Abstract P61: Weighing More than the Risks: Cardiologists' Prescription of Warfarin for Atrial Fibrillation Patients

Abstract

Introduction: Prior research indicates underprescription of warfarin to reduce cardioembolism for eligible atrial fibrillation (AF) patients. Physicians' reluctance to prescribe warfarin for AF patients may be due to perceived increased risk of bleeding or underestimation of stroke risk. However, other factors may influence decisions for warfarin treatment. The purpose of the present study was to develop an in-depth understanding of the cardiologist's decision making process for warfarin anticoagulation and the management of AF. Methods: Qualitative in-depth interviews were conducted with 16 (14 male) cardiologists in a large Midwestern cardiology practice affiliated with an urban hospital. Interviews ranged from 15-35 minutes, culminating in nearly 200 pages of transcripts, and took place in person (n=6) at the hospital or over the telephone (n=10). On average, participants had 13 years of experience in treating patients and all had experience with AF patients who had excessive bleeds and/or strokes within the past 12 months. Interviews were conducted until thematic saturation occurred. Results: Descriptive content analysis found that cardiologists reported consideration of a range of clinical factors: rate and rhythm control, CHADS 2 score, patient co-morbidities, and other prescribed medications in their decision to aggressively treat according to accepted AF treatment guidelines. Additionally, their decision also considered more subjective factors such as the likelihood a patient would comply with a complex therapy and knowledge of patients' drug and alcohol use. “You have to risk profile them individually and go from there” was a recurrent observation. Conclusions: The decision making process used by cardiologists in determining warfarin anticoagulation in the treatment of AF is complex. The cardiologist considers a range of factors when prescribing warfarin beyond the clinical risks including more subjective lifestyle and cultural issues. When these other unmeasurable factors, such as the burden of treatment and lifestyle, are entered into the equation by cardiologists, anticoagulation may be less appealing, regardless of actual clinical risk.