Net Clinical Benefits of Guidelines and Decision Tool Recommendations for Oral Anticoagulant Use among Patients with Atrial Fibrillation

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• 作者：Anand R. Shewale ; MS^* ; Jill T. Johnson ; PharmD ; BCPS^&dagger ; ; Chenghui Li ; PhD^* ; David Nelsen ; MD^&Dagger ; ; Bradley C. Martin ; PharmD ; PhD^* ; ^{bmartin@uams.edu" class="auth_mail" title="E-mail the corresponding author}
• 关键词：Atrial fibrillation ; guideline ; decision tool ; concordance ; net clinical benefit
• 刊名：Journal of Stroke and Cerebrovascular Diseases
• 出版年：2015
• 出版时间：December 2015
• 年：2015
• 卷：24
• 期：12
• 页码：2845-2853
• 全文大小：136 K

文摘

The 2012 American College of Chest Physicians' Evidence-Based Clinical Practice (CHEST), the 2012 European Society of Cardiology, and the 2014 American Heart Association guidelines and published decision tools by LaHaye and Casciano offer oral anticoagulant (OAC) recommendations for patients with atrial fibrillation (AF). The aim of our study was to compare the net clinical benefit (NCB) of OAC prescribing that was concordant with these decision aids.

Methods

A cohort study of the 2001-2013 LifeLink claims data was used. NCB in concordance with each decision aid was defined as adverse events (thromboembolic and major bleed events) prevented per 10,000 person-years. Cox proportional hazard models were used to assess the relative risk of AF adverse events associated in concordance with each decision aid adjusted for potential confounders.

Findings

The study included 15,129 patients with AF, contributing 33,512 person-years. The NCB of the CHEST guidelines was the highest (NCB = 30.07; 95% confidence interval [CI] = 28.66, 31.49) and the European Society of Cardiology guidelines the lowest (NCB = 7.38; 95% CI = 5.97, 8.80). Significant unadjusted decreases in the risk of AF adverse events associated with concordant OAC use/nonuse were found for the CHEST guidelines (hazard ratio [HR] = .825; 95% CI = .695, .979), Casciano tool (HR = .838; 95% CI = .706, .995), and LaHaye tool (HR = .841; 95% CI = .709, .999); however, none were significant after multivariate adjustment.

Conclusion

Concordant OAC use with any of the decision aids except for the aggressive LaHaye tool led to a positive NCB. The decision aids based on the CHA₂DS₂-VASc algorithm did not consistently improve the NCB compared to CHADS₂-based aids. Recommending OAC use when CHA₂DS₂-VASc score = 1 resulted in a lower NCB when all other factors guiding recommendations were held constant.