jsmc-10169

ASSESSMENT OF ANTICOAGULANT DRUGS IN ELIGIBLE PATIENTS WITH ATRIAL FIBRILLATION

Omed Hama Karem a and Karwan Hamza b

a Department of Medicine, College of Medicine, University of Sulaimani. 

b Kurdistan Board of Medical Specialties Candidate.

Submitted: 29/3/2018; Accepted: 12/8/2018; Published 15/10/2018

DOI Link: https://doi.org/10.17656/jsmc.10169 

ABSTRACT

Background 

Atrial fibrillation is associated with substantial mortality and morbidity from stroke and thromboembolism. Despite an efficacious oral anticoagulation, atrial fibrillation patients at high risk for stroke are often under-treated.

Objectives 

To detect the percentage of anticoagulant eligible patients with atrial fibrillation not receiving anticoagulant therapy and its causes, and whether the INR target is reached or not.

Materials and Methods

A cross-sectional study in the medical emergency department and neurology unit of Shar hospital in Slemani city was carried out, from the 1st of Jan 2017 to the 1st of Dec 2017, on a sample of two hundred and seventy-two patients with atrial fibrillation. Data were obtained from the patient’s case notes for their personal detail including age, sex, history of hypertension, diabetes mellitus, vascular disease, heart failure, and thromboembolism.

Results

Two hundred seventy-two patients diagnosed with atrial Atrial Fibrillation, 148 (54.4%) females 124 (45.6%) males, mean age 70.43 years were ana­lyzed and among these patients, 24 had valvular AF and 248 had no valvular AF patients. Warfarin was prescribed in 54(19.85%), antiplatelet in 63 (23.16%) patients, new oral anticoagulant in 19 (6.98%) patients and no antithrombotic therapy in 136 (50%) patients. The common cause behind why most patients with AF were not prescribed anticoagulants was; not prescribed by a physician 107 (53.76%) patients. Regarding those patients prescribed warfarin only 26 (48.1) patients INR level was in the therapeutic range. 

Conclusion

This study demonstrates underuse of oral anticoagulation therapy for atrial fibrillation patients with high risk of stroke.

KEYWORDS

Atrial Fibrillation, Oral anticoagulant, INR.

References 

1. Marini C, De Santis F, Sacco S, et al. Contribution of atrial fibrillation to incidence and outcome of ischemic stroke: results from a population-based study. Stroke 2005 ; 36:1115-1119.

2. Verheugt FW. Novel oral anticoagulants to prevent stroke in atrial fibrillation. Nat Rev Cardiol 2010 ; 7: 149–54.

3. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham study. Stroke 1991;22:983-988.

4. Klein D, Levine M. Are family physicians using the CHADS2 score? Is it useful for assessing the risk of stroke in patients with atrial fibrillation? Can Fam Physician. 2011; 57: e305–e309 [PMC free article] [PubMed]

5.  Lip GY, Nieuwlaat R, Pisters R, et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on atrial fibrillation. Chest. 2010; 137: 263–272[PubMed]

6. Garg, N.; Kumar, A.; Flaker, G.C. Antiplatelet therapy for stroke prevention in atrial fibrillation

7. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 2007;146:857-867.

8. Ansell J, Hirsh J, Hylek E, et al. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest 2008;133:160S-198S 

9. Atarashi H, Inoue H, Okumura K, et al. Present status of anticoagulation treatment in Japanese patients with atrial fibrillation: a report from the J-RHYTHM Registry. Circ J 2011;75:1328-1333.

10. Graham DJ, Reichman ME, Wernecke M, et al. Cardiovascular, bleeding, and mortality risks in elderly Medicare patients treated with dabigatran or warfarin for nonvalvular atrial fibrillation. Circulation 2015;131:157-164.

11. Lip GY, Pan X, Kamble S, et al. Major bleeding risk among non-valvular atrial fibrillation patients initiated on apixaban, dabigatran, rivaroxaban or warfarin: a “real-world” observational study in the United States. Int J Clin Pract 2016;70:752-763.

12.  Sharma M, Cornelius VR, Patel JP, et al. Efficacy and harms of direct oral anticoagulants in the elderly for stroke prevention in atrial fibrillation and secondary prevention of venous thromboembolism: systematic review and meta-analysis. Circulation 2015;132:194-204.

13.  Heidbuchel H, Verhamme P, Alings M, et al. Updated European Heart Rhythm Association Practical guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015;17:1467-1507.

14.  Pollack CV. Introduction to direct oral anticoagulants and rationale for specific reversal agents. Am J Emerg Med 2016;34:1-2.

15.  Eikelboom J, Merli G. Bleeding with direct oral anticoagulants vs warfarin: clinical experience. Am J Emerg Med 2016;34:3-8.

16.  JCS Joint Working Group. Guidelines for pharmacotherapy of atrial fibrillation (JCS 2013): digest version. Circ J 2014;78:1997-2021.

17. Patel DS, Chavda AB, Goswami BI. Clinical study & etiological evaluation of atrial fibrillation at tertiary care hospital, Jamnagar, Gujarat, India. (A study of 100 cases). IJSR. 2012;1(4). 

18. Bhardwaj R, Kandoria A, Marwah R, Vaidya P, Singh B, Dhiman P, et al. Preva¬lence of rheumatic fever and rheumatic heart disease in rural population of Himachal-A population based study. J Assoc Physicians India. 2012;60(5):13-14. 

19. Ewen E, Zhang Z, Simon TA, Kolm P, Liu X, Weintraub WS. Patterns of warfarin use and subsequent outcomes in atrial fibrillation in primary care practices. Vasc Health Risk Manag. 2012;8:587-98. 

20. Mohammed MA, Marshall T, Nirantharakumar K, Stevens A, Fitzmaurice D. Patterns of warfarin use in subgroups of patients with atrial fibrillation: A cross sectional analysis of 430 general practices in the United Kingdom. PLOS ONE. 2013;8(5):e61979. 

21. Shin HW, Kim YN, Bae HJ, Lee HM, Cho HO, Cho YK, et al. KORAF Investigator: Trends in oral anticoagulation therapy among Korean patients with atrial fibrilla¬tion: The Korean atrial fibrillation investigation. Korean Circ J. 2012;42(2):113-17. 

22. Suarez J, Piccini JP, Liang L, Atherton JJ, Hayward CS, Krum H, et al. Interna¬tional variation in use of oral anticoagulation among heart failure patients with atrial fibrillation. Am Heart J. 2012;163(5):804-11.

23. Ceresne L, Upshur RE. Atrial fibrillation in a primary care practice: prevalence and management. BMC Fam Pract. 2002;3(1):11. 

24. Smoyer-Tomic K, Siu K, Walker DR, Johnson BH, Smith DM, Sander S, et al. Anticoagulant use, the prevalence of bridging, and relation to length of stay among hospitalized patients with non-valvular atrial fibrillation. Am J Cardiovasc Drugs. 2012,12(6):403-13. 

25. Niska R, Han B. Anticoagulation for patients with atrial fibrillation in ambulatory care settings. J Am Board Fam Med. 2009;22(3):299-306. 

26. Han W, Shen DT, Wang YM. Comparative study of warfarin and aspirin for stroke prevention in elderly patients with atrial fibrillation. Nan Fang Yi Ke Da Xue Xue Bao. 2006;26(6):851-55. 

27. Ahmad Y, Lip GY. Stroke prevention in atrial fibrillation: concepts and controversies. Current Cardiology Reviews. 2012;8(4):290-301.

28. Burgess C, Ingham T, Woodbridge M, Weatherall M, Nowitz M. The use of antithrombotics in patients presenting with stroke and atrial fibrillation. Ther Clin Risk Manag. 2007;3(3):491-98.

29. Leung CS, Tam KM. Antithrombotic treatment of atrial fibrillation in a regional hospital in Hong Kong. Hong Kong Med J. 2003;9(3):17985.

30. Faergeman O. Challenges to best practice: why are guidelines not implemented? Eur Heart J 1999;1:J12—7.

31.  Gattellari M, Worthington J, Zwar N, et al. Barriers to the use of anticoagulation for nonvalvular atrial fibrillation: a representative survey of Australian family physicians. Stroke 2008;39:227—30.

32.  Piccinocchi G, Laringe M, Guillaro B, Arpino G, Piccinocchi R, Nigro G, et al.Diagnosis and management of atrial fibrillation by primary care physicians in Italy - a retrospective, observational analysis. Clin Drug Investig. 2012;32(11):771-77.

33. Lakshminarayan K, Solid CA, Collins AJ, et al. Atrial fibrillation and stroke in the general medicare population: a 10-year perspective (1992 to 2002). Stroke. 2006; 37: 1969–1974 [PubMed]

34. Brass LMKrurnholz HMScinto JMRadford M Warfarin use among patients with atrial fibrillation. Stroke. 1997;282382- 2389Google ScholarCrossref

35. Albers GWBittar NYoung L et al. Clinical characteristics and management of acute stroke in patients with atrial fibrillation admitted to US university hospitals. Neurology. 1997;481598- 1604Google ScholarCrossref 

Full Text

 © The Authors, published by University of Sulaimani, College of Medicine

This work is licensed under a Creative Commons Attribution 4.0 International License.