ACCP, AHCPR standards form basis for project
ACCP, AHCPR standards form basis for project
Med-surg technologies make stroke preventable
HealthInsight, a nonprofit community quality improvement group in Las Vegas, has created an atrial fibrillation project based on the standards of the Irving, TX-based American College of Chest Physicians’ (ACCP) Fourth Consensus Statement on Antithrombic Therapy and the Agency for Health Care Policy and Research.1
"Our main goal was to improve compliance with the standards of practice and guidelines so that the quality of care could be improved," said Kevin Kennedy, MHS, HealthInsight senior health care analyst, and Justine Bizette, RN, MSN, senior project coordinator, in a written statement.
Stroke is now considered to be as preventable as heart attack. Primary prevention — reducing risk by stopping smoking, losing weight, and lowering blood pressure — is the first line of defense. Current ACCP guidelines and the Fifth Consensus (issued last November) reconfirm the efficacy of warfarin for stroke prevention.2
"There have been several important studies on stroke prevention in atrial fibrillation since 1995," said Daniel Singer, MD, ACCP Fifth Consensus panel member and a cardiologist at Massachusetts General Hospital in Boston. "The guiding principle is that oral anticoagulation markedly decreases the risk of ischemic stroke in patients with atrial fibrillation and that aspirin is much less effective [than warfarin]."
The 1998 guidelines include revised recommendations that consider recent clinical trials evaluating the use of warfarin and aspirin. For example, the recommendation that patients with a history of hypertension but no other risk factors be considered for oral anticoagulation has been strengthened. Other changes relate to a reprioritization of risk factors, such as diabetes, which was found to be a less consistent risk factor in the clinical trials reviewed. "Long-term oral anticoagulation is strongly recommen ded for prevention of stroke in AF patients who have suffered a recent stroke. . . . A target INR of 2.5 is recommended. Oral anticoagulation is also beneficial for prevention of recurrent stroke in patients with several other high risk cardiac sources," the guidelines state.
The challenge is to identify patients with a low enough AF risk to forego anticoagulation safely. "It appears that AF patients younger than 65 with no risk factors for stroke are at low enough risk to be treated with aspirin," Singer said. "For older patients with AF, especially those with risk factors [including hypertension, prior stroke or transient ischemic attack, or left ventricular dysfunction], warfarin is recommended."
References
1. The Fourth ACCP Consensus. Statement of Anti thrombotic Therapy. Chest 1995; 108(Suppl): 225S-522S.
2. Albers GW, Easton D, Sacco RL, et al. Antithrom botic and thrombolytic therapy for ischemic stroke. The Fifth ACCP Consensus Conference on Antithrombotic Therapy. Chest 1998; 114(Suppl):683S-698S.
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