evaluation de la prescription des anti-vitamines K au cours de la fibrillation auriculaire non valvulaire aux urgences
Mots-clés :
Fibrillation auriculaire, Service des urgences médicales, AnticoagulationRésumé
Introduction: Les anti-vitamines K (AVK) sont actuellement la classe thérapeutique la plus prescrite pour la prévention des accidents vasculairescérébraux chez les patients en fibrillation auriculaire non valvulaire (FANV). En dépit de leur efficacité démontrée, les AVK sont sous-utilisés chezles patients à haut risque thromboembolique.L’objectif de ce travail était d’évaluer la prescription des AVK chez les patients en FANV et les facteurs associés à une sous-prescription.
Méthode : Etude prospective, observationnelle, menée dans un service des urgences. Inclusion : patients avec FANV à haut risquethromboembolique et qui ne sont pas sous AVK. Calcul du CHA2DS2-VASc et HASBLED scores. Une étude analytique a été faite afin deconnaitre les facteurs indépendamment associés à la non prescription des AVK.
Résultats : Inclusion de 176 patients. Age moyen= 67±13 ans. Sex-ratio=0,5. Score CHA2DS2VASc moyen=2,88±1,55 et score HASBLEDmoyen=1,52±1,05. Les AVK ont été prescrits dans 36% des cas. En analyse multivariée, l’âge≥70 ans (ORajusté =1,59 ;IC 95%[1,11-2,21];p<0,001), une créatininémie≥110 μmol/l (ORajusté =2,54; IC 95%[1,20–5,37];p=0,01) et la prise d’aspirine (ORajusté=1,7; IC 95%[1,08-2,67];p=0,02) ont été associés de manière indépendante à la non prescription des AVK. Les facteurs cités par l’urgentiste comme associés à lanon prescription des AVK étaient liés: aux caractéristiques du patient (n=38,34%), au médecin urgentiste (n=62,55%), à l’environnement dupatient (n=20,17%) et au médicament (n=22,23%).
Conclusions : La prescription des AVK était faible. Les raisons de non prescription des AVK étaient liées à plusieurs facteurs inhérents au patientet au degré d’adhésion du médecin aux recommandations.
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Références
McDonald AJ, Pelletier AJ, Ellinor PT, et al. Increasing US emergency department visit rates and subsequent hospital admissions for atrial fibrillation from 1993 to 2004. Ann Emerg Med 2008;51:58-65.
Santini M, De Ferrari GM, Pandozi C, et al. FIRE Investigators. Atrialfibrillation requiring urgent medical care. Approach and outcome in thevarious departments of admission. Data from the Atrial Fibrillation/Flutter Italian Registry (FIRE). Ital Heart J 2004;5:205-13.
Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser S et al.The ESC Guidelines for the management of atrial fibrillation:2012focused update. ESC Clinical Practice Guidelines. European HeartJournal 2012;33:2719-47.
Stewart S, Hart CL, Hole DJ, McMurray J. Population prevalence,incidence, and predictors of atrial fibrillation in the Renfrew/Paisleystudy. Heart 2001;86:516-21.
Miyasaka Y, Barnes ME, Gersh BJ. Secular trends in incidence of atrialfibrillation in Olmsted County, Minnesota, 1980 to 2000, and implicationson the projections for future prevalence. Circulation 2006;114:119-25.
Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV.Prevalence of diagnosed atrial fibrillation in adults: national implicationsfor rhythm management and stroke prevention: the Anticoagulation andRisk Factors in Atrial Fibrillation (ATRIA) Study. JAMA 2001;285:2370-5.
European Atrial Fibrillation Trial Study Group. European Atrial FibrillationTrial: secondary prevention in non-rheumatic atrial fibrillation aftertransient ischaemic attack or minor stroke. Lancet 1993;342:1255-62.
The Stroke Prevention in Atrial Fibrillation Investigators. Predictors ofthromboembolism in atrial fibrillation. II. Echocardiographic features ofpatients at risk. Ann Intern Med 1992; 116: 6-12.
Petersen P, Boysen G, Godtfredsen J, Andersen ED, Andersen B.Placebo-controlled, randomised trial of warfarin and aspirin forprevention of thromboembolic complications in chronic atrial fibrillation:The Copenhagen AFASAK study. Lancet 1989; 333:175-9.
The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators.The effects of low-dose warfarin on the risk of stroke in patients withnonrheumatic atrial fibrillation. N Engl J Med 1990; 323:1505-11.
Ezekowitz MD, Bridgers SL, James KE, et al. for the Veterans AffairsStroke Prevention in Nonrheumatic Atrial Fibrillation Investigators.Warfarin in the prevention of stroke associated with nonrheumatic atrialfibrillation. N Engl J Med 1992;327:1406-12.
Van Walraven C, Hart Rg, Singer De et al. Oral anticoagulants vs aspirin in nonvalvular atrial fibrillation: an individual patient meta-analysis. JAMA. 2002;288(19) :2441-8.
Poli D, Antonucci E, Grifoni E et al. Bleeding risk during oralanticoagulation in atrial fibrillation patients older than 80 years. J Am CollCardiol. 2009;54(11):999-1002.Poli D, Antonucci E, Grifoni E et al. Bleeding risk during oralanticoagulation in atrial fibrillation patients older than 80 years. J Am CollCardiol. 2009;54(11):999-1002.
De Breucker S, Herzog G, Pepersack T et al. Could geriatriccharacteristics explain the under-prescription of anticoagulation therapyfor older patients admitted with atrial fibrillation? A retrospectiveobservational study. Drugs Aging. 2010;27(10):807-13.
Kutner M, Nixon G, Silverstone F et al. Physicians' attitudes toward oralanticoagulants and antiplatelet agents for stroke prevention in elderlypatients with atrial fibrillation. Arch Intern Med 1991;151:1950-3
McCrory DC, Matchar DB, Samsa G, Sanders LL, Pritchett ELC et al. Physician attitudes about anticoagulation for nonvalvular atrial fibrillation in the elderly. Arch Intern Med 1995;155:277-81.
Waldo AL, Becker RC, Tapson VF, Colgan KJ et al. The NABOR Steering Committee. Hospitalized patients with atrial fibrillation and a high risk of stroke are not being provided with adequate anticoagulation. J Am Coll Cardiol 2005;46:1729-36.
Laguna P, MartÃn A, Del Arco C, et al; on behalf of the GEFAUR-1 Investigators. Risk factors for stroke and thromboprophylaxis in atrial fibrillation: what happens in daily clinical practice? the GEFAUR-1 study. Ann Emerg Med 2004;44:3-11.
Stroke prevention in Atrial Fibrillation Investigators. The stroke prevention in atrial fibrillation study: Final results. Circulation 1991;84:527-39.
Anderson DC, Asinger RW, Newburg SM, Farmer CC, Wang K, Bundlie SR. Stroke prevention in atrial fibrillation investigators. Stroke prevention in atrial fibrillation study final results. Circulation1991;84:527-9.
Friberg L, Hammar N, Ringh M. Stroke prophylaxis in atrial fibrillation: who gets it and who does not? Report from the Stockholm Cohort-study on Atrial Fibrillation (SCAF-study). Eur Heart J 2006;27(16):1954-64.
Nieuwlaat R, Capucci A, Lip GY. Antithrombotic treatment in real-lifeatrial fibrillation patients: a report from the Euro Heart Survey on AtrialFibrillation. Eur Heart J 2006;27(24):3018-26.
Schwammenthal Y. Anticoagulation remains underused in prevention ofstroke associated with atrial fibrillation: Insights from two consecutivenational surveys. Intern J Cardiol 2010; 0167-5273.
Gladstone DJ. Potentially preventable strokes in high risk patients withatrial fibrillation who are adequately anticoagulated. Stroke 2009;40:234-40.
Waldo AL, Becker RC, Tapson VF, et al. for the NABOR SteeringCommittee. Hospitalized patients with atrial fibrillation and a high risk ofstroke are not being provided with adequate anticoagulation. J Am CollCardiol 2005;46:1729-36.
Ogilvie IM, Newton N, Welner SA, et al. Underuse of oral anticoagulantsin atrial fibrillation: a systematic review. Am J Med 2010;123:638-45.
Mant J, Hobbs FD, Fletcher K, et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet 2007;370:493-503.
Laguna P, MartÃn A, Del Arco C, et al; Spanish Atrial Fibrillation in Emergency Medicine Study Group (GEFAUR-2). Differences among clinical classification schemes for predicting stroke in atrial fibrillation: implications for therapy in daily practice. Acad Emerg Med 2005;12:828-34.
Sjalander S, Sjalander A, Svensson PJ, et al. Atrial fibrillation patients do not benefit from acetylsalicylic acid. Europace 2014;16:631-38.
Lau YC, Lip GY. Acetylsalicylic acid for stroke prevention in atrial fibrillation: a conspiracy that needs to end? Europace 2014;16:619-20.
Bradley BC, Perdue KS, Tisdel KA, Gilligan DM. Frequency of anticoagulation for atrial fibrillation and reasons for its non-use at a veterans affairs medical center. Am J Cardiol 2000;85:568-72.
Beyth RJ, Antani MR, Covinsky KE, et al. Why isn't warfarin prescribed to patients with nonrheumatic atrial fibrillation? J Gen Intern Med 1996;11:721-8.
Coll-Vinent B, Fuenzalida C, GarcÃa A, et al. Management of acute atrial fibrillation in the emergency department: a systematic review of recent studies. Eur J Emerg Med 2013;20:151-9.
Ogilvie IM, Welner SA, Cowell W, et al. Ischaemic stroke and bleeding rates in “real-world” atrial fibrillation patients. Thromb Haemost. 2011;106:34-44.
Scowcroft AC, Lee S, Mant J. Thromboprophylaxis of elderly patients with AF in the UK: an analysis using the General Practice Research Database (GPRD) 2000-2009. Heart 2013;99:127-32.
Singer DE, Chang Y, Fang MC, et al. The net clinical benefit of warfarin anticoagulation in atrial fibrillation. Ann Intern Med 2009;151: 297-305.
Roy B, Desai RV, Mujib M, et al. Effect of warfarin on outcomes in septuagenarian patients with atrial fibrillation. Am J Cardiol 2012;109:370-7.
Friberg L, Rosenqvist M, Lip GHY. Net clinical benefit of warfarin in patients with atrial fibrillation: a report from the Swedish atrial fibrillation cohort study. Circulation 2012; 125:2298-2307.
Coll-Vinent B, Pacheco G, Junyent M, et al. Impact of implementing common guidelines at different care levels in a healthcare area on the improvement of atrial fibrillation treatment. Rev Esp Cardiol 2007;60:392-403.
