Influence of ageism on guideline adeherence in seniors with atrial fibrillation in the local practise of private cardiology clinic among years 2012 a 2017

Czech version

Authors: Peter Olexa ^1,2; Martina Habiňáková ³; Štefan Koval ¹
Authors‘ workplace: Gerontologická a geriatrická klinika, LF UPJŠ, Nemocnica Sv. Michala, Košice, Slovenská republika ¹; TOPCARE, s. r. o., privátna kardiologická ambulancia, Košice, Slovenská republika ²; Ústav lekárskej informatiky LF UPJŠ Košice, Slovenská republika ³
Published in: Vnitř Lék 2020; 66(8): 5-11
Category: Original Contributions

Overview

Background: Atrial fibrillation (AF) is a problem of growing prevalence as a consequence of the ageing population, is associated with high morbidity, mortality, and healthcare costs. The risk is significantly reduced by oral anticoagulation. Adherence to guidelines may lower the risks for both all cause and cardiovascular (CV) deaths.

Methods: Our objective was to evaluate the type and adherence of prescribed antithrombotic treatment according to the 2012 and 2016 European Society of Cardiology (ESC) guidelines in studied group of consecutive patients managed in private cardiology office in years 2012 and 2017. Only patients with diagnosis of AF were analysed. We aimed to prove, if nonadherence is associated with higher rate of adverse outcomes. Data were obtained from consecutive patients managed in private cardiology office in years 2012 and 2017. Only patients with diagnosis of AF older than 65 years were analysed.

Results: Among 2 850 patients examined in 2012, 213 (8 %) were discharged with a diagnosis of AF. In 2017 we examined 4 389 patients, 401 (9 %) diagnosed with AF, among them 350 older than 65 (87.5%). Median age in both groups was 76 ys. Significant differences in the frequency and type of anticoagulation therapy were observed between 2012 and 2016 – warfarin was used in 102 (47 %) vs 110 (31 %), NOACs in 25 (12 %) vs 189 (54 %), ASA or clopidogrel in 68 (32 %) vs. 41 (12 %). None antitrombotics were used in 20 (10 %) vs 10 (3 %). Based on ESC guidelines, both groups were divided into two subgroups according to the guideline adherence to proper anticoagulation therapy. The quality of medical treatment increased significantly from 2012 to 2017. 61 % of patients were on guideline-adherent thromboprophylaxis, 39 % were undertreated in 2012, while in 2017 the guidelines were followed much better – 14 % were undertreated vs 86 % treated properly. We examined statistically the importance of age, frailty, history of ischaemic stroke, minor heamorhage, and values of CHADS2 and HASBLED indexes for the nonadherence to Guideline aproved antitrombotic management. Series of binary logistic analyses showed that increasing age (p = 0.05), and concomitant history of minor bleeding (p = 0.003) were associated with undertreatment in 2012, while in 2017 HASBLED score (p < 0.051), nor other studied factor led to non-adherence to Guideline aproved therapy. AF patients who were guideline adherent had a lower rate of all-cause death (p = 0.007) compared to those non-adherent. Binary logistic regresion analysis showed that guideline-nonadherent patients had a higher risk for all-cause mortality (p = 0.003).

Conclusion: Non-adherence to guidelines is currently less prevalent among elderly AF patients compared to clinical treatment in previous years. Proper Guideline-adherent treatment is being independently associated with lower risk of all-cause mortality. Efforts to improve guideline adherence would lead to better outcomes for elderly and frail AF patients.

Keywords:

antithrombotic therapy – atrial fibrillation – elderly – frailty – guidelines – outcomes

Sources

1. Koval Š. Antropologický rozmer epidemiológie staroby. Košice: PonT, s. r. o., 2001, 176 p.

2. Tulner LR, van Campen JP, Kuper IM, et al. Reasons for undertreatment with oral anticoagulants in frail geriatric outpatients with atrial fibrillation: a prospective, descriptive study. Drugs Aging 2010; 27: 39–50.

3. Kirchhoff P, Benussi S, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal 2016; 38: 2893–2962.

4. Piccini JP, Stevens SR, Singer DE, et al. Renal dysfunction as a predictor of stroke and systemic embolism in patients with nonvalvular atrial fibrillation: validation of the R(2) CHADS(2) index in the ROCKET and ATRIA) study cohorts. Circulation 2013; 127: 224–232.

5. Slezáková V, Varga Z, Potočárová M, et al. Antikoagulačná terapia u geriatrických pacientov s fibriláciou predsiení Klin Farmakol Farm 2013; 27: 13–17.

6. Dúbrava M, Németh F, Drobná T, et al. Echokardiografia a fibrilácia predsiení u seniorov: údaje zo štúdie SAFIS. Cardiology Lett 2016; 26: 443–448.

7. Urban L, et al. Údaje dostupné len elektronicky: http://www.arytmie.sk/registre/slov‑fib/.

8. Proietti M. Adherence to antithrombotic therapy guidelines improves mortality among elderly patients with atrial fibrillation: insights from the REPOSI study. Clinical Research in Cardiology 2016; 105: 912–920.

9. Van Walraven C, Hart RG, Connolly S, et al. Effect of age on stroke prevention therapy in patients with atrial fi brillation: the atrial fibrillation investigators. Stroke 2009; 40: 1410–1416.

10. Ruff CT, Giugliano RP, Braunwald E et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta‑analysis of randomised trials. Lancet 2014; 383: 955–962.

11. Fried LP, Tangen CM, Walston J, et al. Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56: M146–M156.

12. Weber P, Ambrošová A, Weberová D, et al. Geriatrické syndromy a syndrom frailty - zlatý grál geriatrické medicíny. Vnitř Lék 2011; epublished: https://www.vnitrnilekarstvi.eu/casopi‑ sy/vnitrni‑lekarstvi/2011-11/geriatricke‑syndromy‑a-syndrom‑frailty‑zlaty‑gral‑geriatricke‑mediciny-36460.

13. Weber P, Prudius D, Meluzínová H. Geriatric multimorbidity - one of the key problem of contemporary medicine. Vnitř Lék 2015; 61: 1042–1048.

14. Arahamian I, Cezar NOC, Izbicki R, et al. Screening for Frailty With the FRAIL Scale: A Comparison With the Phenotype Criteria. J Am Med Dir Assoc 2017; 18: 592–596.