A Retrospective Study of Current Anticoagulant Use in Patients with Atrial Fibrillation: Results from a Managed Care Database.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 2246-2246
Author(s):  
Miranda Murray ◽  
Howard Friedman
Keyword(s):  
Risk Factors ◽  
Heart Failure ◽  
Atrial Fibrillation ◽  
Congestive Heart Failure ◽  
Managed Care ◽  
Anticoagulant Therapy ◽  
Transient Ischemic Attack ◽  
Clinical Care ◽  
Significant Risk ◽  
Ischemic Attack

Abstract The vitamin K antagonist warfarin is currently the mainstay of anticoagulant therapy for patients with atrial fibrillation (AF), in whom it has been shown to be effective in preventing stroke. However, it is underused because, despite the quality of clinical care, warfarin can be a difficult drug to manage well. When initiating therapy, patients may require several visits to a coagulation clinic to achieve an international normalized ratio (INR) within the safe and effective range (INR 2–3). Thereafter, frequent monitoring of patients receiving warfarin may still be required due to intrapatient variability. Despite the benefits, studies have shown that approximately 50% of patients who should receive warfarin are not prescribed it or do not receive it. This study was performed to investigate the use of warfarin in eligible patients with AF, for whom it was indicated. Using the US PharMetrics database from 51 managed care organizations, data entered between January 1997 and April 2004, from 5940 patients (>18 years of age with a diagnosis of AF [ICD 9] for whom warfarin was indicated), were analyzed. Patients were excluded if they were not in the database 30 days before and 120 days after their initial diagnosis of AF. Patients were divided into four distinct cohorts, based on treatment patterns: steady users (at least 3 months of warfarin use); discontinued users (used warfarin for only 3 months); non-users (warfarin use for <30 days); and intermittent users (used warfarin prior to first diagnosis of AF, or had less than two prescriptions). Analysis showed that only 31% (1854) of patients were steady users, whereas 59% (3521) of patients were non-users. Also, 4% (246) and 5% (319) of patients were discontinued users and intermittent users, respectively. In addition to a diagnosis of AF, many patients had significant risk factors for stroke: hypertension (48%); diabetes (23%); congestive heart failure (21%); age 75 or older (19%); history of stroke or transient ischemic attack (7%). However, the study showed that patients prescribed warfarin did not have more risk factors compared with long-term steady warfarin users and warfarin non-users (see table). Overall, this study shows that warfarin is underused, even in patients with significant risk factors for stroke, which highlights the need for new, simpler, oral anticoagulant therapy. Risk factors Total population [n (%)] Steady warfarin (%) Discontinued (%) Non-warfarin (%) Intermittent (%) NB Cumulative numbers of risk factors were constructed by assigning one point for each of the following: congestive heart failure; hypertension; age >75; diabetes; with two points added for prior stroke or transient ischemic attack 0 2036 (32) 32 29 36 34 1 1774 (30) 30 27 30 30 2 1197 (20) 22 23 19 23 3 623 (10) 11 13 10 8 4 204 (3) 3 4 4 4 5/6 106 (2) 2 3 1 1

P3797Increased risk of cardiovascular events and stroke among patients with atrial fibrillation and obstructive sleep apnea

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
F Dalgaard ◽  
R North ◽  
K Pieper ◽  
B A Steinberg ◽  
K W Mahaffey ◽  
...  
Keyword(s):  
Risk Factors ◽  
Heart Failure ◽  
Atrial Fibrillation ◽  
Obstructive Sleep Apnea ◽  
Sleep Apnea ◽  
Transient Ischemic Attack ◽  
Chronic Obstructive ◽  
Adjusted Risk ◽  
Obstructive Sleep ◽  
Ischemic Attack

Abstract Background Obstructive sleep apnea (OSA) is common in patients with atrial fibrillation (AF). It is not well understood if OSA impacts cardiovascular outcomes in patients with AF. Purpose To investigate patient characteristics and major adverse cardiovascular and neurological events (MACNE) in patients with AF and OSA. Methods Using the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF I) and ORBIT-AF II we compared the adjusted risk of the composite of cardiovascular death, myocardial infarction, stroke/transient ischemic attack/non-CNS embolism (stroke/SE), and new-onset heart failure (MACNE) according to the presence or absence of OSA, using multivariable adjusted Cox proportional hazard models. Secondary outcomes were the individual components of MACNE. Results Among 22,760 patients with AF, there were 4,045 (17.8%) with OSA at baseline. Median follow-up time was 1.5 (IQR: 1–2.2) years. OSA patients were younger (median [IQR] 68 [61–75] years vs. 74 [66–81] years, were more likely to be male (70.7% vs. 55.3%), and had markedly increased body mass index (BMI) (median 34.6 kg/m2 [29.8–40.2] vs. 28.7 kg/m2 [25.2–33.0]). Those with OSA had a higher prevalence of diabetes (39.2% vs. 25.2%), chronic obstructive pulmonary disease (COPD) (20% vs. 12%), heart failure (32.2% vs. 25.1%), and hyperlipidemia (73.2% vs. 66.7%). After adjustment, the presence of OSA was significantly associated with MACNE (HR: 1.16 [95% CI: 1.03–1.31], p=0.011) [Figure]. Stroke/SE was higher in patients with OSA (HR: 1.38 [95% CI 1.12–1.70], p=0.003). Addition of OSA to a model containing the CHA2DS2-VASc risk factors slightly improved discrimination for stroke/SE: CHA2DS2-VASc risk factors alone C-index (Standard Error) was 0.6867 (0.0125) vs. CHA2DS2-VASc risk factors plus OSA 0.6876 (0.0124), p=0.022. Figure 1. Hazard ratios with 95% confidence intervals and event rates for the association between obstructive sleep apnea and major adverse cardiovascular and neurological events combined and separately. Abbreviations: OSA; obstructive sleep apnea MACNE; major adverse cardiovascular and neurological events, CV; cardiovascular, TIA; transient ischemic attack. Conclusion One in five patients with AF in community practice had OSA. The presence of OSA was associated with higher risk of MACNE and stroke/SE. Addition of OSA to CHA2DS2-VASc risk factors only slightly improved discrimination for the occurrence of stroke. Acknowledgement/Funding The Danish Heart Foundation, T32 NIH Grant HL079896. The ORBIT-AF registry is sponsored by Janssen.

scholarly journals A Clinical Score for Predicting Atrial Fibrillation in Patients with Cryptogenic Stroke or Transient Ischemic Attack

Cardiology ◽  
2017 ◽  
Vol 138 (3) ◽  
pp. 133-140 ◽  
Author(s):  
Calvin Kwong ◽  
Albee Y. Ling ◽  
Michael H. Crawford ◽  
Susan X. Zhao ◽  
Nigam H. Shah
Keyword(s):  
Atrial Fibrillation ◽  
Transient Ischemic Attack ◽  
Cryptogenic Stroke ◽  
Significant Risk ◽  
Area Under The Curve ◽  
Clinical Score ◽  
Risk Groups ◽  
Therapeutic Implications ◽  
Using Data ◽  
Ischemic Attack

Objectives: Detection of atrial fibrillation (AF) in post-cryptogenic stroke (CS) or transient ischemic attack (TIA) patients carries important therapeutic implications. Methods: To risk stratify CS/TIA patients for later development of AF, we conducted a retrospective cohort study using data from 1995 to 2015 in the Stanford Translational Research Integrated Database Environment (STRIDE). Results: Of the 9,589 adult patients (age ≥40 years) with CS/TIA included, 482 (5%) patients developed AF post CS/TIA. Of those patients, 28.4, 26.3, and 45.3% were diagnosed with AF 1-12 months, 1-3 years, and >3 years after the index CS/TIA, respectively. Age (≥75 years), obesity, congestive heart failure, hypertension, coronary artery disease, peripheral vascular disease, and valve disease are significant risk factors, with the following respective odds ratios (95% CI): 1.73 (1.39-2.16), 1.53 (1.05-2.18), 3.34 (2.61-4.28), 2.01 (1.53-2.68), 1.72 (1.35-2.19), 1.37 (1.02-1.84), and 2.05 (1.55-2.69). A risk-scoring system, i.e., the HAVOC score, was constructed using these 7 clinical variables that successfully stratify patients into 3 risk groups, with good model discrimination (area under the curve = 0.77). Conclusions: Findings from this study support the strategy of looking longer and harder for AF in post-CS/TIA patients. The HAVOC score identifies different levels of AF risk and may be used to select patients for extended rhythm monitoring.

scholarly journals Development and Validation of a Risk Score Model for Predicting the Cardiovascular Outcomes After Breast Cancer Therapy: The CHEMO‐RADIAT Score

2021 ◽  
Author(s):  
Do Young Kim ◽  
Myung‐Soo Park ◽  
Jong‐Chan Youn ◽  
Sunki Lee ◽  
Jae Hyuk Choi ◽  
...  
Keyword(s):  
Risk Factors ◽  
Myocardial Infarction ◽  
Heart Failure ◽  
Cardiovascular Risk ◽  
Transient Ischemic Attack ◽  
Left Breast ◽  
Major Adverse Cardiovascular Events ◽  
Score Model ◽  
Ischemic Attack ◽  
Anthracycline Dose

Background Cardiovascular disease is an important cause of mortality among survivors of breast cancer (BC). We developed a prediction model for major adverse cardiovascular events after BC therapy, which is based on conventional and BC treatment‐related cardiovascular risk factors. Methods and Results The cohort of the study consisted of 1256 Asian female patients with BC from 4 medical centers in Korea and was randomized in a 1:1 ratio into the derivation and validation cohorts. The outcome measures comprised cardiovascular mortality, myocardial infarction, congestive heart failure, and transient ischemic attack/stroke. To correct overfitting, a penalized Cox proportional hazards regression was performed with a cross‐validation approach. Number of cardiovascular diseases (myocardial infarction, peripheral artery disease, heart failure, and transient ischemic attack/stroke), number of baseline cardiovascular risk factors (hypertension, age ≥60, body mass index ≥30 kg/m 2 , estimated glomerular filtration rate <60 mL/min per 1.73 m 2 , dyslipidemia, and diabetes mellitus), radiation to the left breast, and anthracycline dose per 100 mg/m 2 were included in the risk prediction model. The time‐dependent C‐indices at 3 and 7 years after BC diagnosis were 0.876 and 0.842, respectively, in the validation cohort. Conclusions A prediction score model, including BC treatment‐related risk factors and conventional risk factors, was developed and validated to predict major adverse cardiovascular events in patients with BC. The CHEMO‐RADIAT (congestive heart failure, hypertension, elderly, myocardial infarction/peripheral artery occlusive disease, obesity, renal failure, abnormal lipid profile, diabetes mellitus, irradiation of the left breast, anthracycline dose, and transient ischemic attack/stroke) score may provide overall cardiovascular risk stratification in survivors of BC and can assist physicians in multidisciplinary decision‐making regarding the BC treatment.

scholarly journals Diagnostic Accuracy of the HAS-BLED Bleeding Score in VKA- or DOAC-Treated Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis

2021 ◽  
Vol 8 ◽  
Author(s):  
Xinxing Gao ◽  
Xingming Cai ◽  
Yunyao Yang ◽  
Yue Zhou ◽  
Wengen Zhu
Keyword(s):  
Diabetes Mellitus ◽  
Heart Failure ◽  
Atrial Fibrillation ◽  
Congestive Heart Failure ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Risk Scores ◽  
C Statistic ◽  
Ischemic Attack ◽  
Anticoagulated Patients

Background: Several bleeding risk assessment models have been developed in atrial fibrillation (AF) patients with oral anticoagulants, but the most appropriate tool for predicting bleeding remains uncertain. Therefore, we aimed to assess the diagnostic accuracy of the Hypertension, Abnormal liver/renal function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs/alcohol concomitantly (HAS-BLED) score compared with other risk scores in anticoagulated patients with AF.Methods: We comprehensively searched the PubMed and Embase databases until July 2021 to identify relevant pieces of literature. The predictive abilities of risk scores were fully assessed by the C-statistic, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) values, calibration data, and decision curve analyses.Results: A total of 39 studies met the inclusion criteria. The C-statistic of the HAS-BLED score for predicting major bleeding was 0.63 (0.61–0.65) in anticoagulated patients regardless of vitamin k antagonists [0.63 (0.61–0.65)] and direct oral anticoagulants [0.63 (0.59–0.67)]. The HAS-BLED had the similar C-statistic to the Hepatic or renal disease, Ethanol abuse, Malignancy, Older, Reduced platelet count or function, Re-bleeding risk, Hypertension (uncontrolled), Anemia, Genetic factors, Excessive fall risk, Stroke (HEMORR2HAGES), the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA), the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT), the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF), or the Age, Biomarkers, Clinical History (ABC) scores, but significantly higher C-statistic than the Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, Stroke/transient ischemic attack history (CHADS2) or the Congestive heart failure/left ventricular ejection fraction ≤ 40%, Hypertension, Age ≥75 years, Diabetes mellitus, Stroke/transient ischemic attack/thromboembolism history, Vascular disease, Age 65–74 years, Sex (female) (CHA2DS2-VASc) scores. NRI and IDI values suggested that the HAS-BLED score performed better than the CHADS2 or the CHA2DS2-VASc scores and had similar or superior predictive ability compared with the HEMORR2HAGES, the ATRIA, the ORBIT, or the GARFIELD-AF scores. Calibration and decision curve analyses of the HAS-BLED score compared with other scores required further assessment due to the limited evidence.Conclusion: The HAS-BLED score has moderate predictive abilities for bleeding risks in patients with AF regardless of type of oral anticoagulants. Current evidence support that the HAS-BLED score is at least non-inferior to the HEMORR2HAGES, the ATRIA, the ORBIT, the GARFIELD-AF, the CHADS2, the CHA2DS2-VASc, or the ABC scores.

Abstract 12978: Incident Atrial Fibrillation is Similar in Blacks and Whites With Congestive Heart Failure

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Parin J Patel ◽  
Yuliya Borovskiy ◽  
Anthony Killian ◽  
Francis E Marchlinski ◽  
Rajat Deo
Keyword(s):  
Risk Factors ◽  
Heart Failure ◽  
Atrial Fibrillation ◽  
Congestive Heart Failure ◽  
University Of Pennsylvania ◽  
Common Finding ◽  
Event Analysis ◽  
Black Race ◽  
Blacks And Whites

Introduction: Clinical studies have demonstrated that blacks have a lower prevalence and incidence of atrial fibrillation (AF) compared with whites. Given the strong biologic associations between AF and congestive heart failure (CHF), we hypothesized that the racial disparity for incident AF is attenuated in CHF patients. Methods: The University of Pennsylvania Atrial Fibrillation Free-Congestive Heart Failure (PAFF-CHF) Cohort is a large, multi-hospital retrospective cohort of individuals with clinical CHF and without AF at index visit. Baseline demographic and clinical parameters were obtained, and medical records were queried for incident outcomes. The primary outcome was incident AF, which was defined as a clinical or ECG diagnosis of AF on any follow up encounter. Results: Of 5,131 patients in PAFF-CHF, there were 2,037 blacks (40%) and 3,094 whites (60%). Median follow up time was 4.5 years (1.8, 5.9), with blacks having significantly longer follow up (4.7 v 4.2 yr, p < 0.001). During this follow-up, 851 subjects (16%) developed AF, with rates of 5.1 per 100 person years in whites and 4.9 per 100 person years in blacks (p = 0.8). Time independent risk factors for developing AF included male gender (OR 1.42 [95% CI 1.22 - 1.65], p < 0.001); LBBB on index ECG (1.32 [1.01 - 1.72], p = 0.04); and black race (OR 1.31 [1.13 - 1.52], p < 0.001). In a regression model of traditional risk factors for AF including age, gender, hypertension, coronary artery disease, diabetes, and renal insufficiency, black race remained an independent risk factor for AF (OR 1.45 [1.23 - 1.70], p < 0.001). Finally, time to event analysis showed no difference in freedom from AF and no difference in freedom from AF or death (Figure). Conclusions: In a large cohort of HF patients, incident AF was similar in blacks and whites. Although prior studies have indicated a low prevalence and incidence of AF in blacks compared with whites, the development of AF appears to be a common finding in both races after a diagnosis of CHF.

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