Stroke prophylaxis in high-risk patients with atrial fibrillation: Rhythm vs. rate control strategy

• Published in: European journal of internal medicine 2013-06, Vol.24 (4), p.314-317
• Main Authors: Filippi, Alessandro, Zoni-Berisso, Massimo, Ermini, Giuliano, Landolina, Maurizio, Brignoli, Ovidio, D'Ambrosio, Gaetano, Zingarini, Gianluca, Pedrinazzi, Claudio
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants - therapeutic use; Atrial fibrillation; Atrial Fibrillation - complications; Atrial Fibrillation - drug therapy; Atrial Fibrillation - physiopathology; Female; Heart Rate; Humans; Internal Medicine; Male; Middle Aged; Practice Guidelines as Topic; Practice Patterns, Physicians' - statistics & numerical data; Rate vs. rhythm control; Stroke - etiology; Stroke - prevention & control; Stroke prophylaxis; Surveys and Questionnaires; Warfarin - therapeutic use
• ISSN: 0953-6205; 1879-0828
• DOI: 10.1016/j.ejim.2013.02.002

Abstract Purpose “Rhythm” and “Rate” control strategies require partially different organization, and a different involvement of Specialists and General Practitioners; we verified whether the strategy assignment modified the approach to stroke prophylaxis. Methods Survey in general practice: 233 GPs identified all patients with codified atrial fibrillation (AF) diagnosis, checked the diagnosis (ECG/hospital discharge document), and filled a structured questionnaire on stroke risk-factors, prophylactic therapy, and reasons for warfarin non prescription in CHADS₂ ≥ 2 patients. Data were collected as an “aggregate.” Results Population observed: 295,906 patients aged > 14; 6,036 with confirmed AF; 5,888 with complete data about anti-thrombotic prophylaxis are analyzed here. In the “rhythm strategy” group 45.6% of the CHADS₂ score ≥ 2 patients (594) were on warfarin, vs. 73.2% (1,741) in the “rate strategy” group ( p < 0.0001). Overall reasons for warfarin non-use were significantly different in the two groups: clinical contraindications (12.3% vs. 19.7%), side effects (5.5% vs. 8.5%), patients' refusal (12.2% vs. 15.2%), unreliable patient/care-giver (14.4% vs. 25.9%); reasons were unknown to the GP in 55.6% in rhythm control vs. 30.9% in rate control group. Conclusions Anti-thrombotic prophylaxis in CHADS₂ ≥ 2 patients is different in subjects assigned to the Rhythm vs. the Rate control strategy, as well as reported reasons for warfarin non use. GPs do not know why warfarin is not used in a large percentage of cases, mainly in the rhythm control strategy group. Improving efforts should probably be differently tailored for patients assigned to the “rhythm” or the “rate” control strategy.