Abstract 17022: The Gap Between Indicated and Prescribed Stroke Prevention Therapies in A High-risk Geriatric Population in Ontario

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Mohammed Shurrab ◽  
Eugene Crystal ◽  
Denis O'Donnell ◽  
Hrishikesh Navare ◽  
Paula Neves ◽  
...  
Keyword(s):  
Vitamin K ◽  
Stroke Prevention ◽  
Vitamin K Antagonists ◽  
The Elderly ◽  
Antiplatelet Drugs ◽  
Do Not Resuscitate ◽  
Chads2 Score ◽  
Term Care ◽  
Data Set ◽  
Advanced Directives

Introduction: Atrial fibrillation (AF) is the most common cardiac dysrhythmia, with estimated risk of about 25% by 80 years of age. The use of oral anticoagulation (OAC) in the elderly population treated in long term care (LTC) facilities is inconsistent and poorly studied. Hypothesis: We performed a retrospective analysis to assess the magnitude and sources of the gap between indicated and prescribed use of OAC in the elderly with AF along with the prevalence of different therapies. Methods: We retrospectively scanned 25 LTC facilities in Ontario, Canada. The diagnosis of AF was drawn from electronic medical records. This was merged with a pharmacy database, which was the sole provider of all medications for each resident. Attributable risk factors for possible failure to prescribe use of OAC were: Advanced directives for no hospitalization, Do-Not-Resuscitate order, Dementia, Cognitive Performance Scale, Activities of Daily Living Self Performance Hierarchy scale and Changes in Health, End-Stage Disease, Signs, and Symptoms Scale. Results: In total 3378 active residents were examined in 25 LTC facilities. All patients were ≥ 65 years old with mean age 85 ± 8 years and 2449 (72%) were female. We identified 433 (13%) AF patients with mean age 87 ± 7 years and mean CHADS2 score 3 ± 1; all qualify for OAC therapy. Out of all AF patients, 273 (63%) patients were on OAC therapy. Patients were mostly treated with Vitamin K antagonists (N= 114 (42%)), rivaroxaban (N= 71 (26%)) or apixaban (N= 62 (23%)) followed by dabigatran (N= 26 (10%)). Antiplatelet drugs as the only stroke prevention therapy were used in 88 (20%) patients and 28 (6%) patients were on dual therapy (anticoagulation and antiplatelet drugs). Seventy-two (17%) patients were not on any antiplatelet or antithrombotic therapy. None of the attributable risks identified consistently correlated with the failure to prescribe indicated therapy. Conclusions: This real world data set suggests that 37% of eligible elderly LTC patients fail to receive recommended stroke prevention therapies. Vitamin K antagonists are the most common OAC therapy used in elderly patients in LTC facilities. Lack of use of indicated therapy appears to be idiosyncratic.

scholarly journals Optimal Anticoagulation Strategy for Cardioversion in Atrial Fibrillation

2015 ◽  
Vol 4 (1) ◽  
pp. 44 ◽  
Author(s):  
Philipp Bushoven ◽  
Sven Linzbach ◽  
Mate Vamos ◽  
Stefan H Hohnloser ◽  
◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Stroke Prevention ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Prospective Trial ◽  
Bleeding Complications ◽  
Order Of Magnitude ◽  
Pharmacological Cardioversion

For many patients with symptomatic atrial fibrillation, cardioversion is performed to restore sinus rhythm and relieve symptoms. Cardioversion carries a distinct risk for thromboembolism which has been described to be in the order of magnitude of 1 to 3 %. For almost five decades, vitamin K antagonist therapy has been the mainstay of therapy to prevent thromboembolism around the time of cardioversion although not a single prospective trial has formally established its efficacy and safety. Currently, three new direct oral anticoagulants are approved for stroke prevention in patients with non-valvular atrial fibrillation. For all three, there are data regarding its usefulness during the time of electrical or pharmacological cardioversion. Due to the ease of handling, their efficacy regarding stroke prevention, and their safety with respect to bleeding complications, the new direct oral anticoagulants are endorsed as the preferred therapy over vitamin K antagonists for stroke prevention in non-valvular atrial fibrillation including the clinical setting of elective cardioversion.

scholarly journals Biomarkers and antithrombotic treatment in cervical artery dissection – Design of the TREAT-CAD randomised trial

2020 ◽  
Vol 5 (3) ◽  
pp. 309-319
Author(s):  
Christopher Traenka ◽  
Henrik Gensicke ◽  
Sabine Schaedelin ◽  
Andreas Luft ◽  
Marcel Arnold ◽  
...  
Keyword(s):  
Magnetic Resonance Imaging ◽  
Magnetic Resonance ◽  
Vitamin K ◽  
Vitamin K Antagonists ◽  
Artery Dissection ◽  
Cervical Artery Dissection ◽  
Resonance Imaging ◽  
Antithrombotic Treatment ◽  
Data Set ◽  
Cervical Artery

Introduction The type of antithrombotic treatment in cervical artery dissection patients is still a matter of debate. Most physicians prefer anticoagulants over antiplatelet agents for stroke prevention. However, this approach is not evidence-based and antiplatelets might be as safe and as effective. The ‘Biomarkers and Antithrombotic Treatment in Cervical Artery Dissection’ (‘TREAT-CAD’) trial (clinicaltrials.gov: NCT02046460) compares Aspirin to oral anticoagulants (vitamin K antagonists) with regard to efficacy and safety by using both clinical and imaging surrogate outcome measures. TREAT-CAD tests the hypothesis, that aspirin is as safe and effective as vitamin K antagonists. Patients and methods TREAD-CAD is a Prospective, Randomised controlled, Open-labelled, multicentre, non-inferiority trial with Blinded assessment of outcome Events (PROBE-design). Key eligibility criteria are (i) clinical symptoms attributable to cervical artery dissection and (ii) verification of the cervical artery dissection diagnosis by established magnetic resonance imaging criteria. Patients are randomised to receive either Aspirin 300 mg daily or vitamin K antagonists for 90 days. Results Primary outcomes are assessed at 14 ± 10 days (magnetic resonance imaging and clinical examination) and at 90 ± 30 days (clinical examinations). The primary endpoint is a composite outcome measure – labelled Cerebrovascular Ischemia, major Hemorrhagic events or Death (CIHD) – and includes (i) occurrence of any stroke (including retinal infarction), (ii) new ischaemic lesions on diffusion-weighted magnetic resonance imaging, (iii) any major extracranial haemorrhage, (iv) any symptomatic intracranial haemorrhage, (v) any new haemorrhagic lesion visible on paramagnetic-susceptible sequences and (vi) death. Discussion After database closure, (i) central verification of cervical artery dissection diagnosis will be done by two experienced raters, (ii) adjudication of outcome events will be performed by independent adjudication committees, separately for clinical and imaging outcomes. The primary analysis will be done on the per protocol data set. The targeted sample size consists of 169 evaluable patients in the per protocol data set. Conclusion TREAT-CAD is testing the non-inferiority of Aspirin versus vitamin K antagonists treatment in patients with symptomatic cervical artery dissection by combined clinical and magnetic resonance imaging outcomes.

scholarly journals Ten years of non-vitamin K antagonists oral anticoagulants for stroke prevention in atrial fibrillation: is warfarin obsolete?

2020 ◽  
Vol 22 (Supplement_O) ◽  
pp. O28-O41
Author(s):  
Matthias Hammwöhner ◽  
Andreas Goette
Keyword(s):  
Atrial Fibrillation ◽  
Clinical Data ◽  
Vitamin K ◽  
Stroke Prevention ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Study Data ◽  
Phase Iii ◽  
Clinical Settings ◽  
Specific Patient

Abstract Currently, four non-vitamin K antagonists oral anticoagulants (NOACs) are available for stroke prevention in atrial fibrillation (AF). These have been in clinical use for up to 10 years now. Besides data of the initial phase III clinical trials, now clinical data, several sub-studies, meta-analyses, and studies in special clinical settings and specific patient populations are available. This review shall give an overview on the history of NOAC development, sum up study data and ‘real-world’ clinical data as well as discuss several special clinical settings like NOAC treatment in patients that require coronary artery stenting or cardioversion (CV). Furthermore, treatment considerations in special patient populations like patients with renal impairment, obesity, or patients requiring NOACs for secondary prevention are discussed. The significance of NOAC treatment will be discussed under consideration of the recently published 2020 ESC/EACTS Guidelines for the diagnosis and management of AF.

scholarly journals Real-World Setting Comparison of Nonvitamin-K Antagonist Oral Anticoagulants Versus Vitamin-K Antagonists for Stroke Prevention in Atrial Fibrillation

Stroke ◽  
2017 ◽  
Vol 48 (9) ◽  
pp. 2494-2503 ◽  
Author(s):  
George Ntaios ◽  
Vasileios Papavasileiou ◽  
Konstantinos Makaritsis ◽  
Konstantinos Vemmos ◽  
Patrik Michel ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Real World ◽  
Stroke Prevention ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Real World Setting

scholarly journals 2021 Korean Heart Rhythm Society Guidelines for Stroke Prevention in Atrial Fibrillation

2021 ◽  
Vol 96 (4) ◽  
pp. 296-311
Author(s):  
Ki Hong Lee ◽  
Jin-Bae Kim ◽  
Seung Yong Shin ◽  
Boyoung Joung
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Stroke Prevention ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Optimal Strategies ◽  
Mechanical Valve ◽  
Heart Rhythm ◽  
Bleeding Risk

Atrial fibrillation (AF) is a strong risk factor for ischemic stroke and systemic embolism. To prevent thromboembolic events in patients with AF, anticoagulation therapy is essential. The anticoagulant strategy is determined after stroke and bleeding risk assessments using the CHA2DS2-VASc and HAS-BLED scores, respectively; both consider clinical risk factors. Vitamin K antagonists (VKAs) are the sole anticoagulant option in AF patients with a prosthetic mechanical valve or moderate-severe mitral stenosis; in all other AF patients VKA or non-vitamin K antagonist oral anticoagulants are therapeutic options. However, antiplatelet therapy should not be used for stroke prevention in AF patients. Anticoagulation is not needed in AF patients with low stroke risk but strongly recommended in those with a with low bleeding risk. Left atrial appendage (LAA) occlusion offers an alternative in AF patients in whom long-term anticoagulation is contraindicated. Surgical occlusion or the exclusion of LAA can be considered for stroke prevention in AF patients undergoing cardiac surgery. In this article, we review existing data for stroke prevention and suggest optimal strategies to prevent stroke in AF patients.

scholarly journals DNR Linked to Reduced Depressive Symptoms in Nursing Home Residents During COVID-19 Illness

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 720-721
Author(s):  
Wingyun Mak ◽  
Orah Burack ◽  
Joann Reinhardt ◽  
Himali Weerahandi ◽  
Benjamin Canter ◽  
...  
Keyword(s):  
Nursing Home ◽  
Depressive Symptoms ◽  
Functional Status ◽  
Long Term Care ◽  
Nursing Home Residents ◽  
Do Not Resuscitate ◽  
Term Care ◽  
Data Set ◽  
Care Plans

Abstract Prior work shows that older adults who establish future care plans have a lower risk of depression. Residents in long-term care may benefit from establishing a do-not-resuscitate (DNR) order when cardiopulmonary resuscitation is unlikely to provide medical benefit. The current study examines whether having a DNR order in place prior to COVID-19 diagnosis was associated with fewer depressive symptoms during the illness course. Residents at a NYC skilled nursing facility with a positive COVID-19 PCR test between 3/1/2020 – 6/1/2020 were included (N=338). The Minimum Data Set (3.0) was used to examine residents’ Patient Health Questionnaire-9 (PHQ-9) scores 1-30 days after diagnosis, functional status, cognition, age, and sex. A retrospective chart review was conducted to determine whether participants had an established DNR, DNI, and/or DNH order before developing COVID-19. Forty-eight percent, 46%, and 12% of participants had a DNR, DNI, or DNH order prior to COVID-19 illness, respectively. Average PHQ-9 score was 1.65 (SD=2.37). A hierarchical regression showed that after controlling for age (β=-.13, p=.06), sex (β=-.08, p=.28), cognition (β=.14, p=.04), and functional status (β=.23, p=.001; R2=.10, p=.001), having a DNR (β=-.22, p=.006) order in place prior to COVID illness was associated with lower endorsement of depressive symptoms during illness (ΔR2=.04, p=.01). Results suggest that establishing a DNR in long-term care residents when appropriate may potentially buffer depressive symptoms during illness in nursing home residents regardless of their age, sex, cognitive abilities, and functional status. Future examination of the underlying mechanism is warranted.

Management of vitamin K antagonists in the elderly

2014 ◽  
Vol 72 (2) ◽  
pp. 185-192
Author(s):  
Tiphaine Belleville ◽  
Éric Pautas ◽  
Pascale Gaussem ◽  
Virginie Siguret
Keyword(s):  
Vitamin K ◽  
Vitamin K Antagonists ◽  
The Elderly
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