CardiologyRisk factors for stroke and thromboprophylaxis in atrial fibrillation: what happens in daily clinical practice? The GEFAUR-1 study☆,☆☆,★,★★,☆☆☆
Introduction
Atrial fibrillation currently constitutes a growing public health problem because of its high prevalence and the coincident morbidity and mortality.1 When arrhythmia coexists with determined risk factors,2 it is the cardiac disorder most frequently associated with the development of arterial thromboembolism, which in 90% of cases manifests as ischemic stroke. Although several studies have demonstrated the effectiveness of oral anticoagulation for thromboembolism prophylaxis in atrial fibrillation3 and the indications for therapy are detailed in widely available clinical guidelines, in daily practice it is only prescribed to 15% to 44% of the patients for whom it is theoretically indicated.4
Profound changes have taken place in patient care in most developed countries during the past decades.5 Patients tend to abandon conventional health care routes and go directly to hospital emergency departments (EDs), which have become a main point of entry into the health system.6 ED practice differs greatly from the “ideal” conditions of clinical trials and constitutes an accurate reflection of the normal clinical practice in patients' risk profile, as well as in its management.7 Therefore, the study of thromboembolism prophylaxis in the ED can give an illustration of the real degree of the application of clinical guidelines and recommendations in daily practice, as well as the reasons offered for not following them, and can contribute to the knowledge about what interventions must be established to increase adherence to these guidelines.
The objectives of the Spanish Atrial Fibrillation in Emergency Medicine Study Group8 (GEFAUR-1) study were (1) to determine the risk profile (risk of stroke and risk of hemorrhage) of patients with atrial fibrillation in a representative scenario of routine ED practice; and (2) to analyze the prescription of anticoagulation as stroke prophylaxis and how often this prescription is in accordance with accepted guidelines and recommendations (American College of Chest Physicians' guidelines9).
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Study design and setting
The GEFAUR-1 study was a cross-sectional, multicenter, observational study carried out in the EDs of 12 hospitals of the National Health System in Madrid, Spain, between June 15 and August 1, 2000, and was promoted by the Scientific Committee of the Spanish Society of Emergency Medicine. A detailed description of the GEFAUR-1 study methodology has been published elsewhere.8 The study protocol was approved by the Ethics Committee of the Spanish Society of Emergency Medicine. The protocol was
Characteristics of study subjects
During the study period, there were 66,146 visits to the ED medical areas, and 1,178 episodes of atrial fibrillation were included (3.6% of the medical emergency visits). There were no protocol violations of clinical importance in the recruitment; almost all episodes of atrial fibrillation in the 12 hospitals were included (only 11 eligible patients were missed, or the data collection forms were not accurately filled out). In the study population, the mean age±SD was 74.6±12.2 years, 55.6% of
Limitations
The main limitation of our study is that, as an observational study, no recommendations for therapy were made to the treating physicians. There are numerous guidelines on stroke prophylaxis in atrial fibrillation, with differences among them in risk stratification and in the indications for therapy. Thus, the use of any guideline as a standard for evaluation may be controversial. The American College of Chest Physicians' guidelines are widespread in our setting, they are published in a journal
Discussion
The ED population reported is unique and represents an important cross-spectrum of patients, many of whom are not hospitalized. In contrast, most published reports focus on inpatient or office-based populations.2., 3. In our series, the prevalence of episodes of atrial fibrillation in the overall ED population is larger than previously reported.18 The reasons for this focus are unclear but may be related to the high frequency of ED use in our country and the increased prevalence of elderly
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Stroke Prevention for High-Risk Atrial Fibrillation in the Emergency Setting: The Emergency Physician Perspective
2018, Canadian Journal of CardiologyRegistries in Atrial Fibrillation: From Trials to Real-Life Clinical Practice
2017, American Journal of MedicineDiscrepancy between guidelines for stroke prevention in atrial fibrillation and practice patterns in primary care. the nationwide French AFIGP survey
2015, Archives of Cardiovascular DiseasesStroke prophylaxis in atrial fibrillation: Searching for management improvement opportunities in the emergency department: The HERMES-AF study
2015, Annals of Emergency MedicineCitation Excerpt :As in other studies, this may reflect a certain lack of knowledge of the evidence-based indications for prophylaxis stated in the guidelines.11,19,24 Because the guidelines’ recommendations have been demonstrated to be widely applicable in daily practice9,12,19,26,27 and previous studies in local settings have demonstrated the usefulness of specific training to improve management’s adequacy,4,16,28 educational efforts to increase physicians’ adherence to the guidelines appear warranted and constitute a third area of management improvement found in our study. Antiplatelets were frequently considered by the treating physicians as adequate prophylaxis in high-risk patients, which constitutes a main reason for the lack of prescription of anticoagulation in eligible patients.
An emergency department intervention to increase warfarin use for atrial fibrillation
2014, Journal of Stroke and Cerebrovascular DiseasesAcute Treatment of Atrial Fibrillation in the Emergency Department
2013, Revista Espanola de Cardiologia Suplementos
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Author contributions: AM, CG, PL, and PG conceived and designed the study. AM supervised the conduct of the study and the data collection and was responsible for the design and codification of the data collection sheet. CG provided statistical advice on study design and the data analysis. CG, AM, and PL drafted the manuscript and take responsibility for the paper as a whole.
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Presented in part as an abstract at the XXIV Congress of the European Society of Cardiology, Berlin, Germany, September 1-4, 2002.
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Supported by an unintentional grant of 3M-Spain, which was not involved in any other way in the development of this study and had no influence in the contents of the article.
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Reprints not available from the authors.