IS APPROPRIATE USE OF ORAL ANTICOAGULANTS IMPROVING AMONG ATRIAL FIBRILLATION PATIENTS? RESULTS FROM THE BENCHMARKING AN ORAL ANTICOAGULANT TREATMENT RATE IN PATIENTS WITH NONVALVULAR ATRIAL FIBRILLATION (BOAT-AF) STUDY AND COMPARISON TO 387,975 PARTICIPANTS IN THE PINNACLE REGISTRY®

Abstract Background Anticoagulation treatment reduces the risk of stroke but increases the risk of bleeding in atrial fibrillation (AF) patients. Antidepressants use is associated with increased risk for stroke and bleeds. Objective To assess the association between antidepressant use in AF patients with oral anticoagulants and bleeding and stroke risk. Methods All AF patients newly prescribed with an oral anticoagulant in the Stockholm Healthcare database (n=2.3 million inhabitants) from July 2011 until 2016 were included and followed for one year or shorter if they stopped claiming oral anticoagulant treatment or had an outcome of interest. Outcomes were severe bleeds and strokes, requiring acute hospital care. During follow-up, patients were considered exposed to antidepressant after claiming a prescription for the duration of the prescription. With a time-varying Cox regression, we assessed the association between antidepressant use and strokes and bleeds, adjusting for confounders (i.e., age, sex, comorbidities, comedication, and year of inclusion). In addition, we performed a propensity score matched analysis to test the robustness of our findings. Results Of the 30,595 patients included after claiming a prescription for a NOAC (n=13,506) or warfarin (n=17,089), 4 303 claimed a prescription for an antidepressant during follow-up. A total of 712 severe bleeds and 551 strokes were recorded in the cohort. Concomitant oral anticoagulant and antidepressant use was associated with increased rates of severe bleeds (4.7 vs 2.7 per 100 person-years) compared to oral anticoagulant treatment without antidepressant use (aHR 1.42, 95% CI: 1.12–1.80), but not significantly associated with increased stroke rates (3.5 vs 2.1 per 100 person-years, aHR 1.23, 95% CI: 0.93–1.62). No significant differences were observed between different oral anticoagulant classes (i.e., warfarin or NOAC) or different antidepressant classes (i.e., SSRI, TCA, or other antidepressant). Additional propensity-score matched analyses yielded similar results but showed a significantly increased risk for stroke (HR: 1.47, 95% CI: 1.08–2.02). Incidence rates of strokes and bleeds Conclusion Concomitant use of an oral anticoagulant and an antidepressant, irrespective of type, is associated with an increased bleeding risk. Increased awareness and a critical consideration for the need of an antidepressant is recommended in this population. Acknowledgement/Funding Swedish Heart Lung Foundation

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Oral anticoagulant treatment in geriatric patients with nonvalvular atrial fibrillation in the era of direct oral anticoagulant agents

European Journal of Internal Medicine ◽

10.1016/j.ejim.2014.02.003 ◽

2014 ◽

Vol 25 (5) ◽

pp. e63-e65 ◽

Cited By ~ 2

Author(s):

Marjorie Kayser ◽

Yves Frances ◽

Laurent Bonello ◽

Franck Paganelli ◽

Michael Peyrol

Keyword(s):

Atrial Fibrillation ◽

Oral Anticoagulant ◽

Geriatric Patients ◽

Direct Oral Anticoagulant ◽

Anticoagulant Treatment ◽

Nonvalvular Atrial Fibrillation ◽

Oral Anticoagulant Treatment ◽

Anticoagulant Agents

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The Risk/Benefit Analysis of Oral Anticoagulant Treatment in Atrial Fibrillation Using HAS-BLED and CHA2DS2-VASc Score

Acta Medica Marisiensis ◽

10.1515/amma-2015-0056 ◽

2015 ◽

Vol 61 (4) ◽

pp. 269-272

Author(s):

Silivastru (Cozlea) Ionela ◽

Cozlea Daniel Laurentiu ◽

Keresztesi Arthur Attila ◽

Asofie Gabriela ◽

Cozlea Laurentiu ◽

...

Keyword(s):

Atrial Fibrillation ◽

Oral Anticoagulant ◽

Thromboembolic Events ◽

Anticoagulant Treatment ◽

Bleeding Events ◽

Nonvalvular Atrial Fibrillation ◽

Oral Anticoagulant Treatment ◽

Risk Class ◽

Number Of Patients ◽

History Of

AbstractIntroduction. The purpose of this study is to evaluate the risk and the benefit of oral anticoagulant treatment in nonvalvular atrial fibrillation (AF) patients, using the two scores recommended by the guidelines: the CHA2DS2-VASc score and HAS-BLED score.Material and method. We conducted a retrospective observational study on 144 patients with nonvalvular atrial fibrillation, admitted between 1st of July 2013 and 30th September 2013 in the 3rd Medical Clinic of Tîrgu Mureș with a prospectiv follow-up at 6 months.Based on the data collected from the patient charts, the thromboembolic risk was assessed using the CHA2DS2-VASc score and the hemorrhage risk was assessed using the HAS-BLED score. At 6 months, the patients were contacted via telephone and were questioned regarding their state of health, the existence of hospitalizations in the last 6 months, the international normalized ratio (INR) value, the existence of hemorrhagic or thromboembolic events.Results. The group of patients was composed of 70 female and 74 male with the mean age of 70 ±11 years. From the total number of patients 13 (11.7%) had a history of stroke and the CHA2DS2-VASc score revealed that these 13 were in the high risk class. The presence of arterial hypertension and vascular disease were statistically associated with stroke.Hemorrhagic events were encountered in 19 patients (13.19%) and 16 of them had a higher than 3 HAS-BLED score. A history of bleeding, anemia and labile INR were the factors statistically associated with bleeding.Conclusions. The CHA2DS2-VASc score is useful in stratifying patients with AF in risk groups for thromboembolic events while the HAS-BLED score proved to be a useful tool in predicting bleeding events in anticoagulated patients.

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Status of oral anticoagulant treatment in patients with nonvalvular atrial fibrillation in Spain. REACT-AF study

Revista Clínica Española (English Edition) ◽

10.1016/j.rceng.2014.08.003 ◽

2015 ◽

Vol 215 (2) ◽

pp. 73-82

Author(s):

F. de Andrés-Nogales ◽

I. Oyagüez ◽

L. Betegón-Nicolás ◽

C. Canal-Fontcuberta ◽

J. Soto-Álvarez

Keyword(s):

Atrial Fibrillation ◽

Oral Anticoagulant ◽

Anticoagulant Treatment ◽

Nonvalvular Atrial Fibrillation ◽

Oral Anticoagulant Treatment

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A Comparison of a Moderate with Moderate-high Intensity Oral Anticoagulant Treatment in Patients with Mechanical Heart Valve Prostheses

Thrombosis and Haemostasis ◽

10.1055/s-0038-1656064 ◽

1997 ◽

Vol 77 (05) ◽

pp. 0839-0844 ◽

Cited By ~ 34

Author(s):

Vittorio Pengo ◽

Fabio Barbero ◽

Alberto Banzato ◽

Elisabetta Garelli ◽

Franco Noventa ◽

...

Keyword(s):

Heart Valve ◽

High Intensity ◽

Oral Anticoagulant ◽

Oral Anticoagulants ◽

Mechanical Heart Valve ◽

Moderate Intensity ◽

Minor Bleeding ◽

Anticoagulant Treatment ◽

Oral Anticoagulant Treatment ◽

Valve Prostheses

SummaryBackground. The long-term administration of oral anticoagulants to patients with mechanical heart valve prostheses is generally accepted. However, the appropriate intensity of oral anticoagulant treatment in these patients is still controversial.Methods and Results. From March 1991 to March 1994, patients referred to the Padova Thrombosis Center who had undergone mechanical heart valve substitution at least 6 months earlier were randomly assigned to receive oral anticoagulants at moderate intensity (target INR = 3) or moderate-high intensity (target INR = 4). Principal end points were major bleeding, thromboembolism and vascular death. Minor bleeding was a secondary end-point.A total of 104 patients were assigned to the target 3 group and 101 to the target 4 group; they were followed for from 1.5 years to up 4.5 years (mean, 3 years). Principal end-points occurred in 13 patients in the target 3 group (4 per 100 patient-years) and in 20 patients in the target 4 group (6.9 per 100 patient-years). Major hemorrhagic events occurred in 15 patients, 4 in the target 3 group (1.2 per 100 patient-years) and 11 in the target 4 group (3.8 per 100 patient-years) (p = 0.019). The 12 recorded episodes of thromboembolism, 4 of which consisted of a visual deficit, were all transient ischemic attacks, 6 in the target 3 group (1.8 per 100 patient-years) and 6 in the target 4 group (2.1 per 100 patient- years). There were 3 vascular deaths in each group (0.9 and 1 per 100 patient-years for target 3 and target 4 groups, respectively). Minor bleeding episodes occurred 85 times (26 per 100 patient-years) in the target 3 group and 123 times (43 per 100 patient-years) in the target 4 group (p = 0.001).Conclusions. Mechanical heart valve patients on anticoagulant treatment who had been operated on at least 6 months earlier experienced fewer bleeding complications when maintained on a moderate intensity regimen (target INR = 3) than those on a moderate-high intensity regimen (target INR = 4). The number of thromboembolic events and vascular deaths did not differ between the two groups.

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“Unreal world” or “real world” data in oral anticoagulant treatment of atrial fibrillation

Thrombosis and Haemostasis ◽

10.1160/th16-08-0658 ◽

2016 ◽

Vol 116 (10) ◽

pp. 587-589 ◽

Cited By ~ 41

Author(s):

Gregory Y. H. Lip ◽

Ben Freedman

Keyword(s):

Atrial Fibrillation ◽

Real World ◽

Oral Anticoagulant ◽

Review Process ◽

Anticoagulant Treatment ◽

Real World Data ◽

Oral Anticoagulant Treatment ◽

World Data

Note: The review process for this manuscript was fully handled by Christian Weber, Editor in Chief.

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Switching to Another Oral Anticoagulant and Drug Discontinuation Among Elderly Patients With Nonvalvular Atrial Fibrillation Treated With Different Direct Oral Anticoagulants

Clinical and Applied Thrombosis/Hemostasis ◽

10.1177/1076029619870249 ◽

2019 ◽

Vol 25 ◽

pp. 107602961987024 ◽

Cited By ~ 2

Author(s):

Christine L. Baker ◽

Amol D. Dhamane ◽

Jigar Rajpura ◽

Jack Mardekian ◽

Oluwaseyi Dina ◽

...

Keyword(s):

Atrial Fibrillation ◽

Elderly Patients ◽

Oral Anticoagulant ◽

Cox Regression ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Drug Discontinuation ◽

Research Database ◽

Nonvalvular Atrial Fibrillation ◽

Study Population

We compared the risks of switching to another oral anticoagulant (OAC) and discontinuation of direct oral anticoagulants (DOACs) among elderly patients with nonvalvular atrial fibrillation (NVAF) who were prescribed rivaroxaban or dabigatran versus apixaban. Patients (≥65 years of age) with NVAF prescribed DOACs (January 1, 2013 to September 30, 2017) were identified from the Humana research database and grouped into DOAC cohorts. Cox regression analyses were used to evaluate whether the risk for switching to another OAC or discontinuing index DOACs differed among cohorts. Of the study population (N = 38 250), 55.9% were prescribed apixaban (mean age: 78.6 years; 49.8% female), 37.3% rivaroxaban (mean age: 77.4 years; 46.7% female), and 6.8% dabigatran (mean age: 77.0 years; 44.0% female). Compared to patients prescribed apixaban, patients prescribed rivaroxaban (hazard ratio [HR]: 2.08; 95% confidence interval [CI], 1.92-2.25; P < .001) or dabigatran (HR: 3.74; 95% CI, 3.35-4.18, P < .001) had a significantly higher risk of switching to another OAC during the follow-up; compared to patients prescribed apixaban, the risks of discontinuation were also higher for patients treated with rivaroxaban (HR: 1.10; 95% CI, 1.07-1.13, P < .001) or dabigatran (HR: 1.29; 95% CI, 1.23-1.35, P < .001).

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Atrial Fibrillation Screen, Management, and Guideline‐Recommended Therapy in the Rural Primary Care Setting: A Cross‐Sectional Study and Cost‐Effectiveness Analysis of eHealth Tools to Support All Stages of Screening

Journal of the American Heart Association ◽

10.1161/jaha.120.017080 ◽

2020 ◽

Vol 9 (18) ◽

Cited By ~ 1

Author(s):

Jessica Orchard ◽

Jialin Li ◽

Ben Freedman ◽

Ruth Webster ◽

Glenn Salkeld ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cost Effectiveness ◽

Incremental Cost ◽

Oral Anticoagulant ◽

Population Based ◽

Incremental Cost Effectiveness Ratio ◽

Anticoagulant Treatment ◽

Cost Effectiveness Ratio ◽

Oral Anticoagulant Treatment ◽

Effectiveness Analysis

BACKGROUND Internationally, most atrial fibrillation (AF) management guidelines recommend opportunistic screening for AF in people ≥65 years of age and oral anticoagulant treatment for those at high stroke risk (CHA₂DS₂‐VA≥2). However, gaps remain in screening and treatment. METHODS AND RESULTS General practitioners/nurses at practices in rural Australia (n=8) screened eligible patients (≥65 years of age without AF) using a smartphone ECG during practice visits. eHealth tools included electronic prompts, guideline‐based electronic decision support, and regular data reports. Clinical audit tools extracted de‐identified data. Results were compared with an earlier study in metropolitan practices (n=8) and nonrandomized control practices (n=69). Cost‐effectiveness analysis compared population‐based screening with no screening and included screening, treatment, and hospitalization costs for stroke and serious bleeding events. Patients (n=3103, 34%) were screened (mean age, 75.1±6.8 years; 47% men) and 36 (1.2%) new AF cases were confirmed (mean age, 77.0 years; 64% men; mean CHA₂DS₂‐VA, 3.2). Oral anticoagulant treatment rates for patients with CHA₂DS₂‐VA≥2 were 82% (screen detected) versus 74% (preexisting AF)( P =NS), similar to metropolitan and nonrandomized control practices. The incremental cost‐effectiveness ratio for population‐based screening was AU$16 578 per quality‐adjusted life year gained and AU$84 383 per stroke prevented compared with no screening. National implementation would prevent 147 strokes per year. Increasing the proportion screened to 75% would prevent 177 additional strokes per year. CONCLUSIONS An AF screening program in rural practices, supported by eHealth tools, screened 34% of eligible patients and was cost‐effective. Oral anticoagulant treatment rates were relatively high at baseline, trending upward during the study. Increasing the proportion screened would prevent many more strokes with minimal incremental cost‐effectiveness ratio change. eHealth tools, including data reports, may be a valuable addition to future programs. REGISTRATION URL: https://www.anzctr.org.au . Unique identifier: ACTRN12618000004268.

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THE THROMBOTIC COMPLICATIONS OF TWO GROUPS OF PATIENTS WITH DIFFERENT INR THERAPEUTIC RANGES. THE NECESSITY OF INTENSE ORAL ANTICOAGULANT TREATMENT

10.1055/s-0038-1643263 ◽

1987 ◽

Author(s):

Ir Kontopoulou-Griva ◽

J Spiliotopoulou ◽

L Digenopoulou ◽

J Georgopoulos

Keyword(s):

High Risk ◽

Oral Anticoagulant ◽

Heart Valves ◽

Oral Anticoagulants ◽

Anticoagulant Treatment ◽

Oral Anticoagulant Treatment ◽

Daily Dose ◽

Group A ◽

Thrombotic Complications ◽

Group B

One of the reasons why oral anticoagulants fell into disrepute is the absence of internationally acceptable standarised procedures for controlling the level of anticoagulation. This deplorable situation resulted in over and under coagulation and uncertainty in the therapeutic range. The International Normalised Ratio (INR) can safely be applied in patients on oral anticoagulants.We present two Groups of patients under long term anti coagulation, mainly because of prosthetic heart valves that have recently been added to our outpatients clinic. These patients were till then attended by two cardiologists with different attitudes on the intensity of the anticoagulant treatment. The thromboplastin reagent used is that of ox origin and the results are expressed on INR.The Group A with 32 patients had at the time that we started attending them an INR x = 1,80 ± 0,48 and a daily dose of acenocoumarol x = 1,65 ± 0,51.The Group B with 49 patients had an INR x = 2,75 ± 0,51 and a daily dose of acenocoumarol x = 2,52 ± 1,53.Seven patients of the Group A referred thrombotic complications, while three patients of the Group B referred transiant thrombotic complications.The statistical analysis with the t-test of the INR between the two Groups is p<0,001 while that of the thrombotic complication with the x2 is p<0,05.The introduction of the INR and the acceptance by the medical people of the necessity of the intense oral anticoagulant treatment especially on high risk patients with mechanical heart valves as is the majority of the presented patients, will minimize the thromboembolic complications without high risk of bleeding.

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Stepwise mass screening for atrial fibrillation using N-terminal B-type natriuretic peptide: the STROKESTOP II study

EP Europace ◽

10.1093/europace/euz255 ◽

2019 ◽

Vol 22 (1) ◽

pp. 24-32 ◽

Cited By ~ 12

Author(s):

Katrin Kemp Gudmundsdottir ◽

Tove Fredriksson ◽

Emma Svennberg ◽

Faris Al-Khalili ◽

Leif Friberg ◽

...

Keyword(s):

Atrial Fibrillation ◽

High Risk ◽

Natriuretic Peptide ◽

Oral Anticoagulant ◽

Risk Group ◽

High Risk Group ◽

Low Risk ◽

Screening Procedure ◽

Anticoagulant Treatment ◽

Oral Anticoagulant Treatment

Abstract Aims To study the prevalence of unknown atrial fibrillation (AF) in a high-risk, 75/76-year-old, population using N-terminal B-type natriuretic peptide (NT-proBNP) and handheld electrocardiogram (ECG) recordings in a stepwise screening procedure. Methods and results The STROKESTOP II study is a population-based cohort study in which all 75/76-year-old in the Stockholm region (n = 28 712) were randomized 1:1 to be invited to an AF screening programme or to serve as the control group. Participants without known AF had NT-proBNP analysed and were stratified into low-risk (NT-proBNP <125 ng/L) and high-risk (NT-proBNP ≥125 ng/L) groups. The high-risk group was offered extended ECG-screening, whereas the low-risk group performed only one single-lead ECG recording. In total, 6868 individuals accepted the screening invitation of which 6315 (91.9%) did not have previously known AF. New AF was detected in 2.6% [95% confidence interval (CI) 2.2–3.0] of all participants without previous AF. In the high-risk group (n = 3766/6315, 59.6%), AF was diagnosed in 4.4% (95% CI 3.7–5.1) of the participants. Out of these, 18% had AF on their index-ECG. In the low-risk group, one participant was diagnosed with AF on index-ECG. The screening procedure resulted in an increase in known prevalence from 8.1% to 10.5% among participants. Oral anticoagulant treatment was initiated in 94.5% of the participants with newly diagnosed AF. Conclusion N-terminal B-type natriuretic peptide-stratified systematic screening for AF identified 4.4% of the high-risk participants with new AF. Oral anticoagulant treatment initiation was well accepted in the group diagnosed with new AF.

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