Oral anticoagulation in atrial fibrillation: A pan-European patient survey

doi:10.1016/j.ejim.2006.11.005

European Journal of Internal Medicine

Volume 18, Issue 3, May 2007, Pages 202-208

https://doi.org/10.1016/j.ejim.2006.11.005 Get rights and content

Abstract

Background

Anticoagulation with vitamin K antagonists (VKAs) provides effective stroke prophylaxis in patients with atrial fibrillation (AF). Optimisation of such therapy requires frequent monitoring, dose adjustments and stringent lifestyle restrictions. We conducted a large multinational survey in patients with chronic AF to gain insights into their perceptions and understanding of VKA use.

Methods

Eligible patients were adults with AF who had been prescribed VKAs for at least 1 year. A total of 711 patient interviews were conducted in seven European countries during June and July 2004.

Results

The majority of patients (58% male; mean age 68 years) claimed to understand their treatment programme; despite this, only 7% knew that VKA use is aimed at preventing strokes and 24% stated that they would have liked more information. Patients attended an average of 14 monitoring sessions in the previous year; however, 21% missed appointments, especially younger patients (< 65 years). The International Normalized Ratio (INR) was within the target range in most or all of the last five to ten visits in 64% of patients; nonetheless, 38% were not aware that an INR outside the target range is associated with health risks. On average, patients required dose adjustments every four sessions. VKA treatment impacted 67% of patients in terms of diet, socialising, career and independence, especially younger patients (74%).

Conclusions

Monitoring, dose adjustments and lifestyle restrictions to optimise the intensity of anticoagulation with VKAs are problematic for patients with AF, and their knowledge of the consequences of such therapy is often poor.

Introduction

Atrial fibrillation (AF) is the most common sustained cardiac rhythm disorder and is associated with a substantial risk of stroke and thromboembolism. The presence of AF increases the risk of stroke five-fold [1], and when strokes occur in association with AF, there is increased mortality and morbidity, with a greater probability of remaining disabled [2].

Current treatment guidelines recommend long-term oral anticoagulation with a vitamin K antagonist (VKA), such as warfarin, in patients with AF who are at moderate to high risk of stroke [3], [4]. This recommendation is based on consistent evidence of the efficacy of dose-adjusted VKA therapy [within the International Normalized Ratio (INR) range of 2.0–3.0] from randomised controlled trials. A recent meta-analysis of the effectiveness of aspirin, warfarin and ximelagatran as thromboprophylaxis in patients with non-valvular AF demonstrated that VKA reduced the risk of stroke by 67% compared with controls [5].

Unfortunately, anticoagulation with VKAs has many limitations. VKAs offer a narrow therapeutic range of INR 2.0–3.0; consequently, when INR levels are below this target range, patients are at increased risk of ischaemic stroke, and when they exceed 3.0, the risk of bleeding is increased [6], [7]. Therefore, frequent INR monitoring and dose adjustments are required. In daily practice, the narrow therapeutic window puts patients at considerable risk of ischaemic and bleeding complications, as community-based studies indicate that patients receiving VKAs have INR values within the therapeutic range less than half of the time [8]. Furthermore, anticoagulation intensity can be influenced by multiple drug and food interactions, as well as by alcohol consumption. Therefore, patients taking VKAs have to be cautious about concomitant drug use and adhere to dietary and lifestyle restrictions [9]. From the physician's perspective, there is reluctance to use VKAs, partly due to over-estimation of bleeding risks with anticoagulation [10], [11], [12], [13], [14]. Additionally, the risk of AF-induced stroke appears not to be fully appreciated [14].

The complexity of anticoagulant therapy with VKAs is reflected by the fact that approximately 50% of eligible patients with AF do not currently receive appropriate anticoagulation therapy [15], [16]. Even in the recently published Euro Heart Survey on AF, which encompassed mostly university centres, it was found that VKAs were prescribed in 67% of eligible patients [17]. Moreover, the use of anticoagulant therapy was lowest in elderly patients with AF, who are at the highest risk of stroke [18].

Insight into patient perception and understanding of therapy is required, as their input into the therapeutic partnership is necessary to optimise thromboprophylaxis. However, many patients with AF possess very limited knowledge of their illness and of the need for, risks and consequences of anticoagulant therapy [19]. A survey of patients with AF attending an anticoagulation clinic showed that only half the patients were aware of the reason for anticoagulation, and knowledge regarding risks of AF and anticoagulant treatment was generally poor [19].

To gain a broader view of patient perceptions and understanding of VKA use, we performed an international survey of patients with AF who had been prescribed VKAs for at least 1 year in seven European countries.

Section snippets

Patients and methods

The European Atrial Fibrillation Survey was conducted between June and July 2004 in seven European countries: France, Germany, Italy, Norway, Spain, Sweden and the UK. Patients eligible for inclusion were adults with AF who had been taking VKAs for at least 1 year. Patients were excluded if they had any condition that could adversely affect their ability to participate (e.g. dementia or conditions affecting speech, hearing or general comprehension).

In the UK, patients were recruited via their

Results

In total, 711 patients were included: 108 from France, 102 from Germany, 101 from Italy, 100 from Norway, 100 from Spain, 100 from Sweden and 100 from the UK. The mean age of the surveyed population was 68 years (range 20–93 years), 58% were male, the mean duration of VKA therapy was 6 years and 63% had used their medication for 3 or more years (Table 1). Overall, 81% of the patients were using concomitant prescribed medication, of whom 34% used five or more additional drugs. Over-the-counter

Discussion

The present study showed that patient knowledge regarding reasons for, and consequences of, VKA therapy for stroke prophylaxis is generally poor. While most patients had been given information on their disease and VKA therapy at the time of diagnosis, the level of information recall was weak and variable and many would have liked more information. Many patients missed INR monitoring visits or reported that the INR value was regularly out of range; dose adjustments were similarly frequent,

Learning points

•
Patient knowledge regarding reasons for, and consequences of, VKA therapy for stroke prophylaxis is generally poor, and many want more information.
•
INR monitoring visits are frequently missed, INR values are regularly out of range and dose adjustments are frequent, particularly in the elderly.
•
Many patients are unaware of the risks involved with over- or under-anticoagulation.
•
Consequences of VKA treatment are perceived as a burden on lifestyle in terms of diet, socialising, career, independence

Acknowledgments

This study was initiated by Anticoagulation Europe, coordinated by Ipsos Health (Harrow, UK) and was supported by an unrestricted grant from AstraZeneca R&D, Mölndal, Sweden.

GL, GA and DR have received consulting fees from AstraZeneca. MT is an employee of AstraZeneca. The authors state no conflicts of interest.

References (29)

D.E. Singer et al.
Antithrombotic therapy in atrial fibrillation. The Seventh ACCP Conference on Antithrombotic Therapy and Thrombolytic Therapy
Chest
(2004)
G.Y. Lip et al.
Stroke prevention with aspirin, warfarin and ximelagatran in patients with non-valvular atrial fibrillation: a systematic review and meta-analysis
Thromb Res
(2006)
J. Ansell et al.
The pharmacology and management of the vitamin K antagonists. The Seventh ACCP Conference on Antithrombotic Therapy and Thrombolytic Therapy
Chest
(2004)
R.H. White et al.
Oral anticoagulation in patients with atrial fibrillation: adherence with guidelines in an elderly cohort
Am J Med
(1999)
D.A. Lane et al.
Patient knowledge and perceptions of atrial fibrillation and anticoagulant therapy: effects of an educational intervention programme. The West Birmingham Atrial Fibrillation Project
Int J Cardiol
(2006)
P.A. Wolf et al.
Atrial fibrillation as an independent risk factor for stroke: the Framingham Study
Stroke
(1991)
M. Lamassa et al.
Characteristics, outcome, and care of stroke associated with atrial fibrillation in Europe: data from a multicenter multinational hospital-based registry (The European Community Stroke Project)
Stroke
(2001)
G.Y. Lip et al.
Antithrombotic therapy for atrial fibrillation
Heart
(2006)
E.M. Hylek et al.
Effect of intensity of oral anticoagulation on stroke severity and mortality in atrial fibrillation
N Engl J Med
(2003)
M.C. Fang et al.
Advanced age, anticoagulation intensity, and risk for intracranial hemorrhage among patients taking warfarin for atrial fibrillation
Ann Intern Med
(2004)

G.P. Samsa et al.

Quality of anticoagulation management among patients with atrial fibrillation: results of a review of medical records from 2 communities

Arch Intern Med

(2000)

T.J. Bungard et al.

Why do patients with atrial fibrillation not receive warfarin?

Arch Intern Med

(2000)

P.J Devereaux et al.

Differences between perspectives of physicians and patients on anticoagulation in patients with atrial fibrillation: observational study

BMJ

(2001)

M. Man-Son-Hing et al.

Anticoagulant-related bleeding in older persons with atrial fibrillation: physicians' fears often unfounded

Arch Intern Med

(2003)

Cited by (43)

Survey on atrial fibrillation detection from a single-lead ECG wave for Internet of Medical Things
2021, Computer Communications
Citation Excerpt :
Among them, the AF is a leading cause of death because it is associated with an increased risk of cardiovascular diseases, such as stroke, heart failure, and coronary artery diseases [7,8]. To some extent, AF can be regarded as the indirect cause of the mortality and morbidity [9–11]. Previous research achievements have demonstrated that the prevalence of AF increases with age, up to 15% for those aged 85 years and older [12,13].
Recent advances of Internet of Medical Things have allowed for continuous heart rhythm monitoring in a comfortable fashion. Single lead Electrocardiograph (ECG) is first collected by the wearable devices, and then some intelligent approaches are employed for automatic recognition of heart rhythms. Because the single lead ECG wave is different from traditional 12-leads Holter-based ECG signal in terms of high noise/artifact and the missing of other channels, specific algorithms for pattern recognition of the single lead ECG waves have been proposed in recent years. This paper systematically surveys state-of-the-art methods for screening atrial fibrillation from a single lead ECG wave. The database and performance metrics for this problem are demonstrated, the data preprocessing and feature extraction techniques are collected, and then the learning methods in terms of machine learning and deep learning are comparatively summarized. Specifically, the techniques for data preprocessing are reviewed and the most common and powerful features are listed, which are capable of providing a guideline for researchers aiming at developing AF detection algorithms. Finally, we discuss the potential contributors that are probably helpful for screening the atrial fibrillation from a single lead ECG wave.
Atrial fibrillation patients’ experiences and perspectives of anticoagulation therapy changes
2020, Research in Social and Administrative Pharmacy
Atrial fibrillation (AF) patients’ experiences with changes in their oral anticoagulant (OAC) therapy are understudied.
The objective of this study was to qualitatively describe AF patients’ experiences and perspectives of changes made to their OAC therapy (switches or discontinuations).
A thematic analysis was performed on systematically-collected qualitative data from AF patients who experienced a therapy change (switching or discontinuing an OAC) as part of their participation in a large 2-year prospective observational study.
A total of 56 participants met the inclusion criteria. Six themes emerged from the data: 1. reasons for switch or discontinuation of therapy, 2. attitudes towards changes in therapy attributes, 3. challenges with taking medications after therapy change, 4. relief from perceived burden of medication after discontinuation, 5. patients’ limited involvement in decision-making, and 6. inadequate education and follow up. Patients were found to request changes in therapy based on their subjective experience with it (rather than clinically justified reasons). They were found to have limited knowledge about their medications, differing reactions to changes in their therapy attributes after a switch, an overall negative attitude towards taking medications, adherence challenges after switching from once daily to twice daily medication, feelings of being excluded from the decision-making process about their therapy changes and feelings of being unsupported after these changes.
There are clear opportunities to improve patients’ experiences with OAC therapy changes through improved shared decision-making and patient education/counselling.
Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report
2018, Chest
Citation Excerpt :
Patient knowledge and understanding of the stroke risk associated with AF and the benefit of OAC to prevent stroke are crucial to patient acceptance of anticoagulants, as well as adherence, and life-long persistence (in most cases), to OAC. However, research demonstrates that AF patients generally have poor awareness and knowledge about their condition,467-472 medications used to treat AF, particularly OAC, and do not clearly comprehend the benefit/risk associated with stroke prevention regimens.203,468-471,473-478 Although there is increasing advocacy from clinical guidelines157,158 and expert consensus2,203,479 to incorporate patient preferences for treatment into the decision-making process, a patient’s ability to make an informed decision may be hindered by their lack of understanding about the relationship between AF and stroke and the efficacy/safety of OAC for stroke prevention, particularly at diagnosis, when these decisions are invariably addressed.
The risk of stroke is heterogeneous across different groups of patients with atrial fibrillation (AF), being dependent on the presence of various stroke risk factors. We provide recommendations for antithrombotic treatment based on net clinical benefit for patients with AF at varying levels of stroke risk and in a number of common clinical scenarios.
Systematic literature reviews were conducted to identify relevant articles published from the last formal search perfomed for the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (9th Edition). The overall quality of the evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Graded recommendations and ungraded consensus-based statements were drafted, voted on, and revised until consensus was reached.
For patients with AF without valvular heart disease, including those with paroxysmal AF, who are at low risk of stroke (eg, CHA₂DS₂-VASc [congestive heart failure, hypertension, age ≥ 75 (doubled), diabetes, stroke (doubled)-vascular disease, age 65-74 and sex category (female)] score of 0 in males or 1 in females), we suggest no antithrombotic therapy. The next step is to consider stroke prevention (ie, oral anticoagulation therapy) for patients with 1 or more non-sex CHA₂DS₂-VASc stroke risk factors. For patients with a single non-sex CHA₂DS₂-VASc stroke risk factor, we suggest oral anticoagulation rather than no therapy, aspirin, or combination therapy with aspirin and clopidogrel; and for those at high risk of stroke (eg, CHA₂DS₂-VASc ≥ 2 in males or ≥ 3 in females), we recommend oral anticoagulation rather than no therapy, aspirin, or combination therapy with aspirin and clopidogrel. Where we recommend or suggest in favor of oral anticoagulation, we suggest using a non-vitamin K antagonist oral anticoagulant drug rather than adjusted-dose vitamin K antagonist therapy. With the latter, it is important to aim for good quality anticoagulation control with a time in therapeutic range > 70%. Attention to modifiable bleeding risk factors (eg, uncontrolled BP, labile international normalized ratios, concomitant use of aspirin or nonsteroidal antiinflammatory drugs in an anticoagulated patient, alcohol excess) should be made at each patient contact, and HAS-BLED (hypertension, abnormal renal/liver function [1 point each], stroke, bleeding history or predisposition, labile international normalized ratio, elderly (0.65), drugs/alcohol concomitantly [1 point each]) score used to assess the risk of bleeding where high risk patients (≥ 3) should be reviewed and followed up more frequently.
Oral anticoagulation is the optimal choice of antithrombotic therapy for patients with AF with ≥1 non-sex CHA₂DS₂-VASc stroke risk factor(s).
Perceived advantages and disadvantages of oral anticoagulants, and the trade-offs patients make in choosing anticoagulant therapy and adhering to their drug regimen
2018, Patient Education and Counseling
Citation Excerpt :
Once-daily dosing is preferred over twice-daily intake, a finding previously demonstrated by Böttger et al. [22]. Furthermore, Elewa et al. found that dietary freedom was the major incentive of over half (52%) of patients to switch from VKAs to DOACs [23] and according to several studies INR monitoring is the key difﬁculty for patients taking VKAs [24–33]. Moreover, up to 55% of VKA users are adversely affected by INR fluctuations [26,28,29,31,34–38], and this makes it more difficult to develop habit and routines.
The objective of this study was to explore the perceived advantages and disadvantages of oral anticoagulant therapies (OAT), and the trade-offs patients make in choosing therapy and adhering to their drug regimen.
Five focus group sessions were conducted across Europe among patients with atrial fibrillation to identify the most important factors impacting OAT‘s value and adherence.
The most frequently identified barriers to OAT were lack of knowledge; poor patient-physician relationships; distraction due to employment or social environment; prior bleeding event(s) or the fear of bleeding; and changes in routine. Factors identified as promoting adherence included patients' personality, motivation, attitudes, and medication-taking habits and routines, as well as good quality health services. Inconvenient aspects of vitamin-K antagonists, such as regular blood monitoring and diet restrictions, were not reported to influence adherence, but may trigger patients to switch to direct oral anticoagulants.
Most patients reported that a mixture of modifiable and non-modifiable factors helps them to take their drugs as prescribed. Individual patients’ particular needs and preferences regarding OAT vary.
OAT adherence can be promoted if therapies are tailored to patients’ needs and preferences. Patients should be supported to share their preferences with their clinician.
Synthesis of conductive polymeric ionic liquid/Ni nanocomposite and its application to construct a nanostructure based electrochemical sensor for determination of warfarin in the presence of tramadol
2017, Talanta
Citation Excerpt :
Thromboembolic disorders including stroke and venous thromboembolism are associated with a remarkable increase in mortality and morbidity [1]. These diseases mainly affect older patients with atrial fibrillation, and this group of patients ultimately requires effective and well tolerated long-term therapy [2]. Presently, the most commonly used drug for the prevention of thromboembolic diseases is warfarin [3,4].
In the current study, poly(MImEO8BS)-Ni nanocomposite was synthesized and applied to modify a glassy carbon electrode along with conductive polymeric ionic liquids. The electrochemical investigation of the modified electrode as well as its efficiency for voltammetric oxidation of warfarin is elucidated. The electrode was used to study the voltammetric oxidation of warfarin by employing cyclic voltammetry (CV), linear sweep voltammetry (LSV), chronoamperometry, and square wave voltammetry (SWV) as diagnostic techniques. It has been observed that warfarin oxidation at the surface of modified electrode occurs at a potential of about 230 mV which is less positive than that of an unmodified glassy carbon electrode. SWV demonstrated a linear dynamic range from 1.0×10⁻⁶ to 1.0×10⁻⁴ M and a detection limit of 1.5×10⁻⁷ M for warfarin. In addition, this modified electrode was utilized for simultaneous determination of warfarin and tramadol. Finally, the modified electrode was employed for determination of warfarin and tramadol in pharmaceutical compounds.
Persistence of warfarin therapy for residents in long-term care who have atrial fibrillation
2013, Clinical Therapeutics
Among long-term care (LTC) residents with atrial fibrillation (AF), the use of warfarin to prevent stroke has been shown to be suboptimal. For those who begin warfarin prophylaxis in LTC, persistence on this therapy has not been reported.
This study was conducted to estimate persistence on warfarin among LTC residents with AF.
A retrospective analysis was conducted by using data from an LTC database. Pharmacy dispensing data were used to track warfarin use in residents with a diagnosis of AF who were newly started on warfarin therapy. The main outcome measure was persistence of warfarin over the first year of therapy. Survival analysis included Kaplan-Meier plots and a multivariate Cox proportional hazards model to test the association of resident characteristics and conditions with warfarin discontinuation.
A total of 148 residents new to warfarin therapy met all study inclusion criteria. Median age was 84 years; 69% were female. Median time to therapy discontinuation was 197 days (95% CI, 137–249) across all study residents. By 90 days after the initiation of therapy, 37% (95% CI, 28–47) of study residents had discontinued warfarin; by 1 year, 65% (54%–76%) had discontinued warfarin therapy. The multivariate Cox regression analysis found that the following factors were independently associated with discontinuation of warfarin therapy: age 65 to 74 years (hazard ratio [HR] = 3.01 [95% CI, 1.04–8.73]), female sex (HR = 0.45 [95% CI, 0.24–0.87]), Hispanic race/ethnicity (HR = 2.86 [95% CI, 1.30–6.26]), Midwest region (HR = 2.13 [95% CI, 1.02–4.48]), and Alzheimer disease or dementia (HR = 1.97 [95% CI, 1.05–3.68]).
Although clinical practice guidelines exist for the prevention of stroke in AF patients, persistence on warfarin therapy seems suboptimal in many LTC residents with AF.

View all citing articles on Scopus

View full text

Original ArticleOral anticoagulation in atrial fibrillation: A pan-European patient survey

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Patients and methods

Results

Discussion

Learning points

Acknowledgments

Chest

Thromb Res

Chest

Am J Med

Int J Cardiol

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

Stroke

Characteristics, outcome, and care of stroke associated with atrial fibrillation in Europe: data from a multicenter multinational hospital-based registry (The European Community Stroke Project)

Stroke

Antithrombotic therapy for atrial fibrillation

Heart

Effect of intensity of oral anticoagulation on stroke severity and mortality in atrial fibrillation

N Engl J Med

Advanced age, anticoagulation intensity, and risk for intracranial hemorrhage among patients taking warfarin for atrial fibrillation

Ann Intern Med

Quality of anticoagulation management among patients with atrial fibrillation: results of a review of medical records from 2 communities

Arch Intern Med

Why do patients with atrial fibrillation not receive warfarin?

Arch Intern Med

Differences between perspectives of physicians and patients on anticoagulation in patients with atrial fibrillation: observational study

BMJ

Anticoagulant-related bleeding in older persons with atrial fibrillation: physicians' fears often unfounded

Arch Intern Med

Original Article
Oral anticoagulation in atrial fibrillation: A pan-European patient survey