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Oral anticoagulant nuances may be misunderstood, prescribed more than needed
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Approximately one quarter of patients with atrial fibrillation and the lowest risk for stroke are treated with oral anticoagulants unnecessarily, according to a research letter published in JAMA Internal Medicine.
The findings from a nationally representative sample of adult outpatients aged below 60 years run counter to guideline recommendations and could carry public health implications due to an unfavorable risk-benefit profile in this population.
Gregory Marcus
“The irony is that there is a general push to get providers to prescribe these drugs, and they are also generally under-prescribed among many AF patients who actually need them,” Gregory Marcus, MD, MAS, of the division of cardiology, University of California, San Francisco, said in a news release.
“Our study suggests people are trying to do the right thing but, due to a lack of understanding of some of the critical nuances, go too far in that direction in low-risk patients,” he said.
Marcus, with Jonathan C. Hsu, MD, MAS, a recent UCSF graduate, now of the division of cardiology, University of California, San Diego, and colleagues looked at 10,995 patients with AF enrolled in the National Cardiovascular Data Registry’s Practice Innovation and Clinical Excellence (PINNACLE) Registry between January 2008 and December 2012.
The patients, from 76 cardiology practices in 287 different geographic office sites in 33 states, had no structural heart disease and were at low risk for thromboembolism. All patients had a CHADS2 score of 0; a secondary analysis restricted to patients with a CHA2DS2-VASc score of 0 was also performed.
The investigators developed hierarchical modified Poisson regression models to examine independent relationships between various characteristics and oral anticoagulant prescription outcomes; adjustments were made for demographics and clinical characteristics.
Oral anticoagulants were prescribed to 2,561 (23.3%) patients with a CHADS2 score of 0 and 1,787 (26.6%) patients with a CHA2DS2-VASc score of 0.
Among patients with a CHADS2 score of 0, predictors for oral anticoagulant prescription were older age (adjusted RR = 1.48 per 10 years; 95% CI, 1.41-1.56), male sex (adjusted RR = 1.34; 95% CI, 1.22-1.46), higher BMI (adjusted RR = 1.18 per 5 kg/m2; 95% CI, 1.14-1.22) and Medicare vs. private insurance (adjusted RR = 1.32; 95% CI, 1.17-1.49).
Similar results were seen among patients with a CHA2DS2-VASc score of 0, with older age (adjusted RR = 1.44 per 10 years; 95% CI, 1.36-1.54), higher BMI (adjusted RR = 1.19 per 5 kg/m2; 95% CI, 1.15-1.23), Medicare vs. private insurance (adjusted RR = 1.29; 95% CI, 1.13-1.47) and no insurance vs. private insurance (adjusted RR = 1.19; 95% CI, 1.03-1.37) linked with increased likelihood for oral anticoagulant prescription.
Patients residing in the southern U.S. were less likely to be prescribed oral anticoagulants than patients in the northeastern part of the nation (adjusted RR = 0.67; 95% CI, 0.47-0.96).
“Practitioners who prescribe blood thinners need to be diligent about weighing the risks and benefits of these medications,” Hsu said in the release. “In those patients with no risk factors for stroke, the risk of bleeding likely outweighs the benefit of stroke reduction. The fact that blood thinners were prescribed to so many patients with no risk factors for stroke is a wake-up call that we need to do better for our patients.” – by Allegra Tiver
Disclosure: Hsu reports receiving honoraria from Medtronic. Please see the full study for a list of all other authors’ relevant financial disclosures.
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