"Disconnect" on Oral Anticoagulation Observed Between Patients with AF and their Physicians

Patients with nonvalvular atrial fibrillation (AF) not receiving oral anticoagulation (OAC) are more willing to consider initiating the treatment than their physicians are, according to findings of a recent prospective cohort study.

Considering that approximately 40% of eligible patients are not receiving OAC and that the proportion has remained steady despite widespread availability of nonvitamin K antagonists, study authors emphasize that any prior decision against OAC therapy should be revisited between clinician and patient “in a shared decision-making manner.”

There is little published research on the underuse of anticoagulation in persons with AF, wrote Christopher Cannon, MD, of the division of cardiovascular medicine at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School, and colleagues in JAMA Network Open. The issue may be linked to both patient and clinician prescribing factors, they added, with a handful of studies finding the clinicians concerned for risk of bleeding vs risk of stroke. Very few studies have assessed patient wishes and fewer, if any, have examined patients and physicians concurrently.

Cannon and colleagues conducted the Benchmarking an Oral Anticoagulant Treatment Rate in Patients with Nonvalvular Atrial Fibrillation (BOAT-AF) to better understand why more patients with AF are not on OAC using and assessment of both patient and clinician perceptions about the risk of stroke and the benefits and risks of anticoagulation.

The study tapped 19 sites from the American College of Cardiology’s PINNACLE Registry for patients aged ≥18 years enrolled between January 2017 and May 2018 who had nonvalvular AF with a CHA₂DS₂-VASc score of ≥2 and were not receiving anticoagulation. Eligible patients were required to have had a physician office visit within the prior 18 months and be able to complete the study survey. Investigators collected data from January 18, 2017 to September 30, 2019, and analyzed from April 2022 to March 2023. Physicians for all patients who completed and returned the study survey were sent a separate survey and conducted a clinical review of the patient’s care.

Assessment of willingness for anticoagulation treatment and its appropriateness was adjudicated by a panel of 4 cardiologists. Use of anticoagulation among study participants was reviewed after 1 year.

The final cohort for analysis numbered 817 participants. Median age of the group was 76 years, 45.2% were women and the median CHA₂DS₂-VASc score was 4.

FINDINGS

The top 5 reasons (not mutually exclusive) cited by physicians for the patients not receiving anticoagulation were:

• Low AF burden or successful rhythm control therapy (34.0%)

• Patient refusal (33.3%)

• Perceived low risk of stroke (25.2%)

• Fall risk (21.4%)

• High risk of bleeding (20.4%)

After rereview, 27.1% of physicians said they would reconsider prescribing OAC while 38.1% of patients agreed strongly with the statement that they would consider the treatment. This group included 24.6% whose physician had cited patient refusal of the treatment.

Of the 79.2% patients adjudicated by a 4-cardiologist review panel as "appropriate" or "may be appropriate" for anticoagulation, physicians would reconsider OAC for just 21.2% of them. In contrast, 64.5% of patients would either agree to begin OAC (38.1%) or were neutral to starting the treatment 27.3%.

When Cannon and team reviewed treatment one year later, 14.6% in the BOAT-AF study were prescribed OAC . Of 393 who had never been prescribed OAC before study enrollment, 11.7% were receiving the therapy at follow-up. There were 424 patients who had received OAC in the past but were not taking OAC when they were enrolled; of those, 17% were being treated at follow-up. And, among the 583 participants who had been receiving aspirin only when enrolled, 16% were being treated with OAC 1 year later.

Despite concern about stroke (50%) and fear of bleeding risk (60%) approximately 65% of patients were open to reconsideration of OAC therapy, the authors reemphasize in the study's Discussion. Only 27% of their treating physicians would reconsider, however. Even for patients judged appropriate for OAC by an expert panel, less than half of physicians would reconsider. The authors posit a number of reasons for the divergence related to optimal patient selection and highlight “a need for additional education on guideline recommendations.”

The investigators also highlighted a “disconnect” between clinician and patient assessments, having found that may patients whose physicians thought had refused OAC responded on the survey that they were actually open to the treatment.

“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, they concluded.”

Reference: Cannon CP, Kim JM, Lee JL, et al. Patients and their physician's perspectives about oral anticoagulation in patients wtih atrial fibrillation not receiving an anticoagulant. JAMA Netw Open. 2023;6:e239638. Published online April 24, 2023. doi:10.1001/jamanetworkopen.2023.9638