Risk stratification and stroke prevention therapy care gaps in Canadian atrial fibrillation patients (from the Co-ordinated National Network to Engage Physicians in the Care and Treatment of Patients With Atrial Fibrillation chart audit).
The objectives of this national chart audit (January to June 2013) of 6,346 patients with atrial fibrillation (AF; ≥18 years without a significant heart valve disorder) from 647 primary care physicians were to (1) describe the frequency of stroke and bleed risk assessments in patients with nonvalvular AF by primary care physicians, including the accuracy of these assessments relative to established predictive indexes; (2) outline contemporary methods of anticoagulation used; and (3) report the time in the therapeutic range among patients prescribed warfarin. An annual stroke risk assessment was not undertaken in 15% and estimated without a formal risk tool in 33%; agreement with CHADS2 score estimation was seen in 87% of patients. Major bleeding risk assessment was not undertaken in 25% and estimated without a formal risk tool in 47%; agreement with HAS-BLED score estimation was observed in 64% with physician overestimation in 26% of patients. Antithrombotic therapy included warfarin (58%), dabigatran (22%), rivaroxaban (14%), and apixaban (<1%). Among warfarin-treated patients, the median international normalized ratio was 2.4 and time in therapeutic range (TTR) was 73%; however, the TTR was <50% in 845 (25%), 50% to 69% in 674 (20%), and ≥70% in 1,827 (55%) patients. In conclusion, we describe a contemporary real-world elderly population with AF at important risk for stroke. There is apparent overestimation of bleeding risk in many patients. Warfarin was the dominant stroke prevention treatment; however, the suggested TTR target was achieved in only 55% of these patients.
Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Ashish D
AD
Patel
Canadian Heart Research Centre, Toronto, Ontario, Canada.
Mary K
MK
Tan
Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Paul
P
Angaran
Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Alan D
AD
Bell
Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Nephrology, Humber River Hospital, Toronto, Ontario, Canada.
Murray
M
Berall
Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
Claudia
C
Bucci
Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; Department of Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.
Andrew M
AM
Demchuk
Department of Medicine, McGill University Health Centre, Hôpital Sacré Coeur de Montréal, Montréal, Quebec, Canada.
Vidal
V
Essebag
Canadian Heart Research Centre, Toronto, Ontario, Canada.
Lianne
L
Goldin
Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
Martin S
MS
Green
Department of Medicine, Université de Montréal, Institut de Cardiologie de Montréal, Montréal, Quebec, Canada.
Jean C
JC
Gregoire
Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Juravinski Henderson Hospital, Hamilton, Ontario, Canada.
Peter L
PL
Gross
Department of Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
Brett
B
Heilbron
Canadian Heart Research Centre, Toronto, Ontario, Canada.
Peter J
PJ
Lin
Department of Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
Krishnan
K
Ramanathan
Department of Medicine, Western University, London, Ontario, Canada.
Allan
A
Skanes
Calgary Foothills Primary Care Network, Calgary, Alberta, Canada.
Bruce H
BH
Wheeler
Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Canadian Heart Research Centre, Toronto, Ontario, Canada. Electronic address: goodmans@chrc.net.
Shaun G
SG
Goodman
D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications*; D001562:Benzimidazoles / Q000627:therapeutic use; D002170:Canada; D000069604:Dabigatran; D006470:Hemorrhage / Q000175:diagnosis / Q000209:etiology; D006801:Humans; D008297:Male; D008485:Medical Audit; D009025:Morpholines / Q000627:therapeutic use; D011237:Predictive Value of Tests; D011320:Primary Health Care; D011720:Pyrazoles / Q000627:therapeutic use; D011728:Pyridones / Q000627:therapeutic use; D018570:Risk Assessment; D000069552:Rivaroxaban; D020521:Stroke / Q000175:diagnosis / Q000209:etiology* / Q000517:prevention & control*; D013876:Thiophenes / Q000627:therapeutic use; D014859:Warfarin / Q000627:therapeutic use*; D015091:beta-Alanine / Q000031:analogs & derivatives / Q000627:therapeutic use
D000925:Anticoagulants; D001562:Benzimidazoles; D009025:Morpholines; D011720:Pyrazoles; D011728:Pyridones; D013876:Thiophenes; D015091:beta-Alanine; C522181:apixaban; D014859:Warfarin; D000069552:Rivaroxaban; D000069604:Dabigatran