Atrial Fibrillation
Treatment behavior of atrial fibrillation (part 1 of 2)
Saturday, July 1, 2006
PTINR.com Staff
Treatment rates of AF has improved but has a way to go.
Treatment rates for atrial fibrillation remain low, especially for nursing home patients. The Journal of American Medical Directors Association’s January 2006 issue highlighted the results of a Bronx Hospital’s survey of attitudes toward using warfarin (Coumadin ®) in patients with atrial fibrillation.
Residents, fellows and attending physicians provided feedback through 107 completed surveys. 85% of the patients with atrial fibrillation were not given warfarin “not indicated” however 88% were provided an anti-platelet agent.
J Am Med Dir Assoc, January 1, 2006; 7(1): 23-8
Warfarin is indicated for patients with atrial fibrillation based on recent American College of Chest Physicians (CHEST) in the absence of contraindications. The survey found an astounding 98% of responders stating “risk of falls” as the most common reason for withholding warfarin treatment.
J Am Med Dir Assoc, January 1, 2006; 7(1): 23-8
Interesting how “risk of falling” ranked so high considering 100% of the patients were in a skilled nursing facility suggesting most if not all patients were under professional supervision in a facility where handrails and assistance is available if not required by law.
An additional subgroup of patients with atrial fibrillation not indicated for warfarin include patients under 75 years old and with no underlying cardiovascular disease or co-morbid conditions placing the patient at risk of stroke. Close to one third of responses to withhold warfarin treatment was a short life expectancy. There are many reasons for short life expectancy other than specifically age. Combining risk of falling and short life expectancy would suggest more than 2% of patients in the Our Lady of Mercy facility were eligible candidates.
A treatment bias against warfarin remains even though bleeding risks are lower than the annualized risks of thromboembolism in higher risk patient groups. The authors concluded,
“Although long-term anticoagulation for thromboembolic events in atrial fibrillation is considered beneficial, recent reports suggest that warfarin is underused in older adults, especially in the long-term care setting. Our physician poll, based on a specific case scenario, is consistent with this opinion as reflected by both trainees and practicing physicians. While there are absolute and relative contraindications to the use of long-term warfarin, decisions should be individualized and based on risks, benefits, and quality of life of the resident.” Journal of American Medical Directors Association, 2006