Therapeutic inertia in anti-platelet therapy in patients with a cardiovascular event attended in an emergency department.

Objective As very few studies have assessed therapeutic inertia (TI) in anti-platelet therapy in patients in secondary cardiovascular prevention, the authors designed a study in their hospital emergency department to quantify its magnitude and its associated factors. Methods This descriptive cross-sectional observational study involved a sample of 223 patients with a history of cardiovascular disease and recommendation for anti-platelet therapy who attended the emergency department in a Spanish region in 2016. The main variable was TI in platelet anti-aggregation (lack of a prescription when recommended by the clinical guidelines). The secondary variables were gender, age, educational level, stable partner, hypertension, dyslipidemia, diabetes, smoking, type and number of cardiovascular events, blood pressure, and glomerular filtration rate. The magnitude of TI was quantified and associated factors were studied using a binary logistic regression model. Results TI was present in 107 patients (48.0%). In the multifactorial analysis, the following factors were associated with a higher proportion of TI: female gender (p = .021), higher cultural level (p = .020), and having no previous diagnosis of hypertension (p = .003) or dyslipidemia (p = .002). Conclusions The magnitude of TI in anti-platelet therapy in patients who had already suffered a cardiovascular event was very high. TI was associated with being a woman, having a high cultural level, and not being diagnosed with hypertension or dyslipidemia. More studies are needed to corroborate these results to take the appropriate measures to reduce TI.

A one-year risk score to predict all-cause mortality in hypertensive inpatients.

The aim of this study was to construct and internally validate a scoring system to estimate the probability of death in hypertensive inpatients. Existing predictive models do not meet all the indications for clinical application because they were constructed in patients enrolled in clinical trials and did not use the recommended statistical methodology. This cohort study comprised 302 hypertensive patients hospitalized between 2015 and 2017 in Spain. The main variable was time-to-death (all-cause mortality). Secondary variables (potential predictors of the model) were: age, gender, smoking, blood pressure, Charlson Comorbidity Index (CCI), physical activity, diet and quality of life. A Cox model was constructed and adapted to a points system to predict mortality one year from admission. The model was internally validated by bootstrapping, assessing both discrimination and calibration. The system was integrated into a mobile application for Android. During the study, 63 patients died (20.9%). The points system prognostic variables were: gender, CCI, personal care and daily activities. Internal validation showed good discrimination (mean C statistic of 0.76) and calibration (observed probabilities adjusted to predicted probabilities). In conclusion, a points system was developed to determine the one-year mortality risk for hypertensive inpatients. This system is very simple to use and has been internally validated. Clinically, we could monitor more closely those patients with a higher risk of mortality to improve their prognosis and quality of life. However, the system must be externally validated to be applied in other geographic areas.

Nonadherence to guidelines for prescribing antiplatelet/anticoagulant therapy in patients with atrial fibrillation.

BACKGROUND: We have found no papers evaluating nonadherence to guidelines for the treatment of atrial fibrillation (AF), taking into account the two risk scales [C, congestive heart failure; H, hypertension; A, age; D, diabetes mellitus; S, stroke (CHADS2) and C, congestive heart failure; H, hypertension; A, age; D, diabetes mellitus; S, stroke; V, vascular disease; A, age; Sc, sex category (CHA2DS2-VASc)] and the two types of treatment that are recommended (antiplatelet/anticoagulant therapy). OBJECTIVE: To determine the extent of lack of adherence when prescribing anticoagulant and antiplatelet therapy to patients with AF and associated factors. METHODS: Cross-sectional, observational study of 144 patients with AF who visited the emergency department of Elda Hospital in 2013-14 (Spain). Main variable: the patient was prescribed a therapy different from that indicated by the guidelines (nonadherence) or not prescribed any therapy. Secondary variables: CHADS2, CHA2DS2-VASc, HAS-BLED, type of AF and symptoms related to AF. Multivariate models were constructed to identify the associated factors by calculating the adjusted odds ratios (OR). RESULTS: Nonadherence occurred in 90 patients [62.5%, 95% confidence interval (CI): 54.6-70.4%]. Associated factors were higher CHADS2 (OR = 1.30, 95% CI: 0.96-1.75, P = 0.091) and CHA2DS2-VASc (OR = 1.23, 95% CI: 1.02-1.47, P = 0.027), and lower HAS-BLED (OR = 0.67, 95% CI: 0.49-0.91, P = 0.011). CONCLUSIONS: Nonadherence to guidelines was found in three out of every five patients. A greater cerebrovascular risk and a lower haemorrhagic risk were associated with this behaviour. Qualitative studies are needed to determine the causes.