Use of the CHA(2)DS(2)-VASc and HAS-BLED scores to aid decision making for thromboprophylaxis in nonvalvular atrial fibrillation

University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Dudley Rd, Birmingham, B18 7QH, UK.
Circulation (Impact Factor: 14.95). 08/2012; 126(7):860-5. DOI: 10.1161/CIRCULATIONAHA.111.060061
Source: PubMed
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    • "Information on comorbidities was generated from ICD-9-CM codes in the clinical database with coding algorithms as described by Quan et al. [17]. The CHA 2 DS 2 -VASc score and Charlson comorbidity index were also calculated for each patient for risk stratification [18] [19] [20]. The initiation date and discontinuation date of AADs as well as information on other medications were ascertained via review of the institutional pharmacologic database and clinical notes and orders in the electronic medical record. "
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    ABSTRACT: Introduction Although there are many different antiarrhythmic drugs (AADs) approved for rhythm management of atrial fibrillation (AF), little comparative effectiveness data exist to guide drug selection. Methods We followed 5952 consecutive AF patients who were prescribed amiodarone (N = 2266), dronedarone (N = 488), dofetilide (N = 539), sotalol (N = 1718), or class 1C agents (N = 941) to the primary end point of AF recurrence. Results Median follow-up time was 18.2 months (range 0.1–101.6 months). Patients who were prescribed amiodarone had the highest, while patients on class 1C agents had the lowest baseline CHA2DS2-VASc score, Charlson comorbidity index, and burden of comorbid illnesses including coronary artery disease, congestive heart failure, diabetes mellitus, hyperlipidemia, chronic obstructive lung disease, chronic kidney disease, or cancer (p < 0.05 for all comparisons). After adjusting for baseline characteristics, using dronedarone as benchmark, amiodarone [hazard ratio (HR) 0.58, p < 0.001], class 1C agents (HR 0.70, p < 0.001), and sotalol (HR 0.79, p = 0.008), but not dofetilide (HR 0.87, p = 0.178) were associated with less AF recurrence. In addition, compared to dronedarone, amiodarone and class 1C agents were associated with lower rates of admissions for AF (HR 0.55, p < 0.001 for amiodarone; HR 0.71, p = 0.021 for class 1C agents) and all-cause mortality was lowest in patients treated with class 1C agents (HR 0.42, p = 0.018). The risk of stroke was similar among all groups. Conclusion Compared with dronedarone, amiodarone, class 1C agents, and sotalol are more effective for rhythm control, while dofetilide had similar efficacy. These findings have important implications for clinical practice.
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    ABSTRACT: Older adults are about four to seven times more likely than younger persons to experience adverse drug events (ADEs) that cause hospitalization, especially if they are women and take multiple medications. The prevalence of drug-related hospitalizations has been reported to be as high as 31%, with large heterogeneity between different studies, depending on study setting (all hospital admissions or only acute hospital admissions), study population (entire hospital, specific wards, selected population and/or age groups), type of drug-related problem measured (adverse drug reaction or ADE), method of data collection (chart review, spontaneous reporting or database research) and method and definition used to detect ADEs. The higher risk of drug-related hospitalizations in older adults is mainly caused by age-related pharmacokinetic and pharmacodynamic changes, a higher number of chronic conditions and polypharmacy, which is often associated with the use of potentially inappropriate drugs. Other factors that have been involved are errors related to prescription or administration of drugs, medication non-adherence and inadequate monitoring of pharmacological therapies. A few commonly used drugs are responsible for the majority of emergency hospitalizations in older subjects, i.e. warfarin, oral antiplatelet agents, insulin and oral hypoglycaemic agents, central nervous system agents.The aims of the present review are to summarize recent evidence concerning drug-related hospitalization in older adults, to assess the contribution of specific medications, and to identify potential interventions able to reduce the occurrence of these drug-related events, as they are, at least partly, potentially preventable.
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