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Guideline-adherent therapy for stroke prevention in atrial fibrillation in different health care settings: Results from RAMSES study

Published:February 24, 2017DOI:https://doi.org/10.1016/j.ejim.2017.02.011

      Highlights

      • The quality of stroke prevention therapy might be influenced by healthcare setting.
      • Guideline adherent therapy was not adequate in secondary and tertiary hospitals.
      • Inappropriate therapy was more prevalent in secondary than tertiary hospitals.
      • Special attention should be paid to decrease undertreatment in secondary hospitals.
      • Strategies to prevent overtreatment should be developed in tertiary hospitals.

      Abstract

      Objective

      No studies have been conducted in Turkey to compare the quality of stroke prevention therapies provided in different healthcare settings in patients with atrial fibrillation (AF). Therefore, we aimed to evaluate possible differences between secondary (SH) and tertiary hospital (TH) settings in the effectiveness of implementing AF treatment strategies.

      Methods

      Baseline characteristics of 6273 patients with non-valvular AF enrolled in the RAMSES (ReAl-life Multicentre Survey Evaluating Stroke Prevention Strategies in Turkey) study were compared.

      Results

      Of the study population, 3312 (52.8%) patients were treated in THs and 2961 (47.2%) patients were treated in SHs. Patients treated in the SH setting were older (70.8 ± 9.8 vs. 68.7 ± 11.4 years, p < 0.001), had a lower socioeconomic status, had a higher CHA2DS2VASc and HASBLED scores (3.4 ± 1.4 vs. 3.1 ± 1.7, p < 0.001 and 1.7 ± 1.0 vs. 1.6 ± 1.1, p < 0.001 respectively), and had more comorbidities than patients treated in THs. Inappropriate oral anticoagulant use was more prevalent in SHs than THs (31.4% vs. 25.6%, p < 0.001). When over- and undertreatment rates were compared among hospital types, overtreatment was more prevalent in THs (7.6% vs. 0.9%, p < 0.001) while undertreatment was more common in SHs (30.5% vs. 17.9%, p < 0.001).

      Conclusion

      This study demonstrates the marked disparity between patient groups with AF presenting at SHs and THs. The use of guideline-recommended therapy is not adequate in either type of centre, overtreatment was more prevalent in THs and undertreatment was more prevalent in SHs.

      Keywords

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      References

        • Jørgensen H.S.
        • Nakayama H.
        • Reith J.
        • Raaschou H.O.
        • Olsen T.S.
        Acute stroke with atrial fibrillation. The Copenhagen Stroke Study.
        Stroke. 1996; 27: 1765-1769
        • Lin H.J.
        • Wolf P.A.
        • Kelly-Hayes M.
        • Beiser A.S.
        • Kase C.S.
        • Benjamin E.J.
        • et al.
        Stroke severity in atrial fibrillation. The Framingham Study.
        Stroke. 1996; 27: 1760-1764
        • January C.T.
        • Wann L.S.
        • Alpert J.S.
        • Calkins H.
        • Cigarroa J.E.
        • Cleveland J.C.
        • et al.
        AHA/ACC/HRS Guideline 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 Heart Rhythm Society.
        Vol. 64. 2014: 2014https://doi.org/10.1016/j.jacc.2014.03.022
        • Camm A.J.
        • Lip G.Y.H.
        • De Caterina R.
        • Savelieva I.
        • Atar D.
        • Hohnloser S.H.
        • et al.
        2012 focused update of the ESC Guidelines for the management of atrial fibrillation.
        Eur Heart J. 2012; 33: 2719-2747https://doi.org/10.1093/eurheartj/ehs253
        • Proietti M.
        • Nobili A.
        • Raparelli V.
        • Napoleone L.
        • Mannucci P.M.
        • Lip G.Y.H.
        • et al.
        Adherence to antithrombotic therapy guidelines improves mortality among elderly patients with atrial fibrillation: insights from the REPOSI study.
        Clin Res Cardiol. 2016; https://doi.org/10.1007/s00392-016-0999-4
        • Nieuwlaat R.
        • Olsson S.B.
        • Lip G.Y.H.
        • Camm A.J.
        • Breithardt G.
        • Capucci A.
        • et al.
        Guideline-adherent antithrombotic treatment is associated with improved outcomes compared with undertreatment in high-risk patients with atrial fibrillation. The Euro Heart Survey on Atrial Fibrillation.
        Am Heart J. 2007; 153: 1006-1012https://doi.org/10.1016/j.ahj.2007.03.008
        • Başaran Ö.
        • Doğan V.
        • Memic Sancar K.
        • Altun İ.
        • Mert K.U.
        • Mert G.Ö.
        • et al.
        Rationale, design and methodology of the RAMSES study: ReAl-life Multicenter Survey Evaluating Stroke Prevention Strategies.
        44. 2016: 215-220
        • Camm A.J.
        • Lip G.Y.H.
        • De Caterina R.
        • Savelieva I.
        • Atar D.
        • Hohnloser S.H.
        • et al.
        2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association.
        Eur Heart J. 2012; 33: 2719-2747https://doi.org/10.1093/eurheartj/ehs253
        • Kirchhof P.
        • Nabauer M.
        • Gerth A.
        • Limbourg T.
        • Lewalter T.
        • Goette A.
        • et al.
        Impact of the type of centre on management of AF patients: surprising evidence for differences in antithrombotic therapy decisions.
        Thromb Haemost. 2011; 105: 1010-1023https://doi.org/10.1160/TH11-02-0070
        • Turakhia M.P.
        • Hoang D.D.
        • Xu X.
        • Frayne S.
        • Schmitt S.
        • Yang F.
        • et al.
        Differences and trends in stroke prevention anticoagulation in primary care vs cardiology specialty management of new atrial fibrillation: The Retrospective Evaluation and Assessment of Therapies in AF (TREAT-AF) study.
        Am Heart J. 2013; 165: 93-101.e1https://doi.org/10.1016/j.ahj.2012.10.010
        • Lefebvre M.-C.D.
        • St-Onge M.
        • Glazer-Cavanagh M.
        • Bell L.
        • Kha Nguyen J.N.
        • Viet-Quoc Nguyen P.
        • et al.
        The effect of bleeding risk and frailty status on anticoagulation patterns in octogenarians with atrial fibrillation: the FRAIL-AF study.
        Can J Cardiol. 2016; 32: 169-176https://doi.org/10.1016/j.cjca.2015.05.012
        • McCormick D.
        • Gurwitz J.H.
        • Goldberg R.J.
        • Ansell J.
        Long-term anticoagulation therapy for atrial fibrillation in elderly patients: efficacy, risk, and current patterns of use.
        J Thromb Thrombolysis. 1999; 7: 157-163
        • Lewis W.R.
        • Fonarow G.C.
        • LaBresh K.A.
        • Cannon C.P.
        • Pan W.
        • Super D.M.
        • et al.
        Differential use of warfarin for secondary stroke prevention in patients with various types of atrial fibrillation.
        Am J Cardiol. 2009; 103: 227-231https://doi.org/10.1016/j.amjcard.2008.08.062
        • Agarwal S.
        • Bennett D.
        • Smith D.J.
        Predictors of warfarin use in atrial fibrillation patients in the inpatient setting.
        Am J Cardiovasc Drugs. 2010; 10: 37-48https://doi.org/10.2165/11318870-000000000-00000
        • Basaran O.
        ReAl-life Multicenter Survey Evaluating Stroke prevention strategies in non-valvular atrial fibrillation (RAMSES study).
        Anatol J Cardiol. 2016; https://doi.org/10.14744/AnatolJCardiol.2016.6752
        • Basaran O.
        • Filiz Basaran N.
        • Cekic E.G.
        • Altun I.
        • Dogan V.
        • Mert G.O.
        • et al.
        PRescriptiOn PattERns of Oral Anticoagulants in Nonvalvular Atrial Fibrillation (PROPER study).
        Clin Appl Thromb Hemost. 2015; https://doi.org/10.1177/1076029615614395
        • Ertaş F.
        • Kaya H.
        • Özhan H.
        Epidemiology of atrial fibrillation in Turkey: preliminary results in the multicenter AFTER study. Author reply.
        41. 2013: 370