Study shows discord between AFib patients, physicians in anticoagulant prescribing

When approached again, about a quarter of patients with atrial fibrillation (AFib) not taking anticoagulants due to physician-cited “patient refusal” said they would consider taking the drugs, according to preliminary research presented at the American Heart Association’s Scientific Sessions in Chicago.

Christopher P. Cannon, MD, with Brigham and Women’s Hospital in Boston, and colleagues sought to understand why so many AFib patients who are indicated for oral anticoagulants (OACs) wind up not taking the medications. The proportion of AFib patients who aren’t taking OACs has hovered around 40 percent, Cannon said.

“For the last five years, we’ve been doing education and X,Y and Z, and it doesn’t change much,” Cannon said. “So the idea here was to say, ‘OK, let’s go to individual patients, figure out why for this patient aren’t they being treated,’ rather than look at the big databases and things. And what we uncover is a lot of people who could be (treated).”

The researchers surveyed 817 patients from the American College of Cardiology’s PINNACLE registry who had nonvalvular AFib and a CHA2DS2-VASc score of at least 2 but weren’t taking blood-thinners. The CHA2DS2-VASc score is used to calculate the likelihood of stroke.

Cannon et al. also asked physicians to review each patient’s case and revisit whether they should be treated with OACs. In 27.1 percent of cases, physicians said they would consider prescribing anticoagulants (5.4 percent aspirin; 21.7 percent a non-vitamin K OAC).

But a panel of four cardiologists reviewed the clinical summaries and patient survey responses for each person and determined OAC was “appropriate” based on guidelines in 49.9 percent of those untreated patients and “may be appropriate” in an additional 29.3 percent.

Among 272 patients for whom patient refusal was cited as the reason for not prescribing OACs, 24.6 percent said they would consider taking an anticoagulant.

“It may be in the chart that they refused last year, so this may be a bit of a time lag or a lack of an actual discussion,” Cannon said. “The lack of ongoing communication on this is something that hopefully can change—open the door to revisiting these questions and then saying, ‘Oh, well actually we could get more people on their appropriate therapy.’”

Patients in the study were 76 years old on average, 45 percent women and had a median CHA2DS2-VASc score of 4.

The top five, non-mutually exclusive reasons physicians cited for not giving them anticoagulants were:

  • low AFib burden/successful rhythm control therapy (34 percent)
  • patient refusal (33.3 percent)
  • perceived low risk of stroke (25.2 percent)
  • fall risk (21.4 percent)
  • high risk of bleeding (20.4 percent)

Notably, more patients reported being “somewhat worried” or “very worried” about bleeding risks (56.2 percent) than stroke risks (46.1 percent).

Cannon suggested shared decision-making tools with information to guide patient and provider discussions could be helpful in increasing the OAC uptake among guideline-recommended patients. For example, having infographics on hand to present estimates of stroke and bleeding risks, based on trial data, may aid providers in explaining the benefit-risk balance of treatment.

“More cross-education seems like the answer,” he said. “If there’s more discussion between the patient and the doctor, they’re going to figure out what’s right for that patient. There won’t be anticoagulants for everybody but a lot more people, if there’s a good discussion, will probably emerge as getting the therapy they probably deserve.”

Cannon presented the abstract in poster form on Nov. 11 at the AHA Scientific Sessions.