Reducing the risk of stroke in elderly patients with non-valvular atrial fibrillation: a practical guide for clinicians

Clinical features and outcomes of patients in different age groups with non-valvular atrial fibrillation receiving oral anticoagulants

Background

Patients with non-valvular atrial fibrillation (NVAF) need prophylactically antithrombotic therapies to reduce the risk of stroke. We hypothesized that the prognostic benefits of prophylactic antithrombotic therapies outweighed the bleeding risk among very elderly (≥85 years old) patients.

Methods

We analyzed clinical characteristics and outcomes of patients with NVAF in different age groups who had received different prophylactic antithrombotic therapies. We enrolled 3895 consecutive NVAF patients in the Macau Special Administrative Region (Macau SAR) of China from January 1, 2010, to December 31, 2018. Among 3524 patients [including 1252 (35.53%) very elderly patients] who completed the entire study, 2897 (82.21%) patients had a CHA₂DS₂-VASc score ≥ 2, 2274 (64.53%) had HAS-BLED score < 3, and 1659 (47.08%) had both of the above. The follow-up time was 3.80 (median, interquartile range 1.89–6.56) years. The primary outcome was the first occurrence of ischemic stroke, major bleeding, clinically relevant non-major gastrointestinal bleeding (CRNM-GIB), and all-cause mortality.

Results

A total of 2012 patients (57.09%) received no antithrombotic (NAT), 665 (18.87%) received antiplatelet (AP) agents, 371 (10.53%) received vitamin K antagonist (VKA), and 476 (13.51%) received non-vitamin K antagonist oral anticoagulants (NOACs). Eventually, 610 (17.31%) patients experienced thromboembolic events, with 167 (4.74%) strokes and 483 (13.71%) transient ischemia attack (TIA)/strokes. Bleeding events occurred in 614 (17.42%) patients, with 131 (3.72%) major bleeding, 381 (10.81%) CRNM-GIB and 102 (2.89%) minor bleeding events. All-cause deaths occurred in 483 (13.71%) patients. Compared with patients receiving NAT, patients receiving NOACs and VKA had fewer strokes (hazard ratio [HR]: 0.038; 95 %CI 0.004–0.401; p = 0.006 and HR: 0.544; 95 %CI 0.307–0.965; p = 0.037, respectively), and lower all-cause mortality (HR: 0.270; 95 %CI 0.170–0.429; p < 0.001 and HR: 0.531; 95 %CI 0.373–0.756; p < 0.001, respectively). Of note, very elderly patients with NVAF receiving NOACs had fewer strokes (adjust hazard ratio [_adjHR]: 0.042; 95 %CI 0.002–1.003; p = 0.050) and lower all-cause mortality (_adjHR: 0.308; 95 %CI 0.158–0.601; p = 0.001). Meanwhile, despite higher CRNM-GIB events (_adjHR: 1.736; 95 %CI 1.042–2.892; p = 0.034), major bleeding events (_adjHR: 1.045; 95 %CI 0.366–2.979; p = 0.935) did not significantly increase. VKA neither reduced strokes (_adjHR: 1.015; 95 %CI 0.529–1.948; p = 0.963), nor improved all-cause mortality (_adjHR: 0.995; 95 %CI 0.641–1.542; p = 0.981) in very elderly patients with NVAF.

Conclusions

Antithrombotic treatment (VKA and NOACs) reduces stroke and improves prognosis in patients in different age groups with NVAF. The prognostic benefits of NOACs outweigh their bleeding risks in very elderly patients with NVAF.

Background characteristics and anticoagulant usage patterns of elderly non-valvular atrial fibrillation patients in the ANAFIE registry: a prospective, multicentre, observational cohort study in Japan

OBJECTIVE

To explore anticoagulant usage patterns stratified by stroke and bleeding risk in elderly patients with non-valvular atrial fibrillation (NVAF).

DESIGN

Prospective, multicentre, observational cohort study.

SETTING

The real-world All Nippon AF In the Elderly (ANAFIE) registry.

PARTICIPANTS

Japanese patients aged ≥75 years with NVAF (n=32 726).

OUTCOME MEASURES

The distribution of stroke and bleeding risk scores, and the selection of anticoagulant regimen for patients at high stroke and bleeding risk.

RESULTS

Overall, 18 185 (55.6%) patients had a high risk of stroke (CHADS₂ score ≥3). Of these, 12 561 (38.4% of the total ANAFIE population) had a low bleeding risk (HAS-BLED ≤2) and 5624 (17.2%) had a high bleeding risk (HAS-BLED ≥3). Significant differences were noted between the high versus low bleeding risk groups in sex, height, weight, systolic blood pressure and rates of abnormality of lipid metabolism, gastrointestinal disease, cerebrovascular disorders, chronic kidney disease, angina pectoris, respiratory disease, primary malignant tumour, dementia and fall history within the past year (all p<0.0001). Patients with high stroke and bleeding risks had a lower anticoagulant usage rate versus the low bleeding risk group, and 8.7% and 5.8%, respectively, were not receiving any anticoagulant (p<0.0001). Patients in the high bleeding risk group had a higher usage of warfarin versus the low bleeding risk group (p<0.0001); more patients (14.0%) in the high bleeding risk group receiving warfarin had time in the therapeutic range <40%, versus those in the low bleeding risk group (11.6%, p=0.0146). Direct-acting oral anticoagulants (DOACs) were used less in the high bleeding risk group, without notable differences in the DOAC dose distribution between the two groups.

CONCLUSIONS

In elderly NVAF patients at high stroke risk, significant demographic and clinical differences were observed according to bleeding risk. Administration of low-dose DOACs was frequent, but the dose distribution was unaffected by bleeding risk.

TRIAL REGISTRATION NUMBER

UMIN000024006 (http://www.umin.ac.jp/).

Country-based Comparison of Atrial Fibrillation Patients' Preferences for Oral Anticoagulation: An Evaluation of Discrete Choice Experiments in Five Different Countries

ABSTRACT

The aim of this study was to examine atrial fibrillation (AF) patients' preferences regarding oral anticoagulation (OAC) characteristics and to investigate differences across 5 different countries. A multicenter discrete choice experiment was conducted in Germany, Sweden, Switzerland, Spain, and Taiwan. Study sites enrolled patients with nonvalvular AF who received continuous OAC therapy. The discrete choice experiment design considered the following 4 attributes with 2 attribute levels each: need for bridging (yes/no), interactions with food/alcohol (yes/no), need for regular international normalized ratio (INR) assessments, and frequency of intake (once/twice daily). Generally, patients (n = 1391) preferred treatment alternatives that were characterized by "no need of bridging," "no need for regular INR controls," "no interactions with food/alcohol," and "once daily intake." For this desired treatment regimen, patients were willing to accept a substantially higher travel distance/time. German patients with AF were strongly impacted in their hypothetical treatment decision by the frequency of intake (37.5%). Swedish patients on the other hand gave little importance to intake frequency (12.6%). In Switzerland, patients were especially concerned with food/alcohol interactions of the medication (34.7%), whereas this was the least important attribute for Taiwanese patients (18.9%), who ascribed the most homogenous importance to the different treatment attributes overall. In Spain, the need for regular INR assessments especially impacted the patient's treatment decision (31.9%). Patients of all countries attributed a moderate importance to the need for bridging (25.9%-34.2%). These findings may facilitate country-specific consideration of patients' preferences regarding OAC therapy, potentially increasing treatment acceptance on the patient's side with the ultimate goal of improving treatment adherence and persistence.

Clinical factors associated with safety and efficacy in patients receiving direct oral anticoagulants for non-valvular atrial fibrillation

Although patients suffering from atrial fibrillation have increased worldwide, detailed information about factors associated with bleeding during direct oral anticoagulant therapy remains insufficient. We studied 1086 patients for whom direct oral anticoagulants were initiated for non-valvular atrial fibrillation between April 2011 and June 2017. Endpoints were clinically relevant bleeding or major adverse cardiac and cerebrovascular events until the end of December 2018. Incidences of bleeding and thrombosis were 4.5 per 100 person-years and 4.7 per 100 person-years, respectively. Most bleeding events represented gastrointestinal bleeding. Multivariate analysis revealed initiation of anticoagulants at ≥ 85 years old as significantly associated with bleeding, particularly gastrointestinal bleeding, but not major cardiac and cerebrovascular events. Other significant factors included chronic kidney disease, low-dose aspirin and nonsteroidal anti-inflammatory drugs. For gastrointestinal bleeding alone, histories of gastrointestinal bleeding and malignancy also showed positive correlations, in addition to the above-mentioned factors. Clinicians should pay greater attention to the risk of gastrointestinal bleeding when considering prescription of anticoagulants to patients ≥ 85 years old with atrial fibrillation.

Early rehospitalizations of frail elderly patients - the role of medications: a clinical, prospective, observational trial

BACKGROUND AND OBJECTIVE

Early readmissions of frail elderly patients after an episode of hospital care are common and constitute a crucial patient safety outcome. Our purpose was to study the impact of medications on such early rehospitalizations.

PATIENTS AND METHODS

This is a clinical, prospective, observational study on rehospitalizations within 30 days after an acute hospital episode for frail patients over the age of 75 years. To identify adverse drug reactions (ADRs), underuse of evidence-based treatment and avoidability of rehospitalizations, the Naranjo score, the Hallas criteria and clinical judgment were used.

RESULTS

Of 390 evaluable patients, 96 (24.6%) were rehospitalized. The most frequent symptoms and conditions were dyspnea (n = 25) and worsened general condition (n = 18). The most frequent diagnoses were heart failure (n = 17) and pneumonia/acute bronchitis (n = 13). By logistic regression analysis, independent risk predictors for rehospitalization were heart failure (odds ratio [OR] = 1.8; 95% CI = 1.1-3.1) and anemia (OR = 2.3; 95% CI = 1.3-4.0). The number of rehospitalizations due to probable ADRs was 13, of which two were assessed as avoidable. The number of rehospitalizations probably due to underuse of evidence-based drug treatment was 19, all of which were assessed as avoidable. The number of rehospitalizations not due to ADRs or underuse of evidence-based drug treatment was 64, of which none was assessed as avoidable.

CONCLUSION

One out of four frail elderly patients discharged from hospital was rehospitalized within 1 month. Although ADRs constituted an important cause of rehospitalization, underuse of evidence-based drug treatment might be an even more frequent cause. Potentially avoidable rehospitalizations were more frequently associated with underuse of evidence-based drug treatment than with ADRs. Efforts to avoid ADRs in frail elderly patients must be balanced and combined with evidence-based drug therapy, which can benefit these patients.