Atrial Fibrillation Treatment Guidelines Research Articles

Outpatient Prescription Practices in Patients with Atrial Fibrillation (From the NCDR PINNACLE Registry)

This study sought to evaluate inappropriate prescribing practices in an atrial fibrillation (AF) population, as outlined by the 2016 ACC/AHA Clinical Performance and Quality Measures for Adults with Atrial Fibrillation or Atrial Flutter document. The 2016 AF quality measures document specified medications to avoid in certain AF populations, including aspirin and anticoagulant combination therapy in patients without cardiovascular disease, and non-dihydropyridine calcium channel blockers in patients with reduced ejection fraction. Using data from the NCDR PINNACLE registry, a national outpatient cardiology practice registry, we assessed rates of inappropriate prescription of two types of medications among AF outpatients from 5/1/2008-5/1/2016. Overall rates of inappropriate prescription and variation by practice were calculated. Patient and practice factors associated with inappropriate prescription were assessed in adjusted analyses. A total of 107,759 of 658,250 (16.4%) patients without cardiovascular disease were inappropriately prescribed an antiplatelet and anticoagulant together, and 5,731 of 150,079 (3.8%) patients with reduced ejection fraction were inappropriately prescribed a non-dihydropyridine calcium channel blocker. Overall, 14.8% of AF patients were prescribed medications that were not recommended. Both patient and practice factors were associated with inappropriate prescribing, and the adjusted practice-level median odds ratio for inappropriate prescription was 1.70 (95% CI: 1.61-1.82), indicating a 70% likelihood that 2 random practices would treat identical AF patients differently. In a large registry of AF patients treated in cardiology practices, overall rates of inappropriate prescription practices, as defined by the 2016 AF quality measures, were relatively low, but significant practice variation was present.

Dabigatran-Induced Nephropathy and Gastrointestinal Bleeding and Its Successful Treatment with Idarucizumab: A Case Report.

Recently, the atrial fibrillation treatment guidelines have been updated to now recommend Non-vitamin K antagonist oral anticoagulants (NOACs) as the preferred alternative to warfarin for systemic embolism and stroke prevention in patients with non-valvular atrial fibrillation. NOACs have major pharmacologic advantages over warfarin, although the most common complications are gastrointestinal bleeding and NOAC-induced nephropathy within 6 weeks after starting therapy, as several recent case-reports stated. We are reporting for the first time a chronic delayed adverse reaction (regularly reported to Authorities) observed in an 82-year-old woman 27 months after starting dabigatran (110 mg twice a day), characterized by concomitant gastrointestinal bleeding and nephropathy. Idarucizumab administration immediately improved both bleeding and renal parameters. Moreover, we are going to highlight the importance of the compliance, the adherence to the therapeutic plan and the supervision of the Hospital Pharmacy on drug prescriptions. In fact in our case, dabigatran was firstly prescribed by the neurologist and delivered by the hospital pharmacy, but the patient continued the treatment for 27 months, prescribed by general practitioner without any laboratory control. This lack of supervision certainly contributed to the onset of the adverse reaction reported.

Does the choice of drug in pharmacologic cardioversion correlate with the guidelines? Systematic review

Atrial fibrillation (AF) is the most common sustained arrhythmia, the most common cause of supraventricular tachycardia in the global population and the most common arrhythmia requiring treatment in an emergency department. To systematically review recent literature and quantify the correlation between the choice of pharmacological cardioversion (PCV) drug and the national or international guidelines. A systematic review was performed in accordance with the PRISMA statement methodology. The PubMed search engine was used to search for articles regardless of type or language and published in the last 6 years (May 2014-May 2020). In addition, we searched for AF guidelines and recommendations published online by cardiology and emergency medicine societies. The search strategy returned a total of 2615 abstracts. A total of 2598 full texts were screened; 2540 full texts were excluded with reasons and 58 articles from 32 countries were included in the analysis. In 17 of the 58 articles (29%), we noted discrepancies with the AF guidelines, specifically regarding the PCV drug used, the patients' comorbidities and the contraindications associated with the PCV drug. The most common clinical situation for the use of a contraindicated drug was when ibutilide was administered to patients with heart failure. The analysis did not reveal any statistically significant correlations, although the correlation between the sample size and guideline adherence was close to statistical significance (p < 0.06). Our systematic analysis revealed substantial non-adherence to AF treatment guidelines.

Association of Multimorbidity with Cardiovascular Endpoints and Treatment Effectiveness in Patients 75 Years and Older with Atrial Fibrillation

BackgroundThe burden imposed by multimorbidity on outcomes and on the effectiveness of atrial fibrillation therapies in elderly adults with atrial fibrillation is unknown. MethodsPatients with nonvalvular atrial fibrillation ages ≥75 years in the MarketScan Medicare Supplemental database from 2007-2015. Prevalence of 14 chronic conditions at the time of atrial fibrillation diagnosis were obtained and classified as cardiometabolic or noncardiometabolic. Cox regression estimated the associations of the number and type of conditions with stroke, severe bleeding, and heart failure hospitalizations. Tests for interaction were assessed between atrial fibrillation treatments and multimorbidity. ResultsAmong 275,617 patients with atrial fibrillation (mean age 83 years, 51% women), the mean (SD) number of conditions per participant was 3.0 (2.1). Over a mean follow-up of 23 months, 7814 strokes, 13,622 severe bleeds, and 19,252 heart failure events occurred. After adjustment, an increase in the number of cardiometabolic conditions was associated with greater risk of stroke (hazard ratio [HR] 1.07; 95% confidence interval [CI], 1.05-1.10), severe bleeding (HR 1.09; 95% CI, 1.07-1.11), and heart failure (HR 1.19, 95% CI, 1.18-1.20). In contrast, number of noncardiometabolic conditions had weak or null associations with risk of cardiovascular endpoints. Overall, the effectiveness of atrial fibrillation treatment on stroke and heart failure were similar across multimorbidity status, but bleeding risk associated with atrial fibrillation treatments was higher in patients with overall and subgroup multimorbidity. ConclusionCardiometabolic multimorbidity was associated with worse outcomes and modified bleeding risk in atrial fibrillation patients. These findings underscore the impact of cardiometabolic conditions on atrial fibrillation outcomes and highlights the need to incorporate multimorbidity management in atrial fibrillation treatment guidelines.

Surgical isolation of the left atrial appendage: A new technique

Atrial fibrillation (AF) is a dismal arrhythmia. Thirty to forty percent of patients with mitral valve diseases have chronic AF at the time of surgery with increased incidence of morbidity and mortality postoperatively. Thromboembolism is well known among patients with AF despite adequate anticoagulation therapy and the left atrial appendage (LAA) has been proposed to be its main source. In 2014 LAA has been considered for surgical closure in the AF treatment guidelines. Several surgical techniques have been adopted to exclude LAA during surgery and none of them proved to be completely effective. The main goal of our described new technique is to completely separate the LAA from general circulation avoiding failures of other techniques.

Comparative Efficacy and Usefulness of Acebutolol and Diltiazem for the Prevention of Atrial Fibrillation during Perioperative Time in Patients Undergoing Pulmonary Resection

Postthoracic surgery atrial fibrillation (AF) is the most frequently occurring arrhythmia. Strategies for preventing AF have been amply evaluated, but currently there are no clearly defined guidelines for treatment of AF after thoracic surgery. The study was prospective and randomized controlled trial. Acebutolol and diltiazem versus placebo were compared, among 117 patients postpneumonectomy or lobectomy at the Thoracosurgery Clinic, Poznan University of Medical Sciences in Poland. Patients who were enrolled in the study were randomly assigned to one of the three groups: those who received acebutolol (Group 1) or diltiazem (Group 2) and compared with patients without antiarrhythmic drugs (Group 0). Each group consisted of 39 patients. The patients were continuously monitored postoperatively with 24 ECG (Holter monitor) in the intensive care unit. In patients receiving acebutolol AF occurred in 5% compared with 23% of patients receiving diltiazem and 20% of patients receiving placebo (difference not statistically significant). Acebutolol and diltiazem appear to have been non-effective for the treatment or prevention of AF. Side effects were mild. In comparison to diltiazem, however, acebutolol had a beneficial effect on the circulatory system. Patients who had received acebutolol proved to have had fewer tachycardia episodes and supraventricular ectopy during the postoperative period. It seems that acebutolol can be useful, especially in patients with sympathetic activity dominance.

Costs and clinical consequences of suboptimal atrial fibrillation management

Atrial fibrillation (AF) places a considerable burden on the US health care system, society, and individual patients due to its associated morbidity, mortality, and reduced health-related quality of life. AF increases the risk of stroke, which often results in lengthy hospital stays, increased disability, and long-term care, all of which impact medical costs. An expected increase in the prevalence of AF and incidence of AF-related stroke underscores the need for optimal management of this disorder. Although AF treatment strategies have been proven effective in clinical trials, data show that patients still receive suboptimal treatment. Adherence to AF treatment guidelines will help to optimize treatment and reduce costs due to AF-associated events; new treatments for AF show promise for future reductions in disease and cost burden due to improved tolerability profiles. Additional research is necessary to compare treatment costs and outcomes of new versus existing agents; an immediate effort to optimize treatment based on existing evidence and guidelines is critical to reducing the burden of AF.

Abstract P61: Weighing More than the Risks: Cardiologists' Prescription of Warfarin for Atrial Fibrillation Patients

Introduction: Prior research indicates underprescription of warfarin to reduce cardioembolism for eligible atrial fibrillation (AF) patients. Physicians' reluctance to prescribe warfarin for AF patients may be due to perceived increased risk of bleeding or underestimation of stroke risk. However, other factors may influence decisions for warfarin treatment. The purpose of the present study was to develop an in-depth understanding of the cardiologist's decision making process for warfarin anticoagulation and the management of AF. Methods: Qualitative in-depth interviews were conducted with 16 (14 male) cardiologists in a large Midwestern cardiology practice affiliated with an urban hospital. Interviews ranged from 15-35 minutes, culminating in nearly 200 pages of transcripts, and took place in person (n=6) at the hospital or over the telephone (n=10). On average, participants had 13 years of experience in treating patients and all had experience with AF patients who had excessive bleeds and/or strokes within the past 12 months. Interviews were conducted until thematic saturation occurred. Results: Descriptive content analysis found that cardiologists reported consideration of a range of clinical factors: rate and rhythm control, CHADS 2 score, patient co-morbidities, and other prescribed medications in their decision to aggressively treat according to accepted AF treatment guidelines. Additionally, their decision also considered more subjective factors such as the likelihood a patient would comply with a complex therapy and knowledge of patients' drug and alcohol use. “You have to risk profile them individually and go from there” was a recurrent observation. Conclusions: The decision making process used by cardiologists in determining warfarin anticoagulation in the treatment of AF is complex. The cardiologist considers a range of factors when prescribing warfarin beyond the clinical risks including more subjective lifestyle and cultural issues. When these other unmeasurable factors, such as the burden of treatment and lifestyle, are entered into the equation by cardiologists, anticoagulation may be less appealing, regardless of actual clinical risk.

Bleeding While Starting Anticoagulation for Thromboembolism Prophylaxis in Elderly Patients With Atrial Fibrillation

Growing old is like being increasingly penalized for a crime you haven’t committed. — —Anthony Powell, Temporary Kings Anticoagulation therapy for thromboembolism prophylaxis in patients with atrial fibrillation (AF) is based on quality information derived from numerous randomized controlled trials but continues to be a conundrum for many physicians. The AF treatment guidelines have been revised recently,1 but new information is emerging at such a rapid rate that it is hard to imagine how the guideline process can keep up with the pace. In this issue of the journal, there is new and rather startling information derived from careful observation of the initiation of warfarin therapy in a cohort of elderly patients with AF.2 Several aspects of this study deserve emphasis. Article p 2689 The subjects in the cohort of Hylek et al2 possess some unique characteristics. The obvious one is the age of the patients. All were aged ≥65 years. It is equally notable that none of them had been on warfarin during the preceding year. A substantial proportion of women were included in the cohort. Among those aged ≥80 years, 55% were women. It is also notable that the duration of follow-up was restricted to the first year of warfarin therapy. The most obvious finding to be emphasized is the high proportion of serious bleeding incidents. The reported amount of major bleeding during use of vitamin K antagonists over nearly 2 decades has varied (see Table 42). There is, however, a discernible pattern over time. In general, less major bleeding was reported in older studies than in recent studies. A pooled analysis of the original major randomized controlled trials of anticoagulation for thromboembolism prophylaxis in AF patients reported an annual rate of major hemorrhage of 1.3% in 1994.3 However, it is rare that …