Abstract
BackgroundIn patients with non-valvular atrial fibrillation (NVAF) at high risk for stroke guidelines consistently recommend long-term oral anticoagulation (OAC) with a vitamin K antagonist. However recommendations remain ambiguous in respect to the precise OAC initiation regimens. Based on the clinical observation, that the initiation of OAC for NVAF varies considerably in daily practice, we aimed to assess the current practice in Switzerland.MethodsCross-sectional survey of randomly selected general practitioners, internists and cardiologists from different health care settings in an urban Swiss region that covers 1.4 million inhabitants. The main outcome measures were the preferred antithrombotic initiation regimen and long-term treatment in patients with newly diagnosed NVAF at high risk for stroke.ResultsWe received 226 out of 388 (58.2%) surveys. Compared to physicians working in a hospital setting (33.6% of respondents) physicians in ambulatory care reported more years of experience and claimed lower-use (never or seldom) of guidelines in general (47.6 vs. 12.2%). Regarding long-term thromboembolic prophylaxis 93.7% of all responders followed current recommendation by choosing an OAC. When focussing on guideline-consistent correct OAC initiation (either low-dose initial OAC or a combination of LMWH and OAC) adherence dropped to 60.6% with hospital physicians demonstrating a significantly higher use of guideline-conform OAC regimens (79.7 vs. 51.0%). Medical speciality in non-hospital physicians was not related to correct guideline-use. Hospital setting remained independently associated with a guideline-conform OAC initiation regimen (OR 2.8, p = 0.023) when controlled for medical speciality, physicians' characteristics and clinical experience. Problems when starting an anticoagulation treatment were seldom reported (never or seldom accounting for 94.1% of all responses).ConclusionsThe guideline adherence with respect to OAC initiation regimens in NVAF was significantly lower when compared to long-term treatment and health care setting rather than medical speciality explained guideline-conform OAC initiation. The majority of the physicians did not consider the initiation of anticoagulation to be a major obstacle in outpatient care.
Highlights
In patients with non-valvular atrial fibrillation (NVAF) at high risk for stroke guidelines consistently recommend long-term oral anticoagulation (OAC) with a vitamin K antagonist
Responding rates between the various specialists in ambulatory care and hospital physicians ranged between 47% for general practitioners (GP) and 65% for general internists (GI)
Most of the hospital physicians were specialist in internal medicine (72.4%), which explained the overall high proportion of general internists with the remaining being cardiologists (25%) and general practitioners (2.6%)
Summary
In patients with non-valvular atrial fibrillation (NVAF) at high risk for stroke guidelines consistently recommend long-term oral anticoagulation (OAC) with a vitamin K antagonist. Even though actual guidelines provide clear-cut recommendations regarding the long-term stroke prophylaxis in non-valvular atrial fibrillation (NVAF), they tend to remain somewhat ambiguous with respect to the initiation regimens for oral anticoagulation (OAC) [1,2]. In clinical practice many physicians in Switzerland still tend to a concomitant use of a low-molecular-weight heparin (LMWH) when starting an anticoagulation treatment. Based on the clinical observation, that the initiation regimens for OAC in outpatients with NVAF vary considerably, we conducted a survey aimed to assess current treatment practice in Switzerland. The purpose of our study was to assess the current practice regarding the initiation of OAC for NVAF in Switzerland, to determine the variables that influence guideline consistent treatment and to inquire whether initiation of anticoagulation is generally considered a clinical problem, as the latter might have an impact on the choice of e.g. a novel antithrombotic drug
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