Use Of Anticoagulant Treatment Research Articles

Temporal Trends in the Management Practices of Clinically Important Perioperative Atrial Fibrillation After Noncardiac Surgery

BackgroundClinically important perioperative atrial fibrillation (POAF) is a common cardiac complication after noncardiac surgery. Little is known about how patients with POAF are managed acutely and whether practices have changed over time. MethodsWe conducted an observational substudy of patients who had POAF, were at elevated cardiovascular risk, and were enrolled in the PeriOperative Ischemic Evaluation (POISE)-1, 2 and 3 trials between 2002 and 2021. POAF was defined as new, clinically important atrial fibrillation occurring within 30 days after surgery. We assessed the use of rhythm-control and anticoagulation treatment in response to POAF, at hospital discharge and at 30 days after surgery. We assessed for temporal trends using multivariable logistic regression. ResultsOf the 27,896 patients included, 545 (1.9%) developed clinically important POAF. Patients received rhythm-control treatment in 48.6% of cases. The level of use of rhythm-control treatment increased over the course of the trials (POISE-1 vs POISE-2 vs POISE-3; 40.9% vs 49.5% vs 59.1%). A later randomization date was associated independently with use of rhythm-control treatment (odds ratio, 1.05 per year; 95% confidence interval, 1.01-1.09). Anticoagulation treatment was prescribed in 21% of POAF cases. The level of anticoagulation treatement use was higher in POISE-3, compared to that in the 2 previous trials (POISE-1 vs POISE-2 vs POISE-3—16.4% vs 16.5% vs 33.6%). A later randomization date was associated independently with use of anticoagulation treatment (odds ratio, 1.06 per year; 95% confidence interval, 1.02-1.11). ConclusionsDespite the absence of randomized controlled trials, the level of use of rhythm-control and anticoagulation treatment for POAF is rising. High-quality trials are needed urgently to determine whether these interventions are safe and effective in this population.

Spontaneous Pulmonary Hematoma: Case Report of a Giant Post-COVID-19 Hematoma and Literature Review.

Pulmonary hematomas are a rare pathology. Although they are usually reported post-traumatically, there are also spontaneous forms in pulmonary pathologies or during drug therapy. In these spontaneous entities, primitive forms are rarely described, although the contributory local pulmonary pathological terrain or a specific associated medication has not yet been identified. We present the case of a patient who developed a giant pulmonary hematoma that appeared spontaneously during recovery from COVID-19 infection. It appeared in one of the two bullae-like cystic lung lesions developed during secondary COVID-19 infection. The clinical impact was major, with hypotension and anemia being observed, requiring hemodynamic support and the adjustment of drug therapy. The clinical course was favorable, with a quasi-complete resolution of both the hematoma and a second cystic lesion being observable at 8 months by pulmonary remodeling. Spontaneous pulmonary hematomas may constitute a pathological entity associated with a post-COVID-19 remodeling process of the lung and the related anticoagulant treatment, which should be recognized, especially in the actual COVID-19 pandemic or in the widespread use of anticoagulant treatment. Conservative treatment is the method of choice, even in giant lung forms.

Gastric polyps: a 10-year analysis of 18,496 upper endoscopies

Background/aimsGastric polyps (GPs) are usually asymptomatic lesions of the upper gastrointestinal tract observed in 1–3% of esophagogastroduodenoscopies (EGD). Most GPs are benign. The aim of this study was to precise the frequency of different types of gastric polyps in our population, and to analyze their possible association with other factors.Materials and methodsA total of 18,496 consecutive patients undergoing EGD over a 10-year period (between 2007 and 2018) in a tertiary hospital were retrospectively reviewed. Eighty-six patients diagnosed with gastric polyps were analysed. Demographics, medical history of the patients, and indication for gastroscopy were collected. Morphological, histological characteristics of polyps, and therapeutic management data were also collected.ResultsGPs were found in 86 out of 18,496 (0.46%) reviewed EGD, corresponding to a total of 141 polyps. There were 64 female (74.4%) and 22 male patients (25.6%) with a sex ratio (M/F) of 0.34. The average age was 58.1 years. One hundred and forty one polyps were included, and histopathology was obtained on 127 GPs. The most common location was the fundus (59.6%) and 48.9% were smaller than 5 mm. The polyp was unique in 75.6% of cases. According to Paris classification, 80% of the polyps were sessile (Is). Hyperplastic polyps were the most common (55.9%), followed by sporadic fundic gland polyps observed in 23 patients (18.1%), 7 (5.5%) were adenomas and 4 (3.1%) were neuroendocrine tumors type 1. The following factors were associated with hyperplastic polyps: anemia (p = 0.022), single polyp (p = 0.025) and size ≥ 5 mm (p = 0.048). Comparing hyperplastic polyps’ biopsies to resected polyps, no difference was found in the evolutionary profile of the 2 groups. A size less than 10 mm (p = 0.013) was associated with fundic gland polyps. Sixty polyps (47.2%) were treated by cold forceps, 19 (15%) treated by a mucosal resection and 15 (11.8%) with diathermic snare. Five procedural bleeding incidents were observed (3.9%). Only the use of anticoagulant treatment was associated with a high bleeding risk (p = 0.005). The comparative histological study between specimens of biopsied GPs and endoscopic polypectomy led to an overall agreement of 95.3%.ConclusionIn our study, the GPs frequency was 0.36%. Hyperplastic polyps and fundic gland are the most common in our country. The high frequency of Helicobacter pylori infection in our patients and in our area may explain the high frequency of HP.

Thrombose et TAVI : beaucoup de questions restent sans réponses

Over the past decade, TAVI has become the standard technique for treatment of severe symptomatic aortic stenosis in patients at high or intermediate surgical risk and more recently in low-surgical-risk patients. Like any technique, TAVI is associated with certain complications such as post-TAVI thrombosis. This complication can have clinical manifestations with recurrence of symptoms and/or increase in trans-prosthetic gradients. It can also be infraclinical, i.e asymptomatic without trans-prosthetic gradient elevation as revealed by cardiac CT scan showing a thickening of the valvular leaflets or cusp thrombosis, with potential impairment of the valve opening. This greatly underestimated complication has a 10% to 15% incidence. Biomechanical factors, intrinsic patient-related predisposition as well as post-TAVI anti-thrombotic treatment have all been incriminated in the occurrence of TAVI thrombosis. The use of anticoagulation treatment by AVK or DOAC in the presence of post TAVI prosthetic thrombosis seems obvious. However, their benefit in the treatment of infraclinical thrombosis has not been clearly established.

A proposal for the management of COVID-19-induced coagulopathy in adults.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is the cause of the coronavirus disease 2019 (COVID-19) pandemic, which has a high case fatality rate. Most severely ill patients develop a special type of coagulopathy that had not been described before and that is now considered the main cause of death. For this reason, anticoagulant treatment has become one of the cornerstones of the treatment of this infection. However, the rate at which the evidence regarding the use of anticoagulants is generated is quite fast, and sometimes it is difficult to interpret and conflicting. After having performed an extensive review of the published literature, this proposal for the use of anticoagulant treatment is made, taking into account available resources in Mexico.

Systematic review of the prognostic utility of D-dimer, disseminated intravascular coagulation, and anticoagulant therapy in COVID-19 critically ill patients

During the new pandemic caused by SARS-CoV-2, there is short knowledge regarding the management of different disease areas, such as coagulopathy and interpretation of D-dimer levels, its association with disseminated intravascular coagulation (DIC) and controversy about the benefit of anticoagulation. Thus, a systematic review has been performed to define the role of D-dimer in the disease, the prevalence of DIC and the usefulness of anticoagulant treatment in these patients. A literature search was performed to analyze the studies of COVID-19 patients. Four recommendations were drawn based on expert opinion and scientific knowledge, according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. The present review suggests the presence of higher levels of D-dimer in those with worse prognosis, there may be an overdiagnosis of DIC in the course of the disease and there is no evidence on the benefit of starting anticoagulant treatment based only on isolated laboratory data.

Management of Anticoagulant Treatment and Anticoagulation-Related Complications in Nonagenarians

Given the aging population, the burden of age-dependent diseases is growing. Despite this, elderly patients are often underrepresented in clinical trials and little data are available on current anticoagulant management and outcomes in this unique population, especially those aged 90 years or older. There is uncertainty, and a fear of "doing harm," that often leads to de-prescription of antithrombotic agents in nonagenarian patients. Decision-making concerning the use of anticoagulant treatment needs to balance the risk of thrombotic events against the risk of major bleeding, especially intracranial hemorrhage. In this perspective, the development of direct oral anticoagulants (DOACs), acting as direct and selective inhibitors of a specific step or enzyme of the coagulation cascade, has dramatically changed oral anticoagulant treatment. In fact, given the lower incidence of intracranial hemorrhage, the favorable overall efficacy and safety, and the lack of routine monitoring, DOACs are the currently recommended anticoagulant agents for the treatment of both atrial fibrillation and venous thromboembolism even in very elderly patients. However, given the limited data available on the management of anticoagulation in nonagenarians, a few unanswered questions remain. In this review, we focused on recent evidence for anticoagulant treatment in atrial fibrillation and venous thromboembolism along with management of anticoagulation-related bleeding in nonagenarians.

Systematic review of the prognostic utility of D-dimer, disseminated intravascular coagulation, and anticoagulant therapy in COVID-19 critically ill patients

Durante la nueva pandemia causada por SARS-CoV-2 existe poca evidencia con relación a varios aspectos de la enfermedad, como es el caso de la coagulopatía e interpretación de los niveles de dímero D, su asociación con la coagulación intravascular diseminada (CID) y la controversia en cuanto al beneficio de la anticoagulación. Por ello, se ha hecho una revisión sistemática para definir el rol del dímero D en la enfermedad, la prevalencia y valor pronóstico de la CID y la utilidad del tratamiento anticoagulante en dichos pacientes. Se abordó una búsqueda bibliográfica y análisis de la literatura sobre pacientes con COVID-19. Se elaboraron 4 recomendaciones basadas en la opinión de expertos y en el conocimiento científico, según el sistema Grading of Recommendations Assesment, Development and Evaluation (GRADE). La presente revisión en pacientes con COVID-19 indica la presencia de mayor nivel de dímero D en aquellos con peor pronóstico, que puede haber un sobrediagnóstico de CID en el curso de la enfermedad y que no existe evidencia sobre el beneficio de iniciar tratamiento anticoagulante basándose únicamente en datos aislados de laboratorio.

Rates and Determinants for the Use of Anticoagulation Treatment before Stroke in Patients with Known Atrial Fibrillation

Introduction and Objective: Even though the introduction of less cumbersome anticoagulant agents has improved, the rates ofoverall anticoagulant treatment in eligible patients with atrial fibrillation (AF) remain to be defined. We aimed to assess the rates of and determinants for the use of anticoagulation treatment before stroke in patients with known AF since the introduction of direct oral anticoagulants (DOAC) in clinical practice. Methods: Consecutive patients admitted to an individual stroke unit, from September 2013 through July 2019, for acute ischemic stroke or transient ischemic attack (TIA) with known AF before the event were included in the study. Logistic regression analysis was used to identify independent predictors of the use of anticoagulant treatment. Results: Overall, 155 patients with ischemic stroke/TIA and known AF were included in this study. Among 152 patients with a CHA₂DS₂-VASc score >1, 43 patients were not receiving any treatment, 47 patients were receiving antiplatelet agents, and the remaining 62 patients were on oral anticoagulants. Among 34 patients on DOAC, 13 were receiving a nonlabeled reduced dose and 18 out of 34 patients on vitamin K antagonists had an INR value <2 at the time of admission. Before stroke, only 34 out of 155 patients (21.9%) were adequately treated according to current guidelines. Previous stroke/TIA was the only independent predictor of the use of anticoagulant therapy. Conclusions: Only 21.9% of the patients hospitalized for a stroke or TIA with known AF before the event were adequately treated according to recent treatment guidelines. It is important to improve medical information about the risk of AF and the efficacy of anticoagulants in stroke prevention.

Baseline Characteristics and Clinical Outcomes from the Cancer Associated Thrombosis - Patient Reported Outcomes with Rivaroxaban (COSIMO) Trial

Background: Patients living with cancer who develop venous thromboembolism (VTE) have a high risk of VTE recurrence, and traditional anticoagulants (low molecular weight heparin [LMWH] or vitamin K antagonists [VKAs]) are associated with significant treatment burdens. Rivaroxaban is a direct oral anticoagulant (DOAC) that may provide a more convenient treatment option for these patients. Methods: The COSIMO study was a multinational, prospective, non-interventional, single-arm cohort study designed to collect real-world data on patient treatment satisfaction and outcomes associated with rivaroxaban treatment following ≥4 weeks of LMWH/VKA therapy for the treatment of acute VTE in patients with active cancer. Here, we report on the secondary objectives, which were to provide descriptive analyses of clinical characteristics and patterns of use of anticoagulant treatment, and to assess the safety and effectiveness of rivaroxaban in this patient population. Results: Overall, 505 patients were enrolled, and the qualifying venous thromboembolic event was deep vein thrombosis (DVT) only in 45.3% of patients, pulmonary embolism (PE) only in 37.2% of patients, DVT with PE in 9.7% of patients, and catheter-associated DVT in 7.5% of patients (Table). The majority of patients had solid tumors (n=449, 88.9%); 56 patients had hematological malignancies. The most common reasons to switch to rivaroxaban were patient preference/quality of life (n=310, 61.4%) and physician decision (n=174, 34.5%). A total of 150 (29.7%) patients were treated with concomitant chemotherapy and 79 (15.6%) received concomitant radiotherapy. Overall, 117 (23.2%) patients discontinued the study: 59 (11.7%) died, 21 (4.2%) withdrew consent, and 17 (3.4%) were lost to follow-up. 80.2% of patients were treated with rivaroxaban for at least 3 months, and most patients (78.6%) received rivaroxaban 20 mg once daily on study entry. Treatment-emergent adverse events (AEs) were reported: 312 (61.8%) patients had an AE (148 [29.3%] serious AEs), and 95 (18.8%) patients had a bleeding event reported, of which 18 (3.6%) patients had an adjudicated major bleeding event. Adjudicated symptomatic and incidental VTE recurrence occurred in 15 (3.0%) and 3 (0.6%) patients, respectively. Adjudicated other site thromboembolic events such as splanchnic or cerebral vein thromboses were symptomatic in 1 (0.2%) patient and incidental in 1 (0.2%) patient. Conclusions: Observed incidence rates of VTE and bleeding events in COSIMO were similar to previous studies of DOACs for VTE treatment in patients with active cancer (Young AM et al. J Clin Oncol 2018;36:2017; Raskob GE et al. N Engl J Med 2018;378:615). Study governance Bayer AG Funding The COSIMO study is funded by Bayer AG and Janssen Pharmaceuticals. Trial protocol number NCT02742623. Registered 19 April 2016. Documented approval from appropriate independent ethics committees/institutional review boards will be obtained for all participating centers prior to study start. Patients were asked to provide signed informed consent forms before joining the study. Few patients have yet completed the study, and so no data are available to share. Acknowledgements Editorial assistance was provided by Kate Weatherall of Chameleon Communications Int. Ltd. with funding from Bayer AG and Janssen Scientific Affairs, LLC. Disclosures Maraveyas: Bristol-Myers Squibb: Honoraria; Bayer AG: Honoraria, Research Funding; Pfizer: Honoraria. Beyer-Westendorf:Pfizer: Honoraria, Research Funding; Bayer HealthCare: Honoraria, Research Funding; Boehringer Ingelheim: Honoraria, Research Funding; Daiichi Sankyo: Honoraria, Research Funding. Lee:Pfizer: Consultancy, Honoraria; LEO Pharma: Consultancy, Honoraria; Bayer: Consultancy, Honoraria; Bristol-Myers Squibb: Consultancy, Honoraria, Research Funding. Mantovani:Daiichi Sankyo: Research Funding; Boehringer Ingelheim: Honoraria, Research Funding; Bayer AG: Honoraria; Fondazione Charta: Consultancy; Pfizer: Honoraria. De Sanctis:Bayer US LLC: Employment, Equity Ownership. Abdelgawwad:Bayer AG: Employment. Fatoba:Bayer AG: Employment. Bach:Bayer AG: Employment. Cohen:Daiichi-Sankyo: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; GlaxoSmithKline: Consultancy, Speakers Bureau; Bayer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; ACI Clinical: Consultancy; CSL Behring: Consultancy; Aspen: Consultancy, Speakers Bureau; Bristol-Myers Squibb: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; AbbVie: Consultancy; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Lifeblood: Other: advisor to Lifeblood: the thrombosis charity and is the founder of the European educational charity the Coalition to Prevent Venous Thromboembolism; Portola: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; ONO: Consultancy, Membership on an entity's Board of Directors or advisory committees; Boehringer-Ingelheim: Consultancy, Speakers Bureau; TRN: Consultancy; Sanofi: Consultancy, Membership on an entity's Board of Directors or advisory committees; Takeda: Consultancy; Temasek Capital: Consultancy; Boston Scientific: Consultancy; Guidepoint Global: Consultancy; Medscape: Consultancy, Speakers Bureau; McKinsey: Consultancy; Navigant: Consultancy; UK Government Health Select Committee: Other: advised the UK Government Health Select Committee, the all-party working group on thrombosis, the Department of Health, and the NHS, on the prevention of VTE; Leo Pharma: Consultancy; GLG: Consultancy; Johnson and Johnson: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

Complications du traitement chirurgical des carcinomes basocellulaires après 75 ans. Étude rétrospective des facteurs pronostiques sur 158 cas

Basal cell carcinoma (BCC) is a pathology that evolveslocally and it is common in elderly subjects whose frailty could restrict the indications for the reference treatment, which is based on surgery. The aim of this study was to investigate the morbidity and the mortality associated with surgical treatment of BCC in patients over 75 years of age, so as to identify possible prognostic factors for postoperative complications. This was a retrospective study carried out with patients over 75 years of age who were treated surgically for one or several BCC between 2010 and 2015 in the reconstructive and cosmetic plastic surgery unit of the Saint-Louis Hospital in Paris (France). We collated the demographic characteristics, the characteristics of the treatment, as well as the rate of major postoperative complications. We performed a univariate and then a multivariate analysis of the various risk factors that were identified. A total of 158 patients were analyzed and they exhibited a rate of major complications of 12%. The statistical analysis identified five significant risk factors: being over 85 years of age (P=0.006), long-term use of anticoagulant treatment (P=0.02), the presence of at least one comorbidity (P=0.018), a conventional hospitalization (P=0.002), and the use of general anesthesia (P=1.2e-10). Five risk factors for major postoperative complications with the surgical treatment of BCC in patients over 75 years of age were identified. These factors may provide direction to medico-surgical teams in regard to the optimal treatment of BCC in elderly patients.

Risk profile, management, and outcomes of patients with venous thromboembolism attended in Spanish Emergency Departments: The ESPHERIA registry.

The objective of this study was to determine the clinical profile of and diagnostic and therapeutic approach to patients with venous thromboembolism (VTE) in Spanish Emergency Departments (EDs). Risk factors, adherence to clinical practice guidelines, and outcomes were also evaluated.Patients with VTE diagnosed in 53 Spanish EDs were prospectively and consecutively included. Demographic data, comorbidities, risk factors for VTE, index event characteristics, hemorrhagic risk, and mortality were evaluated. Adherence to clinical practice guidelines was assessed based on clinical probability scales, requests for determination of D-dimer, use of anticoagulant treatment before confirmation of diagnosis, and assessment of bleeding and prognostic risk. Recurrence, bleeding, and death during admission and at 30, 90, and 180 days after diagnosis in the EDs were recorded.From 549,840 ED visits made over a mean period of 40 days, 905 patients were diagnosed with VTE (incidence 1.6 diagnoses per 1000 visits). The final analysis included 801 patients, of whom 49.8% had pulmonary embolism. The most frequent risk factors for VTE were age (≥70 years), obesity, and new immobility. Clinical probability, prognosis, and bleeding risk scales were recorded in only 7.6%, 7.5%, and 1% of cases, respectively. D-dimer was determined in 87.2% of patients with a high clinical probability of VTE, and treatment was initiated before confirmation in only 35.9% of these patients. In patients with pulmonary embolism, 31.3% had a low risk of VTE. Overall, 98.7% of patients with pulmonary embolism and 50.2% of patients with deep venous thrombosis were admitted. During follow-up, total bleeding was more frequent than recurrences: the rates of any bleeding event were 4.4%, 3.9%, 5.3%, and 3.5% at admission and at 30 and 90, and 180 days, respectively; the rates of VTE recurrence were 2.3%, 1.3%, 1.7%, and 0.6%, respectively. Mortality rates were 3.4%, 3.1%, 4.1%, and 2.6% during hospitalization and at 30, 90, and 180 days, respectively.VTE had a substantial impact on Spanish EDs. The clinical presentation and risk profile for the development of VTE in patients diagnosed in the EDs was similar to that recorded in previous studies. During follow-up, bleeding (overall) was more frequent than recurrences. Adherence to clinical practice guidelines could improve significantly.

Anticoagulation-direct oral anticoagulants

Since direct oral anticoagulants (DOAC) have become available, use of anticoagulant treatment has become easier and safer-for patients suffering from thromboembolic diseases as well as for patients with atrial fibrillation: Because of constant bioavailability, fixed dose regimen treatment is possible, monitoring not necessary and severe bleeding complications-particularly intracranial hemorrhages-rare in comparison to vitaminK anticoagulants. To gain all these advantages, it is essential to give DOAC in the correct dosage. Dose reduction of single DOAC has to be considered depending on underlying disease, body weight and renal function. DOAC are not allowed in patients with artificial heart valves, in pregnancy and in children. In case of severe bleeding complications under DOAC treatment, prothrombin complex concentrates is one treatment option. For dabigatran an antidote is available.

Patients\u2019 and physicians\u2019 perceptions and attitudes about oral anticoagulation and atrial fibrillation: a qualitative systematic review

BackgroundOral anticoagulant therapy reduces the risk of stroke in patients with atrial fibrillation, but many patients are still not prescribed this therapy. The causes of underuse of vitamin K antagonists oral anticoagulants are not clear but could be related, in part, to patients’ and physicians’ perceptions and attitudes towards the benefits and downsides of this treatment. The purpose of this systematic review was to evaluate and synthesize patients’ and physicians’ perceptions and attitudes towards the benefits and downsides of vitamin K antagonist, in order to explore potential factors related with its underuse.MethodsWe included studies that used qualitative or mixed methods and focused on patients’ and/or physicians’ perceptions and attitudes towards oral anticoagulation. We systematically searched PubMed, EMBASE, ISI WoK, and PsycINFO from their inception until May 2013. Two reviewers independently assessed the quality of the included studies and synthesized results using a thematic analysis approach.ResultsWe included a total of nine studies. In four studies, the quality assessed was excellent and in five was moderate. We identified three themes that were of interest to both physicians and patients: information to reinforce anticoagulation use, balance of benefits and downsides, roles in decision-making and therapy management. Three additional themes were of interest to patients: knowledge and understanding, impact on daily life, and satisfaction with therapy. The main difficulties with the use of anticoagulant treatment according to physicians were the perceived uncertainty, need of individualised decision-making, and the feeling of delegated responsibility as their main concerns. The main factors for patients were the lack of information and understanding.ConclusionPhysicians’ and patients’ perceptions and attitudes might be potential factors in the underuse of treatment with vitamin K antagonists. Improving the quality and usability of clinical guidelines, developing tools to help with the decision-making, enhancing coordination between primary care and hospital care, and improving information provided to patients could help improve the underuse of anticoagulation.

Malignant Cerebral Venous Sinus Thrombosis in Polycythemia.

Malignant Cerebral Venous Sinus Thrombosis in Polycythemia.

Therapeutic management in ambulatory elderly patients with atrial fibrillation: the S.AGES cohort.

Few epidemiologic studies have specifically focused on very old community dwelling population with atrial fibrillation (AF). The objectives of the AF-S.AGES cohort were to describe real-life therapeutic management of non-institutionalized elderly patients with AF according to age groups, i.e., 65-79 and ≥ 80 and to determine the main factors associated with anticoagulant treatment in both groups. Observational study (N=1072) aged ≥ 65 years old, recruited by general practitioners. Characteristics of the sample were first evaluated in the overall sample and according to age (< 80 or ≥ 80 years) and to use of anticoagulant treatment at inclusion. Logistic models were used to analyze the determinants of anticoagulant prescription among age groups. Mean age was 78.0 (SD=6.5) years and 42% were ≥ 80 years. Nineteen percent had paroxysmal AF, 15% persistent, 56% permanent and 10% unknown type, 77% were treated with vitamin K antagonists (VKA), 17% with antiplatelet therapy with no differences between age groups. Rate-control drugs were more frequently used than rhythm-control drugs (55% vs. 37%, p < 0.001). VKA use was associated with permanent AF, younger age and cancer in patients ≥ 80 years old and with permanent AF and preserved functional autonomy in patients < 80 years old. Hemorrhagic scores were independently associated with non-use of VKA whereas thromboembolic scores were not associated with VKA use. In this elderly AF outpatient population, use of anticoagulant therapy was higher even after 80 years than in previous studies suggesting that recent international guidelines are better implemented in the elderly population.

0456: Therapeutic management in ambulatory elderly patients with atrial fibrillation: the S.AGES cohort

Few data on therapeutic management of patients over 80 years with nonvalvular atrial fibrillation (AF) are available in general population. The objectives of the AF-S.AGES cohort (Sujets AGES) were to describe real-life therapeutic management of non-institutionalized elderly subjects with AF according to age groups, i.e., 65-79 and ≥80 years and to determine factors associated with anticoagulant treatment. General practitioners recruited 1072 patients aged >65 years old between 2009 and 2011. General characteristics were first evaluated in the overall sample and according to age groups and use of anticoagulant treatment at inclusion. Mean age was 78.0 (SD 6.5) years and 42% were older than 80 years. In the overall sample, 19% of patients had paroxysmal AF, 15% persistent, 56% permanent and for 10% AF type was unknown. Vitamin K antagonists (VKA) were used in 77% of patients, antiplatelet therapy in 17% and 12% of patients did not receive any antithrombotic treatment. There were no differences between age-groups (< 80 or ≥80 years) for VKA (78 vs. 76%, p=0.58). Rate control drugs were more frequently used (55%) than rhythm control drugs (37%). Class I and class II antiarrhythmic drugs were less often used in octogenarians than in younger patients (5.6% vs. 12.3%, p<0.001 and 36 vs. 41%, p<0.05). Among patients ≥80 years old, VKA use was associated with permanent AF younger age and cancer. Among patients < 80 years old, the use of VKA was associated with permanent AF and preserved functional autonomy. HAS-BLED and HEMORR2HAGES scores were associated with non-use of VKA in subjects ≥80 and < 80 years, CHADS2 and CHA2DS2-VASc scores were not associated with VKA use in both groups. We observed a higher use of anticoagulant therapy in elderly AF outpatients even after 80 years when compared with previous studies. These results suggest that recent international guidelines are better implemented in the elderly population.

Risks for stroke and bleeding with warfarin or aspirin treatment in patients with atrial fibrillation at different CHA(2)DS(2)VASc scores: experience from the Stockholm region.

This study evaluated the benefits of and possible contraindications to warfarin treatment in patients with atrial fibrillation (AF) prior to the introduction of new oral anticoagulants using health registry data from inpatient care, specialist ambulatory care, and primary care. This is a cohort study including all patients in the region of Stockholm, Sweden (2.1 million inhabitants) with a diagnosis of non-valvular AF (n = 41 810) recorded during 2005-2009. The risks of suffering ischemic stroke, bleeding, or death with warfarin, aspirin, or no antithrombotic treatment during 2010 were related to CHA2DS2VASc scores, age, and complicating co-morbidities. One-year risks for ischemic stroke were 1.0-1.2% with aspirin, 0-0.3% with warfarin, and 0.1-0.2% without treatment at CHA2DS2VASc scores 0-1. Among the aspirin-treated patients with CHA2DS2VASc scores ≥2, half had possible contraindications and high risks for ischemic stroke (5.2%), bleeding (5.0%), and death (19.3%). The other half of the patients with no identified contraindications had a high risk for ischemic stroke (4.0%) but a low bleeding risk (1.8%) and a moderate mortality rate (8.4%). The present observations confirm earlier findings of undertreatment with warfarin and half of the high-risk patients treated with aspirin were obvious candidates for anticoagulant treatment. However, the other half of the patients had complicating co-morbidities, high bleeding risk, and poor prognosis. This and possible overtreatment of low-risk patients should be taken into account when considering more aggressive use of anticoagulant treatment.

S Patent foramen ovale and cryptogenic stroke – a statistical or cause-and-effect relationship? A neurological point of view

Patent foramen ovale and atrial septal aneurysm are considered to be factors conducive to the occurrence of stroke and transient ischaemic attacks. However, there is no clear answer to the question whether patent foramen ovale is an independent risk factor for stroke and what the mechanism of potential cerebral ischaemia in patients with an interatrial septal abnormality is. The paper presents the results of studies regarding the issue, including epidemiological, clinical and neuroimaging data. The subject of secondary prevention in patients with cryptogenic stroke and patent foramen ovale, including the results of research into the effectiveness of pharmacological methods and percutaneous closure of interatrial septal defects, is raised. The available research results do not conclusively suggest a causal relationship between patent foramen ovale and stroke. There is a probable summative effect of atrial septal abnormality and other factors (haemostatic and genetic ones as well as those that are associated with cerebral vessels) leading to cerebral ischaemia. There are no indications for the use of anticoagulant treatment in patients with stroke and presence of patent foramen ovale. In patients at a high risk for stroke, invasive treatment should be considered, which is consistent with the position of the European Stroke Organisation.

Usefulness of Preemptive Anticoagulation in Patients With Suspected Pulmonary Embolism: A Decision Analysis

The diagnostic workup of pulmonary embolism (PE) may take several hours. The usefulness of anticoagulant treatment while awaiting the results of diagnostic tests has not been assessed. The objective of this study was to compare the risks and benefits of bid low-molecular-weight heparin vs no treatment in patients with suspected PE.We developed a decision tree with the following outcomes: mortality related to untreated and treated PE, mortality due to major hemorrhage, and intracranial bleeding. The timeframe extended from the suspicion of PE to its confirmation or exclusion. Most probabilities were derived from data from the Computerized Registry of Patients with VTE (RIETE). We estimated the incidence of bleeding by categories of clinical prediction rules of PE from a recent diagnostic management study of PE. Uncertainty was assessed through one-way and probabilistic sensitivity analyses.The model favored preemptive anticoagulation if the diagnostic delay was > 6.3 h, > 2.3 h, and > 0.3 h (Revised Geneva low, intermediate, and high probability) and > 8.1 h and > 1.7 h (Wells unlikely and likely). With a diagnostic delay of 6 h, the absolute mortality reduction with anticoagulation was 0%, 0.02%, and 0.1% for low, intermediate, and high clinical probability, respectively. In one-way sensitivity analyses, the mortality of untreated PE was the most critical variable. Probabilistic analyses reinforced the superiority of anticoagulation in intermediate- and high-probability patients and suggested that low-probability patients might not benefit from treatment after diagnostic delays of < 6 to 8 h.Our model suggests that patients with intermediate and high/likely probabilities of PE benefit from preemptive anticoagulation. With a low probability, the decision to treat may rely on the expected diagnostic delay.