Utilisation of antithrombotic therapy for stroke prevention in atrial fibrillation in a Sydney hospital: then and now

Abstract

Whilst there have been temporal improvements in the overall utilisation of antithrombotic therapy, including warfarin, there are still significant gaps in the translation of evidence from clinical trials to clinical practice. Further sustainable intervention is warranted to help apply treatment recommendations to the target population.

Underutilization of warfarin for stroke prophylaxis in patients with atrial fibrillation or atrial flutter in Korea

“…We found that age !80 years and female sex were strong predictors of WU, which is in accord with previous studies [23,38,39]. Gage et al [23] conducted chart reviews of 597 Medicare beneficiaries from Missouri hospitals from 1993 to 1996 and identified advanced age as a WU factor, in addition to female gender and rural residency.…”

Pharmacotherapy in the ageing patient: The impact of age per se (A review)

“…A total of 22 studies were identified (Table 1): nine studies pertained to hospital settings (Bajorek et al, 2002;Dudley et al, 2002;Peake et al, 2003;Tran et al, 2004;Avezum et al, 2005;Friberg et al, 2006;Perera et al, 2009;Wright et al, 2009;Bajorek and Ren, 2012); four studies were based in general practice (Simpson et al, 2005;DeWilde et al, 2006;Leizorovicz et al, 2007;; and three studies utilised disease-specific databases (e.g. disease-specific registries) (Woodard et al, 2003;Alibhai et al, 2004;Gladstone et al, 2009).…”

“…Studies have reported the underutilisation of diuretics (Hajjar et al, 2002), ␤-blockers (Dudley et al, 2002;Hajjar et al, 2002;Sloane et al, 2004;Tran et al, 2004;Avezum et al, 2005), statins (Avezum et al, 2005), angiotensin converting enzyme inhibitors (Sloane et al, 2004), aspirin (Dudley et al, 2002;Wright et al, 2009), antidepressants (Hanlon et al, 2011), calcium supplements (Sloane et al, 2004), and chemotherapy (Peake et al, 2003;Woodard et al, 2003), 8 studies specifically reported the underutilisation of warfarin in older patients (Bajorek et al, 2002;Simpson et al, 2005;Waldo et al, 2005;Leizorovicz et al, 2007;Gladstone et al, 2009;Perera et al, 2009;Bajorek and Ren, 2012). These studies reported that 15-21% of atrial fibrillation patients did not receive any anticoagulation therapy (Waldo et al, 2005;Gladstone et al, 2009), despite being at high risk of stroke and guideline recommendation, and in the absence of any contraindication to the therapy (Friberg et al, 2006;Gladstone et al, 2009; • In frail patients (older than non-frail patients), the likelihood to receive warfarin on hospitalisation and discharge from hospital decreased by 2.9 times (95% CI 1.5-6.0) and 8.6 times (95% CI 4.3-17.5) compared to non-frail patients Gladstone et al (2009) Analysis of data from a prospective database of stroke patients [•] • 39% of the AF patients (mean age 77 years) with a previous ischaemic stroke were using warfarin with subtherapeutic normalised ratio, • 15% were not using any antithrombotic medication Analysis of patient data from computerised medical records of general practitioners Bajorek and Ren, 2012).…”

“…These studies reported that 15-21% of atrial fibrillation patients did not receive any anticoagulation therapy (Waldo et al, 2005;Gladstone et al, 2009), despite being at high risk of stroke and guideline recommendation, and in the absence of any contraindication to the therapy (Friberg et al, 2006;Gladstone et al, 2009; • In frail patients (older than non-frail patients), the likelihood to receive warfarin on hospitalisation and discharge from hospital decreased by 2.9 times (95% CI 1.5-6.0) and 8.6 times (95% CI 4.3-17.5) compared to non-frail patients Gladstone et al (2009) Analysis of data from a prospective database of stroke patients [•] • 39% of the AF patients (mean age 77 years) with a previous ischaemic stroke were using warfarin with subtherapeutic normalised ratio, • 15% were not using any antithrombotic medication Analysis of patient data from computerised medical records of general practitioners Bajorek and Ren, 2012). Patients aged 80 years or more (compared to younger counter-parts) were approximately 5 times less likely to receive warfarin therapy (Bajorek et al 2002;DeWilde et al, 2006).…”

“…Among all the studies from tier 1, 11 identified that the chronological age of a patient was an important factor affecting clinical decision-making (Bajorek et al, 2002;Dudley et al 2002;Hajjar et al, 2002;Peake et al, 2003;Woodard et al, 2003;Tran et al 2004;Avezum et al, 2005;Friberg et al, 2006;Harries et al, 2007;Kievit et al, 2010). The cut-off age influencing warfarin utilisation in older patients has ranged between 75 and 85 years (Bajorek et al, 2002;Waldo et al, 2005;DeWilde et al, 2006;Friberg et al, 2006;Bajorek and Ren, 2012). Being over the age of 75 years also decreases the likelihood of receiving thrombolysis and secondary prevention with aspirin and ␤-blockers following acute myocardial infarction (Dudley et al, 2002).…”