Underuse of Oral Anticoagulants in Atrial Fibrillation: A Systematic Review

doi:10.1016/j.amjmed.2009.11.025

The American Journal of Medicine

Volume 123, Issue 7, July 2010, Pages 638-645.e4

Poster was presented at the American College of Cardiology Annual Meeting 2009 in Orlando, Florida on March 29, 2009.

https://doi.org/10.1016/j.amjmed.2009.11.025 Get rights and content

Abstract

Background

Atrial fibrillation is associated with substantial mortality and morbidity from stroke and thromboembolism. Despite an efficacious oral anticoagulation therapy (warfarin), atrial fibrillation patients at high risk for stroke are often under-treated. This systematic review compares current treatment practices for stroke prevention in atrial fibrillation with published guidelines.

Methods

Literature searches (1997-2008) identified 98 studies concerning current treatment practices for stroke prevention in atrial fibrillation. The percentage of patients eligible for oral anticoagulation due to elevated stroke risk was compared with the percentage treated. Under-treatment was defined as treatment of <70% of high-risk patients.

Results

Of 54 studies that reported stroke risk levels and the percentage of patients treated, most showed underuse of oral anticoagulants for high-risk patients. From 29 studies of patients with prior stroke/transient ischemic attack who should all receive oral anticoagulation according to published guidelines, 25 studies reported under-treatment, with 21 of 29 studies reporting oral anticoagulation treatment levels below 60% (range 19%-81.3%). Subjects with a CHADS₂ (congestive heart failure, hypertension, age >75 years, diabetes mellitus, and prior stroke or transient ischemic attack) score ≥2 also were suboptimally treated, with 7 of 9 studies reporting treatment levels below 70% (range 39%-92.3%). Studies (21 of 54) using other stroke risk stratification schemes differ in the criteria they use to designate patients as “high risk,” such that direct comparison is not possible.

Conclusions

This systematic review demonstrates the underuse of oral anticoagulation therapy for real-world atrial fibrillation patients with an elevated risk of stroke, highlighting the need for improved therapies for stroke prevention in atrial fibrillation.

Section snippets

Literature Search

An extensive search of recent biomedical literature was performed using PubMed for studies pertaining to current treatment practices for stroke prevention for atrial fibrillation patients; the search was limited to studies on humans, published after May 1997. Combinations of the following search terms were used: practices, treatment, atrial fibrillation, stroke, antithrombotics, antiplatelets, oral anticoagulants, warfarin, and vitamin K antagonist. Studies were excluded if no stroke risk

Current Treatment Practices

In all, 54 studies were selected from a possible 98 that pertained to treatment of atrial fibrillation patients with oral anticoagulation therapy (Figure 1). The study populations were mostly elderly (over 65 years old). Of the 54 selected studies, 29 contained treatment data for atrial fibrillation patients with prior stroke or transient ischemic attack; these were used for the primary analysis. Additionally, 9 of the 54 studies presented treatment data for atrial fibrillation patients based

Discussion

This systematic review and analysis of available evidence has highlighted suboptimal treatment of high-risk atrial fibrillation patients. Patients with atrial fibrillation and prior stroke or transient ischemic attack were found to be under-treated with oral anticoagulation therapy in the majority of studies. Over two thirds of studies analyzed reported treatment levels of high-risk patients under 60%. Similarly, high-risk subjects based on CHADS₂ stroke risk score also were suboptimally

Conclusion

This systematic review demonstrates that a large proportion of patients with atrial fibrillation who are at high risk of stroke are under-treated with oral anticoagulation, highlighting the need for improvements in thromboprophylaxis for atrial fibrillation.

Acknowledgment

The authors wish to thank Annabelle Shakespeare at Bayer Healthcare, UK, for her help with study design, literature search and data review.

References (78)

J. Friberg et al.
Comparison of the impact of atrial fibrillation on the risk of stroke and cardiovascular death in women versus men (The Copenhagen City Heart Study)
Am J Cardiol
(2004)
M.C. Fang et al.
Comparison of risk stratification schemes to predict thromboembolism in people with nonvalvular atrial fibrillation
J Am Coll Cardiol
(2008)
D.E. Singer et al.
Antithrombotic therapy in atrial fibrillation: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy
Chest
(2004)
S.B. Rowan et al.
Trends in anticoagulation for atrial fibrillation in the U.S.: an analysis of the national ambulatory medical care survey database
J Am Coll Cardiol
(2007)
S.L. Partington et al.
Pre-admission warfarin use in patients with acute ischemic stroke and atrial fibrillation: the appropriate use and barriers to oral anticoagulant therapy
Thromb Res
(2007)
M.R. Reynolds et al.
Patterns and predictors of warfarin use in patients with new-onset atrial fibrillation from the FRACTAL Registry
Am J Cardiol
(2006)
R.H. White et al.
Oral anticoagulation in patients with atrial fibrillation: adherence with guidelines in an elderly cohort
Am J Med
(1999)
A.S. Go et al.
Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study
JAMA
(2001)
N.F. Murphy et al.
A national survey of the prevalence, incidence, primary care burden and treatment of atrial fibrillation in Scotland
Heart
(2007)
Y. Miyasaka et al.
Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence
Circulation
(2006)

H. Watanabe et al.

Metabolic syndrome and risk of development of atrial fibrillation: the Niigata preventive medicine study

Circulation

(2008)

J. Heeringa et al.

Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study

Eur Heart J

(2006)

L. Guize et al.

Atrial fibrillation: prevalence, risk factors and mortality in a large French population with 15 years of follow-up [French]

Bull Acad Natl Med

(2007)

Independent predictors of stroke in patients with atrial fibrillation: a systematic review

Neurology

(2007)

M. Hughes et al.

Stroke and thromboembolism in atrial fibrillation: a systematic review of stroke risk factors, risk stratification schema and cost effectiveness data

Thromb Haemost

(2008)

V. Fuster et al.

ACC/AHA/ESC 2006 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 (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society

Circulation

(2006)

L.B. Goldstein et al.

Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group

Circulation

(2006)

NICE Clinical Guideline 36—Atrial Fibrillation: The Management of Atrial Fibrillation

(2006)

G.J. Hankey

Non-valvular atrial fibrillation and stroke preventionNational Blood Pressure Advisory Committee of the National Heart Foundation

Med J Aust

(2001)

Comparison of 12 risk stratification schemes to predict stroke in patients with nonvalvular atrial fibrillation

Stroke

(2008)

B.F. Gage et al.

Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation

JAMA

(2001)

L. Baruch et al.

Can patients at elevated risk of stroke treated with anticoagulants be further risk stratified?

Stroke

(2007)

P.A. Wolf et al.

Atrial fibrillation as an independent risk factor for stroke: the Framingham Study

Stroke

(1991)

R.G. Hart et al.

Factors associated with ischemic stroke during aspirin therapy in atrial fibrillation: analysis of 2012 participants in the SPAF I-III clinical trialsThe Stroke Prevention in Atrial Fibrillation (SPAF) Investigators

Stroke

(1999)

T.J. Wang et al.

A risk score for predicting stroke or death in individuals with new-onset atrial fibrillation in the community: the Framingham Heart Study

JAMA

(2003)

R. Nieuwlaat et al.

Antithrombotic treatment in real-life atrial fibrillation patients: a report from the Euro Heart Survey on Atrial Fibrillation

Eur Heart J

(2006)

V. Fuster et al.

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

(2001)

S. Dewilde et al.

Trends in the prevalence of diagnosed atrial fibrillation, its treatment with anticoagulation and predictors of such treatment in UK primary care

Heart

(2006)

V. Frykman et al.

Management of atrial fibrillation: discrepancy between guideline recommendations and actual practice exposes patients to risk for complications

Eur Heart J

(2001)

L. Kalra et al.

Prospective cohort study to determine if trial efficacy of anticoagulation for stroke prevention in atrial fibrillation translates into clinical effectiveness

BMJ

(2000)

D.M. Bravata et al.

The use of warfarin in veterans with atrial fibrillation

BMC Cardiovasc Disord

(2004)

A.S. Go et al.

Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study

Ann Intern Med

(1999)

C. Gandolfo et al.

Stroke due to atrial fibrillation and the attitude to prescribing anticoagulant prevention in Italy: a prospective study of a consecutive stroke population admitted to a comprehensive stroke unit

J Neurol

(2008)

K.H. Humphries et al.

Population rates of hospitalization for atrial fibrillation/flutter in Canada

Can J Cardiol

(2004)

A. Evans et al.

Are the results of randomized controlled trials on anticoagulation in patients with atrial fibrillation generalizable to clinical practice?

Arch Intern Med

(2001)

R. Leckey et al.

Atrial fibrillation and the use of warfarin in patients admitted to an acute stroke unit

Can J Cardiol

(2000)

W. Ageno et al.

Atrial fibrillation and antithrombotic treatment in Italian hospitalized patients: a prospective, observational study

J Thromb Thrombolysis

(2001)

A. Meiltz et al.

Atrial fibrillation management by practice cardiologists: a prospective survey on the adherence to guidelines in the real world

Europace

(2008)

S. Suzuki et al.

Prevalence and prognosis of patients with atrial fibrillation in Japan: a prospective cohort of Shinken Database 2004

Circ J

(2008)

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: Funding: This study was funded by Bayer Healthcare, UK.

: Conflict of Interest: Dr. Gregory Y.H. Lip has acted as a consultant for Bayer Healthcare, AstraZeneca, Astellas, and Boehringer; and Warren Cowell is employed by Bayer Healthcare, UK. The other authors have no conflict of interest.

: Authorship: All authors had full access to data for this study and participated in writing and review of the manuscript.

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Clinical research studyUnderuse of Oral Anticoagulants in Atrial Fibrillation: A Systematic Review

Abstract

Background

Methods

Results

Conclusions

Section snippets

Literature Search

Current Treatment Practices

Discussion

Conclusion

Acknowledgment

Am J Cardiol

J Am Coll Cardiol

Chest

J Am Coll Cardiol

Thromb Res

Am J Cardiol

Am J Med

Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study

JAMA

A national survey of the prevalence, incidence, primary care burden and treatment of atrial fibrillation in Scotland

Heart

Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence

Circulation

Metabolic syndrome and risk of development of atrial fibrillation: the Niigata preventive medicine study

Circulation

Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study

Eur Heart J

Atrial fibrillation: prevalence, risk factors and mortality in a large French population with 15 years of follow-up [French]

Bull Acad Natl Med

Independent predictors of stroke in patients with atrial fibrillation: a systematic review

Neurology

Stroke and thromboembolism in atrial fibrillation: a systematic review of stroke risk factors, risk stratification schema and cost effectiveness data

Thromb Haemost

Circulation

Circulation

NICE Clinical Guideline 36—Atrial Fibrillation: The Management of Atrial Fibrillation

Non-valvular atrial fibrillation and stroke preventionNational Blood Pressure Advisory Committee of the National Heart Foundation

Med J Aust

Comparison of 12 risk stratification schemes to predict stroke in patients with nonvalvular atrial fibrillation

Stroke

Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation

JAMA

Can patients at elevated risk of stroke treated with anticoagulants be further risk stratified?

Stroke

Atrial fibrillation as an independent risk factor for stroke: the Framingham Study

Stroke

Factors associated with ischemic stroke during aspirin therapy in atrial fibrillation: analysis of 2012 participants in the SPAF I-III clinical trialsThe Stroke Prevention in Atrial Fibrillation (SPAF) Investigators

Stroke

A risk score for predicting stroke or death in individuals with new-onset atrial fibrillation in the community: the Framingham Heart Study

JAMA

Antithrombotic treatment in real-life atrial fibrillation patients: a report from the Euro Heart Survey on Atrial Fibrillation

Eur Heart J

Circulation

Trends in the prevalence of diagnosed atrial fibrillation, its treatment with anticoagulation and predictors of such treatment in UK primary care

Heart

Management of atrial fibrillation: discrepancy between guideline recommendations and actual practice exposes patients to risk for complications

Eur Heart J

Prospective cohort study to determine if trial efficacy of anticoagulation for stroke prevention in atrial fibrillation translates into clinical effectiveness

BMJ

The use of warfarin in veterans with atrial fibrillation

BMC Cardiovasc Disord

Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study

Ann Intern Med

Stroke due to atrial fibrillation and the attitude to prescribing anticoagulant prevention in Italy: a prospective study of a consecutive stroke population admitted to a comprehensive stroke unit

J Neurol

Population rates of hospitalization for atrial fibrillation/flutter in Canada

Can J Cardiol

Are the results of randomized controlled trials on anticoagulation in patients with atrial fibrillation generalizable to clinical practice?

Arch Intern Med

Atrial fibrillation and the use of warfarin in patients admitted to an acute stroke unit

Can J Cardiol

Atrial fibrillation and antithrombotic treatment in Italian hospitalized patients: a prospective, observational study

J Thromb Thrombolysis

Atrial fibrillation management by practice cardiologists: a prospective survey on the adherence to guidelines in the real world

Europace

Prevalence and prognosis of patients with atrial fibrillation in Japan: a prospective cohort of Shinken Database 2004

Circ J

Clinical research study
Underuse of Oral Anticoagulants in Atrial Fibrillation: A Systematic Review