Patientswith Atrial Fibrillation Research Articles

Discordant Treatment Goals for PatientsWith Atrial Fibrillation and Clinical Trials Metrics.

Most clinical trials define successful atrial fibrillation (AF) treatment as no AF episodes longer than 30 seconds. Yet, there has been minimal study of how patients define successful treatment and whether their perspectives align with trial outcomes. Survey patients with AF to identify: 1) what aspect of AF is most important to address (frequency, duration, or severity of AF episodes); 2) what AF burden would be considered acceptable to consider treatment successful; and 3) to establish patient preferences for successful treatment thresholds for a validated patient-reported outcome (PRO) score. We surveyed patients receiving active care for AF at a single tertiary care center modeled after the Toronto AF Severity Scale (AFSS). The survey consisted of current and "successful treatment" AF frequency, burden, and symptom domains; and baseline socioeconomic information. Of 7,000 invitations, 852 individuals completed the survey (12% response) with a mean age of 65 ± 13 years, 36.5% were female, and they had a mean CHA2DS2-VAsc score of 2.9 ± 1.9. Overall, 114 (13%) selected a decrease in AF episode duration as their top treatment priority, 505 (59%) episode frequency, and 230 (27%) episode severity. Overall, 207 (24%) patients would only consider a treatment successful if they never had AF again, whereas 645 (76%) patients considered success to be fewer AF episodes. A total of 341 (40%) patients would only consider a treatment successful if AF episodes lasted less than a few minutes, whereas 509 (60%) patients would accept AF episodes lasting >30minutes. An AFSS symptom score≤5 was considered a good outcome by 80% of respondents. Patients prioritize decreased AF frequency over improvements in severity or duration, and an AFSS≤5 would be a reasonable outcome of AF treatment. Most patients would consider treatment successful if they had more than 1 AF episode lasting longer than 30 seconds. Future clinical trial design should consider patients' perspectives when designing outcomes.

Why INR is outside the therapeutic range in patients with acuteischemic stroke and atrial fibrillation

Introduction: Warfarin is still the primary drug used to prevent vascular events in patientswith atrial fibrillation (AF), especially in low-income countries. Therapeutic failure and non-adherenceare common causes of recurrent embolic events. The aim of this study was toinvestigate possible reasons why INR was outside the therapeutic range in patients presentingwith acute ischemic stroke and AF. Methods: This prospective study was performed over a ten-month period and all patientsadmitted with acute ischemic stroke were enrolled. Patients with AF who did not have INRwithin the therapeutic range (INR = 2-3) at the time of admission were identified. During a face-to-face interview, the reasons for INR being outside the therapeutic range were assessed basedon a prepared checklist. Results: During the study period, 810 patients had an acute ischemic stroke, of which 177 hadAF heart rhythm (22%). The median age was 76 (IQR: 71-83), and 87 (52%) were male. Of these177 patients, 44 (25%) had a previous history of AF ("previous AF" group) and 133 (75%) werediagnosed with AF during the current hospital admission ("new AF" group). Among patients onwarfarin but with INR outside the therapeutic range (29 in all), 20 (69%) did not see a physicianregularly and/or did not take medication according to the physician’s instructions. Conclusion: The most common reason for INR being outside the therapeutic range was patientslack of awareness of their heart disease (unrecognized AF). Other reasons included irregularvisits to the physician and drug non-adherence.

Clinical significance of bleeding scoring systems

Introduction. Bleeding scoring systems are used for predicting the risk of a specific primary outcome in a specific population.In this article, we present scoring systems frequently used in internist practice. Bleeding scoring systems for acute upper gastrointestinal bleeding. Are divided into clinical, endoscopic,and combined scoring systems, according to the type of variables included. Besides traditional systems (Rockall, Glasgow-Blatchford), we primarily present clinical scoring systems used for upper gastrointestinal bleeding. Bleeding scoring systems for patients with atrial fibrillation on anticoagulant therapy. We refer to the most significant scoring systems - ATRIA, HAS-BLED, and ORBIT. Since the prognostic performance of the existing scoring systems is less than satisfactory, medical organizations suggest they should be used for recognizing patients who deserve close monitoring during anticoagulant therapy. Bleeding scoring systems for patients with acute myocardial infarction treated with percutaneous coronary intervention. ACUITY-HORIZONS was proven to be superior to other scoring systems in predicting bleeding within 30 days in patients with a myocardial infarction treated with transradial percutaneous coronary intervention. Bleeding scoring systems for bleeding disorders. Scoring systems enable the detection of bleeding disorders before performing laboratory tests. Considering the frequency severity of symptoms, newer systems have been developed for the pediatric population and self-testing by modifying the original scoring system. Conclusion. Although medical organizations encourage the implementation of scoring systems in clinical practice, the development of newer and enhanced existing systems requires a comprehensive approach and critical analysis of the existing systems.

Influence of Knowledge about Cardio-Cerebrovascular Disease Symptoms on Self-Management Behaviors in Patients with Atrial Fibrillation

Aim: This study aimed to assess stroke risk and Cardio-cerebrovascular symptom knowledge in patientswith atrial fibrillation, and to determine the relationship between knowledge and self-management in thesepatients.Methods: Using a cross-sectional study design, 120 patients from an outpatient clinic were recruited fromtwo medical centers. Data were collected using a structured questionnaire, and data on risk factors andclinical characteristics were collected from patients’ medical records. The data were analyzed by one-wayanalysis of variance, Pearson correlation coefficient, and hierarchical multiple linear regression analysis.Results: The risk of stroke was estimated to be 82.5%. For the assessment of patient cardio-cerebrovascularsymptom knowledge the correct answer rate was as 37%. Hierarchical regression analysis showed thatknowledge about cardio-cerebrovascular disease symptoms was a significant predictor, explaining anadditional 28.3% of the variance of self-management behaviors.Conclusions: These results suggest the need for education programs that include information about cardiocerebrovasculardisease symptoms and the risks of stroke occurring as a complication, in order to enhanceself-management behaviors in patients with atrial fibrillation.

Asymmetric Organocatalyzed Warfarin Synthesis in Aqueous and Nonaqueous Media: A Discussion in the Era of COVID-19 Pandemic

The recent widespread infection of COVID-19 in the entire world has created a pandemic situation with a serious health challenge to mankind. Numerous incidents of cardiovascular diseases were found among COVID-19 patients with a significantly high morbidity rate. Medication with several anticoagulant or blood thinner drugs are being performed on COVID-19 patients with atrial fibrillation and cardiovascular ailments to minimize the incidence of death. Warfarin is a widely used anticoagulant and cardiovascular drug prescribed as its sodium salt. S-Enantiomer is two to five times more active than R-enantiomer as an anticoagulant. Synthesis of enantiomerically pure warfarin is thus a rational and extremely important task. Organocatalyzed synthetic strategies may be considered as important avenues to produce optically pure warfarin in comparison to biocatalysis and chiral metal complex catalysis. Herein, a comprehensive review of the asymmetric organocatalyzed synthesis of warfarin catalyzed by diamine based organocatalysts, amino acidbased organocatalysts, quinine based organocatalysts, and proline derived organocatalysts in both aqueous and non-aqueous media has been discussed.

Atrial Fibrillation among Jordanian Patients

To estimate the rate of atrial fibrillation (AF) among Jordanian patients, and to identify the clinical data ofsigns and symptoms, diagnostic criteria, complications, prognosis and management. A cross-sectional studyinvolving total- 126-AF patients who admitted to Prince Hamzah Hospital with diagnosis of AF. The studywas begun from January 2018 to July 2019. A non-probability (Convenience) sample of (126) patients withatrial fibrillation who are admitted to the cardiac unit at Prince Hamzah Hospital. A special standardizedquestion form is designed and to be filled by researcher after patient signing his consent paper. The studyincluded (126) Atrial Fibrillation Jordanian patients. The result find the age is important risk factor for atriapatient. The high percentage of patients distributed among old age group. AF was associated with chronicdiseases, such as hypertension (73.01%). In spite of the fact that atrial fibrillation is expected to be anepidemic disease within the next 20-30 years, no clear preventive programs especially for those who havehigh risk like diabetes mellitus, hypertension, ischemic heart disease and overweight regarding educationand changing lifestyle to reduce the incidence of atrial fibrillation.

Seguridad de la exclusión quirúrgica del apéndice auricular izquierdo en pacientes con fibrilación auricular sometidos a cirugía valvular mitral

Introduction: atrial fibrillation is the most common sustained cardiac arrythmia in clinical practice. It is associated tosignificant morbimortality. The prevention of embolic episodes is a pillar of atrial fibrillation treatment and is basedmainly on anticoagulation. However, there is a significant proportion of patients with contraindications for anticoagula tion, to whom alternative treatments must be offered. Surgical exclusion of the left atrial appendage offers benefits inthis regard, and is associated to a lower rate of neurological events.Objective: primary endpoint: to evaluate the safety of the surgical exclusion of the left atrial appendage in patients withatrial fibrillation undergoing mitral valve surgery; secondary endpoint: to analyze the incidence of stroke in this population, and to analyze the survival rate in patients with and without left atrial appendage exclusion.Method: a single center, analytic, observational, retrospective study, comparing exclusion and no exclusion of the leftatrial appendage in patients with atrial fibrillation undergoing mitral valve surgery between January 2012 and December 2018. The variables were obtained from the institutional database. The follow up was telephonic and survival rateswere obtained from a national official database.Results: 69 patients were included (45 underwent surgical left atrial appendage exclusion). Statistically significant features between the groups were age (69.1±8.2 years without left atrial appendage exclusion; 63.6±10.3 years with leftatrial appendage exclusion, p=0.026), and the rate of surgical ablation of atrial fibrillation (29.2% without exclusion;68.9% with exclusion, p=0.002). The follow up was carried out in 33, finding no statistically significant differences between the groups. The survival rate of all patients was analyzed, finding no long term differences.Conclusion: according to the data analyzed, left atrial appendage exclusion is a safe procedure, and adds no furthercomplications to mitral valve surgery in patients with atrial fibrillation. It was not possible to prove that left atrial appendage exclusion significantly reduces the long term prevalence of ischemic stroke or modifies the survival rate.

Patient with cardioembolic stroke: clinical characteristics and typical features

Aim. To evaluate basic clinicopathologicalcharacteristics of patients with atrial fibrillationand pharmacological anamnesis at the time of cardioembolicstroke.Material and Methods. Study included 99 patientswith atrial fibrillation admitted to SeredavinSamara Regional Clinical Hospital due to cardioembolicstroke. The follow-up duration was 1year.Results. The average age of the patients was69.1 ± 8.7 years. Patients with atrial fibrillationand acute cardioembolic stroke were characterizedby multimorbidity. Arterial hypertension, chronickidney disease, and diabetes mellitus were diagnosedin 96/99 (97.0%), 60/99 (60.6%), and 22/99(22.2%) patients, respectively. Average risk scoreaccording to the CHA2DS2-VASc scale before admissionwas 4.51 ± 1.2 points; therefore, 96 patientshad indications for anticoagulant therapy (≥2 points on the CHA2DS2-VASc scale). However,adequate prevention of thromboembolic complicationsbefore admission was carried out only in16/99 (16.2%) patients.Conclusion. These results demonstrate a lowquality of outpatient care in patients with atrialfibrillation. Most likely, this can be explained bythe lack of awareness about the risks of potentialcomplications and low compliance.

Risk of Coronary Events in Atrial Fibrillation

It has been established that cardiovascular events due to coronary heart disease are highly prevalent in the population of patientswith atrial fibrillation. In this review, pathophysiologic mechanisms explaining this association are detailed along with supportingepidemiological evidence. Various methods for the prediction and prevention of coronary events in atrial fibrillation are iscussed,including modification of shared risk factors, antithrombotic therapy and selection of the optimal direct oral anticoagulant interms of favourable influence on ischemic cardiac outcomes.

Selective Serotonin Reuptake Inhibitors and Bleeding Risk in Anticoagulated Patients With Atrial Fibrillation: An Analysis From the ROCKET AF Trial.

BackgroundThere is concern that selective serotonin reuptake inhibitors (SSRIs) substantially increase bleeding risk in patients taking anticoagulants.Methods and ResultsWe studied 737 patients taking SSRIs in the ROCKET AF (Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Embolism and Stroke Trial in Atrial Fibrillation) trial of rivaroxaban compared with warfarin for the prevention of stroke/systemic embolism in patients with atrial fibrillation. These patients were propensity score matched 1:1 to 737 patients not taking SSRIs. The primary outcome measure was major and nonmajor clinically relevant bleeding events, the principal safety outcome in ROCKET AF. Over a mean 1.6 years of follow‐up, the rate of major/nonmajor clinically relevant bleeding was 18.57 events/100 patient‐years for SSRI users versus 16.84 events/100 patient‐years for matched comparators, adjusted hazard ratio (aHR) of 1.16 (95% confidence interval [CI], 0.95–1.43). The aHRs were similar in patients taking rivaroxaban (aHR 1.11 [95% CI, 0.82–1.51]) and those taking warfarin (aHR 1.21 [95% CI, 0.91–1.60]). For the rarer outcome of major bleeding, the aHR for SSRI users versus those not taking SSRIs was 1.13 (95% CI, 0.62–2.06) for rivaroxaban; for warfarin, the aHR was higher, at 1.58 (95% CI, 0.96–2.60) but not statistically significantly elevated.ConclusionsWe found no significant increase in bleeding risk when SSRIs were combined with anticoagulant therapy, although there was a suggestion of increased bleeding risk with SSRIs added to warfarin. While physicians should be vigilant regarding bleeding risk, our results provide reassurance that SSRIs can be safely added to anticoagulants in patients with atrial fibrillation.Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT00403767.

Relation of Body Mass Index to Symptom Burden in Patients withAtrial Fibrillation

Atrial fibrillation (AF) is the most common sustained arrhythmia and is associated with significant morbidity and increased mortality. As body mass index (BMI) is increasingly recognized as an important risk factor for the development of AF, we tested the hypothesis that BMI modulates symptomatic AF burden. Cross-sectional data collected from 1,382 patients in the Vanderbilt AF Registry were analyzed. AF severity was assessed using the Toronto atrial fibrillation severity scale (AFSS). BMI was categorized according to World Health Organization guidelines and patients were grouped according to their present AF treatment regimen: no treatment (n = 185), rate control therapy with atrioventricular nodal blocking agents (n = 351), rhythm control with antiarrhythmic drugs (n = 636), and previous AF ablation (n = 210). Patients with BMI >35 kg/m2 had higher AFSS scores than those with BMI <30 kg/m2 in the rate control (43.57 vs 38.21: p = 0.0057), rhythm control (46.61 vs 41.08: p = 1.6 × 10-4), and ablation (44.01 vs 39.02: p = 0.047) groups. Inunivariate linear models, BMI was associated with an increase in the AFSS score in the rate control (0.27, 95% confidence interval [CI] 0.05 to 0.5, p = 0.02), rhythm control (0.38, 95% CI 0.21 to 0.56, p = 2.49 × 10-5), and ablation (0.38, 95% CI 0.03 to 0.73, p = 0.03) groups. The association remained significant in the rhythm control groups after adjusting for age, gender, race, and comorbidities (0.29, 95% CI 0.11 to 0.49, p = 0.002). In conclusion, increasing BMI was directly associated with patient reported measures of AF symptom severity, burden, and quality of life. This was most significant in patients treated with rhythm-control strategies.

The relationship between anticoagulation knowledge, health literacy, and medication adherence in patients with atrial fibrillation

Introduction: Atrial fibrillation (AF) is associated with significant morbidity, mortality and economic implications. Patients with AF are often prescribed anticoagulants for the prevention of cardioembolic stroke and other embolic events. Patients’ anticoagulation knowledge, level of medication adherence and health literacy are known to affect treatment outcomes. However, contemporary data regarding the relationships between these variables are lacking. Aims: The aim of this study was to determine the relationships between anticoagulation knowledge, health literacy and medication adherence, and to investigate if knowledge is affected by health literacy levels. Methods: A cross-sectional survey was conducted in 48 patients with AF identified from general practices. The Anticoagulation Knowledge Tool (AKT) was used to assess anticoagulation knowledge, the Short Test of Functional Health Literacy in Adults (s-TOHFLA) for health literacy and the 8-item Morisky Medication Adherence Scale (MMAS) for medication adherence. The relationships between study variables were assessed using Pearson’s correlation coefficient, t-tests and regression analysis. Result: Participants in the study had mean scores of 61.6±15.8 for the AKT, 7.2±1.1 for the MMAS-8, and 24.7±9.5 for the sTOHFLA. A significant correlation was observed between both anticoagulation knowledge and health literacy with medication adherence (0.45, p<0.01 and 0.36, p < 0.05, respectively). Participants with adequate health literacy had a significantly higher knowledge score than those with limited health literacy (66.1% vs 55.8%, p <0.05), and regression analysis showed that both anticoagulation knowledge and health literacy scores were significant independent predictors of adherence levels (0.03(95%CI,0.01–0.05), p=0.001 and 0.04(95%CI, 0.01–0.07), p= 0.01, respectively). Discussion: Anticoagulation knowledge, health literacy and medication adherence were closely related and suboptimal in patients with AF. Further research in a larger population is required to definitely elucidate the magnitude of this problem. Future studies should also focus on developing effective interventions to improve anticoagulation knowledge, health literacy and medication adherence in this patient population.

Incidence of complications of antithrombotic treatment in patients with atrial fibrillation

Atrial fibrillation increases the risk of ischemic stroke five fold, while the application of long-term anticoagulant therapy is associated with the occurrence of hemorrhagic complications. The aim of our study was to evaluate the incidence of thrombotic and hemorrhagic complications in patients with atrial fibrillation during antithrombotic treatment. The study included 504 patients that were administered the primary (n=345) or secondary thromboprophylaxis after ischemic stroke (n=159), by applying vitamin K antagonists, or the combination of vitamin K antagonists and low-dose aspirin. The patients were followed for five months in the period of 24 years from 1988 to 2012, the total number of patient's years being 1884, at the Clinical Center of Vojvodina Thromboembolic and hemorrhagic complications were registered during regular check-up examinations. Our results indicate the low incidence of thromboembolic complications (0.01 patient per a year), with a lower incidence in the vitamin K antagonists group than in the group with the combination of vitamin K antagonists and aspirin (0.008 patient per a year versus 0.01 patient per a year). The incidence of hemorrhagic complications was higher in the group with the combined treatment compared to the group treated with vitamin K antagonists (0.1 patient per a year versus 0.06 patient per a year). The frequency of major bleeding was as low as 0.01 patient per a year and more frequent in the group with combined treatment (0.03 patient per a year). The overall incidence of complications in the study group was 0.08 patient per a year. The combined antithrombotic treatment increases the risk of hemorrhagic complications and affects the severity of bleeding. Oral anticoagulant therapy is more efficient in the prevention of ischemic stroke and thromboembolic complications in patients with atrial fibrillation.

Anticoagulação oral nos muito idosos e seus determinantes clínicos

ORAL ANTICOAGULATION THERAPY IN ELDERLY PATIENTS Objectives: To determine the frequency of anticoagulation therapy among patients over 80 years of age registered in a Family Health Unit, to analyze factors associated with this treatment, and to characterize patients with atrial fibrillation using the CHA2DS2VASc and HAS-BLED scales. Type of study: Cross-sectional. Location: Maia Family Health Unit, Portugal. Population: All patients over 80 years old registered in this Family Health Unit. Methods:We studied the electronic medical records of a random sample of elderly patients. We recorded the patients’ age, gender, prescription of oral anticoagulants and antiplatelet agents, indications and contraindications for anticoagulation, the presence of cardiovascular diseases, blood pressure and body mass index. Results: The records of 266 patients were selected for study out of the 609 records of patients over 80 registered in this clinic. The frequency of anticoagulation was 6.8% (95% CI: 3.7 to 9.8%). Anticoagulation was associated with the diagnosis of atrial fibrillation, pulmonary embolism, peripheral arterial disease, heart failure and acute myocardial infarction. Of the 31 patients with atrial fibrillation, 35.5% were receiving anticoagulation therapy, 9.7% had both anticoagulation and antiplatelet therapy, 45.2% used antiplatelet therapy and 9.7% were not receiving any antithrombotic therapy. All patients with atrial fibrillation had indications for anticoagulation. Conclusions: The frequency of anticoagulation among very elderly patients in this family health unit is high. Atrial fibrillation was the most common indication. Most individuals with atrial fibrillation were receiving antithrombotic therapy but the proportion of anticoagulant users was less than expected, based on the use of thrombosis and bleeding risk scales.

Preventing Stroke in Patients with Atrial Fibrillation

ContextAtrial fibrillation, a common disorder that affects nearly one sixth of the population aged 75 years and older, is a major risk factor for stroke.ObjectivesTo review and evaluate the evidence supporting the use of warfarin and/or aspirin for stroke prevention in patients with atrial fibrillation.Data SourcesProspective, randomized trials of patients with atrial fibrillation evaluating either warfarin or aspirin or both, from MEDLINE from January 1, 1966, to February 23, 1999.Study SelectionFive primary prevention placebo-controlled studies, which had been formally pooled, 1 study evaluating secondary prevention of stroke, 1 study comparing warfarin with aspirin, and 3 studies of warfarin in combination with aspirin were identified.Data SynthesisThe risk of developing stroke is heterogeneous and increases with each decade above 65 years; history of high blood pressure, diabetes mellitus, previous transient ischemic attack, or stroke; poor ventricular function; and in women older than 75 years. For patients younger than 65 years, without risk factors, and not receiving antithrombotic therapy, the risk of stroke is 1%/y; those without risk factors between the ages of 65 and 75 years have a risk of 1.1%/y if taking warfarin and 1.4%/y if taking aspirin. For all other patients, stroke risk is reduced from an untreated rate of between 4.3%/y and more than 12%/y to a rate of 1.2%/y to 4%/y with warfarin use.ConclusionThe protection afforded by warfarin is most pronounced in patients at the highest risk for stroke, while aspirin treatment seems adequate in low-risk populations.

Value of quinidine in maintenance of sinus rhythm after electric conversion of atrial fibrillation.

Onehundred andseventy-five patients withatrial fibrillation treated forthefirst timewithDC shock weredivided into twogroupsaccording toyearofbirth. GroupIreceived a long-acting quinidine bisulphate preparation, thedosage ofwhich was adjusted togive serumlevels of1-3mg./l. Side-effects wererarewiththis dosage. Group 2received noquinidine. Ofthe88patients ofgroup I,sinus rhythm was restored in75(85%). Whenleaving thehospital 64(73%) still hadsinus rhythm, andafter 3 months 52(59%). Thecorresponding figures forthe87patients ofGroup2 were 73(84%), 54(62%), and30(34%). Thedifference at3 months isstatistically highly significant. Because ofthese results itisconcluded thatelectric conversion ofatrial fibrillation should beperformed forthefirst timewithout quinidine prophylaxis. Ifthere isfailure orearly recurrence,however, a second electric conversion withsubsequent quinidine treatmentshould be considered.