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Karaban K, Słupik D, Reda A, Gajewska M, Rolek B, Borovac JA, Papakonstantinou PE, Bongiovanni D, Ehrlinder H, Parker WAE, Siniarski A, Gąsecka A. Coagulation Disorders and Thrombotic Complications in Heart Failure With Preserved Ejection Fraction. Curr Probl Cardiol 2024; 49:102127. [PMID: 37802171 DOI: 10.1016/j.cpcardiol.2023.102127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 09/30/2023] [Indexed: 10/08/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is associated with multiple cardiovascular and noncardiovascular comorbidities and risk factors which increase the risk of thrombotic complications, such as atrial fibrillation, chronic kidney disease, arterial hypertension and type 2 diabetes mellitus. Subsequently, thromboembolic risk stratification in this population poses a great challenge. Since date from the large randomized clinical trials mostly include both patients with truly preserved EF, and those with heart failure with mildly reduced ejection fraction, there is an unmet need to characterize the patients with truly preserved EF. Considering the significant evidence gap in this area, we sought to describe the coagulation disorders and thrombotic complications in patients with HFpEF and discuss the specific thromboembolic risk factors in patients with HFpEF, with the goal to tailor risk stratification to an individual patient.
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Affiliation(s)
- Kacper Karaban
- Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Dorota Słupik
- Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Aleksandra Reda
- Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Magdalena Gajewska
- Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Bartosz Rolek
- Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Josip A Borovac
- Division of Interventional Cardiology, Cardiovascular Diseases Department, University Hospital of Split, Split, Croatia
| | - Panteleimon E Papakonstantinou
- Second Cardiology Department, Evangelismos Hospital, Athens, Greece; First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Dario Bongiovanni
- Department of Internal Medicine I, Cardiology, University Hospital Augsburg, University of Augsburg, Augsburg, Germany; Department of Cardiovascular Medicine, Humanitas Clinical and Research Center IRCCS and Humanitas University, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Department of Cardiovascular Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Hanne Ehrlinder
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - William A E Parker
- Cardiovascular Research Unit, Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - Aleksander Siniarski
- Department of Coronary Artery Disease and Heart Failure, Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, Cracow, Poland; John Paul II Hospital, Cracow, Poland
| | - Aleksandra Gąsecka
- Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland.
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Ehrlinder H, Orsini N, Modig K, Wallén H, Gigante B. Antithrombotic treatment switching in elderly patients with atrial fibrillation and the risk of thromboembolism, bleeding, and cardiac death. Res Pract Thromb Haemost 2022; 6:e12823. [PMID: 36313983 PMCID: PMC9596606 DOI: 10.1002/rth2.12823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/17/2022] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Abstract
Background Risks of antithrombotic switching is not investigated in elderly atrial fibrillation patients. Objectives To investigate the effectiveness and safety of antithrombotic treatment and switching of antithrombotic treatment in elderly patients (aged 75 years or older) with atrial fibrillation (AF). Methods We conducted a cohort study of 2943 patients with AF (Carrebean‐elderly), hospitalized during 2010–2017. Cox models were used to estimate the association of antithrombotic treatment (warfarin, direct oral anticoagulants [DOAC] and non–guideline‐recommended therapy [NG], i.e., aspirin and low‐molecular‐weight heparin) at discharge and antithrombotic treatment switching during follow‐up with the risk of a composite and single end points of thromboembolism, bleeding, and cardiac death. Crude and adjusted risk estimates were expressed as hazard ratios (HRs) with 95% confidence intervals (CIs). All‐cause death was evaluated, with competing risk regression and estimates expressed as subhazard ratios and 95% CIs. Results We observed an increased risk for the composite end point associated with NG as compared to warfarin at discharge (HR, 1.18; 95% CI, 1.01–1.38) with congruent competing risk regression results, while no significant risk difference was seen for DOACs compared to warfarin (HR, 1.12; 95% CI, 0.92–1.36). Switching from NG to warfarin/DOAC and from warfarin to DOAC occurred in 30.4% and 33.1% of respective antithrombotic treatment groups at discharge and was associated with a decreased risk for the composite end point with an adjusted HR of 0.45 (95% CI, 0.32–0.63) and a HR of 0.50 (95% CI, 0.38–0.65), respectively. Conclusions Antithrombotic treatment switching is common in the elderly AF population. Importantly, switching to guideline‐recommended treatment has a favorable impact on both effectiveness and safety.
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Affiliation(s)
- Hanne Ehrlinder
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd HospitalKarolinska InstitutetStockholmSweden
| | - Nicola Orsini
- Department of Public Health SciencesKarolinska InstitutetStockholmSweden
| | - Karin Modig
- Unit of EpidemiologyInstitute of Environmental Medicine, Karolinska InstitutetStockholmSweden
| | - Håkan Wallén
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd HospitalKarolinska InstitutetStockholmSweden
| | - Bruna Gigante
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd HospitalKarolinska InstitutetStockholmSweden,Cardiovascular Medicine Unit, Department of Medicine SolnaKarolinska InstitutetStockholmSweden
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Radnahad N, Ehrlinder H, Leander K, Engdahl J, Wallén H, Gigante B. Is the association of QTc with atrial fibrillation and stroke in cohort studies a matter of time? Open Heart 2022; 9:openhrt-2022-002080. [PMID: 36171000 PMCID: PMC9528598 DOI: 10.1136/openhrt-2022-002080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 09/12/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives To investigate the association of the heart rate-corrected QT interval (QTc) with the risk of atrial fibrillation (AF) and ischaemic stroke. Methods We estimated the risk of AF and ischaemic stroke associated with QTc duration (ms) by Cox regression in study participants from the cohort of 60-year-old men and women from Stockholm (60YO) (n=4232). Univariate and multivariate adjusted risk estimates were expressed as HR and 95% CI. Main results were validated in elderly patients with AF, included in the Carebbean-e study, where an ECG in sinus rhythm (SR) (ECG-SR) recorded before the ECG diagnostic for (ECG-AF) was available (n=803). We estimated the correlation between the time interval (years) between the ECG-SR and ECG-AF with the QTc duration, by the Spearman correlation coefficient (rho). Results In the 60YO, the highest QTc duration quartile (>427 ms) associated with the AF risk (n=435) with a multivariable adjusted HR of 1.68 and 95% CI (1.26 to 2.24). No association was observed with ischaemic stroke. In the Carebbean-e study, no significant association was observed between the QTc duration measured on the ECG-SR and risk of ischaemic stroke during follow-up. QTc duration showed an inverse correlation (rho: −0.26, p<0.0001) with the time interval intercurred between ECG-SR and ECG-AF. Conclusions The association of QTc duration with AF risk might depend on the time interval between the QTc measurement and the clinical diagnosis of AF. No association was observed between QTc duration and ischaemic stroke.
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Affiliation(s)
- Navid Radnahad
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Hanne Ehrlinder
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Karin Leander
- Unit of Cardiovascular and Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Johan Engdahl
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Wallén
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Bruna Gigante
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden .,Division of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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Giustozzi M, Ehrlinder H, Bongiovanni D, Borovac JA, Guerreiro RA, Gąsecka A, Papakonstantinou PE, Parker WAE. Coagulopathy and sepsis: Pathophysiology, clinical manifestations and treatment. Blood Rev 2021; 50:100864. [PMID: 34217531 DOI: 10.1016/j.blre.2021.100864] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/31/2021] [Accepted: 06/22/2021] [Indexed: 12/13/2022]
Abstract
Sepsis is a complex syndrome with a high incidence, increasing by 8.7% annually over the last 20 years. Coagulopathy is a leading factor associated with mortality in patients with sepsis and range from slight thrombocytopenia to fatal disorders, such as disseminated intravascular coagulation (DIC). Platelet reactivity increases during sepsis but prospective trials of antiplatelet therapy during sepsis have been disappointing. Thrombocytopenia is a known predictor of worse prognosis during sepsis. The mechanisms underlying thrombocytopenia in sepsis have yet to be fully understood but likely involves decreased platelet production, platelet sequestration and increased consumption. DIC is an acquired thrombohemorrhagic syndrome, resulting in intravascular fibrin formation, microangiopathic thrombosis, and subsequent depletion of coagulation factors and platelets. DIC can be resolved with treatment of the underlying disorder, which is considered the cornerstone in the management of this syndrome. This review presents the current knowledge on the pathophysiology, diagnosis, and treatment of sepsis-associated coagulopathies.
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Affiliation(s)
- Michela Giustozzi
- Internal Vascular and Emergency Medicine and Stroke Unit, University of Perugia, Perugia, Italy.
| | - Hanne Ehrlinder
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Dario Bongiovanni
- Technical University of Munich, School of Medicine, University hospital rechts der Isar, Department of Internal Medicine I, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany; Department of Cardiovascular Medicine, Humanitas Clinical and Research Center IRCCS and Humanitas University, Rozzano, Milan, Italy
| | - Josip A Borovac
- Department of Pathophysiology, University of Split School of Medicine, Split, Croatia; Clinic for Cardiovascular Diseases, University Hospital of Split (KBC Split), Split, Croatia
| | | | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Panteleimon E Papakonstantinou
- Second Cardiology Department, Evangelismos Hospital, Athens, Greece; Hypertension Unit "ESH Excellence Centre", First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - William A E Parker
- Cardiovascular Research Unit, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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Papakonstantinou PE, Borovac JA, Gąsecka A, Bongiovanni D, Ehrlinder H, Giustozzi M, Parker WAE, Guerreiro RA. Anticoagulation therapy in non-valvular atrial fibrillation in the COVID-19 era: is it time to reconsider our therapeutic strategy? Eur J Prev Cardiol 2021; 29:2069-2071. [PMID: 33564838 PMCID: PMC7928961 DOI: 10.1093/eurjpc/zwab021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/19/2021] [Accepted: 01/27/2021] [Indexed: 01/22/2023]
Affiliation(s)
- Panteleimon E Papakonstantinou
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece.,Hypertension Unit "ESH Excellence Centre", First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Josip A Borovac
- Department of Pathophysiology, University of Split School of Medicine, Croatia
| | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Dario Bongiovanni
- Technical University of Munich, School of Medicine, University hospital rechts der Isar, Department of Internal Medicine I, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany.,Department of Cardiovascular Medicine, Humanitas Clinical and Research Center IRCCS and Humanitas University, Rozzano, Milan, Italy
| | - Hanne Ehrlinder
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Michela Giustozzi
- Internal Vascular and Emergency Medicine and Stroke Unit, University of Perugia, Perugia, Italy
| | - William A E Parker
- Cardiovascular Research Unit, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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Ehrlinder H, Orsini N, Modig K, Hofman-Bang C, Wallén H, Gigante B. Clinical characteristics and antithrombotic prescription in elderly hospitalized atrial fibrillation patients: A cross-sectional analysis of a Swedish single-center clinical cohort. Int J Cardiol Heart Vasc 2020; 27:100505. [PMID: 32258363 PMCID: PMC7114891 DOI: 10.1016/j.ijcha.2020.100505] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/27/2020] [Accepted: 03/18/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Antithrombotic treatment represents a dilemma in elderly patients with atrial fibrillation since both risk of thromboembolism and bleeding are age-dependent complications. A paradigm shift occurred over the past 10 years when aspirin was overcome by warfarin and further by the direct oral anticoagulants. Here we present a clinical practice-based analysis of a cohort of elderly inpatient atrial fibrillation patients and investigate the influence of clinical factors in the choice of antithrombotic strategy. METHODS Study participants (n = 2943) are consecutive patients aged 75-104 years discharged from a Swedish university hospital with atrial fibrillation or atrial flutter as main diagnosis between November 1st 2010 and December 31st 2017. Cardiovascular risk factors, comorbidities and antithrombotic treatment at discharge were manually extracted from medical charts. A logistic regression analysis was performed to estimate predictors of the probability to receive direct oral anticoagulants (DOACs) compared to warfarin. RESULTS Patients aged ≥90 y (n = 446, women 73%) showed the highest prevalence of cardiovascular comorbidities and the highest bleeding and thromboembolic risk. DOACs became more commonly prescribed than warfarin in 2016/2017 across all ages. However, the probability to receive DOAC as compared to warfarin was lower in the presence of high bleeding risk (OR 0,55; 95% CI 0,40-0,77; p = 0,00) and high thromboembolic risk (OR 0,74; 95% CI 0,59-0,94; p = 0,01). CONCLUSION Elderly atrial fibrillation patients represent a heterogenous group where the oldest (≥90 years) show both a very high thromboembolic and bleeding risk profile. In the presence of high thromboembolic and bleeding risk, warfarin was still preferred over DOAC.
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Affiliation(s)
- Hanne Ehrlinder
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Nicola Orsini
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Karin Modig
- Unit of Epidemiology. Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Claes Hofman-Bang
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Wallén
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Bruna Gigante
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
- Cardiovascular Medicine Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Ehrlinder H, Gigante B, Bendayan M, Trnkus A, Afilalo J. P3481Incremental value of the Essential Frailty Toolset for fatal and nonfatal adverse events in older adults with atrial fibrillation undergoing cardiac procedures. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p3481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- H Ehrlinder
- Department of Clinical Sciences, Karolinska Institute Danderyd Hospital, Stockholm, Sweden
| | - B Gigante
- Karolinska Institute, Institute of Environmental Medicine, Stockholm, Sweden
| | - M Bendayan
- Jewish General Hospital, McGill University, Montréal, Canada
| | - A Trnkus
- Jewish General Hospital, McGill University, Montréal, Canada
| | - J Afilalo
- Jewish General Hospital, McGill University, Montréal, Canada
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