National Trends in Antiarrhythmic and Antithrombotic Medication Use in Atrial Fibrillation

Fang, Margaret C.; Stafford, Randall S.; Ruskin, Jeremy N.; Singer, Daniel E.

doi:10.1001/archinte.164.1.55

Cited by 208 publications

(136 citation statements)

References 28 publications

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“…1,19,20 Amiodarone does not increase mortality in patients with heart failure; therefore, it is safe to use in this patient population. [21][22][23][24] Nevertheless, amiodarone is among the most toxic antiarrhythmic agents; it is associated with a high incidence of potentially severe extracardiac effects.…”

Section: ■■ Class III Agents Amiodaronementioning

confidence: 99%

Pharmacologic Management of Atrial Fibrillation: Established and Emerging Options

Kalus

2009

JMCP

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BACKGROUND: In patients with atrial fibrillation (AF), antiarrhythmic drug therapy currently plays a greater role in maintaining sinus rhythm after cardioversion than it does in converting AF to sinus rhythm. Amiodarone is the most effective antiarrhythmic agent for maintaining sinus rhythm after cardioversion in patients with AF. However, its pharmacokinetics is complex; the drug interacts with many commonly used medications; and long-term use can cause thyroid dysfunction, hepatotoxicity, and other severe extracardiac adverse effects. The use of antiarrhythmic strategies in patients with AF has decreased because of evidence of greater safety and lower costs for hospitalization obtained from the use of rate-control strategies instead. Nevertheless, some patients require a rhythm-control strategy. Warfarin is used to prevent embolic stroke in many patients with AF, but its use is also complex and requires monitoring. Therefore, efforts have been made to develop antiarrhythmic agents with improved tolerability and anticoagulants that are easy to use.

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Section: ■■ Class III Agents Amiodaronementioning

confidence: 99%

Pharmacologic Management of Atrial Fibrillation: Established and Emerging Options

Kalus

2009

JMCP

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“…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 about the actual rates of death and disability resulting from warfarinassociated hemorrhage, particularly among patients with atrial fibrillation and using current targets of anticoagulation intensity.…”

mentioning

confidence: 99%

Death and Disability from Warfarin-Associated Intracranial and Extracranial Hemorrhages

Fang

Chang

et al. 2007

The American Journal of Medicine

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467

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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...

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“…For 1,355 visits for patients with AF obtained from the National Ambulatory Medical Care Survey (NAMCS), a nationally representative assessment of office-based physician practice, overall use of drugs to control cardiac rhythm decreased from 72% of visits in 1991-1992 to 56% in 1999-2000 (P = 0.01 for trend) due to declining digoxin use (64% to 37%, P <0.001 for trend). 4 The absolute rate of use of beta-blockers, calcium channel blockers, and sinus rhythm medication did not change over the 10 years, but amiodarone use increased from 0.2% to 6.4% (P <0.001 for trend) while quinidine use decreased from 5.0% to 0.0% (P = 0.01 for trend).…”

Section: Ss Rhythm Versus Safety In Amiodarone Therapymentioning

confidence: 89%

Rhythm Versus Safety in Amiodarone Therapy

Curtiss¹

2006

JMCP

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National Trends in Antiarrhythmic and Antithrombotic Medication Use in Atrial Fibrillation

Cited by 208 publications

References 28 publications

Pharmacologic Management of Atrial Fibrillation: Established and Emerging Options

Pharmacologic Management of Atrial Fibrillation: Established and Emerging Options

Death and Disability from Warfarin-Associated Intracranial and Extracranial Hemorrhages

Rhythm Versus Safety in Amiodarone Therapy

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