The Prevalence and Determinants of Inappropriate Oral Anticoagulant Use in Patients with Atrial Fibrillation, in Resource-Limited Setting

Introduction

Anticoagulation treatment is routinely underused in patients with atrial fibrillation (AF), particularly in settings with limited resources. The current study is aimed at evaluating the appropriateness of oral anticoagulation treatment among AF patients at the Yekatit 12 Hospital Medical College (Y12HMC), Addis Ababa, Ethiopia.

Methods

Institutional-based retrospective cross-sectional study conducted in Y12HMC from November 2019 to March 2020. During the study period, 256 patients' medical records were found; 231 of them met the eligibility criteria and were included in the study. The data were analyzed using SPSS version 25, descriptive statistics were used to summarize the data, and binary logistic regression was performed to identify predictors of inappropriate anticoagulation management.

Results

The majority of study participants were males (55.8%), and over half of them (57.6%) had a nonvalvular type of AF. The majority of patients (61.9%) were receiving anticoagulant treatment, and of them, warfarin was prescribed to most of the study subjects (71.3%). Nearly half (47.6%) of the study participants had inappropriate anticoagulation treatment; among these, the majority of them (69.1%) were from a valvular type of AF. Patients with a valvular type of AF and having the diagnosis of congestive heart disease as comorbidity showed a statistically significant association towards inappropriate anticoagulation management.

Conclusion

According to the study, a significant portion of AF patients received inappropriate anticoagulant treatment, which may play a significant role for the increased risk of stroke in these groups of patients. All of the inappropriate cases were due to failure to start anticoagulant treatment.

Predictors of Adherence to Stroke Prevention in the BALKAN-AF Study: A Machine-Learning Approach

Background Compared with usual care, guideline-adherent stroke prevention strategy, based on the ABC (Atrial fibrillation Better Care) pathway, is associated with better outcomes. Given that stroke prevention is central to atrial fibrillation (AF) management, improved efforts to determining predictors of adherence with ‘A’ (avoid stroke) component of the ABC pathway are needed.

Purpose We tested the hypothesis that more sophisticated methodology using machine learning (ML) algorithms could do this.

Methods In this post-hoc analysis of the BALKAN-AF dataset, ML algorithms and logistic regression were tested. The feature selection process identified a subset of variables that were most relevant for creating the model. Adherence with the ‘A’ criterion of the ABC pathway was defined as the use of oral anticoagulants (OAC) in patients with AF with a CHA2DS2-VASc score of 0 (male) or 1 (female).

Results Among 2,712 enrolled patients, complete data on ‘A’-adherent management were available in 2,671 individuals (mean age 66.0 ± 12.8; 44.5% female). Based on ML algorithms, independent predictors of ‘A-criterion adherent management’ were paroxysmal AF, center in capital city, and first-diagnosed AF. Hypertrophic cardiomyopathy, chronic kidney disease with chronic dialysis, and sleep apnea were independently associated with a lower likelihood of ‘A’-criterion adherent management.

ML evaluated predictors of adherence with the ‘A’ criterion of the ABC pathway derived an area under the receiver-operator curve of 0.710 (95%CI 0.67–0.75) for random forest with fine tuning.

Conclusions Machine learning identified paroxysmal AF, treatment center in the capital city, and first-diagnosed AF as predictors of adherence to the A pathway; and hypertrophic cardiomyopathy, chronic kidney disease with chronic dialysis, and sleep apnea as predictors of non adherence.

Non-adherence to Thromboprophylaxis Guidelines in Atrial Fibrillation: A Narrative Review of the Extent of and Factors in Guideline Non-adherence

Atrial fibrillation is the most common arrhythmia. It increases the risk of thromboembolism by up to fivefold. Guidelines provide evidence-based recommendations to effectively mitigate thromboembolic events using oral anticoagulants while minimizing the risk of bleeding. This review focuses on non-adherence to contemporary guidelines and the factors associated with guideline non-adherence. The extent of guideline non-adherence differs according to geographic region, healthcare setting, and risk stratification tools used. Guideline adherence has gradually improved over recent years, but a significant proportion of patients are still not receiving guideline-recommended therapy. Physician-related and patient-related factors (such as patient refusals, bleeding risk, older age, and recurrent falls) also contribute to guideline non-adherence, especially to undertreatment. Quality improvement initiatives that focus on undertreatment, especially in the primary healthcare setting, may help to improve guideline adherence.

A new smartphone application for integrated transmural care of atrial fibrillation, AF-EduApp: Usability and validation study

Introduction

Digital technology creates the opportunity to develop and evaluate new tools, such as smartphone applications, to support integrated atrial fibrillation management. This study aimed to develop, evaluate, and validate a new, integrated care application (AF-EduApp) mainly focusing on targeted atrial fibrillation education to improve patient self-care capabilities and therapy adherence.

Methods

The newly developed AF-EduApp, available for Android and iOS, consists of six different modules. The prototype was validated and optimized for its usability and functionality at Jessa Hospital Hasselt and Antwerp University Hospital in two phases: (1) validity evaluation with interviews of an expert panel with 15 healthcare professionals and 10 atrial fibrillation patients, and (2) a pilot study of 1 month with 20 atrial fibrillation patients.

Results

Both experts and patients found that the application aids atrial fibrillation management. Based on the input of patients and experts, the main optimizations concerned the medication module (patient choice on setting reminder; interactivity of reminders with a “taken” or “snooze” function) and development of a clinical dashboard for the caregivers allowing telemonitoring of measurements and feedback to the patients. After the pilot study ( n = 20), 16 patients indicated they wanted to use the app for a longer period. The measurement (27%) and education (17%) modules were the two most used modules with a significant improvement in knowledge (71.9% to 87.5%; P = 0.013).

Discussion

The AF-EduApp received a positive evaluation from health professionals and atrial fibrillation patients. Further development should be focused on the medication module and improvement of the clinical dashboard.

Appropriate use of anti-thrombotic therapy in patients with atrial fibrillation at single-center experience, Northwest Ethiopia

BACKGROUND

Atrial fibrillation (AF) is the commonest clinically significant ECG-evidenced sustained cardiac arrhythmia in clinical practice. Disability and mortality attributed to AF is high in low-income regions like sub-Saharan Africa. The risk of stroke/TIA in patients with AF can be significantly reduced with anti-thrombotic therapy. Despite the existing evidence of its benefit, significant percentages of AF patients eligible for anti-thrombotic therapy are undertreated in the region.

METHODS

A hospital-based cross-sectional study was conducted to determine the appropriate use of anti-thrombotic therapy in patients with AF between December 1, 2018 and September 30, 2019 at Cardiac Clinic, University of Gondar hospital, Northwest Ethiopia. Consecutive sampling method was used to recruit 210 study subjects. Patients were interviewed to obtain socio-demographic data. Relevant medical history and laboratory parameters were obtained from patients' records. Diagnosis of atrial fibrillation was based on detection of irregular arterial pulse and presence of 'f' waves on 12-lead ECG tracing. Clinical evaluation, echocardiography, chest X-ray and blood chemistry were used to diagnose underlying causes of AF. Data was entered into EPI Info version 4.4.1 and analyzed using SPSS version 20. Bi-variate and multi-variate logistic regression analyses were used to identify associated factors with appropriate use of anti-thrombotic therapy in patients with atrial fibrillation. P-values < 0.05 were used to declare significant association.

RESULTS

A total of 210 patients were included in the study. The mean age of patients was 51.29 ± 17.2 years. Two-thirds (145/210) of participants were females. Seventy-four (35%) had valvular AF, while 136/210 (65%) had non-valvular AF. Sixty-six percent (139/210) of study subjects were appropriately treated with anti-thrombotic therapy. Appropriately treated subjects in valvular AF group and non-valvular AF group were 58/74 (78%) and 81/136 (60%) respectively. On multi-variate analysis, 'can afford for regular INR monitoring' (AOR = 2.60 95% CI: 1.10-6.10, P = 0.001) was significantly associated with appropriate use of anti-thrombotic therapy.

CONCLUSION

Sixty-six percent of AF patients eligible for anti-thrombotic therapy were appropriately treated. Intervention program to access 'regular INR monitoring' should be practiced to escalate utilization rate of anti-thrombotic therapy (warfarin) in eligible AF patients.