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RESEARCH ARTICLE
Year : 2018  |  Volume : 3  |  Issue : 2  |  Page : 53-57

Clinical characteristics and antithrombotic status in 621 very elderly hospitalized patients with atrial fibrillation


Department of Cardiology, The First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, China

Date of Web Publication16-Jul-2018

Correspondence Address:
Li Wang
Department of Cardiology, The First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi - 832 000
China
Wen Liu
Department of Cardiology, The First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi - 832 000
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cp.cp_13_18

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  Abstract 


Background: The prevalence of atrial fibrillation (AF) increases with age and is associated with high morbidity and mortality. The main objective of this study is to describe the clinical characteristics and antithrombotic status and the factors that determine antithrombotic use in hospitalized elderly patients with AF. Methods: Data were collected involving patients hospitalized at the First Affiliated Hospital of Shihezi Medical University from June 2015 to September 2017. Results: A total of 621 patients with an average age of 82.4 ± 5.0 years (42.3% females; 91.8% Han) were included. The prevalence of risk factors and cardiovascular disease: hypertension (56.5%), heart failure (38.2%), coronary artery disease (76.8%), and carotid atherosclerosis (21.3%). Among the 621 patients, 35.7% were taking oral anticoagulant therapy (OAT) including warfarin (25.6%) or a novel oral anticoagulant (10.1%), 32.4% of patients were taking oral antiplatelet therapy, and 31.9% received 17 anticoagulant therapy. According to the European Guidelines for AF management, CHA2DS2-VASc score was used for stroke risk stratification. All patients in this study had a score of ≥2; However, the rate of OAT was 35.7%. Follow-up data were available for 97.3% of the patients (n = 604), of which 26.6% of patients (n = 159) were deceased and 16.75% of patients (n = 104) continued to receive anticoagulation treatment. Hospitalized patients older than 80 years with AF showed numerous comorbidities. The percentage of appropriately anticoagulated patients was suboptimal according to CHA2DS2-VASc score, with only 35.7% of those requiring treatment receiving it. Conclusion: The percentage of patients with AF appropriately anticoagulated at the First Affiliated Hospital of Shihezi Medical University is at a substandard level.

Keywords: Anticoagulation, aspirin, atrial fibrillation, very elderly, warfarin


How to cite this article:
Liu W, Qiu ZF, Wang L, Zhang YF, Chen JN, Wu L, Xin JZ. Clinical characteristics and antithrombotic status in 621 very elderly hospitalized patients with atrial fibrillation. Cardiol Plus 2018;3:53-7

How to cite this URL:
Liu W, Qiu ZF, Wang L, Zhang YF, Chen JN, Wu L, Xin JZ. Clinical characteristics and antithrombotic status in 621 very elderly hospitalized patients with atrial fibrillation. Cardiol Plus [serial online] 2018 [cited 2018 Aug 17];3:53-7. Available from: http://www.cardiologyplus.org/text.asp?2018/3/2/53/236818




  Introduction Top


Atrial fibrillation (AF) is one of the most common heart rhythm disorders in the world and its prevalence increases dramatically with age, reaching 18% in the elderly Spanish population older than 80 years of age.[1] According to the ATRIA (United States) and VAL-FAAP (Europe) studies, 9% and 17.6% of patients aged 80 years or older have AF.[2],[3] In China, the incidence of AF has increased by 20 folds in the past 11 years.[4] AF makes up 31% of hospitalized patients in internal medicine and geriatric units.[5] It is expected that in 2050, there will be >70 million nonagenarians in the world, and thus the prevalence of AF will continue to increase.[6] What's more, the prevalence doubles every decade after age 50 and 2/3rd of the patients with AF are over 75 years old.[7] Elderly patients with AF have a higher risk of thromboembolic events, with high rates of mortality and disability.[8]

In recent years, different national registries have been published which estimate the prevalence of AF and describe a strategic therapeutic approach for patients with AF in primary care and cardiology departments.[3],[9],[10] Anticoagulant drugs have proven highly effective in preventing stroke. However, the epidemiology and the management of AF in older adults may differ from the management of this disease in younger populations, and the studies addressing the prevalence and management of AF specifically in older adults are scarce.

Thus, one of the most challenging issues of clinical practice in patients with AF is anticoagulant therapy used in the so-called very elderly population (aged 80 years and older). This is because age is a risk factor for both thromboembolic and hemorrhagic events due to anticoagulants. AF augments the risk of embolic phenomena, heart failure, and cognitive impairment and is associated with higher mortality.[11] In particular, AF increases the risk of ischemic stroke by 3–5 times and is the direct cause of 23.5% of strokes in patients over 80 years.[12] Despite the high thrombotic risk usually present in very old patients with frequent comorbidities, the influence of functional and cognitive status, polypharmacy and a high hemorrhagic risk limit the use of anticoagulants in this population.[13] Therefore, antithrombotic strategy in elderly patients continues to be a topic of debate. This study investigates the clinical characteristics and antithrombotic status in elderly patients with AF. In this study, we collected, analyzed, and characterized the data of patients hospitalized at the First Affiliated Hospital of Shihezi Medical University from June 2015 to September 2017.


  Methods Top


Patient selection

Patient selection was based on data found in the electronic clinical information system in our hospital. Diagnosis of AF was based on documentation in medical records, evidence from 12-lead electrocardiogram or 24h Holter study. Elderly patients (≥80 years) with AF were included in this study. Patients with valvular AF or those who were reluctant to participate were excluded from this study. The recruitment of patients was carried out between June 2015 and September 2017. A total of 621 patients with AF were recruited. Signed, informed consent was required for participation in this study. The present analysis shows the baseline data of the study population.

Data collection

Demographics, medical history, antithrombotic therapy (including the Vitamin K antagonist (VKA), warfarin, and non-VKA or novel oral anticoagulants (NOACs), dabigatran, rivaroxaban, and apixaban), antiplatelet therapy (aspirin or clopidogrel), ongoing other pharmacological treatment, and laboratory data were collected. Thrombotic risk on admission was assessed using the CHA2D2S-VASc and ATRIA scales and hemorrhagic risk was estimated by the HAS-BLED and ORBIT scales. The study design comprised of baseline data and data collection from a follow-up clinical evaluation.

Statistical analysis

Qualitative data were presented as absolute frequencies and percentages. The quantitative data were presented as mean ± standard deviation or median and interquartile range, depending on the distribution of data. Statistical data were analyzed by the Statistical Package for Social Sciences, version 20.0 software (SPSS, Chicago, IL, USA). P < 0.05 was considered statistically significant.


  Results Top


Patients' clinical characteristics

A total of 621 patients with AF were recruited between June 2015 and September 2017. Mean age of patients was 82.4 ± 5.0 years and 57% of patients were men; 570 patients (91.8%) were Han, 342 patients (55.1%) had an education level of junior high school or below, 426 patients (68.6%) resided in Shihezi city, and 558 patients (89.8%) had urban basic medical insurance. Patients 80 years and older more often lived with their children. The demographic data and baseline characteristics of elderly patients with AF are shown in [Table 1].
Table 1: Demographic data and baseline characteristics of elderly patients with atrial fibrillation

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Atrial fibrillation characteristics

The most common comorbidities and cardiovascular risk factors were hypertension (56.5%), heart failure (38.2%), coronary artery disease (76.8%), diabetes mellitus (28%), chronic obstructive pulmonary disease (25.6%), and cancer (13.5%). The presence of comorbid diseases is presented in detail in [Table 2].
Table 2: The concomitant diseases of elderly patients with atrial fibrillation

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Atrial fibrillation management strategy and antithrombotic status

All patients had a CHA2DS2-VASc score ≥2 (owing to the fact that age 80 and over automatically qualified patients had 2 points). According to 2016 European Society of Cardiology Guidelines for the management of AF, oral anticoagulant therapy (OAT) to prevent thromboembolism is recommended for all male AF patients with a CHA2D2S-VASc score ≥3.[14] The OAT rates found in this study were only 35.7%.

In the current study, the mean score on the CHA2D2S-VASc scale was 3.90 ± 1.25, and the mean HAS-BLED score was 2.19 ± 0.92. Nearly 68.6% of patients were considered to have a low risk of bleeding and 31.4% of patients had a high risk of bleeding [Table 3]. Among the 621 patients, 222 patients (35.7%) received some type of antithrombotic treatment: 32.4% took antiplatelet agents, 25.6% received VKAs, and 10.1% received a NOAC. Nearly 31.9% of patients were not on any OAT and no patients were on dual therapy with an antiplatelet and an anticoagulant. A total of 54 patients (8.7%) were taking anti-arrhythmic drugs (AADs) at baseline and 501 patients (80.67%) were subsequently prescribed AADs to control ventricular rate during their hospital admission [Table 4].
Table 3: The risk scales for predicting stroke and risk of bleeding in elderly patients with atrial fibrillation

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Table 4: The medication use of elderly patients with atrial fibrillation

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Follow-up

Follow-up data were available for 97.3% of the patients (n = 604). Of these, 26.6% of patients (n = 159) were deceased. Among the 445 surviving patients, 215 patients were taking some type of antithrombotic treatment at follow-up, and only 16.75% of patients (n = 104) continued to receive OAT at follow-up.

At follow-up, the mean EQ-VAS score was 81.29 ± 6.7. To help patients describe their health status, we drew a scale (much like a thermometer), where the best health status was labeled 100 and the worst health status was marked as 0 at the bottom. Most elderly patients were satisfied with their health status. Of the 104 patients who continued oral antithrombotic therapy, 51 patients had bleeding events, and the bleeding sites and corresponding drugs are described in [Table 5].
Table 5: Clinical endpoints and adverse events of elderly patients with atrial fibrillation

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  Discussion Top


The patients included in our study were mainly from Shihezi city and surrounding areas. Our data represented a population with a high prevalence of cardiovascular risk factors and comorbidities. The average age of our sample was 82.4 ± 5.0 years, and the most common comorbidities and cardiovascular risk factors were hypertension (56.5%), heart failure (38.2%), coronary artery disease (76.8%), diabetes mellitus (28%), chronic obstructive pulmonary disease (25.6%), and cancer (13.5%). This is consistent with the GARFIELD-AF global registration data. GARFIELD-AF is an observational registry study for patients with newly diagnosed nonvalvular AF, which randomly incorporated 858 research centers in 30 countries during 2010–2013. In 2014, among the GARFIELD-AF Chinese registered subgroup, the distribution of comorbidities was as follows: hypertension (70.7%), coronary heart disease (32.4%), and diabetes mellitus (17.4%).[15] These findings are consistent with our study.

AF is known as one of the most common heart rhythm disorders. Based on the CHA2DS2-VASc score, all very elderly patients enrolled in this study had a score ≥2. Among the 621 patients enrolled, only 222 patients (35.7%) received OAT, of which 159 patients (25.6%) were prescribed warfarin. Our study revealed that compared to other countries, the percentage of very elderly patients treated with anticoagulant therapy was remarkably low. For example, the AF-S. AGES cohort study included 1072 elderly patients with AF, of which 828 (77.2%) patients were treated with an OAT (99.5% with VKA). The anticoagulant use specifically in patients over 80 years was high at 75.6%.[16] Likewise, the EORP-AF Pilot Survey found that 70.9% (2101/2964) of AF patients with a score ≥2 received OAT. Among them, 64.1% (1900/2964) of patients were prescribed VKAs.[17] Moreover, the RE-LY study which enrolled 15,400 patients at 164 sites in 46 countries between September 2008 and April 2011 reported that the use of OAT among patients with a CHADS2 score of ≥2 was higher in North America (65.7%) and was only 11.2% in China.[18] Consistent with these reports, a study based in China collected AF patients from 20 emergency departments nationwide from 2008 to 2011 and revealed that only 12% (105/1608) of the included patients received warfarin treatment.[19] These studies, as well as our own, highlight the fact that the percentage of very elderly patients receiving OAT in China is significantly lower than in other countries. There are several reasons that could help to explain these results. First, there are no current treatment guidelines for anticoagulant therapy in China, so in different hospitals, doctors' perceptions and recommendations for anticoagulants therapy vary widely. Second, differences in education level can influence the utilization of anticoagulants. Our data showed that 55.1% of the patients had a highest level of education of completing junior high school. Several studies have indicated that patients with <12 years of education have suboptimal outcomes related to medication decisions and adherence toward medical management.[20],[21],[22] Third, fear of bleeding events may influence elderly patients to stop their anticoagulant medication. Consequently, it is crucial to focus our attention on the treatment of AF patients, particularly those who are very elderly, in order to reduce poor outcomes.

In our study, among the 621 patients with AF, 201 patients (32.4%) received some type of antiplatelet agent. Oral antiplatelet agents were often used for patients with heart failure and other cardiac disease. In the AF-S. AGES cohort study, 187 patients (17.4%) received antiplatelet therapy and 130 (12.1%) did not receive any antithrombotic treatment.[16] The antiplatelet utilization rate was higher in our study compared with other studies. Clinical practice guidelines do not recommend the use of acetylsalicylic acid as an acceptable alternative to anticoagulant treatment in elderly patients, limiting their use exclusively to patients who reject any type of OAT or who cannot tolerate them due to risk of hemorrhage.[15]

According to our research, among the 621 patients, 63 patients (10.1%) were prescribed a NOAC, which indicates that the rate of NOAC usage in our hospital is high. In the report from the EORP-AF Pilot Survey, NOACs were used in 6.9% (204/2964) of patients.[23] In one study, NOACs were shown to have a lower risk of intracranial hemorrhage and mortality compared with warfarin. However, other studies have shown that the risk of major bleeding is equal.[17]

On follow-up of 97.3% patients (n = 604), 26.6% patients (n = 159) were deceased, and among the 445 surviving patients, 215 patients were taking some type of antithrombotic medication. Only 16.75% of patients (n = 104) continued to receive OAT. In terms of bleeding events, the warfarin group experienced the highest rate of bleeding (up to 4.35%).

OAT should be used in most patients with AF. Despite this, underuse or premature termination of OAT therapy is still common. Several possible reasons may explain this status: (1) Advancing age correlates with various challenges associated with antithrombotic therapy. Thromboembolic and bleeding complications need to be considered in association with an increased falls risk, cognitive impairment, and impaired compliance; (2) Polymedication is very common in AF patients, especially in the elderly population. It has been estimated that AF patients take nearly seven kinds of pills every day.[3],[23] Polymedication and complexity of therapy are associated with poor medication adherence; (3) The low-income family, particularly following retirement, is most susceptible to underanticoagulation. Simultaneously, they have multiple comorbidities, yet have lower health awareness, poor social support, and a lack of easily accessible medical care if living in rural areas. These factors make antithrombotic management more complex.


  Conclusion Top


Our survey revealed that the percentage of patients with AF appropriately anticoagulated at the First Affiliated Hospital of Shihezi Medical University is low. The majority of patients on treatment tend to take antiplatelet drugs, even when anticoagulation is indicated. The high usage of NOACs is also noteworthy.

Financial support and sponsorship

This project was supported by the Focus area innovation team with academy level project (TJ2016-001).

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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