DOAC benefits maintained in oldest AF, stroke patients

The favourable profile of direct oral anticoagulants (DOAC) over vitamin K antagonists (VKA) was maintained in the oldest patients with atrial fibrillation (AF) and recent stroke, a large observational study has confirmed.

The international research, published in the Annals of Neurology, looked at pooled individual patient data from seven prospective cohorts to investigate real-world performance of DOAC versus VKA in patients aged over 85 years with recent AF and stroke.

During 6,874 patient-years follow-up, the impact of DOAC versus VKA on the hazard for the composite outcome of recurrent stroke, intracranial haemorrhage (ICH) and all-cause death did not differ between patients aged more or less than 85 years (HR 0.65 versus 0.79, respectively).

Analyses on recurrent stroke, ICH and death separately were all consistent with findings of the primary analysis, as were sensitivity analyses using a higher age limit of 90 years as a continuous variable, the researchers said.

DOAC had “a similar net clinical benefit” (a balance of stroke reduction versus ICH risk) in patients aged 85 or over (+1.73 to +2.66) compared to those aged under 85 years (+1.90 to +3.36 events/100 patient-years for ICH-weights 1.5 to 3.1).

“The favourable profile of DOAC was maintained in the oldest old, whether defined as aged 85 or 90 years or older. This observation is highly relevant for clinical practice as it contradicts the assumptions of many clinicians who are reluctant to use DOAC in this age group, particularly in multimorbid patients,” the researchers noted.

“In this context, it is clinically important that the beneficial effect of DOAC over VKA persisted after taking into account the high-risk profile of the oldest old. Reassuringly, simple, adjusted, as well as weighted models which controlled for the non-randomised treatment assignment, all yielded consistent results.”

They also stressed that there was “no signal of a safety concern” regarding ICH risk among the oldest DOAC-treated patients with recent ischaemic stroke.

Jury still out on infection risk with IV iron

Concern about infectious complications of intravenous iron have not been resolved despite a major meta-analysis reviewing data from 40 000 patients in 162 clinical trials. The study found a significant increase in the risk of infections (relative risk, 1.17; 95% CI, 1.04-1.31) with IV iron. However, the authors said that much of the data on which they based their analysis were potentially bias, and infections were often poorly documented because the trials were focused on efficacy.

While there were biologically plausible mechanisms to suggest a link between iron and immune responses and infection risk, more conclusive evidence is required from randomised placebo controlled trials, a commentary in JAMA Network Open suggested

“For the present, clinicians should be cautious and defer IV iron therapy during acute infections,” it concluded.

Evidence backs ‘grow your own’ rural medical workforce

The first evidence has emerged to support a ‘grow your own’ rural workforce strategy of selecting doctors from and training them in specific rural regions that are underserviced by medical practitioners.

An analysis of data from more than 6627 doctors participating in the 2017 MABEL workforce survey showed that those who were selected and trained in a specific region of need were 17  more likely to continue working in the same rural region compared with doctors from cities and who spent only brief (< 12 week) duration in rural training.

The study also backed longer periods of rural training, showing that doctor were more than five times more likely to be retained in rural practice if they trained there for a year compared those who completed short periods of rural training.

“Reorienting medical training to selecting and training in specific rural regions where doctors are needed is likely to be an efficient means to correcting healthcare access inequalities,” the University of Queensland Rural Clinical School researchers said in the journal Human Resources for Health.