Oral anticoagulant therapy in adults with congenital heart disease and atrial arrhythmias: Implementation of guidelines

H. Yang, J. F. Heidendael, J. R. de Groot, T. C. Konings, G. Veen, A. P.J. van Dijk, F. J. Meijboom, G. Tj Sieswerda, M. C. Post, M. M. Winter, B. J.M. Mulder, B. J. Bouma

Research output: Contribution to journalArticleAcademicpeer-review

Abstract

Background: Current guidelines on oral anticoagulation (OAC) in adults with congenital heart disease (ACHD) and atrial arrhythmias (AA) consist of heterogeneous and divergent recommendations with limited level of evidence, possibly leading to diverse OAC management and different outcomes. Therefore, we aimed to evaluate real-world implementation and outcome of three guidelines on OAC management in ACHD patients with AA. Methods: The ESC GUCH 2010, PACES/HRS 2014 and ESC atrial fibrillation (AF) 2016 guidelines were assessed for implementation. ACHD patients with recurrent or sustained non-valvular AA from 5 tertiary centers were identified using a national ACHD registry. After two years of prospective follow-up, thromboembolism, major bleeding and death were assessed. Results: In total, 225 adults (mean age 54 ± 15 years, 55% male) with various defects (simple 43%; moderate 37%; complex 20%) and AA were included. Following the most strict indication (OAC is recommended in all three guidelines), one should treat a mere 37% of ACHD patients with AA, whereas following the least strict indication (OAC is recommended in any one of the three guidelines), one should treat 98% of patients. The various guidelines were implemented in 54–80% of patients. From all recommendations, Fontan circulation, CHA2DS2-VASc ≥ 1 and AF were independently associated with OAC prescription. Superiority of any guideline in identifying outcome (n = 15) could not be demonstrated. Conclusions: The implementation of current guidelines on OAC management in ACHD patients with AA is low, probably due to substantial heterogeneity among guidelines. OAC prescription in daily practice was most consistent in patients with AF and CHA2DS2-VASc ≥ 1 or Fontan circulation.

Original languageEnglish
Pages (from-to)67-74
Number of pages8
JournalInternational Journal of Cardiology
Volume257
DOIs
Publication statusPublished - 15 Apr 2018

Cite this

Yang, H. ; Heidendael, J. F. ; de Groot, J. R. ; Konings, T. C. ; Veen, G. ; van Dijk, A. P.J. ; Meijboom, F. J. ; Sieswerda, G. Tj ; Post, M. C. ; Winter, M. M. ; Mulder, B. J.M. ; Bouma, B. J. / Oral anticoagulant therapy in adults with congenital heart disease and atrial arrhythmias : Implementation of guidelines. In: International Journal of Cardiology. 2018 ; Vol. 257. pp. 67-74.
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abstract = "Background: Current guidelines on oral anticoagulation (OAC) in adults with congenital heart disease (ACHD) and atrial arrhythmias (AA) consist of heterogeneous and divergent recommendations with limited level of evidence, possibly leading to diverse OAC management and different outcomes. Therefore, we aimed to evaluate real-world implementation and outcome of three guidelines on OAC management in ACHD patients with AA. Methods: The ESC GUCH 2010, PACES/HRS 2014 and ESC atrial fibrillation (AF) 2016 guidelines were assessed for implementation. ACHD patients with recurrent or sustained non-valvular AA from 5 tertiary centers were identified using a national ACHD registry. After two years of prospective follow-up, thromboembolism, major bleeding and death were assessed. Results: In total, 225 adults (mean age 54 ± 15 years, 55{\%} male) with various defects (simple 43{\%}; moderate 37{\%}; complex 20{\%}) and AA were included. Following the most strict indication (OAC is recommended in all three guidelines), one should treat a mere 37{\%} of ACHD patients with AA, whereas following the least strict indication (OAC is recommended in any one of the three guidelines), one should treat 98{\%} of patients. The various guidelines were implemented in 54–80{\%} of patients. From all recommendations, Fontan circulation, CHA2DS2-VASc ≥ 1 and AF were independently associated with OAC prescription. Superiority of any guideline in identifying outcome (n = 15) could not be demonstrated. Conclusions: The implementation of current guidelines on OAC management in ACHD patients with AA is low, probably due to substantial heterogeneity among guidelines. OAC prescription in daily practice was most consistent in patients with AF and CHA2DS2-VASc ≥ 1 or Fontan circulation.",
keywords = "Adult congenital heart disease, Anticoagulation, Atrial arrhythmias, Guidelines, Implementation",
author = "H. Yang and Heidendael, {J. F.} and {de Groot}, {J. R.} and Konings, {T. C.} and G. Veen and {van Dijk}, {A. P.J.} and Meijboom, {F. J.} and Sieswerda, {G. Tj} and Post, {M. C.} and Winter, {M. M.} and Mulder, {B. J.M.} and Bouma, {B. J.}",
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Oral anticoagulant therapy in adults with congenital heart disease and atrial arrhythmias : Implementation of guidelines. / Yang, H.; Heidendael, J. F.; de Groot, J. R.; Konings, T. C.; Veen, G.; van Dijk, A. P.J.; Meijboom, F. J.; Sieswerda, G. Tj; Post, M. C.; Winter, M. M.; Mulder, B. J.M.; Bouma, B. J.

In: International Journal of Cardiology, Vol. 257, 15.04.2018, p. 67-74.

Research output: Contribution to journalArticleAcademicpeer-review

TY - JOUR

T1 - Oral anticoagulant therapy in adults with congenital heart disease and atrial arrhythmias

T2 - Implementation of guidelines

AU - Yang, H.

AU - Heidendael, J. F.

AU - de Groot, J. R.

AU - Konings, T. C.

AU - Veen, G.

AU - van Dijk, A. P.J.

AU - Meijboom, F. J.

AU - Sieswerda, G. Tj

AU - Post, M. C.

AU - Winter, M. M.

AU - Mulder, B. J.M.

AU - Bouma, B. J.

PY - 2018/4/15

Y1 - 2018/4/15

N2 - Background: Current guidelines on oral anticoagulation (OAC) in adults with congenital heart disease (ACHD) and atrial arrhythmias (AA) consist of heterogeneous and divergent recommendations with limited level of evidence, possibly leading to diverse OAC management and different outcomes. Therefore, we aimed to evaluate real-world implementation and outcome of three guidelines on OAC management in ACHD patients with AA. Methods: The ESC GUCH 2010, PACES/HRS 2014 and ESC atrial fibrillation (AF) 2016 guidelines were assessed for implementation. ACHD patients with recurrent or sustained non-valvular AA from 5 tertiary centers were identified using a national ACHD registry. After two years of prospective follow-up, thromboembolism, major bleeding and death were assessed. Results: In total, 225 adults (mean age 54 ± 15 years, 55% male) with various defects (simple 43%; moderate 37%; complex 20%) and AA were included. Following the most strict indication (OAC is recommended in all three guidelines), one should treat a mere 37% of ACHD patients with AA, whereas following the least strict indication (OAC is recommended in any one of the three guidelines), one should treat 98% of patients. The various guidelines were implemented in 54–80% of patients. From all recommendations, Fontan circulation, CHA2DS2-VASc ≥ 1 and AF were independently associated with OAC prescription. Superiority of any guideline in identifying outcome (n = 15) could not be demonstrated. Conclusions: The implementation of current guidelines on OAC management in ACHD patients with AA is low, probably due to substantial heterogeneity among guidelines. OAC prescription in daily practice was most consistent in patients with AF and CHA2DS2-VASc ≥ 1 or Fontan circulation.

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KW - Adult congenital heart disease

KW - Anticoagulation

KW - Atrial arrhythmias

KW - Guidelines

KW - Implementation

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