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Brunetti E, Presta R, Okoye C, Filippini C, Raspo S, Bruno G, Marabotto M, Monzani F, Bo M. Predictors and Outcomes of Oral Anticoagulant Deprescribing in Geriatric Inpatients With Atrial Fibrillation: A Retrospective Multicenter Cohort Study. J Am Med Dir Assoc 2024; 25:545-551.e4. [PMID: 38359897 DOI: 10.1016/j.jamda.2024.01.011] [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: 07/18/2023] [Revised: 11/28/2023] [Accepted: 01/11/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE To investigate prevalence and predictors of oral anticoagulant therapy (OAT) deprescribing in older inpatients with atrial fibrillation (AF), and its association with 1-year incidence of major clinical outcomes. DESIGN Multicenter retrospective cohort study. SETTING AND PARTICIPANTS Inpatients aged ≥75 years with known AF on OAT at admission discharged from 3 Italian acute geriatric wards between January 2014 and July 2018. METHODS Data from a routine Comprehensive Geriatric Assessment (CGA), along with OAT status at discharge were recorded. One-year incidence of all-cause death, stroke or systemic embolism (SSE), and major and clinically relevant nonmajor bleeding (MB/CRNMB) were retrieved from administrative databases. Associations were explored through multilevel analysis. RESULTS Among 1578 patients (median age 86 years, 56.3% female), OAT deprescription (341 patients, 21.6%) was associated with bleeding risk, functional dependence and cognitive impairment, and inversely, with previous SSE and chronic AF. Incidences of death, SSE, and MB/CRNMB were 56.6%, 1.5%, and 4.1%, respectively, in OAT-deprescribed patients, and 37.6%, 2.9%, and 4.9%, respectively, in OAT-continued patients, without significant differences between groups. OAT deprescription was associated with all-cause mortality [adjusted odds ratio (aOR) 1.41, 95% CI 1.68-1.85], along with older age, comorbidity burden, cognitive impairment, and functional dependence, but with neither SSE nor MB/CRNMB incidence, as opposed to being alive and free from SSE and MB/CNRMB, respectively (aOR 0.68, 95% CI 0.25-1.82, and aOR 0.95 95% CI 0.49-1.85, respectively). Conversely, OAT deprescription was associated with higher odds of being dead than alive both in patients free from SSE and in those free from MB/CRNMB. CONCLUSIONS AND IMPLICATIONS CGA-based OAT deprescribing is common in acute geriatric wards and is not associated with increased SSE. The net clinical benefit of OAT in geriatric patients is strongly related with the competing risk of death, suggesting that functional and cognitive status, as well as residual life expectancy, should be considered in clinical decision making in this population.
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Affiliation(s)
- Enrico Brunetti
- Geriatrics Unit, Department of Medical Sciences, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Roberto Presta
- Geriatrics Unit, Department of Medical Sciences, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Chukwuma Okoye
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy; University of Milano-Bicocca, School of Medicine and Surgery, Milan, Italy
| | | | - Silvio Raspo
- Geriatrics Unit, Hospital Santa Croce e Carle, Cuneo, Italy
| | - Gerardo Bruno
- Geriatrics Unit, Hospital Santa Croce e Carle, Cuneo, Italy
| | | | - Fabio Monzani
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Mario Bo
- Geriatrics Unit, Department of Medical Sciences, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
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Ding J, Sun Y, Zhang K, Huang W, Tang M, Zhang D, Xing Y. Effects of Anticoagulant Therapy and Frailty in the Elderly Patients with Atrial Fibrillation. Clin Interv Aging 2024; 19:247-254. [PMID: 38375240 PMCID: PMC10875184 DOI: 10.2147/cia.s453527] [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] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/30/2024] [Indexed: 02/21/2024] Open
Abstract
Objective This study explored whether anticoagulation is safe for frail and non-frail elderly patients who have nonvalvular atrial fibrillation (NVAF). Methods At hospital discharge, the anticoagulant regimen and frailty status were recorded for 361 elderly patients (aged ≥75 y) with NVAF. The patients were followed for 12 months. The endpoints included occurrence of thrombosis; bleeding; all-cause death; and cardiovascular events. Results At hospital discharge, frailty affected 50.42% of the population and the anticoagulation rate was 44.04%. At discharge, age (OR 0.948, P = 0.006), paroxysmal NVAF (OR 0.384, P < 0.001), and bleeding history (OR 0.396, P = 0.001) were associated with a decrease in rate of receiving anticoagulation, while thrombotic events during hospitalization (OR 2.281, P = 0.021) were associated with an increase. Relative to non-frail patients, those with frailty showed a higher rate of ischemic stroke (5.33% cf. 3.01%), bleeding (P = 0.006) events, and all-cause mortality (P = 0.001). Relative to the group without anticoagulation, in those with anticoagulation the rate of thrombotic events was lower (6.99 cf. 10.98%) and bleeding events were higher (20.98 cf. 12.72%), but the risk of major bleeding was comparable. Conclusion In the elderly patients with NVAF, the decision toward anticoagulation therapy at hospital discharge was influenced by age, bleeding history, paroxysmal atrial fibrillation diagnosis, and absence of thrombosis. Frail patients were at greater risk of bleeding and all-cause mortality. Anticoagulation tended to reduce the risk of thrombotic events.
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Affiliation(s)
- Jiancao Ding
- Department of Geriatrics, First People’s Hospital of Zigong, Sichuan, People’s Republic of China
| | - Ying Sun
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Kan Zhang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Wei Huang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Mei Tang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Dai Zhang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yunli Xing
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
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Presta R, Brunetti E, Polidori MC, Bo M. Impact of frailty models on the prescription of oral anticoagulants and on the incidence of stroke, bleeding, and mortality in older patients with atrial fibrillation: a systematic review. Ageing Res Rev 2022; 82:101761. [PMID: 36270605 DOI: 10.1016/j.arr.2022.101761] [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: 07/19/2022] [Revised: 09/30/2022] [Accepted: 10/14/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Frailty is common in older patients with atrial fibrillation (AF). Current guidelines recommend oral anticoagulant therapy (OAT) except in case of severe frailty or reduced life expectancy, but definitive evidence on which "frailty" tools may help to identify older AF patients expected to derive little or no benefit from OAT is still lacking. Some persistent uncertainties may derive from the different clinical implications that the two major models of frailty, namely the frail phenotype (FP) and the deficit accumulation model (DAM), underlie. We thus conducted a systematic review of published studies to examine the association of the presence of frailty, categorized according to the FP and DAM, with 1) OAT prescription and 2) incidence of clinical outcomes (all-cause mortality, stroke and/or systemic embolism and major or clinically relevant non-major bleeding) in patients receiving OAT. METHODS Embase and MEDLINE were searched from inception until May 31st, 2022, for studies using a validated tool to identify frailty in subjects aged 65 years or older with a diagnosis of non-valvular AF; only studies on patients prescribed an OAT were considered eligible for the analyses involving clinical outcomes. The protocols for each review question have been registered in PROSPERO database (CRD42022308623 and CRD42022308628). FINDINGS Twenty-three studies exploring the association between frailty and OAT prescription on a total of 504 719 subjects were included. Patients with increasing severity of DAM frailty showed consistently lower OAT prescription rates than non-frail patients, whereas use of OAT did not significantly differ between patients with the FP compared with non-frail subjects. Eleven studies exploring the association between frailty and clinical outcomes on a total of 41 985 individuals receiving oral anticoagulation were included. Compared with non-frail subjects, a higher risk of all-cause mortality and clinical outcomes could be observed for AF patients prescribed with OAT with severe frailty according to the DAM, with inconclusive findings for the FP. High levels of heterogeneity were observed in both groups of studies; therefore, a meta-analysis was not performed. CONCLUSIONS Due to the great heterogeneity among different validated frailty measures, indiscriminately relying on "frailty" should not be regarded as the gold standard for clinical decision-making about stroke prevention in older AF patients. Present findings suggest that severe frailty according to the DAM is associated with less use of OAT and increased risk of all-cause mortality, thereby representing at the moment the most reasonable tool to efficiently recognize patients with limited life expectancy and for whom there is so far scant, if any, evidence of a clinical benefit of OAT.
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Affiliation(s)
- Roberto Presta
- Section of Geriatrics, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Molinette, Corso Bramante 88-90, 10126 Turin, Italy.
| | - Enrico Brunetti
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; Section of Internal Medicine, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Sant'Anna, Corso Bramante 88-90, 10126 Turin, Italy.
| | - Maria Cristina Polidori
- Ageing Clinical Research, Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937 Cologne, Germany; Cologne Excellence Cluster On Cellular Stress-Responses in Aging-Associated Diseases (CECAD), University of Cologne, Faculty of Medicine and University Hospital Cologne, Joseph-Stelzmann Straße 26, 50931 Cologne, Germany.
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Molinette, Corso Bramante 88-90, 10126 Turin, Italy.
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Calsolaro V, Okoye C, Rogani S, Calabrese AM, Dell'Agnello U, Antognoli R, Guarino D, Monzani F. Different glomerular filtration rate estimating formula for prescribing DOACs in oldest patients: appropriate dosage and bleeding risk. Post hoc analysis of a prospective cohort. Aging Clin Exp Res 2022; 34:591-598. [PMID: 34661901 PMCID: PMC8894223 DOI: 10.1007/s40520-021-01986-w] [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] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 09/12/2021] [Indexed: 11/29/2022]
Abstract
Background Direct oral anticoagulants (DOACs) pharmacokinetics depends on estimated glomerular filtration rate (eGFR), whose estimation is crucial for optimal risk/benefit balance. Aims To assess the concordance among different eGFR formulas and the potential impact on DOACs prescription appropriateness and bleeding risk in oldest hospitalized patients. Methods Post hoc analysis of a single-centre prospective cohort study. eGFR was calculated by creatinine-based (MDRD, CKD-EPICr, BIS1) and creatinine–cystatin-C-based (CKD-EPIComb and BIS2) formulas. Patients were stratified according to eGFR [severely depressed (SD) 15–29; moderately depressed (MD) 30–49; preserved/mildly depressed (PMD): ≥ 50 ml/min/1.73 m2]. Concordance between the different equations was assessed by Cohen’s kappa coefficient. Results Among AF patients, 841 (59.2% women, mean age 85.9 ± 6.5 years) received DOACs. By CKD-EPICr equation, 135 patients were allocated in the SD, 255 in the MD and 451 in the PMD group. The concordance was excellent only between BIS 2 and CKD-EPIComb and MDRD and CKD-EPICr, while was worse (from good to poor) between the other formulas. Indeed, by adding cystatin-C almost over 1/3 of the patients were reallocated to a worse eGFR class. Bleeding prevalence increased by 2–3% in patients with discordant eGFR between formulas, reallocated to a worse chronic kidney disease (CKD) stage, although without reaching statistical significance. CKD-EPIComb resulted the best predictor of bleeding events (AUROC 0.71, p = 0.03). Discussion This study highlights the variability in CKD staging according to different eGFR formulas, potentially determining inappropriate DOACs dosing. Although the cystatin-C derived CKDEPIComb equation is the most accurate for stratifying patients, BIS1 may represent a reliable alternative. Supplementary Information The online version contains supplementary material available at 10.1007/s40520-021-01986-w.
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Affiliation(s)
- Valeria Calsolaro
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Chukwuma Okoye
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Sara Rogani
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Alessia Maria Calabrese
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Umberto Dell'Agnello
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Rachele Antognoli
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Daniela Guarino
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Fabio Monzani
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
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Singh B, Pai P, Kumar H, George S, Mahapatra S, Garg V, Gupta GN, Makineni K, Ganeshwala G, Narkhede P, Naqvi SMH, Gaurav K, Hukkeri MYK. Expert Recommendations on the Usage of Non-vitamin K Antagonist Oral Anticoagulants (NOACs) from India: Current Perspective and Future Direction. Cardiol Ther 2022; 11:49-79. [PMID: 35137335 PMCID: PMC8933593 DOI: 10.1007/s40119-022-00254-w] [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: 10/27/2021] [Indexed: 11/18/2022] Open
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) are a new class of anticoagulant drugs used in the prevention and treatment of venous thromboembolism (VTE) and atrial fibrillation (AF). Anticoagulation requires the integration of the correct type and dose of oral anticoagulants based on patient characteristic, and therefore therapy needs to be individualized for each patient. Growing scientific evidence from studies on NOACs has led to a better understanding of their benefits and safety. A large amount of available data creates a necessity for an adaptable practical document for the usage of NOACs in India. The current consensus, developed by experts from India, aims to give recommendations on various frequently raised clinical questions with regards to NOACs and its usage. This practical document provides a platform upon which future guidelines, policies, training, and education for the use of NOACs can be tailored.
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Affiliation(s)
- Balbir Singh
- Max Super Speciality Hospital, Saket, New Delhi, India
| | - Paresh Pai
- Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Harish Kumar
- Moorthy Hospital Pvt. Ltd., Trichy, Tamil Nadu, India
| | - Sheeba George
- Sree Mookambika Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| | | | - Vineet Garg
- Blossoms Hospitals, Agra, Uttar Pradesh, India
| | - G N Gupta
- Gupta Heart and Medical Centre, Gorakhpur, Uttar Pradesh, India
| | - Kiran Makineni
- Kirans Vascular Surgery Centre, Vijayawada, Andhra Pradesh, India
| | | | | | - Syed M H Naqvi
- Dr. Reddy's Laboratories Ltd., 8-2-337, Road No. 3, Banjara Hills, Hyderabad, Telangana, 500034, India
| | - Kumar Gaurav
- Dr. Reddy's Laboratories Ltd., 8-2-337, Road No. 3, Banjara Hills, Hyderabad, Telangana, 500034, India.
| | - Mohammed Y K Hukkeri
- Dr. Reddy's Laboratories Ltd., 8-2-337, Road No. 3, Banjara Hills, Hyderabad, Telangana, 500034, India
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Watanabe A. Type of anticoagulation therapy in oldest old, frail people with atrial fibrillation. Eur J Intern Med 2021; 89:112. [PMID: 34030935 DOI: 10.1016/j.ejim.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 05/01/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Atsuyuki Watanabe
- Department of Cardiovascular Surgery, University of Tsukuba Hospital.
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Calsolaro V, Okoye C, Rogani S, Calabrese AM, Monzani F. Type of anticoagulation therapy in oldest old, frail people with atrial fibrillation: Prescription modification over time. Authors' Reply. Eur J Intern Med 2021; 89:113-114. [PMID: 34099369 DOI: 10.1016/j.ejim.2021.05.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 05/21/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Valeria Calsolaro
- Geriatrics Unit, Department of Clinical & Experimental Medicine, Pisa University Hospital, Italy
| | - Chukwuma Okoye
- Geriatrics Unit, Department of Clinical & Experimental Medicine, Pisa University Hospital, Italy
| | - Sara Rogani
- Geriatrics Unit, Department of Clinical & Experimental Medicine, Pisa University Hospital, Italy
| | - Alessia Maria Calabrese
- Geriatrics Unit, Department of Clinical & Experimental Medicine, Pisa University Hospital, Italy
| | - Fabio Monzani
- Geriatrics Unit, Department of Clinical & Experimental Medicine, Pisa University Hospital, Italy
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