Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (J.P.P., H.X., M.C., R.A.M.).
Ronald Reagan-UCLA Medical Center, University of California, Los Angeles (G.C.F.).
Circulation. 2019 Mar 19;139(12):1497-1506. doi: 10.1161/CIRCULATIONAHA.118.035909.
Efforts to improve prescription of oral anticoagulation (OAC) drugs in patients with atrial fibrillation have had limited success in improving guideline adherence.
We evaluated adherence to the American College of Cardiology/American Heart Association performance measures for OAC in eligible patients with a CHADS-VASc score ≥2 and trends in prescription over time in the American Heart Association's Get With The Guidelines-AFIB (atrial fibrillation) registry. Adjusted associations with in-hospital outcomes were also determined. The cohort included 33 235 patients with a CHADS-VASc score ≥2 who were admitted for atrial fibrillation and were enrolled at 115 sites between January 1, 2013, and September 31, 2017.
The median (25th, 75th percentile) age was 73 years (65, 81 years); 51% were female; and the median (25th, 75th percentile) CHADS-VASc score was 4 (3, 5). At admission, 16 206 (59.5%) of 27 221 patients with a previous diagnosis of atrial fibrillation were taking OAC agents, and OAC drug use at admission was associated with a lower adjusted odds of in-hospital ischemic stroke (odds ratio, 0.38; 95% CI, 0.24-0.59; P<0.0001). At discharge, prescription of OAC in eligible patients (no contraindications) was 93.5% (n=25 499 of 27 270). In a sensitivity analysis, when excluding only strict contraindications (4.6%, n=1497 of 32 806), OAC prescription at discharge was 80.3%. OAC prescription at discharge was higher in those aged ≤75 years, men, those with heart failure, those with previous atrial fibrillation ablation, and those with rhythm control ( P<0.0001 for all). OAC use was lowest in Hispanic patients (90.2%, P<0.0001). Prescription of OAC at discharge in eligible patients improved over time from 79.9% to 96.6% ( P<0.0001).
Among hospitals participating in the GWTG-AFIB quality improvement program, OAC prescription at discharge in eligible guideline-indicated patients increased significantly and improved consistently over time. These data confirm that high-level adherence to guideline-recommended stroke prevention is achievable.
改善心房颤动患者口服抗凝药物（OAC）处方的努力在提高指南依从性方面收效甚微。
我们评估了美国心脏病学会/美国心脏协会（ACC/AHA）在 CHADS-VASc 评分≥2 的合格患者中 OAC 治疗表现指标的依从性，以及在美国心脏协会的 Get With The Guidelines-AFIB（心房颤动）注册研究中 OAC 处方随时间的变化趋势。还确定了与院内结局的调整关联。该队列包括 33235 名 CHADS-VASc 评分≥2 的患者，他们因心房颤动入院，于 2013 年 1 月 1 日至 2017 年 9 月 31 日在 115 个地点入组。
中位（25 分位，75 分位）年龄为 73 岁（65 岁，81 岁）；51%为女性；中位（25 分位，75 分位）CHADS-VASc 评分为 4 分（3 分，5 分）。入院时，27221 例有既往心房颤动诊断的患者中，16206 例（59.5%）正在服用 OAC 药物，入院时使用 OAC 药物与调整后的院内缺血性卒中发生几率降低相关（比值比，0.38；95%置信区间，0.24-0.59；P<0.0001）。出院时，合格患者（无禁忌证）的 OAC 处方率为 93.5%（27270 例中的 25499 例）。在敏感性分析中，当仅排除严格禁忌证（4.6%，32806 例中的 1497 例）时，出院时的 OAC 处方率为 80.3%。≤75 岁、男性、心力衰竭、既往心房颤动消融术和节律控制的患者出院时 OAC 处方率较高（所有 P<0.0001）。西班牙裔患者的 OAC 使用最低（90.2%，P<0.0001）。合格患者出院时 OAC 处方随时间从 79.9%显著增加到 96.6%（P<0.0001）。
在参与 GWTG-AFIB 质量改进计划的医院中，合格的指南推荐的卒中预防患者出院时 OAC 处方显著增加，并且随时间持续改善。这些数据证实，高水平的指南推荐的卒中预防是可以实现的。
