Study Finds Strong Disconnect Regarding Use of Anticoagulation Medication Between Physician, Patient

Patients with nonvalvular atrial fibrillation (AF) not on an anticoagulant appear more willing to consider anticoagulation than their physicians, according to the results of a new study published in JAMA Network Open. More research and education are needed to help guide best practices for physician, according to the investigators.

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“We identified a disconnect between the perceptions of physicians and patients and the treatment decision for anticoagulation,” the study authors wrote. “…Among patients with AF who are not anticoagulated, many appear appropriate for anticoagulation, while only a small percentage were actually treated over the next year.”

Oral anticoagulation can reduce thromboembolic events in patients with nonvalvular AF, but many patients with AF and at high risk of stroke do not use it. This issue was previously highlighted in the American College of Cardiology’s (ACC) Practice Innovation and Clinical Excellence Registry (PINNACLE Registry), which found that 40% of patients do not receive treatment. Other past assessments suggest that physicians are more risk averse to oral anticoagulation because of the risk of stroke, but few studies have evaluated a patient’s perception.

Investigators conducted the Benchmarking an Oral Anticoagulant Treatment Rate in Patients with Nonvalvular Atrial Fibrillation (BOAT-AF) study to understand both the patient and physician’s perception on the risks (primarily stroke) and benefits of using an anticoagulant. The study aims to develop a greater understanding about the underuse of anticoagulation in patients with AF.

The trial included 817 patients with AF and a median age of 76 years who completed a survey and then went to their physician for treatment and a clinical review of care.

The 5 most common reasons that a physician did not prescribe anticoagulation include:

• 34.0% of patients had low AF burden with anticoagulation/had successful rhythm control.
• 33.3% refused treatment.
• 25.2% had a perceived low risk of stroke.
• 21.4% were at risk of falling.
• 20.4% had a high bleeding risk.

The results show that 50% and 60% of patients feared stroke and bleeding risk, respectively, but 65% were open to reconsidering anticoagulation medication. Only 27% of physicians would reconsider oral anticoagulation among patients open to taking it, but overall, 16.9% of physicians were open to oral anticoagulation. The data further revealed that physicians follow a practice pattern of not prescribing an anticoagulant to patients who have had successful AF ablation, and it is a decision that may be based on low-quality evidence.

The study includes some limitations, including that it was observational with a moderate sample size. In addition, data were collected in 2018 and attitudes may differ today. Further, the assessment was not validated, left atrial appendage occlusion, or cost issues were not addressed, and the cohort included few patients from minority populations.

“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,” the study authors wrote.

Reference

Cannon C, Kim J, Lee J, et al. Patients and Their Physician’s Perspectives About Oral Anticoagulation in Patients With Atrial Fibrillation Not Receiving an Anticoagulant. JAMA Netw Open. 2023;6(4):e239638. doi:10.1001/jamanetworkopen.2023.9638