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Franc D, Sanak D, Kral M, Hutyra M, Taborsky M, Divisova P, Zapletalova J. Impact of prior oral anticoagulation on admission stroke severity in patients with atrial fibrillation. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2024. [PMID: 39023063 DOI: 10.5507/bp.2024.024] [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: 07/20/2024] Open
Abstract
BACKGROUND AND AIMS In patients with atrial fibrillation, oral anticoagulation therapy is indicated for both primary and secondary prevention of stroke/systemic embolism. Though direct oral anticoagulants with greater safety and efficacy than warfarin were introduced into clinical practice at the beginning of the last decade, even now not all patients with AF have adequate preventative anticoagulant treatment. The primary goal of this study was to evaluate the impact of prior use of oral anticoagulants on admission stroke severity in those with AF. Other aims were, inter alia, to assess the trend in atrial fibrillation prevalence in the years of the HISTORY trials 2012-2021 carried out in the Czech Republic and use of oral anticoagulants (OAC) in ischemic stroke (IS) patients. METHODS We analyzed consecutive ischemic stroke patients who had been enrolled in the HISTORY (Heart and Ischemic STrOke Relationship studY) study registered on ClinicalTrials.gov (identifier NCT01541163) in the year 2012 and carried out a yearly comparison (detailed in the text). RESULTS In total, there were 1059 patients (55.9% males, mean age 71.7±12.8). There was no significant difference over the time period in rate of known (18.3 vs. 16.5%, P=0.442) or newly detected AF (17.0 vs. 16.0%, P=0.665), but sigificantly more patients with known AF were treated with oral anticoagulants before IS in the year 2021 (32.1 vs. 70.7%, P<0.0001), and direct oral anticoagulants (3.6 vs. 35.4%, P<0.0001). The number of patients with atrial fibrillation had not changed significantly over the years (26.2 vs. 31.3%). Patients on OAC had a lower median admission score on the National Institutes of Health Stroke Scale (NIHSS) than those not using an oral anticoagulant (6 vs. 16, P=0.0004) in 2021. CONCLUSIONS There was no significant upward trend in atrial fibrillation in stroke patients admitted between 2012 and 2021, but patients with known AF were significantly more frequently treated with oral anticoagulants and direct oral anticoagulants (DOAC) in 2021. Patients on OAC had lower admission NIHSS scores than those not using any anticoagulent in the year 2021. The difference in the median admission NIHSS between the patients on OAC and those without OAC treatment was not significant in the year 2012 (6 vs. 12, P=0.066). This might be related to the fact that substantially fewer patients in 2012 were on DOACs, which are considered more effective than warfarin.
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Affiliation(s)
- David Franc
- Comprehensive Stroke Centre, Department of Neurology, Faculty of Medicine and Dentristry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Daniel Sanak
- Comprehensive Stroke Centre, Department of Neurology, Faculty of Medicine and Dentristry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Michal Kral
- Comprehensive Stroke Centre, Department of Neurology, Faculty of Medicine and Dentristry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Martin Hutyra
- Department of Cardiology, Faculty of Medicine and Dentristry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Milos Taborsky
- Department of Cardiology, Faculty of Medicine and Dentristry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Petra Divisova
- Comprehensive Stroke Centre, Department of Neurology, Faculty of Medicine and Dentristry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Jana Zapletalova
- Department of Biophysics and Statistics, Faculty of Medicine and Dentristry, Palacky University Olomouc, Olomouc, Czech Republic
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Lilja M, Leaback R, Banefelt J, Park TJ, Shah D, Ferguson WG, Friberg Ö. Postoperative atrial fibrillation is associated with long-term morbidity and mortality in older adults: Analysis from the SWEDEHEART Registry. JTCVS OPEN 2024; 19:116-130. [PMID: 39015455 PMCID: PMC11247231 DOI: 10.1016/j.xjon.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 02/13/2024] [Accepted: 03/04/2024] [Indexed: 07/18/2024]
Abstract
Objectives Postoperative atrial fibrillation (POAF) is the most common perioperative arrhythmia. The association of POAF with negative short-term outcomes after cardiac surgery is well understood; however, the association of POAF with long-term morbidity and mortality is not well described. We compared the risk of long-term clinical outcomes (up to 9 years postdischarge) in patients with and without POAF following open-chest cardiac surgery. Methods This observational, retrospective cohort study used data from the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART) Swedish Cardiac Surgery Registry and National Board of Health and Welfare. Patients aged 55 to 90 years who underwent open-chest coronary artery bypass and/or valvular surgery between 2010 and 2019 were included. Clinical outcomes were adjusted for differences in baseline demographics and clinical history using multivariable Cox regression. Results A total of 30,870 patients with a mean age of 69.2 years were included in the study (no POAF, n = 20,734; POAF, n = 10,136). The median follow-up was 4.6 years. After adjustment, POAF was associated with a significantly higher risk of recurrent atrial fibrillation (hazard ratio [HR], 2.30; 95% CI, 2.21-2.41), heart failure (HR, 1.17; 95% CI, 1.10-1.25), chronic kidney disease (HR, 1.15; 95% CI, 1.07-1.24), all-cause mortality (HR, 1.11; 95% CI, 1.04-1.18), and cardiovascular mortality (HR, 1.16; 95% CI, 1.06-1.26). POAF was also associated with a numerically higher risk of ischemic stroke and major bleed, but these findings were not statistically significant after adjustment. Conclusions These data provide further insight into the long-term clinical outcomes associated with POAF in patients undergoing cardiac surgery.
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Affiliation(s)
| | | | | | | | | | | | - Örjan Friberg
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Teppo K, Airaksinen KEJ, Jaakkola J, Halminen O, Salmela B, Kouki E, Haukka J, Putaala J, Linna M, Aro AL, Mustonen P, Hartikainen J, Lip GYH, Lehto M. Ischaemic stroke in women with atrial fibrillation: temporal trends and clinical implications. Eur Heart J 2024; 45:1819-1827. [PMID: 38606837 PMCID: PMC11129795 DOI: 10.1093/eurheartj/ehae198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/19/2024] [Accepted: 03/18/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND AND AIMS Female sex has been linked with higher risk of ischaemic stroke (IS) in atrial fibrillation (AF), but no prior study has examined temporal trends in the IS risk associated with female sex. METHODS The registry-linkage Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study included all patients with AF in Finland from 2007 to 2018. Ischaemic stroke rates and rate ratios were computed. RESULTS Overall, 229 565 patients with new-onset AF were identified (50.0% women; mean age 72.7 years). The crude IS incidence was higher in women than in men across the entire study period (21.1 vs. 14.9 events per 1000 patient-years, P < .001), and the incidence decreased both in men and women. In 2007-08, female sex was independently associated with a 20%-30% higher IS rate in the adjusted analyses, but this association attenuated and became statistically non-significant by the end of the observation period. Similar trends were observed when time with and without oral anticoagulant (OAC) treatment was analysed, as well as when only time without OAC use was considered. The decrease in IS rate was driven by patients with high IS risk, whereas in patients with low or moderate IS risk, female sex was not associated with a higher IS rate. CONCLUSIONS The association between female sex and IS rate has decreased and become non-significant over the course of the study period from 2007 to 2018, suggesting that female sex could be omitted as a factor when estimating expected IS rates and the need for OAC therapy in patients with AF.
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Affiliation(s)
- Konsta Teppo
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Jussi Jaakkola
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Birgitta Salmela
- Department of Internal Medicine, Heart Center, Päijät-Häme Central Hospital, Lahti, Finland
| | - Elis Kouki
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jari Haukka
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jukka Putaala
- Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Miika Linna
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
- Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland
| | - Aapo L Aro
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pirjo Mustonen
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Juha Hartikainen
- Heart Center, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Aalborg, Denmark
| | - Mika Lehto
- Department of Internal Medicine, Jorvi Hospital, HUS Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Polo-García J, Pallares-Carratalá V, Turegano-Yedro M, Romero-Vigara JC, Prieto-Díaz MA, Cinza-Sanjurjo S. [Current situation of direct oral anticoagulants in primary care in Spain: Positioning of SEMERGEN in 2023]. Semergen 2024; 50:102136. [PMID: 38052147 DOI: 10.1016/j.semerg.2023.102136] [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: 10/11/2023] [Accepted: 10/20/2023] [Indexed: 12/07/2023]
Abstract
Oral anticoagulation is the key to reduce the risk of stroke in atrial fibrillation. Although vitaminK antagonists (VKA) have classically been used for this purpose, they have been largely overcome by direct oral anticoagulants (DOAC), as demonstrated by evidence from clinical trials, real-life and population studies. In fact, all clinical practice guidelines recommend their use preferentially over VKA. However, in Spain the prescription of DOAC is subordinated to an inspection visa that includes the clinical conditions defined in the Therapeutic Positioning Report of the Spanish Medicines Agency, and that still imposes important restrictions on their use, limiting the benefits of using DOACs in patients with atrial fibrillation (AF), and also generating inequalities between the different autonomous communities. In fact, the use of DOAC in Spain is much lower than that observed in neighboring countries. This has made that while in other countries the incidence of ischemic stroke has decreased at the population level, along with a reduction in the cost per patient with AF, in Spain this decrease has been modest. For all these reasons, and for assuring the sustainability of the health care system, we ask for the elimination of the visa so that DOAC can be prescribed according to the recommendations made by the guidelines. In addition, we are also committed to reinforce medical education and decisions made by consensus with the patient, with the primary care physician acquiring a key role in the protection of the patient with AF.
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Affiliation(s)
- J Polo-García
- Medicina Familiar y Comunitaria, Centro de Salud Casar de Cáceres, Casar de Cáceres, Cáceres, España
| | - V Pallares-Carratalá
- Medicina Familiar y Comunitaria, Departamento de Medicina, Universidad JaimeI, Castellón, España.
| | - M Turegano-Yedro
- Medicina Familiar y Comunitaria, Centro de Salud Casar de Cáceres, Casar de Cáceres, Cáceres, España
| | - J C Romero-Vigara
- Medicina Familiar y Comunitaria, Centro de Salud Alfajarín, Alfajarín, Zaragoza, España
| | - M A Prieto-Díaz
- Medicina Familiar y Comunitaria, Centro de Salud Vallobín-La Florida, Oviedo, España
| | - S Cinza-Sanjurjo
- Medicina Familiar y Comunitaria, Centro de Salud Milladoiro, Área de Salud de Santiago de Compostela. Instituto de Investigación en Salud de Santiago de Compostela (IDIS). Centro de Investigación Biomédica en Red-Enfermedades Cardiovasculares (CIBERCV), Santiago de Compostela, La Coruña, España
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Loucera C, Carmona R, Bostelmann G, Muñoyerro-Muñiz D, Villegas R, Gonzalez-Manzanares R, Dopazo J, Anguita M. Evidence of the association between increased use of direct oral anticoagulants and a reduction in the rate of atrial fibrillation-related stroke and major bleeding at the population level (2012-2019). Med Clin (Barc) 2024; 162:220-227. [PMID: 37989706 DOI: 10.1016/j.medcli.2023.10.008] [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: 08/07/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND The introduction of direct-acting oral anticoagulants (DOACs) has shown to decrease atrial fibrillation (AF)-related stroke and bleeding rates in clinical studies, but there is no certain evidence about their effects at the population level. Our aim was to assess changes in AF-related stroke and major bleeding rates between 2012 and 2019 in Andalusia (Spain), and the association between DOACs use and events rates at the population level. METHODS All patients with an AF diagnosis from 2012 to 2019 were identified using the Andalusian Health Population Base, that provides clinical information on all Andalusian people. Annual ischemic and hemorrhagic stroke, major bleeding rates, and used antithrombotic treatments were determined. Marginal hazard ratios (HR) were calculated for each treatment. RESULTS A total of 95,085 patients with an AF diagnosis were identified. Mean age was 76.1±10.2 years (49.7% women). An increase in the use of DOACs was observed throughout the study period in both males and females (p<0.001). The annual rate of ischemic stroke decreased by one third, while that of hemorrhagic stroke and major bleeding decreased 2-3-fold from 2012 to 2019. Marginal HR was lower than 0.50 for DOACs compared to VKA for all ischemic or hemorrhagic events. CONCLUSIONS In this contemporary population-based study using clinical and administrative databases in Andalusia, a significant reduction in the incidence of AF-related ischemic and hemorrhagic stroke and major bleeding was observed between 2012 and 2019. The increased use of DOACs seems to be associated with this reduction.
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Affiliation(s)
- Carlos Loucera
- Computational Medicine Platform, Andalusian Public Foundation Progress and Health-FPS, Sevilla, Spain; Institute of Biomedicine of Seville (IBIS), Hospital Virgen del Rocio, Sevilla, Spain
| | - Rosario Carmona
- Computational Medicine Platform, Andalusian Public Foundation Progress and Health-FPS, Sevilla, Spain; Institute of Biomedicine of Seville (IBIS), Hospital Virgen del Rocio, Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), FPS, Hospital Virgen del Rocio, Sevilla, Spain
| | - Gerrit Bostelmann
- Computational Medicine Platform, Andalusian Public Foundation Progress and Health-FPS, Sevilla, Spain
| | - Dolores Muñoyerro-Muñiz
- Subdirección Técnica Asesora de Gestión de la Información, Servicio Andaluz de Salud, Sevilla, Spain
| | - Román Villegas
- Subdirección Técnica Asesora de Gestión de la Información, Servicio Andaluz de Salud, Sevilla, Spain
| | - Rafael Gonzalez-Manzanares
- Department of Cardiology, Hospital Universitario Reina Sofía, Instituto Maimónides para la Investigación Biomédica de Córdoba, Universidad de Córdoba, Córdoba, Spain
| | - Joaquin Dopazo
- Computational Medicine Platform, Andalusian Public Foundation Progress and Health-FPS, Sevilla, Spain; Institute of Biomedicine of Seville (IBIS), Hospital Virgen del Rocio, Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), FPS, Hospital Virgen del Rocio, Sevilla, Spain; FPS/ELIXIR-ES, Fundación Progreso y Salud (FPS), CDCA, Hospital Virgen del Rocio, Sevilla, Spain
| | - Manuel Anguita
- Department of Cardiology, Hospital Universitario Reina Sofía, Instituto Maimónides para la Investigación Biomédica de Córdoba, Universidad de Córdoba, Córdoba, Spain.
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Ishigami A, Toyoda K, Nakai M, Yoshimura S, Wada S, Sasahara Y, Sonoda K, Miwa K, Koge J, Shiozawa M, Iwanaga Y, Miyamoto Y, Nakahara J, Suzuki N, Kobayashi S, Minematsu K, Koga M. Improvement of Functional Outcomes in Patients with Stroke who Received Alteplase for Over 15 Years: Japan Stroke Data Bank. J Atheroscler Thromb 2024; 31:90-99. [PMID: 37587045 PMCID: PMC10776302 DOI: 10.5551/jat.64200] [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: 02/08/2023] [Accepted: 06/12/2023] [Indexed: 08/18/2023] Open
Abstract
AIM The nationwide verification of intravenous thrombolysis (IVT) was rarely performed after the extension of the therapeutic time window of alteplase or after the expansion of mechanical thrombectomy (MT). We aimed to examine the long-term change in accurate real-world outcomes of IVT in patients with acute ischemic stroke (AIS) using the Japan Stroke Databank, a representative Japan-wide stroke database. METHODS We extracted all patients with AIS who received IVT with alteplase between October 11, 2005, the approval date for alteplase use for AIS in Japan, and December 31, 2020. Patients were categorized into three groups using two critical dates in Japan as cutoffs: the official extension date of the therapeutic time window for IVT to within 4.5 h of symptom onset and the publication date of the revised guideline, where the evidence level of MT was heightened. We assessed the yearly trend of IVT implementation rates and the secular changes and three-group changes in clinical outcomes at discharge. RESULTS Of 124,382 patients with AIS, 9,569 (7.7%) received IVT (females, 41%; median age, 75 years). The IVT implementation rate has generally increased over time and plateaued in recent years. The proportion of favorable outcomes (modified Rankin Scale score of 0-2) increased yearly over 15 years. The results of the changes in the outcomes of the three groups were similar to those of the annual changes. CONCLUSIONS We revealed that IVT implementation rates in patients with AIS increased, and the functional outcome in these patients improved over 15 years. Therefore, the Japanese IVT dissemination strategy is considered appropriate and effective.
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Affiliation(s)
- Akiko Ishigami
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shinichi Wada
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yusuke Sasahara
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazutaka Sonoda
- Department of Neurology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Junpei Koge
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshitaka Iwanaga
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshihiro Miyamoto
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Norihiro Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | | | | | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
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Frost L, Joensen AM, Dam-Schmidt U, Qvist I, Brinck M, Brandes A, Davidsen U, Pedersen OD, Damgaard D, Mølgaard I, Bedsted R, Damgaard Møller Schlünsen A, Chousa MG, Andersen J, Pedersen AR, Johnsen SP, Vinter N. The Danish Atrial Fibrillation Registry: A Multidisciplinary National Pragmatic Initiative for Monitoring and Supporting Quality of Care Based on Data Retrieved from Administrative Registries. Clin Epidemiol 2023; 15:1259-1272. [PMID: 38149081 PMCID: PMC10750776 DOI: 10.2147/clep.s443473] [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: 10/06/2023] [Accepted: 12/09/2023] [Indexed: 12/28/2023] Open
Abstract
Aim The Danish Atrial Fibrillation (AF) Registry monitors and supports improvement of quality of care for all AF patients in Denmark. This report describes the registry's administrative and organizational structure, data sources, data flow, data analyses, annual reporting, and feedback between the registry, clinicians, and the administrative system. We also report the selection process of the quality indicators and the temporal trends in results from 2017-2021. Methods and Results The Danish AF Registry aims for complete registration and monitoring of care for all patients diagnosed with AF in Denmark. Administrative registries provide data on contacts to general practice, contacts to private cardiology practice, hospital contacts, medication prescriptions, updated vital status information, and biochemical test results. The Danish Stroke Registry provides information on stroke events. From 2017 to 2021, the proportion with a reported echocardiography among incident AF patients increased from 39.9% (95% CI: 39.3-40.6) to 82.6% (95% CI: 82.1-83.1). The initiation of oral anticoagulant therapy among patients with incident AF and a CHA2DS2-VASc score of ≥1 in men and ≥2 in women increased from 85.3% (95% CI: 84.6-85.9) to 90.4% (95% CI: 89.9-91.0). The 1-year and 2-year persistence increased from 85.2% (95% CI: 84.5-85.9) to 88.7% (95% CI: 88.0-89.3), and from 85.4% (95% CI: 84.7-86.2) to 88.2% (95% CI: 87.5-88.8), respectively. The 1-year risk of ischemic stroke among prevalent patients with AF decreased from 0.88% (95% CI: 0.83-0.93) to 0.71% (95% CI: 0.66-0.75). Variation in clinical performance between the five administrative Danish regions was reduced. Conclusion Continuous nationwide monitoring of quality indicators for AF originating from administrative registries is feasible and supportive of improvements of quality of care.
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Affiliation(s)
- Lars Frost
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Ulla Dam-Schmidt
- Department of Cardiology, Bispebjerg Hospital, Copenhagen University Hospitals, Copenhagen, Denmark
| | - Ina Qvist
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Margit Brinck
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Axel Brandes
- Department of Cardiology, Esbjerg Hospital – University Hospital of Southern Denmark, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Ulla Davidsen
- Department of Cardiology, Bispebjerg Hospital, Copenhagen University Hospitals, Copenhagen, Denmark
| | - Ole Dyg Pedersen
- Department of Cardiology, Zealand University Hospital, Roskilde, Denmark
| | - Dorte Damgaard
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Inge Mølgaard
- Patient Representative, Aalborg and Roskilde, Denmark
| | | | | | - Miriam Grijota Chousa
- The Danish Clinical Quality Program – National Clinical Registries (RKKP), Aarhus, Denmark
| | - Julie Andersen
- The Danish Clinical Quality Program – National Clinical Registries (RKKP), Aarhus, Denmark
| | | | - Søren Paaske Johnsen
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Nicklas Vinter
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Attelind S, Eriksson N, Sundström A, Wadelius M, Hallberg P. Identification of risk factors for adverse drug reactions in a pharmacovigilance database. Pharmacoepidemiol Drug Saf 2023; 32:1431-1438. [PMID: 37580910 DOI: 10.1002/pds.5679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/11/2023] [Accepted: 08/02/2023] [Indexed: 08/16/2023]
Abstract
INTRODUCTION In addition to identifying new safety signals, pharmacovigilance databases could be used to identify potential risk factors for adverse drug reactions (ADRs). OBJECTIVE To evaluate whether data mining in a pharmacovigilance database can be used to identify known and possible novel risk factors for ADRs, for use in pharmacovigilance practice. METHOD Exploratory data mining was performed within the Swedish national database of spontaneously reported ADRs. Bleeding associated with direct oral anticoagulants (DOACs)-rivaroxaban, apixaban, edoxaban, and dabigatran-was used as a test model. We compared demographics, drug treatment, and clinical features between cases with bleeding (N = 965) and controls who had experienced other serious ADRs to DOACs (N = 511). Statistical analysis was performed by unadjusted and age adjusted logistic regression models, and the random forest based machine-learning method Boruta. RESULTS In the logistic regression, 13 factors were significantly more common among cases of bleeding compared with controls. Eleven were labelled or previously proposed risk factors. Cardiac arrhythmia (e.g., atrial fibrillation), hypertension, mental impairment disorders (e.g., dementia), renal and urinary tract procedures, gastrointestinal ulceration and perforation, and interacting drugs remained significant after adjustment for age. In the Boruta analysis, high age, arrhythmia, hypertension, cardiac failure, thromboembolism, and pharmacodynamically interacting drugs had a larger than random association with the outcome. High age, cardiac arrhythmia, hypertension, cardiac failure, and pharmacodynamically interacting drugs had odds ratios for bleeding above one, while thromboembolism had an odds ratio below one. CONCLUSIONS We demonstrated that data mining within a pharmacovigilance database identifies known risk factors for DOAC bleeding, and potential risk factors such as dementia and atrial fibrillation. We propose that the method could be used in pharmacovigilance for identification of potential ADR risk factors that merit further evaluation.
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Affiliation(s)
- Sofia Attelind
- Department of Medical Sciences, Clinical Pharmacogenomics, Uppsala University, Uppsala, Sweden
- Department of Drug Safety, Swedish Medical Products Agency, Uppsala, Sweden
| | - Niclas Eriksson
- Department of Medical Sciences, Clinical Pharmacogenomics, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University Hospital, Uppsala, Sweden
| | - Anders Sundström
- Department of Drug Safety, Swedish Medical Products Agency, Uppsala, Sweden
| | - Mia Wadelius
- Department of Medical Sciences, Clinical Pharmacogenomics, Uppsala University, Uppsala, Sweden
| | - Pär Hallberg
- Department of Medical Sciences, Clinical Pharmacogenomics, Uppsala University, Uppsala, Sweden
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Teppo K, Airaksinen KEJ, Jaakkola J, Halminen O, Linna M, Haukka J, Putaala J, Mustonen P, Kinnunen J, Hartikainen J, Aro AL, Lehto M. Trends in treatment and outcomes of atrial fibrillation during 2007-17 in Finland. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2023; 9:673-679. [PMID: 36542420 PMCID: PMC10627815 DOI: 10.1093/ehjqcco/qcac086] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 11/08/2023]
Abstract
AIMS Guidelines on the management of atrial fibrillation (AF) have evolved significantly during the past two decades, but the concurrent developments in real-life management and prognosis of AF are unknown. We assessed trends in the treatment and outcomes of patients with incident AF between 2007 and 2017. METHODS AND RESULTS The registry-based nationwide FinACAF (Finnish AntiCoagulation in Atrial Fibrillation) cohort covers all patients with AF in Finland from all levels of care. We determined the proportion of patients who were treated with oral anticoagulants (OACs) or rhythm control therapies, experienced an ischaemic stroke or bleeding event requiring hospitalization, or died within 1-year follow-up after AF diagnosis. We identified 206 909 patients (mean age 72.6 years) with incident AF. During the study period, use of OACs increased from 43.6 to 76.3%, and the increase was most evident in patients with at least moderate stroke risk. One-year mortality decreased from 13.3 to 10.6%, and the ischaemic stroke rate from 5.3 to 2.2%. The prognosis especially improved in patients over 75 years of age. Concurrently, a small increase in major bleeding events was observed. Use of catheter ablation increased continuously over the study period, but use of other rhythm-control therapies decreased after 2013. CONCLUSION Stroke prevention with OACs in patients with incident AF improved considerably from 2007 to 2017 in Finland. This development was accompanied by decreasing 1-year mortality and the reduction of the ischaemic stroke rate by more than half, particularly among elderly patients, whereas there was only slight increase in severe bleeding events.
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Affiliation(s)
- Konsta Teppo
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Jussi Jaakkola
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, EspooFinland
| | - Miika Linna
- Department of Industrial Engineering and Management, Aalto University, EspooFinland
- University of Eastern Finland, Kuopio, Finland
| | | | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | - Pirjo Mustonen
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Janne Kinnunen
- Department of Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | - Juha Hartikainen
- University of Eastern Finland, Kuopio, Finland
- Heart Centre, Kuopio University Hospital, Kuopio, Finland
| | - Aapo L Aro
- Heart and Lung Centre, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mika Lehto
- Heart and Lung Centre, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Jorvi Hospital, Department of Internal Medicine, Helsinki and Uusimaa Hospital District, Espoo, Finland
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10
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Komen JJ, Hunt NB, Pottegård A, Hjemdahl P, Wettermark B, Olesen M, Bennie M, Mueller T, Carragher R, Karlstad Ø, Kjerpeseth LJ, Klungel OH, Forslund T. Heterogeneity after harmonisation: A retrospective cohort study of bleeding and stroke risk after the introduction of direct oral anticoagulants in four Western European countries. Pharmacoepidemiol Drug Saf 2023; 32:1223-1232. [PMID: 37280706 DOI: 10.1002/pds.5650] [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: 03/08/2023] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 06/08/2023]
Abstract
PURPOSE Database heterogeneity can impact effect estimates. Harmonisation provided by common protocols and common data models (CDMs) can increase the validity of pharmacoepidemiologic research. In a case study measuring the changes in the safety and effectiveness of stroke prevention therapy after the introduction of direct oral anticoagulants (DOACs), we performed an international comparison. METHODS Using data from Stockholm, Denmark, Scotland and Norway, harmonised with a common protocol and CDM, two calendar-based cohorts were created: 2012 and 2017. Patients with a diagnosis code of atrial fibrillation 5 years preceding the 1-year cohort window were included. DOAC, vitamin K antagonist and aspirin treatment were assessed in the 6 months prior to the start of each year while strokes and bleeds were assessed during the year. A Poisson regression generated incidence rate ratios (IRRs) to compare outcomes from 2017 to 2012 adjusted for changes in individual-level baseline characteristics. RESULTS In 280 359 patients in the 2012 cohort and 356 779 in the 2017 cohort, treatment with OACs increased on average from 45% to 65%, while treatment with aspirin decreased from 30% to 10%. In all countries except Scotland, there were decreases in the risk of stroke and no changes in bleeding risk, after adjustment for changes in baseline characteristics. In Scotland, major bleeding (IRR 1.09, 95% confidence interval [CI] [1.00; 1.18]) and intracranial haemorrhage (IRR 1.31, 95% CI [1.13; 1.52]) increased from 2012 to 2017. CONCLUSIONS Stroke prevention therapy improved from 2012 to 2017 with a corresponding reduction in stroke risk without increasing the risk of bleeding in all countries, except Scotland. The heterogeneity that remains after methodological harmonisation can be informative of the underlying population and database.
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Affiliation(s)
- J J Komen
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
- Department of Healthcare Development, Stockholm Region, Public Healthcare Services Committee, Stockholm, Sweden
| | - N B Hunt
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | - A Pottegård
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - P Hjemdahl
- Department of Medicine Solna, Clinical Epidemiology/Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - B Wettermark
- Department of Pharmacy, Pharmacoepidemiology & Social Pharmacy, Uppsala University, Uppsala, Sweden
| | - M Olesen
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - M Bennie
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
- Public Health Scotland, Edinburgh, UK
| | - T Mueller
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - R Carragher
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland
| | - Ø Karlstad
- Department of Chronic Diseases and Ageing, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - L J Kjerpeseth
- Department of Chronic Diseases and Ageing, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - O H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - T Forslund
- Department of Healthcare Development, Stockholm Region, Public Healthcare Services Committee, Stockholm, Sweden
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11
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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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12
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Shiozawa M, Koga M, Inoue H, Yamashita T, Yasaka M, Suzuki S, Akao M, Atarashi H, Ikeda T, Okumura K, Koretsune Y, Shimizu W, Tsutsui H, Hirayama A, Nakahara J, Teramukai S, Kimura T, Morishima Y, Takita A, Yamaguchi T, Toyoda K. Risk of both intracranial hemorrhage and ischemic stroke in elderly individuals with nonvalvular atrial fibrillation taking direct oral anticoagulants compared with warfarin: Analysis of the ANAFIE registry. Int J Stroke 2023; 18:986-995. [PMID: 37154598 PMCID: PMC10507992 DOI: 10.1177/17474930231175807] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/21/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND AND AIMS Elderly patients with nonvalvular atrial fibrillation (NVAF) might have a higher risk of intracerebral hemorrhage. To investigate this, we compared the incidence of intracranial hemorrhage (ICH) and its subtypes, as well as ischemic stroke, in patients taking direct oral anticoagulants (DOACs) compared with warfarin in a real-world setting. We also determined the baseline characteristics associated with both ICH and ischemic stroke. METHODS Patients aged ⩾ 75 years with documented NVAF enrolled in the prospective, multicenter, observational All Nippon Atrial Fibrillation in the Elderly Registry between October 2016 and January 2018 were evaluated. The co-primary endpoints were the incidence of ischemic stroke and ICH. Secondary endpoints included subtypes of ICH. RESULTS Of 32,275 patients (13,793 women; median age, 81.0 years) analyzed, 21,585 (66.9%) were taking DOACs and 8233 (25.5%) were taking warfarin. During the median 1.88-year follow-up, 743 patients (1.24/100 person-years) developed ischemic stroke and 453 (0.75/100 person-years) developed ICH (intracerebral hemorrhage, 189; subarachnoid hemorrhage, 72; subdural/epidural hemorrhage, 190; unknown subtype, 2). The incidence of ischemic stroke (adjusted hazard ratio (aHR) 0.82, 95% confidence interval (CI) 0.70-0.97), ICH (aHR 0.68, 95% CI 0.55-0.83), and subdural/epidural hemorrhage (aHR 0.53, 95% CI 0.39-0.72) was lower in DOAC users versus warfarin users. The incidence of fatal ICH and fatal subarachnoid hemorrhage was also lower in DOAC users versus warfarin users. Several baseline characteristics other than anticoagulants were also associated with the incidence of the endpoints. Of these, history of cerebrovascular disease (aHR 2.39, 95% CI 2.05-2.78), persistent NVAF, (aHR 1.90, 95% CI 1.53-2.36), and long-standing persistent/permanent NVAF (aHR 1.92, 95% CI 1.60-2.30) was strongly associated with ischemic stroke; severe hepatic disease (aHR 2.67, 95% CI 1.46-4.88) was strongly associated with overall ICH; and history of fall within 1 year was strongly associated with both overall ICH (aHR 2.29, 95% CI 1.76-2.97) and subdural/epidural hemorrhage (aHR 2.90, 95% CI 1.99-4.23). CONCLUSION Patients aged ⩾ 75 years with NVAF taking DOACs had lower risks of ischemic stroke, ICH, and subdural/epidural hemorrhage than those taking warfarin. Fall was strongly associated with the risks of intracranial and subdural/epidural hemorrhage. DATA ACCESS STATEMENT The individual de-identified participant data and study protocol will be shared for up to 36 months after the publication of the article. Access criteria for data sharing (including requests) will be decided on by a committee led by Daiichi Sankyo. To gain access, those requesting data access will need to sign a data access agreement. Requests should be directed to yamt-tky@umin.ac.jp.
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Affiliation(s)
- Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | | | | | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Cerebrovascular Center, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | | | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | | | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tetsuya Kimura
- Primary Medical Science Department, Daiichi Sankyo, Tokyo, Japan
| | | | - Atsushi Takita
- Data Intelligence Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Takenori Yamaguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
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13
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Kefale AT, Bezabhe WM, Peterson GM. Oral Anticoagulant Use in Patients with Atrial Fibrillation at Low Risk of Stroke and Associated Bleeding Complications. J Clin Med 2023; 12:6182. [PMID: 37834830 PMCID: PMC10573191 DOI: 10.3390/jcm12196182] [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: 08/23/2023] [Revised: 09/20/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND The use of oral anticoagulants (OACs) in patients with atrial fibrillation (AF) and low stroke risk might cause more harm than benefit. Little attention has been given to address its prevalence and associated consequences. This study aimed to investigate the prescription rate of OACs, identify associated factors, and describe incident bleeding events in low-risk patients. METHODS We included patients with a new diagnosis of AF between 1 January 2011 and 31 December 2018 having a low risk of stroke (CHA2DS2-VASc score of 0 for males and 1 for females) from Australian general practice data (MedicineInsight). Patients were classified as OAC users if there was a recorded prescription of an OAC within 60 days of AF diagnosis, and factors associated with the prescription of an OAC were assessed using logistic regression. Recorded incident bleeding events were identified within 6 months after AF diagnosis or after OAC initiation for OAC non-users and users, respectively. The risk of bleeding was compared between the two groups by adjusting their baseline differences using propensity score matching. RESULTS The study included 2810 low-risk patients (62.3% male) with a mean age of 49.3 ± 10.8 years. Of the total, 705 (25.1%) patients had a record of OAC prescription within 60 days of diagnosis of AF. Older age (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.03-1.04) and diagnosis periods (2015-2016 [OR 1.46; 95% CI 1.10-1.94] and 2017-2018 [OR 1.65; 95% CI 1.17-2.23] vs. 2011-2012) were associated with higher odds of OAC initiation. Female sex (OR 0.71; 95% CI 0.59-0.85), higher bleeding risk (ORBIT score; OR 0.80; 95% CI 0.68-0.94), and higher socioeconomic index for areas (SEIFA) quintiles (SEIFA quintiles; 2 [OR 0.65; 95% CI 0.48-0.88], 3 [OR 0.74; 95% CI 0.56-0.98], 4 [OR 0.70; 95% CI 0.52-0.94], 5 [OR 0.69; 95% CI 0.52-0.91] compared with quintile 1) were associated with lower odds of OAC prescription. A total of 52 (in 1.8% of patients) incident bleeds were identified, with 18 (2.6%) among OAC users. The rate of bleeding was not significantly different between users and non-users after matching. However, within OAC users, commencement of OAC was associated with an increased risk of bleeding compared to the period before OAC initiation (p = 0.006). CONCLUSIONS One in four patients at low risk of stroke received an OAC within 60 days of AF diagnosis. Older age and the period following the widespread availability of direct-acting OACs were associated with an increased likelihood of OAC prescription. Positively, using OACs was not associated with an increased rate of bleeding compared to non-users.
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Affiliation(s)
- Adane Teshome Kefale
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS 7001, Australia
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14
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Kang F, Su L, Fan S, Lv L, Luo B. Efficacy and safety of non-vitamin K antagonist oral anticoagulants in patients (≥80 years of age) with atrial fibrillation: systematic review and meta-analysis. Intern Med J 2023; 53:1524-1532. [PMID: 37178051 DOI: 10.1111/imj.16101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 04/14/2023] [Indexed: 05/15/2023]
Abstract
Findings of prior studies about the efficacy and safety of non-vitamin K antagonist oral anticoagulants (NOACs) in patients (≥80 years of age) with atrial fibrillation (AF) are controversial. So we performed a meta-analysis to evaluate the efficacy and safety of NOACs versus vitamin K antagonists (VKAs) in patients (≥80 years of age) with AF. A systematic review of PubMed, Cochrane, Embase, Web of Science and Chinese BioMedical databases was conducted until 1 October 2022. Studies reporting the effects and safety of NOACs versus warfarin in patients (≥80 years of age) with AF were included. Two authors independently performed study selection and data extraction. Discrepancies were resolved by consensus or through an independent third reviewer. Data were synthesised according to the Preferred Reporting Items for Systematic Reviews guidelines. We identified 15 studies providing data of 70 446 participants (≥80 years of age) suffering from AF. According to the meta-analysis (odds ratio (OR) (95% confidence interval, CI)), NOACs conferred better efficacy profile than VKAs in stroke and systemic embolism (0.8 (0.73-0.88)) and all-cause mortality (0.61 (0.57-0.65)). Otherwise, NOACs conferred a better safety profile than VKAs in major bleeding (0.76 (0.70-0.83)) and intracranial haemorrhage (ICH; 0.57 (0.47-0.68)). In conclusion, for patients (≥80 years of age) with AF, the risks of stroke and systemic embolism, all-cause mortality, were lower in NOACs compared to warfarin. The risks of major bleeding and ICH were also lower in NOACs compared to warfarin. NOACs showed better efficacy and safety than warfarin.
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Affiliation(s)
- Fengguang Kang
- Department of Cardiology, Shunde Hospital of Guangzhou University of Chinese Medicine, Foshan, Guangdong, China
| | - Lijun Su
- Department of Cardiology, Shunde Hospital of Guangzhou University of Chinese Medicine, Foshan, Guangdong, China
| | - Shuke Fan
- Department of Cardiology, Junan Hospital Affiliated to Shunde Hospital of Guangzhou University of Chinese Medicine, Guangdong, Foshan, China
| | - Lifen Lv
- Department of Cardiology, Shunde Hospital of Guangzhou University of Chinese Medicine, Foshan, Guangdong, China
| | - Biru Luo
- Department of Cardiology, Shunde Hospital of Guangzhou University of Chinese Medicine, Foshan, Guangdong, China
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15
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Voorhout L, Pisters R, Geurts CHPH, Oostindjer A, van Doorn S, Rila H, Fuijkschot WW, Verheugt F, Hemels MEW. Screening over 100 000 patients in 39 general practices in the Netherlands for anticoagulation underprescription in atrial fibrillation: a descriptive, cross-sectional study. BMJ Open 2023; 13:e072655. [PMID: 37597862 PMCID: PMC10441057 DOI: 10.1136/bmjopen-2023-072655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 07/06/2023] [Indexed: 08/21/2023] Open
Abstract
OBJECTIVES To investigate the underprescription of oral anticoagulation (OAC) in individual atrial fibrillation (AF) patients in primary care. SETTING Screening of patient records in 39 participating general practitioners (GPs) across the Netherlands. PARTICIPANTS We screened 101 207 patient records identifying 2375 non-valvular AF patients. METHODS Using electronic patient files, we were able to screen the entire GP population for AF, CHA2DS2-VASc stroke risk scores, and the use of guidelines recommended OAC prescription. In case of a deviation from guidelines recommended OAC prescription, we checked the electronic patient file for any documented reason. Additionally, 6 weeks following the screening, we asked all GPs to provide information on any actions taken for the underprescribed patients. RESULTS We found a mean CHA2DS2-VASc score of 3.2. OAC prescription consisted of direct OAC in 1342/1984 (68%) and vitamin K-antagonists in the remainder of patients. OAC underprescription was present in 93/944 (9.9%) females and 101/1374 (9.7%) in males, respectively. In 111/146 (76.0%) of the underprescribed AF patients, no reason to withhold OAC was reported. Reported reasons to withhold OAC were patient refusal (n=10), cardiologist advice (n=7) and high risk of bleeding (n=7). Data regarding actions following the identification of OAC underprescription were available for 92/194 (47%) of the OAC underprescribed cases. After consultation OAC was initiated in 9/92 (10%) only. CONCLUSIONS In this large Dutch study among GPs, we observed 9.8% underprescription of OAC in AF patients. In 76% of the AF patients lacking a prescription for OAC, no documentation for deviating from the guidelines was found. Only in a minority of cases detection of OAC underprescription lead to OAC initiation.
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Affiliation(s)
- Leonard Voorhout
- Department of Cardiology, Research, Hospital Rijnstate, Arnhem, The Netherlands
| | - Ron Pisters
- Department of Cardiology, Research, Hospital Rijnstate, Arnhem, The Netherlands
| | | | | | - Sander van Doorn
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
| | | | | | - Freek Verheugt
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Martin E W Hemels
- Department of Cardiology, Research, Hospital Rijnstate, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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16
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Ascenção R, Gil M, Lourenço F, Caldeira D, Oliveira R, Borges M, Silva Miguel L, Costa J. [Oral Anticoagulation and the Incidence of Stroke Associated with Atrial Fibrillation in Mainland Portugal: A Modelling Study]. ACTA MEDICA PORT 2023; 36:458-466. [PMID: 37429703 DOI: 10.20344/amp.19255] [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: 10/26/2022] [Accepted: 03/31/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Atrial fibrillation is the most prevalent persistent dysrhythmia, contributing to a significant social and economic burden. The main objective of this study was to evaluate the association between oral anticoagulant use and the incidence of stroke associated with atrial fibrillation, in mainland Portugal. METHODS The number of episodes of inpatient care with a main diagnosis of stroke and an additional diagnosis of atrial fibrillation, occurring monthly between January 2012 and December 2018, in individuals aged 18 years or over, was extracted from the hospital morbidity database. The number of patients with an atrial fibrillation code documented in this database was used as a proxy for the prevalence of known atrial fibrillation. The number of anticoagulated patients was estimated from total medicine sales of vitamin K antagonists and novel oral anticoagulants (apixaban, dabigatran, edoxaban and rivaroxaban) in mainland Portugal. Descriptive analyses were performed, and seasonal autoregressive integrated moving average (SARIMA) models were built using the R software. RESULTS The mean number of episodes of stroke per month was 522 (± 57). The number of anticoagulated patients increased gradually from 68 943 to 180 389 per month. The decreasing trend in the number of episodes has been observed since 2016, along with the increased use of new oral anticoagulants compared to vitamin K antagonists. The final model indicated that the increase in oral anticoagulation use between 2012 and 2018, in mainland Portugal, was associated with a decrease in the number of episodes of stroke associated with atrial fibrillation. It was estimated that the shift in the type of anticoagulation used, between 2016 and 2018, was associated with a reduction of 833 episodes of stroke in patients with atrial fibrillation (4.2%). CONCLUSION The use of oral anticoagulation was associated with a reduced incidence of stroke in patients with atrial fibrillation in mainland Portugal. This reduction was more relevant in the period between 2016 and 2018, and is probably related with the introduction of the novel oral anticoagulants.
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Affiliation(s)
- Raquel Ascenção
- Centro de Estudos de Medicina Baseada na Evidência. Faculdade de Medicina. Universidade de Lisboa. Lisboa; Instituto de Medicina Preventiva e Saúde Pública. Faculdade de Medicina. Universidade de Lisboa. Lisboa; Centro Cardiovascular da Universidade de Lisboa. Faculdade de Medicina. Universidade de Lisboa. Lisboa. Portugal
| | - Madalena Gil
- Departamento de Matemática. Instituto Superior Técnico. Universidade de Lisboa. Lisboa.Portugal
| | - Francisco Lourenço
- Centro de Estudos de Medicina Baseada na Evidência. Faculdade de Medicina. Universidade de Lisboa. Lisboa. Portugal
| | - Daniel Caldeira
- Centro Cardiovascular da Universidade de Lisboa. Faculdade de Medicina. Universidade de Lisboa. Lisboa; Serviço de Cardiologia. Hospital de Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisboa; Laboratório de Farmacologia Clínica e Terapêutica. Faculdade de Medicina. Universidade de Lisboa. Lisboa.Portugal
| | - Rosário Oliveira
- Departamento de Matemática. Instituto Superior Técnico. Universidade de Lisboa. Lisboa.Portugal
| | - Margarida Borges
- Centro de Estudos de Medicina Baseada na Evidência. Faculdade de Medicina. Universidade de Lisboa. Lisboa; Laboratório de Farmacologia Clínica e Terapêutica. Faculdade de Medicina. Universidade de Lisboa. Lisboa. Portugal
| | - Luís Silva Miguel
- Centro de Estudos de Medicina Baseada na Evidência. Faculdade de Medicina. Universidade de Lisboa. Lisboa. Portugal
| | - João Costa
- Centro de Estudos de Medicina Baseada na Evidência. Faculdade de Medicina. Universidade de Lisboa. Lisboa; Instituto de Medicina Molecular. Faculdade de Medicina. Universidade de Lisboa. Lisboa. Portugal
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Frost L, Halminen O, Lehto M, Airaksinen KEJ, Andersson T, Wändell P, Holzmann M, Cordsen P, Vinter N, Johnsen SP. Geographical Variation in the Use of Oral Anticoagulation and Clinical Outcomes among Patients with Atrial Fibrillation in Denmark, Sweden, and Finland. TH OPEN 2023; 7:e133-e142. [PMID: 37288117 PMCID: PMC10243918 DOI: 10.1055/a-2080-6171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 04/19/2023] [Indexed: 06/09/2023] Open
Abstract
Background Geographical mapping of variations in the treatment and outcomes of a disease is a valuable tool for identifying inequity. We examined international and intranational variations in initiating oral anticoagulation (OAC) therapy and clinical outcomes among patients with atrial fibrillation (AF) in Nordic countries. We also tracked real-world trends in initiating OAC and the clinical outcomes. Methods We conducted a registry-based multinational cohort study of OAC-naive patients with an incident hospital diagnosis of AF in Denmark ( N = 61,345), Sweden ( N = 124,120), and Finland ( N = 59,855) and a CHA 2 DS 2 -VASc score of ≥1 in men and ≥2 in women between 2012 and 2017. Initiation of OAC therapy was defined as dispensing at least one prescription between 90 days before and 90 days after the AF diagnosis. Clinical outcomes included ischemic stroke, intracerebral hemorrhage, intracranial bleeding, other major bleeding, and all-cause mortality. Results The proportion of patients initiating OAC therapy ranged from 67.7% (95% CI: 67.5-68.0) in Sweden to 69.6% (95% CI: 69.2-70.0) in Finland, with intranational variation. The 1-year risk of stroke varied from 1.9% (95% CI: 1.8-2.0) in Sweden and Finland to 2.3% (95% CI: 2.2-2.4) in Denmark, with intranational variation. The initiation of OAC therapy increased with a preference for direct oral anticoagulants over warfarin. The risk of ischemic stroke decreased with no increase in intracranial and intracerebral bleeding. Conclusion We documented inter- and intranational variation in initiating OAC therapy and clinical outcomes across Nordic countries. Adherence to structured care of patients with AF could reduce future variation.
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Affiliation(s)
- Lars Frost
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Mika Lehto
- Department of Internal Medicine, Hospital District of Helsinki and Uusimaa, Lohja Hospital, Lohja, Finland
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Tomas Andersson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Per Wändell
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Martin Holzmann
- Functional Area of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Internal Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Pia Cordsen
- Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | - Nicklas Vinter
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
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18
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Mazón-Ramos P, Cinza-Sanjurjo S, Garcia-Vega D, Portela-Romero M, Rodríguez-Mañero M, Rey-Aldana D, Morandeira AP, Lage-Fernández R, Gude-Sampedro F, González-Juanatey JR. The impact of inter-clinician electronic consultation in patients diagnosed with atrial fibrillation in primary care. Eur J Clin Invest 2023; 53:e13904. [PMID: 36346678 DOI: 10.1111/eci.13904] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND An early diagnosis and early initiation of oral anticoagulants (OAC) are main determinants for outcomes in patients with atrial fibrillation (AF). Inter-clinician electronic consultations (e-consultations) program for the general practitioner referrals to cardiologist may improve health care access by reducing the elapsed time for cardiology care. OBJECTIVE To evaluate the effect of a reduced elapsed time to care after a inter-clinician e-consultations program implementation (2013-2019) in comparison with previous in-person consultation (2010-2012) in the outpatient health care management in a Cardiology Department. METHODOLOGY We included 10,488 patients with AF from 1 January 2010, to 31 December 2019. Until 2012, all patients attended an in-person consultation (2010-2012). In 2013, we instituted an e-consult program (2013-2019) for all primary care referrals to cardiologists that preceded patient's in-person consultation when considered. The shared electronic patient dossier (EPD) was available between GP and cardiologist, and any change in therapy advice from cardiologist was directly implemented in this EPD. RESULTS During the e-consultation period (2013-2019) were referred 6627 patients by GPs to cardiology versus 3861 during the in-person consultation (2010-2012). The e-consultation implementation was associated with a reduction in the elapsed time to anticoagulation prescription (177.6 ± 8.9 vs. 22.5 ± 8.1 days, p < .001), and an increase of OAC use (61% [95% IC: 19.6%-102.4%], p < .001). The e-consult program implementation was associated with a reduction in the 1-year CV mortality (.48 [95% CI: .30-.75]) and all-cause mortality (.42 [95% CI: .29-.62]). The OAC reduces the stroke mortality (.15 [95% CI: .06-.39]) and CV mortality (.43 [95% CI: .29-.62]) and all-cause mortality (.23 [95% CI: .17-.31]). CONCLUSION A shared EPD-based inter-clinician e-consultation program significantly reduced the elapsed time for cardiology consultation and initiation of OAC. The implementation of this program was associated with a lower risk of stroke and cardiovascular/all-cause mortality.
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Affiliation(s)
- Pilar Mazón-Ramos
- Servicio de Cardiología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain.,Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Sergio Cinza-Sanjurjo
- Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,CS Milladoiro, Área Sanitaria Integrada Santiago de Compostela, Ames, Spain
| | - David Garcia-Vega
- Servicio de Cardiología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain.,Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Manuel Portela-Romero
- Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,CS Concepción Arenal, Área Sanitaria Integrada Santiago de Compostela, Santiago de Compostela, Spain
| | - Moisés Rodríguez-Mañero
- Servicio de Cardiología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain.,Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Daniel Rey-Aldana
- Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,CS A Estrada, Área Sanitaria Integrada Santiago de Compostela, A Estrada, Spain
| | | | - Ricardo Lage-Fernández
- Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Francisco Gude-Sampedro
- Unidad de Epidemiología Clínica, Complejo Hospitalario Universitario de Santiago de Compostela, IDIS, redIAPP, Madrid, Spain
| | - José R González-Juanatey
- Servicio de Cardiología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain.,Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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19
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Eriksson M, Grundberg A, Inge E, von Euler M. Stroke Recurrence Following 28 Days After First Stroke in Men and Women 2012 to 2020: Observations From the Swedish Stroke Register. J Am Heart Assoc 2023; 12:e028222. [PMID: 36688356 PMCID: PMC9973638 DOI: 10.1161/jaha.122.028222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background Stroke incidence, care, and survival show continuous improvements in Sweden, including no or decreasing disparities between men and women. In this study, we aimed to estimate and compare the risk of stroke recurrence in men and women over time, accounting for the competing risk of death. Methods and Results We included adult patients with first-time stroke (ischemic or intracerebral hemorrhage) registered in Riksstroke (the Swedish Stroke Register), 2012 to 2020, and followed until December 2020. Stroke recurrences included new events registered in Riksstroke from 28 days after stroke. To account for the competing risk of death, we used the cumulative incidence function to estimate crude incidences, and multivariable Cox regression to estimate cause-specific hazard ratios (HRs) adjusting for differences in patients' risk factor profiles. The study included 72 148 (53.5%) men and 62 689 (46.5%) women. We observed 10 925 stroke recurrences and 81 811 deaths following the initial 28 days after the first stroke. The cumulative incidence of stroke recurrence was 3.7% (95% CI, 3.6-3.8) after 1 year, 7.0 (95% CI, 6.8-7.1) after 3 years, and 9.1% (95% CI, 8.9-9.3) after 5 years. The incidence decreased substantially during the study period (HR, 2019-2020 versus 2012, 0.824 [95% CI, 0.759-0.894]). Overall, men had a lower risk of stroke recurrence. After adjustments for differences in patient characteristics, men had a slightly higher risk of recurrence (of any type) after an ischemic stroke (HR, 1.090 [95% CI, 1.045-1.138]) and a lower risk after hemorrhagic stroke (HR, 0.880 [95% CI, 0.781-0.991]) compared with women. Conclusions The risk of stroke recurrence has decreased in both men and women. Women's higher age and other differences in risk factors partly explain their higher risk of stroke recurrence compared with men.
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Affiliation(s)
| | | | - Erik Inge
- Department of Statistics, USBEUmeå UniversityUmeåSweden
| | - Mia von Euler
- Department of Neurology and Rehabilitation, Faculty of Medicine and HealthÖrebro UniversityÖrebroSweden
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20
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Trend of anticoagulant therapy in elderly patients with atrial fibrillation considering risks of cerebral infarction and bleeding. Sci Rep 2023; 13:192. [PMID: 36604482 PMCID: PMC9814101 DOI: 10.1038/s41598-022-26741-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/20/2022] [Indexed: 01/06/2023] Open
Abstract
The introduction of direct oral anticoagulants (DOACs) has greatly changed the use of anticoagulant therapy in patients with non-valvular atrial fibrillation (Af). Therefore, this study aimed to examine changes in the proportions of oral anticoagulant prescriptions in patients with non-valvular Af aged ≥ 65 years, taking into consideration the risk of cerebral infarction and bleeding. Anticoagulant prescriptions in outpatients aged ≥ 65 years with Af were temporally analyzed using the nationwide claims database in Japan. Trends in anticoagulant prescriptions were examined according to cerebral infarction and bleeding risk. The proportion of anticoagulant prescriptions for 12,076 Af patients increased from 41% in 2011 to 56% in 2015. An increase in DOAC prescriptions was accompanied by an increase in the proportion of anticoagulant prescriptions in each group according to the CHA2DS2-VASc and HAS-BLED scores. The proportion of anticoagulant prescriptions for patients with a high risk of developing cerebral infarction and bleeding showed a marked increase. Trends in anticoagulant prescriptions in Af patient with a CHA2DS2-VASc score ≥ 2 and HAS-BLED scores ≥ 3 showed a marked increase in DOAC prescriptions. The widespread use of DOACs greatly changes the profile the prescription of anticoagulant therapy in patients with Af.
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21
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Díaz-Guzmán J, Freixa-Pamias R, García-Alegría J, Pérez Cabeza AI, Roldán-Rabadán I, Antolin-Fontes B, Rebollo P, Llorac A, Genís-Gironés M, Escobar-Cervantes C. Epidemiology of atrial fibrillation-related ischemic stroke and its association with DOAC uptake in Spain: first national population-based study 2005 to 2018. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:496-505. [PMID: 34518112 DOI: 10.1016/j.rec.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/20/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION AND OBJECTIVES The incidence and prevalence of atrial fibrillation (AF), a major risk factor for stroke, has increased substantially in the past few years. However, several studies have reported a decline in AF-related stroke rates associated with higher uptake of direct oral anticoagulants (DOACs). This ecological study evaluated the association between DOAC uptake in Spain and the incidence rate (IR) of AF-related ischemic stroke. METHODS Data were obtained from the Registry of Activity of Specialized Healthcare of the Spanish Ministry of Health (RAE-MDS). AF-related ischemic strokes were identified using International Classification of Diseases codes. IR were age-standardized and adjusted to the 2013 European standard population. Poisson regression models were used to identify the association between DOAC uptake and AF-related ischemic stroke in patients aged ≥ 65 years. RESULTS Before the use of DOACs, the adjusted IR of AF-related ischemic stroke increased steadily from 2005 (IR=2.20 per 100 000 person/y) to 2012 (IR=2.67). Upon DOAC uptake in Spain from 2012 onwards for AF-related ischemic stroke prevention, the IR remained constant or decreased slightly (IR in 2018=2.66). Poisson regression showed that DOAC uptake was a significant predictor for the rate of AF-related ischemic stroke in patients older than 65 years (IRR=0.995; 95%CI, 0.995-0.996). CONCLUSIONS This study shows an association between DOAC use and a reduced incidence of AF-related ischemic stroke. While this association is based on aggregate data and cannot demonstrate causality, these findings suggest that higher DOAC uptake could improve health outcomes in AF patients in Spain.
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Affiliation(s)
- Jaime Díaz-Guzmán
- Servicio de Neurología, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - Román Freixa-Pamias
- Servicio de Cardiología, Complex Hospitalari Moisès Broggi, Sant Joan Despí, Barcelona, Spain
| | | | - Alejandro-Isidoro Pérez Cabeza
- Servicio de Cardiología, Hospital Universitario Virgen de la Victoria, Málaga, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Inmaculada Roldán-Rabadán
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Instituto de Investigación del Hospital Universitario La Paz (IdiPaz), Hospital Universitario La Paz, Madrid, Spain
| | | | | | - Aleix Llorac
- Departamento de Market Access, Bayer Hispania S.L., Sant Joan Despí, Barcelona, Spain
| | - Mar Genís-Gironés
- Departamento Médico, Bayer Hispania S.L., Sant Joan Despí, Barcelona, Spain
| | - Carlos Escobar-Cervantes
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Instituto de Investigación del Hospital Universitario La Paz (IdiPaz), Hospital Universitario La Paz, Madrid, Spain
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22
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Pérez Cabeza AI, Rivera-Caravaca JM, Roldán-Rabadán I, García Seara J, Bertomeu-Gonzalez V, Leal M, García-Fernandez A, Tercedor Sanchez L, Ayarra M, Ciudad M, Castaño S, Maestre A, Anguita M, Garcia Bolao I, Marín F. Antithrombotic therapy and clinical outcomes at 1 year in the Spanish cohort of the EORP-AF Long-term General Registry. Eur J Clin Invest 2022; 52:e13709. [PMID: 34757635 DOI: 10.1111/eci.13709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/05/2021] [Accepted: 11/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) increases the risk of thromboembolism. We investigate the efficacy and safety of oral anticoagulation (OAC) therapy and explored the number needed to treat for net effect (NNTnet) of OAC in the Spanish cohort of the EURObservational Research Programme-AF (EORP-AF) Long-term General Registry. METHODS The EORP-AF General Registry is a prospective, multicentre registry conducted in ESC countries, including consecutive AF patients. For the present analysis, we used the Spanish cohort, and the primary outcome was any thromboembolism (TE)/acute coronary syndrome (ACS)/cardiovascular death during the first year of follow-up. RESULTS 729 AF patients were included (57.1% male, median age 75 [IQR 67-81] years, median CHA2 DS2 -VASc and HAS-BLED of 3 [IQR 2-5] and 2 [IQR 1-2], respectively). 548 (75.2%) patients received OAC alone (318 [43.6%] on VKAs and 230 [31.6%] on DOACs). After 1 year, the use of OAC alone showed lower rates of any TE/ACS/cardiovascular death (3.0%/year; p < 0.001) compared to other regimens, and non-use of OAC alone (HR 4.18, 95% CI 2.12-8.27) was independently associated with any TE/ACS/cardiovascular death. Balancing the effects of treatment, the NNTnet to provide an overall benefit of OAC therapy was 24. The proportion of patients on OAC increased at 1 year (87% to 88.1%), particularly on DOACs (33.6% to 39.9%) (p = 0.015), with low discontinuation rates. CONCLUSIONS In this contemporary cohort of AF patients, OAC therapy was associated with better clinical outcomes at 1 year and positive NNTnet. OAC use slightly increased during the follow-up, with low discontinuation rates and higher prescription of DOACs.
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Affiliation(s)
| | - José Miguel Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, United Kingdom
| | | | - Javier García Seara
- Department of Cardiology, Hospital Clinico Universitario Santiago de Compostela, CIBERCV, Santiago de Compostela, Spain
| | - Vicente Bertomeu-Gonzalez
- Department of Cardiology, University Hospital San Juan de Alicante, Universidad Miguel Hernandez, CIBERCV, Alicante, Spain
| | - Mariano Leal
- Primary Care Health Center of San Andrés, Murcia, Spain
| | - Amaya García-Fernandez
- Department of Cardiology, Arrhythmias Unit, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Hospital General Universitario de Alicante, Alicante, Spain
| | - Luis Tercedor Sanchez
- Department of Cardiology, University Hospital Virgen de las Nieves, Instituto de Investigación Biosanitaria ibs.Granada, Granada, Spain
| | | | - Marianela Ciudad
- Department of Internal Medicine, University Hospital de La Princesa, Madrid, Spain
| | - Sara Castaño
- Department of Cardiology, Hospital Nuestra Señora del Prado, Talavera de la Reina, Spain
| | - Ana Maestre
- Department of Internal Medicine, Hospital Universitario del Vinalopó, Elche, Spain
| | - Manuel Anguita
- Department of Cardiology, Hospital Universitario Reina Sofía, Universidad de Córdoba, Instituto Maimónides de Investigación Biomédica (IMIBIC), Córdoba, Spain
| | - Ignacio Garcia Bolao
- Department of Cardiology, Clínica Universidad de Navarra, Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
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23
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Norman K, Eriksson M, von Euler M. Sex Differences in Ischemic Stroke Within the Younger Age Group: A Register-Based Study. Front Neurol 2022; 13:793181. [PMID: 35237226 PMCID: PMC8882967 DOI: 10.3389/fneur.2022.793181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background Stroke incidence is decreasing in most developing countries. However, worrisome trends of an increase in the younger population have been described. Aim To investigate sex differences and longitudinal changes in ischemic stroke regarding incidence, cardiovascular risk factors, and outcome, in the young. Methods This is an observational study based on the data from the Swedish national stroke registry, Riksstroke. Patients, 18–54 years of age, having ischemic stroke between 2005 and 2018 were included, resulting in a study population of 16,210 patients. Results The incidence was higher in men than in women (30.6 vs. 19.1 per 100,000, P < 0.001). After an initial increase, the incidence stabilized and then decreased, resulting in a similar level in 2018 as in 2005. Atrial fibrillation, diabetes, and usage of anti-hypertensives at stroke onset were more common among men and did not change over time. Smoking was common and slightly more so in women, but with a reduced prevalence in both men and women during the study period. Dependency in Activities of Daily Living (ADL) and case fatality showed no clear trends or sex differences. Conclusions The results show that there are sex differences in ischemic stroke in the younger age group regarding incidence and vascular risk factors, particularly smoking. Temporal trends in stroke incidence are difficult to interpret as fluctuations are substantial, largely due to stroke being quite uncommon in the younger population.
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Affiliation(s)
| | - Marie Eriksson
- Department of Statistics, USBE, Umeå University, Umeå, Sweden
| | - Mia von Euler
- Department of Neurology and Rehabilitation, School of Medicine, Örebro University, Örebro, Sweden
- *Correspondence: Mia von Euler
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24
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Grymonprez M, Simoens C, Steurbaut S, De Backer TL, Lahousse L. Worldwide trends in oral anticoagulant use in patients with atrial fibrillation from 2010 to 2018: a systematic review and meta-analysis. Europace 2021; 24:887-898. [PMID: 34935033 DOI: 10.1093/europace/euab303] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/12/2021] [Indexed: 12/28/2022] Open
Abstract
AIMS Non-vitamin K antagonist oral anticoagulants (NOACs) are effective and safe alternatives compared with vitamin K antagonists (VKAs) for thromboembolic prevention in atrial fibrillation (AF), while antiplatelets are no longer recommended. However, to which extent NOAC introduction and guideline updates have increased OAC use in AF, is unclear. Therefore, worldwide trends in real-life prescribing of OACs, NOACs, VKAs, and antiplatelet monotherapy in AF patients were investigated. METHODS AND RESULTS Using PubMed and Embase, observational nationwide cohort studies on annual prevalent and/or incident OAC use in non-selected AF patients since 2010 were included. A meta-analysis of single proportions was performed. Twenty-one studies were included assessing prevalent and incident use among 9 758 637 and 197 483 OAC-eligible AF patients, respectively. Worldwide prevalence and incidence of OAC users increased from 0.42 [95% confidence interval (CI) 0.22-0.65] and 0.43 (95% CI 0.37-0.49) in 2010 to 0.78 (95% CI 0.77-0.78) and 0.75 (95% CI 0.74-0.76) in 2018, respectively. Prevalent and incident NOAC users increased globally from 0 in 2010 to 0.45 (95% CI 0.45-0.46) and 0.68 (95% CI 0.67-0.69) in 2018, respectively, whereas prevalent and incident VKA use decreased from 0.42 (95% CI 0.22-0.65) and 0.42 (95% CI 0.36-0.49) in 2010 to 0.32 (95% CI 0.32-0.32) and 0.06 (95% CI 0.06-0.07) in 2018, respectively. Prevalent antiplatelet monotherapy use decreased from 0.37 (95% CI 0.32-0.42) in 2010 to 0.09 (95% CI 0.09-0.10) in 2018. CONCLUSION The proportion of OAC users worldwide almost doubled following NOAC introduction. As one-quarter of OAC-eligible AF subjects were not anticoagulated and 9% were only treated with antiplatelets in 2018, there is still room for improvement.
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Affiliation(s)
- Maxim Grymonprez
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
| | - Cynthia Simoens
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
| | - Stephane Steurbaut
- Centre for Pharmaceutical Research, Research Group of Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, 1090 Jette, Belgium.,Department of Hospital Pharmacy, UZ Brussel, 1090 Jette, Belgium
| | - Tine L De Backer
- Department of Cardiology, Ghent University Hospital, 9000 Ghent, Belgium
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium.,Department of Epidemiology, Erasmus Medical Center, 3015 Rotterdam, The Netherlands
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25
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Brener SJ. What Happened to the Cycle of Knowledge? Circ Cardiovasc Interv 2021; 14:e011549. [PMID: 34932390 DOI: 10.1161/circinterventions.121.011549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sorin J Brener
- New York Presbyterian Brooklyn Methodist Hospital, Brooklyn
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26
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Svennberg E, Friberg L, Frykman V, Al-Khalili F, Engdahl J, Rosenqvist M. Clinical outcomes in systematic screening for atrial fibrillation (STROKESTOP): a multicentre, parallel group, unmasked, randomised controlled trial. Lancet 2021; 398:1498-1506. [PMID: 34469764 DOI: 10.1016/s0140-6736(21)01637-8] [Citation(s) in RCA: 164] [Impact Index Per Article: 54.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/03/2021] [Accepted: 07/08/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Atrial fibrillation is a leading cause of ischaemic stroke. Early detection of atrial fibrillation can enable anticoagulant therapy to reduce ischaemic stroke and mortality. In this randomised study in an older population, we aimed to assess whether systematic screening for atrial fibrillation could reduce mortality and morbidity compared with no screening. METHODS STROKESTOP was a multicentre, parallel group, unmasked, randomised controlled trial done in Halland and Stockholm in Sweden. All 75-76-year-olds residing in these two regions were randomly assigned (1:1) to be invited to screening for atrial fibrillation or to a control group. Participants attended local screening centres and those without a history of atrial fibrillation were asked to register intermittent electrocardiograms (ECGs) for 14 days. Treatment with oral anticoagulants was offered if atrial fibrillation was detected or untreated. All randomly assigned individuals were followed up in the intention-to-treat analysis for a minimum of 5 years for the primary combined endpoint of ischaemic or haemorrhagic stroke, systemic embolism, bleeding leading to hospitalisation, and all-cause death. This trial is registered with ClinicalTrials.gov, NCT01593553. FINDINGS From March 1, 2012, to May 28, 2014, 28 768 individuals were assessed for eligibility and randomly assigned to be invited to screening (n=14 387) or the control group (n=14 381). 408 individuals were excluded from the intervention group and 385 were excluded from the control group due to death or migration before invitation. There was no loss to follow-up. Of those invited to screening, 7165 (51·3%) of 13 979 participated. After a median follow-up of 6·9 years (IQR 6·5-7·2), significantly fewer primary endpoint events occurred in the intervention group (4456 [31·9%] of 13 979; 5·45 events per 100 years [95% CI 5·52-5·61]) than in the control group (4616 [33·0%] of 13 996; 5·68 events per 100 years [5·52-5·85]; hazard ratio 0·96 [95% CI 0·92-1·00]; p=0·045). INTERPRETATION Screening for atrial fibrillation showed a small net benefit compared with standard of care, indicating that screening is safe and beneficial in older populations. FUNDING Stockholm County Council, the Swedish Heart & Lung Foundation, King Gustav V and Queen Victoria's Freemasons' Foundation, the Klebergska Foundation, the Tornspiran Foundation, the Scientific Council of Halland Region, the Southern Regional Healthcare Committee, the Swedish Stroke Fund, Carl Bennet AB, Boehringer Ingelheim, Bayer, and Bristol Myers Squibb-Pfizer.
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Affiliation(s)
- Emma Svennberg
- Karolinska Institutet, Department of Medicine, Karolinska University Hospital Huddinge, Stockholm, Sweden.
| | - Leif Friberg
- Karolinska Institutet, Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd University Hospital, Stockholm, Sweden
| | - Viveka Frykman
- Karolinska Institutet, Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd University Hospital, Stockholm, Sweden
| | - Faris Al-Khalili
- Karolinska Institutet, Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd University Hospital, Stockholm, Sweden
| | - Johan Engdahl
- Karolinska Institutet, Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd University Hospital, Stockholm, Sweden
| | - Mårten Rosenqvist
- Karolinska Institutet, Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd University Hospital, Stockholm, Sweden
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Díaz-Guzmán J, Freixa-Pamias R, García-Alegría J, Pérez Cabeza AI, Roldán-Rabadán I, Antolin-Fontes B, Rebollo P, Llorac A, Genís-Gironés M, Escobar-Cervantes C. Epidemiología del ictus cardioembólico y su asociación con la penetración de los ACOD en España: primer estudio poblacional 2005-2018. Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2021.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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28
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Mitchell A, Snowball J, Welsh TJ, Watson MC, McGrogan A. Prescribing of direct oral anticoagulants and warfarin to older people with atrial fibrillation in UK general practice: a cohort study. BMC Med 2021; 19:189. [PMID: 34461899 PMCID: PMC8406735 DOI: 10.1186/s12916-021-02067-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/20/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Anticoagulation for stroke prevention in atrial fibrillation (AF) has, historically, been under-used in older people. The aim of this study was to investigate prescribing of oral anticoagulants (OACs) for people aged ≥ 75 years in the UK before and after direct oral anticoagulants (DOACs) became available. METHODS A cohort of patients aged ≥ 75 years with a diagnosis of AF was derived from the Clinical Practice Research Datalink (CPRD) between January 1, 2003, and December 27, 2017. Patients were grouped as no OAC, incident OAC (OAC newly prescribed) or prevalent OAC (entered study on OAC). Incidence and point prevalence of OAC prescribing were calculated yearly. The risk of being prescribed an OAC if a co-morbidity was present was calculated; the risk difference (RD) was reported. Kaplan-Meier curves were used to explore persistence with anticoagulation. A Cox regression was used to model persistence with warfarin and DOACs over time. RESULTS The cohort comprised 165,596 patients (66,859 no OAC; 47,916 incident OAC; 50,821 prevalent OAC). Incidence of OAC prescribing increased from 111 per 1000 person-years in 2003 to 587 per 1000 person-years in 2017. Older patients (≥ 90 years) were 40% less likely to receive an OAC (RD -0.40, 95% CI -0.41 to -0.39) than younger individuals (75-84 years). The likelihood of being prescribed an OAC was lower with a history of dementia (RD -0.34, 95% CI -0.35 to -0.33), falls (RD -0.17, 95% CI -0.18 to -0.16), major bleeds (RD -0.17, 95% CI -0.19 to -0.15) and fractures (RD -0.13, 95% CI -0.14 to -0.12). Persistence with warfarin was higher than DOACs in the first year (0-1 year: HR 1.25, 95% CI 1.17-1.33), but this trend reversed by the third year of therapy (HR 0.75, 95% CI 0.63-0.89). CONCLUSIONS OAC prescribing for older people with AF has increased; however, substantial disparities persist with age and co-morbidities. Whilst OACs should not be withheld solely due to the risk of falls, these results do not reflect this national guidance. Furthermore, the under-prescribing of OACs for patients with dementia or advancing age may be due to decisions around risk-benefit management. TRIAL REGISTRATION EUPAS29923 . First registered on: 27/06/2019.
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Affiliation(s)
- Anneka Mitchell
- Department of Pharmacy and Pharmacology, University of Bath, Bath, BA2 7AY, UK.
- Pharmacy Research Centre, University Hospital Southampton, Southampton, SO16 6YD, UK.
| | - Julia Snowball
- Department of Pharmacy and Pharmacology, University of Bath, Bath, BA2 7AY, UK
| | - Tomas J Welsh
- Research Institute for the Care of Older People (RICE), Bath, BA1 3NG, UK
- Institute of Clinical Neurosciences, University of Bristol, Bristol, BS8 1TH, UK
| | - Margaret C Watson
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, G4 0RE, UK
| | - Anita McGrogan
- Department of Pharmacy and Pharmacology, University of Bath, Bath, BA2 7AY, UK
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29
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Forslund T, Braunschweig F, Holzmann MJ, Siddiqui AJ. Early Risk of Stroke in Patients Undergoing Acute Versus Elective Cardioversion for Atrial Fibrillation. J Am Heart Assoc 2021; 10:e021716. [PMID: 34387131 PMCID: PMC8475048 DOI: 10.1161/jaha.121.021716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Electrical cardioversion (ECV) is routinely used to restore sinus rhythm in patients with symptomatic atrial fibrillation. The European guidelines have been updated in recent years. Current information on differences in the risk for stroke after acute versus elective ECV is lacking. Methods And Results All patients with a first‐time acute or elective ECV in the Stockholm regional health care data warehouse from 2011 to 2018 were included. Cox regression analyses were performed evaluating ischemic or unspecified stroke within 30 days after ECV with adjustments for the CHA2DS2‐VASc score, medical treatment, and year of inclusion. The study included 9139 patients, 3094 after acute and 6045 after elective ECV. The mean age was 65.9±11.3 years, 69.5% were men, and the mean CHA2DS2‐VASc score was 2.4±1.7. Before the intervention, 49.6% of patients with an acute ECV and 96.4% of those with an elective ECV had claimed an oral anticoagulant prescription. Ischemic or unspecified stroke occurred in 26 (0.28%) patients within 30 days. The unadjusted risk was higher after acute compared with elective ECV (hazard ratio [HR], 2.29; 95% CI, 1.06–4.96), whereas there was no difference after multivariable adjustments (adjusted HR, 0.99; 95% CI, 0.36–2.72). Both non–vitamin K oral anticoagulants (adjusted HR, 0.28; 95% CI, 0.08–0.98) and warfarin (adjusted HR, 0.17; 95% CI, 0.05–0.53) were associated with a lower risk for stroke compared with no anticoagulation. Conclusions Acute ECV was associated with a higher unadjusted risk for stroke than elective ECV, but the risk was similar after adjustment for anticoagulant treatment. This study indicates the importance of anticoagulation before ECV according to recent European guidelines.
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Affiliation(s)
- Tomas Forslund
- Department of Medicine Karolinska Institutet Solna Stockholm Sweden.,Department of Healthcare Development Stockholm Region Stockholm Sweden
| | - Frieder Braunschweig
- Department of Cardiology Karolinska InstitutetKarolinska University Hospital Stockholm Sweden
| | - Martin J Holzmann
- Department of Medicine Karolinska Institutet Solna Stockholm Sweden.,Department of Emergency Medicine Karolinska University Hospital Huddinge Stockholm Sweden
| | - Anwar J Siddiqui
- Department of Medicine Karolinska Institutet Solna Stockholm Sweden.,Department of Emergency Medicine Karolinska University Hospital Huddinge Stockholm Sweden
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30
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Eriksson M, Åsberg S, Sunnerhagen KS, von Euler M. Sex Differences in Stroke Care and Outcome 2005-2018: Observations From the Swedish Stroke Register. Stroke 2021; 52:3233-3242. [PMID: 34187179 DOI: 10.1161/strokeaha.120.033893] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Previous studies of stroke management and outcome in Sweden have revealed differences between men and women. We aimed to analyze if differences in stroke incidence, care, and outcome have altered over time. METHODS All stroke events registered in the Swedish Stroke Register 2005 to 2018 were included. Background variables and treatment were collected during the acute hospital stay. Survival data were obtained from the national cause of death register by individual linkage. We used unadjusted proportions and estimated age-adjusted marginal means, using a generalized linear model, to present outcome. RESULTS We identified 335 183 stroke events and a decreasing incidence in men and women 2005 to 2018. Men were on average younger than women (73.3 versus 78.1 years) at stroke onset. The age-adjusted proportion of reperfusion therapy 2005 to 2018 increased more rapidly in women than in men (2.3%-15.1% in men versus 1.4%-16.9% in women), but in 2018, women still had a lower probability of receiving thrombolysis within 30 minutes. Among patients with atrial fibrillation, oral anticoagulants at discharge increased more rapidly in women (31.2%-78.6% in men versus 26.7%-81.9% in women). Statins remained higher in men (36.9%-83.7% in men versus 32.3%-81.2% in women). Men had better functional outcome and survival after stroke. After adjustment for women's higher age, more severe strokes, and background characteristics, the absolute difference in functional outcome was <1% and survival did not differ. CONCLUSIONS Stroke incidence, care, and outcome show continuous improvements in Sweden, and previously reported differences between men and women become less evident. More severe strokes and older age in women at stroke onset are explanations to persisting differences.
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Affiliation(s)
- Marie Eriksson
- Department of Statistics, USBE, Umeå University, Sweden (M.E.)
| | - Signild Åsberg
- Department of Neuroscience, Uppsala University, Sweden (S.A.)
| | | | - Mia von Euler
- School of Medicine, Örebro University, Sweden (M.v.E.)
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31
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Zupanic E, Kramberger MG, von Euler M, Norrving B, Winblad B, Secnik J, Fastbom J, Eriksdotter M, Garcia-Ptacek S. Secondary Stroke Prevention After Ischemic Stroke in Patients with Alzheimer's Disease and Other Dementia Disorders. J Alzheimers Dis 2021; 73:1013-1021. [PMID: 31884483 PMCID: PMC7081091 DOI: 10.3233/jad-191011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: Recurrent ischemic stroke (IS) increases the risk of cognitive decline. To lower the risk of recurrent IS, secondary prevention is essential. Objective: Our aim was to compare post-discharge secondary IS prevention and its maintenance up to 3 years after first IS in patients with and without Alzheimer’s disease and other dementia disorders. Methods: Prospective open-cohort study 2007–2014 from the Swedish national dementia registry (SveDem) and the Swedish national stroke registry (Riksstroke). Patients with dementia who experienced an IS (n = 1410; 332 [23.5%] with Alzheimer’s disease) were compared with matched non-dementia IS patients (n = 7150). We analyzed antiplatelet, anticoagulant, blood pressure lowering, and statin treatment as planned medication initiation at discharge and actual dispensation of medications at first, second, and third year post-stroke. Results: At discharge, planned initiation of medication was higher in patients with dementia compared to non-dementia patients for antiplatelets (OR with 95% CI for fully adjusted models 1.23 [1.02–1.48]) and lower for blood pressure lowering medication (BPLM; 0.57 [0.49–0.67]), statins (0.57 [0.50–0.66]), and anticoagulants (in patients with atrial fibrillation – AF; 0.41 [0.32–0.53]). When analysis for antiplatelets was stratified according to the presence of AF, ORs for receiving antiplatelets remained significant only in the presence of AF (in the presence of AF 1.56 [1.21–2.01], in patients without AF 0.99 [0.75–1.33]). Similar trends were observed in 1st, 2nd, and 3rd year post-stroke. Conclusions: Dementia was a predictor of lower statin and BPLM use. Patients with dementia and AF were more likely to be prescribed antiplatelets and less likely to receive anticoagulants.
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Affiliation(s)
- Eva Zupanic
- Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Neurogeriatrics, Solna, Sweden.,Department of Neurology, University Medical Centre, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Milica G Kramberger
- Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Neurogeriatrics, Solna, Sweden.,Department of Neurology, University Medical Centre, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Mia von Euler
- Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset and Department of Medicine, Solna, Stockholm, Sweden.,Department of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - Bo Norrving
- Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Neurology, Lund, Sweden
| | - Bengt Winblad
- Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Neurogeriatrics, Solna, Sweden.,Karolinska University Hospital, Theme Aging, Stockholm, Sweden
| | - Juraj Secnik
- Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Huddinge, Sweden
| | - Johan Fastbom
- Karolinska Institutet and Stockholm University, Department of Neurobiology, Care Sciences and Society, Aging Research Center (ARC), Stockholm, Sweden
| | - Maria Eriksdotter
- Karolinska University Hospital, Theme Aging, Stockholm, Sweden.,Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Huddinge, Sweden
| | - Sara Garcia-Ptacek
- Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Division of Clinical Geriatrics, Huddinge, Sweden.,Department of Internal Medicine Section for Neurology, Södersjukhuset, Stockholm, Sweden
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32
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Steffel J, Collins R, Antz M, Cornu P, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Vanassche T, Potpara T, Camm AJ, Heidbüchel H, Lip GYH, Deneke T, Dagres N, Boriani G, Chao TF, Choi EK, Hills MT, Santos IDS, Lane DA, Atar D, Joung B, Cole OM, Field M. 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation. Europace 2021; 23:1612-1676. [PMID: 33895845 DOI: 10.1093/europace/euab065] [Citation(s) in RCA: 456] [Impact Index Per Article: 152.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Jan Steffel
- Department of Cardiology, Division of Electrophysiology, University Heart Center Zurich, Switzerland
| | - Ronan Collins
- Age-Related Health Care, Tallaght University Hospital / Department of Gerontology Trinity College, Dublin, Ireland
| | - Matthias Antz
- Department of Electrophysiology, Hospital Braunschweig, Braunschweig, Germany
| | - Pieter Cornu
- Faculty of Medicine and Pharmacy, Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lien Desteghe
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Holger Reinecke
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Münster, Germany
| | | | | | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St George's University, London, UK
| | - Hein Heidbüchel
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan & Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | | | - Itamar de Souza Santos
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil.,Departamento de Clínica Médica, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.,Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Boyoung Joung
- Yonsei University College of Medicine, Cardiology Department, Seoul, Republic of Korea
| | - Oana Maria Cole
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Mark Field
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
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33
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Engdahl J, Rosenqvist M. Large-scale screening studies for atrial fibrillation - is it worth the effort? J Intern Med 2021; 289:474-492. [PMID: 33411987 PMCID: PMC8048511 DOI: 10.1111/joim.13217] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/13/2020] [Accepted: 09/15/2020] [Indexed: 12/15/2022]
Abstract
Atrial fibrillation (AF) is a common disease with increasing prevalence, approximately 3.2% in the adult population. In addition, about one third of AF cases are considered asymptomatic. Due to increased longevity, increased detection and increased prevalence of risk factors, the prevalence of AF is expected to at least double by the year 2060. Patients with AF have an increased risk for ischaemic stroke, heart failure, death and cognitive decline. Treatment with oral anticoagulation reduces the risk of ischaemic stroke and mortality, and the effect on cognitive decline is being studied. Based on the increasing prevalence of AF, its often asymptomatic and paroxysmal presentation and the efficacy of oral anticoagulation treatment, screening for AF has been proposed. AF seems to fulfil most of the Wilson-Jungner criteria for screening issued by the World Health Organization, but some knowledge gaps remain, gaps that will be addressed by several ongoing studies. The knowledge gaps in AF screening consist of the magnitude of the net benefit or net harm inflicted by AF screening because the oral anticoagulation treatment will also increase the risk of bleeding, and the psychological effects of AF screening are not very well studied. So far, the AF screening recommendations issued by the European Society of Cardiology have had limited impact on national and regional AF screening activities. Several large-scale AF screening studies will report results on hard endpoints within the next few years, and these results will hopefully manifest AF as a cardiovascular disease which we need to pay more attention to.
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Affiliation(s)
- J. Engdahl
- From theDivision of Cardiovascular MedicineDepartment of Clinical SciencesKarolinska InstitutetDanderyds University HospitalStockholmSweden
| | - M. Rosenqvist
- From theDivision of Cardiovascular MedicineDepartment of Clinical SciencesKarolinska InstitutetDanderyds University HospitalStockholmSweden
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34
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Prevención del ictus en pacientes con fibrilación auricular. Mejorar la protección enla era de la COVID-19. REVISTA ESPAÑOLA DE CARDIOLOGÍA SUPLEMENTOS 2021. [PMCID: PMC8320275 DOI: 10.1016/s1131-3587(21)00002-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
La fibrilación auricular aumenta hasta en 5 veces el riesgo de ictus. Los ictus cardioembólicos habitualmente son más graves y tienen altas tasas de recurrencias y discapacidad permanente en comparación con los ictus de otras etiologías. En consecuencia, la reducción del riesgo de ictus mediante una adecuada anticoagulación es uno de los principales objetivos en el tratamiento de los pacientes con fibrilación auricular. Los antagonistas de la vitamina K han sido ampliamente superados por los anticoagulantes orales de acción directa, ya que tanto los resultados de los ensayos clínicos como los de los estudios de práctica clínica y, últimamente, estudios poblacionales han demostrado que los anticoagulantes orales de acción directa tienen mayores eficacia (menos ictus y muerte) y seguridad (menos hemorragias intracraneales) que los antagonistas de la vitamina K. Además, durante la pandemia de COVID-19, el empleo preferente de anticoagulantes orales de acción directa frente a los antagonistas de la vitamina K constituye una estrategia clave para garantizar una calidad óptima de la anticoagulación y una mejor protección del paciente contra el SARS-CoV-2, al no precisarse control de la razón internacional normalizada.
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35
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Matan D, Löfström U, Corovic Cabrera C, Eriksson B, Ekström M, Hage C, Ljunggren G, Lyngå P, Wallén H, Knudsen Malmqvist K, Linde C, Persson H. Reorganization of heart failure management and improved outcome - the 4D HF Project. SCAND CARDIOVASC J 2020; 55:1-8. [PMID: 32969284 DOI: 10.1080/14017431.2020.1820075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Heart failure (HF) management is suboptimal in Sweden despite available evidence-based guidelines. To improve HF treatment, a comprehensive HF management program (4D project) was implemented in the Stockholm County (>2.1 million inhabitants). Design. A standardized care program centralized at five hospital-based HF clinics was implemented in 2014-2017. We registered from 2012 to 2017: (1) numbers of referrals and visits to HF clinics, (2) numbers of hospital admitted patients per million inhabitants, (3) dispensed HF medications after admission, and (4) covariate-adjusted 1-year all-cause mortality or HF readmission. Results. Yearly visits to the five HF outpatient clinics increased 3.4 times from 3,372 to 11,527. Dispensed HF drug prescriptions increased, in particular, for readmitted patients, compared to 2012 (p<.0001). Total number of hospital admitted HF patients as well as new-onset or readmitted HF patients decreased by 16, 13, and 20%, respectively (p < .0001). The combined 1-year mortality or HF readmission over the period was 48% (n = 17,124/35,880) and improved per year (HR 0.98 [0.97-0.99], p < .001) from 2012. Conclusion. A comprehensive standardized care HF management program including expanded HF clinics was associated with improved evidence-based medication, reduced HF hospitalization, and improvement of the combined outcome of 1-year mortality or HF readmission in Stockholm.
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Affiliation(s)
- Dmitri Matan
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.,Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Ulrika Löfström
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Medicine, Capio St. Göran Hospital, Stockholm, Sweden
| | - Carin Corovic Cabrera
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.,Department of Cardiology, Södersjukhuset, Stockholm, Sweden.,Department of Cardiology, South General Hospital, Stockholm, Sweden
| | - Björn Eriksson
- Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Stockholm, Sweden.,Gustavsberg Academic Health Care Center, Stockholm, Sweden
| | - Mattias Ekström
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.,Department of Cardiology, Danderyd University Hospital, Stockholm, Sweden
| | - Camilla Hage
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Gunnar Ljunggren
- Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Stockholm, Sweden.,Public Health Care Services Committee Administration, Stockholm County Council, Stockholm, Sweden
| | - Patrik Lyngå
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.,Department of Cardiology, South General Hospital, Stockholm, Sweden
| | - Håkan Wallén
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.,Department of Cardiology, Danderyd University Hospital, Stockholm, Sweden
| | - Karin Knudsen Malmqvist
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.,Department of Cardiology, Danderyd University Hospital, Stockholm, Sweden
| | - Cecilia Linde
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Hans Persson
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.,Department of Cardiology, Danderyd University Hospital, Stockholm, Sweden
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36
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Saberwal B, Ioannou A, Lim WY, Beirne AM, Chow AW, Tousoulis D, Ahsan S, Papageorgiou N. Antithrombotic Therapy in Patients with Recent Stroke and Atrial Fibrillation. Curr Pharm Des 2020; 26:2715-2724. [DOI: 10.2174/1381612826666200407150307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/16/2020] [Indexed: 12/31/2022]
Abstract
:
Atrial fibrillation (AF) is a common arrhythmia which carries a significant risk of stroke. Secondary
prevention, particularly in the acute phase of stroke with anti-thrombotic therapy, has not been validated. The aim
of this review is to evaluate the available evidence on the use of antithrombotic therapy in patients with recent
stroke who have AF, and suggest a treatment algorithm for the various time points, taking into account both the
bleeding and thrombosis risks posed at each stage.
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Affiliation(s)
- Bunny Saberwal
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, United Kingdom
| | - Adam Ioannou
- Royal Free Hospital, London NW3 2QG, United Kingdom
| | - Wei Y. Lim
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, United Kingdom
| | - Anne-Marie Beirne
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, United Kingdom
| | - Anthony W. Chow
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, United Kingdom
| | - Dimitris Tousoulis
- First Cardiology Department, Hippokration Hospital, Athens University Medical School, Athens, Greece
| | - Syed Ahsan
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, United Kingdom
| | - Nikolaos Papageorgiou
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, United Kingdom
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37
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Geary L, Hasselström J, Carlsson A, Schenck-Gustafsson K, von Euler M. An audit & feedback intervention for improved anticoagulant use in patients with atrial fibrillation in primary care. Int J Cardiol 2020; 310:67-72. [DOI: 10.1016/j.ijcard.2020.04.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 04/03/2020] [Accepted: 04/07/2020] [Indexed: 01/20/2023]
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38
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Komen JJ, Heerdink ER, Klungel OH, Mantel-Teeuwisse AK, Forslund T, Wettermark B, Hjemdahl P. Long-term persistence and adherence with non-vitamin K oral anticoagulants in patients with atrial fibrillation and their associations with stroke risk. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:f72-f80. [PMID: 32324233 PMCID: PMC8117431 DOI: 10.1093/ehjcvp/pvaa017] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/10/2020] [Accepted: 04/16/2020] [Indexed: 12/21/2022]
Abstract
Aims Studies on adherence and persistence with non-vitamin K oral anticoagulant (NOAC) treatment have relied on data from the early years of NOAC availability. We aimed to study long-term adherence and persistence with NOACs and their association with stroke risk. Methods and results From the Stockholm Healthcare database, we included 21 028 atrial fibrillation patients claiming a first NOAC prescription from July 2011 until October 2018, with more than 1000 patients having more than 5 years of follow-up (median: 2.0, interquartile range: 1.0–3.2). Persistence rates, defined as continuing to claim NOAC prescriptions within a 90-day gap, decreased to 70% at the end of follow-up. However, 85% of the patients were treated at the end of the study due to reinitiations. Adherence, calculated as medication possession rate (MPR) in 3 and 6-month intervals among persistent users, remained stable at 90%, with 75% of patients having an MPR >95% throughout the study period. Using a case–control design, we calculated associations of persistence and adherence with stroke risk, adjusting for potential confounders. The outcome was a composite of ischaemic or unspecified stroke and transient ischaemic attack. Non-persistence and poor adherence were both associated with increased stroke risk [non-persistence adjusted odds ratio (aOR): 2.05; 95% confidence interval (CI): 1.49–2.82, 1% reduction MPR aOR: 1.03; CI: 1.01–1.05]. There was no association between non-persistence or poor adherence and the falsification endpoints; fractions and respiratory infections, indicating no ‘healthy-adherer’ effect. Conclusion Persistence rates decreased slowly over time, but persistent patients had high adherence rates. Both non-persistence and poor adherence were associated with an increased stroke risk.
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Affiliation(s)
- Joris J Komen
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands.,Department of Healthcare Development, Stockholm County Council, Magnus Ladulåsgatan 63, 118 27 Stockholm, Sweden
| | - Eibert R Heerdink
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands.,Research Group Innovations of Pharmaceutical Care, University of Applied Sciences Utrecht, Padualaan 101, 3584 CH Utrecht, The Netherlands
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
| | - Tomas Forslund
- Department of Healthcare Development, Stockholm County Council, Magnus Ladulåsgatan 63, 118 27 Stockholm, Sweden.,Department of Medicine Solna, Clinical Epidemiology Unit/Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital Solna, SE-171 76 Stockholm, Sweden
| | - Björn Wettermark
- Department of Healthcare Development, Stockholm County Council, Magnus Ladulåsgatan 63, 118 27 Stockholm, Sweden.,Department of Medicine Solna, Clinical Epidemiology Unit/Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital Solna, SE-171 76 Stockholm, Sweden
| | - Paul Hjemdahl
- Department of Medicine Solna, Clinical Epidemiology Unit/Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital Solna, SE-171 76 Stockholm, Sweden
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39
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Ehrlinder H, Orsini N, Modig K, Hofman-Bang C, Wallén H, Gigante B. Clinical characteristics and antithrombotic prescription in elderly hospitalized atrial fibrillation patients: A cross-sectional analysis of a Swedish single-center clinical cohort. IJC HEART & VASCULATURE 2020; 27:100505. [PMID: 32258363 PMCID: PMC7114891 DOI: 10.1016/j.ijcha.2020.100505] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/27/2020] [Accepted: 03/18/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Antithrombotic treatment represents a dilemma in elderly patients with atrial fibrillation since both risk of thromboembolism and bleeding are age-dependent complications. A paradigm shift occurred over the past 10 years when aspirin was overcome by warfarin and further by the direct oral anticoagulants. Here we present a clinical practice-based analysis of a cohort of elderly inpatient atrial fibrillation patients and investigate the influence of clinical factors in the choice of antithrombotic strategy. METHODS Study participants (n = 2943) are consecutive patients aged 75-104 years discharged from a Swedish university hospital with atrial fibrillation or atrial flutter as main diagnosis between November 1st 2010 and December 31st 2017. Cardiovascular risk factors, comorbidities and antithrombotic treatment at discharge were manually extracted from medical charts. A logistic regression analysis was performed to estimate predictors of the probability to receive direct oral anticoagulants (DOACs) compared to warfarin. RESULTS Patients aged ≥90 y (n = 446, women 73%) showed the highest prevalence of cardiovascular comorbidities and the highest bleeding and thromboembolic risk. DOACs became more commonly prescribed than warfarin in 2016/2017 across all ages. However, the probability to receive DOAC as compared to warfarin was lower in the presence of high bleeding risk (OR 0,55; 95% CI 0,40-0,77; p = 0,00) and high thromboembolic risk (OR 0,74; 95% CI 0,59-0,94; p = 0,01). CONCLUSION Elderly atrial fibrillation patients represent a heterogenous group where the oldest (≥90 years) show both a very high thromboembolic and bleeding risk profile. In the presence of high thromboembolic and bleeding risk, warfarin was still preferred over DOAC.
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Affiliation(s)
- Hanne Ehrlinder
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Nicola Orsini
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Karin Modig
- Unit of Epidemiology. Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Claes Hofman-Bang
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Wallén
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Bruna Gigante
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
- Cardiovascular Medicine Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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40
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Hill NR, Sandler B, Mokgokong R, Lister S, Ward T, Boyce R, Farooqui U, Gordon J. Cost-effectiveness of targeted screening for the identification of patients with atrial fibrillation: evaluation of a machine learning risk prediction algorithm. J Med Econ 2020; 23:386-393. [PMID: 31855091 DOI: 10.1080/13696998.2019.1706543] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Aims: As many cases of atrial fibrillation (AF) are asymptomatic, patients often remain undiagnosed until complications (e.g. stroke) manifest. Risk-prediction algorithms may help to efficiently identify people with undiagnosed AF. However, the cost-effectiveness of targeted screening remains uncertain. This study aimed to assess the cost-effectiveness of targeted screening, informed by a machine learning (ML) risk prediction algorithm, to identify patients with AF.Methods: Cost-effectiveness analyses were undertaken utilizing a hybrid screening decision tree and Markov disease progression model. Costs and outcomes associated with the detection of AF compared traditional systematic and opportunistic AF screening strategies to targeted screening informed by a ML risk prediction algorithm. Model analyses were based on adults ≥50 years and adopted the UK NHS perspective.Results: Targeted screening using the ML risk prediction algorithm required fewer patients to be screened (61 per 1,000 patients, compared to 534 and 687 patients in the systematic and opportunistic strategies) and detected more AF cases (11 per 1,000 patients, compared to 6 and 8 AF cases in the systematic and opportunistic screening strategies). The targeted approach demonstrated cost-effectiveness under base case settings (cost per QALY gained of £4,847 and £5,544 against systematic and opportunistic screening respectively). The targeted screening strategy was predicted to provide an additional 3.40 and 2.05 QALYs per 1,000 patients screened versus systematic and opportunistic strategies. The targeted screening strategy remained cost-effective in all scenarios evaluated.Limitations: The analysis relied on assumptions that include the extended period of patient life span and the lack of consideration for treatment discontinuations/switching, as well as the assumption that the ML risk-prediction algorithm will identify asymptomatic AF.Conclusions: Targeted screening using a ML risk prediction algorithm has the potential to enhance the clinical and cost-effectiveness of AF screening, improving health outcomes through efficient use of limited healthcare resources.
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Affiliation(s)
| | | | | | | | - Thomas Ward
- Health Economics and Outcomes Research Ltd, Cardiff, UK
| | - Rebecca Boyce
- Health Economics and Outcomes Research Ltd, Cardiff, UK
| | | | - Jason Gordon
- Health Economics and Outcomes Research Ltd, Cardiff, UK
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41
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Hou H, Li A, Zhang L, Qin X, Jiang Y, Zhao H. Analysis of Effectiveness, Safety, and Bleeding Related to Rivaroxaban in Elderly Patients. Clin Appl Thromb Hemost 2020; 26:1076029620925923. [PMID: 32453608 PMCID: PMC7370546 DOI: 10.1177/1076029620925923] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study explored the efficacy and safety of rivaroxaban in elderly patients, at different doses and age of patients, and analyzed risk factors of bleeding. A retrospective analysis was conducted of 299 patients aged 60 years or older who were admitted to the First Hospital of Jilin University between January 2016 and August 2018. It was found that the rate of bleeding events (but not embolism) significantly increased as the dose of oral rivaroxaban increased (P < .001), and with age, especially in patients aged ≥80 years (P = .001, both). The multivariate logistic regression analysis indicated that age (odds ratio [OR]: 2.963, 95% CI: 1.627-5.396) and the daily dose of rivaroxaban (OR: 2.325, 95% CI: 1.483-3.645) were independent risk factors for bleeding. The study determined that rivaroxaban anticoagulant therapy is effective in the elderly patients, but the risk of bleeding increases with age, and is a concern especially in the most old patients. The recommended daily dose of rivaroxaban is effective, but a lower dose is safer for the elderly patients.
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Affiliation(s)
- Huimin Hou
- Department of Geriatrics, the First Hospital of Jilin University, Changchun, China
| | - Ang Li
- Genetic Diagnostic Center, the First Hospital of Jilin University, Changchun, China
| | - Liping Zhang
- Department of Cardiovascular Center, the First Hospital of Jilin University, Changchun, China
| | - Xiujiao Qin
- Department of Geriatrics, the First Hospital of Jilin University, Changchun, China
| | - Yanfang Jiang
- Genetic Diagnostic Center, the First Hospital of Jilin University, Changchun, China
| | - Huiying Zhao
- Department of Geriatrics, the First Hospital of Jilin University, Changchun, China
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42
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Silverio A, Di Maio M, Prota C, De Angelis E, Radano I, Citro R, Carrizzo A, Ciccarelli M, Vecchione C, Capodanno D, Galasso G. Safety and efficacy of non-vitamin K antagonist oral anticoagulants in elderly patients with atrial fibrillation: systematic review and meta-analysis of 22 studies and 440 281 patients. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2019; 7:f20-f29. [PMID: 31830264 DOI: 10.1093/ehjcvp/pvz073] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 10/27/2019] [Accepted: 12/10/2019] [Indexed: 12/31/2022]
Abstract
AIMS The aim of the present meta-analysis was to evaluate the efficacy and safety of non-vitamin K oral antagonists (NOACs) vs. vitamin K antagonists (VKAs) in elderly patients with atrial fibrillation (AF) and indirectly compare NOACs in this population. METHODS AND RESULTS MEDLINE, Cochrane, ISI Web of Sciences, and SCOPUS were searched for randomized or adjusted observational studies comparing NOACs vs. VKAs for stroke prevention in AF patients ≥75 years. The primary efficacy and safety outcomes of this meta-analysis were the composite of stroke and systemic embolism (SSE) and major bleedings, respectively. Other secondary outcomes were also analysed. The analysis included 22 studies enrolling 440 281 AF patients ≥ 75 years. The risk of SSE was significantly lower with NOACs vs. VKAs [hazard ratio (HR) 0.79; 95% confidence interval (CI) 0.70-0.89], whereas no differences were found for major bleedings (HR 0.94; 95% CI 0.85-1.05). NOACs reduced the risk of intracranial bleeding (HR 0.46; 95% CI 0.38-0.58), haemorrhagic stroke (HR 0.61; 95% CI 0.48-0.79) and fatal bleeding (HR 0.46; 95% CI 0.30-0.72) but increased gastrointestinal (GI) bleedings (HR 1.46; 95% CI 1.30-1.65), compared to VKAs. The adjusted indirect comparison showed no significant differences in term of SSE between NOAC agents. Conversely, the risk of major bleeding was higher for rivaroxaban vs. apixaban (HR 1.69; 95% CI 1.39-2.08) and edoxaban (HR 1.37; 95% CI 1.14-1.67), and for dabigatran vs. apixaban (HR 1.47; 95% CI 1.18-1.85). CONCLUSION In elderly patients with AF, NOACs are associated to a lower risk of SSE, intracranial bleeding, haemorrhagic stroke and fatal bleeding than VKAs, but increase GI bleedings. In this analysis, the safety profile of individual NOAC agents was significantly different.
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Affiliation(s)
- Angelo Silverio
- Cardiology Unit, Cardiovascular and Thoracic Department, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, Salerno 84131, Italy
| | - Marco Di Maio
- Division of Cardiology, Department of Cardiothoracic and Respiratory Sciences, University of Campania "Luigi Vanvitelli", Monaldi Hospital, A.O.R.N. "Ospedali dei Colli", Naples 80131, Italy
| | - Costantina Prota
- Cardiology Unit, Cardiovascular and Thoracic Department, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, Salerno 84131, Italy
| | - Elena De Angelis
- Cardiology Unit, Cardiovascular and Thoracic Department, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, Salerno 84131, Italy
| | - Ilaria Radano
- Cardiology Unit, Cardiovascular and Thoracic Department, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, Salerno 84131, Italy
| | - Rodolfo Citro
- Cardiology Unit, Cardiovascular and Thoracic Department, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, Salerno 84131, Italy
| | - Albino Carrizzo
- Vascular Pathophysiology Unit, IRCCS Neuromed, Pozzilli, Isernia 86077, Italy
| | - Michele Ciccarelli
- Cardiology Unit, Cardiovascular and Thoracic Department, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, Salerno 84131, Italy
| | - Carmine Vecchione
- Cardiology Unit, Cardiovascular and Thoracic Department, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, Salerno 84131, Italy.,Vascular Pathophysiology Unit, IRCCS Neuromed, Pozzilli, Isernia 86077, Italy
| | - Davide Capodanno
- Division of Cardiology, AOU Policlinico-Vittorio Emanuele, Catania 95100, Italy
| | - Gennaro Galasso
- Cardiology Unit, Cardiovascular and Thoracic Department, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, Salerno 84131, Italy
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43
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Douketis JD, Spyropoulos AC, Duncan J, Carrier M, Le Gal G, Tafur AJ, Vanassche T, Verhamme P, Shivakumar S, Gross PL, Lee AYY, Yeo E, Solymoss S, Kassis J, Le Templier G, Kowalski S, Blostein M, Shah V, MacKay E, Wu C, Clark NP, Bates SM, Spencer FA, Arnaoutoglou E, Coppens M, Arnold DM, Caprini JA, Li N, Moffat KA, Syed S, Schulman S. Perioperative Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant. JAMA Intern Med 2019; 179:1469-1478. [PMID: 31380891 PMCID: PMC6686768 DOI: 10.1001/jamainternmed.2019.2431] [Citation(s) in RCA: 270] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Patients with atrial fibrillation (AF) who use a direct oral anticoagulant (DOAC) and request elective surgery or procedure present a common clinical situation yet perioperative management is uncertain. OBJECTIVE To investigate the safety of a standardized perioperative DOAC management strategy. DESIGN, SETTING, AND PARTICIPANTS The Perioperative Anticoagulation Use for Surgery Evaluation (PAUSE) cohort study conducted at 23 clinical centers in Canada, the United States, and Europe enrolled and screened patients from August 1, 2014, through July 31, 2018. Participants (n = 3007) had AF; were 18 years of age or older; were long-term users of apixaban, dabigatran etexilate, or rivaroxaban; were scheduled for an elective surgery or procedure; and could adhere to the DOAC therapy interruption protocol. INTERVENTIONS A simple standardized perioperative DOAC therapy interruption and resumption strategy based on DOAC pharmacokinetic properties, procedure-associated bleeding risk, and creatinine clearance levels. The DOAC regimens were omitted for 1 day before a low-bleeding-risk procedure and 2 days before a high-bleeding-risk procedure. The DOAC regimens were resumed 1 day after a low-bleeding-risk procedure and 2 to 3 days after a high-bleeding-risk procedure. Follow-up of patients occurred for 30 days after the operation. MAIN OUTCOMES AND MEASURES Major bleeding and arterial thromboembolism (ischemic stroke, systemic embolism, and transient ischemic attack) and the proportion of patients with an undetectable or minimal residual anticoagulant level (<50 ng/mL) at the time of the procedure. RESULTS The 3007 patients with AF (mean [SD] age of 72.5 [9.39] years; 1988 men [66.1%]) comprised 1257 (41.8%) in the apixaban cohort, 668 (22.2%) in the dabigatran cohort, and 1082 (36.0%) in the rivaroxaban cohort; 1007 patients (33.5%) had a high-bleeding-risk procedure. The 30-day postoperative rate of major bleeding was 1.35% (95% CI, 0%-2.00%) in the apixaban cohort, 0.90% (95% CI, 0%-1.73%) in the dabigatran cohort, and 1.85% (95% CI, 0%-2.65%) in the rivaroxaban cohort. The rate of arterial thromboembolism was 0.16% (95% CI, 0%-0.48%) in the apixaban cohort, 0.60% (95% CI, 0%-1.33%) in the dabigatran cohort, and 0.37% (95% CI, 0%-0.82%) in the rivaroxaban cohort. In patients with a high-bleeding-risk procedure, the rates of major bleeding were 2.96% (95% CI, 0%-4.68%) in the apixaban cohort and 2.95% (95% CI, 0%-4.76%) in the rivaroxaban cohort. CONCLUSIONS AND RELEVANCE In this study, patients with AF who had DOAC therapy interruption for elective surgery or procedure, a perioperative management strategy without heparin bridging or coagulation function testing was associated with low rates of major bleeding and arterial thromboembolism.
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Affiliation(s)
- James D Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Alex C Spyropoulos
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, New York
| | - Joanne Duncan
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Marc Carrier
- Ottawa Hospital Research Institute, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Gregoire Le Gal
- L'Institut du Savoir Montfort, L'Hopital Montfort, Ottawa, Ontario, Canada
| | - Alfonso J Tafur
- Department of Surgery, NorthShore University Health Systems, Evanston, Illinois
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Peter Verhamme
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Sudeep Shivakumar
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Peter L Gross
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Agnes Y Y Lee
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Erik Yeo
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Susan Solymoss
- Department of Medicine, Montreal General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jeannine Kassis
- Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Geneviève Le Templier
- Department of Internal Medicine, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Stephen Kowalski
- Department of Anesthesiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mark Blostein
- Department of Medicine, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Vinay Shah
- Department of Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Elizabeth MacKay
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia Wu
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nathan P Clark
- Department of Pharmacy, Kaiser Permanente Colorado, Aurora, Colorado
| | - Shannon M Bates
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Location AMC, the Netherlands
| | - Donald M Arnold
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Joseph A Caprini
- Department of Surgery, NorthShore University Health Systems, Evanston, Illinois
| | - Na Li
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Karen A Moffat
- Hamilton Regional Laboratory Medicine Program, McMaster University, Hamilton, Ontario, Canada
| | - Summer Syed
- Department of Anesthesiology, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
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44
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Kjerpeseth LJ, Selmer R, Ariansen I, Karlstad Ø, Ellekjær H, Skovlund E. Comparative effectiveness of warfarin, dabigatran, rivaroxaban and apixaban in non-valvular atrial fibrillation: A nationwide pharmacoepidemiological study. PLoS One 2019; 14:e0221500. [PMID: 31449560 PMCID: PMC6709911 DOI: 10.1371/journal.pone.0221500] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 08/09/2019] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To compare effectiveness and safety of warfarin and the direct oral anticoagulants (DOAC) dabigatran, rivaroxaban and apixaban in non-valvular atrial fibrillation in routine care. METHODS From nationwide registries, we identified treatment-naïve patients initiating warfarin, dabigatran, rivaroxaban or apixaban for non-valvular atrial fibrillation from July 2013 to December 2015 in Norway. We assessed prescription duration using reverse waiting time distribution. Adjusting for confounding in a Cox proportional hazards model, we estimated one-year risks for ischemic stroke, transient ischemic attack (TIA) or systemic embolism, major or clinically relevant non-major bleeding; intracranial; gastrointestinal; and other bleeding. We censored at switch of treatment or 365 days of follow-up. RESULTS We included 30,820 treatment-naïve patients. Compared to warfarin, the adjusted hazard ratios (HR) for ischemic stroke, TIA or systemic embolism were 0.96 (95% CI 0.71-1.28) for dabigatran, 1.12 (95% CI 0.87-1.45) for rivaroxaban and 0.97 (95% CI 0.75-1.26) for apixaban. Corresponding hazard ratios for major or clinically relevant non-major bleeding were 0.73 (95% CI 0.62-0.86) for dabigatran, 0.97 (95% CI 0.84-1.12) for rivaroxaban and 0.71 (95% CI 0.62-0.82) for apixaban. Statistically significant differences of other safety outcomes compared to warfarin were fewer intracranial bleedings with dabigatran (HR 0.28, 95% CI 0.14-0.56), rivaroxaban (HR 0.40, 95% CI 0.23-0.69) and apixaban (HR 0.56, 95% CI 0.34-0.92); fewer gastrointestinal bleedings with apixaban (HR 0.70, 95% CI 0.52-0.93); and fewer other bleedings with dabigatran (HR 0.67, 95% CI 0.55-0.81) and apixaban (HR 0.70, 95% CI 0.59-0.83). CONCLUSION After 1 year follow-up in treatment-naïve patients initiating oral anticoagulation for non-valvular atrial fibrillation, all DOACs were similarly effective as warfarin in prevention of ischemic stroke, TIA or systemic embolism. Safety from bleedings was similar or better, including fewer intracranial bleedings with all direct oral anticoagulants, fewer gastrointestinal bleedings with apixaban and fewer other bleedings with dabigatran and apixaban.
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Affiliation(s)
- Lars J. Kjerpeseth
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Chronic Diseases and Ageing, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
- * E-mail:
| | - Randi Selmer
- Chronic Diseases and Ageing, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Inger Ariansen
- Chronic Diseases and Ageing, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Øystein Karlstad
- Chronic Diseases and Ageing, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Hanne Ellekjær
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Stroke Unit, Department of Internal Medicine, St. Olav’s Hospital, Trondheim, Norway
| | - Eva Skovlund
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Chronic Diseases and Ageing, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
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Geary L, Hasselström J, Carlsson AC, Eriksson I, von Euler M. Secondary prevention after stroke/transient ischemic attack: A randomized audit and feedback trial. Acta Neurol Scand 2019; 140:107-115. [PMID: 31017305 DOI: 10.1111/ane.13109] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/10/2019] [Accepted: 04/12/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The clinical benefits of use of secondary preventive pharmacotherapy in ischemic stroke/TIA have been previously demonstrated. A potential target for facilitating the use of recommended medications is primary care physicians. Therefore, we carried out an audit and feedback intervention aimed at primary care centers. The aim was to improve the use of secondary preventive stroke medications and diagnosis recording in ischemic stroke/TIA. MATERIALS AND METHODS The intervention consisted of structured, healthcare database-derived quality reports on secondary preventive medication use and diagnosis recording, sent in 2015 to half of the primary care centers in Stockholm County, with information specific to each primary care center. Medication dispensation (primary outcome) for statins, antihypertensives, antiplatelets, and anticoagulants, as well as diagnosis recording (secondary outcome), was compared between intervention centers and control centers in the 18 months following the intervention. Outcome data were derived from the healthcare databases of Stockholm County (VAL). RESULTS Dispensation of medications to the 12 766 patients analyzed in the study was high. Over 77% of patients used antihypertensives and antithrombotics, and 65%-68% used statins. After the intervention, no differences in medication dispensation were seen between the intervention and control centers, even after adjusting for potential confounders. CONCLUSIONS A simple audit and feedback intervention directed toward physicians in primary care did not improve medication dispensation to ischemic stroke/TIA patients 18 months later. Any future audit and feedback intervention aimed at improving adherence to guidelines for secondary prevention in primary care should consider multiple and continuous reminders, the graphical appeal, and widening the recipients to include patients.
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Affiliation(s)
- Lukas Geary
- Karolinska Institutet Stroke Research Network at Södersjukhuset Stockholm Sweden
- Department of Clinical Science and Education, Södersjukhuset Karolinska Institutet Stockholm Sweden
- Unit of Medicine Capio S:t Görans Sjukhus Stockholm Sweden
| | - Jan Hasselström
- Department of Neurobiology, Care Sciences and Society, Section of Family Medicine and Primary Care Karolinska Institutet Stockholm Sweden
- Academic Primary Health Care Center Stockholm County Council Stockholm Sweden
| | - Axel Carl Carlsson
- Department of Neurobiology, Care Sciences and Society, Section of Family Medicine and Primary Care Karolinska Institutet Stockholm Sweden
| | - Irene Eriksson
- Department of Healthcare Development Stockholm County Council Stockholm Sweden
- Department of Medicine Solna Karolinska Institutet Stockholm Sweden
| | - Mia von Euler
- Karolinska Institutet Stroke Research Network at Södersjukhuset Stockholm Sweden
- Department of Clinical Science and Education, Södersjukhuset Karolinska Institutet Stockholm Sweden
- Department of Medicine Solna Karolinska Institutet Stockholm Sweden
- Department of Clinical Pharmacology Karolinska University Hospital Stockholm Sweden
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Steffel J. Stroke Prevention with Non-Vitamin K Oral Anticoagulants: For Most, but Not for All! Cardiology 2019; 143:121-123. [PMID: 31352454 DOI: 10.1159/000501586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 06/14/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Jan Steffel
- Division of Electrophysiology and Cardiac Devices, Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland,
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Abstract
PURPOSE OF REVIEW Despite the increasing use of NOACs, there is still uncertainty on how to treat NOAC patients presenting with neurological emergencies. Initial assessment of coagulation status is challenging but essential in these patients to provide best-possible treatment in case of ischemic or hemorrhagic stroke. Meanwhile, anticoagulation reversal strategies have been suggested; yet, the optimal management is still unestablished. The current review aims to provide up-to-date information on (i) how to identify patients with NOAC intake, (ii) which therapies are feasible in the setting of ischemic and hemorrhagic stroke as well as traumatic intracranial hemorrhage, and (iii) how to proceed with patients requiring emergency lumbar puncture. RECENT FINDINGS Despite several expert opinions, there is still an ongoing debate which NOAC patients presenting with ischemic stroke may benefit from recanalizing strategies and whether these treatment approaches can be performed safely. Results from two phase IV trials investigating the efficacy of NOAC-specific reversal agents in case of major bleeding seem promising with regard to hemostatic parameters, but these antidotes have not been verified to clinically benefit patients, and approval by authorities in parts is still pending. Specific reversal agents are on the way and will provide new treatment options in patients with NOAC-related ischemic and hemorrhagic stroke. Up to now, the decision which patients should undergo recanalizing treatment for ischemic stroke, or which specific pharmacological reversal treatment in hemorrhagic stroke should be initiated, has to be made cautiously on an individual basis after assessing hemostatic parameters.
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Affiliation(s)
- Stefan T Gerner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany.
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Hohnloser SH, Basic E, Nabauer M. Uptake in antithrombotic treatment and its association with stroke incidence in atrial fibrillation: insights from a large German claims database. Clin Res Cardiol 2019; 108:1042-1052. [PMID: 30771066 DOI: 10.1007/s00392-019-01437-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 02/11/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Underuse of oral anticoagulation (OAC) for stroke prevention in atrial fibrillation (AF) results in thousands of preventable strokes in Germany each year. This study aimed to assess changes in antithrombotic therapy in AF patients after increased use of direct oral anticoagulants (DOACs) in Germany and to evaluate whether the adoption of DOAC therapy was associated with changes in AF-related stroke and bleeding over time. METHODS Analyses were carried out on a large claims-based dataset of 4 million health-insured Germans. The study population consisted of 601,261 prevalent AF patients between 2011 and 2016 who were assigned to one of the following four treatment groups: DOAC, VKA, antiplatelets or no antithrombotic treatment. Treatment patterns were descriptively analysed and represented by cohort and CHA2DS2-VASc score. Clinical outcomes before and after the adoption of DOAC therapy were assessed using Poisson regression models. RESULTS Use of OAC increased from 42 to 61% between 2011 and 2016, mainly due to more frequent prescription of DOACs. However, some underuse of OAC therapy remained even in high risk AF patients. In parallel with the increased prescription rate of OAC, there was an overall 24% incidence reduction in stroke between 2011 and 2016 which was mainly driven by reductions in ischemic strokes. Over the same time period the risk for major bleeding remained unchanged. CONCLUSION Between 2011 and 2016, the use of guideline-conform antithrombotic therapy in Germany has significantly increased. This was associated with a significant decline in strokes without an increased incidence of bleeding complications.
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Affiliation(s)
- Stefan H Hohnloser
- Division Clinical Electrophysiology, Department of Cardiology, Johann Wolfgang Goethe University, Frankfurt, Germany.
| | - Edin Basic
- Pfizer Deutschland GmbH, Berlin, Germany
| | - Michael Nabauer
- Department of Cardiology, Ludwig-Maximilians-University, Munich, Germany
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Affiliation(s)
- Jan Steffel
- Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland
| | - John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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