scholarly journals P050: A prospective cohort study to evaluate discharge care for patients with atrial fibrillation and flutter (AF/AFL)

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S94-S95
Author(s):  
P. Duke ◽  
S. Patrick ◽  
K. Lobay ◽  
M. Haager ◽  
B. Deane ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Previous History ◽  
Antiplatelet Agents ◽  
Bleeding Risk ◽  
Risk Scores ◽  
High Risk Population ◽  
Prescribing Practices ◽  
Increased Risk ◽  
Risk Of Falls ◽  
Atrial Fibrillation And Flutter

Introduction: Atrial fibrillation and flutter (AF/AFL) are the most common arrhythmias encountered in the emergency department (ED); however, little information exists regarding the preventive management of patients with AF/AFL by emergency physicians (EPs). This study explored whether patients with AF/AFL received the recommended thrombo-embolic (TE) prophylaxis at discharge from the ED; patients’ TE risks, bleeding risks, and TE prophylaxis upon discharge from the ED were examined following assessment for symptomatic acute AF/AFL. Methods: Patients ≥18 years of age identified by the EP as having a diagnosis of acute AF/AFL confirmed by ECG were prospectively enrolled from three urban Canadian EDs. Using standardized patient enrollment forms, trained research assistants collected data on the patient’s demographics, TE risk (using the CHADS2 and CHA2DS2-VASc score), bleeding risk (using the HAS-BLED score), and management both in the ED and at discharge. Treating physicians were surveyed on their use of risk scores when making TE prophylaxis decisions as well as their estimate of the patient’s stroke and bleeding risk. Descriptive analyses were performed. Results: From a total of 196 patients, 62% were male and the mean age was 63 years (standard deviation [SD] ±14). Most patients had previous history of AF/AFL (71%); hypertension was documented in 40% of them and ≤10% had other risk factors (e.g., congestive heart failure, vascular disease, diabetes, previous stroke, transient ischemic attack). Based on the CHADS2 score and previous management, there was opportunity for new or revised antiplatelet/anticoagulant treatment by EPs in 19% of the patients. Consultations were requested in 28% of the patients, and the majority (89%) were discharged with anticoagulant or antiplatelet agents. EPs expressed concerns that an increased risk of falls, lack of access to facilities for INR monitoring, and significant cognitive impairment would affect their willingness to prescribe anticoagulation. Conclusion: Most patients in the ED with acute AF/AFL are receiving the recommended TE prophylaxis; however, given the significant morbidity and mortality associated with AF/AFL, improved short-term prescribing practices for anticoagulants would benefit 1 in 5 ED patients. More research on barriers to EPs prescribing anticoagulants is required to improve clinician comfort in treating this high-risk population.

scholarly journals Biomarkers for Risk Assessment in Atrial Fibrillation

2020 ◽  
Author(s):  
David D Berg ◽  
Christian T Ruff ◽  
David A Morrow
Keyword(s):  
Atrial Fibrillation ◽  
Major Bleeding ◽  
Cardiac Troponin ◽  
Clinical History ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Circulating Biomarkers ◽  
Coagulation Activity ◽  
Hemodynamic Stress ◽  
Increased Risk

Abstract Background Atrial fibrillation (AF) is associated with an increased risk of thromboembolism, which can be significantly reduced with anticoagulant treatment. Key goals in the clinical management of AF are the identification of patients at high risk for developing AF and accurate stratification of the risk of stroke and systemic embolic events (S/SEE) as well as treatment-related major bleeding. Content In this review, we describe the expanding evidence regarding the use of circulating biomarkers for predicting the risks of both incident AF and its clinically important complications of S/SEE and treatment-related major bleeding. We also review emerging biomarker-based scores for assessing these risks. Summary Patients with AF undergo progressive cardiac structural remodeling, which may precede the onset of the arrhythmia. Abnormal concentrations of circulating biomarkers reflecting the underlying pathophysiologic mechanisms of hemodynamic stress (i.e., natriuretic peptides), inflammation (i.e., C-reactive protein), and myocardial fibrosis identify patients at higher risk of developing AF. Circulating biomarkers can also be used to identify patients with AF who are at greatest risk for developing S/SEE or major bleeding. In particular, biomarkers of hemodynamic stress, myocardial injury (i.e., cardiac troponin), and coagulation activity (i.e., D-dimer) are key indicators of thromboembolic risk, and cardiac troponin and growth-differentiation factor-15 are strongly associated with risk of anticoagulant-related major bleeding. The biomarker-based age, biomarker, clinical history (ABC)-stroke and ABC-bleeding risk scores improve risk stratification for S/SEE and major bleeding, respectively, when compared with traditional clinical risk scores like the CHA2DS2-VASc and HAS-BLED scores.

Risk Stratification Models in Atrial Fibrillation

2017 ◽  
Vol 43 (05) ◽  
pp. 505-513 ◽  
Author(s):  
Farhan Shahid ◽  
Gregory Lip
Keyword(s):  
Atrial Fibrillation ◽  
Risk Assessment ◽  
Bleeding Risk ◽  
Practical Method ◽  
Assessment Tools ◽  
Risk Scores ◽  
Mortality And Morbidity ◽  
Increased Risk ◽  
Morbidity Risk ◽  
Aid Decision

AbstractAtrial fibrillation (AF) is associated with an increased risk of stroke compared with the general population. AF-related stroke confers a higher mortality and morbidity risk, and thus, early detection and assessment for the initiation of effective stroke prevention with oral anticoagulation are crucial. Simple and practical risk assessment tools are essential to facilitate stroke and bleeding risk assessment in busy clinics and wards to aid decision making. At present, the CHA2DS2VASc score is recommended by guidelines as the most simple and practical method of assessing stroke risk in AF patients. Alongside this, the use of the HAS-BLED score aims to identify patients at high risk of bleeding for more regular review and follow-up, and draws attention to potentially reversible bleeding risk factors. The aim of this review article is to summarize the current risk scores available for both stroke and bleeding in AF patients, and the recommendations for their use.

scholarly journals Safety of Apixaban in Patients with CKD Stage V and ESRD with Venous Thromboembolism

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 2523-2523
Author(s):  
Jahnavi Gollamudi ◽  
Sadeer Al-Kindi ◽  
Petra Martin ◽  
Lalitha V. Nayak
Keyword(s):  
Atrial Fibrillation ◽  
Logistic Regression ◽  
Renal Disease ◽  
Conflicts Of Interest ◽  
Previous History ◽  
Antiplatelet Agents ◽  
Intracranial Bleeding ◽  
Electronic Health Record Data ◽  
Increased Risk ◽  
Ckd Stage

Abstract Introduction Historically, warfarin (Coumadin) was the only choice of anticoagulation in patients with chronic renal disease (CKD) stage V and end stage renal disease on dialysis (ESRD). Although apixaban (Eliquis) is approved for use in patients with CKD for venous thrombosis (VTE), its role in patients with CKD 5 and on dialysis is less defined. The purpose of this retrospective study is to compare the rates of bleeding, particularly gastrointestinal (GI) and intracranial bleeding in patients with CKD stage V or dialysis who are anticoagulated with warfarin or apixaban for indication of VTE. Methods Data for this study was queried from a commercial database (Explorys Inc, Cleveland, OH, USA), an aggregate of electronic health record data from 26 major integrated US healthcare systems representing a sixth of the US population. Cases and controls were identified using Systematized Nomenclature of Medicine (SNOMED) clinical terms or codes. Cases were defined as patients with CKD stage 5 or ESRD and were on apixaban for VTE. Controls were defined as those with CKD stage 5 or ESRD and were on warfarin for VTE. For the primary end point of bleeding, only patients above the age of 15 were selected. Those with previous history of GI or intracranial bleeding, atrial fibrillation, traumatic injury, cancer and cirrhosis were excluded. In the coumadin group, in addition to above, patients who were on for indication of artificial valves, arterial thrombosis and PVD were also excluded. 30 and 90-day rates of GI and intracranial bleeding were recorded for both groups. Logistic regression models were used to adjust of confounding variables (defined a priori as age > 65 or< 65, use of antiplatelet agents, gender, race and presence or absence of hypertension greater than 160/100 mm of hg). Rates or proportions were compared using Chi-squared test using Medcalc software (2018).Logistic regression analysis was done using Statistical Package for Social Sciences (SPSS, version 21, IBM Corp, Armonk, NY). P< 0.05 was considered statistically significant. Results A total of 990 cases and 8110 controls were identified. 30 and 90-day pooled GI and intracranial bleeding rates for apixaban users were 40% and 35% respectively. 30 and 90 day pooled GI and intracranial bleeding rates for warfarin users were 58% and 54% respectively. Difference in 30 day bleeding between cases and controls was 18% (95% CI 14.7-21.2; p< 0.0001) and 90 day bleeding was 19% (95% CI 15.7-22.1; p <0.001) Due to the limitations of the study, both major and minor GI bleeds were included. Given this study was retrospective, efficacy data in preventing recurrent VTE could not be assessed. Logistic regression of risk factors associated with risk of bleeding revealed that age over 65 years, presence hypertension> 160/100 mm of Hg, use of antiplatelet agents, African american race, and use of warfarin as opposed to apixaban were all significantly associated with increased risk of both 30 and 90 day bleeding. Please see Table 1 and 2 for further details. Discussion Our study has shown that pooled rates of GI and intracranial bleeds were lower in the apixaban users even when used in patients with CKD stage V or ESRD patients, showing that apixaban is safe even when used for the indication of VTE prevention in this cohort. The results of this study are in concert with a recently published meta-analysis, which showed similar lower risks of bleeding when used in the advanced CKD cohort when used for the indication of atrial fibrillation. However, more studies are needed to prove its efficacy in this cohort. Disclosures No relevant conflicts of interest to declare.

Biomarkers Associated with Bleeding Risk in the Setting of Atrial Fibrillation

2019 ◽  
Vol 26 (5) ◽  
pp. 824-836 ◽  
Author(s):  
Skevos Sideris ◽  
Stefanos Archontakis ◽  
George Latsios ◽  
George Lazaros ◽  
Konstantinos Toutouzas ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Large Scale ◽  
Oral Anticoagulants ◽  
Significant Risk ◽  
Bleeding Risk ◽  
Hepatic Function ◽  
Risk Scores ◽  
Current Evidence ◽  
Prognostic Impact ◽  
Increased Risk

Background: Prevention of thromboembolic disease, mainly stroke, with oral anticoagulants remains a major therapeutic goal in patients with atrial fibrillation. Unfortunately, despite the high efficacy, anticoagulant therapy is associated with a significant risk of, frequently catastrophic, and hemorrhagic complications. Among different clinical and laboratory parameters related to an increased risk of bleeding, several biological markers have been recognized and various risk scores for bleeding have been developed. Objectives/Methods: The aim of the present study is to review current evidence regarding the different biomarkers associated with raised bleeding risk in atrial fibrillation. Results: Data originating from large cohorts or the recent large-scale trials of atrial fibrillation have linked numerous individual biomarkers to an increased bleeding risk. Such a relation was revealed for markers of cardiac physiology, such as troponin, BNP and NT-proBNP, markers of renal function, such as GFR and Cystatin or hepatic function, markers involving the system of coagulation, such as D-dimer and Von Willebrand factor, hematologic markers, such as low haemoglobin or low platelets, inflammatory markers, such as interleukin-6, other factors such as GDF-15 and vitamin-E and finally genetic polymorphisms. Many such biomarkers are incorporated in the bleeding risk schemata developed for the prediction of the hemorrhagic risk. Conclusions: Biomarkers were introduced in clinical practice in order to better estimate the potential risk of haemorrhage in these patients and increase the prognostic impact of clinical risk scores. In the last years this concept is gaining significant importance.

scholarly journals MP37: Adherence to Canadian Cardiovascular Society guidelines for prescribing oral anticoagulants to patients with atrial fibrillation in the emergency department

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S55-S56
Author(s):  
D. Hung ◽  
M. Butler ◽  
S. Campbell
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Ischemic Stroke ◽  
Oral Anticoagulants ◽  
Previous History ◽  
Retrospective Chart Review ◽  
Prescribing Patterns ◽  
Prescribing Practices ◽  
Increased Risk ◽  
New Onset

Introduction: Atrial fibrillation (AF) is the most common arrhythmia treated in the emergency department (ED) and is associated with an increased risk of ischemic stroke. Studies have shown that only oral anticoagulant (OAC) therapy reduces risk of AF related stroke. Our objective was to measure the prescribing practices for OACs for new onset AF at a tertiary ED and two surrounding community EDs, and identify rates of adverse effects within 90 days. The findings of this study will provide quality assurance information for the management of patients with new onset AF. This information has the potential to promote adherence to prescribing guidelines for AF in the ED and the reduction of common adverse events such as ischemic stroke. Methods: We conducted a retrospective chart review of 385 patients with new onset AF who presented to the ED between November 2014 to Mach 2018. We defined new onset as symptoms &lt;48 hours and had AF confirmed with electrocardiogram. We recorded the selected therapy choice of cardioversion and/or rate control, gender, age, and assessed CHADS-65 score. We recorded who was prescribed OAC and those who were referred to cardiology, family medicine, or did not have a documented follow up plan. Patients with a previous history of AF or current anticoagulant therapy were excluded. We recorded if any patients returned to the ED within 90 days with ischemic stroke, AF recurrence, myocardial infarction, other embolic disease or death. Results: 86 of 294 (29.5%) of patients who qualified under CHADS-65 received OACs appropriately. 64 of 66 (97.0%) of patients who did not qualify under CHADS-65 did not receive OACs appropriately. 5 patients overall returned within 90 days with ischemic stroke, 4 of those were not prescribed OACs, however this was not statistically significant (P = 0.999). Conclusion: This data suggests that physicians in the study are under-prescribing OACs relative to published guidelines. A larger study is necessary to elucidate the effect of ED OAC prescribing patterns on long-term patient outcome.

P4791Performance of the HAS-BLED, ATRIA, and PRECISE-DAPT Bleeding Risk Scores in Atrial Fibrillation Patients Using Antiplatelet Agents or Oral Anticoagulants

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
S Y Choi ◽  
M H Kim ◽  
K M Lee ◽  
C H Jang ◽  
J Y Choi
Keyword(s):  
Atrial Fibrillation ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Oral Anticoagulants ◽  
Antiplatelet Agents ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Bleeding Events ◽  
C Statistic ◽  
Better Than

Abstract Background Various bleeding risk scores have been proposed to assess the risk of bleeding in atrial fibrillation (AF) patients undergoing anticoagulation. PRECISE DAPT score has been developed to assess the out-of hospital bleeding risk in patients receiving dual antiplatelet therapy (DAPT). Our objective was to compare the predictive performance between the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile International Normalized Ratio, Elderly, Drugs/Alcohol), ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation), and PRECISE-DAPT (Predicting Bleeding Complication in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet therapy) score in AF patients using antiplatelet agents or anticoagulants Methods We recruited 1,114 consecutive AF patients (51% male; median age, 71 years) receiving antiplatelet agents or oral anticoagulants from January 2014 through December 2018. Major bleeding was defined as according to the Bleeding Academic Research Consortium (BARC) criteria (type 3 or 5: hemodynamic instability, need for transfusion, drop in hemoglobin ≥3 g, and intracranial, intraocular or fatal bleeding). The performance of risk scores were assessed by C-statistic. Results Bleeding events occurred in 135 patients (12.1%) during 30 days, and 72 patients (6.5%) from 30 days till 1-year follow-up. Based on the C-statistic, PRECISE-DAPT score (AUC: 0.72, 95% CI: 0.69–0.75) had a good performance, significantly better than HAS-BLED (AUC: 0.64, 95% CI: 0.61–0.67) (p=0.008) or ATRIA scores (AUC: 0.57, 95% CI: 0.54–0.60) (p<0.001) for 30-days bleeding prediction. Also, PRECISE-DAPT score had a good C-statistic (AUC: 0.72, 95% CI: 0.69–0.75) for 1-year bleeding events compared with HAS-BLED (AUC: 0.64, 95% CI: 0.60–0.67) (p=0.02) or ATRIA (AUC: 0.61, 95% CI: 0.58–0.65) (p=0.01). ROC curve for bleeding Conclusions The PRECISE-DAPT score has been used for assessing bleeding events during DAPT. Also, the PRECISE-DAPT score predicted bleedings better than HAS-BLED or ATRIA scores in AF patients. So, the PRECISE-DAPT score may be considered as bleeding risk score during DAPT or oral anticoagulation in clinical practice.

scholarly journals Anticoagulation risk assessment for patients with non-valvular atrial fibrillation and venous thromboembolism: A clinical review

2019 ◽  
Vol 24 (2) ◽  
pp. 141-152
Author(s):  
Vincent A Pallazola ◽  
Rishi K Kapoor ◽  
Karan Kapoor ◽  
John W McEvoy ◽  
Roger S Blumenthal ◽  
...  
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Risk Assessment ◽  
Venous Thromboembolism ◽  
Anticoagulant Therapy ◽  
Bleeding Risk ◽  
Assessment Tools ◽  
Risk Scores ◽  
Increased Risk ◽  
Risk Assessment Tools

Non-valvular atrial fibrillation and venous thromboembolism anticoagulation risk assessment tools have been increasingly utilized to guide implementation and duration of anticoagulant therapy. Anticoagulation significantly reduces stroke and recurrent venous thromboembolism risk, but comes at the cost of increased risk of major and clinically relevant non-major bleeding. The decision for anticoagulation in high-risk patients is complicated by the fact that many risk factors associated with increased thromboembolic risk are simultaneously associated with increased bleeding risk. Traditional risk assessment tools rely heavily on age, sex, and presence of cardiovascular comorbidities, with newer tools additionally taking into account changes in risk factors over time and novel biomarkers to facilitate more personalized risk assessment. These tools may help counsel and inform patients about the risks and benefits of starting or continuing anticoagulant therapy and can identify patients who may benefit from more careful management. Although the ability to predict anticoagulant-associated hemorrhagic risk is modest, ischemic and bleeding risk scores have been shown to add significant value to therapeutic management decisions. Ultimately, further work is needed to optimally implement accurate and actionable risk stratification into clinical practice.

scholarly journals Prevalence, Epidemiological Characteristics, and Pharmacotherapy of Coronary Artery Disease among Patients with Atrial Fibrillation: Data from Jo-Fib Study

Medicina ◽  
2021 ◽  
Vol 57 (6) ◽  
pp. 605
Author(s):  
Hanna K. Al-Makhamreh ◽  
Mohammed Q. Al-Sabbagh ◽  
Ala’ E. Shaban ◽  
Abdelrahman F. Obiedat ◽  
Ayman J. Hammoudeh
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Antiplatelet Agents ◽  
Retrospective Case ◽  
Increased Risk ◽  
Artery Disease ◽  
Epidemiological Characteristics ◽  
Cad Risk

Background and Objectives: Patients with AF are at increased risk for Coronary Artery Disease (CAD) owing to their shared etiologies and risk factors. This study aimed to assess the prevalence, cardiovascular risk factors, and used medications of CAD in AF patients. Materials and Methods: This retrospective, case-control study utilized data from the Jordanian Atrial Fibrillation (Jo-Fib) registry. Investigators collected clinical features, history of co-existing comorbidities, CHA2DS2-VASc, and HAS BLED scores for all AF patients aged >18 visiting 19 hospitals and 30 outpatient cardiology clinics. A multivariable binary logistic regression was used to asses for factors associated with higher odds of having CAD. Results: Out of 2000 patients with AF, 227 (11.35%) had CAD. Compared to the rest of the sample, those with CAD had significantly higher prevalence of hypertension (82.38%; p < 0.01), hypercholesterolemia (66.52%, p < 0.01), diabetes (56.83%, p < 0.01), and smoking (18.06%, p = 0.04). Patients with AF and CAD had higher use of anticoagulants/antiplatelet agents combination (p < 0.01) compared to the rest of the sample. Females had lower CAD risk than males (OR = 0.35, 95% CI: 0.24–0.50). AF Patients with dyslipidemia (OR = 2.5, 95% CI: 1.8–3.4), smoking (OR = 1.7, 95% CI: 1.1–2.6), higher CHA2DS2-VASc score (OR = 1.5, 95% CI: 1.4–1.7), and asymptomatic AF (OR = 1.9, 95% CI: 1.3–2.6) had higher risk for CAD. Conclusions: Owing to the increased prevalence of CAD in patients with AF, better control of cardiac risk factors is recommended for this special group. Future studies should investigate such interesting relationships to stratify CAD risk in AF patients. We believe that this study adds valuable information regarding the prevalence, epidemiological characteristics, and pharmacotherapy of CAD in patients with AF.

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