Contemporary management of atrial fibrillation

Nurse practitioners (NPs) frequently treat adults with atrial fibrillation. With new oral antithrombotic agents available, NPs need to be knowledgeable of treatment options to prevent stroke and systemic emboli. This article reviews the latest American College of Cardiology Foundation/American Heart Association guideline on the management of atrial fibrillation. Emphasis is placed on the changing landscape of pharmacological agents. Use of guideline-directed medical therapy will ultimately improve patients’ quality of life and prevent stroke and premature death

Oral anticoagulation treatment in atrial fibrillation - To bleed or not to bleed, that is the question

Background: Oral antigoagulation treatment (OAT) with warfarin have a narrow therapeutic window and patients exhibit a highly variable doseresponse that is attributable to genetic, disease-related,and environmental factors as well as prescription and nonprescription drugs, dietary vitamin K and alcohol. The effect of warfarin treatement on blood coagulation is measured using international normalized ratio (INR). Monitoring and tight control of anticoagulation treatment reduces the risk of both thrombosis and bleeding. The time in therapeutic range (TTR) has been validated as a quality indicator of the anticoagulation treatment given, correlating inversely to complication frequencies. The Swedish national quality registry for atrial fibrillation and anticoagulation (AuriculA) was founded in 2006 and has by August 2011 enrolled 68,000 patients, close to 40 % of all patients on anticoagulation in Sweden. Patients with end stage renal disease are at high risk for both bleeding and thrombosis and even a moderate decrease in glomerular filtration rate (GFR) is associated with thromboembolic and bleeding complications. Impaired kidney function has also been shown to be associated with a greater need of warfarin dose adjustment, poor TTR, and an increased risk of bleeding in patients taking warfarin. New anticoagulants, most of them eliminated by renal route, can be administered in a fix dose, have few drug and no dietary interactions, has been shown to be at least inferior and in some cases superior to OAT with warfarin. Methods: The Anticoagulation Clinic in Malmö participates in AuriculA, and uses this registry for prospective follow-up and as a tool for OAT dosage. This thesis has utilized data from AuriculA for epidemilogical analysis of impaired kidney function, using two equations for estimated glomerular filtration rate (eGFR), TTR, and the correlation of these two markers to major bleeding and thrombo-embolic events. Results: In Paper I, TTR in 18391 patients in the whole Swedish AuriculA population was 76.2%. Compared to recent prospective randomized trials of warfarin treatment, TTR in the AuriculA population was higher. Adherence to treatment, as measured by TTR, was higher in elderly patients with a significant correlation with increasing age. In 4273 patients from two centers in AuriculA the frequency of major bleedings and venous/arterial thromboembolism were 2.6 % and 1.7 % and for atrial fibrillation (AF), 2.6 % and 1.4 %, per treatment year respectively. In Paper II, the fraction of 2603 AF patients on warfarin with eGFR 3.0 (p<0.001 for both). There was no correlation between age, eGFR and thromboembolic events. The prevalence of eGFR <45ml/min/1.73m2 was 52% in patients aged ≥75 years with major bleeding. eGFR levels <30 ml/min/1.73m2 were particularly associated with high risk of bleeding in elderly patients. No correlation between eGFR and thromboembolic events was seen. In Paper IV, 397 patients on OAT with warfarin, there was a positive correlation between results from the point-of-care device (POC) CoaguChek XS and the Owren-type PT assay for INR measurement (r=0.94;p<0.001) and concordance of 88.2%. In patients with 152 double samples analyzed with the CoaguChek XS, a positive correlation of 0.99 was seen; p<0.001. Conclusions: The quality of OAT with warfarin in Sweden is high and comparable to prospective randomized trials of warfarin treatment. Complications were low, probably due to the organization of anticoagulation treatment in Sweden, although the AuriculA dosing algorithm could have contibuted by keeping dosing regimens consistent over all centers. The POC-device CoaguChek XS presents reproducible results, highly comparable with Owren PT at therapeutic levels of INR, offering a more convenient method of monitoring, compared to regular venous INR measurement in patients on OAT with warfarin. Severe renal impairment is common among AF patients on OAT with warfarin, especially at higher ages, indicating one important difference between a ‘real world’ clinical population and those of randomized controlled trials of new oral anticoagulant drugs, where patients with severe renal failure (eGFR <30 ml/min/1.73 m2) were excluded. Given the strong correlation between eGFR and major bleeding events in patients on anticoagulation treatment demonstrated in Paper III, caution is advised in the upcoming era of new oral anticoagulants with elimination by renal route. Monitoring of renal function should be implemented in clinical practice for AF patients treated with new anticoagulants eliminated by the kidneys and registries like AuriculA can be used for prospective follow-up of these patients

Fuel poverty, older people and cold weather: An all-island analysis

Executive Summary This report covers a number of different aspects of fuel poverty and older people. 1. An exploration of existing government survey data from Northern Ireland and the Republic of Ireland with a particular focus on older people and conducting additional targeted analyses where required. 2. An original survey in the Republic of Ireland exploring the lived experience of older people in cold weather. 3. A feasibility study of data logging thermometers placed in the homes of older tenants in local authority accommodation. 4. Analysis of excess winter mortality among older people including a consideration of differences between the two jurisdictions. Older people on the island of Ireland, as in many other countries, experience a ‘dual burden’ in terms of fuel poverty. They are more likely to experience fuel poverty and are also particularly vulnerable to health and social harm as a result of this experience. The numbers of older people vulnerable to ill-effects from cold homes will rise as numbers of people aged 80 and over, and those living with chronic illness or disability, increase. There were significant differences observed between expenditure-based, and subjective (EU-SILC) based fuel poverty indicators, for older people, and between Northern Ireland and Republic of Ireland data. This data required careful interpretation. The higher levels of fuel poverty recorded for older people on the island of Ireland appeared to be driven by all aspects of the fuel poverty model - poor housing condition, energy inefficient housing, rising fuel prices and low income. The majority of older people live in their own home and these homes tend to be older properties which are detached or semi-detached. Older people on the island are over-represented among houses which are in poor condition and which lack central heating in both jurisdictions. Lacking central heating was a more common experience for older people in the Republic of Ireland than in Northern Ireland. Data on energy efficiency measures were not comparable North/South but similar patterns were observed. Older people were less likely than the general population to have attic/loft or wall insulation or double glazing. Older people were also vulnerable from an income point of view. This would seem to be a particular issue in Northern Ireland where rates of income poverty are significantly increasing. In both jurisdictions older people were heavily reliant on social transfers to keep them out of poverty. Coupled with this, there is evidence that many older people are not claiming their full entitlements. Oil dependency was a particular issue in Northern Ireland. Very significant increases were observed in the price of heating oil, as well as electricity and gas in recent years. There was little available research evidence on the relationship between the older consumer and heating oil suppliers

Atrial fibrillation: the current epidemic.

Atrial fibrillation (AF) is the most common arrhythmia diagnosed in clinical practice. The consequences of AF have been clearly established in multiple large observational cohort studies and include increased stroke and systemic embolism rates if no oral anticoagulation is prescribed, with increased morbidity and mortality. With the worldwide aging of the population characterized by a large influx of "baby boomers" with or without risk factors for developing AF, an epidemic is forecasted within the next 10 to 20 years. Although not all studies support this evidence, it is clear that AF is on the rise and a significant amount of health resources are invested in detecting and managing AF. This review focuses on the worldwide burden of AF and reviews global health strategies focused on improving detection, prevention and risk stratification of AF, recently recommended by the World Heart Federation

Atrial Fibrillation and the Role of Thumb ECGs

Atrial fibrillation (AF) may be underdiagnosed, and there is much that remains unknown about this prevalent and potentially life-threatening arrhythmia. AF epidemiology has been thwarted in part by the fact that about a third of patients with AF have no symptoms, those with symptoms may experience them intermittently or have vague symptoms, and it can be challenging to capture an episode on a 12-lead ECG, which is required for diagnosis. There are many significant knowledge gaps in our understanding of AF etiology and progression. A new user-friendly device that allows for frequent self-monitoring of the heart rhythm has been introduced. With the thumb ECG, patients can record a tracing multiple times a day. A smartphone app will soon allow them to interact with their healthcare providers about these ECG recordings. An ECG parser will allow for an algorithm-directed, rapid, automatic interpretation of these recordings with high specificity and sensitivity. This may help researchers learn more about the so-called silent AF, AF progression (and possible remission), and risk factors for AF. This technology holds great promise for patient care as well as for research into AF

Leaving "Hotel California": How Incentives Affect Flows of Benefit Recipients in the Netherlands

This paper discusses developments in the Netherlands concerning unemployment insurance, unemployment assistance and disability insurance.The emphasis is on how incentives for individual workers and firms affect flows of benefit recipients.unemployment benefits;unemployment assistance;disability benefits;incentives

An Open Randomized Comparison of Gatifloxacin versus Cefixime for the Treatment of Uncomplicated Enteric Fever

OBJECTIVE: To assess the efficacy of gatifloxacin versus cefixime in the treatment of uncomplicated culture positive enteric fever. DESIGN: A randomized, open-label, active control trial with two parallel arms. SETTING: Emergency Room and Outpatient Clinics in Patan Hospital, Lagankhel, Lalitpur, Nepal. PARTICIPANTS: Patients with clinically diagnosed uncomplicated enteric fever meeting the inclusion criteria. INTERVENTIONS: Patients were allocated to receive one of two drugs, Gatifloxacin or Cefixime. The dosages used were Gatifloxacin 10 mg/kg, given once daily for 7 days, or Cefixime 20 mg/kg/day given in two divided doses for 7 days. OUTCOME MEASURES: The primary outcome measure was fever clearance time. The secondary outcome measure was overall treatment failure (acute treatment failure and relapse). RESULTS: Randomization was carried out in 390 patients before enrollment was suspended on the advice of the independent data safety monitoring board due to significant differences in both primary and secondary outcome measures in the two arms and the attainment of a priori defined endpoints. Median (95% confidence interval) fever clearance times were 92 hours (84-114 hours) for gatifloxacin recipients and 138 hours (105-164 hours) for cefixime-treated patients (Hazard Ratio[95%CI] = 2.171 [1.545-3.051], p&lt;0.0001). 19 out of 70 (27%) patients who completed the 7 day trial had acute clinical failure in the cefixime group as compared to 1 out of 88 patients (1%) in gatifloxacin group(Odds Ratio [95%CI] = 0.031 [0.004 - 0.237], p&lt;0.001). Overall treatment failure patients (relapsed patients plus acute treatment failure patients plus death) numbered 29. They were determined to be (95% confidence interval) 37.6 % (27.14%-50.2%) in the cefixime group and 3.5% (2.2%-11.5%) in the gatifloxacin group (HR[95%CI] = 0.084 [0.025-0.280], p&lt;0.0001). There was one death in the cefixime group. CONCLUSIONS: Based on this study, gatifloxacin is a better treatment for uncomplicated enteric fever as compared to cefixime. TRIAL REGISTRATION: Current Controlled Trials ISRCTN75784880