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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Atrial fibrillation &#40;AF&#41; is the most common arrhythmia in our setting&#44; especially in older patients or those with associated comorbidity&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> who represent the profile of patients treated in internal medicine departments&#46; In a recent Spanish study&#44; up to 17&#37; of hospitalized patients in the medical area presented AF&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the absence of contraindication&#44; anticoagulation is indicated for most elderly patients with nonvalvular AF &#40;NVAF&#41; to reduce the risk of thromboembolic complications&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> Although the prescription of direct oral anticoagulants is gaining ground&#44; the &#8220;classical&#8221; vitamin K antagonists &#40;VKAs&#41; are still the most widely used drugs for patients with NVAF&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> VKAs are highly effective but have 2<span class="elsevierStyleHsp" style=""></span>significant limitations that can reduce their anticoagulant effect&#58; the narrow therapeutic window and the need for periodic coagulation checks that entail frequent dosage adjustments&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> For the anticoagulation to be effective and safe&#44; we need to maintain an adequate time in therapeutic range &#40;TTR&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> However&#44; data from Bertomeu-Gonz&#225;lez et al&#46; confirm that anticoagulation control in patients treated in outpatient clinics in Spain is insufficient<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> and that there is little information on the management of anticoagulation and its clinical consequences in patients hospitalized with AF&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> We therefore conducted an observational study to assess the degree of anticoagulation control in hospitalized patients with NVAF treated with VKAs&#44; as well as the factors and events associated with this control&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We retrospectively reviewed the medical records of all patients with a previous diagnosis of NVAF hospitalized in our hospital&#39;s Department of Internal Medicine during 2015&#46; The study included 231 patients&#44; most of whom were octogenarians &#40;mean age&#44; 81&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;1 years&#41;&#44; 53&#37; of whom were men&#46; The thromboembolic risk was high&#44; given that 96&#46;1&#37; of the patients had a CHA2DS2-VASc level &#8805;2 &#40;mean&#44; 4&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;5&#41;&#44; with a mean score on the HAS-BLED scale of 2&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;9&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">More than half of the patients had associated comorbidities &#40;Charlson comorbidity index<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>3 in 58&#46;2&#37; of the patients&#41;&#44; with a high prevalence of arterial hypertension &#40;83&#46;1&#37;&#41;&#46; Infectious processes were the main cause of hospitalization &#40;51&#46;1&#37; of cases&#41;&#44; and the mean hospital stay was 8&#46;59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;34 days &#40;range&#44; 3&#8211;29 days&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Most of the patients &#40;96&#46;1&#37;&#41; followed some type of antithrombotic therapy before the hospitalization&#58; oral anticoagulants &#40;77&#46;1&#37;&#58; 67&#46;5&#37; with VKAs and 9&#46;6&#37; with direct oral anticoagulants&#41;&#44; antiplatelets &#40;17&#46;7&#37;&#41; or low-molecular-weight heparins &#40;1&#46;3&#37;&#41;&#46; During the hospitalization&#44; 148 patients &#40;64&#46;1&#37;&#41; continued with VKAs&#44; although only 18 &#40;12&#46;1&#37; of all those treated with VKAs&#41; remained in the therapeutic range&#44; significantly worsening the anticoagulation control in the patients with VKAs &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The multivariate analysis using logistic regression showed that the only variable associated with poor anticoagulation control was an inadequate TTR before the hospitalization &#40;relative risk&#44; 2&#46;5&#59; 95&#37; confidence interval 1&#46;33&#8211;4&#46;68&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;009&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In the patients treated with VKAs and poor coagulation control&#44; the hospitalization was longer &#40;9&#46;09<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;91 vs&#46; 7&#46;03<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;88 days&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;029&#41;&#44; and the number of clinical events during the hospitalization and follow-up was greater than among the patients who remained in the therapeutic range&#44; although the difference did not achieve statistical significance during the hospitalization &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;213&#41;&#44; at 1 month &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;922&#41; or at 3 months of follow-up &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;694&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">After the hospital discharge&#44; 150 patients &#40;64&#46;9&#37;&#41; continued the VKA therapy despite poorer anticoagulation control during their hospitalization&#44; and 60 &#40;26&#37;&#41; did not undergo anticoagulant therapy&#44; which represents a 4&#46;3&#37; increase in the number of patients without anticoagulant therapy compared with baseline&#46; This increase is due to a greater number of patients treated with antiplatelets &#40;19&#46;5&#37;&#41; and especially patients without antithrombotic therapy &#40;6&#46;5&#37;&#41;&#46; In all medical records of the patients without anticoagulant therapy&#44; the reason for the hospitalization was mentioned&#44; which was mainly frequent falls&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patients&#8217; clinical profile &#40;elderly&#44; high thromboembolic risk and numerous comorbidities&#41; was similar to that of other studies<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2&#44;8</span></a> and showed the considerable complexity of patients with AF hospitalized in internal medicine&#46; Despite the high thromboembolic risk&#44; the results showed that a non-negligible portion of patients were not anticoagulated&#46; More than 20&#37; of the patients were not treated with anticoagulant therapy before the hospitalization&#44; and more than 25&#37; did not receive it when discharged&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the elderly population&#44; the use of anticoagulant therapy decreases&#44; and the use of antiplatelets increases&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> However&#44; it has been shown that antiplatelet therapy is highly ineffective for this type of patient and has a hemorrhage risk similar to that of anticoagulation<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> and should therefore be avoided&#46; Various causes have been indicated to explain the underutilization of anticoagulant therapy in elderly patients&#44; such as advanced age&#44; cognitive impairment and the presence of other comorbidities&#44; such as renal failure&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">7&#44;10</span></a> However&#44; none of these causes in isolation is a contraindication for this therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The percentage of patients with good anticoagulation control in our study &#40;12&#37; during the hospitalization&#41; was lower than that observed in other studies &#40;45&#8211;55&#37;&#41;&#46; This difference could be attributed to the older age and number of comorbidities of the study sample&#46; As in the PAULA study&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> the main factor associated with poor anticoagulation control was a labile international normalized ratio&#44; with a low TTR before the hospitalization&#46; The control worsened during the hospitalization&#44; and&#44; as in other studies&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a> this change was associated with a longer hospital stay and more clinical events&#46; Direct oral anticoagulants could be a reasonable alternative to VKA for elderly patients with poor anticoagulation control&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> However&#44; the use of these oral anticoagulants in Spain is relatively low&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; Insenser BB&#44; Uriel UP&#44; Biosca AS&#44; Mart&#237;nez JS&#46; Control de la anticoagulaci&#243;n en pacientes hospitalizados con fibrilaci&#243;n auricular no valvular en tratamiento cr&#243;nico con anticoagulantes orales&#46; Rev Clin Esp&#46; 2018&#59;218&#58;267&#8211;269&#46;</p>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; NVAF&#44; nonvalvular atrial fibrillation&#59; VKA&#44; vitamin K antagonists&#46;</p>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rosendaal method<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
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Vol. 218. Issue 5.
Pages 267-269 (June - July 2018)
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Vol. 218. Issue 5.
Pages 267-269 (June - July 2018)
Correspondence
Anticoagulation control in hospitalized patients with nonvalvular atrial fibrillation undergoing long-term oral anticoagulant therapy
Control de la anticoagulación en pacientes hospitalizados con fibrilación auricular no valvular en tratamiento crónico con anticoagulantes orales
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B. Batalla Insenser, U. Pertierra Uriel, A. Sánchez Biosca, J. Sobrino Martínez
Corresponding author
jsobrino@hes.scs.es

Corresponding author.
Servicio de Medicina Interna, Fundació Hospital de l’Esperit Sant, Santa Coloma de Gramenet (Barcelona), Spain
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Table 1. Time in therapeutic range and appropriate anticoagulation control before and during the hospitalization of patients with nonvalvular atrial fibrillation treated with vitamin K antagonists.

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¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?