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European Journal of Applied Sciences – Vol. 10, No. 2
Publication Date: April 25, 2022
DOI:10.14738/aivp.102.11901. Rweyemamu, S. J., Mutagaywa, R., Kisenge, P. R., Waane, T., Majani, N. (2022). Atrial Fibrillation and Oral
Anticoagulation/Antiplatelet Agents Practices in Low Middle-Income Settings. European Journal of Applied Sciences, 10(2). 380-
390.
Services for Science and Education – United Kingdom
Atrial Fibrillation and Oral Anticoagulation/Antiplatelet Agents
Practices in Low Middle-Income Settings
Samwel Jacob Rweyemamu
Jakaya Kikwete Cardiac Institute
P. O. Box 65141, Dar es Salaam, Tanzania
Reuben Mutagaywa
School of Medicine, Muhimbili University of Health and
Allied Sciences, P.O. BOX 65001, Tanzania
Peter Richard Kisenge
Jakaya Kikwete Cardiac Institute
P. O. Box 65141, Dar es Salaam, Tanzania
Tatizo Waane
Jakaya Kikwete Cardiac Institute
P. O. Box 65141, Dar es Salaam, Tanzania
Naizihijwa Majani
Jakaya Kikwete Cardiac Institute
P. O. Box 65141, Dar es Salaam, Tanzania
ABSTRACT
Background: Atrial fibrillation (AF) is an arrhythmia which is diagnosed by the
finding of irregularly irregular ventricular rhythm without discrete P waves in an
electrocardiogram. Atrial fibrillation increases risk for intra-cardiac thrombosis
and cerebral vascular event. It is a risk factor for ischemic stroke and affects abouts
33 million people globally and is more common in adults above 65 years. It a
common complication among the patients with cardiovascular diseases. Aim of the
study: The aim of this study was to audit the use oral anticoagulation/antiplatelet
agents in patients with Atrial Fibrillation at Jakaya Kikwete Cardiac Institute.
Material and methods: A retrospective descriptive cross-sectional audit study
which was conducted at Jakaya Kikwete cardiac institute among adult patients with
a diagnosis atrial fibrillation. Patients were identified in a medpro systems and
their age and sex were documented. Cross checking for the record of risk scores and
OAC/antiplatelet prescription was done and recoded in a structured questionnaire
which was designed to collect the data. Data analysis: The data entry and analysis
were done using statistical package for social sciences (SPSS) version 20.0. Results:
Of 800 patients. 37(4.6%) were found to have a diagnosis of AF. Among patients
with AF, females were 19 (51.4%), those aged 18-39 years were 13 (35.1%) same as
those aged 40-64 years, 65+ years were 11 (29.7). Based on the structural/none
structural diagnosis among patients with AF, 20 (54.0%) were having valvular heart
diseases. and the rate of use of oral anticoagulation/antiplatelet agents was 73%.
Among those using oral anticoagulation/antiplatelet agents, 24 (88.9%) were using
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381
Rweyemamu, S. J., Mutagaywa, R., Kisenge, P. R., Waane, T., Majani, N. (2022). Atrial Fibrillation and Oral Anticoagulation/Antiplatelet Agents
Practices in Low Middle-Income Settings. European Journal of Applied Sciences, 10(2). 380-390.
URL: http://dx.doi.org/10.14738/aivp.102.11901
warfarin, 2 (7.4%) NOAC and 1 (3.7%) was using antiplatelet (table 2). In terms of
INR checking 24 (64.9%) were checked. Conclusion and Recommendations: The
rate of prescription of OAC were high while that for antiplatelet were low. The rate
of INR checking in those who were using warfarin were high but not hundred
percent. The documentation of risk scores before the prescription of OAC therapy
was not done at all. We recommend for the good practice and follow the
recommendations from ESC guideline 2020, our local protocol and evidence-based
practice for the management of atrial fibrillation.
BACKGROUND
Atrial fibrillation (AF) is an arrhythmia which is diagnosed by the finding of irregularly
irregular ventricular rhythm without discrete P waves in an electrocardiogram. Atrial
fibrillation increases risk for intra-cardiac thrombosis and cerebral vascular event (1). It
predispose a patient to an ischemic stroke if appropriate treatments are not done (2).
More than 33 million people globally are affected by atrial fibrillation and therefore, are likely
to suffer from ischemic stroke and hospitalization (3). The prevalence rate of AF ranges
between 0.5 to 1% globally. It is more common in adults above 65 years and nearly 60% of
patient with a diagnosis of AF are women over 75 years old (4). The prevalence of AF in patients
with clinically significant cardiovascular disease 9.1% as compared to 4.6% in subclinical CVD
and 1.6% in patients without cardiovascular disease .Therefore, the more clinically significant
CVDs is the more likely of suffering from AF (4).The prevalence and incidence of this irregular
supraventricular arrhythmia is higher in developed countries than in developing countries (5).
In Asian countries, the annual incidence of AF is about 5.38 per 1,000 person-years with an
estimated Ischemic stroke ((IS) of 3.0% annually. The prevalence of AF in hospital and
community setting ranges between 0.37% to 3.56% and 2.8% to 15.8%, respectively. The
prevalence of ischemic stroke in patients with AF ranges between 1.9% to 6.0% and 0.36% to
28.3% in community and hospital respectively(2,6).
Atrial fibrillation is common in patients with hypertension, coronary artery diseases and heart
failure and mitral valve stenosis (7–9). In Thailand, among 13207 patients with the diagnosis
of systemic hypertension the prevalence of AF was 3.5% between the year 2011 and 2012.
The prominent risk factors for AF in hypertension are age, male gender, Low HDL cholesterol
and increased uric acid levels. One can clearly note that, the same traditional risk factors for
CVDs are the same as the risk factors for AF (2).
In Africa, the prevalence of AF is lower than in the developed world but is expected to increase
significantly over the next few decades. Patients with a diagnosis of AF in African setting are
young with a diagnosis of rheumatic heart diseases at large (10).
In Sub Saharan Africa, the prevalence of AF was estimated to be 659.8 and 438.1 per 100,000
population for men and women respectively, representing a growth of 3.4% between 1990 and
2010(5)
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European Journal of Applied Sciences (EJAS) Vol. 10, Issue 2, April-2022
Services for Science and Education – United Kingdom
In Ethiopia, the prevalence of AF which was reported in the Global Burden of Disease document
in 2010 among adult population was 4.3% (5). Furthermore, documented risk factors were
hypertension (38%), overweight/obesity (33%), diabetes (12%) and ischemic heart
disease(13%) (5,9,11).
In Tanzania, the prevalence of AF is 10% in patients with a diagnosis of hypertension in tertiary
Hospital. Significantly associated risk factors for development of AF in the high healthy facility
which was documented in this single study are increased body mass index (BMI ≥ 25), left
ventricular ejection fraction < 50% and left atria diameter of > 40 mm (12).
The excess consumption of alcohol increases the likelihood of atrial fibrillation and atrial
remodeling. The study which was conducted in six hospitals in Australia found that abstinence
from alcohol reduced arrhythmia recurrences (8).
The clinically significant forms of AF are newly diagnosed AF, paroxysmal AF, Persistent AF,
long persistent and permanent AF (9). Permanent AF is the most prevalent type of AF in Africa,
possibly due to the lower use of rhythm control strategies than in the developed world.
Mortality rates of patients with AF in Africa are high than the rates in developed countries
perhaps due to poor health care system and suboptimal medical therapy (5).
AF is frequently associated with ischemic stroke and lung infarction due to thromboembolic
events (9). These cardiac and non-cardiac fatal events can be prevented by the use of Vitamin
K antagonists (VKA) or None Vitamin K antagonists (NOAC). A wide range of NOACs are
available such as rivaroxaban , apixaban , dabigatran and are suitably recommended for use in
patients with a diagnosis of none valvular AF and are contraindicated for use in patient with
prosthetic mechanical valves (11,13,14)
In patient without rheumatic heart diseases with moderate to high risk for thromboembolic
events, warfarin reduced the incidence of stroke with minimum bleeding in randomized
controlled trials (15–18). In a Swedish atrial fibrillation cohort study, anticoagulation reduced
the risk of ischemia and other embolic events by about seventy five percent irrespective of their
baseline characteristics (19).
The use of either VKA or NOACs for prevention of stroke in patients with atrial fibrillation is
almost equally effective. The studies which were comparing the efficacy of Warfarin and NOACs
found no significant differences between the two groups of drugs to prevent stroke and
systemic embolism(17,18,20,21). However, apixaban and high dose dabigatran showed
superiority to warfarin in preventing stroke and systemic embolism with low bleeding and
mortality rates (18,21). The use of warfarin or NOACs in high-risk patients reduced stroke and
all causal mortality by 60–65% and 26% respectively.(22).
The prevalent rate of AF at Jakaya Kikwete Institute is 10%. The rate of use of OAC and bleeding
complications and the use of risk scores before the initiation of thrombolytic has not been
audited. Therefore, it is the aim of this study to audit the use oral anticoagulation/antiplatelet
agents in patients with Atrial Fibrillation at Jakaya Kikwete Cardiac Institute.