Lack of concordance between empirical scores and physician assessments of stroke and bleeding risk in atrial fibrillation: results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry

Abstract

Background: Physicians treating patients with atrial fibrillation (AF) must weigh the benefits of anticoagulation in preventing stroke versus the risk of bleeding. Although empirical models have been developed to predict such risks, the degree to which these coincide with clinicians' estimates is unclear.

Methods and results: We examined 10 094 AF patients enrolled in the Outcomes Registry for Better Informed Treatment of AF (ORBIT-AF) registry between June 2010 and August 2011. Empirical stroke and bleeding risks were assessed by using the congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and previous stroke or transient ischemic attack (CHADS2) and Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) scores, respectively. Separately, physicians were asked to categorize their patients' stroke and bleeding risks: low risk (<3%); intermediate risk (3%-6%); and high risk (>6%). Overall, 72% (n=7251) in ORBIT-AF had high-risk CHADS2 scores (≥2). However, only 16% were assessed as high stroke risk by physicians. Although 17% (n=1749) had high ATRIA bleeding risk (score ≥5), only 7% (n=719) were considered so by physicians. The associations between empirical and physician-estimated stroke and bleeding risks were low (weighted Kappa 0.1 and 0.11, respectively). Physicians weighed hypertension, heart failure, and diabetes mellitus less significantly than empirical models in estimating stroke risk; physicians weighted anemia and dialysis less significantly than empirical models when estimating bleeding risks. Anticoagulation use was highest among patients with high stroke risk, assessed by either empirical model or physician estimates. In contrast, physician and empirical estimates of bleeding had limited impact on treatment choice.

Conclusions: There is little agreement between provider-assessed risk and empirical scores in AF. These differences may explain, in part, the current divergence of anticoagulation treatment decisions from guideline recommendations.

Clinical trial registration url: http://www.clinicaltrials.gov. Unique identifier: NCT01165710.

Keywords: atrial fibrillation; hemorrhage; risk assessment; stroke.

Figure 1

Categorization of physician-assigned and empirical risk of stroke (Panel A) and bleeding (Panel B). Figure 1. Factors associated with physician under- or over-estimation of empirical stroke (Panel A) and bleeding (Panel B) risk. NYHA: New York Heart Association; CHF: congestive heart failure; AF: atrial fibrillation; PCI: percutaneous coronary intervention; CABG: coronary artery bypass grafting; EHRA: European Heart Rhythm Association; TIA: transient ischemic attack; CAD: coronary artery disease; eGFR: estimated glomerular filtration rate.

Figure 1

Categorization of physician-assigned and empirical risk of stroke (Panel A) and bleeding (Panel B). Figure 1. Factors associated with physician under- or over-estimation of empirical stroke (Panel A) and bleeding (Panel B) risk. NYHA: New York Heart Association; CHF: congestive heart failure; AF: atrial fibrillation; PCI: percutaneous coronary intervention; CABG: coronary artery bypass grafting; EHRA: European Heart Rhythm Association; TIA: transient ischemic attack; CAD: coronary artery disease; eGFR: estimated glomerular filtration rate.

Figure 2

Rates of OAC use by stroke risk assessments (Panel A) and bleeding risk assessments (Panel B). OAC: oral anticoagulation.