Preference-Based Antithrombotic Therapy in Atrial Fibrillation: Implications for Clinical Decision Making

Man-Son-Hing, Malcolm; Gage, Brian F.; Montgomery, Alan; Howitt, Alistair; Thomson, Richard; Devereaux, P. J.; Protheroe, Joanne; Fahey, Tom; Armstrong, David; Laupacis, Andreas

doi:10.1177/0272989x05280558

Cited by 67 publications

(44 citation statements)

References 59 publications

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“…49,51 More recent SDM studies in AF have reported decreased decisional conflict (the state of uncertainty surrounding a decision, a more accurate measure of the quality of the decision-making process because regret is strongly affected by the outcome the patient experiences, not the communication of the visit), increased patient satisfaction, and a trend toward increased knowledge compared with "traditional counseling" or guideline-based therapies groups, yet the findings have not been consistent. [52][53][54][55][56] Table 3 summarizes the evidence from these studies. 49,[52][53][54][55][56] However, it is critical to note that with the advent of the novel anticoagulants mentioned above since these studies, the number of options for stroke prevention has more than doubled, making this a far more complex decision.…”

Section: Sdm In Thromboembolism Preventionmentioning

confidence: 99%

“…[52][53][54][55][56] Table 3 summarizes the evidence from these studies. 49,[52][53][54][55][56] However, it is critical to note that with the advent of the novel anticoagulants mentioned above since these studies, the number of options for stroke prevention has more than doubled, making this a far more complex decision.…”

Section: Sdm In Thromboembolism Preventionmentioning

confidence: 99%

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Shared Decision Making in Atrial Fibrillation

et al. 2014

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You are seeing Mr Roberts, a 69-year-old retired office manager referred from the emergency department for treatment of atrial fibrillation (AF). He presented the previous night to the emergency department with shortness of breath and palpitations and was found to be in AF with a rapid ventricular response and a heart rate of 140 bpm. He was treated with intravenous diltiazem and spontaneously converted to sinus rhythm. He was then discharged from the emergency department with an outpatient cardiology appointment. He has a background history of hypertension but no other cardiac disease. His only medication is a thiazide diuretic. On questioning, he reports experiencing several episodes of palpitations over the last 2 to 3 years; typically, these are brief and self-limited. His transthoracic echocardiogram, thyroid studies, and electrolytes are all within normal limits. His ECG shows sinus rhythm with no other significant abnormality. His CHADS 2 score is 1 and CHA 2 DS 2 -Vasc score is 2. He has a family history of gastrointestinal hemorrhage-associated death and is uncomfortable about long-term anticoagulation. Additionally, he is reluctant about taking a daily medication plus his blood pressure pill. How might you present current best practice while ensuring that his treatment program is consistent with his goals, values, and preferences? Introduction AF is the most common arrhythmia requiring treatment, affecting ≈5 million Americans, with the prevalence expected to double by 2050.1-3 AF accounts for more than a third of all hospitalizations for cardiac rhythm disturbances. Hospitalization for AF has risen dramatically over the past 20 years and is projected to continue to rise as the population ages. 4 Importantly, AF is associated with a doubling in patient-matched and adjusted mortality.5 Atrial fibrillation can range from completely asymptomatic to highly symptomatic and can negatively affect patients' quality of life if left untreated. 6 Studies have demonstrated significant gaps in AF patient's knowledge about their condition, as well as knowledge of the risks and benefits of the treatment they are currently taking for their AF despite their disease being treated for several years. 7A landmark study in 2007 observed multidisciplinary groups of clinicians and patients discussing AF management and noted that all groups recognized the difficulties in managing the disease, but no group agreed with the other on the optimal way to improve patient care.8 A meta-synthesis of qualitative studies from 2012 examined the perspectives of both clinicians and patients and found that patients often experienced a paternalistic model of decision making, whereas clinicians involved in these same conversations reported that a shared decision making (SDM) model was used. 9 This discordance has been reported by other studies and indicates that patients wish for more information about their treatment options and that clinician bias and practice style, not patient preferences, influenced the outcome of starting oral anticoagul...

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Section: Sdm In Thromboembolism Preventionmentioning

confidence: 99%

Section: Sdm In Thromboembolism Preventionmentioning

confidence: 99%

Shared Decision Making in Atrial Fibrillation

et al. 2014

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“…We do not address the threshold of absolute stroke risk for which anticoagulation is warranted, because this depends on additional considerations, including estimated bleeding risk during anticoagulation, 41 access to quality anticoagulation monitoring, and patient preferences and values. 42 Several million people with atrial fibrillation now receive chronic anticoagulation to prevent stroke. Additional research to identify more discriminating and accurate risk models around which standard recommendations could be developed would encourage more uniform use of antithrombotic agents and would likely lead to better patient outcomes.…”

Section: Stroke Risk In Atrial Fibrillation Working Group Stroke Riskmentioning

confidence: 99%

Comparison of 12 Risk Stratification Schemes to Predict Stroke in Patients With Nonvalvular Atrial Fibrillation

2008

Stroke

217

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Background and Purpose-More than a dozen schemes for stratifying stroke risk in patients with nonvalvular atrial fibrillation have been published. Differences among these schemes lead to inconsistent stroke risk estimates for many atrial fibrillation patients, resulting in confusion among clinicians and nonuniform use of anticoagulation. Methods-Twelve published schemes stratifying stroke risk in patients with nonvalvular atrial fibrillation are analyzed, and observed stroke rates in independent test cohorts are compared with predicted risk status. Results-Seven schemes were based directly on event-rate analyses, whereas 5 resulted from expert consensus. Four considered only clinical features, whereas 7 schemes included echocardiographic variables. The number of variables per scheme ranged from 4 to 8 (median, 6). The most frequently included features were previous stroke/TIA (100% of schemes), patient age (83%), hypertension (83%), and diabetes (83%), and 8 additional variables were included in Ն1 schemes. Based on published test cohorts, all 8 tested schemes stratified stroke risk, but the absolute stroke rates varied widely. Observed rates for those categorized as low risk ranged from 0% to 2.3% per year and those categorized as high risk ranged from 2.5% to 7.9% per year. When applied to the same cohorts, the fractions of patients categorized by the different schemes as low risk varied from 9% to 49% and those categorized by the different schemes as high-risk varied from 11% to 77%. Conclusions-There are substantial, clinically relevant differences among published schemes designed to stratify stroke risk in patients with atrial fibrillation. Additional research to identify an optimum scheme for primary prevention and subsequent standardization of recommendations may lead to more uniform selection of patients for anticoagulant prophylaxsis.

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“…45 Warfarin needs to be dose adjusted with regular monitoring to ensure that the patient stays within the recommended therapeutic international normalised ratio (INR) range, making warfarin unacceptable to some patients. 46,47 Warfarin also has interactions with other medications including over-the-counter preparations, foods high in vitamin K and alcohol, which can impact on quality of life, meaning that some patients are reluctant to take warfarin. Recent NICE guidance DG14 48 has recommended coagulometers, devices that allow patients to self-monitor the INR, which is an alternative to regular INR monitoring, although some patients have experienced difficulties gaining access and support for these devices [Diane Eaton, AntiCoagulation Europe (ACE), 2016, personal communication].…”

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confidence: 99%

Screening strategies for atrial fibrillation: a systematic review and cost-effectiveness analysis

Welton

McAleenan

Thom

et al. 2017

Health Technol Assess

122

116

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BackgroundAtrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of thromboembolic events. Anticoagulation therapy to prevent AF-related stroke has been shown to be cost-effective. A national screening programme for AF may prevent AF-related events, but would involve a substantial investment of NHS resources.ObjectivesTo conduct a systematic review of the diagnostic test accuracy (DTA) of screening tests for AF, update a systematic review of comparative studies evaluating screening strategies for AF, develop an economic model to compare the cost-effectiveness of different screening strategies and review observational studies of AF screening to provide inputs to the model.DesignSystematic review, meta-analysis and cost-effectiveness analysis.SettingPrimary care.ParticipantsAdults.InterventionScreening strategies, defined by screening test, age at initial and final screens, screening interval and format of screening {systematic opportunistic screening [individuals offered screening if they consult with their general practitioner (GP)] or systematic population screening (when all eligible individuals are invited to screening)}.Main outcome measuresSensitivity, specificity and diagnostic odds ratios; the odds ratio of detecting new AF cases compared with no screening; and the mean incremental net benefit compared with no screening.Review methodsTwo reviewers screened the search results, extracted data and assessed the risk of bias. A DTA meta-analysis was perfomed, and a decision tree and Markov model was used to evaluate the cost-effectiveness of the screening strategies.ResultsDiagnostic test accuracy depended on the screening test and how it was interpreted. In general, the screening tests identified in our review had high sensitivity (> 0.9). Systematic population and systematic opportunistic screening strategies were found to be similarly effective, with an estimated 170 individuals needed to be screened to detect one additional AF case compared with no screening. Systematic opportunistic screening was more likely to be cost-effective than systematic population screening, as long as the uptake of opportunistic screening observed in randomised controlled trials translates to practice. Modified blood pressure monitors, photoplethysmography or nurse pulse palpation were more likely to be cost-effective than other screening tests. A screening strategy with an initial screening age of 65 years and repeated screens every 5 years until age 80 years was likely to be cost-effective, provided that compliance with treatment does not decline with increasing age.ConclusionsA national screening programme for AF is likely to represent a cost-effective use of resources. Systematic opportunistic screening is more likely to be cost-effective than systematic population screening. Nurse pulse palpation or modified blood pressure monitors would be appropriate screening tests, with confirmation by diagnostic 12-lead electrocardiography interpreted by a trained GP, with referral to a specialist in the case of an unclear diagnosis. Implementation strategies to operationalise uptake of systematic opportunistic screening in primary care should accompany any screening recommendations.LimitationsMany inputs for the economic model relied on a single trial [the Screening for Atrial Fibrillation in the Elderly (SAFE) study] and DTA results were based on a few studies at high risk of bias/of low applicability.Future workComparative studies measuring long-term outcomes of screening strategies and DTA studies for new, emerging technologies and to replicate the results for photoplethysmography and GP interpretation of 12-lead electrocardiography in a screening population.Study registrationThis study is registered as PROSPERO CRD42014013739.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Preference-Based Antithrombotic Therapy in Atrial Fibrillation: Implications for Clinical Decision Making

Cited by 67 publications

References 59 publications

Shared Decision Making in Atrial Fibrillation

Shared Decision Making in Atrial Fibrillation

Comparison of 12 Risk Stratification Schemes to Predict Stroke in Patients With Nonvalvular Atrial Fibrillation

Screening strategies for atrial fibrillation: a systematic review and cost-effectiveness analysis

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