Search Results for: Associazione FANS e Warfarin

Professore: ‘Ricerca si focalizzi su sostenibilità chirurgia’

This cohort study compares the bleeding risks among warfarin, rivaroxaban, and apixaban users in a national US cohort with atrial fibrillation and HIV.

Objectives
We aimed to understand the (1) perspectives of patients with atrial fibrilation (AF) regarding their experience and implementation of The SAMe-TT2R2 score-guided approach in anticoagulant-nave Thai patients with atrial fibrillation (TREATS-AF) educational intervention for warfarin therapy control, including views on cultural transferability to the Thai context, and (2) healthcare professionals’ (HCPs) experience of implementing the intervention.

Design
Qualitative research study.

Setting
Three university hospitals and four tertiary care hospitals in Thailand.

Participants
13 newly diagnosed patients with AF and 13 HCPs delivering the TREATS-AF intervention, an intensive structured educational programme.

Methods
Semistructured interviews. Patient participants were interviewed at two time points: 4 weeks and 6 months after intervention delivery. HCPs were interviewed when they had at least 6 months experience of intervention delivery. A thematic analysis of content was informed by the framework analytical approach.

Results
13 patients and 13 HCPs were interviewed; most were female (73.3% of patients and all HCPs). Mean age was 70 (68–76) and 40 (38–42.5) years for patients and HCPs, respectively. There were four categories related to the experience of the TREATS-AF intervention: (1) key experiences of the educational sessions, (2) core perceptions of the educational materials provided, (3) suggestions for improving the educational materials and session, and (4) behavioural change and self-management influenced by the TREATS-AF intervention.

Conclusions
The TREATS-AF intervention assisted interviewees who were newly diagnosed with AF in preparing themselves with the necessary knowledge and skills to manage their condition. They stated that it increased their confidence in self-management.
For implementation, regionalised Thai-related food and beverages, patients’ literacy and family support should be considered, and infrastructure support for widespread use in healthcare settings would be required.

Trial registeration number
TCTR20180711003.

Objective
To examine recent patterns regarding oral anticoagulant (OAC) use among patients hospitalised with atrial fibrillation (AF) and quantify the impact of insurance coverage for non-vitamin K oral anticoagulants (NOACs) on quality of care and care inequality regarding OAC use among hospitalised patients with AF.

Design
Interrupted time series analysis.

Setting
Hospitals in China.

Participants
A total of 36 393 patients hospitalised with non-valvular AF were involved between 2015 and 2019 across China.

Primary and secondary outcome measures
Outcome was the impact of insurance coverage for NOACs on quality of care regarding OAC prescription using interrupted time series analysis with segmented regression models.

Results
OAC prescription rate during hospitalisation was 52.1% (31.3% for warfarin and 20.8% for NOACs) in patients with high-risk AF and 66.3% (29.8% for warfarin and 36.5% for NOACs) in low-risk patients. Insurance coverage for NOACs was associated with an immediate 10.9% (95% CI 7.6% to 14.3%) increase in NOAC prescription and a 0.33% (95% CI 0.08% to 0.58%) increase in the slope of the secular trend of NOAC prescription among all the patients. Disparities in NOAC prescription among hospitals decreased from 18.9 before the insurance coverage for NOACs to 3.4 after that. Similar results were found in patients with high risk of stroke.

Conclusion
A large gap exists between clinical practice and guideline recommendations regarding OAC prescription among patients hospitalised with AF in China. Insurance coverage may be an effective healthcare strategy to improve quality of care and reduce care disparities regarding OAC prescription among patients with AF.

Trial registration number
NCT02309398.

Circulation, Ahead of Print. BACKGROUND:Bleeding after starting anticoagulation for atrial fibrillation (AF) may be the first sign of malignancy, especially in elderly individuals. There are no recommendations to guide investigations for malignancy after new-onset bleeding after anticoagulation for AF. Our objective was to determine the association of bleeding after starting oral anticoagulation for AF with new diagnoses of malignancy in a population-wide sample.METHODS:We conducted a population-based cohort study using linked administrative data sets of people ≥66 years of age who newly initiated warfarin or direct oral anticoagulants after diagnosis with AF between 2008 and 2022. Follow-up was 2 years after starting anticoagulation. We excluded patients with valvular disease, chronic dialysis, venous thromboembolism, previous cancer, or previously documented bleeding. Bleeding was identified from hospital/emergency department discharge records and physician billings, then handled as a time-varying covariate in cause-specific regression models while adjusting for baseline characteristics. The primary outcome was incident malignancy. We also determined the site of origin of the malignancy and the stage at diagnosis if indicated in the Ontario Cancer Registry. Analyses were repeated while limiting the exposure to specific bleeding sites.RESULTS:Among 119 480 people (mean age, 77.4 years; 52% male) who started anticoagulants, 26 037 (21.8%) had documented bleeding, and 5800 (4.9%) were diagnosed with malignancy within the next 2 years. Bleeding was associated with a higher hazard of cancer diagnosis with a hazard ratio (HR) of 4.0 (95% CI, 3.8–4.3). The HRs for any malignancy were 5.0 (95% CI, 4.6–5.5) for gastrointestinal, 5.0 (95% CI, 4.4–5.7) for genitourinary, 4.0 (95% CI, 3.5–4.6) for respiratory, 1.8 (95% CI, 1.4–2.2) for intracranial, and 1.5 (95% CI, 1.2–2.0) for nasopharyngeal bleeds. The HRs were substantially higher for cancers concordant with the bleeding site (gastrointestinal, 15.4; genitourinary, 11.8; respiratory, 10.1). Cancers were diagnosed at an earlier stage after bleeding (27.6% stage 4 after bleeding versus 31.3% without bleeding;P=0.029).CONCLUSIONS:In anticoagulated patients with AF, bleeding was strongly associated with new cancer diagnoses. Antecedent bleeding was associated with cancer diagnosis at an earlier stage. This highlights the importance of timely investigations in patients with bleeding after anticoagulation for AF, rather than attributing bleeding as an expected adverse effect.

Poetry conveys meaning not just via the definitions of words, but also in its intentional arrangement of words on the page, and even in the very letters that comprise them. In “DO NOT RESUS_ITATE,” set at the bedside of a patient at the end of life, this almost alchemical property of poetry is immediately apparent in the title: the all-capitals DNR order not only proclaims that the speaker’s father’s death is imminent, but also suggests in its missing silent “C” that perhaps, if medicine can be mistaken, there is still reason to hope. The mutability of text is further entertained as the poem depicts an unlikely birthday celebration, in the consuming of a cake meant for another patient who has already died. We watch the ephemeral happy birthday message (“squiggled in red and green on frosty white”) disappear bite by bite, each vanishing letter sequence an existential question. “I ate ‘Y B.’ Then ‘B I’,” the speaker flatly notes, the literal instability of the written word a kind of wondering at life’s meaning, amidst the irony of juxtaposing a birthday with death. Meanwhile, a football game’s “sudden death overtime” on the radio in the background underscores the poem’s sense that our time is fleeting. By the conclusion, “R A H was no more,” we are suspended between the sweetness suggested by “I licked the frosting off my plate” and distant cheering as “the fans went wild.” Even as words fail us, and lives fade, poetry insists we can yet rejoice.

Introduction
The treatment of patients with cardiogenic shock (CS) has been focused historically on single interventions (medical treatments, percutaneous and surgical interventions and, more recently, various temporary mechanical circulatory supports). However, none of these interventions has significantly changed the short-term prognosis of CS. Moreover, considerable interest in interventions applied in the acute setting has not been matched with comprehensive assessment of patients’ long-term follow-up, not only for survival and rehospitalisation but also for quality of life and functional status, recovery from critical illness and its destructive sequelae, and a global evaluation of the overall sustainability of pathways of care. To fill this knowledge gap, the ENIGMA study will be conducted.

Methods and analysis
This is a prospective and retrospective multicentre registry conducted under the scientific coordination of the IRCCS Fondazione Don Gnocchi and funded by the Italian Ministry of Health (PNRR-MCNT2-2023-12377767). Data referring to 2000 patients included in the Altshock registry, the largest multicentre CS registry in Italy, will be analysed. A standardised protocol of high-intensity cardiac rehabilitation has been defined and will be followed by the involved institutions after the inclusion of the first 1000 patients. Where feasible, this new pathway will be implemented in every institution. All the patients enrolled will be evaluated according to the Long-Term Conditions Questionnaire, the Kansas City Cardiomyopathy Questionnaire and a questionnaire on the patient experience at 6-month follow-up, to evaluate real-life comparative effects on patient outcomes and experiences. In conclusion, a health technology assessment (HTA) analysis, grounded in the EUnetHTA Core Model, will be conducted to define the potential multidimensional benefits and effects with regard to the overall economic, organisational and social sustainability of the innovative dedicated pathway. Various data sources will be used to conduct the HTA: (1) literature evidence, to define the evidence-based comparative indicators considering both surgical approaches; (2) real-world anonymised data from the hospitals included in the study, to enable costing of the rehabilitative pathways; and (3) healthcare professionals’ perceptions, defining the perceived added value of the innovative pathway versus the historical one, based on an evaluation scale ranging from –3 to +3.

Ethics and dissemination
The study was approved by the ethical committee (EC) of Lombardy Region (CET 44/24), on 28 May 2024, and is under evaluation by the EC of three other centres. The study protocol will be evaluated for ethics by 10 more centres in January 2025. Study results will be published in peer-reviewed publications and disseminated through conference presentations. The Associazione Nazionale Scompensati Cardiaci (AISC; ‘National Association of Patients with Heart Failure’), the Progetto Vita initiative and the non-profit organisation ‘Heart Helps Heart’ have endorsed the project and will be involved in disseminating information about the project and its outcomes to the general public.

Clinical trial registration number
The ENIGMA-shock study has been registered at ClincialTrials.gov: NCT06572826.

L’organizzazione accoglie a Roma chi viene da fuori per le cure

Stroke, Volume 56, Issue Suppl_1, Page AWMP102-AWMP102, February 1, 2025. Objectives:Cortical superficial siderosis (cSS) has been implicated as a putative hemorrhagic MRI finding of cerebral small vessel disease (SVD) related to cerebral amyloid angiopathy. Few reports have examined the association between cSS and antithrombotic-related clinical events. The aim of this study is to investigate the association of cSS with the risk of hemorrhagic or ischemic events in patients receiving antithrombotic agents.Methods:This is a prospective, multicenter, observational study that enrolled patients with cerebrovascular or cardiovascular diseases who were taking oral antithrombotic agents from 52 hospitals across Japan between 2016 and 2019. The MRI scans were centrally evaluated for SVD, including white matter hyperintensities (WMH), cerebral microbleeds (CMBs), lacunes, basal ganglia-enlarged perivascular spaces (BGPVS), cortical superficial siderosis (cSS), using a visual scale. The outcomes included subsequent ischemic events (ischemic vascular events [IVE], ischemic stroke [IS]), hemorrhagic events (major bleeding [MB], intracranial hemorrhage [ICH], non-major bleeding[nMB]), and mortality. We calculated incidence rates (IR) per 1,000 patient-years of each event and the IR ratio (IRR).Results:Of 5037 patients (mean age 71.2 ± 11.2 years, 67% men), cSS was detected in 105 (2.0%) patients. The cSS group was older and had a higher proportion of males, atrial fibrillation, histories of intracerebral hemorrhage or subarachnoid hemorrhage and a higher frequency of strictly lobar CMBs, WMH, and lacunes compared to the non-cSS group. During a median 2 [IQR1.8–2.03] years, 278 IVE, 197 IS, 93 MB, 55 ICH, 147 nMB, and 217 deaths were observed. In the cSS group, IVE and IS were numerically less frequent (IVE: IR 20.95 vs 29.13; IS: 15.64 vs 20.34, per 1000 patient-years), while MB and mortality (MB: IR 9.61 vs 5.15; mortality: IR 35.82 vs 21.87) were numerically more frequent, compared to the non-cSS group, but the IRR of each event did not significantly differ between the 2 groups. In the cSS group on warfarin (n=12), there was a trend towards numerically higher rates of MB (IR 80.36 vs 18.54), ICH (IR 80.36 vs 15.84), and mortality (IR 142.95 vs 39.61, per 1000 patient-years) compared to the non-cSS group.Conclusion:Individuals with cSS receiving antithrombotic agents exhibited a higher trend for mortality and major bleeding.

Stroke, Volume 56, Issue Suppl_1, Page ATMP10-ATMP10, February 1, 2025. Introduction:An optimal strategy for the treatment of intracranial atherosclerotic disease (ICAD) has remained unclear, despite medical therapy (antiplatelet therapy and LDL control management) or endovascular therapy (angioplasty or stenting). Recently, cilostazol plus other antiplatelet agents combined therapy (CT) has been reported to reduce recurrent stroke, and eicosapentaenoic acid (EPA) has been reported to reduce the risk of cardiovascular events and plaque progression. Therefore, our hypothesis is that the addition of CT and EPA therapy may reduce stroke recurrence and further regression of stenosis.Methods:Patients with symptomatic and asymptomatic intracranial artery stenosis treated and followed at our institution from January 2009 to December 2023 were included in this study: 198 ICAD lesions in 155 patients (mean follow-up 11 months) were retrospectively evaluated. Each patient was divided into antiplatelet therapy alone (AA) (monotherapy (MT) or CT), antiplatelet therapy plus statin (AS), and antiplatelet therapy plus statin and EPA (AE). Antiplatelet drug monotherapy was aspirin, clopidogrel, or prasugrel and combination therapy was any of them plus cilostazol. ICAD was assessed by MRA and the stenosis rate was calculated by the warfarin-aspirin symptomatic intracranial disease (WASID) method.Results:The improvement in stenosis was significantly better with CT than with MT (Median% interquartile range(IQR)= CT: 21.71% (11.33-41.40) vs. MT: 9.15% (2.69-25.78), P

Stroke, Volume 56, Issue Suppl_1, Page AWP171-AWP171, February 1, 2025. Background:The prevalence of renal disease is increasing in the U.S. Renal dysfunction increases risk of atrial fibrillation, ischemic stroke and systemic bleeding. Lack of randomized trial data in this population has led to conflicting recommendations on management. Our objective was to review a decade of practice in utilization of antithrombotics including oral anticoagulants (OACs) for secondary stroke prevention in patients with severe renal dysfunction.Methods:We analyzed all ischemic stroke patients with atrial fibrillation and impaired renal function (creatinine clearance < 30) who were discharged on antithrombotics in the Get with the Guidelines- Stroke registry from Jan 2013 – Dec 2023. Subjects with other indication for anticoagulation such as venous thromboembolism, pulmonary embolism, and prosthetic valve were excluded. For the analysis, subjects were categorized as advanced chronic kidney disease (CKD, CrCl 15-30) and end stage renal disease (ESRD, CrCl

Stroke, Volume 56, Issue Suppl_1, Page ATMP43-ATMP43, February 1, 2025. Background:Disparities in anticoagulation therapy, driven by race, age, and insurance status, affect access to direct oral anticoagulants (DOACs). These factors also influence discharge disposition across patient groups.Objective:To assess differences in anticoagulation therapy and discharge dispositions between self-pay and insured patients, with a focus on age and race.Methods:This retrospective cohort study analyzed 3,966 patients discharged on anticoagulation therapy for atrial fibrillation (AF), deep vein thrombosis (DVT), or pulmonary embolism (PE). Patients were drawn from neurology, cardiology, and other services. Descriptive statistics were used to compare trends across these groups.Results:Of the 3,966 patients, AF was the most common diagnosis (47.16% self-pay, 67.14% insured), followed by DVT and PE. DOACs were used in 59.09% of self-pay and 65.38% of insured AF patients, while warfarin was more common in self-pay AF patients (25.00% vs. 21.61%). DOAC use in DVT was 82.00% for self-pay and 78.39% for insured patients. For PE, 95.65% of self-pay and 72.40% of insured patients were discharged on DOACs. Warfarin use peaked at 27.6% for insured patients aged 70-79. Non-White self-pay patients were less likely to be discharged on DOACs compared to White patients. Specifically, 52.46% of African American self-pay patients were discharged on DOACs compared to 73.91% of White self-pay patients and 50.85% of patients from other racial backgrounds. Warfarin use was higher among non-White self-pay patients. In the insured group, DOAC usage was consistent across racial groups, with 64.71% of African American patients, 65.06% of White patients, and 63.47% of patients from other racial backgrounds discharged on DOACs. Asian patients had lower overall anticoagulant usage. Discharge disposition varied by age and insurance status; insured elderly patients were more likely to be discharged to extended care facilities. Gender disparities were also observed, with more self-pay males discharged to skilled nursing facilities compared to females (3.8% vs. 0.9%).Conclusion:Among insured patients, age was a more significant factor than race in determining warfarin use, with older patients more likely to receive warfarin. In contrast, among self-pay patients, non-Whites were less likely to be discharged on DOACs, highlighting the influence of race and financial status on anticoagulation therapy.

Stroke, Volume 56, Issue Suppl_1, Page AWP56-AWP56, February 1, 2025. Introduction:Prior studies have shown the association between oral infection, white matter hyperintensity (WMH), a marker of cerebral small vessel disease (CSVD), and asymptomatic intracranial atherosclerosis (ICAS). However, the impact of preventative oral behavior such as dental flossing is unknown. The relationship between flossing CSVD,&ICAS was tested using the Atherosclerosis Risk in Communities (ARIC) cohort study.Methods:3T MRI and MRA were performed in visit 5. CSVD was assessed using the log of WMH volume. WMH volume was derived from a semiautomated segmentation of FLAIR images, 3D time-of-flight MR angiogram and 3D high-isotropic resolution black blood MRI. ICAS was graded according to the criteria established by the Warfarin-Aspirin Symptomatic Intracranial Disease trial. In this study, we evaluated the relationship between flossing and ICAS, defined as ≥50% stenosis. Flossing was assessed by a medical history questionnaire performed in visit 4. Student t-tests were performed to test continuous variables, and X2test was used to compare categorical variables. Analysis of covariance (ANCOVA) was used for multivariate testing of continuous variables and multivariable logistic regression analyses for categorical variables.Results:Among subjects who underwent vascular imaging, 1033 (90%) had