Atrial fibrillation in patients with liver disease: Recent advances

Atrial fibrillation is associated with significant morbidity and mortality, and its incidence is increasing globally. The primary complication of atrial fibrillation is ischemic stroke, whose risk may be reduced with oral anticoagulant agents, i.e., either vitamin K antagonists or direct oral anticoagulants. Patients with atrial fibrillation often have concomitant hepatic impairment, particularly because of increasing rates of non-alcoholic liver disease. However, anticoagulation in patients with liver disease is challenging due to the pathophysiological changes of the coagulation cascade and, as a result, an increased risk of major bleeding in such individuals. Furthermore, monitoring of the degree of anticoagulation is complicated in patients with liver disease due to issues such as spontaneous international normalized ratio (INR) elevation, changes in hepatic drug elimination, and thrombocytopenia. We review the current evidence on atrial fibrillation and anticoagulation in patients with liver disease. We suggest having a strong focus on risk factor management and argue that the risk of ischemic stroke often outweighs the risk of hemorrhagic events in this setting

Validity of the GAITRite Walkway Compared to Functional Balance Tests for Fall Risk Assessment in Geriatric Outpatients

This study examined the concurrent validity between gait parameters from the GAITRite walkway and functional balance test commonly used in fall risk assessment. Patients were sampled from one geriatric outpatient clinic. One physiotherapist evaluated the patients on the GAITRite walkway with three repetitions in both single- and dual-task conditions. Patients were further evaluated with Bergs Balance scale (BBS), Dynamic Gait index (DGI), Timed Up and Go (TUG), and Sit To Stand test (STS). Correlations between quantitative gait parameters and functional balance test were analyzed with Spearman’s rank correlations. Correlations strength was considered as follows: negligible <0.1, weak 0.10–0.39, moderate 0.40–0.69, and strong ≥0.70. We included 24 geriatric outpatients in the study with a mean age of 80.6 years (SD: 5.9). Patients received eight (SD: 4.5) different medications on average, and seven (29.2%) patients used walkers during ambulation. Correlations between quantitative gait parameters and functional balance test ranged from weak to moderate in both single- and dual-task conditions. Moderate correlations were observed for DGI, TUG, and BBS, while STS showed weak correlations with all GAITRite parameters. For outpatients analyzed on the GAITRite while using walkers, correlations showed no clear pattern across parameters with large variation within balance tests

Primiparous women differ from multiparous women after early discharge regarding breastfeeding, anxiety, and insecurity:A prospective cohort study

INTRODUCTION: Breastfeeding and factors influencing breastfeeding are essential when considering the association between parity and neonatal and maternal morbidity risks when mothers are discharged within 24 hours after birth. However, there is a lack of studies examining the effect of parity and breastfeeding in a setting where all healthy mothers are recommended discharge four hours after birth. Therefore, this study examined the association between parity and the time for discharge, breastfeeding, and factors influencing breastfeeding. METHODS: The study was designed as a prospective cohort study. Data were obtained from questionnaires at one and at six weeks after birth, and combined with registered data. All 147 included mothers were healthy, with an uncomplicated birth and a healthy newborn, discharged within 24 hours after birth. RESULTS: This study documented that primiparous women had a higher relative risk (RR=2.62; 95% CI: 1.35–5.10) of having doubts about infant feeding after discharge than multiparous women. Furthermore, 54% of primiparous women contacted the maternity ward after discharge compared to 27% of multiparous women. Twice as many primiparous than multiparous women felt anxious or depressed at one and at six weeks after birth. Finally, the study documented that 13% of primiparous women and 5% of multiparous women discharged within six hours after birth perceived the time before discharge to be too short. CONCLUSIONS: Primiparous women differ from multiparous women regarding breastfeeding, insecurity, and anxiety. Special attention towards primiparous women and a follow-up strategy that allows the mothers to contact the maternity ward after early discharge is recommended

Gastrointestinal bleeding with direct oral anticoagulants in patients with atrial fibrillation and anaemia

Introduction: A high risk of gastrointestinal bleeding has been reported with the use of some direct oral anticoagulants (DOACs). This risk may be of particular concern in individuals with associated anaemia. The aim of this study is to investigate potential differences in the risks of gastrointestinal bleeding and stroke among the four available DOACs in patients with atrial fibrillation (AF) and moderate or severe anaemia.Materials and methods: All Danish patients diagnosed with incident AF who had a baseline haemoglobin measurement and subsequently initiated DOAC therapy between 2012 and 2021 were identified through administrative registries. Only patients with moderate or severe anaemia (N = 7269) were included and evaluated regarding the risk of hospitalization for gastrointestinal bleeding and stroke. Standardized absolute 1-year risks of stroke and gastrointestinal bleeding were calculated from multivariable Cox regression analyses. DOACs were compared pairwise RESULTS: Compared with apixaban, both dabigatran and rivaroxaban were associated with a significantly increased risk of gastrointestinal bleeding with standardized 1-year risk ratios of 1.73 (95 % confidence interval [CI], 1.10-2.35) and 1.56 (95 % CI, 1.18-1.93), respectively, while no significant difference was seen in the comparison of apixaban with edoxaban 1.32 (95 % CI, 0.41-2.32). No significant differences in gastrointestinal bleeding were observed with pairwise comparisons of dabigatran, rivaroxaban and edoxaban. Finally, no significant difference in stroke risk among the four DOACs was observed.Conclusion: In AF patients with moderate or severe anaemia, apixaban was associated with a significantly lower risk of gastrointestinal bleeding than dabigatran and rivaroxaban. No significant difference in stroke risk was observed across all four available DOACs

Return to the workforce following first hospitalization for heart failure: a Danish nationwide cohort study

Background: Return to work is important financially, as a marker of functional status and for self-esteem in patients developing chronic illness. We examined return to work after first heart failure (HF) hospitalization. Methods: By individual-level linkage of nationwide Danish registries, we identified 21455 patients of working age (18-60 years) with a first HF hospitalization in the period of 1997-2012. Of these 11880 (55%) were in the workforce prior to HF hospitalization and comprised the study population. We applied logistic regression to estimate odds ratios (OR) for associations between age, sex, length of hospital stay, level of education, income, comorbidity and return to work. Results: One year after first HF hospitalization, 8040 (67.7%) returned to the workforce, 2981 (25.1%) did not, 805 (6.7%) died and 54 (0.5%) emigrated. Predictors of return to work included younger age (18-30 vs. 51-60 years, OR 3.12; 95% CI 2.42-4.03), male sex (OR 1.22 [1.18-1.34]) and level of education (long-higher vs. basic school OR 2.06 [1.63-2.60]). Conversely, hospital stay >7 days (OR 0.56 [0.51-0.62]) and comorbidity including history of stroke (OR 0.55 [0.45-0.69]), chronic kidney disease (OR 0.46 [0.36-0.59]), chronic obstructive pulmonary disease (OR 0.62 [0.52-0.75]), diabetes (OR 0.76 [0.68-0.85]) and cancer (OR 0.49 [0.40-0.61]) were all significantly associated with lower chance of return to work. Conclusions: Patients in the workforce prior to HF hospitalization had low mortality but high risk of detachment from the workforce one year later. Young age, male sex, and higher level of education were predictors of return to work

Increased 5-year risk of stroke, atrial fibrillation, acute coronary syndrome, and heart failure in out-of-hospital cardiac arrest survivors compared with population controls:A nationwide registry-based study

AimLong-term risks of stroke, atrial fibrillation, or flutter (AF), acute coronary syndrome (ACS), and heart failure (HF) among survivors of out-of-hospital cardiac arrest (OHCA) are unknown. We aimed to examine 5-year risks of these outcomes among 30-day survivors of OHCA.MethodsThirty-day survivors of OHCA without a prior (or within 30 days after cardiac arrest) history of stroke, AF, ACS, or HF and population controls without a prior history of these conditions were identified using Danish nationwide registries. Five-year risks of stroke, AF, ACS, and HF standardized to the distributions of age, sex, and comorbidities among OHCA survivors and controls were obtained using multivariable regression.ResultsOf 4,362 30-day OHCA-survivors, 1,051 were stroke-, AF-, ACS-, and HF-naïve and matched with controls using age, sex, and time of OHCA event. Absolute five-year risks for OHCA survivors vs. controls were for stroke: 6.3% [95% confidence interval (CI) 4.1-8.5] vs. 2.0% [1.6-2.5], AF: 7.9% [5.7-10.2] vs. 2.6% [2.1-3.1], ACS: 5.0% [3.2-6.8] vs. 1.5% [1.1-1.9], and HF: 12.7% [10.1-15.4] vs. 1.2% [0.9-1.6], respectively. Corresponding relative risks were 3.18 [95% CI 1.76-4.61] for stroke, 3.03 [1.93-4.14] for AF, 3.23 [1.69-4.77] for ACS, and 10.40 [6.57-14.13] for HF.ConclusionWhen compared with population controls, OHCA survivors had significantly increased five-year risks of incident stroke, AF, ACS, and HF

Out-of-Hospital Cardiac Arrest in Patients With Psychiatric Disorders - Characteristics and Outcomes

Aims To investigate whether the recent improvements in pre-hospital cardiac arrest-management and survival following out-of-hospital cardiac arrest (OHCA) also apply to OHCA patients with psychiatric disorders. Methods We identified all adult Danish patients with OHCA of presumed cardiac cause, 2001–2015. Psychiatric disorders were defined by hospital diagnoses up to 10 years before OHCA and analyzed as one group as well as divided into five subgroups (schizophrenia-spectrum disorders, bipolar disorder, depression, substance-induced mental disorders, other psychiatric disorders). Association between psychiatric disorders and pre-hospital OHCA-characteristics and 30-day survival were assessed by multiple logistic regression. Results Of 27,523 OHCA-patients, 4772 (17.3%) had a psychiatric diagnosis. Patients with psychiatric disorders had lower odds of 30-day survival (0.37 95% confidence interval 0.32–0.43) compared with other OHCA-patients. Likewise, they had lower odds of witnessed status (0.75 CI 0.70–0.80), bystander cardiopulmonary resuscitation (CPR) (0.77 CI 0.72–0.83), shockable heart rhythm (0.37 95% CI, 0.33–0.40), and return of spontaneous circulation (ROSC) at hospital arrival (0.66 CI 0.59–0.72). Similar results were seen in all five psychiatric subgroups. The difference in 30-day survival between patients with and without psychiatric disorders increased in recent years: from 8.4% (CI 7.0–10.0%) in 2006 to 13.9% (CI 12.4–15.4%) in 2015 and from 7.0% (4.3–10.8%) in 2006 to 7.0% (CI 4.5–9.7%) in 2015, respectively. Conclusion Patients with psychiatric disorders have lower survival following OHCA compared to non-psychiatric patients and the gap between the two groups has widened over time