Addressing barriers to optimal oral anticoagulation use and persistence among patients with atrial fibrillation: Proceedings, Washington, DC, December 3-4, 2012

Abstract

Approximately half of patients with atrial fibrillation (AF) and with risk factors for stroke are not treated with oral anticoagulation (OAC), whether it be with vitamin K antagonists (VKAs) or novel OACs (NOACs); and of those treated, many discontinue treatment. Leaders from academia, government, industry, and professional societies convened in Washington, DC, on December 3–4, 2012, to identify barriers to optimal OAC use and adherence and to generate potential solutions. Participants identified a broad range of barriers, including knowledge gaps about stroke risk and the relative risks and benefits of anticoagulant therapies; lack of awareness regarding the potential use of NOAC agents for VKA-unsuitable patients; lack of recognition of expanded eligibility for OAC; lack of availability of reversal agents and the difficulty of anticoagulant effect monitoring for the NOACs; concerns with the bleeding risk of anticoagulant therapy, especially with the NOACs and particularly in the setting of dual antiplatelet therapy; suboptimal time in therapeutic range for VKA; and costs and insurance coverage. Proposed solutions were to increase awareness of stroke risk as well as the benefits and risks of OAC use via educational initiatives and feedback mechanisms, to develop and disseminate shared decision-making tools, to better define the role of VKA in the current therapeutic era including eligibility and ineligibility for different anticoagulant therapies, to identify NOAC reversal agents and monitoring strategies and make knowledge regarding their use publicly available, to minimize the duration of dual antiplatelet therapy and concomitant OAC where possible, to improve time in therapeutic range for VKA, to leverage observational datasets to refine understanding of OAC use and outcomes in general practice, and to better align health system incentives.

Real-practice thromboprophylaxis in atrial fibrillation

“…Of total of VKA-treated patients, 1,820, ca 37 % patients discontinued the anticoagulant treatment within 6 months. This rate of discontinuation is similar to what has been reported in the literature, where discontinuation rate ranges from 20 to more than 50 % (15,24).…”

“…In particular, anticoagulant treatment is highly recommended for patients with CHADS2 or CHA2DS2-VASC scores ≥ 2. However, even if oral anticoagulation is effective in preventing strokes due to AF (12), there is extensive evidence suggesting that this therapy remains underused (4,10,(13)(14)(15). Despite, the data from the literature is clearly showing that the efficacy of antiplatelet agents in thromboembolic prevention is significantly lower than that of oral anticoagulant therapy (14).…”

“…In particular, female sex, increasing age (≥ 75), antiplatelet drugs and history of major bleeding, resulted negatively to the possibility of receiving VKA therapy. Also, different studies have identified inadequate risk stratification; the advanced age of the patient, bleeding and falling risk, and the difficulties of warfarin management, including adverse events and patient compliance, as potential barriers to an appropriate treatment prescription (13,15,23). Of total of VKA-treated patients, 1,820, ca 37 % patients discontinued the anticoagulant treatment within 6 months.…”

Oral anticoagulant therapy for older patients with atrial fibrillation: a review of current evidence

“…General considerations on oral anticoagulant therapy under-prescription in older patients with atrial fibrillation OAT is still widely underused in older subjects with AF: studies consistently demonstrate that less than half of octogenarians are currently treated with OAT [1,[4][5][6][7][8][9][10][11]24,[35][36][37][38]. Although temporary or permanent contraindications may partially account for this under-prescription [6,7], advanced age and short life-expectancy, fear of bleeding, perceived harm greater than benefit, poor health and geriatric syndromes appear to be the most common reasons why physicians withhold anticoagulants [4][5][6][7]14,[34][35][36][37]. It seems plausible that this persisting therapeutic reluctance relies on intimate skepticism that the clinical benefits demonstrated in randomized trials and observational studies may not be observed at the same extent in more vulnerable older patients.…”

“…Furthermore, additional barriers to optimal use of anticoagulants include knowledge gaps about stroke risk extent and OAT benefit/harm balance, lack of recognition of expanded eligibility for OAT and DOACs in the elderly and in VKAs-unsuitable patients, and concerns about bleeding risk with novel DOACs [14].…”