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Gestione del paziente con fibrillazione atriale nel mondo reale: risorse, difficoltà, dubbi

Gestione del paziente con fibrillazione atriale nel mondo reale: risorse, difficoltà, dubbi. Dott . Alessandro Filippi Società Italiana di Medicina Generale. Risorse e difficoltà. Rete capillare Contatti frequenti con i pazienti a rischio di FA Facilità di contatto/accesso

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Gestione del paziente con fibrillazione atriale nel mondo reale: risorse, difficoltà, dubbi

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  1. Gestione del paziente con fibrillazione atrialenel mondo reale: risorse, difficoltà, dubbi Dott. Alessandro Filippi SocietàItalianadiMedicinaGenerale

  2. Risorse e difficoltà • Rete capillare • Contatti frequenti con i pazienti a rischio di FA • Facilità di contatto/accesso • Disponibilità strutture cardiologici d’eccellenza • Scarsità/assenza personale infermieristico • Scarsità/assenza disponibilità ECG in studio • Difficoltà accesso sistemi esperti TAO • Difficoltà reperire strumenti formativo ad hoc per MG

  3. Atrial fibrillation care: challenges in clinical practice and educational needs assessment. Can J Cardiol. 2011 • METHODS: A mixed-method approach --consisting of qualitative (semistructured interviews) and quantitative data collection techniques (online survey) --was conducted. Findings were triangulated to ensure the reliability and trustworthiness of findings. The combined sample (n = 161) included 43 family physicians/general practitioners, 23 internal medicine specialists, 48 cardiologists, 28 emergency physicians, 14 neurologists, and 5 patients. • RESULTS: Gaps and barriers impeding optimal care were related to an unclear definition of AF, uncertainty of its pathophysiology, and knowledge gaps across the care continuum, including screening, diagnosis, and treatment. Clinical decision-making, individualized patient therapy, communication with patients and between professionals, and application of guidelines were found to be particularly challenging.

  4. Punticritici • Screening FA • Diagnosi FA parossistica “elusiva” • Invio al cardiologo (primo invio) • La profilassi del tromboembolismo • Il monitoraggio del paziente

  5. Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial BMJ 2007 • Interventions Patients in intervention practices were randomly allocated to systematic screening (invitation for electrocardiography) or opportunistic screening (pulse taking and invitation for electrocardiography if the pulse was irregular). • Results The detection rate of new cases of atrial fibrillation was 1.63% a year in the intervention practices and 1.04% in control practices (difference 0.59%, 95% confidence interval 0.20% to 0.98%). Systematic and opportunistic screening detected similar numbers of new cases (1.62% v 1.64%, difference 0.02%, −0.5% to 0.5%). • Conclusion Active screening for atrial fibrillation detects additional cases over current practice. The preferred method of screening in patients aged 65 or over in primary care is opportunistic pulse taking with follow-up electrocardiography

  6. Accuracy of diagnosing atrial fibrillation on electrocardiogram by primary care practitioners and interpretative diagnostic software: analysis of data from screening for atrial fibrillation in the elderly (SAFE) trial BMJ 2007 • ResultsGeneral practitioners detected 79 out of 99 cases of atrial fibrillation on a 12 lead electrocardiogram (sensitivity 80%, 95% confidence interval 71% to 87%) and misinterpreted 114 out of 1355 cases of sinus rhythm as atrial fibrillation (specificity 92%, 90% to 93%). Practice nurses detected a similar proportion of cases of atrial fibrillation (sensitivity 77%, 67% to 85%), but had a lower specificity (85%, 83% to 87%). The interpretative software was significantly more accurate, with a specificity of 99%, but missed 36 of 215 cases of atrial fibrillation (sensitivity 83%). Combining general practitioners' interpretation with the interpretative software led to a sensitivity of 92% and a specificity of 91%. Use of limb lead or single lead thoracic placement electrocardiograms resulted in some loss of specificity.

  7. A national survey of the management of atrial fibrillation with antithrombotic drugs in Italian primary care.Thromb Haemost. 2010

  8. Sintomi “suggestivi” di FA parossistica • Quali indagini • In quali pazienti • Con quale “accanimento” diagnostico

  9. Solo controllo della frequenza

  10. Primo invio al cardiologo (esclusa “urgenza”) • Sempre tutti? • FA parossistica tornata in ritmo spontaneamente? • Solo controllo frequenza? • Con quale modalità • “urgenza differibile”? • PS? • modalità “diagnostica”? • Cosa fare prima • TAO? • Accertamenti? • Farmaci?

  11. A national survey of the management of atrial fibrillation with antithrombotic drugs in Italian primary care.Thromb Haemost. 2010 Antithrombotic drug prescription per risk category according to the CHADS2 score. Correlation between worsening stroke risk and change in AT prescription; P-values: OAC, 0.7683; AP, <0.0001;OAC+AP, 0.7417.

  12. A national survey of the management of atrial fibrillation with antithrombotic drugs in Italian primary care.ThrombHaemost. 2010

  13. A national survey of the management of atrial fibrillation with antithrombotic drugs in Italian primary care.Thromb Haemost. 2010 One- and two-year rates of persistence with oral anticoagulants in patients with atrial fibrillation.

  14. Monitoraggio terapia antiaritmica • Terapia “a vita”? • Sintomi? • Interferenza con altre terapie? • Periodicità ECG • Quando modifiche significative ECG? • Chi ha istruito il paziente e i familiari?

  15. Follow-up • Per chi il cardiologo? • Quando il cardiologo? • Quali esami periodici? • Con quale periodicità? • QuaIi struzioni al paziente? • Chi ha istruito il paziente?

  16. La comunicazione

  17. Scambioinformazioni • Cliniche • Preferenze-scelte paziente • Competenze e disponibilità professionale • Strumenti adatti • Carta e penna • Computer • Patient summary • Fascicolo sanitario

  18. I PDT • Uno strumento da utilizzare bene • Gruppo di lavoro “paritetico” • Reale condivisione • Realistico • Verifiche e feed-back • Diffusione adeguata • Formazione adeguata • Sostegno convinto da parte dei “decisori”

  19. Percorsi diagnostico-terapeutici per la cura della fibrillazione atriale in Italia Steering Committee Massimo Zoni Berisso (Chairman), Giuliano Ermini (Co-Chairman), Giuseppe Boriani , Alessandro Filippi, Massimo Grimaldi, Maurizio Landolina, Gianpiero Maglia, Claudio Pedrinazzi, Maurizio Santomauro , Gianluca Zingarini Comitato Esecutivo Ovidio Brignoli, Massimo Grimaldi, Gianpiero Maglia Comitato Monitoraggio e Qualità Dati Gaetano D’Ambrosio, Italo Paolini

  20. Un passooltre • Un “manuale” per il MMG • Nell’ottica del percorso gestionale • Che affronti i punti critici nell’ottica della medicina generale e della collaborazione con lo specialista • Che dia risposta alle domande • Che sia frutto della condivisione cardiologo-MMG • Che sia applicabile alla realtà quotidiana • Che sia punto di riferimento per Regione ed ASL

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