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Zwart LAR, Spruit JR, Hemels MEW, de Groot JR, Pisters R, Riezebos RK, Jansen RWMM. Design of the Dutch multicentre study on opportunistic screening of geriatric patients for atrial fibrillation using a smartphone PPG app: the Dutch-GERAF study. Neth Heart J 2024; 32:200-205. [PMID: 38619715 DOI: 10.1007/s12471-024-01868-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Screening of high-risk patients is advocated to achieve early detection and treatment of clinical atrial fibrillation (AF). The Dutch-GERAF study will address two major issues. Firstly, the effectiveness and feasibility of an opportunistic screening strategy for clinical AF will be assessed in frail older patients and, secondly, observational data will be gathered regarding the efficacy and safety of oral anticoagulation (OAC). METHODS This is a multicentre study on opportunistic screening of geriatric patients for clinical AF using a smartphone photoplethysmography (PPG) application. Inclusion criteria are age ≥ 65 years and the ability to perform at least three PPG recordings within 6 months. Exclusion criteria are the presence of a cardiac implantable device, advanced dementia or a severe tremor. The PPG application records patients' pulse at their fingertip and determines the likelihood of clinical AF. If clinical AF is suspected after a positive PPG recording, a confirmatory electrocardiogram is performed. Patients undergo a comprehensive geriatric assessment and a frailty index is calculated. Risk scores for major bleeding (MB) are applied. Standard laboratory testing and additional laboratory analyses are performed to determine the ABC-bleeding risk score. Follow-up data will be collected at 6 months, 12 months and 3 years on the incidence of AF, MB, hospitalisation, stroke, progression of cognitive disorders and mortality. DISCUSSION The Dutch-GERAF study will focus on frail older patients, who are underrepresented in randomised clinical trials. It will provide insight into the effectiveness of screening for clinical AF and the efficacy and safety of OAC in this high-risk population. TRIAL REGISTRATION NCT05337202.
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Affiliation(s)
- Lennaert A R Zwart
- Department of Geriatric Medicine, Dijklander Hospital, Hoorn, The Netherlands.
- Department of Geriatric Medicine, Northwest Hospital, Alkmaar, The Netherlands.
- Aging and Later Life, Amsterdam Public Health, Amsterdam University Hospital, Amsterdam, The Netherlands.
| | - Jocelyn R Spruit
- Department of Geriatric Medicine, Northwest Hospital, Alkmaar, The Netherlands
| | - Martin E W Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Hospital, Nijmegen, The Netherlands
| | - Joris R de Groot
- Department of Cardiology, Amsterdam University Hospital, Amsterdam, The Netherlands
| | - Ron Pisters
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Robert K Riezebos
- Heart Centre, Department of Cardiology, OLVG, Amsterdam, The Netherlands
| | - René W M M Jansen
- Department of Geriatric Medicine, Northwest Hospital, Alkmaar, The Netherlands
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Voorhout L, Pisters R, Geurts CHPH, Oostindjer A, van Doorn S, Rila H, Fuijkschot WW, Verheugt F, Hemels MEW. Screening over 100 000 patients in 39 general practices in the Netherlands for anticoagulation underprescription in atrial fibrillation: a descriptive, cross-sectional study. BMJ Open 2023; 13:e072655. [PMID: 37597862 PMCID: PMC10441057 DOI: 10.1136/bmjopen-2023-072655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 07/06/2023] [Indexed: 08/21/2023] Open
Abstract
OBJECTIVES To investigate the underprescription of oral anticoagulation (OAC) in individual atrial fibrillation (AF) patients in primary care. SETTING Screening of patient records in 39 participating general practitioners (GPs) across the Netherlands. PARTICIPANTS We screened 101 207 patient records identifying 2375 non-valvular AF patients. METHODS Using electronic patient files, we were able to screen the entire GP population for AF, CHA2DS2-VASc stroke risk scores, and the use of guidelines recommended OAC prescription. In case of a deviation from guidelines recommended OAC prescription, we checked the electronic patient file for any documented reason. Additionally, 6 weeks following the screening, we asked all GPs to provide information on any actions taken for the underprescribed patients. RESULTS We found a mean CHA2DS2-VASc score of 3.2. OAC prescription consisted of direct OAC in 1342/1984 (68%) and vitamin K-antagonists in the remainder of patients. OAC underprescription was present in 93/944 (9.9%) females and 101/1374 (9.7%) in males, respectively. In 111/146 (76.0%) of the underprescribed AF patients, no reason to withhold OAC was reported. Reported reasons to withhold OAC were patient refusal (n=10), cardiologist advice (n=7) and high risk of bleeding (n=7). Data regarding actions following the identification of OAC underprescription were available for 92/194 (47%) of the OAC underprescribed cases. After consultation OAC was initiated in 9/92 (10%) only. CONCLUSIONS In this large Dutch study among GPs, we observed 9.8% underprescription of OAC in AF patients. In 76% of the AF patients lacking a prescription for OAC, no documentation for deviating from the guidelines was found. Only in a minority of cases detection of OAC underprescription lead to OAC initiation.
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Affiliation(s)
- Leonard Voorhout
- Department of Cardiology, Research, Hospital Rijnstate, Arnhem, The Netherlands
| | - Ron Pisters
- Department of Cardiology, Research, Hospital Rijnstate, Arnhem, The Netherlands
| | | | | | - Sander van Doorn
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
| | | | | | - Freek Verheugt
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Martin E W Hemels
- Department of Cardiology, Research, Hospital Rijnstate, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Sporn ZA, Berman AN, Daly D, Wasfy JH. Improving guideline-based anticoagulation in atrial fibrillation: A systematic literature review of prospective trials. Heart Rhythm 2023; 20:69-75. [PMID: 36122695 DOI: 10.1016/j.hrthm.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/07/2022] [Accepted: 09/12/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Guidelines for anticoagulation in patients with atrial fibrillation (AF) aim to decrease the risk of ischemic stroke. However, there is a gap in actual practice between patients who have an indication for anticoagulation and those who are actually prescribed anticoagulation. OBJECTIVE We sought to evaluate the efficacy of prior population-based interventions aimed at decreasing this AF anticoagulation gap. METHODS This study was prospectively registered in the International Prospective Register of Systematic Reviews database (CRD42021287875). A systematic literature review was conducted to obtain all prospective individually randomized and cluster randomized trials by searching 4 electronic databases: PubMed, Google Scholar, Web of Science, and Medline. RESULTS After a review of 1474 studies, 20 trials were included in this systematic literature review. Forty-five percent were effective in decreasing the AF anticoagulation gap. Trial interventions that improved anticoagulation prescribing included 6 trials of electronic risk assessment or decision support, 1 trial of provider education, 2 trials of new protocol or pathway, and 2 trials of patient education. Six of 15 ambulatory trials, 2 of 4 inpatient trials, and 1 trial that spanned inpatient and outpatient settings improved anticoagulation prescribing rates. Interventions focused on patient education, provider education, and electronic risk assessment or decision support increased absolute appropriate anticoagulation prescribing by 8.3%, 4.9%, and 2.0%, respectively. CONCLUSION Interventions aimed at improving anticoagulation prescribing patterns in AF can be effective, although there is heterogeneity in outcomes across intervention type. The most effective interventions appeared to target patient education, provider education, and electronic risk assessment or decision support.
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Affiliation(s)
- Zachary A Sporn
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
| | - Adam N Berman
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Danielle Daly
- Population Health Management, Performance Analysis and Improvement, Massachusetts General Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts
| | - Jason H Wasfy
- Population Health Management, Performance Analysis and Improvement, Massachusetts General Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts; Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Epidemiology, risk profile, management, and outcome in geriatric patients with atrial fibrillation in two long-term care hospitals. Sci Rep 2022; 12:18725. [PMID: 36333439 PMCID: PMC9636160 DOI: 10.1038/s41598-022-22013-6] [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] [Received: 01/14/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
Abstract
Aim of this study was investigate the prevalence and incidence of atrial fibrillation (AF) and to describe the clinical characteristics, risk profiles, and types of anticoagulant therapy for stroke prevention and the clinical outcomes in persons admitted to a long-term care hospital. We conducted a retrospective cohort study using data from the electronic medical records of patients aged 65 years or older living in two long-term care hospitals between January 1, 2014 and October 31, 2017. Overall data from 1148 patients (mean age 84.1 ± 7.9 years, 74.2% women) were analyzed. At baseline, the median CHA2DS2-VASc score was 4 (IQR 3-5) and the HAS-BLED score 2 (IQR 2-3). We observed patients over a median period of 3.7 years. The point prevalence of AF was 29.6% (95% CI 25.8-33.7) on January 1, 2014. The 1-year cumulative incidence of de novo AF was 4.0% (2.8-5.6). Oral anticoagulants were prescribed in 48% of patients with AF. The cumulative incidence at 1 year for a composite outcome of TIA, stroke, or systemic arterial embolism was 0.6% (0.1-3.1) and 1.7% (0.5-4.6) and for bleeding 2.6% (0.9-6.2) and 1.8% (0.5-4.8) in patients with AF and oral anticoagulants or no oral anticoagulants, respectively. In long-term care hospital patients, we observed a high burden of AF. However, only about half of patients with AF received oral anticoagulation for stroke prevention.
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Rasmussen PV, Sakthivel T, Dalgaard F, Gislason GH, Pallisgaard JL, Hansen ML. Treatment patterns for oral anticoagulants in older patients with atrial fibrillation: a retrospective, cross-sectional, nationwide study from Denmark. BMJ Open 2022; 12:e062353. [PMID: 36581981 PMCID: PMC9438197 DOI: 10.1136/bmjopen-2022-062353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES Atrial fibrillation (AF) is a predominant risk factor of ischaemic stroke and treatment with oral anticoagulants (OACs) is recommended in all patients with risk factors. This study sought to examine treatment patterns of OACs in older patients with AF. DESIGN Retrospective, cross-sectional study. SETTING Danish nationwide administrative and clinical registers and databases. PARTICIPANTS A total of 40 027 patients, >75 years of age, after their first hospital contact due to AF between 2010 and 2018. PRIMARY AND SECONDARY OUTCOMES MEASURES The primary event of interest was claimed prescriptions for OACs within 180 days after first hospital contact due to AF. Proportions of patients treated with OACs were estimated and clinical factors associated with the probability of receiving OAC treatment were identified using adjusted logistic regression models. RESULTS A total of 40 027 patients were included with a slight majority of women (54%). The median age was 81 years (IQR 78-86). We found that an overall 32 235 patients (81%) were prescribed an OAC after their first hospital contact due to AF with a marked increase in the proportion of patients treated from 2010 to 2018. Factors related to a decreased probability of receiving treatment were bleeding risk factors such as a history of haemorrhagic stroke (OR 0.21, 95% CI 0.16 to 0.27), any bleeding (OR 0.58, 95% CI 0.53 to 0.62) as well as markers of frailty such as osteoporosis (OR 0.78, 95% CI 0.71 to 0.85). CONCLUSION In this large nationwide study, we found that in older patients with AF, the overall rates of OAC prescription were generally high (~80%) and increasing during the last decade. Factors associated with not receiving guideline recommended OAC treatment were generally related to bleeding risk factors or frailty.
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Affiliation(s)
| | | | - Frederik Dalgaard
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Gunnar Hilmar Gislason
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Frailty and Outcomes in Older Adults with Non-valvular Atrial Fibrillation from the ANAFIE Registry. Arch Gerontol Geriatr 2022; 101:104661. [DOI: 10.1016/j.archger.2022.104661] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/03/2022] [Accepted: 02/12/2022] [Indexed: 11/18/2022]
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Lack of Sex Disparity in Oral Anticoagulation in Atrial Fibrillation Patients Presenting with Ischemic Stroke in a Rural Population. J Clin Med 2021; 10:jcm10204670. [PMID: 34682796 PMCID: PMC8537827 DOI: 10.3390/jcm10204670] [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] [Received: 08/27/2021] [Revised: 09/30/2021] [Accepted: 09/30/2021] [Indexed: 11/16/2022] Open
Abstract
Various studies on oral anticoagulants (OAC) use among atrial fibrillation (AF) patients have shown high rates of undertreatment and the presence of sex disparity. This study used the 'Geisinger Neuroscience Ischemic Stroke' (GNSIS) database to examine sex differences in OAC treatment among ischemic stroke patients with the pre-event diagnosis of AF in rural Pennsylvania between 2004 and 2019. We examined sex disparities in OAC undertreatment and associated risks based on age group and ischemic stroke year. A total of 1062 patients were included in the study and 1015 patients (96%) had CHA2DS2-VASc score ≥ 2, of which 549 (54.1%) were women. Undertreatment rates were not statistically significant between men and women in the overall cohort (50.0% vs. 54.5%, p = 0.18), and male sex was not found to be a significant factor in undertreatment (OR 0.82, 95% CI 0.62-1.09, p = 0.17). The result persisted even when patients were divided into four age groups and two groups based on the study time period. The undertreatment rates in both sex groups remained consistent following the introduction of novel oral anticoagulants. In conclusion, there was no evidence of sex disparity with respect to OAC treatment, even after stratifying the cohort by age and ischemic stroke year.
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Yamada Y, Kojima T, Umeda-Kameyama Y, Ogawa S, Eto M, Akishita M. Outcomes of anticoagulant prescribing for older patients with atrial fibrillation depends on disability level provided by long-term care insurance. Arch Gerontol Geriatr 2021; 96:104434. [PMID: 34030044 DOI: 10.1016/j.archger.2021.104434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/08/2021] [Accepted: 05/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) in patients aged ≥75 is one of the major risk factors for stroke, and prescription of oral anticoagulants (OACs) should be considered in these patients. We investigated the use of OAC' for patients certificated for long-term care (LTC) insurance, who have a high risk of bleeding among older patients. METHODS AND RESULTS From 1169 consecutive inpatients aged 75 or older who were admitted to the geriatric ward of The University of Tokyo Hospital between 2012 and 2017, we identified 175 patients (men 48%, mean age 85.5 years) who had AF during admission. The patients' background, prescription of OACs on discharge, and the level of LTC insurance were checked. Patients were followed up for 1 to 5 years. Major bleeding, stroke, and all-cause mortality were investigated as outcomes. Among patients with AF, 63.4% were taking OACs. In multivariate analysis, older age, low BMI and no history of stroke were significant factors for not prescribing OACs. Care level patients with OACs had a higher incidence of stroke than others. There was no difference, irrespective of OAC prescription and disability level, in incidence of major bleeding. Care level patients without OACs had higher mortality than others. CONCLUSIONS These results suggest that older care level patients with AF may benefit less from OACs.
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Affiliation(s)
- Yoko Yamada
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Taro Kojima
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Yumi Umeda-Kameyama
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sumito Ogawa
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masato Eto
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; General Education Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Masahiro Akishita
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Diaz J, Koza E, Chaudhary D, Shahjouei S, Naved MMA, Malik MT, Li J, Adibuzzaman M, Griffin P, Abedi V, Zand R. Adherence to anticoagulant guideline for atrial fibrillation: A large care gap among stroke patients in a rural population. J Neurol Sci 2021; 424:117410. [PMID: 33770707 DOI: 10.1016/j.jns.2021.117410] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/12/2021] [Accepted: 03/18/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study aimed to investigate the prevalence and factors associated with oral anticoagulant undertreatment of atrial fibrillation (AF) among a cohort of rural patients with stroke outcomes and examine how undertreatment may influence a patient's one-year survival after stroke. METHODS This retrospective cohort study examined ischemic stroke patients with pre-stroke AF diagnosis from September 2003 to May 2019 and divided them into proper treatment and undertreatment group. Analysis included chi-square test, variance analysis, Kruskal-Wallis test, logistic regression, Kaplan-Meier estimator, and Cox proportional-hazards model. RESULTS Out of 1062 ischemic stroke patients with a pre-stroke AF diagnosis, 1015 patients had a CHA2DS2-VASc score ≥2, and 532 (52.4%) of those were undertreated. Median time from AF diagnosis to index stroke was significantly lower among undertreated patients (1.9 years vs. 3.6 years, p < 0.001). Other thromboembolism, excluding stroke, TIA, and myocardial infarction (OR 0.41, p < 0.001), the number of encounters per year (OR 0.90, p < 0.001), and the median time between AF diagnosis and stroke event (OR 0.86, p < 0.001) were negatively associated with undertreatment. Kaplan-Meier estimator showed no statistical difference in the one-year survival probability between groups (log-rank test, p = 0.29), while the Cox-Hazard model showed that age (HR 1.05, p < 0.001) and history of congestive heart failure (HR 1.88, p < 0.001) increased the risk of mortality. CONCLUSIONS More than half of our rural stroke patients with a pre-index AF diagnosis were not on guideline-recommended treatment. The study highlights a large care gap and an opportunity to improve AF management.
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Affiliation(s)
- Johan Diaz
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Eric Koza
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Durgesh Chaudhary
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, PA, USA
| | - Shima Shahjouei
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, PA, USA
| | | | - Muhammad Taimur Malik
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, PA, USA
| | - Jiang Li
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, PA, USA
| | - Mohammad Adibuzzaman
- Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Paul Griffin
- Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park, PA, USA
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, PA, USA; Biocomplexity Institute, Virginia Tech, Blacksburg, VA, USA
| | - Ramin Zand
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, PA, USA.
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Liu J, Du X, Li M, Jia Z, Lu S, Chang S, Tang R, Bai R, Dong J, Lip GYH, Ma C. Frailty and Anticoagulant Therapy in Patients Aged 65 Years or Older with Atrial Fibrillation. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2020. [DOI: 10.15212/cvia.2019.0562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Elderly adults with atrial fibrillation (AF) are at increased risk of frailty and thromboembolic complications. However, studies on the prevalence of frailty in AF patients and data on the relationship between frailty and the use of anticoagulants are limited.Methods:
We conducted a cross-sectional study involving 500 participants. Patients aged 65 years or older were consecutively selected from the Chinese Atrial Fibrillation Registry study. The patient’s frailty status was assessed with use of the Canadian Study of Health and Aging Clinical Frailty
Scale. We assessed the prevalence of and factors associated with frailty, and how frailty affects anticoagulant therapy.Results: In 500 elderly adults with AF (age 75.2±6.7 years; 51.6% female), 201 patients (40.2%) were frail. The prevalence of frailty was higher in females
(P=0.002) and increased with age and CHA2DS2-VASc score (P for trend less than 0.001 for both). The factors associated with frailty were a history of heart failure (odds ratio [OR] 2.40, 95% confidence interval [CI] 1.39‐4.14), female sex (OR 2.09, 95% CI 1.27‐3.43),
and advanced age (OR 1.13, 95% CI 1.09‐1.17). Frail patients were significantly less likely to have ever been prescribed anticoagulants compared with nonfrail patients (81.7 vs. 54.9%, P<0.001).Conclusions: Frailty is prevalent in elderly adults with AF, especially in
females, those of advanced age, and those with heart failure. Frailty status has a significant impact on prescription of anticoagulants for high-risk AF patients.
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Affiliation(s)
- Jiapeng Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Mengmeng Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Zhaoxu Jia
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Shangxin Lu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Sanshuai Chang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Ribo Tang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Rong Bai
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Jianzeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
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Caso V, Masuhr F. A Narrative Review of Nonvitamin K Antagonist Oral Anticoagulant Use in Secondary Stroke Prevention. J Stroke Cerebrovasc Dis 2019; 28:2363-2375. [PMID: 31281110 DOI: 10.1016/j.jstrokecerebrovasdis.2019.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/17/2019] [Accepted: 05/18/2019] [Indexed: 01/28/2023] Open
Abstract
The prevalence of atrial fibrillation (AF), the most common cardiac arrhythmia, increases with age, predisposing elderly patients to an increased risk of embolic stroke. With an increasingly aged population the number of people who experience a stroke every year, overall global burden of stroke, and numbers of stroke survivors and related deaths continue to increase. Anticoagulation with vitamin K antagonists (VKAs) reduces the risk of ischemic stroke in patients with AF; however, increased bleeding risk is well documented, particularly in the elderly. Consequently, VKAs have been underused in the elderly. Alternative anticoagulants may offer a safer choice, particularly in patients who have experienced previous stroke. The aim of this narrative review is to examine available evidence for the effective treatment of patients with AF and previous cerebral vascular events with non-VKA oral anticoagulants, including the most appropriate time to start or reinitiate treatment after a stroke, systemic embolism, or clinically relevant bleed. For patients with AF treated with oral anticoagulants it is important to balance increased protection against future stroke/systemic embolism and reduced risk of major bleeding events. For patients with AF who have previously experienced a cerebrovascular event, the use of oral anticoagulants alone also appears more effective than low-molecular weight heparin (LMWH) alone or LMWH followed by oral anticoagulants. Available data suggest that significant reduction in stroke, symptomatic cerebral bleeding, and major extracranial bleeding within 90 days from acute stroke can be achieved if oral anticoagulation is initiated at 4-14 days from stroke onset.
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Affiliation(s)
- Valeria Caso
- Stroke Unit and Division of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy.
| | - Florian Masuhr
- Department of Neurology, German Army Hospital, Berlin, Germany
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Patti G, Pecen L, Lucerna M, Huber K, Rohla M, Renda G, Siller-Matula J, Ricci F, Kirchhof P, De Caterina R. Net Clinical Benefit of Non-Vitamin K Antagonist vs Vitamin K Antagonist Anticoagulants in Elderly Patients with Atrial Fibrillation. Am J Med 2019; 132:749-757.e5. [PMID: 30664837 DOI: 10.1016/j.amjmed.2018.12.036] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 12/23/2018] [Accepted: 12/26/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND The risks of thromboembolic and hemorrhagic events in patients with atrial fibrillation both increase with age; therefore, net clinical benefit analyses of anticoagulant treatments in the elderly population are crucial to guide treatment. We evaluated the 1-year clinical outcomes with non-vitamin-K antagonist and vitamin K antagonist oral anticoagulants (NOACs vs VKAs) in elderly (≥75 years) patients with atrial fibrillation in a prospective registry setting. METHODS Data on 3825 elderly patients were pooled from the PREFER in AF and PREFER in AF PROLONGATION registries. The primary outcome was the incidence of the net composite endpoint, including major bleeding and ischemic cardiovascular events on NOACs (n = 1556) compared with VKAs (n = 2269). RESULTS The rates of the net composite endpoint were 6.6%/year with NOACs vs 9.1%/year with VKAs (odds ratio [OR] 0.71; 95% confidence interval [CI], 0.51-0.99; P = .042). NOAC therapy was associated with a lower rate of major bleeding compared with VKA use (OR 0.58; 95% CI, 0.38-0.90; P = .013). Ischemic events were nominally reduced too (OR 0.71; 95% CI, 0.51-1.00; P = .050). Major bleeding with NOACs was numerically lower in higher-risk patients with low body mass index (BMI; OR 0.50; 95% CI, 0.22-1.12; P = .07) or with age ≥85 years (OR 0.44; 95% CI, 0.13-1.49; P = .17). CONCLUSIONS Our real-world data indicate that, compared with VKAs, NOAC use is associated with a better net clinical benefit in elderly patients with atrial fibrillation, primarily due to lower rates of major bleeding. Major bleeding with NOACs was numerically lower also in higher-risk patients with low BMI or age ≥85 years.
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Affiliation(s)
- Giuseppe Patti
- Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Italy.
| | - Ladislav Pecen
- Medical Faculty Pilsen of Charles University, Prague, Czech Republic
| | | | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria; Sigmund Freud University, Medical School, Vienna, Austria
| | - Miklos Rohla
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria; Sigmund Freud University, Medical School, Vienna, Austria
| | - Giulia Renda
- Institute of Cardiology, G. d'Annunzio University, Chieti, Italy
| | - Jolanta Siller-Matula
- Department of Cardiology, Medical University of Vienna, Austria; 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Fabrizio Ricci
- Institute of Advanced Biomedical Technologies, Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti, Italy; Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham and SWBH and UHB NHS Trust, Birmingham, UK
| | - Raffaele De Caterina
- Institute of Cardiology, G. d'Annunzio University, Chieti, Italy; Fondazione G. Monasterio, Pisa, Italy
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Optimizing Anticoagulation in Older Patients with Nonvalvular Atrial Fibrillation. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0599-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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14
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Polo García J, Vargas Ortega D, Formiga F, Unzueta I, Fernández de Cabo S, Chaves J. Profiling of patients with non-valvular atrial fibrillation and moderate-to-high risk of stroke not receiving oral anticoagulation in Spain. Semergen 2018; 45:396-405. [PMID: 30573367 DOI: 10.1016/j.semerg.2018.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 09/28/2018] [Accepted: 10/17/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In non-valvular atrial fibrillation (NVAF) with embolic risk, the guidelines recommend oral anticoagulation (OAC), although not all patients receive it. In this study, an attempt is made to identify these patients, and to study factors related to non-anticoagulation. MATERIAL AND METHODS Non-interventional, cross-sectional, multicentre study was performed on a population of patients ≥18 years with a NVAF diagnosis, moderate-high embolic risk (CHADS2 score≥2), not treated with OAC. Atrial fibrillation (AF) prevalence was also collected. RESULTS AF prevalence was 4.5%, and 80.7% of the patients had NVAF (20.0% did not receive OAC). A total of 1310 non-OAC-treated patients were included (51.8% male, mean age: 76.0 years). The mean time since AF diagnosis was 58.4 months. The main therapeutic decision for stroke prevention was prescription of antiplatelet agents (82.4%, n=1078), and the main reasons were: patient refusal to monitoring (37.3%), high bleeding risk (31.1%), uncontrolled hypertension (27.9%), and frequent falls (27.6%). The mean CHA2DS2-VASc score was 4.6, and the HAS-BLED was 2.7 (55.9% of patients scoring HAS-BLED≥3). The most common thromboembolic risk factors were: hypertension (89.1%), age≥75 years (61.5%); the haemorrhagic factors: use of drugs increasing the bleeding risk (41.2%), uncontrolled blood pressure (33.7%). CONCLUSIONS About 20% of Spanish NVAF patients do not receive OAC in the clinical practice and are treated with antiplatelet agents, which do not reduce haemorrhagic risk. Most patients do not clearly show a contraindication to OACs, particularly considering that there are other available options (direct oral anticoagulant drugs [DOACs]).
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Affiliation(s)
- J Polo García
- Centro de Salud Cañaveral, Calle Doctor Boticario Jiménez 32, 10820 Cáceres, Spain.
| | - D Vargas Ortega
- Unidad de Hospitalización del Hospital de Alta Resolución el Toyo, Camino de la Botica s/n, 04131 Almería, Spain
| | - F Formiga
- Servicio de Medicina Interna del Hospital Bellvitge, Carrer de la Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - I Unzueta
- Medical Department Pfizer (PIH), Avda. Europa 20B, 20108 Alcobendas, Madrid, Spain
| | - S Fernández de Cabo
- Medical Department Pfizer (PIH), Avda. Europa 20B, 20108 Alcobendas, Madrid, Spain
| | - J Chaves
- Medical Department Pfizer (PIH), Avda. Europa 20B, 20108 Alcobendas, Madrid, Spain
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15
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Oh S, Kim JS, Oh YS, Shin DG, Pak HN, Hwang GS, Choi KJ, Kim JB, Lee MY, Park HW, Kim DK, Jin ES, Park J, Oh IY, Shin DH, Park HS, Kim JH, Kim NH, Ahn MS, Seo BJ, Kim YJ, Kang S, Lee J, Kim YH. Quality of Anticoagulation and Treatment Satisfaction in Patients with Non-Valvular Atrial Fibrillation Treated with Vitamin K Antagonist: Result from the KORean Atrial Fibrillation Investigation II. J Korean Med Sci 2018; 33:e323. [PMID: 30505257 PMCID: PMC6262187 DOI: 10.3346/jkms.2018.33.e323] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 08/07/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Vitamin K antagonist (VKA) to prevent thromboembolism in non-valvular atrial fibrillation (NVAF) patients has limitations such as drug interaction. This study investigated the clinical characteristics of Korean patients treated with VKA for stroke prevention and assessed quality of VKA therapy and treatment satisfaction. METHODS We conducted a multicenter, prospective, non-interventional study. Patients with CHADS2 ≥ 1 and treated with VKA (started within the last 3 months) were enrolled from April 2013 to March 2014. Demographic and clinical features including risk factors of stroke and VKA treatment information was collected at baseline. Treatment patterns and international normalized ratio (INR) level were evaluated during follow-up. Time in therapeutic range (TTR) > 60% indicated well-controlled INR. Treatment satisfaction on the VKA use was measured by Treatment Satisfaction Questionnaire for Medication (TSQM) after 3 months of follow-up. RESULTS A total of 877 patients (age, 67; male, 60%) were enrolled and followed up for one year. More than half of patients (56%) had CHADS2 ≥ 2 and 83.6% had CHA2DS2-VASc ≥ 2. A total of 852 patients had one or more INR measurement during their follow-up period. Among those patients, 25.5% discontinued VKA treatment during follow-up. Of all patients, 626 patients (73%) had poor-controlled INR (TTR < 60%) measure. Patients' treatment satisfaction measured with TSQM was 55.6 in global satisfaction domain. CONCLUSION INR was poorly controlled in Korean NVAF patients treated with VKA. VKA users also showed low treatment satisfaction.
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Affiliation(s)
- Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - June-Soo Kim
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong-Seog Oh
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-Gu Shin
- Department of Internal Medicine, Yeungnam University Hospital, Yeungnam University College of Medicine, Daegu, Korea
| | - Hui-Nam Pak
- Department of Internal Medicine, Severance Hospital, Yonsei University Health System, Seoul, Korea
| | - Gyo-Seung Hwang
- Department of Internal Medicine, Ajou University Hospital, Suwon, Korea
| | - Kee-Joon Choi
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Bae Kim
- Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University School of Medicine, Seoul, Korea
| | - Man-Young Lee
- Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyung-Wook Park
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Dae-Kyeong Kim
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Eun-Sun Jin
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jaeseok Park
- Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea
| | - Il-Young Oh
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dae-Hee Shin
- Department of Internal Medicine, Gangneung Asan Hospital, Gangneung, Korea
| | - Hyoung-Seob Park
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Keimyung University College of Medicine, Daegu, Korea
| | - Jun Hyung Kim
- Department of Internal Medicine, Chungnam National University College of Medicine, Chungnam, Korea
| | - Nam-Ho Kim
- Department of Internal Medicine, Wonkwang University Hospital, Iksan, Korea
| | - Min-Soo Ahn
- Department of Internal Medicine, Yonsei University, Wonju Severance Christian Hospital, Wonju, Korea
| | - Bo-Jeong Seo
- Outcomes Research/Real World Data, Corporate Affairs & Health and Value, Pfizer Pharmaceuticals Korea Ltd., Seoul, Korea
| | - Young-Joo Kim
- Outcomes Research/Real World Data, Corporate Affairs & Health and Value, Pfizer Pharmaceuticals Korea Ltd., Seoul, Korea
| | - Seongsik Kang
- Department of Internal Medicine-Medical, Pfizer Pharmaceuticals Korea Ltd., Seoul, Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Young-Hoon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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16
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Guerriero F, Orlando V, Monetti VM, Colaccio FM, Sessa M, Scavone C, Capuano A, Menditto E. Predictors of new oral anticoagulant drug initiation as opposed to warfarin in elderly adults: a retrospective observational study in Southern Italy. Ther Clin Risk Manag 2018; 14:1907-1914. [PMID: 30349269 PMCID: PMC6183659 DOI: 10.2147/tcrm.s171346] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM The aim of this study was to assess the predictive role of age, gender, and number and type of co-treatments for new oral anticoagulant (NOAC) vs warfarin prescription in elderly patients naïve for the aforementioned drugs. MATERIALS AND METHODS Data collected in the period from January 1, 2014, to December 31, 2014, in Caserta Local Health Unit administrative databases (Campania Region, Italy) were screened to identify new users of oral anticoagulants (OACs) who were 75 years or older and whose OAC prescriptions amounted to >90 days of treatment. Age, gender, and number and type of concomitant medications at the time of first OAC dispensation were retrieved. Multivariable logistic regression analysis was used to assess the role of the aforementioned predictors for NOAC initiation as opposed to warfarin. RESULTS Overall, 2,132 incident users of OAC were identified, of whom 967 met all inclusion criteria. In all, 490 subjects (50.7%) received an NOAC and 477 (49.3%) received warfarin. Age >75 years was positively associated with lower odds of NOAC initiation (OR: 0.969, 95% CI: 0.941-0.998, P=0.038). Similarly, multiple concomitant medication was negatively associated with NOAC initiation compared to warfarin (OR [five to nine drugs] group: 0.607, 95% CI: 0.432-0.852, P=0.004; OR [ten+ drugs] group: 0.372, 95% CI: 0.244-0.567, P<0.001). Prior exposure to platelet aggregation inhibitor drugs was associated with the initiation of NOACs (OR: 3.474, 95% CI: 2.610-4.625). CONCLUSION Age and multiple co-medication were negatively associated with NOAC initiation.
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Affiliation(s)
- Francesca Guerriero
- Center of Pharmacoeconomics (CIRFF), University of Naples Federico II, Naples, Italy,
| | - Valentina Orlando
- Center of Pharmacoeconomics (CIRFF), University of Naples Federico II, Naples, Italy,
| | | | | | - Maurizio Sessa
- Department of Experimental Medicine, Section of Pharmacology, Regional Center of Pharmacovigilance, University of Campania "L. Vanvitelli", Naples, Italy
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, DK, Denmark
| | - Cristina Scavone
- Department of Experimental Medicine, Section of Pharmacology, Regional Center of Pharmacovigilance, University of Campania "L. Vanvitelli", Naples, Italy
| | - Annalisa Capuano
- Department of Experimental Medicine, Section of Pharmacology, Regional Center of Pharmacovigilance, University of Campania "L. Vanvitelli", Naples, Italy
| | - Enrica Menditto
- Center of Pharmacoeconomics (CIRFF), University of Naples Federico II, Naples, Italy,
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17
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Alagiakrishnan K, Banach M, Mah D, Ahmed A, Aronow WS. Role of Geriatric Syndromes in the Management of Atrial Fibrillation in Older Adults: A Narrative Review. J Am Med Dir Assoc 2018; 20:123-130. [PMID: 30270028 DOI: 10.1016/j.jamda.2018.07.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 07/15/2018] [Accepted: 07/28/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Atrial fibrillation (AF) is common in older adults and associated with increased risk of cardiovascular events including thromboembolism. However, less is known about its association with noncardiovascular events, especially geriatric syndromes and conditions such as dementia, depression, impaired physical function, polypharmacy, falls, and poor quality of life. This review aims to help healthcare professionals integrate the special needs of older adults into their management of AF. DESIGN Nonsystematic review. A literature search on published articles on AF and geriatric syndromes and conditions was performed using the electronic databases MEDLINE, EMBASE and SCOPUS, and DARE until December 2017. Non-English articles were excluded. SETTINGS AND PARTICIPANTS Older adults with and without AF from different settings. MEASURES Various cognitive, mood, and functional measurements were used in these studies. In studies regarding polypharmacy, the Beers or PRISCUS criteria were used to identify inappropriate medications. In quality of life measurements studies, instruments like Medical Outcomes Study Short Form 36 and Atrial Fibrillation Quality of Life questionnaire were used. RESULTS This literature review finds that AF has a substantial association with geriatric syndromes and conditions and that AF is a risk factor for the development of geriatric syndromes and conditions. Evidence is limited regarding the potential benefit of long-term treatment of AF in lowering the risk of developing geriatric syndromes and conditions. CONCLUSIONS/IMPLICATIONS Considering the impact of AF on cardiovascular outcomes and geriatric syndromes and conditions in older adults, healthcare professionals need to consider these complex dynamics while managing AF in older adults. An individual approach to AF management is needed in older adults with multiple comorbidity and polypharmacy that may help lower the risk of disease-disease, disease-drug, and drug-drug interactions. Special consideration needs to be given to patients' cognitive and functional impairment and ability to adhere to therapy.
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Affiliation(s)
| | - Maciej Banach
- Department of Hypertension, Medical University of Lodz, Zeronskiego, Poland
| | - Darren Mah
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Ali Ahmed
- Veterans Affairs Medical Center and George Washington University, Washington DC
| | - Wilbert S Aronow
- Division of Cardiology, Geriatrics, Pulmonary, and Critical Care, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
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18
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Gebreyohannes EA, Bhagavathula AS, Tegegn HG. Poor outcomes associated with antithrombotic undertreatment in patients with atrial fibrillation attending Gondar University Hospital: a retrospective cohort study. Thromb J 2018; 16:22. [PMID: 30237753 PMCID: PMC6142404 DOI: 10.1186/s12959-018-0177-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 07/12/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is a major risk factor for stroke as it increases the incidence of stroke nearly fivefold. Antithrombotic treatment is recommended for the prevention of stroke in AF patients. However, majorly due to fear of risk of bleeding, adherence to recommendations is not observed. The aim of this study was to investigate the impact of antithrombotic undertreatment, on ischemic stroke and/or all-cause mortality in patients with AF. METHODS A retrospective cohort study was conducted from January 7, 2017 to April 30 2017 using medical records of patients with AF attending Gondar University Hospital (GUH) between November 2012 and September 2016. Patients receiving appropriate antithrombotic management and those on undertreatment, were followed for development of ischemic stroke and/or all-cause mortality. Kaplan-Meier and a log-rank test was used to plot the survival analysis curve. Cox regression was used to determine the predictors of guideline-adherent antithrombotic therapy. RESULTS The final analysis included 159 AF patients with a median age of 60 years. Of these, nearly two third (64.78%) of patients were receiving undertreatment for antithrombotic medications. Upon multivariate analysis, history of ischemic stroke/transient ischemic attack (TIA) was associated with lower incidence of antithrombotic undertreatment. A significant increase (HR: 8.194, 95% CI: 2.911-23.066)] in the incidence of ischemic stroke and/or all-cause mortality was observed in patients with undertreatment. Up-on multivariate analysis, only increased age was associated with a statistically significant increase incidence of ischemic stroke and/or all-cause mortality, while only history of ischemic stroke/TIA was associated with a decrease in the risk of ischemic stroke and/or all-cause mortality. CONCLUSION Adherence to antithrombotic guideline recommendations was found to be crucial in reducing the incidence of ischemic stroke and/or all-cause mortality in patients with AF without increasing the risk of bleeding. However, undertreatment to antithrombotic medications was found to be high (64.78%) and was associated with poorer outcomes in terms of ischemic stroke and/or all-cause mortality. Impact on practice: This research highlighted the magnitude of antithrombotic undertreatment and its impact on ischemic stroke and/or all-cause mortality in patients with AF. This article has to alert prescribers to routinely evaluate AF patients' risk for ischemic stroke and provide appropriate interventions based on guideline recommendations.
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19
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The safety and efficacy of non-vitamin K antagonist oral anticoagulants in atrial fibrillation in the elderly. Int J Cardiol 2018; 265:118-124. [DOI: 10.1016/j.ijcard.2018.02.066] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/28/2018] [Accepted: 02/16/2018] [Indexed: 01/27/2023]
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20
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Walker DM, Gale CP, Lip G, Martin-Sanchez FJ, McIntyre HF, Mueller C, Price S, Sanchis J, Vidan MT, Wilkinson C, Zeymer U, Bueno H. Editor's Choice - Frailty and the management of patients with acute cardiovascular disease: A position paper from the Acute Cardiovascular Care Association. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 7:176-193. [PMID: 29451402 DOI: 10.1177/2048872618758931] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Frailty is increasingly seen among patients with acute cardiovascular disease. A combination of an ageing population, improved disease survival, treatable long-term conditions as well as a greater recognition of the syndrome has accelerated the prevalence of frailty in the modern world. Yet, this has not been matched by an expansion of research. National and international bodies have identified acute cardiovascular disease in the frail as a priority area for care and an entity that requires careful clinical decisions, but there remains a paucity of guidance on treatment efficacy and safety, and how to manage this complex group. This position paper from the Acute Cardiovascular Care Association presents the latest evidence about frailty and the management of frail patients with acute cardiovascular disease, and suggests avenues for future research.
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Affiliation(s)
| | - C P Gale
- 2 Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
| | - G Lip
- 3 Institute for Cardiovascular Sciences, University of Birmingham, UK.,4 Aalborg Thrombosis Research Unit, Aalborg University, Denmark
| | | | | | - C Mueller
- 6 Cardiovascular Research Institute Basel, University of Basel, Switzerland
| | - S Price
- 7 Royal Brompton Hospital, UK
| | - J Sanchis
- 8 Department of Cardiology, University of Valencia, Spain.,9 University of Valencia, CIBER CV, Spain
| | - M T Vidan
- 10 Department of Geriatrics, Universidad Complutense de Madrid Dr Esquerdo, Spain
| | - C Wilkinson
- 2 Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
| | - U Zeymer
- 11 Klinikum Ludwigshafen und Institut for Herzinfarktforschung, Germany
| | - H Bueno
- 12 National Centre for Cardiovascular Research, Spain
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Shah R, Li S, Stamplecoski M, Kapral MK. Low Use of Oral Anticoagulant Prescribing for Secondary Stroke Prevention: Results From the Ontario Stroke Registry. Med Care 2017; 54:907-12. [PMID: 27367867 DOI: 10.1097/mlr.0000000000000589] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Oral anticoagulation reduces the risk of stroke in atrial fibrillation but is often underused. OBJECTIVES To identify factors associated with oral anticoagulant prescribing and adherence after stroke or transient ischemic attack (TIA). RESEARCH DESIGN Retrospective cohort study using linked Ontario Stroke Registry and prescription claims data. SUBJECTS Consecutive patients with atrial fibrillation and ischemic stroke/TIA admitted to 11 stroke centers in Ontario, Canada between 2003 and 2011. MEASURES We used modified Poisson regression models to determine predictors of anticoagulant prescribing and multiple logistic regression to determine predictors of 1-year adherence. RESULTS Of the 5781 patients in the study cohort, 4235 (73%) were prescribed oral anticoagulants at discharge. Older patients were less likely to receive anticoagulation [adjusted relative risk (aRR) for each additional year=0.997; 95% confidence interval (CI), 0.995-0.998], as were those with TIA compared with ischemic stroke (aRR=0.904; 95% CI, 0.865-0.945), prior gastrointestinal bleed (aRR=0.778; 95% CI, 0.693-0.873), dementia (aRR=0.912; 95% CI, 0.856-0.973), and those from a long-term care facility (aRR=0.810; 95% CI, 0.737-0.891). After limiting the sample to those without obvious contraindications to anticoagulation, age, dementia, and long-term care residence continued to be associated with lower prescription of oral anticoagulants. One-year adherence to therapy was similar across most patient groups. CONCLUSIONS Age, dementia, and long-term care residence are predictors of lower oral anticoagulant use for secondary stroke prevention and represent key target areas for quality improvement initiatives.
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Affiliation(s)
- Reema Shah
- *Department of Medicine, McMaster University, Hamilton †Institute for Clinical Evaluative Sciences ‡Institute of Health Policy, Management and Evaluation, University of Toronto §Division of General Internal Medicine, Women's Health Program, and Toronto General Research Institute, University Health Network ∥Department of Medicine, Division of General Internal Medicine, University of Toronto, Toronto, ON, Canada
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22
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Huisman MV, Rothman KJ, Paquette M, Teutsch C, Diener HC, Dubner SJ, Halperin JL, Ma CS, Zint K, Elsaesser A, Bartels DB, Lip GY, Abban D, Abdul N, Abelson M, Ackermann A, Adams F, Adams L, Adragão P, Ageno W, Aggarwal R, Agosti S, Marin JA, Aguilar F, Aguilar Linares JA, Aguinaga L, Ahmad Z, Ainsworth P, Al Ghalayini K, Al Ismail S, Alasfar A, Alawwa A, Al-Dallow R, Alderson L, Alexopoulos D, Ali A, Ali M, Aliyar P, Al-Joundi T, Al Mahameed S, Almassi H, Almuti K, Al-Obaidi M, Alshehri M, Altmann U, Alves AR, Al-Zoebi A, Amara W, Amelot M, Amjadi N, Ammirati F, Andrawis N, Angoulvant D, Annoni G, Ansalone G, Antonescu SA, Ariani M, Arias JC, Armero S, Arora R, Arora C, Ashcraft W, Aslam MS, Astesiano A, Audouin P, Augenbraun C, Aydin S, Azar R, Azim A, Aziz S, Backes LM, Baig M, Bains S, Bakbak A, Baker S, Bakhtiar K, Bala R, Banayan J, Bandh S, Bando S, Banerjee S, Bank A, Barbarash O, Barón G, Barr C, Barrera C, Barton J, Kes VB, Baula G, Bayeh H, Bazargani N, Behrens S, Bell A, Benezet-Mazuecos J, Benhalima B, Berdagué P, Berg van den B, Bergen van P, Berngard E, Bernstein R, Yao J, Yarlagadda C, Yeh KH, Yotov Y, Yvorra S, Zahn R, Zamorano J, Zanini R, Zarich S, Zebrack J, Berrospi P, Zenin S, Zeuthen EL, Zhang X, Zhang Q, Zhang D, Zhang D, Zhang H, Zhao S, Zhao X, Zheng Y, Berti S, Zheng Q, Zhou J, Zhou J, Zimmermann SL, Zimmermann R, Zukerman LS, Zwaan van der C, Bertomeu V, Berz A, Bettencourt P, Betzu R, Beyer-Westendorf J, Bhagwat R, Black T, Blanco Ibaceta JH, Bloom S, Blumberg E, Bo M, Bockisch V, Bøhmer E, Bongiorni MG, Boriani G, Bosch R, Boswijk D, Bott J, Bottacchi E, Kalan MB, Brandes A, Bratland B, Brautigam D, Breton N, Brouwers P, Browne K, Bruguera J, Brunehaut M, Brunschwig C, Buathier H, Buhl A, Bullinga J, Butcher K, Cabrera Honorio JW, Caccavo A, Cadinot D, Cai S, Calvi V, Camm J, Candeias R, Capo J, Capucci A, Cardoso JN, Duarte Vera YC, Carlson B, Carvalho P, Cary S, Casanova R, Casu G, Cattan S, Cavallini C, Cayla G, Cha TJ, Cha KS, Chaaban S, Chae JK, Challappa K, Chand S, Chandrashekar H, Chang M, Charbel P, Chartier L, Chatterjee K, Cheema A, Chen SA, Chevallereau P, Chiang FT, Chiarella F, Chih-Chan L, Cho YK, Choi DJ, Chouinard G, Danny, Chow HF, Chrysos D, Chumakova G, José Roberto Chuquiure Valenzuela EJ, Cieza-Lara T, Nica VC, Ciobotaru V, Cislowski D, Citerne O, Claus M, Clay A, Clifford P, Cohen S, Cohen A, Colivicchi F, Collins R, Compton S, Connors S, Conti A, Buenostro GC, Coodley G, Cooper M, Corbett L, Corey O, Coronel J, Corrigan J, Cotrina Pereyra RY, Cottin Y, Coutu B, Cracan A, Crean P, Crenshaw J, Crijns H, Crump C, Cucher F, Cudmore D, Cui L, Culp J, Darius H, Dary P, Dascotte O, Dauber I, Davee T, Davies R, Davis G, Davy JM, Dayer M, De La Briolle A, de Mora M, De Teresa E, De Wolf L, Decoulx E, Deepak S, Defaye P, Del-Carpio Munoz F, Brkljacic DD, Deluche L, Destrac S, Deumite N, Di Legge S, Dibon O, Diemberger I, Dillinger J, Dionísio P, Naydenov S, Dotani I, Dotcheva E, D'Souza A, Dubrey S, Ducrocq X, Dupljakov D, DuThinh V, Dutra OP, Dutta D, Duvilla N, Dy J, Dziewas R, Eaton C, Eaves W, Ebinger M, Eck van J, Edwards T, Egocheaga I, Ehrlich C, Eisenberg S, El Hallak A, El Jabali A, El Mahmoud R, El Shahawy M, Eldadah Z, Elghelbazouri F, Elhag O, El-Hamdani M, Elias D, Ellery A, El-Sayed H, Elvan A, Erickson B, Espaliat E, Essandoh L, Everington T, Evonich R, Ezhov A, Fácila L, Farsad R, Fayard M, Fedele F, Gomes Ferreira LG, Ferreira D, Santos JF, Ferrier A, Finsen A, First B, Fisher R, Floyd J, Folk T, Fonseca C, Fonseca L, Forman S, Forsgren M, Foster M, Foster N, Frais M, Frandsen B, Frappé T, Freixa R, French W, Freydlin M, Frickel S, Fruntelata AG, Fujii S, Fujino Y, Fukunaga H, Furukawa Y, Gabelmann M, Gabris M, Gadsbøll N, Galin P, Galinier M, Ganim R, Garcia R, Quintana AG, Gartenlaub O, Genz C, Georger F, Georges JL, Georgeson S, Ghanbasha A, Giedrimas E, Gierba M, Gillespie E, Giniger A, Gkotsis A, Gmehling J, Gniot J, Goethals P, Goldberg R, Goldmann B, Goldscher D, Golitsyn S, Gomez Lopez EA, Gomez Mesa JE, Gonzalez E, Cocina EG, Juanatey CG, Gorbunov V, Gordon B, Gorka H, Gornick C, Gorog D, Goss F, Götte A, Goube P, Goudevenos I, Goulden D, Graham B, Grande A, Greco C, Green M, Greer G, Gremmler U, Grena P, Grinshstein Y, Grond M, Gronda E, Grondin F, Grönefeld G, Groot de J, Guardigli G, Guarnieri T, Caiedo CG, Guignier A, Gulizia M, Gumbley M, Gupta D, Hack T, Haerer W, Hakas J, Hall C, Hampsey J, Hananis G, Hanbali B, Handel F, Hargrove J, Hargroves D, Harris K, Hartley D, Haruna T, Hata Y, Hayek E, Healey J, Hearne S, Heggelund G, Hemels M, Hemery Y, Henein S, Henz B, Her SH, Hermany P, Hernandes ME, Higashino Y, Hill M, Hisadome T, Hishida E, Hitchcock J, Hoffer E, Hoghton M, Holmes C, Hong SK, Houppe Nousse MP, Howard V, Hsu LF, Huang CH, Huckins D, Huehnergarth K, Huizenga A, Huntley R, Hussein G, Hwang GS, Igbokidi O, Iglesias I, Ikpoh M, Imberti D, Ince H, Indolfi C, Ionova T, Ip J, Irles D, Iseki H, Ismail Y, Israel N, Isserman S, Iteld B, Ivanchura G, Iyer R, Iyer V, Iza Villanueva RO, Jackson-Voyzey E, Jaffrani N, Jäger F, Jain M, James M, Jamon Y, Jang SW, Pereira Jardim CA, Jarmukli N, Jeanfreau R, Jenkins R, Jiang X, Jiang H, Jiang T, Jiang N, Jimenez J, Jobe R, Joffe I, Johansson B, Jones N, Moura Jorge JC, Jouve B, Jundi M, Jung W, Jung BC, Jung KT, Kabbani S, Kabour A, Kafkala C, Kajiwara K, Kalinina L, Kampus P, Kanda J, Kapadia S, Karim A, Karolyi L, Kashou H, Kastrup A, Katsivas A, Kaufman E, Kawai K, Kawajiri K, Kazmierski J, Keeling P, Kerfes GA, Kerr Saraiva JF, Ketova G, Khaira A, Khalid M, Khludeeva E, Khripun A, Kim DI, Kim DK, Kim NH, Kim KS, Kim YH, Kim JB, Kim JS, Kim JS, Kinova E, Klein A, Kleinschnitz C, Kmetzo J, Kneller GL, Knezevic A, Koch S, Koenig K, Angela Koh SM, Köhrmann M, Koons J, Korabathina R, Korennova O, Koschutnik M, Kosinski E, Kovacic D, Kowalczyk J, Koziolova N, Kragten J, Krause LU, Kreidieh I, Krenning B, Krishnaswamy K, Krysiak W, Kuck KH, Kumar S, Kümler T, Kuniss M, Kuo JY, Küppers A, Kurrelmeyer K, Kwan T, Kyo E, Labovitz A, Lacroix A, Lam A, Lanas Zanetti FT, Landau C, Landini G, Lang W, Larsen TB, Laske V, Lavandier K, Law N, Lee MH, Lee D, Leitão A, Lejay D, Lelonek M, Lenarczyk R, Leprince P, Lequeux B, Leschke M, Ley N, Li Z, Li Y, Li X, Li Z, Li W, Liang J, Lieber I, Lillestol M, Limon Rodriguez RH, Lin H, Lip G, Litchfield J, Liu Z, Liu X, Liu Y, Liu F, Liu W, Llamas Esperon GA, Llisterri JL, Lo T, Lo E, Lobos JM, Lodde BP, Loiselet P, López-Sendón J, Lorga Filho AM, Lori I, Luo M, Lupovitch S, Lyrer P, Zuhairy HM, Ma C, Ma G, Ma H, Madariaga I, Maeno K, Magnin D, Mahmood S, Mahood K, Maid G, Mainigi S, Makaritsis K, Maldonado Villalon JA, Malhotra R, Malik A, Mallecourt C, Mallik R, Manning R, Manolis A, Mantas I, Manzur Jattin FG, Marcionni N, Marín F, Santana AM, Martinez J, Martinez L, Maskova P, Hernández NM, Matskeplishvili S, Matsuda K, Mavri A, May E, Mayer N, Mazon P, McClure J, McCormack T, McGarity W, McGuire M, McIntyre H, McLaughlin P, McLaurin B, Medina Palomino FA, Mehta P, Mehzad R, Meinel A, Melandri F, Mena A, Meno H, Menzies D, Metcalf K, Meyer B, Miarka J, Mibach F, Michalski D, Michel P, Chreih RM, Mikdadi G, Mikhail M, Mikus M, Milicic D, Militaru C, Miller G, Milonas C, Minescu B, Mintale I, Miralles A, Mirault T, Mistry D, Mitchell G, Miu NV, Miyamoto N, Moccetti T, Mohammed A, Nor AM, Molina de Salazar DI, Molon G, Molony D, Mondillo S, Mont L, Moodley R, Moore R, Ribeiro Moreira DA, Mori K, Moriarty A, Morka J, Moschos N, Mota Gomes MA, Mousallem N, Moya A, Mügge A, Mulhearn T, Muller JJ, Muresan CM, Muse D, Musial W, Musumeci F, Nadar V, Nageh T, Nair P, Nakagawa H, Nakamura Y, Nakayama T, Nam KB, Napalkov D, Natarajan I, Nayak H, Nechvatal L, Neiman J, Nerheim P, Neuenschwander FC, Nishida K, Nizov A, Novikova T, Novo S, Nowalany-Kozielska E, Nsah E, Nunez Fragoso JC, Nyvad O, de Los Rios Ibarra MO, O'Donnell M, O'Donnell P, Oh DJ, Oh YS, Daniel Oh CT, O'Hara G, Oikonomou K, Olalla JJ, Olivari Z, Oliver R, Olympios C, Osborne J, Osca J, Osman R, Osunkoya A, Padanilam B, Panchenko E, Pandey AS, Vicenzo de Paola AA, Paraschos A, Pardell H, Park HW, Park JS, Parkash R, Parker I, Parrens E, Parris R, Passamonti E, Patel J, Patel R, Pentz WH, Persic V, Perticone F, Peters P, Petkar S, Pezo LF, Pham D, Cao Phai GP, Phlaum S, Pineau J, Pineda-Velez A, Pini R, Pinter A, Pinto F, Pirelli S, Pivac N, Pizzini AM, Pocanic D, Calin Podoleanu CG, Polanczyk CA, Polasek P, Poljakovic Z, Pollock S, Polo J, Poock J, Poppert H, Porro Y, Pose A, Poulain F, Poulard JE, Pouzar J, Povolny P, Pozzer D, Pras A, Prasad N, Prevot S, Protasov K, Prunier L, Puleo J, Pye M, Qaddoura F, Quedillac JM, Raev D, Rahimi S, Raisaro A, Rama B, Ranadive N, Randall K, Ranjith N, Raposo N, Rashid H, Raters C, Rauch-Kroehnert U, Rebane T, Regner S, Renzi M, Reyes Rocha MA, Reza S, Ria L, Richter D, Rickli H, Rickner K, Rieker W, Rigo F, Ripoll T, Fonteles Ritt LE, Roberts D, Pascual CR, Briones IR, Reyes HR, Roelke M, Roman M, Romeo F, Ronner E, Ronziere T, Rooyer F, Rosenbaum D, Roth S, Rozkova N, Rubacek M, Rubalcava F, Rubanenko O, Rubin A, Borret MR, Rybak K, Sabbour H, Morales OS, Sakai T, Salacata A, Salecker I, Salem A, Salfity M, Salguero R, Salvioni A, Samson M, Sanchez G, Sandesara C, Saporito WF, Sasaoka T, Sattar P, Savard D, Scala PJ, Scemama J, Schaupp T, Schellinger P, Scherr C, Schmitz KH, Schmitz B, Schmitz L, Schnitzler R, Schnupp S, Schoeniger P, Schön N, Schuster S, Schwimmbeck P, Seamark C, Seebass R, Seidl KH, Seidman B, Sek J, Sekaran L, Seko Y, Sepulveda Varela PA, Sevilla B, Shah V, Shah A, Shah N, Shah A, Shanes J, Sharareh A, Sharma VK, Shaw L, Shimizu Y, Shimomura H, Shin DG, Shin ES, Shite J, Shoukfeh M, Shoultz C, Silver F, Sime I, Simmers T, Singal D, Singh N, Siostrzonek P, Sirajuddin M, Skeppholm M, Smadja D, Smith R, Smith D, Soda H, Sofley CW, Sokal A, Sotolongo R, de Souza OF, Sparby JA, Spinar J, Sprigings D, Spyropoulos A, Stakos D, Steinberg A, Steinwender C, Stergiou G, Stites HW, Stoikov A, Strasser R, Streb W, Styliadis I, Su G, Su X, Suarez RM, Sudnik W, Sueyoshi A, Sukles K, Sun L, Suneja R, Svensson P, Ziekenhuis A, Szavits-Nossan J, Taggeselle J, Takagi Y, Takhar A, Tallet J, Tamm A, Tanaka S, Tanaka K, Tang A, Tang S, Tassinari T, Tayama S, Tayebjee M, Tebbe U, Teixeira J, Tesloianu DN, Tessier P, The S, Thevenin J, Thomas H, Timsit S, Topkis R, Torosoff M, Touze E, Traissac T, Trendafilova E, Troyan B, Tsai WK, Tse HF, Tsutsui H, Tsutsui T, Tuininga Y, Turakhia M, Turk S, Turner W, Tveit A, Twiddy S, Tytus R, Ukrainski G, Valdovinos Chavez SB, Van De Graaff E, Vanacker P, Vardas P, Vargas M, Vassilikos V, Vazquez J, Venkataraman A, Verdecchia P, Vester EG, Vial H, Vinereanu D, Vlastaris A, Vogel C, vom Dahl J, von Mering M, Vora K, Wakefield P, Walia J, Walter T, Wang M, Wang N, Wang F, Wang X, Wang Z, Wang KY, Watanabe K, Wei J, Weimar C, Weinrich R, Wen MS, Wheelan K, Wicke J, Wiemer M, Wild B, Wilke A, Willems S, Williams M, Williams D, Winkler A, Wirtz JH, Witzenbichler B, Wong DH, Lawrence Wong KS, Wong B, Wozakowska-Kaplon B, Wu Z, Wu S, Wyatt N, Xu Y, Xu X, Yamada A, Yamamoto K, Yamanoue H, Yamashita T, Bryan Yan PY, Yang Y, Yang T. The Changing Landscape for Stroke Prevention in AF. J Am Coll Cardiol 2017; 69:777-785. [DOI: 10.1016/j.jacc.2016.11.061] [Citation(s) in RCA: 215] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/04/2016] [Accepted: 11/10/2016] [Indexed: 12/13/2022]
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Díez-Manglano J, Bernabeu-Wittel M, Murcia-Zaragoza J, Escolano-Fernández B, Jarava-Rol G, Hernández-Quiles C, Oliver M, Sanz-Baena S. Oral anticoagulation in patients with atrial fibrillation and medical non-neoplastic disease in a terminal stage. Intern Emerg Med 2017; 12:53-61. [PMID: 27514718 DOI: 10.1007/s11739-016-1517-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 08/01/2016] [Indexed: 10/21/2022]
Abstract
Many patients with non-neoplastic disease develop atrial fibrillation in advanced stages of their disease. The aim of this study is to determine the factors associated with the use of oral anticoagulants in patients with atrial fibrillation and non-neoplastic medical disease in a terminal stage, and whether their use is associated with a longer survival. Design is prospective, observational, multicentre study. Patients with atrial fibrillation and non-neoplastic disease (severe not reversible organ insufficiency) in a terminal stage were included between February 2009 and September 2010. A 6-month follow-up was carried out. We included 314 patients with a mean (SD) age of 82.6 (7.0) years. Their mean (SD) scores in CHADS2 and ATRIA scales were 3.4 (1.2) and 4.7 (2.0), respectively. Anticoagulants were prescribed to 112 (37.5 %) patients. The use of anticoagulants was associated with age (OR 0.96 95 % CI 0.93-0.99, p = 0.046) and to the Barthel index (OR 1.01 95 % CI 1.00-1.02; p = 0.034). After performing a propensity score matching analysis, 262 patients were included in the survival analysis. After 6 months, 133 (50.8 %) patients were dead. The mortality is higher among patients who are not treated with oral anticoagulants (57.1 vs. 39.4 %; p = 0.006), but it is independently associated only with the Barthel index score (HR 0.99 95 % CI 0.98-1.00; p = 0.039), delirium (HR 1.60, 95 % CI 1.08-2.36; p = 0.018), anorexia (HR 1.58 95 % CI 1.05-2.38; p = 0.027), and with the use of calcium channel blockers (HR 0.50 95 % CI 0.30-0.84; p = 0.009). In patients with atrial fibrillation and non-neoplastic disease in a terminal stage, the use of oral anticoagulants is not independently associated with a higher probability of survival.
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Affiliation(s)
- Jesús Díez-Manglano
- Internal Medicine Department, Hospital Royo Villanova, Duquesa Villahermosa No 163, 80 D, 50009, Saragossa, Spain.
- Research Group of Comorbidity and Polypathology in Aragon, Aragon Health Sciences Institute, Saragossa, Spain.
- Department of Medicine, Dermatology and Psychiatry, University of Zaragoza School of Medicine, Saragossa, Spain.
| | | | | | | | | | | | - Miguel Oliver
- Internal Medicina Department, Hospital Virgen del Camino, Sanlúcar de Barrameda, Spain
| | - Susana Sanz-Baena
- Internal Medicine Department, Hospital Central de la Cruz Roja Santa Adela y San José, Madrid, Spain
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Mas Dalmau G, Sant Arderiu E, Enfedaque Montes MB, Solà I, Pequeño Saco S, Alonso Coello P. Patients' and physicians' perceptions and attitudes about oral anticoagulation and atrial fibrillation: a qualitative systematic review. BMC FAMILY PRACTICE 2017; 18:3. [PMID: 28086887 PMCID: PMC5234257 DOI: 10.1186/s12875-016-0574-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 12/07/2016] [Indexed: 11/17/2022]
Abstract
Background Oral anticoagulant therapy reduces the risk of stroke in patients with atrial fibrillation, but many patients are still not prescribed this therapy. The causes of underuse of vitamin K antagonists oral anticoagulants are not clear but could be related, in part, to patients’ and physicians’ perceptions and attitudes towards the benefits and downsides of this treatment. The purpose of this systematic review was to evaluate and synthesize patients’ and physicians’ perceptions and attitudes towards the benefits and downsides of vitamin K antagonist, in order to explore potential factors related with its underuse. Methods We included studies that used qualitative or mixed methods and focused on patients’ and/or physicians’ perceptions and attitudes towards oral anticoagulation. We systematically searched PubMed, EMBASE, ISI WoK, and PsycINFO from their inception until May 2013. Two reviewers independently assessed the quality of the included studies and synthesized results using a thematic analysis approach. Results We included a total of nine studies. In four studies, the quality assessed was excellent and in five was moderate. We identified three themes that were of interest to both physicians and patients: information to reinforce anticoagulation use, balance of benefits and downsides, roles in decision-making and therapy management. Three additional themes were of interest to patients: knowledge and understanding, impact on daily life, and satisfaction with therapy. The main difficulties with the use of anticoagulant treatment according to physicians were the perceived uncertainty, need of individualised decision-making, and the feeling of delegated responsibility as their main concerns. The main factors for patients were the lack of information and understanding. Conclusion Physicians’ and patients’ perceptions and attitudes might be potential factors in the underuse of treatment with vitamin K antagonists. Improving the quality and usability of clinical guidelines, developing tools to help with the decision-making, enhancing coordination between primary care and hospital care, and improving information provided to patients could help improve the underuse of anticoagulation. Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0574-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gemma Mas Dalmau
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.
| | - Elisenda Sant Arderiu
- Consorci d'Atenció Primària de Salut de l'Eixample (CAPSE), CAP Casanova, Barcelona, Spain
| | | | - Ivan Solà
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Sandra Pequeño Saco
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain
| | - Pablo Alonso Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
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Mas Dalmau G, Sant Arderiu E, Enfedaque Montes MB, Solà I, Pequeño Saco S, Alonso Coello P. Patients' and physicians' perceptions and attitudes about oral anticoagulation and atrial fibrillation: a qualitative systematic review. BMC FAMILY PRACTICE 2017. [PMID: 28086887 DOI: 10.1186/s12875‐016‐0574‐0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Oral anticoagulant therapy reduces the risk of stroke in patients with atrial fibrillation, but many patients are still not prescribed this therapy. The causes of underuse of vitamin K antagonists oral anticoagulants are not clear but could be related, in part, to patients' and physicians' perceptions and attitudes towards the benefits and downsides of this treatment. The purpose of this systematic review was to evaluate and synthesize patients' and physicians' perceptions and attitudes towards the benefits and downsides of vitamin K antagonist, in order to explore potential factors related with its underuse. METHODS We included studies that used qualitative or mixed methods and focused on patients' and/or physicians' perceptions and attitudes towards oral anticoagulation. We systematically searched PubMed, EMBASE, ISI WoK, and PsycINFO from their inception until May 2013. Two reviewers independently assessed the quality of the included studies and synthesized results using a thematic analysis approach. RESULTS We included a total of nine studies. In four studies, the quality assessed was excellent and in five was moderate. We identified three themes that were of interest to both physicians and patients: information to reinforce anticoagulation use, balance of benefits and downsides, roles in decision-making and therapy management. Three additional themes were of interest to patients: knowledge and understanding, impact on daily life, and satisfaction with therapy. The main difficulties with the use of anticoagulant treatment according to physicians were the perceived uncertainty, need of individualised decision-making, and the feeling of delegated responsibility as their main concerns. The main factors for patients were the lack of information and understanding. CONCLUSION Physicians' and patients' perceptions and attitudes might be potential factors in the underuse of treatment with vitamin K antagonists. Improving the quality and usability of clinical guidelines, developing tools to help with the decision-making, enhancing coordination between primary care and hospital care, and improving information provided to patients could help improve the underuse of anticoagulation.
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Affiliation(s)
- Gemma Mas Dalmau
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.
| | - Elisenda Sant Arderiu
- Consorci d'Atenció Primària de Salut de l'Eixample (CAPSE), CAP Casanova, Barcelona, Spain
| | | | - Ivan Solà
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Sandra Pequeño Saco
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain
| | - Pablo Alonso Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
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Mora-Llabata V, Dubois-Marqués D, Roldán-Torres I, Mateu-Navarro C, Sanz-García JJ, Moreno-Ballester V, Mira-Gimeno S, Albiñana-Fernández F. Prevalencia de fibrilación auricular y características de la fibrilación auricular no valvular en la población general. Registro AFINVA. REVISTA COLOMBIANA DE CARDIOLOGÍA 2017. [DOI: 10.1016/j.rccar.2016.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Oral Anticoagulant Use in Atrial Fibrillation-Associated Ischemic Stroke: A Retrospective, Multicenter Survey in Northwestern China. J Stroke Cerebrovasc Dis 2017; 26:125-131. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.08.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 08/03/2016] [Accepted: 08/27/2016] [Indexed: 01/03/2023] Open
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Staerk L, Fosbøl EL, Gadsbøll K, Sindet-Pedersen C, Pallisgaard JL, Lamberts M, Lip GYH, Torp-Pedersen C, Gislason GH, Olesen JB. Non-vitamin K antagonist oral anticoagulation usage according to age among patients with atrial fibrillation: Temporal trends 2011-2015 in Denmark. Sci Rep 2016; 6:31477. [PMID: 27510920 PMCID: PMC4980590 DOI: 10.1038/srep31477] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 07/18/2016] [Indexed: 02/04/2023] Open
Abstract
Among atrial fibrillation (AF) patients, Danish nationwide registries (2011-2015) were used to examine temporal trends of initiation patterns of oral anticoagulation (OAC) treatment according to age. Overall, 43,299 AF patients initiating vitamin K antagonists (VKA) (42%), dabigatran (29%), rivaroxaban (13%), or apixaban (16%) were included with mean age (SD) 72.1 (11.3), 71.5 (11.0), 74.3 (11.1), and 75.3 (11.1) years, respectively. Patients aged ≥85 years comprised 15%. Trend tests showed increase in patients ≥85 years initiating OAC (p < 0.0001). VKA usage decreased from 92% to 24% (p < 0.0001). This decrease was independent of age. Dabigatran was the most common non-VKA OAC (NOAC) (40% users), but usage decreased from 2014 until study end (6%) (p < 0.0001). Apixaban was the most used OAC at study end (41%), in particular among those ≥85 years (44%). Compared with patients aged <65 years, the odds ratios associated with initiating VKA, dabigatran, rivaroxaban, or apixaban for patients aged ≥85 years were 0.81 (95% CI 0.75-0.86), 0.65 (95% CI 0.60-0.70), 1.52 (95% CI 1.38-1.67), and 2.09 (95% CI 1.89-2.30), respectively. In conclusion, substantial increase in NOAC usage has occurred. Increasing age was associated with upstart of rivaroxaban or apixaban with reference to age <65 within the specific agent.
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Affiliation(s)
- Laila Staerk
- Department of Cardiology, Herlev and Gentofte University Hospital, 2900 Hellerup, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, Rigshospitalet, 2100 Copenhagen Ø, Denmark
- The Danish Heart Foundation, 1127 Copenhagen K, Copenhagen, Denmark
| | - Kasper Gadsbøll
- Department of Cardiology, Herlev and Gentofte University Hospital, 2900 Hellerup, Denmark
| | | | | | - Morten Lamberts
- Department of Cardiology, Herlev and Gentofte University Hospital, 2900 Hellerup, Denmark
| | - Gregory Y. H. Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, United Kingdom
| | | | - Gunnar Hilmar Gislason
- Department of Cardiology, Herlev and Gentofte University Hospital, 2900 Hellerup, Denmark
- The Danish Heart Foundation, 1127 Copenhagen K, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen N, Denmark
- The National Institute of Public Health, University of Southern Denmark, 1353 Copenhagen K, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Herlev and Gentofte University Hospital, 2900 Hellerup, Denmark
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Xing Y, Ma Q, Ma X, Wang C, Zhang D, Sun Y. CHADS2 score has a better predictive value than CHA2DS2-VASc score in elderly patients with atrial fibrillation. Clin Interv Aging 2016; 11:941-6. [PMID: 27478371 PMCID: PMC4951063 DOI: 10.2147/cia.s105360] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Aim The study aims to compare the ability of CHA2DS2-VASc (defined as congestive heart failure, hypertension, age ≥75 years [two scores], type 2 diabetes mellitus, previous stroke, transient ischemic attack, or thromboembolism [TE] [doubled], vascular disease, age 65–74 years, and sex category) and CHADS2 (defined as congestive heart failure, hypertension, age ≥75 years, type 2 diabetes mellitus, previous stroke [doubled]) scores to predict the risk of ischemic stroke (IS) or TE among patients with nonvalvular atrial fibrillation (NVAF). Methods A total of 413 patients with NVAF aged ≥65 years, and not on oral anticoagulants for the previous 6 months, were enrolled in the study. The predictive value of the CHA2DS2-VASc and CHADS2 scores for IS/TE events was evaluated by the Kaplan–Meier method. Results During a follow-up period of 1.99±1.29 years, 104 (25.2%) patients died and 59 (14.3%) patients developed IS/TE. The CHADS2 score performed better than the CHA2DS2-VASc score in predicting IS/TE as assessed by c-indexes (0.647 vs 0.615, respectively; P<0.05). Non-CHADS2 risk factors, such as vascular disease and female sex, were not found to be predictive of IS/TE (hazard ratio 1.518, 95% CI: 0.832–2.771; hazard ratio 1.067, 95% CI: 0.599–1.899, respectively). No differences in event rates were found in patients with the CHADS2 scores of 1 and 2 (7.1% vs 7.8%). It was observed that patients with a CHADS2 score of ≥3 were most in need of anticoagulation therapy. Conclusion In patients with NVAF aged ≥65 years, the CHADS2 score was found to be significantly better in predicting IS/TE events when compared to the CHA2DS2-VASc score. Patients with a CHADS2 score of ≥3 were associated with high risk of IS/TE events.
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Affiliation(s)
- Yunli Xing
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Qing Ma
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiaoying Ma
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Cuiying Wang
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Dai Zhang
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Ying Sun
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
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Mazzone A, Bo M, Lucenti A, Galimberti S, Bellelli G, Annoni G. The role of comprehensive geriatric assessment and functional status in evaluating the patterns of antithrombotic use among older people with atrial fibrillation. Arch Gerontol Geriatr 2016; 65:248-54. [DOI: 10.1016/j.archger.2016.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 04/11/2016] [Accepted: 04/12/2016] [Indexed: 10/21/2022]
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Chang SS, Dong JZ, Ma CS, Du X, Wu JH, Tang RB, Xia SJ, Guo XY, Yu RH, Long DY, Bai R, Liu N, Sang CH, Jiang CX, Liu XH, Pan JH, Lip GYH. Current Status and Time Trends of Oral Anticoagulation Use Among Chinese Patients With Nonvalvular Atrial Fibrillation: The Chinese Atrial Fibrillation Registry Study. Stroke 2016; 47:1803-10. [PMID: 27283198 DOI: 10.1161/strokeaha.116.012988] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 05/19/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND PURPOSE Reported rates of oral anticoagulation (OAC) use have been low among Chinese patients with atrial fibrillation (AF). With improved awareness, changing guidelines, this situation may be changing over time. We aimed to explore the current status and time trends of OAC use in Beijing. METHODS We used the data set from the Chinese Atrial Fibrillation Registry (CAFR), a prospective, multicenter, hospital-based registry study involving 20 tertiary and 12 nontertiary hospitals in Beijing. A total of 11 496 patients with AF were enrolled from 2011 to 2014. RESULTS Seven thousand nine hundred seventy-seven eligible patients were included in this ancillary study. The proportions of OAC use were 36.5% (2268/6210), 28.5% (333/1168), and 21.4% (128/599) for patients with CHA2DS2-VASc scores ≥2, 1, and 0, respectively. Persistent AF, history of stroke/transient ischemic attack/peripheral embolism, diabetes mellitus, higher body mass index, and tertiary hospital management were factors positively associated with OAC use, whereas older age, previous bleeding, hypercholesterolemia, and established coronary artery disease were factors negatively associated with OAC use. Among patients with CHADS2 scores ≥2 and CHA2DS2-VASc scores ≥2, the proportion of OAC use increased from 31.3% to 64.5% and 30.2% to 57.7%, respectively, from 2011 to 2014. Variation in OAC use was substantial among different hospitals. CONCLUSIONS An improvement of OAC use among Chinese patients with AF in Beijing is observed in recent years although only 36.5% of patients with CHA2DS2-VASc score ≥2 received OAC. However, variations between different hospitals were large, suggesting that better education and awareness are needed to improve efforts for stroke prevention among AF patients. CLINICAL TRIAL REGISTRATION URL: http://www.chictr.org.cn/showproj.aspx?proj=5831. Unique identifier: ChiCTR-OCH-13003729.
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Affiliation(s)
- San-Shuai Chang
- From the Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (S.-S.C., J.-Z.D., C.-S.M., X.D., J.-H.W., R.-B.T., S.-J.X., X.-Y.G., R.-H.Y., D.-Y.L., R.B., N.L., C.-H.S., C.X.J., X.-H.L.); Biostatistics Department, Peking University Clinical Research Institute, Beijing, China (J.-H.P.); and University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.P.L.)
| | - Jian-Zeng Dong
- From the Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (S.-S.C., J.-Z.D., C.-S.M., X.D., J.-H.W., R.-B.T., S.-J.X., X.-Y.G., R.-H.Y., D.-Y.L., R.B., N.L., C.-H.S., C.X.J., X.-H.L.); Biostatistics Department, Peking University Clinical Research Institute, Beijing, China (J.-H.P.); and University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.P.L.).
| | - Chang-Sheng Ma
- From the Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (S.-S.C., J.-Z.D., C.-S.M., X.D., J.-H.W., R.-B.T., S.-J.X., X.-Y.G., R.-H.Y., D.-Y.L., R.B., N.L., C.-H.S., C.X.J., X.-H.L.); Biostatistics Department, Peking University Clinical Research Institute, Beijing, China (J.-H.P.); and University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.P.L.)
| | - Xin Du
- From the Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (S.-S.C., J.-Z.D., C.-S.M., X.D., J.-H.W., R.-B.T., S.-J.X., X.-Y.G., R.-H.Y., D.-Y.L., R.B., N.L., C.-H.S., C.X.J., X.-H.L.); Biostatistics Department, Peking University Clinical Research Institute, Beijing, China (J.-H.P.); and University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.P.L.)
| | - Jia-Hui Wu
- From the Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (S.-S.C., J.-Z.D., C.-S.M., X.D., J.-H.W., R.-B.T., S.-J.X., X.-Y.G., R.-H.Y., D.-Y.L., R.B., N.L., C.-H.S., C.X.J., X.-H.L.); Biostatistics Department, Peking University Clinical Research Institute, Beijing, China (J.-H.P.); and University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.P.L.)
| | - Ri-Bo Tang
- From the Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (S.-S.C., J.-Z.D., C.-S.M., X.D., J.-H.W., R.-B.T., S.-J.X., X.-Y.G., R.-H.Y., D.-Y.L., R.B., N.L., C.-H.S., C.X.J., X.-H.L.); Biostatistics Department, Peking University Clinical Research Institute, Beijing, China (J.-H.P.); and University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.P.L.)
| | - Shi-Jun Xia
- From the Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (S.-S.C., J.-Z.D., C.-S.M., X.D., J.-H.W., R.-B.T., S.-J.X., X.-Y.G., R.-H.Y., D.-Y.L., R.B., N.L., C.-H.S., C.X.J., X.-H.L.); Biostatistics Department, Peking University Clinical Research Institute, Beijing, China (J.-H.P.); and University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.P.L.)
| | - Xue-Yuan Guo
- From the Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (S.-S.C., J.-Z.D., C.-S.M., X.D., J.-H.W., R.-B.T., S.-J.X., X.-Y.G., R.-H.Y., D.-Y.L., R.B., N.L., C.-H.S., C.X.J., X.-H.L.); Biostatistics Department, Peking University Clinical Research Institute, Beijing, China (J.-H.P.); and University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.P.L.)
| | - Rong-Hui Yu
- From the Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (S.-S.C., J.-Z.D., C.-S.M., X.D., J.-H.W., R.-B.T., S.-J.X., X.-Y.G., R.-H.Y., D.-Y.L., R.B., N.L., C.-H.S., C.X.J., X.-H.L.); Biostatistics Department, Peking University Clinical Research Institute, Beijing, China (J.-H.P.); and University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.P.L.)
| | - De-Yong Long
- From the Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (S.-S.C., J.-Z.D., C.-S.M., X.D., J.-H.W., R.-B.T., S.-J.X., X.-Y.G., R.-H.Y., D.-Y.L., R.B., N.L., C.-H.S., C.X.J., X.-H.L.); Biostatistics Department, Peking University Clinical Research Institute, Beijing, China (J.-H.P.); and University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.P.L.)
| | - Rong Bai
- From the Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (S.-S.C., J.-Z.D., C.-S.M., X.D., J.-H.W., R.-B.T., S.-J.X., X.-Y.G., R.-H.Y., D.-Y.L., R.B., N.L., C.-H.S., C.X.J., X.-H.L.); Biostatistics Department, Peking University Clinical Research Institute, Beijing, China (J.-H.P.); and University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.P.L.)
| | - Nian Liu
- From the Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (S.-S.C., J.-Z.D., C.-S.M., X.D., J.-H.W., R.-B.T., S.-J.X., X.-Y.G., R.-H.Y., D.-Y.L., R.B., N.L., C.-H.S., C.X.J., X.-H.L.); Biostatistics Department, Peking University Clinical Research Institute, Beijing, China (J.-H.P.); and University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.P.L.)
| | - Cai-Hua Sang
- From the Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (S.-S.C., J.-Z.D., C.-S.M., X.D., J.-H.W., R.-B.T., S.-J.X., X.-Y.G., R.-H.Y., D.-Y.L., R.B., N.L., C.-H.S., C.X.J., X.-H.L.); Biostatistics Department, Peking University Clinical Research Institute, Beijing, China (J.-H.P.); and University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.P.L.)
| | - Chen-Xi Jiang
- From the Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (S.-S.C., J.-Z.D., C.-S.M., X.D., J.-H.W., R.-B.T., S.-J.X., X.-Y.G., R.-H.Y., D.-Y.L., R.B., N.L., C.-H.S., C.X.J., X.-H.L.); Biostatistics Department, Peking University Clinical Research Institute, Beijing, China (J.-H.P.); and University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.P.L.)
| | - Xiao-Hui Liu
- From the Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (S.-S.C., J.-Z.D., C.-S.M., X.D., J.-H.W., R.-B.T., S.-J.X., X.-Y.G., R.-H.Y., D.-Y.L., R.B., N.L., C.-H.S., C.X.J., X.-H.L.); Biostatistics Department, Peking University Clinical Research Institute, Beijing, China (J.-H.P.); and University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.P.L.)
| | - Jian-Hong Pan
- From the Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (S.-S.C., J.-Z.D., C.-S.M., X.D., J.-H.W., R.-B.T., S.-J.X., X.-Y.G., R.-H.Y., D.-Y.L., R.B., N.L., C.-H.S., C.X.J., X.-H.L.); Biostatistics Department, Peking University Clinical Research Institute, Beijing, China (J.-H.P.); and University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.P.L.)
| | - Gregory Y H Lip
- From the Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China (S.-S.C., J.-Z.D., C.-S.M., X.D., J.-H.W., R.-B.T., S.-J.X., X.-Y.G., R.-H.Y., D.-Y.L., R.B., N.L., C.-H.S., C.X.J., X.-H.L.); Biostatistics Department, Peking University Clinical Research Institute, Beijing, China (J.-H.P.); and University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.P.L.)
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Kato ET, Giugliano RP, Ruff CT, Koretsune Y, Yamashita T, Kiss RG, Nordio F, Murphy SA, Kimura T, Jin J, Lanz H, Mercuri M, Braunwald E, Antman EM. Efficacy and Safety of Edoxaban in Elderly Patients With Atrial Fibrillation in the ENGAGE AF-TIMI 48 Trial. J Am Heart Assoc 2016; 5:JAHA.116.003432. [PMID: 27207971 PMCID: PMC4889207 DOI: 10.1161/jaha.116.003432] [Citation(s) in RCA: 180] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background Elderly patients with atrial fibrillation are at higher risk of both ischemic and bleeding events compared to younger patients. In a prespecified analysis from the ENGAGE AF‐TIMI 48 trial, we evaluate clinical outcomes with edoxaban versus warfarin according to age. Methods and Results Twenty‐one thousand one‐hundred and five patients enrolled in the ENGAGE AF‐TIMI 48 trial were stratified into 3 prespecified age groups: <65 (n=5497), 65 to 74 (n=7134), and ≥75 (n=8474) years. Older patients were more likely to be female, with lower body weight and reduced creatinine clearance, leading to higher rates of edoxaban dose reduction (10%, 18%, and 41% for the 3 age groups, P<0.001). Stroke or systemic embolic event (1.1%, 1.8%, and 2.3%) and major bleeding (1.8%, 3.3%, and 4.8%) rates with warfarin increased across age groups (Ptrend<0.001 for both). There were no interactions between age group and randomized treatment in the primary efficacy and safety outcomes. In the elderly (≥75 years), the rates of stroke/systemic embolic event were similar with edoxaban versus warfarin (hazard ratio 0.83 [0.66–1.04]), while major bleeding was significantly reduced with edoxaban (hazard ratio 0.83 [0.70–0.99]). The absolute risk difference in major bleeding (−82 events/10 000 pt‐yrs) and in intracranial hemorrhage (−73 events/10 000 pt‐yrs) both favored edoxaban over warfarin in older patients. Conclusions Age has a greater influence on major bleeding than thromboembolic risk in patients with atrial fibrillation. Given the higher rates of bleeding and death with increasing age, treatment of elderly patients with edoxaban provides an even greater absolute reduction in safety events over warfarin, compared to treatment with edoxaban versus warfarin in younger patients. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00781391.
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Affiliation(s)
- Eri Toda Kato
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA Tokai University Hospital, Isehara, Japan
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Christian T Ruff
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Francesco Nordio
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | | | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Elliott M Antman
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Real-world characteristics of hospitalized frail elderly patients with atrial fibrillation: can we improve the current prescription of anticoagulants? JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2016; 13:226-32. [PMID: 27103917 PMCID: PMC4826892 DOI: 10.11909/j.issn.1671-5411.2016.03.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND In elderly patients, especially those older than 80 years, atrial fibrillation (AF) is associated with an almost 25% increased risk of stroke. Stroke prophylaxis with anticoagulants is therefore highly recommended. The prevalence of factors that have been associated with a lower rate of prescription and adherence to anticoagulant therapy in these patients is little known. The objective of this study was to explore the clinical characteristics of elderly subjects, with and without AF, consecutively admitted to an acute geriatric unit, discussing factors that may decrease the persistence on stroke prophylaxis therapy. We also highlight possible strategies to overcome the barriers conditioning the current underuse of oral anticoagulants in this segment of the population. METHODS A retrospective observational study was performed on a cohort of elderly patients with and without AF admitted to the Acute Geriatric Unit of San Gerardo Hospital (Monza, Italy). RESULTS Compared to patients without AF (n = 1216), those with AF (n = 403) had a higher Charlson Comorbidity Index (3 vs. 2, P < 0.001), number of administered drugs (4 vs. 3, P < 0.001), rate of heart failure (36.5% vs. 12%, P < 0.001) and chronic kidney disease (20.6 vs. 13.2, P < 0.001). Many patients with AF were frail (54%) or pre-frail (29%). CONCLUSIONS Elderly patients with AF have higher rates of conditions that affect adherence to traditional anticoagulant therapy (vitamin K antagonists, VKA). New direct oral anticoagulants (DOAs) can help overcome this problem. In order to prescribe the most appropriate VKA or DOAs, with the best efficacy/safety profile and the highest compliance, a comprehensive geriatric assessment should always accompany the scores for thrombotic and hemorrhagic risk stratification.
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Defensive medicine due to different fears by patients and physicians in geriatric atrial fibrillation patients and second victim syndrome. Int J Cardiol 2016; 212:251-2. [PMID: 27054498 DOI: 10.1016/j.ijcard.2016.03.093] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 03/19/2016] [Indexed: 11/20/2022]
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Yang X, Li Z, Zhao X, Wang C, Liu L, Wang C, Pan Y, Li H, Wang D, Hart RG, Wang Y, Wang Y. Use of Warfarin at Discharge Among Acute Ischemic Stroke Patients With Nonvalvular Atrial Fibrillation in China. Stroke 2016; 47:464-70. [DOI: 10.1161/strokeaha.115.011833] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 11/13/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Guidelines recommend oral anticoagulation for ischemic stroke patients with atrial fibrillation, and previous studies have shown the underuse of anticoagulation for these patients in China. We sought to explore the underlying reasons and factors that currently affect the use of warfarin in China.
Methods—
From June 2012 to January 2013, 19 604 patients with acute ischemic stroke were admitted to 219 urban hospitals voluntarily participating in the China National Stroke Registry II. Multivariable logistic regression models using the generalized estimating equation method were used to identify patient/hospital factors independently associated with warfarin use at discharge.
Results—
Among the 952 acute ischemic stroke patients with nonvalvular atrial fibrillation, 19.4% were discharged on warfarin. The risk of bleeding (52.8%) and patient refusal (31.9%) were the main reasons for not prescribing anticoagulation. Larger/teaching hospitals were more likely to prescribe warfarin. Older patients, heavy drinkers, patients with higher National Institutes of Health Stroke Scale score on admission were less likely to be given warfarin, whereas patients with history of heart failure and an international normalized ratio between 2.0 and 3.0 during hospitalization were significantly associated with warfarin use at discharge.
Conclusions—
The rate of warfarin use remains low among patients with ischemic stroke and known nonvalvular atrial fibrillation in China. Hospital size and academic status together with patient age, heart failure, heavy alcohol drinking, international normalized ratio in hospital, and stroke severity on admission were each independently associated with the use of warfarin at discharge. There is much room for improvement for secondary stroke prevention in nonvalvular atrial fibrillation patients in China.
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Affiliation(s)
- Xiaomeng Yang
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - Zixiao Li
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - Xingquan Zhao
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - Chunjuan Wang
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - Liping Liu
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - Chunxue Wang
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - Yuesong Pan
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - Hao Li
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - David Wang
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - Robert G. Hart
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - Yilong Wang
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
| | - Yongjun Wang
- From the Department of Neurology (X.Y., Z.L., Chunjuan Wang, Y.P., H.L., Yilong Wang, Yongjun Wang, X.Z., L.L.), Tiantan Clinical Trial and Research Center for Stroke (Z.L., C.W., Y.P., H.L., Yilong Wang, Yongjun Wang), Division of Vascular Neurology (X.Z., Yongjun Wang), Neuro-intensive Care Unit (L.L.), and Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology (Chunxue Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of
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Bo M, Sciarrillo I, Maggiani G, Falcone Y, Iacovino M, Grisoglio E, Fonte G, Grosjean S, Gaita F. Health status, geriatric syndromes and prescription of oral anticoagulant therapy in elderly medical inpatients with atrial fibrillation. Geriatr Gerontol Int 2016; 17:416-423. [DOI: 10.1111/ggi.12730] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 11/03/2015] [Accepted: 11/29/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Mario Bo
- SCDU Geriatria e Malattie Metaboliche dell'Osso; Città della Salute e della Scienza-Molinette; Torino Italia
| | - Irene Sciarrillo
- SCDU Geriatria e Malattie Metaboliche dell'Osso; Città della Salute e della Scienza-Molinette; Torino Italia
| | - Guido Maggiani
- SCDU Geriatria e Malattie Metaboliche dell'Osso; Città della Salute e della Scienza-Molinette; Torino Italia
| | - Yolanda Falcone
- SCDU Geriatria e Malattie Metaboliche dell'Osso; Città della Salute e della Scienza-Molinette; Torino Italia
| | - Marina Iacovino
- SCDU Geriatria e Malattie Metaboliche dell'Osso; Città della Salute e della Scienza-Molinette; Torino Italia
| | - Enrica Grisoglio
- SCDU Geriatria e Malattie Metaboliche dell'Osso; Città della Salute e della Scienza-Molinette; Torino Italia
| | - Gianfranco Fonte
- SCDU Geriatria e Malattie Metaboliche dell'Osso; Città della Salute e della Scienza-Molinette; Torino Italia
| | - Simon Grosjean
- SCDU Geriatria e Malattie Metaboliche dell'Osso; Città della Salute e della Scienza-Molinette; Torino Italia
| | - Fiorenzo Gaita
- SCDU Cardiologia; Città della Salute e della Scienza-Molinette; Torino Italia
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Nguyen TN, Cumming RG, Hilmer SN. Atrial fibrillation in older inpatients: are there any differences in clinical characteristics and pharmacological treatment between the frail and the non-frail? Intern Med J 2016; 46:86-95. [DOI: 10.1111/imj.12912] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/04/2015] [Accepted: 09/13/2015] [Indexed: 01/16/2023]
Affiliation(s)
- T. N. Nguyen
- Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital and Kolling Institute of Medical Research, Sydney Medical School; The University of Sydney; Sydney New South Wales Australia
- Sydney School of Public Health; The University of Sydney; Sydney New South Wales Australia
| | - R. G. Cumming
- Sydney School of Public Health; The University of Sydney; Sydney New South Wales Australia
| | - S. N. Hilmer
- Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital and Kolling Institute of Medical Research, Sydney Medical School; The University of Sydney; Sydney New South Wales 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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Discrepancy between guidelines for stroke prevention in atrial fibrillation and practice patterns in primary care. The nationwide French AFIGP survey. Arch Cardiovasc Dis 2015; 108:544-53. [DOI: 10.1016/j.acvd.2015.05.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 04/17/2015] [Accepted: 05/12/2015] [Indexed: 11/21/2022]
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Infrautilización de la anticoagulación oral en el paciente octogenario con fibrilación auricular: perspectiva desde la práctica clínica real. REVISTA COLOMBIANA DE CARDIOLOGÍA 2015. [DOI: 10.1016/j.rccar.2015.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Fumagalli S, Said SA, Laroche C, Gabbai D, Marchionni N, Boriani G, Maggioni AP, Popescu MI, Rasmussen LH, Crijns HJ, Lip GY. Age-Related Differences in Presentation, Treatment, and Outcome of Patients With Atrial Fibrillation in Europe. JACC Clin Electrophysiol 2015; 1:326-334. [DOI: 10.1016/j.jacep.2015.02.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 02/06/2015] [Accepted: 02/26/2015] [Indexed: 10/23/2022]
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Björck F, Renlund H, Svensson PJ, Själander A. Warfarin persistence among stroke patients with atrial fibrillation. Thromb Res 2015; 136:744-8. [PMID: 26254195 DOI: 10.1016/j.thromres.2015.07.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 07/25/2015] [Accepted: 07/27/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Warfarin treatment discontinuation is significant among patients with atrial fibrillation (AF). For AF patients with stroke a warfarin persistence rate of 0.45 after 2years has previously been reported. No consistent predictors for discontinuation have been established. AIMS Evaluation of warfarin persistence and variables associated with discontinuation, in a large Swedish cohort with unselected stroke/TIA patients with AF treated with warfarin. MATERIALS AND METHODS 4 583 patients with stroke/TIA and AF in the Swedish National Patient Register (NPR), from 1. Jan 2006 to 31. Dec 2011, were matched with the Swedish national quality register AuriculA. They were followed until treatment cessation, death or end of study. Baseline characteristics and CHA2DS2VASc score were retrieved from NPR. Treatment-time was retrieved from AuriculA. RESULTS Overall proportion of warfarin persistence was 0.78 (95% confidence interval (CI) 0.76 to 0.80) after one year, 0.69 (95% CI 0.67 to 0.71) after 2years and 0.47 (95% CI 0.43 to 0.51) after 5years. Variables clearly associated with higher discontinuation were dementia (hazard ratio (HR) 2.22, CI 1.51-3.27) and alcohol abuse (HR 1.66, CI 1.19-2.33). Chronic obstructive pulmonary disease (COPD), cancer and chronic heart failure (CHF) were each associated with over 20% increased risk of treatment discontinuation. Higher CHA2DS2VASc score and start-age lead to lower persistence (p<0.001). CONCLUSIONS Persistence to warfarin in unselected stroke/TIA patients with AF is in Sweden greater than previously reported. Lower persistence is found among patients with high treatment start-age, incidence of dementia, alcohol abuse, cancer, CHF, COPD and/or high CHA2DS2VASc score.
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Affiliation(s)
- Fredrik Björck
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
| | - Henrik Renlund
- Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
| | - Peter J Svensson
- Department for Coagulation disorders, University of Lund, Malmö, Sweden
| | - Anders Själander
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Fuenzalida C, Coll-Vinent B, Navarro M, Cervera Á, Camafort M, Mont L. Evolución temporal del tratamiento de los pacientes con fibrilación auricular en un área sanitaria urbana. Med Clin (Barc) 2015; 144:483-6. [DOI: 10.1016/j.medcli.2014.02.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 02/19/2014] [Accepted: 02/20/2014] [Indexed: 01/04/2023]
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Thromboembolic Prevention in Frail Elderly Patients With Atrial Fibrillation: A Practical Algorithm. J Am Med Dir Assoc 2015; 16:358-64. [DOI: 10.1016/j.jamda.2014.12.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 12/05/2014] [Indexed: 11/18/2022]
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Cook DA, Enders F, Caraballo PJ, Nishimura RA, Lloyd FJ. An automated clinical alert system for newly-diagnosed atrial fibrillation. PLoS One 2015; 10:e0122153. [PMID: 25849969 PMCID: PMC4388495 DOI: 10.1371/journal.pone.0122153] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 02/13/2015] [Indexed: 11/18/2022] Open
Abstract
Objective Clinical decision support systems that notify providers of abnormal test results have produced mixed results. We sought to develop, implement, and evaluate the impact of a computer-based clinical alert system intended to improve atrial fibrillation stroke prophylaxis, and identify reasons providers do not implement a guideline-concordant response. Materials and Methods We conducted a cohort study with historical controls among patients at a tertiary care hospital. We developed a decision rule to identify newly-diagnosed atrial fibrillation, automatically notify providers, and direct them to online evidence-based management guidelines. We tracked all notifications from December 2009 to February 2010 (notification period) and applied the same decision rule to all patients from December 2008 to February 2009 (control period). Primary outcomes were accuracy of notification (confirmed through chart review) and prescription of warfarin within 30 days. Results During the notification period 604 notifications were triggered, of which 268 (44%) were confirmed as newly-diagnosed atrial fibrillation. The notifications not confirmed as newly-diagnosed involved patients with no recent electrocardiogram at our institution. Thirty-four of 125 high-risk patients (27%) received warfarin in the notification period, compared with 34 of 94 (36%) in the control period (odds ratio, 0.66 [95% CI, 0.37–1.17]; p = 0.16). Common reasons to not prescribe warfarin (identified from chart review of 151 patients) included upcoming surgical procedure, choice to use aspirin, and discrepancy between clinical notes and the medication record. Conclusions An automated system to identify newly-diagnosed atrial fibrillation, notify providers, and encourage access to management guidelines did not change provider behaviors.
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Affiliation(s)
- David A. Cook
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, United States of America
- Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, United States of America
- Mayo Clinic Online Learning, Mayo Clinic College of Medicine, Rochester, MN, United States of America
- * E-mail:
| | - Felicity Enders
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, United States of America
- Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, MN, United States of America
| | - Pedro J. Caraballo
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, United States of America
- Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, United States of America
| | - Rick A. Nishimura
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, United States of America
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, United States of America
| | - Farrell J. Lloyd
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, United States of America
- Division of Hospital Medicine, Mayo Clinic College of Medicine, Rochester, MN, United States of America
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Abstract
It has recently been proposed that heart failure is a risk factor for Alzheimer's disease. Decreased cerebral blood flow and neurohormonal activation due to heart failure may contribute to the dysfunction of the neurovascular unit and cause an energy crisis in neurons. This leads to the impaired clearance of amyloid beta and hyperphosphorylation of tau protein, resulting in the formation of amyloid beta plaques and neurofibrillary tangles. In this article, we will summarize the current understanding of the relationship between heart failure and Alzheimer's disease based on epidemiological studies, brain imaging research, pathological findings and the use of animal models. The importance of atherosclerosis, myocardial infarction, atrial fibrillation, blood pressure and valve disease as well as the effect of relevant medications will be discussed.
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Affiliation(s)
- P Cermakova
- Division for Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska InstitutetHuddinge, Sweden
- International Clinical Research Center and St. Anne's University HospitalBrno, Czech Republic
| | - M Eriksdotter
- Department of Geriatric Medicine, Karolinska University HospitalStockholm, Sweden
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska InstitutetStockholm, Sweden
| | - L H Lund
- Department of Cardiology, Karolinska University HospitalStockholm, Sweden
- Unit of Cardiology, Department of Medicine, Karolinska InstitutetStockholm, Sweden
| | - B Winblad
- Division for Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska InstitutetHuddinge, Sweden
- Department of Geriatric Medicine, Karolinska University HospitalStockholm, Sweden
| | - P Religa
- Department of Medicine, Center for Molecular Medicine, Karolinska InstitutetStockholm, Sweden
| | - D Religa
- Division for Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska InstitutetHuddinge, Sweden
- Department of Geriatric Medicine, Karolinska University HospitalStockholm, Sweden
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Stroke Prophylaxis in Atrial Fibrillation: Searching for Management Improvement Opportunities in the Emergency Department: The HERMES-AF Study. Ann Emerg Med 2015; 65:1-12. [PMID: 25182543 DOI: 10.1016/j.annemergmed.2014.07.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 06/24/2014] [Accepted: 07/11/2014] [Indexed: 11/22/2022]
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Sauer R, Sauer EM, Bobinger T, Blinzler C, Huttner HB, Schwab S, Köhrmann M. Adherence to Oral Anticoagulation in Secondary Stroke Prevention—The First Year of Direct Oral Anticoagulants. J Stroke Cerebrovasc Dis 2015; 24:78-82. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 07/10/2014] [Accepted: 07/28/2014] [Indexed: 02/07/2023] Open
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Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and has greater prevalence in the increasing ageing population, with an estimated 10% of those over 80 years having AF. Symptoms associated with AF include palpitations, dizziness, shortness of breath and fatigue. Those presenting with these symptoms need to be investigated and the appropriate treatment should be initiated if AF is detected. For those with AF, there is a significant risk of stroke if patients are not adequately anti-coagulated. This article outlines methods for detecting AF in the community and provides an overview of current treatment options, including the newer anti-coagulant agents. The importance of assessing stroke risk and conveying this risk to those with AF is essential. Community health professionals play an important role in monitoring, treating and managing AF within the community setting and supporting and educating the patient in minimising the risk of serious thromboembolic complications such as stroke.
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Affiliation(s)
- Geraldine Lee
- Lecturer, Florence Nightingale School of Nursing and Midwifery, King's College London
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50
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Wang Y, Bajorek B. Safe use of antithrombotics for stroke prevention in atrial fibrillation: consideration of risk assessment tools to support decision-making. Ther Adv Drug Saf 2014; 5:21-37. [PMID: 25083260 DOI: 10.1177/2042098613506592] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Yishen Wang
- Graduate School of Health: School of Pharmacy, University of Technology Sydney (UTS), CB01.13, PO Box 123, Broadway, NSW 2007, Australia
| | - Beata Bajorek
- Graduate School of Health: School of Pharmacy, The University of Technology, Sydney, NSW, Australia
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