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 ... -  《-》

Stroke-prevention strategies in North American patients with atrial fibrillation: The GLORIA-AF registry program.

Antithrombotic prophylaxis with oral anticoagulation (OAC) substantially reduces stroke and mortality in patients with atrial fibrillation (AF). Analysis of data in the Global Registry on Long-Term Antithrombotic Treatments in Patients With Atrial Fibrillation (GLORIA-AF), an international, observational registry of patients with newly diagnosed AF, can identify factors associated with treatment decisions and outcomes. Multivariable regression identified patient, physician, and temporal factors associated with OAC prescription, compared with management with antiplatelet drugs or no antithrombotic drugs in North American patients enrolled between November 2011 and February 2014. Of 3320 eligible patients (mean age, 71 ± 11 years; 1879 males with CHA2 DS2 -VASc ≥1 and 1441 females with CHA2 DS2 -VASc ≥2), 79.3%, 12.5%, and 7.4% received OAC, antiplatelet drugs, or no antithrombotic therapy, respectively. Of those prescribed OAC, 66.4% received non-vitamin K antagonist oral anticoagulation and 24.5% received concomitant therapy with antiplatelet drugs. Independent predictors of OAC therapy were nonparoxysmal AF (odds ratio, 95% confidence interval: 2.02, 1.56-2.63), prior stroke/transient ischemic attack (2.00, 1.37-2.92), specialist care (1.50, 1.04-2.17), more concomitant medications (1.47, 1.13-1.92), commercial insurance (1.41, 1.07-1.85), and heart failure (1.44, 1.07-1.92). Antiplatelet drugs (0.18, 0.14-0.23), prior falls (0.41, 0.27-0.63), and prior bleeding (0.50, 0.35-0.72) were inversely associated with OAC prescription. In GLORIA-AF, 20% of the population comprising males with CHA2 DS2 -VASc ≥1 and females with CHA2 DS2 -VASc ≥2 did not receive OAC therapy. Patient characteristics associated with a lower likelihood of OAC prescription were use of antiplatelet drugs, paroxysmal pattern of AF, history of falls, and prior bleeding.

McIntyre WF ，Conen D ，Olshansky B ，Halperin JL ，Hayek E ，Huisman MV ，Lip GYH ，Lu S ，Healey JS ... -  《-》

Prognosis in patients with atrial fibrillation and CHA2DS2-VASc Score = 0 in a community-based cohort study.

Patients with atrial fibrillation (AF) and a CHA(2) DS(2) -VASc score = 0 have a very low risk of stroke and current guidelines even recommend no antithrombotic therapy to these patients. We investigated the rate and risk of adverse events and the impact of antithrombotic management in a community based cohort of AF patients with a CHA(2)DS(2)-VASc score = 0. Patients with AF seen in our institution between 2000 and 2010 were identified in a database. The adverse outcomes were investigated during follow-up. Among 8,962 patients with AF, 616 (7%) had a congestive heart failure, hypertension, age ≥75 years (doubled), diabetes, stroke/TIA/thromboembolism (doubled), vascular disease (prior myocardial infarction, peripheral artery disease, or aortic plaque), age 65-74 years, sex category (female) (CHA(2)DS(2)-VASc score) = 0. An oral anticoagulant was prescribed in 273 patients (44%), antiplatelet therapy alone in 145 patients (24%), and no antithrombotic treatment in 198 patients (32%). During a follow up of 876 ± 1,135 days (median 244, interquartile range 1,540 days), 38 patients sustained events (10 stroke/thromboembolism, 19 major bleeding, 17 deaths). Among untreated patients, rates of stroke/thromboembolism, major bleeding and mortality were 0.64%, 1.12%, and 1.08% per year. Prescription of oral anticoagulation and/or antiplatelet therapy was not associated with an improved prognosis for stroke/thromboembolism (relative risk [RR] = 0.99, 95% CI 0.25-3.99, P = 0.99), nor improved survival or net clinical benefit (combination of stroke/thromboembolism, bleeding, and death). In a real life cohort study, AF patients with CHA(2)DS(2) VASc score = 0 had a low risk of stroke/thromboembolism that was not significantly different between those taking oral anticoagulation, antiplatelet therapy, or no antithrombotic therapy. This supports current guideline recommendations for no antithrombotic therapy in these "truly low-risk" patients.

Taillandier S ，Olesen JB ，Clémenty N ，Lagrenade I ，Babuty D ，Lip GY ，Fauchier L ... -  《-》

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 ... -  《-》