Elsevier

American Heart Journal

Volume 167, Issue 4, April 2014, Pages 601-609.e1
American Heart Journal

Clinical Investigation
Electrophysiology
Physician practices regarding contraindications to oral anticoagulation in atrial fibrillation: Findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry

https://doi.org/10.1016/j.ahj.2013.12.014Get rights and content

Background

Oral anticoagulation (OAC) therapy reduces the risk of thromboembolic events associated with atrial fibrillation (AF), yet a substantial proportion of patients with AF are not prescribed OAC. The aim of this study is to describe the frequencies of and factors associated with OAC contraindications in contemporary clinical practice.

Methods

We analyzed data from the ORBIT-AF study, a national, prospective, outpatient registry of incident and prevalent AF. Oral anticoagulation contraindications were uniformly collected at enrollment by site personnel using a predefined list. Baseline patient and provider characteristics were compared between participants with and without documented OAC contraindications.

Results

From June 2010 to August 2011, 10,130 patients 18 years or older with electrocardiographically documented AF were enrolled at 176 practices. Of these, 1,330 (13.1%) had contraindications documented at the baseline visit: prior bleed (27.7%), patient refusal/preference (27.5%), high bleeding risk (18.0%), frequent falls/frailty (17.6%), need for dual antiplatelet therapy (10.4%), unable to adhere/monitor warfarin (6.0%), comorbid illness (5.3%), prior intracranial hemorrhage (5.0%), allergy (2.4%), occupational risk (0.8%), pregnancy (0.2%), and other (12.6%). Among patients with reported contraindications, 30.3% were taking warfarin or dabigatran, as compared with 83.0% of those without reported contraindications. Besides “patient refusal/preference,” being labeled as having frequent falls or being frail was associated with the lowest OAC use among patients with high stroke risk.

Conclusions

Contraindications to OAC therapy among patients with AF are common but subjective. Many patients with reported contraindications were receiving OAC, suggesting that the perceived benefit outweighed the potential harm posed by the relative contraindication.

Section snippets

Study population

We used data from the ORBIT-AF study. The study design and population of ORBIT-AF have been described in detail.8 Briefly, ORBIT-AF is a national, prospective registry to improve the quality of care and outcomes for patients with AF. Eligible patients 18 years and older who were able to provide informed consent and follow-up information were consecutively enrolled at 176 sites nationwide. Participating sites were selected to be geographically representative and to include a diverse set of

Results

Of the 10,130 patients enrolled in ORBIT-AF, 1,330 (13.1%) had contraindications to OAC. Table I shows the distribution of specific OAC contraindications among ORBIT-AF patients who listed a contraindication. Overall, the most commonly reported contraindications were patient refusal and prior bleed, both of which were listed for more than one-quarter of contraindicated patients. Other commonly listed contraindications were high bleeding risk (18.0%), frequent falls/frailty (17.6%), other

Discussion

Proper use of anticoagulation is vital to reducing stroke risk among patients with AF, yet OAC is substantially underused in clinical practice.4, 13, 14 We examined patterns of OAC contraindication and associated baseline factors in a large contemporary outpatient population of AF. Our major findings are as follows: (1) 13.1% of patients in our study population had a documented contraindication to OAC at baseline; (2) patients with perceived contraindications were, on average, older, sicker,

Disclosures

The ORBIT-AF registry is sponsored by Janssen Scientific Affairs, LLC, Raritan, NJ. This project was supported (in part) by funding from the Agency of Healthcare Research and Quality through cooperative agreement number 1U19 HS021092. Dr. Singer was, in part, supported by the Eliot B. and Edith C. Shoolman fund of the Massachusetts General Hospital (Boston, MA).

This work was performed at the Duke Clinical Research Institute, Durham, NC.

Dr. O’Brien and Ms. Holmes report no disclosures. Dr.

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    William G. Stevenson, MD, served as guest editor for this article.

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