Antikoagulation in einem geriatrischen Patientenkollektiv in der Ära der neuen Nicht-Vitamin-K-abhängigen oralen Antikoagulantien
Anticoagulation in a geriatric patient collective in the era of new oral non-vitamin K antagonist anticoagulants
von Larissa Maria Braun
Datum der mündl. Prüfung:2023-01-18
Erschienen:2023-01-18
Betreuer:Prof.Dr. Marija Djukic
Gutachter:PD Dr. Katrin Wasser
Gutachter:Prof. Dr. Margarete Schön
Dateien
Name:Antikoagulation in einem geriatrischen Patie...pdf
Size:2.38Mb
Format:PDF
Zusammenfassung
Englisch
The aim of this study was to examine the implementation of the guideline recommendations regarding anticoagulation in a geriatric patient group. The focus here was on patients with atrial fibrillation and flutter and anticoagulant therapy after the widespread introduction of non-vitamin K antagonist oral anticoagulants. For this purpose, the patient files of all patients treated in 2015 in the geriatric department of the Evangelical Hospital Göttingen-Weende were retrospectively evaluated. Anticoagulation in patients with atrial fibrillation and flutter serves to prevent thromboembolic events, in particular to prevent ischemic strokes. The benefit of anticoagulation is counterbalanced by an increased risk of bleeding, particularly in geriatric patients, also as a complication of anticoagulation therapy. This evaluation was based on the European Society of Cardiology (ESC) guideline on atrial fibrillation according to Kirchhof et al. (2016). 431 patients with non-valvular atrial fibrillation and flutter were included. With a CHA2DS2-VASc score ≥ 2 in males and ≥ 3 in females, all 431 patients had a clear indication for anticoagulation. Of these, 378 (87.7%) patients were anticoagulated. Patients most commonly received non-vitamin K antagonist oral anticoagulants (in 221 cases [58.5%]), of which 176 cases (46.6%) were apixaban, 32 cases (8.5% ) was rivaroxaban and 13 cases (3.4%) were dabigatran. The vitamin K antagonist phenprocoumon was found as a therapeutic agent in 107 cases (28.3%) and 50 patients (13.2%) received low molecular weight heparin in a therapeutic dose. Furthermore, the patients with atrial fibrillation were divided into two groups. It was found that 90.9% (n = 209) of patients with long-lasting persistent (> 1 year)/permanent atrial fibrillation (n = 230) received anticoagulation more frequently than 84.4% (n = 169) of patients with paroxysmal atrial fibrillation /persistent (>7 days) atrial fibrillation (n=201). Fifty-three (12.3%) of the patients with prefibrillation did not receive any therapeutic anticoagulation. Twenty-seven (50.9%) of these patients were treated with antiplatelet therapy, which is not considered adequate treatment for a CHA2DS2-VASc score ≥ 2 in males and ≥ 3 in females. Twenty-six (49.1%) patients were not receiving any anticoagulant or antiplatelet therapy. However, in 10 of these 26 cases, there was an absolute contraindication. The main reasons for not having anticoagulant therapy were previous bleeding in the anamnesis or an increased tendency of the patients to fall. At the time of the study (2015), non-vitamin K antagonist oral anticoagulants were still relatively recently approved for the prevention of thromboembolic events in patients with atrial fibrillation in Germany. Therefore, dabigatran (approval: 09/2011), rivaroxaban (12/2011) and apixaban (12/2012) were examined for an adequate dosage, according to their respective product information. Of 221 patients treated with non-vitamin K antagonist oral anticoagulants, 177 patients (80.1%) received an adequate dose. 44 patients (19.9%) received a lower dose than the standard dose. The reasons for this were documented in 42 cases (95.5%) and agreed with the manufacturer's dosage recommendation. In the other two patients, no clear reason for underdosing of anticoagulation could be found. In no case did a patient receive a higher dosage of anticoagulation than recommended by the manufacturer. The most common reasons for a reduced dosage were the presence of renal insufficiency, low body weight or dual platelet aggregation inhibition plus therapeutic anticoagulation. In this study, the feared bleeding complications occurred in only 5.6% (n = 21) of all anticoagulated patients with atrial fibrillation. 5.0% of the bleeding occurred among all patients treated with non-vitamin K antagonist oral anticoagulants, 3.7% among all patients treated with phenprocoumon and 12% among all patients treated with low molecular weight heparin. In 9 cases the bleeding was severe, but none of these bleedings ended fatally. Intracranial bleeding did not occur. With the exception of one patient who suffered a transient ischemic attack while being anticoagulated with an adequate dose of apixaban, there were no other ischemic events in the anticoagulated patient cohort. The introduction of non-vitamin K antagonist oral anticoagulants has led to a sharp increase in anticoagulant therapy for the primary and secondary prevention of thromboembolic events in a geriatric patient population in the department examined.
Keywords: Atrial Fibrillation; non-vitamin K antagonist oral anticoagulants; geriatric patient