Guideline adherence of antithrombotic treatment initiated by general practitioners in patients with nonvalvular atrial fibrillation: a Danish survey.

The aim of this prospective survey was to describe the demographics, stroke risk profile, and the guideline adherence of antithrombotic treatment in a Danish primary care population of patients with nonvalvular atrial fibrillation (AF). We hypothesized that a significant proportion of patients with nonvalvular AF do not receive guideline-adherent antithrombotic treatment in primary care. We performed a cross-sectional survey of antithrombotic treatment using data of AF patients from general practices. Sixty-four general practitioners enrolled 1743 patients with a mean age of 74.8 ± 11.2 years. The mean CHADS2 and CHA2 DS2 -VASc scores were 1.9 ± 1.3 and 3.5 ± 1.8, respectively. Of the patients, 12.4% and 4.04%, respectively, were at truly low risk, with a CHADS2 and CHA2 DS2 -VASc score 0 (P < 0.001). A score of 1 was seen in 28.0% vs 9.0% (P < 0.001) of the patients. Of all patients, 66.3% were treated with oral anticoagulants, 18.7% with antiplatelet drugs only, and 15% received no antithrombotic therapy. Based on the CHADS2 score, 75.7% of the patients were treated in adherence with the guidelines, 16% were undertreated, and 8.4% overtreated. The corresponding numbers for the CHA2 DS2 -VASc score were 75.4%, 22.7%, and 1.8%, respectively. The differences in guideline adherence applying the 2 scores were significant (P < 0.001). Of patients receiving no antithrombotic therapy, 64.1% were treated in adherence to the guidelines according to the CHADS2 score. Applying the CHA2 DS2 -VASc score, this proportion was only 53.4%. Antiplatelet drug treatment was in adherence to the guidelines (CHADS2 and CHA2 DS2 -VASc score of 1) in only 31% and 12% of the patients, respectively. Antithrombotic treatment of AF patients is in general well performed in primary care in Denmark. Further improvements may be achieved by thorough stroke risk stratification on the basis of current evidence-based guidelines.

Brandes A ，Overgaard M ，Plauborg L ，Dehlendorff C ，Lyck F ，Peulicke J ，Poulsen SV ，Husted S ... -  《-》

Do physicians correctly calculate thromboembolic risk scores? A comparison of concordance between manual and computer-based calculation of CHADS2 and CHA2 DS2 -VASc scores.

Clinical risk scores, CHADS2 and CHA2 DS2 -VASc scores, are the established tools for assessing stroke risk in patients with atrial fibrillation (AF). The aim of this study is to assess concordance between manual and computer-based calculation of CHADS2 and CHA2 DS2 -VASc scores, as well as to analyse the patient categories using CHADS2 and the potential improvement on stroke risk stratification with CHA2 DS2 -VASc score. We linked data from Atrial Fibrillation Spanish registry FANTASIIA. Between June 2013 and March 2014, 1318 consecutive outpatients were recruited. We explore the concordance between manual scoring and computer-based calculation. We compare the distribution of embolic risk of patients using both CHADS2 and CHA2 DS2 -VASc scores The mean age was 73.8 ± 9.4 years, and 758 (57.5%) were male. For CHADS2 score, concordance between manual scoring and computer-based calculation was 92.5%, whereas for CHA2 DS2 -VASc score was 96.4%. In CHADS2 score, 6.37% of patients with AF changed indication on antithrombotic therapy (3.49% of patients with no treatment changed to need antithrombotic treatment and 2.88% of patients otherwise). Using CHA2 DS2 -VASc score, only 0.45% of patients with AF needed to change in the recommendation of antithrombotic therapy. We have found a strong concordance between manual and computer-based score calculation of both CHADS2 and CHA2 DS2 -VASc risk scores with minimal changes in anticoagulation recommendations. The use of CHA2 DS2 -VASc score significantly improves classification of AF patients at low and intermediate risk of stroke into higher grade of thromboembolic score. Moreover, CHA2 DS2 -VASc score could identify 'truly low risk' patients compared with CHADS2 score.

Esteve-Pastor MA ，Marín F ，Bertomeu-Martinez V ，Roldán-Rabadán I ，Cequier-Fillat Á ，Badimon L ，Muñiz-García J ，Valdés M ，Anguita-Sánchez M ，FANTASIIA Study Investigators ... -  《-》

Evaluation of Adherence to Guideline-Directed Antithrombotic Therapy for Atrial Fibrillation at Hospital Discharge.

Dupree L ，DeLosSantos M ，Smotherman C 《-》

Improved outcomes with European Society of Cardiology guideline-adherent antithrombotic treatment in high-risk patients with atrial fibrillation: a report from the EORP-AF General Pilot Registry.

Guideline-adherent therapy for stroke prevention in atrial fibrillation has been associated with better outcomes, in terms of thromboembolism (TE) and bleeding. In this report from the EuroObservational Research Programme-Atrial Fibrillation (EORP-AF) Pilot General Registry, we describe the associated baseline features of 'high risk' AF patients in relation to guideline-adherent antithrombotic treatment, i.e. whether they were adherent, over-treated, or under-treated based on the 2012 European Society of Cardiology (ESC) guidelines. Secondly, we assessed the predictors of guideline-adherent antithrombotic treatment. Thirdly, we evaluated outcomes for all-cause mortality, TE, bleeding, and the composite endpoint of 'any TE, cardiovascular death or bleeding' in relation to whether they were ESC guideline-adherent treatment. From the EORP-AF cohort, the follow-up dataset of 2634 subjects was used to assess the impact of guideline adherence or non-adherence. Of these, 1602 (60.6%) were guideline adherent, whilst 458 (17.3%) were under-treated, and 574 (21.7%) were over-treated. Non-guideline-adherent treatment can be related to region of Europe as well as associated clinical features, but not age, AF type, symptoms, or echocardiography indices. Over-treatment per se was associated with symptoms, using the EHRA score, as well as other comorbidities. Guideline-adherent antithrombotic management based on the ESC guidelines is associated with significantly better outcomes. Specifically, the endpoint of 'all cause death and any TE' is increased by >60% by undertreatment [hazard ratio (HR) 1.679 (95% confidence interval (CI) 1.202-2.347)] or over-treatment [HR 1.622 (95% CI 1.173-2.23)]. For the composite endpoint of 'cardiovascular death, any TE or bleeding', over-treatment increased risk by >70% [HR 1.722 (95% CI 1.200-2.470)]. Even in this cohort with high overall rates of oral anticoagulation use, ESC guideline-adherent antithrombotic management is associated with significantly better outcomes, including those related to mortality and TE, as well as the composite endpoint of 'cardiovascular death, any TE or bleeding'. These contemporary observations emphasize the importance of guideline implementation, and adherence to the 2012 ESC guidelines for stroke prevention in AF.

Lip GY ，Laroche C ，Popescu MI ，Rasmussen LH ，Vitali-Serdoz L ，Dan GA ，Kalarus Z ，Crijns HJ ，Oliveira MM ，Tavazzi L ，Maggioni AP ，Boriani G ... -  《-》

Discrepancy between guidelines for stroke prevention in atrial fibrillation and practice patterns in primary care. The nationwide French AFIGP survey.

General practitioners (GPs) play a pivotal role in the long-term management of patients with atrial fibrillation (AF), including anticoagulant prophylaxis for stroke prevention. To investigate the antithrombotic prescription behaviours of GPs in France and compare them with the European Society of Cardiology (ESC) guidelines for stroke prevention, and to identify the major determinants of use of antithrombotic therapy. We conducted a cross-sectional survey, using data from the French Longitudinal Patient Database, on the use of antithrombotic treatments for stroke prevention in 15,623 patients (≥18years of age) with AF who attended at least one GP consultation between July 2010 and June 2011. Data were collected on patient baseline characteristics, stroke risk factors, and prescription of antithrombotic drugs. The mean age was 74.6±11.1years, 59.5% were men, and 83.1% had a CHADS2 score≥1. Over half (52.6%) of the patients with a CHADS2 score≥1 received a vitamin K antagonist (alone or in combination with an antiplatelet), 19.3% received aspirin alone, and 23.4% received no antithrombotic therapy; 3.6% of the patients received dual antiplatelet therapy and 1.1% clopidogrel alone. Over half of the patients (56.3%) were treated in accordance with the ESC 2010 guidelines. Of the remaining patients, 19.4% received no treatment, 13.0% were inadequately treated, and 11.2% were over-treated. Factors associated with antithrombotic treatment were anti-arrhythmic therapy, higher stroke risk, presence of atherothrombotic disease, and use of non-steroidal anti-inflammatory drugs. Female gender was associated with a lower likelihood of antithrombotic treatment. In this large French study, approximately 45% of thromboembolic high-risk patients were either not treated or inadequately treated. Better compliance with evidence-based guidelines is needed to reduce the burden of stroke in the AF population.

Sabouret P ，Bricard M ，Hermann MA ，Cotté FE ，Deret-Bixio L ，Rushton-Smith S ... -  《-》