scholarly journals Pharmacist management of atrial fibrillation: a pilot educational intervention study

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
S Al-Arkee ◽  
J Mason ◽  
L Fabritz ◽  
W Chua ◽  
D.A Lane ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Primary Care ◽  
Vitamin K ◽  
Oral Anticoagulants ◽  
Time Of Day ◽  
Health Science ◽  
Therapeutic Area ◽  
Knowledge Gaps ◽  
Educational Session ◽  
The Mean

Abstract Introduction AF increases the risk of stroke by a factor of five [1], oral anticoagulants (OACs) can reduce stroke by ∼60% and death by ∼25% [2]. Pharmacists, especially those based in primary care are well placed to support patients in this therapeutic area. However, research indicates that pharmacists do not always feel confident in supporting patients on OACs, which are the mainstay of AF management [3]. Purpose The aim of this pilot study is to assess pharmacists' knowledge prior to an educational session on AF and its management. Training was provided on AF, its management and the use of an associated app, AF Manager (Figure) with the intention to re-assess pharmacists' knowledge and use of the app 3, 6 and 12-months post-training. Here, we report the assessment of pharmacist baseline knowledge. Methods Various social media platforms were used to invite UK-based, practicing primary care pharmacists to an educational session. Training was developed in collaboration with consultant pharmacists from an Academic Health Science Network, AF Programme. Participant knowledge was assessed immediately before the educational session by use of the Jessa Atrial Fibrillation Knowledge Questionnaire (JAKQ), adapted for use with pharmacists. Quantitative data were analysed using SPSS version 27. Results Twenty UK-based practicing pharmacists attended the educational session. Four pharmacists were excluded from analysis as they were not based in primary care. The mean practice experience of participants was 14.6±10.5 years; 62.5% were female and 50% had undertaken postgraduate qualifications. For this group of pharmacists, out of a maximum of 19 points, the mean score for the adapted JAKQ was 13.7±2.5. General knowledge about OACs (i.e. that which might be used to counsel patients taking OACs, such as time of day to take the medicines, side effects, drug interactions/contraindications) was high with knowledge about the different types of OACs similar (vitamin K antagonists (VKAs) 66.7±25.3% versus non-vitamin K antagonist oral anticoagulants (NOACs) 66.7±41.6%). However, several important knowledge gaps about AF and its management were identified. Only half of the participants knew that patients taking OACs for AF would continue to experience AF and only five participants (31.3%) knew that AF symptoms could be self-managed. Knowledge of INR monitoring frequency for VKAs and the use of NOAC patient alert cards was also lacking, with nine (56.2%) and thirteen (81.2%) of participants unable to answer these questions, respectively. Conclusions Primary care pharmacists are knowledgeable about the medicines used in AF management. However, there are specific knowledge gaps around AF management that need to be addressed via educational interventions to enable pharmacists to support patients effectively. Our follow-up research will investigate knowledge retention post-training and assess app usability for pharmacists in the management of patients with AF. FUNDunding Acknowledgement Type of funding sources: None. Figure 1. Screenshots of the AF Manager app

scholarly journals Appropriateness of initial dose of non-vitamin K antagonist oral anticoagulants in patients with non-valvular atrial fibrillation in the UK

BMJ Open ◽  
2019 ◽  
Vol 9 (9) ◽  
pp. e031341 ◽  
Author(s):  
Luis Alberto García Rodríguez ◽  
Mar Martín-Pérez ◽  
Pareen Vora ◽  
Luke Roberts ◽  
Yanina Balabanova ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Primary Care ◽  
Renal Impairment ◽  
Vitamin K ◽  
Oral Anticoagulants ◽  
Vitamin K Antagonist ◽  
Reduced Dose ◽  
Daily Dose ◽  
The Uk ◽  
The Eu

ObjectiveTo evaluate the appropriateness of the initial prescribed daily dose of non-vitamin K antagonist oral anticoagulants (NOACs) according to label in patients with non-valvular atrial fibrillation (NVAF) in the UK.DesignPopulation-based cross-sectional study.SettingUK primary care.Population30 467 patients with NVAF and a first prescription for apixaban, dabigatran or rivaroxaban between January 2011 and December 2016.Main outcome measuresPercentage of patients prescribed a NOAC dose according to the European Union (EU) labels (appropriately dosed), and not according to the EU labels (inappropriately dosed—including both underdosed and overdosed patients); percentage of patients prescribed an initial NOAC dose according to renal function status.ResultsA total of 15 252 (50.1%) patients started NOAC therapy on rivaroxaban, 10 834 (35.6%) on apixaban and 4381 (14.4%) on dabigatran. Among patients starting NOAC therapy on rivaroxaban, 17.3% were eligible to receive a reduced dose compared with 12.8% of patients starting on apixaban and 53.8% of patients starting on dabigatran. The majority of patients were prescribed an appropriate dose according to the EU labels: apixaban 74.9 %, dabigatran, 74.4%; rivaroxaban, 84.2%. Underdosing occurred in 21.6% (apixaban), 8.7% (dabigatran), 9.1% (rivaroxaban). Overdosing was more frequent for dabigatran (16.9%) than for rivaroxaban (6.6%) or apixaban (3.5%). There was a trend towards dose reduction with increasing renal impairment. Among patients with severe renal impairment, the majority received a reduced dose NOAC: apixaban, 91.1%, dabigatran, 80.0%, rivaroxaban, 83.0%.ConclusionBetween 2011 and 2016, the majority of patients starting NOAC therapy in UK primary care were prescribed a daily dose in line with the approved EU drug label. Underdosing was more than twice as common among patients starting on apixaban than those starting on dabigatran or rivaroxaban. Research into the patient characteristics that may influence inappropriate underdosing of NOACs in UK primary care is warranted.

scholarly journals Discontinuation of non-Vitamin K antagonist oral anticoagulants in patients with non-valvular atrial fibrillation: a population-based cohort study using primary care data from The Health Improvement Network in the UK

BMJ Open ◽  
2019 ◽  
Vol 9 (10) ◽  
pp. e031342 ◽  
Author(s):  
Ana Ruigómez ◽  
Pareen Vora ◽  
Yanina Balabanova ◽  
Gunnar Brobert ◽  
Luke Roberts ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Primary Care ◽  
Cohort Study ◽  
Vitamin K ◽  
Index Date ◽  
Oral Anticoagulants ◽  
Population Based ◽  
Vitamin K Antagonist ◽  
First Year ◽  
The Uk

ObjectiveTo determine discontinuation rates, patterns of use and predictors of discontinuation of non-vitamin K antagonist oral anticoagulants (NOACs) among patients with non-valvular atrial fibrillation (NVAF) in the first year of therapy.DesignPopulation-based cohort study.SettingUK primary care.Population11 481 patients with NVAF and a first prescription (index date) for apixaban, dabigatran or rivaroxaban (January 2012 to December 2016) with at least 1 year of follow-up and at least one further NOAC prescription in the year following the index date were identified. 1 year rates and patterns of discontinuation were described.Primary and secondary outcome measuresOutcome measures were the percentage of patients who, in the first year from starting NOAC therapy, discontinued with their oral anticoagulant (OAC) therapy (discontinuation was defined as a gap in OAC therapy of >30 days); switched OAC within 30 days; discontinued and reinitiated OAC therapy. Predictors of discontinuation were also evaluated.Results1 year discontinuation rates according to the index NOAC were 26.1% for apixaban, 40.0% for dabigatran and 29.6% for rivaroxaban. Reinitiation rates were 18.1% for apixaban, 21.7% for dabigatran and 17.3% for rivaroxaban, and switching rates were 2.8% for apixaban, 8.8% for dabigatran and 4.9% for rivaroxaban. More than 93% of reinitiations were with the index NOAC. Patients starting on dabigatran were more likely to switch OAC therapy than those starting on apixaban; ORs 4.28 (95% CI 3.24 to 5.65) for dabigatran and 1.89 (95% CI 1.49 to 2.39) for rivaroxaban. Severely reduced renal function was a predictor of any discontinuation, OR 1.77 (95% CI 1.28 to 2.44).ConclusionWhile the majority of patients with NVAF in the UK initiating NOAC treatment received continuous therapy in the first year of treatment, a substantial proportion of patients experienced gaps in treatment leaving them less protected against thromboembolism during these periods.

scholarly journals Residual Stroke Risk in Patients with Atrial Fibrillation Treated with Non-Vitamin K Oral Anticoagulants: An 8-Year Retrospective Cohort Study

2021 ◽  
pp. 9-14
Author(s):  
Cheuk Ling Charing Szeto ◽  
Kwok Fai Hui
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Oral Anticoagulants ◽  
Low Density Lipoprotein ◽  
Density Lipoprotein ◽  
Diabetic Control ◽  
The Mean ◽  
Never Smokers ◽  
Ischemic Attack ◽  
Christian Hospital

<b><i>Background:</i></b> Use of non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention in non-valvular atrial fibrillation (NVAF) is common and significantly reduces stroke occurrence. Yet little is known about patients who have a stroke despite treatment. <b><i>Objective:</i></b> The aim of this work was to study the epidemiology of patients with stroke despite being treated with NOACs. <b><i>Methods:</i></b> We identified a cohort of patients with NVAF admitted to the United Christian Hospital for acute ischemic stroke (AIS) or transient ischemic attack (TIA) while on NOACs. The baseline characteristics, type of NOAC, compliance, duration of use, and dosage were reviewed. <b><i>Results:</i></b> Of 2,090 patients admitted for AIS/TIA from 2012 to 2019, 143 were on NOACs before the index episode. After excluding patients with non-compliance and incomplete data, 109 patients were included in the analysis; 65.1% were female and 79.8% were never smokers, with a mean age of 78 years. The mean CHA2DS2-VASc score was 5; 83.5% had hypertension, 59.3% had hyperlipidemia, and 30.3% had diabetes mellitus. Overall, 52.9% presented with lacunar syndrome, suggesting an atherosclerotic cause of stroke. However, their risk factor control was unexpectedly good; none had HbA1c &#x3e;7% and only 23.9% had a low-density lipoprotein cholesterol level higher than 2.6 mmol/L. <b><i>Conclusions:</i></b> Stroke developed in NVAF patients despite being on NOACs, with the majority being female, older, and hypertensive. Surprisingly, in general they had reasonable lipid and diabetic control.

P2542Adherence to the 2016–2018 ESC guidelines for stroke prevention in atrial fibrillation: an Italian field practice in a cohort of geriatric patients

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
S Marinelli ◽  
M Zoli ◽  
P Calogero ◽  
M L Lunardelli ◽  
L Bastagli
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Stroke Prevention ◽  
Geriatric Patients ◽  
Oral Anticoagulants ◽  
Real Life ◽  
Vitamin K Antagonist ◽  
Esc Guidelines ◽  
The Mean ◽  
New Onset

Abstract Background The 2016 and 2018 ESC guidelines for stroke prevention in atrial fibrillation (AF) recommend the use of non-vitamin K antagonist oral anticoagulants (NOACs) in all AF patients except for the EHRA type 1, for which remains the indication to vitamin K antagonist oral anticoagulants (VKAs). Purpose To evaluate the adherence to the ESC guidelines in the management of anticoagulant therapy (OAC) in the prevention of cardioembolism in geriatric (age ≥65) AF patients at 3 medical-geriatric inpatient wards of the Sant'Orsola Hospital in Bologna (Emilia Romagna region, Italy). Methods Between April 1st and October 1st 2018, 138 consecutive AF inpatients were prospectively enrolled at the start or at the change or at the interruption of the OAC. Results The main characteristics of the cohort were: mean age 84,6 years (range 65–102), M/F = 64/74, mean Charlson score 4,4, mean ADL/IADL 3,45/2,01 and mean CHA2DS2VASc/ HAS-BLED scores 5/3. Thirty-eight percent (N=52) of patients needed walking aids. Polypharmacy (intake of ≥5 drugs) was present in 31,9% (N=44) of patients and anemia in 50% (N=69: acute 6,5%, chronic 34,8%, mixed 8,7%). Half of the patients (N=69) presented new onset AF. Only 68% of patients (N=47) with known AF (N=69) were in OAC (37,6% in VKAs and 30,4% in NOACs). At the admission, the mean INR of AF in VKAs was 3,53 (range 1,54–10). The hospital decision on the anticoagulation in 91 patients (22 with known AF not in OAC at home, and 69 with new-onset AF), defined as “naïve” to OAC, was evaluated: 26,3% (N=24) started NOACs, 45% (N=41)VKAs, 8,7% (N=8) anticoagulant low molecular weight heparin (EBPM), and 20% (N=18) didn't start OAC. The decision was supported by consultant cardiologists and/or angiologists in 72,5% of cases (N=66). The choice of the VKAs was mainly due to chronic kidney disease (CKD) and acute kidney failure. Patients who started NOACs were significantly younger than those who started VKAs (age: 78,2 vs 86,5; p<0.001) and had a better preserved renal function (Cockroft-Gault GFR: 69,6 vs 48,1 ml/min; p<0.001). However, the mean GFR of VKAs patients was clearly above the lower limit set by the guidelines. The main causes of the switching between NOACs and VKAs (N=14, 10,1%) were stroke-TIA occurrence (N=7, 57,1%) and CKD (N=4, 28,5%). OAC was definitively interrupted (N=31, 22,4%) mostly for severe clinical conditions (N=16, 51,6%) and anemia (N=7, 22,5%). Conclusions In this “real life” cohort the deviation from the ESC guidelines was 52%. According to the guidelines only 11 (26,8%) of the patients who started VKAs would have been excluded from treatment with NOACs. Our experience underlines the presence of “fear” in the use of NOACs in geriatric patients, in particular with CKD. Probably it's worth to question if the current guidelines provide reliable indications regarding the safety and manageability of the NOACs in the presence of the most common geriatric syndromes.

Anticoagulant therapy in practice

2012 ◽  
Vol 153 (19) ◽  
pp. 732-736
Author(s):  
Gergely Hofgárt ◽  
Csilla Vér ◽  
László Csiba
Keyword(s):  
Atrial Fibrillation ◽  
Risk Factor ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Anticoagulant Therapy ◽  
Oral Anticoagulants ◽  
Health Science ◽  
Science Centre ◽  
Improper Use ◽  
Current Guidelines

Atrial fibrillation is a risk factor for ischemic stroke. To prevent stroke oral anticoagulants can be administered. Old and new types of anticoagulants are available. Nowadays, old type, acenocumarol based anticoagulants are used preferentially in Hungary. Aim: The advantages and the disadvantages of anticoagulants are well known, but anticoagulants are underused in many cases. Method: The authors retrospectively examined how frequent atrial fibrillation was and whether the usage of anticoagulants in practice was in accordance with current guidelines among acute stroke cases admitted to the Department of Neurology, Medical and Health Science Centre of Debrecen University in 2009. Results: Of the 461 acute stroke cases, 96 patients had known and 22 patients had newly discovered atrial fibrillation. Half of the patients did not receive proper anticoagulation. Only 8.4% of them had their INR levels within the therapeutic range. Conclusions: The findings are similar to those reported in other studies. Many factors may contribute to the high proportion of improper use of anticoagulants, and further investigations are needed to determine these factors. In any case, elimination of these factors leading to a failure of anticoagulation may decrease the incidence of stroke. Orv. Hetil., 2012, 153, 732–736.

scholarly journals Anticoagulation in Atrial Fibrillation Cardioversion: What Is Crucial to Take into Account

2021 ◽  
Vol 10 (15) ◽  
pp. 3212
Author(s):  
Fabiana Lucà ◽  
Simona Giubilato ◽  
Stefania Angela Di Fusco ◽  
Laura Piccioni ◽  
Carmelo Massimiliano Rao ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Thrombus Formation ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Significant Advance ◽  
Thromboembolic Events ◽  
Thromboembolic Risk ◽  
Pharmacological Cardioversion

The therapeutic dilemma between rhythm and rate control in the management of atrial fibrillation (AF) is still unresolved and electrical or pharmacological cardioversion (CV) frequently represents a useful strategy. The most recent guidelines recommend anticoagulation according to individual thromboembolic risk. Vitamin K antagonists (VKAs) have been routinely used to prevent thromboembolic events. Non-vitamin K antagonist oral anticoagulants (NOACs) represent a significant advance due to their more predictable therapeutic effect and more favorable hemorrhagic risk profile. In hemodynamically unstable patients, an emergency electrical cardioversion (ECV) must be performed. In this situation, intravenous heparin or low molecular weight heparin (LMWH) should be administered before CV. In patients with AF occurring within less than 48 h, synchronized direct ECV should be the elective procedure, as it restores sinus rhythm quicker and more successfully than pharmacological cardioversion (PCV) and is associated with shorter length of hospitalization. Patients with acute onset AF were traditionally considered at lower risk of thromboembolic events due to the shorter time for atrial thrombus formation. In patients with hemodynamic stability and AF for more than 48 h, an ECV should be planned after at least 3 weeks of anticoagulation therapy. Alternatively, transesophageal echocardiography (TEE) to rule out left atrial appendage thrombus (LAAT) should be performed, followed by ECV and anticoagulation for at least 4 weeks. Theoretically, the standardized use of TEE before CV allows a better stratification of thromboembolic risk, although data available to date are not univocal.

scholarly journals Plasma natriuretic peptide level is an independent determinant of major clinical outcomes in atrial fibrillation patients without heart failure: the Fushimi AF Registry

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
Y Hamatani ◽  
M Iguchi ◽  
Y Aono ◽  
K Ishigami ◽  
S Ikeda ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Clinical Outcomes ◽  
Prognostic Marker ◽  
Oral Anticoagulants ◽  
Systemic Embolism ◽  
The Mean

Abstract Background Atrial fibrillation (AF) increases the risk of death, stroke/systemic embolism and heart failure (HF). Plasma natriuretic peptide (NP) level is an important prognostic marker in HF patients. However, little is known regarding the prognostic significance of plasma NP level in AF patients without HF. Purpose The aim of this study is to investigate the relationship between plasma NP level and clinical outcomes such as all-cause death, stroke/systemic embolism and HF hospitalization during follow-up period in AF patients without HF. Methods The Fushimi AF Registry is a community-based prospective survey of AF patients in our city. The inclusion criterion of the registry is the documentation of AF at 12-lead electrocardiogram or Holter monitoring at any time, and there are no exclusion criteria. We started to enroll patients from March 2011, and follow-up data were available for 4,466 patients by the end of November 2019. From the registry, we excluded 1,220 patients without a pre-existing HF (defined as having one of the following; prior hospitalization for HF, New York Heart Association class ≥2, or left ventricular ejection fraction &lt;40%). Among 3,246 AF patients without HF, we investigated 1,189 patients with the data of plasma BNP (n=401) or N-terminal pro-BNP (n=788) level at the enrollment. We divided the patients according to the quartile of each plasma BNP or NT-pro BNP level and compared the backgrounds and outcomes between these 4 groups stratified by plasma NP level. Results Of 1,189 patients, the mean age was 72.1±10.2 years, 454 (38%) were female and 684 (58%) were paroxysmal AF. The mean CHADS2 and CHA2DS2-VASc score were 1.6±1.1 and 2.9±1.5, respectively. Oral anticoagulants were prescribed in 671 (56%) at baseline. The median (interquartile range) BNP and N-terminal pro-BNP level were 84 (38, 176) and 500 (155, 984) pg/ml, respectively. Patients with high plasma NP level were older, and demonstrated lower prevalence of paroxysmal AF, higher CHADS2 and CHA2DS2-VASc scores and higher prevalence of chronic kidney disease and oral anticoagulants prescription (all P&lt;0.01). A total of 165 all-cause death, 114 stroke/systemic embolism and 103 HF hospitalization occurred during the median follow-up period of 5.0 years. Kaplan-Meier curves demonstrated that higher plasma NP level was significantly associated with the incidences of all-cause death, stroke/systemic embolism and HF hospitalization in AF patients without HF (Figure 1A). Multivariable Cox regression analysis revealed that plasma NP level could stratify the risk of clinical outcomes even after adjustment by type of AF, CHA2DS2-VASc score, chronic kidney disease and oral anticoagulant prescription (Figure 1B). Conclusion Plasma NP level is a significant prognostic marker for all-cause death, stroke/systemic embolism and HF hospitalization in AF patients without HF, suggesting the importance of measuring plasma NP level in AF patients even without HF. Figure 1 Funding Acknowledgement Type of funding source: None

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