Revisit Not Prescribing Oral Anticoagulation for Nonvalvular AF

Educational Objectives

Summary

Revisiting the Decision to Not Prescribe Oral Anticoagulation for Patients with Nonvalvular Atrial Fibrillation

Some patients with nonvalvular atrial fibrillation (AF) do not receive oral anticoagulation, although the rate has increased in recent years due to the convenience of direct-acting oral anticoagulants (DOACs) compared with warfarin. In a study online in JAMA Network Open (https://doi.org/10.1001/jamanetworkopen.2023.9638), U.S. researchers identified 817 patients with nonvalvular AF (median age, 76; median CHA₂DS₂-VASc score [https://www.mdcalc.com/calc/801/cha2ds2-vasc-score-atrial-fibrillation-stroke-risk], 4 [minimum score, 2]) who were not receiving oral anticoagulation; in ≈80% of patients, anticoagulation was deemed to be definitely or probably appropriate. Patients and their physicians were surveyed to assess perceptions of risks, benefits, and appropriateness of oral anticoagulation.

In the total cohort of 817 patients, 311 (38%) would have agreed to receive anticoagulants. An additional 216 patients were neutral about anticoagulation. For 272 patients, treating physicians cited patient refusal as the reason for not prescribing anticoagulants, but 67 of those patients said they were willing to receive anticoagulation. In the subgroup of 408 patients deemed most appropriate for anticoagulation, treating physicians said they would be willing to do so in 184 (45%). In the full cohort, both physicians and patients agreed that they would be willing to start anticoagulation in 17% of cases.

Many subtleties in anticoagulation decision making would not be captured in this type of study. Nevertheless, the take-home message is that clinicians should periodically revisit previous decisions not to anticoagulate in cases where anticoagulation is recommended strongly. One caveat: These patients were recruited from a 2018 database, and DOAC use and overall rate of anticoagulation for this indication have increased since then.

Thomas L. Schwenk, MD

Readings

Disclosures

Acknowledgements

CME/CE INFO

Accreditation:

Lecture ID:

JW341023

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Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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