open access

Vol 24, No 2 (2017)
Original articles — Clinical cardiology
Published online: 2017-01-02
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Pilot of a Computerised Antithrombotic Risk Assessment Tool Version 2 (CARATV2.0) for stroke prevention in atrial fibrillation

Yishen Wang, Beata Bajorek
DOI: 10.5603/CJ.a2017.0003
·
Pubmed: 28070883
·
Cardiol J 2017;24(2):176-187.

open access

Vol 24, No 2 (2017)
Original articles — Clinical cardiology
Published online: 2017-01-02

Abstract

Background: The decision-making process for stroke prevention in atrial fibrillation (AF) requires a comprehensive assessment of risk vs. benefit and an appropriate selection of antithrombotic agents (e.g., warfarin, non-vitamin K antagonist oral anticoagulants [NOACs]). The aim of this pilot-test was to examine the impact of a customised decision support tool — the Computerised Antithrombotic Risk Assessment Tool (CARATV2.0) using antithrombotic therapy on a cohort of patients with AF.

Methods: In this prospective interventional study, 251 patients with AF aged ≥ 65 years, admitted to a teaching hospital in Australia were recruited. CARATV2.0 generated treatment recommendations based on patient medical information. Recommendations were provided to prescribers for consideration.

Results: At baseline (admission), 30.3% of patients were prescribed warfarin, 26.7% an antiplatelet, 8.4% apixaban, 8.0% rivaroxaban, 3.6% dabigatran. CARATV2.0 recommended a change of therapy for 153 (61.0%) patients. Through recommendations of CARATV2.0, at discharge, 40.2% of patients were prescribed warfarin, 17.7% antiplatelet, 14.3% apixaban, 10.4% rivaroxaban, 5.6% dabigatran. Overall, the proportion of patients receiving an antithrombotic on discharge increased significantly from baseline (admission) (baseline 77.2% vs. 89.2%; p < 0.001). Prescribers moderately agreed with CARATV2.0’s recommendations (kappa = 0.275, p < 0.001). Practical medication safety issues were cited as major reasons for not accepting a desire to continue therapy with CARATV2.0’s recommendations. Factors predicting the prescription of antiplatelets rather than anticoagulants included higher bleeding risk and high risk of falls. An inter-speciality difference in therapy selection was detected.

Conclusions: This decision support tool can help optimise the use of antithrombotic therapy in patients with AF by considering risk versus benefit profiles and rationalising treatment selection. (Cardiol J 2017; 24, 2: 176–187)

Abstract

Background: The decision-making process for stroke prevention in atrial fibrillation (AF) requires a comprehensive assessment of risk vs. benefit and an appropriate selection of antithrombotic agents (e.g., warfarin, non-vitamin K antagonist oral anticoagulants [NOACs]). The aim of this pilot-test was to examine the impact of a customised decision support tool — the Computerised Antithrombotic Risk Assessment Tool (CARATV2.0) using antithrombotic therapy on a cohort of patients with AF.

Methods: In this prospective interventional study, 251 patients with AF aged ≥ 65 years, admitted to a teaching hospital in Australia were recruited. CARATV2.0 generated treatment recommendations based on patient medical information. Recommendations were provided to prescribers for consideration.

Results: At baseline (admission), 30.3% of patients were prescribed warfarin, 26.7% an antiplatelet, 8.4% apixaban, 8.0% rivaroxaban, 3.6% dabigatran. CARATV2.0 recommended a change of therapy for 153 (61.0%) patients. Through recommendations of CARATV2.0, at discharge, 40.2% of patients were prescribed warfarin, 17.7% antiplatelet, 14.3% apixaban, 10.4% rivaroxaban, 5.6% dabigatran. Overall, the proportion of patients receiving an antithrombotic on discharge increased significantly from baseline (admission) (baseline 77.2% vs. 89.2%; p < 0.001). Prescribers moderately agreed with CARATV2.0’s recommendations (kappa = 0.275, p < 0.001). Practical medication safety issues were cited as major reasons for not accepting a desire to continue therapy with CARATV2.0’s recommendations. Factors predicting the prescription of antiplatelets rather than anticoagulants included higher bleeding risk and high risk of falls. An inter-speciality difference in therapy selection was detected.

Conclusions: This decision support tool can help optimise the use of antithrombotic therapy in patients with AF by considering risk versus benefit profiles and rationalising treatment selection. (Cardiol J 2017; 24, 2: 176–187)

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Keywords

decision-making, computer-assisted, anticoagulant agents, warfarin, atrial fibrillation, stroke, clinical decision support

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About this article
Title

Pilot of a Computerised Antithrombotic Risk Assessment Tool Version 2 (CARATV2.0) for stroke prevention in atrial fibrillation

Journal

Cardiology Journal

Issue

Vol 24, No 2 (2017)

Pages

176-187

Published online

2017-01-02

DOI

10.5603/CJ.a2017.0003

Pubmed

28070883

Bibliographic record

Cardiol J 2017;24(2):176-187.

Keywords

decision-making
computer-assisted
anticoagulant agents
warfarin
atrial fibrillation
stroke
clinical decision support

Authors

Yishen Wang
Beata Bajorek

References (31)
  1. Wang Y, Bajorek B. New oral anticoagulants in practice: pharmacological and practical considerations. Am J Cardiovasc Drugs. 2014; 14(3): 175–189.
  2. Lipman T, Murtagh MJ, Thomson R. How research-conscious GPs make decisions about anticoagulation in patients with atrial fibrillation: a qualitative study. Fam Pract. 2004; 21(3): 290–298.
  3. Australian Government Department of Health and Ageing. Review of Anticoagulation Therapies in Atrial Fibrillation. 2012. http://wwwpbsgovau/reviews/atrial-fibrillation-files/report-anticoagulationpdf (Cited 2 Feb 2015).
  4. eTG complete [online]. Therapeutic Guidelines: Cardiovascular. Version 6. Melbourne: Therapeutic Guidelines Limited. ; 2012.
  5. Pharmacy practice. 
  6. January CT, Wann LS, Alpert JS, et al. AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol, .
  7. Camm AJ, Lip GYH, De Caterina R, et al. ESC Committee for Practice Guidelines-CPG, Document Reviewers, ESC Committee for Practice Guidelines (CPG). 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Europace. 2012; 14: 1385–1413.
  8. Bajorek BV, Ogle SJ, Duguid MJ, et al. Management of warfarin in atrial fibrillation: views of health professionals, older patients and their carers. Med J Aust. 2007; 186(4): 175–180.
  9. Wang Y, Bajorek B. Decision-making around antithrombotics for stroke prevention in atrial fibrillation: the health professionals' views. Int J Clin Pharm. 2016; 38(4): 985–995.
  10. Bajorek BV, Krass I, Ogle SJ, et al. Optimizing the use of antithrombotic therapy for atrial fibrillation in older people: a pharmacist-led multidisciplinary intervention. J Am Geriatr Soc. 2005; 53(11): 1912–1920.
  11. Baker WL, Phung OJ. Systematic review and adjusted indirect comparison meta-analysis of oral anticoagulants in atrial fibrillation. Circ Cardiovasc Qual Outcomes. 2012; 5(5): 711–719.
  12. Wang Y, Bajorek B. Clinical pre-test of a computerised antithrombotic risk assessment tool for stroke prevention in atrial fibrillation patients: giving consideration to NOACs. J Eval Clin Pract. 2016; 22(6): 892–898.
  13. NPS MEDICINEWISE Good anticoagulant practice http://wwwnpsorgau/publications/health-professional/medicinewise-news/2013/good. http://wwwnpsorgau/publications/health-professional/medicinewise-news/2013/good-anticoagulant-practice (2013).
  14. You JJ, Singer DE, Howard PA, et al. American College of Chest Physicians. Antithrombotic therapy for atrial fibrillation: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 Suppl): e531S–e575S.
  15. Miller CS, Grandi SM, Shimony A, et al. Meta-analysis of efficacy and safety of new oral anticoagulants (dabigatran, rivaroxaban, apixaban) versus warfarin in patients with atrial fibrillation. Am J Cardiol. 2012; 110(3): 453–460.
  16. Wang Y, Bajorek B. Safe use of antithrombotics for stroke prevention in atrial fibrillation: consideration of risk assessment tools to support decision-making. Ther Adv Drug Saf. 2014; 5(1): 21–37.
  17. Gage BF, Waterman AD, Shannon W, et al. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001; 285(22): 2864–2870.
  18. Lip GYH, Nieuwlaat R, Pisters R, et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010; 137(2): 263–272.
  19. Pisters R, Lane DA, Nieuwlaat R, et al. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010; 138(5): 1093–1100.
  20. Gage BF, Yan Y, Milligan PE, et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J. 2006; 151(3): 713–719.
  21. Heidbuchel H, Verhamme P, Alings M, et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace. 2015; 17(10): 1467–1507.
  22. Lip GYH, Laroche C, Dan GA, et al. A prospective survey in European Society of Cardiology member countries of atrial fibrillation management: baseline results of EURObservational Research Programme Atrial Fibrillation (EORP-AF) Pilot General Registry. Europace. 2014; 16(3): 308–319.
  23. Bungard TJ, Ghali WA, McAlister FA, et al. The relative importance of barriers to the prescription of warfarin for nonvalvular atrial fibrillation. Can J Cardiol. 2003; 19(3): 280–284.
  24. Borg Xuereb C, Shaw RL, Lane DA. Patients' and health professionals' views and experiences of atrial fibrillation and oral-anticoagulant therapy: a qualitative meta-synthesis. Patient Educ Couns. 2012; 88(2): 330–337.
  25. Man-Son-Hing M, Nichol G, Lau A, et al. Choosing antithrombotic therapy for elderly patients with atrial fibrillation who are at risk for falls. Arch Intern Med. 1999; 159(7): 677–685.
  26. Bajorek BV, Ogle SJ, Duguid MJ, et al. Balancing risk versus benefit: the elderly patient's perspective on warfarin therapy. Pharm Pract (Granada). 2009; 7(2): 113–123.
  27. McAlister FA, Man-Son-Hing M, Straus SE, et al. Decision Aid in Atrial Fibrillation (DAAFI) Investigators. Impact of a patient decision aid on care among patients with nonvalvular atrial fibrillation: a cluster randomized trial. CMAJ. 2005; 173(5): 496–501.
  28. Lipman T, Murtagh MJ, Thomson R. How research-conscious GPs make decisions about anticoagulation in patients with atrial fibrillation: a qualitative study. Fam Pract. 2004; 21(3): 290–298.
  29. Bajorek B, Magin P, Hilmer S, et al. Contemporary approaches to managing atrial fibrillation: A survey of Australian general practitioners. Australas Med J. 2015; 8(11): 357–367.
  30. Australian Government Department of Health and Ageing. Review of Anticoagulation Therapies in Atrial Fibrillation. http://wwwpbsgovau/reviews/atrial-fibrillation-files/report-anticoagulationpdf (ccessed October 2013).
  31. Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care. 1986; 24(1): 67–74.

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