scholarly journals An mHealth intervention to improve nurses’ atrial fibrillation and anticoagulation knowledge and practice: the EVICOAG study

2018 ◽  
Vol 18 (1) ◽  
pp. 7-15 ◽  
Author(s):  
Caleb Ferguson ◽  
Louise D Hickman ◽  
Jane Phillips ◽  
Phillip J Newton ◽  
Sally C Inglis ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Risk Assessment ◽  
Anticoagulation Therapy ◽  
Bleeding Risk ◽  
Assessment Tools ◽  
Future Research ◽  
Post Intervention ◽  
Mhealth Intervention ◽  
Quasi Experimental ◽  
Nurses Knowledge

Background: There is a need to improve cardiovascular nurses’ knowledge and practices related to stroke prevention, atrial fibrillation and anticoagulation therapy. Aims: The aim of this study was to evaluate the efficacy of EVICOAG – a novel mHealth, smartphone-based, spaced-learning intervention on nurses’ knowledge of atrial fibrillation and anticoagulation. Methods: Nurses employed in four clinical specialties (neuroscience, stroke, rehabilitation, cardiology) across three hospitals were invited to participate. In this quasi-experimental study, 12 case-based atrial fibrillation and anticoagulation learning scenarios (hosted by an mHealth platform) were delivered to participants’ smartphones over a 6-week period (July–December 2016) using a spaced timing algorithm. Electronic surveys to assess awareness and knowledge were administered pre (T1) and post (T2) intervention. Results: From 74 participants recruited to T1, 40 completed T2. There was a 54% mean improvement in knowledge levels post-intervention. The largest improvement was achieved in domains related to medication interaction and stroke and bleeding risk assessment. Post-intervention, those who completed T2 were significantly more likely to use CHA2DS2-VASc (2.5% vs. 37.5%) and HAS-BLED (2.5% vs. 35%) tools to assess stroke and bleeding risk, respectively ( P<0.01). Conclusion: The EVICOAG intervention improved nurses’ knowledge of atrial fibrillation and anticoagulation, and influenced their uptake and use of stroke and bleeding risk assessment tools in clinical practice. Future research should focus on whether a similar intervention might improve patient-centred outcomes such as patients’ knowledge of their condition and therapies, medication adherence, time in the therapeutic range and quality of life.

Risk Stratification Models in Atrial Fibrillation

2017 ◽  
Vol 43 (05) ◽  
pp. 505-513 ◽  
Author(s):  
Farhan Shahid ◽  
Gregory Lip
Keyword(s):  
Atrial Fibrillation ◽  
Risk Assessment ◽  
Bleeding Risk ◽  
Practical Method ◽  
Assessment Tools ◽  
Risk Scores ◽  
Mortality And Morbidity ◽  
Increased Risk ◽  
Morbidity Risk ◽  
Aid Decision

AbstractAtrial fibrillation (AF) is associated with an increased risk of stroke compared with the general population. AF-related stroke confers a higher mortality and morbidity risk, and thus, early detection and assessment for the initiation of effective stroke prevention with oral anticoagulation are crucial. Simple and practical risk assessment tools are essential to facilitate stroke and bleeding risk assessment in busy clinics and wards to aid decision making. At present, the CHA2DS2VASc score is recommended by guidelines as the most simple and practical method of assessing stroke risk in AF patients. Alongside this, the use of the HAS-BLED score aims to identify patients at high risk of bleeding for more regular review and follow-up, and draws attention to potentially reversible bleeding risk factors. The aim of this review article is to summarize the current risk scores available for both stroke and bleeding in AF patients, and the recommendations for their use.

scholarly journals Recent advances in the understanding and management of atrial fibrillation: a focus on stroke prevention

F1000Research ◽  
2016 ◽  
Vol 5 ◽  
pp. 2887 ◽  
Author(s):  
Farhan Shahid ◽  
Eduard Shantsila ◽  
Gregory Y. H. Lip
Keyword(s):  
Atrial Fibrillation ◽  
Risk Assessment ◽  
Stroke Prevention ◽  
Bleeding Risk ◽  
Assessment Tools ◽  
The European Union ◽  
Mortality And Morbidity ◽  
Recent Advances ◽  
Increased Risk ◽  
Direct Head

Atrial fibrillation (AF) is associated with an increased risk of stroke compared with the general population. It is anticipated that by 2030 an estimated 14–17 million patients will be diagnosed with this most prevalent arrhythmia within the European Union. AF-related stroke confers a higher mortality and morbidity risk, and thus early detection and assessment for the initiation of effective stroke prevention with oral anticoagulation (OAC) is crucial. Recent guidelines point to the use of non-vitamin K antagonist OACs (NOACs) where appropriate in stroke prevention of patients with non-valvular AF. At present, there are four NOACS available, with no direct head-to-head comparisons to suggest the superiority of one drug over another. Simple and practical risk assessment tools have evolved over the years to facilitate stroke and bleeding risk assessment in busy clinics and wards to aid decision-making. At present, the CHA2DS2VASc (congestive heart failure, hypertension, age 65–74/>75, diabetes mellitus, stroke/transient ischemic attack/thromboembolism, vascular disease, female sex) score is recommended by many international guidelines as a simple and practical method of assessing stroke risk in such patients. Alongside this, use of the HAS BLED (hypertension systolic blood pressure >160 mmHg, abnormal liver/renal function [with creatinine ≥200 μmol/L], stroke, bleeding history or predisposition, labile international normalized ratio [range <60% of the time], elderly [>65], concomitant drugs/alcohol) score aims to identify patients at high risk of bleeding for more regular review and follow-up and draws attention to potentially reversible bleeding risk factors. The aim of this review article is to provide an overview of recent advances in the understanding and management of AF with a focus on stroke prevention.

Abstract P081: Association Of Homelessness And Anticoagulation Initiation In Veterans With Atrial Fibrillation: A Nationwide Study

Circulation ◽  
2021 ◽  
Vol 143 (Suppl_1) ◽  
Author(s):  
David Wilson ◽  
Nadejda Kim ◽  
Maria Mor ◽  
Micahel Fine ◽  
Utibe Essien
Keyword(s):  
Atrial Fibrillation ◽  
Renal Disease ◽  
Risk Score ◽  
Oral Anticoagulants ◽  
Random Effect ◽  
Anticoagulation Therapy ◽  
Bleeding Risk ◽  
Homeless Population ◽  
Future Research ◽  
Homeless Veterans

Introduction: Homeless individuals, overrepresented by Veterans, are more likely to have chronic medical conditions and comorbidities. They receive less medical care and have poor health outcomes, though remain understudied. Atrial fibrillation (AF), the most common cardiovascular rhythm disorder, is managed largely through anticoagulation. Direct-acting oral anticoagulants (DOACs) have been shown superior to warfarin anticoagulation in efficacy, safety, and adherence, though costlier. Hypothesis: Homeless Veterans receive a worse standard of care for AF than non-homeless Veterans in terms of initiation of any anticoagulation therapy, and in prescription of DOACs vs warfarin among those who began therapy. Methods: We studied 181,982 Veterans with incident, non-valvular AF in the Veterans Affairs Healthcare system from 2010-2018 who were not previously anticoagulated. Those who died or entered hospice were excluded. We classified Veterans who had experienced homelessness in the 2 years prior to their AF diagnosis using ICD-9/10 diagnosis codes and through VA homeless services use. We used logistic regression to examine the odds of initiation of any, DOAC, or warfarin anticoagulation. Models were adjusted for sociodemographic characteristics (year, age, race, CHA2DS2-VASc stroke risk score, HAS-BLED bleeding risk score, renal disease, BMI) and provider factors (e.g. specialty, had a patient seen a cardiologist within 90 days of their diagnosis). Facility type was modeled as a random effect. Results: Most of our cohort were male (178,400, 98%) and White (155,142, 85.6%). The homeless population of 6,472 was overrepresented by Black patients (1,574, 24.5%) and presented with AF at a younger age. The likelihood of being anticoagulated was lower in all populations before 2014. Having a BMI less than 25, liver disease, or bleeding concerns decreased the likelihood of being anticoagulated, while patients with renal disease were less likely to be prescribed DOACs. Black and Hispanic patients were less likely to be prescribed DOACs, regardless of homelessness status. We found the adjusted odds ratio (aOR) of initiating any anticoagulant therapy for homeless Veterans was 0.71 (95% CI 0.67 - 0.75). Among those who initiated anticoagulation, homeless individuals were less likely than non-homeless Veterans to initiate DOACs (aOR 0.88, 95% CI 0.80-0.96). Conclusions: In a nationwide cohort of Veterans with AF, we found that homeless Veterans were less likely to initiate any anticoagulation, especially more effective DOAC therapy. These findings persisted after adjusting for sociodemographic and clinical factors within an integrated health system with broad access to medical treatment through a uniform drug formulary. Future research must examine and address systematic biases to ensure high quality and equitable care for the most vulnerable populations, including homeless Veterans.

scholarly journals Anticoagulation risk assessment for patients with non-valvular atrial fibrillation and venous thromboembolism: A clinical review

2019 ◽  
Vol 24 (2) ◽  
pp. 141-152
Author(s):  
Vincent A Pallazola ◽  
Rishi K Kapoor ◽  
Karan Kapoor ◽  
John W McEvoy ◽  
Roger S Blumenthal ◽  
...  
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Risk Assessment ◽  
Venous Thromboembolism ◽  
Anticoagulant Therapy ◽  
Bleeding Risk ◽  
Assessment Tools ◽  
Risk Scores ◽  
Increased Risk ◽  
Risk Assessment Tools

Non-valvular atrial fibrillation and venous thromboembolism anticoagulation risk assessment tools have been increasingly utilized to guide implementation and duration of anticoagulant therapy. Anticoagulation significantly reduces stroke and recurrent venous thromboembolism risk, but comes at the cost of increased risk of major and clinically relevant non-major bleeding. The decision for anticoagulation in high-risk patients is complicated by the fact that many risk factors associated with increased thromboembolic risk are simultaneously associated with increased bleeding risk. Traditional risk assessment tools rely heavily on age, sex, and presence of cardiovascular comorbidities, with newer tools additionally taking into account changes in risk factors over time and novel biomarkers to facilitate more personalized risk assessment. These tools may help counsel and inform patients about the risks and benefits of starting or continuing anticoagulant therapy and can identify patients who may benefit from more careful management. Although the ability to predict anticoagulant-associated hemorrhagic risk is modest, ischemic and bleeding risk scores have been shown to add significant value to therapeutic management decisions. Ultimately, further work is needed to optimally implement accurate and actionable risk stratification into clinical practice.

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 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.

Stroke prevention in atrial fibrillation: Past, present and future

2017 ◽  
Vol 117 (07) ◽  
pp. 1230-1239 ◽  
Author(s):  
Gregory Y.H. Lip ◽  
Ben Freedman ◽  
Raffaele De Caterina ◽  
Tatjana S. Potpara
Keyword(s):  
Atrial Fibrillation ◽  
Risk Assessment ◽  
Stroke Prevention ◽  
Review Process ◽  
Treatment Options ◽  
Bleeding Risk ◽  
Review Article ◽  
Ongoing Debate ◽  
New Treatment ◽  
Future Concepts

SummaryConcepts and our approaches to stroke prevention in atrial fibrillation (AF) have changed markedly over the last decade. There has been an evolution over the approach to stroke and bleeding risk assessment, as well as new treatment options. An increasing awareness of AF has led to calls to improve the detection of and population screening for AF. Stroke and bleeding risk assessment continues to evolve, and the ongoing debate on balance between simplicity and practicality, against precision medicine will continue. In this review article, we provide an overview of past, present and the (likely) future concepts and approaches to stroke prevention in AF. We propose three simple steps (the Birmingham ‘3-step’) that offers a practical management pathway to help streamline and simplify decision-making for stroke prevention in patients with AF.Note: The review process for this paper was fully handled by Christian Weber, Editor in Chief.

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