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Why do clinicians withhold anticoagulation in patients with atrial fibrillation and CHA2DS2VASc score of 2 or higher?
Authors : DM Siegal (Hamilton,CA), F Verbrugge (Leuven,BE), AC Martin (Paris,FR), A Fiarresga (Lisboa,PT), J Camm (London,GB), K Pieper (Durham,US), KAA Fox (Edinburgh,GB), JP Bassand (Besançon,FR), S Haas (Munich,DE), SZ Goldhaber (Boston,US), AK Kakkar (London,GB)
D.M. Siegal1
,
F. Verbrugge2
,
A.C. Martin3
,
A. Fiarresga4
,
J. Camm5
,
K. Pieper6
,
K.A.A. Fox7
,
J.P. Bassand8
,
S. Haas9
,
S.Z. Goldhaber10
,
A.K. Kakkar11
,
1McMaster University, Dept. of Medicine - Hamilton - Canada
,
2University Hospitals (UZ) Leuven, Dept. of Cardiovascular Medicine - Leuven - Belgium
,
3Hôpital d'Instruction des Armées Percy - Paris - France
,
4Hospital de Santa Marta, Centro Hospitalar de Lisboa Central - Lisboa - Portugal
,
5St George's University of London - London - United Kingdom
,
6Duke Clinical Research Institute - Durham - United States of America
,
7University of Edinburgh, Centre for Cardiovascular Science - Edinburgh - United Kingdom
,
8University of Besançon, Dept. of Cardiology - Besançon - France
,
9Technical University of Munich, Dept. of Medicine - Munich - Germany
,
10Brigham and Women's Hospital, Dept. of Medicine - Boston - United States of America
,
11University College London - London - United Kingdom
,
Background: Guidelines recommend oral anticoagulant (OAC) therapy to prevent stroke and systemic embolism for atrial fibrillation (AF) patients at high thromboembolic risk (CHA2DS2-VASc score ≥2). Approximately 30–40% of eligible patients do not receive OAC therapy. The reasons for guideline non-adherence are unclear.
Purpose: To identify patient characteristics associated with non-use of OAC for AF.
Methods: The Global Anticoagulant Registry in the FIELD (GARFIELD-AF) registry is a prospective multicentre study of patients with newly diagnosed AF and ≥1 additional risk factors for stroke. We analysed GARFIELD-AF data for patient characteristics associated with non-use of OAC for patients with CHA2DS2-VASc score ≥2 using logistic regression. The rates per 100 person-years (%/y) of all-cause mortality, cardiovascular mortality, stroke or systemic embolism (SSE) and major bleeding were also compared between patients receiving and those not receiving OAC. P-values less than 0.05 were considered statistically significant. To explore patient characteristics that influence decision-making, we distributed a web-based survey to physicians treating AF in Belgium, Canada, France, and Portugal.
Results: In GARFIELD-AF 42,471 (82.9%) had a CHA2DS2-VASc score ≥2 and 12,884 (30.3%) of them did not receive OAC therapy. Use of antiplatelet therapy (OR 15.0, 95% CI 14.1–15.8) and a history of bleeding (OR 2.52, 95% CI 2.18–2.92) were the strongest predictors of withholding OAC. Patients without OAC had an increased incidence of all-cause mortality (5.3 vs. 3.9%/y, p<0.001) and cardiovascular mortality (1.8 vs. 1.4%/y, p<0.001) and SSE (1.6 vs. 1.1%/y, p<0.001). Table 1 shows the most frequently reported characteristics leading to a preference to withhold OAC among 266 survey respondents.
Conclusions: Antiplatelet therapy and history of bleeding were the strongest predictors of OAC non-use in AF patients with CHA2DS2-VASc score ≥2 in the GARFIELD-AF registry. Major/critical site bleeding and cirrhosis may also influence non-use of OAC by some physicians. Guideline-based treatment with OAC was associated with better outcomes. Understanding decision-making may improve OAC prescription rates and outcomes in AF.
Table 1. Survey Results
Characteristic
Respondents reporting a preference to withhold OAC, Total n=266 (%)
Critical site bleeding
87
Major bleeding (requiring hospitalization, intervention, medical management)
In line with the ESC mission, newly presented content is made available to all for a limited time (4 months for ESC Congress, 3 months for other events). ESC Professional Members, Association Members (Ivory & above) benefit from year-round access to all the resources from their respective Association, and to all content from previous years. Fellows of the ESC (FESC), and Professionals in training or under 40 years old, who subscribed to a Young Combined Membership package benefit from access to all ESC 365 content from all events, all editions, all year long. Find out more about ESC Memberships here.
