Daily Dose: Physician and Patient Perspectives on Oral Anticoagulation for AF

Patient Care brings primary care clinicians a lot of medical news every day—it’s easy to miss an important study. The Daily Dose provides a concise summary of one of the website's leading stories you may not have seen.

On April 26, 2023, we reported on a study published in JAMA Network Open that examined why more patients with atrial fibrillation (AF) are not on oral anticoagulation (OAC) by assessing both patient and clinician perceptions about the risk of stroke and the benefits and risks of anticoagulation.

The study

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.

The 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%.

A note from authors

"The findings of this cohort study suggest that patients with AF who are not receiving anticoagulation are more willing to consider anticoagulation than their physicians. These data emphasize the need to revisit any prior decision against anticoagulation in a shared decision-making manner."

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