The CHADS2 and CHA2DS2-VASc scores have been developed to help estimate the risk of thromboembolism in patients with AF based on specific risk factors. “Current guidelines call for using these tools to determine the absolute risk of stroke and help clinicians decide if prescription oral anticoagulants (OACs) are warranted to reduce stroke risk,” says Jonathan Hsu, MD, MAS.
Addressing the Issue
Despite the well-established association of AF with stroke, several large-scale studies indicate that OAC prescription rates are low among at-risk candidates. “Although OACs can benefit patients with AF, little is known about the extent to which OAC prescribing occurs in real-world practice to help reduce the risk of stroke,” says Dr. Hsu. To address this research gap, he and his colleagues had a study published in JAMA Cardiology that evaluated the prevalence of OAC prescription by cardiovascular specialists.
For the study, the authors used outpatient data from a large national registry to examine the real-world prevalence of treatment with OACs, antiplatelet therapy only, or no antithrombotic therapy in patients with AF based on CHADS2 and CHA2DS2-VASc scores. The primary outcome was prescription of an OAC with warfarin sodium or a non–vitamin K antagonist OAC. In total, more than 429,000 outpatients with AF were included in the analysis.
Results of the study showed that cardiovascular disease specialists were more likely to prescribe an OAC in patients with more stroke risk factors, based on both the CHADS2 score and the CHA2DS2-VASc score. Each 1-point increase in risk score correlated with a higher likelihood of AF patients receiving an OAC prescription when compared with aspirin-only prescriptions. “However, fewer than 50% of all patients at the highest ranges of stroke risk were prescribed an OAC,” Dr. Hsu says. Overall, only about 45% of patients were prescribed an OAC, approximately 26% received aspirin only, nearly 6% received aspirin plus a thienopyridine, and almost 24% received no antithrombotic therapy at all.
“Our findings bring attention to important gaps in the appropriate treatment of patients with AF who are at the highest risk of stroke,” says Dr. Hsu. “They also highlight the need to use the CHADS2 and CHA2DS2-VASc scores and act upon those results. Future research should aim to understand the reasons behind these gaps in care and insights to improve them.” He adds that the reasons for variations in treatment patterns remain unclear, but may be related to physician and patient concerns about the bleeding risks associated with OACs. Other possible reasons include differences in insurance coverage, socioeconomic status, or exposure to guidelines through educational programs for healthcare professionals who practice in different regions of the country.
Considering the significant variability that was observed among individual practices, Dr. Hsu and colleagues recommend that practices focus on factors that are the least and most compliant with guideline adherence. Such efforts may prove fruitful in efforts to rectify inadequate anticoagulation prescriptions more broadly.
Jonathan Hsu, MD, MAS, FACC, FAHA, FHRS, has indicated to Physician’s Weekly that he has worked as a consultant for St. Jude Medical, Medtronic, Biotronik, Bristol-Myers Squibb, and Janssen Pharmaceuticals and has received grants/research aid from Biosense-Webster and Biotronik.
Readings & Resources (click to view)
Hsu JC, Maddox TM, Kennedy KF, et al. Oral anticoagulant therapy prescription in patients with atrial fibrillation across the spectrum of stroke risk: insights from the NCDR PINNACLE Registry. JAMA Cardiol. 2016;1:55-62. Available at: http://cardiology.jamanetwork.com/article.aspx?articleid=2503083.
Chan PS, Maddox TM, Tang F, Spinler S, Spertus JA. Practice-level variation in warfarin use among outpatients with atrial fibrillation (from the NCDR PINNACLE program). Am J Cardiol. 2011;108:1136-1140.
Lip GY, Laroche C, Dan GA, et al. ‘Real-world’ antithrombotic treatment in atrial fibrillation: the EORP-AF pilot survey. Am J Med. 2014;127:519-529.
Glazer NL, Dublin S, Smith NL, et al. Newly detected atrial fibrillation and compliance with antithrombotic guidelines. Arch Intern Med. 2007;167:246-252.