Risk Levels and Adverse Clinical Outcomes Among Patients With Nonvalvular Atrial Fibrillation Receiving Oral Anticoagulants

IMPORTANCE

The CHA2DS2-VASc score (calculated as congestive heart failure, hypertension, age 75 years and older, diabetes, stroke or TIA, vascular disease, age 65 to 74 years, and sex category) is the standard for assessing risk of stroke and systemic embolism and includes age and thromboembolic history. To our knowledge, no studies have comprehensively evaluated safety and effectiveness outcomes among patients with nonvalvular atrial fibrillation receiving oral anticoagulants according to independent, categorical risk strata.

OBJECTIVE

To evaluate the incidence of key adverse outcomes among patients with nonvalvular atrial fibrillation receiving oral anticoagulants by CHA2DS2-VASc risk score range, thromboembolic event history, and age group.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was a retrospective claims data analysis using combined data sets from 5 large health claims databases. Eligible participants were adult patients with nonvalvular atrial fibrillation who initiated oral anticoagulants. Data were analyzed between January 2012 and June 2019.

EXPOSURE

Initiation of oral anticoagulants.

MAIN OUTCOMES AND MEASURES

We observed clinical outcomes (including stroke or systemic embolism, major bleeding, and a composite outcome) on treatment through study end, censoring for discontinuation of oral anticoagulants, death, and insurance disenrollment. The population was stratified by CHA2DS2-VASc risk score; history of stroke, systemic embolism, or transient ischemic attack; and age groups. We calculated time to event, incidence rates, and cumulative incidence for outcomes.

RESULTS

We identified 1 141 097 patients with nonvalvular atrial fibrillation; the mean (SD) age was 75.0 (10.5) years, 608 127 patients (53.3%) were men, and over 1 million were placed in the 2 highest risk categories (high risk 1, 327 766 participants; high risk 2, 688 449 participants). Deyo-Charlson Comorbidity Index scores ranged progressively alongside CHA2DS2-VASc risk score strata (mean [SD] scores: low risk, 0.4 [1.0]; high risk 2, 4.1 [2.9]). The crude incidence of stroke and systemic embolism generally progressed alongside risk score strata (low risk, 0.25 events per 100 person-years [95% CI, 0.18-0.34 events]; high risk 2, 3.43 events per 100 person-years [95% CI, 3.06-4.20 events]); patients at the second-highest risk strata with thromboembolic event history had higher stroke incidence vs patients at the highest risk score strata without event history (2.06 events per 100 person-years [95% CI, 2.00-3.12 events] vs 1.18 events per 100 person-years [95% CI, 1.14-1.30 events]). Major bleeding and composite incidence also increased progressively alongside risk score strata (major bleeding: low risk, 0.68 events per 100 person-years [95% CI, 0.56-0.82 events]; high risk 2, 6.29 events per 100 person-years [95% CI, 6.21-6.62 events]; composite incidence: 1.22 events per 100 person-years [95% CI, 1.06-1.41 events]; high risk 2, 10.67 events per 100 person-years [95% CI, 10.26-11.48 events]). The 12-month cumulative incidence proportions for stroke and systemic embolism, major bleeding, and composite outcomes progressed alongside risk score strata (stroke or systemic embolism, 0.30%-1.85%; major bleeding, 0.55%-5.55%; composite, 1.05%-8.23%). Age subgroup analysis followed similar trends.

CONCLUSIONS AND RELEVANCE

The observed incidence of stroke or systemic embolism and major bleeding events generally conformed to an expected increasing incidence by risk score, adding insight into the importance of specific risk score range, thromboembolic event history, and age group strata. These results can help inform clinical decision-making, research, and policy.

Optimizing medication appropriateness in older adults: a randomized clinical interventional trial to decrease anticholinergic burden

BACKGROUND

The complexity of medication therapy in older adults with multiple comorbidities often leads to inappropriate prescribing. Drugs with anticholinergic properties are of particular interest because many are not recognized for this property; their use may lead to increased anticholinergic burden resulting in significant health risks, as well as negatively impacting cognition. Medication therapy management (MTM) interventions showed promise in addressing inappropriate medication use, but the effectiveness of targeted multidisciplinary team interventions addressing anticholinergic medications in older populations is yet to be determined.

METHODS

We conducted an 8-week, parallel-arm, randomized trial to evaluate whether a targeted patient-centered pharmacist-physician team MTM intervention ("targeted MTM intervention") reduced the use of inappropriate anticholinergic medications in older patients enrolled in a longitudinal cohort at University of Kentucky's Alzheimer's Disease Center. Study outcomes included changes in the medication appropriateness index (MAI) targeting anticholinergic medications and in the anticholinergic drug scale (ADS) score from baseline to the end of study.

RESULTS

Between October 1, 2014 and September 30, 2015 we enrolled and randomized 50 participants taking at least one medication with anticholinergic properties. Of these, 35 (70%) were women, 45 (90%) were white, and 33 (66%) were cognitively intact (clinical dementia rating [CDR] = 0); mean age was 77.7 ± 6.6 years. At baseline, the mean MAI was 12.6 ± 6.3; 25 (50%) of the participants used two or more anticholinergics, and the mean ADS score was 2.8 ± 1.6. After randomization, although no statistically significant difference was noted between groups, we identified a potentially meaningful imbalance as the intervention group had more participants with intact cognition, and thus included CDR in all of the analyses. The targeted MTM intervention resulted in statistically significant CDR adjusted differences between groups with regard to improved MAI (change score of 3.6 (1.1) for the MTM group as compared with 1.0 (0.9) for the control group, p = 0.04) and ADS (change score of 1.0 (0.3) for the MTM group as compared with 0.2 (0.3) for the control group, p = 0.03).

CONCLUSIONS

Our targeted MTM intervention resulted in improvement in anticholinergic medication appropriateness and reduced the use of inappropriate anticholinergic medications in older patients. Our results show promise in an area of great importance to ensure optimum outcomes for medications used in older adults.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02172612 . Registered 20 June 2014.

Abstract W P124: Atherosclerosis Of The Circle Of Willis Is Strongly Associated With Downstream Cerebral Amyloid Angiopathy In Parenchymal Arterioles And Capillaries: Possible Mechanism For Atherosclerosis-related Intracranial Hemorrhage

Introduction: Atherosclerosis is highly associated with risk for intracranial hemorrhage. Presumed mechanisms include artery to artery embolization, arteriolar disruption by small vessel atherosclerosis, aberrant angiogenesis in poorly perfused vascular beds, and possible involvement of downstream cerebral amyloid angiopathy (CAA). Direct associations between atherosclerosis and downstream CAA have been not been supported in most studies, however these results may be confounded by the distinction between highly prevalent meningeal CAA and less frequent parenchymal CAA.

Hypothesis: We hypothesized that large vessel intracranial atherosclerosis would be associated with downstream parenchymal, but not meningeal (supplied by extracranial circulation), CAA.

Methods: Data were derived from the University of Kentucky brain bank (n=741). Atherosclerosis of the circle of Willis was graded on semiquantitative scale (1=0-25% occlusion; 2=25-50% occlusion; 3=50-75% occlusion; 4=75-100% occlusion). Cases were divided into those with absent (with or without meningeal CAA; n=493) and those with parenchymal CAA (n=248). Standard descriptive and comparative statistics were used for the analysis.

Results: Atherosclerosis in the circle of Willis was highly associated with parenchymal (p<0.001), but not meningeal CAA.

Conclusions: The strong association seen between severity of atherosclerosis and parenchymal CAA suggests possible shared pathogenesis or perhaps causal development of CAA by high grade atherosclerosis. Further studies exploring this association in animal models would be helpful in clarifying this complex relationship.

Abstract T MP111: Cerebral Amyloid Angiopathy Is Associated With Arteriolar Sclerosis And Microinfarcts, But Not Overt Ischemic Stroke Or Hemorrhage In A Large Autopsy Series

Introduction: Cerebral amyloid angiopathy (CAA) has been associated with various types of cerebrovascular pathology independent of Alzheimer’s disease (AD), including atherosclerosis, arteriosclerosis, ischemic and hemorrhagic infarction. Available studies have frequently produced conflicting results in regards to specific cerebrovascular associations, likely due to confounds of subject selection biases, small sample sizes, and incomplete pathologic analyses. The present study represents one of the largest and most comprehensive clinical-pathologic series to date focused on examining clinical, genetic, and pathologic associations in CAA.

Hypothesis: As CAA represents a vasculopathy of the small arterioles and capillaries, we hypothesized that cerebrovascular associations with CAA would include small vessel pathologies and microinfarcts rather than large or medium vessel pathologies.

Methods: Cases were derived from the University of Kentucky brain bank (n=741). Vascular pathology was graded on semiquantitative scale or as present/absent. Cases were grouped by presence (n=414) or absence of CAA (n=327). Standard descriptive and comparative statistics were used for the analysis.

Results: ApoE status (p<0.001), but not age, was associated with CAA. Cases with and without CAA did not differ in regards to large vessel or lacunar ischemic stroke, hemorrhagic stroke, hippocampal sclerosis, or circle of Willis atherosclerosis. A significant increase in arteriolar sclerosis (p<0.001) and microinfarct burden (p<0.01) was seen in the CAA-positive group.

Conclusions: CAA across the cognitive continuum, appears independent of age, and is a significant contributor to small vessel ischemic changes that may have a profound effect on brain health, including risk for stroke and cognitive impairment. Comprehensive treatment strategies for small vessel ischemic disease need to acknowledge and potentially address the role of CAA as therapeutic treatments for this unique vasculopathy become available in the future.

Cerebrospinal fluid norepinephrine and cognition in subjects across the adult age span

Adequate central nervous system noradrenergic activity enhances cognition, but excessive noradrenergic activity may have adverse effects on cognition. Previous studies have also demonstrated that noradrenergic activity is higher in older than younger adults. We aimed to determine relationships between cerebrospinal fluid (CSF) norepinephrine (NE) concentration and cognitive performance by using data from a CSF bank that includes samples from 258 cognitively normal participants aged 21-100 years. After adjusting for age, gender, education, and ethnicity, higher CSF NE levels (units of 100 pg/mL) are associated with poorer performance on tests of attention, processing speed, and executive function (Trail Making A: regression coefficient 1.5, standard error [SE] 0.77, p = 0.046; Trail Making B: regression coefficient 5.0, SE 2.2, p = 0.024; Stroop Word-Color Interference task: regression coefficient 6.1, SE 2.0, p = 0.003). Findings are consistent with the earlier literature relating excess noradrenergic activity with cognitive impairment.

Outcomes of hospital-based managed care: a multivariate analysis of cost and quality

OBJECTIVE

To determine the effects a hospital-based managed care intervention has on the cost and quality of care.

METHODS

The intervention consisted of a CareMap and a nurse case manager. The CareMap contained both a critical path and a set of expected patient outcomes. The study population comprised all women who delivered by cesarean during the 18 months of the study and who were cared for in the maternity unit at a tertiary-level university hospital. The effects of the intervention were determined by comparing the after group with the before group in regard to length of stay and costs of care post-cesarean delivery, patient ratings of quality of care, and the physical recovery of the patients by discharge and 1 month later.

RESULTS

After the implementation of hospital-based managed care, the average length of stay decreased 13.5% (0.7 days) and the average costs decreased 13.1% ($518). These decreases were statistically significant and remained so after controlling for co-morbid and complicating conditions. Patients perception of the quality of care increased from 4.26 to 4.41 on a 1-5 scale, a statistically significant increase. In particular, patients believed that they had an increased level of participation in their care. The physical recovery scores obtained at discharge did not change.

CONCLUSION

Hospital-based managed care can reduce resource use, length of stay, and cost associated with hospital care while maintaining or improving the quality of care. Whether these effects are reproducible and generalizable to other conditions should be addressed in future studies; the duration of these effects should also be examined.

The assessment of intention-cue detection skills in children: implications for developmental psychopathology

A reliable measure of children's skills in discriminating intention cues in others was developed for this investigation in order to test the hypothesis that intention-cue detection skill is related to social competence in children. Videotapes were prepared in which one child provoked another child. The intention of the first child varied across videotapes. The subject's task was to discriminate among types of intentions. Care was taken to ensure that scores on this measure were not confounded by a child's verbal capacity or general discrimination skill. This instrument was administered to 176 children in kindergarten, second grade, and fourth grade, who were identified by sociometric measures as having a peer status as popular, average, socially rejected, or socially neglected. Scores on this measure were found to increase as a function of increasing age, and normal children (popular and average) were found to score more highly than deviant children (neglected and rejected). The errors by deviant children tended to consist of erroneous labels of prosocial intentions as hostile. Also, children's statements about their probable behavioral responses to provocations by peers were found to vary as a function of subjects' perceptions of the intention of the peer causing the provocation, not as a function of the actual intention portrayed by the peer. Sociometric status differences in these responses were also found. These findings were consistent with a hypothesis of a developmental lag among socially deviant children in the acquisition of intention-cue detection skills.