Anticoagulation in

patients with Atrial

Fibrillation: An Audit.
Adnan Nadir
SHO Medicine
Prevalence begins to increase after age 40
and rises rapidly after age 65.
46 000 new cases per year
More common in men than women
AF accounts for 1.5% of stokes for 50-59
age group and 23.5% for 80-89
(Framingham study)

Atrial Fibrillation:incidence
Rate of ischaemic stroke in AF patients
averages 5%/yr
Risk increases with age, LV dysfunction,
LA dilatation, hypertension, history of
previous embolic event
For patients with a prior cerebrovascular
event the rate is 12%/yr

Atrial Fibrillation: risk of stroke

Numerous studies have demonstrated a
significant stroke reduction with warfarin
The average reduction is approx two thirds
This equates to an absolute reduction of
3%/yr (NNT-32)
For patients with a past history of CVA/TIA
there is an absolute reduction of 8%/yr
(NNT-13)
Aspirin reduces the relative risk by 22%

Arial Fibrillation: anticoagulation

Six RCT with over 2900 patients
Mean age 69yrs. 20% over 75yrs
20% previous CVA/TIA
Average follow up 1.6 yrs
Approximately 10% of patients stopped
warfarin each year over the period of
follow up

Atrial Fibrillation:
anticoagulation
Intracranialbleeding 0.5 - 1% pa
Major extra-cranial bleeding 1 -2% pa

Bleeding rate 1.7% pa <75yrs

 4.2% pa >75yrs

Anticoagulation: risk of bleeding

Document the demographic profile of the
local patient population requiring warfarin
for AF

Compare this with study population from

RCT

Document the use of warfarin where

indicated.

Objectives of anticoagulation
audit
We identified all patients discharged with
a diagnosis of atrial fibrillation between
Jan – June 2005

Case notes requested and anticoagulant

records reviewed

Audit: methods
The following information was extracted
from case/anticoagulant records:
Age, gender
Co-morbidities inc previous history of CVA
Details of any contraindications
Duration of anticoagulation and reason for
stopping

Audit: methods
99 patients were identified requiring
warfarin for AF during the first 6 months
of 2005
Case records were obtained for 97
patients
Demographic details: 40 female, 57 male
Mean age 71.4 yrs: range 26 – 89 yrs
32% of patients > 75yrs

Results: demographics
23 pts (24%) had a PH of CVA/TIA
79 patients had one or more co-morbid
conditions
IHD 43%
Hypertension 33%
LV dysfunction 18%
CCF 23%
Diabetes 8%
MVD/AVD 6%

Results: co-morbidities
Cardioversion was attempted in 26 pts
(27%) and was successful in eight
A further three patients spontaneously
reverted to sinus rhythm

Theaudit revealed that total of 58 pts

(59%) were prescribed warfarin

Results
Comparison of local pt population with those
in RCT

RCT TGH

Mean age (yrs) 69 71.4

% over 75yrs 20 32%

% PH of 20 24%
CVA/TIA
Warfarin was not prescribed in 39 pts.
Reasons:
 reversion to sinus rhythm 7
 bleeding 2
 unknown 6
 recurrent falls 1
 liver dysfunction 1
 aplastic anaemia 1
 GI upset 5

Results: No warfarin
Retrospective rather than prospective
study
Sometimes decision delayed
? Patients Choice
Unclear documentation

Points of caution
The local population of patients requiring
warfarin therapy for AF is similar to those
studied in RCTs, though the % over 75yrs
is greater.
Only around 60% of pts who should be
anticoagulated are being prescribed
warfarin

Conclusions
Extend study to a full one year cohort.
Accumulate more clinical events
Examine INR control and correlation with
clinical events
?future link between anticoagulation
datbase system and EPR

Next steps