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Farinha JM, Jones ID, Lip GYH. Optimizing adherence and persistence to non-vitamin K antagonist oral anticoagulant therapy in atrial fibrillation. Eur Heart J Suppl 2022; 24:A42-A55. [PMID: 35185408 PMCID: PMC8850710 DOI: 10.1093/eurheartj/suab152] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke, which can be prevented by the use of oral anticoagulation. Although non-vitamin K antagonist oral anticoagulants (NOACs) have become the first choice for stroke prevention in the majority of patients with non-valvular AF, adherence and persistence to these medications remain suboptimal, which may translate into poor health outcomes and increased healthcare costs. Factors influencing adherence and persistence have been suggested to be patient-related, physician-related, and healthcare system-related. In this review, we discuss factors influencing patient adherence and persistence to NOACs and possible problem solving strategies, especially involving an integrated care management, aiming for the improvement in patient outcomes and treatment satisfaction.
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Affiliation(s)
- José Maria Farinha
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Ian D Jones
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- School of Nursing and Allied Health, Liverpool John Moores University, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Moudallel S, van den Bemt BJF, Zwikker H, de Veer A, Rydant S, Dijk LV, Steurbaut S. Association of conflicting information from healthcare providers and poor shared decision making with suboptimal adherence in direct oral anticoagulant treatment: A cross-sectional study in patients with atrial fibrillation. PATIENT EDUCATION AND COUNSELING 2021; 104:155-162. [PMID: 32622691 DOI: 10.1016/j.pec.2020.06.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To assess direct oral anticoagulant (DOAC) adherence and to determine possible determinants for suboptimal adherence in Dutch patients with atrial fibrillation (AF). METHODS Cross-sectional study of DOAC users who completed a self-reported questionnaire. Adherence was measured with Morisky8-item Medication Adherence Scale (MMAS-8). Logistic regression analysis was conducted to investigate determinants affecting adherence. RESULTS 398 DOAC users completed the questionnaire (mean age 70.6 ± 9.2years). Approximately one in four patients had suboptimal adherence (MMAS-8 < 8). Multivariable analysis showed that patients who felt to have received conflicting information about the treatment, patients with higher educational level and patients who were not sufficiently involved in the treatment choice had a higher odds of suboptimal adherence. CONCLUSION DOAC adherence was suboptimal. Conflicting information received from different healthcare providers (HCPs), lack of shared decision making and the patients' educational level were determinants negatively affecting DOAC adherence. PRACTICE IMPLICATIONS Efforts towards identifying suboptimally adherent DOAC patients are needed since they are at higher risk to develop thromboembolic events. Adherence counselling should be systematically and repeatedly encouraged and shared decision making should become more mainstream. Moreover, reinforced education of both patients and HCPs combined with interprofessional collaboration are potential solutions to prevent knowledge gaps and communication of conflicting information.
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Affiliation(s)
- Souad Moudallel
- Vrije Universiteit Brussel, Faculty of Medicine and Pharmacy, Centre for Pharmaceutical Research (CePhar), Brussels, Belgium; Department of Clinical Pharmacology and Pharmacotherapy, Universitair Ziekenhuis (UZ) Brussel, Brussels, Belgium.
| | - Bart J F van den Bemt
- Department of Rheumatology and Pharmacy, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Hanneke Zwikker
- Dutch Institute for Rational Use of Medicine (IVM), Utrecht, the Netherlands
| | - Anne de Veer
- Department of Cardiology, St-Antonius Hospital, Nieuwegein, the Netherlands
| | - Silas Rydant
- Vrije Universiteit Brussel, Faculty of Medicine and Pharmacy, Centre for Pharmaceutical Research (CePhar), Brussels, Belgium; KAVA, Royal Pharmaceutical Society of Antwerp, Antwerp, Belgium
| | - Liset van Dijk
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Stephane Steurbaut
- Vrije Universiteit Brussel, Faculty of Medicine and Pharmacy, Centre for Pharmaceutical Research (CePhar), Brussels, Belgium; Department of Clinical Pharmacology and Pharmacotherapy, Universitair Ziekenhuis (UZ) Brussel, Brussels, Belgium
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Noguera-Mas J, Novoa-Parra CD, Torres-Banyuls MJ. Knowledge of ambulatory patients with atrial fibrillation about the oral anticoagulants that they use. Med Clin (Barc) 2020; 157:144-146. [PMID: 32838991 DOI: 10.1016/j.medcli.2020.06.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/04/2020] [Accepted: 06/06/2020] [Indexed: 11/15/2022]
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Runev N, Potpara T, Naydenov S, Vladimirova A, Georgieva G, Manov E. Physicians' Perceptions of Their Patients' Attitude and Knowledge of Long-Term Oral Anticoagulant Therapy in Bulgaria. ACTA ACUST UNITED AC 2019; 55:medicina55070313. [PMID: 31248007 PMCID: PMC6681397 DOI: 10.3390/medicina55070313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/17/2019] [Accepted: 06/21/2019] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Oral anticoagulation (OAC) is widely used in daily clinical practice worldwide for various indications. We aimed to explore the perception of Bulgarian clinicians about their patients' attitude and knowledge of long-term OAC, prescribed for atrial fibrillation (AF) and/or known deep venous thrombosis (DVT)/pulmonary embolism (PE). Materials and Methods: We performed a cross-sectional study that involved 226 specialists: 187 (82.7%) cardiologists, 23 (10.2%) neurologists, and 16 (7.1%) vascular surgeons. They filled in a questionnaire, specially designed for our study, answering various questions regarding OAC treatment in their daily clinical practice. Results: The mean prescription rate of OACs in AF patients was 80.3% and in DVT/PE-88.6%. One hundred and eighty-seven (82.7%) of the participants stated they see their patients on OAC at least once per month. According to more than one-third of the inquired clinicians, the patients did not understand well enough the provided information concerning net clinical benefit of OAC treatment. About 68% of the clinicians declared that their patients would prefer a "mutual" approach, discussing with the physician the OAC options and taking together the final decision, whereas according to 43 (19.0%), the patients preferred the physician to take a decision for them. Patients' OAC treatment had been interrupted at least once within the last year due to a physician's decision by 178 (78.8%) of the participants and the most common reason was elective surgery. The most influential factors for a patient's choice of OAC were the need of a specific diet to be kept, intake frequency, and possible adverse reactions. Conclusions: Our results suggest that a clinician's continuous medical education, shared decision-making, and appropriate local strategies for improved awareness of AF/DVT/PE patients are key factors for improvement of OAC management.
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Affiliation(s)
- Nikolay Runev
- Department of Internal Diseases, Medical University of Sofia, 1431 Sofia, Bulgaria.
| | - Tatjana Potpara
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia.
| | - Stefan Naydenov
- Department of Internal Diseases, Medical University of Sofia, 1431 Sofia, Bulgaria.
| | - Anita Vladimirova
- Boehringer Ingelheim RCV GmbH & Co KG Bulgarian Branch, 1505 Sofia, Bulgaria.
| | - Gergana Georgieva
- Boehringer Ingelheim RCV GmbH & Co KG Bulgarian Branch, 1505 Sofia, Bulgaria.
| | - Emil Manov
- Department of Internal Diseases, Medical University of Sofia, 1431 Sofia, Bulgaria.
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Medlinskiene K, Fay M, Petty D. Uptake of Oral Anticoagulants for Stroke Prevention in Patients with Atrial Fibrillation in a Single Clinical Commissioning Group in England Without Restrictions to Their Use. Clin Drug Investig 2019; 39:401-405. [PMID: 30805790 DOI: 10.1007/s40261-019-00763-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND OBJECTIVE In England, the uptake of direct oral anticoagulants (DOACs) for stroke prevention in atrial fibrillation has been slow and varied across different Clinical Commissioning Groups (CCGs). This study aimed to profile the prescribing of oral anticoagulants for stroke prevention in patients with atrial fibrillation over 3 years in a CCG without restrictions to DOACs use to understand more about organisational and/or individual barriers to the early uptake of DOACs. METHODS Data were collected from nine general practices between 1 April 2012 and 31 March 2015 of patients who were initiated on the oral anticoagulant therapy. Data were analysed descriptively and with independent Student's t test and Chi square test to explore if there was an association between type of oral anticoagulant initiated and sex, age, type of prescriber and prior aspirin use. RESULTS The early uptake of DOACs significantly increased over the study period (p < 0.0001; medium size effect φc = 0.372). There was no statistically significant difference between sex or age and type of oral anticoagulant initiated. Primary-care prescribers were responsible for initiating the majority of oral anticoagulants (71%; N = 257) and driving the use of DOACs (72%, N = 71). Patients switched from aspirin to an oral anticoagulant were more likely to be initiated on warfarin than a DOAC. CONCLUSIONS The early use of DOACs, in a CCG without restrictions to their use, was embraced by primary-care prescribers in this particular CCG.
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Affiliation(s)
- Kristina Medlinskiene
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, BD7 1DP, UK.
- Medicines Management and Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | | | - Duncan Petty
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, BD7 1DP, UK
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Leitão JM, Moreira FMDS, Thiel IE, Spricido IY, Silva RHM, Zétola VF. Alarming lack of knowledge about antithrombotic therapy among patients with atrial fibrillation. ARQUIVOS DE NEURO-PSIQUIATRIA 2018; 76:807-811. [DOI: 10.1590/0004-282x20180126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 08/27/2018] [Indexed: 11/22/2022]
Abstract
ABSTRACT Large population campaigns have been conducted in Brazil to improve knowledge about the signs and symptoms of stroke and the importance of time to care. Objective: Parallel to these important actions, we aimed to evaluate the lay knowledge of patients with atrial fibrillation, a well-recognized etiology of stroke, adequate treatment and management of which can prevent up to 30% of cerebrovascular events. Methods: We questioned 143 patients with atrial fibrillation about the risks associated with the disease. Results: Ninety-one percent were on anticoagulation treatment. Of the total, 63.6% reported having been informed about the risks and benefits of anticoagulants but only 46.9% were able to correctly mention one of these risks. Ischemic stroke was identified as a risk by only 25.9% and hemorrhagic stroke was not mentioned. A CHADS2 ≥ 2 was scored by 84.0% of the patients. Conclusions: Our study showed an alarming knowledge gap in patients with atrial fibrillation. Difficulty in adherence to treatment resulting from the failure of this communication is possibly one of the factors responsible for the high incidence and recurrence of stroke, and should not go unnoticed.
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Desteghe L, Germeys J, Vijgen J, Koopman P, Dilling-Boer D, Schurmans J, Delesie M, Dendale P, Heidbuchel H. Effectiveness and usability of an online tailored education platform for atrial fibrillation patients undergoing a direct current cardioversion or pulmonary vein isolation. Int J Cardiol 2018; 272:123-129. [DOI: 10.1016/j.ijcard.2018.07.065] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 06/26/2018] [Accepted: 07/12/2018] [Indexed: 11/28/2022]
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Desteghe L, Engelhard L, Vijgen J, Koopman P, Dilling-Boer D, Schurmans J, Delesie M, Dendale P, Heidbuchel H. Effect of reinforced, targeted in-person education using the Jessa Atrial fibrillation Knowledge Questionnaire in patients with atrial fibrillation: A randomized controlled trial. Eur J Cardiovasc Nurs 2018; 18:194-203. [PMID: 30328701 DOI: 10.1177/1474515118804353] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The knowledge level of atrial fibrillation patients about their arrhythmia, its consequences and treatment is poor. The best strategy to provide education is unknown. AIM To investigate the effect of reinforced targeted in-person education using the Jessa Atrial fibrillation Knowledge Questionnaire (JAKQ). METHODS Sixty-seven atrial fibrillation patients were randomized to standard care (including brochures) or targeted education. Follow-up visits were scheduled after one, three, six and 12 months. Targeted education during each visit focused on the knowledge gaps revealed by the JAKQ. Patients completed two questionnaires to assess their quality of life and symptom profile. Adherence to non-vitamin K antagonist oral anticoagulants was measured using electronic monitoring. RESULTS Sixty-two patients (31 education; 31 standard care) completed follow-up. Median baseline score on the JAKQ was similar in education (62.5%) and standard care group (56.3%; p=0.815). The intervention group scored significantly better over time (one month: 75.0%, 12 months: 87.5%; p<0.001) whereas there was no significant improvement in the control group (one month: 62.5%, 12 months: 62.5%; p=0.085). Providing targeted education after completion of the JAKQ required on average 6.9±4.6 min. Some improvements in quality of life, symptom burden and adherence were shown, without significant differences between the two groups ( p-values between 0.282 and 0.677). CONCLUSION The JAKQ is an effective tool for providing individualized education. A first targeted educational session significantly improved patients' knowledge level. Additional educational sessions maintained and strengthened this effect. A larger scale study is warranted to evaluate the impact on adherence and outcome measures.
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Affiliation(s)
- Lien Desteghe
- 1 Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.,2 Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Lara Engelhard
- 1 Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Johan Vijgen
- 2 Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Pieter Koopman
- 2 Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
| | | | | | - Michiel Delesie
- 3 University of Antwerp and Antwerp University Hospital, Edegem, Belgium
| | - Paul Dendale
- 1 Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.,2 Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Hein Heidbuchel
- 1 Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.,3 University of Antwerp and Antwerp University Hospital, Edegem, Belgium
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Lane DA, Meyerhoff J, Rohner U, Lip GYH. Patients' Perceptions of Atrial Fibrillation, Stroke Risk, and Oral Anticoagulation Treatment: An International Survey. TH OPEN 2018; 2:e233-e241. [PMID: 31249947 PMCID: PMC6524879 DOI: 10.1055/s-0038-1666803] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/22/2018] [Indexed: 12/27/2022] Open
Abstract
Background Global differences exist in the management of atrial fibrillation (AF), and cultural differences may influence patients' expectations and perceptions of healthcare. This survey investigated whether country-specific differences in patients' perceptions of AF and oral anticoagulation (OAC) exist and if recent stroke influences these perceptions. Methods Cross-sectional survey of 937 adults with nonvalvular AF receiving OAC for stroke prevention was conducted across United States, Canada, Germany, France, and Japan. Thirty-minute online interviews conducted between April and November 2015 included AF patients with recent stroke, and newly diagnosed AF and established AF, both without recent stroke. Results U.S. patients and those with recent stroke perceived AF as more serious (54.0 and 55.2%, respectively) and were more concerned about stroke (50.0 and 68.0%, respectively). Japanese patients were more likely to perceive AF as not serious (41.0%), but 50.4% were frequently concerned about stroke. Patients in the United States, Canada, and Germany and those without recent stroke preferred to be involved in OAC treatment decisions (either shared decision making or patient's choice), while French and Japanese patients and those with recent stroke preferred their doctor to choose. For all country groups, stroke prevention was the most important factor when choosing OAC. Conclusion In this international cohort of AF patients, country-specific differences exist in patients' perceptions of AF, concerns about stroke, and preference for involvement in OAC treatment decisions; recent experience of stroke significantly influenced patients' values and preferences regarding AF and treatment. Stroke prevention was rated as the most important factor when choosing OAC treatment.
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Affiliation(s)
- Deirdre A Lane
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Juliane Meyerhoff
- Boehringer Ingelheim Pharma International GmbH, Ingelheim am Rhein, Germany
| | - Ute Rohner
- Boehringer Ingelheim Pharma International GmbH, Ingelheim am Rhein, Germany
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Balsam P, Borodzicz S, Malesa K, Puchta D, Tymińska A, Ozierański K, Kołtowski Ł, Peller M, Grabowski M, Filipiak KJ, Opolski G. OCULUS study: Virtual reality-based education in daily clinical practice. Cardiol J 2018; 26:260-264. [PMID: 29297178 PMCID: PMC8086674 DOI: 10.5603/cj.a2017.0154] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 12/14/2017] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is associated with high risk of stroke and other thromboembolic complications. The OCULUS study aimed to evaluate the effectiveness of the three-dimensional (3D) movie in teaching patients about the consequences of AF and pharmacological stroke prevention. METHODS The study was based on a questionnaire and included 100 consecutive patients (38% women, 62% with AF history). Using the oculus glasses and a smartphone, a 3D movie describing the risk of stroke in AF was shown. Similar questions were asked immediately after, 1 week and 1 year after the projection. RESULTS Before the projection 22/100 (22.0%) declared stroke a consequence of AF, while immediately after 83/100 (83.0%) (p < 0.0001) patients declared this consequence. Seven days after, stroke as AF consequence was chosen by 74/94 (78.7%) vs. 22/94 (23.4%) when compared to the baseline knowledge; p < 0.0001, a similar trend was also observed in 1-year follow-up (64/90 [71.1%] vs. 21/90 [23.3%]; p < 0.0001). Before the projection 88.3% (83/94) patients responded, that drugs may reduce the risk of stroke, and after 1 week the number of patients increased to (94/94 [100%]; p = 0.001). After 1 year 87/90 (96.7%) answered that drugs may diminish the risk of stroke (p = 0.02 in comparison to the baseline survey 78/90 [86.7%]). Use of oral anticoagulation to reduce the risk of stroke was initially chosen by 66/94 (70.2%), by 90/94 (95.7%; p < 0.0001) 7 days after and by 83/90 (92.2%; p < 0.0001) 1 year after. CONCLUSIONS 3D movie is an effective tool in transferring knowledge about the consequences of AF and the pivotal role of oral anticoagulation in stroke prevention. TRIAL REGISTRATION ClinicalTrials.gov, NCT03104231. Registered on 28 March 2017.
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Affiliation(s)
- Paweł Balsam
- First Chair and Department of Cardiology, Medical University of Warsaw, Poland
| | - Sonia Borodzicz
- First Chair and Department of Cardiology, Medical University of Warsaw, Poland.
| | - Karolina Malesa
- First Chair and Department of Cardiology, Medical University of Warsaw, Poland
| | - Dominika Puchta
- First Chair and Department of Cardiology, Medical University of Warsaw, Poland
| | - Agata Tymińska
- First Chair and Department of Cardiology, Medical University of Warsaw, Poland
| | | | - Łukasz Kołtowski
- First Chair and Department of Cardiology, Medical University of Warsaw, Poland
| | - Michał Peller
- First Chair and Department of Cardiology, Medical University of Warsaw, Poland
| | - Marcin Grabowski
- First Chair and Department of Cardiology, Medical University of Warsaw, Poland
| | | | - Grzegorz Opolski
- First Chair and Department of Cardiology, Medical University of Warsaw, Poland
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Zweiker D, Zweiker R, Winkler E, Roesch K, Schumacher M, Stepan V, Krippl P, Bauer N, Heine M, Reicht G, Zweiker G, Sprenger M, Watzinger N. Association between subjective risk perception and objective risk estimation in patients with atrial fibrillation: a cross-sectional study. BMJ Open 2017; 7:e018242. [PMID: 28951417 PMCID: PMC5623506 DOI: 10.1136/bmjopen-2017-018242] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Oral anticoagulation (OAC) is state-of-the-art therapy for atrial fibrillation (AF), the most common arrhythmia worldwide. However, little is known about the perception of patients with AF and how it correlates with risk scores used by their physicians. Therefore, we correlated patients' estimates of their own stroke and bleeding risk with the objectively predicted individual risk using CHA2DS2-VASc and HAS-BLED scores. DESIGN Cross-sectional prevalence study using convenience sampling and telephone follow-up. SETTINGS Eight hospital departments and one general practitioner in Austria. Patients' perception of stroke and bleeding risk was opposed to commonly used risk scoring. PARTICIPANTS Patients with newly diagnosed AF and indication for anticoagulation. MAIN OUTCOME MEASURES Comparison of subjective risk perception with CHA2DS2-VASc and HAS-BLED scores showing possible discrepancies between subjective and objective risk estimation. Patients' judgement of their own knowledge on AF and education were also correlated with accuracy of subjective risk appraisal. RESULTS Ninety-one patients (age 73±11 years, 45% female) were included in this study. Subjective stroke and bleeding risk estimation did not correlate with risk scores (ρ=0.08 and ρ=0.17). The majority of patients (57%) underestimated the individual stroke risk. Patients feared stroke more than bleeding (67% vs 10%). There was no relationship between accurate perception of stroke and bleeding risks and education level. However, we found a correlation between the patients' judgement of their own knowledge of AF and correct assessment of individual stroke risk (ρ=0.24, p=0.02). During follow-up, patients experienced the following events: death (n=5), stroke (n=2), bleeding (n=1). OAC discontinuation rate despite indication was 3%. CONCLUSIONS In this cross-sectional analysis of OAC-naive patients with AF, we found major differences between patients' perceptions and physicians' assessments of risks and benefits of OAC. To ensure shared decision-making and informed consent, more attention should be given to evidence-based and useful communication strategies. TRIAL REGISTRATION NUMBER NCT03061123.
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Affiliation(s)
- David Zweiker
- Division of Cardiology, Department of Internal Medicine, Medizinische University Graz, Graz, Steiermark, Austria
| | - Robert Zweiker
- Division of Cardiology, Department of Internal Medicine, Medizinische University Graz, Graz, Steiermark, Austria
| | - Elisabeth Winkler
- Division of Cardiology, Department of Internal Medicine, Medizinische University Graz, Graz, Steiermark, Austria
| | - Konstantina Roesch
- Division of Cardiology, Department of Internal Medicine, Medizinische University Graz, Graz, Steiermark, Austria
| | - Martin Schumacher
- Department of Internal Medicine, Hospital Barmherzige Brueder Marschallgasse, Graz, Steiermark, Austria
| | - Vinzenz Stepan
- Department of Internal Medicine, Hospital Elisabethinen, Graz, Austria
| | - Peter Krippl
- Department of Internal Medicine, LKH Fürstenfeld, Krankenhausverbund Feldbach, Fürstenfeld, Austria
| | - Norbert Bauer
- Department of Internal Medicine, LKH Hartberg, Steiermark, Austria
| | - Martin Heine
- Department of Neurology, LKH Feldbach, Krankenhausverbund Feldbach-Fürstenfeld, Feldbach, Steiermark, Austria
| | - Gerhard Reicht
- Department of Internal Medicine, Krankenhaus Barmherzige Bruder Graz-Eggenberg, Graz, Steiermark, Austria
| | - Gudrun Zweiker
- General Practitioner Dr. Gudrun Zweiker, Straden, Austria
| | - Martin Sprenger
- Department of Social Medicine and Epidemiology, Medical University of Graz, Steiermark, Austria
| | - Norbert Watzinger
- Department of Internal Medicine, Landeskrankenhaus Feldbach, Feldbach, Steiermark, Austria
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Potpara TS, Boriani G, Lip GYH. Evaluating adherence to non-vitamin-K antagonist oral anticoagulants in post-approval observational studies of patients with atrial fibrillation. Curr Med Res Opin 2017; 33:1175-1177. [PMID: 28398081 DOI: 10.1080/03007995.2017.1313210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Tatjana S Potpara
- a School of Medicine , Belgrade University , Belgrade , Serbia
- b Cardiology Clinic, Clinical Centre of Serbia , Belgrade , Serbia
| | - Giuseppe Boriani
- c Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine , University of Modena and Reggio Emilia, Policlinico di Modena , Modena , Italy
| | - Gregory Y H Lip
- a School of Medicine , Belgrade University , Belgrade , Serbia
- d University of Birmingham Institute of Cardiovascular Science, City Hospital , Birmingham , United Kingdom
- e Aalborg Thrombosis Research Unit, Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
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Potpara TS, Dagres N, Mujović N, Vasić D, Ašanin M, Nedeljkovic M, Marin F, Fauchier L, Blomstrom-Lundqvist C, Lip GYH. Decision-Making in Clinical Practice: Oral Anticoagulant Therapy in Patients with Non-valvular Atrial Fibrillation and a Single Additional Stroke Risk Factor. Adv Ther 2017; 34:357-377. [PMID: 27933569 PMCID: PMC5331111 DOI: 10.1007/s12325-016-0458-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Indexed: 01/27/2023]
Abstract
Approximately 1 in 3-4 patients presenting with an ischemic stroke will also have atrial fibrillation (AF), and AF-related strokes can be effectively prevented using oral anticoagulant therapy (OAC), either with well-controlled vitamin K antagonists (VKAs) or non-vitamin K antagonist oral anticoagulants (NOACs). In addition, OAC use (both VKAs and NOACs) is associated with a 26% reduction in all-cause mortality (VKAs) or an additional 10% mortality reduction with NOACs relative to VKAs. The decision to use OAC in individual AF patient is based on the estimated balance of the benefit from ischemic stroke reduction against the risk of major OAC-related bleeding [essentially intracranial hemorrhage (ICH)]. Better appreciation of the importance of VKAs' anticoagulation quality [a target time in therapeutic range (TTR) of ≥70%] and the availability of NOACs (which offer better safety compared to VKAs) have decreased the estimated threshold for OAC treatment in AF patients towards lower stroke risk levels. Still, contemporary registry-based data show that OAC is often underused in AF patients at increased risk of stroke. The uncertainty whether to use OAC may be particularly pronounced in AF patients with a single additional stroke risk factor, who are often (mis)perceived as having a "borderline" or insufficient stroke risk to trigger the use of OAC. However, observational data from real-world AF cohorts show that the annual stroke rates in such patients are higher than in patients with no additional stroke risk factors, and OAC use has been associated with reduction in stroke, systemic embolism, or death in comparison to no therapy or aspirin, with no increase in the risk of bleeding relative to aspirin. In this review article, we summarize the basic principles of stroke risk stratification in AF patients and discuss contemporary real-world evidence on OAC use and outcomes of OAC treatment in AF patients with a single additional stroke risk factor in various real-world AF cohorts.
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15
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Raparelli V, Proietti M, Cangemi R, Lip GYH, Lane DA, Basili S. Adherence to oral anticoagulant therapy in patients with atrial fibrillation. Focus on non-vitamin K antagonist oral anticoagulants. Thromb Haemost 2016; 117:209-218. [PMID: 27831592 DOI: 10.1160/th16-10-0757] [Citation(s) in RCA: 129] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 10/07/2016] [Indexed: 01/11/2023]
Abstract
Oral anticoagulation is pivotal in the management of thromboembolic risk in non-valvular atrial fibrillation (NVAF) patients. Effective anticoagulation is important to avoid major adverse events and medication adherence is central to achieve good anticoagulation control. Non-vitamin K antagonist oral anticoagulants (NOACs) are as effective and safe as vitamin K antagonist (VKAs) in NVAF patients. Due to the absence of routine anticoagulation monitoring with NOACs treatment, concerns have been raised about patient's adherence to NOACs and real-life data demonstrates variability in adherence and persistence. A multi-level approach, including patients' preferences, factors determining physicians' prescribing habits and healthcare system infrastructure and support, is warranted to improve initiation and adherence of anticoagulants. Adherence to NOACs is paramount to achieve a clinical benefit. Implementation of educational programs and easy-to-use tools to identify patients most likely to be non-adherent to NOACs, are central issues in improving the quality of NVAF anticoagulation management.
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Affiliation(s)
| | | | | | | | | | - Stefania Basili
- Prof. Stefania Basili, I Clinica Medica, Viale del Policlinico 155, Roma, 00161, Italy, Tel.: +39 06 49974678, Fax: +39 06 49974678, E-mail:
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16
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Desteghe L, Engelhard L, Raymaekers Z, Kluts K, Vijgen J, Dilling-Boer D, Koopman P, Schurmans J, Dendale P, Heidbuchel H. Knowledge gaps in patients with atrial fibrillation revealed by a new validated knowledge questionnaire. Int J Cardiol 2016; 223:906-914. [DOI: 10.1016/j.ijcard.2016.08.303] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Revised: 08/10/2016] [Accepted: 08/19/2016] [Indexed: 10/21/2022]
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17
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Hernández Madrid A, Potpara TS, Dagres N, Chen J, Larsen TB, Estner H, Todd D, Bongiorni MG, Sciaraffia E, Proclemer A, Cheggour S, Amara W, Blomstrom-Lundqvist C. Differences in attitude, education, and knowledge about oral anticoagulation therapy among patients with atrial fibrillation in Europe: result of a self-assessment patient survey conducted by the European Heart Rhythm Association. Europace 2016; 18:463-7. [DOI: 10.1093/europace/euv448] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 12/21/2015] [Indexed: 02/06/2023] Open
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18
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Bongiorni MG, Chen J, Dagres N, Estner H, Hernandez-Madrid A, Hocini M, Larsen TB, Pison L, Potpara T, Proclemer A, Sciaraffia E, Todd D, Blomstrom-Lundqvist C. EHRA research network surveys: 6 years of EP wires activity. Europace 2015; 17:1733-8. [PMID: 26589904 DOI: 10.1093/europace/euv371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Clinical practice should follow guidelines and recommendations mainly based on the results of controlled trials, which are often conducted in selected populations and special conditions, whereas clinical practice may be influenced by factors different from controlled scientific studies. Hence, the real-world setting is better assessed by the observational registries enrolling patients for longer periods of time. However, this may be difficult, expensive, and time-consuming. In 2009, the Scientific Initiatives Committee of the European Heart Rhythm Association (EHRA) has instigated a series of surveys covering the controversial issues in clinical electrophysiology (EP). With this in mind, an EHRA EP research network has been created, which included EP centres in Europe among which the surveys on 'hot topic' were circulated. This review summarizes the overall experience conducting EP wires over the past 6 years, categorizing and assessing the topics regarding clinical EP, and evaluating the acceptance and feedback from the responding centres, in order to improve participation in the surveys and better address the research needs and aspirations of the European EP community.
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Affiliation(s)
| | - Jian Chen
- Department of Clinical Science, Haukeland University Hospital, University of Bergen, Bergen, Norway
| | - Nikolaos Dagres
- Second Cardiology Department, Attikon University Hospital, University of Athens, Athens, Greece
| | - Heidi Estner
- Department of Cardiology Medizinische Klinik und Poliklinik I, LMU Klinikum der Universität München, München, Germany
| | - Antonio Hernandez-Madrid
- Cardiology Department, Ramon y Cajal Hospital, Alcalá University, CarreteraColmenar Viejo, Madrid 28034, Spain
| | - Meleze Hocini
- HôpitalCardiologique du Haut Lévêque Université Victor Segalen Bordeaux II, Bordeaux, Pessac 33604, France
| | - Torben Bjerregaard Larsen
- Department of Cardiology, Cardiovascular Research Centre, Aalborg University Hospital, Aalborg, Denmark
| | - Laurent Pison
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Tatjana Potpara
- School of Medicine, University of Belgrade, Serbia and Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Alessandro Proclemer
- Division of Cardiology, University Hospital S. Maria della Misericordia, IRCAB Foundation Udine, Udine, Italy
| | - Elena Sciaraffia
- Department of Cardiology, Institution of Medical Science, Uppsala University, Uppsala 75185, Sweden
| | - Derick Todd
- Institute of Cardiovascular Medicine and Science Liverpool Heart & Chest Hospital, UK
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19
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Kirchhof P, Breithardt G, Bax J, Benninger G, Blomstrom-Lundqvist C, Boriani G, Brandes A, Brown H, Brueckmann M, Calkins H, Calvert M, Christoffels V, Crijns H, Dobrev D, Ellinor P, Fabritz L, Fetsch T, Freedman SB, Gerth A, Goette A, Guasch E, Hack G, Haegeli L, Hatem S, Haeusler KG, Heidbüchel H, Heinrich-Nols J, Hidden-Lucet F, Hindricks G, Juul-Möller S, Kääb S, Kappenberger L, Kespohl S, Kotecha D, Lane DA, Leute A, Lewalter T, Meyer R, Mont L, Münzel F, Nabauer M, Nielsen JC, Oeff M, Oldgren J, Oto A, Piccini JP, Pilmeyer A, Potpara T, Ravens U, Reinecke H, Rostock T, Rustige J, Savelieva I, Schnabel R, Schotten U, Schwichtenberg L, Sinner MF, Steinbeck G, Stoll M, Tavazzi L, Themistoclakis S, Tse HF, Van Gelder IC, Vardas PE, Varpula T, Vincent A, Werring D, Willems S, Ziegler A, Lip GY, Camm AJ. A roadmap to improve the quality of atrial fibrillation management: proceedings from the fifth Atrial Fibrillation Network/European Heart Rhythm Association consensus conference. Europace 2015; 18:37-50. [DOI: 10.1093/europace/euv304] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 08/13/2015] [Indexed: 12/30/2022] Open
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20
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Amara W, Larsen TB, Sciaraffia E, Hernández Madrid A, Chen J, Estner H, Todd D, Bongiorni MG, Potpara TS, Dagres N, Sagnol P, Blomstrom-Lundqvist C. Patients' attitude and knowledge about oral anticoagulation therapy: results of a self-assessment survey in patients with atrial fibrillation conducted by the European Heart Rhythm Association. Europace 2015; 18:151-5. [PMID: 26462697 DOI: 10.1093/europace/euv317] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 08/20/2015] [Indexed: 01/29/2023] Open
Abstract
The purpose of this European Heart Rhythm Association survey was to assess the attitude, level of education, and knowledge concerning oral anticoagulants (OACs) among patients with atrial fibrillation (AF) taking vitamin K antagonists (VKAs), non-VKA oral anticoagulants (NOACs) or antiplatelets. A total of 1147 patients with AF [mean age 66 ± 13 years, 529 (45%) women] from 8 selected European countries responded to this survey. The overall use of OACs and antiplatelets was 77 and 15.3%, respectively. Of the patients taking OACs, 67% were on VKAs, 33% on NOACs, and 17.9% on a combination of OACs and antiplatelets. Among patients on VKAs, 91% correctly stated the target international normalized ratio (INR) level. The proportion of patients on VKA medication who were aware that monthly INR monitoring was required for this treatment and the proportion of patients on NOAC who knew that renal function monitoring at least annually was mandatory for NOACs was 76 and 21%, respectively. An indirect estimation of compliance indicated that 14.5% of patients temporarily discontinued the treatment, and 26.5% of patients reported having missed at least one dose. The survey shows that there is room for improvement regarding education and adherence of patients taking OACs, particularly regarding monitoring requirements for NOACs.
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Affiliation(s)
- Walid Amara
- Department of Cardiology, Groupe Hospitalier Le Raincy-Montfermeil, Montfermeil, France
| | - Torben B Larsen
- Department of Cardiology, AF Studygroup, Aalborg University Hospital, Aalborg, Denmark
| | - Elena Sciaraffia
- Department of Cardiology, Institution of Medical Science, Uppsala University, Uppsala, Sweden
| | | | - Jian Chen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Heidi Estner
- Department of Cardiology, MedizinischeKlinik I, Ludwig-Maximilians-Universität, Campus Großhadern, Marchioninistrasse 15, München 81377, Germany
| | | | | | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Nikolaos Dagres
- Second Cardiology Department, Attikon University Hospital, University of Athens, Athens, Greece
| | - Pascal Sagnol
- Cardioloy Department, Centre Hospitalier William Marey, 71100 Chalon s/Saone, France
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