Reasons and Consequences of Vitamin K Antagonists Discontinuation in Very Elderly Patients with Non-Valvular Atrial Fibrillation

Anticoagulation in elderly patients with non-valvular atrial fibrillation (NVAF) is still a challenge and suspension of warfarin is common. Aim of this study is to analyse the aspects related to warfarin discontinuation in a real world population.This was an observational cohort study on Very Elderly NVAF patients na\uefve to warfarin therapy (VENPAF). Included subjects were at least 80 years old and started warfarin after NVAF diagnosis. Warfarin discontinuation was assessed and reason reported for discontinuation, person who decided to stop treatment, subsequent antithrombotic therapy and mortality, ischemic and bleeding events were collected. During five years, 148 of 798 patients discontinued warfarin. Despite similar CHA2 DS2 -VASc score, thromboembolic and major bleeding events were significantly higher (p=0.01 and p=0.001, respectively) and time in therapeutic range (TTR) significantly lower (p<0.001) in patients who discontinued warfarin. Independent risk factors for warfarin discontinuation were vascular disease (HR 2.5, p<0.001), 85 years of age or older (HR 1.4, p=0.04), TTR <60% (HR 1.8, p=0.001) and bleeding events (HR 2.3, p<0.001). Main reasons for warfarin discontinuation were physician perceived frailty or low life expectancy (45.9%), bleeding complications (19.6%) and sinus rhythm restoration (16.9%). Event rate and deaths were very high especially in frail patients and in those with bleeding complications. Discontinuation of warfarin is frequent in very elderly patients and is associated to increased risk of death and adverse events. Identification of elderly patients at high risk of bleeding and poor quality of anticoagulation during warfarin is still an unmet clinical problem

Impact of residual pulmonary obstruction on the long-term outcome of patients with pulmonary embolism

The impact of residual pulmonary obstruction on the outcome of patients with pulmonary embolism is uncertain.We recruited 647 consecutive symptomatic patients with a first episode of pulmonary embolism, with or without concomitant deep venous thrombosis. They received conventional anticoagulation, were assessed for residual pulmonary obstruction through perfusion lung scanning after 6 months and then were followed up for up to 3 years. Recurrent venous thromboembolism and chronic thromboembolic pulmonary hypertension were assessed according to widely accepted criteria.Residual pulmonary obstruction was detected in 324 patients (50.1%, 95% CI 46.2-54.0%). Patients with residual pulmonary obstruction were more likely to be older and to have an unprovoked episode. After a 3-year follow-up, recurrent venous thromboembolism and/or chronic thromboembolic pulmonary hypertension developed in 34 out of the 324 patients (10.5%) with residual pulmonary obstruction and in 15 out of the 323 patients (4.6%) without residual pulmonary obstruction, leading to an adjusted hazard ratio of 2.26 (95% CI 1.23-4.16).Residual pulmonary obstruction, as detected with perfusion lung scanning at 6 months after a first episode of pulmonary embolism, is an independent predictor of recurrent venous thromboembolism and/or chronic thromboembolic pulmonary hypertension

Understanding Factors Associated With Psychomotor Subtypes of Delirium in Older Inpatients With Dementia

Objectives: Few studies have analyzed factors associated with delirium subtypes. In this study, we investigate factors associated with subtypes of delirium only in patients with dementia to provide insights on the possible prevention and treatments. Design: This is a cross-sectional study nested in the “Delirium Day” study, a nationwide Italian point-prevalence study. Setting and Participants: Older patients admitted to 205 acute and 92 rehabilitation hospital wards. Measures: Delirium was evaluated with the 4-AT and the motor subtypes with the Delirium Motor Subtype Scale. Dementia was defined by the presence of a documented diagnosis in the medical records and/or prescription of acetylcholinesterase inhibitors or memantine prior to admission. Results: Of the 1057 patients with dementia, 35% had delirium, with 25.6% hyperactive, 33.1% hypoactive, 34.5% mixed, and 6.7% nonmotor subtype. There were higher odds of having venous catheters in the hypoactive (OR 1.82, 95% CI 1.18-2.81) and mixed type of delirium (OR 2.23, CI 1.43-3.46), whereas higher odds of urinary catheters in the hypoactive (OR 2.91, CI 1.92-4.39), hyperactive (OR 1.99, CI 1.23-3.21), and mixed types of delirium (OR 2.05, CI 1.36-3.07). We found higher odds of antipsychotics both in the hyperactive (OR 2.87, CI 1.81-4.54) and mixed subtype (OR 1.84, CI 1.24-2.75), whereas higher odds of antibiotics was present only in the mixed subtype (OR 1.91, CI 1.26-2.87). Conclusions and Implications: In patients with dementia, the mixed delirium subtype is the most prevalent followed by the hypoactive, hyperactive, and nonmotor subtype. Motor subtypes of delirium may be triggered by clinical factors, including the use of venous and urinary catheters, and the use of antipsychotics. Future studies are necessary to provide further insights on the possible pathophysiology of delirium in patients with dementia and to address the optimization of the management of potential risk factors