The Introduction of Direct Oral Anticoagulants Has Not Resolved Treatment Gaps for Frail Patients With Nonvalvular Atrial Fibrillation

Orlandi, Marco; Dover, Douglas C.; Sandhu, Roopinder K.; Hawkins, Nathaniel M.; Kaul, Padma; McAlister, Finlay A.

doi:10.1016/j.cjca.2021.09.021

Cited by 25 publications

(23 citation statements)

References 35 publications

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“…Second, we showed how clinical complexity is closely associated with significant undertreatment and lower persistence of OAC in clinical practice, which were only partially improved by the introduction of NOACs in clinical practice. 28 These data are in line with previous evidence that showed how frail patients are less likely to receive appropriate anticoagulation, 29 30 with little changes after the introduction of NOACs. 29 Renal disease has been also described as a main driver of OAC underuse as well as major outcomes among AF patients, 31 32 and history of bleeding represent a common concern when prescribing antithrombotic.…”

Section: Discussionsupporting

confidence: 84%

“…28 These data are in line with previous evidence that showed how frail patients are less likely to receive appropriate anticoagulation, 29 30 with little changes after the introduction of NOACs. 29 Renal disease has been also described as a main driver of OAC underuse as well as major outcomes among AF patients, 31 32 and history of bleeding represent a common concern when prescribing antithrombotic. Undertreatment and lower persistence, therefore, may reflect the lack of data regarding safety of anticoagulants in frail complex patients, 33 34 which were consistently under-represented in randomized controlled trials, even if NOACs have already been proved to be a safer alternative compared to VKA.…”

Section: Discussionsupporting

confidence: 84%

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Clinical Complexity Domains, Anticoagulation, and Outcomes in Patients with Atrial Fibrillation: A Report from the GLORIA-AF Registry Phase II and III

et al. 2022

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Background Clinical complexity is common in atrial fibrillation (AF) patients. We assessed the impact of clinical complexity on oral anticoagulant (OAC) treatment patterns and major adverse outcomes in a contemporary cohort of AF patients. Methods The GLORIA-AF Phase II and III Registry enrolled newly diagnosed AF patients with at least one stroke risk factor. Among patients with CHA2DS2-VASc score ≥2, we defined four domains of perceived clinical complexity: frail elderly (age ≥75 years and body mass index <23 kg/m2), chronic kidney disease (CKD, creatinine clearance <60 mL/min), history of bleeding, and those with ≥2 of the above conditions. We evaluated the associations between clinical complexity domains and antithrombotic treatment prescription, risk of OAC discontinuation, and major adverse outcomes. Results Among the 29,625 patients included (mean age 69.6 ± 10.7 years, 44.2% females), 9,504 (32.1%) presented with at least one complexity criterion. Clinical complexity was associated with lower OAC prescription, with stronger associations in frail elderly (odds ratio [OR]: 0.47, 95% confidence interval [CI]: 0.36–0.62) and those with ≥2 complexity domains (OR: 0.50, 95% CI: 0.44–0.57). Risk of OAC discontinuation was higher among frail elderly (hazard ratio [HR]: 1.30, 95% CI: 1.00–1.69), CKD (HR: 1.10, 95% CI: 1.02–1.20), and those with ≥2 complexity domains (HR: 1.39, 95% CI: 1.23–1.57). Clinical complexity was associated with higher risk of the primary outcome of all-cause death, thromboembolism, and major bleeding, with the highest magnitude in those with ≥2 criteria (HR: 1.63, 95% CI: 1.43–1.86). Conclusion In AF patients, clinical complexity influences OAC treatment management, and increases the risk of poor clinical outcomes. These patients require additional efforts, such as integrated care approach, to improve their management and prognosis.

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Section: Discussionsupporting

confidence: 84%

Section: Discussionsupporting

confidence: 84%

Clinical Complexity Domains, Anticoagulation, and Outcomes in Patients with Atrial Fibrillation: A Report from the GLORIA-AF Registry Phase II and III

et al. 2022

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“…Canada's publicly-funded, universal health care system has allowed for the deterministic linkage of health care data from different healthcare settings (hospitals, emergency departments, outpatient clinics, and physician offices) to insurance and vital statistics registries to identify predictors of mortality and develop risk stratification algorithms [2][3][4] . These models have been enhanced by the availability of pharmaceutical claims and laboratory data at the population-level in some provinces [5][6][7][8] .…”

Section: Introductionmentioning

confidence: 99%

Towards artificial intelligence-based learning health system for population-level mortality prediction using electrocardiograms

et al. 2023

Self Cite

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The feasibility and value of linking electrocardiogram (ECG) data to longitudinal population-level administrative health data to facilitate the development of a learning healthcare system has not been fully explored. We developed ECG-based machine learning models to predict risk of mortality among patients presenting to an emergency department or hospital for any reason. Using the 12-lead ECG traces and measurements from 1,605,268 ECGs from 748,773 healthcare episodes of 244,077 patients (2007–2020) in Alberta, Canada, we developed and validated ResNet-based Deep Learning (DL) and gradient boosting-based XGBoost (XGB) models to predict 30-day, 1-year, and 5-year mortality. The models for 30-day, 1-year, and 5-year mortality were trained on 146,173, 141,072, and 111,020 patients and evaluated on 97,144, 89,379, and 55,650 patients, respectively. In the evaluation cohort, 7.6%, 17.3%, and 32.9% patients died by 30-days, 1-year, and 5-years, respectively. ResNet models based on ECG traces alone had good-to-excellent performance with area under receiver operating characteristic curve (AUROC) of 0.843 (95% CI: 0.838–0.848), 0.812 (0.808–0.816), and 0.798 (0.792–0.803) for 30-day, 1-year and 5-year prediction, respectively; and were superior to XGB models based on ECG measurements with AUROC of 0.782 (0.776–0.789), 0.784 (0.780–0.788), and 0.746 (0.740–0.751). This study demonstrates the validity of ECG-based DL mortality prediction models at the population-level that can be leveraged for prognostication at point of care.

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“…Patients with active cancer, renal impairment, and those who are old or very old and frail are among these patients [ 3 , 4 , 5 , 6 ]. Frailty is a multidimensional syndrome of poor physiological reserve leading to increased vulnerability to stressors, resulting in dependency and poor health outcomes [ 7 ].…”

Section: Introductionmentioning

confidence: 99%

“…In a recently published retrospective study, among 75,796 patients discharged from an emergency department or hospital between 2009 and 2019 with a new diagnosis of non-valvular AF and an indication for anticoagulant treatment, 22.6% of patients were categorized as frail [ 7 ]. The Hospital Frailty Risk Score was used to define frailty, and the CHA2DS2-VASc and CHADS-65 scores were used to assess if anticoagulation was indicated.…”

Section: Introductionmentioning

confidence: 99%

Direct Oral Anticoagulants in Old and Frail Patients with Atrial Fibrillation: The Advantages of an Anticoagulation Service

Vedovati

Agnelli

2022

JPM

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Despite the recent advancements, oral anticoagulation is still challenging in some patients and this is the case for old and frail patients. The large majority of frail patients with atrial fibrillation should receive anticoagulation since the associated benefits outweigh the risk of bleeding. A multidisciplinary consensus document on the use and prescription of direct oral anticoagulants (DOACs) in older and frail patients with atrial fibrillation has been recently published. In this manuscript we provide a comment on this document and add insights into the management of these patients. The new DOAC age had imposed a paradigm shift in the management of patients with the need for clinically-oriented services rather than laboratory-oriented services. In this paper we provide tools for a structured patient-oriented DOACs treatment service supported by a multidisciplinary approach.

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The Introduction of Direct Oral Anticoagulants Has Not Resolved Treatment Gaps for Frail Patients With Nonvalvular Atrial Fibrillation

Abstract: See editorial by Gula and Skanes, pages 9e10 of this issue.

Cited by 25 publications

References 35 publications

Clinical Complexity Domains, Anticoagulation, and Outcomes in Patients with Atrial Fibrillation: A Report from the GLORIA-AF Registry Phase II and III

Clinical Complexity Domains, Anticoagulation, and Outcomes in Patients with Atrial Fibrillation: A Report from the GLORIA-AF Registry Phase II and III

Towards artificial intelligence-based learning health system for population-level mortality prediction using electrocardiograms

Direct Oral Anticoagulants in Old and Frail Patients with Atrial Fibrillation: The Advantages of an Anticoagulation Service

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