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Anticoagulation treatment for the reduction of stroke in atrial fibrillation: a cohort study to examine the gap between guidelines and routine medical practice

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Abstract

Background

Atrial fibrillation (AF) is the most common heart arrhythmia, affecting 6% of people over 65 years, and carries a 4.5% average annual stroke risk, which can be reduced by appropriate anticoagulation. A multi-centre observational study, Management and Outcomes in the Care of Atrial fibrillation in Germany (MOCA) was conducted to evaluate the current anticoagulation treatment pattern in patients with AF in Germany.

Methods

Patients with AF were recruited from December 2003 to June 2004 in physician practices. Clinical data including International Normalised Ratio (INR) values and anticoagulation strategy were obtained from the physician chart and the patient follow-up, documenting hospitalisations, medications, and complications, was conducted at three and six months. Main outcome measures included anticoagulation methods, practice guidelines adherence and time within recommended anticoagulation range.

Results

361 patients with AF (mean age 71±9, 61% male) were recruited in 45 physician practices. 90% of all patients had been treated with Vitamin K-Antagonists (VKA) at some time since AF-diagnosis, 88% were still treated. 10% of patients received aspirin as their anticoagulation therapy. Monitoring occurred at least once a month in over 70% of patients. Monitored INR values were 56% of the time within, 14% below and 30% over the recommended target range. A gap of 40% existed between the guideline recommendations and actual practice. Younger patients (<60 years of age) with no documented risk factors for stroke were over-treated with VKAs and patients older than 75 years without contraindications for anticoagulation were under-treated.

Conclusions

This study presents ‘real-life’ data in treating patients with AF in Germany and identifies the potential to advance the quality of care with respect to anticoagulation.

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References

  1. Wolf PA, Abbott RD, Kannel WB (1991) Atrial fibrillation as an independent risk factor for stroke: the Framingham study. Stroke 22(8):983–988

    PubMed  CAS  Google Scholar 

  2. Feinberg WM, Blackshear JL, Laupacis A, Kronmal R, Hart RG (1995) Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications. Arch Intern Med 155(5):469–473

    Article  PubMed  CAS  Google Scholar 

  3. Agarwal A, York M, Kantharia BK, Ezekowitz M (2005) Atrial fibrillation: modern concepts, management. Annu Rev Med 56(1):475–494

    Article  PubMed  CAS  Google Scholar 

  4. Benavente O, Hart R, Koudstaal P, Laupacis A, McBride R (2000) Oral anticoagulants for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischaemic attacks. Cochrane Database Syst Rev (2):CD001927

  5. Sherman DG, Kim SG, Boop BS, Corley SD, DiMarco JP, Hart RG et al (2005) Occurrence and characteristics of stroke events in the atrial fibrillation follow-up investigation of sinus rhythm management (AFFIRM) study. Arch Intern Med 165(10):1185–1191

    Article  PubMed  Google Scholar 

  6. van Walraven C, Hart RG, Singer DE, Laupacis A, Connolly S, Petersen P et al (2002) Oral anticoagulants vs aspirin in nonvalvular atrial fibrillation: an individual patient meta-analysis. JAMA 288(19):2441–2448

    Article  PubMed  Google Scholar 

  7. Hart RG (2003) Atrial fibrillation and stroke prevention. N Engl J Med 349(11):1015–1016

    Article  PubMed  CAS  Google Scholar 

  8. Hart RG, Halperin JL, McBride R, Benavente O, Man-Son-Hing M, Kronmal RA (2000) Aspirin for the primary prevention of stroke and other major vascular events: meta-analysis and hypotheses. Arch Neurol 57(3):326–332

    Article  PubMed  CAS  Google Scholar 

  9. Levy S, Breithardt G, Campbell RWF, Camm AJ, Daubert JC, Allessie M et al (1998) Atrial fibrillation: current knowledge and recommendations for management. Eur Heart J 19(9):1294–1320

    Article  PubMed  CAS  Google Scholar 

  10. Fuster V, Ryden LE, Asinger RW, Cannom DS, Crijns HJ, Frye RL et al (2001) ACC/AHA/ESC Guidelines for the management of patients with atrial fibrillation: executive summary a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for practice guidelines and policy conferences (committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology. Circulation 104(17):2118–2150

    PubMed  CAS  Google Scholar 

  11. McCormick D, Gurwitz JH, Goldberg RJ, Ansell J (1999) Long-term anticoagulation therapy for atrial fibrillation in elderly patients: efficacy, risk, and current patterns of use. J Thromb Thrombolysis 7(2):157–163

    Article  PubMed  CAS  Google Scholar 

  12. Cohen N, Moznino-Sarafian D, Alon I, Gorelik O, Koopfer M, Chachashvily S et al (2000) Warfarin for stroke prevention still underused in atrial fibrillation: patterns of omission. Stroke 31(6):1217–1222

    PubMed  CAS  Google Scholar 

  13. Carlsson J, Miketic S, Dees G, Haun S, Cuneo A, Tebbe U (2000) Stroke prevention practices in patients with atrial fibrillation and pacemaker therapy: evidence for under-use of anticoagulation. Europace 2(2):115–118

    Article  PubMed  CAS  Google Scholar 

  14. Laguna P, Martn A, del Arco C, Gargantilla P (2004) Risk factors for stroke and thromboprophylaxis in atrial fibrillation: what happens in daily clinical practice? The GEFAUR-1 study. Ann Emerg Med 44(1):3–11

    Article  PubMed  Google Scholar 

  15. White S, Feely J, O’Neill D (2004) Community-based study of atrial fibrillation and stroke prevention. Ir Med J 97(1):10–12

    PubMed  CAS  Google Scholar 

  16. Connolly SJ (2003) Prevention of vascular events in patients with atrial fibrillation: evidence, guidelines, and practice. J Cardiovasc Electrophysiol 14(9 Suppl):S52–S55

    Article  PubMed  Google Scholar 

  17. Pradhan AA, Levine MA (2002) Warfarin use in atrial fibrillation: a random sample survey of family physician beliefs and preferences. Can J Clin Pharmacol 9(4):199–202

    PubMed  CAS  Google Scholar 

  18. Guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology. Eur Heart J 22(20):1852–1923

  19. Schuchert A, Gulba D, Horstkotte D, Meinertz T, Tebbe U (2003) Kommentar zu den ACC/AHA/ESC-Leitlinien 2001 zur Prävention arterieller Thromboembolien bei Patienten mit Vorhofflimmern. Zeitschrift für Kardiologie 92(7):694–703

    Article  Google Scholar 

  20. Rosendaal FR, Cannegieter SC, van der Meer FJ, Briet E (1993) A method to determine the optimal intensity of oral anticoagulant therapy. Thromb Haemost 69(3):236–239

    PubMed  CAS  Google Scholar 

  21. Menendez-Jandula B, Souto JC, Oliver A, Montserrat I, Quintana M, Gich I et al (2005) Comparing self-management of oral anticoagulant therapy with clinic management: a randomized trial. Ann Intern Med 142(1):1–10

    PubMed  Google Scholar 

  22. Samsa GP, Matchar DB, Goldstein LB, Bonito AJ, Lux LJ, Witter DM et al (2000) Quality of anticoagulation management among patients with atrial fibrillation: results of a review of medical records from 2 communities. Arch Intern Med 160(7):967–973

    Article  PubMed  CAS  Google Scholar 

  23. Turk A, Sidler P, Buhler H, Christen S (2003) [Quality of long-term oral anticoagulation: an observation study]. Schweiz Rundsch Med Prax 92(42):1769–1773

    PubMed  CAS  Google Scholar 

  24. Albers GW, Bittar N, Young L, Hattemer CR, Gandhi AJ, Kemp SM et al (1997) Clinical characteristics and management of acute stroke in patients with atrial fibrillation admitted to US university hospitals. Neurology 48(6):1598–1604

    PubMed  CAS  Google Scholar 

  25. Blich M, Gross B (2004) Thromboembolic prophylaxis in nonrheumatic atrial fibrillation: utilization patterns, efficacy, and complications in a long-term follow-up of community patients. Int J Cardiol 96(1):89–95

    Article  PubMed  Google Scholar 

  26. Maeda K, Sakai T, Hira K, Sato TS, Bito S, Asai A et al (2004) Physicians’ attitudes toward anticoagulant therapy in patients with chronic atrial fibrillation. Intern Med 43(7):553–560

    Article  PubMed  Google Scholar 

  27. Bungard TJ, Ghali WA, Teo KK, McAlister FA, Tsuyuki RT (2000) Why do patients with atrial fibrillation not receive warfarin? Arch Intern Med 160(1):41–46

    Article  PubMed  CAS  Google Scholar 

  28. Flaker GC, Schutz J (2004) Why is warfarin underutilized in patients with atrial fibrillation? J Interv Card Electrophysiol 10:21–25

    Article  PubMed  Google Scholar 

  29. McCrory DC, Matchar DB, Samsa G, Sanders LL, Pritchett EL (1995) Physician attitudes about anticoagulation for nonvalvular atrial fibrillation in the elderly. Arch Intern Med 155(3):277–281

    Article  PubMed  CAS  Google Scholar 

  30. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ (2001) Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 285(22):2864–2870

    Article  PubMed  CAS  Google Scholar 

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Acknowledgments

Many thanks to Annette Wagner for organization of the study office, Birgit Frank and Anna Mattenklotz for data collection and Ulrike Stasun for data management. Funding for this study was granted from AstraZeneca GmbH, Tinsdaler Weg 183, 22880 Wedel, Germany.

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Authors and Affiliations

  1. Institute for Social Medicine, Epidemiology and Health Economics, Charité University Medical Centre, 10098, Berlin, Germany

    Doreen McBride, Bernd Brüggenjürgen, Stephanie Roll & Stefan N. Willich

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  1. Doreen McBride
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  2. Bernd Brüggenjürgen
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  3. Stephanie Roll
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  4. Stefan N. Willich
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Correspondence to Doreen McBride.

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McBride, D., Brüggenjürgen, B., Roll, S. et al. Anticoagulation treatment for the reduction of stroke in atrial fibrillation: a cohort study to examine the gap between guidelines and routine medical practice. J Thromb Thrombolysis 24, 65–72 (2007). https://doi.org/10.1007/s11239-006-0002-8

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  • DOI: https://doi.org/10.1007/s11239-006-0002-8

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