Partnering with patients in shared decision-making for stroke prevention in atrial fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia. The population prevalence of AF ranges from 2.3 to 3.4% and is estimated to double by 2050 as we approach epidemic levels.1 AF is a major, complex and challenging risk factor for stroke. It is estimated that about 20% of all strokes are a consequence of AF. AF-related strokes affect more of the brain, are usually more severe and are associated with greater levels of disability with poorer outcomes.2 Anticoagulation is a well-established pharmacotherapy to reduce the risk of stroke in patients with AF; however, the rates of thromboprophylaxis remain poor,3 with only 60–70% of eligible patients receiving anticoagulation drugs.3 The advent of novel oral anticoagulants, including dabigatran, rivaroxaban, apixaban and edoxaban, has created an increase in the choice of treatment for patients. It is important that patients and caregivers are central to decision-making about anticoagulants. Active patient participation is of the utmost importance in this process and requires education about the risks and benefits of each treatment to inform their decision. Before patients and caregivers are ready to participate in decision-making processes, it is vital that they are comprehensively educated on both their condition and the available therapeutic approaches to stroke prevention in AF. As AF can be a complex condition, it is recommended that clinicians focus on a comprehensive management approach, including rate and rhythm control, the treatment of underlying cardiovascular conditions, risk factors and lifestyle interventions, but, perhaps most crucially, the prevention of thromboembolic complications. The European Society of Cardiology guidelines for the management of AF recommend that stroke risk factors should be assessed in all patients with non-valvular AF using the CHA2DS2-VASc risk score.1 Oral anticoagulant therapy will have clear benefits and should be recommended for patients with a CHA2DS2-VASc score ⩾2 in men and ⩾3 in women. Patients with one stroke risk factor (CHA2DS2-VASC of 1 in men and 2 in women) should be considered for treatment with oral anticoagulants. Decisions on which treatment should be prescribed should take into consideration the risk of bleeding (this can be assessed using the HAS-BLED score) and importantly must consider the patients’ values and preferences for treatment.4 Patients and caregivers must be empowered to understand the range of therapies available and the risks and benefits associated with each. Patient-centred care can be defined as ‘care that is respectful of and responsive to individual patient preferences, needs and values’ and that ensures ‘the patients’ values guide all clinical decisions’. This definition highlights the importance of healthcare professional–patient partnerships to optimize patient outcomes.5,6 Conversations with patients and caregivers, with respect to the decision to ‘anticoagulate or not’ and ‘which anticoagulant is best for them’ are complex, challenging and time consuming. Current clinical practice often faces a lack of time to adequately address these topics and provide a comprehensive approach to AF care. Nurse-led AF clinics have shown evidence of significantly better outcomes related to reduced cardiovascular mortality and hospitalization as well as guideline-adherent anticoagulation prescription.7 Likewise, disease-specific management programmes demonstrate favourable outcomes.8 Key aspects of these models of care include care that is provided following a multidisciplinary approach, where specialists in AF management work closely together, but also where patients and caregivers have time to discuss their condition, symptoms, treatment regimens and lifestyle behaviour with healthcare providers in a less time-poor setting. This structured, integrated approach to care is adopted by the recently launched 2016 European Society of Cardiology guidelines on the management of AF as the recommended AF management approach. The fundamentals of this approach include patient-centred care with multidisciplinary teams providing a comprehensive treatment approach, where possible supported by technology tools.4 Healthcare professionals should not be mistaken by the terms ‘patient involvement’ or ‘patient consultation’; it is imperative that healthcare professionals truly engage with patients and caregivers as partners in making these complex treatment decisions. Healthcare professionals need to provide evidence-based care that meets the values and needs of individual patients. The ESC Guidelines recommend that shared decision-making should be considered to ensure this ‘fit’, which requires active patient engagement and continuous, tailored patient education in all phases of AF management.4 Shared decision-making is a core component of patient-centred care. Shared decision-making provides a framework for communicating with individuals about their healthcare choices with the aim of improving the quality of conversation in the context of anticoagulation medication. It acts as a mechanism for applying evidence-based care to individual patients. Shared decision-making can be characterized by the following key features: (a) both the patient and healthcare professional are engaged in partnership conversations and it is recommended an informal caregiver is also engaged9; (b) there is sharing of information (such as personalized risk-based information on stroke and bleeding risk, as calculated with the CHA2DS2VASc and HAS-BLED tools) – this should be a two-way conversation; (c) there is consensus-building towards a preferred treatment option (anticoagulant choice); (d) an agreed treatment regimen is reached as an outcome; and (e) this is reviewed at regular intervals during follow up and the process may be repeated as required.10 The European Society of Cardiology guidelines for the management of AF recommend that shared decision-making should be considered to ensure these features.4 Nurses have a crucial role in this process and should be proficient in the ability to calculate and interpret stroke and bleeding risks (including CHA2DS2VASc and HAS-BLED scores) and to be able to explain these to patients. Cardiovascular nurses, as part of a multidisciplinary team, have a fundamental role in supporting and educating patients in this complex treatment decision. Moving forward, we provide the following practical advice for cardiovascular nurses. Provide full education on AF as a condition, including symptom recognition, possible complications (e.g. stroke) and treatment options. Ensure that stroke risk factors are assessed during every attendance at clinic. Provide a thorough explanation of the rationale of why oral anticoagulation is important and the mechanism of actions of different pharmacological interventions. Discuss possible treatment options, including vitamin K antagonists and novel oral anticoagulants, and adjust this with the values, beliefs and comprehension of patients and their caregivers. Explain the need to remain on the prescribed therapeutic regimen and the consequences of self-cessation and non-adherence. Regularly assess compliance with the prescribed regimens and provide tools and methods for patients to improve compliance. Communication between the treating physician (cardiologist, neurologist), nurse and referrer (e.g. general practitioner) is of utmost importance, as well as the coordination of care (by nurses). It is vital to ensure good multidisciplinary patient-centred communication between inpatient and outpatient providers.