PROVISION OF EMERGENCY DEPARTMENT PRESCRIPTIONS FOR ORAL ANTICOAGULATION AND SUBSEQUENT LONG-TERM USE IN PATIENTS WITH ATRIAL FIBRILLATION

Abstract Background CHA2DS2-VASc score has been used as a surrogate marker for predicting outcomes beyond thromboembolic risk in patients with atrial fibrillation (AF). Likewise, cardiac troponin I (cTnI) is a predictor of mortality in AF. Purpose This study aimed to investigate the association of cTnI and CHA2DS2-VASc score with long-term prognosis in patients admitted to the emergency department with AF. Methods A retrospective cohort study conducted between January 2012 and December 2013, enrolling patients admitted to the emergency department with AF and having documented cTnI measurements. CHA2DS2-VASc score was estimated. Primary endpoint was 5-year all-cause mortality, readmission for heart failure (HF), readmission for myocardial infarction (MI) and the composite end point of major adverse cardiac events defined as death, readmission for HF or readmission for MI (MACE). Results A total of 578 patients with AF were studied, of whom 252 patients had elevated levels of cTnI (43.6%) and 334 patients had CHA2DS2-VASc score >3 (57.8%). Patients with elevated cTnI tended to be oldercompared with those who did not have cTnI elevation and were more frequently comorbid and of higher ischemic risk, including hypertension, prior MI, prior HF, chronic renal failure and peripheral artery disease. The overall median CHA2DS2-VASc score was higher in those with cTnI elevation compared to those patients elevated cTnI levels (4.2 vs 3.3 points, p<0.001). Main diagnoses at hospital discharge were tachyarrhythmia 30.3%, followed by heart failure 17.7%, respiratory infections 9.5% and acute coronary syndrome 7.3%. At 5-year follow-up, all-cause death was significantly higher for patients with cTnI elevation compared with those who did not have cTnI elevation (56.4% vs. 27%; logrank test p<0.001). Specifically, for readmissions for HF and readmissions for MI there were no differences in between patients with or without cTnI elevation. In addition, MACE was reached in 165 patients (65.5%) with cTnI elevation, compare to 126 patients (38.7%) without cTnI elevation (p<0.001). On multivariable Cox regression analysis, cTnI elevation was an independent predictor of all-cause death (hazard ratio, 1.67, 95% confidence interval [CI]: 1.24–2.26, p=0.001) and of MACE (hazard ratio 1.47, 95% confidence interval 1.15–1.88; P=0.002), but it did not reach statistical significance for readmissions for MI and readmissions for HF. CHA2DS2-VASc score was a predictor on univariate Cox regression analysis for each endpoint, but it did not reach significance on multivariable Cox regression analysis for any endpoint. Conclusions cTnI is independently associated with long-term all-cause mortality in patients attending the emergency department with AF. cTnI compared to CHA2DS2-VASc score is thus a biomarker with predictive capacity for mortality in late follow-up, conferring utility in the risk stratification of patients with atrial fibrillation.

Download Full-text

Practice Gap in Atrial Fibrillation Oral Anticoagulation Prescribing at Emergency Department Home Discharge

Western Journal of Emergency Medicine ◽

10.5811/westjem.2020.3.45135 ◽

2020 ◽

Vol 21 (4) ◽

Author(s):

Bory Kea ◽

Bethany Waites ◽

Amber Lin ◽

Merritt Raitt ◽

David Vinson ◽

...

Keyword(s):

Atrial Fibrillation ◽

Emergency Department ◽

Oral Anticoagulation ◽

Home Discharge ◽

Practice Gap

Download Full-text

THE SAFETY OF DISCONTINUATION OF LONG-TERM ORAL ANTICOAGULATION THERAPY AFTER APPARENTLY SUCCESSFUL ATRIAL FIBRILLATION ABLATION: CHINESE ATRIAL FIBRILLATION REGISTRY STUDY

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(18)30839-8 ◽

2018 ◽

Vol 71 (11) ◽

pp. A298

Author(s):

Wangyang Yang ◽

Xin Du ◽

Nian Liu ◽

Rong Bai ◽

Wei Wang ◽

...

Keyword(s):

Atrial Fibrillation ◽

Oral Anticoagulation ◽

Anticoagulation Therapy ◽

Atrial Fibrillation Ablation ◽

Registry Study ◽

Oral Anticoagulation Therapy

Download Full-text

Qualität des Antikoagulationsmanagements bei ambulanten Patienten mit Vorhofflimmern

Praxis ◽

10.1024/0369-8394.92.21.991 ◽

2003 ◽

Vol 92 (21) ◽

pp. 991-995 ◽

Cited By ~ 1

Author(s):

Gubler ◽

Martina ◽

Arpagaus ◽

Dieterle

Keyword(s):

Atrial Fibrillation ◽

Emergency Department ◽

Oral Anticoagulation ◽

Medical Emergency ◽

Psychiatric Disease ◽

Recurrent Falls ◽

History Of ◽

Acute Condition

Many patients with atrial fibrillation do not receive anticoagulation due to accepted contraindications but also due to considerable underuse. We screened 2215 consecutive patients when they entered the Medical Emergency Department for any acute condition. The decision on correct use or underuse of oral anticoagulation was made from the charts by consensus of two experienced physicians. The prevalence of atrial fibrillation was 3.7%. 43 of 83 patients with atrial fibrillation had oral anticoagulation (52%, mean age 76 years). 32 patients were treated with Aspirin only (38%, mean age 79 years). 29 patients (35%) did not receive anticoagulation because of accepted contraindications, i.e., dementia and risk for recurrent falls (n = 16), history of bleeding (n = 6), drug malcompliance due to forgetfulness (n = 4) and psychiatric disease (n = 1). Underuse of anticoagulation occurred only in three patients (4%, unclear reasons in two patients, patient's unwillingness in one patient). Conclusion: We did not observe substantial underuse of anticoagulation in patients with atrial fibrillation.

Download Full-text

Left atrial appendage closure for atrial fibrillation in a patient with hypertrophic cardiomyopathy in whom long-term oral anticoagulation was not feasible

Advances in Interventional Cardiology ◽

10.5114/aic.2019.87901 ◽

2019 ◽

Vol 15 (3) ◽

pp. 380-381

Author(s):

Mariusz Kłopotowski ◽

Marek Konka ◽

Marcin Demkow ◽

Krzysztof Kukula ◽

Adam Witkowski

Keyword(s):

Atrial Fibrillation ◽

Hypertrophic Cardiomyopathy ◽

Oral Anticoagulation ◽

Left Atrial ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Left Atrial Appendage Closure

Download Full-text

Outpatient Management of Oral Anticoagulation Therapy in Patients with Nonvalvular Atrial Fibrillation

Bosnian Journal of Basic Medical Sciences ◽

10.17305/bjbms.2009.2787 ◽

2009 ◽

Vol 9 (4) ◽

pp. 313-319 ◽

Cited By ~ 2

Author(s):

Aida Kulo ◽

Nedžad Mulabegović ◽

Jasna Kusturica ◽

Hasija Hadžić ◽

Lejla Burnazović-Ristić ◽

...

Keyword(s):

Atrial Fibrillation ◽

Oral Anticoagulation ◽

Anticoagulation Therapy ◽

Dose Titration ◽

Nonvalvular Atrial Fibrillation ◽

Annual Dose ◽

Oral Anticoagulation Therapy ◽

Anticoagulation Treatment ◽

One Year

Due to heightened risk for thromboembolic complications, nonvalvular atrial fibrillation (NVAF) presents an absolute indication for long-term oral anticoagulation therapy. This was an observational, analytical, randomised, one-year clinical study, conducted in the Blood Transfusion Institute Sarajevo, Bosnia & Herzegovina. The aim of this study was to present the oral anticoagulation treatment in terms of International normalised ratio (INR) monitoring and warfarin/acenocoumarol dose titration in 117 patients with NVAF. INR values, the doses of warfarin and acenocoumarol, as well as the tendency and adequacy of their changes were monitored. Percentages of the therapeutic INR values were 51,77% and 53,62%, subtherapeutic 42,84% and 35,86%, and supratherapeutic 5,39% and 10,53% for the warfarin and acenocoumarol treatment, respectively. The average total weekly doses (TWD) which most frequently achieved the therapeutic INR values were 27,89±12,34 mg and 20,44±9,94 mg, for warfarin and aceno- coumarol, respectively. The dose changes with the INR values 1,7 or lower/3,3 or higher were omitted in 13,46% and 15,63%, and with the INR values 1,8-3,2 were noted in 8,62% and 13,48% of all the check-up visits in the warfarin and acenocoumarol group, respectively. The annual dose changes were noted in 24,65% and 31,41%, and the daily dose changes in 74,43% and 73,36% of all the check-up visits of warfarin and acenocoumarol group, respectively. We can conclude that the management of the oral anticoagulation treatment in our country is in accordance with the relevant recommendations, but with the present tendency toward underdosing and unnecessary frequent dose changing.

Download Full-text