Impact of Implementing Common Guidelines at Different Care Levels in a Healthcare Area on the Improvement of Atrial Fibrillation Treatment

Stroke Prophylaxis in Atrial Fibrillation: Searching for Management Improvement Opportunities in the Emergency Department: The HERMES-AF Study

“…As in other studies, this may reflect a certain lack of knowledge of the evidence-based indications for prophylaxis stated in the guidelines. 11,19,24 Because the guidelines' recommendations have been demonstrated to be widely applicable in daily practice 9,12,19,26,27 and previous studies in local settings have demonstrated the usefulness of specific training to improve management's adequacy, 4,16,28 educational efforts to increase physicians' adherence to the guidelines appear warranted and constitute a third area of management improvement found in our study.…”

“…which the elderly population was repeatedly excluded from anticoagulant treatment, 9,17,24,32 although they benefit from anticoagulation the most and compose the majority of atrial fibrillation patients in daily practice. 4,9,19,29,30 This finding demonstrates the excessive effect of age on medical decisions and is probably related to the fear of a greater risk of hemorrhage in aged patients. 9,32,33 Although elderly age is considered an independent risk factor for bleeding, [10][11][12]34 different studies have demonstrated that anticoagulation in this population reduces the risk of stroke without a significant increase of bleeding and that the net benefit of anticoagulation is greater than in younger patients.…”

“…In addition, as a general rule all atrial fibrillation patients discharged from EDs in our setting are referred to another health care level (internal medicine, cardiology, geriatrics, or primary care) for follow-up and to anticoagulation clinics (or primary care) for monitoring anticoagulation and educating patients. 6,9,12 Thus, these patients' management is multidisciplinary and comprehensive to maximize the possibilities of adequate prophylaxis, 3,4,12,15 almost identical to the "short term prophylaxis from EDs" proposed by other authors. 25 In this way, the relevant increase in the prescription of anticoagulants to high-risk patients found in Spanish EDs during this century, from 28% in the GEFAUR-1 study to 69% in HERMES-AF, 9 is promising and supports the concept that adequate thromboprophylaxis is desirable and also feasible in ED patients with atrial fibrillation.…”

“…Patients with score¼0 are considered at low risk of stroke, and either antiplatelets or no prophylaxis is considered acceptable. [10][11][12] If anticoagulation was not prescribed, the treating physician was asked to explain the reason for not prescribing it from a set of multiple-choice possibilities; we included the most frequent causes of a lack of prescription of anticoagulation stated in daily practice studies, 3,4,8,9,[15][16][17] whether adequate or not according to the available evidence, with the aim of capturing the main reasons for this provider behavior: advanced age, disability, allergy, drug abuse (alcohol or illicit substances), poor therapeutic compliance, frequent falls, previous hemorrhage related to oral anticoagulants, potential risk of hemorrhage (active peptic disease, neoplasm, recent bleeding unrelated to anticoagulants, recent stroke, hemostasis disorder, vascular or genitourinary diseases with a high risk of bleeding, and recent surgery or severe trauma), patient's rejection, decision transferred to other specialist, or not considered indicated.…”

“…[1][2][3][4][5] It has important potential consequences, including increased risk of stroke or systemic embolism. Considering its effect on patients' prognosis and quality of life and the high effectiveness of oral anticoagulants in preventing these complications, there is general agreement that stroke prophylaxis is the mainstay of atrial fibrillation management in all health care settings.…”