Risks of Warfarin for Elders with Atrial Fibrillation

描述(申请人提供)：概述：本申请的目的是支持玛格丽特·C·方，医学博士，公共卫生硕士，加州大学旧金山分校(UCSF)接受过奖学金培训的学术住院医师，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中风预防。她将制定一项研究计划，探索与房颤相关的中风和出血的临床和生物风险因素，确定最佳使用抗凝剂以预防与房颤相关的中风，引导人们关注最佳抗凝剂管理的社会和行为障碍，并测试旨在改善与高龄患者抗凝相关的临床决策的干预措施。职业发展计划：方博士将接受正式的教学培训，并在5年的获奖期内进行临床指导研究。教学培训将包括结果评估、倾向得分分析、成本效益分析、遗传流行病学、功能状态评估以及老龄化社会学和生物学方面的课程和教程。她将通过参加加州大学旧金山分校的老年医学核心课程获得临床老年医学方面的培训。由加州大学旧金山分校老年病科主任、她的首席导师塞斯·兰德菲尔德博士领导的高级调查顾问委员会将监督方博士职业发展的方方面面。研究计划：本研究章节的目的是：(1)确定高龄对华法林控制和华法林不良结局的影响；(2)评估功能衰退、跌倒风险和认知障碍是否会导致华法林不良结局；以及(3)开发和中试一种决策工具，帮助临床医生比较老年房颤患者服用华法林的风险和益处。这些目标将通过3个项目实现。在项目1中，方博士将分析来自Atria队列的13559名房颤患者的数据，以确定华法林相关出血和华法林控制的特定年龄比率、风险因素和结果。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预后之间的关系。在项目3中，方博士将开发一个临床决策工具，结合前两项研究获得的数据，帮助临床医生为老年房颤患者决定最佳的抗血栓治疗选择。这一决策工具随后将在加州大学旧金山分校护理心房颤动患者的临床医生中进行试点测试。总而言之，这些项目将为未来的研究提供实践经验并形成基础，这些研究旨在改善最年长的房颤患者的安全性和抗凝剂的使用。

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.