A national survey of the management of atrial fibrillation with antithrombotic drugs in Italian primary care

Summary

The aims of this study were to investigate trends in the incidence of diagnosed atrial fibrillation (AF), and to identify factors associated with the prescription of antithrombotics (ATs) and to identify the persistence of patients with oral anticoagulant (OAC) treatment in primary care. Data were obtained from 400 Italian primary care physicians providing information to the Health Search/Thales Database from 2001 to 2004. The age-standardised incidence of AF was: 3.9–3.0 cases, and 3.6–3.0 cases per 1,000 person-years in males and females, respectively. During the study period, 2,016 (37.2%) patients had no prescription, 1,663 (30.7%) were prescribed an antiplatelet (AP) agent, 1,440 (26.6%) were prescribed an OAC and 301 (5.5%) had both prescriptions. The date of diagnosis (p = 0.0001) affected the likelihood of receiving an OAC. AP, but not OAC, use significantly increased with a worsening stroke risk profile using the CHADS₂ risk score. Older age increased the probability (p < 0.0001) of receiving an AP, but not an OAC. Approximately 42% and 24% of patients persisted with OAC treatment at one and two years, respectively, the remainder interrupted or discontinued their treatment. Underuse and discontinuation of OAC treatment is common in incident AF patients. Risk stratification only partially influences AT management.

Keywords

Antithrombotics - atrial fibrillation - incidence - oral anticoagulant - risk stratification - therapeutic persistence - treatment

• References

• 1 Ryder KM, Benjamin EJ. Epidemiology and significance of atrial fibrillation. Am J Cardiol 1999; 84: 131R-138R.
• 2 Lip GY. et al. Atrial fibrillation--the growing epidemic. Heart 2007; 93: 542-543.
• 3 Murphy NF. et al. A national survey of the prevalence, incidence, primary care burden and treatment of atrial fibrillation in Scotland. Heart 2007; 93: 606-612.
• 4 Benjamin EJ. et al. Impact of atrial fibrillation on the risk of death: the Framing-ham Heart Study. Circulation 1998; 98: 946-952.
• 5 Lip GY, Boos CJ. Antithrombotic treatment in atrial fibrillation. Heart 2006; 92: 155-161.
• 6 Nieuwlaat R. et al. Antithrombotic treatment in real-life atrial fibrillation patients: a report from the Euro Heart Survey on Atrial Fibrillation. Eur Heart J 2006; 27: 3018-3026.
• 7 Marini C. et al. Contribution of atrial fibrillation to incidence and outcome of ischemic stroke: results from a population-based study. Stroke 2005; 36: 1115-1119.
• 8 Jorgensen HS. et al. Acute stroke with atrial fibrillation. The Copenhagen Stroke Study. Stroke 1996; 27: 1765-1769.
• 9 Fuster V. et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006; 114: e257-e354.
• 10 Stafford RS, Singer DE. Recent national patterns of warfarin use in atrial fibrillation. Circulation 1998; 97: 1231-1233.
• 11 Go AS. et al. Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study. Ann Intern Med 1999; 131: 927-934.
• 12 Lip GY, Lim HS. Atrial fibrillation and stroke prevention. Lancet Neurol 2007; 06: 981-993.
• 13 Goldstein LB. et al. Primary prevention of ischemic stroke: A statement for health-care professionals from the Stroke Council of the American Heart Association. Stroke 2001; 32: 280-299.
• 14 Wood VA, Hewer RL. The prevention and management of stroke. J Public Health Med 1996; 18: 423-431.
• 15 Majeed A. et al. Trends in the prevalence and management of atrial fibrillation in general practice in England and Wales, 1994–1998: analysis of data from the general practice research database. Heart 2001; 86: 284-288.
• 16 Lawrenson R. et al. Clinical information for research; the use of general practice databases. J Public Health Med 1999; 21: 299-304.
• 17 Cricelli C. et al. Prevalence estimates for chronic diseases in Italy: exploring the differences between self-report and primary care databases. J Public Health Med 2003; 25: 254-257.
• 18 Filippi A. et al. The database of Italian general practitioners allows a reliable determination of the prevalence of myocardial infarction. Ital Heart J 2005; 06: 311-314.
• 19 Filippi A. et al. Computerized general practice databases provide quick and cost-effective information on the prevalence of angina pectoris. Ital Heart J 2005; 06: 49-51.
• 20 Mazzaglia G. et al. Screening of older community-dwelling people at risk for death and hospitalization: the Assistenza Socio-Sanitaria in Italia project. J Am Geriatr Soc 2007; 55: 1955-1960.
• 21 Gage BF. et al. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. J Am Med Assoc 2001; 285: 2864-2870.
• 22 Poli D. et al. Stroke risk in atrial fibrillation patients on warfarin. Predictive ability of risk stratification schemes for primary and secondary prevention. Thromb Haemost 2009; 101: 367-372.
• 23 Holbrook AM. et al. Systematic overview of warfarin and its drug and food interactions. Arch Intern Med 2005; 165: 1095-1106.
• 24 Fitzmaurice DA. et al. Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial. Br Med J 2007; 335: 383.
• 25 Benjamin EJ. et al. Independent risk factors for atrial fibrillation in a population-based cohort. The Framingham Heart Study. J Am Med Assoc 1994; 271: 840-844.
• 26 Miyasaka Y. et al. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation 2006; 114: 119-125.
• 27 Psaty BM. et al. Incidence of and risk factors for atrial fibrillation in older adults. Circulation 1997; 96: 2455-2461.
• 28 Stewart S. et al. Population prevalence, incidence, and predictors of atrial fibrillation in the Renfrew/Paisley study. Heart 2001; 86: 516-521.
• 29 Heeringa J. et al. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J 2006; 27: 949-953.
• 30 Gage BF. et al. Selecting patients with atrial fibrillation for anticoagulation: stroke risk stratification in patients taking aspirin. Circulation 2004; 110: 2287-2292.
• 31 Friberg L. et al. Stroke prophylaxis in atrial fibrillation: who gets it and who does not? Report from the Stockholm Cohort-study on Atrial Fibrillation (SCAF-study). Eur Heart J 2006; 27: 1954-1964.
• 32 Hylek EM. Contra: ‘Warfarin should be the drug of choice for thromboprophylaxis in elderly patients with atrial fibrillation‘. Caveats regarding use of oral anticoagulant therapy among elderly patients with atrial fibrillation. Thromb Haemost 2008; 100: 16-17.
• 33 Mant JW. Pro: ‘Warfarin should be the drug of choice for thromboprophylaxis in elderly patients with atrial fibrillation‘. Why warfarin should really be the drug of choice for stroke prevention in elderly patients with atrial fibrillation. Thromb Haemost 2008; 100: 14-15.
• 34 Mazzaglia G. et al. Patterns of persistence with antihypertensive medications in newly diagnosed hypertensive patients in Italy: a retrospective cohort study in primary care. J Hypertens 2005; 23: 2093-2100.
• 35 Filippi A. et al. Detected atrial fibrillation in north Italy: rates, calculated stroke risk and proportion of patients receiving thrombo-prophylaxis. Fam Pract 2000; 17: 337-339.
• 36 Nieuwlaat R. et al. Prognosis, disease progression, and treatment of atrial fibrillation patients during 1 year: follow-up of the Euro Heart Survey on atrial fibrillation. Eur Heart J 2008; 29: 1181-1189.
• 37 National Collaborating Centre for Chronic Conditions.. Atrial fibrillation: national clinical guideline for management in primary and secondary care. London: Royal College of Physicians, 2006.
• 38 Lip GY. Paroxysmal atrial fibrillation, stroke risk and thromboprophylaxis. Thromb Haemost 2008; 100: 11-13.
• 39 Hohnloser SH. et al. Incidence of stroke in paroxysmal versus sustained atrial fibrillation in patients taking oral anticoagulation or combined antiplatelet therapy: an ACTIVE W Substudy. J Am Coll Cardiol 2007; 50: 2156-21561.
• 40 Schalekamp T. et al. Effect of oral antiplatelet agents on major bleeding in users of coumarins. Thromb Haemost 2008; 100: 1076-1083.
• 41 Go AS. et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. J Am Med Assoc 2001; 285: 2370-2375.