Excellent review article on the newer anticoagulants for stroke and systemic embolism reduction in AF:
ACP Journal Club 18 Sept 2012The CHA2DS2-VASc score identifies those patients with atrial fibrillation and a CHADS2 score of 1 who are unlikely to benefit from oral anticoagulant therapy
European Heart Journal Oct 2012
Various risk stratification schemes predict ischemic stroke and bleeding in atrial fibrillation
Friberg L, Rosenqvist M, Lip GY. Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation cohort study. Eur Heart J. 2012;33:1500-10.
The CHA2DS2-VASc score had 100% sensitivity and 6% specificity for predicting stroke in patients with atrial fibrillation; CHADS2 and Framingham scores had slightly lower sensitivities but higher specificities.
Commentary: In their analysis of 7 risk stratification schemes, Friberg and colleagues found that CHADS2, CHA2DS2-VASc, and Framingham were the most accurate for predicting ischemic stroke, with c-statistics of 0.66 to 0.67. They also concluded that the 2 risk stratification schemes for bleeding had “similar predictive value,” but HEMORR2HAGES had a higher c-statistic than the HAS-BLED scheme in 7 of 8 subgroups and the same value in 1 subgroup. A new risk stratification scheme, ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation), was not evaluated (1).
Warfarin-associated major hemorrhage predicted by 7 risk stratification schemes in patients with atrial fibrillation
ACP Journal Club 15 Nov 2011
The ATRIA risk score has the potential to be a major clinical tool but needs further validation in other populations and comparisons with similar risk scores, such as HAS-BLED (2).
Patients at High Risk for Falls: A Reason Not to Anticoagulate?
(from Journal Watch)
Donzé J et al. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med 2012 Aug; 125:773 Among patients taking anticoagulants, high risk for falls was not associated with elevated risk for major bleeding.
Despite the proven benefits of oral anticoagulants in preventing and treating certain cardiovascular and cerebrovascular diseases, they are underprescribed. Fear of falls is the most commonly cited reason. Prior studies suggest that high fall risk should not be a contraindication to oral anticoagulant use, but these studies were limited by retrospective design or exclusion of patients at high risk for falls.
Researchers evaluated whether fall risk is associated with risk for major bleeding in a prospective study of 515 patients (median age, 71) who were treated with vitamin K antagonists at a hospital in Switzerland. Patients were considered to be at high risk for falls if they answered yes to either of two validated questions: (1) Did you fall during the last year? (2) Did you notice any problem with gait, balance, or mobility? Sixty percent of patients were categorized as high risk and all others as low risk. Times to first major bleeding event (including fatal or intracranial) within the 12-month follow-up did not differ significantly between the groups. Polypharmacy was associated independently with risk for major bleeds, with a 12% increase in risk for each additional drug taken.
Comment: This study adds to evidence that patients should not be denied oral anticoagulation solely on the basis of high risk for falls. For patients with valid indications for anticoagulation, benefit generally outweighs risk. For example, an analytic model suggests that older patients (age,65) who have a 5% annual risk for stroke (i.e., CHADS2 score of 2–3) and are taking anticoagulants would need to fall approximately 295 times yearly for risks of fall-related subdural hemorrhages to outweigh benefits of stroke prevention (Arch Intern Med 1999; 159:677). In addition, providers should be aware of risks conferred by polypharmacy in patients taking anticoagulants and should discontinue unnecessary medications, monitor patients more closely, or both.
No comments:
Post a Comment