Discrepancy between guidelines for stroke prevention in atrial fibrillation and practice patterns in primary care. The nationwide French AFIGP survey

Abstract

Background: General practitioners (GPs) play a pivotal role in the long-term management of patients with atrial fibrillation (AF), including anticoagulant prophylaxis for stroke prevention.

Aims: To investigate the antithrombotic prescription behaviours of GPs in France and compare them with the European Society of Cardiology (ESC) guidelines for stroke prevention, and to identify the major determinants of use of antithrombotic therapy.

Methods: We conducted a cross-sectional survey, using data from the French Longitudinal Patient Database, on the use of antithrombotic treatments for stroke prevention in 15,623 patients (≥18years of age) with AF who attended at least one GP consultation between July 2010 and June 2011. Data were collected on patient baseline characteristics, stroke risk factors, and prescription of antithrombotic drugs.

Results: The mean age was 74.6±11.1years, 59.5% were men, and 83.1% had a CHADS2 score≥1. Over half (52.6%) of the patients with a CHADS2 score≥1 received a vitamin K antagonist (alone or in combination with an antiplatelet), 19.3% received aspirin alone, and 23.4% received no antithrombotic therapy; 3.6% of the patients received dual antiplatelet therapy and 1.1% clopidogrel alone. Over half of the patients (56.3%) were treated in accordance with the ESC 2010 guidelines. Of the remaining patients, 19.4% received no treatment, 13.0% were inadequately treated, and 11.2% were over-treated. Factors associated with antithrombotic treatment were anti-arrhythmic therapy, higher stroke risk, presence of atherothrombotic disease, and use of non-steroidal anti-inflammatory drugs. Female gender was associated with a lower likelihood of antithrombotic treatment.

Conclusions: In this large French study, approximately 45% of thromboembolic high-risk patients were either not treated or inadequately treated. Better compliance with evidence-based guidelines is needed to reduce the burden of stroke in the AF population.

Keywords: Anticoagulants; Antithrombotics; Atrial fibrillation; Fibrillation atriale; General practitioners; Guidelines; Médecins généralistes; Recommandations.