Adherence to treatment guidelines: the association between stroke risk stratified comparing CHADS2 and CHA2DS2-VASc score levels and warfarin prescription for adult patients with atrial fibrillation

Abstract

BackgroundIschemic stroke is a risk associated with atrial fibrillation (AF) and is estimated to occur five times more often in afflicted patients than in those without AF. Anti-thrombotic therapy is recommended for the prevention of ischemic stroke. Risk stratification tools, such as the CHADS2, and more recently the CHA2DS2-VASc, for predicting stroke in patients with AF have been developed to determine the level of stroke risk and assist clinicians in the selection of antithrombotic therapy. Warfarin, for stroke prevention in AF, is the most commonly prescribed anticoagulant in North America. The purpose of this study was to examine the utility of using the CHADS2 score levels (low and high) in contrast to the CHA2DS2-VASc when examining the outcome of warfarin prescriptions for adult patients with AF. The CHA2DS2-VASc tool was not widely used in 2010, when the data analyzed were collected. It has only been since 2014 that CHA2DS2-VASc criteria has been recommended to guide anticoagulant treatment in updated AF treatment guidelines.MethodsBivariate and multivariate data analysis strategies were used to analyze 2010 National Ambulatory Care Survey (NAMCS) data. NAMCS is designed to collect data on the use and provision of ambulatory care services nationwide. The study population for this research was US adults with a diagnosis of AF. Warfarin prescription was the dependent variable for this study. The study population was 7,669,844 AF patients.ResultsBivariate analysis revealed that of those AF patients with a high CHADS2 score, 25.1% had received a warfarin prescription and 18.8 for those with a high CHA2DS2-VASc score. Logistic regression analysis yielded that patients with AF had higher odds of having a warfarin prescription if they had a high CHADS2 score, were Caucasian, lived in a zip code where < 20% of the population had a university education, and lived in a zip code where < 10% of the population were living in households with incomes below the federal poverty level. Further, the analysis yielded that patients with AF had lesser odds of having a warfarin prescription if they were ≥ 65 years of age, female, or had health insurance.ConclusionsOverall, warfarin appears to be under-prescribed for patients with AF regardless of the risk stratification system used. Based on the key findings of our study opportunities for interventions are present to improve guideline adherence in alignment with risk stratification for stroke prevention. Interprofessional health care teams can provide improved medical management of stroke prevention for patients with AF. These interprofessional health care teams should be constituted of primary care providers (physicians, physician assistants, and nurse practitioners), nurses (RN, LPN), and pharmacists (PharmD, RPh).

Effects of brief mindfulness-based cognitive behavioural therapy on health-related quality of life and sense of coherence in atrial fibrillation patients

“…Patients were prescribed anticoagulants according to guidelines, warfarin or a non-vitamin K antagonist oral anticoagulant based on CHA2DS2-Vasc scores. 31,32 When discharged from hospital, AF patients were encouraged to reduce the risk of new AF episodes by exercising regularly, refraining from smoking or using snuff, not exceeding a moderate intake of alcohol and coffee, and avoiding psychological distress, in accordance with provided guidelines. 33 If the AF episodes occurred occasionally, without body-mind impact, no measures were needed; but if the AF episodes became more frequent or produced symptoms, such as shortness of breath and chest pain, they were advised to contact healthcare.…”

A nurse‐led atrial fibrillation clinic: Impact on anticoagulation therapy and clinical outcomes

“…A report from the PINNACLE registry concluded that a collaborative care model, using both physicians and nurses, may provide an overall comparable quality of outpatient cardiovascular care compared with a physician‐only model 50 . However, there is available evidence showing that a multi‐disciplinary healthcare team constituted of primary care providers (physicians [including cardiologists, arrhythmologists, general practitioners and other specialists], physician assistants and nurse practitioners), nurses and pharmacists can provide improved medical management for stroke prevention in AF patients 51 . Furthermore, a structured AF management within an integrated care approach should include some core components such as: (a) patient‐centeredness; (b) multidisciplinary team; (c) use of smart technology; and (d) application of a comprehensive approach to care with access to all treatment options 39 .…”

Warfarin and the Risk of Death, Stroke, and Major Bleeding in Patients With Atrial Fibrillation Receiving Hemodialysis: A Systematic Review and Meta-Analysis

“…Generally, CHADS 2 /CHA 2 DS 2 VAS C scoring system was frequently used to guide toward oral anticoagulation therapy. As recommended by several guidelines, patients who had CHADS 2 /CHA 2 DS 2 VAS C ≧2 should initiate warfarin treatment (Kim et al, 2016 ; Chapman et al, 2017 ). However, among 12 included studies in our meta-analysis, which mainly enrolled patients who had CHADS 2 /CHA 2 DS 2 VAS C ≧2, there was not a consistent conclusion about the risk-benefit profile of warfarin in these patients (Chan et al, 2009 , 2015 ; Winkelmayer et al, 2011 ; Wakasugi et al, 2013 ; Genovesi et al, 2015 ; Shen et al, 2015 ; Yodogawa et al, 2015 ; Garg et al, 2016 ; Mitsuma et al, 2016 ; Yamashita et al, 2016 ; Kai et al, 2017 ; Yoon et al, 2017 ).…”