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Di Biase L, Lakkireddy DJ, Marazzato J, Velasco A, Diaz JC, Navara R, Chrispin J, Rajagopalan B, Natale A, Mohanty S, Zhang X, Della Rocca D, Dalal A, Park K, Wiley J, Batchelor W, Cheung JW, Dangas G, Mehran R, Romero J. Antithrombotic Therapy for Patients Undergoing Cardiac Electrophysiological and Interventional Procedures: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:82-108. [PMID: 38171713 DOI: 10.1016/j.jacc.2023.09.831] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/24/2023] [Accepted: 09/21/2023] [Indexed: 01/05/2024]
Abstract
Electrophysiological and interventional procedures have been increasingly used to reduce morbidity and mortality in patients experiencing cardiovascular diseases. Although antithrombotic therapies are critical to reduce the risk of stroke or other thromboembolic events, they can nonetheless increase the bleeding hazard. This is even more true in an aging population undergoing cardiac procedures in which the combination of oral anticoagulants and antiplatelet therapies would further increase the hemorrhagic risk. Hence, the timing, dose, and combination of antithrombotic therapies should be carefully chosen in each case. However, the maze of society guidelines and consensus documents published so far have progressively led to a hazier scenario in this setting. Aim of this review is to provide-in a single document-a quick, evidenced-based practical summary of the antithrombotic approaches used in different cardiac electrophysiology and interventional procedures to guide the busy clinician and the cardiac proceduralist in their everyday practice.
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Affiliation(s)
- Luigi Di Biase
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA.
| | | | - Jacopo Marazzato
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Alejandro Velasco
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Juan Carlos Diaz
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Rachita Navara
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Jonathan Chrispin
- Clinical Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | | | - Xiaodong Zhang
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Aarti Dalal
- Division of Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Ki Park
- Department of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA
| | - Jose Wiley
- Division of Cardiology, Mount Sinai Medical Center, New York, New York, USA
| | - Wayne Batchelor
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Jim W Cheung
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - George Dangas
- Division of Cardiology, Mount Sinai Medical Center, New York, New York, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jorge Romero
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
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Martinez KA, Eckman MH, Pappas MA, Rothberg MB. Prescribing of anticoagulation for atrial fibrillation in primary care. J Thromb Thrombolysis 2022; 54:616-624. [PMID: 35449383 PMCID: PMC10481404 DOI: 10.1007/s11239-022-02655-z] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 11/29/2022]
Abstract
Atrial fibrillation (AF) is common in primary care patients. Many patients who could benefit from anticoagulation do not receive it. The objective of this study was to describe anticoagulation prescribing by primary care physicians. We conducted an observational study in the Cleveland Clinic Health System among patients with AF and ≥ 1 primary care appointment between 2015 and 2018 and their physicians. We estimated differences in the odds of an eligible patient receiving anticoagulation versus not and a DOAC versus warfarin using two mixed effects logistic regression models, adjusted for patient sociodemographic factors, history of falls or dementia, and CHA2DS2-VASc and HAS-BLED scores. We categorized physicians into prescribing tertiles, based on their adjusted prescribing rate, which we included as predictors in the models. Among 5253 patients, 47% received anticoagulation. Of those, 56% received a DOAC. CHA2DS2-VASc and HAS-BLED scores were not associated with anticoagulation prescription. Black race was negatively associated with receiving anticoagulation overall (aOR:0.71; 95%CI:0.56-0.89) and with prescription for a DOAC (aOR:0.65; 95%CI:0.45-0.93). Among 195 physicians, the anticoagulation prescribing rate ranged from 27% to 57% and DOAC rates ranged from 34% to 69%. Physician prescribing tertile was associated with odds of a patient receiving anticoagulation overall (aOR:1.51; 95%CI: 1.13-2.01 for the highest versus lowest tertile), but not DOAC prescriptions. When prescribing anticoagulation, physicians appear not to consider risk of stroke or bleeding but patient race is an important determinant. Seeing a physician with a high anticoagulation prescribing rate was strongly associated with a patient receiving it, suggesting a lack of individualization.
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Affiliation(s)
- Kathryn A Martinez
- Cleveland Clinic Center for Value-Based Care Research, 9500 Euclid Ave, G10, Cleveland, OH, 44195, USA.
| | - Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH, USA
| | - Matthew A Pappas
- Cleveland Clinic Center for Value-Based Care Research, 9500 Euclid Ave, G10, Cleveland, OH, 44195, USA
| | - Michael B Rothberg
- Cleveland Clinic Center for Value-Based Care Research, 9500 Euclid Ave, G10, Cleveland, OH, 44195, USA
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Bul M, Shaikh F, McDonagh J, Ferguson C. Frailty and oral anticoagulant prescription in adults with atrial fibrillation: A systematic review. Aging Med (Milton) 2022. [DOI: 10.1002/agm2.12214] [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] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Mary Bul
- Western Sydney University Parramatta New South Wales Australia
| | - Fahad Shaikh
- Western Sydney University Parramatta New South Wales Australia
- Western Sydney Nursing and Midwifery Research Centre Western Sydney Local Health District and Western Sydney University, Blacktown Clinical and Research School, Blacktown Hospital Blacktown New South Wales Australia
| | - Julee McDonagh
- School of Nursing and Midwifery/College of Health, Medicine and Wellbeing The University of Newcastle, Central Coast Clinical School, Gosford Hospital Gosford New South Wales Australia
| | - Caleb Ferguson
- Western Sydney University Parramatta New South Wales Australia
- Western Sydney Nursing and Midwifery Research Centre Western Sydney Local Health District and Western Sydney University, Blacktown Clinical and Research School, Blacktown Hospital Blacktown New South Wales Australia
- School of Nursing, Faculty of Science, Medicine and Health University of Wollongong Wollongong New South Wales Australia
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Akbar MR, Febrianora M, Iqbal M. Warfarin Usage in Patients with Atrial Fibrillation Undergoing Hemodialysis in Indonesian Population. Curr Probl Cardiol 2022; 48:101104. [PMID: 35041867 DOI: 10.1016/j.cpcardiol.2022.101104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 12/16/2021] [Accepted: 01/03/2022] [Indexed: 11/16/2022]
Abstract
The data about the efficacy and safety of warfarin usage in atrial fibrillation (AF) in hemodialysis patients is still limited, especially in the Asia population. The population of this study was end-stage renal disease patients with AF who underwent hemodialysis. The design of the study was a retrospective observational cohort that collected the patient data from 2016 to 2019. The Cox regression model was applied to assess the effect of warfarin on the outcomes. We conducted a survival analysis by comparing Kaplan-Meier curves using the log-rank test. We also measured the time in therapeutic range as a quality indicator of warfarin usage. Among 444 hemodialysis patients, 126 patients with AF matched the inclusion criteria, 88 patients completely followed up. Half patients used warfarin. The mean age was 52.2 ± 12.97 years, the mean follow-up duration was 11 ± 10 months. We observed all-cause death in 86.4% of patients, ischemic stroke in 10.2%, and hemorrhagic stroke in 2.3% of patients. There were no significant differences in all-cause death, ischemic stroke, and hemorrhagic stroke. Warfarin use was not associated with a lower rate for death (HR 0.782; 95% CI, 0.494-1.237, P = 0.293) or ischemic stroke (HR 0.435; 95% CI, 0.103-1.846, P = 0.259) or hemorrhagic stroke (HR 0.564; 95% CI, 0.034-9.386, P = 0.689). None of the patients reach the time in the therapeutic range >65%. Our findings suggest that warfarin has no association with mortality, ischemic stroke, and hemorrhagic stroke events rate in atrial fibrillation patients who underwent hemodialysis in the Indonesian population.
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Affiliation(s)
- Mohammad Rizki Akbar
- Department of Cardiology and Vascular Medicine, Hasan Sadikin General Hospital - Universitas Padjadjaran, Bandung, Indonesia.
| | - Mega Febrianora
- Department of Cardiology and Vascular Medicine, Hasan Sadikin General Hospital - Universitas Padjadjaran, Bandung, Indonesia
| | - Mohammad Iqbal
- Department of Cardiology and Vascular Medicine, Hasan Sadikin General Hospital - Universitas Padjadjaran, Bandung, Indonesia
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Agudo-Fernández S, Castaño Milla C, González Blanco A, Olmos Jerez JA, Calvo Morillas I, Sancho Del Val L. RHEDAR study: Determination of the risk of gastrointestinal hemorrhage in treatment with dabigatran, acenocoumarol and rivaroxaban. J Gastroenterol Hepatol 2021; 36:2794-2802. [PMID: 33978991 DOI: 10.1111/jgh.15547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/18/2021] [Accepted: 05/08/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Atrial fibrillation is a major cause of death and disability due to stroke. Vitamin K antagonist drugs are effective for prevention, but they have a narrow therapeutic range and multiple pharmacological interactions. In recent years, new therapeutic alternatives have been searched to minimize complications. The main objective is to evaluate the risk of gastrointestinal bleeding in anticoagulated patients and compare the classic treatment with new anticoagulants. METHODS We conducted a retrospective cohort study to determine the risk of gastrointestinal bleeding in patients treated with acenocoumarol/dabigatran/rivaroxaban, between 2012 and 2016. We compared the classic with the new anticoagulant group, and a multivariate logistic regression analysis was used to determinate the risk factors of gastrointestinal bleeding. RESULTS A total of 1213 patients were selected, 52.7% male patients, a mean age of 72.6 years old (± 14.563). 73.6% had atrial fibrilation. 14.5% of patients used acetylsalicylic acid, and 4% clopidogrel. 67.2% had a high-risk CHADS-2 Score, and 36.9% a high-risk HAS-BLED Score. We determined a 5.6% (68) of gastrointestinal bleeding, without differences according to anticoagulant used. The multivariate model showed a greater risk for digestive hemorrhage in patients with a previous hemorrhagic event (odds ratio [OR] = 2.422 95% confidence interval [CI]: 1.101-5.327) and the concomitant therapy with clopidogrel (OR = 2.373 95% CI: 0.996-5.652). CONCLUSIONS No differences were found in the risk of gastrointestinal bleeding between the different anticoagulants. A previous gastrointestinal bleeding were considered independent risk factor. The HAS-BLED score should be taken into account to make clinical decisions about to prescribe anticoagulant treatment.
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Affiliation(s)
| | - Carlos Castaño Milla
- Department of Gastroenterology, Rey Juan Carlos Hospital, Móstoles, Madrid, Spain
| | - Ana González Blanco
- Department of Gastroenterology, Rey Juan Carlos Hospital, Móstoles, Madrid, Spain
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Burkhard JPM, Pitteloud C, Klukowska-Rötzler J, Exadaktylos AK, Iizuka T, Schaller B. Changing trends in epidemiology and management of facial trauma in a Swiss geriatric population. Gerodontology 2019; 36:358-364. [PMID: 31274224 DOI: 10.1111/ger.12410] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 12/08/2018] [Revised: 03/25/2019] [Accepted: 04/06/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the prevalence and surgical treatment of facial fractures in a Swiss population aged 65 and over. BACKGROUND The knowledge of the characteristics of geriatric trauma may help to prevent injuries and better allocate clinical resources for the management of multimorbid patients. MATERIAL AND METHODS This study retrospectively evaluated a cohort of 181 patients who presented at the Bern University Hospital in Switzerland from May 2012 to September 2016. Data on age, gender, aetiology and type of trauma, treatment and complications, co-morbidities and associated injuries were obtained. RESULTS Women were most frequently affected (55.2%). Mean age was 80 years. Zygomatic complex fractures were the most frequent type of fractures (37%), followed by isolated orbital fractures (27.6%). Falls were the most common cause of trauma (76.1%). Thirty-five per cent of all patients were taking anticoagulation or platelet aggregation medication. Hospitalisation was required in 88.4%, whereby 92.3% of the patients underwent surgical treatment. Surgery had to be performed immediately in three cases to treat compression of the optic nerve. Median hospital length of stay was 4 days, with 68% of patients returning to a domestic environment and 32% being transferred to another institution for further treatment. CONCLUSION The most common cause of facial injuries is a fall while standing in a domestic environment. Midface fractures were the most common type of fractures.
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Affiliation(s)
- John Patrik Matthias Burkhard
- Department of Cranio-Maxillofacial Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Caroline Pitteloud
- Department of Cranio-Maxillofacial Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Jolanta Klukowska-Rötzler
- Department of Emergency Medicine, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | | | - Tateyuki Iizuka
- Department of Cranio-Maxillofacial Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Benoit Schaller
- Department of Cranio-Maxillofacial Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
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Cha YH, Lee YK, Koo KH, Wi C, Lee KH. Difference in Mortality Rate by Type of Anticoagulant in Elderly Patients with Cardiovascular Disease after Hip Fractures. Clin Orthop Surg 2019; 11:15-20. [PMID: 30838103 PMCID: PMC6389530 DOI: 10.4055/cios.2019.11.1.15] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 09/17/2018] [Accepted: 10/16/2018] [Indexed: 12/26/2022] Open
Abstract
Background The purpose of this study was to investigate the difference in mortalilty rate between cardiovascular disease (CVD) patients and non-CVD patients after hip fracture surgery performed in elderly patients. In addition, we compared the effect of CVD medication on mortality after hip fracture surgery. Methods Patients who underwent surgery for femoral intertrochanteric or neck fracture from January 2003 to December 2013 were enrolled in this study. After applying exclusion criteria, we categorized patients into group I (833 patients, non-CVD group) and group II (811 patients, CVD group). The CVD group was subcategorized as group IIa (332 patients, no medication), group IIb (381 patients, antiplatelet agents), and group IIc (98 patients, anticoagulation agents). Cumulative mortality rate at 30 days, 60 days, 3 months, and 1 year were compared between the groups. Results In the 1,644 patients, the cumulative mortality rate at 30 days, 60 days, 3 months, and 1 year was 0.1%, 0.5%, 0.7%, and 8.2%, respectively, in group I and 1.0%, 1.6%, 2.5%, and 8.8%, respectively, in group II (p = 0.02, p = 0.03. p = 0.01, and p = 0.72, respectively). In the 811 group II patients, the cumulative mortality rate at 30 days, 60 days, 3 months, and 1 year was 0.3%, 0.6%, 1.2%, and 6.6%, respectively, in group IIa; 0.8%, 1.6%, 2.1%, and 9.4%, respectively, in group IIb; and 4.1%, 5.1%, 8.2%, and 13.3%, respectively, in group IIc (p = 0.003, p = 0.01, p = 0.004, and p = 0.10, respectively). Conclusions CVD increases short-term mortality within 30 days, 60 days, and 3 months in elderly hip fracture patients. The use of anticoagulants in CVD patients increases the rate of surgical delay and short-term mortality within 30 days, 60 days, and 3 months.
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Affiliation(s)
- Yong-Han Cha
- Department of Orthopaedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Young-Kyun Lee
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kyung-Hoi Koo
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Chankuk Wi
- Department of Orthopedic Surgery, National Medical Center, Seoul, Korea
| | - Kyung-Hag Lee
- Department of Orthopedic Surgery, National Medical Center, Seoul, Korea
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Heywood EG, Drake TM, Bradburn M, Lee J, Wilson MJ, Lee MJ. Atrial Fibrillation After Gastrointestinal Surgery: Incidence and Associated Risk Factors. J Surg Res 2019; 238:23-8. [PMID: 30735962 DOI: 10.1016/j.jss.2019.01.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/17/2018] [Accepted: 01/08/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a common dysrhythmia that can occur after major physiological stress including surgery (postoperative AF). There are few data on postoperative AF after abdominal surgery. We set out to define the incidence of de novo postoperative AF after abdominal surgery and associated risk factors. METHODS The Patient History Integrated Data store administrative database was interrogated for patients aged ≥65 y undergoing abdominal surgery from April 2012 to April 2014. Patients with pre-existing AF were excluded. The primary outcome was diagnosis of AF. RESULTS Two thousand nine hundred and sixty-seven cases were included of whom 187 developed postoperative AF within 90 d (6.3%). The rate of postoperative AF varied by operation and was highest in small bowel resection (17.2%) and lowest in biliary surgery (4.8%). Median time to detection of postoperative AF was 32 d. Patients who developed postoperative AF were significantly older than those who did not develop AF (median age 75.3 y versus 72.4 y, P < 0.01). Logistic regression modeling found increasing age (odds ratio [OR] 1.03 [confidence interval {CI} 1.01-1.06], hypertension OR 1.73 [CI 1.19-2.51]), congestive cardiac failure (OR 3.04 [CI 1.88-4.92], and vascular disease OR 2.29 [CI 1.39-3.37]) were predictive of the development of postoperative AF within 30 d. The area under the curve for this model was 0.733. CONCLUSIONS Postoperative AF affects a significant number of patients after abdominal surgery. Demographics such as history of cardiovascular disease might aid prediction of postoperative AF. Postoperative AF is mostly identified after discharge, suggesting the need for postoperative screening.
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Romero J, Avendano R, Diaz JC, Taveras J, Lupercio F, Di Biase L. Is it safe to stop oral anticoagulation after catheter ablation for atrial fibrillation? Expert Rev Cardiovasc Ther 2018; 17:31-41. [DOI: 10.1080/14779072.2019.1550718] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 12/19/2022]
Affiliation(s)
- Jorge Romero
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ricardo Avendano
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Juan Carlos Diaz
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jose Taveras
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Florentino Lupercio
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Luigi Di Biase
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Oh S, Kim JS, Oh YS, Shin DG, Pak HN, Hwang GS, Choi KJ, Kim JB, Lee MY, Park HW, Kim DK, Jin ES, Park J, Oh IY, Shin DH, Park HS, Kim JH, Kim NH, Ahn MS, Seo BJ, Kim YJ, Kang S, Lee J, Kim YH. Quality of Anticoagulation and Treatment Satisfaction in Patients with Non-Valvular Atrial Fibrillation Treated with Vitamin K Antagonist: Result from the KORean Atrial Fibrillation Investigation II. J Korean Med Sci 2018; 33:e323. [PMID: 30505257 PMCID: PMC6262187 DOI: 10.3346/jkms.2018.33.e323] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 08/07/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Vitamin K antagonist (VKA) to prevent thromboembolism in non-valvular atrial fibrillation (NVAF) patients has limitations such as drug interaction. This study investigated the clinical characteristics of Korean patients treated with VKA for stroke prevention and assessed quality of VKA therapy and treatment satisfaction. METHODS We conducted a multicenter, prospective, non-interventional study. Patients with CHADS2 ≥ 1 and treated with VKA (started within the last 3 months) were enrolled from April 2013 to March 2014. Demographic and clinical features including risk factors of stroke and VKA treatment information was collected at baseline. Treatment patterns and international normalized ratio (INR) level were evaluated during follow-up. Time in therapeutic range (TTR) > 60% indicated well-controlled INR. Treatment satisfaction on the VKA use was measured by Treatment Satisfaction Questionnaire for Medication (TSQM) after 3 months of follow-up. RESULTS A total of 877 patients (age, 67; male, 60%) were enrolled and followed up for one year. More than half of patients (56%) had CHADS2 ≥ 2 and 83.6% had CHA2DS2-VASc ≥ 2. A total of 852 patients had one or more INR measurement during their follow-up period. Among those patients, 25.5% discontinued VKA treatment during follow-up. Of all patients, 626 patients (73%) had poor-controlled INR (TTR < 60%) measure. Patients' treatment satisfaction measured with TSQM was 55.6 in global satisfaction domain. CONCLUSION INR was poorly controlled in Korean NVAF patients treated with VKA. VKA users also showed low treatment satisfaction.
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Affiliation(s)
- Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - June-Soo Kim
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong-Seog Oh
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-Gu Shin
- Department of Internal Medicine, Yeungnam University Hospital, Yeungnam University College of Medicine, Daegu, Korea
| | - Hui-Nam Pak
- Department of Internal Medicine, Severance Hospital, Yonsei University Health System, Seoul, Korea
| | - Gyo-Seung Hwang
- Department of Internal Medicine, Ajou University Hospital, Suwon, Korea
| | - Kee-Joon Choi
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Bae Kim
- Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University School of Medicine, Seoul, Korea
| | - Man-Young Lee
- Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyung-Wook Park
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Dae-Kyeong Kim
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Eun-Sun Jin
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jaeseok Park
- Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea
| | - Il-Young Oh
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dae-Hee Shin
- Department of Internal Medicine, Gangneung Asan Hospital, Gangneung, Korea
| | - Hyoung-Seob Park
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Keimyung University College of Medicine, Daegu, Korea
| | - Jun Hyung Kim
- Department of Internal Medicine, Chungnam National University College of Medicine, Chungnam, Korea
| | - Nam-Ho Kim
- Department of Internal Medicine, Wonkwang University Hospital, Iksan, Korea
| | - Min-Soo Ahn
- Department of Internal Medicine, Yonsei University, Wonju Severance Christian Hospital, Wonju, Korea
| | - Bo-Jeong Seo
- Outcomes Research/Real World Data, Corporate Affairs & Health and Value, Pfizer Pharmaceuticals Korea Ltd., Seoul, Korea
| | - Young-Joo Kim
- Outcomes Research/Real World Data, Corporate Affairs & Health and Value, Pfizer Pharmaceuticals Korea Ltd., Seoul, Korea
| | - Seongsik Kang
- Department of Internal Medicine-Medical, Pfizer Pharmaceuticals Korea Ltd., Seoul, Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Young-Hoon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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Wang X, Fu Q, Song F, Li W, Yin X, Yue W, Yan F, Zhang H, Zhang H, Teng Z, Wang L, Gong Y, Wang Z, Lu Z. Prevalence of atrial fibrillation in different socioeconomic regions of China and its association with stroke: Results from a national stroke screening survey. Int J Cardiol 2018; 271:92-97. [DOI: 10.1016/j.ijcard.2018.05.131] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 05/14/2018] [Accepted: 05/31/2018] [Indexed: 02/08/2023]
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Moores TS, Chatterton BD, Walker MJ, Roberts PJ. Standardised Warfarin Reversal Expedites Time to Theatre for Fractured Neck of Femur Surgery and Improves Mortality Rates: A Matched Cohort Study. Adv Orthop 2018; 2018:4791214. [PMID: 30420922 PMCID: PMC6215594 DOI: 10.1155/2018/4791214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 09/23/2018] [Accepted: 09/30/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND This study aims to evaluate outcomes for warfarinised hip fracture patients and compare them with a matched nonwarfarinised group, before and after the introduction of national hip fracture guidelines in the United Kingdom. METHODS A retrospective cohort study of 1743 hip fracture patients was undertaken. All patients admitted taking warfarin were identified. These patients were then matched to nonwarfarinised patients using nearest neighbour propensity score matching, accounting for age, sex, hip fracture type, and Nottingham Hip Fracture Score. A pre-guideline group (no standardised warfarin reversal regimen) and a post-guideline group (standardised regimen) were identified. Outcomes assessed included time to INR less than 1.7, time to theatre, length of stay, and 30-day and 1-year mortality. RESULTS Forty-six warfarinised hip fracture patients were admitted in the pre-guideline group (mean age 80.5, F:M 3:1) and 48 in the post-guideline group (mean age 81.2 years, F:M 3:1). Post-guideline patients were reversed to a safe operative INR level within 18 hours of admission, decreasing the time to first dose vitamin K (p<0.001). 70% of warfarinised patients were operated upon within 36 hours, compared to 19.6% with no regimen (p<0.05). After anticoagulation reversal protocol, thirty-day mortality decreased from 15.2% to 8.3% and 1-year mortality from 43.5% to 33% for warfarinised patients, which is comparable to nonwarfarinised matched patients. There was no significant change in the length of stay pre- and post-guideline for both groups of patients. CONCLUSIONS Proactive anticoagulant management and expedient surgery reduces morbidity and mortality when managing this surgically challenging subset of hip fracture patients.
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Affiliation(s)
- Thomas S. Moores
- Department of Trauma and Orthopaedics, Royal Stoke University Hospital, Stoke-on-Trent, Staffordshire, UK
| | - Benjamin D. Chatterton
- Department of Trauma and Orthopaedics, Royal Stoke University Hospital, Stoke-on-Trent, Staffordshire, UK
| | - Matthew J. Walker
- Department of Trauma and Orthopaedics, Royal Stoke University Hospital, Stoke-on-Trent, Staffordshire, UK
| | - Phillip J. Roberts
- Department of Trauma and Orthopaedics, Royal Stoke University Hospital, Stoke-on-Trent, Staffordshire, UK
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13
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Abstract
Objective: The authors aimed at reporting on whether or not primary care doctors follow atrial fibrillation (AF) treatment protocols, and on the mental distress of such patients. Methods: A total of 138 patients with first detected or recurrent AF were examined in a health center. Demographic data were collected and their lifestyle and medical history for rhythm-related pathologies and chronic medication were investigated. Physical examination, electrocardiogram (EKG), and in selected cases, lab analysis were carried-out. CHADS2 index was used for assessing the stroke risk in patients with AF, while the General Health Questionnaire-12 (GHQ-12) for personal health perception was performed in all patients. Results: According to CHADS2 the majority of the patients had at least 1 risk factor and half of those receiving oral vitamin K antagonists presented an out-of-range international normalized ratio (INR). In 24 cases, patients used both aspirin and oral anticoagulants, while in 41 cases, medication was corrected according to index. GHQ-12 seemed to be significantly worse in paroxysmal and persistent cases, as well as in women with recurrent AF. Many paroxysmal AF patients under 75 years continued caffeine intake, whereas an extensive use of benzodiazepines was noticed in the majority of patients. Conclusions: Shortages and limitations of the peripheral or rural units and health centers and inadequate knowledge and application of the guidelines, seemed to be major factors responsible for mismanaging AF patients. More education in prehospital cardiology may contribute in improving management of arrhythmias in primary care.
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14
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Abstract
BACKGROUND Atrial fibrillation is the commonest cardiac dysrhythmia. It is associated with significant morbidity and mortality. There are two approaches to the management of atrial fibrillation: controlling the ventricular rate or converting to sinus rhythm in the expectation that this would abolish its adverse effects. OBJECTIVES To assess the effects of pharmacological cardioversion of atrial fibrillation in adults on the annual risk of stroke, peripheral embolism, and mortality. SEARCH METHODS We searched the Cochrane Controlled Trials Register (Issue 3, 2002), MEDLINE (2000 to 2002), EMBASE (1998 to 2002), CINAHL (1982 to 2002), Web of Science (1981 to 2002). We hand searched the following journals: Circulation (1997 to 2002), Heart (1997 to 2002), European Heart Journal (1997-2002), Journal of the American College of Cardiology (1997-2002) and selected abstracts published on the web site of the North American Society of Pacing and Electrophysiology (2001, 2002). SELECTION CRITERIA Randomised controlled trials or controlled clinical trials of pharmacological cardioversion versus rate control in adults (>18 years) with acute, paroxysmal or sustained atrial fibrillation or atrial flutter, of any duration and of any aetiology. DATA COLLECTION AND ANALYSIS One reviewer applied the inclusion criteria and extracted the data. Trial quality was assessed and the data were entered into RevMan. MAIN RESULTS We identified two completed studies AFFIRM (n=4060) and PIAF (n=252). We found no difference in mortality between rhythm control and rate control relative risk 1.14 (95% confidence interval 1.00 to 1.31).Both studies show significantly higher rates of hospitalisation and adverse events in the rhythm control group and no difference in quality of life between the two treatment groups.In AFFIRM there was a similar incidence of ischaemic stroke, bleeding and systemic embolism in the two groups. Certain malignant dysrhythmias were significantly more likely to occur in the rhythm control group. There were similar scores of cognitive assessment.In PIAF, cardioverted patients enjoyed an improved exercise tolerance but there was no overall benefit in terms of symptom control or quality of life. AUTHORS' CONCLUSIONS There is no evidence that pharmacological cardioversion of atrial fibrillation to sinus rhythm is superior to rate control. Rhythm control is associated with more adverse effects and increased hospitalisation. It does not reduce the risk of stroke. The conclusions cannot be generalised to all people with atrial fibrillation. Most of the patients included in these studies were relatively older (>60 years) with significant cardiovascular risk factors.
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Affiliation(s)
- John Cordina
- Victoria HospitalWard 11Hayfield RoadKirkcaldyUKKY2 5AH
| | - Gillian E Mead
- University of EdinburghCentre for Clinical Brain SciencesRoom S1642, Royal InfirmaryLittle France CrescentEdinburghUKEH16 4SA
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15
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Abstract
BACKGROUND Atrial fibrillation increases stroke risk and adversely affects cardiovascular haemodynamics. Electrical cardioversion may, by restoring sinus rhythm, improve cardiovascular haemodynamics, reduce the risk of stroke, and obviate the need for long-term anticoagulation. OBJECTIVES To assess the effects of electrical cardioversion of atrial fibrillation or flutter on the risk of thromboembolic events, strokes and mortality (primary outcomes), the rate of cognitive decline, quality of life, the use of anticoagulants and the risk of re-hospitalisation (secondary outcomes) in adults (>18 years). SEARCH METHODS We searched the Cochrane CENTRAL Register of Controlled Trials (1967 to May 2004), MEDLINE (1966 to May 2004), Embase (1980 to May 2004), CINAHL (1982 to May 2004), proceedings of the American College of Cardiology (published in Journal of the American College of Cardiology 1983 to 2003), www.trialscentral.org, www.controlled-trials.com and reference lists of articles. We hand-searched the indexes of the Proceedings of the British Cardiac Society published in British Heart Journal (1980 to 1995) and in Heart (1995 to 2002); proceedings of the European Congress of Cardiology and meetings of the Joint Working Groups of the European Society of Cardiology (published in European Heart Journal 1983-2003); scientific sessions of the American Heart Association (published in Circulation 1990-2003). Personal contact was made with experts. SELECTION CRITERIA Randomised controlled trial or controlled clinical trials of electrical cardioversion plus 'usual care' versus 'usual care' only, where 'usual care' included any combination of anticoagulants, antiplatelet drugs and drugs for 'rate control'. We excluded trials which used pharmacological cardioversion as the first intervention, and trials of new onset atrial fibrillation after cardiac surgery. There were no language restrictions. DATA COLLECTION AND ANALYSIS For dichotomous data, odds ratios were calculated; and for continuous data, the weighted mean difference was calculated. MAIN RESULTS We found three completed trials of electrical cardioversion (rhythm control) versus rate control, recruiting a total of 927 participants (Hot Cafe; RACE; STAF) and one ongoing trial (J-RHYTHM). There was no difference in mortality between the two strategies (OR 0.83; CI 0.48 to 1.43). There was a trend towards more strokes in the rhythm control group (OR 1.9; 95% CI 0.99 to 3.64). At follow up, three domains of quality of life (physical functioning, physical role function and vitality) were significantly better in the rhythm control group (RACE 2002; STAF 2003). AUTHORS' CONCLUSIONS Electrical cardioversion (rhythm control) led to a non-significant increase in stroke risk but improved three domains of quality of life.
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Affiliation(s)
- Gillian E Mead
- University of EdinburghCentre for Clinical Brain SciencesRoom S1642, Royal InfirmaryLittle France CrescentEdinburghUKEH16 4SA
| | - Andrew Elder
- Royal Victoria Hospital13 Craigleth RoadEdinburghUK
| | - Andrew D Flapan
- Royal Infirmary of EdinburghDepartment of CardiologyDepartment of Cardiology, New Royal InfirmaryLittle France CrescentEdinburghUKEH16 4SB
| | - John Cordina
- Victoria HospitalWard 11Hayfield RoadKirkcaldyUKKY2 5AH
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16
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Skurk C, Hartung JJ, Landmesser U. [Recent and upcoming randomized trials for left atrial appendage occlusion : Need for a definite assessment of the situation]. Herzschrittmacherther Elektrophysiol 2017; 28:395-402. [PMID: 29101545 DOI: 10.1007/s00399-017-0534-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 08/22/2017] [Accepted: 10/05/2017] [Indexed: 01/20/2023]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia affecting more than 1.6 million patients in Germany. Based on demographic developments, an the number is expected to increase. Embolic strokes in AF patients are particularly severe, and individualized new oral anticoagulant (NOAC) therapy reduces the incidence of stroke in these patients by approximately 70%. Besides vitamin K antagonists, the NOACs rivaroxaban, dabigatran, apixaban, and edoxaban have been introduced into clinical practice; however, major bleeding still occurs at a rate of 2-3% per year. Moreover, randomized studies and real-life registries suggest that >20% of patients with AF and an indication for anticoagulation cannot tolerate chronic oral anticoagulant therapy. Therefore, an alternative method for stroke prevention in AF patients has been developed, i. e., catheter-based exclusion of the left atrial appendage (LAA), a location that is prone for thrombus formation in these patients. The randomized trials of catheter-based LAA occlusion have compared this interventional therapy with vitamin K antagonists. In the future, however, LAA exclusion needs to be compared with NOAC therapy. Moreover, percutaneous LAA exclusion in clinical practice is mostly offered to patients ineligible for long-term oral anticoagulation or with high bleeding risk. However, no controlled, randomized trial data exist for this patient population. These data are needed for appropriate clinical judgment and optimal clinical management. Ongoing studies and scientific questions that are important to define the future for catheter-based LAA closure are discussed in this review.
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Affiliation(s)
- Carsten Skurk
- Medizinische Klinik für Kardiologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Deutschland.,Standort Berlin, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Berlin, Deutschland
| | - Johannes Jakob Hartung
- Medizinische Klinik für Kardiologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Deutschland.,Standort Berlin, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Berlin, Deutschland
| | - Ulf Landmesser
- Medizinische Klinik für Kardiologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Deutschland. .,Standort Berlin, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Berlin, Deutschland. .,Berlin Institute of Health (BIH), Berlin, Deutschland.
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17
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Eckman MH, Lip GYH, Wise RE, Speer B, Sullivan M, Walker N, Kissela B, Flaherty ML, Kleindorfer D, Baker P, Ireton R, Hoskins D, Harnett BM, Aguilar C, Leonard A, Arduser L, Steen D, Costea A, Kues J. Using an Atrial Fibrillation Decision Support Tool for Thromboprophylaxis in Atrial Fibrillation: Effect of Sex and Age. J Am Geriatr Soc 2017; 64:1054-60. [PMID: 27225358 DOI: 10.1111/jgs.14099] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To assess the appropriateness of oral anticoagulant therapy (OAT) in women and elderly adults, looking for patterns of undertreatment or unnecessary treatment. DESIGN Retrospective cohort study. SETTING Primary care practices of an academic healthcare system. PARTICIPANTS Adults (aged 28-93) with nonvalvular atrial fibrillation (AF) seen between March 2013 and February 2014 (N = 1,585). MEASUREMENTS Treatment recommendations were made using an AF decision support tool (AFDST) based on projections of quality-adjusted life expectancy calculated using a decision analytical model that integrates individual-specific risk factors for stroke and hemorrhage. RESULTS Treatment was discordant from AFDST-recommended treatment in 45% (326/725) of women and 39% (338/860) of men (P = .02). Although current treatment was discordant from recommended in 35% (89/258) of participants aged 85 and older and in 43% (575/1,328) of those younger than 85 (P = .01), many undertreated elderly adults were receiving aspirin as the sole antithrombotic agent. CONCLUSION Physicians should understand that female sex is a significant risk factor for AF-related stroke and incorporate this into decision-making about thromboprophylaxis. Treating older adults with aspirin instead of OAT exposes them to significant risk of bleeding with little to no reduction in AF-related stroke risk.
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Affiliation(s)
- Mark H Eckman
- Division of General Internal Medicine, University of Cincinnati, Cincinnati, Ohio.,Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, Ohio.,Center for Health Informatics, University of Cincinnati, Cincinnati, Ohio
| | - Gregory Y H Lip
- Centre for Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Ruth E Wise
- Division of General Internal Medicine, University of Cincinnati, Cincinnati, Ohio.,Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, Ohio
| | - Barbara Speer
- Department of Family and Community Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Megan Sullivan
- Academic Health Center, University of Cincinnati, Cincinnati, Ohio
| | - Nita Walker
- Division of General Internal Medicine, University of Cincinnati, Cincinnati, Ohio.,Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, Ohio
| | - Brett Kissela
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio
| | | | - Dawn Kleindorfer
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio
| | - Peter Baker
- Center for Health Informatics, University of Cincinnati, Cincinnati, Ohio
| | - Robert Ireton
- Center for Health Informatics, University of Cincinnati, Cincinnati, Ohio
| | - Dave Hoskins
- Center for Health Informatics, University of Cincinnati, Cincinnati, Ohio
| | - Brett M Harnett
- Center for Health Informatics, University of Cincinnati, Cincinnati, Ohio
| | - Carlos Aguilar
- Center for Health Informatics, University of Cincinnati, Cincinnati, Ohio
| | - Anthony Leonard
- Department of Family and Community Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Lora Arduser
- Department of English, University of Cincinnati, Cincinnati, Ohio
| | - Dylan Steen
- Division of Cardiology, University of Cincinnati, Cincinnati, Ohio
| | - Alexandru Costea
- Division of Cardiology, University of Cincinnati, Cincinnati, Ohio
| | - John Kues
- Department of Family and Community Medicine, University of Cincinnati, Cincinnati, Ohio
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18
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Ogawa H, Hamatani Y, Doi K, Tezuka Y, An Y, Ishii M, Iguchi M, Masunaga N, Esato M, Chun YH, Tsuji H, Wada H, Hasegawa K, Abe M, Lip GY, Akao M. Sex-Related Differences in the Clinical Events of Patients With Atrial Fibrillation - The Fushimi AF Registry. Circ J 2017; 81:1403-1410. [PMID: 28539562 DOI: 10.1253/circj.cj-17-0071] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Female sex is considered a risk factor for thromboembolism in patients with atrial fibrillation (AF), and is included in the risk stratification scheme, CHA2DS2-VASc score. The purpose of the present study was to investigate the clinical outcomes of female Japanese AF patients.Methods and Results:The Fushimi AF Registry is a community-based prospective survey of the AF patients in Fushimi-ku, Kyoto. Follow-up data were available for 3,878 patients. Female AF patients (n=1,551, 40.0%) were older (77.0 vs. 71.4 years; P<0.001) than male patients (n=2,327, 60.0%). Female patients were more likely to have heart failure (31.1% vs. 23.7%; P<0.001). Previous stroke incidence (19.2% vs. 21.4%; P=0.083) was comparable between male and female patients. During the median follow-up period of 1,102 days, Cox regression analysis demonstrated that female sex was not independently associated with a risk of stroke or systemic embolism (adjusted hazard ratio [HR] 0.74; 95% confidence interval [CI]: 0.54-1.00, P=0.051). However, female sex showed an association with a lower risk of intracranial hemorrhage (adjusted HR 0.54; 95% CI: 0.30-0.95, P=0.032) and all-cause death (adjusted HR 0.56; 95% CI: 0.46-0.68, P<0.001). CONCLUSIONS We demonstrated that female sex is not independently associated with an increased risk of thromboembolism, but is associated with a decreased risk of intracranial hemorrhage and all-cause death in Japanese AF patients enrolled in the Fushimi AF Registry.
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Affiliation(s)
- Hisashi Ogawa
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Yasuhiro Hamatani
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Kosuke Doi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Yuji Tezuka
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Yoshimori An
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Mitsuru Ishii
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Moritake Iguchi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Nobutoyo Masunaga
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Masahiro Esato
- Department of Arrhythmia, Ijinkai Takeda General Hospital
| | - Yeong-Hwa Chun
- Department of Arrhythmia, Ijinkai Takeda General Hospital
| | | | - Hiromichi Wada
- Division of Translational Research, National Hospital Organization Kyoto Medical Center
| | - Koji Hasegawa
- Division of Translational Research, National Hospital Organization Kyoto Medical Center
| | - Mitsuru Abe
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Gregory Yh Lip
- Institute of Cardiovascular Sciences, University of Birmingham.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
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19
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Alipour A, Wintgens LIS, Swaans MJ, Balt JC, Rensing BJWM, Boersma LVA. Novel stroke risk reduction in atrial fibrillation: left atrial appendage occlusion with a focus on the Watchman closure device. Vasc Health Risk Manag 2017; 13:81-90. [PMID: 28293114 PMCID: PMC5345987 DOI: 10.2147/vhrm.s89213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Atrial fibrillation (AF) remains an important clinical problem with severe complications such as stroke, which especially harms those with risk factors as calculated by the CHADS2 or CHA2DS2-VASc. Until now, no therapy has proven 100% effective against AF. Since the left atrial appendage (LAA) is the most prominent nonvalvular AF-related thromboembolic source and (novel) oral anticoagulant [(N)OAC] carries the hazard of bleeding, LAA occlusion may be an alternative, especially in patients who are ineligible for (N)OAC therapy. In this review, we discuss several LAA occlusion techniques with a focus on the Watchman device since this device is the most thoroughly studied device of all.
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Affiliation(s)
- Arash Alipour
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | - Martin J Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Jippe C Balt
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Benno J W M Rensing
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Lucas V A Boersma
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
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20
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Mas Dalmau G, Sant Arderiu E, Enfedaque Montes MB, Solà I, Pequeño Saco S, Alonso Coello P. Patients' and physicians' perceptions and attitudes about oral anticoagulation and atrial fibrillation: a qualitative systematic review. BMC Fam Pract 2017; 18:3. [PMID: 28086887 PMCID: PMC5234257 DOI: 10.1186/s12875-016-0574-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 12/07/2016] [Indexed: 11/17/2022]
Abstract
Background Oral anticoagulant therapy reduces the risk of stroke in patients with atrial fibrillation, but many patients are still not prescribed this therapy. The causes of underuse of vitamin K antagonists oral anticoagulants are not clear but could be related, in part, to patients’ and physicians’ perceptions and attitudes towards the benefits and downsides of this treatment. The purpose of this systematic review was to evaluate and synthesize patients’ and physicians’ perceptions and attitudes towards the benefits and downsides of vitamin K antagonist, in order to explore potential factors related with its underuse. Methods We included studies that used qualitative or mixed methods and focused on patients’ and/or physicians’ perceptions and attitudes towards oral anticoagulation. We systematically searched PubMed, EMBASE, ISI WoK, and PsycINFO from their inception until May 2013. Two reviewers independently assessed the quality of the included studies and synthesized results using a thematic analysis approach. Results We included a total of nine studies. In four studies, the quality assessed was excellent and in five was moderate. We identified three themes that were of interest to both physicians and patients: information to reinforce anticoagulation use, balance of benefits and downsides, roles in decision-making and therapy management. Three additional themes were of interest to patients: knowledge and understanding, impact on daily life, and satisfaction with therapy. The main difficulties with the use of anticoagulant treatment according to physicians were the perceived uncertainty, need of individualised decision-making, and the feeling of delegated responsibility as their main concerns. The main factors for patients were the lack of information and understanding. Conclusion Physicians’ and patients’ perceptions and attitudes might be potential factors in the underuse of treatment with vitamin K antagonists. Improving the quality and usability of clinical guidelines, developing tools to help with the decision-making, enhancing coordination between primary care and hospital care, and improving information provided to patients could help improve the underuse of anticoagulation. Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0574-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gemma Mas Dalmau
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.
| | - Elisenda Sant Arderiu
- Consorci d'Atenció Primària de Salut de l'Eixample (CAPSE), CAP Casanova, Barcelona, Spain
| | | | - Ivan Solà
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Sandra Pequeño Saco
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain
| | - Pablo Alonso Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
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21
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Mas Dalmau G, Sant Arderiu E, Enfedaque Montes MB, Solà I, Pequeño Saco S, Alonso Coello P. Patients' and physicians' perceptions and attitudes about oral anticoagulation and atrial fibrillation: a qualitative systematic review. BMC Fam Pract 2017. [PMID: 28086887 DOI: 10.1186/s12875‐016‐0574‐0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Oral anticoagulant therapy reduces the risk of stroke in patients with atrial fibrillation, but many patients are still not prescribed this therapy. The causes of underuse of vitamin K antagonists oral anticoagulants are not clear but could be related, in part, to patients' and physicians' perceptions and attitudes towards the benefits and downsides of this treatment. The purpose of this systematic review was to evaluate and synthesize patients' and physicians' perceptions and attitudes towards the benefits and downsides of vitamin K antagonist, in order to explore potential factors related with its underuse. METHODS We included studies that used qualitative or mixed methods and focused on patients' and/or physicians' perceptions and attitudes towards oral anticoagulation. We systematically searched PubMed, EMBASE, ISI WoK, and PsycINFO from their inception until May 2013. Two reviewers independently assessed the quality of the included studies and synthesized results using a thematic analysis approach. RESULTS We included a total of nine studies. In four studies, the quality assessed was excellent and in five was moderate. We identified three themes that were of interest to both physicians and patients: information to reinforce anticoagulation use, balance of benefits and downsides, roles in decision-making and therapy management. Three additional themes were of interest to patients: knowledge and understanding, impact on daily life, and satisfaction with therapy. The main difficulties with the use of anticoagulant treatment according to physicians were the perceived uncertainty, need of individualised decision-making, and the feeling of delegated responsibility as their main concerns. The main factors for patients were the lack of information and understanding. CONCLUSION Physicians' and patients' perceptions and attitudes might be potential factors in the underuse of treatment with vitamin K antagonists. Improving the quality and usability of clinical guidelines, developing tools to help with the decision-making, enhancing coordination between primary care and hospital care, and improving information provided to patients could help improve the underuse of anticoagulation.
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Affiliation(s)
- Gemma Mas Dalmau
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.
| | - Elisenda Sant Arderiu
- Consorci d'Atenció Primària de Salut de l'Eixample (CAPSE), CAP Casanova, Barcelona, Spain
| | | | - Ivan Solà
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Sandra Pequeño Saco
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain
| | - Pablo Alonso Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antoni Ma Claret 167, 08025, Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
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22
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Honarbakhsh S, Finlay M, Earley MJ, Lambiase PD, Schilling RJ, Hunter RJ. Management of atrial fibrillation: when are invasive approaches useful? Br J Hosp Med (Lond) 2016; 77:460-6. [PMID: 27487056 DOI: 10.12968/hmed.2016.77.8.460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The management of atrial fibrillation extends from stroke prevention to rate or rhythm control strategies. The role of an invasive strategy is expanding and it remains important to identify suitable candidates early in the disease process.
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Affiliation(s)
- S Honarbakhsh
- Specialist Trainee in the Electrophysiology Department, The Barts Heart Centre, St Bartholomew's Hospital, London
| | - M Finlay
- Consultant in the Electrophysiology Department, The Barts Heart Centre, St Bartholomew's Hospital, London
| | - M J Earley
- Consultant in the Electrophysiology Department, The Barts Heart Centre, St Bartholomew's Hospital, London
| | - P D Lambiase
- Consultant in the Electrophysiology Department, The Barts Heart Centre, St Bartholomew's Hospital, London
| | - R J Schilling
- Consultant in the Electrophysiology Department, The Barts Heart Centre, St Bartholomew's Hospital, London
| | - R J Hunter
- Consultant Cardiologist and Electrophysiologist in the Electrophysiology Department, The Barts Heart Centre, St Bartholomew's Hospital, London EC1A 7BE
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Stewart S. Atrial Fibrillation in the 21st Century: The New Cardiac ‘Cinderella’ and New Horizons for Cardiovascular Nursing? Eur J Cardiovasc Nurs 2016. [DOI: 10.1016/s1474-51510200010-5] [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: 11/29/2022]
Affiliation(s)
- Simon Stewart
- Centre for Research into Nursing and Health Care/School of Nursing and Midwifery, 4th Floor Centenary Building, City East Campus, University of South Australia, Frome Road, Adelaide 5000, Australia
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Goebel B, Wieg S, Hamadanchi A, Otto S, Jung C, Kretzschmar D, Figulla HR, Christian Schulze P, Poerner TC. Interventional left atrial appendage occlusion: added value of 3D transesophageal echocardiography for device sizing. Int J Cardiovasc Imaging 2016; 32:1363-1370. [PMID: 27271934 DOI: 10.1007/s10554-016-0923-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 06/01/2016] [Indexed: 11/28/2022]
Abstract
Aim of this study was the assessment of left atrial appendage (LAA) dimensions comparing 2D- to 3D-TEE measurements in patients with nonvalvular atrial fibrillation undergoing percutaneous LAA occlusion. Patients underwent transesophageal echocardiography (TEE) before, during and 45 days after intervention. The maximal LAA orifice diameters in 2D-TEE (LODmax 2D) were obtained from multiple views. Test-retest reliability (screening vs. implantation), inter- and intra-observer variability for echocardiographic parameters were assessed by two independent examiners. Overall, 74 patients underwent percutaneous LAA occlusion. 2D-TEE significantly underestimated the maximal LAA orifice diameter compared with 3D-TEE (screening LODmax 2D 21.11 ± 2.75 mm vs. 22.52 ± 3.45 mm for LODmax 3D, p < 0.001; during implantation LODmax 2D 21.56 ± 3.48 mm vs. 22.99 ± 3.24 mm for LODmax 3D, p < 0.001). The intraobserver and interobserver variability calculated as coefficient of variation (CV) were both lower for the 3D-TEE quantification of the maximal orifice diameter (intraobserver CV for 3D-TEE 6.07 % vs. 9.31 % for 2D-TEE; interobserver CV for 3D-TEE 6.73 % vs. 9.69 % for 2D-TEE). Compared to 3D-TEE the test-retest reliability of 2D-TEE showed a lower intraclass correlation coefficient calculated as average of raters (0.92 for 3D-TEE vs. for 2D-TEE 0.78). Firstly, 2D-TEE significantly underestimates the maximal LAA orifice diameter compared to 3D-TEE. Secondly, 3D-TEE measurements are associated with a lower observer variability and higher reliability than 2D-TEE.
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Affiliation(s)
- Björn Goebel
- 1st Department of Medicine-Division of Cardiology, University Hospital Jena, Erlanger Allee 101, 07740, Jena, Germany.
| | - Stephanie Wieg
- 1st Department of Medicine-Division of Cardiology, University Hospital Jena, Erlanger Allee 101, 07740, Jena, Germany
| | - Ali Hamadanchi
- 1st Department of Medicine-Division of Cardiology, University Hospital Jena, Erlanger Allee 101, 07740, Jena, Germany
| | - Sylvia Otto
- 1st Department of Medicine-Division of Cardiology, University Hospital Jena, Erlanger Allee 101, 07740, Jena, Germany
| | - Christian Jung
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Daniel Kretzschmar
- 1st Department of Medicine-Division of Cardiology, University Hospital Jena, Erlanger Allee 101, 07740, Jena, Germany
| | - Hans R Figulla
- 1st Department of Medicine-Division of Cardiology, University Hospital Jena, Erlanger Allee 101, 07740, Jena, Germany
| | - P Christian Schulze
- 1st Department of Medicine-Division of Cardiology, University Hospital Jena, Erlanger Allee 101, 07740, Jena, Germany
| | - Tudor C Poerner
- 1st Department of Medicine-Division of Cardiology, University Hospital Jena, Erlanger Allee 101, 07740, Jena, Germany
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Eckman MH, Lip GY, Wise RE, Speer B, Sullivan M, Walker N, Kissela B, Flaherty ML, Kleindorfer D, Baker P, Ireton R, Hoskins D, Harnett BM, Aguilar C, Leonard AC, Arduser L, Steen D, Costea A, Kues J. Impact of an Atrial Fibrillation Decision Support Tool on thromboprophylaxis for atrial fibrillation. Am Heart J 2016; 176:17-27. [PMID: 27264216 DOI: 10.1016/j.ahj.2016.02.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 02/15/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Appropriate thromboprophylaxis for patients with atrial fibrillation (AF) remains a national challenge. METHODS We hypothesized that provision of decision support in the form of an Atrial Fibrillation Decision Support Tool (AFDST) would improve thromboprophylaxis for AF patients. We conducted a cluster randomized trial involving 15 primary care practices and 1,493 adults with nonvalvular AF in an integrated health care system between April 2014 and February 2015. Physicians in the intervention group received patient-level treatment recommendations made by the AFDST. Our primary outcome was the proportion of patients with antithrombotic therapy that was discordant from AFDST recommendation. RESULTS Treatment was discordant in 42% of 801 patients in the intervention group. Physicians reviewed reports for 240 patients. Among these patients, thromboprophylaxis was discordant in 63%, decreasing to 59% 1 year later (P = .02). In nonstratified analyses, changes in discordant care were not significantly different between the intervention group and control groups. In multivariate regression models, assignment to the intervention group resulted in a nonsignificant trend toward decreased discordance (P = .29), and being a patient of a resident physician (P = .02) and a higher HAS-BLED score predicted decreased discordance (P = .03), whereas female gender (P = .01) and a higher CHADSVASc score (P = .10) predicted increased discordance. CONCLUSIONS Among patients whose physicians reviewed recommendations of the decision support tool discordant therapy decreased significantly over 1 year. However, in nonstratified analyses, the intervention did not result in significant improvements in discordant antithrombotic therapy.
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Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke. AF-related strokes cause greater disability and mortality than those in patients without AF, and are associated with a significant clinical and economic burden in Mexico. Antithrombotic therapy reduces stroke risk in patients with AF and is recommended for all patients except those classified as having a low stroke risk. However, its use is suboptimal all around the world; one study showed that only 4 % of Mexican patients with AF who presented with ischemic stroke were in the therapeutic range for anticoagulation. Vitamin K antagonists (VKAs) such as warfarin or acenocoumarin have long been the only oral anticoagulants for stroke prevention in AF. Although effective, VKAs have disadvantages, including the need for regular coagulation monitoring and dose adjustment. Interactions with numerous common medications and foods contribute to the risk of serious bleeding and thrombotic events in VKA-treated patients. Thus novel oral anticoagulants (NOACs), more properly called direct oral anticoagulants (DOACs), such as dabigatran etexilate, rivaroxaban, apixaban, and edoxaban (not available in Mexico), have been developed. These offer the convenience of fixed-dose treatment without the need for monitoring, and have few drug or food interactions. Pivotal phase III trials have demonstrated that these agents are at least as effective as warfarin in preventing stroke and are associated with a reduced risk of intracranial hemorrhage. With apixaban approved in Mexico in April 2013, clinicians now have the choice of three novel DOACs as alternatives to warfarin. However, it is yet to be established which of these agents should be the first choice, and treatment decisions are likely to depend on the individual patient's characteristics.
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Saggu DK, Sundar G, Nair SG, Bhargava VC, Lalukota K, Chennapragada S, Narasimhan C, Chugh SS. Prevalence of atrial fibrillation in an urban population in India: the Nagpur pilot study. Heart Asia 2016; 8:56-9. [PMID: 27326234 DOI: 10.1136/heartasia-2015-010674] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 03/24/2016] [Accepted: 03/26/2016] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice with major public health impact mainly due to the increased risk of stroke. The recent Global Burden of Disease Study reported a lack of prevalence data from India. Our goal was to conduct a pilot study to evaluate the feasibility of assessing AF prevalence and stroke prophylaxis in an urban Indian community. METHODS A screening camp was conducted in Nagpur, India, that evaluated adults aged ≥18 years. We collected demographics, recorded blood pressure, height, weight and the 12-lead electrocardiogram (ECG). The presence of diabetes and hypertension was recorded by self-reported history. Patients diagnosed with AF were evaluated further to assess aetiology and management. RESULTS Of the total 4077 randomly selected, community-dwelling adults studied, 0.196% (eight patients) were found to have AF. Mean age of the population was 43.9±14.8, and 44.5% were female. The mean age of the patients with AF was 60.5±15.8 years (five females). Rheumatic heart disease was found in five patients with AF. Three patients had history of stroke (37.5%) and one had peripheral arterial thrombosis. Three patients were on warfarin, but without routine international normalised ratio (INR) monitoring. One patient was on aspirin. Five patients were on β-blockers and one on both β-blocker and digoxin. CONCLUSIONS The prevalence of AF was low compared with other regions of the world and stroke prophylaxis was underused. A larger study is needed to confirm these findings. This study demonstrates that larger evaluations would be feasible using the community-based techniques employed here.
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Affiliation(s)
| | - Gomathi Sundar
- Department of Cardiology , CARE Hospital , Hyderabad, Telangana , India
| | - Sandeep G Nair
- Department of Cardiology , CARE Hospital , Hyderabad, Telangana , India
| | - Varun C Bhargava
- Department of Cardiology , Ganga CARE Hospital , Nagpur, Maharashtra , India
| | | | | | | | - Sumeet S Chugh
- Heart Institute, Cedars-Sinai , Los Angeles, California , USA
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Djalali S, Valeri F, Gerber B, Meli DN, Senn O. Anticoagulation Control in Swiss Primary Care: Time in Therapeutic Range Percentages Exceed Benchmarks of Phase III Trials. Clin Appl Thromb Hemost 2016; 23:685-695. [PMID: 27056934 DOI: 10.1177/1076029616642514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In randomized controlled trials, non-vitamin K antagonist oral anticoagulants (NOACs) demonstrated noninferiority to vitamin K antagonists (VKAs) in patients who spent limited time in therapeutic range (TTR). In real-life patients, TTR is known to vary significantly across countries and health-care settings. OBJECTIVE We aim to evaluate the quality of VKA treatment in Swiss primary care (PC) by comparing patients' median TTR to levels achieved in the phase III NOAC trials RE-LY, ROCKET-AF, ARISTOTLE, and ENGAGE-AF-TIMI 48. Patient characteristics affecting TTR control shall be estimated. METHODS This is a retrospective longitudinal study in Swiss PC patients receiving VKA for ≥6 months. We identified patients from the PC research database FIRE (Family medicine International Classification of Primary Care Research using Electronic medical records) and calculated TTR according to Rosendaal formula. Comparative data from NOAC trials were retrieved from medical literature. Linear regression models were used to assess predictors of TTR. RESULTS Primary care encounters of 215 patients were analyzed. Like in the NOAC trials, median observation period was 2.2 years, but patients were older (67.9% vs 38% ≥75 years) and differed in terms of concomitant diseases and drugs. Median TTR was 75% (65% in the NOAC trials). Female sex was independently associated with a lower TTR and significantly modified by increasing age. CONCLUSION Practitioners should consider that patients in NOAC trials are only partly representative of PC patients, particularly in terms of TTR control. Only a minority of the observed patients would require a therapy switch to NOACs due to inadequate TTR. Further research is needed in order to identify specific features of care management that are associated with these outcomes.
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Affiliation(s)
- Sima Djalali
- 1 Institute of Primary Care, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Fabio Valeri
- 1 Institute of Primary Care, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Bernhard Gerber
- 2 Department of Hematology, Istituto Oncologico della Svizzera Italiana, Ospedale Regionale Bellinzona e Valli, Bellinzona, Switzerland
| | - Damian N Meli
- 3 General Practice Center Huttwil, Huttwil, Switzerland
| | - Oliver Senn
- 1 Institute of Primary Care, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Sharma P, Scotland G, Cruickshank M, Tassie E, Fraser C, Burton C, Croal B, Ramsay CR, Brazzelli M. The clinical effectiveness and cost-effectiveness of point-of-care tests (CoaguChek system, INRatio2 PT/INR monitor and ProTime Microcoagulation system) for the self-monitoring of the coagulation status of people receiving long-term vitamin K antagonist therapy, compared with standard UK practice: systematic review and economic evaluation. Health Technol Assess 2016; 19:1-172. [PMID: 26138549 DOI: 10.3310/hta19480] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Self-monitoring (self-testing and self-management) could be a valid option for oral anticoagulation therapy monitoring in the NHS, but current evidence on its clinical effectiveness or cost-effectiveness is limited. OBJECTIVES We investigated the clinical effectiveness and cost-effectiveness of point-of-care coagulometers for the self-monitoring of coagulation status in people receiving long-term vitamin K antagonist therapy, compared with standard clinic monitoring. DATA SOURCES We searched major electronic databases (e.g. MEDLINE, MEDLINE In Process & Other Non-Indexed Citations, EMBASE, Bioscience Information Service, Science Citation Index and Cochrane Central Register of Controlled Trials) from 2007 to May 2013. Reports published before 2007 were identified from the existing Cochrane review (major databases searched from inception to 2007). The economic model parameters were derived from the clinical effectiveness review, other relevant reviews, routine sources of cost data and clinical experts' advice. REVIEW METHODS We assessed randomised controlled trials (RCTs) evaluating self-monitoring in people with atrial fibrillation or heart valve disease requiring long-term anticoagulation therapy. CoaguChek(®) XS and S models (Roche Diagnostics, Basel, Switzerland), INRatio2(®) PT/INR monitor (Alere Inc., San Diego, CA USA), and ProTime Microcoagulation system(®) (International Technidyne Corporation, Nexus Dx, Edison, NJ, USA) coagulometers were compared with standard monitoring. Where possible, we combined data from included trials using standard inverse variance methods. Risk of bias assessment was performed using the Cochrane risk of bias tool. A de novo economic model was developed to assess the cost-effectiveness over a 10-year period. RESULTS We identified 26 RCTs (published in 45 papers) with a total of 8763 participants. CoaguChek was used in 85% of the trials. Primary analyses were based on data from 21 out of 26 trials. Only four trials were at low risk of bias. Major clinical events: self-monitoring was significantly better than standard monitoring in preventing thromboembolic events [relative risk (RR) 0.58, 95% confidence interval (CI) 0.40 to 0.84; p = 0.004]. In people with artificial heart valves (AHVs), self-monitoring almost halved the risk of thromboembolic events (RR 0.56, 95% CI 0.38 to 0.82; p = 0.003) and all-cause mortality (RR 0.54, 95% CI 0.32 to 0.92; p = 0.02). There was greater reduction in thromboembolic events and all-cause mortality through self-management but not through self-testing. Intermediate outcomes: self-testing, but not self-management, showed a modest but significantly higher percentage of time in therapeutic range, compared with standard care (weighted mean difference 4.44, 95% CI 1.71 to 7.18; p = 0.02). Patient-reported outcomes: improvements in patients' quality of life related to self-monitoring were observed in six out of nine trials. High preference rates were reported for self-monitoring (77% to 98% in four trials). Net health and social care costs over 10 years were £7295 (self-monitoring with INRatio2); £7324 (standard care monitoring); £7333 (self-monitoring with CoaguChek XS) and £8609 (self-monitoring with ProTime). The estimated quality-adjusted life-year (QALY) gain associated with self-monitoring was 0.03. Self-monitoring with INRatio2 or CoaguChek XS was found to have ≈ 80% chance of being cost-effective, compared with standard monitoring at a willingness-to-pay threshold of £20,000 per QALY gained. CONCLUSIONS Compared with standard monitoring, self-monitoring appears to be safe and effective, especially for people with AHVs. Self-monitoring, and in particular self-management, of anticoagulation status appeared cost-effective when pooled estimates of clinical effectiveness were applied. However, if self-monitoring does not result in significant reductions in thromboembolic events, it is unlikely to be cost-effective, based on a comparison of annual monitoring costs alone. Trials investigating the longer-term outcomes of self-management are needed, as well as direct comparisons of the various point-of-care coagulometers. STUDY REGISTRATION This study is registered as PROSPERO CRD42013004944. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Pawana Sharma
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.,Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Emma Tassie
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Cynthia Fraser
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Chris Burton
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK
| | - Bernard Croal
- Department of Clinical Biochemistry, University of Aberdeen, Aberdeen, UK
| | - Craig R Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Neužil P, Mráz T, Petrů J, Hála P, Mates M, Kmoníček P, Prokopová M, Reddy VY. Percutaneous closure of left atrial appendage for stroke prevention. Cor Vasa 2016. [DOI: 10.1016/j.crvasa.2016.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Romero J, Natale A, Engstrom K, Di Biase L. Left atrial appendage isolation using percutaneous (endocardial/epicardial) devices: Pre-clinical and clinical experience. Trends Cardiovasc Med 2016; 26:182-99. [DOI: 10.1016/j.tcm.2015.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 05/26/2015] [Accepted: 05/27/2015] [Indexed: 01/19/2023]
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Mendelow AD, Gregson BA. Surgery for Intracerebral Hemorrhage. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00070-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Alipour A, Swaans MJ, van Dijk VF, Balt JC, Post MC, Bosschaert MA, Rensing BJ, Reddy VY, Boersma LV. Ablation for Atrial Fibrillation Combined With Left Atrial Appendage Closure. JACC Clin Electrophysiol 2015; 1:486-495. [DOI: 10.1016/j.jacep.2015.07.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 07/08/2015] [Accepted: 07/16/2015] [Indexed: 10/22/2022]
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Anselmino M, Battaglia A, Gallo C, Gili S, Matta M, Castagno D, Ferraris F, Giustetto C, Gaita F. Atrial fibrillation and female sex. J Cardiovasc Med (Hagerstown) 2015; 16:795-801. [DOI: 10.2459/jcm.0000000000000239] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Mitsuma W, Matsubara T, Hatada K, Imai S, Saito N, Shimada H, Miyazaki S. Clinical characteristics of hemodialysis patients with atrial fibrillation: The RAKUEN (Registry of atrial fibrillation in chronic kidney disease under hemodialysis from Niigata) study. J Cardiol 2015; 68:148-55. [PMID: 26527113 DOI: 10.1016/j.jjcc.2015.08.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 08/17/2015] [Accepted: 08/27/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Clinical characteristics, management, and outcomes in hemodialysis patients with atrial fibrillation (AF) remain unclear. METHODS AND RESULTS We studied 423 Japanese patients undergoing maintenance hemodialysis (age 65.2±12.4 years, male 70%, mean duration of hemodialysis 139±124 months). AF was present in 19% (n=82) and was independently related to increased age (odds ratio 1.070, 95% confidence interval 1.043-1.098), longer hemodialysis duration (odds ratio 1.006, 95% confidence interval 1.004-1.008), and congestive heart failure (odds ratio 2.749, 95% confidence interval 1.546-4.891). During observations lasting a mean of 36 months, the incidences of all-cause death, cardiovascular death, and major bleeding, in particular gastrointestinal bleeding, were significantly higher in the AF (n=82) than the non-AF (n=341) patients (p<0.001, p=0.004, p=0.002, p=0.027, respectively), but the incidence of ischemic stroke/systemic embolism was similar in the AF and non-AF patients. AF was independently associated with all-cause death (hazard ratio 1.728, 95% confidence interval 1.123-2.660) and major bleeding (hazard ratio 1.984, 95% confidence interval 1.010-3.896). Warfarin was prescribed in 33% of the AF patients, but the rates of all-cause death, ischemic stroke, and major bleeding during the study period were not significantly different between warfarin (n=27) and non-warfarin (n=55) groups. CONCLUSIONS In our hemodialysis patients, AF was a common comorbidity and was independently associated with all-cause death and major bleeding, but not with increased risk of ischemic stroke.
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Affiliation(s)
- Wataru Mitsuma
- Division of Cardiology, Shinrakuen Hospital, Niigata, Japan.
| | - Taku Matsubara
- Division of Cardiology, Shinrakuen Hospital, Niigata, Japan
| | | | - Shunsuke Imai
- Division of Cardiology, Shinrakuen Hospital, Niigata, Japan
| | - Noriko Saito
- Division of Nephrology, Shinrakuen Hospital, Niigata, Japan
| | - Hisaki Shimada
- Division of Nephrology, Shinrakuen Hospital, Niigata, Japan
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Abstract
Atrial fibrillation (AF) remains the most common arrhythmia encountered in clinical practice. One of its more common deleterious effects is the development of thromboembolism leading to stroke. The left atrial appendage (LAA) has been shown to the site of the majority of thrombus formation leading to stroke. Anticoagulation with warfarin has been the treatment of choice for prevention of embolic events. Newer anticoagulants have been developed but they still have the potential side effect of causing major bleeding. Occlusion of the LAA has emerged as an alternative therapeutic approach to medical therapy. The aim of this article is to discuss in detail the role of the LAA in thromboembolism in AF, role of device and surgical therapies, and the current clinical data supporting their use. This is particularly timely in that there is now an approved LAA closure device approved in the US for stroke prevention in patients with nonvalvular AF.
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Alli O, Asirvatham S, Holmes DR. Strategies to Incorporate Left Atrial Appendage Occlusion Into Clinical Practice. J Am Coll Cardiol 2015; 65:2337-44. [DOI: 10.1016/j.jacc.2015.03.564] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 03/26/2015] [Accepted: 03/30/2015] [Indexed: 11/26/2022]
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Abstract
PURPOSE To evaluate our hospital protocol of low-dose vitamin K titration for preoperative warfarin reversal for early hip fracture surgery. METHODS Records of 16 men and 33 women aged 63 to 93 (mean, 81) years who were taking warfarin for atrial fibrillation (n=40), venous thromboembolism (n=9), cerebrovascular accident (n=3), and prosthetic heart valve (n=3) and underwent surgery for hip fractures were reviewed. The 3 patients with a prosthetic heart valve were deemed high risk for thromboembolism and the remainder low-risk. The international normalised ratio (INR) of patients was checked on admission and 6 hours after administration of vitamin K; an INR of <1.7 was considered safe for surgery. RESULTS No patient developed venous thromboembolism within one year. The 30-day and one-year mortality was 8.2% and 32.6%, respectively. For the 46 low-risk patients, the mean INR on admission was 2.6 (range, 1.1-4.6) and decreased to <1.7 after a mean of 2.2 (range, 0-4) administrations of 2 mg of vitamin K. Their INR was <1.7 within 18 hours (mean, 14 hours). 78% of patients underwent surgery within 36 hours. In the 22% of patients who did not undergo surgery within 36 hours, the delay was due to insufficient operative time or the patient being medically unfit for surgery. The 3 high-risk patients underwent bridging therapy of low-molecular-weight heparin and received no vitamin K; their mean INR on admission was 3.2 (range, 3.1-3.3) and the mean time to surgery was 5.3 (range, 3-8) days. Two low-risk patients and one high-risk patient died within 5 days of surgery. CONCLUSION The low-dose intravenous vitamin K protocol is safe and effective in reversing warfarin within 18 hours. Hip fracture surgery within 36 to 48 hours of admission improves morbidity and mortality.
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Affiliation(s)
- Thomas Steven Moores
- Trauma and Orthopaedic Department, University Hospital of North Staffordshire, United Kingdom
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Bengtson LGS, Lutsey PL, Loehr LR, Kucharska-Newton A, Chen LY, Chamberlain AM, Wruck LM, Duval S, Stearns SC, Alonso A. Impact of atrial fibrillation on healthcare utilization in the community: the Atherosclerosis Risk in Communities study. J Am Heart Assoc 2014; 3:e001006. [PMID: 25359400 PMCID: PMC4338687 DOI: 10.1161/jaha.114.001006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [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] [Indexed: 12/13/2022]
Abstract
Background Atrial fibrillation (AF) is associated with increased risk of hospitalization. Little is known about the impact of AF on utilization of noninpatient health care or about sex or race differences in AF‐related utilization. We examined rates of inpatient and outpatient utilization by AF status in the Atherosclerosis Risk in Communities study. Methods and Results Participants with incident AF enrolled in fee‐for‐service Medicare for at least 12 continuous months between 1991 and 2009 (n=932) were matched on age, sex, race and field center with up to 3 participants without AF (n=2729). Healthcare utilization was ascertained from Medicare claims and classified by primary International Classification of Diseases, ninth revision code. The average annual numbers of days hospitalized were 13.2 (95% CI 11.6 to 15.0) and 2.8 (95% CI 2.5 to 3.1) for those with and without AF, respectively. The corresponding numbers of annual outpatient claims were 53.3 (95% CI 50.5 to 56.3) and 22.9 (95% CI 22.1 to 23.8) for those with and without AF, respectively. Most utilization among AF patients was attributable to non‐AF conditions. The adjusted rate ratio for annual days hospitalized for other cardiovascular disease–related reasons was 4.58 (95% CI: 3.41 to 6.16) for those with AF versus those without AF. The association between AF and healthcare utilization was similar among men and women and among white and black participants. Conclusions Participants with AF had considerably greater healthcare utilization, and the difference in utilization for other cardiovascular disease–related reasons was substantial. In addition to rate or rhythm treatment, AF management should focus on the accompanying cardiovascular comorbidities.
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Affiliation(s)
- Lindsay G S Bengtson
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN (L.S.B., P.L.L., A.A.)
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN (L.S.B., P.L.L., A.A.)
| | - Laura R Loehr
- Department of Epidemiology, University of North Carolina Chapel Hill, Chapel Hill, NC (L.R.L., A.K.N.)
| | - Anna Kucharska-Newton
- Department of Epidemiology, University of North Carolina Chapel Hill, Chapel Hill, NC (L.R.L., A.K.N.)
| | - Lin Y Chen
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN (L.Y.C., S.D.)
| | | | - Lisa M Wruck
- Department of Biostatistics, University of North Carolina Chapel Hill, Chapel Hill, NC (L.M.W.)
| | - Sue Duval
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN (L.Y.C., S.D.)
| | - Sally C Stearns
- Department of Health Policy and Management, University of North Carolina Chapel Hill, Chapel Hill, NC (S.C.S.)
| | - Alvaro Alonso
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN (L.S.B., P.L.L., A.A.)
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Denoël P, Vanderstraeten J, Mols P, Pepersack T. Could some geriatric characteristics hinder the prescription of anticoagulants in atrial fibrillation in the elderly? J Aging Res 2014; 2014:693740. [PMID: 25295192 DOI: 10.1155/2014/693740] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 08/06/2014] [Accepted: 08/19/2014] [Indexed: 11/17/2022] Open
Abstract
Several studies have reported underprescription of anticoagulants in atrial fibrillation (AF). We conducted an observational study on 142 out of a total of 995 consecutive ≥75 years old patients presenting AF (14%) when admitted in an emergency unit of a general hospital, in search of geriatric characteristics that might be associated with the underprescription of anticoagulation therapy (mostly antivitamin K at the time of the study). The following data was collected from patients presenting AF: medical history including treatment and comorbidities, CHADS2 score, ISAR scale (frailty), Lawton's scale (ADL), GDS scale (mood status), MUST (nutrition), and blood analysis (INR, kidney function, and albumin). Among those patients for who anticoagulation treatment was recommended (73%), only 61% were treated with it. In the group with anticoagulation therapy, the following characteristics were observed more often than in the group without such therapy: a recent (≤6 months) hospitalization and medical treatment including digoxin or based on >3 different drugs. Neither the value of the CHADS2 score, nor the geriatric characteristics could be correlated with the presence or the absence of an anticoagulation therapy. More research is thus required to identify and clarify the relative importance of patient-, physician-, and health care system-related hurdles for the prescription of oral anticoagulation therapy in older patients with AF.
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Cotté FE, Benhaddi H, Duprat-Lomon I, Doble A, Marchant N, Letierce A, Huguet M. Vitamin K Antagonist Treatment in Patients With Atrial Fibrillation and Time in Therapeutic Range in Four European Countries. Clin Ther 2014; 36:1160-8. [DOI: 10.1016/j.clinthera.2014.07.016] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 07/11/2014] [Accepted: 07/23/2014] [Indexed: 11/27/2022]
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Chen X, Zhou L, Zhang Y, Yi D, Liu L, Rao W, Wu Y, Ma D, Liu X, Zhou XHA, Lin H, Cheng D, Yi D. Risk factors of stroke in Western and Asian countries: a systematic review and meta-analysis of prospective cohort studies. BMC Public Health 2014; 14:776. [PMID: 25081994 PMCID: PMC4246444 DOI: 10.1186/1471-2458-14-776] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [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: 04/03/2014] [Accepted: 07/03/2014] [Indexed: 01/11/2023] Open
Abstract
Background There has been an increasing trend in the incidence of stroke worldwide in recent years, and the number of studies focusing on the risk factors for stroke has also increased every year. To comprehensively evaluate the risk factors of stroke identified in prospective Western and Asian cohort studies. Methods Population-based cohort studies on stroke were searched in databases (PubMed, EMBASE, Web of Science, Google Scholar, etc.), and the library of the Third Military Medical University was manually searched for relevant information. A meta-analysis of Western and Asian studies on risk factors was performed. The pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated to assess the final group of cohort studies. Results After screening, 22 prospective cohort studies were included in the analyses of this investigation. Two factors, smoking and alcohol consumption, showed statistically significant differences between Western and Asian populations, and the results were as follows (W/A): 2.05 (95% CI, 1.68 ~ 2.49)/1.27 (95% CI, 1.04 ~ 1.55) and 0.89 (95% CI, 0.76 ~ 1.04)/1.28 (95% CI, 1.07 ~ 1.53). The factor BMI = 18.5-21.9 kg/m2 showed statistically significant differences only in Western populations, 0.96 (95% CI, 0.93 ~ 0.99); the factor SBP = 120-139 mm Hg showed statistically significant differences only in Asian populations, 2.29 (95% CI, 1.04 ~ 5.09). Conclusions The prevalences of risk factors affect the stroke morbidity in Western and Asian populations, which may be biased by race. The meta-analysis of population-based studies suggests that different preventive measures should be adopted for Western and Asian population groups that are at high risk for stroke. Electronic supplementary material The online version of this article (doi:10.1186/1471-2458-14-776) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Dong Yi
- Department of Health Statistics, College of Preventive Medicine, Third Military Medical University, PO Box 400038, Chongqing, China.
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Pracoń R, Demkow M, Witkowski A, Rużyłło W. Percutaneous elimination of the left atrial appendage in quest for effective and safe prevention of stroke in patients with atrial fibrillation. Adv Cardiol 2014; 10:71-4. [PMID: 25061450 DOI: 10.5114/pwki.2014.43508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 06/09/2014] [Accepted: 06/09/2014] [Indexed: 11/24/2022]
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GAFOOR SAMEER, FRANKE JENNIFER, BOEHM PATRICK, LAM SIMON, BERTOG STEFAN, VASKELYTE LAURA, HOFMANN ILONA, SIEVERT HORST. Leaving No Hole Unclosed: Left Atrial Appendage Occlusion in Patients Having Closure of Patent Foramen Ovale or Atrial Septal Defect. J Interv Cardiol 2014; 27:414-22. [DOI: 10.1111/joic.12138] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
| | | | | | - SIMON LAM
- Cardiovascular Center Frankfurt; Frankfurt Germany
| | - STEFAN BERTOG
- Cardiovascular Center Frankfurt; Frankfurt Germany
- Minneapolis Veterans Affairs Hospital; Minneapolis Minnesota
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Andrew NE, Hankey GJ, Cadilhac DA. Evidence-to-practice gaps in post-stroke management: a focus on care in a stroke unit and anticoagulation to prevent death, disability and recurrent stroke. Future Neurology 2014. [DOI: 10.2217/fnl.14.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT: The global burden of stroke is large. Over the last 15 years significant advances have been made to improve acute stroke care and prevention management providing the ability to mitigate much of this burden. In this article, we describe the importance of two main elements of stroke care: stroke units to reduce death and disability and anticoagulation therapy to prevent recurrent, often fatal or disabling, cardioembolic stroke. We also describe the issues related to translating these interventions into practice and the related economic implications. Despite the proven effectiveness and cost–effectiveness of these and other interventions, many people experiencing stroke are not receiving these interventions. Effective evidence translation initiatives and routine monitoring of healthcare is needed to address important gaps in stroke management in promoting societal well-being.
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Affiliation(s)
- Nadine E Andrew
- Translational Public Health Unit, Stroke & Ageing Research, Department of Medicine, School of Clinical Sciences, Monash University, 1/43-51 Kanooka Grove, Clayton, VIC 3168, Australia
| | - Graeme J Hankey
- School of Medicine & Pharmacology, The University of Western Australia, Crawley, WA 6009, Australia
| | - Dominique A Cadilhac
- Translational Public Health Unit, Stroke & Ageing Research, Department of Medicine, School of Clinical Sciences, Monash University, 1/43-51 Kanooka Grove, Clayton, VIC 3168, Australia
- Florey Institute of Neuroscience & Mental Health, 245 Burgundy St, Heidelberg, VIC 3084, Australia
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Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia and a major global public health problem due to its associated morbidity, including stroke and heart failure, diminished quality of life, and increased mortality. AF often presents initially in a paroxysmal form and may progress to a more sustained form over time. Evidence from randomized controlled trials suggests that there may be no mortality benefit to using a rhythm control approach in comparison with rate control of AF. Nevertheless, sustained forms of AF may be associated with increased symptoms and cardiovascular morbidity, and consequently they remain an additional target for therapy. The present review evaluates the clinical correlates of arrhythmia progression and risk stratification techniques available to assess probability of AF progression. Further, currently available management options for arrhythmia control in AF are evaluated and their therapeutic effect and efficacy on disease progression are explored.
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Affiliation(s)
- Ashish Shukla
- Division of Cardiology, Department of Medicine, State University of New York, Buffalo, NY, USA
| | - Anne B Curtis
- Division of Cardiology, Department of Medicine, State University of New York, Buffalo, NY, USA
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Cove CL, Albert CM, Andreotti F, Badimon L, Van Gelder IC, Hylek EM. Female sex as an independent risk factor for stroke in atrial fibrillation: possible mechanisms. Thromb Haemost 2013; 111:385-91. [PMID: 24305974 DOI: 10.1160/th13-04-0347] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [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: 04/28/2013] [Accepted: 10/11/2013] [Indexed: 11/05/2022]
Abstract
Atrial fibrillation (AF) is an independent risk factor for thromboembolism and stroke. Women with AF are at a higher overall risk for thromboembolic stroke when compared to men with AF. Recent evidence suggests that female sex, after adjusting for stroke risk profile and sex differences in utilisation of anticoagulation, is an independent stroke risk factor in AF. The inclusion of female sex has improved the accuracy of the CHADS2 stroke risk stratification schema (Congestive heart failure, Hypertension, Age 75 years or greater, Diabetes mellitus, and prior Stroke or TIA). The newly revised and validated schema, CHA2DS2-VASc, dichotomises age and incorporates female sex and vascular disease history. The pathophysiological mechanisms to explain this increased risk in women are not well understood. According to Virchow's triad, thrombosis that leads to stroke in AF should arise from three co-existing phenomena: structural abnormalities, blood stasis, and a hypercoagulable state. Herein, we explore the sex differences in the biological processes that lead to thrombus formation as applied to Virchow's Triad. The objective of this review is to describe the potential mechanisms behind the increased risk of stroke in AF associated with female sex.
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Affiliation(s)
- C L Cove
- Christina L. Cove, MD, Crosstown 2075-D, 801 Massachusetts Avenue, Boston, MA 02118, USA, Tel.: +1 617 414 6908, Fax: +1 617 414 4676, E-mail:
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Polidoro A, Stefanelli F, Ciacciarelli M, Pacelli A, Di Sanzo D, Alessandri C. Frailty in patients affected by atrial fibrillation. Arch Gerontol Geriatr 2013; 57:325-7. [DOI: 10.1016/j.archger.2013.04.014] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Revised: 04/25/2013] [Accepted: 04/27/2013] [Indexed: 11/17/2022]
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50
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Holmes DR, Lakkireddy DR, Whitlock RP, Waksman R, Mack MJ. Left atrial appendage occlusion: opportunities and challenges. J Am Coll Cardiol 2013; 63:291-8. [PMID: 24076495 DOI: 10.1016/j.jacc.2013.08.1631] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 08/23/2013] [Accepted: 08/27/2013] [Indexed: 12/17/2022]
Abstract
Stroke prevention in patients with atrial fibrillation is a growing clinical dilemma as the incidence of the arrhythmia increases and risk profiles worsen. Strategies in patients with nonvalvular atrial fibrillation have included anticoagulation with a variety of drugs. Knowledge that stroke in this setting typically results from thrombus in the left atrial appendage has led to the development of mechanical approaches, both catheter-based and surgical, to occlude that structure. Such a device, if it were safe and effective, might avoid the need for anticoagulation and prevent stroke in the large number of patients who are currently not treated with anticoagulants. Regulatory approval has been difficult due to trial design challenges, balance of the risk-benefit ratio, specific patient populations studied, selection of treatment in the control group, and specific endpoints and statistical analyses selected. Accumulating data from randomized trials and registries with longer-term follow-up continues to support a role for left atrial appendage exclusion from the central circulation as an alternative to anticoagulation in carefully-selected patient populations.
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Affiliation(s)
- David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
| | - Dhanunjaya R Lakkireddy
- Section of Electrophysiology, Bloch Heart Rhythm Center, KU Cardiovascular Research Institute, Mid America Cardiology, University of Kansas Hospital, Kansas City, Kansas
| | - Richard P Whitlock
- Department of Surgery, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Ron Waksman
- Department of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Michael J Mack
- Department of Cardiovascular Medicine, Baylor Healthcare System, Dallas, Texas
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