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Botto GL, Capranzano P, Colonna P, Fornasari DMM, Sciatti E, Riva L. Use of DOACs in frail elderly patients in light of class genericization. Int J Cardiol 2024; 411:132276. [PMID: 38880419 DOI: 10.1016/j.ijcard.2024.132276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 06/12/2024] [Accepted: 06/13/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Frailty and comorbidity influence the therapeutic approach in everyday clinical practice. The DOACs genericization opens a reflection on their differences from a pharmacological and bioavailability point of view, particularly in elderly frail patients. The aim of this project was to create a national Delphi consensus on the topic of the use of DOACs for atrial fibrillation (AF) in such patients, in light of the genericization of the class. METHODS AND RESULTS The consensus dealt with 3 main topics: a) efficacy and safety of DOACs in elderly and/or frail patients; b) therapeutic choice in specific frailty scenarios; c) DOACs genericization. 56 cardiologists, two internists and two neurologists from Italy expressed their level of agreement on each statement by using a 5-point Likert scale (1: strongly disagree, 2: disagree, 3: uncertain, 4: agree, 5: strongly agree). A positive consensus was reached if the percentage of agreement (vote 1-2, positive consensus) or disagreement (votes 4-5, negative consensus) was >66%; otherwise, no consensus was reached. Results are displayed accordingly. CONCLUSIONS After 10 years of everyday clinical management of DOACs for AF, specific elements differentiating a molecule from another, either for efficacy or for safety, are consolidated. However, some uncertainties still exist in particular contexts, such as chronic kidney disease or cancer patients. Clinicians have an unsure attitude towards generic drugs, because clinical practice is lacking as well as a proper knowledge of the topic. Albeit being an alternative, the choice of the generic drug must remain the responsibility of the clinician.
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Affiliation(s)
- Giovanni Luca Botto
- Cardiology and Electrophysiology, Department of Medicine, ASST Rhodense, Rho & Garbagnate Hospitals, Italy.
| | - Piera Capranzano
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Italy
| | | | | | | | - Letizia Riva
- Cardiology Department, Maggiore Hospital, Bologna, Italy
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Yin CY, Scott M, Kimura M, Hakimjavadi R, Girard CI, Clarke A, Sood MM, Siegal DM, Tanuseputro P, Fung C, Sobala M, de Wit K, Hsu AT, Backman C, Kobewka D. Oral Anticoagulant Use and Post-Fall Mortality in Long-Term Care Home Residents. J Am Med Dir Assoc 2024:105233. [PMID: 39222662 DOI: 10.1016/j.jamda.2024.105233] [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: 05/08/2024] [Revised: 07/24/2024] [Accepted: 07/29/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVES Long-term care (LTC) residents are susceptible to falling and the risk of subsequent morbidity and mortality may be compounded with concurrent anticoagulation use. Uncertainty exists around the benefit and harm of anticoagulation use for residents with a high risk for falls because of concerns of major bleeding complications. We aimed to examine if anticoagulant use increases mortality risk among LTC residents who fall. DESIGN A retrospective cohort study. SETTING AND PARTICIPANTS Older adults (≥65 years) admitted to a LTC facility in Ontario, Canada between January 1, 2010, and December 1, 2019, who were transferred to emergency departments for fall-related injuries. METHODS The exposure was the use of an oral anticoagulant (OAC). The primary outcome was mortality within 30 days of transfer. Secondary outcomes were major hemorrhage and care utilization. We used hierarchical logistic regression models to examine the association between the use of OAC and 30-day mortality. RESULTS There were 56,419 residents transferred to the hospital for a fall, of whom 9611 (17.0%) were on an OAC. At 30 days, 5794 (10.3%) of the cohort had died: 12.0% (1151) on an OAC and 9.90% (4643) not on an OAC (risk difference [RD], 2.1%; 95% CI, 1.40%-2.82%). There were 485 major hemorrhage cases: 1.3% (125) on an OAC and 0.8% (360) not on an OAC (RD, 0.5%; 95% CI, 0.26%-0.74%). Multivariable analysis found no significant association between OAC use and 30-day mortality (odds ratio [OR], 0.98; 95% CI, 0.90-1.06), but an increased risk of major hemorrhage (OR, 1.31; 95% CI, 1.04-1.66). Both groups had similar health system and neurosurgical care utilization. CONCLUSIONS AND IMPLICATIONS Among LTC residents transferred to the emergency department for fall-related injuries, OACs did not increase the risk of post-fall mortality. OAC prescribing for frail older adults who experience falls should consider their individual risk profile.
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Affiliation(s)
- Christina Y Yin
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Mary Scott
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; The Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Maren Kimura
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Céline I Girard
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; ICES uOttawa, Ottawa, Ontario, Canada
| | - Anna Clarke
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; ICES uOttawa, Ottawa, Ontario, Canada
| | - Manish M Sood
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Deborah M Siegal
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Bruyère Research Institute, Ottawa, Ontario, Canada; ICES uOttawa, Ottawa, Ontario, Canada
| | - Celeste Fung
- St. Patrick's Home of Ottawa, Ottawa, Ontario, Canada; Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Monica Sobala
- St. Patrick's Home of Ottawa, Ottawa, Ontario, Canada
| | - Kerstin de Wit
- Department of Emergency Medicine and Medicine, Queen's University, Kingston, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amy T Hsu
- Bruyère Research Institute, Ottawa, Ontario, Canada; Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Chantal Backman
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Kobewka
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; ICES uOttawa, Ottawa, Ontario, Canada
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Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM, De Potter TJR, Dwight J, Guasti L, Hanke T, Jaarsma T, Lettino M, Løchen ML, Lumbers RT, Maesen B, Mølgaard I, Rosano GMC, Sanders P, Schnabel RB, Suwalski P, Svennberg E, Tamargo J, Tica O, Traykov V, Tzeis S, Kotecha D. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024:ehae176. [PMID: 39210723 DOI: 10.1093/eurheartj/ehae176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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James K, Jamil Y, Kumar M, Kwak MJ, Nanna MG, Qazi S, Troy AL, Butt JH, Damluji AA, Forman DE, Orkaby AR. Frailty and Cardiovascular Health. J Am Heart Assoc 2024; 13:e031736. [PMID: 39056350 DOI: 10.1161/jaha.123.031736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
The incidence of frailty and cardiovascular disease (CVD) increases as the population ages. There is a bidirectional relationship between frailty and CVD, and both conditions share several risk factors and underlying biological mechanisms. Frailty has been established as an independent prognostic marker in patients with CVD. Moreover, its presence significantly influences both primary and secondary prevention strategies for adults with CVD while also posing a barrier to the inclusion of these patients in pivotal clinical trials and advanced cardiac interventions. This review discusses the current knowledge base on the relationship between frailty and CVD, how managing CVD risk factors can modify frailty, the influence of frailty on CVD management, and future directions for frailty detection and modification in patients with CVD.
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Affiliation(s)
- Kirstyn James
- Department of Geriatric Medicine Cork University Hospital Cork Ireland
| | - Yasser Jamil
- Department of Internal Medicine Yale University School of Medicine New Haven CT USA
| | | | - Min J Kwak
- University of Texas Health Science Center at Houston TX USA
| | - Michael G Nanna
- Department of Internal Medicine Yale University School of Medicine New Haven CT USA
| | | | - Aaron L Troy
- Department of Medicine Beth Israel Deaconess Medical Center Boston MA USA
| | - Jawad H Butt
- British Heart Foundation Cardiovascular Research Centre University of Glasgow UK
- Department of Cardiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
- Department of Cardiology Zealand University Hospital Roskilde Denmark
| | - Abdulla A Damluji
- Johns Hopkins University School of Medicine Baltimore MD USA
- The Inova Center of Outcomes Research Inova Heart and Vascular Institute Baltimore MD USA
| | - Daniel E Forman
- Department of Medicine (Geriatrics and Cardiology) University of Pittsburgh PA USA
- Pittsburgh GRECC (Geriatrics Research, Education and Clinical Center) VA Pittsburgh Healthcare System Pittsburgh PA USA
| | - Ariela R Orkaby
- VA Boston Healthcare System Boston MA USA
- Division of Aging, Brigham and Women's Hospital Harvard Medical School Boston MA USA
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Kim D. What Is a Balanced Way of Anticoagulation for Efficacy and Safety in High-Risk Elderly Patients With Atrial Fibrillation? Korean Circ J 2024; 54:407-408. [PMID: 39005073 PMCID: PMC11252632 DOI: 10.4070/kcj.2024.0170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 06/17/2024] [Indexed: 07/16/2024] Open
Affiliation(s)
- Daehoon Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Kim JA, Najam US, Ternes CMP, Marashly Q, Chelu MG. Clinical Outcomes of Early Rhythm or Rate Control for New Onset Atrial Fibrillation Following Transcatheter Aortic Valve Replacement. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07577-x. [PMID: 38869743 DOI: 10.1007/s10557-024-07577-x] [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] [Accepted: 05/08/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND New onset atrial fibrillation (NOAF) is a common occurrence after transcatheter aortic valve replacement (TAVR) and portends a poorer prognosis. The optimal strategy for managing NOAF in this population is uncertain. METHODS This retrospective cohort study utilized deidentified patient data from the TriNetX Research Network. Patients with TAVR and NOAF were stratified into a rhythm control cohort if they were treated with antiarrhythmics, received AF ablation, or underwent cardioversion within 1 year of AF diagnosis. A rate control cohort was similarly defined by the absence of rhythm control strategies and treatment with a beta blocker, calcium channel blocker, or digoxin. After 1:1 propensity score matching, the Kaplan-Meier survival analysis and Cox proportional hazard ratios (HRs) were used to compare outcomes at 7 years of follow-up. RESULTS We identified 569 patients in each cohort following propensity matching. At 7 years, the primary composite outcome of all-cause death, myocardial infarction, cerebrovascular accident, and heart failure hospitalization was not significantly different between the rhythm and rate control cohorts (HR 0.99, 95% CI 0.83-1.18). The individual components of the primary outcome in addition to all-cause hospitalization were also similar between the groups. CONCLUSIONS Similar outcomes were seen among patients receiving an early rhythm or rate control strategy to manage NOAF after TAVR. The attenuated benefits of an early rhythm control strategy observed in this setting may be due to the overall high burden of comorbidities and advanced age of these patients.
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Affiliation(s)
- Jitae A Kim
- Division of Cardiovascular Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 875 Ellicott Street Suite 7030, Buffalo, NY, 14203, USA.
| | - Usman S Najam
- Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Caique M P Ternes
- Postgraduate Program in Cardiology and Cardiovascular Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Qussay Marashly
- Department of Cardiology, Montefiore Medical Center, New York, NY, USA
| | - Mihail G Chelu
- Department of Internal Medicine, Division of Cardiology, Baylor College of Medicine, Houston, TX, USA
- Cardiovascular Research Institute, Baylor College of Medicine, Houston, TX, USA
- Texas Heart Institute at Baylor St. Luke's Medical Center, Houston, TX, USA
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Palacios-Revilla CD, Ramírez-Martín R, Murillo Gayo C, González-Montalvo JI. [Spontaneous intramuscular hematoma in the anterior compartment of the quadriceps in an older patient: About a case]. Rev Esp Geriatr Gerontol 2024; 59:101465. [PMID: 38218134 DOI: 10.1016/j.regg.2023.101465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/11/2023] [Accepted: 12/15/2023] [Indexed: 01/15/2024]
Affiliation(s)
| | - Raquel Ramírez-Martín
- Servicio de Geriatría, Hospital Universitario La Paz, Madrid, España; Instituto de Investigación Hospital Universitario La Paz, IdiPAZ, Madrid, España
| | | | - Juan I González-Montalvo
- Servicio de Geriatría, Hospital Universitario La Paz, Madrid, España; Instituto de Investigación Hospital Universitario La Paz, IdiPAZ, Madrid, España; Departamento de Medicina, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, España
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Rosas Diaz AN, Troy AL, Kaplinskiy V, Pritchard A, Vani R, Ko D, Orkaby AR. Assessment and Management of Atrial Fibrillation in Older Adults with Frailty. Geriatrics (Basel) 2024; 9:50. [PMID: 38667517 PMCID: PMC11050611 DOI: 10.3390/geriatrics9020050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/28/2024] [Accepted: 04/06/2024] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is a major driver of morbidity and mortality among older adults with frailty. Moreover, frailty is highly prevalent in older adults with AF. Understanding and addressing the needs of frail older adults with AF is imperative to guide clinicians caring for older adults. In this review, we summarize current evidence to support the assessment and management of older adults with AF and frailty, incorporating numerous recent landmark trials and studies in the context of the 2023 US AF guideline.
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Affiliation(s)
| | - Aaron L. Troy
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA (A.L.T.)
| | | | - Abiah Pritchard
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA (A.L.T.)
| | - Rati Vani
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA (A.L.T.)
| | - Darae Ko
- Section of Cardiovascular Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, 1200 Center Street, Boston, MA 02131, USA
| | - Ariela R. Orkaby
- New England GRECC (Geriatric Research, Education and Clinical Center), VA Boston Healthcare System, Boston, MA 02130, USA
- Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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9
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Zhang H, Wang S, Jiang X. Effects of Anticoagulant Therapy and Frailty in the Elderly Patients with Atrial Fibrillation [Letter]. Clin Interv Aging 2024; 19:611-612. [PMID: 38628653 PMCID: PMC11020318 DOI: 10.2147/cia.s468526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 04/08/2024] [Indexed: 04/19/2024] Open
Affiliation(s)
- Huaguo Zhang
- Department of Nursing, Beijing Shijitan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Song Wang
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Xiaolian Jiang
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
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Almegren M. Efficacy and Safety of Direct Oral Anticoagulants Versus Warfarin in Saudi Patients With Atrial Fibrillation. Cureus 2024; 16:e58886. [PMID: 38800246 PMCID: PMC11116736 DOI: 10.7759/cureus.58886] [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] [Accepted: 04/22/2024] [Indexed: 05/29/2024] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) significantly heightens stroke risk, which can be mitigated through anticoagulation therapy. Although warfarin was traditionally employed for this purpose, the use of direct-acting oral anticoagulants (DOACs) is on the rise. METHODS This retrospective study, which spanned from June 2016 to January 2018, focused on adult patients diagnosed with AF. Their treatments, either via warfarin or DOACs (apixaban, rivaroxaban, and dabigatran), were evaluated. Data analysis was done using Statistical Product and Service Solutions (SPSS, version 21; IBM SPSS Statistics for Windows, Armonk, NY). This study aims to evaluate the safety and effectiveness of DOACs versus warfarin in preventing thromboembolic complications among Saudi patients with AF. RESULTS A total of 396 patients with AF, averaging 66 ± 14 years of age, were part of the study. Among them, there were slightly more female patients (205 or 51.8%). The majority of patients (223 or 56.3%) were treated with a DOAC, while the rest (173 or 43.7%) received warfarin. Furthermore, 93 patients (23.5%) were taking anti-platelet drugs. Statistically, the rate of ischemic stroke was significantly higher among patients treated with DOACs than with warfarin (p=0.005), but bleeding rates were similar in both groups. Specifically, the DOACs apixaban and rivaroxaban showed a significant association with the occurrence of stroke when compared to warfarin (p=0.012 and p=007, respectively). CONCLUSION Overall, both DOACs and warfarin presented similar results regarding hemorrhagic complications when treating AF patients. However, the DOACs apixaban and rivaroxaban displayed higher risks of ischemic stroke compared to warfarin.
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Affiliation(s)
- Mosaad Almegren
- Department of Medicine, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
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Bo M, Fumagalli S, Degli Esposti L, Perrone V, Dovizio M, Poli D, Marcucci R, Verdecchia P, Reboldi G, Lip GYH, Ungar A, Boccanelli A, Fumagalli C, Marchionni N. Anticoagulation in atrial fibrillation. A large real-world update. Eur J Intern Med 2024; 121:88-94. [PMID: 37879969 DOI: 10.1016/j.ejim.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/03/2023] [Accepted: 10/10/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION In a large nationwide administrative database including ∼35 % of Italian population, we analyzed the impact of oral anticoagulant treatment (OAT) in patients with a hospital diagnosis of non-valvular atrial fibrillation (NVAF). METHODS AND RESULTS Of 170404 OAT-naïve patients (mean age 78.7 years; 49.4 % women), only 61.1 % were prescribed direct oral anticoagulants, DOACs, or vitamin-K antagonists, VKAs; 14.2 % were given aspirin (ASA), and 24.8 % no anti-thrombotic drugs (No Tx). We compared ischemic stroke (IS), IS and systemic embolism (IS/SE), intracranial hemorrhage (ICH), major bleeding (MB), major gastro-intestinal bleeding, all-cause deaths and the composite outcome, across four propensity-score matched treatment cohorts with >15400 patients each. Over 2.9±1.5 years, the incidence of IS and IS/SE was slightly less with VKAs than with DOACs (1.62 and 1.84 vs 1.81 and 1.99 events.100 person-years; HR=0.85, 95%CI=0.76-0.95 and HR=0.87, 95%CI=0.78-0.97). This difference disappeared in a sensitivity analysis which excluded those patients treated with low-dose of apixaban, edoxaban, or rivaroxaban (41.7% of DOACs cohort). Compared with DOACs, VKAs were associated with greater incidence of ICH (1.09 vs 0.81; HR=1.38, 95%CI=1.17-1.62), MB (3.78 vs 3.31; HR=1.14, 95%CI=1.02-1.28), all-cause mortality (9.66 vs 10.10; HR=1.07, 95%CI=1.02-1.11), and composite outcome (13.72 vs 13.32; HR=1.04, 95%CI=1.01-1.08). IS, IS/SE, and mortality were more frequent with ASA or No Tx than with VKAs or DOACs (p<0.001 for all comparisons). CONCLUSIONS Beyond confirming the association with a better net clinical benefit of DOACs over VKAs, our findings substantiate the large proportion of NVAF patients still inappropriately anticoagulated, thereby reinforcing the need for educational programs.
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Affiliation(s)
- Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza, Molinette, Turin, Italy
| | - Stefano Fumagalli
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. Brambilla 3, Florence 50134, Italy.
| | - Luca Degli Esposti
- CliCon Società Benefit Srl, Health, Economics & Outcome Research, Bologna, Italy
| | - Valentina Perrone
- CliCon Società Benefit Srl, Health, Economics & Outcome Research, Bologna, Italy
| | - Melania Dovizio
- CliCon Società Benefit Srl, Health, Economics & Outcome Research, Bologna, Italy
| | - Daniela Poli
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. Brambilla 3, Florence 50134, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. Brambilla 3, Florence 50134, Italy
| | - Paolo Verdecchia
- Fondazione Umbra Cuore e Ipertensione-ONLUS and Struttura Complessa di Cardiologia, Ospedale S. Maria della Misericordia, Perugia, Italy
| | - Gianpaolo Reboldi
- Department of Medicine and Centro di Ricerca Clinica e Traslazionale (CERICLET), University of Perugia, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Danish Centre for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Andrea Ungar
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. Brambilla 3, Florence 50134, Italy
| | | | - Carlo Fumagalli
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. Brambilla 3, Florence 50134, Italy; Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. Brambilla 3, Florence 50134, Italy
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Brunetti E, Presta R, Okoye C, Filippini C, Raspo S, Bruno G, Marabotto M, Monzani F, Bo M. Predictors and Outcomes of Oral Anticoagulant Deprescribing in Geriatric Inpatients With Atrial Fibrillation: A Retrospective Multicenter Cohort Study. J Am Med Dir Assoc 2024; 25:545-551.e4. [PMID: 38359897 DOI: 10.1016/j.jamda.2024.01.011] [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: 07/18/2023] [Revised: 11/28/2023] [Accepted: 01/11/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE To investigate prevalence and predictors of oral anticoagulant therapy (OAT) deprescribing in older inpatients with atrial fibrillation (AF), and its association with 1-year incidence of major clinical outcomes. DESIGN Multicenter retrospective cohort study. SETTING AND PARTICIPANTS Inpatients aged ≥75 years with known AF on OAT at admission discharged from 3 Italian acute geriatric wards between January 2014 and July 2018. METHODS Data from a routine Comprehensive Geriatric Assessment (CGA), along with OAT status at discharge were recorded. One-year incidence of all-cause death, stroke or systemic embolism (SSE), and major and clinically relevant nonmajor bleeding (MB/CRNMB) were retrieved from administrative databases. Associations were explored through multilevel analysis. RESULTS Among 1578 patients (median age 86 years, 56.3% female), OAT deprescription (341 patients, 21.6%) was associated with bleeding risk, functional dependence and cognitive impairment, and inversely, with previous SSE and chronic AF. Incidences of death, SSE, and MB/CRNMB were 56.6%, 1.5%, and 4.1%, respectively, in OAT-deprescribed patients, and 37.6%, 2.9%, and 4.9%, respectively, in OAT-continued patients, without significant differences between groups. OAT deprescription was associated with all-cause mortality [adjusted odds ratio (aOR) 1.41, 95% CI 1.68-1.85], along with older age, comorbidity burden, cognitive impairment, and functional dependence, but with neither SSE nor MB/CRNMB incidence, as opposed to being alive and free from SSE and MB/CNRMB, respectively (aOR 0.68, 95% CI 0.25-1.82, and aOR 0.95 95% CI 0.49-1.85, respectively). Conversely, OAT deprescription was associated with higher odds of being dead than alive both in patients free from SSE and in those free from MB/CRNMB. CONCLUSIONS AND IMPLICATIONS CGA-based OAT deprescribing is common in acute geriatric wards and is not associated with increased SSE. The net clinical benefit of OAT in geriatric patients is strongly related with the competing risk of death, suggesting that functional and cognitive status, as well as residual life expectancy, should be considered in clinical decision making in this population.
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Affiliation(s)
- Enrico Brunetti
- Geriatrics Unit, Department of Medical Sciences, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Roberto Presta
- Geriatrics Unit, Department of Medical Sciences, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Chukwuma Okoye
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy; University of Milano-Bicocca, School of Medicine and Surgery, Milan, Italy
| | | | - Silvio Raspo
- Geriatrics Unit, Hospital Santa Croce e Carle, Cuneo, Italy
| | - Gerardo Bruno
- Geriatrics Unit, Hospital Santa Croce e Carle, Cuneo, Italy
| | | | - Fabio Monzani
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Mario Bo
- Geriatrics Unit, Department of Medical Sciences, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
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Lee DH, Kim YJ, Kim H, Lee HS. Validation of operational definitions of mortality in a nationwide hemodialysis population using the Health Insurance Review and Assessment Service databases of Korea. Kidney Res Clin Pract 2024; 43:156-164. [PMID: 36908201 PMCID: PMC11016677 DOI: 10.23876/j.krcp.22.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/19/2022] [Accepted: 09/09/2022] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Health Insurance Review and Assessment Service's (HIRA) claims data have been used in studies of hemodialysis patients even though information about mortality is not provided in this database. Mortality analysis using HIRA data has been conducted using various operational definitions that have not been validated. This study aimed to validate operational definitions of mortality for maintenance hemodialysis patients that have been used when analyzing the Korean HIRA database. METHODS This study utilized claims data of the Korean National Health Insurance Service (NHIS) between January 2008 and December 2019. We estimated mortality based on operational definitions applied in previous studies using the HIRA database and compared it with NHIS mortality information to validate accuracy. RESULTS A total of 128,876 patients who started maintenance hemodialysis between January 2009 and December 2019 were analyzed. The accuracy of estimated mortality was the highest at 96% in the group where mortality was defined as an absence of claims data for 150 days. If the period of no claims data was set to 90 days or less, there was a risk of overestimating the mortality for the entire study period. When it was set to 180 days or more, there was a risk of underestimating the mortality, as the follow-up time was close to the end of the study period. CONCLUSION When mortality analysis of maintenance hemodialysis patients is performed using HIRA data, it is most accurate to set the operational definition period as the absence of claims data for 150 days.
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Affiliation(s)
- Dong Hee Lee
- Division of Nephrology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Ye-Jee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyangkyoung Kim
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - Hyung Seok Lee
- Division of Nephrology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
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Søgaard M, Ording AG, Skjøth F, Larsen TB, Nielsen PB. Effectiveness and safety of direct oral anticoagulation vs. warfarin in frail patients with atrial fibrillation. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:137-146. [PMID: 37993415 DOI: 10.1093/ehjcvp/pvad091] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/09/2023] [Accepted: 11/21/2023] [Indexed: 11/24/2023]
Abstract
AIMS Although frail patients with atrial fibrillation (AF) carry a high risk of stroke and treatment-related bleeding complications, evidence for the safety and effectiveness of anticoagulation remains sparse. This study investigated the effectiveness and safety of direct oral anticoagulant (DOAC) vs. warfarin in frail AF patients. METHODS AND RESULTS Nationwide registry-based cohort study including 32 048 anticoagulation naïve frail patients (median age 80 years, 53% female) with incident AF during 2012-20. Frailty was assessed using the hospital frailty risk score. To address baseline confounding, we applied inverse probability of treatment weighting (IPTW) and marginal structural models with weighted pooled regression to compute weighted hazard ratios (wHRs) and risk differences for thromboembolism and major bleeding comparing specific DOAC doses with warfarin. After AF diagnosis, 6747 (21.1%) initiated warfarin, 17 076 (50.3%) initiated standard-dose DOAC, and 9179 (28.6%) initiated reduced-dose DOAC. Comparative effectiveness analyses in the IPTW pseudo-populations revealed similar thromboembolism risk between standard-dose DOAC and warfarin [wHR 0.95, 95% confidence interval (CI) 0.80-1.13] and between reduced-dose DOAC and warfarin (wHR 0.97, 95% CI 0.77-1.23). The 1-year thromboembolic event-free survival difference was -0.2% for DOAC, regardless of dosing, vs. warfarin. Major bleeding risk was significantly lower with standard-dose DOAC (wHR 0.69, 95% CI 0.59-0.87) and reduced-dose DOAC (wHR 0.67, 95% CI 0.55-0.81) vs. warfarin. The 1-year bleeding risk difference with DOAC ranged from -1.3% to -3.0%. CONCLUSION Our findings indicate comparable thromboembolism risk and significantly lower bleeding risk with both standard and reduced DOAC regimens compared with warfarin in frail AF patients in routine care.
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Affiliation(s)
- Mette Søgaard
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg University Hospital, 9260 Gistrup, Denmark
| | - Anne Gulbech Ording
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg University Hospital, 9260 Gistrup, Denmark
| | - Flemming Skjøth
- Unit for Clinical Biostatistics, Aalborg University Hospital, 9000 Aalborg, Denmark
| | | | - Peter Brønnum Nielsen
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg University Hospital, 9260 Gistrup, Denmark
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15
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Ding J, Sun Y, Zhang K, Huang W, Tang M, Zhang D, Xing Y. Effects of Anticoagulant Therapy and Frailty in the Elderly Patients with Atrial Fibrillation. Clin Interv Aging 2024; 19:247-254. [PMID: 38375240 PMCID: PMC10875184 DOI: 10.2147/cia.s453527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/30/2024] [Indexed: 02/21/2024] Open
Abstract
Objective This study explored whether anticoagulation is safe for frail and non-frail elderly patients who have nonvalvular atrial fibrillation (NVAF). Methods At hospital discharge, the anticoagulant regimen and frailty status were recorded for 361 elderly patients (aged ≥75 y) with NVAF. The patients were followed for 12 months. The endpoints included occurrence of thrombosis; bleeding; all-cause death; and cardiovascular events. Results At hospital discharge, frailty affected 50.42% of the population and the anticoagulation rate was 44.04%. At discharge, age (OR 0.948, P = 0.006), paroxysmal NVAF (OR 0.384, P < 0.001), and bleeding history (OR 0.396, P = 0.001) were associated with a decrease in rate of receiving anticoagulation, while thrombotic events during hospitalization (OR 2.281, P = 0.021) were associated with an increase. Relative to non-frail patients, those with frailty showed a higher rate of ischemic stroke (5.33% cf. 3.01%), bleeding (P = 0.006) events, and all-cause mortality (P = 0.001). Relative to the group without anticoagulation, in those with anticoagulation the rate of thrombotic events was lower (6.99 cf. 10.98%) and bleeding events were higher (20.98 cf. 12.72%), but the risk of major bleeding was comparable. Conclusion In the elderly patients with NVAF, the decision toward anticoagulation therapy at hospital discharge was influenced by age, bleeding history, paroxysmal atrial fibrillation diagnosis, and absence of thrombosis. Frail patients were at greater risk of bleeding and all-cause mortality. Anticoagulation tended to reduce the risk of thrombotic events.
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Affiliation(s)
- Jiancao Ding
- Department of Geriatrics, First People’s Hospital of Zigong, Sichuan, People’s Republic of China
| | - Ying Sun
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Kan Zhang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Wei Huang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Mei Tang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Dai Zhang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yunli Xing
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
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16
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Shantsila E, Choi EK, Lane DA, Joung B, Lip GY. Atrial fibrillation: comorbidities, lifestyle, and patient factors. THE LANCET REGIONAL HEALTH. EUROPE 2024; 37:100784. [PMID: 38362547 PMCID: PMC10866737 DOI: 10.1016/j.lanepe.2023.100784] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/25/2023] [Accepted: 11/02/2023] [Indexed: 02/17/2024]
Abstract
Modern anticoagulation therapy has dramatically reduced the risk of stroke and systemic thromboembolism in people with atrial fibrillation (AF). However, AF still impairs quality of life, increases the risk of stroke and heart failure, and is linked to cognitive impairment. There is also a recognition of the residual risk of thromboembolic complications despite anticoagulation. Hence, AF management is evolving towards a more comprehensive understanding of risk factors predisposing to the development of this arrhythmia, its' complications and interventions to mitigate the risk. This review summarises the recent advances in understanding of risk factors for incident AF and managing these risk factors. It includes a discussion of lifestyle, somatic, psychological, and socioeconomic risk factors. The available data call for a practice shift towards a more individualised approach considering an increasingly broader range of health and patient factors contributing to AF-related health burden. The review highlights the needs of people living with co-morbidities (especially with multimorbidity), polypharmacy and the role of the changing population demographics affecting the European region and globally.
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Affiliation(s)
- Eduard Shantsila
- Department of Primary Care and Mental Health, University of Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Brownlow Group GP Practice, Liverpool, United Kingdom
| | - Eue-Keun Choi
- Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Republic of Korea
| | - Deirdre A. Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Denmark
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Denmark
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17
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Søgaard M, Jensen M, Højen AA, Larsen TB, Lip GYH, Ording AG, Nielsen PB. Net Clinical Benefit of Oral Anticoagulation Among Frail Patients With Atrial Fibrillation: Nationwide Cohort Study. Stroke 2024; 55:413-422. [PMID: 38252753 DOI: 10.1161/strokeaha.123.044407] [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: 07/03/2023] [Accepted: 12/11/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Frail people with atrial fibrillation are often undertreated with oral anticoagulants (OACs), and evidence for the net clinical benefit (NCB) of OAC is sparse. We, therefore, examined the risk of thromboembolic events, major bleeding, and NCB of anticoagulation treatment. METHODS This was a nationwide cohort study including frail patients aged with incident atrial fibrillation between 2013 and 2018. Patients were categorized according to OAC treatment exposure. One-year risks of thromboembolic events and major bleeding were ascertained where death was treated as a competing risk. The NCB of anticoagulation was assessed by a bivariate trade-off between thromboembolism and bleeding. RESULTS We identified 36 223 frail patients with atrial fibrillation (median age, 79 years; 50.5% female), of whom 61.8% started OAC therapy, while 38.2% were untreated despite indication for stroke prevention. At 1 year, the risk of thromboembolic events was 2.1% (95% CI, 1.8%-2.3%) among patients not receiving OAC versus 1.5% (95% CI, 1.4%-1.7%) in patients with OAC. The bleeding risk was 3.2% (95% CI, 2.9%-3.5%) among patients without OAC versus 3.5% (95% CI, 3.2%-3.8%) among anticoagulated patients. The NCB was 0.70% (95% CI, 0.32%-1.08%), suggesting a benefit of OAC treatment; however, the NCB declined with age and increasing frailty and was lowest among patients >75 years of age or with high frailty level. CONCLUSIONS Frail patients with atrial fibrillation are often untreated with OAC in routine clinical care despite an indication for stroke prevention. The NCB balancing thromboembolic events and major bleeding was in favor of anticoagulation but decreased with advancing age and increasing frailty.
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Affiliation(s)
- Mette Søgaard
- Department of Cardiology (M.S., M.J., A.A.H., T.B.L., A.G.O., P.B.N.), Aalborg University Hospital, Denmark
- Danish Center for Health Services Research (M.S., A.A.H., A.G.O., G.Y.H.L., P.B.N.), Aalborg University Hospital, Denmark
| | - Martin Jensen
- Department of Cardiology (M.S., M.J., A.A.H., T.B.L., A.G.O., P.B.N.), Aalborg University Hospital, Denmark
| | - Anette Arbjerg Højen
- Department of Cardiology (M.S., M.J., A.A.H., T.B.L., A.G.O., P.B.N.), Aalborg University Hospital, Denmark
- Danish Center for Health Services Research (M.S., A.A.H., A.G.O., G.Y.H.L., P.B.N.), Aalborg University Hospital, Denmark
| | - Torben Bjerregaard Larsen
- Department of Cardiology (M.S., M.J., A.A.H., T.B.L., A.G.O., P.B.N.), Aalborg University Hospital, Denmark
| | - Gregory Y H Lip
- Danish Center for Health Services Research (M.S., A.A.H., A.G.O., G.Y.H.L., P.B.N.), Aalborg University Hospital, Denmark
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, United Kingdom (G.Y.H.L.)
| | - Anne Gulbech Ording
- Department of Cardiology (M.S., M.J., A.A.H., T.B.L., A.G.O., P.B.N.), Aalborg University Hospital, Denmark
- Danish Center for Health Services Research (M.S., A.A.H., A.G.O., G.Y.H.L., P.B.N.), Aalborg University Hospital, Denmark
| | - Peter Brønnum Nielsen
- Department of Cardiology (M.S., M.J., A.A.H., T.B.L., A.G.O., P.B.N.), Aalborg University Hospital, Denmark
- Danish Center for Health Services Research (M.S., A.A.H., A.G.O., G.Y.H.L., P.B.N.), Aalborg University Hospital, Denmark
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18
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Pilotto A, Veronese N, Polidori MC, Strandberg T, Topinkova E, Cruz-Jentoft AJ, Custodero C, Barbagallo M, Maggi S. Frailty and anticoagulants in older subjects with atrial fibrillation: the EUROSAF study. Age Ageing 2023; 52:afad216. [PMID: 39248098 PMCID: PMC11373113 DOI: 10.1093/ageing/afad216] [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: 03/16/2023] [Revised: 08/31/2023] [Indexed: 09/10/2024] Open
Abstract
AIMS Literature regarding anticoagulants in older people affected by atrial fibrillation (AF) is limited to retrospective studies, poorly considering the importance of multidimensional frailty. The main objective of this study is to evaluate in hospitalised older persons with AF the benefit/risk ratio of the anticoagulant treatments, considering the severity of frailty, determined by the multidimensional prognostic index (MPI). METHODS In this European, multicentre, prospective study, older hospitalised patients (≥65 years) with non-valvular AF were followed-up for 12 months. Anticoagulants' use at discharge ascertained using medical records. MPI was calculated using tools derived from comprehensive geriatric assessment, classifying participants in robust, pre-frail or frail. Mortality (primary outcome); vascular events, including ischemic heart disease or ischemic stroke, hemorrhagic stroke or gastrointestinal bleedings (secondary outcomes). RESULTS 2,022 participants (mean age 82.9 years; females 56.6%) were included. Compared with people not taking anticoagulants (n = 823), people using vitamin K antagonists (n = 450) showed a decreased risk of mortality (hazard ratio, HR = 0.74; 95% CI: 0.59-0.93), more pronounced in patients using direct oral anticoagulants (DOACs) (n = 749) (HR = 0.46; 95% CI: 0.37-0.57). Only people taking DOACs reported a significantly lower risk of vascular events (HR = 0.55; 95% CI: 0.31-0.97). The efficacy of DOACs was present independently from frailty status. The risk of gastrointestinal bleedings and hemorrhagic stroke did not differ based on the anticoagulant treatments and by MPI values. CONCLUSIONS Anticoagulant treatment, particularly with DOACs, was associated with reduced mortality in older people, without increasing the risk of hemorrhagic events, overall suggesting the importance of treating with anticoagulants older people with AF.
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Affiliation(s)
- Alberto Pilotto
- Geriatrics Unit, Department of Geriatric Care, OrthoGeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy
- Department of Interdisciplinary Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Nicola Veronese
- Geriatrics Unit, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - Maria Cristina Polidori
- Ageing Clinical Research, Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Timo Strandberg
- University of Helsinki and Helsinki University Hospital, Helsinki Finland
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - Eva Topinkova
- First Faculty of Medicine, Charles University in Prague, Czech Republic
| | | | - Carlo Custodero
- Department of Interdisciplinary Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Mario Barbagallo
- Geriatrics Unit, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - Stefania Maggi
- National Research Council, Neuroscience Section, Padova, Italy
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19
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Corica B, Romiti GF, Proietti M. Anticoagulation in Patients With Atrial Fibrillation Who Are Frail-Toward Better Care. JAMA Netw Open 2023; 6:e2342258. [PMID: 37943562 DOI: 10.1001/jamanetworkopen.2023.42258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2023] Open
Affiliation(s)
- Bernadette Corica
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Giulio Francesco Romiti
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
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20
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Fuat A, Ako E, Hargroves D, Holden D, Caleyachetty A, Carter M, Harris J, Roberts C, Nzeakor N, Vardar B, Williams H. Inappropriate dosing of direct oral anticoagulants: findings from a clinical vignette study and physician survey. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2023; 11:2267327. [PMID: 37954532 PMCID: PMC10634268 DOI: 10.1080/20016689.2023.2267327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/03/2023] [Indexed: 11/14/2023]
Abstract
Objective Direct oral anticoagulants (DOACs) are first-line therapy for stroke prevention for 1.4 million atrial fibrillation (AF) patients in the UK. However, the rates of DOAC dosing below evidence-based recommendations are estimated between 9% and 22%. This study explores specific patient and physician factors associated with prescribing inappropriate DOAC underdoses. Methods DOAC-prescribing physicians within the UK completed both a clinical vignette survey, which contained 12 hypothetical patient profiles designed to replicate DOAC prescribing scenarios, and a physician survey to capture sociodemographic, clinical experience, and prescriber-related beliefs and motivations related to DOAC prescribing. Eight patient factors based on a literature search and an expert consultation process were varied within the vignettes. Associations between the prescribers' dosing choices and patient factors were explored via multilevel logistic regression. The analysis is focused on the most frequently selected DOACs, apixaban and rivaroxaban, both of which have different dosing guidelines. Results In all, 336 prescribers (69% male; 233/336) completed the survey, mostly general physicians (GPs) (45%) or cardiology specialists (36%) with a mean of 17.9 years' experience. Most prescribers (73%; 244/336) inappropriately underdosed at least once; rates between GPs and specialists were nearly identical. Patient factors most strongly associated with apixaban inappropriate underdosing included a history of major bleeding and falls. For rivaroxaban, these were major bleeding and severe frailty. Only 32% (106/335) of prescribers reported DOAC dosing guidelines as the sole influence on their prescribing behaviour. Among prescribers who did not inappropriately underdose, greater prescribing confidence was aligned to increased perception of inappropriate underdose risk. Conclusions Overall, patient factors such as major bleeding and severe frailty were found to be associated with inappropriate underdosing of apixaban and rivaroxaban. Furthermore, prescribers who were more confident in DOAC prescribing, and were more worried about the risk of stroke, were significantly less likely to inappropriately underdose. These findings suggest that all prescribers, regardless of speciality, may benefit from education and training to raise awareness of the risks associated with inappropriate DOAC underdosing.
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Affiliation(s)
- Ahmet Fuat
- Carmel Medical Practice, Nunnery Lane, Darlington, UK
| | - Emmanuel Ako
- Cardiology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - David Hargroves
- Stroke Medicine, East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | | | | | | | | | | | | | | | - Helen Williams
- Department of Medicines Optimisation, South East London Integrated Care System, and UCL Partners, London, UK
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21
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Hu J, Zhou Y, Cai Z. Outcome of novel oral anticoagulant versus warfarin in frail elderly patients with atrial fibrillation: a systematic review and meta-analysis of retrospective studies. Acta Clin Belg 2023; 78:367-377. [PMID: 36814097 DOI: 10.1080/17843286.2023.2179908] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 02/08/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Frail patients with atrial fibrillation (AF) are thought to be at a higher risk for cerebral infarction and death than patients who are not frail, making preventive interventions important. Anticoagulants should be used in frailty patients with AF. However, there are limited data about anticoagulants in frail patients with AF. Therefore, we concucted this meta-analysis to find the best anticoagulation strategy. METHODS Systematic electronic searches were conducted on 4 July 2022 4 July 2022, in PubMed, Embase (Ovid), and Cochrane Library. Relevant and eligible cohort studies were included. A random-effects model was used to estimate the pooled Hazard ratio (HR) and 95% confidence intervals (CI). Furthermore, we performed a publication bias analysis and subgroup analysis to explore the source of heterogeneity. RESULT 3 publications (10 cohorts, 188573 participants) met our inclusion criteria. The pooled analysis showed that ischemic strokes (HR: 0.75; 95%CI: 0.71 to 0.79; I2 = 60.2%), systemic embolism (HR: 0.75; 95%CI: 0.64 to 0.87; I = 68.6%), major bleeding(HR: 0.76; 95%CI: 0.64 to 0.89; I2 = 97.4%), intracranial hemorrhage (HR: 0.57; 95%CI: 0.45 to 0.71; I2 = 54.6%) and cardiovascular death(HR: 0.61; 95%CI: 0.51 to 0.70; I2 = 83.2%) were lower in NOACs as compared with warfarin. Regarding gastrointestinal bleeding, meta-analysis showed no significant differences in the risk of gastrointestinal bleeding (HR: 0.97; 95%CI: 0.69 to 1.36; I2 = 95.9%). . CONCLUSION NOAC was more effective and safety than warfarin in frail patients with AF.
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Affiliation(s)
| | - Yidan Zhou
- Department of Emergency Medicine, Hangzhou Third People's Hospital, Hangzhou, China
| | - Zhaobin Cai
- Department of Emergency Medicine, Hangzhou Third People's Hospital, Hangzhou, China
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22
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Troy AL, Herzig SJ, Trivedi S, Anderson TS. Initiation of oral anticoagulation in US older adults newly diagnosed with atrial fibrillation during hospitalization. J Am Geriatr Soc 2023; 71:2748-2758. [PMID: 37092856 PMCID: PMC10523931 DOI: 10.1111/jgs.18375] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/09/2023] [Accepted: 03/29/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND Atrial fibrillation is a common cause of stroke among older adults and is often first detected during hospitalization, given frequent use of cardiac telemetry. METHODS In a 20% national sample of Medicare fee-for-service beneficiaries, we identified patients aged 65-or-older newly diagnosed with atrial fibrillation while hospitalized in 2016. Our primary outcome was an oral anticoagulant claim within 7-days of discharge. Multivariable logistic regression analyses assessed relationships between anticoagulation initiation and thromboembolic and bleeding risk scores while controlling for demographics, frailty, comorbidities, and hospitalization characteristics. RESULTS Among 38,379 older adults newly diagnosed with atrial fibrillation while hospitalized (mean age 78.2 [SD 8.4]; 51.8% female; 83.3% white), 36,633 (95.4%) had an indication for anticoagulation and 24.6% (9011) of those initiated an oral anticoagulant following discharge. Higher CHA2 DS2 -VASc score was associated with a small increase in oral anticoagulant initiation (predicted probability 20.5% [95% CI, 18.7%-22.3%] for scores <2 and 24.9% [CI, 24.4%-25.4%] for ≥4). Elevated HAS-BLED score was associated with a small decrease in probability of anticoagulant initiation (25.4% [CI, 24.4%-26.4%] for score <2 and 23.1% [CI, 22.5%-23.8%] for ≥3). Frailty was associated with decreased likelihood of oral anticoagulant initiation (24.7% [CI, 23.2%-26.2%] for non-frail and 18.1% [CI, 16.6%-19.6%] for moderately-severely frail). Anticoagulant initiation varied by primary reason for hospitalization, with predicted probability highest among patients with a primary diagnosis of atrial fibrillation (46.1% [CI, 45.0%-47.3%]) and lowest among those with non-cardiovascular conditions (13.8% [CI, 13.3%-14.3%]) and bleeds (3.6% [CI, 2.4%-4.8%]). CONCLUSIONS Oral anticoagulant initiation is uncommon among older adults newly diagnosed with atrial fibrillation during hospitalization, even among patients hospitalized primarily for atrial fibrillation and patients with high thromboembolic risk. Clinicians should discuss risks and benefits of oral anticoagulants with all inpatients found to have atrial fibrillation.
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Affiliation(s)
- Aaron L. Troy
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Shoshana J. Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA
| | - Shrunjal Trivedi
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Timothy S. Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA
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Geller AI, Shehab N, Lovegrove MC, Weidle NJ, Budnitz DS. Bleeding related to oral anticoagulants: Trends in US emergency department visits, 2016-2020. Thromb Res 2023; 225:110-115. [PMID: 37062120 PMCID: PMC10870325 DOI: 10.1016/j.thromres.2023.03.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/12/2023] [Accepted: 03/21/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Clinical trials suggest lower rates of major bleeding with direct-acting oral anticoagulants (DOACs) than with warfarin, but anticoagulant-related bleeding remains one of the most common outpatient adverse drug events. METHODS We estimated the number of emergency department (ED) visits and subsequent hospitalizations for oral anticoagulant-related bleeding in 2016-2020 based on active surveillance in a nationally representative, size-stratified probability sample of 60 U.S. hospitals. We estimated rates of ED visits using a nationally-projected retail prescription dispensing database. RESULTS Based on 19,557 cases, oral anticoagulant-related bleeding resulted in an estimated 1,270,259 (95 % Confidence Interval [CI], 644,686-1,895,832) ED visits for the five years 2016-2020, of which 47.8 % (95 % CI, 40.6 %-55.0 %) resulted in hospitalization. Oral anticoagulant-related bleeding resulted in an estimated 230,163 (95% CI, 109,598-350,728) ED visits in 2016 and 301,433 (95% CI, 138,363-464,503) in 2020. During 2016-2020, ED visits for DOAC-related bleeding increased by an average of 27.9 % (95 % CI, 24.0 %-32.0 %; p < .001) per year, while ED visits for warfarin-related bleeding decreased by an average of 8.8 % (95 % CI, -10.7 % to -7.0 %; p = .001) per year. The estimated rate of bleeding visits per 100 patients dispensed oral anticoagulants at least once in 2016-2020 was highest for patients aged ≥ 80 years (13.1; 95 % CI, 6.2-20.0) and lowest for those aged <45 years (4.0; 95 % CI, 2.6-5.5); it was 5.9 visits per 100 patients dispensed DOACs [95 % CI, 2.5-9.2] and 13.0 visits per 100 patients dispensed warfarin [95 % CI, 7.4-18.7]. CONCLUSIONS Although the rates of ED visits for anticoagulant-related bleeding may be lower for DOACs than for warfarin, persistently large numbers of patients requiring ED visits for anticoagulant-related bleeding despite increased use of DOACs and declining use of warfarin suggest that efforts to improve appropriate prescribing and monitoring of anticoagulants remain important.
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Affiliation(s)
- Andrew I Geller
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA.
| | - Nadine Shehab
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA; Lantana Consulting Group, Atlanta, GA, USA
| | - Maribeth C Lovegrove
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Nina J Weidle
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA; Eagle Global Scientific, LLC, Atlanta, GA, USA
| | - Daniel S Budnitz
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
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Use of Direct Acting Oral Anticoagulants in Elderly Patients with Atrial Fibrillation: A Multicenter, Cross-Sectional Study in Spain. J Clin Med 2023; 12:jcm12031224. [PMID: 36769872 PMCID: PMC9917412 DOI: 10.3390/jcm12031224] [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: 12/01/2022] [Revised: 01/26/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023] Open
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) have substantially improved anticoagulation. However, data on NOAC use among elderly patients are scarce. We sought to describe NOAC use among elderly AF patients in Spain. We performed a non-interventional, multicenter, multispecialty, cross-sectional study in elderly (≥75 years) AF patients treated with NOACs for stroke prevention. Patients' characteristics by NOAC treatment were compared using standardized differences (SDD). NOAC dosing was classified according to the Spanish summary of products characteristics (SmPC) into appropriate (recommended dose) and inappropriate (under and overdosed). Multivariate logistic regression analyses were used to explore factors associated with inappropriate dosing. 500 patients were included. Mean (SD) age was 81.5 (4.7) years, and 50% were women. Mean (SD) creatinine clearance was 57.4 mL/min (18.8), and 23.6% were frail. Dabigatran treatment totaled 38.4%, rivaroxaban 15.2%, apixaban 33.2%, and edoxaban 13.2%. Almost one-fourth of elderly patients treated with NOACs in Spain were inappropriately dosed (underdosing 14.4% and overdosing 9.6%). Underdosing was significantly associated with weight (OR = 1.03, 95%CI = 1.0-1.1), while higher a EHRA score decreased the risk of underdosing (OR = 0.47, 95%CI = 0.2-1.0). Overdosing was significantly associated with a history of ischemic stroke (OR = 2.95, 95%CI = 1.1-7.7). Addressing incorrect dosing among elderly AF patients is relevant to improve patient outcomes.
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25
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Role of cerebral microbleeds in acute ischemic stroke and atrial fibrillation. J Thromb Thrombolysis 2022; 55:553-565. [PMID: 36571659 DOI: 10.1007/s11239-022-02761-y] [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] [Accepted: 12/17/2022] [Indexed: 12/27/2022]
Abstract
Cerebral microbleeds (CMBs) are commonly detected in the brains of patients with acute ischemic stroke (AIS). With the development of neuroimaging, clinicians are paying more attention to the presence of CMBs. CMBs were found to significantly increase the risk of intracranial hemorrhagic transformation and hemorrhage in patients with AIS, especially in patients with concurrent atrial fibrillation (AF). Additionally, the presence of CMBs is thought to be a symbol of a high risk of recurrent ischemic stroke (IS). A few researchers have found that the presence of CMBs has no significant effect on the prognosis of patients with AIS. Therefore, the current views on the role of CMBs in the prognoses of patients with IS are controversial. The use of anticoagulants and other drugs has also become a dilemma due to the special influence of CMBs on the prognosis of these patients. Due to the large number of patients with AF and CMBs, many studies have been conducted on the effects of CMBs on these patients and subsequent pharmacological treatments. However, at present, there are no relevant guidelines to guide the secondary preventive treatment of patients with stroke, CMBs, and AF. In this paper, we summarized the role of CMBs in AIS combined with AF and relevant preventive measures against the recurrence of stroke and the occurrence of intracerebral hemorrhage to help clarify the specifics of drug therapies for this group of patients.
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26
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Manwani B, Finger C, Lisabeth L. Strategies for Maintaining Brain Health: The Role of Stroke Risk Factors Unique to Elderly Women. Stroke 2022; 53:2662-2672. [PMID: 35652344 PMCID: PMC10911965 DOI: 10.1161/strokeaha.121.036894] [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] [Indexed: 11/16/2022]
Abstract
Stroke risk and prevalence increase with advanced age and women tend to be older than men at the time of their first stroke. Advanced age in women confers unique stroke risks that are beyond reproductive factors. Previous reviews and guidelines have largely focused on risk factors specific to women, with a predominant focus on reproductive factors and, therefore, younger to middle-aged women. This review aims to specifically describe stroke risk factors in elderly women, the population of women where the majority of strokes occur, with a focus on atrial fibrillation, hormone therapy, psychosocial risk factors, and cognitive impairment. Our review suggests that prevention and management of stroke risks that are unique or more prevalent in elderly women needs a coordinated system of care from general physicians, general neurologists, vascular and cognitive neurologists, psychologists, cardiologists, patients, and their caretakers. Early identification and management of the elderly woman-specific and traditional stroke risk factors is key for decreasing stroke burden in elderly women. Increased education among elderly women regarding stroke risk factors and their identification should be considered, and an update to the guidelines for prevention of stroke in women is strongly encouraged.
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Affiliation(s)
- Bharti Manwani
- Department of Neurology, University of Texas Health Science Center at Houston (B.M., C.F.)
| | - Carson Finger
- Department of Neurology, University of Texas Health Science Center at Houston (B.M., C.F.)
| | - Lynda Lisabeth
- Department of Epidemiology, University of Michigan, Ann Arbor (L.L.)
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27
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Gosch M. [Pharmacological treatment of cardiovascular diseases in old age : Geriatic perspective]. Z Gerontol Geriatr 2022; 55:471-475. [PMID: 35849160 DOI: 10.1007/s00391-022-02084-w] [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] [Accepted: 06/24/2022] [Indexed: 11/25/2022]
Abstract
Cardiovascular diseases have the highest prevalence in advanced age. Nevertheless, older age groups are frequently underrepresented in randomized controlled trials (RCT). Consequently, in many cases the evidence is often insufficient. Therefore, recommendations from guidelines can only be transferred to this age group to a limited extent. Due to the complexity and vulnerability of geriatric patients, individual considerations in pharmacological therapy are often required. In the following article, the pharmacotherapy of some relevant cardiovascular diseases is discussed from the perspective of a geriatric treatment approach.
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Affiliation(s)
- Markus Gosch
- Klinikum Nürnberg, Medizinische Klinik 2 - Schwerpunkt Geriatrie, Paracelsus Medizinische Privatuniversität Nürnberg, Prof.-Ernst-Nathan-Str. 1, 90419, Nürnberg, Deutschland.
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28
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Chattopadhyay RK, Pugh PJ, Vassiliou VS. Anthropometric parameters and AF outcomes: a path to precision medicine. Eur J Prev Cardiol 2022; 29:1965-1966. [PMID: 35831934 DOI: 10.1093/eurjpc/zwac146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Rahul K Chattopadhyay
- Department of Cardiology, Cambridge University Teaching Hospitals, UK.,Department of Medicine, Norwich Medical School, University of East Anglia
| | - Peter J Pugh
- Department of Cardiology, Cambridge University Teaching Hospitals, UK.,Department of Medicine, Norwich Medical School, University of East Anglia
| | - Vassilios S Vassiliou
- Department of Cardiology, Cambridge University Teaching Hospitals, UK.,Department of Medicine, Norwich Medical School, University of East Anglia.,Department of Cardiology, Norfolk and Norwich University Hospital
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