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Managing AF: A Look at Treating Specialty

Managing AF: A Look at Treating Specialty

About 2.3 million Americans are affected by atrial fibrillation and atrial flutter (AF), a condition that causes 15% of the 700,000 strokes that occur annually in the United States. Anticoagulants like warfarin can help prevent stroke in AF patients, but these therapies can also cause bleeding in some cases. “Prediction tools, such as the CHADS2 score, have been developed to estimate stroke risk and are now recommended by clinical guideline statements,” says Mintu P. Turakhia, MD, MAS. “These guidelines, however, vary considerably in describing how stroke and bleeding risk should be evaluated and integrated into clinical decision making.” Assessing Potential Variations in Warfarin Use It has been suspected that use of warfarin in AF may vary by specialty and over time. In the American Heart Journal, Dr. Turakhia and colleagues had a study published that evaluated differences and trends in warfarin prescription by treating specialty for new AF cases. Using VA data from the TREAT-AF study, the investigators reviewed more than 141,000 participants with newly diagnosed AF in which patients had at least one internal medicine, primary care, or cardiology encounter within 90 days of their diagnosis. The primary outcome was prescription of warfarin. According to results, care of patients with new AF from cardiologists appeared to be associated with a greater likelihood of warfarin prescription when compared with care only from primary care physicians (Table 1), even after adjusting for covariates and a propensity for cardiology care. The observation was also consistent across subgroups of patients, including those who were at lowest risk for bleeding. Furthermore, warfarin prescriptions were more frequently provided to those at highest risk for stroke,...

Resuming Blood Thinner Use After a GI Bleed

Among patients with a warfarin-associated index gastrointestinal (GI) bleeding event, the decision to not resume warfarin within 90 days appears to be associated with higher risks for thrombosis and mortality. A cohort study demonstrated that resuming warfarin did not significantly increase the risk for recurrent GI bleeding. Abstract: Archives of Internal Medicine, September 2012...

Anticoagulants & Preventing Stroke in Atrial Fibrillation

Depending on a patient’s comorbidities and history of prior cerebrovascular events, the rate of stroke among adults with atrial fibrillation (AF) varies widely, ranging between 1% and 20% annually. It is important to stratify the risk of stroke to determine whether prophylactic treatment with an anticoagulant is warranted because the medications used to lower the incidence of AF-related stroke are associated with bleeding. “Aspirin and warfarin have been the primary medications used to prevent stroke in patients with nonvalvular AF (NVAF),” says Larry B. Goldstein, MD, FAAN, FAHA. “Aspirin is indicated primarily for lower-risk patients, while warfarin is reserved for those at greater thromboembolic risk.” Until recently, the American Heart Association and the American Stroke Association (AHA/ASA) have centered their recommendations on preventing stroke in patients with NVAF around using aspirin or warfarin. There are also some data reflecting the use of clopidogrel plus aspirin as compared to warfarin or aspirin alone. The Role of Newer Antithrombotic Agents The new antithrombotics are alternatives to warfarin and aspirin for patients with NVAF. In the August 2, 2012 online issue of Stroke, the AHA/ ASA released a science advisory for healthcare professionals reviewing these new oral antithrombotic agents and providing revised management recommendations. The AHA/ASA scientific advisory updates its existing guidelines based on clinical trial data for three new antithrombotic drugs that have been evaluated in patients with NVAF. “When selecting specific agent for stroke prevention in AF, clinicians must individualize treatment decisions based on risk factors, cost, and tolerability.” —Larry B. Goldstein, MD, FAAN, FAHA “We reviewed recent trials that tested the safety and efficacy of dabigatran—a direct thrombin inhibitor—and...
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