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Liczko J, Schülein S, Tümena T, Gassmann KG. Prevalence and treatment of atrial fibrillation in older adults. Z Gerontol Geriatr 2023; 56:146-152. [PMID: 35091801 DOI: 10.1007/s00391-022-02017-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/30/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most frequent cardiac arrhythmia with an impact on morbidity and mortality found in the geriatric population. OBJECTIVE This retrospective study is the first to investigate the prevalence, treatment and comorbidities of AF in a large cohort of older adults. MATERIAL AND METHODS Older adults with AF hospitalized between 2010 and 2018. The mean age of the 10,700 AF patients in 2018 was 83.2 ± 6.4 years. The frequency of anticoagulation in older adults with AF between 2010 and 2018 was analyzed. The relationship between comorbidities and anticoagulation in 2018 was examined. Logistic regression analysis was used to identify possible predictive factors for anticoagulation. RESULTS The prevalence of AF in 35,887 hospitalized older adults was 29.8% in 2018. The mean CHA2DS2VASc score was 4.4 ± 1.3 (male 3.8 ± 1.3, female 4.7 ± 1.2). From 2010 to 2018, the frequency of anticoagulation for patients with AF rose from 32.1% to 64.2%. Statistically significant differences in the examined characteristics between anticoagulated and not anticoagulated patients were found. Furthermore, there were no predictive factors for anticoagulation in multivariate logistic analysis. CONCLUSION Hospitalized older adults have an increased prevalence of AF compared to the general population. Despite the higher risk of bleeding, older adults were more frequently anticoagulated in the observation period, preferably with direct oral anticoagulants (DOACs). Patients without anticoagulation had more diagnoses and were worse in functional tests. This study suggests that the decision to give anticoagulants to older adults should be personalized.
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Affiliation(s)
- Jacek Liczko
- Geriatrics Center Erlangen, Department of Geriatrics and Geriatric Rehabilitation, Malteser Waldkrankenhaus St. Marien, Rathsberger Straße 57, 91054, Erlangen, Germany.
| | - Samuel Schülein
- Geriatrics Center Erlangen, Department of Geriatrics and Geriatric Rehabilitation, Malteser Waldkrankenhaus St. Marien, Rathsberger Straße 57, 91054, Erlangen, Germany
| | | | - Karl-Günter Gassmann
- Geriatrics Center Erlangen, Department of Geriatrics and Geriatric Rehabilitation, Malteser Waldkrankenhaus St. Marien, Rathsberger Straße 57, 91054, Erlangen, Germany
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Abrignani MG, Lombardo A, Braschi A, Renda N, Abrignani V, Lombardo RM. Time trends in antithrombotic therapy prescription patterns: Real-world monocentric study in hospitalized patients with atrial fibrillation. World J Cardiol 2022; 14:576-598. [PMID: 36483763 PMCID: PMC9724000 DOI: 10.4330/wjc.v14.i11.576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 07/04/2022] [Accepted: 10/28/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Since 2010, the European Society of Cardiology has extended prescription criteria for oral antithrombotic therapy (OAT) in atrial fibrillation (AF). Direct oral anticoagulants (DOACs) were upgraded from an IIAa recommendation in 2012 to an IA in 2016. In real-world scenarios, however, OAC prescription is still suboptimal, mainly for DOACs.
AIM To evaluate OAT temporal prescription patterns in a cohort of patients hospitalized with AF in a Cardiology Department.
METHODS A retrospective observational study was conducted on a cohort of hospitalized patients in a secondary setting (Trapani, Italy) from 2010 to 2021 with AF as the main or secondary diagnosis. For 4089 consecutive patients, the variables extracted from the Cardiology department database were: Sex, age, time of hospitalization, antithrombotic therapy (warfarin, acenocoumarol, apixaban, dabigatran, edoxaban, rivaroxaban, aspirin, clopidogrel, other antiplatelet agents, low molecular weight heparin, and fondaparinux), diagnosis at discharge and used resources. Basal features are presented as percentage values for categorized variables and as mean +/- SD for categorized once.
RESULTS From January 1st, 2010 to October 6th, 2021, 25132 patients were hospitalized in our department; 4089 (16.27%, mean age 75.59+/-10.82) were discharged with AF diagnosis; of them, 2245 were males (54.81%, mean age 73.56+/-11.45) and 1851 females (45.19%, mean age 78.06+/-9.47). Average length of stay was 5.76+/-4.88 days; 154 patients died and 88 were moved to other Departments/Structures. AF was the main diagnosis in 899 patients (21.94%). The most frequent main diagnosis in patients with AF was acute myocardial infarction (1973 discharges, 48.19%). The most frequent secondary cardiac diagnosis was chronic coronary syndrome (1864 discharges, 45.51%), and the most frequent secondary associated condition was arterial hypertension (1010 discharges, 24.66%). For the analysis of antithrombotic treatments, the final sample included 3067 patients, after excluding in-hospital deaths, transferred out or self-discharged patients, as well as discharges lacking indications for prescribed treatments. OAC treatment increased significantly (35.63% in 2010-2012 vs 61.18% in 2019-2021, +25.55%, P < 0.0001), in spite of any antiplatelet agent use. This rise was due to increasing use of DOACs, with or without antiplatelet agents, from 3.04% in 2013-2015 to 50.06% in 2019-2021 (+47.02%, P < 0.0001) and was greater for factor Xa inhibitors, especially apixaban. In addition, treatment with a vitamin K antagonist, in spite of any antiplatelet agent use, decreased from 35.63% in 2010-2012 to 11.12% in 2019-2021 (-24.48%, P < 0.0001), as well as any antiplatelet therapy, alone or in double combination, (49.18% in 2010-2012 vs 34.18% in 2019-2021, -15.00%, P < 0.0001); and patients not receiving antithrombotic therapy declined with time (14.58% in 2010-2012 vs 1.97% in 2021, P < 0.0001).
CONCLUSION Real-world patients with AF are elderly and affected by cardiovascular and non-cardiovascular diseases. The percentage of patients on OAT and DOACs increased. These data suggest a slow, gradual guidelines implementation process.
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Affiliation(s)
- Maurizio Giuseppe Abrignani
- Operative Unit of Cardiology, Department of Medicine, S. Antonio Abate Hospital of Trapani, ASP Trapani, Trapani 91100, Trapani, Italy
| | - Alberto Lombardo
- Operative Unit of Cardiology, Department of Medicine, S. Antonio Abate Hospital of Trapani, ASP Trapani, Trapani 91100, Trapani, Italy
| | - Annabella Braschi
- Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo 90100, Palermo, Italy
| | - Nicolò Renda
- Department of Medicine and Surgery, University of Parma, Parma 43100, Parma, Italy
| | - Vincenzo Abrignani
- Operative Unit of Internal Medicine with Stroke Care, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE) "G. D'Alessandro", University of Palermo, Palermo 90100, Palermo, Italy
| | - Renzo M Lombardo
- Department of Cardiology, Operative Unit of Cardiology, Department of Medicine, S. Antonio Abate Hospital of Trapani, Trapani 91100, Trapani, Italy
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Ali Babar B, Vu M, Koponen M, Taipale H, Tanskanen A, Kettunen R, Tiihonen M, Hartikainen S, Tolppanen AM. Prevalence of oral anticoagulant use among people with and without Alzheimer’s disease. BMC Geriatr 2022; 22:464. [PMID: 35643439 PMCID: PMC9148467 DOI: 10.1186/s12877-022-03144-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 05/18/2022] [Indexed: 11/29/2022] Open
Abstract
Background Although cardio- and cerebrovascular diseases are common among people with Alzheimer’s disease (AD), it is unknown how the prevalence of oral anticoagulant (OAC) use changes in relation to AD diagnosis. We investigated the prevalence of OAC use in relation to AD diagnosis in comparison to a matched cohort without AD. Methods Register-based Medication use and Alzheimer’s disease (MEDALZ) cohort includes 70 718 Finnish people with AD diagnosed between 2005–2011. Point prevalence of OAC use (prescription register) was calculated every three months with three-month evaluation periods, from five years before to five years after clinically verified diagnosis and compared to matched cohort without AD. Longitudinal association between AD and OAC use was evaluated by generalized estimating equations (GEE). Results OAC use was more common among people with AD until AD diagnosis, (OR 1.17; 95% CI 1.13–1.22), and less common after AD diagnosis (OR 0.87; 95% CI 0.85–0.89), compared to people without AD. At the time of AD diagnosis, prevalence was 23% and 20% among people with and without AD, respectively. OAC use among people with AD began to decline gradually two years after AD diagnosis while continuous increase was observed in the comparison cohort. Warfarin was the most common OAC, and atrial fibrillation was the most common comorbidity in OAC users. Conclusion Decline in OAC use among people with AD after diagnosis may be attributed to high risk of falling and problems in monitoring. However, direct oral anticoagulants (DOACs) that are nowadays more commonly used require less monitoring and may also be safer for vulnerable people with AD. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03144-x.
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Paquette M, Mbuagbaw L, Iorio A, Nieuwlaat R. Methodological considerations for investigating oral anticoagulation persistence in atrial fibrillation. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 7:251-260. [PMID: 32428195 PMCID: PMC8141301 DOI: 10.1093/ehjcvp/pvaa052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/20/2020] [Accepted: 05/13/2020] [Indexed: 12/13/2022]
Abstract
AIMS Reports of long-term oral anticoagulant (OAC) therapy for atrial fibrillation (AF) reveal highly variable, and generally suboptimal estimates of medication persistence. The objective of this review is to summarize current literature and highlight important methodological considerations for interpreting persistence research and designing studies of persistence on OAC treatment. METHODS AND RESULTS We summarize differences in study methodology, setting, timing, treatment, and other factors associated with reports of better or worse persistence. For example, prospective compared with retrospective study designs are associated with higher reported persistence. Similarly, patient factors such as permanent AF or high stroke risk, and treatment with non-vitamin K oral antagonists relative to vitamin K antagonists are associated with higher persistence. Persistence has also been reported to be higher in Europe compared with North America and higher when the treating physician is a general practitioner compared with a specialist. We propose a framework for assessing and designing persistence studies. This framework includes aspects of patient selection, reliability and validity of measures, persistence definitions, clinical utility of measurements, follow-up periods, and analytic approaches. CONCLUSIONS Differences in study design, patient selection, treatments, and factors such as the countries/regions where studies are conducted or the type of treating physician may help explain the variability in OAC persistence estimates. A framework is proposed to assess persistence studies. This may have utility to compare and interpret published studies as well as for planning of future studies.
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Affiliation(s)
- Miney Paquette
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4K1, Canada
- Department of Medicine, Boehringer Ingelheim Ltd, Burlington, ON L7L 5H4, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4K1, Canada
- Biostatistics Unit, Father Sean O’Sullivan Research Centre, St Joseph’s Healthcare Hamilton, Hamilton, ON L8N 4A6, Canada
- Centre for the Development of Best Practices in Health, Yaoundé, Cameroon
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4K1, Canada
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Zathar Z, Karunatilleke A, Fawzy AM, Lip GYH. Atrial Fibrillation in Older People: Concepts and Controversies. Front Med (Lausanne) 2019; 6:175. [PMID: 31440508 PMCID: PMC6694766 DOI: 10.3389/fmed.2019.00175] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/19/2019] [Indexed: 12/18/2022] Open
Abstract
Atrial fibrillation (AF) is the commonest cardiac rhythm abnormality and has a significant disease burden. Amongst its devastating complications is stroke, the risk of which increases with age. The stroke risk in an older person with AF is therefore tremendous, and oral-anticoagulation (OAC) therapy is central to minimizing this risk. The presence of age-associated factors such as frailty and multi-morbidities add complexity to OAC prescription decisions in older patients and often, OAC is needlessly withheld from them despite a lack of evidence to support this practice. Generally, this is driven by an over-estimation of the bleeding risk. This review article provides an overview of the concepts and controversies in managing AF in older people, with respect to the existing evidence and current practice. A literature search was conducted on Pubmed and Cochrane using keywords, and relevant articles published by the 1st of May 2019 were included. The article will shed light on common misconceptions that appear to serve as rationale for precluding OAC and focus on clinical considerations that may aid OAC prescription decisions where appropriate, to optimize AF management using an integrated, multi-disciplinary care approach. This is crucial for all patients, particularly older individuals who are most vulnerable to the deleterious consequences of this condition.
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Affiliation(s)
- Zafraan Zathar
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Anne Karunatilleke
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Ameenathul M Fawzy
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Pamela J B, Joseph H, Matthew K, Thomas G B, Lee N, Judith M K, Jamie M R, Frank M S. Warfarin Use and Mortality, Stroke, and Bleeding Outcomes in a Cohort of Elderly Patients with non-Valvular Atrial Fibrillation. J Atr Fibrillation 2019; 12:2155. [PMID: 31687068 DOI: 10.4022/jafib.2155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/14/2018] [Accepted: 12/10/2018] [Indexed: 12/25/2022]
Abstract
Aims To determine exposure to warfarin and the associated outcomes in a population of older patients with non-valvular atrial fibrillation (NVAF). Methods Cohort study of patients aged 65-89 years admitted to hospital July 2003-December 2008 with newly-diagnosed or pre-existing AF. Outcomes at three years among one-year survivors post-index admission (landmark date) were all-cause mortality, stroke/systemic thromboembolism (stroke/TE) and bleeding. Multivariate Cox models were used to identify factors associated with each outcome. Results AF was the principal diagnosis for 27.5% of 17,336 index AF admissions. Of 14,634 (84.4%) patients alive at one-year 1,384 (9.5%) died in the following year. Vascular disease (42%) was the most frequent cause of death.Warfarin use, prior to the index admission and/or the 1-year landmark, did not exceed 40%.Compared to non-exposure or discontinuation at the index admission, initiation or persistence with warfarin prior to the landmark date was associated with reduced risk for all-cause mortality, a statistically non-significant reduction in risk for stroke/TE, and an increased risk for bleeding. Higher CHA2DS2-VASc scores were associated with increased risk for each outcome. Conclusions In a population-based cohort of hospitalised NVAF patients, the initiation and persistent use of warfarin was associated with lower all-cause mortality risk to three years, although reduction in risk for stroke/TE did not reach statistical significance. The apparent under-use of warfarin in this older, high-risk cohort reinforces the opportunity for further reduction in stroke/TE with the uptake of non-vitamin K oral anti-coagulants (NOACs) among those not prescribed, or not persistent with, warfarin.
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Affiliation(s)
- Bradshaw Pamela J
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia
| | - Hung Joseph
- School of Medicine, Sir Charles Gairdner Hospital Unit, The University of Western Australia, Perth, Western Australia
| | - Knuiman Matthew
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia
| | - Briffa Thomas G
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia
| | - Nedkoff Lee
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia
| | - Katzenellebogen Judith M
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia
| | - Rankin Jamie M
- Cardiology Department, Fiona Stanley Hospital, Murdoch, Western Australia
| | - Sanfilippo Frank M
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia
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Fauchier L, Hylek E, Knight E, Lane D, Levi M, Marin F, Palareti G, Collet JP, Rubboli A, Poli D, Camm AJ, Lip G, Andreotti F, Huber K, Kirchhof P. Bleeding risk assessment and management in atrial fibrillation patients. Thromb Haemost 2017; 106:997-1011. [PMID: 22048796 DOI: 10.1160/th11-10-0690] [Citation(s) in RCA: 174] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Accepted: 10/27/2011] [Indexed: 12/13/2022]
Abstract
SummaryIn this executive summary of a Consensus Document from the European Heart Rhythm Association, endorsed by the European Society of Cardiology Working Group on Thrombosis, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in atrial fibrillation (AF) patients. The main aim of the document was to summarise ‘best practice’ in dealing with bleeding risk in AF patients when approaching antithrombotic therapy, by addressing the epidemiology and size of the problem, and review established bleeding risk factors. We also summarise definitions of bleeding in the published literature. Patient values and preferences balancing the risk of bleeding against thromboembolism as well as the prognostic implications of bleeding are reviewed. We also provide an overview of published bleeding risk stratification and bleeding risk schema. Brief discussion of special situations (e.g. periablation, peri-devices such as implantable cardioverter defibrillators [ICD] or pacemakers, presentation with acute coronary syndromes and/or requiring percutanous coronary interventions/stents and bridging therapy) is made, as well as a discussion of the prevention of bleeds and managing bleeding complications. Finally, this document puts forwards consensus statements that may help to define evidence gaps and assist in everyday clinical practice.
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Wilke T, Groth A, Mueller S, Pfannkuche M, Verheyen F, Linder R, Maywald U, Kohlmann T, Feng YS, Breithardt G, Bauersachs R. Oral anticoagulation use by patients with atrial fibrillation in Germany. Thromb Haemost 2017; 107:1053-65. [PMID: 22398417 DOI: 10.1160/th11-11-0768] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Accepted: 02/06/2012] [Indexed: 01/20/2023]
Abstract
SummaryAtrial fibrillation (AF) is the most common significant cardiac rhythm disorder. Oral anticoagulation (OAC) is recommended by guidelines in the presence of a moderate to high risk of stroke. Based on an analysis of claims-based data, the aim of this contribution is to quantify the stroke-risk dependent OAC utilisation profile of German AF patients as well as the possible causes and the associated clinical outcomes of OAC under-use. Our data set was derived from two large mandatory German medical insurance funds. Risk stratification of patients was based on the CHADS2-score and the CHA2DS2-VASc-score. Two different scenarios were constructed to deal with factors potentially disfavouring OAC use. Causes of OAC under-use and its clinical consequences were analysed using multivariate analysis. Observation year was 2008. A total of 183,448 AF patients met the inclusion criteria. This represents an AF prevalence of 2.21%. The average CHADS2-score was 2.8 (CHA2DS2-VASc-score: 4.3). On between 40.5 and 48.7% of the observed patient-days, there was no antithrombotic protection by OAC, other anticoagulants or aspirin. Older female patients with a high number of comorbidities had a higher risk of OAC under-use. Patients who had already experienced a thromboembolic event had a lower risk of OAC under-use. In the observation year, 3,367 patients experienced a stroke (incidence rate 1.8%). In our multi-level Poisson random effects estimate, OAC use decreases the stroke rate by almost 80% (IRR 0.236). In conclusion, OAC under-use is widespread in the German market. It is associated with severe clinical consequences.
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Comparison of HAS-BLED and HAS-BED Versus CHADS 2 and CHA 2DS 2VASC Stroke and Bleeding Scores in Patients With Atrial Fibrillation. Am J Cardiol 2017; 119:1012-1016. [PMID: 28237286 DOI: 10.1016/j.amjcard.2016.12.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 12/22/2016] [Accepted: 12/22/2016] [Indexed: 11/23/2022]
Abstract
Anticoagulation is recommended in patients with atrial fibrillation (AF) for stroke prevention, and the bleeding risk associated suggests the need for a bleeding risk stratification. HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio (INR), elderly >65 years, drugs/alcohol concomitantly) score includes "labile INR" referred to quality of anticoagulation. However, in naïve patients, this item is not available. In addition, stroke and bleeding risk prediction scores shared several risk factors. The aims of our study were as follows: (1) to evaluate if the HAS-BLED score in its refined form excluding "labile INR" (HAS-BED [hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, elderly, drugs/alcohol]) is still associated with bleeding risk and (2) to evaluate the predictive ability for bleeding of both stroke and bleeding prediction models. We followed an inception cohort of 4,579 patients with AF enrolled in the Survey on anticoagulaTed pAtients RegisTer (NCT02219984). Major bleeds were recorded. During follow-up (7,014 patient-years), 115 patients experienced a major bleeding (MB; rate 1.6 × 100 patient-years). Patients at high risk were better identified by HAS-BLED and HAS-BED scores with respect to CHADS2 (congestive heart failure, hypertension, age >75 years, diabetes, previous stroke or transient ischemic attack) and CHA2DS2VASc (congestive heart, failure, hypertension, age [>75 years], diabetes, stroke/transient ischemic attack, vascular disease, age [65 to 74 years], female gender). HAS-BLED has a slightly higher c value in comparison to CHADS2 and CHA2DS2VASc. However, among naïve patients, the predictive ability for hemorrhage of HAS-BED score is overlapping with CHADS2 and CHA2DS2VASc. In low stroke risk patients (CHA2DS2VASc = 0 to 1), only 6 patients are at high bleeding risk, and none of them experienced MB. In conclusion, in our prospective cohort of patients with AF, we found that HAS-BLED and HAS-BED scores identify patients at high bleeding risk. However, the predictive value for MB of HAS-BED used in naïve patients is similar to CHADS2 or CHA2DS2VASc, suggesting that stroke stratification scores could be sufficient for tailoring treatment.
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Ermini G, Perrone V, Veronesi C, Degli Esposti L, Di Pasquale G. Antithrombotic prophylaxis of atrial fibrillation in an Italian real-world setting: a retrospective study. Vasc Health Risk Manag 2017; 13:239-246. [PMID: 28740396 PMCID: PMC5505677 DOI: 10.2147/vhrm.s136009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES The aims of this study were to assess the prevalence of diagnosed atrial fibrillation (AF), the drug use in patients with AF in terms of antithrombotic (AT) strategies used and the compliance with treatment, and to describe the characteristics of patients affected by AF in relation to treatment. METHODS The data collected were provided from databases of general practitioners (GPs) of the Local Health Unit of Bologna in Italy. From January 1, 2009, to December 31, 2012, all subjects aged ≥18 years followed by the 44 GPs enrolled in the study were evaluated, and the subjects with a diagnosis of AF were included in the analysis. RESULTS From 2009 to 2012, we identified 1,413 patients with a diagnosis of AF (2.09% of 67,517 patients of the 44 GPs). A total of 1,413 patients with a diagnosis of AF (2.09% of 67,517 patients of the 44 GPs) were enrolled in the study. During the study, 14% of the enrolled patients did not receive any prescription of ATs, 30% and 39.56% were treated only with antiplatelet (AP) agents and oral anticoagulants (OACs), respectively, and 16.28% of the patients received prescriptions for both an OAC and an AP agent; of the patients receiving prescriptions for both, only 4.17% received these therapies at the same time. Among the OAC users, the percentage of patients still on treatment with the index drug during the last 3 months of observation was 76.9%. CONCLUSION Our findings emphasize that in an Italian real-world setting, the burden of AF in general population from a public health point of view underscores the need for improvement in utilization of appropriate ATs in patients with known AF.
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Affiliation(s)
| | - Valentina Perrone
- CliCon S.r.l. Health, Economics and Outcomes Research, Ravenna, Italy
| | - Chiara Veronesi
- CliCon S.r.l. Health, Economics and Outcomes Research, Ravenna, Italy
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Filippi A, Giampaoli S, Lapi F, Mazzaglia G, Palmieri L, Pecchioli S, Brignoli O, Cricelli C, Simonetti M, Sessa E, Marchioli R. Global cardiovascular risk evaluation. J Cardiovasc Med (Hagerstown) 2016; 17:581-6. [DOI: 10.2459/jcm.0000000000000124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Real life anticoagulation treatment of patients with atrial fibrillation in Germany: extent and causes of anticoagulant under-use. J Thromb Thrombolysis 2016; 40:97-107. [PMID: 25218507 DOI: 10.1007/s11239-014-1136-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Oral anticoagulation (OAC) with either new oral anticoagulants (NOACs) or Vitamin-K antagonists (VKAs) is recommended by guidelines for patients with atrial fibrillation (AF) and a moderate to high risk of stroke. Based on a claims-based data set the aim of this study was to quantify the stroke-risk dependent OAC utilization profile of German AF patients and possible causes of OAC under-use. Our claims-based data set was derived from two German statutory health insurance funds for the years 2007-2010. All prevalent AF-patients in the period 2007-2009 were included. The OAC-need in 2010 was assumed whenever a CHADS2- or CHA2DS2-VASC-score was >1 and no factor that disfavored OAC use existed. Causes of OAC under-use were analyzed using multivariate logistic regression. 108,632 AF-prevalent patients met the inclusion criteria. Average age was 75.43 years, average CHA2DS2-VASc-score was 4.38. OAC should have been recommended for 56.1/62.9 % of the patients (regarding factors disfavouring VKA/NOAC use). For 38.88/39.20 % of the patient-days in 2010 we could not observe any coverage by anticoagulants. Dementia of patients (OR 2.656) and general prescription patterns of the treating physician (OR 1.633) were the most important factors increasing the risk of OAC under-use. Patients who had consulted a cardiologist had a lower risk of being under-treated with OAC (OR 0.459). OAC under-use still seems to be one of the major challenges in the real-life treatment of AF patients. Our study confirms that both patient/disease characteristics and treatment environment/general prescribing behaviour of physicians may explain the OAC under-use in AF patients.
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Bo M, Sciarrillo I, Maggiani G, Falcone Y, Iacovino M, Grisoglio E, Fonte G, Grosjean S, Gaita F. Health status, geriatric syndromes and prescription of oral anticoagulant therapy in elderly medical inpatients with atrial fibrillation. Geriatr Gerontol Int 2016; 17:416-423. [DOI: 10.1111/ggi.12730] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 11/03/2015] [Accepted: 11/29/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Mario Bo
- SCDU Geriatria e Malattie Metaboliche dell'Osso; Città della Salute e della Scienza-Molinette; Torino Italia
| | - Irene Sciarrillo
- SCDU Geriatria e Malattie Metaboliche dell'Osso; Città della Salute e della Scienza-Molinette; Torino Italia
| | - Guido Maggiani
- SCDU Geriatria e Malattie Metaboliche dell'Osso; Città della Salute e della Scienza-Molinette; Torino Italia
| | - Yolanda Falcone
- SCDU Geriatria e Malattie Metaboliche dell'Osso; Città della Salute e della Scienza-Molinette; Torino Italia
| | - Marina Iacovino
- SCDU Geriatria e Malattie Metaboliche dell'Osso; Città della Salute e della Scienza-Molinette; Torino Italia
| | - Enrica Grisoglio
- SCDU Geriatria e Malattie Metaboliche dell'Osso; Città della Salute e della Scienza-Molinette; Torino Italia
| | - Gianfranco Fonte
- SCDU Geriatria e Malattie Metaboliche dell'Osso; Città della Salute e della Scienza-Molinette; Torino Italia
| | - Simon Grosjean
- SCDU Geriatria e Malattie Metaboliche dell'Osso; Città della Salute e della Scienza-Molinette; Torino Italia
| | - Fiorenzo Gaita
- SCDU Cardiologia; Città della Salute e della Scienza-Molinette; Torino Italia
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14
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Tajer C, Ceresetto J, Bottaro FJ, Martí A, Casey M. Assessment of the Quality of Chronic Anticoagulation Control With Time in Therapeutic Range in Atrial Fibrillation Patients Treated With Vitamin K Antagonists by Hemostasis Specialists: The TERRA Registry: Tiempo en rango en la República Argentina. Clin Appl Thromb Hemost 2016; 23:445-453. [PMID: 26739542 DOI: 10.1177/1076029615623378] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Oral anticoagulation therapy with vitamin K antagonists (VKA) such as warfarin and acenocoumarol is recommended in patients with atrial fibrillation (AF) and risk factors for embolism. The quality of anticoagulation control with VKA may be assessed by the time in therapeutic range (TTR). In our country, there are no data available about the quality of anticoagulation in patients with AF. The primary goal of our study was to assess the level of effective anticoagulation in a multicenter network of anticoagulation clinics in Argentina, which included patients with nonvalvular AF (NVAF) treated with VKA oral anticoagulants. METHODS The TERRA trial is a multicenter, cross-sectional study involving 14 anticoagulation clinics that were invited to participate and recruit 100 consecutive patients with NVAF treated with VKA for more than 1 year. The international normalized ratio (INR) values were retrospectively obtained from patient charts, and TTR was calculated using the Rosendaal method. RESULTS A total of 1190 patients were included in the analysis. Mean age was 74.9 ± 9.9 years, and 52.5% of the patients were male. Median TTR was 67.5% (interquartile interval 54-80). During 55% of the TTR, INR was >3. Interinstitution variability was substantial, with a range of 57.7% ± 17% to 87.7% ± 17%, P < .001. The 10th percentile of TTR was 41%, the 20th percentile was 50%, the 30th was 58%, and the 35th percentile was 60%. In 40% of patients, TTR was <70%. CONCLUSION In this multicenter study, mean TTR values in patients with AF under VKA were similar to those in international therapeutic clinical trials (55%-65%). Marked variations among institutions were observed and, although average results obtained were high, one third of the patients exhibited a TTR below 60%. This cutoff value is conservative according to current recommendations, and guidelines suggest that when management with VKA cannot be improved, patients should be switched to direct oral anticoagulants. The addition of TTR calculation to clinical practice may help improve the quality of oral anticoagulation in patients with AF, thus improving anticoagulation outcomes.
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Affiliation(s)
- Carlos Tajer
- 1 Cardiology Deparment, Hospital El Cruce, Florencio Varela, Argentina
| | - José Ceresetto
- 2 Hematology Deparment, Hospital Británico, Buenos Aires, Argentina
| | | | - Alejandra Martí
- 4 Hematology Department, Hospital El Cruce, Florencio Varela, Argentina
| | - Marcelo Casey
- 5 Hematology Department, FLENI, Buenos Aires, Argentina
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15
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Staszewsky L, Cortesi L, Baviera M, Tettamanti M, Marzona I, Nobili A, Fortino I, Bortolotti A, Merlino L, Disertori M, Latini R, Roncaglioni MC. Diabetes mellitus as risk factor for atrial fibrillation hospitalization: Incidence and outcomes over nine years in a region of Northern Italy. Diabetes Res Clin Pract 2015. [PMID: 26220013 DOI: 10.1016/j.diabres.2015.06.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
AIMS Diabetes mellitus (DM) and atrial fibrillation (AF) are worldwide public health challenges and major causes of death and cardiovascular events. The association between DM and AF is controversial in literature and data on outcomes of individuals with both diseases have not been evaluated in population studies. We tested the hypothesis that DM is independently associated to AF hospitalization and assessed the risk of stroke and mortality in people with both conditions. METHODS We conducted a population-based cohort-study of DM patients and their corresponding controls identified in a administrative health database of the Lombardy Region. Both cohorts were followed for nine years. A multivariable Cox proportional-hazards-regression model was used to estimate the hazard ratio (HR) for first hospitalization for AF and for clinical outcomes. RESULTS Out of 9,061,258 residents, 285,428 (3.14%) DM subjects were identified, mean age 65.8±15 years, 49% were women. The cumulative incidence of AF in DM was 10.4% vs. 7.4% in non-DM. DM was a risk factor for AF (HR 1.32, 95% CI 1.30-1.34; p<0.0001). Oral anticoagulants were prescribed in 34.8% of DM patients with AF. DM associated with AF, presented the highest HR for stroke: 2.63; 95% CI 2.47-2.80 and for total death, HR 2.41; 95% CI 2.36-2.47. CONCLUSIONS In this population study, DM was an independent risk factor for AF hospitalization. DM patients with AF had the highest risk of stroke and total mortality. Early identification of AF and a structured plan to optimize the comprehensive management of DM and AF patients is mandatory.
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Affiliation(s)
- Lidia Staszewsky
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Laboratory of Cardiovascular Clinical Pharmacology, Milan, Italy.
| | - Laura Cortesi
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Laboratory of General Practice Research, Milan, Italy
| | - Marta Baviera
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Laboratory of General Practice Research, Milan, Italy
| | - Mauro Tettamanti
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Laboratory of Geriatric Neuropsychiatry, Milan, Italy
| | - Irene Marzona
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Laboratory of General Practice Research, Milan, Italy
| | - Alessandro Nobili
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Laboratory for Quality Assessment of Geriatric Therapies and Services, Milan, Italy
| | - Ida Fortino
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | | | - Luca Merlino
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | | | - Roberto Latini
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Laboratory of Cardiovascular Clinical Pharmacology, Milan, Italy
| | - Maria Carla Roncaglioni
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Laboratory of General Practice Research, Milan, Italy
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16
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Gumbinger C, Holstein T, Stock C, Rizos T, Horstmann S, Veltkamp R. Reasons Underlying Non-Adherence to and Discontinuation of Anticoagulation in Secondary Stroke Prevention among Patients with Atrial Fibrillation. Eur Neurol 2015; 73:184-91. [DOI: 10.1159/000371574] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 12/14/2014] [Indexed: 11/19/2022]
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17
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Cotté FE, Benhaddi H, Duprat-Lomon I, Doble A, Marchant N, Letierce A, Huguet M. Vitamin K Antagonist Treatment in Patients With Atrial Fibrillation and Time in Therapeutic Range in Four European Countries. Clin Ther 2014; 36:1160-8. [DOI: 10.1016/j.clinthera.2014.07.016] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 07/11/2014] [Accepted: 07/23/2014] [Indexed: 11/27/2022]
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18
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Wu D, Mansoor G, Kempf C, Schwalm MS, Chin J. Renal function, attributes and coagulation treatment in atrial fibrillation (R-FACT Study): retrospective, observational, longitudinal cohort study of renal function and antithrombotic treatment patterns in atrial fibrillation patients with documented eGFR in real-world clinical practices in Germany. Int J Clin Pract 2014; 68:714-24. [PMID: 24499317 DOI: 10.1111/ijcp.12379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
AIMS This retrospective, observational, longitudinal study aimed to document the distribution, changes in renal function [measured by estimated glomerular filtration (eGFR)] and antithrombotic treatment pattern in atrial fibrillation (AF) patients in real-world settings managed by general practitioners in Germany. METHODS AND RESULTS Data were extracted from the German Longitudinal Patient Database. A total of 15,900 patients with AF were identified. Among 1660 having eGFR available at baseline, 3.4% had severely impaired eGFR, 9.7% and 25.6% had moderate severe decrease and moderate decrease in eGFR, respectively, and 61.3% had mildly decreased/normal eGFR. Patients with moderately and severely decreased eGFR tended to be older. The proportion of patients with a CHADS2 score ≥ 2 was 92.9% in those with severely decreased eGFR, and 87.0% and 79.1% in those with moderately severe and moderately decreased eGFR. During follow up, 52.1% of patients with severely decreased eGFR, and 26.3% to 23.7% of patients with moderately decreased eGFR were not treated by antithrombotic. When comparing baseline with follow-up eGFR, 55.0% of patients showed decreased eGFR. Age, diabetes, dyslipidaemia and history of myocardial infarction were identified as significant predictors for renal function deterioration based on results from multivariate Cox regression model. CONCLUSIONS Moderate-to-severe renal dysfunction is prevalent (~38%) in German AF patients with documented eGFR managed in actual clinical practices. The risk of stroke, as measured by the CHADS2 score, was associated with decreased renal function. Treatment with anticoagulation therapies decreased with decreasing renal function, despite increasing risk of stroke. Anticoagulation treatments remain suboptimal during the 12-month follow up in patients with moderate or severe renal impairment.
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Affiliation(s)
- D Wu
- Global Health Outcomes, Merck & Co., Inc., Whitehouse Station, NJ, USA
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19
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Molteni M, Cimminiello C. Warfarin and atrial fibrillation: from ideal to real the warfarin affaire. Thromb J 2014; 12:5. [PMID: 24548437 PMCID: PMC3937065 DOI: 10.1186/1477-9560-12-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 11/05/2013] [Indexed: 02/08/2023] Open
Abstract
Vitamin K Antagonists (VKAs) are widely used in clinical practice and nearly 1% of the entire population receives oral anticoagulation at least once in life. However, the rate of prescription of anticoagulation is low, compared to what it should be. No more than 50-60% of patients affected by atrial fibrillation (AF) receive anticoagulation. In the setting of AF, VKAs are safe and effective when properly managed, reducing stroke and systemic embolism by more than 60%. VKAs safety and effectiveness are closely related to the quality of anticoagulation (e.g. time in therapeutic range), and anticoagulation clinics offer the best management of anticoagulant therapy. However, a sizeable proportion of patients are managed elsewhere. In clinical practice, in the setting of AF, a low prescription rate of VKAs is frequently observed and this is due also to difficulties in managing laboratory monitoring and drug dose adjustment. The suboptimal management of therapy with VKAs leads to a lesser efficacy than that reported in clinical trials, and to an increase in adverse reactions. VKAs still remain the first and only available therapy for a number of diseases (e.g. valvular atrial fibrillation and mechanical prosthetic heart valves). Now, since approval of the new oral anticoagulants (NOAs), the choice of anticoagulant therapy in definite settings, such as stroke prevention in non-valvular atrial fibrillation (SPAF) or treatment of venous thromboembolism, has surely become more intriguing but also more problematic. In light of these new therapeutic options, we reviewed VKAs therapy, in the setting of atrial fibrillation, focusing on VKAs impact in real life. We analyzed the data about efficacy and safety of warfarin at three levels: clinical trial and real life, outside and inside anticoagulation clinics.
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Affiliation(s)
- Mauro Molteni
- Internal Medicine, Vimercate Hospital, Azienda Ospedaliera di Desio e Vimercate, Italy
| | - Claudio Cimminiello
- Internal Medicine, Vimercate Hospital, Azienda Ospedaliera di Desio e Vimercate, Italy
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20
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Lip GYH, Ramsay SG. Insights from the RCPE UK Consensus Conference on approaching the comprehensive management of atrial fibrillation. Expert Rev Cardiovasc Ther 2014; 10:697-700. [DOI: 10.1586/erc.12.48] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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21
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Piccinocchi G, Laringe M, Guillaro B, Arpino G, Piccinocchi R, Nigro G, Calabrò P. Diagnosis and management of atrial fibrillation by primary care physicians in Italy : a retrospective, observational analysis. Clin Drug Investig 2013; 32:771-7. [PMID: 23018284 PMCID: PMC3693438 DOI: 10.1007/s40261-012-0005-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with a heavy burden of morbidity and mortality, mainly due to an increased risk of cerebrovascular events and cardiac failure. Oral anticoagulant (OAC) treatment prevents stroke and systemic thromboembolism in patients with AF and its use is strongly recommended in guidelines. However, its use in this patient group remains limited. Primary care physicians (PCPs) have an important role to play in this context. Objective The primary objective was to estimate prevalence and epidemiological features of AF in the primary care setting, focusing on ischaemic and bleeding risk assessment. A secondary objective was to examine the PCPs’ level of adherence to the guidelines for the prevention of thromboembolic risk in these patients. Methods This retrospective, observational study was based on data entered by 128 PCPs into the Health Search (HS) Thales database, identifying patients with a diagnosis of AF at the time of the analysis. Results Out of 167,056 patients analysed, 2,173 (1.3 %) were diagnosed with AF, with 86 % at high risk for ischaemic stroke, according to CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years [doubled], diabetes, stroke [doubled], vascular disease, age 65–74 years, sex category [female]) stratification. After the diagnosis of AF, 84 % of patients were prescribed OAC treatment. However, at 2 years’ follow-up, only 29.6 % were still being treated with OACs. Conclusion The prevalence of AF in this analysis was consistent with previously reported Italian national epidemiological data. Adherence to the European Society of Cardiology AF guidelines by PCPs was low, despite the high levels of stroke risk. At the end of the observation period less than one-third of patients were still on OAC therapy. Awareness of the benefits of OACs in stroke prevention in AF patients needs to be improved.
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Affiliation(s)
- Gaetano Piccinocchi
- Co.Me.Gen. Coop (Cooperativa Medicina Generale Napoli), Cooperative of Primary Care Physicians, Via Cintia Parco S. Paolo 45, 80126, Naples, Italy.
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22
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Pereira de Sousa L, Burba I, Ruperto C, Lattuada L, Barbone F, Di Chiara A. Vitamin K antagonists in patients with nonvalvular atrial fibrillation. J Cardiovasc Med (Hagerstown) 2013; 14:534-40. [DOI: 10.2459/jcm.0b013e32835dbd58] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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23
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Filippi A, Zoni-Berisso M, Ermini G, Landolina M, Brignoli O, D'Ambrosio G, Zingarini G, Pedrinazzi C. Stroke prophylaxis in high-risk patients with atrial fibrillation: rhythm vs. rate control strategy. Eur J Intern Med 2013; 24:314-7. [PMID: 23474251 DOI: 10.1016/j.ejim.2013.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 12/23/2012] [Accepted: 02/08/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE "Rhythm" and "Rate" control strategies require partially different organization, and a different involvement of Specialists and General Practitioners; we verified whether the strategy assignment modified the approach to stroke prophylaxis. METHODS Survey in general practice: 233 GPs identified all patients with codified atrial fibrillation (AF) diagnosis, checked the diagnosis (ECG/hospital discharge document), and filled a structured questionnaire on stroke risk-factors, prophylactic therapy, and reasons for warfarin non prescription in CHADS ≥2 patients. Data were collected as an "aggregate." RESULTS Population observed: 295,906 patients aged >14; 6,036 with confirmed AF; 5,888 with complete data about anti-thrombotic prophylaxis are analyzed here. In the "rhythm strategy" group 45.6% of the CHADS score ≥2 patients (594) were on warfarin, vs. 73.2% (1,741) in the "rate strategy" group (p<0.0001). Overall reasons for warfarin non-use were significantly different in the two groups: clinical contraindications (12.3% vs. 19.7%), side effects (5.5% vs. 8.5%), patients' refusal (12.2% vs. 15.2%), unreliable patient/care-giver (14.4% vs. 25.9%); reasons were unknown to the GP in 55.6% in rhythm control vs. 30.9% in rate control group. CONCLUSIONS Anti-thrombotic prophylaxis in CHADS ≥2 patients is different in subjects assigned to the Rhythm vs. the Rate control strategy, as well as reported reasons for warfarin non use. GPs do not know why warfarin is not used in a large percentage of cases, mainly in the rhythm control strategy group. Improving efforts should probably be differently tailored for patients assigned to the "rhythm" or the "rate" control strategy.
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24
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Gussoni G, Di Pasquale G, Vescovo G, Gulizia M, Mathieu G, Scherillo M, Panuccio D, Lucci D, Nozzoli C, Fabbri G, Colombo F, Riva L, Baldo CI, Maggioni AP, Mazzone A. Decision making for oral anticoagulants in atrial fibrillation: the ATA-AF study. Eur J Intern Med 2013; 24:324-32. [PMID: 23684591 DOI: 10.1016/j.ejim.2013.04.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 04/14/2013] [Accepted: 04/18/2013] [Indexed: 01/27/2023]
Abstract
BACKGROUND Oral anticoagulants offer the best long-term protection against ischemic stroke in patients with atrial fibrillation (AF). However, vitamin K antagonists (VKA) are cumbersome to use and their prescription is far from guidelines recommendations. We report the results of a large survey on the attitudes of prescription of VKA in patients with AF. METHODS 7148 patients were enrolled by 196 Internal Medicine (MED) and 164 Cardiology (CARD) centers, and VKA specifically analyzed. Thrombotic and hemorrhagic risks were evaluated by means of CHADS2 and CHA2DS2VASc scores, and a study-specific bleeding score (modified HAS-BLED). RESULTS 63.9% of non-valvular patients had a CHADS2 score≥2 (MED: 75.3%-CARD: 53.1%), and 28.4% a bleeding score≥3 (41.9% MED-15.8% CARD). VKA were prescribed in 55.5% of non-valvular patients (46.3% MED and 64.2% CARD), in 81% of high-risk valvular patients and in 58.8% of the overall study population. Among patients at high risk of bleeding (score≥3), VKA were prescribed in 26.9% of subjects, while, in the subgroup at high risk of thrombosis (CHADS2 Score<2), these were prescribed in 54.4%. Age≥75, paroxysmal AF, cognitive impairment, need for assistance, CHADS2<2 and bleeding score≥3 were independent predictors of non-use of VKA. CONCLUSIONS Oral anticoagulants are more frequently used in CARD than in MED, plausibly due to greater complexity of MED patients. Stratification of thrombotic and hemorrhagic risk significantly drives the choice for VKA. However the fraction of patients in whom prescription or non-prescription is based on other individual characteristics is not negligible.
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25
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Mitchell SA, Simon TA, Raza S, Jakouloff D, Orme ME, Lockhart I, Drost P. The Efficacy and Safety of Oral Anticoagulants in Warfarin-Suitable Patients With Nonvalvular Atrial Fibrillation. Clin Appl Thromb Hemost 2013; 19:619-31. [DOI: 10.1177/1076029613486539] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The novel oral anticoagulants (NOACs) apixaban, dabigatran, and rivaroxaban have been recently indicated for stroke prevention in patients with atrial fibrillation (AF) . Due to a lack of direct head-to-head trials comparing the NOACs, the current systematic review and network meta-analysis (NMA) were conducted to assess their relative efficacy and safety. Three phase III randomized controlled trials enrolling 50 578 patients were included. Results of the NMA show a clear trend favoring NOACs over warfarin with regard to the key outcomes of stroke/systemic embolism and all-cause mortality, with apixaban also showing a favorable response for major bleeding and total discontinuations. Although there were few significant differences among the NOACS with regard to efficacy outcomes, apixaban and dabigatran 110 mg were associated with significantly lower hazards of major bleeding compared with dabigatran 150 mg and rivaroxaban. The NOACs offer a therapeutic advance over standard warfarin treatment in stoke prevention in patients with nonvalvular AF.
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Affiliation(s)
| | - Teresa A. Simon
- Global Health Economics and Outcomes Research, Bristol-Myers Squibb, Princeton, NJ, USA
| | - Syed Raza
- Analyst Systematic Review, Abacus International, Bicester, UK
| | - David Jakouloff
- Health Outcomes, Bristol-Myers Squibb International, Rueil-Malmaison, France
| | | | - Ian Lockhart
- Evidence Based Medicine Manager, Pfizer, Tadworth, UK
| | - Pieter Drost
- EMEA Health Economics and Outcomes Research, Bristol-Myers Squibb International, Braine-L’Alleud, Belgium
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26
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Zoni-Berisso M, Filippi A, Landolina M, Brignoli O, D'Ambrosio G, Maglia G, Grimaldi M, Ermini G. Frequency, patient characteristics, treatment strategies, and resource usage of atrial fibrillation (from the Italian Survey of Atrial Fibrillation Management [ISAF] study). Am J Cardiol 2013; 111:705-11. [PMID: 23273528 DOI: 10.1016/j.amjcard.2012.11.026] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Revised: 11/14/2012] [Accepted: 11/14/2012] [Indexed: 11/16/2022]
Abstract
Atrial fibrillation (AF) is 1 of the most important healthcare issues and an important cause of healthcare expenditure. AF care requires specific arrhythmologic skills and complex treatment. Therefore, it is crucial to know its real affect on healthcare systems to allocate resources and detect areas for improving the standards of care. The present nationwide, retrospective, observational study involved 233 general practitioners. Each general practitioner completed an electronic questionnaire to provide information on the clinical profile, treatment strategies, and resources consumed to care for their patients with AF. Of the 295,906 patients screened, representative of the Italian population, 6,036 (2.04%) had AF: 20.2% paroxysmal, 24.3% persistent, and 55.5% permanent AF. AF occurred in 0.16% of patients aged 16 to 50 years, 9.0% of those aged 76 to 85 years, and 10.7% of those aged ≥85 years. AF was symptomatic despite therapy in 74.6% of patients and was associated with heart disease in 75%. Among the patients with AF, 24.8% had heart failure, 26.8% renal failure, 18% stroke/transient ischemic attack, and 29.3% had ≥3 co-morbidities. The rate control treatment strategy was pursued in 55%. Of the 6,036 patients with AF, 46% received anticoagulants. The success rate of catheter ablation of the AF substrate was 50%. In conclusion, in our study, the frequency of AF was 2 times greater than previously reported (approximately 0.90%), rate control was the most pursued treatment strategy, anticoagulants were still underused, and the success rate of AF ablation was lower than reported by referral centers.
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27
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Campanini M, Frediani R, Artom A, Pinna G, Valerio A, La Regina M, Marengo S, Lo Pinto G, Del Signore E, Bonizzoni E, Mathieu G, Mazzone A, Vescovo G. Real-world management of atrial fibrillation in Internal Medicine units. J Cardiovasc Med (Hagerstown) 2013; 14:26-34. [DOI: 10.2459/jcm.0b013e328348e5ce] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Palacio Lapuente F, Hernandez Galindo M, Amezqueta Goñi C, Lapuente Heppe I, Sola Saravia C. [Managing the atrial fibrillation process: an integral approach]. REVISTA DE CALIDAD ASISTENCIAL : ORGANO DE LA SOCIEDAD ESPANOLA DE CALIDAD ASISTENCIAL 2013; 28:19-27. [PMID: 22771152 DOI: 10.1016/j.cali.2012.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2012] [Revised: 05/20/2012] [Accepted: 05/21/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES The study was developed in 3 phases, with the following aims: To define the most appropriate management process for atrial fibrillation (AF) from the point of view of the health professionals and the patients. To determine how it is managed in daily practice. To identify the changes required in order that this daily practice may come closer to that of an appropriate management process. DESIGN 1st phase: consensus techniques were used, as well as a failure modes and effects analysis (FMEA), and a focus group with patients. 2nd phase: included a questionnaire. 3rd phase: 3 nominal groups and 3 focus groups were formed. SETTING Primary Care and Cardiology. PARTICIPANTS Family doctors, cardiologists, and patients, in the first phase, and family doctors in the second and third phases. MAIN MEASUREMENTS 1st phase: a flow diagram was designed with its explanatory notes on the correct care process for AF. 2nd phase: how AF was managed in current practice. 3rd phase: barriers for using the correct care process were identified, and proposals for their improvement were defined. RESULTS Almost 40% of the family doctors were involved in the diagnosis and treatment of their patients with FA. Training, cooperation between specialties, motivation, working in a team with nursing, and organisational changes were identified as essential factors for a proper management process. CONCLUSIONS AF can be managed from Primary Care. To do this, important changes are required in the care organisation. Training, along with support and communication between care levels are also seen as necessary.
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Affiliation(s)
- Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, UK
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Aguilar E, García-Díaz AM, Sánchez Muñoz-Torrero JF, Álvarez LR, Piedecausa M, Arnedo G, Monreal M. Clinical outcome of stable outpatients with coronary, cerebrovascular or peripheral artery disease, and atrial fibrillation. Thromb Res 2012; 130:390-5. [DOI: 10.1016/j.thromres.2012.05.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 05/07/2012] [Accepted: 05/11/2012] [Indexed: 10/28/2022]
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Di Pasquale G, Mathieu G, Maggioni AP, Fabbri G, Lucci D, Vescovo G, Pirelli S, Chiarella F, Scherillo M, Gulizia MM, Gussoni G, Colombo F, Panuccio D, Nozzoli C, Berisso MZ. Current presentation and management of 7148 patients with atrial fibrillation in cardiology and internal medicine hospital centers: the ATA AF study. Int J Cardiol 2012; 167:2895-903. [PMID: 22884698 DOI: 10.1016/j.ijcard.2012.07.019] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 07/02/2012] [Accepted: 07/21/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is associated with a high risk of stroke and mortality. AIMS To describe the difference in AF management of patients (pts) referred to Cardiology (CARD) or Internal Medicine (MED) units in Italy. METHODS AND RESULTS From May to July 2010, 360 centers enrolled 7148 pts (54% in CARD and 46% in MED). Median age was 77 years (IQR 70-83). Hypertension was the most prevalent associated condition, followed by hypercholesterolemia (28.9%), heart failure (27.7%) and diabetes (24.3%). MED pts were older, more frequently females and more often with comorbidities than CARD pts. In the 4845 pts with nonvalvular AF, a CHADS2 score ≥ 2 was present in 53.0% of CARD vs 75.3% of MED pts (p<.0001). Oral anticoagulants (OAC) were prescribed in 64.2% of CARD vs 46.3% of MED pts (p<.0001); OAC prescription rate was 49.6% in CHADS2 0 and 56.2% in CHADS2 score ≥ 2 pts. At the adjusted analysis patients managed in MED had a significantly lower probability to be treated with OAC. Rate control strategy was pursued in 51.4% of the pts (60.5% in MED and 43.6% in CARD) while rhythm control was the choice in 39.8% of CARD vs 12.9% of MED pts (p<.0001). CONCLUSIONS Cardiologists and internists seem to manage pts with large epidemiological differences. Both CARD and MED specialists currently fail to prescribe OAC in accordance with stroke risk. Patients managed by MED specialists have a lower probability to receive an OAC treatment, irrespective of the severity of clinical conditions.
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Pisters R, Lip GYH. Periprocedural antithrombotic management of patients undergoing ablation for atrial fibrillation: what we currently do...and what should we do? Can J Cardiol 2012; 29:139-41. [PMID: 22819445 DOI: 10.1016/j.cjca.2012.05.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 05/25/2012] [Indexed: 11/19/2022] Open
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Gattellari M, Worthington JM, Leung DY, Zwar N. Supporting Treatment decision making to Optimise the Prevention of STROKE in Atrial Fibrillation: the STOP STROKE in AF study. Protocol for a cluster randomised controlled trial. Implement Sci 2012; 7:63. [PMID: 22770423 PMCID: PMC3443055 DOI: 10.1186/1748-5908-7-63] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 07/06/2012] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Suboptimal uptake of anticoagulation for stroke prevention in atrial fibrillation has persisted for over 20 years, despite high-level evidence demonstrating its effectiveness in reducing the risk of fatal and disabling stroke. METHODS The STOP STROKE in AF study is a national, cluster randomised controlled trial designed to improve the uptake of anticoagulation in primary care. General practitioners from around Australia enrolling in this 'distance education' program are mailed written educational materials, followed by an academic detailing session delivered via telephone by a medical peer, during which participants discuss patient de-identified cases. General practitioners are then randomised to receive written specialist feedback about the patient de-identified cases either before or after completing a three-month posttest audit. Specialist feedback is designed to provide participants with support and confidence to prescribe anticoagulation. The primary outcome is the proportion of patients with atrial fibrillation receiving oral anticoagulation at the time of the posttest audit. DISCUSSION The STOP STROKE in AF study aims to evaluate a feasible intervention via distance education to prevent avoidable stroke due to atrial fibrillation. It provides a systematic test of augmenting academic detailing with expert feedback about patient management.
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Potpara TS, Lip GYH. Treatment pathways for atrial fibrillation: simplifying the approach to thromboprophylaxis. Int J Clin Pract 2012; 66:4-6. [PMID: 22171898 DOI: 10.1111/j.1742-1241.2011.02816.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Abstract
BACKGROUND Although there has been growing concordance over what constitutes best practice in recent guidelines for treatment of atrial fibrillation (AF), notably regarding anticoagulant use, it remains unclear whether patients are being treated accordingly. AIMS The aims of this study were to explore the pattern of treatment pathways - i.e. how patients are treated over time - for patients with AF, and to test the hypothesis that comparative to patients in lower stroke-risk categories (as measured by CHADS(2) score), patients with higher CHADS(2) scores are less likely to discontinue anticoagulant therapy or, if not started on anticoagulant treatment, more likely to be transferred to anticoagulant therapy, in keeping with guideline recommendations. SETTING A total of 67,857 patients with a diagnosis of AF in practices registered with the General Practice Research Database. METHODS A series of possible treatment pathways were identified, and for each initial treatment, we estimated the probability of treatment change and the average time that a patient newly diagnosed with AF spent on a particular treatment, projected across 5 years and stratified by CHADS(2) score. RESULTS There was no relationship between CHADS(2) score and maintenance or discontinuation of particular approaches to antithrombotic treatment. While those beginning on antiplatelet therapy were more likely to change treatment than those on anticoagulants (approximately 60% vs. 50% within the first year), as much as one-third of treatment time of all those starting on a therapeutic approach involving anticoagulants featured no use of anticoagulants (either as monotherapy or in combination) over the 5-year period, and whether treatment was discontinued or maintained did not vary by CHADS(2) score. No difference was found in treatment pathways controlling for post-2002 diagnoses as against the whole sample. CONCLUSIONS Although there is more evidence of treatment maintenance than treatment change, especially in the first year after diagnosis, the amount of therapeutic change remains noteworthy and appears higher than in some previous studies. Prescription patterns for AF therapy suggest that too few high-risk patients are receiving best practice treatment, and particularly of concern is that some of these patients are being transferred away from best practice treatment over time.
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Affiliation(s)
- J A Hodgkinson
- Department of Primary Care Clinical Sciences, School of Health and Population Sciences, University of Birmingham, Edgbaston, Birmingham, UK.
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Shantsila A, Lip GY. Dronedarone. Am J Cardiovasc Drugs 2011; 11:355-6. [DOI: 10.2165/11595330-000000000-00000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Riva N, Smith DE, Lip GYH, Lane DA. Advancing age and bleeding risk are the strongest barriers to anticoagulant prescription in atrial fibrillation. Age Ageing 2011; 40:653-5. [PMID: 21951858 DOI: 10.1093/ageing/afr128] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Current world literature. Curr Opin Cardiol 2011; 26:356-61. [PMID: 21654380 DOI: 10.1097/hco.0b013e328348da50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Lip GYH, Andreotti F, Fauchier L, Huber K, Hylek E, Knight E, Lane DA, Levi M, Marin F, Palareti G, Kirchhof P, Collet JP, Rubboli A, Poli D, Camm J. Bleeding risk assessment and management in atrial fibrillation patients: a position document from the European Heart Rhythm Association, endorsed by the European Society of Cardiology Working Group on Thrombosis. Europace 2011; 13:723-46. [PMID: 21515596 DOI: 10.1093/europace/eur126] [Citation(s) in RCA: 162] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, UK.
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Marcucci M, Iorio A, Nobili A, Tettamanti M, Pasina L, Marengoni A, Salerno F, Corrao S, Mannucci PM. Factors affecting adherence to guidelines for antithrombotic therapy in elderly patients with atrial fibrillation admitted to internal medicine wards. Eur J Intern Med 2010; 21:516-23. [PMID: 21111937 DOI: 10.1016/j.ejim.2010.07.014] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Revised: 07/14/2010] [Accepted: 07/17/2010] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Current guidelines for ischemic stroke prevention in atrial fibrillation or flutter (AFF) recommend Vitamin K antagonists (VKAs) for patients at high-intermediate risk and aspirin for those at intermediate-low risk. The cost-effectiveness of these treatments was demonstrated also in elderly patients. However, there are several reports that emphasize the underuse of pharmacological prophylaxis of cardio-embolism in patients with AFF in different health care settings. AIMS To evaluate the adherence to current guidelines on cardio-embolic prophylaxis in elderly (> 65 years old) patients admitted with an established diagnosis of AFF to the Italian internal medicine wards participating in REPOSI registry, a project on polypathologies/polytherapies stemming from the collaboration between the Italian Society of Internal Medicine and the Mario Negri Institute of Pharmacological Research; to investigate whether or not hospitalization had an impact on guidelines adherence; to test the role of possible modifiers of VKAs prescription. METHODS We retrospectively analyzed registry data collected from January to December 2008 and assessed the prevalence of patients with AFF at admission and the prevalence of risk factors for cardio-embolism. After stratifying the patients according to their CHADS(2) score the percentage of appropriateness of antithrombotic therapy prescription was evaluated both at admission and at discharge. Univariable and multivariable logistic regression models were employed to verify whether or not socio-demographic (age >80years, living alone) and clinical features (previous or recent bleeding, cranio-facial trauma, cancer, dementia) modified the frequency and modalities of antithrombotic drugs prescription at admission and discharge. RESULTS Among the 1332 REPOSI patients, 247 were admitted with AFF. At admission, CHADS(2) score was ≥ 2 in 68.4% of patients, at discharge in 75.9%. Among patients with AFF 26.5% at admission and 32.8% at discharge were not on any antithrombotic therapy, and 43.7% at admission and 40.9% at discharge were not taking an appropriate therapy according to the CHADS(2) score. The higher the level of cardio-embolic risk the higher was the percentage of antiplatelet- but not of VKAs-treated patients. At admission or at discharge, both at univariable and at multivariable logistic regression, only an age >80 years and a diagnosis of cancer, previous or active, had a statistically significant negative effect on VKAs prescription. Moreover, only a positive history of bleeding events (past or present) was independently associated to no VKA prescription at discharge in patients who were on VKA therapy at admission. If heparin was considered as an appropriate therapy for patients with indication for VKAs, the percentage of patients admitted or discharged on appropriate therapy became respectively 43.7% and 53.4%. CONCLUSION Among elderly patients admitted with a diagnosis of AFF to internal medicine wards, an appropriate antithrombotic prophylaxis was taken by less than 50%, with an underuse of VKAs prescription independently of the level of cardio-embolic risk. Hospitalization did not improve the adherence to guidelines.
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Affiliation(s)
- M Marcucci
- Department of Internal Medicine, University of Perugia, Italy.
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Leenhardt A, Messali A, Denjoy I, Dejode P, Maison-Blanche P, Ben Halima M, Kedra A, Extramiana F. Des recommandations à la pratique quotidienne en rythmologie. ARCHIVES OF CARDIOVASCULAR DISEASES SUPPLEMENTS 2010. [DOI: 10.1016/s1878-6480(10)70366-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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