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[Guidelines and clinical practice: anticoagulant therapy and cardioversion in atrial fibrillation]
S Callegari1, M Pini, L Andreoli
1Unità Operativa di Cardiologia, Ospedale di Fidenza.
Insights
Anticoagulation for atrial fibrillation cardioversion is underused, particularly in elderly patients. Adherence to American College of Chest Physicians guidelines for anticoagulation therapy requires improvement to reduce systemic embolization risk.
Area of Science:
- Cardiology
- Internal Medicine
- Pharmacology
Background:
- Atrial fibrillation cardioversion carries a significant risk of systemic embolization.
- The American College of Chest Physicians (ACCP) provides guidelines for anticoagulation to mitigate this risk.
Purpose of the Study:
- To assess physician compliance with the "Fourth ACCP Consensus Conference on Antithrombotic Therapy" recommendations.
- To evaluate the utilization of anticoagulation in patients undergoing cardioversion for atrial fibrillation.
Main Methods:
- Retrospective chart review of 202 patients admitted with atrial fibrillation in 1998.
- Analysis of anticoagulation use (3 weeks pre- and 4 weeks post-cardioversion) based on ACCP guidelines for patients with atrial fibrillation > 2 days.
Main Results:
- Of 91 patients with atrial fibrillation onset > 48 hours, 34 underwent elective cardioversion.
- 13 of these patients (33%) did not receive anticoagulation in the 2 weeks prior; 8 were over 75.
- Post-cardioversion, 10 patients (33%) did not receive recommended anticoagulation, all over 75.
Conclusions:
- Anticoagulation for cardioversion of atrial fibrillation is underutilized, especially in the elderly.
- Physician adherence to ACCP guidelines needs improvement to ensure appropriate anticoagulation for high-embolic-risk patients.
- Efforts to identify and remove barriers to guideline implementation are crucial for improving hospital treatment quality.
Unlabelled:
The cardioversion of atrial fibrillation is linked to a substantial risk of systemic embolization. In an effort to reduce it, the American College of Chest Physicians (ACCP) periodically publishes guidelines for the use of anticoagulation in the conversion of atrial fibrillation.
Objective:
Determination of the physician's compliance with the recommendations of the "Fourth ACCP Consensus Conference on Antithrombotic Therapy".
Methods:
The charts of people admitted to a community hospital in 1998 with a diagnosis of atrial fibrillation (n = 202) were evaluated retrospectively. Consideration was given to the ACCP's recommendation to give anticoagulants 3 weeks before and 4 weeks after elective cardioversion to patients who had been in atrial fibrillation for more than 2 days.
Results:
Ninety-one of the 202 patients admitted with atrial fibrillation reported the onset of arrhythmia more than 48 hours before. Thirty-four of them underwent elective cardioversion and 13 cases (33%) went without anticoagulation in the preceding 2 weeks. Of these 13 cases, 8 were patients aged over 75 (range 78-88, mean 84). After sinus rhythm had been restored in 30 people (spontaneously in 5 of them), the anticoagulant therapy was not administered during the 4 recommended weeks in 10 people (33%), all of them over 75 (range 77.94, mean 84).
Conclusions:
Anticoagulation for cardioversion of atrial fibrillation is underused, especially among elderly patients. In order not to let age itself be an obstacle to the correct treatment of patients with high embolic risk, our efforts must be improved in order to identify the correct therapeutic choice in each particular case. Initiatives aimed at identifying and removing any impediment to the application of guidelines may contribute to stimulating physicians in the process of evaluating the quality of hospital treatment.