TY - JOUR
T1 - Anticoagulation therapy and outcomes in patients with atrial fibrillation and serious mental illness: A systematic review and meta-analysis
AU - Farran, Dina
AU - Feely, Olwyn
AU - Ashworth, Mark
AU - Gaughran, Fiona
N1 - Funding Information:
Despite evidence supporting the benefits of oral anticoagulation in AF, underuse is consistently reported, particularly in those with SMI (Fenger-Grøn et al., 2021; Jaakkola et al., 2021; Schmitt et al., 2015). Fragmented medical care, poor treatment adherence, drug-drug interactions, along with barriers to medical care and social deprivation have been identified as factors contributing to increased risk of poor outcomes in this vulnerable population (Hudson, 2005; Kennedy et al., 2013; Lawrence and Kisely, 2010; Orensky and Holdford, 2005; Platt et al., 2008; Trivedi, 2006).Research on management and outcomes of AF in people with SMI is scarce. These people are less likely to receive indicated oral anticoagulation therapy and experience poor anticoagulation control when prescribed warfarin. More research is needed to compare the prescription rates of DOACs vs warfarin in this population to determine whether anticoagulation treatment deficit has narrowed since the introduction of DOACs, as well as to examine difference in outcomes in those prescribed a DOAC rather than warfarin. Additionally, more clinical interventions aiming to risk stratify SMI patients and improve the management of their physical conditions are needed. Managing modifiable bleeding risk factors (such as hypertension, alcohol use, and medication predisposing to bleeding such as nonsteroidal anti-inflammatory drugs (NSAIDs) or antiplatelet agents) could increase the prescription of OACs and reduce the risk of adverse events in this vulnerable population. To ensure that no AF cases are missed, future studies should investigate the effectiveness of AF screening interventions (such as single-lead ECG monitoring device) in people with SMI. Additionally, to guarantee a safe and effective treatment, the feasibily and acceptability of electronic clinical decision support systems (eCDSSs) to improve the recording of physical conditions (such as AF, stroke and bleeding risk factors) in electronic health records of patients with SMI should be evaluated. These studies should be repeated post-implementation to detect changes in the prevalence and/or recording of physical conditions among people with SMI. Future studies related to AF should also consider adjusting for stroke and bleeding risk factors as unadjusted rates are difficult to interpret particularly in people with SMI.DF is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration South London (NIHR ARC South London) at King's College Hospital NHS Foundation Trust and by the KCL funded Centre for Doctoral Training (CDT) in Data-Driven Health.FG is in part supported by the National Institute for Health Research's (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, by the Maudsley Charity and by the National Institute for Health Research (NIHR) Applied Research Collaboration South London (NIHR ARC South London) at King's College Hospital NHS Foundation Trust.MA is in part funded by the Guy's and St Thomas' Charity and the National Institute for Health Research (NIHR) Applied Research Collaboration South London (NIHR ARC South London). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
Funding Information:
DF is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration South London (NIHR ARC South London) at King's College Hospital NHS Foundation Trust and by the KCL funded Centre for Doctoral Training (CDT) in Data-Driven Health .
Funding Information:
FG is in part supported by the National Institute for Health Research's (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London , by the Maudsley Charity and by the National Institute for Health Research (NIHR) Applied Research Collaboration South London (NIHR ARC South London) at King's College Hospital NHS Foundation Trust.
Funding Information:
MA is in part funded by the Guy's and St Thomas' Charity and the National Institute for Health Research ( NIHR ) Applied Research Collaboration South London (NIHR ARC South London). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
Publisher Copyright:
© 2022 The Authors
PY - 2022/11/16
Y1 - 2022/11/16
N2 - Objective: A systematic review was conducted to investigate prevalence, management and outcomes of atrial fibrillation (AF) in people with Serious Mental Illnesses (SMI) versus the general population. Data sources: MEDLINE, EMBASE, and PsycINFO were searched for primary research written in English and published between 2004 and 2022. Study selection: A total of 1459 studies were identified in the initial search of which 16 met the inclusion criteria. Studies (n = 4) reporting on ischaemic stroke and major bleeding events were included in the meta-analysis. Data extraction: Two independent reviewers extracted data and assessed risk of bias using the Newcastle-Ottawa Scale. Discrepancies were resolved by consulting a third reviewer. Results: Low rates of AF were reported among people with SMI suggesting under-recognition or recording gaps. People with SMI and AF were less likely to receive oral anticoagulation therapy compared to the general population. When receiving warfarin, those with bipolar disorder experienced poor anticoagulation control as measured by time in INR therapeutic range. Pooled analysis of risk estimates showed that in patients with identified AF, SMI was not significantly associated with an increased risk of stroke (HR: 1.09; 95%CI: 0.85 to 1.40; I2 = 60%, p = 0.04) or major bleeding (HR: 1.11; 95%CI: 0.95 to 1.28; I2 = 57%, p = 0.03) when adjusted for underlying stroke and bleeding risks using the CHA2DS2VASc and HASBLED scales respectively. Conclusion: More research is needed to examine the prevalence, management and outcomes of AF in this population, and to evaluate the effect of the introduction of the novel anti-coagulants on these metrics over time.
AB - Objective: A systematic review was conducted to investigate prevalence, management and outcomes of atrial fibrillation (AF) in people with Serious Mental Illnesses (SMI) versus the general population. Data sources: MEDLINE, EMBASE, and PsycINFO were searched for primary research written in English and published between 2004 and 2022. Study selection: A total of 1459 studies were identified in the initial search of which 16 met the inclusion criteria. Studies (n = 4) reporting on ischaemic stroke and major bleeding events were included in the meta-analysis. Data extraction: Two independent reviewers extracted data and assessed risk of bias using the Newcastle-Ottawa Scale. Discrepancies were resolved by consulting a third reviewer. Results: Low rates of AF were reported among people with SMI suggesting under-recognition or recording gaps. People with SMI and AF were less likely to receive oral anticoagulation therapy compared to the general population. When receiving warfarin, those with bipolar disorder experienced poor anticoagulation control as measured by time in INR therapeutic range. Pooled analysis of risk estimates showed that in patients with identified AF, SMI was not significantly associated with an increased risk of stroke (HR: 1.09; 95%CI: 0.85 to 1.40; I2 = 60%, p = 0.04) or major bleeding (HR: 1.11; 95%CI: 0.95 to 1.28; I2 = 57%, p = 0.03) when adjusted for underlying stroke and bleeding risks using the CHA2DS2VASc and HASBLED scales respectively. Conclusion: More research is needed to examine the prevalence, management and outcomes of AF in this population, and to evaluate the effect of the introduction of the novel anti-coagulants on these metrics over time.
UR - http://www.scopus.com/inward/record.url?scp=85142147456&partnerID=8YFLogxK
U2 - 10.1016/j.jpsychires.2022.11.002
DO - 10.1016/j.jpsychires.2022.11.002
M3 - Review article
SN - 0022-3956
VL - 156
SP - 737
EP - 753
JO - Journal of Psychiatric Research
JF - Journal of Psychiatric Research
ER -