Risks of Warfarin for Elders with Atrial Fibrillation

简介（由申请人提供）：概述：本申请的目的是支持Margaret C. Fang，医学博士，公共卫生硕士，加州大学旧金山分校（UCSF）接受奖学金培训的学术医院医生的以患者为导向的研究计划和职业发展。方医生的总体职业目标是优化老年房颤患者的卒中预防。她将开发一个研究项目，探索与房颤相关的中风和出血的临床和生物学风险因素，确定抗凝药物的最佳使用，以预防房颤相关的中风，直接关注社会和行为障碍，以最佳抗凝管理，并测试干预措施，以改善临床决策，有关抗凝老年患者。职业发展规划：方博士将接受正式的教学培训，并在5年的奖励期内进行指导临床研究。教学培训将包括结果评估、倾向评分分析、成本效益分析、遗传流行病学、功能状态评估以及老龄化的社会学和生物学方面的课程和教程。她将通过参加UCSF核心老年医学课程获得临床老年医学培训。由加州大学旧金山分校老年病学主任和她的主要导师Seth landfield博士领导的高级调查人员咨询委员会将监督方博士职业发展的各个方面。研究计划：本研究申请的目的是：(1)确定高龄如何影响华法林控制和华法林不良后果；(2)评估功能下降、跌倒风险和认知障碍是否会导致华法林治疗的不良结果；(3)开发和试点测试一种决策工具，帮助临床医生比较老年心房颤动患者开华法林的风险和收益。这些目标将通过3个项目来实现。在项目1中，方博士将分析来自13559名心房颤动患者的心房颤动队列数据，以确定年龄特异性发生率、风险因素、华法林相关出血的结局和华法林控制。在项目2中，方博士将召集一群患有房颤的虚弱社区老年人，研究虚弱与华法林控制和结果之间的关系。在项目3中，方博士将开发一种临床决策工具，结合从前两项研究中获得的数据，以帮助临床医生决定老年房颤患者抗血栓治疗的最佳选择。该决策工具随后将在UCSF治疗房颤患者的临床医生中进行试点测试。总之，这些项目将提供实践经验，并为未来寻求提高抗凝剂在老年房颤患者中的安全性和使用的研究奠定基础。

DESCRIPTION (provided by applicant): OVERVIEW: The purpose of this application is to support the patient-oriented research program and career development of Margaret C. Fang, MD, MPH, a fellowship-trained academic hospitalist at the University of California, San Francisco (UCSF). Dr. Fang's overall career goal is to optimize stroke prevention in older patients with atrial fibrillation. She will develop a research program that will explore clinical and biological risk factors for stroke and hemorrhage associated with atrial fibrillation, identify the optimal use of anticoagulants to prevent atrial Fibrillation-related stroke, direct attention towards social and behavioral barriers to optimal anticoagulant management, and test interventions directed at improving clinical decision-making in regards to anticoagulating the oldest patients. CAREER DEVELOPMENT PLAN: Dr. Fang will undergo formal didactic training and conduct mentored clinical research over the 5 year award period. Didactic training will include coursework and tutorials in outcomes assessment, propensity score analysis, cost-effectiveness analysis, genetic epidemiology, functional status assessment, and the sociology and biology of aging. She will obtain training in clinical geriatrics through enrolling in the UCSF Core Geriatrics Curriculum. An advisory committee of senior investigators, led by Dr. Seth Landefeld, the Chief of Geriatrics at UCSF and her Principal Mentor, will oversee all aspects of Dr. Fang's career development. RESEARCH PLAN: The aims of this researchapplication are to (1) determine how advanced age affects warfarin control and poor outcomes from warfarin; (2) assess whether functional decline, fall-risk, and cognitive impairment lead to worse outcomes on warfarin; and (3) develop and pilot test a decision tool that helps Clinicians compare the risks and benefits of prescribing warfarin for older patients with atrial fibrillation. These aims will be accomplished through 3 projects. In Project 1, Dr. Fang will analyze data from the ATRIA cohort of 13,559 people with atrial fibrillation to determine age-specific rates, risk factors, and outcomes of warfarin-associated hemorrhage and warfarin control. In Project 2, Dr. Fang will assemble a cohort of frail community-dwelling elders with atrial fibrillation to study how frailty is associated with warfarin control and outcomes. In Project 3, Dr. Fang will develop a clinical decision tool, incorporating data obtained from the first two studies, to assist clinicians decide on the optimal choice of antithrombotic therapy for older patients with atrial fibrillation. This decision tool will then be pilot tested among clinicians caring for patients with atrial fibrillation at UCSF. Together, these projects will provide practical experience and form the basis for future studies that seek to improve the safety and use of anticoagulants in the oldest patients with atrial fibrillation.