Treatment pathways for patients with atrial fibrillation

Patterns of Medications for Atrial Fibrillation Among Older Women: Results From the Australian Longitudinal Study on Women's Health

PURPOSE

Examine patterns of medication use, changes in medication patterns over time, and investigate factors associated with medication patterns among older Australian women with Atrial Fibrillation (AF).

METHODS

It is a retrospective analysis of the 1921-26 birth cohort of the Australian Longitudinal Study on Women's Health (ALSWH), diagnosed with AF between 2000-2015 (N = 1206). Survey data of these women was linked with national registries for medications and death. Latent Transition Analysis (LTA) identified distinct patterns of medication use and transitions among these patterns for 3 consecutive years following AF diagnosis. LTA with co-variates determined the factors associated with latent status membership.

RESULTS

One-tenth (9.6%, 11.7%, 11.4%) of the study population did not receive any medication for AF in all 3 years following AF diagnosis and about 60% did not receive any medication for the prevention of thromboembolism. Among those who received medications, almost three-quarters (76.6%, 68.4%, 68.5%) received some kind of combination of medications. LTA indicated at least 6 different patterns of AF medications. These patterns had transition probabilities >85% for most of the latent statuses. All factors but diabetes mellitus among the CHA₂DS₂-VA scoring scheme were independently associated with latent status membership at the time of AF diagnosis.

CONCLUSIONS

Evaluation of pharmacological treatment indicates that prevention of thromboembolism is inadequate among women with AF. There exists wide variations in medication patterns. However, once in a particular pattern, women are likely to continue the same medications long-term. This underscores the importance of initial assessment of patient profile and stroke risk score in determining the treatment for AF. Failure to assess risk makes women susceptible to devastating AF complications.

Defining disease phenotypes using national linked electronic health records: a case study of atrial fibrillation

BACKGROUND

National electronic health records (EHR) are increasingly used for research but identifying disease cases is challenging due to differences in information captured between sources (e.g. primary and secondary care). Our objective was to provide a transparent, reproducible model for integrating these data using atrial fibrillation (AF), a chronic condition diagnosed and managed in multiple ways in different healthcare settings, as a case study.

METHODS

Potentially relevant codes for AF screening, diagnosis, and management were identified in four coding systems: Read (primary care diagnoses and procedures), British National Formulary (BNF; primary care prescriptions), ICD-10 (secondary care diagnoses) and OPCS-4 (secondary care procedures). From these we developed a phenotype algorithm via expert review and analysis of linked EHR data from 1998 to 2010 for a cohort of 2.14 million UK patients aged ≥ 30 years. The cohort was also used to evaluate the phenotype by examining associations between incident AF and known risk factors.

RESULTS

The phenotype algorithm incorporated 286 codes: 201 Read, 63 BNF, 18 ICD-10, and four OPCS-4. Incident AF diagnoses were recorded for 72,793 patients, but only 39.6% (N = 28,795) were recorded in primary care and secondary care. An additional 7,468 potential cases were inferred from data on treatment and pre-existing conditions. The proportion of cases identified from each source differed by diagnosis age; inferred diagnoses contributed a greater proportion of younger cases (≤ 60 years), while older patients (≥ 80 years) were mainly diagnosed in SC. Associations of risk factors (hypertension, myocardial infarction, heart failure) with incident AF defined using different EHR sources were comparable in magnitude to those from traditional consented cohorts.

CONCLUSIONS

A single EHR source is not sufficient to identify all patients, nor will it provide a representative sample. Combining multiple data sources and integrating information on treatment and comorbid conditions can substantially improve case identification.

Evaluation of practice patterns in the treatment of atrial fibrillation among the commercially insured

OBJECTIVE

The management of atrial fibrillation (AF) involves two choices: (1) rate control versus rhythm control, and (2) anticoagulation treatment based upon risk of stroke. The objective of the study was to describe practice patterns in both of these treatment areas in patients with newly diagnosed AF among a commercially insured population.

METHODS

This retrospective administrative claims analysis included patients with ≥2 AF claims between 1 January 2008 and 30 September 2010. Patients with AF claims within a year prior to the index date (i.e., the first AF diagnosis date) were excluded. The primary outcome was the proportion of patients treated with rate control (i.e., beta blockers, calcium channel blockers, digoxin) versus rhythm control (i.e., electrical cardioversion, left atrial catheter ablation [LACA], and/or surgical ablation) and the use of anticoagulants stratified by risk of stroke based on CHADS2 score.

RESULTS

Of 48,814 patients with a diagnosis of AF, 38,502 (78.9%) received treatment. Of those treated, the majority received only pharmacologic treatment (73.4%), of which beta blockers were predominantly used in the initial regimen (66.7%). Antiarrhythmic drugs were used in 23.9% of patients, but within the initial regimen in only 11.7% of patients. Direct current cardioversion occurred in 18.2% of patients, with the majority being either first-line (8.5%) or second-line (9.1%) therapy. LACA was used in only 5.2% of patients and was typically reserved for use after pharmacologic treatment or direct current cardioversion. Of 1924 patients who received LACA, 14.6% received a repeat procedure and 53.4% of the repeat procedures occurred within 6 months of the initial one. A little more than half of all patients (57.0%) received anticoagulant therapy (predominantly warfarin); of those at high risk for stroke, 63.8% with a CHADS2 score ≥2 received anticoagulants.

KEY LIMITATIONS

It is a retrospective analysis using administrative claims data from a commercially insured population only. Identification of the first episode of AF may be inaccurate, and we cannot differentiate between paroxysmal and persistent AF.

CONCLUSIONS

Debate continues regarding whether the preferred management of most patients with AF is through rate control or restoration of normal sinus rhythm. Our retrospective study found that treatments to restore normal heart rhythm, including LACA, which could be considered aggressive initial treatment, were typically reserved as second- or third-line alternatives. Initial standard of care for the majority patients was beta blockers. Though use of anticoagulation may be higher than other observational studies, opportunities exist to increase treatment in high risk patients.

[The management of atrial fibrillation and characteristics of its current care in outpatients. AFABE observational study]

AIM

To provide insights into the characteristics and management of outpatients when their atrial fibrillation (AF) was first detected: diagnosis, treatment and follow-up in the context of the public health system.

DESIGN

AFABE is an observational, multicentre descriptive study with retrospective data collection relating to the practice patterns, management and initial strategies of treatment of patients with diagnosed AF in the context of primary care, emergency and cardiologists of the public health system.

SETTING

Primary and Specialist care. Baix Ebre region. Tarragona. Spain.

SUBJECTS

A representative sample of 182 subjects > 60-year-old with AF who have been randomized, recruited among the registered patients with AF in 22 primary care centres in the area of the study.

MESUREMENTS

Demographic data, comorbidities (AF), CHA2DS2-VASc and HAS_BLED scores, and practice patterns results between Primary Care and referral services.

RESULTS

A total of 182 patients were included (mean age 78.5 SD:7.3 years; 50% women). Most patients (68.3% 95%CI; 60.3-76.3) had the first contact in Primary Care, of which 56.3% (95%CI; 45.2-66.0) were sent to Hospital Emergency Department where 72.7% (95%CI: 63.5-79.0) of the oral anticoagulation and 58.4% (95%CI: 49.4-66.9) of antiarrhytmic treatments were started. More than half (55.9%:95%CI; 47.2-64.7, of patients with permanent AF were followed-up by the Cardiology department.

CONCLUSIONS

Most patients with newly diagnosed AF made a first contact with Primary Care, but around half were sent to Hospital Emergency departments, where they were treated with an antiarrhythmic and/or oral anticoagulation.