Patients and Their Physician’s Perspectives About Oral Anticoagulation in Patients With Atrial Fibrillation Not Receiving an Anticoagulant
Authors: Cannon Christopher P. , Kim Joseph M. , Lee Jane J. , Sutherland Julie , Bachireddy Ravinder , Valentine C. Michael , Hearne Steven , Trebnick April , Jaffer Sara , Datta Sudarshana , Semmel Emily , Thorpe Fran , Doros Gheorghe , Cavender Matthew A. , Reynolds Matthew R. ,   Benchmarking an Oral Anticoagulant Treatment Rate in Patients with Nonvalvular Atrial Fibrillation (BOAT-AF) Investigators and Research Coordinators, Ehrlich Clifford L. , Ehrlich Sherrie , Ford Tina , Baumann Cindy , Smiley Nasser , Schmidt Shirley , Philip Diane , Daniels Erica , Huth Mark , Eisenhaure Jean Anne , Mancia Laura , Phillips Paul , Maloney Kate , Selker Linda , Zelik Jennifer , Chen Harvey , Beckner Vicki , Pascual Mario , Kaplan Jeffrey , Calvo Monica , Sahul Zakir , Carulli Carol , Thomas Shelton W. , Puckett Laura , Larned Joshua , Bourque Harmony , Compton Steve , Heaney Lori , Fenster Jeffrey , Robinson Cynthia , Aguilar Francisco , Eaton Claudia , Taylor Jeff , McCabe Judith , Ochoa Anthony B. , Douglas Deborah , Byazrova Eteri , Barnett Shamela , Talavera Jason , Abbott Stephanie , Knapp Mickella 
Published: April 2023

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.