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Why do clinicians prescribe oral anticoagulation in patients with atrial fibrillation despite a low CHA2DS2-VASc score?

Session Poster Session 5

Speaker Frederik Hendrik Verbrugge

Congress : ESC Congress

  • Topic : arrhythmias and device therapy
  • Sub-topic : Oral Anticoagulation
  • Session type : Poster Session
  • FP Number : P4800

Authors : FH Verbrugge (Leuven,BE), A-C Martin (Clamart,FR), D Siegal (Hamilton,CA), A Fiarresga (Lisboa,PT), K Pieper (Durham,US), J Camm (London,GB), KAA Fox (Edinburgh,GB), J-P Bassand (Besançon,FR), S Haas (Munich,DE), SZ Goldhaber (Boston,US), AK Kakkar (London,GB)

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Authors:
F.H. Verbrugge1 , A.-C. Martin2 , D. Siegal3 , A. Fiarresga4 , K. Pieper5 , J. Camm6 , K.A.A. Fox7 , J.-P. Bassand8 , S. Haas9 , S.Z. Goldhaber10 , A.K. Kakkar11 , 1University Hospitals (UZ) Leuven, Cardiovascular Diseases - Leuven - Belgium , 2Percy Military Hospital, Cardiologie - Clamart - France , 3Population Health Research Institute, Medicine - Hamilton - Canada , 4Hospital de Santa Marta, Cardiology - Lisboa - Portugal , 5Duke Clinical Research Institute - Durham - United States of America , 6St George's University of London, Cardiology - London - United Kingdom , 7University of Edinburgh, Centre for Cardiovascular Science - Edinburgh - United Kingdom , 8University of Besançon, Cardiology - Besançon - France , 9Technical University of Munich, Medicine - Munich - Germany , 10Brigham and Women's Hospital, Medicine - Boston - United States of America , 11University College London - London - United Kingdom ,

On behalf: Thrombosis Academy for Learning Education and Networking Training (TALENT)

Citation:
European Heart Journal ( 2018 ) 39 ( Supplement ), 1007-1008

Background: Oral anticoagulant (OAC) therapy is prescribed in approximately 40% of patients with atrial fibrillation (AF) and low thromboembolic risk (CHA2DS2-VASc score 0 [male] or 1 [female]). Guidelines recommend against OAC therapy in such patients because the annual thromboembolic risk (<1%) is outweighed by bleeding.

Purpose: To identify patient characteristics and reasons for clinicians to prescribe OAC therapy in AF despite a low thromboembolic risk.

Methods: Patient characteristics associated with OAC prescription were assessed in the subgroup with a low CHA2DS2-VASc score from the GARFIELD-AF registry. All-cause mortality, ischemic stroke or systemic embolism, and major bleeding were compared according to OAC status. Next, a diverse group of clinicians involved in AF care were questioned through a web-based survey. Items included factors, not included in the CHA2DS2-VASc score, that may influence prescription of OAC therapy in AF.

Results: In the GARFIELD-AF registry (n=52,014), 2,123 patients had a low CHA2DS2-VASc score. OAC therapy was prescribed in 950 (45%). Permanent [OR (95%) = 2.32 (1.52–3.56)] or persistent AF [OR (95%) = 3.08 (2.17–4.38)] and increasing age <65 years [OR (95%) = 1.34 (1.20–1.50)] demonstrated a significant increase in odds for OAC use, while concomitant antiplatelet therapy [OR (95%) = 0.083 (0.065–0.105)] and female gender [OR (95%) = 0.714 (0.561–0.907)] showed a significant decrease in odds. Crude event rates were low for those with as well as without OAC therapy: all-cause mortality (14 versus 20), ischemic stroke or systemic embolism (6 versus 5), and major bleeding (4 versus 3). When clinicians (n=229) were questioned about decision-making regarding OAC therapy for AF patients with low thromboembolic risk, an enlarged left atrium or spontaneous echo contrast was the most frequently cited reason (reach: 59.8%). Adding cardioversion or ablation procedures, rheumatic heart disease, and subjective fear of stroke by the patient increased the reach to 83.8% (Table 1).

Conclusions: There is a discrepancy between patient characteristics predicting OAC use in AF patients with a low CHA2DS2-VASc score and factors reported by clinicians influencing their decision-making.

Table 1
Risk factor combinationsReach, n (%)
Enlarged left atrium or spontaneous echo contrast137 (59.8)
Previous + cardioversion or ablation procedures165 (72.1)
Previous + rheumatic heart disease183 (79.9)
Previous + subjective fear of stroke by the patient192 (83.8)
Reach is the number (percentage) of respondents reporting some or strong preference to prescribe oral anticoagulation therapy when the risk factor combination is present.

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