ACCP, AHCPR standards form basis for project
Med-surg technologies make stroke preventable
HealthInsight’s project was 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," say Kevin Kennedy, MHS, senior health care analyst at HealthInsight, and Justine Bizette, RN, MSN, the project’s senior coordinator, "was to improve compliance with the standards of practice and guidelines so that the quality of care could be improved."
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.
Guidelines confirm drug’s efficacy
Current ACCP guidelines and the Fifth Con-sensus issued last November) both 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 recom-mendations that take into account recent clinical trials evaluating the use of warfarin and aspirin. For example, the recommendation patients with a history of hypertension but no other risk factors be considered for oral anticoagulation has been strengthened. Other changes relate to a reprioriti-zation of risk factors, such as diabetes, which was found to be a less consistent risk factor in the clinical trials reviewed.
From the guidelines: "Long-term oral anticoagulation is strongly recommended for prevention of stroke in AF patients who have suffered a recent stroke. . . . A target INR of 2.5 is recom-mended. Oral anticoagulation is also beneficial for prevention of recurrent stroke in patients with several other high risk cardiac sources."
According to Singer, the challenge is to identify those patients with AF at low enough risk to safely forego anticoagulation. "It appears that AF patients younger than 65 with no risk factors for stroke are at low enough risk to be treated with aspirin, he said. "For older patients with AF, especially those with risk factors [including hypertension, prior stroke or TIA, or left ventricular dysfunction], warfarin is recommended."
References
1. The Fourth ACCP Consensus. Statement of Antithrombotic Therapy. Chest 1995; 108(S): 225S-522S.
2. Albers GW, Easton D, Sacco RL, et al. Antithrombotic and thrombolytic therapy for ischemic stroke. The Fifth ACCP Consensus Conference on Antithrombotic Therapy. Chest 998; 114(S):683S-698S.
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