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 range  Underuse by health care providers  Non-compliance by patients Purpose

Background Atrial Fibrillation Disorganized contractions that disrupt blood flow through the heart 2.66 Million Americans ,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 Medications 1.Availability to Patients 2.Compliance 3.Less Adverse Risks Quality of Life for Patients Need for Education Lower Healthcare Costs

Methods Data Bases: 1.CINAHL Plus 2.MEDLINE 3.Cochrane Data Base of Systemic Reviews Google Search Terms: Anticoagulant, Antiplatelet Atrial Fibrillation, Stroke Prevention, Warfarin, Aspirin, Clopidogrel

Definitions AFibStrokeAnticoagulantAntiplatelet Thromboembolic Events Prevention

Criteria Inclusion Published: 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 283 Articles Found 20 Articles Pertaining to PICO 3 Articles Retained For Study

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 All Stroke (ischemic & Hemorrhagic)Ischemic StrokeAll Cause MortalityPrimary PreventionSecondary PreventionTime INR Within Therapeutic Range

Validity of Findings 12 Point Screening of RCTs Intent Clearly Stated Design Appropriate for Research Question Appropriate Inclusion and Exclusion Criteria Evidence Calculations extrapolated from Sample Size Biases A verted 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 Findings OAC 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 Efficacy Anticoagulation Combination therapy Antiplatelet

PREVENTION Risk Stratification Consider Comorbidities Individualized Treatment Continuous Education

Prospective Queries Is Combination Therapy Better Than Monotherapy for Prevention of Ischemic Stroke? Are the New Antiplatelet Agents Safer Than Warfarin?