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Why do clinicians withhold anticoagulation in patients with atrial fibrillation and CHA2DS2VASc score of 2 or higher?

Session Poster Session 4

Speaker Assistant Professor Deborah Michelle Siegal

Event : ESC Congress 2018

  • Topic : arrhythmias and device therapy
  • Sub-topic : Oral Anticoagulation
  • Session type : Poster Session

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)

Authors:
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 ,

On behalf: GARFIELD-AF Investigators

Citation:
European Heart Journal ( 2018 ) 39 ( Supplement ), 821

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
CharacteristicRespondents reporting a preference to withhold OAC, Total n=266 (%)
Critical site bleeding87
Major bleeding (requiring hospitalization, intervention, medical management)76
Cirrhosis53
CKD (eGFR <15 mL/min or dialysis)47
Suspected heavy/binge drinking38
CKD=chronic kidney disease, eGFR=estimated glomerular filtration rate.

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