Anticoagulants for atrial fibrillation: Why is the treatment rate so low?

Abstract

Summary:The incidence of atrial fibrillation (AF) is increasing in many countries along with aging demographics. Atrial fibrillation is clearly associated with an increased rate of stroke. Numerous large clinical trials have shown that dose-adjusted warfarin can reduce the stroke rate in these patients, particularly in the elderly, and clear guidelines for the use of anticoagulants in such patients have been published. However, many studies show that treatment rates remain disappointingly low (≤ 50%). Numerous barriers to the use of dose-adjusted warfarin exist, including practical, patient-, physician-, and healthcare system-related barriers. These include the complex pharmacokinetics of warfarin, the need for continuous prothrombin time monitoring and dose adjustments, bleeding events, noncompliance, drug interactions, and increased costs of monitoring and therapy. Possible solutions to this problem are discussed and include improved patient and physician education, the use of anticoagulation clinics, new approaches to AF, and potential treatment improvements through use of newer anticoagulants.

The Clinical Profile and Pathophysiology of Atrial Fibrillation

“…OACs (and their attendant monitoring) account for a large portion of AF-related costs. 148 Nevertheless, despite strong evidence of efficacy, OAC use is limited by nonprescription (≈50% patients do not receive OAC, despite an appropriate indication), 159,160 nonadherence (30% 1-year discontinuation for warfarin), 161 and subtherapeutic dosing (≈25%-38% of warfarin-treated patients). 162,163 Suboptimal therapy is costly as a result of the economic burden associated with excess stroke, an observation that is particularly relevant in the case of AF-associated strokes.…”

A novel cross-sector telemedical approach to detect arrhythmia in primary care patients with palpitations using a patient-activated event recorder

“…Furthermore, screening patients with known PAF can also be of relevance regarding anticoagulation management. Many AF patients are not treated with OAC despite a CHA 2 DS 2 VASc score > 1 and missing contraindications [20]. In our study, 18 (51.4%) patients with known PAF and a CHA 2 -DS 2 VASc score > 1 (n = 35, 67.3%) did not receive OAC.…”

What are the barriers to warfarin use in atrial fibrillation?: Development of a questionnaire

“…Moreover, several abstract barriers such as "non-compliance", "age", and "dementia" are noted in the literature; we were interested in understanding the underlying reasons that these factors posed as barriers to anticoagulant use [5,16,21]. Our goal was to develop a questionnaire to assess barriers to anticoagulation for stroke prophylaxis in AF patients.…”

“…Several studies have cited reasons for underutilization of warfarin such as age, disability, confusion, cancer, fall risk, and gastrointestinal bleeding in a given patient population [5,7]. In addition, surveys of perceived physician barriers have also been conducted with some examining the barriers at a patient-level using clinical vignettes [10][11][12][13][14][15][16][17][18][19]. However, there are numerous limitations to this prior work.…”