51
|
Baugh CW, Clark CL, Wilson JW, Stiell IG, Kocheril AG, Luck KK, Myers TD, Pollack CV, Roumpf SK, Tomassoni GF, Williams JM, Patel BB, Wu F, Pines JM. Creation and Implementation of an Outpatient Pathway for Atrial Fibrillation in the Emergency Department Setting: Results of an Expert Panel. Acad Emerg Med 2018. [PMID: 29524340 DOI: 10.1111/acem.13410] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Atrial fibrillation and flutter (AF) is a common condition among emergency department (ED) patients in the United States. Traditionally, ED care for primary complaints related to AF focus on rate control, and patients are often admitted to an inpatient setting for further care. Inpatient care may include further telemetry monitoring and diagnostic testing, rhythm control, a search for identification of AF etiology, and stroke prophylaxis. However, many patients are eligible for safe and effective outpatient management pathways. They are widely used in Canada and other countries but less widely adopted in the United States. In this project, we convened an expert panel to create a practical framework for the process of creating, implementing, and maintaining an outpatient AF pathway for emergency physicians to assess and treat AF patients, safely reduce hospitalization rates, ensure appropriate stroke prophylaxis, and effectively transition patients to longitudinal outpatient treatment settings from the ED and/or observation unit. To support local pathway creation, the panel also reached agreement on a protocol development plan, a sample pathway, consensus recommendations for pathway components, sample pathway metrics, and a structured literature review framework using a modified Delphi technique by a technical expert panel of emergency medicine, cardiology, and other stakeholder groups.
Collapse
Affiliation(s)
| | - Carol L. Clark
- Department of Emergency Medicine Beaumont Health System Royal Oak MI
| | - Jason W. Wilson
- Department of Emergency Medicine Tampa General Hospital Tampa FL
| | - Ian G. Stiell
- Department of Emergency Medicine University of Ottawa Ottawa Hospital Research Institute Ottawa OntarioCanada
| | - Abraham G. Kocheril
- Department of Cardiology Presence Medical Group and University of Illinois Urbana IL
| | | | - Troy D. Myers
- Department of Emergency Medicine CarolinaEast Medical Center New Bern NC
| | - Charles V. Pollack
- Department of Emergency Medicine Thomas Jefferson University Philadelphia PA
| | - Steven K. Roumpf
- Department of Emergency Medicine Indiana University Health IndianapolisIN
| | | | | | - Brian B. Patel
- Department of Emergency Medicine Sturdy Memorial Hospital Attleboro MA
| | - Fred Wu
- Department of Emergency Medicine UCSF Fresno Fresno CA
| | - Jesse M. Pines
- Department of Emergency Medicine George Washington University School of Medicine and Health Sciences Washington DC
| |
Collapse
|
52
|
Lane DA, Meyerhoff J, Rohner U, Lip GYH. Patients' Perceptions of Atrial Fibrillation, Stroke Risk, and Oral Anticoagulation Treatment: An International Survey. TH OPEN 2018; 2:e233-e241. [PMID: 31249947 PMCID: PMC6524879 DOI: 10.1055/s-0038-1666803] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/22/2018] [Indexed: 12/27/2022] Open
Abstract
Background Global differences exist in the management of atrial fibrillation (AF), and cultural differences may influence patients' expectations and perceptions of healthcare. This survey investigated whether country-specific differences in patients' perceptions of AF and oral anticoagulation (OAC) exist and if recent stroke influences these perceptions. Methods Cross-sectional survey of 937 adults with nonvalvular AF receiving OAC for stroke prevention was conducted across United States, Canada, Germany, France, and Japan. Thirty-minute online interviews conducted between April and November 2015 included AF patients with recent stroke, and newly diagnosed AF and established AF, both without recent stroke. Results U.S. patients and those with recent stroke perceived AF as more serious (54.0 and 55.2%, respectively) and were more concerned about stroke (50.0 and 68.0%, respectively). Japanese patients were more likely to perceive AF as not serious (41.0%), but 50.4% were frequently concerned about stroke. Patients in the United States, Canada, and Germany and those without recent stroke preferred to be involved in OAC treatment decisions (either shared decision making or patient's choice), while French and Japanese patients and those with recent stroke preferred their doctor to choose. For all country groups, stroke prevention was the most important factor when choosing OAC. Conclusion In this international cohort of AF patients, country-specific differences exist in patients' perceptions of AF, concerns about stroke, and preference for involvement in OAC treatment decisions; recent experience of stroke significantly influenced patients' values and preferences regarding AF and treatment. Stroke prevention was rated as the most important factor when choosing OAC treatment.
Collapse
Affiliation(s)
- Deirdre A Lane
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Juliane Meyerhoff
- Boehringer Ingelheim Pharma International GmbH, Ingelheim am Rhein, Germany
| | - Ute Rohner
- Boehringer Ingelheim Pharma International GmbH, Ingelheim am Rhein, Germany
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| |
Collapse
|
53
|
Magnani JW, Mujahid MS, Aronow HD, Cené CW, Dickson VV, Havranek E, Morgenstern LB, Paasche-Orlow MK, Pollak A, Willey JZ. Health Literacy and Cardiovascular Disease: Fundamental Relevance to Primary and Secondary Prevention: A Scientific Statement From the American Heart Association. Circulation 2018; 138:e48-e74. [PMID: 29866648 PMCID: PMC6380187 DOI: 10.1161/cir.0000000000000579] [Citation(s) in RCA: 237] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Health literacy is the degree to which individuals are able to access and process basic health information and services and thereby participate in health-related decisions. Limited health literacy is highly prevalent in the United States and is strongly associated with patient morbidity, mortality, healthcare use, and costs. The objectives of this American Heart Association scientific statement are (1) to summarize the relevance of health literacy to cardiovascular health; (2) to present the adverse associations of health literacy with cardiovascular risk factors, conditions, and treatments; (3) to suggest strategies that address barriers imposed by limited health literacy on the management and prevention of cardiovascular disease; (4) to demonstrate the contributions of health literacy to health disparities, given its association with social determinants of health; and (5) to propose future directions for how health literacy can be integrated into the American Heart Association's mandate to advance cardiovascular treatment and research, thereby improving patient care and public health. Inadequate health literacy is a barrier to the American Heart Association meeting its 2020 Impact Goals, and this statement articulates the rationale to anticipate and address the adverse cardiovascular effects associated with health literacy.
Collapse
|
54
|
Stephan LS, Almeida ED, Guimarães RB, Ley AG, Mathias RG, Assis MV, Leiria TLL. Oral Anticoagulation in Atrial Fibrillation: Development and Evaluation of a Mobile Health Application to Support Shared Decision-Making. Arq Bras Cardiol 2018; 110:7-15. [PMID: 29412241 PMCID: PMC5831296 DOI: 10.5935/abc.20170181] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 08/29/2017] [Indexed: 12/13/2022] Open
Abstract
Background Atrial fibrillation is responsible for one in four strokes, which may be
prevented by oral anticoagulation, an underused therapy around the world.
Considering the challenges imposed by this sort of treatment, mobile health
support for shared decision-making may improve patients’ knowledge and
optimize the decisional process. Objective To develop and evaluate a mobile application to support shared decision about
thromboembolic prophylaxis in atrial fibrillation. Methods We developed an application to be used during the clinical visit, including a
video about atrial fibrillation, risk calculators, explanatory graphics and
information on the drugs available for treatment. In the pilot phase, 30
patients interacted with the application, which was evaluated qualitatively
and by a disease knowledge questionnaire and a decisional conflict
scale. Results The number of correct answers in the questionnaire about the disease was
significantly higher after the interaction with the application (from 4.7
± 1.8 to 7.2 ± 1.0, p < 0.001). The decisional conflict
scale, administered after selecting the therapy with the app support,
resulted in an average of 11 ± 16/100 points, indicating a low
decisional conflict. Conclusions The use of a mobile application during medical visits on anticoagulation in
atrial fibrillation improves disease knowledge, enabling a shared decision
with low decisional conflict. Further studies are needed to confirm if this
finding can be translated into clinical benefit.
Collapse
Affiliation(s)
- Laura Siga Stephan
- Instituto de Cardiologia - Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Eduardo Dytz Almeida
- Instituto de Cardiologia - Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Raphael Boesche Guimarães
- Instituto de Cardiologia - Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Antonio Gaudie Ley
- Instituto de Cardiologia - Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Rodrigo Gonçalves Mathias
- Instituto de Cardiologia - Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Maria Valéria Assis
- Instituto de Cardiologia - Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Tiago Luiz Luz Leiria
- Instituto de Cardiologia - Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| |
Collapse
|
55
|
Kotecha D, Chua WWL, Fabritz L, Hendriks J, Casadei B, Schotten U, Vardas P, Heidbuchel H, Dean V, Kirchhof P. European Society of Cardiology smartphone and tablet applications for patients with atrial fibrillation and their health care providers. Europace 2018; 20:225-233. [PMID: 29040548 PMCID: PMC5834097 DOI: 10.1093/europace/eux299] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 09/02/2017] [Indexed: 01/02/2023] Open
Abstract
We are in the midst of a digital revolution in health care, although the application of new and useful technology in routine clinical practice is variable. The Characterizing Atrial fibrillation by Translating its Causes into Health Modifiers in the Elderly (CATCH ME) Consortium, in collaboration with the European Society of Cardiology (ESC), has funded the creation of two applications (apps) in atrial fibrillation (AF) for use in smartphones and tablets. The patient app aims to enhance patient education, improve communication between patients and health care professionals, and encourage active patient involvement in the management of their condition. The health care professional app is designed as an interactive management tool incorporating the new ESC Practice Guidelines on AF and supported by the European Heart Rhythm Association (EHRA), with the aim of improving best practice approaches for the care of patients with AF. Both stand-alone apps are now freely available for Android and iOS devices though the Google Play, Amazon, and Apple stores. In this article, we outline the rationale for the design and implementation of these apps. Our objective is to demonstrate the value of integrating novel digital technology into clinical practice, with the potential for patient engagement, optimization of pharmacological and interventional therapy in AF, and ultimately to improve patient outcomes.
Collapse
Affiliation(s)
- Dipak Kotecha
- University of Birmingham Institute of Cardiovascular Sciences, The Medical School, Vincent Drive, Edgbaston, Birmingham, B15 2TT, UK
- Cardiology Department, University Hospitals Birmingham NHS Trust and Sandwell & West Birmingham Hospitals NHS Trust, Birmingham, UK
- Corresponding author. Tel: +44 121 371 8122; fax: +44 121 371 4175. E-mail address:
| | - Winnie W L Chua
- University of Birmingham Institute of Cardiovascular Sciences, The Medical School, Vincent Drive, Edgbaston, Birmingham, B15 2TT, UK
| | - Larissa Fabritz
- University of Birmingham Institute of Cardiovascular Sciences, The Medical School, Vincent Drive, Edgbaston, Birmingham, B15 2TT, UK
- Cardiology Department, University Hospitals Birmingham NHS Trust and Sandwell & West Birmingham Hospitals NHS Trust, Birmingham, UK
- Department of Cardiovascular Medicine, University Hospital Muenster, Germany
| | - Jeroen Hendriks
- Centre for Heart Rhythm Disorders, University of Adelaide, Australia
- Department of Medical and Health Sciences, University of Linköping, Sweden
| | - Barbara Casadei
- Division of Cardiovascular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Ulrich Schotten
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre+ and Maastricht Centre for Systems Biology, Maastricht, The Netherlands
| | - Panos Vardas
- Cardiology Department, University Hospital of Heraklion, Crete, Greece
| | - Hein Heidbuchel
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
| | - Veronica Dean
- European Society of Cardiology, Sophia-Antipolis, France
| | - Paulus Kirchhof
- University of Birmingham Institute of Cardiovascular Sciences, The Medical School, Vincent Drive, Edgbaston, Birmingham, B15 2TT, UK
- Cardiology Department, University Hospitals Birmingham NHS Trust and Sandwell & West Birmingham Hospitals NHS Trust, Birmingham, UK
- Department of Cardiovascular Medicine, University Hospital Muenster, Germany
| | | |
Collapse
|
56
|
Granger Causality and Jensen-Shannon Divergence to Determine Dominant Atrial Area in Atrial Fibrillation. ENTROPY 2018; 20:e20010057. [PMID: 33265143 PMCID: PMC7512253 DOI: 10.3390/e20010057] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 12/27/2017] [Accepted: 01/05/2018] [Indexed: 01/08/2023]
Abstract
Atrial fibrillation (AF) is already the most commonly occurring arrhythmia. Catheter pulmonary vein ablation has emerged as a treatment that is able to make the arrhythmia disappear; nevertheless, recurrence to arrhythmia is very frequent. In this study, it is proposed to perform an analysis of the electrical signals recorded from bipolar catheters at three locations, pulmonary veins and the right and left atria, before to and during the ablation procedure. Principal Component Analysis (PCA) was applied to reduce data dimension and Granger causality and divergence techniques were applied to analyse connectivity along the atria, in three main regions: pulmonary veins, left atrium (LA) and right atrium (RA). The results showed that, before the procedure, patients with recurrence in the arrhythmia had greater connectivity between atrial areas. Moreover, during the ablation procedure, in patients with recurrence in the arrhythmial both atria were more connected than in patients that maintained sinus rhythms. These results can be helpful for procedures designing to end AF.
Collapse
|
57
|
|
58
|
Kirchhof P. The future of atrial fibrillation management: integrated care and stratified therapy. Lancet 2017; 390:1873-1887. [PMID: 28460828 DOI: 10.1016/s0140-6736(17)31072-3] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 02/20/2017] [Accepted: 03/10/2017] [Indexed: 02/06/2023]
Abstract
Atrial fibrillation is one of the major cardiovascular health problems: it is a common, chronic condition, affecting 2-3% of the population in Europe and the USA and requiring 1-3% of health-care expenditure as a result of stroke, sudden death, heart failure, unplanned hospital admissions, and other complications. Early diagnosis of atrial fibrillation, ideally before the first complication occurs, remains a challenge, as shown by patients who are only diagnosed with the condition when admitted to hospital for acute cardiac decompensation or stroke. Once diagnosed, atrial fibrillation requires chronic, multidimensional management in five domains (acute management, treatment of underlying and concomitant cardiovascular conditions, stroke prevention therapy, rate control, and rhythm control). The consistent provision of these treatment options to all patients with atrial fibrillation is difficult, despite recent improvements in organisation of care, knowledge about atrial fibrillation, and treatment options. Integrated care models that provide patient-centred care in, or close to, the patient's community while maintaining access to all specialist treatment options, emerge as the best approach to achieve consistent delivery of these chronic treatments to all patients with atrial fibrillation. Ongoing research efforts will establish when to initiate oral anticoagulation in patients with device-detected atrial high-rate episodes, quantify the prognostic effect of early and comprehensive rhythm control therapy, including atrial fibrillation ablation, and delineate optimum methods to reduce bleeding complications in patients treated with anticoagulation. Additionally, research efforts are needed to define different types of atrial fibrillation on the basis of the main causes of atrial fibrillation to pave the way for the clinical development of stratified atrial fibrillation therapy.
Collapse
Affiliation(s)
- Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK; Sandwell and West Birmingham Hospitals NHS Trust and University Hospitals Birmingham NHS Foundation NHS Trust, Birmingham, UK; Atrial Fibrillation NETwork, Münster, Germany.
| |
Collapse
|
59
|
Goldstein LB. Anticoagulation in Patients With Atrial Fibrillation in the Setting of Prior Hemorrhage. Stroke 2017; 48:2654-2659. [DOI: 10.1161/strokeaha.117.017082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 06/12/2017] [Accepted: 06/13/2017] [Indexed: 01/15/2023]
|
60
|
Kunneman M, Branda ME, Noseworthy PA, Linzer M, Burnett B, Dick S, Spencer-Bonilla G, Fernandez CA, Gorr H, Wambua M, Keune S, Zeballos-Palacios C, Hargraves I, Shah ND, Montori VM. Shared decision making for stroke prevention in atrial fibrillation: study protocol for a randomized controlled trial. Trials 2017; 18:443. [PMID: 28962662 PMCID: PMC5622521 DOI: 10.1186/s13063-017-2178-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 09/05/2017] [Indexed: 11/21/2022] Open
Abstract
Background Nonvalvular atrial fibrillation (AF) is a common ongoing health problem that places patients at risk of stroke. Whether and how a patient addresses this risk depends on each patient’s goals, context, and values. Consequently, leading cardiovascular societies recommend using shared decision making (SDM) to individualize antithrombotic treatment in patients with AF. The aim of this study is to assess the extent to which the Anticoagulation Choice conversation tool promotes high-quality SDM and influences anticoagulation uptake and adherence in patients with AF at risk of strokes. Methods This study protocol describes a multicenter, encounter-level, randomized trial to assess the effect of using the Anticoagulation Choice conversation tool in the clinical encounter, compared to usual care. The participating centers include an academic hospital system, a suburban community group practice, and an urban safety net hospital, all in Minnesota, USA. Patients with ongoing nonvalvular AF at risk of strokes (CHA2DS2-VASc score ≥ 1 in men, or ≥ 2 in women) will be eligible for participation. We aim to include 999 patients and their clinicians. The primary outcome is the quality of SDM as perceived by participants, and as assessed by a post-encounter survey that ascertains (a) knowledge transfer, (b) concordance of the decision made, (c) quality of communication, and (d) satisfaction with the decision-making process. Recordings of encounters will be reviewed to assess the extent of patient involvement and how participants use the tool (fidelity). Anticoagulant use, choice of agent, and adherence will be drawn from patients’ medical and pharmacy records. Strokes and bleeding events will be drawn from patient records. Discussion This study will provide a valid and precise measure of the effect of the Anticoagulation Choice conversation tool on SDM quality and processes, and on the treatment choices and adherence to therapy among AF patients at risk of stroke. Trial registration ClinicalTrials.gov, NCT02905032. Registered on 9 September 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2178-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Marleen Kunneman
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Megan E Branda
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Health Services Research, Mayo Clinic, Rochester, MN, USA
| | - Peter A Noseworthy
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Heart Rhythm Section, Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mark Linzer
- Division of General Internal Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Bruce Burnett
- Thrombosis Clinic and Anticoagulation Services, Park Nicollet Health Services, St Louis Park, MN, USA
| | - Sara Dick
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Gabriela Spencer-Bonilla
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,School of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, USA
| | - Cara A Fernandez
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Haeshik Gorr
- Division of General Internal Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Mike Wambua
- Division of General Internal Medicine, Hennepin County Medical Center, Minneapolis, MN, USA.,University of Minnesota and Minneapolis Medical Research Foundation, Minneapolis, MN, USA
| | - Shelly Keune
- Thrombosis Clinic and Anticoagulation Services, Park Nicollet Health Services, St Louis Park, MN, USA
| | - Claudia Zeballos-Palacios
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ian Hargraves
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Nilay D Shah
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Division of Health Care and Policy Research, Mayo Clinic, Rochester, MN, USA
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| |
Collapse
|
61
|
O'Neill ES, Grande SW, Sherman A, Elwyn G, Coylewright M. Availability of patient decision aids for stroke prevention in atrial fibrillation: A systematic review. Am Heart J 2017; 191:1-11. [PMID: 28888264 DOI: 10.1016/j.ahj.2017.05.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 05/28/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND Atrial fibrillation is a common irregular heart rhythm that increases patients' risk of stroke. Aspirin, warfarin, direct oral anticoagulants, and an implantable device can reduce this risk. Given the availability of multiple comparable options, this decision depends on patient preferences and is appropriate for the use of decision aids and other efforts to promote shared decision making. The objective of this review was to examine the existence and accessibility of, as well as select outcomes associated with, published, formally evaluated patient decision aids for stroke prevention in atrial fibrillation. METHODS Six databases were searched from inception to March 2016 with a research librarian. Two authors independently reviewed potential articles, selected trials meeting inclusion criteria, and assessed outcome measures. Outcomes included patient knowledge, involvement, choice, and decisional conflict. RESULTS The search resulted in 666 articles; most were excluded for not examining stroke prevention in atrial fibrillation and 7 studies were eventually included. Six decision aids displayed combinations of aspirin, warfarin, or no therapy; 1 included a direct oral anticoagulant. Interventions were associated with increased patient knowledge, increased likelihood of making a choice, and low decisional conflict. Use of decision aids in this review was associated with less selection of warfarin. None of the tested decision aids are currently available. DISCUSSION Published patient decision aids for stroke prevention in atrial fibrillation are not accessible for clinical use. Given the availability of multiple comparable options, there is a need to develop and test new patient decision aids in this context.
Collapse
|
62
|
Russo-Alvarez G, Martinez KA, Valente M, Bena J, Hu B, Luxenburg J, Chaitoff A, Ituarte C, Brateanu A, Rothberg MB. Thromboembolic and Major Bleeding Events With Rivaroxaban Versus Warfarin Use in a Real-World Setting. Ann Pharmacother 2017; 52:19-25. [DOI: 10.1177/1060028017727290] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background: Although randomized trials demonstrate the noninferiority of rivaroxaban compared with warfarin in the context of nonvalvular atrial fibrillation (AF), little is known about how these drugs compare in practice. Objective: To assess the relative effectiveness and safety of rivaroxaban versus warfarin in a large health system and to evaluate this association by time in therapeutic range (TTR). Methods: We conducted a retrospective cohort study with propensity matching in the Cleveland Clinic Health System. The study included patients initiated on warfarin or rivaroxaban for thromboembolic prevention in nonvalvular AF between January 2012 and July 2016. The main outcomes were thromboembolic events and major bleeds. Analyses were stratified by warfarin patients’ TTR. Results: The cohort consisted of 472 propensity-matched pairs. The mean age was 73.6 years (SD = 11.7), and the mean CHADS2 score was 1.8. The median TTR for warfarin patients was 64%. In the propensity-matched analysis, there was no significant difference in thromboembolic or major bleeding events between groups. Among warfarin patients with a TTR <64% and their matched rivaroxaban pairs, there was also no significant difference in thromboembolic or major bleeding events. Conclusions: Under real-world conditions, warfarin and rivaroxaban were associated with similar safety and effectiveness, even among those with suboptimal therapeutic control. Individualized decision making, taking into account the nontherapeutic tradeoffs associated with these medications (eg, monitoring, half-life, cost) is warranted.
Collapse
Affiliation(s)
| | | | | | - James Bena
- Cleveland Clinic Health System, Cleveland, OH, USA
| | - Bo Hu
- Cleveland Clinic Health System, Cleveland, OH, USA
| | | | | | | | | | | |
Collapse
|
63
|
Armstrong MJ. Shared decision-making in stroke: an evolving approach to improved patient care. Stroke Vasc Neurol 2017; 2:84-87. [PMID: 28959495 PMCID: PMC5600016 DOI: 10.1136/svn-2017-000081] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 03/10/2017] [Indexed: 11/21/2022] Open
Abstract
Shared decision-making (SDM) occurs when patients, families and clinicians consider patients' values and preferences alongside the best medical evidence and partner to make the best decision for a given patient in a specific scenario. SDM is increasingly promoted within Western contexts and is also being explored outside such settings, including in China. SDM and tools to promote SDM can improve patients' knowledge/understanding, participation in the decision-making process, satisfaction and trust in the healthcare team. SDM has also proposed long-term benefits to patients, clinicians, organisations and healthcare systems. To successfully perform SDM, clinicians must know their patients' values and goals and the evidence underlying different diagnostic and treatment options. This is relevant for decisions throughout stroke care, from thrombolysis to goals of care, diagnostic assessments, rehabilitation strategies, and secondary stroke prevention. Various physician, patient, family, cultural and system barriers to SDM exist. Strategies to overcome these barriers and facilitate SDM include clinician motivation, patient participation, adequate time and tools to support the process, such as decision aids. Although research about SDM in stroke care is lacking, decision aids are available for select decisions, such as anticoagulation for stroke prevention in atrial fibrillation. Future research is needed regarding both cultural aspects of successful SDM and application of SDM to stroke-specific contexts.
Collapse
Affiliation(s)
- Melissa J Armstrong
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, USA
| |
Collapse
|
64
|
Clarkesmith DE, Lip GYH, Lane DA. Patients' experiences of atrial fibrillation and non-vitamin K antagonist oral anticoagulants (NOACs), and their educational needs: A qualitative study. Thromb Res 2017; 153:19-27. [PMID: 28314139 DOI: 10.1016/j.thromres.2017.03.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 02/27/2017] [Accepted: 03/06/2017] [Indexed: 12/11/2022]
Abstract
PURPOSE Qualitative research on atrial fibrillation (AF) patient's experiences and perceptions of taking the non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention is limited. This study explores patients' experiences of dabigatran and their recommendations for development of educational materials. PATIENTS AND METHODS Semi-structured individual interviews with 8 warfarin-naive and 8 warfarin-experienced AF patients, using qualitative deductive thematic analysis. RESULTS The four main overarching themes included: understanding the diagnosis; reaching a treatment decision; challenges of living with OAC; and patient perceptions of treatment. Patients discussed their shock of diagnosis, and seeking information and support at that time. Narratives suggest patients preferred to be led by the doctor when making treatment decisions, and would often compare dabigatran to warfarin. Patients reported side-effects and challenges with both treatment options, and discussed their beliefs surrounding medications, including misconceptions. In addition to the original framework, two further themes were added: challenges of living with AF, and patient recommendations. Generally patients found AF symptoms distressing, which impacted their quality of life. Patient recommendations included the content and delivery of educational materials and development of tools to help with their understanding of AF and anticoagulation, as well as treatment adherence and anxiety surrounding symptoms and side effects. CONCLUSION Patient recommendations emphasised the need for interventions to relieve anxiety surrounding the diagnosis and possible treatment side effects. Tailored 'disease-specific' support is essential to ensure efficacious treatment. This qualitative study highlights the need for patient involvement in the development of educational materials and resources for patients commencing treatment with NOACs.
Collapse
Affiliation(s)
- Danielle E Clarkesmith
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Dudley Road, Birmingham B18 7QH, United Kingdom
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Dudley Road, Birmingham B18 7QH, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deirdre A Lane
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Dudley Road, Birmingham B18 7QH, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| |
Collapse
|
65
|
Cerasuolo JO, Montero-Odasso M, Ibañez A, Doocy S, Lip GYH, Sposato LA. Decision-making interventions to stop the global atrial fibrillation-related stroke tsunami. Int J Stroke 2017; 12:222-228. [DOI: 10.1177/1747493016687579] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Atrial fibrillation affects 33.5 million people worldwide and its prevalence is expected to double by 2050 because of the aging population. Atrial fibrillation confers a 5-fold higher risk of ischemic stroke compared to sinus rhythm. We present our view of the role of shared medical decision-making to combat global underutilization of oral anticoagulation for stroke prevention in atrial fibrillation patients. Oral anticoagulation underuse is widespread as it is present within atrial fibrillation patients of all risk strata and in countries across all income levels. Reasons for oral anticoagulation underuse include but are probably not limited to poor risk stratification, over-interpretation of contraindications, and discordance between physician prescription preferences and actual administration. By comparing a catastrophic event to the consequences of atrial fibrillation related strokes, it may help physicians and patients understand the negative outcomes associated with oral anticoagulation under-utilization and the magnitude to which oral anticoagulations neutralize atrial fibrillation burden.
Collapse
Affiliation(s)
- Joshua O Cerasuolo
- Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Manuel Montero-Odasso
- Gait and Brain Lab, Parkwood Hospital and Lawson Health Research Institute, London, ON, Canada
- Department of Medicine, Division of Geriatric Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Department of Epidemiology & Biostatistics, Schulich Interfaculty Program in Public Health, Western University, London, ON, Canada
| | - Agustin Ibañez
- Institute of Cognitive and Translational Neuroscience (INCyT), INECO Foundation, Favaloro University, National Scientific and Technical Research Council, Buenos Aires, Argentina
- Center for Social and Cognitive Neuroscience (CSCN), School of Psychology, Universidad Adolfo Ibanez, Santiago de Chile, Chile
- Centre of Excellence in Cognition and its Disorders, Australian Research Council (ARC), New South Wales, Australia
- Universidad Autónoma del Caribe, Barranquilla, Colombia
| | - Shannon Doocy
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Gregory YH Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Luciano A Sposato
- Department of Clinical Neurological Sciences, Department of Anatomy and Cell Biology, London Health Sciences Centre, Western University, London, ON, Canada
- London Stroke, Dementia & Heart Disease Laboratory, Western University, London, ON, Canada
| |
Collapse
|
66
|
Wang SV, Rogers JR, Jin Y, Bates DW, Fischer MA. Use of electronic healthcare records to identify complex patients with atrial fibrillation for targeted intervention. J Am Med Inform Assoc 2017; 24:339-344. [PMID: 27375290 PMCID: PMC7651901 DOI: 10.1093/jamia/ocw082] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 04/07/2016] [Accepted: 04/19/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Practice guidelines recommend anticoagulation therapy for patients with atrial fibrillation (AF) who have other risk factors putting them at an elevated risk of stroke. These patients remain undertreated, but, with increasing use of electronic healthcare records (EHRs), it may be possible to identify candidates for treatment. OBJECTIVE To test algorithms for identifying AF patients who also have known risk factors for stroke and major bleeding using EHR data. MATERIALS AND METHODS We evaluated the performance of algorithms using EHR data from the Partners Healthcare System at identifying AF patients and 16 additional conditions that are risk factors in the CHA 2 DS 2 -VASc and HAS-BLED risk scores for stroke and major bleeding. Algorithms were based on information contained in problem lists, billing codes, laboratory data, prescription data, vital status, and clinical notes. The performance of candidate algorithms in 1000 bootstrap resamples was compared to a gold standard of manual chart review by experienced resident physicians. RESULTS : Physicians reviewed 480 patient charts. For 11 conditions, the median positive predictive value (PPV) of the EHR-derived algorithms was greater than 0.90. Although the PPV for some risk factors was poor, the median PPV for identifying patients with a CHA 2 DS 2 -VASc score ≥2 or a HAS-BLED score ≥3 was 1.00 and 0.92, respectively. DISCUSSION We developed and tested a set of algorithms to identify AF patients and known risk factors for stroke and major bleeding using EHR data. Algorithms such as these can be built into EHR systems to facilitate informed decision making and help shift population health management efforts towards patients with the greatest need.
Collapse
Affiliation(s)
- Shirley V Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - James R Rogers
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Yinzhu Jin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - David W Bates
- Division of General Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael A Fischer
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| |
Collapse
|
67
|
Virdee MS, Stewart D. Optimizing the use of oral anticoagulant therapy for atrial fibrilation in primary care: a pharmacist-led intervention. Int J Clin Pharm 2017; 39:173-180. [DOI: 10.1007/s11096-016-0419-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 12/21/2016] [Indexed: 12/30/2022]
|
68
|
Aronis KN, Edgar B, Lin W, Martins MAP, Paasche-Orlow MK, Magnani JW. Health Literacy and Atrial Fibrillation: Relevance and Future Directions for Patient-centred Care. Eur Cardiol 2017; 12:52-7. [PMID: 28936235 PMCID: PMC5603910 DOI: 10.15420/ecr.2017:2:2] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Atrial fibrillation (AF) is a common cardiac arrhythmia with significant clinical outcomes, and is associated with high medical and social costs. AF is complicated for patients because of its specialised terminology, long-term adherence, symptom monitoring, referral to specialty care, array of potential interventions and potential for adversity. Health literacy is a frequently under-recognised, yet fundamental, component towards successful care in AF. Health literacy is defined as the capacity to obtain, process and understand health information, and has had markedly limited study in AF. However, health literacy could contribute to how patients interpret symptoms, navigate care, and participate in treatment evaluation and decision-making. This review aims to summarise the clinical importance and essential relevance of health literacy in AF. We focus here on central aspects of AF care that are most related to self-care, including understanding the symptoms of AF, shared decision-making, adherence and anticoagulation for stroke prevention. We discuss opportunities to enhance AF care based on findings from the literature on health literacy, and identify important gaps. Our overall objective is to articulate the importance and relevance of integrating health literacy in the care of individuals with AF.
Collapse
Affiliation(s)
| | - Brittany Edgar
- Columbia University School of Nursing, Columbia University, New York, NY, USA
| | - Wendy Lin
- Boston University School of Medicine, Boston University, Boston, MA, USA
| | | | | | - Jared W Magnani
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
69
|
Hospital-level variation and predictors of admission after ED visits for atrial fibrillation: 2006 to 2011. Am J Emerg Med 2016; 34:2094-2100. [DOI: 10.1016/j.ajem.2016.07.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 07/14/2016] [Accepted: 07/15/2016] [Indexed: 12/20/2022] Open
|
70
|
Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:2893-2962. [PMID: 27567408 DOI: 10.1093/eurheartj/ehw210] [Citation(s) in RCA: 4752] [Impact Index Per Article: 594.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
|
71
|
Pandya E, Bajorek BV. Assessment of Web-based education resources informing patients about stroke prevention in atrial fibrillation. J Clin Pharm Ther 2016; 41:667-676. [DOI: 10.1111/jcpt.12446] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 08/11/2016] [Indexed: 01/20/2023]
Affiliation(s)
- E. Pandya
- Graduate School of Health - Discipline of Pharmacy; University of Technology; Sydney NSW Australia
| | - B. V. Bajorek
- Graduate School of Health - Discipline of Pharmacy; University of Technology; Sydney NSW Australia
| |
Collapse
|
72
|
Singh M, Bhatt DL, Stone GW, Rihal CS, Gersh BJ, Lennon RJ, Narula J, Fuster V. Antithrombotic Approaches in Acute Coronary Syndromes: Optimizing Benefit vs Bleeding Risks. Mayo Clin Proc 2016; 91:1413-1447. [PMID: 27712639 DOI: 10.1016/j.mayocp.2016.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 06/14/2016] [Accepted: 06/23/2016] [Indexed: 01/06/2023]
Abstract
It is estimated that in the United States, each year, approximately 620,000 persons will experience an acute coronary syndrome and approximately 70% of these will have non-ST-elevation acute coronary syndrome. Cardiovascular disease still accounts for 1 of every 3 deaths in the United States, and there is an urgent need to improve the prognosis of patients presenting with acute coronary syndrome. Cardiovascular mortality and ischemic complications are common after acute coronary syndrome, and the advent of newer antithrombotic therapies has reduced ischemic complications, but at the expense of greater bleeding. The new antithrombotic agents also raise the challenge of choosing between multiple potential therapeutic combinations to minimize recurrent ischemia without a concomitant increase in bleeding, a decision that often varies according to an individual patient's relative propensity for ischemia versus hemorrhage. In this review, we will synthesize the available information to arm health care providers with the contemporary knowledge on antithrombotic therapy and individualize treatment decisions.
Collapse
Affiliation(s)
- Mandeep Singh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - Gregg W Stone
- Columbia University Medical Center, New York Presbyterian Hospital, and the Cardiovascular Research Foundation, New York, NY
| | | | - Bernard J Gersh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Ryan J Lennon
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Jagat Narula
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | |
Collapse
|
73
|
Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg 2016; 50:e1-e88. [DOI: 10.1093/ejcts/ezw313] [Citation(s) in RCA: 602] [Impact Index Per Article: 75.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
|
74
|
Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016; 18:1609-1678. [PMID: 27567465 DOI: 10.1093/europace/euw295] [Citation(s) in RCA: 1318] [Impact Index Per Article: 164.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Stefan Agewall
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John Camm
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gonzalo Baron Esquivias
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Werner Budts
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Scipione Carerj
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Filip Casselman
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Antonio Coca
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raffaele De Caterina
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Spiridon Deftereos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Dobromir Dobrev
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - José M Ferro
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gerasimos Filippatos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Donna Fitzsimons
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Bulent Gorenek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Maxine Guenoun
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stefan H Hohnloser
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Philippe Kolh
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gregory Y H Lip
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Athanasios Manolis
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John McMurray
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Ponikowski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raphael Rosenhek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Frank Ruschitzka
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Irina Savelieva
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Sanjay Sharma
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Suwalski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Juan Luis Tamargo
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Clare J Taylor
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Isabelle C Van Gelder
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Adriaan A Voors
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stephan Windecker
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Jose Luis Zamorano
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Katja Zeppenfeld
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| |
Collapse
|
75
|
Factors Affecting Patients’ Perception On, and Adherence To, Anticoagulant Therapy: Anticipating the Role of Direct Oral Anticoagulants. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2016; 10:163-185. [DOI: 10.1007/s40271-016-0180-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
76
|
Barnes GD, Izzo B, Conte ML, Chopra V, Holbrook A, Fagerlin A. Use of decision aids for shared decision making in venous thromboembolism: A systematic review. Thromb Res 2016; 143:71-5. [PMID: 27203185 DOI: 10.1016/j.thromres.2016.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 04/29/2016] [Accepted: 05/10/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Optimal care of patients with venous thromboembolism requires the input of patient preferences into clinical decision-making. However, the availability and impact of decision aids to facilitate shared decision making in care of venous thromboembolism is not well known. OBJECTIVES To assess the availability, clinical impact and outcomes associated with the use of decision aids in patients with or at risk for venous thromboembolism. PATIENTS/METHODS A systematic review of the literature was performed exploring the use of decision aids in patients with venous thromboembolism. Criteria for primary inclusion required use of patient values clarification in the decision aid. A secondary review without the requirement of a patient values clarification was performed to be more inclusive. The data was summarized such that knowledge gaps and opportunities for enquiry were identified. RESULTS The primary review identified one study that explored the decision to extend anticoagulation in patients with a recent venous thromboembolism beyond the stipulated 3-month duration. The secondary review identified an additional study exploring the decision to undergo computer tomography testing in patients at low risk for pulmonary embolism in an emergency department setting. Both studies were of modest quality given a lack of control group for comparison analysis. CONCLUSIONS Despite numerous calls to increase use of shared decision-making, a paucity of data exists to help patients engage in the treatment decisions for venous thromboembolism. Future studies of additional VTE clinical decisions with longer-term clinical outcomes appear necessary.
Collapse
Affiliation(s)
- Geoffrey D Barnes
- Frankel Cardiovascular Center, University of Michigan Medical Center, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan Medical Center, Ann Arbor, MI, USA.
| | - Brett Izzo
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Marisa L Conte
- Taubman Health Science Library, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Vineet Chopra
- Institute for Healthcare Policy and Innovation, University of Michigan Medical Center, Ann Arbor, MI, USA; Department of Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Anne Holbrook
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA; VA Salt Lake City, Salt Lake City, UT, USA
| |
Collapse
|
77
|
Steinberg BA, Greiner MA, Hammill BG, Curtis LH, Benjamin EJ, Heckbert SR, Piccini JP. Contraindications to anticoagulation therapy and eligibility for novel anticoagulants in older patients with atrial fibrillation. Cardiovasc Ther 2016; 33:177-83. [PMID: 25930214 DOI: 10.1111/1755-5922.12129] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
AIMS Oral anticoagulation therapy prevents stroke and improves survival in patients with atrial fibrillation, but the therapy is underutilized. We sought to identify the prevalence of contraindications for oral anticoagulation and the proportion of patients potentially eligible for different agents. METHODS We identified patients with nonacute atrial fibrillation in a nationally representative 5% sample of 2009 Medicare data. We divided the population into patients ineligible for any oral anticoagulant, patients eligible for warfarin only, and patients eligible for any anticoagulant. We compared patient characteristics and the use of anticoagulation among the subgroups. RESULTS Among 86,671 patients with atrial fibrillation, 1872 (2.2%) were ineligible for anticoagulation because of an absolute contraindication, most frequently a history of intracranial hemorrhage (60%). Patients ineligible for any anticoagulant were the same age as the overall group (mean age, 80.5 vs. 80.4 years). However, they had higher rates of dementia (19% vs. 8.6%) and heart failure (59% vs. 43%) and higher mean CHADS2 scores (3.8 vs. 2.8). Of the remaining 84,799 patients eligible for anticoagulation, 7146 (8.4%) were eligible for warfarin only (most commonly because of mechanical heart valves [66%] and end-stage renal disease [12%]). Sixty-five percent of patients eligible for anticoagulation received warfarin, and the proportion was similar for patients with a relatively high risk of bleeding. CONCLUSIONS Older adults with atrial fibrillation rarely have absolute contraindications to oral anticoagulation therapy. Among patients without contraindications, most appeared to be eligible for any anticoagulant, and relatively high-risk features appeared not to influence warfarin use.
Collapse
Affiliation(s)
- Benjamin A Steinberg
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Lesley H Curtis
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Emelia J Benjamin
- Framingham Heart Study, Framingham, Massachusetts, USA.,Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Susan R Heckbert
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| |
Collapse
|
78
|
Choi AL, Lai DA, Lai TL. Health Analytics, Economics and Medicine toward a 21<sup>st</sup> Century Health Care System. Health (London) 2016. [DOI: 10.4236/health.2016.85046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
79
|
Kim JH, Borden WB. Within-the-Clinic Shared Decision for an Over-the-Counter Medication. J Am Heart Assoc 2015; 4:JAHA.115.002927. [PMID: 26702080 PMCID: PMC4845293 DOI: 10.1161/jaha.115.002927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ju H Kim
- Division of Cardiology, Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC (J.H.K., W.B.B.)
| | - William B Borden
- Division of Cardiology, Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC (J.H.K., W.B.B.)
| |
Collapse
|
80
|
Kaiser K, Cheng WY, Jensen S, Clayman ML, Thappa A, Schwiep F, Chawla A, Goldberger JJ, Col N, Schein J. Development of a shared decision-making tool to assist patients and clinicians with decisions on oral anticoagulant treatment for atrial fibrillation. Curr Med Res Opin 2015; 31:2261-72. [PMID: 26390360 DOI: 10.1185/03007995.2015.1096767] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Decision aids (DAs) are increasingly used to operationalize shared decision-making (SDM) but their development is not often described. Decisions about oral anticoagulants (OACs) for atrial fibrillation (AF) involve a trade-off between lowering stroke risk and increasing OAC-associated bleeding risk, and consideration of how treatment affects lifestyle. The benefits and risks of OACs hinge upon a patient's risk factors for stroke and bleeding and how they value these outcomes. We present the development of a DA about AF that estimates patients' risks for stroke and bleeding and assesses their preferences for outcomes. RESEARCH DESIGN AND METHODS Based on a literature review and expert discussions, we identified stroke and major bleeding risk prediction models and embedded them into risk assessment modules. We identified the most important factors in choosing OAC treatment (warfarin used as the default reference OAC) through focus group discussions with AF patients who had used warfarin and clinician interviews. We then designed preference assessment and introductory modules accordingly. We integrated these modules into a prototype AF SDM tool and evaluated its usability through interviews. RESULTS Our tool included four modules: (1) introduction to AF and OAC treatment risks and benefits; (2) stroke risk assessment; (3) bleeding risk assessment; and (4) preference assessment. Interactive risk calculators estimated patient-specific stroke and bleeding risks; graphics were developed to communicate these risks. After cognitive interviews, the content was improved. The final AF tool calculates patient-specific risks and benefits of OAC treatment and couples these estimates with patient preferences to improve clinical decision-making. CONCLUSIONS The AF SDM tool may help patients choose whether OAC treatment is best for them and represents a patient-centered, integrative approach to educate patients on the benefits and risks of OAC treatment. Future research is needed to evaluate this tool in a real-world setting. The development process presented can be applied to similar SDM tools.
Collapse
Affiliation(s)
- Karen Kaiser
- a a Department of Medical Social Sciences , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
| | | | - Sally Jensen
- a a Department of Medical Social Sciences , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
| | - Marla L Clayman
- c c Department of Medicine , Northwestern University Feinberg School of Medicine , Chicago , IL , USA at the time of study
- d d American Institutes of Research , Chicago , IL , USA
| | | | | | | | - Jeffrey J Goldberger
- f f Department of Medicine , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
| | - Nananda Col
- g g Shared Decision Making Resources , Georgetown , ME , USA
| | - Jeff Schein
- h h Janssen Scientific Affairs LLC , Raritan , NJ , USA
| |
Collapse
|
81
|
Kirchhof P, Breithardt G, Bax J, Benninger G, Blomstrom-Lundqvist C, Boriani G, Brandes A, Brown H, Brueckmann M, Calkins H, Calvert M, Christoffels V, Crijns H, Dobrev D, Ellinor P, Fabritz L, Fetsch T, Freedman SB, Gerth A, Goette A, Guasch E, Hack G, Haegeli L, Hatem S, Haeusler KG, Heidbüchel H, Heinrich-Nols J, Hidden-Lucet F, Hindricks G, Juul-Möller S, Kääb S, Kappenberger L, Kespohl S, Kotecha D, Lane DA, Leute A, Lewalter T, Meyer R, Mont L, Münzel F, Nabauer M, Nielsen JC, Oeff M, Oldgren J, Oto A, Piccini JP, Pilmeyer A, Potpara T, Ravens U, Reinecke H, Rostock T, Rustige J, Savelieva I, Schnabel R, Schotten U, Schwichtenberg L, Sinner MF, Steinbeck G, Stoll M, Tavazzi L, Themistoclakis S, Tse HF, Van Gelder IC, Vardas PE, Varpula T, Vincent A, Werring D, Willems S, Ziegler A, Lip GY, Camm AJ. A roadmap to improve the quality of atrial fibrillation management: proceedings from the fifth Atrial Fibrillation Network/European Heart Rhythm Association consensus conference. Europace 2015; 18:37-50. [DOI: 10.1093/europace/euv304] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 08/13/2015] [Indexed: 12/30/2022] Open
|
82
|
Govender P, Spurrett D, Biccard BM. Predictors of peri-operative risk acceptance by South African vascular surgery patients at a tertiary level hospital. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2015. [DOI: 10.1080/22201181.2015.1045267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
|
83
|
Lane DA, Aguinaga L, Blomström-Lundqvist C, Boriani G, Dan GA, Hills MT, Hylek EM, LaHaye SA, Lip GYH, Lobban T, Mandrola J, McCabe PJ, Pedersen SS, Pisters R, Stewart S, Wood K, Potpara TS, Gorenek B, Conti JB, Keegan R, Power S, Hendriks J, Ritter P, Calkins H, Violi F, Hurwitz J. Cardiac tachyarrhythmias and patient values and preferences for their management: the European Heart Rhythm Association (EHRA) consensus document endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE). Europace 2015; 17:1747-69. [PMID: 26108807 DOI: 10.1093/europace/euv233] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
84
|
Innovative designs of point-of-care comparative effectiveness trials. Contemp Clin Trials 2015; 45:61-8. [PMID: 26099528 DOI: 10.1016/j.cct.2015.06.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 06/13/2015] [Accepted: 06/17/2015] [Indexed: 12/28/2022]
Abstract
One of the provisions of the health care reform legislation in 2010 was for funding pragmatic clinical trials or large observational studies for comparing the effectiveness of different approved medical treatments, involving broadly representative patient populations. After reviewing pragmatic clinical trials and the issues and challenges that have made them just a small fraction of comparative effectiveness research (CER), we focus on a recent development that uses point-of-care (POC) clinical trials to address the issue of "knowledge-action gap" in pragmatic CER trials. We give illustrative examples of POC-CER trials and describe a trial that we are currently planning to compare the effectiveness of newly approved oral anticoagulants. We also develop novel stage-wise designs of information-rich POC-CER trials under competitive budget constraints, by using recent advances in adaptive designs and other statistical methodologies.
Collapse
|
85
|
Violette PD, Agoritsas T, Alexander P, Riikonen J, Santti H, Agarwal A, Bhatnagar N, Dahm P, Montori V, Guyatt GH, Tikkinen KAO. Decision aids for localized prostate cancer treatment choice: Systematic review and meta-analysis. CA Cancer J Clin 2015; 65:239-51. [PMID: 25772796 DOI: 10.3322/caac.21272] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 01/08/2015] [Accepted: 02/12/2015] [Indexed: 12/21/2022] Open
Abstract
Patients who are diagnosed with localized prostate cancer need to make critical treatment decisions that are sensitive to their values and preferences. The role of decision aids in facilitating these decisions is unknown. The authors conducted a systematic review of randomized trials of decision aids for localized prostate cancer. Teams of 2 reviewers independently identified, selected, and abstracted data from 14 eligible trials (n = 3377 men), of which 10 were conducted in North America. Of these, 11 trials compared decision aids with usual care, and 3 trials compared decision aids with other decision aids. Two trials suggested a modest positive impact on decisional regret. Results across studies varied widely for decisional conflict (4 studies), satisfaction with decision (2 studies), and knowledge (2 studies). No impact on treatment choices was observed (6 studies). In conclusion, scant evidence at high risk of bias suggests the variable impact of existing decision aids on a limited set of decisional processes and outcomes. Because current decision aids provide information but do not directly facilitate shared decision making, subsequent efforts would benefit from user-centered design of decision aids that promote shared decision making.
Collapse
Affiliation(s)
- Philippe D Violette
- Endourology Fellow, Division of Urology, Department of Surgery, Western University, London, ON, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Woodstock General Hospital, Woodstock, ON, Canada
| | - Thomas Agoritsas
- Research Fellow, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada, Division of General Internal Medicine and Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Paul Alexander
- Doctoral Candidate, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Jarno Riikonen
- Consultant, Department of Urology, Tampere University Hospital, Tampere, Finland
| | - Henrikki Santti
- Consultant, Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Arnav Agarwal
- Medical Student, Faculty of Medicine, University of Toronto, Toronto, ON, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Neera Bhatnagar
- Medical Librarian, Health Sciences Library, McMaster University, Hamilton, ON, Canada
| | - Philipp Dahm
- Professor, Department of Urology, University of Minnesota and Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - Victor Montori
- Professor, Knowledge and Evaluation Research Unit, Division of Endocrinology and Diabetes, Departments of Medicine and Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Gordon H Guyatt
- Distinguished Professor, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Kari A O Tikkinen
- Adjunct Professor, Departments of Urology and Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
86
|
Barrett TW, Storrow AB, Jenkins CA, Abraham RL, Liu D, Miller KF, Moser KM, Russ S, Roden DM, Harrell FE, Darbar D. The AFFORD clinical decision aid to identify emergency department patients with atrial fibrillation at low risk for 30-day adverse events. Am J Cardiol 2015; 115:763-70. [PMID: 25633190 PMCID: PMC4346475 DOI: 10.1016/j.amjcard.2014.12.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 12/23/2014] [Accepted: 12/23/2014] [Indexed: 12/18/2022]
Abstract
There is wide variation in the management of patients with atrial fibrillation (AF) in the emergency department (ED). We aimed to derive and internally validate the first prospective, ED-based clinical decision aid to identify patients with AF at low risk for 30-day adverse events. We performed a prospective cohort study at a university-affiliated tertiary-care ED. Patients were enrolled from June 9, 2010, to February 28, 2013, and followed for 30 days. We enrolled a convenience sample of patients in ED presenting with symptomatic AF. Candidate predictors were based on ED data available in the first 2 hours. The decision aid was derived using model approximation (preconditioning) followed by strong bootstrap internal validation. We used an ordinal outcome hierarchy defined as the incidence of the most severe adverse event within 30 days of the ED evaluation. Of 497 patients enrolled, stroke and AF-related death occurred in 13 (3%) and 4 (<1%) patients, respectively. The decision aid included the following: age, triage vitals (systolic blood pressure, temperature, respiratory rate, oxygen saturation, supplemental oxygen requirement), medical history (heart failure, home sotalol use, previous percutaneous coronary intervention, electrical cardioversion, cardiac ablation, frequency of AF symptoms), and ED data (2 hours heart rate, chest radiograph results, hemoglobin, creatinine, and brain natriuretic peptide). The decision aid's c-statistic in predicting any 30-day adverse event was 0.7 (95% confidence interval 0.65, 0.76). In conclusion, in patients with AF in the ED, Atrial Fibrillation and Flutter Outcome Risk Determination provides the first evidence-based decision aid for identifying patients who are at low risk for 30-day adverse events and candidates for safe discharge.
Collapse
Affiliation(s)
- Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Robert L Abraham
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelly M Moser
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephan Russ
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dan M Roden
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Clinical Pharmacology, Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Dawood Darbar
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Clinical Pharmacology, Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
87
|
Rising KL, Printz AD, Hess EP. Patient-Centered Care in Acute Cardiovascular Disease. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2015. [DOI: 10.1007/s40138-014-0061-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
88
|
Barrett TW, Jenkins CA, Self WH. Validation of the Risk Estimator Decision Aid for Atrial Fibrillation (RED-AF) for predicting 30-day adverse events in emergency department patients with atrial fibrillation. Ann Emerg Med 2015; 65:13-21.e3. [PMID: 25245277 PMCID: PMC4275362 DOI: 10.1016/j.annemergmed.2014.08.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 07/17/2014] [Accepted: 08/06/2014] [Indexed: 10/24/2022]
Abstract
STUDY OBJECTIVE In the United States, nearly 70% of emergency department (ED) visits for atrial fibrillation result in hospitalization. The incidence of serious 30-day adverse events after an ED evaluation for atrial fibrillation remains low. This study's goal was to prospectively validate our previously reported Risk Estimator Decision Aid for Atrial Fibrillation (RED-AF) model for estimating a patient's risk of experiencing a 30-day adverse event. METHODS This was a prospective cohort study, which enrolled a convenience sample of ED patients presenting with atrial fibrillation. RED-AF, previously derived from a retrospective cohort of 832 patients, assigns points according to age, sex, coexisting disease (eg, heart failure, hypertension, chronic obstructive pulmonary disease), smoking, home medications (eg, β-blocker, diuretic), physical examination findings (eg, dyspnea, palpitations, peripheral edema), and adequacy of ED ventricular rate control. Primary outcome was occurrence of greater than or equal to 1 atrial fibrillation-related adverse outcome (ED visits, rehospitalization, cardiovascular complications, death) within 30 days. We identified a clinically relevant threshold and measured RED-AF's performance in this prospective cohort, assessing its calibration, discrimination, and diagnostic accuracy. RESULTS The study enrolled 497 patients between June 2010 and February 2013. Of these, 120 (24%) had greater than or equal to 1 adverse event within 30 days. A RED-AF score of 87 was identified as an optimal threshold, resulting in sensitivity and specificity of 96% (95% confidence interval [CI] 91% to 98%) and 19% (95% CI 15% to 23%), respectively. Positive and negative predictive values were 27% (95% CI 23% to 32%) and 93% (95% CI 85% to 97%), respectively. The c statistic for RED-AF was 0.65 (95% CI 0.59 to 0.71). CONCLUSION In this separate validation cohort, RED-AF performed moderately well and similar to the original derivation cohort for identifying the risk of short-term atrial fibrillation-related adverse events in ED patients receiving a diagnosis of atrial fibrillation.
Collapse
Affiliation(s)
- Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN.
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN
| |
Collapse
|
89
|
Abstract
PURPOSE OF REVIEW Cardiac patients are a fast emerging population vulnerable to gastrointestinal bleeding (GIB) due to their use of antithrombotic medications. This review will quantify the GIB risk of cardiac patients prescribed antithrombotic medications, summarize risk-management strategies and highlight knowledge gaps. RECENT FINDINGS As the American population ages, it is anticipated that there will be an increased incidence of upper and lower GIB related to age-specific disease, higher burden of comorbidity and increased use of anticoagulants, antiplatelets and aspirin to treat cardiac disease. New evidence has highlighted the significant and clinically relevant GIB risk. The increased use of aggressive antiplatelet and anticoagulant therapies will alter our current understanding of the epidemiology of GIB. SUMMARY The magnitude of gastrointestinal risk in this vulnerable patient population is still relatively unexplored due to a paucity of literature. This review will highlight changing GIB trends and explore current knowledge regarding GIB risk in cardiac patients. An emphasis on a multidisciplinary approach to the care of these patients will be supported, which involves active patient participation and collaboration between cardiologists and gastroenterologists. Finally, risk-minimization strategies will be suggested and knowledge gaps will be identified.
Collapse
|