Effectiveness and Safety of Antithrombotic Medication in Patients With Atrial Fibrillation and Intracranial Hemorrhage: Systematic Review and Meta-Analysis

BACKGROUND:

For patients with atrial fibrillation who survive an intracranial hemorrhage (ICrH), the decision to offer oral anticoagulation (OAC) is challenging and necessitates balancing risk of thromboembolic events with risk of recurrent ICrH.

METHODS:

This systematic review assesses the effectiveness and safety of OAC and/or antiplatelets in patients with atrial fibrillation with nontraumatic ICrH. Bibliographic databases CENTRAL, MEDLINE, EMBASE, and CINAHL were searched. Articles on adults with atrial fibrillation with spontaneous ICrH (intracerebral, subdural, and subarachnoid), receiving antithrombotic therapy for stroke prevention were eligible for inclusion.

RESULTS:

Twenty articles (50 470 participants) included 2 randomized controlled trials (n=304)‚ 8 observational studies, 8 cohort studies, and 2 studies that meta-analyzed individual-level data from observational studies. OAC therapy was associated with a significant reduction in thromboembolic events (summary relative risk [sRR], 0.51 [95% CI, 0.30–0.86], heterogeneity I 2 =2%; P =0.39, n=5 studies) and all-cause mortality (sRR, 0.52 [95% CI, 0.38–0.71], heterogeneity I 2 =0; P =0.44, n=3 studies). OAC therapy was not associated with an increased risk of recurrent ICrH (sRR, 1.44 [95% CI, 0.38–5.46], heterogeneity I 2 =70%, P =0.02, n=5 studies). Nonvitamin K antagonist OACs were more effective at reducing the risk of thromboembolic events (sRR, 0.65 [95% CI, 0.44–0.97], heterogeneity I 2 =72%, P =0.03, n=3 studies) and were associated with a lower risk of recurrent ICrH (sRR, 0.52 [95% CI, 0.40–0.67], heterogeneity I 2 =0%, P =0.43, n=3 studies) than warfarin.

CONCLUSIONS:

In nontraumatic ICrH survivors with atrial fibrillation, OAC therapy is associated with a reduced risk of thromboembolic events and all-cause mortality without significantly increasing risk of recurrent ICrH. This finding is primarily based on observational data, and further larger randomized controlled trials are needed to corroborate or refute these findings.

Managing uncertainty: Physicians’ decision-making for stroke prevention for patients with atrial fibrillation and intracerebral haemorrhage

Background Stroke prevention in patients with atrial fibrillation (AF) post-intracerebral haemorrhage (ICH) is an area of clinical equipoise. Little is known about the tools and processes that physicians use to make decisions regarding anticoagulation in this high-risk patient population. Objective To explore physicians’ decision-making process regarding stroke prevention in patients with AF and a recent history of ICH. Method Qualitative study, utilising semi-structured interviews and analysed using Framework analysis. Results Twenty physicians from five European countries (Austria, France, Germany, Spain, United Kingdom) participated. The over-arching theme ‘Managing uncertainty’, addressed the process of making high-risk clinical decisions in the context of little available robust clinical evidence for best practice. Three sub-themes were identified under the umbrella theme: (1) ‘Computing the Risks’, captured the challenge of balancing the risks of ischaemic stroke with the risk of recurrent ICH in a complex patient population; (2) ‘Patient Factors’ highlighted the influence that patients’ beliefs and previous experience of stroke had on physicians’ decisions; and (3) ‘Making a Decision’ explored the process of reaching a final decision regarding initiation of OAC therapy or not. Conclusion Physicians described the process of deciding on stroke prevention in patients with AF post-ICH as ‘challenging’ due to considerable ‘clinical equipoise’. Key factors that affected decision-making was patient comorbidities, functional status, and patient willingness to engage with oral anticoagulation therapy. Shared decision-making was believed to be beneficial, but physicians believed that the ultimate responsibility to decide on stroke prevention lay with the clinician.

Abstract WP83: The Challenges Of Stroke Prevention Following Intracerebral Haemorrhage; A Qualitative Study Exploring Physicians’ Decision Making

Introduction: Initiating long-term oral anticoagulation (OAC) therapy in intracerebral haemorrhage (ICH) survivors who have atrial fibrillation (AF) has clinical equipoise for stroke physicians internationally, given the lack of clinical trial evidence. Understanding how physicians make decisions about stroke prevention in these patients will support and improve current decision-making practice and inform future guidelines.

Aim: To explore physicians’ decision-making around prescription of long-term OAC for stroke prevention in patients with AF following an ICH.

Methods: Qualitative sub-study of the PREvention of STroke in Intracerebral haemorrhaGE survivors with Atrial Fibrillation (PRESTIGE-AF) trial [NCT NCT03996772]. Semi-structured interviews with data analysed using Framework analysis.

Results: Twenty stroke physicians (women n = 6 (30%), consultant in stroke medicine n =10, head of stroke department n = 6, geriatrician working in stroke n = 2, residents in neurology n = 2) across five European countries (Spain, France, Germany, Austria, UK) participated. The overarching theme ‘Managing Uncertainty’ highlights the difficulties faced by physicians. It draws together three sub-themes: ‘Computing the risks’, focusing on how physicians weigh-up the risks and benefits of long-term OAC; ‘The patient perspective’, which considers patients’ experiences and preferences; ‘Making the decision together’, which focuses on issues of communication between physicians and patients.

Conclusion: The need to balance risks/benefits in the absence of data from randomised controlled trials and the uncertainty surrounding long-term outcomes of OAC were key challenges for physicians. Physicians rely on past personal clinical experience and collegiate advice to aid decision making. Physicians strive to ensure that patients understand the decision-making process. Future practice should support physicians in communicating clinical uncertainty to patients and encourage patients and physicians to work together to understand individual patients’ needs. Funding: This project has received funding from the European Union’s Horizon 2020 research and innovation programme under Grant Agreement No. 754517.

Antithrombotic therapy for stroke prevention in patients with atrial fibrillation who survive an intracerebral haemorrhage: results of an EHRA survey

The aim of this survey is to provide a snapshot of current practice regarding antithrombotic therapy (ATT) in patients with atrial fibrillation (AF) comorbid with intracerebral haemorrhage (ICH). An online survey was distributed to members of the European Heart Rhythm Association. A total of 163 clinicians responded, mostly cardiologists or electrophysiologists (87.7%), predominantly working in University hospitals (61.3%). Most respondents (47.2%) had seen one to five patients with AF comorbid with ICH in the last 12 months. Among patients sustaining an ICH on oral anticoagulation (OAC), 84.3% respondents would consider some form of ATT post-ICH, with 73.2% preferring to switch from a vitamin-K antagonist (VKA) to a non-VKA oral anticoagulant (NOAC) and 37.2% preferring to switch from one NOAC to another. Most (36.6%) would restart OAC >30 days post-ICH. Among patients considered unable to take OAC, left atrial appendage occlusion procedure was the therapy of choice in 73.3% respondents. When deciding on ATT, respondents considered patient's CHA2DS2-VASc score, ICH type, demographics, risk factors, and patient adherence. The main reason for not restarting or commencing ATT was concern about recurrent ICH (80.8%). National or international clinical guidelines would be advantageous to support decision-making (84.3%). Other helpful resources reported were multidisciplinary team involvement (46.9%) and patient education (82%). In summary, most survey respondents would prescribe OAC therapy for patients with AF who have sustained an ICH on OAC and would restart OAC >30 days post-ICH. The risk of recurrent ICH was the main reason for not prescribing any ATT post-ICH.

Challenges and facilitators in providing effective end of life care in intensive care units

Caring for patients who are at the end of their lives is an essential aspect of practice in intensive care units (ICUs). While intensive care is one of the fastest-growing healthcare specialties as a result of technological and scientific advances, a significant proportion of patients admitted to an ICU in the UK will not survive their ICU stay. Therefore, it is important to examine ways to enhance practice in this area and the factors that might affect the care provided to patients and their families.

AIM

To identify the challenges and facilitators that members of the ICU multidisciplinary team encounter in the delivery of end of life care to dying patients in ICUs.

METHOD

A scoping literature review was undertaken. Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus with full text, MEDLINE Complete and the EBSCOhost E-Journals Database were searched electronically to identify literature from April 2007 to April 2017, alongside hand-searching. Critical appraisal tools were used and thematic analysis was undertaken to analyse the data and identify themes.

FINDINGS

Ten articles were included in the literature review, which identified various challenges and facilitators in providing effective end of life care in ICUs. The main themes identified were: communication, family involvement, personal factors and the ICU environment.

CONCLUSION

All of the studies included in the literature review identified several important challenges related to communication, such as time constraints, disagreements among healthcare professionals, and a lack of knowledge among healthcare professionals about how to conduct challenging conversations with patients and families. Future developments in practice should consider the role of effective multidisciplinary team-working in end of life care.

Application of ventricular tachyarrhythmia definitions of the updated Lambeth Conventions provides incompatibility with earlier results, masks antifibrillatory activity and reduces inter-observer agreement

The Lambeth Conventions (LC I), a landmark guidance document for arrhythmia research was updated and arrhythmia definitions were changed in the new Lambeth Conventions II (LC II). This study examined whether the arrhythmia definitions of LC I and LC II yield the same qualitative results and whether LC II improves inter-observer agreement. Two independent investigators performed blinded arrhythmia analysis of the electrocardiograms of isolated, Langendorff rat hearts subjected to regional ischemia and perfused with Class I antiarrhythmics with 3 or 5 mM K⁺ in the perfusate. Data obtained with arrhythmia definitions of LC I and LC II were compared within and between observers. Applying ventricular fibrillation (VF) definition of LC II significantly increased VF incidence and reduced VF onset time irrespective of treatment by detecting 'de novo' VF episodes not found by LC I. LC II reduced the number of ventricular tachycardia (VT) episodes and simultaneously increased the number of VF episodes as compared with the respective values obtained according to LC I. Using VF definition of LC II masked the significant antifibrillatory effects of flecainide and the high K⁺ concentration identified with the VF definition of LC I. When VF incidence was tested, a very strong inter-observer agreement was found according to LC I, whereas using VF definition of LC II reduced inter-observer agreement. It is concluded that LC II shifts some tachyarrhythmias from VT to VF class, and thus results obtained by arrhythmia definitions of LC I and LC II are not compatible; VF definition of LC II may change the conclusion of pharmacological, physiological and pathophysiological arrhythmia investigations and may reduce inter-observer agreement. Thus, VT and VF definitions of LC II should be amended in order to increase compatibility and inter-observer agreement.

Hyperventilation assists proarrhythmia development during delayed repolarization in clofilium-treated, anaesthetized, mechanically ventilated rabbits

Hyperventilation reduces partial pressure of CO₂ (PCO₂) in the blood, which results in hypokalaemia. Hypokalaemia helps the development of the life-threatening torsades de pointes type ventricular arrhythmia (TdP) evoked by repolarization delaying drugs. This implies that hyperventilation may assist the development of proarrhythmic events. Therefore, this study experimentally investigated the effect of hyperventilation on proarrhythmia development during delayed repolarization. Phenylephrine (an α₁-adrenoceptor agonist) and clofilium (as a representative repolarization delaying agent inhibiting the rapid component of the delayed rectifier potassium current, I_Kr) were administered intravenously to pentobarbital-anaesthetized, mechanically ventilated, open chest rabbits. ECG was recorded, and the onset times and incidences of the arrhythmias were determined. Serum K⁺, pH and PCO₂ were measured in arterial blood samples. Clofilium prolonged the rate corrected QT interval. TdP occurred in 15 animals (TdP+ group), and did not occur in 14 animals (TdP- group). We found a strong, positive, linear correlation between serum K⁺ and PCO₂. There was no relationship between the occurrence of TdP and the baseline K⁺ and PCO₂ values. However, a positive, linear correlation was found between the onset time of the first arrhythmias and the K⁺ and PCO₂ values. The regression lines describing the relationship between PCO₂ and onset time of first arrhythmias were parallel in the TdP+ and TdP- groups, but the same PCO₂ resulted in earlier arrhythmia onset in the TdP+ group than in the TdP- group. We conclude that hyperventilation and hypocapnia with the resultant hypokalaemia assist the multifactorial process of proarrhythmia development during delayed repolarization. This implies that PCO₂ and serum K⁺ should be controlled tightly during mechanical ventilation in experimental investigations and clinical settings when repolarization-delaying drugs are applied.

Challenges in tuberculosis management in Peru and England

Tuberculosis (TB) is a serious but preventable and largely treatable disease caused by the bacterium Mycobacterium tuberculosis. Although there is evidence that the UK incidence remains stable, rates of the disease, particularly in some London boroughs, remain high, earning it the unenviable title of the 'tuberculosis capital of Europe'. In March 2014 Public Health England published a consultation document on a collaborative strategy for tackling tuberculosis in England. This highlights a growing concern surrounding the issue. In the 1990s, Peru's tuberculosis epidemic saw the country listed among the Pan-American Health Organisation's top 23 countries of heaviest burden. Since then overall rates, although remaining significantly higher than those of the UK, have fallen dramatically. This article uses the observations of a BSc Nursing student undertaking an international elective in Peru to highlight some of the challenges faced by nurses in managing TB and draws parallels with those faced in the UK.

Understanding the palliative care needs of heart failure patients

It is increasingly recognised that end-of-life care is suboptimal, especially for those with advanced non-malignant diseases. This study shows that individuals living with heart failure have a number of palliative care needs, including education, communication, symptom management and psychosocial needs. Clinicians struggled to discuss palliation with heart failure patients due to the unclear disease trajectory and cardiac-specific barriers to identifying palliation needs. Carers reported a need for greater social support and better guidance on best practice care. Furthermore, patients struggled to cope physically and psychologically with their reduced physical capabilities and were fearful of being a burden to their carers. Both patients and clinicians recognised a discontinuity between secondary and primary care, which has particular resonance in the context of the intention to relocate care nearer home.