Anticoagulation Therapy by Age and Embolic Risk for Nonvalvular Atrial Fibrillation in Mexico, an Upper-Middle-Income Country: The CARMEN-AF Registry

Prescription of oral anticoagulation in geriatric patients with atrial fibrillation

Objective

To determine the prevalence of prescription of oral anticoagulation in patients aged > 60 years with nonvalvular atrial fibrillation (NVAF).

Methods

Observational, cross-sectional, retrospective study based on a review of the clinical ­histories of patients aged >60 years diagnosed with NVAF from July 1 to September 30, 2019 and seen at the outpatient clinic (cardiology, internal medicine, geriatrics) of a secondary-level hospital in Queretaro, Mexico. Clinical profile and oral anticoagulant treatment were analyzed.

Results

The study population comprised 300 patients (mean age, 77.2±8.3 years; 53.3% women; 81% attended in cardiology). Of these, 91% had a high thromboembolic risk, 22.7% a high bleeding risk, and 1.7% contraindications for anticoagulation. Comorbidity was frequent. As for therapy, 82.7% were taking direct oral anticoagulants (DOAC), 11.0% vitamin K antagonists (VKA), and 6.3% no anticoagulant treatment. Anticoagulant therapy was inappropriate in 29.3% of patients, mainly because DOAC were prescribed without adjusting for age, weight, or serum creatinine and administered without indication according to thromboembolic risk. Only 39.4% of patients taking VKA were within the therapeutic range. Of all patients receiving DOAC, 48.0% were taking rivaroxaban, mainly at 20 mg/d (73.1%).

Conclusions

Thromboembolic risk is high in geriatric patients with NVAF. Anticoagulation is contraindicated in <2% of patients. Oral anticoagulants are prescribed inappropriately in three out of ten patients.

Highlights and comments on EHRA/HRS/APHRS/LAHRS expert consensus on risk assessment in cardiac arrhythmias: use the right tool for the right outcome

Patients with heart disease, or at high risk of developing a cardiac condition, usually undergo risk assessment by primary care physicians, internal medicine doctors, or cardiologists. There are several methods that can be used for this risk assessment, and their applicability differs with respect to availability, complexity, and usefulness in different geographic populations. This document focuses on some of the many relevant clinical topics recently presented in the “Expert Consensus on Risk Assessment in Cardiac Arrhythmias: Use the Right Tool for the Right Outcome,” which include statements based on the best available evidence. In this review, we want to highlight and make some pertinent comments on some of the most relevant points of this Consensus.

Atrial fibrillation in low- and middle-income countries: a narrative review

Preventing premature non-communicable disease mortality necessitates a thorough review of one of the most important risk factors for stroke, which is atrial fibrillation (AF). The latter and AF-related stroke are still considered to be problems of high-income countries and are frequently overlooked in low- and middle-income countries (LMICs). In this narrative review, we provide an overview of studies that evaluated at least one of the following determinants of AF burden in LMICs: current epidemiology and trends, stroke prevention, health outcomes, and economic burden. Studies focusing on samples close to the general population (including community- and primary care-based samples) indicate sex-specific prevalence rates up to 7.4% in LMICs. Although AF prevalence is still higher in high-income countries than LMICs, the gap in AF burden between these two groups has been reducing in the past three decades. Oral anticoagulant (OAC) therapy for stroke prevention is underused in LMICs, and there are little data on OAC therapy in relation to stroke risk scores, such as CHA₂DS₂-VASc. Available data also points to higher morbidity and mortality for patient with AF in LMICs than their counterparts in high-income countries. Data on the consequent economic burden in LMICs is scarce, but it is reasonable to consider it will follow the same trend as that observed for health outcomes. Raising the visibility of AF as a public health problem in LMICs is necessary as a first step to providing adequate care for patients with this condition.