Evaluating Physician Adherence to Antithrombotic Recommendations in Patients with Atrial Fibrillation: A Pathway to Better Medical Education

Background: Atrial fibrillation is a major health problem due to the stroke risk associated with it. To reduce stroke risk, oral anticoagulants (OAC) are prescribed using the CHA2DS2-VASc (Congestive heart failure; Hypertension; Age ≥75 years; Diabetes Mellitus; Stroke; Vascular disease; Age 65–74 years; Sex category) risk score, a clinical probability assessment that includes a combination of risk factors predicting the probability of a stroke. Not all patients with high risk are receiving this treatment. The aim of this study was to assess physician adherence to clinical guidelines concerning the OAC treatment and to identify the factors that were associated with the decision to prescribe it. Methods: Registry data from 784 patients with non-valvular atrial fibrillation were evaluated in this retrospective cross-sectional study. Demographic data, subtype of AF, comorbidities associated with higher stroke and bleeding risk, and antithrombotic treatment received were recorded. We compared stroke and bleeding risk in patients with and without OAC treatment to determine if the clinicians followed guidelines: prescribed when necessary and abstained when not needed. Results: OAC treatment was administered in 617 (78.7%) patients. Of the 167 patients who did not receive OAC, 161 (96.4%) were undertreated according to their risk score, as opposed to those who received OAC in which the percentage of overtreated was 3.2%. Most undertreated patients (60.5%, p < 0.001) were with paroxysmal atrial fibrillation subtype. Conclusions: The decision to use anticoagulants for stroke prevention was based on the type of atrial fibrillation, rather than on the risk of stroke as quantified by CHA2DS2-VASc as per the recommended guidelines.

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Status of CHADS2 and CHA2DS2-VASc Scores in Predicting Risk of Stroke and its Prevention in Iraqi Patients with Atrial Fibrillation

Iraqi Journal of Pharmaceutical Sciences ( P-ISSN 1683 - 3597 E-ISSN 2521 - 3512) ◽

10.31351/vol28iss1pp101-105 ◽

2019 ◽

Vol 28 (1) ◽

pp. 101-105

Author(s):

Mohanad Y. Al-Radeef

Keyword(s):

Atrial Fibrillation ◽

Stroke Prevention ◽

Stroke Risk ◽

Oral Anticoagulants ◽

Hospital Setting ◽

Cross Sectional Study ◽

Elevated Risk ◽

Current Status ◽

Sectional Study ◽

Cross Sectional

Atrial fibrillation is associates with elevated risk of stroke. The simplest stroke risk assessment schemes are CHADS2 and CHA2DS2-VASc score. Aspirin and oral anticoagulants are recommended for stroke prevention in such patients. The aim of this study was to assess status of CHADS2 and CHA2DS2-VASc scores in Iraqi atrial fibrillation patients and to report current status of stroke prevention in these patients with either warfarin or aspirin in relation to these scores. This prospective cross-sectional study was carried out at Tikrit, Samarra, Sharqat, Baquba, and AL-Numaan hospitals from July 2017 to October 2017. CHADS2 and CHA2DS2-VASc scores were manually calculated. One hundred patients were participated, 48 were men and 52 were women. Their mean age was 62.56 ± 14.36 years. Permanent type of atrial fibrillation, palpitation, and hypertension were the most diagnosed type, symptom and comorbidity recorded in this study respectively. Average scores of CHADS2 and CHA2DS2-VASc were 2.34 ± 1.39 and 4.1 ± 2.05, respectively. These scores were not calculated for these patients in hospital setting. Aspirin and warfarin were prescribed regardless to these scores. The result of this study indicated that CHADS2 and CHA2DS2-VASc scores were often neglected in hospitals; and aspirin is still widely used as a strategy to minimize the risk of stroke. Keywords: Atrial fibrillation, CHADS2, CHA2DS2-VASc, aspirin, warfarin.

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Status of CHADS2 and CHA2DS2-VASc Scores in Predicting Risk of Stroke and its Prevention in Iraqi Patients with Atrial Fibrillation

Iraqi Journal of Pharmaceutical Sciences ( P-ISSN 1683 - 3597 E-ISSN 2521 - 3512) ◽

10.31351/vol28iss1pp101-106 ◽

2019 ◽

Vol 28 (1) ◽

pp. 101-106

Author(s):

Mohanad Yasir Radeef

Keyword(s):

Atrial Fibrillation ◽

Stroke Prevention ◽

Stroke Risk ◽

Oral Anticoagulants ◽

Hospital Setting ◽

Cross Sectional Study ◽

Elevated Risk ◽

Current Status ◽

Sectional Study ◽

Cross Sectional

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Novel bleeding risk score for patients with atrial fibrillation on oral anticoagulants, including direct oral anticoagulants

Journal of Thrombosis and Haemostasis ◽

10.1111/jth.15251 ◽

2021 ◽

Author(s):

Luise Adam ◽

Martin Feller ◽

Lamprini Syrogiannouli ◽

Cinzia Del‐Giovane ◽

Jacques Donzé ◽

...

Keyword(s):

Atrial Fibrillation ◽

Risk Score ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Bleeding Risk

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Frequency of Atrial Fibrillation in Heart Failure Patients

10.53350/pjmhs2115113261 ◽

2021 ◽

Vol 15 (11) ◽

pp. 3261-3264

Author(s):

Syed Mohammad Haleem ◽

Muhammad Hashim Kalwar ◽

Muhammad Hassan Butt ◽

Jehangir Hasan ◽

Javed Khurshed Shaikh ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Demographic Data ◽

Treatment Options ◽

Cross Sectional Study ◽

P Value ◽

Cross Sectional ◽

Heart Failure Patients ◽

Cardiac Symptoms ◽

Patients With Heart Failure

Background: An increasing number of people around the world suffer from cardiovascular diseases such as atrial fibrillation (AF) and heart failure (HF). Atrial fibrillation (AF) has been linked to poor prognosis in heart failure (HF) patients with mild to moderate LV dysfunction, and it is most prominent in these patients. Despite advancements in care and treatment options like catheter ablation, managing AF is still a therapeutic challenge even with these advances. Aim/Objective: To determine the frequency of atrial fibrillation in heart failure patients. Subjects and Methods: This cross-sectional study was conducted on 246 patients at Adult Cardiology, NICVD, Karachi for Six months after approval from 31-08-2019 till 29-02-2020. Patients' consent was obtained verbally before data were collected prospectively. There were 246 patients with heart failure who had been diagnosed and met the diagnostic criteria. An overview of the event's history was gathered, as well as demographic data. Qualitative variables were presented as frequency and percentages, while quantitative data were given as simple descriptive statistics such as mean and standard deviation. A p-value of 0.05 or lower is considered statistically significant. Results: A total of 246 patients with heart failure were included in this study. The mean age in our study was 56.78±2.81 years. Whereas, mean BNP and ejection fraction in our study was 1144±87.81 pg./ml and 34.65±4.14 %. 136 (55.3%) were male and 110 (44.7%) were female. Out of 246 patients with heart failure, 52 (21.1%) had atrial fibrillation and 194 (78.9%) did not have atrial fibrillation. Conclusion: The results of this research demonstrated that a large percentage of heart failure patients had atrial fibrillation. Thus, it is essential to focus on a comprehensive way of management of heart failure and its comorbidities rather than primarily treating the cardiac symptoms. Keywords: Heart failure and atrial fibrillation.

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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 ◽

10.1161/circ.130.suppl_2.18538 ◽

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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Abstract 140: Comparison of Major Complication of Oral Anticoagulants in Non-Valvular Atrial Fibrillation: Systematic Review and Meta-Analyses

Arteriosclerosis Thrombosis and Vascular Biology ◽

10.1161/atvb.37.suppl_1.140 ◽

2017 ◽

Vol 37 (suppl_1) ◽

Author(s):

Hong Seok Lee

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Major Bleeding ◽

Oral Anticoagulant ◽

Stroke Risk ◽

Oral Anticoagulants ◽

Bleeding Risk ◽

Gi Bleeding ◽

Ischemic Stroke Risk ◽

Meta Analyses

Background: Oral anticoagulants known as a novel oral anticoagulant have been used for the management of non -valvular atrial fibrillation. There was no enough study regarding the efficacy and safety of three major new oral anticoagulants. We assessed major three oral anticoagulants in terms of major bleeding complication and stroke prevention by meta-analyses studies comparing those drugs. Method: Relevant studies were identified through electronic literature searches of MEDLINE, EMBASE, Cochrane library, and clinicaltrials.gov (from inception to February 24, 2016). RevMan and ITC software were used for direct comparisons, respectively. Results: Apixaban (N=6020), versus dabigatran(N=12038), apixaban versus rivaroxaban(N=8503) and rivaroxaban versus dabigatran were analyzed directly. There was significantly higher major bleeding risks in apixaban compared to dabigatran (both 110mg and 150mg) after adjusting baseline bleeding risk (Relative risk 3.41, 95% confidence interval(2.61 to 4.47) in 110mg, (5.62, 4.83 to 6.54) in 150mg. Intracranial bleeding risk in apixaban was significantly higher than in dabigatran (10.5, 6.10 to18.01). However, apixaban had less GI bleeding risk compared to dabigatran (0.80 , 0.65 to 0.98) and also had less ischemic stroke risk (0.31,0.22 to 0.42). Rivaroxaban showed higher major bleeding risk than dabigatran 110mg (2.34 , 1.81 to 3.03), however, Rivaroxaban had less bleeding risk compared to dabigatran 150mg (0.41, 0.35 to 0.46). Dabigatran 110mg and 150mg had less GI bleeding risk compared to rivaroxaban (0.31 , 0.24 to 0.39) and (0.23,0.17 to 0.29) respectively. Ischemic stroke risk was also decreased in dabigatran110mg (0.46, 0.38 to 0.57). and 150mg (0.66 ,0.52 to 0.83). Conclusion: Observed oral anticoagulants were associated with various complications. Overall, apixaban had higher intracranial bleeding risk than dabigatran. The highest GI bleeding risk in rivaroxaban compared to apixaban and dabigatran. Ischemic stroke risk was the highest in dabigatran. In conclusion, we may use those oral anticoagulant based on risks rates, however, a larger study with longer follow-up is needed to corroborate findings.

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PCV13 COMPARISON OF TREATMENT OUTCOMES OF NEWER ORAL ANTICOAGULANTS VS WARFARIN IN NON-VALVULAR ATRIAL FIBRILLATION: A RETROSPECTIVE CROSS-SECTIONAL STUDY IN SOUTH INDIAN POPULATION

Value in Health ◽

10.1016/j.jval.2020.04.118 ◽

2020 ◽

Vol 23 ◽

pp. S91-S92

Author(s):

L. Morries ◽

S. Abraham ◽

J.J. Joseph ◽

N. Mariya

Keyword(s):

Atrial Fibrillation ◽

Treatment Outcomes ◽

Indian Population ◽

Oral Anticoagulants ◽

Cross Sectional Study ◽

South Indian Population ◽

Sectional Study ◽

Cross Sectional ◽

South Indian

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Role of Biological Markers for Cerebral Bleeding Risk STRATification in Patients with Atrial Fibrillation on Oral Anticoagulants for Primary or Secondary Prevention of Ischemic Stroke (Strat-AF Study): Study Design and Methodology

Medicina ◽

10.3390/medicina55100626 ◽

2019 ◽

Vol 55 (10) ◽

pp. 626 ◽

Cited By ~ 3

Author(s):

Anna Poggesi ◽

Carmen Barbato ◽

Francesco Galmozzi ◽

Eleonora Camilleri ◽

Francesca Cesari ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Biological Markers ◽

Oral Anticoagulant ◽

Stroke Risk ◽

Oral Anticoagulants ◽

Bleeding Risk ◽

Circulating Biomarkers ◽

Cerebral Mri

Background and Objectives: In anticoagulated atrial fibrillation (AF) patients, the validity of models recommended for the stratification of the risk ratio between benefits and hemorrhage risk is limited. Cerebral small vessel disease (SVD) represents the pathologic substrate for primary intracerebral hemorrhage and ischemic stroke. We hypothesize that biological markers—both circulating and imaging-based—and their possible interaction, might improve the prediction of bleeding risk in AF patients under treatment with any type of oral anticoagulant. Materials and Methods: The Strat-AF study is an observational, prospective, single-center hospital-based study enrolling patients with AF, aged 65 years or older, and with no contraindications to magnetic resonance imaging (MRI), referring to Center of Thrombosis outpatient clinic of our University Hospital for the management of oral anticoagulation therapy. Recruited patients are evaluated by means of a comprehensive protocol, with clinical, cerebral MRI, and circulating biomarkers assessment at baseline and after 18 months. The main outcome is SVD progression—particularly microbleeds—as a selective surrogate marker of hemorrhagic complication. Stroke occurrence (ischemic or hemorrhagic) and the progression of functional, cognitive, and motor status will be evaluated as secondary outcomes. Circulating biomarkers may further improve predictive potentials. Results: Starting from September 2017, 194 patients (mean age 78.1 ± 6.7, range 65–97; 61% males) were enrolled. The type of AF was paroxysmal in 93 patients (48%), and persistent or permanent in the remaining patients. Concerning the type of oral anticoagulant, 57 patients (29%) were on vitamin K antagonists, and 137 (71%) were on direct oral anticoagulants. Follow-up clinical evaluation and brain MRI are ongoing. Conclusions: The Strat-AF study may be an essential step towards the exploration of the role of a combined clinical biomarker or multiple biomarker models in predicting stroke risk in AF, and might sustain the incorporation of such new markers in the existing stroke prediction schemes by the demonstration of a greater incremental value in predicting stroke risk and improvement in clinical outcomes in a cost-effective fashion.

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2872Association between sociodemographic factors and choice of Direct Oral Anticoagulants versus warfarin in atrial fibrillation: A population based cross-sectional study using Swedish Registers

European Heart Journal ◽

10.1093/eurheartj/ehx504.2872 ◽

2017 ◽

Vol 38 (suppl_1) ◽

Author(s):

G. Venkatesh Kumar ◽

G. Brobert ◽

L. Friberg

Keyword(s):

Atrial Fibrillation ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Sociodemographic Factors ◽

Population Based ◽

Cross Sectional Study ◽

Sectional Study ◽

Cross Sectional

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Comparison of the CHADS2, CHA2DS2 -VASc and HAS-BLED scores for the prediction of clinically relevant bleeding in anticoagulated patients with atrial fibrillation: The AMADEUS trial

Thrombosis and Haemostasis ◽

10.1160/th13-07-0552 ◽

2013 ◽

Vol 110 (11) ◽

pp. 1074-1079 ◽

Cited By ~ 60

Author(s):

Stavros Apostolakis ◽

Deirdre A. Lane ◽

Harry Buller ◽

Gregory Y. H. Lip

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Risk Assessment ◽

Risk Score ◽

Stroke Risk ◽

Bleeding Risk ◽

Risk Scores ◽

Net Reclassification Improvement ◽

Anticoagulated Patients ◽

Discriminatory Performance

SummaryMany of the risk factors for stroke in atrial fibrillation (AF) are also important risk factors for bleeding. We tested the hypothesis that the CHADS2 and CHA2DS2-VASc scores (used for stroke risk assessment) could be used to predict serious bleeding, and that these scores would compare well against the HAS-BLED score, which is a specific risk score designed for bleeding risk assessment. From the AMADEUS trial, we focused on the trial’s primary safety outcome for serious bleeding, which was “any clinically relevant bleeding”. The predictive value of HAS-BLED/CHADS2/CHA2DS2-VASc were compared by area under the curve (AUC, a measure of the c-index) and the Net Reclassification Improvement (NRI). Of 2,293 patients on VKA, 251 (11%) experienced at least one episode of “any clinically relevant bleeding” during an average 429 days follow up period. Incidence of “any clinically relevant bleeding” rose with increasing HAS-BLED/CHADS2/CHA2DS2-VASc scores, but was statistically significant only for HAS-BLED (p<0.0001). Only HAS-BLED demonstrated significant discriminatory performance for “any clinically relevant bleeding” (AUC 0.60, p<0.0001). There were significant AUC-differences between HAS-BLED (which had the highest AUC) and both CHADS2 (p<0.001) and CHA2DS2VASc (p=0.001). The HAS-BLED score also demonstrated significant NRI for the outcome of “any clinically relevant bleeding” when compared with CHADS2 (p=0.001) and CHA2DS2-VASc (p=0.04). In conclusion, the HAS-BLED score demonstrated significant discriminatory performance for “any clinically relevant bleeding” in anticoagulated patients with AF, whilst the CHADS2 and CHA2DS2-VASc scores did not. Bleeding risk assessment should be made using a specific bleeding risk score such as HAS-BLED, and the stroke risk scores such as CHADS2 or CHA2DS2-VASc scores should not be used.

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