Are patients with persistent Atrial Fibrillation and a
Are patients with persistent Atrial Fibrillation and a CHADS 2 score of ≥ 2 on warfarin? Lucinda Stephenson Binscombe Medical Centre July 2011
Introduction • Prevalence of AF 1. 2% • 18% strokes- AF • AF associated with worse morbidity and mortality • ~ 40% of patients not on warfarin – Prevent 6000 strokes a year – Save 4000 lives a year
CHADS 2 CHAD item Score Congestive heart failure 1 Hypertension 1 ≥ 75 years old 1 Diabetes 1 Prior stroke or TIA 2
Risk calculation for CHADS 2 Total Score Risk of Stroke Antithrombotic therapy indicated 0 Low Aspirin 1 Moderate Warfarin or aspirin ≥ 2 High Warfarin
Risk of stroke stratified by CHADS 2 score Annual stroke risk (95% CI) 0 1. 9% 1 2. 8% 2 4% 3 5. 9% 4 8. 5% 5 12. 5%
Bleeding risk with warfarin • >75 years • Taking anti-platelets or NSAIDS • Multiple drug treatments • Uncontrolled hypertension • History of bleeding • History of poorly controlled anticoagulation therapy • (Falls- 295 times in 1 year)
Contraindications to warfarin • Pregnancy • Hypersensitivity to warfarin • Within 2 days of surgery • Bacterial endocarditis • Severe renal or hepatic disease • Peptic ulcer • Severe hypertension
Standard • All patients with persistent AF who have a CHADS 2 score ≥ 2 and no contraindications to warfarin should be treated with warfarin
Data Collection • Retrospective audit • GRASP – Provides a sat of MIQUEST queries to identify patients with AF – Calculates CHADS 2 score
Results • 240/10315 patients with atrial fibrillation/flutter 2. 33% – CHADS 2 11. 51% score > 65 and AF/flutter Number Percentage 0 39 • Risk profile for thromboembolism 16. 25 1 56 23. 33 >1 145 60. 42
Warfarin use in high risk patients (CHADS 2>1) Number Percentage Patients on warfarin 77 53. 1 Patients not on warfarin 68 46. 9 Patients on warfarin and anti-platelet agents in CHADS 2 groups CHADS 2 score None Antiplatelet Warfarin Both 0 20 11 6 2 1 16 27 11 2 >1 20 48 71 6
CHADS 2 2 • 36 patients not on warfarin • 10 patients warfarin C/I
Consider warfarin • 9 patients • 12487 (SJP)- is on warfarin • 20781 (MDB) • 20972 (MDB) • 21079 (MCW) • 22688 (POD) • 23962 (MCW) • 24188 (MCW) • 29940 (POD) has been referred to cardiology • 33715 (CEG)
Warfarin contraindicated • 9 patients • 11088 (POD) bladder cancer • 20425 (KAJ) GI bleed • 23551 (SJP) oesophageal cancer-palliative • 26180 (MCW) 91 dementia • 42883 (ASC) previous DU • 42912 (POD) dementia, previous subdural • 43139 (POD) dementia • 43248 (CEG) dementia • 44175 (POD) dementia
Cardioversion • 4 patients • 10241 (POD) atrial flutter • 13404 (MCW) atrial flutter • 15018 (CEG) • 20027 (CEG)
Cardiology Review- not suitable • 4 patients • 12114 (MCW) • 12889 (ASC) • 16613 (MCW) • 20339 (ASC)
Paroxysmal Atrial Fibrillation • 8 patients • 11666 (SJP)- 1 episode • 15373 (MCW)- AF resolved • 20676 (MDB) • 20428 (ASC) • 20924 (POD) • 22061 (ASC) paroxysmal atrial tachycardia • 39129 (ASC) seen by cardiology not for warfarin @ present • 44560 (MDB) being ix by cardiology for presyncope
Other • 2 patients • 10618 (SJP) on chemotherapy on therapeutic clexane • 11268 (MDB) ECG SR with 1 ectopic
CHADS 2 3 • 8/33 not on warfarin • 44892 - should be on aspirin – RIP (41799) – Palliative care- carcinoid (PAF-ablation) (12120) – Warfarin stopped- 2 ablations now SR. On aspirin (33896) – 103 started on aspirin by RSCH 2001, warfarin not indicated (34600) – Extreme fragility and dementia. On aspirin (41617) – Dementia, on aspirin (44427) – Warfarin C/I- Upper GI bleed (45018)
CHADS 2 4 • 4/21 not on warfarin – Warfarin stopped 2003 due to falls, still having falls and not safe walking alone (10207) – Paroxysmal AF. Aspirin stopped due to GORD. (20801) – End stage dementia. On clopidogrel (36920) – Warfarin stopped 2006 due to falls. On aspirin and dipyridamole (39301)
CHADS 2 score 5 • 2/9 not on warfarin – New patient in NH, dementia. On Aspirin and dipyridamole (44664) – Ablation and ICD now on aspirin (41941)
Further Action/ Re-audit • Registered GP to review patients’ notes and if in agreement, send letter to invite patients to discuss warfarin/ refer to cardiology • Code patients appropriately that are not suitable for warfarin • Re-audit on a 6 monthly basis • New patients with AF- calculate CHADS 2 score and assess suitability for warfarin
Conclusion • Binscombe are performing well • More a case of coding patients appropriately
References • Lip G, Kakar P, Watson T. Atrial Fibrillation- the growing epidemic. Heart 2007; 93: 542 -543 • Hankey G, Eikelboom J. Ximelagatran or warfarin for stroke prevention in patients with atrial fibrillation? Stroke 2004; 35: 389 -91 • Miller P, Andersson F, Kalra L. Are cost benefits of anticoagulation for stroke prevention in atrial fibrillation underestimated? Stroke 2005; 36: 360 -366 • NICE CG 036 Atrial fibrillation: the management of atrial fibrillation costing report: implementing NICE guidance in England 2006. http: //www. nice. org. uk/Guidance/CG 36/Cost. Report/pdf/English • Brian F, Gage et al. Validation of clinical classification schemes for predicting stroke. JAMA 2001; 285: 2864 -2870 • NHS improvement. Commissioning for stroke prevention in primary care- the role of atrial fibrillation 06/09 • Mant et al The Lancet 370: 11. 08. 07 • BNF March 2009 Pharmaceutical Press • SIGN guideline No 36 http: //www. signs. ac. uk/guidelines/fulltext/36/index. html March 1999 • Man-Son-Hing et al Arch Intern Med 1999; 159 (7): 677 -85
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