Abstract 14775: Barriers to Anticoagulation Treatment in Atrial Fibrillation: A Survey of Providers in a Large Rural Healthcare System

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Macaela N Rudeck ◽  
Catherine P Benziger
Keyword(s):  
Atrial Fibrillation ◽  
Primary Care ◽  
Patient Education ◽  
Healthcare System ◽  
Oral Anticoagulants ◽  
Demographic Data ◽  
Medication Cost ◽  
Rural Healthcare ◽  
Anticoagulation Management ◽  
Increased Risk

Introduction: Atrial fibrillation (AF) is common and oral anticoagulants are recommended to reduce risk of thromboembolism for patients with elevated risk. Barriers to anticoagulation are not well described. Objectives: We aim to evaluate gaps in provider knowledge and barriers to anticoagulation management in AF. Methods: A REDCap survey was sent to providers at Essentia Health (N=894), a large rural healthcare system in MN, WI, and ND. Providers were grouped into 3 categories: cardiology, primary care, and other. Providers were asked how they would manage a hypothetical patient with AF: 67-year-old female with hypertension, recurrent episodes of paroxysmal AF, no other medical history. Answer options included aspirin, warfarin, or novel oral anticoagulant (NOAC). Demographic data were obtained along with answers to questions assessing barriers to anticoagulation use and patient education. Providers who reported they do not see AF patients were excluded (N=23). Results: A total of 220 providers started the survey (75.5% completion rate). Of 157 providers who completed the case study, 74.5% correctly recommended treatment with a NOAC. Providers in cardiology were more likely than those in primary care and other specialties to select NOAC (96.4% vs. 68.5% vs. 76.2%, respectively; p=0.01). Most (92%) providers stated they personally discuss the need for anticoagulation with their patients. Providers noted the primary barrier to educating patients about their increased risk of stroke was: “They have trouble understanding what I am trying to explain to them” (24%), “They think that once their symptoms are being treated, the risk of AF-related stroke goes away” (17%), and “They don't really believe their condition is serious” (13%). Providers cited the top barrier to patient compliance with anticoagulation was patients concern of cost with no difference between specialty (cardiology 40.7% vs. primary care 46.7% vs. other 34.8%; p=0.53). Conclusion: Cardiology providers are more likely to correctly recommend a NOAC, compared to primary care or other specialties, for AF. Primary barriers to patient education and compliance include inadequate patient understanding and medication cost.

scholarly journals Factors Influencing Primary Care Physicians’ Prescribing Behavior of Anticoagulant Therapy for the Management of Patients With Non-valvular Atrial Fibrillation in the Community: a Qualitative Research Study

2021 ◽  
Author(s):  
Shera Chaterji ◽  
Lay Geok Lian ◽  
Ting Yee Lee ◽  
Liwei Chua ◽  
Sabrina Wee ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Primary Care ◽  
Decision Making ◽  
Qualitative Research ◽  
Healthcare System ◽  
Anticoagulant Therapy ◽  
Primary Care Physicians ◽  
Medication Cost ◽  
Care Model ◽  
Factors Influencing

Abstract Background: Oral anticoagulant therapy use in patients with atrial fibrillation (AF) remains suboptimal despite the availability of both warfarin and non-vitamin K antagonist oral anticoagulants (NOACs). Primary care physicians’ (PCP) decision-making to initiate and select appropriate anticoagulant medication is pivotal in reducing complications among patients with AF.Aim: This study explored the factors influencing PCPs’ decision-making in anticoagulant initiation and adjustment for patients with non-valvular AF. Design of study: Qualitative research based on the theoretical framework of the Generalist Wheel of Knowledge, Understanding and Inquiry. Method: In-depth interviews or focus group discussions were conducted with 27 PCPs in general practice in urban Singapore. The audio-recordings were transcribed, audited and coded to identify themes, which are framed according to the “clinician”, “patient”, “medical condition and treatment” and “healthcare system and policy” domains.Results: Personal training and experience with anticoagulant therapy; understanding patient risk-stratification; AF detection during clinical practice; medication cost; clinical support services for anticoagulation monitoring and constraints in existing care model influenced PCPs in their anticoagulant prescription. PCPs preferred to seek guidance from cardiologists in managing patients with newly diagnosed AF and attempted to engage their patients in decision-making regarding anticoagulant therapy. They perceived sub-specialized primary care clinics focusing on AF co-management with cardiologists as an ideal setting for initiation and maintenance of anticoagulant therapy.Conclusion: PCPs’ decisions on anticoagulant therapy is influenced by personal attributes, patients, clinical presentations, anticoagulant properties and healthcare system. Their proposed care model to address the barriers awaits feasibility and acceptance assessment in future research.

scholarly journals How Much Atrial Fibrillation is Enough to Warrant Oral Anticoagulation: Management of Subclinical Atrial Fibrillation?

2018 ◽  
Vol 13 (SP1) ◽  
Author(s):  
Jeff Healey
Keyword(s):  
Atrial Fibrillation ◽  
Oral Anticoagulation ◽  
Continuous Monitoring ◽  
Absolute Risk ◽  
Oral Anticoagulants ◽  
Heart Rhythm ◽  
Anticoagulation Management ◽  
Specific Patient ◽  
Increased Risk ◽  
Patient Groups

Stroke due to atrial fibrillation (AF) is common, the cause of significant morbidity and mortality, but is highly preventable with the appropriate use of oral anticoagulants. Recent advances in implantable and wearable electrocardiographic (ECG) technologies now allow continuous monitoring of a patient’s heart rhythm for months or years at a time.  Cohort studies have shown that using such methods, it is very common to find asymptomatic, short-lasting episodes of subclinical AF. Subclinical AF is also associated with an increased risk of stroke; however, the risk is lower than with traditional, ECG-detected AF and the absolute risk appears to depend on the overall burden of AF.  There is currently great uncertainty as to what duration of AF should trigger the use of oral anticoagulation in specific patient groups. Large randomized trials are underway to help clarify this issue; however, in the meantime, researchers and guideline committees have proposed some guidance to assist clinicians.

Advances in anticoagulation management of patients undergoing cardioversion of nonvalvular atrial fibrillation

2017 ◽  
Vol 37 (04) ◽  
pp. 277-285 ◽  
Author(s):  
Maria Bonou ◽  
Konstantinos Toutouzas ◽  
Panagiotis Diamantopoulos ◽  
Nora Viniou ◽  
John Barbetseas ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Stroke Risk ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Baseline Risk ◽  
Therapeutic Approaches ◽  
Anticoagulation Management ◽  
Nonvalvular Atrial Fibrillation ◽  
Recent Onset ◽  
Increased Risk

SummaryAtrial fibrillation (AF) is a major cause of stroke. The restoration of sinus rhythm through cardioversion, either chemical or electrical is a common practice. Interestingly, there is an incremental increase from the baseline risk for embolisation in the immediate post-cardioversion period, with most events occurring within 10 days from cardioversion. Especially patients with recent onset AF show the lowest rates of antithrombotic therapy, while having a high stroke risk. Despite the increased risk for embolisation, anticoagulation in patients undergoing cardioversion of atrial fibrillation is often inadequate. Moreover, since the implementation of non-vitamin K antagonists oral anticoagulants (DOACs) there are several therapeutic approaches for pericardioversion anticoagulant therapy and not all suits to all patients. In addition, the extensive use of transesophageal echocardiography provides an alternative strategy, especially useful for patients of high haemorrhagic risk. In this review article, we aim to provide an update on the anticoagulation strategies for patients undergoing cardioversion of non-valvular atrial fibrillation in the advent of the use of DOACs.

scholarly journals Differential Risk of Dementia Between Patients With Atrial Flutter and Atrial Fibrillation: A National Cohort Study

2021 ◽  
Vol 8 ◽  
Author(s):  
Hui-Ting Wang ◽  
Yung-Lung Chen ◽  
Yu-Sheng Lin ◽  
Huang-Chung Chen ◽  
Shaur-Zheng Chong ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Atrial Flutter ◽  
Oral Anticoagulants ◽  
Demographic Data ◽  
Previous History ◽  
Research Database ◽  
Subdistribution Hazard ◽  
Valvular Surgery ◽  
Increased Risk ◽  
History Of

Objectives: Atrial fibrillation (AF) is linked to an increased risk of stroke and dementia. Atrial flutter (AFL) is also linked to an increased risk of stroke but at a different level of risk as compared to AF. Little is known about the difference in the risk of dementia between AF and AFL. This study aims to investigate whether the risk of dementia is different between AF and AFL.Methods: Patients with newly diagnosed AF and AFL during 2001–2013 were retrieved from Taiwan's National Health Insurance Research Database. Patients with incomplete demographic data, aged <20 years, history of valvular surgery, rheumatic heart disease, hyperthyroidism, and history of dementia were excluded. The incidence of new-onset dementia was set as the primary outcome and analyzed in patients with AF and AFL after propensity score matching (PSM).Results: A total of 232,425 and 7,569 patients with AF and AFL, respectively, were eligible for analysis. After 4:1 PSM, we included 30,276 and 7,569 patients with AF and AFL, respectively, for analysis. Additionally, patients with AF (n = 29,187) and AFL (n = 451) who received oral anticoagulants were enrolled for comparison. The risk of dementia was higher in patients with AF compared with patients with AFL (subdistribution hazard ratio (SHR) = 1.52, 95% CI 1.39–1.66; p < 0.0001) before PSM and remained higher in patients with AF (SHR = 1.14, 95% CI 1.04–1.25; p = 0.0064) after PSM. The risk of dementia was higher in patients with AF without previous history of stroke after PSM but the risk did not differ between patients with AF and AFL with previous history of stroke. Among patients who received oral anticoagulants, the cumulative incidences of dementia were significantly higher in patients with AF than in patients with AFL before and after PSM (all P < 0.05).Conclusions: This study found that, among patients without history of stroke, the risk of dementia was higher in patients with AF than in patients with AFL, and CHA2DS2-VASc score might be useful for risk stratification of dementia between patients with AF and AFL.

Abstract 16732: Urinary 11-Dehydro-Thromboxane B2 is Associated With Vascular and Non-Vascular Events in Atrial Fibrillation Patients

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Daniele Pastori ◽  
Pasquale Pignatelli ◽  
Roberto Cangemi ◽  
William Hiatt ◽  
Alessio Farcomeni ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Cardiovascular Events ◽  
Oral Anticoagulants ◽  
Cardiovascular Death ◽  
Cox Proportional Hazards ◽  
Thromboxane B2 ◽  
Vascular Events ◽  
Residual Cardiovascular Risk ◽  
Increased Risk ◽  
Anticoagulated Patients

Introduction: Non-Valvular Atrial Fibrillation (AF) patients show high residual cardiovascular risk despite oral anticoagulants. Urinary 11-dehydro-thromboxane B2 (TxB2) is associated with an increased risk of cardiovascular events, but its predictive value in anticoagulated AF patients is unknown. Hypothesis: Aim of this was to assess whether urinary 11-dehydro-TxB2 is a predictor of cardiovascular events in anticoagulated patients with AF. Methods: Prospective single-center cohort study, including 864 consecutive AF patients. Mean time of follow-up was 30.0 months yielding 2062 person-years of observation. Urinary 11-dehydro-TxB2 was measured at baseline. The primary end-point was the composite of myocardial infarction, ischemic stroke, cardiac revascularization, cardiovascular death and deaths from any cause. Results: Cardiovascular events occurred in 98 (11.3%), whilst 81 patients died (9.4%), including 55 from cardiovascular and 26 from non-cardiovascular causes. At baseline, urinary 11-dehydro-TxB2 levels were higher in patients who experienced a cardiovascular event (p<0.001). An increased rate of cardiovascular events, cardiovascular death and all-cause death was observed across tertiles of 11-dehydro-TxB2 (p<0.001). On Cox proportional hazards analysis, CHA2DS2-VASc score, second and third tertile of 11-dehydro-TxB2, compared to the first tertile, were significant predictors of vascular and non-vascular events. On a logistic regression analysis, 11-dehydro-TxB2 levels progressively increase with increasing CHA2DS2-VASc scores. Conclusions: Urinary 11-dehydro-TxB2 predicts residual risk of cardiovascular events in anticoagulated atrial fibrillation patients. Urinary 11-dehydro-TxB2 progressively increases with increasing CHA2DS2-VASc score suggesting that anticoagulated patients with high CHA2DS2-VASc score may need additional antithrombotic strategies.

Should the Presence or Extent of Coronary Artery Disease be Quantified in the CHA2DS2-VASc Score in Atrial Fibrillation? A Report from the Western Denmark Heart Registry

2018 ◽  
Vol 118 (12) ◽  
pp. 2162-2170 ◽  
Author(s):  
Kamilla Steensig ◽  
Kevin Olesen ◽  
Troels Thim ◽  
Jens Nielsen ◽  
Svend Jensen ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Coronary Artery Disease ◽  
Risk Factor ◽  
Coronary Artery ◽  
Coronary Angiography ◽  
Ischaemic Stroke ◽  
Independent Risk Factor ◽  
Oral Anticoagulants ◽  
Increased Risk ◽  
Artery Disease

Background Patients with atrial fibrillation (AF) have an increased risk of ischaemic stroke. The risk can be predicted by the CHA2DS2-VASc score, in which the vascular component refers to previous myocardial infarction, peripheral artery disease and aortic plaque, whereas coronary artery disease (CAD) is not included. Objectives This article explores whether CAD per se or extent provides independent prognostic information of future stroke among patients with AF. Materials and Methods Consecutive patients with AF and coronary angiography performed between 2004 and 2012 were included. The endpoint was a composite of ischaemic stroke, transient ischaemic attack and systemic embolism. The risk of ischaemic events was estimated according to the presence and extent of CAD. Incidence rate ratios (IRR) were calculated in reference to patients without CAD and adjusted for parameters included in the CHA2DS2-VASc score and treatment with anti-platelet agents and/or oral anticoagulants. Results Of 96,430 patients undergoing coronary angiography, 12,690 had AF. Among patients with AF, 7,533 (59.4%) had CAD. Mean follow-up was 3 years. While presence of CAD was an independent risk factor for the composite endpoint (adjusted IRR, 1.25; 1.06–1.47), extent of CAD defined as 1-, 2-, 3- or diffuse vessel disease did not add additional independent risk information. Conclusion Presence, but not extent, of CAD was an independent risk factor of the composite thromboembolic endpoint beyond the components already included in the CHA2DS2-VASc score. Consequently, we suggest that significant angiographically proven CAD should be included in the vascular disease criterion in the CHA2DS2-VASc score.

Oral anticoagulants in atrial fibrillation with valvular heart disease and bioprosthetic heart valves

Heart ◽  
2019 ◽  
Vol 105 (18) ◽  
pp. 1432-1436 ◽  
Author(s):  
Aaqib H Malik ◽  
Srikanth Yandrapalli ◽  
Wilbert S Aronow ◽  
Julio A Panza ◽  
Howard A Cooper
Keyword(s):  
Atrial Fibrillation ◽  
Heart Disease ◽  
Major Bleeding ◽  
Valvular Heart Disease ◽  
Heart Valves ◽  
Meta Analysis ◽  
Oral Anticoagulants ◽  
Cardiac Events ◽  
Increased Risk ◽  
Randomised Controlled

ObjectiveCurrent guidelines endorse the use of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation (AF). However, little is known about their safety and efficacy in valvular heart disease (VHD). Similarly, there is a paucity of data regarding NOACs use in patients with a bioprosthetic heart valve (BPHV). We, therefore, performed a network meta-analysis in the subgroups of VHD and meta-analysis in patients with a BPHV.MethodsPubMed, Cochrane and Embase were searched for randomised controlled trials. Summary effects were estimated by the random-effects model. The outcomes of interest were a stroke or systemic embolisation (SSE), myocardial infarction (MI), all-cause mortality, major adverse cardiac events, major bleeding and intracranial haemorrhage (ICH).ResultsIn patients with VHD, rivaroxaban was associated with more ICH and major bleeding than other NOACs, while edoxaban 30 mg was associated with least major bleeding. Data combining all NOACs showed a significant reduction in SSE, MI and ICH (0.70, [0.57 to 0.85; p<0.001]; 0.70 [0.50 to 0.99; p<0.002]; and 0.46 [0.24 to 0.86; p<0.01], respectively). Analysis of 280 patients with AF and a BPHV showed similar outcomes with NOACs and warfarin.ConclusionsNOACs performed better than warfarin for a reduction in SSE, MI and ICH in patients with VHD. Individually NOACs performed similarly to each other except for an increased risk of ICH and major bleeding with rivaroxaban and a reduced risk of major bleeding with edoxaban 30 mg. In patients with a BPHV, results with NOACs seem similar to those with warfarin and this needs to be further explored in larger studies.

scholarly journals Screening for Atrial Fibrillation in Older Adults at Primary Care Visits: the VITAL-AF Randomized Controlled Trial

2021 ◽  
Author(s):  
Steven Lubitz ◽  
Steven J. Atlas ◽  
Jeffrey M. Ashburner ◽  
Ana Lipsanopoulos ◽  
Leila Borowsky ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Primary Care ◽  
Usual Care ◽  
Controlled Trial ◽  
Oral Anticoagulants ◽  
Care Practice ◽  
Control Group ◽  
Newly Diagnosed ◽  
One Year ◽  
And Control

Background: Undiagnosed atrial fibrillation (AF) may cause preventable strokes. Guidelines differ regarding AF screening recommendations. We tested whether point-of-care screening with a handheld single lead electrocardiogram (ECG) at primary care practice visits increases diagnoses of AF. Methods: We randomized 16 primary care clinics 1:1 to AF screening using a handheld single-lead ECG (AliveCor KardiaMobile) during vital sign assessments, or usual care. Patients included were aged ≥ 65 years. Screening results were provided to primary care clinicians at the encounter. All confirmatory diagnostic testing and treatment decisions were made by the primary care clinician. New AF diagnoses over one-year follow-up were ascertained electronically and manually adjudicated. Proportions and incidence rates were calculated. Effect heterogeneity was assessed. Results: Of 30,715 patients without prevalent AF (n=15,393 screening [91% screened], n=15,322 control), 1.72% of individuals in the screening group had new AF diagnosed at one year versus 1.59% in the control group (risk difference [RD] 0.13%, 95% confidence interval [CI] -0.16,0.42, P=0.38). New AF diagnoses in the screening and control groups differed by age with the greatest effect observed for those aged ≥ 85 years (5.56% versus 3.76%, respectively, RD 1.80%, 95% CI 0.18,3.30). The difference in newly diagnosed AF between the screening period and the prior year was marginally greater in the screening versus control group (0.32% versus -0.12%, RD 0.43%, 95% CI -0.01,0.84). The proportion of individuals with newly diagnosed AF who were initiated on oral anticoagulants was similar in the screening (n=194, 73.5%) and control (n=172, 70.8%) arms (RD 2.7%, 95% CI -5.5,10.4). Conclusions: Screening for AF using a single-lead ECG at primary care visits was not associated with a significant increase in new AF diagnoses among individuals aged 65 years or older compared to usual care. However, screening may be associated with an increased likelihood of diagnosing AF among individuals aged 85 years or older and warrants further evaluation.

scholarly journals Anticoagulation in Patients with End-Stage Renal Disease and Atrial Fibrillation: Confusion, Concerns and Consequences

2020 ◽  
Vol 22 (3) ◽  
pp. 306-316
Author(s):  
Narender Goel ◽  
Deepika Jain ◽  
Danny B. Haddad ◽  
Divya Shanbhogue
Keyword(s):  
Atrial Fibrillation ◽  
Renal Disease ◽  
End Stage Renal Disease ◽  
Clinical Decision Making ◽  
Controlled Trial ◽  
Oral Anticoagulants ◽  
Increased Risk ◽  
Stage Renal Disease ◽  
End Stage ◽  
Esrd Patients

End-stage renal disease (ESRD) patients have a higher prevalence of diabetes mellitus, hypertension, congestive heart failure and advanced age, along with an increased incidence of non-valvular atrial fibrillation (AF), thereby increasing the risk for cerebrovascular accidents. Systemic anticoagulation is therefore recommended in patients with ESRD with AF to reduce the risk and complications from thromboembolism. Paradoxically, these patients are at an increased risk of bleeding due to great degree of platelet dysfunction and impaired interaction between platelet and endothelium. Currently, CHA2DS2-VASc and Hypertension, Abnormal liver/kidney function, Stroke, Bleeding, Labile INR, Elderly, Drugs or alcohol (HAS-BLED) are the recommended models for stroke risk stratification and bleeding risk assessment in patients with AF. There is conflicting data regarding benefits and risks of medications such as antiplatelet agents, warfarin and direct oral anticoagulants in ESRD patients with AF. Moreover, there is no randomized controlled trial data to guide the clinical decision making. Hence, a multi-disciplinary approach with annual re-evaluation of treatment goals and risk-benefit assessment has been recommended. In this article, we review the current recommendations with risks and benefits of anticoagulation in patients with ESRD with AF.

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