scholarly journals Thromboembolic and hemorrhagic risk stratification in patients with atrial fibrillation. Part II: hemorrhagic risk and guidelines recommendations

2015 ◽  
Vol 80 (3) ◽  
Author(s):  
Maurizio Giuseppe Abrignani ◽  
Vincenzo Abrignani
Keyword(s):  
Atrial Fibrillation ◽  
Risk Stratification ◽  
Oral Anticoagulant Therapy ◽  
Vitamin K Antagonists ◽  
International Normalized Ratio ◽  
Score System ◽  
Hemorrhagic Events ◽  
Hemorrhagic Risk ◽  
Embolic Risk ◽  
Robust Evidence

Robust evidence exists on the efficacy of traditional anticoagulant oral therapy in the prevention of thrombo-embolic risk in patients with non valvular atrial fibrillation, but fears and concerns of hemorrhagic events for the physicians and logistic difficulties related to the periodic International Normalized Ratio evaluation for the patients are at the basis of a noticeable under-utilization of the therapy with vitamin K antagonists in the real world. Stratification of the hemorrhagic risk has, thus, particular importance; for this objective we may use now several score system, among whom the more suggested is the HASBLED, with the principal aim to select and trait modifiable risk factors for bleeding. These score systems have been evaluated in some recent clinical trials. During the last years, a number of national and international guidelines on the prevention of the thrombo-embolic risk in patients with non valvular atrial fibrillation have been updated. These guidelines, generally, recommend the use of the CHA2DS2VaSC score for the evaluation of the thrombo-embolick risk, and of the HAS-BLED score for the evaluation of the hemorrhagic one. The consequent risk stratification is fundamental as a clinical guide for the use of oral anticoagulant therapy.

scholarly journals Thromboembolic and hemorrhagic risk stratification in patients with atrial fibrillation. Part I: the thromboembolic risk

2015 ◽  
Vol 80 (2) ◽  
Author(s):  
Maurizio Giuseppe Abrignani ◽  
Furio Colivicchi
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Vascular Diseases ◽  
International Normalized Ratio ◽  
Cerebrovascular Events ◽  
Hemorrhagic Events ◽  
Hemorrhagic Risk ◽  
Risk Patients ◽  
Embolic Risk

Atrial fibrillation, whose prevalence is in constant increase, is associated to a noticeably greater thrombo-embolic risk. Various associated factors, such as older age, arterial hypertension, heart failure, previous cerebrovascular events (stroke and transient ischemic attacks), diabetes mellitus, female sex and vascular diseases determine a further increase of the risk of stroke in patients with atrial fibrillation. Robust evidence exists on the efficacy of traditional anticoagulant oral therapy in the prevention of thrombo-embolic risk in these patients, but fears and concerns of hemorrhagic events for the physicians and the logistic difficulties related to the periodic International Normalized Ratio evaluation for the patients are at the basis of a noticeable under-utilization of the therapy with vitamin K antagonists in the real world. Stratification of the thrombo-embolic risk has thus particular importance; for this scope we may use now score systems as CHA2DS2 and, above all, CHA2DS2-Vasc, that allows the identification of truly low risk patients, which do not require an antithrombotic treatment. Novel oral anticoagulants, lastly, will help physicians in order to obtain a better management of trombo-embolic risk in atrial fibrillation.

Assays of fibrin network properties altered by VKAs in atrial fibrillation – importance of using an appropriate coagulation trigger

2015 ◽  
Vol 113 (04) ◽  
pp. 851-861 ◽  
Author(s):  
Michal Ząbczyk ◽  
Margareta Blombäck ◽  
Jacek Majewski ◽  
Grzegorz Karkowski ◽  
Hakan N. Wallen ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Thrombin Generation ◽  
Vitamin K Antagonists ◽  
International Normalized Ratio ◽  
Clot Lysis ◽  
Flow Measurements ◽  
Fibrin Networks ◽  
Fibrin Network ◽  
Long Term Treatment

SummaryAtrial fibrillation (AF) is a prothrombotic condition, involving increased thrombin generation and fibrinogen concentrations. Vitamin K antagonists (VKAs) prevent arterial thromboembolism if optimal anticoagulation is achieved by individualised drug doses, assessed by determining the Prothrombin time-related International Normalized Ratio (Pt-INR). There is evidence that formation of tight-laced fibrin networks is pathogenic in prothrombotic diseases. This study was performed among AF patients, to test whether long-term treatment with VKAs affects the structure of fibrin networks, and whether the effect is altered by employing different coagulation triggers: exogenous thrombin (1 IU/ml), 10 pM tissue factor (TF) or a commercial Pt-INR reagent (containing 400-fold more TF). In the thrombin-based method, fibrin network porosity (scanning electron microscopy) and liquid permeability (flow measurements) correlated inversely to fibrinogen concentrations, while positive correlations to the degree of anticoagulation were shown with the Pt-INR reagent. In the method with 10 pM TF, the two above relationships were detected, though the influence of Pt-INR was more profound than that of fibrinogen concentrations. Moreover, greater shortening of clot lysis time (CLT) arose from more permeable clots. As a coagulation trigger, 10 pM TF vs exogenous thrombin or the Pt-INR reagent is more informative in reflecting the in vivo process from thrombin generation to fibrin formation. Since fibrin network permeability rose in parallel to elevations of INR and shortening of CLT in AF patients, antithrombotic effects on prevention of thrombotic complications may be achieved from impairment of thrombin generation, resulting in formation of permeable clots susceptible to fibrinolysis.

scholarly journals 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

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.

scholarly journals The international normalized ratio (INR) as seen in a population of patients with atrial fibrillation and cerebral infarction undergoing long-term treatment with vitamin K antagonists

2015 ◽  
Vol 28 (4) ◽  
pp. 269-272
Author(s):  
Anna Szczepańska-Szerej ◽  
Magdalena Wojtan ◽  
Beata Szajnoga
Keyword(s):  
Atrial Fibrillation ◽  
Cerebral Infarction ◽  
Vitamin K ◽  
Vitamin K Antagonists ◽  
International Normalized Ratio ◽  
Blood Parameters ◽  
Term Treatment ◽  
Adequate Treatment ◽  
Long Term Treatment

Abstract It is estimated that nearly 20% of all cerebral infarctions in the total population are the result of a complication of atrial fibrillation (AF). While oral anticoagulation with vitamin K antagonists (AVKs) substantially reduces this risk, this requires regular monitoring of the international normalized ratio (INR) in order to achieve therapeutic levels (2,0-3,0). The aim of this study was to evaluate a group at high risk of cerebral infarction, among patients with AF undergoing long-term treatment with VKAs, taking into account the significance of therapeutic INR values. The analysed group consisted of 90 acute ischaemic stroke patients with paroxysmal or chronic “non-valvular” AF, receiving treatment with VKAs. As a result of the study, therapeutic INR values (≥ 2) were seen in thirty-five of these individuals (38,8%), while 55 (61,2%) showed non-therapeutic INR values. Moreover, there were no differences in demographics, vascular risk factors, biochemical and morphological blood parameters, mean CHA2DS2-VASc score and TOAST classification between either of the two groups. Furthermore, no additional factor that would increase their risk of cerebral infarction during the adequate treatment with VKAs was found. However, patients with non-therapeutic INR values had a statistically significantly higher frequency of concomitant moderate pathology of the bicuspid valve, p<0.05. Hence, a lack of proper control of INR can proved to be particularly dangerous for this subgroup of patients. Hence, this is a group with an elevated risk of cerebral infarction and therefore requires special oversight of VKA treatment or NOA treatment.

scholarly journals Target International Normalized Ratio Values for Preventing Thromboembolic and Hemorrhagic Events in Japanese Patients With Non-Valvular Atrial Fibrillation

2013 ◽  
Vol 77 (9) ◽  
pp. 2264-2270 ◽  
Author(s):  
Hiroshi Inoue ◽  
Ken Okumura ◽  
Hirotsugu Atarashi ◽  
Takeshi Yamashita ◽  
Hideki Origasa ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Japanese Patients ◽  
International Normalized Ratio ◽  
Hemorrhagic Events

scholarly journals Dabigatran in the ischemic patient undergoing atrial fibrillation ablation

ABOUTOPEN ◽  
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)

scholarly journals New artificial intelligence prediction model using serial prothrombin time international normalized ratio measurements in atrial fibrillation patients on vitamin K antagonists: GARFIELD-AF

2019 ◽  
Vol 6 (5) ◽  
pp. 301-309 ◽  
Author(s):  
Shinichi Goto ◽  
Shinya Goto ◽  
Karen S Pieper ◽  
Jean-Pierre Bassand ◽  
Alan John Camm ◽  
...  
Keyword(s):  
Neural Network ◽  
Artificial Intelligence ◽  
Atrial Fibrillation ◽  
Prothrombin Time ◽  
Clinical Outcomes ◽  
Vitamin K ◽  
Vitamin K Antagonists ◽  
International Normalized Ratio ◽  
One Dimensional ◽  
Major Bleed

Abstract Aims Most clinical risk stratification models are based on measurement at a single time-point rather than serial measurements. Artificial intelligence (AI) is able to predict one-dimensional outcomes from multi-dimensional datasets. Using data from Global Anticoagulant Registry in the Field (GARFIELD)-AF registry, a new AI model was developed for predicting clinical outcomes in atrial fibrillation (AF) patients up to 1 year based on sequential measures of prothrombin time international normalized ratio (PT-INR) within 30 days of enrolment. Methods and results Patients with newly diagnosed AF who were treated with vitamin K antagonists (VKAs) and had at least three measurements of PT-INR taken over the first 30 days after prescription were analysed. The AI model was constructed with multilayer neural network including long short-term memory and one-dimensional convolution layers. The neural network was trained using PT-INR measurements within days 0–30 after starting treatment and clinical outcomes over days 31–365 in a derivation cohort (cohorts 1–3; n = 3185). Accuracy of the AI model at predicting major bleed, stroke/systemic embolism (SE), and death was assessed in a validation cohort (cohorts 4–5; n = 1523). The model’s c-statistic for predicting major bleed, stroke/SE, and all-cause death was 0.75, 0.70, and 0.61, respectively. Conclusions Using serial PT-INR values collected within 1 month after starting VKA, the new AI model performed better than time in therapeutic range at predicting clinical outcomes occurring up to 12 months thereafter. Serial PT-INR values contain important information that can be analysed by computer to help predict adverse clinical outcomes.

P4765Men who live alone have poor anticoagulation control: results from Danish registries

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
A N Bonde ◽  
J Bjerre ◽  
M Proietti ◽  
G Gislason ◽  
G Y H Lip ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K Antagonists ◽  
International Normalized Ratio ◽  
Living Alone ◽  
Efficacy And Safety ◽  
Men And Women ◽  
Anticoagulation Control ◽  
Cohabitation Status ◽  
Multivariable Adjustment

Abstract Background Efficacy and safety of vitamin K antagonists (VKAs) depend on quality of anticoagulation control, usually measured as time in therapeutic range (TTR). Factors that predict low TTR on VKAs could be used to identify patients who might benefit from interventions, or who would be better treated with a non-VKA oral anticoagulant (NOAC). Patients living alone may have difficulties in taking their medications, managing their diets, or coming to clinic for monitoring. Purpose To assess influence of cohabitation status on TTR with VKA among men and women. Methods We identified all Danish patients with atrial fibrillation (AF) who initiated VKA between 1997 and 2012, and studied patients who had 6 months of continuous VKA use and international normalized ratio (INR) monitoring. Patients were divided according to sex and whether they lived alone or with others. We calculated TTR using the Rosendaal method, and INR variability using Fihns method. We used a linear regression model to test for associations between TTR and covariates, and adjusted for age, income, medications and comorbidities. Results We identified 4,772 AF patients with 6 months of continuous VKA use and INR monitoring. 713 (15%) were men living alone, 1,073 (23%) were women living alone, 2,164 (45%) were men not living alone and 822 (17%) were women not living alone. INR was measured a median of 11 (interquartile range 8–15) times during the 180 days of VKA use, but men who lived alone had 0.6 (95% confidence interval (CI): 0.2 to 1.2) fewer INR measurements during the period. Median TTR was lowest among men living alone (57.2%), followed by women living alone (58.8%), women not living alone (61.0%) and men not living alone (62.5%). After multivariable adjustment, men who lived alone had a 3.6% (CI −5.6 to −1.6) lower TTR compared with men not living alone, but women who lived alone did not have significantly lower TTR (P=0.80) compared with women not living alone. Living alone had significantly greater effect on TTR among men than among women (interaction P=0.02). Men living alone also had higher adjusted INR variability (0.2, CI 0.0 to 0.4) compared with men not living alone. Conclusion Living alone was significantly related to low quality of anticoagulation control among men, but not among women. Acknowledgement/Funding this study was funded by an unrestricted grant from the Capital Region of Denmark, Foundation for Health Research

scholarly journals Prevalence of Valvular and Non-valvular Atrial Fibrillation and the Application of Antithrombotic Treatment in a Tertiary Care Hospital

2020 ◽  
Vol 58 (231) ◽  
Author(s):  
Sahadeb Prasad Dhungana ◽  
Rinku Ghimire
Keyword(s):  
Atrial Fibrillation ◽  
Risk Stratification ◽  
Tertiary Care Hospital ◽  
Oral Anticoagulants ◽  
Tertiary Care ◽  
International Normalized Ratio ◽  
Care Hospital ◽  
Clinical Practices ◽  
Antithrombotic Treatment ◽  
Increased Risk

Introduction: Atrial fibrillation is a common atrial tachyarrhythmia with an increased risk of thromboembolism. This study aims to provide information about the application of antithrombotic treatment based on risk stratification schemes for stroke in real-life clinical practices. Methods: This was a descriptive cross-sectional study in 260 patients admitted at the tertiary care hospital with a diagnosis of atrial fibrillation from January 2019 to February 2020 after approval from the Institutional Review Committee (ref. no. 207/2018). Convenient sampling was used. Predisposing conditions for atrial fibrillation, risk factors for stroke, and the use of antithrombotics were obtained based on the pre-structured questionnaires. Data were analyzed by Statistical Package for the Social Sciences version 20. Results: The prevalence of valvular and non-valvular atrial fibrillation was 125 (48.0%), and 135 (51.9%) respectively. Among patients with a non-valvular variant, 102 (75.5%) had a CHA2DS2VASC score of ≥ 2 who were eligible for oral anticoagulants, 13 (9.6 %) patients received it with a majority having sub-therapeutic international normalized ratio. Among patients with valvular type, only 47 (37.6%) patients were receiving oral anticoagulants and 20 (42.5%) patients achieved therapeutic international normalized ratio. Two hundred forty three (93.4%) patients had dilated left atrium (≥40mm), 119 (45.9%) had hypertension and 27 (10.3%) had diabetes mellitus. Conclusions: Antithrombotics were markedly underused in patients with atrial fibrillation. There is a need for proper application of risk stratification schemes for stroke and appropriate use of antithrombotics to prevent thromboembolism.

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