title: Adherence to antithrombotic therapy guidelines improves mortality among elderly patients with atrial fibrillation: insights from the REPOSI study.
abstract: BACKGROUND
  Atrial fibrillation (AF) is associated with a substantial risk of thromboembolism and mortality, significantly reduced by oral anticoagulation. Adherence to guidelines may lower the risks for both all cause and cardiovascular (CV) deaths.
  
  
  METHODS
  Our objective was to evaluate if antithrombotic prophylaxis according to the 2012 European Society of Cardiology (ESC) guidelines is associated to a lower rate of adverse outcomes. Data were obtained from REPOSI; a prospective observational study enrolling inpatients aged ≥65 years. Patients enrolled in 2012 and 2014 discharged with an AF diagnosis were analysed.
  
  
  RESULTS
  Among 2535 patients, 558 (22.0 %) were discharged with a diagnosis of AF. Based on ESC guidelines, 40.9 % of patients were on guideline-adherent thromboprophylaxis, 6.8 % were overtreated, and 52.3 % were undertreated. Logistic analysis showed that increasing age (p = 0.01), heart failure (p = 0.04), coronary artery disease (p = 0.013), peripheral arterial disease (p = 0.03) and concomitant cancer (p = 0.003) were associated with non-adherence to guidelines. Specifically, undertreatment was significantly associated with increasing age (p = 0.001) and cancer (p < 0.001), and inversely associated with HF (p = 0.023). AF patients who were guideline adherent had a lower rate of both all-cause death (p = 0.007) and CV death (p = 0.024) compared to those non-adherent. Kaplan-Meier analysis showed that guideline-adherent patients had a lower cumulative risk for both all-cause (p = 0.002) and CV deaths (p = 0.011). On Cox regression analysis, guideline adherence was independently associated with a lower risk of all-cause and CV deaths (p = 0.019 and p = 0.006).
  
  
  CONCLUSIONS
  Non-adherence to guidelines is highly prevalent among elderly AF patients, despite guideline-adherent treatment being independently associated with lower risk of all-cause and CV deaths. Efforts to improve guideline adherence would lead to better outcomes for elderly AF patients.
authors.affiliation: Institute of Cardiovascular Sciences, City Hospital, University of Birmingham, Birmingham, Dudley Road, B18 7QH, UK. marco.proietti@uniroma1.it.|Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Rome, Italy. marco.proietti@uniroma1.it.
authors.forename: Marco
authors.initials: M
authors.lastname: Proietti
authors.affiliation: Department of Neuroscience, IRCCS, Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Nobili
authors.affiliation: Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Rome, Italy.|Department of Experimental Medicine, Sapienza-University of Rome, Rome, Italy.
authors.forename: Valeria
authors.initials: V
authors.lastname: Raparelli
authors.affiliation: Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Rome, Italy.|Department of Experimental Medicine, Sapienza-University of Rome, Rome, Italy.
authors.forename: Laura
authors.initials: L
authors.lastname: Napoleone
authors.affiliation: IRCCS Fondazione Cà Granda, A. Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.
authors.forename: Pier Mannuccio
authors.initials: PM
authors.lastname: Mannucci
authors.affiliation: Institute of Cardiovascular Sciences, City Hospital, University of Birmingham, Birmingham, Dudley Road, B18 7QH, UK. g.y.h.lip@bham.ac.uk.|Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark. g.y.h.lip@bham.ac.uk.
authors.forename: Gregory Y H
authors.initials: GY
authors.lastname: Lip
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D016009:Chi-Square Distribution; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D019983:Guideline Adherence / Q000639:trends*; D006801:Humans; D007558:Italy; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000639:trends*; D016016:Proportional Hazards Models; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D013923:Thromboembolism / Q000175:diagnosis / Q000401:mortality / Q000517:prevention & control*; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents
keywords: Antithrombotic therapy; Atrial fibrillation; Elderly; Guidelines; Outcomes