The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation

background Current guidelines recommend oral anticoagulation therapy for patients with atrial fibrillation who are at moderate-to-high risk of stroke, however anticoagulation control (time in therapeutic range (TTR)) is dependent on many factors. Educational and behavioural interventions may impact on patients’ ability to maintain their International Normalised Ratio (INR) control. Objectives To evaluate the effects on TTR of educational and behavioural interventions for oral anticoagulation therapy (OAT) in patients with atrial fibrillation (AF). Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) in The Cochrane Library (2012, Issue 7 of 12), MEDLINE Ovid (1950 to week 4 July 2012), EMBASE Classic + EMBASE Ovid (1947 to Week 31 2012), PsycINFO Ovid (1806 to 2012 week 5 July) on 8 August 2012 and CINAHL Plus with Full Text EBSCO (to August 2012) on 9 August 2012. We applied no language restrictions. Selection criteria The primary outcome analysed was TTR. Secondary outcomes included decision conflict (patient's uncertainty in making health-related decisions), percentage of INRs in the therapeutic range, major bleeding, stroke and thromboembolic events, patient knowledge, patient satisfaction, quality of life (QoL), and anxiety. Data collection and analysis The two review authors independently extracted data. Where insufficient data were present to conduct a meta-analysis, effect sizes and confidence intervals (CIs) of the included studies were reported. Data were pooled for two outcomes, TTR and decision conflict. Main results Eight trials with a total of 1215 AF patients (number of AF participants included in the individual trials ranging from 14 to 434) were included within the review. Studies included education, decision aids, and self-monitoring plus education. For the primary outcome of TTR, data for the AF participants in two self-monitoring plus education trials were pooled and did not favour self-monitoring plus education or usual care in improving TTR, with a mean difference of 6.31 (95% CI -5.63 to 18.25). For the secondary outcome of decision conflict, data from two decision aid trials favoured usual care over the decision aid in terms of reducing decision conflict, with a mean difference of -0.1 (95% CI -0.2 to -0.02). Authors' conclusions This review demonstrated that there is insufficient evidence to draw definitive conclusions regarding the impact of educational or behavioural interventions on TTR in AF patients receiving OAT. Thus, more trials are needed to examine the impact of interventions on anticoagulation control in AF patients and the mechanisms by which they are successful. It is also important to explore the psychological implications for patients suffering from this long-term chronic condition.

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Educational and behavioural interventions for anticoagulant therapy in patients with atrial fibrillation

Background: Multiple factors influence warfarin metabolism and can significantly affect the risk of adverse events. The extent to which patients understand the modifiable factors th

Warfarin Knowledge in Patients with Atrial Fibrillation: Implications for Safety, Efficacy, and Education Strategies

The role of the patient as an active partner in health care, and not just a passive object of diagnostic testing and medical treatment, is widely accepted. Providing information to patients is considered a crucial issue and the central focus in patient educational activities. It is necessary to educate patients on the nature of the outcomes and the benefits and risks of the procedures to involve them in the decision-making process and enable them to achieve fully informed consent. Information materials must contain scientifically reliable information and be presented in a form that is acceptable and useful to patients. Given the mismatch between public beliefs and current evidence, strategies for changing the public perceptions are required. Traditional patient education programmes have to face the potential barriers of storage, access problems and the need to keep content materials up to date. A computer-based resource provides many advantages, including “just-in-time” availability and a private learning environment. The use of the Internet for patient information needs will continue to expand as Internet access becomes readily available. However, the problem is no longer in finding information, but in assessing the credibility and validity of it. Health Web sites should provide health information that is secure and trustworthy. The large majority of the Web sites providing information related to spinal disorders are of limited and poor quality. Patient Line (PL), a patient information section in the Web site of Eurospine, was born in 2005 to offer patients and the general population the accumulated expertise represented by the members of the society and provide up-to-date information related to spinal disorders. In areas where evidence is scarce, Patient Line provides a real-time opinion of the EuroSpine membership. The published data reflect the pragmatic and the common sense range of treatments offered by the Eurospine membership. The first chapters have been dedicated to sciatica, scoliosis, cervical pain syndromes, low back pain and motion preservation surgery. Since 2008, the information has been available in English, German, French and Spanish. The goal is for Patient Line to become THE European patient information Web site on spinal disorders, providing reliable and updated best practice and evidence-based information where the evidence exists.

Patient information and education with modern media: the Spine Society of Europe Patient Line

Pulmonary Embolism (PE) is an important cause of death in the industrialized world (1,2). Ionizing radiation administered for medical imaging is of increasing clinical concern, particularly for younger patients and female patients (3,4). In a recent epidemiological study, medical radiation at the 50 mSv level was shown to have increased incidence of brain malignancy and leukemia above what could be expected in an unexposed population (5). Chest radiation for younger women is potentially problematic due to its cumulative effects and the radiation sensitivity of breast tissue (3,6). In symptomatic patients with a clinical suspicion for pulmonary embolus, the currently accepted reference standard is computed tomographic angiography (CTA-PE) (7–12). An alternative test that requires no ionizing radiation for the detection of pulmonary embolism would be highly beneficial, so long as it has sufficient effectiveness (4–12).

There is recent evidence showing that the number of pulmonary embolism (PE) diagnoses has significantly increased in the United States without a corresponding significant drop in death rate (13–15). CTA-PE is a frequently ordered test that maybe over-used (16). This high degree of usage by clinicians likely reflects the excellent performance (efficacy) of CTA-PE and its ability to diagnose even tiny, subsegmental pulmonary emboli. Recently, some authors have challenged the necessity to treat all sub-segmental PE with anti-coagulation (13,14,17), noting the 4–8% incidence of serious bleeding complications from treatment of PE (1,14,18,19). For this reason, alternative exams such as pulmonary MR angiography (MRA-PE), which have a lower accuracy (efficacy) than CTA-PE for diagnosis of subsegmental PE, may be more than adequate for detection of clinically significant emboli that require anticoagulation. (17,20–24).

Use of patient outcomes for the determination of test effectiveness is often employed when there is no available reference standard to determine the efficacy of a test. Recently, Douglas and colleagues have suggested that the determination of test effectiveness, as established by patient outcomes, is actually much more important for the evaluation of clinical utility than test efficacy (29). Lack of a measurable adverse clinical event over the follow-up period is a useful surrogate for utility of a test in this situation. In the clinical evaluation of heart disease, the patient outcome surrogate is a Major Adverse Cardiac Event (MACE) during the chosen follow-up interval (29). In the nuclear medicine literature, outcomes analysis have be used for many years in the determination of test negativity in the workup of suspected PE (30). Use of 1-year outcomes for the determination of CTA-PE effectiveness has been reported by the highly respected cardio-pulmonary radiology group in Lille, France (31). They studied 185 patients and found that CTA-PE had a negative predictive value of 98%, with three episodes of fatal PE (31).

Early work on the efficacy of MRA-PE was published in 1999 by Gupta and colleagues has now been shown to be on target with current results (25). They found that larger PEs (lobar and segmental) are well seen with contrast enhanced MRA-PE, but that the sub-segmental PEs were frequently missed (25). There are many studies showing that MRA-PE is a test of lower efficacy than CTA-PE for the diagnosis of subsegmental pulmonary embolism (20,21,28,32–34). However, a conclusion from the PIOPED III study was that if the MRA-PE could be performed in a technically adequate manner, that MRA-PE is highly diagnostic for this condition (20). The purpose of our retrospective study was to determine the effectiveness of MRA-PE in symptomatic patients, using the clinical outcome measure of Venous ThromboEmbolism (VTE, deep venous thrombosis and/or PE) or death from PE as determined by review of the electronic medical record (EMR) for 3 months following the MRA-PE and a second review at 1 year.

Effectiveness of MR Angiography for the Primary Diagnosis of Acute Pulmonary Embolism: Clinical Outcomes at 3 Months and 1 Year

Patient education is an essential component in quality management of the anticoagulated patient. Because it is time consuming for clinicians and overwhelming for patients, education of the anticoagulated patient is often neglected. We surveyed the medical literature in order to identify the best patient education strategies. Study Selection: Two reviewers independently searched the MEDLINE and Google Scholar databases (last search March 2007) using the terms "warfarin" or "anticoagulation", and "patient education". The initial search identified 206 citations, A total of 166 citations were excluded because patients were of pediatric age (4), the article was not related to patient education (48), did not contain original data or inadequate program description (141), was focused solely on patient self-testing (1), was a duplicate citation (3), the article was judged otherwise irrelevant (44), or no abstract was available (25). Data Extraction: Clinical setting, study design, group size, content source, time and personnel involved, educational strategy and domains, measures of knowledge retention. Data Synthesis: A total of 32 articles were ultimately used for data extraction. Thirteen articles adequately described features of the educational strategy. Five programs used a nurse or pharmacist, 4 used a physician, and 2 studies used other personnel/vehicles (lay educators (1), videotapes (1)). The duration of the educational intervention ranged from 1 to 10 sessions. Patient group size most often averaged 3 to 5 patients but ranged from as low as 1 patient to as much as 11 patients. Although 12 articles offered information about education content, the wording and lack of detail in the description made it too difficult to accurately assign categories of education topics and to compare articles with one another. For the 17 articles that reported measures of patient knowledge, 5 of the 17 sites where the surveys were administered were located in anticoagulation clinics/centers. The number of questions ranged from as few as 4 to as many as 28, and questions were most often of multiple choice format. Three were self-administered, and 2 were completed over the telephone. Two reports described instruments along with formal testing of the validity and reliability of the instrument. Published reports of patient education related to warfarin anticoagulation vary greatly in strategy, content, and patient testing. Prioritizing the educational domains, standardizing the educational content, and delivering the content more efficiently will be necessary to improve the quality of anticoagulation with warfarin.

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Megan D Wells

Papers

Best strategies for patient education about anticoagulation with warfarin: a systematic review