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 <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.

scholarly journals Bleeding and thromboembolism due to drug-drug interactions with non-vitamin K antagonist oral anticoagulants—a Swedish, register-based cohort study in atrial fibrillation outpatients

2020 ◽  
Author(s):  
Johan Holm ◽  
Buster Mannheimer ◽  
Rickard E Malmström ◽  
Erik Eliasson ◽  
Jonatan D Lindh
Keyword(s):  
Atrial Fibrillation ◽  
Cohort Study ◽  
Ischemic Stroke ◽  
Vitamin K ◽  
Cox Regression ◽  
Oral Anticoagulants ◽  
Outcome Data ◽  
Vitamin K Antagonist ◽  
Drug Register ◽  
Increased Risk

Abstract Purpose To study the association between interacting drugs and bleeding or thromboembolism in atrial fibrillation outpatients treated with non-vitamin K antagonist oral anticoagulants (NOACs). Methods Population-based cohort study of outpatients treated with NOACs in Sweden from 2008 to 2017. Patients with atrial fibrillation and newly initiated NOAC treatment were identified in the Prescribed Drug Register. Comorbidities and outcome data were retrieved from the Patient Register and the Cause of Death Register. Cox-regression analyses were performed to evaluate the primary endpoints any severe bleed and ischemic stroke/transient ischemic attack/stroke unspecified during the first six months of treatment. Secondary endpoints were gastrointestinal bleeding, intracranial bleeding, ischemic stroke, and venous thromboembolism. Results Increased risk of any severe bleed was found when NOAC treatment, and drugs with pharmacodynamic effect on bleeding were combined, compared to NOAC only. An increased risk with these combinations was evident for apixaban (hazard ratio (HR) 1.47; 95% CI 1.33–1.63), rivaroxaban (HR 1.7; 95% CI 1.49–1.92), and dabigatran (HR 1.26; 95% CI 1.05–1.52). For apixaban, there was an increased risk of any severe bleed when combined with CYP3A4 and/or P-glycoprotein (P-gp) inhibitors (HR 1.23; 95% CI 1.01–1.5). The use of inducers of CYP3A4 and/or P-gp was low in this cohort, and effects on ischemic stroke/TIA/stroke unspecified could not be established. Conclusion Increased risk of bleeding was seen for pharmacodynamic and pharmacokinetic interactions with NOACs. Prescribers need to be vigilant of the effect of interacting drugs on the risk profile of patients treated with NOACs.

scholarly journals Higher Long-term Visit-to-Visit Glycemic Variability Predicts New-Onset Atrial Fibrillation in Patients with Diabetes Mellitus

2021 ◽  
Author(s):  
Jung-Chi Hsu ◽  
Yen-Yun Yang ◽  
Shu-Lin Chuang ◽  
Chih-Chieh Yu ◽  
Lian-Yu Lin
Keyword(s):  
Diabetes Mellitus ◽  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Cox Regression ◽  
Total Mortality ◽  
Glycemic Variability ◽  
University Hospital ◽  
Cardiac Mortality ◽  
Increased Risk ◽  
New Onset

Abstract BackgroundAtrial fibrillation (AF) is prevalent in patients with type 2 diabetes mellitus (T2DM). Glycemic variability (GV) is associated with risk of micro- and macrovascular diseases. However, whether the GV can increase the risk of AF remains unknown.MethodsThe cohort study used a database from National Taiwan University Hospital, a tertiary medical center in Taiwan. Between 2014 and 2019, a total of 27246 adult patients with T2DM were enrolled for analysis. Each individual was assessed to determine the coefficients of variability of fasting glucose (FGCV) and HbA1c variability score (HVS). The GV parameters were categorized into quartiles. Multivariate Cox regression models were employed to estimate the relationship between the GV parameters and the risk of AF, transient ischemic accident (TIA)/ischemic stroke and mortality in patients with T2DM.ResultsThe incidence rates of AF and TIA/ischemic stroke were 21.31 and 13.71 per 1000 person-year respectively. The medium follow-up period was 70.7 months. In Cox regression model with full adjustment, the highest quartiles of FGCV was not associated with increased risk of AF (Hazard ratio (HR): 1.11, 95% confidence interval (CI): 0.96-1.29, p=0.165) or TIA/ischemic stroke (HR: 1.03, 95% CI: 0.82-1.29, p=0.821), but was associated with increased risk of total mortality (HR: 1.34, 95% CI: 1.13-1.60, p<0.001) and non-cardiac mortality (HR: 1.42, 95% CI: 1.17-1.72, p<0.001). The highest HVS was significantly associated with increased risk of AF (HR: 1.29, 95% CI: 1.12-1.48, p<0.001), total mortality (HR: 2.44, 95% CI: 2.04-2.91, p<0.001), cardiac mortality (HR: 1.48, 95% CI: 1.04-2.10, p=0.028) and non-cardiac mortality (HR: 2.83, 95% CI: 2.31-3.14, p<0.001) but was not associated with TIA/ischemic stroke (HR: 1.00, 95% CI: 0.79-1.26, p=0.989). The Kaplan-Meier analysis showed significantly higher risk of AF, cardiac and non-cardiac mortality according to the magnitude of GV(log-rank<0.001). ConclusionsHigher GV is independently associated with the development of new-onset AF in patients with T2DM. Reducing GV may be a potential new therapeutic target to prevent AF.

Abstract 14022: Effect of Discontinuation and Nonadherence to Oral Anticoagulants on Atrial Fibrillation Stroke Risk

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Xiaoxi Yao ◽  
Neena S Abraham ◽  
Peter A Noseworthy ◽  
G. Caleb Alexander ◽  
Lindsey R Sangaralingham ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Oral Anticoagulants ◽  
Baseline Risk ◽  
Predicted Probability ◽  
Increased Risk ◽  
Risk Patients ◽  
Cox Proportional Hazard Models ◽  
One Year ◽  
Ischemic Attack

Introduction: Medicines don’t work in those who don’t take them. Although novel oral anticoagulants (NOACs) are more convenient than warfarin due to fewer drug-drug interactions and less need for laboratory monitoring, their considerable costs and lack of regular interactions with the healthcare system may also contribute to poor adherence. Little is known about the persistence and adherence in the era of NOACs, nor how such behaviors are associated with the risk of ischemic stroke and transient ischemic attack (TIA) among patients of varying baseline risk. Methods: We conducted a retrospective analysis using a large U.S. commercial insurance database, and identified 61,646 patients with atrial fibrillation who initiated one of OACs (warfarin, dabigatran, rivaroxaban and apixaban) between October 2010 and September 2014. We defined discontinuation as being off OACs for at least 3 months and adherence as the proportion of days covered of at least 80%. Cox proportional hazard models was used to examine whether the time that patients were off OACs, including both the gaps between medication fills and the time of discontinuation, increased the risk of ischemic stroke and TIA. Results: Approximately 1 in 3 patients discontinued OACs within one year after initiation and 1 in 10 switched to another OAC. The estimated likelihood of adherence was 0.77 during the time when patients were on their first-line medications. Apixaban had the highest continuation rate (65% at 1 year), while rivaroxaban had the best adherence (predicted probability of adherence 0.83). The event rate of stroke was 1.6 per 100 person years. Patients with high baseline risk (CHA2DS2-VASc ≥2) were more likely to have a stroke when they were off OACs for 1-3 months (HR=1.47, p<0.01), 3-6 months (HR=1.78, p<0.001) and ≥6 months (HR=2.16, p<0.001), compared to off OACs for less than a week. No significant effect was found among low-risk patients (CHA2DS2-VASc 0 or 1). Switching to another OAC was related to 22% increased risk of stroke (p=0.05). Conclusions: Despite their greater convenience relative to warfarin, discontinuation and nonadherence to NOACs is high. Lack of persistence and adherence was associated with increased risk of ischemic stroke and TIA among patients with elevated baseline risk.

scholarly journals Atrial Fibrillation Predicts Cognitive Impairment in Patients With Ischemic Stroke

2011 ◽  
Vol 26 (8) ◽  
pp. 623-626 ◽  
Author(s):  
Eliyahu Hayim Mizrahi ◽  
Anna Waitzman ◽  
Marina Arad ◽  
Abraham Adunsky
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Cognitive Impairment ◽  
Chart Review ◽  
Multiple Logistic Regression Analysis ◽  
Retrospective Chart Review ◽  
Cognitive Status ◽  
Increased Risk ◽  
Review Study ◽  
State Examination

Background: Atrial fibrillation (AF) is considered as a risk factor for cognitive impairment. Methods: This retrospective chart review study was conducted in a patient stroke rehabilitation ward of a university-affiliated referral hospital. The participants were 707 patients admitted for a standard rehabilitation course after an ischemic stroke. Cognitive status was assessed by the Mini-Mental State Examination (MMSE), and scores lower than 24 points were considered as suggestive of cognitive impairment. Results: Atrial fibrillation, age, gender, diabetes, and dementia emerged as the only statistically significant parameters differing between those with MMSE score lower than 24 or higher. In a multiple logistic regression analysis, AF (odds ratio 1.6, 95% confidence interval 1.03-2.47, P = .03) was associated with an increased risk of cognitive impairment. Conclusions:Our findings suggest that atrial fibrillation upon admission is independently associated with lower MMSE scores in patients with ischemic stroke.

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 Higher long-term visit-to-visit glycemic variability predicts new-onset atrial fibrillation in patients with diabetes mellitus

2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Jung-Chi Hsu ◽  
Yen-Yun Yang ◽  
Shu-Lin Chuang ◽  
Chih-Chieh Yu ◽  
Lian-Yu Lin
Keyword(s):  
Diabetes Mellitus ◽  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Cox Regression ◽  
Total Mortality ◽  
Glycemic Variability ◽  
Rank Test ◽  
Cardiac Mortality ◽  
Increased Risk ◽  
New Onset

Abstract Background Atrial fibrillation (AF) is prevalent in patients with type 2 diabetes mellitus (T2DM). Glycemic variability (GV) is associated with risk of micro- and macrovascular diseases. However, whether the GV can increase the risk of AF remains unknown. Methods The cohort study used a database from National Taiwan University Hospital, a tertiary medical center in Taiwan. Between 2014 and 2019, a total of 27,246 adult patients with T2DM were enrolled for analysis. Each individual was assessed to determine the coefficients of variability of fasting glucose (FGCV) and HbA1c variability score (HVS). The GV parameters were categorized into quartiles. Multivariate Cox regression models were employed to estimate the relationship between the GV parameters and the risk of AF, transient ischemic accident (TIA)/ischemic stroke and mortality in patients with T2DM. Results The incidence rates of AF and TIA/ischemic stroke were 21.31 and 13.71 per 1000 person-year respectively. The medium follow-up period was 70.7 months. In Cox regression model with full adjustment, the highest quartile of FGCV was not associated with increased risk of AF [Hazard ratio (HR): 1.12, 95% confidence interval (CI) 0.96–1.29, p = 0.148] or TIA/ischemic stroke (HR: 1.04, 95% CI 0.83–1.31, p = 0.736), but was associated with increased risk of total mortality (HR: 1.33, 95% CI 1.12–1.58, p < 0.001) and non-cardiac mortality (HR: 1.41, 95% CI 1.15–1.71, p < 0.001). The highest HVS was significantly associated with increased risk of AF (HR: 1.29, 95% CI 1.12–1.50, p < 0.001), total mortality (HR: 2.43, 95% CI 2.03–2.90, p < 0.001), cardiac mortality (HR: 1.50, 95% CI 1.06–2.14, p = 0.024) and non-cardiac mortality (HR: 2.80, 95% CI 2.28–3.44, p < 0.001) but was not associated with TIA/ischemic stroke (HR: 0.98, 95% CI 0.78–1.23, p = 0.846). The Kaplan–Meier analysis showed significantly higher risk of AF, cardiac and non-cardiac mortality according to the magnitude of GV (log-rank test, p < 0.001). Conclusions Our data demonstrate that high GV is independently associated with the development of new-onset AF in patients with T2DM. The benefit of maintaining stable glycemic levels to improve clinical outcomes warrants further studies.

scholarly journals Drug-drug interactions in atrial fibrillation patients receiving direct oral anticoagulants

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Ji Yun Lee ◽  
Il-Young Oh ◽  
Ju-Hyeon Lee ◽  
Seok Kim ◽  
Jihoon Cho ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Drug Interactions ◽  
Major Bleeding ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Multiple Logistic Regression Analysis ◽  
Common Data Model ◽  
Concomitant Treatment ◽  
Increased Risk

AbstractPolypharmacy is common in patients with atrial fibrillation (AF), making these patients vulnerable to the occurrence of potential drug-drug interactions (DDIs). We assessed the risk of ischemic stroke and major bleeding in the context of concomitant treatment with potential DDIs in patients with AF prescribed direct oral anticoagulants (DOACs). Using the common data model (CDM) based on an electronic health record (EHR) database, we included new users of DOACs from among patients treated for AF between January 2014 and December 2017 (n = 1938). The median age was 72 years, and 61.8% of the patients were males, with 28.2% of the patients having a CHA2DS2-VASc score in category 0–1, 49.4% in category 2–3, and 22.4% in category ≥ 4. The CHA2DS2-VASc score was significantly associated with ischemic stroke occurrence and hospitalization for major bleeding. Multiple logistic regression analysis showed that increased risk of ischemic stroke and hospitalization for major bleeding was associated with the number of DDIs regardless of comorbidities: ≥ 2 DDIs was associated with ischemic stroke (OR = 18.68; 95% CI, 6.22–55.27, P < 0.001) and hospitalization for major bleeding (OR = 5.01; 95% CI, 1.11–16.62, P < 0.001). DDIs can cause reduced antithrombotic efficacy or increased risk of bleeding in AF patients prescribed DOACs.

scholarly journals Direct oral anticoagulants for prevention of stroke and other cardiovascular outcomes in patients aged 80 years or older with atrial fibrillation

2021 ◽  
Vol 30 (1) ◽  
pp. 16-23
Author(s):  
S. Moiseev
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Elderly Patients ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Very Elderly ◽  
Once Daily ◽  
Increased Risk ◽  
Reduced Kidney Function

Over the last decade, the number of people aged 80 years or over in Russia increased by 41% up to 5.7 mln. At least 10% of these individuals develop atrial fibrillation (AF). Treatment of rhythm disorders in the very elderly patients is challenging due to the high occurrence of comorbidities, including cognitive dysfunction, changes in the pharmacokinetics of drugs as a result of reduced kidney function, increased risk of interaction of drugs. The very elderly patients with AF have a higher risk of ischemic stroke and other cardiovasculat outcomes, including myocardial infarction, and should be treated with oral anticoagulants. The results of randomized controlled trials and prospective and retrospective observational studies suggest that in patients aged 80 years or older with non-valvular AF direct oral anticoagulants (DOAC) are at least as effective as vitamin K antagonists for prevention of ischemic stroke and are associated with a lower risk of intracerebral haemorrhage. The use of DOAC (once daily rivaroxaban in particular) impoves compliance to anticoagulation in the very elderly patients with non-valvular AF.

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