Cardiology
Risk factors for stroke and thromboprophylaxis in atrial fibrillation: what happens in daily clinical practice? The GEFAUR-1 study,☆☆,,★★,☆☆☆

https://doi.org/10.1016/j.annemergmed.2004.01.010Get rights and content

Abstract

Study objectives

We determine the risk for stroke of patients with atrial fibrillation in the emergency department (ED) and analyze the use of stroke prophylaxis in this setting.

Methods

This was a cross-sectional study carried out in 12 EDs. Clinical variables, risk factors for stroke, the prophylaxis prescribed, and the reasons for not initiating anticoagulation were collected. Risk factors and indications for therapy were evaluated according to the American College of Chest Physicians' 1998 recommendations.

Results

Of 1,178 patients included, 69% were not taking anticoagulants. Of the latter, 89% patients had indications for anticoagulation (age >75 years 59%, hypertension 56%, cardiac disorders 29%, heart failure 22%, diabetes 22%, previous embolism 14%), and 63% of the patients had 2 or more risk factors. Anticoagulation was prescribed in the ED to 27% of patients (67% with warfarin, 33% low-weight heparin plus warfarin), antiplatelets to 20% of patients, and no thromboprophylaxis to 53% of these eligible patients. Anticoagulants were prescribed in only 9% of patients with risk factors and current prophylaxis with antiplatelet agents. The main reasons for not prescribing anticoagulation in the presence of risk factors were advanced age (11%), contraindication for anticoagulation (27%), or because it was not considered to be indicated by the physicians (23%).

Conclusion

Most patients seen in the ED with atrial fibrillation are at high risk of stroke. Despite this risk, anticoagulation is underused in this setting, mainly because of the influence of advanced age on medical decisions and the reluctance to change current antiplatelet therapy.

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).

Section snippets

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

References (29)

  • D.M. Fatovich

    Emergency medicine: recent developments

    BMJ

    (2002)
  • G. Magnusson

    The hospital emergency department as the primary source of medical care

    Scand J Soc Med

    (1980)
  • A. Martı́n et al.

    The Spanish Atrial Fibrillation in Emergency Medicine Study Group (GEFAUR): background, aims and design of a prospective multicenter study of atrial fibrillation in hospital emergency departments

    Emergencias

    (2001)
  • F. Villar et al.

    Situation of cardiovascular diseases in Spain

    Rev Clin Esp

    (2003)
  • Cited by (50)

    • Stroke prophylaxis in atrial fibrillation: Searching for management improvement opportunities in the emergency department: The HERMES-AF study

      2015, Annals of Emergency Medicine
      Citation 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.

    • Acute Treatment of Atrial Fibrillation in the Emergency Department

      2013, Revista Espanola de Cardiologia Suplementos
    View all citing articles on Scopus

    The participating investigators are listed in the Appendix.

    ☆☆

    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.

    Presented in part as an abstract at the XXIV Congress of the European Society of Cardiology, Berlin, Germany, September 1-4, 2002.

    ★★

    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.

    ☆☆☆

    Reprints not available from the authors.

    View full text