Anticoagulant and antiplatelet combined therapy in patients 75 years and over with atrial fibrillation: a prospective observational study assessing adherence to clinical guidelines

Abstract

ObjectiveAccording to current guidelines on atrial fibrillation (AF), the addition of an antiplatelet therapy to an anticoagulant for a stable vascular disease does not decrease the ischaemic hazard but increases the risk of bleeding. The aim of the study was to assess compliance of practices with existing clinical guidelines concerning the use of anticoagulant-antiplatelet combined therapy in patients 75 years and over with AF.MethodsThis prospective observational study was carried out at the University Hospital of Strasbourg (France) between August 2016 and January 2017 with data collection on 1 day of every month. To be included, the patient had to be 75 years and over with AF and treated with anticoagulant-antiplatelet therapy. The population included all the patients admitted at the hospital excluding those from the Gynaecology-Obstetrics and Paediatrics departments. With regard to clinical ongoing guidelines (French, European, American and Canadian), the patients were sorted into three groups. Group 1: combined therapy in compliance with recommendations; Group 2: combined therapy debatable as to benefit-risk ratio; and Group 3: combined therapy not compliant with recommendations.ResultNinety-three out of 3307 patients 75 years and over received anticoagulant-antiplatelet combined therapy prior to their hospital admission. Thirty-two patients (34.4% – Group 1) had experienced an acute event and/or revascularisation within the past year. Twenty-four patients (25.8% – Group 2) had not experienced recent revascularisation and had stable coronary disease but were suffering from peripheral artery disease. Group 3 consisted of 37 patients (39.8%), none of which had experienced recent revascularisation or had unstable coronary disease. For all groups, the main dual therapy was acetylsalicylic acid + fluindione (59.1%).ConclusionIn our study, 37 antiplatelet (39.8%) treatments could have been stopped. These results should spur prescribers into regular reassessment of combination antithrombotic therapy since it contributes to polypharmacy and increases the risk of adverse events.

Unintentional guideline deviations in hospitalized patients with two or more antithrombotic agents: an intervention study

“…Therefore, the results are not comparable with our results. Minary et al found that in a French university hospital, 37 out of 93 (39.8%) patients with atrial fibrillation who were over 75 years old and used a VKA in combination with an antiplatelet agent, the antiplatelet agent should have been stopped [19]. These results are not completely comparable with our results because they only included patients over 75 years old with the indication of atrial fibrillation.…”

“…Several studies have evaluated the guideline adherence in patients using antithrombotic medication [16][17][18][19]. Proietti et al and Lip et al found that in patients with atrial fibrillation, 40.9-60.6% received adequate antithrombotic treatment, 6.8-21.7% were overtreated and 52.3-17.3% were undertreated and received no antithrombotic treatment [16,17].…”

“…Warlé-van Herwaarden et al and Minary et al studied if patients with DAPT or a combination of anticoagulant therapy and antiplatelet therapy were overtreated. They found that 14-39.8% were overtreated with antithrombotic therapy [18,19]. These studies showed that a considerable proportion of patients is under-or overtreated with antithrombotic therapy, thereby exposing patients to an increased bleeding risk or thrombotic risk [16][17][18][19].…”

“…They found that 14-39.8% were overtreated with antithrombotic therapy [18,19]. These studies showed that a considerable proportion of patients is under-or overtreated with antithrombotic therapy, thereby exposing patients to an increased bleeding risk or thrombotic risk [16][17][18][19]. These non-intervention studies, mainly focused on patients treated with antithrombotics for a specific indication, were executed in a small non-hospital setting and did not check whether guideline deviation was intentional or unintentional.…”

From Rat Poison to Medicine: Medical Applications of Coumarin Derivatives

“…Seven decades later, warfarin is still in use as an anticoagulant [22]. In the meantime, several other coumarins with anticoagulant properties like acenocoumarol, phenprocoumon, and fluindione have been developed, and they are used in a variety of clinical settings [23][24][25].…”