Paul Angaran1, Paul Dorian1, Mary K Tan2, Charles R Kerr3, Martin S Green4, David J Gladstone5, L Brent Mitchell6, Carl Fournier7, Jafna L Cox8, Mario Talajic9, Peter J Lin10, Anatoly Langer2, Lianne Goldin2, Shaun G Goodman11. 1. Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada. 2. Canadian Heart Research Centre, Toronto, Ontario, Canada. 3. St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada. 4. University of Ottawa Heart Institute, Ottawa, Ontario, Canada. 5. Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada. 6. Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada. 7. Hôpital Notre-Dame, Université de Montréal, Montreal, Quebec, Canada. 8. Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada. 9. Montreal Heart Institute, Montreal, Quebec, Canada. 10. Canadian Heart Research Centre, Toronto, Ontario, Canada; LinCorp Medical Inc, Toronto, Ontario, Canada. 11. Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Heart Research Centre, Toronto, Ontario, Canada. Electronic address: goodmans@chrc.net.
Abstract
BACKGROUND: Canadian atrial fibrillation (AF) guidelines recommend that all AF patients be risk stratified with respect to stroke and bleeding, and that most should receive antithrombotic therapy. METHODS: As part of the Canadian Facilitating Review and Education to Optimize Stroke Prevention in Atrial Fibrillation (FREEDOM AF) chart audit, data were collected on 4670 patients ≥ 18 years old without significant valvular heart disease from the primary care practices of 474 physicians (February to September, 2011). RESULTS: Physicians did not provide an estimate of stroke and bleeding risk in 15% and 25% of patients, respectively. When risks were provided, they were on the basis of a predictive stroke and bleeding risk index in only 50% and 26% of patients, respectively. There were over- and underestimation of stroke and bleeding risk in a large proportion of patients. Antithrombotic therapy included warfarin (90%); 24% of patients had a time in the therapeutic range (TTR) < 50%, 9% between 50% and 60%, 11% between 60% and 70%, and 56% had a TTR ≥ 70%. CONCLUSIONS: In a large Canadian AF population, primary care physicians did not provide a stroke or bleeding risk in a substantial proportion of their AF patients. When estimates were provided, they were on the basis of a predictive stroke and bleeding risk index in less than half of the patients. Furthermore, there was under- and overestimation of stroke and bleeding risk in a substantial proportion of patients. As many as 1 in 3 patients receiving warfarin have their TTR < 60%. These findings suggest an opportunity to enhance knowledge translation to primary care physicians.
BACKGROUND: Canadian atrial fibrillation (AF) guidelines recommend that all AFpatients be risk stratified with respect to stroke and bleeding, and that most should receive antithrombotic therapy. METHODS: As part of the Canadian Facilitating Review and Education to Optimize Stroke Prevention in Atrial Fibrillation (FREEDOM AF) chart audit, data were collected on 4670 patients ≥ 18 years old without significant valvular heart disease from the primary care practices of 474 physicians (February to September, 2011). RESULTS: Physicians did not provide an estimate of stroke and bleeding risk in 15% and 25% of patients, respectively. When risks were provided, they were on the basis of a predictive stroke and bleeding risk index in only 50% and 26% of patients, respectively. There were over- and underestimation of stroke and bleeding risk in a large proportion of patients. Antithrombotic therapy included warfarin (90%); 24% of patients had a time in the therapeutic range (TTR) < 50%, 9% between 50% and 60%, 11% between 60% and 70%, and 56% had a TTR ≥ 70%. CONCLUSIONS: In a large Canadian AF population, primary care physicians did not provide a stroke or bleeding risk in a substantial proportion of their AFpatients. When estimates were provided, they were on the basis of a predictive stroke and bleeding risk index in less than half of the patients. Furthermore, there was under- and overestimation of stroke and bleeding risk in a substantial proportion of patients. As many as 1 in 3 patients receiving warfarin have their TTR < 60%. These findings suggest an opportunity to enhance knowledge translation to primary care physicians.