Abstract 14763: Patients With a Perceived High-bleeding Risk in a Randomized Controlled Trial of Alert-based Computerized Decision Support for Stroke Prevention in Atrial Fibrillation: An Af-Alert Substudy

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Gregory Piazza ◽  
Shelley Hurwitz ◽  
Brett Carroll ◽  
Samuel Z Goldhaber
Keyword(s):  
Atrial Fibrillation ◽  
High Risk ◽  
Stroke Prevention ◽  
Antithrombotic Therapy ◽  
Controlled Trial ◽  
Bleeding Risk ◽  
Computerized Decision Support ◽  
Risk Of Bleeding ◽  
Randomized Controlled ◽  
Risk For Bleeding

Introduction: A perceived increased risk of bleeding is one of the most frequent reasons for failure to prescribe anticoagulation for stroke prevention in atrial fibrillation (AF). We previously conducted a randomized controlled trial of alert-based computerized decision support (CDS) to increase prescription of antithrombotic therapy in 458 high-risk hospitalized patients with AF who were not being anticoagulated. Hypothesis: We hypothesized that patients with a perceived high risk for bleeding would have a similar HAS-BLED score and rate of major and clinically-relevant non-major bleeding. Methods: To determine the clinical characteristics and outcomes of these patients determined to be high-risk for bleeding, we analyzed the 248 patients in the alert group. Results: A perceived high risk of bleeding was the most common reason (77%) for omitting antithrombotic therapy. Median HAS-BLED scores were similar in these patients compared with those who were not deemed to have an increased bleeding risk (3 vs. 3, p=0.44). Despite being categorized as too high-risk for bleeding to receive antithrombotic therapy for stroke prevention at the time of the alert, nearly 12% of these patients were ultimately prescribed anticoagulation over the ensuing 90 days. The frequency of major and clinically-relevant non-major bleeding was similar between the two groups. Conclusions: In conclusion, a perceived high risk of bleeding was the most common reason for failure to prescribe antithrombotic therapy after the CDS alert. History of a prior bleeding event or underlying bleeding disorder was not reflected in a higher HAS-BLED score. Implementation of an alert-based CDS with specific attention to assessment of bleeding risk and mitigation warrants further study to encourage adherence to evidence-based clinical practice guideline recommendations for stroke prevention in AF.

scholarly journals Gastrointestinal Endoscopy in Patients Receiving Antithrombotic Therapy

2021 ◽  
Vol 22 (2) ◽  
pp. 134-139
Author(s):  
Supriadi Supriadi ◽  
Titong Sugihartono
Keyword(s):  
High Risk ◽  
Antithrombotic Therapy ◽  
Gastrointestinal Endoscopy ◽  
Bleeding Risk ◽  
Thromboembolic Events ◽  
Antithrombotic Agents ◽  
Therapeutic Tool ◽  
Minimum Duration ◽  
Risk Of Bleeding ◽  
Risk For Bleeding

Gastrointestinal endoscopy is used as a diagnostic and therapeutic tool. Patients receiving antithrombotic agents are at higher risk for bleeding in this procedure. Regarding its thromboembolic versus bleeding risk, physicians should consider to adjust antithrombotic therapy in patients undergoing gastrointestinal endoscopy. Some important factors including the urgency of the procedure, bleeding risk from the procedure and antithrombotic itself, and the risk of thromboembolic events during endoscopy if antithrombotic is to be stopped need to be considered wisely. Based on recommendations of ASGE, ESGE, and BSG, endoscopic procedures were divided based on the level of emergency, namely elective and urgent. In elective endoscopy with high risk of bleeding and thromboembolism, antithrombotic therapy is given in the minimum duration required and then discontinued before the procedure. In elective endoscopy with low risk of bleeding and thromboembolism, antithrombotic can be continued as usual. In urgent endoscopy due to gastrointestinal bleeding, all antithrombotic should be discontinued. Antithrombotic can be restarted within 48 hours after the procedure if no bleeding is evident

scholarly journals Changes in Antithrombotic Therapy of Atrial Fibrillation in the Hospital in 2011-2012 and 2016-2017 (Pharmacoepidemiological Analysis)

2020 ◽  
Vol 16 (5) ◽  
pp. 686-692
Author(s):  
O. V. Reshetko ◽  
A. V. Sokolov ◽  
N. V. Furman ◽  
V. V. Agapov
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
High Risk ◽  
Antithrombotic Therapy ◽  
Heart Defects ◽  
Oral Anticoagulants ◽  
Prosthetic Heart Valve ◽  
Saratov Region ◽  
Coronary Syndrome ◽  
Risk Of Bleeding

Aim. To study the changes that have occurred in the pharmacotherapy of atrial fibrillation (AF) in the Saratov Region for 5 years by analyzing the antithrombotic therapy of patients who were admitted in a specialized department of the multidisciplinary hospital in Saratov in 2011-2012 and in 2016-2017.Material and methods. A pharmacoepidemiological retrospective study was conducted. The object of the study was the medical records of inpatients (Form 003/y) with the diagnosis “Atrial fibrillation” (ICD-X code I48), that consecutively admitted to the cardiology department of the multidisciplinary hospital in Saratov from January 1, 2011 to December, 31, 2012 (n=211) and from January 1, 2016 to December, 31, 2017 (n=227). Criteria for inclusion in the study: patients over 18 years of age, established diagnosis of non-valvular AF of ischemic genesis. Exclusion criteria from the study: non-ischemic cardiomyopathy, thyrotoxicosis, congenital heart defects, rheumatic heart damage, acute coronary syndrome, endocarditis, myocarditis, pericarditis, pulmonary thromboembolism, the presence of prosthetic heart valve. Pharmacoepidemiological analysis was carried out for the drugs prescribed during hospitalization and given by doctors at discharge of patients from the hospital. The risk of ischemic stroke was assessed using the CHA2DS2-VASc score, and the risk of bleeding – according to the HAS-BLED score.Results. When analyzing the risk of ischemic stroke, it was found that 100% of patients in 2011-2012 years and 98.2% in 2016-2017 years had indications for the prescription of oral anticoagulants (OAСs). In 2011-2012 there were no patients with a low risk of stroke (CHA2DS2-VASc=0). High risk of bleeding (HAS-BLED≥3) occurred in 4.7% of patients in 2011-2012 and in 10.6% in 2016-2017, however, due to the high risk of stroke, the refusal to prescribe OAC in these patients was inappropriate in accordance with the recommendations for the treatment of AF. In the group of patients with CHA2DS2-VASc=0 in 2016-2017 antiplatelet therapy was prescribed in 100% at the hospital stage and at discharge, which contradicts the guidelines, according to which antithrombotic therapy is not recommended to patients with CHA2DS2-VASc=0. In patients with CHA2DS2-VASc=1, a low percentage of anticoagulants prescription was noted. In 2016-2017 OACs were prescribed only in 12.5% of patients at all stages of observation. In 2011-2012 OAC alone was prescribed only to 1 person (20%) at the hospital stage, which does not comply with modern guidelines for the treatment of patients with AF, according to which patients with a risk score CHA2DS2-VASc=1 are recommended to receive OACs in the absence of contraindications. OACs prescription in group CHA2DS2-VASc≥2 occurred only in 15% of patients in 2011-2012 and in a third of patients in 2016-2017 (p<0.05). The frequency of isolated use of OACs significantly increased in 2016-2017 compared to 2011-2012 mainly due to the increase in the spectrum of direct OACs (DOACs) (p<0.05).Conclusion. For 5 years there have been significant changes in the antithrombotic therapy of AF in the Saratov Region. The frequency of prescribing OACs according to indications has increased mainly due to the introduction of the DOACs into clinical practice. However, prevention of stroke remains insufficient.

scholarly journals Antithrombotic therapy in patients with atrial fibrillation and percutaneous coronary intervention: what has changed in the guidelines in 2020?

2020 ◽  
pp. 56-64
Author(s):  
E. P. Panchenko
Keyword(s):  
Atrial Fibrillation ◽  
Percutaneous Coronary Intervention ◽  
High Risk ◽  
Stent Thrombosis ◽  
Antithrombotic Therapy ◽  
Oral Anticoagulants ◽  
Coronary Intervention ◽  
Antiplatelet Drug ◽  
Risk Of Bleeding ◽  
Percutaneous Coronary

The article presents an analytical review of the studies aimed at determining the optimal antithrombotic therapy in patients with atrial fibrillation undergoing elective or emergency percutaneous coronary intervention (PCI) due to the development of acute coronary syndrome (ACS). The results of the WOEST study are analysed. This study was the first to demonstrate an opportunity to safely discontinue administration of aspirin as part of the multicomponent antithrombotic therapy that included warfarin as an anticoagulant. Three studies were analysed - PIONEER AF-PCI, RE-DUAL-PCI and AUGUSTUS, where direct oral anticoagulants (DOACs) - rivaroxaban, dabigatran and apixaban were used as anticoagulants as part of the multicomponent therapy. The results of these studies formed the backbone of the updated European guidelines for the diagnosis and treatment of atrial fibrillation, 2020. The guidelines offer to divide patients with AF and ACS, who require multicomponent antithrombotic therapy, into two categories. The first group includes AF patients with uncomplicated PCI without a high risk of stent thrombosis, as well as patients with a risk of bleeding that prevails over the risk of stent thrombosis. The second category of patients, in contrast, is characterized by a high risk of stent thrombosis, which prevails over the risk of bleeding. In the absence of contraindications, the patients of both categories should choose DOAC as an anticoagulant and be prescribed clopidogrel as a P2Y12 inhibitor for 12 months. In AF patients with uncomplicated PCI without a high risk of stent thrombosis, as well as in patients with a risk of bleeding, which prevails over the risk of stent thrombosis, the period of treatment with the second antiplatelet drug (aspirin) should belimited to the hospital stay. Patients at increased risk of stent thrombosis and reduced risk of bleeding can extend the aspirin therapy for 1 month. The approaches to the choice of the duration and composition of the multicomponent antithrombotic therapy in AF patients taking oral anticoagulants after elective PCI are similar to those in ACS patients, except for the duration of clopidogrel therapy, which is reduced to 6 months in all patients.

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