Abstract Atrial fibrillation (AF) is an extremely common clinical problem with an important population morbidity and mortality burden. The management of AF is complex and fraught with many uncertain ...and contentious issues, which are being addressed by extensive ongoing basic and clinical research. The Canadian Cardiovascular Society AF Guidelines Committee produced an extensive set of evidence-based AF management guidelines in 2010 and updated them in the areas of anticoagulation and rate/rhythm control in 2012. In late 2013, the committee judged that sufficient new information regarding AF management had become available since 2012 to warrant an update to the Canadian Cardiovascular Society AF Guidelines. After extensive evaluation of the new evidence, the committee has updated the guidelines for: (1) stroke prevention principles; (2) anticoagulation of AF patients with chronic kidney disease; (3) detection of AF in patients with stroke; (4) investigation and management of subclinical AF; (5) left atrial appendage closure in stroke prevention; (6) emergency department management of AF; (7) periprocedural anticoagulation management; and (8) rate and rhythm control including catheter ablation. This report presents the details of the updated recommendations, along with their background and rationale. In addition, a complete set of presently applicable recommendations, those that have been updated and those that remain in force from previous guideline versions, is provided in the Supplementary Material.
Abstract The Canadian Cardiovascular Society (CCS) Atrial Fibrillation (AF) Guidelines Committee provides periodic reviews of new data to produce focused updates that address clinically important ...advances in AF management. This 2016 Focused Update deals with: (1) the management of antithrombotic therapy for AF patients in the context of the various clinical presentations of coronary artery disease; (2) real-life data with non-vitamin K antagonist oral anticoagulants; (3) the use of antidotes for the reversal of non-vitamin K antagonist oral anticoagulants; (4) digoxin as a rate control agent; (5) perioperative anticoagulation management; and (6) AF surgical therapy including the prevention and treatment of AF after cardiac surgery. The recommendations were developed with the same methodology used for the initial 2010 guidelines and the 2012 and 2014 Focused Updates. Using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) standards, individual studies and literature were reviewed for quality and bias; the literature review process and evidence tables are included in the Supplementary Material, and on the CCS Web site. The section on concomitant AF and coronary artery disease was developed in collaboration with the CCS Antiplatelet Guidelines Committee. Details of the updated recommendations are presented, along with their background and rationale. This document is linked to an updated summary of all CCS AF Guidelines recommendations, from 2010 to the present 2016 Focused Update.
A Review of the Cost of Atrial Fibrillation Wodchis, Walter P., PhD; Bhatia, R. Sacha, MD, MBA, FRCP; Leblanc, Kori, PharmD ...
Value in health,
03/2012, Letnik:
15, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Abstract Objectives To systematically review and synthesize the literature on the costs of atrial fibrillation (AF) with attention to study design and costing methods, geography, and intervention ...approaches. Methods A systematic search for previously published studies reporting the costs for AF patients was conducted. Data were analyzed in three steps: first by evaluating overall system costs; second by evaluating the relative contribution of specific cost components; and third by examining variations across study designs, across primary treatment approach, and by geography. Finally, a specific review of the treatment costs associated with anticoagulation treatment was examined given the clinical importance and attention given to these costs in the literature. Results The literature search resulted in 115 articles. On review of the abstracts or full text of these articles, 21 articles met all study criteria and reported on health system AF-related direct costs. A further six articles focused exclusively on anticoagulation costs for patients with AF. The overall average annual system cost across 27 estimates obtained from the literature was $5450 (SD = $3624) in 2010 Canadian dollars and ranged from a low of $1,632 to a high of $21,099. About one-third of these costs could be attributed to anticoagulation management. The largest cost component was acute care, followed by outpatient and physician and then medication-related costs. Conclusion AF-related medical costs are high, reflecting resource-intensive and long-term treatments including anticoagulation treatment. These costs, accompanied with increasing prevalence, justify increased attention to the management of patients with AF. Future studies of AF cost should ensure a broad assessment of the incremental direct medical and societal cost associated with this diagnosis.
Abstract Misalignment between evidence-informed clinical care guideline recommendations and reimbursement policy has created care gaps that lead to suboptimal outcomes for patients denied access to ...guideline-based therapies. The purpose of this article is to make the case for addressing this growing access barrier to optimal care. Stroke prevention in atrial fibrillation (AF) is discussed as an example. Stroke is an extremely costly disease, imposing a significant human, societal, and economic burden. Stroke in the setting of AF carries an 80% probability of death or disability. Although two-thirds of these strokes are preventable with appropriate anticoagulation, this has historically been underprescribed and poorly managed. National and international guidelines endorse the direct oral anticoagulants as first-line therapy for this indication. However, no Canadian province has provided these agents with an unrestricted listing. These decisions appear to be founded on silo-based cost assessment—the drug costs rather than the total system costs—and thus overlook several important cost-drivers in stroke. The discordance between best scientific evidence and public policy requires health care providers to use a potentially suboptimal therapy in contravention of guideline recommendations. It represents a significant obstacle for knowledge translation efforts that aim to increase the appropriate anticoagulation of Canadians with AF. As health care professionals, we have a responsibility to our patients to engage with policy-makers in addressing and resolving this barrier to optimal patient care.
Up to 30% of patients with atrial fibrillation (AF) have coronary artery disease, and many undergo percutaneous coronary intervention (PCI). In the setting of acute coronary syndrome with PCI, or ...high-risk elective PCI, Canadian AF guidelines recommend 1-30 days of acetylsalicylic acid, 1-12 months of clopidogrel, and oral anticoagulation (OAC) with doses that may change throughout the 12 months post-PCI. The complexity of these regimens may contribute to unplanned modifications (UPMs), increasing the risk of thrombosis and/or bleeding. We describe what happens to these patients and their antithrombotic therapy (ATT) after discharge.
Prospective follow-up was conducted of patients with AF requiring OAC who underwent PCI and were discharged on combination ATT. Patients were contacted at 1, 3, 6, and 12 months post-PCI.
Sixty-five patients were enrolled, with data at any time point available for 61 of them (94%). Of these, 44 (68%) experienced at least one UPM to ATT. In total, 105 UPMs occurred. The most common UPM was an extended duration of P2Y12 inhibitor (23 instances; 22%). The most common UPM with acetylsalicylic acid was extended (11 instances; 11%) or shortened (11 instances; 11%) duration. Thirty-nine UPMs (37%) were related to OACs; 9 (23%) were related to warfarin, and 30 (77%) were related to direct OACs. Of all patients with at least one UPM, 33 (75%) experienced bleeding.
More than 2 in 3 patients with AF undergoing PCI experienced a UPM to their ATT. This study underscores the challenges of combination ATT for patients and clinicians alike, emphasizing the need for patient support after discharge.
Jusqu’à 30 % des patients atteints de fibrillation auriculaire (FA) ont une coronaropathie, et nombre d’entre eux doivent subir une intervention coronarienne percutanée (ICP). En présence d’un syndrome coronarien aigu nécessitant une ICP ou dans le cas d’une ICP non urgente associée à un risque élevé, on recommande, dans les lignes directrices canadiennes sur la FA, un traitement de 1 à 30 jours par l’acide acétylsalicylique, de 1 à 12 mois par le clopidogrel, et une anticoagulothérapie orale (ACO) à des doses pouvant varier durant les 12 mois suivant l’ICP. La complexité de ces schémas posologiques peut contribuer à des modifications non planifiées (MNP) du traitement, ce qui accroît le risque de thrombose et/ou de saignement. Nous décrivons ce qui advient de ces patients et de leur traitement antithrombotique (TAT) après le congé de l’hôpital.
Un suivi prospectif a été réalisé chez des patients atteints de FA nécessitant une ACO, ayant subi une ICP et recevant un TAT lors de leur congé de l’hôpital. Les patients ont été contactés 1, 3, 6 et 12 mois après leur ICP.
Parmi les soixante-cinq patients inscrits, des données ont été obtenues pour 61 d’entre eux (94 %) à un moment ou à un autre. Au moins une MNP du TAT a eu lieu chez 44 (68 %) de ces 61 patients, pour un total de 105 MNP. La MNP la plus fréquente était la prolongation de la durée du traitement par un inhibiteur du P2Y12 (23 cas, soit 22 %). La MNP la plus fréquente du traitement par l’acide acétylsalicylique était la prolongation (11 cas, soit 11 %) ou le raccourcissement (11 cas, soit 11 %) de la durée du traitement. Au total, 39 MNP (37 %) étaient liées à des anticoagulants oraux, 9 (23 %) à la warfarine et 30 (77 %) à des anticoagulants oraux directs. Sur l’ensemble des patients ayant fait l’objet d’au moins une MNP, 33 (75 %) ont subi un saignement.
Une MNP du TAT a eu lieu chez plus des deux tiers des patients atteints de FA ayant subi une ICP. Cette étude souligne les difficultés que pose un TAT d’association, tant pour les patients que pour les médecins, ce qui met en évidence la nécessité d’accompagner les patients après leur congé de l’hôpital.
Since 2006, the Canadian Cardiovascular Society heart failure (HF) guidelines have published annual focused updates for cardiovascular care providers. The 2010 Canadian Cardiovascular Society HF ...guidelines update focuses on an increasing issue in the western world – HF in ethnic minorities – and in an uncommon but important setting – the pregnant patient. Additionally, due to increasing attention recently given to the assessment of how care is delivered and measured, two critically important topics – disease management programs in HF and quality assurance – have been included. Both of these topics were written from a clinical perspective. It is hoped that the present update will become a useful tool for health care providers and planners in the ongoing evolution of care for HF patients in Canada.
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