101
|
Lip GYH, Potpara T, Boriani G, Blomström-Lundqvist C. A tailored treatment strategy: a modern approach for stroke prevention in patients with atrial fibrillation. J Intern Med 2016; 279:467-76. [PMID: 27001354 DOI: 10.1111/joim.12468] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The main priority in atrial fibrillation (AF) management is stroke prevention, following which decisions about rate or rhythm control are focused on the patient, being primarily for management of symptoms. Given that AF is commonly associated with various comorbidities, risk factors such as hypertension, heart failure, diabetes mellitus and sleep apnoea should be actively looked for and managed in a holistic approach to AF management. The objective of this review is to provide an overview of modern AF stroke prevention with a focus on tailored treatment strategies. Biomarkers and genetic factors have been proposed to help identify 'high-risk' patients to be targeted for oral anticoagulation, but ultimately their use must be balanced against that of more simple and practical considerations for everyday use. Current guidelines have directed focus on initial identification of 'truly low-risk' patients with AF, that is those patients with a CHA2 DS2 -VASc [congestive heart failure, hypertension, age ≥75 years (two points), diabetes mellitus, stroke (two points), vascular disease, age 65-74 years, sex category] score of 0 (male) or 1 (female), who do not need any antithrombotic therapy. Subsequently, patients with ≥1 stroke risk factors can be offered effective stroke prevention, that is oral anticoagulation. The SAMe-TT2 R2 [sex female, age <60 years, medical history (>2 comorbidities), treatment (interacting drugs), tobacco use (two points), race non-Caucasian (two points)] score can help physicians make informed decisions on those patients likely to do well on warfarin (SAMe-TT2 R2 score 0-2) or those who are likely to have a poor time in therapeutic range (SAMe-TT2 R2 score >2). A clinically focused tailored approach to assessment and stroke prevention in AF with the use of the CHA2 DS2 VASc, HAS-BLED [hypertension, abnormal renal/liver function (one or two points), stroke, bleeding history or predisposition, labile international normalized ratio, elderly (>65 years) drugs/alcohol concomitantly (one or two points)] and SAMeTT2 R2 scores to evaluate stroke risk, bleeding risk and likelihood of successful warfarin therapy, respectively, is discussed.
Collapse
Affiliation(s)
- G Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - T Potpara
- Cardiology Clinic, Clinical Centre of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - G Boriani
- Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - C Blomström-Lundqvist
- Department of Cardiology, Institution of Medical Science, Uppsala University, Uppsala, Sweden
| |
Collapse
|
102
|
Hernández Madrid A, Potpara TS, Dagres N, Chen J, Larsen TB, Estner H, Todd D, Bongiorni MG, Sciaraffia E, Proclemer A, Cheggour S, Amara W, Blomstrom-Lundqvist C. Differences in attitude, education, and knowledge about oral anticoagulation therapy among patients with atrial fibrillation in Europe: result of a self-assessment patient survey conducted by the European Heart Rhythm Association. Europace 2016; 18:463-7. [DOI: 10.1093/europace/euv448] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 12/21/2015] [Indexed: 02/06/2023] Open
|
103
|
Developing a Complex Educational-Behavioural Intervention: The TREAT Intervention for Patients with Atrial Fibrillation. Healthcare (Basel) 2016; 4:healthcare4010010. [PMID: 27417598 PMCID: PMC4934544 DOI: 10.3390/healthcare4010010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 01/04/2016] [Accepted: 01/05/2016] [Indexed: 11/17/2022] Open
Abstract
This article describes the theoretical and pragmatic development of a patient-centred intervention for patients with atrial fibrillation (AF). Theoretical models (Common Sense Model, Necessity-Concerns Framework), clinical frameworks, and AF patient feedback contributed to the design of a one-off hour-long behaviour-change intervention package. Intervention materials consisted of a DVD, educational booklet, diary and worksheet, which were patient-centred and easy to administer. The intervention was evaluated within a randomised controlled trial. Several “active theoretical ingredients” were identified (for e.g., where patients believed their medication was less harmful they spent more time within the therapeutic range (TTR), with general harm scores predicting TTR at 6 months). Allowing for social comparison and adopting behaviour change techniques enabled accurate patient understanding of their condition and medication. The process of developing the intervention using theory-derived content and evaluation tools allowed a greater understanding of the mechanisms by which this intervention was successful. Alleviating concerns about treatment medication by educating patients can help to improve adherence. This process of intervention development could be adopted for a range of chronic illnesses and treatments. Critical elements should include the use of: (1) clinical guidelines; (2) appropriate theoretical models; (3) patient input; and (4) appropriate evaluation tools.
Collapse
|
104
|
Hendriks JML, Walfridsson U, Johansson P, Strömberg A. E-health in patients with atrial fibrillation. Eur J Cardiovasc Nurs 2015; 15:200-2. [DOI: 10.1177/1474515115616723] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Jeroen ML Hendriks
- Department of Health and Medical Sciences, Linköping University, Linköping, Sweden
- Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, The University of Adelaide, Adelaide, Australia
| | - Ulla Walfridsson
- Department of Health and Medical Sciences, Linköping University, Linköping, Sweden
- Department of Cardiology, Linköping University, Linköping, Sweden
| | - Peter Johansson
- Department of Health and Medical Sciences, Linköping University, Linköping, Sweden
- Department of Cardiology, Linköping University, Linköping, Sweden
| | - Anna Strömberg
- Department of Health and Medical Sciences, Linköping University, Linköping, Sweden
- Department of Cardiology, Linköping University, Linköping, Sweden
| |
Collapse
|
105
|
Lee SI, Sayers M, Lip GYH, Lane DA. Use of non-vitamin K antagonist oral anticoagulants in atrial fibrillation patients: insights from a specialist atrial fibrillation clinic. Int J Clin Pract 2015; 69:1341-8. [PMID: 26234557 DOI: 10.1111/ijcp.12712] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 07/14/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Non-vitamin K antagonist oral anticoagulants (NOACs) are broadly preferable to vitamin K antagonists (VKAs) for stroke prevention in non-valvular atrial fibrillation (AF) given their overall net clinical benefit. We report an audit of the profile of OAC usage and adverse events in patients attending a specialist AF clinic. METHODS Patients attending our specialist AF clinic who were commenced on NOACs for SPAF between January 2013 and August 2014 were included and electronic medical records were retrospectively reviewed between August 2014 and November 2014, to collect demographic, clinical and outcome data. Outcomes included cerebrovascular and bleeding events, death, switching between NOACs or to VKA, dose changes, cessation of NOACs and the reasons for these. To provide perspective, descriptive comparisons were made with a historical cohort of warfarin users attending the specialist AF clinic prior to the introduction of NOACs. RESULTS We report data on 813 patients as follows: (i) 233 consecutive patients (mean (standard deviation) age 74 (10) years, 45.1% female) initiated on NOACs, with median (interquartile range) CHA2 DS2 -VASc score 3 (2-5) and HAS-BLED score 1 (1-2); and (ii) a historical cohort of 580 patients on warfarin (mean (SD) age 75 (10) years, 42.1% female) with broadly similar demographics. Overall, 54.5% (127/233) were started on rivaroxaban, 22.7% (53/233) on dabigatran and 22.7% on apixaban. Two patients experienced a transient ischaemic attack; 31 patients (13%) contributed to 37 documented bleeding events of which five bleeds (in four patients, 1.7%) were classified as major. There were seven deaths; cause of death was not available for three and the others were not related to NOACs. Eighteen (7.7%) patients switched NOACs, 2 (0.9%) patients switched to warfarin and 8 (3.4%) had their NOACs stopped. There were no ischaemic strokes in the NOAC cohort, compared with nine in the warfarin cohort, with a similar rate of major bleeding (1.7% for NOACs and 1.6% for warfarin). There were more gastrointestinal haemorrhages in the NOAC cohort (3.4% vs. 0.7% with warfarin). CONCLUSION In this specialist AF clinic, patients prescribed NOACs had a favourable adverse event profile with good efficacy for stroke prevention, with a low rate of cessation or switch to warfarin.
Collapse
Affiliation(s)
- S I Lee
- University of Birmingham Centre for Cardiovascular Sciences, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
- Cardiology Department, City Hospital, Birmingham, UK
| | - M Sayers
- Cardiology Department, City Hospital, Birmingham, UK
| | - G Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - D A Lane
- University of Birmingham Centre for Cardiovascular Sciences, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| |
Collapse
|
106
|
Hohnloser SH, Cappato R, Ezekowitz MD, Evers T, Sahin K, Kirchhof P, Meng IL, van Eickels M, Camm AJ. Patient-reported treatment satisfaction and budget impact with rivaroxaban vs. standard therapy in elective cardioversion of atrial fibrillation: a post hoc analysis of the X-VeRT trial. Europace 2015; 18:184-90. [PMID: 26487668 PMCID: PMC4767121 DOI: 10.1093/europace/euv294] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 08/03/2015] [Indexed: 11/23/2022] Open
Abstract
Aims We compared patient-reported treatment satisfaction and the economic impact of anticoagulation therapy with rivaroxaban vs. vitamin K antagonists (VKAs) in patients with non-valvular atrial fibrillation undergoing elective cardioversion procedures. Methods and results The current study is a post hoc analysis of the prospective, multicentre X-VeRT (EXplore the efficacy and safety of once-daily oral riVaroxaban for the prevention of caRdiovascular events in subjects with non-valvular aTrial fibrillation scheduled for cardioversion) trial. Patient-reported treatment satisfaction with anticoagulation therapy was assessed using the Treatment Satisfaction Questionnaire for Medication version II in seven countries (US, UK, Canada, Germany, France, Italy, and the Netherlands). An economic model was also developed to estimate the impact of postponed cardioversions for two countries (UK and Italy). This model estimated the total costs of cardioversion, taking into consideration the costs for drug therapy (including extended treatment duration due to cardioversion postponement), international normalized ratio monitoring of VKAs, the cardioversion procedure, and rescheduling the procedure. These costs were linked to the respective X-VeRT study data to estimate the total costs. Patients receiving rivaroxaban in the delayed cardioversion group had significantly higher scores for Convenience, Effectiveness, and Global satisfaction (81.74 vs. 65.78; 39.41 vs. 32.95; and 82.07 vs. 66.74, respectively; P < 0.0001). Based on the total patient population included in the treatment satisfaction substudy (n = 632) in the delayed cardioversion group in X-VeRT, the use of rivaroxaban was estimated to result in a saving of £421 and €360 per patient in UK and Italian settings, respectively. Conclusion The use of rivaroxaban in the setting of cardioversion resulted in greater patient satisfaction and cost savings, compared with that of VKA.
Collapse
Affiliation(s)
- Stefan H Hohnloser
- Department of Cardiology, Division of Clinical Electrophysiology, J.W. Goethe University, Frankfurt, Germany
| | - Riccardo Cappato
- Arrhythmia and Electrophysiology Center, IRCCS Humanitas Research Hospital, Milan, Italy Humanitas Gavazzeni Hospital, Bergamo, Italy
| | - Michael D Ezekowitz
- The Sidney Kimell Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Kurtulus Sahin
- ClinStat GmbH, Statistics and Health Economics, Cologne, Germany
| | - Paulus Kirchhof
- Centre for Cardiovascular Sciences, School of Clinical and Experimental Medicine, University of Birmingham, SWBH and UHB NHS Trusts, Birmingham, UK Department of Cardiovascular Medicine, Hospital of the University of Münster, Münster, Germany
| | | | | | - A John Camm
- Division of Clinical Sciences, St George's, University of London, London, UK
| | | |
Collapse
|
107
|
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
|
108
|
Amara W, Larsen TB, Sciaraffia E, Hernández Madrid A, Chen J, Estner H, Todd D, Bongiorni MG, Potpara TS, Dagres N, Sagnol P, Blomstrom-Lundqvist C. Patients' attitude and knowledge about oral anticoagulation therapy: results of a self-assessment survey in patients with atrial fibrillation conducted by the European Heart Rhythm Association. Europace 2015; 18:151-5. [PMID: 26462697 DOI: 10.1093/europace/euv317] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 08/20/2015] [Indexed: 01/29/2023] Open
Abstract
The purpose of this European Heart Rhythm Association survey was to assess the attitude, level of education, and knowledge concerning oral anticoagulants (OACs) among patients with atrial fibrillation (AF) taking vitamin K antagonists (VKAs), non-VKA oral anticoagulants (NOACs) or antiplatelets. A total of 1147 patients with AF [mean age 66 ± 13 years, 529 (45%) women] from 8 selected European countries responded to this survey. The overall use of OACs and antiplatelets was 77 and 15.3%, respectively. Of the patients taking OACs, 67% were on VKAs, 33% on NOACs, and 17.9% on a combination of OACs and antiplatelets. Among patients on VKAs, 91% correctly stated the target international normalized ratio (INR) level. The proportion of patients on VKA medication who were aware that monthly INR monitoring was required for this treatment and the proportion of patients on NOAC who knew that renal function monitoring at least annually was mandatory for NOACs was 76 and 21%, respectively. An indirect estimation of compliance indicated that 14.5% of patients temporarily discontinued the treatment, and 26.5% of patients reported having missed at least one dose. The survey shows that there is room for improvement regarding education and adherence of patients taking OACs, particularly regarding monitoring requirements for NOACs.
Collapse
Affiliation(s)
- Walid Amara
- Department of Cardiology, Groupe Hospitalier Le Raincy-Montfermeil, Montfermeil, France
| | - Torben B Larsen
- Department of Cardiology, AF Studygroup, Aalborg University Hospital, Aalborg, Denmark
| | - Elena Sciaraffia
- Department of Cardiology, Institution of Medical Science, Uppsala University, Uppsala, Sweden
| | | | - Jian Chen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Heidi Estner
- Department of Cardiology, MedizinischeKlinik I, Ludwig-Maximilians-Universität, Campus Großhadern, Marchioninistrasse 15, München 81377, Germany
| | | | | | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Nikolaos Dagres
- Second Cardiology Department, Attikon University Hospital, University of Athens, Athens, Greece
| | - Pascal Sagnol
- Cardioloy Department, Centre Hospitalier William Marey, 71100 Chalon s/Saone, France
| | | |
Collapse
|
109
|
Thylén I, Moser DK, Strömberg A, Dekker RA, Chung ML. Concerns about implantable cardioverter-defibrillator shocks mediate the relationship between actual shocks and psychological distress. Europace 2015; 18:828-35. [PMID: 26324839 DOI: 10.1093/europace/euv220] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 05/15/2015] [Indexed: 11/14/2022] Open
Abstract
AIMS Although most implantable cardioverter-defibrillator (ICD) patients cope well, fears about receiving ICD shocks have been identified as a major determinant of psychological distress. The relationships among ICD-related concerns, receipt of defibrillating shocks, and symptoms of anxiety and depression have not yet been investigated. Our objective was to examine whether the relationship between receipt of defibrillating shocks and psychological distress was mediated by patients' concerns related to their ICD. METHODS AND RESULTS All Swedish ICD-recipients were invited to this cross-sectional correlational study; 3067 completing the survey (55% response rate). Their mean age was 66 ± 11 years, and 80% were male. One-third (35%) had received defibrillating shocks, and 26% had high ICD-related concerns. Regression analyses demonstrated that having received at least one shock significantly predicted symptoms of anxiety and depression [odds ratio (OR) 1.58 and OR 3.04, respectively]. The association between receipt of shocks and psychologically distress was mediated by high ICD-related concerns which explained 68% of the relationship between shocks and symptoms of anxiety, and 54% of the relationship between shocks and symptoms of depression. CONCLUSION Implantable cardioverter-defibrillator-related concerns have a bigger impact on psychological distress than receipt of an actual shock. Assessing ICD-related concerns in clinical practice can identify patients at risk for psychological distress. Further research on assessment of, and interventions targeting, ICD-related concerns is warranted.
Collapse
Affiliation(s)
- Ingela Thylén
- Department of Medicine and Health Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden Department of Cardiology, County Council of Östergötland, Linköping University, Linköping, Sweden
| | - Debra K Moser
- College of Nursing, University of Kentucky, 527 CON, 751 Rose Street, Lexington, KY 40536-0232, USA University of Ulster, Newtownabbey, UK
| | - Anna Strömberg
- Department of Medicine and Health Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden Department of Cardiology, County Council of Östergötland, Linköping University, Linköping, Sweden
| | - Rebecca A Dekker
- College of Nursing, University of Kentucky, 527 CON, 751 Rose Street, Lexington, KY 40536-0232, USA
| | - Misook L Chung
- College of Nursing, University of Kentucky, 527 CON, 751 Rose Street, Lexington, KY 40536-0232, USA
| |
Collapse
|
110
|
Heidbuchel H, Verhamme P, Alings M, Antz M, Diener HC, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015; 17:1467-507. [PMID: 26324838 DOI: 10.1093/europace/euv309] [Citation(s) in RCA: 723] [Impact Index Per Article: 80.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 02/10/2015] [Indexed: 12/24/2022] Open
Abstract
The current manuscript is an update of the original Practical Guide, published in June 2013[Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-51; Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, et al. EHRA practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary. Eur Heart J 2013;34:2094-106]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with non-valvular atrial fibrillation (AF). Both physicians and patients have to learn how to use these drugs effectively and safely in clinical practice. Many unresolved questions on how to optimally use these drugs in specific clinical situations remain. The European Heart Rhythm Association set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group defined what needs to be considered as 'non-valvular AF' and listed 15 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 15 topics are (i) practical start-up and follow-up scheme for patients on NOACs; (ii) how to measure the anticoagulant effect of NOACs; (iii) drug-drug interactions and pharmacokinetics of NOACs; (iv) switching between anticoagulant regimens; (v) ensuring adherence of NOAC intake; (vi) how to deal with dosing errors; (vii) patients with chronic kidney disease; (viii) what to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a risk of bleeding?; (xi) management of bleeding complications; (x) patients undergoing a planned surgical intervention or ablation; (xi) patients undergoing an urgent surgical intervention; (xii) patients with AF and coronary artery disease; (xiii) cardioversion in a NOAC-treated patient; (xiv) patients presenting with acute stroke while on NOACs; and (xv) NOACs vs. VKAs in AF patients with a malignancy. Additional information and downloads of the text and anticoagulation cards in >16 languages can be found on an European Heart Rhythm Association web site (www.NOACforAF.eu).
Collapse
|