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Clinical Trial
. 2023 Apr 3;6(4):e239638.
doi: 10.1001/jamanetworkopen.2023.9638.

Patients and Their Physician's Perspectives About Oral Anticoagulation in Patients With Atrial Fibrillation Not Receiving an Anticoagulant

Christopher P Cannon  1   2 , Joseph M Kim  1 , Jane J Lee  2 , Julie Sutherland  2 , Ravinder Bachireddy  3 , C Michael Valentine  4 , Steven Hearne  5 , April Trebnick  2 , Sara Jaffer  2 , Sudarshana Datta  2 , Emily Semmel  6 , Fran Thorpe  6 , Gheorghe Doros  2   7 , Matthew A Cavender  2   8 , Matthew R Reynolds  2   9 ; Benchmarking an Oral Anticoagulant Treatment Rate in Patients with Nonvalvular Atrial Fibrillation (BOAT-AF) Investigators and Research Coordinators
Collaborators, Affiliations
Clinical Trial

Patients and Their Physician's Perspectives About Oral Anticoagulation in Patients With Atrial Fibrillation Not Receiving an Anticoagulant

Christopher P Cannon et al. JAMA Netw Open. .

Abstract

Importance: The underuse of oral anticoagulation in patients with nonvalvular atrial fibrillation (AF) is a major issue that is not well understood.

Objective: To understand the lack of anticoagulation by assessing the perceptions of patients with AF who are not receiving anticoagulation and their physician's about the risk of stroke and the benefits and risks of anticoagulation.

Design, setting, and participants: This cohort study included patients with nonvalvular AF and a CHA2DS2-VASc score of 2 or more (calculated as congestive heart failure, hypertension, age 75 years and older, diabetes, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, and sex category) who were not receiving anticoagulation and were enrolled from 19 sites within the National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence Registry (PINNACLE Registry) between January 18, 2017, and May 7, 2018. Data were collected from January 18, 2017, to September 30, 2019, and analyzed from April 2022 to March 2023.

Exposure: Each patient enrolled in the study completed a survey, and their treating physician then conducted a clinical review of their care.

Main outcomes and measures: Assessment of willingness for anticoagulation treatment and its appropriateness after central review by a panel of 4 cardiologists. Use of anticoagulation at 1 year follow-up was compared vs similar patients at other centers in the PINNACLE Registry.

Results: Of the 817 patients enrolled, the median (IQR) age was 76.0 (69.0-83.0) years, 369 (45.2%) were women, and the median (IQR) CHA2DS2-VASc score was 4.0 (3.0-6.0). The top 5 reasons physicians cited for no anticoagulation were low AF burden or successful rhythm control (278 [34.0%]), patient refusal (272 [33.3%]), perceived low risk of stroke (206 [25.2%]), fall risk (175 [21.4%]), and high bleeding risk (167 [20.4%]). After rereview, 221 physicians (27.1%) would reconsider prescribing oral anticoagulation as compared with 311 patients (38.1%), including 67 (24.6%) whose physician cited patient refusal. Of 647 patients (79.2%) adjudicated as appropriate or may be appropriate for anticoagulation, physicians would reconsider anticoagulation for only 177 patients (21.2%), while 527 patients (64.5%) would either agree to starting anticoagulation (311 [38.1%]) or were neutral (216 [27.3%]) to starting anticoagulation. Upon follow-up, 119 patients (14.6%) in the BOAT-AF study were prescribed anticoagulation, as compared with 55 879 of 387 975 similar patients (14.4%) at other centers in the PINNACLE Registry.

Conclusions and relevance: The findings of this cohort study suggest that patients with AF who are not receiving anticoagulation are more willing to consider anticoagulation than their physicians. These data emphasize the need to revisit any prior decision against anticoagulation in a shared decision-making manner.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Cannon reported receiving grants from Amgen, Better Therapeutics, Boehringer-Ingelheim (BI), Bristol-Myers Squibb (BMS), Daiichi Sankyo, Merck, Novo Nordisk, Pfizer and receiving personal fees from Amryt, Alnylam, Amarin, Amgen, Applied Therapeutics, Ascendia, Biogen, BI, BMS, Eli Lilly, Janssen, Lexicon, Merck, Pfizer, Rhoshan, and Sanofi advisory boards during the conduct of the study. Ms Trebnick reported receiving personal fees from Baim Institute and the American College of Cardiology during the conduct of the study and receiving personal fees from Cerevel Therapeutics and Sage Therapeutics outside the submitted work. Dr Cavender reported receiving personal fees from NovoNordisk, Bayer, Medtronic, Zoll, Merck, and Boston Scientific and receiving grants from Boerhinger Ingleheim, Amgen, CSL Behring, AstraZeneca, and Novartis outside the submitted work. No other disclosures were reported.

Figures

Figure.
Figure.. Differences in the Assessment of Physicians vs Clinical Events Committee (CEC) Recommendation
AC indicates anticoagulation.
See this image and copyright information in PMC

References

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