Prospective observational registry of perioperative and periprocedural management of antithrombotic therapy in "real world": the REQXAA study

INTRODUCTION AND OBJECTIVES

There is scarce real-world evidence on the management of perioperative antithrombotic treatment according to current recommendations. The aim of this study was to analyze the management of antithrombotic treatment in patients undergoing surgery or another invasive intervention and to assess the consequences of this management on the occurrence thrombotic or bleeding events.

METHODS

This prospective, observational, multicenter and multispecialty study analyzed patients receiving antithrombotic therapy who underwent surgery or another invasive intervention. The primary endpoint was defined as the incidence of adverse (thrombotic and/or hemorrhagic) events after 30 days of follow-up with respect to management of perioperative antithrombotic drugs.

RESULTS

We included 1266 patients (male: 63.5%; mean age 72.6 years). Nearly half of the patients (48.6%) were under chronic anticoagulation therapy (mainly for atrial fibrillation; CHA2DS2-VASC: 3.7), while 53.3% of the patients were under chronic antiplatelet therapy (mainly for coronary artery disease). Low ischemic and hemorrhagic risk was found in 66.7% and 51.9%, respectively. Antithrombotic therapy management was in line with current recommendations in only 57.3% of the patients. Inappropriate management of antithrombotic therapy was an independent risk factor for both thrombotic and hemorrhagic events.

CONCLUSIONS

The implementation of recommendations on the perioperative/periprocedural management of antithrombotic therapy in real-world patients is poor. Inappropriate management of antithrombotic treatment is associated with an increase in both thrombotic and hemorrhagic events.

Preliminary results from REALITY: a nation-wide study of a database with 1.8 million real-life patients to study atherosclerotic cardiovascular disease and familial hypercholesterolemia in Spain

Introduction

Ischemic heart disease and stroke are the leading causes of premature death worldwide. Atherosclerotic cardiovascular disease (ASCVD) is the main determining factor for these and other life-threatening pathologies, such as peripheral artery disease (PAD). LDL-lowering therapies are the gold standard to prevent ASCVD. These treatments are also used for familial hypercholesterolemia (FH), a genetic disorder manifesting with high LDL levels. It is crucial to evaluate the management and level of LDL control in “real-life” patients with ASCVD and FH, but so far very few large-scale studies have focussed on these issues. REALITY is an observational retrospective study of ASCVD and FH in Spain.

Purpose

The goals of REALITY included the analysis of the demographic and clinical characteristics, comorbidities, and concomitant medication of patients with ASCVD and/or FH by a multidisciplinary group of experts. The lipid-lowering therapies used in Spain were assessed, and patient LDL levels were evaluated according to treatment intensity during the two-year follow-up period.

Methods

Electronic medical records were retrieved from the BIG-PAC® database that includes anonymized data of patients from seven health areas in Spain. The study population included patients presenting a new or recurrent episode of ASCVD (n=26,976) or a new diagnosis of FH (n=572) during the recruitment period (from 01/01/2017 to 31/12/2018). The index date was defined as the date of the event/diagnosis, and a 2-year follow-up was established.

Results

The average age was 69.9±11.5 for ASCVD patients and 60.1±12 for FH patients (59.4% and 48.6% males, respectively). The average Charlson index was 2.2±1.6 in ASCVD and 1.2±1.4 in FH. The comorbidities most frequently observed in ASCVD vs. FH were hypercholesterolaemia (55% vs. 100%), arterial hypertension (65% vs. 54%), diabetes mellitus (31% vs. 29%) and obesity (31% vs. 21%). Around 25% and 6% of patients with ASCVD and FH, respectively, presented CV events in the follow-up. During the 24-month period, the highest rate of ischemic heart disease was observed in patients with LDL levels of 55–69 mg/dL, whereas LDL levels below 55 mg/dL were associated with the highest incidence of PAD. The highest lipid biochemical reductions in ASCVD vs. FH were observed in total cholesterol (−52±17.4 vs. −53.5±21.3 mg/dL), triglycerides (−53±7.9 vs. −54.2±8.8 mg/dL) and LDL (−27.4±10.4 vs. −29±12.3 mg/dL). HDL levels showed an average increase of 8.5±2 vs. 9.3±2.5 mg/dL. Treatment intensity correlated with reduction of LDL levels in all ASCVD disease subgroups and FH patients (Table 1).

Conclusions

The results of REALITY provide an estimated clinical picture of ASCVD and FH in Spain. The impact of therapeutical approaches on LDL levels and the prevention of CV events were evaluated by a multidisciplinary group of experts. The findings of the study will help lower the burden of ASCVD and FH in Spain.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): REALITY study was sponsored by Novartis. Statistical analysis of the BIG-PAC® database was performed by Atrys Health. Medical writing and editing were provided by Medical Science Consulting. All funded by Novartis.

The REALITY project: analysis of a national database with 1.8 million real-life patients to study atherosclerotic cardiovascular disease and familial hypercholesterolemia in Spain

Introduction

Atherosclerotic cardiovascular disease (ASCVD), hypercholesterolaemia, and familial hypercholesterolaemia (FH) are associated with high mortality, morbidity and direct/indirect economic costs worldwide. However, information about patient characteristics, clinical practice, treatment effectiveness, and economic costs is limited in Spain. To address this issue, a multidisciplinary working group of cardiologists, hospital pharmacists, family physicians, internal medicine specialists, and neurologists took part in the nationwide, observational, retrospective REALITY study. Using information from the Spanish National Health System (SNHS), the group will describe the treatment patterns and clinical profiles of patients with ASCVD and/or FH in Spain.

Methods and results

REALITY will access 1.8 million electronic medical records in the BIG-PAC® database, which collects anonymised data (in compliance with Organic Law 3/2018 of 5 December) from SNHS primary care centres and hospitals across seven regional health areas in Spain. REALITY was approved by the Hospital of Terrassa Ethics Committee on 17/11/2020. Patients presenting a new/recurrent episode of ASCVD or diagnosed with FH from 01/01/2017 to 31/12/2018 were recruited. The index date was the date of the event/diagnosis, and a two-year follow-up was established. Patients were classified as FH or ASCVD on the basis of their primary diagnosis (five subgroups: stable/unstable angina, acute myocardial infarction, ischemic stroke, transient ischemic attack, and peripheral arterial disease). Primary objectives were to determine demographic and clinical characteristics, comorbidities, and concomitant medication. Secondary objectives were to determine the lipid-lowering therapy applied, persistence of medication and modifications, the rationale for switching therapy, and treatment adherence (including data from non-adherent patients). Endpoints were low-density lipoprotein (LDL) levels, prevalence and incidence of new events, use of healthcare resources (e.g., medical visits or tests, coronary artery bypass surgery, hospitalizations, etc.), and healthcare costs. Using the aforementioned variables, these endpoints were analysed globally according to disease classification. Exploratory objectives included estimation of the percentage of statin-intolerant patients, and a subanalysis of costs according to the intensity of the lipid-lowering treatment and LDL levels.

Conclusions

The power of the “real-life” data from the BIG-PAC® database and the multidisciplinary approach used in this study will facilitate a wide range of analyses/subanalyses of various clinical issues, including treatment, disease burden, and economic costs. This study will give healthcare practitioners and policy makers valuable data for cardiovascular secondary prevention, control, and strategies to improve management.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The REALITY study is sponsored by Novartis. Statistical analysis of the BIG-PAC® database was performed by Atrys Health. Medical writing and editing were provided by Medical Science Consulting. All funded by Novartis.

[Dapagliflozin in the prevention and treatment of heart failure]

To substantially reduce the risk of hospitalization and death among subjects with heart failure (HF) and reduced left ventricular ejection fraction, it is necessary to make a comprehensive approach of the different neurohormonal systems that are implied in its etiopathogenesis, including not only sympathetic nervous system, and renin-angiotensin system, but also vasoactive peptides and sodium-glucose transport protein 2. The DAPA-HF trial demonstrated that the addition of dapagliflozin to the standard treatment in HF with reduced left ventricular ejection fraction, markedly decreases the risk of cardiovascular death, HF hospitalization and overall death. In addition, dapagliflozin improves functional class and quality of life. Importantly, the prognostic benefit starts early after initiating treatment with dapagliflozin, regardless baseline therapy or the presence of diabetes. All these evidences make dapagliflozin as one of the mainstays of treatment for the management of HF with reduced left ventricular ejection fraction.

Cost and burden of poor anticoagulation control with vitamin K antagonists in patients with nonvalvular atrial fibrillation in Spain

INTRODUCTION AND OBJECTIVES

The aim of this analysis was to evaluate the burden and cost of complications due to poor anticoagulation control in patients with nonvalvular atrial fibrillation (NVAF) treated with vitamin K antagonists (VKA) in Spain.

METHODS

An analytical model was used to estimate annual differences in ischemic stroke, major bleeding, deaths, costs, and potential years of life lost between patients with poor anticoagulation control (time in therapeutic range <65%) and adequate control (time in therapeutic range ≥ 65%) with a 1-year time horizon. Information on the target population (patients ≥ 65 years), event rates, and costs were obtained from national sources. Direct costs in euros (2018) were included from the perspective of the national health system (NHS) and direct and indirect costs from the societal perspective. A sensitivity analysis was performed with post-hoc data from the SPORTIF III/V trials.

RESULTS

We analyzed a hypothetical cohort of 594 855 patients, 48.3% with poor anticoagulation control, with an increase of 2321 ischemic strokes, 2236 major bleeding events and 14 463 deaths, and an annual incremental cost between €29 578 306 from the NHS perspective and €75 737 451 from the societal perspective. The annual impact of mortality was 170 502 potential years of life lost. The results of the sensitivity analysis showed that the annual cost would reach €97 787 873 from the societal perspective.

CONCLUSIONS

Poor anticoagulation control with AVK has a strong impact on loss of health and on increased spending for the NHS.

[Telemedicine consultation for the clinical cardiologists in the era of COVID-19: present and future. Consensus document of the Spanish Society of Cardiology]

La pandemia producida por la infección por el coronavirus SARS-CoV-2 (COVID-19) ha cambiado la forma de entender nuestras consultas. Para reducir el riesgo de contagio de los pacientes más vulnerables (aquellos con cardiopatías) y del personal sanitario, se han suspendido la mayoría de las consultas presenciales y se han puesto en marcha las consultas telemáticas. Este cambio se ha implementado en muy poco tiempo, pero parece que ha venido para quedarse. No obstante, hay grandes dudas sobre aspectos organizativos, legales, posibilidades de mejora, etc. En este documento de consenso de la Sociedad Española de Cardiología, tratamos de dar las claves para mejorar la calidad asistencial en nuestras nuevas consultas telemáticas, revisando las afecciones que el cardiólogo clínico atiende con más frecuencia en su consulta ambulatoria y proponiendo unos mínimos en ese proceso asistencial. Estas enfermedades son la cardiopatía isquémica, la insuficiencia cardiaca y las arritmias. En los 3 escenarios tratamos de clarificar los aspectos fundamentales que hay que revisar en la entrevista telefónica, a qué pacientes habrá que atender en una consulta presencial y cuáles serán los criterios para su seguimiento en atención primaria. El documento también recoge distintas mejoras que pueden introducirse en la consulta telemática para mejorar la asistencia de nuestros pacientes.

Recommendations to improve lipid control. Consensus document of the Spanish Society of Cardiology

T***he current control of low-density lipoprotein cholesterol among patients with atherosclerotic cardiovascular disease is very low and this is associated with an increase of cardiovascular outcomes. In addition, the latter this happens, the risk will be greater. This is mainly due to an insufficient use of the lipid-lowering therapy currently available. In fact, with current treatments (statins, ezetimibe and PCSK9 inhibitors), the majority of patients in secondary prevention should achieve low-density lipoprotein cholesterol goals. For these reasons, in this manuscript promoted by the Spanish Society of Cardiology we propose three simple and feasible decision-making algorithms that include the majority of clinical scenarios among patients with ischemic heart disease, with the double aim of attaining therapeutic goals in the majority of patients as soon as possible; in secondary prevention the magnitude of the benefit is risk- and time-dependent.

P3815Cost and burden of poor control of the level of anticoagulation in patients with non-valvular atrial fibrillation treated with vitamin K antagonist in the Spanish National Health Service

Introduction

Poorly controlled non-valvular atrial fibrillation (NVAF) patients treated with vitamin K antagonists (VKA) experience higher rates of clinical events compared to well controlled patients. In Spain a high percentage of NVAF patients present an inadequate control of anticoagulation therapy, whose economic impact has not been reported yet.

Purpose

To estimate the impact on resource consumption, clinical events and mortality of poorly controlled NVAF patients≥65 years treated with VKA in Spain.

Methods

A cost-consequence analytic model was developed to estimate differences on clinical events and cost between poorly controlled (TTR<65%) and well controlled (TTR≥65%) NVAF patients treated with VKA over 1 year. A hypothetical cohort of NVAF patients was estimated by using local epidemiological studies. Anticoagulation control rates, as measured by Rosendaal method, were retrieved from a literature review of Spanish real-world studies.

Clinical event rates (ischemic stroke-IS-, hemorrhagic stroke-HS-, major bleeding-MB-, systemic embolism-SE- and death for any cause) were derived from a post-hoc analysis of SPORTIF III/V trials. A sensitivity analysis (SA) was performed by using event rates from a prospective single-center study carried out in Spain.

Societal and National Health Service (NHS) perspectives were considered. Total annual costs (€ 2018) included clinical event direct, non-direct healthcare cost and indirect-costs. Potential life years lost (PLYL) were calculated to report impact on mortality. An expert panel composed by a cardiologist, a haematologist and general practitioners validated the model inputs.

Results

The target population comprised 594,855 NVAF patients treated with VKA (mean age 73.2 years, 49.4% women, 74.1% CHADS≥2). Poorly controlled anticoagulated patients accounted for 48.3% of the cohort. The inadequate control of anticoagulation was associated with a higher incidence of clinical events compared to well controlled patients within a year (additional 2,143 IS, 390 HS, 201 SE, 6,190 MB and 6,856 deaths). From NHS perspective, the incremental total annual costs associated to poorly controlled patients were €46,685,756.60 (€173.96/patient-year). When considering the societal perspective, the incremental total annual costs of inadequate anticoagulation control reached €97,787,872.59 (€367.51/patient-year). Mortality due to poorly anticoagulation control implied 80,830.65 PLYL (0.136 PLYL/patient-year). The SA confirmed the base case results.

Conclusions

In the Spanish NHS, around 50% of NVAF patients ≥65 years treated with VKA present an inadequate control of the anticoagulation therapy (287,089 patients), which is associated with the increase of clinical events, mortality and costs (up to €100 million). The results of this study highlight a call to action to increase the awareness of the consequences of a poor anticoagulation control and emphasize the need for a better clinical of patients receiving anticoagulation.

Acknowledgement/Funding

BMS and PFIZER contributed to finance the no conditioned to the results of this work.

Perioperative and Periprocedural Management of Antithrombotic Therapy: Consensus Document of SEC, SEDAR, SEACV, SECTCV, AEC, SECPRE, SEPD, SEGO, SEHH, SETH, SEMERGEN, SEMFYC, SEMG, SEMICYUC, SEMI, SEMES, SEPAR, SENEC, SEO, SEPA, SERVEI, SECOT and AEU

During the last few years, the number of patients receiving anticoagulant and antiplatelet therapy has increased worldwide. Since this is a chronic treatment, patients receiving it can be expected to need some kind of surgery or intervention during their lifetime that may require treatment discontinuation. The decision to withdraw antithrombotic therapy depends on the patient's thrombotic risk versus hemorrhagic risk. Assessment of both factors will show the precise management of anticoagulant and antiplatelet therapy in these scenarios. The aim of this consensus document, coordinated by the Cardiovascular Thrombosis Working Group of the Spanish Society of Cardiology, and endorsed by most of the Spanish scientific societies of clinical specialities that may play a role in the patient-health care process during the perioperative or periprocedural period, is to recommend some simple and practical guidelines with a view to homogenizing daily clinical practice.

Clinical characteristics and management of patients with atrial fibrillation treated with direct oral anticoagulants according to blood pressure control

OBJECTIVE

To determine the clinical characteristics and management of hypertensive patients with nonvalvular atrial fibrillation (AF) treated with direct oral anticoagulants (DOACs) according to blood pressure (BP) control.

METHODS

For this purpose, data from two observational, cross-sectional and multicenter studies were combined. In both studies, patients on chronic treatment with anticoagulants and that were on current treatment with DOACs at least for 3 months were included. Adequate BP was defined as a systolic BP<140mmHg and a diastolic BP<90mmHg (<140/85mmHg if diabetes).

RESULTS

Overall, 1036 patients were included. Of these, 881 (85%) had hypertension that were finally analyzed. The presence of other risk factors and cardiovascular disease was common. Mean BP was 132.6±14.3/75.2±9.2mmHg and 70.5% of patients achieved BP goals. Those patients with a poor BP control had more frequently diabetes, and a history of prior labile INR. Patients had a high thromboembolic risk, but without significant differences according to BP control. By contrast, more patients with a poor BP control had a higher bleeding risk (HAS-BLED ≥3: 24.0% vs 35.4%; P<0.001). HAS-BLED score was an independent predictor of poor BP control (odds ratio 1.435; 95% confidence interval 1.216-1.693; P<0.001). Satisfaction with anticoagulant treatment was independent of BP control.

CONCLUSIONS

More than two thirds of our patients with hypertension and AF anticoagulated with DOACs achieve BP targets, what is clearly superior to that reported in the general hypertensive population.

[Clinical characteristics of patients with atrial fibrillation treated with direct oral anticoagulants attended in primary care setting. The SILVER-AP study]

Objetivo

Describir las características clínicas y el manejo de pacientes con fibrilación auricular no valvular (FANV) tratados con anticoagulantes orales de acción directa (ACOD).

Diseño

Estudio observacional, transversal y multicéntrico.

Emplazamiento

Comunidades autónomas en las que el médico de atención primaria puede prescribir ACOD (n = 9).

Participantes

Un total de 790 pacientes con riesgo de ictus o embolia sistémica que estuviesen en tratamiento crónico con anticoagulantes, que hubiesen modificado su pauta terapéutica, y que actualmente estuviesen en tratamiento con un ACOD durante al menos 3 meses.

Mediciones principales

Recogida de datos sociodemográficos y de manejo clínico.

Resultados

La edad media de los sujetos fue de 78,6 ± 8,4 años; un 50,5% eran varones; CHADS₂: 2,6 ± 1,2; CHA₂DS₂-VASc: 4,3 ± 1,6; HAS-BLED: 2,3 ± 1,0. La duración media del tratamiento con ACOD fue de 15,8 ± 12,5 meses. El ACOD más frecuentemente prescrito fue rivaroxabán (57,8%), seguido de dabigatrán (23,7%) y apixabán (18,5%). De los pacientes que tomaban rivaroxabán, el 70,2% recibieron la dosis de 20 mg/día. En el caso de dabigatrán, el 41,7% tomaban la dosis de 150 mg/12 h, y con respecto a apixabán, el 56,2% tomaban la dosis de 5 mg/12 h. La satisfacción con el tratamiento con ACOD (cuestionario ACTS: 52,0 ± 7,2 puntos en la escala Carga y 12,1 ± 2,2 puntos en la escala Beneficio) y el cumplimiento (97,8% de los pacientes fueron cumplidores) fueron elevados.

Conclusiones

Los pacientes en tratamiento con ACOD en España tienen un elevado riesgo tromboembólico. Una proporción significativa de sujetos reciben una dosis menor de ACOD de la que les correspondería por sus características clínicas. La satisfacción y la adherencia son elevadas.

Left Ventricular Geometric Patterns After 1 Year of Antihypertensive Treatment

Left ventricular hypertrophy increases the risk for cardiovascular target organ damage, myocardial infarction, and stroke. The authors assessed the patterns of ventricular adaptation in 107 essential hypertensives whose treatment had been withdrawn and its modification after 1 year of hypertension treatment. Blood pressure decreased from 158+/-17/96+/-12 mm Hg to 137+/-15/83+/-10 mm Hg (mean +/- SD; p<0.001); 45% of the patients (49 of 107) had their blood pressure controlled below 140 mm Hg and 90 mm Hg. Although a significant decrease of left ventricular mass index was found in the study, the percentage of patients with normal left ventricular geometry at the completion of the study increased by only 9% (27% to 36%, p>0.05). Left ventricular mass geometry improved in 31% of the patients, remained unaffected in 51%, and worsened in 18%. The data suggest that even while suboptimal antihypertensive treatment reduces left ventricular mass index, either left ventricular hypertrophy or concentric remodeling remains present in a significant number of patients at the end of a 1-year treatment period. The authors conclude that these patients should be considered as a subgroup at high risk and should be treated more aggressively.

[The usefulness of intravascular echography during the percutaneous dilatation of aortic coarctation]

An intravascular ultrasound study was performed in a patient, to assess the anatomy of aortic coarctation and the results obtained after percutaneous dilation with a balloon catheter. Intravascular ultrasound imaging provides important additional information, not obtainable with other diagnostic procedures, regarding aortic wall structure and thickness. After balloon dilation, aortic disruption was clearly observed, accounting, together with the stretching of the outer layers of the aortic wall, for the increase in aortic luminal area. Intravascular ultrasound permitted also the accurate assessment of the improvement obtained. Intravascular imaging was clearly superior not only to conventional angiography, but also to transesophageal echocardiography in detecting the mechanism of dilation. We conclude that ultravascular ultrasound, with the additional information that it provides, may help in the selection of patients for percutaneous dilation of the coarctation as well as contributing to the identification of the mechanism of dilation.