Racial differences in the utilization of oral anticoagulant therapy in heart failure: A study of elderly hospitalized patients

To assess racial differences in the use of oral anticoagulant therapy for patients with heart failure, we conducted a cohort study of 30 hospitals in northeast Ohio. For 12,911 Medicare enrollees consecutively admitted in 1992 through 1994 with heart failure, crude and adjusted odds of being on oral anticoagulation were determined. The crude and adjusted odds of being African Americans on oral anticoagulant therapy relative to whites were 0.57 (95% confidence interval 0.47-0.69) and 0.55 (95% confidence interval 0. 45-0.67), respectively. African-Americans with heart failure were much less likely than whites to receive oral anticoagulant therapy, even after adjusting for other variables associated with anticoagulant use.     

Antithrombotic therapy in atrial fibrillation

Warfarin is highly effective at reducing the risk of stroke in atrial fibrillation. The benefit of oral anticoagulant therapy strongly outweighs the risk in most patients with atrial fibrillation. More data are needed to define better the overall risk-to-benefit ratio for patients age 80 years and greater. Because a significant proportion of elderly individuals may not be optimal candidates for anticoagulant therapy, alternative stroke prevention strategies must continue to be evaluated while redoubling efforts to understand the mechanisms underlying atrial fibrillation and thrombogenesis.     

老年无卒中房颤病人的痴呆发病风险及其危险因素分析

目的 探讨老年无卒中房颤病人的痴呆发病风险及其危险因素.方法 纳入2014年7月至2017年2月我院收治的113例无卒中房颤病人,按照随访其是否发生痴呆分为痴呆组和对照组.分析2组病人的临床资料、用药情况,采用多因素Logistic回归分析影响无卒中房颤病人发生痴呆的危险因素.结果 113例病人的中位随访时间为41(2...     

The use of anticoagulant treatment in patients with nonrheumatic atrial fibrillation

INTRODUCTION: The efficacy of anticoagulant treatment in the prevention of thromboembolic complications among patients with nonrheumatic atrial fibrillation is established. In our country, data on the use of this therapy in clinical practice are not available. OBJECTIVE: To examine anticoagulants use among patients with nonrheumatic atrial fibrillation and to analyze the influence of several thromboembolic risk factors in anticoagulant use. PATIENTS AND METHODS: We have studied, 302 patients retrospectively, with nonrheumatic atrial fibrillation. We determined the presence of heart failure, hypertension, previous thromboembolism, diabetes and left atrium dilation. We added age, sex, pattern of non-permanent arrhythmia and hospitalization and we conducted univariate and multivariate analyses to identify their influence the establishment of the anticoagulant treatment. RESULTS: 28.8% of patients were treated with oral anticoagulants, 83.7% were treated with oral anticoagulant or antiplatelet agents. Only three patients, out of 49, aged 80 years or older were treated with anticoagulants. Multivariate analysis showed that previous thromboembolism (odds ratio 4.03 [1.9-8.1]), permanent atrial fibrillation (odds ratio 2.6 [1.3-5.3]), left atrium dilation (odds ratio 2.3 [1.2-4.1]) and heart failure (odds ratio 1.9 [1.07-3.6]) were factors that predicted higher use of anticoagulant treatment. CONCLUSIONS: a) Anticoagulant treatment is underused among patients with nonrheumatic atrial fibrillation; b) previous thromboembolism, left atrium dilation and heart failure have conditioned higher probability of undergoing anticoagulant treatment, and c) patients aged 80 years and over and non permanent atrial fibrillation predicted less use of the therapy.     

Retrospective investigation of hospitalised patients with atrial fibrillation in mainland China

OBJECTIVE: To evaluate the epidemiology and status of atrial fibrillation in China. METHODS: Retrospective analysis of hospital records of patients with a primary diagnosis of atrial fibrillation, discharged between January 1999 and December 2001. RESULTS: Data were analysed from 9297 patients (mean age 65.5 years) from 41 hospitals in mainland China. During the period studied, atrial fibrillation admissions (mean 7.9%) increased as a proportion of cardiovascular admissions. The distribution of atrial fibrillation increased with age. Causes and associated conditions were advanced age (58.1%), hypertension (40.3%), coronary heart disease (34.8%), heart failure (33.1%), rheumatic valvular disease (23.9%), idiopathic atrial fibrillation (7.4%), cardiomyopathy (5.4%) and diabetes (4.1%). Permanent atrial fibrillation accounted for almost half of the patients (49.5%), and paroxysmal and persistent atrial fibrillation the remainder (33.7% and 16.7%, respectively). Paroxysmal atrial fibrillation was treated mainly by rhythm control (56.4%). In 82.8% of patients with chronic atrial fibrillation, a rate-control strategy was used. The prevalence of stroke was 17.5%. In non-valvular atrial fibrillation, risk factors associated with stroke included advanced age, history of hypertension, coronary heart disease and type of atrial fibrillation. A total of 64.5% of patients received antithrombotic therapy, predominantly with antiplatelet agents. Patients managed with antiplatelet or anticoagulant drugs had a significantly lower stroke rate than those receiving neither treatment, but there was no significant difference between antiplatelet and anticoagulant agents. CONCLUSION: Most of the atrial fibrillation-related epidemiological factors in this population were similar to those reported in other countries. Antiplatelet and anticoagulant treatment both reduced stroke rate significantly.     

Anticoagulant use for atrial fibrillation in the elderly

OBJECTIVES: To determine the influence of advanced age on anticoagulant use in subjects with atrial fibrillation and to explore the extent to which risk factors for stroke and contraindications to anticoagulant therapy predict subsequent use. DESIGN: Retrospective cohort study. SETTING: The Veterans Affairs Boston Healthcare System. PARTICIPANTS: A total of 2,217 subjects with nonvalvular atrial fibrillation. MEASUREMENTS: Administrative databases were use to identify subject's age, anticoagulant use, and the presence of a diagnosis of atrial fibrillation, cerebrovascular accident, hypertension, diabetes mellitus, congestive heart failure, or gastrointestinal or cerebral hemorrhage. RESULTS: Unadjusted analysis showed no difference in warfarin use between those aged 75 and older and younger subjects regardless of the presence (33.9% vs 35.7%, P=.37) or absence (33.4% vs 34.7%, P=.58) of contraindications to anticoagulant therapy. Multivariate modeling demonstrated a 14% reduction (95% confidence interval (CI)=4-22%) in anticoagulant use with each advancing decade of life. Intracranial hemorrhage was a significant deterrent (odds ratio (OR)=0.27 95% CI=0.06-0.85). History of hypertension (OR=2.90, 95% CI=2.15-3.89), congestive heart failure (OR=1.70, 95% CI=1.41-2.04), and cerebrovascular accident (OR=1.54, 95% CI=1.25-1.89) were significant independent predictors for anticoagulant use. CONCLUSION: Despite consensus guidelines to treat all atrial fibrillation patients aged 75 and older with anticoagulants, advancing age was found to be a deterrent to warfarin use. Better estimates of the risk:benefit ratio for oral anticoagulant therapy in older patients with atrial fibrillation are needed to optimize decision-making.     

Clinical strategies for selecting oral anticoagulants in patients with atrial fibrillation

Atrial fibrillation is a common arrhythmia. One of the important aspects of the management of atrial fibrillation is stroke prevention. Warfarin has been the longstanding anticoagulant used for stroke prevention in patients with atrial fibrillation. There are now three novel oral anticoagulants, which have been studied in randomized controlled trials and subsequently approved by the Federal Drug Administration for stroke prevention in patients with atrial fibrillation. Special patient populations, including renal insufficiency, elderly, prior stroke, and extreme body weights, were represented to varying degrees in the clinical trials of the novel oral anticoagulants. Furthermore, there is variation in the pharmacokinetics and pharmacodynamics of each anticoagulant, which affect the patient populations differently. Patients and clinicians are faced with the task of selecting among the available anticoagulants, and this review is designed to be a tool for clinical decision-making.     

Anticoagulant therapy for chronic cardiac diseases. Atrial fibrillation, valvular heart disease, congestive heart failure

In cardiology, anticoagulant therapy is absolutely indicated after mechanical valve replacement, but is much more often necessary as a prophylactic measure in atrial fibrillation for prevention of embolic stroke. For more than 50 years, there has been no alternative to the oral application of vitamin K antagonists (VKA), which are known to have a very narrow therapeutic window. Despite being highly effective in preventing embolic stroke, many patients are not adequately treated with VKA, and up to 45% of the time the values lie outside the therapeutic range. The reasons for this might be difficult adjustment of VKA dosage, interactions with drugs and food, the necessity of constant monitoring of the blood coagulation, and the fear of severe bleeding complications. More recently, different anticoagulants binding directly to thrombin or factor Xa have been developed, which allows anticoagulant therapy without the need for numerous coagulation checks, representing a major breakthrough in anticoagulant therapy. In this review, the new guidelines for the use of antithrombotic therapy in atrial fibrillation are presented, followed by a discussion of study results with the new thrombin inhibitors and factor Xa inhibitors for prevention of thromboembolic stroke. Moreover, principles of anticoagulant therapy in valvular heart disease and chronic heart failure are described.     

Large variations in the use of oral anticoagulants in stroke patients with atrial fibrillation: a Swedish national perspective

OBJECTIVES: To explore nation-wide use of anticoagulation in stroke patients with atrial fibrillation, in routine clinical practice in Sweden. DESIGN: Cross-sectional cohort study. SETTING: Patients included in Riks-Stroke, the Swedish national quality register for stroke care, during 2001. SUBJECTS: Hospitals with incomplete coverage were excluded, leaving 4538 stroke patients with atrial fibrillation amongst 18 276 stroke patients from 75 hospitals in six health care regions. MAIN OUTCOME MEASURE: Treatment with oral anticoagulants. RESULTS: At stroke onset, the proportion of patients with atrial fibrillation and first-ever stroke, receiving oral anticoagulants as primary prevention was 11.0% (range 8.4-13.5% between regions and 2.5-24.4% between hospitals). Younger age, male sex and diabetes at stroke onset independently predicted primary prevention with oral anticoagulants. The proportion of stroke patients with atrial fibrillation receiving oral anticoagulants as secondary prevention at discharge was 33.5% (range 29.9-40.6% between regions and 16.4-61.9% between hospitals). Independent predictors for secondary prevention were younger age, male sex and independent activities of daily life (ADL) function before the stroke, being discharged to home, being fully conscious on admission and health care region. CONCLUSION: There were variations between hospitals and regions that differences in age, sex, functional impairments and comorbidities could not fully explain. This indicates that evidence-based primary and secondary prevention of embolic stroke is insufficiently practised. Local factors seem to determine whether patients with atrial fibrillation gain access to optimal prevention of stroke or not.     

Antikoagulation bei chronischen Herzerkrankungen

In cardiology, anticoagulant therapy is absolutely indicated after mechanical valve replacement, but is much more often necessary as a prophylactic measure in atrial fibrillation for prevention of embolic stroke. For more than 50?years, there has been no alternative to the oral application of vitamin?K antagonists (VKA), which are known to have a very narrow therapeutic window. Despite being highly effective in preventing embolic stroke, many patients are not adequately treated with VKA, and up to 45% of the time the values lie outside the therapeutic range. The reasons for this might be difficult adjustment of VKA dosage, interactions with drugs and food, the necessity of constant monitoring of the blood coagulation, and the fear of severe bleeding complications. More recently, different anticoagulants binding directly to thrombin or factor?Xa have been developed, which allows anticoagulant therapy without the need for numerous coagulation checks, representing a major breakthrough in anticoagulant therapy. In this review, the new guidelines for the use of antithrombotic therapy in atrial fibrillation are presented, followed by a discussion of study results with the new thrombin inhibitors and factor?Xa inhibitors for prevention of thromboembolic stroke. Moreover, principles of anticoagulant therapy in valvular heart disease and chronic heart failure are described.     

Physicians' Attitudes and the Use of Oral Anticoagulants: Surveying the Present and Envisioning Future

Atrial fibrillation has the highest prevalence in the elderly. While the elderly are at the highest risk for stroke and would benefit the most from anticoagulation, they are also the least likely to receive anticoagulation. In a pooled analysis of the primary prevention trials, warfarin reduced stroke by 68% compared with placebo, and aspirin reduced stroke by 18%. Age, history of hypertension, diabetes, heart failure or reduced left ventricular function, and previous transient ischemic events and stroke are independent risk factors for stroke in patients with atrial fibrillation. Less than 50% of the elderly who have clear-cut indications and no contraindications for warfarin receive anticoagulant therapy. This low use of warfarin is driven by many factors, but physicians' fear of hemorrhage is among the most important. Better adherence to evidence-driven guidelines, better patient and physician education, point-of-care monitoring of INR and the future development of user friendly anticoagulant drugs are likely to result in higher rates of anticoagulation use.     

Oral anticoagulation and hemorrhagic complications in an elderly population with atrial fibrillation

BACKGROUND: Warfarin sodium therapy in patients with atrial fibrillation markedly reduces the incidence of embolic stroke. However, in elderly patients warfarin therapy is often underused owing to the perceived higher risk of hemorrhagic complications. OBJECTIVES: To assess the quality of anticoagulant control and the incidence of hemorrhagic complications and stroke in an elderly population (>75 years old) compared with a younger control group (between 60 and 69 years) and to assess the quality of anticoagulant control and incidence of hemorrhagic complications in those patients who recently commenced receiving warfarin therapy (first year of therapy). PATIENTS AND METHODS: In this retrospective follow-up study, anticoagulant control and the incidence of hemorrhagic complications and stroke were assessed in an elderly population (>75 years old) compared with a younger control group (between 60 and 69 years), all with atrial fibrillation(target international normalized ratio [INR] 2.5) and attending a hospital outpatient anticoagulant clinic. RESULTS: A total of 328 patients were studied over a 21-month period. There were 204 patients in the control group providing 288 patient-years of follow-up and 124 patients in the elderly group providing 170 patient-years of follow-up. The percentage of INR results in the target range was not statistically significantly different between the elderly and control groups (71.5% vs 66.1%) and the occurrences of incidences of INR greater than 7 were 4.2% in the control group and 4.7% in the elderly group (P =.96). The incidences of major hemorrhage were 2.8% per year in the elderly group and 2.9% per year in the control group (P =.96); overall incidence was 2.8% (95% confidence interval, 1.3%-4.4%). One hundred one of the 328 patients studied commenced warfarin therapy during or within 3 months of the start of the study. In this induction group, 62.1% of INRs were within the target range compared with 70.9% of INRs in patients who had been receiving warfarin therapy for more than 3 months at the start of the study (P =.002). The incidences of INR greater than 7 and major hemorrhage were 7.9% per year and 6.9% per year, respectively, in the cohort who recently began warfarin therapy compared with 3.4% per year and 1.7% per year in the group who were receiving warfarin therapy for more than 3 months. CONCLUSION: While it was impossible to consider any selection bias at the level of referral to the clinic, these findings suggest that the elderly population attending our anticoagulant clinic did not have poorer anticoagulant control or an increased incidence of hemorrhage while receiving warfarin therapy.     

Bleeding complications to long-term oral anticoagulant therapy

Objective: To evaluate the incidence of bleeding complications in recent randomized trials on oral anticoagulant treatment for prevention of arterial thromboembolism.Data sources: International publications on studies of prevention of arterial thromboembolism by oral anticoagulant therapy.Study selection and data extraction: Randomized trials on oral anticoagulant therapy in patients with atrial fibrillation, recent myocardial infarction, and prosthetic heart valves were selected. For comparison older nonrandomized studies were studied.Background: Oral anticoagulant drugs are recommended for primary prevention of thromboembolic events in patients with chronic atrial fibrillation, recent myocardial infarction, and prosthetic heart valves. Still many physicians hesitate to prescribe anticoagulant drugs, presumably for fear of bleeding complications.Results: In six recent trials of warfarin in patients with atrial fibrillation, the highest annual incidence of fatal and major bleeding was 0.8% and 2.0%, respectively. In patients treated with warfarin after a recent myocardial infarction, the incidence of fatal and major bleeding was 0.2% and 0.5% per year, respectively. The annual incidence of fatal and major bleeding in patients with prosthetic heart valves on warfarin treatment was found to be 1.4% and 5.2%, respectively. The mean incidence of fatal and major bleeding in patients on warfarin in these eight trials was 0.5% and 1.7% per year, respectively. The mean incidence of fatal and major bleeds in patients on placebo was 0.1% and 0.7% per year, respectively. In three randomized trials evaluating aspirin versus warfarin, the respective mean incidences of fatal and major bleeding during aspirin treatment were 0.2% and 0.8% per year. A remarkable decrease in the incidence of major bleeding complications to oral anticoagulant therapy is revealed by these trials as compared to previous studies. Reasons for this decline may be less intensive anticoagulant regimes, better control of anticoagulant therapy due to the introduction of the international normalized ratio, and careful pretreatment evaluation of risk factors for bleeding. In all prospective trials of oral anticoagulation, the risk of bleeding was more than over-weighed by the beneficial effect on the incidence of stroke and peripheral thromboemboli.     

Use of oral anticoagulants in patients discharged with atrial fibrillation in 2000

INTRODUCTION AND OBJECTIVES: Although there is consensus about the use of oral anticoagulants to prevent thrombi and embolisms in most patients with atrial fibrillation, this treatment is underused in actual practice. Our objective was to determine and analyze the use of acenocoumarol in patients diagnosed as having atrial fibrillation at discharge. PATIENTS AND METHOD: Between January and July 2000, we retrospectively studied 501 consecutive patients with a diagnosis of atrial fibrillation. We recorded whether they were discharged with or without oral anticoagulation treatment. RESULTS: We identified 482 patients with at least one associated thromboembolic risk factor, who comprised the study population. Mean age was 79.3 years, and 33.3% of the patients were men. Forty-six percent were discharged with acenocoumarol, and 36.3% with platelet antiaggregants. Twenty-three percent had a known contraindication for acenoroumarol. Nearly 62% of the patients without contraindications for anticoagulation received treatment with acenocoumarol. Multivariate analysis showed that rheumatic mitral valve disease, previous stroke or thromboembolism and dilated left atrium were associated with a higher probability of receiving anticoagulant treatment. Age over 75 years was associated with a lower likelihood of receiving acenocoumarol. CONCLUSIONS: Oral anticoagulation was given in an inadequate proportion of patients who were discharged from a secondary-level hospital with atrial fibrillation and no contraindications. Rheumatic mitral valve disease, previous stroke or thromboembolism, and dilated left atrium were associated with a higher probability of anticoagulant treatment. Age over 75 years was related with less frequent use of this therapy.     

Bleeding risks associated with vitamin K antagonists

Vitamin K antagonists are widely used for the prevention of stroke due to atrial fibrillation, treatment and secondary prevention of venous thromboembolism, prevention of valvular thromboembolism in patients with prosthetic heart valves, and secondary prevention of acute myocardial infarction. The most common adverse event experienced by patients receiving anticoagulant therapy is major bleeding. The incidence of major bleeding in patients receiving long-term anticoagulation with a vitamin K antagonist in contemporary studies is 1–3% per year. To determine if the benefits of anticoagulant therapy outweigh the risk of bleeding in an individual patient, physicians must be aware of the risk factors associated with major bleeding. This narrative review will provide an overview of the incidence of major bleeding in patients receiving therapeutic anticoagulant therapy with vitamin K antagonists, discuss the risk factors for bleeding, and outline the most commonly used clinical prediction rules for bleeding.     

非瓣膜病房颤缺血性脑卒中的预防

非瓣膜病房颤缺血性脑卒及体动脉栓塞的发病率很高,预防这一事件的发生现已成为国内外研究的热题。抗凝治疗无疑是卒中预防中重要环节之一,新型口服抗凝剂相较华法林可能对亚洲房颤人群血栓栓塞的预防效果更好,不良事件发生率更低,正在成为一种全新的选择。随着左心耳封堵技术日渐成熟,给不适合抗凝治疗的房颤患者带来了福音。许多大型临床研究显示射频消融不仅可以恢复窦律,还可以降低房颤负荷,减少血栓栓塞事件的发生,对于栓塞风险较高的病人来说,新型口服抗凝药联合射频消融对卒中预防效果可能会更好。肥胖、吸烟、嗜酒、高血压、糖尿病等危险因素在房颤病程进展中扮演了重要角色,包括房颤危险因素在内的综合管理对缺血性脑卒中的预防效果更佳。     

Risk factors for stroke in patients with nonrheumatic atrial fibrillation: a case-control study

PURPOSE: Randomized controlled trials have demonstrated that anticoagulant therapy is very effective at preventing stroke among patients with nonrheumatic atrial fibrillation. However, these trials have reported too few strokes for powerful risk factor analysis. Observational studies may provide additional information. The purpose of this study was to identify risk factors in a larger number of patients with stroke and nonrheumatic atrial fibrillation, using case-control methodology. PATIENTS AND METHODS: We identified all patients discharged from one hospital over an 8-year period who met our case definition of nonrheumatic atrial fibrillation and ischemic stroke (n = 134), and compared them with contemporaneous control subjects who were discharged with nonrheumatic atrial fibrillation without stroke (n = 131). RESULTS: Cases and controls were similar in terms of duration of atrial fibrillation; proportion with paroxysmal atrial fibrillation; percentage with a past medical history of angina, myocardial infarction, congestive heart failure, diabetes, or smoking; and mean left atrial size. In contrast, cases were significantly older than controls (78.5 versus 74.8 years, p = 0.002) and more likely to have a history of hypertension (55% versus 38%, p = 0.0093). The relative odds for stroke was 1.91 for patients with hypertension, 1.73 for patients older than 75 years, and 3.26 for patients with both factors. CONCLUSIONS: Our analysis suggests that age and hypertension should be considered when deciding upon long-term anticoagulant therapy to prevent stroke in patients with nonrheumatic atrial fibrillation.     

Antithrombotic therapy in elderly patients with atrial fibrillation: effects and bleeding complications: a stratified analysis of the NASPEAF randomized trial.

AIMS: Atrial fibrillation patients with prior embolism have a high risk of vascular events in spite of anticoagulant therapy and elderly patients carry an additional risk. We analysed and compared vascular events-rate between older and younger than 75 years atrial fibrillation patients randomized to anticoagulant-alone or combined antiplatelet plus moderate-level anticoagulant therapy. METHODS AND RESULTS: A total of 967 patients stratified by age and the history of prior embolism were randomized to therapeutic doses of anticoagulant-alone or combined antithrombotic therapy. Primary events were fatal and non-fatal ischaemic or haemorrhagic stroke/transient ischaemic attack, systemic embolism and myocardial infarction, sudden death and death from bleeding. The elderly, compared with the younger patients, had higher event-rate [hazard ratio 2.31 (95% confidence interval 1.37-3.90), P < 0.003]. The elderly suffered higher severe bleeding event-rate during anticoagulant therapy. The combined, compared with the anticoagulant therapy, reduced the vascular events-rate in the elderly (P = 0.012) and caused less intracranial haemorrhages and less bleeding mortality, although more non-fatal gastric bleeding. CONCLUSION: The elderly with AF had a higher event-rate than the younger patients. A higher severe bleeding event-rate was also registered in elderly patients receiving anticoagulant therapy. Combined, compared with anticoagulant therapy, significantly reduced vascular events and bleeding mortality in elderly patients.     

Additional risk factors in atrial fibrillation patients not receiving warfarin.

OBJECTIVE: To study how many elderly inpatients with previously diagnosed atrial fibrillation were not receiving anticoagulant prophylaxis, and the prevalence of additional risk factors in these patients. METHODS: All new admissions to a department of medicine for the elderly were screened for atrial fibrillation. Additional risk factors were analysed in those with established atrial fibrillation who were not receiving warfarin. Previous hospital admissions, documentation of why prophylaxis was not being used and use of aspirin as an alternative agent were also examined. RESULTS: 56 patients had previously diagnosed atrial fibrillation; 82% were not taking warfarin and 71% of these were not on aspirin either. All patients not taking warfarin had one additional risk factor for stroke and 95% had two or more. Fifty-two percent had attended hospital when atrial fibrillation was present within the previous 3 years and there was nothing documented in their records to explain why anticoagulation had not been used. CONCLUSIONS: Most elderly inpatients with established atrial fibrillation were not taking warfarin. All had additional risk factors for stroke, which increase the absolute benefit of anticoagulation.