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Chan DZL, Kerr AJ, Tavleeva T, Debray D, Poppe KK. Validation Study of Cardiovascular International Statistical Classification of Diseases and Related Health Problems, Tenth Edition, Australian Modification (ICD-10-AM) Codes in Administrative Healthcare Databases (ANZACS-QI 77). Heart Lung Circ 2024:S1443-9506(24)00198-7. [PMID: 38760188 DOI: 10.1016/j.hlc.2024.03.015] [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: 10/16/2023] [Revised: 03/21/2024] [Accepted: 03/29/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Administrative healthcare databases can be utilised for research. The accuracy of the International Statistical Classification of Diseases and Related Health Problems, Tenth Edition, Australian Modification (ICD-10-AM) coding of cardiovascular conditions in New Zealand is not known and requires validation. METHOD International Statistical Classification of Diseases and Related Health Problems, Tenth Edition, Australian Modification coded discharges for acute coronary syndrome (ACS), heart failure (HF) and atrial fibrillation (AF), in both primary and secondary diagnostic positions, were identified from four district health boards between 1 January 2019 and 31 June 2019. A sample was randomly selected for retrospective clinician review for evidence of the coded diagnosis according to contemporary diagnostic criteria. Positive predictive values (PPVs) for ICD-10-AM coding vs clinician review were calculated. This study is also known as All of New Zealand, Acute Coronary Syndrome-Quality Improvement (ANZACS-QI) 77. RESULTS A total of 600 cases (200 for each diagnosis, 5.0% of total identified cases) were reviewed. The PPV of ACS was 93% (95% confidence interval [CI] 89%-96%), HF was 93% (95% CI 89%-96%) and AF was 96% (95% CI 92%-98%). There were no differences in PPV between district health boards. PPV for ACS were lower in Māori vs non-Māori (72% vs 96%; p=0.004), discharge from non-Cardiology vs Cardiology services (89% vs 96%; p=0.048) and ICD-10-AM coding for unstable angina vs myocardial infarction (81% vs 95%; p=0.011). PPV for HF were higher in the primary vs secondary diagnostic position (100% vs 89%; p=0.001). CONCLUSIONS The PPVs of ICD-10-AM coding for ACS, HF, and AF were high in this validation study. ICD-10-AM coding can be used to identify these diagnoses in administrative databases for the purposes of healthcare evaluation and research.
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Affiliation(s)
- Daniel Z L Chan
- Department of Cardiology, Te Whatu Ora Health New Zealand Te Tai Tokerau Whangarei, New Zealand.
| | - Andrew J Kerr
- Department of Cardiology, Te Whatu Ora Health New Zealand Counties Manukau, Auckland, New Zealand; Section of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Tatiana Tavleeva
- Department of Medicine, Te Whatu Ora Health New Zealand Waitemata, Auckland, New Zealand
| | - David Debray
- Department of Medicine, Te Whatu Ora Health New Zealand Counties Manukau, Auckland, New Zealand
| | - Katrina K Poppe
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Leung ANW, Bhat A. Use of Anticoagulation for Thromboembolic Prophylaxis in Patients With Atrial High-Rate Episodes on Device Monitoring: A Narrative Review. Am J Cardiol 2024; 211:183-190. [PMID: 37944778 DOI: 10.1016/j.amjcard.2023.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/21/2023] [Accepted: 11/01/2023] [Indexed: 11/12/2023]
Abstract
Ischemic stroke and systemic thromboembolism are primary drivers of significant morbidity and mortality in patients with atrial fibrillation (AF). Although stroke is commonly the first index presentation of clinically silent AF, the growing use of continuous rhythm monitoring through cardiac implanted electronic devices has enabled earlier and increased detection of AF in patients who are otherwise asymptomatic before stroke development. Atrial high-rate episodes (AHREs) are atrial tachyarrhythmias frequently detected by cardiac implanted electronic devices; these events represent subclinical AF and other atrial tachyarrhythmias that can lead to stroke development and AF. Although the presence of AHREs increases the risk of developing both clinical AF and stroke compared with absence of AHREs, there has been a significant clinical variability in anticoagulation initiation in these subjects. In this narrative review, we explore the current evidence and published research surrounding the association between AHREs and stroke development in addition to the utility of anticoagulation in this population for thromboembolic prophylaxis.
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Affiliation(s)
- Alice Ngar Wing Leung
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia.
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Weber C, Hung J, Atkins ER, Hickling S, Briffa T, Li I. Long-Term Pattern and Associated Costs of Re-hospitalisations in Patients After Index Atrial Fibrillation Admission in Western Australia, 2011-2017. Heart Lung Circ 2024; 33:55-64. [PMID: 38160127 DOI: 10.1016/j.hlc.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/08/2023] [Accepted: 12/03/2023] [Indexed: 01/03/2024]
Abstract
AIMS This study aimed to determine total and cardiovascular-specific re-hospitalisation patterns and associated costs within 2 years of index atrial fibrillation (AF) admission in Western Australia (WA). METHOD Patients aged 25-94 years, surviving an index (first-in-period) AF hospitalisation (principal diagnosis) from 2011 to 2015 were identified from WA-linked administrative data and followed for 2 years. Person-level hospitalisation costs ($ Australian dollar) were computed using the Australian Refined Diagnosis Related Groups and presented as median with first and third quartile costs. RESULTS The cohort comprised 17,080 patients, 59.0% men, mean age 69.6±13.3 (standard deviation) years, and 59.0% had a CHA2DS2-VA (one point for congestive heart failure, hypertension, diabetes mellitus, vascular disease or age 65-74 years; two points for prior stroke/transient ischaemic attack or age ≥75 years) score of 2 or more. Within 2 years, 13,776 patients (80.6%) were readmitted with median of 2 (1-4) readmissions. Among total all-cause readmissions (n=54,240), 40.1% were emergent and 36.6% were cardiovascular-related, led by AF (19.5%), coronary events (5.8%), and heart failure (4.2%). The median index AF admission cost was $3,264 ($2,899-$7,649) while cardiovascular readmission costs were higher, particularly stroke ($10,732 [$4,179-23,390]), AF ablation ($7,884 [$5,283-$8,878]), and heart failure ($6,759 [$6,081-$13,146]). Average readmission costs over 2 years per person increased by $4,746 (95% confidence interval [CI] $4,459-$5,033) per unit increase in baseline CHA2DS2-VA score. The average 2-year hospitalisation costs per patient, including index admission, was $27,820 (95% CI $27,308-$28,333) and total WA costs were $475.2 million between 2011 and 2017. CONCLUSIONS Patients after index AF hospitalisation have a high risk of cardiovascular and other readmissions with considerable healthcare cost implications. Readmission costs increased progressively with baseline CHA2DS2-VA score. Better integrated management of AF and coexistent comorbidities is likely key to reducing readmissions and associated costs.
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Affiliation(s)
- Courtney Weber
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia.
| | - Joseph Hung
- Medical School, The University of Western Australia, Perth, WA, Australia
| | - Emily R Atkins
- Health Systems Science, The George Institute for Global Health, UNSW, Sydney, NSW, Australia
| | - Siobhan Hickling
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - Tom Briffa
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - Ian Li
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
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Dong H, Chen H, Hidru TH, Xia Y, Yang X. Sinus node dysfunction and stroke risk: a systematic review and meta-analysis. BMJ Open 2023; 13:e076499. [PMID: 37977871 PMCID: PMC10660976 DOI: 10.1136/bmjopen-2023-076499] [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: 06/10/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVES The role of cardiac arrhythmia in ischaemic stroke is widely studied, but the size of the stroke risk in patients with sinus node dysfunction (SND) with and without atrial fibrillation (AF) is unclear. This systematic review and meta-analysis aimed to compare the risk of stroke and its associated factors in patients with SND with and without AF. DESIGN A systematic review and meta-analysis was conducted based on the Grading of Recommendations, Assessment, Development and Evaluation approach. DATA SOURCES PubMed, EMBASE and Cochrane Database were searched until December 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Studies that investigate stroke in patients with SND diagnosed with or without AF/atrial flutter. DATA EXTRACTION AND SYNTHESIS Two independent authors screened studies for inclusion and extracted data. Literature quality assessment was performed using the Newcastle-Ottawa Scale and the Cochrane Collaboration Tool. The overall risk of stroke was estimated using the random-effects model. The generic inverse variance method was used to calculate the pooled estimates of stroke-associated factors. We performed a sensitivity analysis using a fixed-effects model. RESULTS Of the 929 records retrieved, 6 papers (106 163 patients) met the inclusion criteria. The average yearly stroke incidence in patients with SND was 1.542% (95% CI: 1.334% to 1.749%). The stroke incidence was similar between the isolated SND (1.587%; 95% CI: 1.510% to 1.664%) and non-isolated (SND+AF) (1.660%; 95% CI: 0.705% to 2.615%) groups. AF (HR, 95% CI: 1.53 (1.01 to 2.33)), stroke/transient ischaemia attack/other thrombotic events (HR, 95% CI: 2.54 (1.14 to 5.69)), hypertension (HR, 95% CI: 1.51 (1.11 to 2.07)) and heart failure (HR, 95% CI: 1.41 (1.01 to 1.97)) were associated with stroke in the SND population. CONCLUSION Our findings suggest that patients with SND carry a similar risk of stroke to those with combined SND and AF. Future studies are needed to investigate whether interventions targeting stroke prevention, such as anticoagulation therapy, can help to prevent stroke in patients with SND. PROSPERO REGISTRATION NUMBER CRD42023408436.
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Affiliation(s)
- Haoyu Dong
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Hao Chen
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | | | - Yunlong Xia
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Xiaolei Yang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
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5
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Segan L, Nanayakkara S, Spear E, Shirwaiker A, Chieng D, Prabhu S, Sugumar H, Ling L, Kaye DM, Kalman JM, Voskoboinik A, Kistler PM. Identifying Patients at High Risk of Left Atrial Appendage Thrombus Before Cardioversion: The CLOTS-AF Score. J Am Heart Assoc 2023; 12:e029259. [PMID: 37301743 PMCID: PMC10356043 DOI: 10.1161/jaha.122.029259] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/13/2023] [Indexed: 06/12/2023]
Abstract
Background Transesophageal echocardiography-guided direct cardioversion is recommended in patients who are inadequately anticoagulated due to perceived risk of left atrial appendage thrombus (LAAT); however, LAAT risk factors remain poorly defined. Methods and Results We evaluated clinical and transthoracic echocardiographic parameters to predict LAAT risk in consecutive patients with atrial fibrillation (AF)/atrial flutter undergoing transesophageal echocardiography before cardioversion between 2002 and 2022. Regression analysis identified predictors of LAAT, combined to create the novel CLOTS-AF risk score (comprising clinical and echocardiographic LAAT predictors), which was developed in the derivation cohort (70%) and validated in the remaining 30%. A total of 1001 patients (mean age, 62±13 years; 25% women; left ventricular ejection fraction, 49.8±14%) underwent transesophageal echocardiography, with LAAT identified in 140 of 1001 patients (14%) and dense spontaneous echo contrast precluding cardioversion in a further 75 patients (7.5%). AF duration, AF rhythm, creatinine, stroke, diabetes, and echocardiographic parameters were univariate LAAT predictors; age, female sex, body mass index, anticoagulant type, and duration were not (all P>0.05). CHADS2VASc, though significant on univariate analysis (P<0.001), was not significant after adjustment (P=0.12). The novel CLOTS-AF risk model comprised significant multivariable predictors categorized and weighted according to clinically relevant thresholds (Creatinine >1.5 mg/dL, Left ventricular ejection fraction <50%, Overload (left atrial volume index >34 mL/m2), Tricuspid Annular Plane Systolic Excursion (TAPSE) <17 mm, Stroke, and AF rhythm). The unweighted risk model had excellent predictive performance with an area under the curve of 0.820 (95% CI, 0.752-0.887). The weighted CLOTS-AF risk score maintained good predictive performance (AUC, 0.780) with an accuracy of 72%. Conclusions The incidence of LAAT or dense spontaneous echo contrast precluding cardioversion in patients with AF who are inadequately anticoagulated is 21%. Clinical and noninvasive echocardiographic parameters may identify patients at increased risk of LAAT better managed with a suitable period of anticoagulation before undertaking cardioversion.
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Affiliation(s)
- Louise Segan
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Shane Nanayakkara
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- Monash UniversityMelbourneAustralia
| | | | | | - David Chieng
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Sandeep Prabhu
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Hariharan Sugumar
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Liang‐Han Ling
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - David M. Kaye
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- Monash UniversityMelbourneAustralia
| | - Jonathan M. Kalman
- University of MelbourneMelbourneAustralia
- Royal Melbourne HospitalMelbourneAustralia
| | - Aleksandr Voskoboinik
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- Monash UniversityMelbourneAustralia
| | - Peter M. Kistler
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
- Monash UniversityMelbourneAustralia
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6
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Enayati A, Gin JH, Sajeev JK, Cooke JC, Carey P, MacPherson M, Roberts L, Buntine P, Teh AW, Nogic J. Efficacy of intravenous magnesium for the management of non-post operative atrial fibrillation with rapid ventricular response: A systematic review and meta-analysis. J Cardiovasc Electrophysiol 2023; 34:1286-1295. [PMID: 37186322 DOI: 10.1111/jce.15911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/05/2023] [Accepted: 04/09/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Intravenous magnesium (IV Mg), a commonly utilized therapeutic agent in the management of atrial fibrillation (AF) with rapid ventricular response, is thought to exert its influence via its effect on cellular automaticity and prolongation of atrial and atrioventricular nodal refractoriness thus reducing ventricular rate. We sought to undertake a systematic review and meta-analysis of the effectiveness of IV Mg versus placebo in addition to standard pharmacotherapy in the rate and rhythm control of AF in the nonpostoperative patient cohort given that randomized control trials (RCTs) have shown conflicting results. METHODS Randomized controlled trials comparing IV Mg versus placebo in addition to standard of care were identified via electronic database searches. Nine RCTs were returned with a total of 1048 patients. Primary efficacy endpoints were study-defined rate control and rhythm control/reversion to sinus rhythm. The secondary endpoint was patient experienced side effects. RESULTS Our analysis found IV Mg in addition to standard care was successful in achieving rate control (odd ratio [OR] 1.87, 95% confidence interval [CI] 1.13-3.11, p = .02) and rhythm control (OR 1.45, 95% CI 1.04-2.03, p = .03). Although not well reported among studies, there was no significant difference between groups regarding the likelihood of experiencing side effects. CONCLUSIONS IV Mg, in addition to standard-of-care pharmacotherapy, increases the rates of successful rate and rhythm control in nonpostoperative patients with AF with rapid ventricular response and is well tolerated.
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Affiliation(s)
- Anees Enayati
- Department of Cardiology, Austin Hospital, Melbourne, Victoria, Australia
| | - Julian H Gin
- Department of Cardiology, Austin Hospital, Melbourne, Victoria, Australia
| | - Jithin K Sajeev
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jennifer C Cooke
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Patrick Carey
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Michael MacPherson
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Louise Roberts
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Paul Buntine
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
- Emergency Medicine Program, Eastern Health, Melbourne, Victoria, Australia
| | - Andrew W Teh
- Department of Cardiology, Austin Hospital, Melbourne, Victoria, Australia
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
- Austin Health Clinical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Jason Nogic
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
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Vinson DR, Rauchwerger AS, Karadi CA, Shan J, Warton EM, Zhang JY, Ballard DW, Mark DG, Hofmann ER, Cotton DM, Durant EJ, Lin JS, Sax DR, Poth LS, Gamboa SH, Ghiya MS, Kene MV, Ganapathy A, Whiteley PM, Bouvet SC, Babakhanian L, Kwok EW, Solomon MD, Go AS, Reed ME. Clinical decision support to Optimize Care of patients with Atrial Fibrillation or flutter in the Emergency department: protocol of a stepped-wedge cluster randomized pragmatic trial (O'CAFÉ trial). Trials 2023; 24:246. [PMID: 37004068 PMCID: PMC10064588 DOI: 10.1186/s13063-023-07230-2] [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: 07/11/2022] [Accepted: 03/08/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Management of adults with atrial fibrillation (AF) or atrial flutter in the emergency department (ED) includes rate reduction, cardioversion, and stroke prevention. Different approaches to these components of care may lead to variation in frequency of hospitalization and stroke prevention actions, with significant implications for patient experience, cost of care, and risk of complications. Standardization using evidence-based recommendations could reduce variation in management, preventable hospitalizations, and stroke risk. METHODS We describe the rationale for our ED-based AF treatment recommendations. We also describe the development of an electronic clinical decision support system (CDSS) to deliver these recommendations to emergency physicians at the point of care. We implemented the CDSS at three pilot sites to assess feasibility and solicit user feedback. We will evaluate the impact of the CDSS on hospitalization and stroke prevention actions using a stepped-wedge cluster randomized pragmatic clinical trial across 13 community EDs in Northern California. DISCUSSION We hypothesize that the CDSS intervention will reduce hospitalization of adults with isolated AF or atrial flutter presenting to the ED and increase anticoagulation prescription in eligible patients at the time of ED discharge and within 30 days. If our hypotheses are confirmed, the treatment protocol and CDSS could be recommended to other EDs to improve management of adults with AF or atrial flutter. TRIAL REGISTRATION ClinicalTrials.gov NCT05009225 . Registered on 17 August 2021.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, CA, USA.
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA, USA.
| | - Adina S Rauchwerger
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Chandu A Karadi
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Judy Shan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - E Margaret Warton
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Jennifer Y Zhang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Dustin W Ballard
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Rafael Medical Center, San Rafael, CA, USA
| | - Dustin G Mark
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Erik R Hofmann
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA
| | - Dale M Cotton
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA
| | - Edward J Durant
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Modesto Medical Center, Modesto, CA, USA
| | - James S Lin
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA
| | - Dana R Sax
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Luke S Poth
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA
| | - Stephen H Gamboa
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Meena S Ghiya
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente South San Francisco Medical Center, San Francisco, CA, USA
| | - Mamata V Kene
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Leandro Medical Center, San Leandro, CA, USA
| | - Anuradha Ganapathy
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Patrick M Whiteley
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - Sean C Bouvet
- The Permanente Medical Group, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA
| | | | | | - Matthew D Solomon
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Cardiology, Oakland Medical Center, Oakland, CA, USA
| | - Alan S Go
- The Permanente Medical Group, Oakland, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Departments of Epidemiology, Biostatistics, and Medicine, University of California, San Francisco, CA, USA
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Mary E Reed
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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8
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Teh R, Kerse N, Pillai A, Lumley T, Rolleston A, Kyaw TA, Connolly M, Broad J, Monteiro E, Clair VWS, Doughty RN. Atrial fibrillation incidence and outcomes in two cohorts of octogenarians: LiLACS NZ. BMC Geriatr 2023; 23:197. [PMID: 36997900 PMCID: PMC10064671 DOI: 10.1186/s12877-023-03902-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 03/17/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF), the most common cardiac arrhythmia in the general population, has significant healthcare burden. Little is known about AF in octogenarians. OBJECTIVE To describe the prevalence and incidence rate of AF in New Zealand (NZ) octogenarians and the risk of stroke and mortality at 5-year follow-up. DESIGN Longitudinal Cohort Study. SETTING Bay of Plenty and Lakes health regions of New Zealand. SUBJECTS Eight-hundred-seventy-seven (379 indigenous Māori, 498 non-Māori) were included in the analysis. METHODS AF, stroke/TIA events and relevant co-variates were established annually using self-report and hospital records (and ECG for AF). Cox proportional-hazards regression models were used to determine the time dependent AF risk of stroke/TIA. RESULTS AF was present in 21% at baseline (Māori 26%, non-Māori 18%), the prevalence doubled over 5-years (Māori 50%, non-Māori 33%). 5-year AF incidence was 82.6 /1000-person years and at all times AF incidence for Māori was twice that of non-Māori. Five-year stroke/TIA prevalence was 23% (22% in Māori and 24% non- Māori), higher in those with AF than without. AF was not independently associated with 5-year new stroke/TIA; baseline systolic blood pressure was. Mortality was higher for Māori, men, those with AF and CHF and statin use was protective. In summary, AF is more prevalent in indigenous octogenarians and should have an increased focus in health care management. Further research could examine treatment in more detail to facilitate ethnic specific impact and risks and benefits of treating AF in octogenarians.
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Grants
- 06/068B, 09/068B Health Research Council of New Zealand
- 06/068B, 09/068B Health Research Council of New Zealand
- 06/068B, 09/068B Health Research Council of New Zealand
- 06/068B, 09/068B Health Research Council of New Zealand
- 06/068B, 09/068B Health Research Council of New Zealand
- 06/068B, 09/068B Health Research Council of New Zealand
- 06/068B, 09/068B Health Research Council of New Zealand
- 06/068B, 09/068B Health Research Council of New Zealand
- 06/068B, 09/068B Health Research Council of New Zealand
- 06/068B, 09/068B Health Research Council of New Zealand
- 345426/00 Ministry of Health, New Zealand
- 345426/00 Ministry of Health, New Zealand
- 345426/00 Ministry of Health, New Zealand
- 345426/00 Ministry of Health, New Zealand
- 345426/00 Ministry of Health, New Zealand
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Affiliation(s)
- Ruth Teh
- Department of General Practice and Primary Health Care, Faculty of Medical and Health Sciences, University of Auckland, PO Box 92019, Auckland, New Zealand.
| | - Ngaire Kerse
- Department of General Practice and Primary Health Care, Faculty of Medical and Health Sciences, University of Auckland, PO Box 92019, Auckland, New Zealand
| | - Avinesh Pillai
- Department of Statistics, Faculty of Science, University of Auckland, Auckland, New Zealand
| | - Thomas Lumley
- Department of Statistics, Faculty of Science, University of Auckland, Auckland, New Zealand
| | - Anna Rolleston
- Manawa Ora, The Centre for Health, Tauranga, New Zealand
| | - Tin Aung Kyaw
- Department of General Practice and Primary Health Care, Faculty of Medical and Health Sciences, University of Auckland, PO Box 92019, Auckland, New Zealand
| | - Martin Connolly
- Department of Geriatric Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Joanna Broad
- Department of Geriatric Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Elaine Monteiro
- Department of General Practice and Primary Health Care, Faculty of Medical and Health Sciences, University of Auckland, PO Box 92019, Auckland, New Zealand
| | - Valerie Wright-St Clair
- Centre for Active Ageing, Auckland University of Technology New Zealand, Auckland, New Zealand
| | - Robert N Doughty
- Department of Medicine, University of Auckland and Greenlane Cardiovascular Service, Auckland District Health Board, Auckland, New Zealand
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9
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Glenister K, Bolitho L, Bourke L, Simmons D. Prevalence of atrial fibrillation in a regional Victoria setting, findings from the crossroads studies (2001-2003 and 2016-2018). Aust J Rural Health 2023; 31:80-89. [PMID: 35938603 PMCID: PMC10947292 DOI: 10.1111/ajr.12914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 07/17/2022] [Accepted: 07/24/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To estimate the prevalence of atrial fibrillation (AF) in regional Victoria at two time points (2001-2003 and 2016-2018), and to assess the use of electrocardiogram rhythm strips in a rural, community-based study for AF investigation. DESIGN Repeated cross-sectional design involving survey of residents of randomly selected households and a clinic. Predictors of AF were assessed using Firth penalised logistic regression, as appropriate for rare events. SETTING Goulburn Valley, Victoria. PARTICIPANTS Household residents aged ≥16 years. Non-pregnant participants aged 18+ were eligible for the clinic. MAIN OUTCOME MEASURES Atrial fibrillation by 12 lead electrocardiogram (earlier study) or electrocardiogram rhythm strip (AliveCor® device) (recent study). RESULTS The age standardised prevalence of AF was similar between the two studies (1.6% in the 2001-2003 study and 1.8% in the 2016-2018 study, 95% confidence interval of difference -0.010, 0.014, p = 0.375). The prevalence in participants aged ≥65 years was 3.4% (1.0% new cases) in the recent study. Predictors of AF in the earlier study were male sex, older age and previous stroke, while in the recent study they were previous stroke and self-reported diabetes. AliveCor® traces were successfully classified by the in-built algorithm (91%) vs physician (100%). CONCLUSION The prevalence of AF among community-based participants in regional Victoria was similar to predominantly metropolitan-based studies, and was unchanged over time despite increased rates of risk factors. Electrocardiogram rhythm strip investigation was successfully utilised, and particularly benefited from physician overview.
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Affiliation(s)
- Kristen Glenister
- Department of Rural HealthUniversity of MelbourneWangarattaVic.Australia
| | - Leslie Bolitho
- Wangaratta Cardiology & Respiratory CentreWangarattaVic.Australia
| | - Lisa Bourke
- Department of Rural HealthUniversity of MelbourneSheppartonVic.Australia
| | - David Simmons
- Department of Rural HealthUniversity of MelbourneSheppartonVic.Australia
- School of MedicineWestern Sydney UniversityCampbelltownNSWAustralia
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10
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De Silva K, Kumar S. Catheter Ablation for Atrial Fibrillation: Are We Isolating Our Most Vulnerable Patients? Heart Lung Circ 2022; 31:1315-1317. [PMID: 36162873 DOI: 10.1016/j.hlc.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Kasun De Silva
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia.
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11
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Faulx MD, Mehra R, Reis Geovanini G, Ando SI, Arzt M, Drager L, Fu M, Hoyos C, Hai J, Hwang JJ, Karaoguz R, Kimoff J, Lee PL, Mediano O, Patel SR, Peker Y, Louis Pepin J, Sanchez-de-la-Torre M, Sériès F, Stadler S, Strollo P, Tahrani A, Thunström E, Yamauchi M, Redline S, Phillips CL. Obstructive sleep apnea and its management in patients with atrial fibrillation: An International Collaboration of Sleep Apnea Cardiovascular Trialists (INCOSACT) global survey of practicing cardiologists. IJC HEART & VASCULATURE 2022; 42:101085. [PMID: 35879970 PMCID: PMC9307582 DOI: 10.1016/j.ijcha.2022.101085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/21/2022] [Accepted: 07/06/2022] [Indexed: 12/01/2022]
Abstract
Background Among international cardiologists it is unclear whether equipoise exists regarding the benefit of diagnosing and managing obstructive sleep apnea (OSA) to improve atrial fibrillation (AF) outcomes and whether clinical practice and equipoise are linked. Methods Between January 2019 and June 2020 we distributed a web-based 12-question survey regarding OSA and AF management to practicing cardiologists in 16 countries. Results The United States, Japan, Sweden, and Turkey accounted for two-thirds of responses. 863 cardiologists responded; half were general cardiologists, a quarter electrophysiologists. Responses regarding treating OSA with CPAP to improve AF endpoints were mixed. 33% of respondents referred AF patients for OSA screening. OSA was diagnosed in 48% of referred patients and continuous positive airway pressure (CPAP) was prescribed for 59% of them. Nearly 70% of respondents believed randomized controlled trials (RCTs) of OSA treatment in AF patients were necessary and indicated willingness to contribute to such trials. Conclusions There was no clinical equipoise among surveyed cardiologists; a majority expressed certainty that combined OSA and AF treatment is superior to AF treatment alone for improving AF outcomes. However, a minority of surveyed cardiologists referred AF patients for OSA testing, and while half of screened AF patients had OSA, CPAP was prescribed in little more than half of them, reflecting the view that better clinical trial evidence is needed to support this practice. Our results underscore the need for larger, multi-national prospective studies of OSA treatment and AF outcomes to inform more uniform society guideline recommendations.
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Affiliation(s)
- Michael D. Faulx
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
- Corresponding author.
| | - Reena Mehra
- Director, Sleep Disorders Research. Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Glaucylara Reis Geovanini
- Sleep Laboratory, Pulmonary Division, Heart Institute (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Shin-ichi Ando
- Sleep Apnea Center. Kyushu University Hospital, 3-1-1 Maidashi Higashiku Fukuoka, 814-8582, Japan
| | - Michael Arzt
- Department of Internal Medicine II, University Hospital Regensburg, Franz-Josef-Strauss-Allee (u1) 11, 93053 Regensburg, Germany
| | - Luciano Drager
- Unidade de Hipertensao, Institute do Coraçao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Michael Fu
- Senior Consultant Physician/Cardiologist, University of Gothenburg, Su sahlgrenska, 41345 Göteborg, Sweden
| | - Camilla Hoyos
- The University of Sydney, Faculty of Science, School of Psychology, Sydney, Australia and Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Glebe, Sydney, Australia
| | - Jo Hai
- Queen Mary Hospital and LKS Faculty of Medicine, the University of Hong Kong, Hong Kong
| | - Juey-Jen Hwang
- Cardiovascular Division, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, No. 7, Chung Shan S. Rd, Taipei 100225, Taiwan
| | - Remzi Karaoguz
- Department of Cardiology, Güven Hospital, Cankaya, 06540 Ankara, Turkey
| | - John Kimoff
- Respiratory Division, Room D05.2505. McGill University Health Centre, Glen Site 1001 Décarie, Montréal, Québec H4A 3J1, Canada
| | - Pei-Lin Lee
- Center of Sleep Disorders, National Taiwan University Hospital, No.7, Chung Shan S. Rd., Taipei 100225, Taiwan
| | - Olga Mediano
- Sleep Unit, Pneumology Department, Hospital Universitario de Guadalajara. Medicine Department. Universidad de Alcalá. Madrid. Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Sanjay R. Patel
- Center for Sleep and Cardiovascular Outcomes Research, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yüksel Peker
- Department of Pulmonary Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Jean Louis Pepin
- HP2 Laboratory, Grenoble Alpes University/INSERM U 1300 Unit, Faculty of Medicine, Domaine de la Merci, 38700 La Tronche, France
| | - Manuel Sanchez-de-la-Torre
- Precision Medicine in Chronic Diseases, Hospital Universitari Arnau de Vilanova-Santa Maria, IRB Lleida, Department of Nursing and Physiotherapy, Faculty of Nursing and Physiotherapy. University of Lleida, Lleida, Spain. 2 Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, CIBERES, Madrid, Spain
| | - Frédéric Sériès
- Département de Médecine Université Laval. Centre de Pneumologie, Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 chemin sainte Foy, Québec, Québec G1V 4G5, Canada
| | - Stefan Stadler
- Department of Internal Medicine II, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Patrick Strollo
- Division of Allergy, Pulmonary and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - A.A. Tahrani
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK. Centre for endocrinology, diabetes and metabolism (CEDAM), Birmingham Health Partners, Birmingham, UK
| | - Erik Thunström
- Department of Medicine, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Motoo Yamauchi
- Department of Respiratory Medicine. Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
| | - Susan Redline
- Brigham and Women's Hospital. Department of Medicine, Division of Sleep and Circadian Disorders. 75 Francis Street, Boston, MA 02115, USA
| | - Craig L. Phillips
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
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12
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Matthews S, Atkins B, Walton N, Mitchell JA, Jennings G, Buttery AK. Development and Use of a Cardiac Clinical Guideline Mobile App in Australia: Acceptability and Multi-Methods Study. JMIR Form Res 2022; 6:e35599. [PMID: 35930350 PMCID: PMC9391980 DOI: 10.2196/35599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/03/2022] [Accepted: 06/20/2022] [Indexed: 11/28/2022] Open
Abstract
Background Implementation of clinical guidelines into routine practice remains highly variable. Strategies to increase guideline uptake include developing digital tools and mobile apps for use in clinical practice. The National Heart Foundation of Australia in collaboration with the Cardiac Society of Australia and New Zealand published 3 key cardiac clinical guidelines, including the Australian clinical guidelines for the (1) prevention and detection of atrial fibrillation, (2) detection and management of heart failure, and (3) management of acute coronary syndromes. To improve access and uptake for health care providers, we developed the Smart Heart Guideline App. Objective This study aims to evaluate the acceptability, implementation, and usability of an Australian-specific cardiac guidelines mobile app. Methods We used an iterative multiple methods development and implementation approach. First, we conducted a cross-sectional web-based survey with end users (n=504 health professionals) in 2017 to determine the acceptability of an Australian-specific cardiac clinical guidelines mobile app. Second, the Smart Heart Guidelines app was created using a design, user testing, and revision process. The app includes interactive algorithms and flowcharts to inform diagnosis and management at the point of care. The freely available app was launched in October 2019 on iOS and Android operating systems and promoted and implemented using multiple methods. Third, data from 2 annual national cross-sectional general practitioner (GP) surveys in 2019 and 2020 were evaluated to understand the awareness and use of the clinical guidelines and the app. Fourth, data from the app stores were analyzed between October 1, 2019, and June 30, 2021, to evaluate usage. Results Most health professionals surveyed (447/504, 89%) reported accessing resources electronically, and most (318/504, 63%) reported that they would use an Australian-specific cardiac guidelines app. GPs surveyed in 2019 were aware of the heart failure (159/312, 51%) and atrial fibrillation (140/312, 45%) guidelines, and in 2020, a total of 34 of 189 (18%) reported that they were aware of the app. The app was downloaded 11,313 times (7483, 66% from the Apple App Store; 3830, 34% from Google Play) during the first 20-month period. Most downloads (6300/7483, 84%) were a result of searching for the app in the stores. Monthly download rates varied. App Store data showed that people used the app twice (on average 2.06 times) during the 20 months. Many (3256/3830, 85%) Android users deleted the app. Conclusions Health professionals supported the development of the Smart Heart Guidelines app. Although initial downloads were promising, the frequency of using the app was low and deletion rates were high. Further evaluation of users’ experience of the most and least useful components of the app is needed.
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Affiliation(s)
- Stacey Matthews
- National Heart Foundation of Australia, Melbourne, Australia
- Royal Melbourne Hospital, Cardiothoracic Surgery Unit, Parkville, Australia
| | - Brooke Atkins
- National Heart Foundation of Australia, Melbourne, Australia
| | - Natalie Walton
- National Heart Foundation of Australia, Melbourne, Australia
| | | | - Garry Jennings
- National Heart Foundation of Australia, Melbourne, Australia
- Baker Heart and Diabetes Institute, Melbourne, Australia
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13
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Ferguson C, Hickman LD, Lombardo L, Downie A, Bajorek B, Ivynian S, Inglis SC, Wynne R. Educational Needs of People Living with Atrial Fibrillation: A Qualitative Study. J Am Heart Assoc 2022; 11:e025293. [PMID: 35876410 PMCID: PMC9375481 DOI: 10.1161/jaha.122.025293] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background This study explored the educational and self‐management needs of adults living with atrial fibrillation (AF). Methods and Results This is a qualitative study of adults living with AF, clinicians, and expert key stakeholders. Interviews were conducted via a one‐to‐one semistructured videoconference or phone and transcribed verbatim for thematic analysis. A total of 34 participants were recruited and included in analyses (clinicians n=13; experts n=13, patients n=8). Interviews were on average 40 (range 20–70) minutes in duration. Three key themes were identified: (1) “Patient‐centered AF education”; (2) “Prioritizing AF education”; and (3) “Timing AF education.” The availability of credible information was perceived as highly variable. Information primarily focused on anticoagulation, or procedural information, as opposed to other aspects of management, such as risk factor reduction. Factors to optimize learning, such as multimedia, apps, case studies, or the use of visuals were perceived as important. Continuity of care, including engagement of caregivers, was important to help develop relationships, and facilitate understanding, while concurrently creating opportunities for timely targeted education. Clinicians described acute care as a suboptimal setting to deliver education. Competing interests aligned with the time‐pressured context of acute care were prioritized over patient education. In contrast, patients valued continuity of care. AF education strategies need to pivot from a “one size fits all” approach and modernize to implement a range of approaches. Conclusions There remain many unmet needs in the provision of quality AF education to support self‐management. Multimodal offerings and the ability to tailor to individual patient needs are important design considerations for new education programs.
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Affiliation(s)
- Caleb Ferguson
- Western Sydney Nursing & Midwifery Research Centre Western Sydney Local Health District and Western Sydney University, Blacktown Hospital Blacktown New South Wales Australia.,School of Nursing University of Wollongong Wollongong New South Wales Australia
| | - Louise D Hickman
- School of Nursing University of Wollongong Wollongong New South Wales Australia
| | - Lien Lombardo
- Western Sydney Nursing & Midwifery Research Centre Western Sydney Local Health District and Western Sydney University, Blacktown Hospital Blacktown New South Wales Australia
| | - Annie Downie
- Department of Cardiology The Sutherland Hospital Caringbah Australia
| | - Beata Bajorek
- Faculty of Health University of Technology Sydney Sydney New South Wales Australia
| | - Serra Ivynian
- Faculty of Health University of Technology Sydney Sydney New South Wales Australia
| | - Sally C Inglis
- Faculty of Health University of Technology Sydney Sydney New South Wales Australia
| | - Rochelle Wynne
- Western Sydney Nursing & Midwifery Research Centre Western Sydney Local Health District and Western Sydney University, Blacktown Hospital Blacktown New South Wales Australia.,School of Nursing & Midwifery Deakin University Geelong Australia
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14
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Abbott AL. Extra-Cranial Carotid Artery Stenosis: An Objective Analysis of the Available Evidence. Front Neurol 2022; 13:739999. [PMID: 35800089 PMCID: PMC9253595 DOI: 10.3389/fneur.2022.739999] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 01/24/2022] [Indexed: 12/26/2022] Open
Abstract
Background and Purpose Carotid stenosis is arterial disease narrowing of the origin of the internal carotid artery (main brain artery). Knowing how to best manage this is imperative because it is common in older people and an important cause of stroke. Inappropriately high expectations have grown regarding the value of carotid artery procedures, such as surgery (endarterectomy) and stenting, for lowering the stroke risk associated with carotid stenosis. Meanwhile, the improving and predominant value of medical intervention (lifestyle coaching and medication) continues to be underappreciated. Methods and Results This article aims to be an objective presentation and discussion of the scientific literature critical for decision making when the primary goal is to optimize patient outcome. This compilation follows from many years of author scrutiny to separate fact from fiction. Common sense conclusions are drawn from factual statements backed by original citations. Detailed research methodology is given in cited papers. This article has been written in plain language given the importance of the general public understanding this topic. Issues covered include key terminology and the economic impact of carotid stenosis. There is a summary of the evidence-base regarding the efficacy and safety of procedural and medical (non-invasive) interventions for both asymptomatic and symptomatic patients. Conclusions are drawn with respect to current best management and research priorities. Several "furphies" (misconceptions) are exposed that are commonly used to make carotid stenting and endarterectomy outcomes appear similar. Ongoing randomized trials are mentioned and why they are unlikely to identify a routine practice indication for carotid artery procedures. There is a discussion of relevant worldwide guidelines regarding carotid artery procedures, including how they should be improved. There is an outline of systematic changes that are resulting in better application of the evidence-base. Conclusion The cornerstone of stroke prevention is medical intervention given it is non-invasive and protects against all arterial disease complications in all at risk. The "big" question is, does a carotid artery procedure add patient benefit in the modern era and, if so, for whom?
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Affiliation(s)
- Anne L. Abbott
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Neurology Private Practice, Knox Private Hospital, Wantirna, VIC, Australia
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15
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Improving Knowledge and Early Detection of Atrial Fibrillation through a Community-Based Opportunistic Screening Program: What's Your Beat? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19116860. [PMID: 35682443 PMCID: PMC9180497 DOI: 10.3390/ijerph19116860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/20/2022] [Accepted: 06/01/2022] [Indexed: 12/07/2022]
Abstract
A community-based opportunistic screening program was implemented to (i) improve atrial fibrillation (AF) awareness and detection and (ii) assess the performance of the Microlife WatchBP Home A for detecting AF when used in community screening. Screening sessions were conducted among people aged ≥ 65 years with no history of AF at public events across Tasmania, Australia. Participants with positive screening results were referred to their general medical practitioner for assessment. The device’s performance was assessed using the positive predictive value. A total of 1704 eligible participants were screened at 79 sessions. Of these people, 50 (2.9%) had a positive screening result. The device correctly identified AF in 22 (46.8%) participants with positive results. Among those with subsequently confirmed AF, 6 (27.3%) had a history of AF but were not aware of the diagnosis, and 16 (72.7%) were identified to have previously undiagnosed AF, with an overall prevalence of 0.9% (95% CI, 0.58 to 1.52). Oral anticoagulation therapy was initiated in 12 (87.5%) eligible participants. The positive predictive value of the device was 46.8% (95% CI, 33.3 to 60.7). Given the relatively low performance of the device, its application in community-based opportunistic screening programs for AF is unlikely to be cost-effective.
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16
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Tavazzi L, Maggioni AP, Rapezzi C, Ferrari R. Heart failure and catheter ablation of atrial fibrillation: Navigating the difficult waters of heart failure phenotypes. Eur J Intern Med 2022; 99:13-18. [PMID: 35241349 DOI: 10.1016/j.ejim.2022.02.021] [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: 10/29/2021] [Revised: 02/07/2022] [Accepted: 02/16/2022] [Indexed: 11/03/2022]
Abstract
The use of catheter ablation of atrial fibrillation (AFA) is increasing and it has now been extended to include higher risk patients with heart failure (HF), based on evidence from observational studies and meta-analyses of randomized controlled trials (RCTs) indicating it as safe and beneficial in terms of quality of life, AF recurrence and hospital readmissions in the short-to-middle term. However, the RCTs so far have been relatively small with short follow-up, and few larger trials with long follow-up inconclusive about hard outcomes for large patient crossover undermining the robustness of the results. Importantly, most RCTs involved HF patients with reduced left ventricular ejection fraction (HFrEF). In contrast, most observational studies show that the majority of ablated HF patients in clinical practice have a preserved ejection fraction (HFpEF), a condition representing roughly half of all HF patients. This article provides an overview of the available scientific evidence in this clinical field and examines the current guideline recommendations. In the absence of robust evidence-based research, the recommendations on AFA in HF may be inconsistent or abstain from taking firm positions, particularly regarding AFA in HFpEF. There is need for clinical research in such a surprisingly orphan setting, in parallel with the current attempts to sort out the knotty question of the HF phenotypes, in particular, again, of the HFpEF phenotypes.
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Affiliation(s)
- Luigi Tavazzi
- Maria Cecilia Hospital, GVM Care&Research, Cotignola (RA), Italy.
| | - Aldo P Maggioni
- Maria Cecilia Hospital, GVM Care&Research, Cotignola (RA), Italy; Centro Studi ANMCO, Firenze, Italy
| | - Claudio Rapezzi
- Maria Cecilia Hospital, GVM Care&Research, Cotignola (RA), Italy; Azienda Ospedaliero-Universitaria di Ferrara "Arcispedale S. Anna", Cona, Ferrara, Italy
| | - Roberto Ferrari
- Scientific Department, Medical Trial Analysis, Lugano, Switzerland
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17
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Himmelreich JCL, Harskamp RE, Geelhoed B, Virdone S, Lucassen WAM, Gansevoort RT, Rienstra M. Validating risk models versus age alone for atrial fibrillation in a young Dutch population cohort: should atrial fibrillation risk prediction be expanded to younger community members? BMJ Open 2022; 12:e057476. [PMID: 35173009 PMCID: PMC8852746 DOI: 10.1136/bmjopen-2021-057476] [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: 11/03/2022] Open
Abstract
BACKGROUND Advancing age is the primary selection criterion for community screening for atrial fibrillation (AF), with selection often restricted to those aged ≥65 years. If multivariable models were shown to have considerable additional value over age alone in predicting AF risk among younger individuals, AF screening could be expanded to patients with lower age, but with high AF risk as per a validated risk model. METHODS We validated risk models CHARGE-AF (Cohorts for Heart and Aging Research in Genomic Epidemiology model for AF) and FHS-AF (Framingham Heart Study model for AF), and risk scores CHA2DS2-VASc and CHA2DS2-VA, and presented their predictive abilities for 5-year and 10-year AF risk versus that of age alone in a young Dutch population cohort (PREVEND) free from AF at baseline. We assessed discrimination by the C-statistic and calibration by the calibration plot and stratified Kaplan-Meier plot using survey-weighted Cox models. RESULTS During 5-year and 10-year follow-up there were n=98 (2.46/1000 person-years) and n=249 (3.29/1000 person-years) new AF cases, respectively, among 8265 participants with mean age 49±13 years. CHARGE-AF and FHS-AF both showed good discrimination for 5-year and 10-year AF (C-statistic range 0.83-0.86) with accurate calibration for 5-year AF, but overestimation of 10-year AF risk in highest-risk individuals. CHA2DS2-VASc and CHA2DS2-VA relatively underperformed. Age alone showed similar discrimination to that of CHARGE-AF and FHS-AF both in the overall, young PREVEND cohort and in subgroups for lower age and lower stroke risk. CONCLUSION Multivariable models accurately discriminate for 5-year and 10-year AF risk among young European community-dwelling individuals. However, their additional discriminatory value over age alone was limited. Selection strategies for primary AF screening using multivariable models should not be expanded to younger individuals.
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Affiliation(s)
- Jelle C L Himmelreich
- Department of General Practice, Amsterdam Public Health, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Ralf E Harskamp
- Department of General Practice, Amsterdam Public Health, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Bastiaan Geelhoed
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Saverio Virdone
- Department of Statistics, Thrombosis Research Institute, London, UK
| | - Wim A M Lucassen
- Department of General Practice, Amsterdam Public Health, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Ron T Gansevoort
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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18
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Seelig J, Chu G, Trinks-Roerdink EM, Pisters R, de Vries TA, Cate HT, Geersing GJ, Rutten FH, Huisman MV, Hemels ME. Unequal prescription of anticoagulants among females and males with atrial fibrillation and similar stroke risk - should we omit sex category from the CHA2DS2-VASc score? Heart Rhythm 2022; 19:860-861. [PMID: 35033666 DOI: 10.1016/j.hrthm.2022.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/05/2022] [Accepted: 01/10/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Jaap Seelig
- Department of Cardiology, Rijnstate, Arnhem, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Gordon Chu
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Emmy M Trinks-Roerdink
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Ron Pisters
- Department of Cardiology, Rijnstate, Arnhem, the Netherlands
| | - Tim Ac de Vries
- Department of Cardiology, Rijnstate, Arnhem, the Netherlands; Department of Cardiology, Amsterdam University Medical Centers location Academic Medical Center, Amsterdam, the Netherlands
| | - Hugo Ten Cate
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands; Department of Internal Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Geert-Jan Geersing
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Frans H Rutten
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Martin Ew Hemels
- Department of Cardiology, Rijnstate, Arnhem, the Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
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19
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Faulx M, Mehra R, Geovanini GR, Ando SI, Arzt M, Drager L, Fu M, Hoyos CM, Hai J, Hwang JJ, Karaoguz R, Kimoff J, Lee PL, Mediano O, Patel S, Peker Y, Pepin JL, Sanchez-de-la-Torre M, Series F, Stadler S, Strollo P, Tahrani AA, Thunstrom E, Yamauchi M, Redline S, Phillips CL. Obstructive Sleep Apnea and its Management in Patients with Atrial Fibrillation: An International Collaboration of Sleep Apnea Cardiovascular Trialists (INCOSACT)) Global Survey of Practicing Cardiologists. SSRN ELECTRONIC JOURNAL 2022. [DOI: 10.2139/ssrn.4105038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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20
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Sussman M, Barnes GD, Guo JD, Tao CY, Gillespie JA, Ferri M, Adair N, Cato MS, Shirkhorshidian I, Di Fusco M. The burden of undertreatment and non-treatment among patients with non-valvular atrial fibrillation and elevated stroke risk: a systematic review. Curr Med Res Opin 2022; 38:7-18. [PMID: 34632887 DOI: 10.1080/03007995.2021.1982684] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Global treatment guidelines recommend treatment with oral anticoagulants (OACs) for patients with non-valvular atrial fibrillation (NVAF) and an elevated stroke risk. However, not all patients with NVAF and an elevated stroke risk receive guideline-recommended therapy. A literature review and synthesis of observational studies were undertaken to identify the body of evidence on untreated and undertreated NVAF and the association with clinical and economic outcomes. METHODS An extensive search (1/2010-4/2020) of MEDLINE, the Cochrane Library, conference proceedings, and health technology assessments (HTAs) was conducted. Studies must have evaluated rates of nontreatment or undertreatment in NVAF. Nontreatment was defined as absence of OACs (but with possible antiplatelet treatment), while undertreatment was defined as treatment with only antiplatelet agents. RESULTS Sixteen studies met our inclusion criteria. Rates of nontreatment for patients with elevated stroke risk ranged from 2.0-51.1%, while rates of undertreatment ranged from 10.0-45.1%. The clinical benefits of anticoagulation were reported in the evaluated studies with reductions in stroke and mortality outcomes observed among patients treated with anticoagulants compared to untreated or undertreated patients. Adverse events associated with all bleeding types (i.e. hemorrhagic stroke, major bleeding or gastrointestinal hemorrhaging) were found to be higher for warfarin patients compared to untreated patients in real-world practice. Healthcare resource utilization was found to be lower among patients highly-adherent to warfarin compared to untreated patients. CONCLUSIONS Rates of nontreatment and undertreatment among NVAF patients remain high and are associated with preventable cardiovascular events and death. Strategies to increase rates of treatment may improve clinical outcomes.
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Affiliation(s)
- Matthew Sussman
- Modeling and Strategy Services, Panalgo LLC, Boston, MA, USA
| | | | - Jennifer D Guo
- Patient and Health Impact, Bristol Myers Squibb, New Brunswick, NJ, USA
| | - Charles Y Tao
- Modeling and Strategy Services, Panalgo LLC, Boston, MA, USA
| | | | - Mauricio Ferri
- Patient and Health Impact, Bristol Myers Squibb, New Brunswick, NJ, USA
| | - Nicholas Adair
- Modeling and Strategy Services, Panalgo LLC, Boston, MA, USA
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21
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Mills MT, Warriner DR. A guide to the management of atrial fibrillation in Santa Claus. Med J Aust 2021; 215:529-531. [PMID: 34897725 DOI: 10.5694/mja2.51341] [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: 06/26/2021] [Revised: 09/06/2021] [Accepted: 09/29/2021] [Indexed: 11/17/2022]
Abstract
•In view of his advanced age and risk factors, Santa Claus is at high risk of developing atrial fibrillation. Despite this, no guidelines exist on the subject. •Following a review of the literature, we present our position on the management of atrial fibrillation in Santa Claus, and propose the use of the SANTA CLAUS mnemonic to aid clinicians: Screen for atrial fibrillation; Anticoagulate; Normalise heart rate; Treat comorbidities; Anti-arrhythmic drugs; Cardioversion; Lifestyle measures; Ablation treatment; Understand emotional and psychological impact; Save Santa Claus.
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Affiliation(s)
- Mark T Mills
- University of Sheffield, Sheffield, United Kingdom.,Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - David R Warriner
- Doncaster and Bassetlaw, Teaching Hospitals NHS Foundation Trust, Doncaster, United Kingdom.,Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
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22
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Park S, Je NK. Factors Influencing the Selection of Non-Vitamin K Antagonist Oral Anticoagulants for Stroke Prevention in Patients With Non-Valvular Atrial Fibrillation. J Cardiovasc Pharmacol Ther 2021; 26:656-664. [PMID: 34558337 DOI: 10.1177/10742484211049919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Major atrial fibrillation (AF) guidelines recommend non-vitamin K antagonist oral anticoagulants (NOACs) over warfarin, except in rare clinical circumstances based on 4 randomized controlled trials comparing each NOAC with warfarin. We aimed to investigate the current NOAC prescription behaviors in alignment with the recent clinical evidence available. METHOD We conducted a cross-sectional analysis of NOAC-using patients with non-valvular atrial fibrillation (NVAF) who were aged ≥65 years on the index date (July 1, 2018) based on nationwide claims data. The types of NOACs being taken were analyzed using chi-squared tests, and factors influencing NOAC selection were identified using multinomial logistic regression analysis. RESULTS A total of 6,061 patients were included. Among the 4 NOACs, rivaroxaban was the most used NOAC. Patients aged ≥75 years (odds ratio [OR] = 1.270, confidence interval [CI] = 1.089-1.450) and women (OR = 1.148, CI = 1.011-1.284) were more likely to use apixaban relative to rivaroxaban. Patients with prior stroke/transient ischemic attack/thromboembolism had higher odds of using dabigatran (OR = 1.508, CI = 1.312-1.704) and apixaban (OR = 1.186, CI = 1.026-1.346). Patients with renal disease had higher odds of using apixaban (OR = 1.466, 95% CI = 1.238-1.693). These findings are consistent with the efficacy and safety profiles reported in pivotal trials and observational studies comparing individual NOACs. CONCLUSION Among the 4 NOACs, rivaroxaban was the most commonly used NOAC. Apixaban was preferred for patients aged ≥75 years, females, and patients with renal disease.
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Affiliation(s)
- Susin Park
- College of Pharmacy, 34996Pusan National University, Busan, Republic of Korea
| | - Nam Kyung Je
- College of Pharmacy, 34996Pusan National University, Busan, Republic of Korea
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23
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da Fonseca MH, Kovaleski F, Picinin CT, Pedroso B, Rubbo P. E-Health Practices and Technologies: A Systematic Review from 2014 to 2019. Healthcare (Basel) 2021; 9:healthcare9091192. [PMID: 34574966 PMCID: PMC8470487 DOI: 10.3390/healthcare9091192] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/17/2021] [Accepted: 08/26/2021] [Indexed: 12/17/2022] Open
Abstract
E-health can be defined as a set of technologies applied with the help of the internet, in which healthcare services are provided to improve quality of life and facilitate healthcare delivery. As there is a lack of similar studies on the topic, this analysis uses a systematic literature review of articles published from 2014 to 2019 to identify the most common e-health practices used worldwide, as well as the main services provided, diseases treated, and the associated technologies that assist in e-health practices. Some of the key results were the identification of the four most common practices used (mhealth or mobile health; telehealth or telemedicine; technology; and others) and the most widely used technologies associated with e-health (IoT, cloud computing, Big Data, security, and systems).
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Affiliation(s)
- Maria Helena da Fonseca
- Department of Production Engineering, Federal University of Technology—Paraná (UTFPR), Ponta Grossa 84017-220, Brazil; (F.K.); (C.T.P.)
- Correspondence: ; Tel.: +55-42-999388129
| | - Fanny Kovaleski
- Department of Production Engineering, Federal University of Technology—Paraná (UTFPR), Ponta Grossa 84017-220, Brazil; (F.K.); (C.T.P.)
| | - Claudia Tania Picinin
- Department of Production Engineering, Federal University of Technology—Paraná (UTFPR), Ponta Grossa 84017-220, Brazil; (F.K.); (C.T.P.)
| | - Bruno Pedroso
- Division of Physical Education, State University of Ponta Grossa—Paraná (UEPG), Ponta Grossa 84030-900, Brazil;
| | - Priscila Rubbo
- Department of Accounting Sciences, Federal University of Technology—Paraná (UTFPR), Pato Branco 85503-390, Brazil;
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24
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Sun W, Freedman B, Martinez C, Wallenhorst C, Yan B. Atrial Fibrillation Detected by Single Timepoint Handheld ECG Screening and the Risk of Ischemic Stroke. Thromb Haemost 2021; 122:286-294. [PMID: 34399432 DOI: 10.1055/a-1588-8867] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We evaluated stroke risk in patients with single timepoint screen-detected atrial fibrillation (AF) and the effect of oral anticoagulants (OAC). METHODS Consecutive patients aged ≥65 years attending medical outpatient clinics were prospectively enrolled for AF-screening using handheld single-lead ECG (AliveCor) from 12/2014 to 12/2017 (NCT02409654). Repeated screening was performed in patients with >1 visit during this period. Three cohorts were formed, screen-detected AF, clinically-diagnosed AF and no AF. Ischemic stroke risk was estimated using adjusted sub-distribution hazard ratios (aSHR) from multivariate regression and no AF as reference, and stratified according to OAC use. RESULTS Of 11,972 subjects enrolled, 2,238 (18.7%) had clinically-diagnosed AF at study enrollment. The yield of screen-detected AF on initial screening was 2.3% (n=223/9,734). AF was clinically-diagnosed during follow-up in 2.3% (n=216/9,440) and during subsequent screening in 71 initially screen-negative patients. Compared to no AF, patients with screen-detected AF without OAC treatment had the highest stroke risk (aSHR 2.63; 95% confidence interval 1.46-4.72), while aSHR for clinically-diagnosed AF without OAC use was 2.01 (1.54-2.62). Among screen-detected AF the risk of stroke was significantly less with OAC (no strokes in 196 person-years) compared with those not given OAC (12 strokes in 429 person-years), p=0.01. CONCLUSION The prognosis of single timepoint ECG screen-detected AF is not benign. The risk of stroke is high enough to warrant OAC use, and reduced by OAC.
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Affiliation(s)
- Wen Sun
- The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Ben Freedman
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Carlos Martinez
- Institute for Epidemiology, Statistics and Informatics GmbH, Frankfurt, Germany
| | | | - Bryan Yan
- The Chinese University of Hong Kong, Hong Kong, Hong Kong
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25
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Thijs V, Witte KK, Guarnieri C, Makino K, Tilden D, Gillespie J, Huynh M. Cost-effectiveness of insertable cardiac monitors for diagnosis of atrial fibrillation in cryptogenic stroke in Australia. J Arrhythm 2021; 37:1077-1085. [PMID: 34386135 PMCID: PMC8339089 DOI: 10.1002/joa3.12586] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/07/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Detection of atrial fibrillation (AF) is required to initiate oral anticoagulation (OAC) after cryptogenic stroke (CS). However, paroxysmal AF can be difficult to diagnose with short term cardiac monitoring. Taking an Australian payer perspective, we evaluated whether long-term continuous monitoring for 3 years with an insertable cardiac monitor (ICM) is cost-effective for preventing recurrent stroke in patients with CS. METHODS A lifetime Markov model was developed to simulate the follow-up of patients, comparing long-term continuous monitoring with an ICM to monitoring by conventional care. We used a linked evidence approach to estimate the rates of recurrent stroke when AF detection leads to initiation of OAC, as detected using ICM during the lifetime of the device or as detected using usual care. All diagnostic and patient management costs were modeled. Other model inputs were determined by literature review. Probabilistic sensitivity analysis (PSA) was undertaken to explore the effect of parameter uncertainty according to CHADS2 score and OAC treatment effect. RESULTS In the base-case analysis, the model predicted an incremental cost-effectiveness ratio (ICER) of A$29 570 per quality-adjusted life year (QALY). Among CHADS2 subgroups analyses, the ICER ranged from A$26 342/QALY (CHADS2 = 6) to A$42 967/QALY (CHADS2 = 2). PSA suggested that the probabilities of ICM strategy being cost-effective were 53.4% and 78.7%, at thresholds of $30 000 (highly cost-effective) and $50 000 per QALY (cost-effective), respectively. CONCLUSIONS Long-term continuous monitoring with an ICM is a cost-effective intervention to prevent recurrent stroke in patients following CS in the Australian context.
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Affiliation(s)
- Vincent Thijs
- Florey Institute of Neuroscience and Mental HealthUniversity of MelbourneParkvilleVictoriaAustralia
| | - Klaus K. Witte
- Division of Cardiovascular and Diabetes ResearchUniversity of LeedsLeedsUK
| | | | - Koji Makino
- THEMA Consulting Pty Ltd.PyrmontNew South WalesAustralia
| | - Dominic Tilden
- THEMA Consulting Pty Ltd.PyrmontNew South WalesAustralia
| | - John Gillespie
- Medtronic Australasia Pty Ltd.Macquarie ParkNew South WalesAustralia
| | - Marianne Huynh
- Medtronic Australasia Pty Ltd.Macquarie ParkNew South WalesAustralia
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26
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Wallenhorst C, Martinez C, Freedman B. Risk of Ischemic Stroke in Asymptomatic Atrial Fibrillation Incidentally Detected in Primary Care Compared with Other Clinical Presentations. Thromb Haemost 2021; 122:277-285. [PMID: 34192776 DOI: 10.1055/a-1541-3885] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND It is uncertain whether stroke risk of asymptomatic ambulatory atrial fibrillation (AA-AF) incidentally detected in primary care is comparable with other clinical AF presentations in primary care or hospital. METHODS The stoke risk of 22,035 patients with incident nonvalvular AF from the United Kingdom primary care Clinical Practice Research Datalink with linkage to hospitalization and mortality data was compared with 23,605 controls without AF (age- and sex-matched 5:1 to 5,409 AA-AF patients). Incident AF included 5,913 with symptomatic ambulatory AF (SA-AF); 4,989 with primary and 5,724 with nonprimary hospital AF discharge diagnosis (PH-AF and non-PH-AF); and 5,409 with AA-AF. Ischemic stroke adjusted subhazard ratios (aSHRs) within 3 years of AA-AF were compared with SA-AF, PH-AF, non-PH-AF, and no AF, accounting for mortality as competing risk and adjusted for ischemic stroke risk factors. RESULTS There were 1,026 ischemic strokes in 49,544 person-years in patients with incident AF (crude incidence rate: 2.1 ischemic strokes/100 person-years). Ischemic stroke aSHR over 3 years showed no differences between AA-AF and SA-AF, PH-AF, and non-PH-AF groups (aSHR: 0.87-1.01 vs. AA-AF). All AF groups showed a significantly higher aSHR compared with no AF. CONCLUSION Ischemic stroke risk in patients with AA-AF incidentally detected in primary care is far from benign, and not less than incident AF presenting clinically in general practice or hospital. This provides justification for identification of previously undetected AF, e.g., by opportunistic screening, and subsequent stroke prevention with thromboprophylaxis, to reduce the approximately 10% of ischemic strokes related to unrecognized AF.
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Affiliation(s)
| | - Carlos Martinez
- Institute for Epidemiology, Statistics and Informatics GmbH, Frankfurt, Germany
| | - Ben Freedman
- Heart Research Institute, Charles Perkins Centre, University of Sydney, Sydney, Australia.,Department of Cardiology, Concord Hospital, Sydney, Australia.,ANZAC Research Institute, Concord Hospital, Sydney, Australia
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27
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Farkowski MM, Jubele K, Marín F, Gandjbakhch E, Ptaszynski P, Merino JL, Lenarczyk R, Potpara TS. Diagnosis and management of left atrial appendage thrombus in patients with atrial fibrillation undergoing cardioversion or percutaneous left atrial procedures: results of the European Heart Rhythm Association survey. Europace 2021; 22:162-169. [PMID: 31501852 DOI: 10.1093/europace/euz257] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 08/19/2019] [Indexed: 12/24/2022] Open
Abstract
Practices regarding indications and timing for transoesophageal echocardiography (TOE) before cardioversion (CV) of atrial fibrillation (AF) or left atrial (LA) interventional procedures, and preferred imaging techniques and pharmacotherapy, in cases of thrombus resistant to chronic oral anticoagulation (OAC) treatment, are largely unknown. The European Heart Rhythm Association (EHRA) conducted a survey to capture contemporary clinical practice in those areas of AF care. A 22-item online questionnaire was developed and distributed among the EHRA electrophysiology research network centres. The survey contained questions regarding indications, type and timing of imaging before CV or LA procedures and management of LA appendage (LAA) thrombus with special emphasis on thrombus resistant to OAC. Of 54 responding centres 63% were university hospitals. Most commonly, TOE would be performed in cases of inadequate or unclear pre-procedural anticoagulation, even in AF lasting <48 h (52% and 50%, respectively), and 15% of centres would perform TOE before AF ablation in all patients. If thrombus was diagnosed despite chronic OAC, the prevalent strategy was to change current OAC to another with different mechanism of action; 51% of centres would wait 3-4 weeks after changing the OAC before using another imaging test, and 60% of centres reported two attempts to dissolve the thrombus. Our survey showed a significant utilization of TOE before CV or AF ablation in European centres, extending beyond AF guidelines-suggested indications. When thrombus was diagnosed despite chronic pre-procedural OAC, most centres would use another anticoagulant drug with different mode of action.
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Affiliation(s)
- Michal M Farkowski
- Heart Arrhythmia Ward, II Department of Coronary Artery Disease, Institute of Cardiology, Alpejska 42, Warsaw, Poland
| | - Kristine Jubele
- P. Stradins Clinical University Hospital, Riga Stradins University, Riga, Latvia
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, CIBERCV, University of Murcia, Murcia, Spain
| | - Estelle Gandjbakhch
- Sorbonne Universités, APHP, Institute of Cardiology ICAN, Pitié-Salpêtrière University Hospital, Paris, France
| | - Pawel Ptaszynski
- Department of Electrocardiology, Medical University of Lodz, Lodz, Poland
| | - Jose L Merino
- Unidad de Arritmias y Electrofisiología Robotizada, La Paz University Hospital, IDIPAZ, Universidad Autonoma de Madrid, Madrid, Spain
| | - Radoslaw Lenarczyk
- First Department of Cardiology and Angiology, Silesian Centre for Heart Disease, Zabrze, Poland
| | - Tatjana S Potpara
- School of Medicine, Belgrade University; Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
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28
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Rao K, Bhindi R. Underusage of Oral Anticoagulation in Atrial Fibrillation: Can We Prevent More Strokes? Heart Lung Circ 2021; 30:1107-1109. [PMID: 34090795 DOI: 10.1016/j.hlc.2021.05.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Karan Rao
- Department of Cardiology, Westmead Hospital, Sydney, and University of Sydney, Sydney, NSW, Australia
| | - Ravinay Bhindi
- Department of Cardiology, Royal North Shore Hospital, Sydney, and University of Sydney, Sydney, NSW, Australia.
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29
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Stavrakis S, Elkholey K, Lofgren MM, Asad ZUA, Stephens LD, Freedman B. Screening for Atrial Fibrillation in American Indian Adults in a Tribal Primary Care Clinic. J Am Heart Assoc 2021; 10:e020069. [PMID: 33878888 PMCID: PMC8200768 DOI: 10.1161/jaha.120.020069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background American Indian adults have a higher risk of atrial fibrillation (AF) compared with other racial groups. We implemented opportunistic screening to detect silent AF in American Indian adults attending a tribal health system using a mobile, single-lead ECG device. Methods and Results American Indian patients aged ≥50 years followed in a tribal primary care clinic with no history of AF underwent a 30-second ECG. A cardiologist overread all tracings to confirm the diagnosis of AF. After AF was confirmed, patients were referred to their primary care physician for initiation of anticoagulation. Patients seen over the same time period, who were not undergoing screening, served as controls. A total of 1019 patients received AF screening (mean age, 61.5±8.9 years, 62% women). Age and sex distribution of those screened was similar to the overall clinic population. New AF was diagnosed in 15 of 1019 (1.5%) patients screened versus 4 of 1267 (0.3%) patients who were not screened (mean difference, 1.2%; 95% CI, 0.3%-2.2%, P=0.002). Eight of 15 with new screen-detected AF were aged <65 years. Those with screen-detected AF were slightly older and had a higher CHA2DS2-VASc score than those without AF. Fourteen of 15 patients diagnosed with new AF had a CHA2DS2-VASc score ≥1 and initiated anticoagulation. Conclusions Opportunistic, mobile single-lead ECG screening for AF is feasible in tribal clinics, and detects more AF than usual care, leading to appropriate initiation of anticoagulation. AF develops at a younger age in American Indian adults who would likely benefit from earlier AF screening. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03740477.
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Affiliation(s)
- Stavros Stavrakis
- Heart Rhythm Institute University of Oklahoma Health Sciences Center Oklahoma City OK
| | - Khaled Elkholey
- Heart Rhythm Institute University of Oklahoma Health Sciences Center Oklahoma City OK
| | | | - Zain U A Asad
- Heart Rhythm Institute University of Oklahoma Health Sciences Center Oklahoma City OK
| | - Lancer D Stephens
- Oklahoma Shared Clinical and Translational Resources Center Oklahoma City OK
| | - Ben Freedman
- Heart Research Institute Charles Perkins Centre University of Sydney Australia
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30
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Ma M, Hyun K, D'Souza M, Chew D, Brieger D. Missed Opportunities to Initiate Oral Anticoagulant in Atrial Fibrillation: Insights from Australian Acute Coronary Syndrome Registries. Heart Lung Circ 2021; 30:1157-1165. [PMID: 33642171 DOI: 10.1016/j.hlc.2021.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 11/29/2020] [Accepted: 01/07/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Many patients with atrial fibrillation (AF) do not receive oral anticoagulant (OAC) therapy. The aims of this study were to 1) document receipt of OAC among patients with a history of AF admitted with an acute coronary syndrome (ACS); and to 2) determine whether hospital admission was associated with an improvement in prescription of OAC therapy. METHODS Using Australian data from the Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE) and Global Registry of Acute Coronary Events (GRACE) registries, 1,479 patients with a history of AF presenting with an ACS were separated into two groups: aspirin monotherapy/no therapy (No OAC) or oral anticoagulant ± aspirin (OAC). Clinical characteristics and in-hospital treatments and outcomes were compared. RESULTS Of 1,479 patients, 532 (36%) with a history of AF presented on OAC with the remainder receiving antiplatelet (n=580 [39%]) or no antithrombotic therapy (n=367 [25%]). Treatment with OAC prior to presentation increased during the 18 years of the study (27% to 56%, p=0.0002). Ninety-five per cent (95%) of the OAC group had a CHA2DS2-VA score >1 vs 88% of the No OAC group (p<0.001). Patients receiving OAC had a lower prevalence of bleeding risk factors than no OAC patients (p<0.001). Only 39% of this cohort was discharged on an OAC, although this increased during the observational period (26-61%, p≤0.0001). CONCLUSION In patients presenting with an ACS with a history of AF, receipt of OAC has improved over time but remains suboptimal. There is minimal escalation in provision of OAC therapy during hospital care, indicating missed opportunities to address this evidence practice gap.
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Affiliation(s)
- Miles Ma
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Karice Hyun
- ANZAC Research Institute, University of Sydney, Sydney, NSW, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Mario D'Souza
- Sydney Local Health District Clinical Research Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Derek Chew
- Department of Cardiology, Flinders University, Adelaide, SA, Australia
| | - David Brieger
- Department of Cardiology, Concord Hospital, Sydney, NSW, Australia.
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31
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Giskes K, Lowres N, Li J, Orchard J, Hespe C, Freedman B. Atrial fibrillation self screening, management and guideline recommended therapy (AF SELF SMART): A protocol for atrial fibrillation self-screening in general practice. IJC HEART & VASCULATURE 2021; 32:100683. [PMID: 33364334 PMCID: PMC7750156 DOI: 10.1016/j.ijcha.2020.100683] [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: 09/20/2020] [Revised: 11/17/2020] [Accepted: 11/23/2020] [Indexed: 11/01/2022]
Abstract
BACKGROUND Opportunistic screening for silent atrial fibrillation (AF) is recommended to reduce stroke, but screening rates are sub-optimal in general practice. We hypothesize that patient self-screening in the waiting room may improve screening and detection of AF. METHODS AND ANALYSES This proof-of-concept study tests a purpose-designed AF self-screening station and customised software which seamlessly integrates with general practice electronic medical records and workflow. The self-screening station records a lead-1 ECG. The software automatically (1) identifies eligible patients (aged ≥65 years, no AF diagnosis) from the practice appointment diary; (2) sends eligible patients an automated SMS reminder prior to their appointment; (3) creates individualised QR code to scan at self-screening station; and (4) imports the ECG and result directly into the patients' electronic medical record. Between 5 and 8 general practices in New South Wales, Australia, will participate with an aim of 1500 patients undertaking self-screening. The main outcome measures will be the proportion of eligible patients that undertook self-screening, incidence of newly-diagnosed AF, and patient and staff experience of the self-screening process. De-identified data will be collected using a clinical audit tool, and qualitative interviews will determine patient and staff acceptability. ETHICS AND DISSEMINATION Ethics approval was received from the University of Sydney Human Research Ethics Committee in June 2019 (Project no: 2019/382) and the University of Notre Dame Human Research Ethics Committee (Project no: 019145S) in October 2019. Results will be disseminated through various forums, including peer-reviewed publication and conference presentations.Trial registration numberACTRN12620000233921.
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Affiliation(s)
- Katrina Giskes
- Department of General Practice, School of Medicine, University of Notre Dame, Sydney, Australia
- Sydney Medical School and Charles Perkins Centre, University of Sydney, Sydney, Australia
- Heart Research Institute, Sydney, New South Wales, Australia
| | - Nicole Lowres
- Sydney Medical School and Charles Perkins Centre, University of Sydney, Sydney, Australia
- Heart Research Institute, Sydney, New South Wales, Australia
| | - Jialin Li
- Sydney Medical School and Charles Perkins Centre, University of Sydney, Sydney, Australia
- Heart Research Institute, Sydney, New South Wales, Australia
| | - Jessica Orchard
- Sydney Medical School and Charles Perkins Centre, University of Sydney, Sydney, Australia
- Heart Research Institute, Sydney, New South Wales, Australia
| | - Charlotte Hespe
- Department of General Practice, School of Medicine, University of Notre Dame, Sydney, Australia
| | - Ben Freedman
- Sydney Medical School and Charles Perkins Centre, University of Sydney, Sydney, Australia
- Heart Research Institute, Sydney, New South Wales, Australia
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Benjamin EJ, Go AS, Desvigne-Nickens P, Anderson CD, Casadei B, Chen LY, Crijns HJ, Freedman B, Hills MT, Healey JS, Kamel H, Kim DY, Link MS, Lopes RD, Lubitz SA, McManus DD, Noseworthy PA, Perez MV, Piccini JP, Schnabel RB, Singer DE, Tieleman R, Turakhia MP, Van Gelder IC, Cooper LS, Al-Khatib SM. Research Priorities in Atrial Fibrillation Screening: A Report From a National Heart, Lung, and Blood Institute Virtual Workshop. Circulation 2021; 143:372-388. [PMID: 33493033 PMCID: PMC8776506 DOI: 10.1161/circulationaha.120.047633] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Clinically recognized atrial fibrillation (AF) is associated with higher risk of complications, including ischemic stroke, cognitive decline, heart failure, myocardial infarction, and death. It is increasingly recognized that AF frequently is undetected until complications such as stroke or heart failure occur. Hence, the public and clinicians have an intense interest in detecting AF earlier. However, the most appropriate strategies to detect undiagnosed AF (sometimes referred to as subclinical AF) and the prognostic and therapeutic implications of AF detected by screening are uncertain. Our report summarizes the National Heart, Lung, and Blood Institute's virtual workshop focused on identifying key research priorities related to AF screening. Global experts reviewed major knowledge gaps and identified critical research priorities in the following areas: (1) role of opportunistic screening; (2) AF as a risk factor, risk marker, or both; (3) relationship between AF burden detected with long-term monitoring and outcomes/treatments; (4) designs of potential randomized trials of systematic AF screening with clinically relevant outcomes; and (5) role of AF screening after ischemic stroke. Our report aims to inform and catalyze AF screening research that will advance innovative, resource-efficient, and clinically relevant studies in diverse populations to improve the diagnosis, management, and prognosis of patients with undiagnosed AF.
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Affiliation(s)
- Emelia J. Benjamin
- Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, and Department of Epidemiology, Boston University School of Public Health, Boston, MA 02118 (E.J.B.)
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612. Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, CA 94143. Departments of Medicine, Health Research and Policy, Stanford University, Stanford, CA 94305 (A.S.G.)
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892 (P.D.N., L.S.C.)
| | - Christopher D. Anderson
- Department of Neurology, Center for Genomic Medicine, and McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA 02114 (C.D.A.)
| | - Barbara Casadei
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX39DU, UK (B.C.)
| | - Lin Y. Chen
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN 55455 (L.Y.C.)
| | - Harry J.G.M. Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands (H.J.G.M.C.)
| | - Ben Freedman
- Heart Research Institute, Charles Perkins Centre, and Concord Hospital Department of Cardiology, Concord Clinical School, University of Sydney, Sydney, Australia (B.F.)
| | - Mellanie True Hills
- StopAfib.org, American Foundation for Women’s Health, Decatur, TX 76234 (M.T.H.)
| | - Jeff S. Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.S.H.)
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY 10021 (H.K.)
| | - Dong-Yun Kim
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892 (D.Y.K.)
| | - Mark S. Link
- Department of Medicine, Division of Cardiology, UT Southwestern Medical Center, Dallas, TX 75390 (M.S.L.)
| | - Renato D. Lopes
- Division of Cardiology and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, 27710 (R.D.L., J.P.P., S.M.A.)
| | - Steven A. Lubitz
- Cardiovascular Research Center and Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA (S.A.L.)
| | - David D. McManus
- Department of Medicine, Division of Cardiology, University of MA Medical School, Worcester, MA 01655 (D.D.M.)
| | - Peter A. Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902 (P.A.N.)
| | - Marco V. Perez
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA 95125 (M.V.P.)
| | - Jonathan P. Piccini
- Division of Cardiology and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, 27710 (R.D.L., J.P.P., S.M.A.)
| | - Renate B. Schnabel
- Department of Cardiology, University Heart Center Hamburg, Hamburg, Germany; DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck (R.B.S.)
| | - Daniel E. Singer
- Division of General Internal Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, MA, 02114 (D.E.S.)
| | - Robert Tieleman
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands (I.C.V.G, R.T.)
- Department of Cardiology, Martini Hospital, Groningen, The Netherlands (R.T.)
| | - Mintu P. Turakhia
- Veterans Affairs Palo Alto Health Care System, Palo Alto CA; Center for Digital Health, Stanford University, Stanford, CA (M.P.T.)
| | - Isabelle C. Van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands (I.C.V.G, R.T.)
| | - Lawton S. Cooper
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892 (P.D.N., L.S.C.)
| | - Sana M. Al-Khatib
- Division of Cardiology and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, 27710 (R.D.L., J.P.P., S.M.A.)
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Ng VWS, Siu CW, Chiu PKC, Kng CPL, Jamieson E, Wong ICK, Lam MPS. Understanding the barriers to using oral anticoagulants among long-term aspirin users with atrial fibrillation - a qualitative study. BMC Health Serv Res 2020; 20:1084. [PMID: 33238989 PMCID: PMC7691100 DOI: 10.1186/s12913-020-05947-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite international treatment guidelines currently advocating oral anticoagulants (OACs) as the only appropriate stroke prevention therapy for patients with atrial fibrillation (AF) and evidence that OACs can greatly reduce the risk of stroke with similar risk of bleeding compared with aspirin, the underuse of OACs in patients with AF is common globally, especially in Asia. This study aimed to identify the barriers to prescribing and using OACs among long-term aspirin users with AF. METHOD Face-to-face interviews were conducted with fourteen eligible patients with AF using a semi-structured interview guide. The interview recordings were transcribed verbatim and data was analyzed according to the principles of thematic analysis. RESULTS Five themes were developed: awareness of AF symptoms and diagnosis; knowledge and understanding of AF and stroke prevention therapy; role of decision-making in prescribing; willingness to switch from aspirin to OACs; and impact of OAC regimen on daily living. The majority of the patients were not aware of the symptoms and diagnosis of AF and only had a vague understanding of the illness and stroke prevention therapy, leading to their minimal involvement in decisions relating to their treatment. Some patients and their caregivers were particularly concerned about the bleeding complications from OACs and perceived aspirin to be a suitable alternative as they find the adverse effects from aspirin manageable and so preferred to remain on aspirin if switching to OACs was not compulsory. Lastly, the lifestyle modifications required when using warfarin, e.g. alternative dosing regimen, diet restriction, were seen as barriers to some patients and caregivers. CONCLUSION The findings revealed patients' knowledge gap in AF management which may be targeted using educational interventions to improve patients' understanding of AF and its management and hence encourage active participation in the decision-making of their treatment in the future.
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Affiliation(s)
- Vanessa W S Ng
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
| | - Chung-Wah Siu
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Patrick K C Chiu
- Division of Geriatrics, Department of Medicine, Queen Mary Hospital, Hong Kong SAR, China
| | - Carolyn P L Kng
- Division of Geriatrics, Ruttonjee and Tang Shiu Kin Hospitals, Hong Kong SAR, China
| | - Elizabeth Jamieson
- Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
| | - Ian C K Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China.,Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
| | - May P S Lam
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China.
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Waranugraha Y, Rizal A, Setiawan D, Aziz IJ. Additional complex fractionated atrial electrogram ablation does not improve the outcomes of non-paroxysmal atrial fibrillation: A systematic review and meta-analysis of randomized controlled trials. Indian Heart J 2020; 73:63-73. [PMID: 33714411 PMCID: PMC7961253 DOI: 10.1016/j.ihj.2020.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/04/2020] [Accepted: 11/03/2020] [Indexed: 12/19/2022] Open
Abstract
Background Non-paroxysmal atrial fibrillation (AF) has a complex pathophysiological process. The standard catheter ablation approach is pulmonary vein isolation (PVI). The additional value of complex fractionated electrogram (CFAE) ablation is still unclear. We aimed to investigate the additional value of CFAE ablation for non-paroxysmal AF. Methods We performed a systematic review and meta-analysis of randomized controlled studies up to May 2020. Articles comparing pulmonary vein isolation (PVI) plus CFAE ablation and PVI alone for AF were obtained from the electronic scientific databases. The pooled mean difference (MD) and pooled risk ratio (RR) were assessed. Results A total of 8 randomized controlled trials (RCTs) including 1034 patients were involved. Following a single catheter ablation procedure, the presence of any atrial tachyarrhythmia (ATA) with or without the use of antiarrhythmic drugs (AADs) between both groups were not significantly different (RR = 1.1; 95% confidence interval [CI] = 0.97–1.24; p = 0.13). Similar results were also obtained for the presence of any ATA without the use of AADs (RR = 1.08; 95% CI = 0.96–1.22; p = 0.2). The additional CFAE ablation took longer procedure times (MD = 46.95 min; 95% CI = 38.27–55.63; p = < 0.01) and fluoroscopy times (MD = 11.69 min; 95% CI = 8.54–14.83; p = < 0.01). Conclusion Additional CFAE ablation failed to improve the outcomes of non-paroxysmal AF patients. It also requires a longer duration of procedure times and fluoroscopy times.
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Affiliation(s)
- Yoga Waranugraha
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia; Brawijaya Cardiovascular Research Center, Malang, Indonesia.
| | - Ardian Rizal
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia; Brawijaya Cardiovascular Research Center, Malang, Indonesia
| | - Dion Setiawan
- Brawijaya Cardiovascular Research Center, Malang, Indonesia
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Freedman B, Kamel H, Van Gelder IC, Schnabel RB. Atrial fibrillation: villain or bystander in vascular brain injury. Eur Heart J Suppl 2020; 22:M51-M59. [PMID: 33664640 PMCID: PMC7916423 DOI: 10.1093/eurheartj/suaa166] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Atrial fibrillation (AF) and stroke are inextricably connected, with classical Virchow pathophysiology explaining thromboembolism through blood stasis in the fibrillating left atrium. This conceptualization has been reinforced by the remarkable efficacy of oral anticoagulant (OAC) for stroke prevention in AF. A number of observations showing that the presence of AF is neither necessary nor sufficient for stroke, cast doubt on the causal role of AF as a villain in vascular brain injury (VBI). The requirement for additional risk factors before AF increases stroke risk; temporal disconnect of AF from a stroke in patients with no AF for months before stroke during continuous ECG monitoring but manifesting AF only after stroke; and increasing recognition of the role of atrial cardiomyopathy and atrial substrate in AF-related stroke, and also stroke without AF, have led to rethinking the pathogenetic model of cardioembolic stroke. This is quite separate from recognition that in AF, shared cardiovascular risk factors can lead both to non-embolic stroke, or emboli from the aorta and carotid arteries. Meanwhile, VBI is now expanded to include dementia and cognitive decline: research is required to see if reduced by OAC. A changed conceptual model with less focus on the arrhythmia, and more on atrial substrate/cardiomyopathy causing VBI both in the presence or absence of AF, is required to allow us to better prevent AF-related VBI. It could direct focus towards prevention of the atrial cardiomyopathy though much work is required to better define this entity before the balance between AF as villain or bystander can be determined.
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Affiliation(s)
- Ben Freedman
- Heart Research Institute, Charles Perkins Centre and Concord Hospital Department of Cardiology, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Renate B Schnabel
- University Heart and Vascular Centre, Department of Cardiology, Hamburg, Germany; German Centre for Cardiovascular Research (DZHK e.V.), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
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Hermans ANL, van der Velden RMJ, Gawalko M, Verhaert DVM, Desteghe L, Duncker D, Manninger M, Heidbuchel H, Pisters R, Hemels M, Pison L, Sohaib A, Sultan A, Steven D, Wijtvliet P, Tieleman R, Gupta D, Dobrev D, Svennberg E, Crijns HJGM, Pluymaekers NAHA, Hendriks JM, Linz D. On-demand mobile health infrastructures to allow comprehensive remote atrial fibrillation and risk factor management through teleconsultation. Clin Cardiol 2020; 43:1232-1239. [PMID: 33030259 PMCID: PMC7661648 DOI: 10.1002/clc.23469] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 01/07/2023] Open
Abstract
Background Although novel teleconsultation solutions can deliver remote situations that are relatively similar to face‐to‐face interaction, remote assessment of heart rate and rhythm as well as risk factors remains challenging in patients with atrial fibrillation (AF). Hypothesis. Mobile health (mHealth) solutions can support remote AF management. Methods Herein, we discuss available mHealth tools and strategies on how to incorporate the remote assessment of heart rate, rhythm and risk factors to allow comprehensive AF management through teleconsultation. Results Particularly, in the light of the coronavirus disease 2019 (COVID‐19) pandemic, there is decreased capacity to see patients in the outpatient clinic and mHealth has become an important component of many AF outpatient clinics. Several validated mHealth solutions are available for remote heart rate and rhythm monitoring as well as for risk factor assessment. mHealth technologies can be used for (semi‐)continuous longitudinal monitoring or for short‐term on‐demand monitoring, dependent on the respective requirements and clinical scenarios. As a possible solution to improve remote AF care through teleconsultation, we introduce the on‐demand TeleCheck‐AF mHealth approach that allows remote app‐based assessment of heart rate and rhythm around teleconsultations, which has been developed and implemented during the COVID‐19 pandemic in Europe. Conclusion Large scale international mHealth projects, such as TeleCheck‐AF, will provide insight into the additional value and potential limitations of mHealth strategies to remotely manage AF patients. Such mHealth infrastructures may be well suited within an integrated AF‐clinic, which may require redesign of practice and reform of health care systems.
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Affiliation(s)
| | | | - Monika Gawalko
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Dominique V M Verhaert
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.,Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lien Desteghe
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.,Heart Center Hasselt, Jessa Hospital, Hasselt, Belgium.,Department of Cardiology, Antwerp University Hospital and Antwerp University, Antwerp, Belgium
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Martin Manninger
- Department of Cardiology, Medizinische Universität Graz, Graz, Austria
| | - Hein Heidbuchel
- Department of Cardiology, Antwerp University Hospital and Antwerp University, Antwerp, Belgium
| | - Ron Pisters
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Martin Hemels
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Laurent Pison
- Department of Cardiology, Hospital East Limburg, Genk, Belgium
| | - Afzal Sohaib
- Department of Cardiology, St Bartholomew's Hospital, Bart's Health NHS Trust, London, UK.,Department of Cardiology, King George Hospital, London, UK
| | - Arian Sultan
- Department of Electrophysiology, Heart Center, University Hospital Cologne, Cologne, Germany
| | - Daniel Steven
- Department of Electrophysiology, Heart Center, University Hospital Cologne, Cologne, Germany
| | - Petra Wijtvliet
- Department of Cardiology, Martini Hospital, Groningen, The Netherlands
| | - Robert Tieleman
- Department of Cardiology, Martini Hospital, Groningen, The Netherlands
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Dobromir Dobrev
- Institute of Pharmacology, West German Heart and Vascular Centre, University Duisburg-Essen, Essen, Germany
| | - Emma Svennberg
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Nikki A H A Pluymaekers
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Jeroen M Hendriks
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia.,College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Dominik Linz
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.,Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia.,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Sim V, Galbraith K. Effectiveness of multimedia interventions in the provision of patient education on anticoagulation therapy: A review. PATIENT EDUCATION AND COUNSELING 2020; 103:2009-2017. [PMID: 32532633 DOI: 10.1016/j.pec.2020.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 04/30/2020] [Accepted: 05/03/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE A literature review was conducted to identify available evidence on the use of multimedia patient educational interventions on anticoagulation therapy. METHODS A literature search was conducted on 9/4/2020 via six research databases. Publications that evaluated the effects of these interventions on anticoagulation therapy were included. RESULTS The review included ten original research studies (five randomized controlled trials, four observational studies and a pre- and post-interventional study), a systematic review and meta-analysis, three systematic reviews, a scoping review, and a literature review. Multimedia interventions significantly improved knowledge after education, but no significant differences found when compared to traditional methods. There was insufficient evidence to conclude whether knowledge retained over time. Patients were equally satisfied with both methods. Multimedia interventions significantly reduced healthcare professional's time required for education. Heterogeneity in intervention, methodology and results limited comparison and combination of findings across studies. CONCLUSION Multimedia patient educational interventions on anticoagulation therapy have similar outcomes to traditional methods in knowledge improvement and satisfaction, but they save health personnel time. PRACTICE IMPLICATIONS There is lack of evidence to support the effectiveness of multimedia interventions in educating patients on anticoagulation therapy. Larger randomized studies evaluating their benefits in health outcomes and clinical practice are warranted.
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Affiliation(s)
- Valerie Sim
- Royal Adelaide Hospital, Pharmacy Department, 1 Port Road, Adelaide, South Australia 5000, Australia.
| | - Kirsten Galbraith
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia.
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Abstract
AF is associated with an increased risk of thromboembolic events, which is usually managed with oral anticoagulation therapy. However, despite a broad range of anticoagulant options and improved uptake in anticoagulation over the past decade, there are some limitations to this approach. Percutaneous left atrial appendage occlusion has been shown to be an effective alternative in this setting, and population data suggest a clear demand for this procedure. Over the past decade, several important changes to the commissioning and delivery of this service have occurred in the UK. In this article, the authors describe the use of percutaneous left atrial appendage occlusion in the UK and discuss the challenges that lie ahead.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
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Ding WY, Mandrola J, Gupta D. Left Atrial Appendage Occlusion: Past, Present and Future. Thromb Haemost 2020; 120:1484-1491. [DOI: 10.1055/s-0040-1714654] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AbstractThere are several situations whereby oral anticoagulation may be unsuitable for stroke prevention in patients with atrial fibrillation (AF). Percutaneous left atrial appendage (LAA) occlusion has received much attention in this area. Various devices have already been developed and tested for this purpose. Data from registries and cohort studies have indicated favourable short- and long-term outcomes with LAA occlusion, and several international guidelines recommend its use in AF patients with contraindications to oral anticoagulation. However, prospective controlled trials in this very population are lacking. Furthermore, while modelling studies on cost analyses have suggested that LAA occlusion may be a cost-effective strategy compared with standard medical therapy, these have not been performed in high-risk patients who may have limited survival in the medium to long term. Thus, while LAA occlusion offers promise, there is a strong need for additional research to investigate its exact role, its long-term outcomes and cost efficacy.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, Department of Cardiology, University of Liverpool, Liverpool, United Kingdom
- Department of Cardiology, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - John Mandrola
- Department of Cardiology, Baptist Health Louisville, Louisville, Kentucky, United States
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, Department of Cardiology, University of Liverpool, Liverpool, United Kingdom
- Department of Cardiology, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
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Diagnostic accuracy of handheld electrocardiogram devices in detecting atrial fibrillation in adults in community versus hospital settings: a systematic review and meta-analysis. Heart 2020; 106:1211-1217. [DOI: 10.1136/heartjnl-2020-316611] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/20/2020] [Accepted: 03/29/2020] [Indexed: 02/06/2023] Open
Abstract
With increasing use of handheld ECG devices for atrial fibrillation (AF) screening, it is important to understand their accuracy in community and hospital settings and how it differs among settings and other factors. A systematic review of eligible studies from community or hospital settings reporting the diagnostic accuracy of handheld ECG devices (ie, devices producing a rhythm strip) in detecting AF in adults, compared with a gold standard 12-lead ECG or Holter monitor, was performed. Bivariate hierarchical random-effects meta-analysis and meta-regression were performed using R V.3.6.0. The search identified 858 articles, of which 14 were included. Six studies recruited from community (n=6064 ECGs) and eight studies from hospital (n=2116 ECGs) settings. The pooled sensitivity was 89% (95% CI 81% to 94%) in the community and 92% (95% CI 83% to 97%) in the hospital. The pooled specificity was 99% (95% CI 98% to 99%) in the community and 95% (95% CI 90% to 98%) in the hospital. Accuracy of ECG devices varied: sensitivity ranged from 54.5% to 100% and specificity ranged from 61.9% to 100%. Meta-regression showed that setting (p=0.032) and ECG device type (p=0.022) significantly contributed to variations in sensitivity and specificity. The pooled sensitivity and specificity of single-lead handheld ECG devices were high. Setting and handheld ECG device type were significant factors of variation in sensitivity and specificity. These findings suggest that the setting including user training and handheld ECG device type should be carefully reviewed.
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Screening for atrial fibrillation and other arrhythmias in primary care. BMC FAMILY PRACTICE 2020; 21:79. [PMID: 32375662 PMCID: PMC7201749 DOI: 10.1186/s12875-020-01151-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 04/26/2020] [Indexed: 02/07/2023]
Abstract
Background Atrial fibrillation (AF) and other arrhythmias are prevalent and often encountered by general practitioners (GPs). In response to the growing prevalence and to assist practitioners in the diagnosis and management of AF, the Cardiac Society of Australia & New Zealand and Heart Foundation of Australia published the first Australian AF Guidelines in 2018. We aimed to examine (a) the proportion of GPs who performed any form of AF screening and identify the methods they applied, (b) GPs’ awareness of the AF Guidelines and approaches to arrhythmia screening, (c) the roles of conventional 12-lead ECG and mobile health devices, and (d) GPs’ confidence in ECG interpretation and need for training. Methods A cross-sectional online survey titled “GPs Screen their patients for Atrial Fibrillation and othEr aRrhythmia (GPSAFER)” was conducted from October 2018 to March 2019. The participants were recruited via various GP networks across Australia. Ethics approval was granted by The University of Sydney. Results A total of 463 surveys were completed. Many GPs (394/463, 85.1%, 95% CI 81.5–88.2%) performed some forms of AF screening and applied at least one AF screening method, most frequently pulse palpation (389/463, 84.0%). Some (299/463, 64.6%) GPs considered assessing their patients for other arrhythmias (237/299, 79.3% for complete heart block and 236/299, 78.9% for long-QT). Most GPs (424/463, 91.6%) were not using mobile ECG devices in their practice but some (147/463, 31.7%) were contemplating it. One third (175/463, 37.8%) of GPs were aware of the Australian AF Guidelines; those aware were more likely to perform AF screening (98.9% vs 76.7%, p < 0.001). Factors significantly and positively associated with AF screening were “awareness of the AF Guidelines” (p < 0.001), “number of years working in general practice” (p < 0.001), and “confidence in ECG interpretation of AF” (p = 0.003). Most GPs reported that they were very or extremely confident in interpreting AF (381/463, 82.3%) and complete heart block (266/463, 57.5%). Many GPs (349/463, 75.4%) would like to receive online ECG interpretation training. Conclusions Assessment of arrhythmias is common in general practice and GPs are open to further training in ECG interpretation and using mobile ECG devices to aid their clinical practice. Increasing awareness of AF Guidelines and improving confidence in ECG interpretation may increase AF screening.
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Zhao J, Zhou D, Chen M, Zhuo C, Lin Z, Zheng L, Wang Q. CHA2DS2-VASc and SAMe-TT2R2 scores as predictors of recurrence for nonvalvular atrial fibrillation patients on vitamin K antagonists after radiofrequency catheter ablation. J Cardiovasc Med (Hagerstown) 2020; 21:200-208. [PMID: 31977539 DOI: 10.2459/jcm.0000000000000930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Atrial fibrillation is the most common sustained arrhythmia in the general population, and circumferential pulmonary vein isolation has emerged as a cornerstone in the treatment of drug-resistant atrial fibrillation. However, there is a paucity of data regarding the CHA2DS2-VASc and SAMe-TT2R2 scores as predictors of outcomes among patients with nonvalvular atrial fibrillation on vitamin K antagonists after radiofrequency catheter ablation (RFCA). METHODS The current prospective observational study enrolled 304 consecutive patients with atrial fibrillation who underwent RFCA. Warfarin was maintained for at least 3 months after RFCA. The 1-year atrial fibrillation recurrence rate was documented. RESULTS Persistent atrial fibrillation (P = 0.003), heart failure (P < 0.001), an enlarged left atrium (P = 0.003), current smoking (P < 0.001), the CHA2DS2-VASc score (P = 0.001), and the SAMe-TT2R2 score (P < 0.001) were univariate associated with recurrent atrial fibrillation. Cutoff analysis showed that a CHA2DS2-VASc score at least 3 (areas under the curve = 0.612; 95% confidence interval 0.537-0.687) and a SAMe-TT2R2 score at least 5 (areas under the curve = 0.642, 95% confidence interval 0.575-0.708) had the highest predictive value for atrial fibrillation recurrence. Patients with a CHA2DS2-VASc score at least 3 (P < 0.001) and a SAMe-TT2R2 score at least 5 (P = 0.001) had a higher probability of experiencing atrial fibrillation recurrence after RFCA compared with patients with a CHA2DS2-VASc score less than 3 and a SAMe-TT2R2 score less than 5. CONCLUSION CHA2DS2-VASc and SAMe-TT2R2 scores were associated with 1-year recurrence of atrial fibrillation in patients on vitamin K antagonists after RFCA. For CHA2DS2-VASc and SAMe-TT2R2 scores, a cutoff value of at least 3 and at least 5 had the highest predictive value for atrial fibrillation recurrence, respectively.
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Affiliation(s)
- Jianqiang Zhao
- Department of Cardiology and Atrial Fibrillation Center of The First Affiliated Hospital of Zhejiang University, Hangzhou
| | - Dongchen Zhou
- Department of Cardiology and Atrial Fibrillation Center of The First Affiliated Hospital of Zhejiang University, Hangzhou
| | - Miao Chen
- Department of Cardiology and Atrial Fibrillation Center of The First Affiliated Hospital of Zhejiang University, Hangzhou
| | - Chengui Zhuo
- Department of Cardiology and Atrial Fibrillation Center of The First Affiliated Hospital of Zhejiang University, Hangzhou
| | - Zhongyuan Lin
- Department of Cardiology of Haining People's Hospital of Zhejiang Province, Jiaxing, Zhejiang Province, People's Republic of China
| | - Liangrong Zheng
- Department of Cardiology and Atrial Fibrillation Center of The First Affiliated Hospital of Zhejiang University, Hangzhou
| | - Qiqi Wang
- Department of Cardiology and Atrial Fibrillation Center of The First Affiliated Hospital of Zhejiang University, Hangzhou
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Choo A, Bragagnolo A, Ekanayake SKDM, Alghamry A. Sustained resolution of anticoagulation related iron deficiency anemia with the use of apixaban. Clin Case Rep 2020; 8:127-131. [PMID: 31998502 PMCID: PMC6982485 DOI: 10.1002/ccr3.2585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 10/13/2019] [Accepted: 10/31/2019] [Indexed: 11/25/2022] Open
Abstract
Successful resolution of iron deficiency anemia in the context of anticoagulation with rivaroxaban was seen when apixaban is used alternatively. Prospective cohort studies utilizing similar or different approaches are required.
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Affiliation(s)
- Alex Choo
- Internal Medicine ServicesThe Prince Charles HospitalChermsideQldAustralia
- Faculty of MedicineThe University of QueenslandBrisbaneQldAustralia
| | | | - Siyaguna K. D. M. Ekanayake
- School of MedicineGriffith UniversityGold CoastQldAustralia
- Intensive Care UnitThe Holy Spirit Northside Private HospitalBrisbaneQldAustralia
| | - Alaa Alghamry
- Internal Medicine ServicesThe Prince Charles HospitalChermsideQldAustralia
- Faculty of MedicineThe University of QueenslandBrisbaneQldAustralia
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Tomasdottir M, Friberg L, Hijazi Z, Lindbäck J, Oldgren J. Risk of ischemic stroke and utility of CHA 2 DS 2 -VASc score in women and men with atrial fibrillation. Clin Cardiol 2019; 42:1003-1009. [PMID: 31490011 PMCID: PMC6788468 DOI: 10.1002/clc.23257] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 08/07/2019] [Accepted: 08/26/2019] [Indexed: 12/15/2022] Open
Abstract
Background The magnitude of increased risk of stroke in women with atrial fibrillation (AF) remains uncertain. Hypothesis We investigated the risk of ischemic stroke and death in women and men with AF, and the risk associated with individual non‐sex CHA2DS2‐VASc risk factors. Methods Retrospective cohort study of 231 077 (48.1% women) nonselected patients with AF not receiving oral anticoagulation from 2006 to 2014. Data from cross‐linked national Swedish registers. The outcome was the first occurrence of ischemic stroke or death. Median age was 82 and 75 years in women and men, respectively. Mean follow‐up was 2.5 years. Results Hazard ratios, adjusted for non‐sex CHA2DS2‐VASc risk factors, for women vs men were 1.53, 95% CI: 1.49‐1.58 for ischemic stroke and 1.24, 95% CI: 1.22‐1.26 for death, respectively. When divided into age groups the differences in ischemic stroke rates between women and men were attenuated. In patients with only one non‐sex CHA2DS2‐VASc risk factor allotted 1 point, ischemic stroke rates per 100 person‐years were 1.22 in women (n = 9838) and 1.02 in men (n = 15 609), respectively, P < .006. In both women and men, age of 65 to 74 years was associated with higher ischemic stroke risk compared to other non‐sex CHA2DS2‐VASc risk factors allotted 1 point. Conclusions The risk of ischemic stroke was 1.5‐fold higher in women compared to men but this association appears to be the result of confounding by age. In the low risk end, the CHA2DS2‐VASc risk score underestimates the ischemic stroke risk conferred by age 65 to 74 years, while it overestimates the risk conferred by female sex.
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Affiliation(s)
| | - Leif Friberg
- Department of Clinical Sciences at Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Ziad Hijazi
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Johan Lindbäck
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Jonas Oldgren
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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Yiu A, Bajorek B. Patient-focused interventions to support vulnerable people using oral anticoagulants: a narrative review. Ther Adv Drug Saf 2019; 10:2042098619847423. [PMID: 31205676 PMCID: PMC6535713 DOI: 10.1177/2042098619847423] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 04/01/2019] [Indexed: 12/18/2022] Open
Abstract
The aim of this review was to identify patient-focused interventions that have been trialed to support vulnerable patient populations taking oral anticoagulants (warfarin and the direct-acting oral anticoagulants (DOACs)) such as older persons (65 years and over), those with limited health literacy, and those from culturally and linguistically diverse (CALD) backgrounds. This review also aimed to report on the effects of these interventions on outcomes relevant to the use of anticoagulant therapy. Original articles published between 1 January 1995 and 30 June 2017 were identified using several electronic databases such as Medline, Ovid, Embase, Scopus, Cochrane, and Google Scholar. The following terms were used for the three-tiered search: Tier 1, elderly, aged, older adult, geriatrics; Tier 2, health literacy, literacy, low health literacy, low English proficiency, patient literacy; and Tier 3, ethnicity, ethnic, ethnic groups, CALD, culturally and linguistically diverse, NESB, non-English speaking background, race, racial groups, religion, religious groups, and minority groups. The terms for each tier were combined with the following terms: anticoagulants, anticoagulation, warfarin, apixaban, dabigatran, rivaroxaban, DOACS, new oral anticoagulants, novel oral anticoagulants, patient care, patient knowledge, comprehension, patient education, patient participation, and communication. A total of 41 studies were identified. Most of the interventions identified included older persons taking warfarin who were monitored using the international normalized ratio (INR) and who received patient education. Many interventions reported a significant positive impact on patients' knowledge, reduction in the number of adverse events caused by hemorrhage, and better INR control. More research on patient-focused interventions is needed that includes patients with limited health literacy, those from CALD backgrounds, and family members and caregivers of patients taking oral anticoagulants.
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Affiliation(s)
- Angela Yiu
- Graduate School of Health – Pharmacy, University Technology of Sydney, Level 4, Building 7, 67 Thomas Street, Ultimo, NSW 2007, Australia
| | - Beata Bajorek
- Graduate School of Health – Pharmacy, University of Technology Sydney and Pharmacy Department, Royal North Shore Hospital, Australia
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Atherton JJ, Sindone A, De Pasquale CG, Driscoll A, MacDonald PS, Hopper I, Kistler P, Briffa TG, Wong J, Abhayaratna WP, Thomas L, Audehm R, Newton PJ, OˈLoughlin J, Connell C, Branagan M. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of heart failure 2018. Med J Aust 2018; 209:363-369. [DOI: 10.5694/mja18.00647] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 10/12/2018] [Indexed: 01/14/2023]
Affiliation(s)
- John J Atherton
- Royal Brisbane and Womenˈs Hospital and University of Queensland, Brisbane, QLD
| | | | | | - Andrea Driscoll
- Deakin University, Melbourne, VIC
- Austin Health, Melbourne, VIC
| | | | | | | | | | - James Wong
- Royal Melbourne Hospital, Melbourne, VIC
| | | | | | | | | | | | - Cia Connell
- National Heart Foundation of Australia, Melbourne, VIC
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