Background
Most atrial fibrillation (AF) patients have coexisting cardiovascular pathologies that worsen prognosis and require management. Although anticoagulation has received significant attention in AF patients, there is scarce data on the quality of the total cardiovascular care for AF patients. Our aim was to explore the gap between guideline recommendations and the actual comprehensive cardiovascular care of a well anticoagulated clinical trial AF population.
Methods
At the end of RE-LY, a randomized trial of two dabigatran doses in patients with AF at high risk of stroke, patients were offered to continue the randomized double-blinded dabigatran dose in the extended RELY-ABLE study.
Table 1
shows all treatment targets for the management of AF and its concomitant cardiovascular issues that were distilled from international guidelines. Audit of RE-LY and RELY-ABLE data was done to assess whether these targets were achieved in individual patients at RELY-ABLE baseline.
Results
Of the 12,091 patients who received dabigatran in RE-LY, 5,849 patients among 546 centers in 35 countries were enrolled in RELY-ABLE. Overall, the mean age is 73 ± 8 years, 35% female, 81% hypertension, 27% coronary artery disease, 18% heart failure and 22% diabetes.
Table 1
shows for how many patients each treatment target was relevant, and in whom the target was achieved. For example, of 1,483 patients at with diabetes, 986 (66.5%) patients achieved the target and had an HbA1c value <7.0%, and 497 (33.5%) patients did not achieve the target. We identified a total of 23,868 relevant treatment targets, of which 5064 (21.2%) were not achieved.
Conclusions
We indentified many opportunities to improve the total cardiovascular care for AF patients who were already well anticoagulated and successfully completed RE-LY. RELY-ABLE is an ongoing cluster-randomized trial that will test if a multifaceted knowledge translation intervention can assist to close this gap and improve patient outcomes.
RELY-ABLE baseline achievement of treatment targets
Treatment target
Relevant group (% of RELY-ABLE
Achieving target (% of relevant group)
Not achieving target (% of relevant group)
Blood pressure <140mmHg (<130mmHg for diabetics)
4,785 (81.2%)
3,378 (70.6%)
1,407 (29.4%)
HbA1c <7.0% in diabetics
1,483 (25.2%)
986 (66.5%)
497 (33.5%)
LDL <70mg/dL with high risk (<100mg/dL with moderate risk)
2,873 (48.7%)
1,408 (49.0%)
1,65 (51.0%)
Not smoking
5,895 (100%)
5,551 (94.1%)
345 (5.9%)
Stop antiarrhythmic drug if no sinus rhythm in past year
1,083 (18.4%)
667 (61.6%)
416 (38.4%)
Rate control in rest <100 bpm
2,553 (43.3%)
2,377 (93.1%)
177 (6.9%)
Stop aspirin if no history of stroke/CAD
3,550 (60.2%)
3,153 (88.8%)
397 (11.2%)
Prescribe beta blocker for heart failure
822 (9.9%)
620 (75.4%)
202 (14.6%)
Prescribe ACEi/ARB for heart failure
822 (9.9%)
664 (80.8%)
158 (19.2%)
Testing feedback message framing and comparators to address prescribing of high-risk medications in nursing homes: protocol for a pragmatic, factorial, cluster-randomized trial
