Comparison of bleeding risk scores and evaluation of major bleeding predictive factors in patients with major bleeding due to vitamin K antagonist use.

Background: Major bleeding in the treatment of atrial fibrillation is closely associated with an increased risk of death and major adverse outcomes in both the short and long term, but all bleeding events are associated with a reduced quality of life. Bleeding events are also known to reduce medication adherence. In this sense, bleeding risk scores are important tools to help predict major bleeding. However, it is not clear which scoring system is superior. Aim: In this study, our aim was to compare bleeding risk scores and to examine the factors associated with bleeding in patients with major bleeding while using vitamin K antagonists. Methods: In this retrospective and single-center study, scoring, laboratory and demographic data were analyzed with SPSS 20.0 statistical program. Results: The mean age of a total of 1434 patients included in our study was 68.2 ± 11.3 years, range was 39-93 years and 769 (53.6%) of these patients were male. Of 588 patients with major bleeding, 93 (15.8%) had intracranial hemorrhage. Logistic regression analysis comparing the scoring systems among themselves revealed that the GARFIELD-AF scoring system had a predictive effect on major bleeding independent of the effect of other scoring systems (OR: 1.532, 95% CI 1.348-1.741, p < 0.001). The area under the curve (AUC) for GARFIELD-AF was 0.690 (0.662-0.718) as a result of the ROC analysis considering the best cut-off point of 3.2% calculated for 2 years. AUC 0.659 (0.630-0.687) for HAS-BLED, AUC 0.636 (0.606-0.665) for ORBIT and AUC 0.611 (0.5810.642) for ATRIA. When we compare the patient group with the control group, it can be said that intracranial hemorrhage occurred independently of INR and TTR values, unlike in the major bleeding group (p:0.129, p:0.545). Conclusion: In patients using vitamin K antagonists for atrial fibrillation, the GARFIELD-AF risk score was found to be superior to important bleeding risk scores such as HAS-BLED, ORBIT and ATRIA in terms of predicting major bleeding. It is an important result that intracranial hemorrhages, which have a special place among major hemorrhages, were independent of INR and TTR levels. It is noteworthy that 8.2% of patients with major bleeding had a history of minor bleeding in the last year.

Real-World Evaluation of Anticoagulant Treatment Patterns in Patients with Atrial Fibrillation: Data from Multicenter ROTA Study.

OBJECTIVE: Oral anticoagulant therapy is the cornerstone of atrial fibrillation management to prevent stroke and systemic embolism. However, there is limited real-world information regarding stroke and systemic embolism prevention strategies in patients with atrial fibrillation. The aim of the ROTA study is to obtain the real-world data of anticoagulant treatment patterns in patients with atrial fibrillation. METHODS: The ROTA study is a prospective, multicenter, and observational study that included 2597 patients with atrial fibrillation. The study population was recruited from 41 cardiology outpatient clinics between January 2021 and May 2021. RESULTS: The median age of the study population was 72 years (range: 22-98 years) and 57.4% were female. The median CHA2DS2-VASc and HAS-BLED scores were 4 (range: 0-9) and 1 (range: 0-6), respectively. Vitamin K antagonists and direct oral anticoagulants were used in 15.9% and 79.4% of patients, respectively. The mean time in therapeutic range was 52.9% for patients receiving vitamin K antagonists, and 76% of those patients had an inadequate time in therapeutic range with <70%. The most common prescribed direct oral anticoagulants were rivaroxaban (38.1%), apixaban (25.5%), and edoxaban (11.2%). The rate of overuse of vitamin K antagonists and direct oral anticoagulants was high (76.1%) in patients with low stroke risk, and more than one-fourth of patients on direct oral anticoagulant therapy were receiving a reduced dose of direct oral anticoagulants. Among patients who were on direct oral anticoagulant treatment, patients with apixaban treatment were older, had higher CHA2DS2-VASc and HAS-BLED scores, and had lower creatinine clearance than the patients receiving other direct oral anticoagulants. CONCLUSIONS: The ROTA study provides important real-world information about anticoagulant treatment patterns in patients with atrial fibrillation.time in therapeutic range with <70%.

Diagnostic accuracy of refractometry methods for estimating passive immunity status in neonatal beef calves.

BACKGROUND: Assessing the inadequate transfer of passive immunity (ITPI) in beef calves is crucial because calves with ITPI are at high risk for morbidity and mortality. OBJECTIVES: The aim of this study was to determine the accuracy of digital Brix (D-BRIX) and digital serum total protein (D-STP) refractometers to estimate different passive immunity status in beef calves and to determine the robustness of thresholds. METHODS: Blood samples were collected from 202 (1-7 days old) beef calves. Serum total solid percentages, total protein concentrations, and IgG concentrations were measured with the D-BRIX refractometer, D-STP refractometer, and gold standard radial immunodiffusion (RID) assay, respectively. Data were analyzed using diagnostic test accuracy, areas under the receiver operating characteristics curve, Cohen's kappa coefficient, and misclassification costs analysis to estimate IgG concentrations <10, <16, and <24 mg/mL. RESULTS: For the prediction of serum IgG concentrations <10, <16 and <24 mg/mL, the optimal cut-off values were determined to be <8.5% (Se: 100.0% (95% CI: 87.9-100.0); Sp: 94.2% [95% CI: 89.6-97.2]), <8.5% (Se: 92.1% [95% CI: 78.6-98.2]; Sp: 97.6% [95% CI: 93.9-99.3]), and <10.1% (Se: 88.8% [95% CI: 79.7-94.7]; Sp: 67.2% [95% CI: 58.1-75.4]), respectively, for the D-BRIX refractometer; and <5.2 g/dL (Se: 100.0% [95% CI: 87.9-100.0]; Sp: 93.6% [95% CI: 88.9-96.8]), <5.2 g/dL (Se: 92.1% [95% CI: 78.6-98.2]; Sp: 97.0% [95% CI: 93.0-99.0]), and <6.4 g/dL (Se: 87.5% [95% CI: 78.2-93.8]; Sp: 69.7% [95% CI: 60.7-77.7]), respectively, for the D-STP refractometer. CONCLUSIONS: The digital Brix and digital serum total protein refractometers can be used as monitoring tools for assessing passive immunity transfer in neonatal beef calves.

Relationship Between Prognostic Nutritional Index and Contrast-Associated Acute Kidney Injury in Patients With Non-ST Segment Elevation Myocardial Infarction Undergoing Coronary Angiography.

Prognostic nutritional index (PNI), consisting of inflammatory-nutritional parameters, has been investigated in terms of outcomes and renal function in patients with coronary artery disease. The objective of this study is to assess the predictive power of the PNI in predicting the risk for developing contrast-associated acute kidney injury (CA-AKI), an important complication following coronary angiography in patients with non-ST-elevation myocardial infarction (NSTEMI). The study population (336 patients with the diagnosis of NSTEMI) was divided into two groups: patients with CA-AKI and patients without CA-AKI. The mean age of the whole population was 62.0 ± 12.7 (21-95) years. CA-AKI was detected in 68 (20%) patients. Prognostic nutritional index values were significantly (P < .001) lower in the CA-AKI (+) group. Low PNI values (cutoff < 48.5%) were independent predictors of CA-AKI with Odds ratio (OR): .913, 95% confidence interval (CI): .866-.962, P:.001, with a sensitivity 70.6% and specificity 69.4%. Prognostic nutritional index seems to be an easily assessable and promising scoring system that can be used in clinical practice for predicting the risk of developing CA-AKI.

PrevAleNce and Associated factors of inappropriaTe dosing of direct Oral anticoaguLants In pAtients with Atrial Fibrillation: the ANATOLIA-AF Study.

PURPOSE: Inappropriate dosing of direct oral anticoagulants is associated with an increased risk of stroke, systemic embolism, major bleeding, cardiovascular hospitalization, and death in patients with atrial fibrillation. The main goal of the study was to determine the prevalence and associated factors of inappropriate dosing of direct oral anticoagulants in real-life settings. METHODS: This study was a multicenter, cross-sectional, observational study that included 2004 patients with atrial fibrillation. The study population was recruited from 41 cardiology outpatient clinics between January and May 2021. The main criteria for inappropriate direct oral anticoagulant dosing were defined according to the recommendations of the European Heart Rhythm Association. RESULTS: The median age of the study population was 72 years and 58% were women. Nine-hundred and eighty-seven patients were prescribed rivaroxaban, 658 apixaban, 239 edoxaban, and 120 dabigatran. A total of 498 patients (24.9%) did not receive the appropriate dose of direct oral anticoagulants. In a logistic regression model, advanced age, presence of chronic kidney disease and permanent atrial fibrillation, prescription of reduced doses of direct oral anticoagulants or edoxaban treatment, concomitant use of amiodarone treatment, and non-use of statin treatment were significantly associated with potentially inappropriate dosing of direct oral anticoagulants. CONCLUSION: The study demonstrated that the prevalence of inappropriate direct oral anticoagulant dosing according to the European Heart Rhythm Association recommendations was 24.9% in patients with atrial fibrillation. Several demographic and clinical factors were associated with the inappropriate prescription of direct oral anticoagulants.

Rivaroxaban and apixaban in patients with atrial fibrillation; a real-world data.

BACKGROUND: This study aims to analyze the real-life data of patients who were prescribed rivaroxaban and apixaban and to emphasize the points that we think will make a difference compared to randomized controlled studies. METHODS: The patients who accepted to participate in the study in whom rivaroxaban (15-20 mg) and apixaban (2.5-5 mg) were started with the diagnosis of atrial fibrillation between 01 January 2018 and 31 December 2019 and whose records were fully accessed through the hospital automation system were included in the study. RESULTS: One hundred and ninety-four (48.5%) of a total of 400 patients using rivaroxaban and apixaban were women. The mean age was 73.34 ± 10.45 years, and the age range was 41-98. There was no significant difference in terms of demographic characteristics, background information of the patients, and the medications. Drug-induced complications and mortality rates were also similar. The GFR change rates of the patients in both groups were similar even though the initial GFRs were significantly higher in rivaroxaban group. The mean age and ejection fractions of the patients using rivaroxaban 15 mg were found to be lower than those of patients using rivaroxaban 20 mg whereas the mean systolic blood pressure and HAS-BLED score were found to be higher. Ischemic stroke and mortality rates were higher in patients using 15 mg rivaroxaban than patients using 20 mg rivaroxaban. The rates of nonmajor bleeding in patients using rivaroxaban 15 mg were lower compared to those using 20 mg, and this difference was statistically significant. DISCUSSION: Stroke rates were found to be higher and to have similar bleeding rates compared to major clinical studies in our real-life analysis. However, high ischemic cerebrovascular event and low nonmajor bleeding rates are remarkable in low dose use of rivaroxaban. It is clear that there is a need to consider existing dose reduction criteria in terms of correct prescribing.

An Evaluation of Aspirin Treatment Preferences ORIGINAL INVESTIGATION of Physicians in Hypertensive Patients in Terms of Current Guidelines: A Subgroup Analysis of the ASSOS Trial in Turkey.

BACKGROUND: The Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study trial has been the largest study ever conducted among patients in Turkey regarding aspirin treatment. In the subgroup analysis of the hypertensive group of the Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study trial, we aimed to evaluate the physicians' adherence to current guidelines regarding their aspirin treatment preferences. METHODS: The Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study trial is a cross-sectional and multicenter study conducted among 5007 consecutive patients aged ≥18 years. The study population consisted of outpatients on aspirin treatment (80-300 mg). The patient data were obtained from 30 different cardiology clinics of 14 cities from all over Turkey. In this subgroup analysis, patients were divided into 2 groups: the hypertensive group (n=3467, 69.3%) and the group without hypertension (n=1540, 30.7%) according to the 2018 European Society of Cardiology/ European Society of Hypertension Guidelines for the Management of Arterial Hypertension. RESULTS: Aspirin use for primary prevention was higher in patients with hypertension compared to patients without hypertension [328 (21.3%); 1046 (30.2%); P < .001]. Treatment with a dose of 150 mg aspirin (n=172, 5%) was mostly preferred by internists for hypertensive patients (n =226, 6.5%); however, a daily dose of 80-100 mg aspirin therapy (n=1457, 94.6%) was mostly prescribed by cardiologists (n=1347, 87.5%) for patients without hypertension. CONCLUSION: Aspirin was found to be used commonly among patients with hypertension for primary prevention despite the current European Society of Cardiology Arterial Hypertension Guideline not recommending aspirin for primary prevention in patients with hypertension.

Design and rationale for the ASSOS study: Appropriateness of aspirin use in medical outpatients a multicenter and observational study.

OBJECTIVE: The aim of this study was to describe the current status of aspirin use and the demographic characteristics of patients on aspirin for primary and secondary prevention of cardiovascular diseases. METHODS: The Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study (ASSOS) trial was a multicenter, cross-sectional, and observational study conducted in Turkey. The study was planned to include 5000 patients from 14 cities in Turkey. The data were collected at one visit, and the current clinical practice regarding aspirin use was evaluated (ClinicalTrials.gov number NCT03387384). RESULTS: The study enrolled all consecutive patients who were admitted to the outpatient cardiology clinics from March 2018 until June 2018. Patients should be at least 18 years old, have signed written informed consent, and on aspirin (80-325 mg) therapy within the last 30 days. Cardiologists from the hospital participates in the study. Patients were divided into 2 categories according to presence or absence of atherosclerotic cardiovascular disease, namely secondary prevention group and primary prevention group, respectively. The appropriate use of aspirin in the primary and secondary prevention groups was assessed according to the European Society of Cardiology guidelines and US Preventive Services Task Force. The patients' gastrointestinal bleeding risk factors and colorectal cancer risk were evaluated. CONCLUSION: The ASSOS registry will be the most comprehensive and largest study in Turkey evaluating the appropriateness of aspirin use. The results of this study help understand the potential misuse of aspirin in a real-world setting.

Awareness of Pleiotropic and Cardioprotective Effect of Statins in Patients with Coronary Artery Disease.

BACKGROUND: Statins are commonly used in the secondary prevention of coronary artery disease. Studies have shown that the rate of statin use is low among patients with coronary artery disease. In this study, we aimed to investigate the reasons for poor patient compliance with statin treatment. METHODS: A total of 504 patients diagnosed with coronary heart disease were included in the study. Patients were asked 5 questions to assess their level of knowledge about statin therapy. RESULTS: Among the patients not using statins, 42% stated they did not take the medication because their cholesterol was not high or they did not know they should renew their prescription when they ran out and 35% because they were influenced by news reports in the media suggesting that cholesterol-lowering drugs were harmful. When patients who were aware of the pleiotropic/cardioprotective effects of statins were compared with patients who were not, the more knowledgeable patients had lower noncompliance rate and mean LDL-C level and a higher rate of LDL-C level optimization. CONCLUSION: We found that patients who are aware of the pleiotropic effects of statins were more compliant with treatment. We believe that spending more time explaining and emphasizing the mechanisms of action, reason for prescribing, and necessary treatment duration of drugs that patients must use will result in greater compliance and improve patient care. In this way, patients may be less influenced by misinformation presented by the media.

Dabigatran Versus Warfarin in Atrial Fibrillation: Multicenter Experience in Turkey.

Safety issues have been raised about dabigatran. We aimed to investigate the occurrence of safety outcomes in patients who had atrial fibrillation and a risk of stroke. We analyzed 439 patients prescribed dabigatran (n = 220) or warfarin (n = 219). Ischemic stroke occurred in 15 (6.8%) patients in the warfarin group versus 5 (5.2%) patients in the 110-mg group versus 1 (0.8%) patient in the 150-mg dabigatran group (P = .015). Intracranial hemorrhage occurred in 6 (2.7%) patients in the warfarin group versus 3 (2.4%) patients in the 150-mg dabigatran group (P = .104). Death from any cause occurred in 10 (4.6%) patients in the warfarin group versus 1 (1.0%) patient in the 110-mg dabigatran group (P = .005). Dabigatran was associated with less ischemic stroke and death from any cause than warfarin. Dabigatran may be a better option for stroke prophylaxis, where recommended monitoring with warfarin is suboptimal.