Oral anticoagulant therapy at hospital admission associates with lower mortality in older COVID-19 patients with atrial fibrillation. An insight from the Covid Registry

Abstract Funding Acknowledgements Type of funding sources: None. OnBehalf the GeroCovid Investigators Introduction. Atrial fibrillation (AF), the arrhythmia most frequently diagnosed in older patients, associates with serious, thrombo-embolic, complications and high mortality. COVID-19 severely affects aged subjects, determining an important prothrombotic status. Purpose. Aim of this study was to evaluate mortality-related factors in older AF patients with COVID-19. Methods. We included 806 in-hospital COVID-19 patients aged 60 years or more hospitalized between March 1st and June 6th 2020 and enrolled in a multicenter observational study. Results. The prevalence of AF was 21.8%. In-hospital mortality was higher in the AF group (36.9 vs. 27.5%; p = 0.015). Among AF patients, those who survived were younger (81 ± 8 vs. 84 ± 7 years; p = 0.002), had a lower CHA2DS2-VASc score (3.9 ± 1.6 vs. 4.4 ± 1.3; p = 0.02) and were more frequently treated with oral anticoagulants at admission (63.1 vs. 32.3%; p < 0.001) than those who died in hospital. At multivariable logistic regression analysis, lower age (p = 0.042), a better functional profile (p = 0.007), less severe COVID-19 manifestations at admission (p = 0.001), and the use of Vitamin K antagonists (OR = 0.16, 95%CI: 0.03-0.84; p = 0.031) or DOACs (OR = 0.22, 95%CI: 0.08-0.56; p = 0.002), compared to antiplatelet therapy or no treatment at all, were associated with a lower chance of in-hospital death. Conclusions. AF is a prevalent condition and a severity factor in older COVID-19 patients. Advanced age, dependency and severe clinical manifestations of disease characterized older AF subjects with a worse prognosis. Interestingly, pre-admission anticoagulant therapy correlated positively with in-hospital survival.

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COVID-19 and atrial fibrillation in older patients. Does oral anticoagulant therapy provide a survival benefit? An insight from the GeroCovid Registry

Thrombosis and Haemostasis ◽

10.1055/a-1503-3875 ◽

2021 ◽

Author(s):

Stefano Fumagalli ◽

Caterina Trevisan ◽

Susanna Del Signore ◽

Giulia Pelagalli ◽

Stefano Volpato ◽

...

Keyword(s):

Atrial Fibrillation ◽

Anticoagulant Therapy ◽

Older Patients ◽

Oral Anticoagulant Therapy ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Geriatric Medicine ◽

Multivariable Analysis ◽

Clinical Manifestations ◽

Hospital Death

Introduction. Atrial fibrillation (AF), the most frequent arrhythmia of older patients, associates with serious thrombo-embolic complications and high mortality. COVID-19 severely affects aged subjects, determining an important prothrombotic status. Aim of this study was to evaluate mortality-related factors in older AF patients with COVID-19. Methods. Between March and June 2020, we enrolled >=60 years in-hospital COVID-19 patients (N=806) in GeroCovid, a multicenter observational study promoted by the Italian Society of Gerontology and Geriatric Medicine. Results. The prevalence of AF was 21.8%. In-hospital mortality was higher in the AF group (36.9 vs. 27.5%, p=0.015). At admission, 51.7%, 10.2% and 38.1% of AF cases were taking, respectively, oral anticoagulants (OACs), antiplatelet agents and no antithrombotic therapy. During hospitalization, 51% patients switched to low-molecular weight heparins. AF patients who survived were younger (81±8 vs. 84±7 years; p=0.002) and had a lower CHA2DS2-VASc score (3.9±1.6 vs. 4.4±1.3; p=0.02) than those who died. OACs use before (63.1% vs. 32.3%; p<0.001) and during hospitalization (34.0% vs. 12.7%; p=0.002) was higher among survivors. At multivariable analysis, lower age, higher self-sufficiency, less severe initial COVID-19 presentation, and the use of Vitamin K antagonists (OR=0.16, 95%CI: 0.03-0.84) or DOACs (OR=0.22, 95%CI: 0.08-0.56) at admission, or the persistence of OAC during hospitalization (OR=0.05, 95%CI: 0.01-0.24), were associated with a lower chance of in-hospital death. Conclusions. AF is a prevalent and severe condition in older COVID-19 patients. Advanced age, dependency and relevant clinical manifestations of disease characterized a worse prognosis. Pre-admission and in-hospital anticoagulant therapy were positively associated with survival.

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ANTICOAGULANT THERAPY IN CANCER PATIENTS WITH ATRIAL FIBRILLATION. CONSIDERING AGE FACTOR

Успехи геронтологии ◽

10.34922/ae.2020.33.1.013 ◽

2020 ◽

pp. 99-106

Author(s):

В. И. Потиевская ◽

А. А. Ахобеков ◽

М. Ф. Баллюзек

Keyword(s):

Atrial Fibrillation ◽

Cancer Patients ◽

Anticoagulant Therapy ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Current Data ◽

Related Factors ◽

Age Related ◽

Liver And Kidney ◽

After Cancer

Рассматривается современное состояние вопроса выбора антикоагулянтной терапии при фибрилляции предсердий (ФП) у онкологических больных. Отмечается, что сложность выбора антикоагулянта при злокачественных новообразованиях (ЗНО) определяется такими факторами, как коморбидные сердечно-сосудистые заболевания, нарушения функции печени и почек, метаболические дисфункции, свойственные, прежде всего, пациентам старшей возрастной группы. Приводятся актуальные данные по оценке риска геморрагических и тромбоэмболических осложнений ФП при ЗНО в аспекте возраста. Обсуждаются возможные причины увеличения риска развития ФП во время и после лечения ЗНО, в том числе и в связи с возраст-ассоциированностью этих патологий. Рассмотрены вопросы выбора антикоагулянтов у пациентов, находящихся на активной противоопухолевой терапии, особенно на препаратах из группы прямых оральных антикоагулянтов (ПОАК). Согласно данным обсервационных исследований, именно ПОАК являются перспективным, относительно безопасным и эффективным выбором для онкологических пациентов с ФП, в связи с чем их применение должно активно изучаться в рандомизированных клинических исследованиях с учетом фактора возраста. Подчеркивается, что подбор схемы антикоагулянтной терапии у пациентов с ФП и ЗНО требует междисциплинарного участия кардиологов и онкологов, а часто и гериатров, чтобы индивидуализировать лечение и предложить наиболее эффективную терапию. The current issue of the choice of anticoagulant therapy of atrial ﬁbrillation (AF) in cancer patients is considered. It is noted that the difﬁculty of choosing an anticoagulant in malignancies is largely determined by age-related factors, such as comorbid cardiovascular diseases, liver and kidney dysfunction, metabolic disorders common for in elderly patients. Current data on the risk assessment of hemorrhagic and thromboembolic complications of AF in cancer patients in the aspect of age presented. During and after cancer treatment, the risk of developing AF can increase, also in connection with the age-associated pathology. Possible reasons of it are discussed. The choice of different anticoagulants groups in patients treated with anticancer therapy, including direct oral anticoagulants (DOAC) is considered. According to available data from observational studies, it is the DOAC that is a promising, relatively safe and effective choice for cancer patients with AF, and therefore their use should be actively studied in randomized trials, considering the factor of age. It is particularly noted that solving this problem requires the interdisciplinary involvement of cardiologists, oncologists, and sometimes, geriatrics, to individualize treatment for each case and to offer the most effective therapy.

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HAS-BLED scor system for the assessment of risk of breathing of patients on oral anticoagulant therapy // HAS-BLED skor sistem bodovanja za procjenu rizika od krvarenja pacijenata na oralnoj antikoagulantnoj terapiji

SESTRINSKI ŽURNAL ◽

10.7251/sez0118011d ◽

2018 ◽

Vol 5 (1) ◽

pp. 11

Author(s):

Daniela Dobrovoljski

Keyword(s):

Atrial Fibrillation ◽

Oral Anticoagulant ◽

Oral Anticoagulant Therapy ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Heart Rhythm ◽

Clinical Problem ◽

Coagulation Factors ◽

Heart Rhythm Disorders ◽

Anticoagulant Drugs

Oral anticoagulant drugs (OALs) are effective agents in the prevention and treatment of thromboembolic complications. However, despite standardization and application progression, OALs represent a significant clinical problem because they are small-therapeutic medicines that easily interact with food and medicine, which can substantially affect the increased or weakened therapeutic effect. Oral anticoagulants are 4-hydroxycoumarin derivatives and vitamin K antagonists, and their pharmacological activity is based on inhibition of the synthesis of coagulation factors in the liver. These drugs are effective in the prevention of venous thromboembolism, acute myocardial infarction (AIM), heart rhythm disorders by type of atrial fibrillation, stroke prevention, and the like. The most important and clinically commonly undesirable effect of OAL is bleeding. The risk of bleeding is greatest during the introduction of the drug in therapy and for the first few months of the onset of therapy. HAS-BLED scor is a skoring system developed to estimate the 1-year risk of major bleeding in patients with atrial fibrillation and is also used for other indications.

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Dabigatran in the ischemic patient undergoing atrial fibrillation ablation

ABOUTOPEN ◽

10.19156/abtpn.2018.0065 ◽

2018 ◽

Vol 4 (1) ◽

pp. 154-157

Author(s):

Roberto Spoladore

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Anticoagulant Therapy ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Poor Response ◽

Rf Ablation ◽

Ablation Procedure ◽

Total Period ◽

Hemorrhagic Events

Trans-catheter ablation of atrial fibrillation (AF) is a common treatment for symptomatic AF. Among the major complications of AF ablation are stroke, transient ischemic attacks and peri-procedural cardiac tamponade. Various clinical trials have shown that uninterrupted treatment with vitamin K antagonists (VKA) is associated with a lower incidence of embolic events compared to discontinuation of therapy; until recently, in the absence of equally solid evidence, this practice was not extended to the new oral anticoagulants (NOAC) not VKA due to the fear of hemorrhagic complications potentially associated with the use of an "irreversible" anticoagulant. The case of a patient suffering from numerous comorbidities is reported here. In light of the poor response to anti-arrhythmics, a TC-RF ablation was performed, with suspension of dabigatran administration only on the day of the procedure (for a total period <24 hours). Although the fear of the risk of bleeding potentially associated with the trans-catheter ablation procedure may still induce clinicians to stop anticoagulant therapy, even the decision to discontinue anticoagulant therapy with dabigatran on the day of surgery alone is challenged by recent evidence in the literature supporting the efficacy of dabigatran in reducing the incidence of hemorrhagic events during and after ablation, including the results of the RE-CIRCUIT study (Cardiology)

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Comparative Analysis of Antithrombotic Therapy in In-Patients with Atrial Fibrillation

Rational Pharmacotherapy in Cardiology ◽

10.20996/1819-6446-2019-15-1-49-53 ◽

2019 ◽

Vol 15 (1) ◽

pp. 49-53

Author(s):

V. I. Petrov ◽

O. V. Shatalova ◽

A. S. Gerasimenko ◽

V. S. Gorbatenko

Keyword(s):

Atrial Fibrillation ◽

High Risk ◽

Anticoagulant Therapy ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Thromboembolic Complications ◽

Antithrombotic Agents ◽

Cardiology Department ◽

Number Of Patients

Aim. To study the frequency of prescribing antithrombotic agents in patients with non-valvular atrial fibrillation (AF) who were hospitalized in the cardiology department of a multidisciplinary hospital.Material and methods. A retrospective one-time study of medical records of 765 patients with non-valvular AF treated in the cardiology department of a multidisciplinary hospital in 2012 and 2016 was performed.Results. All patients were stratified in three groups depending on the CHA2DS2-VASc score. The frequency of prescribing antithrombotic agents was evaluated in each group. A low risk of thromboembolic complications was found in 1% (n=3) of patients in 2012 and 0.6% (n=3) in 2016. All these patients received antithrombotic agents. CHA2DS2-VASc=1 was found in 6% (n=15) of patients with AF in 2012 and in 3.4% (n=17) in 2016. A significant number of patients in this group received anticoagulant therapy with vitamin K antagonists (warfarin) or with direct oral anticoagulants. A high risk of thromboembolic complications (CHA2DS2-VASc≥2) was found in 93% of patient (n=245) in 2012 and in 96% (n=482) in 2016. Anticoagulant therapy was prescribed in 70.2% (n=172) patients with high risk in 2012 and 80% (n=387) in 2016. However, some patients with high risk of thromboembolic complications did not have the necessary therapy.Conclusion. Positive changes in the structure and frequency of prescribing anticoagulant drugs in patients with AF and a high risk of thromboembolic complications were found during the years studied.

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New Cancer Diagnosis After Bleeding in Anticoagulated Patients With Atrial Fibrillation

Journal of the American Heart Association ◽

10.1161/jaha.120.016836 ◽

2020 ◽

Vol 9 (22) ◽

Author(s):

Sergio Raposeiras Roubín ◽

Emad Abu Assi ◽

Cristina Barreiro Pardal ◽

María Cespón Fernandez ◽

Isabel Muñoz Pousa ◽

...

Keyword(s):

Atrial Fibrillation ◽

Anticoagulant Therapy ◽

Cancer Diagnosis ◽

Oral Anticoagulant ◽

Oral Anticoagulant Therapy ◽

Oral Anticoagulants ◽

Bleeding Events ◽

Using Data ◽

Anticoagulated Patients

Background Bleeding is frequent in patients with atrial fibrillation (AF) treated with oral anticoagulant therapy, and may be the first manifestation of underlying cancer. We sought to investigate to what extent bleeding represents the unmasking of an occult cancer in patients with AF treated with oral anticoagulants. Methods and Results Using data from CardioCHUVI‐AF (Retrospective Observational Registry of Patients With Atrial Fibrillation From Vigo's Health Area), 8753 patients with AF aged ≥75 years with a diagnosis of AF between 2014 and 2017 were analyzed. Of them, 2171 (24.8%) experienced any clinically relevant bleeding, and 479 (5.5%) were diagnosed with cancer during a follow‐up of 3 years. Among 2171 patients who experienced bleeding, 198 (9.1%) were subsequently diagnosed with cancer. Patients with bleeding have a 3‐fold higher hazard of being subsequently diagnosed with new cancer compared with those without bleeding (4.7 versus 1.4 per 100 patient‐years; adjusted hazard ratio [HR], 3.2 [95% CI, 2.6–3.9]). Gastrointestinal bleeding was associated with a 13‐fold higher hazard of new gastrointestinal cancer diagnosis (HR, 13.4; 95% CI, 9.1–19.8); genitourinary bleeding was associated with an 18‐fold higher hazard of new genitourinary cancer diagnosis (HR, 18.1; 95% CI, 12.5–26.2); and bronchopulmonary bleeding was associated with a 15‐fold higher hazard of new bronchopulmonary cancer diagnosis (HR, 15.8; 95% CI, 6.0–41.3). For other bleeding (nongastrointestinal, nongenitourinary, nonbronchopulmonary), the HR for cancer was 2.3 (95% CI, 1.5–3.6). Conclusions In patients with AF treated with oral anticoagulant therapy, any gastrointestinal, genitourinary, or bronchopulmonary bleeding was associated with higher rates of new cancer diagnosis. These bleeding events should prompt investigation for cancers at those sites.

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Incidence of complications of antithrombotic treatment in patients with atrial fibrillation

Medicinski pregled ◽

10.2298/mpns1312470n ◽

2013 ◽

Vol 66 (11-12) ◽

pp. 470-475

Author(s):

Sladjana Novakovic-Anucin ◽

Sanja Gnip ◽

Visnja Canak ◽

Pavica Radovic ◽

Jelena Kovacev ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Anticoagulant Therapy ◽

Vitamin K ◽

Oral Anticoagulant Therapy ◽

Vitamin K Antagonists ◽

Combined Treatment ◽

Thromboembolic Complications ◽

Antithrombotic Treatment ◽

Hemorrhagic Complications

Introduction. Atrial fibrillation increases the risk of ischemic stroke five fold, while the application of long-term anticoagulant therapy is associated with the occurrence of hemorrhagic complications. The aim of our study was to evaluate the incidence of thrombotic and hemorrhagic complications in patients with atrial fibrillation during antithrombotic treatment. Material and Methods. The study included 504 patients that were administered the primary (n=345) or secondary thromboprophylaxis after ischemic stroke (n=159), by applying vitamin K antagonists, or the combination of vitamin K antagonists and low-dose aspirin. The patients were followed for five months in the period of 24 years from 1988 to 2012, the total number of patient?s years being 1884, at the Clinical Center of Vojvodina. Thromboembolic and hemorrhagic complications were registered during regular check-up examinations. Results and Discussion. Our results indicate the low incidence of thromboembolic complications (0.01 patient per a year), with a lower incidence in the vitamin K antagonists group than in the group with the combination of vitamin K antagonists and aspirin (0.008 patient per a year versus 0.01 patient per a year). The incidence of hemorrhagic complications was higher in the group with the combined treatment compared to the group treated with vitamin K antagonists (0.1 patient per a year versus 0.06 patient per a year). The frequency of major bleeding was as low as 0.01 patient per a year and more frequent in the group with combined treatment (0.03 patient per a year). Conclusion. The overall incidence of complications in the study group was 0.08 patient per a year. The combined antithrombotic treatment increases the risk of hemorrhagic complications and affects the severity of bleeding. Oral anticoagulant therapy is more efficient in the prevention of ischemic stroke and thromboembolic complications in patients with atrial fibrillation.

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Anticoagulation therapy in the elderly with non-valvular atrial fibrillation: a double-edged sword

Geriatric Care ◽

10.4081/gc.2017.6371 ◽

2017 ◽

Vol 3 (2) ◽

Cited By ~ 3

Author(s):

Francesco Vetta ◽

Gabriella Locorotondo ◽

Giampaolo Vetta

Keyword(s):

Atrial Fibrillation ◽

Elderly Patients ◽

Anticoagulant Therapy ◽

Vitamin K ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Anticoagulation Therapy ◽

Treatment Strategies ◽

The Elderly ◽

Hemorrhagic Events

Prevalence of non-valvular atrial fibrillation is increasing over time. Particularly in elderly population, treatment strategies to reduce the rate of stroke are challenging and still represent an unsolved cultural question. Indeed, the risk of thromboembolism increases in the elderly in parallel with the risk of bleeding. The frequent coexistence of several morbidities, frailty syndrome, polypharmacy, chronic kidney disease and dementia strengthens the perception that risk-benefit ratio of anticoagulant therapy could be unfavorable, and explains why such treatment is underused in the elderly. Recently, the introduction of non-vitamin K oral anticoagulants (NOACs) has allowed us to overcome the large number of limitations imposed by the use of vitamin K antagonists. In this manuscript, the benefits of individual NOACs in comparison with warfarin in elderly patients are reviewed. Targeted studies on complex elderly patients are needed to test usefulness of a geriatric comprehensive assessment, besides the scores addressing risk of thromboembolic and hemorrhagic events. In the meantime, it is mandatory that use of anticoagulant therapy in most elderly people, currently excluded from randomized controlled trials, is prudent and responsible.

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Safety and differences between direct oral anticoagulants and vitamin K antagonists in the risk of post-traumatic intrathoracic bleeding after rib fractures in elderly patients

Emergency Care Journal ◽

10.4081/ecj.2021.10284 ◽

2021 ◽

Vol 17 (4) ◽

Author(s):

Gianni Turcato ◽

Arian Zaboli ◽

Andrea Tenci ◽

Giorgio Ricci ◽

Massimo Zannoni ◽

...

Keyword(s):

Anticoagulant Therapy ◽

Vitamin K ◽

Oral Anticoagulant ◽

Oral Anticoagulant Therapy ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Vitamin K Antagonist ◽

Traumatic Bleeding ◽

Post Traumatic

Closed chest traumas are frequent consequences of falls in the elderly. The presence of concomitant oral anticoagulant therapy can increase the risk of post-traumatic bleeding even in cases of trauma with non-severe dynamics. There is limited information about the differences between vitamin K antagonists and direct oral anticoagulants in the risk of post-traumatic bleeding. To assess differences in the risk of developing intra-thoracic hemorrhages after chest trauma with at least one rib fracture caused by an accidental fall in patients over 75 years of age taking oral anticoagulant therapy. This study involved data from four emergency departments over two years. All patients on oral anticoagulant therapy and over 75 years of age who reported a closed thoracic trauma with at least one rib fracture were retrospectively evaluated. Patients were divided into two study groups according their anticoagulant therapy. Of the 342 patients included in the study, 38.9% (133/342) were treated with direct oral anticoagulants and 61.1% (209/342) were treated with vitamin K antagonist. A total of 7% (24/342) of patients presented intrathoracic bleeding, while 5% (17/342) required surgery or died as a result for the trauma. Posttraumatic intrathoracic bleeding occurred in 4.5% (6/133) of patients receiving direct oral anticoagulants and 8.6% (18/209) of patients receiving vitamin K antagonist. Logistic regression analysis, revealed no difference in the risk of intrathoracic haemorrhages between the two studied groups. Direct oral anticoagulants therapy presents a risk of post-traumatic intrathoracic haemorrhage comparable to that of vitamin K antagonist therapy.

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