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Athreya DS, Saczynski JS, Gurwitz JH, Monahan KM, Bamgbade BA, Paul TJ, Sogade F, Lessard DM, McManus DD, Helm RH. Cognitive impairment and treatment strategy for atrial fibrillation in older adults: The SAGE-AF study. J Am Geriatr Soc 2024. [PMID: 38742376 DOI: 10.1111/jgs.18949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 04/11/2024] [Accepted: 04/15/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Cognitive impairment is strongly associated with atrial fibrillation (AF). Rate and rhythm control are the two treatment strategies for AF and the effect of treatment strategy on risk of cognitive decline and frailty is not well established. We sought to determine how treatment strategy affects geriatric-centered outcomes. METHODS The Systematic Assessment of Geriatric Elements-AF (SAGE-AF) was a prospective, observational, cohort study. Older adults with AF were prospectively enrolled between 2016 and 2018 and followed longitudinally for 2 years. In a non-randomized fashion, participants were grouped by rate or rhythm control treatment strategy based on clinical treatment at enrollment. Baseline characteristics were compared. Longitudinal binary mixed models were used to compare treatment strategy with respect to change in cognitive function and frailty status. Cognitive function and frailty status were assessed with the Montreal Cognitive Assessment Battery and Fried frailty phenotype tools. RESULTS 972 participants (mean age = 75, SD = 6.8; 49% female, 87% non-Hispanic white) completed baseline examination and 2-year follow-up. 408 (42%) were treated with rate control and 564 (58%) with rhythm control. The patient characteristics of the two groups were different at baseline. Participants in the rate control group were older, more likely to have persistent AF, prior stroke, be treated with warfarin and have baseline cognitive impairment. After adjusting for baseline differences, participants treated with rate control were 1.5 times more likely to be cognitively impaired over 2 years (adjusted OR: 1.47, 95% CI:1.12, 1.98) and had a greater decline in cognitive function (adjusted estimate: -0.59 (0.23), p < 0.01) in comparison to rhythm control. Frailty did not vary between the treatment strategies. CONCLUSIONS Among those who had 2-year follow-up in non-randomized observational cohort, the decision to rate control AF in older adults was associated with increased odds of decline in cognitive function but not frailty.
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Affiliation(s)
- Deepti S Athreya
- College of Science, Northeastern University, Boston, Massachusetts, USA
| | - Jane S Saczynski
- Department of Pharmacy and Health System Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts, USA
| | - Jerry H Gurwitz
- Meyers Primary Care Institute and Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Kevin M Monahan
- Evans Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Benita A Bamgbade
- Department of Pharmacy and Health System Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts, USA
| | - Tenes J Paul
- Division of Cardiology, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Felix Sogade
- Department of Medicine, Mercer University School of Medicine, Mercer, Georgia, USA
| | - Darleen M Lessard
- Division of Epidemiology of Chronic Diseases, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - David D McManus
- Division of Cardiology, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Robert H Helm
- Evans Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
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Ma J, Chen H, Zou C, Yang G. Association evaluations of oral anticoagulants with dementia risk based on genomic and real-world data. Prog Neuropsychopharmacol Biol Psychiatry 2024; 130:110929. [PMID: 38154516 DOI: 10.1016/j.pnpbp.2023.110929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 11/20/2023] [Accepted: 12/23/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Several observational studies have suggested that oral anticoagulants (OACs) might reduce the risk of dementia in the elderly, but the evidence is inconclusive. And the consistency of this relationship across different OAC classes and dementia subtypes is still uncertain. METHODS To comprehensively evaluate this association, we applied Mendelian randomization (MR) combined with pharmacovigilance analysis. MR was used to assess the associations between genetic proxies for three target genes of OACs (VKORC1, F2, and F10) and dementia, including Alzheimer's disease (AD) and vascular dementia (VaD). This genetic analysis was supplemented with real-world pharmacovigilance data, employing disproportionality analysis for more reliable causal inference. RESULTS Increased expression of the VKORC1 gene was strongly associated with increased risk of dementia, especially for AD (OR = 1.28, 95% CI = 1.14-1.43; p value < 0.001). Based on pharmacovigilance data, vitamin K antagonists (VKAs, inhibitors targeting VKORC1) exhibited a protective effect against dementia risk (ROR = 0.43, 95% CI = 0.28-0.67). Additional sensitivity analyses, including different MR models and cohorts, supported these results. Conversely, no strong causal associations of genetically proxied F2 and F10 target genes with dementia and its subtypes were found. CONCLUSIONS This study reveals that the inhibition of genetically proxied VKORC1 expression or VKAs exposure is associated with a reduced risk of Alzheimer's dementia. However, there is little evidence to support similar associations with direct oral anticoagulants (F2 inhibitors and F10 inhibitors). Further research is warranted to clinically validate our findings.
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Affiliation(s)
- Junlong Ma
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha 410013, Hunan, China; Hubei Provincial Clinical Research Center for Umbilical Cord Blood Hematopoietic Stem Cells, Taihe Hospital, Hubei University of Medicine, Shiyan, 442000, Hubei, China
| | - Heng Chen
- Department of Pharmacy, The First Hospital of Changsha, Changsha 410013, Hunan, China
| | - Chan Zou
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha 410013, Hunan, China
| | - Guoping Yang
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha 410013, Hunan, China.
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Shantsila E, Choi EK, Lane DA, Joung B, Lip GY. Atrial fibrillation: comorbidities, lifestyle, and patient factors. THE LANCET REGIONAL HEALTH. EUROPE 2024; 37:100784. [PMID: 38362547 PMCID: PMC10866737 DOI: 10.1016/j.lanepe.2023.100784] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/25/2023] [Accepted: 11/02/2023] [Indexed: 02/17/2024]
Abstract
Modern anticoagulation therapy has dramatically reduced the risk of stroke and systemic thromboembolism in people with atrial fibrillation (AF). However, AF still impairs quality of life, increases the risk of stroke and heart failure, and is linked to cognitive impairment. There is also a recognition of the residual risk of thromboembolic complications despite anticoagulation. Hence, AF management is evolving towards a more comprehensive understanding of risk factors predisposing to the development of this arrhythmia, its' complications and interventions to mitigate the risk. This review summarises the recent advances in understanding of risk factors for incident AF and managing these risk factors. It includes a discussion of lifestyle, somatic, psychological, and socioeconomic risk factors. The available data call for a practice shift towards a more individualised approach considering an increasingly broader range of health and patient factors contributing to AF-related health burden. The review highlights the needs of people living with co-morbidities (especially with multimorbidity), polypharmacy and the role of the changing population demographics affecting the European region and globally.
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Affiliation(s)
- Eduard Shantsila
- Department of Primary Care and Mental Health, University of Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Brownlow Group GP Practice, Liverpool, United Kingdom
| | - Eue-Keun Choi
- Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Republic of Korea
| | - Deirdre A. Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Denmark
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Denmark
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Srichawla BS, Hamel AP, Cook P, Aleyadeh R, Lessard D, Otabil EM, Mehawej J, Saczynski JS, McManus DD, Moonis M. Is catheter ablation associated with preservation of cognitive function? An analysis from the SAGE-AF observational cohort study. Front Neurol 2024; 14:1302020. [PMID: 38249728 PMCID: PMC10799336 DOI: 10.3389/fneur.2023.1302020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/14/2023] [Indexed: 01/23/2024] Open
Abstract
Objectives To examine the associations between catheter ablation treatment (CA) vs. medical management and cognitive impairment among older adults with atrial fibrillation (AF). Methods Ambulatory patients who had AF, were ≥65-years-old, and were eligible to receive oral anticoagulation could be enrolled into the SAGE (Systematic Assessment of Geriatric Elements)-AF study from internal medicine and cardiology clinics in Massachusetts and Georgia between 2016 and 2018. Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA) tool at baseline, 1-, and 2 years. Cognitive impairment was defined as a MoCA score ≤ 23. Multivariate-adjusted logistic regression of longitudinal repeated measures was used to examine associations between treatment with CA vs. medical management and cognitive impairment. Results 887 participants were included in this analysis. On average, participants were 75.2 ± 6.7 years old, 48.6% women, and 87.4% white non-Hispanic. 193 (21.8%) participants received a CA before enrollment. Participants who had previously undergone CA were significantly less likely to be cognitively impaired during the 2-year study period (aOR 0.70, 95% CI 0.50-0.97) than those medically managed (i.e., rate and/or rhythm control), even after adjusting with propensity score for CA. At the 2-year follow-up a significantly greater number of individuals in the non-CA group were cognitively impaired (MoCA ≤ 23) compared to the CA-group (311 [44.8%] vs. 58 [30.1%], p = 0.0002). Conclusion In this 2-year longitudinal prospective cohort study participants who underwent CA for AF before enrollment were less likely to have cognitive impairment than those who had not undergone CA.
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Affiliation(s)
- Bahadar S. Srichawla
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Alexander P. Hamel
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Philip Cook
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Rozaleen Aleyadeh
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Darleen Lessard
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Edith M. Otabil
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Jordy Mehawej
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Jane S. Saczynski
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - David D. McManus
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Majaz Moonis
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, United States
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Srichawla BS, Hamel AP, Cook P, Aleyadeh R, Lessard D, Otabil EM, Mehawej J, Saczynski JS, McManus DD, Moonis M. Is Catheter Ablation Associated with Preservation of Cognitive Function? An Analysis From the SAGE-AF Observational Cohort Study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.11.20.23298768. [PMID: 38045229 PMCID: PMC10690357 DOI: 10.1101/2023.11.20.23298768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Objectives To examine the associations between catheter ablation treatment (CA) versus medical management and cognitive impairment among older adults with atrial fibrillation (AF). Methods Ambulatory patients who had AF, were ≥ 65-years-old, and were eligible to receive oral anticoagulation could be enrolled into the SAGE (Systematic Assessment of Geriatric Elements)-AF study from internal medicine and cardiology clinics in Massachusetts and Georgia between 2016 and 2018. Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA) tool at baseline, one-, and two years. Cognitive impairment was defined as a MoCA score ≤ 23. Multivariate-adjusted logistic regression of longitudinal repeated measures was used to examine associations between treatment with CA vs. medical management and cognitive impairment. Results 887 participants were included in this analysis. On average, participants were 75.2 ± 6.7 years old, 48.6% women, and 87.4% white non-Hispanic. 193 (21.8%) participants received a CA before enrollment. Participants who had previously undergone CA were significantly less likely to be cognitively impaired during the two-year study period (aOR 0.70, 95% CI 0.50-0.97) than those medically managed (i.e., rate and/or rhythm control), even after adjusting with propensity score for CA. At the two-year follow-up a significantly greater number of individuals in the non-CA group were cognitively impaired (MoCA ≤ 23) compared to the CA-group (311 [44.8%] vs. 58 [30.1%], p=0.0002). Conclusions In this two-year longitudinal prospective cohort study participants who underwent CA for AF before enrollment were less likely to have cognitive impairment than those who had not undergone CA.
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Affiliation(s)
- Bahadar S. Srichawla
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, U.S.A
| | - Alexander P. Hamel
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, U.S.A
| | - Philip Cook
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, U.S.A
| | - Rozaleen Aleyadeh
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, U.S.A
| | - Darleen Lessard
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, U.S.A
| | - Edith M. Otabil
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, U.S.A
| | - Jordy Mehawej
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, U.S.A
| | - Jane S. Saczynski
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, U.S.A
| | - David D. McManus
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, U.S.A
| | - Majaz Moonis
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, U.S.A
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Patel N, Kania T, Demissie S, Le T, Fusco P, Yoon J, Lee B, Doran J, Liu J, Singer T, Glinik G, Azab B, Haney O, Esposito C, Mukherjee I, Atanassov K, Khodorkovsky B, Younan D. Preexisting anticoagulation is an independent predictor of mortality in geriatric trauma patients - a retrospective cohort study. Ann Med Surg (Lond) 2023; 85:4223-4227. [PMID: 37663698 PMCID: PMC10473288 DOI: 10.1097/ms9.0000000000000927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/16/2023] [Indexed: 09/05/2023] Open
Abstract
Introduction Preexisting anticoagulation is common among geriatric trauma patients. Geriatric trauma patients have a higher risk of mortality compared to younger patients. We sought to evaluate the association of preexisting anticoagulation with mortality in a group of geriatric trauma patients. Methods A retrospective review of geriatric trauma patients was conducted for those admitted to a Level 1 trauma center from January 2018 to December 2020. Vital signs, demographics, injury characteristics, laboratory data, and mortality were all collected. Multivariable logistic regression analysis was performed for the association of preexisting anticoagulation and a primary endpoint of all-cause mortality. These groups were controlled for preexisting comorbidities, injury severity scores, and systolic blood pressure in the emergency department. Results Four thousand four hundred thirty-two geriatric patients were admitted during the study period. This cohort was made up of 36.9% men and 63.1% women. Three thousand eight hundred fifty-nine (87.2%) were white; the average age was 81±8.5 years, and the median injury severity score (ISS) was 5. The mean systolic blood pressure was 150±32 mmHg, mean heart rate was 81±16 bpm, mean lactate was 2.3±1.3, mean hematocrit was 37.3±8.8, and mean international normalized ratio (INR) was 1.7±10.3. One thousand five hundred ninety-two (35.9%) patients were on anticoagulation (AC) upon presentation. One hundred and sixty-five (3.7%) mortalities were recorded. Multivariable logistic regression analysis results show that preexisting anticoagulation [ odds ratio (OR) 1.92, 95% CI 1.36-2.72] was independently predictive of death. The analysis was adjusted for systolic BP in the emergency department less than90 mmHg (OR 5.55, 95% CI 2.83-10.9), having more than 1 comorbidity (OR 2.30, 95% CI 1.57-3.38) and ISS (OR 1.13, 95% CI 1.10-1.15). Conclusion Our study indicates that preexisting anticoagulation is associated with mortality among geriatric trauma patients.
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Affiliation(s)
- Nikhil Patel
- Department of Surgery, Staten Island University Hospital, Staten Island
| | - Thomas Kania
- Department of Surgery, Staten Island University Hospital, Staten Island
| | - Seleshi Demissie
- Biostatistics Unit, Zucker School of Medicine at Hofstra/Northwell Health, Long Island
| | - Timothy Le
- Department of Surgery, Staten Island University Hospital, Staten Island
| | | | - Justin Yoon
- Touro Medical School, New York, New York, USA
| | - Bryan Lee
- Department of Surgery, Staten Island University Hospital, Staten Island
| | - Joseph Doran
- Department of Surgery, Staten Island University Hospital, Staten Island
| | | | | | - Galina Glinik
- Department of Surgery, Staten Island University Hospital, Staten Island
| | - Basem Azab
- Department of Surgery, Staten Island University Hospital, Staten Island
| | - Olivia Haney
- Department of Surgery, Staten Island University Hospital, Staten Island
| | | | | | | | | | - Duraid Younan
- Department of Surgery, Staten Island University Hospital, Staten Island
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Manning E, Burns K, Laurie M, Patten L, Ho M, Sandhu A. Factors associated with oral anticoagulant prescription status among patients with a new diagnosis of atrial fibrillation. Clin Cardiol 2023; 46:937-941. [PMID: 37401357 PMCID: PMC10436786 DOI: 10.1002/clc.24077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 06/15/2023] [Accepted: 06/20/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common sustained arrhythmia in adults and increases stroke risk. Treatment with oral anticoagulants (OACs) may reduce this risk however many patients do not receive OAC therapy. This study aimed to use electronic health record data to identify newly diagnosed AF patients at high risk for stroke and not anticoagulated as well as factors associated with OAC prescription. HYPOTHESIS Timely prescription of OACs among patients with newly diagnosed AF is poor. METHODS We performed a retrospective study of patients with a new diagnosis of AF. We assessed stroke risk with the CHA2 DS2 -VASc score. The primary outcome was prescription of an OAC within 6 months following diagnosis. We used logistic regression to see how the odds of being prescribed an OAC differs for 17 independent variables. RESULTS We identified 18 404 patients with a new diagnosis of AF. Among patients at high risk for stroke, 41.3% received an OAC prescription within 6 months. Male sex, Caucasian compared to African American race, stroke, obesity, congestive heart failure, vascular disorder, current antiplatelet, beta blocker, or calcium channel blocker prescription, and increasing CHA2 DS2 -VASc score were positively associated with receiving an OAC. Whereas anemia, renal dysfunction, liver dysfunction, antiarrhythmic drug use and increasing HAS-BLED score were negatively associated. CONCLUSIONS Most newly diagnosed AF patients at high stroke risk do not receive an OAC prescription in the first 6 months following diagnosis. Our analysis suggests that patient sex, race, comorbidities, and additional prescriptions are associated with rates of OAC prescribing.
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Affiliation(s)
- Evan Manning
- Internal Medicine Residency Training ProgramUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Kelley Burns
- Data Science to Patient Value (D2V)University of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Melissa Laurie
- US Health Economics & Outcomes ResearchBristol Myers SquibbLawrencevilleNew JerseyUSA
| | - Luke Patten
- Center for Innovative Design & AnalysisUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Michael Ho
- Deparment of MedicineUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Amneet Sandhu
- Deparment of MedicineUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
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Sanghai S, Henrikson CA. ABCs: A Better Chance to Improve Outcomes in Atrial Fibrillation. JACC. ASIA 2023; 3:592-594. [PMID: 37614547 PMCID: PMC10442875 DOI: 10.1016/j.jacasi.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Affiliation(s)
- Saket Sanghai
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Charles A. Henrikson
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
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Pierre-Louis IC, Saczynski JS, Lopez-Pintado S, Waring ME, Abu HO, Goldberg RJ, Kiefe CI, Helm R, McManus DD, Bamgbade BA. Characteristics associated with poor atrial fibrillation-related quality of life in adults with atrial fibrillation. J Cardiovasc Med (Hagerstown) 2023; 24:422-429. [PMID: 37129916 PMCID: PMC10699883 DOI: 10.2459/jcm.0000000000001479] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
PURPOSE Few studies have examined the relationship between poor atrial fibrillation-related quality of life (AFQoL) and a battery of geriatric factors. The objective of this study is to describe factors associated with poor AFQoL in older adults with atrial fibrillation (AF) with a focus on sociodemographic and clinical factors and a battery of geriatric factors. METHODS Cross-sectional analysis of a prospective cohort study of participants aged 65+ with high stroke risk and AF. AFQoL was measured using the validated Atrial Fibrillation Effect on Quality of Life (score 0-100) and categorized as poor (<80) or good (80-100). Chi-square and t -tests evaluated differences in factors across poor AFQoL and significant characteristics ( P < 0.05) were entered into a logistic regression model to identify variables related to poor AFQoL. RESULTS Of 1244 participants (mean age 75.5), 42% reported poor AFQoL. Falls in the past 6 months, pre/frail and frailty, depression, anxiety, social isolation, vision impairment, oral anticoagulant therapy, rhythm control, chronic obstructive pulmonary disease and polypharmacy were associated with higher odds of poor AFQoL. Marriage and college education were associated with a lower odds of poor AFQoL. CONCLUSIONS More than 4 out of 10 older adults with AF reported poor AFQoL. Geriatric factors associated with higher odds of reporting poor AFQoL include recent falls, frailty, depression, anxiety, social isolation and vision impairment. Findings from this study may help clinicians screen for patients with poor AFQoL who could benefit from tailored management to ensure the delivery of patient-centered care and improved well being among older adults with AF.
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Affiliation(s)
| | - Jane S. Saczynski
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy
| | | | - Molly E. Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT
| | - Hawa O. Abu
- Division of Cardiovascular Medicine, Department of Medicine, UMass Chan Medical School, Worcester
- Internal Medicine Department Saint Vincent Hospital, Worcester
| | - Robert J. Goldberg
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester
| | - Catarina I. Kiefe
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester
| | - Robert Helm
- Department of Radiology, Boston University, Boston, MA, USA
| | - David D. McManus
- Division of Cardiovascular Medicine, Department of Medicine, UMass Chan Medical School, Worcester
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10
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Bolt J, Barry AR, Yuen J, Madden K, Dhillon M, Inglis C. Retrospective Cross-sectional Analysis of Older Adults Living with Frailty and Anticoagulant Use for Atrial Fibrillation. Can Geriatr J 2023; 26:259-265. [PMID: 37265983 PMCID: PMC10198680 DOI: 10.5770/cgj.26.643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
Background Oral anticoagulation (OAC) is recommended for most individuals with atrial fibrillation (AF), including those who are frail. Based on previous literature, those who are frail may be less likely to be prescribed OAC, and up to one-third may receive an inappropriate dose if prescribed a direct oral anticoagulant (DOAC). The objectives of this study were to determine the proportion of frail ambulatory older adults with AF who are prescribed OAC, compare the rates of OAC use across the frailty spectrum, assess the appropriateness of DOAC dosing, and identify if frailty and geriatric syndromes impact OAC prescribing patterns. Methods Retrospective cross-sectional review of individuals with AF referred to an ambulatory clinic for older adults living with frailty and/or geriatric syndromes. Rockwood clinical frailty score of ≥4 was used to define frailty and DOAC appropriateness was assessed based on the Canadian Cardiovascular Society AF guidelines. Results Two hundred and ten participants were included. The mean age was 84 years, 49% were female and the median frailty score was 5. Of the 185 participants who were frail, 82% were prescribed an OAC (83% with frailty score of 4, 85% with a frailty score of 5, and 78% with a frailty score of 6). Of those prescribed a DOAC, 70% received a guideline-approved dose. Conclusions Over 80% of ambulatory older adults with frailty and AF were prescribed an OAC. However, of those prescribed a DOAC, 30% received an unapproved dose, suggesting more emphasis should be placed on initial and ongoing dosage selection.
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Affiliation(s)
- Jennifer Bolt
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver
- Pharmacy Services, Interior Health Authority, Kelowna
| | - Arden R. Barry
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver
- Pharmacy Services, Fraser Health Authority, Surrey
- Faculty of Medicine, University of British Columbia, Vancouver
| | - Jamie Yuen
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver
| | - Kenneth Madden
- Faculty of Medicine, University of British Columbia, Vancouver
- Geriatric Medicine, Vancouver General Hospital, Vancouver
| | - Manrubby Dhillon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver
| | - Colleen Inglis
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver
- Island Health Authority, Courtenay, BC, Canada
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Ko D, Bostrom JA, Qazi S, Kramer DB, Kim DH, Orkaby AR. Frailty and Cardiovascular Mortality: A Narrative Review. Curr Cardiol Rep 2023; 25:249-259. [PMID: 36795307 PMCID: PMC10130976 DOI: 10.1007/s11886-023-01847-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2023] [Indexed: 02/17/2023]
Abstract
PURPOSE OF REVIEW The goal of the narrative review is to provide an overview of the epidemiology of frailty in cardiovascular disease and cardiovascular mortality and discuss applications of frailty in cardiovascular care of older adults. RECENT FINDINGS Frailty is highly prevalent in older adults with cardiovascular disease and is a robust, independent predictor of cardiovascular death. There is a growing interest in using frailty to inform management of cardiovascular disease either through pre- or post-treatment prognostication or by delineating treatment heterogeneity in which frailty serves to distinguish patients with differential harms or benefits from a given therapy. Frailty can enable more individualized treatment in older adults with cardiovascular disease. Future studies are needed to standardize frailty assessment across cardiovascular trials and enable implementation of frailty assessment in cardiovascular clinical practice.
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Affiliation(s)
- Darae Ko
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
- Section of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, USA
| | - John A Bostrom
- Section of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, USA
| | - Saadia Qazi
- Department of Medicine, VA Boston Healthcare System, Boston, MA, USA
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA, USA
- Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel B Kramer
- Richart A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
- Division of Gerontology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, USA
| | - Ariela R Orkaby
- Department of Medicine, VA Boston Healthcare System, Boston, MA, USA.
- Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.
- New England GRECC (Geriatric Research, Education, and Clinical Center) VA Boston Healthcare System, 150 South Huntington, 02130, Boston, MA, USA.
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Bamgbade BA, McManus DD, Briesacher BA, Lessard D, Mehawej J, Gurwitz JH, Tisminetzky M, Mujumdar S, Wang W, Malihot T, Abu HO, Waring M, Sogade F, Madden J, Pierre-Louis IC, Helm R, Goldberg R, Kramer AF, Saczynski JS. Medication cost-reducing behaviors in older adults with atrial fibrillation: The SAGE-AF study. J Am Pharm Assoc (2003) 2023; 63:125-134. [PMID: 36171156 PMCID: PMC10699884 DOI: 10.1016/j.japh.2022.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 08/25/2022] [Accepted: 08/31/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND As patient prices for many medications have risen steeply in the United States, patients may engage in cost-reducing behaviors (CRBs) such as asking for generic medications or purchasing medication from the Internet. OBJECTIVE The objective of this study is to describe patterns of CRB, cost-related medication nonadherence, and spending less on basic needs to afford medications among older adults with atrial fibrillation (AF) and examine participant characteristics associated with CRB. METHODS Data were from a prospective cohort study of older adults at least 65 years with AF and a high stroke risk (CHA2DS2VASc ≥ 2). CRB, cost-related medication nonadherence, and spending less on basic needs to afford medications were evaluated using validated measures. Chi-square and t tests were used to evaluate differences in characteristics across CRB, and statistically significant characteristics (P < 0.05) were entered into a multivariable logistic regression to examine factors associated with CRB. RESULTS Among participants (N = 1224; mean age 76 years; 49% female), 69% reported engaging in CRB, 4% reported cost-related medication nonadherence, and 6% reported spending less on basic needs. Participants who were cognitively impaired (adjusted odds ratio 0.69 [95% CI 0.52-0.91]) and those who did not identify as non-Hispanic white (0.66 [0.46-0.95]) were less likely to engage in CRB. Participants who were married (1.88 [1.30-2.72]), had a household income of $20,000-$49,999 (1.52 [1.02-2.27]), had Medicare insurance (1.38 [1.04-1.83]), and had 4-6 comorbidities (1.43 [1.01-2.01]) had significantly higher odds of engaging in CRB. CONCLUSION Although CRBs were common among older adults with AF, few reported cost-related medication nonadherence and spending less on basic needs. Patients with cognitive impairment may benefit from pharmacist intervention to provide support in CRB and patient assistance programs.
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Affiliation(s)
- Benita A. Bamgbade
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - David D. McManus
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA; and Professor, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Becky A. Briesacher
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - Darleen Lessard
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA; and Biostatistician, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Jordy Mehawej
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Jerry H. Gurwitz
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA; Executive Director, Meyers Health Care Institute, Worcester, MA; and Professor, Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Mayra Tisminetzky
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA; and Associate Professor, Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, MA
| | | | - Weija Wang
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, MD
| | - Tanya Malihot
- Faculty of Nursing, Universite de Montreal, Montreal, Quebec, Canada; and Member, Montreal Heart Institute Research Center, Montreal, Quebec, Canada
| | - Hawa O. Abu
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Molly Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT
| | - Felix Sogade
- Department of Medicine, Mercer University School of Medicine, Mercer, GA
| | - Jeanne Madden
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | | | - Robert Helm
- Cardiovascular Medicine, Department of Medicine, School of Medicine, Boston University, Boston, MA
| | - Robert Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Arthur F. Kramer
- Department of Psychology, Northeastern University, Boston, MA; and Professor, Beckman Institute, University of Illinois at Urbana-Champaign, Urbana, IL
| | - Jane S. Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
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13
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Presta R, Brunetti E, Polidori MC, Bo M. Impact of frailty models on the prescription of oral anticoagulants and on the incidence of stroke, bleeding, and mortality in older patients with atrial fibrillation: a systematic review. Ageing Res Rev 2022; 82:101761. [PMID: 36270605 DOI: 10.1016/j.arr.2022.101761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/30/2022] [Accepted: 10/14/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Frailty is common in older patients with atrial fibrillation (AF). Current guidelines recommend oral anticoagulant therapy (OAT) except in case of severe frailty or reduced life expectancy, but definitive evidence on which "frailty" tools may help to identify older AF patients expected to derive little or no benefit from OAT is still lacking. Some persistent uncertainties may derive from the different clinical implications that the two major models of frailty, namely the frail phenotype (FP) and the deficit accumulation model (DAM), underlie. We thus conducted a systematic review of published studies to examine the association of the presence of frailty, categorized according to the FP and DAM, with 1) OAT prescription and 2) incidence of clinical outcomes (all-cause mortality, stroke and/or systemic embolism and major or clinically relevant non-major bleeding) in patients receiving OAT. METHODS Embase and MEDLINE were searched from inception until May 31st, 2022, for studies using a validated tool to identify frailty in subjects aged 65 years or older with a diagnosis of non-valvular AF; only studies on patients prescribed an OAT were considered eligible for the analyses involving clinical outcomes. The protocols for each review question have been registered in PROSPERO database (CRD42022308623 and CRD42022308628). FINDINGS Twenty-three studies exploring the association between frailty and OAT prescription on a total of 504 719 subjects were included. Patients with increasing severity of DAM frailty showed consistently lower OAT prescription rates than non-frail patients, whereas use of OAT did not significantly differ between patients with the FP compared with non-frail subjects. Eleven studies exploring the association between frailty and clinical outcomes on a total of 41 985 individuals receiving oral anticoagulation were included. Compared with non-frail subjects, a higher risk of all-cause mortality and clinical outcomes could be observed for AF patients prescribed with OAT with severe frailty according to the DAM, with inconclusive findings for the FP. High levels of heterogeneity were observed in both groups of studies; therefore, a meta-analysis was not performed. CONCLUSIONS Due to the great heterogeneity among different validated frailty measures, indiscriminately relying on "frailty" should not be regarded as the gold standard for clinical decision-making about stroke prevention in older AF patients. Present findings suggest that severe frailty according to the DAM is associated with less use of OAT and increased risk of all-cause mortality, thereby representing at the moment the most reasonable tool to efficiently recognize patients with limited life expectancy and for whom there is so far scant, if any, evidence of a clinical benefit of OAT.
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Affiliation(s)
- Roberto Presta
- Section of Geriatrics, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Molinette, Corso Bramante 88-90, 10126 Turin, Italy.
| | - Enrico Brunetti
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; Section of Internal Medicine, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Sant'Anna, Corso Bramante 88-90, 10126 Turin, Italy.
| | - Maria Cristina Polidori
- Ageing Clinical Research, Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937 Cologne, Germany; Cologne Excellence Cluster On Cellular Stress-Responses in Aging-Associated Diseases (CECAD), University of Cologne, Faculty of Medicine and University Hospital Cologne, Joseph-Stelzmann Straße 26, 50931 Cologne, Germany.
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Molinette, Corso Bramante 88-90, 10126 Turin, Italy.
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14
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Pilotto A, Veronese N, Polidori MC, Strandberg T, Topinkova E, Cruz-Jentoft AJ, Custodero C, Maggi S. The role of prognostic stratification on prescription of anticoagulants in older patients with atrial fibrillation: a multicenter, observational, prospective European study (EUROSAF). Ann Med 2022; 54:2411-2419. [PMID: 36062815 PMCID: PMC9448408 DOI: 10.1080/07853890.2022.2117407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Literature suggests that different risks of mortality could influence physicians in prescribing or not anticoagulants in older patients with atrial fibrillation (AF). The Multidimensional Prognostic Index (MPI) can be considered a tool for the detection of multidimensional frailty. The aim of this cross-sectional study was to evaluate whether prescription patterns of oral anticoagulants exist, based on MPI values. METHODS Older hospitalised patients (age ≥ 65 years) with non-valvular AF were included across 24 European centres. MPI was calculated using validated and standardised tools derived from a comprehensive geriatric assessment. Other functional and clinical information were collected to calculate indexes specific for haemorrhagic and thromboembolic risk in AF. RESULTS Altogether, 2,012 participants affected by AF (mean age was 83.2 ± 7.5, range: 65-104 years), with a higher presence of women (57.0%), were included. Overall, 440 took vitamin K antagonists VKAs (22.0%), 667 (33.4%) direct oral anticoagulants (DOACs), whilst 44.6% did not take any anticoagulant treatment. Prescription of anticoagulants was associated with MPI values, with people taking anticoagulants having lower mean MPI values. Anticoagulant therapy was not used in 53.1% of the group with the highest risk of mortality, compared with 32.3% of those in the group with the lowest mortality risk. People with higher scores in MPI were less frequently treated with anticoagulant therapy, after adjusting for several potential confounders. CONCLUSIONS The EURopean study of Older Subjects with Atrial Fibrillation (EUROSAF) suggested that almost half of the older persons with AF do not receive anticoagulants and that MPI is an important determinant in prescribing or not anticoagulants. Trial Registration: https://clinicaltrials.gov/ct2/show/NCT02973984KEY POINTSAtrial fibrillation is a common condition in older people. The data regarding the use of anticoagulants is mainly derived from randomised controlled trials that do not include a sufficient number of older frail people.Our study suggests that a consistent part of older people affected by atrial fibrillation was not treated with anticoagulants, in particular, older frail patients; however, it is unclear if this choice is supported or not by evidence.The prognostic evaluation through the multidimensional prognostic index could be useful information for the choice in the prescription of anticoagulants in older people affected by atrial fibrillation.
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Affiliation(s)
- Alberto Pilotto
- Geriatrics Unit, Department of Geriatric Care, OrthoGeriatrics and Rehabilitation, E.O. Galliera Hospital, Genova, Italy.,Department of Interdisciplinary Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Nicola Veronese
- Geriatrics Unit, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - Maria Cristina Polidori
- Ageing Clinical Research, Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Timo Strandberg
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Eva Topinkova
- First Faculty of Medicine, Charles University in Prague, Czech Republic
| | | | - Carlo Custodero
- Department of Interdisciplinary Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Stefania Maggi
- National Research Council, Neuroscience Section, Padova, Italy
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15
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Wang W, Saczynski JS, Lessard D, Goldberg RJ, Parish D, Helm R, Kiefe CI, Trymbulak K, Mehawej J, Abu H, Hayward R, Gore J, Gurwitz JH, McManus DD. Presence of Geriatric Conditions Is Prognostic of Major Bleeding in Older Patients with Atrial Fibrillation: a Cohort Study. J Gen Intern Med 2022; 37:3893-3899. [PMID: 35102482 PMCID: PMC9640487 DOI: 10.1007/s11606-022-07410-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/07/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND In older patients with atrial fibrillation (AF), physical, cognitive, and psychosocial limitations are prevalent. The prognostic value of these conditions for major bleeding is unclear. OBJECTIVE To determine whether geriatric conditions are prospectively associated with major bleeding in older patients with AF on anticoagulation. DESIGN Multicenter cohort study with 2-year follow-up from 2016 to 2020 in Massachusetts and Georgia from cardiology, electrophysiology, and primary care clinics. PARTICIPANTS Diagnosed with AF, age 65 years or older, CHA2DS2-VASc score of 2 or higher, and taking oral anticoagulant (n=1,064). A total of 6507 individuals were screened. MAIN MEASURES A six-component geriatric assessment of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Main outcome was major bleeding adjudicated by a physician panel. KEY RESULTS At baseline, participants were, on average, 75.5 years old and 49% were women. Mean CHA2DS2-VASc score was 4.5 and the mean HAS-BLED score was 3.3. During 2.0 (± 0.4) years of follow-up, 95 (8.9%) participants developed an episode of major bleeding. After adjusting for key covariates and accounting for competing risk from death, cognitive impairment (hazard ratio [HR] 1.62, 95% confidence interval [CI]: 1.02-2.56) and frailty (HR 2.77, 95% CI 1.38-5.58) were significantly associated with the development of major bleeding. CONCLUSIONS In older patients with AF taking anticoagulants, cognitive impairment and frailty were independently associated with major bleeding.
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Affiliation(s)
- Weijia Wang
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA.
| | - Jane S Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, USA
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert J Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - David Parish
- Department of Medicine, School of Medicine, Mercer University, Macon, GA, USA
| | - Robert Helm
- Department of Medicine, School of Medicine, Boston University, Boston, MA, USA
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Katherine Trymbulak
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, North Haven, CT, USA
| | - Jordy Mehawej
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Hawa Abu
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert Hayward
- Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA
| | - Joel Gore
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jerry H Gurwitz
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
- Meyers Health Care Institute, University of Massachusetts Medical School, Worcester, MA, USA
| | - David D McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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16
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Dai Q, Mehawej J, Saczynski JS, Tran KV, Abu HO, Lessard D, Fillippaios A, Paul T, Hariri E, Wang W, Tisminetzky M, Soni A, Howard-Wilson S, Waring ME, Goldberg RJ, McManus DD. Usefulness of Self-Reported Physical Activity and Clinical Outcomes in Older Patients With Atrial Fibrillation. Am J Cardiol 2022; 181:32-37. [PMID: 35985871 PMCID: PMC10427165 DOI: 10.1016/j.amjcard.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/29/2022] [Accepted: 07/05/2022] [Indexed: 11/18/2022]
Abstract
Current guidelines encourage regular physical activity (PA) to gain cardiovascular health benefit. However, little is known about whether older adults with atrial fibrillation (AF) who engage in the guideline-recommended level of PA are less likely to experience clinically relevant outcomes. We did a retrospective study based on the data from Systemic Assessment of Geriatric Elements in AF (SAGE-AF) prospective cohort study. The study population consisted of older participants with AF (≥65 years) and a congestive heart failure, hypertension, age, diabetes, stroke vascular disease, age 65 to 75 and sex(CHA2DS2-VASc) score ≥2. PA was quantified by self-reported Minnesota Leisure Time PA questionnaire. Competing risk models were used to examine the association between PA level and clinical outcomes over 2 years while controlling for several potentially confounding variables. A total of 1,244 participants (average age 76 years; 51% men; 85% non-Hispanic White) were studied. A total of 50.5% of participants engaged in regular PA. Meeting the recommended level of PA was associated with lower mortality over 2 years (adjusted hazard ratio 0.60, 95% confidence interval 0.38 to 0.95) but was not associated with rates of stroke or major bleeding. In conclusion, older adults with AF who engaged in guideline-recommended PA are more likely to survive in the long term. Healthcare providers should promote and encourage engagement in PA and tailor interventions to address barriers of engagement.
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Affiliation(s)
- Qiying Dai
- Division of Cardiology, Department of Medicine, Saint Vincent Hospital, Worcester, Massachusetts.
| | - Jordy Mehawej
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jane S Saczynski
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, Massachusetts
| | - Khanh-Van Tran
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Hawa O Abu
- Division of Cardiology, Department of Medicine, Saint Vincent Hospital, Worcester, Massachusetts
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Andreas Fillippaios
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Tenes Paul
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Essa Hariri
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Weijia Wang
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Mayra Tisminetzky
- Division of Geriatrics, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Apurv Soni
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Sakeina Howard-Wilson
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Molly E Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, Connecticut
| | - Robert J Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David D McManus
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
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17
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Abu HO, Wang W, Otabil EM, Saczynski JS, Mehawej J, Mishra A, Tisminetzky M, Blanchard G, Gurwitz JH, Goldberg RJ, McManus DD. Perception of atrial fibrillation symptoms: Impact on quality of life and treatment in older adults. J Am Geriatr Soc 2022; 70:2805-2817. [PMID: 35791806 PMCID: PMC9588564 DOI: 10.1111/jgs.17954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 05/09/2022] [Accepted: 06/08/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND In managing older adults with atrial fibrillation (AF), their symptomatology impacts their well-being and may inform treatment decision-making. We examined AF symptom perception, its impact on quality of life (QoL), and its relation to treatment strategies in older adults with AF. METHODS Data were obtained from older adults with AF enrolled in a multicenter study conducted at clinic sites in Massachusetts and Georgia between 2016 and 2018. Participants were stratified into three age groups: 65-74 (youngest-old), 75-84 (middle-old), and ≥85 (oldest). Perception of AF symptoms was assessed by participant self-report during their clinic visit and at study enrollment by the Atrial Fibrillation Effect on Quality-of-Life Questionnaire which assessed cardiac-specific and non-specific, non-cardiac AF symptoms and their impact on QoL. Treatment strategies (rate or rhythm control) utilized were ascertained from electronic medical records. RESULTS Among the 1184 participants (mean age 75 years, 48% women, 86% Non-Hispanic White), 51% were aged 65-74 years, 36% were 75-84 years, and 13% were ≥ 85 years. The most commonly reported AF symptoms were non-specific, non-cardiac symptoms (fatigue, dyspnea, lightheadedness) with similar prevalence and impact on QoL in all age groups. Cardiac-specific AF symptoms (palpitations, irregular heartbeat, pause in heart activity) were less prevalent, but most commonly reported by the youngest participants (65-74 years), who endorsed considerable impact of these symptoms on their QoL. Overall, those who reported experiencing any AF symptoms during their clinic visit were more likely to have received rhythm compared with rate control (OR: 1.56; 95% CI: 1.18-2.04) with similar findings for all age groups except those aged ≥85 years. CONCLUSIONS Our findings suggest a high prevalence of non-specific, non-cardiac symptoms among older adults with AF and that cardiac-specific AF symptoms may exert considerable impact on their QoL. The presence of any AF symptoms may drive more rhythm control in a majority of older adults.
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Affiliation(s)
- Hawa O. Abu
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
- Department of Internal Medicine, Saint Vincent Hospital, Worcester MA
| | - Weijia Wang
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
| | - Edith M. Otabil
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
| | - Jane S. Saczynski
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston MA
| | - Jordy Mehawej
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
| | - Ajay Mishra
- Department of Internal Medicine, Saint Vincent Hospital, Worcester MA
| | - Mayra Tisminetzky
- Division of Geriatric Medicine and Meyers Health Care Institute. Department of Medicine, University of Massachusetts Medical School, Worcester MA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Gary Blanchard
- Division of Geriatrics, Department of Internal Medicine, Saint Vincent Hospital, Worcester MA
| | - Jerry H. Gurwitz
- Division of Geriatric Medicine and Meyers Health Care Institute. Department of Medicine, University of Massachusetts Medical School, Worcester MA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Robert J. Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - David D. McManus
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
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18
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Karnik AA, Saczynski JS, Chung JJ, Gurwitz JH, Bamgbade BA, Paul TJ, Lessard DM, McManus DD, Helm RH. Cognitive impairment, age, quality of life, and treatment strategy for atrial fibrillation in older adults: The SAGE-AF study. J Am Geriatr Soc 2022; 70:2818-2826. [PMID: 35735210 PMCID: PMC10719956 DOI: 10.1111/jgs.17886] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/18/2022] [Accepted: 04/23/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) treatment includes anticoagulation for high stroke risk individuals and either rate or rhythm control strategies. We aimed to investigate the impact of age, geriatric factors, and medical comorbidities on choice of rhythm versus rate control strategy in older adults. METHODS Patients with AF aged ≥65 years with CHA2 DS2 VASc score ≥2 and eligible for anticoagulation were recruited for the Systematic Assessment of Geriatric Elements-AF (SAGE-AF) prospective cohort study. An interview that included measures of HRQoL, cognitive function, vision, hearing, and frailty was performed. The association between these elements and AF treatment strategy was examined by multivariable logistic regression models. RESULTS One thousand two hundred forty-four participants (mean age 76 years; 49% female; 85% non-Hispanic white) were enrolled. Rate and rhythm control were used in 534 and 710 participants, respectively. Compared to participants <75 years, those ≥75 were more likely to be treated with a rate control strategy (age 75-84 adjusted odds ratio [aOR] 1.37 [95% CI 0.99, 1.88]; age 85+ aOR = 2.05, 95% CI 1.30, 3.21). Those treated with a rate control strategy were more likely to have cognitive impairment (aOR = 1.50, 95% CI 1.13, 1.99), and peripheral vascular disease (PVD) (aOR = 1.82, 95% CI 1.22, 2.72) but less likely to have visual impairment (aOR 0.73 [0.55, 0.98]), congestive heart failure (CHF; aOR 0.68 [0.49, 0.94]) or receive anticoagulation (aOR 0.53, 95% CI 0.36, 0.78). CONCLUSION Older age, cognitive impairment, and PVD were associated with use of rate control strategy. Visual impairment, CHF, and anticoagulation use were associated with a rhythm control strategy. There was no difference in HRQoL between the rate and rhythm control groups. This study suggests that certain geriatric elements may be associated with AF treatment strategies. Further study is needed to evaluate how these decisions affect outcomes.
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Affiliation(s)
- Ankur A. Karnik
- Evans Department of Medicine, Cardiovascular Medicine Section, Arrhythmia Service, Boston University School of Medicine, Boston, MA
| | - Jane S. Saczynski
- Bouvé College of Health Sciences, Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - Joseph J. Chung
- Evans Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Jerry H. Gurwitz
- Meyers Primary Care Institute and Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Benita A. Bamgbade
- Bouvé College of Health Sciences, Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - Tenes J. Paul
- Meyers Primary Care Institute and Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Darleen M. Lessard
- Division of Epidemiology of Chronic Diseases, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - David D. McManus
- Division of Cardiology, Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Robert H. Helm
- Evans Department of Medicine, Cardiovascular Medicine Section, Arrhythmia Service, Boston University School of Medicine, Boston, MA
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Proietti M, Romiti GF, Raparelli V, Diemberger I, Boriani G, Dalla Vecchia LA, Bellelli G, Marzetti E, Lip GY, Cesari M. Frailty prevalence and impact on outcomes in patients with atrial fibrillation: A systematic review and meta-analysis of 1,187,000 patients. Ageing Res Rev 2022; 79:101652. [PMID: 35659945 DOI: 10.1016/j.arr.2022.101652] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/20/2022] [Accepted: 05/23/2022] [Indexed: 12/14/2022]
Abstract
Frailty is a clinical syndrome characterized by a reduced physiologic reserve, increased vulnerability to stressors and an increased risk of adverse outcomes. People with atrial fibrillation (AF) are often burdened by frailty due to biological, clinical, and social factors. The prevalence of frailty, its management and association with major outcomes in AF patients are still not well quantified. We systematically searched PubMed and EMBASE, from inception to September 13th, 2021, for studies reporting the prevalence of frailty in AF patients. The study was registered in PROSPERO (CRD42021235854). 33 studies were included in the systematic review (n = 1,187,651 patients). The frailty pooled prevalence was 39.7 % (95 %CI=29.9 %-50.5 %, I2 =100 %), while meta-regression analyses showed it is influenced by age, history of stroke, and geographical location. Meta-regression analyses showed that OAC prescription was influenced by study-level mean age, baseline thromboembolic risk, and study setting. Frail AF patients were associated with a higher risk of all-cause death (OR=5.56, 95 %CI=3.46-8.94), ischemic stroke (OR=1.59, 95 %CI=1.00-2.52), and bleeding (OR=1.64, 95 %CI=1.11-2.41), when compared to robust individuals. In this systematic review and meta-analysis, the prevalence of frailty was high in patients with AF. Frailty may influence the prognosis and management of AF patients, thus requiring person-tailored interventions in a holistic or integrated approach to AF care.
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Affiliation(s)
- Marco Proietti
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Italy; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
| | | | - Valeria Raparelli
- Department of Translational Medicine, University of Ferrara, Italy; University Center for Studies on Gender Medicine, University of Ferrara, Italy; University of Alberta, Faculty of Nursing, Edmonton, Alberta, Canada
| | - Igor Diemberger
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Italy
| | | | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Emanuele Marzetti
- Università Cattolica del Sacro Cuore, Department of Geriatrics and Orthopedics, Rome, Italy; Center for Geriatric Medicine (Ce.M.I.), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome,Italy
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Matteo Cesari
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Italy
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20
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Di Carlo A, Mori F, Consoli D, Bellino L, Zaninelli A, Baldereschi M, D'Alfonso MG, Gradia C, Cattarinussi A, Sgherzi B, Pracucci G, Piccardi B, Polizzi BM, Inzitari D. Influence of atrial fibrillation subtypes on anticoagulant therapy in a high-risk older population: the FAI project. Aging Clin Exp Res 2022; 34:2185-2194. [PMID: 35543807 PMCID: PMC9464178 DOI: 10.1007/s40520-022-02140-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 04/14/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIM Benefits of oral anticoagulants (OAC) in atrial fibrillation (AF) patients with moderate-to-high risk of stroke are independent of AF pattern. We evaluated whether AF clinical subtype influenced OAC use in a representative sample of the Italian older population. METHODS A cross-sectional examination of all subjects aged 65 + years from three general practices in northern, central, and southern Italy started in 2016. A double-screening procedure was followed by clinical and ECG confirmation. Patients were categorized as having paroxysmal, persistent, or permanent AF. OAC use was evaluated in confirmed AF patients. RESULTS The sample included 6016 subjects. Excluding 235 non-eligible, participation was 78.3%, which left 4528 participants (mean age 74.5 ± 6.8 years, 47.2% men). Overall, 319 AF cases were identified: 43.0% had paroxysmal, 21.3% persistent, and 35.7% permanent AF. Frequency of OAC therapy was 91.2% in permanent, 85.3% in persistent, and only 43.0% in paroxysmal AF (P < 0.001). In multivariate analysis, controlled for baseline variables and risk scales, persistent and permanent AF were associated with a significant increase in the likelihood of receiving OAC compared with paroxysmal AF (P < 0.001). This was confirmed for permanent AF also in multivariate analyses considering separately vitamin K antagonists or direct-acting oral anticoagulants (OR, 4.37, 95% CI, 2.43-7.85; and 1.92, 95% CI, 1.07-3.42, respectively) and for persistent AF and direct-acting oral anticoagulants (OR, 4.33, 95% CI, 2.30-8.15). CONCLUSIONS In a population-based survey, AF pattern was an independent predictor of OAC treatment. Paroxysmal AF is still perceived as carrying a lower risk of vascular events.
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Affiliation(s)
- Antonio Di Carlo
- Institute of Neuroscience, Italian National Research Council, Via Madonna del Piano, 10 - 50019 Sesto Fiorentino, Florence, Italy.
| | - Fabio Mori
- Cardiovascular Unit, Careggi University Hospital, Florence, Italy
| | | | | | | | - Marzia Baldereschi
- Institute of Neuroscience, Italian National Research Council, Via Madonna del Piano, 10 - 50019 Sesto Fiorentino, Florence, Italy
| | | | | | | | | | | | | | - Bianca Maria Polizzi
- National Centre for Disease Prevention and Control, Italian Ministry of Health, Rome, Italy
| | - Domenico Inzitari
- Institute of Neuroscience, Italian National Research Council, Via Madonna del Piano, 10 - 50019 Sesto Fiorentino, Florence, Italy
- Department of Neurofarba, University of Florence, Florence, Italy
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21
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Bezabhe WM, Bereznicki LR, Radford J, Wimmer BC, Salahudeen MS, Garrahy E, Bindoff I, Peterson GM. Oral Anticoagulant Treatment and the Risk of Dementia in Patients With Atrial Fibrillation: A Population-Based Cohort Study. J Am Heart Assoc 2022; 11:e023098. [PMID: 35301852 PMCID: PMC9075457 DOI: 10.1161/jaha.121.023098] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background We compared the dementia incidence rate between users and nonusers of oral anticoagulants (OACs) in a large cohort of primary care patients with atrial fibrillation. Methods and Results We performed a retrospective study using an Australia‐wide primary care data set, MedicineInsight. Patients aged ≥18 years and newly diagnosed with atrial fibrillation between January 1, 2010, and December 31, 2017, and with no recorded history of dementia or stroke were included and followed until December 31, 2018. We applied a propensity score for 1:1 pair matching of baseline covariates and Cox regression for comparing the dementia incidence rates for OAC users and nonusers. Data were analyzed for 18 813 patients with atrial fibrillation (aged 71.9±12.6 years, 47.1% women); 11 419 had a recorded OAC prescription for at least 80% of their follow‐up time. During the mean follow‐up time of 3.7±2.0 years, 425 patients (2.3%; 95% CI, 2.1%–2.5%) had a documented diagnosis of dementia. After propensity matching, the incidence of dementia was significantly lower in OAC users (hazard ratio [HR], 0.59; 95% CI, 0.44–0.80; P<0.001) compared with nonusers. Direct‐acting oral anticoagulant users had a lower incidence of dementia than non‐OAC users (HR, 0.49; 95% CI, 0.33–0.73; P<0.001) or warfarin users (HR, 0.46; 95% CI, 0.28–0.74; P=0.002). No significant difference was seen between warfarin users and non‐OAC users (HR, 1.08; 95% CI, 0.70–1.70; P=0.723). Conclusions In patients with atrial fibrillation, direct‐acting oral anticoagulant use may result in a lower incidence of dementia compared with treatment with either warfarin or no anticoagulant.
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Affiliation(s)
| | - Luke R Bereznicki
- School of Pharmacy and Pharmacology University of Tasmania Hobart Tasmania Australia
| | - Jan Radford
- Launceston Clinical School Tasmanian School of Medicine University of Tasmania Launceston Tasmania Australia
| | - Barbara C Wimmer
- School of Pharmacy and Pharmacology University of Tasmania Hobart Tasmania Australia
| | - Mohammed S Salahudeen
- School of Pharmacy and Pharmacology University of Tasmania Hobart Tasmania Australia
| | - Edward Garrahy
- Launceston Clinical School Tasmanian School of Medicine University of Tasmania Launceston Tasmania Australia
| | - Ivan Bindoff
- School of Pharmacy and Pharmacology University of Tasmania Hobart Tasmania Australia
| | - Gregory M Peterson
- School of Pharmacy and Pharmacology University of Tasmania Hobart Tasmania Australia
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22
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Proietti M, Camera M, Gallieni M, Gianturco L, Gidaro A, Piemontese C, Pizzetti G, Redaelli F, Scimeca B, Tadeo CS, Cesari M, Bellelli G, Dalla Vecchia LA. Use and Prescription of Direct Oral Anticoagulants in Older and Frail Patients with Atrial Fibrillation: A Multidisciplinary Consensus Document. J Pers Med 2022; 12:jpm12030469. [PMID: 35330468 PMCID: PMC8955844 DOI: 10.3390/jpm12030469] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/08/2022] [Accepted: 03/12/2022] [Indexed: 11/25/2022] Open
Abstract
In the last twelve years the clinical management of patients with atrial fibrillation has been revolutionised by the introduction of direct oral anticoagulants. Despite the large amount of evidence produced, some populations remain relatively poorly explored regarding the effectiveness and safety of direct oral anticoagulants, such as the oldest and/or frailest individuals. Frailty is clinical syndrome characterized by a reduction of functions and physiological reserves which results in individuals having higher vulnerability. While current evidence underlines a relationship between atrial fibrillation and frailty, particularly in determining a higher risk of adverse outcomes, data regarding effectiveness and safety of direct oral anticoagulants in frailty atrial fibrillation patients are still lacking, leaving uncertainty about how to guide prescription in this specific subgroup. On these premises, this multidisciplinary consensus document explains why it would be useful to integrate the clinical evaluation performed through comprehensive geriatric assessment to gather further elements to guide prescription of direct oral anticoagulants in such a high-risk group of patients.
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Affiliation(s)
- Marco Proietti
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, 20138 Milan, Italy; (M.P.); (M.C.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L7 3FA, UK
| | - Marina Camera
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy;
- Department of Pharmaceutical Sciences, University of Milan, 20133 Milan, Italy
| | - Maurizio Gallieni
- Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, 20131 Milan, Italy;
- Department of Biomedical and Clinical Sciences ‘Luigi Sacco’, University of Milan, 20157 Milan, Italy;
| | - Luigi Gianturco
- Cardiology Unit, IRCCS Orthopedic Institute Galeazzi, 20161 Milan, Italy;
| | - Antonio Gidaro
- Department of Biomedical and Clinical Sciences ‘Luigi Sacco’, University of Milan, 20157 Milan, Italy;
| | - Carlo Piemontese
- Cardiology Unit, Sant’Anna Hospital, ASST Lariana, 22042 Como, Italy;
| | - Giuseppe Pizzetti
- Division of Cardiology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | | | - Barbara Scimeca
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Cà Granda Maggiore Hospital Foundation, 20122 Milan, Italy;
| | | | - Matteo Cesari
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, 20138 Milan, Italy; (M.P.); (M.C.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy;
- Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, 20900 Monza, Italy
| | - Laura Adelaide Dalla Vecchia
- Department of Cardiology, IRCCS Istituti Clinici Scientifici Maugeri, 20138 Milan, Italy
- Correspondence: ; Tel.: +39-02-50725120
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23
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Mehawej J, Mishra A, Saczynski JS, Waring ME, Lessard D, Abu HO, La V, Tisminetzky M, Tran KV, Hariri E, Filippaios A, Paul T, Soni A, Wang W, Ding EY, Bamgbade BA, Mathew J, Kiefe C, Goldberg RJ, McManus DD. Online Health Information Seeking, Low AF-Related Quality of Life, and High Perceived Efficacy in Patient-Physician Interactions in Older Adults with Atrial Fibrillation. CARDIOVASCULAR DIGITAL HEALTH JOURNAL 2022; 3:118-125. [PMID: 35720678 PMCID: PMC9204795 DOI: 10.1016/j.cvdhj.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Little is known about online health information–seeking behavior among older adults with atrial fibrillation (AF) and its association with self-reported outcomes. Objective To examine patient characteristics associated with online health information seeking and the association between information seeking and low AF-related quality of life and high perceived efficacy in patient-physician interaction. Methods We used data from the SAGE-AF (Systematic Assessment of Geriatric Elements in AF) study, which includes older participants aged ≥65 years with AF and a CHA2DS2-VASc risk score ≥2. To assess online health information seeking, participants who reported using the Internet were asked at baseline if they used the Internet to search for advice or information about their health in the past 4 weeks (not at all vs at least once). Atrial Fibrillation Effect on Quality of Life and Perceived Efficacy in Patient-Physician Interactions questionnaires were used to examine AF-related quality of life (QOL) and patient-reported confidence in physicians. Logistic regression models were used to examine demographic and clinical factors associated with online health information seeking and associations between information seeking and low AF-related QOL (AFEQT <80) and high perceived efficacy for patient-physician interactions (PEPPI ≥45). Results A total of 874 online participants (mean age 74.5 years, 51% male, 91% non-Hispanic White) were studied. Approximately 60% of participants sought health information online. Participants aged 74 years or older and those on anticoagulation were less likely, while those with a college degree were more likely, to seek online health information after adjusting for potential confounders. Participants who sought health information online, compared to those who did not, were significantly more likely to have a low AF-related QOL, but less likely to self-report confidence in patient-physician interaction (aOR = 1.56, 95% CI: 1.15–2.13; aOR = 0.68, 95% CI: 0.49–0.93, respectively). Conclusion Clinicians should consider barriers to patient-physician interaction in older adults who seek health information online, encourage shared decision-making, and provide patients with a list of online resources for AF in addition to disease education plans to help patients manage their health.
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24
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Ai Y, Xing Y, Yan L, Ma D, Gao A, Xu Q, Zhang S, Mao T, Pan Q, Ma X, Zhang J. Atrial Fibrillation and Depression: A Bibliometric Analysis From 2001 to 2021. Front Cardiovasc Med 2022; 9:775329. [PMID: 35252380 PMCID: PMC8888833 DOI: 10.3389/fcvm.2022.775329] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/18/2022] [Indexed: 01/13/2023] Open
Abstract
BackgroundThe control of diseases related to atrial fibrillation (AF) may reduce the occurrence of AF, delay progression, and reduce complications, which is beneficial to the prevention and treatment of AF. An increasing number of studies have shown that AF is associated with depression. However, to date, there has not been a bibliometric analysis to examine this field systematically. Our study aimed to visualize the publications to determine the hotspots and frontiers in research on AF and depression and provide guidance and reference for further study.MethodsPublications about AF and depression between 2001 and 2021 were retrieved from the Web of Science Core Collection (WOSCC) database. CiteSpace 5.8. R1, VOSviewer 1.6.16, and Excel 2019 software tools were used to conduct this bibliometric study.ResultsIn total, 159 articles and reviews were analyzed. The number of publications has been increased sharply since 2018. David D. McManus had the largest number of publications. The most prolific country was the USA with 54 publications but the centrality was <0.1. The most prolific institution was Northeastern University. Three clusters were formed based on keywords: The first cluster was composed of atrial fibrillation, depression, anxiety, symptoms, ablation, and quality of life, et al. The second cluster were risk, prevalence, mortality, heart failure, association, et al. While the third cluster included anticoagulation, impact, stroke, management, warfarin, et al. After 2019, stroke and prediction are the keywords with strongest citation bursts.ConclusionResearch on AF and depression is in its infancy. Cooperation and exchanges between countries and institutions must be strengthened in the future. The effect of depression on prevalence and mortality in AF, depression on ablation in AF, and impact of depression on anticoagulation treatment in AF have been the focus of current research. Stroke prevention (including anticoagulant therapy) is the research frontier, which may still be the focus of research in the future.
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Affiliation(s)
- Yuzhen Ai
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yaxuan Xing
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Longmei Yan
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Dan Ma
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Anran Gao
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Qiwu Xu
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Shan Zhang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Ting Mao
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Qiu Pan
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiaojuan Ma
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- *Correspondence: Xiaojuan Ma
| | - Jingchun Zhang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Jingchun Zhang
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25
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Mehawej J, Saczynski JS, Kiefe CI, Abu HO, Tisminetzky M, Wang W, Bamgbade BA, Ding E, Lessard D, Otabil EM, Saleeba C, Goldberg RJ, McManus DD. Association between risk of obstructive sleep apnea and cognitive performance, frailty, and quality of life among older adults with atrial fibrillation. J Clin Sleep Med 2022; 18:469-475. [PMID: 34432629 PMCID: PMC8805012 DOI: 10.5664/jcsm.9622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 02/03/2023]
Abstract
STUDY OBJECTIVES Geriatric impairments and obstructive sleep apnea (OSA) are prevalent among older patients with atrial fibrillation (AF). Little is known about the association between OSA and geriatric impairments, including frailty, cognitive performance, and AF-related quality of life. The objective of this study was to examine the associations of OSA with frailty, cognitive performance, and AF-related quality of life among older adults with AF. METHODS Data from the Systemic Assessment of Geriatrics Elements-AF study were used, which included AF participants 65 years and older and with a CHA2DS2-VASc ≥ 2. The STOP-BANG questionnaire was used to assess the risk of OSA. Multivariable logistic regression models were used to examine the association between risk of OSA and geriatric impairments, adjusting for sociodemographic, geriatric, and clinical characteristics. RESULTS A total of 970 participants (mean age 75 years; 51% male) were studied. Of the 680 participants without a medical history of OSA, 26% (n = 179) of participants had a low risk of OSA, 53% (n = 360) had an intermediate risk, and 21% (n = 141) had a high risk for OSA. Compared to those with low risk of OSA, participants with an intermediate or high risk of OSA were more likely to be frail (adjusted odds ratio = 1.67, 95% confidence interval: 1.08-2.56; adjusted odds ratio = 3.00, 95% confidence interval: 1.69-5.32, respectively) in the fully adjusted models. CONCLUSIONS Our findings identify a group of patients at high risk who would benefit from early screening for OSA. Future longitudinal studies are needed to assess the effect of OSA treatment on frailty, physical functioning, and quality of life among patients with AF. CITATION Mehawej J, Saczynski JS, Kiefe CI, et al. Association between risk of obstructive sleep apnea and cognitive performance, frailty, and quality of life among older adults with atrial fibrillation. J Clin Sleep Med. 2022;18(2):469-475.
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Affiliation(s)
- Jordy Mehawej
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jane S. Saczynski
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, Massachusetts
| | - Catarina I. Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Hawa O. Abu
- Department of Medicine, Saint Vincent Hospital, Worcester, Massachusetts
| | - Mayra Tisminetzky
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
- Division of Geriatrics, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Weijia Wang
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Benita A. Bamgbade
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, Massachusetts
| | - Eric Ding
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Edith Mensah Otabil
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Connor Saleeba
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Robert J. Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David D. McManus
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
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26
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Study on Influencing Factors of Frailty in Elderly Patients with Type II Diabetes. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:7244847. [PMID: 35132360 PMCID: PMC8817860 DOI: 10.1155/2022/7244847] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/05/2022] [Accepted: 01/12/2022] [Indexed: 02/07/2023]
Abstract
The purpose of this study was to analyze the influencing factors of frailty in elderly patients with type II diabetes. 332 elderly patients with type II diabetes admitted to our hospital from May 2018 to December 2019 were selected as the study subjects. The degree of frailty was evaluated by the Fried fragility phenotype scale, and the general information and the clinical data of patients were collected by inquiry and questionnaire survey. After that, all the data were analyzed by SPSS 20.0. Univariate analysis showed that there were significant differences in age, medication types, dietary habits, exercise tolerance, exercise capacity, body balance, coordination ability, urinary incontinence, anxiety, etc., in elderly patients with type II diabetes who suffered from different degrees of frailty (P < 0.01). In addition, there were significant differences in the presence of coronary heart disease, heart failure, atrial fibrillation, pulmonary diseases, osteoarticular diseases, anemia, and other blood diseases of elderly patients with type II diabetes who suffered from different degrees of frailty (P < 0.01). Multiple Logistic regression analyses indicated that weakened exercise tolerance, reduced exercise capacity, atrial fibrillation, anemia, and other blood diseases were the influencing factors of the frailty in elderly patients with type II diabetes. The degree of frailty in elderly patients with diabetes is affected by many factors, such as exercise tolerance, exercise capacity, atrial fibrillation, anemia, and other blood diseases; thus, reasonable intervention should be implemented for elderly patients with type II diabetes according to the influencing factors so as to effectively relieve frailty.
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27
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The impact of mental health conditions on oral anticoagulation therapy and outcomes in patients with atrial fibrillation: A systematic review and meta-analysis. Am J Prev Cardiol 2021; 7:100221. [PMID: 34611647 PMCID: PMC8387298 DOI: 10.1016/j.ajpc.2021.100221] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/02/2021] [Accepted: 06/24/2021] [Indexed: 12/14/2022] Open
Abstract
One third of patients with atrial fibrillation (AF) are estimated to suffer from mental health conditions (MHCs). We conducted a systematic review and meta-analysis to investigate the impact of MHCs on the prevalence and quality of oral anticoagulation (OAC) therapy and outcomes in patients with AF. Medline database was searched for studies published before March 1st 2021 evaluating AF patients with comorbid MHCs reporting on the prevalence of OAC therapy, time in therapeutic range (TTR) in warfarin-receiving patients, adherence to OAC therapy or adverse outcomes (ischemic stroke, hemorrhage or mortality). Studies reporting on outcome events were included in the meta-analysis. The literature search yielded 17 studies including 977,535 patients that fulfilled the inclusion criteria of this review. AF patients with MHCs had a lower prevalence of OAC use and poorer TTR compared with patients without MHCs. Evidence on OAC quality in patients receiving direct oral anticoagulants (DOACs) was minimal and inconclusive. A decrease in depression-associated deficit in OAC prevalence was observed after the introduction of DOACs. Pooled analysis of five studies reporting on outcomes showed that MHCs were an independent risk factor for both stroke (RR 1.25, 95%CI 1.08-1.45, I2 0%) and major bleeding (RR 1.17, 95%CI 1.08-1.27, I2 27%). Data on mortality were lacking and therefore not included in the meta-analysis. Evidence on the impact of specific MHCs on the outcomes were inadequate. In conclusion, MHCs are independent risk factors for stroke and major bleeding in patients with AF. Future studies are needed to confirm the findings of this meta-analysis, to evaluate the prognostic impact of different MHCs and to clarify whether the introduction of DOACs might have improved the outcomes of these patients.
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Guo Y, Wang H, Kotalczyk A, Wang Y, Lip GYH. One-year Follow-up Results of the Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry. J Arrhythm 2021; 37:1227-1239. [PMID: 34621421 PMCID: PMC8485828 DOI: 10.1002/joa3.12608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/07/2021] [Accepted: 07/21/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The high prevalence of atrial fibrillation (AF) in the very elderly population (aged >80 years) might be underestimated. The elderly are at increased risk of both fatal stroke and bleeding. The Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry provides contemporary management strategies among the elderly Chinese patients in the new era of non-vitamin K antagonists. OBJECTIVE To present the 1-year follow-up data from the ChiOTEAF registry, focusing on the use of antithrombotic therapy, rate vs. rhythm control strategies, and determinants of mortality and stroke. METHODS The ChiOTEAF registry analyzed consecutive AF patients presenting in 44 centers from 20 Chinese provinces from October 2014 to December 2018. Endpoints of interest were mortality, thromboembolism, major bleedings, cardiovascular comorbidities, and hospital re-admissions. RESULTS Of the 7077 patients enrolled at baseline, 657 patients (9.3%) were lost to the follow-up and 435 deaths (6.8%) occurred. The overall use of anticoagulants remains low, approximately 38% of the entire cohort at follow-up, with similar proportions of vitamin K antagonists (VKA) and non-vitamin K antagonists (NOACs). Antiplatelet therapy was used in 38% of the entire cohort at follow-up, and more commonly among high-risk patients (41%). Among those on a NOAC at baseline, 22.4% switched to antiplatelet therapy alone after one year.Independent predictors of stroke/transient ischemic attack/peripheral embolism and/or mortality were age, heart failure, chronic kidney disease, prior ischemic stroke, dementia, and chronic obstructive pulmonary disease. CONCLUSIONS The ChiOTEAF registry provides contemporary data on AF management, including stroke prevention. The poor adherence of NOACs and common use of antiplatelet in these high-risk elderly population calls for multiple comorbidities management.
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Affiliation(s)
- Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease Sixth Medical Centre Chinese PLA General Hospital Beijing China
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool UK
| | - Hao Wang
- Department of Cardiology Second Medical Center Chinese PLA General Hospital Beijing China
| | - Agnieszka Kotalczyk
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool UK
- Department of Cardiology Congenital Heart Diseases and Electrotherapy Medical University of Silesia Silesian Centre for Heart Diseases Zabrze Poland
| | - Yutang Wang
- Department of Cardiology Second Medical Center Chinese PLA General Hospital Beijing China
| | - Gregory Y H Lip
- Department of Pulmonary Vessel and Thrombotic Disease Sixth Medical Centre Chinese PLA General Hospital Beijing China
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool UK
- Aalborg Thrombosis Research Unit Department of Clinical Medicine Aalborg University Aalborg Denmark
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Papanastasiou A, Kartas A, Samaras A, Vrana E, Papazoglou A, Moysidis DV, Baroutidou A, Botis M, Liampas E, Vouloagkas I, Mareti E, Karagiannidis E, Karvounis H, Tzikas A, Giannakoulas G. Oral anticoagulation patterns and prognosis in octogenarian patients with atrial fibrillation. J Thromb Thrombolysis 2021; 53:851-860. [PMID: 34562201 DOI: 10.1007/s11239-021-02571-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2021] [Indexed: 11/28/2022]
Abstract
The relationship between oral anticoagulants (OACs) and prognosis in elderly patients with atrial fibrillation (AF) has not been adequately explored. In this retrospective cohort study, we identified subjects aged over 80 from a database of 1140 AF patients discharged from the cardiology ward of a single tertiary center between 2015 and 2018. We examined the OAC treatment of octogenarian patients at discharge [VKA (vitamin K antagonist), NOAC (non-vitamin K antagonist oral anticoagulant), no OAC treatment]. We analyzed follow-up data of patients on OAC at discharge. The primary endpoint was all-cause death. The secondary endpoint was the incidence of stroke and major bleeding. The association of NOAC versus VKA treatment with these endpoints was assessed with multivariable Cox regression, using the VKA group as reference. A total of 330 octogenarian patients with AF were included with a mean (± SD) age of 83.9 ± 3.5 years. At discharge, 53.3% received a NOAC, 30% a VKA, and 16.7% no OAC. Patients on OAC were followed-up over a median of 2.6-years . The adjusted risk of all-cause death was not different in the NOAC group, compared with the VKA group (hazard ratio [HR], 0.72; 95% confidence intervals [CI] 0.50-1.03; P = 0.07). The risk of stroke or major bleeding was not different either (all P > 0.05). In conclusion, in this cohort of post-discharge octogenarian patients with AF, the risk for all-cause death was similar in NOAC versus VKA users, after adjustment for baseline covariates. No differences in stroke and major bleeding events among these treatment groups were revealed.
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Affiliation(s)
- Anastasios Papanastasiou
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Anastasios Kartas
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Athanasios Samaras
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Eleni Vrana
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Andreas Papazoglou
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Dimitrios V Moysidis
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Amalia Baroutidou
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Michail Botis
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Evaggelos Liampas
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Ioannis Vouloagkas
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Evangelia Mareti
- 2nd Department of Obstetrics and Gynecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efstratios Karagiannidis
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Haralambos Karvounis
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Apostolos Tzikas
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece.,Interbalkan European Medical Center, Asklipiou 10, Pylaia, Thessaloniki, Greece
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636, Thessaloniki, Greece.
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Guo Y, Kotalczyk A, Imberti JF, Wang Y, Lip GY. Oral anticoagulation improves survival in very elderly Chinese patients with atrial fibrillation: A report from the Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry. Int J Stroke 2021; 17:661-668. [PMID: 34551637 DOI: 10.1177/17474930211046743] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Advancing age is a major risk factor for ischemic stroke in atrial fibrillation. We aimed to evaluate the predictors of all-cause death/any thromboembolism and the impact of oral anticoagulant on clinical outcomes in very elderly (≥85 years) Chinese atrial fibrillation patients. METHODS The ChiOTEAF is a prospective registry proceeded in 44 sites from 20 provinces in China between October 2014 and December 2018. Outcomes of interest were all-cause mortality, any thromboembolism, major bleeding, and new onset/worsening heart failure. RESULTS The eligible cohort for this analysis included 6416 patients and 1215 (18.9%) patients were aged ≥85 years. Only 320 (26.4%) very elderly patients were treated with oral anticoagulant, of whom 205 (64.1%) received non-vitamin K antagonist oral anticoagulants, while antiplatelet therapy was used among 642 (53.1%) very elderly patients. On multivariate analysis, the use of oral anticoagulant was an independent predictor of a lower risk of the composite outcome (OR: 0.46; 95% CI: 0.32-0.66) and all-cause death (OR: 0.47; 95% CI: 0.32-0.69) among these very elderly atrial fibrillation patients. CONCLUSIONS Advanced age should not be a reason to withhold oral anticoagulant, since the use of oral anticoagulants is safe and improves survival.
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Affiliation(s)
- Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Centre, Chinese PLA General Hospital, Beijing, China.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Agnieszka Kotalczyk
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Jacopo F Imberti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Yutang Wang
- Department of Cardiology, Second Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Gregory Yh Lip
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Centre, Chinese PLA General Hospital, Beijing, China.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Bamgbade BA, McManus DD, Helm R, Mehawej J, Gurwitz JH, Mailhot T, Abu HO, Goldberg R, Wang Z, Tisminetzky M, Pierre‐Louis IC, Saczynski JS. Differences in Perceived and Predicted Bleeding Risk in Older Adults With Atrial Fibrillation: The SAGE-AF Study. J Am Heart Assoc 2021; 10:e019979. [PMID: 34398677 PMCID: PMC8649256 DOI: 10.1161/jaha.120.019979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 05/18/2021] [Indexed: 11/16/2022]
Abstract
Background Little research has evaluated patient bleeding risk perceptions in comparison with calculated bleeding risk among oral anticoagulant users with atrial fibrillation. Our objective was to investigate underestimation of bleeding risk and to describe the characteristics and patient-reported outcomes associated with underestimation of bleeding risk. Methods and Results In the SAGE-AF (Systematic Assessment of Geriatric Elements in Atrial Fibrillation) study, a prospective cohort study of patients ≥65 years with atrial fibrillation, a CHA2DS2-VASc risk score ≥2 and who were on oral anticoagulant therapy, we compared patients' self-reported bleeding risk with their predicted bleeding risk from their HAS-BLED score. Among the 754 participants (mean age 74.8 years, 48.3% women), 68.0% underestimated their bleeding risk. Participants who were Asian or Pacific Islander, Black, Native American or Alaskan Native, Mixed Race or Hispanic (non-White) (adjusted OR [AOR], 0.45; 95% CI, 0.24-0.82) and women (AOR, 0.62; 95% CI, 0.40-0.95) had significantly lower odds of underestimating their bleeding risk than respective comparison groups. Participants with a history of bleeding (AOR, 3.07; 95% CI, 1.73-5.44) and prior hypertension (AOR, 4.33; 95% CI, 2.43-7.72), stroke (AOR, 5.18; 95% CI, 1.87-14.40), or renal disease (AOR, 5.05; 95% CI, 2.98-8.57) had significantly higher odds of underestimating their bleeding risk. Conclusions We found that more than two-thirds of patients with atrial fibrillation on oral anticoagulant therapy underestimated their bleeding risk and that participants with a history of bleeding and several comorbid conditions were more likely to underestimate their bleeding risk whereas non-Whites and women were less likely to underestimate their bleeding risk. Clinicians should ensure that patients prescribed oral anticoagulant therapy have a thorough understanding of bleeding risk.
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Affiliation(s)
- Benita A. Bamgbade
- Department of Pharmacy and Health System SciencesNortheastern UniversityBostonMA
| | - David D. McManus
- Cardiology DivisionDepartment of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
- Department of Population and Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Robert Helm
- Department of MedicineCardiovascular MedicineBoston University School of MedicineBostonMA
| | - Jordy Mehawej
- Cardiology DivisionDepartment of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Jerry H. Gurwitz
- Department of Population and Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
- Meyers Primary Care InstituteWorcesterMA
- Division of Geriatric MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Tanya Mailhot
- Faculty of NursingUniversite de MontrealMontrealQuebecCanada
- Montreal Heart Institute Research CenterMontrealQuebecCanada
| | - Hawa O. Abu
- Cardiology DivisionDepartment of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Robert Goldberg
- Department of Population and Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Ziyue Wang
- Department of Population and Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Mayra Tisminetzky
- Department of Population and Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
- Division of Geriatric MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
| | | | - Jane S. Saczynski
- Department of Pharmacy and Health System SciencesNortheastern UniversityBostonMA
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Mehawej J, Saczynski J, Abu HO, Gagnier M, Bamgbade BA, Lessard D, Trymbulak K, Saleeba C, Kiefe CI, Goldberg RJ, McManus DD. Factors Associated With Patient Engagement in Shared Decision-Making for Stroke Prevention Among Older Adults with Atrial Fibrillation. Can Geriatr J 2021; 24:174-183. [PMID: 34484500 PMCID: PMC8390325 DOI: 10.5770/cgj.24.475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To examine the extent of, and factors associated with, patient engagement in shared decision-making (SDM) for stroke prevention among patients with atrial fibrillation (AF). METHODS We used data from the Systematic Assessment of Geriatric Elements-Atrial Fibrillation study which includes older ( ≥65 years) patients with AF and a CHA2DS2-VASc≥2. Participants reported engagement in SDM by answering whether they actively participated in choosing to take an oral anticoagulant (OAC) for their condition. Multiple logistic regression was used to assess associations between sociodemographic, clinical, geriatric, and psychosocial factors and patient engagement in SDM. RESULTS A total of 807 participants (mean age 75 years; 48% female) on an OAC were studied. Of these, 61% engaged in SDM. Older participants (≥80 years) and those cognitively impaired were less likely to engage in SDM, while those very knowledgeable of their AF associated stroke risk were more likely to do so than respective comparison groups. CONCLUSIONS A considerable proportion of older adults with AF did not engage in SDM for stroke prevention with older patients and those cognitively impaired less likely to do so. Clinicians should identify patients who are less likely to engage in SDM, promote patient engagement, and foster better patient-provider communication which may enhance long-term patient outcomes.
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Affiliation(s)
- Jordy Mehawej
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jane Saczynski
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston, MA, USA
| | - Hawa O. Abu
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Marc Gagnier
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Benita A. Bamgbade
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston, MA, USA
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Katherine Trymbulak
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Connor Saleeba
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Catarina I. Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert J. Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - David D. McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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Forrester SN, McManus DD, Saczynski JS, Pierre-Louis IC, Bamgbade BA, Kiefe CI. A cross-sectional analysis of racial differences in accelerated aging and cognitive function among patients with atrial fibrillation: The SAGE-AF study: Forrester, Accelerated aging and cognitive function. EClinicalMedicine 2021; 39:101060. [PMID: 34386761 PMCID: PMC8342899 DOI: 10.1016/j.eclinm.2021.101060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/12/2021] [Accepted: 07/15/2021] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Non-Whites are more likely to suffer from cognitive impairment and complications of atrial fibrillation (AF) than Whites, though Whites are more likely to be diagnosed with AF. We examined whether non-Whites with AF are biologically older than Whites with AF and whether accelerated biological aging is associated with cognitive functioning. METHODS We used baseline data from the ongoing Systematic Assessment of Geriatric Elements in Atrial Fibrillation prospective cohort study, collected 2016-2020 across ambulatory care practices in Massachusetts and Georgia. Of 1244 enrolled, 974 participants with full biological data were included in the present analysis. Accelerated aging (AccA) was calculated based on a combination of biomarkers associated with age and physiological "wear and tear." FINDINGS The main outcome was score on Montreal Cognitive Assessment (MoCA). Non-Whites had 2.9 years more AccA than Whites and higher AccA was associated with a lower MoCA score among both Whites (-0.06, 95% CI: -0.10, -0.03) and non-Whites (-0.14, 95% CI: -0.27, 0.02). This association was significantly greater among non-whites (-0.11, 95% CI: -0.20, -0.01). INTERPRETATION Non-White AF patients are functionally "older" than their White counterparts and experience a stronger deleterious association between AccA and cognition. These findings underscore the importance of taking functional age into account when treating patients with AF, particularly non-White patients, to enhance treatment and improve AF outcomes.
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Affiliation(s)
- Sarah N. Forrester
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street AS6-1075, Worcester, MA 01605, United States
- Corresponding author.
| | - David D. McManus
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Jane S. Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston MA, United States
| | - Isabelle C. Pierre-Louis
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston MA, United States
| | - Benita A. Bamgbade
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston MA, United States
| | - Catarina I. Kiefe
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston MA, United States
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Alcusky M, Baek J, Tjia J, McManus DD, Lapane KL. Geographic Variation in Anticoagulant Use and Resident, Nursing Home, and County Characteristics Associated With Treatment Among US Nursing Home Residents. J Am Med Dir Assoc 2021; 22:164-172.e9. [PMID: 33357746 DOI: 10.1016/j.jamda.2020.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/01/2020] [Accepted: 10/04/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To quantify geographic variation in anticoagulant use and explore what resident, nursing home, and county characteristics were associated with anticoagulant use in a clinically complex population. DESIGN A repeated cross-sectional design was used to estimate current oral anticoagulant use on December 31, 2014, 2015, and 2016. SETTING AND PARTICIPANTS Secondary data for United States nursing home residents during the period 2014-2016 were drawn from the Minimum Data Set 3.0 and Medicare Parts A and D. Nursing home residents (≥65 years) with a diagnosis of atrial fibrillation and ≥6 months of Medicare fee-for-service enrollment were eligible for inclusion. Residents in a coma or on hospice were excluded. METHODS Multilevel logistic models evaluated the extent to which variation in anticoagulant use between counties could be explained by resident, nursing home, and county characteristics and state of residence. Proportional changes in cluster variation (PCVs), intraclass correlation coefficients (ICCs), and adjusted odds ratios (aORs) were estimated. RESULTS Among 86,736 nursing home residents from 11,860 nursing homes and 1694 counties, 45% used oral anticoagulants. The odds of oral anticoagulant use were 18% higher in 2016 than 2014 (aOR: 1.18; 95% confidence interval: 1.14-1.22). Most states had counties in the highest (51.3-58.9%) and lowest (31.1%-41.4%) deciles of anticoagulant use. Compared with the null model, adjustment for resident characteristics explained one-third of the variation between counties (PCV: 34.8%). The full model explained 65.5% of between-county variation. Within-county correlation was a small proportion (ICC < 2.2%) of total variation. CONCLUSIONS AND IMPLICATIONS In this older adult population at high risk for ischemic stroke, less than half of the residents received treatment with anticoagulants. Variation in treatment across counties was partially attributable to the characteristics of residents, nursing homes, and counties. Comparative evidence and refinement of predictive algorithms specific to the nursing home setting may be warranted.
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Affiliation(s)
- Matthew Alcusky
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.
| | - Jonggyu Baek
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jennifer Tjia
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - David D McManus
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA; Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Kate L Lapane
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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Proietti M, Cesari M. Describing the relationship between atrial fibrillation and frailty: Clinical implications and open research questions. Exp Gerontol 2021; 152:111455. [PMID: 34153440 DOI: 10.1016/j.exger.2021.111455] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/13/2021] [Indexed: 11/26/2022]
Abstract
In the recent years a lot of attention has been gathered by the issue of frailty outside the boundaries of the geriatric medicine, for example in the field of cardiovascular medicine. Atrial fibrillation (AF) is known as a very common cardiological condition, often burdened by high level of clinical complexity. Aim of this narrative review is to examine the most relevant evidence about the relationship between frailty and AF, focusing also on its impact on clinical management and natural history of patients with this condition. Data reported underline how a relevant relationship exists between these two conditions, even though the burden of frailty among AF cohorts is still unclear. Frailty seems to affect the clinical management, even though no definitive data are yet available. Lastly, frailty significantly increases the risk of all-cause mortality but it's still unclear the impact on thromboembolic and bleeding events. Despite several data are already available, more research is still needed to fully elucidate the relationship between these two clinical entities.
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Affiliation(s)
- Marco Proietti
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Italy; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
| | - Matteo Cesari
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Italy
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Fernández MS, Marín F, Rafols C, Arribas F, Barrios V, Cosín-Sales J, Sánchez MA. Thromboembolic and bleeding events with rivaroxaban in clinical practice in Spain: impact of inappropriate doses (the EMIR study). J Comp Eff Res 2021; 10:583-593. [PMID: 33787316 DOI: 10.2217/cer-2020-0286] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Aim: To analyze the frequency and variables related to inappropriate rivaroxaban dosage in clinical practice and its impact on outcomes after 2 years. Materials & methods: Postauthorization, observational, multicenter study, in which atrial fibrillation patients, treated with rivaroxaban ≥6 months were included. Results: A total of 1421 patients (74.2 ± 9.7 years, CHA2DS2-VASc 3.5 ± 1.6) were included. Overall, 22.9% received rivaroxaban 15 mg. The proper dose of rivaroxaban was taken by 83.3% (9.7% underdosed, 7.0% overdosed). Older age and renal insufficiency were associated with inadequate rivaroxaban dosage. There was a trend toward higher all-cause mortality among underdosed patients (adjusted hazard ratio 1.39; 95% CI 0.75-2.58), and more bleedings in overdosed patients (2.29 vs 0.80 events/100 patient-years; p = 0.14). Conclusion: In clinical practice, rivaroxaban is properly dosed in most patients.
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Affiliation(s)
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, CIBERCV, Murcia, Spain
| | - Carles Rafols
- Department of Medical Affairs, Bayer Hispania, Barcelona, Spain
| | - Fernando Arribas
- Department of Cardiology, Hospital Universitario 12 de Octubre; Department of Medicine, Facultad de Medicina, Universidad Complutense de Madrid (UCM); Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12); CIBERCV, Madrid, Spain
| | - Vivencio Barrios
- Department of Cardiology, Hospital Ramón y Cajal; Alcalá University, Madrid, Spain
| | - Juan Cosín-Sales
- Department of Cardiology, Hospital Arnau de Vilanova, Valencia, Spain
| | - Manuel Anguita Sánchez
- Department of Cardiology, Hospital Universitario Reina Sofia, IMIBIC, University of Córdoba, Córdoba, Spain
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Wang W, Lessard D, Saczynski JS, Goldberg RJ, Mehawej J, Gracia E, McManus DD. Prognostic value of geriatric conditions for death and bleeding in older patients with atrial fibrillation. IJC HEART & VASCULATURE 2021; 33:100739. [PMID: 33728372 PMCID: PMC7935705 DOI: 10.1016/j.ijcha.2021.100739] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 01/20/2021] [Accepted: 02/08/2021] [Indexed: 11/24/2022]
Abstract
Background Geriatric conditions, such as frailty and cognitive impairment, are prevalent in older patients with atrial fibrillation (AF). We examined the prognostic value of geriatric conditions for predicting 1-year mortality and bleeding events in these patients. Methods SAGE (Systematic Assessment of Geriatric Elements)-AF study is a multicenter cohort study which enrolled individuals (mean age 75 years, 48% women, 86% taking oral anticoagulation) 65 years and older with AF and CHA2DS2 -VASc score of 2 or higher from clinics in Massachusetts and Georgia, USA between 2016 and 2018. A six-component geriatric assessment included validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing was performed at baseline. Study endpoints included all-cause mortality and clinically relevant bleeding. Results At 1 year, 1,097 (96.5%) individuals attended the follow up visit, 44 (3.9%) had died, and 56 (5.1%) had clinically relevant bleeding. After adjustment for demographic and clinical factors, social isolation (odds ratio [OR] 1.69, 95% confidence interval [CI]: 1.01–2.84), depression (OR 1.94, 95% CI: 1.28–2.95) and frailty (OR 2.55, 95% CI: 1.55–4.19) were significantly associated with the composite endpoint of death or clinically relevant bleeding. After multivariable adjustment, depression (OR 1.79, 95% CI 1.09–2.93) and frailty (OR 2.83, 95% CI 1.55–5.17) were significantly associated with clinically relevant bleeding. Conclusions Social isolation, depression, and frailty were prognostic of dying or experiencing clinically relevant bleeding during the coming year in older men and women with AF. Assessing geriatric impairments merits consideration in the care of these patients.
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Affiliation(s)
- Weijia Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jane S Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, USA
| | - Robert J Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jordy Mehawej
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Ely Gracia
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - David D McManus
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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Mehawej J, S Saczysnki J, I Kiefe C, Ding E, O Abu H, Lessard D, H Helm R, A Bamgbade B, Saleeba C, Wang W, D McManus D, J Goldberg R. Factors Associated with Moderate Physical Activity Among Older Adults with Atrial Fibrillation. J Atr Fibrillation 2021; 13:2454. [PMID: 34950335 PMCID: PMC8691360 DOI: 10.4022/jafib.2454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/22/2020] [Accepted: 01/15/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Engaging patients with atrial fibrillation (AF) in moderate-intensity physical activity has been encouraged by published guidelines. We examined factors associated with engagement in moderate physical activity among older adults with AF. METHODS This was a retrospective study involving ninety patients with episodes of Afib with RVR duData are from the SAGE (Systematic Assessment of Geriatric Elements)-AF study. Older adults (≥ 65 years) with AF and a CHA2DS2-VASc ≥ 2 were recruited from several clinics in Massachusetts and Georgia between 2015 and 2018. The Minnesota Leisure Time Physical Activity questionnaire was used to assess whether participants engaged in moderate-intensity physical activity (i.e. at least 150 minutes of moderate exercise). Logistic regression was utilized to examine the sociodemographic and clinical characteristics and geriatric elements associated with engaging in moderate-intensity physical activity. RESULTS Participants were on average 76 years old and 48% were women. Approximately one-half (52%) of study participants engaged in moderate-intensity physical activity. Morbid obesity (adjusted OR [aOR]=0.41, 90%CI=0.23-0.73), medical history of renal disease (aOR= aOR=0.68,90%CI= 0.48-0.96), slow gait speed (aOR=0.44, 90%CI=0.32-0.60), cognitive impairment (aOR=0.74, 90%CI=0.56-0.97), and social isolation (aOR=0.58, 90%CI= 0.40-0.84) were independently associated with a lower likelihood, while higher AF related quality of life score (aOR=1.64, 90%CI=1.25-2.16) a greater likelihood, of meeting recommended levels of moderate physical activity. CONCLUSIONS Nearly one-half of older adults with NVAF did not engage in moderate-intensity exercise. Clinicians should identify older patients with NVAF who are less likely to engage in physical activity and develop tailored interventions to promote regular physical activity.
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Affiliation(s)
- Jordy Mehawej
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
| | - Jane S Saczysnki
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston MA
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Eric Ding
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Hawa O Abu
- Department of Medicine, Saint Vincent Hospital, Worcester, MA
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Robert H Helm
- Department of Cardiovascular Medicine, Boston University Medical, Boston, MA
| | - Benita A Bamgbade
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston MA
| | - Connor Saleeba
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
| | - Weijia Wang
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
| | - David D McManus
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
| | - Robert J Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
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Sedney C, Abu HO, Trymbulak K, Mehawej J, Wang Z, Waring ME, Saczynski J, McManus DD. Sociodemographic, behavioral, and clinical factors associated with low atrial fibrillation knowledge among older adults with atrial fibrillation: The SAGE-AF study. PATIENT EDUCATION AND COUNSELING 2021; 104:194-200. [PMID: 32690396 PMCID: PMC7749812 DOI: 10.1016/j.pec.2020.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 07/08/2020] [Accepted: 07/10/2020] [Indexed: 05/07/2023]
Abstract
BACKGROUND Management of AF requires patient engagement in disease management which requires adequate knowledge about AF. OBJECTIVE To identify the patient characteristics associated with low AF knowledge among older adults with AF. METHODS The SAGE-AF cohort enrolled adults aged ≥65 diagnosed with AF in 2016-2018. Patient characteristics associated with low AF knowledge (<6/8 JAKQ items correct) were examined using multivariable adjusted logistic regression models. RESULTS Participants (N = 950) were on average 74 years old (SD: 6.7), 50 % female, and 87 % non-Hispanic white. The average JAKQ score was 68.7 (SD: 17.1), and 78 % had low AF knowledge. Participants aged ≥ 75 (OR: 1.55, 95 % CI: 1.03, 2.33), without a college degree (OR: 0.46, 95 % CI: 0.32, 0.65), cognitively impaired (OR: 1.72, 95 % CI: 1.15, 2.58), with a history of anxiety (OR: 1.76, 95 % CI: 1.09, 2.83), myocardial infarction (OR: 1.82, 95 % CI: 1.08, 3.07), and heart failure (OR: 1.84, 95 % CI: 1.16, 2.91) were more likely to have low AF knowledge. PRACTICE IMPLICATIONS Characteristics available in the electronic medical record may identify patients at risk for low AF knowledge. Formal assessment of AF knowledge may identify areas of weakness and allow for targeted education.
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Affiliation(s)
- Colleen Sedney
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA, United States.
| | - Hawa O Abu
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA, United States
| | - Katherine Trymbulak
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA, United States
| | - Jordy Mehawej
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA, United States
| | - Ziyue Wang
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA, United States
| | - Molly E Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs CT, United States
| | - Jane Saczynski
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston MA, United States
| | - David D McManus
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA, United States
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Mailhot T, McManus DD, Waring ME, Lessard D, Goldberg R, Bamgbade BA, Saczynski JS. Frailty, Cognitive Impairment, and Anticoagulation Among Older Adults with Nonvalvular Atrial Fibrillation. J Am Geriatr Soc 2020; 68:2778-2786. [PMID: 32780497 PMCID: PMC8567309 DOI: 10.1111/jgs.16756] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 07/21/2023]
Abstract
BACKGROUND/OBJECTIVES Oral anticoagulation (OAC) is challenging in older patients with nonvalvular atrial fibrillation (NVAF) who are often frail and have cognitive impairment. We examined the characteristics of older NVAF patients associated with higher odds of physical and cognitive impairments. We also examined if these high-risk patients have different OAC prescribing patterns and their satisfaction with treatment because it may impact optimal management of their NVAF. METHODS The patients in the Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF study cohort 2016-2018) had NVAF, were aged 65 and older, and eligible for the receipt of OAC. Measures included frailty (Fried Frailty scale), cognitive impairment (Montreal Cognitive Assessment Battery), OAC prescribing and type (direct oral anticoagulant [DOAC] or vitamin K antagonist [VKA]), depressive symptoms (Patient Health Questionnaire-9), bleeding, stroke risk, and treatment benefit (Anti-Clot Treatment Scale). RESULTS Patients (n = 1,244) were 49% female, aged 76 (standard deviation = 7) years. A total of 14% were frail, and 42% had cognitive impairment. Frailty and cognitive impairment co-occurred in 9%. Odds of having both impairments versus none were higher with depression (odds ratio [OR] = 4.62; 95% confidence interval [CI] = 2.59-8.26), older age (OR = 1.56; 95% CI = 1.29-1.88), lower education (OR = 3.81; 95%CI = 2.13-6.81), race/ethnicity other than non-Hispanic White (OR = 7.94; 95% CI = 4.34-14.55), bleeding risk (OR = 1.43; 95% CI = 1.12-1.81), and stroke risk (OR = 1.35; 95% CI = 1.13-1.62). OAC prescribing was not associated with CI and frailty status. Among patients taking OACs (85%), those with both impairments were more likely to take DOAC than VKA (OR = 1.69; 95% CI = 1.01-2.80). Having both impairments (OR = 1.87; 95% CI = 1.08-3.27) or cognitive impairment (OR = 1.56; 95% CI = 1.09-2.24) was associated with higher odds of reporting lower treatment benefit. CONCLUSION In a large cohort of older NVAF patients, half were frail or cognitively impaired, and 9% had both impairments. We highlight the characteristics of patients who may benefit from cognitive and physical function screenings to maximize treatment and enhance prognosis. Finally, the co-occurrence of impairment was associated with low perceived benefit of treatment that may impede optimal management.
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Affiliation(s)
- Tanya Mailhot
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - David D. McManus
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Molly E. Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Benita A. Bamgbade
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - Jane S. Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
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Incident frailty and cognitive impairment by heart failure status in older patients with atrial fibrillation: the SAGE-AF study. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2020; 17:653-658. [PMID: 33343643 PMCID: PMC7729184 DOI: 10.11909/j.issn.1671-5411.2020.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Atrial fibrillation (AF) and heart failure (HF) frequently co-occur in older individuals. Among patients with AF, HF increases risks for stroke and death, but the associations between HF and incident cognition and physical impairment remain unknown. We aimed to examine the cross-sectional and prospective associations between HF, cognition, and frailty among older patients with AF. Methods The SAGE-AF (Systematic Assessment of Geriatric Elements in AF) study enrolled 1244 patients with AF (mean age 76 years, 48% women) from five practices in Massachusetts and Georgia. HF at baseline was identified from electronic health records using ICD-9/10 codes. At baseline and 1-year, frailty was assessed by Cardiovascular Health Survey score and cognition was assessed by the Montreal Cognitive Assessment. Results Patients with prevalent HF (n = 463, 37.2%) were older, less likely to be non-Hispanic white, had less education, and had greater cardiovascular comorbidity burden and higher CHA2DS2VASC and HAS-BLED scores than patients without HF (all P's < 0.01). In multivariable adjusted regression models, HF (present vs. absent) was associated with both prevalent frailty (adjusted odds ratio [aOR]: 2.38, 95% confidence interval [CI]: 1.64-3.46) and incident frailty at 1 year (aOR: 2.48, 95% CI: 1.37-4.51). HF was also independently associated with baseline cognitive impairment (aOR: 1.60, 95% CI: 1.22-2.11), but not with developing cognitive impairment at 1 year (aOR 1.04, 95%CI: 0.64-1.70). Conclusions Among ambulatory older patients with AF, the co-existence of HF identifies individuals with physical and cognitive impairments who are at higher short-term risk for becoming frail. Preventive strategies to this vulnerable subgroup merit consideration.
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Trymbulak K, Ding E, Marino F, Wang Z, Saczynski JS. Mobile health assessments of geriatric elements in older patients with atrial fibrillation: The Mobile SAGE-AF Study (M-SAGE). CARDIOVASCULAR DIGITAL HEALTH JOURNAL 2020; 1:123-129. [PMID: 35265884 PMCID: PMC8890350 DOI: 10.1016/j.cvdhj.2020.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Geriatric conditions (eg, cognitive impairment, frailty) are increasingly recognized for their impact on clinical and quality-of-life outcomes in older patients with cardiovascular disease, but are not systematically assessed in the context of clinical visits owing to time constraints. Objective To examine feasibility of remote monitoring of the physical, cognitive, and psychosocial status of older adults with atrial fibrillation (AF) via a novel smartphone app over 6 months. Methods Forty participants with AF and eligible for anticoagulation therapy (CHA2DS2VASc ≥2) enrolled in an ongoing cohort study participated in a mobile health pilot study. A 6-component geriatric assessment, including validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing, was deployed via a smartphone app and 6-minute walk test was completed using a Fitbit. Adherence to mobile assessments was examined over 6 months. Results Participants were an average of 71 years old (range 65-86 years) and 38% were women. At 1 month, 75% (30/40) of participants completed the app-based geriatric assessment and 63% (25/40) completed the 6-minute walk test. At 6 months, 52% (15/29) completed the geriatric assessment and 28% (8/29) completed the walk test. There were no differences in demographic, clinical, or psychosocial factors between participants who completed the surveys at 6 months and those who did not. Participants, on average, required less than 10 minutes of telephone support over the 6-month period. Conclusion It is feasible, among smartphone users, to use a mobile health app and wearable activity monitor to conduct serial geriatric assessments in older patients with AF for up to 6 months.
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Affiliation(s)
- Katherine Trymbulak
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, North Haven, Connecticut
- Address reprint requests and correspondence: Ms Katherine Trymbulak, Frank H. Netter M.D. School of Medicine at Quinnipiac University, 370 Bassett Rd, North Haven, CT 06473.
| | - Eric Ding
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Francesca Marino
- Center for Clinical Investigation, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ziyue Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jane S. Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts
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Abstract
Effective stroke prevention with oral anticoagulation (OAC) is the cornerstone of the management of patients with atrial fibrillation. The use of OAC reduces the risk of stroke and death. For most patients with atrial fibrillation without moderate or severe mitral valve stenosis or prosthetic mechanical heart valves, treatment options include vitamin K antagonists, such as warfarin, and non-vitamin K antagonist oral anticoagulants (NOACs). Although most guidelines generally recommend NOACs as the first-line OAC, caution is required in some groups of patients with atrial fibrillation at high risk of stroke and bleeding who have been under-represented or not studied in the randomized clinical trials on NOACs for stroke prevention. In addition to OAC, non-pharmacological, percutaneous therapies, including left atrial appendage occlusion, for stroke prevention have emerged, sometimes used in combination with catheter ablation for the treatment of the atrial fibrillation. High-risk groups of patients with atrial fibrillation include patients with end-stage renal failure (including those receiving dialysis), extremely old patients (such as those aged >80 years with multiple risk factors for bleeding), patients with dementia or those living in a long-term care home, patients with previous intracranial bleeding or recent acute bleeding (such as gastrointestinal bleeding), patients with acute ischaemic stroke and patients with an intracardiac thrombus. This Review provides an overview of stroke prevention strategies, including left atrial appendage occlusion, in patients with atrial fibrillation at high risk of stroke and bleeding.
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Shah SJ, Fang MC, Jeon SY, Gregorich SE, Covinsky KE. Geriatric Syndromes and Atrial Fibrillation: Prevalence and Association with Anticoagulant Use in a National Cohort of Older Americans. J Am Geriatr Soc 2020; 69:349-356. [PMID: 32989731 DOI: 10.1111/jgs.16822] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/14/2020] [Accepted: 08/16/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although guidelines recommend focusing primarily on stroke risk to recommend anticoagulants in atrial fibrillation (AF), physicians report that geriatric syndromes (e.g., falls and disability) are important when considering anticoagulants. Little is known about the prevalence of geriatric syndromes in older adults with AF or the association with anticoagulant use. METHODS We performed a cross-sectional analysis of the 2014 Health and Retirement Study, a nationally representative study of older Americans. Participants were asked questions to assess domains of aging, including function, cognition, and medical conditions. We included participants 65 years and older with 2 years of continuous Medicare enrollment who met AF diagnosis criteria by claims codes. We examined five geriatric syndromes: one or more falls within the last 2 years, receiving help with activities of daily living (ADLs) or instrumental ADLs (IADL), experienced incontinence, and cognitive impairment. We determined the prevalence of geriatric syndromes and their association with anticoagulant use, adjusting for ischemic stroke risk (i.e., CHA2 DS2 -VASc score [congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, and sex]). RESULTS In this study of 779 participants with AF (median age = 80 years; median CHA2 DS2 -VASc score = 4), 82% had one or more geriatric syndromes. Geriatric syndromes were common: 49% reported falls, 38% had ADL impairments, 42% had IADL impairments, 37% had cognitive impairments, and 43% reported incontinence. Overall, 65% reported anticoagulant use; guidelines recommend anticoagulant use for 97% of participants. Anticoagulant use rate decreased for each additional geriatric syndrome (average marginal effect = -3.7%; 95% confidence interval = -1.4% to -5.9%). Lower rates of anticoagulant use were reported in participants with ADL dependency, IADL dependency, and dementia. CONCLUSION Most older adults with AF had at least one geriatric syndrome, and geriatric syndromes were associated with reduced anticoagulant use. The high prevalence of geriatric syndromes may explain the lower than expected anticoagulant use in older adults.
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Affiliation(s)
- Sachin J Shah
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Margaret C Fang
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sun Y Jeon
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Steven E Gregorich
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Kenneth E Covinsky
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
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Multimorbidity, physical frailty, and self-rated health in older patients with atrial fibrillation. BMC Geriatr 2020; 20:343. [PMID: 32917137 PMCID: PMC7488548 DOI: 10.1186/s12877-020-01755-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 09/02/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Holistic care models emphasize management of comorbid conditions to improve patient-reported outcomes in treatment of atrial fibrillation (AF). We investigated relations between multimorbidity, physical frailty, and self-rated health (SRH) among older adults with AF. METHODS Patients (n = 1235) with AF aged 65 years and older were recruited from five medical centers in Massachusetts and Georgia between 2015 and 2018. Ten previously diagnosed cardiometabolic and 8 non-cardiometabolic conditions were assessed from medical records. Physical Frailty was assessed with the Cardiovascular Health Study frailty scale. SRH was categorized as either "excellent/very good", "good", and "fair/poor". Separate multivariable ordinal logistic models were used to examine the associations between multimorbidity and SRH, physical frailty and SRH, and multimorbidity and physical frailty. RESULTS Overall, 16% of participants rated their health as fair/poor and 14% were frail. Hypertension (90%), dyslipidemia (80%), and heart failure (37%) were the most prevalent cardiometabolic conditions. Arthritis (51%), anemia (31%), and cancer (30%), the most common non-cardiometabolic diseases. After multivariable adjustment, patients with higher multimorbidity were more likely to report poorer health status (Odds Ratio (OR): 2.15 [95% CI: 1.53-3.03], ≥ 8 vs 1-4; OR: 1.37 [95% CI: 1.02-1.83], 5-7 vs 1-4), as did those with more prevalent cardiometabolic and non-cardiometabolic conditions. Patients who were pre-frail (OR: 1.73 [95% CI: 1.30-2.30]) or frail (OR: 6.81 [95% CI: 4.34-10.68]) reported poorer health status. Higher multimorbidity was associated with worse frailty status. CONCLUSIONS Multimorbidity and physical frailty were common and related to SRH. Our findings suggest that holistic management approaches may influence SRH among older patients with AF.
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Abu HO, Saczynski JS, Mehawej J, Tisminetzky M, Kiefe CI, Goldberg RJ, McManus DD. Clinically Meaningful Change in Quality of Life and Associated Factors Among Older Patients With Atrial Fibrillation. J Am Heart Assoc 2020; 9:e016651. [PMID: 32875941 PMCID: PMC7726984 DOI: 10.1161/jaha.120.016651] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background Among older patients with atrial fibrillation, there are limited data examining clinically meaningful changes in quality of life (QoL). We examined the extent of, and factors associated with, clinically meaningful change in QoL over 1‐year among older adults with atrial fibrillation. Methods and Results Patients from cardiology, electrophysiology, and primary care clinics in Massachusetts and Georgia were enrolled in a cohort study (2015–2018). The Atrial Fibrillation Effect on Quality‐of‐Life questionnaire was used to assess overall QoL and across 3 subscales: symptoms, daily activities, and treatment concern. Clinically meaningful change in QoL (ie, difference between 1‐year and baseline QoL score) was categorized as either a decline (≤−5.0 points), no clinically meaningful change (−5.0 to +5.0 points), or an increase (≥+5.0 points). Ordinal logistic models were used to examine factors associated with QoL changes. Participants (n=1097) were on average 75 years old, 48% were women, and 87% White. Approximately 40% experienced a clinically meaningful increase in QoL and 1 in every 5 patients experienced a decline in QoL. After multivariable adjustment, women, non‐Whites, those who reported depressive and anxiety symptoms, fair/poor self‐rated health, low social support, heart failure, or diabetes mellitus experienced clinically meaningful declines in QoL. Conclusions These findings provide insights to the magnitude of, and factors associated with, clinically meaningful change in QoL among older patients with atrial fibrillation. Assessment of comorbidities and psychosocial factors may help identify patients at high risk for declining QoL and those who require additional surveillance to maximize important clinical and patient‐centered outcomes.
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Affiliation(s)
- Hawa O. Abu
- Division of Cardiovascular MedicineDepartment of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Jane S. Saczynski
- Department of Pharmacy and Health Systems SciencesSchool of PharmacyNorth Eastern UniversityBostonMA
| | - Jordy Mehawej
- Division of Cardiovascular MedicineDepartment of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Mayra Tisminetzky
- Division of Geriatrics and Meyers Primary Care InstituteDepartment of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
- Department of Population and Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Catarina I. Kiefe
- Department of Population and Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Robert J. Goldberg
- Department of Population and Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
| | - David D. McManus
- Division of Cardiovascular MedicineDepartment of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
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Self-reported risk of stroke and factors associated with underestimation of stroke risk among older adults with atrial fibrillation: the SAGE-AF study. J Geriatr Cardiol 2020; 17:502-509. [PMID: 32952525 PMCID: PMC7475213 DOI: 10.11909/j.issn.1671-5411.2020.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Though engaging patients with atrial fibrillation (AF) in understanding their stroke risk is encouraged by guidelines, little is known regarding AF patients' perceived stroke risk or its relationship with oral anticoagulation (OAC) use. We aim to identify factors associated with underestimation of stroke risk among older patients with AF and relate this to OAC use. METHODS Data are from the ongoing SAGE (Systematic Assessment of Geriatric Elements)-AF study, which included older patients (> 65 years) with non-valvular AF and a CHA2DS2-VASc score of ≥ 2. Participants reported their perceived risk of having a stroke without OAC. We compared the perceived risk to CHA2DS2-VASc predicted stroke risk and classified participants as "over" or "under" estimators, and identified factors associated with underestimation of risk using multiple logistic regression. RESULTS The average CHA2DS2-VASc score of 915 participants (average age: 75 years, 47% female, 86% white) was 4.3 ± 1.6, 43% of participants had discordant predicted and self-reported stroke risks. Among the 376 participants at highest risk (CHA2DS2-VASc score ≥ 5), 46% of participants underestimated their risk. Older participants (≥ 85 years) were more likely and OAC treated patients less likely to underestimate their risk of developing a future stroke than respective comparison groups. CONCLUSIONS A significant proportion of study participants misperceived their stroke risk, mostly by overestimating. Almost half of participants at high risk of stroke underestimated their risk, with older patients more likely to do so. Patients on OAC were less likely to underestimate their risk, suggesting that successful efforts to educate patients about their stroke risk may influence treatment choices.
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Mlynarska A, Mlynarski R, Marcisz C, Golba KS. Modified Frailty as a Novel Factor in Predicting the Maintenance of the Sinus Rhythm After Electrical Cardioversion of Atrial Fibrillation in the Elderly Population. Clin Interv Aging 2020; 15:1193-1199. [PMID: 32764905 PMCID: PMC7381784 DOI: 10.2147/cia.s255853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 06/13/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction Frailty is a common geriatric syndrome that causes an elevated risk of catastrophic declines in the health and function among older adults – we hypothesized that frailty may be related to the maintenance of sinus rhythm after cardioversion. Methods The study sample was a group of 199 consecutive patients over 60 (average age 71.41 ± 6.99; 40.2% women) with AF who were hospitalized in order to perform electrical cardioversion. The Tilburg Frailty Indicator (TFI) was used to assess frailty before cardioversion. The six-month visit after the electrical cardioversion was a follow-up. The follow-up period for the maintenance of sinus rhythm after electrical cardioversion was 180 ± 14 days. Results Patients in whom cardioversion was effective had a statistically significantly lower severity of frailty syndrome (3.44 ± 1.83 vs 5.87 ± 1.12; p=0.000) and its components: physical components (2.14 ± 1.33 vs 3.62 ± 1.05 p=0.000); emotional components (0.92 ± 0.79 vs 1.29 ± 0.86 p=0.037) and social components (0.37 ± 0.56 vs 0.96 ± 0.46; p=0.000) compared to those patients in which cardioversion was ineffective. In the logistic regression, frailty (OR: 0.65, 95% CI:0.5010–0.8330; p=0.000) was observed to be an independent predictor for maintaining sinus rhythm. Conclusion Frailty is a novel, independent factor that can be used to predict the effectiveness of electrical cardioversion and the maintenance of sinus rhythm in the elderly population. Modifying the level of recognition in the Tilburg Frailty Indicator to a 4 improved the prediction of the effectiveness of electrical cardioversion as well as the maintenance of sinus rhythm.
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Affiliation(s)
- Agnieszka Mlynarska
- Department of Gerontology and Geriatric Nursing, School of Health Sciences, Medical University of Silesia, Katowice, Poland.,Department of Electrocardiology, Upper Silesian Heart Centre, Katowice, Poland
| | - Rafal Mlynarski
- Department of Electrocardiology, Upper Silesian Heart Centre, Katowice, Poland.,Department of Electrocardiology and Heart Failure, School of Health Sciences, Medical University of Silesia, Katowice, Poland
| | - Czeslaw Marcisz
- Department of Gerontology and Geriatric Nursing, School of Health Sciences, Medical University of Silesia, Katowice, Poland
| | - Krzysztof S Golba
- Department of Electrocardiology, Upper Silesian Heart Centre, Katowice, Poland.,Department of Electrocardiology and Heart Failure, School of Health Sciences, Medical University of Silesia, Katowice, Poland
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Abu HO, Saczynski JS, Ware J, Mehawej J, Paul T, Awad H, Bamgbade BA, Pierre-Louis IC, Tisminetzky M, Kiefe CI, Goldberg RJ, McManus DD. Impact of comorbid conditions on disease-specific quality of life in older men and women with atrial fibrillation. Qual Life Res 2020; 29:3285-3296. [PMID: 32656722 DOI: 10.1007/s11136-020-02578-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Older persons with atrial fibrillation (AF) experience significant impairment in quality of life (QoL), which may be partly attributable to their comorbid diseases. A greater understanding of the impact of comorbidities on QoL could optimize patient-centered care among older persons with AF. OBJECTIVE To assess impairment in disease-specific QoL due to comorbid conditions in older adults with AF. METHODS Patients aged ≥ 65 years diagnosed with AF were recruited from five medical centers in Massachusetts and Georgia between 2015 and 2018. At 1 year of follow-up, the Quality of Life Disease Impact Scale-for Multiple Chronic Conditions was used to provide standardized assessment of patient self-reported impairment in QoL attributable to 34 comorbid conditions grouped in 10 clusters. RESULTS The mean age of study participants (n = 1097) was 75 years and 48% were women. Overall, cardiometabolic, musculoskeletal, and pulmonary conditions were the most prevalent comorbidity clusters. A high proportion of participants (82%) reported that musculoskeletal conditions exerted the greatest impact on their QoL. Men were more likely than women to report that osteoarthritis and stroke severely impacted their QoL. Patients aged < 75 years were more likely to report that obesity, hip/knee joint problems, and fibromyalgia extremely impacted their QoL than older participants. CONCLUSIONS Among older persons with AF, while cardiometabolic diseases were highly prevalent, musculoskeletal conditions exerted the greatest impact on patients' disease-specific QoL. Understanding the extent of impairment in QoL due to underlying comorbidities provides an opportunity to develop interventions targeted at diseases that may cause significant impairment in QoL.
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Affiliation(s)
- Hawa O Abu
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
| | - Jane S Saczynski
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, MA, USA
| | - John Ware
- John Ware Research Group, Watertown, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jordy Mehawej
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
| | - Tenes Paul
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
| | - Hamza Awad
- Departments of Community Medicine and Internal Medicine, Mercer University School of Medicine, Macon, GA, USA
| | - Benita A Bamgbade
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, MA, USA
| | - Isabelle C Pierre-Louis
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, MA, USA
| | - Mayra Tisminetzky
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
- Division of Geriatrics, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert J Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - David D McManus
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
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Psychosocial and cognitive multimorbidity and health-related quality of life and symptom burden in older adults with atrial fibrillation: The systematic assessment of geriatric elements in atrial fibrillation (SAGE-AF) cohort study. Arch Gerontol Geriatr 2020; 90:104117. [PMID: 32474170 PMCID: PMC7434686 DOI: 10.1016/j.archger.2020.104117] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 05/13/2020] [Accepted: 05/17/2020] [Indexed: 11/25/2022]
Abstract
Background: Depression, anxiety, and cognitive impairments occur in up to 40 % of adults with AF and are associated with poorer health-related quality of life (HRQoL) and higher symptom burden. However, it is unknown how often these impairments co-occur, or multimorbidity, and how multimorbidity effects HRQoL and symptom burden. Methods: Patients with AF age ≥65 years with a CHA2DS2VASC risk score ≥ 2 and eligible for oral anticoagulation therapy were recruited from five clinics in a prospective cohort study. Participants completed validated measures of depression (PHQ9) and anxiety (GAD7), cognitive impairment (MoCA), and HRQOL and AF symptom burden (AFEQT). Multinomial logistic regression was used. Results: Participants (N = 1244, 49 % female) were on average 76 ± 7 years; 86 % were non-Hispanic white. Approximately 35 % of participants had 1 impairment, 17 % had 2 impairments and 8% had 3 impairments; 39 % had none of the 3 impairments examined. Compared to participants with no impairments, patients with 1, 2 and 3 impairments had higher odds of poor HRQoL (adjusted OR [AOR] = 1.77, 95 % CI 1.21, 2.60; AOR = 6.64, 95 % CI 4.43, 9.96; and AOR = 7.50, 95 % CI 4.40, 12.77, respectively) and those with 2 and 3 impairments had higher odds of high symptom burden (AOR = 3.69 95 % CI 2.22, 6.13; and AOR = 5.41 95 % CI 2.85, 10.26). Conclusions: Psychosocial/cognitive multimorbidity is common among older adults with AF and is associated with poor HRQoL and high symptom burden. Clinicians might consider incorporating psychosocial and cognitive screens into routine care as this may identify a high-risk population.
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