Use of antiarrhythmic drug therapy and clinical outcomes in older patients with concomitant atrial fibrillation and coronary artery disease.

AIMS: Atrial fibrillation (AF) and coronary artery disease (CAD) are common in older patients. We aimed to describe the use of antiarrhythmic drug (AAD) therapy and clinical outcomes in these patients. METHODS AND RESULTS: We analysed AAD therapy and outcomes in 1738 older patients (age ≥65) with AF and CAD in the Duke Databank for cardiovascular disease. The primary outcomes were mortality and rehospitalization at 1 and 5 years. Overall, 35% of patients received an AAD at baseline, 43% were female and 85% were white. Prior myocardial infarction (MI, 31%) and heart failure (41%) were common. Amiodarone was the most common AAD (21%), followed by pure Class III agents (sotalol 6.3%, dofetilide 2.2%). Persistence of AAD was low (35% at 1 year). After adjustment, baseline AAD use was not associated with 1-year mortality [adjusted hazard ratio (HR) 1.23, 95% confidence interval (CI) 0.94-1.60] or cardiovascular mortality (adjusted HR 1.27, 95% CI 0.90-1.80). However, AAD use was associated with increased all-cause rehospitalization (adjusted HR 1.20, 95% CI 1.03-1.39) and cardiovascular rehospitalization (adjusted HR 1.20, 95% CI 1.01-1.43) at 1 year. This association did not persist at 5 years; however, these patients were at very high risk of death (55% for those >75 and on AAD) and all-cause rehospitalization (87% for those >75 and on AAD) at 5 years. CONCLUSIONS: In older patients with AF and CAD, antiarrhythmic therapy was associated with increased rehospitalization at 1 year. Overall, these patients are at high risk of longer-term hospitalization and death. Safer, better-tolerated, and more effective therapies for symptom control in this high-risk population are warranted.

Quality of anticoagulation with warfarin in patients with nonvalvular atrial fibrillation in the community setting.

BACKGROUND: The benefit of oral anticoagulation therapy with warfarin for stroke prevention in atrial fibrillation (AF) is directly dependent on the quality of anticoagulation (QoA), which in the US is provided predominantly in the community setting. With the emergence of new oral anticoagulation agents, the current QoA needs to be assessed. OBJECTIVES: The purpose of our study is to define the QoA with warfarin in patients with nonvalvular AF who are managed exclusively in community practices, and to compare the quality in the community setting with the quality demonstrated in the recent large randomized control trials. In addition, this study will assess the differences in the QoA based on cardiology vs primary care practices. METHODS: This is a retrospective, observational, multi-center study of 392 patients with AF in the community who were initiated on anticoagulation with warfarin for stroke prevention. International Normalized Ratio (INR) values were collected over a one-year period and the QoA was expressed as time in therapeutic range (TTR) calculated by the linear interpolation method. RESULTS: One hundred patients from cardiology practices and 292 patients from primary care were studied. During the one-year period, the overall mean TTR was 56.7%. The TTR in the primary care vs cardiology practices was 55.3% vs. 60.8% (p=0.02). Both practices had similar percent of time below therapeutic range, 29.8% vs. 29.2%. However, the primary care practice patients were above the therapeutic range 15% of the time vs. 10% in cardiology (p<0.001). There were one death secondary to intracranial bleed and one major bleed in the primary care group. There were no strokes during the study period in either group. CONCLUSION: The QoA with warfarin, as assessed by TTR, in the current community setting remains suboptimal, and there has been little to no improvement in current clinical practices. TTR should be considered when assessing the recent comparative studies evaluating novel pharmacologic agents to warfarin for the treatment of AF. SUBJECT AREAS: Arrhythmias, preventive cardiology, anticoagulation, thromboembolism, cardiovascular disease risk factors.

Uso de agentes antiarrítmicos y resultados clínicos en pacientes añosos con fibrilación auricular y enfermedad coronaria concomitante

Objetivo: la fibrilación auricular (FA) y la enfermedad coronaria (EC) son comunes en los pacientes añosos. En este estudio nos propusimos describir el uso de agentes antiarrítmicos (AAA) y los resultados clínicos en estos pacientes. Métodos y resultados: se analizó el tratamiento con AAA y los resultados observados en 1.738 pacientes mayores (edad ³65) con FA y EC registrados en el Banco de Datos para Enfermedad Cardiovascular de Duke. Los resultados primarios fueron mortalidad y rehospitalización al año y a los cinco años. En términos generales, 35% de los pacientes recibían un AAA al inicio, 43% eran mujeres y 85% eran blancos. Fueron frecuentes los antecedentes de infarto de miocardio (IM, 31%) e insuficiencia cardíaca (41%). La amiodarona era el AAA más frecuente (21%), seguida de agentes de Clase III pura (sotalol 6,3%, dofetilida 2,2%). La persistencia de los AAA fue baja (35% al año). Luego del ajuste, el uso de AAA al inicio no se asoció con la mortalidad al año (cociente de riesgo ajustado (HR) 1,23, intervalo de confianza (IC) 95%: 0,94-1,60) o con la mortalidad cardiovascular (HR ajustado 1,27, IC 95% 0,90-1,80). Sin embargo, el uso de AAA sí se asoció con un aumento de la rehospitalización por todas las causas (HR ajustado 1,20, IC 95%: 1,03-1,39) y rehospitalización cardiovascular (HR ajustado 1,20, IC 95% 1,01-1,43) al año. Esta asociación no se mantiene a los cinco años; sin embargo, estos pacientes tuvieron un elevado riesgo de muerte (55% para los >75 años y que recibían AAA) y rehospitalización (87% para aquellos >75 años que recibían AAA) a los cinco años. Conclusiones: en pacientes añosos que padecen FA y EC, la terapia antiarrítmica se acompañó de aumento de la rehospitalización al año. En términos generales, estos pacientes presentan un alto riesgo de internación y muerte a largo plazo. Se necesitan desarrollar terapias más seguras, mejor toleradas y que brinden un control de los síntomas más eficaz en esta población de alto riesgo.