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Cools F, Johnson D, Camm AJ, Bassand J, Verheugt FWA, Yang S, Tsiatis A, Fitzmaurice DA, Goldhaber SZ, Kayani G, Goto S, Haas S, Misselwitz F, Turpie AGG, Fox KAA, Pieper KS, Kakkar AK. Risks associated with discontinuation of oral anticoagulation in newly diagnosed patients with atrial fibrillation: Results from the GARFIELD-AF Registry. J Thromb Haemost 2021; 19:2322-2334. [PMID: 34060704 PMCID: PMC8390436 DOI: 10.1111/jth.15415] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/06/2021] [Accepted: 05/19/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Oral anticoagulation (OAC) in atrial fibrillation (AF) reduces the risk of stroke/systemic embolism (SE). The impact of OAC discontinuation is less well documented. OBJECTIVE Investigate outcomes of patients prospectively enrolled in the Global Anticoagulant Registry in the Field-Atrial Fibrillation study who discontinued OAC. METHODS Oral anticoagulation discontinuation was defined as cessation of treatment for ≥7 consecutive days. Adjusted outcome risks were assessed in 23 882 patients with 511 days of median follow-up after discontinuation. RESULTS Patients who discontinued (n = 3114, 13.0%) had a higher risk (hazard ratio [95% CI]) of all-cause death (1.62 [1.25-2.09]), stroke/systemic embolism (SE) (2.21 [1.42-3.44]) and myocardial infarction (MI) (1.85 [1.09-3.13]) than patients who did not, whether OAC was restarted or not. This higher risk of outcomes after discontinuation was similar for patients treated with vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) (p for interactions range = 0.145-0.778). Bleeding history (1.43 [1.14-1.80]), paroxysmal vs. persistent AF (1.15 [1.02-1.29]), emergency room care setting vs. office (1.37 [1.18-1.59]), major, clinically relevant nonmajor, and minor bleeding (10.02 [7.19-13.98], 2.70 [2.24-3.25] and 1.90 [1.61-2.23]), stroke/SE (4.09 [2.55-6.56]), MI (2.74 [1.69-4.43]), and left atrial appendage procedures (4.99 [1.82-13.70]) were predictors of discontinuation. Age (0.84 [0.81-0.88], per 10-year increase), history of stroke/transient ischemic attack (0.81 [0.71-0.93]), diabetes (0.88 [0.80-0.97]), weeks from AF onset to treatment (0.96 [0.93-0.99] per week), and permanent vs. persistent AF (0.73 [0.63-0.86]) were predictors of lower discontinuation rates. CONCLUSIONS In GARFIELD-AF, the rate of discontinuation was 13.0%. Discontinuation for ≥7 consecutive days was associated with significantly higher all-cause mortality, stroke/SE, and MI risk. Caution should be exerted when considering any OAC discontinuation beyond 7 days.
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Affiliation(s)
| | - Dana Johnson
- Department of StatisticsNorth Carolina State UniversityRaleighNCUSA
| | - Alan J. Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research InstituteSt. George’s University of LondonLondonUK
| | | | | | - Shu Yang
- North Carolina State UniversityRaleighNCUSA
| | | | | | | | | | - Shinya Goto
- Tokai University School of MedicineKanagawaJapan
| | - Sylvia Haas
- Formerly Department of MedicineTechnical University of MunichMunichGermany
| | | | | | - Keith A. A. Fox
- Centre for Cardiovascular ScienceUniversity of EdinburghEdinburghUK
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Clinical Impact of the Time in Therapeutic Range on Early Hospital Readmission in Patients with Acute Heart Failure Treated with Oral Anticoagulation in Internal Medicine. ACTA ACUST UNITED AC 2021; 57:medicina57040365. [PMID: 33918627 PMCID: PMC8069311 DOI: 10.3390/medicina57040365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/27/2021] [Accepted: 04/07/2021] [Indexed: 11/17/2022]
Abstract
Background and objectives: Patients with heart failure (HF) often present with non-valvular atrial fibrillation and require oral anticoagulation with coumarin anticoagulants such as acenocoumarol. The objective of this study was to evaluate the relationship between time in therapeutic range (TTR) and the risk of early readmission. Materials and Methods: A retrospective descriptive study was carried out on hospitalized patients with a diagnosis of HF between 2014 and 2018 who had adverse effects due to oral anticoagulation with acenocoumarol (underdosing, overdosing, or hemorrhage). Clinical, analytical, therapeutic, and prognostic variables were collected. TTR is defined as the duration of time in which the patient’s International Normalized Ratio (INR) values were within a desired range. Early readmission was defined as readmission within 30 days after hospital discharge. Patients were divided into two groups depending on whether or not they had a TTR less than 60% (TTR < 60%) over the 6 months prior to the adverse event. Results: In the cohort of 304 patients, the mean age was 82 years, 59.9% of the patients were female, and 54.6% had a TTR < 60%. Patients with TTR < 60% had a higher HAS-BLED score (4.04 vs. 2.59; p < 0.001) and INR (6 vs. 5.31; p < 0.05) but lower hemoglobin (11.67 vs. 12.22 g/dL; p < 0.05). TTR < 60% was associated with early readmission after multivariate analysis (OR: 2.05 (CI 95%: 1.16–3.61)). They also had a higher percentage of hemorrhagic events and in-hospital mortality but without reaching statistical significance. Conclusions: Patients with HF and adverse events due to acenocoumarol often have poor INR control, which is independently associated with a higher risk of early readmission.
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Dubner S, Saraiva JFK, Fragoso JCN, Barón-Esquivias G, Teutsch C, Gurusamy VK, Marler S, Huisman MV, Lip GYH, Zeballos C. Effectiveness and safety of dabigatran in Latin American patients with atrial fibrillation: Two years follow up results from GLORIA-AF registry. IJC HEART & VASCULATURE 2020; 31:100666. [PMID: 33195793 PMCID: PMC7644920 DOI: 10.1016/j.ijcha.2020.100666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/18/2020] [Accepted: 10/14/2020] [Indexed: 11/29/2022]
Abstract
Background Real-world data from different regions are needed to support the external validity of controlled trials and assess the impact of new oral anticoagulants (NOAC) in clinical practice. Methods “GLORIA-AF” is a large, ongoing, multicenter, global, prospective registry program in patients with newly diagnosed non-valvular atrial fibrillation (NVAF) at risk of stroke. Newly diagnosed patients with NVAF (within 4.5 months) and a CHA2DS2-VASc score ≥ 1 were consecutively enrolled. The study objective was to estimate the incidence rate of stroke and major bleeding after a two year follow up of patients on dabigatran that participated in the “GLORIA-AF” study (Phase II) in Latin America. Results Latin America included 378 eligible patients that received dabigatran in eight countries (Argentina, Brazil, Chile, Colombia, Ecuador, Mexico, Perú, and Venezuela): 56.3% were male; mean age was 70.3 ± 10.8 years; 43.4% had paroxysmal AF; 36.0% persistent AF and 20.6% permanent AF. Mean CHA2DS2-VASc score was 3.2 ± 1.4; mean HAS-BLED score was 1.2 ± 0.8. Incidence rates for clinical events after 2-years of follow-up per 100 patient-years were as follows: stroke 0.33 (95% CI: 0.04–1.17), major bleeding 0.49 (95% CI: 0.10–1.42) and all-cause death 4.06 (95% CI: 2.63–6.00). Persistence with dabigatran at 6, 12 and 24 months was 91%, 86%, and 80%, respectively. Conclusion These regional data shows the sustained safety and effectiveness of dabigatran over two years of follow-up, consistent with already available evidence. An increase in accessibility and incorporation of NOAC to anticoagulant treatment strategies could potentially have a positive impact on AF stroke prevention in Latin America.
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Affiliation(s)
- Sergio Dubner
- Clinica y Maternidad Suizo Argentino Buenos Aires, Argentina
| | | | | | - Gonzalo Barón-Esquivias
- Cardiology and Cardiac Surgery Department. Hospital Universitario Virgen del Rocío. Universidad de Sevilla Institution, Seville, Spain
| | - Christine Teutsch
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | | | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, and Liverpool Heart and Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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4
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Rush KL, Burton L, Ollivier R, Wilson R, Loewen P, Janke R, Schaab K, Lukey A, Galloway C. Transitions in Atrial Fibrillation Care: A Systematic Review. Heart Lung Circ 2019; 29:1000-1014. [PMID: 32094081 DOI: 10.1016/j.hlc.2019.11.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/26/2019] [Accepted: 11/28/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with atrial fibrillation (AF) commonly transition between care settings and providers. These transitions are often points in the health care system where errors and clinical deterioration can occur. Anticoagulation interruption or discontinuation and sub-optimal follow-up post-emergency department (ED) discharge are considered major transitional issues. OBJECTIVE The purpose of this study was to synthesise the evidence examining the impact of transitional care interventions on patient, provider, and health care utilisation outcomes. METHODS This systematic mixed studies review examined citations from four databases Medline, CINAHL, EMBASE, and Cochrane Central Controlled Register of Trials (CENTRAL) using relevant search terms. Fourteen (14) moderate to high quality articles were selected. RESULTS The available evidence reporting impacts of transitional interventions on health care utilisation, provider, and patient outcomes in AF patients is mixed and of variable quality. The stronger evidence revealed improvements in patient outcomes including knowledge, quality of life, and medication adherence and increased provider anticoagulant prescriptions resulting from transitional interventions. Hospital admissions and ED visits were not significantly affected by any interventions. CONCLUSIONS Apps and educational toolkits improved patient knowledge. Pathways increased patient quality of life and provider prescription rates. There is a need for more research to determine the AF transition interventions which maximise patient, provider and health care outcomes.
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Affiliation(s)
- Kathy L Rush
- School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada.
| | - Lindsay Burton
- School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Rachel Ollivier
- School of Nursing, Dalhousie University, Halifax, NS, Canada
| | - Ryan Wilson
- School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Peter Loewen
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Robert Janke
- Library, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Kira Schaab
- School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Alexandra Lukey
- School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Camille Galloway
- School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada
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5
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Liu C, Du X, Jiang C, He L, Chang SS, Guo XY, Yu RH, Long DY, Bai R, Liu N, Sang CH, Jiang CX, Dong JZ, Lip GYH, Ma CS. Long-Term Persistence with Newly-Initiated Warfarin or Non-VKA Oral Anticoagulant (NOAC) in Patients with Non-Valvular Atrial Fibrillation: Insights from the Prospective China-AF Registry. Med Sci Monit 2019; 25:2649-2657. [PMID: 30971681 PMCID: PMC6475121 DOI: 10.12659/msm.915875] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Oral anticoagulants (OACs) such as warfarin and non-VKA oral anticoagulants (NOACs) have been recommended for patients with atrial fibrillation (AF) who are at risk for stroke. Whether NOACs have a higher persistence than warfarin is still unclear. This is especially true in China. Material/Methods Data from a large hospital-based cohort in China (China-AF Registry) from 2011 to 2017 were used for this study. Non-valvular AF patients with newly initiated OACs were included. A time-to-event approach was used to analyze patient persistence. The survival distributions of persistence were compared using the log-rank test. A multivariable Cox regression model was used to explore predictors of warfarin and NOACs non-persistence. Results Patients with newly initiated warfarin (n=4845) or NOACs (n=854) were included in this study. Persistence rates at 1, 2, and 3 years were 93.2%, 89.4%, and 87.2% in the warfarin group and 88.8%, 84.3%, and 81.3% in the NOAC group respectively. Non-persistence was significantly higher with NOACs than with warfarin. On multivariate analysis, age <75 years old, outpatient clinic visits, asymptomatic AF, paroxysmal AF, duration of AF <3 years, history of peptic ulcer, and no previous TIA, stroke or thromboembolism were strong predictors of warfarin non-persistence, while in the NOACs group, age <75 years old, outpatient clinic visits, lower education status and no history of congestive heart failure were predictors. Conclusions Treatment persistence of NOACs was lower than that of warfarin among Chinese patients with AF. Patients with characteristics of non-persistence predictors need special attention to maintain their therapy.
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Affiliation(s)
- Chang Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (mainland)
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (mainland)
| | - Chao Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (mainland)
| | - Liu He
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (mainland)
| | - San-Shuai Chang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (mainland)
| | - Xue-Yuan Guo
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (mainland)
| | - Rong-Hui Yu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (mainland)
| | - De-Yong Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (mainland)
| | - Rong Bai
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (mainland)
| | - Nian Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (mainland)
| | - Cai-Hua Sang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (mainland)
| | - Chen-Xi Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (mainland)
| | - Jian-Zeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (mainland)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, China (mainland).,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Chang-Sheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (mainland)
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Tingting C, Yuzhu W, Lin Z, Ran L, Jing L, Yi W, Xiaoyu L, Qianzhou L. Utilization of Anticoagulants in Nonvalvular Atrial Fibrillation Before and After Catheter Ablation at Shanghai, China. Clin Appl Thromb Hemost 2019; 25:1076029619826260. [PMID: 30754983 PMCID: PMC6714957 DOI: 10.1177/1076029619826260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Both vitamin K antagonists (VKAs) and novel oral anticoagulants (NOACs) are effective for stroke prevention in nonvalvular atrial fibrillation (NVAF) patients. This study evaluated the utilization of VKA and NOACs in NVAF patients before and after catheter ablation in China. Prescription data were retrospectively collected between January 1, 2016, and December 31, 2016, including indication of use, dose, renal function, and risk assessment (CHA2DS2-VASc score and HAS-BLED score) in Zhongshan Hospital of Fudan University. Trends and factors associated with anticoagulants use before and after ablation were evaluated. A total of 475 patients with NVAF who received ablation were included in the analysis. Of all, 53.26% of them received antithrombotic therapy preablation. Warfarin was prescribed in 35.26%, with NOACs in 11.37%. Four hundred seventy-three patients received antithrombotic therapy (99.58%) postablation, 236 patients with NOACs (49.68%). CHA2DS2-VASc score, HAS-BLED score, hypertension, diabetes mellitus, and alcohol were independently associated with anticoagulant utilization before catheter ablation. The higher CHA2DS2-VASc score was associated with less frequent prescription of NOACs postablation. The preablation anticoagulation use was still inadequate in China, and CHA2DS2-VASc score was a significant factor influencing the preablation anticoagulant utilization. The utilization rate of NOACs increased significantly postablation, especially for dabigatran, which implied that more physicians prefer to prescribe NOACs for NVAF patients after ablation in our country and may be attributed to the aspects such as ease of NOAC use but also possibly the greater safety and efficacy. Furthermore, the physicians may reluctant to use NOACs for high stroke risk atrial fibrillation patients after catheter ablation.
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Affiliation(s)
- Chen Tingting
- 1 Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wang Yuzhu
- 1 Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhang Lin
- 1 Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li Ran
- 1 Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li Jing
- 1 Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wu Yi
- 1 Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li Xiaoyu
- 1 Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lv Qianzhou
- 1 Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
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Brieger D, Amerena J, Attia J, Bajorek B, Chan KH, Connell C, Freedman B, Ferguson C, Hall T, Haqqani H, Hendriks J, Hespe C, Hung J, Kalman JM, Sanders P, Worthington J, Yan TD, Zwar N. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation 2018. Heart Lung Circ 2019; 27:1209-1266. [PMID: 30077228 DOI: 10.1016/j.hlc.2018.06.1043] [Citation(s) in RCA: 199] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
| | - David Brieger
- Department of Cardiology, Concord Hospital, Sydney, Australia; University of Sydney, Sydney, Australia.
| | - John Amerena
- Geelong Cardiology Research Unit, University Hospital Geelong, Geelong, Australia
| | - John Attia
- University of Newcastle, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Beata Bajorek
- Graduate School of Health, University of Technology Sydney & Department of Pharmacy, Royal North Shore Hospital, Australia
| | - Kim H Chan
- Royal Prince Alfred Hospital, Sydney, Australia; Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Cia Connell
- The National Heart Foundation of Australia, Melbourne, Australia
| | - Ben Freedman
- Sydney Medical School, The University of Sydney, Sydney, Australia; Heart Research Institute, Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Caleb Ferguson
- Western Sydney University, Western Sydney Local Health District, Blacktown Clinical and Research School, Blacktown Hospital, Sydney, Australia
| | | | - Haris Haqqani
- University of Queensland, Department of Cardiology, Prince Charles Hospital, Brisbane, Australia
| | - Jeroen Hendriks
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia; Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Charlotte Hespe
- General Practice and Primary Care Research, School of Medicine, The University of Notre Dame Australia, Sydney, Australia
| | - Joseph Hung
- Medical School, Sir Charles Gairdner Hospital Unit, University of Western Australia, Perth, Australia
| | - Jonathan M Kalman
- University of Melbourne, Director of Heart Rhythm Services, Royal Melbourne Hospital, Melbourne, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - John Worthington
- RPA Comprehensive Stroke Service, Royal Prince Alfred Hospital, Sydney, Australia
| | | | - Nicholas Zwar
- Graduate Medicine, University of Wollongong, Wollongong, Australia
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Díez-Manglano J, Mostaza JM, Pose A, Formiga F, Cepeda JM, Gullón A, Camafort M, Castiella J, Rovira E, Jarauta E, Suárez C. Factors associated with discontinuing or not starting oral anticoagulant therapy in older hospitalized patients with non-valvular atrial fibrillation. Geriatr Gerontol Int 2018; 18:1219-1224. [PMID: 29897154 DOI: 10.1111/ggi.13451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 04/17/2018] [Accepted: 04/25/2018] [Indexed: 12/16/2022]
Abstract
AIM To determine the factors associated with discontinuing or not starting oral anticoagulation (OA) therapy in older patients with non-valvular atrial fibrillation (NVAF). METHODS A prospective, multicenter cohort study was carried out of patients aged >75 years with NVAF hospitalized in internal medicine departments in Spain. For each patient, we recorded creatinine, hemoglobin and platelets levels, as well as CHA2DS2-VASc and HAS-BLED scores and the Charlson Comorbidity Index. We measured the ability to carry out basic activities of daily life with the Barthel Index, and the cognitive state with the Short Portable Mental Status questionnaire. RESULTS We included 723 patients with NVAF, with a mean age of 84.8 years (SD 5.2 years); 390 (53.9%) of the patients were women. Before admission, 375 (51.9%) patients were treated with OA. Previously diagnosed NVAF (OR 4.099, 95% CI 1.824-9.211, P = 0.001), the number of errors in the Short Portable Mental Status questionnaire (OR 1.180, 95% CI 1.020-1.365, P = 0.026), peripheral arterial disease (OR 0.285, 95% CI 0.114-0.711, P = 0.007) and hemoglobin levels (OR 0.812, 95% CI 0.682-0.966, P = 0.019) were independently associated with not starting OA therapy at discharge. Of the 375 patients treated with OA at admission, 87 (23.2%) had their OA discontinued at discharge. The HAS-BLED score (OR 1.516, 95% CI 1.211-1.897, P < 0.001) and previous acute myocardial infarction (OR 0.327, 95% CI 0.121-0.883, P = 0.027) were associated with the discontinuation of OA. CONCLUSIONS There are factors associated with discontinuing or not starting OA in older patients with NVAF, which often have no clinical justification. Geriatr Gerontol Int 2018; 18: 1219-1224.
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Affiliation(s)
- Jesús Díez-Manglano
- Internal Medicine Department, Miguel Servet University Hospital, Zaragoza, Spain
| | | | - Antonio Pose
- Internal Medicine Department, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Francesc Formiga
- Internal Medicine Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Alejandra Gullón
- Internal Medicine Department, University Hospital of La Princesa, Madrid, Spain
| | - Miguel Camafort
- Internal Medicine Department, Cinic University Hospital, Barcelona, Spain
| | - Jesús Castiella
- Internal Medicine Department, Calahorra Foundation Hospital, Calahorra, Spain
| | - Eduardo Rovira
- Internal Medicine Department, Ribera University Hospital, Alzira, Spain
| | - Estíbaliz Jarauta
- Internal Medicine Department, Miguel Servet University Hospital, Zaragoza, Spain
| | - Carmen Suárez
- Internal Medicine Department, University Hospital of La Princesa, Madrid, Spain
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Huisman MV, Rothman KJ, Paquette M, Teutsch C, Diener HC, Dubner SJ, Halperin JL, Ma CS, Zint K, Elsaesser A, Lu S, Bartels DB, Lip GY. Two-year follow-up of patients treated with dabigatran for stroke prevention in atrial fibrillation: Global Registry on Long-Term Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF) registry. Am Heart J 2018; 198:55-63. [PMID: 29653649 DOI: 10.1016/j.ahj.2017.08.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 08/23/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE GLORIA-AF is a large, global, prospective registry program of newly diagnosed atrial fibrillation (AF) patients with ≥1 stroke risk factors. We describe the effectiveness and safety of dabigatran etexilate over 2 years from routine clinical practice in nearly 3000 patients from GLORIA-AF who are newly diagnosed with non-valvular AF and at risk of stroke. METHODS Consecutive enrollment into phase II of GLORIA-AF was initiated following approval of dabigatran for stroke prevention in non-valvular AF. Within this Phase II, 2937 dabigatran patients completed 2-year follow-up by May 2016 and were eligible for analysis. Patients who took at least 1 dose of dabigatran (n=2932) were used to estimate incidence rates. RESULTS Overall incidence rates per 100 person-years of 0.63 (95% confidence interval [CI], 0.42-0.92) for stroke, 1.12 (0.83-1.49) for major bleeding, 0.47 (0.29-0.72) for myocardial infarction, and 2.69 (2.22-3.23) for all-cause death were observed. For patients taking 150 mg dabigatran twice daily (BID), corresponding rates (95% CI) were 0.56 (0.30-0.94), 1.00 (0.64-1.47), 0.48 (0.25-0.83), and 2.07 (1.55-2.72), respectively. For patients taking 110 mg dabigatran BID, event rates (95% CI) were 0.67 (0.33-1.20), 1.16 (0.70-1.80), 0.43 (0.17-0.88), and 3.16 (2.36-4.15). CONCLUSIONS These global data confirm the sustained safety and effectiveness of dabigatran over 2 years of follow-up, consistent with the results from clinical trials as well as contemporary real-world studies. WHAT IS KNOWN • Non-vitamin K antagonist (VKA) anticoagulants (NOACs) are the preferred therapy for prevention of ischemic stroke based on phase 3 trials, but there is insufficient information on their efficacy and safety in daily practice, based on prospectively collected data. WHAT IS NEW • This study shows that in non-valvular AF patient population, with up to 2 years of follow-up, the use of dabigatran led to a low incidence of ischemic stroke, major bleeding, and myocardial infarction in routine clinical care, confirming the sustained safety and effectiveness of dabigatran in clinical practice over 2 years of follow-up.
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An J, Niu F, Zheng C, Rashid N, Mendes RA, Dills D, Vo L, Singh P, Bruno A, Lang DT, Le PT, Jazdzewski KP, Aranda G. Warfarin Management and Outcomes in Patients with Nonvalvular Atrial Fibrillation Within an Integrated Health Care System. J Manag Care Spec Pharm 2018; 23:700-712. [PMID: 28530526 PMCID: PMC10398296 DOI: 10.18553/jmcp.2017.23.6.700] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Warfarin is a common treatment option to manage patients with nonvalvular atrial fibrillation (NVAF) in clinical practice. Understanding current pharmacist-led anticoagulation clinic management patterns and associated outcomes is important for quality improvement; however, currently little evidence associating outcomes with management patterns exists. OBJECTIVES To (a) describe warfarin management patterns and (b) evaluate associations between warfarin treatment and clinical outcomes for patients with NVAF in an integrated health care system. METHODS A retrospective cohort study was conducted among NVAF patients with warfarin therapy between January 1, 2006, and December 31, 2011, using Kaiser Permanente Southern California data, and followed until December 31, 2013. Management patterns related to international normalized ratio (INR) monitoring, anticoagulation clinic pharmacist intervention (consultation), and warfarin dose adjustments were investigated along with yearly attrition rates, time-in-therapeutic ranges (TTRs), and clinical outcomes (stroke or systemic embolism and major bleeding). Descriptive statistics and multivariable Cox proportional hazard models were used to determine associations between TTR and clinical outcomes. RESULTS A total of 32,074 NVAF patients on warfarin treatment were identified and followed for a median of 3.8 years. About half (49%) of the patients were newly initiating warfarin therapy. INR monitoring and pharmacist interventions were conducted roughly every 3 weeks after 6 months of warfarin treatment. Sixty-three percent of the study population had ≥ 1 warfarin dose adjustments with a mean (SD) of 6.7 (6.3) annual dose adjustments. Warfarin dose adjustments occurred at a median of 1 day (interquartile ranges [IQR] 1-3) after the INR measurement. Yearly attrition rate was from 3.3% to 6.3% during the follow-up, and median (IQR) TTR was 61% (46%-73%). Patients who received frequent INR monitoring (≥ 27 times per year), pharmacist interventions (≥ 24 times per year), or frequently adjusted warfarin dose (≥ 11 times per year) consistently showed poor TTRs (mean TTR for the highest quartiles was 45.3%-48.3%). A higher TTR was associated with a lower risk of clinical outcomes regardless of frequency of INR monitoring, pharmacist interventions, or number of dose adjustments. Patients whose TTRs were < 65%, even with frequent pharmacist interventions, had similar stroke or systemic embolism event rates, as compared with patients with TTRs < 65% and less frequent interventions (1.88 vs. 1.54 stroke or systemic embolism rates per 100 person-years, respectively, P = 0.78). The lowest TTR quartile (< 46%) was associated with a 3 times higher risk of stroke or systemic embolism (hazard ratio [HR] = 3.19, 95% CI = 2.71-3.77) and a 2 times higher risk of major bleeding (HR = 2.10, 95% CI = 1.96-2.24) compared with the highest TTR quartile (≥ 73%). CONCLUSIONS Despite close monitoring with timely warfarin dose adjustments, there were still a substantial number of challenging patients whose TTRs were suboptimal despite a higher number of pharmacist interventions. These patients eventually experienced more stroke or systemic embolism and bleeding events among NVAF patients managed by anticoagulation clinics. New individualized treatment or management strategies for patients who are not able to reach optimal therapeutic ranges are necessary to improve outcomes. DISCLOSURES This research and manuscript were funded by Bristol-Myers Squibb Company and Pfizer. Authors from Bristol-Myers Squibb Company and Pfizer participated in the design of the study, interpretation of the data, review/revision of the manuscript, and approval of the final version of the manuscript. An received a grant for research support from Bristol-Myers Squibb/Pfizer. Niu, Rashid, and Zheng received a grant from Bristol-Myers Squibb/Pfizer to their institutions for salary reimbursement. Vo, Singh, and Aranda are employed by Bristol-Myers Squibb; Bruno was employed by Bristol-Myers Squibb at the time of this study. Mendes and Dills are employed by Pfizer, and Mendes was a member of the Pfizer Cardiovascular and Metabolic Field Medical Team during the time of this study. Lang, Jazdzewski, and Le have no known conflicts of interest to report. Study concept and design were contributed primarily by An and Rashid, along with the other authors. Niu took the lead in data collection, along with Zheng, and data interpretation was performed by An, along with Mendes and Dills, with assistance from the other authors. The manuscript was written by An and revised by Mendes, Dills, Vo, Singh, Bruno, and Aranda, along with Lang, Le, and Jazdezewski. Part of this study's findings was presented at the CHEST 2015 Annual Meeting in Montreal, Canada, on October 28, 2015.
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Affiliation(s)
- JaeJin An
- 1 Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, Pomona, California
| | - Fang Niu
- 2 Drug Information Services, Kaiser Permanente Southern California, Downey
| | - Chengyi Zheng
- 4 Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Nazia Rashid
- 2 Drug Information Services, Kaiser Permanente Southern California, Downey
| | | | - Diana Dills
- 5 North America Medical Affairs, Pfizer, New York, New York
| | - Lien Vo
- 6 Health Economic Outcomes Research, Bristol-Myers Squibb, Plainsboro, New Jersey
| | - Prianka Singh
- 6 Health Economic Outcomes Research, Bristol-Myers Squibb, Plainsboro, New Jersey
| | - Amanda Bruno
- 6 Health Economic Outcomes Research, Bristol-Myers Squibb, Plainsboro, New Jersey
| | - Daniel T Lang
- 7 Los Angeles Medical Center, The Permanente Medical Group, Kaiser Permanente Southern California, Los Angeles
| | - Paul T Le
- 3 Medication Therapy Management, Kaiser Permanente Southern California, Downey
| | | | - Gustavus Aranda
- 6 Health Economic Outcomes Research, Bristol-Myers Squibb, Plainsboro, New Jersey
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Henk HJ, Cao F, Tuell K, Price K, Singh P, Mardekian J, Odell K, Patel C, Tan W, Sands GH, Singhal S, Trocio J, Vo L. Treatment and discharge patterns among patients hospitalized with non-valvular atrial fibrillation transitioning from the inpatient to outpatient setting. Curr Med Res Opin 2018; 34:539-546. [PMID: 29235900 DOI: 10.1080/03007995.2017.1417029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate inpatient oral anticoagulant (OAC) treatment, discharge location, and post-discharge OAC treatment for patients hospitalized with non-valvular atrial fibrillation (NVAF). RESEARCH DESIGN AND METHODS Retrospective study using claims data linked to hospital electronic health records (EHR). Patients (n = 2,484) were hospitalized with a primary (38%) or secondary (62%) diagnosis of AF without evidence of mitral valvular heart disease or valve replacement between January 2009 and September 2013. Inpatient OAC treatment was identified from EHR data. MAIN OUTCOME MEASURES Inpatient and post-discharge OAC treatment [direct OAC (DOAC; apixaban, rivaroxaban, dabigatran), warfarin, no OAC] and discharge location (long-term care, home health-care, home self-care). RESULTS Mean age was 72.6 years, 61.2% were male, and 89.5% had a CHA2DS2-VASc score ≥2. Overall, 6.4% received a DOAC, 38.0% warfarin, and 55.6% no OAC during hospitalization. Compared to other treatment groups, patients receiving DOAC were younger and more likely to be male. The majority (72.2%) were discharged to home health-care, 13.2% home self-care, and 6.0% long-term care. Among patients who were treated with warfarin during hospitalization, 40.3% filled a warfarin prescription within 30 days post-discharge, whereas among patients who were treated with a DOAC, 52.4% filled a DOAC prescription within 30 days post-discharge. Some NVAF patients not treated with an OAC during hospitalization filled a prescription for warfarin (18.0%) or DOAC (1.9%) within 30 days post-discharge. Results were similar among patients with CHA2DS2-VASc score ≥2. CONCLUSIONS Most patients hospitalized for NVAF were discharged to home support, and the majority did not have OAC treatment during hospitalization or the 30 days post-discharge. Additional investigation should be conducted on trends beyond 30 days post-hospitalization, and the reasons for not receiving anticoagulation therapy in patients at moderate-to-severe risk of stroke or systemic embolism. Helping to avoid preventable strokes is an important goal for public health.
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Affiliation(s)
- Henry J Henk
- a Health Economics and Outcomes Research, Optum , Eden Prairie , MN , USA
| | - Feng Cao
- a Health Economics and Outcomes Research, Optum , Eden Prairie , MN , USA
| | - Kenneth Tuell
- b Health Economics and Outcomes Research, Bristol Myers-Squibb , Princeton , NJ , USA
| | - Kwanza Price
- c Health Economics and Outcomes Research, Pfizer , New York , NY , USA
| | - Prianka Singh
- b Health Economics and Outcomes Research, Bristol Myers-Squibb , Princeton , NJ , USA
| | - Jack Mardekian
- c Health Economics and Outcomes Research, Pfizer , New York , NY , USA
| | - Kevin Odell
- c Health Economics and Outcomes Research, Pfizer , New York , NY , USA
| | - Chad Patel
- b Health Economics and Outcomes Research, Bristol Myers-Squibb , Princeton , NJ , USA
| | - Wilson Tan
- d US Medical Affairs, Pfizer , New York , NY , USA
| | | | - Shalabh Singhal
- b Health Economics and Outcomes Research, Bristol Myers-Squibb , Princeton , NJ , USA
| | - Jeffrey Trocio
- c Health Economics and Outcomes Research, Pfizer , New York , NY , USA
| | - Lien Vo
- b Health Economics and Outcomes Research, Bristol Myers-Squibb , Princeton , NJ , USA
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12
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Yokoyama S, Tanaka Y, Nakagita K, Hosomi K, Takada M. Bleeding Risk of Warfarin and Direct Oral Anticoagulants in Younger Population: A Historical Cohort Study Using a Japanese Claims Database. Int J Med Sci 2018; 15:1686-1693. [PMID: 30588192 PMCID: PMC6299405 DOI: 10.7150/ijms.28877] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 09/14/2018] [Indexed: 12/18/2022] Open
Abstract
A historical cohort analysis of the Japan medical data center (JMDC) claims databases was performed to compare the incidence rates of bleeding events with warfarin (WF) versus direct oral anticoagulant (DOAC) treatment in patients with non-valvular atrial fibrillation. The aim of this study is to clarify the risk factors for bleeding events in younger patients newly treated with WF or DOAC in clinical practice setting. Patients who newly initiated WF or DOAC treatment from April 2012 to March 2015 were selected from the JMDC claims database. A 1:1 propensity score matching analysis was used for new users of WF or DOAC. Kaplan-Meier curves were generated to depict the time to bleeding event (total bleeding events, gastrointestinal hemorrhage, and intracranial hemorrhage) during the follow-up period. Cox proportional regression models were used to estimate the hazard ratios for total bleeding events caused by oral anticoagulants. Overall, 2,046 patients (503 WF and 1,543 DOAC) were included. After applying propensity score matching, Kaplan-Meier analysis of the WF and DOAC groups displayed comparable incidences of total bleeding events, gastrointestinal hemorrhage, and intracranial hemorrhage. Cox proportional hazards modeling showed that the use of WF was not associated with total bleeding events compared with DOAC (hazard ratio: 1.21, 95% confidence interval: 0.93-1.54, p = 0.15). This historical cohort study using a claims database indicates that the bleeding risk of DOAC was comparable to that of WF in Japanese younger population.
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Affiliation(s)
- Satoshi Yokoyama
- Division of Clinical Drug Informatics, Faculty of Pharmacy Kindai University, Japan
| | - Yuki Tanaka
- Division of Clinical Drug Informatics, Faculty of Pharmacy Kindai University, Japan
| | - Kazuki Nakagita
- Division of Clinical Drug Informatics, Faculty of Pharmacy Kindai University, Japan.,Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kouichi Hosomi
- Division of Clinical Drug Informatics, Faculty of Pharmacy Kindai University, Japan
| | - Mitsutaka Takada
- Division of Clinical Drug Informatics, Faculty of Pharmacy Kindai University, Japan
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Roldan T, Villamañán E, Rios JJ, Waxman AB. Assessment of the quality of anticoagulation management in patients with pulmonary arterial hypertension. Thromb Res 2017; 160:83-90. [DOI: 10.1016/j.thromres.2017.10.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 10/29/2017] [Accepted: 10/30/2017] [Indexed: 01/08/2023]
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Deitelzweig SB, Evans M, Trocio J, Gupta K, Lingohr-Smith M, Menges B, Lin J. Impact of Warfarin Persistence on Health-Care Utilization and Costs Among Patients With Atrial Fibrillation Managed in Anticoagulation Clinics in the United States. Clin Appl Thromb Hemost 2017; 24:364-371. [PMID: 28135822 DOI: 10.1177/1076029616685427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Warfarin is a recommended therapy to reduce the risk of stroke in patients with nonvalvular atrial fibrillation (NVAF). The objectives of this study were to identify potential factors associated with warfarin persistence and evaluate the impact of warfarin persistence on health-care resource utilization and costs among patients with NVAF in the United States. Patients (≥18 years) with ≥1 inpatient or ≥2 outpatient diagnoses of AF without valvular disease were identified from an electronic medical record database (January 1, 2004, to January 31, 2015). The patients with NVAF were grouped into 2 cohorts-persistent with warfarin therapy and not persistent (warfarin discontinuation in <365 days). A multivariable regression was used to identify potential predictors of warfarin persistence. Health-care costs were evaluated during a 12-month follow-up period for study cohorts. Among the study population, 52%, (n = 4086) were persistent with warfarin therapy and 48% (n = 3722) were not. Patients with NVAF with higher Charlson comorbidity index and CHADS2 scores versus those with scores of 0 were more likely to demonstrate persistence with warfarin therapy. After adjusting for patient characteristics, patients with NVAF persistent with warfarin therapy versus those who were not were 30% less likely to be hospitalized during the follow-up period ( P < .001). Additionally, total all-cause health-care costs (US $2183, P < .001) and stroke-related costs (US $788, P < .001) were significantly lower among patients persistent with warfarin therapy versus those who were not. Patients with NVAF who have greater comorbidity and stroke risk are more likely to be persistent with warfarin therapy. Patients with NVAF who are persistent with warfarin therapy versus those who are not have lower all-cause and stroke-related health-care costs.
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Affiliation(s)
- Steven B Deitelzweig
- 1 Department of Hospital Medicine, Ochsner Clinic Foundation, Ochsner Health System, New Orleans, LA, USA
| | - Michael Evans
- 2 Geisinger Health System, Enterprise Pharmacy, Danville, PA, USA
| | - Jeffrey Trocio
- 3 Global Health and Value, Outcomes and Evidence, Pfizer, Inc, New York, NY, USA
| | - Kiran Gupta
- 4 Health Economics and Outcomes Research, Bristol-Myers Squibb, Plainsboro, NJ, USA
| | | | - Brandy Menges
- 5 Health Economics and Outcomes Research, Novosys Health, Green Brook, NJ, USA
| | - Jay Lin
- 5 Health Economics and Outcomes Research, Novosys Health, Green Brook, NJ, USA
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15
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Bista D, Chalmers L, Peterson GM, Bereznicki LRE. Anticoagulant Use in Patients With Nonvalvular Atrial Fibrillation: Has Prescribing Improved? Clin Appl Thromb Hemost 2016; 23:573-578. [DOI: 10.1177/1076029616642511] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Discordance between international guideline recommendations and anticoagulant prescribing patterns among patients with nonvalvular atrial fibrillation (NVAF) has been frequently reported. This study was designed to compare the anticoagulant utilization pattern to earlier data in the same population and identify predictors of anticoagulant prescribing among patients with NVAF. We reviewed patients with NVAF admitted to Tasmania’s 3 major hospitals between January 2011 and June 2012 and compared the anticoagulant utilization pattern to earlier data. Patients were excluded if they had only 1 episode of NVAF that reverted spontaneously or upon cardioversion. Multivariate logistic regression analysis was used to identify predictors of anticoagulant prescribing. Overall, 53.8% of patients received anticoagulant treatment compared to 40.4% 15 years ago. Among eligible patients at high-risk of stroke, 52.5% were receiving anticoagulant therapy (vs 42.1% 15 years ago). Approximately 10% of patients with a CHADS2 score ≥2 were not receiving any antithrombotic treatment, reduced from 18.2% in the earlier cohort, whereas anticoagulant use increased among those at low risk (score 0) to 48.5% from 14.2%. Younger age (odds ratio [OR] 0.99, 95% confidence interval [CI] 0.97-1.0; P = .04); CHADS2 = 1, relative to 0 (OR 1.68, 95% CI 1.07-2.63; P = .02); CHF (OR 1.56, 95% CI 1.12-2.15; P = .008); and embolic disease history (OR 1.77, 95% CI 1.09-2.86; P = .02) were significant predictors of anticoagulant prescribing. While there has been improvement over the past 15 years, suboptimal use of anticoagulant therapy among high-risk patients with NVAF remains common. There is significant potential for improvement in the quality of stroke prophylaxis in patients with NVAF.
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Affiliation(s)
- Durga Bista
- Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Leanne Chalmers
- Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Gregory M. Peterson
- Health Services Innovation (Tasmania), School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
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Bista D, Chalmers L, Peterson GM, Bereznicki LRE. Patient Characteristics and Antithrombotic Prescribing Patterns in Patients With Atrial Fibrillation in Tasmania. Clin Appl Thromb Hemost 2015; 23:438-444. [DOI: 10.1177/1076029615623375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Limited data are available on atrial fibrillation (AF) and its clinical management and outcomes from an Australian perspective. This study was designed to examine the patient characteristics and antithrombotic treatment patterns among patients with AF in Tasmania, Australia. This retrospective observational study reviewed and followed patients with AF admitted to Tasmania’s 3 major hospitals between January 2011 and June 2012. Patients were excluded if they had only 1 episode of AF that reverted spontaneously or upon cardioversion without any documented recurrences. We reviewed the records of 2502 patients (≥18 years), and1469 were subsequently included in the study. The mean (±standard deviation [SD]) age of the patients was 76 (±12.3) years. The mean (± SD) CHADS2 score was 2.1 (±1.3), and 65.7% had a score ≥2. In total, only 55.6% of patients with CHADS2 score ≥2 were receiving anticoagulation and 9.9% were not receiving any antithrombotic treatment, whereas 85.4% of those at low risk (score 0) were on antithrombotic therapy. Hospitalization was associated with a significant increase in the rate of combination (antiplatelet plus anticoagulant) therapy ( P < .001). Suboptimal use of antithrombotic therapy highlights the need to improve AF management in our jurisdiction.
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Affiliation(s)
- Durga Bista
- Pharmacy, School of Medicine, University of Tasmania, Hobart, Australia
| | - Leanne Chalmers
- Pharmacy, School of Medicine, University of Tasmania, Hobart, Australia
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Suárez Fernández C, Fernández S, Formiga F, Camafort M, Cepeda Rodrigo M, Rodrigo JC, Díez-Manglano J, Pose Reino A, Reino P, Tiberio G, Mostaza JM. Antithrombotic treatment in elderly patients with atrial fibrillation: a practical approach. BMC Cardiovasc Disord 2015; 15:143. [PMID: 26530138 PMCID: PMC4632329 DOI: 10.1186/s12872-015-0137-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 10/26/2015] [Indexed: 12/23/2022] Open
Abstract
Background Atrial fibrillation (AF) in the elderly is a complex condition. It has a direct impact on the underuse of antithrombotic therapy reported in this population. Discussion All patients aged ≥75 years with AF have an individual yearly risk of stroke >4 %. However, the risk of hemorrhage is also increased. Moreover, in this population it is common the presence of other comorbidities, cognitive disorders, risk of falls and polymedication. This may lead to an underuse of anticoagulant therapy. Direct oral anticoagulants (DOACs) are at least as effective as conventional therapy, but with lesser risk of intracranial hemorrhage. The simplification of treatment with these drugs may be an advantage in patients with cognitive impairment. The great majority of elderly patients with AF should receive anticoagulant therapy, unless an unequivocal contraindication. DOACs may be the drugs of choice in many elderly patients with AF. Summary In this manuscript, the available evidence about the management of anticoagulation in elderly patients with AF is reviewed. In addition, specific practical recommendations about different controversial issues (i.e. patients with anemia, thrombocytopenia, risk of gastrointestinal bleeding, renal dysfunction, cognitive impairment, risk of falls, polymedication, frailty, etc.) are provided.
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Affiliation(s)
| | - Suárez Fernández
- Hospital Universitario de La Princesa, Grupo de Riesgo Vascular de la SEMI, Madrid, España. .,Servicio de Medicina Interna, Hospital Universitario de La Princesa, C/Diego de León 62, 28006, Madrid, Spain.
| | - Francesc Formiga
- Hospital Universitari de Bellvitge, Grupo de Riesgo Vascular de la SEMI, Hospitalet de Llobregat, Barcelona, España
| | - Miguel Camafort
- Atrial Fibrillation Unit (UFA), Internal Medicine Department, Hospital Clinic. University of Barcelona. Research Group in Cardiovascular Risk, Nutrition and Aging. Area. 'August Pi i Sunyer' Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | | | - Jose Cepeda Rodrigo
- Hospital Vega Baja de Orihuela, Grupo de Riesgo Vascular de la SEMI, Orihuela, Alicante, España
| | - Jesús Díez-Manglano
- Hospital Royo Villanova, Grupo de Riesgo Vascular de la SEMI, Zaragoza, España
| | | | - Pose Reino
- Complexo Hospitalario Universitario de Santiago, Grupo de Riesgo Vascular de la SEMI, Santiago de Compostela, España
| | - Gregorio Tiberio
- Hospital Virgen del Camino, Grupo de Riesgo Vascular de la SEMI, Pamplona, España
| | - Jose María Mostaza
- Hospital Carlos III, Grupo de Riesgo Vascular de la SEMI, Madrid, España
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