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Original Research: Cardiovascular Disease |

Stroke/Thromboembolism and Intracranial Hemorrhage in a Real-world Atrial Fibrillation PopulationComplications in Patients With Atrial Fibrillation: The Complications of Atrial Fibrillation in the Bologna Area (CAFBO) Study

Gualtiero Palareti, MD; Luisa Salomone, MD; Mario Cavazza, MD; Marcello Guidi, MD; Antonio Muscari, MD; Giuseppe Boriani, MD; Antonio Di Micoli, MD; Giordano Guizzardi, MD; Gaetano Procaccianti, MD; Angelo Guidetti, MD; Nicola Binetti, MD; Simona Malservisi, MD; Marco Masina, MD; Antonella Viola, MD; Vincenzo Bua, MD; Maurizio Ongari, MD; Giampaolo Diaspri, MD; Gregory Y. H. Lip, MD
Author and Funding Information

From the Angiologia e Malattie della Coagulazione (Drs Palareti and Salomone), Medicina D’Urgenza e Pronto Soccorso (Drs Cavazza and Guidi), Stroke Unit, Medicina Interna (Dr Muscari), and Institute of Cardiology (Dr Boriani), Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant’Orsola-Malpighi University Hospital, Bologna, Italy; Pronto Soccorso e Medicina D’Urgenza Ospedale Maggiore (Drs Di Micoli and Guizzardi), Bologna, Italy; IRCCS Institute of Neurological Sciences, Maggiore Hospital Stroke Unit (Dr Procaccianti), Bologna, Italy; Pronto Soccorso ed Emergenza Territoriale Area Nord (Dr Guidetti and Binetti), Bologna, Italy; Stroke Care, Geriatria, Ospedale di Bentivoglio (Drs Malservisi and Masina), Bologna, Italy; Pronto Soccorso ed Emergenza Territoriale Area Sud (Drs Viola and Bua), Bologna, Italy; UOC Medicina Porretta-Vergato (Drs Ongari and Diaspri), Bologna, Italy; and University of Birmingham Centre for Cardiovascular Sciences (Dr Lip), City Hospital, Birmingham, England.

CORRESPONDENCE TO: Gualtiero Palareti, MD, Department of Angiology and Blood Coagulation, University Hospital Policlinico S. Orsola-Malpighi, Via Albertoni 15, 40138 Bologna, Italy; e-mail: gualtiero.palareti@unibo.it


FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(4):1073-1080. doi:10.1378/chest.13-2443
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BACKGROUND:  Ischemic events (IEs) and intracranial hemorrhages (ICHs) are feared complications of atrial fibrillation (AF) and of antithrombotic treatment in patients with these conditions.

METHODS:  Patients with AF admitted to the EDs of the Bologna, Italy, area with acute IE or ICH were prospectively recorded over 6 months.

RESULTS:  A total of 178 patients (60 male patients; median age: 85 years) presented with acute IE. Antithrombotic therapy was as follows: (1) vitamin K antagonists (VKAs) in 31 patients (17.4%), with international normalized ratio (INR) at admission of < 2.0 in 16 patients, 2.0 to 3.0 in 13 patients, and > 3.0 in two patients; (2) aspirin (acetylsalicylic acid) (ASA) in 107 patients (60.1%); and (3) no treatment in 40 patients (22.5%), mainly because AF was not diagnosed. Twenty patients (eight male patients; median age: 82 years) presented with acute ICH: 13 (65%) received VKAs (INR, 2.0-3.0 in 11 patients and > 3.0 in two patients), while six (30%) received ASA. Most IEs (88%) and ICHs (95%) occurred in patients aged > 70 years. A modeling analysis of patients aged > 70 years was used to estimate annual incidence in subjects anticoagulated with VKAs in our Network of Anticoagulation Centers (NACs), or those expected to have AF but not included in NACs. The expected incidence of IE was 12.0%/y (95% CI, 10.7-13.3) in non-NACs and 0.57%/y (95% CI, 0.42-0.76) in NACs (absolute risk reduction [ARR], 11.4%/y; relative risk reduction [RRR], 95%; P < .0001). The incidence of ICH was 0.63%/y (95% CI, 0.34-1.04) and 0.30%/y (95% CI, 0.19-0.44), respectively (ARR, 0.33%/y; RRR, 52.4%/y; P = .04).

CONCLUSIONS:  IEs occurred mainly in elderly patients who received ASA or no treatment. One-half of patients with IEs receiving anticoagulant treatment had subtherapeutic INRs. Therapeutic approaches to elderly subjects with AF require an effective anticoagulant treatment strategy.

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