Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, PO Box 85500, 3508 AB Utrecht, the Netherlands.
Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, PO Box 85500, 3508 AB Utrecht, the Netherlands.
Int J Cardiol. 2018 Dec 15;273:123-129. doi: 10.1016/j.ijcard.2018.08.096. Epub 2018 Sep 8.
Guidelines on atrial fibrillation (AF) recommend the CHADS-VASc rule for anticoagulant decision-making, but underuse exists. We studied the impact of an automated decision support on stroke prevention in patients with AF in a cluster randomised trial in general practice.
Intervention practices were provided with a CHADS-VASc based anticoagulant treatment recommendation. Reference practices provided care as usual. The primary outcome was incidence of ischaemic stroke, transient ischaemic attack (TIA) and/or thromboembolism (TE). Secondary outcomes were bleeding and the proportion of patients on guideline recommended anticoagulant treatment.
In total, 1129 AF patients were included in the 19 intervention practices and 1226 AF patients in the 19 reference practices. The median age was 77 (interquartile range (IQR) 68-75) years, the median CHADS-VASc score was 3.0 (IQR 2.0-5.0). Underuse of anticoagulants in patients with CHADS-VASc score ≥ 2 was 6.6%. After a median follow-up of 2.7 years (IQR 2.3-3.0), the incidence rate per 100 person-years of ischaemic stroke/TIA/TE was 1.96 in the intervention group and 1.42 in the reference group (hazard ratio (HR) 1.3, 95% C.I. 0.8-2.1). No difference was observed in the rate of bleeding (0.79 versus 0.82), or in the underuse (7.2% versus 8.2%) or overuse (8.0% versus 7.9%) of anticoagulation.
In this study in patients with AF in general practice, underuse of anticoagulants was relatively low. Providing practitioners with CHADS-VASc based decision support did not result in a reduction in stroke incidence, affect bleeding risk or anticoagulant over- or underuse.
心房颤动（AF）指南建议使用 CHADS-VASc 规则来决定抗凝治疗，但存在使用率不足的情况。我们在一项针对普通实践中 AF 患者的群组随机试验中，研究了自动化决策支持对预防中风的影响。
干预实践提供了基于 CHADS-VASc 的抗凝治疗建议。参考实践提供了常规护理。主要结果是缺血性中风、短暂性脑缺血发作（TIA）和/或血栓栓塞（TE）的发生率。次要结果是出血和遵循指南推荐抗凝治疗的患者比例。
共有 1129 例 AF 患者被纳入 19 个干预实践，1226 例 AF 患者被纳入 19 个参考实践。中位年龄为 77 岁（四分位间距[IQR] 68-75），中位 CHADS-VASc 评分为 3.0（IQR 2.0-5.0）。CHADS-VASc 评分≥2 的患者中抗凝剂使用率不足为 6.6%。中位随访 2.7 年后（IQR 2.3-3.0），干预组缺血性中风/TIA/TE 的发生率为 1.96/100 人年，对照组为 1.42/100 人年（风险比[HR] 1.3，95%置信区间[CI] 0.8-2.1）。出血率（0.79 与 0.82）或抗凝剂使用率不足（7.2%与 8.2%）或过度使用（8.0%与 7.9%）无差异。
在这项普通实践中 AF 患者的研究中，抗凝剂使用率不足相对较低。为医生提供基于 CHADS-VASc 的决策支持并未降低中风发生率，也未影响出血风险或抗凝剂的过度或不足使用。
