You may have to determine yourself if you are receiving the optimal treatment. That would assume you could find the stroke protocol for afib stroke prevention.
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Under- and over-prescribing and misdosing of oral anticoagulation
therapy also occurring, according to a new report in the Canadian
Journal of Cardiology
Patients with atrial fibrillation (AF) have an increased risk for
stroke and are often prescribed oral anticoagulation (OAC) therapy. OAC
therapy can prevent disastrous strokes, but at the expense of increased
bleeding risks. There are now well-established guidelines to assess the
risk of stroke and bleeding in AF patients to determine whether OAC is
needed. However, in a new study in the Canadian Journal of Cardiology,
researchers found that primary care physicians were often under- or
over-estimating stroke and/or bleeding risk, in part because they failed
to utilize guideline-recommended risk scoring approaches in one-half
and three-quarters of their patients, respectively. This, in turn led to
under- and over-prescription of OACs, misdosing, and other problems
that could result in an unnecessarily increased risk of stroke and
bleeding events.
“Anticoagulation in patients at risk for stroke is an important
intervention to reduce the risk of this potentially devastating
complication,” explained lead investigator Shaun G. Goodman, MD, MSc, of
the Canadian Heart Research Centre, a cardiologist at St Michael’s
Hospital, and the Heart & Stroke Foundation of Ontario Polo Chair at
the University of Toronto. “The Canadian Cardiovascular Society (CCS)
AF Guidelines recommend that all patients with AF should be stratified
using a predictive index for the risk of stroke and for the risk of
bleeding, and that most patients should receive antithrombotic therapy.
However, despite these recommendations, the uptake of these
evidence-based therapies was suboptimal. Among those who did receive
anticoagulation with warfarin, as many as four in 10 patients spent less
time in the therapeutic range we know is optimal to reduce the risk of
stroke.”
A multi-institutional team of researchers collected data on 4,670
patients from the primary care practices of 474 physicians in Canada. As
part of the Canadian Facilitating Review and Education to OptiMize
stroke prevention in Atrial Fibrillation (FREEDOM AF) knowledge
translation program (February-September 2011), primary care physicians
were asked to classify patients for both stroke and bleeding risk as
low, intermediate, or high in each category. They also noted whether a
specific stroke or bleeding predictive index had been used to evaluate
risk. Data included demographics as well as details about current stroke
prevention therapies in use and other cardiovascular-related details.
The researchers then calculated risk estimates using established systems
called CHADS2 for stroke and HAS-BLED for bleeding, two well-known
scoring methods that have been validated in many studies.
The investigators found that physicians did not provide any estimates
of stroke risk for 15% of their patients and bleeding risk for 25% of
patients. When risks were provided, they were based on a predictive
stroke and bleeding risk index for only 50% and 26% of patients,
respectively. The physicians provided both over- and under-estimation of
stroke and bleeding risk in a large proportion of patients. Although
antithrombotic therapy with warfarin was prescribed for 90% of the
patients, 44% of patients were not receiving a proper dosage for over
70% of the time.
In an accompanying editorial, Laurent Macle, MD, Montreal Heart
Institute, University of Montreal, and Jason G. Andrade, MD, Montreal
Heart Institute and Vancouver General Hospital, discuss the implications
of these results. “This study suggests that the decision to initiate
OAC is complex and considers many factors beyond simple risk prediction
tools, likely relating to the inherent subjectivity within the risk
prediction scores. Specifically, previous studies indicate physicians
selectively emphasize components of the risk prediction models,
attributing greater weight to certain factors such as previous stroke
and age, in preference to others such as hypertension and diabetes. As a
result, for the same empiric CHADS2 score, a physician may subjectively
categorize a patient as being at higher or lower risk. Given this
complexity, the need exists for future knowledge translation activities
with respect to the management of AF and stroke prevention, as well as
for follow-up studies to ensure these knowledge translation activities
are effecting appropriate changes in practice.”
Dr. Macle and Dr. Andrade caution that patients in this study were
already being treated with OAC at a significantly greater rate than
would be expected in a general AF population, so that the results might
not be generalizable. Moreover, these data predate the release of newer
OAC drugs such as apixaban, dabigatran, and rivaroxaban, which have
different risk-benefit profiles and are now prescribed more frequently
than warfarin.
Full bibliographic information“The
Risk Stratification and Stroke Prevention Therapy Care Gap in Canadian
Atrial Fibrillation Patients: Insights from the FREEDOM AF Program,” by
Paul Angaran, MD; Paul Dorian, MD; Mary K. Tan, MSc; Charles R. Kerr,
MD; Martin S. Green, MD; David J. Gladstone, MD, PhD; L. Brent Mitchell,
MD; Carl Fournier, MD; Jafna L. Cox, MD; Mario Talajic, MD; Peter J.
Lin, MD; Anatoly Langer, MD, MSc; Lianne Goldin; Shaun G. Goodman, MD,
MSc (DOI: http://dx.doi.org/10.1016/j.cjca.2015.07.012).
“Evidence-Based
Anticoagulation Decision Making for Atrial Fibrillation – How We Are
Doing (Maybe Not So Well?),” by Laurent Macle, MD, and Jason Guy
Andrade, MD (DOI: http://dx.doi.org/10.1016/10.1016/j.cjca.2015.06.025).
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