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ADHERNCE TO ORAL ANTICOAGULANTS
AMONG PATIENTS WITH CHRONIC Atrial
fibrillation IN Al-NASSIRIYA 2016
This study was submitted in partial fulfillment of the
requirement for the M.B.Ch.B.
Faculty: Thi-Qar College of medicine/University of Thi-Qar.
By:
 Ousama Mohamad Jasim
 Mustafa Qusay Sagban
Supervised by:
 Assistant prof. Dr. Adnan Al-Ta’aan
1
Abstract
Health care professionals must be alert to the high prevalence of low adherence to treatment,
because Low adherence increases morbidity and medical complications, contributes to poorer
quality of life and an overuse of the health care system. Many different factors have an impact
on adherence. However, critical factors to consider in teens are their developmental stage and
challenges, emotional issues and family dysfunction. Direct and indirect methods have been
described to assess adherence. Eliciting an adherence history is the most useful way for
clinicians to evaluate adherence, and could be the beginning of a constructive dialogue with
the adolescent. Interventions to improve adherence are multiple – managing mental health
issues appropriately, building a strong relationship, customizing the treatment regimen if
possible, empowering the adolescent to deal with adherence issues, providing information,
ensuring family and peer support, and motivational enhancement therapy. Evaluation of
adherence at regular intervals should be an important aspect of health care for adolescents.
The term adherence has been used more in recent literature, and is defined as “the extent to
which a person’s behaviour, in terms of taking medications, following diets, or executing
lifestyle changes, coincides with medical or health advice”. Although compliance and
adherence are often used interchangeably, in the present article, adherence is used because it
focuses on whether a person adheres to the regimen rather than passively follows the
doctor’s orders. Rates of adherence in the adolescent population vary widely, from 10% to
89%, for chronic illnesses.
In this paper, we did a cross-sectional study conducted on 60-patients whom are known
cases of chronic AF, with specially-constructed questionnaire to obtain information. The
retrospective design, small number of patients & the non-randomized nature of the study and
the non-homogeneity of the population leave the possibility of selection bias.
The results showed that adherence can be influenced by a number of factors, including: the
patient’s gender, education ,the SES, the patient’s psychology & the presence of more
comorbid illnesses.The recommendations for future are each patient should be provided
with card contain full informations about patient illness and treatment , more studies should
be done to discuss the cause of non-adherence to anti coagulants treatment and Giving
tutorial programs about Anticoagulants drugs and risk of non adherence to therapy
2
Objective: This study aims to determine the adherence to guidelines on
anticoagulant management among patients with chronic AF attend nasiriyah heart
center ,CCU in hussain teaching hospital and their affection by demographic
characteristics.
Introduction and literature review
Atrial fibrillation (AF) is the commonest cardiac arrhythmia. The incidence
increases with age and affects 5% of UK population above the age of 65 yr and
10% above 75 yr. In the United States, AF accounts for more than 35% of all
admissions for cardiac arrhhmytias (1,2) . Men are 1.5 times more likely to develop
AF than women (3) . AF is often associated with structural heart disease, but in
many patients it can occur with no detectable disease (lone AF). Thromboembolic
events and heart failure resulting from AF lead to significant morbidity, mortality
and increased cost of management.
Table 1
Causes and risk factors for AF
Acute causes
AF associated with
cardiovascular disease
Alcohol binge drinking
Cardiac and non-cardiac surgery
Following myocardial infarction
Hypertension, especially if
leftventricular hypertrophy
Myocarditis/pericarditis
Pulmonary embolism
Chest infections
Hyperthyroidism
Valvular heart disease (often
mitral)
Congenital heart disease, mainly
atrial septal defects (ASD)
Sick sinus syndrome
Diabetes mellitus
Neurogenic AF
Familial AF
High vagal tone (nocturnal episodes)
Identified in a small group of
patients11
Pulmonary hypertension
High sympathetic tone (daytime episodes; associated with
ischaemic heart disease, stress, excessive caffeine, alcohol)
3
Definition and electrocardiographic patterns
AF is a supraventricular arrhythmia characterised by complete absence of
coordinated atrial contractions. On the electrocardiogram there is consistent
absence of P waves which are replaced by fibrillatory waves. AF is associated with
an irregular and frequently rapid ventricular response if atrioventricular conduction
is intact. Regular R-R intervals are possible in the presence of atrioventricular
block or interference by ventricular or junctional tachycardia. A wide QRS
complex tachycardia that is rapid, irregular or sustained strongly suggests
underlying bundle branch block or conduction over an accessory pathway (e.g.
Wolf–Parkinson–White syndrome) especially if the ventricular rate is extremely
rapid (over 200 beats min−1). (3)
AF can be commonly associated with other arrhythmias such as atrial flutter or
atrial tachycardia. Atrial flutter is a more organised and regular form of atrial
activation resulting in a saw-tooth pattern or flutter waves (f) on the
electrocardiogram. Atrial flutter can arise during treatment of AF with
antiarrhythmic drugs. Atrial flutter itself can degenerate into AF, can be triggered
by AF or the pattern can alternate between AF and flutter. Other atrial arrhythmias
can also trigger AF and are identified by the presence of P waves which are
separated by an isoelectric baseline.
Classification
Classification of AF has always been controversial. The current classification is
based on two important elements: patterns of evolution of arrhythmia and the
response to treatment (3,4,5) .
First onset AF is the first clinical presentation where the patient is still in AF and
the episode has been present for less than 48 h.
Paroxysmal AF is the occurrence of recurrent episodes that typically last minutes
to hours, occasionally days, but eventually self-terminate.
4
Persistent AF is present when arrhythmia is not self-terminating, but
pharmacological or electrical cardioversion is required to restore sinus rhythm.
AF is permanent when all attempts to restore sinus rhythm have been abandoned
because of physician or patient decision, frequent recurrence, or inability to
cardiovert the patient.
Pathophysiology and mechanisms
The mechanisms of AF are not fully clear, but at least three aspects seem to be
important in its genesis and maintenance:



There may be enhanced automaticity within ‘sleeves’ of atrial tissue that extend
into the pulmonary veins or vena caval junctions. These foci can act as trigger
points to generate multiple atrial ectopics leading to AF and their elimination by
means of ablation may possibly provide a permanent cure, particularly in those
with structurally normal hearts.(6)
In chronic AF, maintenance of arrhythmia is sustained by multiple re-entering and
randomly circulating wavelets that collide and divide into ‘daughter-wavelets’ thus
maintaining the chaotic electrical state.(8,9)
The longer the duration of AF, the more difficult it is to restore sinus rhythm and
prevent recurrences. This is due to electrical and structural remodelling of atrial
tissue resulting in shortening of effective refractory periods, thereby maintaining
and increasing the duration of AF.(8,9)
Causes and risk factors
As described above, the risk of developing AF increases with age. Whilst
rheumatic valvular disease remains the most common cause for AF in developing
countries, most patients develop AF on the basis of coronary artery disease and
systemic hypertension. Clinically important causes and risk factors for AF are
summarised in Table 1. Echocardiographic predictors include large atria,
diminished ventricular function and increased left ventricular wall thickness. When
5
AF occurs in normal hearts without signs of any demonstrable cardiovascular
disease, it is termed ‘lone atrial fibrillation’
Principles of management
The management of AF still represents one of the major therapeutic challenges in
medicine. Based on current evidence and guidelines, there are four main principles
(3)
:
i.
ii.
iii.
iv.
Restoration of sinus rhythm by pharmacological or electrical means.
Control of ventricular rate during paroxysmal or persistent AF, and chronically in
those with permanent AF.
Prevention of recurrence of paroxysmal or persistent AF following successful
restoration of sinus rhythm.
Prevention of thromboembolic phenomena.
When a patient is seen in the emergency setting, the main priority is to control the
fast ventricular response and, depending on the haemodynamic status of patient,
this can be achieved either by urgently restoring sinus rhythm or by controlling the
ventricular rate. Immediate electrical cardioversion is indicated in patients with a
rapid ventricular rate who are either haemodynamically unstable or have evidence
of acute myocardial ischaemia or heart failure that do not respond promptly to
pharmacological measures. In less acute situations, pharmacological cardioversion
can be attempted, thereby avoiding the requirement for general anaesthesia.
Cardioversion by either means carries a risk of thromboembolism, particularly
when the arrhythmia has been present for longer than 48 h; anticoagulation
prophylaxis must be initiated before the procedure. In the long-run, it may become
appropriate to accept the arrhythmia as permanent.
Recent studies have pointed out that rate controlling the AF could be at least as
effective as restoration of sinus rhythm in terms of symptom control and survival,
particularly in stable patients aged approximately 60 years old
6
Restoration of sinus rhythm
Direct current cardioversion
Direct current cardioversion (DCC) involves a synchronised direct current
electrical shock delivered across the chest wall. Sinus rhythm can be restored in a
significant proportion of patients with success rates varying between 65% and
90%. The success of DCC appears to be greater with anterior-posterior positioning
of paddles (sternum and left scapular) than with anterior-lateral (ventricular apex
and right infraclavicular). Other factors include nature of heart disease,
transthoracic resistance and output waveform (monophasic or biphasic).(1,2,3)
Elective DCC is performed under adequate short-acting anaesthesia. In an
emergency situation, the need for anaesthesia depends on the nature of the
emergency and conscious level of the patient; it is reasonable to perform DCC
under conscious sedation if the urgency of the situation is such that there can be no
delay. In a recent report, elective DCC performed under conscious sedation was
also shown to be safe and not associated with any intolerable discomfort to the
patient.(12)
Devices that deliver a monophasic waveform of current have been conventionally
used for cardioversion. Initial shock energy of 200 J is recommended for
cardioversion of AF using a monophasic device. The sequence of energy
commonly used is: 200 J; 200 J; 300 J; and 360 J.3 Biphasic machines achieve
cardioversion at much lower energy levels and are increasingly replacing
monophasic devices.
It is safe to cardiovert patients with implanted devices such as permanent
pacemaker or internal defibrillator provided the implanted device is interrogated
immediately before and after cardioversion to assess any malfunction. The paddles
used for cardioversion should be placed as far as possible from the implanted
device, preferably in the anterior-posterior position.
7
Brief arrhythmias can arise immediately following DCC. These are mainly
ventricular and supraventricular premature beats, bradycardia and short periods of
sinus arrest.
Ventricular tachycardia or fibrillation can be precipitated in patients with
hypokalaemia and digitalis intoxication. Patients with underlying conduction
defects are at risk of developing profound bradycardia, complete heart block or
asystolic periods following cardioversion. These patients are identified by having a
slow ventricular response to AF in the absence of rate-reducing medications and
facilities for temporary external or endocardial pacing must be made available
prior to attempting cardioversion.
Electrical cardioversion can also lead to transient ST segment elevation with a rise
in blood concentrations of cardiac troponins and CK-MB, even without cardiac
damage. The rate of relapse after DCC is high unless anti-arrhythmic drug therapy
to maintain sinus rhythm is given concomitantly. However, prophylactic therapy to
prevent recurrences following DCC should be considered individually for each
patient.
Pharmacological restoration of sinus rhythm
Prior to considering any anti-arrhythmic therapy, it is important to realise that up to
60% of patients with recent onset AF spontaneously revert to sinus rhythm within
24 h to a few days. Pharmacological cardioversion is considered in patients who
are haemodynamically stable; it is often successful in AF of <48 h.(13)
Anti-arrhythmic drugs are classified according to the Vaughan Williams
classification (Table 2). Current guidelines on the management of AF3 recommend
use of propafenone, flecainide, ibutilide or dofetilide as first choice for
pharmacological cardioversion of AF of <7 days duration (conversion rates of up
to 90%). Flecainide and propafenone are safe in patients who do not have evidence
of ischaemic heart disease or myocardial dysfunction. Dofetilide and ibutilide are
relatively new class III agents and are most useful for cardioverting atrial flutter.
8
However, there is an increased incidence of torsade de points or polymorphic
ventricular tachycardia with use of these drugs.(13)
Table 2
Vaughan Williams Classification of Antiarrhythmic Drugs
Class
Action
Drugs
I
Sodium channel blockade
Prolong repolarisation
Quinidine, procainamide,
disopyramide
Shorten repolarisation
Lidocaine, mexiletine,
tocainide, phenytoin
Little effect on repolarisation
Encainide, flecainide,
propafenone
II
Beta-adrenergic blockade
Propanolol, esmolol,
acebutolol, l-sotalol
III
Prolong repolarisation
(potassium channel blockade;
other)
Amiodarone,
bretylium, d,l-sotalol,
ibutilide
IV
Calcium channel blockade
Verapamil, diltiazem,
bepridil
Miscellaneous
Miscellaneous Actions
Adenosine, digitalis,
IA
IB
IC
In clinical practice, amiodarone is a reasonable alternative to class Ic agents and is
the drug of choice in patients with ventricular dysfunction and ischaemic heart
disease. Amiodarone also has an added advantage of providing prompt rate control
in addition to its anti-arrhythmic effect. This rate controlling effect (beta blockade
and calcium channel blockade properties) is observed early following i.v. loading;
9
the class III anti-arrhythmic properties take effect at 8–24 h. Most of the toxicity of
amiodarone is dose-dependent and related to chronic treatment; however, it should
be used with caution in patients with acute ischaemia or myocardial dysfunction, as
profound hypotension may be induced by i.v. or high-dose oral loading. There is
emerging evidence that i.v. and oral amiodarone have different
electrophysiological properties and it may be possible to administer i.v.
amiodarone to cardiovert AF in patients who are already on chronic oral
treatment.(14)
Maintenance of sinus rhythm
The relapse rate of AF following initial cardioversion is high (25–50% at 1 month).
Maintenance of sinus rhythm after successful cardioversion is achieved by
continuation of oral therapy with class I or III anti-arrhythmic drugs. Pre-treatment
with these drugs also improves success rates of repeated DCC. Sotalol is useful for
preventing recurrences of paroxysmal AF. However, it is vital to be aware of the
pro-arrhythmic effects of these agents; they can prolong the QT interval and lead to
dangerous ventricular arrhythmias. Thus, regular monitoring of corrected QT
interval (QTc) and QRS duration is important during outpatient reviews. Renal
insufficiency and electrolyte imbalance also predispose to polymorphic ventricular
tachycardia.
Rate control of atrial fibrillation
It is necessary to control the ventricular rate in persistent AF. Also, rate control
may be a preferred strategy in patients with paroxysmal AF who are stable at
presentation, as 60% of these patients can spontaneously revert to sinus rhythm
within 24 h.
The aim of rate control in AF is to improve symptoms and prevent worsening of
ventricular dysfunction. Recent evidence from randomised trials
(AFFIRM,(15) PIAF,(16) RACE,(17) STAF (18) ) has shown that rate control is at least
as effective as rhythm control in improving symptoms and functional capacity,
particularly in those over 65 yr of age. What is considered adequate rate control
10
remains controversial. Heart rate should neither be too high (leads to tachycardia
induced cardiomyopathy) or too low (facilitates heart failure); it is considered to be
controlled when the ventricular rate is 60–80 bpm at rest and 90–115 bpm during
exercise.
Rate control is achieved by drugs which predominantly affect conduction through
the AV node. Commonly used agents are digoxin, beta-blockers (atenolol,
propranolol, metoprolol, esmolol) and non-dihydropyridine calcium channel
blockers (verapamil and diltiazem). In permanent AF, digoxin can usually provide
adequate rate control. However, digoxin does not prevent excessive heart rates
during exercise and combination therapy with beta-blockers or calcium antagonists
may be necessary, especially in younger active individuals. In stable patients with
acute AF, calcium antagonists or beta-blockers (oral or i.v.) are preferred to
digoxin due to their rapid onset of action (3–7 min). Digoxin is the drug of choice
for rate control in patients with heart failure, though there is emerging evidence in
support of beta-blockers.
Patients with sick sinus syndrome with AF and present with episodes of
bradycardia, usually require the support of a permanent pacemaker to allow the use
of rate controlling medications. Drugs acting on the AV node are contraindicated
in patients with accessory conduction pathways (e.g. Wolf–Parkinson–White
syndrome) as they can result in dangerously fast ventricular rates by increasing the
conduction via the accessory pathway. In these situations amiodarone, flecainide or
procainamide are drugs of choice.
Prevention of thromboembolism
Chronic AF is associated with a 3–7% annual risk of ischaemic stroke from
thromboembolism. Guidelines (3) recommend administration of heparin prior to, or
concurrently during, immediate electrical or pharmacological cardioversion. If AF
has been present for longer than 48 h or the duration is unknown, warfarin should
be given for 3–4 weeks following successful cardioversion. Patients admitted for
elective cardioversion require adequate anticoagulation with warfarin 3–4 weeks
before and after the procedure (INR 2–3). Those patients who cannot be
11
anticoagulated due to contraindications prior to cardioversion should undergo
transoesophageal echocardiographic examination to exclude the presence of
thrombus.
In chronic AF, the risks and benefits of antithrombotic therapy (aspirin, warfarin)
must be considered in each individual patient. Chronic hypertension, age >65 yr,
diabetes mellitus, previous ischaemic stroke, ventricular dysfunction and coexistent ischaemic or valvular heart disease are considered as high risk factors for
thromboembolism in AF. All such high risk patients must receive warfarin unless
contraindicated. In the absence of these factors (low risk patients) or when warfarin
cannot be given, aspirin 300 mg daily is an alternative. Young patients with AF
who do not have any clinical or echocardiographic evidence of heart disease (‘lone
AF’) are also at low risk of thromboembolism.
Anticoagulation can be interrupted for a period of up to 1 week for surgical and
diagnostic procedures that carry a risk of bleeding. However, these patients must
receive heparin if they are at high risk of thromboembolism or have mechanical
prosthetic valves.
Principles of prevention of thromboembolism in patients with atrial flutter are the
same as those for AF. New anticoagulants and thrombin inhibitors which do not
require regular monitoring and blood tests are currently being compared with
warfarin in various trials.
Non-pharmacological management
A wide variety of non-pharmacological approaches now exist for managing AF
and provide rhythm or rate control when drug treatment has failed. Commonly
used strategies are outlined in Table 3.
12
Table 3
Non-pharmacological management of AF
Rhythm control
Device therapy
•Atrial pacing (single or
multisite)
•Atrial defibrillators (standalone or with pacemaker
function)
Ablation therapy
•Operative (Maze procedure,
Pulmonary vein isolation, His
bundle ablation)
Rate control
Stroke prevention
•Transcatheter AV junctional
ablation and permanent
pacemaker implantation
•Radiofrequency transcatheter
AV junction modification
•Percutaneous left atrial
appendage transcatheter
occlusion (PLAATO)
Significant effort is currently being devoted to percutaneous catheter based
ablation of the triggers of AF (atrial premature beats, monomorphic atrial
tachycardias, atrial flutter). The vast majority (>90%) of these triggers are now
known to arise from ‘sleeves’ of atrial tissue with abnormal automaticity present
within the pulmonary veins. The procedure involves isolation of pulmonary veins
and radiofrequency ablation of the triggers of AF. Although the technique can
provide long-term maintenance of sinus rhythm in a majority of patients, it can
lead to systemic embolism and pulmonary vein stenosis, especially if multiple
trigger areas are present. Methods using other energy sources, such a cryotherapy
and ultrasound, are currently being evaluated and may minimize such
complications.
Management in special situations
Cardiac surgery
The incidence of AF after cardiac surgery is high; 27–37% of patients undergoing
coronary artery bypass grafting and 50% of those following valvular surgery will
develop AF in the post-operative period. The majority of AF episodes occur within
first 4 days of cardiac surgery with a peak incidence on the second post-operative
13
day. Whilst it is still unclear why some patients develop AF post-operatively,
certain factors have shown a statistical relationship with AF (Table 4) (14) .
Table 4
Factors related to development of post-operative AF
1-Advanced age
9-Prolonged P waves on ECG
2-Males
10-Atrial dilatation
3-Previous AF
11-High left ventricular end-diastolic pressure
4-Cardiac failure
12-Cardiomegaly on chest X-ray
5-Hypertension
13-Right coronary artery grafting
6-Chronic obstructive
airway disease
14-Prolonged bypass time Inadequate
cardioprotection and hypothermia
7-Chronic renal
failure
8-Previous cardiac
surgery
There is clear evidence that C-reactive protein, a marker of inflammation, peaks on
the second post-operative day coinciding with the peak incidence of AF. This
suggests a unique role of inflammation during the post-operative period in about
40% of patients, particularly when it involves the pericardium or the heart
muscle(20) .
Post-operative AF is associated with increased morbidity and mortality, largely due
to heart failure, stroke and prolonged hospital stay.
14
Various therapies have been investigated for prophylaxis of post-operative
AF.(21.22) Guidelines (3) recommend use of beta-blockers in patients undergoing
cardiac surgery. Once a common practice to discontinue beta-blockers prior to
surgery, these agents have now been shown to reduce the risk of post-operative AF
by about 60%. No major differences exist between different beta-blockers (sotalol,
metoprolol, propranolol) in preventing post-operative AF. Pre-operative use of
amiodarone also appears to be equally effective.
Haemodynamically unstable patients with AF should be cardioverted urgently,
either by direct current or pharmacologically using amiodarone. Ibutilide is
particularly useful in patients with atrial flutter. It is recommended that, following
successful DCC, patients should receive oral amiodarone for 6–8 weeks. The vast
majority of post-operative AF spontaneously reverts to sinus rhythm within 2
weeks. Thus, haemodynamically stable patients can be commenced on betablockers, provided these are not contraindicated, to achieve a rate control of <100
beats min−1. The treatment can be supplemented or substituted with i.v. digoxin
and/or calcium channel blockers (verapamil or Diltiazem).
All patients who develop AF post-operatively must be anticoagulated with heparin
and warfarin as soon as it is deemed safe. Anticoagulation should be continued for
4 weeks after discontinuing amiodarone or documentation of spontaneous return of
sinus rhythm.
Left, right or bi-atrial pacing have also shown to reduce the occurrence of AF by
30–60%. Other therapies including use of magnesium and inflammatory agents
have been incompletely evaluated.
Acute myocardial infarction
Intractable ischaemia or haemodynamic instability requires urgent electrical
cardioversion. In patients with heart failure, i.v. digoxin or amiodarone is given to
slow the ventricular response and improve left ventricular function. I.V. betablockers can be prescribed for rate control to patients who do not have evidence of
clinical left ventricular dysfunction, bronchospasm or atrio-ventricular block. In
15
the setting of acute myocardial ischaemia, administration of class Ic antiarrhythmic
drugs can be harmful and these agents are best avoided.
Pregnancy
Digoxin, beta-blockers or calcium channel antagonists can be used for rate control
of AF during pregnancy. Haemodynamically unstable patients should be
electrically cardioverted. Current guidelines (3) recommend use of antithrombotic
therapy (anticoagulant or aspirin) throughout the duration of pregnancy in all
patients with AF, except those with ‘lone AF’. Oral anticoagulants carry a risk of
teratogenicity and should be avoided if possible, especially in the first and third
trimesters of pregnancy.
Ventricular pre-excitation
In patients with Wolf–Parkinson–White syndrome, AF can lead to extremely rapid
ventricular rates. Unstable patients require urgent DCC to prevent ventricular
fibrillation. I.V. flecainide or ibutilide should be given to restore sinus rhythm if
there is no haemodynamic compromise. Drugs acting on the AV node (betablockers, digitalis glycosides, calcium channel antagonists, adenosine) are
contraindicated since these can increase the conduction of electrical activity
through the accessory pathway.
Hyperthyroidism
During the hyperthyroid state, beta-blockers are necessary to control the
ventricular response, unless contraindicated when diltiazem or verapamil can be
given. Anticoagulation is recommended if there are risk factors for stroke. Once
patients are rendered euthyroid, antithrombotic prophylaxis is the same as for those
without hyperthyroidism.
Pulmonary disease
It is once again important to realise that the vast majority of these patients will
spontaneously revert to sinus rhythm and unless there is haemodynamic
16
compromise, all that may be needed is rate control with adequate anticoagulation.
Correction of hypoxaemia and acidosis are primary measures in patients who
develop AF during acute pulmonary illness or exacerbation of obstructive airway
disease. Calcium channel antagonists, verapamil or diltiazem, are preferred agents
for rate control. Theophylline can sustain AF, whilst beta-blockers, sotalol,
propafenone and adenosine are contraindicated in patients with bronchospastic
lung disease. The long-term use of amiodarone can lead to pulmonary fibrosis and
is best avoided.
METHODOLOGY

Profile of Study area:
 The study was carried out in Al-Nassiriya city, which is the capital of Thi-Qar governorate.
It is located in the south of Iraq 370 Km to the south of Baghdad. Thi-Qar govenorate is the
4th most populated city in Iraq after Baghdad, Nineveh, and Basra with an estimated
population (1979561) in 2014. Al-Nassiriya city lies on the Euphrates near the ruuns of the
ancient city of Ur.
 Gender distribution is 52% males & 48% females.
 Geographic distribution is 63% urban & 27% rural. People aged 60 years and more are
(99140) which represent 5% of the total population.

Study Type & Duration:
 This is a cross-sectional study with an analytic element & was conducted on 60 patients
who have been diagnosed with chronic atrial fibrillation in CCU department of Al-Hussein
Teaching Hospital, after we obtained their verbal consents with reassurance that data
would be kept confidential and not be used for other than the research objective. The study
was conducted during the period from November, 2016 – February, 2017.
 The Al-Hussein Teaching Hospital is a specialized health & teaching hospital and
biomedical research facility of Thi-Qar medical college. It was instituted in 1980. It is one
of the major health facilities dealing with various medical & surgical diseases in the
country. It consists of several clinics with professional doctors and qualified laboratories.
17
Questionnaire
Adherence Anticoagulant Management Among
Patients with chronic Atrial Fibrillation
Name:
Age:
Gender:
Socioeconomic status: □ good □ fair □ poor
Level of education: □ none □ alimentary □ secondary □ high
Duration of AF : □ Acute
□ Chronic □ Unknown
Type of AF :
co-morbid illness
DM
HT
Stroke
MI
Duration (years)
□ smoking pack per year:□ valvular heart disease
□ alchohol
□ prostatic valve
Anticoagulant drug:
dose:
duration :
Anti platelet drug:
dose:
duration :
Side effect
International Normalized Ratio (INR):
Side effect :-
□ yes
□ No
Adherence to clinic visit:
Patient adherence to treatment : □ Good □ poor
18
thyroid disease
others
 Sample selection & workout:
 To be included in the study, the patients should be a known case of chronic atrial
fibrillation.
 For each patient; the following variables were assessed: age, sex, socioeconomic status,
smoking, drinking, adherence of clinic visit, type of drug use, INR and specific
complications.
 A special form of Questionnaire was planned to collect information.
 An ECG report.
 INR
 Definition of variables




Age: All are young aged students; their mean ages was (20-22 years).
Sex (male or female).
Level of education: None, primary, secondary, university.
Socioeconomic status: it was classified into three levels (low, middle, and high)
according to the following score:
1. Living in owned house = 1
2. Living in rented/illegal house = 0
3. Having private car = 1
4. No private car = 0
5. Electrical appliances in household:
- Up to 2 = 1
- 3-5 = 2
- 6 or more = 3
An over all score was calculated for each subject as follow:
- 2 or less means low status.
- 3-4 means middle.
- > 4 means high.
 Smoking habits: pack year smoke = (No. of cigarettes smoked/day * No. of years) / 20
 Drinking habits.
 Past medical & family history of DM, HTN, CVA, MI, thyroid diseases, valvular heart
diseases.
 Adherence to treatment: In general, Adherence in medicine describes the degree to
which a patient correctly follows medical advice. Most commonly, it refers to
medication or drug compliance, but it can also apply to other situations such as
medical device use, self care, self-directed exercises, or therapy sessions in case of
chronic atrial fibrillation. We assessed the patient adherence by:
19
1. INR
2. Follow up (twice semi annually) but if less frequently it means poor adherence.
3. Signs and symptoms – hospitalization
4. Missed doses
Statistical analysis: Statistical package for Social Sciences (SPSS) version 23.0 was used
for analysis of descriptive statistics, percentages, associations, test of significance (ChiSquare).
Results & Discussion:
The mean age of the patients was ranging 30 - 86 years; 8.33% of them were
young (30-44years) , 31.66% of them were middle age (45-59 years) , 60% of them
were old age( 60 years and more ) . The distribution of the study sample by gender
revealed higher percentage of women(63.3%).Displaying the education; 47% of
the respondents had elementary education, 17% reached the secondary level, 11%
had higher education and 25% are not educated .Scanning of socioeconomic status
Displaying revealed that 15% of them was poor , 78% was fair and 7% were good.
adherence to clinic vist ; 28% of them was poor adherent ( less than 2 per year)
and 72% of them were good (more then 2 per year).Scanning of comorbid disease
;27% of them had one comorbid disease , 55% of them had 2 comorbid diseases
and 18% of them had three.
20
Table (1). Demographic characteristics of the sample
No.
Demographic characteristic
%
Age
Young
Middle
Old
5
19
36
8.33
31.66
60
Gender
Female
Male
Level of education
None
Elementary
Secondary
High
38
22
63.3
36.7
15
28
10
7
25
47
17
11
Socioeconomic
Poor
Fair
Good
9
47
4
15
78
7
Adherence to clinic visit
Poor
Good
17
43
28
72
16
33
11
27
55
18
Comorbid illnesses
One comorbid illness
Two comorbid illnesses
Three or more comorbid
illnesses
21
Table (2). Adherence & age
Adherence to Rx
no
Age
Count 2
% within
100.0%
age
30-44
Count 0
% within
0.0%
age
45-59
Count 0
% within
0.0%
age
>59
Count 0
% within
0.0%
age
Total
Count 2
% within
3.2%
age
yes
Total
0
0
2
0.0%
0.0%
100.0%
1
4
5
20.0%
80.0%
100.0%
4
14
18
22.2%
77.8%
100.0%
19
18
37
51.4%
48.6%
100.0%
24
36
62
38.7%
58.1%
100.0%
Monte Carlo Sig. (2-sided)
Value
df
Asymptotic
Significance
(2-sided) Significance
99% Confidence Interval
Lower Bound
Pearson Chi-Square 67.363a
6
.000
.000b
.000
Likelihood Ratio 23.093
6
.001
.001b
.000
.001b
.000
Fisher's Exact Test 19.275
N of Valid Cases 62
22
From table 2 We can see that percent of adherence decrease with increment of age
as in young
80% was adherent while 20% were not, this percent of adherence were decrease in
middle age reaching 77.2% and percent of non adherence reach 22.2% while in old
age there is remarkable decrease in percent of adherence to 48.6% while percent of
non adherence reach 51.4%.
Table (3). Adherence and gender: the reflection of non-adherence among women is
higher than men; for now, explanations for that are simply conjecture “she’s less
likely to pay attention to her own chronic issues, but more for her children’s” (24).
Adherence to Rx
no
Gender
Count 2
0
Count 0
% within
0.0%
gender
female
Count 0
% within
0.0%
gender
Total
Count 2
% within
3.2%
gender
Total
0
2
0.0%
100.0%
6
16
22
27.3%
72.7%
100.0%
18
20
38
47.4%
52.6%
100.0%
24
36
62
38.7%
58.1%
100.0%
% within
100.0% 0.0%
gender
male
yes
23
Table (4). Adherence and level of education
Adherence to Rx
no
Level of
education
Count 2
0
Count 0
% within level of
0.0%
education
Elementary
Count 0
% within level of
0.0%
education
Secondary
Count 0
% within level of
0.0%
education
High
Count 0
% within level of
0.0%
education
Total
Count 2
% within level of
3.2%
education
24
Total
0
2
0.0%
100.0%
9
6
15
60.0%
40.0%
100.0%
12
16
28
42.9%
57.1%
100.0%
2
8
10
20.0%
80.0%
100.0%
1
6
7
14.3%
85.7%
100.0%
24
36
62
38.7%
58.1%
100.0%
% within level of
100.0% 0.0%
education
None
yes
Value
df
Monte Carlo Sig. (2-sided)
Asymptoti
c
99% Confidence Interval
Significanc Signific
e (2-sided)
ance
Lower Bound
Pearson Chi-Square 68.397a 8
.000
.000b
.000
Likelihood Ratio 24.249 8
.002
.001b
.000
.002b
.001
Fisher's Exact Test 19.629
From table (4) We can see that percent of adherence is increase with increase the
level of education. The effect of educational level on non-compliance was
equivocal after reviewing thirteen articles which focused on the impact of
educational level as they used different criteria for “higher” and “lower” education.
Several studies found that patients with higher educational level might have higher
compliance (Apter et al 1998; Okuno et al 2001; Ghods and Nasrollahzadeh 2003;
Yavuz et al 2004), while some studies found no association (Norman et al 1985;
Horne and Weinman 1999; Spikmans et al 2003; Kaona et al 2004; Stilley et al
2004; Wai et al 2005). Intuitively, it may be expected that patients with higher
educational level should have better knowledge about the disease and therapy and
therefore be more compliant.
25
Table (5). Adherence and socioeconomic status:
Adherence to Rx
no
Socioeconomic
Count 2
0
Count 0
% within
0.0%
socioeconomic
Fair
Count 0
% within
0.0%
socioeconomic
Good
Count 0
% within
0.0%
socioeconomic
Total
Count 2
% within
3.2%
socioeconomic
26
Total
0
2
0.0%
100.0%
6
3
9
66.7%
33.3%
100.0%
17
30
47
36.2%
63.8%
100.0%
1
3
4
25.0%
75.0%
100.0%
24
36
62
38.7%
58.1%
100.0%
% within
100.0% 0.0%
socioeconomic
Poor
yes
Monte Carlo Sig. (2-sided)
Value
Df
Asymptotic
Significanc
e (2-sided) Significance
99% Confidence Interval
Lower Bound
Pearson Chi-Square 65.44
6
0a
.000
.000b
.000
Likelihood Ratio 20.96
6
3
.002
.001b
.000
.001b
.000
Fisher's Exact Test 18.17
8
N of Valid Cases 62
It is suggested that SES is consistently associated with higher adherence to medical
treatment in patients suffering from chronic diseases, such as asthma, diabetes, and
post-myocardial infarction. Suggested pathways in which SES might be associated
with adherence, as well as morbidity and mortality, include education's effect on
shaping a financially stable future, and on acquiring health literacy and knowledge
to use health resources, while income plays a big part in obtaining better housing
conditions, recreational facilities and better health care. Moreover, occupation in
terms of employment status affects the ongoing stress of the patients and their
ability to use health care facilities, while occupational status can be reflected on the
physical (possible environmental exposure to damaging agents) and psychosocial
(lack of control over one's daily program) aspects of a low-SES patient's life. All of
these parameters influence accessibility to appropriate treatment and the patients'
will to comply.
27
Table (6). Adherence and clinical visit
Adherence to Rx
no
Adherence to clinic
visit
Count 2
0
Count 0
% within adherence
0.0%
to clinic visit
Good
Count 0
% within adherence
0.0%
to clinic visit
Total
Count 2
% within adherence
to clinic visit 3.2%
Total
0
2
0.0%
100.0%
10
7
17
58.8%
41.2%
100.0%
14
29
43
32.6%
67.4%
100.0%
24
36
62
38.7%
58.1%
100.0%
% within adherence
100.0% 0.0%
to clinic visit
Poor
yes
Monte Carlo Sig. (2-sided)
Value
df
Asymptotic
Significance
(2-sided)
99% Confidence Interval
Significance
Lower Bound
Pearson Chi-Square 65.619a 4
.000
.000b
.000
Likelihood Ratio 21.131
.000
.000b
.000
.000b
.000
4
Fisher's Exact Test 17.598
28
The table above has clarified that regular clinical visit increases the patient’s
adherence to treatment, this could be explained by the actual rule that the doctor
plays to influence the patient’s compliance.
Table (7). Adherence vs. comorbid illness
Adherence to Rx
yes
Comorbid in
illness
Count 0
% within
comorbid in 0.0%
illness
one comorbid illness
Count 13
% within
comorbid in 81.3%
illness
two comorbid
illnesses
Count 22
% within
comorbid in 66.7%
illness
three comorbid
illnesses
Count 1
% within
comorbid in 9.1%
illness
Total
Count 36
% within
comorbid in 58.1%
illness
29
no
Total
2
2
100,0%
100.0%
3
16
18.7%
100.0%
11
33
33.3%
100.0%
10
11
90.9%
100.0%
26
62
41.9%
100.0%
From table (7) We can see that problems with level of adherence to anti coagulant are
highly prevalent among patients with more comorbid illnesses, because of
polypharmacy, concerns about polypharmacy include increased adverse drug reactions,
drug interactions, prescribing cascade, and higher costs. Polypharmacy is often
associated with a decreased quality of life, including decreased mobility and cognition
(25)
.
Study Limitations:
1. The retrospective design.
2. Small number of patients.
3. The non-randomized nature of the study and the non-homogeneity of the population leave
the possibility of selection bias.
Conclusion:
Non-adherence to therapies of chronic illnesses is common & it is a
recognized and important barrier to the successful management of these diseases. The true
prevalence of non-adherence to anti-AF treatment is not known & further researches are
needed to bring this issue into the spotlights.
Cues to action are aids that remind patients to take their medication. They can take a variety
of forms including text messages, telephone calls, reminder packaging, or memory strategies.
Many offices already use text messages or telephone calls to remind patients of office
appointments. This strategy is an effective means of improving attendance.(26)
If a physician senses that a patient may benefit from daily reminders, then a medication
reminder application for smart phones can be recommended. Other reminder strategies that
have demonstrated a positive effect on adherence include weekly pill boxes and multidrug
punch cards.(27)
30
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