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Abstract
Atrial fibrillation (AF) is the most common sustained cardiac dysrhythmia encountered in practice. It is currently estimated that AF affects approximately 2% of the general population; however, the true prevalence of AF is likely to be at least 3%-4% when asymptomatic AF is considered. For clinically apparent AF, the investigations and management are relatively well established. The identification of minimally symptomatic patients is challenging, and furthermore, the optimal management is less certain. Although there is some debate about the ideal treatment pathway for asymptomatic AF, in most cases, the investigations and comprehensive management follow the same recommendations as clinically apparent AF. In contrast, beyond risk factor optimisation, the ideal management of subclinical or device-detected AF remains undefined. The purpose of the current review is to discuss the assessment and management of asymptomatic AF.
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Affiliation(s)
- Jason G Andrade
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Cardiovascular Innovation, Vancouver, British Columbia, Canada
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Marc W Deyell
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Cardiovascular Innovation, Vancouver, British Columbia, Canada
| | - Richard Bennett
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Cardiovascular Innovation, Vancouver, British Columbia, Canada
| | - Laurent Macle
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
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Bacchi S, Kovoor JG, Goh R, Gupta AK, Tan S, Ovenden CD, To MS, Moey A, Sanders P, Chew DP, Schultz D, Kovoor P, Kleinig T, Jannes J. Pre-stroke anticoagulation for atrial fibrillation in primary English speakers and non-primary English speakers: a multicentre retrospective cohort study. Intern Med J 2024; 54:620-625. [PMID: 37860995 DOI: 10.1111/imj.16253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/16/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Anticoagulation can prevent most strokes in individuals with atrial fibrillation (AF); however, many people presenting with stroke and known AF are not anticoagulated. Language barriers and poor health literacy have previously been associated with decreased patient medication adherence. The association between language barriers and initiation of anticoagulation therapy for AF is uncertain. AIMS The aims of this study were to determine whether demographic factors, including non-English primary language, were (1) associated with not being initiated on anticoagulation for known AF prior to admission with stroke, and (2) associated with non-adherence to anticoagulation in the setting of known AF prior to admission with stroke. METHODS A multicentre retrospective cohort study was conducted for consecutive individuals admitted to the three South Australian tertiary hospitals with stroke units over a 5-year period. RESULTS There were 6829 individuals admitted with stroke. These cases included 5835 ischaemic stroke patients, 1333 of whom had pre-existing AF. Only 40.0% presenting with ischaemic stroke in the setting of known pre-existing AF were anticoagulated. When controlling for demographics, socioeconomic status and past medical history (including the components of the CHADS2VASC score and anticoagulation contraindications), having a primary language other than English was associated with a lower likelihood of having been commenced on anticoagulant for known pre-stroke AF (odds ratio: 0.52, 95% confidence interval: 0.36-0.77, P = 0.001), but was not associated with a differing likelihood of anticoagulation adherence. CONCLUSIONS A significant proportion of patients with stroke have pre-existing unanticoagulated AF; these rates are substantially higher if the primary language is other than English. Targeted research and interventions to minimise evidence-treatment gaps in this cohort may significantly reduce stroke burden.
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Affiliation(s)
- Stephen Bacchi
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joshua G Kovoor
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Rudy Goh
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- University of Adelaide, Adelaide, South Australia, Australia
- Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Sheryn Tan
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Christopher D Ovenden
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Minh-Son To
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Andrew Moey
- Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Prashanthan Sanders
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - David Schultz
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Pramesh Kovoor
- Westmead Private Hospital, Sydney, New South Wales, Australia
| | - Timothy Kleinig
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jim Jannes
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Kapoor A, Patel P, Chennupati S, Mbusa D, Sadiq H, Rampam S, Leung R, Miller M, Vargas KR, Fry P, Lowe MM, Catalano C, Harrison C, Catanzaro JN, Crawford S, Smith AM. Comparing the Efficacy of Targeted and Blast Portal Messaging in Message Opening Rate and Anticoagulation Initiation in Patients With Atrial Fibrillation in the Preventing Preventable Strokes Study II: Prospective Cohort Study. JMIR Cardio 2024; 8:e49590. [PMID: 38265849 PMCID: PMC10851125 DOI: 10.2196/49590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 10/24/2023] [Accepted: 11/24/2023] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND The gap in anticoagulation use among patients with atrial fibrillation (AF) is a major public health threat. Inadequate patient education contributes to this gap. Patient portal-based messaging linked to educational materials may help bridge this gap, but the most effective messaging approach is unknown. OBJECTIVE This study aims to compare the responsiveness of patients with AF to an AF or anticoagulation educational message between 2 portal messaging approaches: sending messages targeted at patients with upcoming outpatient appointments 1 week before their scheduled appointment (targeted) versus sending messages to all eligible patients in 1 blast, regardless of appointment scheduling status (blast), at 2 different health systems: the University of Massachusetts Chan Medical School (UMass) and the University of Florida College of Medicine-Jacksonville (UFL). METHODS Using the 2 approaches, we sent patient portal messages to patients with AF and grouped patients by high-risk patients on anticoagulation (group 1), high-risk patients off anticoagulation (group 2), and low-risk patients who may become eligible for anticoagulation in the future (group 3). Risk was classified based on the congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke, vascular disease, age between 65 and 74 years, and sex category (CHA2DS2-VASc) score. The messages contained a link to the Upbeat website of the Heart Rhythm Society, which displays print and video materials about AF and anticoagulation. We then tracked message opening, review of the website, anticoagulation use, and administered patient surveys across messaging approaches and sites using Epic Systems (Epic Systems Corporation) electronic health record data and Google website traffic analytics. We then conducted chi-square tests to compare potential differences in the proportion of patients opening messages and other evaluation metrics, adjusting for potential confounders. All statistical analyses were performed in SAS (version 9.4; SAS Institute). RESULTS We sent 1686 targeted messages and 1450 blast messages. Message opening was significantly higher with the targeted approach for patients on anticoagulation (723/1156, 62.5% vs 382/668, 57.2%; P=.005) and trended the same in patients off anticoagulation; subsequent website reviews did not differ by messaging approach. More patients off anticoagulation at baseline started anticoagulation with the targeted approach than the blast approach (adjusted percentage 9.3% vs 2.1%; P<.001). CONCLUSIONS Patients were more responsive in terms of message opening and subsequent anticoagulation initiation with the targeted approach.
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Affiliation(s)
- Alok Kapoor
- University of Massachusetts Chan Medical School, Worcester, MA, United States
- University of Massachusetts Memorial Health Care, Worcester, MA, United States
| | - Parth Patel
- University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Soumya Chennupati
- University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Daniel Mbusa
- University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Hammad Sadiq
- University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Sanjeev Rampam
- University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Robert Leung
- University of Massachusetts Chan Medical School, Worcester, MA, United States
- University of Massachusetts Memorial Health Care, Worcester, MA, United States
| | - Megan Miller
- College of Pharmacy, University of Florida, Jacksonville, FL, United States
| | | | - Patrick Fry
- College of Medicine, University of Florida, Jacksonville, FL, United States
| | | | - Christina Catalano
- College of Medicine, University of Florida, Jacksonville, FL, United States
| | - Charles Harrison
- College of Medicine, University of Florida, Jacksonville, FL, United States
| | | | - Sybil Crawford
- University of Massachusetts Chan Medical School, Worcester, MA, United States
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Yoshida K. Under-Dose Prescription of Direct Oral Anticoagulants in Japanese Elderly Patients - Are One Fifth of the Prescriptions All "Inappropriate"? Circ J 2023; 87:1775-1776. [PMID: 37612070 DOI: 10.1253/circj.cj-23-0531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Affiliation(s)
- Kentaro Yoshida
- Department of Cardiology, Ibaraki Prefectural Central Hospital
- Department of Cardiology, Institute of Medicine, University of Tsukuba
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Nagaratnam SA, Edwards L, Blair C, Evans J, O'Brien W. Functional outcomes of patients with ischaemic stroke with known atrial fibrillation not on therapeutic anticoagulation. Intern Med J 2023; 53:1987-1993. [PMID: 36872853 DOI: 10.1111/imj.16044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/07/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Anticoagulation significantly reduces the risk of ischaemic stroke in patients with atrial fibrillation (AF). There are a proportion of patients with known AF who remain off anticoagulation. Aims This study aims to retrospectively compare the baseline characteristics, treatments and functional outcomes between patients with ischaemic stroke and known AF based on their anticoagulation status. METHODS A single-centre, retrospective review of consecutive patients with an ischaemic stroke and a known history of AF was conducted. RESULTS Two hundred four patients with an ischaemic stroke had documented AF prior to the index admission, of which 126 were anticoagulated. Median admission National Institutes of Health Stroke Scale score was lower for anticoagulated patients, though not statistically significant (5.1 vs 7.0, P = 0.09). Median baseline modified Rankin score (mRS) did not significantly differ. Nonanticoagulated patients were more likely to have large vessel occlusions (37.2% vs 23.8%, P = 0.04) and more likely to receive intravenous thrombolysis (15.4% vs 1.6%, P < 0.01). There was no difference in rates of endovascular clot retrieval between groups (P > 0.05). Unfavourable functional outcome at 90 days (mRS ≥ 3) did not significantly differ between groups (P = 0.51). A total of 38.5% of nonanticoagulated patients had no documented reason for this. Of the patients who survived the index admission, 81.5% of patients who were not anticoagulated on admission received anticoagulation. CONCLUSIONS Baseline anticoagulation was associated with milder stroke severity in ischaemic stroke patients with known AF. There was no significant difference in functional outcomes at 90 days between groups. Larger observational studies are required to further assess this cohort.
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Affiliation(s)
- Sai A Nagaratnam
- Department of Neurology, Gosford Hospital, Gosford, New South Wales, Australia
| | - Leon Edwards
- Department of Neurology, Gosford Hospital, Gosford, New South Wales, Australia
| | - Christopher Blair
- Department of Neurology, Gosford Hospital, Gosford, New South Wales, Australia
| | - James Evans
- Department of Neurology, Gosford Hospital, Gosford, New South Wales, Australia
| | - William O'Brien
- Department of Neurology, Gosford Hospital, Gosford, New South Wales, Australia
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Bamberg C, Ladegaard CT, Aalling M, Jensen DM, Madsen CL, Kamil S, Gudbergsen H, Saxild T, Schiøtz ML, Grew J, Castillo LS, Tousgaard I, Johansen RLR, Bardram JE, Frølich A, Domínguez H. Reaching the Frail Elderly for the Diagnosis and Management of Atrial Fibrillation-REAFEL. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6783. [PMID: 37754642 PMCID: PMC10530387 DOI: 10.3390/ijerph20186783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/13/2023] [Accepted: 09/16/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Frail elderly patients are exposed to suffering strokes if they do not receive timely anticoagulation to prevent stroke associated to atrial fibrillation (AF). Evaluation in the cardiological ambulatory can be cumbersome as it often requires repeated visits. AIM To develop and implement CardioShare, a shared-care model where primary care leads patient management, using a compact Holter monitor device with asynchronous remote support from cardiologists. METHODS CardioShare was developed in a feasibility phase, tested in a pragmatic cluster randomization trial (primary care clinics as clusters), and its implementation potential was evaluated with an escalation test. Mixed methods were used to evaluate the impact of this complex intervention, comprising quantitative observations, semi-structured interviews, and workshops. RESULTS Between February 2020 and December 2021, 314 patients (30% frail) were included, of whom 75% had AF diagnosed/not found within 13 days; 80% in both groups avoided referral to cardiologists. Patients felt safe and primary care clinicians satisfied. In an escalation test, 58 primary-care doctors evaluated 93 patients over three months, with remote support from four hospitals in the Capital Region of Denmark. CONCLUSIONS CardioShare was successfully implemented for AF evaluation in primary care.
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Affiliation(s)
- Carsten Bamberg
- Cardiology Department Y Bispebjerg and Frederiksberg Hospital, Capital Region, 2000 Frederiksberg, Denmark; (C.B.); (C.T.L.); (D.M.J.); (C.L.M.); (S.K.)
- Department of Biomedicine, University of Copenhagen, 1165 Copenhagen, Denmark
| | - Caroline Thorup Ladegaard
- Cardiology Department Y Bispebjerg and Frederiksberg Hospital, Capital Region, 2000 Frederiksberg, Denmark; (C.B.); (C.T.L.); (D.M.J.); (C.L.M.); (S.K.)
- Department of Biomedicine, University of Copenhagen, 1165 Copenhagen, Denmark
| | - Mathias Aalling
- VihTek Research Center for Welfare Technology Capital Region, 2600 Copenhagen, Denmark;
| | - Dorthea Marie Jensen
- Cardiology Department Y Bispebjerg and Frederiksberg Hospital, Capital Region, 2000 Frederiksberg, Denmark; (C.B.); (C.T.L.); (D.M.J.); (C.L.M.); (S.K.)
- Department of Biomedicine, University of Copenhagen, 1165 Copenhagen, Denmark
| | - Christoffer Læssøe Madsen
- Cardiology Department Y Bispebjerg and Frederiksberg Hospital, Capital Region, 2000 Frederiksberg, Denmark; (C.B.); (C.T.L.); (D.M.J.); (C.L.M.); (S.K.)
- Department of Biomedicine, University of Copenhagen, 1165 Copenhagen, Denmark
| | - Sadaf Kamil
- Cardiology Department Y Bispebjerg and Frederiksberg Hospital, Capital Region, 2000 Frederiksberg, Denmark; (C.B.); (C.T.L.); (D.M.J.); (C.L.M.); (S.K.)
- Department of Biomedicine, University of Copenhagen, 1165 Copenhagen, Denmark
| | - Henrik Gudbergsen
- Section of General Practice, Department of Public Health, University of Copenhagen, 1165 Copenhagen, Denmark;
| | - Thomas Saxild
- Grøndalslægerne Godthåbsvej 239a, Vanløse, 2720 Copenhagen, Denmark;
| | - Michaela Louise Schiøtz
- Center for Clinical Research and Prevention Bispebjerg and Frederiksberg Hospital, 2400 Copenhagen, Denmark; (M.L.S.); (J.G.)
| | - Julie Grew
- Center for Clinical Research and Prevention Bispebjerg and Frederiksberg Hospital, 2400 Copenhagen, Denmark; (M.L.S.); (J.G.)
| | | | - Iben Tousgaard
- Department of Quality and Education, Bispebjerg and Frederiksberg Hospital, 2400 Copenhagen, Denmark; (I.T.); (R.L.R.J.)
| | - Rie Laurine Rosenthal Johansen
- Department of Quality and Education, Bispebjerg and Frederiksberg Hospital, 2400 Copenhagen, Denmark; (I.T.); (R.L.R.J.)
| | - Jakob Eyvind Bardram
- Department of Health Technology, Digital Health, Personalized Health Technology, Technical University of Denmark, 2800 Copenhagen, Denmark;
| | - Anne Frølich
- Innovation and Research Centre for Multimorbidity, Slagelse Hospital, Region Zealand, 4180 Sorø, Denmark;
- Section of General Practice, Faculty of Health and Medical Sciences, University of Copenhagen, 1165 Copenhagen, Denmark
| | - Helena Domínguez
- Cardiology Department Y Bispebjerg and Frederiksberg Hospital, Capital Region, 2000 Frederiksberg, Denmark; (C.B.); (C.T.L.); (D.M.J.); (C.L.M.); (S.K.)
- Department of Biomedicine, University of Copenhagen, 1165 Copenhagen, Denmark
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Patel J, Bhaskar SMM. Atrial Fibrillation and Reperfusion Therapy in Acute Ischaemic Stroke Patients: Prevalence and Outcomes-A Comprehensive Systematic Review and Meta-Analysis. Neurol Int 2023; 15:1014-1043. [PMID: 37755356 PMCID: PMC10537209 DOI: 10.3390/neurolint15030065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/28/2023] Open
Abstract
Atrial fibrillation (AF) significantly contributes to acute ischaemic stroke (AIS), yet its precise influence on clinical outcomes post-intravenous thrombolysis (IVT) and post-endovascular thrombectomy (EVT) has remained elusive. Furthermore, the overall prevalence of AF in AIS patients undergoing reperfusion therapy has not been clearly determined. Employing random-effects meta-analyses, this research aimed to estimate the pooled prevalence of AF among AIS patients undergoing reperfusion therapy, while also examining the association between AF and clinical outcomes such as functional outcomes, symptomatic intracerebral haemorrhage (sICH) and mortality. Studies comparing AF and non-AF patient groups undergoing reperfusion therapy were identified and included following an extensive database search. Forty-nine studies (n = 66,887) were included. Among IVT patients, the prevalence of AF was 31% (Effect Size [ES] 0.31 [95%CI 0.28-0.35], p < 0.01), while in EVT patients, it reached 42% (ES 0.42 [95%CI 0.38-0.46], p < 0.01), and in bridging therapy (BT) patients, it stood at 36% (ES 0.36 [95%CI 0.28-0.43], p < 0.01). AF was associated with significantly lower odds of favourable 90-day functional outcomes post IVT (Odds Ratio [OR] 0.512 [95%CI 0.376-0.696], p < 0.001), but not post EVT (OR 0.826 [95%CI 0.651-1.049], p = 0.117). Our comprehensive meta-analysis highlights the varying prevalence of AF among different reperfusion therapies and its differential impact on patient outcomes. The highest pooled prevalence of AF was observed in EVT patients, followed by BT and IVT patients. Interestingly, our analysis revealed that AF was significantly associated with poorer clinical outcomes following IVT. Such an association was not observed following EVT.
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Affiliation(s)
- Jay Patel
- Global Health Neurology Lab., Sydney, NSW 2150, Australia
- South Western Sydney Clinical Campuses, University of New South Wales (UNSW) Medicine and Health, UNSW Sydney, Sydney, NSW 2170, Australia
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, NSW 2170, Australia
| | - Sonu M. M. Bhaskar
- Global Health Neurology Lab., Sydney, NSW 2150, Australia
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital & South Western Sydney Local Health District (SWSLHD), Sydney, NSW 2170, Australia
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Kalscheur MM, Akbilgic O. AI-Enabled ECG for Paroxysmal Atrial Fibrillation Detection: One Step to Closer to the Finish Line. JACC Clin Electrophysiol 2023; 9:1783-1785. [PMID: 37498242 PMCID: PMC10928874 DOI: 10.1016/j.jacep.2023.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 05/14/2023] [Indexed: 07/28/2023]
Affiliation(s)
- Matthew M Kalscheur
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.
| | - Oguz Akbilgic
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Ashburner JM, Chang Y, Borowsky LH, Khurshid S, McManus DD, Ellinor PT, Lubitz SA, Singer DE, Atlas SJ. Effect of clinic-based single-lead electrocardiogram rhythm assessment on oral anticoagulation prescriptions in patients with previously diagnosed atrial fibrillation. Heart Rhythm O2 2023; 4:469-477. [PMID: 37645259 PMCID: PMC10461197 DOI: 10.1016/j.hroo.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
Background Despite benefits of oral anticoagulation (OAC), many individuals with diagnosed atrial fibrillation (AF) do not receive OAC. Objective The purpose of this study was to assess whether cardiac rhythm assessment for AF impacted use of OAC in patients with previously diagnosed AF. Methods VITAL-AF was a cluster randomized controlled trial conducted in 16 primary care practices assessing the efficacy of AF rhythm assessment with single-lead electrocardiogram in routine care. Patients 65 years and older were offered rhythm assessment at visits. In this secondary analysis, we evaluated rhythm assessment uptake and compared initiation and discontinuation of OAC in patients with previously diagnosed AF from intervention and control arms over 1 year. Results The study included 4593 patients with previously diagnosed AF (2250 intervention; 2343 control). In the intervention arm, 2022 (89.9%) completed rhythm assessment (median 2 visits with rhythm assessment) and 40.1% had ≥1 "Possible AF" result. Initiation of OAC was similar in the intervention (17.7%) and control (19.1%) arms but was influenced by the rhythm assessment result: higher with a "Possible AF" (26.1%; adjusted odds ratio [aOR] 1.62; 95% confidence interval [CI] 1.04-2.51), and lower with a "Normal" result (9.9%; aOR 0.45; 95% CI 0.29-0.71) compared to control. OAC discontinuation was similar in the intervention (6.3%) and control (7.2%) arms, with lower discontinuation with a "Possible AF" result (3.8%; aOR 0.51; 95% CI 0.32-0.81). Conclusions Including patients with previously diagnosed AF in a point-of-care rhythm assessment strategy did not increase overall OAC use compared to the control arm. However, the rhythm assessment result influenced both initiation and discontinuation of OAC.
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Affiliation(s)
- Jeffrey M. Ashburner
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Leila H. Borowsky
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Shaan Khurshid
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
- Demoulas Center for Cardiac Arrhythmias, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - David D. McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Patrick T. Ellinor
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
- Demoulas Center for Cardiac Arrhythmias, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Steven A. Lubitz
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
- Demoulas Center for Cardiac Arrhythmias, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel E. Singer
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Steven J. Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
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Tan CD, Liu JZ, Zheng YP, Li ZJ, Zhou SX. Left atrial enlargement and high uric acid level are risk factors for left atrial thrombus or dense spontaneous echo contrast in atrial fibrillation patients with low to moderate embolic risk assessed by CHA 2DS 2-VAS C score. Front Cardiovasc Med 2023; 10:937770. [PMID: 37465453 PMCID: PMC10351038 DOI: 10.3389/fcvm.2023.937770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/12/2023] [Indexed: 07/20/2023] Open
Abstract
Aims To investigate the correlation and predictive value of left atrial diameter and blood uric acid levels with the occurrence of left atrial thrombus or dense spontaneous echo contrast in atrial fibrillation patients with low to moderate CHA2DS2-VASc scores. Methods and results A total of 849 inpatients diagnosed with atrial fibrillation who had low to moderate CHA2DS2-VASc scores and complete transesophageal echocardiography were included in this study. Among them, 66 patients had left atrial thrombus or dense spontaneous echo contrast. When different models were used to correct other known risk factors, acid levels and abnormal left atrial diameter were identified as additional risk factors for left atrial thrombus or dense spontaneous echo contrast. The incidence of left atrial thrombus or dense spontaneous echo contrast was higher in patients with abnormal serum uric acid levels than in the control group (12.4% vs. 5.6%, p < 0.05), and this difference persisted after correcting the baseline data with propensity score matching (10.6% vs. 4.1%, p < 0.05). Abnormal left atrial diameter was another risk factor suggested by regression analysis, with an increased incidence of left atrial thrombus or dense spontaneous echo contrast in the abnormal left atrial diameter group compared to the control group, both before (18.0% vs. 3.5%, p < 0.05) and after (15.5% vs. 5.2%, p < 0.05) propensity score matching. The best predictive value was obtained by adding both abnormal serum uric acid levels and abnormal left atrial diameter. Conclusion Left atrial enlargement and high uric acid levels increase the risk of left atrial thrombus or dense spontaneous echo contrast in atrial fibrillation patients with low to moderate CHA2DS2-VASc scores.
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Andrade JG, Shah A, Godin R, Lanitis T, Kongnakorn T, Brown L, Dhanda D, Dhamane A, Nault I. Cost-effectiveness of atrial fibrillation screening in Canadian community practice. Heart Rhythm O2 2023; 4:103-110. [PMID: 36873310 PMCID: PMC9975014 DOI: 10.1016/j.hroo.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Contemporary guidelines recommend opportunistic screening for atrial fibrillation (AF). Objective The objective of this study was to assess the cost-effectiveness of single time point opportunistic AF screening for patients 65 years and older by using the single-lead electrocardiogram. Methods An established Markov cohort model was adapted by updating the background mortality estimates, epidemiology, screening efficacy, treatment patterns, resource use, and cost inputs to reflect a Canadian health care setting. Inputs were derived from a contemporary prospective screening study performed in Canadian primary care settings (screening efficacy and epidemiology) and the published literature (unit costs, epidemiology, mortality, utility, and treatment efficacy). The impact of screening and oral anticoagulant treatment on the cost and clinical outcomes was analyzed. A Canadian payer perspective over lifetime was used for analysis, with costs expressed in 2019 Canadian dollars. Results Among the estimated screening-eligible population of 2,929,301 patients, the screening cohort identified an additional 127,670 AF cases compared with the usual care cohort. The model estimated avoidance of 12,236 strokes and incremental quality-adjusted life-years of 59,577 (0.02 per patient) over lifetime in the screening cohort. Cost savings were substantial because of improved health outcomes, reflecting screening being the dominant strategy (affordable and effective). Model results were robust across sensitivity and scenario analyses. Conclusion Single time point opportunistic screening of AF using a single-lead electrocardiogram device in Canadian patients 65 years and older without known AF may provide improved health outcomes with cost savings from the perspective of a single payer health care environment.
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Affiliation(s)
- Jason G Andrade
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Center for Cardiovascular Innovation, Vancouver, British Columbia, Canada.,Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
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12
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Martinez KA, Eckman MH, Pappas MA, Rothberg MB. Prescribing of anticoagulation for atrial fibrillation in primary care. J Thromb Thrombolysis 2022; 54:616-624. [PMID: 35449383 PMCID: PMC10481404 DOI: 10.1007/s11239-022-02655-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 11/29/2022]
Abstract
Atrial fibrillation (AF) is common in primary care patients. Many patients who could benefit from anticoagulation do not receive it. The objective of this study was to describe anticoagulation prescribing by primary care physicians. We conducted an observational study in the Cleveland Clinic Health System among patients with AF and ≥ 1 primary care appointment between 2015 and 2018 and their physicians. We estimated differences in the odds of an eligible patient receiving anticoagulation versus not and a DOAC versus warfarin using two mixed effects logistic regression models, adjusted for patient sociodemographic factors, history of falls or dementia, and CHA2DS2-VASc and HAS-BLED scores. We categorized physicians into prescribing tertiles, based on their adjusted prescribing rate, which we included as predictors in the models. Among 5253 patients, 47% received anticoagulation. Of those, 56% received a DOAC. CHA2DS2-VASc and HAS-BLED scores were not associated with anticoagulation prescription. Black race was negatively associated with receiving anticoagulation overall (aOR:0.71; 95%CI:0.56-0.89) and with prescription for a DOAC (aOR:0.65; 95%CI:0.45-0.93). Among 195 physicians, the anticoagulation prescribing rate ranged from 27% to 57% and DOAC rates ranged from 34% to 69%. Physician prescribing tertile was associated with odds of a patient receiving anticoagulation overall (aOR:1.51; 95%CI: 1.13-2.01 for the highest versus lowest tertile), but not DOAC prescriptions. When prescribing anticoagulation, physicians appear not to consider risk of stroke or bleeding but patient race is an important determinant. Seeing a physician with a high anticoagulation prescribing rate was strongly associated with a patient receiving it, suggesting a lack of individualization.
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Affiliation(s)
- Kathryn A Martinez
- Cleveland Clinic Center for Value-Based Care Research, 9500 Euclid Ave, G10, Cleveland, OH, 44195, USA.
| | - Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH, USA
| | - Matthew A Pappas
- Cleveland Clinic Center for Value-Based Care Research, 9500 Euclid Ave, G10, Cleveland, OH, 44195, USA
| | - Michael B Rothberg
- Cleveland Clinic Center for Value-Based Care Research, 9500 Euclid Ave, G10, Cleveland, OH, 44195, USA
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13
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Boehme C, Domig L, Komarek S, Toell T, Mayer L, Dejakum B, Krebs S, Pechlaner R, Bernegger A, Mueller C, Rumpold G, Griesmacher A, Vigl M, Schoenherr G, Schmidauer C, Ferrari J, Lang W, Knoflach M, Kiechl S. Long-term outcome of a pragmatic trial of multifaceted intervention (STROKE-CARD care) to reduce cardiovascular risk and improve quality-of-life after ischaemic stroke and transient ischaemic attack: study protocol. BMC Cardiovasc Disord 2022; 22:347. [PMID: 35915405 PMCID: PMC9344624 DOI: 10.1186/s12872-022-02785-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/22/2022] [Indexed: 11/16/2022] Open
Abstract
Background Patients with ischaemic stroke or transient ischaemic attack (TIA) are at high risk of incident cardiovascular events and recurrent stroke. Despite compelling evidence about the efficacy of secondary prevention, a substantial gap exists between risk factor management in real life and that recommended by international guidelines. We conducted the STROKE-CARD trial (NCT02156778), a multifaceted pragmatic disease management program between 2014 and 2018 with follow-up until 2019. This program successfully reduced cardiovascular risk and improved health-related quality of life and functional outcome in patients with acute ischaemic stroke or TIA within 12 months after the index event. To investigate potential long-term effects of STROKE-CARD care compared to standard care, an extension of follow-up is warranted. Methods We aim to include all patients from the STROKE-CARD trial (n = 2149) for long-term follow-up between 2019 and 2021 with the study visit scheduled 3–6 years after the stroke/TIA event. The co-primary endpoint is the composite of major recurrent cardiovascular events (nonfatal stroke, nonfatal myocardial infarction, and vascular death) from hospital discharge until the long-term follow-up visit and health-related quality of life measured with the European Quality of Life-5 Dimensions (EQ-5D-3L) at the final visit. Secondary endpoints include overall mortality, long-term functional outcome, and target-level achievement in risk factor management. Discussion This long-term follow-up will provide evidence on whether the pragmatic post-stroke/TIA intervention program STROKE-CARD is capable of preventing recurrent cardiovascular events and improving quality-of-life in the long run. Trial registration clinicaltrials.gov: NCT04205006 on 19 December 2019.
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Affiliation(s)
- Christian Boehme
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Lena Domig
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.,VASCage, Research Centre On Vascular Ageing and Stroke, Innsbruck, Austria
| | - Silvia Komarek
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.,VASCage, Research Centre On Vascular Ageing and Stroke, Innsbruck, Austria
| | - Thomas Toell
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Lukas Mayer
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Benjamin Dejakum
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.,VASCage, Research Centre On Vascular Ageing and Stroke, Innsbruck, Austria
| | - Stefan Krebs
- Department of Neurology, Hospital St. John's of God, Vienna, Austria
| | - Raimund Pechlaner
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | | | - Christoph Mueller
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Gerhard Rumpold
- Department of Medical Psychology, Medical University of Innsbruck, Innsbruck, Austria
| | - Andrea Griesmacher
- Central Institute of Medical and Chemical Laboratory Diagnostics, University Hospital of Innsbruck, Innsbruck, Austria
| | - Marion Vigl
- Department of Neurology, Hospital St. John's of God, Vienna, Austria
| | - Gudrun Schoenherr
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Christoph Schmidauer
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Julia Ferrari
- Department of Neurology, Hospital St. John's of God, Vienna, Austria
| | - Wilfried Lang
- Department of Neurology, Hospital St. John's of God, Vienna, Austria.,Medical Faculty, Sigmund Freud Private University, Vienna, Austria
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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14
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Zhao J, Wu X, Li S, Gu Q. Effectiveness and safety of oral anticoagulant therapy in patients with atrial fibrillation with prior gastrointestinal bleeding: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:937320. [PMID: 35966547 PMCID: PMC9363568 DOI: 10.3389/fcvm.2022.937320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/06/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundGastrointestinal bleeding (GIB) commonly complicates anticoagulant therapy for patients with atrial fibrillation (AF). However, AF patients with prior GIB were excluded from most randomized controlled trials on anticoagulation therapy. Therefore, we conducted a systematic review and meta-analysis to assess the effect of oral anticoagulant (OAC) therapy in this specific population.MethodsRandomized trials and observational studies reporting the data about the resumption of OAC therapy among AF patients with prior GIB were included. The search was performed in the PubMed and Embase databasesup to March 2022. The adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were pooled by a random-effects model with an inverse variance method.ResultsA total of 7 studies involving 57,623 patients were included. Compared with no anticoagulant therapy, OAC therapy was associated with decreased risks of stroke or systemic embolism (HR = 0.71, 95% CI: 0.59–0.84) and all-cause death (HR = 0.66, 95% CI: 0.60–0.72), but there was no significant difference in the risk of recurrent GIB (HR = 1.22, 95% CI: 0.94–1.59). Compared with vitamin K antagonists, non-vitamin K antagonist oral anticoagulants (NOACs) were associated with reduced risks of stroke or systemic embolism (HR = 0.61, 95% CI: 0.54–0.68), all-cause mortality (HR = 0.86, 95% CI: 0.75–0.99), major bleeding (HR = 0.75, 95% CI: 0.66–0.84), and GIB recurrence (HR = 0.83, 95% CI: 0.72–0.96).ConclusionsIn AF patients with prior GIB, OAC therapy (especially NOACs) demonstrated superior effectiveness compared with no anticoagulant therapy.
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Affiliation(s)
- Jie Zhao
- Department of Cardiovascular Medicine, Wuhan Third Hospital & Tongren Hospital of Wuhan University, Wuhan, China
| | - Xiaojuan Wu
- Department of Gastroenterology, Ganzhou People’s Hospital, Ganzhou, China
- *Correspondence: Xiaojuan Wu,
| | - Siyuan Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Siyuan Li,
| | - Qiuping Gu
- Department of Gastroenterology, Ganzhou People’s Hospital, Ganzhou, China
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15
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Singer DE, Atlas SJ, Go AS, Lopes RD, Lubitz SA, McManus DD, Revkin JH, Mills D, Crosson LA, Lenane JC, Aronson RS. ReducinG stroke by screening for UndiAgnosed atRial fibrillation in elderly inDividuals (GUARD-AF): Rationale and design of the GUARD-AF randomized trial of screening for atrial fibrillation with a 14-day patch-based continuous ECG monitor. Am Heart J 2022; 249:76-85. [PMID: 35472303 DOI: 10.1016/j.ahj.2022.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/28/2022] [Accepted: 04/19/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Screening for atrial fibrillation (AF) is attractive because AF independently raises the risk of ischemic stroke, this risk is largely reversible by long-term oral anticoagulant therapy (OAC), and many patients with AF remain undiagnosed and untreated. Recent trials of one-time brief screening for AF have not produced a significant increase in the proportion of patients diagnosed with AF. Trials of longer-term screening have demonstrated an increase in AF diagnoses, primarily paroxysmal AF. To date, however, no trials have demonstrated that screening for AF results in lower rates of stroke. Clinical practice guidelines conflict in their level of support for screening for AF. METHODS The GUARD-AF individually randomized trial is designed to test whether screening for AF in individuals age 70 years or greater using a 2-week single-lead electrocardiographic patch monitor can identify patients with undiagnosed AF and lead to treatment with OAC, resulting in a reduced rate of stroke in the screened population. The trial's efficacy end point is hospitalization for stroke (either ischemic or hemorrhagic) and the trial's safety end point is hospitalization for a bleeding event. End points will be ascertained via Medicare claims or electronic health records at 2.5 years after study start. Enrollment is based in primary care practices and the OAC decision for screen-detected cases is left to the patient and their physician. The initial planned target sample size was 52,000, with 26,000 allocated to either screening or to usual care. RESULTS Trial enrollment was severely hampered by the novel coronavirus disease 2019 (COVID-19) pandemic and stopped at a total enrollment of 11,931 participants. Of 5,965 randomized to the screening arm, 5,713 patients (96%) returned monitors with analyzable results. Incidence of screen-detected and clinically detected AF and associated stroke and bleeding outcomes will be ascertained. CONCLUSIONS GUARD-AF is the largest AF screening randomized trial using a longer-term patch-based continuous electrocardiographic monitor. The results will contribute important information on the yield of patch-based AF screening, the "burden" of AF detected (percent time in AF, longest episode), and physicians' OAC decisions as a function of AF burden. GUARD-AF's stroke and bleed results will contribute to pooled trial analyses of AF screening, thereby informing future studies and guidelines.
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Affiliation(s)
- Daniel E Singer
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Steven J Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA; Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, CA
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Steven A Lubitz
- Harvard Medical School, Boston, MA; Cardiac Arrhythmia Service and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA
| | - David D McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA
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16
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Timing of anticoagulation after acute ischemic stroke in patients with atrial fibrillation. Neurol Sci 2022:1-12. [PMID: 35762354 DOI: 10.1017/cjn.2022.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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17
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Reaching Frail Elderly Patients to Optimize Diagnosis and Management of Atrial Fibrillation (REAFEL): A Feasibility Study of a Cross-Sectoral Shared-Care Model. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19127383. [PMID: 35742632 PMCID: PMC9223795 DOI: 10.3390/ijerph19127383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/25/2022] [Accepted: 06/11/2022] [Indexed: 11/17/2022]
Abstract
Introduction: Atrial fibrillation (AF) management in primary care often requires a referral to cardiology clinics, which can be strenuous for frail patients. We developed “cardio-share” (CS), a new cross-sector collaboration model, to ease this process. General practitioners (GPs) can use a compact Holter monitor (C3 from Cortrium) to receive remote advice from the cardiologist. Objective: To test the feasibility and acceptability of the CS model to manage suspected AF in frail elderly patients. Methods: We used a mixed methods design, including the preparation of qualitative semistructured interviews of GPs and nurses. Results: Between MAR-2019 and FEB-2020, 54 patients were consulted through the CS model, of whom 35 underwent C3 Holter monitoring. The time from referral to a final Holter report was shortened from a mean (SD) of 117 (45) days in usual care to 30 days (13) with the CS model. Furthermore, 90% of the patients did not need to attend visits at the cardiology clinic. The GPs and nurses highlighted the ease of using the C3 monitor. Their perception was that patients were confident in the GPs’ collaboration with cardiologists. Conclusions: The CS model using a C3 monitor for AF is both feasible and seems acceptable to GPs. The elapsed time from referral to the Holter report performed for the diagnosis was significantly reduced.
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18
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Kalisnik JM, Santarpino G, Balbierer AI, Zibert J, Vogt FA, Fittkau M, Fischlein T. Left Atrial Appendage Amputation for Atrial Fibrillation during Aortic Valve Replacement. J Clin Med 2022; 11:jcm11123408. [PMID: 35743478 PMCID: PMC9224923 DOI: 10.3390/jcm11123408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 05/25/2022] [Accepted: 06/03/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Occluding the left atrial appendage (LAA) during cardiac surgery reduces the risk of ischemic stroke; nonetheless, it is currently only softly recommended with "may be considered" by the current guidelines. We aimed to assess thromboembolic risk after LAA amputation in patients with atrial fibrillation (AF) and aortic stenosis undergoing biological aortic valve replacement (AVR) as primary cardiac surgery. METHODS Two cohorts were generated retrospectively: patients with AF undergoing AVR alone or combined with revascularization either with LAA amputation or without. Data were collected from the hospital-specific data system. Follow-up was completed by telephone interview or in person. Thirty-day and follow-up results were compared in patients with vs. without LAA amputation. RESULTS One hundred and fifty-seven patients were investigated retrospectively, and seventy-four pairs were matched with regard to baseline characteristics. Patients with LAA amputation exhibited a lower incidence of cumulative and late ischemic stroke (6.4% vs. 25%, p = 0.028 and 3.2% vs. 20%, p = 0.008, respectively; hazard ratio 0.30; 95% confidence interval 0.11; 0.84; p = 0.021) during follow-up of 48 months vs. patients without intervention during follow-up of 45 months, p = 0.494. No significant differences were observed in postoperative stroke, 2 (2.7%) vs. 3 (4.1%), p = 1.000, re-exploration for bleeding 3 (4.1%) vs. 6 (8.1), p = 0.494 or late pericardial effusion 2 (2.7%) vs. 3 (4.1%), p = 1.000, in-hospital 2 (2.7%) vs. 4 (5.4%), p = 0.681 and all-cause mortality 15 (23.8%) vs. 9 (15%), p = 0.315 in patients with vs. without LAA amputation, respectively. CONCLUSIONS A combination of leading aortic stenosis and AF in patients undergoing isolated or combined biological AVR represents a subpopulation with excessive thromboembolic risk. Concomitant LAA amputation during cardiac surgery reduces the risk of ischemic stroke without posing an additional periprocedural risk for the patient. Therefore, the minimal invasive approach at the expense of omitting LAA amputation should be discouraged to maximize the clinical benefits of AVR in this setting.
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Affiliation(s)
- Jurij M. Kalisnik
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University Nuremberg, 90471 Nuremberg, Germany; (F.A.V.); (M.F.); (T.F.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Correspondence: ; Tel.: +49-(0)-911-398-5441; Fax: +49-(0)-911-398-5443
| | - Giuseppe Santarpino
- Klinikum Nürnberg, Paracelsus Medical University, Campus Nuremberg, 90419 Nuremberg, Germany; (G.S.); (A.I.B.)
- Department of Cardiac Surgery, Città di Lecce Hospital, GVM Care & Research, 73100 Lecce, Italy
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy
| | - Andrea I. Balbierer
- Klinikum Nürnberg, Paracelsus Medical University, Campus Nuremberg, 90419 Nuremberg, Germany; (G.S.); (A.I.B.)
| | - Janez Zibert
- Department of Biostatistics, Faculty of Health Sciences, University of Ljubljana, 1000 Ljubljana, Slovenia;
| | - Ferdinand A. Vogt
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University Nuremberg, 90471 Nuremberg, Germany; (F.A.V.); (M.F.); (T.F.)
- Department of Cardiac Surgery, Artemed Clinic Munich-South, 81379 Munich, Germany
| | - Matthias Fittkau
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University Nuremberg, 90471 Nuremberg, Germany; (F.A.V.); (M.F.); (T.F.)
| | - Theodor Fischlein
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University Nuremberg, 90471 Nuremberg, Germany; (F.A.V.); (M.F.); (T.F.)
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Bernegger A, Mikšová D, Posekany A, Krebs S, Ferrari J, Greisenegger S, Gattringer T, Lang W, Kiechl S, Sykora M. Time trends in stroke severity in the years 2005 to 2020: results from the Austrian Stroke Unit Registry. J Neurol 2022; 269:4396-4403. [PMID: 35307755 DOI: 10.1007/s00415-022-11079-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE With aging population, there is an increase of atrial fibrillation (AF) and other vascular risk factors. We investigated trends in stroke severity at hospital admission with respect to AF and other risk factors in a prospective national stroke registry from 2005 to 2020. METHODS Data from the prospective Austrian Stroke Unit Registry were used to study demographic and clinical factors associated with the change in admission stroke severity over years. Time trends in admission stroke severity of patients with pre-stroke modified Rankin Score ≤ 3 were investigated with respect to clinical variables and predefined age groups 18-54, 55-64, 65-74, 75-84 and ≥ 85 years. Time trends were studied using robust generalized linear models assuming normal distribution with a log link. Stroke severity on admission was assessed according to the National Institutes of Health Stroke Scale Score (NIHSS). RESULTS In total, 140,312 patients with acute ischemic stroke were included in the analysis. Within the study period, mean patients' age increased from 70 to 72 years (p < 0.001) and median NIHSS at admission decreased from 4 to 3 (p < 0.001). The frequency of AF increased from 25 to 32% (p < 0.001). The decrease in median admission NIHSS was evident in all relevant subgroups but more pronounced in patients with risk factors including AF, diabetes, hypercholesterolemia, smoking, elderly patients and those with pre-stroke disability. CONCLUSION Despite an aging population and generally increasing AF frequency, we observed a consistent trend towards less disabling strokes on admission.
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Affiliation(s)
| | | | - Alexandra Posekany
- Gesundheit Österreich GmbH/BIQG, Vienna, Austria.,Research Unit of Computational Statistics, University of Technology, Vienna, Austria
| | - Stefan Krebs
- Department of Neurology, St. John's Hospital, Vienna, Austria
| | - Julia Ferrari
- Department of Neurology, St. John's Hospital, Vienna, Austria
| | | | - Thomas Gattringer
- Department of Neurology, Medical University of Graz, Graz, Austria.,Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Wilfried Lang
- Department of Neurology, St. John's Hospital, Vienna, Austria.,Medical Faculty, Sigmund Freud University Vienna, Vienna, Austria
| | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.,VASCage, Research Centre on Vascular Ageing and Stroke, Innsbruck, Austria
| | - Marek Sykora
- Department of Neurology, St. John's Hospital, Vienna, Austria. .,Medical Faculty, Sigmund Freud University Vienna, Vienna, Austria.
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20
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Patel J, Sadiq H, Catanzaro J, Crawford S, Wright A, Manning G, Allison J, Mazor K, McManus D, Kapoor A. SUPPORT-AF IV: Supporting use of AC through provider prompting about oral anticoagulation therapy for AF clinical trial study protocol. CARDIOVASCULAR DIGITAL HEALTH JOURNAL 2022; 2:222-230. [PMID: 35265912 PMCID: PMC8890051 DOI: 10.1016/j.cvdhj.2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Six million Americans suffer from atrial fibrillation (AF), a heart rhythm abnormality that significantly increases the risk of stroke. AF is responsible for 15% of ischemic strokes, which lead to permanent disability in 60% of cases and death in up to 20%. Anticoagulation (AC) is the mainstay for stroke prevention in patients with AF. Despite guidelines recommending AC for patients, up to half of eligible patients are not on AC. Clinical decision support tools in the electronic health record (EHR) can help bridge the disparity in AC prescription for patients with AF. Objective To enhance and assess the effectiveness of our previous rule-based alert on AC initiation and persistence in a diverse patient population from UMass-Memorial Medical Center and University of Florida at Jacksonville. Methods/Results Using the EHR, we will track AC initiation and persistence. We will interview both patients and providers to determine a measure of satisfaction with AC management. We will track digital crumbs to better understand the alert’s mechanism of effect and further add enhancements. These enhancements will be used to refine the alert and aid in developing an implementation toolkit to facilitate use of the alert at other health systems. Conclusion If the number of AC starts, the likelihood of persisting on AC, and the frequency alert use are found to be higher among intervention vs control providers, we believe such findings will confirm our hypothesis on the effectiveness of our alert.
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Affiliation(s)
- Jay Patel
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Hammad Sadiq
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - John Catanzaro
- Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Sybil Crawford
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Adam Wright
- Department of Biomedical Informatics, University of Vanderbilt School of Medicine, Nashville, Tennessee
| | - Gordon Manning
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,University of Massachusetts Memorial Health Care, Worcester, Massachusetts
| | - Jeroan Allison
- University of Massachusetts Memorial Health Care, Worcester, Massachusetts.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Kathleen Mazor
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,University of Massachusetts Memorial Health Care, Worcester, Massachusetts.,Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts
| | - David McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,University of Massachusetts Memorial Health Care, Worcester, Massachusetts
| | - Alok Kapoor
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,University of Massachusetts Memorial Health Care, Worcester, Massachusetts
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21
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Bah A, Nuotio I, Palomäki A, Mustonen P, Kiviniemi T, Ylitalo A, Hartikainen P, Airaksinen KEJ, Hartikainen JEK. Inadequate oral anticoagulation with warfarin in women with cerebrovascular event and history of atrial fibrillation: the FibStroke study. Ann Med 2021; 53:287-294. [PMID: 33475002 PMCID: PMC7877996 DOI: 10.1080/07853890.2021.1875499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 01/08/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Women with atrial fibrillation (AF) may be treated less actively with oral anticoagulation (OAC) than men. PATIENTS AND METHODS We assessed sex differences in the implementation of stroke risk stratification with CHADS2 and CHA2DS2-VASc scores and reasons not to use OAC in 1747 AF patients suffering their first cerebrovascular event after the AF diagnosis. RESULTS Women were older and had more often a high stroke risk (CHADS2/CHA2DS2-VASc ≥2) than men (p < .001). On admission, 46.4% of women and 48.2% of men were on OAC with no sex difference (p = .437). However, of patients without OAC, 74.4% of women and 49.5% of men should have been on OAC based on CHADS2/CHA2DS2-VASc ≥2 (p < .001). Conversely, 34.8% of men and 17.5% of women on OAC had a low or moderate risk (CHADS2/CHA2DS2-VASc 0-1, p < .001). A valid reason to omit OAC was reported in 38.6% of patients and less often in women (p < .001). CONCLUSIONS OAC was underused in high-risk AF patients, particularly women, but prescribed often in men with low or moderate stroke risk. Reasons for omitting OAC treatment were poorly reported, particularly for women. KEY MESSAGE Women were at higher stroke risk, but were less often treated with oral anticoagulation (OAC). Men were more often on OAC at low or moderate stroke risk. Reasons for omitting guideline based OAC were poorly reported, particularly for women.
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Affiliation(s)
- Aissa Bah
- Heart Center, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Ilpo Nuotio
- Department of Acute Internal Medicine, Turku University Hospital, Turku, Finland
| | - Antti Palomäki
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Pirjo Mustonen
- Department of Medicine, Keski-Suomi Central Hospital, Jyväskylä, Finland
- Faculty of Information Technology, Jyväskylä University, Jyväskylä, Finland
| | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Antti Ylitalo
- Heart Center, Satakunta Central Hospital, Pori, Finland
| | | | | | - Juha E. K. Hartikainen
- Heart Center, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
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22
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Kapoor A, Hayes A, Patel J, Patel H, Andrade A, Mazor K, Possidente C, Nolen K, Hegeman-Dingle R, McManus D. Usability and Perceived Usefulness of the AFib 2gether Mobile App in a Clinical Setting: Single-Arm Intervention Study. JMIR Cardio 2021; 5:e27016. [PMID: 34806997 PMCID: PMC8663604 DOI: 10.2196/27016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/21/2021] [Accepted: 10/03/2021] [Indexed: 11/15/2022] Open
Abstract
Background Although the American Heart Association and other professional societies have recommended shared decision-making as a way for patients with atrial fibrillation (AF) or atrial flutter to make informed decisions about using anticoagulation (AC), the best method for facilitating shared decision-making remains uncertain. Objective The aim of this study is to assess the AFib 2gether mobile app for usability, perceived usefulness, and the extent and nature of shared decision-making that occurred for clinical encounters between patients with AF and their cardiology providers in which the app was used. Methods We identified patients visiting a cardiology provider between October 2019 and May 2020. We measured usability from patients and providers using the Mobile App Rating Scale. From the 8 items of the Mobile App Rating Scale, we reported the average score (out of 5) for domains of functionality, esthetics, and overall quality. We administered a 3-item questionnaire to patients relating to their perceived usefulness of the app and a separate 3-item questionnaire to providers to measure their perceived usefulness of the app. We performed a chart review to track the occurrence of AC within 6 months of the index visit. We also audio recorded a subset of the encounters to identify evidence of shared decision-making. Results We facilitated shared decision-making visits for 37 patients visiting 13 providers. In terms of usability, patients’ average ratings of functionality, esthetics, and overall quality were 4.51 (SD 0.61), 4.26 (SD 0.51), and 4.24 (SD 0.89), respectively. In terms of usefulness, 41% (15/37) of patients agreed that the app improved their knowledge regarding AC, and 62% (23/37) agreed that the app helped clarify to their provider their preferences regarding AC. Among providers, 79% (27/34) agreed that the app helped clarify their patients’ preferences, 82% (28/34) agreed that the app saved them time, and 59% (20/34) agreed that the app helped their patients make decisions about AC. In addition, 32% (12/37) of patients started AC after their shared decision-making visits. We audio recorded 25 encounters. Of these, 84% (21/25) included the mention of AC for AF, 44% (11/25) included the discussion of multiple options for AC, 72% (18/25) included a provider recommendation for AC, and 48% (12/25) included the evidence of patient involvement in the discussion. Conclusions Patients and providers rated the app with high usability and perceived usefulness. Moreover, one-third of the patients began AC, and approximately 50% (12/25) of the encounters showed evidence of patient involvement in decision-making. In the future, we plan to study the effect of the app on a larger sample and with a controlled study design. Trial Registration ClinicalTrials.gov NCT04118270; https://clinicaltrials.gov/ct2/show/NCT04118270 International Registered Report Identifier (IRRID) RR2-21986
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Affiliation(s)
- Alok Kapoor
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Anna Hayes
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Jay Patel
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Harshal Patel
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Andreza Andrade
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Kathleen Mazor
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Carl Possidente
- Division of Medical Affairs, Pfizer Inc, New York, NY, United States
| | - Kimberly Nolen
- Division of Medical Affairs, Pfizer Inc, New York, NY, United States
| | | | - David McManus
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
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23
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Leblanc K, MacGillivray J, Carroccia A, Macle L, Andrade JG. The 2020 CCS atrial fibrillation guidelines for pharmacists: Top 10 takeaways. Can Pharm J (Ott) 2021; 155:107-118. [PMID: 35300017 PMCID: PMC8922222 DOI: 10.1177/17151635211058160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/19/2021] [Accepted: 06/09/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Kori Leblanc
- University Health Network, Toronto, Ontario
- Leslie Dan Faculty of Pharmacy, University of Toronto, Ontario
| | | | | | - Laurent Macle
- Institut de Cardiologie de Montreal, Montreal, Quebec
| | - Jason G. Andrade
- Faculty of Medicine, University of British Columbia, Vancouver, BC
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24
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Xu Y, Siegal DM. Anticoagulant-associated gastrointestinal bleeding: Framework for decisions about whether, when and how to resume anticoagulants. J Thromb Haemost 2021; 19:2383-2393. [PMID: 34273241 DOI: 10.1111/jth.15466] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 11/27/2022]
Abstract
Gastrointestinal (GI) bleeding is the most frequent single site of oral anticoagulant (OAC)-associated major bleeding. Patients with major GI bleeding experience morbidity and a substantial risk of short-term all-cause mortality up to 10%. While OACs are frequently discontinued during acute bleeding, there is substantial uncertainty about whether, when, and how OACs should be resumed after bleeding has resolved. Limited evidence suggests a lower risk of thromboembolism and death, and a higher risk of recurrent bleeding with OAC resumption. However, the absolute risks and optimal timing of anticoagulation remain uncertain based on these observational studies at risk of bias, particularly due to baseline confounding. In addition to an individualized approach to determining the benefits and harms of treatment decisions informed by the best available evidence about thrombosis and recurrent bleeding, discussions should meaningfully incorporate patient values and preferences. The objective of this review is to provide a framework for decision-making by summarizing the epidemiology and clinical outcomes of OAC-associated GI bleeding, providing an approach for assessment and risk stratification for OAC resumption and its timing, and outlining strategies for the prevention of recurrent GI bleeding.
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Affiliation(s)
- Yan Xu
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Deborah M Siegal
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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25
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Liran O, Banon T, Grossman A. Detection of occult atrial fibrillation with 24-hour ECG after cryptogenic acute stroke or transient ischaemic attack: A retrospective cross-sectional study in a primary care database in Israel. Eur J Gen Pract 2021; 27:152-157. [PMID: 34240675 PMCID: PMC8274499 DOI: 10.1080/13814788.2021.1947237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Ischaemic stroke or cerebrovascular accident (CVA) due to occult atrial fibrillation (AF) may cause severe morbidity and mortality. Diagnosing occult AF can be challenging and there is no consensus regarding the optimal duration of screening. A 24-hour Holter electrocardiogram (ECG) is frequently employed to detect occult AF following ischaemic CVA. Objectives Demonstration of occult AF detection rate using a 24-hour Holter ECG in a primary care setting with descriptive analyses of independent variables to compare AF detected and non-detected patients. Methods This retrospective cross-sectional study utilised primary care data and included patients 50 years and older with a new CVA or transient ischaemic attack (TIA) diagnosis followed by a 24-hour Holter examination within 6 months, between 01 January 2013 and 01 June 2019. The analyses included descriptive statistics comparing demographics and clinical characteristics in patients who had AF or Atrial Flutter (AFL) detection to those who did not. Results Out of 5015 eligible patients, 66 (1.3%) were diagnosed with AF/AFL, with a number needed to screen of 88.5. Compared with those without AF/AFL detection, those diagnosed were older (75.42 ± 7.89 vs. 69.89 ± 9.88, p = 0.050), had a higher prevalence of hypertension (80.3% vs. 66.8%, p = 0.021) and chronic kidney disease (CKD) (71.2% vs. 44.2%, p < 0.001). Conclusion 24-hour Holter has a low AF/AFL detection rate. Older persons and those with hypertension or CKD are more likely to be detected with AF/AFL using this method.
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Affiliation(s)
- Ori Liran
- Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Tamar Banon
- Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Alon Grossman
- Maccabi Healthcare Services, Tel-Aviv, Israel.,Department of Internal Medicine B, Rabin Medical Center, Petah Tikva, Israel
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26
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Kotadia ID, Sim I, Mukherjee R, O’Hare D, Chiribiri A, Birns J, Bhalla A, O’Neill M, Williams SE. Secondary Stroke Prevention Following Embolic Stroke of Unknown Source in the Absence of Documented Atrial Fibrillation: A Clinical Review. J Am Heart Assoc 2021; 10:e021045. [PMID: 34212774 PMCID: PMC8403300 DOI: 10.1161/jaha.121.021045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Approximately one-third of ischemic strokes are classified as cryptogenic strokes. The risk of stroke recurrence in these patients is significantly elevated with up to one-third of patients with cryptogenic stroke experiencing a further stroke within 10 years. While anticoagulation is the mainstay of treatment for secondary stroke prevention in the context of documented atrial fibrillation (AF), it is estimated that up to 25% of patients with cryptogenic stroke have undiagnosed AF. Furthermore, the historical acceptance of a causal relationship between AF and stroke has recently come under scrutiny, with evidence to suggest that embolic stroke risk may be elevated even in the absence of documented atrial fibrillation attributable to the presence of electrical and structural changes constituting an atrial cardiomyopathy. More recently, the term embolic stroke of unknown source has garnered increasing interest as a subset of patients with cryptogenic stroke in whom a minimum set of diagnostic investigations has been performed, and a nonlacunar infarct highly suspicious of embolic etiology is suspected but in the absence of an identifiable secondary cause of stroke. The ongoing ARCADIA (Atrial Cardiopathy and Antithrombotic Drugs in Prevention After Cryptogenic Stroke) randomized trial and ATTICUS (Apixiban for Treatment of Embolic Stroke of Undetermined Source) study seek to further define this novel term. This review summarizes the relationship between AF, embolic stroke, and atrial cardiomyopathy and provides an overview of the clinical relevance of cardiac imaging, electrocardiographic, and serum biomarkers in the assessment of AF and secondary stroke risk. The implications of these findings on therapeutic considerations is considered and gaps in the literature identified as areas for future study in risk stratifying this cohort of patients.
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Affiliation(s)
- Irum D. Kotadia
- King’s College LondonLondonUnited Kingdom
- Guy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Iain Sim
- King’s College LondonLondonUnited Kingdom
| | | | | | | | - Jonathan Birns
- Guy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Ajay Bhalla
- Guy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Mark O’Neill
- King’s College LondonLondonUnited Kingdom
- Guy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Steven E. Williams
- King’s College LondonLondonUnited Kingdom
- Centre for Cardiovascular ScienceUniversity of EdinburghUnited Kingdom
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27
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Watanabe K, Okazaki S, Kitano T, Sugiyama S, Ohara M, Kanki H, Sasaki T, Sakaguchi M, Mochizuki H, Todo K. Stroke Severity and Outcomes in Patients With Newly Diagnosed Atrial Fibrillation. Front Neurol 2021; 12:666491. [PMID: 34267720 PMCID: PMC8275857 DOI: 10.3389/fneur.2021.666491] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/31/2021] [Indexed: 12/03/2022] Open
Abstract
Background and Purpose: Once a stroke occurs in a patient with atrial fibrillation (AF), it is likely to be severe. Patients with newly diagnosed AF after stroke and those with known AF before stroke have different background characteristics, yet the difference in stroke severity has not been sufficiently evaluated. In the current study, we compared the stroke severity and in-hospital outcomes between these patient groups. Methods: We retrospectively analyzed a database of 196 patients with acute ischemic stroke and AF between January 2010 and October 2019. We divided the patients into two groups: patients with “newly diagnosed AF” and those with “known AF.” We assessed the stroke severity using the National Institutes of Health Stroke Scale (NIHSS) score on admission and in-hospital outcomes using the modified Rankin Scale (mRS) score at discharge. Results: The proportion of newly diagnosed AF was 33% (64/196). There were no differences in age, hypertension, diabetes mellitus, and past history of heart failure between patients with newly diagnosed AF and those with known AF. Patients with newly diagnosed AF were associated with a lower proportion of male sex (male; 50 vs. 67%, p < 0.05), a lower proportion of past history of stroke (12 vs. 35%, p < 0.01), a lower CHA2DS2-VASc score (median [interquartile range]; 3 [2–4] vs. 3.5 [3–5], p < 0.01), and a lower proportion of pre-stroke oral anticoagulation (5 vs. 59%, p < 0.01). There were no differences in the NIHSS score on admission (12 [4–19] vs. 9 [3–19]) or the mRS score at discharge (3 [1–5] vs. 3 [1–5]). After adjustment for relevant covariates, newly diagnosed AF was not associated with the NIHSS score on admission [adjusted common odds ratio (OR), 0.85; 95% confidence interval (CI), 0.45–1.60] or the mRS score at discharge (adjusted common OR, 1.67; 95% CI, 0.88–3.18). After propensity score matching, newly diagnosed AF was not associated with the NIHSS score on admission (adjusted common OR, 0.91; 95% CI, 0.48–1.73) and the mRS score at discharge (adjusted common OR, 1.77; 95% CI, 0.92–3.43). Conclusion: Stroke severity and in-hospital outcomes in patients with newly diagnosed AF did not differ from those in patients with known AF after adjustment for clinically relevant factors. The importance of detection of latent AF and subsequent anticoagulation in preventing severe stroke should be further emphasized.
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Affiliation(s)
- Kotaro Watanabe
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shuhei Okazaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takaya Kitano
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shintaro Sugiyama
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Mariko Ohara
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideaki Kanki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tsutomu Sasaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Manabu Sakaguchi
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
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28
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Botto GL, Ameri P, De Caterina R. Many Good Reasons to Switch from Vitamin K Antagonists to Non-Vitamin K Antagonists in Patients with Non-Valvular Atrial Fibrillation. J Clin Med 2021; 10:jcm10132866. [PMID: 34203416 PMCID: PMC8268480 DOI: 10.3390/jcm10132866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/17/2021] [Accepted: 06/19/2021] [Indexed: 12/14/2022] Open
Abstract
Non-vitamin K oral anticoagulants (NOACs) are the first choice for prophylaxis of cardioembolism in patients with non-valvular atrial fibrillation (AF) who are anticoagulant-naïve, as well as the preferable anticoagulation strategy in those who are on vitamin K antagonists (VKAs), but with a low time in therapeutic range (TTR). Nonetheless, there are many good reasons to consider switching from VKAs to NOACs also when TTR is >70%. From the pharmacological standpoint, anticoagulation with VKAs may remain erratic even in those patients who have high TTR values, owing to the mode of action of this drug class. Furthermore, experimental data suggest that, unlike VKAs, NOACs favorably modulate the effects of factor Xa and thrombin in the cardiovascular system through the protease-activated receptor family. Clinically, the most striking advantage provided by NOACs over VKAs, irrespective of the TTR, is the substantially lower risk of intracranial hemorrhage. NOACs have also been associated with less deterioration of renal function as compared with VKAs and may confer protection against cardiovascular events not strictly related to AF, especially the acute complications of peripheral artery disease. In this narrative review, we discuss the evidence according to which it is warranted to systematically substitute NOACs for VKAs for the prevention of AF-related stroke and systemic embolism.
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Affiliation(s)
- Giovanni Luca Botto
- Department of Cardiology—Electrophysiology, ASST Rhodense, Garbagnate Milanese, 20024 Milan, Italy; or
| | - Pietro Ameri
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, 16132 Genova, Italy
- Department of Internal Medicine, University of Genova, 16132 Genova, Italy
- Correspondence: ; Tel.: +39-010-353-8928; Fax: +39-010-555-6513
| | - Raffaele De Caterina
- Division of Cardiology, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, 56124 Pisa, Italy;
- Fondazione Villa Serena per la Ricerca, Città Sant’Angelo, 65103 Pescara, Italy
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29
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Botto G, Ameri P, Cappellari M, Dentali F, Ferri N, Parrini I, Porto I, Squizzato A, Camporese G. Unmet Clinical Needs in Elderly Patients Receiving Direct Oral Anticoagulants for Stroke Prevention in Non-valvular Atrial Fibrillation. Adv Ther 2021; 38:2891-2907. [PMID: 34019247 PMCID: PMC8189975 DOI: 10.1007/s12325-021-01769-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 04/30/2021] [Indexed: 12/11/2022]
Abstract
Vitamin K antagonists have been used for many years as the treatment of choice for long-term oral anticoagulation in patients with non-valvular atrial fibrillation. Unfortunately, the use of those drugs in the real-world setting, particularly among elderly patients, is suboptimal because of their limitations in management. Therefore, many patients were not adequately anticoagulated. Direct oral anticoagulants have been demonstrated to overcome almost all the limitations derived from the use of vitamin K antagonists. Direct oral anticoagulants are at least as effective as vitamin K antagonists in preventing thromboembolic events in patients with non-valvular atrial fibrillation and safer in reducing the risk of intracranial haemorrhage and all-cause mortality. However, as a result of the strict inclusion and exclusion criteria applied to patients, data coming from randomized controlled trials might not apply to the general population. Furthermore, elderly patients were scarcely represented in randomized controlled trials with direct oral anticoagulants. Therefore in elderly patients with non-valvular atrial fibrillation, unmet clinical needs still exist. This review article highlights some of them and provides potential answers based on the results coming from randomized clinical trials, real-world data, and the authors' clinical experience.
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Affiliation(s)
- Gianluca Botto
- Cardiologia Elettrofisiologia, ASST Rhodense, Rho and Garbagnate Hospitals, Milan, Italy
| | - Pietro Ameri
- Cardiovascular Disease Unit, Department of Internal Medicine, IRCCS Ospedale Policlinico, University of Genova, Genoa, Italy
| | - Manuel Cappellari
- Stroke Unit, Department of Neurosciences, University Hospital of Verona, Verona, Italy
| | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Nicola Ferri
- Department of Pharmaceutical and Pharmacological Sciences, University of Padua, Padua, Italy
| | - Iris Parrini
- S.C. Cardiologia, Ospedale Mauriziano Umberto I, Turin, Italy
| | - Italo Porto
- Clinic of Cardiovascular Diseases, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
| | | | - Giuseppe Camporese
- Angiology Unit, Department of Cardiac, Thoracic and Vascular Sciences, University Hospital of Padua, Padua, Italy.
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30
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Besford M, Leahy TP, Sammon C, Ulvestad M, Carroll R, Mehmud F, Alikhan R, Ramagopalan S. CHA 2DS 2-VASc and HAS-BLED risk scores and real-world oral anticoagulant prescribing decisions in atrial fibrillation. Future Cardiol 2021; 17:855-864. [PMID: 33890499 DOI: 10.2217/fca-2020-0175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Guidelines indicate that oral anticoagulant (OAC) treatment decisions in atrial fibrillation should be based on a balanced consideration of thromboembolic and bleeding risk. Materials & methods: A retrospective cohort of nonvalvular atrial fibrillation patients were identified. Univariate logistic regression and conditional inference trees were used to quantify the importance of the CHA2DS2-VASc and modified HAS-BLED scores and their individual components on OAC treatment decisions. Results: The individual components of these risk scores provided more distinguishability between treated and untreated patients than the risk scores themselves, with bleeding risk factors strongly associated with nontreatment. Conclusion: While individual components of risk scores drive OAC treatment decisions according to guidelines, the relationship between bleeding risk factors and nontreatment warrants further consideration.
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Affiliation(s)
| | | | | | | | - Robert Carroll
- Centre for Observational Research & Data Sciences, Bristol Myers Squibb, Uxbridge, UK
| | | | - Raza Alikhan
- University Hospital of Wales, Cardiff & Vale University Health Board, UK
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31
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Kapoor A, Andrade A, Hayes A, Mazor K, Possidente C, Nolen K, Hegeman-Dingle R, McManus D. Usability, Perceived Usefulness, and Shared Decision-Making Features of the AFib 2gether Mobile App: Protocol for a Single-Arm Intervention Study. JMIR Res Protoc 2021; 10:e21986. [PMID: 33625361 PMCID: PMC7946587 DOI: 10.2196/21986] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 12/23/2020] [Accepted: 01/15/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Centers for Disease Control and Prevention has estimated that atrial fibrillation (AF) affects between 2.7 million and 6.1 million people in the United States. Those who have AF tend to have a much higher stroke risk than others. Although most individuals with AF benefit from anticoagulation (AC) therapy, a significant majority are hesitant to start it. To add, providers often struggle in helping patients negotiate the decision to start AC therapy. To assist in the communication between patients and providers regarding preferences and knowledge about AC therapy, different strategies are being used to try and solve this problem. In this research study, we will have patients and providers utilize the AFib 2gether app with hopes that it will create a platform for shared decision making regarding the prevention of stroke in patients with AF receiving AC therapy. OBJECTIVE The aim of our study is to measure several outcomes related to encounters between patients and their cardiology providers where AFib 2gether is used. These outcomes include usability and perceived usefulness of the app from the perspective of patients and providers. In addition, we will assess the extent and nature of shared decision making. METHODS Eligible patients and providers will evaluate the AFib 2gether mobile app for usability and perceived usefulness in facilitating shared decision making regarding understanding the patient's risk of stroke and whether or not to start AC therapy. Both patients and providers will review the app and complete multiple questionnaires about the usability and perceived usefulness of the mobile app in a clinical setting. We will also audio-record a subset of encounters to assess for evidence of shared decision making. RESULTS Enrollment in the AFib 2gether shared decision-making study is still ongoing for both patients and providers. The first participant enrolled on November 22, 2019. Analysis and publishing of results are expected to be completed in spring 2021. CONCLUSIONS The AFib 2gether app emerged from a desire to increase the ability of patients and providers to engage in shared decision making around understanding the risk of stroke and AC therapy. We anticipate that the AFib 2gether mobile app will facilitate patient discussion with their cardiologist and other providers. Additionally, we hope the study will help us identify barriers that providers face when placing patients on AC therapy. We aim to demonstrate the usability and perceived usefulness of the app with a future goal of testing the value of our approach in a larger sample of patients and providers at multiple medical centers across the country. TRIAL REGISTRATION ClinicalTrials.gov NCT04118270; https://clinicaltrials.gov/ct2/show/NCT04118270. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/21986.
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Affiliation(s)
- Alok Kapoor
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Andreza Andrade
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Anna Hayes
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Kathleen Mazor
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | | | - Kim Nolen
- Medical Affairs, Pfizer Inc, New York, NY, United States
| | | | - David McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
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Lin Y, Wang X, Li XB, Wu BQ, Zhang ZH, Guo WH, Wu CC, Chen X, Chen ML, Dai Z, Chen FY, Zhu R, Liang CX, Tian YP, Yang G, Yan CQ, Lu J, Wang HY, Li JL, Tu JF, Li HW, Yang DD, Yu FT, Wang Y, Yang JW, Shi GX, Yan SY, Wang LQ, Liu CZ. Acupuncture for persistent atrial fibrillation after catheter ablation: study protocol for a pilot randomized controlled trial. Trials 2021; 22:35. [PMID: 33413569 PMCID: PMC7792186 DOI: 10.1186/s13063-020-04967-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 12/11/2020] [Indexed: 12/17/2022] Open
Abstract
Background Atrial fibrillation (AF) is a common arrhythmia, which is closely related to cardiovascular morbidity and mortality. Although acupuncture is used in the treatment of AF, the evidence is insufficient. The objective of this pilot trial is to evaluate the feasibility, preliminary efficacy, and safety of acupuncture in reducing AF burden for persistent AF after catheter ablation (CA). Methods and design This will be a multi-center, 3-arm, pilot randomized controlled trial in China. Sixty patients in total will be randomly assigned to the specific acupoints group, the non-specific acupoints group, or the non-acupoints group in a 1:1:1 ratio. The whole study period is 6 months, including a 3-month treatment period and a 3-month follow-up period. All patients will receive 18 sessions of acupuncture over 12 weeks after CA and appropriate post-ablation routine treatment. The primary outcome is AF burden at 6 months after CA measured by electrocardiography patch that can carry out a 7-day continuous ambulatory electrocardiographic monitoring. The secondary outcomes include AF burden at 3 months after CA, recurrence of AF, quality of life, etc. The adverse events will also be recorded. Discussion This pilot study will contribute to evaluating the feasibility, preliminary efficacy, and safety of acupuncture in reducing AF burden for persistent AF after CA. The results will be used for the sample size calculation of a subsequent large-scale trial. Trial registration Chinese Clinical Trial Registry ChiCTR2000030576. Registered on 7 March 2020. Supplementary information Supplementary information accompanies this paper at 10.1186/s13063-020-04967-y.
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Affiliation(s)
- Ying Lin
- Acupuncture Research Center, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, 100029, China
| | - Xian Wang
- Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing University Cardiology Research Institute of Traditional Chinese Medicine, Beijing, 100700, China
| | - Xue-Bin Li
- Department of Cardiology, Peking University People's Hospital, Beijing, 100044, China
| | - Bang-Qi Wu
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital, Tianjin University of Traditional Chinese Medicine, Tianjin, 300193, China
| | - Zhao-Hui Zhang
- Department of Acupuncture and Moxibustion, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Wei-Hua Guo
- Department of Cardiology, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Cun-Cao Wu
- Department of Cardiology, Peking University People's Hospital, Beijing, 100044, China
| | - Xin Chen
- Department of Cardiology, Tianjin First Center Hospital, Tianjin, 300192, China
| | - Ming-Long Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Zhong Dai
- Department of Traditional Chinese Medicine, Peking University People's Hospital, Beijing, 100044, China
| | - Fu-Yan Chen
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, First Teaching Hospital, Tianjin University of Traditional Chinese Medicine, Tianjin, 300193, China
| | - Rui Zhu
- Department of Acupuncture and Moxibustion, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Chu-Xi Liang
- Department of Traditional Chinese Medicine, Peking University People's Hospital, Beijing, 100044, China
| | - Yun-Peng Tian
- Department of Cardiology, Tianjin First Center Hospital, Tianjin, 300192, China
| | - Gang Yang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Chao-Qun Yan
- Department of Acupuncture and Moxibustion, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Jing Lu
- Department of Acupuncture and Moxibustion, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Hai-Ying Wang
- Department of Cardiology, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Jin-Ling Li
- Acupuncture Research Center, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, 100029, China
| | - Jian-Feng Tu
- Department of Acupuncture and Moxibustion, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, 100010, China
| | - He-Wen Li
- Acupuncture Research Center, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, 100029, China
| | - Dan-Dan Yang
- Department of Cardiology, Peking University People's Hospital, Beijing, 100044, China
| | - Fang-Ting Yu
- Acupuncture Research Center, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, 100029, China
| | - Yu Wang
- Acupuncture Research Center, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, 100029, China
| | - Jing-Wen Yang
- Acupuncture Research Center, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, 100029, China
| | - Guang-Xia Shi
- Acupuncture Research Center, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, 100029, China
| | - Shi-Yan Yan
- Acupuncture Research Center, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, 100029, China
| | - Li-Qiong Wang
- Acupuncture Research Center, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, 100029, China.
| | - Cun-Zhi Liu
- Acupuncture Research Center, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, 100029, China
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Kawakami H, Nolan MT, Phillips K, Scuffham PA, Marwick TH. Cost-effectiveness of combined catheter ablation and left atrial appendage closure for symptomatic atrial fibrillation in patients with high stroke and bleeding risk. Am Heart J 2021; 231:110-120. [PMID: 32822655 DOI: 10.1016/j.ahj.2020.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 08/12/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Combined catheter ablation (CA) and left atrial appendage closure (LAAC) have been proposed for management of symptomatic atrial fibrillation (AF) in patients with high stroke and bleeding risk. We assessed the cost-effectiveness of combined CA and LAAC compared with CA and standard oral anticoagulation (OAC) in symptomatic AF. METHODS A Markov model was developed to assess total costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio among 2 post-CA strategies: (1) standard OAC and (2) LAAC (combined CA and LAAC procedure). The base-case used a 10-year time horizon and consisted of a hypothetical cohort of patients aged 65 years with symptomatic AF, with high thrombotic (CHA2DS2-VASc = 3) and bleeding risk (HAS-BLED = 3), and planned for AF ablation. Values for transition probabilities, utilities, and costs were derived from the literature. Costs were converted to 2020 US dollars. Half-cycle correction was applied, and costs and QALYs were discounted at 3% annually. Sensitivity analyses were performed for significant variables and scenario analyses for higher embolic risk. RESULTS In the base-case cohort of 10,000 patients followed for 10 years, total costs for the LAAC strategy were $29,027 and for OAC strategy were $27,896. The LAAC strategy was associated with 122 fewer disabling strokes and 203 fewer intracranial hemorrhages per 10,000 patients compared with the OAC strategy. The LAAC strategy had an incremental cost-effectiveness ratio of $11,072/QALY. In sensitivity analyses, although cost-effectiveness was highly dependent on the risk of intracranial hemorrhage in the LAAC strategy and the cost of the combined procedure, LAAC was superior to OAC under the most circumstances. Scenario analyses demonstrated that the combined procedure was more cost-effective in patients with higher stroke risk. CONCLUSIONS In symptomatic AF patients with high stroke and bleeding risk who are planned for CA, the combined CA and LAAC procedure may be a cost-effective therapeutic option and be more beneficial to patients with CHA2DS2-VASc risk score ≥3.
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Affiliation(s)
- Hiroshi Kawakami
- Department of Cardiac Imaging, Baker Heart and Diabetes Institute, Melbourne, Australia; School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
| | - Mark T Nolan
- Department of Cardiac Imaging, Baker Heart and Diabetes Institute, Melbourne, Australia
| | | | - Paul A Scuffham
- Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Thomas H Marwick
- Department of Cardiac Imaging, Baker Heart and Diabetes Institute, Melbourne, Australia; School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia.
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Yang KT, Sun WC, Tsai TJ, Tsay FW, Chen WC, Cheng JS. The Risk of Gastrointestinal Bleeding between Non-Vitamin K Antagonist Oral Anticoagulants and Vitamin K Antagonists in the Asian Atrial Fibrillation Patients: A Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 18:ijerph18010137. [PMID: 33375495 PMCID: PMC7795910 DOI: 10.3390/ijerph18010137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/11/2020] [Accepted: 12/23/2020] [Indexed: 05/04/2023]
Abstract
Background: Non-vitamin K antagonist oral anticoagulants (NOACs) are more commonly used to prevent atrial fibrillation (AF) patients from thromboembolic events than vitamin K antagonists (VKAs). However, the gastrointestinal bleeding (GIB) risk in the Asian AF patients associated with NOACs in comparison with VKAs remained unaddressed. Materials and Methods: A systematic search of studies on NOACs and VKAs in the Asian AF patients was conducted in PubMed, Cochrane Library, and ClinicalTrials.gov. The primary outcome was the hazard ratio (HR) of any GIB associated with NOACs versus VKAs. The secondary outcome was the GIB risks in different kinds of NOACs compared with VKAs. Results: This meta-analysis included two randomized controlled trials (RCTs) and four retrospective studies, comprising at least 200,000 patients in total. A significantly lower HR of GIB risks was found in all kinds of NOACs than VKAs in the Asian AF patients (HR: 0.633; 95% confidence interval: 0.535-0.748; p < 0.001). Additionally, the GIB risks of different NOACs were apixaban (HR: 0.392), edoxaban (HR: 0.603), dabigatran (HR: 0.685), and rivaroxaban (HR: 0.794), respectively. Conclusions: NOACs significantly reduced the risk of GIB in the Asian AF patients compared with VKAs. In the four NOACs compared with VKAs, apixaban probably had a trend of the least GIB risk. We need further head-to-head studies of different NOACs to confirm which NOAC is the most suitable for Asian AF patients and to know the optimal dosage regimen of different NOACs.
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Affiliation(s)
- Kuang-Tsu Yang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 81362, Taiwan; (K.-T.Y.); (W.-C.S.); (T.-J.T.); (F.-W.T.); (J.-S.C.)
| | - Wei-Chih Sun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 81362, Taiwan; (K.-T.Y.); (W.-C.S.); (T.-J.T.); (F.-W.T.); (J.-S.C.)
| | - Tzung-Jiun Tsai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 81362, Taiwan; (K.-T.Y.); (W.-C.S.); (T.-J.T.); (F.-W.T.); (J.-S.C.)
- School of Medicine, National Yang-Ming University, Taipei 11221, Taiwan
| | - Feng-Woei Tsay
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 81362, Taiwan; (K.-T.Y.); (W.-C.S.); (T.-J.T.); (F.-W.T.); (J.-S.C.)
- School of Medicine, National Yang-Ming University, Taipei 11221, Taiwan
| | - Wen-Chi Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 81362, Taiwan; (K.-T.Y.); (W.-C.S.); (T.-J.T.); (F.-W.T.); (J.-S.C.)
- School of Medicine, National Yang-Ming University, Taipei 11221, Taiwan
- Department of Chemistry, College of Science, National Kaohsiung Normal University, Kaohsiung 80201, Taiwan
- Correspondence: ; Tel.: +886-7-346-8078; Fax: +886-7-346-8237
| | - Jin-Shiung Cheng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 81362, Taiwan; (K.-T.Y.); (W.-C.S.); (T.-J.T.); (F.-W.T.); (J.-S.C.)
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Wong E, Aaqib M, Thijs V. High Frequency of Anticoagulation Management Errors Preceding Ischemic Strokes in Atrial Fibrillation. Intern Med J 2020; 52:1024-1028. [PMID: 33346950 DOI: 10.1111/imj.15167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/21/2020] [Accepted: 12/13/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Anticoagulants are recommended to prevent cardioembolic stroke in most patients with atrial fibrillation (AF). Management errors with anticoagulation and use of aspirin instead of anticoagulants have been documented worldwide, especially with vitamin K antagonists. We assessed the rate of anticoagulant mismanagement errors in patients admitted with ischemic stroke, and the clinical correlates with stroke outcomes in the era of non-vitamin K oral anticoagulants. METHODS We performed a retrospective analysis of patients admitted with ischemic stroke and history of AF to a single-centre tertiary hospital stroke unit in Melbourne, Australia, between January 2016 and June 2019. We assessed management errors as defined using European Heart Rhythm Association criteria with anticoagulation in the two weeks prior to the index stroke. RESULTS A total of 306 patients with AF and ischemic stroke were included, of whom 196 (64%) had management errors. Patients with management errors were older (median age 84 versus 81 years [p=0.002]) and more often female (53% verse 38% [p=0.02]). Of those with management errors, 74 (37%) were not prescribed any anticoagulation despite increased stroke risk and absence of contraindications and 40 (20%) had anticoagulation inappropriately ceased. Mortality at 3-months was 32% in those with management errors, compared to 17% in the appropriately anticoagulated group (p=0.005). CONCLUSIONS Inappropriate management of anticoagulants is present in the majority of acute ischemic stroke in the 2 weeks preceding the event and is linked to higher mortality. Improved anticoagulation practice has the potential to substantially reduce stroke rates in patients with AF. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Muhammad Aaqib
- Department of Neurology, Austin Health.,Florey Institute of Neuroscience and Mental Health, Austin Campus
| | - Vincent Thijs
- Department of Neurology, Austin Health.,Florey Institute of Neuroscience and Mental Health, Austin Campus
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Haeusler KG, Tütüncü S, Kunze C, Schurig J, Malsch C, Harder J, Wiedmann S, Dimitrijeski B, Ebinger M, Hagemann G, Hamilton F, Honermann M, Jungehulsing GJ, Kauert A, Koennecke HC, Leithner C, Mackert BM, Masuhr F, Nabavi D, Rocco A, Schmehl I, Schmitz B, Sparenberg P, Stingele R, von Brevern M, Völzke E, Dietzel J, Heuschmann PU, Endres M. Oral anticoagulation in patients with atrial fibrillation and acute ischaemic stroke: design and baseline data of the prospective multicentre Berlin Atrial Fibrillation Registry. Europace 2020; 21:1621-1632. [PMID: 31397475 DOI: 10.1093/europace/euz199] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 06/28/2019] [Indexed: 12/11/2022] Open
Abstract
AIMS The Berlin Atrial Fibrillation Registry was designed to analyse oral anticoagulation (OAC) prescription in patients with atrial fibrillation (AF) and acute ischaemic stroke. METHODS AND RESULTS This investigator-initiated prospective multicentre registry enrolled patients at all 16 stroke units located in Berlin, Germany. The ongoing telephone follow-up is conducted centrally and will cover 5 years per patient. Within 2014 and 2016, 1080 patients gave written informed consent and 1048 patients were available for analysis. Median age was 77 years [interquartile range (IQR) 72-83], 503 (48%) patients were female, and 254 (24%) had a transient ischaemic attack (TIA). Overall, 470 (62%) out of 757 patients with known AF and a (pre-stroke) CHA2DS2-VASc ≥ 1 were anticoagulated at the time of stroke. At hospital discharge, 847 (81.3%) of 1042 patients were anticoagulated. Thereof 710 (68.1%) received a non-vitamin K-dependent oral anticoagulant (NOAC) and 137 (13.1%) a vitamin K antagonist (VKA). Pre-stroke intake of a NOAC [odds ratio (OR) 15.6 (95% confidence interval, 95% CI 1.97-122)] or VKA [OR 0.04 (95% CI 0.02-0.09)], an index TIA [OR 0.56 (95% CI 0.34-0.94)] rather than stroke, heart failure [OR 0.49 (95% CI 0.26-0.93)], and endovascular thrombectomy at hospital admission [OR 12.9 (95% CI 1.59-104)] were associated with NOAC prescription at discharge. Patients' age or AF type had no impact on OAC or NOAC use, respectively. CONCLUSION About 60% of all registry patients with known AF received OAC at the time of stroke or TIA. At hospital discharge, more than 80% of AF patients were anticoagulated and about 80% of those were prescribed a NOAC.
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Affiliation(s)
- Karl Georg Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Josef-Schneider-Str. 11, Würzburg, Germany
| | - Serdar Tütüncü
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany
| | - Claudia Kunze
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany
| | - Johannes Schurig
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Germany
| | - Carolin Malsch
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Germany.,Comprehensive Heart Failure Center, University of Würzburg, Clinical Trial Centre Würzburg, University Hospital Würzburg, Germany
| | - Janek Harder
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Germany
| | - Silke Wiedmann
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Germany.,Strategic Corporate Development, Charité-Universitätsmedizin Berlin, Germany
| | | | - Martin Ebinger
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany.,Department of Neurology, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Georg Hagemann
- Department of Neurology, Helios Klinik Berlin-Buch, Berlin, Germany
| | - Frank Hamilton
- Department of Neurology, Vivantes Auguste-Viktoria-Klinikum, Berlin, Germany
| | - Martin Honermann
- Department of Neurology, Vivantes Klinikum Spandau, Berlin, Germany
| | - Gerhard Jan Jungehulsing
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany.,Department of Neurology, Jüdisches Krankenhaus Berlin, Germany
| | - Andreas Kauert
- Department of Neurology, Evangelisches Krankenhaus Königin Elisabeth Herzberge, Berlin, Germany
| | | | | | | | - Florian Masuhr
- Department of Neurology, Bundeswehrkrankenhaus Berlin, Germany
| | - Darius Nabavi
- Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Andrea Rocco
- Department of Neurology, Charité - Universitätsmedizin Berlin, Germany
| | - Ingo Schmehl
- Department of Neurology, BG Klinikum Unfallkrankenhaus Berlin, Germany
| | - Bettina Schmitz
- Department of Neurology, Vivantes Humboldt-Klinikum, Berlin, Germany
| | - Paul Sparenberg
- Department of Neurology, BG Klinikum Unfallkrankenhaus Berlin, Germany
| | - Robert Stingele
- Department of Neurology, German Red Cross Hospital Berlin, Köpenick, Germany
| | | | - Enrico Völzke
- Department of Neurology, Schlosspark-Klinik Berlin, Germany
| | - Joanna Dietzel
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany
| | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Germany.,Comprehensive Heart Failure Center, University of Würzburg, Clinical Trial Centre Würzburg, University Hospital Würzburg, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Partner Site, Berlin, Germany.,German Center for Cardiovascular Diseases (DZHK), Partner Site, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
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Evaluación del tratamiento de la fibrilación auricular valvular y no valvular y su relación con eventos adversos en pacientes hospitalizados en el servicio de urgencias de un hospital de tercer nivel. REVISTA COLOMBIANA DE CARDIOLOGÍA 2020. [DOI: 10.1016/j.rccar.2019.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Spence JD, Azarpazhooh MR, Larsson SC, Bogiatzi C, Hankey GJ. Stroke Prevention in Older Adults: Recent Advances. Stroke 2020; 51:3770-3777. [PMID: 33121384 DOI: 10.1161/strokeaha.120.031707] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The risks of stroke and dementia increase steeply with age, and both are preventable. At present, the best way to preserve cognitive function is to prevent stroke. Therapeutic nihilism based on age is common and unwarranted. We address recent advances in stroke prevention that could contribute greatly to prevention of stroke and dementia at a time when the aging of the population threatens to markedly increase the incidence of both. Issues discussed: (1) old patients benefit even more from lipid-lowering therapy than do younger patients; (2) patients with stiff arteries are at risk from a target systolic blood pressure <120 mm Hg; (3) the interaction of the intestinal microbiome, age, and renal function has important dietary implications for older adults; (4) anticoagulation with direct-acting oral anticoagulants should be prescribed more to old patients with atrial fibrillation; (5) B vitamins to lower homocysteine prevent stroke; and (6) most old patients in whom intervention is warranted for carotid stenosis would benefit more from endarterectomy than from stenting. An 80-year-old person has much to lose from a stroke and should not have effective therapy withheld on account of age. Lipid-lowering therapy, a more plant-based diet, appropriate anticoagulation or antiplatelet therapy, appropriate blood pressure control, B vitamins to lower homocysteine, and judicious intervention for carotid stenosis could do much to reduce the growing burden of stroke and dementia.
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Affiliation(s)
- J David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, ON, Canada (J.D.S., M.R.A.)
| | - M Reza Azarpazhooh
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, ON, Canada (J.D.S., M.R.A.)
| | - Susanna C Larsson
- Unit of Nutritional Epidemiology, Karolinska Institutet, Stockholm, Sweden (S.C.L.)
| | - Chrysi Bogiatzi
- Department of Neurology, McMaster University, Hamilton, ON, Canada (C.B.)
| | - Graeme J Hankey
- Department of Neurology, The University of Western Australia, Perth (G.J.H.)
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Andrade JG, Aguilar M, Atzema C, Bell A, Cairns JA, Cheung CC, Cox JL, Dorian P, Gladstone DJ, Healey JS, Khairy P, Leblanc K, McMurtry MS, Mitchell LB, Nair GM, Nattel S, Parkash R, Pilote L, Sandhu RK, Sarrazin JF, Sharma M, Skanes AC, Talajic M, Tsang TSM, Verma A, Verma S, Whitlock R, Wyse DG, Macle L. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2020; 36:1847-1948. [PMID: 33191198 DOI: 10.1016/j.cjca.2020.09.001] [Citation(s) in RCA: 319] [Impact Index Per Article: 79.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/05/2020] [Accepted: 09/05/2020] [Indexed: 12/20/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | - Martin Aguilar
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jafna L Cox
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Paul Khairy
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stanley Nattel
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Jean-François Sarrazin
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Mukul Sharma
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Mario Talajic
- Montreal Heart Institute, University of Montreal, Montréal, Quebec, Canada
| | - Teresa S M Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
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40
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Zhou K, Liu Y, Zhao Z, Wang Y, Huang L, Chai R, Li G, Jiang T. ABCC8 mRNA expression is an independent prognostic factor for glioma and can predict chemosensitivity. Sci Rep 2020; 10:12682. [PMID: 32728190 PMCID: PMC7391768 DOI: 10.1038/s41598-020-69676-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/16/2020] [Indexed: 12/22/2022] Open
Abstract
Glioma is the most common primary intracranial tumor and is associated with very low survival rates. The development of reliable biomarkers can help to elucidate the molecular mechanisms involved in glioma development. Here the expression of ABCC8 mRNA, clinical characteristics, and survival information based on 1893 glioma samples from four independent databases were analyzed. The expression patterns of ABCC8 mRNA were compared by a Chi square test. The overall survival rate of gliomas was evaluated according to the expression level of ABCC8 mRNA. The prognostic value of this marker in gliomas was tested using Cox single factor and multi factor regression analyses. We found patients with low WHO grade, oligodendrocytoma, low molecular grade, IDH mutation, and 1p19q combined deletion had high ABCC8 mRNA expression. The patients with high expression of ABCC8 mRNA had longer survival. ABCC8 mRNA expression was a new independent prognostic index for glioma. Temozolomide chemotherapy was an independent index to prolong overall survival in high ABCC8 mRNA expression glioma patients, whereas in patients with low expression, there was no significant difference. So ABCC8 mRNA expression could be an independent prognostic indicator for glioma patients and could predict the sensitivity of glioma to temozolomide.
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Affiliation(s)
- Kaijia Zhou
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, 100070, China
| | - Yanwei Liu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, 100070, China
| | - Zheng Zhao
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, 100070, China
| | - Yinyuan Wang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, 100070, China
| | - Lijie Huang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, 100070, China
| | - Ruichao Chai
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, 100070, China
| | - Guanzhang Li
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, 100070, China
| | - Tao Jiang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, 100070, China. .,Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China. .,Center of Brain Tumor, Beijing Institute for Brain Disorders, Beijing, 100070, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, 100070, China.
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41
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Toscos T, Drouin M, Pater JA, Flanagan M, Wagner S, Coupe A, Ahmed R, Mirro MJ. Medication adherence for atrial fibrillation patients: triangulating measures from a smart pill bottle, e-prescribing software, and patient communication through the electronic health record. JAMIA Open 2020; 3:233-242. [PMID: 32734164 PMCID: PMC7382621 DOI: 10.1093/jamiaopen/ooaa007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 01/28/2020] [Accepted: 03/23/2020] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Our primary objectives were to examine adherence rates across two technologies (e-prescribing software and smart pill bottle) with cross-validation from alert-triggered messaging within the patient electronic health record (EHR) portal and to explore the benefits and challenges faced by atrial fibrillation (AF) patients in using a smart pill bottle. MATERIALS AND METHODS We triangulated the rate of oral anticoagulant medication adherence among 160 AF patients over 6 months using an EHR in combination with data from the AdhereTech© Wireless Smart Pill Bottle and Surescripts©. In addition, we collected qualitative feedback on patients' Smart Pill Bottle usage through structured interviews with 153 participants. RESULTS Patients maintained an average adherence rate of 90.0% according to the smart pill bottle; however, when dose misses were calibrated based on patient or provider feedback, the adjusted adherence was 93.6%. Surescripts adherence rates for refills were 92.2%. Participants generally found the bottle easy to operate but suggested that its size and functionality did not fit seamlessly into their existing routine, as many used weekly pill organizers to manage multiple medications. DISCUSSION Though each method of tracking adherence has positive and negative attributes, combining them and seeking patient feedback may help capture a more accurate adherence rate than any single technological intervention. Technologies may have different design considerations for research and consumer use. CONCLUSION Overall, these technologies provide useful but imperfect adherence data for research purposes, and smart pill bottles could be improved with patient-centered design. LAY SUMMARY Medication adherence is very important for those with chronic health issues. For those with heart disease, medication adherence not only offers opportunities for improving quality of life, but it also can be life-saving. Nonetheless, many patients with heart disease, including those with atrial fibrillation (the target group for this study) do not take their medications regularly. As technologies advance, there is unprecedented opportunity to track patients' medication adherence through various methods, which might provide motivation and information to patients as they make daily choices about medication use. In this study, we cross-referenced the results of two of these measures over 6 months-a smart pill bottle, which we used to track pill bottle openings, and e-prescribing software, which we used to track medication refills. We also supplemented these measures with nurse-patient communication via the EHR messaging portal to record exceptions (eg, travel and medication changes) and interviewed patients about their medication use during the 6-month trial. Overall, the tracking technologies worked relatively well to track patient (n = 160) medication behavior; however, they did not capture exceptions. Hence, triangulating data from different sources, with a patient feedback loop, appears critical for gathering accurate data on medication adherence.
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Affiliation(s)
- Tammy Toscos
- Health Services and Informatics Research, Parkview Mirro Center for Research and Innovation, Fort Wayne, Indiana, USA
| | - Michelle Drouin
- Health Services and Informatics Research, Parkview Mirro Center for Research and Innovation, Fort Wayne, Indiana, USA
- Psychology Department, Purdue University Fort Wayne, Fort Wayne, Indiana, USA
| | - Jessica A Pater
- Health Services and Informatics Research, Parkview Mirro Center for Research and Innovation, Fort Wayne, Indiana, USA
| | - Mindy Flanagan
- Health Services and Informatics Research, Parkview Mirro Center for Research and Innovation, Fort Wayne, Indiana, USA
| | - Shauna Wagner
- Health Services and Informatics Research, Parkview Mirro Center for Research and Innovation, Fort Wayne, Indiana, USA
| | - Amanda Coupe
- Health Services and Informatics Research, Parkview Mirro Center for Research and Innovation, Fort Wayne, Indiana, USA
| | - Ryan Ahmed
- Health Services and Informatics Research, Parkview Mirro Center for Research and Innovation, Fort Wayne, Indiana, USA
| | - Michael J Mirro
- Health Services and Informatics Research, Parkview Mirro Center for Research and Innovation, Fort Wayne, Indiana, USA
- School of Informatics, Indiana University, Indianapolis, Indiana, USA
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He J, Fu Z, Yang L, Liu W, Tian Y, Liu Q, Jiang Z, Tian L, Huang J, Tian S, Zhao Y. The predictive value of a concise classification of left atrial appendage morphology to thrombosis in non-valvular atrial fibrillation patients. Clin Cardiol 2020; 43:789-795. [PMID: 32406558 PMCID: PMC7368353 DOI: 10.1002/clc.23381] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 03/28/2020] [Accepted: 04/22/2020] [Indexed: 01/08/2023] Open
Abstract
Background The complexity of left atrial appendage (LAA) in patients with nonvalvular atrial fibrillation (NVAF) is closely related to LAA thrombosis and stroke incidence. But the classification of LAA morphology is not uniform and controversial. Hypothesis This study divided the LAA into two categories according to the LAA morphology to investigate the risk of thrombosis related to the LAA structural complexity in NVAF patients. Methods A total of 336 NVAF patients were enrolled continuously in this study. The patients were divided into thrombosis group and non‐thrombosis group according to whether the thrombus presence in LAA. Through computer LAA three‐dimensional reconstruction, LAA morphology was divided into the complex type and simple type according to with or without the clearly lobulated structure judged by imaging experts. The relationship between LAA thrombosis and various potential risk factors was analyzed. Results A total of 19 potential risk factors for LAA thrombosis in NVAF patients were enrolled into statistical analysis. The coincidence rate of LAA morphology classification was 96.4% (324/336) between two imaging experts. Multivariate logistic regression analysis showed that complex LAA morphology (OR 4.168, 95% CI 1.871‐9.288, P < .001) was associated with the presence of LAA thrombus, independently of other enrolled risks. Conclusions It is a concise and reliable method to divide the LAA morphology into complex type and simple type according to whether with the clearly lobulated structure. The complex LAA is an independent risk factor for LAA thrombosis in NVAF patients.
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Affiliation(s)
- Jionghong He
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China
| | - Zenan Fu
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China.,Department of Respiratory, The Third Affiliated Hospital of Zunyi Medical University, Zunyi City, Guizhou Province, China
| | - Long Yang
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China
| | - Wei Liu
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China
| | - Ye Tian
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China
| | - Qifang Liu
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China
| | - Zhi Jiang
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China
| | - Longhai Tian
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China
| | - Jing Huang
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China
| | - Shui Tian
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China
| | - Yidong Zhao
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang City, China
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Kapoor A, Amroze A, Vakil F, Crawford S, Der J, Mathew J, Alper E, Yogaratnam D, Javed S, Elhag R, Lin A, Narayanan S, Bartlett D, Nagy A, Shagoury BK, Fischer MA, Mazor KM, Saczynski JS, Ashburner JM, Lopes R, McManus DD. SUPPORT-AF II: Supporting Use of Anticoagulants Through Provider Profiling of Oral Anticoagulant Therapy for Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2020; 13:e005871. [DOI: 10.1161/circoutcomes.119.005871] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Previous provider-directed electronic messaging interventions have not by themselves improved anticoagulation use in patients with atrial fibrillation. Direct engagement with providers using academic detailing coupled with electronic messaging may overcome the limitations of the prior interventions.
Methods and Results:
We randomized outpatient providers affiliated with our health system in a 2.5:1 ratio to our electronic profiling/messaging combined with academic detailing intervention. In the intervention, we emailed providers monthly reports of their anticoagulation percentage relative to peers for atrial fibrillation patients with elevated stroke risk (CHA
2
DS
2
-VASc ≥2). We also sent electronic medical record-based messages shortly before an appointment with an anticoagulation-eligible but untreated atrial fibrillation patient. Providers had the option to send responses with explanations for prescribing decisions. We also offered to meet with intervention providers using an academic detailing approach developed based on knowledge gaps discussed in provider focus groups. To assess feasibility, we tracked provider review of our messages. To assess effectiveness, we measured the change in anticoagulation for patients of intervention providers relative to controls. We identified 85 intervention and 34 control providers taking care of 3591 and 1908 patients, respectively; 33 intervention providers participated in academic detailing. More than 80% of intervention providers read our emails, and 98% of the time a provider reviewed our in-basket messages. Replies to messages identified patient refusal as the most common reason for patients not being on anticoagulation (11.2%). For the group of patients not on anticoagulation at baseline assigned to an intervention versus control provider, the adjusted percent increase in the use of anticoagulation over 6 months was 5.2% versus 7.4%, respectively (
P
=0.21).
Conclusions:
Our electronic messaging and academic detailing intervention was feasible but did not increase anticoagulation use. Patient-directed interventions or provider interventions targeting patients declining anticoagulation may be necessary to raise the rate of anticoagulation.
Clinical Trial Registration
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT03583008.
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Affiliation(s)
- Alok Kapoor
- University of Massachusetts Memorial Health Care, Worcester (A.K., A.A, E.A., R.E., D.D.M.)
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester (A.K., A.A., K.M.M., D.D.M.)
| | - Azraa Amroze
- University of Massachusetts Memorial Health Care, Worcester (A.K., A.A, E.A., R.E., D.D.M.)
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester (A.K., A.A., K.M.M., D.D.M.)
| | - Fatima Vakil
- Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH (F.V.)
| | - Sybil Crawford
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | | | - Jomol Mathew
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Eric Alper
- University of Massachusetts Memorial Health Care, Worcester (A.K., A.A, E.A., R.E., D.D.M.)
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Dinesh Yogaratnam
- Mass College of Pharmacy and Health Sciences, Worcester, MA (D.Y., D.B.)
| | - Saud Javed
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Rasha Elhag
- University of Massachusetts Memorial Health Care, Worcester (A.K., A.A, E.A., R.E., D.D.M.)
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Abraham Lin
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Siddhartha Narayanan
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Donna Bartlett
- Mass College of Pharmacy and Health Sciences, Worcester, MA (D.Y., D.B.)
| | - Ahmed Nagy
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Bevin Kathleen Shagoury
- The National Resource Center for Academic Detailing, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA (B.K.S., M.A.F.)
| | - Michael A. Fischer
- The National Resource Center for Academic Detailing, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA (B.K.S., M.A.F.)
| | - Kathleen M. Mazor
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester (A.K., A.A., K.M.M., D.D.M.)
| | - Jane S. Saczynski
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
- Northeastern University, Boston, MA (J.D., J.S.S.)
| | - Jeffrey M. Ashburner
- Division of General Internal Medicine, Massachusetts General Hospital, Boston (J.M.A.)
| | - Renato Lopes
- Duke Clinical Research Institute, Durham, NC (R.L.)
| | - David D. McManus
- University of Massachusetts Memorial Health Care, Worcester (A.K., A.A, E.A., R.E., D.D.M.)
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester (A.K., A.A., K.M.M., D.D.M.)
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Kapoor A, Foley G, Zhang N, Zhou Y, Crawford S, McManus D, Gurwitz J. Geriatric Conditions Predict Discontinuation of Anticoagulation in Long-Term Care Residents With Atrial Fibrillation. J Am Geriatr Soc 2020; 68:717-724. [PMID: 31967319 DOI: 10.1111/jgs.16335] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 12/25/2019] [Accepted: 12/27/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Anticoagulation (AC) for stroke prevention in long-term care (LTC) residents with atrial fibrillation (AF) involves a challenging risk-benefit evaluation. We measured the association of geriatric conditions with discontinuation of AC. DESIGN Retrospective cohort analysis. SETTING LTC facilities across the United States. PARTICIPANTS A total of 48 545 individuals residing in LTC facilities in 2015 with AF and sufficient information to establish their status as someone who stopped AC vs someone who continued AC. MEASUREMENTS We measured the association of six geriatric conditions-recent fall, severe activity of daily living (ADL) dependency (21-28 on a 28-point scale), mobility impairment, cognitive impairment, body mass index (BMI) less than 18.5 kg/m2 , and weight loss (≥5% in 1 month or ≥10% in 6 months)-with discontinuation of AC. To identify cases of discontinuation, we required a pattern of being on AC over two consecutive recordings of the Minimum Data Set, the nursing home quality control data set recorded every 90 days, followed by two assessments being off AC-pattern of "on-on-off-off." By contrast, we required a pattern of "on-on-on-on" for continuers. We then constructed six logistic regression models to measure the independent association between each geriatric condition and discontinuation of AC, adjusted for CHA2 DS2 -VASc stroke risk score, recent bleeding hospitalization, and other confounders. RESULTS There were 4172 discontinuers and 44 373 continuers. Recent fall predicted a 1.9-fold increase in the odds of discontinuation (odds ratio = 1.91; 95% confidence interval = 1.66-2.20), whereas mobility and cognitive impairment only increased the odds by 14% to 17%. Severe ADL dependency, BMI less than 18.5 kg/m2 , and weight loss of 10% each increased odds of discontinuation by 55% to 68%. CHA2 DS2 -VASc score did not predict discontinuation. CONCLUSION Several geriatric conditions predicted discontinuation of AC, whereas CHA2 DS2 -VASc score did not. Future research should examine the association of geriatric conditions and discontinuation of warfarin discrete from newer anticoagulants and association of geriatric conditions with development of stroke and bleeding. J Am Geriatr Soc 68:717-724, 2020.
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Affiliation(s)
- Alok Kapoor
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts.,University of Massachusetts Medical School, Worcester, Massachusetts
| | - Gray Foley
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts
| | - Ning Zhang
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts.,Department of Health Policy and Promotion, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts
| | - Yanhua Zhou
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts
| | - Sybil Crawford
- University of Massachusetts Medical School, Worcester, Massachusetts
| | - David McManus
- University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jerry Gurwitz
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts
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Brachmann J, Lewalter T, Akin I, Sievert H, Geist V, Zeymer U, Erkapic D, Mudra H, Pleger S, Hochadel M, Senges J. Interventional occlusion of left atrial appendage in patients with atrial fibrillation. Acute and long-term outcome of occluder implantation in the LAARGE Registry. J Interv Card Electrophysiol 2019; 58:273-280. [PMID: 31707534 DOI: 10.1007/s10840-019-00635-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 09/25/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Left atrial appendage occluder (LAAO) implantation is an alternative method for stroke prevention in atrial fibrillation (AF) patients who are not eligible for long-term oral anticoagulation. The present paper describes the acute and 1-year follow-up outcome data of the prospective, multicenter German left atrial appendage occlusion registry (LAARGE). METHODS LAARGE enrolled 641 patients who were scheduled for LAAO implantation. The data collected included demographics, clinical characteristics, procedure indication, details of implantation, and outcome; patients were followed at 1-year post-implant. Efficacy and safety during follow-up are assessed by the occurrence of thrombembolic and bleeding events, respectively. RESULTS A total of 641 consecutive patients (mean age: 75.9 ± 8.0) were enrolled from July 2014 to January 2016 in 38 hospitals in Germany. Patient demographics represent a critically-ill population with a calculated mean CHA2DS2-VASc score and HASBLED score of 4.5 and 3.9, respectively, with bleeding events as the main indication for LAAO implantation (79.4%). One-year all-cause mortality post-procedure was 11.5% with a non-fatal stroke/TIA rate of 1.3% (8 patients) and a rate of major bleeding of 1.6% (10 patients). The anticoagulation regimen after 1 year consisted of oral anticoagulation in 5.5% of patients and an antiplatelet therapy (APT) rate of 84.1% (majority single APT with ASS (74.5%), dual APT in 6.7%). CONCLUSIONS LAARGE, a prospective multicenter real-world and all-comer registry, is unique in its concept, as it is non-manufacturer sponsored and includes all commercially available devices. LAAO implantation is mainly performed in elderly, critically-ill patients with a history of bleeding. LAARGE demonstrates a favorable outcome at 1-year follow-up in terms of stroke/TIA (1.3%) and major bleeding (1.6%) while using a single APT in the vast majority of patients.
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Affiliation(s)
| | - Thorsten Lewalter
- Department of Cardiology and Intensive Care, Peter Osypka Heart Center Munich, Hospital for Internal Medicine Munich South, Am Isarkanal 36, 81379, Munich, Germany.
| | - Ibrahim Akin
- Department of Cardiology, University Hospital Mannheim, Mannheim, Germany
| | - Horst Sievert
- Department of Cardiology, Katharinenhospital Frankfurt, Frankfurt, Germany
| | - Volker Geist
- Department of Cardiology, Klinkum Bad Segeberg, Bad Segeberg, Germany
| | - Uwe Zeymer
- Department of Cardiology, Klinikum Ludwigshafen, Ludwigshafen, Germany.,Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Damir Erkapic
- Department of Cardiology, University Hospital Giessen, Giessen, Germany
| | - Harald Mudra
- Department of Cardiology, Klinikum Neuperlach, Munich, Germany
| | - Sven Pleger
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Jochen Senges
- Institut für Herzinfarktforschung, Ludwigshafen, Germany
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Boehme C, Toell T, Mayer L, Domig L, Pechlaner R, Willeit K, Tschiderer L, Seekircher L, Willeit P, Griesmacher A, Knoflach M, Willeit J, Kiechl S. The dimension of preventable stroke in a large representative patient cohort. Neurology 2019; 93:e2121-e2132. [DOI: 10.1212/wnl.0000000000008573] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 07/22/2019] [Indexed: 01/03/2023] Open
Abstract
ObjectiveTo analyze the frequency of inadequately treated risk factors in a large representative cohort of patients with acute ischemic stroke or TIA and to estimate the proportion of events potentially avertable by guideline-compliant preventive therapy compared to the status quo.MethodsA total of 1,730 patients from the Poststroke Disease Management STROKE-CARD trial (NCT02156778) were recruited between 2014 and 2017. We focused on 8 risk conditions amenable to drug therapy and 3 lifestyle risk behaviors and assessed pre-event risk factor control in retrospect.ResultsThe proportion of patients with at least 1 inadequately treated risk condition was 79.5% (95% confidence interval [CI] 77.6%–81.4%) and increased to 95.1% (95% CI 94.1%–96.1%) upon consideration of the lifestyle risk behaviors. Risk factor control was worse in patients with recurrent vs first-ever events (p < 0.001), men vs women (p = 0.003), and patients ≤75 vs >75 years of age (p < 0.001). The estimated degree of stroke preventability ranged from 0.4% (95% CI 0.2%–0.6%) to 13.7% (95% CI 12.2%–15.2%) for the individual risk factors. Adequate control of the 5 most relevant risk factors combined (hypertension, hypercholesterolemia, atrial fibrillation, smoking, and overweight) would have averted ≈1 of 2 events or 1 in 4 with a highly conservative computation approach.ConclusionsOur study confirms the existence of a considerable gap between risk factor control recommended by guidelines and real-world stroke prevention. Our study intends to increase awareness among physicians about stroke preventability and provides a quantitative basis for the emerging discussion on how to best tackle this challenge.
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47
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Healthcare resource utilization and costs among patients with direct oral anticoagulant or warfarin-related major bleeding. Thromb Res 2019; 182:12-19. [DOI: 10.1016/j.thromres.2019.07.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 07/11/2019] [Accepted: 07/31/2019] [Indexed: 01/19/2023]
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48
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Seelig J, Pisters R, Hemels ME, Huisman MV, Ten Cate H, Alings M. When to withhold oral anticoagulation in atrial fibrillation - an overview of frequent clinical discussion topics. Vasc Health Risk Manag 2019; 15:399-408. [PMID: 31571891 PMCID: PMC6755244 DOI: 10.2147/vhrm.s187656] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 08/28/2019] [Indexed: 12/14/2022] Open
Abstract
Stroke prevention with oral anticoagulants in patients with atrial fibrillation predisposes for bleeding. As a result, in select patient groups anticoagulation is withheld because of a perceived unfavorable risk-benefit ratio. Reasons for withholding anticoagulation can vary greatly between clinicians, often leading to discussion in daily clinical practice on the best approach. To guide clinical decision-making, we have reviewed available evidence on the most frequently reported reasons for withholding anticoagulation: previous bleeding, frailty and age, and an overall high bleeding risk.
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Affiliation(s)
- Jaap Seelig
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Ron Pisters
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Martin E Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands.,Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Hugo Ten Cate
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.,Anticoagulation Clinic Maastricht, Maastricht, The Netherlands
| | - Marco Alings
- Department of Cardiology, Amphia Hospital, Breda, The Netherlands
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Amroze A, Mazor K, Crawford S, O’Day K, McManus DD, Kapoor A. Survey of confidence in use of stroke and bleeding risk calculators, knowledge of anticoagulants, and comfort with prescription of anticoagulation in challenging scenarios: SUPPORT-AF II study. J Thromb Thrombolysis 2019; 48:629-637. [DOI: 10.1007/s11239-019-01950-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Fastner C, Nienaber CA, Park JW, Brachmann J, Zeymer U, Goedde M, Sievert H, Geist V, Lewalter T, Krapivsky A, Käunicke M, Maier J, Özdemir B, Hochadel M, Schneider S, Senges J, Akin I. Impact of left atrial appendage morphology on indication and procedural outcome after interventional occlusion: results from the prospective multicentre German LAARGE registry. EUROINTERVENTION 2019; 14:151-157. [PMID: 29508766 DOI: 10.4244/eij-d-17-00866] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Interventional left atrial appendage closure (LAAC) is an emerging alternative to oral anticoagulation (OAC) for stroke prevention in atrial fibrillation (AF) in concomitance with a contraindication for standard OAC. This sub-analysis of the LAARGE registry aimed to investigate differences between different LAA morphologies in a real-world setting. METHODS AND RESULTS This prospective, multicentre, observational registry included 562 patients from 37 centres with ineligibility for long-term OAC between April 2014 and January 2016. Baseline characteristics, indications, procedural data and complications were registered according to each LAA morphology (i.e., chicken wing, cauliflower, windsock, cactus and atypical morphologies). Implantation success was high across the four typical anatomies (≥97.5%, p=n.s.); only atypical anatomies exhibited a lower success rate (94%). The cactus-shaped LAA was linked to a trend indicating a shorter fluoroscopy time, while the atypical LAA was linked to a significantly prolonged fluoroscopy time (p=0.089 and p=0.025 versus the overall mean, respectively). Periprocedural and intra-hospital complications were generally rare, with no differences among the different morphologies (p=n.s.). CONCLUSIONS Procedural success as well as the complication rates of LAAC were not different among the four typical LAA morphologies. A lower implantation success rate was only obvious in patients with atypical LAA morphologies.
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Affiliation(s)
- Christian Fastner
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site Heidelberg/Mannheim, University of Heidelberg, Mannheim, Germany
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