Antiplatelet or Anticoagulant: Do They Have the same Efficacy? University of Central Florida Deborah...
-
Upload
antony-bridges -
Category
Documents
-
view
217 -
download
1
Transcript of Antiplatelet or Anticoagulant: Do They Have the same Efficacy? University of Central Florida Deborah...
Antiplatelet or Anticoagulant:Do They Have the same
Efficacy?
University of Central Florida
Deborah Andrews RN, BSN
• To evaluate antiplatelet versus anticoagulant agents for prevention of thromboembolic stroke in atrial fibrillation patients
• Anticoagulants: small therapeutic rangeUnderuse by health care providersNon-compliance by patients
Purpose
BackgroundAtrial Fibrillation
Disorganized contractions that disrupt
blood flow through the heart
2.66 Million Americans
2009 11,555 deaths attributed to AFib
Risk increases with age
6.4 Billion dollars annually in U.S.
Stroke
AFib increases risk by 5 fold
159,000 annually attributed to AFib
Ischemia is responsible for 87%
Strokes regardless of cause cost Americans
23 Billion dollars annually
24% of AFib patients not offered
pharmacologic treatment
Anticoagulant Agents
Warfarin reduces stroke by 60%
Inhibits Vitamin K clotting enzymes
Small therapeutic range
Multiple adverse effects
Only oral anticoagulant used in U.S.
Antiplatelet Agents
Aspirin: Up to 20% Stroke reduction
COX inhibitor
Readily available, Inexpensive,
Familiar
Adverse effects: GI, Bleeding, toxicity
New Antiplatelets: Clotting Cascade
Research Question
Do Antiplatelet Medications Have the
Same Efficacy as Anticoagulants for
Preventing Thromboembolic Events
in Atrial Fibrillation patients?
Relevance to Nursing
Management of Patient Medications1. Availability to Patients
2. Compliance
3. Less Adverse Risks
Quality of Life for Patients
Need for Education
Lower Healthcare Costs
MethodsData Bases:1. CINAHL Plus2. MEDLINE3. Cochrane Data Base of Systemic
Reviews
GoogleSearch Terms: Anticoagulant, Antiplatelet Atrial Fibrillation, Stroke Prevention, Warfarin, Aspirin, Clopidogrel
Definitions
Criteria
Inclusion
• Published: 2000 - 2010
• AFib Patients >60 years
• Available in English
• Measurable Outcomes
• Prevention of
Thromboembolic Events
• Oral agents
• Randomized
Exclusion
• Duplicate Studies
• Published prior to 2000
• Embolic events From
Other Sources
• Intravenous agents
• Patients < 60 years
• Poor Quality
Methods
Findings
1 Meta-Analysis: 29 trials = 28,044 Pts (Level 1)
2 Random Control Trials: (Level 2)973 & 574 Pts
United States, United Kingdom, & Spain(Global studies)
Randomization
Intention to Treat
Adjusted Dose Warfarin
Aspirin or Other Antiplatelet
Ischemic Stroke, All Stroke, Other Thromboembolic events
Study Characteristics
Sample Characteristics
Atrial Fibrillation Patients
Age: > 60 & < 85
With or Without Prior Stroke
Average follow up: 1.5 – 4.92 yrs.
Women: 45%
Randomized to either Warfarin or Antiplatelet agent
Themes
Validity of Findings12 Point Screening of RCTs
Intent Clearly Stated
Design Appropriate for Research Question
Appropriate Inclusion and Exclusion Criteria
Evidence Calculations extrapolated from Sample Size
Biases Averted
Proper Descriptions of Interventions and Controls
Outcomes Are Relevant Clinically
Similarities Between Groups were Similar
All With Intention to Treat
Studies Align with Previous Studies
Participants Equivalent to Current Patients
Findings Support Practice Change
Synopsis of Finding
Synopsis of Findings
Hart et al., 2007 & Mant et al., 2007
Synopsis FindingsOAC
Bover et al., 2009 & Hart et al. 2007
Total of All Trials, 29,457 Patients 4.8% Stroke Rate
Bover et al., 2009, Hart et al. ,2007, & Mant et al., 2007
Time in Therapeutic Range
INR Ranges Varied Study to Study
Average Time in Therapeutic Range
67% - 69%
(Meta-Analysis: undetermined)
Bover et al., 2009, Hart et al. ,2007, & Mant et al., 2007
Recommendations for Nursing
Prospective Queries
Is Combination Therapy Better Than Monotherapy for Prevention of Ischemic Stroke?Are the New Antiplatelet Agents Safer Than Warfarin?