Abstract 18097: Predictors of Non-adherence with Guidelines for Antithrombotic Treatment and Subsequent Prognosis in Patients with Atrial Fibrillation.
In atrial fibrillation (AF), ‘non-adherence’ to guidelines for antithrombotic treatment and undertreatment are likely to be associated with a worse prognosis in declarative surveys. Our objective was to evaluate if this was also the case in a large contemporary series of unselected AF patients in ‘real world’ clinical practice and to determine factors leading to undertreatment.
Methods: All patients with AF seen in our institution between 2000 and 2007 were identified in a database and followed up for mortality and stroke. Patients who died or were lost to follow-up within 30 days of their index event were excluded. Antithrombotic guideline adherence was assessed according to the 2006 ACC/AHA/ESC guidelines.
Results: We reviewed outcomes in 3646 consecutive patients with AF (age 71±14 years; mean CHADS2 score 1.5±1.1). Antithrombotic treatment was in agreement with the guidelines in 53% of patients, whereas 31% were classed as ‘undertreated’ and 16% as ‘overtreated’. In a Cox-regression analysis, older age (p<0.0001), renal failure (p=0.008), female sex (0.0008), and non permanent AF (0.01) were independently associated with undertreatment. During a follow-up of 953±767 days (median=771), 580 adverse events (composite endpoint of mortality and stroke) were recorded (498 deaths and 82 strokes as a first endpoint), distributed as follows: 283 (49%) in the undertreated group, 267 (46%) in the guideline adherent group, and 30 (5%) in the overtreated group. Guideline adherence was associated with a lower risk of adverse events compared to undertreatment (odds ratio= 0.48, 95%CI 0.40–0.56, p<0.0001). In multivariate analysis, factors independently associated with increased mortality and stroke were antithrombotic undertreatment (p<0.0001), older age (p<0.0001), heart failure (p<0.0001), renal failure (p=0.001), diabetes (p=0.005) and previous history of stroke (p=0.02).
Conclusions: Guideline non-adherence and undertreatment with antithrombotic undertreatment in unselected patients with AF is independently associated with a higher risk of mortality and stroke. Older age, female sex and non permanent AF are associated with an increased risk of undertreatment. Adherence with guidelines should thus be improved for these patients in the future.
- © 2010 by American Heart Association, Inc.