Stroke prevention in patients with non-valvular atrial fibrillation: a current community perspective

Balancing risk versus benefit: the elderly patient's perspective on warfarin therapy

Warfarin therapy is underused in the target at-risk elderly population. Clinicians perceive that older patients are reluctant to use this therapy, however the perspective of patients or their carers has yet to be explored.

Objective:

To explore in-depth the perspectives of elderly patients and/or their carers regarding the use of warfarin therapy.

Method:

A qualitative study, using semi-structured group interviews was undertaken. The audio-taped discussions were transcribed verbatim, then thematically analysed to identify emergent themes. Group discussions were conducted at a major Sydney teaching hospital, over a 2-month period. Individuals aged 65 years or older (and/or their carers) who were using long-term (6 months) warfarin therapy were recruited by voluntary response to study flyers.

Results:

17 patients and carers (mean age 77.2 SD=7.5 years) participated in one of two focus groups. Five core themes emerged regarding warfarin therapy: inadequate knowledge and understanding about it, patients/carers variable experience of information provision, cycle of reactions to being on it, issues in its practical management, and the spectrum of experiences with it. Overall, participants were very accepting of the therapy, describing a high level of compliance, despite initial fears and anxieties, and a relative lack of knowledge. Patients felt somewhat abandoned in their management of warfarin due to the lack of ongoing support services in the community, and inadequate information provision.

Conclusions:

Elderly patients and their carers appear to be quite accepting of warfarin therapy, in contrast to the perceptions of health care professionals. More effort is needed, however, in terms of information provision, particularly in the form of community-based services, to assist patients in the long-term management of warfarin.

Management of warfarin in atrial fibrillation: views of health professionals, older patients and their carers

OBJECTIVE

To identify the views of health professionals, patients and their carers on strategies to improve the use and management of warfarin in older patients with atrial fibrillation.

DESIGN

Qualitative study based on analysis of group interviews.

SETTING

A major metropolitan teaching hospital, from 1 March to 30 April 2003.

PARTICIPANTS

14 patients (>/= 65 years) with established atrial fibrillation and taking warfarin, three carers, 12 specialists, eight general practitioners, six community pharmacists, nine hospital pharmacists, and 11 nurses volunteered in response to flyers promoting the study.

RESULTS

Suggested strategies to improve warfarin management targeted support services for GPs and patients. Hospital-based clinicians felt that dissemination of trial evidence to GPs to support treatment recommendations is required, and that GPs need to enlist allied health professionals in the management of patients taking warfarin. GPs preferred access to practical advice from expert colleagues on the day-to-day management. Patients requested more information about warfarin therapy, as access to information is inadequate, particularly from primary sources (GPs, community pharmacists). Verbal and written information are equally important, but a single counselling session or supply of a booklet was viewed as inadequate. Participants identified various interventions for all levels of warfarin management; from the collective input, a framework for management strategies was developed.

CONCLUSIONS

Health professionals and patients require more customised information to support warfarin use and management.

Non-valvular atrial fibrillation and stroke: Implications for nursing practice and therapeutics

Atrial fibrillation (AF) is the most common sustained cardiac rhythm disturbance and is increasing in prevalence due to the ageing of the population, and rates of chronic heart failure. Haemodynamic compromise and thromboembolic events are responsible for significant morbidity and mortality in Australian communities. Non-valvular AF is a significant predictor for both a higher incidence of stroke and increased mortality. Stroke affects approximately 40,000 Australians every year and is Australia's third largest killer after cancer and heart disease. The burden of illness associated with AF, the potential to decrease the risk of stroke and other embolic events by thromboprophylaxis and the implications of this strategy for nursing care and patient education, determine AF as a critical element of nursing practice and research. A review of the literature was undertaken of the CINAHL, Medline, EMBASE and Cochrane Databases from 1966 until September 2002 focussing on management of atrial fibrillation to prevent thrombotic events. This review article presents key elements of this literature review and the implications for nursing practice.

Risk factors for ischemic stroke: Dubbo Study of the elderly

BACKGROUND AND PURPOSE

One in 10 deaths in Australia is due to stroke. The predictors of ischemic stroke have not been well defined, although hypertension, atrial fibrillation, and previous stroke have been consistently reported. We report on 98 months' follow-up in a prospective study of cardiovascular disease in the Australian elderly, the Dubbo Study.

METHODS

The cohort, first examined in 1988, was composed of 2805 men and women 60 years and older. The prediction of ischemic stroke by potential risk factors was examined in a Cox proportional hazards model, after linkage to hospital and death records.

RESULTS

Three hundred six men and women manifested an ischemic stroke event (ICD-9-CM 433 to 437), and 95 subjects suffered a fatal stroke event. In the multivariate model, the significant independent predictors of stroke were advancing age, female sex (48% lower risk), being married (30% lower risk), prior history of stroke (227% higher risk), use of antihypertensive drugs (37% higher risk), belonging to the highest category of blood pressure reading (67% higher risk), presence of atrial fibrillation (58% higher risk), HDL cholesterol (36% lower risk for each 1-mmol/L increment), impaired peak expiratory flow (77% higher risk for tertile I than for tertile III), physical disability (59% higher risk), and depression score (41% higher risk for tertile III than for tertile I).

CONCLUSIONS

These findings suggest that morbidity and mortality associated with ischemic stroke can be predicted by various clinical indicators, some of which may be amenable to intervention. The matters of impaired peak expiratory flow, depression score, and ischemic stroke require further study.

Review of antithrombotic drug usage in atrial fibrillation

BACKGROUND

The important prophylactic role of antithrombotic therapy against stroke in nonrheumatic atrial fibrillation (AF) has been clearly established in recent clinical trials. There have been suggestions, however, that practice has been slow to change in light of the findings of these trials.

AIM

To review cases of AF at the major teaching hospital in Tasmania, Australia, to determine whether the recommendations from the results of the trials had been translated into local clinical practice.

METHODS

A retrospective review of the medical records for consecutive patients who had AF documented on ECG between 1 January and 30 June 1997 was performed. An extensive range of demographic and clinical variables were recorded for patients with chronic or paroxysmal nonrheumatic AF. These included antithrombotic and other drug therapy at admission and discharge from hospital care, risk factors for stroke, contraindications to antithrombotic use, and incidents of ischaemic stroke and bleeding complications that occurred during the period from January 1996 up to 3 months after the hospital admission that was studied.

RESULTS

The 228 patients included in the study had a mean (+/-SD) age of 75.3+/-10.9 years. Sixty-eight per cent had chronic AF and 32% had paroxysmal AF. According to two risk stratification criteria, 91% and 86% of the patients with previously diagnosed chronic or paroxysmal nonrheumatic AF (n=186) had a high risk of developing stroke at the time of admission to hospital care. However, less than one-third of these patients were receiving warfarin (or warfarin plus aspirin), with almost another one-third receiving no antithrombotic agent. Of those who were not taking warfarin, about 60% had no apparent contraindication to warfarin. For those high risk patients who had a possible contraindication to warfarin, only approximately one-third had been prescribed aspirin. Only a slight increase in the use of antithrombotic agents had occurred by the time of discharge from hospital care. The majority of international normalized ratio (INR) values on admission for patients who had been taking warfarin were subtherapeutic. The estimated annual incidence of bleeding complications in patients taking warfarin was 15.0% overall, 5.0% for major bleeds and 3.8% for intracranial haemorrhages.

CONCLUSIONS

While a number of published trials have demonstrated that antithrombotic agents confer substantial protection against stroke in patients with nonrheumatic AF, the drugs were underused in our setting. There is a need to improve antithrombotic use and to develop a better monitoring system for the provision of safer and more effective antithrombotic therapy.