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Table of Contents
Year : 2021  |  Volume : 18  |  Issue : 2  |  Page : 121-124

Nonadherence to guideline-directed anticoagulations in atrial fibrillation in Iraq

1 Department of Internal Medicine, College of Medicine, University of Duhok, Duhok, Kurdistan Region, Iraq
2 Department of Medicine, Zakho Teaching Hospital, Duhok, Kurdistan Region, Iraq

Date of Submission23-Jan-2021
Date of Acceptance10-Feb-2021
Date of Web Publication26-Jun-2021

Correspondence Address:
Ameen M Mohammad
Department of Internal Medicine, College of Medicine, University of Duhok, Duhok, Kurdistan Region
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/MJBL.MJBL_5_21

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Background: Anticoagulations remain an essential step to minimize the mortality and morbidity associated with thromboembolic phenomena in atrial fibrillation (AF). Nevertheless, the adherence to OAC stands for (Oral Anticoagulant) throughout the paper is not universal among the different populations. In Iraq, there are no data about adherence to (OAC) in patients with AF. Objectives: This study aimed to assess the adherence to oral anticoagulants (OAC) based on the American College of Cardiology/American Heart Association performance measures in eligible patients with a CHA2DS2-VASc ≥2 in patients with AF in Duhok, Iraq. Materials and Methods: A total of 132 patients who were diagnosed with AF were consecutively reviewed during 2018–2019 in Azadi Teaching Hospital, Duhok, Kurdistan Region, Iraq. For eligibility of taking an OAC, the VAS score derived from CHA2DS2-VASc for all patients was calculated. Results: The mean age of the patients was 65.29 (standard deviation [SD]: 17.18 years). The average duration of AF was (2.0) years. The mean of VAS score was 2.97 (SD: 1.75, ranged between 0 and 8.0). 78.0% of all patients were eligible for OAC at admission. Only 15.9% of the patients were on OAC. In the logistic regression analysis, none of the patient's characteristics predict significantly the nonadherence to OAC. Conclusion: The present study showed that a high percentage of AF patients were eligible for OAC. However, only a small percentage of them were receiving OAC at admission in our area.

Keywords: Atrial fibrillation, guideline adherence, oral anticoagulants

How to cite this article:
Mohammad AM, Nerway DA. Nonadherence to guideline-directed anticoagulations in atrial fibrillation in Iraq. Med J Babylon 2021;18:121-4

How to cite this URL:
Mohammad AM, Nerway DA. Nonadherence to guideline-directed anticoagulations in atrial fibrillation in Iraq. Med J Babylon [serial online] 2021 [cited 2023 May 29];18:121-4. Available from: https://www.medjbabylon.org/text.asp?2021/18/2/121/319504

  Introduction Top

The current evidence presents a low rate of anticoagulant taking in patients with AF.[1] The quality improvement in the treatment of many cardiovascular (CV) diseases, including myocardial infarction, stroke, and heart failure has been confirmed by American Heart Association's (AHA's) Get with the Guidelines program. This program was started in 2013 to improve the quality of care in patients with AF.[2],[3]

AF has been shown to contribute to both thromboembolic events and mortality whether from all causes or from CV causes.[4],[5],[6] The risk of thromboembolism and mortality amongst AF patients is significantly decreased by taking oral anticoagulant (OAC) therapy.[6] Both OAC persistence and good quality anticoagulation control reduce major adverse events among AF patients.[7],[8],[9],[10]

The physician has different attitudes and adherence to prescription OAC.[11] The recent data from the EURO observational Research Programme AF (EORP-AF) Pilot Registry showed that up to 40% of the patients who were managed by European cardiologists do not adhere to European Society of Cardiology guidelines. This under treatment has been shown to associate with worse outcomes.[12]

This study aimed to assess the adherence to OAC based on the American College of Cardiology/AHA's performance measures in eligible patients with a CHA2DS2-VASc score ≥2 in patients with AF in Duhok province, Iraq.

  Materials and Methods Top

Study design and patients

A total of 132 patients who were diagnosed with atrial fibrillation (AF) were consecutively reviewed for OAC taking during 2018–2019 in Azadi Teaching Hospital, Duhok, Kurdistan Region, Iraq. Patients met enrolment eligibility if they were male or female, aged 18 years and older and diagnosed with AF whether primary or secondary. Those patients with already diagnosed with significant mitral valve stenosis and a mechanical heart valve were excluded from the study.

Baseline demographic of the patients, including age and gender, was taken. Major chronic diseases including diabetes mellitus, hypertension, congestive heart failure, transient ischemic attack/ischemic stroke, and any vascular diseases including myocardial infarction, peripheral arterial diseases were recorded. The [VAS] score of the patients, the duration of AF, and the status of anticoagulants were documented. The diagnosis of AF was performed in accordance with the International Classification of Diseases–9th Edition system.

The risk of thrombo-embolic was defined according to the CHA2DS2-VASc score. In this assessment, the male and female patients with low risk of thrombosis were given 0 and 1, respectively. The male patients with moderate risk were given 1, and all patients with a high risk were rated ≥2.[12]

Statistical analysis

The difference in baseline and clinical characteristics between the patients on OAC and not on OAC was examined in independent t-test and Chi-square tests. The predictors of non-adherence to OAC were examined in binary logistic regression analysis model. The statistically significant difference was determined in a P < 0.05. The statistical calculations were performed by the Statistical Package for the Social Sciences software version 24.0 (SPSS, IBM Company, Chicago, IL 60606, USA).

Ethical consideration

The study was conducted in accordance with the ethical principles that have their origin in the declaration of Helsinki. It was carried out with patients verbal and analytical approval before the sample was taken. The study protocol and the subject information and consent form were reviewed and approved by the ethical committee of the Iraqi Board for Medical Specializations, Duhok center in 2018.

  Results Top

The mean age of the patients was 65.29 years (standard deviation [SD]: 14.18) ranged between 26 and 95 years. Females were 64.4%. Among our patients, hypertension constituted 62.1% followed by ischemic heart failure (39.4%), diabetes mellitus (25.8%), and transient ischemic attack (10.6%). No difference in the demographic and CV characteristics of the patients who were on OAC and not on OAC was found (P = 0.415, 0.463), as shown in [Table 1].
Table 1: Baseline patient characteristics in patients with a atrial fibrillation and were on oral anticoagulants and not on oral anticoagulants

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The mean VAS score of patients was 2.97 (SD: 1.75) ranged between 0 and 8.0. The mean duration of AF was 2.00 years. In addition, the study revealed that 78.0% of the patients were eligible for OAC taking. However, only 15.9% of all patients were on anticoagulant at admission, as shown in [Table 2].
Table 2: Disease-related characteristics of patients with atrial fibrillation

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The comparison of VAS scores and disease duration between the patients on OAC and not on OAC showed nonsignifcant difference (3.00 vs. 2.96; P = 0.918 and 3.10 vs. 2.51; P = 0.280, respectively), as shown in [Table 3].
Table 3: Comparison of VAS scores and disease duration between the patients on oral Anticoagulants and not on oral anticoagulants

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The eligibility for oral anticoagulant was considered dependent variable and other characteristics as independent variables in binary regression analysis. The study did not show that the eligibility is predicted by any factors in the patients [Table 4].
Table 4: Predictors of nonadherent to oral anticoagulant in patients with atrial fibrillation

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  Discussion Top

The total percentage of the patients who were eligible for OAC was 78.0%, but only 15.9% were receiving the OAC in the region. This is a very low percentage of eligible patients who were receiving OAC. We found a far fewer rates of adherence to OAC in our study compared to many studies worldwide, and this should encourage our doctors and cardiologists to prescribe more OAC in cases of AF to minimize the rate of ischemic strokes and other complications related to thrombo-embolic phenomena in AF.

Piccini et al. evaluated the adherence to guidelines of prescribing OAC in patients diagnosed with AF in their study. It showed that 59.5% of AF patients were taking OAC agents at admission and at discharge of patients from hospital in their study, the rate of OAC in eligible patients with no contraindications was reached to 93.5%.[13]

Proietti et al. from Italy assessed the physicians' adherence to guidelines in a cohort AF patient who were admitted to internal medicine and geriatric wards. In addition, to explain the main factors related to guideline non-adherence. The investigators found that 40.9% of the patients were on guideline-adherent thromboprophylaxis, 6.8% of them were overtreated, and 52.3% were undertreated. The factors that were associated with nonadherence to guidelines were increasing age, coronary artery disease (CAD), heart failure, concomitant cancer, and peripheral arterial disease. Specifically, under-treatment was significantly associated with increasing age and cancer and inversely associated with HF (P = 0.023), and guideline adherence was independently associated with a lower risk of all-cause and CV deaths (P = 0.019 and P = 0.006).[14] In the present study, we did not find any specific predictors of nonadherence to OAC.

Navarro-Juan et al.[15] study from Spain determined the extent of lack of adherence to oral anticoagulant and antiplatelet therapy in patients diagnosed with AF. They found that nonadherence to the OAC among their patients was 62.5%. The greater nonadherence was found in older patients. Interestingly, they found that the patients with a higher VAS score were more likely to have a lack of adherence to the OAC. The patients with an increased risk of stroke were more likely to have a lack of adherence to the guidelines.

The present study did not find a significant difference in adherence to OAC in patients with different age groups. However, increased age has been showing to associate with under treatment. However, the younger ages, female, and a previous history of CAD, stroke, TIA were related to overtreatment OAC and antiplatelet therapy. The undertreatment has been shown to contribute to both all-cause and CV mortalities.[16]

In the present study, a very low percentage of the patients who were eligible for OAC were treated with OAC. This possibility raises the risk of morbidity and mortality in this kind of patients. The rate of adherence to guideline-directed OAC in eligible AF cases was quite lower than it's reported in other investigations.[16],[17],[18] The burden of morbidity and mortality from AF due to thromboembolic phenomena in the region potentially will be significant, taken in the consideration that, the resistance to antiplatelet including to aspirin and clopidogrel is higher than many other countries according to available studies from the region.[19],[20],[21],[22]

Up to our knowledge, this is the first study conducted on nonadherence to OAC in Iraq. However, the study has many limitations including the lack of including the contraindications of OAC in AF patients. In addition, the VAS score was not measured at discharge for the patients and absence of follow-up of patients who were not receiving the OAC for either CV events or prescription of OAC.

  Conclusion Top

The present study showed a high rate of eligible patients for OAC; however, only small percentage of them was receiving the OAC. Besides, there was no significant difference in the baseline clinical characteristics between the patients on OAC and those not on OAC. The VAS score between the patients on OAC and those not on OAC was not differ significantly, and there were no particular predictors for nonadherence to OAC in this study. Based on these conclusions, we do recommend to enhance the adherence to guidelines in the treatment of AF in our area. Moreover, further studies are warranted to search to potential causes and mechanisms, related to patients and their doctors, behind the undertreatment of AF in Iraq.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Hsu JC, Maddox TM, Kennedy KF, Katz DF, Marzec LN, Lubitz SA, et al. Oral anticoagulant therapy prescription in patients with atrial fibrillation across the spectrum of stroke risk: Insights from the NCDR PINNACLE registry. JAMA Cardiol 2016; 1:55-62.  Back to cited text no. 1
Lewis WR, Piccini JP, Turakhia MP, Curtis AB, Fang M, Suter RE, et al. Get with the guidelines AFIB: Novel quality improvement registry for hospitalized patients with atrial fibrillation. Circ Cardiovasc Qual Outcomes 2014; 7:770-7.  Back to cited text no. 2
Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, et al. Prevalence of diagnosed atrial fibrillation in adults: National implications for rhythm management and stroke prevention: The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA 2001; 285:2370-5.  Back to cited text no. 3
Writing Group Members, Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, et al. Heart disease and stroke statistics-2016 update: A report from the American Heart Association. Circulation 2016;133: e38-360.  Back to cited text no. 4
Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012; 33:2719-47.  Back to cited text no. 5
Lip GY, Lane DA. Stroke prevention in atrial fibrillation: A systematic review. JAMA 2015; 313:1950-62.  Back to cited text no. 6
Wan Y, Heneghan C, Perera R, Roberts N, Hollowell J, Glasziou P, et al. Anticoagulation control and prediction of adverse events in patients with atrial fibrillation: A systematic review. Circ Cardiovasc Qual Outcomes 2008; 1:84-91.  Back to cited text no. 7
Gallagher AM, Setakis E, Plumb JM, Clemens A, van Staa TP. Risks of stroke and mortality associated with suboptimal anticoagulation in atrial fibrillation patients. Thromb Haemost 2011; 106:968-77.  Back to cited text no. 8
De Caterina R, Husted S, Wallentin L, Andreotti F, Arnesen H, Bachmann F, et al. Vitamin K antagonists in heart disease: Current status and perspectives (Section III). Position paper of the ESC Working Group on Thrombosis – Task Force on Anticoagulants in Heart Disease. Thromb Haemost 2013; 110:1087-107.  Back to cited text no. 9
Kirchhof P, Breithardt G, Bax J, Benninger G, Blomstrom-Lundqvist C, Boriani G, et al. A roadmap to improve the quality of atrial fibrillation management: Proceedings from the fifth Atrial Fibrillation Network/European Heart Rhythm Association consensus conference. Europace 2016; 18:37-50.  Back to cited text no. 10
Pugh D, Pugh J, Mead GE. Attitudes of physicians regarding anticoagulation for atrial fibrillation: A systematic review. Age Ageing 2011; 40:675-83.  Back to cited text no. 11
Lip GY, Laroche C, Popescu MI, Rasmussen LH, Vitali-Serdoz L, Dan GA, et al. Improved outcomes with European Society of Cardiology guideline-adherent antithrombotic treatment in high-risk patients with atrial fibrillation: A report from the EORP-AF General Pilot Registry. Europace 2015; 17:1777-86.  Back to cited text no. 12
Piccini JP, Xu H, Cox M, Matsouaka RA, Fonarow GC, Butler J, et al. Get With The Guidelines-AFIB Clinical Working Group and Hospitals. Adherence to Guideline-Directed Stroke Prevention Therapy for Atrial Fibrillation Is Achievable. Circulation 2019;139:1497-1506.  Back to cited text no. 13
Proietti M, Nobili A, Raparelli V, Napoleone L, Mannucci PM, Lip GY, et al. Adherence to antithrombotic therapy guidelines improves mortality among elderly patients with atrial fibrillation: Insights from the REPOSI study. Clin Res Cardiol 2016; 105:912-20.  Back to cited text no. 14
King DE, Dickerson LM, Sack JL. Acute management of atrial fibrillation: Part I. Rate and rhythm control. Am Fam Physician 2002; 66:249-56.  Back to cited text no. 15
Navarro-Juan M, Carbonell-Torregrosa MÁ, Palazón-Bru A, Martínez-Díaz AM, Gil-Guillén VF. Nonadherence to guidelines for prescribing antiplatelet/anticoagulant therapy in patients with atrial fibrillation. Fam Pract 2016; 33:290-5.  Back to cited text no. 16
Lip GY, Clementy N, Pericart L, Banerjee A, Fauchier L. Stroke and major bleeding risk in elderly patients aged 75 years with atrial fibrillation: The Loire Valley atrial fibrillation project. Stroke 2015;46:143-50.  Back to cited text no. 17
Marcucci M, Iorio A, Nobili A, Tettamanti M, Pasina L, Marengoni A, et al. Factors affecting adherence to guidelines for antithrombotic therapy in elderly patients with atrial fibrillation admitted to internal medicine wards. Eur J Intern Med 2010; 21:516-23.  Back to cited text no. 18
Raparelli V, Proietti M, Buttà C, Di Giosia P, Sirico D, Gobbi P, et al. Medication prescription and adherence disparities in non-valvular atrial fibrillation patients: An Italian portrait from the ARAPACIS study. Intern Emerg Med 2014; 9:861-70.  Back to cited text no. 19
Mohammad AM, Al-Allawi NA. CYP2C19 genotype is an independent predictor of adverse cardiovascular outcome in Iraqi patients on clopidogrel after percutaneous coronary intervention. J Cardiovasc Pharmacol 2018; 71:347-51.  Back to cited text no. 20
Mohammad AM. Prevalence and associated factors of Aspirin non-responsiveness in patients undergoing percutaneous coronary intervention in Duhok, Iraq. Duhok Med J 2021;14:30-9.  Back to cited text no. 21
Mohammad AM, Jehangeer HI, Shaikhow SK. Prevalence and risk factors of premature coronary artery disease in patients undergoing coronary angiography in Kurdistan, Iraq. BMC Cardiovasc Disord 2015; 15, 155. https://doi.org/10.1186/s12872-015-0145-7).  Back to cited text no. 22


  [Table 1], [Table 2], [Table 3], [Table 4]


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