More than half of patients with atrial fibrillation do not receive guideline-based therapy
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In a rural health system, more than half of patients with atrial fibrillation did not receive treatment consistent with guidance from the American Heart Association, American College of Cardiology and Heart Rhythm Society, data show.
These societies recommend oral anticoagulants for patients with a CHA2DS2-VASc (congestive heart failure, hypertension, age greater than 75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, sex category) score of two or higher, Johan Diaz, a medical student at Geisinger School of Medicine in Scranton, Pennsylvania, and colleagues wrote.
According to the researchers, previous reports showed that 20% to 60% of eligible patients do not receive oral anticoagulants, but there is limited evidence on the risk factors for undertreatment. Therefore, they retrospectively reviewed data from 1,062 patients (47.6% men; median age, 75.5 years) who were diagnosed with atrial fibrillation and then later experienced an ischemic stroke.
Diaz and colleagues reported in the Journal of the Neurological Sciences that 52.4% of the 1,015 patients with CHA2DS2-VASc scores of two or higher were undertreated. In addition, the median time from atrial fibrillation diagnosis to index stroke was significantly lower among undertreated patients (1.9 vs. 3.6 years).
A history of other thromboembolism — excluding stroke, transient ischemic attack and myocardial infarction — (OR = 0.41), the number of patient encounters annually (OR = 0.9), and the median time between atrial fibrillation diagnosis and stroke event (OR = 0.86) were negatively associated with undertreatment, according to the researchers.
A Kaplan-Meier estimator revealed lower 1-year survival probability from the stroke index date among patients who were undertreated (68.6%) vs. those receiving guideline-based treatment (71.2%), but the researchers said this finding was not significant. However, a Cox-hazard model indicated that age (HR = 1.05) and a history of congestive heart failure (HR = 1.88) were associated with an increased risk for mortality.
The findings are “consistent with previous observations,” Ramin Zand, MD, a neurologist at Geisinger Health System in Scranton, Pennsylvania, and a study co-author, told Healio Primary Care. He said that a multidisciplinary approach to care would likely improve atrial fibrillation management.
“Closing the gap requires a collaboration between different specialties, including pharmacists, cardiologists, neurologists, PCPs, etc.,” Zand told Healio Primary Care. “Patients should also be involved in this process” through shared decision-making.
Perspective
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Diaz and colleagues’ finding that a major care gap exists in the delivery of appropriate oral anticoagulation for patients in rural locations with the history of atrial fibrillation at a high risk for stroke is consistent with other studies that have been done in urban centers.
Atrial fibrillation is the most common heart rhythm disorder that we encounter in clinical practice and is a leading cause of stroke. Stroke related to atrial fibrillation is more severe and recurrent than stroke unrelated to atrial fibrillation yet is highly preventable. We have overwhelming evidence that oral anticoagulation is highly effective and safe at preventing stroke and numerous clinical guidelines to help identify individuals with atrial fibrillation who stand to benefit from oral anticoagulation. But we seem to have this care gap where we are not reaching a substantial proportion of atrial fibrillation patients who would benefit from oral anticoagulation in real-world practice.
Each health care encounter provides an opportunity to review for a history of atrial fibrillation. If present, stroke risk should be evaluated, and oral anticoagulation initiation should be discussed with the patient.
We also need to focus our research efforts on interventions targeted at the patient, provider and system level, which may be contributing to oral anticoagulation underutilization. Addressing this care gap is imperative to improving clinical outcomes for individuals with atrial fibrillation.
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