Barriers to Anticoagulant Use in Atrial Fibrillation

Use of anticoagulants in atrial fibrillation (AF) patients remains unacceptably low, with some estimates showing that only half of patients receive anticoagulants as indicated by current AF treatment guidelines.

In the January 2015 issue of the Journal of the Saudi Heart Association, Ralph J. Verdino, MD, director of the Cardiology Electrophysiology Fellowship Program at the University of Pennsylvania, examined untreated AF in the United States and proposed 3 barriers to anticoagulant treatment in patients at high risk of stroke:

• Some clinicians may be unaware of the conditions that elevate stroke risk and fail to identify patients who would benefit from anticoagulation the most. A key point is that patients with paroxysmal or self-limiting AF are at equally high risk as those in persistent or permanent AF. Using the CHADS2 score routinely to estimate stroke risk is advised.
• Clinicians are prone to overestimate anticoagulants’ bleeding risk, especially in elderly patients. Dr. Verdino suggested that consistent use of the HAS-BLED scoring system can help identify bleeding risk more accurately. He also reminded clinicians that patients are able to evaluate risk-benefit when bleeding risks are explained to them.
• Patients’ reluctance to take anticoagulants has continued even though better drugs are now available. They know—and fear—warfarin’s complications, including drug and food interactions.

Warfarin’s reputation has lingered and influenced patients’ opinions of all anticoagulation therapy. However, sufficient patient education can dispel the myths and emphasize drug safety.

Dr. Verdino noted that anticoagulants prevent AF’s thromboembolic complications extremely well. He promoted the use of the novel anticoagulants (NOACs) as indicated, since the drugs have improved patient adherence and decreased patient concerns. Consideration of NOACs for more patients could increase compliance with AF guidelines, Dr. Verdino concluded.