MANAGEMENT OF PATIENTS WITH ATRIAL FIBRILLATION BY FAMILY MEDICINE GROUPS IN QUÉBEC: INSIGHTS FROM THE I-FACILITER STUDY

Abstract

During the last five years, the management of patients with atrial fibrillation (AF) has rapidly evolved with introduction of the novel oral anticoagulants (NOAC)s. The Canadian Cardiovascular Society (CCS) has issued recent guidelines to facilitate appropriate anticoagulation (AC) of patients with AF. The awareness and application of these CCS AC guidelines by family medicine groups (FMG) have not yet been evaluated in Québec. We aim to evaluate AC management by FMG in Québec. In 2014, we completed a cross-sectional study of patients with AF seen at 15 FMGs in 6 Québec regions. We extracted data on baseline characteristics, AC therapy, and contra-indications. Risk of major bleeding, history of major bleeding and unreliable compliance to AC were considered valid contra-indications. There were 431 patients with 52% females. The mean age was 77.3±10.4 years. The median CHADS2 score and HASBLED score were 1.3 and 1.7, respectively. Thirty percent of patients had diabetes mellitus, 32% had heart failure, 76% were hypertensive, and 17% had prior cerebro-vascular disease. Ninety-nine percent of these patients should be anticoagulated according to the CCS guidelines 2014 (≥ 65 years or CHADS2 ≥ 1). Most patients were anticoagulated (93.1%) with use of warfarin (65%) and NOACs (28.1%). Aspirin (ASA) was used in combination with warfarin in 15.8% and with NOACs in 4.6% of patients. Five percent of patients received only ASA, and 1.8% of patients did not receive any antiplatelet or AC. Excluding contra-indications and patients' refusal, most patients were appropriately anticoagulated with 97.3% in patients age ≥65 years and 97.2% in patients with CHADS2 ≥1. The majority of patients were referred to at least one specialist for AF management (88%) with 84% evaluated by a cardiologist. Adjustment of warfarin were undertaken by the FMG (52.1%), warfarin clinics (37.5%), and pharmacies (10.4%). We noted important regional differences in referral practices (cardiologists' referral varied from 48% to 100%) and warfarin's adjustment (by FMG from 2% to 100%). Although most patients with AF were appropriately anticoagulated, we noted that primary care of patients with AF could be further improved by decreasing the combination of ASA and AC, and increasing the proportion of AC follow-up at the FMGs. Further knowledge translation initiatives should be undertaken to disseminate the CCS 2014 AC guidelines to facilitate optimal initiation and follow-up of AC by the FMGs in Québec.