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1.
Circ Arrhythm Electrophysiol ; : 101161CIRCEP121007955, 2022 May 02.
Artigo em Inglês | MEDLINE | ID: mdl-35491871

RESUMO

Antiarrhythmic drugs (AAD) play an important role in the management of arrhythmias. Drug interactions involving AAD are common in clinical practice. As AADs have a narrow therapeutic window, both pharmacokinetic as well as pharmacodynamic interactions involving AAD can result in serious adverse drug reactions ranging from arrhythmia recurrence, failure of device-based therapy, and heart failure, to death. Pharmacokinetic drug interactions frequently involve the inhibition of key metabolic pathways, resulting in accumulation of a substrate drug. Additionally, over the past 2 decades, the P-gp (permeability glycoprotein) has been increasingly cited as a significant source of drug interactions. Pharmacodynamic drug interactions involving AADs commonly involve additive QT prolongation. Amiodarone, quinidine, and dofetilide are AADs with numerous and clinically significant drug interactions. Recent studies have also demonstrated increased morbidity and mortality with the use of digoxin and other AAD which interact with P-gp. QT prolongation is an important pharmacodynamic interaction involving mainly Vaughan-Williams class III AAD as many commonly used drug classes, such as macrolide antibiotics, fluoroquinolone antibiotics, antipsychotics, and antiemetics prolong the QT interval. Whenever possible, serious drug-drug interactions involving AAD should be avoided. If unavoidable, patients will require closer monitoring and the concomitant use of interacting agents should be minimized. Increasing awareness of drug interactions among clinicians will significantly improve patient safety for patients with arrhythmias.

2.
Vasc Health Risk Manag ; 18: 313-318, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35502192

RESUMO

Further research is needed to refine risk prediction models for adverse cardiovascular outcomes following stroke in contemporary clinical practice, such as incident atrial fibrillation (AF), recurrent stroke, and cognitive impairment and dementia. The aims of this study are to prospectively investigate cardiovascular outcomes and risk factors for incident cardiovascular disease in a post-stroke cohort, and to externally validate, refine and expand current risk prediction models for cardiovascular and cardiovascular-related outcomes. The study sample size was based on the development of post-stroke risk prediction models for AF and was calculated as 1222 participants. The study design is a multicentre, prospective, observational cohort study. Participants will be adult patients admitted for ischaemic stroke confirmed by stroke physician or transient ischaemic attack (TIA) confirmed by MRI. Routinely collected data will be used in addition to the completion of simple validated questionnaires by the participants. Follow-up will be undertaken 12-months from the date of admission to hospital, in addition to linkage to routinely collected follow-up hospitalisation and mortality data. The primary outcomes are cardiovascular outcomes (including incident AF, stroke, TIA and myocardial infarction) at 12-month follow-up, all-cause mortality and mortality from cardiovascular causes, and incident cognitive impairment and dementia. Secondary outcomes include changes in function, depression, anxiety, fatigue and quality of life. The study has received approval from the Health Research Authority Research Ethics Committee (21/WA/0209), and is registered on https://www.clinicaltrials.gov/ (Identifier NCT05132465). Recruitment for the study began in October 2021 with completion of recruitment at all participating centres anticipated by October 2022.


Assuntos
Fibrilação Atrial , Isquemia Encefálica , Doenças Cardiovasculares , Demência , Ataque Isquêmico Transitório , Acidente Vascular Cerebral , Adulto , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Encéfalo/diagnóstico por imagem , Isquemia Encefálica/complicações , Doenças Cardiovasculares/complicações , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Proteínas de Transporte , Estudos de Coortes , Citocinas , Demência/complicações , Fatores de Risco de Doenças Cardíacas , Humanos , Ataque Isquêmico Transitório/complicações , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/epidemiologia , Estudos Multicêntricos como Assunto , Estudos Observacionais como Assunto , Estudos Prospectivos , Qualidade de Vida , Fatores de Risco , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia
3.
J Med Internet Res ; 24(5): e37970, 2022 May 09.
Artigo em Inglês | MEDLINE | ID: mdl-35532989

RESUMO

BACKGROUND: There is insufficient evidence for the use of single-lead electrocardiogram (ECG) monitoring with an adhesive patch-type device (APD) over an extended period compared to that of the 24-hour Holter test for atrial fibrillation (AF) detection. OBJECTIVE: In this paper, we aimed to compare AF detection by the 24-hour Holter test and 72-hour single-lead ECG monitoring using an APD among patients with AF. METHODS: This was a prospective, single-center cohort study. A total of 210 patients with AF with clinical indications for the Holter test at cardiology outpatient clinics were enrolled in the study. The study participants were equipped with both the Holter device and APD for the first 24 hours. Subsequently, only the APD continued ECG monitoring for an additional 48 hours. AF detection during the first 24 hours was compared between the two devices. The diagnostic benefits of extended monitoring using the APD were evaluated. RESULTS: A total of 200 patients (mean age 60 years; n=141, 70.5% male; and n=59, 29.5% female) completed 72-hour ECG monitoring with the APD. During the first 24 hours, both monitoring methods detected AF in the same 40/200 (20%) patients (including 20 patients each with paroxysmal and persistent AF). Compared to the 24-hour Holter test, the APD increased the AF detection rate by 1.5-fold (58/200; 29%) and 1.6-fold (64/200; 32%) with 48- and 72-hour monitoring, respectively. With the APD, the number of newly discovered patients with paroxysmal AF was 20/44 (45.5%), 18/44 (40.9%), and 6/44 (13.6%) at 24-, 48-, and 72-hour monitoring, respectively. Compared with 24-hour Holter monitoring, 72-hour monitoring with the APD increased the detection rate of paroxysmal AF by 2.2-fold (44/20). CONCLUSIONS: Compared to the 24-hour Holter test, AF detection could be improved with 72-hour single-lead ECG monitoring with the APD.


Assuntos
Fibrilação Atrial , Fibrilação Atrial/diagnóstico , Estudos de Coortes , Eletrocardiografia , Eletrocardiografia Ambulatorial/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
4.
Artif Intell Med ; 128: 102307, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35534145

RESUMO

Diagnosis assignment is the process of assigning disease codes to patients. Automatic diagnosis assignment has the potential to validate code assignments, correct erroneous codes, and register completion. Previous methods build on text-based techniques utilizing medical notes but are inapplicable in the absence of these notes. We propose using patients' medication data to assign diagnosis codes. We present a proof-of-concept study using medical data from an American dataset (MIMIC-III) and Danish nationwide registers to train a machine-learning-based model that predicts an extensive collection of diagnosis codes for multiple levels of aggregation over a disease hierarchy. We further suggest a specialized loss function designed to utilize the innate hierarchical nature of the disease hierarchy. We evaluate the proposed method on a subset of 567 disease codes. Moreover, we investigate the technique's generalizability and transferability by (1) training and testing models on the same subsets of disease codes over the two medical datasets and (2) training models on the American dataset while evaluating them on the Danish dataset, respectively. Results demonstrate the proposed method can correctly assign diagnosis codes on multiple levels of aggregation from the disease hierarchy over the American dataset with recall 70.0% and precision 69.48% for top-10 assigned codes; thereby being comparable to text-based techniques. Furthermore, the specialized loss function performs consistently better than the non-hierarchical state-of-the-art version. Moreover, results suggest the proposed method is language and dataset-agnostic, with initial indications of transferability over subsets of disease codes.


Assuntos
Registros Eletrônicos de Saúde , Aprendizado de Máquina , Humanos
5.
Eur J Intern Med ; 2022 May 05.
Artigo em Inglês | MEDLINE | ID: mdl-35527179

RESUMO

BACKGROUND: The prevalence of atrial fibrillation(AF) and diabetes mellitus is rising to epidemic proportions. We aimed to assess the impact of diabetes on the management and outcomes of patients with AF. METHODS: The EORP-AF General Long-Term Registry is a prospective, observational registry from 250 centres across 27 European countries. Outcomes of interest were as follows: i)rhythm control interventions; ii)quality of life; iii)healthcare resource utilisation; and iv)major adverse events. RESULTS: Of 11,028 patients with AF, the median age was 71 (63-77) years and 2537 (23.0%) had diabetes. Median follow-up was 24 months. Diabetes was related to increased use of anticoagulation but less rhythm control interventions. Using multivariable analysis, at 2-year follow-up, patients with diabetes were associated with greater levels of anxiety (p = 0.038) compared to those without diabetes. Overall, diabetes was associated with worse health during follow-up, as indicated by Health Utility Score and Visual Analogue Scale. Healthcare resource utilisation was greater with diabetes in terms of length of hospital stay (8.1 (±8.2) vs. 6.1 (±6.7) days); cardiology and internal medicine/general practitioner visits; and emergency room admissions. Diabetes was an independent risk factor of major adverse cardiovascular event (MACE; HR 1.26 [95% CI, 1.04-1.52]), all-cause mortality (HR 1.28 [95% CI, 1.08-1.52]), and cardiovascular mortality (HR 1.41 [95% CI, 1.09-1.83]). CONCLUSION: In this contemporary AF cohort, diabetes was present in 1 in 4 patients and it served as an independent risk factor for reduced quality of life, greater healthcare resource utilisation and excess MACE, all-cause mortality and cardiovascular mortality. There was increased use of anticoagulation therapy in diabetes but with less rhythm control interventions.

6.
Eur J Intern Med ; 2022 May 04.
Artigo em Inglês | MEDLINE | ID: mdl-35525635

RESUMO

Clinical practice in atrial fibrillation (AF) patient management is constantly evolving. In the past 3 years, various new AF guidelines or focused updates have been published, given this rapidly evolving field. In 2019, the American College of Cardiology/American Heart Association published a focused update of the 2014 guidelines. In 2020, both the European Society of Cardiology and the Canadian Cardiovascular Society released their new guidelines. Finally, the most recent guidelines were those published in 2021 by the Asian Pacific Heart Rhythm Society, which updates their 2017 version and the 2021 National Institute for Health and Care Excellence (NICE) guidelines. In the present narrative review, we compare these guidelines, emphasizing similarities and differences in the following mainstay elements of patient care: thromboembolic risk assessment, oral anticoagulants (OACs) prescription, bleeding risk evaluation, and integrated patient management. A formal evaluation of baseline thromboembolic and bleeding risks and their reassessment during follow-up is evenly recommended, although some differences in using risk stratification scores. OACs prescription is highly encouraged where appropriate, and prescription algorithms are broadly similar. The importance of an integrated and multidisciplinary approach to patient care is emerging, aiming to address several different aspects of a multifaceted disease.

7.
J Clin Lipidol ; 2022 Apr 26.
Artigo em Inglês | MEDLINE | ID: mdl-35525793

RESUMO

BACKGROUND: Apolipoproteins are associated with risk of coronary heart disease but the association with risk of incident atrial fibrillation (AF) has been inconsistent. OBJECTIVES: This study investigated the association of apolipoproteins A-1 (apoA-1) and B (apoB), and lipid levels including triglyceride (TG), total cholesterol (TC), very low-density lipoprotein cholesterol (VLDL-C), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), with the risk of new-onset AF. METHODS: A total of 2533 men from the prospective, population-based Kuopio Ischaemic Heart Disease Risk Factor Study, aged 42-60 years, were studied. Cox proportional hazards adjusted for potential confounders was used to estimate hazard ratio (HR) of incident events across serum lipid, lipoprotein, and apoA-1 and apoB concentrations. RESULTS: During the mean follow-up of 22.4 years, 594 AF cases occurred. Cox proportional hazards regression indicated that higher serum HDL-C and apoA-1 concentrations were associated with lower risk of AF [the extreme-quartile multivariable-adjusted HR 0.72 (95% CI 0.57-0.92, P = 0.02) for HDL-C, and 0.72 (95% CI 0.52-1.00, P = 0.05)] for apoA-1]. No significant associations were observed for apoB and other lipids (TC, VLDL-C, LDL-C, non-HDL-C, and TG) with risk of incident AF. CONCLUSION: Over the time of follow-up in this study lower new-onset incident AF was in association with higher HDL-C and apo-A1 levels. Future studies should investigate mechanisms underlying the association of low HDL-C and low apoA1 with higher risk of incident AF.

8.
Artigo em Inglês | MEDLINE | ID: mdl-35579733

RESUMO

INTRODUCTION: There are a paucity of real-world data examining effectiveness and safety of non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin in nonvalvular atrial fibrillation (NVAF) patients with prior bleeding. METHODS: This retrospective analysis included data from 5 insurance claims databases and included NVAF patients prescribed OACs with prior bleeding. One-to-one propensity score matching was conducted between NOACs and warfarin and between NOACs in each database. Cox proportional hazards models were used to evaluate the risk of stroke/systemic embolism (SE) and MB. RESULTS: A total of 244,563 patients (mean age 77; 50% female) with prior bleeding included 55,094 (22.5%) treated with apixaban, 12,500 (5.1%) with dabigatran, 38,246 (15.6%) with rivaroxaban, and 138,723 (56.7%) with warfarin. Apixaban (hazard ratio [HR]: 0.76 [95% CI: 0.70, 0.83]) and rivaroxaban (HR: 0.79 [95% CI: 0.71, 0.87]) had a lower risk of stroke/SE vs. warfarin. Apixaban (HR: 0.67 [95% CI: 0.64, 0.70]) and dabigatran (HR: 0.88 [95% CI: 0.81, 0.96]) had a lower risk of MB vs. warfarin. Apixaban patients had a lower risk of stroke/SE vs. dabigatran (HR: 0.70 [95% CI: 0.57, 0.86]) and rivaroxaban (HR: 0.85 [95% CI: 0.76, 0.96]) and a lower risk of MB than dabigatran (HR: 0.73 [95% CI: 0.67, 0.81]) and rivaroxaban (HR: 0.64 [95% CI: 0.61, 0.68]). CONCLUSIONS: In this real-world analysis of a large sample of NVAF patients with prior bleeding, NOACs were associated with similar or lower risk of stroke/SE and MB vs. warfarin and variable risk of stroke/SE and MB against each other.

9.
Nutrients ; 14(9)2022 May 02.
Artigo em Inglês | MEDLINE | ID: mdl-35565874

RESUMO

Evidence for the association between vitamin D and risk of recurrent stroke remains sparse and limited. We aimed to assess the relationship between serum circulating 25-hydroxyvitamin D (25(OH)D) level and risk of recurrent stroke in patients with a stroke history, and to identify the optimal 25(OH)D level in relation to lowest recurrent stroke risk. Data from the nationwide prospective United Kingdom Biobank were used for analyses. Primary outcome was time to first stroke recurrence requiring a hospital visit during follow-up. We used Cox proportional hazards regression model with restricted cubic splines to explore 25(OH)D level in relation to recurrent stroke. The dose-response relationship between 25(OH)D and recurrent stroke risk was also estimated, taking the level of 10 nmol/L as reference. A total of 6824 participants (mean age: 60.6 years, 40.8% females) with a baseline stroke were included for analyses. There were 388 (5.7%) recurrent stroke events documented during a mean follow-up of 7.6 years. Using Cox proportional hazards regression model with restricted cubic splines, a quasi J-shaped relationship between 25(OH)D and risk of recurrent stroke was found, where the lowest recurrent stroke risk lay at the 25(OH)D level of approximate 60 nmol/L. When compared with 10 nmol/L, a 25(OH)D level of 60 nmol/L was related with a 48% reduction in the recurrent stroke risk (hazard ratio = 0.52, 95% confidence interval: 0.33-0.83). Based on data from a large-scale prospective cohort, we found a quasi J-shaped relationship between 25(OH)D and risk of recurrent stroke in patients with a stroke history. Given a lack of exploring the cause-effect relationship in this observational study, more high-quality evidence is needed to further clarify the vitamin D status in relation to recurrent stroke risk.

10.
Eur Heart J ; 2022 May 13.
Artigo em Inglês | MEDLINE | ID: mdl-35552401

RESUMO

The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient 'journey' or 'patient pathway,' supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management: • A: Appropriate Antithrombotic therapy. • B: Better functional and psychological status. • C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).

11.
Clin Res Cardiol ; 2022 Apr 29.
Artigo em Inglês | MEDLINE | ID: mdl-35488127

RESUMO

BACKGROUND: First-line ablation for atrial fibrillation (AF) reduces the risk of recurrent atrial arrhythmias compared to medical therapy. However, the prognostic benefit of early AF ablation remains undetermined. Herein, we aimed to evaluate the effects of early AF ablation compared to medical therapy. METHODS: Using data from phase II/III of the GLORIA-AF registry, we studied patients who were consecutively enrolled with newly diagnosed AF (< 3 months before baseline visit) and an increased risk of stroke (CHA2DS2-VASc ≥ 1). At baseline visit, 445 (1.7%) patients were treated with early AF ablation and 25,518 (98.3%) with medical therapy. Outcomes of interest were the composite outcome of all-cause death, stroke and major bleeding, and pre-specified outcomes of all-cause death, cardiovascular (CV) death, non-CV death, stroke and major bleeding. RESULTS: A total of 25,963 patients (11733 [45.2%] females; median age 71 [IQR 64-78] years; 17424 [67.1%] taking non-vitamin K antagonist oral anticoagulants [NOACs]) were included. Over a follow-up period of 3.0 (IQR 2.3-3.1) years, after adjustment for confounders, early AF ablation was associated with a significant reduction in the composite outcome of all-cause death, stroke and major bleeding (HR 0.50 [95% CI 0.30-0.85]) and all-cause death (HR 0.45 [95% CI 0.23-0.91]). There were no statistical differences between the groups in terms of CV death, non-CV death, stroke and major bleeding. Similar results were obtained in a propensity-score matched analysis of patients with comparable baseline variables. CONCLUSIONS: Early AF ablation in a contemporary prospective cohort of AF patients who were predominantly treated with NOACs was associated with a survival advantage compared to medical therapy alone. TRIAL REGISTRATION: Clinical trial registration: http://www. CLINICALTRIALS: gov . Unique identifiers: NCT01468701, NCT01671007 and NCT01937377. Created with BioRender.com.

12.
J Pers Med ; 12(4)2022 Apr 04.
Artigo em Inglês | MEDLINE | ID: mdl-35455694

RESUMO

AIMS: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and a key risk factor for ischaemic stroke. Following AF detection, treatment with oral anticoagulation can significantly lower mortality and morbidity rates associated with this risk. The availability of several hand-held devices which can detect AF may enable trained health professionals to adopt AF screening approaches which do not interfere with people's daily routines. This study aims to investigate the effectiveness of a hand-held device (the MyDiagnostick single-lead Electrocardiogram (ECG) sensor) in screening for AF when embedded into the handles of supermarket trolleys. METHODS: A mixed methods two-phase approach will be taken. The quantitative first phase will involve the recruitment of 2000 participants from a convenience sample at four large supermarkets with pharmacies. Prospective participants will be asked to conduct their shopping using a trolley embedded with a MyDiagnostick sensor. If the device identifies a participant with AF, the in-store pharmacist will be dispatched to take a manual pulse measurement and a static control sensor reading and offer a cardiologist consultation referral. When the sensor does not detect AF, a researcher will confirm the reading with a manual pulse measurement. ECGs will be compiled, and the sensitivity, specificity and positive and negative predictive values will be determined. A qualitative second phase will consist of semi-structured interviews carried out with those pharmacists and store managers in-store during the running of the trial period. These will explore the perceptions of staff regarding the merits of embedding sensors in the handles of supermarket trolleys to detect AF. CONCLUSION: This feasibility study will inform a larger future definitive trial.

13.
J Pers Med ; 12(4)2022 Apr 10.
Artigo em Inglês | MEDLINE | ID: mdl-35455726

RESUMO

Regular physical activity and exercise training are integral for the secondary prevention of cardiovascular disease. Despite recent advances in more holistic care pathways for people with atrial fibrillation (AF), exercise rehabilitation is not provided as part of routine care. The most recent European Society of Cardiology report for AF management states that patients should be encouraged to undertake moderate-intensity exercise and remain physically active to prevent AF incidence or recurrence. The aim of this review was to collate data from primary trials identified in three systematic reviews and recent real-world cohort studies to propose an AF-specific exercise rehabilitation guideline. Collating data from 21 studies, we propose that 360-720 metabolic equivalent (MET)-minutes/week, corresponding to ~60-120 min of exercise per week at moderate-to-vigorous intensity, could be an evidence-based recommendation for patients with AF to improve AF-specific outcomes, quality of life, and possibly prevent long-term major adverse cardiovascular events. Furthermore, non-traditional, low-moderate intensity exercise, such as Yoga, seems to have promising benefits on patient quality of life and possibly physical capacity and should, therefore, be considered in a personalised rehabilitation programme. Finally, we discuss the interesting concepts of short-term exercise-induced cardioprotection and 'none-response' to exercise training with reference to AF rehabilitation.

16.
Artigo em Inglês | MEDLINE | ID: mdl-35426602

RESUMO

BACKGROUND: The risk of stroke according to clinical classification of atrial fibrillation (AF) remains poorly defined. Here, we assessed the impact of AF type on stroke risk in vitamin K antagonist-treated patients with AF in 'real-world' and 'clinical trial' cohorts. METHODS: Post-hoc analysis of patient-level data from the Murcia AF Project and AMADEUS trial. Clinical classification of AF was based on contemporary recommendations from international guidelines. Study endpoint was the incidence rate of ischaemic stroke. Stroke risk was determined using CHA2DS2-VASc score and CARS. A modified CHA2DS2-VAS'c' score that applied one additional point for a 'c' criterion of continuous AF (i.e. non-paroxysmal AF) was calculated. RESULTS: We included 5,917 patients: 1,361 (23.0%) real-world and 4,556 (77.0%) clinical trial. Baseline demographics were balanced in the real-world cohort but clinical trial participants with non-pAF (vs. pAF) were older, male-predominant and had more comorbidities. Crude stroke rates were comparable between the groups in real-world patients (IRR 0.72 [95% CI,0.37-1.28], p = 0.259) though clinical trial participants with non-pAF had a significantly higher crude rate of stroke events (IRR 4.66 [95%,CI,2.41-9.48], p < 0.001). Using multivariable analysis, AF type was not independently associated with stroke risk in the real-world (adjusted HR 1.41 [95% CI,0.80-2.50], p = 0.239) and clinical trial (adjusted HR 1.16 [95% CI,0.62-2.20], p = 0.646) cohorts, after accounting for other risk factors. There was no significant improvement in the CHA2DS2-VAS'c' compared to CHA2DS2-VASc score in either cohorts (p > 0.05). CONCLUSIONS: Overall, our results support the need for anticoagulation based on thromboembolic risk profile rather than AF type.

17.
JAMA Cardiol ; 2022 Apr 13.
Artigo em Inglês | MEDLINE | ID: mdl-35416910

RESUMO

Importance: Long-term use of oral anticoagulants (OACs) is necessary for stroke prevention in patients with atrial fibrillation (AF). The effectiveness and safety of OACs in extremely older patients (ie, aged 80 years or older) with AF and at high risk of bleeding needs to be elucidated. Objective: To examine the effects of very low-dose edoxaban (15 mg) vs placebo across 3 age strata (80-84 years, 85-89 years, and ≥90 years) among patients with AF who were a part of the Edoxaban Low-Dose for Elder Care Atrial Fibrillation Patients (ELDERCARE-AF) trial. Design, Setting, and Participants: This prespecified subanalysis of a phase 3, randomized, double-blind, placebo-controlled trial was conducted from August 5, 2016, to December 27, 2019. Patients with AF aged 80 years or older who were not considered candidates for standard-dose OACs were included in the study; reasons these patients could not take standard-dose OACs included low creatinine clearance (<30 mL per minute), low body weight (≤45 kg), history of bleeding from critical organs, continuous use of nonsteroidal anti-inflammatory drugs, or concomitant use of antiplatelet drugs. Eligible patients were recruited randomly from 164 hospitals in Japan and were randomly assigned 1:1 to edoxaban or placebo. Interventions: Edoxaban (15 mg once daily) or placebo. Main Outcomes and Measures: The primary efficacy end point was the composite of stroke or systemic embolism. The primary safety end point was International Society on Thrombosis and Hemostasis-defined major bleeding. Results: A total of 984 patients (mean [SD] age: age group 80-84 years, 82.2 [1.4] years; age group 85-89 years, 86.8 [1.4] years; age group ≥90 years, 92.3 [2.1] years; 565 women [57.4%]) were included in this study. In the placebo group, estimated (SE) event rates for stroke or systemic embolism increased with age and were 3.9% (1.2%) per patient-year in the group aged 80 to 84 years (n = 181), 7.3% (1.7%) per patient-year in the group aged 85 to 89 years (n = 184), and 10.1% (2.5%) per patient-year in the group aged 90 years or older (n = 127). A 15-mg dose of edoxaban consistently decreased the event rates for stroke or systemic embolism with no interaction with age (80-84 years, hazard ratio [HR], 0.41; 95% CI, 0.13-1.31; P = .13; 85-89 years, HR, 0.42; 95% CI, 0.17-0.99; P = .05; ≥90 years, HR, 0.23; 95% CI, 0.08-0.68; P = .008; interaction P = .65). Major bleeding and major or clinically relevant nonmajor bleeding events were numerically higher with edoxaban, but the differences did not reach statistical significance, and there was no interaction with age. There was no difference in the event rate for all-cause death between the edoxaban and placebo groups in all age strata. Conclusions and Relevance: Results of this subanalysis of the ELDERCARE-AF randomized clinical trial revealed that among Japanese patients aged 80 years or older with AF who were not considered candidates for standard OACs, a once-daily 15-mg dose of edoxaban was superior to placebo in preventing stroke or systemic embolism consistently across all 3 age strata, including those aged 90 years or older, albeit with a higher but nonstatistically significant incidence of bleeding. Trial Registration: ClinicalTrials.gov Identifier: NCT02801669.

18.
Cardiol Clin ; 40(2): 245-258, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-35465898

RESUMO

Heart failure (HF) and atrial fibrillation (AF), increasingly common in the aging population, are closely related and commonly found together. This article explores the relationship between AF and HF and the thromboembolic effect of these diseases. Morbidity and mortality are increased when the 2 conditions are seen together. Stroke risks are significant with AF and all subtypes of HF. This article suggests that all patients with AF and HF should be considered for anticoagulation. Current evidence suggests that non-vitamin K antagonist oral anticoagulants are effective and safe in AF and HF in comparison with warfarin.


Assuntos
Fibrilação Atrial , Insuficiência Cardíaca , Acidente Vascular Cerebral , Administração Oral , Idoso , Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Fibrinolíticos/uso terapêutico , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/tratamento farmacológico , Humanos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle
19.
Am J Med ; 2022 Apr 03.
Artigo em Inglês | MEDLINE | ID: mdl-35381212

RESUMO

OBJECTIVE: Hemoglobin levels and platelet counts have been associated with adverse clinical outcomes in patients with cardiovascular conditions. We aimed to assess the impact of oral anticoagulant use for patients with atrial fibrillation and concomitant anemia or thrombocytopenia. METHODS: We used medical data from a multicenter health care system in Taiwan including 37,074 patients with atrial fibrillation. Patients were categorized into 3 groups based on hemoglobin and platelet levels: Group 1 (hemoglobin >10g/dL and platelet>100 K/µL; n = 29,147), Group 2 (hemoglobin<10 g/dL or platelet<100 K/µL; n = 7078), and Group 3 (hemoglobin <10 g/dL and platelet <100 K/µL; n = 849). Patients in each category were further stratified as 3 groups according to their stroke prevention strategies: no oral anticoagulant use (non-OAC), warfarin, or nonvitamin K antagonist oral anticoagulants (NOACs). RESULTS: A higher hemoglobin or platelet level was associated with a higher risk of ischemic stroke/systemic embolism but lower risks of intracranial hemorrhage and major bleeding. The composite risks of ischemic stroke/systemic embolism, intracranial hemorrhage and major bleeding were higher in Group 3 or Group 2, compared with Group 1 (6.79% a year vs 6.41% year vs 4.13% year). Compared to non-OACs, warfarin was not associated with a lower composite risk in the 3 groups. NOACs were associated with a lower composite risk in Group 1 (adjusted hazard ratio:0.68, [95% confidence interval:0.60-0.76]) and Group 2 (adjusted hazard ratio:0.73, [95% confidence interval:0.53-0.99]) but was nonsignificant in Group 3. CONCLUSIONS: Patients with atrial fibrillation with anemia or thrombocytopenia were a high-risk population. Compared with no OAC use, NOACs were associated with better clinical outcomes for patients with atrial fibrillation and advanced anemia (hemoglobin <10g/dL) or thrombocytopenia (platelet <100 K/µL) but not for those with both conditions.

20.
Syst Rev ; 11(1): 63, 2022 Apr 08.
Artigo em Inglês | MEDLINE | ID: mdl-35395931

RESUMO

BACKGROUND: Atrial fibrillation affects an estimated 33 million individuals worldwide and is a major cause of stroke, heart failure, and death. Anticoagulants substantially reduce the risk of stroke but are also associated with an increased risk of bleeding and especially intracranial hemorrhage which is the most concerning complication. Because of this, many patients are not offered anticoagulants, particularly patients at risk of falls or with a history of falls. It is unclear what anticoagulant treatment these patients should be offered. The Liverpool AF-Falls project aims to investigate this area, and this protocol for a systematic review and meta-analysis aims to define what is the most appropriate anticoagulant treatment option for the management of atrial fibrillation patients at risk of falls or with a history of falls. METHODS: This systematic review and meta-analysis will include randomized and non-randomized studies evaluating the safety and efficacy of different anticoagulant treatments (vitamin K antagonist and non-vitamin K antagonist oral anti-coagulant). Bibliographic databases (Cochrane Central Register of Controlled Trials, CINAHL, ClinicalTrials.gov , Embase, MEDLINE, Scopus and Web of Science) will be searched according to a pre-specified search strategy. Titles, abstracts, and full texts will be assessed by two independent reviewers and disagreements resolved with a third independent reviewer. The Cochrane Risk of Bias tool 2 (RoB 2) will be used to assess the risk of bias in randomized trials, and the Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I) tool will be used for non-randomized studies. A pairwise meta-analysis based on the fixed and random-effects models will be conducted. Publication bias will be evaluated with a funnel plot and Egger's test. Heterogeneity will be assessed with the I2 statistic. If conditions for indirect comparison are met and sufficient data are available, a network meta-analysis will be conducted using frequentist and Bayesian methodologies. DISCUSSION: This review will be the first to summarize direct and indirect evidence on the safety and efficacy of anticoagulant treatments in atrial fibrillation patients at risk of falls or with a history of falls. The findings will be important to patients, clinicians, and health policy-makers to inform best practices in the use of these treatments. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registry number: CRD42020201086.


Assuntos
Fibrilação Atrial , Acidente Vascular Cerebral , Administração Oral , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Teorema de Bayes , Humanos , Metanálise como Assunto , Literatura de Revisão como Assunto , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Revisões Sistemáticas como Assunto
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