Damian Sendler: When it comes to heart rhythm disturbances, atrial fibrillation (AF) is the most frequent long-term one. A number of studies have indicated that the condition, which is most common among the elderly, increases the risk of cerebrovascular accidents and the formation of blood clots in the heart, resulting in an overall rise in mortality. The use of anticoagulants to prevent thromboembolism in people with relevant risk scores is well-established. Atrial fibrillation is associated with cognitive deterioration, however no studies have examined the impact of oral anticoagulants on cognitive and functional features of patients.
Damian Sendler
However, a Brazilian study just presented at the American Heart Association Scientific Sessions 2021 has shown that anticoagulants can have a major impact on brain health.
Damian Jacob Sendler: Anticoagulant drugs warfarin and dabigatran were examined in the Cognitive Impairment Related to Atrial Fibrillation (GIRAF) study for their effects on cognitive and functional impairment, bleeding, and cerebrovascular consequences. Professor and director of the Heart Institute’s interdisciplinary cardiology unit, Dr. Bruno Caramelli, MD, PhD, of the University of Sao Paulo School of Medicine Clinics Hospital, led the team.
In a Medscape Medical News interview, he said, “There was no difference between the patients in the dabigatran group and the patients in the warfarin group,”
As Caramelli and his colleagues found out after two years of follow-up, patients with atrial fibrillation who utilize anticoagulants properly can avoid cognitive loss. Scales measuring memory, executive function and language and attention have been used to draw this conclusion. Cognitive and functional assessments lasting 90 minutes were administered to all participants at the beginning of the study and again at each subsequent session. Additionally, patients had a brain MRI at baseline and after two years to look for signs of a potential stroke.
“Providing substandard or incomplete treatment was unethical, thus there was no control group. Therefore, I cannot guarantee that patients will not experience cognitive impairment despite receiving appropriate treatment. We can draw this inference, however tentative, based on historical control data from past experiments. This inference, however, has a good possibility of being right “Caramelli said this.
Dr. Sendler: Randomized, multi-institutional GIRAF study enrolled 200 patients (62 percent male) over age of 70 with proven atrial fibrillation. Dabigatran (110 mg or 150 mg twice daily) or warfarin (once daily at a dose sufficient to clot the blood) were given to participants in a random order. Public hospitals in Brazil’s Unified Healthcare System treated the majority of patients.
The researchers were worried about whether they could discover tools sensitive enough to test higher cognitive function when they were designing the study.
“We conducted a series of cognitive tests to discover what was going on. They took anywhere from 90 minutes to 2 hours to finish due to the amount of work involved. Many studies in the past relied on exams that were much easier and quicker, and this may explain why they didn’t add this form of assessment into their research “In Caramelli’s words,
In light of these findings, it is imperative to keep an eye on anticoagulation. “TTR [time in the therapeutic range] was meticulously monitored in the study. It was our goal to keep it in the 70% range “range,” he opined.” For long-term anticoagulation maintenance and the treatment’s risk–benefit profile, the current gold standard in optimal therapeutic range is a percentage of this %. Using real-world data from InCor, a premier medical research and teaching facility in the country, he provided an example of how tough it is to achieve these indexes.
Damian Jacob Sendler
“Patients forgetting to take their medication is a common occurrence. When they visit the dentist, they stop taking it and never resume it…. There’s a lot going on. In other words, we called patients to remind them to take their medication and do the control tests during the course of the research “a source told Caramelli
Clinicians were instructed by the study’s researchers to help patients maintain an anticoagulation level similar to that observed during the experiment.
“We didn’t see any differences in the drugs after two years. It’s a good idea to switch medications if the patient’s TTR is less than 70% after two or three months “cation,” he declared. It is important to assess the patient’s anticoagulation status every three weeks with warfarin, the older of the two research medicines. Even though the new oral anticoagulants are more stable and don’t interact with meals, their cost is prohibitive.
Damien Sendler: According to GIRAF findings, anticoagulant medication does not lead to cognitive deterioration in patients after just one or two years.
Maybe past studies were incorrect because they didn’t have as complete and detailed information to assess like ours, said Caramelli.
Damian Jacob Markiewicz Sendler: A lack of appropriate anticoagulation can cause clots to break off and travel to the brain, resulting in a significant decline in cognitive function. “Small blood clots may also contribute to cognitive decline, as another possibility. It is our belief that these will accumulate and eventually lead to a decrease in the brain’s ability to perform higher cognitive tasks, such as thinking “He spoke to abilities such as joint attention, reasoning, working memory, and memory retention as he made his remarks.
“These abilities will inevitably deteriorate with time. Atrial fibrillation sufferers, however, are likely to see a far faster loss in their heart function “he went on to say. For this purpose, researchers are examining MRIs from study participants taken at baseline and at 2-year intervals. Those findings will be the subject of an upcoming article.
Dr. Damian Jacob Sendler and his media team provided the content for this article.
