Oral Anticoagulants for Afib: Which Decision Aids Work Best?

Health care providers walk a tightrope when they employ oral anticoagulants in the treatment of atrial fibrillation.

Use too much medication, and bleeding risk increases. Use too little medication, and stroke risk rises.

Multiple decision aids exist to assist providers with this delicate balancing act and parse out the relative risk of these opposite adverse events. However, these tools vary slightly in their recommendations, and until now, no study has compared their predictive ability.

The Journal of Stroke and Cardiovascular Diseases has published a study scrutinizing the net clinical benefit when oral anticoagulants are used concordantly and discordantly with available decision aids.

The authors compared 2 decision tools developed by Casciano et al. and LaHaye et al. with the 3 atrial fibrillation guidelines: the 2012 American College of Chest Physicians’ Evidence-Based Clinical Practice (CHEST) guidelines, the 2012 European Society of Cardiology (ESC) guidelines, and the 2014 American Heart Association (AHA) guidelines.

The authors drew data from the PharMetrics Lifelink database that included inpatient claims, outpatient claims, prescription claims, and eligibility data about commercially insured patients from 2001 through 2013.

Decision aids using CHADS₂ scores generally produced a greater net clinical benefit than CHADS₂-VASc score-based algorithms.

The LaHaye tool based on CHADS₂-VASc aggressively reduced the risk of stroke but at the expense of increased bleeding risk.

The CHEST guidelines demonstrated the superiority of CHADS₂-based algorithms and produced the best outcomes. This guideline employed the older CHADS₂ score system due to limited evidence of efficacy for CHADS₂-VASc.

The novel oral anticoagulants were not available for most of the data set’s time period, so a comparison between warfarin and these other drugs is not possible.

Almost all of the decision aids, except for the LaHaye tool, had a positive net clinical benefit.

Decision aids that incorporated bleeding risk into their algorithms performed better than those that only sought reduced stroke risk.

“Our study findings are important for building upon the evidence base demonstrating implications of guideline/decision tool recommendations in real-world settings, particularly highlighting that adherence to different decision aid recommendations could result in improved outcomes,” the study authors concluded.

They warned that their findings should not be implemented in direct practice, as larger epidemiological studies are needed to verify them prior to incorporation into everyday patient decisions.