การใช้ยาต้านการแข็งตัวของเลือดชนิดรับประทานของผู้ป่วยนอกที่มี Nonvalvular Atrial Fibrillation โรงพยาบาลสวรรค์ประชารักษ์

ณัฏฐ์ น้อมพรรโณภาส

Authors

ณัฏฐ์ น้อมพรรโณภาส โรงพยาบาลสวรรค์ประชารักษ์

Keywords:

Nonvalvular Atrial Fibrillation, Anticoagulation, Ambulatory Patients

Abstract

Objective : To assess the rate and the associated factors of oral anticoagulant using among ambulatory patients with nonvalvular AF.

Method : The retrospective cross-sectional study of ambulatory patients with a confirmed diagnosis of nonvalvular AF at Sawanpracharak hospital during 1 October 2018 to 30 September 2020, medical records were reviewed. Demographic data were collected such as date of first diagnosis of nonvalvular AF (Index date), age, gender, treatment rights, comorbidities, contraindications, oral anticoagulant medications and the risk assessed by CHA2DS2-VASc score and HAS-BLED score. Factors associated with oral anticoagulant use were analyzed by using chi-square test and determined the correlation by using binary logistic regression at a 95% confidence interval.

Results : According to 959 patients with nonvalvular atrial fibrillation, 53.5% was male and two-third (67.1%) were 65 years of age or older. Oral anticoagulants were prescribed for 703 patients (73.3%). Among patients at high, moderate and low risk for stroke, rate of oral anticoagulant use was 78.4%, 69.6% and 17.5% respectively. Factors that significantly increased the rate of oral anticoagulants use were those who had previous Stroke/ transient ischemic attack /thromboembolism (OR_adj =2.47; 95%CI 1.61-3.79), congestive heart failure/ left ventricular dysfunction (OR_adj =2.13; 95%CI 1.41-3.21), Hypertension (OR_adj =1.43; 95%CI 1.02-2.01), female gender (OR_adj =1.39; 95%CI 1.01-1.90) and Age: Patients aged 65 to 74 years (OR_adj =4.33; 95%CI 2.67-7.01) were most likely to use anticoagulants. Factors that significantly reduced the rate of anticoagulant use were Bleeding tendency /Major bleeding (OR_adj =0.09; 95%CI 0.04-0.22), abnormal renal function (OR_adj =0.44; 95%CI 0.21-0.92) and vascular disease (OR_adj =0.52; 95%CI 0.33-0.81).

Conclusion : Ambulatory nonvalvular AF patients with high stroke risk had underuse rate of oral anticoagulants. The strong predictors of increasing oral anticoagulant use were previous stroke and congestive heart failure. The strong predictor of reducing oral anticoagulant use was bleeding tendency or major bleeding.

Key words : Nonvalvular Atrial Fibrillation, Anticoagulation, Ambulatory Patients

References

Phrommintikul A, Detnuntarat P, Prasertwitayakij N, Wongcharoen W. Prevalence of atrial fibrillation in Thai elderly. J Geriatr Cardiol 2016;13(3):270-3.

ภัทราณี ลีละพัฒนะ. ใน: กมล แก้วกิติณรงค์, กำพล สุวรรณพิมลกุล, ณัฐวุฒิ โตวนำชัย, ปิยะพันธ์ พฤกษพานิช, ลลิตา วัฒนะจรรยา, วาสิตา วราชิต ภาคสุข, บรรณาธิการ. Comprehensive review in internal medicine. สมุทรสาคร: ปรินท์แอนด์มอร์; 2563.หน้า 411-37.

Wehbe RM, Yadlapati A. Underuse of oral anticoagulants for nonvalvular atrial fibrillation: past, present, and future. Tex Heart Inst J 2016; 43(4):287-90.

Jirapattrathamrong S. Use of oral anticoagulant for prevention of embolic stroke and systemic embolism in atrial fibrillation. Vajira Med J 2018; 62 Suppl3: S64-74.

วรรณวรางค์ วงศ์เจริญ. ใน: นราวุฒิ ประเสริฐวิทยากิจ, พรรณนิภา สุวรรณสม, บรรณาธิการ. Precision cardiology customization of treatment in cardiology patients. เชียงใหม่: ทริค ธิงค์; 2562.หน้า 308-18.

January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, et al. 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation 2014; 2014(130): 2071–104.

Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, et al. Guidelines for the management of atrial fibrillation: the task force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010;31:2369–429.

Camm AJ, Lip GY, DeCaterina R, Savelieva I, Atar D, Hohnloser SH, et al. 2012 Focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation: developed with the special contribution of the American College of Cardiology. Eur Heart J 2012;2012(33):2719–47.

Kirchhof P, Benussi S, Kotecha D, Ahlsson1 A, Atar D, Casadei B, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS: the task force for the management of atrial fibrillation of the European Society of Cardiology (ESC). European Heart Journal 2016; 37: 2893–962.

Singer DE, Hughes RA, Gress DR, Sheehan MA, Oertel LB, Maraventano SW, et al. The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation: the Boston area anticoagulation trial for atrial fibrillation investigators. N Engl J Med 1990;323:1505-11.

Ezekowitz MD, Bridgers SL, James KE, Carliner NH, Colling CL, Gornick CC, et al. Warfarin in the prevention of stroke associated with nonrheumatic atrial fibrillation: veterans affairs stroke prevention in nonrheumatic atrial fibrillation investigators. N Engl J Med 1992;327:1406-12.

Sweeney KG, GRAY DP, Steele R, Evans P. Use of warfarin in non-rheumatic atrial fibrillation: a commentary from general practice. Br J Gen Pract 1995;45:153-8.

Yang X, Li Z, Zhao X, Wang C, Liu L, Wang C, et al. Use of warfarin at discharge among acute ischemic stroke patients with nonvalvular atrial fibrillation in China. Stroke 2016;47:464-70.

Go AS, Hylek EM, Borowsky LH, Phillips KA, Selby JV, Singer DE. Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study. Ann Intern Med 1999;131:927-34.

Bartholomay E, Polli I, Borges AP, Kalil C, Arroque A, Kohler I, et al. Prevalence of oral anticoagulation in atrial fibrillation. Clinics 2014;69(9):615-20.

Akao M, Chun YH, Esato M, Abe M, Tsuji H, Wada H, et al. Inappropriate use of oral anticoagulants for patients with atrial fibrillation. Circ J 2014;78(9):2166-72.

Kirchhof P, Ammentorp B, Darius H, Caterina RD, Heuzey J-YL, Schilling RJ, et al. Management of atrial fibrillation in seven European countries after the publication of the 2010 ESC Guidelines on atrial fibrillation: primary results of the PREvention of thromboemolic events—European Registry in Atrial Fibrillation (PREFER in AF). Europace 2014;16:6–14.

Lip GYH, Laroche C, Dan G-A, Santini M, Kalarus Z, Rasmussen LH, et al. A prospective survey in European Society of Cardiology member countries of atrial fibrillation management: baseline results of EURObservational Research Programme Atrial Fibrillation (EORP-AF) Pilot General Registry. Europace 2014;16:308–19.

Shantsila E, Wolff A, Lip GY, Lane DA. Optimising stroke prevention in patients with atrial fibrillation: application of the GRASP-AF audit tool in a UK general practice cohort. Br J Gen Pract 2015;65(630):e16-23.

Hsu JC, Maddox TM, Kennedy KF, Katz DF, Marzec LN, Lubitz SA, et al. Oral anticoagulant therapy prescription in patients with atrial fibrillation across the spectrum of stroke risk: insights from the NCDR PINNACLE Registry. JAMA Cardiol 2016;1:55–62.

Barnes GD, Lucas E, Alexander GC, Goldberger ZD. National trends in ambulatory oral anticoagulant use. Am J Med 2015; 128(12): 1300–5.

Waldo AL, Becker RC, Tapson VF, Colgan KJ. Hospitalized patients with atrial fibrillation and a high risk of stroke are not being provided with adequate anticoagulation. J Am Coll Cardiol 2005;46(9):1729-36.

Krittayaphong R, Phrommintikul A, Ngamjanyaporn P, Siriwattana K, Kanjanarutjawiwat W, Chantrarat T, et al. Rate of anticoagulant use, and factors associated with not prescribing anticoagulant in older Thai adults with non-valvular atrial fibrillation: a multicenter registry. J Geriatr Cardiol 2019; 16(3): 242–50.

Choudhry NK, Soumerai SB, Normand SLT, Ross-Degnan D, Laupacis A, Anderson GM. Warfarin prescribing in atrial fibrillation: the impact of physician, patient, and hospital characteristics. Am J Med 2006;119(7):607-15.