Anticoagulation therapy in elderly patients with atrial fibrillation: results from the Registry of Atrial Fibrillation To Investigate the Implementation of New Guidelines (RAFTING).

BACKGROUND: Patients with atrial fibrillation aged 75 years or older have a CHA2DS2VASc score that dictates oral anticoagulants. We recorded physicians' anticoagulation attitudes in elderly patients with atrial fibrillation and assessed the impact of stroke and bleeding risk. METHODS: Atrial Fibrillation To Investigate the Implementation of New Guidelines , a countrywide prospective registry performed in Greece during 2010, a period when only vitamin-K antagonists (VKA) were available, enrolled 1127 patients with atrial fibrillation diagnosis during Emergency Departments visit in 31 representative hospitals; 807 patients had known atrial fibrillation and of those, 342 aged 75 years or older. We recorded preadmission anticoagulation treatment and associated it with clinical characteristics and stroke/bleeding risk. RESULTS: Patients on VKA (n = 207; 61%) were younger (81 ±â€Š4 vs. 83 ±â€Š5; P < 0.001) but no other significant differences were noticed, including mean CHA2DS2VASc (high: 2-4, very high: >4) or modified HASBLED (low: 0-2, high: >2) scores. VKA were prescribed in 65% of patients with very high CHA2DS2VASc score as compared with 55% of those with high score (P = 0.065). VKA were used equally in low or high-modified HASBLED score (61% vs. 59%; P = 0.78). The interaction between CHA2DS2VASc and HASBLED was significant (P < 0.001) in patients on VKA; in patients with low HASBLED, VKA use was similar in high versus very high CHA2DS2VASc score (58 vs. 64%), whereas in patients with high HASBLED, VKA use tended to be higher in very high versus high CHA2DS2VASc score (66 vs. 43%). CONCLUSION: In this countrywide atrial fibrillation registry, 61% of elderly patients received VKA, a decision driven mainly by stroke risk. VKA use was not higher in patients with low bleeding risk.

Clinical profile and therapeutic management of patients with atrial fibrillation in Greece: results from the Registry of Atrial Fibrillation to Investigate New Guidelines (RAFTING).

INTRODUCTION: Atrial fibrillation (AF) is the most common arrhythmia with significant morbidity, including a 5-fold increase in stroke risk. The management of AF, including antithrombotic therapy (AT), varies considerably among countries. Representative data concerning AF features and management in Greece are generally lacking. METHODS: The Registry of Atrial Fibrillation To Investigate New Guidelines (RAFTING) is a country-wide prospective observational study of AF in Greece that enrolled consecutive patients with a diagnosis of AF in emergency departments of 31 hospitals of different types according to the population's geographical distribution. RESULTS: RAFTING enrolled 1127 patients, 51% females, aged 71 ± 12 years. Paroxysmal AF was present in 54% of patients and newly diagnosed AF in 28%; 68% of patients with a previous AF history had undergone a median of 4 cardioversions. A high rate of comorbidities was present, including arterial hypertension in 75% and heart failure in 40%. The median CHADS2 and CHA2DS2VASc scores were 2 and 3, respectively; AT had been prescribed in 87% of non-newly diagnosed patients, with warfarin being prescribed in 56% of them. Among all patients on warfarin, INR values were within therapeutic range in 34% of cases during inhospital measurement. Hospital admission occurred in 82% of cases, with in-hospital mortality 0.8%. CONCLUSIONS: RAFTING provides updated insights into the current features and management of AF in Greece. The majority of patients have a sufficiently high risk to warrant oral anticoagulation and further attempts to comply with the existing guidelines are warranted.

Overestimation and underestimation of cardiovascular risk in clinical practice: usefulness of risk estimation charts.

INTRODUCTION: Charts for the estimation of cardiovascular risk contribute greatly to clinical decision making in the management of asymptomatic individuals. However, most decisions are taken without consulting the charts. The aim of our study was to record the degree of overestimation or underestimation of cardiovascular risk in everyday clinical practice. METHODS: Seven cases of asymptomatic individuals at different levels of cardiovascular risk as a result of different combinations of risk factors (one at very low, one at very high and five at intermediate risk) were presented in random order to 30 doctors who deal with primary prevention consultations in their daily clinical practice. They were asked if hypolipidaemic therapy was needed and their answers were compared with the recommended management of the current European guidelines on prevention using the risk charts of the European Society of Cardiology. RESULTS: The mean percentage of agreement was 70%. In the two extreme cases agreement with the guidelines was absolute, but in the intermediate cases it varied widely. Particularly in those cases with cholesterol level 200-240 mg/dl it was just 40%, due either to overestimation or to underestimation of the risk. CONCLUSION: In the cases of obviously low or obviously high risk, clinical judgement is in accordance with the guidelines. However, in cases of intermediate risk there is either overestimation of risk with non-indicated prescription of hypolipidaemic treatment, or underestimation of risk with no administration of indicated therapy. The use of risk charts in clinical practice may provide substantial help towards a more objective practice of prevention.