Differences and trends in stroke prevention anticoagulation in primary care vs cardiology specialty management of new atrial fibrillation: The Retrospective Evaluation and Assessment of Therapies in AF (TREAT-AF) study

Turakhia, Mintu P.; Hoang, Donald D.; Xu, Xiangyan; Frayne, Susan M.; Schmitt, Susan; Yang, Felix; Phibbs, Ciaran S.; Than, Claire T.; Wang, Paul J.; Heidenreich, Paul A.

doi:10.1016/j.ahj.2012.10.010

Cited by 72 publications

(80 citation statements)

References 36 publications

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“…Finally, clinicians may be anticoagulating these patients simply because they have AF, regardless of their low rate of thrombotic events. 26 Regardless, these high rates of OAC in patients at low risk for stroke in this study and other reports 24,25 raise the question about the potential for inappropriate anticoagulation in some patients with AF. Future studies are necessary to determine the specific reasons for these trends.…”

Section: Anticoagulation In Low-risk Patientsmentioning

confidence: 57%

“…20,22 Other reports, however, have documented rates of OAC exceeding 50% in stable outpatients with AF and a CHADS 2 score of 0. 24,25 In our subjects with CHADS 2 scores of 0, rates of OAC increased with additional stroke risk factors (Table 3). This finding suggests that clinicians caring for these patients were incorporating the CHA 2 DS 2 -VASc score or other risk prediction models into their clinical decision making, thus lowering the threshold at which patients qualify for OAC.…”

Section: Anticoagulation In Low-risk Patientsmentioning

confidence: 99%

“…Previous studies have shown lower rates of OAC among patients who do not see cardiologists. [23][24][25] It is possible that sites voluntarily participating in ORBIT-AF may reflect providers at those sites who are more aware of guideline recommendations and quality measures. Therefore, some degree of selection bias could explain the higher rates of OAC observed in this study.…”

Section: Overall Rates Of Oacmentioning

confidence: 99%

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Risks and Benefits of Anticoagulation in Atrial Fibrillation

Cullen

Kim

Piccini

et al. 2013

Circ: Cardiovascular Quality and Outcomes

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A trial fibrillation (AF) is the most common cardiac arrhythmia.1 Guidelines strongly and uniformly recommend anticoagulation in patients with AF and risk factors for cardioembolic events to mitigate the likelihood of stroke or thromboembolism. [2][3][4][5] The benefits of oral anticoagulant therapy are directly proportional to the underlying stroke risk as measured by the congestive heart failure, hypertension, age, diabetes mellitus, prior stroke (CHADS 2 ) or congestive heart failure or left ventricular systolic dysfunction, hypertension, age, diabetes mellitus, prior stroke, vascular disease, and sex (CHA 2 DS 2 -VASc) scores.6 Despite the documented benefits of anticoagulation in high-risk patients, several prior studies have found that those with higher CHADS 2 scores are less likely to receive anticoagulation compared with healthier patients at lower risk for thromboembolism. This risk-treatment paradox with AF has been described in patients after acute ischemic stroke or transient ischemic attack, 7 in patients hospitalized for heart failure, 8 and in patients with acute coronary syndromes. 9,10The reasons for these patterns remain unclear. One hypothesis suggests that providers may withhold anticoagulation from Background-Patients with atrial fibrillation (AF) at the highest stroke risk derive the largest benefit from oral anticoagulation (OAC). Those with the highest stroke risk have been paradoxically less likely to receive OAC. This study assessed the association between stroke and bleeding risk on rates of OAC. Methods and Results-We analyzed OAC use among 10 098 patients with AF from 174 community-based outpatient practices enrolled in 2010-2011 in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). OAC was defined as warfarin or dabigatran use at study enrollment. Stroke and bleeding risk were calculated using congestive heart failure, hypertension, age, diabetes mellitus, prior stroke (CHADS 2 ), and anticoagulation and risk factors in AF (ATRIA) scores, respectively. The mean subject age was 73 years; 58% were men. Overall, 76% of patients received OAC (71% warfarin and 5% dabigatran). The use of OAC increased among those with higher CHADS 2 scores, from 53% for CHADS 2 =0 to 80% for CHADS 2 ≥2 (P<0.001). OAC use fell slightly with increasing ATRIA bleeding risk score, from 81% for ATRIA=3 to 73% for ATRIA≥5 (P<0.001

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Section: Anticoagulation In Low-risk Patientsmentioning

confidence: 57%

Section: Anticoagulation In Low-risk Patientsmentioning

confidence: 99%

Section: Overall Rates Of Oacmentioning

confidence: 99%

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Risks and Benefits of Anticoagulation in Atrial Fibrillation

Cullen

Kim

Piccini

et al. 2013

Circ: Cardiovascular Quality and Outcomes

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“…Other data have shown that the overall VA warfarin prescription rate is consistent with North American norms. 29 One can only speculate whether a more broadly representative population would have experienced an even greater improvement in quality of life from PST over conventional in-clinic testing.…”

Section: Discussionmentioning

confidence: 99%

At-Home Versus In-Clinic INR Monitoring: A Cost–Utility Analysis from The Home INR Study (THINRS)

et al. 2016

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BACKGROUND: Effective management of patients using warfarin is resource-intensive, requiring frequent inclinic testing of the international normalized ratio (INR). Patient self-testing (PST) using portable at-home INR monitoring devices has emerged as a convenient alternative. As revealed by The Home INR Study (THINRS), event rates for PST were not significantly different from those for in-clinic high-quality anticoagulation management (HQACM), and a cumulative gain in quality of life was observed for patients undergoing PST. OBJECTIVE: To perform a cost-utility analysis of weekly PST versus monthly HQACM and to examine the sensitivity of these results to testing frequency. PATIENTS/INTERVENTIONS: In this study, 2922 patients taking warfarin for atrial fibrillation or mechanical heart valve, and who demonstrated PST competence, were randomized to either weekly PST (n = 1465) or monthly inclinic testing (n = 1457). In a sub-study, 234 additional patients were randomized to PST once every 4 weeks (n = 116) or PST twice weekly (n = 118). The endpoints were quality of life (measured by the Health Utilities Index), health care utilization, and costs over 2 years of follow-up. RESULTS: PST and HQACM participants were similar with regard to gender, age, and CHADS 2 score. The total cost per patient over 2 years of follow-up was $32,484 for HQACM and $33,460 for weekly PST, representing a difference of $976. The incremental cost per qualityadjusted life year gained with PST once weekly was $5566 (95 % CI, −$11,490 to $25,142). The incremental cost-effectiveness ratio (ICER) was sensitive to testing frequency: weekly PST dominated PST twice weekly and once every 4 weeks. Compared to HQACM, weekly PST was associated with statistically significant and clinically meaningful improvements in quality of life. The ICER for weekly PST versus HQACM was well within accepted standards for cost-effectiveness, and was preferred over more or less frequent PST. These results were robust to sensitivity analyses of key assumptions. CONCLUSION: Weekly PST is a cost-effective alternative to monthly HQACM and a preferred testing frequency compared to twice weekly or monthly PST.

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“…Furthermore, the development of antidotes for these anticoagulants and establishing a means of measuring their therapeutic effect can allow safer clinical practice. [31][32][33] Further large-scale trials correlating treatment with factors potentially associated with greater risk of thrombotic events (history of venous thromboembolism, thrombophilia or cancer) or hemorrhagic events (minor cerebral hemorrhages and more in-depth analysis of neuroimaging) are obviously needed, especially considering the escalating incidence of cerebrovascular complications in an aging population and its severe and several sequelae. 34,35 Therapeutic decisions could be more safely guided by some important factors, such as the volume of acute lesions, etiology, age, gender, and time of occurrence (i.e., how many hours after the ictus is the anticoagulation safe).…”

Section: Methodsmentioning

confidence: 99%

Anticoagulation in acute ischemic stroke: A systematic search

Froio

Montgomery

David‐Neto

et al. 2017

Rev. Assoc. Med. Bras.

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Introduction: Stroke is one of the most important diseases worldwide. Several clinical scenarios demand full dose of anticoagulants primary to stroke etiology or to the treatment of comorbidity. However, controversy exists over many issues regarding anticoagulation treatment in stroke such as time for initiation, efficacy according to stroke etiology, the ideal dose of anticoagulants, and whether novel anticoagulants should be used. Method: Computerized search for clinical trials and randomized controlled clinical trials was done to the present date at Medline, Scielo, Embase, PsychInfo, and Cochrane Library using MeSH terms and the keywords stroke, ischemic stroke, anticoagulation, anticoagulants, heparin, low-molecular-weight heparin, warfarin, dabigatran, rivaroxaban, apixaban. The PRISMA statement was used to evaluate clinical trials. Results: Fourteen clinical trials were selected based on inclusion criteria. No evidence was found supporting the early use of heparin, heparinoids or low--molecular-weight heparin (LMWH) early after stroke. No consistent evidence for the use of warfarin and the newer oral anticoagulants were found. Argatroban was the only anticoagulant with significant positive results early after large-artery ischemic stroke. Conclusion:The ideal time for initiating anticoagulation remains undefined, requiring further investigation. Early anticoagulation for ischemic stroke is not recommended, with few exceptions, such as that of argatroban.

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Differences and trends in stroke prevention anticoagulation in primary care vs cardiology specialty management of new atrial fibrillation: The Retrospective Evaluation and Assessment of Therapies in AF (TREAT-AF) study

Cited by 72 publications

References 36 publications

Risks and Benefits of Anticoagulation in Atrial Fibrillation

Risks and Benefits of Anticoagulation in Atrial Fibrillation

At-Home Versus In-Clinic INR Monitoring: A Cost–Utility Analysis from The Home INR Study (THINRS)

Anticoagulation in acute ischemic stroke: A systematic search

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