Warfarin therapy for an octogenarian who has atrial fibrillation

Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline

BACKGROUND

The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug.

METHODS

Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines.

RESULTS

A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures.

CONCLUSIONS

Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.

Frailty Status Affects the Decision for Long-Term Anticoagulation Therapy in Elderly Patients with Atrial Fibrillation

BACKGROUND

Elderly patients are underrepresented in the studies concerning anticoagulation therapy (AT) in atrial fibrillation (AF), while patients' frailty status is lacking in most of the studies.

OBJECTIVE

Our objective was to evaluate AT in AF elderly patients and study the effect of patients' frailty status on their long-term AT.

METHODS

We conducted an observational prospective study that enrolled consecutive AF patients (≥ 75 years) who were hospitalized in the Department of Internal Medicine of the University Hospital of Heraklion, Crete, Greece from 1 June 2015 to 1 June 2016. We recorded the AT on admission and at discharge, all-cause mortality, and hospital readmission in a follow-up period of 1 year after hospital discharge. Frailty status was assessed by pre-established scores.

RESULTS

One hundred and four consecutive patients (49% male; median age 87 years) were enrolled, 78 (78.8%) of whom received AT at discharge. Patients who did not receive AT at discharge had a higher HEMORR₂HAGES (Hepatic or renal disease, Ethanol abuse, Malignancy, Older age, Reduced platelet count or function, Re-bleeding, Hypertension, Anemia, Genetic factors, Excessive fall risk and Stroke) score (5.5 ± 1.15 vs. 4.79 ± 1.68; p = 0.032), a lower Katz score (2.48 ± 2.23 vs. 4.08 ± 2.25; p = 0.006), and a higher Clinical Frailty Scale score (7 ± 1.95 vs. 5.57 ± 2.05; p = 0.006). Sixty-five patients (62.5%) were readmitted to a hospital during the follow-up period. In-hospital death occurred in five patients (4.8%) and 57 patients (57.6%) died within the follow-up period.

CONCLUSION

A high percentage of the elderly AF patients did not receive AT, even at discharge. Patients who did not receive AT at discharge had higher bleeding and frailty scores. In the 1-year follow-up period after hospital discharge, high all-cause mortality and a high number of hospital readmissions were recorded.

Comparative effectiveness of dabigatran, rivaroxaban, apixaban, and warfarin in the management of patients with nonvalvular atrial fibrillation

Alternative anticoagulants to warfarin (dabigatran, rivaroxaban, and apixaban) are becoming available for the prevention of thromboembolic stroke in atrial fibrillation (AF), but there is a lack of information on their comparative effectiveness. Using a discrete event simulation method adopting a lifetime horizon of analysis, we made an indirect comparison of the RE-LY, ROCKET-AF, and ARISTOTLE trial results for AF patients in the US population. Over a lifetime, apixaban, dabigatran, and rivaroxaban accrued 0.130 (95% central range (CR) -0.030 to 0.264), 0.106 (95% CR -0.048 to 0.248), and 0.095 (95% CR -0.052 to 0.242) more quality-adjusted life-years (QALYs), respectively, than warfarin, with apixaban having a 55% probability of accruing the highest total QALYs. In the absence of a definitive trial, and acknowledging the limitations of an indirect comparison, the available evidence suggests apixaban to be the most effective anticoagulant.

Improving the management of warfarin in aged-care facilities utilising innovative technology: a proof-of-concept study

Objective

In aged-care facilities (ACFs) monitoring of warfarin can be logistically challenging and International Normalised Ratio (INR control) is often suboptimal. We aimed to determine whether an integrated information and communications technology system and the use of point-of-care (POC) monitors by nursing staff could improve the INR control of aged-care facility residents who take warfarin.

Methods

Nursing staff identified residents who were prescribed warfarin in participating ACFs. A computer program (MedePOC) was developed to store and transmit INR results from the ACFs to general practitioners (GPs) for dosage adjustment. Nursing staff received training in the use of the CoaguChek XS point-of-care INR monitor and the MedePOC software. Following a run-in phase, eligible patients were monitored weekly for up to 12 weeks. The primary outcome was the change in the time in therapeutic range (TTR) in the intervention phase compared to the TTR in the 12 months preceding the study. All GPs, nursing staff and patients were surveyed for their experiences and opinions of the project.

Key findings

Twenty-four patients and 19 GPs completed the trial across six ACFs. The mean TTR for all patients improved non-significantly from 58.9 to 60.6% (P = 0.79) and the proportion of INR tests in range improved non-significantly from 57.1 to 64.1% (P = 0.21). The mean TTR improved in 14 patients (58%) and in these patients the mean absolute improvement in TTR was 23.1%. A post hoc analysis of the INR data using modified therapeutic INR ranges to reflect the dosage adjustment practices of GPs suggested that the intervention did lead to improved INR control. The MedePOC program and POC monitoring was well received by nursing staff.

Conclusions

Weekly POC INR monitoring conducted in ACFs and electronic communication of the results and warfarin doses resulted in non-significant improvements in INR control in a small cohort of elderly residents. Further research involving modification to the communication strategy and a longer follow-up period is warranted to investigate whether this strategy can improve INR control and clinical outcomes in this vulnerable population.

Cost of dabigatran for atrial fibrillation

Cost effective in patients at high risk of stroke, unless INR is well controlled

Challenges of Older Patients’ Knowledge About Warfarin Therapy

Objective: To review the challenges of warfarin education for older patients (aged 65 years or older) in terms of knowledge, access to warfarin education, and education resources. Methods: A quasi-systematic review of the literature was performed via electronic database searches (eg, Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, International Pharmaceutical Abstracts, Meditext, and Google Scholar) from 1990 to May 2011. Results: The 62 articles reviewed found that improved patient knowledge results in better anticoagulation control. The review also found that between 50% and 80% of older patients have inadequate knowledge about the basic aspects of warfarin therapy (eg, action, benefits and risks, interactions with other drugs or foods, international normalized ratio management). Demographic factors, such as advancing age, lower family income, and limited health literacy, were found to inversely affect patients’ warfarin knowledge, and access to warfarin education and information resources were often suboptimal in different practice settings. Finally, a number of educational strategies and resources that could be readily incorporated to improve the effectiveness of current warfarin education programs were extracted from the review. Conclusion: This comprehensive review highlights that education about warfarin in older patients is currently suboptimal and may in part contribute to poor therapeutic outcomes. This review article also acknowledges the need to identify, target, and develop educational strategies and resources to further improve older patients’ knowledge about their warfarin therapy.

Vitamin K antagonist use in the elderly: special considerations

As the population ages, the number of patients aged 75 years and over treated with vitamin K antagonists (VKAs) is steadily increasing. In this age group, the two main indications for oral anticoagulant therapy are the treatment of venous thromboembolic disease and the prevention of systemic embolism in patients with nonvalvular atrial fibrillation. In both indications, a target international normalized ratio of 2.5 (range: 2.0-3.0) is recommended. Although VKAs are beneficial in thromboembolic disorders, they are still underused. In this review, we will focus on two crucial topics in elderly patients, the specific management of VKAs in these patients and the hemorrhagic risk. Current recommendations concerning the management at the start of treatment, education and adequate monitoring may help to minimize the hemorrhagic risk in these frail patients.

Anticoagulation in Elderly Patients Who Fall Frequently: A Therapeutic Dilemma

There is general agreement that patients with persistent atrial fibrillation, who are at risk of having a stroke, need to be anticoagulated. However, clinicians often are in a difficult dilemma when these patients also are at increased risk of falling. Falls can lead to serious injuries in anticoagulated individuals, including intracranial hemorrhages. This case study describes an 88-year-old patient with a history of falling. She received multiple injuries following a fall, including a subdural hematoma. Warfarin was among the patient's many medications. Upon admission to the hospital this patient had a supratherapeutic INR that most likely contributed to her injuries. A question facing the medical team was should she continue to receive warfarin to prevent stroke after discharge from the hospital? Much controversy exists over whether older patients receiving anticoagulation therapy are at increased risk of major hemorrhagic complications. This article discusses the relationship between anticoagulation, falling, and the risks of hemorrhagic events. It also discusses opinions on when to restart anticoagulation following resolution of the subdural hematoma. In addition, the patient was taking multiple medications that are known to contribute to falls in older people. Recommendations for lowering this patient's fall risks are presented.

A composite screening tool for medication reviews of outpatients: general issues with specific examples

Regular performance of medication reviews is prominent among methods that have been advocated to reduce the extent and seriousness of drug-related problems, such as adverse drug reactions, drug-disease interactions, drug-drug interactions, drug ineffectiveness and cost ineffectiveness. Several screening tools have been developed to guide practising healthcare professionals and researchers in reviewing the medication patterns of elderly patients; however, each of these tools has its own limitations. This review discusses a wide range of general prescription-, treatment- and patient-related issues that should be taken into account when reviewing medication patterns by implicit screening. These include generic and therapeutic substitution; potentially superfluous or inappropriate medications; potentially inappropriate dosages or duration of treatment; drug-disease and drug-drug interactions; under-treatment; making use of laboratory test results; patient adherence, experiences and habits; appropriate dosage forms and packaging. A broad selection of specific examples and references that can be used as a basis for explicit screening of medication patterns in outpatients is also offered.

Pharmacogenetics of warfarin: regulatory, scientific, and clinical issues

Using pharmacogenetics-based therapy, clinicians can estimate the therapeutic warfarin dose by genotyping patients for single nucleotide polymorphisms (SNPs) that affect warfarin metabolism or sensitivity. SNPs in the cytochrome P450 complex (CYP2C9) affect warfarin metabolism: patients who have the CYP2C9*2 and/or CYP2C9*3 variants metabolize warfarin slowly and are more likely to have an elevated International Normalized Ratio INR or to hemorrhage during warfarin initiation than patients without these variants. SNPs in vitamin K epoxide reductase (VKORC1) correlate with warfarin sensitivity. Patients who are homozygous for a common VKORC1 promoter polymorphism, -1639 G>A (also designated as VKOR 3673, haplotype A, or haplotype*2), are warfarin sensitive and typically require lower warfarin doses. By providing an estimate of the therapeutic warfarin dose, pharmacogenetics-based therapy may improve the safety of anticoagulant therapy. To improve drug safety, the FDA updates labels of previously approved drugs as new clinical and genetic evidence accrues. The labels of medical products serve to inform prescribers and patients about potential ways to improve the benefit/risk ratio and/or optimize doses of medical products. On August 16, 2007, the FDA updated the label of warfarin to include information on pharmacogenetic testing and to encourage, but not require, the use of this information in dosing individual patients initiating warfarin therapy. The FDA completed the label update in August 2007.

Value of Pacemaker Atrial Diagnostic Data in Patients with Paroxysmal Atrial Fibrillation: An Opportunity to Improve Rates of Warfarin Utilization

Atrial diagnostic data within implantable devices provide an opportunity to assess the frequency and quantity of atrial fibrillation (AF) episodes (AF burden) and its impact on appropriate warfarin anticoagulation. Cardiologists were given clinical scenarios to review with different types of pacemaker diagnostic data in an elderly patient with risk factors for stroke. AF specific data was associated with increased warfarin utilization, but only at intermediate rates. Potential reasons and clinical implications are discussed.

Atrial fibrillation

The incidence and prevalence of atrial fibrillation are increasing because of both population ageing and an age-adjusted increase in incidence of atrial fibrillation. Deciding between a rate control or rhythm control approach depends on patient age and comorbidities, symptoms and haemodynamic consequences of the arrhythmia, but either approach is acceptable. Digoxin is no longer a first-line drug for rate control: beta-blockers and verapamil and diltiazem control heart rate better during exercise. Anti-arrhythmic drugs have only a 40%-60% success rate of maintaining sinus rhythm at 1 year, and have significant side effects. The selection of optimal antithrombotic prophylaxis depends on the patient's risk of ischaemic stroke and the benefits and risks of long-term warfarin versus aspirin, but is independent of rate or rhythm control strategy. Ischaemic stroke risk is best estimated with the CHADS2 score (Congestive heart failure, Hypertension, Age > or = 75 years, Diabetes, 1 point each; prior Stroke or transient ischaemic attack, 2 points). For patients with valvular atrial fibrillation or a CHADS(2) score > or = 2, anticoagulation with warfarin is recommended (INR 2-3, higher for mechanical valves) unless contraindicated or annual major bleeding risk > 3%. Aspirin or warfarin may be used when the CHADS(2) score = 1. Aspirin, 81-325 mg daily, is recommended in patients with a CHADS(2) score of 0 or if warfarin is contraindicated. Stroke rate is similar for paroxysmal, persistent, and permanent atrial fibrillation, and probably for atrial flutter.

Oral anticoagulant treatment: risk factors involved in 500 intracranial hemorrhages

Intracranial bleeding is the most severe complication caused by anticoagulant or antiplatelet treatment. The increasing use of this therapy, especially in older people, makes the balance between clinical benefit and bleeding risk an important consideration. A retrospective study of all consecutive 500 intracranial hemorrhages in the West Valladolid area, approximately 220,000 people, during the period 1998 to 2004, was performed. In relation to mortality, predisposing conditions were included, such as age, antithrombotic treatment, arterial hypertension, cancer, blood diseases, vascular malformations, and traumatisms. The incidence of intracranial hemorrhage was 310 per 100,000 per year with a mortality of 30%. Higher mortality was found in antiplatelet-treated patients (44.9%) than in anticoagulated patients (31.1%). This may be related to a different mean age of 78 vs. 71 years. Arterial hypertension was the most frequent risk factor (45.1% in nontreated patients, 60% anticoagulated, and 75.5% antiplatelet). The relative risk of intracranial bleeding in anticoagulated patients was 11.2 (p < 0.001) with an incidence of 0.03% and a median of 14 months since treatment began. The median INR was 3.3. In 40% of the patients the previous five controls were in range. Strict consideration of indications criteria joined to a better control of risk factors may avoid intracranial bleeding episodes.

Stroke: epidemiology, classification, risk factors, complications, diagnosis, prevention, and medical and dental management

Cerebrovascular accident, or stroke, refers to an acute onset of neurologic deficits lasting more than 24 hours or culminating in death caused by a sudden impairment of cerebral circulation. Stroke is the third leading cause of death and a major cause of long-term disability in the United States. This article provides the dental community with an up-to-date understanding of the epidemiology, classification, risk factors, complications, diagnosis, prevention, and medical and dental management issues pertaining to stroke.

The risks of warfarin use in the elderly

The use of warfarin in the elderly, particularly for stroke prevention in chronic atrial fibrillation, is steadily increasing. Although the benefits of warfarin are greatest in the elderly, so are the risk of adverse outcomes and the difficulties of anticoagulant management. Clinical systems need to improve to counter this therapeutic dilemma, as warfarin is likely to remain the only widely available oral anticoagulant for the foreseeable future. Aspects that require attention are: the careful selection of patients in whom treatment with warfarin is appropriate; initiating therapy in a low dose (e.g., 2.5-5 mg/day); thorough education of patients and carers; close monitoring, especially with any change in the patient's regular drug therapy; involving patients more in the management of their warfarin therapy (self-monitoring/management in suitable patients); and ongoing review of the appropriateness of therapy as circumstances change.

Warfarin pharmacology, clinical management, and evaluation of hemorrhagic risk for the elderly

Elderly patients as a group may present more of a challenge in managing warfarin therapy because of alterations in pharmacokinetics from other medications, diet, and disease; pharmacodynamic changes; increased risk for hemorrhage; and difficulty in monitoring. The elderly, however, may derive the most benefit from warfarin therapy for certain indications, such as the prevention of stroke in atrial fibrillation or recurrent events following deep venous thrombosis. Warfarin can be managed as effectively as in other populations with careful attention to these issues.

Pharmacogenetics-Based Coumarin Therapy

To reduce the risk of hemorrhage, experts advocate prescribing the anticipated therapeutic dose to patients who are beginning coumarin therapy, but until now there was no accurate way to estimate that dose. Using pharmacogenetics-based coumarin therapy, clinicians can now estimate the therapeutic dose by genotyping their patients for single nucleotide polymorphisms (SNPs) that affect coumarin metabolism or sensitivity.

SNPs in the cytochrome P450 complex (CYP2C9) affect coumarin metabolism. Patients with either of two common variants, CYP2C9*2 or CYP2C9*3, metabolize coumarins slowly and are twice as likely to have a laboratory or clinical adverse event, unless their initial coumarin doses are reduced. SNPs in vitamin K epoxide reductase (VKORC1) correlate with coumarin sensitivity. Patients known to be homozygous for a common VKORC1 promoter polymorphism, −1639 G>A (also designated as VKOR 3673, haplotype A, or haplotype*2), should be started on lower coumarin doses than genotype GG patients. By providing an estimate of the therapeutic coumarin dose, pharmacogenetics-based therapy may improve the safety and effectiveness of coumarin therapy.

Haemorrhagic Complications of Vitamin K Antagonists in the Elderly

In patients >75 years of age, the two main indications for oral anticoagulant therapy with vitamin K antagonists (VKAs) are treatment of venous thromboembolic disease and prevention of systemic embolism in patients with nonvalvular atrial fibrillation. In both indications, a target International Normalized Ratio of 2.5 (range 2.0-3.0) is recommended. Bleeding is the adverse effect feared by physicians that most limits the use of VKAs in older frail patients. In this paper, we discuss (i) the risk of VKA-related bleeding with advancing age; (ii) the severity of bleeding complications and particularly the risk of intracranial haemorrhage in older patients; (iii) the risk factors for bleeding related to patient characteristics; and (iv) the risk factors or determinants for bleeding related to treatment variables (warfarin induction and maintenance administration, instability of anticoagulation, poor compliance and patient's education level, and concomitant use of drugs). Avoiding over-anticoagulation and/or reducing periods of overdosing in the course of oral anticoagulant treatment with tailored monitoring may help to minimise the risk of bleeding in older patients.

Warfarin therapy in older adults: managing treatment in the primary care setting

Oral anticoagulant therapy with war farin is commonly used to prevent thromboembolic events in patients at risk. The degree of anticoagulation is variable among individuals and is influenced by many factors; therefore, patients must be monitored frequently to assess for potential adverse effects related to treatment. Individuals older than age 65 are at particular risk for thromboembolic events as well as anticoag ulant-related complications. Because of these factors, elderly individuals pose a unique challenge in maintain ing anticoagulant control. The purpose of this article is to revisit the role of warfarin therapy for elderly individ uals in the primary care setting and to provide nurse practitioners with the information necessary to prescribe and monitor this medication appropriately. This article provides indications for warfarin therapy and also identifies potential barriers to effective management with specific implications for the older population.

Improving the outcomes of anticoagulation: an evaluation of home follow-up of warfarin initiation

OBJECTIVES

A number of studies have reported that the risk of bleeding associated with warfarin is highest early in the course of therapy. This study examined the effect of a programme focused on the transition of newly anticoagulated patients from hospital to the community.

DESIGN

Open-label randomized controlled trial.

SETTING

Home-based follow-up of patients discharged from acute care hospital in southern Tasmania, Australia.

SUBJECTS

A total of 128 patients initiated on warfarin in hospital and subsequently discharged to general practitioner (GP) care were enrolled in the study. Sixty were randomized to home monitoring (HM) and 68 received usual care (UC).

INTERVENTIONS

HM patients received a home-visit by the project pharmacist and point-of-care international normalized ratio (INR) testing on alternate days on 4 occasions, with the initial visit two days after discharge. The UC group was solely managed by the GP and only received a visit 8 days after discharge to determine anticoagulant control.

RESULTS

At discharge, 42% of the HM group and 45% of the UC group had a therapeutic INR. At day 8, 67% of the HM patients had a therapeutic INR, compared with 42% of UC patients (P < 0.002). In addition, 26% of UC patients had a high INR, compared with only 4% of HM patients. Bleeding events were assessed 3 months after discharge and occurred in 15% of HM patients, compared with 36% of the UC group (P < 0.01).

CONCLUSIONS

This programme improved the initiation of warfarin therapy and resulted in a significant decrease in haemorrhagic complications in the first 3 months of therapy.

Non-valvular atrial fibrillation and stroke: Implications for nursing practice and therapeutics

Atrial fibrillation (AF) is the most common sustained cardiac rhythm disturbance and is increasing in prevalence due to the ageing of the population, and rates of chronic heart failure. Haemodynamic compromise and thromboembolic events are responsible for significant morbidity and mortality in Australian communities. Non-valvular AF is a significant predictor for both a higher incidence of stroke and increased mortality. Stroke affects approximately 40,000 Australians every year and is Australia's third largest killer after cancer and heart disease. The burden of illness associated with AF, the potential to decrease the risk of stroke and other embolic events by thromboprophylaxis and the implications of this strategy for nursing care and patient education, determine AF as a critical element of nursing practice and research. A review of the literature was undertaken of the CINAHL, Medline, EMBASE and Cochrane Databases from 1966 until September 2002 focussing on management of atrial fibrillation to prevent thrombotic events. This review article presents key elements of this literature review and the implications for nursing practice.

Cost-savings analysis of using a portable coagulometer for monitoring homebound elderly patients taking warfarin

The authors present a prospective cost-savings analysis to determine how the use of portable coagulometers in the home health setting affects medical expenditure. Thirty-five elderly patients (mean age 67 years) receiving cardiac home health care and long-term oral anticoagulation were evaluated with paired measurements of the international normalized ratio by both a traditional, laboratory-based prothrombin time and a point-of-care coagulometer (CoaguChek, Roche Diagnostics, Basel, Switzerland). Costs for materials, procedures, transportation, and labor were summed for both methods, and it was found that cost of international normalized ratio determination by the portable coagulometer was significantly less than the traditional method ($6.85 vs. $17.30; p<0.001). The authors conclude that by saving on the costs of transporting and processing traditional international normalized ratio specimens, use of point-of-care coagulometers by home health nurses could reduce medical expenditure. The cost savings and potential improvement in quality of care argue for equipping home health nurses with portable coagulometers.

Antithrombotic drugs in secondary stroke prevention among a community dwelling older population

BACKGROUND

Patients who suffer a cerebrovascular event are at high risk of a recurrence. Secondary prevention is crucial in reducing the burden of cerebrovascular disease.

OBJECTIVE

To estimate the percentage of stroke survivors receiving antiplatelet or anticoagulant drugs and to identify factors associated with such treatment.

DESIGN

Cross sectional retrospective cohort study.

METHODS

Data were analysed from a large collaborative observational study, the Italian "silver network" home care project, which collected data (from 1997 to 2001) on patients admitted to home care programmes (n = 5372). Twenty two home health agencies participated in evaluating the implementation of the minimum dataset for home care (MDS-HC) instrument. For the present study, 648 individuals with a diagnosis of stroke were selected and the initial MDS-HC assessment reported.

RESULTS

70% of stroke survivors did not receive any antiplatelet or anticoagulant drugs (95% confidence interval (CI), 66.5 to 73.5). Among all age categories, aspirin and ticlopidine were the two most commonly prescribed drugs. Living alone (odds ratio (OR), 0.49 (95% CI, 0.24 to 0.89)), dependency in activities of daily living (0.66 (0.40 to 0.99)), cognitive impairment (0.58 (0.38 to 0.86)), and low educational level (0.58 (0.34 to 0.98)) were associated with a reduced likelihood of receiving secondary stroke prevention treatment. Cardiac arrhythmias, coronary artery disease, heart failure, and peripheral vascular disease were associated with the use of antiplatelet or anticoagulant treatment.

CONCLUSIONS

Negative attitudes among physicians with respect to secondary stroke prevention are prevalent and reinforce the need for increased awareness of existing data on the risks and benefits for elderly individuals. Social problems and functional impairment may be issues concerning physicians when deciding whether or not the risks of treatment exceed the benefit.

Drotrecogin alfa (activated) treatment of older patients with severe sepsis

The incidence of severe sepsis increases dramatically with advanced age, with a mortality rate that approaches 50%. The main purpose of this investigation was to determine both short- and long-term survival outcomes among 386 patients aged >or=75 years who were enrolled in the Protein C Worldwide Evaluation of Severe Sepsis (PROWESS) trial. Subjects who were treated with drotrecogin alfa (activated; DAA) had absolute risk reductions in 28-day and in-hospital mortality of 15.5% and 15.6%, respectively (P=.002 for both), compared with placebo recipients. The relative risk (RR) for 28-day mortality was 0.68 (95% confidence interval [CI], 0.54-0.87), and the in-hospital RR was 0.70 (95% CI, 0.56-0.88). Resource use and patient disposition for DAA-treated patients compared favorably with those for placebo recipients. In addition, long-term follow-up data were available for 375 subjects (97.2%), and survival rates for DAA recipients were significantly higher over a 2-year period (P=.02). The incidences of serious adverse bleeding during the 28-day study period in the DAA and placebo groups were 3.9% and 2.2%, respectively (P=.34). There was no interaction between age and bleeding rates (P=.97). In conclusion, older patients with severe sepsis have higher short- and long-term survival rates when treated with DAA than when treated with placebo but an increased risk of serious bleeding that is not aged related.

Atrial fibrillation in the elderly: facts and management

Although atrial fibrillation is not widely known by the general public, in developed countries it is the most common arrhythmia. The incidence increases markedly with advancing age. Thus, with the growing proportion of elderly individuals, atrial fibrillation will come to represent a significant medical and socioeconomic problem. The consequences of atrial fibrillation have the greatest impact. The risk of thromboembolism is well known; other outcomes of atrial fibrillation are less well recognised, such as its relationship with dementia, depression and death. Such consequences are responsible for diminished quality of life and considerable economic cost. Atrial fibrillation is characterised by rapid and disorganised atrial activity, with a frequency between 300 and 600 beats/minute. The ventricles react irregularly, and may contract rapidly or slowly depending on the health of the conduction system. Clinical symptoms are varied, including palpitations, syncope, dizziness or embolic events. Atrial fibrillation may be paroxysmal, persistent or chronic, and a number of attacks are asymptomatic. Suspicion or confirmation of atrial fibrillation necessitates investigation and, as far as possible, appropriate treatment of underlying causes such as hypertension, diabetes mellitus, hypoxia, hyperthyroidism and congestive heart failure. In the evaluation of atrial fibrillation, cardiac exploration is invaluable, including electrocardiogram (ECG) and echocardiography, with the aim of detecting cardiac abnormalities and directing management. In elderly patients (arbitrarily defined as aged >75 years), the management of atrial fibrillation varies; it requires an individual approach, which largely depends on comorbid conditions, underlying cardiac disease, and patient and physician preferences. This management is essentially based on pharmacological treatment, but there are also nonpharmacological options. Two alternatives are possible: restoration and maintenance of sinus rhythm, or control of ventricular rate, leaving the atria in arrhythmia. Pharmacological options include antiarrhythmic drugs, such as class III agents, beta-blockers and class IC agents. These drugs have some adverse effects, and careful monitoring is necessary. The nonpharmacological approach to atrial fibrillation includes external or internal direct-current cardioversion and new methods, such as catheter ablation of specific foci, an evolving science that has been shown to be successful in a very select group of atrial fibrillation patients. Another serious challenge in the management of chronic atrial fibrillation in older individuals is the prevention of stroke, its primary outcome, by choosing an appropriate antithrombotic treatment (aspirin or warfarin). Several risk-stratification schemes have been validated and may be helpful to determine the best antithrombotic choice in individual patients.

[Anticoagulation in permanent atrial fibrillation after 75 years of age]

PURPOSE

More than 10% of the population over 75 years old is concerned by non valvular permanent atrial fibrillation which is responsible for at least 30% of ischemic strokes. The indication of an anticoagulant therapy is discussed in two different situations: primary or secondary prevention of stroke and acute phase of stroke.

CURRENT KNOWLEDGE AND KEY POINTS

Patients over 75 years old have a high risk of stroke (> 8% year). All the studies have demonstrated the benefit of a primary or secondary prevention by antivitamin K with an INR between 2 and 3 (reduction of the relative risk of about 68%). Conversely, the efficacy of aspirin has not been proven in this population of elderly patients. Once stroke has occurred, it is not recommended to initiate an anticoagulation (unfractioned or low molecular weight heparin) within the first hours. Prevention of venous thrombosis remains necessary.

FUTURE PROSPECTS AND PROJECTS

Currently, less than 30% of the patients older than 75 years are given anticoagulation, the risk of the treatment being probably overestimated. The risk benefit ratio should be evaluated more properly for a given patient.

Warfarin therapy for atrial fibrillation in the elderly

OBJECTIVE

To evaluate a clinical practice model that addresses special needs for managing anticoagulation in a community-dwelling elderly population with atrial fibrillation and high risk of stroke.

METHODS

Medical records of 18 patients (mean age 82 y) followed by the Geriatric Ambulatory Program over 2 years, with a target international normalized ratio (INR) of 2.0-3.0, were reviewed. Risk factors for stroke, number and results of INR tests, suspected reasons for suboptimal response, and adverse events were analyzed. Patients were defined as having cognitive impairment if they had a Folstein Mini-Mental State Exam score < or = 26. Functional impairment was defined by > or = 2 disabilities in activities of daily living.

RESULTS

Eighty-three percent (15/18) had > or = 2 additional stroke risk factors. Fifty-one percent (273/541) of INR responses were therapeutic. Female gender (p = 0.015) and cognitive (p = 0.019) and functional impairment (p = 0.001) were associated with supratherapeutic INR response. All patients with cognitive impairment and 85% of those with functional impairment received caregiver support for medication administration. There were 4 minor bleeding events and no thromboembolic events. The mean number of medications was 9.3 in those with bleeding versus 6.8 in those without bleeding (p = 0.052).

CONCLUSIONS

Elderly patients with high stroke risk achieved therapeutic INR responses. However, those with significant cognitive or functional impairment require caregiver support and special consideration for anticoagulation management.