scholarly journals P094: The frequency of stroke risk assessment tools used to assess patients presenting to the emergency department with atrial fibrillation and flutter

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S109-S110
Author(s):  
T. Nikel ◽  
S.W. Kirkland ◽  
S. Campbell ◽  
B.H. Rowe
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Stroke Risk ◽  
Grey Literature ◽  
Anticoagulation Therapy ◽  
Adult Patients ◽  
Assessment Tools ◽  
Risk Scores ◽  
Atrial Fibrillation And Flutter ◽  
Attending Physicians

Introduction: Acute atrial fibrillation or flutter (AFF) is the most common dysrhythmia managed in the emergency department (ED). A key component of managing AFF in the ED is the prevention of stroke. Predictive indices (e.g., CHADS2 , HAS-BLED) should be used to assess each patient’s risk of stroke and bleeding to determine the appropriate anticoagulation therapy. The frequency of use of these predictive indices in the emergency department to determine appropriate anticoagulation therapy remains unclear. This systematic review is designed to examine the use of risk scores in the ED to determine the management of patients presenting to the ED for atrial fibrillation and flutter. Methods: An extensive search of eight electronic databases and grey literature was conducted. Quasi-experimental studies were eligible for inclusion. Studies had to report on the ED management of adult patients presenting with AFF to be included. Two independent reviewers judged the relevance, inclusion, and risk of bias of the studies. Individual and pooled statistics were calculated as odds ratios (OR) with 95% CI using a random effects model and heterogeneity (I2) was reported. Results: From 1,648 citations, 37 studies were included in this review. Heterogeneity was very high, precluding pooling. Only one of the included studies documented the use of CHADS2 scores by attending physicians; while no studies documented the use of HAS-BLED. There was variability in the ED management strategies of AFF. The utilization of rhythm control in the treatment of AFF ranged considerable (OR: 0.04-9.84) in comparison to rate control. Of the 17 studies reporting cardioversion approaches, chemical (9 {53%}) cardioversion was the most common management strategy of AFF. Conclusion: Our results suggests that either few physicians are documenting stroke risk scores in adult patients with AFF, or that research studies assessing ED management of AFF are not reporting scores documented by the attending physicians. Future research needs to examine the use of stroke risk scores to determine the optimal and appropriate care for patients.

Abstract 18538: The ATRIA Stroke Risk Score Predicts Ischemic Stroke Better than CHADS2 and CHA2DS2-VASc in a large Swedish Cohort of Patients with Atrial Fibrillation

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Sara Aspberg ◽  
Yuchiao Chang ◽  
Daniel Singer
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Risk Score ◽  
Stroke Risk ◽  
Anticoagulation Therapy ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Cut Points ◽  
Net Clinical Benefit ◽  
Better Than

Introduction: Atrial fibrillation (AF) is a major risk factor for acute ischemic stroke (AIS). Anticoagulation therapy (OAC) effectively prevents AIS, but increases bleeding risk. There is a need for better AIS risk prediction to optimize the anticoagulation decision in AF. The ATRIA stroke risk score (ATRIA) (table) was superior to CHADS2 and CHA2DS2-VASc in two large California community AF cohorts. We now report the performance of the 3 scores in a very large Swedish AF cohort. Methods: The cohort consisted of all Swedish patients hospitalized with a diagnosis of AF from July 1, 2005 to December 31, 2008. Predictor variables and the outcome, AIS, were obtained from inpatient ICD-10 codes. Warfarin use was determined from National Pharmacy Database. Risk scores were assessed via c-index (C) and net reclassification index (NRI). Results: The cohort included 158,370 AF patients off warfarin who contributed 340,332 person-years of follow-up, and 11,823 incident AIS, for an overall AIS rate of 3.47%/yr, higher than the 2%/yr seen in the California cohorts. Using the entire point score, ATRIA had a good C of 0.712 (0.708-0.716), significantly better than CHADS2, 0.694 (0.689-0.698), or CHA2DS2-VASc, 0.697 (0.693-0.702). Using published cut-points for Low/Moderate/High AIS risk, C deteriorated for all scores but ATRIA and CHADS2 were superior to CHA2DS2-VASc. NRI favored ATRIA; 0.16 (0.15-0.18) versus CHADS2; 0.22 (0.21-0.24) versus CHA2DS2-VASc. However, NRI decreased to near-zero when cut-points were altered to better fit the cohort’s stroke rates. Conclusion: Findings in this large Swedish AF cohort validate those in the California AF cohorts, with the ATRIA score predicting stroke risk better than CHADS2 or CHA2DS2-VASc. However, relative performance of the categorical scores varied by population stroke risk. Knowledge about this population risk may be needed to optimize cut-points on the multipoint scores to achieve better net clinical benefit from OAC.

Abstract 169: Bleeding Incidence By Stroke Risk Among Patients With Nonvalvular Atrial Fibrillation In A Large Managed Care Population

2012 ◽  
Vol 5 (suppl_1) ◽  
Author(s):  
Steven B Deitelzweig ◽  
Brett Pinsky ◽  
Erin Buysman ◽  
Michael Lacey ◽  
Dinara Makenbaeva ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Managed Care ◽  
Real World ◽  
Stroke Risk ◽  
Anticoagulation Therapy ◽  
Administrative Claims ◽  
Bleeding Events ◽  
Nonvalvular Atrial Fibrillation ◽  
Outpatient Hospital

Introduction Stroke prevention among patients with nonvalvular atrial fibrillation (NVAF) requires careful assessment of both the risk of stroke and bleeding. Hypothesis We hypothesized that in a real-world managed care population of patients with NVAF, bleeding incidence increases with CHADS2 stroke risk. Methods Administrative claims data were used for this retrospective study. Adults with healthcare claims related to AF (ICD-9-CM 427.31) between Jan 2005 and Jun 2009 but no evidence of valvular disease were included. Patients were followed until the earliest of death, disenrollment from the health plan, or 30 Jun 2010. Patients were categorized based on CHADS2 scores of 0, 1, 2, or ≥3, with higher scores indicating more risk factors. A bleeding event was considered major if it was associated with any of the following: inpatient care, blood transfusion, decreased hemoglobin or hematocrit, death, physician guided medical or surgical treatment, or intracranial bleed. Serious non-major events were those involving vascular injury or critical site bleeding and were associated with outpatient hospital care or an emergency department visit. Minor bleeds were those associated with noncritical anatomical sites and an emergency department, outpatient hospital, or office visit. Results The mean (SD) age of the study sample (N=48,260) was 67±13 years and 62% of the patients were male. Mean follow-up duration was 802±540 days (median 673 days). Mean (SD) baseline CHADS2 score was 1.48±1.15. Event rates for each bleeding category increased with increasing CHADS2 scores (Table). Conclusions Patients with NVAF in a real-world managed care setting who had high stroke risk also had a high rate of bleeding events, including major events. Patients at high risk for stroke might require more careful selection of anticoagulation therapy to avoid bleeding events.

Interventions to Improve Emergency Department–Related Transitions in Care for Adult Patients With Atrial Fibrillation and Flutter

2019 ◽  
Vol 57 (4) ◽  
pp. 501-516 ◽  
Author(s):  
James Gilbertson ◽  
Retha Moghrabi ◽  
Scott W. Kirkland ◽  
Kaitlyn Tate ◽  
William Sevcik ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Adult Patients ◽  
Transitions In Care ◽  
Atrial Fibrillation And Flutter

Stroke Risk Scores as Predictors of Severe Outcomes in Atrial Fibrillation

2021 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Andreea Cristina Ivănescu ◽  
Cătălin Adrian Buzea ◽  
Caterina Delcea ◽  
Gheorghe Andrei Dan
Keyword(s):  
Atrial Fibrillation ◽  
Stroke Risk ◽  
Risk Scores

Abstract 77: Balancing Risks and Benefits of Anticoagulation Therapy in Atrial Fibrillation in Community Practice: Results from the ORBIT-AF Registry

2012 ◽  
Vol 5 (suppl_1) ◽  
Author(s):  
Michael W Cullen ◽  
Sunghee Kim ◽  
Jonathan P Piccini ◽  
Alan S Go ◽  
Gregg C Fonarow ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Stroke Risk ◽  
Anticoagulation Therapy ◽  
Bleeding Risk ◽  
Community Practice ◽  
Chads2 Score ◽  
Risk Patients ◽  
Study Population ◽  
Risk Treatment ◽  
The Cost

Background Oral anticoagulation (OAC) can reduce stroke risk at the cost of increased bleeding risk in those with atrial fibrillation (AF). Observational data have shown that higher-risk patients with AF most likely to benefit from OAC are less likely to receive OAC at hospital discharge. Methods We used data from ORBIT-AF Registry, a cohort of 9,589 AF patients enrolled among 173 participating outpatient practices. OAC was defined as warfarin or dabigatran use at study enrollment. Stroke and bleeding risk were calculated using the CHADS2 and ATRIA scores, respectively. Results The study population had a mean age of 73.5 years; 57.8% were men. Overall, 76.4% of patients received OAC. Use of OAC rose with increasing CHADS2 stroke risk, from 67% for CHADS2 <1 to 80% for CHADS2 ≥2 (p<0.0001). OAC use fell slightly with increasing ATRIA bleeding risk, from 77% for ATRIA score ≤3 to 74% with ≥5 (p=0.002 for trend). Among patients with low bleeding risk, rates of OAC increased commensurate with stroke risk (p<0.0001 for interaction; see figure). Higher bleeding risk tended to decrease rates of OAC among patients with a CHADS2 score ≥2 (p=0.13 for interaction). Conclusions In community-based outpatients with AF, use of OAC rose with increasing thromboembolic risk and declined with higher bleeding risk. These findings suggest that the risk-treatment paradox may be less that previously reported. Provision of OAC in community practice appears to appropriately consider patients' stroke and bleeding risks. Further research is required to understand how quality improvement initiatives can further improve stroke prevention.

scholarly journals Use of mHealth Devices to Screen for Atrial Fibrillation: Cost-Effectiveness Analysis (Preprint)

2020 ◽  
Author(s):  
Godwin D Giebel
Keyword(s):  
Atrial Fibrillation ◽  
Cost Effectiveness ◽  
Economic Burden ◽  
Health Care Systems ◽  
Anticoagulation Therapy ◽  
Risk Scores ◽  
Increased Risk ◽  
Care Systems ◽  
Additional Costs ◽  
The Cost

BACKGROUND With an estimated prevalence of around 3% and an about 2.5-fold increased risk of stroke, atrial fibrillation (AF) is a serious threat for patients and a high economic burden for health care systems all over the world. Patients with AF could benefit from screening through mobile health (mHealth) devices. Thus, an early diagnosis is possible with mHealth devices, and the risk for stroke can be markedly reduced by using anticoagulation therapy. OBJECTIVE The aim of this work was to assess the cost-effectiveness of algorithm-based screening for AF with the aid of photoplethysmography wrist-worn mHealth devices. Even if prevented strokes and prevented deaths from stroke are the most relevant patient outcomes, direct costs were defined as the primary outcome. METHODS A Monte Carlo simulation was conducted based on a developed state-transition model; 30,000 patients for each CHA<sub>2</sub>DS<sub>2</sub>-VASc (Congestive heart failure, Hypertension, Age≥75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category [female]) score from 1 to 9 were simulated. The first simulation served to estimate the economic burden of AF without the use of mHealth devices. The second simulation served to simulate the economic burden of AF with the use of mHealth devices. Afterwards, the groups were compared in terms of costs, prevented strokes, and deaths from strokes. RESULTS The CHA<sub>2</sub>DS<sub>2</sub>-VASc score as well as the electrocardiography (ECG) confirmation rate had the biggest impact on costs as well as number of strokes. The higher the risk score, the lower were the costs per prevented stroke. Higher ECG confirmation rates intensified this effect. The effect was not seen in groups with lower risk scores. Over 10 years, the use of mHealth (assuming a 75% ECG confirmation rate) resulted in additional costs (€1=US $1.12) of €441, €567, €536, €520, €606, €625, €623, €692, and €847 per patient for a CHA<sub>2</sub>DS<sub>2</sub>-VASc score of 1 to 9, respectively. The number of prevented strokes tended to be higher in groups with high risk for stroke. Higher ECG confirmation rates led to higher numbers of prevented strokes. The use of mHealth (assuming a 75% ECG confirmation rate) resulted in 25 (7), –68 (–54), 98 (–5), 266 (182), 346 (271), 642 (440), 722 (599), 1111 (815), and 1116 (928) prevented strokes (fatal) for CHA<sub>2</sub>DS<sub>2</sub>-VASc score of 1 to 9, respectively. Higher device accuracy in terms of sensitivity led to even more prevented fatal strokes. CONCLUSIONS The use of mHealth devices to screen for AF leads to increased costs but also a reduction in the incidence of stroke. In particular, in patients with high CHA<sub>2</sub>DS<sub>2</sub>-VASc scores, the risk for stroke and death from stroke can be markedly reduced.

scholarly journals An mHealth intervention to improve nurses’ atrial fibrillation and anticoagulation knowledge and practice: the EVICOAG study

2018 ◽  
Vol 18 (1) ◽  
pp. 7-15 ◽  
Author(s):  
Caleb Ferguson ◽  
Louise D Hickman ◽  
Jane Phillips ◽  
Phillip J Newton ◽  
Sally C Inglis ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Risk Assessment ◽  
Anticoagulation Therapy ◽  
Bleeding Risk ◽  
Assessment Tools ◽  
Future Research ◽  
Post Intervention ◽  
Mhealth Intervention ◽  
Quasi Experimental ◽  
Nurses Knowledge

Background: There is a need to improve cardiovascular nurses’ knowledge and practices related to stroke prevention, atrial fibrillation and anticoagulation therapy. Aims: The aim of this study was to evaluate the efficacy of EVICOAG – a novel mHealth, smartphone-based, spaced-learning intervention on nurses’ knowledge of atrial fibrillation and anticoagulation. Methods: Nurses employed in four clinical specialties (neuroscience, stroke, rehabilitation, cardiology) across three hospitals were invited to participate. In this quasi-experimental study, 12 case-based atrial fibrillation and anticoagulation learning scenarios (hosted by an mHealth platform) were delivered to participants’ smartphones over a 6-week period (July–December 2016) using a spaced timing algorithm. Electronic surveys to assess awareness and knowledge were administered pre (T1) and post (T2) intervention. Results: From 74 participants recruited to T1, 40 completed T2. There was a 54% mean improvement in knowledge levels post-intervention. The largest improvement was achieved in domains related to medication interaction and stroke and bleeding risk assessment. Post-intervention, those who completed T2 were significantly more likely to use CHA2DS2-VASc (2.5% vs. 37.5%) and HAS-BLED (2.5% vs. 35%) tools to assess stroke and bleeding risk, respectively ( P<0.01). Conclusion: The EVICOAG intervention improved nurses’ knowledge of atrial fibrillation and anticoagulation, and influenced their uptake and use of stroke and bleeding risk assessment tools in clinical practice. Future research should focus on whether a similar intervention might improve patient-centred outcomes such as patients’ knowledge of their condition and therapies, medication adherence, time in the therapeutic range and quality of life.

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