Baseline characteristics in stroke patients with atrial fibrillation: clinical trials versus clinical practice

Comprehensive Geriatric Care in Older Adults: Walking Ability after an Acute Fracture

BACKGROUND/OBJECTIVES

Comprehensive Geriatric Care (CGC) is a specific multimodal treatment for older patients. In the current study, we aimed to investigate walking performance after CGC in medically ill patients versus those with fractures.

METHODS

The timed up and go test (TuG), a 5-grade scale assessment (1 = no walking impairment to 5 = no walking ability at all) for evaluating individual walking ability was performed in all patients who underwent CGC prior to and after treatment. Factors associated with improvement in walking ability were analyzed in the subgroup of patients with fractures.

RESULTS

Out of 1263 hospitalized patients, 1099 underwent CGC (median age: 83.1 years (IQR 79.0-87.8 years); 64.1% were female). Patients with fractures (n = 300) were older than those without (n = 799), (median 85.6 versus 82.4 years, p = 0.001). Improvement in TuG after CGC was found in 54.2% of the fracture patients compared to just 45.9% of those without fractures. In fracture group patients, TuG improved from median 5 on admission to median 3 on discharge (p = 0.001). In fracture patients, improvement in walking ability was associated with higher Barthel index values on admission (median 45 (IQR: 35-55) versus 35 (IQR: 20-50): p = 0.001) and Tinetti assessment scores (median 9 (IQR: 4-14.25) versus 5 (IQR: 0-13); p = 0.001) and was negatively associated with the diagnosis of dementia (21.4% versus 31.5%; p = 0.058).

CONCLUSION

CGC improved walking ability in more than half of all patients examined. Older patients in particular might benefit from undergoing the procedure after an acute fracture. A better initial functional status favors a positive result following the treatment.

Evaluation of ECG Features for the Classification of Post-Stroke Survivors with a Diagnostic Approach

Stroke is considered as a major cause of death and neurological disorders commonly associated with elderly people. Electrocardiogram (ECG) signals are used as a powerful tool in diagnosing stroke, and the analysis of ECG signals has become the focus of stroke research. ECG changes and autonomic dysfunction are reportedly seen in patients with stroke. This study aimed to analyze the ECG features and develop a classification model with highly ranked ECG features as input variables based on machine-learning techniques for diagnosing stroke disease. The study included 52 stroke patients (mean age 72.7 years, 63% male) and 80 control subjects (mean age 75.5 years, 39% male) for a total of 132 elderly subjects. Resting ECG signals in the lying down position are measured using the BIOPAC MP150 system. The ECG signals are denoised using the discrete wavelet transform (DWT) method, and the features such as heart rate variability (HRV), indices of time and spectral domains and statistical and impulsive metrics, in addition to fiducial features, are extracted and analyzed. Our results showed that the values of the HRV variables were lower in the stroke group, revealing autonomic dysfunction in stroke patients. A statistically significant difference was observed in low-frequency (LF)/high-frequency (HF), time interval measured after the S wave to the beginning of the T wave (ST) and time interval measured from the beginning of the Q wave to the end of the T wave (QT) (p < 0.05) between the groups. Our study also highlighted some of the risk factors of stroke, such as age, male sex and dyslipidemia (p < 0.05), that are statistically significant. The k-nearest neighbors (KNN) model showed the highest classification results (accuracy 96.6%, precision 94.3%, recall 99.1% and F1-score 96.6%) than the random forest, support vector machine (SVM), Naïve Bayes and logistic regression models. Thus, our study reported some of the notable ECG changes in the study participants and also indicated that ECG could aid in diagnosing stroke disease.

Real-world on-treatment and initial treatment absolute risk differences for dabigatran vs warfarin in older US adults

PURPOSE

Trials and past observational work compared dabigatran and warfarin in patients with atrial fibrillation, but few reported estimates of absolute harm and benefit under real-world adherence patterns, particularly in older adults that may have differing benefit-harm profiles. We aimed to estimate risk differences for ischemic stroke, death, and gastrointestinal bleeding after initiating dabigatran and warfarin in older adults (a) when patients adhere to treatment and (b) under real-world adherence patterns.

METHODS

In a 20% sample of nationwide Medicare claims from 2010 to 2015, we identified beneficiaries aged 66 years and older initiating warfarin and dabigatran. We followed individuals from initiation until death or October 2015 (initial treatment, IT) and separately censored individuals' follow-up after drug switches and gaps in supply (on-treatment, OT). We applied inverse probability of treatment and standardized morbidity ratio weights, as well as inverse probability of censoring weights, to estimate two-year risk differences (RDs) for dabigatran vs warfarin.

RESULTS

We identified 10,717 dabigatran and 74,891 warfarin initiators. Weighted OT RDs suggested decreased ischemic stroke risk for dabigatran vs warfarin; IT RDs indicated increased or no change in ischemic stroke risk. Regardless of follow-up approach and weighting strategy, risk of death appeared lower and risk of gastrointestinal bleeding appeared higher when comparing dabigatran vs warfarin.

CONCLUSIONS

Dabigatran use was associated with lower risks of mortality and ischemic stroke in routine care when older adults stayed on treatment. IT analyses suggested that these benefits may be diminished under real-world patterns of switching and discontinuation.

Adherence to recommendations of the Therapeutic Positioning Report about treatment with oral anticoagulants in elderly patients with atrial fibrillation. The ESPARTA study

BACKGROUND AND OBJECTIVE

To evaluate the adherence to the recommendations in clinical practice performed by the Therapeutic Positioning Report (TPR) of the Spanish Agency of Medicines and Sanitary Products about the treatment with oral anticoagulants in patients aged≥75 years old with nonvalvular atrial fibrillation (NVAF) treated in Internal Medicine departments in Spain.

PATIENTS AND METHODS

Observational, cross-sectional and multicenter study in which 837 patients aged≥75 years old with NVAF, with stable treatment with oral anticoagulants at least 3 months before inclusion, and that had started treatment with oral anticoagulants before the inclusion period were included.

RESULTS

Mean age was 83.0±5.0 years old, mean CHADS₂ score 3.2±1.2, mean CHA₂DS₂-VASc score 5.0±1.4, and mean HAS-BLED score 2.1±0.9. A percentage of 70.8 of patients were treated with vitamin K antagonists (VKA) and the rest of patients with direct oral anticoagulants (DOACs). A percentage of 65.6 of patients treated with VKA did not follow the recommendations made by the TPR compared with 43.0% of patients treated with DOACs (P<.0001). In the case of VKA, the main reason for being considered as not appropriate according to the TPR was having poor control of anticoagulation and not switching to DOACs, whereas in the case of DOACs, it was not receiving the adequate dose according to the TPR.

CONCLUSIONS

In a high proportion of anticoagulated elderly patients with NVAF in Spain, the recommendations performed by the TPR are not followed, particularly with VKA, since patients are not switched to DOACs despite time in therapeutic range.

Has the clinical profile of patients with nonvalvular atrial fibrillation treated with rivaroxaban changed in the last 5 years of use?

AIM

To analyze the evolution of clinical profile of patients with nonvalvular atrial fibrillation treated with rivaroxaban.

METHODS

Retrospective study in which patients treated with rivaroxaban were divided into two groups according to the data in which the initial prescription was performed (November 2012-December 2013 and January 2014-January 2017).

RESULTS

211 patients (mean age 76.7 ± 9.2 years; CHA₂DS₂-VASc 3.8 ± 1.5; HAS-BLED 2.0 ± 0.8.) were included. Age and bleeding risk were higher in those subjects in which the prescription started earlier. Rates of stroke/TIA, major bleeding and intracranial hemorrhage were 2.3/4.2/0.6 events/100 patient-years, respectively.

CONCLUSION

Although, the initial prescription of rivaroxaban was mainly performed in very elderly patients and/or with a higher bleeding risk, this has been extended to the overall nonvalvular atrial fibrillation population.

Ischaemic and haemorrhagic stroke associated with non-vitamin K antagonist oral anticoagulants and warfarin use in patients with atrial fibrillation: a nationwide cohort study

Background

Non-vitamin K antagonist (VKA) oral anticoagulants (NOACs) are widely used as stroke prophylaxis in non-valvular atrial fibrillation (AF), but comparative data are sparse.

Purpose

To compare dabigatran, rivaroxaban, and apixaban vs. VKA and the risk of stroke/thromboembolism (TE) and intracranial bleeding in AF.

Methods

Using Danish nationwide registries (2011-15), anticoagulant-naïve AF patients were identified when initiating VKA or an NOAC. Outcomes were stroke/TE and intracranial bleeding. Multiple outcome-specific Cox regression was performed to calculate average treatment effects as standardized differences in 1-year absolute risks.

Results

Overall, 43 299 AF patients initiated VKA (42%), dabigatran (29%), rivaroxaban (13%), and apixaban (16%). Mean CHA2DS2-VASc (SD) score was: VKA 2.9 (1.6), dabigatran 2.7 (1.6), rivaroxaban 3.0 (1.6), and apixaban 3.1 (1.6). Within patient-specific follow-up limited to the first 2 years, 1054 stroke/TE occurred and 261 intracranial bleedings. Standardized absolute risk (95% CI) of stroke/TE at 1 year after initiation of VKA was 2.01% (1.80% to 2.21%). In relation to VKA, the absolute risk differences were for dabigatran 0.11% (-0.16% to 0.42%), rivaroxaban 0.05% (-0.33% to 0.48%), and apixaban 0.45% (-0.001% to 0.93%). For the intracranial bleeding outcome, the standardized absolute risk at 1 year was for VKA 0.60% (0.49% to 0.72%); the corresponding absolute risk differences were for dabigatran -0.34% (-0.47% to - 0.21%), rivaroxaban -0.13% (-0.33% to 0.08%), and apixaban -0.20% (-0.38% to - 0.01%).

Conclusions

Among anticoagulant-naïve AF patients, treatment with NOACs was not associated with significantly lower risk of stroke/TE compared with VKA, but intracranial bleeding risk was significantly lower with dabigatran and apixaban.

Effectiveness and safety of rivaroxaban in a cohort of 142 patients with nonvalvular atrial fibrillation treated with rivaroxaban for the prevention of stroke

Aim: To evaluate the clinical profile and effectiveness/safety of patients taking rivaroxaban in clinical practice. Methods: Retrospective study that included patients with nonvalvular atrial fibrillation treated with rivaroxaban for the prevention of stroke between January 2012 and December 2016 in a tertiary hospital in Spain. Results: A total of 142 patients (median age 78 years, 40.1% men, 32.4% creatinine clearance <50 ml/min; 96.5% CHA2DS2-VASc ≥2; 44.3% HAS-BLED ≥3) were included. Only two patients had a thromboembolic event (in both cases ischemic stroke) and three patients had major bleeding (rates of 1.3 and 1.9 events/100 patient years, respectively). Conclusion: Data regarding effectiveness and safety in our cohort were consistent with previous studies, showing that rivaroxaban can be effective and safely used in our setting.

Use of rivaroxaban for the prevention of stroke in patients with nonvalvular atrial fibrillation in Spain

Aim: To analyze the clinical profile and rates of stroke, major bleeding and intracranial hemorrhage of patients with atrial fibrillation (AF) treated with rivaroxaban in clinical practice. Methods: Retrospective study of AF patients anticoagulated with rivaroxaban in a Healthcare Area of Valencia, Spain. Patients started treatment with rivaroxaban from July 2012 to December 2015. Results: A total of 230 patients (mean age 76.9 ± 9.9 years; CHA2DS2-VASc 4.3 ± 1.7; HAS-BLED 1.7 ± 0.9) were included. Rates of stroke, major bleeding and intracranial bleeding were 0.4, 1.9 and 0.5 events per 100 patient-years, respectively. Conclusion: In this cohort of AF patients anticoagulated with rivaroxaban, despite patients being older and having a high thromboembolic risk, rates of stroke, major bleeding and intracranial bleeding were low.

Clinical characteristics and type of antithrombotic treatment in a Spanish cohort of elderly patients with atrial fibrillation according to dependency, frailty and cognitive impairment

BACKGROUND

Available data regarding clinical profile and management of elderly patients with atrial fibrillation (AF) according to dependency, fragility and cognitive impairment are scarce. The objective of the study was to analyze the biodemographic data, clinical profile and antithrombotic treatment according to dependency, fragility and cognitive impairment in elderly AF patients.

METHODS

Cross-sectional and multi-center study performed in consecutive AF patients ≥ 75 years treated with oral anticoagulants ≥ 3 months attended in Internal Medicine Departments in Spain.

RESULTS

A total of 837 patients (83.0 ± 5.0 years; CHA2DS2-VASc: 5.0 ± 1.4; HAS-BLED: 2.1 ± 0.9) were included. 44.4% of patients had some degree of dependency, 43.3% were fragile, and 32.3% had cognitive impairment. Patients with any of these conditions were older, had a worse clinical profile, with more comorbidities and higher risks of thromboembolic and bleeding events. All these conditions were independently associated among them. Overall, 70.8% of patients were taking vitamin K antagonists, the remaining 29.2% direct oral anticoagulants and 9.7% oral antiplatelets. This distribution was independent of the presence of dependency or fragility, but there was a trend to a higher prescription of vitamin K antagonists in those patients with cognitive impairment (75.2% vs. 68.8%; P = 0.05).

CONCLUSIONS

Approximately 32%-44% of elderly anticoagulated AF patients attended have some degree of dependency, fragility and/or cognitive impairment. Patients with any of these conditions are older and have a worse clinical profile. Approximately 71% of patients are taking vitamin K antagonists, regardless dependency or frailty, but with a trend to higher prescription in patients with cognitive impairment.

Type and doses of oral anticoagulants and adherence to anticoagulant treatment in elderly patients with atrial fibrillation: the ESPARTA study

AIM

To analyze the use of oral anticoagulants in elderly patients with atrial fibrillation in clinical practice.

PATIENTS & METHODS

Cross-sectional and multicenter study performed in atrial fibrillation patients ≥75 years treated with oral anticoagulants ≥3 months.

RESULTS

837 patients (83.0 ± 5.0 years; CHA₂DS₂-VASc 5.0 ± 1.4; HAS-BLED 2.1 ± 0.9; 70.8% vitamin K antagonists; 29.2% direct oral anticoagulants [DOACs]) were included. Poor adherence was observed in 27.9% of patients. Higher scores in the Pfeiffer's test and FRAIL scale were associated with poorer adherence. Among patients treated with DOACs, 62.3% received the lower doses. Having high CHADS₂ score and being older were associated with the use of low doses.

CONCLUSION

28% of patients had a poor adherence to anticoagulant treatment. 62% of patients were treated with the lower doses of DOACs.

Real-world Data and Recommended Dosage of Non-vitamin K Oral Anticoagulants for Korean Patients

Regulatory approvals of non-vitamin K antagonist oral anticoagulants (NOACs) have been based on large randomized phase III trials evaluating dabigatran, rivaroxaban, apixaban, or edoxaban relative to warfarin for atrial fibrillation (AF). The results of the trials showed that all NOACs were at least non-inferior to warfarin in the prevention of stroke/thromboembolism and showed lower rates of intracranial bleeding than those associated with warfarin. However, the trials were designed differently, varied in the inclusion/exclusion criteria, and used either one dose or a low/high dose of the NOAC drug. Some of these differences have challenged the ability to directly compare various NOACs, and comparative data on effectiveness and intracranial bleeding are sparse in "real-world" patients. Real-world data complement data from large randomized phase III trials by providing new aspects of the "real-world" absolute risks of ischemic and hemorrhagic stroke associated with NOACs vs. warfarin. Moreover, "real-world" fragile patients might have been included (e.g., patients with increased risk of bleeding, liver disease, and chronic kidney disease), although these patients would be less represented in trials. This paper introduces recently published real-world data of NOACs and further suggests the recommended dosage of NOACs for Korean patients.