The Atrial Fibrillation And Stroke Thromboprophylaxis in hEart failuRe (AFASTER) study : patient-centered approaches to thromboprophylaxis in heart failure with atrial fibrillation

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BACKGROUND Atrial fibrillation (AF) is a common arrhythmia in heart failure (HF) and presents a significant risk factor for thromboembolic stroke. Despite recommendations in best practice guidelines, implementation of risk stratification, therapeutic approaches for AF and thromboprophylaxis are not uniformly applied in practice. PURPOSE This study aims to identify both barriers and enablers to thromboprophylaxis in patients with HF and AF as a concomitant condition at the levels of the patient, provider and health system. METHODS This was undertaken through a series of discrete studies, including: (1) a prospective cohort study of individuals with HF and AF at St Vincent’s Hospital, Sydney; (2) bedside interviews with patients, and medical file note review; and (3) an electronic survey of cardiovascular nurses to explore their current knowledge and practice patterns. RESULTS Patient level: Results of this research demonstrate that patient choice and preference were important factors in thromboprophylaxis decisions, including treatment burden, unfavorable or intolerable side effects and patient refusal. Facilitators to successful prescription and adherence were caregiver support, reminders and routine, self-testing and the use of technology. At a health system level, financial barriers included cost of travel; medication cost and reimbursement were important considerations. Provider level: Survey findings revealed mixed levels of education on AF, stroke risk, anticoagulation and health behavior modification. The CHA2DS2VASc and HAS-BLED risk stratification tools were reported to be underused. Nurses reported key barriers to anticoagulation to include; fears of patients falling, fears of poor adherence to medication taking and routine monitoring. Additionally, patient self-monitoring and self-management were reported to be underutilized. Cardiovascular nurses reported their key role to be counselling and advising patients on therapy regimens. Anticoagulant-drug interaction knowledge was generally poor. From the medical file note review, clinician reticence included fear of falls, frailty, age, fear of bleeding and the challenges of multi-morbidity. Psychological factors included psychiatric illness, cognitive impairment and depression. Social barriers included homelessness and the absence of a caregiver or lack of caregiver assistance. The cohort study revealed that 66% of participants were prescribed an anticoagulant at discharge from hospital. Self-reported self-care behavior and ‘not for CPR’ were associated with not receiving anticoagulation at discharge. Whilst statistical significance was not achieved, those who were assessed as frail or having greater comorbidity, were less likely to receive anticoagulation at discharge from hospital. RECOMMENDATIONS 1. Treatment decisions must be tailored to meet the needs of individuals, whilst balanced in the context of the best available evidence. 2. There is need to formalize the role of the caregiver in the management of AF and CHF. 3. Improved focus on AF within existing chronic care programs is warranted, given the aging population. 4. Developing quality patient education materials and self-management strategies are key priority areas for enhancing sustainable models of care. 5. There is scope for improvement in nurses’ knowledge and practice in contemporary AF management. 6. Patient preference, choice and attributes must be considered when making complex thromboprophylaxis treatment decisions. CONCLUSION The findings of this thesis point to the need for patient-centered approaches to the management of AF in the setting of HF, as well as increased skills and competencies for nurses. This thesis demonstrates that although stroke and bleeding risk calculation are important there are other salient considerations in making clinical decisions for thromboprophylaxis including cognitive impairment, multimorbidity, self-care ability and frailty. These factors not only influence decision making on the part of provider and patient but also influence clinical outcomes. Shared decision making provides a framework for patients and providers to have quality communication, negotiate consensus and find agreements on treatment goals. These findings underscore the need for shared decision making when making complex treatment decisions around thromboprophylaxis.
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