The risks of warfarin use in the elderly

Benefits, risks and impacts on quality of life of medications used in multimorbid older adults: a Delphi study

Background Multimorbidity and polypharmacy are common in older people. Despite the existence of quality criteria for medication use among this population, there is little guidance for managing the complex pharmacological arsenal in a multimorbidity context. Objective To establish consensus on benefits, risks and impacts on quality of life of medications used in an older adult with three chronic diseases that require complex pharmacotherapy. Setting International experts in pharmacology. Method A panel of experts responded to three rounds of a Delphi survey. They assessed the benefits, risks and positive impacts on quality of life of 50 different medications or medication classes that could be used by a hypothetical multimorbid older patient aged 65-75 years, with type 2 diabetes, heart failure and chronic obstructive pulmonary disease. Each aspect was evaluated on a 5-level Likert scale. Main outcome measure Percentage of agreement on each of the three aspects for all medication. Results Consensus was reached on 95% of items (166/174). Only two medication classes were associated with both the highest category of benefits and positive impacts on quality of life, and the lowest risk category: long-acting anticholinergics and long-acting beta-2-agonists. Nine other medications/classes of medications were categorized within the highest benefits level (metformin, DPP-4-inhibitors, short-acting beta-2-agonists, ACE inhibitors, beta-blockers, warfarin, non-vitamin K oral anticoagulants, nitrates and acetaminophen). Fifteen medications were included in the highest level of risks, among which warfarin and Non-vitamin K oral anticoagulants. Conclusions Medications recommended in clinical guidelines for individual diseases are generally considered positive for multimorbid older patients. Nevertheless, a non-negligible number of medications was deemed negative or very negative by our panelists. For multimorbid patients, individualizing treatment according to their preferences seems of utmost importance.

Distribution characteristics and factors influencing oral warfarin adherence in patients after heart valve replacement

PURPOSE

Oral warfarin anticoagulation is a long-term treatment that is required after heart valve replacement. This treatment can prevent serious complications, such as embolism, thereby increasing patients' postoperative survival rates and quality of life. Patients treated with artificial mechanical heart valve replacement were followed up over the phone at different times after the procedure, which is an effective method for preventing accidents related to postoperative oral warfarin anticoagulation. Our goal was to determine a method for providing theoretical guidance to patients on oral warfarin anticoagulation following heart valve replacement.

PATIENTS AND METHODS

The participants of this study were patients who received artificial mechanical heart valve replacements and were followed up for 2 years after the procedure. Patient adherence to medical advice was calculated, and the distribution characteristics of adherence to prescribed timing, prescribed dose, and regular clinical follow-up among patients of both sexes and of different ages, regions, and educational levels attained were compared.

RESULTS

Univariate and multifactorial logistic regression analyses were used to evaluate the factors influencing adherence. Our analyses showed that adherence to oral warfarin anticoagulation in patients after heart valve replacement is influenced by sex, age, residential location, and educational attainment. The medication habits of patients can be evaluated accordingly via phone follow-up. As such, dose adjustment recommendations can be provided, significantly increasing the adherence to oral warfarin anticoagulation in patients after heart valve replacement.

CONCLUSION

Adherence to oral warfarin anticoagulation among patients after heart valve replacement is affected by sex, age, type of residence, and educational level, as well as adherence to clinical follow-up over the phone. The follow-up sessions help establish good doctor-patient communication, which is critical for timely medication guidance, thus shortening medication administration delays and decreasing the overall length of therapy.

Safe use of antithrombotics for stroke prevention in atrial fibrillation: consideration of risk assessment tools to support decision-making

Clinical guidelines advocate stroke prevention therapy in atrial fibrillation (AF) patients, specifically anticoagulation. However, the decision to initiate treatment is based on the risk (bleeding) versus benefit (prevention of stroke) of therapy, which is often difficult to assess. This review identifies available risk assessment tools to facilitate the safe and optimal use of antithrombotic therapy for stroke prevention in AF. Using key databases and online clinical resources to search the literature (1992-2012), 19 tools have been identified and published to date: 11 addressing stroke risk, 7 addressing bleeding risk and 1 integrating both risk assessments. The stroke risk assessment tools (e.g. CHADS2, CHA2DS2-VASc) share common risk factors: age, hypertension, previous cerebrovascular attack. The bleeding risk assessment tools (e.g. HEMORR2HAGES, HAS-BLED) share common risk factors: age, previous bleeding, renal and liver impairment. In terms of their development, six of the stroke risk assessment tools have been derived from clinical studies, whilst five are based on refinement of existing tools or expert consensus. Many have been evaluated by prospective application to data from real patient cohorts. Bleeding risk assessment tools have been derived from trials, or generated from patient data and then validated via further studies. One identified tool (i.e. Computerised Antithrombotic Risk Assessment Tool [CARAT]) integrates both stroke and bleeding, and specifically considers other key factors in decision-making regarding antithrombotic therapy, particularly those increasing the risk of medication misadventure with treatment (e.g. function, drug interactions, medication adherence). This highlights that whilst separate tools are available to assess stroke and bleeding risk, they do not estimate the relative risk versus benefit of treatment in an individual patient nor consider key medication safety aspects. More effort is needed to synthesize these separate risk assessments and integrate key medication safety issues, particularly since the introduction of new anticoagulants into practice.

Arthrocentesis: the latest on joint pain relief

Arthrocentesis is a procedure in the diagnostic workup and treatment of joint pain that has few complications. Analysis of joint fluid yields important treatment data. Corticosteroid and local anesthetic injections provide longer pain relief.

Evaluation of demographic factors that influence acute radiation response

Casualty estimation tools are critical in planning for nuclear event scenarios. Current consequence assessment models based on healthy adult males may not adequately represent the population. To develop an understanding of the impact of demographic variables on casualty estimates, human data was surveyed to identify key demographic factors that affect acute radiation response. Information on in utero exposures, gender, age, and comorbidity status was collected from atomic bomb survivors, radiation accidents, and clinical oncology. Burn and trauma studies were also examined to gain insight into the impact of demographic variables on acute injury outcomes. Fetal radiation sensitivity is well documented; increased mortality or malformations are observed depending on gestational age. A greater incidence of radiation syndrome was observed among male atomic bomb survivors. Trauma data show increased mortality in males, apparently due to immunological differences between genders. Limited data suggest vulnerability in the very young and old due to immunological status and comorbidities, respectively. Certain genetically susceptible subpopulations demonstrate marked increased sensitivity to radiation exposure. Interaction of radiation and comorbid conditions has not been well studied; however, burn and trauma data indicate that comorbidities negatively impact response to acute injury. Key factors evaluated together with their prevalence indicate the importance of modeling demographic variability in casualty estimations. Also they can help identify vulnerable subpopulations and provide insight on treatment requirements.

Challenges of Older Patients’ Knowledge About Warfarin Therapy

Objective: To review the challenges of warfarin education for older patients (aged 65 years or older) in terms of knowledge, access to warfarin education, and education resources. Methods: A quasi-systematic review of the literature was performed via electronic database searches (eg, Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, International Pharmaceutical Abstracts, Meditext, and Google Scholar) from 1990 to May 2011. Results: The 62 articles reviewed found that improved patient knowledge results in better anticoagulation control. The review also found that between 50% and 80% of older patients have inadequate knowledge about the basic aspects of warfarin therapy (eg, action, benefits and risks, interactions with other drugs or foods, international normalized ratio management). Demographic factors, such as advancing age, lower family income, and limited health literacy, were found to inversely affect patients’ warfarin knowledge, and access to warfarin education and information resources were often suboptimal in different practice settings. Finally, a number of educational strategies and resources that could be readily incorporated to improve the effectiveness of current warfarin education programs were extracted from the review. Conclusion: This comprehensive review highlights that education about warfarin in older patients is currently suboptimal and may in part contribute to poor therapeutic outcomes. This review article also acknowledges the need to identify, target, and develop educational strategies and resources to further improve older patients’ knowledge about their warfarin therapy.

Clinical outcomes three years after PLAATO implantation

BACKGROUND

The percutaneous left atrial appendage transcatheter occlusion system (PLAATO) is an alternative to coumadin in patients with atrial fibrillation (AF) and contraindications to anticoagulation. It appears to be protective against stroke in intermediate follow-up studies.

HYPOTHESIS

The PLAATO system is protective against stroke and is safe in long-term follow-up.

METHODS

Eleven patients (age 72 +/- 9 years) enrolled in the PLAATO feasibility and safety trial at our institution were followed (36 +/- 1.4) months. All patients had contraindications to anticoagulation and had at least one risk factor for stroke. The predicted stroke risk for this cohort was 8.6% per year as calculated using the CHADS2 score (A validated scoring system assigning 1 point for CHF, hypertension, diabetes, and age >75 years, and 2 points for history of stroke). The primary end-point was the incidence of stroke, and secondary end points were complications related to PLAATO device and systemic embolic events.

RESULTS

There was one stroke during follow-up; the stroke risk in our population was 3% per year. Interestingly, the observed stroke risk in these patients after occluding the left atrial appendage is comparable to what would have been observed with warfarin. No systemic embolic events were noted in our cohort and no long term complications related to PLAATO were seen.

CONCLUSION

The PLAATO device decreases the risk of stroke in a high-risk cohort of AF patients. Furthermore, the safety of this device is confirmed during this long-term follow-up study. A larger trial is needed to validate these findings.