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Are patients with persistent Atrial Fibrillation and a CHADS2 score of ≥ 2 on warfarin?

Are patients with persistent Atrial Fibrillation and a CHADS2 score of ≥ 2 on warfarin?. Lucinda Stephenson Binscombe Medical Centre July 2011. Introduction. Prevalence of AF 1.2% 18% strokes- AF AF associated with worse morbidity and mortality ~ 40% of patients not on warfarin

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Are patients with persistent Atrial Fibrillation and a CHADS2 score of ≥ 2 on warfarin?

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  1. Are patients with persistent Atrial Fibrillation and a CHADS2 score of ≥ 2 on warfarin? Lucinda Stephenson Binscombe Medical Centre July 2011

  2. Introduction • Prevalence of AF 1.2% • 18% strokes- AF • AF associated with worse morbidity and mortality • ~ 40% of patients not on warfarin • Prevent 6000 strokes a year • Save 4000 lives a year

  3. CHADS2

  4. Risk calculation for CHADS2

  5. Risk of stroke stratified by CHADS2 score

  6. Bleeding risk with warfarin • >75 years • Taking anti-platelets or NSAIDS • Multiple drug treatments • Uncontrolled hypertension • History of bleeding • History of poorly controlled anticoagulation therapy • (Falls- 295 times in 1 year)

  7. Contraindications to warfarin • Pregnancy • Hypersensitivity to warfarin • Within 2 days of surgery • Bacterial endocarditis • Severe renal or hepatic disease • Peptic ulcer • Severe hypertension

  8. Standard • All patients with persistent AF who have a CHADS2 score ≥ 2 and no contraindications to warfarin should be treated with warfarin

  9. Data Collection • Retrospective audit • GRASP • Provides a sat of MIQUEST queries to identify patients with AF • Calculates CHADS2 score

  10. Results • 240/10315 patients with atrial fibrillation/flutter 2.33% • 11.51% > 65 and AF/flutter • Risk profile for thromboembolism

  11. Patients on warfarin and anti-platelet agents in CHADS2 groups

  12. CHADS2 2 • 36 patients not on warfarin • 10 patients warfarin C/I

  13. Consider warfarin • 9 patients • 12487 (SJP)- is on warfarin • 20781 (MDB) • 20972 (MDB) • 21079 (MCW) • 22688 (POD) • 23962 (MCW) • 24188 (MCW) • 29940 (POD) has been referred to cardiology • 33715 (CEG)

  14. Warfarin contraindicated • 9 patients • 11088 (POD) bladder cancer • 20425 (KAJ) GI bleed • 23551 (SJP) oesophageal cancer-palliative • 26180 (MCW) 91 dementia • 42883 (ASC) previous DU • 42912 (POD) dementia, previous subdural • 43139 (POD) dementia • 43248 (CEG) dementia • 44175 (POD) dementia

  15. Cardioversion • 4 patients • 10241 (POD) atrial flutter • 13404 (MCW) atrial flutter • 15018 (CEG) • 20027 (CEG)

  16. Cardiology Review- not suitable • 4 patients • 12114 (MCW) • 12889 (ASC) • 16613 (MCW) • 20339 (ASC)

  17. Paroxysmal Atrial Fibrillation • 8 patients • 11666 (SJP)- 1 episode • 15373 (MCW)- AF resolved • 20676 (MDB) • 20428 (ASC) • 20924 (POD) • 22061 (ASC) paroxysmal atrial tachycardia • 39129 (ASC) seen by cardiology not for warfarin @ present • 44560 (MDB) being ix by cardiology for presyncope

  18. Other • 2 patients • 10618 (SJP) on chemotherapy on therapeutic clexane • 11268 (MDB) ECG SR with 1 ectopic

  19. CHADS2 3 • 8/33 not on warfarin • 44892- should be on aspirin • RIP (41799) • Palliative care- carcinoid (PAF-ablation) (12120) • Warfarin stopped- 2 ablations now SR. On aspirin (33896) • 103 started on aspirin by RSCH 2001, warfarin not indicated (34600) • Extreme fragility and dementia. On aspirin (41617) • Dementia, on aspirin (44427) • Warfarin C/I- Upper GI bleed (45018)

  20. CHADS2 4 • 4/21 not on warfarin • Warfarin stopped 2003 due to falls, still having falls and not safe walking alone (10207) • Paroxysmal AF. Aspirin stopped due to GORD. (20801) • End stage dementia. On clopidogrel (36920) • Warfarin stopped 2006 due to falls. On aspirin and dipyridamole (39301)

  21. CHADS2 score 5 • 2/9 not on warfarin • New patient in NH, dementia. On Aspirin and dipyridamole (44664) • Ablation and ICD now on aspirin (41941)

  22. Further Action/ Re-audit • Registered GP to review patients’ notes and if in agreement, send letter to invite patients to discuss warfarin/ refer to cardiology • Code patients appropriately that are not suitable for warfarin • Re-audit on a 6 monthly basis • New patients with AF- calculate CHADS2 score and assess suitability for warfarin

  23. Conclusion • Binscombe are performing well • More a case of coding patients appropriately

  24. References • Lip G, Kakar P, Watson T. Atrial Fibrillation- the growing epidemic. Heart 2007; 93: 542-543 • Hankey G, Eikelboom J. Ximelagatran or warfarin for stroke prevention in patients with atrial fibrillation? Stroke 2004; 35: 389-91 • Miller P, Andersson F, Kalra L. Are cost benefits of anticoagulation for stroke prevention in atrial fibrillation underestimated? Stroke 2005; 36: 360-366 • NICE CG036 Atrial fibrillation: the management of atrial fibrillation costing report: implementing NICE guidance in England 2006. http://www.nice.org.uk/Guidance/CG36/CostReport/pdf/English • Brian F, Gage et al. Validation of clinical classification schemes for predicting stroke. JAMA 2001; 285:2864-2870 • NHS improvement. Commissioning for stroke prevention in primary care- the role of atrial fibrillation 06/09 • Mant et al The Lancet 370: 11.08.07 • BNF March 2009 Pharmaceutical Press • SIGN guideline No 36 http://www.signs.ac.uk/guidelines/fulltext/36/index.html March 1999 • Man-Son-Hing et al Arch Intern Med 1999; 159 (7):677-85

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