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Teppo K, Airaksinen KEJ, Jaakkola J, Halminen O, Salmela B, Kalatsova K, Kouki E, Haukka J, Putaala J, Linna M, Aro AL, Mustonen P, Hartikainen J, Lehto M. Temporal trends of gender disparities in oral anticoagulant use in patients with atrial fibrillation. Eur J Clin Invest 2024; 54:e14107. [PMID: 37823410 DOI: 10.1111/eci.14107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/02/2023] [Accepted: 10/05/2023] [Indexed: 10/13/2023]
Abstract
AIMS To investigate sex-specific temporal trends in the initiation of oral anticoagulant (OAC) therapy among patients diagnosed with atrial fibrillation (AF) in Finland between 2007 and 2018. METHODS The registry-linkage Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) Study included all patients with incident AF in Finland from 2007 to 2018. The primary outcome was the initiation of any OAC therapy. RESULTS We identified 229,565 patients with new-onset AF (50.0% women; mean age 72.7 years). The initiation of OAC therapy increased continuously during the observation period. While women were more likely to receive OAC therapy overall, after adjusting for age, stroke risk factors and other confounding factors, female sex was associated with a marginally lower initiation of OACs (unadjusted and adjusted hazard ratios comparing women to men: 1.08 (1.07-1.10) and 0.97 (0.96-0.98), respectively). Importantly, the gender disparities in OAC use attenuated and reached parity by the end of the observation period. Furthermore, when only patients eligible for OAC therapy according to the contemporary guidelines were included in the analyses, the gender inequalities in OAC initiation appeared minimal. Implementation of direct OACs for stroke prevention was slightly slower among women. CONCLUSION This nationwide retrospective cohort study covering all patients with incident AF in Finland from 2007 to 2018 observed that although female sex was initially associated with a lower initiation of OAC therapy, the sex-related disparities resolved over the course of the study period.
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Affiliation(s)
- Konsta Teppo
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Jussi Jaakkola
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Birgitta Salmela
- Heart Center, Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland
| | | | - Elis Kouki
- University of Helsinki, Helsinki, Finland
| | | | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Miika Linna
- Aalto University, Espoo, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Aapo L Aro
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pirjo Mustonen
- Turku University Hospital and University of Turku, Turku, Finland
| | - Juha Hartikainen
- Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Mika Lehto
- Jorvi Hospital, Department of Internal Medicine, HUS Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Gurol ME, Wright CB, Janis S, Smith EE, Gokcal E, Reddy VY, Merino JG, Hsu JC. Stroke Prevention in Atrial Fibrillation: Our Current Failures and Required Research. Stroke 2024; 55:214-225. [PMID: 38134262 PMCID: PMC11167726 DOI: 10.1161/strokeaha.123.040447] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Nonvalvular atrial fibrillation is a common rhythm disorder of middle-aged to older adults that can cause ischemic strokes and systemic embolism. Lifelong use of oral anticoagulants reduces the risk of these ischemic events but increases the risk of major and clinically relevant hemorrhages. These medications also require strict compliance for efficacy, and they have nontrivial failure rates in higher-risk patients. Left atrial appendage closure is a nonpharmacological method to prevent ischemic strokes in atrial fibrillation without the need for lifelong anticoagulant use, but this procedure has the potential for complications and residual embolic events. This workshop of the Roundtable of Academia and Industry for Stroke Prevention discussed future research needed to further decrease the ischemic and hemorrhagic risks among patients with atrial fibrillation. A direct thrombin inhibitor, factor Xa inhibitors, and left atrial appendage closure are FDA-approved approaches whereas factor XIa inhibitors are currently being studied in phase 3 randomized controlled trials for stroke prevention. The benefits, risks, and shortcomings of these treatments and future research required in different high-risk patient populations are reviewed in this consensus statement.
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Affiliation(s)
- M Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.E.G., E.G.)
| | - Clinton B Wright
- Division of Clinical Research, NINDS, Bethesda, MD (C.B.W., S.J.)
| | | | - Eric E Smith
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada (E.E.S.)
| | - Elif Gokcal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.E.G., E.G.)
| | - Vivek Y Reddy
- Helmsley Trust Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York (V.Y.R.)
| | - José G Merino
- Department of Neurology, Georgetown University Medical Center (J.G.M.)
| | - Jonathan C Hsu
- Department of Cardiology, University of California, San Diego, La Jolla (J.C.H.)
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Atwater BD, Guo JD, Keshishian A, Delinger R, Russ C, Rosenblatt L, Jiang J, Yuce H, Ferri M. Temporal trends in anticoagulation use and clinical outcomes among medicare beneficiaries with non-valvular atrial fibrillation. J Thromb Thrombolysis 2024; 57:1-10. [PMID: 37530955 PMCID: PMC10830709 DOI: 10.1007/s11239-023-02838-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 08/03/2023]
Abstract
PURPOSE Oral anticoagulants effectively prevent stroke/systemic embolism among patients with non-valvular atrial fibrillation but remain under-prescribed. This study evaluated temporal trends in oral anticoagulant use, the incidence of stroke/systemic embolism and major bleeding, and economic outcomes among elderly patients with non-valvular atrial fibrillation and CHA2DS2-VASc scores ≥ 2. METHODS Retrospective analyses were conducted on Medicare claims data from January 1, 2012 through December 31, 2017. Non-valvular atrial fibrillation patients aged ≥ 65 years with CHA2DS2-VASc scores ≥ 2 were stratified by calendar year (2013-2016) of care to create calendar-year cohorts. Patient characteristics were evaluated across all cohorts during the baseline period (12 months before diagnosis). Treatment patterns and clinical and economic outcomes were evaluated during the follow-up period (from diagnosis through 12 months). RESULTS Baseline patient characteristics remained generally similar between 2013 and 2016. Although lack of oral anticoagulant prescriptions among eligible patients remained relatively high, utilization did increase progressively (53-58%). Among treated patients, there was a progressive decrease in warfarin use (79-52%) and a progressive increase in overall direct oral anticoagulant use (21-48%). There were progressive decreases in the incidence of stroke/systemic embolism 1.9-1.4 events per 100 person years) and major bleeding (4.6-3.3 events per 100 person years) as well as all-cause costs between 2013 and 2016. CONCLUSIONS The proportions of patients with non-valvular atrial fibrillation who were not prescribed an oral anticoagulant decreased but remained high. We observed an increase in direct oral anticoagulant use that coincided with decreased incidence of clinical outcomes as well as decreasing total healthcare costs.
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Affiliation(s)
- Brett D Atwater
- Inova Heart and Vascular Institute, 4Th Floor Medical Directors Suite, 3300 Gallows Road, Falls Church, VA, 22042, USA.
| | | | | | | | | | | | - Jenny Jiang
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | - Huseyin Yuce
- New York City College of Technology, City University of New York, New York, NY, USA
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Kefale AT, Bezabhe WM, Peterson GM. Oral Anticoagulant Use in Patients with Atrial Fibrillation at Low Risk of Stroke and Associated Bleeding Complications. J Clin Med 2023; 12:6182. [PMID: 37834830 PMCID: PMC10573191 DOI: 10.3390/jcm12196182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/20/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND The use of oral anticoagulants (OACs) in patients with atrial fibrillation (AF) and low stroke risk might cause more harm than benefit. Little attention has been given to address its prevalence and associated consequences. This study aimed to investigate the prescription rate of OACs, identify associated factors, and describe incident bleeding events in low-risk patients. METHODS We included patients with a new diagnosis of AF between 1 January 2011 and 31 December 2018 having a low risk of stroke (CHA2DS2-VASc score of 0 for males and 1 for females) from Australian general practice data (MedicineInsight). Patients were classified as OAC users if there was a recorded prescription of an OAC within 60 days of AF diagnosis, and factors associated with the prescription of an OAC were assessed using logistic regression. Recorded incident bleeding events were identified within 6 months after AF diagnosis or after OAC initiation for OAC non-users and users, respectively. The risk of bleeding was compared between the two groups by adjusting their baseline differences using propensity score matching. RESULTS The study included 2810 low-risk patients (62.3% male) with a mean age of 49.3 ± 10.8 years. Of the total, 705 (25.1%) patients had a record of OAC prescription within 60 days of diagnosis of AF. Older age (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.03-1.04) and diagnosis periods (2015-2016 [OR 1.46; 95% CI 1.10-1.94] and 2017-2018 [OR 1.65; 95% CI 1.17-2.23] vs. 2011-2012) were associated with higher odds of OAC initiation. Female sex (OR 0.71; 95% CI 0.59-0.85), higher bleeding risk (ORBIT score; OR 0.80; 95% CI 0.68-0.94), and higher socioeconomic index for areas (SEIFA) quintiles (SEIFA quintiles; 2 [OR 0.65; 95% CI 0.48-0.88], 3 [OR 0.74; 95% CI 0.56-0.98], 4 [OR 0.70; 95% CI 0.52-0.94], 5 [OR 0.69; 95% CI 0.52-0.91] compared with quintile 1) were associated with lower odds of OAC prescription. A total of 52 (in 1.8% of patients) incident bleeds were identified, with 18 (2.6%) among OAC users. The rate of bleeding was not significantly different between users and non-users after matching. However, within OAC users, commencement of OAC was associated with an increased risk of bleeding compared to the period before OAC initiation (p = 0.006). CONCLUSIONS One in four patients at low risk of stroke received an OAC within 60 days of AF diagnosis. Older age and the period following the widespread availability of direct-acting OACs were associated with an increased likelihood of OAC prescription. Positively, using OACs was not associated with an increased rate of bleeding compared to non-users.
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Affiliation(s)
- Adane Teshome Kefale
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS 7001, Australia
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Pauklin P, Marandi T, Kals M, Ainla T, Martinson K, Eha J, Kampus P. Lifeday coverage of oral anticoagulants and one-year relative survival in patients with atrial fibrillation: a population-based study in Estonia. BMC Cardiovasc Disord 2023; 23:398. [PMID: 37568101 PMCID: PMC10422845 DOI: 10.1186/s12872-023-03415-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Routine oral anticoagulation (OAC) is recommended for almost all high-risk patients with atrial fibrillation, yet registries show that OACs are still underused. Our aim was to study the lifeday coverage (LDC) of OAC prescriptions and its relationship with one-year mortality rates of AF patients aged ≥ 65 in Estonia for the years 2019 and 2020. METHODS Medical data for AF patients aged ≥ 65 years from 2018 and alive as of 01.01.2019 (cohort I) and new AF documentation from 2019 and alive as of 01.01.2020 (cohort II) was obtained from the Health Insurance Fund's electronic database. The data was linked to the nationwide Estonian Medical Prescription Centre's database of prescribed OACs. For LDC analysis, daily doses of guideline-recommended OACs were used. The patients were categorized into three LDC groups: 0%, 1-79%, and ≥ 80%. The data was linked to the Estonian Causes of Death Registry to establish the date of death and mortality rate for the whole Estonian population aged ≥ 65. RESULTS There were 34,018 patients in cohort I and 9,175 patients with new AF documentation (cohort II), previously not included in cohort I. Of the patients, 77.7% and 68.6% had at least one prescription of OAC in cohorts I and II respectively. 57.4% in cohort I and 44.5% in cohort II had an LDC of ≥ 80%. The relative survival estimates at 1 year for LDC lifeday coverage groups 0%, 1-79%, and ≥ 80% were 91.2%, 98.2%, and 98.5% (cohort I), and 91.9%, 95.2%, and 97.6% (cohort II), respectively. CONCLUSIONS Despite clear indications for OAC use, LDC is still insufficient and anticoagulation is underused for stroke prevention in Estonia. Further education of the medical community and patients is needed to achieve higher lifeday coverage of prescribed OACs.
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Affiliation(s)
- Priit Pauklin
- Department of Cardiology, Institute of Clinical Medicine, University of Tartu, 8 Puusepa Street, 50406, Tartu, Estonia.
- Heart Clinic, Tartu University Hospital, 8 Puusepa Street, 50406, Tartu, Estonia.
| | - Toomas Marandi
- Department of Cardiology, Institute of Clinical Medicine, University of Tartu, 8 Puusepa Street, 50406, Tartu, Estonia
- Centre of Cardiology, North Estonia Medical Centre, 19 Sütiste Street, 13419, Tallinn, Estonia
| | - Mart Kals
- Estonian Genome Center, Institute of Genomics, University of Tartu, 23b Riia Street, 51010, Tartu, Estonia
| | - Tiia Ainla
- Department of Cardiology, Institute of Clinical Medicine, University of Tartu, 8 Puusepa Street, 50406, Tartu, Estonia
- Centre of Cardiology, North Estonia Medical Centre, 19 Sütiste Street, 13419, Tallinn, Estonia
| | - Katrin Martinson
- Linnamõisa Family Medicine Center, 16 Koskla Street, 10615, Tallinn, Estonia
| | - Jaan Eha
- Department of Cardiology, Institute of Clinical Medicine, University of Tartu, 8 Puusepa Street, 50406, Tartu, Estonia
- Heart Clinic, Tartu University Hospital, 8 Puusepa Street, 50406, Tartu, Estonia
| | - Priit Kampus
- Department of Cardiology, Institute of Clinical Medicine, University of Tartu, 8 Puusepa Street, 50406, Tartu, Estonia
- Centre of Cardiology, North Estonia Medical Centre, 19 Sütiste Street, 13419, Tallinn, Estonia
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Ashburner JM, Chang Y, Borowsky LH, Khurshid S, McManus DD, Ellinor PT, Lubitz SA, Singer DE, Atlas SJ. Effect of clinic-based single-lead electrocardiogram rhythm assessment on oral anticoagulation prescriptions in patients with previously diagnosed atrial fibrillation. Heart Rhythm O2 2023; 4:469-477. [PMID: 37645259 PMCID: PMC10461197 DOI: 10.1016/j.hroo.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
Background Despite benefits of oral anticoagulation (OAC), many individuals with diagnosed atrial fibrillation (AF) do not receive OAC. Objective The purpose of this study was to assess whether cardiac rhythm assessment for AF impacted use of OAC in patients with previously diagnosed AF. Methods VITAL-AF was a cluster randomized controlled trial conducted in 16 primary care practices assessing the efficacy of AF rhythm assessment with single-lead electrocardiogram in routine care. Patients 65 years and older were offered rhythm assessment at visits. In this secondary analysis, we evaluated rhythm assessment uptake and compared initiation and discontinuation of OAC in patients with previously diagnosed AF from intervention and control arms over 1 year. Results The study included 4593 patients with previously diagnosed AF (2250 intervention; 2343 control). In the intervention arm, 2022 (89.9%) completed rhythm assessment (median 2 visits with rhythm assessment) and 40.1% had ≥1 "Possible AF" result. Initiation of OAC was similar in the intervention (17.7%) and control (19.1%) arms but was influenced by the rhythm assessment result: higher with a "Possible AF" (26.1%; adjusted odds ratio [aOR] 1.62; 95% confidence interval [CI] 1.04-2.51), and lower with a "Normal" result (9.9%; aOR 0.45; 95% CI 0.29-0.71) compared to control. OAC discontinuation was similar in the intervention (6.3%) and control (7.2%) arms, with lower discontinuation with a "Possible AF" result (3.8%; aOR 0.51; 95% CI 0.32-0.81). Conclusions Including patients with previously diagnosed AF in a point-of-care rhythm assessment strategy did not increase overall OAC use compared to the control arm. However, the rhythm assessment result influenced both initiation and discontinuation of OAC.
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Affiliation(s)
- Jeffrey M. Ashburner
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Leila H. Borowsky
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Shaan Khurshid
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
- Demoulas Center for Cardiac Arrhythmias, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - David D. McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Patrick T. Ellinor
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
- Demoulas Center for Cardiac Arrhythmias, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Steven A. Lubitz
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
- Demoulas Center for Cardiac Arrhythmias, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel E. Singer
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Steven J. Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
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Manning E, Burns K, Laurie M, Patten L, Ho M, Sandhu A. Factors associated with oral anticoagulant prescription status among patients with a new diagnosis of atrial fibrillation. Clin Cardiol 2023; 46:937-941. [PMID: 37401357 PMCID: PMC10436786 DOI: 10.1002/clc.24077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 06/15/2023] [Accepted: 06/20/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common sustained arrhythmia in adults and increases stroke risk. Treatment with oral anticoagulants (OACs) may reduce this risk however many patients do not receive OAC therapy. This study aimed to use electronic health record data to identify newly diagnosed AF patients at high risk for stroke and not anticoagulated as well as factors associated with OAC prescription. HYPOTHESIS Timely prescription of OACs among patients with newly diagnosed AF is poor. METHODS We performed a retrospective study of patients with a new diagnosis of AF. We assessed stroke risk with the CHA2 DS2 -VASc score. The primary outcome was prescription of an OAC within 6 months following diagnosis. We used logistic regression to see how the odds of being prescribed an OAC differs for 17 independent variables. RESULTS We identified 18 404 patients with a new diagnosis of AF. Among patients at high risk for stroke, 41.3% received an OAC prescription within 6 months. Male sex, Caucasian compared to African American race, stroke, obesity, congestive heart failure, vascular disorder, current antiplatelet, beta blocker, or calcium channel blocker prescription, and increasing CHA2 DS2 -VASc score were positively associated with receiving an OAC. Whereas anemia, renal dysfunction, liver dysfunction, antiarrhythmic drug use and increasing HAS-BLED score were negatively associated. CONCLUSIONS Most newly diagnosed AF patients at high stroke risk do not receive an OAC prescription in the first 6 months following diagnosis. Our analysis suggests that patient sex, race, comorbidities, and additional prescriptions are associated with rates of OAC prescribing.
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Affiliation(s)
- Evan Manning
- Internal Medicine Residency Training ProgramUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Kelley Burns
- Data Science to Patient Value (D2V)University of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Melissa Laurie
- US Health Economics & Outcomes ResearchBristol Myers SquibbLawrencevilleNew JerseyUSA
| | - Luke Patten
- Center for Innovative Design & AnalysisUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Michael Ho
- Deparment of MedicineUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Amneet Sandhu
- Deparment of MedicineUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
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McDermott A, Kim N, Hausmann LRM, Magnani JW, Good CB, Litam TMA, Mor MK, Omole TD, Gellad WF, Fine MJ, Essien UR. Association of Neighborhood Disadvantage and Anticoagulation for Patients with Atrial Fibrillation in the Veterans Health Administration: the REACH-AF Study. J Gen Intern Med 2023; 38:848-856. [PMID: 36151447 PMCID: PMC10039185 DOI: 10.1007/s11606-022-07810-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 09/13/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a common arrhythmia, the management of which includes anticoagulation for stroke prevention. Although disparities in anticoagulant prescribing have been well documented for individual socioeconomic factors, less is known about the association of neighborhood-level disadvantage and anticoagulation for AF. OBJECTIVE To assess the association between neighborhood disadvantage and anticoagulant initiation for patients with incident AF. DESIGN Retrospective cohort study. PARTICIPANTS A cohort of patients enrolled in the Veterans Health Administration (VA) with incident AF from January 2014 through December 2020 from the Race, Ethnicity, and Anticoagulant CHoice in Atrial Fibrillation (REACH-AF) Study. MAIN MEASURES The primary exposure was neighborhood disadvantage quantified using area deprivation index (ADI), classified by quintiles (Q). The outcomes were initiation of any anticoagulant therapy (warfarin or direct oral anticoagulant, DOAC) within 90 days of AF diagnosis and DOAC use among initiators. We used mixed effects logistic regression to assess the association between ADI and anticoagulant therapy, incorporating a fixed effect for treatment site and baseline patient, provider, and facility covariates. KEY RESULTS Among 161,089 patients, 105,489 (65.5%) initiated any anticoagulant therapy, and 78,903 (74.8%) used DOACs. Any anticoagulant therapy increased 3.2 percentage points (63.0% to 66.2%; p<.001) from Q1 to Q5, whereas DOAC use decreased 8.2 percentage points (79.4% to 71.2%; p<.0001) across quintiles. The adjusted odd ratios of any anticoagulant therapy were non-significantly different for Q2-Q5 than Q1. The adjusted odds of DOAC use decreased progressively from 0.89 (95% CI, 0.84-0.94) in Q2 to 0.77 (95% CI, 0.73-0.83) in Q5 compared to Q1 (p<.0001). CONCLUSIONS Among Veterans with incident AF, we observed similar initiation of any anticoagulant, though neighborhood deprivation was associated with decreased DOAC use among anticoagulant initiators. Future interventions to improve pharmacoequity in anticoagulant prescribing for AF should consider the role of neighborhood-level determinants of health inequities.
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Affiliation(s)
- Annie McDermott
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nadejda Kim
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jared W Magnani
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Centers for Value-Based Pharmacy Initiatives and High-Value Health Care, UPMC Health Plan, Pittsburgh, PA, USA
| | - Terrence M A Litam
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Toluwa D Omole
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Utibe R Essien
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Wang PJ, Lu Y, Mahaffey KW, Lin A, Morin DP, Sears SF, Chung MK, Russo AM, Lin B, Piccini J, Hills MT, Berube C, Pundi K, Baykaner T, Garay G, Lhamo K, Rice E, Pourshams IA, Shah R, Newswanger P, DeSutter K, Nunes JC, Albert MA, Schulman KA, Heidenreich PA, Bunch TJ, Sanders LM, Turakhia M, Verghese A, Stafford RS. Randomized Clinical Trial to Evaluate an Atrial Fibrillation Stroke Prevention Shared Decision-Making Pathway. J Am Heart Assoc 2023; 12:e028562. [PMID: 36342828 PMCID: PMC9973612 DOI: 10.1161/jaha.122.028562] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
Abstract
Background Oral anticoagulation reduces stroke and disability in atrial fibrillation (AF) but is underused. We evaluated the effects of a novel patient-clinician shared decision-making (SDM) tool in reducing oral anticoagulation patient's decisional conflict as compared with usual care. Methods and Results We designed and evaluated a new digital decision aid in a multicenter, randomized, comparative effectiveness trial, ENHANCE-AF (Engaging Patients to Help Achieve Increased Patient Choice and Engagement for AF Stroke Prevention). The digital AF shared decision-making toolkit was developed using patient-centered design with clear health communication principles (eg, meaningful images, limited text). Available in English and Spanish, the toolkit included the following: (1) a brief animated video; (2) interactive questions with answers; (3) a quiz to check on understanding; (4) a worksheet to be used by the patient during the encounter; and (5) an online guide for clinicians. The study population included English or Spanish speakers with nonvalvular AF and a CHA2DS2-VASc stroke score ≥1 for men or ≥2 for women. Participants were randomized in a 1:1 ratio to either usual care or the shared decision-making toolkit. The primary end point was the validated 16-item Decision Conflict Scale at 1 month. Secondary outcomes included Decision Conflict Scale at 6 months and the 10-item Decision Regret Scale at 1 and 6 months as well as a weighted average of Mann-Whitney U-statistics for both the Decision Conflict Scale and the Decision Regret Scale. A total of 1001 participants were enrolled and followed at 5 different sites in the United States between December 18, 2019, and August 17, 2022. The mean patient age was 69±10 years (40% women, 16.9% Black, 4.5% Hispanic, 3.6% Asian), and 50% of participants had CHA2DS2-VASc scores ≥3 (men) or ≥4 (women). The primary end point at 1 month showed a clinically meaningful reduction in decisional conflict: a 7-point difference in median scores between the 2 arms (16.4 versus 9.4; Mann-Whitney U-statistics=0.550; P=0.007). For the secondary end point of 1-month Decision Regret Scale, the difference in median scores between arms was 5 points in the direction of less decisional regret (P=0.078). The treatment effects lessened over time: at 6 months the difference in medians was 4.7 points for Decision Conflict Scale (P=0.060) and 0 points for Decision Regret Scale (P=0.35). Conclusions Implementation of a novel shared decision-making toolkit (afibguide.com; afibguide.com/clinician) achieved significantly lower decisional conflict compared with usual care in patients with AF. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04096781.
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Affiliation(s)
- Paul J. Wang
- Stanford University Department of MedicinePalo AltoCA
| | - Ying Lu
- Stanford University Department of Biomedical Data ScienceStanfordCA
| | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | - Amy Lin
- Stanford University Department of Biomedical Data ScienceStanfordCA
| | | | - Samuel F. Sears
- East Carolina University Department of PsychologyGreenvilleNC
| | - Mina K. Chung
- Cleveland Clinic Foundation Department of MedicineClevelandOH
| | | | - Bryant Lin
- Stanford University Department of MedicinePalo AltoCA
| | | | | | | | - Krishna Pundi
- Stanford University Department of MedicinePalo AltoCA
| | - Tina Baykaner
- Stanford University Department of MedicinePalo AltoCA
| | - Gotzone Garay
- Stanford University Department of MedicinePalo AltoCA
| | - Karma Lhamo
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | - Eli Rice
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | | | - Rushil Shah
- Stanford University Department of MedicinePalo AltoCA
| | - Paul Newswanger
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | | | | | - Michelle A. Albert
- University of California San Francisco Department of MedicineSan FranciscoCA
| | | | - Paul A. Heidenreich
- Stanford University Department of MedicinePalo AltoCA
- Palo Alto Veterans Administration Health Care Department of MedicinePalo AltoCA
| | - T. Jared Bunch
- University of Utah Department of MedicineSalt Lake CityUT
| | | | - Mintu Turakhia
- Stanford University Department of MedicinePalo AltoCA
- iRhythm TechnologiesSan FranciscoCA
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10
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Teppo K, Jaakkola J, Biancari F, Halminen O, Linna M, Haukka J, Putaala J, Mustonen P, Kinnunen J, Hartikainen J, Airaksinen KEJ, Lehto M. Association of income and educational levels on initiation of oral anticoagulant therapy in patients with incident atrial fibrillation: A Finnish nationwide cohort study. Br J Clin Pharmacol 2023; 89:351-360. [PMID: 35986926 PMCID: PMC10087474 DOI: 10.1111/bcp.15501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 07/16/2022] [Accepted: 08/08/2022] [Indexed: 12/01/2022] Open
Abstract
AIMS Socioeconomic disparities have been reported in the outcomes of patients with atrial fibrillation (AF). We assessed the hypothesis that AF patients with higher income or educational level are more frequently initiated with oral anticoagulant (OAC) therapy for stroke prevention. METHODS The nationwide registry-based Finnish AntiCoagulation in Atrial Fibrillation cohort covers all patients with AF from all levels of care in Finland. Patients were divided into income quartiles according to their highest annual income during 2004-2018 and into three categories based on educational attainment. The outcome was the first redeemed OAC prescription. RESULTS We identified 239 222 patients (mean age 72.7 ± 13.2 years, 49.8% female) with incident AF during 2007-2018. Higher income was associated with higher OAC initiation rate: compared to the lowest income quartile the adjusted SHRs (95% CI) for OAC initiation were 1.09 (1.07-1.10), 1.13 (1.11-1.14) and 1.13 (1.12-1.15) in the second, third and fourth income quartiles, respectively. Patients in the highest educational category had a slightly lower OAC initiation rate than patients in the lowest educational category (adjusted SHR 0.92 [95% CI 0.90-0.93]). Income-related disparities were larger and education-related disparities only marginal among patients at high risk of ischemic stroke. The socioeconomic disparities in OAC initiation within 1-year follow-up decreased from 2007 to 2018. The adoption of direct OACs as the initial anticoagulant was faster among patients with higher income or educational levels. CONCLUSION These findings highlight potential missed opportunities in stroke prevention, especially among AF patients with low income, whereas the education-related disparities in OAC initiation appear controversial.
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Affiliation(s)
| | - Jussi Jaakkola
- University of Turku, Turku, Finland.,Heart Unit, Satakunta Central Hospital, Pori, Finland
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.,Clinica Montevergine, GVM Care & Research, Mercogliano, Italy
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Miika Linna
- Aalto University, Espoo, Finland.,University of Eastern Finland, Kuopio, Finland
| | - Jari Haukka
- University of Helsinki, Faculty of Medicine, Clinicum, Helsinki, Finland
| | - Jukka Putaala
- Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | | | - Janne Kinnunen
- Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | - Juha Hartikainen
- University of Eastern Finland, Kuopio, Finland.,Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - K E Juhani Airaksinen
- University of Turku, Turku, Finland.,Heart Center, Turku University Hospital, Turku, Finland
| | - Mika Lehto
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland.,University of Helsinki, Faculty of Medicine, Clinicum, Helsinki, Finland.,Department of Internal Medicine, Lohja Hospital, Lohja, Finland
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11
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Patient Education Strategies to Improve Risk of Stroke in Patients with Atrial Fibrillation. CURRENT CARDIOVASCULAR RISK REPORTS 2022. [DOI: 10.1007/s12170-022-00709-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
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12
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Teppo K, Jaakkola J, Langén VL, Biancari F, Halminen O, Linna M, Haukka J, Putaala J, Mustonen P, Kinnunen J, Luojus A, Hartikainen J, Airaksinen KEJ, Lehto M. Rural-urban differences in the initiation of oral anticoagulant therapy in patients with incident atrial fibrillation: A Finnish nationwide cohort study. PLoS One 2022; 17:e0276612. [PMID: 36315505 PMCID: PMC9621410 DOI: 10.1371/journal.pone.0276612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 10/10/2022] [Indexed: 01/24/2023] Open
Abstract
AIMS Little is known about rural-urban differences in the treatment and outcomes in patients with atrial fibrillation (AF). We aimed to assess whether the initiation of oral anticoagulant (OAC) therapy in patients with AF differs between those with rural and urban residence. METHODS The registry-based FinACAF cohort covers all patients with AF from all levels of care in Finland. Patients were divided into rural and urban categories and into urbanization degree tertiles based on their municipality of residence at the time of AF diagnosis. The outcome was the first redeemed OAC prescription. RESULTS We identified 222 419 patients (50.1% female; mean age 72.8 (SD 13.2) years) with incident AF during 2007-2018. Urban residence was associated with a lower rate of OAC therapy initiation (adjusted subdistribution hazard ratio (SHR) (95% CI) 0.96 (0.95-0.97)). Correspondingly, an inverse graded dose-response relationship was observed between higher urbanization degree tertile and OAC initiation rate (highest tertile compared to lowest: adjusted SHR (95% CI) 0.94 (0.93-0.95)). The adoption of direct oral anticoagulants for stroke prevention was faster among patients with urban residence. CONCLUSION This nationwide cohort study documented that urban residence is associated with a slightly lower rate of OAC therapy initiation in patients with incident AF, but faster adoption of direct oral anticoagulant use.
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Affiliation(s)
| | - Jussi Jaakkola
- University of Turku, Turku, Finland
- Heart Unit, Satakunta Central Hospital, Pori, Finland
| | - Ville L. Langén
- Division of Medicine, Turku University Hospital, Turku, Finland
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
- Clinica Montevergine, GVM Care & Research, Mercogliano, Italy
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo Finland
| | - Miika Linna
- Aalto University, Espoo, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Jari Haukka
- Faculty of Medicine, Clinicum, University of Helsinki, Helsinki, Finland
| | - Jukka Putaala
- Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Janne Kinnunen
- Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Alex Luojus
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
- Faculty of Medicine, Clinicum, University of Helsinki, Helsinki, Finland
| | - Juha Hartikainen
- University of Eastern Finland, Kuopio, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | | | - Mika Lehto
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
- Faculty of Medicine, Clinicum, University of Helsinki, Helsinki, Finland
- Department of Internal Medicine, Lohja Hospital, Lohja, Finland
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13
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Ivany E, Ritchie LA, Lip GY, Lotto RR, Werring DJ, Lane DA. Effectiveness and Safety of Antithrombotic Medication in Patients With Atrial Fibrillation and Intracranial Hemorrhage: Systematic Review and Meta-Analysis. Stroke 2022; 53:3035-3046. [DOI: 10.1161/strokeaha.122.038752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND:
For patients with atrial fibrillation who survive an intracranial hemorrhage (ICrH), the decision to offer oral anticoagulation (OAC) is challenging and necessitates balancing risk of thromboembolic events with risk of recurrent ICrH.
METHODS:
This systematic review assesses the effectiveness and safety of OAC and/or antiplatelets in patients with atrial fibrillation with nontraumatic ICrH. Bibliographic databases CENTRAL, MEDLINE, EMBASE, and CINAHL were searched. Articles on adults with atrial fibrillation with spontaneous ICrH (intracerebral, subdural, and subarachnoid), receiving antithrombotic therapy for stroke prevention were eligible for inclusion.
RESULTS:
Twenty articles (50 470 participants) included 2 randomized controlled trials (n=304)‚ 8 observational studies, 8 cohort studies, and 2 studies that meta-analyzed individual-level data from observational studies. OAC therapy was associated with a significant reduction in thromboembolic events (summary relative risk [sRR], 0.51 [95% CI, 0.30–0.86], heterogeneity I
2
=2%;
P
=0.39, n=5 studies) and all-cause mortality (sRR, 0.52 [95% CI, 0.38–0.71], heterogeneity I
2
=0;
P
=0.44, n=3 studies). OAC therapy was not associated with an increased risk of recurrent ICrH (sRR, 1.44 [95% CI, 0.38–5.46], heterogeneity I
2
=70%,
P
=0.02, n=5 studies). Nonvitamin K antagonist OACs were more effective at reducing the risk of thromboembolic events (sRR, 0.65 [95% CI, 0.44–0.97], heterogeneity I
2
=72%,
P
=0.03, n=3 studies) and were associated with a lower risk of recurrent ICrH (sRR, 0.52 [95% CI, 0.40–0.67], heterogeneity I
2
=0%,
P
=0.43, n=3 studies) than warfarin.
CONCLUSIONS:
In nontraumatic ICrH survivors with atrial fibrillation, OAC therapy is associated with a reduced risk of thromboembolic events and all-cause mortality without significantly increasing risk of recurrent ICrH. This finding is primarily based on observational data, and further larger randomized controlled trials are needed to corroborate or refute these findings.
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Affiliation(s)
- Elena Ivany
- Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom. (E.I., L.A.R., G.Y.H.L., R.R.L., D.A.L.)
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom. (E.I., L.A.R., G.Y.H.L., D.A.L.)
| | - Leona A. Ritchie
- Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom. (E.I., L.A.R., G.Y.H.L., R.R.L., D.A.L.)
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom. (E.I., L.A.R., G.Y.H.L., D.A.L.)
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom. (E.I., L.A.R., G.Y.H.L., R.R.L., D.A.L.)
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom. (E.I., L.A.R., G.Y.H.L., D.A.L.)
- Liverpool Heart and Chest Hospital, United Kingdom (G.Y.H.L., D.A.L.)
- Department of Clinical Medicine, Aalborg University, Denmark (G.Y.H.L., D.A.L.)
| | - Robyn R. Lotto
- Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom. (E.I., L.A.R., G.Y.H.L., R.R.L., D.A.L.)
- School of Nursing and Allied Health, Faculty of Health, Liverpool John Moores University, United Kingdom (R.R.L.)
| | - David J. Werring
- Stroke Research Centre, University College London, Queen Square Institute of Neurology, United Kingdom (D.J.W.)
| | - Deirdre A. Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom. (E.I., L.A.R., G.Y.H.L., R.R.L., D.A.L.)
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom. (E.I., L.A.R., G.Y.H.L., D.A.L.)
- Liverpool Heart and Chest Hospital, United Kingdom (G.Y.H.L., D.A.L.)
- Department of Clinical Medicine, Aalborg University, Denmark (G.Y.H.L., D.A.L.)
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14
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Baykaner T, Pundi K, Lin B, Lu Y, DeSutter K, Lhamo K, Garay G, Nunes JC, Morin DP, Sears SF, Chung MK, Paasche-Orlow MK, Sanders LM, Bunch TJ, Hills MT, Mahaffey KW, Stafford RS, Wang PJ. The ENHANCE-AF clinical trial to evaluate an atrial fibrillation shared decision-making pathway: Rationale and study design. Am Heart J 2022; 247:68-75. [PMID: 35092723 DOI: 10.1016/j.ahj.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 01/20/2022] [Accepted: 01/20/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Shared decision making (SDM) may result in treatment plans that best reflect the goals and wishes of patients, increasing patient satisfaction with the decision-making process. There is a knowledge gap to support the use of decision aids in SDM for anticoagulation therapy in patients with atrial fibrillation (AF). We describe the development and testing of a new decision aid, including a multicenter, randomized, controlled, 2-arm, open-label ENHANCE-AF clinical trial (Engaging Patients to Help Achieve Increased Patient Choice and Engagement for AF Stroke Prevention) to evaluate its effectiveness in 1,200 participants. METHODS Participants will be randomized to either usual care or to a SDM pathway incorporating a digital tool designed to simplify the complex concepts surrounding AF in conjunction with a clinician tool and a non-clinician navigator to guide the participants through each step of the tool. The participant-determined primary outcome for this study is the Decisional Conflict Scale, measured at 1 month after the index visit during which a decision was made regarding anticoagulation use. Secondary outcomes at both 1 and 6 months will include other decision making related scales as well as participant and clinician satisfaction, oral anticoagulation adherence, and a composite rate of major bleeding, death, stroke, or transient ischemic attack. The study will be conducted at four sites selected for their ability to enroll participants of varying racial and ethnic backgrounds, health literacy, and language skills. Participants will be followed in the study for 6 months. CONCLUSIONS The results of the ENHANCE-AF trial will determine whether a decision aid facilitates high quality shared decision making in anticoagulation discussions for stroke reduction in AF. An improved shared decision-making experience may allow patients to make decisions better aligned with their personal values and preferences, while improving overall AF care.
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15
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Ivany E, Lane DA, Dan GA, Doehner W, Farkowski MM, Iliodromitis K, Lenarczyk R, Potpara TS. Antithrombotic therapy for stroke prevention in patients with atrial fibrillation who survive an intracerebral haemorrhage: results of an EHRA survey. Europace 2021; 23:806-814. [PMID: 34020460 DOI: 10.1093/europace/euaa423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/30/2020] [Indexed: 11/13/2022] Open
Abstract
The aim of this survey is to provide a snapshot of current practice regarding antithrombotic therapy (ATT) in patients with atrial fibrillation (AF) comorbid with intracerebral haemorrhage (ICH). An online survey was distributed to members of the European Heart Rhythm Association. A total of 163 clinicians responded, mostly cardiologists or electrophysiologists (87.7%), predominantly working in University hospitals (61.3%). Most respondents (47.2%) had seen one to five patients with AF comorbid with ICH in the last 12 months. Among patients sustaining an ICH on oral anticoagulation (OAC), 84.3% respondents would consider some form of ATT post-ICH, with 73.2% preferring to switch from a vitamin-K antagonist (VKA) to a non-VKA oral anticoagulant (NOAC) and 37.2% preferring to switch from one NOAC to another. Most (36.6%) would restart OAC >30 days post-ICH. Among patients considered unable to take OAC, left atrial appendage occlusion procedure was the therapy of choice in 73.3% respondents. When deciding on ATT, respondents considered patient's CHA2DS2-VASc score, ICH type, demographics, risk factors, and patient adherence. The main reason for not restarting or commencing ATT was concern about recurrent ICH (80.8%). National or international clinical guidelines would be advantageous to support decision-making (84.3%). Other helpful resources reported were multidisciplinary team involvement (46.9%) and patient education (82%). In summary, most survey respondents would prescribe OAC therapy for patients with AF who have sustained an ICH on OAC and would restart OAC >30 days post-ICH. The risk of recurrent ICH was the main reason for not prescribing any ATT post-ICH.
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Affiliation(s)
- Elena Ivany
- Liverpool Centre for Cardiovascular Science, University of Liverpool, 6 West Derby Street, Liverpool L7 8TX, UK
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, 6 West Derby Street, Liverpool L7 8TX, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gheorghe-Andrei Dan
- 'Internal Medicine, Carol Davila' University of Medicine, Colentina University Hospital, Bucharest, Romania
| | - Wolfram Doehner
- Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany.,Department of Cardiology (Virchow Klinikum), Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Michal M Farkowski
- II Department of Heart Arrhythmia, National Institute of Cardiology, Warsaw, Poland
| | | | - Radoslaw Lenarczyk
- Department of Cardiology, Congenital Heart Defects and Electrotherapy, Medical University of Silesia, Silesian Center of Heart Disease, Zabrze, Poland
| | - Tatjana S Potpara
- Serbia School of Medicine, University of Belgrade, Belgrade, Serbia.,Department for Intensive Care in Cardiac Arrhythmias, Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
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16
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MAUDE Database Analysis of Post-Approval Outcomes following Left Atrial Appendage Closure with the Watchman Device. Am J Cardiol 2021; 152:78-87. [PMID: 34116792 DOI: 10.1016/j.amjcard.2021.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 11/20/2022]
Abstract
Left atrial appendage closure (LAAC) is an important strategy to reduce stroke risk in patients with non-valvular atrial fibrillation (AF) who are at high risk of bleeding on long-term anticoagulation. Real-world assessments of the safety of the Watchman LAAC device remain limited. The objective of this study was to determine the frequency and timing of adverse events associated with Watchman LAAC device implants performed after FDA approval. Adverse events associated with Watchman LAAC implants performed between March 2015 and March 2019 were identified through a search of the FDA Manufacturer and User Facility Device Experience (MAUDE) database. During the study period, 3,652 unique adverse events were identified. An estimated 43,802 Watchman implants were performed in the United States during the study period. The overall adverse event rate was 7.3% and the mortality rate was 0.4%. Of the 159 unique types of adverse events identified, pericardial effusion was most common (1.4%). Most adverse events (73%) occurred intraoperatively (59%) or within 1 day of the procedure (15%). However, 19% of deaths, 24% of strokes and 27% of device embolizations occurred >1 month after implantation. The rates of most Watchman-related adverse events reported in the MAUDE database were comparable to those observed in clinical trials. A majority of adverse events occurred within 1 day of implant. In conclusion, while the absolute event rates were low, a significant proportion of device embolizations, strokes, and deaths occurred >1 month after Watchman implant.
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17
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Bartolazzi F, Ribeiro ALP, de Sousa WJFN, Vianna MS, da Silva JLP, Martins MAP. Relationship of health literacy and adherence to oral anticoagulation therapy in patients with atrial fibrillation: a cross-sectional study. J Thromb Thrombolysis 2021; 52:1074-1080. [PMID: 33855686 DOI: 10.1007/s11239-021-02432-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 11/28/2022]
Abstract
Oral anticoagulant therapy (OAT) has increased substantially due to the aging population and prevalence rise of atrial fibrillation (AF). Medication adherence is important to achieve effectiveness and safety of OAT. The study aim was to investigate the relationship between health literary (HL) and the adherence to OAT in patients with atrial fibrillation (AF). This is a cross-sectional study conducted in a public cardiology clinic in Brazil, 2019. Sociodemographic and clinical data were collected by the review of medical records and interviews with patients. The relation between health literacy (HL) and adherence to OAT was investigated by a multiple logistic regression model. Overall, 100 AF patients were included in this study, with average age of 68.8 ± 13.8 years and predominance of women (54 %). Inadequate HL was found in 79 % of the patients and non-adherence was identified in 66 % of the participants. Sex was the only variable with a statistically significant association with non-adherence to OAT. Men presented a 2.54-fold greater chance of non-adherence to OAT, when compared to the women (Odds ratio (OR) = 2.54; 95 % confidence interval (CI): 1.03-6.62; p = 0.047). No statistically significant relationship was found between inadequate HL and non-adherence to OAT (OR 1.48; 95 % CI, 0.47-4.61; p = 0.49). High rates of inadequate HL and non-adherence to OAT were identified in this study; however, this relationship did not prove to be statistically significant. Further studies are needed to investigate factors associated with non-adherence to OAT in large samples of vulnerable populations and strategies for its improvement in public health.
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Affiliation(s)
- Frederico Bartolazzi
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 190, Santa Efigênia, Belo Horizonte, Minas Gerais, CEP 30130-100, Brazil
| | - Antônio Luiz Pinho Ribeiro
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 190, Santa Efigênia, Belo Horizonte, Minas Gerais, CEP 30130-100, Brazil.,Hospital das Clínicas da Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 110, Santa Efigênia, Belo Horizonte, Minas Gerais, CEP 30130-100, Brazil
| | - Waleska Jaclyn Freitas Nunes de Sousa
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 190, Santa Efigênia, Belo Horizonte, Minas Gerais, CEP 30130-100, Brazil
| | - Mayara Sousa Vianna
- Faculdade de Farmácia, Universidade Federal de Minas Gerais, Av. Pres. Antônio Carlos, 6.627, Campus Pampulha, Belo Horizonte, Minas Gerais, CEP 31270-901, Brazil
| | - José Luiz Padilha da Silva
- Universidade Federal do Paraná, Edifício do Setor de Ciências Exatas - 2 o andar, Centro Politécnico, Jardim das Américas, Curitiba, Paraná, CEP 81531-980, Brazil
| | - Maria Auxiliadora Parreiras Martins
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 190, Santa Efigênia, Belo Horizonte, Minas Gerais, CEP 30130-100, Brazil. .,Hospital das Clínicas da Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 110, Santa Efigênia, Belo Horizonte, Minas Gerais, CEP 30130-100, Brazil. .,Faculdade de Farmácia, Universidade Federal de Minas Gerais, Av. Pres. Antônio Carlos, 6.627, Campus Pampulha, Belo Horizonte, Minas Gerais, CEP 31270-901, Brazil.
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Antiplatelet patterns and outcomes in patients with atrial fibrillation not prescribed an anticoagulant after stroke. Int J Cardiol 2020; 321:88-94. [PMID: 32805327 DOI: 10.1016/j.ijcard.2020.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/14/2020] [Accepted: 08/07/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND To determine association of discharge antiplatelet therapy prescription with 1-year outcomes among patients with AF admitted with acute ischemic stroke and discharged without oral anticoagulation. METHODS In a retrospective cohort study from the Get With The Guidelines-Stroke registry, we identified all Medicare fee-for-service beneficiaries 65 years or older with AF or atrial flutter admitted with acute ischemic stroke and discharged without oral anticoagulation from April 2003 through December 2014, and we determined association of discharge antiplatelet therapy prescription with 1-year outcomes using Medicare claims data. Primary outcomes were 1-year mortality and composite endpoint of major adverse cardiovascular/neurologic/bleeding events (MACNBE). RESULTS Of 64,228 subjects (median [interquartile range] age, 84 [78-89] years; 62.5% female), 54,621 (85.0%) were discharged with antiplatelet therapy, and 9607 (15.0%) were discharged with no antithrombotic therapy. The unadjusted rates of 1-year mortality were lower among patients receiving antiplatelet therapy (37.3%) than among those receiving no antithrombotic therapy (48.1%); unadjusted rates of MACNBE were lower for those receiving antiplatelet therapy (45.5%) compared with those receiving no antithrombotic therapy (55.2%). After adjusting for potential confounders, antiplatelet therapy prescription was associated with reduced 1-year mortality (adjusted hazard ratio [HR] 0.64, 95% confidence interval [CI] 0.62-0.66, P < .001) and MACNBE (adjusted HR 0.69, 95% CI 0.67-0.71, P < .001). CONCLUSIONS Among Medicare beneficiaries with AF admitted for acute ischemic stroke but not discharged on oral anticoagulant therapy, antiplatelet therapy, compared with no antithrombotic therapy, was associated with reduced 1-year mortality and MACNBE.
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Chen HB, Xiu J, Li YH, Yu TH. The risk of bleeding and all-cause mortality with edoxaban versus vitamin K antagonists: A meta-analysis of phase III randomized controlled trials. Thromb Res 2020; 194:82-90. [DOI: 10.1016/j.thromres.2020.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/13/2020] [Accepted: 06/03/2020] [Indexed: 12/29/2022]
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Caro Martinez C, Cerezo Manchado JJ, Flores Blanco PJ, Elvira Ruíz G, Albendín Iglesias H, Lova Navarro A, Arregui Montoya F, García Alberola A, Andrés Pascual Figal D, Bailén Lorenzo JL, Navarro-Almenzar B, García-Candel F, Manzano Fernández S. Effectiveness and safety of rivaroxaban in nonvalvular atrial fibrillation: data from a contemporary Spanish registry. Curr Med Res Opin 2019; 35:1463-1471. [PMID: 30912682 DOI: 10.1080/03007995.2019.1600483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Objective: To ascertain the clinical profile, management and rates of thromboembolic and bleeding complications in a contemporary cohort of patients with nonvalvular atrial fibrillation (NVAF) on rivaroxaban treatment, with a particular focus on some subgroups of patients. Methods: Retrospective study that included all NVAF patients who started treatment with rivaroxaban for the prevention of stroke or systemic embolism between December 2012 and December 2015. Rates of outcomes (stroke, nonfatal myocardial infarction, major bleeding, intracranial bleeding and death) during follow-up were calculated. Results: A total of 732 patients (mean age 76.4 ± 9.2 years; 54.5% women) were included. Comorbidities were common (hypertension 87.5%; diabetes 26.5%; renal insufficiency 24.6%; prior stroke/transient ischemic attack 16.8%). Mean CHA2DS2-VASc was 3.9 ± 1.5 and HAS-BLED 2.3 ± 0.9; 61.9% of patients were rivaroxaban naïve users. After a mean treatment period of 22.7 ± 7.4 months, rates of stroke, nonfatal myocardial infarction, major bleeding, intracranial bleeding and death were 1.8, 1.0, 3.2, 0.4 and 5.5 events per 100 patient-years, respectively. Rates of stroke and death were higher in patients >75 years (vs. ≤75 years) and in patients with prior stroke/transient ischemic attack or renal insufficiency. Rates of major bleeding were higher among patients >75 years and in patients with prior stroke/transient ischemic attack. Conclusions: In this contemporary Spanish cohort of NVAF patients on rivaroxaban, patients had many comorbidities, a high thromboembolic risk and a moderate bleeding risk. Overall, rates of stroke and bleeding complications were low and similar to other previous studies. These data suggest that rivaroxaban is effective and safe in routine practice.
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Affiliation(s)
| | - Juan José Cerezo Manchado
- b Servicio de Hematología , Hospital Clínico Universitario Virgen de la Arrixaca , El Palmar , Spain
| | - Pedro José Flores Blanco
- c Servicio de Cardiología , Hospital Clínico Universitario Virgen de la Arrixaca , El Palmar , Spain
| | - Ginés Elvira Ruíz
- c Servicio de Cardiología , Hospital Clínico Universitario Virgen de la Arrixaca , El Palmar , Spain
| | - Helena Albendín Iglesias
- d Departamento de Medicina Interna, Facultad de Medicina , Universidad de Murcia , Spain
- e Servicio de Medicina Interna , Hospital Clínico Universitario Virgen de la Arrixaca , El Palmar , Spain
| | - Alejandro Lova Navarro
- c Servicio de Cardiología , Hospital Clínico Universitario Virgen de la Arrixaca , El Palmar , Spain
| | - Francisco Arregui Montoya
- c Servicio de Cardiología , Hospital Clínico Universitario Virgen de la Arrixaca , El Palmar , Spain
| | - Arcadio García Alberola
- c Servicio de Cardiología , Hospital Clínico Universitario Virgen de la Arrixaca , El Palmar , Spain
- d Departamento de Medicina Interna, Facultad de Medicina , Universidad de Murcia , Spain
- f Instituto Murciano de Investigación Biosanitaria , El Palmar , Spain
| | - Domingo Andrés Pascual Figal
- c Servicio de Cardiología , Hospital Clínico Universitario Virgen de la Arrixaca , El Palmar , Spain
- d Departamento de Medicina Interna, Facultad de Medicina , Universidad de Murcia , Spain
- f Instituto Murciano de Investigación Biosanitaria , El Palmar , Spain
| | | | - Begoña Navarro-Almenzar
- b Servicio de Hematología , Hospital Clínico Universitario Virgen de la Arrixaca , El Palmar , Spain
| | - Faustino García-Candel
- b Servicio de Hematología , Hospital Clínico Universitario Virgen de la Arrixaca , El Palmar , Spain
- f Instituto Murciano de Investigación Biosanitaria , El Palmar , Spain
| | - Sergio Manzano Fernández
- c Servicio de Cardiología , Hospital Clínico Universitario Virgen de la Arrixaca , El Palmar , Spain
- d Departamento de Medicina Interna, Facultad de Medicina , Universidad de Murcia , Spain
- f Instituto Murciano de Investigación Biosanitaria , El Palmar , Spain
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Cervantes CE, Merino JL, Barrios V. Edoxaban for the prevention of stroke in patients with atrial fibrillation. Expert Rev Cardiovasc Ther 2019; 17:319-330. [DOI: 10.1080/14779072.2019.1598263] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Carlos Escobar Cervantes
- Cardiology Service, Unidad de electrofisiología cardíaca robotizada, Hospital Universitario La Paz, Madrid, Spain
| | - José Luis Merino
- Cardiology Service, Unidad de electrofisiología cardíaca robotizada, Hospital Universitario La Paz, Madrid, Spain
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Cerdá M, Cerezo-Manchado JJ, Johansson E, Martínez F, Fernández M, Varela A, Rodríguez S, Bosch F, Santamaría A. Facing real-life with direct oral anticoagulants in patients with nonvalvular atrial fibrillation: outcomes from the first observational and prospective study in a Spanish population. J Comp Eff Res 2019; 8:165-178. [DOI: 10.2217/cer-2018-0134] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Aim: To analyze the effectiveness and safety of direct oral anticoagulants (DOACs) in atrial fibrillation (AF) patients attended in clinical practice. Methods: Observational and prospective study of AF patients that started treatment with DOACs. Results: 1443 patients (age 77.2 ± 9.7 years, CHA2DS2-VASc = 4.1 ± 1.5) were included. 46.0% were taking rivaroxaban, 24.4% dabigatran, 22.5% apixaban and 7.1% edoxaban. Patients taking dabigatran were younger, had lower CHA2DS2-VASc and lesser renal insufficiency. Patients taking apixaban had higher CHA2DS2-VASc and more renal insufficiency. Rates of stroke/major bleeding/intracranial bleeding were 0.7/1.3/0.2 events/100 patient-years, respectively. Conclusion: This was the first prospective study that analyzed the use of all DOACs in AF patients in Spain, showing a good profile in terms of safety and effectiveness in accordance with pivotal studies.
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Affiliation(s)
- María Cerdá
- Servicio de Hematología, Hospital Vall d'Hebron, Barcelona, Spain
| | | | - Erik Johansson
- Servicio de Hematología, Hospital Vall d'Hebron, Barcelona, Spain
| | | | | | - Ana Varela
- Servicio de Hematología, Hospital Vall d'Hebron, Barcelona, Spain
| | - Saray Rodríguez
- Servicio de Hematología, Hospital Vall d'Hebron, Barcelona, Spain
| | - Francesc Bosch
- Servicio de Hematología, Hospital Vall d'Hebron, Barcelona, Spain
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Electronic physician notifications to improve guideline-based anticoagulation in atrial fibrillation: a randomized controlled trial. J Gen Intern Med 2018; 33:2070-2077. [PMID: 30076573 PMCID: PMC6258628 DOI: 10.1007/s11606-018-4612-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 06/20/2018] [Accepted: 07/18/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Oral anticoagulants reduce the risk of stroke in patients with atrial fibrillation. However, many patients with atrial fibrillation at elevated stroke risk are not treated with oral anticoagulants. OBJECTIVE To test whether electronic notifications sent to primary care physicians increase the proportion of ambulatory patients prescribed oral anticoagulants. DESIGN Randomized controlled trial conducted from February to May 2017 within 18 practices in an academic primary care network. PARTICIPANTS Primary care physicians (n = 175) and their patients with atrial fibrillation, at elevated stroke risk, and not prescribed oral anticoagulants. INTERVENTION Patients of each physician were randomized to the notification or usual care arm. Physicians received baseline email notifications and up to three reminders with patient information, educational material and primary care guidelines for anticoagulation management, and surveys in the notification arm. MAIN MEASURES The primary outcome was the proportion of patients prescribed oral anticoagulants at 3 months in the notification (n = 972) vs. usual care (n = 1364) arms, compared using logistic regression with clustering by physician. Secondary measures included survey-based physician assessment of reasons why patients were not prescribed oral anticoagulants and how primary care physicians might be influenced by the notification. KEY RESULTS Over 3 months, a small proportion of patients were newly prescribed oral anticoagulants with no significant difference in the notification (3.9%, 95% CI 2.8-5.3%) and usual care (3.2%, 95% CI 2.4-4.2%) arms (p = 0.37). The most common, non-exclusive reasons why patients were not on oral anticoagulants included atrial fibrillation was transient (30%) or paroxysmal (12%), patient/family declined (22%), high bleeding risk (20%), fall risk (19%), and frailty (10%). For 95% of patients, physicians stated they would not change their management after reviewing the alert. CONCLUSIONS Electronic physician notification did not increase anticoagulation in patients with atrial fibrillation at elevated stroke risk. Primary care physicians did not prescribe anticoagulants because they perceived the bleeding risk was too high or stroke risk was too low. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT02950285.
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Hsu JC, Freeman JV. Response to: “Enlisting Emergency Medicine Clinicians to Help Reduce Strokes in High-Risk Patients With Atrial Fibrillation and Flutter”. Clin Pharmacol Ther 2018; 104:615. [DOI: 10.1002/cpt.1143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/31/2018] [Indexed: 11/07/2022]
Affiliation(s)
- Jonathan C. Hsu
- University of California San Diego Medical Center; La Jolla California USA
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Vinson DR, Kea B, Coll-Vinent B, Barrett TW, Atzema CL. Enlisting Emergency Medicine Clinicians to Help Reduce Strokes in High-Risk Patients With Atrial Fibrillation and Flutter. Clin Pharmacol Ther 2018; 104:613-614. [PMID: 30006942 DOI: 10.1002/cpt.1144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 05/17/2018] [Indexed: 11/09/2022]
Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, California, USA.,Kaiser Permanente Division of Research, Oakland, California, USA.,The CREST Network, Oakland, California, USA.,Department of Emergency Medicine, Kaiser Permanente Sacramento Medical Center, Sacramento, California, USA
| | - Bory Kea
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Blanca Coll-Vinent
- Arrhythmia Division, Spanish Society of Emergency Medicine, Madrid, Spain.,Emergency Area Research Group, Hospital Clinic, Barcelona, Spain
| | - Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Clare L Atzema
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Division of Emergency Medicine, Department of Medicine, the Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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