Title : Oral Anticoagulation Therapy (OAT) among Stroke Survivors

 Assessment of Knowledge Regarding Oral Anticoagulation Therapy (OAT) among Stroke Survivors

Abstract

There has been a dramatic increase in the number of patients undergoing long term oral anti-coagulation therapy (OAT) with warfarin in recent years. Successful anticoagulation treatment is dependent on the patient’s knowledge of OAT. The present study was undertaken to assess the knowledge regarding OAT among stroke survivors and to determine the association between knowledge and selected socio-personal and clinical variables. The study revealed that only 5 percent of sample had good knowledge and the knowledge level was more among males and those who had previous exposure to lecture class/information pamphlet regarding OAT. Patients had poor knowledge in the area of dietary interaction of warfarin followed by precau-tions to be taken while on OAT and signs of side effects of OAT.

Stroke is a global health problem and an emerging epidemic in India (Sridharan et al, 2009). Globally, stroke is the second leading cause of death above the age of 60 years (WHF, 2016). An estimated 20 percent of all ischaemic strokes are a result of cardiogenic embolism, which can occur because of a variety of cardiac conditions, such as atrial fibrillation (AF), rheumatic heart disease, valvular heart disease etc. (Goldstein et al, 2006). Patients who have experienced stroke should undergo medical management for secondary prevention.

Oral anticoagulant treatment is recommended for stroke prevention in individuals with atrial fibrillation (Furie et al, 2011). Treatment regimens for preventing thromboembolism in AF patients range from vitamin K antagonists such as Warfarin or coumadins, antiplatelet drugs like aspirin or clopidogrel, to newly developed orally available anti-thrombotics like the direct thrombin inhibitor dabigatran, or the factor Xa-inhibitor rivaroxaban (Maegdefessel et al, 2010). For most patients with a stroke or transient ischaemic attack (TIA) in the setting of AF, it is reasonable to initiate oral anticoagulation within 14 days after the onset of neuro-logical symptoms (Kernan et al, 2014). The most commonly used anticoagulants include Warfarin (caumadin), heparin and enoxaparin (NINDS, 2015). For over 50 years, warfarin has been the drug of choice in preventing AF-related strokes (Hinojar et al, 2015).

A global increase in the number of patients requiring OAT is expected over the next decades (Rich, 2009). If patients discontinue anti-coagulation therapy, it leads to major complications such as stroke, thromboembolism, cardiovascular complications and sudden cardiac death. At the same time, regular anticoagulation therapy can cause bleeding also. Anticoagulation is a high-risk treatment, which commonly leads to adverse drug events due to the complexity of dosing these medications, monitoring their effects, and ensuring patient compliance with outpatient therapy (Ansell et al, 2004). Interactions with other drugs, dietary intake, poor adherence with medication and deficiency in pa-tient knowledge are factors associated with non-therapeutic treatment outcomes. Therefore, it is pertinent to assess the patients’ knowledge about OAT (Yahaya et al, 2009).

Objectives
This study sought to:
1.  Assess the knowledge regarding oral anticoagu-lation therapy (OAT) among stroke survivors at-tending stroke clinic in SCTIMST, Thiruvanan-thapuram.
2.  Determine the association between knowledge and selected socio-personal variables.

 

Review of Literature
 
The awareness of anticoagulation-related risk of bleedings was found lowest in patients without schooling (38.5%) and highest in those with college and university education (57%) by Madrid et al (2016). In this European study among 1147 patients with atrial fibrillation, the authors also reported that the patients with college education had less frequent deviations from their target international normalised ratio (INR) compared with those without schooling. The education level and patients’ knowledge had a direct influence on the global manage-ment of the anticoagulation.
 
In a cross-sectional study to assess compliance with and awareness about OAT among 162 Saudi patients, and their willingness to use the point-of-care (POC) - INR testing device for self-monitoring, Al-Omair et al, (2016) reported poor knowledge about OAT and medium adherence to drug therapy. Majority were eager to make use of the POC-INR device. Nevertheless, the authors recommended an education programme to help patients in improving their medication control and reducing clinical vis-its.
 
Alphonsa et al (2015) conducted a descriptive cross-sectional study to assess the knowledge regarding OAT among 240 patients with stroke and those at high risk of thromboembolic events. Half of the patients were having poor knowledge score (<50%), 36.7 percent of them had average knowl-edge score (50%-70%), and only 13.3 percent of pa-tients had a good knowledge score (>70%). The mean percentage knowledge scores on individual compo-nents of assessment showed the lowest score for dietary interactions (25%) followed by adverse effects (40%), drug interactions (40%), PT/INR monitoring
 
(46%), and basic drug information (62%). Patient’s knowledge about OAT was suboptimal. The findings support the need for educational interventions to improve the knowledge regarding OAT and, thereby, achieve an appropriate and safe secondary preven-tion of stroke.
 
Joshua & Kakkar (2015) found an overall poor knowledge status among 101 patients on oral an-ticoagulant therapy and less than one fifths of the patients (17.8%) only had adequate OAT knowledge.
 
Materials and Methods
 
Setting: This descriptive survey was conducted in the stroke clinic of a tertiary hospital in Kerala, India. This institute of national importance has 253 bed tertiary care of cardiovascular and neurological diseases and a 7-bedded comprehensive stroke care unit. More than 2250 patients got admitted in the comprehensive stroke care unit in the past six years. The unit receives an average of 35-40 patients in a month. Among these, six to nine patients are having cardio-embolic stroke; 60 to 75 patients attend the stroke clinic, which is run on every Friday. Out of this, 4-5 patients are on OAT. Some stroke survivors are attending the stroke clinic for more than 8 years. This shows the intensity and severity of stroke incidence in the population.
 
Sample: Patients who had cardio embolic stroke and presently on OAT attending the stroke clinic were purposively selected during July 2016 to October 2016. Those below 18 years having cognitive impairment or those who did not know to read and write Malayalam were not included in the study.
 
Data collection: The data was collected from 22 July 2016 to 14 October 2016. Formal permission from the authorities and informed consent from the patients were obtained. A self-structured and verified questionnaire was used for data collection, which consisted of three parts; demographic and clinical data to obtain information about the participant’s socioeconomic characteristics and medical treatment respectively, and a questionnaire to assess knowledge on OAT. The knowledge assessment questionnaire consisted of 20 multiple choice questions under two subheadings.
 
The first section consisted of 15 questions related to oral anticoagulants. These questions as-sessed the patients’ knowledge regarding the purpose of oral anticoagulants, its side effects and signs of side effects, precautions to be taken while on OAT, interaction of OAT with food and other medications. This section also included questions which assess what the patients do when they miss a dose, when they have to undergo any dental procedures, when they get injured and when they have to take other medications for any other reason. The second section included five questions related to PT/ INR (pro-thrombin time/ international normalised ratio) test. Questions in this section assessed the patients’ knowledge regarding the purpose of PT/INR test, factors which affect PT/INR value, what happens when the PT/INR level goes above and below the expected range and the frequency of checking PT/ INR after its level come to the desirable range. A pilot study was done among four patients to find out the feasibility of the study.
  
Data analysis: Data were analysed using OpenEpi version 3.01. The results were expressed as number and percentages and comparison of groups was
 
 
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performed with the chi-square tests or Fisher-ex-act tests where appropriate. Probability value of 0.05 or less was the criteria used to measure statistical significance.
  
Results & Discussion
 
Thirty-seven stroke survivors on OAT attended stroke clinic were included. Their age ranged from 21 to 71 years with a mean (±SD) of 51.9 (±12.4). The assessment of knowledge regarding OAT showed that only 2 (5%) sample had good knowledge (75%-100%), 22 (60%) had average knowledge (50%-74%) and 13 (35%) had poor knowledge (<50%) (Table 1). Patients had poor knowledge in the area of di-etary interaction followed by precautions to be taken while on OAT and signs of side effects of OAT. Knowl-edge ranged from six (30%) to 17 (85%).
 
The association between knowledge and selected socio-personal variables and clinical data revealed that there was a significant association between knowledge and gender (p=0.005), knowledge and du-ration of OAT (p = 0.03), knowledge and previous exposure to lecture class/information pamphlet re-  garding OAT (p = 0.03) (Table 2).
 
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The present study showed that the knowledge re-garding OAT was more among males and those who had previous exposure to lecture class/information pamphlet and as the duration of OAT increased the knowledge decreased. There was no significant difference in the level of knowledge regarding OAT according to age or education.
 
Patients had poor knowledge in the area of dietary interaction (11%) followed by precautions to be taken while on OAT (19%), signs of side effects of OAT (19%), interference of alcohol intake with INR values (24%) and consumption of greenleafy veg-etables while on OAT (30%). Similarly, a study con-ducted by Alphonsa et al (2015) in a tertiary care hospital in India showed that half of the patients were having poor knowledge score (<50%), 36.7 per-cent of them had average knowledge score (50%-70%), and 13.3 percent of patients had good knowledge score. The mean percentage knowledge scores on individual components of assessment showed the lowest score for dietary interactions (25%), followed by adverse effects (40%), drug interactions (40%), PT/INR monitoring (46%), and basic drug informa-tion (62%). Similar findings have been reported by Khudair et al (2010) who found the least level of knowledge was on warfarin drug interactions, effect of a missing dose and its management.
 
Majority of the stroke survivors had only average knowledge regarding OAT. However, all stroke sur-vivors who had attended health education classes and/or read information pamphlet on OAT scored more than 60 percent. These findings support the need to have educational interventions for patients to improve their knowledge regarding OAT. More-over, majority of stroke survivors who were on OAT for more than three years scored less than 60 per-cent, underscoring the importance of periodic health education.
 
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Recommendations and Implications
 
Nursing Research: A similar study can be replicated on a large scale in different government and private hospitals to generalise the findings. A comparative study on knowledge, attitude and practice can be conducted among patients on prolonged OAT for different indications such as mechanical heart valve prosthesis, cardiac rhythm abnormalities and cardioembolic stroke.
 
Nursing administration: The nursing administration should develop and update health education pam-phlets/protocols/videos for patients on OAT and utilise them to give health education through nurseled clinics / outpatient clinics.
 
Nursing Education: Specialty nursing students should follow evidence-based practices, utilise research findings to impart updated knowledge to their clients. Timely, appropriate health education and treatment can prevent many cardioembolic strokes especially in young clients.
 

 

References
 
1.     Sridharan SE, Unnikrishnan JP, Sukumaran S, Sylaja PN, Nayak SD, Sarma PS, et al. Incidence, types, risk factors and outcome of stroke in a developing country. Stroke 2009; 40(4): 1212-18
 
2.     World Heart Federation (CH). World Heart Federation: Stroke (Internet). Geneva : World Heart Federation; 2016 (cited 2016 Sep 20) Available from: www.world-heart federation.org/ cardiovascular-health/stroke/
 
3.     Goldstein LB, Adams R, Alberts MJ, Appel LJ, Bass LM, Bushnell CD, et al. Primary prevention of ischemic stroke: A guideline from the American Heart Association / Ameri-can Stroke Association stroke council. Stroke 2006; 37: 1583-1633
 
4.     Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: A guide-line for healthcare professionals from the American Heart Association / American Stroke Association. Stroke 2011; 42(1): 227-76
 
5.     Maegdefessel L, Azuma J, Tsao PS. Modern role for clopidogrel in management of atrial fibrillation and stroke reduction. Vasc Health Risk Manag 2010; 6: 95-103
 
6.     Kernan W N, Ovbiagele B, Black HR, Bravata DM, Chimowitz M, Ezekowitz M D. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: A guide-line for healthcare professionals from the American Heart Association / American Stroke Association. Stroke 2014;45:  2160-2236
 
7.     National Institute of Neurological Disorders and Stroke (US). Stroke: Hope Through Research (Internet). Bethesda: National Institute of Health; 2015 (last updated 2016 May 26; cited 2016 Jul 22). Available from www.ninds.nih.gov ›Disorders A - Z › Stroke
 
8.     Hinojar R, Jime´nez-Natcher JJ, Ferna´ndez-Golfý´n C, Zamorano JL. New oral anticoagulants: A practical guide for physicians. European Heart Journal – Cardiovascular Pharmacotherapy 2015; 1: 134-45
 
9.     Rich MW. Epidemiology of atrial fibrillation. J Interv Card Electrophysiol 2009; 25: 3-8
 
10.   Ansell J, Hirsh J, Poller L, Bussey H, Jacobson A, Hylek E. The pharmacology and management of the vitamin K an-tagonists: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126(3): 204-33
 
11.   Yahaya, Hassali, Awaisu, Shafie. Factors associated with warfarin therapy knowledge and anticoagulation control among patients attending a Warfarin Clinic in Malaysia. Journal of clinical and Diagnostic Research 2009; 3(4): 1663-70
 
12.   Madrid AH, Potpara TS, Dagres N, Chen J, Larsen TB, Estner H, et al. Differences in attitude, education, and knowledge about oral anticoagulation therapy among pa-tients with atrial fibrillation in Europe: Result of a self-assessment patient survey conducted by the European Heart Rhythm association. Europace 2016; 18(3): 463-67
 
13.   Al-Omair SF, Musallam NA, Al-deghaither NY, Al-Sadoun NA, Bayoumy NM. Compliance with and awareness about long-term oral anticoagulant therapy among Saudi pa-tients in a University Hospital, Riyadh, Saudi Arabia. J Appl Hematol 2016; 7: 10-16
 
14.   Alphonsa A, Sharma KK, Sharma G, Bhatia R. Knowledge regarding oral anticoagulation among patients with stroke and those at high risk of thromboembolic events. Journal of Stroke and Cerebrovascular Diseases 2015; 24(3): 668-72
 
15.   Joshua JK, Kakkar N. Lacunae in patient knowledge about oral anticoagulant treatment: results of a questionnaire survey. Indian J Hematol Blood Transfus 2015; 31(2): 275-80
 
16.   Khudair IF, Hanssens YI. Evaluation of patients’ knowl-edge on Warfarin in outpatient anticoagulation clinics in a teaching hospital in Qatar. Saudi Med J 2010; 31: 672-77.
 
Author:Jinu Joseph1, Saramma PP2, Sylaja PN3

 

The authors are: 1. II Year Diploma in Neuronursing student; 2. Senior Lecturer in Nursing and ; 3. Additional Professor of Nursing & I/c Compre-hensive Stroke Care Programme, all at Sree Chitra Tirunal Institute for Medical Sciences & Technology, Thiruvananthapuram (Kerala).

 

Source: TNAI Journal

 

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