Anticoagulation in atrial fibrillation for stroke prevention in resource-limited settings: A report from Arsi University Referral Hospital in Ethiopia

Abstract Background Atrial fibrillation (AF) significantly increases the risk of thromboembolic events, particularly stroke, highlighting the need for effective anticoagulation therapy. In Ethiopia, factors such as healthcare resource availability, medication access, provider education, and patient awareness may impact the understanding and implementation of these therapies. This study seeks to evaluate the prevalence of atrial fibrillation, prescribing practices for anticoagulation, and the health outcomes for patients with AF in this context. Methods A hospital-based cross-sectional study was conducted on selected patients with atrial fibrillation on follow-up at Arsi University referral hospital from July 15, 2020, to December 15, 2020. The data was collected using a structured questionnaire, with the components intended to assess the prevalence of atrial fibrillation, prescribing practices for anticoagulation, and the health outcomes of patients with atrial fibrillation. The collected data is checked for completeness, cleaned, and then entered into Epidata for analysis. Descriptive statistics were utilized, and multivariable logistic regression was conducted to identify independent factors associated with the practice and level of utilization of anticoagulation, with a significance threshold set at an odds ratio of 95% CI with a P-value < 0.05. Results The study analyzed 126 patients with atrial fibrillation and included all participants in the final analysis. The mean age of patients was 46.2 years, the majority being females (69.8%). The majority of participants (54.0%) reported monthly earnings between 2001 and 4000 ETB, with the most indicated average follow-up costs of 851–1000 ETB (42.1%), with those on warfarin incurring notably higher expenses. Atrial fibrillation was confirmed via ECG for all participants, with almost all (99.2%) having underlying heart disease, predominantly valvular AF due to rheumatic mitral stenosis (61.9% of 126 study participants), as confirmed with echocardiographic evaluation. Furthermore, 7.2% of patients presented with thrombus in the left atrium or related structures. The median CHA2DS2-VASc score of 45 patients with non-valvular atrial fibrillation (NVAF) was 3 (range of 0–5). 79 (62.7%) of them were on warfarin, in which only 32 of 79 (40.5%) valvular AF participants had target INR for stroke prevention, less as compared to 7 of 15 (46.7%) NVAF participants. Nearly one-third (30.1%) of patients on warfarin had sub-therapeutic INR. Serum creatinine derangement was recorded as the common laboratory abnormality, which occurred in 13.5% of patients and was associated with a 4.12-fold reduction in the use of anticoagulation (p = 0.032). Financial difficulty in coping with warfarin monitoring, followed by fear of bleeding, was the main reason for treatment discontinuation. Stroke occurred in 6.3% of the total participants, of which half of them were in those using aspirin. Bleeding episodes were recorded in 14.5% of patients taking warfarin, with a mean INR of 7.24 (ranging from 3.4 to 9.68) at the time of bleeding, though they necessitated transfusion in only one patient. Males were more likely to use warfarin than females (AOR: 7.03 (1.60, 30.95), P = 0.001), as were urban participants compared to rural residents [AOR: 40 40 (2.56, 630.26), P = 0.009]. Those with valvular AF are more likely to use warfarin than NVAF [P = 0.004]. Conclusion The study found that atrial fibrillation is a common problem that is more common in females at risk. Almost all cases are due to structural heart disease, of which valvular AF, mainly due to rheumatic mitral stenosis, was predominant, necessitating anticoagulation. The CHA2DS2-VASc score is also high among those with NVAF, though anticoagulation was limited in the setup, leading to an increased risk for stroke. Furthermore, target INR was also not achieved in a significant number of patients on warfarin. Financial difficulty in coping with warfarin monitoring and fear of bleeding were the main reasons for either treatment discontinuation or hesitance for initiation. Though bleeding episodes occurred in those on warfarin, almost all were minor and necessitated transfusion in only one patient. As a result, encouraging warfarin therapy and advice on adherence in those patients with atrial fibrillation would reduce the risk of stroke with minimal bleeding episodes in this resource-limited setting.