Atrial Fibrillation and Stroke in Elderly Patients

The increasing prevalence of stroke, with an estimated annual cost of $71.5 billion, has made it a major health problem that increases disability and death, particularly in patients with atrial fibrillation. Although advanced age and atrial fibrillation are recognized as strong risk factors for stroke, the basis for this susceptibility are not well defined. Aging or associated diseases are accompanied by changes in rheostatic, humoral, metabolic and hemodynamic factors that may contribute more to stroke predisposition than rhythm abnormality alone. Several thromboembolism-predisposing clinical characteristics and serum biomarkers with prognostic significance have been identified in patients with atrial fibrillation. Although anticoagulation decreases the risk of thromboembolism, management in the elderly remains complex due to major concerns about bleeding. New anticoagulants and nonpharmacologic strategies are helpful to reduce the risk of bleeding, particularly in older-elderly patients. Herein, we review the pathogenesis and management of select issues of thromboembolism in the elderly with atrial fibrillation

Atrial Fibrillation and Stroke in Elderly Patients

The increasing prevalence of stroke, with an estimated annual cost of $71.5 billion, has made it a major health problem that increases disability and death, particularly in patients with atrial fibrillation. Although advanced age and atrial fibrillation are recognized as strong risk factors for stroke, the basis for this susceptibility are not well defined. Aging or associated diseases are accompanied by changes in rheostatic, humoral, metabolic and hemodynamic factors that may contribute more to stroke predisposition than rhythm abnormality alone. Several thromboembolism-predisposing clinical characteristics and serum biomarkers with prognostic significance have been identified in patients with atrial fibrillation. Although anticoagulation decreases the risk of thromboembolism, management in the elderly remains complex due to major concerns about bleeding. New anticoagulants and nonpharmacologic strategies are helpful to reduce the risk of bleeding, particularly in older-elderly patients. Herein, we review the pathogenesis and management of select issues of thromboembolism in the elderly with atrial fibrillation

Hypotension associated with advanced Hodgkin lymphoma

Hypotension is an extremely rare manifestation of Hodgkin lymphoma. We report the case of a patient who presented with new onset hypotension and was diagnosed with urosepsis and septic shock requiring pressor support for maintaining his blood pressure. computed tomography (CT) scan of abdomen showed liver lesions, which were new on comparison with a CT abdomen done 3 weeks back. Biopsy of the liver lesions and subsequently a bone marrow biopsy showed large atypical Reed-Sternberg cells, positive for CD15 and CD 30 and negative for CD45, CD3 and CD20 on immunohistochemical staining, hence establishing the diagnosis of Hodgkin lymphoma. The mechanism involved in Hodgkin lymphoma causing hypotension remains anecdotal, but since it is mostly seen in patients with advanced Hodgkin lymphoma, it is hypothetically related to a complex interaction between cytokines and mediators of vasodilatation. Here we review relevant literature pertaining to presentation and pathogenesis of this elusive and rare association

Octreotide for the Management of Gastrointestinal Bleeding in a Patient with a HeartWare Left Ventricular Assist Device

HeartWare is a third generation left ventricular assist device (LVAD), widely used for the management of advanced heart failure patients. These devices are frequently associated with a significant risk of gastrointestinal (GI) bleeding. The data for the management of patients with LVAD presenting with GI bleeding is limited. We describe a 56-year-old lady, recipient of a HeartWare device, who experienced recurrent GI bleeding and was successfully managed with subcutaneous (SC) formulations of octreotide

Predicting outcomes in patients with atrial fibrillation and acute mesenteric ischemia

Background: Acute mesenteric ischemia (AMsI) is an infrequent but catastrophic condition associated with high mortality and morbidity. Thromboembolism due to atrial fibrillation (AF) is one of the causes of AMsI, but the overall effect of AF and anticoagulation on outcomes in these patients is not known. The objectives of the study were to evaluate the difference in outcomes in patients with and without AF developing AMsI and the impact of anticoagulation in AF patients on these outcomes. Methods: We identified patients with a discharge diagnosis of AMsI in the National Inpatient Sample from 2007. Multivariate regression model was used to compare outcomes of AMsI in patients with and without AF, and the impact of anticoagulation on outcomes also was determined. Results: We identified 48,872 patients with a discharge diagnosis of AMsI, of which 8,306 had a co-diagnosis of AF. Of the 8,306 with AF, 680 patients also had a co-diagnosis of chronic anticoagulation. Patients with AF were more likely to be older and to have hypertension, heart failure, valvular heart disease, peripheral vascular disease, chronic lung disease and renal disease. After adjusting for potential confounders, AF remained independently associated with higher mortality (OR 1.59, 95% CI 1.3-1.9, p=0.0001). Patients on anticoagulation were less likely to have complications including small bowel resections (25% vs 16%, p=0.03), colectomy (25% vs 11%, p=0.0002), shock (10% vs 17%, p=0.02) and need for intubation (10% vs 35%, p=0.0001), but the overall inpatient hospital mortality was not different from those not on chronic anticoagulation. The length of hospital stay and hospital charges were significantly lower in the anticoagulation group. Conclusions: In patients with acute mesenteric ischemia, those with AF had a significantly higher mortality. Among AF patients, those on anticoagulation had a lower incidence of complications like small bowel resection, colectomy, shock and need for intubation. Length of stay and hospital charges also were significantly lower in the anticoagulation group

Incremental value of estimated glomerular filtration rate in improving stroke risk stratification in patients with and without atrial fibrillation considered to be low risk by CHA2DS2VASc score

BACKGROUND: CHA 2 DS 2 VASc scoring system is a useful clinical tool to characterize stroke risk in patients with and without atrial Fibrillation (AF), yet thromboembolic complications occur in patients deemed low risk for stroke (0-1 score for AF and 0-3 score for non-AF patients). We hypothesized that incorporating information about renal dysfunction will improve risk stratification of patients with CHA 2DS 2 VASc score of 0 to 3. METHODS: Consecutive patients with or without AF evaluated at a large community based academic medical center from 2012 to 2015 were identified and those with a CHA 2 DS 2 VASc Score of 0-3 assessed for incident stroke. Based on estimated glomerular filtration rate (eGFR) relative improvement in risk stratification of stroke in AF and non-AF patients were determined using cochrane armitage test. RESULTS: The overall proportion of stroke over 3 years mean follow-up in patients with or without AF with baseline CHA 2 DS 2 VASc score 0-3 with eGFR and improvement in risk stratification is summarized in Table. CONCLUSIONS: In patients considered low risk by CHA 2 DS 2 VASc score, incorporating eGFR information improves risk stratification and decision for anticoagulation. Open full size imag