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Non-vitamin K antagonist oral anticoagulants and atrial fibrillation guidelines in practice: barriers to and strategies for optimal implementation.

Camm AJ, Pinto FJ, Hankey GJ, Andreotti F, Hobbs FD, Writing Committee of the Action for Stroke Prevention allian - Europace (2015)

Bottom Line: However, despite this guidance, registry data indicate that anticoagulation is still widely underused.With a focus on the 2012 update of the European Society of Cardiology (ESC) guidelines for the management of AF, the Action for Stroke Prevention alliance writing group have identified key reasons for the suboptimal implementation of the guidelines at a global, regional, and local level, with an emphasis on access restrictions to guideline-recommended therapies.Following identification of these barriers, the group has developed an expert consensus on strategies to augment the implementation of current guidelines, including practical, educational, and access-related measures.

View Article: PubMed Central - PubMed

Affiliation: Department of Clinical Cardiology, St George's University of London, London SW17 0RE, UK jcamm@sgul.ac.uk.

No MeSH data available.


Related in: MedlinePlus

European Society of Cardiology (ESC) guideline recommendations for the prevention of stroke in patients with AF.12 Antiplatelet therapy with ASA plus clopidogrel, or—less effectively—ASA only, should be considered in patients who refuse any oral anticoagulant or cannot tolerate anticoagulants for reasons unrelated to bleeding. If there are contraindications to oral anticoagulation or antiplatelet therapy, left atrial appendage occlusion, closure, or excision may be considered. CHA2DS2-VASc score: turquoise, 0; yellow, 1; red, ≥2. Line: solid, best option; dashed, alternative option. aIncludes rheumatic valvular disease and prosthetic valves. AF, atrial fibrillation; ASA, acetylsalicylic acid; CHA2DS2-VASc, ESC-recommended stroke risk score [Congestive heart failure/left ventricular dysfunction, Hypertension, Age ≥75 years (doubled) Diabetes, Stroke (doubled), Vascular disease, Age 65–74 years, Sex category (female)]; HAS-BLED, [ESC-recommended bleeding risk score, defined as Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly (e.g. age >65 years, frailty, etc.), Drugs/alcohol use]; NOAC, non-vitamin K antagonist oral anticoagulant; VKA, vitamin K antagonist. From Camm et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation. European Heart Journal Nov 2012, 33(21) 2719–2747. Reproduced with permission of Oxford University Press (UK) © European Society of Cardiology, www.escardio.org/guidelines
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EUV068F2: European Society of Cardiology (ESC) guideline recommendations for the prevention of stroke in patients with AF.12 Antiplatelet therapy with ASA plus clopidogrel, or—less effectively—ASA only, should be considered in patients who refuse any oral anticoagulant or cannot tolerate anticoagulants for reasons unrelated to bleeding. If there are contraindications to oral anticoagulation or antiplatelet therapy, left atrial appendage occlusion, closure, or excision may be considered. CHA2DS2-VASc score: turquoise, 0; yellow, 1; red, ≥2. Line: solid, best option; dashed, alternative option. aIncludes rheumatic valvular disease and prosthetic valves. AF, atrial fibrillation; ASA, acetylsalicylic acid; CHA2DS2-VASc, ESC-recommended stroke risk score [Congestive heart failure/left ventricular dysfunction, Hypertension, Age ≥75 years (doubled) Diabetes, Stroke (doubled), Vascular disease, Age 65–74 years, Sex category (female)]; HAS-BLED, [ESC-recommended bleeding risk score, defined as Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly (e.g. age >65 years, frailty, etc.), Drugs/alcohol use]; NOAC, non-vitamin K antagonist oral anticoagulant; VKA, vitamin K antagonist. From Camm et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation. European Heart Journal Nov 2012, 33(21) 2719–2747. Reproduced with permission of Oxford University Press (UK) © European Society of Cardiology, www.escardio.org/guidelines

Mentions: A focused update of the 2010 ESC guidelines for the management of AF was issued in 2012.12 This was partly in response to positive Phase III clinical trial data with the NOACs dabigatran, rivaroxaban, and apixaban,14–16 and their subsequent approval for stroke prevention in at-risk patients with non-valvular AF. The NOACs have shown equivalent or improved efficacy compared with warfarin in randomized controlled trials, with a reduction in the risk of severe bleeding events, in particular intracranial haemorrhage (ICH).14–17 In addition, they all offer fixed-dose regimens (with some dose reductions mandated in special populations, such as patients with renal impairment) that eliminate the need for the routine coagulation monitoring associated with vitamin K antagonists (VKAs). Edoxaban is currently the only one of these NOACs that is not yet widely approved in this indication. The ESC guidelines now recommend the use of the NOACs in most patients with a CHA2DS2-VASc [Congestive heart failure/left ventricular dysfunction, Hypertension, Age ≥75 years (doubled) Diabetes, Stroke (doubled), Vascular disease, Age 65–74 years, Sex category (female)] score of ≥1 in preference to VKAs (Figure 2), although in certain patients, e.g. those with severe renal impairment or underlying disease on echocardiogram, VKAs remain preferred. Antithrombotic treatment is not recommended in low-risk patients with a CHA2DS2-VASc score of 0.12 However, the latter group represented only 3–7% of patients in two large cohort studies,13,18 indicating that the majority of patients with AF are candidates for oral anticoagulation.Figure 2


Non-vitamin K antagonist oral anticoagulants and atrial fibrillation guidelines in practice: barriers to and strategies for optimal implementation.

Camm AJ, Pinto FJ, Hankey GJ, Andreotti F, Hobbs FD, Writing Committee of the Action for Stroke Prevention allian - Europace (2015)

European Society of Cardiology (ESC) guideline recommendations for the prevention of stroke in patients with AF.12 Antiplatelet therapy with ASA plus clopidogrel, or—less effectively—ASA only, should be considered in patients who refuse any oral anticoagulant or cannot tolerate anticoagulants for reasons unrelated to bleeding. If there are contraindications to oral anticoagulation or antiplatelet therapy, left atrial appendage occlusion, closure, or excision may be considered. CHA2DS2-VASc score: turquoise, 0; yellow, 1; red, ≥2. Line: solid, best option; dashed, alternative option. aIncludes rheumatic valvular disease and prosthetic valves. AF, atrial fibrillation; ASA, acetylsalicylic acid; CHA2DS2-VASc, ESC-recommended stroke risk score [Congestive heart failure/left ventricular dysfunction, Hypertension, Age ≥75 years (doubled) Diabetes, Stroke (doubled), Vascular disease, Age 65–74 years, Sex category (female)]; HAS-BLED, [ESC-recommended bleeding risk score, defined as Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly (e.g. age >65 years, frailty, etc.), Drugs/alcohol use]; NOAC, non-vitamin K antagonist oral anticoagulant; VKA, vitamin K antagonist. From Camm et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation. European Heart Journal Nov 2012, 33(21) 2719–2747. Reproduced with permission of Oxford University Press (UK) © European Society of Cardiology, www.escardio.org/guidelines
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4482288&req=5

EUV068F2: European Society of Cardiology (ESC) guideline recommendations for the prevention of stroke in patients with AF.12 Antiplatelet therapy with ASA plus clopidogrel, or—less effectively—ASA only, should be considered in patients who refuse any oral anticoagulant or cannot tolerate anticoagulants for reasons unrelated to bleeding. If there are contraindications to oral anticoagulation or antiplatelet therapy, left atrial appendage occlusion, closure, or excision may be considered. CHA2DS2-VASc score: turquoise, 0; yellow, 1; red, ≥2. Line: solid, best option; dashed, alternative option. aIncludes rheumatic valvular disease and prosthetic valves. AF, atrial fibrillation; ASA, acetylsalicylic acid; CHA2DS2-VASc, ESC-recommended stroke risk score [Congestive heart failure/left ventricular dysfunction, Hypertension, Age ≥75 years (doubled) Diabetes, Stroke (doubled), Vascular disease, Age 65–74 years, Sex category (female)]; HAS-BLED, [ESC-recommended bleeding risk score, defined as Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly (e.g. age >65 years, frailty, etc.), Drugs/alcohol use]; NOAC, non-vitamin K antagonist oral anticoagulant; VKA, vitamin K antagonist. From Camm et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation. European Heart Journal Nov 2012, 33(21) 2719–2747. Reproduced with permission of Oxford University Press (UK) © European Society of Cardiology, www.escardio.org/guidelines
Mentions: A focused update of the 2010 ESC guidelines for the management of AF was issued in 2012.12 This was partly in response to positive Phase III clinical trial data with the NOACs dabigatran, rivaroxaban, and apixaban,14–16 and their subsequent approval for stroke prevention in at-risk patients with non-valvular AF. The NOACs have shown equivalent or improved efficacy compared with warfarin in randomized controlled trials, with a reduction in the risk of severe bleeding events, in particular intracranial haemorrhage (ICH).14–17 In addition, they all offer fixed-dose regimens (with some dose reductions mandated in special populations, such as patients with renal impairment) that eliminate the need for the routine coagulation monitoring associated with vitamin K antagonists (VKAs). Edoxaban is currently the only one of these NOACs that is not yet widely approved in this indication. The ESC guidelines now recommend the use of the NOACs in most patients with a CHA2DS2-VASc [Congestive heart failure/left ventricular dysfunction, Hypertension, Age ≥75 years (doubled) Diabetes, Stroke (doubled), Vascular disease, Age 65–74 years, Sex category (female)] score of ≥1 in preference to VKAs (Figure 2), although in certain patients, e.g. those with severe renal impairment or underlying disease on echocardiogram, VKAs remain preferred. Antithrombotic treatment is not recommended in low-risk patients with a CHA2DS2-VASc score of 0.12 However, the latter group represented only 3–7% of patients in two large cohort studies,13,18 indicating that the majority of patients with AF are candidates for oral anticoagulation.Figure 2

Bottom Line: However, despite this guidance, registry data indicate that anticoagulation is still widely underused.With a focus on the 2012 update of the European Society of Cardiology (ESC) guidelines for the management of AF, the Action for Stroke Prevention alliance writing group have identified key reasons for the suboptimal implementation of the guidelines at a global, regional, and local level, with an emphasis on access restrictions to guideline-recommended therapies.Following identification of these barriers, the group has developed an expert consensus on strategies to augment the implementation of current guidelines, including practical, educational, and access-related measures.

View Article: PubMed Central - PubMed

Affiliation: Department of Clinical Cardiology, St George's University of London, London SW17 0RE, UK jcamm@sgul.ac.uk.

No MeSH data available.


Related in: MedlinePlus