Variation in Anticoagulant Recommendations by the Guidelines and Decision Tools among Patients with Atrial Fibrillation

Abstract

Published atrial fibrillation (AF) guidelines and decision tools offer oral anticoagulant (OAC) recommendations; however, they consider stroke and bleeding risk differently. The aims of our study are: (i) to compare the variation in OAC recommendations by the 2012 American College of Chest Physicians guidelines, the 2012 European Society of Cardiology (ESC) guidelines, the 2014 American Heart Association (AHA) guidelines and two published decision tools by Casciano and LaHaye; (ii) to compare the concordance with actual OAC use in the overall study population and the population stratified by stroke/bleed risk. A cross-sectional study using the 2001-2013 Lifelink claims data was used to contrast the treatment recommendations by these decision aids. CHA₂DS₂-VASc and HAS-BLED algorithms were used to stratify 15,129 AF patients into nine stroke/bleed risk groups to study the variation in treatment recommendations and concordance with actual OAC use/non-use. The AHA guidelines which were set to recommend OAC when CHA₂DS₂-VASc = 1 recommended OAC most often (86.30%) and the LaHaye tool recommended OAC the least often (14.91%). OAC treatment recommendations varied considerably when stroke risk was moderate or high (CHA₂DS₂-VASc > 0). Actual OAC use/non-use was highly discordant (>40%) with all of the guidelines or decision tools reflecting substantial opportunities to improve AF OAC decisions.

Keywords: atrial fibrillation; decision tools; guidelines; oral anticoagulants; overuse; recommendations; underuse; warfarin.

Figure 1

Actual OAC use: Number of patients that received and did not receive OAC stratified by stroke and bleeding risk scores. * Data shown are the number of patients who were exposed to OAC/non-OAC within 90 days after index diagnosis. Low stroke: CHA₂DS₂-VASc score = 0, Med stroke: CHA₂DS₂-VASc score = 1, high stroke: CHA₂DS₂-VASc score ≥ 2, Low bleed: HAS BLED score = 0, Med bleed: HAS BLED score = 1 or 2, high bleed: HAS BLED score ≥ 3).