Treatment pathways for patients with atrial fibrillation

Abstract

BackgroundAtrial fibrillation (AF) is a common rhythm disorder and the most common chronic arrhythmia. AF is associated with increased morbidity and mortality (1), and, in particular, is a major independent risk factor for stroke (2), particularly in older patients. The prevalence of AF in the UK is more than 12⁄ 1000, but this increases to at least 10% in people aged 85 years and over (3) or to 16% according to recent data (4).Atrial fibrillation represents a challenging arrhythmia. A rational approach to management of the individual case depends on careful assessment of the temporal pattern of the arrhythmia, any associated cardiovascular disease and any particular features suggesting the advisability or risks of specific treatment regimens. The nature of an arrhythmia and of individual patient factors changes over time, requiring a flexible approach to long-term treatment that may be defined only after months or years (5). In particular, key considerations are the use of anticoagulants and ⁄ or antiplatelets as antithrombotic therapy, and the pursuance of a rate-or rhythm-control approach. SUMMARYBackground: Although there has been growing concordance over what constitutes best practice in recent guidelines for treatment of atrial fibrillation (AF), notably regarding anticoagulant use, it remains unclear whether patients are being treated accordingly. Aims: The aims of this study were to explore the pattern of treatment pathways -i.e. how patients are treated over time -for patients with AF, and to test the hypothesis that comparative to patients in lower stroke-risk categories (as measured by CHADS 2 score), patients with higher CHADS 2 scores are less likely to discontinue anticoagulant therapy or, if not started on anticoagulant treatment, more likely to be transferred to anticoagulant therapy, in keeping with guideline recommendations. Setting: A total of 67,857 patients with a diagnosis of AF in practices registered with the General Practice Research Database. Methods: A series of possible treatment pathways were identified, and for each initial treatment, we estimated the probability of treatment change and the average time that a patient newly diagnosed with AF spent on a particular treatment, projected across 5 years and stratified by CHADS 2 score. Results: There was no relationship between CHADS 2 score and maintenance or discontinuation of particular approaches to antithrombotic treatment. While those beginning on antiplatelet therapy were more likely to change treatment than those on anticoagulants (approximately 60% vs. 50% within the first year), as much as one-third of treatment time of all those starting on a therapeutic approach involving anticoagulants featured no use of anticoagulants (either as monotherapy or in combination) over the 5-year period, and whether treatment was discontinued or maintained did not vary by CHADS 2 score. No difference was found in treatment pathways controlling for post-2002 diagnoses as against the whole sample. Conclusions: Although there is more evidence of tr...

Evaluation of practice patterns in the treatment of atrial fibrillation among the commercially insured

“…However, earlier evidence suggested that use of anticoagulants in patients with atrial fibrillation lags behind the use of antiarrhythmic drugs and ablation. As many as 20% to 80% of those at risk for stroke fail to receive recommended anticoagulant therapy, even taking into consideration the proportion of patients who have contraindications 7,[20][21][22][23][24][25][26][27][28] .…”

Patterns of Medications for Atrial Fibrillation Among Older Women: Results From the Australian Longitudinal Study on Women’s Health

“…11 Literature, however, indicates that medication use does not correlate well with the stroke risk. 12 Rather, the use of anticoagulant decreases with increasing stroke risk especially among women and older patients. 13 Women with AF are particularly at increased risk of AF complications such as stroke and death compared to men.…”

Treatment pathways for atrial fibrillation: simplifying the approach to thromboprophylaxis

“…In this issue of the International Journal of Clinical Practice, Hodgkinson et al. (10) report a retrospective longitudinal treatment analysis of a very large (but essentially contemporary) cohort of ∼68,000 AF patients from a general practice database in the United Kingdom (9). Treatment with VKAs was analyzed according to the stroke risk, as measured by CHADS 2 score (Congestive heart failure, Hypertension, Age > 75 years, Diabetes mellitus, previous Stroke/TIA), and there was no relationship between maintenance or discontinuation of VKAs during 5‐year follow‐up and the baseline risk of stroke.…”

“…Hodgkinson et al. (10) also reported that patients with CHADS 2 = 0 and no thromboprophylaxis at baseline received such treatment for almost 70% of treatment time. Assuming that most of them initially had so‐called ‘lone’ AF, it should be emphasised that apparently lone AF might be associated with subclinical atherosclerosis or other conditions predisposing to stroke, which necessitates a regular reassessment of lone AF patients (15), and even amongst lone AF patients, the development of new cardiac diseases and older age predicted adverse outcomes, including thromboembolism (16).…”