, although race, sex, and education differences exist in early cardiology involvement after AF diagnosis, the influence of cardiology involvement on anticoagulant prescription fills and AF-related outcomes does not vary by these factors. Initiatives to improve early cardiology referral in nonwhites, women, and those with lower educational attainment may improve AF outcomes.
Collapse
|
33
|
Cardy C, Ardisson KM, Widmar SB. Atrial fibrillation clinical decision aid for emergency medicine providers: An initiative to improve quality healthcare outcomes in adults with new-onset atrial fibrillation. Heart Lung 2018; 47:314-321. [DOI: 10.1016/j.hrtlng.2018.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 05/11/2018] [Indexed: 02/07/2023]
|
34
|
Gadsbøll K, Staerk L, Fosbøl EL, Sindet-Pedersen C, Gundlund A, Lip GYH, Gislason GH, Olesen JB. Increased use of oral anticoagulants in patients with atrial fibrillation: temporal trends from 2005 to 2015 in Denmark. Eur Heart J 2018; 38:899-906. [PMID: 28110293 DOI: 10.1093/eurheartj/ehw658] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 12/22/2016] [Indexed: 12/11/2022] Open
Abstract
Aim The aim of this study is to examine temporal trends in the use oral anticoagulants (OAC) as stroke prophylaxis in patients with atrial fibrillation (AF) and to examine factors associated with OAC initiation. Methods and results From Danish nationwide registries, we identified patients diagnosed with AF at Danish hospitals and outpatient clinics between January 2005 and June 2015. OAC initiation was assessed from prescription fills ±180 days from date of AF diagnosis. We identified a total of 108 410 patients with newly diagnosed AF. Before 2010, 40-50% initiated OAC treatment. From 2010, OAC initiation rates increased (P < 0.0001 for trend) and by June 2015, 66.5% of the incident AF patients were initiated on OAC (74.5% increase since December 2009). Increased OAC prescription was especially seen among females and 'fragile' patients (age > 75 years and high risk of stroke). The increased OAC initiation was accompanied by introduction and increased uptake of the NOACs. By the end of the study, NOACs accounted for 72.5% of all OACs prescribed in newly diagnosed AF patients. OAC initiation was associated with male gender, age 65-74 years, few comorbidities and increased risk of stroke. Conclusion Since 2010, more incident AF patients in Denmark were initiated on OAC therapy with predominant NOAC prescription. The increase was pronounced among females, among patients at high risk of stroke, and among older patients.
Collapse
Affiliation(s)
- Kasper Gadsbøll
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup 2900, Denmark
| | - Laila Staerk
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup 2900, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen Ø 2100, Denmark.,The Danish Heart Foundation, Copenhagen K, Copenhagen 1127, Denmark
| | - Caroline Sindet-Pedersen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup 2900, Denmark
| | - Anna Gundlund
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup 2900, Denmark
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, UK
| | - Gunnar Hilmar Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup 2900, Denmark.,The Danish Heart Foundation, Copenhagen K, Copenhagen 1127, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen N 2200, Denmark.,The National Institute of Public Health, University of Southern Denmark, Copenhagen K 1353, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup 2900, Denmark
| |
Collapse
|
35
|
Roldán Rabadán I, Esteve-Pastor MA, Anguita-Sánchez M, Muñiz J, Camacho Siles J, Quesada MA, Ruiz Ortiz M, Marín F, Martínez Sellés M, Bertomeu V, Lip GYH, Cequier Fillat A, Badimón L. Relation of quality of anticoagulation control with different management systems among patients with atrial fibrillation: Data from FANTASIIA Registry. Eur J Clin Invest 2018; 48:e12910. [PMID: 29424018 DOI: 10.1111/eci.12910] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 02/04/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Anticoagulation control in patients with atrial fibrillation (AF) has a multidisciplinary approach although is usually managed by general practitioners (GP) or haematologists. The aim of our study was to assess the quality of anticoagulation control with vitamin K antagonists (VKAs) in relation to the responsible specialist in a "real-world" AF population. METHODS We consecutively enrolled VKA anticoagulated patients included in the FANTASIIA Registry from 2013 to 2015. We analysed demographical, clinical characteristics and the quality of anticoagulation control according to the specialist responsible (ie GPs or haematologists). RESULTS Data on 1584 patients were included (42.5% females, mean age 74.0 ± 9.4 years): 977 (61.7%) patients were controlled by GPs and 607 (38.3%) by haematologists. Patients managed by GPs had higher previous heart disease (53.2% vs 43.3%, P < .001), heart failure (32.9% vs 26.5%, P < .008) and dilated cardiomyopathy (15.2% vs 8.7%, P < .001) with better renal function (69.3 ± 24.7 vs 63.1 ± 21.4 mL/min, P < .001) compared to patients managed by haematologists. There was no difference between groups in the type of AF, CHA2 DS2 -VASc or HAS-BLED scores, but patients with electrical cardioversion were more prevalent in GP group. The overall mean time in therapeutic range (TTR) assessed by Rosendaal method was 61.5 ± 24.9%; 52.6% of patients had TTR<65% and 60% of patients had TTR<70%. TTR was significantly lower in patients controlled by haematologists than by GPs (63 ± 24.4 vs 59.2 ± 25.6, P < .005). CONCLUSIONS About 60% of AF patients anticoagulated with VKAs had poor anticoagulation control (ie TTR<70%), and their management was only slightly better than when it is managed by general practitioners.
Collapse
Affiliation(s)
- Inmaculada Roldán Rabadán
- Department of Cardiology, Hospital Universitario La Paz, Instituto de Investigación de La Paz (IDIPAZ), CIBER-CV, Madrid, Spain
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | | | - Javier Muñiz
- Instituto Universitario de Ciencias de la Salud, Instituto de Investigación Biomedica de A Coruña (INIBIC), Universidade da Coruña, CIBER-CV, A Coruña, Spain
| | - José Camacho Siles
- Department of Internal Medicine, Hospital Universitario La Paz, Madrid, Spain
| | | | - Martín Ruiz Ortiz
- Department of Cardiology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Manuel Martínez Sellés
- Department of Cardiology, Hospital Universitario Gregorio Marañón, Complutense University, European University of Madrid, CIBER-CV, Madrid, Spain
| | - Vicente Bertomeu
- Department of Cardiology, Hospital Universitario de San Juan, CIBER-CV, Alicante, Spain
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Lina Badimón
- Cardiovascular Research Center, CSIC-ICCC, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, CIBER-CV, Barcelona, Spain
| | | |
Collapse
|
36
|
Effect of Electrophysiology Assessment on Mortality and Hospitalizations in Patients With New-Onset Atrial Fibrillation. Am J Cardiol 2018; 121:830-835. [PMID: 29397105 DOI: 10.1016/j.amjcard.2017.12.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 12/03/2017] [Accepted: 12/27/2017] [Indexed: 11/22/2022]
Abstract
Few patients with atrial fibrillation (AF) receive care by cardiac electrophysiologists. Although previous work has highlighted differential care for patients with AF treated by electrophysiologists, it is unclear whether this is associated with improved clinical outcomes. This retrospective population-level propensity score-matched cohort study included patients aged 20 to 80 years with new-onset AF presenting to an emergency department (ED) in Ontario, Canada, between 2010 and 2012. Patients were followed until March 31, 2015. Patients who saw an electrophysiologist within 1 year of the index ED visit were matched to patients who did not see an electrophysiologist. Linked administrative databases were used for cohort construction and allow 1-year follow-up to assess for the clinical end points of all-cause mortality and hospitalization for AF, heart failure, bleeding, and stroke. A total of 5,221 unique pairs of patients were matched. One hundred seventeen patients (2.2%) in the electrophysiologist cohort underwent an AF ablation procedure during the 1-year follow-up period. All-cause mortality (hazard ratio [HR] = 1.1, p = 0.17) and stroke (HR = 1.4, p = 0.09) were not significantly different between the 2 groups. Hospitalization for AF (HR = 1.4, p <0.001), bleeding (HR = 1.5, p = 0.0001), and congestive heart failure (HR = 1.5, p <0.0001) was increased in the group that saw an electrophysiologist. In conclusion, electrophysiologist care was not associated with improved clinical outcomes in patients with new-onset AF.
Collapse
|
37
|
O'Neal WT, Sandesara PB, Claxton JS, MacLehose RF, Chen LY, Bengtson LGS, Chamberlain AM, Norby FL, Lutsey PL, Alonso A. Provider Specialty, Anticoagulation Prescription Patterns, and Stroke Risk in Atrial Fibrillation. J Am Heart Assoc 2018. [PMID: 29525778 PMCID: PMC5907557 DOI: 10.1161/jaha.117.007943] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Differences in anticoagulation rates and direct oral anticoagulant use by provider specialty may identify an area of practice improvement to reduce future stroke events in patients with atrial fibrillation (AF). Methods and Results We examined anticoagulant prescription fills in 388 045 (mean age, 68±15 years; 59% male) patients with incident AF from the MarketScan databases between 2009 and 2014. Provider specialty and filled anticoagulant prescriptions around the time of AF diagnosis (3 months before through 6 months after) were obtained from outpatient services and pharmacy claims. We estimated the association of provider specialty (cardiology versus primary care) with filling oral anticoagulant prescriptions, adjusting for patient characteristics. The risk of stroke and bleeding events also was explored. A total of 235 739 patients (61%) had a cardiology provider claim, whereas 152 306 (39%) were exclusively managed by primary care. Patients seen by cardiology providers were more likely to fill anticoagulant prescriptions than those seen by primary care (39% versus 27%; relative risk, 1.39; 95% confidence interval [CI], 1.37–1.40). Differences were observed for direct oral anticoagulants (relative risk, 1.74; 95% CI, 1.71–1.78) and warfarin (relative risk, 1.24; 95% CI, 1.22–1.26). A reduced risk of stroke events was observed among those seen by cardiology providers (hazard ratio, 0.90; 95% CI, 0.86–0.94) compared with primary care, without an increased bleeding risk (hazard ratio, 1.03; 95% CI, 0.98–1.07). Conclusions Patients seen by an outpatient cardiology provider shortly after AF diagnosis were more likely to initiate oral anticoagulation and were at lower risk of future stroke events without a higher rate of bleeding. Early referral to cardiology specialists may increase initiation of anticoagulant therapies and improve outcomes in AF.
Collapse
Affiliation(s)
- Wesley T O'Neal
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Pratik B Sandesara
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - J'Neka S Claxton
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Lin Y Chen
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | | | | | - Faye L Norby
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| |
Collapse
|
38
|
Mazurek M, Huisman MV, Rothman KJ, Paquette M, Teutsch C, Diener HC, Dubner SJ, Halperin JL, Ma CS, Zint K, Elsaesser A, Lu S, Lip GYH. Regional Differences in Antithrombotic Treatment for Atrial Fibrillation: Insights from the GLORIA-AF Phase II Registry. Thromb Haemost 2017; 117:2376-2388. [PMID: 29212125 PMCID: PMC6260111 DOI: 10.1160/th17-08-0555] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Introduction
Although guideline-adherent antithrombotic therapy (ATT) for stroke prevention in atrial fibrillation (AF) is associated with lower mortality and thromboembolism, ATT uptake shows geographic variation worldwide. We aimed to assess thromboembolic risk and baseline ATT by geographic region and identify factors associated with prescription of ATT in a large, truly global registry of patients with recently diagnosed AF.
Methods and Results
Our analysis comprises 15,092 patients newly diagnosed with non-valvular AF at risk for stroke, enrolled in Phase II of Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF). Global oral anticoagulation (OAC) use was 79.9%, being highest in Europe (90.1%), followed by Africa/Middle East (87.4%) and Latin America (85.3%), North America (78.3%) and Asia (55.2%). Among OAC users, vitamin K antagonists (VKAs) have been replaced by non-VKA OACs (NOACs) as the more prevalent OAC option in all regions, with highest use in North America (66.5%) and lowest in Asia (50.2%). In Asia, OAC was 80.4% in community hospitals but only 49.8% in university hospitals and 42.6% in specialist offices, and varied from 21.0% in China to 89.7% in Japan (NOACs at 5.8% in China and 83.3% in Japan). Globally, 76.5% of low-risk patients were prescribed ATT (46.1% OAC), whereas 17.7% high-risk patients were not anticoagulated (Europe 8.8%; North America 18.9%; Asia 42.4%).
Conclusion
Substantial inter- and intra-regional differences in ATT for stroke prevention in AF are evident in this global registry. While guideline-adherent ATT can be further improved, NOACs are the main contributor to high OAC use worldwide.
Collapse
Affiliation(s)
- Michał Mazurek
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Kenneth J Rothman
- RTI Health Solutions, Research Triangle Institute, Research Triangle Park, North Carolina, United States
| | - Miney Paquette
- Department of Medicine, Boehringer Ingelheim, Burlington, Canada
| | - Christine Teutsch
- Department of Clinical Development and Medical Affairs, Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | | | - Sergio J Dubner
- Clínica y Maternidad Suizo Argentina, Buenos Aires, Argentina
| | | | - Chang Sheng Ma
- Department of Cardiology, Atrial Fibrillation Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Kristina Zint
- Department of Cardiology, Atrial Fibrillation Center, Boehringer Ingelheim, Ingelheim, Germany
| | - Amelie Elsaesser
- Department of Biostatistics and Data Sciences, Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | - Shihai Lu
- Department of Biostatistics and Data Sciences, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, United States
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | |
Collapse
|
39
|
Singh SM, Qiu F, Webster L, Austin PC, Ko DT, Tu JV, Wijeysundera HC. The Relationship Between Cardiologist Care and Clinical Outcomes in Patients With New-Onset Atrial Fibrillation. Can J Cardiol 2017; 33:1693-1700. [DOI: 10.1016/j.cjca.2017.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 10/02/2017] [Accepted: 10/02/2017] [Indexed: 12/23/2022] Open
|
40
|
Treating Specialty and Outcomes in Newly Diagnosed Atrial Fibrillation: From the TREAT-AF Study. J Am Coll Cardiol 2017; 70:78-86. [PMID: 28662810 DOI: 10.1016/j.jacc.2017.04.054] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 04/13/2017] [Accepted: 04/28/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) occurs in many clinical contexts and is diagnosed and treated by clinicians across many specialties. This approach has resulted in treatment variations. OBJECTIVES The goal of this study was to evaluate the association between treating specialty and AF outcomes among patients newly diagnosed with AF. METHODS Using data from the TREAT-AF (Retrospective Evaluation and Assessment of Therapies in AF) study from the Veterans Health Administration, patients with newly diagnosed, nonvalvular AF between 2004 and 2012 were identified who had at least 1 outpatient encounter with primary care or cardiology within 90 days of the AF diagnosis. Cox proportional hazards regression was used to evaluate the association between treating specialty and AF outcomes. RESULTS Among 184,161 patients with newly diagnosed AF (age 70 ± 11 years; 1.7% women; CHA2DS2-VASc score 2.6 ± 1.7), 40% received cardiology care and 60% received primary care only. After adjustment for covariates, cardiology care was associated with reductions in stroke (hazard ratio [HR]: 0.91; 95% confidence interval [CI]: 0.86 to 0.96; p < 0.001) and death (HR: 0.89; 95% CI: 0.88 to 0.91; p < 0.0001) and increases in hospitalizations for AF/supraventricular tachycardia (HR: 1.38; 95% CI: 1.35 to 1.42; p < 0.0001) and myocardial infarction (HR: 1.03; 95% CI: 1.00 to 1.05; p < 0.04). The propensity-matched cohort had similar results. In mediation analysis, oral anticoagulation prescription within 90 days of diagnosis may have mediated reductions in stroke but did not mediate reductions in survival. CONCLUSIONS In patients with newly diagnosed AF, cardiology care was associated with improved outcomes, potentially mediated by early prescription of oral anticoagulation therapy. Although hypothesis-generating, these data warrant serious consideration and study of health care system interventions at the time of new AF diagnosis.
Collapse
|
41
|
Marzec LN, Wang J, Shah ND, Chan PS, Ting HH, Gosch KL, Hsu JC, Maddox TM. Influence of Direct Oral Anticoagulants on Rates of Oral Anticoagulation for Atrial Fibrillation. J Am Coll Cardiol 2017; 69:2475-2484. [PMID: 28521884 DOI: 10.1016/j.jacc.2017.03.540] [Citation(s) in RCA: 208] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 03/03/2017] [Accepted: 03/10/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND Oral anticoagulation (OAC) with warfarin is underused for atrial fibrillation (AF). The availability of direct oral anticoagulants (DOACs) may improve overall OAC rates in AF patients, but a large-scale evaluation of their effects has not been conducted. OBJECTIVES This study assessed the effect of DOAC availability on overall OAC rates for nonvalvular AF. METHODS Between April 1, 2008 and September 30, 2014, we identified 655,000 patients with nonvalvular AF and a CHA2DS2-VASc score of >1 in the National Cardiovascular Data Registry PINNACLE registry. Temporal trends in overall OAC and individual warfarin and DOAC use were analyzed. Multivariable hierarchical logistic regression identified patient factors associated with OAC and DOAC use. Practice variation of OAC and DOAC use was also assessed. RESULTS Overall OAC rates increased from 52.4% to 60.7% among eligible AF patients (p for trend <0.01). Warfarin use decreased from 52.4% to 34.8% (p for trend <0.01), and DOAC use increased from 0% to 25.8% (p for trend <0.01). An increasing CHA2DS2-VASc score was associated with higher OAC use (odds ratio [OR]: 1.06; 95% confidence interval [CI]: 1.05 to 1.07), but with lower DOAC use (OR: 0.97; 95% CI: 0.96 to 0.98). Significant practice variation was present in OAC use (median odds ratio [MOR]: 1.52; 95% CI: 1.45 to 1.57) and in DOAC use (MOR: 3.58; 95% CI: 3.05 to 4.13). CONCLUSIONS Introduction of DOACs in routine practice was associated with improved rates of overall OAC use for AF, but significant gaps remain. In addition, there is significant practice-level variation in OAC and DOAC use.
Collapse
Affiliation(s)
- Lucas N Marzec
- University of Colorado School of Medicine, Aurora, Colorado; Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado.
| | - Jingyan Wang
- Mid America Heart Institute, Kansas City, Missouri
| | | | - Paul S Chan
- Mid America Heart Institute, Kansas City, Missouri
| | - Henry H Ting
- New York Presbyterian Hospital, The University Hospital of Columbia and Cornell University, New York, New York
| | | | - Jonathan C Hsu
- University of California, San Diego, La Jolla, California
| | - Thomas M Maddox
- Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado
| |
Collapse
|
42
|
Nelson WW, Laliberté F, Patel AA, Germain G, Pilon D, McCormick N, Lefebvre P. Stroke risk reduction outweighed bleeding risk increase from vitamin K antagonist treatment among nonvalvular atrial fibrillation patients with high stroke risk and low bleeding risk. Curr Med Res Opin 2017; 33:631-638. [PMID: 28008771 DOI: 10.1080/03007995.2016.1275936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Warfarin is widely used for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). We compared the rates of stroke and major bleeding in NVAF patients with a high stroke risk and low bleeding risk profile during warfarin treated (W+) and warfarin untreated (W-) periods. METHOD Insurance claims from six commercial, Medicaid or Medicare databases were analyzed from 2000 to 2014. NVAF patients treated with warfarin, with a CHADS2/CHA2DS2-VASc score ≥2, and an ATRIA score ≤3 at baseline were identified. Incidence rate ratios (IRRs) of stroke and major bleeding were calculated for W + versus W- episodes of person-time, as well as for first 30 days versus beyond 30 days of W + episodes. RESULTS Among 316,145 patients, anticoagulant prophylaxis with warfarin significantly reduced stroke risk, with IRRs ranging from 0.48 (95% CI: 0.46-0.51) to 0.80 (95% CI: 0.70-0.91), and increased major bleeding risk, with IRRs ranging from 1.13 (95% CI: 1.10-1.15) to 1.95 (95% CI: 1.10-3.45). Stroke and major bleeding rates were higher during the first 30 days of W + than beyond. CONCLUSION In NVAF patients at high risk for stroke and low risk for bleeding, our data confirm the effectiveness of anticoagulation for stroke prevention. The decrease in stroke risk of anticoagulation may outweigh the risk of major bleeding events, particularly among elderly patients. Potential risks of warfarin during initiation warrant attention, especially among patients who stop and start therapy repeatedly.
Collapse
Affiliation(s)
| | | | - Aarti A Patel
- a Janssen Scientific Affairs LLC , Raritan , NJ , USA
| | | | | | | | | |
Collapse
|
43
|
Factors Associated With Cardiac Electrophysiologist Assessment and Catheter Ablation Procedures in Patients With Atrial Fibrillation. JACC Clin Electrophysiol 2017; 3:302-309. [DOI: 10.1016/j.jacep.2016.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 08/09/2016] [Accepted: 09/01/2016] [Indexed: 11/20/2022]
|
44
|
Mazurek M, Huisman MV, Lip GYH. Registries in Atrial Fibrillation: From Trials to Real-Life Clinical Practice. Am J Med 2017; 130:135-145. [PMID: 27746290 DOI: 10.1016/j.amjmed.2016.09.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/08/2016] [Accepted: 09/09/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Recent improvements in atrial fibrillation diagnosis and management have prompted the initiation of various registries, predominantly to assess adherence to new guidelines but also to address the pending questions of safety and effectiveness of newly introduced management options in "real-world" clinical practice settings. In this review, we appraise antithrombotic treatment patterns for stroke prevention in atrial fibrillation registries. METHODS We searched PubMed, Science Direct, and the Cochrane databases for registries focusing on stroke thromboprophylaxis in atrial fibrillation. RESULTS Registry data show that over the last decade, the proportion of patients receiving oral anticoagulation has increased (from ∼67% to >80%), whereas the proportion of those treated with aspirin only or untreated has diminished. Vitamin K antagonists are being replaced gradually by non-vitamin K antagonist oral anticoagulants as the more prevalent option. Regional and country differences in anticoagulation are evident, with its highest uptake in Europe (90.2%) and lowest in Asia (57.4%). Moreover, oral anticoagulation is given to approximately 50% of patients with no stroke risk factors, whereas more than one third of high-risk subjects are not anticoagulated but often prescribed antiplatelet therapy alone or untreated. Guideline-nonadherent thromboprophylaxis results in an increase in all-cause mortality and thromboembolism. CONCLUSIONS Registry data show that despite an increase in anticoagulation rates over the last decade, management gaps in stroke prevention are still evident with approximately one third of patients not treated in line with the guidelines. Mortality rates of atrial fibrillation patients remain relatively high, mostly because of the comorbid disease.
Collapse
Affiliation(s)
- Michał Mazurek
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, United Kingdom; Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Menno V Huisman
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, The Netherlands
| | - Gregory Y H Lip
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark.
| |
Collapse
|
45
|
Heidt ST, Kratz A, Najarian K, Hassett AL, Oral H, Gonzalez R, Nallamothu BK, Clauw D, Ghanbari H. Symptoms In Atrial Fibrillation: A Contemporary Review And Future Directions. J Atr Fibrillation 2016; 9:1422. [PMID: 27909518 DOI: 10.4022/jafib.1422] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 05/30/2016] [Accepted: 05/31/2016] [Indexed: 12/31/2022]
Abstract
Atrial fibrillation (AF) is the most prevalent arrhythmia leading to hospital admissions in the United States. The majority of patients with AF report symptoms associated with this condition that can lead to a decrease in health related quality of life (HRQOL) and functional status. Therefore, along with reducing the risk of stroke and mortality, improvements in such symptoms are important therapeutic goals in the management of patients with AF. Our current understanding of how AF and symptoms are linked is hampered by the dominant assessment paradigm, where symptoms thought to be associated with AF are measured at a single point in time (frequently at a clinic visit). Unfortunately, this "static" snapshot does not capture the variability of symptoms and heart rhythm within a person over time and does not shed light on how symptoms are related to heart rhythm. This focused review summarizes current methods for assessing symptoms including generic and AF-specific HRQOL and functional status tools. It also describes gaps in the current assessment paradigm and where future research using mobile applications and digital technology might be able to assist with patient care.
Collapse
Affiliation(s)
- Steven T Heidt
- University of Michigan- Department of Cardiovascular Medicine
| | - Anna Kratz
- University of Michigan - Department of Physical Medicine and Rehabilitation
| | - Kayvan Najarian
- University of Michigan - Department of Computational Medicine and Bioinformatics
| | | | - Hakan Oral
- University of Michigan- Department of Cardiovascular Medicine
| | | | | | - Daniel Clauw
- University of Michigan - Department of Anesthesiology
| | - Hamid Ghanbari
- University of Michigan- Department of Cardiovascular Medicine
| |
Collapse
|
46
|
Golwala H, Jackson LR, Simon DN, Piccini JP, Gersh B, Go AS, Hylek EM, Kowey PR, Mahaffey KW, Thomas L, Fonarow GC, Peterson ED, Thomas KL. Racial/ethnic differences in atrial fibrillation symptoms, treatment patterns, and outcomes: Insights from Outcomes Registry for Better Informed Treatment for Atrial Fibrillation Registry. Am Heart J 2016; 174:29-36. [PMID: 26995367 DOI: 10.1016/j.ahj.2015.10.028] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 10/13/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Significant racial/ethnic differences exist in the incidence of atrial fibrillation (AF). However, less is known about racial/ethnic differences in quality of life (QoL), treatment, and outcomes associated with AF. METHODS Using data from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation, we compared clinical characteristics, QoL, management strategies, and long-term outcomes associated with AF among various racial/ethnic groups. RESULTS We analyzed 9,542 participants with AF (mean age 74 ± 11 years, 43% women, 91% white, 5% black, 4% Hispanic) from 174 centers. Compared with AF patients identified as white race, patients identified as Hispanic ethnicity and those identified as black race were younger, were more often women, and had more cardiac and noncardiac comorbidities. Black patients were more symptomatic with worse QoL and were less likely to be treated with a rhythm control strategy than other racial/ethnic groups. There were no significant racial/ethnic differences in CHA2DS2-VASc stroke or ATRIA bleeding risk scores and rates of oral anticoagulation use were similar. However, racial and ethnic minority populations treated with warfarin spent a lower median time in therapeutic range of international normalized ratio (59% blacks vs 68% whites vs 62% Hispanics, P < .0001). There was no difference in long-term outcomes associated with AF between the 3 groups at a median follow-up of 2.1 years. CONCLUSION Relative to white and Hispanic patients, black patients with AF had more symptoms, were less likely to receive rhythm control interventions, and had lower quality of warfarin management. Despite these differences, clinical events at 2 years were similar by race and ethnicity.
Collapse
|
47
|
Wiske CP, Palisoul M, Tapé C, Baird J, McGregor AJ. Physician Specialty Influences Care of Pelvic Inflammatory Disease. J Womens Health (Larchmt) 2015; 25:723-8. [PMID: 26720306 DOI: 10.1089/jwh.2015.5349] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND CDC guidelines recommend Neisseria gonorrhoeae, Chlamydia trachomatis, and HIV testing, as well as specific antibiotic regimens in the diagnosis and treatment of pelvic inflammatory disease (PID), although latitude in adhering to these guidelines is common. We hypothesized that adherence to CDC guidelines for antibiotic regimens and laboratory testing, coverage for anaerobic organisms, and the use of diagnostic imaging techniques do not differ significantly between practitioners with emergency medicine (EM) versus obstetrics and gynecology (OB-GYN) training. MATERIALS AND METHODS We conducted a retrospective medical chart review on patients (N = 351) discharged with a diagnosis of PID over a 20-month period at two neighboring emergency care facilities-one with EM-trained providers and the other with OB-GYN-trained providers. RESULTS Adjusted for demographic predictors and chief complaint, there was no significant difference in adherence to N. gonorrhoeae and C. trachomatis antibiotic coverage guidelines between the two facilities (adjusted odds ratio [AOR] 1.34; 95% CI 0.66-2.74), using the OB-GYN facility in the numerator of the AOR. Anaerobic coverage was significantly more common at the OB-GYN facility (AOR 9.11; 95% CI 5.36-15.48). Both sites had very low rates of adherence to CDC laboratory testing guidelines with overall rates of adherence at 4.0% (95% CI 1.9%-5.9%). Utilization of diagnostic tests differed greatly between facilities: ultrasound utilization was 66.7% (95% CI 58.2%-75.2%) at the OB-GYN facility and 39.7% (95% CI 33.4%-45.9%) at the EM facility. CONCLUSIONS The diagnostic pathway for PID and adherence to guidelines differ significantly depending on physician specialty and practice environment, suggesting the need for further standardization, perhaps with cross-disciplinary training.
Collapse
Affiliation(s)
- Clay P Wiske
- 1 Alpert Medical School of Brown University , Providence, Rhode Island
| | - Marguerite Palisoul
- 1 Alpert Medical School of Brown University , Providence, Rhode Island.,2 Women and Infants Hospital , Providence, Rhode Island
| | - Chantal Tapé
- 3 Department of Emergency Medicine, Rhode Island Hospital , Providence, Rhode Island
| | - Janette Baird
- 3 Department of Emergency Medicine, Rhode Island Hospital , Providence, Rhode Island.,4 Injury Prevention Center, Rhode Island Hospital , Providence, Rhode Island
| | - Alyson J McGregor
- 1 Alpert Medical School of Brown University , Providence, Rhode Island.,3 Department of Emergency Medicine, Rhode Island Hospital , Providence, Rhode Island
| |
Collapse
|
48
|
Bista D, Chalmers L, Peterson GM, Bereznicki LRE. Patient Characteristics and Antithrombotic Prescribing Patterns in Patients With Atrial Fibrillation in Tasmania. Clin Appl Thromb Hemost 2015; 23:438-444. [DOI: 10.1177/1076029615623375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Limited data are available on atrial fibrillation (AF) and its clinical management and outcomes from an Australian perspective. This study was designed to examine the patient characteristics and antithrombotic treatment patterns among patients with AF in Tasmania, Australia. This retrospective observational study reviewed and followed patients with AF admitted to Tasmania’s 3 major hospitals between January 2011 and June 2012. Patients were excluded if they had only 1 episode of AF that reverted spontaneously or upon cardioversion without any documented recurrences. We reviewed the records of 2502 patients (≥18 years), and1469 were subsequently included in the study. The mean (±standard deviation [SD]) age of the patients was 76 (±12.3) years. The mean (± SD) CHADS2 score was 2.1 (±1.3), and 65.7% had a score ≥2. In total, only 55.6% of patients with CHADS2 score ≥2 were receiving anticoagulation and 9.9% were not receiving any antithrombotic treatment, whereas 85.4% of those at low risk (score 0) were on antithrombotic therapy. Hospitalization was associated with a significant increase in the rate of combination (antiplatelet plus anticoagulant) therapy ( P < .001). Suboptimal use of antithrombotic therapy highlights the need to improve AF management in our jurisdiction.
Collapse
Affiliation(s)
- Durga Bista
- Pharmacy, School of Medicine, University of Tasmania, Hobart, Australia
| | - Leanne Chalmers
- Pharmacy, School of Medicine, University of Tasmania, Hobart, Australia
| | | | | |
Collapse
|
49
|
Conundrums for Atrial Fibrillation Management in Older Adults. CURRENT GERIATRICS REPORTS 2015. [DOI: 10.1007/s13670-015-0143-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
50
|
Fauchier L, Samson A, Chaize G, Gaudin AF, Vainchtock A, Bailly C, Cotté FE. Cause of death in patients with atrial fibrillation admitted to French hospitals in 2012: a nationwide database study. Open Heart 2015; 2:e000290. [PMID: 26688739 PMCID: PMC4680587 DOI: 10.1136/openhrt-2015-000290] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 06/29/2015] [Accepted: 08/26/2015] [Indexed: 11/16/2022] Open
Abstract
Objective Most patients with atrial fibrillation (AF) have risk factors and coexisting conditions that increase their mortality risk. We performed a cause-of-death analysis to identify predictors of mortality in hospitalised patients with AF in France. Methods and results In this retrospective, population-based cross-sectional study, the Programme de médicalisation des systèmes d'information was used to identify 533 044 adults with a diagnosis of AF or atrial flutter hospitalised for any reason in France from January through December 2012. Stepwise multivariable analyses were performed to identify determinants of mortality. The mean age was 78.0±11.4 years, 47.1% were women, and the mean CHA2DS2-VASc score was 4.0±1.8. During hospitalisation, 9.4% (n=50 165) of the patients died, 34% due to a cardiovascular event, most often heart failure (16.6%), stroke/transient ischaemic attack/systemic embolism (9.8%) or vascular or ischaemic disease (4.0%). The strongest predictors of overall death were age ≥75 years (OR 2.57, 95% CI 2.47 to 2.68), renal failure (OR 1.85, 95% CI 1.81 to 1.89), cancer (OR 1.81, 95% CI 1.78 to 1.85) and lung disease (OR 1.58, 95% CI 1.55 to 1.62). Conclusions Cardiovascular events were the most common cause of death, occurring in one-third of patients, in this comprehensive study of hospitalised patients with AF. Despite the high risk of stroke in this population, only 10% died from stroke/transient ischaemic attack/systemic embolism. The strongest predictors of overall death were non-cardiovascular. Physicians should be encouraged to focus on preventable serious and disabling cardiovascular events (such as stroke) as well as on potentially fatal non-cardiovascular comorbidities.
Collapse
Affiliation(s)
- Laurent Fauchier
- Service de Cardiologie et Laboratoire d'Electrophysiologie Cardiaque , Pôle Cœur Thorax; asculaire, Centre Hospitalier Universitaire Trousseau , Tours , France ; Faculté de Médecine , Université François Rabelais , Tours , France
| | | | | | | | | | | | | |
Collapse
|