Optimizing the Use of Anticoagulants (Heparins and Oral Anticoagulants) in the Elderly

Drugs & Aging ◽  
2013 ◽  
Vol 30 (9) ◽  
pp. 687-699 ◽  
Author(s):  
Virginie Siguret ◽  
Isabelle Gouin-Thibault ◽  
Pascale Gaussem ◽  
Eric Pautas
Keyword(s):  
Oral Anticoagulants ◽  
The Elderly

scholarly journals Stroke Prevention: Little-Known and Neglected Aspects

2021 ◽  
pp. 1-14
Author(s):  
M. Reza Azarpazhooh ◽  
Chrysi Bogiatzi ◽  
J. David Spence
Keyword(s):  
Stroke Prevention ◽  
Oral Anticoagulants ◽  
Blood Pressure Reduction ◽  
The Elderly ◽  
Lipid Lowering ◽  
Lipid Lowering Therapy ◽  
Enteric Coating ◽  
Asymptomatic Carotid ◽  
Lowering Therapy ◽  
Direct Acting

Combining available therapies has the potential to reduce the risk of stroke by 80% or more. A comprehensive review of all aspects of stroke prevention would be very lengthy; in this narrative review, we focus on some aspects of stroke prevention that are little-known and/or neglected. These include the following: (1) implementation of a Mediterranean diet; (2) B vitamins to lower homocysteine; (3) coordinated approaches to smoking cessation; (4) intensive lipid-lowering therapy; (5) lipid lowering in the elderly; (6) physiologically individualized therapy for hypertension based on renin/aldosterone phenotyping; (7) avoiding excessive blood pressure reduction in patients with stiff arteries; (8) treatment of insulin resistance with pioglitazone in stroke patients with prediabetes and diabetes; (9) impaired activation of clopidogrel in patients with variants of CYP2C19; (10) aspirin pseudoresistance due to enteric coating; (11) rationale for anticoagulation in patients with embolic stroke of unknown source; (12) pharmacologic properties of direct-acting oral anticoagulants that should be considered when choosing among them; (13) the identification of which patients with asymptomatic carotid stenosis are at a high enough risk to benefit from carotid endarterectomy or stenting; and (14) the importance of age in choosing between endarterectomy and stenting. Stroke prevention could be improved by better recognition of these issues and by implementation of the principles derived from them.

scholarly journals Prescription of oral anticoagulants and antiplatelets for stroke prophylaxis in atrial fibrillation: nationwide time series ecological analysis

EP Europace ◽  
2020 ◽  
Vol 22 (9) ◽  
pp. 1311-1319 ◽  
Author(s):  
Jianhua Wu ◽  
Eman S Alsaeed ◽  
James Barrett ◽  
Marlous Hall ◽  
Campbell Cowan ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Temporal Trends ◽  
Antiplatelet Agents ◽  
The Elderly ◽  
Early Years ◽  
Prescription Data ◽  
Ecological Analysis ◽  
General Practices

Abstract Aims To investigate trends in the prescription of oral anticoagulants (OACs) and antiplatelet agents for atrial fibrillation (AF). Methods and results Prescription data for 450 518 patients with AF from 3352 General Practices in England, was obtained from the GRASP-AF registry, 2009–2018. Annualized temporal trends for OAC and antiplatelet prescription were reported according to eligibility based on stroke risk (CHADS2 or CHA2DS2-VASc scores ≥1 or >2, respectively). From 2009 to 2018, the prevalence of AF increased from 1.6% [95% confidence interval (CI) 1.5–1.7%] to 2.4% (2.3–2.5%), and for those with AF the proportion prescribed OAC increased from 47.6% to 75.0% (P-trend < 0.001; relative risk 1.57, 95% CI 1.55–1.60) and for antiplatelet decreased from 37.4% to 9.2% (P-trend < 0.001). In early-years (2009–2013), eligible patients aged ≥80 years were less likely to be prescribed OAC than patients aged <80 years [odds ratio (OR) 0.55, 95% CI 0.51–0.59 for CHADS2≥1 in 2009] (all P-trends < 0.001). This ‘OAC prescription gap’ reduced over the study period (OR 0.93, 0.90–0.96 in 2018). Whilst the prescription of direct oral anticoagulant (DOAC) as a proportion of all OAC increased from 0.1% (95% CI 0.0–0.2%) in 2011 to 58.8% (58.4–59.2%) in 2018, it was inversely associated with patient age (P-trend < 0.001) and their risk of stroke. Conclusion Between 2009 and 2018, in England, the use of OAC for stroke prophylaxis in AF increased, with DOAC accounting for over half of OAC uptake in 2018. Despite a reduction in the OAC-prescription gap, a new paradox exists relating to DOAC prescription for the elderly and those at higher risk of stroke.

scholarly journals ROLE OF NOVEL ORAL ANTICOAGULANTS (NOACS)IN PATIENTS WITH ATRIAL FIBRILLATION CARDIOVERSION- AN EXECUTIVE SUMMARY

2021 ◽  
Vol 9 (02) ◽  
pp. 853-861
Author(s):  
Wang Jing ◽  
Phav Sophearith
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Standard Of Care ◽  
The Elderly ◽  
Novel Oral Anticoagulants ◽  
Special Focus ◽  
Factor X ◽  
Systemic Embolism ◽  
Executive Summary

In patients with non-valvular atrial fibrillation (NVAF), oral anticoagulation is necessary for prevention of stroke and systemic embolism especially during cardioversion. While Vitamin K antagonists (VKAs) have historically been the standard of care, these medications are limited by numerous food and drug interactions with requirements for frequent monitoring (INR) and dose adjustments. Over the past decade, several novel oral anticoagulants (NOACs) have been developed to directly inhibit factor IIa/thrombin (dabigatran) or activated factor X (apixaban, rivaroxaban, edoxaban). These medications have been shown to be at least as effective as warfarin for stroke prevention in NVAF with more favorable safety profiles. However, their advantages are underscored by a lack of specific antidotes and assays quantifying their anticoagulant effects. This review addresses how well do the Rivaroxaban prevents stroke and systemic embolism compare to VKAs in patients with NVAF, with a special focus on high-risk populations, including the elderly, those with renal disease, diabetes mellitus, coronary artery disease, and previous stroke.

Risks and outcomes of gastrointestinal malignancies in anticoagulated atrial fibrillation patients experiencing gastrointestinal bleeding

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
T.F Chao ◽  
G.Y.H Lip ◽  
S.A Chen
Keyword(s):  
Atrial Fibrillation ◽  
Oral Anticoagulants ◽  
The Elderly ◽  
Prior History ◽  
Research Database ◽  
Gi Bleeding ◽  
Gi Tract ◽  
Gastrointestinal Malignancies ◽  
Risk Of Mortality ◽  
Gi Cancers

Abstract Background Oral anticoagulants (OACs) may serve as a type of “screening test” for the diagnosis of occult gastrointestinal (GI) tract malignancies through a clinical presentation with bleeding. Objective We aimed to investigate the 1-year incidence and predictors of GI cancers after GI bleeeding events among patients with atrial fibrillation (AF) treated with warfarin or NOACs. Second, we aimed to compare the risk of mortality after GI cancers between patients treated with warfarin or NOACs. Methods A total of 10,845 anticoagulated AF patients who experienced hospitalizations due to GI bleeding without prior history of GI cancers were identified from the Taiwan National Health Insurance Research Database. Patients were followed up for incident GI cancers for up to 1 year. Results Within 1 year after GI bleeding, 290 (2.67%) patients were diagnosed to have GI tract cancers. More patients treated with NOACs were diagnosed to have GI cancers than those receiving warfarin (68/1,759; 3.87% [NOACs] versus 222/9,086; 2.44% [warfarin], p<0.001) with an odds ratio (OR) 1.606 (95% CI: 1.208–2.117, p<0.001). Age (OR 1.025 [95% CI: 1.012–1.037] per 1 year increment) and male sex (1.356 [95% CI: 1.050–1.700]) were independently associated with the diagnosis of GI cancers within 1 year after GI bleeding. Among 290 patients diagnosed to have GI cancers, 131 (45.2%) experienced mortality within 1 year. The risk of mortality was lower for patients treated with NOACs compared to those receiving warfarin (23.5% versus 51.8%) with an adjusted hazard ratio (aHR) 0.441 (95% CI: 0.262–0.744, p<0.001) (Figure). Conclusions Incident GI cancers were diagnosed in 1 in 37 AF patients at 1 year after OAC-related GI bleeding, which were more common among patients treated with NOACs (1 in 26) compared to warfarin (1 in 41). Detailed surveys for occult GI cancers were necessary for these patients, especially for the elderly males. Survival curves Funding Acknowledgement Type of funding source: None

scholarly journals Relevance of the health insurance databases to study potentially inappropriate prescriptions

2019 ◽  
Vol 29 (Supplement_4) ◽  
Author(s):  
M Jardin ◽  
M C Banide ◽  
G Saba ◽  
E Burlot ◽  
F Jozancy ◽  
...  
Keyword(s):  
Health Insurance ◽  
Oral Anticoagulants ◽  
The Elderly ◽  
Administrative Databases ◽  
Insurance Fund ◽  
Health Insurance Fund ◽  
Prescribing Practices ◽  
National Guidelines ◽  
Long Term Treatment ◽  
Inappropriate Prescriptions

Abstract Issue/problem Potentially inappropriate prescriptions (PIP) for the elderly constitute a major issue in the quality of ambulatory care. In France, people aged 80 years or older use on average five drugs per day. This polypharmacy is justified in most cases by multimorbidity but it increases the risk of adverse events. Description of the problem In order to optimize general practitioners’ (GPs) prescribing practices for the elderly, a project involving the Southeastern Health Regional Observatory (ORS Paca), the Regional Medical Department of Health Insurance Fund (DRSM Paca-Corse) and the Regional Union of Private Practitioners (URPS-ML Paca) was conducted in 2014-2016. Its main objective was to set up a regional mapping tool giving GPs access to drug prescriptions indicators for the elderly in their practice area. Results Based on national guidelines and advice of experts in the field, we calculated 7 different indicators of potentially inappropriate prescriptions (PIPs) for people aged 65 years or older, using drug reimbursement data from the Health Insurance Fund. Those indicators were calculated among patient lists of GPs and covered prescriptions of benzodiazepines, non-steroidal anti-inflammatory (NSAI) drugs, new oral anticoagulants, proton pump inhibitors, antiplatelet therapy... PIPs’ prevalence were calculated among GPs’ lists of patients. PIPs prevalence differed between drugs type, GPs and territories: for example, the age standardized prevalence of long-term treatment with NSAI drugs varied in 2014 from 2 to 15% between municipalities and from 0 to 14% in 2017. Lessons These results allowed to identify priority areas for intervention, in which continuous medical education sessions with an individual feedback to GPs on their own indicators were implemented, to improve prescribing practices. Key messages A substantial proportion of elderly people receive PIPs. Medico-administrative databases can be used to produce indicators of prescription practices to be used to guide public health interventions.

Abstract P260: Ischemic Strokes on Direct Oral Anticoagulants

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Digvijaya Navalkele ◽  
Ashok Polu ◽  
Janis Ginnane ◽  
Michael R Frankel ◽  
Nirav Bhatt ◽  
...  
Keyword(s):  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
The Elderly ◽  
Internal Carotid Artery Stenosis ◽  
Vessel Occlusion ◽  
Patient Reported ◽  
Underlying Causes ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Stroke Mechanism

Introduction: The objective of our study was to identify the underlying causes of acute ischemic strokes (AIS) in patients prescribed direct oral anticoagulants (DOACs). Methods: This is a retrospective study of patients presenting to a large urban comprehensive stroke center from December 1, 2019 to May 31, 2020 who were prescribed DOACs at the index event. Two board-certified vascular neurologists independently reviewed medical charts including patient baseline characteristics, laboratory results, stroke mechanism, and patient-reported adherence. DOAC “failure” was defined as AIS occurring in the setting of self-reported adherence to the FDA-indicated dosing regimen. Results: Of 302 AIS patients admitted during the study period, 18 (6.0%) patients had AIS while on DOACs. Median age was 82 (IQR 72, 86) years, 9 (50%) were black and 14 (78%) were female. Eight patients (44%) presented within the IV Alteplase window and 5 (28%) patients presented with large vessel occlusion. At the time of stroke, 13 (72%) patients were on apixaban, 4 (22%) were on rivaroxaban and 1 (6%) on dabigatran. Atrial fibrillation (mean CHADS-VASc score 4.7) was the most common indication for DOAC (72%), followed by deep venous thrombosis (17%), and embolic stroke (11%). The most frequent causes of AIS on DOACs were underdosing in patients ≥ 80 years (n=6), known active malignancy (n=5), and non-adherence (n=4). The remaining cases included procedure-related discontinuation of the DOAC (n=1), symptomatic extracranial internal carotid artery stenosis (n=1), and unknown cause (n=1). Overall, the frequency of DOAC “failure” was 39%. In 6 (33%) patients, the initial anticoagulant was switched to an alternative anticoagulant at discharge. Conclusion: In this cohort of patients who had AIS while on DOAC therapy, 39% of cases were attributed to DOAC “failure” and primarily occurred in patients with active malignancy. Underdosing in the elderly and non-adherence remained the leading cause of AIS in patients on DOAC. Our findings highlight the importance of accurate dosing in the elderly and reinforcing adherence to medications. Further studies are needed to understand the role of DOACs in patients with active malignancy.

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