Use of anticoagulation at the time of discharge in patients with heart failure and atrial fibrillation

[Resumen] Introducción y objetivos. Evaluar el grado de cumplimiento de las guías sobre uso de anticoagulación crónica en pacientes con insuficiencia cardíaca y fibrilación auricular. Pacientes y método. Se usó la base de datos del estudio INCARGAL, analizando datos de 195 pacientes consecutivos (88 varones, edad 76 ± 10 años) admitidos con ambos diagnósticos en tres hospitales gallegos entre enero y junio de 1999. Se asumió que todos deberían de haber recibido anticoagulación al alta hospitalaria en ausencia de contraindicaciones. Se comparó el tratamiento al alta (anticoagulación o no) con la presencia o ausencia de contraindicaciones. Resultados. Un total de 152 pacientes (78%) no tenían contraindicaciones para la anticoagulación y 43 presentaban alguna (absoluta, 11; relativa, 32). De los pacientes sin contraindicación, sólo recibieron anticoagulación al alta el 50%. Ningún paciente con contraindicación absoluta y tres con contraindicación relativa recibieron anticoagulación. La prescripción de anticoagulación en los pacientes sin contraindicaciones fue menor en los que tenían una mayor edad, antecedente de cardiopatía isquémica, ausencia de valvulopatía, uso de bloqueadores beta, no realización de ecocardiograma e ingreso en un servicio diferente del de cardiología (p < 0,05). En el análisis multivariante, la edad, el infarto de miocardio previo y la ausencia de valvulopatía significativa permanecieron como predictores independientes de menor uso de anticoagulación. Conclusiones. El empleo de anticoagulación al alta hospitalaria en pacientes sin contraindicación para su uso, con fibrilación auricular e insuficiencia cardíaca, es menor del recomendado. La edad avanzada disminuye su empleo. La presencia de otras indicaciones para la antiagregación o la anticoagulación parecen determinar la elección de una u otra terapia. No hubo mala adecuación por exceso de prescripción.[Abstract] Introduction and objectives. To assess the degree of compliance with current guidelines for chronic anticoagulation in patients with heart failure and atrial fibrillation. Patients and method. From the INCARGAL Study database, we analyzed data from 195 consecutive patients (88 men; mean age 76 ± 10 years) with both conditions, admitted to three Galician hospitals between January and March 1999. It was assumed that these patients should have received anticoagulant therapy at discharge, unless contraindicated. We studied the association of treatment at discharge (anticoagulation or not) with the presence or absence of contraindications. Results. -152 patients (78%) had no contraindication for anticoagulation and 43 had at least one (absolute: 11, relative: 32). Only 50% of patients without contraindications received anticoagulation at the time of discharge. No patient with an absolute contraindication and 3 with a relative one received anticoagulation. Factors related with the less frequent prescription of anticoagulation therapy in patients without a formal contraindication were: age, a previous history of coronary heart disease, absence of valvular heart disease, prior' myocardial infarction, treatment with beta-blocking agents, non performance of an echocardiogram, and admission to a department other than cardiology. On multivariate analysis, age, prior myocardial infarction, and non-valvular disease were found to be independent predictors of less use of anticoagulation. Conclusions. Anticoagulant therapy is used less often than recommended at discharge in patients with heart failure and atrial fibrillation for whom there were no contraindications. Advanced age reduces its use. The presence of other indications for antiplatelet or anticoagulatión therapy appears to determine the choice of one or the other. Noncompliance with the guidelines due to overprescription was not found

Presente y futuro del tratamiento anticoagulante oral

The alternative new oral anticoagulants open a new era in antithrombotic treatment. For more than half a century, vitamin K antagonists have defined oral anticoagulant therapy for the long-term management of thrombotic disorders. However, vitamin-K antagonists have multiple, well-known limitations, including numerous interactions with other drugs and the need for regular blood monitoring and dose adjustments. Novel anticoagulants are directed against either thrombin (Dabigatran) or factor Xa (Rivaroxaban and Apixaban), have a short half-life in patients with normal renal function and rapid onset of action. Thousands of patients in clinical trials in prophylaxis and treatment of venous and arterial thrombosis have been treated. Nowadays, they are approved for hip and knee replacement prophylaxis, non valvular atrial fibrillation, venous deep thrombosis and pulmonary embolism. Also, there are reports of their potential utility in recent coronary syndrome. Though open questions remains such as how to manage hemorrhage and invasive procedures and many aspects of their use will be unfamiliar to practicing clinicians, it seems that the paradigm of oral anticoagulation has completely changed. In the future, the question will probably be who should not receive a direct action oral anticoagulantLos nuevos anticoagulantes orales abren una nueva era en el tratamiento antitrombótico.Durante más de cincuenta años los antagonistas de la vitamina K han tenido el papel protagonista en el tratamiento anticoagulante oral. Sin embargo, los antagonistas de la vitamina K tienen multiples limitaciones, incluyendo numerosas interacciones con otros fármacos y la necesidad de control biologico frecuente. Los nuevos anticoagulantes orales dirigidos ya contra trombina (Dabigatrán) o factor Xa ((Rivaroxabán y Apixabán), tienen una vida media corta en pacientes con function renal normal y una acción rápida. Miles de pacientes ya han sido tratados en ensayos clínicos en profilaxis y tratamiento de trombosis venosa y arterial. Actualmente están aprobados en profilaxis de cirugía protésica de cadera y rodilla, fibrilación auricular no valvular, trombosis venosa profunda y embolismo pulmonar. Además, hay datos preliminares de su potencial utilidad en sindrome coronario. Aunque todavía hay aspectos de debate tales como la actitud ante una hemorragia o ante procedimientos invasivos y muchos aspectos de su utlización no son familiares en la práctica clínica, parece que el paradigma de la anticoagulación oral ha cambiado. En el futuro, la pregunta sera probablemente que paciente con indicación de anticoagulación no debe recibir un anticoagulante oral de acción directa

Tratamiento antiarrítmico actual de la fibrilación auricular no valvular en España: datos del Registro FANTASIIA

[Abstract] Introduction and objectives. Recently, there have been many developments in the management of nonvalvular atrial fibrillation, antiarrhythmic and anticoagulant therapy, and nonpharmacological treatment, but these developments are not applied immediately in clinical practice. The aim of this study was to identify the overall management and antiarrhythmic therapy used in the current general population of patients with nonvalvular atrial fibrillation in Spain. Methods. A prospective, observational study of 1318 consecutive anticoagulated patients with nonvalvular atrial fibrillation, recruited between June 2013 and March 2014. We analyzed the patients’ general characteristics, management, and antiarrhythmic therapy. Results. Mean age was 73.8 ± 9.4 years; 42.5% were women. Atrial fibrillation was paroxysmal in 28% of the patients, permanent in 50%, persistent in 17.6%, long-standing persistent in 4.5%, and new-onset in 66 patients (5%). A rhythm control strategy was chosen in 39.4% of the patients and rate control in 60.6%. Beta-blockers were prescribed in 60.2% of the patients, digoxin in 19.5%, and calcium channel antagonists in 10.7%. The antiarrhythmic agents used were amiodarone (12.6%), flecainide (8.9%), propafenone (0.4%), sotalol (0.5%), and dronedarone (2.3%). Cardioversion had been performed previously in 41.9% of the patients, ablation in 3.4%, and atrial appendage closure in 0.2%. Conclusions. Currently, patients with nonvalvular atrial fibrillation in Spain are managed mainly with rate control, and beta-blockers in particular. They receive few antiarrhythmic agents and only a very small number of these patients undergo nonpharmacological treatments.[Resumen] Introducción y objetivos. Recientemente se han producido numerosas novedades en el manejo de la fibrilación auricular no valvular y el tratamiento antiarrítmico, anticoagulante y no farmacológico empleado, pero su aplicación a la clínica no es inmediata. El objetivo del trabajo es conocer las características generales de manejo y tratamiento antiarrítmico de una población general de pacientes con fibrilación auricular no valvular actualmente en España. Métodos. Estudio observacional y prospectivo de 1.318 pacientes consecutivos con fibrilación auricular no valvular, anticoagulados y reclutados entre junio de 2013 y marzo de 2014. Se analizan sus características generales, el manejo y el tratamiento antiarrítmico utilizado. Resultados. La media de edad era 73,8 ± 9,4 años; eran mujeres el 42,5%. La fibrilación auricular fue paroxística en el 28% de los casos, permanente en el 50%, persistente en el 17,6%, persistente de larga duración en el 4,5% y de novo en 66 pacientes (5%). Se eligió control del ritmo en el 39,4% de los casos y de frecuencia en el 60,6%. Tomaron bloqueadores beta el 60,2%, digoxina el 19,5% y antagonistas del calcio el 10,7%. Los antiarrítmicos empleados fueron amiodarona (12,6%), flecainida (8,9%), propafenona (0,4%), sotalol (0,5%) y dronedarona (2,3%). Se realizó cardioversión previa en el 41,9%, ablación en el 3,4% y cierre de orejuela en el 0,2%. Conclusiones. Actualmente en nuestro país se maneja a los pacientes con fibrilación auricular no valvular preferentemente con control de frecuencia, sobre todo con bloqueadores beta, reciben pocos antiarrítmicos y se los somete en muy baja proporción a tratamientos no farmacológicos

Fibrilación auricular y terapéutica anticoagulante

La fibrilación auricular es la taquiarritmia más frecuente en la población general. La frecuencia de dicha arritmia aumenta con la edad, presentándose en un 1.5% de los 50 a 59 años a 8-10% de los 80 a 89 años. La fibrilación auricular incrementa el riesgo de sufrir un evento cerebrovascular isquémico cardioembólico en 5 veces y causa el 15% de todos los accidentes cerebrovasculares isquémicos. El manejo de la fibrilación auricular se enfoca, principalmente, en la prevención de los fenómenos tromboembólicos y en el control de la frecuencia y ritmo cardiaco. La anticoagulación, ha demostrado ser la principal herramienta en la prevención de eventos cardioembólicos. Aunque las complicaciones hemorrágicas por el tratamiento son esperables, y aumentan con la edad, sobrepasa por mucho, el beneficio de usar anticoagulación, al riesgo de sangrados. Precisamente debido a la heterogeneidad clínica de esta arritmia y a la dificultad de establecer un tratamiento adecuado para cada caso en particular, el American College of Cardiology, la American Heart Association, la European Society of Cardiology y el American College of Chest Physicians han establecido unas guías para mejorar el manejo de los pacientes. La revisión de esta patología y de estas directrices propuestas pueden facilitar y mejorar notablemente el tratamiento de los pacientes con fibrilación auricular.Atrial fibrillation is the most frequent arrhythmia in general population. Its frequency increases with age, being 1.5% from 50 to 59 years old and 8-10% from 80 to 89 years old. Atrial fibrillation increases 5 fold the risk of suffering a stroke and causes 15% of all strokes. Atrial fibrillation management focuses in the prevention of thromboembolic phenomena and heart rate and rhythm control. Anticoagulation, when is indicated, has demonstrated to be the main tool in the prevention of these thromboembolic events. Although bleeding complications are frequent in this population and increase with age, anticoagulation benefits are greater than the risks of bleeding. Due to the clinically heterogeneous nature of this arrythmia and the difficulty of establishing appropriate treatment for each particular case, the American College of Cardiology, the American Heart Association, European Society of Cardiology and American College of Chest Physicians have established guidelines to improve the management these patients. The review of thist condition and the proposed directives can notably facilitate and improve the mangement of the patients with atrial fibrillation.Fil: Prieto, S.. Hospital Británico de Buenos Aires. Servicio de HematologíaFil: Ceresetto, J.. Hospital Británico de Buenos Aires. Servicio de Hematologí

Oral anticoagulation in elderly patiens as secondary prevention of cardioembolic strokes

Background: Stroke incidence increases with age. Atrial fibrillation (AF) is an important risk factor for ischemic stroke and its incidence also increases with age. However oral anticoagulant therapy (OAT) tends to be underused in the elderly population. Methods: Elderly patients (> = 80 years) with an ischemic stroke admitted in our department between 1/7/2003 and 31/6/2005 were prospectively evaluated. Baseline characteristics, risk factors, treatment and etiology according to TOAST criteria were recorded. Patients treated with OAT were followed up in order to assess any side effect and stroke recurrence. Mean follow-up was of 19.5 months (7-45) from discharge. Results: Sixty four out of a hundred and fifty nine elderly patients (40.25%) were classified as cardioembolic; mean age was 84.5 years (80-97) and 64.6% were women. AF had been previously identified in 60% of them (16.9% were on OAT and 40.6% on antiplatelet therapy). At discharge, 32 patients (49.2%) were on OAT. In the follow-up 4 patients (12.5%) suffered systemic haemorrhages (3 urinary, 1 gastrointestinal bleeding), with no change in their functional status. Mean INR in this group was 5.9 [3-11] and, in 3 of them, OAT was cancelled. No brain haemorrhages were recorded. Ischemic stroke recurred in 4 patients (INR < 1.8 in 3 of them; the other, INR 2.35). Three patients had died at the end of the follow-up, one of them as a consequence of ischemic stroke recurrence. Discussion: Twenty eight point eight of stroke patients admitted in the period of study were >80 years. The high proportion of cardioembolic strokes in this age segment contrasts with the general underuse of OAT as antithrombotic prophylaxis. Our study suggests that OAT is a safe strategy when carefully prescribed, even for elderly patients

Cardiac papillary fibroelastomas: A 10-year single-center surgical experience and long-term echocardiographic follow-up study

Aims. Limited contemporary data are available on the clinical and echocardiographic outcomes after surgery for cardiac papillary fibroelastoma (CPF). The aim of this study was to review the clinical manifestations, pathological characteristics, surgical management, and prognoses of patients with histologically verified CPF, who underwent surgery at our cardiac surgery center from 2008 to 2018. Methods and Results. Twelve patients of median age 62 years (28 to 77 years) were treated. Embolic stroke or transient ischemic attack (five patients, 42%) were the only CPF clinical manifestations. Eleven (92%) tumors were localized on the valves, with the aortic valve being the most common tumor site (seven patients; 58%). Multiple factor analysis revealed no independent predictor of CPF-related embolization. Simple shave tumor excision was sufficient in most patients (10 patients, 83%). No operative or tumor-related late mortality during the median follow-up period of 4.7 years (1.1 to 10.2 years) was recorded. Asymptomatic metachronous valve tumor recurrence (in a location different from that of the original tumor) was revealed in two patients (17%) by transesophageal echocardiography (TEE), not detected by transthoracic echocardiography (TTE). One of these two patients underwent repeated surgery for CPF but later suffered a recurrent embolic stroke, due to another tumor recurrence. Conclusion. CPF can be safely and effectively treated surgically. TEE is superior to the TTE option in CPF post-operative recurrence detection. There is a clear need for a prospective study to determine criteria for embolization risk stratification and optimum management in patients with CPF.Web of Science1641918

Duration of Atrial Fibrillation Episodes and Implications for the Thromboembolic Risk

Introdução: A fibrilhação auricular é uma arritmia comum e com risco tromboembólico bem documentado, estando definidas nas recomendações internacionais indicações referentes ao uso de anticoagulantes orais. Existem, contudo, lacunas de informação nomeadamente no que se refere à duração dos episódios de fibrilhação auricular e sua relação com o risco de tromboembolismo. Esta questão tem particular interesse em doentes com dispositivos electrónicos cardíacos implantados com documentação contínua da duração de episódios de taquidisritmias auriculares, que são frequentemente curtos e assintomáticos. Material e Métodos: Foi feita uma análise crítica da evidência disponível sobre a relação da duração dos episódios de FA paroxística e a ocorrência de eventos embólicos, com base numa pesquisa na base de dados bibliográfica PubMed. Resultados: Foram selecionados oito artigos com abordagens diferentes no estudo deste tema; sete com recurso a monitorização cardíaca com dispositivos electrónicos cardíacos implantados (pacemakers, cardioversores-desfibilhadores implantáveis e ressincronizadores cardíacos) e um com base em registo de Holter. Metade destas publicações, correspondendo globalmente às maiores amostragens, aborda a questão do ponto de vista do somatório diário de episódios de fibrilhação auricular (carga diária) e não da duração de cada episódio. O risco tromboembólico aumenta gradualmente com a carga arrítmica, tendo sido demonstrado um aumento significativo do risco quando esta ultrapassa os cinco minutos num dia. Discussão: A formação de um trombo intracavitário, e consequente potencial embólico, é um processo dinâmico que resulta da interacção de várias condicionantes anatómicas e funcionais. O risco individual dependerá da interacção destes factores. A associação entre fenómenos embólicos e curtos períodos de fibrilhação auricular é inequívoca, apesar do mecanismo não ser óbvio, tendo em conta a discrepância frequentemente observada entre os períodos de fibrilhação auricular e os eventos clínicos. Conclusões: O risco de eventos tromboembólicos aumenta significativamente mesmo para períodos curtos de fibrilhação auricular (≥ cinco minutos de fibrilhação auricular em um dia), apesar da relação causa-efeito não estar definida. A decisão final sobre o recurso à anticoagulação oral deve basear-se na avaliação clínica individualizada