Low-Dose Edoxaban in Very Elderly Patients with Atrial Fibrillation

Okumura, Ken; Akao, Masaharu; Yoshida, Tetsuro; Kawata, Masahito; Okazaki, Osamu; Akashi, Shintaro; Eshima, Kenichi; Tanizawa, Kimihiko; Fukuzawa, Masahiro; Hayashi, Takuya; Akishita, Masahiro; Lip, Gregory Y.H.; Yamashita, Takeshi

doi:10.1056/nejmoa2012883

Cited by 233 publications

(247 citation statements)

References 27 publications

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“…To ameliorate stroke-related disability, optimizing anticoagulant use and left atrial closure devices continues to be a primary concern. 24,25 While this study demonstrates the importance of stroke-independent disability, the causes of stroke-independent disability are not well defined. Some have postulated a direct link between the dysrhythmia itself and function independent of stroke.…”

Section: Discussionmentioning

confidence: 81%

Long-term individual and population functional outcomes in older adults with atrial fibrillation

Shah¹,

Fang²,

Jeon³

et al. 2020

Preprint

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Background: While guidelines recommend focusing primarily on stroke risk to recommend anticoagulants in atrial fibrillation (AF), physicians report that geriatric syndromes (e.g., falls, disability) are important when considering anticoagulants. Little is known about the prevalence of geriatric syndromes in older adults with AF or the association with anticoagulant use. Methods: We performed a cross-sectional analysis of the 2014 Health and Retirement Study, a nationally representative study of older Americans. Participants were asked questions to assess domains of aging, including function, cognition, and medical conditions. We included participants ≥65 years with two years of continuous Medicare enrollment who met AF diagnosis criteria by claims codes. We examined five geriatric syndromes: one or more falls within the last two years, receiving help with activities of daily living (ADL) or instrumental activities of daily living (IADL), experienced incontinence, and cognitive impairment. We determined the prevalence of geriatric syndromes and their association with anticoagulant use adjusting for ischemic stroke risk (i.e., CHA2DS2-VASc score). Results: In this study of 779 participants with AF (median age 80 years, median CHA2DS2-VASc score 4), 82% had ≥1 geriatric syndrome. Geriatric syndromes were common: 49% reported falls, 38% had ADL impairments, 42% had IADL impairment, 37% had cognitive impairments, and 43% reported incontinence. Overall, 65% reported anticoagulant use; guidelines recommend anticoagulant use for 97% of participants. Anticoagulant use rate decreased for each additional geriatric syndrome (average marginal effect -3.7%; 95% CI -1.4% to -5.9%). Lower rates of anticoagulant use were reported in participants with ADL dependency, IADL dependency, and dementia. Conclusion: Most older adults with AF had at least one geriatric syndrome, and geriatric syndromes were associated with reduced anticoagulant use. The high prevalence of geriatric syndromes may explain the lower than expected anticoagulant use in older adults.

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Section: Discussionmentioning

confidence: 81%

Long-term individual and population functional outcomes in older adults with atrial fibrillation

Shah¹,

Fang²,

Jeon³

et al. 2020

Preprint

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“…To ameliorate stroke-related disability, optimizing anticoagulant use and left atrial closure devices continues to be a primary concern. 24,25 While this study demonstrates the importance of strokeindependent disability, the causes of stroke-independent disability are not well defined. Some have postulated a direct link between the dysrhythmia itself and function independent of stroke.…”

Section: Discussionmentioning

confidence: 83%

Long-term individual and population functional outcomes in older adults with atrial fibrillation

Parks¹,

Jeon

Boscardin

et al. 2020

Preprint

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Background: Older adults with atrial fibrillation (AF) have multiple risk factors for disablement. Long-term function and the contribution of strokes to disability has not been previously characterized. Methods: We performed a longitudinal, observational study in the nationally representative Health and Retirement Study (1992-2014). We included participants ≥65 years with Medicare claims who met incident AF diagnosis claims criteria. We examined the association of incident stroke with three functional outcomes: independence with activities of daily living (ADL) and instrumental activities of daily living (IADL) and community-dwelling. We fit separate logistic regression models with repeated measures adjusting for comorbidities and demographics to estimate the effect of stroke on function. We estimate the contribution of strokes to the overall population burden of functional impairment using the method of recycled predictions. Results: Among 3530 participants (median age 79 years, 53% women, median CHA2DS2-VASc 5), 262 had a stroke over 17,396 person-years. Independent of stroke and accounting for population comorbidities, annually, ADL dependence increased by 4.4%, IADL dependence increased by 3.9%, and nursing home residence increased by 1.2% (p<0.05 for all). Accounting for comorbidities, of those who experienced a stroke, 31.9% developed new ADL dependence, 26.5% developed new IADL dependence, and 8.6% newly moved to a nursing home (p<0.05 for all). Considering all causes of function loss, 1.7% of ADL disability-years, 1.2% of IADL disability-years, and 7.3% of nursing home years could be attributed to stroke over 7.4years. Conclusion: Older adults lose substantial function over time following AF diagnosis, independent of stroke. Stroke was associated with a significant decline in function and an increase in the likelihood of nursing home move, but stroke did not accelerate subsequent disability accrual. Because of the high background rate of functional loss, stroke was not the dominant determinant of population-level disability in older adults with AF.

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“…As extreme elderly NVAF patients are at high risk for the incidence of ischemic stroke [7], the guideline-based adequate OAC therapy is considered and recommended after careful assessment of bleeding risk, cognitive state, mobility, frailty, and socioeconomic factors. Recent phase 3 randomized double-blind study to compare a once-daily edoxaban 15 mg with placebo in Japanese patients 80 years of age or older demonstrated that edoxaban 15 mg was superior to placebo in preventing stroke or systemic embolism and did not have a significantly higher incidence of major bleeding than placebo [23]. Furthermore, multicenter prospective observational studies of Japanese NVAF patients aged ≥75 years have been conducted [24,25].…”

Section: Discussionmentioning

confidence: 99%

Persistent or permanent atrial fibrillation is associated with severe cardioembolic stroke in patients with non-valvular atrial fibrillation

et al. 2021

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Background Little is known about the difference in the severity of cardioembolic (CE) stroke between patients with paroxysmal atrial fibrillation (PAF) and persistent/permanent AF (PerAF). We assessed stroke severity in patients with CE stroke divided by the type of AF. Methods Three hundred and fifty-eight consecutive patients with CE stroke within 48 h of onset and with a modified Rankin Scale (mRS) score ≤ 1 before onset were studied. We compared basic characteristics, stroke severity, and functional outcome between patients with PAF (n = 127) and PerAF (n = 231). Results Patients with PerAF were more likely to take oral anticoagulants (OACs) than those with PAF (37% vs. 13%, P < 0.0001), even though still underuse of OAC in both patients. Regarding stroke severity on admission, patients with PerAF exhibited a tendency toward a higher score on the National Institutes of Health Stroke Scale (NIHSS) compared with patients with PAF (12 [5–20] vs. 9 [4–18]; P = 0.12). Mortality and mRS score at discharge were higher in the PerAF than in the PAF group (13% vs. 4%; P = 0.005, and 3 [1–5] vs. 2 [1–4]; P = 0.01, respectively). Multivariate analyses confirmed that PerAF was a significant determinant of severe stroke (NIHSS score > 8) on admission (odds ratio [OR] to PAF = 1.80; 95% confidence interval [CI] 1.08–2.98; P = 0.02) and of an mRS score ≥ 3 at discharge (OR = 2.07; 95% CI 1.24–3.46; P = 0.006). Patients with PerAF had three times more internal carotid artery occlusion evaluated by magnetic resonance angiography, which indicated a more severe cerebral embolism compared with patients with PAF. Conclusions We found underuse of OAC in high risk AF patients with CE stroke. PerAF is significantly associated with severe stroke on admission and an unfavorable functional outcome at discharge in Japanese patients with CE stroke.

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Low-Dose Edoxaban in Very Elderly Patients with Atrial Fibrillation

Cited by 233 publications

References 27 publications

Long-term individual and population functional outcomes in older adults with atrial fibrillation

Long-term individual and population functional outcomes in older adults with atrial fibrillation

Long-term individual and population functional outcomes in older adults with atrial fibrillation

Persistent or permanent atrial fibrillation is associated with severe cardioembolic stroke in patients with non-valvular atrial fibrillation

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