Elsevier

American Heart Journal

Volume 168, Issue 3, September 2014, Pages 239-247.e1
American Heart Journal

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

https://doi.org/10.1016/j.ahj.2014.04.007Get rights and content

Approximately half of patients with atrial fibrillation 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 define reasons for oral anticoagulant underuse classified in ways that can guide intervention and improve use, to increase awareness of stroke risk as well as the benefits and risks of OAC use via educational initiatives and feedback mechanisms, 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 data sets to refine understanding of OAC use and outcomes in general practice, and to better align health system incentives.

Section snippets

Lack of awareness of stroke risk and the risks and benefits of oral anticoagulation

At least one-third of patients diagnosed with AF are unaware of the associated stroke risk.14, 15 Although awareness of stroke risk is increasing among physicians, 16 OAC use varies considerably according to specialty, with primary care physicians prescribing OAC less commonly than cardiologists.17 Unfortunately, time during outpatient clinical encounters is often limited; and AF may be only one of several comorbidities to be addressed in any given office visit, particularly by general

Conclusions

It is estimated that 50,000 preventable strokes occur annually in the United States alone related to suboptimal anticoagulation care for AF. In view of the opportunity to improve care and public health, interventions to improve OAC use are needed at the levels of patients, providers, and health care systems. Patients and providers would benefit from increased awareness of stroke risk and the effects of treatment, which may be achieved with the implementation of educational initiatives and

Acknowledgements

We give special recognition to Robert Temple, MD, for his important contributions to this manuscript.

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