Abstract 18703: Impact of the 2014 Atrial Fibrillation Guideline on the Proportion of Patients Recommended for Oral Anticoagulation

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Emily C O’Brien ◽  
Sunghee Kim ◽  
Paul L Hess ◽  
James V Freeman ◽  
Laine Thomas ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Oral Anticoagulation ◽  
Stroke Risk ◽  
Treatment Guidelines ◽  
Treatment Guideline ◽  
Risk Scores ◽  
Community Based ◽  
Chads2 Score ◽  
Number Of Patients ◽  
Using Data

Introduction: In 2014, the AHA/ACC/HRS published new atrial fibrillation (AF) treatment guidelines recommending use of a refined stroke risk score and revised threshold for oral anticoagulation (OAC) initiation. Methods: Using data from ORBIT-AF, an ongoing, national, outpatient AF registry conducted at 176 sites, we examined changes in the number of patients qualifying for OAC based on clinical stroke risk scores under 2011 ACCF/AHA/HRS versus 2014 AHA/ACC/HRS guidelines. Patients were considered recommended for OAC under the 2011 guideline with a CHADS2 score >=2 and under the 2014 guideline with a CHA2DS2-VASC score >=2. We reported the fraction of patients treated with OAC (warfarin or dabigatran) among patients qualifying for OAC under each guideline. Results: From 2009 - 2010, 10132 patients were enrolled in ORBIT-AF (median age [IQR] = 75 years [67 - 82]; 42.3% female). The proportion of patients qualifying for OAC increased from 71.8% under the 2011 guideline to 90.8% under the 2014 guideline (Figure). For patients under the age of 65, the proportion qualifying for treatment with OAC increased from 43.1% to 60.6%. Similar increases were observed for patients over the age of 65: 79.1% indicated for OAC under the 2011 guideline, compared with 98.5% under the 2014 guideline. There were 97.7% of women who qualified for OAC under the 2014 guideline, compared with 76.7% under the 2011 guideline. The fraction of indicated patients who were not receiving OAC increased under the 2014 guideline (21.9% vs. 19.9% under the 2011 guideline), with the highest undertreatment rates for patients younger than 65 (25.4%). Conclusions: The 2014 AF treatment guideline substantially increased the proportion of patients who qualified for OAC, with near-universal indication for women and for patients older than 65. Under the 2014 guideline, approximately 22% of the indicated patients in our community-based cohort did not receive OAC.

Abstract 237: Anticoagulant Use For the Prevention of Stroke in Patients with Atrial Fibrillation: Findings From a Multi-Payer Analysis

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Kathleen Lang ◽  
Duygu Bozkaya ◽  
Aarti A Patel ◽  
Brian Macomson ◽  
Winnie Nelson ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
High Risk ◽  
Stroke Risk ◽  
Treatment Guidelines ◽  
Treatment Guideline ◽  
Software Tool ◽  
Outpatient Setting ◽  
Chads2 Score ◽  
Anticoagulant Medication

Background: Oral anticoagulation is recommended by the American College of Chest Physicians for stroke prevention in intermediate/high stroke risk atrial fibrillation (AF) patients. This study analyzed recent pharmacy and medical claims from Medicaid, Medicare and commercial insurance databases to estimate the risk of stroke, occurrence of stroke hospitalization, and the use of treatment guideline-recommended anticoagulants among patients with AF. Methods: Retrospective data analyses were performed using the Anticoagulant Quality Improvement Analyzer, a software tool designed to analyze health plan data to evaluate stroke risk and identify gaps in care in specific populations with AF. Four data sources were analyzed: 1) IMS LifeLink Database (IMS)- includes commercially insured claims; 2) MarketScan Commercial Database (MarketScanComm)- includes commercially insured claims; 3) MarketScan Medicare Supplemental Database (MarketScanMedicare)- includes employer-sponsored Medicare Supplemental plans only; and 4) Florida Medicaid Database (Medicaid). Included patients were ≥ 18 years old with a new or existing diagnosis of AF. The first observed AF diagnosis constituted the index date, with patient outcomes assessed over a maximum of two years. Study measures included stroke risk (as identified by CHADS2 Score), inpatient stroke hospitalization, and anticoagulant use (stratified by stroke risk and hospitalization). Results: Total samples (mean age) included 25,710 (71.6) from IMS, 21,976 (56.2) from MarketScanComm, 38,643 (79.7) from MarketScanMedicare, and 4,901 (66.8) from Medicaid. High stroke risk (CHADS2 ≥2 points) was estimated in 54% (IMS), 22% (MarketScanComm), 64% (MarketscanMedicare), and 62% (Medicaid) of the total eligible population. Overall, 35%, 29%, 38%, and 16% of all AF patients received an anticoagulant medication in IMS, MarketScanComm, MarketScanMedicare, and Medicaid, respectively. Among patients at high risk for stroke, 39% (5,414/13,955; IMS), 39% (1,934/4,935; MarketScanComm), 40% (9,822/24,776; MarketScanMedicare), and 19% (566/3,015; Medicaid) received any anticoagulant. Rates of stroke hospitalization ranged from 1 - 2% across databases. Of patients hospitalized for stroke, 28% (173/616; IMS), 37% (54/146; MarketScanComm), 37% (341/912; MarketScanMedicare) and 50% (20/40; Medicaid) were treated with an anticoagulant in the outpatient setting. Conclusions: Many AF patients in selected commercial, Medicare-eligible, and Medicaid populations, including those at high risk of stroke, do not receive appropriate thromboprophylaxis, as recommended by treatment guidelines. Increased use of the analyzer and similar software may support enhanced education efforts aimed at improving adherence to guidelines and quality of care.

Abstract 274: Prevalence of undiagnosed non-valvular atrial fibrillation in the United States

2014 ◽  
Vol 7 (suppl_1) ◽  
Author(s):  
Mintu P Turakhia ◽  
Jason Shafrin ◽  
Katalin Bognar ◽  
Jeffrey B Brown ◽  
Jeffrey Trocio ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
High Risk ◽  
The Elderly ◽  
The United States ◽  
Risk Scores ◽  
Chads2 Score ◽  
Aged Patients ◽  
Number Of Patients ◽  
Working Age ◽  
Back Calculation

Background: Because atrial fibrillation (AF) is often asymptomatic, clinically silent and therefore undiagnosed, the prevalence of AF is difficult to estimate. In fact, ischemic stroke is often the first clinical sign of AF among previously undiagnosed patients. In this study, we estimated the prevalence of undiagnosed AF using a back-calculation approach that relies on the fact that AF causes stroke but causality generally does not run from stroke to AF. Methods: We first estimated the prevalence of diagnosed non-valvular AF in the elderly (65+) and working age (18-64) U.S. population from a 5% Medicare sample and an OptumInsight commercial claims database from 2004-2010 using validated ICD9 algorithms. To estimate the prevalence of undiagnosed non-valvular AF, our back-calculation methodology used two measured inputs: (i) the number of patients who are diagnosed with new non-valvular AF in the current or subsequent quarter after a stroke; (ii) the probability that patients with non-valvular AF have a stroke, based on CHADS2 risk scores. We confirmed calibration by comparing our prevalence estimates of diagnosed AF with prior Medicare and commercial claims analyses. Results: Between 2005 and 2009, the estimated prevalence of AF gradually increased, reaching 9.9% of the elderly U.S. population and 0.88% of the working aged population by 2009. Among the Medicare AF cases in 2009, 11% of these cases (1.1% out of 9.9%) were undiagnosed; among working aged patients with AF, 8% of cases (0.07% out of 0.88%) were undiagnosed. In addition, a large share of the undiagnosed cases was at high risk of stroke. Among the undiagnosed AF cases for elderly and working age adults, 26% and 37%, respectively have a CHADS2 score of 1, and 68% and 26% have a CHADS2 score of 2+. Conclusions: Among elderly and working adult U.S. populations, a substantial proportion of individuals with undiagnosed AF have moderate to high risk of stroke. Screening for AF could favorably impact the disease burden.

The CHADS2 score predicts ischemic stroke in chronic heart failure patients without atrial fibrillation: comparison to other stroke risk scores

2016 ◽  
Vol 32 (2) ◽  
pp. 193-200 ◽  
Author(s):  
Takumi Kondo ◽  
Takahisa Yamada ◽  
Takashi Morita ◽  
Yoshio Furukawa ◽  
Shunsuke Tamaki ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Chronic Heart Failure ◽  
Stroke Risk ◽  
Risk Scores ◽  
Chads2 Score ◽  
Heart Failure Patients

Stroke Risk Scores as Predictors of Severe Outcomes in Atrial Fibrillation

2021 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Andreea Cristina Ivănescu ◽  
Cătălin Adrian Buzea ◽  
Caterina Delcea ◽  
Gheorghe Andrei Dan
Keyword(s):  
Atrial Fibrillation ◽  
Stroke Risk ◽  
Risk Scores

Abstract 77: Balancing Risks and Benefits of Anticoagulation Therapy in Atrial Fibrillation in Community Practice: Results from the ORBIT-AF Registry

2012 ◽  
Vol 5 (suppl_1) ◽  
Author(s):  
Michael W Cullen ◽  
Sunghee Kim ◽  
Jonathan P Piccini ◽  
Alan S Go ◽  
Gregg C Fonarow ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Stroke Risk ◽  
Anticoagulation Therapy ◽  
Bleeding Risk ◽  
Community Practice ◽  
Chads2 Score ◽  
Risk Patients ◽  
Study Population ◽  
Risk Treatment ◽  
The Cost

Background Oral anticoagulation (OAC) can reduce stroke risk at the cost of increased bleeding risk in those with atrial fibrillation (AF). Observational data have shown that higher-risk patients with AF most likely to benefit from OAC are less likely to receive OAC at hospital discharge. Methods We used data from ORBIT-AF Registry, a cohort of 9,589 AF patients enrolled among 173 participating outpatient practices. OAC was defined as warfarin or dabigatran use at study enrollment. Stroke and bleeding risk were calculated using the CHADS2 and ATRIA scores, respectively. Results The study population had a mean age of 73.5 years; 57.8% were men. Overall, 76.4% of patients received OAC. Use of OAC rose with increasing CHADS2 stroke risk, from 67% for CHADS2 <1 to 80% for CHADS2 ≥2 (p<0.0001). OAC use fell slightly with increasing ATRIA bleeding risk, from 77% for ATRIA score ≤3 to 74% with ≥5 (p=0.002 for trend). Among patients with low bleeding risk, rates of OAC increased commensurate with stroke risk (p<0.0001 for interaction; see figure). Higher bleeding risk tended to decrease rates of OAC among patients with a CHADS2 score ≥2 (p=0.13 for interaction). Conclusions In community-based outpatients with AF, use of OAC rose with increasing thromboembolic risk and declined with higher bleeding risk. These findings suggest that the risk-treatment paradox may be less that previously reported. Provision of OAC in community practice appears to appropriately consider patients' stroke and bleeding risks. Further research is required to understand how quality improvement initiatives can further improve stroke prevention.

scholarly journals P094: The frequency of stroke risk assessment tools used to assess patients presenting to the emergency department with atrial fibrillation and flutter

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S109-S110
Author(s):  
T. Nikel ◽  
S.W. Kirkland ◽  
S. Campbell ◽  
B.H. Rowe
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Stroke Risk ◽  
Grey Literature ◽  
Anticoagulation Therapy ◽  
Adult Patients ◽  
Assessment Tools ◽  
Risk Scores ◽  
Atrial Fibrillation And Flutter ◽  
Attending Physicians

Introduction: Acute atrial fibrillation or flutter (AFF) is the most common dysrhythmia managed in the emergency department (ED). A key component of managing AFF in the ED is the prevention of stroke. Predictive indices (e.g., CHADS2 , HAS-BLED) should be used to assess each patient’s risk of stroke and bleeding to determine the appropriate anticoagulation therapy. The frequency of use of these predictive indices in the emergency department to determine appropriate anticoagulation therapy remains unclear. This systematic review is designed to examine the use of risk scores in the ED to determine the management of patients presenting to the ED for atrial fibrillation and flutter. Methods: An extensive search of eight electronic databases and grey literature was conducted. Quasi-experimental studies were eligible for inclusion. Studies had to report on the ED management of adult patients presenting with AFF to be included. Two independent reviewers judged the relevance, inclusion, and risk of bias of the studies. Individual and pooled statistics were calculated as odds ratios (OR) with 95% CI using a random effects model and heterogeneity (I2) was reported. Results: From 1,648 citations, 37 studies were included in this review. Heterogeneity was very high, precluding pooling. Only one of the included studies documented the use of CHADS2 scores by attending physicians; while no studies documented the use of HAS-BLED. There was variability in the ED management strategies of AFF. The utilization of rhythm control in the treatment of AFF ranged considerable (OR: 0.04-9.84) in comparison to rate control. Of the 17 studies reporting cardioversion approaches, chemical (9 {53%}) cardioversion was the most common management strategy of AFF. Conclusion: Our results suggests that either few physicians are documenting stroke risk scores in adult patients with AFF, or that research studies assessing ED management of AFF are not reporting scores documented by the attending physicians. Future research needs to examine the use of stroke risk scores to determine the optimal and appropriate care for patients.

Abstract 171: Warfarin Use And Stroke Risk Among Patients With Nonvalvular Atrial Fibrillation In A Large Managed Care Population

2012 ◽  
Vol 5 (suppl_1) ◽  
Author(s):  
Steven B Deitelzweig ◽  
Erin Buysman ◽  
Brett Pinsky ◽  
Michael Lacey ◽  
Yonghua Jing ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Managed Care ◽  
Treatment Period ◽  
Real World ◽  
Warfarin Therapy ◽  
Stroke Risk ◽  
Nonvalvular Atrial Fibrillation ◽  
Chads2 Score ◽  
Warfarin Treatment

Introduction Warfarin discontinuation among real world nonvalvular atrial fibrillation (NVAF) patients is common. Hypothesis We hypothesized that in a managed care population, warfarin discontinuation is associated with increased stroke risk. Methods Patients who initiated warfarin therapy between Jan 2005 and Jun 2009 and had a healthcare claim related to AF within 30 days prior to the first warfarin claim, but no evidence of valvular disease, were included. Warfarin discontinuation was defined as a supply gap of >60 days without evidence of International Normalized Ratio (INR) measurements. Follow-up was divided into periods of warfarin treatment and discontinuation. Stroke events were identified based on claims for inpatient stays with a primary diagnosis for stroke or transient ischemic attack (TIA). Cox proportional hazards models were constructed to assess the relationship between warfarin discontinuation and incident stroke while adjusting for baseline demographics, stroke and bleeding risk, and comorbidities, as well as time-dependent antiplatelet use, stroke, and bleeding events in the prior warfarin treatment period. Results The mean (SD) age of the study sample (N=16,253) was 67±12 years; 64.8% was male. Mean CHADS2 score was 1.84±1.30; mean HAS-BLED score was 2.00±1.18. Half (51.4%) of patients discontinued warfarin therapy at least once and the overall sample had a mean of 1.87 warfarin treatment periods during a mean of 668 days follow-up. Approximately 1186 patients (7%) had a stroke or TIA at any site of service during follow-up. Risk of stroke significantly increased during warfarin discontinuation periods compared with therapy periods (HR 1.60; 95%CI 1.35-1.90; P<.0001). Stroke risk was significantly increased for patients with baseline CHADS2 score ≥2 (HR 2.69; 95%CI 1.44-5.03; P=.002), HAS-BLED score ≥3 (HR 1.46; 95%CI 1.05-2.05; P=.027), or who had a bleeding (HR 1.29; 95%CI 1.06-1.57; P=.013) or stroke event (HR 3.04; 95%CI 2.47-3.75; P<.0001) in the prior treatment period. Conclusions In the real world, over half of patients on anticoagulation therapy had treatment gaps or permanently discontinued therapy. These usage patterns, as well as prior bleeding, were associated with increased stroke risk.

Abstract 18538: The ATRIA Stroke Risk Score Predicts Ischemic Stroke Better than CHADS2 and CHA2DS2-VASc in a large Swedish Cohort of Patients with Atrial Fibrillation

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Sara Aspberg ◽  
Yuchiao Chang ◽  
Daniel Singer
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Risk Score ◽  
Stroke Risk ◽  
Anticoagulation Therapy ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Cut Points ◽  
Net Clinical Benefit ◽  
Better Than

Introduction: Atrial fibrillation (AF) is a major risk factor for acute ischemic stroke (AIS). Anticoagulation therapy (OAC) effectively prevents AIS, but increases bleeding risk. There is a need for better AIS risk prediction to optimize the anticoagulation decision in AF. The ATRIA stroke risk score (ATRIA) (table) was superior to CHADS2 and CHA2DS2-VASc in two large California community AF cohorts. We now report the performance of the 3 scores in a very large Swedish AF cohort. Methods: The cohort consisted of all Swedish patients hospitalized with a diagnosis of AF from July 1, 2005 to December 31, 2008. Predictor variables and the outcome, AIS, were obtained from inpatient ICD-10 codes. Warfarin use was determined from National Pharmacy Database. Risk scores were assessed via c-index (C) and net reclassification index (NRI). Results: The cohort included 158,370 AF patients off warfarin who contributed 340,332 person-years of follow-up, and 11,823 incident AIS, for an overall AIS rate of 3.47%/yr, higher than the 2%/yr seen in the California cohorts. Using the entire point score, ATRIA had a good C of 0.712 (0.708-0.716), significantly better than CHADS2, 0.694 (0.689-0.698), or CHA2DS2-VASc, 0.697 (0.693-0.702). Using published cut-points for Low/Moderate/High AIS risk, C deteriorated for all scores but ATRIA and CHADS2 were superior to CHA2DS2-VASc. NRI favored ATRIA; 0.16 (0.15-0.18) versus CHADS2; 0.22 (0.21-0.24) versus CHA2DS2-VASc. However, NRI decreased to near-zero when cut-points were altered to better fit the cohort’s stroke rates. Conclusion: Findings in this large Swedish AF cohort validate those in the California AF cohorts, with the ATRIA score predicting stroke risk better than CHADS2 or CHA2DS2-VASc. However, relative performance of the categorical scores varied by population stroke risk. Knowledge about this population risk may be needed to optimize cut-points on the multipoint scores to achieve better net clinical benefit from OAC.

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