Variation in Anticoagulant Recommendations by the Guidelines and Decision Tools among Patients with Atrial Fibrillation

Anand Shewale,Chenghui Li,Bradley Martin,David Nelsen,Jill Johnson

doi:10.3390/healthcare3010130

Anand Shewale, Chenghui Li + Show 3 more

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https://doi.org/10.3390/healthcare3010130

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Journal: Healthcare	Publication Date: Mar 5, 2015
Citations: 35	License type: CC BY 4.0

Affiliation: University of Arkansas for Medical Sciences

Abstract

Published atrial fibrillation (AF) guidelines and decision tools offer oral anticoagulant (OAC) recommendations; however, they consider stroke and bleeding risk differently. The aims of our study are: (i) to compare the variation in OAC recommendations by the 2012 American College of Chest Physicians guidelines, the 2012 European Society of Cardiology (ESC) guidelines, the 2014 American Heart Association (AHA) guidelines and two published decision tools by Casciano and LaHaye; (ii) to compare the concordance with actual OAC use in the overall study population and the population stratified by stroke/bleed risk. A cross-sectional study using the 2001–2013 Lifelink claims data was used to contrast the treatment recommendations by these decision aids. CHA2DS2-VASc and HAS-BLED algorithms were used to stratify 15,129 AF patients into nine stroke/bleed risk groups to study the variation in treatment recommendations and concordance with actual OAC use/non-use. The AHA guidelines which were set to recommend OAC when CHA2DS2-VASc = 1 recommended OAC most often (86.30%) and the LaHaye tool recommended OAC the least often (14.91%). OAC treatment recommendations varied considerably when stroke risk was moderate or high (CHA2DS2-VASc > 0). Actual OAC use/non-use was highly discordant (>40%) with all of the guidelines or decision tools reflecting substantial opportunities to improve AF OAC decisions.

Highlights

Atrial fibrillation (AF) is the most common type of cardiac arrhythmia which increases the risk of ischemic stroke 4 to 5 fold [1]
The proportion of patients with moderate to high HAS-BLED score was higher among the oral anticoagulant (OAC) exposed group compared to the OAC unexposed group (84.89% vs. 76.79%, p value < 001)
(0 to 9) which is different than the European Society of Cardiology (ESC) guidelines in which we only considered bleed risk to be a factor when CHA2DS2VASc = 1, which led to a 70.98% difference in OAC recommendations

Summary

Introduction

Atrial fibrillation (AF) is the most common type of cardiac arrhythmia which increases the risk of ischemic stroke 4 to 5 fold [1]. Oral anticoagulants (OACs) are more effective than aspirin in reducing the stroke risk, but are associated with an increased bleeding risk. Anticoagulant recommendations depend upon balancing the expected benefit of stroke risk reduction against the increased harm from bleeding in patients with different factors that are prognostic for strokes and bleeding [2]. Several studies have shown that anticoagulant prescribing is often poorly related to patient stroke risk with underuse of anticoagulants in AF being more common, especially among elevated stroke risk patients [3,4,5]. Oral anticoagulants are underused but are overused in the patients with low stroke risk [8]

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