Skip to main content

Misperceptions About AF Risk Persist Among Physicians, Patients

Analysis  |  By Debra Shute  
   March 30, 2017

Anti-clotting therapies in patients at high risk for stroke are grossly underused. A researcher speculates that physician misconceptions and poor patient education about medication to reduce the risk of atrial fibrillation underlie the problem.

"It's really a sad story," says Ying Xian, MD, PhD, of the Duke University Medical Center in Durham, NC, about research he and colleagues recently published in The JAMA Network Journals.

Their somber discovery: Out of 94,474 patients who had an acute ischemic stroke and known history of atrial fibrillation, 84% were not receiving evidence-recommended therapeutic anticoagulation therapy that could have prevented or mitigated the severity of the event.

Moreover, the researchers found that of those patients admitted to hospitals participating in the Get With the Guidelines-Stroke program:

  • 30% were not receiving any antithrombotic treatment prior to stroke
  • 7.6% were receiving therapeutic warfarin
  • 8.8% were receiving non-vitamin K antagonist oral anticoagulants (NOACs)
  • 40% were receiving antiplatelet therapy only

The most common documented reasons for no oral anticoagulation at discharge among at-risk patients included risk of bleeding (16.3%), risk of falls (10.3%), and terminal illness (6.2%).


When Evidence Says No, But Doctors Say Yes


Xian spoke with HealthLeaders about possible explanations for the two-thirds (65.8%) of patients whose records showed no documented reason to forego the therapy. The following transcript has been lightly edited.

HealthLeaders: Why do you suppose so many at-risk patients did not receive the recommended treatment?

Xian: First, two caveats. One is that I can't give you definite answers because our study design did not collect patients' reasons for not taking these medications prior to stroke. Second, lack of documented reasons precluding anti-clotting therapy doesn't necessarily mean they didn't exist.

But I can provide speculation. On the patient side, they may not appreciate the benefit of getting treated with oral anticoagulation because a stroke hasn't happened to them yet. They might not truly realize their risk of having a stroke, but they hear their physicians talking about the risks, such as bleeding.

Warfarin and some similar medications have a bit of a bad reputation for being hard to use. They require patients to get their blood checked every few weeks, which is not easy. There's also the difficulty that these medications can interact with certain foods and other medications.

HealthLeaders: What are the factors on the physician side?

Xian: There is still some concern within medical societies that patients may not benefit from treatment. Meanwhile, misconceptions persist that Warfarin is too risky to give or that baby aspirin is a sufficient therapy that carries lower risk of bleeding, but this isn't true.

Mounting research demonstrates that aspirin is not as effective as Warfarin or a NOAC.

HealthLeaders: Is drug cost a potential problem here?

Xian: Warfarin has been used for more than 50 years, so the cost of the medication is not bad. However, we do have to consider the cost and burden to patients of having their blood tested every few weeks.

On the other hand, NOACs are newer and in general they are quite expensive. So they can represent a substantial cost to a patient without medical insurance or carrying a high copay or deductible.

HealthLeaders: What can physicians do to improve treatment rates?

Xian: Patient education is very important. It so happens that this study was founded by the Patient-Centered Outcomes Research Institute. When we were talking with our patient investigators, they consistently brought up the concern that patients diagnosed with AF did not receive enough information from their physicians.

It takes more than five to ten minutes to fully explain the risks and benefits of using oral anticoagulation with AF.

Debra Shute is the Senior Physicians Editor for HealthLeaders Media.

Tagged Under:


Get the latest on healthcare leadership in your inbox.