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Bamberg C, Ladegaard CT, Aalling M, Jensen DM, Madsen CL, Kamil S, Gudbergsen H, Saxild T, Schiøtz ML, Grew J, Castillo LS, Tousgaard I, Johansen RLR, Bardram JE, Frølich A, Domínguez H. Reaching the Frail Elderly for the Diagnosis and Management of Atrial Fibrillation-REAFEL. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6783. [PMID: 37754642 PMCID: PMC10530387 DOI: 10.3390/ijerph20186783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/13/2023] [Accepted: 09/16/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Frail elderly patients are exposed to suffering strokes if they do not receive timely anticoagulation to prevent stroke associated to atrial fibrillation (AF). Evaluation in the cardiological ambulatory can be cumbersome as it often requires repeated visits. AIM To develop and implement CardioShare, a shared-care model where primary care leads patient management, using a compact Holter monitor device with asynchronous remote support from cardiologists. METHODS CardioShare was developed in a feasibility phase, tested in a pragmatic cluster randomization trial (primary care clinics as clusters), and its implementation potential was evaluated with an escalation test. Mixed methods were used to evaluate the impact of this complex intervention, comprising quantitative observations, semi-structured interviews, and workshops. RESULTS Between February 2020 and December 2021, 314 patients (30% frail) were included, of whom 75% had AF diagnosed/not found within 13 days; 80% in both groups avoided referral to cardiologists. Patients felt safe and primary care clinicians satisfied. In an escalation test, 58 primary-care doctors evaluated 93 patients over three months, with remote support from four hospitals in the Capital Region of Denmark. CONCLUSIONS CardioShare was successfully implemented for AF evaluation in primary care.
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Affiliation(s)
- Carsten Bamberg
- Cardiology Department Y Bispebjerg and Frederiksberg Hospital, Capital Region, 2000 Frederiksberg, Denmark; (C.B.); (C.T.L.); (D.M.J.); (C.L.M.); (S.K.)
- Department of Biomedicine, University of Copenhagen, 1165 Copenhagen, Denmark
| | - Caroline Thorup Ladegaard
- Cardiology Department Y Bispebjerg and Frederiksberg Hospital, Capital Region, 2000 Frederiksberg, Denmark; (C.B.); (C.T.L.); (D.M.J.); (C.L.M.); (S.K.)
- Department of Biomedicine, University of Copenhagen, 1165 Copenhagen, Denmark
| | - Mathias Aalling
- VihTek Research Center for Welfare Technology Capital Region, 2600 Copenhagen, Denmark;
| | - Dorthea Marie Jensen
- Cardiology Department Y Bispebjerg and Frederiksberg Hospital, Capital Region, 2000 Frederiksberg, Denmark; (C.B.); (C.T.L.); (D.M.J.); (C.L.M.); (S.K.)
- Department of Biomedicine, University of Copenhagen, 1165 Copenhagen, Denmark
| | - Christoffer Læssøe Madsen
- Cardiology Department Y Bispebjerg and Frederiksberg Hospital, Capital Region, 2000 Frederiksberg, Denmark; (C.B.); (C.T.L.); (D.M.J.); (C.L.M.); (S.K.)
- Department of Biomedicine, University of Copenhagen, 1165 Copenhagen, Denmark
| | - Sadaf Kamil
- Cardiology Department Y Bispebjerg and Frederiksberg Hospital, Capital Region, 2000 Frederiksberg, Denmark; (C.B.); (C.T.L.); (D.M.J.); (C.L.M.); (S.K.)
- Department of Biomedicine, University of Copenhagen, 1165 Copenhagen, Denmark
| | - Henrik Gudbergsen
- Section of General Practice, Department of Public Health, University of Copenhagen, 1165 Copenhagen, Denmark;
| | - Thomas Saxild
- Grøndalslægerne Godthåbsvej 239a, Vanløse, 2720 Copenhagen, Denmark;
| | - Michaela Louise Schiøtz
- Center for Clinical Research and Prevention Bispebjerg and Frederiksberg Hospital, 2400 Copenhagen, Denmark; (M.L.S.); (J.G.)
| | - Julie Grew
- Center for Clinical Research and Prevention Bispebjerg and Frederiksberg Hospital, 2400 Copenhagen, Denmark; (M.L.S.); (J.G.)
| | | | - Iben Tousgaard
- Department of Quality and Education, Bispebjerg and Frederiksberg Hospital, 2400 Copenhagen, Denmark; (I.T.); (R.L.R.J.)
| | - Rie Laurine Rosenthal Johansen
- Department of Quality and Education, Bispebjerg and Frederiksberg Hospital, 2400 Copenhagen, Denmark; (I.T.); (R.L.R.J.)
| | - Jakob Eyvind Bardram
- Department of Health Technology, Digital Health, Personalized Health Technology, Technical University of Denmark, 2800 Copenhagen, Denmark;
| | - Anne Frølich
- Innovation and Research Centre for Multimorbidity, Slagelse Hospital, Region Zealand, 4180 Sorø, Denmark;
- Section of General Practice, Faculty of Health and Medical Sciences, University of Copenhagen, 1165 Copenhagen, Denmark
| | - Helena Domínguez
- Cardiology Department Y Bispebjerg and Frederiksberg Hospital, Capital Region, 2000 Frederiksberg, Denmark; (C.B.); (C.T.L.); (D.M.J.); (C.L.M.); (S.K.)
- Department of Biomedicine, University of Copenhagen, 1165 Copenhagen, Denmark
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C1QC, VSIG4, and CFD as Potential Peripheral Blood Biomarkers in Atrial Fibrillation-Related Cardioembolic Stroke. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2023; 2023:5199810. [PMID: 36644582 PMCID: PMC9837713 DOI: 10.1155/2023/5199810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 11/28/2022] [Accepted: 12/09/2022] [Indexed: 01/07/2023]
Abstract
Atrial fibrillation (AF) is a major risk factor for ischemic stroke. We aimed to identify novel potential biomarkers with diagnostic value in patients with atrial fibrillation-related cardioembolic stroke (AF-CE).Publicly available gene expression profiles related to AF, cardioembolic stroke (CE), and large artery atherosclerosis (LAA) were downloaded from the Gene Expression Omnibus (GEO). Differentially expressed genes (DEGs) were identified and then functionally annotated. The support vector machine recursive feature elimination (SVM-RFE) and least absolute shrinkage and selection operator (LASSO) regression analysis were conducted to identify potential diagnostic AF-CE biomarkers. Furthermore, the results were validated by using external data sets, and discriminability was measured by the area under the ROC curve (AUC). In order to verify the predictive results, the blood samples of 13 healthy controls, 20 patients with CE, and 20 patients with LAA stroke were acquired for RT-qPCR, and the correlation between biomarkers and clinical features was further explored. Lastly, a nomogram and the companion website were developed to predict the CE-risk rate. Three feature genes (C1QC, VSIG4, and CFD) were selected and validated in the training and the external datasets. The qRT-PCR evaluation showed that the levels of blood biomarkers (C1QC, VSIG4, and CFD) in patients with AF-CE can be used to differentiate patients with AF-CE from normal controls (P < 0.05) and can effectively discriminate AF-CE from LAA stroke (P < 0.05). Immune cell infiltration analysis revealed that three feature genes were correlated with immune system such as neutrophils. Clinical impact curve, calibration curves, ROC, and DCAs of the nomogram indicate that the nomogram had good performance. Our findings showed that C1QC, VSIG4, and CFD can potentially serve as diagnostic blood biomarkers of AF-CE; novel nomogram and the companion website can help clinicians to identify high-risk individuals, thus helping to guide treatment decisions for stroke patients.
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Reaching Frail Elderly Patients to Optimize Diagnosis and Management of Atrial Fibrillation (REAFEL): A Feasibility Study of a Cross-Sectoral Shared-Care Model. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19127383. [PMID: 35742632 PMCID: PMC9223795 DOI: 10.3390/ijerph19127383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/25/2022] [Accepted: 06/11/2022] [Indexed: 11/17/2022]
Abstract
Introduction: Atrial fibrillation (AF) management in primary care often requires a referral to cardiology clinics, which can be strenuous for frail patients. We developed “cardio-share” (CS), a new cross-sector collaboration model, to ease this process. General practitioners (GPs) can use a compact Holter monitor (C3 from Cortrium) to receive remote advice from the cardiologist. Objective: To test the feasibility and acceptability of the CS model to manage suspected AF in frail elderly patients. Methods: We used a mixed methods design, including the preparation of qualitative semistructured interviews of GPs and nurses. Results: Between MAR-2019 and FEB-2020, 54 patients were consulted through the CS model, of whom 35 underwent C3 Holter monitoring. The time from referral to a final Holter report was shortened from a mean (SD) of 117 (45) days in usual care to 30 days (13) with the CS model. Furthermore, 90% of the patients did not need to attend visits at the cardiology clinic. The GPs and nurses highlighted the ease of using the C3 monitor. Their perception was that patients were confident in the GPs’ collaboration with cardiologists. Conclusions: The CS model using a C3 monitor for AF is both feasible and seems acceptable to GPs. The elapsed time from referral to the Holter report performed for the diagnosis was significantly reduced.
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Liu QY, Duan Q, Fu XH, Jiang M, Xia HW, Wan YL. Wall shear stress can improve prediction accuracy for transient ischemic attack. World J Clin Cases 2019; 7:2722-2733. [PMID: 31616688 PMCID: PMC6789401 DOI: 10.12998/wjcc.v7.i18.2722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 08/05/2019] [Accepted: 08/20/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Early prediction of transient ischemic attack (TIA) has important clinical value. To date, systematic studies on clinical, biochemical, and imaging indicators related to carotid atherosclerosis have been carried out to predict the occurrence of TIA. However, their prediction accuracy is limited.
AIM To explore the role of combining wall shear stress (WSS) with conventional predictive indicators in improving the accuracy of TIA prediction.
METHODS A total of 250 patients with atherosclerosis who underwent carotid ultrasonography at Naval Military Medical University Affiliated Gongli Hospital were recruited. Plaque location, plaque properties, stenosis rate, peak systolic velocity, and end diastolic velocity were measured and recorded. The WSS distribution map of the proximal and distal ends of the plaque shoulder was drawn using the shear stress quantitative analysis software, and the average values of WSS were recorded. The laboratory indicators of the subjects were recorded. The patients were followed for 4 years. Patients with TIA were included in a TIA group and the remaining patients were included in a control group. The clinical data, laboratory indicators, and ultrasound characteristics of the two groups were analyzed. Survival curves were plotted by the Kaplan-Meier method. Receiver operating characteristic curves were established to evaluate the accuracy of potential indicators in predicting TIA. Logistic regression model was used to establish combined prediction, and the accuracy of combined predictive indicators for TIA was explored.
RESULTS The intraclass correlation coefficients of the WSS between the proximal and distal ends of the plaque shoulder were 0.976 and 0.993, respectively, which indicated an excellent agreement. At the end of the follow-up, 30 patients suffered TIA (TIA group) and 204 patients did not (control group). Hypertension (P = 0.037), diabetes (P = 0.026), homocysteine (Hcy) (P = 0.022), fasting blood glucose (P = 0.034), plaque properties (P = 0.000), luminal stenosis rate (P = 0.000), and proximal end WSS (P = 0.000) were independent influencing factors for TIA during follow-up. The accuracy of each indicator for predicting TIA individually was not high (area under the curve [AUC] < 0.9). The accuracy of the combined indicator including WSS (AUC = 0.944) was significantly higher than that of the combined indicator without WSS (AUC = 0.856) in predicting TIA (z = 2.177, P = 0.030). The sensitivity and specificity of the combined indicator including WSS were 86.67% and 92.16%, respectively.
CONCLUSION WSS at plaque surface combined with hypertension, diabetes, Hcy, blood glucose, plaque properties, and stenosis rate can significantly improve the accuracy of predicting TIA.
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Affiliation(s)
- Qiu-Yun Liu
- Department of Ultrasound, Naval Military Medical University Affiliated Gongli Hospital, Shanghai 200000, China
| | - Qi Duan
- Department of Ultrasound, Shanghai Hemujia Hospital, Shanghai 200000, China
| | - Xiao-Hong Fu
- Department of Ultrasound, Naval Military Medical University Affiliated Gongli Hospital, Shanghai 200000, China
| | - Mei Jiang
- Department of Neurology, Naval Military Medical University Affiliated Gongli Hospital, Shanghai 200000, China
| | - Hong-Wei Xia
- Department of Ultrasound, Naval Military Medical University Affiliated Gongli Hospital, Shanghai 200000, China
| | - Yong-Lin Wan
- Department of Ultrasound, Naval Military Medical University Affiliated Gongli Hospital, Shanghai 200000, China
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Rivera-Caravaca JM, Esteve-Pastor MA, Marín F, Valdés M, Vicente V, Roldán V, Lip GYH. A Propensity Score Matched Comparison of Clinical Outcomes in Atrial Fibrillation Patients Taking Vitamin K Antagonists: Comparing the "Real-World" vs Clinical Trials. Mayo Clin Proc 2018; 93:1065-1073. [PMID: 29730090 DOI: 10.1016/j.mayocp.2018.01.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 01/05/2018] [Accepted: 01/18/2018] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To investigate the incidence and risk of adverse clinical outcomes in a "real-world" cohort of patients with atrial fibrillation (AF) anticoagulated with vitamin K antagonists (VKAs) from the Murcia AF Project in comparison with the warfarin arm of the randomized clinical trial (RCT) AMADEUS (Evaluating the Use of SR34006 Compared to Warfarin or Acenocoumarol in Patients With Atrial Fibrillation). PATIENTS AND METHODS We included 1361 patients with AF from the Murcia AF Project (recruitment from May 1, 2007, to December 1, 2007) and 2293 from the AMADEUS trial (started in September 2003 and primary completed in March 2006), all taking VKA treatment. After propensity score matching (PSM), we investigated differences in rates and risks of several events, including major bleeding, ischemic stroke, and all-cause mortality at 365 (interquartile range, 275-428) days of follow-up. RESULTS After PSM there were 1324 patients for the comparative analysis, whereby annual event rates for most adverse events were significantly higher in the "real-world" population. Cox regression analyses demonstrated that the risk of primary outcomes was also increased in the "real-world" (vs RCT: hazard ratio [HR], 6.32; 95% CI, 2.84-14.03 for major bleeding; HR, 3.56, 95% CI, 1.22-10.42 for ischemic stroke; HR, 5.13, 95% CI, 3.02-8.69 for all-cause mortality). The risk of all other adverse events was higher in the real-world cohort, except for cardiovascular mortality. CONCLUSION This study comparing the Murcia AF Project and the AMADEUS trial demonstrates that there is a great heterogeneity in both populations, which is translated into a higher risk of several adverse outcomes in the real-world cohort, including major bleeding, ischemic stroke, and mortality.
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Affiliation(s)
- José Miguel Rivera-Caravaca
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Mariano Valdés
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Vicente Vicente
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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