1
|
Farran D, Feely O, Ashworth M, Gaughran F. Anticoagulation therapy and outcomes in patients with atrial fibrillation and serious mental illness: A systematic review and meta-analysis. J Psychiatr Res 2022; 156:737-753. [PMID: 36417811 DOI: 10.1016/j.jpsychires.2022.11.002] [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] [Received: 07/11/2022] [Revised: 10/06/2022] [Accepted: 11/12/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE A systematic review was conducted to investigate prevalence, management and outcomes of atrial fibrillation (AF) in people with Serious Mental Illnesses (SMI) versus the general population. DATA SOURCES MEDLINE, EMBASE, and PsycINFO were searched for primary research written in English and published between 2004 and 2022. STUDY SELECTION A total of 1459 studies were identified in the initial search of which 16 met the inclusion criteria. Studies (n = 4) reporting on ischaemic stroke and major bleeding events were included in the meta-analysis. DATA EXTRACTION Two independent reviewers extracted data and assessed risk of bias using the Newcastle-Ottawa Scale. Discrepancies were resolved by consulting a third reviewer. RESULTS Low rates of AF were reported among people with SMI suggesting under-recognition or recording gaps. People with SMI and AF were less likely to receive oral anticoagulation therapy compared to the general population. When receiving warfarin, those with bipolar disorder experienced poor anticoagulation control as measured by time in INR therapeutic range. Pooled analysis of risk estimates showed that in patients with identified AF, SMI was not significantly associated with an increased risk of stroke (HR: 1.09; 95%CI: 0.85 to 1.40; I2 = 60%, p = 0.04) or major bleeding (HR: 1.11; 95%CI: 0.95 to 1.28; I2 = 57%, p = 0.03) when adjusted for underlying stroke and bleeding risks using the CHA2DS2VASc and HASBLED scales respectively. CONCLUSION More research is needed to examine the prevalence, management and outcomes of AF in this population, and to evaluate the effect of the introduction of the novel anti-coagulants on these metrics over time.
Collapse
Affiliation(s)
- Dina Farran
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Olwyn Feely
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Mark Ashworth
- School of Life Course and Population Sciences, King's College London, London, UK
| | - Fiona Gaughran
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; South London and Maudsley NHS Foundation Trust, London, UK
| |
Collapse
|
2
|
Anticoagulation for atrial fibrillation in people with serious mental illness in the general hospital setting. J Psychiatr Res 2022; 153:167-173. [PMID: 35816976 DOI: 10.1016/j.jpsychires.2022.06.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 06/13/2022] [Accepted: 06/24/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE People with serious mental illnesses (SMI) have an increased risk of stroke compared to the general population. This study aims to evaluate oral anticoagulation prescription trends in atrial fibrillation (AF) patients with and without a comorbid SMI. METHODS An open-source retrieval system for clinical data (CogStack) was used to identify a cohort of AF patients with SMI who ever had an inpatient admission to King's College Hospital from 2011 to 2020. A Natural Language Processing pipeline was used to calculate CHA2DS2-VASc and HASBLED risk scores from Electronic Health Records free text. Antithrombotic prescriptions of warfarin and Direct acting oral anti-coagulants (DOACs) (apixaban, rivaroxaban, dabigatran, edoxaban) were extracted from discharge summaries. RESULTS Among patients included in the study (n = 16 916), 2.7% had a recorded co-morbid SMI diagnosis. Compared to non-SMI patients, those with SMI had significantly higher CHA2DS2-VASc (mean (SD): 5.3 (1.96) vs 4.7 (2.08), p < 0.001) and HASBLED scores (mean (SD): 3.2 (1.27) vs 2.5 (1.29), p < 0.001). Among AF patients having a CHA2DS2-VASc ≥2, those with co-morbid SMI were less likely than non-SMI patients to be prescribed an OAC (44% vs 54%, p < 0.001). However, there was no evidence of a significant difference between the two groups since 2019. CONCLUSION Over recent years, DOAC prescription rates have increased among AF patients with SMI in acute hospitals. More research is needed to confirm whether the introduction of DOACs has reduced OAC treatment gaps in people with serious mental illness and to assess whether the use of DOACs has improved health outcomes in this population.
Collapse
|
3
|
Ziani PR, Feiten JG, Goularte JF, Colombo R, Antqueviezc B, Géa LP, Rosa AR. Potential Candidates for Biomarkers in Bipolar Disorder: A Proteomic Approach through Systems Biology. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2022; 20:211-227. [PMID: 35466093 PMCID: PMC9048014 DOI: 10.9758/cpn.2022.20.2.211] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/02/2021] [Accepted: 07/03/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Paola Rampelotto Ziani
- Laboratory of Molecular Psychiatry, Hospital Clinic of Porto Alegre, Porto Alegre, Brasil
- Postgraduate Program in Biological Sciences: Pharmacology and Therapeutics - Institute of Basic Health Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brasil
| | - Jacson Gabriel Feiten
- Laboratory of Molecular Psychiatry, Hospital Clinic of Porto Alegre, Porto Alegre, Brasil
- Postgraduate Program in Psychiatry and Behavioral Sciences, Faculty of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brasil
| | | | - Rafael Colombo
- Laboratory of Molecular Psychiatry, Hospital Clinic of Porto Alegre, Porto Alegre, Brasil
- University of Caxias do Sul, Caxias do Sul, Brasil
| | - Bárbara Antqueviezc
- Laboratory of Molecular Psychiatry, Hospital Clinic of Porto Alegre, Porto Alegre, Brasil
| | - Luiza Paul Géa
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Adriane Ribeiro Rosa
- Laboratory of Molecular Psychiatry, Hospital Clinic of Porto Alegre, Porto Alegre, Brasil
- Postgraduate Program in Biological Sciences: Pharmacology and Therapeutics - Institute of Basic Health Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brasil
- Postgraduate Program in Psychiatry and Behavioral Sciences, Faculty of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brasil
| |
Collapse
|
4
|
Characteristics and management of patients with stroke and major hemorrhagic episodes with atrial fibrillation under vitamin K antagonist therapy. EVENTHO study. Med Clin (Barc) 2022; 159:366-371. [DOI: 10.1016/j.medcli.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 12/07/2021] [Accepted: 12/13/2021] [Indexed: 11/20/2022]
|
5
|
Essien UR, Kornej J, Johnson AE, Schulson LB, Benjamin EJ, Magnani JW. Social determinants of atrial fibrillation. Nat Rev Cardiol 2021; 18:763-773. [PMID: 34079095 PMCID: PMC8516747 DOI: 10.1038/s41569-021-00561-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 02/05/2023]
Abstract
Atrial fibrillation affects almost 60 million adults worldwide. Atrial fibrillation is associated with a high risk of cardiovascular morbidity and death as well as with social, psychological and economic burdens on patients and their families. Social determinants - such as race and ethnicity, financial resources, social support, access to health care, rurality and residential environment, local language proficiency and health literacy - have prominent roles in the evaluation, treatment and management of atrial fibrillation. Addressing the social determinants of health provides a crucial opportunity to reduce the substantial clinical and non-clinical complications associated with atrial fibrillation. In this Review, we summarize the contributions of social determinants to the patient experience and outcomes associated with this common condition. We emphasize the relevance of social determinants and their important intersection with atrial fibrillation treatment and outcomes. In closing, we identify gaps in the literature and propose future directions for the investigation of social determinants and atrial fibrillation.
Collapse
Affiliation(s)
- Utibe R. Essien
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,
| | - Jelena Kornej
- Sections of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Amber E. Johnson
- Division of Cardiology, Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lucy B. Schulson
- Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Emelia J. Benjamin
- Sections of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Jared W. Magnani
- Division of Cardiology, Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
6
|
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.
Collapse
|
7
|
Chebrolu P, Patil S, Laux TS, Al-Hammadi N, Jain Y, Gage B. Quality of anticoagulation with warfarin in rural Chhattisgarh, India. Indian J Med Res 2021; 152:303-307. [PMID: 33107491 PMCID: PMC7881821 DOI: 10.4103/ijmr.ijmr_1201_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background & objectives In most of rural India, warfarin is the only oral anticoagulant available. Among patients taking warfarin, there is a strong association between poor control of the international normalized ratio (INR) and adverse events. This study was aimed to quantify INR control in a secondary healthcare system in rural Chhattisgarh, India. Methods The INR data were retrospectively obtained from all patients taking warfarin during 2014-2016 at a secondary healthcare system in rural Chhattisgarh, India. Patients attending the clinic had their INR checked at the hospital laboratory and their warfarin dose adjusted by a physician on the same day. The time in therapeutic range (TTR) was calculated for patients who had at least two INR visits. Results The 249 patients had 2839 INR visits. Their median age was 46 yr, and the median body mass index was 17.7 kg/m[2]. They lived a median distance of 78 km (2-3 h of travel) from the hospital. The median INR was 1.7 for a target INR of 2.0-3.0 (n=221) and 2.1 for a target of 2.5-3.5 (n=28). The median TTR was 13.0 per cent, and INR was subtherapeutic 66.0 per cent of the time. Distance from the hospital was not correlated with TTR. Interpretation & conclusions INR values were subtherapeutic two-thirds of the time, and TTR values were poor regardless of distance from the health centre. Future studies should be done to identify interventions to improve INR control.
Collapse
Affiliation(s)
- Puja Chebrolu
- Department of Medicine, Washington University in St. Louis, Missouri, USA
| | | | - Timothy S Laux
- Department of Hospital Medicine, Columbia University Medical Center, New York, USA
| | - Noor Al-Hammadi
- Division of Biostatistics, Washington University in St. Louis, St. Louis, Missouri, USA
| | | | - Brian Gage
- Department of Medicine, Washington University in St. Louis, Missouri, USA
| |
Collapse
|
8
|
Avery P, Clairon Q, Henderson R, James Taylor C, Wilson E. Robust and adaptive anticoagulant control. J R Stat Soc Ser C Appl Stat 2020. [DOI: 10.1111/rssc.12403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
9
|
Henderson JB, Iyer P, Coniglio AC, Katz JN, Chien C, Hollis IB. Predictors of Warfarin Time in Therapeutic Range after Continuous‐Flow Left Ventricular Assist Device. Pharmacotherapy 2019; 39:1030-1035. [DOI: 10.1002/phar.2324] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
| | - Prashanth Iyer
- University of North Carolina (UNC) Health Care Chapel Hill North Carolina
| | | | - Jason N. Katz
- University of North Carolina (UNC) Health Care Chapel Hill North Carolina
| | - Christopher Chien
- University of North Carolina (UNC) Health Care Chapel Hill North Carolina
| | - Ian B. Hollis
- University of North Carolina (UNC) Health Care Chapel Hill North Carolina
| |
Collapse
|
10
|
Association between insurance status, anticoagulation quality, and clinical outcomes in patients with acute venous thromboembolism. Thromb Res 2019; 173:124-130. [DOI: 10.1016/j.thromres.2018.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 11/01/2018] [Accepted: 11/11/2018] [Indexed: 11/19/2022]
|
11
|
Perreault S, Shahabi P, Côté R, Dumas S, Rouleau-Mailloux É, Feroz Zada Y, Provost S, Mongrain I, Dorais M, Huynh T, Kouz S, Diaz A, Blostein M, de Denus S, Turgeon J, Ginsberg J, Lelorier J, Lalonde L, Busque L, Kassis J, Talajic M, Tardif JC, Dubé MP. Rationale, design, and preliminary results of the Quebec Warfarin Cohort Study. Clin Cardiol 2018. [PMID: 29542828 DOI: 10.1002/clc.22948] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Over- and undercoagulation with warfarin are associated with hemorrhagic and thromboembolic events, respectively. Genetic and clinical factors affect warfarin response, and the causes of this variability remain unclear. We present descriptive statistics and test for predictors of poor anticoagulation control. The Quebec Warfarin Cohort (QWC) comprises 1059 new warfarin users, with prospective follow-up using telephone questionnaires every 3 months for 1 year, and using healthcare administrative databases (RAMQ and Med-Echo) for 5 years prior to cohort entry and up to 10 years following active patient participation. Genetic material was collected, and genotyping of CYP2C9 and VKORC1 genes was conducted. Measured outcomes included the percentage of time patients spent within therapeutic range, anticoagulation control, warfarin dose, bleeding, and thromboembolic events. We report baseline characteristics and outcomes after 1 year of follow-up. Poor anticoagulation control was defined as time in therapeutic range <60% in the 3- to 12-month interval. Participants had a mean age of 71 years, and 62% were men. The most common indication for warfarin was atrial fibrillation (87%). Mean time in therapeutic range was 56% (±25%) in the 3 months following warfarin initiation, and 70% (±21%) in the 3- to 12-month interval. During follow-up, the rate of stroke or systemic embolism was 1.8 events per 100 person-years; for major bleeding events, 3.3 events per 100 person-years. Independent predictors of poor anticoagulation control were chronic kidney disease, heart failure, dyslipidemia, and age. The QWC represents a good research cohort to investigate clinical and genetic factors in a warfarin-anticoagulated population.
Collapse
Affiliation(s)
- Sylvie Perreault
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - Payman Shahabi
- Université de Montréal Beaulieu-Saucier Pharmacogenomics Centre, Montreal, Quebec, Canada.,Montreal Heart Institute, Montreal, Quebec, Canada.,Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Robert Côté
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada.,Department of Neurology and Neurosurgery, Montreal General Hospital, Montreal, Quebec, Canada
| | - Stéphanie Dumas
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Centre, Montreal, Quebec, Canada.,Montreal Heart Institute, Montreal, Quebec, Canada
| | - Étienne Rouleau-Mailloux
- Université de Montréal Beaulieu-Saucier Pharmacogenomics Centre, Montreal, Quebec, Canada.,Montreal Heart Institute, Montreal, Quebec, Canada.,Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Yassamin Feroz Zada
- Université de Montréal Beaulieu-Saucier Pharmacogenomics Centre, Montreal, Quebec, Canada.,Montreal Heart Institute, Montreal, Quebec, Canada
| | - Sylvie Provost
- Université de Montréal Beaulieu-Saucier Pharmacogenomics Centre, Montreal, Quebec, Canada.,Montreal Heart Institute, Montreal, Quebec, Canada
| | - Ian Mongrain
- Université de Montréal Beaulieu-Saucier Pharmacogenomics Centre, Montreal, Quebec, Canada.,Montreal Heart Institute, Montreal, Quebec, Canada
| | - Marc Dorais
- StatSciences Inc., Notre-Dame-de-l'Île-Perrot, Quebec, Canada
| | - Thao Huynh
- Department of Medicine, Montreal General Hospital, Montreal, Quebec, Canada
| | - Simon Kouz
- Département de médecine spécialisée, Centre hospitalier régional de Lanaudière, Joliette, Quebec, Canada
| | - Ariel Diaz
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.,CIUSSS-MCQ, Université de Montréal, Campus Mauricie, Trois-Rivières, Quebec, Canada
| | - Mark Blostein
- Division of Hematology, Department of Medicine, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada
| | - Simon de Denus
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada.,Université de Montréal Beaulieu-Saucier Pharmacogenomics Centre, Montreal, Quebec, Canada.,Montreal Heart Institute, Montreal, Quebec, Canada
| | - Jacques Turgeon
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada.,Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Jeffrey Ginsberg
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jacques Lelorier
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Lyne Lalonde
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - Lambert Busque
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Department of Medicine, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada
| | - Jeannine Kassis
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Department of Medicine, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada
| | | | - Jean-Claude Tardif
- Montreal Heart Institute, Montreal, Quebec, Canada.,Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Marie-Pierre Dubé
- Université de Montréal Beaulieu-Saucier Pharmacogenomics Centre, Montreal, Quebec, Canada.,Montreal Heart Institute, Montreal, Quebec, Canada.,Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| |
Collapse
|
12
|
Williams BA, Evans MA, Honushefsky AM, Berger PB. Clinical Prediction Model for Time in Therapeutic Range While on Warfarin in Newly Diagnosed Atrial Fibrillation. J Am Heart Assoc 2017; 6:JAHA.117.006669. [PMID: 29025746 PMCID: PMC5721868 DOI: 10.1161/jaha.117.006669] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Though warfarin has historically been the primary oral anticoagulant for stroke prevention in newly diagnosed atrial fibrillation (AF), several new direct oral anticoagulants may be preferred when anticoagulation control with warfarin is expected to be poor. This study developed a prediction model for time in therapeutic range (TTR) among newly diagnosed AF patients on newly initiated warfarin as a tool to assist decision making between warfarin and direct oral anticoagulants. Methods and Results This electronic medical record–based, retrospective study included newly diagnosed, nonvalvular AF patients with no recent warfarin exposure receiving primary care services through a large healthcare system in rural Pennsylvania. TTR was estimated as the percentage of time international normalized ratio measurements were between 2.0 and 3.0 during the first year following warfarin initiation. Candidate predictors of TTR were chosen from data elements collected during usual clinical care. A TTR prediction model was developed and temporally validated and its predictive performance was compared with the SAMe‐TT2R2 score (sex, age, medical history, treatment, tobacco, race) using R2 and c‐statistics. A total of 7877 newly diagnosed AF patients met study inclusion criteria. Median (interquartile range) TTR within the first year of starting warfarin was 51% (32, 67). Of 85 candidate predictors evaluated, 15 were included in the final validated model with an R2 of 15.4%. The proposed model showed better predictive performance than the SAMe‐TT2R2 score (R2=3.0%). Conclusions The proposed prediction model may assist decision making on the proper mode of oral anticoagulant among newly diagnosed AF patients. However, predicting TTR on warfarin remains challenging.
Collapse
|
13
|
Dumas S, Rouleau-Mailloux E, Bouchama N, Lahcene H, Talajic M, Tardif JC, Gaulin MJ, Provost S, Dubé MP, Perreault S. Pillbox Use and INR Stability in a Prospective Cohort of New Warfarin Users. J Manag Care Spec Pharm 2017; 22:676-84. [PMID: 27231795 PMCID: PMC10397751 DOI: 10.18553/jmcp.2016.22.6.676] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Warfarin, a frequently prescribed oral anticoagulant, is well known for its narrow therapeutic index. Adherence to warfarin may help to achieve a stable international normalized ratio (INR), but little data are available regarding the impact of using a pillbox as a potential adherence aid device. OBJECTIVE To evaluate the association between pillbox use and time in therapeutic range (TTR) < 60% and INR instability pattern. METHODS This study was based on a prospective cohort of 1,069 new warfarin users who initiated warfarin between May 2010 and July 2013 within 17 hospitals in Quebec, Canada. Demographic, lifestyle, and clinical data were collected for 3 months to a year after warfarin initiation, and genetic factors were assessed. Patients usingh self-prepared and pharmacist-prepared pillboxes were compared with nonusers for the 3- to 12-month follow-up period. The primary outcome was a TTR < 60%, which represents a low percentage of time in the INR therapeutic range or an unstable patient. The secondary outcome was the INR instability pattern (unstable below range; unstable over range; unstable with erratic pattern; and stable) to better describe patient INR profiles. A multivariate generalized linear mixed model was used for the primary outcome, along with a multivariate multinomial linear mixed model for the secondary outcome. RESULTS The cohort included patients with a mean age of 70.4 ± 11.7 years; 61.8% of patients were men; 76.3% had atrial fibrillation as warfarin's primary indication; and 35.6% had a previous history of myocardial infarction or angina. Self-prepared and pharmacist-prepared pillbox use was not associated with TTR < 60% or a specific INR instability pattern. A sensitivity analysis showed that self-prepared pillbox users had a higher TTR than nonusers (3.55% ± 1.69%; P = 0.036). This effect was greater among patients aged < 70 years (5.48% ± 2.50%; P = 0.029) than among older patients (1.92% ± 2.31%; P =0.406). CONCLUSIONS Pillbox use was not associated with TTR < 60% or a specific INR instability pattern. The impact of self-prepared pillbox use was greater among younger patients, but results were not clinically significant. Future studies adjusting for concomitant drug use are needed to clarify these results. DISCLOSURES This study was funded by Canadian Institutes of Health Research (CIHR) and the Centre for Excellence in Personalised Medicine. Both funding sources were not involved in the design, conduct, and reporting of this study. The data used for this study came from the Quebec Warfarin Cohort Study (QWCS), which was supported by the CIHR and the Centre for Excellence in Personalised Medicine. Dumas received a doctoral training award from the CIHR. Perreault and Dubé received a salary award from the Fonds Québécois de Recherche en Santé. Study concept and design were contributed by Talajic, Tardif, Dubé, and Perreault. Dumas, Rouleau-Mailloux, Bouchama, and Lahcene collected the data, which was interpreted by Dumas, Dubé, and Perreault. The manuscript was written and revised by Dumas, Dubé, and Perreault.
Collapse
Affiliation(s)
- Stephanie Dumas
- 1 Faculty of Pharmacy, Université de Montréal, and Montreal Heart Institute, Beaulieu-Saucier Université de Montréal Pharmacogenomics Centre, Montreal, Quebec, Canada
| | - Etienne Rouleau-Mailloux
- 2 Montreal Heart Institute, Beaulieu-Saucier Université de Montréal Pharmacogenomics Centre, and Faculty of Medicine, Department of Pharmacology, Université de Montréal, Quebec, Canada
| | - Nawal Bouchama
- 3 Faculty of Pharmacy, Université de Montréal, Quebec, Canada
| | - Halema Lahcene
- 3 Faculty of Pharmacy, Université de Montréal, Quebec, Canada
| | - Mario Talajic
- 4 Montreal Heart Institute, Beaulieu-Saucier Université de Montréal Pharmacogenomics Centre, and Faculty of Medicine, Department of Medicine, Université de Montréal, Quebec, Canada
| | - Jean-Claude Tardif
- 5 Montreal Heart Institute, Beaulieu-Saucier Université de Montréal Pharmacogenomics Centre, and Faculty of Medicine, Department of Medicine, Université de Montréal, Quebec, Canada
| | - Marie-José Gaulin
- 7 Montreal Heart Institute, Beaulieu-Saucier Université de Montréal Pharmacogenomics Centre, Montreal, Quebec, Canada
| | - Sylvie Provost
- 7 Montreal Heart Institute, Beaulieu-Saucier Université de Montréal Pharmacogenomics Centre, Montreal, Quebec, Canada
| | - Marie-Pierre Dubé
- 6 Montreal Heart Institute, Beaulieu-Saucier Université de Montréal Pharmacogenomics Centre, and Faculty of Medicine, Department of Medicine, Université de Montréal, Quebec, Canada
| | | |
Collapse
|
14
|
Contreras Muruaga MDM, Vivancos J, Reig G, González A, Cardona P, Ramírez-Moreno JM, Martí J, Suárez Fernández C. Satisfaction, quality of life and perception of patients regarding burdens and benefits of vitamin K antagonists compared with direct oral anticoagulants in patients with nonvalvular atrial fibrillation. J Comp Eff Res 2017; 6:303-312. [PMID: 28353372 DOI: 10.2217/cer-2016-0078] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
AIM To compare the satisfaction of patients treated with vitamin K antagonists (VKA) with that of patients treated with direct oral anticoagulants (DOACs) and to determine the impact on quality of life of both treatments in patients with nonvalvular atrial fibrillation (NVAF). METHODS Cross-sectional multicenter study in which outpatients with NVAF completed the ACTS (Anti-Clot Treatment Scale), SAT-Q (Satisfaction Questionnaire) and EQ-5D-3L (EuroQol 5 dimensions questionnaire, 3 level version) questionnaires. RESULTS The study population comprised 1337 patients, of whom 587 were taking DOACs and 750 VKAs. Compared with VKAs, DOACs were more commonly prescribed in patients with a history of stroke and in patients with a higher thromboembolic risk. The study scores were as follows: SAT-Q: 63.8 ± 17.8; EQ-5D-3L total score: 75.6 ± 20.9; visual analog scale: 63.1 ± 20.6; ACTS Burdens: 51.8 ± 8.4 and ACTS Benefits: 11.9 ± 2.4. The ACTS Burdens score and ACTS Benefits score were higher with DOACs than with VKAs (54.83 ± 6.11 vs 49.50 ± 9.15; p < 0.001 and 12.36 ± 2.34 vs 11.48 ± 2.46; p < 0.001 respectively). CONCLUSION NVAF patients treated with oral anticoagulants had many comorbidities and a high thromboembolic risk. Satisfaction and quality of life with oral anticoagulants were high, although they were both better with DOACs than with VKAs.
Collapse
Affiliation(s)
| | - José Vivancos
- Servicio de Neurología, Hospital Universitario de La Princesa, Madrid, Spain
| | - Gemma Reig
- Servicio de Neurología, Hospital Universitario de La Princesa, Madrid, Spain
| | - Ayoze González
- Servicio de Neurología y Neurofisiología Clínica, Hospital San Roque Las Palmas, Las Palmas, Spain
| | - Pere Cardona
- Servicio de Neurología, Hospital Universitario de Bellvitge (HUB), Barcelona, Spain
| | - José Mª Ramírez-Moreno
- Unidad de Ictus. Servicio de Neurología. Departamento de Ciencias Biomédicas. Hospital Universitario Infanta Cristina, Madrid, Spain
| | - Joan Martí
- Servicio de Neurología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | | |
Collapse
|
15
|
Hellyer JA, Azarbal F, Than CT, Fan J, Schmitt SK, Yang F, Frayne SM, Phibbs CS, Yong C, Heidenreich PA, Turakhia MP. Impact of Baseline Stroke Risk and Bleeding Risk on Warfarin International Normalized Ratio Control in Atrial Fibrillation (from the TREAT-AF Study). Am J Cardiol 2017; 119:268-274. [PMID: 27836133 DOI: 10.1016/j.amjcard.2016.09.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 09/27/2016] [Accepted: 09/27/2016] [Indexed: 10/20/2022]
Abstract
Warfarin prevents stroke and prolongs survival in patients with atrial fibrillation and flutter (AF, collectively) but can cause hemorrhage. The time in international normalized ratio (INR) therapeutic range (TTR) mediates stroke reduction and bleeding risk. This study sought to determine the relation between baseline stroke, bleeding risk, and TTR. Using data from The Retrospective Evaluation and Assessment of Therapies in Atrial Fibrillation (TREAT-AF) retrospective cohort study, national Veterans Health Administration records were used to identify patients with newly diagnosed AF from 2003 to 2012 and subsequent initiation of warfarin. Baseline stroke and bleeding risk was determined by calculating CHA2DS2-VASc and HAS-BLED scores, respectively. Main outcomes were first-year and long-term TTR and INR monitoring rate. In 167,190 patients, the proportion of patients with TTR (>65%) decreased across increasing strata of CHA2DS2-VASc and HAS-BLED. After covariate adjustment, odds of achieving TTR >65% were significantly associated with high CHA2DS2-VASc or HAS-BLED score. INR monitoring rate was similar across risk strata. In conclusion, increased baseline stroke and bleeding risk is associated with poor INR control, despite similar rates of INR monitoring. These findings may paradoxically limit warfarin's efficacy and safety in high-risk patients and may explain observed increased bleeding and stroke rates in this cohort.
Collapse
|
16
|
Hofmann E, Faller N, Limacher A, Méan M, Tritschler T, Rodondi N, Aujesky D. Educational Level, Anticoagulation Quality, and Clinical Outcomes in Elderly Patients with Acute Venous Thromboembolism: A Prospective Cohort Study. PLoS One 2016; 11:e0162108. [PMID: 27606617 PMCID: PMC5015908 DOI: 10.1371/journal.pone.0162108] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 08/17/2016] [Indexed: 12/05/2022] Open
Abstract
Whether the level of education is associated with anticoagulation quality and clinical outcomes in patients with acute venous thromboembolism (VTE) is uncertain. We thus aimed to investigate the association between educational level and anticoagulation quality and clinical outcomes in elderly patients with acute VTE. We studied 817 patients aged ≥65 years with acute VTE from a Swiss prospective multicenter cohort study (09/2009-12/2013). We defined three educational levels: 1) less than high school, 2) high school, and 3) post-secondary degree. The primary outcome was the anticoagulation quality, expressed as the percentage of time spent in the therapeutic INR range (TTR). Secondary outcomes were the time to a first recurrent VTE and major bleeding. We adjusted for potential confounders and periods of anticoagulation. Overall, 56% of patients had less than high school, 25% a high school degree, and 18% a post-secondary degree. The mean percentage of TTR was similar across educational levels (less than high school, 61%; high school, 64%; and post-secondary, 63%; P = 0.36). Within three years of follow-up, patients with less than high school, high school, and a post-secondary degree had a cumulative incidence of recurrent VTE of 14.2%, 12.9%, and 16.4%, and a cumulative incidence of major bleeding of 13.3%, 15.1%, and 15.4%, respectively. After adjustment, educational level was neither associated with anticoagulation quality nor with recurrent VTE or major bleeding. In elderly patients with VTE, we did not find an association between educational level and anticoagulation quality or clinical outcomes.
Collapse
Affiliation(s)
- Eveline Hofmann
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicolas Faller
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
- * E-mail:
| | - Andreas Limacher
- Clinical Trials Unit Bern, Department of Clinical Research, and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Marie Méan
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Tobias Tritschler
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
17
|
Canavero I, Cavallini A, Sacchi L, Quaglini S, Arnò N, Perrone P, DeLodovici ML, Marcheselli S, Micieli G. Safely Addressing Patients with Atrial Fibrillation to Early Anticoagulation after Acute Stroke. J Stroke Cerebrovasc Dis 2016; 26:7-18. [PMID: 27614403 DOI: 10.1016/j.jstrokecerebrovasdis.2016.08.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 07/25/2016] [Accepted: 08/12/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND It has been widely reported that anticoagulants (ACs) are underused for primary and secondary prevention of ischemic stroke in patients with atrial fibrillation (AFib). Furthermore, precise evidence-based guidelines about the best timing for AC initiation after acute stroke are currently lacking. METHODS AND RESULTS In this retrospective, observational study, we analyzed prescription trends in AFib patients with acute ischemic stroke who were hospitalized in four neurologic stroke units of our region (Lombardia, Italy). In-hospital antithrombotic prescription was performed in highly heterogeneous patterns. A prestroke treatment with AC was the leading factor enhancing AC prescription during hospitalization. The other factors promoting AC were male gender, younger age, lower prestroke disability and stroke severity, and smaller stroke volumes. AFib subtype influenced AC prescription only in AC-naïve patients. Interestingly, Congestive heart failure, Hypertension, Age higher than 75 years, Diabetes, previous Stroke or TIA or thromboembolism, Vascular disease, Age 64-75 years, female Sex (CHA2DS2-VASc) and Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile INRs, Elderly, Drugs and alcohol (HAS-BLED) scores were not associated with AC prescription. However, patients who were treated with AC, including early treatment (<48 hours), showed a low rate of bleeding. CONCLUSIONS Our findings potentially suggest that, although apparently neglecting the common risk stratification tools, our neurologists were able to select the more suitable candidates for prompt AC treatment. Further studies are needed to develop new scoring systems to aid ischemic and hemorrhagic risk estimation in the secondary prevention of stroke.
Collapse
Affiliation(s)
- Isabella Canavero
- Department of Emergency Neurology and Stroke Unit, National Neurological Institute "Casimiro Mondino" IRCCS, Pavia, Italy.
| | - Anna Cavallini
- Department of Emergency Neurology and Stroke Unit, National Neurological Institute "Casimiro Mondino" IRCCS, Pavia, Italy
| | - Lucia Sacchi
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Silvana Quaglini
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Natale Arnò
- Department of Emergency Neurology and Stroke Unit, National Neurological Institute "Casimiro Mondino" IRCCS, Pavia, Italy
| | - Patrizia Perrone
- Department of Neurosciences, Neurology Unit, "Ospedale Civile", Legnano, Italy
| | - Maria Luisa DeLodovici
- Stroke Unit, Department of Neurology, "Fondazione Macchi-Ospedale di Circolo", Insubria University, Varese, Italy
| | - Simona Marcheselli
- Emergency Neurology and Stroke Unit, "Istituto Clinico Humanitas", Milan, Italy
| | - Giuseppe Micieli
- Department of Emergency Neurology and Stroke Unit, National Neurological Institute "Casimiro Mondino" IRCCS, Pavia, Italy
| |
Collapse
|
18
|
Abohelaika S, Wynne H, Avery P, Robinson B, Kesteven P, Kamali F. Impact of age on long-term anticoagulation and how gender and monitoring setting affect it: implications for decision making and patient management. Br J Clin Pharmacol 2016; 82:1076-83. [PMID: 27314636 DOI: 10.1111/bcp.13046] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 06/02/2016] [Accepted: 06/12/2016] [Indexed: 01/06/2023] Open
Abstract
AIMS Stabilization of anticoagulation control is seminal to reducing the risk of adverse effects of vitamin K antagonists. Reliable information on how ageing influences this is lacking. We set out to assess the true age-related changes in anticoagulation control, how gender and patient setting influence this, and the possible implications of these for patient outcomes and management. METHODS In atrial fibrillation (AF) patients of a unified anticoagulant service monitoring patients in general practice or hospital-based clinics and housebound patients at home, international normalized ratio (INR) and warfarin dose data between 2000 and 2013 were extracted via the DAWN dosing program. Anticoagulation control was assessed by calculating percentage time spent within target INR (TTR). RESULTS A total of 2094 AF patients [938 (44.8%) in general practice (GP) and 531 (25.4%) in hospital (H)-based clinics and 625 (29.8%) through the domiciliary service (D)] were evaluated. The frequency of warfarin dose changes and INR monitoring events declined until about age 67, then increased as patients got older. The TTR according to age was significantly lower and the probability of having a TTR ≤65% according to age was higher for D than for H and GP, and females had a greater probability of having a TTR ≤65% than age-matched males. CONCLUSION Identification of factors underlying poorer anticoagulation control in older housebound patients and the introduction of effective modifications to improve the clinical effectiveness of anticoagulation in such patients is needed.
Collapse
Affiliation(s)
- Salah Abohelaika
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Hilary Wynne
- Older People's Medicine, Newcastle upon Tyne Hospitals, NHS Foundation Trust, UK
| | - Peter Avery
- School of Mathematics and Statistics, Newcastle University, Newcastle upon Tyne, UK
| | - Brian Robinson
- Department of Haematology, Newcastle upon Tyne Hospitals, NHS Foundation Trust, UK
| | - Patrick Kesteven
- Department of Haematology, Newcastle upon Tyne Hospitals, NHS Foundation Trust, UK
| | - Farhad Kamali
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.
| |
Collapse
|
19
|
Ziff OJ, Camm AJ. Individualized approaches to thromboprophylaxis in atrial fibrillation. Am Heart J 2016; 173:143-58. [PMID: 26920607 DOI: 10.1016/j.ahj.2015.10.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 10/28/2015] [Indexed: 12/26/2022]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia worldwide. The prevalence of AF in persons older than 55 years is at least 33.5 million globally and is predicted to more than double in the next half-century. Anticoagulation, heart rate control, and heart rhythm control comprise the 3 main treatment strategies in AF. Anticoagulation is aimed at preventing debilitating stroke, systemic embolism, and associated mortality. Historically, anticoagulation in AF was achieved with a vitamin K antagonist such as warfarin, which is supported by evidence demonstrating reduced incident stroke and all-cause mortality. However, warfarin has unpredictable pharmacokinetics with many drug-drug interactions that require regular monitoring to ensure patients remain in the therapeutic anticoagulant range. Non-vitamin K antagonist oral anticoagulants including dabigatran, rivaroxaban, apixaban, and edoxaban provide a possible solution to these issues with their more predictable pharmacokinetics, rapid onset of action, and greater specificity. Results from large randomized, controlled trials indicate that these agents are at least noninferior to warfarin in prevention of stroke. These trials also demonstrate a consistently lower incidence of intracranial hemorrhage, almost always all life-threatening bleeds, and many forms of major bleeds with the possible exception of gastrointestinal and some other forms of mucosal bleeding, compared with warfarin. Patients with AF are a heterogeneous population with diverse risk of stroke and bleeding, and different subgroups respond differently to anticoagulation. Important clinical questions have arisen regarding optimal anticoagulation drug selection in distinct populations such as those with renal impairment, older age, coronary artery disease, and heart failure as well as those at particularly high risk for bleeding or thromboembolism. In this review, treatment strategies in AF management are discussed in the context of different individual subgroups of patients.
Collapse
|
20
|
Barrios V, Escobar C, Prieto L, Osorio G, Polo J, Lobos JM, Vargas D, García N. Control de la anticoagulación en pacientes con fibrilación auricular no valvular asistidos en atención primaria en España. Estudio PAULA. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2015.04.017] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
21
|
Barrios V, Escobar C, Prieto L, Osorio G, Polo J, Lobos JM, Vargas D, García N. Anticoagulation Control in Patients With Nonvalvular Atrial Fibrillation Attended at Primary Care Centers in Spain: The PAULA Study. ACTA ACUST UNITED AC 2015; 68:769-76. [PMID: 26169326 DOI: 10.1016/j.rec.2015.04.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 04/28/2015] [Indexed: 01/30/2023]
Abstract
INTRODUCTION AND OBJECTIVES To determine the current status of anticoagulation control in patients with nonvalvular atrial fibrillation treated with vitamin K antagonists in the primary care setting in Spain. METHODS The PAULA study was a multicenter cross-sectional/retrospective observational study conducted throughout Spain. The study included patients with nonvalvular atrial fibrillation who had been receiving vitamin K antagonist therapy during the past year and were attended at primary care centers. International normalized ratio (INR) values over the past 12 months were recorded. The degree of anticoagulation control was defined as the time the patient had remained within the therapeutic range and was determined by both the direct method (poor control < 60%) and by the Rosendaal method (poor control < 65%). RESULTS The study assessed 1524 patients (mean age, 77.4 ± 8.7 years; 48.6% women; 64.2% in permanent atrial fibrillation; CHADS2 mean, 2.3 ± 1.2; CHA2DS2-VASc, 3.9 ± 1.5, and HAS-BLED, 1.6 ± 0.9). The mean number of INR readings recorded per patient was 14.4 ± 3.8. A total of 56.9% of patients had adequate INR control according to the direct method and 60.6% according to the Rosendaal method. The multivariate analysis identified the following predictors for poor INR control: female sex, dietary habits potentially affecting anticoagulation with vitamin K antagonists, multidrug therapy, and a history of labile INR. CONCLUSIONS Approximately 40% of patients (43.1% by the direct method and 39.4% by the Rosendaal method) with nonvalvular atrial fibrillation who were receiving anticoagulation therapy with vitamin K antagonists in primary care in Spain had poor anticoagulation control during the previous 12 months.
Collapse
Affiliation(s)
- Vivencio Barrios
- Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | - Carlos Escobar
- Servicio de Cardiología, Hospital Universitario La Paz, Madrid, Spain
| | - Luis Prieto
- Bioestadística Médica, Universidad Católica San Antonio de Murcia (UCAM), Murcia, Spain
| | | | - José Polo
- Centro de Salud Casar de Cáceres, Casar de Cáceres, Cáceres, Spain
| | - José María Lobos
- Centro de Salud Jazmín, Área 4 de Atención Primaria, Madrid, Spain
| | - Diego Vargas
- Unidad de Hospitalización Polivalente, Hospital de Alta Resolución El Toyo, Hospital de Poniente El Ejido, Almería, Spain
| | - Nicolás García
- Departamento Médico, Bayer Hispania S.L., Barcelona, Spain
| |
Collapse
|
22
|
Shields AM, Lip GYH. Choosing the right drug to fit the patient when selecting oral anticoagulation for stroke prevention in atrial fibrillation. J Intern Med 2015; 278:1-18. [PMID: 25758241 DOI: 10.1111/joim.12360] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide and is a growing health problem that is associated with a significantly increased risk of stroke and thromboembolism. Oral anticoagulant (OAC) therapy reduces the risk of stroke and all-cause mortality in patients with AF. OAC therapy is commonly given as a well-controlled vitamin K antagonist (VKA; e.g. warfarin) and can reduce the risk of stroke in AF patients by almost two-thirds. However, the widespread use of VKAs has been hampered by the unpredictable pharmacokinetic and pharmacodynamic properties of the drugs and justifiable concerns about the consequent risk of haemorrhage. The non-VKA OACs (NOACs) have revolutionized thromboprophylaxis in AF by providing therapeutic options with predictable pharmacodynamic and pharmacokinetic properties that are as efficacious as warfarin in the prevention of stroke and thromboembolism but are more convenient to use. In this review, we provide a patient-centred framework to assist clinicians in recommending the right OAC therapy to fit the individual patient with AF, including methods for stratifying the risk of stroke and haemorrhage and the chances of achieving tight control of VKA anticoagulation, and we discuss the properties of the NOACs that favour their use in particular patient cohorts.
Collapse
Affiliation(s)
- A M Shields
- Acute Medicine Directorate, Croydon University Hospital, London, UK
| | - G Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| |
Collapse
|