Differences between perspectives of physicians and patients on anticoagulation in patients with atrial fibrillation: observational study Commentary: Varied preferences reflect the reality of clinical practice

Devereaux, P.J.; Anderson, David R.; Gardner, Martin J.; Putnam, Wayne; Flowerdew, Gordon; Brownell, Brenda; Nagpal, Seema; Cox, Jafna L.; Fahey, Tom

doi:10.1136/bmj.323.7323.1218

Cited by 380 publications

(301 citation statements)

References 31 publications

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“…Although extracranial hemorrhages certainly result in hospitalizations, invasive procedures, and discontinuation of antithrombotic therapy, 18 the longer-term functional impact of such hemorrhages is generally much less than that of intracranial hemorrhages or ischemic strokes. Investigations by Devereaux and colleagues 19 reveal that patients are much more willing than physicians to accept a far higher risk of gastrointestinal hemorrhage in return for an associated reduction in the risk of stroke.…”

Section: Discussionmentioning

confidence: 99%

Death and Disability from Warfarin-Associated Intracranial and Extracranial Hemorrhages

Fang

Chang

et al. 2007

The American Journal of Medicine

463

274

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OBJECTIVES-Little is known about the outcomes of patients who have hemorrhagic complications while receiving warfarin therapy. We examined the rates of death and disability resulting from warfarin-associated intracranial and extracranial hemorrhages in a large cohort of patients with atrial fibrillation.METHODS-We assembled a cohort of 13,559 adults with nonvalvular atrial fibrillation and identified patients hospitalized for warfarin-associated intracranial and major extracranial hemorrhage. Data on functional disability at discharge and 30-day mortality were obtained from a review of medical charts and state death certificates. The relative odds of 30-day mortality by hemorrhage type were calculated using multivariable logistic regression.RESULTS-We identified 72 intracranial and 98 major extracranial hemorrhages occurring in more than 15,300 person-years of warfarin exposure. At hospital discharge, 76% of patients with intracranial hemorrhage had severe disability or died, compared with only 3% of those with major extracranial hemorrhage. Of the 40 deaths from warfarin-associated hemorrhage that occurred within 30 days, 35 (88%) were from intracranial hemorrhage. Compared with extracranial hemorrhages, intracranial events were strongly associated with 30-day mortality (odds ratio 20.8 [95% confidence interval, 6.0-72]) even after adjusting for age, sex, anticoagulation intensity on admission, and other coexisting illnesses. CONCLUSIONS-Among anticoagulated patients with atrial fibrillation, intracranialhemorrhages caused approximately 90% of the deaths from warfarin-associated hemorrhage and the majority of disability among survivors. When considering anticoagulation, patients and clinicians need to weigh the risk of intracranial hemorrhage far more than the risk of all major hemorrhages. Atrial fibrillation is the most common clinically significant cardiac arrhythmia and increases the risk for ischemic stroke 4-to 5-fold. 1 Anticoagulation therapy with warfarin can reduce the risk for ischemic stroke by 68% but also increases the risk for major hemorrhagic complications. 2 Clinical decision-making regarding the appropriateness of warfarin therapy for patients with atrial fibrillation has generally relied on balancing the risk of ischemic strokes without warfarin therapy with the risk of all major hemorrhage with warfarin therapy. KeywordsRates of ischemic stroke in patients with atrial fibrillation who are not taking warfarin can be as high as 12% per year, 2,3 and the proportion of patients who have major functional disability after an atrial fibrillation-related ischemic stroke is substantial, as high as 59%. 4 Yet multiple studies demonstrate that patients with atrial fibrillation are frequently not prescribed warfarin despite its benefits in ischemic stroke risk reduction. [5][6][7] The primary deterrent to prescribing warfarin is the fear of inducing life-threatening hemorrhage. 8 Although concerns about hemorrhage prevent many patients from receiving warfarin, there are relatively little data a...

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Section: Discussionmentioning

confidence: 99%

Death and Disability from Warfarin-Associated Intracranial and Extracranial Hemorrhages

Fang

Chang

et al. 2007

The American Journal of Medicine

463

274

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“…low, intermediate or high) for different scores do not correspond to the same annual risk of stroke or bleeding (and so to the same absolute effect of the treatment), as reported in the online Appendix A. In addition, a more appropriate way of using the score-based predictions of risk to individualize treatment recommendations should take into account also the different weight that a patient might assign to such clinical events, as stroke and bleeding [20][21][22].…”

Section: Discussionmentioning

confidence: 99%

Joint use of cardio-embolic and bleeding risk scores in elderly patients with atrial fibrillation

Marcucci

Nobili

Tettamanti

et al. 2013

European Journal of Internal Medicine

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Background: Scores for cardio-embolic and bleeding risk in patients with atrial fibrillation are described in the literature. However, it is not clear how they co-classify elderly patients with multimorbidity, nor whether and how they affect the physician's decision on thromboprophylaxis. Methods: Four scores for cardio-embolic and bleeding risks were retrospectively calculated for ≥65 year old patients with atrial fibrillation enrolled in the REPOSI registry. The co-classification of patients according to risk categories based on different score combinations was described and the relationship between risk categories tested. The association between the antithrombotic therapy received and the scores was investigated by logistic regressions and CART analyses. Results: At admission, among 543 patients the median scores (range) were: CHADS 2 2 (0-6), CHA 2 DS 2 -VASc 4 (1-9), HEMORR 2 HAGES 3 (0-7), HAS-BLED 2 (1-6). Most of the patients were at high cardio-embolic/high-intermediate bleeding risk (70.5% combining CHADS 2 and HEMORR 2 HAGES, 98.3% combining CHA 2 DS 2 -VASc and HAS-BLED). 50-60% of patients were classified in a cardio-embolic risk category higher than the bleeding risk category. In univariate and multivariable analyses, a higher bleeding score was negatively associated with warfarin prescription, and positively associated with aspirin prescription. The cardio-embolic scores were associated with the therapeutic choice only after adjusting for bleeding score or age. Conclusion: REPOSI patients represented a population at high cardio-embolic and bleeding risks, but most of them were classified by the scores as having a higher cardio-embolic than bleeding risk. Yet, prescription and type of antithrombotic therapy appeared to be primarily dictated by the bleeding risk.

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“…In the fifty-five years since these regulations were developed, research has highlighted the limitations of expert opinion. For example, expert opinion can differ both across sub-groups and from the opinions of those who will have to live with the consequences of expert recommendations, [1][2][3][4][5][6][7][8] and experts have been found to use non-systematic methods when they review research, which frequently result in recommendations that do not reflect systematic summaries of the best available evidence. 9,10 Evidence of the effects of alternative policies, programs and services is essential for wellinformed decisions.…”

Section: The Use Of Evidence In Who Recommendationsmentioning

confidence: 99%

Use of evidence in WHO recommendations

2007

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Differences between perspectives of physicians and patients on anticoagulation in patients with atrial fibrillation: observational study Commentary: Varied preferences reflect the reality of clinical practice

Abstract: Objective To determine and compare physicians' and patients' thresholds for how much reduction in risk of stroke is necessary and how much risk of excess bleeding is acceptable with antithrombotic treatment in people with atrial fibrillation.

Cited by 380 publications

References 31 publications

Death and Disability from Warfarin-Associated Intracranial and Extracranial Hemorrhages

Death and Disability from Warfarin-Associated Intracranial and Extracranial Hemorrhages

Joint use of cardio-embolic and bleeding risk scores in elderly patients with atrial fibrillation

Use of evidence in WHO recommendations

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