Anticoagulation for the prevention of stroke in non-valvular AF in general practice: room for improvement

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Abstract 

Objective: Our aim was to assess whether the recommendations and guidelines for thromboprophylaxis in patients with atrial fibrillation (AF) have been adopted in general practice (GP).

Methods: We conducted a retrospective study using the GP computer database (Hatfield, UK) on all 9400 patients to assess the quality of anticoagulation in patients with a recorded diagnosis of AF.

Results: Of the 180 patients with a diagnosis of AF, 107 (59.4%) were treated with warfarin, 19 (10.6%) with a novel oral anticoagulant (NOAC), 31 (17.2%) with aspirin or clopidogrel, and 23 (12.8%) received none. Thirty-seven patients (34.6%) who were taking warfarin had a time in the therapeutic range (TTR) of less than 65%. Forty-five (27.6%) of the 163 patients who had a CHA2DS2VASc score of two or more were not prescribed a vitamin K antagonist (VKA) or a NOAC. None had a HAS-BLED greater than the CHA2DS2VASc score.

Conclusion: Our study demonstrates that one in four patients with non-valvular AF, at risk of a stroke, is not being adequately treated with an oral anticoagulant in primary care. The majority were treated with warfarin, a third of which had a low TTR. A high proportion of patients are prescribed antiplatelet therapy instead. This is despite overwhelming evidence that VKAs and NOACs, and not aspirin or clopidogrel, improve outcome in patients with non-valvular AF. We suggest that a review of GP practice databases should be considered to identify patients with non-valvular AF, at risk of a disabling or fatal event, and measures taken to initiate anticoagulant therapy.

Keywords: cardiovascular, arrhythmias, atrial fibrillation, warfarin, apixaban, dabigatran, rivaroxaban, general practice, stroke.

Citation: Ioannou A, Metaxa S, Kassianos G, Missouris CG. Anticoagulation for the prevention of stroke in non-valvular AF in general practice: room for improvement. Drugs in Context 2016; 5: 212295. DOI: 10.7573/dic.212295

Contributions: All four authors (Dr Adam Ioannou, Dr Sofia Metaxa, Dr George Kassianos, and Dr Constantinos Missouris) contributed to the manuscript. All were involved in the design of the study, collection of data, and analysis and interpretation of data. All authors were involved in drafting the manuscript, and all authors approved a final version of the manuscript before it was sent to be published.

Potential conflicts of interest: All authors (Dr Adam Ioannou, Dr Sofia Metaxa, Dr George Kassianos, and Dr Constantinos Missouris) declare that they have no relationships with any companies that might have an interest in the submitted work; their spouses, partners, or children have no financial relationships that may be relevant to the submitted work; and all authors (Dr Adam Ioannou, Dr Sofia Metaxa, Dr George Kassianos, and Dr Constantinos Missouris) have no non-financial interests that may be relevant to the submitted work. The International Committee of Medical Journal Editors’ (ICMJE) Potential Conflicts of Interests forms for the authors are available for download at: http://www.drugsincontext.com/wp-content/uploads/2016/05/dic.212295-COI.pdf.

Funding declaration: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Ethics approval: As a survey report using clinically collected, non-identifiable data, this work does not fall under the remit of National Health Service Research Ethics Committees and does not require ethics approval. Consent was not obtained but the presented data are anonymised and there is minimal risk of identification.

Clinical trial registration: Due to this trial not requiring ethics approval, it was not registered.

Copyright: Copyright © 2016 Ioannou A, Metaxa S, Kassianos G, Missouris CG. Distributed under the terms of the Creative Commons License Deed CC BY NC ND 3.0 which allows anyone to copy, distribute, and transmit the article provided it is properly attributed in the manner specified below. No commercial use without permission.

Correct attribution: Copyright © 2016 Ioannou A, Metaxa S, Kassianos G, Missouris CG. http://dx.doi.org/10.7573/dic.212295. Published by Drugs in Context under Creative Commons License Deed CC BY 3.0.

Article URL: http://www.drugsincontext.com/anticoagulation-for-the-prevention-of-stroke-in-non-valvular-af-in-general-practice-room-for-improvement

Correspondence: Dr Constantinos G. Missouris, MD, FRCP, Frimley Health NHS Foundation Trust, Wexham Street, Slough, UK. dinos.missouris@fhft.nhs.uk

Provenance: Submitted; externally peer reviewed

Submitted: 28 March 2016; Peer review comments to author: 21 April 2016; Revised manuscript received: 27 April 2016; Publication date: 27 May 2016

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