Consider revisiting reasons for anticoagulant nonuse among patients with AF
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Key takeaways:
- Differing perceived risk between physicians vs. patients with atrial fibrillation may partially explain low rates of oral anticoagulant use.
- Revisiting reasons for nonuse could improve anticoagulant use.
Revisiting reasons for patient refusal or physician choice not to prescribe oral anticoagulation could improve use of anticoagulants in patients with atrial fibrillation at increased risk, researchers reported.
The results of the Benchmarking an Oral Anticoagulant Treatment Rate in Patients with Nonvalvular Atrial Fibrillation (BOAT-AF) study were published in JAMA Network Open.
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“Prior data from the American College of Cardiology’s PINNACLE Registry has found approximately 40% of patients are not receiving anticoagulants, with little change over time, despite the availability of the nonvitamin K antagonists,” Christopher P. Cannon, MD, professor of medicine in the division of cardiovascular medicine at Brigham and Women’s Hospital and Harvard Medical School and executive director of cardiometabolic trials at the Baim Institute for Clinical Research in Boston, and colleagues wrote. “Because underuse may relate to both physician prescribing and patient factors, some studies have looked at physician assessment of the risk of bleeding vs. risk of stroke, finding physicians tend to be risk averse. Only a handful of studies have directly assessed patient wishes, and few if any assessed patients and physicians concurrently.”
To better understand patient and physician perceptions of anticoagulation for AF, Cannon and colleagues conducted the BOAT-AF trial using prospective data from 19 sites enrolled in the ACC’s National Cardiovascular Data Registry PINNACLE Registry.
The study included 817 patients with nonvalvular AF and a CHA2DS2-VASc score of 2 or more not receiving anticoagulation (median age, 76 years; 45.2% women; median CHA2DS2-VASc score, 4).
Enrolled patients completed a survey on their reasons for nonuse of anticoagulation, and their treating physician conducted a review of their care.
The primary outcomes were patient and physician willingness for anticoagulation; its appropriateness after review by a panel of four cardiologists; and anticoagulation use at 1 year compared with similar patients at other PINNACLE Registry centers.
Patient vs. physician views on oral anticoagulation
Overall, 70% of patients reported their treating physician had previously discussed oral anticoagulation for AF.
More than half of patients reported they had taken oral anticoagulation but stopped due to bleeding (17.8%), personal preference (9.1%), no further AF (9.1%) or some other reason (13.7%).
Reasons physicians cited for anticoagulation nonuse or discontinuation included low AF burden or successful rhythm control (34%), patient refusal (33.3%), perceived low risk for stroke (25.2%), fall risk (21.4%) and high bleeding risk (20.4%).
After rereview, 27.1% of treating physicians said they would reconsider prescribing oral anticoagulation compared with 38.1% of patients, according to the study.
After panel review, 79.2% of patients were deemed either appropriate or possibly appropriate for anticoagulation; however, physicians stated they would only reconsider anticoagulation for 21.2% of these individuals, whereas 38.1% of patients agreed to consider taking an oral anticoagulant and 26.4% were neutral on the issue.
At 1-year follow-up, 14.6% of patients in the BOAT-AF cohort were prescribed anticoagulation compared with 14.4% of similar patients at other centers in the PINNACLE Registry, according to the study.
‘Disconnect between patient and physician’
“Even among patients who were centrally reviewed by a physician panel and considered to be appropriate for anticoagulation, less than half of physicians said they would reconsider anticoagulation,” the researchers wrote. “There was a disconnect between patient and physician assessments, where many patients who the physicians thought had refused oral anticoagulation were actually open to anticoagulation when asked directly in the survey. ... Our data emphasize the need to revisit any prior decision against oral anticoagulation and to use shared decision-making between patient and physician to arrive at an optimal treatment plan.”
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