Using an Atrial Fibrillation Decision Support Tool for Thromboprophylaxis in Atrial Fibrillation: Effect of Sex and Age

Abstract

Objectives Among patients with atrial fibrillation (AF), female gender has been associated with an increased risk of stroke and a decreased likelihood of receiving oral anticoagulant therapy (OAT). The elderly are less likely to receive OAT due to concerns about falling and frailty. This study assessed the appropriateness of OAT among women and the elderly, looking for patterns of under-treatment or unnecessary treatment. Design Retrospective cohort study. Setting Primary care practices of an academic healthcare system. Participants 1,585 adults with non-valvular AF seen between March 2013 and February 2014. Intervention Treatment recommendations were made by an Atrial Fibrillation Decision Support Tool (AFDST) based on projections for quality-adjusted life expectancy calculated by a decision analytic model that integrates patient-specific risk factors for stroke and hemorrhage. Results Treatment was discordant from AFDST-recommended treatment in 45% (326/725) of women and in 39% (338/860) of men (p = 0.02). While current treatment was discordant from recommended in 35% (89/258) of the elderly (age ≥ 85), and in 43% (575/1328) of patients < 85 years of age (p = 0.01) a large proportion of under-treated elderly patients were receiving aspirin as the sole antithrombotic agent. Conclusion Physicians should understand that female gender is a significant risk factor for AF-related stroke and incorporate this into decision-making about thromboprophylaxis. By treating older patients with aspirin instead of oral anticoagulant therapy we are exposing them to a significant risk of bleeding with little to no benefit relative to reduction of AF-related stroke risk.

Mobile Health Technology for Atrial Fibrillation Management Integrating Decision Support, Education, and Patient Involvement: mAF App Trial

“…21 Another option is the Atrial Fibrillation Decision Support Tool, which is a patient-specific decision analytic model composed of a 29-state Markov simulation, using information from the Electronic Health Record to integrate patient-specific risk factors for stroke and hemorrhage in its calculations. 22 However, the intervention with the Atrial Fibrillation Decision Support Tool did not result in significant improvements in discordant antithrombotic therapy in a population with atrial fibrillation. 23 Other Apps have been developed to provide stroke and bleeding risk calculations; for example, the Computerised Antithrombotic Risk Assessment Tool Version 2 could calculate the CHADS2 (Congestive heart failure, Hypertension, Age over 75 years, Diabetes Mellitus, Stroke), CHA2DS2-VASc, HAS-BLED, and HEMORR2-HAGES (Hepatic or renal disease, Ethanol abuse, Malignancy, Older age, Reduced platelet count or function, Rebleeding risk, Hypertension, Anemia, Genetic factors, Excessive fall risk, Stroke) scores.…”

Real‐World Clinical Characteristics and Treatment Patterns of Individuals Aged 80 and Older with Nonvalvular Atrial Fibrillation: Results from the ReAl‐life Multicenter Survey Evaluating Stroke Study

“…13 Although elderly adults with AF are more likely to benefit from OAC than younger individuals, 14 OACs may be underused in elderly adults. [15][16][17][18] Most clinical trials have not specifically addressed very elderly adults, and most study subjects are not representative of those aged 80 and older. Although current data from studies targeting older adults indicate that proper treatment planning and specific geriatric assessment can result in a safe treatment of older adults, 19,20 the use of OACs and adherence to guidelines in elderly adults varies in national and multinational registries.…”

“…Age is one of the strongest risk factors for ischemic stroke in individuals with AF, and the current data support the use of anticoagulants in older adults, as found in the Birmingham Atrial Fibrillation Treatment of the Aged Study, the NOAC trials, and analyses in elderly adults in the United States . Although elderly adults with AF are more likely to benefit from OAC than younger individuals, OACs may be underused in elderly adults . Most clinical trials have not specifically addressed very elderly adults, and most study subjects are not representative of those aged 80 and older.…”

Antiplatelet Therapy of Atrial Fibrillation: Focus on the Elderly

“…По мнению авторов большого (n=1585) обсерва-ционного исследования применение АСК вместо ан-тикоагулянтов у очень пожилых людей (≥85 лет) под-вергает их значительному риску развития кровотечения при минимальной пользе или отсутствии таковой с точ-ки зрения профилактики инсульта [35], а анализ дан-ных Шведского национального регистра пациентов позволяет предположить, что гериатрические пациен-ты, которые не подходят для терапии пероральными ан-тикоагулянтами, могут получить большую пользу от от-сутствия антитромботической терапии, чем от приме-нения АСК [15].…”