Woo Brigitte Fong Yeong, Lim Toon Wei, Tam Wilson Wai San
Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, 117597, Singapore.
National University Heart Centre, 119228, Singapore.
Heart Lung Circ. 2019 Apr;28(4):605-614. doi: 10.1016/j.hlc.2018.02.024. Epub 2018 Mar 12.
Atrial fibrillation (AF) is a clinically significant cardiac arrhythmia known to increase the risk of stroke by at least four times. Stroke-risk assessment and thromboprophylaxis are vital components in AF management. Guidelines are available to standardise AF management, but physicians' adherence to the recommended guidelines has been low. The aims were to: 1. Examine and compare the level of knowledge and current practice in AF management between cardiologists and non-cardiologist physicians in Singapore; 2. Identify physicians' perceived barriers to prescribing oral anticoagulants (OACs) when indicated; 3. Identify strategies to optimise AF management.
From June 2017 to August 2017, a cross-sectional online survey involving physicians was conducted in Singapore. The survey instrument was adapted from a previously developed instrument, and validated locally by five cardiologists. It explored the physicians' stroke-risk assessment practices, estimation of stroke risk and benefits of anticoagulation, likelihood of prescribing anticoagulation when indicated, perceived barriers to anticoagulation, and strategies to optimise AF management.
Sixty-three (63) physicians completed the survey (14 cardiologists and 49 non-cardiologist physicians). No significant difference was found between cardiologists and non-cardiologist physicians in their assessment and estimation of stroke risk for stable AF patients. However, when presented with an AF patient with stroke risk, cardiologists were more likely than non-cardiologist physicians to prescribe novel OACs (93% vs. 51%; χ=7.933, p=0.004). Compared to cardiologists, the majority of the non-cardiologist physicians thought the risk of falls were usually or always barriers to prescribing OACs (29% vs 69%; χ=7.579, p=0.006). Among the suggested strategies to support them in AF management, physicians have overwhelmingly rated two as "quite useful" and "very useful": the establishment of clinics for monitoring anticoagulated patients (100%); and involvement of pharmacists in managing patients on warfarin (98.4%).
Physicians possess good knowledge about stroke-risk assessment in AF patients yet it is not translated into effective measures for stroke prevention. Physicians, especially non-cardiologist ones, were not anticoagulating AF patients when indicated. Although novel OACs are safer alternatives to warfarin, non-cardiologist physicians were less inclined to use them for stroke prevention. All physicians opined that establishing anticoagulation clinics and collaborating with pharmacists were useful strategies to optimise AF management. Existing barriers to anticoagulation impeded the translation of knowledge into practice in the management of AF patients in Singapore, for which optimal strategies to optimise AF management are ascertained.
心房颤动（房颤）是一种具有临床意义的心律失常，已知会使中风风险增加至少四倍。中风风险评估和血栓预防是房颤管理的重要组成部分。虽然有指南可用于规范房颤管理，但医生对推荐指南的依从性一直较低。本研究旨在：1. 检查并比较新加坡心脏病专家和非心脏病专家在房颤管理方面的知识水平和当前实践；2. 确定医生在有指征时开具口服抗凝剂（OAC）的认知障碍；3. 确定优化房颤管理的策略。
2017年6月至2017年8月，在新加坡对医生进行了一项横断面在线调查。调查工具改编自之前开发的工具，并经五位心脏病专家在当地进行了验证。该工具探讨了医生的中风风险评估实践、中风风险估计以及抗凝的益处、有指征时开具抗凝剂的可能性、抗凝的认知障碍以及优化房颤管理的策略。
63名医生完成了调查（14名心脏病专家和49名非心脏病专家）。在对稳定房颤患者的中风风险评估和估计方面，心脏病专家和非心脏病专家之间未发现显著差异。然而，当面对有中风风险的房颤患者时，心脏病专家比非心脏病专家更有可能开具新型OAC（93%对51%；χ=7.933，p=0.004）。与心脏病专家相比，大多数非心脏病专家认为跌倒风险通常或总是开具OAC的障碍（29%对69%；χ=7.579，p=0.006）。在支持他们进行房颤管理的建议策略中，医生压倒性地将两项评为“相当有用”和“非常有用”：设立抗凝门诊患者监测诊所（100%）；药剂师参与华法林治疗患者的管理（98.4%）。
医生对房颤患者的中风风险评估有较好的知识，但尚未转化为有效的中风预防措施。医生，尤其是非心脏病专家，在有指征时未对房颤患者进行抗凝治疗。尽管新型OAC是华法林更安全的替代品，但非心脏病专家不太倾向于使用它们进行中风预防。所有医生都认为建立抗凝门诊和与药剂师合作是优化房颤管理的有用策略。抗凝的现有障碍阻碍了新加坡房颤患者管理中知识转化为实践，为此确定了优化房颤管理的最佳策略。
