Mixed messages? Exposure to reports about alcohol's suggested cardiovascular effects and hazardous alcohol use: a cross-sectional study of patients in cardiology care.

BACKGROUND: Hazardous alcohol use is a leading risk factor for disability and death, yet observational studies have also reported reduced cardiovascular disease mortality among regular, low-level drinkers. Such findings are refuted by more recent research, yet have received significant media coverage. We aimed to explore: (1) how patients with cardiovascular diseases access health information about moderate drinking and cardiovascular health; (2) the perceived messages these sources convey, and (3) associations with own level of alcohol use. METHODS: We conducted a cross-sectional survey of patients in cardiology services at three hospitals in Sweden. The study outcome was hazardous alcohol use, assessed using the AUDIT-C questionnaire and defined as ≥ 3 in women and ≥ 4 in men. The exposure was accessing information sources suggesting that moderate alcohol consumption can be good for the heart, as opposed to accessing information that alcohol is bad for the heart. Health information sources were described using descriptive statistics. Gender, age and education were adjusted for in multiple logistic regression analyses. RESULTS: A total of 330 (66.3%) of 498 patients (mean age 70.5 years, 65% males) who had heard that drinking moderately can affect the heart described being exposed to reports that moderate alcohol use can be good for the heart, and 108 (21.7%) met criteria for hazardous alcohol use. Health information sources included newspapers (32.9%), television (29.2%), healthcare staff (13.4%), friends/family (11.8%), social media (8.9%) and websites (3.7%). Participants indicated that most reports (77.9%) conveyed mixed messages about the cardiovascular effects of moderate drinking. Exposure to reports of healthy heart effects, or mixed messages about the cardiovascular effects of alcohol, was associated with increased odds of hazardous alcohol use (OR = 1.67, 95%CI = 1.02-2.74). CONCLUSIONS: This study suggests that many patients in cardiology care access health information about alcohol from media sources, which convey mixed messages about the cardiovascular effects of alcohol. Exposure to reports that moderate drinking has protective cardiovascular effects, or mixed messages about the cardiovascular effects of alcohol, was associated with increased odds of hazardous alcohol use. Findings highlight a need for clear and consistent messages about the health effects of alcohol.

Feasibility of alcohol interventions in cardiology: A qualitative study of clinician perspectives in Sweden.

AIM: To identify barriers and facilitators to implementing alcohol screening and brief interventions (SBI) in cardiology services. METHODS AND RESULTS: Qualitative study. Individual, semi-structured interviews were conducted with 24 clinical cardiology staff (doctors, nurses, assistant nurses) of varying experience levels, and from various clinical settings (high dependency unit, ward, outpatient clinic), in three regions of Sweden. Reflexive thematic analysis was used, with deductive coding applying the Capability, Opportunity, Motivation (COM-B) theoretical framework. A total of 41 barriers and facilitators were identified, including twelve related to capability, nine to opportunity, and 20 to motivation. Four themes were developed: 1. Uncharted territory, where clinicians expressed a need to address alcohol use but lacked knowledge and a roadmap for implementing SBI; 2. Cardiology as a cardiovascular specialty, where tasks were prioritized according to established roles; 3. Alcohol stigma, where alcohol was reported to be a sensitive topic that staff avoid discussing with patients; 4. Window of opportunity, where staff expressed potential for implementing SBI in routine cardiology care. CONCLUSION: Findings suggest that opportunities exist for early identification and follow-up of hazardous alcohol use within routine cardiology care. Several barriers, including low knowledge, stigma, a lack of ownership, and a greater focus on other risk factors must be addressed prior to the implementation of SBI in cardiology. To meet current clinical guidelines, there is a need to increase awareness and to improve pathways to addiction care. In addition, there may be a need for clinicians dedicated to alcohol interventions within cardiology services. REGISTRATION: OSF (osf.io/hx3ts).

Safety and Efficacy of Bridging With Low-Molecular-Weight Heparin During Temporary Interruptions of Warfarin: A Register-Based Cohort Study.

Low-molecular-weight heparin (LMWH) is often recommended as a bridging therapy during temporary interruptions in warfarin treatment, despite lack of evidence. The aim of this study was to see whether we could find benefit from LMWH bridging. We studied all planned interruptions of warfarin within the Swedish anticoagulation register Auricula during 2006 to 2011. Low-molecular-weight heparin bridging was compared to nonbridging (control) after propensity score matching. Complications were identified in national clinical registers for 30 days following warfarin cessation, and defined as all-cause mortality, bleeding (intracranial, gastrointestinal, or other), or thrombosis (ischemic stroke or systemic embolism, venous thromboembolism, or myocardial infarction) that was fatal or required hospital care. Of the 14 556 identified warfarin interruptions, 12 659 with a known medical background had a mean age of 69 years, 61% were males, mean CHADS2 (1 point for each of congestive heart failure, hypertension, age ≥75 years, diabetes, and 2 points for stroke or transient ischemic attack) score was 1.7, and CHA2DS2-VASc score was 3.4. The total number of LMWH bridgings was 7021. Major indications for anticoagulation were mechanical heart valve prostheses 4331, atrial fibrillation 1097, and venous thromboembolism 1331. Bridging patients had a higher rate of thrombotic events overall. Total risk of any complication did not differ significantly between bridging (1.5%) and nonbridging (1.2%). Regardless of indication for warfarin treatment, we found no benefit from bridging. The type of procedure prompting bridging was not known, and the likely reason for the observed higher risk of thrombosis with LMWH bridging is that low-risk procedures more often meant no bridging. Results from randomized trials are needed, especially for patients with mechanical heart valves.

Warfarin treatment quality and prognosis in patients with mechanical heart valve prosthesis.

OBJECTIVES: To study the impact of time in therapeutic range (TTR) and international normalised ratio (INR) variability on the risk of thromboembolic events, major bleeding complications and death after mechanical heart valve (MHV) implantation. Additionally, the importance of different target INR levels was elucidated. METHODS: A retrospective, non-randomised multicentre cohort study including all patients with mechanical heart valve (MVH) prosthesis registered in the Swedish National Quality Registry Auricula from 2006 to 2011. Data were merged with the Swedish National Patient Registry, SWEDEHEART and Cause of Death Registry. RESULTS: In total 4687 ordination periods, corresponding to 18 022 patient-years on warfarin, were included. High INR variability (above mean ≥0.40) or lower TTR (≤70%) was associated with a higher risk of bleeding (rate per 100 years 4.33 (95% CI 3.87 to 4.82) vs 2.08 (1.78 to 2.41); HR 2.15 (1.75 to 2.61) and 5.13 (4.51 to 5.82) vs 2.30 (2.03 to 2.60); HR 2.43 (2.02 to 2.89)), respectively. High variability and low TTR combined was associated with an even higher risk of bleedings (rate per 100 years 4.12 (95% CI 3.68 to 4.51) vs 2.02 (1.71 to 2.30); HR 2.16 (1.71 to 2.58) and 4.99 (4.38 to 5.52) vs 2.36 (2.06 to 2.60); HR 2.38 (2.05 to 2.85)) compared with the best group.Higher treatment intensity (mean INR 2.8-3.2 vs 2.2-2.7) was associated with higher rate of bleedings (2.92 (2.39 to 3.47) vs 2.48 (2.21 to 2.77); HR 1.29 (1.06 to 1.58)), death (3.36 (2.79 to 4.02) vs 1.89 (1.64 to 2.17), HR 1.65 (1.31 to 2.06)) and complications in total (6.61 (5.74 to 7.46) vs 5.65 (5.20 to 6.06); HR 1.24 (1.06 to 1.41)) after adjustment for MHV position, age and comorbidity. CONCLUSIONS: A high warfarin treatment quality improves outcome after MHV implantation, both measured with TTR and INR variability. No benefit was found with higher treatment intensity (mean INR 2.8-3.2 vs 2.2-2.7).

Glomerular filtration rate and association to stroke, major bleeding, and death in patients with mechanical heart valve prosthesis.

AIMS: The impact of estimated glomerular filtration rate (eGFR) on adverse events in patients with mechanical heart valves (MHVs) is unknown. We analyzed the independent association of eGFR and thromboembolism (TE), major bleeding, and mortality in patients with MHV in an observational cohort study. METHODS AND RESULTS: All patients (n = 520) with MHV replacement on anticoagulation treatment were followed up prospectively regarding TE, major bleeding, and death at 2 anticoagulation centers during 2008 to 2011. The mean age was 69 years, 72% with aortic valve replacement, and time in therapeutic range 2.0 to 4.0 was 91%. The incidence of the combined end point of major bleeding, TE, and death increased sharply with each decreasing eGFR stratum: 5.5, 8.4, 16, and 32 per 100 patient-years for eGFR >60, 45 to 60, 30 to 45, and <30 mL/min per 1.73 m(2), respectively. After multivariate adjustment for comorbidities, every unit decrease in eGFR increased the risk of major bleeding by 2%, death by 3%, and the combined end point by 1%. There was no association between eGFR and TE. There was an increased proportion of international normalized ratio >3.0 and >4.0 and decreasing time in therapeutic range for each decreasing eGFR stratum (P < .001 for trend). The hazard ratios of the combined end point for eGFR <30, 30 to 45, and 45 to 60 mL/min per 1.73 m(2) were 3.2 (95% CI 1.8-5.6), 1.5 (95% CI 0.9-2.5), and 0.9 (95% CI 0.6-1.5), respectively, compared to eGFR >60 mL/min per 1.73 m(2). CONCLUSION: In patients with MHV on anticoagulation, eGFR is an independent predictor of major bleeding and death and not TE.

Safety and efficacy of well managed warfarin. A report from the Swedish quality register Auricula.

The safety and efficacy of warfarin in a large, unselected cohort of warfarin-treated patients with high quality of care is comparable to that reported for non-vitamin K antagonists. Warfarin is commonly used for stroke prevention in atrial fibrillation, as well as for treatment and prevention of venous thromboembolism. While reducing risk of thrombotic/embolic incidents, warfarin increases the risk of bleeding. The aim of this study was to elucidate risks of bleeding and thromboembolism for patients on warfarin treatment in a large, unselected cohort with rigorously controlled treatment. This was a retrospective, registry-based study, covering all patients treated with warfarin in the Swedish national anticoagulation register Auricula, which records both primary and specialised care. The study included 77,423 unselected patients with 100,952 treatment periods of warfarin, constituting 217,804 treatment years. Study period was January 1, 2006 to December 31, 2011. Atrial fibrillation was the most common indication (68 %). The mean time in therapeutic range of the international normalised ratio (INR) 2.0-3.0 was 76.5 %. The annual incidence of severe bleeding was 2.24 % and of thromboembolism 2.65 %. The incidence of intracranial bleeding was 0.37 % per treatment year in the whole population, and 0.38 % among patients with atrial fibrillation. In conclusion, warfarin treatment where patients spend a high proportion of time in the therapeutic range is safe and effective, and will continue to be a valid treatment option in the era of newer oral anticoagulants.

Thromboembolism, major bleeding and mortality in patients with mechanical heart valves- a population-based cohort study.

INTRODUCTION: Low incidences of thromboembolism (TE) and bleeding in patients with mechanical heart valves (MHV) have previously been reported. This study assesses the incidence of and clinical risk factors predicting TE, major bleeding and mortality in a clinical setting. METHODS AND RESULTS: All 546 patients undergoing anticoagulation treatment due to MHV replacement at hospitals in Malmö and Sundsvall in Sweden were monitored during 2008-2011 and the incidence of TE, major bleeding and mortality was prospectively followed. There were 398, 122 and 26 patients in the aortic group (AVR), mitral (MVR) group and the combined aortic/mitral valve group respectively. The incidence of TE was 1.8 and 2.2 per 100 patient-years in the AVR group MVR group respectively. The corresponding incidences of bleeding were 4.4 and 4.6, respectively. Independent predictor of thromboembolism was vascular disease (Odds ratio {OR}: 4.2; 95% CI: 1.0-17.4). Predictor of bleeding was previous bleeding (OR: 2.7; 95% CI: 1.4-5.3). Independent predictors of mortality was age (Hazard ratio {HR}: 1.03; 95% CI: 1.00-1.05), hypertension (HR: 2.4; 95% CI: 1.3-4.5), diabetes (HR: 2.4; 95% CI: 1.3-4.3) and alcohol overconsumption (HR: 5.2; 95% CI: 1.7-15.9). Standardized mortality/morbidity ratio for mortality and AMI was 0.99 (95% CI: 0.8-1.2) and 0.87 (95% CI: 0.5-1.2) respectively. CONCLUSION: The incidence of TE and major bleeding in this unselected clinical population exceeds that of previously reported retrospective and randomized trials. Despite this, mortality is equal to that of the general population.

Mechanical heart valve prosthesis and warfarin - treatment quality and prognosis.

INTRODUCTION: Every year about 2500 patients in Sweden undergo surgery due to heart valve disease. A mechanical heart valve prosthesis causes risk of thromboembolic stroke or thrombus formation in the valve while anticoagulant treatment increases the risk of bleeding. Treatment quality with warfarin is crucial for patients with mechanical valve prostheses. It has previously been shown that poorly controlled warfarin treatment increases mortality in this patient group. TTR (Time in Therapeutic Range) on warfarin has been shown to affect the risk of complications in atrial fibrillation, but has not been studied in patients with mechanical heart valves. Our aim is to evaluate the impact of TTR on the risk of complications in this patient group. MATERIALS AND METHODS: A non-randomized, prospective study of 534 adults with mechanical heart valve prostheses from Malmö and Sundsvall registered in the Swedish National Quality Registry Auricula between 01.01.2008 and 31.12.2011. Quartiles regarding individual TTR levels were compared regarding risk of complications. RESULTS: The risk of complications was significantly higher at lower TTR levels for all complications (p=0.005), bleeding (p=0.01) and death (p=0.018) but not for thromboembolism. In multivariate analysis the risk was significantly increased at lower TTR levels for bleeding and all complications but not for death or thromboembolism. CONCLUSION: Patients with a lower warfarin treatment quality measured by TTR have a higher risk of complications such as severe bleeding or death. A TTR of 83% or higher at the individual level should be obtained for best outcome.

Computer aided warfarin dosing in the Swedish national quality registry AuriculA - Algorithmic suggestions are performing better than manually changed doses.

INTRODUCTION: Warfarin treatment with a high time in therapeutic range (TTR) is correlated to fewer complications. The TTR in Sweden is generally high but varies partly depending on local expertise and traditions. A dosing algorithm could minimize variations and increase treatment quality. Here we evaluate the performance of a computerized dosing algorithm. MATERIALS AND METHODS: 53.779 warfarin treated patients from 125 centers using the Swedish national quality registry AuriculA. If certain criteria are met, the algorithm gives one of seven possible dose suggestions, which can be unchanged, decreased or increased weekly dose by 5, 10 or 15%. The outcome evaluated by the resulting INR value was compared between dose suggestions arising from the algorithm that were accepted and those that were manually changed. There were no randomization, and outcomes were retrospectively analyzed. RESULTS: Both the algorithm-based and the manually changed doses had worse outcome if only two instead of three previous INR values were available. The algorithm suggestions were superior to manual dosing regarding percent samples within the target range 2-3 (hit-rate) or deviation from INR 2.5 (mean error). Of the seven possible outcomes from the algorithm, six were significantly superior and one equal to the manually changed doses when three previous INR:s were present. CONCLUSIONS: The algorithm-based dosing suggestions show better outcome in most cases. This can make dosing of warfarin easier and more efficient. There are however cases where manual dosing fares better. Here the algorithm will be improved to further enhance its dosing performance in the future.

Computerised assistance for warfarin dosage--effects on treatment quality.

BACKGROUND: Well-managed warfarin treatment with a high time in therapeutic range (TTR) corresponds to fewer bleedings or thromboembolic complications. Many small centres manage their warfarin dosing manually, with little or no knowledge of their treatment quality as measured by TTR. AuriculA is a Swedish National web-based anticoagulation dosing system. Our hypothesis was that the web based dosing system, compared to manual dosing, would improve the TTR. METHODS: Retrospective cohort study of medical records from patients with atrial fibrillation on warfarin treatment from two centres, with previously manual warfarin dosing regimens. Data for calculation of TTR was extracted manually from medical records from the time when using manual dosing and compared with the computerised regimen. RESULTS: In centre 1, the mean TTR was significantly increased after the introduction of AuriculA, from 64.3% (95% CI 58.8-69.8) to 71.3% (95% CI 67.7-74.8), p=0.03. In centre 2, a high TTR of 73.6% (95% CI 71.3-75.9) was maintained after the implementation, 74.0% (95% CI 71.6-76.3). INR tests were prescribed significantly more frequent after the introduction of AuriculA in both centres; 20% more often at centre 1 and 21% at centre 2. CONCLUSION: Computerised dosing assistance within the Swedish national quality registry AuriculA improves or maintains a high treatment quality with warfarin as measured by TTR.