Researchers find "disconnect" between AF patients and their doctors when it came to oral anticoagulation

According to results of a new prospective cohort research, patients with nonvalvular atrial fibrillation (AF) who are not already taking oral anticoagulation (OAC) are more likely to consider starting the medication than their doctors are.

There has been a "disconnect" between patients with AF and their doctors about oral anticoagulation.

The authors of the study stress that any prior decision against OAC therapy should be reconsidered between clinician and patient "in a shared decision-making manner" given that about 40% of eligible patients are not receiving OAC and that the proportion has remained stable despite widespread availability of nonvitamin K antagonists.

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 stated in JAMA Network Open that there is little published evidence on the underuse of anticoagulation in people with AF. According to a few studies, doctors are more worried with the danger of bleeding than the risk of stroke, which suggests that the problem may be related to patient and clinician prescribing characteristics. Very few studies have looked at patient preferences, and even fewer, if any, have looked at patients and doctors simultaneously.

To better understand why more patients with AF are not taking OAC, Cannon and colleagues conducted the Benchmarking an Oral Anticoagulant Treatment Rate in Patients with Nonvalvular Atrial Fibrillation (BOAT-AF) study. They assessed how patients and clinicians perceived the risk of stroke and the advantages and disadvantages of anticoagulation.

The research accessed 19 locations from the PINNACLE Registry of the American College of Cardiology for individuals under the age of 18 who had nonvalvular AF with a CHA2DS2-VASc score of less than two and were not getting anticoagulation between January 2017 and May 2018. A doctor office visit within the last 18 months was a requirement for eligibility, as well as the ability to complete the research survey. Data was gathered by the investigators between January 18, 2017, and September 30, 2019, and was then examined between April 2022, and March 2023. A second survey was provided to each patient's doctor, who also undertook a clinical assessment of the patient's treatment for every patient who completed and returned the research survey.

A panel of four cardiologists made the determination on the patient's desire to receive anticoagulant therapy and the need of it. After a year, a reassessment of study participants' anticoagulant use was conducted.

The final analytic cohort included 817 individuals. The group's median age was 76 years, 45.2% of the participants were female, and the median CHA2DS2-VASc score was 4.

RESULTS

Physicians gave the following top 5 reasons—which were not mutually exclusive—for why their patients did not take anticoagulation:

Successful rhythm control treatment or low AF load (34.0%) refusal by a patient (33.3%) perceived as having a low risk of stroke (25,2%) Risk of falls (21.4%) Significant bleeding risk (20.4%)

Following reexamination, 27.1% of doctors stated they would think twice before prescribing OAC, while 38.1% of patients strongly agreed with the statement that they would think about the treatment. In this group, there were 24.6% of patients whose doctor had noted a treatment rejection.

Physicians would only revisit OAC for 21.2% of the 79.2% of patients who were determined by a 4-cardiologist review panel to be "appropriate" or "may be appropriate" for anticoagulation. In comparison, 64.5% of patients were either in favor of commencing OAC (38.1%) or were ambivalent about it (27.3%).

One year later, when Cannon and colleagues examined the course of therapy, 14.6% of participants in the BOAT-AF trial had been given OAC. 11.7% of 393 participants who had never before been administered OAC were still on the medication at the time of the follow-up. There were 424 patients who had previously had OAC but were not taking it at the time of enrollment; 17% of them were still receiving treatment at the time of the follow-up. And 1 year after enrollment, 16% of the 583 participants who had been taking only aspirin were still receiving OAC.

The authors underline in the study's Discussion that, despite worry about stroke (50%) and fear of bleeding risk (60%) roughly 65% of patients were willing to reconsidering OAC treatment. However, only 27% of their attending physicians would change their minds. Less than half of doctors would change their minds even for patients who were determined to be suitable for OAC by an expert panel. The authors provide a variety of explanations for the discrepancy in optimum patient selection and emphasize "a need for additional education on guideline recommendations."

The researchers also drew attention to a "disconnect" between clinician and patient evaluations after discovering that many patients whose doctors believed had rejected OAC actually indicated on the survey that they were receptive to the therapy.

The statistics highlight the necessity to reconsider any past choice against oral anticoagulation and to employ patient and doctor shared decision-making to come up with an ideal treatment strategy, they found.

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