Net Clinical Benefit of Oral Anticoagulation Among Frail Patients With Atrial Fibrillation: Nationwide Cohort Study

Søgaard, Mette; Jensen, Martin; Højen, Anette Arbjerg; Larsen, Torben Bjerregaard; Lip, Gregory Y.H.; Ording, Anne Gulbech; Nielsen, Peter Brønnum

doi:10.1161/strokeaha.123.044407

Cited by 2 publications

(1 citation statement)

References 39 publications

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“…Recently, Soogard and colleagues performed a nationwide cohort study in Denmark to investigate the net clinical benefit of DOAC therapy in frail elderly patients with AF, taking into account both thromboembolic and hemorrhagic events. The results showed that the net clinical benefit was favorable (0.7%) in the whole cohort, but it tended to disappear with increasing age and frailty and was lowest among patients aged >75 years or with a high frailty level [ 59 ].…”

Section: Do We Need New Scores For a Better Prediction Of Stroke And ...mentioning

confidence: 99%

Atrial High-Rate Episodes in Elderly Patients: The Anticoagulation Therapy Dilemma

Pimpini,

Biscetti,

Matacchione

et al. 2024

JCM

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Atrial fibrillation (AF) has been associated with higher morbidity and mortality rates, especially in older patients. Subclinical atrial fibrillation (SCAF) is defined as the presence of atrial high-rate episodes (AHREs) > 190 bpm for 10 consecutive beats > 6 min and <24 h, as detected by cardiac implanted electronic devices (CIEDs). The selection of eligible patients for anticoagulation therapy among elderly individuals with AHREs detected through CIEDs remains a contentious issue. The meta-analysis of ARTESiA and NOAH-AFNET 6 clinical trials revealed that taking Edoxaban or Apixaban as oral anticoagulation therapy can reduce the risk of stroke by approximately 32% while increasing the risk of major bleeding by approximately 62%. However, it is still unclear which are, among patients with SCAF, those who can take the highest net clinical benefit from anticoagulant therapy. The present review summarizes the current evidence on this intriguing issue and suggests strategies to try to better stratify the risk of stroke and systemic embolism in patients with AHREs. We propose incorporating some parameters including chronic kidney disease (CKD), obesity, enlarged left atrial volume, the efficacy in blood pressure management, and frailty into the traditional CHA2DS2-VASc score. Future trials will be needed to verify the clinical usefulness of the proposed prognostic score mainly in the view of a personalized therapeutic approach in patients with SCAF.

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Section: Do We Need New Scores For a Better Prediction Of Stroke And ...mentioning

confidence: 99%

Atrial High-Rate Episodes in Elderly Patients: The Anticoagulation Therapy Dilemma

Pimpini,

Biscetti,

Matacchione

et al. 2024

JCM

View full text Add to dashboard Cite

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Decision Support Intervention and Anticoagulation for Emergency Department Atrial Fibrillation

Vinson,

Warton,

Durant

et al. 2024

JAMA Netw Open

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ImportanceOral anticoagulation for adults with atrial fibrillation or atrial flutter (AFF) who are at elevated stroke risk reduces the incidence of ischemic stroke but remains underused. Efforts to increase anticoagulation initiation on emergency department (ED) discharge have yielded conflicting results.ObjectiveTo evaluate the effectiveness of a multipronged intervention supporting anticoagulation initiation for eligible adult ED patients.Design, Setting, and ParticipantsThe Clinical Decision Support to Optimize Care of Patients With Atrial Fibrillation or Flutter in the Emergency Department (O’CAFÉ) pragmatic, stepped-wedge cluster randomized clinical trial was conducted from July 1, 2021, through April 30, 2023, at 13 community medical centers (in 9 clusters) of an integrated health system in Northern California. The study included adult ED patients with primary AFF eligible for anticoagulation initiation when discharged home. Clusters were randomly assigned to staggered dates for 1-way crossover from the control phase (usual care) to the intervention phase.InterventionPhysician education, facility-specific audit and feedback, and access to decision support, which identified eligible patients and recommended shared decision-making, anticoagulation initiation (if suitable), and timely follow-up.Main Outcomes and MeasuresThe main outcome was a composite of anticoagulation on discharge or within 30 days. A primary intention-to-treat analysis (decision support access regardless of use) and a secondary per-protocol analysis (decision support use) were performed. Multivariable analyses adjusted for intervention and exposure months with random effects, accounting for clustering by facility and patient.ResultsA total of 3388 eligible patients with atrial fibrillation were discharged home: 2185 (64.5%) were receiving pre-ED arrival anticoagulation and 1203 (35.5%) were eligible for anticoagulation. Among the 1203 patients with an initiation-eligible encounter, the median age was 74.0 (IQR, 68.0-82.0) years and approximately half (618 [51.4%]) were men. Among the 387 patients with an initiation-eligible control encounter, 244 (63.0%) received anticoagulation (190 [49.0%] at discharge and 54 [14.0%] within 30 days). Among the 816 patients with an initiation-eligible intervention encounter, 558 (68.4%) received anticoagulation (428 [52.5%] on discharge and 130 [15.9%] within 30 days). There was no statistically significant change in initiation of anticoagulation associated with the intervention (adjusted odds ratio, 1.33 [95% CI, 0.75-2.35]; P = .13). Decision support was used for 217 eligible case patients (26.6%) (per protocol) and was associated with a statistically significant change in anticoagulation initiation when compared with 599 patients for whom decision support was not used (164 [75.6%] vs 394 [65.8%]; P = .008).Conclusions and RelevanceIn this trial, a multipronged intervention to facilitate thromboprophylaxis among eligible ED patients with AFF did not significantly increase anticoagulation initiation. Opportunities exist to further improve stroke prevention among ED patients with primary AFF.Trial RegistrationClinicalTrials.gov Identifier: NCT05009225

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Net Clinical Benefit of Oral Anticoagulation Among Frail Patients With Atrial Fibrillation: Nationwide Cohort Study

Cited by 2 publications

References 39 publications

Atrial High-Rate Episodes in Elderly Patients: The Anticoagulation Therapy Dilemma

Atrial High-Rate Episodes in Elderly Patients: The Anticoagulation Therapy Dilemma

Decision Support Intervention and Anticoagulation for Emergency Department Atrial Fibrillation

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