Additional risk factors in atrial fibrillation patients not receiving warfarin

Mortality and rate of stroke or embolism in atrial fibrillation during long-term follow-up in the embolism in left atrial thrombi (ELAT) study

BACKGROUND

Patients with atrial fibrillation (AF) have a higher mortality and risk of stroke/embolism than patients with sinus rhythm.

HYPOTHESIS

The aim of the study was to assess the association of clinical and echocardiographic characteristics with mortality and stroke/embolism and the use of antithrombotic medication in the year 2000 in patients who participated 1990-1995 in the Embolism in Left Atrial Thrombi (ELAT) study.

METHODS

The study included 409 outpatients with nonrheumatic AF (62 +/- 12 years, 36% women, 39% intermittent AF). Patients with thrombi received anticoagulation, patients without thrombi aspirin until follow-up in 1995; thereafter, anticoagulation according to clinical risk factors was recommended. Primary events were death and secondary events were stroke/embolism. All patients were contacted during the year 2000.

RESULTS

Mean follow-up was 102 months. Mortality was 4%/year; the cause of death was cardiac (n = 84), fatal stroke (n = 26), malignancy (n = 23), sepsis (n = 5), and unknown (n = 24). Multivariate analysis identified age (p < 0.0001), heart failure (p = 0.0013), and reduced left ventricular systolic function (p = 0.0353) as predictors of mortality. Stroke/embolism occurred in 83 patients, with a rate of 3%/year. Multivariate analysis identified age (p = 0.0006) and previous stroke (p = 0.0454) as predictors of stroke/embolism. In the year 2000, 51 (21%) of the 247 surviving patients received no antithrombotic medication, 88 received (36%) oral anticoagulants, 102 (41%) acetylsalicylic acid, and 6 (2%) low-molecular heparin.

CONCLUSIONS

Therapy for heart failure and oral anticoagulation in AF should be seriously considered, especially in elderly patients and in those with previous stroke.

Primary and secondary stroke prevention in nonrheumatic atrial fibrillation by oral anticoagulation

The risk of stroke or embolism in atrial fibrillation (AF) patients can be reduced by 68% by oral anticoagulation (OAC). This review is aimed to (1) summarize indications for OAC in patients with AF, (2) give an overview of the current knowledge of risk factors for bleeding complications of OAC and (3) give practical recommendations for an optimal OAC therapy in the neurological setting. Indications for OAC are increased age (>75 years), arterial hypertension, diabetes mellitus, previous thromboembolism, heart failure and, probably, coronary heart disease. Risk factors for bleeding complications are overanticoagulation with international normalized ratios (INRs) >3.0, increased age, arterial hypertension, diabetes mellitus, previous thromboembolism, polypharmacy, the early phase of OAC therapy and a lack of patients' education. Before initiation of OAC, the patient should be screened for potential bleeding sites. Careful monitoring of OAC comprises fixed appointments for the INR value determination, tracking for the patient, if he does not attend, advices about pain therapy, information about the influence of diet on the INR value and drug interaction, unscheduled INR determination in case of acute disorders and regular assessment if OAC is still indicated. Monitoring of OAC needs an effort, which has to be adequately estimated by the health care system.

Quality of blood pressure control and risk of cerebral bleeding in patients with oral anticoagulation

BACKGROUND

We assessed how many patients on long-term oral anticoagulation (OAC) (i) suffer from arterial hypertension (AH), (ii) are aware of AH, (iii) need improvement of their therapy and (iv) suffer from cerebral bleeding.

METHODS

Outpatients on long-term OAC were asked to measure blood pressure at least 4 times. Blood pressure was classified as normotensive if at least 75 % of all measurements were < 139/89 mm Hg; as mild/moderate AH if > 25 % of all measurements were 140 - 179 mm Hg systolic or 90 - 109 mm Hg diastolic; and as severe AH if > 25 % of all measurements were > 180 mm Hg systolic or > 110 mm Hg diastolic. Bleeding complications were registered.

RESULTS

Of the 235 patients (108 female, 67 +/- 12 years), 80 % suffered from AH. Severe AH was present in 5 %. Only 56 % were aware of suffering from AH. An improvement of antihypertensive therapy was needed in 64 %. Over 225 days, only one cerebral bleeding occurred. Blood pressure was normotensive in 30 % with known AH.

CONCLUSIONS

Blood pressure control seems better in OAC patients than in normals, if the patient is aware of AH. Patients with AH on OAC are not aware of AH in > 50 %. Repeated blood pressure measurements in OAC are recommended, even if patients are not aware of AH.

Evaluation of risk factors for stroke/embolism and of complications due to anticoagulant therapy in atrial fibrillation

BACKGROUND AND PURPOSE

We sought to assess in outpatients with atrial fibrillation and oral anticoagulation (1) whether the complication rate is influenced by the presence of the risk factors age >65 years, arterial hypertension, diabetes, or previous stroke; (2) whether the complication rate is influenced by the number of additional drugs taken by patients; and (3) whether problems and interventions differ between patients with or without complications.

METHODS

- Clinical characteristics, drugs, problems, interventions, and complications were registered during 2 years.

RESULTS

- Three hundred sixty patients (mean age, 68 years; 43% female) were observed for 383 patient-years. Patients aged >65 years had more serious, life-threatening, or fatal complications (11% versus 5.3%/100 patient-years; P=0.0428) than younger patients. Patients with diabetes had more life-threatening and fatal complications (2.8% versus 0.6%/100 patient-years; P=0.0354) than patients without. The complication rate did not differ regarding the presence of previous stroke or hypertension. Patients who took </=3 drugs had fewer complications than patients who took more (4.3% versus 24.4%/100 patient-years; P=0.0041). Patients with complications complained more of chest (48% versus 28%/100 patient-years; P=0.0113) and abdominal pain (30% versus 13%/100 patient-years; P=0.0057), more frequently failed to keep appointments (134% versus 107%/100 patient-years; P=0.0321), had a higher tracking rate (134% versus 105%/100 patient-years; P=0.0272), and took more additional drugs (4.6 versus 3.5 drugs per day; P=0.0063) than patients with no complications.

CONCLUSIONS

- Patients with increased age or diabetes mellitus or those who take >3 drugs per day have an increased complication rate and thus need especially careful monitoring of oral anticoagulation, including adequate pain control.