Antithrombotic Management Of Atrial Fibrillation Research Articles

Evolution of Antithrombotic Management of Atrial Fibrillation After Percutaneous Coronary Intervention Over 10 Years and Guidelines Uptake

BackgroundThe management of atrial fibrillation and/or flutter (AF) patients requiring percutaneous coronary intervention (PCI) has evolved significantly. The Canadian Cardiovascular Society AF guidelines, last updated in 2020, seek to aid physicians in balancing both bleeding and thrombotic risks. MethodsA tertiary academic centre registry of patients with AF who had PCI was examined for the antithrombotic therapy at discharge in 4 time periods (cohort 2010–2011; cohort 2014–2015; cohort 2017; cohort 2019). Discharge prescription patterns were compared among the cohorts, using the χ2 test. In addition, antithrombotic management in cohorts 2017 and 2019 were compared to guideline-expected therapy, using the χ2 test. ResultsA total of 576 AF patients undergoing PCI were included. Clinical and procedural characteristics were similar among cohorts, except for an increase in drug-eluting stent use in the most recent cohort (94% vs 99%; P = 0.04). The rate of oral anticoagulation increased over time (75% vs 89%; P < 0.01), driven primarily by an increase in direct oral anticoagulants prescription (63% vs 84%; P < 0.01). In contrast to previous cohorts, there was no significant difference between the observed and the guideline-expected anticoagulation rate in cohort 2019 (89% vs 94%; P = 0.23). ConclusionsA combination of expert guidance and educational initiatives in the past decade contributed to dramatic changes in the management of patients with AF undergoing PCI.

Prevalence and Antithrombotic Management of Atrial Fibrillation in the Elderly Patients

Atrial fibrillation is associated with an increased risk of thromboembolic events like stroke which is a leading cause of morbidity and mortality worldwide. If AF is treated with anticoagulant therapy in selected patients, it improves outcome in such patients. Out of 200 elderly patients aged between 65 to 78 years of age selected for the study 30 patients (15%) were diagnosed as Atrial Fibrillation. Out of these 30 patients with AF 7(23.3%) were alcoholic, 6(20%) had generalized anxiety, 8(26.6%) had stressful life, 5(16.6%) were having over intake of salt and fatty food, 4(13.3%) were tobacco chewers. Seven patients (23.3%) were hypertensive, 5(10.6%) had Diabetes mellitus, 8(26.6%) had coronary heart disease, 4(13.3%) had hyperthyroidism, 3(10%) had abnormal cardiac valve, 3(10%) had peripheral arterial diseases. In the study of Bleeding risk scores Atria Scores had-3 anemic, 2 had severe renal disease, 1 was above 76 years of age, 2 had HTN. In HAS-BLED score 1 had HTN, 1 had abnormal liver or kidney function, 1 had stroke, 1 had bleeding, 1 was above 76 years of age, 1 had drug or alcohol abuse, In Hemorrhagic score 1 had hepatic or renal disease, 1 was above 75, 1 had reduced platelet count, 1 had re-bleeding, 1 had HTN, 1was anemic, 1 had genetic factor, 1 had stroke. Aspirin and clopidogrel are in routine use as antithrombotic while heparin and various oral agents are widely used as anticoagulant. This study in elderly patient highlights the need for screening for detection and appropriate treatment of AF to prevent various embolic complications like stroke and mitigate the burden of high morbidity and mortality in such patients.

Optimal long-term antithrombotic management of atrial fibrillation: life cycle management.

Optimal antithrombotic management of atrial fibrillation equals balancing between prevention of arterial thromboembolism, predominantly ischaemic stroke, and haemorrhagic complications. Over time different antithrombotic agents and strategies have been developed. At present, non-vitamin K antagonist oral anticoagulants (NOACs) are the first-line therapy for stroke prevention in patients with non-valvular atrial fibrillation (i.e. without a mechanical valve prosthesis or rheumatic heart disease). Considering the impact of the suboptimal adoption of recommended oral anticoagulant therapy, as experienced with the previous first-line vitamin K antagonists, this review focuses on adequate use of NOACs. As such, we address the most important and clinically challenging issues in the antithrombotic life cycle management for long-term stroke prevention in atrial fibrillation.

Do CHA2 DS2 VASc and HAS-BLED scores influence 'real-world' anticoagulation management in atrial fibrillation? 1556 patient registry from the reference cardiology centre.

Although recommendations for the antithrombotic management of atrial fibrillation (AF) are based on strong evidence, the European guidelines are not fully implemented into practice. The objective of this study is to analyse antithrombotic treatment in AF in Poland after the publication of the European Society of Cardiology Guidelines in 2012. We retrospectively studied 1556 patients with AF from the Reference Cardiology University Centre in Poland in 2012-2014. CHA2 DS2 VASc and HAS-BLED scores were 3.5 ± 1.7 and 2.4 ± 1.1. Anti-vitamin K agent were prescribed in 59%, with non-vitamin K antagonist oral anticoagulants in 12%, acetylsalicylic acid (ASA) alone in 18%. Older patients (p < 0.0001) and with paroxysmal AF were less likely to receive oral anticoagulation (OAC, p < 0.0001). The risk of stroke according to CHA2 DS2 VASc score was higher in patients who did not receive OAC (p < 0.0001). The use of OAC increased with increasing CHA2 DS2 VASc score but was less frequent in score ≥ 4. The risk of bleeding was higher in patients without OAC (p < 0.0001). The odds of non-vitamin K antagonist oral anticoagulants use were lower for older patients, patients with ischaemic heart disease, chronic heart failure, anaemia, HAS-BLED ≥ 3 and valvular AF. ASA was given in 39% of the patients, especially in paroxysmal AF (p < 0.0001). The odds of ASA alone were higher for older patients, with ischaemic heart disease and history of myocardial infarction (p < 0.0001). The odds of use of ASA as the only treatment were 5.5 times higher for HAS-BLED ≥ 3 (p < 0.0001). Antithrombotic management in AF is well implemented in Polish conditions, but we show the lack of pattern concerning who is being treated with OAC and ASA when it comes to the risk of stroke and bleeding.

Prevalence and antithrombotic management of atrial fibrillation in hospitalised patients

ObjectivesThe objective of this study was to determine the prevalence of atrial fibrillation (AF) in a tertiary care centre, to describe the comorbidity profile of hospitalised patients with AF, and...

Potential use of NOACs in developing countries: pros and cons

Although vitamin K antagonists (VKAs) are effective for long-term thromboprophylaxis in atrial fibrillation (AF), their limitations have led to widespread underutilisation, especially in the developing world. Novel oral anticoagulants (NOACs) have emerged as promising alternatives to VKAs, although there are some particular considerations and challenges to their introduction in developing countries. This review summarises the current state of antithrombotic management of AF in the developing world, explores the early evidence for the NOACs and describes some of the special considerations that must be taken into account when considering the role of the NOACs within developing countries' health care systems. A literature search was conducted via PubMed and Google Scholar to find articles published in English between the years 2000 to 2014. Search terms used were "atrial fibrillation", "oral anticoagulants", "warfarin", "NOACs", "dabigatran", "rivaroxaban", "apixaban", "edoxaban", "time in therapeutic range", "International Normalized Ratio" "cost-effectiveness", "stroke", "adverse-drug reactions" and "drug-drug interactions", together with the individual names of developing countries as listed by the World Bank. We reviewed the results of randomized clinical trials, relevant retrospective and prospective studies, case-studies and review articles. Many developing countries lack or have sporadic data on the quality of AF management, making it difficult to anticipate the potential impact of NOACs in these settings. The utilisation of anticoagulants for AF appears highly variable in developing countries. Given the issues associated with VKA therapy in many developing countries, NOACs offer some potential advantages; however, there is insufficient evidence to advocate the widespread replacement of warfarin at present. VKAs may continue to have a role in selected patients or countries, especially if alternative monitoring strategies can be utilised. The evaluation of the introduction of NOACs should consider safety, budget concerns and the quality of oral anticoagulation care achieved by each country. Prospective registries will be important in developing countries to better elucidate the comparative safety, efficacy and cost-effectiveness of NOACs and VKAs as NOACs are introduced into practice.

Incidence, prevalence, and antithrombotic management of atrial fibrillation in elderly Germans

Data on the epidemiology of atrial fibrillation (AF) and its antithrombotic management in elderly populations are scarce. The aims of this study were to estimate the incidence and prevalence of AF in the elderly in Germany and to describe antithrombotic management of AF cases. Estimation of prevalence and incidence was based on data of three German statutory health insurances, which insured more than 800 000 people aged 65 years and older in the study period. The 1-year period prevalence of AF was estimated for each of the years 2004-2007. The incidence rate of AF in 2007 was assessed in patients with a preceding continuous 3-year insurance period without diagnoses of AF. Antithrombotic management of AF was described among incident AF cases in 2008 and predictors for lack of prescriptions of oral anticoagulants were identified. Age-standardized period prevalence of AF among those 65 years or older was 7.7% in 2004, 9.4% in 2005, 9.8% in 2006, and 10.3% in 2007. The age-standardized incidence of AF was 27.4 of 1000 person-years in 2007. Prevalence and incidence increased with age and were higher in men than in women. In 2008, 58.2% of new AF cases received antithrombotic drugs. Treatment was less common among women and older people. Incidence and prevalence of AF are relatively high in the elderly in Germany. A considerable fraction of new AF cases did not receive antithrombotic drugs in routine care.

Predictors of left atrium appendage clot detection despite on-target warfarin prevention for atrial fibrillation

The antithrombotic management of atrial fibrillation (AF) is currently based on clinical scores (CHADS(2) or CHA(2)DS(2)VASc). The prevalence of left atrium (LA) thrombi in effectively anticoagulated AF patients has been reported as being up to 7.7 %. We tried to correlate LA/LA appendage (LAA) thrombus detection with possible clinical predictors in warfarin-treated patients. We performed trans-esophageal echocardiography on 430 patients (mean age, 60.3 ± 9.8 years) receiving oral anticoagulant (OAC) therapy and undergoing pulmonary vein isolation. In 10/430 (2.3 %), an LA thrombus was found despite therapeutic OAC (mean INR 2.6 ± 0.6; range, 2.0-3.8) over the previous 4 weeks. Two study groups were identified: 1. T-positive group = with LAA thrombus (10 patients) 2. T-negative group = without LAA thrombus (420 patients) The T-positive patients had a higher CHADS(2) score (1.5 ± 0.7 versus 0.7 ± 0.8; p = 0.004), a lower LVEF (54.7 ± 9.5 % versus 60.2 ± 7.4; p = 0.02), and a larger LA size (LA diameter, 56 ± 12.2 mm versus 46 ± 6.5 mm; p < 0.001and normalized LA volume: 140.2 ± 66 ml/m² vs. 67 ± 39 ml/m²; p < 0.05). On multivariate analysis, a larger LA diameter and normalized LA volume (OR, 1.14; 95 % C.I., 1.04-1.26; p = 0.006 and OR, 1.02; 95 % C.I., 1.01-1.03; p = 0.001, respectively) and a higher CHA(2)DS(2)VASc score (OR, 2.4; 95 % C.I., 1.4-4.2; p = 0.001) predicted left atrium appendage (LAA) thrombus. In another 42/430 (9.8 %) patients, an LA spontaneous echo-contrast (SEC) was detected. Thus, cumulatively, 52/430 (12.1 %) patients had either LAA thrombi (10 patients) or SEC (42 patients). LA diameter continued to predict the presence of either thrombi or SEC (OR, 1.14; 95 % C.I., 1.07-1.2; p < 0.05). We found a 2.3 % prevalence of LA thrombus (12.1 % when SEC was also considered). The thrombus was present despite on-target warfarin prevention. In addition to a higher CHA(2)DS(2)VASc score, a larger LA size was a strong predictor of clot detection.

Evaluation of antithrombotic usage for atrial fibrillation in aged care facilities

Warfarin is an important drug for the prevention of thromboembolic events such as stroke in patients with atrial fibrillation (AF). However, it is commonly implicated in major adverse drug events, which may result in reluctance to prescribe warfarin, especially in the institutionalised elderly population. This study aimed to assess the current trends in the antithrombotic management of AF in aged care facilities (ACFs) in Tasmania, Australia, and to compare this with current recommendations. We performed a non-experimental, retrospective cohort study designed to evaluate antithrombotic usage for AF in ACF residents in Tasmania. Residents with AF were identified on a patient-by-patient basis from residential case-note summaries collected from 29 of the 64 ACFs in Tasmania. The CHADS-2 score and the presence or absence of documented contraindications were used to determine the appropriateness of the current antithrombotic therapy prescribed. Fifteen per cent (262/1737) of the ACF residents were diagnosed with AF. Nine per cent of the residents with AF had a contraindication to antithrombotic therapy (either warfarin or antiplatelet therapy). Eighty-one per cent of residents were eligible for treatment with warfarin according to the CHADS-2 score and did not appear to have a contraindication to warfarin. Of these, only 38% were prescribed warfarin; 16% (40/255) did not receive any antithrombotic treatment, despite being eligible for treatment with warfarin or antiplatelet therapy. Residents who did not receive any antithrombotic treatment or who received antiplatelet treatment were significantly older than those treated with anticoagulants. Our results indicate that antithrombotic therapy, particularly warfarin, is underused in ACF-dwelling elderly patients who are eligible for treatment.

Antithrombotic Management of Atrial Fibrillation

Antithrombotic Management of Atrial Fibrillation

Anticoagulation in atrial fibrillation: selected controversies including optimal anticoagulation intensity, treatment of intracerebral hemorrhage

Clinical trials during the past 20 years have revolutionized the antithrombotic management of atrial fibrillation. Based on consideration of 30 randomized trials involving 29,017 participants, adjusted-dose warfarin remains the most efficacious prophylaxis against stroke for atrial fibrillation patients at moderate-to-high risk (compared with antiplatelet agents, warfarin reduces stroke by about 40%). The optimal INR for prevention of stroke for most atrial fibrillation patients is probably 2.0-2.5; INRs of 1.6-1.9 provide substantial protection, 80-90% of that afforded by higher intensities. Warfarin-associated intracerebral hemorrhage is an increasing problem as more elderly patients with atrial fibrillation are anticoagulated. Modest reductions in blood pressure results in large decreases in this most dreaded complication of warfarin; anticoagulation of elderly atrial fibrillation patients should be accompanied by a firm commitment to control hypertension. Warfarin-associated intracerebral hemorrhage has a 50% early mortality. A wide range of acute treatments to urgently reverse anticoagulation have been recommended by experts, but prevention is a far better option than treatment of this devastating problem.

Implementation of antithrombotic management in atrial fibrillation

The aim of the study was to assess the extent to which published recommendations on the antithrombotic management of atrial fibrillation had been adopted into clinical practice in a busy...

Antithrombotic Management of Atrial Fibrillation for Stroke Prevention in Older People

Atrial fibrillation (AF) is a common cardiac condition in the elderly population. The primary concern in individuals with AF is the risk of stroke. The management of AF for stroke prevention requires an understanding of the relative risks and benefits of antithrombotic therapy. Numerous randomized clinical trials have improved tremendously our understanding of the relative merits of anticoagulation and aspirin, and indicate that anticoagulation is the appropriate treatment for the majority of individuals with AF. In patients who have contraindications to anticoagulation, aspirin is recommended.

Antithrombotic management of atrial fibrillation

Antithrombotic management of atrial fibrillation