scholarly journals Which scores should use cardiologist to predict outcomes in patients with nonvalvular atrial fibrillation?

2020 ◽  
Vol 29 (4) ◽  
pp. 5-16
Author(s):  
S. Moiseev
Keyword(s):  
Atrial Fibrillation ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Nonvalvular Atrial Fibrillation ◽  
High Bleeding Risk ◽  
Medical University ◽  
Risk Symptom

Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia Management of patients with atrial fibrillation (AF) includes anticoagulation for prevention of stroke and systemic embolism, improvement of AF-related symptoms by rate or rhythm control, and treatment for cardiovascular and other comorbidities. The structured characterization of AF should address four AF-related domains, that is, stroke risk, symptom severity, AF burden (type of AF, number and duration of episodes, etc.), and substrate severity. Various scores, i.e.CHA 2 DS 2 -VASc (stroke risk), HAS-BLED (bleeding risk), EHRA (severity of AF-related symptoms), and 2MACE (risk of cardiovascular events), can be used to estimate the risk of outcomes and for treatment decisions. Noteworthy, bleeding risk assessment using HAS-BLED score focuses attention on modifiable risk factors that should be managed to improve safety of anticoagulation, whereas a high bleeding risk score should not lead to withholding oral anticoagulants. New clini- cal and biomarker-based risk scores were developed. However, their potential advantages over existing scores should be confirmed in clinical studies.

Stand-Alone Thoracoscopic Left Atrial Appendage Closure in Nonvalvular Atrial Fibrillation Patients at High Bleeding Risk

2020 ◽  
Vol 15 (6) ◽  
pp. 541-546
Author(s):  
Marco Franciulli ◽  
Giuseppe De Martino ◽  
Mariateresa Librera ◽  
Ahmed Desoky ◽  
Antonio Mariniello ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Left Atrial ◽  
Left Atrial Appendage ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Atrial Appendage ◽  
Nonvalvular Atrial Fibrillation ◽  
High Bleeding Risk ◽  
Laa Closure

Objective In nonvalvular atrial fibrillation (AF) patients at high bleeding risk, oral anticoagulants (OAC) may be contraindicated, and percutaneous left atrial appendage (LAA) closure has been advocated. However, following percutaneous procedure, either OAC or dual antiplatelet treatment is required. In this study, we present our experience in treating nonvalvular AF patients at high bleeding risk with thoracoscopic LAA closure with no subsequent antithrombotic therapy. Methods From April 2019 to January 2020, 20 consecutive AF patients, mean age 75.1 years, 16 (80%) males, underwent thoracoscopic LAA closure as a stand-alone procedure, using an epicardial clip device. OAC and antiplatelet therapy were contraindicated. Mean CHA2DS2-VASc score was 3.61, and the mean HAS-BLED score was 4.42. Successful LAA closure was assessed by transesophageal echocardiography. Primary endpoints were complete LAA closure (no residual LAA flow), operative complications, and all-cause mortality; secondary endpoints were 30-day and 6-month complications (death, ischemic stroke, hemorrhagic stroke, transient ischemic attack, any bleeding). Mean follow-up was 6 ± 4 months. Results Complete LAA closure was achieved in all patients. No operative clip-related complications or deaths occurred. At follow-up, freedom from postoperative complications was 95% and from any cerebrovascular events was 100%. Overall survival rate was 100%. Conclusions In nonvalvular AF patients at high bleeding risk (HAS-BLED score >3), thoracoscopic LAA closure appears to be a valid alternative to percutaneous techniques not requiring dual antiplatelet or OAC treatment. Apparently, external LAA clipping minimizes the risk of thromboembolic events as compared with percutaneous procedures.

Abstract 169: The Role Of Clinical Prediction Factors On Anticoagulant Selection In Atrial Fibrillation

2014 ◽  
Vol 7 (suppl_1) ◽  
Author(s):  
Julie Lauffenburger
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Patient Characteristics ◽  
Treatment Selection ◽  
Risk Scores ◽  
Treatment Benefit ◽  
Risk Treatment

Background: Atrial fibrillation (AF) often benefits from the use of anticoagulants for prevention of stroke or systemic embolism. While novel oral anticoagulants have emerged as possible alternatives to warfarin, it is unknown how treatment selection is determined in practice with clinical guidelines still evolving. This study examined whether and to what extent anticoagulant selection has been driven by clinical predictions of stroke risk (treatment benefit) and bleeding risk (treatment harm) in real-world practice in the US. Methods: A nationwide database of commercial and Medicare Part D supplement claims from 2009-2011 was used to extract a cohort of non-valvular AF patients who were newly-initiating therapy after dabigatran availability in Oct 2010. Patients were excluded if they had claims associated with a reversible AF condition. Risk scores of ischemic stroke (CHADS2 and CHA2DS2-VASc) and bleeding (ATRIA) were used to examine associations with either warfarin or dabigatran use, calculated via claims in the outpatient pharmaceutical, inpatient medical, outpatient, and provider claims files. Baseline demographic and clinical characteristics were also measured as covariates, including concomitant diseases and medications. Multivariable log-binomial regression models assessed the association between each risk score and anticoagulant use, adjusting for the measured covariates. C-statistics were also used to examine the variation in treatment selection explained by inclusion of the risk scores. Results: In total, 37,401 patients were identified with 31% initiating dabigatran. New users of dabigatran were more likely to be younger, male, and have comorbidities. Patients at intermediate stroke risk (CHADS2 or CHA2DS2-VASc =1) were equally likely to receive warfarin and dabigatran (RR, 95% CI: 0.98, 0.93-1.02), while selection for warfarin was significantly associated with high ischemic stroke risk (CHADS2 or CHA2DS2-VASc ≥2) (RR, 95% CI: 0.87, 0.83-0.92). New users of dabigatran were significantly less likely to have high bleeding risk (ATRIA≥5) versus warfarin (RR, 95%: 0.70, 0.66-0.74). The c-statistic of the base model, which included the other measured covariates, was only marginally increased with the addition of any of the risk scores. Conclusions: Despite controlling for other patient characteristics, bleeding risk was strongly associated with the selection of a specific anticoagulant. However, the extent of selection explained by predictions of treatment harm was minimal. Providers appear to base anticoagulant selection on factors other than predictions of treatment benefit, which has implications for studying the anticoagulants’ comparative effectiveness.

Comparison of Bleeding Risk Scores in Patients With Nonvalvular Atrial Fibrillation Starting Direct Oral Anticoagulants

2017 ◽  
Vol 70 (10) ◽  
pp. 878-880
Author(s):  
César Caro Martínez ◽  
José Manuel Andreu Cayuelas ◽  
Pedro José Flores Blanco ◽  
Mariano Valdés ◽  
José Luis Bailén Lorenzo ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Nonvalvular Atrial Fibrillation

scholarly journals Impact of a Computerized Antithrombotic Risk Assessment Tool on the Prescription of Thromboprophylaxis in Atrial Fibrillation: Hospital Setting

2016 ◽  
Vol 24 (1) ◽  
pp. 85-92 ◽  
Author(s):  
E. Pandya ◽  
N. Masood ◽  
Y. Wang ◽  
I. Krass ◽  
B. Bajorek
Keyword(s):  
Atrial Fibrillation ◽  
Risk Assessment ◽  
Stroke Risk ◽  
Assessment Tool ◽  
Oral Anticoagulants ◽  
Hospital Setting ◽  
Bleeding Risk ◽  
Risk Assessment Tool ◽  
Treatment Recommendation ◽  
Nonvalvular Atrial Fibrillation

The computerized antithrombotic risk assessment tool (CARAT) is an online decision-support algorithm that facilitates a systematic review of a patient’s stroke risk, bleeding risk, and pertinent medication safety considerations, to generate an individualized treatment recommendation. The CARAT was prospectively applied across 2 hospitals in the greater Sydney area. Its impact on antithrombotics utilization for thromboprophylaxis in patients with nonvalvular atrial fibrillation was evaluated. Factors influencing prescribers’ treatment selection were identified. The CARAT recommended a change in baseline therapy for 51.8% of patients. Among anticoagulant-eligible patients (ie, where the risk of stroke outweighed the risk of bleeding) using “nil therapy” or antiplatelet therapy at baseline, the CARAT recommended an upgrade to warfarin in 60 (30.8%) patients. For those in whom the bleeding risk outweighed the stroke risk, the CARAT recommended a downgrade from warfarin to safer alternatives (eg, aspirin) in 37 (19%) patients. Among the “most eligible” (ie, high stroke risk, low bleeding risk, no contraindications; n = 75), the CARAT recommended warfarin for all cases. Discharge therapy observed a marginal increase in anticoagulation prescription in eligible patients (n = 116; 57.8% vs 64.7%, P = .35) compared to baseline. Predictors of warfarin use (vs antiplatelets) included congestive cardiac failure, diabetes mellitus, and polypharmacy. The CARAT was able to optimize the selection of therapy, increasing anticoagulant use among eligible patients. With the increasing complexity of decision-making, such tools may be useful adjuncts in therapy selection in atrial fibrillation. Future studies should explore the utility of such tools in selecting therapies from within an expanded treatment armamentarium comprising the non-vitamin K antagonist oral anticoagulants.

scholarly journals Improvement of the management of anticoagulation in Atrial Fibrillation patients in the emergency and acute medical departments; a service quality improvement report

2021 ◽  
Vol 2 (3) ◽  
pp. 18-24
Author(s):  
Amr Elkammash ◽  
Yosra Taha ◽  
Saleh Kanaan ◽  
Martin Taylor
Keyword(s):  
Atrial Fibrillation ◽  
Quality Improvement ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Junior Doctors ◽  
Improvement Project ◽  
Risk Of Bleeding

Atrial fibrillation (AF) is considered one of the main causes of ischemic stroke. The CHA2DS2VASC score can predict the stroke risk. Proper anticoagulation can significantly reduce such risk. Anticoagulation involves a risk of bleeding, which can be predicted by the HAS-BLED score. The non-documentation of both AF risk scores in the medical notes of patients presenting with acute or paroxysmal AF has alerted our team, for fear of missing administering the proper anticoagulation. A baseline audit showed that the CHA2DS2VASC score was documented in 27% of such patients, while the HAS-BLED score was documented in 5% of them. A quality improvement project was planned and included two PDSA cycles over a period of five months. The first cycle was based on raising the awareness of the junior doctors on risk assessment of AF patients and the importance of anticoagulation prescription. This involved educational posters, emails, and presentations. On the second cycle, the baseline audit showed a 69% improvement (from 27% to 46%) in the rate of CHA2DS2VASC score assessment and a 140% improvement (from 5% to 12%) in the rate of HAS-BLED scoring. However, the rate of anticoagulation prescription remained almost the same in both cycles (55% and 52%). A doctors’ survey showed that they are not quite comfortable prescribing long-term anticoagulation on acute care units because of the inadequate assessment of the bleeding risk, and the associated comorbidities that can disturb the action of the oral anticoagulants. They preferred to refer the patient to a specialised AF clinic for further assessment and prescription. On auditing the patient referral on discharge, it was found that 91% of the patient were seen at the AF clinic in 2 weeks. The remainders were referred to their GP for further assessment and prescription. That seemed to be a safer way of anticoagulation prescription for such patients.

Abstract 18538: The ATRIA Stroke Risk Score Predicts Ischemic Stroke Better than CHADS2 and CHA2DS2-VASc in a large Swedish Cohort of Patients with Atrial Fibrillation

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Sara Aspberg ◽  
Yuchiao Chang ◽  
Daniel Singer
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Risk Score ◽  
Stroke Risk ◽  
Anticoagulation Therapy ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Cut Points ◽  
Net Clinical Benefit ◽  
Better Than

Introduction: Atrial fibrillation (AF) is a major risk factor for acute ischemic stroke (AIS). Anticoagulation therapy (OAC) effectively prevents AIS, but increases bleeding risk. There is a need for better AIS risk prediction to optimize the anticoagulation decision in AF. The ATRIA stroke risk score (ATRIA) (table) was superior to CHADS2 and CHA2DS2-VASc in two large California community AF cohorts. We now report the performance of the 3 scores in a very large Swedish AF cohort. Methods: The cohort consisted of all Swedish patients hospitalized with a diagnosis of AF from July 1, 2005 to December 31, 2008. Predictor variables and the outcome, AIS, were obtained from inpatient ICD-10 codes. Warfarin use was determined from National Pharmacy Database. Risk scores were assessed via c-index (C) and net reclassification index (NRI). Results: The cohort included 158,370 AF patients off warfarin who contributed 340,332 person-years of follow-up, and 11,823 incident AIS, for an overall AIS rate of 3.47%/yr, higher than the 2%/yr seen in the California cohorts. Using the entire point score, ATRIA had a good C of 0.712 (0.708-0.716), significantly better than CHADS2, 0.694 (0.689-0.698), or CHA2DS2-VASc, 0.697 (0.693-0.702). Using published cut-points for Low/Moderate/High AIS risk, C deteriorated for all scores but ATRIA and CHADS2 were superior to CHA2DS2-VASc. NRI favored ATRIA; 0.16 (0.15-0.18) versus CHADS2; 0.22 (0.21-0.24) versus CHA2DS2-VASc. However, NRI decreased to near-zero when cut-points were altered to better fit the cohort’s stroke rates. Conclusion: Findings in this large Swedish AF cohort validate those in the California AF cohorts, with the ATRIA score predicting stroke risk better than CHADS2 or CHA2DS2-VASc. However, relative performance of the categorical scores varied by population stroke risk. Knowledge about this population risk may be needed to optimize cut-points on the multipoint scores to achieve better net clinical benefit from OAC.

Abstract 140: Comparison of Major Complication of Oral Anticoagulants in Non-Valvular Atrial Fibrillation: Systematic Review and Meta-Analyses

2017 ◽  
Vol 37 (suppl_1) ◽  
Author(s):  
Hong Seok Lee
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Major Bleeding ◽  
Oral Anticoagulant ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Gi Bleeding ◽  
Ischemic Stroke Risk ◽  
Meta Analyses

Background: Oral anticoagulants known as a novel oral anticoagulant have been used for the management of non -valvular atrial fibrillation. There was no enough study regarding the efficacy and safety of three major new oral anticoagulants. We assessed major three oral anticoagulants in terms of major bleeding complication and stroke prevention by meta-analyses studies comparing those drugs. Method: Relevant studies were identified through electronic literature searches of MEDLINE, EMBASE, Cochrane library, and clinicaltrials.gov (from inception to February 24, 2016). RevMan and ITC software were used for direct comparisons, respectively. Results: Apixaban (N=6020), versus dabigatran(N=12038), apixaban versus rivaroxaban(N=8503) and rivaroxaban versus dabigatran were analyzed directly. There was significantly higher major bleeding risks in apixaban compared to dabigatran (both 110mg and 150mg) after adjusting baseline bleeding risk (Relative risk 3.41, 95% confidence interval(2.61 to 4.47) in 110mg, (5.62, 4.83 to 6.54) in 150mg. Intracranial bleeding risk in apixaban was significantly higher than in dabigatran (10.5, 6.10 to18.01). However, apixaban had less GI bleeding risk compared to dabigatran (0.80 , 0.65 to 0.98) and also had less ischemic stroke risk (0.31,0.22 to 0.42). Rivaroxaban showed higher major bleeding risk than dabigatran 110mg (2.34 , 1.81 to 3.03), however, Rivaroxaban had less bleeding risk compared to dabigatran 150mg (0.41, 0.35 to 0.46). Dabigatran 110mg and 150mg had less GI bleeding risk compared to rivaroxaban (0.31 , 0.24 to 0.39) and (0.23,0.17 to 0.29) respectively. Ischemic stroke risk was also decreased in dabigatran110mg (0.46, 0.38 to 0.57). and 150mg (0.66 ,0.52 to 0.83). Conclusion: Observed oral anticoagulants were associated with various complications. Overall, apixaban had higher intracranial bleeding risk than dabigatran. The highest GI bleeding risk in rivaroxaban compared to apixaban and dabigatran. Ischemic stroke risk was the highest in dabigatran. In conclusion, we may use those oral anticoagulant based on risks rates, however, a larger study with longer follow-up is needed to corroborate findings.

scholarly journals GARFIELD-AF model for prediction of stroke and major bleeding in atrial fibrillation: a Danish nationwide validation study

BMJ Open ◽  
2019 ◽  
Vol 9 (11) ◽  
pp. e033283 ◽  
Author(s):  
Frederik Dalgaard ◽  
Karen Pieper ◽  
Freek Verheugt ◽  
A John Camm ◽  
Keith AA Fox ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischaemic Stroke ◽  
Major Bleeding ◽  
Risk Model ◽  
Oral Anticoagulants ◽  
External Validation ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Secondary Outcome

ObjectivesTo externally validate the accuracy of the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) model against existing risk scores for stroke and major bleeding risk in patients with non-valvular AF in a population-based cohort.DesignRetrospective cohort study.SettingDanish nationwide registries.Participants90 693 patients with newly diagnosed non-valvular AF were included between 2010 and 2016, with follow-up censored at 1 year.Primary and secondary outcome measuresExternal validation was performed using discrimination and calibration plots. C-statistics were compared with CHA2DS2VASc score for ischaemic stroke/systemic embolism (SE) and HAS-BLED score for major bleeding/haemorrhagic stroke outcomes.ResultsOf the 90 693 included, 51 180 patients received oral anticoagulants (OAC). Overall median age (Q1, Q3) were 75 (66–83) years and 48 486 (53.5%) were male. At 1-year follow-up, a total of 2094 (2.3%) strokes/SE, 2642 (2.9%) major bleedings and 10 915 (12.0%) deaths occurred. The GARFIELD-AF model was well calibrated with the predicted risk for stroke/SE and major bleeding. The discriminatory value of GARFIELD-AF risk model was superior to CHA2DS2VASc for predicting stroke in the overall cohort (C-index: 0.71, 95% CI: 0.70 to 0.72 vs C-index: 0.67, 95% CI: 0.66 to 0.68, p<0.001) as well as in low-risk patients (C-index: 0.64, 95% CI: 0.59 to 0.69 vs C-index: 0.57, 95% CI: 0.53 to 0.61, p=0.007). The GARFIELD-AF model was comparable to HAS-BLED in predicting the risk of major bleeding in patients on OAC therapy (C-index: 0.64, 95% CI: 0.63 to 0.66 vs C-index: 0.64, 95% CI: 0.63 to 0.65, p=0.60).ConclusionIn a nationwide Danish cohort with non-valvular AF, the GARFIELD-AF model adequately predicted the risk of ischaemic stroke/SE and major bleeding. Our external validation confirms that the GARFIELD-AF model was superior to CHA2DS2VASc in predicting stroke/SE and comparable with HAS-BLED for predicting major bleeding.

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