1
|
Emad E, Khaled E, Eshtyag B, Fatima AE, Ghada S. Role of Clinical Pharmacy anticoagulation service on Apixaban prescribing appropriateness in atrial fibrillation in Saudi Arabia. Curr Probl Cardiol 2024; 49:102517. [PMID: 38521288 DOI: 10.1016/j.cpcardiol.2024.102517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 03/13/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Inappropriate DAOC dosing is precuarious and frequently encountered. Apixaban is the most reported DOAC to be inappropriately dosed. We examined the effect of adding a Clinical Pharmacist to the cardiology team rounds to the standard practice in Apixaban prescription patterns in a tertiary center in KSA. OBJECTIVE To determine the effect of clinical pharmacy services on Apixaban dose appropriateness upon discharge in Atrial Fibrillation patient pobulation. METHODS This is a single-center, retrospective cohort of patients with atrial fibrillation using a quasi-experiment of pre-post design to evaluate Apixaban dose appropriateness using clinical pharmacy services. Clinical pharmacist was added to the team to evaluate and change the regimen according to FDA dosing. Data were collected for 9 months for each, patients were followed up for efficacy and safety outcomes for 1 year. RESULTS A total of 550 patients were initially collected after follow-up, the number of patients was in the pre-phase cohort (NO CCP; n= 112) from July 2018 to the March 2019 and compared to post phase cohort (CCP, n=103) from July 2019 to March 2020. 215 Patients were included, For primary end point, CCP cohort had significantly appropriate prescriptions of apixaban compared to Non-CCP (90.2 % vs 71.5 %, p<0.001)., no differences in thromboembolic and hemorrhagic adverse events betewwn 2 cohorts. CONCLUSION A multidisciplinary team approach including clinical pharmacy services is effective in increasing the appropriate use of Apixaban upom discharge without apparent increased risk of bleeding or Adverse events.
Collapse
Affiliation(s)
- Elkholy Emad
- Pharmaceutical Service Department, King Abdullah Medical City, Makkah, KSA, Saudi Arabia.
| | - Elshammaa Khaled
- Pharmaceutical Service Department, King Abdullah Medical City, Makkah, KSA, Saudi Arabia
| | - Bajnaid Eshtyag
- Pharmaceutical Service Department, King Abdullah Medical City, Makkah, KSA, Saudi Arabia
| | - Aboul-Enein Fatima
- Cardiology Center, King Abdullah Medical City, Makkah, KSA, Saudi Arabia; Cardiology Department, Faculty of Medicine, Alexandria University, Egypt
| | - Shalaby Ghada
- Cardiology Center, King Abdullah Medical City, Makkah, KSA, Saudi Arabia; Cardiology Department, Faculty of Medicine, Zagazig University, Egypt
| |
Collapse
|
2
|
Stuby J, Haschke M, Tritschler T, Aujesky D. Oral anticoagulant therapy in older adults. Thromb Res 2024; 238:1-10. [PMID: 38636204 DOI: 10.1016/j.thromres.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 03/06/2024] [Accepted: 04/11/2024] [Indexed: 04/20/2024]
Abstract
Patients aged ≥65 years not only account for the majority of patients with atrial fibrillation (AF) and venous thromboembolism (VTE), they are also at a higher risk of morbidity, mortality, and undertreatment than younger patients. Several age-related physiological changes with effects on drug pharmacokinetics/-dynamics and blood vessel fragility as well as the higher prevalence of geriatric conditions such as frailty, multimorbidity, polypharmacy, fall risk, dementia, and malnutrition make older persons more vulnerable to disease- and anticoagulation-related complications. Moreover, because older patients with AF/VTE are underrepresented in oral anticoagulation (OAC) trials, evidence on OAC in older adults with AF/VTE is mainly based on subgroup analyses from clinical trials and observational studies. A growing body of such limited evidence suggests that direct oral anticoagulants (DOACs) may be superior in terms of efficacy and safety compared to vitamin K antagonists in older persons with AF/VTE and that specific DOACs may have a differing risk-benefit profile. In this narrative review, we summarize the evidence on epidemiology of AF/VTE, impact of age-related physiological changes, efficacy/safety of OAC, specifically considering individuals with common geriatric conditions, and review OAC guideline recommendations for older adults with AF/VTE. We also propose a research agenda to improve the evidence basis on OAC older individuals with AF/VTE, including the conduct of advanced age-specific and pragmatic studies using less restrictive eligibility criteria and patient-reported health outcomes, in order to compare the effectiveness and safety of different DOACs, and investigate lower-dose regimens and optimal OAC durations in older patients.
Collapse
Affiliation(s)
- J Stuby
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - M Haschke
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Clinical Pharmacology & Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - T Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - D Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| |
Collapse
|
3
|
Rosas Diaz AN, Troy AL, Kaplinskiy V, Pritchard A, Vani R, Ko D, Orkaby AR. Assessment and Management of Atrial Fibrillation in Older Adults with Frailty. Geriatrics (Basel) 2024; 9:50. [PMID: 38667517 PMCID: PMC11050611 DOI: 10.3390/geriatrics9020050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/28/2024] [Accepted: 04/06/2024] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is a major driver of morbidity and mortality among older adults with frailty. Moreover, frailty is highly prevalent in older adults with AF. Understanding and addressing the needs of frail older adults with AF is imperative to guide clinicians caring for older adults. In this review, we summarize current evidence to support the assessment and management of older adults with AF and frailty, incorporating numerous recent landmark trials and studies in the context of the 2023 US AF guideline.
Collapse
Affiliation(s)
| | - Aaron L. Troy
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA (A.L.T.)
| | | | - Abiah Pritchard
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA (A.L.T.)
| | - Rati Vani
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA (A.L.T.)
| | - Darae Ko
- Section of Cardiovascular Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, 1200 Center Street, Boston, MA 02131, USA
| | - Ariela R. Orkaby
- New England GRECC (Geriatric Research, Education and Clinical Center), VA Boston Healthcare System, Boston, MA 02130, USA
- Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|
4
|
Yao A, Gao L, Zhang J, Cheng JM, Kim DH. Frailty as an Effect Modifier in Randomized Controlled Trials: A Systematic Review. J Gen Intern Med 2024:10.1007/s11606-024-08732-8. [PMID: 38592606 DOI: 10.1007/s11606-024-08732-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 03/15/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The effect of clinical interventions may vary by patients' frailty status. Understanding treatment effect heterogeneity by frailty could lead to frailty-guided treatment strategies and reduce overtreatment and undertreatment. This systematic review aimed to examine the effect modification by frailty in randomized controlled trials (RCTs) that evaluate pharmacological, non-pharmacological, and multicomponent interventions. METHODS We searched PubMed, Web of Science, EMBASE, and ClinicalTrial.gov, from their inception to 8 December 2023. Two reviewers independently extracted trial data and examined the study quality with senior authors. RESULTS Sixty-one RCTs that evaluated the interaction between frailty and treatment effects in older adults were included. Frailty was evaluated using different tools such as the deficit accumulation frailty index, frailty phenotype, and other methods. The effect of several pharmacological interventions (e.g., edoxaban, sacubitril/valsartan, prasugrel, and chemotherapy) varied according to the degree of frailty, whereas other treatments (e.g., antihypertensives, vaccinations, osteoporosis medications, and androgen medications) demonstrated consistent benefits across different frailty levels. Some non-pharmacological interventions had greater benefits in patients with higher (e.g., chair yoga, functional walking, physical rehabilitation, and higher dose exercise program) or lower (e.g., intensive lifestyle intervention, psychosocial intervention) levels of frailty, while others (e.g., resistance-type exercise training, moderate-intensive physical activity, walking and nutrition or walking) produced similar intervention effects. Specific combined interventions (e.g., hospital-based disease management programs) demonstrated inconsistent effects across different frailty levels. DISCUSSION The efficacy of clinical interventions often varied by frailty levels, suggesting that frailty is an important factor to consider in recommending clinical interventions in older adults. REGISTRATION PROSPERO registration number CRD42021283051.
Collapse
Affiliation(s)
- Aaron Yao
- VillageMD Research Institute, Chicago, IL, USA.
- Virginia Commonwealth University, Richmond, VA, USA.
| | | | - Jiajun Zhang
- Qingdao Municipal Hospital, Qingdao, Shandong, China
| | - Joyce M Cheng
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
5
|
Rose RA, Howlett SE. Preclinical studies on the impacts of frailty in the aging heart. Can J Cardiol 2024:S0828-282X(24)00200-9. [PMID: 38460611 DOI: 10.1016/j.cjca.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/20/2024] [Accepted: 03/04/2024] [Indexed: 03/11/2024] Open
Abstract
Age is a major risk factor for the development of cardiovascular diseases in men and in women. However, not all people age at the same rate and those who are aging rapidly are considered frail, when compared to their fit counterparts. Frailty is an important clinical challenge because those who are frail are more likely to develop and die from illnesses, including cardiovascular diseases, than fit people of the same age. This increase in susceptibility to cardiovascular diseases in older individuals may occur as the cellular and molecular mechanisms involved in the aging process facilitate structural and functional damage in the heart. Consistent with this, recent studies in murine frailty models have provided strong evidence that maladaptive cardiac remodeling in older mice is the most pronounced in mice with a high level of frailty. For example, there is evidence that ventricular hypertrophy and contractile dysfunction increase as frailty increases in aging mice. Additionally, fibrosis and slowing of conduction in the sinoatrial node and atria are proportional to the level of frailty. These modifications could predispose frail older adults to diseases like heart failure and atrial fibrillation. This preclinical work also raises the possibility that emerging interventions designed to "treat frailty" may also treat or prevent cardiovascular diseases. These findings may help to explain why frail older people are most likely to develop these disorders as they age.
Collapse
Affiliation(s)
- Robert A Rose
- Department of Cardiac Sciences and; Department of Physiology and Pharmacology, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Susan E Howlett
- Department of Pharmacology and; Department of Medicine (Geriatric Medicine), Faculty of Medicine, Dalhousie University, Halifax, NS, Canada.
| |
Collapse
|
6
|
Brunetti E, Presta R, Okoye C, Filippini C, Raspo S, Bruno G, Marabotto M, Monzani F, Bo M. Predictors and Outcomes of Oral Anticoagulant Deprescribing in Geriatric Inpatients With Atrial Fibrillation: A Retrospective Multicenter Cohort Study. J Am Med Dir Assoc 2024; 25:545-551.e4. [PMID: 38359897 DOI: 10.1016/j.jamda.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/28/2023] [Accepted: 01/11/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE To investigate prevalence and predictors of oral anticoagulant therapy (OAT) deprescribing in older inpatients with atrial fibrillation (AF), and its association with 1-year incidence of major clinical outcomes. DESIGN Multicenter retrospective cohort study. SETTING AND PARTICIPANTS Inpatients aged ≥75 years with known AF on OAT at admission discharged from 3 Italian acute geriatric wards between January 2014 and July 2018. METHODS Data from a routine Comprehensive Geriatric Assessment (CGA), along with OAT status at discharge were recorded. One-year incidence of all-cause death, stroke or systemic embolism (SSE), and major and clinically relevant nonmajor bleeding (MB/CRNMB) were retrieved from administrative databases. Associations were explored through multilevel analysis. RESULTS Among 1578 patients (median age 86 years, 56.3% female), OAT deprescription (341 patients, 21.6%) was associated with bleeding risk, functional dependence and cognitive impairment, and inversely, with previous SSE and chronic AF. Incidences of death, SSE, and MB/CRNMB were 56.6%, 1.5%, and 4.1%, respectively, in OAT-deprescribed patients, and 37.6%, 2.9%, and 4.9%, respectively, in OAT-continued patients, without significant differences between groups. OAT deprescription was associated with all-cause mortality [adjusted odds ratio (aOR) 1.41, 95% CI 1.68-1.85], along with older age, comorbidity burden, cognitive impairment, and functional dependence, but with neither SSE nor MB/CRNMB incidence, as opposed to being alive and free from SSE and MB/CNRMB, respectively (aOR 0.68, 95% CI 0.25-1.82, and aOR 0.95 95% CI 0.49-1.85, respectively). Conversely, OAT deprescription was associated with higher odds of being dead than alive both in patients free from SSE and in those free from MB/CRNMB. CONCLUSIONS AND IMPLICATIONS CGA-based OAT deprescribing is common in acute geriatric wards and is not associated with increased SSE. The net clinical benefit of OAT in geriatric patients is strongly related with the competing risk of death, suggesting that functional and cognitive status, as well as residual life expectancy, should be considered in clinical decision making in this population.
Collapse
Affiliation(s)
- Enrico Brunetti
- Geriatrics Unit, Department of Medical Sciences, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Roberto Presta
- Geriatrics Unit, Department of Medical Sciences, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Chukwuma Okoye
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy; University of Milano-Bicocca, School of Medicine and Surgery, Milan, Italy
| | | | - Silvio Raspo
- Geriatrics Unit, Hospital Santa Croce e Carle, Cuneo, Italy
| | - Gerardo Bruno
- Geriatrics Unit, Hospital Santa Croce e Carle, Cuneo, Italy
| | | | - Fabio Monzani
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Mario Bo
- Geriatrics Unit, Department of Medical Sciences, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| |
Collapse
|
7
|
Søgaard M, Ording AG, Skjøth F, Larsen TB, Nielsen PB. Effectiveness and safety of direct oral anticoagulation vs. warfarin in frail patients with atrial fibrillation. Eur Heart J Cardiovasc Pharmacother 2024; 10:137-146. [PMID: 37993415 DOI: 10.1093/ehjcvp/pvad091] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/09/2023] [Accepted: 11/21/2023] [Indexed: 11/24/2023]
Abstract
AIMS Although frail patients with atrial fibrillation (AF) carry a high risk of stroke and treatment-related bleeding complications, evidence for the safety and effectiveness of anticoagulation remains sparse. This study investigated the effectiveness and safety of direct oral anticoagulant (DOAC) vs. warfarin in frail AF patients. METHODS AND RESULTS Nationwide registry-based cohort study including 32 048 anticoagulation naïve frail patients (median age 80 years, 53% female) with incident AF during 2012-20. Frailty was assessed using the hospital frailty risk score. To address baseline confounding, we applied inverse probability of treatment weighting (IPTW) and marginal structural models with weighted pooled regression to compute weighted hazard ratios (wHRs) and risk differences for thromboembolism and major bleeding comparing specific DOAC doses with warfarin. After AF diagnosis, 6747 (21.1%) initiated warfarin, 17 076 (50.3%) initiated standard-dose DOAC, and 9179 (28.6%) initiated reduced-dose DOAC. Comparative effectiveness analyses in the IPTW pseudo-populations revealed similar thromboembolism risk between standard-dose DOAC and warfarin [wHR 0.95, 95% confidence interval (CI) 0.80-1.13] and between reduced-dose DOAC and warfarin (wHR 0.97, 95% CI 0.77-1.23). The 1-year thromboembolic event-free survival difference was -0.2% for DOAC, regardless of dosing, vs. warfarin. Major bleeding risk was significantly lower with standard-dose DOAC (wHR 0.69, 95% CI 0.59-0.87) and reduced-dose DOAC (wHR 0.67, 95% CI 0.55-0.81) vs. warfarin. The 1-year bleeding risk difference with DOAC ranged from -1.3% to -3.0%. CONCLUSION Our findings indicate comparable thromboembolism risk and significantly lower bleeding risk with both standard and reduced DOAC regimens compared with warfarin in frail AF patients in routine care.
Collapse
Affiliation(s)
- Mette Søgaard
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg University Hospital, 9260 Gistrup, Denmark
| | - Anne Gulbech Ording
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg University Hospital, 9260 Gistrup, Denmark
| | - Flemming Skjøth
- Unit for Clinical Biostatistics, Aalborg University Hospital, 9000 Aalborg, Denmark
| | | | - Peter Brønnum Nielsen
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg University Hospital, 9260 Gistrup, Denmark
| |
Collapse
|
8
|
Guo X, Du J, Yang Y, Wu M, Ou W, Han X, Wang Z, Jin J, Zhang P, Zhang Z, Chen G, Long M, Yin G, Liu T, Wang X, Li D, Chen M, Dong Y, Lai C, Zhang X, Yi Y, Xiang J, Chen C, Unverdorben M, Ma C. Edoxaban for stroke prevention in atrial fibrillation and factors associated with dosing: patient characteristics from the prospective observational ETNA-AF-China registry. Sci Rep 2024; 14:2778. [PMID: 38307927 PMCID: PMC10837439 DOI: 10.1038/s41598-024-51776-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/09/2024] [Indexed: 02/04/2024] Open
Abstract
Real-world data on effectiveness and safety of a single non-vitamin K antagonist oral anticoagulant in the Chinese population with atrial fibrillation (AF) are limited. This study reports characteristics of patients treated with edoxaban and factors associated with dosing patterns from routine care in China. ETNA-AF-China (NCT04747496) is a multicentre, prospective, observational study enrolling edoxaban-treated patients from four economic regions with a targeted 2-year follow-up. Of the 4930 patients with AF (mean age: 70.2 ± 9.5 years; male, 57.1%), the mean creatinine clearance (CrCl), CHA2DS2-VASc, and HAS-BLED scores were 71.2 mL/min, 2.9, and 1.6. Overall, 6.4% of patients were perceived as frail by investigators. Available label dose reduction criteria (N = 4232) revealed that 3278 (77.5%) patients received recommended doses and 954 (22.5%) non-recommended doses. Northeast (53.0%) and West (43.1%) regions had the highest prescriptions of 60 mg and 30 mg recommended doses, respectively. Non-recommended 30 mg doses were more frequently prescribed in patients with antiplatelet use and history of heart failure than recommended 60 mg. Multivariate analysis identified advanced age as the strongest associated factor with non-recommended doses. Frailty had the strongest association with 30 mg except for age, and history of TIA was the most relevant factor associated with 60 mg. In conclusion, patients in the ETNA-AF-China study were predominantly aged 65 years and older, had mild-to-moderate renal impairment and good label adherence. Advanced age was associated with non-recommended doses, with frailty most common for non-recommended 30 mg and a history of TIA for the non-recommended 60 mg dose.
Collapse
Affiliation(s)
- Xueyuan Guo
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Juan Du
- Medical Department, Daiichi Sankyo (China) Holdings Co., Ltd, Shanghai, 200040, China
| | - Yang Yang
- Department of Cardiology, The Second Affiliated Hospital of Shenyang Medical College, Shenyang, 110004, Liaoning, China
| | - Mingxing Wu
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, 411199, Hunan, China
| | - Wenchao Ou
- Department of Cardiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510260, Guangdong, China
| | - Xuebin Han
- Department of Cardiology, Shanxi Cardiovascular Hospital, Taiyuan, 030024, Shanxi, China
| | - Zhifang Wang
- Deparment of Vasculocardiology, Xinxiang Central Hospital, Xinxiang, 453001, Henan, China
| | - Jing Jin
- Department of Cardiology, The Fourth Hospital of Changsha, Changsha, 410006, Hunan, China
| | - Ping Zhang
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, Beijing, 102218, Beijing, China
| | - Zheng Zhang
- Department of Cardiology, QingPu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai, 201799, Shanghai, China
| | - Guoqin Chen
- Department of Cardiology, Guangzhou Panyu Central Hospital, Guangzhou, 511486, Guangdong, China
| | - Mingzhi Long
- Department of Cardiology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210003, Jiangsu, China
| | - Guotian Yin
- Department of Cardiology, The Third Affiliated Hospital Of Xinxiang Medical University, Xinxiang, 453699, Henan, China
| | - Tong Liu
- Department of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, Tianjin, China
| | - Xiaoyan Wang
- Department of Cardiology, Affiliated Hospital of Jiangnan University, Wuxi, 214125, Jiangsu, China
| | - Dongsheng Li
- Department of Cardiology, Wuhan Third Hospital, Wuhan, 430074, Hubei, China
| | - Manhua Chen
- Department of Cardiology, The Central Hospital of Wuhan, Wuhan, 430014, Hubei, China
| | - Yugang Dong
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, Guangdong, China
| | - Chunlin Lai
- Department of Cardiology, Shanxi Provincial People's Hospital, Taiyuan, 043599, Shanxi, China
| | - Xuelian Zhang
- Department of Cardiology, Jilin Province People's Hospital, Changchun, 130021, Jilin, China
| | - Yuan Yi
- Medical Department, Daiichi Sankyo (China) Holdings Co., Ltd, Shanghai, 200040, China
| | - Jing Xiang
- Medical Department, Daiichi Sankyo (China) Holdings Co., Ltd, Shanghai, 200040, China
| | - Cathy Chen
- Medical Department, Daiichi Sankyo Inc., Basking Ridge, NJ, 07920-2311, USA
| | - Martin Unverdorben
- Medical Department, Daiichi Sankyo Inc., Basking Ridge, NJ, 07920-2311, USA
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China.
| |
Collapse
|
9
|
Shantsila E, Choi EK, Lane DA, Joung B, Lip GY. Atrial fibrillation: comorbidities, lifestyle, and patient factors. Lancet Reg Health Eur 2024; 37:100784. [PMID: 38362547 PMCID: PMC10866737 DOI: 10.1016/j.lanepe.2023.100784] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/25/2023] [Accepted: 11/02/2023] [Indexed: 02/17/2024]
Abstract
Modern anticoagulation therapy has dramatically reduced the risk of stroke and systemic thromboembolism in people with atrial fibrillation (AF). However, AF still impairs quality of life, increases the risk of stroke and heart failure, and is linked to cognitive impairment. There is also a recognition of the residual risk of thromboembolic complications despite anticoagulation. Hence, AF management is evolving towards a more comprehensive understanding of risk factors predisposing to the development of this arrhythmia, its' complications and interventions to mitigate the risk. This review summarises the recent advances in understanding of risk factors for incident AF and managing these risk factors. It includes a discussion of lifestyle, somatic, psychological, and socioeconomic risk factors. The available data call for a practice shift towards a more individualised approach considering an increasingly broader range of health and patient factors contributing to AF-related health burden. The review highlights the needs of people living with co-morbidities (especially with multimorbidity), polypharmacy and the role of the changing population demographics affecting the European region and globally.
Collapse
Affiliation(s)
- Eduard Shantsila
- Department of Primary Care and Mental Health, University of Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Brownlow Group GP Practice, Liverpool, United Kingdom
| | - Eue-Keun Choi
- Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Republic of Korea
| | - Deirdre A. Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Denmark
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Denmark
| |
Collapse
|
10
|
Grymonprez M, Petrovic M, De Backer TL, Steurbaut S, Lahousse L. Impact of frailty on the effectiveness and safety of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation: a nationwide cohort study. Eur Heart J Qual Care Clin Outcomes 2024; 10:55-65. [PMID: 36941126 PMCID: PMC10785587 DOI: 10.1093/ehjqcco/qcad019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/04/2023] [Accepted: 03/17/2023] [Indexed: 03/23/2023]
Abstract
AIMS Data on non-vitamin K antagonist oral anticoagulants (NOACs) use in patients with atrial fibrillation (AF) and frailty are scarce. Therefore, the impact of frailty on AF-related outcomes and benefit-risk profiles of NOACs in patients with frailty were investigated. METHODS AND RESULTS AF patients initiating anticoagulation between 2013 and 2019 were included using Belgian nationwide data. Frailty was assessed with the Claims-based Frailty Indicator. Among 254 478 anticoagulated AF patients, 71 638 (28.2%) had frailty. Frailty was associated with higher all-cause mortality risks [adjusted hazard ratio (aHR) 1.48, 95% confidence interval (CI) (1.43-1.54)], but not with thromboembolism or bleeding. Among subjects with frailty (78 080 person-years of follow-up), NOACs were associated with lower risks of stroke or systemic embolism (stroke/SE) [aHR 0.77, 95%CI (0.70-0.86)], all-cause mortality [aHR 0.88, 95%CI (0.84-0.92)], and intracranial bleeding [aHR 0.78, 95%CI (0.66-0.91)], a similar major bleeding risk [aHR 1.01, 95%CI (0.93-1.09)], and higher gastrointestinal bleeding risk [aHR 1.19, 95%CI (1.06-1.33)] compared with VKAs. Major bleeding risks were lower with apixaban [aHR 0.84, 95%CI (0.76-0.93)], similar with edoxaban [aHR 0.91, 95%CI (0.73-1.14)], and higher with dabigatran [aHR 1.16, 95%CI (1.03-1.30)] and rivaroxaban [aHR 1.11, 95%CI (1.02-1.21)] compared with VKAs. Apixaban was associated with lower major bleeding risks compared with dabigatran [aHR 0.72, 95%CI (0.65-0.80)], rivaroxaban [aHR 0.78, 95%CI (0.72-0.84)] and edoxaban [aHR 0.74, 95%CI (0.65-0.84)], but mortality risk was higher compared with dabigatran and edoxaban. CONCLUSION Frailty was an independent risk factor of death. Non-vitamin K antagonist oral anticoagulants had better benefit-risk profiles than VKAs in patients with frailty, especially apixaban, followed by edoxaban.
Collapse
Affiliation(s)
- Maxim Grymonprez
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000Ghent, Belgium
| | - Mirko Petrovic
- Department of Geriatrics, Ghent University Hospital, C. Heymanslaan 10, 9000Ghent, Belgium
| | - Tine L De Backer
- Department of Cardiology, Ghent University Hospital, C. Heymanslaan 10, 9000Ghent, Belgium
| | - Stephane Steurbaut
- Centre for Pharmaceutical Research, Research group of Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Jette, Belgium
- Department of Hospital Pharmacy, UZ Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000Ghent, Belgium
- Department of Epidemiology, Erasmus Medical Center, PO Box 2040, Rotterdam 3000CA, The Netherlands
| |
Collapse
|
11
|
Crispino P. Hemorrhagic Coagulation Disorders and Ischemic Stroke: How to Reconcile Both? Neurol Int 2023; 15:1443-1458. [PMID: 38132972 PMCID: PMC10745771 DOI: 10.3390/neurolint15040093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 11/22/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023] Open
Abstract
Coagulation and fibrinolytic system disorders are conditions in which the blood's ability to clot is impaired, resulting in an increased risk of thrombosis or bleeding. Although these disorders are the expression of two opposing tendencies, they can often be associated with or be a consequence of each other, contributing to making the prognosis of acute cerebrovascular events more difficult. It is important to recognize those conditions that are characterized by dual alterations in the coagulation and fibrinolytic systems to reduce the prognostic impact of clinical conditions with difficult treatment and often unfortunate outcomes. Management of these individuals can be challenging, as clinicians must balance the need to prevent bleeding episodes with the potential risk of clot formation. Treatment decisions should be made on an individual basis, considering the specific bleeding disorder, its severity, and the patient's general medical condition. This review aims to deal with all those forms in which coagulation and fibrinolysis represent two sides of the same media in the correct management of patients with acute neurological syndrome. Precision medicine, personalized treatment, advanced anticoagulant strategies, and innovations in bleeding control represent future directions in the management of these complex pathologies in which stroke can be the evolution of two different acute events or be the first manifestation of an occult or unknown underlying pathology.
Collapse
Affiliation(s)
- Pietro Crispino
- Medicine Unit, Santa Maria Goretti Hospital, Via Scaravelli Snc, 04100 Latina, Italy
| |
Collapse
|
12
|
Liu J, Chai K, Zhu W, DU M, Meng C, Yang L, Cui L, Guo D, Sun N, Wang H, Yang J. Implication of different frailty criteria in older people with atrial fibrillation: a prospective cohort study. BMC Geriatr 2023; 23:604. [PMID: 37759173 PMCID: PMC10537815 DOI: 10.1186/s12877-023-04330-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND the prevalence of physical and multidimensional frailty and their prognostic impact on clinical outcomes in patients with atrial fibrillation (AF) is unclear. OBJECTIVE to evaluated frailty in a cohort of patients with AF according to different criteria, and studied the prevalence and its prognostic impact on clinical outcomes. METHODS in this multicenter prospective cohort, 197 inpatients ≥ 65 years old with AF were recruited from September 2018 to April 2019.We used Fried Frailty phenotype (Fried) to assess physical frailty, and comprehensive geriatric assessment-frailty index (CGA-FI) to assess multidimensional frailty. The primary outcome was a composite of all-cause mortality or rehospitalization. RESULTS the prevalence of frailty was determined as 34.5% by Fried, 42.6% by CGA-FI. Malnutrition and ≥ 7 medications were independently associated with frailty. Kaplan-Meier survival curve showed that the presence of frailty by CGA-FI had significantly lower all-cause mortality or rehospitalization survival rate (log-rank P = 0.04) within 1 year. Multivariate Cox regression adjusted for age and sex showed that the frailty by CGA-FI was significantly associated with the risk of all-cause mortality or rehospitalization within 1 year (HR 1.79, 95% CI 1.10-2.90). However, those associations were absent with the physical frailty. After broader multivariate adjustment, those associations were no longer statistically significant for both types of frailty. CONCLUSIONS in older people with AF, Multidimensional frailty is more significantly associated with a composite of all-cause mortality or rehospitalization within 1 year than physical frailty, but these association are attenuated after multivariate adjustment. CLINICAL TRIAL REGISTRATION ChiCTR1800017204; date of registration: 07/18/2018.
Collapse
Affiliation(s)
- Junpeng Liu
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Ke Chai
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Wanrong Zhu
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China
- Peking University Fifth School of Clinical Medicine, Beijing, 100730, China
| | - Minghui DU
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Chen Meng
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Lin Yang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Lingling Cui
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Di Guo
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Ning Sun
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Hua Wang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China.
| | - Jiefu Yang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1, Da Hua Road, Dongcheng District, Beijing, 100730, People's Republic of China
| |
Collapse
|
13
|
Diaz AB, Chow J, Hoo FK, Koh KW, Lee GCK, Teo WS, Venketasubramanian N, Wang CC, Mehta R. Early experiences with edoxaban for stroke prevention in atrial fibrillation in the Southeast Asia region. Drugs Context 2023; 12:2023-3-3. [PMID: 37711730 PMCID: PMC10499367 DOI: 10.7573/dic.2023-3-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 08/01/2023] [Indexed: 09/16/2023] Open
Abstract
Edoxaban, a once-daily, direct-acting oral anticoagulant, is approved to prevent stroke or systemic embolism in non-valvular atrial fibrillation (NVAF) and treat venous thromboembolism. The clinical benefit of edoxaban for stroke prevention in Asian patients with NVAF has been demonstrated in clinical and real-world studies. We share early clinical experiences with once-daily edoxaban and discuss its evidence-based use in patients with NVAF in Southeast Asia through several cases of patients at high risk, including frail patients, elderly patients with multiple comorbidities and patients with increased bleeding risk. These cases demonstrate the effectiveness and safety of once-daily edoxaban in patients with NVAF in Southeast Asia.
Collapse
Affiliation(s)
| | - Jeremy Chow
- Asian Heart & Vascular Centre, Singapore, Singapore
| | - Fan Kee Hoo
- University Putra Malaysia, Serdang, Malaysia
| | - Kok Wei Koh
- Subang Jaya Medical Centre, Subang Jaya, Malaysia
| | | | - Wee Siong Teo
- Mount Elizabeth Medical Centre, Singapore, Singapore
| | | | - Chun-Chieh Wang
- Chang Gung Memorial Hospital, Linkou and Chang Gung University, Taoyuan, Taiwan
| | - Radhika Mehta
- A. Menarini Asia-Pacific Pte Ltd, Singapore, Singapore
| |
Collapse
|
14
|
Lip GYH, Proietti M, Potpara T, Mansour M, Savelieva I, Tse HF, Goette A, Camm AJ, Blomstrom-Lundqvist C, Gupta D, Boriani G. Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal. Europace 2023; 25:euad226. [PMID: 37622590 PMCID: PMC10451006 DOI: 10.1093/europace/euad226] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 08/26/2023] Open
Abstract
Stroke prevention in patients with atrial fibrillation (AF) is one pillar of the management of this common arrhythmia. Substantial advances in the epidemiology and associated pathophysiology underlying AF-related stroke and thrombo-embolism are evident. Furthermore, the introduction of the non-vitamin K antagonist oral anticoagulants (also called direct oral anticoagulants) has clearly changed our approach to stroke prevention in AF, such that the default should be to offer oral anticoagulation for stroke prevention, unless the patient is at low risk. A strategy of early rhythm control is also beneficial in reducing strokes in selected patients with recent onset AF, when compared to rate control. Cardiovascular risk factor management, with optimization of comorbidities and attention to lifestyle factors, and the patient's psychological morbidity are also essential. Finally, in selected patients with absolute contraindications to long-term oral anticoagulation, left atrial appendage occlusion or exclusion may be considered. The aim of this state-of-the-art review article is to provide an overview of the current status of AF-related stroke and prevention strategies. A holistic or integrated care approach to AF management is recommended to minimize the risk of stroke in patients with AF, based on the evidence-based Atrial fibrillation Better Care (ABC) pathway, as follows: A: Avoid stroke with Anticoagulation; B: Better patient-centred, symptom-directed decisions on rate or rhythm control; C: Cardiovascular risk factor and comorbidity optimization, including lifestyle changes.
Collapse
Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Irina Savelieva
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Hung Fat Tse
- Cardiology Division, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Andreas Goette
- Medizinische Klinik II: Kardiologie und Intensivmedizin, St. Vincenz-Krankenhaus Paderborn, Am Busdorf 2, 33098 Paderborn, Germany
| | - A John Camm
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Carina Blomstrom-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, via del Pozzo 71, 41125 Modena, Italy
| |
Collapse
|
15
|
Dulai R, Uy CP, Sulke N, Patel N, Veasey RA. A retrospective analysis of frailty status on atrial fibrillation catheter ablation outcomes. Pacing Clin Electrophysiol 2023; 46:855-860. [PMID: 37382367 DOI: 10.1111/pace.14768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION Catheter ablation for atrial fibrillation (AF) reduces symptoms and improves the quality of life compared with medical treatment. It is unclear if frailty impacts on the outcome of catheter ablation in patients with symptomatic AF. We sought to evaluate the association between frailty as measured by the validated NHS electronic Frailty Index (eFI) and outcomes post-AF ablation. METHODS Two hundred forty eight patients who had undergone AF ablation with a mean age of 72.9 ± 5.16 were included in the study retrospectively. The primary endpoint for success was defined as freedom from atrial arrhythmia lasting >30 s beyond the 3-month blanking periods. Frailty was based on the eFI, and the cohort split into four groups: fit (no frailty), mild, moderate and severe frailty. RESULTS Frailty was categorized as fit (118/248; 47.6%), mild (66/248; 26.6%), moderate (54/248; 21.8%), and severe (10/248; 4.0%). Freedom from arrhythmia occurred in 167 of 248 (67.3%) patients after a mean follow-up of 25.8 +/- 17.3 months. Fit patients had significantly greater freedom from arrhythmia (92/118; 78%) compared to mild frailty (40/66; 60.6%, p-value = .020), moderate frailty (31/54; 57.4%, p-value = .006), or severe frailty (4/10; 40.0%, p-value < .001). There was also a significant difference in arrhythmia occurrence between patients with mild frailty and severe frailty (p-value = .044). CONCLUSION Frailty is associated with poorer outcomes in patients undergoing AF ablation. The eFI may be used in the prognostic evaluation of AF ablation outcomes. Further studies are essential to confirm the findings of this study.
Collapse
Affiliation(s)
- Rajdip Dulai
- Cardiology Research Department, Eastbourne District General Hospital, East Sussex Hospitals NHS Trust, Saint Leonards-on-Sea, UK
| | - Christopher Patrick Uy
- Cardiology Research Department, Eastbourne District General Hospital, East Sussex Hospitals NHS Trust, Saint Leonards-on-Sea, UK
| | | | - Nikhil Patel
- Cardiology Research Department, Eastbourne District General Hospital, East Sussex Hospitals NHS Trust, Saint Leonards-on-Sea, UK
| | - Rick A Veasey
- Cardiology Research Department, Eastbourne District General Hospital, East Sussex Hospitals NHS Trust, Saint Leonards-on-Sea, UK
| |
Collapse
|
16
|
Cerezo Manchado JJ, Iturbe Hernández T, Martínez Pacheco MDC, Gil Ortega I, Campoy D, Canals Pernas T, Martínez Serra L, Flores Aparco KJ, Velásquez Escandón CA, Martínez Francés A, Olivera P. Impact of atrial fibrillation and anticoagulation on the risk of death, thromboembolic disease and bleeding in patients with COVID-19: the ACO-VID Registry. Curr Med Res Opin 2023; 39:811-817. [PMID: 37189306 DOI: 10.1080/03007995.2023.2204009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To describe the clinical profile, risk of complications and impact of anticoagulation in COVID-19 hospitalized patients, according to the presence of atrial fibrillation (AF). METHODS Multicenter, retrospective, and observational study that consecutively included patients >55 years admitted with COVID-19 from March to October 2020. In AF patients, anticoagulation was chosen based on clinicians' judgment. Patients were followed-up for 90 days. RESULTS A total of 646 patients were included, of whom 75.2% had AF. Overall, mean age was 75 ± 9.1 years and 62.4% were male. Patients with AF were older and had more comorbidities. The most common anticoagulants used during hospitalization in patients with AF were edoxaban (47.9%), low molecular weight heparin (27.0%), and dabigatran (11.7%) and among patients without AF, these numbers were 0%, 93.8% and 0%. Overall, during the study period (68 ± 3 days), 15.2% of patients died, 8.2% of patients presented a major bleeding and 0.9% had a stroke/systemic embolism. During hospitalization, patients with AF had a higher risk of major bleeding (11.3% vs 0.7%; p < .01), COVID-19-related deaths (18.0% vs 4.5%; p = .02), and all-cause deaths (20.6% vs 5.6%; p = .02). Age (HR 1.5; 95% CI 1.0-2.3) and elevated transaminases (HR 3.5; 95% CI 2.0-6.1) were independently associated with all-cause mortality. AF was independently associated with major bleeding (HR 2.2; 95% CI 1.1-5.3). CONCLUSIONS Among patients hospitalized with COVID-19, patients with AF were older, had more comorbidities and had a higher risk of major bleeding. Age and elevated transaminases during hospitalization, but not AF nor anticoagulant treatment increased the risk of all-cause death.
Collapse
Affiliation(s)
| | | | | | - Ignacio Gil Ortega
- Department of Cardiology, Hospital Clínico Universitario Santa Lucía, Cartagena, Spain
| | - Desirée Campoy
- Thrombosis and Hemostasis Unit, Department of Hematology, Valld'Hebron University Hospital, Barcelona, Spain
| | - Tania Canals Pernas
- Departament of Hematology, Hospital Universitario Sant Joan de Reus, Reus, Spain
| | - Laia Martínez Serra
- Department of Hematology, University Hospital Sant Joan de Reus, Tarragona, Spain
| | | | | | | | - Pável Olivera
- Thrombosis and Hemostasis Unit, Department of Hematology, Valld'Hebron University Hospital, Barcelona, Spain
| |
Collapse
|
17
|
Abstract
PURPOSE OF REVIEW The goal of the narrative review is to provide an overview of the epidemiology of frailty in cardiovascular disease and cardiovascular mortality and discuss applications of frailty in cardiovascular care of older adults. RECENT FINDINGS Frailty is highly prevalent in older adults with cardiovascular disease and is a robust, independent predictor of cardiovascular death. There is a growing interest in using frailty to inform management of cardiovascular disease either through pre- or post-treatment prognostication or by delineating treatment heterogeneity in which frailty serves to distinguish patients with differential harms or benefits from a given therapy. Frailty can enable more individualized treatment in older adults with cardiovascular disease. Future studies are needed to standardize frailty assessment across cardiovascular trials and enable implementation of frailty assessment in cardiovascular clinical practice.
Collapse
Affiliation(s)
- Darae Ko
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
- Section of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, USA
| | - John A Bostrom
- Section of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, USA
| | - Saadia Qazi
- Department of Medicine, VA Boston Healthcare System, Boston, MA, USA
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA, USA
- Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel B Kramer
- Richart A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
- Division of Gerontology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, USA
| | - Ariela R Orkaby
- Department of Medicine, VA Boston Healthcare System, Boston, MA, USA.
- Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.
- New England GRECC (Geriatric Research, Education, and Clinical Center) VA Boston Healthcare System, 150 South Huntington, 02130, Boston, MA, USA.
| |
Collapse
|
18
|
D'Amario D, Galli M, Cappannoli L, Canonico F, Restivo A, Arcudi A, Scacciavillani R, Riccioni ME, Vergallo R, Montone RA, Conte A, Meleo E, Lancellotti S, Sacco M, Antonelli M, Andreotti F, DE Cristofaro R, Crea F. Oral anticoagulants in fragile patients with percutaneous endoscopic gastrostomy and atrial fibrillation: the ORIGAMI pilot investigation. Minerva Cardiol Angiol 2023; 71:109-116. [PMID: 35166091 DOI: 10.23736/s2724-5683.21.05903-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Extensive data support the superior safety without any trade-off in efficacy of direct oral anticoagulants (DOACs) compared to vitamin K antagonists (VKA) in patients with nonvalvular atrial fibrillation, deep venous thrombosis or pulmonary embolism. Whether DOACs may be successfully used to treat complex and fragile patients with percutaneous endoscopic gastrostomy (PEG) remains to be proven. The purpose of this pilot study was to evaluate the feasibility, anticoagulant effect, and preliminary safety/efficacy profile of edoxaban administered via PEG in patients with an indication for long-term oral anticoagulation. METHODS In this prospective, single-arm, pilot study, 12 patients with PEG and guideline-recommended indication for anticoagulation for nonvalvular atrial fibrillation were prospectively enrolled. Crushed edoxaban at approved doses was administered via PEG. Quantitative measures of edoxaban's antifactor Xa activity were performed at steady state. Thromboembolic and bleeding events were assessed at one-month follow-up. RESULTS Steady state edoxaban plasma levels were at therapeutic range in all patients; mean plasma concentration was 208.5 (±78.6) ng/mL. At one month follow-up, none had suffered a thromboembolic event; one developed minor bleeding, and one died from non-cardiovascular death, owing to sudden worsening of a pre-existing underlying severe condition. CONCLUSIONS In this pilot investigation, we report for the first time that crushed edoxaban, administered at approved doses through PEG in fragile and complex patients, is feasible, results in therapeutic edoxaban concentrations, and is apparently effective and safe.
Collapse
Affiliation(s)
- Domenico D'Amario
- Department of Cardiovascular Sciences, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy - .,Sacred Heart Catholic University, Rome, Italy -
| | - Mattia Galli
- Department of Cardiovascular Sciences, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy.,Sacred Heart Catholic University, Rome, Italy
| | | | - Francesco Canonico
- Department of Cardiovascular Sciences, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | | | | | | | | | - Rocco Vergallo
- Department of Cardiovascular Sciences, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy.,Sacred Heart Catholic University, Rome, Italy
| | - Rocco A Montone
- Department of Cardiovascular Sciences, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Amelia Conte
- NEMO Center, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Emiliana Meleo
- NEMO Center, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | | | | | - Massimo Antonelli
- Sacred Heart Catholic University, Rome, Italy.,NEMO Center, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy.,Department of Emergency Sciences, Anesthesiology and Intensive Care, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Felicita Andreotti
- Department of Cardiovascular Sciences, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy.,Sacred Heart Catholic University, Rome, Italy
| | - Raimondo DE Cristofaro
- Sacred Heart Catholic University, Rome, Italy.,NEMO Center, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy.,Department of Emergency Sciences, Anesthesiology and Intensive Care, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy.,Section of Hemorrhagic and Thrombotic Diseases, Department of Medicine and Translational Surgery, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular Sciences, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy.,Sacred Heart Catholic University, Rome, Italy
| |
Collapse
|
19
|
Ballestri S, Romagnoli E, Arioli D, Coluccio V, Marrazzo A, Athanasiou A, Di Girolamo M, Cappi C, Marietta M, Capitelli M. Risk and Management of Bleeding Complications with Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Venous Thromboembolism: a Narrative Review. Adv Ther 2023; 40:41-66. [PMID: 36244055 PMCID: PMC9569921 DOI: 10.1007/s12325-022-02333-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/21/2022] [Indexed: 01/25/2023]
Abstract
Atrial fibrillation (AF) and venous thromboembolism (VTE) are highly prevalent conditions with a significant healthcare burden, and represent the main indications for anticoagulation. Direct oral anticoagulants (DOACs) are the first choice treatment of AF/VTE, and have become the most prescribed class of anticoagulants globally, overtaking vitamin K antagonists (VKAs). Compared to VKAs, DOACs have a similar or better efficacy/safety profile, with reduced risk of intracerebral hemorrhage (ICH), while the risk of major bleeding and other bleeding harms may vary depending on the type of DOAC. We have critically reviewed available evidence from randomized controlled trials and observational studies regarding the risk of bleeding complications of DOACs compared to VKAs in patients with AF and VTE. Special patient populations (e.g., elderly, extreme body weights, chronic kidney disease) have specifically been addressed. Management of bleeding complications and possible resumption of anticoagulation, in particular after ICH and gastrointestinal bleeding, are also discussed. Finally, some suggestions are provided to choose the optimal DOAC to minimize adverse events according to individual patient characteristics and bleeding risk.
Collapse
Affiliation(s)
- Stefano Ballestri
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy.
| | - Elisa Romagnoli
- Internal Medicine and Critical Care Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Dimitriy Arioli
- Internal Medicine and Critical Care Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Valeria Coluccio
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Alessandra Marrazzo
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Afroditi Athanasiou
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Maria Di Girolamo
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Cinzia Cappi
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Marco Marietta
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Mariano Capitelli
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| |
Collapse
|
20
|
Desai R, Li A, Mondal A, Shenwai P, Merugu B, Guzman FJN, Jain A. Direct Oral Anticoagulants Versus Vitamin K Antagonist (Warfarin) For Stroke Prevention In Frail Patients With Atrial Fibrillation: A Meta-Analysis. Proc AMIA Symp 2023; 36:274-275. [PMID: 36876251 PMCID: PMC9980567 DOI: 10.1080/08998280.2022.2155926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Rupak Desai
- Independent Outcomes Researcher, Atlanta, Georgia
| | - Aobo Li
- Department of Internal Medicine, Beijing Anzhen Hospital, Beijing, China
| | - Avilash Mondal
- Internal Medicine, Nazareth Hospital Philadelphia, Philadelphia, Pennsylvania
| | - Priya Shenwai
- Department of Surgery, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York
| | - Bhavyasri Merugu
- Department of Medicine, Vydehi Institute of Medical Sciences and Research Centre, Karnataka, India
| | | | - Akhil Jain
- Department of Internal Medicine, Mercy Catholic Medical Center, Darby, Pennsylvania
| |
Collapse
|
21
|
Cappannoli L, Laborante R, Galli M, Canonico F, Ciliberti G, Restivo A, Princi G, Arcudi A, Sabatelli M, De Cristofaro R, Crea F, D’Amario D. Feasibility, effectiveness, and safety of edoxaban administration through percutaneous endoscopic gastrostomy: 12-months follow up of the ORIGAMI study. Front Cardiovasc Med 2022; 9:1052053. [PMID: 36620634 PMCID: PMC9815104 DOI: 10.3389/fcvm.2022.1052053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
Background and aims Edoxaban proved to be safe and effective also in fragile patients, but its administration through percutaneous endoscopic gastrostomy (PEG) has not been previously investigated. The purpose of this study was to evaluate the feasibility and the preliminary safety and efficacy profiles of edoxaban administered via PEG in patients with an indication for long-term oral anticoagulation. Methods ORIGAMI was a prospective, single-arm, observational study (NCT04271293). Patients with PEG and an indication for long-term anticoagulation were prospectively enrolled. Crushed edoxaban at approved doses was administered via PEG. The primary endpoint was the composite of cardio-embolic events consisting of ischemic stroke, systemic embolism, or symptomatic deep venous thrombosis/pulmonary embolism (DVT/PE). Secondary endpoints were the number of bleeding events and edoxaban plasma concentrations at steady state. We here report the 12-month results. Results A total of 12 patients were enrolled. The main indication for PEG implantation was amyotrophic lateral sclerosis (10/12). The primary endpoint of cardio-embolic events did not occur in any patients at 12 months. All patients were in the therapeutic range of steady-state edoxaban plasma levels. Three minor bleedings were observed, while no major bleedings occurred during the observational period. A total of five patients died. All deaths were from non-cardiovascular causes and were consistent with the natural history of the pre-existing severe disease. Conclusion Our study suggests that edoxaban administration via PEG is feasible and appears safe and effective in fragile, comorbid patients, resulting in therapeutic plasma concentrations of edoxaban. Clinical trial registration [ClinicalTrials.gov], identifier [NCT04271293].
Collapse
Affiliation(s)
- Luigi Cappannoli
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,Università Cattolica del Sacro Cuore (UCSC), Rome, Italy
| | - Renzo Laborante
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,Università Cattolica del Sacro Cuore (UCSC), Rome, Italy
| | - Mattia Galli
- Università Cattolica del Sacro Cuore (UCSC), Rome, Italy,Gruppo Villa Maria (GVM) Care & Research, Maria Cecilia Hospital, Cotignola, Italy
| | - Francesco Canonico
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giuseppe Ciliberti
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,Università Cattolica del Sacro Cuore (UCSC), Rome, Italy
| | - Attilio Restivo
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,Università Cattolica del Sacro Cuore (UCSC), Rome, Italy
| | - Giuseppe Princi
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,Università Cattolica del Sacro Cuore (UCSC), Rome, Italy
| | - Alessandra Arcudi
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,Università Cattolica del Sacro Cuore (UCSC), Rome, Italy
| | - Mario Sabatelli
- Università Cattolica del Sacro Cuore (UCSC), Rome, Italy,Centro NEuroMuscular Omnicenter (NEMO), Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Raimondo De Cristofaro
- Università Cattolica del Sacro Cuore (UCSC), Rome, Italy,Servizio Malattie Emorragiche e Trombotiche, Dipartimento di Medicina e Chirurgia Traslazionale, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Filippo Crea
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,Università Cattolica del Sacro Cuore (UCSC), Rome, Italy
| | - Domenico D’Amario
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,Università Cattolica del Sacro Cuore (UCSC), Rome, Italy,*Correspondence: Domenico D’Amario, ;
| |
Collapse
|
22
|
Bai W, Hao B, Meng W, Qin J, Xu W, Qin L. Association between frailty and short- and long-term mortality in patients with critical acute myocardial infarction: Results from MIMIC-IV. Front Cardiovasc Med 2022; 9:1056037. [PMID: 36588580 PMCID: PMC9797732 DOI: 10.3389/fcvm.2022.1056037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022] Open
Abstract
Background Frailty has been recognized as an important prognostic indicator in patients with acute myocardial infarction (AMI). However, no study has focused on critical AMI patients. We aimed to determine the impact of frailty on short- and long-term mortality risk in critical AMI patients. Methods Data from the Medical Information Mart for Intensive Care (MIMIC)-IV database was used. Frailty was assessed using the Hospital Frailty Risk Score (HFRS). Outcomes were in-hospital mortality and 1-year mortality. Logistic regression and Cox proportional-hazards models were used to investigate the association between frailty and outcomes. Results Among 5,003 critical AMI patients, 2,176 were non-frail (43.5%), 2,355 were pre-frail (47.1%), and 472 were frail (9.4%). The in-hospital mortality rate was 13.8%, and the 1-year mortality rate was 29.5%. In our multivariable model, frailty was significantly associated with in-hospital mortality [odds ratio (OR) = 1.30, 95% confidence interval (CI): 1.20-1.41] and 1-year mortality [hazard ratio (HR) = 1.29, 95% CI: 1.24-1.35] as a continuous variable (per five-score increase). When assessed as categorical variables, pre-frailty and frailty were both associated with in-hospital mortality (OR = 2.80, 95% CI: 2.19-3.59 and OR = 2.69, 95% CI: 1.93-3.73, respectively) and 1-year mortality (HR = 2.32, 95% CI: 2.00-2.69 and HR = 2.81, 95% CI: 2.33-3.39, respectively) after adjustment for confounders. Subgroup analysis showed that frailty was only associated with in-hospital mortality in critically ill patients with non-ST-segment elevation myocardial infarction (STEMI) but not STEMI (p for interaction = 0.012). In addition, frailty was associated with 1-year mortality in both STEMI and non-STEMI patients (p for interaction = 0.447). The addition of frailty produced the incremental value over the initial model generated by baseline characteristics for both in-hospital and 1-year mortality. Conclusion Frailty, as assessed by the HFRS, was associated with both in-hospital and 1-year mortality in critical AMI patients. Frailty improves the prediction of short- and long-term mortality in critical AMI patients and may have potential clinical applications.
Collapse
Affiliation(s)
- Weimin Bai
- Department of Emergency, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, People’s Hospital of Henan University, Zhengzhou, China
| | - Benchuan Hao
- Medical School of Chinese People’s Liberation Army (PLA), Beijing, China,Department of Cardiology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Wenwen Meng
- The Northern District of PLA General Hospital, Beijing, China
| | - Ji Qin
- Medical School of Chinese People’s Liberation Army (PLA), Beijing, China,Department of Cardiology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Weihao Xu
- Haikou Cadre’s Sanitarium of Hainan Military Region, Haikou, China,*Correspondence: Weihao Xu,
| | - Lijie Qin
- Department of Emergency, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, People’s Hospital of Henan University, Zhengzhou, China,Lijie Qin,
| |
Collapse
|
23
|
Presta R, Brunetti E, Polidori MC, Bo M. Impact of frailty models on the prescription of oral anticoagulants and on the incidence of stroke, bleeding, and mortality in older patients with atrial fibrillation: a systematic review. Ageing Res Rev 2022; 82:101761. [PMID: 36270605 DOI: 10.1016/j.arr.2022.101761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/30/2022] [Accepted: 10/14/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Frailty is common in older patients with atrial fibrillation (AF). Current guidelines recommend oral anticoagulant therapy (OAT) except in case of severe frailty or reduced life expectancy, but definitive evidence on which "frailty" tools may help to identify older AF patients expected to derive little or no benefit from OAT is still lacking. Some persistent uncertainties may derive from the different clinical implications that the two major models of frailty, namely the frail phenotype (FP) and the deficit accumulation model (DAM), underlie. We thus conducted a systematic review of published studies to examine the association of the presence of frailty, categorized according to the FP and DAM, with 1) OAT prescription and 2) incidence of clinical outcomes (all-cause mortality, stroke and/or systemic embolism and major or clinically relevant non-major bleeding) in patients receiving OAT. METHODS Embase and MEDLINE were searched from inception until May 31st, 2022, for studies using a validated tool to identify frailty in subjects aged 65 years or older with a diagnosis of non-valvular AF; only studies on patients prescribed an OAT were considered eligible for the analyses involving clinical outcomes. The protocols for each review question have been registered in PROSPERO database (CRD42022308623 and CRD42022308628). FINDINGS Twenty-three studies exploring the association between frailty and OAT prescription on a total of 504 719 subjects were included. Patients with increasing severity of DAM frailty showed consistently lower OAT prescription rates than non-frail patients, whereas use of OAT did not significantly differ between patients with the FP compared with non-frail subjects. Eleven studies exploring the association between frailty and clinical outcomes on a total of 41 985 individuals receiving oral anticoagulation were included. Compared with non-frail subjects, a higher risk of all-cause mortality and clinical outcomes could be observed for AF patients prescribed with OAT with severe frailty according to the DAM, with inconclusive findings for the FP. High levels of heterogeneity were observed in both groups of studies; therefore, a meta-analysis was not performed. CONCLUSIONS Due to the great heterogeneity among different validated frailty measures, indiscriminately relying on "frailty" should not be regarded as the gold standard for clinical decision-making about stroke prevention in older AF patients. Present findings suggest that severe frailty according to the DAM is associated with less use of OAT and increased risk of all-cause mortality, thereby representing at the moment the most reasonable tool to efficiently recognize patients with limited life expectancy and for whom there is so far scant, if any, evidence of a clinical benefit of OAT.
Collapse
Affiliation(s)
- Roberto Presta
- Section of Geriatrics, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Molinette, Corso Bramante 88-90, 10126 Turin, Italy.
| | - Enrico Brunetti
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; Section of Internal Medicine, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Sant'Anna, Corso Bramante 88-90, 10126 Turin, Italy.
| | - Maria Cristina Polidori
- Ageing Clinical Research, Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937 Cologne, Germany; Cologne Excellence Cluster On Cellular Stress-Responses in Aging-Associated Diseases (CECAD), University of Cologne, Faculty of Medicine and University Hospital Cologne, Joseph-Stelzmann Straße 26, 50931 Cologne, Germany.
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza - Molinette, Corso Bramante 88-90, 10126 Turin, Italy.
| |
Collapse
|
24
|
Guo Y, Romiti GF, Proietti M, Bonini N, Zhang H, Lip GYH. Mobile health technology integrated care in older atrial fibrillation patients: a subgroup analysis of the mAFA-II randomised clinical trial. Age Ageing 2022; 51:6806168. [PMID: 36370146 DOI: 10.1093/ageing/afac245] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 07/03/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The Mobile Health Technology for Improved Screening and Optimized Integrated Care in AF (mAFA-II) randomised trial demonstrated the efficacy of a mobile health (mHealth) technology-implemented 'Atrial fibrillation Better Care' (ABC) pathway-approach (mAFA intervention) in reducing the risk of adverse events in patients with atrial fibrillation (AF). Whether these benefits also apply to older patients is unclear. In this ancillary analysis, we evaluated the effect of mAFA intervention among older AF patients. METHODS The mAFA-II trial enrolled adult AF patients across 40 centres in China. For this analysis, we defined older patients as those aged ≥75 years. Primary outcome was the composite of ischemic stroke or thromboembolism, all-cause death and rehospitalisation. The effect of mAFA intervention was assessed through multivariable Cox-regression models. We also evaluated the interaction between age and effect of the mAFA intervention in the main trial population. RESULTS In this analysis, we included 1,163 AF patients ≥75 years (mean age: 82.6 ± 5.3 years, 43.1% females); 520 were allocated to mAFA intervention, 643 to usual care. mAFA intervention was associated with a significant reduction of the primary composite outcome (adjusted hazard ratio [aHR]: 0.58, 95% confidence interval [CI]: 0.35-0.97) and rehospitalisations alone (aHR: 0.47, 95%CI: 0.24-0.91). Significant interaction between age and mAFA intervention effect was observed for both the composite outcome (P = 0.002) and rehospitalisation alone (P = 0.015), with the effect decreasing as age increased, particularly among patients ≥80 years old. CONCLUSIONS A mHealth technology-implemented ABC pathway is effective in reducing adverse clinical outcomes in older AF patients. The benefits obtained with mAFA intervention were attenuated at extreme ages.
Collapse
Affiliation(s)
- Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
- Liverpool Centre for Cardiovascular Sciences at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Sciences at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Sciences at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Niccolò Bonini
- Liverpool Centre for Cardiovascular Sciences at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Hui Zhang
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Gregory Y H Lip
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
- Liverpool Centre for Cardiovascular Sciences at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| |
Collapse
|
25
|
Andrew MK, Matthews S, Kim JH, Riley ME, Curran D. An Easy-to-Implement Clinical-Trial Frailty Index Based on Accumulation of Deficits: Validation in Zoster Vaccine Clinical Trials. Clin Interv Aging 2022; 17:1261-1274. [PMID: 36017192 PMCID: PMC9397533 DOI: 10.2147/cia.s364997] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 07/02/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Despite being among those most in need of protection, frail older adults are often not well represented in clinical trials. Although frailty likely influences responses to treatments and vaccines, frailty may not be explicitly considered in trials even when frail participants are enrolled due to the perception that frailty is difficult to measure effectively and efficiently without adding to participant or data collection burden. We developed an easy-to-implement frailty index, the Clinical Trial-Frailty Index (CT-FI), based on baseline medical history and standard patient-reported outcomes using data from clinical trials of recombinant Zoster vaccine (the ZOE-50 and ZOE-70 studies). Our objective was to demonstrate that the CT-FI is a robust measure that may be used retrospectively or prospectively in clinical trials where sufficient patient data have been collected. Methods The CT-FI was based on baseline medical history and Quality of Life questionnaires (SF-36 and EQ-5D). Items meeting criteria for inclusion were scored from 0 to 1, then summed for each participant and divided by the total number of deficits considered. Validation analyses included descriptive verification of distribution and age- and sex-associations in relation to usual patterns of the frailty index, regressions in relation to outcomes hypothesized to be related to frailty, and resampling methods within the index. Results The CT-FI distribution was well represented by a gamma distribution with a range of 0–0.70. Deficit accumulation increased with chronological age and was higher for females. Multivariate Cox regression survival analysis showed that the CT-FI, age, and sex were significant predictors of mortality. Jackknife and Bootstrap resampling methods highlighted the robustness of the CT-FI, which was not sensitive to inclusion/exclusion of specific individual or groups of variables. Conclusion We have developed a reliable, robust and easy-to-implement CT-FI with potential retrospective or prospective application in other clinical trials. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/VbOCDZYBxwI
Collapse
Affiliation(s)
- Melissa K Andrew
- Department of Medicine (Division of Geriatric Medicine), Dalhousie University, Halifax, Nova Scotia, Canada
| | | | | | | | | |
Collapse
|
26
|
Affiliation(s)
- Chris Wilkinson
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, Tyne and Wear, UK .,Hull York Medical School, University of York, York, North Yorkshire, UK.,Academic Cardiovascular Unit, South Tees NHS Foundation Trust, Middlesbrough, UK
| | - Kenneth Rockwood
- Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| |
Collapse
|
27
|
Akishita M, Suzuki S, Inoue H, Akao M, Atarashi H, Ikeda T, Koretsune Y, Okumura K, Shimizu W, Tsutsui H, Toyoda K, Hirayama A, Yasaka M, Yamaguchi T, Teramukai S, Kimura T, Morishima Y, Takita A, Yamashita T. Frailty screening index and atrial fibrillation outcomes in the All Nippon AF In the Elderly registry. Geriatr Gerontol Int 2022; 22:899-902. [DOI: 10.1111/ggi.14458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 07/24/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Masahiro Akishita
- Department of Geriatric Medicine, Graduate School of Medicine The University of Tokyo Tokyo Japan
| | | | | | - Masaharu Akao
- Department of Cardiology National Hospital Organization Kyoto Medical Center Kyoto Japan
| | | | - Takanori Ikeda
- Department of Cardiovascular Medicine Toho University Faculty of Medicine Tokyo Japan
| | | | - Ken Okumura
- Division of Cardiology Saiseikai Kumamoto Hospital Cardiovascular Center Kumamoto Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine Nippon Medical School Tokyo Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences Kyushu University Fukuoka Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Osaka Japan
| | | | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Cerebrovascular Center National Hospital Organization Kyushu Medical Center Fukuoka Japan
| | - Takenori Yamaguchi
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Osaka Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Tetsuya Kimura
- Primary Medical Science Department Daiichi Sankyo Tokyo Japan
| | | | - Atsushi Takita
- Data Intelligence Department, Daiichi Sankyo Co., Ltd. Tokyo Japan
| | | |
Collapse
|
28
|
Proietti M, Romiti GF, Vitolo M, Harrison SL, Lane DA, Fauchier L, Marin F, Näbauer M, Potpara TS, Dan GA, Maggioni AP, Cesari M, Boriani G, Lip GYH, Ekmekçiu U, Paparisto V, Tase M, Gjergo H, Dragoti J, Goda A, Ciutea M, Ahadi N, el Husseini Z, Raepers M, Leroy J, Haushan P, Jourdan A, Lepiece C, Desteghe L, Vijgen J, Koopman P, Van Genechten G, Heidbuchel H, Boussy T, De Coninck M, Van Eeckhoutte H, Bouckaert N, Friart A, Boreux J, Arend C, Evrard P, Stefan L, Hoffer E, Herzet J, Massoz M, Celentano C, Sprynger M, Pierard L, Melon P, Van Hauwaert B, Kuppens C, Faes D, Van Lier D, Van Dorpe A, Gerardy A, Deceuninck O, Xhaet O, Dormal F, Ballant E, Blommaert D, Yakova D, Hristov M, Yncheva T, Stancheva N, Tisheva S, Tokmakova M, Nikolov F, Gencheva D, Shalganov T, Kunev B, Stoyanov M, Marchov D, Gelev V, Traykov V, Kisheva A, Tsvyatkov H, Shtereva R, Bakalska-Georgieva S, Slavcheva S, Yotov Y, Kubíčková M, Marni Joensen A, Gammelmark A, Hvilsted Rasmussen L, Dinesen P, Riahi S, Krogh Venø S, Sorensen B, Korsgaard A, Andersen K, Fragtrup Hellum C, Svenningsen A, Nyvad O, Wiggers P, May O, Aarup A, Graversen B, Jensen L, Andersen M, Svejgaard M, Vester S, Hansen S, Lynggaard V, Ciudad M, Vettus R, Muda P, Maestre A, Castaño S, Cheggour S, Poulard J, Mouquet V, Leparrée S, Bouet J, Taieb J, Doucy A, Duquenne H, Furber A, Dupuis J, Rautureau J, Font M, Damiano P, Lacrimini M, Abalea J, Boismal S, Menez T, Mansourati J, Range G, Gorka H, Laure C, Vassalière C, Elbaz N, Lellouche N, Djouadi K, Roubille F, Dietz D, Davy J, Granier M, Winum P, Leperchois-Jacquey C, Kassim H, Marijon E, Le Heuzey J, Fedida J, Maupain C, Himbert C, Gandjbakhch E, Hidden-Lucet F, Duthoit G, Badenco N, Chastre T, Waintraub X, Oudihat M, Lacoste J, Stephan C, Bader H, Delarche N, Giry L, Arnaud D, Lopez C, Boury F, Brunello I, Lefèvre M, Mingam R, Haissaguerre M, Le Bidan M, Pavin D, Le Moal V, Leclercq C, Piot O, Beitar T, Martel I, Schmid A, Sadki N, Romeyer-Bouchard C, Da Costa A, Arnault I, Boyer M, Piat C, Fauchier L, Lozance N, Nastevska S, Doneva A, Fortomaroska Milevska B, Sheshoski B, Petroska K, Taneska N, Bakrecheski N, Lazarovska K, Jovevska S, Ristovski V, Antovski A, Lazarova E, Kotlar I, Taleski J, Poposka L, Kedev S, Zlatanovik N, Jordanova S, Bajraktarova Proseva T, Doncovska S, Maisuradze D, Esakia A, Sagirashvili E, Lartsuliani K, Natelashvili N, Gumberidze N, Gvenetadze R, Etsadashvili K, Gotonelia N, Kuridze N, Papiashvili G, Menabde I, Glöggler S, Napp A, Lebherz C, Romero H, Schmitz K, Berger M, Zink M, Köster S, Sachse J, Vonderhagen E, Soiron G, Mischke K, Reith R, Schneider M, Rieker W, Boscher D, Taschareck A, Beer A, Oster D, Ritter O, Adamczewski J, Walter S, Frommhold A, Luckner E, Richter J, Schellner M, Landgraf S, Bartholome S, Naumann R, Schoeler J, Westermeier D, William F, Wilhelm K, Maerkl M, Oekinghaus R, Denart M, Kriete M, Tebbe U, Scheibner T, Gruber M, Gerlach A, Beckendorf C, Anneken L, Arnold M, Lengerer S, Bal Z, Uecker C, Förtsch H, Fechner S, Mages V, Martens E, Methe H, Schmidt T, Schaeffer B, Hoffmann B, Moser J, Heitmann K, Willems S, Willems S, Klaus C, Lange I, Durak M, Esen E, Mibach F, Mibach H, Utech A, Gabelmann M, Stumm R, Ländle V, Gartner C, Goerg C, Kaul N, Messer S, Burkhardt D, Sander C, Orthen R, Kaes S, Baumer A, Dodos F, Barth A, Schaeffer G, Gaertner J, Winkler J, Fahrig A, Aring J, Wenzel I, Steiner S, Kliesch A, Kratz E, Winter K, Schneider P, Haag A, Mutscher I, Bosch R, Taggeselle J, Meixner S, Schnabel A, Shamalla A, Hötz H, Korinth A, Rheinert C, Mehltretter G, Schön B, Schön N, Starflinger A, Englmann E, Baytok G, Laschinger T, Ritscher G, Gerth A, Dechering D, Eckardt L, Kuhlmann M, Proskynitopoulos N, Brunn J, Foth K, Axthelm C, Hohensee H, Eberhard K, Turbanisch S, Hassler N, Koestler A, Stenzel G, Kschiwan D, Schwefer M, Neiner S, Hettwer S, Haeussler-Schuchardt M, Degenhardt R, Sennhenn S, Steiner S, Brendel M, Stoehr A, Widjaja W, Loehndorf S, Logemann A, Hoskamp J, Grundt J, Block M, Ulrych R, Reithmeier A, Panagopoulos V, Martignani C, Bernucci D, Fantecchi E, Diemberger I, Ziacchi M, Biffi M, Cimaglia P, Frisoni J, Boriani G, Giannini I, Boni S, Fumagalli S, Pupo S, Di Chiara A, Mirone P, Fantecchi E, Boriani G, Pesce F, Zoccali C, Malavasi VL, Mussagaliyeva A, Ahyt B, Salihova Z, Koshum-Bayeva K, Kerimkulova A, Bairamukova A, Mirrakhimov E, Lurina B, Zuzans R, Jegere S, Mintale I, Kupics K, Jubele K, Erglis A, Kalejs O, Vanhear K, Burg M, Cachia M, Abela E, Warwicker S, Tabone T, Xuereb R, Asanovic D, Drakalovic D, Vukmirovic M, Pavlovic N, Music L, Bulatovic N, Boskovic A, Uiterwaal H, Bijsterveld N, De Groot J, Neefs J, van den Berg N, Piersma F, Wilde A, Hagens V, Van Es J, Van Opstal J, Van Rennes B, Verheij H, Breukers W, Tjeerdsma G, Nijmeijer R, Wegink D, Binnema R, Said S, Erküner Ö, Philippens S, van Doorn W, Crijns H, Szili-Torok T, Bhagwandien R, Janse P, Muskens A, van Eck M, Gevers R, van der Ven N, Duygun A, Rahel B, Meeder J, Vold A, Holst Hansen C, Engset I, Atar D, Dyduch-Fejklowicz B, Koba E, Cichocka M, Sokal A, Kubicius A, Pruchniewicz E, Kowalik-Sztylc A, Czapla W, Mróz I, Kozlowski M, Pawlowski T, Tendera M, Winiarska-Filipek A, Fidyk A, Slowikowski A, Haberka M, Lachor-Broda M, Biedron M, Gasior Z, Kołodziej M, Janion M, Gorczyca-Michta I, Wozakowska-Kaplon B, Stasiak M, Jakubowski P, Ciurus T, Drozdz J, Simiera M, Zajac P, Wcislo T, Zycinski P, Kasprzak J, Olejnik A, Harc-Dyl E, Miarka J, Pasieka M, Ziemińska-Łuć M, Bujak W, Śliwiński A, Grech A, Morka J, Petrykowska K, Prasał M, Hordyński G, Feusette P, Lipski P, Wester A, Streb W, Romanek J, Woźniak P, Chlebuś M, Szafarz P, Stanik W, Zakrzewski M, Kaźmierczak J, Przybylska A, Skorek E, Błaszczyk H, Stępień M, Szabowski S, Krysiak W, Szymańska M, Karasiński J, Blicharz J, Skura M, Hałas K, Michalczyk L, Orski Z, Krzyżanowski K, Skrobowski A, Zieliński L, Tomaszewska-Kiecana M, Dłużniewski M, Kiliszek M, Peller M, Budnik M, Balsam P, Opolski G, Tymińska A, Ozierański K, Wancerz A, Borowiec A, Majos E, Dabrowski R, Szwed H, Musialik-Lydka A, Leopold-Jadczyk A, Jedrzejczyk-Patej E, Koziel M, Lenarczyk R, Mazurek M, Kalarus Z, Krzemien-Wolska K, Starosta P, Nowalany-Kozielska E, Orzechowska A, Szpot M, Staszel M, Almeida S, Pereira H, Brandão Alves L, Miranda R, Ribeiro L, Costa F, Morgado F, Carmo P, Galvao Santos P, Bernardo R, Adragão P, Ferreira da Silva G, Peres M, Alves M, Leal M, Cordeiro A, Magalhães P, Fontes P, Leão S, Delgado A, Costa A, Marmelo B, Rodrigues B, Moreira D, Santos J, Santos L, Terchet A, Darabantiu D, Mercea S, Turcin Halka V, Pop Moldovan A, Gabor A, Doka B, Catanescu G, Rus H, Oboroceanu L, Bobescu E, Popescu R, Dan A, Buzea A, Daha I, Dan G, Neuhoff I, Baluta M, Ploesteanu R, Dumitrache N, Vintila M, Daraban A, Japie C, Badila E, Tewelde H, Hostiuc M, Frunza S, Tintea E, Bartos D, Ciobanu A, Popescu I, Toma N, Gherghinescu C, Cretu D, Patrascu N, Stoicescu C, Udroiu C, Bicescu G, Vintila V, Vinereanu D, Cinteza M, Rimbas R, Grecu M, Cozma A, Boros F, Ille M, Tica O, Tor R, Corina A, Jeewooth A, Maria B, Georgiana C, Natalia C, Alin D, Dinu-Andrei D, Livia M, Daniela R, Larisa R, Umaar S, Tamara T, Ioachim Popescu M, Nistor D, Sus I, Coborosanu O, Alina-Ramona N, Dan R, Petrescu L, Ionescu G, Popescu I, Vacarescu C, Goanta E, Mangea M, Ionac A, Mornos C, Cozma D, Pescariu S, Solodovnicova E, Soldatova I, Shutova J, Tjuleneva L, Zubova T, Uskov V, Obukhov D, Rusanova G, Soldatova I, Isakova N, Odinsova S, Arhipova T, Kazakevich E, Serdechnaya E, Zavyalova O, Novikova T, Riabaia I, Zhigalov S, Drozdova E, Luchkina I, Monogarova Y, Hegya D, Rodionova L, Rodionova L, Nevzorova V, Soldatova I, Lusanova O, Arandjelovic A, Toncev D, Milanov M, Sekularac N, Zdravkovic M, Hinic S, Dimkovic S, Acimovic T, Saric J, Polovina M, Potpara T, Vujisic-Tesic B, Nedeljkovic M, Zlatar M, Asanin M, Vasic V, Popovic Z, Djikic D, Sipic M, Peric V, Dejanovic B, Milosevic N, Stevanovic A, Andric A, Pencic B, Pavlovic-Kleut M, Celic V, Pavlovic M, Petrovic M, Vuleta M, Petrovic N, Simovic S, Savovic Z, Milanov S, Davidovic G, Iric-Cupic V, Simonovic D, Stojanovic M, Stojanovic S, Mitic V, Ilic V, Petrovic D, Deljanin Ilic M, Ilic S, Stoickov V, Markovic S, Kovacevic S, García Fernandez A, Perez Cabeza A, Anguita M, Tercedor Sanchez L, Mau E, Loayssa J, Ayarra M, Carpintero M, Roldán Rabadan I, Leal M, Gil Ortega M, Tello Montoliu A, Orenes Piñero E, Manzano Fernández S, Marín F, Romero Aniorte A, Veliz Martínez A, Quintana Giner M, Ballesteros G, Palacio M, Alcalde O, García-Bolao I, Bertomeu Gonzalez V, Otero-Raviña F, García Seara J, Gonzalez Juanatey J, Dayal N, Maziarski P, Gentil-Baron P, Shah D, Koç M, Onrat E, Dural IE, Yilmaz K, Özin B, Tan Kurklu S, Atmaca Y, Canpolat U, Tokgozoglu L, Dolu AK, Demirtas B, Sahin D, Ozcan Celebi O, Diker E, Gagirci G, Turk UO, Ari H, Polat N, Toprak N, Sucu M, Akin Serdar O, Taha Alper A, Kepez A, Yuksel Y, Uzunselvi A, Yuksel S, Sahin M, Kayapinar O, Ozcan T, Kaya H, Yilmaz MB, Kutlu M, Demir M, Gibbs C, Kaminskiene S, Bryce M, Skinner A, Belcher G, Hunt J, Stancombe L, Holbrook B, Peters C, Tettersell S, Shantsila A, Lane D, Senoo K, Proietti M, Russell K, Domingos P, Hussain S, Partridge J, Haynes R, Bahadur S, Brown R, McMahon S, Y H Lip G, McDonald J, Balachandran K, Singh R, Garg S, Desai H, Davies K, Goddard W, Galasko G, Rahman I, Chua Y, Payne O, Preston S, Brennan O, Pedley L, Whiteside C, Dickinson C, Brown J, Jones K, Benham L, Brady R, Buchanan L, Ashton A, Crowther H, Fairlamb H, Thornthwaite S, Relph C, McSkeane A, Poultney U, Kelsall N, Rice P, Wilson T, Wrigley M, Kaba R, Patel T, Young E, Law J, Runnett C, Thomas H, McKie H, Fuller J, Pick S, Sharp A, Hunt A, Thorpe K, Hardman C, Cusack E, Adams L, Hough M, Keenan S, Bowring A, Watts J, Zaman J, Goffin K, Nutt H, Beerachee Y, Featherstone J, Mills C, Pearson J, Stephenson L, Grant S, Wilson A, Hawksworth C, Alam I, Robinson M, Ryan S, Egdell R, Gibson E, Holland M, Leonard D, Mishra B, Ahmad S, Randall H, Hill J, Reid L, George M, McKinley S, Brockway L, Milligan W, Sobolewska J, Muir J, Tuckis L, Winstanley L, Jacob P, Kaye S, Morby L, Jan A, Sewell T, Boos C, Wadams B, Cope C, Jefferey P, Andrews N, Getty A, Suttling A, Turner C, Hudson K, Austin R, Howe S, Iqbal R, Gandhi N, Brophy K, Mirza P, Willard E, Collins S, Ndlovu N, Subkovas E, Karthikeyan V, Waggett L, Wood A, Bolger A, Stockport J, Evans L, Harman E, Starling J, Williams L, Saul V, Sinha M, Bell L, Tudgay S, Kemp S, Brown J, Frost L, Ingram T, Loughlin A, Adams C, Adams M, Hurford F, Owen C, Miller C, Donaldson D, Tivenan H, Button H, Nasser A, Jhagra O, Stidolph B, Brown C, Livingstone C, Duffy M, Madgwick P, Roberts P, Greenwood E, Fletcher L, Beveridge M, Earles S, McKenzie D, Beacock D, Dayer M, Seddon M, Greenwell D, Luxton F, Venn F, Mills H, Rewbury J, James K, Roberts K, Tonks L, Felmeden D, Taggu W, Summerhayes A, Hughes D, Sutton J, Felmeden L, Khan M, Walker E, Norris L, O’Donohoe L, Mozid A, Dymond H, Lloyd-Jones H, Saunders G, Simmons D, Coles D, Cotterill D, Beech S, Kidd S, Wrigley B, Petkar S, Smallwood A, Jones R, Radford E, Milgate S, Metherell S, Cottam V, Buckley C, Broadley A, Wood D, Allison J, Rennie K, Balian L, Howard L, Pippard L, Board S, Pitt-Kerby T. Epidemiology and impact of frailty in patients with atrial fibrillation in Europe. Age Ageing 2022; 51:6670566. [PMID: 35997262 DOI: 10.1093/ageing/afac192] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 06/08/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent. OBJECTIVES We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients. METHODS A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined. RESULTS Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty. CONCLUSIONS In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.
Collapse
Affiliation(s)
- Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Translational and Precision Medicine, Sapienza - University of Rome, Italy
| | - Marco Vitolo
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Stephanie L Harrison
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Tours, France
| | - Francisco Marin
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, CIBER-CV, Murcia, Spain
| | - Michael Näbauer
- Department of Cardiology, Ludwig-Maximilians-University, Munich, Germany
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Clinical Center of Serbia, Belgrade, Serbia
| | - Gheorghe-Andrei Dan
- University of Medicine, 'Carol Davila', Colentina University Hospital, Bucharest, Romania
| | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Matteo Cesari
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Akashi S, Oguri M, Ikeno E, Manita M, Taura J, Watanabe S, Hayashi T, Akao M, Okumura K, Akishita M, Yamashita T. Outcomes and Safety of Very-Low-Dose Edoxaban in Frail Patients With Atrial Fibrillation in the ELDERCARE-AF Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2228500. [PMID: 35997978 PMCID: PMC9399878 DOI: 10.1001/jamanetworkopen.2022.28500] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The prevalence of atrial fibrillation (AF) increases with age and is more common in frail patients. However, data are lacking on outcomes of oral anticoagulants (OACs) in very elderly patients with AF with frailty, who are ineligible for standard anticoagulant treatment. OBJECTIVE To compare very-low-dose edoxaban (15 mg daily) vs placebo across frailty status, including each of 5 frailty assessment parameters, among patients with AF involved in the ELDERCARE-AF (Edoxaban Low-Dose for Elder Care Atrial Fibrillation Patients) trial. DESIGN, SETTING, AND PARTICIPANTS This is a cohort study using data from ELDERCARE-AF, a multicenter, randomized, double-blind, placebo-controlled phase 3 study of Japanese patients with AF aged 80 years or older who were ineligible for OACs at doses approved for stroke prevention because of their high bleeding risks. Eligible patients were randomly assigned (1:1) to receive edoxaban or placebo. The study duration was from August 5, 2016, to November 5, 2019, with the last patient followed up on December 27, 2019. Data analysis was performed from February 2021 to February 2022. EXPOSURE Edoxaban (15 mg) once daily or placebo. MAIN OUTCOMES AND MEASURES The primary efficacy end point was the composite of stroke or systemic embolism, and the primary safety end point was major bleeding. RESULTS A total of 984 patients were randomly assigned to treatment (492 each to the edoxaban and placebo groups); 944 patients (402 frail patients [42.6%]; 542 nonfrail patients [57.4%]; mean [SD] age, 86.6 [4.3] years; 541 women [57.3%]) were included in this analysis. In the placebo group, the estimated event rates (SE) for stroke or systemic embolism were 7.1% (1.6%) per patient-year in the frail group and 6.1% (1.3%) per patient-year in the nonfrail group. Edoxaban was associated with lower event rates for stroke or systemic embolism with no interaction with frailty status or frailty assessment parameters. Major bleeding and major or clinically relevant nonmajor bleeding events were both numerically higher in the edoxaban group than in the placebo group, and no heterogeneity was observed with frailty status. Although both all-cause death and net clinical composite outcome occurred more frequently in the frail group than in the nonfrail group, there was no association with frailty status between the edoxaban and placebo groups. CONCLUSIONS AND RELEVANCE Regardless of frailty status, among Japanese patients with AF aged 80 years or older who were ineligible for standard OACs, once-daily 15-mg edoxaban was associated with reduced incidence of stroke or systemic embolism and may be a suitable treatment option for these patients.
Collapse
Affiliation(s)
- Shintaro Akashi
- Division of Cardiology, National Hospital Organization Hamada Medical Center, Hamada, Japan
| | - Mitsutoshi Oguri
- Department of Cardiology, Kasugai Municipal Hospital, Kasugai, Japan
| | - Eiichiro Ikeno
- Department of Cardiology, Okitama Public General Hospital, Yamagata, Japan
| | - Mamoru Manita
- Cardiology Department, Naha Municipal Hospital, Naha, Japan
| | - Junki Taura
- Clinical Development Department III, Development Function, Research and Development Division, Daiichi Sankyo Co Ltd, Tokyo, Japan
| | - Saori Watanabe
- Clinical Development Department III, Development Function, Research and Development Division, Daiichi Sankyo Co Ltd, Tokyo, Japan
| | - Takuya Hayashi
- Data Intelligence Group, Data Intelligence Department, Digital Transformation Management Division, Daiichi Sankyo Co Ltd, Tokyo, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Masahiro Akishita
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| |
Collapse
|
30
|
Wilkinson C, Wu J, Clegg A, Nadarajah R, Rockwood K, Todd O, Gale CP. Impact of oral anticoagulation on the association between frailty and clinical outcomes in people with atrial fibrillation: nationwide primary care records on treatment analysis. Europace 2022; 24:1065-1075. [PMID: 35244709 PMCID: PMC9326851 DOI: 10.1093/europace/euac022] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/04/2022] [Indexed: 12/04/2022] Open
Abstract
AIMS People with atrial fibrillation (AF) frequently live with frailty, which increases the risk of mortality and stroke. This study reports the association between oral anticoagulation (OAC) and outcomes for people with frailty, and whether there is overall net benefit from treatment in people with AF. METHODS AND RESULTS Retrospective open cohort electronic records study. Frailty was identified using the electronic frailty index. Primary care electronic health records of 89 996 adults with AF and CHA2DS2-Vasc score of ≥2 were linked with secondary care and mortality data in the Clinical Practice Research Database (CPRD) from 1 January 1998 to 30 November 2018. The primary outcome was a composite of death, stroke, systemic embolism, or major bleeding. Secondary outcomes were stroke, major bleeding, all-cause mortality, transient ischaemic attack, and falls. Of 89 996 participants, 71 256 (79.2%) were living with frailty. The prescription of OAC increased with degree of frailty. For patients not prescribed OAC, rates of the primary outcome increased alongside frailty category. Prescription of OAC was associated with a reduction in the primary outcome for each frailty category [adjusted hazard ratio, 95% confidence interval, no OAC as reference; fit: vitamin K antagonist (VKA) 0.69, 0.64-0.75, direct oral anticoagulant (DOAC) 0.42, 0.33-0.53; mild frailty: VKA 0.52, 0.50-0.54, DOAC 0.57, 0.52-0.63; moderate: VKA 0.54, 0.52-0.56, DOAC 0.57, 0.52-0.63; severe: VKA 0.48, 0.45-0.51, DOAC 0.58, 0.52-0.65], with cumulative incidence function effects greater for DOAC than VKA. CONCLUSION Frailty among people with AF is common. The OAC was associated with a reduction in the primary endpoint across all degrees of frailty.
Collapse
Affiliation(s)
- Chris Wilkinson
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Jianhua Wu
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, 6.090a Worsley Building, Leeds LS2 9JT, UK
- Leeds Institute for Data Analytics, University of Leeds, 6.090a Worsley Building, Leeds LS2 9JT, UK
| | - Andrew Clegg
- Academic Unit for Ageing and Stroke Research, Leeds Institute of Health Sciences, University of Leeds, 6.090a Worsley Building, Leeds LS2 9JT, UK
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Ramesh Nadarajah
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, 6.090a Worsley Building, Leeds LS2 9JT, UK
- Leeds Institute for Data Analytics, University of Leeds, 6.090a Worsley Building, Leeds LS2 9JT, UK
| | - Kenneth Rockwood
- Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Oliver Todd
- Academic Unit for Ageing and Stroke Research, Leeds Institute of Health Sciences, University of Leeds, 6.090a Worsley Building, Leeds LS2 9JT, UK
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, 6.090a Worsley Building, Leeds LS2 9JT, UK
- Leeds Institute for Data Analytics, University of Leeds, 6.090a Worsley Building, Leeds LS2 9JT, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| |
Collapse
|
31
|
Zeng S, Zheng Y, Jiang J, Ma J, Zhu W, Cai X. Effectiveness and Safety of DOACs vs. Warfarin in Patients With Atrial Fibrillation and Frailty: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:907197. [PMID: 35811719 PMCID: PMC9263568 DOI: 10.3389/fcvm.2022.907197] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/31/2022] [Indexed: 11/20/2022] Open
Abstract
Background Patients with atrial fibrillation (AF) and frailty are a considerable group in clinical practice. However, existing studies provide insufficient evidence of anticoagulation strategies for these patients. Therefore, we conducted a meta-analysis to determine the effectiveness and safety outcomes of direct oral anticoagulants (DOACs) for these patients. Methods Randomized controlled trials or observational studies reporting the data about the DOACs and warfarin therapy among frail AF patients were included. The search was performed in the PubMed and Embase databases up to March 2022. Frailty was defined using the most widely used claims-based frailty index or the cumulative deficit model-based frailty index. Results A total of 4 studies involving 835,520 patients were included. Compared with warfarin, DOACs therapy reduced the risks of stroke or systemic embolism (HR = 0.79, 95%CI: 0.69–0.90), ischemic stroke (HR = 0.79, 95%CI: 0.71–0.87), hemorrhagic stroke (HR = 0.52, 95%CI: 0.35–0.76), and all-cause death (HR = 0.90, 95%CI: 0.84–0.96). In safety outcomes, DOACs was significantly associated with reduced risks of major bleeding (HR = 0.79, 95%CI: 0.64–0.97) and intracranial hemorrhage (HR = 0.58, 95%CI: 0.52–0.65) compared to warfarin, but there were no statistically differences in gastrointestinal bleeding (HR = 0.97, 95%CI: 0.73–1.29). Conclusions DOACs exerted superior effectiveness and safety outcome than warfarin in AF patients with frailty.
Collapse
Affiliation(s)
- Shan Zeng
- Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Department of Cardiology, First Affiliated Hospital, Ministry of Education, Gannan Medical University, Ganzhou, China
| | - Yuxiang Zheng
- Second Clinical Medical College, Nanchang University, Nanchang, China
| | - Jingzhou Jiang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jianyong Ma
- Department of Pharmacology and Systems Physiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Wengen Zhu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xingming Cai
- Department of Geriatric, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
32
|
Hohmann C, Lutz M, Vignali S, Borchert K, Seidel K, Braun S, Baldus S, Näbauer M. Clinical outcomes in patients receiving edoxaban or phenprocoumon for prevention of stroke in atrial fibrillation: a German real-world cohort study. Thromb J 2022; 20:37. [PMID: 35787710 PMCID: PMC9251920 DOI: 10.1186/s12959-022-00395-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 06/19/2022] [Indexed: 11/10/2022] Open
Abstract
Background Appropriate and timely anticoagulant therapy with vitamin K antagonists (VKAs) or non-vitamin K oral antagonists (NOACs) is essential for stroke prevention in non-valvular atrial fibrillation (NVAF). Comparative data regarding effectiveness and safety for edoxaban vs phenprocoumon, the predominant VKA in Germany, are scarce. Objectives The study evaluates effectiveness and safety of edoxaban vs phenprocoumon in NVAF patients in a German real-world setting. Methods German statutory health insurance claims data of the Institute for Applied Health Research Berlin (InGef) Research Database from 2014 until 2019 were analyzed. In NVAF patients, new users of edoxaban and phenprocoumon were compared to assess effectiveness (stroke/systemic embolism (SE)) and safety (bleeding) during therapy. Hazard ratios (HR) were estimated through multiple outcome-specific cox proportional hazard models adjusting for baseline characteristics. Outcomes of geriatric patients were analyzed in subgroup analyses. Results Between 2015 and 2018, 7,975 and 13,319 NVAF patients newly initiated treatment with edoxaban or phenprocoumon. After adjusting for baseline confounders, the risk of stroke/SE (HR: 0.85, 95% CI: 0.70–1.02) was numerically but not significantly lower, while the risk of major bleeding (HR: 0.69, 95% CI: 0.58–0.81) was significantly lower for edoxaban. In the geriatric subgroups, homogenous results compared to the main analysis were obtained. Conclusion The results of this real-world analysis indicated better effectiveness and safety outcomes in patients with NVAF initiating edoxaban treatment compared to phenprocoumon. The findings confirm that the beneficial effects observed in the pivotal ENGAGE AF-TMI 48 trial can also be achieved in real-world use of edoxaban. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-022-00395-x.
Collapse
Affiliation(s)
- Christopher Hohmann
- Department III for Internal Medicine, Heart Center, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
| | - Magnus Lutz
- Daiichi Sankyo Deutschland GmbH, Zielstattstr. 48, 81379, Munich, Germany
| | - Sheila Vignali
- Daiichi Sankyo Deutschland GmbH, Zielstattstr. 48, 81379, Munich, Germany
| | | | | | | | - Stephan Baldus
- Department III for Internal Medicine, Heart Center, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Michael Näbauer
- Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
| |
Collapse
|
33
|
Yang F, Li N, Yang L, Chang J, Yan A, Wei W. Association of Pre-stroke Frailty With Prognosis of Elderly Patients With Acute Cerebral Infarction: A Cohort Study. Front Neurol 2022; 13:855532. [PMID: 35711265 PMCID: PMC9196308 DOI: 10.3389/fneur.2022.855532] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 04/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Frailty is a state of cumulative degradation of physiological functions that leads to adverse outcomes such as disability or mortality. Currently, there is still little understanding of the prognosis of pre-stroke frailty status with acute cerebral infarction in the elderly. Objective We investigated the association between pre-stroke frailty status, 28-day and 1-year survival outcomes, and functional recovery after acute cerebral infarction. Methods Clinical data were collected from 314 patients with acute cerebral infarction aged 65–99 years. A total of 261 patients completed follow-up in the survival cohort analysis and 215 patients in the functional recovery cohort analysis. Pre-stroke frailty status was assessed using the FRAIL score, the prognosis was assessed using the modified Rankin Scale (mRS), and disease severity using the National Institutes of Health Stroke Scale (NIHSS). Results Frailty was independently associated with 28-day mortality in the survival analysis cohort [hazard ratio (HR) = 4.30, 95% CI 1.35–13.67, p = 0.014]. However, frailty had no independent effect on 1-year mortality (HR = 1.47, 95% CI 0.78–2.79, p = 0.237), but it was independently associated with advanced age, the severity of cerebral infarction, and combined infection during hospitalization. Logistic regression analysis after adjusting for potential confounders in the functional recovery cohort revealed frailty, and the NIHSS score was significantly associated with post-stroke severe disability (mRS > 2) at 28 days [pre-frailty adjusted odds ratio (aOR): 8.86, 95% CI 3.07–25.58, p < 0.001; frailty aOR: 7.68, 95% CI 2.03–29.12, p = 0.002] or 1 year (pre-frailty aOR: 8.86, 95% CI 3.07–25.58, p < 0.001; frailty aOR: 7.68, 95% CI 2.03–29.12, p = 0.003). Conclusions Pre-stroke frailty is an independent risk factor for 28-day mortality and 28-day or 1-year severe disability. Age, the NIHSS score, and co-infection are likewise independent risk factors for 1-year mortality.
Collapse
Affiliation(s)
- Fuxia Yang
- Department of Neurology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Nan Li
- Department of Neurology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Lu Yang
- Department of Neurology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Jie Chang
- Department of Neurology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Aijuan Yan
- Department of Neurology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Wenshi Wei
- Department of Neurology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| |
Collapse
|
34
|
Bul M, Shaikh F, McDonagh J, Ferguson C. Frailty and oral anticoagulant prescription in adults with atrial fibrillation: A systematic review. Aging Med (Milton) 2022. [DOI: 10.1002/agm2.12214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Mary Bul
- Western Sydney University Parramatta New South Wales Australia
| | - Fahad Shaikh
- Western Sydney University Parramatta New South Wales Australia
- Western Sydney Nursing and Midwifery Research Centre Western Sydney Local Health District and Western Sydney University, Blacktown Clinical and Research School, Blacktown Hospital Blacktown New South Wales Australia
| | - Julee McDonagh
- School of Nursing and Midwifery/College of Health, Medicine and Wellbeing The University of Newcastle, Central Coast Clinical School, Gosford Hospital Gosford New South Wales Australia
| | - Caleb Ferguson
- Western Sydney University Parramatta New South Wales Australia
- Western Sydney Nursing and Midwifery Research Centre Western Sydney Local Health District and Western Sydney University, Blacktown Clinical and Research School, Blacktown Hospital Blacktown New South Wales Australia
- School of Nursing, Faculty of Science, Medicine and Health University of Wollongong Wollongong New South Wales Australia
| |
Collapse
|
35
|
Proietti M, Romiti GF, Raparelli V, Diemberger I, Boriani G, Dalla Vecchia LA, Bellelli G, Marzetti E, Lip GY, Cesari M. Frailty prevalence and impact on outcomes in patients with atrial fibrillation: A systematic review and meta-analysis of 1,187,000 patients. Ageing Res Rev 2022; 79:101652. [PMID: 35659945 DOI: 10.1016/j.arr.2022.101652] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/20/2022] [Accepted: 05/23/2022] [Indexed: 12/14/2022]
Abstract
Frailty is a clinical syndrome characterized by a reduced physiologic reserve, increased vulnerability to stressors and an increased risk of adverse outcomes. People with atrial fibrillation (AF) are often burdened by frailty due to biological, clinical, and social factors. The prevalence of frailty, its management and association with major outcomes in AF patients are still not well quantified. We systematically searched PubMed and EMBASE, from inception to September 13th, 2021, for studies reporting the prevalence of frailty in AF patients. The study was registered in PROSPERO (CRD42021235854). 33 studies were included in the systematic review (n = 1,187,651 patients). The frailty pooled prevalence was 39.7 % (95 %CI=29.9 %-50.5 %, I2 =100 %), while meta-regression analyses showed it is influenced by age, history of stroke, and geographical location. Meta-regression analyses showed that OAC prescription was influenced by study-level mean age, baseline thromboembolic risk, and study setting. Frail AF patients were associated with a higher risk of all-cause death (OR=5.56, 95 %CI=3.46-8.94), ischemic stroke (OR=1.59, 95 %CI=1.00-2.52), and bleeding (OR=1.64, 95 %CI=1.11-2.41), when compared to robust individuals. In this systematic review and meta-analysis, the prevalence of frailty was high in patients with AF. Frailty may influence the prognosis and management of AF patients, thus requiring person-tailored interventions in a holistic or integrated approach to AF care.
Collapse
Affiliation(s)
- Marco Proietti
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Italy; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
| | | | - Valeria Raparelli
- Department of Translational Medicine, University of Ferrara, Italy; University Center for Studies on Gender Medicine, University of Ferrara, Italy; University of Alberta, Faculty of Nursing, Edmonton, Alberta, Canada
| | - Igor Diemberger
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Italy
| | | | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Emanuele Marzetti
- Università Cattolica del Sacro Cuore, Department of Geriatrics and Orthopedics, Rome, Italy; Center for Geriatric Medicine (Ce.M.I.), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome,Italy
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Matteo Cesari
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Italy
| |
Collapse
|
36
|
Diemberger I, Fumagalli S, Mazzone AM, Bakhai A, Reimitz PE, Pecen L, Manu MC, Gordillo de Souza JA, Kirchhof P, De Caterina R. Perceived vs. objective frailty in patients with atrial fibrillation and impact on anticoagulant dosing: an ETNA-AF-Europe sub-analysis. Europace 2022; 24:1404-1411. [PMID: 35512229 PMCID: PMC9559908 DOI: 10.1093/europace/euac004] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS Frailty is common in patients with atrial fibrillation (AF), with possible impact on therapies and outcomes. However, definitions of frailty are variable, and may not overlap with frailty perception among physicians. We evaluated the prevalence of frailty as perceived by enrolling physicians in the Edoxaban Treatment in Routine Clinical Practice for Patients With Non-Valvular AF (ETNA-AF)-Europe registry (NCT02944019), and compared it with an objective frailty assessment. METHODS AND RESULTS ETNA-AF-Europe is a prospective, multi-centre, post-authorization, observational study. There we assessed the presence of frailty according to (i) a binary subjective investigators' judgement and (ii) an objective measure, the Modified Frailty Index. Baseline data on frailty were available in 13 621/13 980 patients. Prevalence of perceived frailty was 10.6%, with high variability among participating countries and healthcare settings (range 5.9-19.6%). Conversely, only 5.0% of patients had objective frailty, with minimal variability (range 4.5-6.7%); and only <1% of patients were identified as frail by both approaches. Compared with non-frailty-perceived, perceived frail patients were older, more frequently female, and with lower body weight; conversely, objectively frail patients had more comorbidities. Non-recommended edoxaban dose regimens were more frequently prescribed in both frail patient categories. CONCLUSIONS Physicians' perception of frailty in AF patients is variable, mainly driven by age, sex, and weight, and quite different compared with the results of an objective frailty assessment. Whatever the approach, frailty appears to be associated with non-recommended anticoagulant dosages. Whether this apparent inappropriateness influences hard outcomes remains to be assessed.
Collapse
Affiliation(s)
- Igor Diemberger
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, University of Bologna, Policlinico S.Orsola-Malpighi, 40138 Bologna, Italy
| | - Stefano Fumagalli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; and AOU Careggi, Florence, Italy
| | - Anna Maria Mazzone
- Cardiology Department, 'G. Pasquinucci' Heart Hospital, 'G. Monasterio' Foundation, Massa, Italy
| | - Ameet Bakhai
- Royal Free Hospital London NHS Foundation Trust, London, UK.,Cardiology Department, Barnet General Hospital, Thames House, Enfield, UK
| | | | - Ladislav Pecen
- Department of Immunochemistry Diagnostics, Faculty of Medicine in Pilsen of Charles University, Pilsen, Czech Republic
| | | | | | - Paulus Kirchhof
- University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany.,German Center for Cardiovascular REserach (DZHK), partner site Hamburg/Kiel/Lübeck, Germany.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Raffaele De Caterina
- Department of Surgical, Medical and Molecular Pathology and of Critical Sciences, University of Pisa, Pisa, Italy.,Division of Cardiology, Azienda Ospedaliero-Universitaria Pisana, via Paradisa, 2, 56124 Pisa, Italy.,Fondazione VillaSerena per la Ricerca, Città Sant'Angelo-Pescara, Pescara, Italy
| |
Collapse
|
37
|
Proietti M, Camera M, Gallieni M, Gianturco L, Gidaro A, Piemontese C, Pizzetti G, Redaelli F, Scimeca B, Tadeo CS, Cesari M, Bellelli G, Dalla Vecchia LA. Use and Prescription of Direct Oral Anticoagulants in Older and Frail Patients with Atrial Fibrillation: A Multidisciplinary Consensus Document. J Pers Med 2022; 12:jpm12030469. [PMID: 35330468 PMCID: PMC8955844 DOI: 10.3390/jpm12030469] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/08/2022] [Accepted: 03/12/2022] [Indexed: 11/25/2022] Open
Abstract
In the last twelve years the clinical management of patients with atrial fibrillation has been revolutionised by the introduction of direct oral anticoagulants. Despite the large amount of evidence produced, some populations remain relatively poorly explored regarding the effectiveness and safety of direct oral anticoagulants, such as the oldest and/or frailest individuals. Frailty is clinical syndrome characterized by a reduction of functions and physiological reserves which results in individuals having higher vulnerability. While current evidence underlines a relationship between atrial fibrillation and frailty, particularly in determining a higher risk of adverse outcomes, data regarding effectiveness and safety of direct oral anticoagulants in frailty atrial fibrillation patients are still lacking, leaving uncertainty about how to guide prescription in this specific subgroup. On these premises, this multidisciplinary consensus document explains why it would be useful to integrate the clinical evaluation performed through comprehensive geriatric assessment to gather further elements to guide prescription of direct oral anticoagulants in such a high-risk group of patients.
Collapse
Affiliation(s)
- Marco Proietti
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, 20138 Milan, Italy; (M.P.); (M.C.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L7 3FA, UK
| | - Marina Camera
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy;
- Department of Pharmaceutical Sciences, University of Milan, 20133 Milan, Italy
| | - Maurizio Gallieni
- Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, 20131 Milan, Italy;
- Department of Biomedical and Clinical Sciences ‘Luigi Sacco’, University of Milan, 20157 Milan, Italy;
| | - Luigi Gianturco
- Cardiology Unit, IRCCS Orthopedic Institute Galeazzi, 20161 Milan, Italy;
| | - Antonio Gidaro
- Department of Biomedical and Clinical Sciences ‘Luigi Sacco’, University of Milan, 20157 Milan, Italy;
| | - Carlo Piemontese
- Cardiology Unit, Sant’Anna Hospital, ASST Lariana, 22042 Como, Italy;
| | - Giuseppe Pizzetti
- Division of Cardiology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | | | - Barbara Scimeca
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Cà Granda Maggiore Hospital Foundation, 20122 Milan, Italy;
| | | | - Matteo Cesari
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, 20138 Milan, Italy; (M.P.); (M.C.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy;
- Acute Geriatrics Unit, San Gerardo Hospital ASST Monza, 20900 Monza, Italy
| | - Laura Adelaide Dalla Vecchia
- Department of Cardiology, IRCCS Istituti Clinici Scientifici Maugeri, 20138 Milan, Italy
- Correspondence: ; Tel.: +39-02-50725120
| |
Collapse
|
38
|
Shrauner W, Lord EM, Nguyen XMT, Song RJ, Galloway A, Gagnon DR, Driver JA, Gaziano JM, Wilson PWF, Djousse L, Cho K, Orkaby AR. Frailty and cardiovascular mortality in more than 3 million US Veterans. Eur Heart J 2022; 43:818-826. [PMID: 34907422 PMCID: PMC9890630 DOI: 10.1093/eurheartj/ehab850] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 06/17/2021] [Accepted: 11/29/2021] [Indexed: 02/05/2023] Open
Abstract
AIMS Frailty is associated with an increased risk of all-cause mortality and cardiovascular (CV) events. Limited data exist from the modern era of CV prevention on the relationship between frailty and CV mortality. We hypothesized that frailty is associated with an increased risk of CV mortality. METHODS AND RESULTS All US Veterans aged ≥65 years who were regular users of Veteran Affairs care from 2002 to 2017 were included. Frailty was defined using a 31-item previously validated frailty index, ranging from 0 to 1. The primary outcome was CV mortality with secondary analyses examining the relationship between frailty and CV events (myocardial infarction, stroke, revascularization). Survival analysis models were adjusted for age, sex, ethnicity, geographic region, smoking, hyperlipidaemia, statin use, and blood pressure medication use. There were 3 068 439 US Veterans included in the analysis. Mean age was 74.1 ± 5.8 years in 2002, 76.0 ± 8.3 years in 2014, 98% male, and 87.5% White. In 2002, the median (interquartile range) frailty score was 0.16 (0.10-0.23). This increased and stabilized to 0.19 (0.10-0.32) for 2006-14. The presence of frailty was associated with an increased risk of CV mortality at every stage of frailty. Frailty was associated with an increased risk of myocardial infarction and stroke, but not revascularization. CONCLUSION In this population, both the presence and severity of frailty are tightly correlated with CV death, independent of underlying CV disease. This study is the largest and most contemporary evaluation of the relationship between frailty and CV mortality to date. Further work is needed to understand how this risk can be diminished. KEY QUESTION Can an electronic frailty index identify adults aged 65 and older who are at risk of CV mortality and major CV events? KEY FINDING Among 3 068 439 US Veterans aged 65 and older, frailty was associated with an increased risk of CV mortality at every level of frailty. Frailty was also associated with an increased risk of myocardial infarction and stroke, but not revascularization. TAKE HOME MESSAGE Both the presence and severity of frailty are associated with CV mortality and major CV events, independent of underlying CV disease.
Collapse
Affiliation(s)
- William Shrauner
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA 02130, USA
- Division of Aging, Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, 1620 Tremont St Boston, MA 02120, USA
- Division of Cardiology, Department of Medicine, Boston Medical Center, One Boston Medical Center Pl, Boston, MA 02118, USA
| | - Emily M Lord
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA 02130, USA
| | - Xuan-Mai T Nguyen
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA 02130, USA
| | - Rebecca J Song
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA 02130, USA
| | - Ashley Galloway
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA 02130, USA
| | - David R Gagnon
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA 02130, USA
- New England GRECC (Geriatric Research, Education, and Clinical Center) VA Boston Healthcare System, 150 South Huntington Ave Boston, MA 02130, USA
| | - Jane A Driver
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA 02130, USA
- Division of Aging, Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, 1620 Tremont St Boston, MA 02120, USA
- New England GRECC (Geriatric Research, Education, and Clinical Center) VA Boston Healthcare System, 150 South Huntington Ave Boston, MA 02130, USA
| | - J Michael Gaziano
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA 02130, USA
- Division of Aging, Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, 1620 Tremont St Boston, MA 02120, USA
| | - Peter W F Wilson
- Atlanta VA Medical Center, 1670 Clairmont Rd, Decatur, GA 30033, USA
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1525 Clifton Rd, Atlanta, GA 30322, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA 30322, USA
| | - Luc Djousse
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA 02130, USA
- Division of Aging, Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, 1620 Tremont St Boston, MA 02120, USA
| | - Kelly Cho
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA 02130, USA
- Division of Aging, Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, 1620 Tremont St Boston, MA 02120, USA
| | - Ariela R Orkaby
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA 02130, USA
- Division of Aging, Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, 1620 Tremont St Boston, MA 02120, USA
- New England GRECC (Geriatric Research, Education, and Clinical Center) VA Boston Healthcare System, 150 South Huntington Ave Boston, MA 02130, USA
| |
Collapse
|
39
|
Wleklik M, Denfeld Q, Lisiak M, Czapla M, Kałużna-Oleksy M, Uchmanowicz I. Frailty Syndrome in Older Adults with Cardiovascular Diseases-What Do We Know and What Requires Further Research? Int J Environ Res Public Health 2022; 19:ijerph19042234. [PMID: 35206422 PMCID: PMC8872246 DOI: 10.3390/ijerph19042234] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 02/07/2023]
Abstract
Cardiovascular diseases (CVD) affect 60% of people over 60 years of age and are one of the main causes of death in the world. Diagnosed cardiovascular disease also triples the likelihood of Frailty syndrome (FS). FS has become increasingly relevant in cardiology and cardiac surgery and occurs in a significant number of patients with CVD, with prevalence ranging from 25% to 62%. Viewed in a multidimensional, biopsychosocial perspective, FS increases a patient's vulnerability, making them susceptible to several adverse clinical outcomes. Frailty syndrome also is a predictor of mortality in patients with CVD regardless of age, severity of disease, multi-morbidity, and disability. Frailty syndrome potentially can be prevented in patients with CVD and its early identification is important to avoid the development of disability, dependence on others and reduced quality of life. The aim of this paper is to show the relationship between FS and specific CVDs (coronary artery disease, hypertension, atrial fibrillation, heart failure) and cardiac procedures (device implantation, cardiac surgery, and transcatheter aortic valve implantation). Furthermore, we highlight those areas that require further research to fully understand the relationship between FS and CVD and to be able to minimize or prevent its adverse effects.
Collapse
Affiliation(s)
- Marta Wleklik
- Department of Nursing and Obstetrics, Faculty of Health Sciences, Wroclaw Medical University, 51-618 Wroclaw, Poland; (M.W.); (M.L.); (I.U.)
- Institute of Heart Diseases, University Hospital, 50-566 Wroclaw, Poland
| | - Quin Denfeld
- School of Nursing, Oregon Health and Science University, Portland, OR 97239, USA;
| | - Magdalena Lisiak
- Department of Nursing and Obstetrics, Faculty of Health Sciences, Wroclaw Medical University, 51-618 Wroclaw, Poland; (M.W.); (M.L.); (I.U.)
- Institute of Heart Diseases, University Hospital, 50-566 Wroclaw, Poland
| | - Michał Czapla
- Institute of Heart Diseases, University Hospital, 50-566 Wroclaw, Poland
- Laboratory for Experimental Medicine and Innovative Technologies, Department of Emergency Medical Service, Wroclaw Medical University, 51-616 Wroclaw, Poland
- Correspondence:
| | - Marta Kałużna-Oleksy
- 1st Department of Cardiology, University of Medical Sciences in Poznan, 61-848 Poznan, Poland;
| | - Izabella Uchmanowicz
- Department of Nursing and Obstetrics, Faculty of Health Sciences, Wroclaw Medical University, 51-618 Wroclaw, Poland; (M.W.); (M.L.); (I.U.)
- Institute of Heart Diseases, University Hospital, 50-566 Wroclaw, Poland
| |
Collapse
|
40
|
Akishita M, Suzuki S, Inoue H, Akao M, Atarashi H, Ikeda T, Koretsune Y, Okumura K, Shimizu W, Tsutsui H, Toyoda K, Hirayama A, Yasaka M, Yamaguchi T, Teramukai S, Kimur T, Morishima Y, Takita A, Yamashita T. Frailty and Outcomes in Older Adults with Non-valvular Atrial Fibrillation from the ANAFIE Registry. Arch Gerontol Geriatr 2022. [DOI: 10.1016/j.archger.2022.104661] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/03/2022] [Accepted: 02/12/2022] [Indexed: 11/18/2022]
|
41
|
He L, He R, Huang J, Zou C, Fan Y. Impact of frailty on all-cause mortality and major bleeding in patients with atrial fibrillation: A meta-analysis. Ageing Res Rev 2022; 73:101527. [PMID: 34839042 DOI: 10.1016/j.arr.2021.101527] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/27/2021] [Accepted: 11/15/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND Conflicting results have been reported on the impact of frailty on adverse outcomes in patients with atrial fibrillation (AF). The aim of this meta-analysis was to evaluate the impact of frailty on death and major bleeding in patients with AF. METHODS We comprehensively searched PubMed and Embase databases until June 30, 2021 for the relevant studies that investigated the impact of frailty on all-cause mortality and major bleeding in AF patients. Pooled multivariable-adjusted risk ratio (RR) and 95% confidence intervals (CI) was estimated for the frail vs. nonfrail patients using a random-effect model. RESULTS Ten studies involving 97,413 patients with AF satisfied the inclusion criteria. The prevalence of frailty in patients with AF ranged between 5.9% and 89.5%. Meta-analysis indicated that frailty was associated with higher risk of all-cause mortality (RR 2.77; 95% CI 1.68-4.57) and major bleeding (RR 1.83; 95% CI 1.24-2.71). Subgroup analysis showed that the impact of frailty on all-cause mortality was consistently found in each subgroup. CONCLUSION Frailty independently predicts all-cause mortality and major bleeding in patients with AF. Determination of frailty status may play an important role in risk classification of AF patients. However. lack of standardized definition of frailty is the most important limitations of this meta-analysis.
Collapse
|
42
|
Kim M, Kim J, Kim JB, Park J, Park JK, Kang KW, Shim J, Choi EK, Lee YS, Park HW, Joung B. Association of Gender With Clinical Outcomes in a Contemporary Cohort of Patients With Atrial Fibrillation Receiving Oral Anticoagulants. Korean Circ J 2022; 52:593-603. [PMID: 35656931 PMCID: PMC9353255 DOI: 10.4070/kcj.2021.0399] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/25/2022] [Accepted: 03/30/2022] [Indexed: 11/28/2022] Open
Abstract
We evaluated the relationship between biological sex and adverse clinical events in a contemporary atrial fibrillation (AF) cohort, mainly those taking direct oral anticoagulants, among patients with more-than-intermediate risk of stroke. Sex-based differences are noted in the outcomes of patients with AF who used anticoagulants, primarily vitamin K antagonist. The stroke or systemic embolism risk and major bleeding risk did not differ between the sexes, although women had a lower risk of all-cause mortality in contemporary anticoagulation for AF. Female may not be a risk factor for adverse clinical events associated with anticoagulation for AF. Background and Objectives In patients with atrial fibrillation (AF), females taking vitamin K antagonist are at higher risk of stroke or systemic embolism (SSE), bleeding and all-cause death than males. This study investigated the relationship between sex and adverse clinical events in a contemporary AF patient cohort taking anticoagulation. Methods This prospective multicenter AF registry study comprised 6,067 patients with AF (mean age, 70±9 years; men, 59%) with intermediate to high risk of stroke (CHA2DS2-VAscore ≥1) and receiving oral anticoagulation therapy. Adverse clinical outcomes, including SSE, bleeding, death were evaluated in patients stratified by sex and anticoagulation patterns. Results Women were older and used more direct oral anticoagulants (85% vs. 78%, p<0.001) than men. During a median (25th and 75th percentiles) follow-up of 30 (24, 38) months, the incidence rate and risk of SSE (0.7 in women vs. 0.7 in men per 100 person-years) and major bleeding (0.1 in women vs. 0.1 in men per 100 person-years) were not different between the sexes. However, women had a lower all-cause death rate (0.4 in women vs. 0.6 in men per 100 person-years, hazard ratio: 0.48, 95% confidence interval: 0.25–0.91, p=0.025) than men. Conclusions In contemporary anticoagulation for AF, SSE and major bleeding risks did not differ between sexes. However, women showed a lower risk of all-cause death rate than men, indicating that the use of oral anticoagulants for treating AF in females does not appear to be a risk factor for adverse clinical events. Trial Registration ClinicalTrials.gov Identifier: NCT02786095
Collapse
Affiliation(s)
- Minjeong Kim
- Division of Cardiology, Department of Internal Medicine, Division of Cardiology, Myongji Hospital, Goyang, Korea
| | - Jun Kim
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Bae Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University, Seoul, Korea
| | - Junbeom Park
- Department of Cardiology, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Jin-Kyu Park
- Department of Cardiology, Hanyang University Seoul Hospital, Seoul, Korea
| | - Ki-Woon Kang
- Division of Cardiology, Eulji University Hospital, Daejeon, Korea
| | - Jaemin Shim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Young Soo Lee
- Division of Cardiology, Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu, Korea
| | - Hyung Wook Park
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
43
|
Orlandi M, Dover DC, Sandhu RK, Hawkins NM, Kaul P, McAlister FA. The Introduction of Direct Oral Anticoagulants Has Not Resolved Treatment Gaps for Frail Patients With Nonvalvular Atrial Fibrillation. Can J Cardiol 2022; 38:77-84. [DOI: 10.1016/j.cjca.2021.09.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/17/2021] [Accepted: 09/18/2021] [Indexed: 11/02/2022] Open
|
44
|
Strom JB, Xu J, Orkaby AR, Shen C, Song Y, Charest BR, Kim DH, Cohen DJ, Kramer DB, Spertus JA, Gerszten RE, Yeh RW. The Role of Frailty in Identifying Benefit from Transcatheter Versus Surgical Aortic Valve Replacement. Circ Cardiovasc Qual Outcomes 2021; 14:e008566. [PMID: 34779656 DOI: 10.1161/circoutcomes.121.008566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Frailty is associated with a higher risk for adverse outcomes after aortic valve replacement (AVR) for severe aortic valve stenosis, but whether or not frail patients derive differential benefit from transcatheter (TAVR) vs. surgical (SAVR) AVR is uncertain. Methods: We linked adults ≥ 65 years old in the US CoreValve High Risk (HiR) or Surgical or Transcatheter Aortic-Valve Replacement in Intermediate Risk Patients (SURTAVI) trial to Medicare claims, 2/2/2011-9/30/2015. Two frailty measures, a deficit-based (DFI) and phenotype-based (PFI) frailty index, were generated. The treatment effect of TAVR vs. SAVR was evaluated within frailty index (FI) tertiles for the primary endpoint of death and non-death secondary outcomes, using multivariable Cox regression. Results: Of 1,442 (linkage rate = 60.0%) individuals included, 741 (51.4%) individuals received TAVR and 701 (48.6%) received SAVR (mean age 81.8 ± 6.1 years, 44.0% female). Though 1-year death rates in the highest FI tertiles (DFI 36.7%, PFI 33.8%) were 2-3-fold higher than the lowest tertiles (DFI 13.4%, HR 3.02, 95% CI 2.26-4.02, p < 0.001; PFI 17.9%; HR 2.05, 95% CI 1.58-2.67, p < 0.001), there were no significant differences in the relative or absolute treatment effect of SAVR vs. TAVR across FI tertiles for all death, non-death, and functional outcomes (all interaction p-values > 0.05). Results remained consistent across individual trials, frailty definitions, and when considering the non-linked trial data. Conclusions: Two different frailty indices based on Fried and Rockwood definitions identified individuals at higher risk of death and functional impairment but no differential benefit from TAVR vs. SAVR.
Collapse
Affiliation(s)
- Jordan B Strom
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, MA; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Jiaman Xu
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Ariela R Orkaby
- Harvard Medical School, Boston, MA; Veterans Affairs Healthcare System, Boston, MA
| | - Changyu Shen
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Yang Song
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Brian R Charest
- Harvard Medical School, Boston, MA; Veterans Affairs Healthcare System, Boston, MA
| | - Dae H Kim
- Harvard Medical School, Boston, MA; Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Daniel B Kramer
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, MA; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - John A Spertus
- Section of Cardiovascular Disease, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Robert E Gerszten
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Robert W Yeh
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, MA; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| |
Collapse
|
45
|
Howlett SE, Rutenberg AD, Rockwood K. The degree of frailty as a translational measure of health in aging. Nat Aging 2021; 1:651-665. [PMID: 37117769 DOI: 10.1038/s43587-021-00099-3] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 07/06/2021] [Indexed: 04/30/2023]
Abstract
Frailty is a multiply determined, age-related state of increased risk for adverse health outcomes. We review how the degree of frailty conditions the development of late-life diseases and modifies their expression. The risks for frailty range from subcellular damage to social determinants. These risks are often synergistic-circumstances that favor damage also make repair less likely. We explore how age-related damage and decline in repair result in cellular and molecular deficits that scale up to tissue, organ and system levels, where they are jointly expressed as frailty. The degree of frailty can help to explain the distinction between carrying damage and expressing its usual clinical manifestations. Studying people-and animals-who live with frailty, including them in clinical trials and measuring the impact of the degree of frailty are ways to better understand the diseases of old age and to establish best practices for the care of older adults.
Collapse
Affiliation(s)
- Susan E Howlett
- Geriatric Medicine Research Unit, Department of Medicine, Dalhousie University & Nova Scotia Health, Halifax, Nova Scotia, Canada
- Department of Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Andrew D Rutenberg
- Department of Physics and Atmospheric Science, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kenneth Rockwood
- Geriatric Medicine Research Unit, Department of Medicine, Dalhousie University & Nova Scotia Health, Halifax, Nova Scotia, Canada.
| |
Collapse
|
46
|
Proietti M, Cesari M. Describing the relationship between atrial fibrillation and frailty: Clinical implications and open research questions. Exp Gerontol 2021; 152:111455. [PMID: 34153440 DOI: 10.1016/j.exger.2021.111455] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/13/2021] [Indexed: 11/26/2022]
Abstract
In the recent years a lot of attention has been gathered by the issue of frailty outside the boundaries of the geriatric medicine, for example in the field of cardiovascular medicine. Atrial fibrillation (AF) is known as a very common cardiological condition, often burdened by high level of clinical complexity. Aim of this narrative review is to examine the most relevant evidence about the relationship between frailty and AF, focusing also on its impact on clinical management and natural history of patients with this condition. Data reported underline how a relevant relationship exists between these two conditions, even though the burden of frailty among AF cohorts is still unclear. Frailty seems to affect the clinical management, even though no definitive data are yet available. Lastly, frailty significantly increases the risk of all-cause mortality but it's still unclear the impact on thromboembolic and bleeding events. Despite several data are already available, more research is still needed to fully elucidate the relationship between these two clinical entities.
Collapse
Affiliation(s)
- Marco Proietti
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Italy; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
| | - Matteo Cesari
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Italy
| |
Collapse
|
47
|
Andrew MK, Schmader KE, Rockwood K, Clarke B, McElhaney JE. Considering Frailty in SARS-CoV-2 Vaccine Development: How Geriatricians Can Assist. Clin Interv Aging 2021; 16:731-738. [PMID: 33953551 PMCID: PMC8088982 DOI: 10.2147/cia.s295522] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/02/2021] [Indexed: 12/15/2022] Open
Abstract
The COVID-19 pandemic has disproportionately impacted frail older adults, especially residents of long-term care (LTC) facilities. This has appropriately led to prioritization of frail older adults and LTC residents, and those who care for them, in the vaccination effort against COVID-19. Older adults have distinct immunological, clinical, and practical complexity, which can be understood through a lens of frailty. Even so, frailty has not been considered in studies of COVID-19 vaccines to date, leading to concerns that the vaccines have not been optimally tailored for and evaluated in this population even as vaccination programs are being implemented. This is an example of how vaccines are often not tested in Phase 1/2/3 clinical trials in the people most in need of protection. We argue that geriatricians, as frailty specialists, have much to contribute to the development, testing and implementation of COVID-19 vaccines in older adults. We discuss roles for geriatricians in ten stages of the vaccine development process, covering vaccine design, trial design, trial recruitment, establishment and interpretation of illness definitions, safety monitoring, consideration of relevant health measures such as frailty and function, analysis methods to account for frailty and differential vulnerability, contributions in regulatory and advisory roles, post-marketing surveillance, and program implementation and public health messaging. In presenting key recommendations pertinent to each stage, we hope to contribute to a dialogue on how to push the field of vaccinology to embrace the complexity of frailty. Making vaccines that can benefit frail older adults will benefit everyone in the fight against COVID-19.
Collapse
Affiliation(s)
- Melissa K Andrew
- Department of Medicine, Division of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Canadian Center for Vaccinology, Halifax, Nova Scotia, Canada
| | - Kenneth E Schmader
- Division of Geriatrics, Duke University Medical Center and GRECC, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Kenneth Rockwood
- Department of Medicine, Division of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Barry Clarke
- Department of Family Medicine, Dalhousie University, Halifax, Canada
| | | |
Collapse
|