Advanced age, anticoagulation intensity, and risk for intracranial hemorrhage among patients taking warfarin for atrial fibrillation

Fang, Margaret C.; Chang, Yu-Lien

doi:10.1016/j.accreview.2005.02.016

Cited by 74 publications

(98 citation statements)

References 0 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Palareti et al [7], among patients over 75 years, reported a rate of cerebral bleedings of 1.1 per 100 pt/years, a finding similar to ours. As previously observed by several Authors [6][7][8][14][15][16][17][18][19], most bleeding events occurred with INR within the therapeutic range. Fang et al [16] found an increase in intracranial haemorrhages in AF patients over the age of 85 years; the rate was increased in particular in those with INR N 3.5, but intracranial haemorrhage did occur also in patients with subtherapeutic INRs (b 2).…”

Section: Discussionsupporting

confidence: 57%

Risk of bleeding in very old atrial fibrillation patients on warfarin: Relationship with ageing and CHADS2 score

Poli

Antonucci

Marcucci

et al. 2007

Thrombosis Research

View full text Add to dashboard Cite

Aims: In atrial fibrillation (AF) patients, age z75 years is one of the major risk factors for stroke. However, it is not clear if an upper limit for the indication to OAT exists. Methods and results: For this reason, we performed a prospective study on 290 AF patients on OAT aged z75 years (median age 82 years, total follow-up period 814 pt/ years) followed by our Anticoagulation Clinic. Seventeen major bleeding events were recorded (rate 2.1 × 100 pt/years), 11 of which cerebral (1.35 × 100 pt/years). The occurrence of major bleedings was associated with history of previous TIA or stroke [OR 3.4 (1.1-12.5), p = 0.01] and with diabetes .7) p = 0.01]. We found a trend to a progressive increase in the rate of bleeding risk with the increase of the CHADS 2 score: patients with score 4-6 showed a rate of 3.4 × 100 pt/years with respect to 1.5 × 100 pt/years of patients with lower score. Number Needed to Harm (NNH) was calculated in relation to different classes of age (75-89, 80-84, z85 years) and to CHADS 2 score. For patients in CHADS 2 score 1-3 NNH remained stable across the different age classes. Instead for patients in CHADS 2 score 4-6, NNH varied among the 3 groups of ages, reaching a value of 10 in patients ≥ 85 years. Conclusion: Our data suggest that: 1) in AF patients older than 75 years with CHADS 2 score 1-3 the risk of bleeding is low, 2) in AF patients N85 years with CHADS 2 4-6 the risk of bleeding is high so that the use of OAT should be highly individualised.

show abstract

Section: Discussionsupporting

confidence: 57%

Risk of bleeding in very old atrial fibrillation patients on warfarin: Relationship with ageing and CHADS2 score

Poli

Antonucci

Marcucci

et al. 2007

Thrombosis Research

View full text Add to dashboard Cite

show abstract

“…[13][14][15][16] Although intracranial hemorrhages are generally rare events, the adverse consequences resulting from them are considerably higher than those observed from the more common extracranial hemorrhage events. Extracranial hemorrhages, primarily of gastrointestinal origin in this study, are more likely to be remediable events, making residual deficits uncommon.…”

Section: Discussionmentioning

confidence: 97%

“…Older age, elevated INR level, and history of ischemic stroke have all been identified as risk factors for intracranial hemorrhage, but because older age and prior stroke are also risk factors for ischemic stroke, additional investigation into unique risk factors for intracranial hemorrhage is clearly needed. 2,15,24 Modifiable measures, such as maintaining anticoagulation intensity within the therapeutic range of INR 2.0 to 3.0, can reduce but will not entirely remove the risk of bleeding associated with warfarin. 15,25 A study of Medicare patients with atrial fibrillation showed that a high fall risk was associated with an increased risk of intracranial hemorrhage, 16 although the high rate of ischemic stroke (13.7 per 100 person-years) among this subset of patients with a high fall risk made warfarin the preferred option for most patients.…”

Section: Discussionmentioning

confidence: 99%

Death and Disability from Warfarin-Associated Intracranial and Extracranial Hemorrhages

Fang

Chang

et al. 2007

The American Journal of Medicine

467

274

View full text Add to dashboard Cite

OBJECTIVES-Little is known about the outcomes of patients who have hemorrhagic complications while receiving warfarin therapy. We examined the rates of death and disability resulting from warfarin-associated intracranial and extracranial hemorrhages in a large cohort of patients with atrial fibrillation.METHODS-We assembled a cohort of 13,559 adults with nonvalvular atrial fibrillation and identified patients hospitalized for warfarin-associated intracranial and major extracranial hemorrhage. Data on functional disability at discharge and 30-day mortality were obtained from a review of medical charts and state death certificates. The relative odds of 30-day mortality by hemorrhage type were calculated using multivariable logistic regression.RESULTS-We identified 72 intracranial and 98 major extracranial hemorrhages occurring in more than 15,300 person-years of warfarin exposure. At hospital discharge, 76% of patients with intracranial hemorrhage had severe disability or died, compared with only 3% of those with major extracranial hemorrhage. Of the 40 deaths from warfarin-associated hemorrhage that occurred within 30 days, 35 (88%) were from intracranial hemorrhage. Compared with extracranial hemorrhages, intracranial events were strongly associated with 30-day mortality (odds ratio 20.8 [95% confidence interval, 6.0-72]) even after adjusting for age, sex, anticoagulation intensity on admission, and other coexisting illnesses. CONCLUSIONS-Among anticoagulated patients with atrial fibrillation, intracranialhemorrhages caused approximately 90% of the deaths from warfarin-associated hemorrhage and the majority of disability among survivors. When considering anticoagulation, patients and clinicians need to weigh the risk of intracranial hemorrhage far more than the risk of all major hemorrhages. Atrial fibrillation is the most common clinically significant cardiac arrhythmia and increases the risk for ischemic stroke 4-to 5-fold. 1 Anticoagulation therapy with warfarin can reduce the risk for ischemic stroke by 68% but also increases the risk for major hemorrhagic complications. 2 Clinical decision-making regarding the appropriateness of warfarin therapy for patients with atrial fibrillation has generally relied on balancing the risk of ischemic strokes without warfarin therapy with the risk of all major hemorrhage with warfarin therapy. KeywordsRates of ischemic stroke in patients with atrial fibrillation who are not taking warfarin can be as high as 12% per year, 2,3 and the proportion of patients who have major functional disability after an atrial fibrillation-related ischemic stroke is substantial, as high as 59%. 4 Yet multiple studies demonstrate that patients with atrial fibrillation are frequently not prescribed warfarin despite its benefits in ischemic stroke risk reduction. [5][6][7] The primary deterrent to prescribing warfarin is the fear of inducing life-threatening hemorrhage. 8 Although concerns about hemorrhage prevent many patients from receiving warfarin, there are relatively little data a...

show abstract

“…We obtained data through the Partners Healthcare Research Patient Data Registry, a central clinical data warehouse for .1.8 million inpatients and outpatients designed for research and quality improvement (23)(24)(25). Approval for this study was granted by the Institutional Review Board at Brigham and Women's Hospital and the need for informed consent was waived.…”

Section: Data Collectionmentioning

confidence: 99%

Incidence, Outcomes, and Comparisons across Definitions of AKI in Hospitalized Individuals

Zeng

McMahon

Brunelli³

et al. 2014

Clinical Journal of the American Society of Nephrology

379

258

View full text Add to dashboard Cite

SummaryBackground and objectives At least four definitions of AKI have recently been proposed. This study sought to characterize the epidemiology of AKI according to the most recent consensus definition proposed by the Kidney Disease Improving Global Outcomes (KDIGO) Work Group, and to compare it with three other definitions.Design, setting, participants, & measurements This was a retrospective cohort study of 31,970 hospitalizations at an academic medical center in 2010. AKI was defined and staged according to KDIGO criteria, the Acute Dialysis Quality Initiative's RIFLE criteria, the Acute Kidney Injury Network (AKIN) criteria, and a definition based on a model of creatinine kinetics (CK). Outcomes of interest were incidence, in-hospital mortality, length of stay, costs, readmission rates, and posthospitalization disposition.Results AKI incidence was highest according to the KDIGO definition (18.3%) followed by the AKIN (16.6%), RIFLE (16.1%), and CK (7.0%) definitions. AKI incidence appeared markedly higher in those with low baseline serum creatinine according to the KDIGO, AKIN, and RIFLE definitions, in which AKI may be defined by a 50% increase over baseline. AKI according to all definitions was associated with a significantly higher risk of death and higher resource utilization. The adjusted odds ratios for in-hospital mortality in those with AKI were highest with the CK definition (5.2; 95% confidence interval [95% CI], 4.1 to 6.6), followed by the RIFLE (2.9; 95% CI, 2.2 to 3.6), KDIGO (2.8; 95% CI, 2.2 to 3.6), and AKIN (2.6; 95% CI, 2.0 to 3.3) definitions. Concordance in diagnosis and staging was high among the KDIGO, AKIN, and RIFLE definitions. ConclusionsThe incidence of AKI in hospitalized individuals varies depending on the definition used. AKI according to all definitions is associated with higher in-hospital mortality and resource utilization. AKI may be inappropriately diagnosed in those with low baseline serum creatinine using definitions that incorporate percentage increases over baseline.

show abstract

Advanced age, anticoagulation intensity, and risk for intracranial hemorrhage among patients taking warfarin for atrial fibrillation

Cited by 74 publications

References 0 publications

Risk of bleeding in very old atrial fibrillation patients on warfarin: Relationship with ageing and CHADS2 score

Risk of bleeding in very old atrial fibrillation patients on warfarin: Relationship with ageing and CHADS2 score

Death and Disability from Warfarin-Associated Intracranial and Extracranial Hemorrhages

Incidence, Outcomes, and Comparisons across Definitions of AKI in Hospitalized Individuals

Contact Info

Product

Resources

About