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Lin J, Long D, Jiang C, Sang C, Tang R, Li S, Wang W, Guo X, Ning M, Sun Z, Yang N, Hao Y, Liu J, Liu J, Du X, Morgan L, Fonarow GC, Smith SC, Lip GY, Zhao D, Dong J, Ma C. Oral anti-coagulants use in Chinese hospitalized patients with atrial fibrillation. Chin Med J (Engl) 2024; 137:172-180. [PMID: 38146256 PMCID: PMC10798766 DOI: 10.1097/cm9.0000000000002915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND Oral anti-coagulants (OAC) are the intervention for the prevention of stroke, which consistently improve clinical outcomes and survival among patients with atrial fibrillation (AF). The main purpose of this study is to identify problems in OAC utilization among hospitalized patients with AF in China. METHODS Using data from the Improving Care for Cardiovascular Disease in China-Atrial Fibrillation (CCC-AF) registry, guideline-recommended OAC use in eligible patients was assessed. RESULTS A total of 52,530 patients with non-valvular AF were enrolled from February 2015 to December 2019, of whom 38,203 were at a high risk of stroke, 9717 were at a moderate risk, and 4610 were at a low risk. On admission, only 20.0% (6075/30,420) of patients with a diagnosed AF and a high risk of stroke were taking OAC. The use of pre-hospital OAC on admission was associated with a lower risk of new-onset ischemic stroke/transient ischemic attack among the diagnosed AF population (adjusted odds ratio: 0.54, 95% confidence interval: 0.43-0.68; P <0.001). At discharge, the prescription rate of OAC was 45.2% (16,757/37,087) in eligible patients with high stroke risk and 60.7% (2778/4578) in eligible patients with low stroke risk. OAC utilization in patients with high stroke risk on admission or at discharge both increased largely over time (all P <0.001). Multivariate analysis showed that OAC utilization at discharge was positively associated with in-hospital rhythm control strategies, including catheter ablation (adjusted odds ratio [OR] 11.63, 95% confidence interval [CI] 10.04-13.47; P <0.001), electronic cardioversion (adjusted OR 2.41, 95% CI 1.65-3.51; P <0.001), and anti-arrhythmic drug use (adjusted OR 1.45, 95% CI 1.38-1.53; P <0.001). CONCLUSIONS In hospitals participated in the CCC-AF project, >70% of AF patients were at a high risk of stroke. Although poor performance on guideline-recommended OAC use was found in this study, over time the CCC-AF project has made progress in stroke prevention in the Chinese AF population.Registration:ClinicalTrials.gov, NCT02309398.
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Affiliation(s)
- Jing Lin
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Deyong Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Chenxi Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Caihua Sang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Ribo Tang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Songnan Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Wei Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Xueyuan Guo
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Man Ning
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Zhaoqing Sun
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Na Yang
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Yongchen Hao
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Jun Liu
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Jing Liu
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Louise Morgan
- International Quality Improvement Department, American Heart Association, Dallas, TX 07076, USA
| | - Gregg C. Fonarow
- Division of Cardiology, Geffen School of Medicine at University of California, Los Angeles CA 90024, USA
| | - Sidney C. Smith
- Division of Cardiology, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Gregory Y.H. Lip
- Department of Cardiology, Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L143PE, UK
- Department of Clinical Medicine, Aalborg University, Aalborg 9000, Denmark
| | - Dong Zhao
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Jianzeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
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Sehrawat O, Kashou AH, Van Houten HK, Cohen K, Joe Henk H, Gersh BJ, Abraham NS, Graff-Radford J, Friedman PA, Siontis KC, Noseworthy PA, Yao X. Contemporary trends and barriers to oral anticoagulation therapy in Non-valvular atrial fibrillation during DOAC predominant era. IJC HEART & VASCULATURE 2023; 46:101212. [PMID: 37168417 PMCID: PMC10164915 DOI: 10.1016/j.ijcha.2023.101212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/11/2023] [Accepted: 04/18/2023] [Indexed: 05/13/2023]
Abstract
There is a need to reassess contemporary oral anticoagulation (OAC) trends and barriers against guideline directed therapy in the United States. Most previous studies were performed before major guideline changes recommended direct oral anticoagulant (DOAC) use over warfarin or have otherwise lacked patient level data. Data on overuse of OAC in low-risk group is also limited. To address these knowledge gaps, we performed a nationwide analysis to analyze current trends. This is a retrospective cohort study assessing non-valvular AF identified using a large United States de-identified administrative claims database, including commercial and Medicare Advantage enrollees. Prescription fills were assessed within a 90-day follow-up from the patient's index AF encounter between January 1, 2016, and December 31, 2020. Among the 339,197 AF patients, 4.4%, 8.0%, and 87.6% were in the low-, moderate-, and high-risk groups (according to CHA2DS2-VASc score). An over (29.6%) and under (52.2%) utilization of OAC was reported in low- and high-risk AF patients. A considerably high frequency for warfarin use was also noted among high-risk group patients taking OAC (33.1%). The results suggest that anticoagulation use for stroke prevention in the United States is still comparable to the pre-DOAC era studies. About half of newly diagnosed high-risk non-valvular AF patients remain unprotected against stroke risk. Several predictors of OAC and DOAC use were also identified. Our findings may identify a population at risk of complications due to under- or over-treatment and highlight the need for future quality improvement efforts.
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Affiliation(s)
- Ojasav Sehrawat
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Anthony H. Kashou
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Holly K. Van Houten
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
| | - Ken Cohen
- Optum Center for Research and Innovation, Minnetonka, MN, United States
| | - Henry Joe Henk
- UnitedHealthcare, 9700 Health Care Lane, Minnetonka, MN 55343, USA
| | - Bernard J. Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Neena S. Abraham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Scottsdale, AZ, United States
| | | | - Paul A. Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | | | - Peter A. Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
- Corresponding author at: Department of Cardiovascular Medicine Mayo Clinic, 200 First Street SW |, Rochester, MN 55905, United States.
| | - Xiaoxi Yao
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
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Machado-Duque ME, Gaviria-Mendoza A, Reyes JM, Mesa A, Castaño-Gamboa N, Valladales-Restrepo LF, Machado-Alba JE. Clinical Characteristics, Patterns of Use, and incidence of Adverse Events in Patients With Nonvalvular Atrial Fibrillation Treated With Oral Anticoagulants in Colombia. Vasc Health Risk Manag 2023; 19:157-167. [PMID: 37008594 PMCID: PMC10065118 DOI: 10.2147/vhrm.s391549] [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: 10/08/2022] [Accepted: 02/27/2023] [Indexed: 03/29/2023] Open
Abstract
Purpose The aim was to analyze the characteristics, treatment patterns, and clinical outcomes of Colombian patients with non-valvular atrial fibrillation (NVAF) under treatment with oral anticoagulants (OAs). Patients and Methods Retrospective cohort in patients with NVAF identified from a drug dispensing database, aged ≥18 years, with first prescription of an OA (index) between January/2013 and June/2018, and a follow-up until June/2019. Data from the clinical history, pharmacological variables, and outcomes were searched. International Classification of Diseases-10 codes were used to identify the patient sample and outcomes. Patients were followed until a general composite outcome of effectiveness (thrombotic events), bleeding/safety or persistence (switch/discontinuation of anticoagulant) events. Descriptive and multivariate analyzes (Cox regressions comparing warfarin and direct oral anticoagulants-DOACs) were carried out. Results A total of 2076 patients with NVAF were included. The 57.0% of patients were women and the mean age was 73.3±10.4 years. Patients were followed for a mean of 2.3±1.6 years. 8.7% received warfarin before the index date. The most frequent OA was rivaroxaban (n=950; 45.8%), followed by warfarin (n=459; 22.1%) and apixaban (n=405; 19.5%). Hypertension was present in 87.5% and diabetes mellitus in 22.6%. The mean CHA2DS2-VASc Score was 3.6±1.5. The 71.0% (n=326/459) of the warfarin patients presented the general composite outcome, and 24.6% of those with DOACs (n=397/1617). The main effectiveness and safety outcomes were stroke (3.1%) and gastrointestinal bleeding (2.0%) respectively. There were no significant differences between patients with warfarin and DOACs regarding thrombotic events (HR: 1.28; 95% CI: 0.68-2.42), but warfarin was associated with higher bleeding/safety events (HR: 4.29; 95% CI: 2.82-6.52) and persistence events (HR: 4.51; 95% CI: 3.81 -5.33). Conclusion The patients with NVAF in this study were mainly older adults with multiple comorbidities. Compared to warfarin, DOACs were found to be equally effective, but safer and had a lower probability of discontinuation or switch.
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Affiliation(s)
- Manuel E Machado-Duque
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Colombia
- Grupo de Investigación en Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
| | - Andrés Gaviria-Mendoza
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Colombia
- Grupo de Investigación en Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
| | | | | | | | - Luis Fernando Valladales-Restrepo
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Colombia
- Grupo de Investigación en Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
| | - Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Colombia
- Correspondence: Jorge Enrique Machado-Alba, Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Calle 105 No. 14-140, Pereira, Risaralda, 660003, Colombia, Tel +57 3108326970, Fax +57 63137822, Email
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Martinez KA, Eckman MH, Pappas MA, Rothberg MB. Prescribing of anticoagulation for atrial fibrillation in primary care. J Thromb Thrombolysis 2022; 54:616-624. [PMID: 35449383 PMCID: PMC10481404 DOI: 10.1007/s11239-022-02655-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 11/29/2022]
Abstract
Atrial fibrillation (AF) is common in primary care patients. Many patients who could benefit from anticoagulation do not receive it. The objective of this study was to describe anticoagulation prescribing by primary care physicians. We conducted an observational study in the Cleveland Clinic Health System among patients with AF and ≥ 1 primary care appointment between 2015 and 2018 and their physicians. We estimated differences in the odds of an eligible patient receiving anticoagulation versus not and a DOAC versus warfarin using two mixed effects logistic regression models, adjusted for patient sociodemographic factors, history of falls or dementia, and CHA2DS2-VASc and HAS-BLED scores. We categorized physicians into prescribing tertiles, based on their adjusted prescribing rate, which we included as predictors in the models. Among 5253 patients, 47% received anticoagulation. Of those, 56% received a DOAC. CHA2DS2-VASc and HAS-BLED scores were not associated with anticoagulation prescription. Black race was negatively associated with receiving anticoagulation overall (aOR:0.71; 95%CI:0.56-0.89) and with prescription for a DOAC (aOR:0.65; 95%CI:0.45-0.93). Among 195 physicians, the anticoagulation prescribing rate ranged from 27% to 57% and DOAC rates ranged from 34% to 69%. Physician prescribing tertile was associated with odds of a patient receiving anticoagulation overall (aOR:1.51; 95%CI: 1.13-2.01 for the highest versus lowest tertile), but not DOAC prescriptions. When prescribing anticoagulation, physicians appear not to consider risk of stroke or bleeding but patient race is an important determinant. Seeing a physician with a high anticoagulation prescribing rate was strongly associated with a patient receiving it, suggesting a lack of individualization.
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Affiliation(s)
- Kathryn A Martinez
- Cleveland Clinic Center for Value-Based Care Research, 9500 Euclid Ave, G10, Cleveland, OH, 44195, USA.
| | - Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH, USA
| | - Matthew A Pappas
- Cleveland Clinic Center for Value-Based Care Research, 9500 Euclid Ave, G10, Cleveland, OH, 44195, USA
| | - Michael B Rothberg
- Cleveland Clinic Center for Value-Based Care Research, 9500 Euclid Ave, G10, Cleveland, OH, 44195, USA
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5
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Chandrasekhar J, Baber U, Sartori S, Goel R, Nicolas J, Vogel B, Snyder C, Kini A, Briguori C, Witzenbichler B, Iakovou I, Sardella G, Marzo K, DeFranco A, Stuckey T, Chieffo A, Colombo A, Shlofmitz R, Capodanno D, Dangas G, Pocock S, Mehran R. Antithrombotic strategy variability in atrial fibrillation and obstructive coronary disease revascularised with percutaneous coronary intervention: primary results from the AVIATOR 2 international registry. EUROINTERVENTION 2022; 18:e656-e665. [PMID: 35656720 PMCID: PMC10241278 DOI: 10.4244/eij-d-21-01044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/06/2022] [Indexed: 10/09/2023]
Abstract
BACKGROUND Managing percutaneous coronary intervention (PCI) patients with atrial fibrillation (AF) presents challenges given that there are several potential antithrombotic therapy (ATT) strategies. AIMS We examined ATT patterns, agreement between subjective physician ratings and validated risk scores, physician-patient perceptions influencing ATT and 1-year outcomes. METHODS The AVIATOR 2 prospective registry enrolled 514 non-valvular AF-PCI patients from 11 sites. Treating physicians selected ATT and completed smartphone surveys rating stroke and bleeding risks, compared against CHA2DS2-VASc and HAS-BLED scores. Patients completed surveys regarding treatment understanding. Primary outcomes were 1-year major adverse cardiac or cerebrovascular events (MACCE: composite of death, myocardial infarction, definite/probable stent thrombosis, stroke, target lesion revascularisation) and actionable bleeding (Bleeding Academic Research Consortium 2, 3 or 5). RESULTS The mean patient age was 73.2±9.0 years, including 25.8% females. Triple therapy (TT: 1 anticoagulant and 2 antiplatelet agents) was prescribed in 66.5%, dual antiplatelet therapy (DAPT) in 20.7% and dual therapy (1 anticoagulant+1 antiplatelet agent) in 12.8% of patients. Physician ratings and validated risk scores showed poor agreement (stroke: kappa=0.03; bleeding: kappa=0.07). Physicians rated bleeding-related safety (93.8%) as the main factor affecting ATT choice. Patients worried about stroke over bleeding (50.6% vs 14.8%). No group differences by ATT strategy were observed in 1-year MACCE (TT 14.1% vs dual therapy 12.7% vs DAPT 18.5%; p=0.25), or actionable bleeding (14.7% vs 7.9% vs 15.1%, respectively; p=0.89). CONCLUSIONS The AVIATOR 2 study is the first digital health study examining physician-patient perspectives on ATT choices after AF-PCI. TT was the most common strategy without differences in 1-year outcomes in ATT strategy. Physicians rated safety first when prescribing ATT; patients feared stroke over bleeding. CLINICALTRIALS gov: NCT02362659.
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Affiliation(s)
- Jaya Chandrasekhar
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Box Hill Hospital, Eastern Health Clinical School and Monash University, Melbourne, Australia
| | - Usman Baber
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - Ridhima Goel
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- State University of New York, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Johny Nicolas
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Birgit Vogel
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Clayton Snyder
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | | | - Kevin Marzo
- NYU Langone Hospital-Long Island, Mineola, NY, USA
| | | | | | | | - Antonio Colombo
- Department of Biomedical Sciences, Humanitas University, Milan, Italy and IRCCS Humanitas Research Hospital, Italy
| | | | | | - George Dangas
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Sanghai SR, Liu W, Wang W, Rongali S, Orkaby AR, Saczynski JS, Rose AJ, Kapoor A, Li W, Yu H, McManus DD. Prevalence of Frailty and Associations with Oral Anticoagulant Prescribing in Atrial Fibrillation. J Gen Intern Med 2022; 37:730-736. [PMID: 33948795 PMCID: PMC8904680 DOI: 10.1007/s11606-021-06834-1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 04/14/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Frailty is often cited as a factor influencing oral anticoagulation (OAC) prescription in patients with non-valvular atrial fibrillation (NVAF). We sought to determine the prevalence of frailty and its association with OAC prescription in older veterans with NVAF. METHODS We used ICD-9 codes in Veterans Affairs (VA) records and Medicare claims data to identify patients with NVAF and CHA2DS2VASC ≥2 receiving care between February 2010 and September 2015. We examined rates of OAC prescription, further stratified by direct oral anticoagulant (DOAC) or vitamin K antagonist (VKA). Participants were characterized into 3 categories: non-frail, pre-frail, and frail based on a validated 30-item EHR-derived frailty index. We examined relations between frailty and OAC receipt; and frailty and type of OAC prescribed in regression models adjusted for factors related to OAC prescription. RESULTS Of 308,664 veterans with NVAF and a CHA2DS2VASC score ≥2, 121,839 (39%) were prescribed OAC (73% VKA). The mean age was 77.7 (9.6) years; CHA2DS2VASC and ATRIA scores were 4.6 (1.6) and 5.0 (2.9) respectively. Approximately a third (38%) were frail, another third (32%) were pre-frail, and the remainder were not frail. Veterans prescribed OAC were younger, had higher bleeding risk, and were less likely to be frail than participants not receiving OAC (all p's<0.001). After adjustment for factors associated with OAC use, pre-frail (OR: 0.89, 95% CI: 0.87-0.91) and frail (OR: 0.66, 95% CI: 0.64-0.68) veterans were significantly less likely to be prescribed OAC than non-frail veterans. Of those prescribed OAC, pre-frail (OR:1.27, 95% CI: 1.22-1.31) and frail (OR: 1.75, 95% CI: 1.67-1.83) veterans were significantly more likely than non-frail veterans to be prescribed a DOAC than a VKA. CONCLUSIONS There are high rates of frailty among older veterans with NVAF. Frailty using an EHR-derived index is associated with decreased OAC prescription.
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Affiliation(s)
- Saket R Sanghai
- Division of Cardiac Electrophysiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA.
| | - Weisong Liu
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Weijia Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | | | - Ariela R Orkaby
- New England GRECC, VA Boston Health Care System, Boston, MA, USA
- Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jane S Saczynski
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, USA
| | - Adam J Rose
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Alok Kapoor
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Wenjun Li
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Hong Yu
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- University of Massachusetts, Lowell, MA, USA
- Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA, USA
| | - David D McManus
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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7
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Kozieł M, Teutsch C, Bayer V, Lu S, Gurusamy VK, Halperin JL, Rothman KJ, Diener H, Ma C, Huisman MV, Lip GYH. Changes in anticoagulant prescription patterns over time for patients with atrial fibrillation around the world. J Arrhythm 2021; 37:990-1006. [PMID: 34386125 PMCID: PMC8339088 DOI: 10.1002/joa3.12588] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 06/07/2021] [Accepted: 06/09/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Prescribing patterns for stroke prevention in atrial fibrillation (AF) patients evolved with approval of non-Vitamin K antagonist oral anticoagulants (NOACs) over time. OBJECTIVES To assess changes in anticoagulant prescription patterns in various geographical regions upon first approval of a NOAC and to analyze the evolution of oral anticoagulants (OACs) use over time in relation to CHA2DS2-VASc and HAS-BLED risk profiles. METHODS Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF) Phases II and III reported data on antithrombotic therapy for patients with newly diagnosed AF and ≥1 stroke risk factor. We focused on sites enrolling patients in both phases and reported treatment patterns for the first 4 years after initial NOAC approval. RESULTS From GLORIA-AF Phases II and III, 27 432 patients were eligible for this analysis. When contrasting the first year with the fourth year of enrolment, the proportion of NOAC prescriptions increased in Asia from 29.2% to 60.8%, in Europe from 53.4% to 75.8%, in North America from 49.0% to 73.9% and in Latin America from 55.7% to 71.1%. The proportion of Vitamin K antagonists (VKAs) use decreased across all regions over time, in Asia from 26.0% to 9.8%, in Europe from 35.5% to 16.8%, in North America from 28.9% to 12.1%, and in Latin America from 32.4% to 17.8%. In the multivariable analysis, factors associated with NOAC prescription were as follows: enrolment year, type of site, region, stroke and bleeding risk scores, and type and categorization of AF. CONCLUSIONS During 4 years after the approval of the first NOAC, NOAC use increased, while VKA use decreased, across all regions.
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Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart and Chest HospitalLiverpoolUK
- Department of Cardiology and AngiologySilesian Centre for Heart DiseasesZabrzePoland
| | - Christine Teutsch
- Department of Clinical Development and Medical AffairsTherapeutic Area CardiometabolismBoehringer Ingelheim International GmbHIngelheimGermany
| | - Valentina Bayer
- Biostatistics and Data Sciences DepartmentBoehringer Ingelheim Pharmaceuticals, Inc.RidgefieldCTUSA
| | - Shihai Lu
- Biostatistics and Data Sciences DepartmentBoehringer Ingelheim Pharmaceuticals, Inc.RidgefieldCTUSA
| | | | | | | | | | - Chang‐Sheng Ma
- University of Duisburg‐EssenEssenGermany
- Cardiology DepartmentAtrial Fibrillation CenterBeijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Menno V. Huisman
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart and Chest HospitalLiverpoolUK
- Department of Cardiology and AngiologySilesian Centre for Heart DiseasesZabrzePoland
- Aalborg Thrombosis Research UnitDepartment of Clinical MedicineAalborg UniversityAalborgDenmark
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Xie X, Li T. Anticoagulation for atrial fibrillation patients with the CHA2DS2-VASc score =1 (beyond sex). Acta Cardiol 2021; 76:258-264. [PMID: 32056508 DOI: 10.1080/00015385.2020.1720197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We investigated the risk of ischaemic stroke in patients with 1 another stroke risk factor (i.e. CHA2DS2-VASc score =1 [males] or 2 [females]) and the impact of different component risk factors. METHODS Database were collected from two hospitals in the city of Hohhot in china. Among 3148 Nonvalvular AF patients not on antiplatelet or anticoagulant therapy, we evaluated males with a CHA2DS2-VASc score of 1 and females with a CHA2DS2-VASc score of 2. The clinical endpoint was the occurrence of ischaemic stroke. RESULTS Among 546 AF male patients with a CHA2DS2-VASc score of 1, there were 44 patients (8.06%) who experienced ischaemic stroke during follow-up (3.4 ± 2.1 years) with an annual stroke rate of 2.62%. The risk of ischaemic stroke ranged from 1.86%/year for patients with vascular diseases to 3.33%/year for those age 65-74 years of age. For the female patients with 653 AF, 54 (8.27%) experienced ischaemic stroke during follow-up (3.4 ± 2.1 years) , for an annual stroke rate of 2.76%. The risk of ischaemic stroke increased from 1.96%/year for patients with vascular diseases to 3.38%/year for those 65-74 years of age. CONCLUTIONS The risk of each factor is not equal in CHA2DS2-VASc score, with age 65-74 years associated with the highest stroke rate. Oral anticoagulation should be considered for AF patients with 1 another stroke risk factor given their high risk of ischaemic stroke.Article summary:The risk of each factor is not equal in CHA2DS2-VASc score.Atrial fibrillation is a risk factor of ischaemic stroke.Oral anticoagulation should be considered for AF patients with 1 another stroke risk factor given their high risk of ischaemic stroke.It is the retrospective nature of the study.We were not able to clearly confirm the cause of ischaemic stroke because it can be due to AF-related thromboembolism or atherosclerosis and thrombosis of the cerebral artery.
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Affiliation(s)
- XiuFeng Xie
- Southern Medical University, Guangzhou, China
- The Sixth Medical Center of PLA General Hospital, Beijing, China
| | - TianChang Li
- Southern Medical University, Guangzhou, China
- The Sixth Medical Center of PLA General Hospital, Beijing, China
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9
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Torres Roldan VD, Brand-McCarthy SR, Ponce OJ, Belluzzo T, Urtecho M, Espinoza Suarez NR, Toloza FJK, Thota AD, Organick PW, Barrera F, Liu-Sanchez C, Jaladi S, Prokop L, Ozanne EM, Fagerlin A, Hargraves IG, Noseworthy PA, Montori VM, Brito JP. Shared Decision Making Tools for People Facing Stroke Prevention Strategies in Atrial Fibrillation: A Systematic Review and Environmental Scan. Med Decis Making 2021; 41:540-549. [PMID: 33896270 PMCID: PMC8191170 DOI: 10.1177/0272989x211005655] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Shared decision making (SDM) tools can help implement guideline recommendations for patients with atrial fibrillation (AF) considering stroke prevention strategies. We sought to characterize all available SDM tools for this purpose and examine their quality and clinical impact. METHODS We searched through multiple bibliographic databases, social media, and an SDM tool repository from inception to May 2020 and contacted authors of identified SDM tools. Eligible tools had to offer information about warfarin and ≥1 direct oral anticoagulant. We extracted tool characteristics, assessed their adherence to the International Patient Decision Aids Standards, and obtained information about their efficacy in promoting SDM. RESULTS We found 14 SDM tools. Most tools provided up-to-date information about the options, but very few included practical considerations (e.g., out-of-pocket cost). Five of these SDM tools, all used by patients prior to the encounter, were tested in trials at high risk of bias and were found to produce small improvements in patient knowledge and reductions in decisional conflict. CONCLUSION Several SDM tools for stroke prevention in AF are available, but whether they promote high-quality SDM is yet to be known. The implementation of guidelines for SDM in this context requires user-centered development and evaluation of SDM tools that can effectively promote high-quality SDM and improve stroke prevention in patients with AF.
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Affiliation(s)
- Victor D Torres Roldan
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sarah R Brand-McCarthy
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Oscar J Ponce
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Tereza Belluzzo
- General Medicine, Charles University in Prague, Medical Faculty of Hradec Králové, Hradec Kralove, Czech Republic
| | - Meritxell Urtecho
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nataly R Espinoza Suarez
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Freddy J K Toloza
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anjali D Thota
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paige W Organick
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Francisco Barrera
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), School of Medicine, Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico
| | | | - Soumya Jaladi
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Larry Prokop
- Department of Library-Public Services, Mayo Clinic, Rochester MN, USA
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA.,Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation
| | - Ian G Hargraves
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Peter A Noseworthy
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Victor M Montori
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Juan P Brito
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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10
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Sherwood MW, Gupta A, Vemulapalli S, Li Z, Piccini J, Harrison JK, Dai D, Vora AN, Mack MJ, Holmes DR, Rumsfeld JS, Cohen DJ, Thourani VH, Kirtane AJ, Peterson ED. Variation in Antithrombotic Therapy and Clinical Outcomes in Patients With Preexisting Atrial Fibrillation Undergoing Transcatheter Aortic Valve Replacement: Insights From the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Circ Cardiovasc Interv 2021; 14:e009963. [PMID: 33877866 DOI: 10.1161/circinterventions.120.009963] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Matthew W Sherwood
- Duke Clinical Research Institute, Durham, NC (M.W.S., S.V., Z.L., J.P., J.K.H., A.N.V., E.D.P.).,Inova Heart and Vascular Institute, Falls Church, VA (M.W.S.)
| | - Aakriti Gupta
- Section of Cardiovascular Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY (A.G., A.J.K.).,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (A.G.).,Cardiovascular Research Foundation, New York, NY (A.G., A.J.K.)
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, NC (M.W.S., S.V., Z.L., J.P., J.K.H., A.N.V., E.D.P.).,Division of Cardiology, Duke University Medical Center, Durham, NC (S.V., J.P., D.D., A.N.V., E.D.P.)
| | - Zhuokai Li
- Duke Clinical Research Institute, Durham, NC (M.W.S., S.V., Z.L., J.P., J.K.H., A.N.V., E.D.P.)
| | - Jonathan Piccini
- Duke Clinical Research Institute, Durham, NC (M.W.S., S.V., Z.L., J.P., J.K.H., A.N.V., E.D.P.).,Division of Cardiology, Duke University Medical Center, Durham, NC (S.V., J.P., D.D., A.N.V., E.D.P.)
| | - J Kevin Harrison
- Duke Clinical Research Institute, Durham, NC (M.W.S., S.V., Z.L., J.P., J.K.H., A.N.V., E.D.P.)
| | - David Dai
- Division of Cardiology, Duke University Medical Center, Durham, NC (S.V., J.P., D.D., A.N.V., E.D.P.)
| | - Amit N Vora
- Duke Clinical Research Institute, Durham, NC (M.W.S., S.V., Z.L., J.P., J.K.H., A.N.V., E.D.P.).,Division of Cardiology, Duke University Medical Center, Durham, NC (S.V., J.P., D.D., A.N.V., E.D.P.)
| | - Michael J Mack
- Department of Cardiovascular Surgery, Baylor Scott & White Health, Plano, TX (M.J.M.)
| | - David R Holmes
- Department of Cardiology, Mayo Foundation, Rochester, MN (D.R.H.)
| | - John S Rumsfeld
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora (J.S.R.)
| | - David J Cohen
- Department of Cardiology, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Vinod H Thourani
- MedStar Heart and Vascular Institute/Georgetown University, Washington, DC (V.H.T.)
| | - Ajay J Kirtane
- Section of Cardiovascular Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY (A.G., A.J.K.).,Cardiovascular Research Foundation, New York, NY (A.G., A.J.K.)
| | - Eric D Peterson
- Duke Clinical Research Institute, Durham, NC (M.W.S., S.V., Z.L., J.P., J.K.H., A.N.V., E.D.P.).,Division of Cardiology, Duke University Medical Center, Durham, NC (S.V., J.P., D.D., A.N.V., E.D.P.)
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11
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Damen NL, de Vos MS, Moesker MJ, Braithwaite J, de Lind van Wijngaarden RAF, Kaplan J, Hamming JF, Clay-Williams R. Preoperative Anticoagulation Management in Everyday Clinical Practice: An International Comparative Analysis of Work-as-Done Using the Functional Resonance Analysis Method. J Patient Saf 2021; 17:157-165. [PMID: 29994818 DOI: 10.1097/pts.0000000000000515] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Preoperative anticoagulation management (PAM) is a complex, multidisciplinary process important to patient safety. The Functional Resonance Analysis Method (FRAM) is a novel method to study how complex processes usually go right at the frontline (labeled Safety-II) and how this relates to predefined procedures. This study aimed to assess PAM in everyday practice and explore the usability and utility of FRAM. METHODS The study was conducted at an Australian and European Cardiothoracic Surgery Department. A FRAM model of work-as-imagined was developed using (inter)national guidelines. Semistructured interviews with 18 involved professionals were used to develop models reflecting work-as-done at both sites, which were presented to staff for validation. Workload in hours was estimated per process step. RESULTS In both centers, work-as-done differed from work-as-imagined, such as in the division of tasks among disciplines (e.g., nurses/registrars rather than medical specialists), but control mechanisms had been developed locally to ensure safe care (e.g., crosschecking with other clinicians). Centers had organized the process differently, revealing opportunities for improvement regarding patient information and clustering of clinic visits. Presenting FRAM models to staff initiated discussion on improvement of functions in the model that are vital for success. Overall workload was estimated at 47 hours per site. CONCLUSIONS This FRAM analysis provided insight into PAM from the perspective of frontline clinicians, revealing essential functions, interdependencies and variability, and the relation with guidelines. Future studies are warranted to study the potential of FRAM, such as for guiding improvements in complex systems.
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Affiliation(s)
- Nikki L Damen
- From the Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Marit S de Vos
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Marco J Moesker
- Amsterdam Public Health Research Institute, Department of Public and Occupational Health, VU University Medical Centre, Amsterdam
| | - Jeffrey Braithwaite
- From the Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | | | - Jason Kaplan
- Faculty of Medicine and Health Sciences, Macquarie University Hospital, Sydney, Australia
| | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Robyn Clay-Williams
- From the Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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12
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Tu SJ, Hanna-Rivero N, Elliott AD, Clarke N, Huang S, Pitman BM, Gallagher C, Linz D, Mahajan R, Lau DH, Sanders P, Wong CX. Associations of anemia with stroke, bleeding, and mortality in atrial fibrillation: A systematic review and meta-analysis. J Cardiovasc Electrophysiol 2021; 32:686-694. [PMID: 33476452 DOI: 10.1111/jce.14898] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/31/2020] [Accepted: 01/10/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anemia frequently coexists with atrial fibrillation (AF) and has been variably associated with worse outcomes. We performed a systematic review and meta-analysis to comprehensively assess the effect of anemia on mortality, stroke/systemic thromboembolism, and bleeding events in patients with AF. METHODS MEDLINE and Embase were searched from inception until May 2020. Studies examining associations of anemia with the above outcomes in AF patients were included, and maximally adjusted hazard ratios (HRs) meta-analysed. PROSPERO registration number CRD42020171113. RESULTS Twenty-eight studies involving 365 484 patients (41% female, mean age 74.7 years) were included. The average study follow-up ranged from 0.2 to 4.0 years, and the prevalence of anemia was 16%. Anemia was associated with a 78% increase in all-cause mortality (HR, 1.78; 95% confidence interval [CI], 1.44-2.20), 60% increase in cardiovascular mortality (HR, 1.60; 95% CI, 1.17-2.19), 134% increase in noncardiovascular mortality (HR, 2.34; 95% CI, 1.58-3.47) 15% increase in stroke/systemic thromboembolism (HR, 1.15; 95% CI, 1.01-1.31), 78% increase in major bleeding (HR, 1.78; 95% CI, 1.54-2.05), and 77% increase in gastrointestinal bleeding (HR, 1.77; 95% CI, 1.23-2.55). Sensitivity analyses including studies that reported odds ratios did not result in any material change. CONCLUSION Anemia is a frequently observed comorbidity in patients with AF, and is associated with an increased risk of all-cause, cardiovascular and noncardiovascular mortality, stroke/systemic thromboembolism, and major and gastrointestinal bleeding. Future studies are required to explore the causes of anemia in AF, and whether investigation and treatment may be clinically beneficial in affected individuals.
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Affiliation(s)
- Samuel J Tu
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Nicole Hanna-Rivero
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Adrian D Elliott
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Nicholas Clarke
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Sonia Huang
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Bradley M Pitman
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Celine Gallagher
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Dominik Linz
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Rajiv Mahajan
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Dennis H Lau
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Prashanthan Sanders
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Christopher X Wong
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
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13
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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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14
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Ticagrelor Monotherapy After Coronary Stenting. J Am Coll Cardiol 2019; 74:2235-2237. [DOI: 10.1016/j.jacc.2019.08.1037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 12/26/2022]
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15
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McManus DD, Kiefe C, Lessard D, Waring ME, Parish D, Awad HH, Marino F, Helm R, Sogade F, Goldberg R, Hayward R, Gurwitz J, Wang W, Mailhot T, Barton B, Saczynski J. Geriatric Conditions and Prescription of Vitamin K Antagonists vs. Direct Oral Anticoagulants Among Older Patients With Atrial Fibrillation: SAGE-AF. Front Cardiovasc Med 2019; 6:155. [PMID: 31737647 PMCID: PMC6831524 DOI: 10.3389/fcvm.2019.00155] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 10/11/2019] [Indexed: 12/18/2022] Open
Abstract
Background: Geriatric conditions are common among patients with atrial fibrillation (AF) and relate to complications of oral anticoagulation (OAC). Objective: To examine the prevalence of geriatric conditions among older patients with AF on OAC and relate type of OAC to geriatric conditions. Methods: Participants had a diagnosis of AF, were aged ≥65 years, CHA2DS2VASC ≥ 2, and had no OAC contraindications. Participants completed a 6-component geriatric assessment that included validated measures of frailty (CHS Frailty Scale), cognitive function (MoCA), social support (MOS), depressive symptoms (PHQ9), vision, and hearing. Type of OAC prescribed was documented in medical records. Results: 86% of participants were prescribed an OAC. These participants were on average aged 75.7 (SD: 7.1) years, 49% were women, two thirds were frail or pre-frail, and 44% received a DOAC. DOAC users were younger, had lower CHA2DS2VASC and HAS-BLED scores, and were less likely to be frail. In Massachusetts, pre-frailty was associated with a significantly lower odds of DOAC vs. VKA use (OR = 0.64, 95%CI 0.45, 0.91). Pre-frailty (OR = 0.33, 95%CI 0.18–0.59) and social isolation (OR = 0.38, 95%CI 0.14–0.99) were associated with lower odds of DOAC receipt in patients aged 75 years or older. Social isolation was associated with higher odds of DOAC use (OR = 2.13, 95%CI 1.05–4.29) in patients aged 65–74 years. Conclusions: Geriatric conditions were common and related to type of OAC prescribed, differentially by age group. Research is needed to evaluate whether a geriatric examination can be used clinically to better inform OAC decision-making in older patients with AF.
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Affiliation(s)
- David D McManus
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.,Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Catarina Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.,Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Molly E Waring
- Department of Allied Health Sciences, University of Connecticut, Mansfield, MA, United States
| | - David Parish
- Department of Community Medicine/Internal Medicine, Mercer University School of Medicine, Macon, GA, United States
| | - Hamza H Awad
- Department of Community Medicine/Internal Medicine, Mercer University School of Medicine, Macon, GA, United States
| | - Francesca Marino
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Robert Helm
- Department of Medicine, Boston University School of Medicine, Boston, MA, United States
| | - Felix Sogade
- Department of Medicine, Mercer University School of Medicine, Macon, GA, United States
| | - Robert Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Robert Hayward
- Department of Electrophysiology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, United States
| | - Jerry Gurwitz
- Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Weijia Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Tanya Mailhot
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, United States.,Montreal Heart Institute Research Center, Montreal, QC, Canada
| | - Bruce Barton
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Jane Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, United States
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16
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Saczynski JS, Sanghai SR, Kiefe CI, Lessard D, Marino F, Waring ME, Parish D, Helm R, Sogade F, Goldberg R, Gurwitz J, Wang W, Mailhot T, Bamgbade B, Barton B, McManus DD. Geriatric Elements and Oral Anticoagulant Prescribing in Older Atrial Fibrillation Patients: SAGE-AF. J Am Geriatr Soc 2019; 68:147-154. [PMID: 31574165 DOI: 10.1111/jgs.16178] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/23/2019] [Accepted: 08/23/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Oral anticoagulants are the cornerstone of stroke prevention in high-risk patients with atrial fibrillation (AF). Geriatric elements, such as cognitive impairment and frailty, commonly occur in these patients and are often cited as reasons for not prescribing oral anticoagulants. We sought to systematically assess geriatric impairments in patients with AF and determine whether they were associated with oral anticoagulant prescribing. DESIGN Cross-sectional analysis of baseline data from the ongoing Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF) prospective cohort study. SETTING Multicenter study with site locations in Massachusetts and Georgia that recruited participants from cardiology, electrophysiology, and primary care clinics from 2016 to 2018. PARTICIPANTS Participants with AF age 65 years or older, CHA2 DS2 -VASc (congestive heart failure; hypertension; aged ≥75 y [doubled]; diabetes mellitus; prior stroke, transient ischemic attack, or thromboembolism [doubled]; vascular disease; age 65-74; female sex) score of 2 or higher, and no oral anticoagulant contraindications (n = 1244). MEASUREMENTS A six-component geriatric assessment included validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Oral anticoagulant use was abstracted from the medical record. RESULTS A total of 1244 participants (mean age = 76 y; 49% female; 85% white) were enrolled; 42% were cognitively impaired, 14% frail, 53% pre-frail, 12% socially isolated, and 29% had depressive symptoms. Oral anticoagulants were prescribed to 86% of the cohort. Oral anticoagulant prescribing did not vary according to any of the geriatric elements (adjusted odds ratios [ORs] for oral anticoagulant prescribing and cognitive impairment: OR = .75; 95% confidence interval [CI] = .51-1.09; frail OR = .69; 95% CI = .35-1.36; social isolation OR = .90; 95% CI = .52-1.54; depression OR = .79; 95% CI = .49-1.27; visual impairment OR = .98; 95% CI = .65-1.48; and hearing impairment OR = 1.05; 95% CI = .71-1.54). CONCLUSION Geriatric impairments, particularly cognitive impairment and frailty, were common in our cohort, but treatment with oral anticoagulants did not differ by impairment status. These geriatric impairments are commonly cited as reasons for not prescribing oral anticoagulants, suggesting that prescribers may either be unaware or deliberately ignoring the presence of these factors in clinical settings. J Am Geriatr Soc 68:147-154, 2019.
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Affiliation(s)
- Jane S Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts
| | - Saket R Sanghai
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Darleen Lessard
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Francesca Marino
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Molly E Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, Connecticut
| | - David Parish
- Department of Community Medicine/ Internal Medicine, Mercer University School of Medicine, Macon, Georgia
| | - Robert Helm
- Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Felix Sogade
- Department of Medicine, Mercer University School of Medicine, Mercer, Georgia
| | - Robert Goldberg
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jerry Gurwitz
- Geriatric Medicine Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Weijia Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Tanya Mailhot
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts.,Montreal Heart Institute Research Center, Montreal, Quebec, Canada
| | - Benita Bamgbade
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts
| | - Bruce Barton
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David D McManus
- Cardiology Division, 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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17
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de Moraes ERFL, Cirenza C, Lopes RD, Carvalho AC, Guimaraes PO, Rodrigues AAE, de Paola AAV. Prevalence of atrial fibrillation and stroke risk assessment based on telemedicine screening tools in a primary healthcare setting. Eur J Intern Med 2019; 67:36-41. [PMID: 31320151 DOI: 10.1016/j.ejim.2019.04.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/01/2019] [Accepted: 04/19/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Worldwide atrial fibrillation (AF) prevalence varies between 0.1% and 4.0%, and has been increasing. Little is known about the prevalence of AF in Brazil. Our objective was to estimate the prevalence of AF in several regions of Brazil using recordings of long-distance electrocardiogram (ECG) transmission. METHODS Patients from 125 outpatient general practitioner units covered by the telemedicine service of the Federal University of São Paulo were included. Only one ECG was considered per patient. A scripted telephone interview was also performed. We analyzed the data to project the prevalence of AF in the Brazilian population and estimate it for the year 2025. The overall AF prevalence was calculated based on ECGs from primary care units where patients went for routine visits. RESULTS Based on 676,621 ECG exams from January 2009 through April 2016, the mean age (±SD) of patients was 51.38 (±19.05) years, with 57.5% being female. The 7-year period prevalence of AF was 2.2% (n = 14,968). The prevalence of AF countrywide was projected to be 1.5% in 2016 and 1.7% in 2025. In the subset of patients with AF who were interviewed (n = 301), 91 (30.2%) were not receiving any type of treatment for rate or rhythm control. Among patients interviewed, 189 (62.8%) were at high risk for stroke; only 28 (14.8%) were regular oral anticoagulant users. CONCLUSIONS Our study highlights the importance of screening for AF in the primary care setting in Brazil and identifies important gaps in the treatment of AF in this population.
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Affiliation(s)
| | | | - Renato D Lopes
- Federal University of São Paulo (UNIFESP), Brazil; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States of America.
| | | | - Patricia O Guimaraes
- Federal University of São Paulo (UNIFESP), Brazil; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States of America
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18
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Maura G, Billionnet C, Drouin J, Weill A, Neumann A, Pariente A. Oral anticoagulation therapy use in patients with atrial fibrillation after the introduction of non-vitamin K antagonist oral anticoagulants: findings from the French healthcare databases, 2011-2016. BMJ Open 2019; 9:e026645. [PMID: 31005934 PMCID: PMC6500377 DOI: 10.1136/bmjopen-2018-026645] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES To describe (i) the trend in oral anticoagulant (OAC) use following the introduction of non-vitamin K antagonist oral anticoagulant (NOAC) therapy for stroke prevention in atrial fibrillation (AF) patients and (ii) the current patterns of use of NOAC therapy in new users with AF in France. DESIGN (i) Repeated cross-sectional study and (ii) population-based cohort study. SETTING French national healthcare databases (50 million beneficiaries). PARTICIPANTS (i) Patients with identified AF in 2011, 2013 and 2016 and (ii) patients with AF initiating OAC therapy in 2015-2016. PRIMARY AND SECONDARY OUTCOME MEASURES: (i) Trend in OAC therapy use in patients with AF and (ii) patterns of use of NOAC therapy in new users with AF. RESULTS Between 2011 and 2016, use of OAC therapy moderately increased (+16%), while use of antiplatelet therapy decreased (-22%) among all patients with identified AF. In 2016, among the 1.1 million AF patients, 66% used OAC therapy and were more likely to be treated by vitamin K antagonist (VKA) than NOAC therapy, including patients at higher risk of stroke (63.5%), while 33% used antiplatelet therapy. Among 192 851 new users of OAC therapy in 2015-2016 with identified AF, NOAC therapy (66.3%) was initiated more frequently than VKA therapy, including in patients at higher risk of stroke (57.8%). Reduced doses were prescribed in 40% of NOAC new users. Several situations of inappropriate use at NOAC initiation were identified, including concomitant use of drugs increasing the risk of bleeding (one in three new users) and potential NOAC underdosing. CONCLUSIONS OAC therapy use in patients with AF remains suboptimal 4 years after the introduction of NOACs for stroke prevention in France and improvement in appropriate prescribing regarding NOAC initiation is needed. However, NOAC therapy is now the preferred drug class for initiation of OAC therapy in patients with AF, including in patients at higher risk of stroke.
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Affiliation(s)
- Géric Maura
- Department of Studies in Public Health, French National Health Insurance (Caisse Nationale de l’Assurance Maladie/Cnam), Paris, France
- University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology - UMR 1219, Bordeaux, France
| | - Cécile Billionnet
- Department of Studies in Public Health, French National Health Insurance (Caisse Nationale de l’Assurance Maladie/Cnam), Paris, France
| | - Jérôme Drouin
- Department of Studies in Public Health, French National Health Insurance (Caisse Nationale de l’Assurance Maladie/Cnam), Paris, France
| | - Alain Weill
- Department of Studies in Public Health, French National Health Insurance (Caisse Nationale de l’Assurance Maladie/Cnam), Paris, France
| | - Anke Neumann
- Department of Studies in Public Health, French National Health Insurance (Caisse Nationale de l’Assurance Maladie/Cnam), Paris, France
| | - Antoine Pariente
- University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology - UMR 1219, Bordeaux, France
- CHU Bordeaux, Bordeaux, France
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19
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Abstract
Stroke remains a leading cause of disability and death worldwide despite significant scientific and therapeutic advances. Therefore, there is a critical need to improve stroke prevention and treatment. In this review, we describe several examples that leverage nucleic acid therapeutics to improve stroke care through prevention, acute treatment, and recovery. Aptamer systems are under development to increase the safety and efficacy of antithrombotic and thrombolytic treatment, which represent the mainstay of medical stroke therapy. Antisense oligonucleotide therapy has shown some promise in treating stroke causes that are genetically determined and resistant to classic prevention approaches such as elevated lipoprotein (a) and cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). Targeting microRNAs may be attractive because they regulate factors involved in neuronal cell death and reperfusion-associated injury, as well as neurorestorative pathways. Lastly, microRNAs may aid reliable etiologic classification of stroke subtypes, which is important for effective secondary stroke prevention.
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Affiliation(s)
- Nils Henninger
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Ave, North, Worcester, MA, 01655, USA.
- Department of Psychiatry, University of Massachusetts Medical School, 55 Lake Ave, North, Worcester, MA, 01655, USA.
| | - Yunis Mayasi
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
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20
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Woo HG, Chung I, Gwak DS, Kim BK, Kim BJ, Bae HJ, Han MK. Recurrent ischemic stroke in atrial fibrillation with non-vitamin K antagonist oral anticoagulation. J Clin Neurosci 2019; 64:127-133. [PMID: 30929960 DOI: 10.1016/j.jocn.2019.03.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 02/25/2019] [Accepted: 03/21/2019] [Indexed: 11/29/2022]
Abstract
The etiology or rate of recurrent ischemic stroke according to dosing methods including drug adherence in patients taking non-vitamin K antagonist oral anticoagulants (NOACs) remain uncertain. We investigated the association between dosing methods including drug adherence achieved with NOACs and the presence of major vessel occlusion (MVO) in patients with ischemic stroke with non-valvular atrial fibrillation (NVAF). From July 2013 through December 2016, 120 patients with recurrent ischemic stroke with NVAF on NOACs were retrospectively analyzed. Patients taking non-standard doses of NOACs were divided into the missed dose group that discontinued NOACs for ≥48 h prior to arrival, and the under-dose group that used lower doses of NOACs. A logistic regression analysis was performed to determine the association between MVO and dosing methods including drug adherence. There were 60 (50.0%), 39 (32.5%), and 21 (17.5%) patients, respectively, in the standard dose, under-dose, and missed dose groups. Twelve patients (20.0%) in the standard dose group, 15 (38.5%) in the under-dose group, and 13 (61.9%) in the missed dose group had MVO. MVO was significantly higher in the missed dose group than in the standard dose and under-dose groups (P = 0.002). In patients with ischemic stroke with NVAF, who are on NOACs, anticoagulation caused by missed or lowered doses of NOACs was significantly associated with MVO in patients with recurrent cardioembolic stroke.
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Affiliation(s)
- Ho Geol Woo
- Department of Neurology, Ewha Womans University, College of Medicine, Seoul, Republic of Korea
| | - Inyoung Chung
- Department of Neurology, Seoul National University Bundang Hospital, Republic of Korea
| | - Dong Seok Gwak
- Department of Neurology, Seoul National University Bundang Hospital, Republic of Korea
| | - Baik Kyun Kim
- Department of Critical Care Medicine, Seoul National University Bundang Hospital, Republic of Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea.
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21
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Ding WY, Gupta D, Lip GYH. Physician Estimation of Thrombotic and Bleeding Risks in Atrial Fibrillation: Let's Talk About Sex. Can J Cardiol 2019; 35:145-146. [PMID: 30760418 DOI: 10.1016/j.cjca.2018.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 12/07/2018] [Indexed: 11/19/2022] Open
Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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22
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Association Between Patient and Physician Sex and Physician-Estimated Stroke and Bleeding Risks in Atrial Fibrillation. Can J Cardiol 2019; 35:160-168. [DOI: 10.1016/j.cjca.2018.11.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 11/27/2018] [Accepted: 11/28/2018] [Indexed: 11/19/2022] Open
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23
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Wang KL, Lopes RD, Patel MR, Büller HR, Tan DSY, Chiang CE, Giugliano RP. Efficacy and safety of reduced-dose non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: a meta-analysis of randomized controlled trials. Eur Heart J 2018; 40:1492-1500. [DOI: 10.1093/eurheartj/ehy802] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 08/14/2018] [Accepted: 11/26/2018] [Indexed: 12/12/2022] Open
Affiliation(s)
- Kang-Ling Wang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt Street, Durham, NC 27710, USA
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt Street, Durham, NC 27710, USA
| | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Doreen Su-Yin Tan
- Department of Pharmacy, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Robert P Giugliano
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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24
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Kapoor A, Amroze A, Golden J, Crawford S, O'Day K, Elhag R, Nagy A, Lubitz SA, Saczynski JS, Mathew J, McManus DD. SUPPORT-AF: Piloting a Multi-Faceted, Electronic Medical Record-Based Intervention to Improve Prescription of Anticoagulation. J Am Heart Assoc 2018; 7:e009946. [PMID: 30371161 PMCID: PMC6201433 DOI: 10.1161/jaha.118.009946] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 07/24/2018] [Indexed: 01/24/2023]
Abstract
Background Only 50% of eligible atrial fibrillation ( AF ) patients receive anticoagulation ( AC ). Feasibility and effectiveness of electronic medical record (EMR)-based interventions to profile and raise provider AC percentage is poorly understood. The SUPPORT-AF (Supporting Use of AC Through Provider Profiling of Oral AC Therapy for AF) study aims to improve rates of adherence to AC guidelines by developing and delivering supportive tools based on the EMR to providers treating patients with AF. Methods and Results We emailed cardiologists and community-based primary care providers affiliated with our institution reports of their AC percentage relative to peers. We also sent an electronic medical record-based message to these providers the day before an appointment with an atrial fibrillation patient who was eligible but not receiving AC . The electronic medical record message asked the provider to discuss AC with the patient if he or she deemed it appropriate. To assess feasibility, we tracked provider review of our correspondence. We also tracked the change in AC for intervention providers relative to alternate primary care providers not receiving our intervention. We identified 3786, 1054, and 566 patients cared for by 49 cardiology providers, 90 community-based primary care providers, and 88 control providers, respectively. At baseline, the percentage of AC was 71.3%, 63.5%, and 58.3% for these 3 respective groups. Intervention providers reviewed our e-mails and electronic medical record messages 45% and 96% of the time, respectively. For providers responding, patient refusal was the most common reason for patients not being on AC (21%) followed by high bleeding risk (19%). At follow-up 10 weeks later, change in AC was no different for either cardiology or community-based primary care providers relative to controls (0.2% lower and 0.01% higher, respectively). Conclusions Our intervention profiling AC was feasible, but not sufficient to increase AC in our population.
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Affiliation(s)
- Alok Kapoor
- University of Massachusetts Memorial Health CareWorcesterMA
- University of Massachusetts Medical SchoolWorcesterMA
- Meyers Primary Care Institutea joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthWorcesterMA
| | - Azraa Amroze
- Meyers Primary Care Institutea joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthWorcesterMA
| | | | | | - Kevin O'Day
- University of Massachusetts Memorial Health CareWorcesterMA
| | - Rasha Elhag
- University of Massachusetts Memorial Health CareWorcesterMA
| | - Ahmed Nagy
- University of Massachusetts Memorial Health CareWorcesterMA
| | - Steve A. Lubitz
- Massachusetts General HospitalBostonMA
- Harvard Medical SchoolBostonMA
| | - Jane S. Saczynski
- University of Massachusetts Medical SchoolWorcesterMA
- Meyers Primary Care Institutea joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthWorcesterMA
- Northeastern UniversityBostonMA
| | - Jomol Mathew
- University of Massachusetts Medical SchoolWorcesterMA
| | - David D. McManus
- University of Massachusetts Memorial Health CareWorcesterMA
- University of Massachusetts Medical SchoolWorcesterMA
- Meyers Primary Care Institutea joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthWorcesterMA
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25
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Lip GYH, Coca A, Kahan T, Boriani G, Manolis AS, Olsen MH, Oto A, Potpara TS, Steffel J, Marín F, de Oliveira Figueiredo MJ, de Simone G, Tzou WS, Chiang CE, Williams B, Dan GA, Gorenek B, Fauchier L, Savelieva I, Hatala R, van Gelder I, Brguljan-Hitij J, Erdine S, Lovic D, Kim YH, Salinas-Arce J, Field M. Hypertension and cardiac arrhythmias: a consensus document from the European Heart Rhythm Association (EHRA) and ESC Council on Hypertension, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE). Europace 2018; 19:891-911. [PMID: 28881872 DOI: 10.1093/europace/eux091] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 03/11/2017] [Indexed: 12/23/2022] Open
Abstract
Hypertension is a common cardiovascular risk factor leading to heart failure (HF), coronary artery disease, stroke, peripheral artery disease and chronic renal insufficiency. Hypertensive heart disease can manifest as many cardiac arrhythmias, most commonly being atrial fibrillation (AF). Both supraventricular and ventricular arrhythmias may occur in hypertensive patients, especially in those with left ventricular hypertrophy (LVH) or HF. Also, some of the antihypertensive drugs commonly used to reduce blood pressure, such as thiazide diuretics, may result in electrolyte abnormalities (e.g. hypokalaemia, hypomagnesemia), further contributing to arrhythmias, whereas effective control of blood pressure may prevent the development of the arrhythmias such as AF. In recognizing this close relationship between hypertension and arrhythmias, the European Heart Rhythm Association (EHRA) and the European Society of Cardiology (ESC) Council on Hypertension convened a Task Force, with representation from the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE), with the remit to comprehensively review the available evidence to publish a joint consensus document on hypertension and cardiac arrhythmias, and to provide up-to-date consensus recommendations for use in clinical practice. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and the patient in light of all of the circumstances presented by that patient.
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Affiliation(s)
- Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Antonio Coca
- Hypertension and Vascular Risk Unit, Department of Internal Medicine, Hospital Clínic (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Thomas Kahan
- Karolinska Institutet Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden.,Department of Cardiology, Danderyd University Hospital Corp, Stockholm, Sweden
| | - Giuseppe Boriani
- Cardiology Department, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Antonis S Manolis
- Third Department of Cardiology, Athens University School of Medicine, Athens, Greece
| | - Michael Hecht Olsen
- Department of Internal Medicine, Holbaek Hospital and Centre for Individualized Medicine in Arterial Diseases (CIMA), Odense University Hospital, University of Southern Denmark, Denmark
| | - Ali Oto
- Department of Cardiology, Memorial Ankara Hospital, Heart and Health Foundation of Turkey, Ankara, Turkey
| | - Tatjana S Potpara
- School of Medicine, Cardiology Clinic, Clinical Centre of Serbia, Belgrade University, Belgrade, Serbia
| | - Jan Steffel
- Electrophysiology and Cardiac Devices, Department of Cardiology, University Heart Center Zurich; Zurich, Switzerland
| | - Francisco Marín
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, Murcia, Spain
| | | | - Giovanni de Simone
- Department of Translational Medical Sciences, Federico II University Hospital, via S. Pansini 5, bld # 1, Napoli 80131, Italy
| | - Wendy S Tzou
- Cardiac Electrophysiology, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Chern-En Chiang
- Division of Cardiology, Taipei Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan
| | - Bryan Williams
- Institute of Cardiovascular Science, University College London, UK
| | | | - Gheorghe-Andrei Dan
- Colentina University Hospital, Medicine Faculty, University of Medicine "Carol Davila"-Bucharest Romania
| | | | | | | | - Robert Hatala
- National Cardiovascular Institute, NUSCH, Bratislava, Slovak Republic
| | - Isabelle van Gelder
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jana Brguljan-Hitij
- University Medical Centre, Hypertension Department, Hospital Dr. Peter Drzaja, Ljubljana, Slovenia
| | - Serap Erdine
- Istanbul University Cerrahpasa Medical School, Head of Hypertension Department, Istanbul, Turkey
| | - Dragan Lovic
- Clinic for internal disease Intermedica, Cardiology department-Hypertension centere, Serbia
| | | | | | - Michael Field
- University of Wisconsin, Clinical Science Center, Madison, USA
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26
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Diferencias en el manejo de los pacientes con fibrilación auricular según inicie el tratamiento con anticoagulantes orales de acción directa el médico de atención primaria o el especialista. Estudios SILVER-AP y BRONCE-AP. Semergen 2018; 44:323-334. [DOI: 10.1016/j.semerg.2017.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 08/23/2017] [Accepted: 09/12/2017] [Indexed: 12/31/2022]
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27
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Hovaguimian F, Köppel S, Spahn DR. Safety of Anticoagulation Interruption in Patients Undergoing Surgery or Invasive Procedures: A Systematic Review and Meta-analyses of Randomized Controlled Trials and Non-randomized Studies. World J Surg 2018; 41:2444-2456. [PMID: 28608011 DOI: 10.1007/s00268-017-4072-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The safety of anticoagulation interruption in patients requiring surgical or invasive procedures remains unclear. We thus performed a systematic review and meta-analyses of randomized controlled trials (RCTs) and non-randomized studies (NRS). METHODS MEDLINE, Embase and Central databases were searched to March 2017 without date or language restrictions. We considered RCTs and NRS comparing anticoagulation interruption with any anticoagulation (continuation or heparin bridging) in adult surgical patients taking oral anticoagulation. Data were independently extracted. The quality of the evidence was assessed following recommendations from the Cochrane collaboration (GRADE approach). Risk ratios were calculated for 30-day events: thromboembolic (TE) events, major bleeding and mortality. Additional analyses explored the effects of different anticoagulation strategies. RESULTS Twelve reports were included: 4 RCTs (2190 participants) and 8 NRS (18993 participants). Trials included mostly participants with atrial fibrillation. Interrupting anticoagulation did not seem to increase TE events (RR 0.65, 95% CI [0.33, 1.30]-4 studies, 2190 participants) and resulted in less bleeding (RR 0.41, 95% CI [0.22, 0.78]-3 studies, 2126 participants) compared to anticoagulation continuation or heparin bridging. The GRADE assessment was moderate. Similar results were found in non-randomized studies, but the quality of the evidence was low. Possible strategy-specific effects were identified: forgoing heparin bridging seemed beneficial, but these effects were less clear with other strategies. CONCLUSION Interrupting anticoagulation in patients requiring invasive procedures did not seem to result in harm and protected against major bleeding. Uncertainty remains regarding the safety of this strategy in indications other than atrial fibrillation and in moderate- to high-risk surgery. STUDY REGISTRATION http://www.en.anaesthesie.usz.ch/research/Pages/Study-protocols.aspx.
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Affiliation(s)
- Frédérique Hovaguimian
- Institute of Anesthesiology, University of Zurich and University Hospital of Zurich, 8091, Zurich, Switzerland.
| | - Sabrina Köppel
- Institute of Anesthesiology, University of Zurich and University Hospital of Zurich, 8091, Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anesthesiology, University of Zurich and University Hospital of Zurich, 8091, Zurich, Switzerland
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Steinberg BA, Shrader P, Pieper K, Thomas L, Allen LA, Ansell J, Chan PS, Ezekowitz MD, Fonarow GC, Freeman JV, Gersh BJ, Kowey PR, Mahaffey KW, Naccarelli GV, Reiffel JA, Singer DE, Peterson ED, Piccini JP. Frequency and Outcomes of Reduced Dose Non-Vitamin K Antagonist Anticoagulants: Results From ORBIT-AF II (The Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II). J Am Heart Assoc 2018; 7:JAHA.117.007633. [PMID: 29453305 PMCID: PMC5850192 DOI: 10.1161/jaha.117.007633] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Non–vitamin K antagonist oral anticoagulants (NOACs) are indicated for stroke prevention in atrial fibrillation (AF) but require lower doses in certain patients. We sought to describe the frequency, appropriateness (according to Food and Drug Administration labeling), and outcomes of patients prescribed reduced doses of NOACs in community practice. Methods and Results We analyzed data from the ORBIT‐AF II (The Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II) registry, a prospective, national, observational registry of AF patients. Among 7925 AF patients receiving NOACs, we assessed patterns of use of reduced NOAC doses and associated cardiovascular and bleeding outcomes at median follow‐up of 1 year. Overall, 6636 patients (84%) received a NOAC at standard dose, which was consistent with US Food and Drug Administration labeling in 6376 (96%). Reduced NOAC dose was prescribed to 1289 (16% overall), which was consistent with Food and Drug Administration labeling in only 555 patients (43%). Compared with those whose NOAC dose was appropriately reduced, patients receiving inappropriate dose reductions were younger (median age 79 versus 84, P<0.0001) and had lower ORBIT bleeding risk scores (26% ≥4 versus 45%, P<0.0001). Compared with those appropriately receiving standard dosing, patients receiving inappropriately reduced‐dose NOACs had higher unadjusted rates of thromboembolic events (2.11 versus 1.35 events per 100 patient years, hazard ratio 1.56, 95% confidence interval 0.92‐2.67) and death (6.77 versus 2.60, hazard ratio 2.61, 95% confidence interval 1.86‐3.67). After adjustment, outcomes were not significantly different but tended to favor patients dosed appropriately. Conclusions The majority of dose reductions of NOACs in AF are inconsistent with US Food and Drug Administration recommendations. There appear to be opportunities to improve current NOAC dosing in community practice. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01701817.
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Affiliation(s)
- Benjamin A Steinberg
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT
| | | | | | | | - Larry A Allen
- Division of Cardiology and the Colorado Cardiovascular Outcomes Research Consortium, University of Colorado School of Medicine, Aurora, CO
| | - Jack Ansell
- Department of Medicine, Hofstra Northwell School of Medicine, Hempstead, NY
| | - Paul S Chan
- Saint Luke's Mid America Heart Institute, Kansas City, MO.,Department of Medicine, University of Missouri-Kansas City, Kansas City, MO
| | | | | | | | | | - Peter R Kowey
- Lankenau Institute for Medical Research, Wynnewood, PA
| | | | | | - James A Reiffel
- Columbia University College of Physicians and Surgeons, New York, NY
| | - Daniel E Singer
- Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - Eric D Peterson
- Duke Clinical Research Institute, Durham, NC.,Duke University Medical Center, Durham, NC
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Durham, NC.,Duke University Medical Center, Durham, NC
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Kuroda J. Detrimental Effects of Insufficient Warfarin Therapy ― A Warning Against Imprudent Use of Warfarin for Atrial Fibrillation Patients ―. Circ J 2018; 82:1258-1259. [DOI: 10.1253/circj.cj-18-0292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Junya Kuroda
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University
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Scott-Herridge JA, Seifer CM, Steigerwald R, Drobot G, McIntyre WF. A multi-hospital analysis of predictors of oral anticoagulation prescriptions for patients with actionable atrial fibrillation who attend the emergency department. ACTA ACUST UNITED AC 2017; 18:71-78. [DOI: 10.1080/17482941.2017.1406954] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | - Colette M Seifer
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ron Steigerwald
- Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Glen Drobot
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - William F McIntyre
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Medicine and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
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de la Figuera M, Cinza S, Marín N, Egocheaga I, Prieto MA. [Clinical characteristics of patients with atrial fibrillation treated with direct oral anticoagulants attended in primary care setting. The SILVER-AP study]. Aten Primaria 2017; 50:359-367. [PMID: 28764897 PMCID: PMC6839200 DOI: 10.1016/j.aprim.2017.05.009] [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] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 05/30/2017] [Indexed: 01/06/2023] Open
Abstract
Objetivo Describir las características clínicas y el manejo de pacientes con fibrilación auricular no valvular (FANV) tratados con anticoagulantes orales de acción directa (ACOD). Diseño Estudio observacional, transversal y multicéntrico. Emplazamiento Comunidades autónomas en las que el médico de atención primaria puede prescribir ACOD (n = 9). Participantes Un total de 790 pacientes con riesgo de ictus o embolia sistémica que estuviesen en tratamiento crónico con anticoagulantes, que hubiesen modificado su pauta terapéutica, y que actualmente estuviesen en tratamiento con un ACOD durante al menos 3 meses. Mediciones principales Recogida de datos sociodemográficos y de manejo clínico. Resultados La edad media de los sujetos fue de 78,6 ± 8,4 años; un 50,5% eran varones; CHADS2: 2,6 ± 1,2; CHA2DS2-VASc: 4,3 ± 1,6; HAS-BLED: 2,3 ± 1,0. La duración media del tratamiento con ACOD fue de 15,8 ± 12,5 meses. El ACOD más frecuentemente prescrito fue rivaroxabán (57,8%), seguido de dabigatrán (23,7%) y apixabán (18,5%). De los pacientes que tomaban rivaroxabán, el 70,2% recibieron la dosis de 20 mg/día. En el caso de dabigatrán, el 41,7% tomaban la dosis de 150 mg/12 h, y con respecto a apixabán, el 56,2% tomaban la dosis de 5 mg/12 h. La satisfacción con el tratamiento con ACOD (cuestionario ACTS: 52,0 ± 7,2 puntos en la escala Carga y 12,1 ± 2,2 puntos en la escala Beneficio) y el cumplimiento (97,8% de los pacientes fueron cumplidores) fueron elevados. Conclusiones Los pacientes en tratamiento con ACOD en España tienen un elevado riesgo tromboembólico. Una proporción significativa de sujetos reciben una dosis menor de ACOD de la que les correspondería por sus características clínicas. La satisfacción y la adherencia son elevadas.
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Affiliation(s)
| | - Sergio Cinza
- Centro de Saúde (CS) Porto do Son, Santiago de Compostela, España
| | - Nuria Marín
- Bayer Hispania S.L., General Medicine CV, Barcelona, España.
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Appropriate dosing of nonvitamin K antagonist oral anticoagulants for stroke prevention in atrial fibrillation. Trends Cardiovasc Med 2017; 27:567-572. [PMID: 28750830 DOI: 10.1016/j.tcm.2017.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 05/31/2017] [Accepted: 06/10/2017] [Indexed: 12/20/2022]
Abstract
The development of nonvitamin K antagonist oral anticoagulants (NOACs) has been a major advance in therapy for patients requiring oral anticoagulation, particularly for long-term indications such as stroke prevention in atrial fibrillation (AF). The NOACs are generally easier to dose and manage due to less heterogeneity of effect across individuals and fewer drug and food interactions, compared with warfarin. However, the treatment effect of NOACs may vary based on important patient characteristics, particularly renal function. Therefore, the package inserts for these drugs have dosing recommendations for patients with impaired kidney function, which are frequently but not always based on evidence from large-scale, randomized, clinical trials. Furthermore, there is evidence that NOAC dosing inconsistent with the regulatory labeling may be associated with adverse clinical outcomes. This review discusses the evidence supporting the current NOAC dosing, current dosing practices, associated outcomes, and gaps in knowledge regarding use of NOACs in patients with AF.
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Hess PL, Kim S, Fonarow GC, Thomas L, Singer DE, Freeman JV, Gersh BJ, Ansell J, Kowey PR, Mahaffey KW, Chan PS, Steinberg BA, Peterson ED, Piccini JP. Absence of Oral Anticoagulation and Subsequent Outcomes Among Outpatients with Atrial Fibrillation. Am J Med 2017; 130:449-456. [PMID: 27888051 DOI: 10.1016/j.amjmed.2016.11.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 10/30/2016] [Accepted: 11/01/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Prior studies have shown a treatment gap in oral anticoagulation (OAC) use among patients with atrial fibrillation yet have incompletely characterized factors associated with failure to treat and subsequent outcomes in contemporary practice. METHODS Using data collected between June 2010 and August 2011 from 174 ambulatory care sites in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation, we identified factors associated with absence of OAC via stratified logistic regression. Using weighted Cox regression, we assessed the association between OAC non-use and subsequent outcomes over 2.5 years. RESULTS Among 9553 patients, 2202 (23.0%) were not on OAC. Among OAC nonrecipients, 1846 (83.8%) had a CHA2DS2-VASc score ≥2. Factors independently associated with OAC non-use included atrial fibrillation type (paroxysmal odds ratio [OR] 0.73, 95% confidence interval [CI] 0.54-0.99; persistent OR 0.14, 95% CI 0.10-0.21; permanent OR 0.35, 95% CI 0.25-0.49; reference = new-onset), left atrial diameter enlargement (mild OR 0.80, 95% CI 0.66-0.97; moderate 0.58, 95% CI 0.47-0.73; severe 0.53, 95% CI 0.42-0.68; reference = normal diameter), and age >80 years (OR 1.04, 95% CI 1.02-1.08). Untreated patients had a higher risk of death (adjusted hazard ratio [HR] 1.22, 95% CI 1.05-1.41), a lower bleeding risk (adjusted HR 0.35, 95% CI 0.15-0.81), and a nonsignificant trend toward higher risk of stroke/non-central nervous system embolism/transient ischemic attack than those treated (adjusted HR 1.18, 95% CI 0.91-1.54). CONCLUSIONS A majority of atrial fibrillation patients not treated with an OAC in current community practice meet guideline indications for treatment. Atrial fibrillation burden, chronicity, and comorbidity are associated with nontreatment. Untreated patients are at increased risk for adverse outcomes.
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Affiliation(s)
- Paul L Hess
- Cardiology Section, VA Eastern Colorado and Health Care System, Denver; Department of Medicine, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora.
| | - Sunghee Kim
- Duke Clinical Research Institute, Durham, NC
| | - Gregg C Fonarow
- Department of Medicine, University of California, Los Angeles
| | | | - Daniel E Singer
- Harvard Medical School and Massachusetts General Hospital, Boston
| | - James V Freeman
- Department of Medicine, Yale University School of Medicine, New Haven, Conn
| | - Bernard J Gersh
- Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minn
| | - Jack Ansell
- Department of Medicine, New York School of Medicine, Lenox Hill Hospital
| | - Peter R Kowey
- Lankenau Institute for Medical Research, Wynnewood, Penn
| | - Kenneth W Mahaffey
- Department of Medicine, Stanford University School of Medicine, Palo Alto, Calif
| | - Paul S Chan
- Department of Cardiovascular Research, St. Luke's Mid America Heart Institute, Kansas City, Mo; Department of Medicine, University of Missouri-Kansas City
| | - Benjamin A Steinberg
- Duke Clinical Research Institute, Durham, NC; University of Utah, Salt Lake City
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Barón-Esquivias G, Marín F, Sanmartín Fernandez M. Rivaroxaban in patients with atrial fibrillation: from ROCKET AF to everyday practice. Expert Rev Cardiovasc Ther 2017; 15:403-413. [DOI: 10.1080/14779072.2017.1309293] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Westenbrink BD, Alings M, Granger CB, Alexander JH, Lopes RD, Hylek EM, Thomas L, Wojdyla DM, Hanna M, Keltai M, Steg PG, De Caterina R, Wallentin L, van Gilst WH. Anemia is associated with bleeding and mortality, but not stroke, in patients with atrial fibrillation: Insights from the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial. Am Heart J 2017; 185:140-149. [PMID: 28267467 DOI: 10.1016/j.ahj.2016.12.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 12/16/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients with atrial fibrillation (AF) are prone to cardiovascular events and anticoagulation-related bleeding complications. We hypothesized that patients with anemia are at increased risk for these outcomes. METHODS We performed a post hoc analysis of the ARISTOTLE trial, which included >18,000 patients with AF randomized to warfarin (target international normalized ratio, 2.0-3.0) or apixaban 5 mg twice daily. Multivariable Cox regression analysis was used to determine if anemia (defined as hemoglobin <13.0 in men and <12.0 g/dL in women) was associated with future stroke, major bleeding, or mortality. RESULTS Anemia was present at baseline in 12.6% of the ARISTOTLE population. Patients with anemia were older, had higher mean CHADS2 and HAS-BLED scores, and were more likely to have experienced previous bleeding events. Anemia was associated with major bleeding (adjusted hazard ratio [HR], 1.92; 95% CI, 1.62-2.28; P<.0001) and all-cause mortality (adjusted HR, 1.68; 95% CI, 1.46-1.93; P<.0001) but not stroke or systemic embolism (adjusted HR, 0.92; 95% CI, 0.70-1.21). The benefits of apixaban compared with warfarin on the rates of stroke, mortality, and bleeding events were consistent in patients with and without anemia. CONCLUSIONS Chronic anemia is associated with a higher incidence of bleeding complications and mortality, but not of stroke, in anticoagulated patients with AF. Apixaban is an attractive anticoagulant for stroke prevention in patients with AF with or without anemia.
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Affiliation(s)
- B Daan Westenbrink
- University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
| | - Marco Alings
- Working Group on Cardiovascular Research, Utrecht, Netherlands
| | | | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Laine Thomas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Matyas Keltai
- Hungarian Institute of Cardiology, Budapest, Hungary
| | - P Gabriel Steg
- DHU FIRE, Université Paris-Diderot, Hôpital Bichat, AP-HP, INSERM, Paris, France
| | | | - Lars Wallentin
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Wiek H van Gilst
- University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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Cerasuolo JO, Montero-Odasso M, Ibañez A, Doocy S, Lip GYH, Sposato LA. Decision-making interventions to stop the global atrial fibrillation-related stroke tsunami. Int J Stroke 2017; 12:222-228. [DOI: 10.1177/1747493016687579] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Atrial fibrillation affects 33.5 million people worldwide and its prevalence is expected to double by 2050 because of the aging population. Atrial fibrillation confers a 5-fold higher risk of ischemic stroke compared to sinus rhythm. We present our view of the role of shared medical decision-making to combat global underutilization of oral anticoagulation for stroke prevention in atrial fibrillation patients. Oral anticoagulation underuse is widespread as it is present within atrial fibrillation patients of all risk strata and in countries across all income levels. Reasons for oral anticoagulation underuse include but are probably not limited to poor risk stratification, over-interpretation of contraindications, and discordance between physician prescription preferences and actual administration. By comparing a catastrophic event to the consequences of atrial fibrillation related strokes, it may help physicians and patients understand the negative outcomes associated with oral anticoagulation under-utilization and the magnitude to which oral anticoagulations neutralize atrial fibrillation burden.
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Affiliation(s)
- Joshua O Cerasuolo
- Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Manuel Montero-Odasso
- Gait and Brain Lab, Parkwood Hospital and Lawson Health Research Institute, London, ON, Canada
- Department of Medicine, Division of Geriatric Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Department of Epidemiology & Biostatistics, Schulich Interfaculty Program in Public Health, Western University, London, ON, Canada
| | - Agustin Ibañez
- Institute of Cognitive and Translational Neuroscience (INCyT), INECO Foundation, Favaloro University, National Scientific and Technical Research Council, Buenos Aires, Argentina
- Center for Social and Cognitive Neuroscience (CSCN), School of Psychology, Universidad Adolfo Ibanez, Santiago de Chile, Chile
- Centre of Excellence in Cognition and its Disorders, Australian Research Council (ARC), New South Wales, Australia
- Universidad Autónoma del Caribe, Barranquilla, Colombia
| | - Shannon Doocy
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Gregory YH Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Luciano A Sposato
- Department of Clinical Neurological Sciences, Department of Anatomy and Cell Biology, London Health Sciences Centre, Western University, London, ON, Canada
- London Stroke, Dementia & Heart Disease Laboratory, Western University, London, ON, Canada
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Mazurek M, Huisman MV, Lip GYH. Registries in Atrial Fibrillation: From Trials to Real-Life Clinical Practice. Am J Med 2017; 130:135-145. [PMID: 27746290 DOI: 10.1016/j.amjmed.2016.09.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/08/2016] [Accepted: 09/09/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Recent improvements in atrial fibrillation diagnosis and management have prompted the initiation of various registries, predominantly to assess adherence to new guidelines but also to address the pending questions of safety and effectiveness of newly introduced management options in "real-world" clinical practice settings. In this review, we appraise antithrombotic treatment patterns for stroke prevention in atrial fibrillation registries. METHODS We searched PubMed, Science Direct, and the Cochrane databases for registries focusing on stroke thromboprophylaxis in atrial fibrillation. RESULTS Registry data show that over the last decade, the proportion of patients receiving oral anticoagulation has increased (from ∼67% to >80%), whereas the proportion of those treated with aspirin only or untreated has diminished. Vitamin K antagonists are being replaced gradually by non-vitamin K antagonist oral anticoagulants as the more prevalent option. Regional and country differences in anticoagulation are evident, with its highest uptake in Europe (90.2%) and lowest in Asia (57.4%). Moreover, oral anticoagulation is given to approximately 50% of patients with no stroke risk factors, whereas more than one third of high-risk subjects are not anticoagulated but often prescribed antiplatelet therapy alone or untreated. Guideline-nonadherent thromboprophylaxis results in an increase in all-cause mortality and thromboembolism. CONCLUSIONS Registry data show that despite an increase in anticoagulation rates over the last decade, management gaps in stroke prevention are still evident with approximately one third of patients not treated in line with the guidelines. Mortality rates of atrial fibrillation patients remain relatively high, mostly because of the comorbid disease.
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Affiliation(s)
- Michał Mazurek
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, United Kingdom; Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Menno V Huisman
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, The Netherlands
| | - Gregory Y H Lip
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark.
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Tsao HM, Hu WC, Tsai PH, Lee CL, Wang HH, Chang SL, Chao TF, Chen SA. Functional Remodeling of Both Atria is Associated with Occurrence of Stroke in Patients with Paroxysmal and Persistent Atrial Fibrillation. ACTA CARDIOLOGICA SINICA 2017; 33:50-57. [PMID: 28115807 DOI: 10.6515/acs20160411a] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND It is critical to recognize high risk patients who are prone to develop stroke in the management of atrial fibrillation (AF). The purpose of this study was to identify the determinants of AF related stroke by assessing the anatomical and functional remodeling of cardiac chambers. METHODS We compared the cardiac structure and function of 28 consecutive patients with paroxysmal and persistent AF-related stroke with 69 patients with AF and 21 controls without stroke using contrast-enhanced 64-slice multi-detector computed tomography during sinus rhythm. RESULTS The volume of left atrium (LA), LA appendage (LAA) and right atrium (RA) were significantly increased across the groups with sinus rhythm (SR), AF and AF-related stroke (p < 0.001 for each, respectively). The emptying fraction and booster-pump function of LA, LAA and RA were decreased across the groups (p < 0.001 for each). In addition, the left ventricular mass index was increased in AF related stroke (p = 0.003). Using multivariate analysis, increased age (p = 0.003), reduced booster-pump function of LA (p = 0.01), LAA (p < 0.001) and RA (p < 0.001) were shown to be independently associated with the occurrence of stroke. CONCLUSIONS The dilatation and contractile dysfunction of both atria are related to the development of stroke in patients with paroxysmal and persistent AF. Our results suggested that the use of substrate-based assessment may help improve risk stratification of stroke in patients with AF.
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Affiliation(s)
- Hsuan-Ming Tsao
- Division of Cardiology, National Yang Ming University Hospital, Yi-Lan
| | - Wei-Chih Hu
- Department of Biomedical Engineering, Chung-Yuan Christian University, Chungli
| | | | | | - Hsueh-Han Wang
- Department of Radiology, National Yang Ming University Hospital
| | - Shih-Lin Chang
- Cardiovascular Research Center, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Tze-Fan Chao
- Cardiovascular Research Center, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Shih-Ann Chen
- Cardiovascular Research Center, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
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Frain B, Castelino R, Bereznicki LR. The Utilization of Antithrombotic Therapy in Older Patients in Aged Care Facilities With Atrial Fibrillation. Clin Appl Thromb Hemost 2017; 24:519-524. [PMID: 28068791 DOI: 10.1177/1076029616686421] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Oral anticoagulants are essential drugs for the prevention of thromboembolic events in patients with atrial fibrillation (AF). Anticoagulants are, however, commonly withheld in older people due to the risk and fear of hemorrhage. Although the underutilization of anticoagulants in patients with AF has been demonstrated internationally, few studies have been conducted among aged care residents. The aim of this study was to determine the utilization of anticoagulants among people with AF residing in aged care facilities. We performed a non-experimental, retrospective analysis designed to evaluate antithrombotic usage in patients with AF in Australia residing in aged care facilities, using data collected by pharmacists while performing Residential Medication Management Reviews (RMMRs). The utilization of antithrombotic therapy and the appropriateness of therapy were determined based on the CHADS2, CHA2DS2-VASc, and HAS-BLED risk stratification schemes in consideration of documented contraindications to treatment. Predictors of anticoagulant use were determined using multivariate logistic regression. A total of 1952 RMMR patients with AF were identified. Only 35.6% of eligible patients (CHADS2 score ≥2 and no contraindications to anticoagulants) received an anticoagulant. As age increased, the likelihood of receiving an anticoagulant decreased and the likelihood of receiving an antiplatelet or no therapy increased. In patients at high risk of stroke (CHADS score ≥2), utilization of anticoagulants dropped by 19.7% when the HAS-BLED score increased from 2 to 3, suggesting that physicians placed a heavier weighting on bleeding risk rather than stroke risk. Prescribing of anticoagulants was influenced to a greater extent by bleeding risk than it was by the risk of stroke. Further research investigating whether the growing availability of direct oral anticoagulants influences practice in this patient population is needed.
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Affiliation(s)
- Bridget Frain
- 1 Unit for Medication Outcomes Research and Education, Division of Pharmacy, School of Medicine, Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
| | - Ronald Castelino
- 1 Unit for Medication Outcomes Research and Education, Division of Pharmacy, School of Medicine, Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
| | - Luke R Bereznicki
- 1 Unit for Medication Outcomes Research and Education, Division of Pharmacy, School of Medicine, Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
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Steinberg BA, Shrader P, Kim S, Thomas L, Fonarow GC, Ansell J, Kowey PR, Singer DE, Gersh BJ, Mahaffey KW, Peterson ED, Piccini JP. How well does physician risk assessment predict stroke and bleeding in atrial fibrillation? Results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Am Heart J 2016; 181:145-152. [PMID: 27823686 DOI: 10.1016/j.ahj.2016.07.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 07/22/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Assessments of stroke and bleeding risks are essential to selecting oral anticoagulation in patients with atrial fibrillation (AF). We aimed to assess outcomes according to physician assessed risk, with comparison to empirical risk scores. METHODS This was a prospective, observational study of 9,715 outpatients with AF enrolled in ORBIT-AF, a US national registry. Stroke and bleeding risks were quantified by physician assignment, CHADS2 and CHA2DS2-VASc stroke scores, and ATRIA and HAS-BLED bleeding scores. Outcomes were stroke or systemic embolism and major bleeding during a median follow-up of 28 months. RESULTS Physician-assigned risk was associated with thromboembolic events: low risk (0.71 per 100 patient-years [95% CI 0.56-0.91], n=3,991), intermediate risk (0.98 [95% CI 0.79-1.20], n=4,148), and high risk (1.84 [95% CI 1.43-2.37], n=1,576, P<.0001), and major bleeding: low (3.43 [95% CI 3.07-3.82], n=4,250), intermediate (4.55 [95% CI 4.03-5.15], n=2,702), and high (5.76 [95% CI 4.42-7.50], n=468; P<.0001). Discrimination of stroke risk was similar with CHADS2 (c=0.59, 95% CI 0.57-0.61) vs physician assessment (c=0.58, 95% CI 0.55-0.62). Among patients on oral anticoagulation, bleeding risk discrimination was higher with ATRIA (c=0.63, 95% CI 0.61-0.65) and HAS-BLED (c=0.60, 95% CI 0.59-0.62) than with physician assessment (0.55, 95% CI 0.53-0.57). Physician-assessed risk categories did not add significantly to empirical risk scores, in Cox models for outcomes (Padjusted>.05 for all physician assessments vs Padjusted<.05 for empirical scores). CONCLUSION Physician-assigned risk showed a graded relationship with outcomes, and both physician-based and empirical scores yielded only moderate discrimination. Although empirical scores provided valuable risk stratification information (with or without physician judgment), physician assessment added little to existing scores. These data support the use of empirical scores for stroke and bleeding risk stratification, and the need for novel approaches to risk stratification in this population.
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Abstract
Atrial Fibrillation (AF) is accompanied by an increased risk for thromboembolic events in most affected patients. Current guidelines therefore recommend antithrombotic therapy with vitamin K antagonist (VKA) or non VKA oral anticoagulant (NOAC) in the majority of AF patients. Current AF treatment guidelines recommend that only patients younger than 65 years of age with lone AF, meaning without further concomitant risk factors for thromboembolic events should not be anticoagulated. NOACs, like the direct thrombin inhibitor dabigatran and the factor X inhibitors rivaroxaban, apixaban, and edoxaban have undergone large phase III clinical trials concerning treatment efficacy and bleeding risk in comparison to the VKA warfarin. In most cases, treatment with NOACs has been shown to decrease thromboembolic risk and/or decrease bleeding risk when compared with warfarin. Especially, as major hemorrhages like life threatening or intracranial bleeds are reduced, the question arises, if due to favourable adverse event ratios the indication for oral anticoagulation therapy should be broadened and all patients with diagnosed AF should be anticoagulated. This article gives a review on currently used thromboembolic and bleeding risk scores. Furthermore, the impact of NOAC therapy on stroke and bleeding risk is summarized, especially taking pharmacological interactions of NOAC therapy altering thromboembolic or bleeding risk into consideration. Differences of currently available guidelines are discussed. Finally, ongoing recent studies on treatment of low risk patients are debated.
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Sanmartín-Fernández M, Marzal-Martín D. Safety of Non-Vitamin K Antagonist Oral Anticoagulants in Clinical Practice: Focus on Rivaroxaban in Stroke Prevention in Patients With Atrial Fibrillation. Clin Appl Thromb Hemost 2016; 23:711-724. [PMID: 27624737 DOI: 10.1177/1076029616668404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Despite direct oral anticoagulants (DOACs) have overcome the most relevant limitations of vitamin K antagonists, many patients with atrial fibrillation are not receiving the appropriate anticoagulant therapy. In addition, when patients are anticoagulated with DOACs, some of them are not taking the dose recommended in the summary of product characteristics. This may be related, at least in part, to the concern about the applicability of findings from randomized clinical trials to real-life patients. In this context, performing studies in daily clinical practice to assess the efficacy and safety of DOACs in real-world setting is mandatory. The aim of this review is to update the current evidence regarding safety of rivaroxaban in clinical practice. The Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET-AF) showed that rivaroxaban was at least as effective as warfarin for preventing stroke or systemic embolism, with similar rates of major bleeding but with lesser risk of intracranial and fatal bleedings. Data from noninterventional studies and registries have confirmed the good results of ROCKET-AF. Even more, rates of bleeding may be inferior in real-life patients, since they have a lower risk profile than those included in ROCKET-AF.
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Wang KL, Giugliano RP, Goto S, Chiu CC, Lin CY, Lai EY, Chiang CE. Standard dose versus low dose non-vitamin K antagonist oral anticoagulants in Asian patients with atrial fibrillation: A meta-analysis of contemporary randomized controlled trials. Heart Rhythm 2016; 13:2340-2347. [PMID: 27614026 DOI: 10.1016/j.hrthm.2016.09.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Although randomized controlled trials (RCTs) indicated that standard dose non-vitamin K antagonist oral anticoagulants (NOACs) were more compelling, low dose NOACs are commonly used in clinical practice in Asia. OBJECTIVE The purpose of this study was to assess the relative therapeutic benefit and risk of standard dose vs low dose NOACs in Asian patients enrolled in contemporary RCTs. METHODS We performed a prespecified meta-analysis of 3155 Asian patients with NOACs in the RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) and ENGAGE AF-TIMI 48 (Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48) trials. Efficacy and safety with standard dose vs low dose NOACs were compared by risk ratios (RRs) and 95% confidence intervals (CIs) in a random-effects model. An evidence network incorporating additional Asian patients from ROCKET AF, J- ROCKET AF, and ARISTOTLE was constructed with the Bayesian method. RESULTS Risks of stroke or systemic embolism and ischemic stroke were significantly reduced with standard dose vs low dose NOACs (RR 0.62, 95% CI 0.45-0.85; and RR 0.55, 95% CI 0.38-0.79, respectively). Rates of major, intracranial, and life-threatening bleeding with 2 dosing regimens were broadly similar (RR 1.31, 95% CI 0.74-2.33; RR 1.54, 95% CI 0.72-3.30; and RR 1.49, 95% CI 0.87-2.55, respectively). Absolute rates of all-cause mortality and the net clinical outcome with standard dose NOACs were lower but not statistically significant (absolute reduction 0.4% per year and 1.1% per year, respectively). Network meta-analyses demonstrated that standard dose NOACs had the most favorable risk-benefit profile among oral anticoagulants. CONCLUSION In Asian patients, standard dose NOACs represent a more appealing therapeutic option than low dose NOACs, with a significant reduction in ischemic stroke without an excess of major bleeding.
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Affiliation(s)
- Kang-Ling Wang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Robert P Giugliano
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Shinya Goto
- Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Chun-Chih Chiu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chun-Yi Lin
- School of Nursing, National Yang-Ming University, Taipei, Taiwan
| | - En-Yu Lai
- Institute of Information Science, Academia Sinica, Taipei, Taiwan
| | - Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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Frain BE, Castelino R, Bereznicki L. The Utilization of Antithrombotic Therapy in Older Australians With Atrial Fibrillation. Clin Appl Thromb Hemost 2016; 23:671-676. [DOI: 10.1177/1076029616637184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
What is known and Objective: Oral anticoagulants are essential drugs for the prevention of thromboembolic events in patients with atrial fibrillation (AF). Anticoagulants are, however, commonly withheld due to a perceived risk of severe adverse events. The underutilization of anticoagulants in patients with AF has been demonstrated internationally, but to date, there are limited data available in the Australian context. The aim of this study was to determine the utilization patterns of anticoagulants (including novel oral anticoagulants) with respect to stroke and bleeding risk among patients with AF within the community. Methods: We performed a nonexperimental, retrospective analysis designed to evaluate antithrombotic usage for AF in Australia. The utilization of antithrombotic therapy and the appropriateness of therapy were determined based on CHADS2, CHA2DS2-VASc and HAS-BLED risk stratification schemes. The presence of documented contraindications was used to determine the appropriateness of antithrombotic therapy. What is new and Conclusion: Anticoagulants were overutilized in patients at low risk of stroke and underutilized in patients at higher risk of stroke. As the HAS-BLED score increased, the likelihood of patients receiving an anticoagulant decreased regardless of CHADS2 or CHA2DS2-VASc scores.
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Affiliation(s)
- Bridget Elise Frain
- Division of Pharmacy, Unit for Medication Outcomes Research and Education, Faculty of Health, School of Medicine, University of Tasmania, Hobart, Australia
| | - Ronald Castelino
- Division of Pharmacy, Unit for Medication Outcomes Research and Education, Faculty of Health, School of Medicine, University of Tasmania, Hobart, Australia
| | - Luke Bereznicki
- Division of Pharmacy, Unit for Medication Outcomes Research and Education, Faculty of Health, School of Medicine, University of Tasmania, Hobart, Australia
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Bibas L, Levi M, Touchette J, Mardigyan V, Bernier M, Essebag V, Afilalo J. Implications of Frailty in Elderly Patients With Electrophysiological Conditions. JACC Clin Electrophysiol 2016; 2:288-294. [PMID: 29766886 DOI: 10.1016/j.jacep.2016.04.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 03/25/2016] [Accepted: 04/27/2016] [Indexed: 01/22/2023]
Abstract
A growing number of complex older adults are referred for electrophysiological conditions and age alone is insufficient to guide management decisions such as implantable cardioverter-defibrillator (ICD) implantation or atrial fibrillation anticoagulation. The concept of frailty has emerged as a geriatric vital sign to gain insight into physiological reserve and prognostic risk beyond chronological age and comorbidities. To date, a number of published studies have evaluated frailty in patients with electrophysiological conditions. These studies collectively demonstrate that frail patients have an increased prevalence of atrial fibrillation, lower use of oral anticoagulation, higher risk of bleeding complications from oral anticoagulation, and higher risk of stroke and mortality. A paucity of studies have explored frailty in the setting of device implantation, with a signal suggesting that frail heart failure patients may have a lower likelihood of being considered for ICD and cardiac resynchronization therapy devices, and a higher risk of fatal and nonfatal events after ICD and cardiac resynchronization therapy implantation. Whether frailty modulates the risks and benefits of these devices is a critical knowledge gap for which further study is clearly warranted.
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Affiliation(s)
- Lior Bibas
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; Division of Cardiology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Michael Levi
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; Division of Cardiology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Jacynthe Touchette
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Vartan Mardigyan
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Martin Bernier
- Division of Cardiology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Vidal Essebag
- Division of Cardiology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Jonathan Afilalo
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.
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Fauchier L, Chaize G, Gaudin AF, Vainchtock A, Rushton-Smith SK, Cotté FE. Predictive ability of HAS-BLED, HEMORR2HAGES, and ATRIA bleeding risk scores in patients with atrial fibrillation. A French nationwide cross-sectional study. Int J Cardiol 2016; 217:85-91. [PMID: 27179213 DOI: 10.1016/j.ijcard.2016.04.173] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 04/15/2016] [Accepted: 04/30/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The HAS-BLED, ATRIA, and HEMORR2HAGES risk scores were created to evaluate individual bleeding risk in atrial fibrillation (AF). We sought to estimate and compare the predictive ability of these scores for major hemorrhage in AF, including elderly (≥80years) and non-elderly (<80years) patients. METHODS This cross-sectional study is based on the French National Hospital Database (PMSI), which covers the entire French population. Data from all patients with an AF diagnosis in 2012 were extracted. Demographic and comorbidity data were used to calculate the three bleeding risk scores for each patient. Patients hospitalized with a principal diagnosis of major bleeding were identified. RESULTS Of the 533,044 AF patients identified, 53.2% were ≥80years; 7013 patients (1.3%) were hospitalized for a bleeding event (1785 for intracranial hemorrhage). Bleeding occurred more frequently in patients with higher HAS-BLED, HEMORR2HAGES, and ATRIA scores. In patients ≥80years, the c-statistics did not differ (p=0.27) between HAS-BLED (0.54; 95% confidence interval [CI]: 0.53-0.54), HEMORR2HAGES (0.53; 95% CI: 0.53-0.54), and ATRIA (0.53; 95% CI: 0.52-0.54). In patients <80years, HAS-BLED (0.59; 95% CI: 0.58-0.60) had a slightly higher c-statistic than HEMORR2HAGES (0.56; 95% CI: 0.55-0.57) and ATRIA (0.55, 95% CI: 0.55-0.56) (p<0.0001). CONCLUSIONS Given its simplicity and similar performance, HAS-BLED may be an attractive alternative to HEMORR2HAGES for estimation of bleeding risk in AF patients <80years. However, accurate determination of bleeding risk among the elderly is difficult with existing risk-prediction scores, indicating a clear need for improvement in their clinical utility.
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Affiliation(s)
- Laurent Fauchier
- Service de Cardiologie et Laboratoire d'Electrophysiologie Cardiaque, Pôle Cœur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau, Tours 37044, France; Faculté de Médecine, Université François Rabelais, Tours 37032, France.
| | | | | | | | - Sophie K Rushton-Smith
- Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA, USA
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Goodman SG. Prior bleeding, future bleeding and stroke risk with oral anticoagulation in atrial fibrillation: What new lessons can ARISTOTLE teach us? Am Heart J 2016; 175:168-71. [PMID: 27179736 DOI: 10.1016/j.ahj.2016.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 02/10/2016] [Indexed: 10/22/2022]
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Ali AN, Athavale NV, Abdelhafiz AH. Anemia: An Independent Predictor Of Adverse Outcomes In Older Patients With Atrial Fibrillation. J Atr Fibrillation 2016; 8:1366. [PMID: 27909494 DOI: 10.4022/jafib.1366] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 04/13/2016] [Accepted: 04/13/2016] [Indexed: 01/02/2023]
Abstract
Both anemia and atrial fibrillation are common in older people and their prevalence is age dependent which increases as population ages. Anemia, especially acute onset, predisposes to new onset atrial fibrillation which is likely to be mediated through inducing heart failure first and this predisposition seems to be potentiated by the presence of renal impairment. Anemia adds to the comorbidity burden of patients with atrial fibrillation and independently increases the risks of adverse outcomes such as increased hospitalization, mortality, bleeding and thromboembolic events. Early detection and correction of anemia in patients with atrial fibrillation may have a positive impact on reducing these adverse events.
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Affiliation(s)
- Ali N Ali
- Stroke Unit, Sheffield Teaching Hospitals, Sheffield
| | | | - Ahmed H Abdelhafiz
- Department of Geriatric Medicine, Rotherham General Hospital, Rotherham, UK
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Mochalina N, Jöud A, Carlsson M, Sandberg ME, Själander A, Juhlin T, Svensson PJ. Antithrombotic therapy in patients with non-valvular atrial fibrillation in Southern Sweden: A population-based cohort study. Thromb Res 2016; 140:94-99. [DOI: 10.1016/j.thromres.2016.02.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/21/2016] [Accepted: 02/22/2016] [Indexed: 10/22/2022]
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Mastoris I, Maria Mathias P, Dangas GD. Dual Antiplatelet Therapy Duration: A Review of Current Available Evidence. Clin Ther 2016; 38:961-73. [PMID: 26992662 DOI: 10.1016/j.clinthera.2016.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 01/31/2016] [Accepted: 02/12/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE Multiple regimens of antiplatelet and anticoagulation therapy have been used in the past in patients undergoing percutaneous coronary intervention (PCI). Later trials of PCI stenting demonstrated the efficacy of dual-antiplatelet therapy (DAPT) in reducing stent- and non-stent-related thrombotic events in this specific population. Nonetheless, the required duration of DAPT has not yet been elucidated. In this article we sought to identify various randomized clinical trials (RCTs), pooled analyses, meta-analyses, and data pertaining to the optimal duration of DAPT and attempt some recommendations based on patients' clinical and procedural profiles. METHODS We performed an extensive search using MEDLINE, Scopus, Cochrane Library, and Internet sources for abstracts, manuscripts, and conference reports without any language or date restrictions. In our review we included all available evidence from RCTs, meta-analyses, observational studies, and abstracts pertaining to our topic. Search results that were deemed irrelevant or that would not serve the goal or topic of our review were excluded. RESULTS Our search yielded 10 RCTs directly comparing different durations of DAPT, 3 meta-analyses amassing the evidence resulting from randomized data, and numerous observational studies that served the aim of our review. The observational studies included in the manuscript are directly related to instances in which RCTs could not be performed or introduce important concepts related to the duration of DAPT. IMPLICATIONS There is no conclusive evidence that determines the mandatory DAPT duration after PCI. In addition, there are distinct patient populations that need specific treatment regimens, such as diabetic patients or those on long-term oral anticoagulation. Therefore, clinical judgement and meticulous examination of all pertaining risk factors are required for each individual. These factors include those related to a patient's characteristics, treatment procedures, lesion complexity, and stent type. Currently ongoing studies are anticipated to further elucidate and integrate our understanding with regard to DAPT.
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Affiliation(s)
- Ioannis Mastoris
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York; Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York.
| | | | - George D Dangas
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York
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